Education for Medical Students Is Key to Reducing Obesity Bias

Kristin Jenkins

August 02, 2017

A comprehensive educational curriculum that gives medical students a solid working knowledge of the complex issues underlying obesity is effective in creating more positive attitudes toward patients who are obese, researchers said.

The study, which followed 718 first- through fourth-year students through medical school, showed there was a significant increase in knowledge among students taking the first year of the obesity-specific curriculum compared with the precurriculum cohort (< .01).

Attitudes assessed using the Fat Phobia Scale (Int J Obes Relat Metab Disord. 2001;25:252-257) also revealed there was a significant reduction in negative bias toward obesity among first-year medical students and that this was sustained through all 4 years of school, according to Gregory G Gayer, PhD, of the Touro University College of Osteopathic Medicine (TUCOM), Vallejo, California, and colleagues.

Before the obesity curriculum was offered, the negative bias in each of the 4 years of medical school at TUCOM was 3.65, 3.76, 3.57, and 3.61, respectively, the study authors report in the August issue of the Journal of the American Osteopathic Association. After the curriculum, the bias in each of the 4 years was significantly reduced to 3.47, 3.38, 3.34, and 3.37, respectively (< .05).

"The current study demonstrated that improving a medical student's basic knowledge of obesity can improve any obesity-related bias," the investigators write. "To our knowledge, this is the first study to demonstrate a sustained 4-year decrease in obesity bias." They add that more evaluation of the curriculum is needed to see whether the results can be reproduced at other medical schools.

Negative attitudes toward those who are obese are "ubiquitous in our society," Dr Gayer told Medscape Medical News, noting that "clinicians are not excluded from this bias. We hope that this reduction in bias will enable students to be better prepared to address the concerns of their obese patients and ultimately translate into better clinical outcomes as they progress into their postgraduate years."

Importantly, it is hoped that the positive attitudes "can be maintained as these medical students become residents, fellows, and preceptors for future medical students," said Dr Gayer, noting that "bias can be positively and negatively influenced by student mentors."

A Vicious Circle: Bias Begets Worse Care

Studies have shown that when clinicians have a negative bias toward patients who are obese, patient care also suffers. It can significantly reduce the effectiveness of communication, resulting in less preventive care and more emergent care. Clinicians may also avoid initiating a discussion about obesity itself, which can sabotage clinical outcome, the study authors note.

"Medical students, both osteopathic and allopathic, have been found to share a similar bias, whether implicit or explicit, against people with obesity," they write. "Furthermore, negative comments or discriminatory behavior toward patients with obesity by faculty or staff may influence the attitudes of students toward these patients."

In recognizing this harmful dynamic, many medical schools have added obesity-specific behavioral medicine as well as motivational interview training to their curricula. However, few prospective studies have examined the effectiveness of these programs (Teach Learn Med. 2012;24:267-272), the study authors say.

The obesity curriculum at TUCOM, which is a modified version of an earlier curriculum (BMC Medical Education. 2005; DOI: 10.1186/1472-6920-5-4), was launched in 2011 for students in the classes of 2013 through 2018 in a bid to decrease student bias against obesity and, "by extension, change new physician behavior in treating patients with obesity," the study authors point out.

The initiative follows the failure of the Healthy People 2010 program to achieve its goals to reduce obesity, they explain, noting that the American Osteopathic Association passed a resolution the following year stipulating that the obesity epidemic had to be addressed in the practices of all osteopathic physicians.

TUCOM's obesity curriculum has evolved each year since 2011, supported by several foundational underpinnings: an annual survey to assess bias before and after the curriculum; lectures in the first and second year with a postcurriculum multiple-choice exam to assess gained knowledge about obesity; and interactive case-study simulations during third year. In the fourth year, there was no educational intervention, but students were again surveyed to see whether the impact of the curriculum on the way they thought about obesity was holding.

At the time the curriculum was initiated in 2011, second- and third-year medical students of the graduating classes of 2014 and 2013 who did not complete the curriculum were given an examination to establish baseline values. They served as the control group.

Greater Knowledge Following Completion of Obesity Curriculum

The 528 students who completed the first year of the obesity curriculum showed significantly greater medical knowledge about obesity when compared with controls. Multiple-choice exam scores demonstrated their superior understanding of obesity-related epidemiology, pathophysiology, and metabolic factors as well as nutrition, diet, physical activity, behavior modification, pharmacologic and nonpharmacologic interventions, and associated chronic disorders.

By comparison, the controls who didn't receive the curriculum "significantly underperformed" on the exam, "demonstrating their lack of knowledge on the topic of obesity," the study authors say.

The pooled average first-year examination scores for the multiple-choice obesity test for students who completed the obesity curriculum were 72.4%, 92.6%, 91.2%, and 89.0% for graduation years 2015 to 2018 inclusive, compared with 47.2% and 52.6% (P < 0.01) for the controls in graduation years 2013 and 2014 (who had not completed the obesity curriculum).

TUCOM's obesity curriculum may be one of the first to address health disparities and ethnic differences in obesity, Dr Gayer and colleagues say. In addition, it includes information on the global burden of the obesity epidemic and the interaction between obesity, metabolic syndrome, and climate change/air pollution. This conforms to the recent position paper on climate change and health issued by the American College of Physicians, they note.

Change Will Take Time

Ridding the healthcare system of negative attitudes about obesity won't happen overnight, but the first step is awareness and education, Dr Gayer told Medscape Medical News. "Shifts in any foundational belief system take time to develop."

Previous studies show that when an obesity curriculum emphasizes only controllable causes such as diet and exercise, students are more biased toward obesity than those taught both controllable and uncontrollable causes of obesity, such as genetics and environment.

Will a comprehensive obesity-specific curriculum be enough to make positive attitudes stick? The study authors will be launching phase 2 and 3 of the current study to find out.

In phase 2, the comprehensive obesity-specific curriculum will be packaged into online-learning modules for use by other medical schools and residency programs. In phase 3, the curriculum will be modified for specific residency-specialty programs and extended to residents in continuity-of-care clinics. The "ultimate goal," explained Dr Gayer, is to determine whether the improved knowledge and change in attitude toward obesity can endure — and result in better clinical outcomes for residents' overweight and obese patients.

The study authors report no relevant financial relationships.

J Am Osteopath Assoc. 2017;117:495-502. Article

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