Weight bias among health care professionals: A systematic review and meta-analysis

Policy Interventions to Enhance Medical Care for People With Obesity in the United States-Challenges, Opportunities, and Future Directions

Policy Points Health policymakers have insufficiently addressed care for people with obesity (body mass index ≥ 30 kg/m2) in the United States. Current federal policies targeting obesity medications reflect this unfortunate reality. We argue for a novel policy framework to increase access to effective obesity therapeutics and care, recognizing that, though prevention is critical, the epidemic proportions of obesity in the United States warrant immediate interventions to augment care. Reducing barriers to and improving the quality of existing anti-obesity medications, intensive behavioral therapy, weight management nutrition and dietary counseling, and bariatric surgery are critical. Moreover, to ensure continuity of care and patient-clinician trust, combating physician and broader weight stigma must represent a central component of any viable obesity care agenda.

Dietitian-led micronutrient management in a public bariatric surgery outpatient clinic

AIMS

This study aimed to explore the multidisciplinary team attitudes and knowledge of bariatric surgery micronutrient management (pre- and postoperative care) and to evaluate the implementation of an extended-scope of practice dietitian-led model of care for micronutrient monitoring and management.

METHODS

A mixed method study design included quantitative evaluation of micronutrient testing practices and deficiency rates. Qualitative reflexive thematic analysis was used to interpret multidisciplinary experience with micronutrient monitoring in a traditional and dietitian-led model of care. In addition, deductive analysis used normalisation process theory mapping of multidisciplinary experience with the implementation of the dietitian-led model of care.

RESULTS

In the traditional model, a lack of quality evidence to guide micronutrient management, and a tension in trust between surgeons and patients related to adherence to micronutrient prescriptions were described as challenges in current practice. The dietitian-led model was seen to overcome some of these challenges, increasing collaborative, and coordinated, consistent and personalised patient care that led to increased testing for and detection of micronutrient deficiencies. Barriers to sustainability of the dietitian-led model included a lack of workforce succession planning, and no clearly defined delegation for some aspects of care.

CONCLUSION

An extended scope dietitian-led model of care for micronutrient management after bariatric surgery improves clinical care. Challenges such as succession planning must be considered in design of extended scope services.

Gallstones as a cause in presumed acute alcoholic pancreatitis: observational multicentre study

BACKGROUND

Data on the incidence and clinical relevance of gallstones in patients with suspected acute alcoholic pancreatitis are lacking and are essential to minimize the risk of recurrent acute pancreatitis. The aim of this study was to assess the incidence of gallstones and the associated rate of recurrent acute pancreatitis in patients with presumed acute alcoholic pancreatitis.

METHODS

Between 2008 and 2019, 23 hospitals prospectively enrolled patients with acute pancreatitis. Those diagnosed with their first episode of presumed acute alcoholic pancreatitis were included in this study. The term gallstones was used to describe the presence of cholelithiasis or biliary sludge found during imaging. The primary outcome was pancreatitis recurrence during 3 years of follow-up.

RESULTS

A total of 334 patients were eligible for inclusion, of whom 316 were included in the follow-up analysis. Gallstone evaluation, either during the index admission or during follow-up, was performed for 306 of 334 patients (91.6%). Gallstones were detected in 54 patients (17.6%), with a median time to detection of 6 (interquartile range 0-42) weeks. During follow-up, recurrent acute pancreatitis occurred in 121 of 316 patients (38.3%), with a significantly higher incidence rate for patients with gallstones compared with patients without gallstones (59% versus 34.2% respectively; P < 0.001), while more patients with gallstones had stopped drinking alcohol at the time of their first recurrence (41% versus 24% respectively; P = 0.020). Cholecystectomy was performed for 19 patients with gallstones (36%). The recurrence rate was lower for patients in the cholecystectomy group compared with patients who did receive inadequate treatment or no treatment (5/19 versus 19/34 respectively; P = 0.038).

CONCLUSION

Gallstones were found in almost one in every five patients diagnosed with acute alcoholic pancreatitis. Gallstones were associated with a higher rate of recurrent pancreatitis, while undergoing cholecystectomy was associated with a reduction in this rate.

Determining Associations Among Health Orientation, Fitness Orientation, and Attitudes Toward Fatness in Physiotherapists and Physiotherapy Students Using Structural Equation Modeling

Purpose

Research suggests physiotherapists hold negative attitudes and beliefs toward fatness and fat people. Physiotherapists are also health-conscious, and invested in healthy lifestyle behaviours including physical activity. Our purpose was to describe relationships between health orientation, fitness orientation, and fat attitudes.

Methods

Physiotherapists (n = 187) and physiotherapy students (n = 34) completed an online survey (Health Orientation Scale, Multidimensional Body-Self Relations Questionnaire, Fat Attitudes Assessment Toolkit). Structural equation modeling estimated associations between fat attitudes (dependent variable) and health and fitness orientation (independent variables).

Results

Participants scored high in orientation toward fitness and health. We found strong positive associations between fitness orientation and health orientation (p < 0.001). Health orientation was not significantly associated with fat attitudes (p = 0.075), whereas increased age was associated with more positive fat attitudes (p < 0.01). Although most participants acknowledged that factors outside an individual's control contribute to body weight, many also agreed with normative negative perspectives.

Conclusions

Physiotherapists are highly oriented toward fitness and health. This may underlie beliefs in the controllability of body weight and contribute to negative attitudes toward fatness and fat people. Further research, with greater sample sizes is necessary to further investigate associations between health orientation and fat attitudes.

Racialized Inequities in Knee Arthroplasty Receipt After Osteoarthritis Diagnosis in the US Military Health System

OBJECTIVE

The goal was to evaluate institutional inequities in the US Military Health System in knee arthroplasty receipt within three years of knee osteoarthritis diagnosis when accounting for other treatments received (eg, physical therapy, medications).

METHODS

In this retrospective observational cohort study, medical record data of patients (n = 29,734) who received a primary osteoarthritis diagnosis in the US Military Health System between January 2016 and January 2020 were analyzed. Data included receipt of physical therapy one year before diagnosis and up to three years after diagnosis, prediagnosis opioid and nonopioid prescription receipt, health-related factors associated with levels of racism, and the primary outcome, knee arthroplasty receipt within three years after diagnosis.

RESULTS

In a generalized additive model with time-varying covariates, Asian and Pacific Islander (incidence rate ratio [IRR] 0.58, 95% confidence interval [CI] 0.45-0.74), Black (IRR 0.52, 95%CI 0.46-0.59), and Latine (IRR 0.66, 95%CI 0.52-0.85) patients experienced racialized inequities in knee arthroplasty receipt, relative to white patients (all P < 0.001).

CONCLUSIONS

In the present sample, Asian and Pacific Islander, Black, and Latine patients were significantly less likely to receive a knee arthroplasty, relative to white patients. Taken together, system-level resources are needed to identify and address mechanisms underlying institutional inequities in knee arthroplasty receipt, such as factors related to systemic and structural, institutional, and personally mediated racism.

Putting weight-related conversations into practice: Lessons learned from implementing a knowledge translation casebook in a disability context

BACKGROUND

Due to reported challenges experienced by healthcare providers (HCPs) when having weight-related conversations with children with disabilities and their families, a knowledge translation (KT) casebook was developed, providing key communication principles with supportive resources. Our aim was to explore how the KT casebook could be implemented into a disability context. Study objectives were to develop and integrate needs-based implementation supports to help foster the uptake of the KT casebook communication principles.

METHODS

A sample of nurses, physicians, occupational therapists and physical therapists were recruited from a Canadian paediatric rehabilitation hospital. Informed by the Theoretical Domains Framework, group interviews were conducted with participants to understand barriers to having weight-related conversations in their context. Implementation strategies were developed to deliver the KT casebook content that addressed these identified barriers, which included an education workshop, simulations, printed materials, and a huddle and email strategy. Participant experiences with the implementation supports were captured through workshop evaluations, pre-post surveys and qualitative interviews. Post-implementation interviews were analysed using descriptive content analysis.

RESULTS

Ten HCPs implemented the KT casebook principles over 6 months. Participants reported that the workshop provided a clear understanding of the KT casebook content. While HCPs appreciated the breadth of the KT casebook, they found the abbreviated printed educational materials more convenient. Strategies developed to address participants' need for a sense of community and opportunities to learn from each other did not achieve their aim. Increased confidence in integrating the KT casebook principles into practice was not demonstrated, due, in part, to having few opportunities to practice. This was partly because of the increase in competing clinical demands at the onset of the COVID-19 pandemic.

CONCLUSIONS

Despite positive feedback on the product itself, changes in the organisational and environmental context limited the success of the implementation plan. Monitoring and adapting implementation processes in response to unanticipated changes is critical to the success of implementation efforts.

Weight Bias Among Certified Nurse-Midwives and Certified Midwives: Findings From a National Sample

INTRODUCTION

Weight bias toward individuals with higher body weights permeates health care settings in the United States and has been associated with poor weight-related communication and quality of care as well as adverse health outcomes. However, there has been limited quantitative investigation into weight bias among perinatal care providers. Certified nurse-midwives (CNMs)/certified midwives (CMs) attend approximately 11% of all births in the United States. The aims of this study were to measure the direction and extent of weight bias among CNMs/CMs and compare their levels of weight bias to the US public and other health professionals.

METHODS

Through direct postcard distribution, social media accounts, professional networks, and email listservs, American Midwifery Certification Board (AMCB)-certified midwives were solicited to complete an online survey of their implicit weight bias using the Implicit Association Test and their explicit weight bias using the Antifat Attitudes Questionnaire, Fat Phobia Scale, and Preference for Thin People measure.

RESULTS

A total of 2257 midwives participated in the survey, yielding a completion rate of 17.7%. Participants were mostly White and female, with a median age of 46 years and 11 years since AMCB certification. More than 70% of midwives have some level of implicit weight bias, although to a lesser extent compared with previously published findings among the US public (P < .01) and other health professionals (P < .01). In a subsample comparison of female midwives to female physicians, implicit weight bias levels were similar (P > .05). Midwives also express explicit weight bias, but at lower levels than the US public and other health professionals (P < .05).

DISCUSSION

This study provides the first quantitative research documenting weight bias among a national US sample of perinatal care providers. Findings can inform educational efforts to mitigate weight bias in the perinatal care setting and decrease harm.

Drivers and facilitators of weight stigma among preconception, pregnant, and postpartum women: A systematic review

Women in the preconception, pregnant, or postpartum period are susceptible to weight stigma, particularly due to the risk of excess weight gain during the reproductive life period and the negative effects of stigma on the health of both the mother and the child. Identifying the drivers and facilitators of weight stigma will help guide focused weight stigma prevention interventions. This systematic review aimed to identify the drivers and facilitators of weight stigma among preconception, pregnant, and postpartum women. In May 2022, Medline, Embase, PsycINFO, and the Maternity and Infant Care Database were searched for peer-reviewed articles published since 2010 using search terms weight AND stigma AND preconception, OR pregnant, OR postpartum. Of the 1724 articles identified, 34 fulfilled the inclusion criteria and were included in a narrative synthesis. Women reported facing insensitive language, misconceptions about obesity across all settings, and inappropriate media representation. The unavailability of appropriate equipment at facilities was reported by both women and health professionals. Our findings indicate that a rigorous effort by all stakeholders is necessary to promote regulatory, legal, and educational initiatives designed to reduce weight stigma and discrimination against women in the reproductive period.

Implicit and Explicit Weight Bias among Midwives: Variations Across Demographic Characteristics

INTRODUCTION

Weight bias toward individuals with higher body weights is present in health care settings. However, there has been limited quantitative exploration into weight bias among perinatal care providers and its potential variations based on demographic characteristics. The aim of this study was to examine if the direction and extent of weight bias among midwives certified by the American Midwifery Certification Board (AMCB) varied across age, years since certification, body mass index (BMI), race, ethnicity, and US geographic region.

METHODS

Through direct email listservs, postcard distribution, social media accounts, and professional networks, midwives were invited to complete an online survey of their implicit weight bias (using the Implicit Association Test) and their explicit weight bias using the Anti-Fat Attitudes Questionnaire (AFA), Fat Phobia Scale (FPS), and Preference for Thin People (PTP) measure.

RESULTS

A total of 2106 midwives who identified as Black or White and resided in one of 4 US geographic regions participated in the survey. Midwives with a lower BMI expressed higher levels of implicit (P <.01) and explicit (P ≤.01) weight bias across all 4 measures except for the AFA Fear of Fat Subscale. Implicit weight bias levels also varied by age (P <.001) and years since certification (P <.001), with lower levels among younger midwives (vs older) and those with fewer years (vs more) since certification. Only age and BMI remained significant (P <.001) after adjusting for other demographic characteristics. Lower explicit weight bias levels were found among midwives who identified as Black (vs White) on 2 measures (FPS: adjusted β = -0.07, P = .004; PTP: P = .01).

DISCUSSION

This was the first quantitative study of how weight bias varies across demographic characteristics among a national sample of midwives. Further exploration is needed in more diverse samples. In addition, research to determine whether weight bias influences clinical decision-making and quality of care is warranted.

Obesity bias: How can this underestimated problem affect medical decisions in healthcare? A systematic review

INTRODUCTION

Obesity is often labeled as a physical characteristic of a patient rather than a disease and it is subject to obesity bias by health providers, which harms the equality of healthcare in this population.

OBJECTIVE

Identifying whether obesity bias interferes in clinical decision-making in the treatment of patients with obesity.

METHODS

A systematic review of observational studies published between 1993 and 2023 in MEDLINE, Embase, and Cochrane Library on obesity bias and therapeutic decisions was carried out. The last search was conducted on June 30, 2023. The main outcome was the difference between clinical decisions in the treatment of individuals with and without obesity. The Newcastle-Ottawa scale for observational studies was used to assess for quality. After the selection process, articles were presented in narrative and thematic synthesis categories to better organize the descriptive analysis.

RESULTS

Of the 2546 records identified, 13 were included. The findings showed fewer screening exams for cancer in patients with obesity, who were also susceptible to less frequent pharmacological treatment intensification in the management of diabetes. Women with obesity received fewer pelvic exams and evidence of diminished visual contact and physician confidence in treatment adherence was reported. Some studies found no disparities in treatment for abdominal pain and tension headaches between patients presented with and without obesity.

CONCLUSION

The presence of obesity bias has negative effects on medical decision-making and on the quality of care provided to patients with obesity. These findings reveal the urgent necessity for reflection and development of strategies to mitigate its adverse impacts. (The protocol was registered with the international prospective register of systematic reviews, PROSPERO, under the number CRD42022307567).

Is Obesity a Cause for Shame? Weight Bias and Stigma among Physicians, Dietitians, and Other Healthcare Professionals in Poland-A Cross-Sectional Study

Weight bias and weight stigma pose significant challenges in healthcare, particularly affecting obesity management practices and patient care quality. Our study evaluates their prevalence and impact among healthcare professionals in Poland. Using the Fat Phobia Scale and custom questions, we surveyed 686 professionals via Computer-Assisted Web Interview (CAWI). Results reveal a moderate level of explicit weight bias (mean score: 3.60 ± 0.57), with significant variations across professional groups: physicians (3.70 ± 0.48), dietitians (3.51 ± 0.48), and others (3.44 ± 0.77). Common feelings towards individuals with obesity include willingness to help (57.0%) and compassion (37.8%), yet 29.9% perceive obesity as shameful. The results also vary depending on the respondent's sex or BMI. These findings underscore the need for evidence-based interventions to mitigate weight stigma and enhance understanding of obesity among healthcare professionals.

Mitigating Weight Bias in the Clinical Setting: A New Approach to Care

Weight bias toward patients in larger bodies is pervasive among health care providers and can negatively influence provider-patient communication, as well as patients' behavior and health outcomes. Weight bias has historical roots that perpetuate thinness and Whiteness as the cultural norm. Although weight bias remains socially acceptable in US culture, contributing factors to an individual's body size are complex and multifactorial. Providers and health care systems also consistently use body mass index (BMI) as an indicator of health status, despite its limitations and harmful effects in the clinical setting. This state of the science review presents 8 evidence-based strategies that demonstrate how to mitigate harm from weight bias and improve quality of care and health outcomes for patients living in larger bodies. Person-centered approaches to care include (1) eliminating clinical recommendations to lose weight; (2) shifting from a focus on weight to health; (3) implementing a size and weight-inclusive approach; (4) engaging in weight bias self-evaluation; (5) creating a welcoming environment for patients of all sizes; (6) seeking permission and learning the patient's story; (7) using weight-inclusive language; and (8) re-evaluating clinical guidelines and policies based on BMI. Midwives and other health care providers may benefit from training that re-imagines the delivery of health care to patients in larger bodies.

"I don´t put people into boxes, but…" A free-listing exercise exploring social categorisation of asylum seekers by professionals in two German reception centres

Newly arriving asylum seekers in Germany mostly live in large reception centres, depending on professionals in most aspects of their daily lives. The legal basis for the provision of goods and services allows for discretionary decisions. Given the potential impact of social categorisation on professionals' decisions, and ultimately access to health and social services, we explore the categories used by professionals. We ask of what nature these categorisations are, and weather they align with the public discourse on forced migration. Within an ethnographic study in outpatient clinics of two refugee accommodation centres in Germany, we conducted a modified free-listing with 40 professionals (physicians, nurses, security-personnel, social workers, translators) to explore their categorisation of asylum seekers. Data were qualitatively analysed, and categories were quantitatively mapped using Excel and the Macro "Flame" to show frequencies, ranks, and salience. The four most relevant social categorisations of asylum seekers referred to "demanding and expectant," "polite and friendly" behaviour, "economic refugees," and "integration efforts". In general, sociodemographic variables like gender, age, family status, including countries and regions of origin, were the most significant basis for categorisations (31%), those were often presented combined with other categories. Observations of behaviour and attitudes also influenced categorisations (24%). Professional considerations, e.g., on health, education, adaption or status ranked third (20%). Social categorisation was influenced by public discourses, with evaluations of flight motives, prospects of staying in Germany, and integration potential being thematised in 12% of the categorisations. Professionals therefore might be in danger of being instrumentalised for internal border work. Identifying social categories is important since they structure perception, along their lines deservingness is negotiated, so they potentially influence interaction and decision-making, can trigger empathy and support as well as rejection and discrimination. Larger studies should investigate this further. Free-listing provides a suitable tool for such investigations.

Can equity in care be achieved for stigmatized patients? Discourses of ideological dilemmas in perioperative care

BACKGROUND

In the perioperative care of individuals with obesity, it is imperative to consider the presence of risk factors that may predispose them to complications. Providing optimal care in such cases proves to be a multifaceted challenge, significantly distinct from the care required for non-obese patients. However, patients with morbidities regarded as self-inflicted, such as obesity, described feelings of being judged and discriminated in healthcare. At the same time, healthcare personnel express difficulties in acting in an appropriate and non-insulting way. In this study, the aim was to analyse how registered nurse anaesthetists positioned themselves regarding obese patients in perioperative care.

METHODS

We used discursive psychology to analyse how registered nurse anaesthetists positioned themselves toward obese patients in perioperative care, while striving to provide equitable care. The empirical material was drawn from interviews with 15 registered nurse anaesthetists working in a hospital in northern Sweden.

RESULTS

Obese patients were described as "untypical", and more "resource-demanding" than for the "normal" patient in perioperative care. This created conflicting feelings, and generated frustration directed toward the patients when the care demanded extra work that had not been accounted for in the schedules created by the organization and managers.

CONCLUSIONS

Although the intention of these registered nurse anaesthetists was to offer all patients equitable care, the organization did not always provide the necessary resources. This contributed to the registered nurse anaesthetists either consciously or unconsciously blaming patients who deviated from the "norm".

Feasibility of Telehealth and Innovative Technologies to Limit Excessive Gestational Weight Gain

OBJECTIVE

To test the feasibility of using telehealth to deliver nutritional counseling by tracking gestational weight gain remotely using Bluetooth weight scales.

DESIGN

Quasi-experimental feasibility study.

SETTING

One-on-one nutritional counseling was conducted remotely via a telehealth platform using a registered dietitian.

PARTICIPANTS

Twenty-nine pregnant individuals ages 18 years or older, between 12 and 27 weeks' gestation, with a prepregnancy body mass index of ≥30 kg/m2, singleton fetus, and English proficiency were recruited for the study. Among the 29 potential participants, 20 completed the initial survey and met the criteria; 11 completed the study.

METHODS

This study tested the feasibility of using telehealth to deliver nutritional counseling for 30 minutes, once a week, for 6 weeks. Self-weighing was tracked through a preconfigured Bluetooth scale given to study participants that enabled weight data to be automatically uploaded each time the scale was used.

RESULTS

Among the 11 study participants receiving Bluetooth scales, adherence to self-weighing was high (81%). All five participants randomized to nutritional counseling found that telehealth visits with a registered dietitian were easy to use and helpful. Although participants who received nutritional counseling gained 2.5 lb less than those who did not receive nutritional counseling (p = .523), there was no significant difference between the intervention group and historical control individuals (p = .716).

CONCLUSION

Incorporating telehealth for nutrition counseling and accurate remote weight data collection may be part of a comprehensive strategy to address gestational weight gain in high-risk pregnant populations. Further research with larger samples is needed.

Patient perspectives of weight stigma across the cancer continuum: A scoping review

BACKGROUND

Weight stigma has been defined as the social devaluation and denigration of individuals because of their weight. The purpose of this scoping systematic review was to assess and understand patient experiences with weight stigma in the cancer care setting.

METHODS

We conducted a systematic scoping review of studies examining shame, prejudice, bias, and stigma in relation to weight and cancer-related care using five databases: PubMed, CINAHL Plus Full Text (ProQuest), Cochrane Library, PsycINFO (EBSCO), and Scopus. Articles were uploaded into Covidence for de-duplication and screening. Included studies were peer reviewed, reported adult patient experiences in cancer-related care, and were published in English between October 2012 and February 2023. Study characteristics and key findings were abstracted and qualitatively synthesized.

RESULTS

Publications meeting inclusion criteria yielded five studies (n = 113 participants). Most focused on the experiences of women (n = 4) and cancers which predominantly impact women (i.e., breast, cervical, endometrial; n = 4). All stages of the cancer continuum were included with studies examining screening (n = 2), treatment (n = 1), and post-treatment survivorship (n = 2). Weight discrimination was discussed in four studies and weight-biased stereotypes were discussed in three studies. Experiences of weight bias internalization were reported in four studies. One study described an instance of implicit weight bias.

CONCLUSIONS

Limited studies examine patient experiences of weight stigma in cancer care; however, current evidence suggests that patients do experience weight stigma in cancer-related care. This review highlights critical gaps and a need for more research on the prevalence and impact of weight stigma in cancer screening and care.

Raising awareness of anti-fat stigma in healthcare through lived experience education: a continuing professional development pilot study

BACKGROUND

Anti-fat attitudes and weight-based discrimination are prevalent in healthcare settings and among healthcare practitioners and clinical trainees, and can result in immense harm to patients. There is increasing recognition that anti-fat bias in healthcare is a critical issue that must be addressed, but there is a dearth of evidence demonstrating sustained attitude and behavioural change among clinicians, illustrating a need for more innovative educational approaches and rigorous evaluation. We describe the co-design and delivery of a narrative-based continuing professional development curriculum aimed at raising awareness of weight-based bias and stigma.

METHODS

Our research team of lived experience educators, clinicians and researchers collaboratively developed a series of seven podcast episodes comprised of narrative descriptions of lived experiences with and impacts of weight bias, stigma and discrimination in healthcare settings, as well as a post-podcast workshop to facilitate reflection and discussion between participants. The curriculum was piloted among 20 clinicians practicing at a large urban hospital in Mississauga, Canada. We explored feasibility, acceptability and learning impact by analyzing responses to questionnaires completed following each podcast episode and responses shared during the workshops and follow-up feedback sessions.

RESULTS

We observed high acceptability and feasibility of the curriculum. Participants experienced the podcast as a practical and convenient learning format and the workshop as a valuable opportunity to collectively debrief and reflect. The learning impact of the curriculum was strong; participants described a range of emotions elicited by the podcasts, engaged in self-reflection, and expressed a desire to modify clinical approaches. Barriers to the application of learnings identified by participants include pervasiveness of the use of body mass index (BMI) as an indicator of risk and a criterion for referral; discomfort with difficult conversations; prevalent biomedical understandings about the association between weight and health; and clinicians' defensiveness.

CONCLUSION

This pilot study yielded promising findings and demonstrated potential impact on weight bias and stigma among healthcare providers. Necessary next steps include conducting larger scale, rigorous evaluations of the curriculum among broader populations, both health professions trainees and current healthcare providers.

Normalisation and equity of referral to the NHS Low Calorie Diet programme pilot; a qualitative evaluation of the experiences of health care staff

BACKGROUND

Health and wellbeing can be profoundly impacted by both obesity and type 2 diabetes, while the normalisation and equity of care for people living with these non-communicable diseases remain as challenges for local health systems. The National Health Service Low Calorie Diet programme in England, aims to support people to achieve type 2 diabetes remission, while also reducing health inequalities. We have explored the experiences of health care staff who have made a referral to the LCD programme, while identifying effective and equitable delivery of programme referrals, and their normalisation into routine care.

METHODS

Nineteen individual semi-structured interviews were completed health care staff in the first year of the Low Calorie Diet programme. Interviewees were purposively sampled from the ten localities who undertook the Low Calorie Diet programme pilot. Each interview explored a number of topics of interest including communication and training, referrals, equity, and demands on primary care, before being subjected to a thematic analysis.

RESULTS

From the data, five core themes were identified: Covid-19 and the demands on primary care, the expertise and knowledge of referrers, patient identification and the referral process, barriers to referrals and who gets referred to the NHS LCD programme. Our findings demonstrate the variation in the real world settings of a national diabetes programme. It highlights the challenge of COVID-19 for health care staff, whereby the increased workload of referrals occurred at a time when capacity was curtailed. We have also identified several barriers to referral and have shown that referrals had not yet been normalised into routine care at the point of data collection. We also raise issues of equity in the referral process, as not all eligible people are informed about the programme.

CONCLUSIONS

Referral generation had not yet been consistently normalised into routine care, yet our findings suggest that the LCD programme runs the risk of normalising an inequitable referral process. Inequalities remain a significant challenge, and the adoption of an equitable referral process, normalised at a service delivery level, has the capacity to contribute to the improvement of health inequalities.

Is It Time to Say Goodbye to BMI? A Commentary

The linkage between weight and health is complicated and our current body of evidence is inconsistent. We cannot have a discussion about weight without understanding the larger context of our antifat society and the influence of the diet industrial complex. Weight bias and a focus on weight in health care produce known harms. Additionally, clinicians often recommend losing weight without a nuanced discussion of the evidence showing that most people are unlikely to be successful with sustained weight loss. In this piece, I argue that using our precious time with patients and health care dollars to focus on health behaviors with indisputable evidence such as increasing physical activity and promoting smoking cessation is a more effective use of resources and more closely aligns with our ethical obligation to "do no harm."

A multifaceted training tool to reduce weight bias among healthcare students: A randomized controlled trial

BACKGROUND

Weight bias toward people with obesity (PwO) is common in healthcare settings. Efforts to address weight bias in healthcare settings should begin during university studies. This study aimed to explore the effect of a multifaceted intervention on weight bias among undergraduate healthcare students.

METHODS

An open label randomized controlled trial. The intervention tool consisted of short video lectures on obesity, vignettes simulating interactions between health professionals and PwO, and open discourse with a PwO. The control group received a short-written document on obesity. Online questionnaires on Anti-Fat Attitudes ('AFA'), short form of the Fat-Phobia Scale ('FPS'), Weight Implicit Association Test ('Weight-IAT'), and knowledge about obesity were administered at baseline, 1-week, and 6-week post-intervention.

RESULTS

A total of 162, 152, and 146 students participated in the study at baseline, 1-week, and 6-week post-intervention, respectively. Their mean age was 25.8 ± 6.7 years and 88.3% were women. Means of AFA total scores and FPS scores decreased significantly over time only within the intervention group (P Time*Group = 0.002 and 0.014). Both groups showed a similar trend over time in mean scores of Weight-IAT (P Time*Group = 0.868) and knowledge about obesity (P Time*Group = 0.115).

CONCLUSIONS

A multifaceted intervention resulted in a significant reduction in explicit weight bias but did not yield any additional advantages over the control group in implicit weight bias and knowledge about obesity.

CLINICALTRIALS

GOV NUMBER

NCT05482802.

Obesity bias in diagnostic radiography students: A survey of attitudes, perceptions and technical confidence

INTRODUCTION

Obesity bias exists in healthcare professionals and students from numerous disciplines and negatively impacts the quality of care, outcomes, engagement, and satisfaction of their patients. With obesity rates continuing to rise in the United Kingdom (UK), more patients will be affected than ever, and it is becoming an increasingly important issue to tackle. This study aims to assess the attitudes to obesity of student diagnostic radiographers and determine if obesity bias exists in this population.

METHOD

Student radiographers (n = 140) at a single university in the UK were invited to complete an online survey comprising measures designed to assess levels of bias and attitudes towards obesity, including the Attitude Towards Obese Persons (ATOP) scale. Likert-type scales were used to collect quantitative data, and data analysis included descriptive statistics, frequencies, and Spearman's rank correlation coefficient.

RESULTS

Responses were received from n = 38 students. The mean ATOP score for participants was 70.37 (SD = 19.26). With 26 % (n = 10) scoring below 60, demonstrating strong negative attitudes towards obese individuals. Additionally, students (76.3 %; n = 29) indicated that they observed high levels of obesity bias whilst on clinical placement. There was a statistically significant correlation between levels of weight bias and students' confidence in working with obese patients (r(36) = 0.4, p 0.01). Students who are less confident working with obese patients had higher levels of obesity bias.

CONCLUSIONS

Obesity bias exists in radiography students at levels comparable to those that have been found previously in other healthcare professionals and students. Furthermore, radiography students lacked confidence in their technical ability to work with obese patients and lower confidence levels were associated with higher levels of obesity bias.

IMPLICATIONS FOR PRACTICE

The findings of this study provide preliminary knowledge upon which future research can be built.

A scoping review of obesity education interventions for current and prospective medical professionals in Canada

Background

Obesity is a prevalent chronic disease in Canada. Individuals living with obesity frequently interact with medical professionals who must be prepared to provide evidence-based and person-centred care options. The purpose of this scoping review was to summarize existing educational interventions on obesity in Canada for current and prospective medical professionals and to identify key future directions for practice and research.

Methods

A scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. The search strategy was conducted using Medline (via PubMed), Embase, Eric, CBCA, Proquest Education, and Proquest Theses. The inclusion criteria included delivery of an educational intervention on obesity for current medical professionals, medical undergraduate trainees, or residents administered in Canada. Data were extracted from the included studies to thematically summarize the intervention content, and main outcomes assessed. Future directions for research and practice were identified.

Results

Eight studies met the inclusion criteria. The interventions ranged in terms of the mode of delivery, including interactive in-person workshops and seminars, online learning modules, webinars, and videos. The main outcomes assessed were attitudes towards patients living with obesity, self-efficacy for having sensitive obesity-related discussions, skills to assess obesity and provision of management options. All studies reported improvements in the outcomes. Future directions identified were the need to develop standardized obesity competencies for inclusion across medical education programs, further research on effective pedagogical approaches to integrating content into existing curricula and the need for broader awareness and assessment of the quality of obesity education resources.

Conclusion

Although there have been few obesity-specific educational interventions for current and prospective medical professionals in Canada, existing evidence shows positive learning outcomes. These findings advocate for continued investment in the development of obesity medical training and educational interventions.

Knowledge, experiences, and perceptions relating to obesity management among primary care physicians in the Lazio Region, Italy

Background

Primary care providers (PCPs) play an essential role in obesity care as they represent the first contact for patients seeking weight loss interventions.

Objective

This study explored the knowledge, experiences, and perceptions of PCPs in the Lazio Region of Italy in the management of obesity.

Design and subjects

We conducted an anonymous survey delivered from March to July 2022 via the newsletter of Rome Provincial Order of Physicians and Dentists and at the annual meeting of the regional section of the Italian Obesity Society.

Approach

The survey consisted of 24 closed-ended questions grouped into 5 sections: sociodemographic and work information; assessment of obesity; management of obesity; connections with regional Centres for Obesity Management; attitudes towards obesity.

Key results

A total of 92 PCPs accessed the survey. Of those, 2.2% were excluded because they did not see any patients with obesity. A total of 68 PCPs (75.6%) had complete questionnaires and were included in this analysis. All participants reported asking their patients about their eating habits, lifestyle, and clinical complications at the first assessment. Body weight and blood pressure were measured by 98.5% of participants and 82% calculate body mass index (BMI), while a small proportion of PCPs analysed body composition and fat distribution. Over 80% prescribed laboratory tests and ECG. Approximately 40% of PCPs did not refer patients for nutritional counselling, and most prescribed a low-calorie diet. Sixty-three percent referred patients to an endocrinologist, 48.5% to a psychotherapist, and a minority to specialists for obesity complications. Twenty-three percent prescribed anti-obesity medications and 46.5% referred patients for bariatric surgery only in severe cases. Ninety-one percent stated that obesity is "a complex and multifactorial disease" and 7.4% considered obesity to be secondary to other conditions.

Conclusions

Despite most PCPs adopt a correct approach to manage patients with obesity, many aspects could be improved to ensure optimal and multidisciplinary management.

Validation of the Universal Measure of Bias-Fat (UMB Fat) among Malaysian health practitioners using Rasch analysis

OBJECTIVE

This study aimed to evaluate the structural validity of the Universal Measures of Bias - Fat (UMB Fat) among Malaysian healthcare practitioners using Rasch analysis.

METHODS

Data from a cross-sectional survey of 268 public and private doctors and allied health practitioners in Peninsular Malaysia were used for this analysis. Using Rasch analysis, overall model fit and item fit of the summary UMB Fat and domain scores were examined, together with unidimensionality, response threshold ordering, internal consistency, measurement invariance, and item targeting.

RESULTS

Data showed overall misfit to the Rasch model for both the summary UMB Fat score and domain scores. Whilst unidimensionality was observed for the domain scores, this was not evident for the summary score where multiple local dependencies were present. Disordered thresholds were observed for the response format, in which the majority improved with modification. Suboptimal targeting was also detected with an uneven distribution of items at the upper and lower end of the logit scale for the summary and domain scores. Despite this, excellent internal consistency reliability was observed (person separation index: 0.76-0.89), and no measurement invariance was detected.

CONCLUSION

The Rasch model supports reporting of the UMB Fat domain scores but not the summary score. Several issues related to local dependencies and response format were identified that could benefit from refining the UMB Fat to improve measurement accuracy, particularly when used by healthcare practitioners in Asian countries.

The experience of living with obesity for adults in Asian countries: A scoping review of qualitative studies

Sociocultural and biological backgrounds significantly influence people's experience of obesity. Yet the experience within the Asian sociocultural context is underexplored. This scoping review aims to summarize the qualitative evidence that explores the lived experience of adults with obesity in Asian countries. Guided by the Joanna Briggs Institute (JBI) approach, we systematically searched five databases (MEDLINE, EMBASE, PsychINFO, CINAHL, and Scopus) for studies exploring the lived experience of adults with obesity in Asian countries. Eligible studies with English full text were screened by two reviewers and analyzed using a descriptive qualitative content analysis. Of the 16,764 articles retrieved, 11 were included. The qualitative data can be summarized into three categories: (1) cultural norms shaped the lived experience with obesity, (2) the influence of obesity on social relationships, and (3) coping with life challenges. Despite the small number of studies, a strong influence of the sociocultural environment on the lived experience of obesity was evident, particularly on social roles and expectations, social relationships, the stigma of obesity, and life challenges. The extent and significance of this sociocultural influence on the Asian population warrant further exploration. Future research should fully report the qualitative methods to provide contextual information about the study.

Life course effects of genetic susceptibility to higher body size on body fat and lean mass: prospective cohort study

BACKGROUND/OBJECTIVES

Different genetic variants are associated with larger body size in childhood vs adulthood. Whether and when these variants predominantly influence adiposity are unknown. We examined how genetic variants influence total body fat and total lean mass trajectories.

METHODS

Data were from the Avon Longitudinal Study of Parents and Children birth cohort (N = 6926). Sex-specific genetic risk scores (GRS) for childhood and adulthood body size were generated, and dual-energy X-ray absorptiometry scans measured body fat and lean mass six times between the ages of 9 and 25 years. Multilevel linear spline models examined associations of GRS with fat and lean mass trajectories.

RESULTS

In males, the sex-specific childhood and adulthood GRS were associated with similar differences in fat mass from 9 to 18 years; 8.3% [95% confidence interval (CI) 5.1, 11.6] and 7.5% (95% CI 4.3, 10.8) higher fat mass at 18 years per standard deviation (SD) higher childhood and adulthood GRS, respectively. In males, the sex-combined childhood GRS had stronger effects at ages 9 to 15 than the sex-combined adulthood GRS. In females, associations for the sex-specific childhood GRS were almost 2-fold stronger than the adulthood GRS from 9 to 18 years: 10.5% (95% CI 8.5, 12.4) higher fat mass at 9 years per SD higher childhood GRS compared with 5.1% (95% CI 3.2, 6.9) per-SD higher adulthood GRS. In females, the sex-combined GRS had similar effects, with slightly larger effect estimates. Lean mass effect sizes were much smaller.

CONCLUSIONS

Genetic variants for body size are more strongly associated with adiposity than with lean mass. Sex-combined childhood variants are more strongly associated with increased adiposity until early adulthood. This may inform future studies that use genetics to investigate the causes and impact of adiposity at different life stages.

Weight bias reduction intervention among nurse practitioner students using simulation-based experiences

ABSTRACT

Few nurse practitioner (NP) programs include obesity and weight bias education in their curriculum. However, NPs will likely provide care for people living with obesity, many of whom have been discriminated against based on their weight by previous providers, and many NP students may feel unprepared to navigate weight management competently. This pilot study included a weight bias reduction (WBR) intervention, which included a simulation-based experience (SBE) with a standardized participant (SP) and educational activities embedded within the NP curriculum. Nineteen NP students participated in this pilot study, but only seven students had matching data for preintervention to postintervention scores. There were no statistically significant differences in preintervention and postintervention Attitudes Toward Obese Persons (ATOP) or Beliefs About Obese Persons (BAOP) scores. Despite this small sample size and not achieving statistical significance, SBE-SP holds promise to depict realistic patient encounters to improve NPs' attitudes and beliefs toward persons with obesity and to reduce weight bias. Therefore, incorporating SBE-SP may be a feasible component of the NP curriculum.

The relationship between internalized weight stigma and physical and mental health-related quality of life in a large sample of women: a structural equation modeling analysis

PURPOSE

Health-related quality of life (HRQOL) refers to an individual's perception of their physical and mental health status over time. Although emerging evidence has documented a negative association between weight stigma (i.e., negative weight-related attitudes and beliefs towards individuals with overweight or obesity) and mental HRQOL, its influence on physical HRQOL still needs to be fully clarified. This study aims to investigate the impact of internalized weight stigma on mental and physical HRQOL by employing a structural equation modeling (SEM) approach.

METHODS

The Short Form Health Survey 36 (SF-36) and the Weight Bias Internalization Scale (WBIS) were administered to a sample of 4450 women aged 18-71 (M_age = 33.91 years, SD = 9.56) who self-identified in a condition of overweight or obesity (M_BMI = 28.54 kg/m²; SD = 5.86). Confirmatory factor analysis (CFA) was conducted to assess the dimensionality of the scales before testing the proposed structural model.

RESULTS

After establishing the adequacy of the measurement model, SEM results revealed that internalized weight stigma was significantly and negatively associated with both mental (β = - 0.617; p < 0.001) and physical (β = - 0.355, p < 0.001) HRQOL.

CONCLUSION

These findings offer additional support to prior research by confirming the association between weight stigma and mental HRQOL. Moreover, this study contributes to the existing literature by strengthening and extending these associations to the physical HRQOL domain. Although this study is cross-sectional in nature, it benefits from a large sample of women and the use of SEM, which offers advantages over traditional multivariate techniques, e.g., by explicitly accounting for measurement error.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional study.

Weight Stigma and Barriers to Effective Obesity Care

Weight stigma is prevalent with negative consequences for health and well-being. This problem is present in health care; stigmatizing attitudes toward patients with obesity are expressed by medical professionals across diverse specialties and patient care settings. This article summarizes the ways in which weight stigma creates barriers to effective care, including poor patient-provider communication, reduced quality of care, and healthcare avoidance. Priorities for stigma reduction in healthcare are discussed, with a clear need for multifaceted approaches and inclusion of people with obesity whose perspectives can inform strategies to effectively remove bias-related barriers to patient care.

Explicit and implicit weight bias among health care students: a cross-sectional study of 39 Australian universities

Background

Weight bias exhibited by health care students may continue into their future practice, compromising the provision of care that people living with overweight or obesity receive. This highlights the need to comprehensively examine the extent to which weight bias is present among health care students and the factors that may be associated with students' weight bias.

Methods

In this cross-sectional study, Australian university students enrolled in health care courses were invited via social media advertisements, snowball and convenience sampling, and by making direct contact with universities to complete an online survey. Students provided demographic information including discipline of study, perceived weight status, and state of residence. Students then completed several measures which assessed their explicit and implicit weight bias, and empathy. Descriptive statistics established the presence of explicit and implicit weight bias, and ANCOVAs, ANOVA, and multiple regression analyses were conducted to examine the potential factors associated with students' exhibited weight bias.

Findings

Between March 08, 2022, and March 15, 2022, 900 eligible health care students attending 39 Australian universities participated in the study. Students reported varying levels of explicit and implicit weight bias, with minimal differences between disciplines on most outcome measures. Students who identified as men (vs. women) exhibited higher of both explicit and implicit bias (Beliefs About Obese Persons (BAOP): p = 0.0002, Antifat Attitudes Questionnaire (AFA)-Dislike: p = 0.019, AFA Willpower p < 0.0001, Empathy for Obese Patients: p = 0.0011, Implicit Association Test: p = 0.022), and students who displayed greater (vs. less) empathic concern exhibited lower levels of explicit bias (BAOP, AFA Dislike and Willpower, and Empathy for Obese Patients: p < 0.0001). Having witnessed the enactment of weight stigma sporadically (vs. regularly) by role models was associated with greater attribution of the causes of obesity to willpower (a few times a month vs. daily: p = 0.020, a few times a year vs. daily: p = 0.022), and less time spent with people living with overweight or obesity outside of study was associated with more dislike (a few times a month vs. daily: p = 0.0048, once a month vs. daily: p = 0.0002) and less fear of fat (once a month vs. daily: p = 0.036, and once a month vs. a few times a week: p = 0.0028).

Interpretation

Results demonstrate the presence of both explicit and implicit weight bias among Australian health care students. Several characteristics and experiences of students were associated with their weight bias. Validity of the exhibited weight bias should be established in practical interactions with people living with overweight or obesity and novel interventions should be developed to ameliorate weight bias.

Funding

Research Training Program (RTP) Scholarship, Australian Government, Department of Education.

Person-First Treatment Strategies: Weight Bias and Impact on Mental Health of People Living with Obesity

Stigma and bias surrounding body weight is both explicit and implicit, but the most concerning impact on individuals is internalized stigma which is correlated with poor physical and mental health. Strategies to combat this public health concern include increasing awareness, education around the complex disease of obesity, proper use of communication and language surrounding weight, health, and treatment approaches, addressing equipment and practices in the clinical environment, and larger, systemic approaches to policy. Addressing stigma for a condition impacting the majority of our population is critical for the best health and well-being of our patients and ourselves.

Weight bias and stigma in healthcare professionals: a narrative review with a Singapore lens

Addressing weight stigma is essential to obesity management as it causes inequalities in healthcare and impacts the outcomes of health. This narrative review summarises systematic review findings about the presence of weight bias in healthcare professionals, and interventions to reduce weight bias or stigma in these professionals. Two databases (PubMed and Cumulative Index to Nursing and Allied Health Literature [CINAHL]) were searched. Seven eligible reviews were identified from 872 search results. Four reviews identified the presence of weight bias, and three investigated trials to reduce weight bias or stigma in healthcare professionals. The findings may help further research and the treatment, health and well-being of individuals with overweight or obesity in Singapore. Weight bias was prevalent among qualified and student healthcare professionals globally, and there is a lack of clear guidance for effective interventions to reduce it, particularly in Asia. Future research is essential to identify the issues and inform initiatives to reduce weight bias and stigma among healthcare professionals in Singapore.

Medical Nutrition Therapy Interventions Provided by Dietitians for Adult Overweight and Obesity Management: An Academy of Nutrition and Dietetics Evidence-Based Practice Guideline

Overweight and obesity affect most adults living in the United States and are causally linked to several adverse health outcomes. Registered dietitian nutritionists or international equivalents (dietitians) collaborate with each client and other health care professionals to meet client-centered goals, informed by the best available evidence, and translated through a lens of clinical expertise and client circumstances and preferences. Since the last iteration of the Academy of Nutrition and Dietetics guideline on adult weight management in 2014, considerable research has been conducted and circumstances confronting dietitians have evolved. Thus, updated guidance is needed. The objective of this evidence-based practice guideline is to provide recommendations for dietitians who deliver medical nutrition therapy behavioral interventions for adults (18 years and older) with overweight and obesity to improve cardiometabolic outcomes, quality of life, and weight outcomes, when appropriate for and desired by the client. Recommendations in this guideline highlight the importance of considering complex contributors to overweight and obesity and individualizing interventions to client-centered goals based on specific needs and preferences and shared decision making. The described recommendations have the potential to increase access to care and decrease costs through utilization of telehealth and group counseling as effective delivery methods, and to address other barriers to overweight and obesity management interventions. It is essential for dietitians to collaborate with clients and interprofessional health care teams to provide high-quality medical nutrition therapy interventions using the nutrition care process to promote attainment of client-centered outcomes for adults with overweight or obesity.

Effect of health-care professionals' weight status on patient satisfaction and recalled advice: a prospective cohort study

BACKGROUND

Research has demonstrated that healthcare professionals are not immune to weight stigma attitudes, with evidence showing that people living with overweight or obesity may experience direct and indirect stigma and discrimination. This can impact the quality of care provided and impact patients' engagement in healthcare. Despite this, there is a paucity of research examining patient attitudes towards healthcare professionals living with overweight or obesity, which can also hold implications for the patient-practitioner relationship. Thus, this study examined whether healthcare professionals' weight status impacts patient satisfaction and recalled advice.

METHODS

In this prospective cohort study, using an experimental design, 237 participants (113 women, 125 men) aged 32 ± 8.92 with a body mass index of 25.87 ± 6.79 kg m² were recruited through a participant pooling service (ProlificTM), word of mouth, and social media. The majority of participants were from the UK: 119, followed by participants from the USA: 65, Czechia: 16, Canada: 11, and other countries (N = 26). Participants completed an online experiment consisting of questionnaires assessing satisfaction with healthcare professionals and recalled advice after exposure to one of eight conditions assessing the impact of healthcare professional weight status (lower weight or obesity), gender (woman or man) and profession (psychologist or dietitian). A novel approach to creating the stimuli was used to exposure participants to healthcare professionals of different weight status. All of the participants responded to the experiment hosted on Qualtrics™ in the period from June 8, 2016 to July 5, 2017. Study hypotheses were examined using linear regression with dummy variables and follow up post-hoc analysis to estimate marginal means with adjustment for planned comparisons.

FINDINGS

The only statistically significant result was a difference with a small effect in patient satisfaction, where satisfaction was significantly higher in healthcare professional who was a women living with obesity compared to healthcare professional who was a man living with obesity (estimate = -0.30; SE = 0.08; df = 229; ωₚ² = 0.05; CI = -0.49 to -0.11; p < 0.001), and healthcare professional who was a women living with lower weight compared to healthcare professional who was a man living with lower weight (estimate = -0.21; SE = 0.08; df = 229; CI = -0.39 to -0.02; ωₚ² = 0.02; p = 0.02). There were no statistically significant differences in satisfaction of healthcare professionals and recall of advice in the lower weight compared to obesity conditions.

INTERPRETATION

This study has used novel experimental stimuli to examine weight stigma towards healthcare professionals which is vastly under-researched and holds implications for the patient-practitioner relationship. Our findings showed statistically significant differences and a small effect where satisfaction with healthcare professionals both living with obesity and with a lower weight were higher when the healthcare professional was a woman compared to man. This research should act as a stimulus for further research that aims to examine the impact of healthcare professional gender on patient responses, satisfaction and engagement, and weight stigma from patients towards healthcare professionals.

FUNDING

Sheffield Hallam University.

How do looking patterns, anti-fat bias, and causal weight attributions relate to adults' judgements of child weight?

Prevailing weight-normative approaches to health pressure adults to visually categorise children's weight, despite little understanding of how such judgements are made. There is no evidence this strategy improves child health, and it may harm children with higher weights. To understand decision-making processes and identify potential mechanisms of harm we examined perceptual and attitudinal factors involved in adults' child weight category judgements. Eye movements of 42 adults were tracked while categorizing the weight of 40 computer-generated images of children (aged 4-5 & 10-11 years) varying in size. Questionnaires assessed child-focused weight bias and causal attributions for child weight. Participants' eye movement patterns resembled those previously reported for adult bodies. Categorisation data showed a perceptual bias towards the 'mid-range' category. For higher weight stimuli, participants whose category judgements most closely matched the stimulus's objective weight had higher child-focused anti-fat bias and weaker genetic attributions for child weight - i.e,. adults who 'label' higher weight in children in line with BMI categories report more stigmatising beliefs about such children, suggesting a possible mechanism of harm. Overall, adults' judgements reflect both unalterable perceptual biases and potentially harmful attitudinal factors, calling into question the feasibility and appropriateness of public health efforts to promote visual child weight categorisation.

Incorporating handgrip strength examination into dietetic practice: A quality improvement project

Protein-energy malnutrition is both prevalent and costly within the inpatient rehabilitation population. Registered dietitians play a key role in identifying, diagnosing, and treating protein-energy malnutrition. Handgrip strength has been shown to correlate with clinical outcomes, including malnutrition. Reduced handgrip strength is included as a criterion in national and international consensus guidelines of malnutrition diagnoses for functional changes. However, limited research and quality improvement projects have reported on its actual use in the clinical setting. The purpose of this quality improvement project was to (1) implement handgrip strength testing into dietitian care on three inpatient rehabilitation units to allow dietitians to identify and treat nutrition-related muscle function losses and (2) evaluate the feasibility, clinical utility, and clinical impact of this project. This quality improvement educational intervention demonstrated that handgrip strength is feasible, does not impact dietitian efficiency, and is clinically useful. Dietitians reported three areas in which handgrip strength provided value: assessing nutrition status, motivating patients, and monitoring responses to nutrition interventions. Specifically, they were able to shift away from focusing solely on change in weight to focusing on functional ability and strength. Although outcome measures demonstrated favorable outcomes, the results must be interpreted cautiously because of the small sample and pre-post uncontrolled design. Further high-quality research is required to provide more in-depth information on the utility and limitations of handgrip strength as an assessment, motivational, and monitoring tool for clinical dietetics.

Younger Women with Lipedema, Their Experiences with Healthcare Providers, and the Importance of Social Support and Belonging: A Qualitative Study

Lipedema is a chronic adipose tissue disorder affecting approximately 11% of women worldwide. The illness is often misdiagnosed as obesity, and because of this, women often struggle in meetings with healthcare providers. Few studies have assessed these encounters of younger women with lipedema. The aims of this qualitative study were to explore women's experiences in meetings with healthcare providers and the importance of social support and belonging, with a focus on younger women. Fifteen women with lipedema between the ages of 21 and 47 years (mean age 36.2 years) were interviewed. The results indicated that women felt stigmatized by healthcare providers and that younger women in their 20s and early 30s struggled more often than women of higher age when receiving their diagnosis. The feeling of shame and stigma were also dependent on the woman's resources in handling the illness. The younger women reported that their self-confidence and romantic relationships were challenging. Social support and the feeling of belonging through romantic relationships or support groups were important resources for managing the illness. Highlighting the experiences of women may aid in increasing recognition and knowledge of lipedema. This in turn may reduce the stigma and lead to equitable healthcare services.

Midwives' survey of their weight management practice before and after the GLOWING guideline implementation intervention: A pilot cluster randomised controlled trial

BACKGROUND

Maternal weight management is a priority due to pregnancy risks for women and babies. Interventions significantly improve maternal diet, physical activity, weight, and pregnancy outcomes. There are complex barriers to midwives' implementation of guidelines; low self-efficacy is a core implementation barrier. The GLOWING intervention uses social cognitive theory (SCT) to address evidence-based barriers to practice. The intervention aimed to support midwives' implementation of guidelines.

METHODS

An external rehearsal pilot cluster randomised controlled trial in four NHS Trusts (clusters) in England, UK. Clusters were randomised to intervention (where all eligible midwives received the intervention) or control (no intervention delivered) arms. A random sample of 100 midwives were invited to complete questionnaires pre- and post-intervention. UK guideline recommendations relating to midwives' practice were categorised into: 1) communication-related behaviours (including weight- and risk-communication), and 2) support/intervention-related behaviours (including diet/nutrition, physical activity, weight management, referrals/signposting). Questionnaires were developed using SCT constructs (self-efficacy, outcome expectancies, intentions, behaviours) and 7-point Likert scale, converted to a 0-100 scale. Higher scores were more positive. Descriptive statistics compared intervention and control arms, pre- and post-intervention.

RESULTS

Seventy-four midwives consented and 68 returned questionnaires. Pre-intervention, self-efficacy for support/intervention-related behaviours scored lowest. In controls, there was limited difference between the pre- and post-intervention scores. Post-intervention, mean (SD) scores were consistently higher among intervention midwives than controls, particularly for support/intervention self-efficacy (71.4 (17.1) vs. 58.4 (20.1)). Mean (SD) self-efficacy was higher post-intervention than pre-intervention for all outcomes among intervention midwives, and consistently higher than controls. Mean differences pre- and post-intervention were greatest for support/intervention self-efficacy (17.92, 95% CI 7.78-28.07) and intentions (12.68, 95% CI 2.76-22.59). Self-efficacy was particularly increased for diet/nutrition and physical activity (MD 24.77, 95% CI 14.09-35.44) and weight management (18.88, 95% CI 7.88-29.88) behaviours, which showed the largest increase in scores.

CONCLUSIONS

This study supports the theoretical models used to develop GLOWING, where low self-efficacy was a core implementation barrier. Results suggest that GLOWING successfully targets self-efficacy, potentially with a positive impact on guideline implementation. A definitive trial is required to determine effectiveness.

TRIAL REGISTRATION

ISRCTN46869894, retrospectively registered 25/05/2016, http://isrctn.com/ISRCTN46869894.

Effects of weight bias training on student nurse empathy: A quasiexperimental study

AIM

This study aimed to identify the efficacy of weight bias training on the empathy skills of student nurses when working with a person with obesity.

BACKGROUND

Weight bias with nurses harboring negative attitudes towards patients with obesity results in inferior care and patients' reluctance to seek medical care. Empathy is a communication skill used in nursing to build trust and rapport with patients to provide optimal patient-centered care.

METHODS

This study used a quasi-experimental design with 121 undergraduate nursing students in their first semester of the nursing program. The students completed learning activities on weight bias, including reading an article on weight bias, watching a video showing an individual with obesity's experiences in the healthcare setting and participating in a group discussion and reflection on the article and video. In addition, students completed the Jefferson Scale of Empathy-Health Professions Students' version before and after the learning activities. Following the learning activities, students participated in a simulation activity with a standardized patient wearing an obesity suit. The standardized patient completed the Jefferson Scale of Patient Perceptions of Nurse Empathy to rate the patient's perception of the nursing student's level of empathy based on their interactions in the simulation scenario.

RESULTS

A comparison of the scores on the Jefferson Scale of Empathy-HPS showed there was not a significant difference in the scores before learning activities (M = 15.45, SD = 12.7) and post-learning activities (M = 15.94, SD = 11.5); t(120) = 0.476, p = .635. Data analysis identified significant changes in empathy scores on the Jefferson Scale of Empathy-HPS in the accelerated second-degree cohort with differences in scores before learning activities (M = 113.7, SD = 10.5) and post-learning activities (M = 116.5, SD = 13.4); t(50) = 2.02, p = .049. The traditional cohort did not have a significant change in empathy scores. Empathy scores and the patient's perception of empathy scores showed no relationship. Most (79 %) of the patient's perception of empathy scores was moderate. Student comments in this study support the findings that some nursing students harbor weight bias towards individuals with obesity.

CONCLUSION

There is a need to identify learning activities that eliminate weight bias in the nursing student population and result in the student's ability to demonstrate appropriate communication skills and nursing behaviors in a nondiscriminatory manner to the patient with obesity. To improve empathy behaviors, students should practice communication skills throughout the nursing curriculum.

"Is it time to throw out the weighing scales?" Implicit weight bias among healthcare professionals working in bariatric surgery services and their attitude towards non-weight focused approaches

BACKGROUND

People living with overweight or obesity (PLwO) can be stigmatised by healthcare professionals (HCPs). Reducing focus on weight is a proposed strategy to provide less threatening healthcare experiences. Given the lack of research on weight bias within obesity services, this study aimed to explore implicit bias among obesity specialist HCPs and explore views on non-weight focused approaches.

METHODS

Obesity specialist HCPs were invited to a webinar, "An exploration of non-weight focused approaches within bariatric services", held in October 2021. Implicit weight bias was examined using the BiasProof mobile device test, based on the Implicit Association Test. Poll data was analysed descriptively, and qualitative data was analysed using framework analysis.

FINDINGS

82 of the 113 HCPs who attended the webinar consented to contribute data to the study. Over half (51%) had an implicit weight bias against PLwO. Most (90%) agreed/strongly agreed that obesity services are too weight focused and that patients should not be weighed at every appointment (86%). Perceived benefits of taking a non-weight focused approach included patient-led care, reducing stigma and supporting patient wellbeing, while perceived barriers included loss of objectivity, inducing risk and difficulty demonstrating effectiveness.

INTERPRETATION

Our findings indicate that half of obesity specialists HCPs in our sample of 82 providers, who are primarily dieticians and psychologists, have an implicit weight bias against PLwO. HCPs feel that a weight-focused approach within services was a barrier to patient care, but that there is a lack of alternative non-weight focused measures. Further research is needed into substitute outcome measures for clinical practice, also seeking the views of PLwO, and into interventions to address implicit weight bias.

FUNDING

Johnson & Johnson funded the BiasProof licence and publication open access charge.

"I was bullied for being fat in every situation, in every outfit, at every celebration": A qualitative exploratory study on experiences of weight-based oppression in Qatar

Introduction

Weight-based oppression (WBO) has been documented as a widespread phenomenon in Western countries and is associated with a range of psychological, physiological, and behavioral harms. Research on weight-based oppression is largely absent from the Arab region.

Methods

We conducted a qualitative exploratory study using semi-structured in-depth interviews to examine the internalized attitudes, values, and beliefs related to body weight, and experiences of external weight-based oppression of 29 staff, faculty, and students at Qatar University.

Results

Thematic analysis revealed six major themes on the characteristics of internalized WBO, and the nature, timing, source, extent, and impact of external WBO. WBO was regarded as so common in the Arab culture as to be normative, with damaging exposure to WBO beginning in early childhood.

Conclusion

WBO in the Arab region is an important and unrecognized public health issue. Programs to reduce WBO should be developed in all sectors.

Stages of lipoedema: experiences of physical and mental health and health care

PURPOSE

Lipoedema is a progressive adipose (fat) disorder, and little is known about its psychological effect. This study aimed to determine the experiences of physical and mental health and health care across stages of lipoedema.

METHODS

Cross-sectional, secondary data from an anonymous survey (conducted 2014-2015) in Dutch and English in those with self-reported lipoedema were used (N = 1,362, Mdnage = 41-50 years old, 80.2% diagnosed). χ² analyses of categorical data assessed lipoedema stage groups 'Stage 1-2' (N = 423), 'Stages 3-4' (N = 474) and 'Stage Unknown' (N = 406) experiences of health (physical and psychological), and health care.

RESULTS

Compared to 'Stage 1-2', 'Stage 3-4' reported more loss of mobility (p =  < .001), pain (p =  < .001), fatigue (p = .002), problems at work (p =  < .001) and were seeking treatment to improve physical functioning (p =  < .001) more frequently. 'Stage 3-4' were more likely to report their GP did not have knowledge of lipoedema, did not take them seriously, gave them diet and lifestyle advice, dismissed lipoedema, and treated them 'badly' due to overweight/lipoedema compared to 'Stage 1-2' (p =  < .001). 'Stage 3-4' were more likely to report depression (p =  < .001), emotional lability (p = .033) eating disorders (p = .018) and feeling lonelier, more fearful, and stayed at home more (p =  < .001) and less likely to have visited a psychologist (p =  < .001) compared to 'Stage 1-2'.

CONCLUSIONS

A divergent pattern of physical and psychological experiences between lipoedema stages reflects physical symptom differences and differences in psychological symptoms and health care experiences. These findings increase the understanding of lipoedema symptoms to inform psychological supports for women with lipoedema in navigating chronic health care management.

Who is trying to lose weight? Trends and prevalence in past-year weight loss attempts among US adults 1999-2018 at the intersection of race/ethnicity, gender, and weight status

Common stereotypes of those who desire or attempt to lose weight often center on the experience of White, thin women. However, prior studies have neglected how systems of oppression at intersection of race/ethnicity, gender, and weight status may interact to place certain subpopulations at elevated risk. Repeated cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) 1999-2018 (n = 53,528), a population-representative sample of US adults, were used to 1) assess trends in past-year weight loss attempts using the Kendall-Mann trend test stratifying by race/ethnicity, gender, and weight status, and 2) estimate the adjusted prevalence of weight loss attempts over the combined 20-year period for combinations of race/ethnicity, gender, and weight status using logistic regression. There were significant monotonic trends from 1999 to 2018 for non-Hispanic Black men (43.8% to 67.8%, FDR adjusted p = .022) with an obese BMI, but not for any other groups. After adjusting for covariates, weight loss attempt prevalence was positively associated with BMI category for all race/ethnicity-gender combinations, although the degree of association differed. These findings underscore the need to use an intersectional lens in weight-related research. Despite limited long-term beneficial health impact, certain population subgroups, particularly Black men with an obese BMI, are increasingly trying to lose weight.

Interventions for reducing weight bias in healthcare providers: An interprofessional systematic review and meta-analysis

Weight bias is prevalent in many healthcare disciplines and negatively impacts the quality of care for patients with obesity. This warrants interventions to reduce weight bias shown by providers to improve care for individuals with obesity. However, past reviews have identified only marginal success in improving the attitudes and beliefs of healthcare providers about individuals with obesity. This systematic review and meta-analysis identifies and synthesizes recent peer-reviewed intervention studies aimed at reducing weight bias in healthcare students and professionals. The databases Embase, Cumulative Index to Nursing and Allied Health Literature, PsychINFO, PubMed and Google Scholar were searched for peer-reviewed studies published between 2016 and August 2021. Search terms included a combination of surrogate terms for the concepts of weight bias, intervention and healthcare students or professionals. The search yielded 1136 articles, and 14 articles met the inclusion criteria for the systematic review. Nineteen effect sizes from nine studies were included in the meta-analysis. Overall, the interventions in the included studies result in a 0.38 SD reduction (Hedge's g) in obesity-bias with 95% confidence intervals from -0.52 to -0.24, indicating a small to moderate effect size in the reduction of weight bias. Most studies included students and focused on evoking empathy or educating on the causality/controllability of obesity. Measurement tools, intervention type, limitations of the studies and recommendations for future research are discussed.

White as milk: Biocentric bias in the framing of lactose intolerance and lactase persistence

The majority of the world population is lactose intolerant, as 65%-70% of people lose the enzymes to digest lactose after infancy. Yet, in the United States, where lactose intolerance is predicted to affect only 36% of people, this phenomenon is often framed as a deficiency as opposed to the norm. This is because the United States has a higher prevalence of people who are lactase persistent. Lactase persistence is a genetic trait most common among Europeans and some African, Middle Eastern and southern Asian groups with a history of animal domestication and milk consumption. In this study, we take the case of lactose intolerance to examine how popular media maintains biocentric biases. Analysing relevant articles published in The New York Times and Scientific American between 1971 and 2020, we document how ideas about milk, health and race evolve over time. Over this fifty-year period, writers shifted from framing lactose intolerance as racial difference to lactase persistence as evolutionary genetics. Yet, articles on the osteoporosis 'epidemic' and vitamin D deficiency worked to perpetuate lactose intolerance as a health concern and standardise the dairy-heavy American diet. Studying media portrayals of lactose intolerance and lactase persistence, we argue that popular discourses normalise biocentric biases through messages about eating behaviours and health.

Understanding obesity and addressing stigma: the role of healthcare professionals

The coronavirus disease 2019 (COVID-19) pandemic has further emphasised the importance of recognising obesity as a health issue for adults and children, with associated increases in obesity prevalence and risk of severe illness and death from COVID-19. Obesity is highly visible and highly stigmatised. It is frequently regarded as a result of lifestyle choices and behaviours, with a focus on personal responsibility rather than as a complex, multifactorial disease with a strong genetic component. Healthcare professionals, including nurses, have an important role in supporting behaviour changes, and discussing weight with patients in neutral and respectful ways. This article outlines the effects of the COVID-19 pandemic on weight and weight-related behaviours and discusses the complexity of obesity and weight stigma. It also emphasises the importance of nurses advocating for action to address the obesogenic environment.