Bariatric Times

APR 2018

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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14 Review Bariatric Times • April 2018 which a lecture on the uncontrollable causes of obesity resulted in decreased explicit weight bias. 72 A third study examined whether reading about genetic or behavioral causes of obesity would affect a virtual encounter with a standardized patient with obesity. 73 The investigators found that the group who read about genetic causes of obesity displayed less negative weight stereotyping, but also were less likely to provide screening and counseling for weight loss, exercise, and diet for patients with obesity. These results might suggest that this form of intervention alone is insufficient. A fourth study assessed students who were instructed to read and discuss two articles on communication challenges regarding weight and obesity stigma with a preceptor. Investigators evaluated the effects of the intervention with a standardized patient encounter. 74 Immediately post-intervention, students displayed reduced negative stereotyping and increased empathy and confidence when treating patients with obesity. After one year, students maintained improved empathy and confidence; however, they returned to their baseline negative stereotypes. Two studies examined bariatric sensitivity training for weight bias reduction in which practicing health professionals completed educational modules or training on bariatric sensitivity. 68,69 While this strategy increased awareness of how attitudes can impact bariatric patients, it did not improve weight-based attitudes or beliefs toward patients with obesity. Together, these studies suggest that traditional classroom instruction and educational modules might be effective in the short-term for improving the explicit and implicit attitudes of students, but there is insufficient evidence to determine the effect these modalities have on practicing professionals. Limited evidence demonstrates traditional instruction might have positive long- term effects in some dimensions for students; therefore, it might be prudent to introduce traditional instruction regarding obesity during training for healthcare professionals. Media-based instruction regarding obesity. Although interventions traditionally involve classroom instruction, researchers have studied the use of media-based weight-bias reduction interventions since the early 1990s. Specifically, use of videos, audio recordings, role- playing, and plays as tools to reduce weight bias in the healthcare setting have been studied. In 1992, Wiese and colleagues 5 worked to reduce weight stigma in medical students through a multimedia course with video, audio, and written components. The course was effective at reducing the explicit negative attitudes and stereotypes of medical students regarding patients with obesity for at least five weeks, and the intervention group was less likely to blame patients with obesity for their condition one year later. In an attempt to replicate these findings and expand upon this study, Rukavina and colleagues 76 exposed pre-professional kinesiology students to an audiotape and role-playing activities to increase their awareness of bias and stigma. The investigators reported results consistent with the prior study, in that participants displayed reduced explicit weight bias. Implicit weight bias was not affected. 76 Researchers have also studied the effectiveness of videos in reducing weight bias. In one study, participants watched a 17-minute video that promoted stigma reduction by addressing attributions of weight controllability, inducing empathy, and debunking weight-based stereotypes. Participants displayed increased beliefs that genetic and environmental factors had critical roles in causing obesity and demonstrated a decrease in negative stereotypes and negative attitudes. 77 Another study found that brief, anti-stigma videos improved explicit, but not implicit, attitudes and beliefs regarding patients with obesity among dietetic and medical students immediately after viewing. These results were not sustained at six weeks. 78 Finally, a study by Martharu et al 79 examined the effects of reading a dramatic play about obesity to determine its effectiveness in reducing prejudice as compared to a traditional lecture. The authors found that while both the lecture and the play reduced explicit anti-fat bias and increased empathy, those who read the play had a higher decrease in explicit anti- fat bias. Implicit attitudes were not affected by either intervention. Overall, media-based interventions show promise in reducing explicit bias against patients with obesity, but do not appear to affect implicit bias. There is mixed and insufficient evidence to conclude whether media-based interventions are effective long-term. These findings suggest it might be helpful to incorporate multimedia into a traditional curriculum to further combat weight bias, especially in today's technological age. Experiential learning regarding obesity. More recently, researchers have examined the effects of experiential learning on weight stigma. Experiential learning includes witnessing the treatments recommended for patients with obesity, interacting with patients with obesity, and working with senior healthcare professionals who treat patients with obesity. A longitudinal survey of medical students by Phelan et al 80 found that limited positive contact with patients with obesity, as well as higher exposure to negative faculty role modeling and comments regarding patients who have obesity, was associated with increasing implicit and explicit anti-fat bias from the Year 1 to Year 4 of medical school. Cotunga and Mallick 81 found that students who followed a calorie- restricted diet for one week had decreased negative attitudes toward patients with obesity. Moreover, students displayed increased respect for patients struggling to lose weight. A study of kinesiology pre- professionals had students participate in a service-learning project in which the intervention group worked with patients who were overweight or obese. 76 They found that students in the intervention group had reduced explicit bias, but implicit bias was unchanged. Similarly, another study paired medical students with patients preparing to undergo bariatric surgery and found that students had reduced negative attitudes toward patients with obesity. In addition, the students were more able to recognize weight-related bias and stigma among their senior professionals. 82 Together, these studies provide preliminary evidence that experiential learning can be a critical intervention in reducing weight stigma. Exposing students personally to obesity treatments, including dieting and bariatric surgery, might decrease negative attitudes toward patients with obesity. Moreover, limited contact and negative role modeling appear to increase weight bias. Therefore, it might be beneficial for healthcare students to have thorough, prolonged, positive exposure to both patients with and treatments for obesity. Future bias reduction interventions. Although there are several interventions for bias reduction, most remain untested among practicing clinicians. However, when examining interventions that have been successful in students, programs with multiple components (i.e., traditional classroom instruction, media- based instruction, and experiential learning) and multi-faceted content seem most effective in reducing weight bias. As demonstrated above, education on the causes of weight loss and gain should include genetic, environmental, biological, psychological, and social contributors. 71–73,77 Moreover, clinicians might benefit from training FIGURE 1. This framework illustrates both clinician factors (gray boxes) and patient factors (white boxes) that might influence the healthcare experience and treatment received (black box) for patients with obesity. This framework was modified from a proposed framework to assess the contributions made by healthcare providers to systemic inequality for racial/ethnic minority patients by van Ryn. 34

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