Background: An estimated 40% of individuals in the U.S. are classified with obesity (BMI ≥ 30; Hales, Carroll, Fryar, & Ogden, 2017). Obesity affects all ages, racial and ethnic groups, and genders. Women of lower socioeconomic status are 50% more likely to have obesity compared to women with higher socioeconomic status (Eberhardt, Ingram, & Makuc, 2001). Epidemiological research has demonstrated a positive relationship between obesity and poor health as well as increased risk for death. Common co-morbidities associated with obesity are diabetes, hypertension, high cholesterol, asthma, arthritis, and overall poor health status (Mokdad et al., 2003). Because obesity is such a prevalent illness affecting individuals across the lifespan, the need for empathetic, evidence-based, patient-centered care is warranted.
Obesity bias and stigma are discriminatory beliefs or behaviors among healthcare providers that may impact patients’ willingness to seek treatment and preventive care. For instance, medical providers reported altering their practices and choices of treatment when interacting with patients with obesity compared to patients with a normal BMI (Ferrante, Piasecki, Ohman-Strickland, & Crabtree, 2009; Helb & Xu, 2001; Ward-Smith & Peterson, 2016). The medical environment may be perceived as unsupportive and insensitive to individuals struggling to incorporate healthier lifestyle changes to reduce their BMI. Social stigmatization within the medical field may engender reluctance to seek treatment for obesity (fearful of being shamed or marginalized) leading to exacerbation of weight issues and co-occurring conditions unrelated to weight (Puhl & Heuer, 2010).
Mismanagement of individuals with obesity by healthcare providers may stem from a lack of graduate coursework and formal training. One study found only 56% of physicians (N=250) felt qualified to treat patients with obesity, expressed feeling frustrated with that population (Jay et al., 2009). In another study, only a few of 398 nurses reported training on obesity management, and of those few, only approximately 5% of their clinical activities were dedicated towards obesity management (Brown, Stride, Psarou, Bewins, & Thomas, 2007).
Nurse practitioner (NP) students are often unaware of their own obesity bias (Phelan et al., 2015). Embedded topics in educational settings on evidence-based treatments for weight-related issues may reduce the potential for obesity bias and stigmatization in professional settings.
Purpose: The purpose of this project was to collect data on NP students’ attitudes and perceptions toward obesity based on their clinical, educational experiences to inform future obesity-specific training programs for NP students. This study requested that NP students become more aware of provider weight bias and discrimination and reflect on how those beliefs and attitudes may cause patients with obesity to avoid preventative healthcare and screenings.
Methods: A total of 45 female NP students (M=34 years old; SD=7.9) in a Women’s Health NP course at a mid-sized university on the Gulf Coast provided qualitative feedback on an online classroom forum. Ethnic composition of the sample was 53% White, 40% Black, 4% Hispanic/Latino, and 2% Asian. Self-reported BMI ranged from 18 to 43 (M=27.5; SD=5.9). The students were asked to provide feedback on their encounters with obesity bias during their clinical, educational experiences, and strategies they would recommend in the practice setting to decrease obesity stigma and bias. Two researchers compiled the responses to identify common themes.
Results: Five themes emerged from NP student responses:
First, students pointed out that changes could be made in office settings and equipment to accommodate the needs of patients who have obesity.
- “In the clinical setting [they do] not carry bigger gowns for patients, and nurses are often searching for larger blood pressure cuffs because they are not kept in every room.”
- “The scale is in a wall nook that is only thirty-two inches wide. Even for a patient that is in the upper level of normal body mass index, this width is rather narrow. When a [patient having obesity] needs to be weighed, the scale must be pulled out of the nook for the patient to step on it, leading to unnecessary embarrassment”
- “The central location and expectation to step on the scale in front of everyone could be enough to make those wavering on their decision to come [to the clinic] …. I can imagine that would be much pressure for patients wondering if someone is going to see their weight as they walk by or if other people are listening.”
Second, students reflected on preceptors’ reactions and frustrations inside and outside of the examination room regarding patients that have obesity.
- “Physicians in the OB/GYN clinic frequently feel more frustrated with patients who are obese compared to thinner patients due to the feeling that they are non-compliant with their treatment plans, and they perceive the GYN examination as being more difficult to ”
- “The potential for complications during the pregnancy due to existing co-morbidities and concerns for delivery are often explicitly voiced, the possible need for cesarean delivery, the difficulty of performing the cesarean on a patient who is obese, and the complications that may arise during the recovery”
- “One of the medical assistants was preparing to bring a patient into an examination room. Once she reviewed her medical record and noticed she was diagnosed with obesity, the assistant asked another staff member if there were any extra-large speculum because the patient was ‘huge.’”
- “The author had watched a doctor shame a patient for gaining weight, get frustrated in front of a patient when the patient offers excuses for weight gain and cut a patient’s appointment off when the provider did not feel that the patient was trying to move forward in the program…. The provider feels that the patients are not making an effort, are lazy, and are wasting the physician’s time”
Third, NP students suggested training on weight-related issues and sensitivity should be available for medical providers, medical staff, and students.
- “Teaching staff about appropriate phrases to use when discussing a patient’s weight and being sensitive to patient’s emotional well-being when discussing treatment options would be of utmost importance to establish in quality care”
- “The key to decreasing the incidence of obesity bias is education and is a must in the medical community as well as the local community. Educating people on all levels allows those who discriminate to be knowledgeable of the consequences of these actions and how they impact the lives of others.”
- “Educating peers on the importance of assisting patients in setting a goal to obtain and maintain a healthy lifestyle is important”
- “Non-clinical staff should be taught that obesity is a complex condition, and many patients have attempted to lose weight numerous times but may have failed due to non-controllable factors such as genetics and chronic health condition”
- “Learning more effective ways to manage obesity, such as regular nutrition counseling and referrals to a dietician, community programs, and a bariatric surgeon when indicated, will provide patients with the guidance and tools needed to achieve weight loss.”
- “[A] recommendation to reduce obesity bias is through the use of supportive communication and language by choosing words that do not stigmatize or blame the patient”
Fourth, the NP students expressed a desire for medical professionals to change the societal perception of obesity.
- “It may be a long time before society changes its framing of obesity, but health care professionals and clinics are positioned to lead the way toward greater acceptance and better patient care”
- Their family clinic “offers a structured weight loss program affiliated with the hospital system, which is detailed in a pamphlet located in all exam rooms.”
- “The female staff members represent all different weight ranges which I believe reflects well upon patient”
- The role of healthcare professionals is to “[spread] awareness to the local and state communities”
- “In the clinical setting, it is important to emphasize healthy lifestyles instead of focusing on achieving the ideal weight This will encourage the patient to attain goals that lead them to successful weight loss without the pressure of obesity stigma.”
- “Blaming individuals for being responsible for their weight is an assumption. To provide fair and proper treatment, it is essential for all healthcare providers to evaluate their thoughts related to obesity."
Fifth, there was an emphasis on systemic and community-based action plans to increase motivation to live healthier.
- “[An obesity action plan] must be culturally sensitive.”
- The Obesity Action Coalition “promotes guidelines to decrease provider obesity bias, as well as guidelines for media portrayals of individuals affected by obesity, which shapes public understanding and attitude”
Conclusions: Women’s Health NP students are exposed to and aware of obesity bias in their clinical, educational experiences, enhancing the probability that they too may engage in obesity bias when caring for patients with obesity if they do not receive a specific education focused on obesity bias during the NP curriculum. Often, students and preceptors alike are unaware of their personal biases and their expression of them. It is important that both students and those teaching them are aware of how the language they use, and the specific clinical environment may impact patient care. Preventing obesity stigma and bias is critical for high-quality patient care.