544908
research-article2014
QHRXXX10.1177/1049732314544908Qualitative Health ResearchOwen-Smith et al.
Article
“Vicious Circles”: The Development of
Morbid Obesity
Qualitative Health Research
1­–9
© The Author(s) 2014
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DOI: 10.1177/1049732314544908
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Amanda Owen-Smith1, Jenny Donovan1, and Joanna Coast2
Abstract
Although there has been extensive research around the etiology of moderate obesity, there are still important
questions relating to the development and lived experience of extreme obesity. We present a synthesis of data from
two in-depth qualitative studies in which morbidly obese participants (N = 31) were able to explain the development
of the condition in their own terms. We identified consistent themes in the two datasets, and undertook a detailed
data synthesis. Particularly salient themes in the development of morbid obesity related to family structures and early
socialization experiences, and the role of emotional distress was dominant in both initial weight gain and ongoing
cycles of loss and regain. All informants accepted some responsibility for their health state, but identified a number
of mitigating factors that limited personal culpability that were often related to the fulfillment of gendered social
expectations.
Keywords
comparative analysis; embodiment / bodily experiences; emotions / emotion work, interviews; lived experience; metaethnography; obesity / overweight; research, qualitative; social identity
Morbid obesity in adults is clinically defined as having a
body mass index (BMI) of at least 40kg/m2, or 35kg/m2
or greater in the presence of significant comorbidity
(National Institute of Health and Clinical Excellence
[NICE], 2006). Having a BMI within the morbidly obese
range is associated with a number of cardiovascular, metabolic, musculoskeletal, psychiatric, and respiratory disorders (Picot et al., 2009), and the mortality rate of adults
living with the condition is approximately double that for
those who are at a healthy weight (Bennett, Mehta, &
Rhodes, 2007). Approximately 2.1% of adults in the
United Kingdom live with morbid obesity, and it is estimated that prevalence will double over the next two
decades (Lobstein & Jackson Leach, 2007; National
Health Service [NHS] Information Centre, 2008).
Although prevalence data on morbid obesity are sparse,
World Health Organization (WHO; 2010) data on steeply
increasing rates of overweight and obesity across the
globe indicate the international nature of the problem and
underline the importance of obesity as a key international
public health concern.
The biological and social drivers behind the increase
in overweight and obesity are topics of ongoing interest
within both the academic and the popular literature.
Ecological and epidemiological studies have identified a
number of mechanisms that have contributed to the
increasing prevalence and severity of obesity. Particular
importance has been attached to broad social changes
such as alterations in the levels of physical activity customarily undertaken as part of occupational and leisure
pursuits, and the marketing practices of food manufacturers and distributors (Keith et al., 2006). Additionally,
increasing attention has been paid to investigating the
biological underpinnings of obesity, and in particular
identifying specific genes that predispose particular individuals to gain weight within favorable conditions—the
so-called obesogenic environment (Walley, Asher, &
Froguel, 2009).
Despite the international concern about the increasing
prevalence of obesity, qualitative evidence relating to its
development is surprisingly sparse, with few studies
focusing specifically on the experiences of the morbidly
obese. Reports of studies that are available identified factors such as pregnancy, physical illness, patterns of
socialization, and repeated dieting as important in the
development of severe overweight and obesity (Greener,
Douglas, & van Teiljlingen, 2010; Ogden, Clementi, &
Aylwin, 2006; Smith & Holm, 2011; Thomas, Hyde,
Karunaratne, Herbert, & Komesaroff, 2008; Throsby,
1
University of Bristol, Bristol, United Kingdom
University of Birmingham, Birmingham, United Kingdom
2
Corresponding Author:
Amanda Owen-Smith, School of Social and Community Medicine,
Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, United Kingdom.
Email: [email protected]
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Qualitative Health Research 
2007). Although these studies are useful in identifying a
number of core themes in the development of morbid
obesity, they were limited either by their reliance on predominantly female samples (Ogden et al., 2006; Throsby)
or their focus mainly on the experiences of those with
lower levels of obesity (Greener et al., 2010; Smith &
Holm, 2011; Thomas et al., 2008). This means that the
experiences of men and those with very high weights
were not explored in depth.
Those with a BMI falling within the morbidly obese
range are significantly more likely to experience comorbidities associated with their excess weight, with consequent impacts on health-resource usage and individual
quality of life (Picot et al., 2009). It is therefore important
to investigate the etiology of this extreme condition from
a qualitative perspective to gain insight into individual
perceptions of its development. Reports of qualitative
studies focusing on the lived experience of obesity have
revealed that the condition is often associated with a significant degree of psychological distress, which is partly
linked to experiences of stigma and social isolation
(Lewis et al., 2011; Thomas et al., 2008; Throsby, 2007).
Qualitative evidence on the experience of stigma by
obese individuals has been confirmed in large quantitative surveys undertaken in the United States. These surveys showed that obese individuals were vulnerable to
weight-related discrimination in a number of social
spheres, including employment, education, and accessing
health care (Puhl & Heuer, 2009; Puhl, Moss-Racusin,
Schwartz, & Brownell, 2008). Reports on the few studies
focusing on the experiences of extreme obesity (BMI in
excess of 35kg/m2) indicate that stigma becomes more
acute at higher weights (Lewis et al., 2011; Throsby,
2007), and a quantitative study in the United States
revealed that experiences of felt stigma increased in line
with BMI (Brewis, Hruschka, & Wutich, 2011). Here we
present a synthesis of data from two qualitative studies in
which both the development and the experience of living
with morbid obesity in men and women were explored in
depth.
Methodology
We took a qualitative approach to both studies, using indepth interviews to investigate individual experiences of
developing and living with morbid obesity. We undertook
the first study (Study 1) as part of a broader investigation
into patients’ experiences of implicit and explicit rationing, the core results of which have been published elsewhere (Owen-Smith, Coast, & Donovan, 2009, 2010).
We are undertaking the second study (Study 2) as part of
an ongoing longitudinal study investigating how clinicians communicate with patients about the availability of
treatment in the context of resource scarcity. Investigating
the development of morbid obesity was not one of our
explicit objectives in Study 1, and we primarily gathered
these data to provide a contextual backdrop to individual
experiences of accessing care. However, the richness and
complexity of emergent narratives meant that investigating the experience of the development of morbid obesity
became an important theme in the analysis, and we
included it as an explicit objective of Study 2 from the
outset.
In both studies, National Health Service (NHS) professionals involved in the provision of secondary care
weight management facilitated the identification of
potential contributors to the research. We then sent these
individuals invitations to participate or gave them information at weight-loss surgery clinics (Study 1 only). The
main inclusion criteria used for both studies were (a) that
individuals met the United Kingdom NICE criteria for a
diagnosis of morbid obesity (BMI of at least 40kg/m2, or
35kg/m2 in the presence of significant comorbidity), and
(b) that they had sought access to treatment for their condition. Individuals responded directly to us as the research
team; we had no prior access to personal information, and
therefore we could not follow up with nonresponders. In
both studies, our sampling became more purposeful as
the research progressed, to ensure that we included those
with a range of experiences of accessing care and that we
could follow up emerging themes.
We collected data in both studies using in-depth interviews conducted by the first author, mostly in participants’ homes. We used brief topic guides to ensure that
we covered all topics of interest and to enable us to compare between accounts, and digitally recorded and fully
transcribed all interviews. We conducted interviews
between December 2005 and April 2007 (Study 1), and
between July and November 2011 (Study 2). We obtained
ethical approval from the NHS Wales National Research
Ethics Service prior to any fieldwork being carried out.
All informants gave informed consent.
We continued sampling in both studies until we had
achieved an adequate understanding of themes important
to the core research objectives. In Study 1, clear themes
linked to the development and lived experience of morbid
obesity emerged but, because this was not an explicit
research objective, we did not pursue these to saturation.
We carried out more purposeful sampling as part of Study
2, to ensure that we could explore these themes in greater
depth and access the experiences of different groups
(Glaser & Strauss, 1967).
We analyzed the two datasets separately and the first
author later synthesized them. We used the constant comparative method as the primary analysis technique for
both datasets. This method is part of the grounded theory
approach recommended by Glaser and Strauss (1967),
and starts from the premise that theoretical constructs
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Owen-Smith et al.
should be built up from the data itself, rather than seeking
to impose any a priori hypothetical framework onto the
phenomenon under study. We read and reread transcripts
repeatedly to identify emerging themes, and the first
author wrote detailed descriptive accounts of the data.
This enabled us to identify relationships between themes
and to organize codes into hierarchical structures. We
used ATLAS.ti (Scientific Software Development, 1999)
to facilitate coding and data management. The third
author reviewed all analytic documents relating to Study
1, which the first author undertook as part of her doctoral
research. For Study 2 (which was a postdoctoral study),
we all met at frequent intervals to discuss the data and
emerging coding frameworks. We conducted data collection and analysis concurrently in each individual study.
The first author undertook the data synthesis. Given
the similarity in themes emerging from the two sets of
accounts, we adopted a reciprocal translation approach
whereby the themes identified in each dataset were reciprocally applied until a set of concepts able to explain the
complete dataset was achieved (Noblit & Hare, 1988).
Undertaking a reciprocal translation is recommended by
Noblit and Hare when two ethnographies address similar
topics of interest, meaning that the metaphors used in
each individual study can be reciprocally applied until a
comprehensive set of metaphors explaining the whole
data set is achieved. Here we report the results of this
synthesis and discuss the implications of these findings in
the context of other published studies. Although acknowledging that the number of participants who mentioned a
particular issue does not always equate with its social significance, we decided to include a limited number of data
counts in the reporting of results to assist in the intelligibility of findings to readers (Strauss & Corbin, 1990).
Results
We recruited 13 informants to Study 1 and 18 to Study 2
(N = 31). Eight participants, primarily in Study 1, had
undergone weight-reduction surgery at the time of interview, although only 1 had lost sufficient weight so that her
BMI was outside of the morbidly obese range at the time
of interview (see Table 1). Nine of the 31 informants were
men, and ages ranged from 23 to 60 years (see Table 2).
All informants provided complex and multifactorial
accounts of the development of their morbid obesity, and
nearly all had lived with the condition for many years.
The constant battle to lose weight was thus a core part of
the experience of living with morbid obesity, and some
said it had become a defining characteristic of their biography from an early age:
I can’t remember it [weight] not being a problem. . . . I think
I was big from a toddler, from a baby . . . It’s just always
Table 1. Weight History of Informants at Time of Interview.
Characteristic
Study 2
(n = 13)
Body Mass Index in morbidly obese range?
Yes
12
No
1
Had undergone weight loss surgery
Yes (National Health
3
Service)
Yes (Private Sector)
4
No
6
Length of time struggled with weight
< 10 years
1
10–19 years
3
20–29 years
5
30–39 years
3
> 40 years
1
Study 2
(n = 18)
Total
(N = 31)
18
0
30
1
1
4
0
17
4
23
0
5
7
4
2
1
8
12
7
3
Table 2. Demographic Characteristics of Informants.
Characteristic
Gender
Male
Female
Age Group (years)
<20
20–29
30–39
40–49
50–59
60+
Occupational Group
Nonmanual employment
Manual employment
Homeworker / carer
Retired
Unemployed
Study 1
(n = 13)
Study 2
(n = 18)
Total
(N = 31)
2
11
7
11
9
22
0
1
5
6
1
0
0
2
6
1
8
1
0
3
11
7
9
1
5
1
5
0
1
10
4
0
1
3
15
5
5
1
4
been an issue. . . . I joined my first diet class when I was
eight. (Study 1 [1], female [F])
Twenty-two informants reported having struggled
with their weight for more than 20 years. One informant
described a (fairly short) illness trajectory wherein she
had developed binge eating as a response to posttraumatic stress disorder. Her account was quite different
from the other informants, and she described the disruption that her short-term weight gain had had on her experience of her body:
Because I never had a weight problem until quite late on in
life, I’d have this thing where I’d suddenly walk past a
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Qualitative Health Research 
mirror and catch sight of myself and be really shocked.
Because to my mind, I was still a size ten. (1F)
Using the reciprocal translation technique (Noblit &
Hare, 1988), we identified some core themes running
through the majority of accounts, and we discuss these
below under the broad categories of “personal responsibility and the morality of health,” “the role of family
structure and the importance of gender,” “the role of emotional distress and the impact on the body,” and “vicious
circles and downward spirals.” These broad categories
were identified following repeated discussions within the
research team and numerous diagrammatical iterations of
the data to understand how previously identified themes
interacted and could most meaningfully be grouped.
Personal Responsibility and the Morality of
Health
We identified a number of core themes arising under the
category of “personal responsibility and the morality of
health.” These included individual attitudes toward culpability for health, factors mitigating individual culpability, and the importance of public and private accounts. In
accounts of obesity development, informants expressed a
constant struggle between accepting and rejecting personal culpability for weight gain, and nearly all felt that at
times they had unfairly been held culpable for their poor
health state by others: “I don’t eat a lot for the amount I
weigh” (1F). “I’ve got the sort of body which is difficult
to lose the weight” (Study 2 [2] male [M]). Many informants made admissions of culpability as part of a private
account of their behavior, and tended to reveal these in
later parts of the interview once the interviewer had
established rapport:
I was always fit, always healthy, never stopped. . . . We never
had sweets, we never had anything fattening . . . always up
[at] the gym. [Early in interview] . . . If I’m depressed I
might just eat toast all day. . . . I know that the last few years,
because of everything, crap going on, it [weight gain] is selfinflicted. [Later in the same interview] (1F)
Participants reflected on a number of personal and
social factors in periodic attempts to mitigate personal
responsibility for weight gain. These included childhood
socialization patterns, physical and mental illnesses,
pregnancy and caring responsibilities, working patterns,
failed dieting, and suppositions about familial traits and
genetic predisposition (see Figure 1). The need to find
reasons for their current health state was an important
issue for informants, and the construction of narratives
was often infused with anxiety and contradiction:
You think, “Is it my head? Can it be fixed with just my head,
[or] is there a real problem that could be treated? Is there a
reason why I’m susceptible to all this weight gain? Is there
something like a gene missing?” You know, you do think of
all these things and you hope that it is something, to keep
you sane, because otherwise you just think, “Why me? Why
can’t I just lose weight like a normal person?” (2F)
The Role of Family Structure and the
Importance of Gender
We identified a number of themes in the data that we
eventually included under the broad analytic category of
“the role of family structure and the importance of gender.” These included family histories of obesity, socialization practices, familial roles and weight gain, and the
gendered nature of obesity development. Although we
initially identified family structure and gender as discrete
themes in the analysis, we report them together here
because of the close interplay between the two themes in
informants’ accounts. This was particularly the case for
women, whose reflections on the importance of gender
roles in the development of their obesity were frequently
indistinguishable from their reflections on the importance
of their role in the family structure.
The majority of informants in both studies reported a
family history of obesity, and the roles of family structure
and childhood socialization patterns were key to many
accounts. However, nearly all those who had their own
children commented that they had been very careful not
to repeat their own negative socialization experiences:
My mum [mother] was one of twenty-three. You ate what
was on your plate. . . . With my two, as soon as they say
they’re full up, that’s fine. . . . I’ve had to change . . . because
I don’t want my kids [children] fat. (1F)
Nevertheless, 6 of the 23 informants who were parents
reported that their children had had problems maintaining
a healthy weight, and 4 said they had children who were
already morbidly obese. This was a source of extreme
distress and anxiety for all these informants, who reflected
at length on their own role in the development of their
children’s weight-management difficulties:
He’s [son, age 26] twenty-four stone [336 pounds]. . . . I
know it’s going to end up [in] diabetes and strokes. . . . I am
afraid my son saw how I acted when I was younger, and he
sort of copied that—same as me with my father. (2M)
Informants’ accounts of the development of morbid
obesity within the context of the family structure were
often highly gendered, and for many of those women who
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Owen-Smith et al.
Childhood socialization patterns
It was the day of you eat every single thing that’s on your plate and you don’t move until you’ve eaten it . . . and my mum
[mother] was one of these that stacked the plates, stacked them. . . . And that was just the way we grew up, and I didn’t really
get out of that until I left home. (2F)
Physical and mental illnesses
They push it so much: “You must be thin, you must be thin.” And then you’re thinking to yourself, “It’s medically impossible [for
me] to be thin. [Crying] I can’t be thin with everything that’s bloody wrong with me.” (1F)
When I was about eighteen, I didn’t have a job for ages, and I just didn’t do anything. I’d just sit in bed. This is when I first got
diagnosed with depression. . . . Didn’t work much, or maybe I had a job for a week and then quit it. . . . Obviously you put on
more weight if you just sit in bed all day. You still get hungry, so you eat things, but you’d normally be doing stuff. (2F)
Pregnancy and caring responsibilities
I spent so much time focusing on the health of my children, the health of my husband, my home, decorating, I forgot about me,
really, and I completely neglected myself. (1F)
I don’t get enough time to myself to dedicate a lot of time [to weight loss], because I’m a carer for my husband. (2F)
Working patterns
I was a professional wrestler for about fifteen years. Well, all as I could get to eat then, like after, was fish and chips or Chinese.
You’d be sitting in the car two or three hours and then coming home straight into bed. And you weren’t burning it off, and I did
put weight on then. (1M)
Failed dieting
I just have to eat such small amounts and I just put weight on. . . . They reckon it goes back to sort of caveman days. . . .
If you’ve starved yourself so much to lose weight, when you do start eating just a bit more, your body just saves it as fat. (1F)
Familial traits and genetic disposition
We all are [diabetic]—all the females in my family . . . all got weight problems, as well. . . . Years ago they used to say, “Well,
you’re fat. Your mother’s fat, so you’re going to be fat.” (1F)
They’ve [half-brothers] obviously got the same genes as me. We’re all pigs in our family. (2F)
Figure 1. Factors mitigating personal responsibility for weight gain.
Note. 1 = Study 1; 2 = Study 2; F = Female; M = Male.
had children, the burden of pregnancy and childcare were
dominant themes:
I had [daughter], and at the time didn’t really have much
money, and couldn’t afford to go to diet clubs and stuff like
that. And I was sort of wrapped up with the baby and one
thing and another, and never really lost my [pregnancy]
weight, so the first two stone [28 pounds] goes on. Then I
had twin boys . . . and I sort of managed to keep three stone
[42 pounds] of that weight. And then it’s just sort of piled on
from there. (1F)
The foremost themes in the accounts of women who
either did not have children or did not mention childbearing as key in the etiology of their condition related to
experiences of comorbidity and childhood trauma. For
example, several informants suffered from debilitating
physical conditions that they believed had either contributed to the development of their condition or impacted on
their ability to lose weight: “Because of the ME [myalgic
encephalopathy], I’m sleeping fifteen or more hours a
day, and exercise is out of the question because I can’t
even walk to the end of the road” (1F). Informants’ experiences of childhood trauma were normally in relation to
histories of abuse. By contrast, 7 of the 9 male informants
focused on the role of workplace responsibilities and the
restriction that employment commitments put on their
ability to maintain a healthy lifestyle and weight:
When I qualified—in those days you did work hundred-hour
weeks as doctors . . . it was just work, eat, and sleep. And we
earned money for the first time so we could eat properly; we
could drink alcohol and go to parties. And you start putting
weight on. (1M)
The remaining 2 men focused on a family history of obesity and the presumed role of genetics in the etiology of
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Qualitative Health Research 
excess weight gain: “My dad’s big. . . . My nan [grandmother] was big. It’s like it’s in the family” (2M).
The Role of Emotional Distress and the
Impact on the Body
Nearly all informants talked about emotional distress,
which was indicated as either a cause or a consequence of
morbid obesity, and in many cases, both. Several informants conceptualized this in terms of a downward spiral,
whereby the distress that led them to overeat was compounded when the impact on their body restricted their
social activities and reduced their self-esteem further:
I put on an awful lot of weight through stress. . . . I was just
getting bigger and bigger and bigger—and then becoming
less and less active, because I was struggling then, where I’d
put on so much weight. . . . And then I was feeling bad
because I couldn’t go out anywhere and I couldn’t do
anything, so I’d eat more. And it got worse and worse and
worse. (1F)
It was not uncommon for female informants to report
episodes of acute distress, and 6 related episodes of selfharm and/or suicidality relating to their weight: “I don’t
remember getting bullied that much in secondary school
because I would mouth off at people if they started on me,
but then I’d go home and I’d cry and cut myself to pieces”
(2F). Three female informants interpreted their overeating itself in the context of self-harm; one of them said,
If he [ex-husband] was drinking I would eat. And if he came
home drunk I would go and make a pile of sandwiches and
say. “Look what you have made me do.” . . . It was almost as
though I was using it as a weapon, but it was harming me,
not him. (2F)
Vicious Circles and Downward Spirals
Alongside relating experiences of emotional distress,
informants described a number of other “vicious circles”
that resulted in downward spirals of weight gain and
health deficit. These included experiences of physical
comorbidity and disablement, which were compounded
when informants were unable to access appropriate NHS
treatment for their condition: “I’ve got osteoarthritis in
both hips, so that means I can’t exercise properly—how
I’d want to. And that means pain, eating, stopping in, and
not exercising properly” (2M). “I can’t walk without that
knee replacement. . . . I can’t have it because I’m overweight” (2F). Some informants also used the term
“vicious circle” to describe the impact of failed attempts
to tackle their obesity, which reduced their sense of selfefficacy, and sometimes led to feelings of despair when
they felt they had exhausted their options for weight loss:
Every time you go on a diet and it fails, you dislike yourself
a bit more. And so then you compound that and you do it
again, and then compound it again, and it’s just—it really is
a vicious circle. (1F)
A third theme we identified under the category of
vicious circles related to the experience of social stigma
and discrimination, which were ubiquitous in the accounts
of female informants, and arose within the accounts of 6
of the 9 male informants. Encountering stigmatized attitudes resulted in extreme distress and sometimes further
maladaptive eating patterns:
It’s no good somebody calling you the back end of a bus or
anything. . . . It doesn’t make you think, “Oh God, I’ve got
to lose weight.” It just makes you eat—just makes you
depressed, and that makes you eat. (1F)
In addition, several informants reported a self-imposed
social exclusion because of the fear of encountering discriminatory attitudes, which sometimes restricted their
access to health-promoting activities:
I don’t go out—not much. I’m on medication only because,
where I’ve sort of got it into my head so much that people
are looking at me. . . . It’s a nightmare. (1F)
My boyfriend doesn’t understand. . . . He’s like, “Why don’t
you just go to the gym? Why don’t you just go for a run
around town?” I thought, “No way.” My worst nightmare is
bumping into somebody, bright red, sweating, can’t even say
hello because I can’t breathe. (2F)
Informants became particularly upset when they experienced discriminatory attitudes from health professionals:
“I get abscesses and he [NHS consultant] said, ‘Well,
you’re fat, you’re diabetic. What more do you expect?’ . . .
I came out and bawled [cried] my brains out” (1F).
Discussion
The data reported above provide a rare opportunity to
hear the voices of morbidly obese individuals, many of
whom had considered themselves marginalized by a society which they felt could neither accommodate their
overweight bodies nor understand how these intertwined
with their experiences of emotional distress and social
isolation. Much of the data constitutes “private accounts”
given by participants (Cornwell, 1984), which reflect
their struggle to align their current health state with conceptions of culpability and the morality of health.
Individuals reported long and complex histories of weight
gain, and particularly salient themes in the development
of morbid obesity related to family structures and early
socialization experiences. In addition, the role of
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Owen-Smith et al.
Familial Factors
Personal Factors
Social Factors
Weight Gain
Comorbidities
Stigma
Restriction on social/
health-related activity
Emotional Distress
Figure 2. A conceptualization of the relationship between weight gain and emotional distress in morbid obesity.
emotional distress was dominant in both initial weight
gain and ongoing cycles of loss and regain.
These findings consolidate and extend a number of
themes found within the literature. Many of the factors
informants mentioned when accounting for their BMI—
such as the impact of primary socialization, physical illness, and pregnancy—reinforce findings reported from
earlier studies (Ogden et al., 2006; Throsby, 2007).
However, the importance of emotional distress as both a
cause and a consequence of morbid obesity appeared to
come through more strongly in this study. Here, the findings were more similar to those reported in a Danish
study that sought to set accounts of the development of
moderate obesity (BMI 30-35kg/m2) within a life-course
perspective (Smith & Holm, 2011). However, only 3 of
the 20 contributors to the Danish study reported experiencing difficulties with weight since childhood, which
contrasts with 20 of the 31 contributors to the studies
reported here. This suggests that not only do those with
more extreme obesity tend to have a longer illness trajectory, but also that the behavior patterns associated with
the development of the condition are often laid down in
childhood.
Our data also add to the mounting evidence that obese
individuals struggle with the daily impact of stigma and
discrimination (Lewis et al., 2011; Ogden & Clementi,
2010; Puhl & Heuer, 2009; Puhl et al., 2008; Thomas et
al., 2008; Throsby, 2007). Despite some argument from
politicians and academics that the existence of stigma and
discrimination might encourage weight loss among obese
individuals (Bayer, 2008; Triggle, 2010), both our data
and the data reported from other qualitative studies suggest that the opposite is true (Lewis et al.; Ogden &
Clementi; Throsby). Indeed, the informants in our studies
said they encountered a series of “vicious cycles” relating
to both experiences of social stigma and discrimination,
and the impact of physical illness and disability. These
experiences further hindered attempts to lose weight
through restricting participation in social and healthrelated activity, leading to further emotional distress and
ongoing weight gain (see Figure 2).
For the individuals participating in our studies, experiences of stigma and discrimination were particularly difficult when they occurred in the context of health care
provision, which reports from both large-scale quantitative studies and smaller qualitative studies show is common (Malterud & Ulriksen, 2011; Puhl & Brownwell,
2006; Thomas et al., 2008). These findings suggest a need
for additional training to help health professionals realize
the impact their attitudes can have on people’s experiences of accessing health care, and suggest that further
research is necessary to develop interventions to tackle
weight-related stigma in society as a whole. In addition,
the findings suggest that health professionals need to
understand cycles of ongoing emotional distress and
weight gain, and to help individuals find ways to weaken
this cycle, such as by supporting people to find healthrelated activities that do not worsen existing experiences
of stigma and comorbidity and by providing access to
emotional support when necessary.
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8
Qualitative Health Research 
Many informants related their experiences of developing morbid obesity and the difficulties faced in living
with the condition as part of a private discourse. The use
of qualitative techniques meant that in-depth accounts
could be accessed and sufficient rapport could be established to ensure the uncovering of these private accounts
(Cornwell, 1984). This is particularly salient in the context of a stigmatized condition such as morbid obesity,
and through this research we are able to highlight the
voices of rarely heard, often socially excluded individuals. However, we undertook sampling for both studies
within the context of secondary care weight-management
clinics, which meant that all participants were sufficiently
concerned about their eating and weight difficulties to
have consulted their general practitioner and been referred
to secondary care. We do not know whether the views of
those who did not consult, or were not referred, are in line
with those expressed by these participants.
Despite this, the identification of similar themes in the
two studies and the application of a reciprocal translation
synthesis enhance confidence in our analysis and the
validity of the results presented here (Noblit & Hare,
1988). It is notable that a number of the themes identified
in the data overlap and, in common with all qualitative
research, the distinction between broad analytic categories was to some extent determined by the research team.
In particular, it is worth noting that the analytic category
of personal responsibility and the morality of health ran
throughout accounts, and to some extent underpinned
other categories reported. Although informants reflected
on a myriad of factors that were important in the development of morbid obesity, the lived experience of the condition was suffused with shame and distress, challenging
health professionals to take a more holistic approach to
care and society as a whole to demonstrate a more compassionate and inclusive approach to those suffering with
extreme obesity.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The authors disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
The National Institute of Health Research provided funding for
the research as part of the first author’s postdoctoral
fellowship.
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Author Biographies
Amanda Owen-Smith, PhD, is a postdoctoral research fellow
at the School of Social and Community Medicine, University of
Bristol, in Bristol, United Kingdom.
Jenny Donovan, PhD, is a professor of social medicine at the
School of Social and Community Medicine, University of
Bristol, in Bristol, United Kingdom.
Joanna Coast, PhD, is a professor of health economics at the
Health Economics Unit, University of Birmingham, in
Birmingham, United Kingdom.
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