Supporting healthcare professionals to reduce weight stigma

Weight stigma refers to negative stereotypes, attitudes and discriminatory behaviours towards people living with overweight or obesity.¹ At its core, weight stigma is based on the devaluation of people with overweight and obesity, with individuals often assumed to be lazy, lacking willpower and self-discipline and unmotivated to manage their health.² These assumptions are fuelled by the misconception that all causes of obesity are within an individual’s control.³ Experiences of weight stigma have been associated with a myriad of poor health outcomes, including increased physiological stress and inflammation, psychological distress (eg depression, anxiety) and disordered eating.⁴ Extensive evidence shows that weight stigma is a psychosocial contributor to obesity.²

The prevalence and harms of weight stigma in healthcare settings, including general practice, have been well documented.^1,5,6 Although most primary care professionals do not intentionally stigmatise patients, evidence suggests that, like the general community, they often hold negative attitudes towards people with overweight or obesity; might attribute presenting health concerns to the individual’s weight, potentially at the expense of exploring other causes; and might provide weight management advice unrelated to the patient’s original concerns.⁶ Physical barriers within the care environment (eg lack of suitable medical equipment for people with obesity) can exacerbate stigmatising experiences and provoke anxiety in many healthcare settings.⁵ Such stigmatising experiences can reduce healthcare access,⁷ ultimately posing a greater threat to patients’ long-term health⁸ than that posed by weight alone.⁹ Reducing weight stigma in primary care, and healthcare more generally, is therefore critical to supporting and improving the health of people living with overweight or obesity.

Here, we present our views on key issues relating to weight stigma in general practice and healthcare more broadly and provide recommendations for healthcare professionals and policymakers to reduce weight stigma in healthcare. These issues and recommendations were generated following our participation in a transdisciplinary codesign workshop that aimed to understand why and how weight stigma can be addressed in healthcare.

Identifying solutions to reduce weight stigma in healthcare

There is limited evidence articulating how weight stigma perpetuated by healthcare professionals can be reduced¹⁰ and, to our knowledge, no previous studies have incorporated codesign methods. Yet, action is urgently required to address this issue and work towards eliminating weight stigma. We (the authors) were invited as researchers with expertise on the topic of weight stigma (ie stigma experts) to participate in an online workshop to codesign guidance useful for the development of education both suitable for and acceptable to healthcare professionals to reduce weight stigma in practice. Other invitees were lived experience experts (community members), healthcare professionals, including general practitioners, nurses, allied health specialists, health policy specialists and government (eg Commonwealth Department of Health and New South Wales Health) representatives. Not all stakeholders were familiar with the concept of weight stigma prior to the workshop.

The 3.5-hour online workshop was facilitated by an external organisation (The Shape Agency). Key workshop activities included presentations on understanding weight stigma and the state of evidence in healthcare, the science of obesity, lived experience and practitioner perspectives and message framing around obesity. Facilitated discussions elicited stakeholder views on the barriers and enablers relevant to weight stigma in clinical practice, and their perspectives on the appropriate content of education for implementation to reduce weight stigma in healthcare. After the workshop, we convened to discuss the issues and potential solutions raised. From our discussions we identified four themes: support, not blame; acknowledge personal biases; address structural drivers of weight stigma; and transdisciplinary action. We distilled these themes into five key recommendations that can be used to empower and enable healthcare professionals to address weight stigma in their practice.

Support, not blame

To enhance healthcare professionals’ acceptance of, and engagement with, weight stigma initiatives, consideration should be given to how they will be communicated. Two motivations should inform initiative framing. First, health professionals ultimately want to help and ‘do no harm’. However, there is a perceived lack of confidence in navigating weight-related discussions and a fear of offending that might lead to patient disengagement. Second, health professionals want applied solutions to improve quality of care. Thus, stigma-reduction initiatives that present positively framed, practical solutions designed to improve quality of care and, relatedly, patient engagement with (and continuity of) care might be acceptable to health professionals. It is already well established that a blame narrative is unlikely to be effective or acceptable.¹¹

Acknowledge personal biases

Limited knowledge of the science and drivers of obesity raises obstacles for healthcare professionals. Understanding the biology of obesity can facilitate a change from the ‘personal responsibility’ narrative to an appropriate evidence-based framing that reflects obesity as a chronic health condition and a complex systemic issue.¹¹ Therefore, it is important to understand that weight biases, particularly those that are implicit, are normal for most people. However, self-reflection and analysis can help overcome implicit biases (ie people behaving in a biased way and not being aware that their behaviour is biased¹²) and tools to facilitate this would be highly sought by stakeholders. In line with previous literature,¹¹ another facet of challenging personal biases is to recognise the patient with lived experience as the expert of their experiences of weight stigma and obesity.

Address structural drivers of weight stigma

There are significant structural barriers hindering healthcare professionals’ ability to reduce weight stigma in their practice. For example, the media and public health sector often portray people with obesity negatively and perpetuate misperceptions regarding the personal controllability of weight.^1,11 Thus, healthcare professionals regularly receive messages that perpetuate and normalise weight stigma. In healthcare systems, medical language can itself be stigmatising (eg ‘obese’).¹³ Currently, there are no national policies or codes of conduct for general practitioners or other healthcare professionals regarding non-stigmatising approaches to discuss patient health and, when necessary, their weight.

There is a need for more tools and resources to support non-stigmatising provider–patient interactions. This includes training and professional development opportunities, appropriately sized medical equipment and inclusive environments (eg blood pressure cuffs, chairs), funding for the time needed to have sensitive conversations and access to specialist referral options. These identified structural barriers have been widely documented by weight stigma researchers.¹⁴ Hence, weight stigma reduction efforts must extend beyond individual attitudes and behaviour to include large-scale coordinated policies that facilitate structural-level change.¹⁵

Transdisciplinary action

A transdisciplinary approach is needed to effectively support patients with complex health conditions and to effect cultural change within complex healthcare systems.¹⁶ This approach requires stakeholders to work together as teams to provide solutions that optimise health outcomes for both individuals and systems. To effectively address weight stigma in healthcare, it will be critical to engage the support and leadership from government, medical organisations and health service providers, in addition to the healthcare workforce, in consultation with people with obesity.¹ Collaborative pathways for action can contribute to formal programs transcending health services and, indeed, individual healthcare professionals.

Recommendations

Empowering and enabling healthcare professionals to address weight stigma in their practice is key. This should occur in the context of policy changes that lead to improvements in social, physical and fiscal environments and that are fundamental to supporting individual healthcare professional initiatives. We acknowledge that the themes presented above stem from a single transdisciplinary workshop and do not include all possible perspectives or solutions to weight stigma in healthcare. Nevertheless, we provide specific, actionable recommendations to move forward (summarised in Box 1):

• Frame weight stigma reduction initiatives to appeal to healthcare professionals’ goals of ‘do no harm’ and improving care quality.
• Increase professional development and training opportunities that equip healthcare professionals to care for their patients effectively. Suggested training content includes: education on the science of obesity; lived experience perspectives of patients and healthcare professionals, information about bias, weight stigma and associated negative health outcomes; opportunities for coaching and role playing; and self-reflection exercises to identify and manage implicit biases.
• Develop and disseminate clear practical guidelines on non-stigmatising care provision for patients with overweight or obesity. Guidelines for health professionals might include recommended non-stigmatising language; when and how to navigate discussions about weight; evidence-based referral options; and a code of conduct for consistency in communication. Guidelines for patients might consider how patients can be supported to identify, cope and/or challenge weight stigma in healthcare interactions.
• Develop and disseminate physical environment checklists to enable clinic audits of appropriate medical equipment and facilities.
• Develop and fund formal pathways and strategies to optimise transdisciplinary collaboration and shared patient-centred care of patients with overweight or obesity.