Investigating the Relationship between Fatherhood and Provider Weight-Related Practices and Counseling in Clinical Settings

Abstract

Objective:

To assess whether weight-related practices and counseling between men and their medical providers are associated with the patient’s fatherhood status.

Methods:

Using the 2015–2017 National Survey of Family Growth, logistic regression models were constructed to examine the odds of men being weighed, told a weight status, or referred for nutrition/exercise counseling during a medical visit in the past year.

Results:

The sample included 2,562 men and 1272 fathers. Respectively, 90%, 76% and 49% of fathers were weighed by a provider, told their weight status, and referred for nutrition/exercise counseling. There were no associations between fatherhood status and being weighed or provider weight status communication. Fathers were more likely to be referred for nutrition/exercise counseling compared to those without children during a medical [AOR=1.61, 95% CI 1.003, 2.583] or routine visit [AOR=1.81, 95% CI 1.04, 3.16].

Conclusions and Implications:

The increased likelihood of nutrition or exercise counseling referrals among fathers presents an opportunity to address obesity within families.

INTRODUCTION

Rates of obesity in the United States continue to rise, especially among men. Over a third (35%) of men aged 20–39 and 41% of men aged 40–59 years are obese with a body mass index (BMI) ≥ 30 kg/m².¹ Men in general may not be receiving appropriate connection to effective, evidence-based nutrition and exercise counseling. The topic of obesity is critical to address, as obese men are at risk for significant morbidity, including cardiovascular sequelae and increased risks for cancer (e.g., colon and liver).^2–4 Among men struggling with obesity, fathers may have unique challenges. The transition to fatherhood can be associated with weight gain and increases in men’s BMI.⁵ Furthermore, physical inactivity is common among parents⁶ and may further contribute to a father’s overweight and obesity status.⁷

In addition to the detrimental impact of a father’s obesity and physical inactivity on their own health, these issues can have ripple effects for children. A father’s intake of fruits and unhealthy snacks and their BMI z-score were positively associated with their children’s intake of these items and BMI z-score.^8,9 Furthermore, obese children with obese fathers (or mothers) were nearly 3 times more likely to remain at an obese weight status as an adult when compared to children with parents of normal weight.¹⁰ Given the rising rates of obesity in men, the fact that 6 in 10 men are fathers, and the potential impact of obesity through generations, it is important to address barriers and facilitators to optimal weight maintenance, healthy diets, and physical activity among men who are already fathers or may become fathers in the near future.

Providers are essential facilitators in the prevention and treatment of adult obesity. The U.S. Preventative Services Task Force recommends that providers screen adults for obesity and refer patients to multicomponent behavioral interventions.¹¹ Based on their assessment of a patient’s weight, nutritional intake and physical activity level, they can provide positive reinforcement, guidance on lifestyle changes, and/or referrals to behavioral interventions. However, in a survey of adult providers, less than 50% reported always providing specific diet or physical activity guidance.¹² Individual patient characteristics often predict whether providers discuss weight. Studies suggest that adult patients who are overweight or obese are more likely to receive advice about weight loss if they are of higher socioeconomic status and have higher educational attainment.^13,14

The purpose of this study was to examine the association between fatherhood status and weight-related counseling and practices by providers. Despite the well-documented link between parental and childhood obesity, adult providers are generally focused on adult patients’ outcomes and infrequently document a patient’s parental status or living situation.¹⁵ As such, it was hypothesized that fatherhood status would not be associated with frequency of providers’ weight-related practices or counseling referrals.

METHODS

Study Design and Data

A secondary analysis was performed using data collected in the 2015–2017 National Survey of Family Growth (NSFG), which includes 4,540 men.¹⁶ The NSFG is a national cross-sectional survey that gathers data on fertility, marital status, use of medical services, and general and reproductive health. The NSFG is based on a national multistage probability sample designed to represent non-institutional men and women 15–49 years of age. Adolescents, black and Hispanic patients were oversampled. For the purposes of this analysis, only men over the age of 19 years, who had a clinic/medical visit in the prior 12 months and had data for each of 3 outcomes were assessed (see Measures). The Research Ethics Review Board at the National Center for Health Statistics approved the NSFG survey and use of data.

Measures

Dichotomous outcome variables assessed included whether participants were: 1) weighed by a medical provider at a medical/clinic visit in the past 12 months; 2) informed of their weight status category (i.e., underweight, normal weight, overweight, or obese) at the visit(s); and 3) referred by a medical provider to nutrition or exercise counseling. All outcomes were self-reported by participants. Men who answered ‘yes’ to being weighed at a visit were asked if a provider told them their weight status. Respondents who indicated that a provider had told them that they were overweight or obese were asked if they were referred for nutrition or exercise counseling.

The primary predictor was having a child (yes/no). This included all men who reported having a biological child regardless of residential status (living with or apart from the child). Covariates included the following self-reported sociodemographic variables: age, race/ethnicity, education level, socioeconomic status, body mass index (BMI) (calculated from respondent self-reported height and weight) and consistent health insurance coverage for the last 12 months.

Statistical Analysis

STATA software¹⁷ was used for all analyses. Sociodemographic characteristics between men with and without children were compared using Pearson chi-square test. Unadjusted and adjusted odds ratios with 95% CI using logistic regression were calculated to examine the association between sociodemographic predictors and providers’ weight-related practices. Sociodemographic variables were retained in the regression analyses if they demonstrated a significant bivariate association with the outcome (p<0.1) or because prior research demonstrated significant associations with patient-provider interactions. Race/ethnicity and socioeconomic status were retained in the model for this reason.¹⁸ Statistical significance was set at p<0.05. Analyses were weighted using survey settings to generate nationally representative descriptive statistics and odds ratios. Missing data were imputed using sequential regression and logical imputation methods per the NSFG design and data collection methods.¹⁶ Regression imputation was used for 9.6% of cases for socioeconomic status and less than 2% for all other variables. Missing data for weight-related outcomes (<1%) were not included in imputation analysis and these cases were not included in the analysis.

RESULTS

This sample included 2,562 men aged 20–50 years (Table 1). Overall, 89% of men were weighed by a provider in the past year; 76% of those weighed indicated that their provider informed them of their weight status. Forty-three percent of men who were told by a provider that they were overweight or obese were referred for nutrition or exercise counseling.

Table 1.

Demographic Characteristics of Men Aged 20–50 Years by Fatherhood Status^a

Variable	Overall (N=2562)	No children (N =1290)	Has children (N =1272)	P-value
Age
20–39 years	67%	85%	50%	<0.001
40–50 years	33%	15%	50%
Race/Ethnicity
Non-Hispanic White	59%	61%	58%	0.15
Non-Hispanic Black	12%	11%	13%
Hispanic	20%	18%	22%
Otherb	9%	10%	8%
Education
≤9th grade	4%	2%	6%	<0.001
10–12th grade	30%	25%	35%
College or above	66%	73%	59%
Socioeconomic statusc
<100%	13%	12%	14%	<0.001
100–499%	57%	52%	61%
>499%	30%	36%	25%
Self-reported BMId
Normal	26%	34%	20%	<0.001
Underweight	1%	1%	1%
Overweight	37%	34%	40%
Obese	35%	32%	38%
Consistent health insurance coverage for last 12 months	81%	82%	80%	0.43
Weighed by provider in last 12 months	89%	88%	90%	0.19
Told weight status resulte	76%	77%	76%	0.81
Provided referral for nutrition or exercise counselingf	43%	35%	49%*	0.01

Chi-squared test used for analysis.

^aWeighted to reflect the U.S. male civilian noninstitutional population.

^bOther: Asian, Pacific Islander, Alaskan native, and American Indian

^cLevel defined by the U.S. Census Bureau for the preceding year (2014–2016) and takes into account the total household income and family size.

^dSelf-reported body mas index (BMI) is based on the height and weight the father provided at the time of the interview.

^eBased on sample size of N=2292

^fBased on sample size of N=710

Half of the men in the sample were fathers (n=1272). Fathers were predominantly white, attended some college, had moderate socioeconomic status, and reported consistent health insurance coverage for the last 12 months. Fathers were more likely than men who were not fathers to have a self-reported BMI consistent with being overweight (40 % vs 34%, p<0.001) or obese (38% vs 32%, p<0.001). Nearly all fathers were weighed by a provider, and 76% of those weighed were informed of their weight status. Overweight/obese fathers were also more likely to be referred for nutrition or exercise counseling compared to overweight/obese men without children (49% vs 35%, p=0.01).

Table 2 shows results from logistic regression analyses for the full sample. In unadjusted models, older age and consistent health insurance coverage were associated with increased odds of being weighed by a provider, compared to younger age and inconsistent health coverage [OR=1.63, 95% CI 1.03, 2.57; OR=1.61, 95% CI 1.04, 2.51, respectively] (data not shown). There were no factors significantly associated with being weighed by a provider in adjusted models. In unadjusted and adjusted models, non-Hispanic Black and Hispanic men were more likely to be told their weight status compared to non-Hispanic white men [AOR=1.56, 95% CI 1.08, 2.27; AOR=1.81, 95% CI 1.20, 2.73, respectively]. A man with an overweight BMI was less likely to be told his weight status compared to a man with a normal BMI [AOR=0.64, 95% CI 0.47, 0.88]. Higher socioeconomic status was associated with decreased odds of nutrition or exercise referral [> 499% poverty level, OR=0.52, 95% CI 0.20, 0.95], in unadjusted models only. In unadjusted and adjusted analyses, having a child was associated with increased odds of being referred for nutrition or exercise counseling [AOR=1.61, 95% CI 1.003, 2.583].

Table 2.

Adjusted Odds of Being Weighed, Told Weight Status and Referred for Nutrition or Exercise Counseling by A Provider^a

Variable	Weighed by provider (N=2562)	Told weight status (N=2292)	Provided referral (N=710)	*P-value
Has children	1.33 (0.87–2.03)	0.99 (0.69–1.41)	1.61 (1.003–2.583)*	0.048
Age
20–39 years	Reference	Reference	Reference
40–50 years	1.50 (0.89–2.53)	0.94 (0.69–1.29)	1.28 (0.77–2.11)
Race/Ethnicity
Non-Hispanic White	Reference	Reference	Reference
Non-Hispanic Black	1.11 (0.66–1.85)	1.56 (1.08–2.27)*	1.51 (0.76–2.98)	0.02
Hispanic	1.16 (0.71–1.89)	1.81 (1.20–2.73)*	1.00 (0.53–1.92)	<0.001
Otherb	1.34 (0.79–2.28)	1.38 (0.76–2.49)	1.65 (0.71–3.86)
Education
≤9th grade	Reference	Reference	Reference
10–12th grade	1.11 (0.38–3.24)	0.53 (0.22–1.31)	0.78 (0.24–2.52)
College or above	1.74 (0.54–5.56)	0.51 (0.22–1.21)	0.68 (0.19–2.45)
Socioeconomic statusc
<100%	Reference	Reference	Reference
100–499%	0.86 (0.50–1.47)	1.03 (0.67–1.58)	0.78 (0.38–1.60)
>499%	1.02 (0.49–2.08)	1.41 (0.87–2.29)	0.52 (0.20–1.33)
Self-reported BMId
Normal	Reference	Reference
Underweight	0.32 (0.4–2.33)	1.21 (0.24–6.02)	NA
Overweight	0.60 (0.35–1.05)	0.64 (0.47–0.88)*		<0.001
Obese	1.06 (0.65–1.72)	1.20 (0.82–1.76)
Consistent health insurance coverage for last 12 months	1.46 (0.91–2.36)	0.92 (0.62–1.35)	1.12 (0.60–2.09)

^*Exact p-value provided.

Logistic regression used for analysis.

Model adjusted for all other covariates in the table.

^aWeighted to reflect the U.S. male civilian noninstitutional population.

^bOther: Asian, Pacific Islander, Alaskan native, and American Indian

^cLevel defined by the U.S. Census Bureau for the preceding year (2014–2016) and takes into account the total household income and family size.

^dSelf-reported body mass index (BMI) is based on the height and weight the father provided at the time of the interview.

Sixty-five percent of clinic visits were routine visits, while the remaining 35% were for sick visits. Men were more likely to be weighed and told their weight status during a routine visit when compared to a sick visit (p<0.001). However, being weighed by a provider and told one’s weight status did not differ by parental status for routine or sick visits (p=0.34–0.77). There was no statistical difference in referral rate for nutrition or exercise counseling by visit type (p=0.21). Compared to overweight/obese men without children, overweight/obese fathers were more likely to be referred for nutrition or exercise counseling in routine visits, [AOR=1.81, 95% CI 1.04, 3.16] but not in sick visits [AOR=1.01, 95% CI 0.34, 2.96] (data not shown).

DISCUSSION

This study characterized medical providers’ weight monitoring and counseling practices for adult male patients who were and who were not fathers. Sociodemographic factors of adult male patients were not associated with being weighed by a provider. However, a man’s race/ethnicity and self-reported BMI predicted whether a provider told him his weight status. This study also corroborates other researchers’ findings that only 20–40% of obese patients report receiving nutrition or weight loss counseling.^19,20 Contrary to the stated hypothesis that fatherhood status would not be associated with providers’ weight related practices or counseling referrals, the results suggest that overweight and obese men who were fathers were more likely than men without children to be referred for nutrition or exercise counseling, after adjusting for sociodemographic characteristics.

In the current study, a provider weighed nearly 90% of men in the last year. There were not significant associations between being weighed by a provider or other sociodemographic characteristics. Although the high percentage of completed weight measurements among men is encouraging, based on the U.S. Preventative Services Task Force recommendation to screen all patients for obesity, one may expect these rates to be even higher. While some men may refuse to be weighed at clinic visits, failure to obtain a weight is likely dependent on the provider, clinic and encounter type. Similar to the inpatient setting, workload demands, conflicting priorities, and disruption in workflow may limit the time and attention allotted for body weight measurements.^21,22 Furthermore, limited time during visits, negative attitudes about a patient’s weight, lack of training, and low competence in obesity management may negatively affect a provider’s decision to disclose weight results.^23–25

The results suggest that non-Hispanic Black and Hispanic men were more likely to be told their weight status compared to non-Hispanic white men, and individuals with a self-reported overweight BMI were less likely to be told their weight status compared to men with a self-reported normal weight BMI. Increased communication of weight status among minorities may suggest that providers are focusing efforts on patients who are at increased risk for adverse health outcomes related to weight, as minorities have higher prevalence of hypertension and diabetic complications.^26,27

Discussions about physical activity and weight are sensitive topics and can be difficult conversations for patients and providers. For providers who may feel uncomfortable initiating the topic, physical activity screening to assess a patient’s current activity level offers a less fraught way to start a conversation.²⁸ Clinic encounters in which men are not told their weight status represent missed opportunities to facilitate preventative care management. This may be especially true among overweight patients, who are more likely to report weight loss when their provider told them they were overweight.²⁹ Patients who know or believe that they are overweight or obese may be more receptive to messaging about weight and exercise modifications. Furthermore, formally documenting an overweight or obesity diagnosis and having a conversation was a strong predictor in having a treatment plan for patients.³⁰ It is important for providers to disclose any overweight status so that patients might consider lifestyle changes and avoid crossing the threshold into obesity.

While fathers were more likely to be overweight or obese compared to men without children, they were not more likely to be weighed or told their weight status during any clinical encounter. When fathers’ weight was discussed during routine visits, providers were more likely to give opportunities for them to improve their weight, nutrition and exercise by referring them to nutrition or exercise counseling. The mechanism for this unexpected finding of greater referrals to nutrition or exercise counseling for fathers is unclear. It may suggest that providers are capitalizing on men’s willingness to make positive changes during fatherhood.³¹ This is especially meaningful given the influential effect that fathers have on their child’s nutrition, physical activity and weight.^8,32,33 The lack of association between fatherhood status and weight counseling referrals for sick visits likely reflect providers’ focus on the acute complaint. Given men’s inadequate utilization of preventive care services in the U.S. in general,³⁴ any clinical encounter is an opportunity for fathers to be made aware of the increased risks associated with elevated BMIs and receive treatment and/or referral.

Fathers’ commitment to their children have increased over the last half century as evidenced by the increased time (doubled) that fathers spend on a child’s care.³⁵ Through providing care and engaging with their children, fathers are able to form independent and close relationships with their children. These father-child relationships have been shown to give men satisfaction and strengthen their commitment to their child.³⁶ Researchers have documented that fathers are more committed to weight programs that enable them to support their children (and families) and focus on child health and well-being rather than solely on their own health.^37,38 For example, the “Healthy Dads, Healthy Kids” program showed improvement in nutrition and physical activity outcomes for both fathers and children.³⁹ The program encouraged fathers to act as key decision makers in their family units by modeling healthy behaviors for their children. By encouraging father-child nutrition and exercise interventions, not only do adult providers have the opportunity to help fathers assess and improve their health individually, but also to build bonds within family and influence outcomes for these fathers’ children.

This analysis has several limitations. The survey responses were collected by self-report and are subject to recall and desirability bias. In addition, the cross sectional nature of the data can only suggest association, not causation. This study did not formally adjust for multiple comparisons due to the small number of planned comparisons and the fact that certain approaches (e.g., Bonferroni corrections) can be considered overly conservative and mask potentially important findings. Finally, the available data do not include information about actual uptake of obesity prevention activities, only referrals for counseling.

IMPLICATIONS FOR RESEARCH AND PRACTICE

This paper furthers general understanding of weight-related practices and management during clinic visits for men in general and fathers in particular. Any clinical encounter is a potential opportunity to address weight and physical activity. This study demonstrates that providers weigh most men, but communication of this result can vary by race/ethnicity, a patient’s weight status and visit type. Education and training that supports providers’ comfort with weight-related topics and encourages discussions at any visit may increase conversations about weight for patients of elevated BMI. These analyses also suggest that providers are more likely to refer men with children to nutrition or exercise counseling compared to men without children during routine visits. The increased likelihood of referral among fathers can have a positive influence on adult and childhood obesity outcomes, but the degree of impact is likely related to the chosen intervention. It is important for adult providers to consider the type of intervention that they refer men to, as fathers are more likely to engage in programs that are child and family focused.^37,38 Providers who are referring fathers for nutrition or exercise counseling might consider connecting these patients to programs that would help with childhood obesity prevention as well.