Years in the making: The Weight-Inclusive Toolkit

A new weight-inclusive toolkit is set to be part of the training for the dietitians of tomorrow, addressing the generations-long issue of weight stigma in healthcare settings. The University of Arizona is one of a small number of universities with a dedicated curriculum in weight-inclusive health education, and working on the toolkit was a valuable opportunity to contribute to the field.

For more than five years, educators from the School of Nutritional Sciences & Wellness (SNSW) have made it their goal to take this one step further by contributing to a toolkit on weight inclusive care that will be adopted by the Accreditation Council for Education in Nutrition and Dietetics (ACEND), which is responsible for establishing standards for curriculum. The adoption of this toolkit makes it available to all dietetic internship locations, teaching future generations of dietitians the foundational knowledge of weight inclusive care.

Historically, the field of dietetics has been characterized by a weight-centric teaching approach, and many dietitians use weight loss as the primary solution to health issues. The weight-inclusive toolkit is encouraging professionals to dig deeper and look at the other determinants of health, like access to care, environment, and social factors.

“I think folks forget sometimes that weight-inclusive care means trauma-informed care, and it means diverse inclusive care, and really zooming out and understanding that we encounter communities and people and populations that are very different. We can’t teach the same thing that’s been taught for years and years,” said Ashley Carrillo, one of the contributors to the toolkit and an assistant professor of practice at SNSW.

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Acknowledging weight stigma

In order to promote real change in the world of dietetics, one of the first steps is acknowledging that bias surrounding weight exists in the healthcare system. In the world of healthcare, weight bias is still very prevalent – meaning there are negative attitudes and stereotypes surrounding patients with higher body weight. In dietetics specifically, this could be attributed to the fact that much of the training has taken an “obesity as a disease” approach, using body mass index (BMI), as the standard screening tool for determining weight-related health issues.

“When we move students towards understanding how unhelpful BMI is, and how weight is not a proxy for health; you have to go back to history. You have to understand the root causes of where things came from. We have to understand the origins of things to challenge them and to understand them from a critical perspective,” Carrillo said.

The toolkit’s approach isn’t to completely discredit weight-centric care, but to acknowledge and analyze its limitations and history of misuse and to offer alternative frameworks and solutions, which also helps promote trust between patients and providers. According to the National Library of Medicine, about 21% to 32% of patients with higher body weights feel judged or stigmatized by their doctors, creating lower trust in the healthcare system.

“When you’re a person in a larger body, there’s just so much reluctance to go to the doctor or see a provider because providers will just automatically recommend weight loss, or they’ll just blame symptoms on the person's weight,” said Katelyn Barker, toolkit contributor and assistant director of the Didactic Program in Dietetics at SNSW. “As a patient, that’s so frustrating because, one, do you think they don’t know they're a person of size? Because yes, they do. And then two, do you think they've never tried losing weight before? Because the answer is very likely yes."

A key aspect of acknowledging that stigma surrounding weight exists was including those with lived experiences in the toolkit. Over one hundred people, both professionals and those who have experienced the effects of weight-stigma in the healthcare space worked on the piece.

“They really wanted a toolkit that aligned with the drafted standards that we as dietitians, as accrediting institutions, teach dietitians to follow. So, they wanted a toolkit that taught curriculum, taught weight-inclusive care, to be taught in programs that train dietitians,” Carrillo said.

Pushback and barriers to change

Considering this weight-centric style of teaching has been the standard education model in the field of dietetics, educators and toolkit contributors aren’t oblivious to the challenges that are likely to arise.

Some of those challenges include lack of awareness and familiarity with these concepts, resistance to changing long-held beliefs, and the discomfort in questioning prior education.

“The toolkit has twenty lectures and one hundred contributors because these are big topics. These are big cultural shifts and they require a lot of dialogue and a lot of practice. So I think that will be the hesitation; it’s different. It’s a pivot and pivots are hard. It challenges centuries old narratives and that is going to take time,” Carrillo said.

So far, students in SNSW have overall been quite accepting of the toolkit and the barriers it’s aiming to address in the dietetic world. However, even those who may disagree are encouraged to express themselves and their potential grievances.

“Students are super receptive to this content. Even if they don’t agree with it. Which is fine. We welcome discourse in our classes, you’ll never get marked off for having a different angle towards it,” Carrillo said. “It’s about exposure to information. It’s about critically thinking about best serving the patient. So, even if they disagree with it at its face, they are grappling and unlearning things they’ve been told forever, or experiences that they’ve had in their own body.”