Received: 17 June 2020 Revised: 22 July 2020 Accepted: 11 August 2020

DOI: 10.1111/cob.12406

ORIGINAL RESEARCH ARTICLE

“I am terrified of something happening to me” The lived

experience of people with obesity during the COVID-19
pandemic

Andrew Grannell1 | Carel W. le Roux1 | Deirdre McGillicuddy2

1
Diabetes Complications Research Centre,
Conway Institute, University College Dublin, Summary
Dublin, Ireland Obesity is emerging as a risk factor for COVID-19 disease severity. The impact of
2
School of Education, University College
the pandemic and knowledge of obesity as a risk factor on the lived experience of
Dublin, Dublin, Ireland
people with obesity is not fully understood. The aim of this study was to investigate
Correspondence
the impact of the COVID-19 pandemic on people living with severe obesity (BMI
Andrew Grannell, Medfit, Blackrock Business
Park, Carysfort Avenue, Blackrock, Co., Dublin, ≥35 kg/m2), currently engaged in multi-modal treatment. The primary objectives
Ireland.
were to examine the impact of the pandemic on their lived experience from a treat-
Email: [email protected]
ment and psychosocial standpoint and additionally explore their awareness of obe-
Funding information
sity as a risk factor for COVID-19 disease severity. An in-depth qualitative study
Innovative Medicines Initiative, Grant/Award
Number: 875534 was adopted employing semi-structured interviews with open-ended questions.
Interpretive thematic analysis was adopted to analyse the data and identify key
themes taking a grounded approach. Themes that emerged from the perspective
of impact on lived experience were (a) challenge sustaining treatment and (b) psycho-
social impact. There was an even split regarding awareness and lack of awareness of
obesity as risk factor which itself contributes towards a negative psychosocial
impact in most patients. The COVID-19 pandemic is posing a diverse challenge to
people with obesity. This has implications for their on-going treatment. From an eth-
ical standpoint, there is a need to fully elucidate the link between obesity and
COVID-19, disseminate this information using people friendly language and imagery
in a manner that does not exacerbate a harmful psychosocial response or lead to
stigmatization.

KEYWORDS

COVID-19, experience, obesity, psychosocial, treatment

1 | I N T RO DU CT I O N derangements commonly associated with obesity.3 While patients

with class 2 and class 3 obesity are more likely to require intubation,
Since its emergence as a novel pathogen in late 2019, the severe this does not appear to be the case in patients with class 1 obesity or
acute respiratory syndrome coronavirus 2 (SARS-CoV2) and the sub- lower4 but this relationship is not completely understood.5
sequent pandemic due to the coronavirus disease 2019 (COVID-19) is On 8 May 2020, the Irish Health Service Executive declared indi-
impacting all aspects of life. A body mass index (BMI) above 40 kg/m2 viduals with “obesity” are high risk for complications of COVID-19
is associated with worse outcomes of COVID-19.1,2 The pathophysi- advising, “staying at home, social distancing and washing your hands
ology of COVID-19 in patients with obesity is thought to be exacer- regularly”.6 The Centres for Disease Control and Prevention in the
bated by mechanical, vascular, metabolic and immunological United States stated “severe obesity” is a risk factor for severe

Clin Obes. 2020;10:e12406. wileyonlinelibrary.com/journal/cob © 2020 World Obesity Federation 1 of 9

https://doi.org/10.1111/cob.12406
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2 of 9 GRANNELL ET AL.

illness.7 Patient advocacy groups have called for action regarding the
appropriate treatment of people with obesity in relation to COVID-19
What is already known about this subject
to avoid weight bias and stigma (EASO and Obesity Canada).

• A body mass index above 40 kg/m2 is emerging as an

1.1 | Obesity as a disease—treatment and independent risk factor for COVID-19 complications.
sustaining response • This is one of the first studies examining the lived experience
of people with obesity during the COVID-19 pandemic.
Obesity is a chronic disease which reduces life expectancy and has • Adverse psychosocial responses have been captured in
complications impacting mental, metabolic and mechanical function.8 healthcare workers and the general population in China.
Patients require both treatment of the condition itself and its compli-
cations. There is increasing concern that the COVID-19 pandemic due What this study adds
to lockdown measures may lead to weight gain.3 Furthermore concern
is that inappropriate communication may increase anxiety.3 Dee et al9
• People with obesity are responding heterogeneously to
have argued that obesity treatment is significantly under resourced.
the pandemic.
This paper posits that such inequality of provision within healthcare
• COVID-19 is having a negative impact on psychosocial
systems will only further compound the difficulties experienced by
wellbeing.
people living with obesity during the COVID-19 pandemic. For people
• Both dietary and physical activity behaviours have been
with obesity, from an existential standpoint, living with the disease
impacted.
has been described as a burden with experiences of objectification,
• Many people with obesity were unaware obesity may be
alienation and judgement.10 In “normal times” people with obesity
a risk factor for COVID-19 severity.
face several existential challenges in their everyday life due to their
disease.11 How the early stage of the pandemic is further impacting
this lived experience, their lifeworld so to speak, has yet to be
explored in depth.
treatment and sustaining response and the impact on the psychosocial
affective domain.
1.2 | The psychosocial affective domain

Identity can be considered as something we “do” rather than what we 2 | M A T E R I A L S A N D M ET H O D S

“are” 12
negotiated in the complex intersection with the affective. 13

The internal and meaning-making process of identity formation 2.1 | Ethics approval and consent to participate
defines how we see ourselves within our social worlds, informed
through our stories and emotions.14 This deeply embodied approach Data collection was granted full ethical approval by UCD Human
to meaning making in our daily lives is mediated by the Research Ethics Board Committee (HS-20-12-McGillicuddy). This
psychosocial,15 evident in the emotional labour of how individuals study has been conducted in accordance with the principles of the
live, experience and cope in their lives.16 For people with obesity a Helsinki Declaration. All participants were told they could withdraw
significant psychosocial burden has been described which goes on to their participation at any stage without penalty. To overcome poten-
17
impact psychosocial functioning. Evidence from the 2003 SARS out- tial imbalance in power and avoid perceptions of coercion, patients
break, identified the profound psychosocial impact on patients and were informed taking part would have no impact on continued treat-
healthcare workers who experienced post-traumatic stress.18,19 Pre- ment and were reminded they could withdraw any moment without
liminary evidence from the COVID-19 pandemic indicates higher inci- penalty. To protect identity, pseudonyms were assigned. Written
20-24
dence of anxiety and stress. Indeed Lancet Psychiatry has called informed consent was obtained from all subjects.
for increased clinical and research strategies in the domain of mental
health in response to COVID-19. However, obesity was not detailed
as a vulnerable population group.25 Considering the psychosocial bur- 2.2 | Study design
den people with obesity experience during “normal times” coupled
with potential for infectious disease pandemics to cause psychological A qualitative study was employed utilizing a cross-section of subjects
trauma both directly and indirectly, it is of interest to understand the with obesity. The study was designed to explore the experience of
impact of the COVID-19 pandemic on the lived experience of people patients with obesity during the COVID-19 pandemic. To capture
with obesity from this perspective. The aim of this study was to cap- experiences of subjects in-depth, semi-structured interviews were
ture lived experiences of people with severe obesity in the early undertaken. This qualitative study utilized a phenomenological
stages of the COVID-19 pandemic in Ireland, particularly in relation to approach.26,27 This approach involves the investigator analysing and
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GRANNELL ET AL. 3 of 9

then describing the lived experience of the participant in relation to TABLE 1 Participant characteristics
specific phenomenon as described by the participant. The rich and Gender (M: 10, F: 13) Mean (±SD) Range
detailed description that emerges captures the experience for several
Age 57.8 (8.1) 43-72
individuals who have all experienced the phenomenon.26
BMI (kg/m2) 42 (6) 35.1-55.8
Treatment
Lifestyle only 6 (26.1%)
2.3 | Study setting
Pharmacotherapy and lifestyle 16 (69.6%)

Semi-structured interviews with open-ended questions were con- Surgery and lifestyle 1 (4.3%)

ducted with patients (n = 23) previously referred to the Obesity Com- Complications present
plications Clinic (St Vincent's University Hospital, Dublin, Ireland) and 1 9
actively engaging with treatment in an Irish Clinic. Lifestyle treatment 2 8
is prescribed to all patients with exercise training delivered via local >3 6
gym or a home exercise programme with its contents dependent on Hypertension 18 (78.3%)
the health status of the patient. Treatment options also available to Dyslipidaemia 8 (34.8%)
patients and delivered along with lifestyle intervention include phar-
Type 2 diabetes 4 (17.4%)
macotherapy and bariatric surgery. The multi-disciplinary team
Chronic kidney disease 5 (21.7%)
includes Bariatric Surgeon, Obesity Physician, Endocrinologist, Psy-
Obstructive sleep apnoea 10 (43.5%)
chologist, Dietician, Exercise Physiologist and Physiotherapist.
Cardiovascular disease 3 (13%)
Atrial fibrillation 2 (8.7%)

2.4 | Participant recruitment

Eligibility criteria required potential participants to have a BMI However, the participants were not chosen at random which must be
≥35 kg/m2 and to actively be involved in weight loss management. considered a limitation.
Purposive sampling strategy was used to capture rich and varied data
relevant to the research question,28 allowing for patients treated with
lifestyle intervention, pharmacotherapy and/or bariatric surgery to be 2.5 | Semi-structured interviews
included. Participants were recruited by the lead author, a male PhD
researcher and exercise physiologist. To overcome potential imbal- Data were collected via semi-structured interviews enabling beliefs
ance in power and avoid perceptions of coercion in participation, and perceptions to be captured in-depth. Interviews were conducted
patients were informed who taking part would have no impact on in English with audio recorded digitally. A distress protocol was put in
their continued treatment and were reminded that they could with- place taking into consideration the potential sensitive nature of
draw at any moment without penalty. Potential participants were first topics.29 While phone interviews have been suggested to result in
contacted by phone to discuss the study in detail. If the participant lower quality of data compared to face-to-face due to challenges esta-
indicated they wished to participate in the study, the information leaf- blishing rapport and inability to response to visual cues, they are
let and consent form was posted to them. Out of the 24 patients advantageous from a logistical and practicality standpoint and may
approached, 23 patients consented to participate in the study and ret- indeed improve data quality as the subject may have a heightened
urned the consent form to the researcher via post. It was not possible perception of anonymity and privacy.30 Phenomenological research
to establish contact with the one patient who was not recruited into approach was taken in order to describe the lived experiences of the
the study. The sample was not homogenous with regards to severity patients in relation to the phenomenon described by the patient.26,27
of disease, complications, time course of treatment or type of treat- A total of 23 patients were interviewed via telephone between April
ment received (Table 1). Descriptive characteristics are presented in 25 and May 6, 2020 when the COVID-19 pandemic was reaching a
Table 1 with BMI at baseline reported. All patients were Irish Cauca- peak in Ireland. During this period Ireland was in “lockdown” whereby
sian. Patients (18/23) were given a personalized home exercise pro- citizens were advised to remain at home and stay within a 2 km radius
gramme at the beginning of the pandemic to help transition the of their residence.
delivery of exercise. Diet itself was unchanged with some patients The interviews were designed to explore the beliefs and percep-
early on in the weight loss phase and others attempting to maintain tions of patients with obesity regarding their lived experience with
weight loss. The investigators at time of recruitment had not been in the disease, obesity as a disease, complications and fears, along with
direct communication with the participants since the “lockdown” and desired responses and previous difficulties with losing weight. As an
thus had no insight into the impact of the pandemic on their lived overarching topic, COVID-19 was also part of the interview schedule
experience. Coupled with an emphasis then placed on recruiting both and data related to this topic was examined in this study. Patients
males and females across all treatments, selection bias was mitigated. were asked open questions to explore the following two topics
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4 of 9 GRANNELL ET AL.

related to COVID-19: (a) the impact of COVID-19 pandemic on their psychosocial impact of COVID-19 pandemic on patient lived experi-
lived experience of obesity and (b) Their perceived risks associated ence with obesity (Table 2).
between obesity and COVID-19. A semi-structured interview guide
was developed for the interviews with the following questions and
prompts serving as a guide for the topic of COVID-19: 3.1 | Engaging in and sustaining response to
Q1: How has the COVID-19 pandemic impacted your lived expe- treatment for obesity during COVID-19
rience with obesity?
Prompt: Tell me about any challenges you have faced during the Patients in this study reported how COVID-19 was impacting both
pandemic with regards to living with obesity. negatively and positively on their engagement and sustained response
Q2. If you have been informed of any risks regarding obesity and to their treatment. The majority of patients referred to the negative
COVID-19 can you please tell me about this experience? impact on their dietary behaviours from a temporospatial perspective,
Prompt: How does this make you feel? posing challenges regarding decisions around food and leading to lack
Prompt: How do you feel about moving forward into the future? of routine. Paul (BMI 36 kg/m2) spoke about how COVID-19 “has
Prior to commencing digital recording of the interview, 5 to confined me at home and I am home every day saying what am I going
10 minutes was spent in general conversation making sure the partici- to eat, what can I eat, or what should I eat …I would have had a rou-
pant had an opportunity to feel at ease. The objective of the interview tine …but now I am sitting at home…that routine is gone now”. The
was reiterated to the participant and once they had verbally commu- temporospatial impact of COVID-19 was echoed by Angela (BMI
nicated they felt comfortable to commence, the interview was started. 40 kg/m2) stating that “my routine that has been thrown out and I
The interviews lasted between 16 and 56 minutes. To avoid bias think that has affected my food.” Being at home all day and the lack
in this process all interviews followed in the schedule with regards to of routine meant “you're around food all day…you are deciding what
the order of questions and necessary prompts. will you have to eat with the cup of coffee…definitely it is a challenge
to stop” (Barbara, BMI 37 kg/m2).
The restrictions on movement during the lockdown were also
2.6 | Analysis impacting on accessing treatment, creating a barrier to exercise.
Conor (BMI 35 kg/m2) highlighted the “physical difficulties of doing
Phenomenological research approach was used to analyse the your gym work or getting your walks in” while Liam (BMI 37 kg/m2)
lived experiences of the patients in relation to the described was finding it “hard to do 7000 steps….you can't get out because
phenomenon.26 Interviews were transcribed and analysed using the there were some times I would walk about 4 miles, 5 miles to the gym
phenomenological approach while remaining non-judgemental and or back and I would be able to do that I can't do that anymore because
open-minded.31 After careful reading of the transcripts, relevant seg- I am stuck in.” The temporospatial factor of lockdown impacted on
ments of text aligning with the aims and objectives were coded and Mark (BMI 50 kg/m2), “the gyms and swimming pools have shut so
then demarcated using Microsoft Word to commence the process of that is a big impact on me” with his own physical barrier further
thematic analysis.26 Coding was employed as a means of identifying impacting on his ability to exercise as “I can't walk that far.”
topics and issues with both similarities and differences in the narra- Limited access resulted in one patient delaying their engagement
tives of the patients as interpreted by the investigator. 32
Utilizing in treatment whereby “I wouldn't really have been able to exercise
Microsoft Word codes were highlighted and then subsequently beforehand because of my joints and joint pains. I had so many times
reduced, collapsed and drawn together into categories and then
general themes and sub-themes relevant to the study aims to present
the findings in a meaningful and coherent manner in one master docu- TABLE 2 Themes
ment. This followed an iterative process where at each stage authors (1) Sustaining Accessibility/temporospatial (diet and
AG and DMcG (a) discussed the highlighted codes, (b) discussed and response exercise)
agreed on the emergent categories and (c) discussed and agreed upon Psychosocial (diet)
the themes/sub-themes framework. Thereafter quotations (phrases Familial element (diet)
and paragraphs) corresponding to each sub-theme were extracted and Physical barrier (exercise)
organized. Data analysis was carried out by two members of the
Body image and self-confidence (exercise)
research team (A.G. and D.M.). To protect the identity of the partici-
(2) Psychosocial Fear
pants pseudonyms were used in the presentation of quotes. impact
Anxiety and stress
Boredom
3 | RESULTS
Determination
Limited concern/scepticism
The results are presented under two core themes; (a) sustaining
Frustration
response to treatment during the COVID-19 pandemic and (b) the
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GRANNELL ET AL. 5 of 9

planned start swimming in a local pool, that now on hold I suppose it is frightening and it does worry me that
again”(Graham, BMI 40 kg/m2). my lungs would be the problem, with having the
2
However, for Greg (BMI 38 kg/m ), the travel restrictions have asthma and that worries whether I pull through it if I
“been a help” as he has “to drive nearly 10 miles to a decent shop.” got it. (Patricia, BMI 49 kg/m2)
The lack of change in routine for Graham (BMI 40 kg/m ) who “works
2
I am carrying I think so many risk factors. (Katie, BMI
from home anyway” meant “I am in the house it hasn't changed any 41 kg/m2)
2
patterns that I can see.” Patricia (BMI 49 kg/m ) reported that she
“actually finds I have more time to concentrate and think about what I This fear was having a profound impact for how patients were liv-
am doing and planning and things like that so in that sense I think it ing their lives, especially when considering “what if I brought some-
has been good.” thing home” (Emily, BMI 41 kg/m2) and in terms of engaging socially.
Familial networks of support were particularly important to
engaging in and sustaining treatment throughout the lockdown. Dolo- I literally have been afraid to go down the road
res (BMI 37 kg/m2) had moved in with her son who is “very, very sup- because the road is very narrow and the neighbours
portive and we have a little routine going and we have set a menu are there, they will stop, they will come over too close
every week and we stick to that and I go out and he motivates me….I “Terrified.” (Katie, BMI 41 kg/m2)
am in a better place since corona started with my food patterns and
my eating habits than I have been in a long time.” There was particular fear for other family members living with other
Caring for her parents meant that Megan (BMI 38 kg/m2) was complex health conditions:
“having to do the shopping now” meaning she was “being more con-
scious about what I am buying too. You know I am cooking as well.” I am scared for my wife she has had cancer. (Liam,
Self-stigma emerged as a barrier for Patricia (BMI 49 kg/m2) who BMI 37 kg/m2)
was finding it difficult to “get out the door.” Scared. Because if one or the other of us get it, it's seri-
ous because we are in such poor health condition.”
You know you are self-conscious as well. Your body, (David, BMI 44 kg/m2)
when you are out… my walk would be just a slow walk,
you know you see…a lot of people out power walking However, one patient, Hannah (BMI 40 kg/m2), spoke about the
and even cycling on a bike, you are conscious. Well I fear associated with COVID-19 and obesity stating that “you skip
am conscious of my weight. So I don't know whether along thinking I'll be ok because… I don't have type 2 diabetes, I don't
that mentally restricts me. (Patricia) have high blood pressure. I don't have those. I have been very afraid
from day 1.” Feeling “nervous” and “vulnerable,” Patricia (BMI 49 kg/
This self-stigmatization was impacting on how Patricia was engaging m2) believed that “obviously people of all sizes and all ages are worry-
with the broader social world, impacting on how she felt about herself ing about it but I am worrying about it because I had a clot in my lung
evoking a psychosocial response limiting her engagement with the last year and then having the diabetes and the overweight.”
outside world. Anxiety and stress also permeated patient psychosocial narra-
tives. This resulted from worry having “to put my mother into a nurs-
ing home…if she passed away she would have no one beside her”
3.2 | The psychosocial impact of COVID-19 on (Derek, BMI 46 kg/m2) and from being separated from “my family in a
patients living with obesity very long time” (Laure, BMI 56 kg/m2).
There was a particular “anxiety attached to there is a virus out
Emergent from the interviews with the patients was the deeply affec- there and it can kill me” (Paul, BMI 36 kg/m2) and the reality that
tive impact of COVID-19 on their experience of obesity. Patients “people you know are talking about people they know who died”
spoke of their deeply embodied response to living with obesity during (Barbara, BMI 37 kg/m2).
the pandemic evident in their experience of the affective, the most Patients spoke about how this affective response to COVID-19
profound of which was fear. was impacting on the nature of engagement in their treatment.
The comorbidities with which patients lived their lives amplified Hannah (BMI 40 kg/m2) indicated that she is “a boredom eater, so
this fear: that is what I have found most challenging” while Emily (BMI 41 kg/
m2) stated that for the “first 3 weeks I just ate everything out of pure
terrified of something happening to me. (Katie, BMI boredom.” The “fedupidness” experienced by Susan resulted in feeling
42 kg/m2) “you need something to I suppose, comfort eating.”
It's a bit frightening because I am one of these people While the majority of patients interviewed for this study referred
whose immune system is suppressed. I have ankylosing to the negative psychosocial impact of COVID-19 on their lived expe-
spondylitis. (Paul, BMI 36 kg/m2) rience of obesity, one patient indicted her determination to ensure
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6 of 9 GRANNELL ET AL.

that it does not “change my weight loss journey. I am determined to obese in Ireland certainly have a million and the rest
do that” (Lauren, BMI 56 kg/m2). are moving that way. I am no statistician but it's gotta
Interestingly some patients expressed a lack of concern regarding be big numbers and unless they are afraid that they will
obesity as a risk factor with some openly sceptical. Matthew (BMI frighten the hell out of people if they throw that into
39 kg/m2) cited ambivalence in news reporting on the topic a cause the mix as well. But I also think pandemic times is a
for scepticism, feeling that obesity is typically “blamed” for many good time to let people know obesity is a further com-
illnesses: plication you do not need and it's not the time to put
People blame overweight on loads of things so whether it is true on extra stones if you can manage it. I think you gotta
or not I don't know. There are a lot of things I am reading at the give them a leeway and say look if you are a couple of
moment that I am not necessarily believing. (Matthew) pounds extra so be it but there will be people 4 or
2
Mark (BMI 50 kg/m ) similarly was sceptical of obesity as a risk 5 stone more at the end of this and that is not
factor saying “my sister keeps telling me overweight is a big issue with on.” (Liam)
COVID but I don't know if there is a lot of proof of that” and cited
COVID-19 as “like the flu. You gotta live with it. These risks exist, you
have just got to carry on. There is no point being frightened or wor- 4 | DI SCU SSION
ried about it. Just be logical and take the right approach.”
Indeed, Susan (BMI 40 kg/m2) acknowledged that “I know I am The aim of this study was to explore the impact of the COVID-19
obese but I would consider myself that I am fairly resilient and I don't pandemic on the lived experience of patients with severe obesity
drink or smoke so I would have thought if I was a smoker for example (BMI ≥35 kg/m2). Obesity is a chronic disease33 requiring sustained
that I would be at more risk than due to my weight.” intervention and treatment over time. Participants in this study
However, this stance juxtaposed with that held by other patients (n = 23) were actively engaged in lifestyle intervention alone or com-
who were particularly frustrated with the lack of seriousness and due bined with pharmacotherapy or surgery. Two key themes emerged
attention being paid to the link between obesity and COVID-19 out- from thematic analysis of the semi-structured interviews exploring
comes. Emily expressed her frustration that “when someone says long how patients were experiencing living with obesity during the pan-
term illness they don't consider obesity as a long term illness” (Emily, demic; engaging in and sustaining response to treatment and the psy-
BMI 41 kg/m2). chosocial impact of negotiating their identity as individuals living with
2
Graham (BMI 40 kg/m ) referred to reluctance on behalf of the obesity during the pandemic.
public to broadcast obesity as a risk factor while other risk factors This study indicated the profound impact COVID-19 was having
were being communicated. For him the connection between obesity on how patients experienced and sustained treatment for obesity dur-
and COVID-19 was obvious: ing the pandemic. While some patients described improvements in
dietary behaviours due to familial support and the affordance of time
Maybe because no one is brave enough in the public enabling more mindful decision-making around food, a negative
to highlight it in the news casts and stuff like that or impact was more pronounced. Due to temporospatial factors and
it's just not politically correct to do it. They are very adverse psychosocial responses, altered routine, boredom, anxiety
quick to say that people of a certain age or underlying and stress were described. Diet was impacted with “comfort eating,”
conditions. They are very quick to constantly put those “fedupidness” and eating “out of pure boredom” reported. This has
two things as a reason for higher risk but one thing implications for patients undergoing treatment for their obesity as this
that you can obviously see is that quite a lot of the poses an added significant challenge. Indeed the association between
people who were affected worse are overweight.” obesity and emotional eating is well established.34 Early intervention
(Graham) for disordered eating may be key to prevent complications arising
from obesity.35
The implications of this lack of due regard was particularly unset- Personalized exercise for treatment of obesity supports weight
2
tling for Liam (BMI 37 kg/m ) who stated: loss maintenance36 and improves health.37 We showed the barriers
experienced by patients when seeking to access resources (such as
I cannot understand why public health, or maybe it is the gym and swimming pool) during the pandemic as a result in the
just too much for the general public to take, but I can- restrictions in movement. Indeed, one patient spoke about the limiting
not understand why public health haven't turned impact of self-stigmatization on their ability to engage with the treat-
around and said in an emphatic way that obesity is an ment. Self-stigmatization is a phenomenon that has been captured in
underlying illness. And that is not coming through, I people with obesity previously.38 While only one participant
have actually voiced it once or twice with some serious described this experience, it is of interest to explore in detail how the
commentators on it and the only conclusion I can come pandemic might impact on self-stigmatization and thus mental health.
to is the health services are just afraid because there Overall, these barriers and the lack of accessibility to resources during
has got to be the guts of a million people who are the pandemic are having a profound impact on the nature of patient
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GRANNELL ET AL. 7 of 9

engagement in treatment. COVID-19 associated sedentariness may develop mental health research and clinical efforts in the face of
have a negative impact on health, regardless of weight status.39 Our COVID-19.25 Notably a Lancet position piece did not detail patients
findings reveal a negative impact of the pandemic on sustaining exer- with obesity as a vulnerable population group. Negative biological
cise due to temporospatial, musculoskeletal and psychosocial factors. effects of psychological stress reflected in heightened amygdala activity
For the patients with obesity, if this impact on physical activity con- which predicts cardiovascular events in the long term.49 The potential
tinues unabated, this may have a downstream impact on mental for functional impairment in relation to return to normal living in the
40 41 42
health, appetite regulation, metabolic health and cardiovascular recovery phase and increased risk of developing sequela such as mood-
function.43 Personalized on-going support for these patients is imper- or stress-related disorders is a reality, as was similarly speculated in
ative to ensure their lifestyle treatment remains optimized. response to the SARS outbreak of 2003.50 Clinically this requires multi-
COVID-19 has been identified as having a profound impact on disciplinary teams managing patients with obesity to utilize their psy-
the psychosocial wellbeing of healthcare workers, students and the chological services to deliver personalized on-going management.
general population in Asia.20-24 Particularly striking from this study This study identified the polarization in perceptions regarding the
was the impact COVID-19 had on how patients were negotiating their emerging link between obesity and COVID-19. While some patients
identity and experiences living with obesity. Weight stigma is perva- indicated their scepticism and lack of concern, others expressed the
44,45
sive across all aspects of contemporary society. For people with frustration about the lack of seriousness and due regard considering
obesity their lived experience is directly impacted in a negative man- the profound implication for their lives as patients living with obesity.
ner by weight stigma, with deleterious effects on psychological and For one patient, this translated into a lack of empathy and care for
physiological health. Social identity which can be defined as the indi- their situation, positioned them as value-less citizens within society.
viduals self-concept emerging from their perception of where they fit Although Ireland has declared individuals living with “obesity” as at
in society, is significantly impacted by weight stigma in “normal greater risk of negative COVID-19 outcomes,6 patients in this study
46
times”. Specifically people with obesity within their lived experience believed more could be done in disseminating information and com-
feel devalued as a result of negative stereotypes.46 Weight-based municating more broadly regarding this increased risk. In the words of
social identity threat has been described as a psychological state trig- Liam “I cannot understand why public health haven't turned around
gered situationally whereby the individual has been or is concerned and said in an emphatic way that obesity is an underlying illness.”
they will be treated negatively as a result of their weight such as
devaluation, discrimination, rejection or stereotyping.46 It has been
proposed that this phenomenon is partly responsible for the lived 4.1 | Strengths and limitations of the study
experience of people with obesity being subjectively diminished.
Based on our findings there is concern that the pandemic may exacer- This study captures a small sample size located in one hospital in one
bate this phenomenon. Specifically ambivalence in government com- country. As a result findings presented cannot be extrapolated beyond
munication of risk related to COVID-19 may lead to people with the individuals who supplied the data. However, this approach has
obesity feeling devalued. Coupled with media portrayal of obesity provided an in-depth insight into how patients are experiencing living
being due to personal failing and social media norms enabling “fat with obesity during the early stages of the pandemic. At the time of
jokes” and hostility towards people with obesity,47 there is a danger conducting this study and from the perspective of “time to vaccine”
that the identity of people with obesity will be further devalued and the COVID-19 pandemic was still in its early stages with less than
lead to long-term health consequences. As described in this study the 5 months since the World Health Organisation Country Office in
pandemic has been having a profound influence on the affective China first received notification of an epidemic of pneumonia cases in
response of the participants, particularly on how they embodied feel- Wuhan. To the authors knowledge this is one of the first studies to
ings of fear, anxiety, boredom, guilt and shame. Such narratives were investigate the impact of the pandemic on patients living with severe
affecting their psychosocial response to living with obesity, resulting obesity and also their awareness regarding obesity as a risk factor.
in particular concern about risk of infection. As described in the intro- Overall the findings represent just a snapshot in time. While they are
duction, people with obesity experience a psychosocial burden during important and can shed insight into the lived experience of people
“normal times”. 17
Our findings suggest this negative element of lived with obesity during the early stages of the pandemic they cannot be
experience shared amongst many living with the disease of obesity interpreted to reflect how the individual continuous to experience life
has the potential to become amplified during the pandemic. Indeed, as the pandemic unfolds.
given the strong association between obesity, depression and
anxiety,48 the influence of COVID-19 on patient psychosocial
wellbeing cannot be understated and should be further explored. 5 | CONC LU SION
Following the 2003 SARS epidemic quarantined individuals were
2 to 3 times more likely to experience post-traumatic stress,18 with 5.1 | Implications for clinical practice
fear, anxiety, depression and feelings of stigmatization found in survi-
vors and family members.19 Consequences of these responses must Patients are impacted heterogeneously by the pandemic regarding
be considered and there has already been a call for strategies to sustaining treatment and psychosocial responses. Patients with
 17588111, 2020, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/cob.12406 by Ankara University Library, Wiley Online Library on [06/03/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
8 of 9 GRANNELL ET AL.

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