Anti-fat bias and weight-based discrimination are prevalent in health care settings and among clinicians and clinical trainees and can result in immense harm to patients. “Raising awareness of anti-fat stigma in health care through lived experience education,” a recently published paper led by Christine Heidebrecht, Research Associate, Family and Child Health Initiative (FCHI), Institute for Better Health, describes the co-design and delivery of a narrative-based curriculum aimed at raising awareness of anti-fat bias to dismantle weight-based discrimination in health-care spaces.  Patient, caregiver and provider co-design is the central component of the Learning Health System approach. Co-design requires direct engagement with people impacted by health challenges – patients, caregivers, care providers, community members – along with others (e.g., health care professionals, managers) who can influence or are involved in moving the co-designed service or innovation toward successful implementation.

Heidebrecht spoke about the curriculum and why addressing this stigma in health care settings is important.

What does weight-based discrimination in health care look like? Describe how it may harm patients.

Anti-fat discrimination in health care can come in many forms, from unwelcoming environments (clinics with non-size-inclusive furniture, clothing or equipment) and assumptions (e.g., that patients in larger bodies will not follow recommendations) to derogatory comments about body size and less time spent with patients in larger bodies. Moreover, clinicians may attribute patients’ symptoms to their weight and prescribe weight loss rather than perform clinical investigations. Clinicians often bring up weight and recommend weight loss to fat[1] patients regardless of the reason for the patient’s visit.

This can result in numerous harms to patients, such as feelings of shame, anxiousness, stress and inadequacy; avoidance or delay in seeking health-care services; missed or delayed diagnoses; disordered eating; and weight cycling (repeated weight loss and gain).

Clinicians who believe that there is a direct link between high weight and poor health may think that they’re doing what’s best for their patients by focusing on weight and prescribing weight loss. However, a multitude of factors influence both health and body size, and weight stigma itself is associated with many of the health conditions that are linked with higher weight, as well as numerous other harms. Further, sustained weight loss is not possible for most individuals and repeated attempts negatively impact health. A clinical approach focusing on weight and weight loss can thus cause much more harm than good. Many of the clinicians who participated in this pilot study were surprised at the harm that fat patients experience during and because of health care interactions.

Describe the piloted study.

Our research team of lived experience educators, clinicians and researchers collaboratively developed a curriculum consisting of two components:

  • Seven narrative-based podcast episodes and accompanying reflection questions and resources that were collaboratively developed with and feature the voices and experiences of individuals who have experienced anti-fat stigma in health care spaces.
  • A facilitated group discussion during which clinician participants had the opportunity to discuss and reflect on the podcast content and their reactions to it.

What are the benefits of lived experience education?

An educational approach prioritizes patient knowledge and stories – especially one that uses an auditory format in which patient voices are telling those stories – helps learners understand the human side of the information being communicated, fostering empathy, compassion and a deeper understanding of patient experiences.

How was it evaluated?

We asked clinician participants to complete a survey after they listened to each podcast episode. These surveys asked respondents to share their reflections or responses to the episode and describe the most and least relevant content to their clinical practices. Participants were also asked to rate the usefulness of how the information was delivered, the sound quality and the appropriateness of the episode’s length.

These data were used with notes taken during the reflection sessions to assess the curriculum’s acceptability, feasibility and learning impact.

What was the response of clinicians who participated in the curriculum pilot?

The clinicians who participated in the pilot study found the curriculum extremely impactful. Many expressed anger, sadness and shock at hearing how awful health care experiences had been for the lived experience educators. They desired to modify their approaches to provide more inclusive patient care. A few clinicians felt defensive when listening to the content, as their intention was not to harm patients. (This is an example of intention not being aligned with impact; the narrative format of this curriculum can help clinicians understand the impact of a weight-focused approach to care.) Participants found it very powerful to hear patients’ voices describe their lived experiences and appreciated the curriculum’s blended format of podcast episodes followed by group reflection sessions.

What are the next steps for this work?

We hope that the curriculum – or a modified version – will be incorporated into various types and levels of medical and health care education, including required learning for staff at Trillium Health Partners. It will be valuable for the curriculum to be applied on a larger scale and assessed using a more comprehensive evaluation, including follow-up components to explore how much it impacts clinical practice and behaviours.

[1] In our paper we use the word ‘fat.’ Many individuals and communities have reclaimed it as a source of empowerment and resistance and as a neutral descriptor rather than a derogatory term

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