Caring for obese patients in a culturally safe way: obesity is a culturally constructed concept and nurses need to be culturally safe in their practice, when caring for those labelled obese.New Zealand's "obesity epidemic" has received large amounts of publicity in the media. Obesity undoubtedly can cause multiple health problems for individuals; however, a focus on obesity as solely a health problem to be treated, can lead to less than optimal nursing care. Nursing's notions of obesity and the need for treatment are shaped by a culture located within "western" views of ideal body shape, a biomedical bi·o·med·i·cal adj. 1. Of or relating to biomedicine. 2. Of, relating to, or involving biological, medical, and physical sciences. idea of obesity as disease, and obese people as the cause of their own health problems. We suggest nurses, while not ignoring the potential for health problems that obesity can cause, embrace the cultural safety tenant of nursing "regardful re·gard·ful adj. 1. Showing attention; heedful. 2. Showing deference; respectful. re·gard  ful·ly adv. " of
difference, when providing care for such patients.
Obesity is defined by a body mass index (BMI BMI body mass index. BMI abbr. body mass index Body mass index (BMI) A measurement that has replaced weight as the preferred determinant of obesity. ) where weight is adjusted for height, although other measures are used, such as the waist to hip ratio, which measures abdominal fat accumulation, and the waist circumference. (1,2) Links with socio-economic inequalities Obesity affects males and females and is more prevalent for Pacific Island and Maori than other ethnic groups. (3) Significant markers for obesity are emerging, eg ten percent of school age children in New Zealand New Zealand (zē`lənd), island country (2005 est. pop. 4,035,000), 104,454 sq mi (270,534 sq km), in the S Pacific Ocean, over 1,000 mi (1,600 km) SE of Australia. The capital is Wellington; the largest city and leading port is Auckland. have been found to be obese, and there are links to socio-economic inequality. In global terms, New Zealand is considered to have a relatively high rate of obesity, sitting only fourth behind the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. (US), the United Kingdom and Australia. (3) It is estimated that almost half of New Zealand's adult population is already either overweight or obese. The explanation given for such statistics includes sedentary lifestyles and the consumption of energy rich foods and drink, resulting in a positive energy balance, which leads to excess body weight. (4) There are a number of chronic and disabling conditions associated with obesity. These include diabetes mellitus diabetes mellitus Disorder of insufficient production of or reduced sensitivity to insulin. Insulin, synthesized in the islets of Langerhans (see Langerhans, islets of), is necessary to metabolize glucose. In diabetes, blood sugar levels increase (hyperglycemia). type 2, ischaemic heart disease Ischaemic (or ischemic) heart disease, or myocardial ischemia, is a disease characterized by reduced blood supply to the heart. It is the most common cause of death in most western countries. Ischaemia means a "reduced blood supply". , stroke and some cancers. (5,6) These conditions are generally highlighted in media reports on obesity. However, there are other debilitating de·bil·i·tat·ing adj. Causing a loss of strength or energy. Debilitating Weakening, or reducing the strength of. Mentioned in: Stress Reduction conditions which can lead to a reduced quality of life. These include osteo-arthritis, gall bladder gall bladder, small pear-shaped sac that stores and concentrates bile. It is connected to the liver (which produces the bile) by the hepatic duct. When food containing fat reaches the small intestine, the hormone cholecystokinin is produced by cells in the intestinal disease, respiratory, fertility and skin problems. (6) While the medical conditions See carpal tunnel syndrome, computer vision syndrome, dry eyes and deep vein thrombosis. that can arise from obesity make for somewhat alarming reading, being obese can result in stigma, reduced job and social opportunities, lowered self esteem, and can lead to clinical depression. (6,7) Nurses need to be aware of their own values in relation to obesity, to avoid stigmatising obese patients. Obesity has been the focus of media attention in the last few months. There is much discussion in the media currently around obesity and being overweight. (8,9,10,11,12) The term "epidemic" has been used uncritically in nearly all media reports and in the government, nursing and medical literature we reviewed. (1,2,6,13) In New Zealand, the notion that there is an obesity "epidemic" is based on an increased number of observed shifts in BMI, which is used as an indicator of excess body weight. Acceptable body shape is culturally constructed. In "western" societies a strong cultural value is placed on thinness, especially for women. This valuing of thinness is a contemporary value, as a perusal of any museum or art gallery will attest. Famous masters provide evidence of acceptance and celebration of what we might describe today as "large': The sizes represented there would not make the covers of most women's magazines this is a list of women's magazines, magazines that have been published primarily for a readership of women. Currently published
Cultural interpretations There are also differences in interpretation between cultures. In the US, Black Americans, Caucasian Americans and Latino Americans often hold differing beliefs towards obesity from health care professionals. (14) Two American health American Health Inc. is a company that manufactures health supplements. It is located in Holbrook, New York. One of its products is labeled the "Chewable Original Papaya Enzyme" with the attached registered trademark, "The 'After Meal Supplement'". researchers found that culture played a significant role in how obesity was viewed within and between cultures. One of their main findings was the assumption that obesity can be universally measured and understood. The researchers suggested this needed to be challenged. Black Americans believed obesity to be positively related to attractiveness and sexual desirability, which contrasted greatly with Caucasian Americans, who viewed obesity in a negative way. The researchers concluded that these differences illustrated potential threats to effective communication between health care professionals and the people they were caring for, and that health care professionals must be responsive to the beliefs of their patients. (14) It is likely New Zealand health care professionals, including nurses, also have different values about body size than many patients. Obesity as a 'disease' The culture of nursing is partly based within a biomedical model The biomedical model of medicine, has been around since the mid-nineteenth century as the predominant model used by physicians in the diagnosis of disease. This model focuses on the physical processes, such as the pathology, the biochemistry and the physiology of a disease. which views obesity as a "disease" to be treated. One nursing article goes so far as to state that "generally, the obese patient is a compulsive eater" and that "self doubt plagues their livelihoods, their social lives and their relationships". (15) Although this may be viewed as an extreme judgment, viewing obesity as a disease and obese patients as persons with "uncontrollable urges" can be translated into the care that nurses provide. While obesity may be medically problematic, the labeling of people as "obese" locates the person as their disease and, by implication, makes then solely responsible for their ill health. This association can lead to viewing people who are obese as undeserving of health care. Although there is a complexity of causation of obesity, (6) there is anecdotal evidence anecdotal evidence, n information obtained from personal accounts, examples, and observations. Usually not considered scientifically valid but may indicate areas for further investigation and research. that people who are obese are judged on their obesity by health care professionals, including nurses, and receive lesser health care. A qualitative New Zealand study of self identified larger bodied women found they experienced stigma and discrimination by nursing and medical professionals. (16) The study found dieting was the intervention suggested by many health care professionals, even though obesity, for many, results from years of such dieting. (16) It seems that people are treated as creators of their own unwellness. The judgments made by nurses and other health care professionals can lead to people avoiding contact with health care professionals, ironically resulting in poorer health outcomes. Cultural safety is premised on the notion that culture includes people who differ from nurses by age, gender, disability, socio-economic status, immigrants, religious or spiritual differences and ethnicity. (17) Therefore any person who stands before nurses as a client or user of the service is likely to differ from nurses. Nursing has a unique culture with associated culturally constructed beliefs, skills and attitudes. By viewing obesity as a disease we do not acknowledge the cultural, social or economic determinants of obesity. Nursing needs to broaden the concept of the categories of difference to respond in a culturally safe way to obesity. Cultural safety also asks that nurses care for people "regardful" of difference. This means nurses must reflect on the care we give, so we are not merely replicating the biomedical model. As nurses, we are required to ensure we do not stereotype or judge others, or "victim blame" those who are unwell. (18) In the case of obesity this requires nurses to examine the "evidence" provided about obesity. For example, we have shown that lay literature and health articles tend to focus on the health problems associated with obesity, but, as culturally safe nurses, we also need to examine our own beliefs and attitudes and how these may affect the person identified as overweight or obese. Cultural safety suggests that nurses should not demean de·mean 1 tr.v. de·meaned, de·mean·ing, de·means To conduct or behave (oneself) in a particular manner: demeaned themselves well in class. , diminish or disempower dis·em·pow·er tr.v. dis·em·pow·ered, dis·em·pow·er·ing, dis·em·pow·ers To deprive of power or influence. dis clients. (19) Additionally, nurses must value and respect those who differ from us, so they are not placed at cultural risk, but feel safe within health services health services Managed care The benefits covered under a health contract . People who feel demeaned, diminished or disempowered will not use services again and this can affect their health. Nurse-led clinics offer an opportunity for practices based on nursing values of care and cultural safety. Such clinics are based on nursing's social model of health, rather than a biomedical, disease-focused model. Such clinics have been suggested as one way of practising in a better way with people who are obese. (5,16) Nurse-led clinics are important in the delivery of primary health care, where obesity management can be discussed prior to adverse health issues arising. They can also afford a deeper understanding of the complex issues, causes and effects of obesity on the individual and their families. Nurse-led clinics may also be useful in providing an alternative venue for people who are identified as obese or overweight to go, where non-judgmental care can be provided. This is vital, as increasing self esteem makes patients less likely to give up the programmes designed for them, and such support is a key to success. (5) The culturally constructed views of obesity can lead to less than optimal nursing care for patients. While there is evidence that obesity can lead to poor health outcomes, negative nursing views of such people can also lead to poor care. Nursing is in a unique position to provide care based on the principles of cultural safety. Such care would, we believe, lead to better health outcomes for people who are obese. This article was reviewed by Kai Tiaki Nursing New Zealand's practice article review committee in April 2007. References (1) Ministry of Health. (2004) Tracking the obesity epidemic New Zealand (1977-2003). Wellington: Author. (2) Ministry of Health. (2006) Embodying social rank: How body fat varies with social status, gender and ethnicity in New Zealand. Wellington: Author. (3) Ministry of Social Development. (2006) Obesity, Social report, http://www.socialreport.msd.govt.nz. Retrieved 13/11/06. (4) Ministry of Health. (2004) A portrait of health; Key results of the 2002/03 New Zealand Health Survey. Wellington: Author. (5) Brown, N. (2004) Fighting fat [Electronic version]. Practice Nurse; 28: 6, 63-69. (6) New Zealand Health Strategy. (2001) DHB DHB District Health Board (New Zealand) DHB Deutscher Handball Bund (German) DHB Deutschen Hausfrauen-Bundes (Darmstadt) DHB DHB Capital Group, Inc. Toolkit: Obesity: To reduce the rate of obesity. [Electronic version] www.newhealth.govt.nz/toolkits/obesity/Obesity. Retrieved 11/11/06. (7) Paquette, M. & Raine, K. (2004) Sociocultural so·ci·o·cul·tur·al adj. Of or involving both social and cultural factors. so  ci·o·cul context of
women's body image {Electronic version}. Social Science and
Medicine; 59: 5, 1047-1058.
(8) $67 million for anti obesity campaign. (2006, September 21). The New Zealand Herald; APN APN abbr. advanced practice nurse News & Media: Auckland. p3. (9) Watson, C. (executive producer) (2006, October 11) Breakfast [Television broadcast]. Auckland: TV One. (10) Watson, C. (executive producer) (2006, November 15) Breakfast [Television broadcast]. Auckland: TV One. (11) Spratt, A. & Ussher, J. (2006, November) The Big Picture. New Zealand Listener. APN Holdings: Auckland. p 14-20. (12) NZ can lead fat battle, (2006, September 27) The New Zealand Herald; APN News & Media: Auckland. p6. (13) Wilson, N., Watts, C., Signal L. & Thomson, G. (2006) Acting upstream to control the obesity epidemic in New Zealand. The New Zealand Medical Journal; 119: 1231, 1-6. (14) Davidson, M. & Knafl, K. A. (2006) Dimensional analysis dimensional analysis Technique used in the physical sciences and engineering to reduce physical properties such as acceleration, viscosity, energy, and others to their fundamental dimensions of length, mass, and time. of the concept of obesity [Electronic version]. Journal of Advanced Nursing; 54: 3,342-350. (15) Obesity Epidemic [Electronic version]. (2005) The New Mexico New Mexico, state in the SW United States. At its northwestern corner are the so-called Four Corners, where Colorado, New Mexico, Arizona, and Utah meet at right angles; New Mexico is also bordered by Oklahoma (NE), Texas (E, S), and Mexico (S). Nurse; (Oct-Dec), 2. (16) Carryer, J. (2001) Embodied largeness: A significant women's health Women's Health Definition Women's health is the effect of gender on disease and health that encompasses a broad range of biological and psychosocial issues. issue. Nursing Inquiry; 8: 2, 90-97. (17) Nursing Council of New Zealand The Nursing Council of New Zealand (NCNZ) are the professional body responsible for the registration of nurses in New Zealand, setting standards for nursing education and practice. The council was established in 1902. . (2002) Guidelines for cultural safety, the Treaty of Waitangi The Treaty of Waitangi (Māori: Tiriti o Waitangi) is a treaty signed on February 6, 1840 by representatives of the British Crown, and Māori chiefs from the North Island of New Zealand. and Maori health in nursing education and practice. Wellington: Author. (18) Ramsden, I, (1996) The Treaty of Waitangi and cultural safety: The role of the Treaty in nursing and midwifery midwifery (mĭd`wī'fərē), art of assisting at childbirth. The term midwife for centuries referred to a woman who was an overseer during the process of delivery. In ancient Greece and Rome, these women had some formal training. education. Guidelines for Cultural Safety in Nursing and Midwifery Education in Aotearoa. Wellington: Nursing Council of New Zealand. (19) Wood, P. & Schwass, M. (1993) Cultural safety: A framework for changing attitudes. Nursing Praxis in New Zealand; 81: 1, 4-15. Margaret Hughes, RN,BN,PGDip Health Systems Man., MBS See Mb/sec. MBS - mobile broadband services , PGCert (nursing), Cert. Adlt. Tchg, was a senior nursing lecturer at Christchurch Institute of Technology (CPIT CPIT Continual Process Improvement Team CPIT C3I System Program Integration Team CPIT Cockpit ) when she co-wrote this article. She now works as a resource writer at Careerforce. Tony Farrow farrow see farrowing. , RN, BN,Dip Health (Mental Health Nursing), MHSc, Grad. Cert. Higher Ed, is a senior nursing lecturer at CPIT. |
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