Weight Bias & Obesity Stigma in Healthcare Nursing CE Course

2.0 ANCC Contact Hours AACN Category

Syllabus

Background

The obesity epidemic is a major global health challenge, and despite its negative impact on health, it is projected to rise substantially over the next several decades (Batsis & Zagaria, 2018). Obesity is associated with some of the leading causes of preventable death, including heart disease, stroke, type II diabetes, and certain types of cancer. The Centers for Disease Control and Prevention (CDC, 2019b) define obesity as abnormal or excessive fat accumulation in relation to height, classified as a body mass index (BMI) of 30 or higher (see Table 1). A high BMI can be an indicator of excess body weight and is used as a screening tool for obesity. According to the World Health Organization (WHO, 2019), BMI is the most useful population-level measurement tool of overweight and obesity, as it can be utilized in both males and females and across the lifespan. Individuals who are overweight or obese are routinely subjected to scrutiny and unfair treatment as a direct consequence of their weight. Obesity stigma is ubiquitous in our society, prevalent within workplace settings, educational systems, and media outlets. However, studies have shown that weight bias is also highly common in healthcare (Phelan et al., 2015). The complexities of treating obesity and the challenges endured when attempting to help patients achieve and sustain long-term weight loss can be a daunting undertaking for providers and patients alike. Provider frustrations may manifest as obvious or subtle forms of weight bias towards patients, who subsequently become increasingly reluctant to seek medical attention regarding any health concern due to perceived provider discrimination. Data from the Rudd Center for Food Policy and Obesity (n.d.) demonstrate that 69% of obese adults report feeling stigmatized by their healthcare provider, as well as other healthcare professionals when seeking medical care. 


Table 1. Adult BMI Chart

Classification

BMI (kg/m2)

Underweight

< 18.5

Normal

18.5 – 24.9

Overweight

≥ 25.0

Obese

≥ 30.0

Obese Class I

30.0 – 34.9

Obese Class II

35.0 – 39.9

Obese Class III

≥ 40.0

(WHO, 2019)

Epidemiology

Obesity has more than tripled since the 1960s and has now become more prevalent than smoking or the opioid crisis (Waters & DeVol, 2016). According to the most recent data acquired through the Food Research Action Center (2019), 39.6 % of the US adult population is currently obese, with an additional 31.6% overweight and 7.7% severely obese. In 2016, more than 1.9 billion adults aged 18 years and older were overweight, and of these, over 650 million adults were classified as obese (WHO, 2019). In general, rates of obesity are higher for Black and Hispanic women, Hispanic men, and in the south and midwest regions, and these percentages tend to rise with age. Among children and adolescents aged 2-19, 18.5% are currently obese. Childhood obesity is one of the most severe public health challenges, as overweight children are more likely to become obese as adults and endure significant health consequences related to lifelong obesity. According to the Behavior Risk Factor Surveillance System, adult obesity rates exceed 35% in seven states, 30% in 29 states, and 25% in 48 states (CDC, 2019a). 

Obesity is also associated with an increased risk of death, particularly among adults younger than 65. Obese adults are nearly two times more likely to die before the age of 70 as compared to adults who maintain a healthy weight (Turner, Jannah, Kahan, Gallagher, & Dietz, 2018). More than 2.8 million people die annually as a result of complications or conditions related to being overweight or obese (WHO, 2019). Obesity is associated with numerous health problems, and the leading causes of death among adults with obesity include heart disease, type 2 diabetes, respiratory diseases, and several types of cancer (LeBlanc et al., 2018). The World Cancer Research Fund (2018) estimates that about 20% of all cancers diagnosed in the US are related to excess body weight, physical inactivity, and poor nutrition.

Etiology

The etiology of obesity is a complex interplay of multiple factors; however, most commonly, it is the result of a constant imbalance between calorie consumption and calorie expenditure. Socioeconomic, environmental, and cultural influences also contribute to obesity development. Studies have demonstrated that diet and physical activity habits among children are largely influenced by their surrounding environment. These influences include social and economic factors, agricultural and food processing policies, and physical activity patterns (CDC, 2019b). As the obesity epidemic expands, children are reportedly consuming increased quantities of energy-dense foods without an equal increase in physical activity level, promoting unhealthy weight gain, and leading to a steady rise in childhood obesity and subsequent ramifications of lifelong obesity. Additionally, biology and genetics can also contribute to a predisposition to obesity development in some individuals as a byproduct of metabolism and hormonal influences (WHO, 2019).

Financial Burden

In the US, obesity is one of the biggest drivers of preventable chronic diseases and healthcare costs (Waters & DeVol, 2016). Obesity poses a detrimental financial burden on the nation, as economic costs continue to rise dramatically, and the obesity epidemic expands. Adults with obesity incur 42% higher medical costs per capita than their normal-weight counterparts (Turner et al., 2018). The estimated annual medical cost of obesity within the US ranges from $147 billion to $210 billion, and these costs climb alongside rising BMI. For instance, the difference in emergency room visit costs for patients presenting with chest pains are 22% higher in patients who are overweight, 28% higher for patients who are obese, and 41% higher for those who are severely obese, when compared to their healthy-weight counterparts (Peitz et al., 2014). In 2014, the Milken Institute calculated the direct health care costs of obesity at $427 billion. When combined with indirect costs, such as lost productivity, the annual cost to the US economy rose to $1.4 trillion (Waters & DeVol, 2016).

Terminology

Obesity is exceedingly stigmatized within our society, and individuals have become vulnerable to negative bias, prejudice, and discrimination across healthcare settings. The devaluation of others based on weight has been on the rise for decades and is considered the last socially acceptable form of prejudice. Weight bias refers to negative attitudes, beliefs, assumptions, stereotypes, and judgments toward individuals who are overweight or obese. It can emerge in subtle forms, such as through social exclusion and rejection, or it can be expressed directly with verbal teasing or physical aggression. Weight bias can lead to obesity stigma, which is a socially degraded characteristic such as a stereotype or label affixed to a person that interferes with the individual's identity, causing them to be socially discredited. Obesity stigma may progress to actions taken against people with obesity that can lead to exclusion, marginalization, and inequities. Weight discrimination is the unequal and unfair treatment due to weight, such as when individuals with obesity do not receive optimal care, or when they are discriminated against in the workplace. Common examples of weight discrimination involve being denied a position or a job promotion, being denied access to certain medical procedures, or being offered inferior medical care due to weight (Bradley, & Dietz, 2017).

Bias is generally considered to be either implicit or explicit. Implicit bias refers to attitudes that are automatic, subconscious, often occurring outside of awareness, and in contrast to explicitly held beliefs. Implicit bias may influence individual behavior without clearness or insight into the rationale. Explicit bias refers to an individual's conscious, outward, and intentionally expressed opinions and beliefs (Fruh et al., 2016). Puhl and Suh (2015) examined trends of weight discrimination through a 10-year period from 1995-2005, and their findings demonstrated a 66% rise in weight discrimination. Since then, the numbers have steadily climbed to surpass rates of discrimination due to race, ethnicity, physical disability, or sexual orientation. As body weight increases, the probability of being discriminated against rises (Turner et al., 2018).

Consequences of Weight Bias 

Mass media is one of the major driving forces behind the social acceptance and stigmatization of obesity, as cultural importance and social value have become directly correlated with body image. The media routinely perpetuates stereotypical illustrations of obese individuals and reinforces the social acceptance of weight bias. ‘Thin' is promoted as ideal and a representation of self-discipline, whereas ‘fat' is associated with failure and an invitation for public scrutiny. Individuals with obesity endure stigma from all avenues of life, including educators, employers, supervisors, co-workers, friends, and family (Phelan et al., 2014). The Rudd Center for Food Policy and Obesity (n.d.) reports that children with obesity experience a 63% higher chance of being bullied than their normal-weight peers. Adults have a 54% chance of being stigmatized by co-workers or employers due to their weight. 

The weight bias and obesity stigma within our society lead to severe consequences for individuals, as there are well-documented inequalities in employment, education, interpersonal relationships, and opportunities among individuals with obesity. The quality of care these patients receive is routinely compromised, leading to substantial harm to health in the form of poorer physical and mental conditioning, feelings of shame, worthlessness, embarrassment, and increased risk for depression and anxiety. Obesity stigma and weight bias are highly correlated with poor self-esteem and body image, leading to internalized weight bias, which is defined as holding negative beliefs about oneself due to weight or size (WHO, 2019). Research illustrates that ‘fat-shaming' individuals to lose weight does not encourage weight loss, and in fact, more commonly leads to weight gain. Among females with obesity who are actively working toward weight loss, many internalize negative weight stigmas, are less likely to be successful in their weight loss goals, and more likely to discontinue weight loss plans prematurely and engage in binge eating (Fruh et al., 2016).

Weight Bias in Healthcare 

Weight bias among healthcare professionals may surpass that of the general population. Many patients with obesity report a reduced level of trust in health professionals, leading to avoidance of health care appointments and poor self-care (Phelan et al., 2015). For purposes of this module, the terminology 'healthcare professionals' or 'HCPs' will be used to represent all individuals who work in healthcare settings, including physicians, advanced practitioners, nurses, medical assistants, medical receptionists, nutritionists, physical therapists, and so forth. 

Attitudes of Healthcare Professionals

Weight bias has been observed and documented in nearly every aspect of healthcare, including attitudes of front desk reception staff, patient care transport, nursing, and even among hospital volunteers (Puhl, Luedicke, & Grilo, 2014). Surveys demonstrate physician attitudes toward patients who are overweight and obese are negative and harmful. Physicians are cited as viewing these patients as lazy, weak-willed, non-complaint, unsuccessful, dishonest, lacking self-control, and as less intelligent than normal-weight equivalents. As BMI increases, physicians report increasingly negative attitudes, such as having less respect, reduced patience, and diminished compassion for them. Patients with obesity are viewed as a waste of the physician's time and are less desirable to care for. Many physicians blame obesity for nearly every ailment, illness, or complaint the patient describes, even when their symptoms are unrelated to weight, such as a cold or virus. Physicians may blame the patient for their weight, expressing beliefs that obesity is largely a behavioral problem caused by inactivity and overeating, and therefore the patient's fault (Panza et al., 2018). 

Ward-Smith and Peterson (2015) obtained data regarding the self-reported attitudes and beliefs of 358 nurse practitioners (NPs) toward patients with obesity. NPs perceived patients who were overweight or obese as less successful than others, not suitable for marriage, untidy, and unhealthy. Medical students demonstrate similar outlooks and find it socially acceptable to elicit derogatory humor toward patients with obesity in the clinical setting. A national sample survey involving 4,732 medical students from 49 medical schools revealed that 74% hold implicit weight biases, and 67% demonstrate explicit bias. They were found to have a more negative bias toward obesity than sexual orientation, poverty, race, or ethnicity (Phelan et al., 2014). In a study of 107 post-graduate health students, 55% labeled patients with obesity as non-compliant, 36% expressed frustration when caring for them, and 33% described them as lacking the motivation to make a change (Puhl et al., 2014).

Biases in the Physical Environment

Beyond the attitudes of HCPs and staff, tangible weight biases are prevalent within the physical environment of many healthcare settings, including inappropriately sized medical equipment. Medical office waiting room chairs may be too small or have arms preventing patients with obesity from fitting comfortably in them. Extra-large adult blood pressure cuffs or thigh blood pressure cuffs are routinely lacking, and surveys reveal the vast majority of medical offices do not have scales that record weight over 350 pounds. Further, many patients report derogatory and embarrassing weight practices, such as being weighed in a public area (i.e., the hallway or waiting room), staff discussing or disclosing weight in front of others, or being subjected to unsolicited weight loss advice and commentary by staff when recording their weight. Additionally, patient gowns are rarely large enough to fit patients with obesity, rendering them ashamed and vulnerable as they are not able to adequately cover themselves while waiting for the provider (Fruh et al., 2016; Puhl et al., 2014). 

Impact on Care

A keen awareness and understanding of the impact of weight bias and obesity stigmatization on care are critical. Provider-patient interactions are predominantly affected, as providers spend less time with patients who are obese, develop less rapport, and provide less health counseling. Providers tend to have decreased expectations of patients with obesity, focus less on patient-centered care, and offer fewer treatment interventions or options. Further, there is a reduced focus on health exams, screenings, and preventative medicine. As a byproduct of the various facets of weight bias and obesity stigma in healthcare, patients with obesity suffer many consequences from this vicious cycle of weight bias in healthcare, as displayed below in Figure 1 (Fruh et al., 2016).

When patients with obesity seek assistance from health care providers, the most commonly offered help they receive can reinforce and intensify the shameful feelings the patient may experience daily. In turn, patients develop a mistrust for doctors and other HCPs, which leads to avoidance of care, delay in receiving care, and increased likelihood of canceling medical appointments. Some patients may turn to food to dissociate from the shameful feelings and experiences. At times, even when well-intentioned providers counsel patients on simplistic, one-size-fits-all, behavioral weight loss, such as the "eat fewer carbohydrates, fat, and sugar, and exercise more", the patient may feel more powerless (Phelen et al., 2015). Patients tend to become more socially isolated as their obesity progresses, leading to a heightened risk for emotional and psychological distress, such as anxiety and depression, contributing to poor self-esteem and body image. Those affected by low self-esteem are more inclined to develop counterproductive responses, such as maladaptive eating (i.e., binge eating), which leads to further weight gain. When shame is exacerbated, the illness remains untreated, and the patient can enter a vicious cycle driven by hopelessness and helplessness, as they can't overcome the behavior on their own. This brutal cycle leads to increased risk for morbidity from obesity-driven conditions, negative overall health outcomes, poor quality of life, early mortality, and rising costs to the healthcare system (Puhl et al., 2014).

Figure 1. The Cycle of Obesity Impacted by Weight Bias in Healthcare  

 

Evidenced-Based Guidelines

There are several evidence-based obesity management guidelines put forth by credible organizations and grounded in extensive research and expert consensus, including the American Heart Association (AHA), American College of Cardiologists (ACC), The Obesity Society, National Heart, Lung, and Blood Institute (NHLBI), and the US Preventative Services Task Force (USPSTF). Despite their wide prevalence and accessibility, implementation of obesity guidelines across clinical settings remains inadequate (Turner et al., 2018).

The USPSTF (2018) recommends that adults with a BMI equal to or greater than 30 are offered or referred for intensive behavioral therapy (IBT). The USPSTF and the Centers for Medicare and Medicaid Services (CMMS) advise that obesity counseling is provided at least twice monthly in an individual or group setting for at least six months. The IBT interventions outlined by the USPSTF are designed to help individuals achieve or maintain clinically significant weight loss through a combination of dietary changes and increased physical activity. Clinically significant weight loss is considered a 5% or greater reduction in body weight. IBT interventions are grounded in problem-solving skills to identify barriers, self-monitoring of weight, peer support, and relapse prevention as part of the treatment plan. IBT consists of a dietary and nutritional assessment by a medical provider, registered dietician, or nutritionist to promote sustained weight loss through high-intensity interventions on diet and exercise. IBT interventions are generally consistent with the ‘5-A framework', as outlined below in Table 2 (USPSTF, 2018).


Table 2. Intensive Behavioral Therapy (IBT) 5-A Framework

Assess

Ask about (assess) behavioral health risks and factors affecting behavior change goals. 

Advise

Provide clear, specific, and personalized behavior change advice, such as information about personal health harms and benefits.

Agree

Select patient-centered appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.

Assist

Using behavior change techniques (self-help, counseling), help the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments (i.e., pharmacological therapy or bariatric surgery) when indicated or desired.

Arrange

Schedule follow-ups to provide ongoing assistance and support, and to modify the treatment plan as needed, including referral to more intensive or specialized treatment modalities.

(USPSTF, 2018)

The USPSTF also recommends the use of tools to support weight loss or weight loss maintenance, such as food scales, pedometers, and smartphone applications tracking calorie intake and energy expenditure, as well as exercise videos. Pharmacotherapy and bariatric surgery are also addressed and considered effective strategies that may be used to support clinically significant weight loss in some individuals with obesity (Ritten & LaManna, 2017). The USPSTF additionally recommends screening adults for 

  • abnormal blood glucose levels and type 2 diabetes,
  • high blood pressure, statin use in persons at risk for cardiovascular disease, 
  • counseling for tobacco smoking cessation, 
  • aspirin use in certain persons for prevention of cardiovascular disease.

Additionally, screening for obesity in children and adolescents is advised, but evidence-based recommendations from the USPSTF are still incomplete for persons in these age groups (USPSTF, 2018). 

Legislation and Action

Effective in 2011, the CMMS put forth a memo stating the following: 

The evidence is adequate to conclude that intensive behavioral therapy for obesity, defined as a body mass index (BMI) ≥ 30 kg/m2, is reasonable and necessary for the prevention or early detection of illness or disability and is appropriate for individuals entitled to benefits under Part A or enrolled under Part B and is recommended with a grade of A or B by the US Preventive Services Task Force (p.1). 

With this memo, obesity counseling, treatment, and management became billable medical appointments. The goal was to enhance the medical management of obesity in an attempt to combat the obesity epidemic. In 2013, the American Medical Association (AMA) House of Delegates endeavored to dispel some of the biases toward obesity by instating a new policy in which they recognize obesity as a disease state with multiple pathophysiological aspects requiring a range of interventions to advance obesity treatment and prevention (AMA, 2013). 

Currently, Medicare guidelines and ICD-10-CM official guidelines for coding and reporting for FY 2019 allow beneficiaries who meet criteria for obesity based on a BMI of 30 or greater, are deemed eligible for:

• One face-to-face visit every week for the first month;

• One face-to-face visit every other week for months two through six; and

• One face-to-face visit every month for months seven through twelve if the beneficiary meets the 3kg (6.6 lbs.) weight loss requirement during the first six months. 

However, ICD-10-CM guidelines stipulate that the associated diagnosis (such as overweight or obesity) must be documented by the provider with the appropriate ICD-10-CM BMI code (CMMS, 2019).

Limitations 

Despite these efforts, there has been a slow acceptance of obesity as an accepted health condition or illness. To date, there remains a lack of HCP training in obesity management, as there is no standardized obesity-related education and training that HCPs should receive. While there is an abundance of obesity management guidelines, there is an overall lack of uniformity and consensus on disease staging, best practice guidelines, and disease management and treatment. In general, obesity guidelines have not been consistently or effectively translated to clinical practice across settings, partly due to the lack of alignment and consensus among the guidelines (Ritten & LaManna, 2017). Survey studies demonstrate that less than 25% of physicians report feeling adequately trained to counsel patients on healthy eating, physical activity, and weight management (Bradley & Dietz, 2017). Turner and colleagues (2018) assessed healthcare provider knowledge of evidence-based guidelines for the nonsurgical treatment of obesity. They were able to obtain a nationally representative sample of 1,506 physicians and NPs. Findings demonstrated that provider understanding of appropriate clinical care for obesity is largely inconsistent with evidence-based recommendations. Most participants (84%) failed to identify practices consistent with evidence-based obesity treatment guidelines for the majority of survey questions. Only 49% correctly identified that 150 minutes of moderate-intensity physical activity per week is the guideline-recommended minimum level of physical activity to achieve substantial health benefits (Turner et al., 2018). 

Opportunities for Improvement: Reframing Obesity

It has become nearly impossible to work in healthcare and not be faced with the complex challenges of obesity. Healthcare professionals play a vital role in the prevention, treatment, and control of obesity and need to draw upon science to inform and support their approach to obesity care. Knowledge can be taught or learned. Nursing theory, much like evidence-based guidelines, are taught, whereas caring is learned through experience. The same principles apply when caring for patients with obesity. As a whole, the medical community must learn how to promote and embrace a shift from an individual medical perspective to a structural social perspective regarding obesity. To effectively care for patients with obesity and combat the rising obesity epidemic, professionals must embrace new practice approaches to break the vicious cycle. Adapting fresh perspectives, accepting obesity as a true disease, and recognizing its dynamic interaction with contextual social factors is essential (USPSTF, 2019).

Weight bias and obesity stigma are finally starting to be addressed within updated obesity prevention and treatment guidelines. In 2017, the Obesity Medicine Association (2017) put forth obesity guidelines that were inclusive of a list of recommendations for patient-friendly office equipment, such as providing sturdy‚ armless chairs, extra-large patient gowns, large adult blood pressure cuffs or thigh cuffs for patients with an upper-arm circumference greater than 34 cm, as well as weight scales with the capacity to record up to 500 pounds. Many offices, hospitals, and healthcare settings will require restructuring to remove these tangible biases from the physical setting. Private locations should be provided for weighing patients, as many patients feel anxious about being weighed or measured in a public space (Fruh et al., 2016).

It is the responsibility of each HCP to become accountable for their own pre-existing implicit and explicit biases, as the first step toward changing the culture is for each individual to recognize biases within him/herself. HCPs must take responsibility for the messages they send to patients. Obesity is a disease, and like any disease, it needs to be addressed; with empathy, compassion, respect, and evidence-based, patient-centered medical care. Obesity and weight management counseling are sensitive topics, and those in need of weight loss respond more positively to an empathetic, honest approach. HCPs must recognize that patients have had prior negative experiences, and the topic must be approached with sensitivity and without judgment. Research demonstrates that patients who receive empathetic, nonbiased care are much more likely to follow advice from providers, which in turn leads to better health outcomes (Puhl & Suh, 2015). 

As a medical community, how patients with obesity are referred to must be transformed to eliminate labeling, remove stereotypes, and reframe insensitive language. Weight neutrality should be adapted and enforced throughout medical care in all dialects, as well as engaging in "people-first" language. Labeling individuals by their obesity (i.e., "obese patient") can exacerbate the widespread extent of weight bias in healthcare. It is advised that healthcare professionals adopt people-first language (i.e., "patients with obesity") to preserve and uphold the respect and dignity of these individuals (Rudd Center for Food Policy & Obesity, n. d.). There are serious consequences for employers, employees, organizations, and students who make derogatory racial slurs in the 21st Century. Institution policy changes can undergo valuable and simple modifications to enforce the transition to weight-neutral language (Turner et al., 2018).


Table 3. Using Weight Neutral Language and Communication

Language to Avoid

Language to Use

Fat, chubby, heavy, large size

Unhealthy weight

Morbidly obese

Healthier weight

Weight problem

Overweight

Diet (dieting)

Eating Habits

Excessive Weight

High BMI

Obese patient

Patient with obesity

Treating the obese patient

Treating the patient with obesity

(Rudd Center for Food Policy & Obesity, n.d.)

Employers should mandate sensitivity training and competencies to create a benchmark in obesity care. Medical and graduate schools should develop curricula for healthcare students to spearhead and eradicate the problem early in their education. Individuals with obesity have become a vulnerable and targeted population. The medical community has a responsibility to take measures to shift the focus away from the numbers on the scale and towards behavior change and overall health. The consequences of weight bias and obesity stigma do not just impact the individual, as there are equally prominent public health ramifications. Impaired obesity prevention efforts lead to increased health disparities, social inequalities, and disregard for societal and environmental contributors to obesity. Accordingly, as morbidity and mortality rise, so do the costs to the US healthcare system and economy (Turner et al., 2018).

Healthcare professionals can serve as positive influences by making appropriate changes and delivering evidence-based, cost-effective medical care utilizing the defining principles of weight neutrality. These changes are pivotal to combating the obesity epidemic, eradicating this last socially acceptable form of prejudice, improving global health outcomes, and rescinding the financial burden to the US economy (Puhl & Suh, 2015; Ritten & LaManna, 2017).

Take-home Points

  • Weight bias and obesity stigma must be integrated with evidence-based obesity guidelines.
  • Providers must examine their own conscious (explicit) and subconscious (implicit) biases to disrupt checkpoints in the healthcare weight bias cycle.
  • HCPs must be equipped with effective & innovative interventions and tools to sustainably reduce weight stigmatizing attitudes and address weight in a culturally sensitive, non-offensive, nonjudgmental manner. 
  • Tangible weight bias should be removed from the physical environment of medical offices and hospitals, and all language should be reformed to mandate weight neutrality. 
  • HCPs would benefit from mandated competencies in a stigma-awareness-raising lens.
  • Patients who receive empathetic, nonbiased care are much more likely to follow advice from providers, which in turn leads to healthier outcomes for the patient, the population, and the economy.

                                                     References

American Medical Association House of Delegates. (2013). Resolution: 420 (A-13) Recognition of obesity as a diseaseRetrieved from https://www.npr.org/documents/2013/jun/ama-resolution-obesity.pdf

Batsis, J. A., & Zagaria, A. B. (2018). Addressing obesity in aging patients. Med Clin North America, 102 (1), 65-65. doi: 10.1016/j.mcna.2017.08.007

Bradley, D., & Dietz, W. (2017). Provider competencies for the prevention and management of obesity. Retrieved from https://www.lsuhsc.edu/administration/academic/cipecp/docs/Provider-Competencies-for-the-Prevention-and-Management-of-Obesity(1).pdf

The Centers for Disease Control and Prevention. (2019a). Behavioral risk factor surveillance system. Retrieved from https://www.cdc.gov/brfss/index.html

The Centers for Disease Control and Prevention. (2019b). Overweight & obesity. Retrieved from https://www.cdc.gov/obesity/

Centers for Medicare & Medicaid Services. (2011). Decision memo for intensive behavioral therapy for obesity (CAG-00423N). Retrieved from https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?&NcaName=Intensive%20Behavioral%20Therapy%20for%20Obesity&NCAId=253

Centers for Medicare & Medicaid Services. (2019). ICD-10-CM official guidelines for coding and reporting FY 2019. Retrieved from https://www.cdc.gov/nchs/icd/data/10cmguidelines-FY2019-final.pdf

Food Research Action Center. (2019). Obesity in the US. Retrieved from https://frac.org/obesity-health/obesity-u-s

Fruh, S. M., Nadglowski, J., Hall, H. R., Davis, S. L., Crook, E. D., & Zlomke, K. (2016). Obesity stigma and bias. Journal for Nurse Practitioners, 12(7), 425-432. doi: 10.1016/j.nurpra.2016.05.013

LeBlanc, E. S., Patnode, C. D., Webber, E. M., Redmond, N., Rushkin, M., & O’Connor, E. A. (2018). Behavioral and pharmacotherapy weight loss interventions to prevent obesity-related morbidity and mortality in adults: Updated evidence report and systematic review for the US preventative services task force. JAMA, 320(11), 1172-1191. doi: 10.1001/jama.2018.7777

US Preventative Services Task Force. (2019). Behavioral weight loss interventions to prevent obesity-related morbidity and mortality in adults: Recommendation statement.  American Family Physician, 99(8), 516-517. Retrieved from https://www.aafp.org/afp/2019/0415/od1.html

Obesity Medicine Association. (2017). Obesity guidelines. Retrieved from https://obesitymedicine.org/2017-obesity-guidelines/

 Panza, G.A., Armstrong, L. E, Taylor B, A., Puhl, R. M., Livingston, J., & Pescatello, L. S. (2018). Weight bias among exercise and nutrition professionals: A systematic review. Obesity Rev, 19(11), 1492-1503. doi: 10.1111/obr.12743 

Peitz, G. W., Troyer, J., Jones, A. E., Shapiron, N. I., Nelson, R. D., Hernandez, J., & Kline, J. A. (2014). Association of body mass index with increased cost of care and length of stay for emergency department patients with chest pain and dyspnea. Circ Cardiovasc Qual Outcomes, 7(2), 292-298. doi: 10.1161/CIRCOUTCOMES.113.000702

Phelan, S. M., Dovidio, J. F., Puhl, R. M., Burgess, D. J., Nelson, D. B., Yeazel, M. W., … van Ryn, M. (2014). Implicit and explicit weight bias in a national sample of 4,732 medical students: The medical student CHANGES study. Obesity (Silver Spring), 22(4), 1201-1208. doi: 10.1002/oby.20687

Phelan, S. M., Burgess, D. J., Yeazel, M. W., Hellerstedt, W. L., Griffin, J. M., & van Ryn, M. (2015). Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev, 16(4), 319-326. doi: 10.1111/obr.12266.

Puhl, R. M., Luedicke, J., & Grilo, C. M. (2014). Obesity bias in training: Attitudes, beliefs and observations among advanced trainees in professional health disciplines. Obesity (Silver Spring), 22(4), 1008-1015. doi: 10.1002/oby.20637

Puhl, R. M., & Suh, Y. (2015). Health consequences of weight stigma: Implications for obesity prevention and treatment. Curr Obesity Rep, 4(2), 182-190. doi: 10.1007/s13679-015-0153-z

Ritten, A., & LaManna, J. (2017). Unmet needs in obesity management: From guidelines to clinic. Journal of the American Association of Nurse Practitioners, 29(51), S30-S42. doi: 10.1002/2327-6924.12507

Rudd Center for Food Policy & Obesity (n.d.). Weight bias and stigma. Retrieved from http://www.uconnruddcenter.org/weight-bias-stigma

Turner, M., Jannah, N., Kahan, S., Gallagher, C., & Dietz, W. (2018). Current knowledge of obesity treatment guidelines by health care professionals. Obesity, 26(4), 665-671. doi: 10.1002/oby.22142

United States Preventative Services Task Force. (2018). Weight loss to prevent obesity-related morbidity and mortality in adults: Behavioral interventions. Retrieved from https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/obesity-in-adults-interventions1

Ward-Smith, P., & Peterson, J. (2015). Development of an instrument to assess nurse practitioner attitudes and beliefs about obesity. Journal of the American Association of Nurse Practitioners, 28(3), 125-129.

Waters, H., & DeVol, R. (2016). Weighing down America: The health and economic impact of obesity. Milken Institute, 1-66. Retrieved from http://assets1b.milkeninstitute.org/assets/Publication/ResearchReport/PDF/Weighing-Down-America-WEB.pdf

World Cancer Research Fund. (2018). Diet, nutrition, physical activity and cancer: A global perspective [3rd Expert Report]. Retrieved from https://www.wcrf.org/dietandcancer

World Health Organization. (2019). Global strategy on diet, physical activity and health. Retrieved from https://www.who.int/dietphysicalactivity/childhood_what/en/