Shame and stigma in weight management during pregnancy and post bariatric surgery : perspectives of patients and healthcare providers

Sammanfattning: Background: Body mass index (BMI) increases across the world, yet there is an alarming lack of obesity prevention and treatments that are effective, harmless and available for everyone in need. Stigmatizing attitudes towards people with obesity and discrimination are widespread, adding to the individuals’ burden of medical risks. Achieving large and sustained weight loss by dieting and exercise alone, is extremely difficult. Bariatric surgery is the most effective method for long-term weight loss success, but even after weight loss surgery, weight regain may occur. Thus, there is a need to explore both how patients may be supported to obtain best possible surgery outcome, but also to explore how obesity may be prevented. Excessive gestational weight gain (GWG) is associated with the development of obesity, both in women and offspring. In addition, excessive GWG increase the risk for adverse pregnancy events. Even with intervention programs developed to promote a healthy lifestyle and limit GWG, many pregnant women still gain excessively, indicating that there is room for improvement also in gestational weight management support. The overall aim of this thesis was to identify potential areas for improvement in two different existing weight interventions (bariatric surgery and gestational weight limiting interventions) focusing on communication and social interactions between patients and their health care providers, family and friends. Specific aims were: to characterize women’s perceived reasons for their excessive postpartum weight retention (I), to identify barriers and facilitators in communication about body weight in pregnancy from the perspective of midwives, and of women with obesity (II, III), and to explore perceived and preferred support in patients with weight regain after bariatric surgery (IV). Methods: All four studies were qualitative and explorative and used semi-structured interviews. Study I contains data from 15 women with ³10kg weight retention one year postpartum, about their perceived reasons for their unhealthy weight development. Study II explored how 17 midwives in maternity care initiate and discuss the topic of body weight with pregnant women. In study III, focus groups and individual interviews were used to collect data from 17 women of reproductive age with obesity, about their opinions and wishes regarding future weight management and treatment in maternity care. Study IV collected interview data from 16 patients who experienced weight regain after bariatric surgery, about how they perceived, and would have preferred to be supported by family, friends and health care. Qualitative data from study I and II were analysed using manifest and latent content analysis respectively. Thematic analysis was used to process the data from study III and IV. Results: In study I, women commonly used eating as a way to relieve both psychological and physical discomfort, e.g., pain, nausea, stress or depression. Women perceived midwives as unconcerned about weight, and believed that own lack of knowledge about GWG recommendations, misconceptions about the feasibility of postpartum weight loss, barriers to physical activity, and lack of weight management support, contributed to their excessive postpartum weight retention. In study II, all midwives acknowledged obesity and excessive weight gain as important health risks that should be addressed in pregnancy. Meanwhile, several midwives found it hard to combine their professional tasks, i.e., talking about body weight with women with obesity, while also trying to attend to women’s emotional needs. As a result, some midwives avoided the topic of body weight so as not to cause concern, induce shame or make pregnant women feel guilty. Midwives wished to receive education about obesity, training in communication skills, and access to supervision in complicated cases. Both midwives and women in study I and III desired access to dieticians, physiotherapists and psychologists/ counsellors. In Study III, most women described that they wanted information about risks and recommendations regarding weight gain in pregnancy. However, it was emphasized that discussions about body weight need to be conducted in a respectful manner, and nonjudgmental atmosphere, or else women may "close their ears" to advice and information. Women suggested that midwives should ask for permission to talk about body weight, assess women’s previous knowledge, assess any need for psychological support, focus on positive health messages, use words like BMI and weight category (as opposed to obese or obesity), and offer individualized advice if women wanted it. In study IV, patients with weight regain experienced the years following bariatric surgery as a lonely struggle, where unfavourable treatment or lack of support increased the feeling of abandonment. Other people were seen as both positive sources of acceptance, compassion and respectful treatment, as well as sources of external control functions (primarily health care providers) that may facilitate the maintenance of healthy habits. Participants commonly blamed themselves for the weight gain. Shame and fear of being judged affected patients’ inclination to engage in social activities and seek medical care. Concrete actions (such as healthy eating or exercising together), empathetic treatment, pro-active healthcare and access to dieticians, physiotherapists and psychological support were desired. Conclusions: The shame associated with obesity or excessive GWG may constitute a salient communication obstacle in gestational weight management. Efforts may be needed to ensure that weight discussions are not avoided by midwives due to lack of time, material, obesity knowledge or communication skills. Self-blame and fear of stigmatizing treatment may lead to reluctance to seek medical help among patients with post-surgery weight regain. Pro-active follow-up, and increased knowledge in health care providers about causes of obesity and weight loss surgery procedures may be beneficial. Access to a multidisciplinary team may improve weight interventions as well as midwives’ work situation.