‘Just Bloody Fat!’: A Qualitative Study of Body Image, Self-Esteem and Coping in Obese Adults

Class 3 Obesity and Oral Health in Adults: A Scoping Review of the Challenges for Oral Healthcare Services

Background: Obesity is one of the most neglected public health problems affecting both developed and developing countries. The most clinically severe obesity (Class 3 obesity) has both clinical and service delivery implications on dental services. However, associations between Class 3 obesity and oral health are minimally explored in the literature and thus poorly understood. Aims: This scoping review aimed to explore the existing evidence on Class 3 obesity and oral health. Methods: A literature search was performed via Medline, Scopus, Google scholar and Embase research databases. Results: A total of 375 papers were sourced from the database search. Twenty seven full-text papers were included in the final literature review. Results revealed findings from both quantitative and qualitative studies. Papers included results pertaining to associations with dental disease, oral health and associated behaviours, oral health-related quality of life and the barriers experienced by adults with Class 3 obesity in accessing dental services. Conclusions: While mixed findings were identified, this scoping review reports associations between Class 3 obesity and poor oral health across various domains including clinical parameters and oral health related quality of life. The literature has also highlighted important barriers to dental care in those with the most severe Class 3 obesity. Based upon our findings, we have summarised current oral health management implications and directions for future research.

'My goal was to become normal'-A qualitative investigation of coping with stigma, body image and self-esteem long-term after bariatric surgery

Improved self-esteem and body image, as well as reduced experiences of weight stigma are important patient-reported obesity treatment outcomes. However, more knowledge is needed about how individuals who have undergone metabolic and bariatric surgery (MBS) perceive themselves and their bodies and use different coping strategies in relation to body image and self-esteem long-term after MBS. In this qualitative study body image, self-esteem, weight stigma and coping strategies were explored among 18 individuals who underwent MBS more than 10 years ago when interviewed. Using reflexive thematic analysis, two primary themes were identified: 'Experiences of living with a stigmatised body' and 'Coping with weight stigma, body image and self-esteem', and eight sub-themes. Findings capture frequent experiences of weight stigma before bariatric surgery, the need for coping with stigma and body dissatisfaction before and after MBS, and how different coping strategies are related to participants' perceptions of their bodies and self-concepts. More adaptive coping strategies, such as confrontation and cognitive restructuring may facilitate more positive body image outcomes, than more ruminative and avoidant strategies. Understanding adaptive coping strategies can be useful to develop interventions to reduce negative consequences of weight stigma on body image and self-esteem.

Weight Inclusive Practice: Shifting the Focus from Weight to Social Justice

Obesity is framed by mainstream media and health care professionals as an "epidemic" contributing to the ill health of the population. This paper reviews literature related to dominant discourses about weight in dietetics, drawing on literature from other health care disciplines, and how these discourses influence patient care. Emerging, competing discourses are also reviewed. Literature highlighted that dietitians and dietetic students are often biased and hold stigmatizing beliefs toward "overweight" and "obese" patients. No research has been conducted in Canada addressing this question, leaving this as an opportunity for future research. Weight stigma and interventions focused on weight have multiple negative implications for individuals, especially those living in larger bodies, including reluctance to seek health care, poor body image, subsequent weight gain, and increased disordered eating. There are alternative discourses emerging, which shift the focus away from weight and toward social justice. The ways in which dietetic students are trained to "manage" weight, and how dominant discourses influence this training, is an important area of future exploration. Dietetic professionals are encouraged to reflect on their weight biases and educate themselves on weight inclusive approaches to health, such as Health at Every Size and Well Now.

Experiences of the Pharmacy-Led Weight Management Service: Views of Service Providers in England

Obesity constitutes one of the main modifiable risks of developing cardiovascular disease. In the UK, in 2016, 30% of the adult population were obese (30% of females and 29% of males). Community pharmacies are ideally situated to offer weight management (WM) services, enabling individuals to control and lose their excess weight. This study aimed at exploring the views of the pharmacy-led WM service providers in England. Semi-structured interviews were conducted with 15 trained community pharmacists and pharmacy staff-11 (73.3%) from Kent, three (20%) from Kingston and Richmond and one (6.7%) from Hackney and City-offering the WM service, either owning or working in independent pharmacies or for pharmacy chains. All interviews were audio-recorded, transcribed and anonymised. The analysis was conducted using thematic analysis. Three themes emerged: training and support, barriers and approach. Interestingly, service providers (SP) stated that obesity is a tough topic to talk about: they found it difficult to start a conversation about it, even if they had received training to facilitate this role. Additionally, several barriers for running such a service were identified, such as lack of time, too much work pressure and too little advertising, which could potentially lead to poor sustainability of the service. SPs can effectively intervene in an individual's weight through the WM service that they offer. It is clear that further training should be provided in order for SPs to feel more comfortable in approaching and communicating with people and to increase the public's awareness of the pharmacy-led WM service, so as to ensure the service's sustainability.

Conceptualization of body image in the bariatric surgery patient

Bariatric (weight loss) surgery is more popular than ever. The American Society for Metabolic and Bariatric Surgery in 2016 reported that 216,000 bariatric procedures were performed in the United States. Bariatric surgery has major physiological benefits; its use is expected to increase globally. However, patients may not anticipate the profound impact that rapid and massive weight loss may have on their body image after bariatric surgery. The construct of body image in this population needs to be explicated to facilitate continued research regarding this increasingly prevalent healthcare procedure. This article describes the formulation of a model of relevant concepts and dimensions within the construct of body image in the bariatric surgery patient. In the process of creating the model, we identified many factors influencing body image in patients before and after bariatric surgery, summarized eight measures, and developed a new definition based on prior work. Theoretical considerations are discussed. The long-term objective of this model building approach is to encourage researchers and clinicians to test the feasibility of systematic clinical measurement of body image at office visits before as well as multiple times after bariatric surgery.

Fat is fashionable and fit: A comparative content analysis of Fatspiration and Health at Every Size® Instagram images

In step with the proliferation of Thinspiration and Fitspiration content disseminated in popular web-based media, the fat acceptance movement has garnered heightened visibility within mainstream culture via the burgeoning Fatosphere weblog community. The present study extended previous Fatosphere research by comparing the shared and distinct strategies used to represent and motivate a fat-accepting lifestyle among 400 images sourced from Fatspiration- and Health at Every Size^®-themed hashtags on Instagram. Images were systematically analyzed for the socio-demographic and body size attributes of the individuals portrayed alongside content reflecting dimensions of general fat acceptance, physical appearance pride, physical activity and health, fat shaming, and eating and weight loss-related themes. #fatspiration/#fatspo-tagged images more frequently promoted fat acceptance through fashion and beauty-related activism; #healthateverysize/#haes posts more often featured physically-active portrayals, holistic well-being, and weight stigma. Findings provide insight into the common and unique motivational factors and contradictory messages encountered in these fat-accepting social media communities.

Predictors of dieting and non-dieting approaches among adults living in Australia

BACKGROUND

There is a dearth of research comparing why dieting and non-dieting approaches are adopted. A greater understanding of reasons underlying dieting and non-dieting attempts will help to identify target beliefs for interventions to support and motivate adults to attempt whatever approach they are willing and/or able to pursue. We investigated the predictors of dieting and non-dieting approaches in Australian adults using predictors that were identified in a previous qualitative study.

METHODS

We conducted a prospective study, with two waves of data collection occurring 4 weeks apart. At baseline, participants completed a questionnaire assessing constructs drawn from the theory of planned behaviour (attitude, subjective norm, and self-efficacy), past behaviour, non-planning, attributions for dieting failure, weight control beliefs, and dieting and non-dieting intentions. We used path modelling to analyse responses.

RESULTS

At baseline, 719 adults (52.2% male) aged between 18 and 76 completed the questionnaire. Four weeks later, 64% of participants (n = 461) reported on their dieting and non-dieting behaviour in the past month. Past behaviour, attitude, subjective norm, and self-identity significantly predicted dieting intentions. Dieting intentions and past behaviour significantly predicted dieting behaviour, while non-planning and self-efficacy did not. The model explained 74.8% of the variance in intention and 52.9% of the variance in behaviour. While most findings were similar for the non-dieting model, subjective norms and self-identity did not predict intention, while self-efficacy and self-identity both predicted non-dieting behaviour directly. The non-dieting model explained 58.2% of the variance in intention and 37.5% of the variance in behaviour.

CONCLUSIONS

The findings from this study provide support for the application of TPB and identity theory constructs in the context of both dieting and non-dieting behaviour. Self-efficacy and self-identity appear more relevant to non-dieting behaviour than dieting behaviour, while subjective norms was more influential in predicting dieting. Practitioners wishing to encourage either approach in their clients should attempt to modify the constructs that influence each approach.

The role of the "Healthy Weight" discourse in body image and eating concerns: An extension of sociocultural theory

Sociocultural models of body image and eating concerns have highlighted the role of the social discourse in promoting the pursuit of the thin-ideal. Recently, another weight-focused social discourse has gained ground, focused on the goal of maintaining body weight within the boundaries of a weight-range defined as "Healthy." This discourse is somewhat different to the promotion of the thin-ideal; however, it might also be implicated in the development of body image and eating concerns. The present study aimed to extend sociocultural theories of the development of body image and eating concerns by (1) proposing a theoretical model accounting for pressure to maintain a "Healthy Weight", and (2) reviewing the existing evidence for the pathways included in this model. In the proposed model, pressure to maintain a Healthy Weight leads to the internalization of anti-fat attitudes and the need to control weight as well as beliefs in the controllability of weight through diet and exercise. These beliefs may then lead to body preoccupation and disordered eating. The extant literature provides initial support for these relationships; however, empirical testing of this model is necessary to determine its usefulness as an explanatory model and in providing intervention targets for future prevention and intervention efforts.

Outcomes of a community-based weight management programme for morbidly obese populations

BACKGROUND

Morbid obesity is an ongoing concern worldwide. There is a paucity of research reporting primary care outcomes focussed on complex and morbidly obese populations. The National Institute for Health and Care Excellence (NICE) recommends a specialist, multidisciplinary weight management team for the successful management of such populations. This is the first service evaluation reporting both primary (weight change) and secondary [body mass index (BMI), waist circumference, physical activity levels, fruit and vegetable intake, Rosenberg self-esteem score] outcomes in these patients.

METHODS

The present study comprised a prospective observational study of a cohort data set for patients (n = 288) attending their 3-month and 6-month (n = 115) assessment appointments at a specialist community weight management programme.

RESULTS

Patients had a mean (SD) initial BMI of 45.5 (6.6) kg m^- ²; 66% were females. Over 80% of patients attending the service lost some weight by 3 months. Average absolute weight loss was 4.11 (4.95) kg at 3 months and 6.30 (8.41) kg at 6 months, equating to 3.28% (3.82%) and 4.90% (6.26%), respectively, demonstrating a statistically significant weight change at both time points (P < 0.001). This meets NICE best practice guidelines for the commissioning of services leading to a minimum of 3% average weight loss, with at least 30% of patients losing at ≥5% of their initial weight. Waist measurement and BMI were reduced significantly at 3 months. Improvements were also seen in physical activity levels, fruit and vegetable consumption, and self-esteem levels (P < 0.001).

CONCLUSIONS

This service was successful in aiding weight loss in morbidly obese populations. The findings of the present study support the view that weight-loss targets of 3% are realistic.

Felt stigma and obesity: introducing the generalized other

People with a big body are tainted in western societies. Although most research on obesity occurs in the medical context, few studies investigate characteristics and effects of feelings and fears related to the fat stigma in the absence of overt discrimination. By linking Norbert Elias's and George H. Mead's theoretical frameworks, this paper offers a different approach to understanding and investigating felt stigma. The study is based on secondary data (25 semistructured interviews with children and adolescents). It explores internalized societal perspectives on overweight and obesity and inquires into the way in which interviewees handle the blame frame of personal responsibility during their interview. The preliminary findings suggest that specific forms of managing one's self-presentation in interviews indicate felt stigma. Consequently, the paper argues for an analytical approach that extends the focus on the content of interviews to include its dynamics.

Longitudinal associations of obesity with affective disorders and suicidality in the Baltimore epidemiologic catchment area follow-up study

Our aim was to examine the longitudinal associations between obesity and mental health variables (psychiatric diagnoses and suicidal behaviors). Data were from waves 3 and 4 of the Baltimore Epidemiologic Catchment Area study (N = 1071). Participants were aged 30 to 86 years at wave 3 (mean, 47.6 years; SD, 12.8). The prevalence of obesity increased from 27.6% to 39.1% during the follow-up. Logistic regression analyses revealed no associations between baseline obesity and onset of mental disorders or suicidal behaviors between waves 3 and 4 in fully adjusted models; however, baseline obesity predicted new-onset suicide attempts in models adjusted for sociodemographics and mental disorders. Baseline depression predicted weight gain during the 11-year follow-up period (F = 4.014, p < 0.05), even after controlling for important confounders. Overall, most mental health variables were not associated with obesity, suggesting that clinicians and others should be wary of "weight-ism" and avoid making the assumption that higher body weight relates to mental health problems.

On the relationship between weight status and doctor shopping behavior-evidence from Australia

OBJECTIVE

A recent study has suggested that overweight and obese people are more likely to consult a range of physicians (doctor shopping). The consistency of this finding with multiple measures of doctor shopping and controls for socioeconomic circumstances was interrogated.

DESIGN AND METHODS

Ninety-nine thousand four hundred seven Australians aged 45 and over who had sought primary healthcare at least five times within 6 months of a survey (2006-2008). (i) The count of different physicians consulted; a binary indicator of (ii) >= three different physicians; (iii) >= five different physicians; and iv) a measure that took into account multiple consultations with the same physician were investigated. Weight status was measured using Body Mass Index (BMI) based on self-reported height and weight. Controls included socioeconomic circumstances, demographics, health, and neighborhood factors.

RESULTS

In comparison to people with "normal" BMI, the likelihood of doctor shopping was lower among overweight (Incidence Rate Ratio: 0.97, 95%CI: 0.96, 0.98) and obese people (0.95: 0.93, 0.96). This negative correlation between doctor shopping behavior and weight status was consistent after full adjustment and across different outcome measures.

CONCLUSIONS

In contrast with recent evidence from the US, overweight and obese Australians are less prone to doctor shopping behavior than their peers with "normal" BMI.

'I'm searching for solutions': why are obese individuals turning to the Internet for help and support with 'being fat'?

INTRODUCTION

This study explores what types of information obese individuals search for on the Internet, their motivations for seeking information and how they apply it in their daily lives.

METHOD

In-depth telephone interviews with an Australian community sample of 142 individuals with a BMI ≥ 30 were conducted. Theoretical, purposive and strategic samplings were employed. Data were analysed using a constant comparative method.

RESULTS

Of the 142 individuals who participated in the study, 111 (78%) searched for information about weight loss or obesity. Of these, about three quarters searched for weight loss solutions. The higher the individual's weight, the more they appeared to search for weight loss solutions. Participants also searched for information about health risks associated with obesity (n = 28), how to prevent poor health outcomes (n = 30) and for peer support forums with other obese individuals (n = 25). Whilst participants visited a range of websites, including government-sponsored sites, community groups and weight loss companies, they overwhelmingly acted upon the advice given on commercial diet websites. However, safe, non-judgemental spaces such as the Fatosphere (online fat acceptance community) provided much needed solidarity and support.

CONCLUSIONS

The Internet provides a convenient source of support and information for obese individuals. However, many turn to the same unsuccessful solutions online (e.g. fad dieting) they turn to in the community. Government and community organisations could draw upon some lessons learned in other consumer-driven online spaces (e.g. the Fatosphere) to provide supportive environments for obese individuals that resonate with their health and social experiences, and address their needs.

The role of the fatosphere in fat adults' responses to obesity stigma: a model of empowerment without a focus on weight loss

Obese adults face pervasive and repeated weight-based stigma. Few researchers have explored how obese individuals proactively respond to stigma outside of a dominant weight-loss framework. Using a grounded theory approach, we explored the experiences of 44 bloggers within the Fatosphere--an online fat-acceptance community. We investigated participants' pathways into the Fatosphere, how they responded to and interacted with stigma, and how they described the impact of fat acceptance on their health and well-being. The concepts and support associated with the fat-acceptance movement helped participants shift from reactive strategies in responding to stigma (conforming to dominant discourses through weight loss) to proactive responses to resist stigma (reframing "fat" and self-acceptance). Participants perceived that blogging within the Fatosphere led them to feel more empowered. Participants also described the benefits of belonging to a supportive community, and improvements in their health and well-being. The Fatosphere provides an alternative pathway for obese individuals to counter and cope with weight-based stigma.

Decisions about weight management: a synthesis of qualitative studies of obesity

There is a high non-attendance and dropout attrition from weight management interventions for adults with obesity. Patient dissatisfaction with consultations involving decisions about interventions may be a factor. A systematic review was undertaken of qualitative studies reporting perceptions, experiences, contexts and influences for adults facing, or reflecting on, weight management. The aim was to synthesize a generic model of influences on decision-making about weight management for adult patients. Electronic database and hand searches identified 29 qualitative studies involving 1387 participants (mean age 45.3 years; mean BMI 37.1 kg m(-2) ; 79.9% women). Seven overarching themes were inductively derived from extracted data spanning: cultural identity; social structures such as gender; responses to obesity stigma; previous weight loss experiences; personal motivators and barriers; social support; and practical resources. A model is presented in the paper. Improving decisions about weight management requires attention to how diffuse cultural and psycho-social factors, such as obesity stigma, influence patient choices. Reflection on experiences of previous attempts at weight loss is also essential, as are practical resource factors - particularly for less affluent groups. Considering these factors along with more established theories of individual psychological motivations and barriers may help to improve initial participation and retention within interventions.

"The solution needs to be complex." Obese adults' attitudes about the effectiveness of individual and population based interventions for obesity

BACKGROUND

Previous studies of public perceptions of obesity interventions have been quantitative and based on general population surveys. This study aims to explore the opinions and attitudes of obese individuals towards population and individual interventions for obesity in Australia.

METHODS

Qualitative methods using in-depth semi-structured telephone interviews with a community sample of obese adults (Body Mass Index >or=30). Theoretical, purposive and strategic recruitment techniques were used to ensure a broad sample of obese individuals with different types of experiences with their obesity. Participants were asked about their attitudes towards three population based interventions (regulation, media campaigns, and public health initiatives) and three individual interventions (tailored fitness programs, commercial dieting, and gastric banding surgery), and the effectiveness of these interventions.

RESULTS

One hundred and forty two individuals (19-75 years) were interviewed. Participants strongly supported non-commercial interventions that were focused on encouraging individuals to make healthy lifestyle changes (regulation, physical activity programs, and public health initiatives). There was less support for interventions perceived to be invasive or high risk (gastric band surgery), stigmatising (media campaigns), or commercially motivated and promoting weight loss techniques (commercial diets and gastric banding surgery).

CONCLUSION

Obese adults support non-commercial, non-stigmatising interventions which are designed to improve lifestyles, rather than promote weight loss.

"I don't eat a hamburger and large chips every day!" A qualitative study of the impact of public health messages about obesity on obese adults

BACKGROUND

We are a society that is fixated on the health consequences of 'being fat'. Public health agencies play an important role in 'alerting' people about the risks that obesity poses both to individuals and to the broader society. Quantitative studies suggest people comprehend the physical health risks involved but underestimate their own risk because they do not recognise that they are obese.

METHODS

This qualitative study seeks to expand on existing research by exploring obese individuals' perceptions of public health messages about risk, how they apply these messages to themselves and how their personal and social contexts and experiences may influence these perceptions. The study uses in depth interviews with a community sample of 142 obese individuals. A constant comparative method was employed to analyse the data.

RESULTS

Personal and contextual factors influenced the ways in which individuals interpreted and applied public health messages, including their own health and wellbeing and perceptions of stigma. Individuals felt that messages were overly focused on the physical rather than emotional health consequences of obesity. Many described feeling stigmatised and blamed by the simplicity of messages and the lack of realistic solutions. Participants described the need for messages that convey the risks associated with obesity while minimising possible stigmatisation of obese individuals. This included ensuring that messages recognise the complexity of obesity and focus on encouraging healthy behaviours for individuals of all sizes.

CONCLUSION

This study is the first step in exploring the ways in which we understand how public health messages about obesity resonate with obese individuals in Australia. However, much more research--both qualitative and quantitative--is needed to enhance understanding of the impact of obesity messages on individuals.