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Sarah Thompson, founder of Resilient Fat Goddess, writes about body positivity, body liberation, and fat liberation at the intersections of gender, sexuality, and eating disorders. 

Evaluating Weight Bias Research Among Eating Disorder and Health Care Professionals

Examining the implicit bias of medical and mental health care providers is crucial in understanding the health outcomes for individuals at higher weights, including those with an eating disorder.

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Disclaimer: I do not endorse or encourage the use of words "overweight" or "obese", because they stigmatize higher weight people. Body size is naturally diverse, and there is not anything inherently wrong with having a larger body. Due to the use of these terms in research, the following article includes “o” words. I want to be clear that I do not endorse the use of these terms. For more on language, please read this blog.

 

While there is research to support that weight stigma is a risk factor for binge eating disorder, it doesn’t appear that medical professionals or administrators are taking action to reduce weight stigma. There continues to be a high rate of implicit bias within medical professionals. A recent study focused on the weight bias within eating disorder treatment professionals which shows that they are not immune from a high rate of implicit bias like other medical professionals. Amount of people surveyed, the methods, and the outcomes will be evaluated for the two research articles, Weight bias among professionals treating eating disorders: Attitudes about treatment and perceived patient outcomes and Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Examining the implicit bias of medical and mental health care providers is crucial in understanding the health outcomes for individuals at higher weights, including those with an eating disorder.

In the first research article, Weight bias among professionals treating eating disorders: Attitudes about treatment and perceived patient outcomes, 329 people’s answers were used, but 371 finished and 522 people started the online questionnaire. At a 28.9% dropout rate, the researchers found no other study on weight bias with this level of attrition. “The largest attrition occurred when the explicit measures of weight bias were presented to participants, and then when participants were queried about their attitudes towards obese patients.” This is a note-worthy finding that makes one wonder why eating disorder professionals had a harder time than other medical professionals when asked about their weight bias. Meanwhile in Impact of weight bias and stigma on quality of care and outcomes for patients with obesity, there were no participants surveyed, because it is an analysis of several research articles. Clearly these two articles are very different when it comes to the way in which the research was conducted.

The methods used in Weight bias among professionals treating eating disorders: Attitudes about treatment and perceived patient outcomes and Impact of weight bias and stigma on quality of care and outcomes for patients with obesity are very different from each other. The first article used anonymous, online self-report questionnaires to assess their explicit weight bias, perceived causes of obesity, attitudes toward treating obese patients, perceptions of treatment compliance and success of obese patients, and perceptions of weight bias among other practitioners. The second article “conducted a narrative review of this literature to highlight the ways that the obesity stigma may interrupt the healthcare process and impede many healthcare providers’ goal of providing equitable high-quality care.” They did this by reviewing all the original obesity stigma and impact of obesity stigma research studies published during the fall of 2014. After reviewing this body of research, they focused on articles pertinent to the potential impact of obesity stigma on medical professional’s behavior, patient health outcomes and interactions with medical professionals. They never cite how many studies that was. The citation list is packed with 109 articles, but we can’t assume that those were all the articles reviewed.

In Weight bias among professionals treating eating disorders: Attitudes about treatment and perceived patient outcomes, eating disorder professionals were recruited through several professional organizations: Academy for Eating Disorders, Binge Eating Disorder Association, National Eating Disorders Association, and Eating Disorders Research Society. The seven online questionnaires were the Fat Phobia Scale, the Universal Measure of Bias-FAT scale, modified version of beliefs about the causes of obesity by Foster et al, four questions about their perceptions of treatment outcomes of obese patients, forced choice questions on whether they are currently trying to lose weight and if they had a personal history of having an eating disorder, and finally, the Fear of Fat Subscale of the Anti-Fat Attitudes Questionnaire. This seems to be quite a thorough evaluation of eating disorder professional’s attitudes and beliefs about patients at the higher end of the weight spectrum.

In Weight bias among professionals treating eating disorders: Attitudes about treatment and perceived patient outcomes, it was the first time that eating disorder professionals were surveyed. There have been many studies on weight bias among physicians, medical students, dieticians, and nurses, and the article, Impact of weight bias and stigma on quality of care and outcomes for patients with obesity, is a continuation of this body of work. Now let’s take a look at the outcomes of these two papers. In the quantitative study surveying mental health professionals who treat people with eating disorders, it showed that there is weight stigma, but lower than that of other medical professionals. However, when questioned about their peers, 56% reported that they had heard or witnessed other professionals in their field making negative comments about obese patients, 42% perceived that other practitioners who treat eating disorders often have negative stereotypes about obese patients, 35% perceived that practitioners feel uncomfortable caring for obese patients, and 29% perceived that their colleagues tend to have negative attitudes toward obese patients. There seems to be a disconnect between personal perception and observations of colleagues.

It’s also important to note that of all the professionals surveyed - 38% had a history of an eating disorder, 23% were trying to lose weight, and 42% had experienced weight-based victimization. Those who were trying to lose weight had higher levels of negative attitudes towards obese patients. They also found the higher an eating disorder professional’s weight bias, the more likely to attribute obesity to behavioral causes, express more negative attitudes and frustrations about treating obese patients, and perceive poorer treatment outcomes for these patients.  Approximately 84% of these professionals did feel prepared and confident to work with obese patients. More research is needed to assess the impact of eating disorder professional’s bias on treatment outcomes for individuals with an eating disorder at higher weights.

The second study starts to examine the impact of weight bias on outcomes for patients at higher weights in general. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity found that primary care providers, medical trainees, nurses and other healthcare professionals hold explicit, as well as, implicit negative opinions about people with obesity. They acknowledge that is often more acceptable to show explicit weight bias, than other forms of discrimination, such as, racial. The article discusses how weight bias decreases a provider’s ability to be patient-centered while interacting with larger patients which does effect the quantity of care provided, as well as, patient compliance. It was found that negative weight attitudes of providers are associated with lower mental health outcomes for patients of higher weights. Another finding of note is that physicians may over-attribute symptoms and problems to obesity, and fail to refer the patient for diagnostic testing or to consider treatment options beyond advising the patient to lose weight.

Medical professional’s “attitudes about obesity may cause their patients with obesity to feel disrespected, inadequate or unwelcome, thus negatively affecting the encounter quality and their willingness to seek needed care.” It is very important to acknowledge that while most health care providers are trying to deliver compassionate care, many have glaring blind spots when it comes to weight. This impacts patient’s physical being and is a major hindrance for people at higher weights access to care. They even address the increase in obesity recommendations being a problem in increasing actions that will be perceived as a threat by larger patients. In addition, the actual physical setting and props in medical environments often do not fit patients at higher weights, thus making them feel even more unwelcome. This article does a respectable job qualitatively explaining how and why implicit and explicit bias among health care professionals effects patient experience and outcomes.

With one paper being a qualitative review and the other being a quantitative method, it makes comparing the two very difficult though they are quite complementary because of their different methods. They both support that medical professionals have implicit and explicit bias towards larger bodied patients. One was specific to eating disorder professionals, and the other focused on medical practitioners in general. The first article didn’t focus on the patient experience, but the second article did.  Weight bias among professionals treating eating disorders: Attitudes about treatment and perceived patient outcomes is an excellent demonstration of why the second article, Impact of weight bias and stigma on quality of care and outcomes for patients with obesity, is necessary. The outcomes of these two articles, however similar or different, is quite alarming.

Citations

Christopher G. Fairburn, DM, MPhil, FRCPsych. Risk Factors for Binge Eating Disorder. Archives of General Psychiatry http://jamanetwork.com/journals/jamapsychiatry/fullarticle/203880. Published May 1, 1998. Accessed August 20, 2017.

Puhl RM, Latner JD, King KM, Luedicke J. Weight bias among professionals treating eating disorders: attitudes about treatment and perceived patient outcomes. The International journal of eating disorders. https://www.ncbi.nlm.nih.gov/pubmed/24038385. Published January 2014. Accessed August 20, 2017.

Phelan SM, Burgess DJ, Yeazel MW, Hellerstedt WL, Griffin JM, Ryn M. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obesity Reviews. http://onlinelibrary.wiley.com/doi/10.1111/obr.12266/full. Published March 5, 2015. Accessed August 20, 2017.

Alberga AS, Russell-Mayhew S, Ranson KMvon, McLaren L. Weight bias: a call to action. Journal of Eating Disorders. https://jeatdisord.biomedcentral.com/articles/10.1186/s40337-016-0112-4. Published November 7, 2016. Accessed August 20, 2017.

Phelan SM, Dovidio JF, Puhl RM, et al. Implicit and explicit weight bias in a national sample of 4,732 medical students: The medical student CHANGES study. Obesity. http://onlinelibrary.wiley.com/doi/10.1002/oby.20687/full. Published January 9, 2014. Accessed August 20, 2017.


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