Effective strategies in ending weight stigma in healthcare

Summary Weight stigma impacts negatively healthcare quality and hinders public health goals. The aim of this review was to identify strategies for minimizing weight bias among healthcare professionals and explore future research directions. An electronic search was performed in PubMed, PsycINFO and Scopus (until June 2020). Studies on weight stigma reduction in healthcare students, trainees and professionals were assessed based on specific inclusion and exclusion criteria. A narrative synthesis was undertaken to analyze emerging themes. We identified five stigma reduction strategies in healthcare: (i) increased education, (ii) causal information and controllability, (iii) empathy evoking, (iv) weight‐inclusive approach, and (v) mixed methodology. Weight stigma needs to be addressed early on and continuously throughout healthcare education and practice, by teaching the genetic and socioenvironmental determinants of weight, and explicitly discussing the sources, impact and implications of stigma. There is a need to move away from a solely weight‐centric approach to healthcare to a health‐focused weight‐inclusive one. Assessing the effects of weight stigma in epidemiological research is equally important. The ethical argument and evidence base for the need to reduce weight stigma in healthcare and beyond is strong. Although evidence on long‐term stigma reduction is emerging, precautionary action is needed.


Summary
Weight stigma impacts negatively healthcare quality and hinders public health goals.
The aim of this review was to identify strategies for minimizing weight bias among healthcare professionals and explore future research directions. An electronic search was performed in PubMed, PsycINFO and Scopus (until June 2020). Studies on weight stigma reduction in healthcare students, trainees and professionals were assessed based on specific inclusion and exclusion criteria. A narrative synthesis was undertaken to analyze emerging themes. We identified five stigma reduction strategies in healthcare: (i) increased education, (ii) causal information and controllability, (iii) empathy evoking, (iv) weight-inclusive approach, and (v) mixed methodology. Weight stigma needs to be addressed early on and continuously throughout healthcare education and practice, by teaching the genetic and socioenvironmental determinants of weight, and explicitly discussing the sources, impact and implications of stigma. There is a need to move away from a solely weight-centric approach to healthcare to a health-focused weight-inclusive one. Assessing the effects of weight stigma in epidemiological research is equally important. The ethical argument and evidence base for the need to reduce weight stigma in healthcare and beyond is strong. Although evidence on longterm stigma reduction is emerging, precautionary action is needed.
healthcare professionals, obesity stigma, weight bias

| INTRODUCTION
Social stigma is a fundamental driver of population health inequalities. 1 Although this has been recognized for decades, 2 detrimental effects of the stigma of body size and weight have gained wider acknowledgement only recently. 3 Societal weight stigma is pervasive 4,5 and suggested to be in part driven by the increased blame and shame framing of obesity in media and public health, 6-8 the cultural reinforcement of a slim ideal 9 and proclivities for social stratification. 10 Between 2017 and 2020, weight shaming, a manifestation of weight stigma, decreased slightly in the United States, and although this is promising, blaming individuals with obesity saw little change in the United Kingdom. 11 However, there is substantive evidence to show that weight stigma is unfair and unjustified, it creates health disparities and hampers healthcare and public health efforts. 3,12 The stress of stigmatization, from direct experience, but also from stigma suspicion and anticipation, can elicit physiological, psychological and behavioral responses, which harm health over time. Studies show that weight stigma can negatively impact on cortisol, glycated hemoglobin, oxidative stress and C-reactive protein, 13 as well as promote global dysregulation of lipid and glucose metabolism, and inflammation. 14 People with obesity experience weight stigma frequently, almost daily on average. 15,16 When compared with lower weight counterparts, those with measured or self-perceived overweight have shown blunted cortisol responses to acute stressful stimuli, 17 suggestive of sustained elevated cortisol levels. This is consistent with prior research [18][19][20] showing that although acute stigmatizing stimuli is associated with cortisol reactivity, blunted cortisol responses are more common after persistent and severe chronic exposure to stressors, including weight-related stigmatization, which often results in feelings of shame. 21 Although the relationship between adiposity and glucocorticoid dysregulation is complex and several other metabolic and genetic mechanisms have been suggested, 22 weight stigma has been found to contribute to the interindividual variation in stress response 23 among people with obesity. Jung et al. 23 showed that among people with body mass index (BMI) > 30 kg/m 2 , those with low levels of self-stigma react to acute psychological stress as predicted with an increase in cortisol secretion, whereas those with medium or high self-stigma show an atypical blunted cortisol response. When obesity was found to predict physiological dysregulation over a 4-year period, 29% of this effect was explained by weight discrimination alone. 24 Furthermore, weight stigma is linked to psychological distress, depression, anxiety, 25 low self-esteem, and body image disturbances, 13 often leading to decreased health motivation 16 and maladaptive coping such as avoidance of timely healthcare, social isolation, reduced physical activity and disordered eating behaviors. 26 Weight stigma has been shown to increase risk of developing obesity, 8,27 and it may shorten life-expectancy, as it is associated with nearly 60% greater mortality risk, not accounted for by traditional physical and psychological risk factors. 28 Mounting evidence shows associations between weight stigma and increased food intake, eating in the absence of hunger, emotional eating, binge eating and long-term weight gain. [29][30][31] Multiple experimental studies have shown that weight discriminatory experiences lead to decreased inhibitory control and increased caloric intake. [32][33][34] These eating behaviors are likely mediated by emotional distress and dysregulation 35,36 and should not be considered personal failings but maladaptive coping strategies to unfair treatment. 26,[37][38][39] Furthermore, weight stigma is unique compared with other social stigmas, as prejudices tend to be accepted by people across the weight spectrum. 40 Internalized weight bias (IWB) encompasses self-blame and self-devaluation that results from endorsing negative social messages around weight and applying them to the self. 3 IWB is believed to explain the relationship between acutely experienced or indirectly perceived weight stigma and maladaptive eating behaviors 41-43 as well as body shame and dissatisfaction, exercise and healthcare behaviors, bodily pain and parental weight talk. 44 Stigma may lead to efforts of escaping discrimination through weight-loss attempts, 45 and thus, some have argued that it may have a positive role in motivating individuals to engage in health behaviors. However, stigmatization creates a dual and countervailing effect of increasing motivation to engage in unhealthy weight-control behaviors, while simultaneously decreasing the perceived capacity to control weight, 46 and is consistently linked to adverse health behaviors and decreased long-term health. [47][48][49] Moralizing elicits an acute urge to defend one's moral identity, prompting responses that are perhaps visible, but not conducive of health. 50 Furthermore, while the moralized framing of weight common in healthcare may be done with the intention to motivate a desired behavior, it is most likely to have the opposite effect of disengagement and avoidance of said behavior. 50 Hunger et al. 38 have proposed a social identity threat model that elucidates the processes linking weight stigma and the cascade of mechanisms causing the deterioration of physical and psychological health, many of which are bidirectionally linked with eating behaviors. 51 Additionally, the cyclic obesity/weight-based stigma (COBWEBS) model by Tomiyama 52 represents weight stigma as a positive feedback loop perpetuated by stigma-induced increased cortisol and eating behaviors, which promote weight gain and thus further stigmatization.
Healthcare is one of the most common contexts where weight stigmatization occurs. 39 Physicians have been reported as the second most common source of weight stigma and discrimination. 39 Remmert et al. 29 found that over 70% of US adults enrolling in a weight loss programme report stigmatizing healthcare incidences. Similarly, Puhl et al. 53 found this proportion to be two thirds among adults in weight management programmes across six different countries. Furthermore, people with obesity are twice as likely to report healthcare discrimination compared with those at lower weight. 54 Extensive evidence highlights strong weight bias among healthcare professionals (HCP) including physicians, nurses, dietitians, psychologists, kinesiologists, students of these disciplines and even obesity specialists. 55 HCPs are unlikely to deliberately discriminate against their patients. For example, when measured by the Harvard Implicit Association Test, a validated measure of unconscious weight bias, most medical and nursing students exhibit stronger bias when compared with what they knowingly self-report. 56,57 Notwithstanding, underlying negative attitudes can lead to enacted stigma, that is, social cues and behaviors that cause the recipient to feel devalued, disrespected or humiliated.
Indeed, the majority of weight stigmatizing healthcare experiences reported by patients are not overt, but subtle. 29 These may include avoiding eye-contact or physical touch, providing unsolicited or oversimplified weight-loss advice or not having appropriately sized equipment at hand. Biases behind enacted stigma can be explicit, referring to conscious beliefs, stereotypes and attitudes, or implicit, referring to unconscious and automatic processes. Explicit and implicit bias has been shown to lead to over-attribution of health problems to weight, less time spent with patients and less patient-centered, positive affective communication. 58 Additionally, patients with high IWB report greater healthcare avoidance, increased perceived judgement from doctors, lower frequency of obtaining routine check-ups, less frequent listening and respect from providers, and lower quality healthcare. 53 Thus, unchecked weight bias among HCPs as well as IWB among patients potentially undermines successful diagnosis, treatment, and outcome. 59,60 Identifying widely applicable ways to effectively reduce healthcare related weight stigma is urgently needed. In addition to improving healthcare provision, and the health and well-being of patients with obesity, healthcare that not only avoids, but actively addresses and reduces IWB may help patients better cope with and reduce the effects of stigma until it is minimized in society. Not surprisingly, while stigmatizing does the opposite, 16,61 empathetic, non-stigmatizing weight-related communication can increase patients' health motivation and intention to comply with health professionals' advice. 62 A recent joint international consensus statement from leading health authorities has called for the elimination of weight stigma, 3 a process essential to achieving public health goals globally. Addressing negative biases in the healthcare community will help advocate for a culture and society where the respect, dignity and care afforded to each person is not dependent on their body weight. Stigma reduction interventions are a current research priority. 27 However, there is a paucity in agreed-upon, effective and practical strategies to target weight-related prejudice, which contributes to a lack of strategic antistigma actions. Therefore, the aim of this review was to systematically evaluate current knowledge on strategies for minimizing weight bias in healthcare professionals and to identify future research directions.

| Literature search
A systematic strategy was used to identify weight stigma studies related to healthcare settings and eating behaviors. An electronic search was performed in three online databases (PubMed, PsycINFO and Scopus) from their inception until June 2020. Combinations of the following keywords were used in all databases: "weight bias," "weight stigma," "weight discrimination," "obesity bias," "obesity stigma," "obesity discrimination" or "anti-fat bias"; and "healthcare" or "quality of care," or "food choice," "food intake," "food behav*," "dietary intake," "dietary choice" or "eating behav*". The search strategy was adapted to each database by using additional subject headings in PubMed and PsycINFO. We included papers written in English language and involving human participants. Bibliographies of all included studies were searched manually to identify any literature not retrieved by the main search.

| Study eligibility and selection
Studies looking at ways to reduce weight stigma in HCPs were assessed. Inclusion criteria included participants who were healthcare professionals, trainees or students and interventional study designs.
Studies were excluded when there was no measurement of effects on stigma. Review papers and observational studies were also excluded. Figure 1 illustrates the selection process in more detail.

| Data extraction and synthesis
For all eligible studies, a standardized data extraction table was used to extract data on study authors and year; population and country; F I G U R E 1 Flow diagram of studies retrieved and included in the scoping review intervention type and duration; outcome measures and principal findings. A narrative synthesis was undertaken to identify and analyze emerging themes.

| Key characteristics
The initial search identified a total of 3773 records. A total of 25 interventional studies were included in this review from which seven were randomized controlled trials, four were controlled trials and 14 used a pre-post intervention design. Three trials included HCPs, two included healthcare trainees, 19 included students, and one trial included both professionals, trainees and students, with a total of 3554 participants across all studies. The duration of studies varied from less than 1 day to 3 years. A summary of studies in healthcare professionals, trainees, and students (Table 1) is presented below. A narrative analysis revealed five major strategies: (i) increased education, (ii) causal information and controllability, (iii) empathy evoking, (iv) weight-inclusive approach, and (v) mixed methodology. Results are presented below according to these strategies.
3.2 | Reducing weight stigma among healthcare professionals and students

| Increased education
Literature on medical education suggests that HCPs feel inadequate in caring for patients with obesity. 63 Negative attitudes towards people with overweight or obesity may be shaped by experiences with poor treatment success, patient non-adherence and poor long-term outcome data that result from inadequate knowledge and skills. A possible solution has been to develop educational programmes on obesity and weight-related health. 64 Five studies used strategies based upon increasing knowledge of obesity in both students [65][66][67] and HCPs. 68,69 The first study used a brief 2.5-min video that focused on the etiology and treatment of obesity and showed no influence on weight bias in medical students, nurse trainees, nurses or physicians. 69 In contrast, a comprehensive obesity curriculum delivered to medical students over 3 years did show small, but significant reductions in bias as assessed by the Fat-Phobia Scale questionnaire; this was maintained at 1-year follow-up. 66 However, resulting values still indicated moderate amounts of weight bias and the clinical relevance of this change is unclear.
Three of the educational studies highlighted a social influence component, 65,67,68 which is the idea that social factors have a strong impact on people's beliefs and attitudes. 70 Accordingly, Jones et al. 68 trialed an 8-h educational seminar on obesity and osteoarthritis among physiotherapists. The seminar was delivered by respected obesity experts and opinion leaders and the content centered around the complex causes and complications of obesity. Although results showed moderate improvements in beliefs about weight controllability, negative attitudes increased after the seminar. The authors noted that seminar discussions tended to focus on practical and safety considerations, which might have contributed to worsening of attitudes by emphasizing the difficulties of working with patients with obesity.
Geller et al. 67 studied the impact of an ethics seminar embedded within a standard obesity, nutrition and behavior change course. The session revolved around group discussions on the personal experiences (74% struggled with their weight) and social norms (70% showed a thin-preference on the Implicit Attitudes Test among students). Four months after course completion, 30% of students selfreported improved attitudes, 53% reported no change and 10% reported more negative attitudes. Barra  Cross-sectional data suggest that increased general education and a deeper understanding of obesity alone is likely to be insufficient for reducing weight stigma 72 and in contrast, bias may actually increase as a result. 73 This may be due to the enforcement of and further socialization to weight stigma norms that are commonly expressed in health-related education and working environments. 74 The degree of social influence is dependent on the clarity of social norms expressed by group members, 70 and thus, even a single person, such as faculty role models, 75 can have immediate and long-term effects on student's views and opinions on obesity. The implicit and explicit communication of social norms in educational interventions warrants careful attention, given the possibility of changing bias in both directions. Another possible explanation for the lack of stigma reduction through increased knowledge relates to the content of standard obesity education, which tends to discuss weight from an individualized and medicalized perspective. 76 Indeed, focusing on individual behaviors as drivers of and as solutions to weight-related health has been show to increase implicit bias in previous studies. 77 Therefore, health education needs improvement perhaps not only through the introduction of broader uncontrollable determinants of weight, but also through discussions of the harm caused by social and cultural norms and messages concerning body weight. Opportunities to practice non-stigmatizing care throughout the education may further support this aim. This may be achieved with inclusive imagery and medical instruments as well as positive patient interactions.

| Causal information and controllability
In line with attribution theory, weight bias is arguably shaped by beliefs about the controllability, and thus responsibility, over body  [80][81][82][83] Reading about the genetic determinants of body weight before a virtual clinical encounter led to reduced controllability beliefs when compared with reading about behavioral determinants, or reading nothing. 83  In another study, three weekly tutorials that presented research on the uncontrollable determinants of weight were successful in improving measures of explicit and implicit attitudes, whereas tutorials focusing on behavioral determinants showed an increase in negative implicit attitudes. 82 However, although beliefs about controllability decreased when presenting genetic/environmental information, this was not found to be a mediating factor for attitudes in this study.
Although post hoc tests revealed a decrease in the dislike subscale of anti-fat attitudes in the genes/environment group, scores in the willpower subscale, indicating attribution of blame, increased. This, the authors explain, might have been due to regression to the mean, but could also reflect stable beliefs that people with obesity should lose weight regardless of the level of controllability and thus they must require high levels of willpower to overcome any barriers.
When teaching from a weight-centric perspective, causality inter-

| Empathy evoking
Empathy, the ability to understand the lived experience of another and to communicate that understanding, 86 is essential to effective therapeutic care. 87 Empathy-evoking interventions aim to change attitudes and reduce weight stigma by increasing acceptance and liking of individuals with obesity. 88 Additionally, limited evidence suggests that in general, weight-biased attitudes are more easily influenced compared with weight-biased beliefs. 88 [89][90][91][92][93][94] Reading about weight stigma, followed by a brief 8-min interaction with a patient led to significant improvements in empathy and stereotyping in medical students. 92 However, at 1-year follow-up, while empathy remained, negative stereotyping reverted back to the baseline mean. In another study where participants read an interview with a person with obesity, designed to evoke either status or empathy and coupled with or without an interview with an obesity expert, no significant changes occurred in any condition. 90 Reading the expert interview did increase participants' knowledge of obesity, but this did not contribute to changes in attitudes.
Molloy et al. 94 91 In a post-intervention focus group, students described the experience as "hard," "feeling trapped," and "embarrassing," and later recognized that caring for patients with obesity can be "emotionally draining" and "stressful." No follow-up was done, and how this impacted weight stigma in the long-term is unknown. Furthermore, others have argued that if empathy-building is not possible without wearing a costume to assume a stigmatized identity, then doing so will be unlikely to be meaningful 95 because there is a notable proportion of individuals in whom empathy-building interventions produce paradoxical effects. 85 People who respond better to this method on the other hand will be able to see that effect using less debatable methods.
Matharu et al. 93 used dramatic play reading to promote active empathic engagement in medical students. This was compared with a standard 1-h lecture on the medical management of obesity. Empathy increased in both groups similarly, but attitudes improved significantly only in the theatre group, whereas implicit bias remained unchanged in both. Given that empathy increased similarly in both groups, it is possible that the decreased reporting on explicit attitudes was influenced by social desirability because the discriminatory nature of weight bias was made salient only in the theatre group. Moreover, after 4 months, a follow-up survey revealed that students in the theatre group did not show increased recognition of weight stigma as something that needed to be addressed in society. However, they were more likely to take a patient-centered approach to obesity care, whereas students receiving the standard lecture were more likely to take a prescriptive approach and recommend weight loss and exercise. Finally, to increase reflective skills and reduce healthcare students' negative attitudes, Cotugna et al. 89 had dietetic and health promotion students follow a 1 week 1200-1500 kcal diet, commonly prescribed in weight management. In journal comments, students expressed their difficulty dealing with hunger and social events with 35% not being able to successfully restrict their calories. Limited postintervention results showed self-reported increases in empathy and a significant reduction in negative stereotyping.
The utility and long-term effects of empathy-evoking interventions in healthcare populations is unclear. Research shows that empathy does not necessarily decrease weigh stigma. 85,96 Daníelsd ottir et al. 85 have argued that evoking empathy is ineffective when it emphasizes the negative aspects of obesity, which reinforces stereotypes of helplessness and weakness. They suggested that rather than eliciting pity, a more constructive aim might be to emphasize size acceptance, respect and the human right for dignity. Size acceptance may be an effective strategy for both HCPs and patients, as accepting one's size, including when living with obesity, has shown to reduce stigma in others. 97

| Weight-inclusive approach
Concerns over the long-term ineffectiveness 98  Two interventions combined general education and causal information. 111 attributions. Anticipating and focusing on the narrative of the "difficult patient" has been shown to increase weight bias in medical students. 115 Thus, not all discussions and activities around stigma are conducive to its reduction.
Two studies used lectures combined with video, articles, role-play and reflective writing. 116,117 Both aimed to change controllability beliefs and evoke empathy and in both studies stereotyping decreased, whereas beliefs and attitudes improved according to some, but not all subscales. These changes remained significant at both 4-week and 1-year follow-up. Wijayatunga et al. 117 found that participants exhibited high implicit weight bias, which remained unchanged.
Importantly, a control group, who received a traditional obesity curriculum centering exercise and diet in weight management, was more likely to show increased implicit bias at 4-week follow-up. 117 Finally, two studies in kinesiology students combined lectures, addressing the multi-factorial determinants of weight and the prevalence and effects of weight stigma, with empathy-evoking activities and an additional field-based service-learning project. 118,119 In both, beliefs about controllability improved, but attitudes and stereotypes did not. Contrary to test scores, reflective writing revealed that many students had strong beliefs about personal control over weight. 118 This somewhat higher resistance to change may relate to the field of study, as exercise science related disciplines tend to focus on physique and thinness. 120 Rukavina et al. 119 also measured implicit bias, which improved, but did not reach significance and thus, remained strong among the students. Again, explicit bias increased in the control group taking other classes, highlighting the possible accumulating negative effects of not addressing weight stigma in health education. 119 There is a lack of evidence to suggest that using either single or multiple methods is better for reducing weight stigma. 121  determinants of weight regulation, as well as the science of weightinclusive health promotion. In this review, interventions that were based on or informed by causal information, and/or critical weight science and HAES were successful in improving explicit bias, whereas empathy-evoking was less successful. One important distinction between, for example, the weight-inclusive approach and the less effective empathy-evoking approach may be in the feelings they provoke. Rather than eliciting pity by emphasizing the hardships of living with obesity, a more productive approach to reducing stigma could be to highlight common humanity and the civil right to healthcare.
Second, there is a need to move away from a solely weightcentric approach to healthcare to a more health-focussed approach including weight-inclusivity. Equally important to the question of "how not to," is the question of "how and what" we provide in healthcare services. Our findings indicate that clinical encounters are an important element in the formation of HCPs beliefs and attitudes. In several studies, negative expectations or experiences regarding patient care, compliance and outcomes contributed to weight bias retention. All healthcare facilities should be equipped with appropriately sized instruments including, but not limited to, chairs, blood pressure cuffs and gowns. Importantly, being aware of and able to use interventions that improve patients' health regardless of their weight or weight change has the potential to reduce HCPs negative experiences and stereotypes of the so called "difficult patient," and instead promote a mutually beneficial provider-patient relationship focussed on health. Data show that patients benefit psychologically and physically from weight-inclusive programmes that address IWB, the psychological aspects of eating, and the social experience of living with overweight or obesity. 102,123 Addressing IWB is likely to be of greatest benefit when delivered within a weight-inclusive health promotion programme and before commencing with behavioral weight loss because IWB is higher in those seeking weight loss when compared with the general population. 124 It remains questionable whether and to what extent a weight-loss goal reinforces beliefs about weight controllability and blame, and is thus in itself stigmatizing. 125 Furthermore, working to decrease IWB within weight-loss programmes may prove challenging because a weight-loss goal may make improvements in IWB conditional on weight loss and maintenance. Screening for and addressing IWB in people with overweight or obesity looking to improve their eating behaviors, while also funding, designing and implementing long-term stigma reducing interventions, may help to reduce weight bias in HCPs, as it enables continuous reinforcement and enactment on anti-weight stigma values. Additionally, although the responsibility of reducing weight stigma in healthcare settings must fall on the provider, reducing IWB can empower patients to advocate for care they deserve.
Lastly, when conducting research on the relationship between weight, health and mortality, there is a need to ensure that researchers measure and account for the confounding and/or mediating effects of weight stigma. 24,28,126 Weight stigma, as experienced and/or internalized, is largely absent from current epidemiological research, which informs medical, political, and social discourse. Preliminary research shows that a significant proportion of the relationship between obesity and health outcomes can be explained not by body weight itself, but by the negative experiences commonly shared by people with overweight and obesity. More research is needed to understand this relationship and to highlight the importance of weight stigma on health outcomes in the scientific community.
Although the ethical argument and evidence base for the need to reduce stigma in healthcare and beyond is strong, research attention needs to move towards finding rigorous empirical evidence into the specific approaches to reduce weight stigma not just in the short term but in the long-term. Designing robust, randomized controlled trials with large population sizes and sufficient follow-up will uphold this aim. Nevertheless, the magnitude and consequences of the issue demand precautionary action, even as evidence is still emerging.
Eradicating weight stigma in society should be treated as a public health priority. This requires a whole systems approach, with co-operation of a wide range of stakeholders among whom HCPs, educators, researchers and policymakers as well as patients play an essential role.