Are your staff callous to overweight patients?
Psychologists offer tips for improving sensitivity
In an age of increasing sensitivity toward race, gender, culture, disability, religion, and sexual orientation, fat people are the last socially acceptable targets of tasteless jokes, stereotypes, and off-handed cruelty. In fact, making fun of obese individuals is so ingrained in American society that even the most sensitive rehabilitation professionals will engage in the practice, according to two psychologists who are experts on obesity.
Discrimination and derision toward obese people is widespread, even as the population increasingly becomes overweight. For example, last year a San Francisco fitness club chain advertised on a billboard that featured a fierce-looking alien face. The caption read, "When they come, they will eat the fat ones first."
That prompted activists on behalf of obese people to lobby the city to include fat people among the groups protected by discrimination laws, according to a May 9, 2000, article in Reuters news service. So earlier this year, San Francisco’s Board of Supervisors unanimously voted to add body size to city laws that ban discrimination based on race, color, age, ancestry, religion, sex, disability, sexual orientation, place of birth, and gender identity. Similar laws exist in Washington, DC, Michigan, and Santa Cruz, CA.
First step is changing staff attitudes
While it may take many years to change the American public’s attitudes about weight and obese people, rehab facilities can do something more immediate about changing staff attitudes, suggests Judy Clementson, PhD, a psychologist with Madonna Rehabilitation Hospital in Lincoln, NE.
"Because of the stigma in our society, I don’t believe an obese person can heal emotionally while there’s an undercurrent of blaming them or stigmatizing them," Clementson says. "We see this as a form of sensitivity and diversity training. We make it clear that it’s not acceptable to be joking or gossiping or using malicious humor about obese patients."
After undergoing the sensitivity training, the Madonna Rehab staff became aware of unkind remarks, even those made by peers outside of their own hospital, Clementson notes.
For example, the rehab staff had a telephone conference call with peers at another rehab hospital. During the call, the other hospital’s staff made some jokes about fat patients and how much of a pain in the neck they were. When Madonna therapists told how they were able to treat some obese patients who entered the hospital in a wheelchair and left the hospital on their own feet, the response was, "You’re kidding! How did you manage that? I can’t imagine any of ours walking out," Clementson recalls.
"This was very demeaning and done in a collegial way," she adds. The Madonna staff were uncomfortable with the exchange because they no longer talk about obese patients in that manner. "The climate of our unit has really changed so that there’s more respect for obese patients, and the assumption now is that they’re here because they are medically ill and want to get better," she explains.
Cape Fear Valley Medical Center in Fayetteville, NC, also held an inservice for staff on being more sensitive to issues affecting obese patients.
"I think the general public views obesity as a will power issue, and people don’t recognize that it’s not related to will power," says Nicole A. Engel, PhD, a Chapel Hill, NC, clinical psychologist who has worked with overweight patients and gave the inservice at Cape Fear Valley.
"For very overweight people, not someone who has a desk job and gains 10 lbs, food is a coping strategy," Engel says. "It helps them with many things."
Clementson and Engel offer the following strategies for teaching rehab staff about becoming more sensitive to the needs of obese patients and how to help obese patients deal with their own shame and other issues regarding their weight:
- Discuss the causes of obesity.
"Many of our patients have metabolisms and lifestyles in which their weight doesn’t reflect the kind of gluttony that many people might expect," Clementson says. For example, recent research has shown that black women tend to have a lower metabolism than other women when they are at rest. That means they are more likely to gain weight at desk jobs or by spending time in front of the television or a computer.
Genes, viruses may cause obesity
Research has indicated that specific genes and even viral infections could play a role in whether someone is slender or obese. Children who experience physical, sexual, or emotional abuse also may be prone to becoming obese adults.
All of those factors contribute to what has become a societal problem. In American society, there is a great deal of emphasis on fast food, products containing refined sugars, snack foods, and sweetened soft drinks. Researchers are concluding that this type of eating trend has led to a fatter American population.
In populations such as in Asia, where people are typically lean, there is a general emphasis on eating fish, vegetables, and other foods that are not bought in grocery store packages.
- Consider the stereotypes and derision aimed at obese individuals.
"There’s an actual anger at obese people, and there’s a lot of blaming them for the problem," Clementson says. "Fat people are the last group we can displace our anger and alienation onto."
This contempt for obese people begins in early childhood, she notes. "When kindergarten and second grade students are asked to say what is true about a picture of an obese person, they will say the fat person is lazy, dishonest, and stupid. It’s in our culture that you are to blame for your weight."
Other studies of young students show that if they are asked which child would be their friend, and they are shown pictures of a fat child, a child in a wheelchair, children of different ethnic groups, and a child of normal weight, the children invariably select the fat child as their last choice, says Clementson.
Rehab professionals may be familiar with other research in which people with disabilities are asked whether they would trade their disability for a different one. Most respondents — including people with blindness, diabetes, and spinal cord injury — said they would keep the disability they had. The only exception were people whose disability was obesity. Most people in that group said they would trade their disability for something else, including amputation, blindness, or deafness, she says.
- Treat obese patients for depression and help them improve their self-esteem.
"There’s a lot of shame and issues of self-esteem in obese people, so helping obese people feel good about themselves and helping them to feel empowered is very important," Engel says. "Tackling eating problems and trying to change your lifestyle and change eating patterns, exercise patterns, and coping strategies takes a lot of energy. It’s hard to take care of yourself when you’re not feeling good about yourself."
Because many obese people have carried the burden of being overweight since childhood, their low self-esteem is ingrained. "They’ve suffered a lot of teasing and shaming about their body," Engel says.
Obese individuals often have suppressed their emotions to the extent that they may not be aware of their own anger and depression, Clementson says. "Part of a therapy goal is to increase their level of awareness of their feelings," she explains. "But the main goal is to increase their self-efficacy, a belief that you have the ability to cope with circumstances."
Severely obese people often have made multiple attempts to lose weight, and when those attempts ultimately failed, they learned to feel helpless about their obesity, Clementson says. Compounding that feeling of having no control over their bodies, she points out, is the message health care professionals give them: "There’s nothing we can do until you lose weight."
Hearing that message, obese patients stop speaking up about their pain and physical problems, which increases their feelings of depression.
Occupational therapists and physical therapists can help obese patients gain some successes physically through therapy. As patients become successful at the little steps, they will gain independence and become better able to manage their pain, Clementson suggests. "After they become physically stronger and are able to do more independently, including improving their grooming and hygiene, their self-esteem increases."
- Make malicious humor and gossip unacceptable in the rehab climate.
Obese individuals typically are very aware and sensitive to jokes and derision about their appearance. "We found early on that this group of patients knew everything that was being said and done," Clementson says. "They overhear a lot, so it’s obviously a part of staff training to maintain discretion and confidentiality."
She often tells rehab staff that because of an obese person’s early history, he or she will notice, hear, and be hurt by offhand comments or jokes that employees assume they didn’t hear. "Another part of staff training has been that in one or two rare instances, we have had staff members who, because of their own histories, have had very strong negative reactions to this patient group, and I really think that’s much more common than we like to think," she says.
- Explain how personal hygiene problems often occur in obese people.
Obese people sometimes have body odor that’s difficult to control even though they may bathe as frequently as normal-weight individuals, says Clementson. "If you’re on the nursing staff or therapy staff and have to have close physical contact with an obese patient, it can be difficult."
For example, nurses and other staff have gone into a few patients’ rooms and immediately suggested the patients shower. "The fifth time that happens in one day, it’s very hurtful," says Clementson.
To prevent staff from inadvertently hurting patients’ feelings, the hospital assigned one person, an occupational therapist, to be in charge of obese patients’ hygiene. That way, nurses know not to ask about showers because they know the personal hygiene issues are being addressed.
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