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Undergraduate, female, nutrition students' perceptions of curricular influence on attitudes toward individuals with obesity.

INTRODUCTION

Weight bias among nutrition students has been researched and documented for almost 2 decades, with early research findings suggesting that nutrition curricula should address the topic of weight bias [1]. This view continues as subsequent researchers made similar suggestions to increase awareness of weight bias in nutrition curricula and to provide information to challenge nutrition students' assumptions about people with obesity [2]. Some of these assumptions include the belief that individuals with obesity are inherently lazy, unmotivated, content with their weight, and uninterested in being active [3]. Incorporating weight-bias information in curricula has shown to be an effective means of addressing and reducing weightbias attitudes [4]. Furthermore, this is relevant to dietetic practice because research shows that the knowledge and skills acquired during nutrition education influences behaviour for many years post-graduation [5].

It is important to explore nutrition students' attitudes toward individuals with obesity because these students are trained to understand specific dietary and lifestyle recommendations for a variety of illnesses and conditions, including overweight and obesity. If weight bias is present among nutrition students, then these negative attitudes may influence their work with individuals who are overweight and obese. Although weight-bias attitudes among nutrition students have been examined [1,2, 6-8], most of this work has been quantitative research [2, 7-9] and has been done in the United States [2, 7], the United Kingdom [9], and Australia [8]. In contrast, qualitative research about dietetic students' education was conducted at Ryerson University in Toronto, Ontario, but the study examined the general experiences of education and preparation for practice among first- and final-year nutrition students [10]. Perceptions of the curricula and the influence of the curricula on attitudes toward people with obesity were not addressed in that study.

Limited qualitative studies have been done and more Canadian qualitative research is needed to understand nutrition students' perceptions of how the university undergraduate curricula influence their attitudes toward people with obesity. The study described in this article, which is a component of a larger research project that examined students' perceptions of the causes of obesity and their weight bias (unpublished data), had the following main research objective: to qualitatively explore senior-level undergraduate, nutrition students' perceptions of the extent to which obesity and weight bias are addressed in the curricula and how the curricula influenced their attitudes toward individuals with obesity.

METHODS

Theoretical approach

This research was guided by a phenomenological approach and relied on the participants' descriptions of their experiences relevant to the phenomenon of interest [11]. Phenomenology explores lived experience based on what is experienced and how it is experienced [12]. Using a phenomenological approach in this research allowed for a deep understanding of students' experiences of the nutrition curricula.

Participants

Participants were 20 current senior-level undergraduate, female students (8 third year, 11 fourth year, and 1 greater than fourth year) from the Bachelor of Applied Science--Applied Human Nutrition (AHN) program at the University of Guelph. Senior-level students were purposefully selected because they had the greatest exposure to the curricula and had acquired the most experience in their program. This is 1 of 3 English-language nutrition programs in Ontario accredited by Dietitians of Canada. Information obtained from a demographic questionnaire completed by participants showed an average age of 22.4 years (SD = 3.4). Most participants identified as White/Caucasian (80%), reported work experience in the health field (60%), rated their nutrition knowledge as good or very good (95%), and believed that they are in the normal weight category (80%).

Semi-structured interview guide

An interview guide was developed to address various factors influencing attitudes toward individuals with obesity. However, given the focus of this article, only the responses to the following interview questions are described: (i) During your time at this university, have you covered any material regarding obesity in any course(s)? (ii) During your time at this university, have you covered material about bias or discrimination toward individuals who are obese or overweight in any course(s)? and (iii) Do you think your education at this university has influenced your attitudes and behaviours toward obese or overweight individuals (and if so, how)? Closed-ended questions were used to first determine whether participants covered material in courses and then prompts were used to enhance the discussion and elicit detailed description from the participants. A definition of obesity was not given to participants, as we did not want to influence their perceptions. Participants responded to the questions based on their personal views about obesity and individuals with obesity.

Procedure

The University of Guelph Research Ethics Board provided ethics clearance for the study. The second author, who was a graduate student during the study and is an alumna of the AHN program, purposively recruited senior-level nutrition students from the AHN program through flyers, email, and announcements about the study in courses. Students were eligible if they were fluent in English, in at least their third year of study, and female. Only females were recruited to achieve homogeneity, to limit gender as a possible confounding variable, and to reflect the dietetic profession that is 96% female [13]. Recruiting both females and males would not have yielded enough male students to explore possible gender differences in the results as an initial step in the data analyses. Participants were invited to participate in an individual interview for 75 minutes in April 2013. Interviews were held in a private room on campus and conducted by the second author. Participants were welcomed when arriving at the room and provided an explanation of what would occur during the interview. Consent and demographic forms were completed and then the interview was conducted in a comfortable seating area. The interviews were audio recorded on 2 devices to deal with possible audio recorder malfunction. Participants received $20 as a token of appreciation. The 20 interviews were subsequently transcribed verbatim and analyzed.

Analysis

NVivo 10 (QSR International, 2012) was used to conduct thematic analysis of the transcripts. The second and third authors independently performed open coding, which entailed assigning preliminary themes in the margins of transcripts, as they read the transcripts for the first time [14]. A constant comparison approach was used to develop these preliminary themes. Both authors independently generated a list of themes by continually referring to themes already generated [15, 16]. Next, both authors worked together to perform axial coding, which involved examining how the preliminary themes are connected and then organizing them into larger clusters [14]. Both authors agreed upon a master list of themes, definitions of themes, and codes for themes. Then they independently performed selective coding as they read each transcript again to apply the master list of codes to segments of text and to highlight good illustrations of themes [14]. This comprehensive and systematic process ensured trustworthiness of the results through credibility, transferability, dependability, and confirmability [17]. Triangulation (e.g., 2 authors cross-checking to generate themes) and thick description of data (e.g., via an in-depth account of participants' experiences and perspectives as senior-level students in the AHN program) established credibility and transferability, respectively [17]. Dependability and confirmability were ensured through an audit trail (e.g., the second author kept detailed records related to the audio recordings, transcripts, preliminary ideas written on transcripts, and tables that showed themes with corresponding descriptions of themes and illustrative quotes) [17]. Theoretical saturation was reached after 15 transcripts were analysed, in that later transcripts yielded little or no change to the existing themes [18].

RESULTS

Curricular material about obesity

Participants discussed several materials as sources of information about obesity in the curricula. The materials are summarized below and illustrative quotes are shown in Table 1. First, participants mentioned nutrition courses most frequently as sources of information about obesity. Participants recalled obesity material across the program in their first-, second-, third-, and fourth-year nutrition courses, though they spoke about obesity material being covered more in the clinical nutrition course. Secondly, many participants mentioned learning about obesity during case studies in nutrition courses. They said that the case studies focused on an illness or a disease associated with obesity, rather than focusing entirely on obesity. Thirdly, several participants spoke about obesity material in non-nutrition courses. The most common other subject area was psychology. Participants mentioned covering obesity material when learning about appetite regulation and eating disorders in non-nutrition courses.

Curricular material about weight bias

Participants discussed several materials as sources of information about weight bias in the curricula. The materials are summarized below and illustrative quotes are shown in Table 2. First, some participants discussed learning about discrimination toward obese individuals in their nutrition courses. They mainly described learning about weight bias in the form of several presentation slides during a clinical nutrition lecture. Secondly, similar to obesity material being covered in non-nutrition courses, several participants mentioned the topic of weight bias being taught in non-nutrition courses. They referred to human resources courses that addressed employment issues related to obesity and psychology courses that examined societal ideals regarding weight. Thirdly, other participants mentioned limited coverage of weight-bias material in the university curricula. They stated that the topic of weight bias only appeared a few times in their nutrition curricula. They mentioned learning about the topic in other ways such as reading about it on their own.

Curricular influence on attitudes toward individuals with obesity

Four themes for curricular influence on attitudes toward people with obesity were identified: increased knowledge of obesity, understanding the complexity of obesity, increased empathy toward obese individuals, and better ability to avoid stereotypes toward obese individuals. First, many participants indicated that their education increased their knowledge of obesity. Participants mentioned learning about factors that contribute to obesity and realized that the causes of obesity are more complicated than simply diet and physical activity. Participants identified that their increased knowledge expanded their perceptions of obesity. Typical comments were:
   You learn all about nutrition and calories [at first], and then
   you almost think that it's someone's fault. But then when you get
   into clinical [clinical nutrition course], you start to understand
   all the different factors and know that it's not their
   fault. (P4)

   More of an understanding of what it is to be overweight or obese.
   If it was just eating and exercising, then we would have solved the
   problem, but it's clearly so much more than
   that and we're exploring other causes. We're constantly building up
   on our knowledge. (P6)


Secondly, similar to the theme of increased knowledge, when discussing the complexity of obesity, participants emphasized that it results from more than just diet and physical activity. Participants talked about being more educated than the average person and having a better understanding of obesity. This allows them to challenge what society and the media say about obesity. Some examples were:
   I would say that I have a bigger, wider scope of obesity and
   why and how it happens. People think "Oh, it's because you're lazy,
   you don't do physical activity, and you eat too much, so therefore
   you're fat." But I'm like "no, there are so many other aspects to
   it. " That's what I think my univer- sity degree has done for me.
   (P14)

   It has opened my mind to the fact that obesity is so complicat- ed.
   You don't hear about the other factors toward obesity in the
   general media, it's always diet and exercise, which are huge
   contributors but it's just not that. (P6)


Thirdly, many participants discussed having more empathy for obese individuals. Participants discussed how they are more patient and compassionate because of their increased understanding of obesity. Some examples of comments were:
   It [education] definitely helped me to empathize for them
   [obese individuals]. If nutrition is a career path that I want to
   pursue, I think it's important to be understanding and be able to
   put myself into their perspectives. (P1)

   I'm really trying to learn to have compassion for these
   [obese]
   people. I think it is society on one hand being like "oh these
   people are so lazy, " but then there are other reasons that people
   are overweight. I know it's a big struggle and it can be very,
   very discouraging. It can be a continuous cycle that they just
   can't get out of. I think my education has opened my eyes to that
   and the difficulties that people face, and just to be more
   empathetic. (P3)


The fourth theme was better ability to avoid stereotypes and negative attitudes toward people with obesity. Many participants said that, without their education, they would believe the negative stereotypes about individuals with obesity. Participants commented on how their education has made them less judgemental and less likely to make negative assumptions about people with obesity. Participants said:
   I'm able to understand the mechanisms behind obesity rather
   than just looking at it and thinking "oh, they eat too much " or
   "oh, they don 'tget enough exercise. " There's such a stigma behind
   obesity and they [obese individuals] think it's their fault, but
   there's so many other factors that can be going on. (P18)

   We're taught in our clinical nutrition class that you can't look at
   an obese person and just think they're lazy or not motivated. You
   never know what external factors there are causing that obesity,
   like disease, or where they were raised, or culture. (P17)

   We learned all about the background of obesity and all the factors
   that contribute to it [in clinical nutrition course], so now I
   don't just see someone who's overweight and assume that they have
   bad habits. (P10)


DISCUSSION

This qualitative study explored undergraduate nutrition students' perceptions of the extent to which obesity and weight bias toward obesity are addressed in the curricula. It also explored how the curricula have influenced nutrition students' attitudes toward individuals with obesity. While much of the existing research to date on attitudes toward obese individuals among nutrition students has been quantitative [1, 2, 6, 7], the current study utilized qualitative methods to allow for a richer understanding of perceptions. Participants provided insight into the nature of the nutrition curricula and its influence on attitudes toward people with obesity.

This study's phenomenon under investigation differs from that of the limited qualitative work in the field. Research has explored nutrition students' experiences of their education, as well as the influence of the educational process [10]. However, this research did not seek to understand perceptions of the curricula and the influence of the curricula on attitudes toward people with obesity [10]. Additionally, research has explored weight stigmatization among adults who are overweight or obese and weight-bias reduction suggestions [19], but it has not explored obesity and weight stigma and weight-bias reduction in the nutrition curricula. Researchers examining attitudes toward individuals with obesity among nutrition students have suggested the need to increase education and awareness of weight bias in nutrition curricula [1,2]. Based on the various identified themes regarding the curricula in the present study, it is evident that more direct education on the topics of obesity and weight bias is needed.

Limitations of this study are acknowledged. The results may not generalize beyond the purposive sample of nutrition students examined in this study; however, this is acceptable as generalizability is not an expected outcome of qualitative research [20]. Nonetheless, the findings suggest that some students would benefit from further and more coordinated coverage of obesity-related issues in the curricula. The small sample size might initially be considered another limitation. However, theoretical saturation was reached with this sample size [21] in that analysis of new transcripts did not yield new themes [18]. A strength of this study is that participants were senior-level students who had more exposure to the curricula and will soon become practitioners. Also, this study addresses a gap in that, to our knowledge, there are limited data on Canadian health students' perceptions of the curricula and its influence on attitudes toward people with obesity.

In conclusion, this study highlights the various perceptions of the amount and type of obesity and weight-bias material in the nutrition curricula. It also highlights the influence of the curricula on students' attitudes toward individuals with obesity. Future research could entail needs assessments among nutrition students and professionals to explore modifications needed in the curricula to provide more coordinated coverage of obesity and weight bias. Future intervention research could examine which methods of presenting obesity and weight-bias information are most effective.

RELEVANCE TO PRACTICE

These findings are useful to university professors teaching nutrition/health courses, nutrition students, and registered dietitians and health professionals mentoring students during dietetic internships following graduation. Health students and professionals can utilize these results to reflect on their own attitudes toward individuals with obesity. Those responsible for curricula can enrich nutrition education by incorporating weight-bias material and reflective practice into undergraduate coursework. This could be in the form of lectures, guest speakers, research assignments, and/or workshops. Ultimately, enhanced coverage of obesity and weight-bias information in dietetic curricula has the potential to improve knowledge about obesity and weight-bias attitudes of nutrition students, which can enhance future registered dietitians' practices regarding obesity.

Sources of financial support: None.

Conflicts of interest: The authors declare that they have no competing interests.

References

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JOHN J. M. DWYER, PhD; ANDREA STARR, MSc; CHRISTINE MILLS, BASc; JESS HAINES, PhD, RD

Department of Family Relations and Applied Nutrition, University of Guelph, Guelph, ON
Table 1. Illustrative quotes regarding obesity material in
university curricula.

Obesity material                  Illustrative quotes

Nutrition courses       In nutrition education, we watched
                        videos about how the United States is
                        campaigning against obesity. It was
                        crazy. It was a parent giving a kid a
                        hamburger or something and being like
                        "you're killing your child." It was
                        really in your face, and that really
                        stuck with me. (P2)

                        In clinical nutrition, we covered
                        obesity. We covered obesity but kind of
                        in the disease section. So obesity and
                        dyslipidemia, type 2 diabetes, and how
                        obesity is a risk factor for all these
                        things. (P8)

                        Hypertension and diabetes. For the most
                        part, it was looking at, okay so this
                        person is overweight and has diabetes,
                        how would you counsel that person. (P12)

Case studies            We had case studies. We would have to
                        make nutrition care plans for people
                        with obesity, diabetes, or metabolic
                        syndrome. We had presentations and we
                        talked about the case. (P1)

                        Type 2 diabetes. Within that, we talked
                        about obesity. So the case study wasn't
                        about obesity necessarily, but obesity
                        was definitely involved with the type 2
                        diabetes. (P5)

                        We did a case study regarding adult
                        obesity a couple weeks ago, targeting
                        eating healthier and more activity. [We
                        covered] all the risk factors associated
                        with it [obesity]. A lot of cultures and
                        ethnic backgrounds are at higher risk,
                        disease factors, and that kind of stuff.
                        And that puts you at risk for other
                        diseases as well, like cardiovascular
                        disease and hypertension, and all that
                        stuff. (P17)

Non-nutrition courses   I think it was in a first-year
                        psychology class that we learned about
                        hormones that could affect if someone
                        were to become obese or not. We talked
                        about the hormone leptin, [how] it
                        affects your appetite, and how it's
                        something you can't control. Genetics
                        [determines] how much leptin you have in
                        your body. That affected me a lot
                        because it's just one of those things
                        where the individual has no control over
                        it. (P7)

                        I think it was abnormal psychology. We
                        did a section called health, physical
                        health or something like that, where we
                        [covered] obesity and eating disorders.
                        We were learning about the
                        neurotransmitters for controlling
                        hunger, like leptin and ghrelin. (P18)

Table 2. Illustrative quotes regarding weight-bias material
in university curricula.

Weight-bias material               Illustrative quotes

Nutrition courses       It would be the last lecture we had. Our
                        professor was talking about some of the
                        ways that overweight and obese people
                        are discriminated against all the time.
                        She was talking about hospitals or a
                        doctor's waiting room and how all of the
                        chairs have arms. So if you're really
                        large, you can't even sit down in the
                        waiting room. You're constantly being
                        [reminded] that you don't fit in or
                        you're not normal. (P11) She [the
                        professor] had 4 or 5 slides about
                        weight bias. Addressing our own
                        attitudes.... To make sure we're a
                        resource to help them [obese
                        individuals] get past their barriers,
                        not to be an additional barrier (P20)

                        One slide touched on it. One or 2 slides
                        in this unit [in clinical nutrition
                        course]. We were talking about the
                        etiology of obesity. She [the professor]
                        put up this image that we couldn't even
                        read because it was so big. It was
                        hundreds of different things that all
                        linked back to why a person is obese.
                        There were just so many factors. You
                        realize that you can't assume anything
                        about someone who is obese because it
                        could be any number of dozens or
                        hundreds of different factors that are
                        all having a synergistic effect on why
                        they're obese. You can't really
                        discriminate or be biased against them
                        if you don't know why they are the way
                        they are. (P10)

Non-nutrition courses   We may have done something in my third-
                        year human resources class. It was about
                        what discrimination is. Essentially like
                        the 101 of discrimination and what you
                        can ask in certain questions when you
                        are doing interviews.... I think it was
                        more related to potential sick days and
                        how you can't just assume that they
                        [obese individuals] are going to be sick
                        more often and less productive. (P14) I
                        took a social psychology class. We were
                        learning about attractiveness and how we
                        associate fit people as being beautiful
                        and fat people as being ugly. (P7)

Limited coverage        Maybe it has come up once or twice, but
                        nothing concrete. (P3)

                        I'm sure we did talk about the fact that
                        obese people tend to be judged in a
                        certain way, but nothing really in depth
                        or specific that I can think of. (P9)
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Article Details
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Title Annotation:Research/Recherche
Author:Dwyer, John J.M.; Starr, Andrea; Mills, Christine; Haines, Jess
Publication:Canadian Journal of Dietetic Practice and Research
Article Type:Report
Geographic Code:1CANA
Date:Dec 1, 2016
Words:4203
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