Training Reduces Clinicians' Obesity Bias, Improves Practice

Medscape

4 hours ago

Many healthcare providers (HCPs) harbor bias against people with excess weight or obesity, and that stigmatization can negatively affect patient care. Now, an innovative two-endpoint continuing medical education (CME) initiative has shown that clinicians can change when brought face to face with their negative attitudes and less than optimal referral behaviors regarding patients with obesity.
Amanda Velazquez, MD
Reporting in the Journal of General Internal Medicine, researchers led by Amanda Velazquez, MD, of the Center for Weight Management and Metabolic Health and the Jim and Eleanor Randall Department of Surgery at Cedars-Sinai Medical Center in Los Angeles, found a 4-hour CME program, conducted in April 2021, significantly reduced HCPs' self-reported negative stereotypes compared with baseline. Self-reported empathy and confidence in caring for patients with obesity significantly increased immediately post intervention and endured at 4- and 12-month follow-up.
Additionally, the 4-hour symposium led to objectively improved diagnosis and referral to obesity care for patients treated across different specialties.
'There is considerable gap in the education of healthcare professionals about obesity,' Velazquez told Medscape Medical News , adding that established data have confirmed the existence of anti-weight bias among HCPs. 'Our study was unique in that it had a broad target group and invited professionals across all specialties from plastic surgeons and Ob/Gyns to nurses and emergency medical technicians. Our goal was to move the needle toward greater comfort in referring their patients to appropriate obesity management.'
She noted that excessive weight exacerbates many conditions treated outside of obesity medicine, such as psoriasis, cardiometabolic disease, and impaired fertility.
The Intervention
Conducted at a single site in the Kaiser Permanente Southern California healthcare system, the symposium invited a diverse population of 472 eligible HCPs.
Weight Bias: Weight bias was assessed by a 16-item questionnaire originally developed for medical students by Robert F. K ushner and colleagues, designed to assess negative prejudicial beliefs about patients with obesity. This measure captured three types of weight bias: negative obesity stereotypes (eg, 'Individuals with obesity have themselves to blame'); empathy for patients (eg, 'People with obesity feel stigmatized by the medical profession'); and confidence in clinical interaction with patients with obesity (eg, 'I feel comfortable talking to people about their weight').
As a result of the program, negative obesity stereotypes among attendees, according to the post-program questionnaire, were significantly reduced over baseline levels (2.81 ± 0.47 vs 2.50 ± 0.46; P < .001), while both their empathy (3.33 ± 0.64 vs 3.47 ± 0.63; P = .006) and confidence (3.10 ± 0.86 vs 3.85 ± 0.79; P < .001) significantly increased.
Practice Patterns: Behavioral outcomes of interest, according to electronic medical records, were participants' objective practice changes regarding obesity diagnosis and referrals to healthy lifestyle programs, obesity medicine, and bariatric surgery. Comparative analyses were done for 218 attendees and 89 nonparticipants.
After adjustment for years in practice, race/ethnicity, gender, profession type, practice type, and panel size, HCPs who attended the program had significantly increased odds of obesity diagnosis and obesity-related referrals in the 12 months following the intervention vs those not attending.
Specifically, compared with nonattendees, participants had increased odds of changes across several measures. Diagnosing obesity: odds ratio [OR], 1.60; (95% CI,1.54-1.66); referring patients to healthy lifestyle programs: OR, 1.27 (95% CI, 1.19-1.36); and referrals to an obesity medicine specialty clinic: OR, 1.87 (95% CI, 1.63-2.14). For patients with a BMI ≥ 35, the post-intervention OR for referral to bariatric surgery was 2.12 (95% CI, 1.70-2.67) in the 12 months following the intervention. The comparison group's odds either decreased or did not change.
As to participation by profession type, physicians were the most likely to attend, with physicians from family medicine, internal medicine, and obstetrics/gynecology more likely to participate than those from orthopedics and ophthalmology.
While Velazquez was not surprised by the level of anti-weight bias the symposium revealed, she was not prepared for the magnitude of objective change it effected in practice patterns. 'The increase in the number of referrals to obesity care was so overwhelming, we had to change the BMI eligibility criterion to handle the influx,' she said. With referrals to the obesity clinic doubling, the threshold for new referrals was raised from BMI ≥ 30 to BMI ≥ 35 to address the overwhelming demand.
Leslie Heinberg, PhD
Offering a nonparticipant's perspective on the intervention, Leslie Heinberg, PhD, a professor of medicine and vice chair for psychology in the Department of Psychiatry and Psychology at the Cleveland Clinic in Cleveland, called it 'an interesting and comprehensive study that goes beyond previous work in attitudinal change to look at change in actual practice behavior around obesity.'
She was not surprised at the shift in attitude immediately after the symposium. 'We all know the right answers to give, but the change in attitudes persisted long after the intervention,' In her practice, patients often report experiencing weight stigma during interaction with their HCPs. 'But healthcare should be sensitive to patients across the entire weight spectrum.'
Heinberg noted HCPs typically get little or no training in obesity issues, including the psychological aspects of this complex multifactorial condition. 'They might get one lecture during training, but 40% of the patients they treat will have obesity,' she said. Training is needed in how to talk to patients about excess weight. Her institution requires all new hires in any clinical capacity to have on-boarding training in obesity bias, with a yearly refresher course as well.
Carolynn Francavilla, MD, an obesity medicine specialist and owner of Green Mountain Partners for Health in Lakewood, Colorado, also applauded the study. 'As someone who dedicates a significant amount of my time to developing CME and educating clinicians, I find it very encouraging that this study was able to demonstrate both reduced weight bias and improved referrals for care,' she told Medscape Medical News. 'While most physicians are now aware of treatment options, many do not understand the chronic nature of the disease and many still believe that willpower is enough to treat obesity.'
The authors concluded that a focused CME intervention aimed at mitigating HCPs' weight bias and behavior can lead to improved diagnosis and referral to the full range of current options in obesity care. 'We're hoping to apply the intervention in other groups to see if it has the same positive impact on practice,' Velazquez said. 'But it will need some updating since the original interventions was conducted in 2021 before the explosion of GLP-1 therapy.'
Future research should focus on integrating obesity pharmacotherapy into the CME content and further examining practice behaviors. 'In addition to a randomized trial of the intervention, future research should also assess longitudinal practice changes beyond 1 year, the authors wrote.