The article is about patients' lived experiences of being overweight. This seeks towards a greater understanding for this overlooked group of patients.
In Denmark the number of overweight and fat people is increasing greatly, and nearly one third of the Danish population is overweight. The care for overweight patients appears to be a taboo in nursing.
The aim of focusing on this group of patients is that the nurse, when encountering the overweight patient, can understand what it is like to be overweight, and which meaning the body has to the individual.
The article builds on a hermeneutic study of five people's lived experiences of overweight. A wide interpretation of the interviewees' statements is sought, and S. Kvale's interpretation levels are used. The leading theory is the American nurse Rosemarie Parse's theory of nursing, which focuses on true presence and respect.
Two French philosophers, René Descartes and Merleau-Ponty, are used to discuss body image.
The findings consist of five topics: To hide and to show one's body. To be oneself and to be different. To want to and not to want to lose weight. Food as a source of social fulfilment or as a comfort. To dare to face the future.
The study showed that there was no correlation between body weight and the person's body image. The three female patients felt different and allowed food to rule their lives.
Motivation for weight loss was not to be taken for granted.
Food and social fulfilment are linked, and it appeared that several of the persons in the study lost control of their food intake. They were compulsive eaters when they were alone and felt lonely. All of them did not dare to face the future.
The purpose of this article is to present the result of a study of overweight focusing especially on what it means for the obese person's body image.
The background of the study is the fact that seen in a social perspective overweight is a growing problem. One third of the Danish population is overweight, and the number is rising (1:13). From 1987 and up to 1994 there has been a rise from 25 per cent to 28 per cent, and the frequency of obesity has risen from six per cent to eight per cent (2:25-26). However, overweight as seen in a nursing and care perspective seems to be an overlooked or underestimated area in spite of the many health risks and the increased mortality following in its wake. With the growing number of overweight persons that will appear in the health sector, more and better offers of treatment for overweight persons are called for, and different health promoting measures are needed (3:4509, 4:2684).
Therefore, the study is relevant to nursing, focusing on what the body means for the overweight person, and also because understanding the person's body can be the basis of a more fruitful encounter between nurse and patient. Information retrieval of obesity in general in the Article Base, International Nursing Index and CINAHL produced comprehensive documentation. It has been investigated how the big body can be measured (5:535-545) and also how obesity can be treated and prevented (4:2684, 6:2679-2705, 7:335-353). A Swedish ten-year follow-up study conducted by a nurse and a physician showed that behavioural changes were possible if cognitive training, cooking and dietary behaviour were combined with exercise, and close contact with an interdisciplinary health personnel was maintained (8:623-625). Moreover it has been investigated how important cultural patterns are for the perception of normal body size (9:265-272, 10:173-180). And it was found that the connection between a diet consisting of low fat and high carbohydrate food will change the fat deposits of the body (11:83-92, 6:2679-2705).
A more specific search for information about obesity combined with the search word body image gave a modest result. Research on the influence of culture on changes of body size, and the way in which the expression of the big body influences the person psychologically is still in its infancy (12:224-253). More recent American research deals in particular with women's dissatisfaction with the appearance of their bodies, where obesity is considered an expression of lack of control of the body, and where food in large quantities is regarded as overeating (13:889-897, 14:190-214).
Research on nursing dealing with understanding and care of overweight persons is sparse. An Icelandic and an American study of fluctuations in women's weight showed that the experience of the body varied considerably from woman to woman, and that it was not immediately linked to their weight (15:5-44, 16:29-36). The American study demonstrated that for women living with overweight is an eternal fight against the image of themselves. The women withdraw. Two central opinions on weight problems emerged: ''Fear of being disappointed'' and ''The delight of being complimented by others on loss of weight'' (16).
In Denmark little is said in the nursing world about understanding overweight. Few articles have dealt with this problem (17:38-47).
The limited documentation of overweight persons' body image and playing down health problems led to the approach to the problem of the study:
''How do obese persons regard their bodies?''
The purpose of the study is generally to describe what it is like to live with overweight. An understanding the nurse can use in her encounter with the overweight patient.
Theory and method
The object of the study determined the choice of the qualitative in-depth interview as a research method. In this form of interview it is sought to obtain a deeper understanding of the meaning of a phenomenon, in this case overweight (18:68). It was aimed to gather descriptions of the overweight person's world of living and then to analyse these descriptions in a hermeneutic frame of understanding.
Theory of science
The central frames of the theory of science from which the study originated were Descartes' dualism (19,20), Merleau-Ponty's phenomenology (21) and Gadamer's
(22) and Ricoeur's (23) hermeneutics.
In his body philosophy Merleau-Ponty has dealt with the dualism of the body and tries to combine the view of the body into a whole thereby clashing with Descartes' dualism. The two scientific theories are opposite, each with their view of the body, and have been chosen to discuss the participants' different lived experiences. In Descartes' dualism the body is subordinate and totally separated from the soul (19). The relevance of including the philosopher Rene Descartes' view of the body is that as the founder of modern philosophy he has had a decisive impact on the body image that has been predominant in Europe the last 350 years. The bio-medical view of the body with dualistic or dichotomy body image, of which Descartes is the originator, has characterized the tradition in the nursing profession, for which reason his thoughts have been used for the interpretation of the interviews. Descartes' dualism between soul and body sees man as a biologically conscious being, where the body is subordinated. Carried to its logical conclusion Descartes' thinking means that the body is made an object and becomes a kind of case separated from consciousness (20).
In contrast, Merleau-Ponty's general view of the body with its built-in ambiguous concepts holds the complexity which appears in obese persons' perception of their bodies. His view: ''That I am my body'' can be used precisely relative to understanding obese persons' body image, also when they choose to distance themselves from their body by ''I have a body'' (21:107). The body is at once a phenomenal body which he describes as man is his body, and on the other hand the body is an objective body, understood as man has a body. What the body is can only be said from what the body can. The contour of the body is a limit which the spatial relations do not exceed.
It is in the action that the spatiality of the body is accomplished. That means that the body is active, and that the meaning of the body is expressed in action. According to Merleau-Ponty the body is both living and lived. That the body is living means that the body is not only a lifeless or reified body for natural science to study. The bodily experience is the body as a whole, lived as an experience in the world of living (21). Hermeneutics was the central methodology of the study significant to the gathering and analysis of the material studied. Hermeneutics is relevant in a professional health context, because it is a question of understanding another human being and oneself. The study is concerned with the way in which lived experiences of overweight find expression in order to elicit the participants' opinions. In a hermeneutic sense Gadamer (22) talks about a fusion of horizons which occurs when both the researcher and the participant arrive at a common understanding.
In Gadamer's sense human beings are discoursing beings. My frame of reference for understanding interviews is a philosophical frame which stresses pre-understanding in interpretation, and where the researcher must stake his pre-understanding and his own prejudices. Interpretation of text is not without qualifications and assumptions (18). In qualitative studies the number of participants is small. The quality of the interview is more important than the number (18). The researcher's task is to gather sufficient data to cover variations and to look for recurring patterns.
With the theories chosen questions were constructed dealing both with the subject and how the subject is understood as integrated in the surroundings.
The theory of nursing
The framework of nursing theory governing the study was Parse's human becoming theory (24). The theory builds on existentialistic phenomenology and develops Merleau-Ponty's thinking of bodily experiences. This has been chosen as the governing theory because it can predicate something about the meaning the individual puts in her/his life and thus the understanding and meaning of the body as viewed in a nursing context. It stresses the paradoxes of human life and how the human body can form patterns relative to lived experiences.
Parse's theory of nursing focuses on the encounter between the nurse and the person and can lead to a more genuine relationship and provide the opportunity of creating an understanding of exactly the particular person's lived experiences.
Parse's nursing theory of the human becoming is to be seen as an alternative to traditional thinking in nursing, which has been developed positivistically and therefore is restricting, as it only includes one small part of nursing (24:3).
Her approach focuses on the importance of obtaining a genuine relationship with the patient. If the nurse is not really interested, an unfortunate relationship will arise, where, for example, the nurse ends up by using a pointed finger or her power to make the patient change behaviour.
Parse describes in detail (24:13) how she is inspired by Martha Rogers, the late American nursing theorist, (1914-1994) and her scientific knowledge of the unique man. Parse's theory was published in book form in 1981 and has later been revised in 1992 under the title of ''The Human Becoming Theory'' (25:5).
Parse's theory consists of nine fundamental assumptions from which she distinguishes three main themes (24:8).
Meaning, rhythmicity and cotranscendence
These themes are synthesised into three central principles.
Principle 1:'' Structuring meaning multidimensionally is cocreating reality through the languaging of valuing and imaging''
Principle 2:'' Cocreating rhythmical patterns of relating is living the paradoxical unity of revealing-concealing and enabling-limiting while connecting-separating''
Principle 3:'' Cotranscending with the possibles is powering unique ways of originating in the process of transforming.''
This means that because different persons perceive the same situation differently each of them also puts their meaning in it. The meaning often appears in relation to others. Rhythmical patterns are created when the person interrelates with others in the surroundings in a mutual process and he/she identifies with these patterns. Rhythmicity has built-in paradoxes which are two sides of the same rhythm. When a person makes a choice there will always at the same time and in the same rhythm be an urge in one direction and a limitation in another. In any choice there will be opportunities and limitations in the situation. When the nurse and the person cotranscend a personal development process occurs which causes an activity and a development beyond the person's limits.
Parse considers health in a way different from what we normally do in nursing, where it is looked upon as absence of illness. She sees health as a process of development and not as a contrast between health and illness (24:30). From that point of view the person can be both healthy and ill at the same time. Man's health is a way of living. Viewed in this light nursing becomes a relationship between nurse and patient. The nurse must understand the reality, patterns and paradoxes of the other person and follow the possibilities this provides for the individual. The nurse must accept, for example, that there may be some obese persons who want to remain obese. In other words, that health is individual, and that it is the person who is an expert on herself/himself.
The theoretical framework of the study has previously been described in detail (26) and will not be elaborated on.
The study included five persons - three women and two men, all of whom were attached to an out-patient
clinic as they had a recognised weight problem. The criteria for inclusion were, in addition to a recognised weight problem, that the participants were over 18 years of age, and that they were willing to tell about their lives. To ensure as much variation as possible the participants were selected with due regard to the aim of the study. Such a selection and variation should ensure that the study was concentrated on the most informative persons (27:142) in relation to, for example, age, sex and weight class. With this in view the selection of participants was made after the group meetings with the dietician.
They were all willing to participate in the study.
The mean age of the participants was 56 years (range 40-68). They weighed from 90 kilos up to 140 kilos. Two of the participants lived alone, three were married or cohabitating.
Two of the women, called Ann and Christel, had been overweight since childhood. They were very big and inhibited in their movements, hated their bodies and were what could be termed food misusers and compulsive eaters (28).
Ann said that her weight problem arose in connection with bereavement, and that she was motivated for losing weight as she hated her big body.
Christel stated that the first time she was on a slimming diet was at the age of six, and that she had a food misuse. The third woman, Beth, had developed overweight in adulthood. She said she had become overweight in connection with the birth of her last child and the start of hormone treatment. Beth was not as big as the others, but was quite preoccupied with her body and weight. Among other things Beth could not go to a dinner party in friends' homes and said:
''All my life is one long slimming diet.''
One of the male participants was called Dan. He was physically hampered by his overweight, but not particularly preoccupied with his body. He found out that he was overweight as his suit was too tight across his stomach. He said:
''I just have to get rid of this paunch.''
In private he wore a track suit. The other man, Erik, was obese, but he was neither shy nor ashamed of his body. He had many physical problems because of his overweight, for example he was greatly troubled by dyspnoea. He had been overweight since childhood, when he was served fat old-fashioned food. He considered both heredity and diet to be the cause of his overweight. Dan was 68 years old and thus an old-age pensioner. Of the other four participants only Beth had contact with the labour market, working part time. The other three had taken early retirement.
After obtaining formal contact to a large out-patient clinic it was decided to follow the overweight person's course in the hospital in order that I as a researcher could be close to the field. Patient interviews with the nurse, the physician and the dietician were attended just as I was a participant at several group meetings with ten overweight persons and the dietician.
The participants were interviewed once in their own homes or at the out-patient clinic according to their own wishes. Four of the participants chose to be interviewed at home. The fifth participant, a man, was interviewed at the out-patient clinic in a quiet and undisturbed place. At the interviews in the respective homes the researcher was a guest and was understood to be ''the nurse.'' In three of the homes high calorie food and drink in the form of cake and soft drinks were served, whereas tea, juice and fruit was served in the fourth home. The interviews lasted from one to two hours and were carried out without any pressure of time whatever. There was enough time both to establish a good contact with the participant before the tape recorder was started, and the interview started with a briefing (18) where the aim of the study was repeated. The interview was concluded with a debriefing (18). The interviews were recorded on tape and transcribed verbatim.
During the interviews I made an effort to listen and to be open, and to show a genuine interest, and also to create a good and trustful atmosphere (18). In order to get an additional picture of the participants' body image they were asked to draw their body and explain what they were drawing. This was inspired by research done by physiotherapists and psychologists on body image (28,29).
Guide for interviewing
The interviews were administered by a semi-structured guide for interviewing worked out for the purpose and inspired by the thoughts of Descartes, Merleau-Ponty and Parse. Interviewing is one method of gathering empirical material in order, as in this case, to elicit opinions of, for example, body image, and where interviewing is used as a tool (30:14). Steinar Kvale's hermeneutic understanding of qualitative research interviews is used to focus on lived experiences of being overweight. A research interview comprises both the design and the interpretation of a text, and thereby hermeneutics becomes doubly relevant (18:56). In accordance with the philosopher Paul Ricoeur's
understanding (23) the interviewer must be open to the interviews, which are considered ''texts,'' just as Ricoeur considers both action and speech to be text.
The guide for interviewing contained questions about diet in childhood and the times at which the participants regarded themselves as overweight. They were also asked what importance they attached to their overweight, and what they believed to be the cause of this. Other questions were directed towards body image, and the negative and positive aspects of overweight. Moreover they were asked about their future expectations.
Analysis of data
The analysis of data was done in several stages and followed Kvale's method of analysis. This was chosen because his three types of questions with three interpretation levels are operational, just as his many questions for the text of the interview leave room for a wide interpretation, and also the importance of many perspectives being embodied in the text, which is a force hermeneutically.
The first type of Kvale's questions is distributed on three levels of interpretation:
The level of self-understanding, the level of common sense and the theoretical level where within the scope of each level various questions are asked to the text.
The first level is the participant's self-understanding. Here the researcher tries to give a concentrated opinion of the particular person's own opinion of the statements and what the interviewee herself/himself understands is produced. The point is to understand the participant's own statements and then afterwards to summarize their meaning. At Kvale's second level common sense knowledge is involved as a universally agreed knowledge of the contents of the statement. Common sense goes beyond the interviewee's opinion and comprises a wider frame of understanding. At the third level a theoretical interpretation is applied, or the theoretical frame which goes beyond both the self-understanding and common sense level is involved (18).
In the analysis and discussion of the interview texts Kvale's three levels division has been followed, knowing quite well that there are gradual transitions between them. Kvale's interpretation levels were used for each statement. On the basis of the interpretation of data five themes were distinguished as recurring themes in the analysis. The method of distinguishing themes serves to obtain control and reconstruct data to form a comprehensive view of the large number of transcribed pages or to ''spot elements in the text'' which often appear (31:87). The themes can be looked upon as lived experiences. This is an expression used by both Van Manen (31) and Parse (24) originating from phenomenology where precisely lived experiences are considered the point of departure for a research seeking to find the meaning of the lived experiences. As the last part of the methodical procedure the themes were discussed in relation to the theoretical frames, and afterwards the findings of the study were summarized and the conclusion drawn therefrom (table 1).
TABLE 1. STAGES FOR ANALYSIS AND INTERPRETATION OF THE INTERVIEWS
Interpretation directly during and immediately after the interviews
Transcription of the interview text, perusal of text and listening to tapes
Interpretation of each statement according to Kvale's first type of question with three levels
Discussion of themes by means of Kvale's types of question and use of theories.
Summary of findings
Ethical considerations were divided into formal and informal considerations.
The formal ethical considerations were to be in order at the outset. Both at the planning stage and in the course of the study and also at the end many ethical dilemmas had to be settled. It was important not to reduce the ethical requirements, and it was imperative that those interviewed should keep their integrity.
Formally, the code of ethics from Sygeplejerskernes Samarbejde i Norden (Cooperation of Nurses in the Nordic Countries) (32) was followed with regard to volunteered consent, verbal and written information and anonymity. Before the gathering of data began permission to carry out the study had been obtained from the persons in charge of the out-patient clinic.
The participants were informed verbally and given time to consider their acceptance. Furthermore, they were told that the researcher did not have access to medical records or any influence at all on the participants' treatment at the hospital. During the course of the entire project they were also informed of ethical considerations. As the first contact was important, the introduction of the researcher to the participants at the group meetings with the dietician was given high priority. One of the things considered was not to misuse power towards the participants (33). According to Løgstrup's thoughts of openness of speech one should be aware of how much a person feels like opening up. One must not ''seduce'' the interviewee to express any view on more than he/she feels like doing.
The analysis of data led to five themes: To hide and to show one's body to be oneself and to be different- to want and not to want to lose weight food as a source of social fulfilment or as comfort to dare to face the future. The headings have been taken from the participants' own statements, and the themes developed with words inspired by Parse's second principle of the paradoxes of life (Table 2).
TABLE 2. THE FIVE THEMES OF THE STUDY
To hide and to show one's body
To be oneself and to be different
To want and not to want to lose weight
Food as a source of social fulfilment or as a comfort
To dare to face the future.
Theme 1: To hide and to show one's body.
The first and most essential theme dealt, in the nature of the case, with the body. The participants both hid and showed their bodies in a variety of ways. There were great differences between the interviewees' body image and no unequivocal body image was ascertained. As the starting point the participants' self-understanding was discussed. Ann spoke about her small body within the big body, saying:
''I absolutely dislike my body. It is the whole body. It is inside, I am not satisfied.'' Beth said: '' I feel 20 kilos bigger.''
Four of the five participants did not live in conformity with their physical body, but had a distance to it. They lived in a contrast to their bodies as a big or small body. Erik used a metaphor about his stomach:
''It is just that paunch I have to get rid of.'' In this way he showed his body. Christel showed her distance to her body by saying:
''In the mirror I see a strange lady who isn't me.''
Merleau-Ponty (21) talks about body and soul as intertwined as a whole. On the face of it it looked as if none of the five persons lived in this whole or experienced their body as phenomenal. One of the men was close to living his body, but nevertheless indicated a distance from the head to the parts of the body, which was seen in the drawing of his body where he drew a giant head and a small body as a pendent.
It was obvious that the body image had been established in childhood, and even great weight fluctuations later in life did not change the body image. In their bodies they bore the lived bodily experiences of earlier times when a layer of fat was a sign of health. For the three women it was a dilemma whether to withdraw and live alone with their body or conversely to have social contacts. Even if they knew that it is not possible, like the ostrich, to bury one's head in the sand, they wanted to hide their bodies as much as possible, and when they were out among other people they hid their bodies in big clothes, or kept close to persons they knew. The men were less shy about showing their big bodies. They indicated living with their bodies and did not let it restrict their social contacts. Dan's body image had not changed after he had become overweight, and he viewed his body as an object according to Descartes (19). In contrast, Erik had always been big and accepted his weight.
The women had been preoccupied with their bodies throughout life and had many problems with their overweight. All their existence was filled with their big body in more than one sense. In their social contacts food was part of social fulfilment, which caused another problem for them when, at the same time, it involved the risk of a change of their body in an unwanted direction. All their becoming was focused on their body.
The big difference in regard to sex was that the men did not isolate themselves because of their big bodies. Dan because he ignored his overweight, and Erik because he accepted his overweight and lived his body according to Merleau-Ponty's view. The pattern that emerges is related to Parse's paradox of enabling/limiting. The shame of the big body resulted in a negative body image, for which reason the body is hidden in big and loose-fitting clothes. The participants' widely different body image was also reflected in their sexuality, which some of them chose to do without, whereas one participant found that some men are fond of fat women.
Theme 2: To be oneself and to be different
The five interviews showed clear differences in relation to the theme of being oneself and being different. Dan did not think he was overweight, and therefore did not feel different. His social life was not experienced as affected by his body size. It was solely information from the health personnel which made him try to lose weight. In contrast to Dan, Erik lived quite conscious of being different, which he had realized since childhood. Erik's acceptance of his body made him exist in harmony with it (24):
''When I was a little boy I was called the fat one, and I began to seem to be fat at the age of seven. Now we are more of the same sort,'' Erik continued when he told about his earlier problems of buying big clothes.
All three women experienced the disharmony in their lived bodies, both when they were together with others and when they were alone. In relation to the body they found patterns in which to appear, for example by wearing loose-fitting clothes and on the whole to hide.
The otherness was not accepted by the other children. All three who were big in childhood had been bullied. By attending an out-patient clinic the otherness was stressed, and they were subject to the health authorities' opinion of health and not their own view of health. In their meeting with a health person they experienced to be met by a preconceived attitude to their body in the light of Descartes' body image. This contributed to creating patterns which made them hide their body because it was defective.
Theme 3: To want and not to want to lose weight
It appeared that the interviewees had great knowledge of food and its energy composition, but in spite of their knowledge they made choices contrary to that knowledge and continued to be overweight even if they actually wanted to lose weight. Sadness about the body and dietary behaviour were not sufficient for them to lose weight. It is the person herself/himself who must be motivated for a weight loss and receive help to reduce weight. Ann said:
''I know a lot about food, but efforts must be concentrated on avoiding impulse buying.''
Christel said: '' I have no control of food. Suddenly I am at the baker's''.
There was a conflict between knowledge of food and the personal choices made. The difficulty was tochange habits and to stick to them, and it was easy to fall back on previous inappropriate patterns. The awareness of the powerlessness of changed. Patterns had the effect that several of the interviewees were ready to try new medicine to relieve a weight loss. Ann said:
''Overweight is a disease. We are sort of food addicts.''
The participants showed lack of control, which to some extent could be the cause of the condemnation that exists in society in relation to obese persons. ''You are what you eat.''
In the light of Parse's theory the overweight persons did not weigh possibilities of changes but allowed limitations to overshadow their becoming.
The endocrinological out-patient clinic can be looked upon as the last resort after numerous attempts in vain to lose weight. The participants were after all not motivated for weight loss. The out-patient clinic was the first contact with the hospital. Here was an interface between healthy and unhealthy, which not only depended on a diagnosis, but on the particular person's own opinion, which is consistent with Parse's view on health as an individual matter. By attending the out-patient clinic the participants could signal to their circle of acquaintances that they wanted to lose weight to rectify the defects of the body.
Theme 4: Food as a source of social fulfilment or as a comfort
Food intake involved a dilemma. A social dimension was experienced if food was a source of social fulfilment and also an isolation involving compulsive eating. A fat diet was considered the cause of overweight, and dietary habits in childhood were not easy to
change. Some of the interviewees called themselves food addicts and had no control of their food intake. In our culture food is part of social fulfilment, and this resulted in a withdrawal on the part of the female participants who evaded social situations to avoid the temptation of offers of food. This could result in compulsory eating when alone at home with consequent dwindling self-esteem. Isolation becomes a pattern which it is difficult to break. Getting out and being involved was experienced as a fight, and there was a conflict between food as a source of social fulfilment and isolation because of the overweight. Friends said: to Erik:
''You mustn't damned well lose weight and lose your good spirits.''
At the same time visits to the out-patient clinic contributed to breaking the interviewees' isolation. Beth said:
'' For example, I hate help yourself tables. The body wins when I am out.''
Dan said: ''Food is part of social fulfilment in a stable relationship.''
Theme 5: To dare to face the future
The participants feared once more that they would not succeed seen in relation to society's demand for disciplining the body. They seemed to say:'' Once fat always fat''.
None of the five interviewees seemed to see any possibility of choosing not to be overweight in their lives. The question is whether this would make them happier.? For even if they hoped to lose weight a thinner body might reveal unforeseen things which might expose them. Beth said:
''My hope is negative.''
''I must reduce my weight to 100 kilos perhaps NUPO * for a month'' (* brand name of a slimming product)
By pinpointing the meaning of overweight as a disease or absence of health they disclaimed responsibility and wanted to put it on to others in their circle of acquaintancies or to the medical practitioner. All five thought that the practitioner's identification with their weight problems was more important than professional skill.
''If I do not attend the out-patient clinic any longer, I put on weight again,'' said both Ann and Beth.
Sickness or focus on the figures from weight and Body Mass Index (BMI) seemed to point towards making the body an object, which thereby became something distant. The interviewees dared not take the full responsibility for their own lives, and did not make themselves responsible enough for their own process of development. They felt ''hit,'' which made them passive. In summing up the results it can be said that there were individual differences between body image and sex differences as to hiding or wanting to show one's body. That the weight in kilos could not predicate problems with the body and man's becoming. That the body/soul dichotomy was apparent in the participants. They formed individual patterns to cope with relations to others, but felt different. Knowledge of a healthy diet did not lead to any change of habits. Motivation for loss of weight could not be taken for granted. The participants felt powerless and could not change their becoming.
The limited knowledge of the lives of overweight persons shows the demand for more research on the field of overweight persons' lived experiences. Even through these findings, which cannot be generalized beyond this study, health personnel can gain an insight into overweight persons' lives and experiences. Those interviewed are all persons who have recognized their problems of overweight and therefore were referred to the out-patient clinic, and the selection was made among them. If it were to have been persons randomly selected, it could have been overweight persons met in the street. The most important difference is the recognition of the weight problem.
In order to strengthen the validity in a qualitative study it is necessary to validate throughout the entire research process. As early as during the interviews the statements were validated (18). It was considered, for example, how lived experiences were arrived at as lived and not only as observed. Because the hermeneutic concept of truth is seen as relative, the themes studied open up many possibilities of interpretation and make the validity difficult (30).
By considering whether, for example, some of the statements were platitudes compared to real knowledge Kvale's considerations of communicative validation were followed (18). Another essential aspect of validation is how to obtain knowledge of a phenomenon in order to ask meaningful questions. In addition to the theoretical acquisition of knowledge it is important for the researcher to stay for some time in the field, in this case the out-patient clinic in question, where knowledge is gained of everyday routines and the local language.
The validity of the process of analysis was concerned with constructing such meanings from the data material as appeared most adequate (34). Kvale's analysis stages have been followed slavishly, and it has been
attempted to keep them separate in order to secure consistency and to be faithful to the themes arrived at, so that the knowledge gained is sustainable.
In qualitative research there is a discussion about population and a sufficient number of people covered by it (18). The population included in this study consists of five overweight persons, which gave a variation as to sex, weight and social status, but not as to age. The contents of the interviews were considered richly diversified and adequate to cover what it was like living with overweight.
The strength of the study is the topical interest of the subject. Moreover I found on my way through the study that it was important that as an interviewer, I myself was not slender as this contributed to the participants very soon opening up. As Kvale establishes (18), the participant/interviewer relation is important for agood result of the study because the interviewer uses herself or himself as an instrument. Even if the subjectivity of the researcher can become a limiting factor, as too great involvement may have the effect that the researcher's critical aspect is not disclosed, a good relationship was successfully established. The researcher's tool consists of a balanced cognitive and emotional part.
One essential element of the findings was that when the nurse meets an overweight person, the particular person perceives herself/himself as big or not big. But the perception is not immediately linked to the person's body size. When the nurse meets a person for the first time she must understand that even an obese person needs not feel overweight. And also the opposite that a person of normal weight may have many problems associated with the feeling of having too big a body. This can be related to Gadamer's fusion of horizons (22) where the nurse not only views the patient from one angle, but via the dialogue reaches a common understanding. The question is whether the nurse wishes to understand the person behind the weight ?
Related to the Icelandic study (15) Árnadóttir's findings are consistent with the findings of this study, that the perception of weight is an individual matter. The fact that there were great differences between the participants' body image shows that there was a contrast between the perception of a small body versus a big body. The participants lived in a duality as to their subjective perception of the body and body size. Only in the case of one of the interviewees can it be said that he lived his body according to Merleau-Ponty's thoughts. Nevertheless he did not live his body fully, and an influence of Descartes' dual way of imagining ones's body was revealed. The other four participants lived with their bodies at a distance. Likewise they ignored the enormously fat body and made it an object. According to Santopinto, the American nursing researcher (16) women are very preoccupied with the reaction of their surroundings and statements about their bodies, which is of great importance to them. This also appears from Theme 1 with regard to hiding the body.
In spite of the limited number of participants the study seems to point to tendencies towards sex differences relative to body image. The new aspects of lived experiences of overweight showed that the two men were unaffected by their body size. Asking about adults' life with overweight opens up the complexity of life, and many paradoxes were met. It was typical that the women lived in the paradox of withdrawing or involving themselves, as Parse's second principle indicates (24).
This meant that their bodies had an influence on them in their entire becoming. The question is how great an influence the psychical constellation has on the weight development and what overweight is expressive of. The endocrinological out-patient clinic of the hospital contributed to locking them in their perception of being different, for example by stamping them as being ill.
According to Björvell, the Swedish nursing researcher (8), behavioural changes over time are necessary for a successful loss of weight. An interdisciplinary team of medical professionals is a must. The question iswhether the health sector is willing to set aside resources or whether it can afford not to do so ?
If there was not a motivation automatically for loss of weight, even if they were attached to the out-patient clinic, the treatment took a different course. Perhaps loss of weight was not the participants' goal, but they felt pressurized to try the out-patient clinic.What is happiness and quality of life as far as weight loss is concerned is individual. When some participants referred to themselves as food addicts, this can be interpreted as explaining away their problem because they were not able to break their dietary pattern. Some of the participants loved eating and considered food a source of social fulfilment.That they were compulsive eaters when alone may have a psychological explanation. The reason why the participants did not dare to face the future can be due to failing acceptance and low self-esteem.The discovery of an obesity gene will presumably result in less condemnation from the surroundings and provide a rescue for overweight persons.
In summary it can be said that the subject is of topical interest, and many have a firmly rooted opinion on overweight, which may cause condemnation. Today overweight is made an individual matter, even if society
influences our attitude. Therefore, it is important how the nurse tackles the new knowledge of overweight persons' lived experiences and relate to it. This to avoid prejudices when she meets overweight persons in her profession.
In relation to the purpose of the study which was to describe lived experiences of overweight multifarious experience has arrived at. Great differences were seen in the body image of the interviewees, and no unequivocal body image was found. Four out of the five interviewees did not live in conformity with their physical body, but had a distance to it. Great weight fluctuations by way of dietetic treatment did notchange the body image. For the three women it was a dilemma between withdrawing and living alone with their bodies and on the other hand to have social contacts. They wanted to hide their bodies. Throughout life the women had been preoccupied with their bodies, and their entire existence was filled by their big body in more than one sense.
There were clear differences among the participants in relation to being oneself and being different. The participants had great knowledge of food, but in spite of knowledge they made choices contrary to that knowledge and thus continued being overweight. The difficulty was to change habits and to stick to them, and the particular person fell back on previous inexpedient patterns. Some participants referred to themselves as food addicts and had no control of their intake of food. Food is part of social fulfilment in our culture, which resulted in a withdrawal on the part of the female participants, who evaded social contacts to avoid the temptation of offers of food. Getting out and being involved was experienced as a fight, and there was a conflict between food as a source of social fulfilment and isolation due to the overweight. The great difference as far as sex was concerned, was that the men did not isolate themselves because of their big bodies, and they showed their bodies.
The interviewees feared once more to be unsuccessful seen in the light of the demands of society for disciplining the body. None of the five interviewees seemed to see any possibility of choosing not to be obese, and they disclaimed responsibility for their overweight.
The importance of the study
In this hermeneutic study overweight persons' statements have been analysed, and these statements can be considered knowledge gained from practice with a view to understanding overweight persons' lived experiences of their body. Wide use of this knowledge can be made within nursing and nursing research. The study shows that nursing should have a new and different point of departure in connection with obese persons. The obese persons are visible in society. Nevertheless there is silence about the body within nursing. In the encounter between the nurse and the overweight person Parse's proposition of respect and genuine interest for the patient can be seen as a basis of successful nursing. Perhaps the health personnel will have to accept that there are patient groups who cannot be reached with the present nursing education. There may be overweight patients who want to remain overweight, which has to be respected.
In relation to nursing of obese persons the nurse's attitude will be of decisive importance. If one has to work from Parse's theory of nursing and relate to the obese persons, the nurse must learn to step aside and allow the patient's world of living to be in focus. Moreover the nurse must be aware of her prejudices to overweight persons. In understanding Merleau-Ponty's universal thinking the possibility of moving away from reductionistic Cartesianism exists. Merleau-Ponty's body philosophy is a realistic proposition of letting the body come to the fore in nursing.
Successful measures of care can move in two directions. The result may be that the person chooses not to reduce her weight or that the obese person understands the signals of her body in such a way that she becomes motivated to reduce her body weight. Motivation can be brought about via the nurse's genuine interest for her as a person. Not until the person is in harmony with her body may a weight loss, if any, be obtained. At the social level the development of overweight and obesity in the western world is on the rise among those at a disadvantage educationally and socially. From this it will be seen that there is a central social theme in relation to the treatment of obese persons. Overweight is both a sign of lack of control at the individual level and at the social level. Continued research is necessary as there is a rising number of obese persons. For that reason alone nursing is bound to deal with the background of obesity its causes and development and also to think of it in a nursing context.
Ovesen L. Fedme og fedmebehandling og slankeindustrien. København: FADL's debatbøger; 1996; Nr. 11: 9-35.
Kjøller M et al. Sundhed og Sygelighed i Danmark 1994. Og udviklingen siden 1987. København: DIKE; 1995: 9-61, 95-6.
Balle J, Almdal T. Behandling af adipositas i patientgrupper. Ugeskr Laeger 1996; 158/32: 4509-12.
Glanville J, Glenny A, Melville A, O'Meara S, Sharp F, Sheldon T et al. Effective Health Care NHS Centre for Reviews and Dissemination. University of York; Churchill Livingstone 1997; no. 2: 1-12.
Heitmann BL. Body fat in adult Danish population aged 35-65 years: an epidemiological study. Int J Obes 1991; 15:435-54.
Astrup A. Adipositas. In: Lorenzen I, editor. Medicinsk Kompendium; 2. København: Nyt Nordisk Forlag Arnold Busck; 1994. p. 2679-705.
Stunkard A, Wadden TA. Obesity Theory and Therapy. New York: Raven Press Ltd. Second Edition; 1993: 335-53.
Björvell H, Rössner S. Short communication: A ten-year follow-up of weight change in severe obese subjects treated in a combined behavioral modification programme. Macmillan Press Ltd. Int J Obes 1992; (16): 623-5.
Turner BS. Missing bodies, towards a sociology of embodiment. Sociol Health Illn. 13 (2): 265-72.
Ritenbaugh C. Body Size and Shape: A Dialogue of Culture and Biology. Medical Anthropology. 1991; 13: 173-80.
Van Strien T. On the relationship between dieting and ''obese'' and bulimic eating patterns. Int J Eat-Disord; 1996; 19 (1): 83-92.
Markus HR, Kitayama S. Culture and the Self: Implications for Cognition, Emotion, and Motivation. Psychological Review 1991; 98 (2): 224-53.
Butters JW, Cash TF. Cognitive Behavioral Treatment of Women's Body-Image Dissatisfaction. J Consult Clin Psycho 1987; 55 (6): 889-97.
Cash TF, Pruzinski T. Body Images Development, Deviance, and Change. New York London: The Guiford Press 1990; p. 190-214.
Árnadóttir M. Fear of fatness The Young Woman' s Lived Experience of Her Body. Nordiska Hälsovårdshögskolan Göteborg; MPH 1996:8.
Santopinto MDA. The Relentless Drive to be Ever Thinner A Study Using The Phenomenological Method. Nurs Sci Q 1989; (2): 29-36.
Andersen HS. En social epidemi. Sygeplejersken 1997; (4): 38-47.
Kvale S. Inter View. En introduktion til det kvalitative forskningsinterview. København: Hans Reitzels Forlag; 1997.
Hartnack J, Sløk J, editors. Descartes De store tænkere. København: Munksgaard; 1991: 7-43.
Stigen A. Tenkningens historie 1 + 2 Oslo: Ad Notam Gyldendal; Norsk Forlag 1995. p. 347-403, 796-845.
Merleau-Ponty M. Kroppens fænomenologi. Frederiksberg: Det lille Forlag Frederiksberg; 1994. p. 1-195.
Gadamer HG. Truth and Method. Second Revised Edition. London: Sheed & Ward; 1989: 171-380.
Ricoeur P. Från Text till Handling. Stockholm/Stehag: Brutus Östlings Bokförlag; 1993. p. 9-98, 237-44.
Parse RR. Man-Living-Health A Theory Of Nursing. New York: John Wiley & Sons; 1981.
Parse RR. Illuminations The Human Becoming Theory In Practice And Research. New York: National League For Nursing Press; 1995.
Overgaard D. At leve med overvægt en undersøgelse af overvægtiges levede erfaringer. Århus: Skrift-serie fra Danmarks Sygeplejerskehøjskole ved Aarhus Universitet; 1998; nr. 56.
Maunsbach M, Lunde IM. Udvælgelse i kvalitativ forskning i Humanistisk forskning. København: Akademisk Forlag; 1995.
Buhl C. Overvekt og slanking. Oslo: Universitetsforlaget; 1996.
Bunkan BH. Muskelspændinger og kropsbillede. København: Munksgaard; 1989.
Fog J. Med samtalen som udgangspunkt. København: Akademisk Forlag; 1997.
Van Manen M. Researching Lived Experience. State University of New York Press; 1990.
Helsinki-deklaration II Dansk oversættelse, april 1988 bilag 9. Sygeplejerskers samarbejde i Norden (SSN's) etiske retningslinier for sygeplejeforskning i Norden, Bilag 10 i: Den centrale videnskabsetiske komité retsgrundlag og rekommandationer, Forskningsrådene; 1994.
Løgstrup KE. Ophav og omgivelser. København: Gyldendal; 1984: 105-60.
Jørgensen PS. Generalisering i kvalitativ forskning. København: Akademisk Forlag; 1995.
Thanks to Elisabeth O.C. Hall, lecturer at Danmarks Sygeplejerskehøjskole, Aarhus, for valuable comments.