Abstract
Two-thirds of American adults are labeled as overweight or obese by current body mass index weight status categories. Individuals categorized as overweight or obese are at risk of weight bias and, subsequently, poorer health care experiences and outcomes. However, schools and colleges of pharmacy may not be providing robust education or training to student pharmacists on weight bias, assessment of their own bias, or how to address and mitigate weight bias against patients. This commentary explores the impact of weight bias on patient care and how efforts can be advanced to recognize and address weight bias in pharmacy education and pharmacy practice to provide optimal care to patients of all sizes.
INTRODUCTION
Pharmacists provide education and pharmacological and nonpharmacological recommendations for promoting health and for treating and preventing illness. One area in which pharmacists may find themselves offering guidance and making recommendations is weight management. This interaction with patients can occur through weight management programs, in the setting of treatment of concurrent health conditions, or with individuals with no known health problems.1 No matter the setting, pharmacists remain accessible health care professionals who improve the health of patients, reduce suffering, and advocate for patients and changes that improve patient care.
Issues of bias are an unfortunate reality for patients. One form of bias that has not been reviewed or extensively documented in pharmacy education or practice is weight bias.1 This is especially notable because approximately two-thirds of adults in the United States are overweight or obese, as calculated by body mass index (BMI).2 These individuals may face the negative impacts of weight bias, including stigma and discrimination, which can put them at risk for developing low self-esteem, depression, and a lower quality of life.3 A key role of pharmacists is to advocate to improve the well-being of their patients and to reduce their vulnerability to psychological and social distress.4
Weight bias is defined as the negative attitudes and beliefs toward others due to their weight. This form of bias can affect anyone, but it most commonly affects people who are labeled overweight or obese. People can experience this bias in any aspect of life, including at the workplace, in health care, among interpersonal relationships, and within education.4 Weight bias can manifest as stigma, stereotypes, prejudice, and discrimination. Weight stigma, or marking an individual as having a lower social value because of their weight, can lead to discrimination.3 In employment settings and daily interpersonal relationships, weight discrimination has been reported as often as race discrimination and, in some adults, more often than gender or age discrimination.5 Weight discrimination may be most prevalent in minority ethnic and racial groups.5
The latest Center for the Advancement of Pharmacy Education (CAPE) Educational Outcomes, from 2013, include patient advocacy and cultural sensitivity as part of the structured framework for pharmacy educational outcomes, noting that students should “assure that patients’ best interests are represented” and “recognize social determinants of health to diminish disparities and inequities in access to quality care.”6 However, there is limited guidance on how best to implement this within pharmacy curriculum. Education on the multifactorial and nonuniform influences on obesity is necessary for the profession to understand patients’ experiences and behaviors, to mitigate weight bias, and, thus, to improve patient care.7,8
DISCUSSION
Health Care Disparities and the Impact of Weight Bias
Weight bias negatively impacts health. Regardless of BMI, it has been found that people who perceive themselves as heavy experience the stress of weight bias and have correspondingly elevated cortisol, which is linked to negative health outcomes, stimulates eating, and directly promotes abdominal adiposity, therefore continuing to perpetuate weight bias.9 People experiencing weight bias are also at increased risk of psychological issues such as depression, anxiety, disordered eating, and body dissatisfaction.3,4,9 A stronger association has been found between weight discrimination and mortality rates compared to other attributions for discrimination, such as race, ethnicity, sex, age, appearance, or sexual orientation.10
Because weight bias is present in all aspects of society and because the resulting discrimination is harmful to the health of its victims, it is important to first review how pervasive weight bias is in health care. High levels of weight bias have been found among health care clinicians, including primary care providers and health promotion specialists, resulting in beliefs that larger patients are lazy, weak-willed, and bad. Those same clinicians reported having less respect for larger-bodied patients and see them as a waste of time. These beliefs were found to lead to a lower quality of care.3 Physicians have also been found to engage in less health education with higher-weight patients, and 69% of respondents in a survey reported that doctors were the source of their experiences with weight bias.11,12 These biases and resulting behaviors are present in other health care professions, including nursing and psychology. Due to poor experiences with health care providers or expectations of poor treatment, larger patients may avoid seeking medical attention, mistrust providers, and have higher risk of treatment nonadherence.3
Recognizing Weight Bias
The first step in addressing weight bias is to identify and recognize one’s own biases. Bias is characterized as either implicit or explicit. Implicit biases are automatic, often unconscious, and impact one’s behavior without awareness. Implicit biases are commonly assessed through latency response tests, such as the Implicit Association Test (IAT) from Project Implicit, which measures the strength of associations between concepts and evaluations of stereotypes.13 The Thin-Fat IAT uses pictures of fat and thin people and compares the time required for respondents to categorize these pictures with positive (eg, beautiful, joyful) and negative (eg, ugly, awful) words.14,15 In contrast to implicit biases, explicit biases are conscious, intentional, and assessed through self-reporting tools. Explicit bias tools for weight stigma include Crandall’s Antifat Attitudes Test (AFAT) or asking about respondents’ feelings or preferences toward thin versus larger-bodied people, such as with these questions: What stereotypes do I have about people with obesity? How do I feel when I work with patients of different body sizes? Do I make assumptions regarding a person’s character, intelligence, abilities, health status or behaviors based only on their weight? How do my patients in larger bodies feel when they leave? Do they feel confident and empowered, or otherwise? 12,13,15
With this understanding of weight bias and its negative effects in health care, health professions schools and colleges have sought to determine the prevalence of weight bias among their students. In a large national sample of medical students, the majority exhibited weight bias comparable to more negative toward people identified as obese than toward racial and ethnic minority groups.13 Implicit bias toward overweight individuals was also identified in a study of nursing and psychology students.16 Limited information exists on weight bias in pharmacists or student pharmacists. The profession has rarely been assessed alone or grouped with other health care professionals in studies that have shown both implicit and explicit weight bias.1,17 Clements and Akins’s recent study of 84 student pharmacists at one college of pharmacy found neutral attitudes toward obesity. However, only measures for explicit bias were used.18
Addressing Weight Bias
Limited information exists on how weight bias is being addressed within schools and colleges of pharmacy.1,18 At the University of Kentucky College of Pharmacy, weight bias is not mapped in the curriculum and was found to only be listed as a form of bias in an unconscious bias training course. Curriculum mapping and a better understanding of the current extent to which weight bias is taught in schools and colleges of pharmacy will provide additional insight into the additional need for education and assurance that CAPE outcomes are met. Expanding the entrustable professional activities (EPAs) for new pharmacy graduates to include sensitivity and communication skills with diverse populations should also be considered.19
Within discussions on advocacy, sensitivity, and health disparities in pharmacy curricula, weight bias should be included. This can occur concomitantly with discussions of other forms of bias or throughout the curriculum as the topic of weight or obesity show up, such as in courses focused on wellness and health promotion, nutrition, endocrine disorders, cardiology, public health and policy, and patient care laboratory courses. Concurrently, students should be educated on the complex, uncontrollable, and nonmodifiable genetic and environmental factors that influence behaviors and obesity, such as genetics and biology as well sociodemographic, socioeconomic, and physical environments.7,8 Further, because BMI is often used to define obesity, is not a direct measure of body fat or health, alternative definitions and assessments of obesity and health should be described, such as alternative measurement tools, physical activity, and dietary intake.20 Inclusion and input from people with lived experiences should be used when discussing weight bias.7 This may include guest panel discussions and didactic lectures or including/highlighting these topics in standardized patient scenarios, case-based learning exercises, and implicit bias or cultural competency training. Additionally, schools and colleges of pharmacy should ensure a body-inclusive environment, including furniture, equipment (eg, blood pressure cuffs), and space (eg, distance between furniture) for students, faculty, and guests of all sizes to feel comfortable.
Sensitivity training, specifically including weight bias, should be provided to all faculty, staff, and students. Educating future pharmacists on weight bias requires faculty to take time to assess their own implicit and explicit biases using tools like the Thin-Fat IAT and AFAT, respectively, and to critically reflect on how this may impact not just what they teach but how they teach. Faculty should pay close attention to not propagate weight bias in and out of the classroom and avoid the use of stigmatizing and blaming words. Person-first language should be used in lectures, active-learning sessions, and introductory and advanced pharmacy practice experiences with emphasis on the person and not a characteristic or diagnosis. For example, one should use terms like person with obesity or patient affected by obesity instead of obese patient or morbidly obese.7,12 Faculty should facilitate a safe space for learners and patients and not accept or tolerate weight bias in any form, serving as a mentors and modeling advocacy. If miscommunication occurs, recognition of the mistake and apologies should be provided.
Evaluation and assessment of weight biases can be completed by students during active-learning sessions, interprofessional education, or self-reflection to gain an understanding of their own personal biases. Interprofessional education provides an opportunity for student pharmacists to work with other health professions students to collaboratively treat patients with a weight-neutral and inclusive approach. It can also be used to develop and find resources, such as health care providers who provide weight-inclusive care. Students should practice speaking up against biases, such as weight bias, and have the tools to advocate for patients if they are discriminated against.
CONCLUSION
Pharmacists and future pharmacists are in an optimal position to mitigate weight bias and discrimination in many areas, including pharmacy curricula, retail settings, hospitals, and ambulatory care settings, which will help improve health care experiences and increase access for millions of people.
- Received August 9, 2021.
- Accepted January 3, 2022.
- © 2022 American Association of Colleges of Pharmacy