The Role of Pharmacy Education in Mitigating Weight Bias

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.