Preventive Medicine 62 (2014) 103–107

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Preventive Medicine

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Perceived judgment about weight can negatively influence weight loss:A cross-sectional study of overweight and obese patients

Kimberly A. Gudzune a,b,⁎, Wendy L. Bennett a,b, Lisa A. Cooper a,b,c,d, Sara N. Bleich d

a Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USAb Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USAc Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USAd Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

⁎ Corresponding author at: The Johns Hopkins UnDepartment of Medicine, Division of General Internal MRoom 2-611, Baltimore, MD 21205, USA. Fax: +1 410 955

E-mail address: gudzune@jhu.edu (K.A. Gudzune).

0091-7435/$ – see front matter © 2014 Elsevier Inc. All rihttp://dx.doi.org/10.1016/j.ypmed.2014.02.001

a b s t r a c t

a r t i c l e i n f o

Available online 9 February 2014

Keywords:ObesityPatient–providerPrimary carePsychosocial research

Objective. To examine the association between patient-perceived judgments about weight by primary careproviders (PCPs) and self-reported weight loss.

Methods. We conducted a national internet-based survey of 600 adults engaged in primary care with abodymass index (BMI)≥25 kg/m2 in2012. Ourweight loss outcomes included attemptedweight loss and achieved≥10% weight loss in the last 12 months. Our independent variable was “feeling judged about my weight by myPCP.” We created an interaction between perceiving judgment and PCP discussing weight loss as an independent

variable. We conducted a multivariate logistic regression model adjusted for patient and PCP factors using surveyweights.

Results. Overall, 21% perceived that their PCP judged them about their weight. Respondents who perceivedjudgment were significantly more likely to attempt weight loss [odds ratios (OR) 4.67, 95% confidence interval(CI) 1.96–11.14]. They were not more likely to achieve ≥10% weight loss [OR 0.87, 95%CI 0.42–1.76]. Amongpatients whose PCPs discussed weight loss, 20.1% achieved ≥10% weight loss if they did not perceive judgmentby their PCP as compared to 13.5% who perceived judgment.

Conclusions.Weight loss discussions between patients and PCPsmay lead to greaterweight loss in relationshipswhere patients do not perceive judgment about their weight.

© 2014 Elsevier Inc. All rights reserved.

Introduction

The U.S. Preventive Services Task Force has issued a recommenda-tion that healthcare providers counsel obese patients to lose weight(McTigue et al., 2003; Moyer, 2012). Recent evidence from a meta-analysis found that behavioralweight loss interventions can be effectivein the primary care setting and lead to improved control of obesity-related conditions including hypertension (LeBlanc et al., 2011).Primary care provider (PCP) advice on weight loss has also beenshown to have a significant influence on patients' engagement in weightloss efforts (Rose et al., 2013).

Yet, the pervasiveness of negative provider attitudes and weightstigma could limit the effectiveness of PCP advice and behavioralcounseling for obese patients. Physicians have been shown to haveless respect for obese patients (Huizinga et al., 2009), and obese individ-uals commonly report stigmatizing experiences during interactions

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ghts reserved.

with the healthcare system (Puhl and Brownell, 2001, 2006; Puhl andHeuer, 2009). Obese patients have reported avoiding or delayingmedical services such as gynecological cancer screening due to negativeexperiences (Amy et al., 2006). Evidence also suggests that PCPs engagein less emotional rapport building during visits with overweight andobese patients (Gudzune et al., 2013a), whichmay negatively influencethe patient–provider relationship and decrease the effectiveness of be-havior change counseling. Obese patients may be less receptive toweight loss counseling and be less likely to lose weight if theyperceive negative attitudes from their PCP; however, we are aware ofno studies that have examined this question.

Our primary objective was to evaluate whether overweight andobese patients who perceive being judged by their PCPs about theirweight report differences in weight loss attempts and weight loss suc-cess as compared those who do not perceive judgment. We hypothe-sized that patients, who perceived being judged by their PCP, wouldbe less likely to achieve clinically significant weight loss. Our secondobjective was to evaluate whether greater weight loss success occursamong patients who receive weight loss counseling from a providerperceived to be free of weight-related judgment as compared to otherscenarios. We hypothesized that patients who report that their PCPdiscussed weight loss and did not perceive being judged about their

Table 1Patient and PCP characteristics between patients who did and did not perceive weight-related judgment.

Not judged(n = 472)

Judged(n = 127)

p-Value

Patient characteristicsMean age (years) 49.4 40.0 b0.01Female 49% 41% 0.18Race/ethnicityNon-Hispanic white 78% 66% b0.01Non-Hispanic black 14% 14%Othera 7% 20%

Mean BMI (kg/m2) 31.1 33.0 0.01Insurance statusPrivate insurance 53% 61% 0.20Government insuranceb 38% 27%Uninsured 8% 12%

EducationHigh school or less 35% 29% 0.49Vocational or some college 40% 41%College or beyond 26% 31%

PCP relationship ≥5 years 51% 29% b0.01

PCP characteristicsApproximate PCP age

25–44 years 32% 38% 0.30≥45 years 68% 62%

Female PCP 37% 34% 0.59Perceived PCP race/ethnicityNon-Hispanic white 69% 61% 0.06Non-Hispanic black 5% 7%Asian 10% 19%Othera 16% 13%

Approximate PCP BMINormal 19% 11% b0.01Overweight 56% 43%Obese 26% 45%

PCP primary care provider.a For patients, other race includes Asian, Native American, Pacific Islander, or Hispanic.

For PCPs, other race includes Native American, Pacific Islander, or Hispanic.b Government insurance includes Medicare, Medicaid, and military. Estimates

generated using survey weights.

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weight would lose more weight than those patients who reportedreceiving counseling but perceived being judged.

Methods

Design and participants

Weconducted a cross-sectional, internet-based survey of a nationally repre-sentative sample of 600 overweight and obese U.S. adults about physician fac-tors that influence patient trust (Bleich et al., 2013). Experts in obesity andpatient–physician relationships reviewed the survey instrument for content,which was then pretested for length and comprehension and revised with theassistance of Social Science Research Solutions. The survey was administeredonline through the Authentic Response web panel, which includes approxi-mately 4,000,000 registeredmembers. This panel consistently updates itsmem-ber profiles to ensure the accuracy of its information and uses algorithms toidentify and exclude professional survey-takers. We recruited panel membersthrough invitation to represent a general U.S. population sample. Invited mem-bers were eligible for the survey if they had seen their PCP within the last12 months and their BMI was ≥25 kg/m2. We excluded pregnant women.

This study was approved by the Institutional Review Board of the JohnsHopkins Bloomberg School of Public Health.

Measures: association of perceived judgment and weight loss

Our independent variable was patient perceptions of PCP judgment abouttheir weight. We asked participants, “In the last 12 months, did you ever feelthat this doctor judged you because of your weight?” with the options on an-swering “often,” “sometimes,” or “never.” Participants were asked to keeptheir current PCP in mind when answering this question. We dichotomizedthis variable as ‘felt judged’ if participants indicated that they were “often” or“sometimes” judged, otherwise they were labeled as “not judged.”

Our dependent variables included two weight loss-related outcomes: weightloss attempted and clinically significant weight loss achieved. To determine ifweight loss was attempted, we asked participants, “In the last 12 months, howmuch did you try to lose weight?” with the options of answering “a lot,” “only alittle,” or “not at all.”We defined ‘weight loss attempted’ if participants answeredeither “a lot” or “only a little.” To determine if clinically significant weight loss wasachieved, we asked participants, “In the last 12 months, have you lost anyweight?” (yes/no). Participants who reported losing weight were then asked,“In the last 12 months, how much weight did you lose?” and they could thenenter their pounds lost. We then calculated the percentage of weight lost foreach participant. We defined ‘clinically significant weight loss achieved’ if partici-pants reported at least a 10% weight loss in the last 12 months (NIH, 1998).

Measures: relationship factors associated with weight loss

Our independent variable represents an interaction between ‘patient feelingsof PCP judgment about their weight’ described above and ‘PCP discussed weightloss.’ For the later variable, we asked participants, “In the last 12 months, didyou and this doctor talk aboutweight loss a lot, only a little, or not at all?”. We de-fined participants as PCP discussed weight loss if they answered “a lot” or “only alittle.”We first used PCP discussion as an independent variable, and thenwe com-bined the two concepts by creating a new variable with the following categories:‘not judged + not discussed,’ ‘not judged + discussed,’ ‘judged + not discussed,’and ‘judged + discussed.’ Our dependent variables were our weight loss at-tempted and clinically significant weight loss achieved variables described above.

Covariates

Our covariates included several patient- and PCP-level variables. Categoricalvariables were modeled as shown in Table 1. Patient covariates included age,sex, race/ethnicity, BMI, insurance status, education, and duration of relationshipwith PCP. Patients reported characteristics about their PCP. These PCP covariatesincluded approximate age, sex, perceived race/ethnicity, and approximate BMIevaluated by body size pictogram. Pictograms have been previously used to iden-tify others' body weight (Stunkard et al., 1983; Sorenson et al., 1983).

Statistical analyses

All analyses were conducted using STATA, version 11 (College Station, TX).We used weighting to address systematic under- or over-representations of

subpopulations within the panel, account for systematic non-response alongknown demographic characteristics, and adjust for sampling biases due to dif-ferences in response rates (Keeter et al., 2000). We used STATA's SVY functionto adjust for the complex survey design in all analyses described below. Theweighted margin of error was +/−4.9%.

We performed descriptive analyses for all variables using chi-square andt-tests as appropriate. For both objectives, we conducted multivariate logisticregression analyses to evaluate the relationship between the independent anddependent variables outlined above. All models were adjusted for patient age,patient sex, patient race, patient BMI, PCP relationship duration, PCP race, andperceived PCP BMI. We included these covariates based on their prior associa-tions with weight loss behaviors and/or the patient–physician relationship(Johnson et al., 2004; Roter andHall, 2006; Ghods et al., 2008), regardless of sta-tistical significance. Using STATA's post-estimation adjust command, we calcu-lated the adjusted predicted probabilities for all outcomes.

Given that our outcomes were common (prevalence N10%), logistic regres-sion may lead to inflated estimates of the odds ratios (OR). Therefore, we con-ducted a sensitivity analysis using Poisson regression to calculate prevalenceratios (PR), which more accurately reflect the magnitude of effect but overesti-mate the variance estimates (Cummings, 2009). For each objective,we conduct-ed multivariate Poisson regression analyses to evaluate the relationshipbetween the independent and dependent variables outlined above, adjustingfor all the same covariates as in the logistic regression models.

Results

We screened 1380 panel members who responded to the surveyinvitation, and excluded 335 participants who had not seen their PCPin the last year, 396 who did not have a BMI ≥25 kg/m2, 6 who werecurrently pregnant, and 43 who had incomplete survey responses. Ourfinal sample included 600 participants. Mean age was 47.4 years, 48%

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were female, 76%were white, andmean BMI was 31.5 kg/m2. In the last12 months, 66% reported that their PCP discussed weight loss, 83%attempted weight loss, and 15% reported achieving a clinically signifi-cant weight loss. Overall, 21% of respondents perceived that their PCPjudged them about their weight, where 12% felt sometimes judgedand 9% felt often judged.

Table 1 compares patient and PCP characteristics between thoseparticipants who perceived judgment by their PCP because of theirweight with those who did not feel judged. Patients who perceivedjudgment were significantly younger, had greater BMI, and had newerrelationships with their PCPs. Patients who reported their PCP as havinggreater BMI were more likely to perceive judgment about their ownweight by this provider.

Results: association of perceived judgment and weight loss

Respondents who perceived judgment were significantly more like-ly to report attemptingweight loss [OR 4.67, 95%CI 1.96–11.14; PR 1.15,95%CI 1.07–1.24]. Despite the increased attempts, they were not morelikely to report having achieved a clinically significant weight loss[OR 0.87, 95%CI 0.42–1.76; PR 0.89, 95%CI 0.50–1.60] as compared torespondents who did not perceive judgment. Fig. 1 shows the adjustedpredicted probabilities for attempting weight loss and achievingclinically significant weight loss for patients who did and did notperceive judgment by their PCP about theirweight. Over 95% of patientswho perceived judgment attempted weight loss, while 84% of patientswho did not perceive judgment made weight loss attempts. However,only 13% and 14% of patients in these groups, respectively, achieved aclinically significant weight loss.

Results: relationship factors associated with weight loss

Respondents who reported that their PCP discussed weight losswere significantly more likely to attempt weight loss [OR 5.15, 95%CI2.81–9.42; PR 1.33, 95%CI 1.18–1.51] and achieve a clinically significantweight loss [OR 3.74, 95%CI 1.80–7.78; PR 3.01, 95%CI 1.58–5.73].

Table 2 shows how perceptions of PCP judgment may influencethe effectiveness of PCPs' weight loss counseling in helping patientsto achieve weight loss. The replication of these analyses with Poissonregression revealed similar trends (Appendix Table 1).

Fig. 1. Comparison of predicted probabilities for attempting weight loss and achievingclinically significant weight loss in the past 12 months by whether or not patientsperceived judgment by their primary care provider (PCP) about their weight. Patientswho perceived judgment by their PCP were significantly more likely to report attemptingweight loss; however, therewere no significant differences in achieving clinically significantweight loss (≥10%) between the two groups. Predicted probabilities and p-values estimatedfrom logistic regressionmodel adjusted for patient age, patient sex, patient race, patient BMI,PCP relationship duration, PCP race and perceived PCP BMI. Estimates generated usingsurvey weights.

Fig. 2 shows the adjusted predicted probabilities for attemptingweight loss for these same groups. Patients whose PCPs discussedweight loss, regardless of whether the patient perceived judgment ornot, were significantly more likely to attempt weight loss [OR 18.94,95%CI 5.90–60.71; OR 4.22, 95%CI 2.24–7.96, respectively].

The only group significantlymore likely to achieve a clinically signif-icant weight loss was patients who's PCP discussed weight loss withoutcreating perceptions of judgment [OR 4.36, 95%CI 1.99–9.56] (Table 2).Fig. 2 also shows the adjusted predicted probabilities for achievingclinically significant weight loss for these same groups.

Discussion

Over 20% of overweight and obese patients perceived judgmentfrom their current PCPs because of their weight. Prior studies havedescribed the pervasiveness of healthcare providers' negative attitudestowards patients with obesity (Puhl and Brownell, 2001, 2006; Amyet al., 2006; Huizinga et al., 2009; Puhl and Heuer, 2009), and thisstudy confirms that patients' perceive judgment from their PCPs. Wefound that respondent perceptions of being judged were associatedwith weight loss attempts; however, this perceived judgment was notassociated with greater weight loss. Our results may suggest thatnegative encounters can prompt a weight loss attempt, but they donot necessarily facilitate successful weight loss. On the other hand,patients were significantly more likely to report a clinically significantweight loss if they had a PCP that discussed weight loss and fromwhom they did not perceive judgment. Future studies should considerexploring how patients' perceived judgment by their PCP about theirweight might influence other patient–provider relationship elementssuch as trust or lead patients to switch to a new healthcare provider.

In 2011, the Centers for Medicare and Medicaid announced newbenefits coverage for intensive behavioral counseling for obese patients(BMI ≥30 kg/m2) by their PCP (Center for Medicaid and Medicare,2011). PCPs now have additional encouragement to provide counselingfor their obese Medicare patients, although many PCPs may be waryof potentially creating a rift in the patient–provider relationship bydiscussing weight loss with their patients. A prior study of PCPs hasdocumented that some avoid the weight loss discussion for this veryreason (Gudzune et al., 2012). However, we saw that those patientswho had a weight loss discussion with their PCP, regardless of percep-tions of judgment, were more likely to make a weight loss attempt.Other studies have found that healthcare providers can be a powerfulinfluence on patient weight loss behavior (Rose et al., 2013). Mostpatients reported recently attempting weight loss in our study, whichhas previously ranged from 49 to 78% of obese U.S. adults (Krugeret al., 2004; Zhao et al., 2009). These patients may engage in healthyand unhealthy weight loss practices during these attempts (Krugeret al., 2004). Overall, our results suggest that PCPs should not avoid

Table 2Logistic regression analysis examining whether weight loss outcomes differ by PCPjudgment-weight loss discussion groups.

N ORa 95%CI

Attempting weight lossNot judged + not discussed 188 REF –

Judged + not discussed 15 1.58 0.42–5.92Judged + discussed 112 18.94 5.90–60.71Not judged + discussed 284 4.22 2.24–7.96

Achieving clinically significant weight loss (≥10%)Not judged + not discussed 188 REF –

Judged + not discussed 15 1.71 0.34–8.49Judged + discussed 112 2.70 0.95–7.63Not judged + discussed 284 4.36 1.99–9.56

PCP primary care provider.a Logistic regression model adjusted for patient age, patient sex, patient race, patient

BMI, duration of PCP relationship, PCP race and perceived PCP BMI. Estimates generatedusing survey weights.

Fig. 2. Predicted probabilities for attempting weight loss and achieving clinically signifi-cant weight loss in the past 12 months across different primary care provider (PCP)judgment-weight loss discussion groups. Patients who had PCPs that discussed weightloss, regardless of whether the patient perceived PCP judgment, were significantly morelikely to attempt weight loss. Patients who had PCPs that discussed weight loss and didnot perceive judgment were significantly more likely to achieve a clinically significantweight loss (≥10%), as compared to patients who did not perceive judgment butdid not have weight loss discussed. Predicted probabilities and p-values estimated fromlogistic regression model adjusted for patient age, patient sex, patient race, patient BMI,PCP relationship duration, PCP race and perceived PCP BMI. Estimates generated usingsurvey weights.

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discussing weight loss with their patients; rather these conversationscan be an impetus for patients to attempt losing weight and be anopportunity for PCPs to discuss healthy weight loss practices.

Importantly, we found that nearly half of our patients reported thattheir PCP discussed weight loss and they did not perceive being judgedby this PCP. The differential experience between patients may speakmore to how the individual PCP approaches and engages the patientin the weight loss discussion, rather than the weight loss discussionitself. Some patients may also be more sensitive to discussing theirweight and weight loss. In general, PCPs have more challenges buildingrapport with overweight and obese patients such as expressing empa-thy, concern, reassurance, and partnership (Gudzune et al., 2013a).Given the combination of these findings, PCPs may benefit fromadditional training in communication skills as well as specific guidanceon how to discuss weight loss with overweight and obese patients.An observational study found that patients lost more weight whenthey had weight loss counseling visits with physicians who used moti-vational interviewing strategies (Pollak et al., 2010). Additional PCPtraining in this area would benefit the patient–provider relationship,as research has shown that such patent-center communication strate-gies lead to greater patient satisfaction (Beck et al., 2002; Dwamenaet al., 2012), improvement in some clinical outcomes (Hojat et al.,2011), and less physician burnout (Krasner et al., 2009). We alsofound that patients, whose PCPs discussed weight loss without leadingto perceived patient judgment, more often achieved clinically signifi-cant weight loss than their other peers. These findings suggest that im-proved PCP communication skills regarding weight loss may lead toimproved patient weight loss outcomes.

We found that patients who reported their PCP was obese weremore likely to perceive judgment about their own weight by thisprovider, which we previously reported and discussed (Bleich et al.,2013). In brief, we hypothesized that this result could reflect an inter-nalization of negative attitudes and experiences by obese providers,which are behaviors that they then spread to their patients (GarcíaColl et al., 2004). Future studies are needed to test this hypothesis.

Our study has several limitations. This study relied upon self-reported weights to calculate the percentage of weight lost, as wellas BMI. Participants often underestimate their weights when self-reported (Merrill and Richardson, 2009). Therefore, our calculationsfor BMI and percent weight lost may be underestimated and may nottake into account any weight regain patients may have experienced.We used a single question to determine whether an individual feltjudged by their provider. Patients may have different interpretationsof what they perceive as ‘judgment.’We did not evaluate what particu-lar attributes about the patients' encounters with their PCPs lead themto perceive that their PCP judged thembecause of their weight. Multiplefactors likely influence this perception that we did not capture in oursurvey. Our overall survey included questions on other topics such aswellness programs and physician trust, which likely minimizes hypoth-esis guessing that may occur with self-reported data. We only includedpatients who were actively engaged in primary care, so our populationlikely excludes patients who switch providers due to dissatisfactionwith care. A prior study found that overweight and obese patientswere more likely to “doctor shop” (Gudzune et al., 2013b), soour results may underestimate the prevalence of patient-perceivedweight-related judgment by providers. We were only able to capturePCP attributes as perceived by the patients, which may not accuratelyreflect the true characteristics of their PCPs. We were unable to assessthe PCPs' educational background, years of work experience, or priortraining in weight management or communication skills. These factorsmay be important contributors to successful weight loss counseling(Smith et al., 2011). Finally, this was a cross-sectional study, whichlimits our ability to make causal inferences or examine temporal rela-tionships between perceived provider attitudes and patient behaviors.

Conclusion

PCPs may need to consider additional training in preparation for thenew Medicare benefit covering intensive behavioral counseling forweight loss. While seeking additional training on basic weightmanage-ment will be essential to address knowledge deficiencies previouslyidentified in this area (Block et al., 2003; Jay et al., 2008), our findingssuggest that PCPs should consider adding communication skills trainingto this experience. Building communication skills helps improve PCPs'capacity to show concern and empathy for patients' struggles, avoidjudgment and criticism, and give emotional support and encourage-ment, which may all improve PCPs' ability to execute more sensitiveweight loss discussions. Healthcare providers will need both the knowl-edge about obesity as well as the ability to considerately counsel obesepatients for this benefit to facilitate patients' successful weight loss.

Supplementary data to this article can be found online at http://dx.doi.org/10.1016/j.ypmed.2014.02.001.

Conflict of interest statement

The authors declare no conflicts of interest.

Acknowledgments

KAG and SNB were supported by trainee awards from the NationalHeart, Lung, and Blood Institute's (NHLBI) Center for PopulationHealth and Health Disparities (P50HL0105187). NHLBI also providedsupport through the following grants: KAG (K23HL116601); WLB(K23HL098476); LAC (K24HL083113); and SNB (K01HL096409).

References

Amy, N.K., Aalborg, A., Lyons, P., Keranen, L., 2006. Barriers to routine gynecological cancerscreening for White and African-American obese women. Int. J. Obes. (Lond.) 30,147–155.

Beck, R.S., Daughtridge, R., Sloane, P.D., 2002. Physician–patient communication in theprimary care office: a systematic review. J. Am. Board Fam. Pract. 15, 25–38.

Bleich, S.N., Gudzune, K.A., Bennett, W.L., Jarlenski, M., Cooper, L.A., 2013. How doesphysician BMI impact patient trust and perceived stigma? Prev. Med. 57, 120–124.

107K.A. Gudzune et al. / Preventive Medicine 62 (2014) 103–107

Block, J.P., DeSalvo, K.B., Fisher,W.P., 2003. Are physicians equipped to address the obesityepidemic? Knowledge and attitudes of internal medicine residents. Prev. Med. 36,669–675.

Center for Medicaid andMedicare, 2011. DecisionMemo for Intensive Behavioral Therapyfor Obesity (CAG-00423N).

Cummings, P., 2009. Methods for estimating adjusted risk ratios. Stata J. 9, 175–196.Dwamena, F., Holmes-Rovner, M., Gaulden, C.M., et al., 2012. Interventions for providers

to promote patient-center approach in clinical consultations. Cochrane Database Syst.Rev. 12, CD003267.

García Coll, C.T., Bearer, E.L., Lerner, R.M., 2004. Nature and Nurture: The ComplexInterplay of Genetic and Environmental Influences on Human Behavior and Develop-ment. Lawrence Erlbaum Associates, Mahwah, NJ.

Ghods, B.K., Roter, D.L., Ford, D.E., Larson, S., Arbelaez, J.J., Cooper, L.A., 2008. Patient–physician communication in primary care visits with African-Americans and whiteswith depression. J. Gen. Intern. Med. 23, 600–606.

Gudzune, K.A., Clark, J.M., Appel, L.J., Bennett, W.L., 2012. Primary care providers' commu-nication with patients during weight counseling: a focus group study. Patient Educ.Couns. 89, 152–157.

Gudzune, K.A., Beach, M.C., Roter, D.L., Cooper, L.A., 2013a. Physicians build less rapportwith obese patients. Obesity (Silver Spring) 21, 2146–2152.

Gudzune, K.A., Bleich, S.N., Richards, T.M., Weiner, J.P., Hodges, K., Clark, J.M., 2013b.Doctor shopping my overweight and obese patients is associated with increasedhealthcare utilization. Obesity (Silver Spring) 21, 1328–1334.

Hojat, M., Louis, D.Z., Markham, F.W., Wender, R., Rabinowitz, C.G., 2011. Physi-cians' empathy and clinical outcomes for diabetic patients. Acad. Med. 86,359–364.

Huizinga, M.M., Cooper, L.A., Bleich, S.N., Clark, J.M., Beach, C.M., 2009. Physician respectfor patients with obesity. J. Gen. Intern. Med. 24, 1236–1239.

Jay, M., Gillespie, C., Ark, T., et al., 2008. Do internists, pediatricians, and psychiatrists feelcompetent in obesity care?: using a needs assessment to drive curriculum design.J. Gen. Intern. Med. 23, 1066–1070.

Johnson, R.L., Roter, D., Powe, N.R., Cooper, L.A., 2004. Patient race/ethnicity and quality ofpatient–physician communication during medical visits. Am. J. Public Health 94,2084–2090.

Keeter, S., Miller, C., Kohut, A., Groves, R.M., Presser, S., 2000. Consequences of reducingnon-response in a national telephone survey. Public Opin. Q. 64, 125–148.

Krasner, M.S., Epstein, R.M., Beckman, H., Suchman, A.L., Chapman, B., Mooney, C.J., 2009.Association of an educational program in mindful communication with burnout,empathy, and attitudes among primary care physicians. J. Am. Med. Assoc. 302,1284–1293.

Kruger, J., Galuska, D.A., Serdula, M.K., Jones, D.A., 2004. Attempting to lose weight:specific practices among U.S. adults. Am. J. Prev. Med. 26, 402–406.

LeBlanc, E.S., O'Conner, E., Whitlock, E.P., Patnode, C.D., Kapka, T., 2011. Effectivenessof primary care — relevant treatments for obesity in adults: a systematic evidencereview for the U.S. Preventive Services Task Force. Ann. Intern. Med. 155, 434–447.

McTigue, K.M., Harris, R., Hemphill, B., et al., 2003. Screening and interventions for obesityin adults: summary of the evidence for the U.S. Preventive Services Task Force. Ann.Intern. Med. 139, 933–949.

Merrill, R.M., Richardson, J.S., 2009. Validity of self-reported height, weight, and bodymass index: findings from the National Health and Nutrition Examination Survey,2001–2006. Prev. Chronic Dis. 6, A121.

Moyer, V.A., 2012. Screening for and management of obesity in adults: U.S. PreventiveServices Task Force recommendation statement. Ann. Intern. Med. 157, 373–378.

NIH, NHLBI Obesity Education Initiative, 1998. Clinical Guidelines on the Identification,Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report(NIH, Publication No. 98–4098).

Pollak, K.I., Alexander, S.C., Coffman, C.J., et al., 2010. Physical communication techniquesand weight loss in adults: Project CHAT. Am. J. Prev. Med. 39, 321–328.

Puhl, R., Brownell, K.D., 2001. Bias, discrimination, and obesity. Obes. Res. 9, 788–805.Puhl, R.M., Brownell, K.D., 2006. Confronting and coping with weight stigma: an investi-

gation of overweight and obese adults. Obesity (Silver Spring) 14, 1802–1815.Puhl, R.M., Heuer, C.A., 2009. The stigma of obesity: a review and update. Obesity (Silver

Spring) 17, 941–964.Rose, S.A., Poynter, P.S., Anderson, J.W., Noar, S.M., Conigliaro, J., 2013. Physician weight

loss advice and patient weight loss behavior change: a literature review and meta-analysis of survey data. Int. J. Obes. (Lond.) 37, 118–128.

Roter, D., Hall, J.A., 2006. Doctors Talking with Patients/Patients Talking with Doctors:Improving Communication in Medical Visits, second ed. Praeger Publishers,Westport, CT.

Smith, A.W., Borowski, L.A., Liu, B., et al., 2011. U.S. primary care physicians' diet-, physicalactivity-, and weight-related care of adult patients. Am. J. Prev. Med. 41, 33–42.

Sorenson, T.I., Stunkard, A.J., Teasdale, T.W., Higgins, M.W., 1983. The accuracy of reportsof weight: children's recall of their parents' weights 15 years earlier. Int. J. Obes. 7,115–122.

Stunkard, A.J., Sorensen, T., Schulsinger, F., 1983. Use of a Danish adoption register for thestudy of obesity and thinness. In: Kety, S.S., Rowland, L.P., Sidman, R.L., Matthysse,S.W. (Eds.), The Genetics of Neurological and Psychiatric Disorders. Raven Press,New York, NY, pp. 115–120.

Zhao, G., Ford, E.S., Li, C., Mokdad, A.H., 2009. Weight control behaviors in overweight/obeseU.S. adults with diagnosed hypertension and diabetes. Cardiovasc. Diabetol. 6, 13.