Exploring Patient Perspectives of Body Image Conversations in Primary Care: Understandings, Experiences, and Expectations.

Primary care physicians (PCPs) and patients identified body image conversations to be difficult but necessary. As first points of contact in the healthcare system, PCPs are ideal candidates for addressing body image concerns. Through latent thematic analysis of 12 interviews, this paper explores patient preferences with body image conversations in primary care. We identified challenges that patients faced in sharing body image concerns, expectations they hold for physicians, and suggested potential areas of future research and ways to improve care.

Introduction

Body image—feelings, thoughts, and perceptions about one's body—has distinct, variable, nuanced qualities (1). Body image impacts both physical and mental health-related quality of life outcomes (2). As first points of contact in the healthcare system, primary care physicians (PCPs) are key candidates for addressing body image concerns (3,4). Yet insufficient information, embarrassment, and lack of prompting deter patients from discussing body image with their PCPs, and they may even avoid seeking care (3,5,6). Furthermore, physicians perceive little issue in body image-related patient care outside of equipment limitations for larger patients and health and safety concerns (6). In a recent qualitative study interviewing 20 PCPs and allied health care providers, Lamarche et al (7) found that participants acknowledged the importance of body image, yet struggled with its explicit identification in care interactions and provision of active support for such concerns. Examining the existing literature, body image is largely studied in the context of morbidity, disability, and illness (8,9). In addition, current research largely focuses on negative body image and ignores the distinct qualities of positive body image (10). This qualitative paper aims to describe patient expectations and preferences with body image conversations in primary care outside of morbidity and illness.

Methods

Twelve patients, ranging in age, gender, sexual orientation, and ethnicity were recruited through snowball sampling (Table 1). Patients were interviewed one-on-one via Zoom following a semi-structured guide (Table 2). Interview questions were adapted from existing research (7, 11). Five undergraduate students of different demographics were initially recruited through word of mouth, interviewed, and encouraged to share LY's contact information with others. There were no restrictions beyond age ≥18 years and comfort with interviewing in English. After 12 interviews, LY and LL agreed to end recruitment as the data was rich and complex enough to answer the research question. Audio recordings were transcribed verbatim using Otter AI, participant IDs were assigned, and identifying information was removed. LY inductively coded the interviews and conducted a latent thematic analysis following the steps outlined by Braun and Clarke (12). LL reviewed the codes, and LL and CE independently reviewed theme boundaries and integrity. Methodological decisions were guided by a pragmatic paradigm (13).

Table 1.

Participant Demographic Information.

Pseudonym	Age	Gender	Ethnicity	Employment	Sexuality
P1	21	Prefer not to answer	White	University student	Gay
P2	53	Woman	White	Office work	Heterosexual
P3	65	Man	White	Retired	Heterosexual
P4	52	Woman	White	Office work	Heterosexual
P5	20	Woman	East Asian	University student	Heterosexual
P6	21	Man/Nonbinary	East Asian	University student	Bisexual
P7	60	Woman	White	Office work	Heterosexual
P8	55	Man	White	Office work	Heterosexual
P9	55	Woman	White	Office work	Heterosexual
P10	42	Woman	White	Office work	Heterosexual
P11	21	Woman	East Asian	University student	Bisexual
P12	21	Man	East Asian	University student	Heterosexual

Table 2.

Interview Guide.

What do you think body image is?

How do you define body image?

What do you think having a positive body image means?

How do you define positive body image? What does a positive body image look like to you?

What do you think having a negative body image means?

How do you define negative body image? What does a negative body image look like to you?

What is your own experience with body image?

How do you view your body?

How do you see body image impacting your health?

Positive and/or negative Physical and/or mental

To what extent do body image conversations occur with primary care physicians? Have you ever talked about body image with your primary care physician?

If so, could you describe your experience? How often do you have these conversations? Is it as often as you would like? If not, have you ever wanted to talk about body image with your physician? Why did you/didn’t you want to have this conversation?

Are there any medical or health condition(s) you have and would like to share with me?

Do these conditions relate to or affect your body image? Does body image enter any conversations you might have about these conditions with your doctor?

How does primary care support body image concerns? What would encourage you to have more conversations about body image?

Has anything discouraged you in the past to have these conversations about body image?

What would make these conversations helpful?

What would make these conversations comfortable?

Do you find primary care physicians to be receptive to such conversations?

Results

Participants discussed challenges with initiating body image conversations, called for more physician training in body image topics, as well as highlighted the importance of a strong patient–physician relationship when navigating sensitive conversations.

Initiating Body Image Conversations

Most patients expressed that they wanted more body image discussions with their PCPs (67%). However, body image was described as an uncomfortable conversation for patients to initiate, and physicians often avoided the topic (P1, P5, P6, P11). Only three patients felt confident that their body image concerns would be followed up (P1, P8, P9). Further, P6 expressed that negative encounters with one physician extended distrust toward others:

[It’s like] a bowl of M&Ms, one is poisoned, you don’t want to randomly pick that one.

P2 pointed out that the way the physician initiates the conversation also makes a difference:

If the doctor would come up with an experience, an example to tell me, then I would be encouraged to talk about it. But if she just asked me how are you feeling? “Oh I’m fine, thank you.” Done.

P9 shared examples of statements that would encourage her to share body image concerns, such as “How do you feel about yourself?” and “Is that something you want to pick up today?”

Patients also identified functionality as an element of body image (42%). Since physical functionality is an expected topic of discussion with a physician, it can help ease into more delicate topics of body image.

Skill Building: Training, Knowledge & Advice

Patients identified a need for PCPs to have more training on body image issues (42%). P1 pointed out that “if they [PCPs] were to ask about body image, they should be prepared for it to be negative, rather than acting shocked when something comes up… So maybe having more training or being more prepared with resources.” Participants also wished PCPs would have a more nuanced understanding of body image, including “reading between the lines” (P9), understanding social determinants of health (P7, P9), and recognizing unique LGBTQ+ experiences (P6).

All participants saw a link between mental health, physical health, and body image, therefore they found discussions with PCPs that focus on physical health alone superficial. Consequently, patients look for physicians that are “interested in the whole aspect of your being” (P7, P9). As patients believe that body image is impacted by sociocultural contexts, patients also prefer discussions that explore these aspects (50%). For example, P11 mentioned that “in Chinese Canadian culture, especially with older people, instead of saying, ‘How are you,’ they say, ‘You got fatter.’” In the context of Western beauty standards, these comments contributed to her negative body image. P11 also shared that in her culture, it might be harder to receive support on body image: “At home, [it's] not a very safe or open place to have public conversations about how we feel.”

In three cases, patients felt patronized when their own knowledge was not explored (P2, P3, P8). P3 shared, “I thought, ‘I’ve run how many marathons? You’re telling me about fitness?’” Patients were also less receptive when their physicians did not take their values into account (P2, P3). P2 explained, “If they start telling me to cut the coffee…that's it, they lost me. Because I’m not going to cut the coffee.” Patients hoped for more conversations beyond weight loss, exercise, and nutrition (P2, P3, P8, P10, P11) and believe the PCP's expertise lies in navigating body image resources (P5), goal setting (P8), suggesting solutions (P1), discussing risks (P8), sharing research findings (P2, P7–10), and referring to specialists (P9).

Patients described positive body image as feeling good (67%), healthy (25%), and satisfied (33%), while negative body image as dissatisfied (42%), preoccupied (33%), and inaccurate (42%). With this conceptualization of body image, patients might be discouraged by typical discussions of body image in primary care, where advice on weight loss, exercise, and nutrition highlights a physical deficiency. These feelings can then discourage patients from bringing up body image or lead them to avoid healthcare altogether.

Patient–Physician Relationship Building

Patients identified similar physician qualities that helped them feel more comfortable with body image conversations: sympathetic (58%), receptive (42%), trustworthy (25%), and good listeners (33%). Most patients found comfort in shared lived experience with their PCPs, whether of gender, racialization, or health status (50%). On the other hand, some patients felt dissuaded by physicians who ask invasive questions (P6, P11), pass judgment (P1, P4, P5), or use a checklist (P1, P5).

The subjective nature of body image makes it challenging for patients to recognize negative body image; having a PCP can help them make sense of it. Middle-aged patients generally appreciated physicians discussing the norms for their age (P2, P4, P7). When P4 was concerned about weight gain, she was able to accept her body after her physician joked, “‘At this age, […] if you drink a glass of water, you gain weight.’ I said, ‘Okay, then I have to accept it.’” However, with its subjective nature, PCPs might not always acknowledge body image: P11 pointed out her expectation for her family doctor to notice the “red flags” of her eating disorder because she saw him as “someone who's known me my whole life, knows more or less what I look like when I’m healthy.”

Discussion and Conclusion

This study explored patient expectations of body image conversations in primary care. An emergent finding was how conceptualization of body image shaped physician–patient encounters. As body image is connected to sociocultural influences, mental health, and physical health, it is understandable that patients find current practices centering on weight loss, exercise, and nutrition insufficient. Interestingly, a past study found PCPs also saw body image as an elusive idea and tended to automatically associate it with appearance. Together, there appears to be a need for more patient-facing resources and PCP training in body image. Such training on what body image is and how to initiate culturally competent discussions must be informed by patient experiences.

In creating comfortable environments for these sensitive discussions, physicians face the challenge of maintaining professional boundaries while connecting with patients. Recent shifts to emphasize co-creation of health narratives could help develop a framework for “safe” physician–patient relationships (14).

Limitations and Future Directions

We highlight a snapshot of perspectives of 12 patients, who were mostly white or East Asian and university students or white-collar workers, recruited through snowball sampling; an important detail that clarifies the extent to which our findings and conclusions are transferable. Although our findings provide converging evidence with past research about the nature of body image conversations in primary care (7), since body image is socioculturally rooted, future research should unpack the nuances of these conversations across diverse patients and PCPs. We purposefully kept eligibility criteria broad in terms of interactions with PCPs to explore the breadth of experiences, but this limits the depth of analysis. Exploring body image conversations based on specific settings, frequency of visits, or medicalized issues is valuable.