March 2019 Issue

Weight Bias in Dietetics Education
By Carrie Dennett, MPH, RDN, CD
Today’s Dietitian
Vol. 21, No. 3, P. 36

The Impact on Student Well-Being, Professional Diversity, and Patient Care

Weight bias—negative, prejudiced attitudes about weight—and their overt manifestations of weight stigma and discrimination,1,2 impact both psychological and physical health, contributing directly to anxiety, depression, disordered eating behaviors, high blood pressure, high cortisol levels, and systemic inflammation.3-9

While there are many sources of weight bias, when bias comes from health care providers, including dietitians, the harm can be particularly acute,10-12 in part because it may lead to avoidance of health care.12-14 This is one reason the World Health Organization says weight bias is a fundamental cause of health inequalities.15

The Academy of Nutrition and Dietetics’ code of ethics includes three principles that are incompatible with weight bias.16 Nonmaleficence (“do no harm”) says that dietitians should act in a caring and respectful manner, being mindful of individual differences. Beneficence (“acting to help others”) includes making decisions that contribute to the well-being of clients and patients and refraining from harassment. Justice calls on dietitians to help reduce health disparities, protect human rights, and provide fair and equitable treatment.

In spite of this, weight bias is present in dietetics education in overt, subtle, and systemic forms. Today’s Dietitian looks at the scope of the problem, and what many students and faculty are doing to bring about change within dietetics and beyond.

Problem 1: Overt Bias and Lack of Diversity of Body Size
Among the comments dietetics students have recently reported hearing from nutrition faculty are, “If your patient is obese and tells you they’re eating healthy, then they’re lying to you,” which is neither caring, respectful, nor true, and, “If you exercise and don’t replace those calories with food, you’ll lose weight,” which ignores the complexities of weight science. It’s also common for faculty to self-disclose by talking about their bodies or their latest weight loss diet, which could be triggering for students with eating disorder histories.

Dietetics intern Kimmie Singh, MS, who received her nutrition degree from the University of North Carolina at Greensboro, says it wasn’t uncommon for professors to include dehumanizing images and cartoons of fat bodies on their slides. In her first nutrition class, the professor said, “I miss the days where you can call someone fat and joke about it” and used a laser pointer to point at parts of those bodies—while making jokes about size. She says many of her professors weren’t explicitly fat phobic, but were uncomfortable talking about weight bias. “They really didn’t know how to approach it,” Singh says.

Ani Janzen completed an undergraduate dietetics program and is currently in a graduate coordinated program. She says she’s experienced more weight-biased messages and images in nutrition lectures than she has from consuming regular media, which is itself weight biased. “There are some presentations where you can just feel their hatred for fat people,” she says. “You can talk about the science all day long, but when you talk about people with such hatred, that needs to be called out in academia.”

Laurie Allen, MEd, RDN, LD, an assistant professor and didactic program director at the University of North Carolina at Greensboro, says that nutrition professionals need to be role models. “If we’re not showing sensitivity to people of all body types, then who is? We as nutrition professionals can be the ones who are educating other health care professionals. That’s part of helping students understand their role in the health care team—that they have value and they are going to improve this patient’s care,” she says.

Dawn Clifford, PhD, RDN, an associate professor at Northern Arizona University, says students in larger bodies have reported feeling that they didn’t fit in among their classmates or in the profession as a whole and have declined opportunities to provide nutrition counseling and even switched majors altogether.

Daphne Levy, currently a dietetics intern, has a history of chronic dieting that later turned into an eating disorder, for which she began treatment her junior year. “I walk into work and don’t know how I’m going to get traumatized. It’s mostly because of the continuation of the diet messages. It’s very weight centric. I find it difficult to promote weight loss messages that don’t align with my values as part of the conventional training in dietetics,” she says, adding that because she’s in a larger body, she’s exposed to stigma every day in her personal and professional life. “I know how to navigate being oppressed, but I shouldn’t have to.”

Janzen also identifies as fat. “Every new internship site, every new class, there’s a look up and down, like ‘Are you who I’m supposed to be talking to?’” This leads to Janzen constantly having to self-advocate in her clinical rotations. “It surprised me how infrequently I was ever asked for more information about my perspective on Health At Every Size [HAES], and was instead given information, which they assumed I didn’t know, about how ‘dangerous’ obesity is,” she says.

Julie Duffy Dillon, RDN, a Greensboro, North Carolina–based consultant, says that including more people of size in dietetics will help lessen weight bias toward patients. “Currently, fat dietitians or fat dietitians-in-training get the message they are not good PR to include on the front lines of health. Not only is this inaccurate—because we can’t judge a person’s health by size—but it’s discriminatory,” she says. “We RDs need to do more to help improve the diversity of our profession, including diversity of size.”

Allen says it’s important to have students examine their attitude toward their own bodies, why they got into nutrition, and how they feel about their own eating and health. “It’s hard to be a dietitian; there’s a lot of judgment we face, and students have to deal with that,” she says. “As much stigma as we’re trying to dispel, we also get stigma toward us, ‘Oh, you’re the dietitian and you need to be this weight.’ If you don’t work on that, then it’s hard to be body positive toward your patients.”

Problem 2: Representation of Obesity Research
Despite current research showing that weight loss isn’t always within one’s personal control, whether due to metabolic adaptations or genetics, and lack of clinical research demonstrating long-term benefits from weight loss interventions—partly because follow-up periods in weight intervention studies rarely last more than two years and many participants are lost to follow-up—dietetics education at many institutions remains weight centric, emphasizing weight and weight loss when defining health and well-being.17

“There are a lot of studies looking at associations between weight and disease, but we know that there are major limitations to epidemiologic data, especially when researchers don’t control for lifestyle patterns,” Clifford says. “So when we teach students, ‘BMI is linked with morbidity and mortality, end of story,’ we’re really not teaching a full picture of the evidence.”

Dillon says that although dietitians are trained to view a person as an individual and treat as an individual, this often doesn’t extend to body size. “If a person is metabolically healthy and a person of size, the traditional dietetics practice says to treat with a weight loss diet,” she says. “This side of dietetics has to change if we actually want to promote long-term health.”

Lauren Newman, RD, LD, who recently completed her dietetics internship at the University of Texas at Austin, had an epiphany when reading her MNT textbook, which covers malnutrition, eating disorders, and obesity all in the same chapter. “On one page, there are recommendations for people who need to lose weight and what type of intervention you would do,” she says. “Then a few pages later, it’s defining the Diagnostic and Statistical Manual of Mental Disorders criteria for eating disorders, and they’re exactly the same as the weight loss recommendations. I felt like, how are other people not seeing this?”

Solution 1: Consider HAES
One part of the solution may be to integrate a weight-inclusive approach into dietetics curriculum, which views health and well-being as multifaceted.17 This would include teaching students how to help patients with behavior changes that promote health and well-being, regardless of body size. This is something that many dietitians agree on, whether or not they specifically identify with the HAES paradigm, which is also weight inclusive.18-24

“As a HAES dietitian, I feel constantly conflicted in my teaching,” Clifford says. “There are concepts that I don’t feel are evidence based that are promoted in the profession, such as ‘weight management’ for cardiovascular disease. Researchers have found that individuals can improve cholesterol levels and blood pressure through dietary changes without changing body weight. I require that my students memorize BMI categories and understand their use as a screening tool, but also tell them not to make treatment decisions based on this highly flawed measurement.”

Clifford does say it’s important that students feel fully accepted and cared for regardless of their opinions on weight and health. “I am very upfront with telling students how, when exploring all of the literature surrounding weight and health with a critical eye for research design, it was very clear to me that practicing as a HAES dietitian was the most ethical choice,” she says. “However, I do not pressure my students into becoming HAES dietitians. I simply expose them to a nondiet paradigm, the literature in support of that paradigm, and allow them to make a decision for themselves.”

Clifford also tells students that it’s normal, expected, and even beneficial for faculty within the same department to have differing views. “Students who have the opportunity to be exposed to different views on weight and health are very fortunate because they have a wider view of the body of literature,” she says.

Ginger Hultin, MS, RDN, CSO, health writer and creator of the blog Champagne Nutrition, says this is the type of education craved by the dietetics students and interns she mentors. “They want a variety of clinical support so they can develop their own future practice,” she says.

As a practitioner, Hultin considers herself “moderate” on the issue of weight. “I don’t think we can be all HAES or all weight loss,” she notes. “I talk to people all the time about non-weight-related health markers, about improving energy. I ask them, ‘How would it feel if you never lost another pound?’ I also help people lose weight if they want to and I determine that it’s safe for them mentally. I think it’s important to encourage students to develop their clinical judgment and be able to meet patients with different wants and needs.”

Allen says that in the past few years, she’s noticed that students are searching for HAES in the curriculum. Similarly, Anne Lund, MPH, RDN, director of the graduate coordinated program at the University of Washington, says that, at her students’ request, she showed them a recording of the recent FNCE® debate “A Conversation on Weight Management and Health At Every Size.”

Monica Milonovich, MS, RD, LD, an assistant professor at the University of Texas at Austin who teaches MNT 1 and 2 and works with the dietetics interns, says it’s important to remove barriers to health care, and HAES fits in with that. “I will say that there’s so much research about weight and chronic disease that you can’t totally discount it, but if you want to make effective change, you can’t just focus on the weight,” she says. (Newman, one of her former students, is helping her modify the energy balance section of the MNT classes.) “We put the material in and I tell people about HAES, but I don’t tell them they have to be HAES. I tell them that we have to be aware of barriers to care and remove them,” Milonovich says.

Allen has reworked the energy balance and weight chapter in her Introductory Nutrition class—attended by both nutrition majors and nonmajors, including nursing students—to discuss the limitations of BMI in assessing health. She’s also made changes to the Nutrition Assessment class for dietetics students.

“This year we were talking about how when we take nutrition- and food-related histories, we need to provide a safe environment for people to give that information because it’s so personal,” she says.

Clifford says that while students need to be taught the concepts and skills necessary to meet Accreditation Council for Education in Nutrition and Dietetics competencies and pass the RD exam, many nutrition and dietetics students have a higher incidence of eating disorders,25,26 so it’s important that dietetics educators consider that when teaching certain concepts. “Messages promoting weight loss and calorie counting can be triggering for a student who is struggling—and we know that eating disorders are the deadliest of all mental illnesses,” she says. “We really need to be careful.”

Solution 2: Be Willing to Be Uncomfortable
Weight bias can exist in explicit, or conscious, and implicit, or unconscious, forms. Allen’s senior students take the Implicit Association Test (IAT) in their Professionalism in Dietetics class, which anyone can take online through Harvard University’s Project Implicit.27 The IAT measures the strength of implicit, or subconscious, associations between certain groups of people and the concepts of “good” and “bad.”

“I’ve found that the students are really receptive when I say, this is something I want to do for all of us,” Allen says.

Lund says that not only do dietitians need to examine their own biases but they also need to be willing to have uncomfortable conversations. She’s witnessed both since the recent adoption of an antiracism competency in the university’s school of public health, which the nutrition program is part of. “It might be uncomfortable for a long time—but then we move forward,” Lund says.

Newman says that while conversations about weight bias and HAES can be heated, they don’t have to be. “When you say, ‘We’ll just agree to disagree,’ that puts us on different sides. We’re on the same side; we want to help people,” she says. “I approach it like, ‘Hey, there might be more to this story. I know something and you know something—let’s piece it together.’ We accept that about other areas of nutrition science.”

Milonovich says Newman had to tell her about HAES three times before she fully understood it. She likens the conversation about HAES and weight bias to politics. “Whenever you have a conversation with someone who doesn’t have the same political values as you but you can have an open conversation, it becomes a valuable conversation,” Milonovich says.

“I think most people want to do better,” Singh says. “It was after I started opening up to professors about weight stigma that I started getting more support. When I spoke to my internship cohort this year, all of the interns were very excited and very happy to talk about weight stigma.”

Allen is excited to have students like Singh who are working to dispel bias, adding that, “She’s learning from me, I’m learning from her.”

Allen says faculty also have been receptive. “It brings up issues that they haven’t even thought about, including how they talk about obesity, and that individuals of all body sizes can be portrayed in a positive manner in class presentations,” she says.

Milonovich says faculty and preceptors need to have an open dialogue with students. “I’ve enjoyed working with students because I love to say, ‘Here’s what I’m working on; how would you solve it?’ We tend to do the same solutions for the same problems over and over again, and that’s not necessarily the best thing,” she notes. “Even though I have all this clinical experience, they’ll ask, ‘Why do we do it this way?’ Some faculty might take that as threatening, and that’s hard. Students want to have this dialogue—they’re not trying to tell you you’re stupid.”

— Carrie Dennett, MPH, RDN, CD, is the nutrition columnist for The Seattle Times, owner of Nutrition By Carrie, and author of Healthy for Your Life: A Holistic Guide to Optimal Wellness.

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