Today's training topic is focused on improving health outcomes for people with obesity by learning how we go about reducing weight stigma and bias in obesity care. My name is Samar Hafida and I'm the moderator of today's training to share just a little bit about myself. I'm an endocrinologist and I specialize in the management of people living with diabetes and obesity here at the Boston Medical Center. I'm an assistant professor of medicine at the Boston University and it is my pleasure to be your moderator today. Today we'll be learning from three amazing experts in this field. Each will provide their unique perspective on this topic. I'd like to go ahead and introduce our faculty today in order of their presentations. First we'll hear from Dr. Joe Naglowski who is the current president and CEO of the Obesity Action Coalition, which is a nonprofit organization dedicated to elevating and empowering individuals affected by obesity through education, advocacy, and support. Dr. Joe is a frequent speaker and author and is especially passionate about access to obesity treatments, tackling weight bias, and sharing his own experiences with obesity. He is no stranger to this field with more than 25 years of experience working in patient advocacy, public policy, and education, and he is a graduate of the University of Florida. Next we'll be hearing from Dr. Ryan Tweet. Dr. Tweet is a clinical psychologist and an associate professor of medicine in the division of endocrinology, diabetes, and clinical nutrition at Oregon Health and Science University, where he also serves as the director of behavioral health. Dr. Ryan has an extensive clinical background that ranges from working with patients in the bariatric surgery space, to oncology, to trauma and acute surgical care. In the last four years, Dr. Ryan has been working in the field of diabetes and endocrinology, where he specializes in supporting individuals living with diabetes, helping people with challenges such as diabetes distress, and maintaining positive relationships with food. His passion is helping people achieve their pro-health behavior goals, while also supporting his multidisciplinary team when navigating the biopsychosocial complexities of patient care. Not only is Dr. Tweet dedicated to clinical care, he is devoted to giving back to the diabetes community, serving on the ADA's health wellness advisory group, and recently serving as a contributing author to the sixth edition of the Handbook of Health Behavior Change. And last but not least, we'll hear from Dr. Tracy Oliver, who is an associate professor in the M. Louise Fitzpatrick College of Nursing at Villanova University. Dr. Oliver earned her bachelor's degree in clinical dietetics and nutrition from the University of Pittsburgh, and both her master's and PhD degrees from Temple University in the field of kinesiology, focusing especially on exercise physiology. Dr. Oliver serves on the Executive Committee for the Weight Management Dietetic Practice Group, and is currently the Weight Management Virtual Symposium Planning Committee chairperson. Her research interests include minimizing weight bias among health care providers through delivering educational programs. Thank you so much to our faculty members for joining us today and putting together what I know are many hours of work to make this training event possible. All right, so this is our agenda, everyone, for today. We'll spend today's training following the agenda here on the screen. We're going to be identifying defining weight bias, followed by patient internalization, and we're going to talk about strategies to mitigate weight bias. So by the end of the training, you'll be able to learn the following here. We're going to recognize the impact of weight stigma and common biases about obesity during communications with people with obesity, and we will identify strengths, strengths-based person-centered language and strategies within clinical care for each member of the team to reduce bias and stigma in patient care. All right, so I will gladly pass it on to Dr. Joe here. Thank you so much, everyone. Thanks, Dr. Hafida, and appreciate the opportunity to present here today. You know, when I give these talks, you know, I think about, you know, if we were here today talking about cancer, we'd all agree that cancer is bad, but we have compassion and empathy for people with cancer. However, when we talk about obesity, I think we all agree now that obesity is bad, but somehow in making obesity bad, we've made the people with obesity bad, and so that's what we're going to talk about today, kind of me taking a more, you know, patient-oriented approach to this kind of thing, and maybe simplifying some of the language we use. So, you know, here we go. We're going to jump in, and so what are bias and stigma? You see these advanced definitions here on the screen. I really think of bias as simply being, you know, negative attitudes that you might have about someone because of their body size, and it leads to potentially much worse things, and leads to stigma, which is actually the stereotypes you will hear me use and probably my colleagues use bias and stigma interchangeably, but they are slightly different. Bias are the attitudes. Stigma is the stereotypes moving forward, but I will be very clear here that, again, as mentioned early on in this definition here, bias and stigma can lead to much worse things, and in fact often lead to outright discrimination, which is not protected, not a protected class in most places here in the United States. And then there are different types of weight bias and stigma as well. You know, you saw some of that in the questions that you saw raised earlier on preparing for this course. So you have explicit, which are kind of the intentional or conscious decisions, making fun of someone outright because of, and saying it out loud because of their body size. For example, you see this implicit or these unintentional or unconscious attitudes that people have, often internal, often not expressed vocally, but felt internally. You see two other types that people often talk about when you talk about types. One is association, kind of like where you get biased from your work teams or your friends' circles or your family. And then, of course, there's public bias, where people get that from society and from the media, et cetera. We'll talk more about that later. And I intentionally skipped the last one on there, because I think it's one of the most important. And in fact, Ryan's going to dedicate his time in this presentation to that. And that is kind of internalized bias. So many of us, myself included, you've absorbed all of this explicit bias you face, the association bias you face, the public bias you face, and you start internalizing it, and you start to believe it yourself. And in fact, I can honestly say, as a person who lives with obesity, currently well-treated, that no one has said anything worse to me about my body size than me, myself. I've said the worst things to myself, but that is because I've internalized some of those biases moving forward. And we have to recognize that. Again, more about that topic in a little bit, because we dedicated significant time to it. So how common is bias and stigma? I will tell you that people accuse me of seeing bias and stigma everywhere, and I'll be honest with you, because this is what I do. I do see it everywhere. But most adults, about between 40% and 45% of adults report they have actually faced bias and stigma, and even going farther to say they've been victimized or discriminated against. It's kind of a weird thing to compare types of discrimination, but there are studies that do this. And so if you look at that, it is the second most common form of discrimination for women after gender itself, the third most common form of discrimination for men behind race and age. You will see very clearly in all the data around bias and stigma, you're much more likely to experience it if you're a woman. Men don't experience it nearly the same way. And even when we look at the consequences of bias and stigma, for example, wage penalties, we see that predominantly impacts women, where, for example, women with larger bodies or women who live with obesity often are paid less than their normal weight counterparts. And probably this last one is common sense, but worth acknowledging that the heavier someone is, the larger their body is, the more likely they are going to face bias and discrimination and stigma. So why are they important? And I think you can see all the technical reasons here on the screen, but I will tell you that it's my honest belief that we are not going to be able to address obesity as a nation and as a world unless we address bias and stigma. Because I believe very strongly that people with obesity don't ask for help with their obesity because of bias and stigma, because they blame and shame themselves. Healthcare providers often don't offer it because either they're worried about being perceived as blaming and shaming the patient, or they have their own bias and stigma and don't feel as if the patient needs help. And then finally, that the system, because of all this bias and stigma that exists, is actually puts forward barriers to people, for example, what we see every day, like the lack of coverage and or lack of consistent policies around trying to help people who live with obesity. You know, as I mentioned earlier, and I think it's worth repeating, it is perfectly legal in this country, except in one state, which is Michigan, to discriminate against someone because of their body weight. We do not protect people with this. You know, it is so ingrained or accepted in society that it's OK to stigmatize someone or discriminate against someone or make fun of someone because of their weight, that we just don't say anything and we don't protect people. And that's a real problem. And honestly, in order to address obesity, I think we're going to have to change that to really give people a chance of having the best success possible. So how are bias and stigma expressed? You can read these all on the screen. I won't go through all of them. But I think a couple of things that I often remind people about and ask them to challenge themselves about as they're thinking about this topic is about, for example, what assumptions you have based on on someone based on their body size. You know, oftentimes I like to say, like someone could walk by your room that you're in right now and they weigh 400 pounds and you might automatically jump to an assumption about their health and or their behaviors. And I will tell you that unless you are that person's direct health care provider, you can't do that. Right. You haven't had a real conversation with them. You don't know if that person, for example, weighed 500 pounds the year before and has done something remarkable, which is maintain a 100 pound weight loss. So we have to really think about our own ideas and our own actions, because they lead to all the consequences that you see there as well. The other thing I will talk about is, you know, bias and stigma comes out and we can give you examples of very overt cases. But again, there's very subtle ways that bias and stigma really impact people's lives. And honestly, it is the buildup of all those subtle experiences that many of us have that actually harm our ability to get the care that we need to achieve the best health possible moving forward. So not not all bias is overt. And honestly, I'll be I'll be frank here. I don't think most bias is intentional. I think most people are good people. I think society has just taught them it's OK to make fun of someone or say something negative about someone because of their body weight. And therefore, they do it. So when I actually approach addressing bias and stigma, I really encourage us not to blame and shame people who are blaming and shaming people. Right. We're actually making it worse by doing that. And actually, the solution to weight bias and stigma is not actually blaming and shaming people who engage in it, because then we're just doing the same thing that they are. Here are the common stereotypes. I think all of you have probably seen these before. It's repeated over and over again when we actually look at how people consider people with larger bodies from lazy to unmotivated, you know, personally to blame for their weight. Probably no surprises here, but but this is kind of the standard belief around people who live in larger bodies. And you know, when we talk about who engages in this kind of this weight bias behaviors, we see it across the board. Right. It's not just one group. I'm going to pick a little bit on health care providers and a little bit. But it's not just health care providers who do this. You see it from your friends. You see it from work. You see it from our lawmakers. And my gosh, I could do a whole hour on this. You see it all over the media, whether it's news media or television or movies, things along those lines. The reality is bias is everywhere and it's perpetuated everywhere. And honestly, if people see bias, they are more likely to repeat it. So it's it's it's worth acknowledging that we're going to have to tackle some of these broader areas, especially in the media, to really address this issue. I mentioned health care before, but honestly, you know, if we if you people and calls coming to my organization at the ABC Action Coalition, the most commonplace people talk about facing bias is their family members and then the health care environment about equally as much. And when we look at the data, we know that physicians, nurses, psychologists, dieticians, doctors all have levels of bias and stigma that are either equal or slightly higher than the public. And again, I said I would pick on a few health care providers earlier and you can see here, but I think it's important to recognize that, you know, you see the negative comments here. All of us who live with obesity likely can share with you a negative experience we've had with a health care provider. But I'm here to tell you right now that if you can actually engage your patients in a good, positive, compassionate way, that you can make a meaningful difference in their lives, because it was a health care provider who was compassionate, empathetic to me that actually helped me seek and ultimately achieve better health. So this is when we look at the actual bias, what happens in health care. So you know, you can see this this chart here of, you know, we have less respect and empathy for patients. We are blaming patients for their or their kids. Gosh, if you're a parent of a child with obesity, you face a special time of stigma. And in fact, many patients actually will tell me I have a good friend who says this, that you can actually if you actually go into if I went into my doctor's office today on an ax sticking out of my forehead, my doctor would say my head hurts because I'm fat right now. Obviously, that's an exaggeration. But it's just a reminder that we have to be careful in recognizing that obesity, yes, causes lots of health problems, but it doesn't cause every health problem. And we need to do that. And all of this less discussion makes less time, all less care makes people who live with obesity less likely to actually talk about their body weight and less likely to address it. And if we take this from the other side, this is how patients feel. You see that there's poor communication. Many people with obesity, delay care is something I can share with you very personally, you know, you know, every year when it came time for my annual checkup, I delayed it three months or six months or nine months because I was hoping to lose 20 pounds, I wouldn't get lectured by my health care provider. Right. And so we have to overcome that. Right. We have to we have to actually make it a partnership between the patient and the health care provider so that they don't avoid that care, because in my case, I didn't suffer any negative consequences because of it. But many people do. And we have to overcome that. Where does weight bias occur again, we touched on this a little bit earlier, but many environments from health care to at work and the education system, you know, as a nation right now, we've been having a conversation about bullying for the last couple of years. You know what the original form of bullying in schools is. It's weight based bullying. And honestly, if you took a look at weight based bullying policies around this country, almost none of them actually mentioned weight based bullying. Look at that bullying policies. None of them have weight based bullying in it. That's because it's so ingrained in our society that it's OK to make some fun of someone because of their body weight. It doesn't even make the bullying guides. And that's something that has to change. And then obviously we saw this in media and in personal relations, again, interpersonal relationships. People talk a lot about what their family members have said and what kind of judgment that has left on them over a lifetime. And obviously the challenges we face with the youth could merit an hour long or two hour long discussion alone. So this is my last slide, but I really will just say that I think bias and stigma really hurt people. And as I mentioned earlier, I think we're only going to be able to address obesity if we ultimately address bias and stigma, because it really does keep people from getting help, keeps providers from offering it and really keeps society from saying, you know what, it's worth investing in addressing obesity. And that's what we need to do. And so with that, I am gonna turn it over to my colleague, Ryan, to lead us through the patient internalization section. Thanks Joe for that wonderful foundation to the rest of today's training and thanks for sharing your personal experiences. And hello all and welcome. I just realized how much of a satire I am with a beard and a couch being a psychologist. Don't really take myself all that seriously, but I definitely take this topic serious. And as a psychologist, I'm gonna flip to the other side of the weight stigma and bias coin to discuss the intrapersonal effects of weight bias and stigma and its impact on weight management, overall health and quality of life. And then wrap things up with a few ways that we can work toward fostering a therapeutic alliance rather than a rupture in patient care when broaching the topic of obesity care and weight management. So weight stigma and bias can persist, it can persist throughout the lifestand. We see it occurring as early as preschool age with teasing and bullying as Joe was describing and evolving into unfair treatment and discrimination. And as someone navigates life with these explicit environmental inflictions, their experience and interpretation of stigmatizing situation may develop into what's known as internalized weight bias. So sorry for the typo that adds to the confusion between words, but this is essentially the textbook definition of internalized bias that can be applied to all stigmatized populations. So it's an awareness of negative stereotypes about one's identity, such as being an overweight person or agreement with these stereotypes, which can occur in the form of a sort of pernacious brainwashing over time. An application of these stereotypes, such as attributing a bad day at work or a skipped workout, not to external circumstances, such as being too stressed or tired because of daycare pickups, prepping dinner, getting kids to bed. I'm just projecting now, sorry. But instead to a belief that they are inherently lazy or undisciplined because of their weight. And then lastly, and related to the latter, self-devaluation because of one's social identity, which can really come in many forms, such as maybe not applying for a job or not pursuing relationships in similar scenarios because of that internalization, that self-devaluation. So in other words, the negative societal judgments these individuals face becomes an internalized process of self-blame and self-judgment from applying their awareness of weight-based stereotypes to themselves in a way that can cause a sort of self-fulfilling prophecy. And unfortunately, studies show that this is quite common. So for example, in this cited very compelling national study that uses a sample of adults with obesity and heightened risk of weight stigma and an online sample and national online panel, the latter two with and without people with obesity, at least 44% of adults endorsed a mean level of internalized weight bias. And in the general population, around one in five people endorsed high levels of internalized weight bias and over half of individuals with obesity reported engaging in self-blame and self-stigma. And this trend is especially common in lower socioeconomic status, lower education, those with a higher BMI who are trying to lose weight, especially women. So why does this matter for health and weight and obesity care? So it probably goes without saying, but I'm gonna say it anyway, but people who struggle with weight and obesity who internalize all these negative stereotypes about themselves are just more likely to develop harmful mental health issues such as depression, anxiety, body image dissatisfaction or distortions. And this can lead to or bi-directionally exacerbate comorbid issues such as disordered eating behaviors like binge eating or restrictive dieting that are often seen as coping strategies for negative emotions associated with stigma. And all of which creates this loop through worsening mental and physical health. There's growing research in fact, showing that internalized weight bias can be just as damaging as external stigma. And that even internalized weight bias may be a stronger predictor of poor health outcomes regardless of body size or direct stigma experiences. And lastly, for this slide, the meta-analysis noted in very, very small font below highlights that individuals with internalized bias experience greater psychological distress and adopt maladaptive behaviors that harm their health because it tends to affect motivational factors such as self-efficacy and avoidance in pro-health behaviors which is understandable because we don't tend to like to engage in things that make us feel bad or what has historically made us feel bad about ourselves. And this also correlates with lower physical health related quality of life and higher risk for issues like cardiometabolic conditions. And again, many of the studies evaluated in this analysis controlled for BMI and how much stigma they actually experienced. So let's look at how this impacts weight management. So in one very large study of individuals participating in Weight Watchers, I believe it was something like 19,000 participants, researchers found that internalized weight bias, not external experiences of stigma was linked to higher odds of weight regain, worse weight management behaviors such as lower self-efficacy around eating, less food monitoring. And again, this relationship held even after controlling for BMI and descriptive factors which just really highlights the powerful role that internalized weight bias plays in weight-related health outcomes. And in addition to internalized weight bias being a barrier to weight loss, it may also interfere with weight loss maintenance. So in another study with individuals who had lost at least 10% of their body weight over the past year, Dr. Poole and her colleagues from the Rudd Center found that internalized weight stigma played a significant role in determining whether they maintained or regained the weight. And specifically as levels of internalized weight bias increased, the likelihood of maintaining weight loss decreased by nearly 30%. That really suggesting that self-blame and stigma can undermine efforts to sustain weight loss regardless of how much weight-related stigma the person faced. And so when you consider all of this, when you consider psychological stress, related internal bias, it's important to consider poor weight management and related coping behaviors. So taking a step back for a moment, if I were to use guilt and shame in my work as a psychologist, few people would probably schedule a follow-up visit with me because I have very little leverage beyond their hope of improvement through working with me. And in fact, if guilt and shame motivates anyone, it's often short-lived. It's actually widely documented across subject matters that shaming someone can instead do quite the opposite and result in poor coping. And when it comes to internalized and externalized weight stigma, the stress of being stigmatized can lead to harmful or maladaptive coping behaviors such as exercise avoidance, less food monitoring, more binge eating and so forth that just really reinforces unhealthy eating habits and other risk factors for weight gain. Researchers have also demonstrated that they may use fewer adaptive strategies such as seeking social supports. And as Joe mentioned earlier, some of those social supports may even be contributing to this. And to summarize what Dr. Poole often says about this topic, and if you're not familiar with Rebecca Poole, you should look her up if you're interested in learning more about this topic because she's a big name in this field. But she says, it's best to think of weight stigma and internalized weight bias not only as a contributor to weight gain, but also as a consequence of it. So lastly for this section, many researchers have demonstrated the adverse relationship between the psychosocial stress of weight stigma and internalized weight bias and physiological stress, which has implications for body weight. That is people who experience weight stigma have internalized weight bias, can have elevated stress responses that increase risk for things like cardiovascular disease, metabolic, endocrine disorders through typical stress markers that we see like elevated HbA1c, higher levels of C-reactive protein, high cortisol, high blood pressure. And once again, these effects are often observed regardless of an individual's BMI, suggesting that stigma itself rather than body weight that's driving these physiological stress responses. If you're wondering what came first, the chicken or the egg, if you're familiar with that, I would love to tell you about the research in our breakouts if we have time. So what does all this tell us? So beyond the health effects, as Joe indicated earlier, weight stigma also has impacts to healthcare experiences and providers often spend less time with higher weight patients, engage less, may intervene less, while patients report lower trust, less empathy, and fear that their weight will be blamed for unrelated issues, leading some to avoid healthcare altogether. And we see this in multinational studies with internalized weight bias being a key driver and these experiences being consistent across countries and unrelated to BMI. So in essence, weight stigma affects psychological wellbeing, eating behaviors, physical activity, stress level, weight gain, and the quality of care patients receive. And I know I listed a bunch of studies, but weight stigma shouldn't just be an academic topic. I mean, it really is a public health issue and it's something that needs to be addressed to improve both individual health outcomes and the overall quality of healthcare for people of all body sizes. And I'm sure it's none of you, but 66% of participants in that very large study I mentioned earlier, indicated that they experienced weight stigma from healthcare providers multiple times. But again, I don't do guilt and shame, so I'm sure it's none of you. But I do hope that if I did my job correctly so far, if I've been doing my job correctly, it should be clear that addressing state weight stigma in healthcare is very, very important. And that might leave you wondering what you can do. Well, the first step is admitting that we have a problem, right? So we need to accept that we all have biases and make assumptions or have heuristic processes, whether they come from societal norms, cultural contexts, or personal experiences. I mean, adaptively these mental shortcuts help us to navigate life without a thorough investigation that would just simply take too much time for survival or getting things done. Like probably should have inspected my chair for sabotage today, because I have toddlers running around. But generally I assume that if I sit in a chair, it's gonna support me because of my experience sitting in chairs in the past, right? Unfortunately, on a more serious note, sometimes these processes can be harmful, such as in the case of prejudice and racism, as well as stigma and bias. And in this context, such natural tendencies can lead to negative impacts or can negatively impact the relationship we have with our patients. And while we can stick our foot in our mouth from time to time, and believe me, I do that as well, just ask my wife, I believe it's our responsibility as healers to actively work on ourselves in a way that will help our patients feel more in control of their health without the burden of shame. And considering that many of the times when we say things that are hurtful or harmful to patients, it's because of implicit or unrecognized biases or blind spots. Recognition is key to reducing these incidents. So one way we can be aware is by taking things like the weight-focused implicit association test through Harvard that's listed here. And taking the test and leaning into the results with self-reflection can be a very good start at bringing to the surface how our unconscious and subconscious worldview shapes how we interact with people. And additionally, and I don't want to reveal all of Dr. Oliver's cards here, but because she's going to go into great detail about this, but we want to engage in self-reflection before, during, and after patient care. So before I pass the proverbial microphone, here are a few self-reflection examples to ask yourself while interacting with patients. So the first one is, am I focusing on weight because it genuinely affects patient care or is it a default assumption? So weight's often an easy target in healthcare. And we want to consider if, you know, we're attributing a patient's health concern to their weight without fully exploring other factors. You may even ask yourself if it's necessary to ask about weight every time. Sometimes it may be necessary, right? But I'm just encouraging you to consider if it's necessary every single time. Next, is my question or comment helpful to patient care or could it be perceived as judgmental? So sometimes well-meaning advice can come off as passive aggressive. So instead of asking, have you thought about losing weight? You may ask, how do you feel about your health goals? Are there any barriers you're experiencing? And this can help you to meet the patient where they are and start where they want to start. Another question is, am I being too passive about addressing weight stigma in the room? So on the other side of it, avoiding the topic of weight altogether could also send the wrong message. So it's something to be ashamed of. So we want to normalize conversations around weight by framing them in terms of health behaviors, while also emphasizing that health can exist at every size. You just have to meet them where they're at so we can find, you know, where they want to start and work on things that are meaningful to them. And then is this question motivated by curiosity or the patient's wellbeing? So you just want to make sure that your questions are serving the patient's best interest and not your personal curiosity about their lifestyle choices. I mean, this is something that I do all the time. I'm genuinely curious and want to get to know people, but I often have to ask people like, is this actually moving the appointment along? Is this actually helping them get closer to their goal? And then lastly, is my approach rooted in empathy or judgment? This is a very big topic, but you know, in short, judgmental questions often stem from our own discomfort with the subject matter, which is another reason why you might want to fold these things to the surface. A simple shift in tone though can sometimes make the difference. And just considering if you're coming from a place of care and compassion rather than judgment. All right. Well, thank you all for your time so far. And I look forward to talking more with some of you in a bit. Next, we're going to hear from Dr. Oliver about further strategies to mitigate weight bias. Thank you, Ryan. So I want to move our conversation into thinking about strategies to mitigate weight bias and further this conversation. So my colleagues have done an exceptional job setting the stage about defining weight bias and weight stigma, discussing the prevalence of weight bias and weight stigma, as well as the detriment that our patients experience when they've had these experiences. So with that in mind, I want us to think about, and I am going to focus a bit on the healthcare lens, that when these patients come to see their providers, they've had these experiences. They are coming into our offices having experienced this firsthand. And when we know that and take consideration of that, they have their guard up and we must be on our toes to think about how to set the stage to have the most successful session. So both of my colleagues have talked a bit about raising awareness. And when we think about implicit bias, right, many times this is very unintentional and a provider may not even be aware that they are construing bias during those interactions. And Ryan did start to speak about this, but when we think about these non-verbal cues or just sort of setting the stage, if someone has, if a provider has bias, it's coming through in their body language. Maybe they are rushing through the appointment. Maybe they are making limited eye contact with their patient. Maybe they have their arms crossed and they're checking off the list of things that they want to ask the patient. They may be raising eyebrows or making facial expressions, all of which that patient is observing, feeling and feeling judged by. But when we start to raise our own awareness as a provider, we can begin to nip these behaviors in the bud. Are we leaning in to that experience with that patient? Are we sitting close enough, not too close, but close enough that it's comfortable to engage with that patient and setting a warm, welcoming environment for that patient care interaction? Another thing to consider when we raise our own awareness about weight bias is our own understanding about the complexity of obesity. Many times we, I don't know, I feel like maybe in school, we probably learned along the way that obesity is the cause of too much energy in and not enough energy out. And that very erroneous, simplistic belief of obesity leads to increased stigma and increased stereotyping. We know that obesity is far more complex than poor eating choices and a lack of physical activity. So when we, as providers, acknowledge the complexity of obesity and focus in on those genetic, metabolic and environmental causes, this in and of itself reduces the stigma, increases the patient's self-efficacy and reduces their self-blame when we're thinking about just the conversations pertaining to obesity. And further, when we think about avoiding blame, we know that many patients walking into our offices have tried multiple, countless, numerous strategies to potentially have to lose weight and many times ultimately have been unsuccessful. Perhaps they were successful for a short period of time or found a strategy that worked really well, but then over time found that that was no longer successful for them. So many times they're coming in feeling defeated, feeling that many of these conventional weight management methods have been ineffective for them. And again, as providers, we need to consider these other factors as well as the complexity of this disease. It's also important to think about effective communication strategies. And we know that the way in which we communicate with patients will promote these positive and patient-centered interactions. So you'll hear me say a lot, these patient-centered interactions. We also know that common language that we may be using may unintentionally be communicating bias and altering our language and being more patient-centered is proven to be supportive and empowering. So ask yourself, is referring to someone as obese a form of weight bias? And I realize the answer is right there, but I do have some words on the next slide that really talks about preferred language. And that really comes from words that patients prefer that might be used when we're talking about obesity. We know that when we use the word obese, it's often labeling and it doesn't necessarily focus on the disease aspect of obesity and therefore stigmatizes it even more, making that patient feel less of worth. And that they're no more than their condition. So you've heard us model it in this webinar, but we are going to be thinking about, patients living with obesity or affected by obesity as preferred terms. So here is the slide on word choice. And this is research coming from, again, Rebecca Poole, but they actually interviewed patients and asked, what would be your preferred word choice when discussing weight or obesity? And you can see on the left, you're going to see less stigmatizing or less blaming words. And we'll see weight may be described or BMI. And those are generally very neutral terms. You may see some others, weight problem, unhealthy weight. And then of course we have our list of most stigmatizing and more blaming words. I don't feel like I even need to say these out loud, but we do see morbidly obese or morbid obesity showing up on medical records. And sometimes as it's categorizing obesity. I think the biggest takeaway from this slide is ask the patient. If we are going to take a moment to ask the patient, what is your preferred word that we might use to discuss your weight status? That is the ideal. Because even if this research might suggest that weight or BMI may be less preferred, it is really what that patient's preference is. And that could vary greatly patient to patient. Next, and again, I think you've heard us all model this quite well during our talk today is using person first language. And again, acknowledging the respect and dignity towards patients with obesity. And again, we don't want to think about labeling patients as obese as it further perpetuates weight bias. Joe started the conversation today and it made me think of this. He started the conversation to say, when we think about patients with cancer, we automatically have a natural empathy towards them, but we would never call them our cancerous patients. And yet we see the terminology quite often, obese patients, obese adults, and quite frankly, it's very inappropriate. So to model person first language, it is best to say adults living with obesity or adults who are living with overweight or obesity. Again, recognizing that obesity is a disease and not a physical characteristic. And we do see this throughout healthcare. I feel like we've gotten really good at saying, patient with diabetes instead of our diabetic patient. So more on talking about weight, we know that there's more to the conversation than simply talking about the terms that we use. And it is very much about the way that we communicate about eating habits, physical activity and weight related behaviors. So Ryan started to talk a little bit about this by giving us some examples when we engage in the conversation pertaining to weight. And the biggest thing you'll see sort of bolded at the top is asking permission. What did that patient come in there to talk to you about today? Why have you come in? What are your health priorities that you'd like to talk about? What are your health concerns that you would like to address at this visit? And then finally, what are the health concerns that you would like to address at this visit? It's patient centered. It gives the patient the opportunity to drive that session and really discuss whether weight might be something that they want to talk about that day or if they are indeed just coming in to talk to you about their earache. So the other thing, if the conversation does gear towards weight, how do we ask permission to engage in that conversation further? So again, I have some examples but I always like to think about, use an example that feels right for you. Don't use my words, use words that feel right for you, but that model this, such as would it be all right to discuss your weight or maybe how do you feel about your weight at this time? Again, it puts the patient in charge of that conversation where maybe they say, not today, that's not a priority for me today or I'm satisfied with my weight at this time. Again, maybe Joe's example, that 500 pound patient previously is now 400 pounds and making great progress. So they're okay in their current progress with that. Another thing that's not on the slide that I'll have you consider though, is also asking the patient if they would like to be weighed at their visit. And I know sometimes this comes with varied viewpoints, but simply asking, is it okay if we get your weight today? And then maybe further, would you like to see that number? But it is an important piece about giving that asking permission, and again, allowing that patient to drive that patient care visit. Another consideration is ways in which we might reframe language about eating habits. The biggest thing that comes to mind for me here is many times, if we think about the assumptions that my colleagues have already described for us, many times we engage in weight-related or eating-related conversations with some assumptions. And I'm going to ask you to kind of challenge those assumptions. Sometimes I'll hear providers say, well, tell me about your sugar, sweet, and beverage intake, or tell me about how many fried foods you're eating. And it might come back and be like, well, that patient didn't say that they were eating fried foods or had any sugar, sweet, and beverages. So again, thinking about being very mindful to mitigate any sort of assumptions during this conversation. And to further some examples, right, using some of, instead of using some of that negative terminology, such as cheating or overindulging, it's better to say things such as, can you describe some challenging situations or times in which you've had difficulty staying on track? It's received much better. It allows that patient to engage in that conversation without feeling that they have to defend maybe their eating habits. Another question for you, is it weight bias if a healthcare professional doesn't have office equipment for people living with obesity, such as chairs, gowns, or blood pressure cuffs? And yes, the answer is revealed for you, but patients living with obesity should be welcomed into a healthcare environment where they can receive any type of an examination in comfort, just like any other patient. I have a slide coming up, but one of the things I'll have you consider is creating a comfortable and welcoming clinical environment is one of the most important ways to show a patient of all body sizes that they can equally receive care in this setting. And these are some of those unintentional ways that we may be showing bias if our clinical environment isn't set up to accommodate these types of patients. So some examples, and I'm gonna go out of order. I'm gonna start with waiting room, because I think it's the first thing that the patient might enter and see is your waiting room set up to accommodate patients of larger bodies. So are the chairs without arms and can they support a body size of greater than 300 pounds? Are doorways and hallways accommodating to wheelchairs or walkers of a larger size? Once that patient walks into that exam room, are they provided a gown that is appropriate for their size? I'm thinking about that first question where it was like, hey, this gown might fit you, but are there all sizes that, you know, there's a selection that a patient would feel, you know, there's a gown to fit me. Are there appropriate size blood pressure cups for all body sizes, wider, sturdier exam tables, and again, those armless chairs. Speaking of the scale, first, where is that scale located? Many office settings, it's located in the middle of the hallway where there's providers and patients walking back and forth and it lacks privacy and confidentiality. So is there any chance that that scale can be moved into a private space? Can that scale accommodate bodies of greater than 350 pounds? And possibly, can it have arm supports or like handles for that weighing visit? And then further, just some imaging, when we think about different medical types of procedures, MRI table size restraints, DEXA scan size restraints, CT scans, and do those tables lower, maybe to allow for patients to easily access them or move onto those. So I'll just wrap up our weight bias component here, right? Increasing the awareness, which I hope we've done throughout this training and its detrimental impact on health and consequences. Thinking about ways we can be sensitive when communicating about weight, using effective communication strategies to engage patients in health-related conversations and using clinical practices that can support and empower patients who are vulnerable to weight loss. And to weight bias and weight stigma. All right, wow. What a wealth of information, everyone. Thank you so much, Joe, Ryan, and Tracy. Thank you to our participants. So faculty, share with us, what did you guys talk about in your breakout rooms? Let's go with you, Joe, first. I was, a lot of me talking, I had a little bit of a quiet group, but I think the key message, and again, one of our participants bravely shared in the chat around this, is that we have to focus on the whole person, not just their body weight, and have this empathetic and compassionate conversations. I think it is when we get so obsessed with the pounds on the scale that sometimes we unintentionally fall down that path of stigma. So focus on the whole person, think about victories, health victories, what we call non-scale victories, victories beyond the scale to really focus on a person's health and quality of life, because that's the real reason why people are seeking care. I love that, focus on the whole person. Ryan, do you want to tell us what you guys talked about? There were questions about how to, the first one was about how to address observed weight stigma in clinic, and how to talk to colleagues, as well as how to talk to patients who have experienced it. Really great question. I don't know if I had the best answer, kind of dance around a little bit about it, because it's a tough question. I think if you are in a leadership position, being able to suggest to your people, attending workshops like this, providing literature, anything you can do to increase exposure to the problems that we've discussed today, it can be a great start to helping people have those conversations and start to work on themselves around the way that they discuss these things with patients. And then the, what was that? I would say absolutely, yes, I agree with you. Yeah, and I'll leave it at that for the sake of time. Yeah, it's definitely a touchy subject when you sort of have to correct your colleague there. Tracy, what did you guys talk about? Yeah, so we worked through some good, better, and best scenario examples, where we sort of talked about what does it look like when we're engaging with a patient, and what is the best way to approach this conversation? And I think in all of the examples, we were all craving a bit more, what would you like to talk about today? You know, really turning that table so that the patient is driving all of the conversation and that we're listening more than we're speaking. Yes, and eventually the patient will bring the topic up if it's bothering them, when they're comfortable doing so, absolutely. I thank you for sharing that. And I guess I'll share what our amazing group talked about. And we're just observing what happens in our clinic and thinking about when a patient comes in and they don't wanna get weighed, or where our equipment is placed, or reactions to some encounters with other people, how we could change and do better and bring it up to the broader clinical setting, I guess. So I think we are about a minute away from our time. I'm gonna, you know, recap here. Thank you again to all of our attendees. Thank you to the ADA team and special thank you to all of our speakers. Here are the key takeaways from today's session. Remember, weight bias directly impacts care, how it's delivered and how it's received. Self-awareness starts with all of us and all of you. Go ahead and practice strategies. We only get better if we practice over and over again. It's because we really do wanna be reducing this weight bias in our practices. Self-reflect before, during, and after care. It's okay if you don't get it right the first time. Keep on going and keep on trying. And communication really does make all the difference when you are providing care. Practice person-centered language, listen to when it's not being practiced, and maybe we can help create a community where obesity stigma and biases are eliminated from our clinical world. All right, I think we're at the time. Thank you everyone again. And here are some amazing resources put together by the ADA and only more to come. Thank you everyone.

weight stigma

obesity care

weight bias

healthcare discrimination

patient-centered communication

internalized bias

empathy

self-awareness

stigma-free healthcare