A qualitative exploration of obesity bias and stigma in Irish healthcare; the patients' voice

"Treated as second class citizens" - the lived experience of obesity-related stigma: an IMI2 SOPHIA study

PURPOSE

Obesity-related stigma impacts on and shapes the physical and psychosocial wellbeing of individuals living with obesity. Often absent from the literature in the field is the voice(s) of those living with obesity capturing the nuances of the lived experiences of obesity-related stigma.

METHODS

This study adopted a qualitative approach encompassing individual (n = 15) and photovoice method (n = 12), with a purposeful sample of patients accessing treatment for obesity within the healthcare setting during 2021. Analysis was undertaken using thematic analysis.

RESULTS

Key themes developed from the analysis related to experiencing obesity-related stigma as exposure to external judgement, societal exclusion and felt environmental stigmatization. Exposure to external judgement was described as judgemental comments resulting in hypervigilance to societal judgement. Participants reported how being overlooked and ignored by others had various negative effects and compounded obesity-related stigma through societal exclusion. Public spaces lacking suitable equipment further made obesity-related stigma visible through felt environmental stigmatization when pursuing hobbies and in everyday life.

CONCLUSIONS

Obesity-related stigma had a profoundly negative impact on participants in this study, particularly in shaping social interaction, limiting life experiences and impacting psychosocial wellbeing.

'Beyond the Scale': A Qualitative Exploration of the Impact of Weight Stigma Experienced by Patients With Obesity in General Practice

OBJECTIVE

Obesity is a complex, chronic, relapsing disease that requires an individualised approach to treatment. However, weight stigma (WS) experienced in healthcare settings poses a significant barrier to achieving person-centred care for obesity. Understanding the experiences of people living with obesity (PwO) can inform interventions to reduce WS and optimise patient outcomes. This study explores how patients with obesity perceive WS in general practice settings; its impact on their psychological well-being and health behaviours, and the patients suggestions for mitigating it.

METHODS

In-depth semistructured interviews were conducted with 11 PwO who had experienced WS in general practice settings in Ireland. The interviews were conducted online via Zoom between May and August 2023; interviews lasted between 31 and 63 min (M = 34.36 min). Interviews were audio-recorded, transcribed verbatim and analysed using inductive reflexive thematic analysis.

RESULTS

Three overarching themes specific to participants' experience of WS in general practice were generated: (1) shame, blame and 'failure'; (2) eat less, move more-the go-to treatment; (3) worthiness tied to compliance. A fourth theme: (4) the desire for a considered approach, outlines the participants' suggestions for reducing WS by improving the quality of patient-provider interactions in general practice.

CONCLUSION

The findings call for a paradigm shift in the management of obesity in general practice: emphasising training for GPs in weight-sensitive communication and promoting respectful, collaborative, and individualised care to reduce WS and improve outcomes for people with obesity.

PATIENT OR PUBLIC CONTRIBUTION

PPI collaborators played an active and equal role in shaping the research, contributing to the development of the research questions, refining the interview schedule, identifying key themes in the data, and granting final approval to the submitted and published version of the study.

The lived experiences of patients with severe obesity during hospital admissions in Norway: A phenomenological hermeneutic study

AIM

To explore the lived experiences of patients with severe obesity during hospital admissions.

DESIGN

Qualitative study design.

METHODS

Semi-structured individual interviews with 14 participants with severe obesity from Norway were conducted between May and October 2021. A qualitative phenomenological hermeneutical approach inspired by Paul Riceour was used to analyse the data.

RESULTS

The following three themes were identified through the analysis of the lived experiences of patients with severe obesity during hospital admissions: blaming my weight, being prejudged and feeling different. The participants shared various emotional experiences of encounters with healthcare professionals at hospitals. They struggled to be recognized and welcomed like everyone else and found it difficult to be judged by someone who did not know them. The various experiences resulted in a vicious circle, ultimately leading to a fear of future hospitalization.

CONCLUSION

Being a patient with obesity in a hospital setting can present various challenges, leading to feelings of shame and guilt. Experiences of stigma may not necessarily be related to the overall hospital context but rather to encounters with healthcare professionals who may be unfamiliar with the patient's history, which can lead to stigmatizing behaviours.

IMPACT

Understanding how patients with severe obesity experience their hospital admissions and the importance of familiarizing themselves with the individual patients to avoid stigmatizing behaviours is important for healthcare professionals caring for obese patients.

REPORTING METHOD

Consolidated Criteria for Reporting Qualitative Research.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

IMPACT STATEMENT

Patients with obesity often encounter stigmatization and negative attitudes from healthcare professionals, particularly in primary care settings. Patients with severe obesity experienced various challenging encounters with healthcare professionals during hospital admissions, resulting in a vicious circle, ultimately leading to a fear of future hospitalization. It is crucial for healthcare professionals involved in the care of patients with obesity to acquaint themselves with individual patients to prevent stigmatizing behaviours.

A qualitative study of perceived barriers and facilitators to interrupting sedentary behavior among adults living with obesity

Introduction

Both obesity and sedentary behavior (SB) are associated with negative health consequences including cardiovascular disease, diabetes, certain cancers and all-cause mortality. To date, perceived barriers and facilitators to interrupting SB in adults living with obesity have not been identified.

Objective

This study aimed to identify these perceived barriers and facilitators by conducting a behavioral analysis underpinned by the theoretical domains framework (TDF) and the Capability, Opportunity, Motivation-Behavior (COM-B) model to enhance knowledge and inform future intervention development.

Methods

A purposive and snowball sample (N = 21) of adults living with obesity took part in semi-structured interviews, guided by the TDF, to investigate perceived barriers or facilitators to interrupt SB. Transcribed interviews were inductively coded using reflexive thematic analysis. Key themes and subthemes were generated by grouping similar and recurring codes. Finally, subthemes were mapped to the TDF and COM-B.

Results

Five key themes were identified, which influence SB across all domains of living. These relate to (i) physical and mental wellbeing; (ii) motivational readiness; (iii) roles, responsibilities and support; (iv) weight bias and stigma; and (v) the environment. These themes were then deductively mapped to all 14 TDF domains and all six of the COM-B constructs.

Conclusion

A complex interplay of individual, societal and policy factors contributes to the development and habituation of SB patterns in adults living with obesity. Factors identified in this study could assist in the development of interventions, strategies and policies designed to interrupt or reduce sedentary behavior in this population.

Experiences of Vegans with General Practitioners in the Austrian Health Care System: A Qualitative Study

This article explores the factors influencing the choice of general practitioners (GPs) and their role in the health care of vegans in Austria. The number of people identifying as vegan is on the rise, and GPs are increasingly confronted with vegan patients. A qualitative method was chosen for this study, and 14 semi-structured interviews with vegans were conducted between April 2022 and July 2022. Participants were recruited primarily through vegan social media groups. In their experiences with health care, vegans felt treated unequally or sometimes incorrectly. The experiences described highlight that participants felt that most GPs were biased against their veganism. Information exchange among vegans primarily takes place online and through publications of vegan associations, while GPs play a minor role in information provision. As the number of vegans grows, an appreciative way of communicating between GPs and vegan patients ought to be promoted. Voluntary interdisciplinary nutritional training, collaboration of the medical field with support organizations, provision of evidence-based information, and collaboration with dietitians and nutritionists could enrich the care of patients with a vegan diet.

Changing the global obesity narrative to recognize and reduce weight stigma: A position statement from the World Obesity Federation

Weight stigma, defined as pervasive misconceptions and stereotypes associated with higher body weight, is both a social determinant of health and a human rights issue. It is imperative to consider how weight stigma may be impeding health promotion efforts on a global scale. The World Obesity Federation (WOF) convened a global working group of practitioners, researchers, policymakers, youth advocates, and individuals with lived experience of obesity to consider the ways that global obesity narratives may contribute to weight stigma. Specifically, the working group focused on how overall obesity narratives, food and physical activity narratives, and scientific and public-facing language may contribute to weight stigma. The impact of weight stigma across the lifespan was also considered. Taking a global perspective, nine recommendations resulted from this work for global health research and health promotion efforts that can help to reduce harmful obesity narratives, both inside and outside health contexts.

Primary care-led weight-management intervention: qualitative insights into patient experiences at one-year follow up

INTRODUCTION

The global prevalence of overweight and obesity is continuously increasing. Long-term weight loss results remain disappointing. This study aims to identify factors and strategies for successful long-term weight loss in a primary care-led weight-loss intervention from the perspective of participants.

MATERIALS AND METHODS

This qualitative interview study is the first follow-up study in a 2-year study series of participants with overweight or obesity. Methods utilized are semi-structured interviews (n = 20) with quantitative self-description. The data were transcribed from audio-taped interviews and analysed thematically.

RESULTS

This study found that clear, continuously evolving self-monitoring strategies facilitated by strong routines and a long-term focus enhanced successful outcomes. Challenges faced included stress, disappointment and loss of routine along with external criticism and discouragement. Benefits experienced due to weight loss included improved health, self-esteem, communal support and encouragement, which continued to fuel motivation. Receiving continuous support and encouragement from healthcare practitioners was instrumental for long-term success.

CONCLUSION

This study highlighted the complex, multifaceted experiences patients encounter in the pursuit of trying to achieve long-term weight loss. Personalized treatment protocols taking into account the diverse requirements and circumstances of individuals have the potential to improve treatment outcomes. Continuous, professional support may enhance long-term outcomes.

Weight stigma experienced by patients with obesity in healthcare settings: A qualitative evidence synthesis

Weight stigma research is largely focused on quantifiable outcomes with inadequate representation of the perspectives of those that are affected by it. This study offers a comprehensive systematic review and synthesis of weight stigma experienced in healthcare settings, from the perspective of patients living with obesity. A total of 1340 studies was screened, of which 32 were included in the final synthesis. Thematic synthesis generated three overarching analytical themes: (1) verbal and non-verbal communication of stigma, (2) weight stigma impacts the provision of care, and (3) weight stigma and systemic barriers to healthcare. The first theme relates to the communication of weight stigma perceived by patients within patient-provider interactions. The second theme describes the patients' perceptions of how weight stigma impacts upon care provision. The third theme highlighted the perceived systemic barriers faced by patients when negotiating the healthcare system. Patient suggestions to reduce weight stigma in healthcare settings are also presented. Weight stigma experienced within interpersonal interactions migrates to the provision of care, mediates gaining equitable access to services, and perpetuates a poor systemic infrastructure to support the needs of patients with obesity. A non-collaborative approach to practice and treatment renders patients feeling they have no control over their own healthcare requirements.

Obesity Stigma: Causes, Consequences, and Potential Solutions

PURPOSE OF REVIEW

This review aims to examine (i) the aetiology of obesity; (ii) how and why a perception of personal responsibility for obesity so dominantly frames this condition and how this mindset leads to stigma; (iii) the consequences of obesity stigma for people living with obesity, and for the public support for interventions to prevent and manage this condition; and (iv) potential strategies to diminish our focus on personal responsibility for the development of obesity, to enable a reduction of obesity stigma, and to move towards effective interventions to prevent and manage obesity within the population.

RECENT FINDINGS

We summarise literature which shows that obesity stems from a complex interplay of genetic and environment factors most of which are outside an individual's control. Despite this, evidence of obesity stigmatisation remains abundant throughout areas of media, entertainment, social media and the internet, advertising, news outlets, and the political and public health landscape. This has damaging consequences including psychological, physical, and socioeconomic harm. Obesity stigma does not prevent obesity. A combined, concerted, and sustained effort from multiple stakeholders and key decision-makers within society is required to dispel myths around personal responsibility for body weight, and to foster more empathy for people living in larger bodies. This also sets the scene for more effective policies and interventions, targeting the social and environmental drivers of health, to ultimately improve population health.

At home and at risk: The experiences of Irish adults living with obesity during the COVID-19 pandemic

BACKGROUND

People living with obesity are at elevated risk of hospitalisation, serious illness and mortality due to COVID-19. Little is known about their experience of living with obesity during the pandemic and its associated stay-at-home orders. This study sought to understand the experiences of people living with obesity during the COVID-19 pandemic.

METHODS

A stratified sample of Irish adults (n = 15) living with obesity engaged in open, phenomenological, interviews and a participatory photovoice methodology to capture both verbal and visual accounts of their experiences during the COVID-19 pandemic. Interviews, conducted throughout 2021, were transcribed verbatim and analysed thematically.

FINDINGS

Two overarching themes were identified. A) The pandemic and associated stay-at-home orders had a positive impact on the health and well-being of some participants; a negative impact on others; and this impact changed over time as the pandemic progressed. B) People living with obesity reported feeling stigmatised and 'othered' by their 'at risk' categorisation. Public health messaging and public discourse relating to obesity resulted in some people feeling segregated and punished by society.

INTERPRETATION

Changes in lifestyle initiated by the pandemic's stay-at-home orders had a varied impact on the health behaviours and outcomes of people with obesity. This variance offers helpful insight into the psychosocial aspects of obesity. Furthermore, the 'othering' effect of public health messaging during the pandemic warrants caution in light of the already stigmatised nature of this disease.

FUNDING

This study is part of the SOPHIA project which received funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No 875534.

Obesity in Adults: A 2022 Adapted Clinical Practice Guideline for Ireland

BACKGROUND

This Clinical Practice Guideline (CPG) for the management of obesity in adults in Ireland, adapted from the Canadian CPG, defines obesity as a complex chronic disease characterised by excess or dysfunctional adiposity that impairs health. The guideline reflects substantial advances in the understanding of the determinants, pathophysiology, assessment, and treatment of obesity.

SUMMARY

It shifts the focus of obesity management toward improving patient-centred health outcomes, functional outcomes, and social and economic participation, rather than weight loss alone. It gives recommendations for care that are underpinned by evidence-based principles of chronic disease management; validate patients' lived experiences; move beyond simplistic approaches of "eat less, move more" and address the root drivers of obesity.

KEY MESSAGES

People living with obesity face substantial bias and stigma, which contribute to increased morbidity and mortality independent of body weight. Education is needed for all healthcare professionals in Ireland to address the gap in skills, increase knowledge of evidence-based practice, and eliminate bias and stigma in healthcare settings. We call for people living with obesity in Ireland to have access to evidence-informed care, including medical, medical nutrition therapy, physical activity and physical rehabilitation interventions, psychological interventions, pharmacotherapy, and bariatric surgery. This can be best achieved by resourcing and fully implementing the Model of Care for the Management of Adult Overweight and Obesity. To address health inequalities, we also call for the inclusion of obesity in the Structured Chronic Disease Management Programme and for pharmacotherapy reimbursement, to ensure equal access to treatment based on health-need rather than ability to pay.