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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 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" of difference, when providing care for such patients.

Obesity is defined by a body mass index (BMI) 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 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 (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 type 2, ischaemic heart disease, stroke and some cancers. (5,6) These conditions are generally highlighted in media reports on obesity. However, there are other debilitating conditions which can lead to a reduced quality of life. These include osteo-arthritis, gall bladder disease, respiratory, fertility and skin problems. (6)

While the medical conditions 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 as representations of what is considered desirable today.

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 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 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 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, diminish or disempower 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. 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.


(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, 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 Toolkit: Obesity: To reduce the rate of obesity. [Electronic version] Retrieved 11/11/06.

(7) Paquette, M. & Raine, K. (2004) Sociocultural 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 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 of the concept of obesity [Electronic version]. Journal of Advanced Nursing; 54: 3,342-350.

(15) Obesity Epidemic [Electronic version]. (2005) The New Mexico Nurse; (Oct-Dec), 2.

(16) Carryer, J. (2001) Embodied largeness: A significant women's health issue. Nursing Inquiry; 8: 2, 90-97.

(17) Nursing Council of New Zealand. (2002) Guidelines for cultural safety, the Treaty of Waitangi 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 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, PGCert (nursing), Cert. Adlt. Tchg, was a senior nursing lecturer at Christchurch Institute of Technology (CPIT) when she co-wrote this article. She now works as a resource writer at Careerforce.

Tony Farrow, RN, BN,Dip Health (Mental Health Nursing), MHSc, Grad. Cert. Higher Ed, is a senior nursing lecturer at CPIT.
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Title Annotation:EDUCATION
Author:Farrow, Tony
Publication:Kai Tiaki: Nursing New Zealand
Geographic Code:8NEWZ
Date:May 1, 2007
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