Weight bias and health care utilization: a scoping review

Longitudinal trends of sleep services for veterans with and without serious mental illness in VA electronic health records

Sleep problems commonly co-occur with serious mental illnesses (SMI) and are associated with negative outcomes, though may be underrecognized and undertreated. This study examined whether clinical services for sleep disorders among Veterans with and without SMI changed during the past decade. The sample included Veterans with a diagnosed sleep disorder in VA VISN 4 (Pennsylvania and sections of Ohio, New Jersey and Delaware) electronic health record data from 2011 to 2019 (N = 77,898). Results revealed that, across 9 years of data, half of Veterans received no sleep services, but among those that did, sleep medications were most common., Notably, Veterans with SMI and sleep disorders were more likely than those without SMI to receive any sleep services, but the proportion of all Veterans receiving sleep services declined across the study period. Results from this study demonstrate that the needs of Veterans with SMI and sleep disorders are met equally well as those of Veterans without SMI, but there remains a large unmet need for all Veterans with sleep disorders, half of whom did not receive any services. Future work should investigate provider and patient perspectives regarding barriers and facilitators to engaging with sleep services, particularly services other than medication.

Beyond the physical: The interplay of experienced weight stigma, internalised weight bias and depression in lipoedema

This study explored experienced weight stigma, internalised weight bias and depressive symptom severity in lipoedema, a chronic health condition that primarily affects women and involves painful and disproportionate adipose tissue. This study utilised an international cross-sectional online survey involving N = 1070 women over 18 years old (Mage = 48.9 years old) with self-reported diagnosed or suspected lipoedema. Participants completed measures of demographic and health characteristics, experienced weight stigma, internalised weight bias and depressive symptoms (PHQ-9). Chi-square analysis showed experienced weight stigma differed between those with stage 1 (n = 57), stage 2 (n = 311), Stage 3 (n = 664) and stage unknown (n = 38) lipoedema. Hierarchical linear regression determined the effects of weight stigma on depression and the mediating role of internalised weight bias. Experienced weight stigma (p < .001) and internalised weight bias (p < .001) were related to depressive symptoms beyond age and symptoms of lipoedema (BMI, lipoedema symptom severity and mobility). Internalised weight bias partially mediated the effect of experienced weight stigma on depression. Psychological attributes of experienced weight stigma and internalised weight bias uniquely contribute to depressive symptoms in lipoedema. Increased awareness of the psychological effects of weight stigma and the role of internalised weight bias in women's experience of lipoedema on depression is needed.

Body image and interest in GLP-1 weight loss medications

There has been extensive discourse about new weight loss medications, glucagon-like peptide 1 agonists (GLP-1s), and their potential to induce significant weight loss among users. Past research reveals strong associations between body size and body image, which may lead some users of GLP-1s to expect an increase in body satisfaction. To date, no research has explored the relationship between body image and interest in using GLP-1s, which is the focus of the current study. Two hundred and twenty-five participants from a university in the Northeastern U.S. (Mage = 20.03; 71.2 % women) completed assessments of their awareness and interest regarding GLP-1s using questions developed specifically for this study. Participants also completed measures of body appreciation, body neutrality, self-objectification (body shame and surveillance), weight bias, concerns about weight, and attempts at weight loss; they self-reported their height and weight. Results indicated that participants who were most interested in trying GLP-1s and willing to tolerate their common side effects reported greater body shame, body surveillance, weight concerns, anti-fat bias, disordered eating behaviors, and higher BMIs, as well as lower body appreciation and body neutrality. Simultaneous regression analyses revealed that BMI and recent attempts at weight loss uniquely accounted for variance in interest in GLP-1 use and willingness to tolerate side effects of GLP-1s. Notably, body appreciation moderated one of these findings, suggesting that a higher appreciation for one's body may serve as a protective factor against interest in using GLP-1s for weight loss.

Weight Bias in the Perinatal Period: An Integrative Review

BACKGROUND

Weight bias toward individuals with higher body weights in healthcare settings is associated with adverse health behaviors, reduced healthcare utilization, and poor health outcomes. The purpose of this integrative review was to explore: (1) What has been measured and described regarding perinatal care providers' and students' weight bias toward pregnant, birthing, and postpartum individuals with higher body weights? (2) What has been measured and described regarding pregnant, birthing, and postpartum individuals' experiences of weight bias? (3) What is the association of experiences of weight bias with perinatal and mental health outcomes among pregnant, birthing, and postpartum individuals?

METHODS

We conducted a systematic search in CINAHL, PubMed, and PsycINFO databases to identify relevant research publications related to the Medical Subject Headings (MeSH) terms weight prejudice (and related terms) and pregnancy (and related terms). The review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), Johns Hopkins Nursing Evidence-Based Practice model for study quality determination, and the Whittemore and Knafl integrative review framework for data extraction and analyses.

RESULTS

Twenty-two publications met inclusion criteria, representing six countries and varying study designs. This review found pervasive sources of explicit weight bias in the perinatal period, including care providers and close relationships. Experiences of weight bias among pregnant and postpartum individuals are associated with adverse perinatal and mental health outcomes.

DISCUSSION

The findings address a knowledge gap regarding a summary of literature on weight bias in the perinatal period and elucidate its prevalence as well as its negative influence on perinatal and mental health outcomes. Future research efforts on this topic must examine the nature and extent of perinatal care providers' weight bias by demographic factors and explore its association with clinical decision-making and perinatal and mental health outcomes.

Weight loss dietary knowledge, attitudes, and practices among different body weight groups in Northeast China

Unhealthy dietary habits are prevalent in Northeast China, contributing to a high prevalence of obesity. This study aimed to assess the knowledge, attitudes, and practices (KAP) of the general population regarding weight loss dietary patterns in this region, with additional analysis of normal weight or underweight versus overweight and obesity subgroups. A cross-sectional study was conducted from September to November 2024 in Liaoning Province, China, using a self-administered questionnaire to collect demographic information and KAP scores. A total of 595 valid responses were analyzed (representing 91.4% of eligible participants), with 450 females (75.63%) and 145 males (24.37%). The overall knowledge score was 13.64 ± 5.88, with median attitude and practice scores of 28[25,31] and 35[32,42], respectively. Participants with overweight and obesity demonstrated higher scores in weight loss plateau understanding (p = 0.015) and realistic goal-setting (p < 0.001) compared to those with normal weight or underweight. Structural equation modeling identified significant associations between knowledge and both attitude (β=-0.40, 95% CI: -0.54,-0.20, p < 0.001) and practice, with knowledge showing a positive direct association with practice (β = 0.44, 95% CI: 0.30,0.58, p < 0.001) and a significant indirect association through attitude (β = 0.23, 95% CI: 0.14,0.31, p < 0.001) in the overall population. While participants demonstrated moderate levels of knowledge and attitudes regarding weight management, their practice levels were relatively low. Knowledge was significantly associated with both attitudes and practices, suggesting that educational interventions might be considered as a component in comprehensive approaches to weight management behaviors.

Perceptions of cancer risk communication in individuals with overweight or obesity- a qualitative interview study

BACKGROUND

Addressing obesity and overweight is crucial for cancer prevention. However, ensuring that such efforts do not harm individuals with obesity requires careful consideration to avoid reinforcing the widespread stigmatisation of individuals with obesity. This study aims to explore how individuals who have overweight or obesity perceive cancer risk information addressing obesity as a cancer risk factor.

METHODS

Semi-structured interviews were conducted during autumn 2023 and spring 2024, with 11 Swedish men and women, aged 24 to 70 years, who self-assessed as having overweight or obesity. The collected data were analysed using reflexive thematic analysis as described by Braun and Clarke.

RESULTS

The first theme, Reflecting on personal risk, included the subthemes: It is about me and my body and Awareness can be a burden. The second theme, Healthcare encounters: building trust and providing support, included the subthemes: Past encounters influence how risk information is perceived, Need to act and succeed, and Consider receptivity and power imbalances. The third theme, Distribution of responsibility and blameworthiness, included subthemes: Being personally blamed and fearing increased discrimination and A need for shared responsibility.

CONCLUSION

Participants experienced that risk information, when presented as simplified associations between obesity and cancer, felt personally relevant but difficult to act upon, and therefore burdensome to bear. Consequently, the information risks failing to prevent cancer and may instead cause harm to the people it purports to benefit. Participants suggested several ways to improve the provision and benefit of such information, including introducing multiple ways to act to reduce cancer risk that goes beyond weight reduction, and raising public awareness of the causes of obesity. Efforts to communicate risk, both to the public and to patients, require better ethical considerations of their benefits and harms. Furthermore, risk communicators should act with compassion and responsibility.

Weight Bias Interventions for Healthcare Professionals: An Integrative Review

AIM

To describe interventions to mitigate weight bias among practicing healthcare providers and examine their effectiveness.

DESIGN

An integrative review.

METHODS

The framework of Whittemore and Knafl (2005) was utilised to identify and synthesise studies of weight bias interventions. Covidence reference management software facilitated screening using predetermined eligibility criteria that is, published in peer-reviewed journals, reported in English, and described outcomes for weight bias mitigation interventions among healthcare providers with a professional practice licence. We evaluated study quality using Joanna Briggs Institute's Critical Appraisal Tools for qualitative and quantitative studies.

DATA SOURCES

Five databases were searched (CINAHL, Embase, EBSCOhost, APA PsycINFO, and Scopus) in July 2024.

RESULTS

Sixteen articles met the inclusion criteria. Four themes emerged: (1) active learning lessens weight bias more than passive learning, (2) multicomponent approaches yield better outcomes, (3) healthcare providers are willing to change their practices, and (4) explicit attitudes and beliefs are more amenable to change than implicit ones. Four sub-themes within theme one included the use of in-person workgroups; films, computer-based, and podcast delivery; written modules; and physical characteristic modifications, such as the use of an adiposity empathy suit. Intervention designs using a theory-based, active learning approach with repeated sessions were most successful at decreasing negative weight-biased attitudes and beliefs.

CONCLUSIONS

Interventions that effectively reduce weight bias among practicing healthcare providers vary, yet evidence suggests that weight bias mitigation is achievable. These interventions offer strategies to improve patient-centred care among patients living with obesity.

IMPACT

Healthcare providers often display weight bias. This review synthesises information on effective interventions for reducing bias, which may limit the subsequent negative patient outcomes associated with it.

REPORTING METHOD

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses was the structure used for this paper.

PATIENT OR PUBLIC CONTRIBUTION

There were no patient or public contributions.

Weight stigma and bias: standards of care in overweight and obesity-2025

Weight bias involves negative attitudes and stereotypes towards individuals based on their weight, which can be explicit or implicit. This bias contributes to weight stigma, or the mistreatment and social devaluation of individuals based on weight. Weight stigma is linked to adverse physical and mental health outcomes, leading to reduced access and quality of healthcare for individuals with obesity. The American Diabetes Association (ADA)'s Obesity Association developed guidelines on recognizing and addressing weight bias and stigma. All healthcare professionals and staff should receive training on weight bias and stigma to improve care for individuals with obesity. Training should start early and continue throughout medical education and practice. Multicomponent training that combines education with hands-on learning is recommended to reduce explicit and implicit weight bias. Clinical practices, a potential source of stigmatization for people living with obesity, should be equipped with appropriate furniture and equipment to establish an inclusive environment. Privacy and sensitivity during anthropometric measurements are essential to minimize stigmatization. Healthcare professionals should use person-centered, non-judgmental language and engage individuals in shared decision-making to consider their health and goals. Asking permission to discuss weight and respecting individual preferences is crucial. The ADA's Obesity Association encourages adopting these guidelines to reduce weight bias and stigma, emphasizing education, inclusive clinical environments, and effective communication to improve obesity care.

Weight Bias in Nursing: A Pilot Study on Feasibility and Negative Attitude Assessment Among Primary Care Nurses

Background: Weight bias in healthcare can affect the quality of care and create health disparities. In nursing, the presence of weight-biassed attitudes influences the therapeutic relationship and clinical decision-making. However, in Spain, research on this phenomenon remains scarce, hindering the development of strategies to mitigate its impact. Objectives: This study aimed to assess the methodological feasibility of a study on weight bias in nursing, and to explore nurses' attitudes towards being overweight and obesity and their association with sociodemographic and body image variables. Methods: A cross-sectional, quantitative pilot study was conducted with 22 primary care nurses. The Anti-Fat Attitudes (AFA) and Beliefs About Obese Persons (BAOP) scales, previously validated in Spanish-speaking populations, were applied. Response distribution, the internal consistency of the instruments, and the relationship between variables were analysed. Results: Difficulties were identified in the recruitment of participants and the reliability of certain items of the questionnaire, as well as in the internal consistency of the scales. A trend towards moderate weight-biassed attitudes was observed in the sample, with the highest scores in the AFA's "Willpower" subscale. The BAOP scale showed a significant negative correlation with the AFA (r = -0.55, p = 0.009), indicating that a lower attribution of obesity to individual control is associated with less discriminatory attitudes. Conclusions: This pilot study helped identify methodological improvements and confirmed the presence of weight bias in nursing. It is recommended that the sample be expanded and the measuring instruments refined before performing the full study.

Navigating weight stigma: An integrative review of midwives' knowledge, attitudes and beliefs about caring for larger-bodied women

PROBLEM

Women are vulnerable to weight bias during their reproductive years. However, little is known about midwives' knowledge, attitudes and beliefs about caring for larger bodied women.

BACKGROUND

Women have reported experiencing weight stigma during interactions with healthcare providers, including midwives. Weight stigma is associated with reduced quality of health and primary healthcare avoidance. In Australia over half of pregnant women are of a higher weight during their reproductive years.

AIM

To describe what is currently known about midwives' knowledge, attitudes and beliefs relating to caring for larger bodied women across the peripartum period.

METHODS

An integrative review was undertaken, involving a systematic literature search, quality appraisal, and synthesis of findings within the socioecological framework.

FINDINGS

Sixteen articles were included. Across the socioecological levels: individual level themes related to midwives' attitudes and beliefs and midwives' own body size; interpersonal themes related to communication and relationships; community themes related to the influence of cultural norms; organisation/institutional level themes related to BMI and weight checks, the need for training and education, and the role of healthcare practices and guidelines emerged; finally, at the policy level, system level factors and a weight inclusive approach were identified.

DISCUSSION

This review highlighted that some midwives and student midwives hold negative, stigmatising views towards larger bodied women. Midwives are impacted by their own attitudes and beliefs as well as interpersonal, societal, organisational and system level factors.

CONCLUSION

Efforts to reduce weight stigma require a multi-level socio-ecological approach, including educational strategies aimed at shifting current and future midwives' stigmatising attitudes and beliefs towards larger bodied women.

Weight Stigma in Adolescents With Obesity From Low-Income Backgrounds: Qualitative Perspectives From Adolescents and Caregivers

PURPOSE

Weight stigma is a common experience for adolescents at high weight statuses. Prior research regarding experiences of weight stigma in adolescence has been in primarily homogenous samples. The present study sought to characterize weight stigma experiences and internalization in adolescents from low-income backgrounds. This was done by reporting on teen's experiences of weight stigma in daily life and in conversations with health-care professionals, and examining the effect of internalization of this stigma.

METHODS

This study is a secondary analysis of semi-structured qualitative interviews conducted with adolescents with high weight from low-income backgrounds who had been referred to weight management, as well as their caregivers. Data was analyzed using applied thematic analysis.

RESULTS

Fifty-five participants (29 adolescents and 26 caregivers) from low-income backgrounds participated in semi-structured interviews. Given the broader focus of the primary study, weight stigma was not a focus of interviews. However, almost all participants identified weight stigma and bias as influencing their lives and medical care. Identified themes included the following: (1) difficulty identifying preferences regarding weight-related terminology; (2) commonality of experienced weight stigma; and (3) significant effect of internalized weight bias on adolescent daily living.

DISCUSSION

Overall, the present study identified nearly ubiquitous experiences of weight stigma for a sample of youth from low-income backgrounds living in larger bodies. This highlights the pervasive presence of weight stigma and bias throughout adolescents' lives, including in health-care settings. These findings are particularly stark, given that weight stigma was not a topic within the interview guide.

Feasibility and acceptability of a pilot randomized trial of a single session of imagery rescripting targeting the primary consequences of negative experiences with eating and appearance

BACKGROUND

Negative experiences related to eating and appearance (NEREAs), such as critical commentary from parents about food, are common and associated with depression and disordered eating. Imagery rescripting (IR) is a therapeutic process during which individuals are guided through recalling and bringing support into distressing memories, like NEREAs. Single sessions of IR demonstrate promise in shifting the primary negative consequences of NEREAs in clinical samples of women. The primary objectives of this pilot trial were to evaluate the feasibility and acceptability of a remote-delivered, single session of IR and a nutrition education control group in a community sample of adults with NEREAs.

METHODS

In this parallel two-arm pilot trial, participants completed an in-person baseline visit, one remote-delivered, single-session intervention (IR or attention-matched nutrition education control), and in-person 1- and 3-month follow-up visits between February 2023 and April 2024 in Oregon, USA. Markers of feasibility included recruitment, visit and survey completion rates, and intervention fidelity; acceptability was evaluated using participant feedback and instances of adverse events.

RESULTS

One hundred one adults completed a phone screen; 96% reported at least one NEREA. Most of these adults were ineligible because they met psychiatric disorder criteria and/or were taking medication known to influence mood and/or appetite. Thirty-two participants completed a baseline study visit; 89% of these participants (N = 27; mean age [SD] = 32.52 [15.78], range = 18-73; 56% cisgender women; 74.1% non-Hispanic White, 14.8% Asian, 11.1% Hispanic/Latine, 7.4% Black, and 3.7% multiracial) were randomly assigned (using a random number generator) to and completed an intervention condition (13 IR, 14 control). Curriculum adherence, on average, was 94% for IR and 97% for control. One-month retention was 82%, and 3-month retention was 59%. Post-intervention ratings indicated good acceptability for both arms. No adverse events occurred.

CONCLUSIONS

The delivered interventions are feasible and acceptable to a community sample of men and women; as such, a future definitive trial is recommended. Additional strategies for increasing retention are needed. Single-session interventions, like IR, have the potential for high impact and reach. They are inherently flexible and cost-effective interventions that can be delivered across systems of care, while remote delivery mitigates concerns with stigma and access.

TRIAL REGISTRATION

ClinicalTrial.gov, NCT06610318 . Registered on 23 September 2024-retrospectively registered.

Dieting among a community sample of adults with chronic pain

Chronic pain and dieting represent significant threats to public health. Larger individuals and individuals with chronic pain are often stigmatized for their conditions and subsequently internalize stigma, exacerbating their negative mental and physical health impacts. Given the multiplicative effects of pain, stigma, and excess weight, research should examine associations among chronic pain, dieting behaviors, and experiences of health-related stigma. Adults (N = 286; Mage = 36.75, SD = 11.56; 62.6% female) with chronic pain participated in an online survey. Over half (57.9%) reported engaging in maladaptive weight loss behaviors. Higher levels of both experienced and internalized stigma were associated with more dieting behavior among smaller-bodied individuals. Maladaptive attempts at weight loss are fairly common among adults with chronic pain, and stigma can relate to these attempts among smaller-bodied individuals who have chronic pain. Screenings for disordered eating among chronic pain patients may be beneficial in clinical settings.

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.

Dealing with lipoedema: women's experiences of healthcare, self-care, and treatments-a mixed-methods study

BACKGROUND

Lipoedema is a loose connective tissue disease primarily affecting women characterized by an abnormal build-up of painful fat in the legs and arms. In healthcare, lipoedema is often confused with obesity, and today, diagnostic tools and standardized guidelines for adequate treatments are lacking. Still, research on how affected women manage their health problems and whether they are satisfied with their care remains sparse. Therefore, this study aimed to contribute knowledge on healthcare experiences, and their use and self-reported effects of self-care and treatments among women with lipoedema.

METHODS

This national study, with a mixed-methods design, involved 245 women with lipoedema, recruited from all Lipoedema Association groups across Sweden. Data were collected between June and September 2021 through an online survey that included closed- and open-ended questions on self-care, lipoedema treatment, patient satisfaction, and healthcare experiences. Data were analysed using descriptive and inferential statistics, and qualitative reflexive thematic analysis.

RESULTS

The results showed a delay in diagnosis spanning decades, often preceded by numerous healthcare visits. Many women attempted to cope with their health problems using various self-care approaches. However, lipoedema treatments performed by healthcare providers were deemed the most effective. Overall, the women reported significantly low satisfaction with healthcare. The lowest score, 48 points out of 100, was found in the overall impression of offered care, reflecting perceived inefficiency and unmet expectations. Compared to a general Swedish female population, the most significant gaps were found in the dimensions of information and knowledge, and emotional support, 22 and 25 points lower, respectively. The women described their experiences in healthcare as a challenging and isolated journey. Four themes were generated: A lonely and demanding journey in the healthcare system; An uncertainty of and inconsistency in available healthcare; A burden of being unheard and disrespected in healthcare; and The impact of lack of knowledge in healthcare.

CONCLUSIONS

Seeking care for lipoedema is a long and burdensome journey with limited access to tailored care. Many women make significant efforts to manage their health problems independently. This emphasizes a need for timely lipoedema diagnosis, improved support, and better access to effective treatments.

Doctor-patient communication in obesity disease - the perspective of Polish primary care physicians

BACKGROUND

Obesity is a chronic disease that is affecting an increasing number of patients. The prevalence of obesity, the age of patients affected, and the range of associated comorbidities suggest that general practitioners will engage with this patient group extensively throughout their professional careers. It is regrettable that numerous obstacles impede the efficacious treatment of obesity by primary care physicians. These include inadequate training in obesity management and communication with patients, as well as a pervasive and problematic bias in the approach to the treatment of patients with obesity.

METHODS

The objective of the study was to examine the knowledge, self-assessment, experiences and perceptions of primary care doctors in Poland with regard to the communication and management of obesity. The data were collected via computer-assisted telephone interviewing (CATI). The sample was deliberately random selected from the available database of numbers. The inclusion criteria were aged 24 or over and active working as a primary care doctor in Poland. The research sample comprised 150 primary care doctors with various medical specialties, including the following: family medicine, internal medicine, pediatrics, endocrinology, diabetology, and others. An even distribution of participants was not ensured with respect to the parameters considered.

RESULTS

The findings of our study indicate that primary care physicians mostly disagreed with the view that patients living with obesity are less hardworking or more demanding but just over half disagreed that these patients are lazier than others. Doctors reported rarely using fear-based language or blaming excessive food consumption for obesity. Instead, many emphasized that obesity is a disease and considered the patient's perspective. Doctors who rated their communication skills and medical knowledge needed for conversations with patients living with obesity more highly were more likely to address this topic during a visit for an unrelated medical condition. Those who avoided the topic often felt they lacked the skills or knowledge to engage patients effectively. Almost half of the surveyed physicians had not received any training in communicating with patients living with obesity and only 11% had the issue addressed in a course for specialization.

CONCLUSIONS AND IMPLICATIONS

The study indicates a necessity for changes in the curricula of both pre- and postgraduate education, including an enhancement of the knowledge and abilities of primary care providers in the domain of communication during visits with patients with obesity, the encouragement of lifestyle modifications and the implementation of efficacious treatments for obesity, as well as activities designed to modify the negative attitudes of primary care physicians towards patients living with obesity which should not appear in healthcare at all.

Women's Improvements in Cardiorespiratory Fitness Following Cardiac Rehabilitation Differ by Body Mass Index Category

Background

Improving women's cardiovascular outcomes requires optimizing cardiorespiratory fitness (CRF), as higher CRF predicts improved mortality in people with cardiovascular disease (CVD). As such, increasing CRF is a key goal of cardiac rehabilitation (CR). This study assesses the potential influence of body habitus, assessed by body mass index (BMI), on improvements in CRF in women with CVD.

Methods

Women (18+ years) diagnosed with CVD who completed a 12-week exercise-based CR program between 1996 and 2016 were included in this retrospective analysis. Women completed a symptom-limited graded exercise test before CR and at CR completion to determine CRF via peak metabolic equivalents (METs). Women were categorized by baseline BMI: normal = 18.5 to 24.9 kg/m2, overweight = 25.0 to 29.9 kg/m2, and obese ≥ 30 kg/m2. Mixed analysis of covariance (ANCOVA) was performed to evaluate the impact of BMI classification on ΔMETs at 12 weeks.

Results

Data from 1313 women (mean age = 62 ± 11 years) were analyzed. Results from mixed ANCOVA indicated a significant time (pre-CR, 12 weeks) by BMI category interaction (F [2,1307] = 3.20, P = 0.041, ƞp2 = 0.005). Follow-up analyses of variance (ANOVAs) showed significant improvements in ΔMETs in women with normal and overweight BMI categories (standard mean difference =1.03, n = 454 and 0.92, n = 461, respectively, P < 0.001). However, ΔMETs among women classified as obese was nonsignificant using a Bonferroni-adjusted alpha of 0.017 (standardized mean difference [SMD] = 0.79, P = 0.028; n = 398).

Conclusions

A 12-week exercise-based CR program increased CRF in women classified as normal or overweight by BMI, whereas those with obesity did not realize similar improvements. Women with obesity may need tailored strategies to increase their improvements in CRF in CR.

Clinical Trial Registration

REB18-0083.

An Assessment of the Long-Term Efficacy of an Undergraduate Curriculum-Embedded Weight Bias Intervention in Practicing Registered Nurses

Background

Individuals with obesity often experience weight bias in healthcare, which may negatively impact health outcomes. Weight bias (WB) can be reduced by provider participation in weight bias interventions. This mixed-methods study investigated the sustainability of reduced WB in those who received a weight bias intervention.

Method

Registered nurses (RNs) who completed a weight bias intervention during their nursing education and those who did not were recruited to complete an online survey. WB scores and approaches towards caring for patients with obesity were compared.

Results

Eighty-four RNs (50 intervention; 34 control) participated. Reduced WB was sustained over 4 and 6 years compared to pre-intervention scores (p < 0.001). No significant WB differences were found between the groups (p = 0.501). Thematic analysis identified three overarching themes: physical care differences, recognition of obesity's causality and controllability, and equal treatment of all patients.

Conclusions

Weight bias intervention effects were sustained, but non-intervention nurses had comparable WB scores, indicating multifaceted influences on WB in clinical practice. In order for nurses to provide unbiased care for individuals with obesity, it is important to develop and implement both high-impact educational interventions that support reduced weight bias and organizational and structural supports in the practice environment.

Identifying characteristics of intersectoral health interventions between the primary care and community settings for people living with obesity: an environmental scan protocol

INTRODUCTION

Obesity, a complex chronic disease, is on the rise, leading to increased mortality, morbidity and societal challenges. This study explores intersectoral interventions focusing on the needs of people living with obesity (PLO).

METHODS AND ANALYSIS

An environmental scan of the published and unpublished literature will be conducted using Medline, Embase, Cumulated Index in Nursing and Allied Health Literature and specialised websites. To be included, citations must describe or evaluate an intersectoral intervention for PLO developed in primary care or community settings. Title and abstract, full-text screening and extraction will be completed by two independent reviewers. Discrepancies will be resolved through consensus. Data such as study and intervention characteristics will be extracted using a customised extraction template on Covidence and synthesised in a table. Findings from this study will guide intervention design and enhance intersectoral collaboration in primary care and community settings. A multidisciplinary group, including clinicians and two patient partners, will be consulted throughout the process. Despite the challenges of defining intersectoral collaboration and limited data on obesity as a chronic disease, this study is foundational for developing effective intersectoral interventions for PLO.

ETHICS AND DISSEMINATION

Ethics approval is not required. Findings will be disseminated through presentations at relevant conferences and other knowledge translation activities and will be published in a peer-reviewed journal.

Mapping Psychological Well-Being in Morbid Obesity: A Network Analysis Approach

Background/Objectives: Identifying key psychological well-being factors in morbid obesity is crucial for designing effective mental health and weight management interventions. This study explores the interconnections between the dimensions of psychological well-being in a large sample of adults with morbid obesity enrolled in an inpatient nutritional rehabilitation program. Methods: A sample of 3212 participants (F = 58%; mean age = 57.18 years; mean Body Mass Index = 43.40 kg/m2) completed the Psychological General Well-Being Index (PGWBI) upon admission to the clinic. A network analysis approach examined the relationships among the PGWBI dimensions (anxiety, depression, positive well-being, self-control, vitality, and general health). Results: Network analysis revealed that vitality and positive well-being exhibited the highest values across closeness (1.432; 0.353), strength (0.853; 0.917), and expected influence (0.853; 0917), indicating their key role in psychological well-being. Depression also demonstrated moderate relevance, suggesting its connection to other well-being factors, though it was not the primary determinant. In contrast, self-control and general health had negative strength and expected influence values (-0.660; -1.641), indicating a less central role in the network. Additionally, anxiety and depression displayed negative betweenness (-0.645), reinforcing their more peripheral position. Conversely, positive well-being and vitality showed the highest betweenness (1.291), highlighting their role as key connecting nodes within the well-being network. Conclusions: Findings suggest interventions targeting positive well-being and vitality may most effectively enhance psychological well-being in morbid obesity, emphasizing strength-based approaches that foster positive affect, motivation, and resilience rather than focusing solely on reducing distress or weight-related concerns.

Reckoning with the past: a qualitative analysis of medical students describing their formative experiences with weight bias

INTRODUCTION

Most healthcare providers exhibit weight bias (i.e., negative assumptions, beliefs, or discriminatory acts toward someone based on their weight/body size) in their interactions with patients with obesity. Such bias can be exacerbated in medical training and may lead to reduced healthcare utilization and worsened patient outcomes. This study explored reflections of pre-clinical medical students on formative experiences they perceived to be related to their newly identified implicit weight bias.

METHOD

Seven hundred and sixteen second-year medical students completed the Weight Implicit Association Test (IAT) between April 2019-April 2022 and were instructed to write a reflective response based on their results. Of this sample, 212 students described experiences from childhood in their reflections, and these participant quotes were pulled for analysis. Inductive coding techniques were used to identify themes that were generated from medical students' reflections on formative experiences using the software program Dedoose Version 8.3.35.

RESULTS

The identified themes highlighted medical students' own struggles with weight management and body dissatisfaction in childhood, a fear of having obesity, the prioritization of a "healthy" (i.e., thin) body and the stigmatization of larger bodies, and the influence of culture of origin on thin-ideal internalization. Results recognize the manifold experiences that these medical students have before entering their formalized medical training.

DISCUSSION

Despite the proven negative impact on patient care caused by clinician weight bias there is a paucity of medical training programs that address weight bias. This research highlights the need for a more intentional educational curriculum to counteract the deeply rooted implicit weight bias existent in some future healthcare providers.

Patient Perspectives on Impact of Weight and Weight Stigma on Breast and Cervical Cancer Treatment: A Qualitative Study

BACKGROUND

Higher weight individuals report experiencing weight-based stigma in the healthcare setting; within the cancer continuum, the most robust evidence exists for cancer screening. More research is needed to understand whether and how higher weight patients experience weight stigma during cancer treatment.

METHODS

We conducted semi-structured interviews with 15 breast and 15 cervical cancer survivors diagnosed 2017-2019 in Iowa who had a pre-diagnosis body mass index of 30+ kg/m2 calculated from their driver's license height and weight. Interviews focused on whether individuals perceived being treated differently because of their weight in daily life, in healthcare, or during cancer treatment. Data were coded using a combination of inductive and deductive approaches, and analyzed using a multi-phase thematic analysis.

RESULTS

Almost all interviewees reported positive experiences during cancer treatment; several described their weight as never being an issue. Some identified weight stigma during cancer diagnosis or treatment that resulted in delayed diagnoses or changes in treatment. Many interviewees described situations where their weight was discussed negatively during cancer treatment, but most did not identify these as stigmatizing because their providers were only "concerned about [their] health." Additional themes developed included experiencing environmental stigma, the discussion of cancer recurrence by providers only as it related to weight, and misconceptions of the causes and consequences of obesity.

CONCLUSIONS

While several participants did not feel that their weight impacted cancer treatment, some reported experiences of weight stigma pre-diagnosis and during treatment. When individuals noted their weight was discussed during treatment, internalized bias may have impacted whether they considered these discussions stigmatizing.

Inequities time-to-follow-up care and administrative action after low back pain diagnosis in active duty service members

ABSTRACT

As healthcare systems adopt data-driven methods to determine resource allocation for treating low back pain (LBP), it is critical to evaluate equity in time-to-follow-up care after an index visit and long-term occupational outcomes. This retrospective observational study included medical records of 525,252 active duty US service members who received an LBP index diagnosis from June 2016 to February 2022. Poisson generalized additive models evaluated time-to-LBP follow-up visit (primary outcome) and administrative action receipt (eg, disability evaluation; secondary outcome). Service members assigned female in the medical record compared to service members assigned male had lower cumulative hazards of follow-up visit at 1-week, but higher hazards by 4 weeks. Asian and Pacific Islander, Black, and Latino service members compared to white service members had lower cumulative hazards of follow-up visit during the acute/subacute period (up to 7, 19, 31, weeks, respectively), then higher cumulative hazards. Service members whose race and ethnicity was recorded as Other had lower hazards across time. Service members assigned female in the medical record compared to service members assigned male had lower cumulative hazards of administrative action receipt, as did Asian and Pacific Islander, Black, and Latino service members and service members whose race and ethnicity was recorded as Other compared to white service members. Overall, inequities in LBP follow-up visit timing warrant system-level programming to mitigate healthcare barriers acutely and subacutely after an LBP index visit, as well as system-level evaluation of pathways to administration action receipt.

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.

Physical Health in Psychosis: a Perspective on the Recovery Paradigm

This paper explores the intersection of physical health and recovery-oriented approaches in psychosis, offering a unique perspective through autoethnography. By combining personal experience with a broader analysis of existing mental health frameworks, the paper highlights the often overlooked importance of physical health in the recovery process for individuals with psychosis. The autoethnographic narrative reveals the complex challenges posed by antipsychotic medications, including weight gain and metabolic complications, and their impact on overall well-being. It emphasizes the dual stigma of mental health challenges and weight gain, highlighting the need for a more integrated, holistic approach to mental health care. Recommendations include enhanced education for healthcare providers, personalized care plans, and a multidisciplinary approach aimed at bridging the gap between physical and mental health in psychosis recovery.

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.

Efficacy of interventions aimed at reducing explicit and implicit weight bias in healthcare students: A systematic review and meta-analysis

We conducted a systematic review and meta-analysis to determine the efficacy of interventions aimed at reducing weight bias in healthcare students, and to explore factors that may impact intervention success. A systematic review and random-effects meta-analyses were conducted by including studies that examined the efficacy of weight bias reduction interventions for healthcare students. Of the 3463 journal articles and dissertations screened, 67 studies (within 64 records) met inclusion criteria, with 35 studies included in the meta-analyses (explicit = 35, implicit [and explicit] = 10) and 32 studies included in the narrative synthesis (explicit = 34, implicit [and explicit] = 3). Weight bias interventions had a small but positive impact, g = -0.31 (95% CI = -0.43 to -0.19, p < 0.001), in reducing students' explicit weight bias but there was no intervention effect on implicit weight bias, g = -0.12 (95% CI = -0.26 to 0.02, p = 0.105). There was considerable heterogeneity in the pooled effect for explicit bias (I2 = 74.28, Q = 132.21, df = 34, p < 0.001). All subgroup comparisons were not significant (p > 0.05) and were unable to explain the observed heterogeneity. Narrative synthesis supported meta-analytic findings. The small but significant reduction of explicit weight bias encourages the continued testing of interventions, irrespective of variation in individual intervention components. Contrarily, reductions in implicit weight bias may only be possible from a large societal shift in negative beliefs and attitudes held towards people living in larger bodies.

'It's not a solution to keep telling me to lose weight!' Exploring endometrial cancer survivors' experiences of nutrition and well-being advice: A qualitative study

AIMS

The aim was to explore Endometrial cancer (EC) survivors' experiences of being offered nutrition and well-being advice.

METHODS

This qualitative study was conducted at two tertiary centres in Aotearoa New Zealand. Semi-structured conversations with people who had completed treatment for EC in the past 12 months were undertaken to explore how they were offered nutrition and well-being advice as part of standard follow-up care. Interviews were analysed using reflexive thematic analysis.

RESULTS

Fifteen people of Pacific, Māori and European ethnicity participated. Five themes were derived: (i) isolation and vulnerability, (ii) importance of language, (iii) inconsistent availability and relevance of nutrition and well-being information, (iv) competing priorities and influences and (v) holistic and culturally responsive support. People often experienced judgement associated with their weight as part of their care, with limited understanding of their lived realities. Nutrition and well-being advice was not widely available or accessible, and people had to explicitly ask for it. Social and environmental factors were barriers to making changes to health behaviours. A need for culturally safe holistic care was identified.

CONCLUSION

Enhancing survivorship after EC is ultimately premised on providing culturally safe and responsive care. Expanding workforce training in communication around high weight as well as education and self-assessment of cultural safety could enable aspects of this. A holistic care program could facilitate wider access to nutrition and well-being advice and better meet the needs of this population.

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.

Remote Lifestyle Intervention to Reduce Postpartum Weight Retention: Protocol for a Community-Engaged Hybrid Type I Effectiveness-Implementation Randomized Controlled Trial

BACKGROUND

Maternal obesity is associated with significant racial disparities. People who identify as non-Hispanic Black and Latinx are at the highest risk related adverse short- and long-term health outcomes (eg, hypertension in pregnancy and postpartum weight retention). Remote lifestyle interventions delivered during and after pregnancy hold promise for supporting healthy weight outcomes; however, few are tested in groups of people who self-identify as non-Hispanic Black and Latinx or address the neighborhood-level and psychosocial factors driving maternal health disparities. Implementing remote lifestyle interventions within community-based programs that serve birthing people may optimize trust and engagement, promote scalability and sustainability, and have the broadest public health impact.

OBJECTIVE

The goal of this trial is to test the effectiveness of a culturally adapted remote lifestyle intervention (Healthy for Two-Home Visiting) implemented within home visiting compared to usual home visiting services on postpartum weight retention among pregnant or postpartum individuals, in particular those who identify as non-Hispanic Black and Latinx. Facilitators and barriers to implementation of the intervention within home visiting will be examined.

METHODS

We describe the rationale and protocol for this hybrid type I effectiveness-implementation randomized controlled trial. In this paper, we highlight the community-engaged approach and trial design features that enable the implementation of the intervention within home visiting and demonstrate its applicability to the target population. Participants will be 360 pregnant individuals with overweight or obesity enrolled between 20 and 33 weeks of gestation and randomized 1:1 to Healthy for Two-Home Visiting or usual home visiting services. The primary outcome is weight retention at 6 months post partum, calculated as 6-month postpartum weight minus earliest pregnancy weight (≤18 wk of gestation). The measures of implementation include intervention feasibility, acceptability, reach, adoption, and fidelity. Throughout the paper, we highlight the community input used to improve intervention effectiveness and study implementation and as a strategy to promote maternal health equity.

RESULTS

This study was funded in June 2021, and recruitment began in April 2023. As of November 2024, we enrolled 90 participants. Data collection to assess the intervention's effectiveness is expected to end in June 2026. Implementation evaluation is expected to conclude in December 2026.

CONCLUSIONS

This hybrid type I effectiveness-implementation randomized controlled trial integrates a culturally adapted remote lifestyle intervention into early home visiting services to examine its effectiveness on postpartum weight retention compared to usual home visiting. We anticipate that the study results will enable an understanding of the drivers of successful implementation within a community-based setting to maximize the future sustainability and dissemination of a strategy for reducing long-term obesity and other maternal health disparities.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05619705; https://clinicaltrials.gov/study/NCT05619705.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/62847.

Obesity and postpartum hospital use among individuals without additional medical comorbidities

OBJECTIVE

The objective of this study was to examine whether obesity without preexisting or gestational comorbidities is associated with postpartum hospital use (PHU).

METHODS

We studied 2016 to 2018 birth certificate and discharge data on 178,729 New York City births without International Classification of Diseases, Tenth Revision (ICD-10) codes at delivery for diabetes; hypertension; placental disease; anemia; thyrotoxicosis; bariatric surgery; and pulmonary, cardiac, renal, bleeding, autoimmune, digestive, neuromuscular, mental, or substance-use disorders. We defined PHU as ≥1 readmission or emergency department visit within 30 days of delivery discharge. We used ICD-10 codes to specify postpartum hypertension, infection, or hemorrhage during PHU (i.e., "cause-specific PHU") because these are leading mortality causes. We examined associations between prepregnancy BMI and PHU using multivariable logistic regression.

RESULTS

PHU incidence was 3.7% for those with normal weight, 5.1% for those with overweight, 6.3% for those with class 1 or 2 obesity, and 9.1% for those with class 3 obesity. A positive association persisted after adjustment. Obesity was associated with cause-specific PHU of postpartum hypertension (adjusted odds ratio [aOR]: 2.2, 95% confidence limits [CL]: 1.8-2.7, normal weight referent) and wound infection (aOR: 1.5, 95% CL: 1.2-1.8), but not hemorrhage (aOR: 0.9, 95% CL: 0.7-1.3), mastitis, or genitourinary infection (aOR: 1.1, 95% CL: 0.9-1.3).

CONCLUSIONS

Among individuals without other comorbidities, elevated BMI was associated with PHU. Findings can inform obstetric management to reduce morbidity during the critical fourth trimester.

Weightism in Asia: A Narrative Review and Implications for Practice

Weightism, also known as weight-related discrimination, is pervasive and believed to be one of the socially accepted types of discrimination in Asia. Weightism is pervasive, impactful, and has significant repercussions on individuals grappling with excess weight. Despite being a major risk factor for obesity, excess weight is not well documented in the Asian literature. This narrative review explores compelling evidence indicating that weightism adversely affects both physical and psychological well-being across various aspects of life. Research findings suggest that weightism be deemed socially unacceptable in Asia to mitigate the obesity epidemic and enhance overall well-being. Consequently, several recommendations for reducing weight stigma in Asian culture are proposed to support a healthier future.

Weight-Inclusive Approaches to Nutrition and Dietetics: A Needed Paradigm Shift

This Perspective article encourages the field of nutrition and dietetics to move away from a weight-centric paradigm that emphasizes weight loss and weight management as primary health outcomes. This approach can perpetuate weight stigma, which is associated with poorer health behaviors, poorer mental health, disordered eating, and even increased mortality risk. We propose an alternative approach-adopting a weight-inclusive paradigm-that focuses on providing care across the weight spectrum by centering health behaviors rather than weight. This approach allows individuals of all sizes to have equitable access to high-quality nutrition and dietetics care.

"Constantly justifying my existence": Lower-income, higher-weight Canadian adults' stigma coping mechanisms

Individuals who are higher-weight and low-income may disproportionately experience weight and income stigmas in healthcare experiences compared to lower-weight, higher-income individuals. The ways that weight and income stigmas interact in healthcare should be better understood in order to provide better, less stigmatizing care to higher-weight, low-income patients. This study assesses how patients manage stigmatizing experiences in both healthcare and everyday experiences and how that impacts health seeking and stigma management behaviors through semi-structured interviews with 11 higher-weight (Body Mass Index ≥30), low-income adults (≥18 years of age) in an Atlantic Canadian province. Participants took part in two interviews that focused on healthcare experiences and both positive and negative places/spaces. The two face-to-face interviews for each participant (total 21 interviews) were audio-recorded and professionally transcribed verbatim. The transcripts were analyzed using thematic analysis to identify recurring concepts and patterns within the data. Two major themes emerged from the data, uptake of stigmatizing, neoliberal health messaging and coping with stigma. Coping with stigma included subthemes control over stigmatizing experiences and stoicism in the face of stigma. The findings suggest that individuals understand their health and wellness through a neoliberal lens and that they deploy strategies of control and stoicism to cope with the stigmas they face.

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.

The Body Advocacy Movement-Health: a pilot randomized trial of a novel intervention targeting weight stigma among health professional students

BACKGROUND

Weight stigma among healthcare professionals is associated with negative health impacts on patients, yet there are few effective strategies to combat weight stigma among health professional learners. The Body Advocacy Movement-Health (BAM-Health) is a novel group-based, peer-led stigma reduction intervention for health professional students that targets weight stigma across intrapersonal, interpersonal, and structural levels. The present study (1) assesses short-term impacts of BAM-Health participation on intrapersonal and interpersonal weight bias compared to an informational brochure control condition and (2) explores the feasibility and acceptability of BAM-Health among a sample of health professional students.

METHODS

Sixty-seven health professional students participated in BAM-Health (n = 34) or received an informational brochure about weight stigma (n = 33). Participants completed validated self-report surveys assessing internalized weight/ appearance concerns and interpersonal weight stigma prior to their assigned intervention (baseline), immediately following intervention (post-intervention), and four weeks after intervention (follow-up). Baseline to post-intervention and baseline to follow-up effect sizes on each measure were calculated. At post-intervention, participants completed feedback surveys for thematic assessment.

RESULTS

BAM-Health participation had a large baseline to post-intervention effect on internalized weight/ appearance concerns that diminished slightly at follow-up (Cohen's d = -0.88; d = -0.62). Receipt of the informational brochure had a small effect on internalized weight/ appearance concerns (d = -0.27); however, these changes were not sustained at follow-up (d = 0.04). BAM-Health participation resulted in reductions in interpersonal obesity stigma and anti-fatness with small effect sizes (d = -0.32; d = -0.31). The effect on obesity stigma was slightly amplified at follow-up (d = -0.43); however, decreases in anti-fatness were not sustained (d = -0.13). The brochure condition failed to demonstrate effects on anti-fatness (d = 0.13, d = 0.14) or obesity stigma (d = -0.12; d = -0.12) at either time point. Between-session attrition rates of 4.5%, favorable quantitative ratings on post-session acceptability surveys, and free responses demonstrating appreciation of the virtual group environment and session activities reflect feasibility and acceptability of BAM-Health.

CONCLUSIONS

BAM-Health is a novel peer-led intervention that aims to reduce weight stigma among health professional students. BAM-Health met feasibility benchmarks and received positive feedback from participants, demonstrating acceptability and indicating interest among health professional students in analyzing and reducing weight stigma in their personal lives and careers. The intervention led to promising decreases in internalized and interpersonal weight stigma at post-intervention, some of which were sustained at follow-up. However, lack of effect on internalized weight/ appearance concerns measures may indicate that BAM-Health participants are more likely to reject weight stigma directed toward others following intervention, while maintaining thin ideals for themselves. Further investigation of BAM-Health with a larger sample and continued program development is warranted.

The association between excess weight and COVID-19 outcomes: An umbrella review

This umbrella review assessed the association between excess weight and COVID-19 outcomes. MEDLINE, PsycINFO, and CINAHL were systematically searched for reviews that assessed the association between excess weight and COVID-19 outcomes. A second-order meta-analysis was conducted on the available data for intensive care unit admission, invasive mechanical ventilation administration, disease severity, hospitalization, and mortality. The quality of included reviews was assessed using the AMSTAR-2 appraisal tool. In total, 52 systematic reviews were included, 49 of which included meta-analyses. The risk of severe outcomes (OR = 1.86; 95% CI: 1.70 to 2.05), intensive care unit admission (OR = 1.58; 95% CI: 1.45 to 1.72), invasive mechanical ventilation administration (OR = 1.70; 95% CI: 1.57 to 1.83), hospitalization (OR = 1.82; 95% CI: 1.61 to 2.05), and mortality (OR = 1.35; 95% CI: 1.24 to 1.48) following COVID-19 infection was significantly higher in individuals living with excess weight compared with those with a healthy weight. There was limited evidence available in the included reviews regarding the influence of moderating factors such as ethnicity, and the majority of included reviews were of poor quality. Obesity appears to represent an important modifiable pre-infection risk factor for severe COVID-19 outcomes, including death.

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.

Lessons learned from patients' weight-related medical encounters: Results from 34 interviews

OBJECTIVES

How to best care for larger-bodied patients is a complicated issue in modern medicine. The present study seeks to inform current medical practices to ensure the delivery of high-quality and evidence-based care through the examination of higher-weight patients' experiences with weight-related care.

METHODS

Higher-weight patients (N = 34) completed semi-structured interviews about their experiences and recommendations for weight-related care. Interviews were coded by two independent coders and harmonized. Findings were organized into broad domains of 1) negative care experiences and 2) positive care experiences and recommendations.

RESULTS

Patients described a range of negative care experiences, including stigmatization from providers (e.g., rude, attacking, or insulting communication about weight), while concurrently expressing insufficient weight management support from providers. Positive care experiences and recommendations included patient-centered care (e.g., physician humility and empathy) and attending to the patient's weight, which conveyed concern for the patient.

CONCLUSIONS

Our findings reflect patients' ambivalent attitudes toward weight-related care: while weight-focused provider communication can be highly stigmatizing, patients simultaneously desire more weight-management support from providers.

PRACTICE IMPLICATIONS

Providers who wish to move their practices from a weight-loss focus to one targeting healthy living should provide a rationale for these shifts to inform patients' perceptions of high-quality care.

Accommodating patients with obesity in ambulatory care: A clinical environment checklist

Objective

Individuals with obesity face unique challenges when visiting healthcare providers, including inadequate equipment. These negative care experiences, often exacerbated by weight stigma, frequently lead to mistrust and reluctance to seek future care. Currently, few instruments exist to ensure that an ambulatory clinic is welcoming to patients with obesity. The following clinical environment checklist was created with an aim to identify weaknesses in accommodating individuals of size.

Methods

A checklist of equipment considered ideal for the care of patients with obesity was developed through a comprehensive review of the literature and feedback from office staff. Eight ambulatory clinics within an urban Midwest setting were assessed, focusing on their accommodations for patients with obesity. Feedback from clinic staff was incorporated to further refine the checklist.

Results

Common equipment deficiencies included extra-large blood pressure cuffs, wheelchair-accessible scales, 2XL gowns, and adequate seat dimensions in the waiting area. Healthcare workers reported moral distress for their patients when unable to provide proper care due to these limitations. Newly constructed clinics exhibited better-equipped facilities for patients with obesity.

Conclusions

Many clinics lack proper equipment to accommodate patients with obesity, resulting in negative care experiences. This clinical environment checklist can identify problem areas and provide solutions to create more welcoming environments, encouraging future care-seeking behaviors.

Patient Perceptions of Weight Stigma Experiences in Healthcare: A Qualitative Analysis

BACKGROUND

Weight stigma is the social devaluation and denigration of individuals because of their excess body weight, resulting in poorer physical and mental health and healthcare avoidance. Attribution Theory and Goffman's theory of spoiled identity provided a general overarching framework for understanding weight stigma experiences.

OBJECTIVE

Our purpose was to explore weight stigma experiences from a broad range of perspectives emphasizing identities typically excluded in the weight stigma literature.

DESIGN

We conducted a qualitative descriptive study with data drawn from 73 substantive narrative comments from participants who responded to a larger survey.

RESULTS

Analysis developed five themes: Working on weight, Not being overweight, Lack of help and empathy, Exposure and embarrassment and Positive experiences. Individuals who would be clinically assessed as overweight, especially men, often did not identify with having a weight problem and found the framing of personal responsibility for weight empowering. Participants with larger body sizes more often attributed embarrassment and shame about weight to treatment in the clinical setting. Older participants were more likely to have positive experiences.

CONCLUSIONS

The findings suggest ongoing tension between the framing of weight as a personal responsibility as opposed to a multifactorial condition with many uncontrollable aspects. Gender, age and body size shaped respondent perspectives, with some young male respondents finding empowerment through perceived personal control of weight. The healthcare system perpetuates weight stigma through lack of adequate equipment and excessively weight-centric medical counselling. Recommending a healthy lifestyle to patients without support or personalized medical assessment may perpetuate weight stigma and associated detrimental health outcomes.

PATIENT OR PUBLIC CONTRIBUTION

Patients with obesity and overweight were integral to this study, providing comments for our qualitative analyses.

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.

"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.

The relationship between person-centred care and well-being and satisfaction with care of patients living with obesity

Person-centred care (PCC) is associated with improved patient well-being and higher levels of satisfaction with care but its impact on individuals living with obesity is not well-established. The main aim of this study was to assess the relationship between PCC and the physical and social well-being of patients living with obesity, as well as their satisfaction with care. This study is based on a cross-sectional, web-based survey administered among a representative panel of Dutch individuals living with obesity. The primary outcomes were physical and social well-being and satisfaction with care. The primary exposure was a rating of overall PCC, encompassing its eight dimensions. In addition, covariates considered in the analyses included sex, age, marital status, education level, body mass index, and chronic illness. The data from a total of 590 participants were analysed using descriptive statistics, correlation analyses, and multiple regression analyses. Among PCC dimensions, participants rated 'access to care' the highest (M 4.1, SD 0.6), while 'coordination of care' (M 3.5, SD 0.8) was rated lower than all other dimensions. Participants' overall PCC ratings were positively correlated with their physical (r = 0.255, P < .001) and social well-being (r = 0.289, P < .001) and their satisfaction with care (r = 0.788, P < .001), as were the separate dimension scores. After controlling for sex, age, marital status, education level, body mass index, and chronic illness in the regression analyses, participants' overall PCC ratings were positively related to their physical (β = 0.24, P < .001) and social well-being (β = 0.26, P < .001), and satisfaction with care (β = 0.79, P < .001). PCC holds promise for improved outcomes among patients living with obesity, both in terms of physical and social well-being, as well as satisfaction with care. This is an important finding, particularly when considering the profound physical, social, and psychological consequences associated with obesity. In addition to highlighting the potential benefits of PCC in the healthcare of individuals living with obesity, the findings offer valuable insights into strategies for further refining the provision of PCC to meet the specific needs of these patients.

Navigating weight, risk and lifestyle conversations in maternity care: a qualitative study among pregnant women with obesity

BACKGROUND

Pregnant women with obesity face heightened focus on weight during pregnancy due to greater risk of medical complications. Closer follow-up in maternety care may contribute to reduce risk and promote health in these women. The aim of this study was to gain a deeper insight in how pregnant women with obesity experience encounters with healthcare providers in maternity care. How is the received maternity care affected by their weight, and how do they describe the way healthcare providers express attitudes towards obesity in pregnancy?

METHODS

We conducted in-depth interviews with 14 women in Trøndelag county in Norway with pre-pregnancy BMI of ≥ 30 kg/m2, between 3 and 12 months postpartum. The study sample was strategic regarding age, relationship status, education level, obesity class, and parity. Themes were developed using reflexive thematic analysis. The analysis was informed by contextual information from a prior study, describing the same participants' weight history from childhood to motherhood along with their perceptions of childhood quality.

RESULTS

This study comprised of an overarching theme supported by three main themes. The overarching theme, Being pregnant with a high BMI: a vulnerable condition, reflected the challenge of entering maternity care with obesity, especially for women unprepared to be seen as "outside the norm". Women who had grown up with body criticism and childhood bullying were more prepared to have their weight addressed in maternity care. The first theme, Loaded conversations: a balancing act, emphasizes how pregnant women with a history of body criticism or obesity-related otherness proactively protect their integrity against weight bias, stigma and shame. The women also described how some healthcare providers balance or avoid weight and risk conversations for the same reasons. Dehumanization: an unintended drawback of standardized care makes apparent the pitfalls of prioritizing standardization over person-centered care. Finally, the third theme, The ambivalence of discussing weight and lifestyle, represent women's underlying ambivalence towards current weight practices in maternity care.

CONCLUSIONS

Our findings indicate that standardized weight and risk monitoring, along with lifestyle guidance in maternity care, can place the pregnant women with obesity in a vulnerable position, contrasting with the emotionally supportive care that women with obesity report needing. Learning from these women's experiences and their urge for an unloaded communication to protect their integrity highlights the importance of focusing on patient-centered practices instead of standardized care to create a safe space for health promotion.

The impact of obesity on reproductive health and metabolism in reproductive-age females

Obesity is a highly prevalent chronic disease that impacts >40% of reproductive-aged females. The pathophysiology of obesity is complex and can be understood simply as a chronic energy imbalance whereby caloric intake exceeds caloric expenditure with an energy surplus stored in adipose tissue. Obesity may be categorized into degrees of severity as well as different phenotypes on the basis of metabolic health and underlying pathophysiology. Obesity and excess adiposity have a significant impact on fertility and reproductive health, with direct effects on the hypothalamic-pituitary-ovarian axis, the ovary and oocyte, and the endometrium. There are significant adverse pregnancy outcomes related to obesity, and excess weight gain before, during, and after pregnancy that can alter the lifelong risk for metabolically unhealthy obesity. Given the high prevalence and pervasive impact of obesity on reproductive health, there is a need for better and individualized care for reproductive-aged females that considers obesity phenotype, underlying pathophysiology, and effective and sustainable interventions to treat obesity and manage weight gain before, during, and after pregnancy.