1. Practical Approaches to Reducing Weight Bias in the Outpatient Setting Colony S. Fugate, D.O., FACOP Diplomate American Board of Obesity Medicine Clinical Associate Professor of Pediatrics Director, Family Health and Nutrition Clinic Oklahoma State University Center for Health Sciences colony.fugate@okstate.edu

2. Objectives Differentiate between implicit and explicit bias. Identify common sources of bias and stigma for individuals who are overweight or obese. Examine the impact of weight bias on patient care. Discuss the impact of weight bias and stigma on patient adherence to care recommendations. Identify strategies providers can use to ensure sensitive, compassionate and effective care that is free of weight bias.

3. Definitions Bias: A tendency to believe that certain people or ideas are better than others that may lead to unfair treatment of certain individuals Weight bias: Negative attitudes towards individuals who are overweight or obese Stereotypes: The belief that most members of a group have some characteristic Explicit: A stereotype that you deliberately think about and report Implicit: A stereotype that is outside of conscious awareness and control Prejudice: Reported and approved negative attitudes towards outgroups Stigma: Mark of disgrace Project Implicit

4. Sources of Weight Bias Employment settings Media Educational settings Interpersonal relationships Healthcare settings Puhl, R.M., 2009

5. Employment Individuals with obesity: Experience derogatory humor and pejorative comments from coworkers and supervisors Are less likely to be hired, are passed over for promotions, and experience wrongful termination Have lower wages Are considered to lack self-discipline, have low supervisory potential, poor personal hygiene, to be less ambitious, and less productive Puhl, R.M., Heuer, C.A. 2009 Obesity Action Coalition

6. Employment Out of 2,249 women surveyed: 25% experienced job discrimination 54% reported weight stigma from co-workers 43% reported weight stigma from supervisors 60% report experiencing weight stigma on more than 4 occasions The relationship is linear: the greater a person’s weight the more likely they are to have experienced stigma Puhl, R.M., Heuer, C.A. 2009

7. Media 72% of photographs and 65% of videos paired with on-line news stories are stigmatizing. News photographs and videos portray individuals with obesity: Headless At unflattering angles In stereotypical behaviors (eating unhealthy foods or engaging in sedentary behavior) Heuer, C.A., et al 2011 Puhl, R.M., et al 2013 UConn Rudd Center

8. Interpersonal Relationships Source of BiasEver ExperiencedExperienced Multiple Times Family72%62% Doctor69%52% Classmates64%56% Sales Clerks60%47% Friends60%42% Nurses46%34% Employer43%26% Dietitians37%26% Teachers/professors32%21% Mental Health Professionals 21%13% Puhl 2006

9. Sources of Bias in Healthcare Physicians Nurses Dietitians Mental Health Providers Medical Students Schwartz, M.B., et al 2002; Berryman, DE, et al 2006; Jay M., et al 2009; Hebl, M.R., Xu J. 2001; Mc Arthur, L.H., Ross, J.K. 1997; Persky, S., Eccleston, C. 2011; Bagley, C. R. et al 1989

10. Stereotypes Professionals from multiple health related disciplines endorse the following statements related to patients who are overweight or obese: LazyLacking willpower StupidNon-adherent WorthlessEmotional RepulsiveUgly UnmotivatedAwkward SloppyInsecure Schwartz, MB et al. 2003; Hebl, M.R., Xu J. 2001; Persky, S., Eccleston, C. 2011; Foster, et al. 2003

11. Impact on the Provider- Patient Relationship Providers demonstrate less emotional rapport with patients who are overweight or obese Patient obesity is associated with decreased physician respect Physicians spend less time in appointments Physicians are reluctant to perform some health screenings Gudzune, K.A., et al 2012; Huizinga, et al 2009; Hebl, M.R., Xu, J. 2001

12. Consequences of Weight Bias Individuals who experience weight bias are at risk for: depression, anxiety, low self-esteem, social rejection, and suicidality Individuals who experience weight bias are more likely to engage in: unhealthy weight control behaviors, binge-eating episodes, avoidance of physical activities Patients with obesity are more likely to delay or cancel appointments and preventive health screenings Women who are obese delay preventative gynecological care. UConn Rudd Center for Food Policy and Obesity Preventing Weight Bias: Helping Without Harming in Clinical Practice; Amy, N.K., et al 2005

13. In Response to a Stigmatizing Experience 80% of women and 79% of men report eating 76% of women and 75% of men report crying/isolation 73% of respondents report negative self talk 75% refuse to diet 41% avoid/leave the situation Drury C.A., Louis M., 2002; Puhl, R.M, Brownell, K.D 2006

14. Strategies to Reduce Weight Bias BECOME SELF-AWARE Recognize the complex etiology of obesity and its multiple contributors, including genetics, biology, sociocultural influences, the environment, and individual behavior Consider that patients may have had negative experiences with health professionals, and approach patients with sensitivity and empathy Emphasize the importance of behavior changes rather than just weight Recognize that many patients with obesity have tried to lose weight repeatedly Explore all causes of presenting problems, in addition to body weight Acknowledge the difficulty of achieving sustainable and significant weight loss Recognize that small weight losses can result in meaningful health gains Create a welcoming environment Rudd Center, Preventing Weight Bias Helping Without Harming in Clinical Practice

15. Self Assessment What assumptions do I make based only on weight regarding a person’s character, intelligence, professional success, health status, or lifestyle behaviors? Could my assumptions be impacting my ability to help my patients? How comfortable am I working with patients of different sizes? Am I sensitive to the needs and concerns of individuals with obesity? Do I consider all of the patient’s presenting problems, in addition to weight? What are my views about the causes of obesity? How does this impact my attitudes about individuals with obesity? Do I treat the individual or only the condition? What are common stereotypes about obese persons? Do I believe these to be true or false? What are my reasons for this? UConn Rudd Center

16. Implicit Attitudes https://implicit.harvard.edu/implicit/

17. Practice with Empathy Stigmatizing Language Weight problem Unhealthy body weight Unhealthy BMI Heaviness Large size Obesity Excess Fat Fatness Preferred Language Weight Excess Weight BMI Wadden, T. A., Didie, E., 2003

18. Practice with Empathy Use people first language: Instead of- “I am seeing the obese woman in room 4.” Use- “The woman in room 4 is affected by obesity.”

19. Practice with Empathy Remember to ask permission to discuss a person’s weight. Examples of ways to start the conversation: – Mr. Thomas, would it be ok if we discussed your weight today? – Are you concerned about the effect your weight may have on your health? STOP Obesity Alliance

20. Evidence Based Models of Health Behavior Change Providers commonly report a lack of patient motivation and non-adherence to care recommendations as areas of high frustration Physicians predict that heavier patients would be less compliant and less likely to benefit from counseling High levels of satisfaction have been found with non-judgmental psychological support and practical advice Puhl, R.M., Heuer, C.A., 2009 Hebl M.R., Xu J. 2001 Brown I et al. 2006

21. Evidence Based Models of Health Behavior Change Models used extensively in evidenced based obesity medicine include: Cognitive behavioral therapy 5 As Transtheoretical model (stages of change) Motivational interviewing

22. What is Motivation? Motivation is a key to change. Motivation is multidimensional. Motivation is dynamic and fluctuating. Motivation is influenced by social interactions. Motivation can be modified. Motivation is influenced by the clinician’s style. The clinician’s task is to elicit and enhance motivation.

23. Patients are motivated. Most patients have tried to lose weight previously There is mismatch between patients’ actual level of motivation and the perceived level of motivation by physicians. Befort et al, found that a motivational level of “10” was reported by 30% of females and 21% of males (physician ratings were 2.5% and 3.1% respectively) Befort et al, 2006

24. Create a Welcoming Environment Provide wide‐based, higher weight capacity chairs, preferably armless, available in the waiting area and other patient areas Consider specialized bariatric chairs, when possible Offer large size or even thigh‐sized blood pressure cuffs Provide a higher capacity scale, ideally to >500 lbs. (be sure that the scale is situated in a private or near‐private area to minimize the anxiety and discomfort associated with being weighed) Make bathrooms wheelchair accessible and ADA compliant and have pedestal toilets rather than wall‐mounted toilets, if possible Have extra‐large gowns available Educate your staff about obesity and weight bias STOP Obesity Alliance Why Weight? A Guide to Discussing Obesity and Health With Your Patients

25. Resources University of Connecticut Rudd Center for Food Policy and Obesity “Preventing Weight Bias: Helping Without Harming in Clinical Practice” http://www.uconnruddcenter.org/http://www.uconnruddcenter.org/ Strategies to Overcome and Prevent (STOP) Obesity Alliance “Why Weight? A Guide to Discussing Obesity and Health With Your Patients” http://www.stopobesityalliance.org/http://www.stopobesityalliance.org/ National Institute of Diabetes and Digestive and Kidney Diseases “Weight Control and Healthy Living: Medical Care for Patients with Obesity http://www.niddk.nih.gov/health-information/health- topics/weight-control/medical/Pages/medical-care-for-patients- with-obesity.aspxhttp://www.niddk.nih.gov/health-information/health- topics/weight-control/medical/Pages/medical-care-for-patients- with-obesity.aspx Obesity Action Coalition http://www.obesityaction.org/http://www.obesityaction.org/ Project Implicit https://implicit.harvard.edu/implicit/https://implicit.harvard.edu/implicit/

26. References Puhl, R.M., Heuer, C. A. The Stigma of Obesity: A Review and Update. Obesity 2009, 17: 941-964 Puhl, R., Brownell, KD. Bias, Discrimination, and Obesity. Obes Res 2001, 9 (12):788-805. Schwartz, MB et al. Weight Bias among Health Professionals Specializing in Obesity. Obes Res 2003, 11 (9): 1033- 1039. Hebl, M.R., Xu J. Weighing the care: physicians’ reactions to the size of a patient. Int J Obes 2001, 25: 1246-1252. Jay, M., et al. Physicians’ attitudes about obesity and their associations with competency and specialty: A cross sectional study. BMC Health Serv Res 2009, 9: 106. Berryman, D et al. Dietetics students possess negative attitudes towards obesity similar to nondietetic students. J Am Diet Assoc 2006, 106: 1678-1682. Mc Arthur, L.H., Ross, J.K. Attitudes of registered dietitians toward personal overweight and overweight clients. J Am Diet Assoc 1997, 97(1): 63-66. Persky, S., Eccleston, C. Medical Student Bias and Care Recommendations for an Obese versus Non-Obese Virtual Patient. Int J Obes 2011, 35 (5): 728-735. Bagley, C. R. et al, Attitudes of Nurses Towards Obesity and Obese Patients. Perceptual Motor Skills 1989, 68: 954. Foster, G.D., et al. Primary Care Physicians’ Attitudes about Obesity and Its Treatment. Obes Res 2003, 11: 1168- 1177. Gudzone, K.A., et al. Physicians Build Less Rapport With Obese Patients. Obesity 2013, 21: 2146-2152. Huizinga, M.M., et al. Physician Respect for Patients with Obesity. J Gen Int Med 2009, 24 (11): 1236-1239. Amy, N.K., et al. Barriers to routine gynecological cancer screening for White and African-American obese women. Int J Obes 2006, 30: 147-155. Drury, C.A., Louis, M. Exploring the association between body weight, stigma of obesity, and health care avoidance. J Am Acad Nurse Pract 2002, 14 (12): 554-61. Wadden, T.A., Elizabeth, D. What’s in a Name? Patients’ Preferred Terms for Describing Obesity. Obes Res 2003, 11(9): 1140-1146.

27. References Phelan, S.M., et al. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev 2015, 16(4): 319-326. Kahan, S. Addressing Weight Bias in Health Care. American Society of Bariatric Physicians Fall Obesity Summit 2015. Puhl R. M., Andreyeva, T., Brownell, K.D. Perceptions of weight discrimination: prevalence and comparison to race and gender discrimination in America. Int J Obes 2008, 32: 992-1000. Puhl, R.M., Brownell, K.D. Confronting and Coping with Weight Stigma: An Investigation of Overweight and Obese Adults. Obesity 2006, 14: 1802-1815. Andreyeva, T., Puhl, R.M., Brownell, K.D. Changes in perceived weight discrimination among Americans, 1995- 1996 through 2004-2006. Obesity 2008, 16(5): 1129-1134. Teachman B and Brownell K. Int J Obes Relat Metab Discord. 2001;25: 1525-1531. Brown I et al. Br J Gen Pract. 2006, 56:666-672. UCLA Center for Human Nutrition http://www.cellinteractive.com/ucla/physcian_ed/scripts_for_change.htmlhttp://www.cellinteractive.com/ucla/physcian_ed/scripts_for_change.html Heuer, C.A., et al. Obesity Stigma in Online News: A Visual Content Analysis. J Health Comm 2011, 16: 976-987. Puhl, R.M., Headless, Hungry, and Unhealthy: A Video Content Analysis of Obese Persons Portrayed in Online News. J Health Comm 2013. Befort et al. Weight-Related Perceptions Among Patients and Physicians. How Well do Physicians Judge Patients’ Motivation to Lose Weight? J Gen Intern Med 2006, 21:1086-1090. Special Acknowledgements: Rebecca Puhl, PhD Rudd Center for Food Policy and Obesity and Scott Kahan, MD, MPH STOP Obesity Alliance for resources and content assistance