Person-first Language, Weight Bias & Obesity Research

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Okay, I'll just get started. We'll get started and then anybody joining can jump in the call. So hi everyone, welcome to the latest eLearning Hub event which is hosted by the European Association for the Study of Obesity's Early Career Network or also called the EASO-ECN.

So thanks very much for joining today's session which will explore person-first language, weight bias and their implications for obesity research. Our expert speaker today is Dr. Ximena Ramos-Salas and we're very pleased to have you Dr. Ramos-Salas. My name is Lisa Hege, I'm one of the EASO Early Career Network board members and joining me from the board today are Bram and Emile.

So Bram's going to be sharing some helpful information of interest to ECN members on upcoming events and Emile's going to be sharing helpful links in the chat so keep an eye on on those things. Please remember that today's webinar is being recorded and the session will be available after the event and also along with any sort of relevant resources that Ximena chooses to share. In a few minutes we're going to hear from Bram like I mentioned about upcoming events and then we will be guided through today's topic by Dr. Ramos-Salas.

We will have a Q&A at the very end of the session so if you do have questions please use the chat function, add your questions into the chat and we'll make sure those questions are asked to Ximena. So I'm now going to hand over to Bram for a few minutes before we get into today's topic and just as a final comment from me for now this ECN series is supported by an unrestricted educational grant from Bollringer Ingelheim. So thanks very much and here's Bram.

Thanks Lisa. So yeah we have some updates for the upcoming European Congress on Obesity in Venice because this year we'll have our own early career network lounge and this is really nice because it's our own place where we can meet each other and talk about our work and it will be very close to the catering area so you can just bring in your lunch and have a chat with us and we will be using this lounge during the breaks so you can always find one of the ECN board members or some of the Italian representatives as well in this lounge and we're planning to have some events during the lunch breaks because in Venice actually the lunches are pretty long so we decided to make the most of it and have some networking workshops. So we'll start already on Sunday we'll just have an open door and you can come in and meet us and on Monday and Tuesday we will have networking workshops.

On Monday it's from quarter to two until quarter past three we will introduce ourselves and we will get to know each other by doing some fun games and then on the second day on Tuesday we will be having short interviews with key opinion leaders in research and also we will have a young adult representative from the ECPO and then of course as always we will hand out the best thesis award so on Monday 13 May from 5 to 6 30 we will be hosting the ECN best thesis award session so please make sure to check that out. Okay and then we have some upcoming webinars so of course our next webinar is on 16 April and it's about publishing in obesity journals and it will be with the co-editor-in-chief of the International Journal on Obesity Professor David Stenzel and I would also like to invite all of you to the next EASO Collaborating Centers for Obesity Management Network webinar and this is on the 26th of March from 12 30 to 1 30 Central European time and this webinar is mainly of interest to healthcare professionals and will explore the social physical and emotional care needs of people living with obesity beyond weight management so join in to learn about disparities in obesity care and hear about the lived experience of receiving care in a clinical setting and that's all from me so do I give back to you Lisa or do we go straight to Jimena okay Lisa you can take over. Thanks Bram thanks I'll just quickly introduce Jimena so I'm excited to introduce our expert speaker Dr Jimeno Ramos-Salas.

Dr Ramos-Salas holds a PhD in public health specialising in health promotion and socio-behavioural sciences from the University of Alberta in Canada. She is also chair of Bias 180 a global non-profit organisation with a mandate to address bias, stigma and discrimination in healthcare. Serving as an independent consultant Dr Ramos-Salas also provides technical expertise and project management to numerous Canadian and international organisations such as the EASO and the World Health Organization.

With a focus on public health and patient-oriented health research Jimena's overarching objective is to address the perpetuation of weight bias and obesity stigma by advocating for impactful health research education policy. So with that I will hand over to Jimena for today's webinar. Thanks thank you Lisa and Bram thank you for having me I'm going to share my screen and you can see my screen now yeah I can see it thank you yay perfect okay I'm just gonna actually stop sharing because I don't think I share the sound I'm gonna do it again share sound share yeah okay how's that you can see it I can see word some sort of word share screen sound optimised video clip share what about that that's perfect I can see it now thank you perfect all right so thank you everyone for being here today it's uh five o'clock in the afternoon here in Sweden it's nice to see everyone here I know that this is being recorded so hopefully other people might be able to see it afterwards so thank you Lisa for the introduction for the invitation to participate in this webinar as Lisa mentioned I am a public health researcher and an advocate and my focus has been on reducing weight bias and stigma as a way to improve health equity for people living with obesity and today we're going to talk about weight stigma, person first language, and the implications of these concepts for health research and specifically obesity research so I understand that today's audience is mainly researchers and including future scientists that are part of the obesity research community so my presentation is very focused on research and how we do research and how weight bias impacts our research but I will use some examples of weight stigma in other areas such as public health clinical practice and media so let's get started so I usually start by declaring my potential conflicts of interest and these are this is for a transparency purpose I am an independent research consultant and I run my own consulting company here in Sweden I have received research grants from various organizations including public and private organizations all these grants are unrestricted and funders usually don't have any influence on my research outputs and I did not receive an honoraria for this presentation today however now the other thing that I like to do as a qualitative researcher is to also talk about my personal biases so my work is focused on pursuing the establishment of a person-centered healthcare system and for clarification what I mean by that is as person- centered healthcare systems are systems that are organized around the needs of people rather than diseases and to me this healthcare approach emphasizes collaboration empathy and respect for the autonomy and dignity of patients so this is my lens that I usually carry in my presentations and based on that idea of person-centered healthcare systems I believe we should strive to provide patient-centered healthcare and WHO or the World Health Organization defines patient-centered healthcare as being able to afford people dignity compassion and respect offering coordinated and personalized care supporting and helping people with treatments and supporting people to recognize more importantly and enable them to develop their own strengths and abilities to enable them to live an independent and meaningful and fulfilling life so for me in the context of this bias that I have it's important to know that while I pursue this person-centered healthcare system and patient-centered healthcare practices I believe it's equally as important to support person-centered health research and for me person-centered health research and systems should be organized around the needs of people and health outcomes rather than solely on research outputs and diseases so that's my bias and what the way that I consider why it's important why we should do it what we should pursue person-centered research is because it's an approach that prioritizes the experiences and perspectives and needs of individuals within a specific context and this methodology places the individual at the center of the research process aiming to understand their unique viewpoints their preferences and their lived experiences in order to inform future policies and healthcare practices so that we can have a patient-centered healthcare system so for me health research should be always person-centered so that we can improve and integrate it into healthcare practice and healthcare systems so now that you have heard my biases I want to talk a little bit about weight bias so weight bias is defined as our own personal negative attitudes and beliefs about weight and these attitudes and beliefs can be explicit implicit or internalized when we talk about explicit we mean that we have overtly displaying displays of negative attitudes and beliefs about weight and about people who have a higher weight and when we talk about implicit we mean it's unconscious negative attitudes and beliefs like we're not aware that we have these negative attitudes and beliefs about weight and about people who have a higher weight.

Sometimes these beliefs and attitudes can become internalized, meaning that we start applying these negative attitudes and beliefs towards ourselves. And another way that some people refer to this is called self-stigma. So the other concept that I wanted to discuss is the concept of weight stigma.

And so I view weight stigma as the manifestation of weight bias through harmful social stereotypes about weight and about people who have a higher weight. These stereotypes include beliefs that people with a higher weight are lazy, unmotivated, non-compliant with healthcare recommendations, for example. They're unintelligent and generally lacking self-discipline and self-control.

These are deeply ingrained in our society. And I will show you some of the examples later on in this presentation. Now, the last concept I wanted to discuss is the concept of weight-based discrimination.

And weight-based discrimination is the unfair treatment of people because of their weight. So from my perspective, it is important to distinguish between these three concepts. Weight bias refers to our own personal negative beliefs.

Weight stigma refers to the social stereotypes about people because of their weight. And weight-based discrimination refers to the unfair treatment of people because of their weight. And when you think about these three concepts, as you see in these three different layers, you see that we're talking about issues at the individual level, at the social level, and at the policy level.

So to address weight bias, we may need interventions to change individual attitudes and beliefs. And to address weight stigma, we may need social interventions to change the negative portrayal and the stereotypes associated with people living with obesity. And to address weight-based discrimination, we might need more policies and laws to prevent the unfair treatment and discrimination against people with obesity.

Now, the reason why I also distinguish between those three concepts is because, in the levels, is because research currently demonstrates that weight bias, weight stigma, and weight-based discrimination are very common, and that people with a higher weight, or those living with obesity, experience these types of experiences across their lifespan and across all settings. So here you see that children as young as three years of age can have weight-biased attitudes and beliefs, and that adolescents and adults experience bullying and stigmatization in schools and healthcare settings. This is also important to know that there's a growing amount of research that spans decades that show that healthcare professionals hold negative attitudes and beliefs towards people with overweight and obesity.

And in this systematic review and meta-analysis from studies from 1989 to 2020, they found that studies measure explicit and implicit weight bias have been conducted with many healthcare professionals, as you see in that long list. And the impact of healthcare professionals having negative attitudes and beliefs about people's weight is that patients perceive that healthcare providers are not attentive to their health concerns and that they don't spend sufficient time listening to their concerns. Patients also perceive patronizing and disrespectful language and inadequate provision of healthcare services.

These factors impact, these impacts can have like a strong and significant consequence for healthcare services because patients will avoid healthcare services and will avoid specific treatments for fear of being shamed and blamed for their weight. Now research also shows that weight bias, stigma, and discrimination are issues that are being investigated more and more across the world. It's not just an area of research in North America and Europe anymore.

And in this scoping review, we wanted to see the extent and the focus of weight stigma research in Latin America, Asia, the Middle East, and Africa. And we found 130 publications spanning 33 countries, but most were published very recently, as you can see from 2018 and on. And we found that these studies focus very much on similar areas that we have also studies in North America and Europe.

So on stigma in healthcare, stigma in schools, stigma in public workplaces, etc. So it's a growing, growing concern globally. Now I wanted to talk about examples of these biased attitudes and beliefs towards people living with obesity.

So I'm going to give you examples from explicit, implicit, and internalized. Examples of explicit negative attitudes and beliefs can be the use of judgmental words and moralistic language such as you're lazy, you're fat, you're morbidly obese, or you are what you eat. These words and language are perceived by patients as shameful.

And in fact, some people actually shame people for their weight quite openly by saying things like, weight management is easy and simple, you just need to change your lifestyle. Or they say things like, don't you know that obesity is bad for you, or you're killing yourself. Implicit weight bias examples.

Remember, implicit is unconscious, we're not aware of our own negative attitudes there. It can include examples of us believing that obesity is just an individual responsibility, or that weight control is just about energy in and energy out. Or thinking that people with obesity are not trying hard enough to control their eating and their weight.

Or believing that obesity is not really a chronic disease, and that it's simply a lifestyle choice, or believing that obesity treatments such as medications, behavior interventions, psychological interventions, surgery, are not necessary, and they're not effective, and simply just an easy way out for patients. Internalized bias refers to us applying these negative beliefs and attitudes about our own weight towards ourselves. And it includes feeling anxious about our weight, or feeling less capable because of our weight, or thinking that we deserve the unfair treatment from others, because obesity is our own fault and our own responsibility.

Now, what is causing all weight bias, stigma, and discrimination? So this is my conceptualization of what's happening. I believe that we're living in a perpetual cycle of weight bias, stigma, and discrimination that starts with uneducated public perceptions that chronic diseases can be mainly prevented through healthy lifestyles, and individual behaviors such as eating healthy and exercising more. And that combined with our personal values that health is an individual responsibility starts the whole cycle.

These incorrect perceptions and values lead us to frame obesity and other stigmatized diseases as modifiable lifestyle choices, modifiable lifestyle or behaviors, and an individual responsibility. And this framing leads to healthcare practices and policies where weight is treated as a behavior. And it results in us shaming and stigmatizing others because of their weight, so that we can express our own values that health is a personal responsibility, which causes more stigma.

And this results in people with obesity internalizing shame, blame, and social stereotypes about weight, and about people with a higher weight, which results in people with obesity believing obesity is their own responsibility, and that they do not need to go and ask for help from a qualified healthcare professional. And this is a loop that we need to break at the individual level, at the community level, and at the policy level, in my opinion. Now, let me show you some examples of this perpetuating narrative in public health, clinical practice, and the media, as well as research.

We constantly see public health campaigns against childhood obesity that use a narrative that obesity is dangerous and scary. Children with obesity are not seen as children, and their parents are portrayed as responsible for their children's weight and or obesity. The messages are very simplified as children with obesity eating too much junk food, and not being able to control themselves, and needing parental control.

This is not, in my opinion, a message, a public health message, that allows children and their parents to recognize and develop their own strengths and abilities, and enable them to live an independent and fulfilling life. The framing of obesity being personal, a personal responsibility, is pervasive in public health campaigns for chronic disease prevention. The message here is that weight is a personal characteristic that contributes to a person's identity and value as a human being.

People are basically their weight. People should be a healthy weight. These images and campaigns encourage people to measure their weight and body size, and imply that people can choose their weight or body size.

In other words, a healthy weight is a personal choice. And I'm going to show you this short clip, and it's going to take less than a minute. The message here is that people can choose their portion size and control their weight, and it's easy.

The stigmatizing image of the tight shirt and the stomach, speaking to the person to say no to food, is a classic example of this narrative, to be responsible and to choose to be a healthy weight. So, public health campaigns on obesity during World Obesity Day this year continue to use this framing, being preventable, you know, obesity is preventable through healthy lifestyles, but also continue to use this scary language such as fight against obesity, tackling obesity, which can be perceived by people with obesity as a fight against them as individuals. The images associate unhealthy behaviors with obesity, and healthy behaviors and lifestyles with healthy weight or healthy bodies.

Now, in this, you can see more of a policy level example. These messages and images are highly negative and shaming towards individuals living with obesity, and I hate using them, but it's an example of what I want you to see to understand. People with obesity are portrayed as sad, tired, and unattractive, and as you see in this media campaign, the message is that obesity is bad for the economy, and the media, public health, and governments need to educate people and warn them that individuals with obesity are contributing to an economic burden in society.

Now, in terms of weight stigma in research, we see there is a lot there as well. Here are a few social media posts to promote scientific conferences and research results. The focus is very much on the disease or the conditions associated with obesity, and I would not consider these as approaches that are person-centered health research.

They're focused on the disease, as I said, and they're not focused on the needs of people, but rather they are focused on research outputs and diseases, research publications and diseases. Now, here on this slide, you see examples of posters used to recruit study participants in obesity trials. You see the language is very much focused on weight and weight loss.

There's no personal first language, and people with obesity are portrayed as frustrated, and this approach to scientific inquiry, to me, does not prioritize the experiences of people living with obesity or the perspectives of people living with obesity. It places emphasis on weight and the disease itself, and it doesn't certainly portray a power balance between researchers and research participants. Now, from a clinical perspective, we see simplistic messages about obesity surgery and other treatments, for example.

The focus is on weight and weight loss, and the use of celebrities is certainly not reflective of the lived experiences of the majority of people living with obesity, or the general public for that matter. But more concerning message in this slide is the idea that weight regain, which is expected following any obesity treatment because it's a chronic disease, including bariatric surgery, is the idea that this is a personal failure and that treatments didn't fail, the patient failed. And again, this approach doesn't place the individual at the center of our healthcare research, and it's focused on weight, body size, and diseases, instead of the health of individuals.

Now, I'm not going to go through all these study findings, but I just wanted to show you how many research studies we have demonstrated that weight bias, stigma, and discrimination can have bad outcomes for people. Weight bias and stigma impact physical health outcomes, mental health outcomes, as well as access to and the quality of healthcare services that are provided to patients living with obesity. It also affects their social outcomes, such as education and employment outcomes, independent of their weight or BMI.

Now, the question that I ask and that you might ask is, how does this happen? How does weight bias, stigma, and discrimination impact these outcomes? And here's one model from fellow colleagues in the US, and I adapted it a little bit. So, I argue that weight bias, weight stigma, and a lack of obesity education and training amongst healthcare professionals can impact clinical practice towards people living with obesity. So, weight stigma can create a threatening clinical environment, for example, when you see a lack of physical accommodations in the clinic, such as lack of chairs and medical equipment that accommodate different body sizes, or the use of stereotypical images in magazines in the waiting room.

They can send messages to patients living with obesity that this is not a welcoming environment. Healthcare professionals have weight bias as well, and when they interact with patients living with obesity, it can affect the way that they make clinical decisions about the care for that patient. For example, they may not refer patients for specific disease screening, like cancer screening, and this can lead to the third column, which is showing you that it affects patients' behaviors, right? Patients will avoid healthcare services, experience more stress when interacting with healthcare professionals, they will have low adherence to medical programs, and they will have less trust in healthcare providers, which affect their communications with healthcare providers.

And weight stigma can also lead to, you know, as I said, this feeling of feeling included in the healthcare system, as well as through examples such as lack of coverage of obesity treatments, for example. So this biased clinical decision-making is not patient-centered and non-cooperative in nature and impact health outcomes. Now, if we apply this model to health research or obesity research, weight bias and stigma can impact our research questions, our participant recruitment, and our research communications.

So as we saw in the previous images of research practices, the framing of obesity continues to be on obesity as a lifestyle risk factor or a personal choice. And this means that studies sometimes do not conceptualize obesity as a chronic disease, which obviously limits the scope of the studies to behavioral strategies, which in turn can be perpetuating that message that obesity is an individual responsibility and a personal behavior choice. This leads to us having less evidence about how to effectively prevent and treat obesity.

And from a research participant perspective, this may lead to them feeling blamed, rejected, ashamed, guilty, unworthy, and responsible for their own disease. And as a result, we end up with outcomes such as persons with obesity avoiding research trials for fear of being blamed and shamed for their weight. Participants may drop out of studies or not adhere to the study or the intervention, which of course impacts our study results.

So it's not an ideal situation in health research to have weight bias. Now, from a more broader level, there's some research that support my hypothesis that weight stigma impacts research. We can look at these existing evidence studies that show that people with obesity are underrepresented in clinical trials.

And in this paper, they were talking about other randomized control trials, not directly related to obesity treatments. These were general randomized control trials where people with obesity often go underrepresented in drug development trials. And this is a critical gap, this person says, because it leaves drug makers and doctors unsure of the efficacy or the risk that this medication may have for this patient population.

So how is weight bias and stigma enacted in health research? Well, in this article, authors point out that researchers exclude participants above a specific BMI in drug trials, or they fail to recruit and retain people with obesity in the drug trials. And very often drug trials publications do not report the rates of obesity in the study sample, or they fail to perform the relevant or necessary sub-analysis. But is this the researcher's fault, or is this the drug company's fault? Whose fault is it? Well, I think it's a combination.

It is really a public policy issue. In the US, as this quote says, there are no requirements to evaluate how drugs act in people with obesity, and it is unknown whether all drugs are safe and effective for people with obesity. And the person continues, pharmaceutical companies are not required to include people with obesity in clinical studies, and the FDA has recognized that people with obesity are often excluded in an effort to reduce the variability in the effects of a drug.

So it's a very, very critical issue. And in this study, they reviewed 201 drug approval trials registered in the US government clinical trials website in 2022, and they found that 64% did not include weight or BMI inclusion or exclusion criteria, and 75% of the trials used BMI criteria to exclude patients with obesity. So similarly, in this study, the authors found that people with obesity are underrepresented in obesity-related cancer trials, which may affect the generalizability of the results of these trials.

In the review, they found that it was only possible to estimate the proportion of participants with obesity in eight out of the 76 cancer trials they looked at, and the subgroup analysis was only conducted in one of these trials. So this has significant implications for the care of people living with obesity who also develop cancer and who also may need cancer treatments. So my question to you and to me is, how can we develop a person-centered healthcare system if the research we do is not person-centered and equitable? And so all this to say is that weight bias and stigma and discrimination, in my opinion, are preventable.

So let's talk about what we can do to stop weight bias, weight bias and stigma and discrimination. As I mentioned before, we need to address weight bias at the individual level, weight stigma at the societal level, and weight-based discrimination at the policy level. And we have some evidence about what works, and I'm going to show you a little bit of that.

So first, at the individual level, the first thing that research shows that we can do is to assess our own implicit and unconscious weight bias. So once we become aware of our own attitudes and beliefs about weight, we can start thinking about whether these bias attitudes and beliefs are affecting our behavior, our interactions with people living with obesity, and our clinical practices or research practices, for example. Here are a few examples of questions that you might want to ask yourself to check your own implicit attitudes and beliefs.

Do you assume that a person's health, characteristics, behaviors, and abilities are based on their body size, weight, or body shape? Well, we know that people come in different body sizes and shapes. Body size, weight, and shape are not directly associated. There is no research that there's a direct correlation or association with a person's health, work ethic, willpower, intelligence, or skills.

The second question we might want to ask, do you think that everyone with a larger body size or higher BMI or higher weight has obesity and needs to lose weight? Well, we know that obesity is a chronic disease characterized by excess or dysfunctional body fat that impairs health and well-being. BMI is not a good diagnostic for obesity, and it's not a good indicator of health. Not everyone with a higher BMI has obesity.

Another question that you might want to ask is, do you believe that people with obesity are personally responsible for their condition? Many people believe this, and they think that obesity can be controlled mainly through healthy eating and exercise, but there are many factors. We know that from research. We are researchers.

We know that there are many factors that can cause obesity, and many of these factors are actually outside of the control of individuals. So, blaming or framing obesity management as a self-care idea is not okay. All chronic diseases require self-care and self-management, but in obesity, we only focus on the self-care and self-management portion, and we wouldn't do that with diabetes or cancer or hypertension.

We wouldn't say to a patient with cancer, obesity, cancer is your responsibility. You need to manage your own behavior to prevent and treat cancer. Now, the other thing that you could do is go to this link and do the implicit association test, which actually contributes to research that is published on a regular basis from this team at Harvard.

Now, I wanted to show you this slide because it's a recent position statement from the World Obesity Federation that was published last year, and there's some key recommendations here on how to change the global obesity narrative to recognize and reduce weight stigma. And so, a key outcome of this was that we needed more research globally from around the world. There's too much focus on North America, Europe, and Australasia, so we need to go beyond that, but I think what we recommended in this paper was that we need to distinguish between body size and obesity.

We need to promote a human rights-based approach to address weight stigma and discrimination. We need to consider individual language preferences across the world, use non-stigmatizing language and imagery, engage in weight-neutral health promotion, raise awareness about weight stigma, and engage in legislative and policy efforts to reduce stigma. Now, in this paper, we try to assess the impact of Obesity Canada's policy to change and require person-first language in all our scientific conferences and research papers.

And in this study, we specifically looked at various constructs to assess the impact of this policy, the person-first language policy, for obesity research in Canada. And you could see that we looked at the use of person-first language in research abstracts, the incorporation of the lived experience in research studies, the consideration of weight bias and stigma in studies, the use of alarmist language, the framing of obesity as a chronic disease versus lifestyle risk factor, et cetera. So based on these contracts, we concluded that there has been an increase in the use of person-first language in Canada, and also a trend towards an increase towards more person-centered research.

EASO also has a person-first language policy for scientific communications related to obesity. And here's some examples of how we do this. So instead of saying obese participants, we say participants with obesity.

Instead of saying morbidly obese, we say patients with severe or complex obesity. Here's another example. Participants were stratified by sex, gender, and BMI category, healthy, overweight, and obese.

Well, we can change that to say participants were classified with healthy weight, overweight, or obesity based on body mass index categories. Or participants were stratified by sex, gender, and BMI category, and the categories are healthy weight, overweight, and obesity, not obese. Now, the representation issue in clinical trials is important, and that requires policies, right? So then we need policies to improve the representation of people living with obesity in clinical trials.

And in this paper, they recommend that clinical trial guidance and regulations should make it clear that medications must be assessed for efficacy in patients with obesity and or higher body weights. It should be a standard practice for researchers to include patients with obesity across the body weight spectrum. Pharmaceutical companies should identify drugs that may have an altered pharmacokinetics in people living with obesity.

Manufacturers should include information on the effects of obesity on specific drugs, of obesity on specific drugs, and the drug in the drug package insert so that we can increase more awareness among health providers. And we can use electronic health record systems to update and alert clinicians of potential complications or dosing changes in people living with obesity. And I think for these medications that are mentioned here, which are very commonly prescribed to patients with obesity, we need more studies to actually see whether these obesity medications have a different clinical outcome or effect on people living with obesity.

Now, in this paper, which I'm going to leave you the link here, you're not going to read everything, but basically the idea is that we as researchers need to ask ourselves critical questions so that we are aware whether our weight bias and stigma and discrimination stereotypes about obesity actually impact the way that we do research. So I'll leave you this here. And finally, I think it's important one way to reduce weight bias and stigma and discrimination is to eliminate the negative portrayal of people living with obesity that is perpetuated through images in public health campaigns, research practices, clinical practices, and the media, etc.

There are many non-stigmatizing images to choose from in this image bank provided for free by the European Coalition for People Living with Obesity that encourage researchers and research scientists and future scientists to use in their studies. And finally, I can't resist including a link to my colleague Ted Kyle's blog post, who inspires me to think critically about the research and advocacy I do to improve health and social equity for people living with obesity. I think reading Ted's blog post every day challenges me to think critically and envision really how does a person-centered healthcare system look for everyone, regardless of their weight, body size, or illness.

And today, he specifically blogged about the need to address self-stigma. And this is an important issue that we need to address that many people with obesity face. And the power of celebrities like Oprah can have to change the social stigma associated with obesity.

The fact that she did this TV documentary last night is an example of how we can address social stigma associated with obesity. And with that, I'm going to thank you very much for listening. And I hope we have some time for questions.

Thank you very much, Jimena. Thanks very much for an excellent presentation and lots and lots of things to think about, especially early career researchers at the start of their career and thinking about how biases can affect their work. So I want to remind everybody, if you would like to ask questions, please do ask them in the chat and we'll use them as discussion points over the next 15 minutes or so.

So I'll start off with one of the questions that we received, Jimena, from the chat. So the question is, does internalized weight stigma apply only to people living with obesity and patients? I'm doing some research using the WBISM, which I think stands for the weight bias internalization scale, and don't know how to explain that some people without obesity, which is categorized as a BMI of less than 30, had high scores. Thank you, Jimena.

Excellent, as always. So I'm wondering what you think of that question. Thank you for that question.

Yes, internalized weight bias is prevalent across the weight spectrum. So it has been measured in people who are underweight, healthy weight in quotations, I'm going to put it in quotations, normal weight, overweight and obesity. So there's no, it just shows you how ingrained the attitudes are about being a healthy weight and having a healthy body size.

Even kids as young as three years old have these beliefs that children who have a higher weight are less healthy and are less fun to play with and are less, they show children images of pictures of children with different disabilities or different characteristics. And children as young as three years of age will choose the child with obesity last to be their friends. So these attitudes are not dependent on our own BMI or weight.

These attitudes affect everyone, everywhere. And this is why I use we when I speak, because we all have it. Like it doesn't matter how much we weigh, we all have it.

If we live in this world, if we consume all the social media in this world, we all have some of these beliefs. Yeah, thanks. And just reminder, if you've got any questions, please, please do add them into the chat.

I will ask a question of my own. So I wanted to find out from you if you have any tips for situations where you might be in with other researchers who perhaps even have the best intentions around around research in the area, but are possibly presenting and maybe stigmatizing images or talking about obesity and people living with obesity in a stigmatizing way. Do you have any tips on how you can address this in a professional situation where you can kind of get across the main the main points and help educate someone without blaming? Maybe people of the early career network might benefit from having some sort of, you know, set phrases, go to phrases to kind of start the conversation.

Yeah, that's really good. It's not easy to confront people because I know that researchers and people are well meaning and they may not be aware they may have this implicit bias. They're not aware that they have weight bias beliefs and attitudes and they might not be aware that these stigmatizing images can have an impact on patient behavior, on our policies, our health care approaches.

They might not be aware of it. So, you know, rather than pointing fingers and shaming others for having weight bias, I think it's important to acknowledge that we all have it and that we need to think about it critically and consider how people perceive these images, especially people living with obesity, especially if you're presenting in a conference about obesity or an obesity conference and consider, you know, the realities that people with obesity live today, where they face constant shaming and blaming and stigmatization for their weight, wherever they go, wherever they live, doesn't matter which part of the world, this happens to them all the time. So, we as researchers are well meaning and we want to help and we want to develop this person-centered health care system and we want to make sure we are doing no more harm and so we need to frame it as, you know, I'm trying to, you know, have a discussion with you about how this image that you use in your presentation may actually contribute to more weight stigma and having thought about it, I thought about it, I perceived it as this and I've done this before, you know, like I take a lot of responsibility for the language that I used 20 years ago when I started working in obesity, right, like I used to say obese people, morbid obese, right, I used to say those words but, you know, we learned as researchers, scientists, we are educable, we can learn and we can change our practices and our own behaviors and so if we're not aware of it, we can't change our behavior, so we have to become aware of it and I think there are, the other level is, as I mentioned, is the policy, right, so EASO has policies about the use of personal first language and non-stigmatizing images in science and obesity research, so these images and these policies should be used in all chronic disease conferences and scientific conferences, right, so people with diabetes are stigmatized because of their weight, people with disabilities are stigmatized for their weight, right, like people experience weight stigma across different diseases, across different weight statuses and across different settings, so it's not specific to people living with obesity and so that's why sometimes I don't use the word obesity stigma, I call it weight stigma because it can happen and it can be experienced by people in different statuses, weight statuses and in different chronic diseases and it's that fundamental belief that chronic diseases are preventable and are primarily a personal responsibility, right, and so this NCD language and framing that we have can be stigmatizing for people who have excess weight.

Yeah, thanks, I just wanted to direct people's attention to the chat and Cherie has shared a helpful link and said that Jimena has developed an update to the person first language guide to be used in addressing weight bias, so please feel free to have a look at this, I'll look at this after today's session which I'm sure will have lots and lots of helpful details. So I'll go back to the questions, so we have one that asks how can we distinguish stigma and reality, for example all studies show that people living with obesity are less compliant to healthcare but in the same time it's a stigma to think that. Yes, yes that's a very good question, so it's kind of like a chicken and egg situation, are people not adherent to, and I would use the word adherence instead of compliance for any chronic disease, we use the word the terminology adherence, so people can be non-adherent to all kinds of interventions and there are many things that are happening in their lives that may prevent them from adhering to a specific research trial or medication or program, right, we as healthcare professionals have to understand that providing person-centered healthcare means that we need to understand patients realities, right, that is what person-centered healthcare is, that we're not just there to tell them do this, we need to ask them can you do this, what is your capacity to do this, what barriers do you have to do this, right, and so we need to work with patients collaboratively to understand what are the barriers for people not adhering to a treatment, you know, like I think it's not just in obesity, right, like we see that most people that get a prescription for hypertension medication, for example, don't take it, they don't even go to the pharmacist and pick up the medication, but we tend to say that it's people with obesity that are non-adherent with obesity medications or obesity treatments, but non-adherence is a huge issue across diseases, it's not just people with obesity who don't adhere and I think we have to be aware of that internalized implicit bias that we have that people with obesity are not responsible for their health, they're not behaving in a responsible way and this is why they're not adhering to the treatment, so this is the path that we go to, like the autopilot in our brain, our implicit bias makes us think that people are not adhering because they have obesity and they're lazy, they're unmotivated, they don't follow our recommendations, they don't listen to healthcare providers, they're just difficult to work with, all of these biased beliefs are social stereotypes about obesity and there is no evidence that patients living with obesity are more or less adherent than other patients with other chronic diseases, so I think we just need to be looking at the facts, talking about person-centered healthcare and thinking about how our assumptions about people's behaviors are driven by this implicit bias.

Thank you. I think so, I think so, and please feel free to add more questions into the chat if you would like Jimena to expand on this topic, but I think it leads us nicely into another question which was a lot of obesity research is focused on individual weight loss, are we not perpetuating stigma ourselves? Do we need more research on what matters to patients? Yeah, yeah, I think so, I tend to agree with that comment and I mean I would love somebody here in this community to do a study and assess all the research studies that are happening in obesity right now and to assess the percentage of these studies that are focused on weight loss, and a clear example that I can tell you is when I was part of the committee that developed the Canadian clinical practice guidelines for obesity management in adults, and when we did our literature review, our systematic review of the evidence, we found, you know, it was a huge process, we found 500,000 publications on obesity and all of these based on these questions that we came up with, and the majority had outcomes focused on weight and weight loss and BMI changes, right, and so and that's the all the evidence we and so when you're developing clinical practice guidelines and all the evidence is based on BMI weight and weight loss outcomes, it's hard for you to make recommendations beyond those outcomes, you can't make those recommendations, and so we actually had to put in the Canadian clinical practice guidelines our recommendation for scientists to look beyond BMI weight and weight loss in the outcomes of clinical trials and intervention trials, because otherwise we cannot change clinical practice to go beyond weight and BMI and weight loss, and if we cannot change clinical practice, we cannot change policies, healthcare policies to go beyond weight, weight loss and BMI, right, and so if we want to go from a system, a healthcare system that is, you know, focusing on people and helping people to live meaningful, fulfilling lives, we cannot just continue to focus on these numbers, these quantitative numbers that, you know, even when you talk to patients living with obesity, yes, BMI and weight are important, but for them, the other important factors are being able to participate in their lives, being able to go to work, being able to have a family, to be happy, the outcomes are important for patients are way beyond weight and BMI, so we as scientists need to reevaluate that whole cycle, because again, it's a cycle we're perpetuating by doing more studies based on BMI and weight and weight loss outcomes, we're perpetuating this framing that obesity is about weight, that obesity is not a chronic disease, it's a behavioral weight control issue. Thank you, thanks for that.

Okay, so I'll move on to just the other questions, I would love to answer them all during this session, so another question from the chat is, how does stigma in obesity disease, obesity as a disease, compare with other stigmas, such as smoking and lung cancer, alcohol and liver disease, do you think? What are the similarities and what are the differences? Well, I think a lot of the similarities are driven by that perception that these are controllable individual behaviors that cause these diseases, so metabolic syndrome, liver, fatty liver disease, I think they changed the name, sorry, because the word fatty is stigmatizing, MAFLD, a lot of the drivers for the stigma in those diseases is the belief that people did this to themselves, that people should have controlled their diet, should have controlled their exercise levels, should have followed our health promotion recommendations, and they wouldn't have gotten this disease if they would have done what we told them to do, so we as healthcare professionals, we're like the missionaries trying to convince everybody to eat healthy and exercise, and if you don't do it, then it's your fault, right, and so all of this causes the stigma of all these, you know, non-communicable diseases that we frame as lifestyle diseases, I think there's a lot of them, if you compare it to mental illness, I think, you know, that used to be, well, it's not until we figure out that it was, you know, neurons in your brain that were causing you to feel like this, it was always like, well, you just have a bad attitude, you just need to smile more, you need to be happy, but then we changed that perspective, with HIV and AIDS, it was the same, it's like, well, it's just people having unprotected sex and their behaviors causing them to have HIV and AIDS, so it's their fault, right, and so individual responsibility, that value that we have in our Western society, that our health is our own personal responsibility, drives this, and it wasn't until HIV AIDS researchers found the virus and made it, you know, found the treatments for this virus that we started changing the narrative that, yeah, this is a disease, this is not a behavioral issue, this is not, you know, someone's fault, so I think we can learn from those disease areas, and that's why I think we can compare models, we can compare studies, but weight stigma in itself deserves its own research focus because it's so prevalent, right, and obesity is such a prevalent condition around the world, so I think ignoring it further is not a good idea, and ignoring it in our own research is not a good idea. Thank you, thanks, and I think time for one more question, and then possibly we'll move to close the session, but I wanted to ask specifically for researchers who are in the area of public health and perhaps communicate with people in the community and would like to have focuses on obesity in their research, but also public health and enhancing public health in general, how can these researchers who communicate with the community reduce weight biases in their work? I think it's the weight neutral health promotion, right, so instead of using obesity as the hook to promote healthy eating, as the hook to promote more exercise, as the hook for having less stressful lives, we frame all these health behaviors as healthy for everyone, like health promotion is about impacting population health outcomes, and so our messages are more generic, right, and so instead of saying, oh, you need to eat healthy so that you can have a healthy weight, no, you need to eat healthy to be healthy, right, you need to exercise more so you can have a healthy weight, no, the message is you need to exercise regularly so that you can be healthy and be happy and have more energy, whatever, like take the weight outside of that health promotion focus and focus on promoting health and well-being, and that's, I think, my key message for my fellow public health colleagues, I love you all, but we need to change that a little bit. Perfect, thank you, I think that's a nice message to close the session on, so I'll say thank you to all of the audience members, everybody for coming along and also for participating in the Q&A, just a quick message to say to the attendees, for anyone who doesn't know, these eLearning Hub events are open, openly available and accessible to all, the content is developed for the ASO Early Career Network, so if you do know early career people who potentially aren't members of the ECN or would benefit from coming along to these sessions, please do share the information with them so we can have more active and interesting discussions and Q&A like we did today.

So the webinars are available throughout the year and we have one more webinar this year and then we'll take a quick break for the summer and then we'll be back in September, so please keep an eye on the ASO website and social medias to see when the next sessions are and what the topics are going to be, and please do follow ASO and the ECN social media accounts which Amila has been sharing into the chat. I'll just say thank you very much, Amina, thank you for all of the information that you shared and everyone, the recording will be available after the session if you would like to re-watch. So thanks again and I'll close the session.

Bye everyone. Bye, thank you, bye. Thanks Lisa, thanks Amina.