Weight bias reduction in health professionals: a systematic review · 2016-05-30 · Weight bias reduction in health professionals: a systematic review A. S. Alberga1, B. J. Pickering1,

Weight bias reduction in health professionals:a systematic review

A. S. Alberga1, B. J. Pickering1, K. Alix Hayden2, G. D. C. Ball3, A. Edwards4, S. Jelinski5,6, S. Nutter1,S. Oddie7, A. M. Sharma8 and S. Russell-Mayhew1

1Werklund School of Education, University of

Calgary, Calgary, AB, Canada; 2Libraries and

Cultural Resources, University of Calgary,

Calgary, AB, Canada; 3Department of

Pediatrics, University of Alberta, Edmonton,

AB, Canada; 4Cumming School of Medicine,

University of Calgary, Calgary, AB, Canada;5Emergency Strategic Clinical Network,

Alberta Health Services, Edmonton, AB,

Canada; 6Department of Emergency

Medicine, University of Alberta, Edmonton,

AB, Canada; 7Applied Research and

Evaluation Services, Primary Health Care,

Alberta Health Services, Edmonton, AB,

Canada; 8Faculty of Medicine and Dentistry,

University of Alberta, Edmonton, AB, Canada

Received 20 December 2015; revised 7

March 2016; accepted 5 April 2016

Address for correspondence: Shelly Russell-

Mayhew, PhD, Werklund School of Education,

University of Calgary, EDT 634, 2500

University Drive, NW Calgary, Alberta,

Canada T2N 1N4.

E-mail: [email protected]

SummaryInnovative and coordinated strategies to address weight bias among health profes-sionals are urgently needed. We conducted a systematic literature review of empir-ical peer-reviewed published studies to assess the impact of interventions designedto reduce weight bias in students or professionals in a health-related field. Combi-nation sets of keywords based on three themes (1: weight bias/stigma; 2: obesity/overweight; 3: health professional) were searched within nine databases. Oursearch yielded 1447 individual records, of which 17 intervention studies satisfiedthe inclusion criteria. Most studies (n = 15) included medical, dietetic, health pro-motion, psychology and kinesiology students, while the minority included practi-cing health professionals (n = 2). Studies utilized various bias-reduction strategies.Many studies had methodological weaknesses, including short assessment periods,lack of randomization, lack of control group and small sample sizes. Althoughmany studies reported changes in health professionals’ beliefs and knowledgeabout obesity aetiology, evidence of effectiveness is poor, and long-term effects ofintervention strategies on weight bias reduction remain unknown. The findingshighlight the lack of experimental research to reduce weight bias among healthprofessionals. Although changes in practice will likely require multiple strategiesin various sectors, well-designed trials are needed to test the impact of interven-tions to decrease weight bias in healthcare settings.

Keywords: Healthcare, obesity, prejudice, stigma.

Introduction

Despite obesity being classified as a chronic disease by theAmerican Medical Association (1), the Canadian MedicalAssociation (2) and substantial research evidence showingthe genetic basis (3) and complexity of the condition (4),stigmatization of individuals living with obesity hasincreased in frequency and intensity over the last few dec-ades (5). Weight bias, stigma and discrimination, alsoknown as negative attitudes, beliefs and behaviourstowards individuals with obesity, have been observed inhealthcare professionals and student trainees across various

health disciplines, including; physicians and medical resi-dents (6–18), medical and dental students (19–21), nurses(22–24), dieticians (25–27), kinesiologists (28,29), phy-siotherapists (30), health science students (31) and profes-sionals specializing in obesity (32,33). Up to 69% ofwomen with overweight or obesity have reported bias fromhealth providers (34).Weight bias is defined as ‘negative weight-related atti-

tudes, beliefs, assumptions and judgments toward indivi-duals who are overweight and obese (and weight stigma) isthe social sign that is carried by a person who is a victim of

© 2016 World Obesity. clinical obesity 6, 175–188 175

clinical obesity doi: 10.1111/cob.12147

prejudice and weight bias’ ((35), p. 1). Weight bias can fur-thermore be understood as a preconceived adverse judg-ment or opinion targeted at individuals perceived as fat,whereas weight discrimination is the overt behaviouralmanifestation of weight bias (e.g. derogatory humour(19), receiving unsolicited advice and inappropriate com-ments about weight (36)). Stigma can be enacted if theprovider has explicit or implicit negative attitudes aboutpeople with obesity. ‘Explicit attitudes are conscious andreflect a person’s opinions or beliefs about a group’ ((37),p. 320). Medical students’ explicit attitudes or impres-sions of patients with obesity tend to be that they arenon-compliant (20), lazy, sloppy and lacking self-control(38), less adherent to lifestyle recommendations and thatthey are personally responsible for causing their obe-sity (39).Contrary to self-reported explicit attitudes, ‘[…] peo-

ple also possess implicit or unconscious beliefs or biasesthat exist in memory but are often distinct from con-scious values and beliefs’ (40). Unconsciously associating‘fat people’ with negative words like lazy, gluttonous,stupid, undisciplined and worthless are examples ofimplicit biases. A study from a large representative sam-ple showed that both medical doctors and the generalpublic hold strong explicit and implicit weight-biasedattitudes (40).Although perhaps unintentional, there may also be more

structural stigmatizing barriers in healthcare settings, whichcan be embarrassing and increase likelihood of healthcareavoidance for patients with obesity (e.g. small waiting roomchairs and equipment like blood pressure cuffs, examina-tion gowns and weight scales too small to be functional(37) or feeling humiliated about being weighed publicly(41)). Weight bias can affect both verbal and non-verbalcommunication whereby health professionals have reportedless respect for patients living with obesity (14,18). A studythat evaluated 215 patient–physician encounters with30 different physicians in primary care showed that havingless respect for patients could predict less empathetic com-munication and less provision of information to the patients(42). Downstream effects of weight bias among health pro-fessionals include less patient-centred communication andcare such as spending less clinical contact time with them(14) and providing less information (43), which could riskfailing to refer a patient for other diagnostic testing becauseof the focus on the patient’s obesity. The negative physio-logical and psychological implications of patients experien-cing weight bias are widespread and can increase the risk ofengaging in unhealthy behaviours, including increased foodconsumption (44,45) and decreased physical activity(45,46), patient non-adherence, delay in seeking health careor its avoidance (47), feelings of anxiety, depression, lowself-esteem and suicidal thoughts (41).

Given the high prevalence of obesity worldwide andincreasing evidence of weight bias by health professionalsand its detrimental effects on patients, there is an urgentneed to address weight bias among health professionals.The purpose of this paper was to systematically reviewpeer-reviewed published interventions designed to reduceweight bias in health professionals. Other terms such asanti-fat bias, anti-fat stigma and anti-fat prejudice havealso been used synonymously with weight bias. For thepurpose of this paper, weight bias will be used as the all-encompassing term of bias, stigma and prejudice againstindividuals who are overweight or have obesity.

Methods

In conducting our review, we followed the protocol out-lined in the Cochrane Handbook for Systematic Reviews ofInterventions (48). We report our findings in accordancewith the PRISMA (Preferred Reporting Items for System-atic Reviews and Meta-Analyses) statement (49).

Data sources

A health sciences librarian (K.A.H.) developed the searchstrategy and conducted both the preliminary and the finalsearches. The search focused on three main concepts:(i) weight bias/stigma, (ii) obesity/overweight and(iii) health professional. Keywords were generated for eachconcept by reviewing subject indexing and key terms andby reviewing search strategies from similar systematicreviews. The preliminary search strategy was pre-tested toensure that relevant known studies were retrieved. Thefinal search strategy incorporated both keywords and sub-ject headings. Keywords were the same for each database,whereas subject headings were translated for each data-base. The search strategy was limited to the English orFrench language and from the publication date of 1990onwards. Searches were conducted in nine databases(MEDLINE, EMBASE, CINAHL, PsycINFO, SocINDEX,Social Work Abstracts, ERIC, Cochrane Database of Sys-tematic Reviews and Cochrane Central Register of Con-trolled Trials). The search strategy was conducted in earlyApril 2014 and was saved for each database, so it could bere-run to update the search. All searches were updated inearly September 2015 by the same librarian (K.A.H.), andabstracts were reviewed by the same researchers (A.S.A.and B.P.). The updated search identified 225 citationsindexed since April 2014.

Studies published between 1990 and September 2015were included if they met the following criteria:(i) published in English or French, (ii) original primaryempirical research and (iii) where weight bias was the focusof the intervention identified in students or professionals in

© 2016 World Obesity. clinical obesity 6, 175–188

176 Weight bias reduction in health professionals A. S. Alberga et al. clinical obesity

a health-related field. Comments, editorials, letters,abstracts and grey literature were excluded. Reference listsof related publications were also examined for furthersources not identified in online searches.

Results

The search strategy yielded 1447 abstracts of which931 were duplicates. Two authors reviewed (A.S.A. andB.P.) 516 abstracts and discussed to reach consensus ifthere was any discrepancy. We identified 17 interventionstudies (38,50–65) (12 were identified through the databasesearch and five previously identified through personallibraries). Five studies were not identified by databasesearching because (i) there was no indication of an associa-tion with a ‘health’ discipline in indexing and/or in theabstract; (ii) there was no indication that students in a

health discipline were the population under study in index-ing and/or the abstract; and/or (iii) the search would havebeen much to broad to search ‘students’ or ‘undergradu-ates’ without a ‘health’ qualifier.The updated search in September 2015 did not identify

any new studies. Figure 1 represents the PRISMA flow dia-gram. The original detailed MEDLINE search strategy canbe found in Appendix S1.

Data extraction and quality assessment

Two reviewers (A.S.A. and B.P.) independently reviewed(Table 1) and evaluated the 17 extracted studies for meth-odological quality and descriptive purposes using the Qual-ity Assessment Scale (68) (Table 2). Any uncertainties wereresolved through discussion. Higher scores on the scale(range: 0–1) represented higher quality study ratings. The

Figure 1 PRISMA diagram showing selectionof articles.


clinical obesity Weight bias reduction in health professionals A. S. Alberga et al. 177

Tab

le1

Cha

racteristic

sof

stud

iesthat

met

theinclus

ioncrite

ria

No.

Autho

rsSa

mple

size

Hea

lthprofes

sion

Stud

yde

sign

/interven

tion

Guiding

theo

ryWeigh

tbiasmea

suremen

ttool(s)

Durationof

follow-up

Summaryof

find

ings

1Ciaoan

dLa

tner

2011

(63)

64Und

ergrad

uate

psyc

hology

stud

ents

Ran

domized

controlledtrial,

3grou

ps:

1.Cog

nitivedisson

ance

2.So

cial

cons

ensu

s3.

Con

trol

Social

cons

ensu

stheo

ryan

dco

gnitive

disson

ance

theo

ry

Explicitattitud

es:A

FAT

Others:

Marlowe-Crowne

Social

Des

irabilitySc

ale,

Portrait

Values

Que

stionn

aire,p

ost-

feed

back

ques

tions

1wee

kAtp

ost-interve

ntion,

AFA

Tmea

nsin

cogn

itive

disson

ance

grou

pwerelower

than

control(1.80

vs.2

.01).N

oAFA

Tdiffe

renc

esfoun

dbe

twee

nso

cial

cons

ensu

san

dco

ntrol.Cog

nitive

disson

ance

interven

tions

canch

ange

attitud

esab

outa

ppea

ranc

ean

dattra

ctiven

essof

individu

alswith

obes

ity2

Crand

all

1994

(65)

42Und

ergrad

uatesin

aps

ycho

logy

clas

sAssignm

entto1of

2grou

ps:

1.‘Persu

ade’

cond

ition

.Pa

rticipa

ntswereread

ape

rsua

sive

mes

sage

andgive

nafact

shee

tabo

utthe

unco

ntrollabilityof

weigh

t2.

Con

trolc

onditio

n.Pa

rticipa

nts

wereread

ames

sage

andgive

nafact

shee

tabo

uttherole

ofps

ycho

logica

lstre

sson

illne

ss(unrelated

toweigh

t)

Attribution

theo

ryEx

plicitattitud

es:A

FA,F

earo

fFa

tSca

leOthers:

factua

lque

stions

conc

erning

weigh

t

Immed

iately

after

Participa

ntsin

thepe

rsua

deco

ndition

scored

lower

inwillpo

wer

(4.65vs.5

.57)

anddislike(1.75vs.2

.52)

than

control

cond

ition

,res

pectively.

Nodiffe

renc

eson

theFe

arof

FatS

cale

inpe

rsua

devs.c

ontro

l(6.19

vs.6

.50).P

ersu

ading

stud

ents

ontheun

controllabilityof

weigh

tmay

redu

ceas

sumptions

abou

twillpo

wer

anddisliketo

decrea

sean

ti-fata

ttitude

s

3Cotug

naet

al.

2010

(50)

40Dietetic

andhe

alth

prom

otion/he

alth

beha

viou

rscien

cemajor

stud

ents

enrolledin

anu

tritio

ncu

rriculum

elec

tive

Participa

ntsco

mpleted

theFa

tPh

obia

Scalebe

fore

andaftera

1-wee

kca

lorie

-res

tricted

diet

(120

0ca

lorie

sforw

omen

,150

0ca

lorie

sform

en)

Simulation

theo

ryof

empa

thy

Explicitattitud

es:F

PSOther

:jou

rnal

reflec

tions

1wee

kFa

tpho

biasc

ores

decrea

sedaftera

1-wee

kca

lorie

-res

tricted

diet.M

anyjourna

len

tries

reflec

tedane

wfoun

dresp

ectfor

individu

alsstrugg

lingto

lose

weigh

tand

chan

gein

priorn

egativeattitud

es.

Stud

ents

repo

rtedthat

thisex

perie

nce

wou

ldim

pact

theirfuturede

alings

with

overweigh

t/obe

seclients.

Participa

ntsfelt

that

thisdiet

prov

ided

real

expe

rienc

ean

dhe

lped

them

relate

morean

dbe

moreem

pathetic

toindividu

alstry

ingto

lose

weigh

t4

Diedrichs

etal.

2011

(51)

Initial

n=14

0,fina

ln=85

Und

ergrad

uate

stud

ents

enrolledin

threeps

ycho

logy

course

s

Pre-po

stex

perim

entald

esign,

assign

edto

3grou

ps.

1.Interven

tion=sp

ecially

deve

lope

dlecture

2.Com

paris

on=us

ualc

ourse

lecture

3.Con

trol=

nolecture

Attribution

theo

ryEx

plicitattitud

es:A

FAT(W

eigh

tCon

trol/B

lame,

Una

ttrac

tiven

es,S

ocial

disp

arag

emen

tsub

scales

)

Pre-test

(Tim

e1),

immed

iately

after(Time

2po

st-

interven

tion)

&3wee

ksfollow-up

(Tim

e3)

AtT

ime2Interven

tiongrou

pwereless

likely

tobe

lieve

that

weigh

tisco

ntrollablean

dless

likelyto

hold

anti-fata

ttitude

san

drate

overweigh

tand

obes

epe

ople

asun

attra

ctiveco

mpa

redto

pre-test

atTime

1.Th

eseim

prov

emen

tsweremaintaine

d3wee

kspo

st-in

terven

tionalbe

itwith

noch

ange

sin

social

disp

arag

emen

t.No

chan

gein

theco

mpa

rison

andco

ntrol

grou

psfora

nti-fat

attitud

esor

controllabilityof

weigh

tacros

s3tim

epo

ints



Tab

le1

Con

tinue

d

No.

Autho

rsSa

mple

size

Hea

lthprofes

sion

Stud

yde

sign

/interven

tion

Guiding

theo

ryWeigh

tbiasmea

suremen

ttool(s)

Durationof

follow-up

Summaryof

find

ings

5Fa

lker

etal.

2011

(52)

30Hea

lthca

reprofes

sion

als

(nurse

s,pa

tient

care

tech

nician

san

dun

itse

cretaries)

Com

pleted

apo

st-surve

yon

attitud

estowards

baria

tric

patie

nts1-mon

thafter

completionof

the44

-pag

ewrittenform

atof

theBariatric

Sens

itivity

Self-Le

arning

Educ

ationa

lMod

ule

Simulation

theo

ryof

empa

thy

Others:

‘The

Careof

theBariatric

Patie

ntNursing

Survey

’

(mea

surin

gstaff’s

know

ledg

ean

dse

nsitivity

towardob

ese

patie

nts)

1mon

thPo

st-surve

yresu

ltsreve

aled

20%

increa

sed

awaren

essthat

theira

ttitude

sca

nim

pact

theca

reprov

ided

toba

riatricpa

tients.

Aba

riatricse

nsitivity

educ

ationa

lmod

ule

decrea

sesstigmatizationof

healthca

reprofes

sion

als

6Gujrale

tal.

2011

(53)

266

Nurse

s2grou

ps:

1.Interven

tionba

riatricse

nsitivity

training(H

ospital1

)2.

Con

trol(Hos

pital2

)

Non

esp

ecified

orallude

dto

Explicitattitud

es:A

TOP,

BAOP

Interven

tiongrou

pATO

Pweremod

estly

grea

tertha

nthos

eforc

ontro

l(18

.0vs.1

6.1,

P=.03).N

odiffe

renc

esbe

twee

nBAOPsc

ores

forinterve

ntion

vs.c

ontro

l(67

.1vs.6

7.1,

P=.86).A

nnua

lba

riatricse

nsitivity

trainingmight

improv

enu

rsingattitud

estowardob

esepa

tients,

butitd

oesno

timprov

enu

rsingbe

liefs,

rega

rdless

oftheresp

onde

nt’sBMI

7Harris

1991

(64)

244

Und

ergrad

uate

psyc

hology

stud

ents

Ran

domlyas

sign

edto

cond

ition

s.Pa

rticipa

ntsread

andratedon

eof

6interviewsof

a2(exp

ert

interviewor

none

)×3(high

status

,empa

thyor

nomod

el)

factoriald

esign.

Participa

nts

wereprov

ided

(i)factua

linform

ationor

nota

nd(ii)e

xpos

ureto

either

nomod

els,

high

-statusmod

elswith

obes

ityor

mod

elswho

were

similartothepa

rticipa

nts

Attribution

theo

ry12

-item

obes

itykn

owledg

esc

ale,

feelings

abou

tmen

and

wom

enwho

aresu

bstantially

overweigh

t

Immed

iately

after

Participa

ntswho

read

theex

pertinterview

scored

high

eron

thekn

owledg

etest

scores

than

thos

ewho

hadno

t(19

.04

vs.1

6.74

,P<0.00

1).T

here

wereno

effectson

attitud

estowards

men

and

wom

enwho

areov

erweigh

t.While

know

ledg

eab

outo

besity

increa

sed,

there

wereno

chan

gesin

attitud

es

8Kus

hner

etal.

2014

(54)

127

Firsty

earm

edical

stud

ents

Pre-po

stex

perim

entald

esign.

Participa

ntsread

2artic

leson

commun

icationissu

esab

out

weigh

tand

obes

itystigmathen

hadan

8-min

enco

unterw

itha

stan

dardized

patie

ntfollowed

byde

briefing

andfacilitated

reflec

tionan

ddisc

ussion

with

theSP

,other

stud

ents

andthe

facu

ltyprec

eptor.Pa

rticipa

nts

completed

thesu

rvey

onewee

kbe

fore,immed

iately

aftera

nd1-

year

followingtheen

coun

ter

Con

tact

theo

rySe

lected

itemsfro

mex

istin

gqu

estio

nnaireswereus

edto

crea

teane

w16

-item

5-po

int

likerts

cale

ques

tionn

aire

(6,62,66

,67).Q

uestionn

aire

asse

ssed

3sc

ales

:neg

ative

obes

itystereo

type

s,em

pathy

foro

bese

patie

ntsan

dstud

ents’co

nfide

nceon

their

ability

tointeract

with

obes

epa

tients

Immed

iately

afterthe

enco

unter

(pos

t-interven

tion)

and

1follow-up

Sign

ifica

ntim

prov

emen

tsin

stereo

type

s,em

pathyan

dco

nfide

ncepo

st-

interven

tion.

53%

ofstud

ents

indica

ted

less

obes

itystereo

typing

,48.4%

indica

tedmoreem

pathyforo

bese

patie

nts,

and86

.7%

show

edmore

confi

denc

ein

clinical

interactionwith

obes

epa

tientsat

post-in

terven

tion.

At

1ye

ar,h

owev

er,n

egativeob

esity

stereo

typing

regres

sedto

base

lineleve

ls.

Empa

thyan

dco

unse

lling

scores

were

maintaine

dat

1-ye

arfollow-up



Tab

le1

Con

tinue

d

No.

Autho

rsSa

mple

size

Hea

lthprofes

sion

Stud

yde

sign

/interven

tion

Guiding

theo

ryWeigh

tbiasmea

suremen

ttool(s)

Durationof

follow-up

Summaryof

find

ings

9O’Brie

net

al.

2010

(55)

159

Hea

lthstud

ents

(Hea

lthprom

otion/

public

health

bach

elor

degree

prog

ram)

Ran

domized

controlledtrial,

3grou

ps.

1.Obe

sity

curriculum

onco

ntrollablereas

onsforo

besity

(31-hclas

ses)

2.Prejud

ice-redu

ctionco

ndition

:ob

esity

curriculum

onthe

unco

ntrollablereas

onsfor

obes

ity(3

1-hclas

ses)

3.Con

trolc

urric

ulum

focu

sedon

alco

holu

sein

youn

gpe

ople

(41-hclas

ses)

Elab

oration

Like

lihoo

dMod

el

Explicitattitud

es:A

FAIm

plicitattitud

es:IAT

Beliefs

abou

tobe

sity

&ca

uses

:BAOP,

TheDietin

gBeliefs

Scale

4wee

ksTh

ege

nes/en

vironm

entc

onditio

nsh

owed

a27

%de

crea

sein

theim

plicitgo

od/bad

andade

crea

seof

12%

inthemotivated

/lazy

implicitan

ti-fatp

rejudice

relativeto

othe

rcon

ditio

ns.T

hediet/exe

rcise

cond

ition

show

eda27

%increa

sein

one

mea

sure

ofim

plicitan

ti-fatp

rejudice

(motivated

/lazy).Th

erewereno

sign

ifica

ntgrou

pdiffe

renc

esin

explicit

anti-fatp

rejudice

betwee

nco

ndition

s,ho

wev

er,red

uctio

nsin

Dislikesc

ores

werese

enin

thege

nes/en

vironm

ent

cond

ition

.Nosign

ifica

ntch

ange

sin

beliefs

abou

tobe

sepe

ople

ordieting

controlb

eliefs

werefoun

dac

ross

cond

ition

s.Anti-fat

prejud

iceca

nbe

redu

cedor

exac

erba

tedde

pend

ingon

theca

usal

inform

ationprov

ided

abou

tob

esity

10Pe

rsky

etal.

2011

(56)

110

Third

andfourth

year

med

ical

stud

ents

Con

trolledrand

omized

expe

rimen

tal,2grou

ps:

1.Rea

dab

outg

enetic

orbe

haviou

ralm

echa

nism

sof

obes

ity2.

Rea

dab

outa

controltop

ic.

Stud

ents

then

interacted

with

anob

esevirtu

alpa

tient

inavirtu

alclinic

andco

mpleted

aba

ttery

ofmea

sures

Attribution

theo

ryEx

plicitattitud

es:n

egative

stereo

typing

(OPT

S)Others:

beliefinartic

leprem

ise,

caus

albe

liefs,p

erce

ptions

ofpa

tient’sresp

onsibility,

health

beha

viou

rrec

ommen

datio

ns,

patie

nt’san

ticipated

adhe

renc

e

Immed

iately

after(po

st-

interven

tion)

Rates

ofmos

thea

lthbe

haviou

rscree

ning

reco

mmen

datio

ns(w

eigh

tlos

s,ex

ercise

,an

ddiet

cons

ultatio

ns)werelower

amon

gpa

rticipa

ntsex

pose

dto

gene

ticca

usal

inform

ationthan

control.Th

ege

netic

caus

alinform

ationgrou

pex

hibitedless

nega

tivestereo

typing

ofthepa

tient

than

control,F(1,10

5)=5.00

,P=0.02

8,bu

tdidno

tdiffer

inan

ticipated

patie

ntad

herenc

e,F(1,10

5)=3.18

,P=0.07

711

Poutsc

hiet

al.

2013

(57)

64Con

venien

cesa

mple

ofse

cond

-yea

rmed

ical

stud

ents

attend

inganu

tritio

nco

urse

andthird

-ye

armed

ical

stud

ents

inafamily

med

icineclerkship

Pre-po

stex

perim

entald

esign.

1-h

interven

tionco

nsistedof

watch

inga17

-min

vide

oab

out

weigh

tbias:

Weigh

tBiasin

Hea

lthca

re,a

swella

spo

stvide

odisc

ussion

Attribution

theo

ryEx

plicitattitud

es:B

AOP,

ATO

P,FP

SIm

med

iately

after(po

st-

interven

tion)

Interven

tionincrea

sedthebe

lieftha

tgen

etic

anden

vironm

entalfac

tors

play

anim

porta

ntrole

intheca

useof

obes

ity(BAOPincrea

sedfro

m16

.53to

19.27)

andde

crea

sedne

gativestereo

type

sab

outo

bese

patie

nts(FPS

decrea

sed

from

3.65

to3.45

)

12Pu

hlet

al.

2005

(62)

Stud

y1,

N=60

Stud

y2,

N=55

Stud

y3,

N=20

0

Und

ergrad

uate

stud

ents

enrolledin

anintro

ductory

psyc

hology

course

Participa

ntsco

mpleted

self-repo

rtmea

suresof

attitud

estowards

peop

lewith

obes

itypriortoan

dafterm

anipulated

cons

ensu

sfeed

back

depictingattitud

esof

othe

rs

Perceive

dso

cial

cons

ensu

smod

el

Explicitattitud

es:O

PTS,

BAOP

Others:

Marlowe-Crowne

Social

Des

irabilitySc

ale,

Just

World

Scale

1wee

kFa

vourab

leco

nsen

susfeed

back

from

anin-

grou

pha

smoreinflue

nceon

repo

rted

attitud

esthan

whe

nitco

mes

from

anou

t-grou

p.Fa

vourab

leco

nsen

susfeed

back

increa

sedbe

liefs

that

caus

esof

obes

ityareno

tund

erpe

rson

alco

ntrola

nd



Tab

le1

Con

tinue

d

No.

Autho

rsSa

mple

size

Hea

lthprofes

sion

Stud

yde

sign

/interven

tion

Guiding

theo

ryWeigh

tbiasmea

suremen

ttool(s)

Durationof

follow-up

Summaryof

find

ings

Stud

y1:

Participa

ntsrece

ived

inform

ationab

outo

thers’

stereo

type

dbe

liefs

Stud

y2:

Participa

ntsweregive

nfavo

urab

leco

nsen

susfeed

back

from

anin-group

vs.a

nou

t-grou

pStud

y3:

Participa

ntswere

expo

sedto

oneof

5co

ndition

sto

compa

reco

nsen

sus

inform

ation

show

edmorepo

sitivean

dless

nega

tive

traits

abou

tpeo

plewith

obes

ity.R

eading

abou

tthe

unco

ntrollableca

uses

ofob

esity

decrea

sedbe

liefs

that

obes

ityis

caus

edby

controllablefactors,

redu

ced

nega

tivetra

itsbu

tdid

notimprov

epo

sitivetra

its

13Rob

erts

etal.

2011

(58)

14stud

ents

participa

ted

inthe

elec

tive

principa

lclinical

expe

rienc

eprog

ram

(PCE):

4stud

ents

enrolledin

baria

tric

surgery

long

itudina

lpa

tient

pilot

prog

ram,

9co

ntrols

Third

year

med

ical

stud

ents

Pre-po

stex

perim

entald

esign.

Clinical

clerkstud

ents

paire

dwith

avo

luntee

rpatient

sche

duledto

unde

rgoba

riatricsu

rgeryfor

1ye

ar.L

ongitudina

lbariatric

surgerypa

tient

elec

tive

includ

es:c

urric

ulum

,interdisciplinarypa

tient

visits,

clinical

skillbu

ilding,

long

itudina

lfac

ulty

men

torship

andse

lf-reflec

tion.

Stud

enta

ttitude

sbe

fore

third

year

clerkshipan

dag

ainat

theen

dof

theye

arus

ingbo

thqu

alita

tive&qu

antitative

metho

ds

Non

esp

ecified

orallude

dto

Others:

Attitude

Asses

smen

tSu

rvey

(asu

rvey

ofattitud

esan

dkn

owledg

eof

obes

ity&

baria

tricsu

rgery),refl

ectio

nes

saythem

atic

analysis

1ye

arTh

epilotp

rogram

memay

have

helped

maintainpo

sitiveattitud

estowards

obes

ity.R

eflec

tiones

saythem

atic

analysisreve

aled

that

extend

edlong

itudina

lrelations

hips

(multip

levisits

andwith

multip

lesp

ecialists)w

ithan

individu

alpa

tient

nega

tedprev

ious

lyhe

ldstereo

type

sab

outo

besity

14Ruk

avina

etal.

2008

(59)

69Kines

iology

pre-

profes

sion

alsfro

m4diffe

rent

unde

rgradu

ate

conc

entra

tions

(38clinical

exercise

physiology

,10

fitnes

sman

agem

ent,

13ph

ysical

educ

ationstud

ent

teac

hers

and8sp

ort

commun

ication

majors).T

here

was

Pre-po

stex

perim

entald

esign.

Interven

tioninclud

edbo

tha

clas

sroo

mco

mpo

nent

and

completionof

ase

rvice-learning

projec

t;then

,the

yad

ministered

theFITN

ESSG

RAM

to3–

5clas

sesof

fourth

andfifth

grad

ech

ildren

Attribution

theo

ry,

Expe

riential

learning

theo

ry

Explicitattitud

es:A

FAT,

ERTs

6wee

ksAFA

Tsc

ores

onweigh

tcon

trollability

decrea

sedfollowingtheinterven

tionbu

ttherewereno

diffe

renc

eson

theothe

r2AFA

Tsc

ales

.Interve

ntiondidno

tch

ange

stud

ents’en

dorsem

enttha

tfat

peop

lewerelazy.R

eflec

tivepa

pers

reve

aled

five

them

es:h

ealth

ylifes

tyle

asan

individu

alch

oice

,barrie

rsto

physical

activity,m

ulti-factorialn

atureof

obes

ityan

dprom

otionof

physical

activity

throug

hinform

ationan

den

courag

emen

t



Tab

le1

Con

tinue

d

No.

Autho

rsSa

mple

size

Hea

lthprofes

sion

Stud

yde

sign

/interven

tion

Guiding

theo

ryWeigh

tbiasmea

suremen

ttool(s)

Durationof

follow-up

Summaryof

find

ings

noco

ntrolg

roup

inthisstud

y15

Ruk

avina

etal.

2010

(60)

Totaln

=78

,ex

perim

ental

n=42

,co

ntrol,

n=36

Kines

iology

pre-

profes

sion

als69

pts

from

4diffe

rent

unde

rgradu

ate

conc

entra

tions

(38clinical

exercise

physiology

,10

fitnes

sman

agem

ent,

13ph

ysical

educ

ationstud

ent

teac

hers

and8sp

ort

commun

ication

majors).T

here

was

noco

ntrolg

roup

inthisstud

y

Pre-po

stex

perim

entald

esign.

Multi-co

mpo

nent

interven

tion

(service

-learning

base

dinterven

tionwhich

includ

eda

clas

sroo

msco

mpo

nent)

cons

istin

gof

attribu

tiontheo

ry(red

ucingpe

rcep

tions

ofco

ntrollabilityto

redu

ceblam

e),

cons

ciou

snes

sraising,

and

evok

ingem

pathythroug

hpe

rspe

ctivetaking

,roleplay

ing

andex

posu

reto

overweigh

tindividu

als.

Ptsco

nduc

teda

FITN

ESS-GRAM

with

scho

olag

edch

ildren(8–10

years)

asthese

rvicelearning

compo

nent.

Similartoea

rlier

2008

stud

ybu

tinclud

edamea

sure

ofim

plicitbias

Attribution

theo

ryEx

plicitattitud

es:A

FAT,

ERTs

Implicitattitud

es:IAT

1mon

thPa

rticipa

tionin

theinterven

tionredu

ced

explicitbias

ontheAFA

Tso

cial

charac

ter

disp

arag

emen

tand

weigh

tcon

trol/b

lame

subs

cales,

butthe

rewereno

sign

ifica

ntch

ange

sin

implicitbias

16Sw

iftet

al.

2013

(61)

n=43

atba

seline,

n=2-

at6wee

kf/u

19dietetic

stud

ents

and24

thrid

-yea

rmed

ical

scienc

estud

ents

PilotR

CT,

2grou

ps.

1.Interven

tion,

n=22

.Pa

rticipa

ntswatch

edtwoan

ti-stigma17

-min

film

s2.

Con

trol,n=21

.A34

-min

extra

ctfro

mahistorical

docu

men

tary

serie

sun

relatedto

food

andweigh

t

Attribution

theo

ryEx

plicitattitud

es:F

PS,

BAOP,

AFA

.Im

plicitattitud

es:b

ad/goo

dIAT

andlazy/m

otivated

IAT

6wee

ksTh

einterven

tionsign

ifica

ntlyim

prov

edex

plicitattitud

esan

dbe

liefs

towardob

ese

peop

le.Interve

ntionde

crea

sedF-Sc

ale

from

base

lineto

post-in

terven

tion(3.7

to3.2,

P<0.00

1)vs.n

och

ange

sin

the

controlg

roup

(4.0

to4.0)

Atp

ost-interve

ntion,

BOAPincrea

sedfro

m11

.2to

19.9

at6-wee

kfollow-upin

the

interven

tiongrou

p(P

<0.00

1)vs.n

och

ange

sin

theco

ntrolg

roup

(11.4to

11.7).At6

-wee

kfollow-up,

AFA

Dislike

decrea

sedfro

m1.86

to1.57

(P<0.05

)in

theinterven

tiongrou

p,whe

reas

noch

ange

swereob

served

inco

ntrols(2.39

to2.54

).AFA

Willpo

wer

decrea

sedfro

mba

selineto

post-in

terven

tion(5.42to

3.88

,P<0.01

)vs.

noch

ange

inco

ntrols(5.78

to5.94

).Th

erewereno

chan

gesin

implicitweigh

tbias



studies assessed ranged from 0.45 to 1.00 (mean: 0.71). All17 studies were included in the narrative analysis regardlessof quality rating.

Interpretation

The results of this systematic review demonstrated a lackof robust interventions that address weight bias reductionamongst students and health professionals. Many includedstudies had methodological weaknesses, including short-term follow-up periods (<6 months); lack of randomizationand control groups; and inconsistency of outcome variablesthat limited comparability. Most studies were conducted inlaboratory settings, limiting their generalizability in naturalsettings, which tend to be more complex. It is essential toalso understand how the context in which interventionswere carried out impacted the results. Overall, there is/areno definitive approach(es) that has/have demonstratedeffectiveness to reduce weight bias among student traineesand health professionals.The studies we reviewed examined the effects of weight

bias reduction interventions, with student trainees pursuinga health-related degree and practicing health professionals.These included students in undergraduate programmes,including dietetics and health promotion (50), dietetics andmedicine (61), health promotion/public health (55), kinesi-ology (59,60), medicine (38,54,56–58), psychology(51,62–65) and health professionals such as nurses (53)and a combination of professionals in a healthcare setting(nurses, patient care technicians and unit secretaries) (52).A literature and environmental scan highlighted four pri-

mary approaches that have been incorporated into inter-ventions designed to reduce weight bias amongst healthprofessionals (69). The first approach emphasized intellec-tual understanding of weight, overweight, obesity andweight-related bias, stigma and discrimination by provid-ing basic information for health professionals. The secondapproach focused on empathy with the lived experience ofpeople who are classified as obese by targeting peoples’emotions. The third approach emphasizes self-awarenessthrough self-reflection and gaining an understanding ofones’ own attitudes and biases. Lastly, the influence ofrespected and trusted leaders or peers who can ‘sway’ peo-ple to think one way or another can be utilized. To date,there is insufficient evidence as to which approach is moresuccessful for reducing weight bias among healthprofessionals.The components and guiding theories of the interven-

tions varied drastically among studies. Some studies uti-lized a single component approach (e.g. being put on a 1-week calorie-restricted diet) (50), receiving a single lecture(51), attending multiple lectures within a course on theuncontrollable causes of obesity (55), completing a self-learning module (52), providing an article on theT

able

1Con

tinue

d

No.

Autho

rsSa

mple

size

Hea

lthprofes

sion

Stud

yde

sign

/interven

tion

Guiding

theo

ryWeigh

tbiasmea

suremen

ttool(s)

Durationof

follow-up

Summaryof

find

ings

17Wiese

etal.

1992

(38)

75Firsty

earm

edstud

ents

Con

trolledde

sign

,2grou

ps.

1.Interven

tion=32

Broad

-ban

dman

ipulation:

expo

sure

toavide

otap

edinterviewwith

apa

tient

expres

sing

difficu

lties

with

dieting,

2role-playex

ercise

san

daradiosp

ecialo

nca

uses

ofob

esity

2.Con

trol=

43

Elab

oration

likelihoo

dmod

el,

attribu

tion

theo

ry,

control

theo

ry

Explicitattitud

es:1

9-ite

mob

esity

attitud

esqu

estio

nnaire

deve

lope

dby

rese

arch

ers

5wee

ksan

d1ye

arAt5

-wee

kas

sessmen

t,interven

tiondiffe

red

controlg

roup

onsixof

eigh

tmea

suresof

attitud

estowardob

esepe

ople..One

year

afterc

ourse,

interven

tiongrou

pwas

sign

ifica

ntlymorelikelyto

rate

gene

ticfactorsas

impo

rtant

inob

esity

andless

likelyto

blam

eob

esepe

ople

forthe

irco

ndition

AFA

,anti-fat

attitud

esqu

estio

nnaire;A

FAT,

anti-fata

ttitude

stest;A

TOP,

attitud

estowardob

esepe

rson

s;BAOP,

beliefs

abou

tobe

sepe

rson

ssc

ale;

ERTs

,exp

licitratin

gstests;

FPS,

fatp

hobiasc

ale(also

know

nas

F-sc

ale);IAT,

implicitas

sociationtest;O

PTS,

obes

epe

rson

stra

itsu

rvey

.



uncontrollable causes of obesity (56), receiving feedbackabout their level of stigma (cognitive dissonance vs. socialconsensus) (63), training in bariatric sensitivity (53) andviewing videos about weight bias (57,61). Others utilizedmulti-component strategies, including education plus real-world experience in working with a patient with obesity(54,58–60) and education plus another form of self-reflection (38). Although there is insufficient evidence tosuggest one approach and/or a combination of approachesis better for weight bias reduction, results from a previousreview and environmental scan learning from other modelsof discrimination suggested that ‘any approach must bemulti-faceted and multi-level in order to address the manymechanisms that can lead to harm’ ((69), p. 5).Many of the interventions reviewed used attribution

theory to guide the weight bias reduction interventiondesign by providing information about the ‘controllability’ ofweight (62,64,65). In the case of weight bias, attributiontheory posits that the more people believe weight is a function

of personal control and willpower (i.e. ‘controllable’causes such as diet and exercise), the more negative theirattitude will be towards individuals living with obesity.Weight bias interventions based on attribution theory areassumed to work by primarily using education aimed atchanging beliefs and understanding about the controllabil-ity of the stigmatized characteristic (i.e. weight). The abilityto control weight (i.e. believing that people are responsiblefor their weight) is an important contributor to anti-fat atti-tudes (70). Of the studies reviewed, some interventionschanged attitudes about the controllability of weight(38,55,62,65) by presenting facts about the uncontrollable/non-modifiable causes of obesity (i.e. genetics, biology,environment and sociocultural influences). However,interventions designed to change attitudes and beliefsabout people with obesity (i.e. character, attractiveness andnegative stereotypes) have been less successful (64).Information-providing interventions yielded mixed results,with some studies showing improved attitudes (51,62,65)

Table 2 Quality assessment of included studies

No. Reference Quality assessment checklist

Summarysc

ore

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Que

stion/ob

jectivesu

fficien

tlyde

scrib

ed

Stud

yde

sign

eviden

tan

dap

prop

riate

Metho

dof

subjec

t/com

paris

ongrou

pse

lectionor

source

ofinform

ation/

inpu

tva

riables

desc

ribed

andap

prop

riate?

Subjec

t(and

compa

rison

grou

p,ifap

plicab

le)ch

arac

teris

ticssu

fficien

tlyde

scrib

ed

Ifinterven

tiona

land

rand

omalloca

tion

was

possible,was

itrepo

rted?

Ifinterven

tionan

dblinding

ofinve

stigatorswas

possible,

was

itrepo

rted?

Ifinterven

tiona

land

blinding

ofsu

bjec

tswas

possible,was

itrepo

rted?

Outco

mean

d(ifap

plicab

le)ex

posu

remea

sure(s)welld

efined

androbu

stto

mea

suremen

t/misclas

sific

ationbias

?Mea

nsof

asse

ssmen

trepo

rted?

Samplesize

approp

riate?

Ana

lytic

metho

dsde

scrib

ed/justified

andap

prop

riate?

Somees

timateof

varia

nceis

repo

rted

forthemainresu

lts?

Con

trolledforco

nfou

nding?

Res

ults

repo

rtedin

sufficien

tdetail?

Con

clus

ions

supp

ortedby

theresu

lts?

1 Ciao and Latner 2011 (63) 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1.002 Crandall 1994 (65) 2 2 1 1 1 2 1 1 1 1 0 0 0 1 0.503 Cotugna 2010 (50) 2 2 1 0 n/a n/a n/a 1 2 1 0 0 0 1 0.454 Diedrichs 2011 (51) 2 1 1 2 n/a n/a 0 2 1 2 2 0 2 2 0.715 Falker 2011 (52) 2 2 2 2 n/a n/a n/a 1 1 1 0 0 0 0 0.506 Gujral 2011 (53) 2 1 2 1 n/a n/a n/a 2 1 1 1 2 2 1 0.647 Harris 1991 (64) 1 1 1 1 2 0 1 1 2 1 0 0 1 1 0.468 Kushner 2014 (54) 2 2 2 2 n/a n/a n/a 2 2 2 0 0 1 1 0.739 O’Brien 2010 (55) 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1.0010 Persky 2011 (56) 2 2 2 2 2 n/a 1 2 1 2 2 0 2 2 0.8511 Poustchi 2013 (57) 2 2 0 2 n/a n/a n/a 2 1 2 0 0 1 1 0.5912 Puhl et al. 2005 (62) 2 2 2 2 2 1 1 2 2 2 2 1 2 2 0.8913 Roberts 2011 (58) 2 2 2 2 2 2 2 2 2 2 2 2 2 2 0.6414 Rukavina 2008 (59) 2 2 1 2 0 n/a n/a 2 1 2 2 0 2 2 0.7515 Rukavina 2010 (60) 2 2 2 2 1 n/a n/a 2 1 2 2 0 2 2 0.8316 Swift 2013 (61) 2 2 2 2 2 1 2 2 1 2 1 0 2 2 0.8217 Wiese 1992 (38) 2 2 2 1 2 n/a n/a 2 2 2 0 0 2 2 0.79

The scoring rubric for quality assessment was 2 = yes, 1 = partial, 0 = no and n/a = not available. Summary scores were calculated by total sum/totalpossible sum. Total sum = (number of ‘yes’*2) + (number of ‘partials’*1); Total possible sum = 28 − (number of ‘n/a’*2). (68).



and others no change (56,64). Diedrichs and Barlow(2011) conducted an intervention study with undergradu-ate psychology students and found that participants whoreceived a lecture about the multiple determinants ofweight were less likely to hold negative attitudes towardspeople with overweight and obesity or to rate them asunattractive (51). Other studies have also suggested thatbrief educational interventions show some success in chal-lenging weight controllability beliefs and reducing weightbias in health students (51,62,65). Similarly, a study ofmedical students found that having students read materialshighlighting the genetic contributions to obesity led tosome reduction in weight bias (56); however, this interven-tion also resulted in greater avoidance of discussions withpatients about health behaviours such as diet and exercise.Wiese et al. (1992) evaluated an educational interventionconsisting of a videotaped interview with an individual dis-cussing her history of obesity and experiences with healthprofessionals, reading materials about genetic and environ-mental causes of obesity and role-play, taking on the per-spective of a person living with obesity. This weight biasreduction intervention increased empathy and changedmedical students’ stereotypes about people with obesity,but their willingness to blame people of size for their obe-sity remained unchanged.

O’Brien et al. (2010) used a randomized controlleddesign to evaluate changes in explicit and implicit anti-fatprejudice amongst health students after a series of compul-sory tutorial classes (55). One group received educationabout the uncontrollable causes of obesity; anotherreceived information about the controllable causes, whilethe control group received curriculum on alcohol use inyoung people. Decreases in implicit anti-fat prejudice werefound amongst the uncontrollable causes group, whileincreases in implicit anti-fat prejudice were found amongstthe controllable causes group. They concluded that ‘anti-fat prejudice can be reduced or exacerbated, depending onthe causal information provided about obesity’ (p. 1) andthat ‘health educators should ensure that information ongenetic, social and environmental causes of obesity, andtheir interactions, is delivered in a convincing manneralongside traditional information on causes and treatmentsof obesity, such as diet and exercise’ (p. 6). Phelan et al.(2015) (71) speculate that implicit bias influences subtlenon-verbal communication through changes in spontane-ous behaviour and improvements in patient satisfaction(72,73). It is plausible that more respectful patient-centredcare and improved patient experiences and outcomes mayensue as a result of decreasing implicit weight biases (71).

Despite yielding mixed results, other individual-orientedapproaches have been used in weight bias reduction inter-ventions among health professionals. Ciao and Latner(2011) successfully used a Cognitive Dissonance Theoryintervention (targeting value consistency and self-worth)

and demonstrated decreased negative attitudes about theappearance and attractiveness of people with obesity (63).Another study by Roberts et al. (2011) showed that ongo-ing contact with patients who had undergone bariatric sur-gery led to more positive attitudes (58). Other studiesevoking empathy and/or enhancing personal appreciationof the experience of heavier individuals have shown modesteffects (59,62).There is not enough evidence to suggest that attribution-

based approaches are sufficient to reduce weight bias, add-ing further support to the findings by Danielsdottir et al.(2010) that using one approach, such as manipulatingbeliefs/attributions about the causes and controllability ofobesity, is not sufficient to reduce the implicit attitudes thatcould be robust and durable among health professionals(74). Rukavina et al. (2008) (59) also suggested that inter-ventions will likely have to be multi-faceted and appliedrepeatedly to address both issues of changing controllabil-ity attributions (65) and having trainees reject negativestereotypes (59). The authors also proposed that if studentsare placed with patients who do not exhibit stereotypicalbehaviours, this could potentially help reduce their biases(59). Due to the diversity of the interventions’ theoreticalunderpinnings and approaches, comparison between inter-vention methods could not be assessed. There is a need toevaluate interventions that are based on theoretical frame-works other than attribution theory, and future studiesshould discern differences in effectiveness betweenapproaches to reduce weight bias.Our results show that there is no clear way to decipher

successful strategies to reduce weight bias because of thevariety of approaches used and the lack of high-qualityarticles published to date. Thus, while attributions areimportant, as is sharing information about the uncontrolla-bility of obesity, these approaches are, in and of them-selves, insufficient to change weight bias. It is likely thattrue change requires a change in social norms and theunderlying dominant ideologies about weight (75).Whether that should begin with individuals or broadersocial approaches, or both, is a question worth exploringfurther. Future research needs to assess and compare theeffects of single approaches (i.e. attribution theory basedon the controllability of weight) as well as multiple cumula-tive approaches (i.e. attribution theory, empathy evoking,encounters with standardized patients and peer modelling/shadowing) on weight bias reduction.There is some evidence to suggest that weight bias reduc-

tion interventions may not last over the long term. A studyby Kushner et al. (2014) examined changes in attitudes andbeliefs about obesity and their confidence in communica-tion skills in 127 first-year medical students after an educa-tional intervention, including an encounter with anoverweight standardized patient. Questionnaires wereadministered before, immediately after and one year after



the clinical encounter. The authors showed that the imme-diate decrease in stereotyping observed following a clinicalencounter with an overweight standardized patient was notsustained at 1-year follow-up (54). However, the authorsdid show that increases in mean empathy and confidence incounselling were maintained at 1-year follow-up. It wasspeculated that perhaps this encounter was not sufficient tooverride other clinical and personal experiences that shapehealth professionals’ attitudes and beliefs about individualsliving with obesity. This study highlights the need to sup-port additional educational experiences relating to obesityin the medical curriculum. There is a strong need to exam-ine the long-term effects of interventions (≥1-year duration)and to understand why stereotypes remain or revert tobaseline levels over time.

Strengths and limitations

To our knowledge, this was the first systematic review tosynthesize the evidence on weight bias reduction interven-tions uniquely in students or professionals in a health-related field. This research should inform the design andmethods of future randomized controlled trials and otherinvestigations to reduce weight bias in trainees or practi-cing health professionals. Due to the low number of studiesthat met our inclusion criteria, our limitations included thelarge variety of samples of health professionals (studenttrainees and practicing clinicians who represented a num-ber of different fields), diversity of intervention designs andapproaches and durations of follow-up assessments. Asthere was a lack of robust trials, transparency of methodsand presence of potential bias and heterogeneity in studydesigns, we could not determine the efficacy of the inter-ventions through a quantitative meta-analysis.

Conclusion and future directions

Our systematic review showed that there is no clearlydefined approach to reduce weight bias among studentsand professionals in a health discipline. The findings high-light the need to conduct randomized controlled trials todevelop evidence-informed, effective weight bias reductionpractices in healthcare settings. Health professionals mustbe aware of their own attitudes and behaviours towardspatients living with obesity and how negative stereotypescan impact patient care and engagement in the healthcaresystem. We argue that as students training to becomehealth professionals are still learning and forming attitudes,pre-professional education is a valued target for weightbias reduction, and health professional curriculum revi-sions are warranted. Phelan et al. (2015) (71) suggestedthat the medical school curricula about disparities and stig-matized populations should include discussion about

caring for patients with obesity. The authors also suggestincorporating positive experiences of medical studentswhen placed in contact with a patient living with obesity(known as contact theory). It has also been suggested thatsharing positive experiences and hearing from role modelswho treat patients with obesity with respect and dignitycould be influential for medical students in training.Addressing these factors could be important avenues toconsider when designing future weight bias reduction inter-ventions among health professionals.

Promoting positive attitudes, beliefs, skills and compe-tencies regarding obesity during student training mayincrease preparedness of future health professionals andoptimize the quality of care of individuals with obesityentering the healthcare system. However, there is a need tomove beyond awareness and information provision to raiseskills and competencies in health professionals regardingweight, obesity and weight bias. Furthermore, differenthealth professionals are grounded in different philosophicalmodels; interventions that work for one group might needto be modified to be effective for another. It would beimportant to investigate weight bias reduction in the con-text of the unique and diverse professional and healthcarecultures. Future research and evaluations should also assesschanges in behaviour and practices, which often stem fromresponses to changes in beliefs and attitudes. Long-termfollow-up is needed to evaluate whether changes in knowl-edge and attitudes will translate into changes in practicewhen treating patients with large bodies without stigma.As the education and training of health professionals areembedded in a society often fraught with weight bias, chan-ging the larger, systemic, social norms may be necessary tomake meaningful inroads into its reduction.

Conflict of Interest Statement

No conflict of interest was declared.

Acknowledgements

This work was funded by a Canadian Institutes of HealthResearch (CIHR) Partnerships for Health System Improve-ment (PHSI) Grant (201302MHS-302821) under PrincipalInvestigator Dr. Shelly Russell-Mayhew. Dr. AngelaS. Alberga currently holds a Banting CIHR PostdoctoralFellowship (BPF-139175) and was previously funded by anEyes High Postdoctoral Fellowship from the University ofCalgary. We gratefully acknowledge Gail MacKean andKathy GermAnn for their helpful guidance throughout thesystematic review process and for their insight and advicewhile reviewing and editing this manuscript.



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Supporting Information

Additional Supporting Information may be found in theonline version of this article at the publisher’s web-site:

Appendix S1. Detailed MEDLINE search strategy



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Weight bias reduction in health professionals: a systematic review · 2016-05-30 · Weight bias reduction in health professionals: a systematic review A. S. Alberga1, B. J. Pickering1,