A new understanding of stigmatised groups?

Natasha Hill, Hannah Jerome and Anna Smith consider the impact of Covid-19 on vulnerable bariatric patients.

There has been a huge shift in the nation’s recognition of the value and skills of essential workers, particularly in professions that may not have been appreciated prior to the Covid-19 pandemic (e.g. retail workers and carers). Following the crisis, will there be a similar shift in the nation’s perception of the needs and vulnerabilities of previously stigmatised patient groups? The potential challenges and opportunities that bariatric patients, and the NHS teams that support them, may face as a result of Covid-19 will be considered. 

Bariatric surgery and patients

In the UK, bariatric surgery is a treatment available to individuals living with severe obesity (categorised as a BMI of over 35) and associated health comorbidities. Often seen as a “last resort”, this life-altering surgery requires significant behaviour change, commitment, and adjustment. Typically, patients seeking bariatric surgery are a highly stigmatised group who experience weight related discrimination across education, work and healthcare settings (Puhl & Brownell, 2012). They experience increased levels of mental health difficulties such as anxiety, depression, and personality disorders, as well as a higher incidence of physical, sexual, and emotional abuse when compared to the general population (Ratcliffe, 2018).

Psychologists embedded within the MDT hold different responsibilities: supporting patients pre and post-surgery with behaviour change interventions and advocating for the specialist psychological needs of bariatric patients (Ogden et al., 2019). There is overwhelming evidence for the benefits of bariatric surgery for patients and the NHS. It improves physical and mental health and alleviates many financial pressures intrinsic to the comorbidities related to obesity, such as type II diabetes. Despite these advantages, bariatric surgery is an elective procedure, and so has been suspended during Covid-19, with many staff redeployed to other areas. 

Challenges 

Although there is uncertainty as to what the 'new normal' may look like, it is expected that there will be medium to long term shifts in staff roles and NHS priorities beyond the peak of the virus. As an elective procedure, bariatric surgeries are unlikely to be a focus, and patients awaiting surgery can expect major delays as other surgeries (e.g. cancer) take precedence. 

The deprioritisation of bariatric surgery, alongside media coverage of obesity as a risk factor for worse outcomes in people with Covid-19 (Stefan et al., 2020), may perpetuate weight stigma and reinforce patients’ perception that they are a devalued group. External devaluation is intrinsically linked with internal devaluation and is likely to further worsen bariatric patients’ self-evaluation and self-esteem (Ratcliffe & Ellison, 2015). This can have a negative impact on problematic eating behaviours, weight management, mood, and levels of anxiety (Ratcliffe & Ellison, 2015). In the months to come, staff who ordinarily work with bariatric patients, and who may have been redeployed have a responsibility to reflect on their role in the narrative of bariatric surgery within the NHS and those who seek it being 'unimportant'.

In addition to potentially lower self-esteem, internalised weight stigma and its consequences, bariatric patients may have struggled to implement or maintain essential weight management behavioural changes, as explained by the Capability Opportunity Motivation-Behaviour framework (Michie, van Stralen & West, 2011). The anxiety and fear generated by Covid-19 may have overwhelmed psychological capacity to engage in behaviours for preparation for surgery. Opportunities to take part in physical activity and purchase foods in line with dietetic guidance may have been limited. Motivation towards behaviour change for surgery may have been impaired due to the cancellation of surgery dates, lack of contact with the MDT and shifting NHS priorities and will likely continue to do so in the coming months. 

Faced with the challenges of this 'new normal', bariatric psychology teams will have to consider how they balance their roles. On the one hand, supporting staff and colleagues who have responded so valiantly to the crisis and, on the other, meeting the increased needs of bariatric services and patients. This may lead to clinicians feeling disconnected, overwhelmed, pulled between priorities, and never quite feeling like they are doing the 'right thing'.

Opportunities 

Despite these anticipated difficulties, the 'new normal' of life following the pandemic may offer opportunities for evolved relationships between bariatric patients, MDTs and (hopefully) the general population. 

Restrictive measures resulting from Covid-19 have led to a major shift in daily functioning for a large proportion of people: no longer leaving the house unless doing so is essential, experiencing social isolation and loneliness, restrictions on activities and financial uncertainty. However, these experiences are not new for many bariatric patients whose physical health, size, and exposure to weight stigma can mean living an restricted life (Friedman et al., 2008). Looking forward, hopefully the collective national insight into the difficulties of living an isolated life might invite more understanding and compassion of those for whom this 'new normal' is, in fact, not new at all.                     

Moreover, as the nation experiences higher levels of anxiety and uncertainty, it is anticipated that there may be a greater collective insight into how food can be used as a way to manage difficult emotions, particularly without access to their normal coping mechanisms (van Strien, 2018). This may generate more consideration for the overestimated autonomy attributed to bariatric patients for their weight and accompanied co-morbidities, challenging the idea that they simply lack willpower (Wott & Carels, 2010).

Unanswered questions from the 'new normal'

The disruptions Covid-19 has caused in the daily lives of society reflect some of the challenges that bariatric patients experience ordinarily. This shared experience of suffering, albeit to varying degrees, raises questions regarding this vulnerable group. Will it enable a deeper sense of compassion towards them? Will there be an increased sense of common humanity and shared suffering? Or will stigma, blaming, and distancing, both social and emotional, of a group who are viewed as responsible for their own health vulnerabilities increase? How will this be reflected in the care that the NHS provides? 

As the 'new normal' unfolds the answers to these questions will become apparent. Whatever the outcomes, psychologists in bariatric services should continue to promote and nurture connection and compassion within and between MDTs, bariatric patients and the NHS.

Natasha Hill, Chelsea and Westminster Hospital, Twitter: @Natashapsych1

Dr Hannah Jerome Twitter: @drhannahjerome

Dr Anna Smith, Chelsea and Westminster Hospital, Twitter: @drannazsmith

References

Friedman, K. E., Ashmore, J. A. and Applegate, K. L. (2008). Recent experiences of weight-based stigmatization in a weight loss surgery population: psychological and behavioral correlates. Obesity, 16, 69–74.

Michie, S., van Stralen, M. M., & West, R. (2011). The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation Science : IS, 6, 42. https://doi.org/10.1186/1748-5908-6-42

Ogden, J, Ratcliffe, D, Snowdon‐Carr, V. British Obesity Metabolic Surgery Society endorsed guidelines for psychological support pre‐ and post‐bariatric surgery. Clin Obes. 2019; 9:e12339. https://doi.org/10.1111/cob.12339 

Puhl, R.M. and Brownell, K.D. (2006), Confronting and Coping with Weight Stigma: An Investigation of Overweight and Obese Adults. Obesity, 14: 1802-1815. doi:10.1038/oby.2006.208

Ratcliffe, D., & Ellison, N. (2015). Obesity and Internalized Weight Stigma: A Formulation Model for an Emerging Psychological Problem. Behavioural and Cognitive Psychotherapy, 43(2), 239-252. doi:10.1017/S1352465813000763

Ratcliffe, D. (2018). Living with Bariatric Surgery: Managing Your Mind and Your Weight. Oxford, England: Routledge. 

Stefan, N., Birkenfeld, A.L., Schulze, M.B. et al. Obesity and impaired metabolic health in patients with COVID-19. Nat Rev Endocrinol (2020). https://doi.org/10.1038/s41574-020-0364-6

van Strien, T. Causes of Emotional Eating and Matched Treatment of Obesity. Curr Diab Rep 18, 35 (2018). https://doi.org/10.1007/s11892-018-1000-x

Wott, C. B. and Carels, R. A. (2010). Overt weight stigma, psychological distress and weight loss treatment outcomes. Journal of Health Psychology, 15, 608–614. 

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