Abstract
Context:
Obesity is a major health concern in the United States, and its prevalence continues to rise. Although it is a common health issue, many people, including health care professionals, are biased against people with obesity.
Objective:
To determine whether a comprehensive obesity curriculum presented to students in medical school can positively influence their attitudes toward obesity.
Methods:
The study was designed around a comprehensive educational obesity curriculum at Touro University College of Osteopathic Medicine-CA, involving the classes of 2013 through 2018. A survey to assess student attitudes toward obesity was distributed to first-year students before the curriculum, directly after completion, and each year after until graduation (graduating classes of 2015 through 2018). Second- and third-year medical students in 2011 (graduating classes of 2014 and 2013), who did not complete the curriculum, were given an examination to establish baseline values and served as the control group. The obesity curriculum consisted of lectures delivered during the first and second year of medical school and case study simulations during the third year. Knowledge gained from the curriculum was assessed with a multiple-choice examination, and bias was assessed using the Fat Phobia Scale.
Results:
A total of 718 first- through fourth-year students were included. Students who completed the first year of the obesity curriculum (n=528) showed significantly greater medical knowledge regarding obesity-related epidemiology, pathogenesis, biochemistry, pathophysiology, and metabolic factors; nutrition, diet, physical activity, self-control, and behavior modification; pharmacologic and nonpharmacologic interventions; and associated chronic disorders, based on their multiple-choice examination scores compared with the control group. The examination scores indicated significant increases in medical knowledge compared with the precurriculum cohort after the curriculum (OMS I students: 130 [72.4%]; 133 [92.6%]; 133 [91.1%]; 132 [89.0%]; vs control: 105 [47.2%]; 134 [52.6%], respectively [P<.01]). In all 4 years observed, there was a significant reduction in bias among first-year medical students after obesity curriculum (before: 3.65, 3.76, 3.57, 3.61, and after: 3.47, 3.38, 3.34, 3.37, respectively) (P<.05). The reduction in bias was also significantly sustained throughout the fourth year.
Conclusion:
A comprehensive obesity curriculum throughout medical school resulted in an improvement in students’ attitudes toward and knowledge of obesity.
The prevalence of obesity in the United States continues to rise even though the government has prioritized obesity as a major health concern.
1,2 Concurrent with the rise in obesity is the stigmatization of people with obesity.
3 Long-standing stereotypes of overweight and obese individuals, including an association with lesser intelligence, sexual unattractiveness, laziness, lack of will power, and gluttony remain prevalent.
4-6 Furthermore, many studies
7,8 have demonstrated that this bias against people with obesity is also present in health care professionals. Health care professionals with negative attitudes toward patients with obesity may not have successful communication with patients, which can result in less preventive care, more emergent care, avoidance of initiating a discussion about obesity, and the potential to create an environment that results in worse eating behaviors for the patient.
15,19-26
Medical students, both osteopathic and allopathic, have been found to share a similar bias, whether implicit or explicit, against people with obesity.
27,28 Furthermore, negative comments or discriminatory behavior toward patients with obesity by faculty or staff may influence the attitudes of students toward these patients.
16,19,29-31
To address this issue of bias against obesity, many medical schools have incorporated obesity-related behavioral medicine didactics, motivational interview training, and interprofessional learning activities into their curriculum.
28,32-36 However, few prospective studies
28,33,37,38 have examined the effect of these programs on students’ attitudes toward obesity.
Medical students are aware of multiple causes of obesity; however, their perception of these causes varies considerably.
15 O'Brien et al
39 compared a curriculum that emphasized controllable causes of obesity, such as diet and exercise, with a curriculum that emphasized both controllable and uncontrollable causes of obesity, such as genetics and environment, and concluded that there was an increased bias toward obesity in the students who were taught only the controllable causes of obesity. To our knowledge, no study to date has demonstrated a sustainable decrease in bias caused by a program in any health sciences school, nor has any study proved a change in bias to be caused by a deeper understanding of the multiple factors complicit in the obesity epidemic.
The purpose of this study was to determine whether a comprehensive obesity curriculum could increase obesity knowledge and positively influence the attitudes of students at Touro University College of Osteopathic Medicine-CA (TUCOM) toward people with obesity. We hypothesized that a comprehensive obesity-specific curriculum designed to increase knowledge regarding obesity would have a positive effect on students’ bias toward these patients.
For second-year students in the class of 2015, the curriculum consisted of 3 hours of course material, which provided updated information based on new reviewed data over the previous year, reemphasized selected obesity topics, and included the following 2 additional topics: (1) the interaction through subclinical inflammation between obesity, metabolic abnormalities, and environmental change; and (2) a distinctive osteopathic approach to managing obesity. For second-year students in the classes of 2016 through 2018, the curricular materials were deemed too dense for 3 hours, and the curriculum was increased to 4 hours. Students in the classes of 2015 through 2017 received a 25-question multiple-choice obesity examination.
The classes of 2013 and 2014 (second- and third-year students, respectively) were surveyed, although they did not receive the comprehensive obesity curriculum, to provide a secondary control group. These students did attend 2 to 3 hours of cumulative lectures on various topics (eg, metabolic syndrome, type 2 diabetes mellitus, obstructive sleep apnea, infertility, nutrition, diet) and how they related to obesity. These students also took the multiple-choice examination that was given to the class of 2015, except that the examination for the class of 2013 had only 13 questions.
After the failure to achieve the Healthy People 2010 goals in reducing obesity, the American Osteopathic Association's house of delegates passed Resolution 435A in 2011, which stipulated that all osteopathic physicians should address the obesity epidemic in their practice. In 2011, TUCOM's comprehensive obesity curriculum was implemented with the aim to decrease student bias against obesity and, by extension, change new physician behavior in treating patients with obesity.
The participants in the current study who did not receive the obesity curriculum significantly underperformed on the multiple-choice examination compared with the participants who received the curriculum, demonstrating their lack of knowledge on the topic of obesity. The relatively high scores of students who received the curriculum suggest that students learned from the content taught in the curriculum. Concomitant with this increase in knowledge was a significant decrease in bias toward obesity, as indicated by the decrease in survey scores. By spanning the informational aspect of the program over medical school years 1 through 3, this decreased bias was sustained during all 4 years of medical school (for those students who had 3 years of the curriculum, classes 2015 and 2016). To our knowledge, this is the first study to demonstrate a sustained 4-year decrease in obesity bias.
The current data suggest that providing a comprehensive obesity-related curriculum that includes biologic, psychosocial, epidemiologic, pathologic, and clinical aspects to medical students is vital to reducing bias against obesity and can better prepare them to address the concerns of their patients with obesity. In addition, to our knowledge, TUCOM's obesity curriculum is the first to include information on health disparities and ethnic differences. The curriculum also included the important topic of climate change as it relates to the obesity epidemic, which included teaching students the global burden of disease attributable to the interaction between obesity, metabolic syndrome, and climate change/air pollution, which conforms to the recent American College of Physicians
40 position paper on climate change and health.
Limitations of the study include the use of only 1 tool to measure the level of bias toward obesity (ie, the survey). Other surveys are available to measure both intrinsic and extrinsic bias, which could have been used.
31 Further research is needed to determine whether there is a measurable difference in the type of bias that students have against obesity (ie, intrinsic or extrinsic). Another limitation to this study is inherent in the use of a single-arm study design and the fact that the students involved were all from a single institution. The small reduction in bias, although statistically significant, still means that bias is present. Whether this improvement will be clinically relevant has yet to be determined.
This study only addressed student bias toward obesity. It has yet to be determined if this reduction in bias can be maintained in their medical practice and if it will translate into better patient care. It is possible that as medical students progress through their clinical training, increased exposure to the clinical components of obesity may be countered by the greater exposure to bias from their health care team as they interact with patients with obesity. This concept will be further explored in the next study phase. No existing curriculum had been replaced by the obesity curriculum at TUCOM, which added less than a 3% increase in material provided during the semester.
In phase 2 of this study, we intend to determine whether electronic-learning modules developed to provide content addressed in the obesity curriculum can achieve a similar reduction in bias at other medical schools. Phase 3 will then modify the curriculum to align with the specific residency specialty programs and extend it to residents in continuity of care clinics to determine whether the improved knowledge and change in attitude will result in better clinical outcomes for their overweight and obese patients.