Bariatric Times

APR 2017

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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10 Brief Report Bariatric Times • April 2017 BACKGROUND The literature is replete with reports of "weight bias" or the "stigma of obesity," terms used to describe the negative weight-related attitudes and beliefs that are manifested by stereotypes, rejection and prejudice towards individuals because they have overweight or obesity. 1 Individuals with obesity are often negatively perceived as weak- willed, lazy, unmotivated, unsuccessful and/or unintelligent people who have poor will-power, lack self-discipline, and are nonadherent to weight loss treatment. 2 Research suggests that the prevalence of weight bias has increased, rather than decreased in recent years. 3 Weight bias has been documented in all settings, such as places of employment or within the family. 4 Most recently Puhl, et al 5 reported data from 461 patients with obesity of whom 91.5 percent reported experiencing weight stigma. Healthcare professionals have exhibited weight bias against their patients with obesity as well. For example, Hebl and Xu 6 found that physicians prescribed more tests for, spent less time with, and viewed patients with obesity more negatively than patients without obesity. Bertakis and Azari 7 found that obesity and the length of appointment were not significantly associated; however, whether the patient had obesity did influence the content of the visit. Foster et al, 8 studying 620 physicians, reported that "more than 50 percent of physicians viewed patients with obesity as awkward, unattractive, ugly, and noncompliant." Schwarz et al 9 found that what they called the "anti-fat bias" was significant, even among these healthcare professionals who worked with patients with obesity or researched obesity. Ogden et al, 10 noted that general practitioners blamed a patient's obesity on the patient and felt that the patient held the solution to losing weight. They noted that healthcare professionals may fall victim to a common societal assumption—the idea that individuals with obesity are the "architects of their own ill health" and are personally responsible and to blame for their weight. While previous studies have demonstrated bias against individuals with obesity, the focus has generally been on the existence, source, and manifestation of bias, rather than what the patient experiences as a result of having obesity. Understanding the experience from the patient's perspective might aid in decreasing negative attitudes. Hearing the accounts of patients with obesity may help dispel the bias held by both the general public and healthcare providers. In this article, we recount patient perspectives regarding the pain, indignity, and actual suffering related to obesity, w hich, in many cases, led to seeking relief through surgery. CURRENT STUDY In a qualitative study reported in 2016, 11 we conducted interviews with patients with obesity and their spouses who had undergone bariatric surgery within the past year. The study was designed to elicit their perceptions of how the surgery had affected their couple relationship. During the interviews, the participants revealed interesting and sometimes heartbreaking experiences related to their own psychological or physical pain and suffering attendant upon the obesity. Their comments were reported in the following themes: devaluation of self, embarrassment in social situations, embarrassment about appearance, repeated failure of weight loss diets, frustration arising from limitations. Devaluation of self. One couple, both of whom had obesity, reported that when agreeing to marry their first (previous) spouse, they "settled" (i.e., they were not in love, but felt that because of their appearance, they would be unable to attract anyone more desirable as a mate). Thus, they "settled" for the person who was available to them. These marriages both ended in divorce. Embarrassment in social situations. One postoperative participant reported that prior to his bariatric surgery he went to an amusement park with his family. While waiting for a ride, the attendant required him to move to the very back in order to "balance the weight distribution." Then, he felt embarassed when he had trouble closing the safety bar on the seat because of his size. He said, "Everybody else was already in, ready to roll, and I'm trying to get it locked, and it won't fit, and they're like, 'We've got to unlock everybody and let the fat guy off.' I had my head all down, like, "Don't look at me." It was embarrassing. It was horrible. It made m e feel miserable. I didn't want to go back after that trip." Embarrassment about appearance. This same participant also reported that he was embarrassed by having to go to the section of the department store reserved for "big men" because he found very little selection in larger sizes. Another participant's spouse noted about his wife, "We couldn't go places because she didn't have anything that she felt comfortable wearing without feeling like a beached whale." Another participant worked in an industrial environment that was hot and she perspired a lot. She reported that she simply stopped trying to take care of her appearance, noting, "Well, I'm going to look like a walking whale, and it doesn't matter what I look like. It doesn't matter whether I do my hair or not. It doesn't matter whether I do my makeup." Repeated failure of weight loss diets. Evidence suggests that patients with obesity have tried weight loss diets, often repeatedly. In many patients, these efforts fail. 13 The spouse of one participant said of his partner, "this (bariatric surgery) is your last option. Those diets and everything you tried have ended in failure. Surgery is your last chance. You can go through the rest of your life being "large Marge" or you can try again to do something about it." Frustration arising from limitations. Being unable to do what a person sets out to do is frustrating. One participant was quite disabled because of the co-morbidities associated with his obesity. He was unable to stand for even a short period of time, and this meant that he could not do the things that men normally do in a couple relationship, such as help his spouse do home repair projects. This caused him distress and he jokingly referred to his spouse as "having to do by MARY LISA PORIES, PhD, LCSW, and MARY ANN ROSE, MSN, EdD Bariatric Times. 2017;14(4):10–11. FROM STIGMA TO EMPATHY: Reframing Our View of the Bariatric Patient ABSTRACT In this article, the authors examine the stigma of obesity from the patient perspective and suggest strategies for stigma-reduction. The authors report the results of qualitative interviews conducted among 10 patients with obesity and their significant others, which r evealed indignities and stressful situations experienced as a result of their obesity. Patient experiences were reported in the following themes: devaluation of self, embarrassment in social situations, embarrassment about appearance, repeated failure of weight loss diets, frustration arising from limitations. Patient accounts reflect the indignity and suffering of obesity and should thus help mitigate the negative attitudes toward individuals with obesity. The authors review the litrature on obesity stigma in the healthcare setting and offer strategies for overcoming negative attitudes in both an interpersonal and system-wide basis KEYWORDS Obesity, weight bias, discrimination, stigma, suffering, negative attitudes, patient perspective

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