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

Incorporating Nondiet and Weight-Neutral Principles in a University Dietetics Curriculum

OBJECTIVE

To evaluate student attitudes toward nondiet, weight-neutral (NDWN) principles after reading Anti-Diet in a medical nutrition therapy (MNT) course.

DESIGN

A quasi-experimental design with no control group and a mixed-methods study approach.

SETTING AND PARTICIPANTS

Adult undergraduate students (n = 112) enrolled in an MNT course.

INTERVENTION

A traditional MNT course and reading Anti-Diet (January-May, 2021), which introduces multiple topics that support weight-inclusive approaches to health.

PHENOMENA OF INTEREST

Change in student agreement with NDWN principles. Written reflections were collected to determine students' rationale for their level of agreement.

ANALYSIS

Likert scale responses (1-5) of student ratings were analyzed with multivariate linear regression, a linear mixed-effect model, and a Wilcoxon signed rank test with continuity correction. Reflections were analyzed using thematic analysis methods. The triangulation methods compared quantitative and qualitative data.

RESULTS

Students ratings shifted significantly away from dieting for weight loss and toward agreement with NDWN principles (99.7) = 7.35, P < 0.001; mean difference = 0.83 with 95% confidence interval, 0.61-1.05. Two main themes emerged: (1) NDWN topics led to critical analysis of weight-centric knowledge, and (2) specific topics were more effective at shifting weight-based attributions.

CONCLUSIONS AND IMPLICATIONS

Incorporating specific NDWN principles in an undergraduate MNT curriculum can shift students' weight-based attributions. More systematic development and testing of anti-fat bias reduction curricula are needed to support broader dissemination and standardization in dietetics curricula.

The association of age of onset of obesity with experienced weight stigma in adulthood

BACKGROUND

Experienced weight stigma (EWS) is linked to adverse physical and mental health outcomes, including maladaptive health behaviors and attenuated weight loss in people with obesity. Limited research is available regarding the association between the age of onset and severity of obesity and lifetime experience of EWS among adults with obesity.

METHODS

Cross-sectional survey data (n = 686) from a single-site academic obesity medicine program was analyzed, including demographics, anthropometric measures, and the Stigmatizing Situations Inventory (SSI-B). The median SSI-B score was used to dichotomize the EWS outcome variable. Crude associations were assessed by chi-square and logistic regression analyses. Multivariable logistic regression determined age-adjusted odds ratios (aOR) of EWS with body mass index (BMI) at age 18 years and peak BMI.

RESULTS

Participants had a mean age of 55.8 years (SD = 12.7), and the majority were female and white. EWS was correlated with BMI at age 18 years (r = 0.38; p = 0.001) and peak BMI (r = 0.48; p = 0.001) before and after adjustment. Those with severe obesity (BMI ≥ 40) by 18 years had 2.79 times higher odds (aOR = 2.79; 95% CI: 1.38, 5.62; p < 0.01) of severe EWS vs. those who developed severe obesity after 18 years; 2.17 higher odds [aOR = 2.17; 95% CI: 1.08, 4.35; p = 0.009] of severe EWS versus those with BMI < 40 at 18 years; 2.98 times higher odds [aOR = 2.98; 95% CI: 1.44, 6.15; p = 0.001] of severe EWS vs. those with BMI < 30 at 18 years; and 4.06 times higher odds [aOR = 4.06; 95% CI: 1.39, 6.73; p = 0.001] of severe EWS vs. those with BMI < 25 at 18 years.

CONCLUSION

Those with severe obesity before the age of 18 years were nearly 3 times more likely to report severe EWS than people who developed severe obesity later in life. Healthcare providers should consider screening for EWS in people with early onset of severe obesity, to identify those who may benefit from weight stigma interventions and support.

Effect of interdisciplinary obesity care on metabolic markers and body weight in people with type 2 diabetes in a rural setting: A randomised controlled trial

Management of type 2 diabetes includes medications that can unintentionally increase obesity and insulin resistance. This unblinded, single-centre, randomised controlled trial focused on rural Australian adults with type 2 diabetes (aged 18-75 and body mass index [BMI] >30 kg/m2), measuring the effectiveness of a tailored interdisciplinary obesity care approach compared with usual diabetes care. Led by a nurse practitioner with allied health support (dietitian ± psychologist and physiotherapist), the bariatric treatment involved reducing weight-gaining medications, a 500-calories/day deficit, an unsupervised exercise program emphasising movement/strength and psychotherapy, 3-monthly to 24-months with support phone calls at weeks 2, 4, 8 and 10. Outcomes from the 224 (113 intervention/111 control) participants were differences in biomedical and physical markers within- and between-groups estimated using multivariate mixed-effects linear regression between recruitment and 6-monthly follow-ups. Greater change occurred in intervention compared with control groups at 12 and 24 months in mean: body weight (-5.9 kg [95% confidence interval, CI: -8.53, -3.23] and -9.0 kg [95% CI: -13.2, -4.77]); BMI (-2.03 kg/m2 [95% CI: -2.92, -1.15] and -3.51 kg/m2 [95% CI: -4.93, -2.08]); and glycated haemoglobin (-0.26% [95% CI: -0.69%, 0.18%] and -0.63% [95% CI: -1.17%, 0.08%]). The control group showed a significant increase in mean leptin level, resulting in a between-group difference (-27.1 [95% CI: -42.7, -11.5]). Lipids and blood pressure differences were inconclusive, while exploratory analysis showed greater decline in estimated glomerular filtration rate in the control group. The interdisciplinary obesity approach, compared with usual diabetes care, resulted in sustained weight loss and improved diabetes control over 2 years. Trial registration number: ACTRN12622000240741.

Tackling the complexity of obesity in the US through adaptation of public health strategies

Obesity prevalence continues to rise in the US despite more than two decades of recommendations and guidelines for its prevention and management. The encouragement of individuals to adopt a healthy diet and lifestyle has remained the focus of clinical interventions and recommendations despite these efforts alone proving ineffective for long-term weight management. There are many recognized barriers to obesity prevention and management in community and clinical settings including political factors, social determinants of health, weight bias and stigma, and inequities in access to treatment and insurance coverage. We discuss these barriers in more detail and attempt to identify areas where public health and healthcare approaches can be better aligned, allowing for better advocating by public health officials to enable a more meaningful and population-level change in obesity prevention and management in the US.

Definition and diagnostic criteria of clinical obesity

Current BMI-based measures of obesity can both underestimate and overestimate adiposity and provide inadequate information about health at the individual level, which undermines medically-sound approaches to health care and policy. This Commission sought to define clinical obesity as a condition of illness that, akin to the notion of chronic disease in other medical specialties, directly results from the effect of excess adiposity on the function of organs and tissues. The specific aim of the Commission was to establish objective criteria for disease diagnosis, aiding clinical decision making and prioritisation of therapeutic interventions and public health strategies. To this end, a group of 58 experts—representing multiple medical specialties and countries—discussed available evidence and participated in a consensus development process. Among these commissioners were people with lived experience of obesity to ensure consideration of patients’ perspectives. The Commission defines obesity as a condition characterised by excess adiposity, with or without abnormal distribution or function of adipose tissue, and with causes that are multifactorial and still incompletely understood. We define clinical obesity as a chronic, systemic illness characterised by alterations in the function of tissues, organs, the entire individual, or a combination thereof, due to excess adiposity. Clinical obesity can lead to severe end-organ damage, causing life-altering and potentially life-threatening complications (eg, heart attack, stroke, and renal failure). We define preclinical obesity as a state of excess adiposity with preserved function of other tissues and organs and a varying, but generally increased, risk of developing clinical obesity and several other non-communicable diseases (eg, type 2 diabetes, cardiovascular disease, certain types of cancer, and mental disorders). Although the risk of mortality and obesity-associated diseases can rise as a continuum across increasing levels of fat mass, we differentiate between preclinical and clinical obesity (ie, health vs illness) for clinical and policy-related purposes. We recommend that BMI should be used only as a surrogate measure of health risk at a population level, for epidemiological studies, or for screening purposes, rather than as an individual measure of health. Excess adiposity should be confirmed by either direct measurement of body fat, where available, or at least one anthropometric criterion (eg, waist circumference, waist-to-hip ratio, or waist-to-height ratio) in addition to BMI, using validated methods and cutoff points appropriate to age, gender, and ethnicity. In people with very high BMI (ie, >40 kg/m2), however, excess adiposity can pragmatically be assumed, and no further confirmation is required. We also recommend that people with confirmed obesity status (ie, excess adiposity with or without abnormal organ or tissue function) should be assessed for clinical obesity. The diagnosis of clinical obesity requires one or both of the following main criteria: evidence of reduced organ or tissue function due to obesity (ie, signs, symptoms, or diagnostic tests showing abnormalities in the function of one or more tissue or organ system); or substantial, age-adjusted limitations of daily activities reflecting the specific effect of obesity on mobility, other basic activities of daily living (eg, bathing, dressing, toileting, continence, and eating), or both. People with clinical obesity should receive timely, evidence-based treatment, with the aim to induce improvement (or remission, when possible) of clinical manifestations of obesity and prevent progression to end-organ damage. People with preclinical obesity should undergo evidence-based health counselling, monitoring of their health status over time, and, when applicable, appropriate intervention to reduce risk of developing clinical obesity and other obesity-related diseases, as appropriate for the level of individual health risk. Policy makers and health authorities should ensure adequate and equitable access to available evidence-based treatments for individuals with clinical obesity, as appropriate for people with a chronic and potentially life-threatening illness. Public health strategies to reduce the incidence and prevalence of obesity at population levels must be based on current scientific evidence, rather than unproven assumptions that blame individual responsibility for the development of obesity. Weight-based bias and stigma are major obstacles in efforts to effectively prevent and treat obesity; health-care professionals and policy makers should receive proper training to address this important issue of obesity. All recommendations presented in this Commission have been agreed with the highest level of consensus among the commissioners (grade of agreement 90–100%) and have been endorsed by 76 organisations worldwide, including scientific societies and patient advocacy groups.

Subjectivity of Obese Female Adolescents in South Korea Regarding Ego-Types and Characteristics

Background/Objectives: The current study aims to explore the subjective ego types and characteristics of obese female adolescents in South Korea, providing insights into their self-perception and psychosocial challenges. Methods: Utilizing Q-methodology, a total of 49 Q-statements were derived from a comprehensive Q-population. From these, 20 adolescents diagnosed with obesity were selected as the P-Sample. Q-sorting was conducted, and the data collected were analyzed using the PQ Method software version 2.35, employing centroid factor analysis and varimax rotation. Results: The results revealed five distinct types, accounting for a cumulative explanatory variance of 63%. Type 1 (N = 5) was characterized as "obsession with weight loss". Type 2 (N = 3) was identified as "overreacting to peer gaze". Type 3 (N = 6) was labeled "lack of confidence in daily life". Type 4 (N = 4) was described as "difficulty adapting to school life". Finally, Type 5 (N = 2) was characterized as "passivity in physical activity". Furthermore, the consensus statements among each type were examined in Q4 and Q7. Conclusions: These findings provide insights into the self-perception of obese female adolescents, emphasizing the need for tailored psychological interventions to improve their self-image and well-being.

Assessing weight bias among Turkish dietitians: determinants and impact on professional practice

BACKGROUND

Weight bias, whether explicit or implicit, has a detrimental effect on the physiological and psychological well-being of individuals, thereby complicating obesity management, particularly in healthcare settings. The objective of this study was to examine weight bias among Turkish dietitians. A further aim was to investigate the effect of the patient's weight status on the dietitian's assessment and dietetic practice.

METHODS

This cross-sectional web-based study analyzed data from 411 Turkish dietitians. The participants completed a series of sociodemographic information, anthropometric measurements, and scales, including the Fat Phobia Scale (FPS) and Attitudes Toward Obese Persons Scale (ATOP). After completing the scales, the dietitians were randomly assigned to a case study on lactose intolerance via an online survey platform. All patient information was identical, except for the patient's weight and photography. The objective of the case study was to evaluate how the body weight of a patient who consulted a dietitian for a reason unrelated to the body weight affected professional practices.

RESULTS

A total of 66.9% of dietitians exhibited fat phobia. While men had higher FPS scores than women (p = 0.022), dietitians with a family history of obesity (p = 0.032) had lower FPS scores. BMI was negatively associated with FPS scores (β = -0.036, p = 0.026). However, dietitians with a history of feeling overweight had higher FPS scores (p = 0.024). Dietitians' assessments of cases differed according to the patient's body weight status. Although, there were no statistically significant differences in FPS and ATOP scores between dietitians assigned to cases with higher or lower body weight (p > 0.05 for each), those assessing the case with higher body weight rated patients' nutritional (p = 0.025) and biochemical status (p < 0.001) as worse and were more inclined to recommend weight management strategies.

CONCLUSIONS

The issue of fat phobia and weight bias represents a significant concern among dietitians, with notable impacts on their professional practice. It is therefore of crucial importance to address and resolve these issues within the context of dietetic education.

TRIAL REGISTRATION

ClinicalTrials.gov registration number: NCT06624111 (submitted 01/10/2024).

Weight bias among students and employees in university settings: an exploratory study

BACKGROUND

Weight bias and stigmatization are highly prevalent in modern society, especially in educational settings, such as universities. Despite extensive documentation of the adverse consequences on students' daily functioning and psychological health, there is limited literature regarding factors associated with weight bias and its extent in Quebec universities.

OBJECTIVES

This exploratory study aims to assess the prevalence of weight bias and experiences of weight-related stigmatization, as well as to examine their associations with gender, psychological health problems, and status (students or employees) in a college environment in the province of Quebec.

METHODS

Participants were recruited via their university emails. A total of 292 students and 129 university employees participated in an online survey distributed via the secure REDCap platform. The following data was collected: sociodemographic information, status (students or employees), body weight, experiences of stigma, and prejudice towards people living with a higher weight (Fat Phobia Scale; FPS).

RESULTS

Approximately half of the respondents reported experiencing weight-related stigma (44.7%), and half indicated holding prejudice towards overweight people (51.1%), with a moderate rate of bias according to the FPS (3.25). Experience of weight-related stigma was found to be associated with gender (X2 = 7.88, p = 0.019), and a higher prevalence of psychological health problems (X2 = 9.41, p = 0.002), while having prejudice was associated with gender, with men scoring higher at the FPS (F = 7.64, p = 0.006), but not with the status (student or employee). The regression model identified significant effects of status [F(4, 347) = 2.856, p = 0.005] and the interaction between gender and status [F(4, 347) = -2.326, p = 0.021] on the FPS scores.

CONCLUSIONS

Various factors are associated with the experience of weight bias and stigmatization towards people with higher weight in the college population. Campaigns to prevent and reduce weight-related bias should be aimed specifically at staff members as well as students. Future research should examine weight bias internalization as a mediator between self-perceived weight and prejudice.

The impact of patient weight on US mental health providers' diagnosis of bulimia nervosa

This study examined how patient weight influences mental health providers' diagnosis of bulimia nervosa (BN). US mental health providers (N = 200) from PsychologyToday.com and professional listservs participated in an online experiment, reading vignettes about patients with major depressive disorder (MDD) and BN with the compensatory behavior of excessive exercise. For the BN vignette, participants were randomized to read about a patient whose weight status was described as "healthy weight" or "obesity." Participants reported their diagnoses, confidence, treatment recommendations, and perceived symptom severity. Only 27% of participants accurately diagnosed BN, with 38% of participants instead diagnosing binge eating disorder. There were no significant differences between weight conditions in diagnostic accuracy, confidence, or treatment recommendations for the BN vignette (ps > .05). However, symptoms within the BN vignette were perceived as more severe in the "obesity" condition compared to the "healthy weight" condition (M = 5.08 ± 0.80 vs. M = 4.72 ± 0.99 on a 1-7 scale, p = .005). Within-subjects analyses revealed that participants were more accurate and confident in diagnosing MDD than BN (ps < .01). These findings suggest poor detection of BN among mental health providers when patients present with healthy or higher weights. Providers may benefit from improved training for detecting BN when excessive exercise is used as the primary compensatory behavior.

Attitudes and Behaviors of Nurses and Nursing Students Toward Patients with Obesity: A Systematized Review

Background: The prevalence of people with obesity is increasing worldwide, facing challenges in terms of discrimination and prejudice across all settings, including healthcare. Objective: The objective of this review is to compare and synthesize recent scientific literature regarding nurses' behaviors and attitudes toward patients with obesity. Methods: A systematized methodology was employed, conducting a literature search of studies published in the bibliographic resources (Academic Search Complete, CINAHL Complete, Web of Science, and Scopus from 2018 to 2023); using specific terms combined with the Boolean operators, AND and OR. Inclusion criteria: Quantitative, qualitative, or mixed research conducted on nurses and/or nursing students in a context focused on the care of adult patients with obesity. Critical appraisal tools from the Joanna Briggs Institute (JBI) were used to evaluate the included studies, and their level of evidence was also determined. Results: Initially, the search yielded 166 articles, of which 14 were included in this review. The results found focused on the use of scales and tools heterogeneous to each other. The findings can be categorized into two main areas: studies investigating interventions aimed at reducing negative behaviors related to weight bias and prejudice, and studies focusing on assessing these attitudes. The evidence points in a consistent direction: nurses exhibit negative attitudes toward patients with obesity. Conclusions: The need for multilevel strategies, from clinical to academic training, to address this challenge is highlighted, alongside the development of research that complements the current evidence with a deeper and more detailed understanding of this phenomenon.

Body Weight and Breast Cancer Treatment Experiences: Results From the Share Thoughts on a Breast Cancer Study

PURPOSE

Differences in breast cancer recurrence and survival occur by body size; the role of treatment differences in these disparities has been underexplored. Our objective was to evaluate differences in treatments received, patient experiences of care, and treatment decision-making processes among breast cancer survivors by body size.

METHODS

We used data from the Share Thoughts on Breast Cancer study. Participants (n = 1198) completed a survey that included information on demographics, treatments received, quality of care, and decision-making. We used descriptive statistics to evaluate differences in survey response by BMI category, and multivariable-adjusted multinomial and logistic regression to examine associations of BMI with treatments received.

RESULTS

Those with higher BMI were more likely to be older, report fair/poor health, not have a college-level education, be non-white, not be insured, have an income under $50,000, be unemployed, and report a history of several chronic diseases. Although there were unadjusted associations, after adjustment, women with obesity were not significantly less likely to receive mastectomy [OR 0.79 (0.50, 1.26) and OR 0.66 (0.38, 1.16), for BMI 30-35 and 35+ kg/m2 respectively] or contralateral prophylactic mastectomy [OR 0.92 (0.59, 1.44) and OR 0.80 (0.46, 1.39)] than those without obesity. Similarly, we found no association of BMI with reconstructive surgery [OR 0.97 (0.58, 1.60) and OR 0.58 (0.30, 1.11)] after adjustment. Women with obesity were less likely to report that their breast cancer care was excellent or very good (p = 0.026).

CONCLUSIONS

We observed no differences in breast cancer treatments received by BMI after adjustment for key covariates in this study sample. Further research is necessary to determine why quality of care may be perceived as lower among women with obesity.

Discussing Weight with Patients in Primary Care in Australia: A Mixed Methods Experimental Study

BACKGROUND

Weight bias is characterised by negative attitudes towards people with a higher weight and is widespread in healthcare. Primary care professionals sometimes avoid discussing weight with patients due to concerns about upsetting them, insufficient training, resources, or referral pathways. There is, however, a responsibility for primary care professionals to address the health needs of patients, which may require discussing weight.

OBJECTIVE

The current study aimed to understand primary care professionals and trainee perceptions of the appropriateness of weight-centric, weight-inclusive/holistic, and avoidant approaches for discussing weight with higher weight individuals when patients were and were not seeking weight management advice.

DESIGN

Mixed methods design.

PARTICIPANTS

Primary care professionals and trainees (N = 112) within Australia.

APPROACH

Participants first completed an online survey and provided demographic data and completed measures of implicit and explicit weight bias. Secondly, participants viewed simulated patient consultations, reflecting each of the three approaches (weight-centric, weight-inclusive/holistic, and avoidant) in a weight-related and non-weight related context. Participants then evaluated the appropriateness of the language and strategies used.

KEY RESULTS

The participants showed, on average, low to moderate levels of explicit weight bias but high levels of implicit weight bias. For the consultations, language and strategies of the holistic approach were considered the most appropriate in both contexts. In the weight-related consultation, language used in the weight-centric and avoidant approaches were deemed equally inappropriate. However, weight-centric strategies were considered more appropriate than avoidant strategies. In the non-weight related consultation, the language and strategies of the avoidant approach were considered more appropriate than those of the weight-centric approach.

CONCLUSIONS

Primary care professionals and trainees favoured the holistic approach to discussing weight when patients presented with weight-related or non-weight related concerns. These findings have potential practical implications for health professional education.

Understanding barriers and facilitators to lifestyle management in people with polycystic ovary syndrome: A mixed method systematic review

Polycystic ovary syndrome (PCOS) is an endocrine disorder affecting 10-13% of reproductive-aged women. Lifestyle management through diet and physical activity changes can improve reproductive, metabolic, and psychological comorbidities. The aim of this systematic review is to understand the barriers and facilitators to lifestyle changes from the perspective of people with PCOS and health care professionals (HCP) using the theoretical domains framework and capability, opportunity, motivation, and behavior model. Six databases were systematically searched for qualitative, quantitative, and mixed-methods studies to 22nd September 2022. Quantitative outcomes from quantitative and mixed-methods studies were narratively synthesized and all studies were thematically analyzed. Sixty-eight papers met the eligibility criteria. HCP education on lifestyle management in PCOS was viewed by all to be inadequate, impacting the quality of care and health outcomes. Lifestyle advice delivered by a multidisciplinary team, including dietitians, was identified as a key component for change. All agreed that there was a need for individualized and PCOS-specific lifestyle advice. Weight stigma was identified as negatively impacting both those in larger and smaller bodies with PCOS, reducing the quality of care and affecting self-perception and mental health. People with PCOS perceived that lifestyle management was overly focused on weight loss and fertility, independent of their own personal motivations and goals. Systemic changes, including increasing HCP education on lifestyle management and multidisciplinary collaboration, focusing on lifestyle advice that meets individual needs, and reducing the use of weight-centric care are necessary for long-term sustainable changes and improvements in health outcomes in people with PCOS.

Motivational Interviewing (MI) in Obesity Care: Cultivating Person-Centered and Supportive Clinical Conversations to Reduce Stigma: A Narrative Review

Background

Patients perceive high levels of weight prejudice, stigma, and discrimination within health systems, affecting their ability to manage their obesity and related chronic conditions. Scientific and patient obesity associations worldwide have prioritized the reduction of weight stigma to improve patient experiences in health systems and overall health outcomes. Since a significant proportion of the population is now living with multiple chronic diseases related to obesity, healthcare systems must shift toward multi-disease management frameworks incorporating person-centered and non-stigmatizing clinical conversations. Motivational Interviewing (MI) has the potential to transform clinical interactions by using non-stigmatizing language, communication, and practices. Studies using MI in obesity management have solely focused on weight loss outcomes, while other patient experience related outcomes would also be relevant to evaluate.

Methods

A narrative review was undertaken to critically analyze the potential impact of MI on obesity and chronic disease management practices and experiences.

Findings

An analysis and contextualization of the MI theoretical framework for obesity management, based on the philosophy of motivational spirit, was reviewed, assessing micro skills or strategies.

Conclusion

MI may assist healthcare professionals conduct non-stigmatizing clinical conversations in accordance with basic principles of collaborative therapeutic alliances. A proposal for research considerations that can help illuminate the potential for of MI in obesity management is also outlined.

How Weight Bias and Stigma Undermine Healthcare Access and Utilization

PURPOSE OF REVIEW

To highlight recent evidence of the impact of weight bias and stigma on healthcare access and utilization.

RECENT FINDINGS

Healthcare access for patients with obesity is limited by weight-discriminatory policies such as body mass index cutoffs and weight loss requirements. These policies are based on flawed justifications without demonstrated medical benefits. Healthcare providers continue to hold negative views of patients with obesity, but recent evidence does not suggest that providers' weight-stigmatizing attitudes affect obesity treatment referrals. With the rise of new anti-obesity medications, more research is needed to understand how weight stigma may or may not affect providers' prescribing behavior and patients' access to this form of treatment. Experienced, anticipated, and internalized weight stigma is associated with patients' avoidance of healthcare and reduced utilization. Weight bias and stigma limit healthcare access and utilization. Structural changes are needed to remove weight-discriminatory barriers to care.

Weight loss advice from a healthcare provider is motivating, but it is also stigmatizing: an experimental, scenario-based approach

BACKGROUND

It is standard practice for healthcare providers to give weight loss advice or counseling to higher-weight patients (ie, those with a BMI ≥ 30 kg/m2), but the immediate psychological consequences of this practice have rarely been examined.

PURPOSE

We hypothesized that receiving weight loss advice from a healthcare provider might lead people to feel both motivated to engage in healthy behaviors and stigmatized for their weight.

METHODS

Participants with higher weight (N = 294) were randomly assigned to read one of two doctor-patient interaction scenarios, and they were asked to imagine that they were the patient receiving advice. The scenario either involved the doctor giving behavioral weight loss advice (ie, standard diet and exercise recommendations) or control advice, which did not address weight or weight loss. Immediately after reading, participants reported their levels of behavioral motivation and weight-based identity threat.

RESULTS

Participants who received weight loss (versus control) advice reported significantly greater motivation for healthy eating and greater weight-based identity threat (Ps < .001, ds from 0.42 to 0.64). There were no significant group differences in perceptions of provider empathy or willingness to engage with the healthcare system in the future (Ps > .1, ds from 0.13 to 0.2).

CONCLUSIONS

As hypothesized, receiving weight loss advice made participants feel motivated to engage in healthy eating behavior, but it also made them feel stigmatized. These findings suggest that the standard practice of delivering weight loss advice should be reexamined, as it may harm higher-weight people and perpetuate inequity.

8. Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

A cross-sectional survey benchmarking the coverage and importance of obesity-related competencies in U.S. dietetic supervised practice programs

BACKGROUND

Registered Dietitian Nutritionists (RDNs) have long been part of the interdisciplinary team recommended for obesity treatment. Obesity education for RDNs is important not only for ensuring adequate knowledge but also for reducing weight stigma. The objective of this study was to benchmark the inclusion of obesity-related competencies in dietetic supervised practice programs, as self-reported by supervised practice directors, to begin to understand the training that U.S. RDNs receive.

METHODS

This was an exploratory, cross-sectional, online survey of U.S. dietetic supervised practice directors distributed in July of 2022. The directors were asked about the importance and extent of inclusion of 31 obesity-related competencies, as well as barriers for inclusion. The competencies were derived from the 2017 Provider Competencies on the Prevention and Management of Obesity.

RESULTS

We received 36 survey responses, representing 10.4% of supervised practice directors in the U.S. Very few programs reported 'not at all incorporated' for any competencies; the most frequent were 'potential role of genetics/epigenetics' (15%, n = 5) and 'physiology/pathophysiology of obesity' (12%, n = 4). The competencies most frequently reported as 'very important' were 'perform effectively in an interprofessional team' and 'discuss obesity in a non-judgmental manner'. Lack of time in the curriculum was the most frequently reported barrier.

CONCLUSIONS

For programs hoping to both expand obesity education and decrease weight stigma in a limited amount of time, improving coverage of competencies related to non-modifiable causes of obesity may be an area to prioritize.

Malnutrition in patients with obesity: An overview perspective

Malnutrition in patients with obesity presents a complex and often overlooked clinical challenge. Although obesity is traditionally associated with overnutrition and excessive caloric intake, it can also coincide with varying degrees of malnutrition. The etiopathogenesis of obesity is multifaceted and may arise from several factors such as poor diet quality, nutrient deficiencies despite excess calorie consumption, genetics, and metabolic abnormalities affecting nutrient absorption and utilization. Moreover, a chronic low-grade inflammatory state resulting from excess adipose tissue, commonly observed in obesity, can further exacerbate malnutrition by altering nutrient metabolism and increasing metabolic demands. The dual burden of obesity and malnutrition poses significant risks, including immune dysfunction, delayed wound healing, anemia, metabolic disturbances, and deficiencies in micronutrients such as vitamin D, iron, magnesium, and zinc, among others. Malnutrition is often neglected or not given enough attention in individuals with obesity undergoing rapid weight loss through aggressive caloric restriction, pharmacological therapies, and/or surgical interventions. These factors often exacerbate vulnerability to nutrition deficiencies. We advocate for healthcare practitioners to prioritize nutrition assessment and initiate medical intervention strategies tailored to address both excessive caloric intake and insufficient consumption of essential nutrients. Raising awareness among healthcare professionals and the general population about the critical role of adequate nutrition in caring for patients with obesity is vital for mitigating the adverse health effects associated with malnutrition in this population.

Concordance of data collected by an app for medical history taking and in-person interviews from patients in primary care

Objective

This study investigates the concordance of patient information collected using a medical history app compared to in-person interviews.

Materials and Methods

In this cross-sectional study we used an app to collect medical data from patients in family practice in Germany. Collected information included age, height, weight, perceived severity of complaints, and 38 current complaints. Subsequently, in-person interviews based on the query structure of the app were conducted with patients directly after the patient finished filling out the app. Concordance was assessed as exact matches between the data collected app-based and in-person interviews, with the in-person interview as a reference. Regression analysis examined which patient characteristics were associated with mismatching and underreporting of complaints.

Results

Three hundred ninety-nine patients were included in the study. Concordance of reported age, weight, and height, as well as perceived severity of complaints ranged from 76.2% to 96.7%. Across all 38 complaints, 64.4% of participants showed completely identical complaint selection in app-based and in-person interviews; 18.5% of all participants overreported; and 17.0% underreported at least 1 complaint when using the app. Male sex, higher age, and higher number of stated complaints were associated with higher odds of underreporting at least one complaint in the app.

Discussion

App-collected data regarding age, weight, height, and perceived severity of complaints showed high concordance. The discordance shown concerning various complaints should be examined regarding their potential for medical errors.

Conclusion

The introduction of apps for gathering information on complaints can improve the efficiency and quality of care but must first be improved.

Trial registration

The study was registered at the German Clinical Trials Register No. DRKS00026659 registered November 3, 2021. World Health Organization Trial Registration Data Set, https://trialsearch.who.int/Trial2.aspx?TrialID=DRKS00026659.

Developing a Weight-Neutral Health Intervention in Denmark: Protocol for a Co-Design Process

Background

Lifestyle interventions for weight loss are generally ineffective in achieving clinically meaningful long-term reductions in body weight and may contribute to negative behavior such as weight cycling or disordered eating. Negative focus on high weight may also contribute to weight stigma. Weight stigma includes negative attitudes and discriminatory behavior toward people with big bodies and can result in psychological stress and unfavorable health outcomes. Taken together, it is possible that the potential harms of lifestyle-based weight loss interventions may exceed the potential benefits. Weight-neutral health (WNH) has emerged as an alternative strategy advocating for size diversity, intuitive eating, and joyful physical movement, all without placing emphasis on weight reduction.

Objective

This protocol outlines the study design for the co-design process of developing a WNH complex intervention, engaging relevant stakeholders in Denmark.

Methods

We base our understanding of WNH on the principles from Health at Every Size: body acceptance, joyful movement, intuitive eating, and weight stigma reduction. The co-design development process is based on the Medical Research Council's framework for complex interventions and applies methods from human-centered design through 4 iterative design phases of engaging stakeholders-discover: search existing literature, and conduct interviews with Danish municipal stakeholders working with WNH and other expert stakeholders; define: coproduction of seminars with health professionals (HPs) with knowledge of WNH, and semistructured interviews with people with BMI≥30 kg/m2 who have participated in existing WNH interventions; design: content-creating workshops with HPs and people with BMI≥30 kg/m2; and validate: evaluate seminars, plan feasibility, and produce materials. The data will be analyzed thematically to build a scaffold for the intervention activities and components. In further analysis, we will explore how health is performed, meaning the actions and dialogues that arise when dealing with health guidelines, the societal body, weight, and health expectations, in the context of the intervention.

Results

The project is fully funded. As of August 2024, the co-design process was in the closing phase. In total, 15 HPs were included, some of whom have larger body sizes. This provides a dual perspective, combining their personal experiences of living with a high BMI with their professional expertise. In total, 16 people with BMI≥30 kg/m2 have generously shared their experiences with WNH programs, including the difficulties of moving away from external demands and personal wishes for weight loss. Their contributions have nuanced and unfolded our understanding of the principles of WNH in a Danish setting.

Conclusions

The intervention designed in and from the co-design process will be tested for feasibility in 2025. The findings from the feasibility study will inform a future randomized controlled trial and present novel findings in the field of health management. The long-term goal is to implement the intervention in a Danish municipal setting free of charge.

Women's Relationships With Healthcare and Providers: The Role of Weight Stigma in Healthcare and Weight Bias Internalization

BACKGROUND

Weight stigma (devaluation due to body weight) in healthcare is common and influences one's engagement in healthcare, health behaviors, and relationship with providers. Positive patient-provider relationships (PPR) are important for one's healthcare engagement and long-term health.

PURPOSE

To date, no research has yet investigated whether weight bias internalization (self-stigma due to weight; WBI) moderates the effect of weight stigma on the PPR. We predict that weight stigma in healthcare is negatively associated with (i) trust in physicians, (ii) physician empathy, (iii) autonomy and competence when interacting with physicians, and (iv) perceived physician expertise. We also predict that those with high levels of WBI would have the strongest relationship between experiences of weight stigma and PPR outcomes.

METHODS

We recruited women (N = 1,114) to complete a survey about weight stigma in healthcare, WBI and the previously cited PPR outcomes.

RESULTS

Weight stigma in healthcare and WBI were associated with each of the PPR outcomes when controlling for age, BMI, education, income, race, and ethnicity. The only exception was that WBI was not associated with trust in physicians. The hypothesis that WBI would moderate the effect of weight stigma in healthcare on PPR outcomes was generally not supported.

CONCLUSIONS

Overall, this research highlights how weight stigma in healthcare as well as one's own internalization negatively impact PPRs, especially how autonomous and competent one feels with their provider which are essential for one to take an active role in their health and healthcare.

Partnerships with primary care providers: Opportunities to prevent eating disorders and mitigate their progression in young people

Epidemiologic research has identified numerous interpersonal and individual risk factors for and warning signs of emerging eating disorders in adolescents. These findings have informed public health prevention and treatment strategies, including translation of findings to clinical recommendations for primary care providers (PCPs). A next step in this translational work could include a comprehensive approach where PCPs are seen as partners in efforts to improve population health outcomes. PCPs have great potential to implement high-yield interventions that prevent or attenuate the course of adolescent eating disorders. To illustrate this potential, we present a case that highlights missed opportunities for a PCP to prevent, detect, and intervene during a patient's developing eating disorder. We then relate the case to two emerging research programs that utilize PCP partnerships: one trains PCPs in Strengths-Based Adolescent Healthcare to improve eating disorder prevention; the other adapts Family-Based Treatment for primary care to improve early access to evidence-based treatment. In addition to these promising areas of research, efforts are needed to widen requirements for eating disorder curricula in medical training programs and to address weight stigma in primary care. Together these efforts will help PCPs become effective partners in the prevention and treatment of eating disorders.

The lived experiences of patients with severe obesity during hospital admissions in Norway: A phenomenological hermeneutic study

AIM

To explore the lived experiences of patients with severe obesity during hospital admissions.

DESIGN

Qualitative study design.

METHODS

Semi-structured individual interviews with 14 participants with severe obesity from Norway were conducted between May and October 2021. A qualitative phenomenological hermeneutical approach inspired by Paul Riceour was used to analyse the data.

RESULTS

The following three themes were identified through the analysis of the lived experiences of patients with severe obesity during hospital admissions: blaming my weight, being prejudged and feeling different. The participants shared various emotional experiences of encounters with healthcare professionals at hospitals. They struggled to be recognized and welcomed like everyone else and found it difficult to be judged by someone who did not know them. The various experiences resulted in a vicious circle, ultimately leading to a fear of future hospitalization.

CONCLUSION

Being a patient with obesity in a hospital setting can present various challenges, leading to feelings of shame and guilt. Experiences of stigma may not necessarily be related to the overall hospital context but rather to encounters with healthcare professionals who may be unfamiliar with the patient's history, which can lead to stigmatizing behaviours.

IMPACT

Understanding how patients with severe obesity experience their hospital admissions and the importance of familiarizing themselves with the individual patients to avoid stigmatizing behaviours is important for healthcare professionals caring for obese patients.

REPORTING METHOD

Consolidated Criteria for Reporting Qualitative Research.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

IMPACT STATEMENT

Patients with obesity often encounter stigmatization and negative attitudes from healthcare professionals, particularly in primary care settings. Patients with severe obesity experienced various challenging encounters with healthcare professionals during hospital admissions, resulting in a vicious circle, ultimately leading to a fear of future hospitalization. It is crucial for healthcare professionals involved in the care of patients with obesity to acquaint themselves with individual patients to prevent stigmatizing behaviours.

Associations Between Weight Discrimination, Eating-Disorder-Related Psychiatric Impairment, and Eating-Disorder Treatment Interest Across the Weight Spectrum

OBJECTIVE

Only approximately 20% of college students with an eating disorder (ED) seek treatment. One barrier to seeking treatment is weight discrimination. Past research demonstrates that experiencing weight discrimination is associated with increased ED risk and decreased in-person treatment engagement. Weight discrimination may be a particularly relevant treatment barrier for students who have a higher body weight given their higher likelihood of experiencing weight discrimination.

METHODS

College students with a probable ED diagnosis (N = 372; Mage = 23.94; 73.12% women, 18.55% men, 6.18% another gender; 11.29% Asian, 4.57% Black, 12.63% Hispanic, 83.60% White, 4.84% Native American, and 0.54% another race) completed an online self-report survey that included the Clinical Impairment Assessment (CIA), Experience of Weight Discrimination (EWD) Scale, and a 0-100 scale to indicate interest in participating in virtual guided self-help ED treatment.

RESULTS

Linear regression showed significant positive relationships between weight discrimination and ED-related psychiatric impairment and treatment interest.

DISCUSSION

Elevations in CIA scores corroborate past literature that suggested that weight discrimination was positively related to ED psychopathology. Contrary to past research, college students who experienced weight discrimination had greater treatment interest. Students who experience weight discrimination may view virtual self-guided treatment as less weight-stigmatizing due to the "do-it-yourself" approach and no in-person interactions. Findings highlight the potential impacts of weight discrimination on acceptability of ED-related care. Future research is needed to identify ways to reduce weight discrimination and promote weight-inclusive practices in the medical system.

Weight Stigma in the Development, Maintenance, and Treatment of Eating Disorders: A Case Series Informing Implications for Research and Practice

Weight-centric health practices are based on the principle that excess weight predicts chronic disease, informing a growing sociopolitical movement to address an "obesity epidemic." This hyper-focus on preventing obesity may contribute to weight stigma (i.e., the devaluation and discrimination of individuals based on body size) and other iatrogenic outcomes for youth, including the development and maintenance of eating disorders (EDs). Current evidence-based treatments for EDs include language and practices that may reinforce fears of fatness, body shame, and unhealthy dietary restriction without guidance on addressing weight stigma. Here, we present case examples from three adolescent patients across ED presentations and body sizes to (1) elucidate the role of weight stigma in ED development, (2) highlight the ubiquity and harms of weight stigma within ED treatments, and (3) outline thoughtful protocol adaptations to avoid further harm and facilitate recovery. We conclude with a call for immediate action to advance research characterizing the harms of weight-centric approaches in existing ED interventions to reduce the risk of iatrogenic effects on youth with EDs and advance weight-inclusive approaches to ED treatment.

Assessing Bias Toward a Black or White Simulated Patient with Obesity in a Virtual Reality-Based Genomics Encounter

Interpersonal bias based on weight and race is widespread in the clinical setting; it is crucial to investigate how emerging genomics technologies will interact with and influence such biases in the future. The current study uses a virtual reality (VR) simulation to investigate the influence of apparent patient race and provision of genomic information on medical students' implicit and explicit bias toward a virtual patient with obesity. Eighty-four third- and fourth-year medical students (64% female, 42% White) were randomized to interact with a simulated virtual patient who appeared as Black versus White, and to receive genomic risk information for the patient versus a control report. We assessed biased behavior during the simulated encounter and self-reported attitudes toward the virtual patient. Medical student participants tended to express more negative attitudes toward the White virtual patient than the Black virtual patient (both of whom had obesity) when genomic information was absent from the encounter. When genomic risk information was provided, this more often mitigated bias for the White virtual patient, whereas negative attitudes and bias against the Black virtual patient either remained consistent or increased. These patterns underscore the complexity of intersectional identities in clinical settings. Provision of genomic risk information was enough of a contextual shift to alter attitudes and behavior. This research leverages VR simulation to provide an early look at how emerging genomic technologies may differentially influence bias and stereotyping in clinical encounters.

Pediatric Obesity Pharmacotherapy: State of the Science, Research Gaps, and Opportunities

Pediatric obesity is a major public health problem, affecting nearly 20% of children and adolescents living in the United States. In 2023, the American Academy of Pediatrics released its first clinical practice guideline for the evaluation and management of child and adolescent obesity and recommended integrating health behavior and lifestyle interventions with pharmacological treatment when medically indicated. However, there is a limited evidence base to guide antiobesity medication treatment decisions in clinical practice and limited data on long-term safety during this critical period of growth and development in youth. Thus, in November of 2023, the National Institute of Diabetes and Digestive and Kidney Diseases sponsored a workshop to identify knowledge gaps and opportunities for research on the use of pharmacotherapy for obesity in children and adolescents. Leading scientific and clinical experts in obesity pathophysiology and treatment, pharmacotherapy, clinical trial design, and health equity and disparities, among others, identified gaps in clinical trial design, guidance for clinical use of medications in children and adolescents, additional treatment outcomes beyond body fat or weight, and improvement in care delivery. Adolescent patients and caregivers with lived experience of obesity and weight management were also invited to participate in a panel discussion, providing personal perspectives on living with obesity, clinical care considerations, and research needs. This article summarizes the workshop proceedings on the state of the science and identifies gaps and opportunities for future research to inform optimal and equitable medical management of children and adolescents with obesity.

An exploratory examination of medical and nursing students' intentions to discuss body image, weight, and eating disorders with their patients

BACKGROUND

Although many people have concerns about their body image, weight, and eating behaviors these issues are not usually discussed in a productive manner with medical providers. Thus, we examined nursing and medical students' willingness to discuss patients' weight, body image, and eating disorders and reasons why they may do so.

METHOD

One hundred and eighty-three nursing and medical students (Mage = 25.06, SD = 5.43) participated in this study. Participants completed open-ended questions pertaining to their willingness to discuss body image, eating, and weight-related issues with future patients. We further queried students' perspective on body mass index (BMI) as a measure of weight status and sought to determine if participants' own weight, weight concerns, appearance evaluation, body appreciation, and experiences of stigma were associated with their willingness to discuss weight-related issues with prospective patients.

RESULTS

Coding of qualitative data indicated that nursing and medical students were "sometimes" willing to discuss prospective patients' weight, body image, and eating disorders, especially if a health concern was evident. Nursing students seemed somewhat more willing to discuss weight issues than medical students and willingness to discuss one of these issues (e.g., body image) was positively associated with willingness discuss the others. Plans for future discussions of body image and weight were marginally associated with personal experiences of weight stigma. The majority of participants indicated that BMI was not a valid measure of health.

CONCLUSIONS

Taken together, findings suggest that future providers' conversations with patients about these sensitive topics are less likely to be associated with their own experiences and more with the relevance of these topics to specific patients.

Bias related to overweight and obesity among French psychiatrists: Results of a national survey

BACKGROUND

According to people with a higher weight, physicians are the second most stigmatizing group related to excess weight. As a result of these weight-related biases, the therapeutic relationship with the patient and the quality of care would be negatively affected. In addition, this stigma could negatively impact the clinical practice related to higher weight and avoidance of care.

OBJECTIVES

The objective of this study was to assess the stigma of overweight and obesity among psychiatric residents and psychiatrists in France. Specifically, the study aimed to assess factors that may influence weight-related bias among psychiatrists, to explore the relevance of visual assessment of body mass index, and to determine how they this feature is integrated into their practice.

METHOD

An online questionnaire including sociodemographic items, the Fat Phobia Scale, the Beliefs About Obese Persons Scale, the Body Shape Scales, and questions about their clinical practice was distributed via national professional mailing lists and social networks.

RESULTS

The survey was answered by 271 seniors or residents in psychiatry. The results indicated a moderate level of weight-related bias among psychiatrists as assessed by the Fat Phobia Scale which was higher in residents than in senior psychiatrists. Over a third of the respondents had no material to assess their patient's weight, and two thirds did not systematically assess overweight or obesity. Finally, the results demonstrate that psychiatrists failed to accurately evaluate overweight or obesity based on male or female silhouettes.

CONCLUSION

It appears that measures should be taken to raise awareness among psychiatrists of the stigmatization of individuals living with a higher weight, as well as to enhance the quality of weight gain care in psychiatry.

Weight-Inclusive Podcasts Improved Intuitive Eating, Body Appreciation, and Anti-Fat Attitudes Among Nutrition Students

OBJECTIVE

Assess the impact of a weight-inclusive podcast (WIP) intervention on body appreciation, intuitive eating (IE), anti-fat attitudes, and weight and health attitudes in university students enrolled in an upper-division nutrition course.

METHODS

Quasi-experimental design: Intervention participants listened to 8 weekly WIP episodes (n = 16); the comparison group listened to 8 weekly general nutrition podcasts (n = 29). Intuitive eating, body appreciation, anti-fat attitudes, and general weight and health attitudes were measured preintervention and postintervention.

RESULTS

Two-way, repeated measures analysis of variance revealed significant interaction effects of time × group, with participants in the WIP group experiencing significantly greater improvements in body appreciation (P = 0.03) and IE (P = 0.02) and greater reductions in anti-fat attitude scores (P = 0.006) than the comparison group.

CONCLUSIONS AND IMPLICATIONS

Podcasts may be a cost-effective tool to improve body appreciation and IE and reduce anti-fat attitudes in future nutrition professionals. Future research would benefit from recruiting prehealth professionals across different majors.

Weight Bias and Stigma in Pediatric Obesity

Weight stigma is pervasive during childhood and adolescent years. Well-established physical and psychosocial health consequences of weight stigma, like disordered eating behaviors, low self-esteem, and higher depressive symptoms, make it especially harmful during a critical period of development for youth. Lasting negative health impacts of these experiences highlight the importance of addressing weight stigma early on. The pediatric health care setting, both physical and social components, can be one of many sources of weight-stigmatizing experiences for youth. This observation has prompted calls for action in the health care setting to reduce weight biases and stigmatizing behavior among pediatric providers.

Physicians' stigmatizing attitudes about individuals with type 2 diabetes: Associations with communication practices and perceived barriers to care

AIMS

The stigma of type 2 diabetes (T2D) has received growing attention in the healthcare setting. However, there has been almost no research examining how healthcare professional biases about diabetes relate to patient care. This cross-sectional study examined how physicians' self-reported biases, stereotypes, and attributions about diabetes and obesity were related to their patient care practices.

METHODS

Physicians treating T2D, specializing in internal medicine or endocrinology (n=205), completed a battery of online questionnaires.

RESULTS

Physicians who attributed poor patient compliance as the primary barrier to provision of diabetes care had worse perceptions of individuals with T2D and were less likely to use person-centered approaches with their patients. Physicians' stigmatizing attitudes about T2D were associated with less use of person-first language, while more positive perceptions of individuals with T2D were associated with greater use of motivational interviewing. Weight-related stigma was associated with less use of person-centered approaches to care and less confidence in their ability to provide care.

CONCLUSIONS

Findings reiterate the associations between weight stigma and poorer physician communication and suggest that similar patterns occur in the provision of care for individuals with T2D. Physicians who treat T2D may benefit from stigma reduction interventions for both diabetes and weight-related stigmas.

Does dissection influence weight bias among doctor of physical therapy students?

Anatomy with human dissection may help to develop respect for the human body and professionalism; however, dissection may worsen students' attitudes about body weight and adiposity. The purpose of this study was to measure weight bias among Doctor of Physical Therapy (DPT) students enrolled in gross anatomy and determine if, and how the experience of dissection impacts weight bias. Ninety-seven DPT students (70 University of Colorado [CU], 27 Moravian University [MU]) were invited to complete a survey during the first and final weeks of their anatomy course. The survey included demographic items, two measures of weight bias-the Modified Weight Bias Internalized Scale (M-WBIS) and the Attitudes Towards Obese Persons (ATOP) Scale-and open-ended questions for the students who participated in dissection (CU students) that explored attitudes about body weight and adiposity. At baseline, there were no significant differences (p > 0.202) in ATOP, M-WBIS, or BMI between the two universities. The mean scores on both the ATOP and M-WBIS indicated a moderate degree of both internalized and externalized weight bias. There were no significant changes in ATOP (p = 0.566) or M-WBIS scores (p = 0.428). BMI had a low correlation with initial M-WBIS scores (⍴ = 0.294, p = 0.038) and a high correlation with change scores in CU students (⍴ = 0.530, p = 0.011). Future studies should utilize the same measures of weight bias in other healthcare trainees to facilitate comparison and incorporate larger populations of DPT students.

Stigmatizing attitudes and beliefs about obesity among dental team members

Background

Weight stigma is prevalent within healthcare settings and is an aspect of the lived experience of people living with obesity. There is international evidence of weight stigma in the dental setting, where currently there is also evidence indicating limited training amongst dental professionals regarding obesity or obesity-related stigma. There has been Australian research and none have included dental support staff.

Aims

This cross-sectional survey aimed to assess stigmatizing attitudes and beliefs of dental professionals (registered general dentists, oral health therapists) and support staff (dental assistants, dental receptionists) working in private and public regional practices in New South Wales and specialists in Special Needs Dentistry across Australia toward people living with obesity.

Methods

An anonymous electronic validated survey was administered through REDCap™ to assess stigmatizing attitudes and beliefs held amongst respondents in relation to people living with obesity.

Results

Fifty-three participants completed the survey (n = 33 clinicians, n = 20 support staff). The majority 47/53 (88.7%) held positive attitudes toward people living with obesity. Of the clinicians, 15/33 (45.5%) reported 1 hour or less and 14/33 (42.4%) reported two to 5 hours of obesity-related education. 14/20 (70%) of the support staff reported no prior education or training about obesity. Of responses reflecting weight stigma, only three clinicians reported negative reactions toward the appearance, or discomfort during examination, of a patient with obesity, or a perception of laziness, compared with normal weight individuals. A higher proportion 4/20 (20%) of support staff reported responses indicating negative attitudes for people with obesity compared with normal weight individuals.

Conclusion

Survey responses reflected evidence of weight stigma in both dental professionals and support staff. Professional development targeting weight stigma reduction in the dental setting is needed for both clinicians and support staff.

Clinical observations of weight stigma among nursing students: A descriptive approach

Background

Mistreatment of individuals due to their body size or weight stigma has been described as a source of stress and as a deterrent for engagement in the healthcare system. Efforts to reduce weight stigma have included curricular interventions to reduce weight bias among future healthcare professionals. However, few studies have examined students' observations of weight stigma and subsequent socialization to healthcare environmental norms.

Aims

The purpose of this study is to evaluate observed weight stigma among pre-licensure nursing students and recent graduates during clinical rotations and its effect on the perceived ability to provide respectful care to people in larger bodies.

Materials and Methods

A cross-sectional, descriptive study was conducted from February to March 2023. Participants answered questions related to personal weight bias (Fat Phobia Scale), observations of weight stigma, and perceived ability to provide respectful care.

Results

Ninety-one participants completed the survey, of whom half (n = 48) held a high level of weight bias. A quarter of participants (n = 23) reported that they engaged in weight stigma behaviors and a quarter (n = 24) of participants observed weight stigma behaviors from two or more healthcare professional roles. Almost one-third (n = 10) of participants who observed weight stigma behaviors perceived that it impacted their ability to provide respectful care to patients in larger bodies.

Conclusions

These findings describe that weight stigma enacted by multiple healthcare professional roles is observed by nursing students during clinical rotations and is perceived to impact their ability to provide respectful care. Efforts to improve healthcare professionals' sensitivity to the effects of weight bias and weight stigma should include addressing the role of socialized norms on weight bias among future healthcare professionals.

Healthcare professionals' perspectives on the barriers and facilitators of integrated childhood obesity care

BACKGROUND

Both the causes and consequences of childhood obesity can be complex. To provide healthcare that is suitably tailored to the specific needs of children with obesity integrated care is required. The objective of this study was to explore the perceived barriers and facilitators of healthcare professionals (HCPs) in providing integrated care for children with obesity, to support them in tailoring the healthcare approach.

METHODS

In this qualitative study, semi-structured in-depth interviews were conducted with 18 healthcare professionals with experience in childhood obesity care; pediatricians, youth healthcare nurses and a youth healthcare physician. A two-phased thematic content analysis was performed: an inductive analysis with open and selective coding and a deductive analysis with axial coding using the patient-centered care model by Stewart.

RESULTS

Overall, the healthcare professionals defined the etiology of obesity as complex, and experienced the integrated care as complicated. The results fit into the four theme-structure of the patient-centered care model, with the integrated care system as an additional fifth theme. The main barriers were perceived within the sub-themes of illness and healthcare experiences, and sensitivity over talking about weight-related issues. The main facilitators were perceived within the sub-themes of conducting a biomedical, psychosocial and lifestyle assessment, tailoring the approach to families' situation and investing in a family-professional relationship. Weight stigma appeared to be an underlying barrier for healthcare professionals that impacted, both explicitly and implicitly, upon all themes.

CONCLUSIONS

Healthcare professionals providing integrated care for children with obesity, experience this type of care as complicated and comprising many barriers and facilitators regarding the four themes of the patient-centered care model and the fifth theme of the integrated care system. This paper demonstrates the patient-centered care model could prove helpful structuring a tailored approach within integrated care. This approach supports healthcare professionals in adopting a broad perspective towards individual and environmental factors and investing in the relationship, with respect to the sensitivity and complexity of childhood obesity.

Healthcare outcomes and dispositions in persons with obesity within emergency departments in Ontario, Canada: A cross-sectional analysis of the National Ambulatory Care Reporting System (NACRS), 2018-2022

INTRODUCTION

The experience of persons with obesity (PwO) in the Canadian healthcare setting has not been widely studied. The objective of this study was to assess care in PwO in emergency departments in Ontario, Canada.

METHODS

This secondary analysis made use of 2018-2022 Canadian Institute for Health Information's National Ambulatory Care Reporting System. The sample consisted of 4547 individuals with an obesity diagnosis, and 4547 controls who were matched for sex, age, and main diagnosis. Ordinal logistic and multiple linear regression analyses were used to assess triage scores, wait times, and length of stay.

RESULTS

PwO had 4.8 minutes longer wait time for a physician initial assessment (p<0.01), 3.56 hours longer length of stay in the emergency department (p<0.0001), and 55% greater odds (OR = 1.55, 95% CI: 1.43-1.68) of having a less urgent triage score compared to controls matched for main diagnosis. When further matched for triage score, PwO experienced over three hours longer length of stay for triage level 2 (emergent, p<0.01), five hours longer for triage level 3 (urgent, p<0.01), and nearly two hours longer for triage level 4 (less urgent, p<0.05) cases.

CONCLUSION

PwO were rated as less urgent and experienced longer wait times and length of stay, compared to controls matched by sex, age, and main diagnosis. Additional research is needed to confirm the consistency of these findings in other provinces/territories, and to examine clinical outcomes, and the underlying reasons for differences.

"The healthcare system did fail me repeatedly": a qualitative study on experiences of healthcare among Canadian women with Cushing's syndrome

BACKGROUND

As a rare endocrine disorder, Cushing's Syndrome (Cushing's) is characterized by numerous symptoms and a non-specific presentation, leading to a delay to diagnosis for patients with this disease. To date, research examining the lived experiences of patients with Cushing's in healthcare is absent in the literature. This preliminary inquiry into the healthcare experiences of women with Cushing's aimed to examine the utility of this line of inquiry to support the patient centered care of individuals with Cushing's.

METHODS

Seven women from across Canada with endogenous Cushing's participated in the study. Semi-structured interviews were conducted examining participants' healthcare and body-related experiences with Cushing's. Results pertaining to healthcare experiences were analyzed for the current study using reflexive thematic analysis.

RESULTS

Four themes emerged whereby women with Cushing's experienced (1) a lack of patient centered care, characterized by provider miscommunication and medical gaslighting; (2) a misunderstanding of their symptoms as related to weight gain; (3) weight stigma in healthcare encounters; and (4) a shift in their quality of care following diagnosis.

CONCLUSIONS

The results highlight the importance of patient centered care as well as the negative impact of commonly reported barriers to patient centered care. Cushing's specific barriers to patient centered care may include weight stigma as well as the rare incidence of Cushing's. Further research is needed to better understand the healthcare experiences of people with Cushing's in Canada.

Weight stigma and binge eating related to poorer perceptions of healthcare provider interaction quality in a community-based sample

BACKGROUND

Weight stigma refers to the social rejection, discrimination, and ideological devaluation of individuals because of body size and is a direct result of weight bias and anti-fat attitudes. Individuals with higher weight may be less likely to seek healthcare due to weight stigma, and if or when they do present for care, medical providers with weight bias may fail to provide high quality care. Little, however, is known about the intersectionality of weight stigma and perceptions of healthcare interactions as experienced by individuals who also binge eat.

METHODS

Community-based adults completed online self-report questionnaires regarding generalized weight stigma (Attitudes Towards Obese Persons1), healthcare interaction quality (Patient Perceptions of Healthcare Provider Interaction Quality; PPH), and disordered eating (Eating Disorder Examination-Questionnaire) via Amazon's Mechanical Turk platform. For this cross-sectional study, participants were categorized by the presence and absence of regular binge episodes. Pearson's correlations, T-tests, ANOVA/ANCOVA, and a multivariate regression were used to examine relationships among demographic variables, weight stigma, disordered eating, and the PPH.

RESULTS

Participants (N = 648) primarily identified as female (65.4%) and White, non-Hispanic (72.7%). Participants' average age and body mass index (BMI) were 37.5 (SD = 12.3) years old and 27.3 (SD = 6.9) kg/m2, respectively. Higher healthcare provider interaction quality ratings (PPH) were significantly related to lower BMI (r(648)=-0.098,p = 0.012), less weight stigma (r(648) = 0.149,p < 0.001), and identifying as a woman (t(514) = 2.09, p = 0.037, Cohen's d = 0.165) or White, non-Hispanic (t(646)=-2.73, p = 0.007, Cohen's d=-0.240). Participants reporting regular binge eating endorsed significantly worse perceptions of healthcare provider quality than those who did not, even after accounting for BMI, F(1, 645) = 8.42, p = 0.004, η2 = 0.013. A multivariate linear regression examining the PPH as dependent, and weight stigma and binge eating as independent, variable/s, was significant even after accounting for covariates (sex, race, BMI), F(95, 640) = 7.13,p < 0.001, R2 = 0.053 (small effect).

CONCLUSIONS

More negative experiences with healthcare providers was associated with worse weight stigma, higher BMI, regular binge eating and overall disordered eating, and for participants identifying as male or a Person of Color. These data have implications for non-clinical community populations and are particularly important as experiencing poorer quality of interactions with healthcare providers may decrease individuals' likelihood of seeking needed care for both disordered eating and health-related concerns.

TRIAL REGISTRATION

N/A.

Role of Adverse Childhood Experiences in the Onset of Overweight/Obesity

PURPOSE OF REVIEW

The goal of this chapter was to summarize the literature on childhood adversity and obesity, discuss treatment implications with a case example, and provide recommendations for trauma-informed care for clinicians who work with individuals living with obesity.

RECENT FINDINGS

Adversity in childhood is related directly and indirectly to obesity development. Upstream contributors like adverse childhood experiences (ACEs) and other factors can lead to experiences of toxic stress and increased allostatic load, resulting in downstream effects of obesity and other chronic health conditions. A well-established literature has linked ACEs and obesity suggesting complex interactions between genetic, biological, behavioral, mental health, social, and environmental factors and obesity. Trauma-informed care strategies can be used to optimize care for individuals living with obesity. Care pathways should include individual (clinician) and systemic (organizational) evidence-based interventions.

Assessing Weight Stigma: Validating Attitudes and Beliefs Questionnaires Among Future Healthcare Professionals

Background This study aimed to establish the reliability and validity of the Anti-Fat Attitudes (AFA) questionnaire and the Beliefs About Obese Persons (BAOP) scale. Methodology A convenience sample of 257 students from three distinct sections of the University of Medicine and Pharmacy "Grigore T. Popa" Iasi (Medical Faculty, Nutrition and Dietetics, and Nursing) participated in an observational study. Construction validity was tested with exploratory factor analysis. The students completed a form containing sociodemographic data, the AFA questionnaire, and the BAOP scale. Weight and height were self-reported and used to determine the body mass index. Results The value of the Cronbach alpha coefficient for the AFA questionnaire indicated adequate internal consistency (0.862). The exploratory factor analysis identified the following three factors corresponding to the original questionnaire: Dislike, Fear of Fat, and Willpower. We validated a single-factor structure of the BAOP scale, which had adequate internal consistency (0.781). There were statistically significant differences (AFA: p = 0.02; BAOP: p = 0.03) between the scores of the students from Nutrition and Dietetics, Nursing, and General Medicine. Conclusions This study demonstrated that the AFA questionnaire and the BAOP scale could be used to evaluate weight stigma in healthcare students, providing a useful tool to assess the effects of weight stigma awareness interventions in this population.

Examining weight bias attitudes and obesity beliefs among undergraduate students

Objective: This cross-sectional study examined the weight bias attitudes and obesity beliefs of health science (HS), nursing, and pre-medicine undergraduate students. Methods: Using snowballing and convenience sampling strategies, students (N = 139) completed an online survey, including a 24-item Antifat Attitudes Scale (AFAS) and eight-item Belief About Obese Persons (BAOP) scale. Results: HS students have higher weight bias than nursing and pre-medicine students combined (M = 43.45, SD = 10.75), t(137) = -2.45, p = .016). A negative correlation exists between AFAS and BAOP suggesting high weight bias influences a belief that obesity is controllable. Gender positively predicted weight bias attitudes (ß = -11.43, t = -4.33, p < .001) and obesity beliefs (ß = 3.75, t = 3.01, p = . 003). Conclusions: Findings confirm that HS students have weight bias attitudes. This supports undergraduate curricular changes on obesity etiology that may improve treatment plans of individuals who are obese.

Current trends and future directions in internalized weight stigma research: a scoping review and synthesis of the literature

BACKGROUND

Since the first papers focused on internalized weight stigma were published in the mid 2000's, the literature has grown into a robust field that complements existing knowledge on weight stigma. Recently, researchers have documented the need for increased conceptual and measurement clarity, to distinguish internalized weight stigma from body dissatisfaction. Although several systematic reviews have been conducted on portions of the internalized weight stigma literature, no review to date has been conducted examining the entirety of the literature.

OBJECTIVE

The aim of this research was to conduct a systematic scoping review and synthesis of research on internalized weight stigma. Specifically, we sought to examine the broad scope of the literature, terms used to refer to internalized weight stigma, how internalized weight stigma is defined, sample characteristics, and weight-based framings of internalized weight stigma research.

METHODS

We conducted a single-concept search across six databases (EMBASE, Medline, PsychINFO, PubMed, SCOPUS, and Web of Science) of peer-reviewed papers published in English on internalized weight stigma. Data were extracted for article authors, year published, journal name and type, general article topic(s), study design, study location, sample characteristics, variables measured, paper framing, term used to describe internalized weight stigma, and definition of internalized weight stigma.

RESULTS

Of the 931 unique records screened, 376 were identified for inclusion in the scoping review. The majority of internalized weight stigma research is characterized by cross-sectional methods, has been conducted in the US, and has utilized samples of higher weight white women. Further, 40 unique terms were used across the literature to refer to internalized weight stigma, and 19 different components of definitions of internalized weight stigma were identified. The literature is also characterized by a focus on understanding the association between internalized weight stigma and health outcomes with an emphasis on obesity.

CONCLUSIONS

This scoping review confirms a lack of concept clarity of internalized weight stigma, in part influenced by an inconsistency in definitions of internalized weight stigma across the literature. Considerations are provided for steps to enhance conceptual and measurement clarity. Given the obesity focused framing of much of the research on internalized weight stigma, considerations are also provided for reducing weight-centric approaches to research. In the early 2000's, researchers began to pay more attention to the potential health impacts of believing societal stereotypes, negative attitudes, and beliefs about higher weight people. When these stereotypes, negative attitudes, and beliefs are directed towards the self, it can have significant consequences for an individual's perceptions of self. This research collected and summarized all existing research published in English on internalized weight stigma. Our results highlighted that researchers do not use consistent terminology to refer to internalized weight stigma and that they do not have a consistent definition of internalized weight stigma. Further, a large proportion of the research is focused on obesity or weight loss, which may unintentionally perpetuate weight stigma in scientific research. We provide several recommendations for researchers to address these challenges in future research on internalized weight stigma as well as recommendations to address other identified gaps in the existing literature.

Improving Weight Bias Awareness Among Providers in the Sexual and Reproductive Health care Setting

Introduction

Provider bias against patients of higher weights can contribute to poor health outcomes and decreased quality of care and patient experience. Addressing weight stigma in sexual and reproductive health settings is important, as these encounters can often be patients' only health care touchpoint. Health care providers must be educated about the harms of weight stigma, ways to recognize and confront their biases, and how to advocate for patients of all sizes.

Methods

In this quality improvement project, Planned Parenthood health center providers participated in a three-part virtual workshop to improve provider weight bias awareness and understanding using the Health at Every Size framework. Providers completed a pre- and post-survey, as well as a 3-month follow-up survey to assess changes in bias awareness and confidence in applying weight-neutral principles in care interactions.

Results

Analysis of pre- and post-survey results showed significant improvements in provider awareness of bias as well as changes in implicit bias scores and confidence providing weight-neutral care.

Conclusion

Educating providers about weight contributes to equity of care for patients of higher weights. Formal education such as workshops have the potential to reduce the harms of weight stigma in health care as changing attitudes and confidence are a precursor to behavior change. Research is needed to assess ideal education modalities and whether receiving care from weight bias-prepared providers affects patient outcomes and experiences.

Anatomy's missing faces: An assessment of representation gaps in atlas and textbook imagery

Previous research suggests that underrepresentation in medical curricula perpetuates inequities in healthcare. This study aimed to quantify the prevalence of human phenotypic diversity (e.g., skin tone, sex, body size, and age) across 11 commonly used anatomy atlases and textbooks in pre-clerkship medical education, published from 2015 to 2020. A systematic visual content analysis was conducted on 5001 images in which at least one phenotypic attribute was quantifiable. Anatomy images most prevalently portrayed light skin tones, males, persons with intermediate body sizes, and young to middle-aged adults. Of the 3883 images in which there was a codable skin tone, 81.2% (n = 3154) depicted light, 14.3% (n = 554) depicted intermediate, and 4.5% (n = 175) depicted dark skin tones. Of the 2384 images that could be categorized into a sex binary, 38.4% (n = 915) depicted females and 61.6% (n = 1469) depicted males. A male bias persisted across all whole-body and regional-body images, including those showing sex organs or those showing characteristics commonly associated with a specific sex (e.g. for males, facial hair and/or muscle hypertrophy). Within sex-specific contexts, darker skin was underrepresented, but male depictions displayed greater overall skin tone variation. Although most images could not be assigned to a body size or age category, when codable, these images overwhelmingly depicted adults (85.0%; 482 of 567) with smaller (34.7%; 93 of 268) or intermediate (64.6%; 173 of 268) body sizes. Ultimately, these outcomes provide reference metrics for monitoring ongoing and future efforts to address representation inequalities portrayed in anatomical imagery.

Practical strategies to manage obesity in type 2 diabetes

The rising phenomenon of obesity, a major risk factor for the development and progression of type 2 diabetes, is a complex and multifaceted issue that requires a comprehensive and coordinated approach to be prevented and managed. Although novel pharmacological measures to combat obesity have achieved unprecedented efficacy, a healthy lifestyle remains essential for the long-term success of any therapeutic intervention. However, this requires a high level of intrinsic motivation and continued behavioural changes in the face of multiple metabolic, psychological and environmental factors promoting weight gain, particularly in the context of type 2 diabetes. This review is intended to provide practical recommendations in the context of a holistic, person-centred approach to weight management, including evidence-based and expert recommendations addressing supportive communication, shared decision-making, as well as nutritional and pharmacological therapeutic approaches to achieve sustained weight loss.