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- IMPLICATIONS FOR PRACTICE

SchoIaTIy PTCjeCt foI the Degree (If M S N
‘ MICHIGAN STATE UNIVERSITY
CINDY K TOKARZ
- 1999 ' '

 

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ASSESSMENT 0F.ADVANCED PRACTICE NURSE’S.ATTITUDES TOWARD
CLIENTS WHO PRESENT WITH WEIGHT-RELATED CONCERNS IN
PRIMARY CARE: IMPLICATIONS FOR PRACTICE

BY
Cindy K. Tokarz

A.SCHOLARLY PROJECT

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1999

ABSTRACT
ASSESSMENT OF.ADVANCED PRACTICE NURSE’S ATTITUDES TOWARD

CLIENTS WHO PRESENT WITH WEIGHT-RELATED CONCERNS IN PRIMARY
CARE: IMPLICATIONS FOR PRACTICE

BY

Cindy K. Tokarz

Current literature supports the ineffectiveness and
probable physiological and psychological risks of popular
weight loss regimens. Advanced Practice Nurses (APNs)
frequently counsel primary care clients who present with
weight-related concerns. Because traditional methods of
weight and diet counseling have been shown to ineffective,
APNs need to learn newer, more effective and compassionate
approaches for counseling these clients.

This paper reports the development of an assessment to
examine APN's attitudes toward clients presenting with
weight-related concerns. This assessment will function as a
beginning step for the APN in appraising and determining his
or her attitudes toward large clients in the primary care
setting. This initial step is important because research has
shown that health professionals share the negative attitudes
of the general public toward larger-than-average clients.
Negative attitudes of health care professionals are likely
to impair the effectiveness of weight-focused counseling

interventions for these clients.

To my family for all their sacrifices and help in

reaching my dream

iii

ACKNOWLEDGMENTS

I would like to thank my mentor and chairperson,
Celia Wills, for all the guidance, assistance,
understanding, and setting realistic deadlines for myself to
complete this scholarly project. I would also like to thank
my other committee members, Brigid Warren and Jon Robison,
for their ongoing support and feedback, and for the time
they devoted to reviewing the many versions of this

scholarly project.

iv

TABLE OF CONTENTS

LIST OF FIGURES ......................................... Vi
INTRODUCTION ............................................. 1
PROJECT PURPOSE .......................................... 5
THEORETICAL FRAMEWORK .................................... 7
Prochaska’s Model ................................... 8
Watson's Model ...................................... 9
Conceptual Definitions ............................. l4
Adapted Conceptual Model ........................... 15
REVIEW OF LITERATURE .................................... 18
Current Weight Paradigm ............................ 18
Personal Attitudes ................................. 24
New Weight Paradigm ................................ 28
PROJECT DEVELOPMENT PLAN ................................ 33
IMPLICATIONS FOR THE APN ................................ 38
REFERENCES .............................................. 41
APPENDIX A: GLOSSARY .' ................................... 50
.APPENDIX B: PROCHASKA’S MODEL ........................... 52
APPENDIX C: WATSON’S CARATIVE FACTORS ................... 53
APPENDIX D: ATTITUDES TOWARD OBESE PERSONS IATOP) ....... 54
APPENDIX E: ATTITUDES TOWARD OBESE.ADULT PATIENTS ....... 56
APPENDIX F: FAT PHOBIA.SCALE (FPS) ...................... 57

LIST OF FIGURES

Figure Page
1 Watson’s Model of Humanistic Caring .................... 10
2 An Adapted Model of a Caring Relationship .............. 17

vi

INTRODUCTION

Obesity, an excess of body fat, has long been
considered an epidemic throughout the United States. Body
mass index (BMI), defined as weight (in kilograms) divided
by height (in meters) squared, is the medical standard used
to define obesity. A.BMI greater than 27 indicates obesity
(Thomas, 1995). Healthful weights are defined as those
associated with BMIs of 19 to 25 (Meisler & St. Jeor, 1996).
The latest national survey data demonstrates a striking
increase in obesity in all segments of the population during
the last 20 years (Kuczmarski, Flegal, Campbell, & Johnson,
1994)..As a nation that “eats too much and exercises too
little,” the US has been accused of exporting an obesity-
prone lifestyle to other nations around the globe. The
weight loss industry accounts for nearly 50 billion dollars
annually, and about 65 million Americans are dieting at any
one time (Robison, 1997). Weight loss programs produce short
term effects, with a 90 to 98% failure rate, with dieters
regaining the lost weight within two to five years (National
Institutes of Health, 1992).

Fraser (1997) and Gaesser (1996) report that Americans
today are “obsessed” by weight loss and dieting. The reasons
given for dieting often stem from the purported health

benefits of weight loss and the societal pressures to be

thin. Traditional advertisements have used thin models and
have added to the creation of the current weight paradigm
that equates obesity with poor health. What has resulted
from this “obsession” are large percentages of chronic
dieters who have lost pounds for a short time, not only

regaining the lost weight, but often additional weight.

An epidemic of serious eating disorders, anorexia
nervosa and bulimia, has been exacerbated by a weight-
preoccupied society. Approximately 50 percent of adolescent
and young adult age women are dieting, even though at least
half of these individuals are at or below normal weight
(Centers for Disease Control, 1991). These young girls and
women feel pressured to spend significant amounts of their
energy and resources in pursuit of an “ideal” body shape and
size that, for the vast majority, is neither achievable nor
healthy (Fallon, Katzman, & Wooley, 1994). Eating disorders
affect men as well, reflecting a dissatisfaction with one's
own natural body and an intense desire to change it (Berg,
1995). According to Berg (1995), the current high rates of
eating disorders are believed by many specialists to be the
inevitable outcome of 60 to 80 million Americans dieting,
losing weight, rebounding, and learning to be chronic
dieters. Also, most professionals agree that dieting
precedes the onset of an eating disorder, and dieting is
suggested as an important step in the progression from

weight dissatisfaction to binge eating (Parham, 1996;

Gaesser, 1996). The result of Americans having this
preoccupation with weight is not only an increase in the
incidence of eating disorders, but also it may contribute to
the increase in overweight. (Polivy, 1996). Both of these
conditions in turn lead to lowered self-esteem, body image,

quality of life, and health status (Wooley & Garner, 1991).

Our culture’s preoccupation with thinness has resulted in
social stigma that causes tremendous suffering and social
isolation for individuals of larger-than-average size.
American society labels obese people as “weak-willed,”
“ugly,” and “awkward,” and there is evidence that obese
people are discriminated against because of their weight
(Murphree, 1994). Obesity research and health interventions
to reduce weight need to be more closely examined. Although
severe obesity is clearly associated with increased
mortality, the health consequences of being mildly to
moderately overweight remain controversial (Ernsberger &
Haskew, 1987; Pamuk, et al., 1992; Troiano, Frongillo,
Sobal, & Levitsky, 1996).

Despite evidence that the current diet paradigm is not
effective in producing lasting change, and growing evidence
of potentially dangerous physical and psychological
consequences of dieting, weight-related research and
interventions continue to focus on the promotion of weight
loss through dietary restriction. The current diet paradigm

applies a model of therapy: behavior interventions of

dieting, which are not supported as effective in research on
behavior change (Glanz, Lewis, & Rimer, 1997). These models
of therapy are theories of personality and psychopathology
which deal with why people do not change and are not
consistent with research on stages of behavior change
(Prochaska, 1992). Effective treatment for obesity should
focus on strategies that can produce health benefits
independently of weight loss (National Institutes of Health,
1992; Kratina, King, & Hayes, 1996).

There is a need in the primary care setting for an
introduction of a new paradigm for weight management, one
which does not consider “fat”(for definition see Appendix A)
a fatal disease. With the immense social stigma associated
with being “overweight” (for definition see Appendix A),
weight lossis a predominant reason for patients coming to
their primary care provider (Wooley & Garner, 1991). It is
also one of the most commonly prescribed interventions to
treat chronic conditions such as heart disease,
hypertension, and diabetes. In addition, obese patients
encounter great social stigmatization, and research
literature shows that these patients often encounter similar
discrimination when dealing with health professionals who
are supposed to be helping them (Maroney & Golub, 1992;
McArthur & Ross, 1997; Sobal & Devine, 1995).

Most counseling of patients by advanced practice nurses
(APNs) around weight-related concerns occurs in primary care

(Allison, 1995; Keller, Oveland, & Hudson, 1997). As

professionals, seeking to enhance the health of large
people, APNs must be sensitive to the devastating effects of
“fatism” (for definition see Appendix A), and be willing to
examine their own assumptions, beliefs, and behaviors (Berg,
1995; Kratina et al., 1996). In addition, it is important
for APNs to gain an understanding of the new weight paradigm
to enable them in guiding and motivating patients to a
healthier lifestyle.
PROJECT PURPOSE

The purpose of this project was to develop an
assessment to examine APN's attitudes toward clients who
present with weight-related concerns in primary care.
Prochaska and Watson provided the theoretical perspectives
for the basis of this project. The project specifically
focuses on objective number 2 (*) listed below. An entire
(comprehensive) educational module is outlined in the
Project Development Plan section, and addresses the
remaining objectives. The overall goal of the module is for
APNs to gain an understanding of the new weight paradigm and
to learn new approaches for working with their clients
effectively and compassionately. The specific objectives of
the project are:

1. Examine the current paradigm of dieting and review

the information regarding failure rates and the

risks involved in weight fluctuation.

*2.

Examine personal attitudes about obesity and how
these attitudes are communicated to obese and/or
overweight patients.

Present information on the association of weight
and health risks.

Explore a new weight paradigm focusing on
healthier lifestyle which includes elements of
physical activity, normalizing eating habits, and
promotion of self-acceptance and self-esteem.
Develop interventions relative to client

readiness.

THEORETICAL FRAMEWORK

This project is based on two theoretical perspectives:
Prochaska’s (1992) processes of human behavior change and
Watson’s humanistic caring (1985). Two models were chosen as
Prochaska’s model does not provide a fully sufficient
conceptualization to guide the project, but is successfully
utilized in combination with Watson's model, which adds
essential holistic sensitivity aspects.

There are certain assumptions inherent in these
frameworks which are important in helping the.APN guide
interventions when working with clients on weight-related
problems. An “intervention” is a concept defined as an act
performed to improve the mental, emotional, or physical
function of a patient (Anderson, Anderson, and Glanze,
1998).

A key assumption from Prochaska is that it is important
to assess “where the client is” relative to making behavior
changes. “Behavior change” can be defined as new behaviors
that clients willingly undertake to achieve self-selected
goals or desired outcomes (Pender, 1996). Before introducing
interventions leading to a healthier lifestyle, these
interventions should be based on the clinical assessment.
Behavior change is complex, and involves the human aspect,
not just a systematic passage through a sequence of stages.
A linear progression through stages of change is rare; most
people relapse at some point (Prochaska, 1994). During

relapse, individuals go back to functioning at an earlier

stage of change. Some relapsers feel like failures-
embarrassed, ashamed, and guilty, becoming demoralized, and
resist thinking about behavior change (Prochaska,
DiClemente, & Norcross, 1992).

A key assumption from Watson is that the client-nurse
relationship is approached on the basis of compassion and
caring. Another assumption applicable to compassion and
client readiness is that a caring environment offers the
development of potential while allowing the person to choose
the best action for themselves at a given point in time
(Fitzpatrick & Whall, 1996). The client’s life context,
including barriers to change, must be considered when a
client is ready to explore options for a healthier
lifestyle. For example, a client may be going through a
divorce, changing a job, or experiencing an illness; these
issues may assume priority at first.

Prochaska's Model

 

Dr. James O. Prochaska (1992) developed the
Transtheoretical Model to explain how people change and what
is involved in successful behavior change. He has identified
six stages of behavior change: precontemplation,
contemplation, preparation, action, maintenance, and
termination (see Appendix B for model). Although Prochaska
presents an analysis of weight loss in his research on
behavior change, weight loss itself is not a behavior
change, but an outcome of interventions which lead to a

healthier lifestyle. Prochaska’s model is helpful in trying

to determine where the patient is on the trajectory of
change and to implement interventions which are appropriate
for a given stage of change.

According to Prochaska (1994) the reason people do not
exercise and eat less fat is because change does not begin
with action even when they know these things are “good” for
them. Whenever advice to change starts with action, as
consistent with assumptions of the current diet paradigm, it
sets up failure. Cessation of problem behaviors or
installation of more adaptive responses does not occur
automatically with one bold action or effort; change
requires movement through successive stages in order to
achieve maintained cessation or initiation (Prochaska &
DiClemente, 1992). Effective change depends on engaging the
right process at the right time.

Watson's Model

 

Jean Watson developed a model of nursing that uses
humanistic caring as the framework for nursing intervention
(Watson, 1985). The Theory of Human Caring applies to this
project’s central theme of creating a therapeutic
relationship to facilitate healthy change. The major
concepts of Watson's (1985) model are human care,
transpersonal caring relationship, carative factors, self,
phenomenal field, event, and an actual caring occasion (for
definitions see Appendix A). Watson's model of humanistic

caring is shown in Figure 1.

'stic caring.
1 Watson's model of humani

' re . .

Tagzson, 1985, p. 59)

 

”IV
MI)

ll .40)
a
c I" I

5 If(

10

For the purposes of this project, an APN will be
defined as a nurse practitioner prepared at the master’s
level, who utilizes transpersonal caring relationships in
working with patients who present with weight—related

concerns in primary care. A transpersonal caring

 

relationship is defined by Watson (1985) as a specific type

 

of professional human-to-human contact having the goal of
restoring the patient's experience of inner harmony. The APN

uses and discloses self while engaging in the phenomenal

 

fields of the other. When both parties choose to be in a
transpersonal caring relationship, a new phenomenal field is
created that is different from the unique fields of the APN

and patient.

Watson describes the carative factors as intervention

 

processes or modalities used in a transpersonal caring
relationship (see Appendix C for list). The fourth factor,
development of a helping-trust relationship, is directly
linked to the process of empathy. Wheeler and Barrett (1994)
define empathy as the capacity to understand other’s
feelings as if they were their own, while remaining fully
aware of their own identity. Wheeler and Barrett (1994) also
state that empathy is the quality responsible for creating a
caring environment. Empathy is considered crucial to caring
and assists the development of a helping-trust relationship
between the APN and patient. The process of empathy relates

to this project's overall goal of enabling APN's to use

11

their coaching/counseling role to effectively assist
patients to make positive changes to improve the quality of

their lives regardless of weight status.

An event occurs when two people with their unique
histories and phenomenal fields engage in a human care

transaction. An actual caring occasion, a particular type of

 

event, is the result of a transpersonal caring relationship,
and has a phenomenal field that is unique to the event and
greater than the actual time-bound occasion (Fawcett, 1993).
It involves actions and choice by the APN and the
individual. The moment of coming together in a caring
occasion presents the two persons with the opportunity to
decide how to be in the relationship-what to do with the

moment.

Watson also defines a human being as a valued person to
be cared for, respected, nurtured, understood, and assisted.
In relation to this project, the concept of human care is
important in dispelling the prejudice against large people,
or sometimes called “fatism” (Kratina et al., 1996). As
professionals who seek to enhance the health of large
people, APNs must be sensitive to the devastating effects of
fatism, and be willing to examine their own assumptions,
beliefs, and behaviors. Watson contends that caring can
assist the patient to gain control, become knowledgeable,

and promote health changes (George, 1995).

12

Watson is the only nursing theorist who assigns special
significance in human existence to the soul. The
characteristics relating to the soul that she identifies are
self-awareness, high and greater degrees of consciousness,
inner strength and power (Nicoll, 1997). These
characteristics relate to the importance of APN’s educator
role by helping patients develop normalized eating skills by
becoming aware of their body's inner signals and feelings,
and to help examine their souls to gain the strength and

power to love the body they already have. Instillation of

 

faith-hope, the 2nd carative factor, also describes the

 

APN's role in promoting wellness by helping the patient
adopt positive health behaviors. Harmony of body and soul is
important in the APN’s holistic approach in the
relationship. Holistic care is the basis of the traditional

nursing model.

Furthermore, Watson's theory acknowledges the concept

of causal past and proposes that a troubled inner soul can

 

lead to underlying causes of unhealthy behaviors thereby
producing illness. This concept relates to a weight cycling
patient, who from repeated experiences of weight gain in the
past, directly effects their health physically with the
development of other diseases, and psychologically by
creating feelings of depression, shame, and disappointment.
The goal of the APN utilizing their coaching/counseling role

is to assist the patient to a healthful lifestyle that can

13

be maintained indefinitely, rather than a short term “diet”
that will most likely be abandoned and produce more

overweight and psychological discomfort (Polivy, 1995).

Conceptual Definitions

 

To aid in the understanding of the adapted model for

the project, definitions of the key concepts of knowledge,

 

attitude, paradigms, current weight paradigm, and new weight

 

 

 

paradigm are defined. The dictionary's (Merriam-Webster,
1994) definition of knowledge is information acquired
through learning or the condition of being aware of
something. Attitude is defined as a learned tendency that
can change with new information (Pender, 1996). Paradigms
are defined by Kratina et al. (1996) as the theoretical
frameworks by which professional practices are formulated,
evaluated, and adapted. Paradigms can shift due to repeated
experiences with limitations and failures of existing
paradigms (Robison, 1997). The current weight or traditional
diet paradigm is a concept also defined by Kratina et al.
(1996) that teaches that there is a lean optimal body weight
for all persons to maintain and achieve and is used as a
measure of success. This paradigm argues that diets are
necessary because the incidence of disease and premature
death increases in direct proportion to body weight. Kratina
et al. defines the new weight or non-dieting weight paradigm
as a concept that focuses on a healthy lifestyle regardless

of weight status; it is a holistic, nondiet view that

14

recognizes the many dimensions of personal health, including

its physical, emotional, mental, and spiritual aspects.

Adapted Conceptual Model

 

For the purpose of this project, an adapted conceptual
model has been developed to represent the relationship of
empathy within Watson's theory (see Figure 2). Depicted in
the model is that by increasing the knowledge of the.APN of
the current and new weight paradigms with the associated
weight and health risks, and by increasing positive
attitudes of the APN, interventions of the APN result which
are positive. At the same time, the APN is sensitive to
assessing where the patient is in terms of readiness for
change. This model shows the worlds of the nurse and patient
merging in an exchange of their feelings in the present

moment and empathy occurs. The future and past of both

 

selves (APN and patient) are influences of the interaction.
The outcome of this transaction is a transpersonal caring
relationship which results in motivating positive patient
behavior to the new weight paradigm. These specific patient
behaviors include normalized eating habits, pleasure driven
physical activity, self acceptance and increased self-
esteem, with the resulting overall goal of a healthy
lifestyle regardless of weight status. The ability of the
APN to have empathy for the patient gives depth and meaning
to the relationship, adding a dimension of real

understanding and communication between the participants.

15

Prochaska’s spiral model of stages of change is
conceptually consistent within Watson's theory of human
caring in relation to this project. In Prochaska’s
contemplation and preparation stages, it is important for
the individual to become more aware of themselves and their
behavior by seeking new information, understanding and
feedback. Change does not begin with action and
prerequisites of awareness, decision making, and readiness
are necessities in contemplation and preparation. Watson’s
theory is consistent here as it contends that caring aids
the patient in gaining control, becoming knowledgeable, and
promoting health change. Furthermore, Prochaska's action
stage utilizes helping relationships for support during
attempts to change behavior from individuals (APNs) who
understand and care about their behavior. This is congruent
with Watson's central theme of creating a therapeutic
helping-trust relationship by using empathy to promote

healthy changes thereby leading to a healthy lifestyle.

16

Figgre 2. An adapted model of a caring relationship.

 

 

 

 

 

 

 

 

A. B.
INCREASE KNOWLEDGE of APN INCREASE POSITIVE
A TTITUDES of APN
0 Current weight paradigm
0 New weight paradigm
0 Weight & health risks
1 J

 

c. I

POSITIVE INTERVENTIONS of APN
(Assess patient readiness)

 

 

 

 

 

  
   

 
    
 
    
 

Futu EMPA THY ture
occurs here Patient’s
Present moment world
PI ~ Perception & feelings Past

exchanged

 

Transpersonal Caring
Relationsz formed

 

Guides & motivates positive patient behavior to
NEW WEIGHT PARADIGM

1. Normalized eating

2. Pleasure driven physical activity

3. Self acceptance and increased self-esteem

"‘ Overall Goal: Healthy lifestyle regardless
of weight status

 

 

 

* Caption: This project focuses on “B,” attitudes of APNs

A. = Increasing the knowledge of the APN

*B. = Increase positive attitudes of APN
C. = APNs are now intervening using knowledge of the New Weight Paradigm
D. = Clinical Outcomes for patients

17

REVIEW OF LITERATURE

Current Weight Paradigm

 

Diets, as defined in the traditional paradigm,
prescribe restrictions on usual eating behavior (Kratina et
al., 1996). The restrictions could be on calories, type of
food, or time when food could be eaten. Research shows these
types of restrictions do not work. The resulting effect is
exactly the opposite of what the dieter intended. Starvation
and self-imposed dieting appear to result in eating binges
once food is available as well as psychological
manifestations such as preoccupation with food and eating
and distractibility (Polivy, 1996). This diet/binge cycle is
very common among those who diet frequently.

All dietary weight loss programs are able to
demonstrate moderate Success in promoting at least some
short-term weight loss, but there is virtually no evidence
that significant weight loss can be maintained over the
long-term by the vast majority of people (National
Institutes of Health, 1992). Because health professionals
recommend weight loss as the treatment of choice for people
who are judged to be overweight, it appears that health care
providers as a whole need to become more knowledgeable about
the relationship of body weight and health (Garner & Wooley,
1991).

Few studies in the medical literature indicate weight
loss decreases mortality risk. According to Manson et al.

(1995), in examining the results of the Nurses’ Health

18

Study, there is not conclusive evidence to support that
weight loss increases longevity, and conversely, weight loss
may increase mortality. Other studies have indicated that
weight loss may actually contribute to a shortened life
span. For example, Ernsberger and Haskew (1987) found that
weight reduction in obese people was associated with a
nearly two-fold increase in probability of dying. According
to Gaesser (1996) and Berg (1995), research shows that fat
people have a lower incidence of and mortality from lung and
breast cancer, decreased overall cancer rates and increased
survival, decreased osteoporosis and number of hip
fractures, decreased lung diseases, and decreased incidence
of infectious diseases, especially tuberculosis. “Many of
the cardiovascular changes in obesity, such as increased
cardiac output, can be attributed to increased lean body
mass, rather than adipose stores” (Ernsberger & Haskew, p.
30). Furthermore, it has been shown that body shape is of
great importance in determining such health risks as
cardiovascular disorders. This is significant when one
considers that heart disease is the leading cause of death.
The person whose body fat is concentrated in the abdominal
area is at greater risk. Thus, “the highest mortality (29%)
is in lean persons who have relatively narrow hips relative
to their waist” (Ernsberger, 1989, p. 129).

The relationship of obesity to an increased incidence
of cardiovascular disease and all-cause mortality has been

questioned because of conflicting results from

19

epidemiological studies (Garner & Wooley, 1991). “The data
linking overweight and death, as well as the data showing
the beneficial effects of weight loss, are limited,
fragmentary, and often ambiguous” (Kassirer & Angell, 1998).
Most of the evidence has been derived from epidemiologic
studies which have serious methodologic flaws. Kassirer and
Angell (1998) also stated that many of these studies fail to
account for a number of extraneous variables that may be
important to conclusions of the studies. An example given is
that mortality among obese people may be misleadingly high
because overweight people are more likely to be sedentary
and of low socioeconomic status. Therefore, although some
claim that every year 300,000 deaths in the U.S. are caused
by obesity, the validity of this research has not been well
established. Study conclusions may be derived from weak
data, and also questionable on methodological grounds
(Kassirer & Angell, 1998).

The medical profession considers obesity to be a
chronic disease that increases the likelihood of premature
morbidity and mortality. Because of the assumption that
obesity is synonymous with poor health, people have become
accustomed to viewing obesity as illness. Although severe
obesity is clearly associated with increased mortality, the
health consequences of being mildly to moderately overweight
remain controversial. Leanness has been linked to elevated
mortality in several studies (Manson et al., 1995; Troiano

et al., 1996).

20

In some studies, the health risks associated with being
fat do not escalate until severely obese, or about 75 to 100
pounds over an ideal weight. Severe obesity means a BMI of
35 or heavier (Gaesser, 1996). Overweight does not mean the
same as obese. Overweight, defined as a BMI of 27 to 30, is
termed by some researchers as “mildly obese,” and is not
associated with poor health. Several studies found that
obese people who exercise live longer than lean people who
do not exercise. They discovered that being heavy did not
increase the risk of dying prematurely, but when considered
in combination with fitness level, being overweight seemed
to be better than being underweight according to Blair et
al. (1989), Ekelund et al. (1988), Paffenbarger et al.
(1986), as cited in Garner and Wooley (1991, p. 763).
Inactivity may be the cause of many of the problems
associated with obesity, not obesity itself (Troiano et al.,
1996).

Permanent weight loss is almost impossible to maintain
and the effects of yo-yo dieting appear to be deleterious.
Yo-yo dieters develop a constant cycle of weight loss and
gain which is called weight cycling or “yo-yoing,” resulting
in adverse effects on their health status, physiologically
and psychologically (Foreyt et al., 1995). Recent research
has shown that this cycling has health consequences for a
number of people and it has been suggested that people have
a biologically determined natural weight which they would be

better off maintaining (Wooley & Garner, 1991; Brownell &

21

Rodin, 1994). The weight cyclers or “yo-yoers,” by gaining
and losing considerable amount of weight, are found to have
higher rates of heart disease due to the artery-clogging
increases in cholesterol during the weight-regaining phase
of the cycle (Gaesser, 1996).

In a study done by Foreyt et al. (1995), an attempt was
made to determine psychological correlates of weight
fluctuation. Nonfluctuators reported significantly higher
general well-being, greater self-efficacy, and lower stress
than weight fluctuators, regardless of body weight. People
with a history of weight cycling showed greater pathologic
characteristics than people with stable weights, independent
of weight. Results suggested that weight fluctuation is
strongly associated with negative psychological attributes
in both normal weight and obese individuals.

The negative societal attitude toward obesity finds its
way into medical as well as standard dictionaries, where the
word is typically defined as “excessive bodily fat,”
“excessive weight,” or “grown fat by eating.” Gaesser (1996)
stated that dictionaries do not generally distinguish
between “fat” and “weight,” a distinction that has become
fashionable only in the last couple of decades. Other
definitions of obesity used at various times, now and in the
past, are 20 percent or more over “ideal” or “desirable”
weight (National Institutes of Health, 1992). Because
obesity is usually measured using either body weight, body

mass index, or percentage of body fat, pathological levels

22

of any of these measures are most often decided using
guidelines based on height and weight charts originally
developed by the life insurance companies. These
recommendations, unfortunately, suffer from a lack of
scientific validity. According to Garner and Wooley (1991),
the use of height and weight tables to define obesity is
arbitrary as there is no consideration of the different
shapes and sizes of bodies.

Health professionals have advised their patients to
lose weight as a preventative measure to reduce chronic
disease and early death (Ernsberger & Haskew, 1987; Garner &
Wooley, 1991). The opinion that weight loss or dieting is a
benign activity, has not been questioned until relatively
recently. The American Dietetic Association (1997) has
stated that there is only a 5% success rate for the
maintenance of weight loss, and success was defined as
weight loss with maintenance for only 1 year. Despite these
figures it has been estimated that at any one time
approximately 25% of men and 45% of women are trying to lose
weight (Williamson et al., 1992). With the failure of
dieting, it has been documented that there is an increased
incidence of negative cognitive states (Foreyt et al., 1995;
Polivy, 1996). Depression is one of the most common
diagnoses in primary care, with an estimated one in eight
people requiring treatment during their lifetime (Depression
Guideline Panel, 1993). Psychological treatment of obese

people often centers on looking for underlying emotional

23

problems that led to obesity (Wooley & Garner, 1991). For
many people, there are no underlying emotional problems and
therapy may create problems where there were none (Burgand &
Lyons, 1991; Kratina et al., 1996; Hirschmann & Munter,
1995).

Diets for weight reduction have always been an easy
intervention for the professional. If the diet failed, it
was the patient’s fault. Of course, the diet companies did
not mind either because these failures kept an ample supply
of new recruits wanting a quick and easy remedy. Previous
studies have shown the five year success rate to be low. One
in twenty who try will reach their weight loss goal. The
National Institutes of Health (1992) emphasizes that there
have been few scientific studies evaluating the safety and
effectiveness of most weight loss methods. Most health care
professionals are trained in college to give advice based on
the traditional medical model. Research suggests that
guidance, rather than advising, is actually more effective
in helping people change lifestyle (Reiff & Reiff, 1992).
Giving advice is much more specific and time-efficient than
providing a client with guidance (Kratina et al., 1996).

Personal Attitudes

 

The ways that health professionals have been educated
have fostered negative attitudes towards overweight clients.
There are many definitions of attitude in the psychology
literature and several in health practice sources. Several

conceptualizations were incorporated from the literature to

24

define attitude for this project. Attitude was viewed as a
concept that could change with new information, and the
values of the individual had an influence on the attitude.
Furthermore, an attitude, which could be either positive or
negative, was a learned tendency based on personal beliefs,

values, perceptions, and experiences.

Obesity is one of the last conditions in the United
States in which prejudice is still socially acceptable
(Segal-Iaacson, 1996). This is a vast problem considering
that more than one-third of U.S. adults are overweight
(Kuczmarski et al., 1994). Bias against overweight people,
“fattism” or “fat oppression,” extends to many areas in life
and drives the need to diet and lose weight (Berg, 1995).
Discrimination against the overweight is prevalent in hiring
and promotion opportunities, in education, in life
insurance, and everyday social relationships (Sobal &
Devine, 1995). As a result, the overweight have come to be
judged on the basis of their appearance rather than upon

their character.

Research has shown that US health professionals share
in the negative attitudes of the general public of the obese
and assume that they bring on their condition on themselves
through lack of willpower and self-control (Garner & Wooley,
1991). A recent study by McArthur and Ross (1997) assessed
the attitudes of dietitians toward personal overweight and

overweight clients. Results showed that dietitians believed

25

that client overweight was due to emotional factors and that
overweight clients can not set realistic goals for weight
loss. It was also shown that dietitians had more positive
attitudes toward personal overweight status than toward

overweight clients.

Another study by Bagley et al. (1989) referenced
similar findings of prejudice against overweight patients
and demonstrated nurses’ withdrawal from obese patients. It
was noted that older nurses exhibited more withdrawal which
may have been attributed with fear of lifting. The study
also found that nurses with more years of professional
education had more favorable attitudes toward the obese.
Another finding was that dissatisfaction with own body
weight was linked to negative attitudes towards obese
adults. A comparable study by Maroney and Golub (1992),
regarding nurses' attitudes toward obese persons, found
similar results with negative stereotypic attitudes toward
the obese. They reported that nurses felt uncomfortable,
physically exhausted and psychologically stressed when
caring for an obese patient. Both studies concluded with the
need for continued education in the care of unpopular obese

patients to reduce some of this stigmatization.

Several classic studies show that physicians also hold
negative attitudes toward the obese. Maddox, Back, and
Liederman (1968) found that physicians regarded overweight

patients as weak-willed, ugly and awkward. Maiman et al.

26

(1968) discovered that 84% of physicians and health
professionals considered the obese to be self-indulgent, 88%
assumed they ate to compensate for other problems, and 70%
assumed they were emotionally disturbed. Lazare (1987)
suggests that physicians may deal with their patients in a
negative way because they, themselves, are feeling shame and
humiliation when their therapy is not producing the desired

result.

Since women are more likely to be judged on how they
look, the stigmatization of overweight and obese women
exceeds that of men. Unfortunately, many women delay or
avoid needed health care because they are overweight and
fear being criticized or embarrassed. Olson, Schumaker, and
Yawn (1994) found that this occurs even when the women are
health care providers themselves. In addition, many
physicians report that they are reluctant to perform
preventative health exams on obese patients (Adams, Smith,

Wilbur, & Gray 1993).

Not surprisingly, these negative stereotypical views of
the obese begin in early childhood. Studies indicated that
children as young as six already understood the importance
of looking good and being thin and expressed consistent
aversion to “chubby silhouettes” (Goldfield & Chrisler,
1995). Other frequently cited historical studies have shown
that by grade school children associated larger body shapes

with adjectives such as “stupid,” “dirty,” “sloppy,” “mean,”

27

and “sad” (Staffieri, 1967; Staffieri, 1972; Lerner &
Gellert, 1969).

Presently, there are great limitations in what can be
predicted or safely accomplished in terms of permanent,
significant weight loss (Ernsberger & Haskew, 1987; Berg,
1995). Health care professionals need to recognize that it
is unrealistic for most people to attain society’s ideal
weight and instead need to guide patients toward the new
paradigm. Differences need to be accepted, not scorned.
There is great human diversity in genetics, body size, and
shape. APNs, in their role as primary care providers, have a
need for evaluating their own attitudes towards patients'
overweight to successfully affect patient outcomes.

New Weight Paradigm

 

The new weight or non-dieting paradigm is'a concept
that moves away from diets and focuses on total health
rather than on the number of pounds on the scale. Weight is
only a single measurement, which may or may not have a
direct bearing on health status. Being overweight according
to the height and weight charts does not automatically imply
poor health, just as being “ideal weight” does not guarantee
good health (Kassirer & Angell, 1998). The overall goal in
the nondiet approach is to support a healthy lifestyle by
focusing on four basic tenents (Kratina et al., 1996;
Robison, 1997) (See list of four basic tenants at end of

this section).

28

An important aspect in the new weight paradigm, which
needs addressing, is the terminology used to describe the
relationship between health and weight. In order to work
compassionately and effectively with clients with weight-
related concerns, it is important for new paradigm
practitioners to avoid such labels as obese, overweight,
overfat, and morbidly obese (Robison & Erdman, 1998). It is
recommended that they not be used as not only are they not
compassionate, but they are not scientifically defensible
(Garner & Wooley, 1991; Kassirer & Angell, 1998).

Many health professionals, APNs as well as physicians,
have not been introduced to the new non-dieting weight
paradigm. They do not realize that a person can be “fit and
fat,” and continue to prescribe disastrous interventions
such as restricted calorie diets, instead of treating the
underlying health conditions (Berg, 1995). The underlying
causes of overweight are unknown. The National Institutes of
Health (1992) notes that “increasing physiological,
biochemical and genetic evidence suggests that overweight is
not a simple problem of will power, as is sometimes implied,
but a complex disorder of appetite regulation and energy
metabolism” (p. 943).

The APN can use other interventions in place of
promoting restrictive eating. The role of the APN in the
non-diet approach is to facilitate a path to self-care.
Unlike a diet, this new paradigm is not a quick fix. “If

indeed the lifestyle factors are responsible for health

29

risks, then it may be more prudent to focus directly on
lifestyle rather than obesity, where treatment compliance
and long term weight reduction results have been so poor”
(Garner & Wooley, 1991, p. 761).

The literature indicates that an active lifestyle, with
normalized eating habits will promote health and well-being,
even without the achievement of weight loss (Kratina et al.,

1996). In their book, Moving Away From Diets, (p. 6), the

 

authors cite four basic tenets the new paradigm is concerned

 

with:

1. Total health enhancement and well-being, rather
than weight loss or achieving a specific ideal
weight.

2. Self-acceptance and respect for the diversity of
healthy, beautiful bodies, rather than the pursuit
of an idealized weight at all cost.

3. The pleasure of eating well, based on internal
cues of hunger and satiety, rather than on
external food plans or diets.

4. The joy of movement, encouraging all physical
activities rather than prescribing a specific
routine of regimented exercise.

Erdman (1996) advises large women to “eat healthfully

(no diets); move your body because it feels good, not
because you think it will help you to lose weight; and get
on with your life” (p. 21). In addition, exercise has been

shown to produce significant improvements in blood pressure,

30

lowered lipoproteins, lowered fasting plasma insulin,
reduced stress, and there is evidence that physical fitness
reduces mortality (Garner & Wooley, 1991). Many larger
individuals may be too discouraged to engage in exercise for
fear of the embarrassment and ridicule that they have
experienced over the years. Pleasure-driven physical
activity can help them reveal and reconnect to the bodies
they have been accustomed to hate and neglect (Robison,

1997).

Whatever the patient's size, self-acceptance is
essential in the non-dieting paradigm. Feeling good about
their bodies and trusting internal signals are essential.
For some, self-acceptance and body-size aCceptance is one of
the most difficult components to grasp. It directly relates
to self-esteem and is essential for building a healthy
lifestyle. Individuals are motivated to successful behavior
change when they learn self-acceptance skills and feel good

about themselves (Robison, 1997).

Normalized eating is another importance focus of this
new paradigm which involves reducing anxiety about food,
calories, fat, etc. and relearning to regulate food intake
in response to physical hunger and satiety cues (Satter,
1987). Increased attention to internal needs and mindful
eating is accomplished by re-teaching patients how to
recognize true hunger, as distinguished from cravings.

Chronic dieters often have learned to ignore hunger and

31

their satiety signals are altered. Normalized eating enables
them to use normal physiological and psychological cues to

guide food intake.

Since the current dieting weight paradigm has been
shown to be ineffective in producing lasting results and
creates more problems for clients, both physiological and
psychological, the need for the introduction of an
alternative paradigm is needed. The widespread presumption
that fatness is always pathological and the relentless
pressure to lose weight has created a stigmatization and
social prejudice for large people. This attitude has been
documented in many studies to be shared by health
professionals and actually impedes the development of

compassionate, and clinically effective care.

Since most counseling of clients around weight-related
concerns occurs in primary care, APNs must be sensitive to
the devastating effects of their own negative attitudes. In
order to be effective in the treatment of these clients,
they need to be introduced to the new weight paradigm to
develop positive interventions to guide and motivate
positive patient behavior to the new weight paradigm. A
theoretical framework adapted from Watson’s theory of human
caring will be instrumental in promoting a caring
relationship between the APN and their clients. The overall

goal for APNs in the alternative paradigm is to use these

32

new approaches to empower people to live healthier, more

fulfilled lives regardless of weight status.

PROJECT DEVELOPMENT PLAN

The purpose of this project is to develop an assessment
to examine APN’s attitudes toward clients who present with
weight-related concerns. This assessment will function as a
beginning step for the APN in appraising and determining
their attitudes toward large clients in the primary care
setting. The first step is important because the literature
has shown that US health professionals share in negative
attitudes of the general public (Garner & Wooley, 1991)
toward large clients, and these negative attitudes
potentially hinder the effectiveness of counseling
interventions for clients. Because attitudes are defined as
learned tendencies that can change with new information,
this project has the potential to result in positive
attitude change by increasing the APN's knowledge of the new
weight paradigm. A desirable result of this change is use of
clinical interventions, enabling APNs to therapeutically
guide and motivate clients to a healthier lifestyle.

A comprehensive educational module would present
information on current and new weight paradigms, assess
APN’s attitudes and knowledge, and teach the four tenets of
the new weight paradigm. The comprehensive program is

outlined below:

33

*I.

II.

III.

Assess APN's attitudes toward the overweight

A. Attitudes Toward Obese Persons Scale (ATOP)
B. Attitudes Toward Obese Adult Patients

C. Scale Fat Phobia (FPS)

*Focus of current project

Assess APN knowledge of current and new weight

paradigms

A. Short quiz on assessing knowledge of weight
paradigms

B. Present information on the current weight
paradigm

C. Present information on the new weight
paradigm

D. Present information on the correlation of

weight and health

Address the four tenets of the new weight paradigm

A. Normalized eating
B. Pleasure-driven physical activity
C. Self acceptance and increased self-esteem,

including how to “size-friendly” their office
setting

D. Total health and well-being, rather than

weight loss
* Resource List for the non—dieting (new)

weight paradigm made available to include:

34

books, magazines, videos, organizations,
catalogs, workshops, and newsletters
For the purposes of this project, the first objective:
“Assessing.APN’s attitudes toward the overweight” is
addressed. This objective is the first step in the
educational module, to assess the nature of the health
professional’s attitudes prior to the actual teaching
portion of the module.

This project is for use in the primary care setting to
assess APN attitudes toward clients who present with weight-
related concerns. This project uses a series of three
previously-developed surveys that assess attitudes and
beliefs about obese people (from Allison, 1995; see
Appendices D, E, F). Attitude scales consist of a series of
statements that respondents rate by indicating the extent of
their agreement or disagreement with each statement, or by
selecting appropriate adjectives from a list they are given.
These surveys can be distributed either through the mail or
in person to APNs. Questionnaires are usually considered to
be less expensive and more objective than interviews, which
can bias answers, by the way the questions are asked
(Allison, 1995). Assurance of confidentiality will be
important as personal attitudes are a socially sensitive
topic. Incentives for the participants to complete and
return the surveys will assure a higher representation,
i.e., entering their name in a raffle, a pre-addressed,

stamped return envelope.

35

A demographic questionnaire will be completed together
with surveys. This portion of the assessment will include
personal information about the participants (APNs): gender,
age, APN's height and weight, number of years in practice as
an APN, practice setting or type of specialty, education
level, whether the respondent currently practices as an APN,
and a response to the question, “What is the new weight
paradigm?”.

The first survey listed in Appendix D, “Attitudes
Toward Obese Persons Scale or (ATOP),” was adapted from
Yuker and Block (1995). This model tends to focus on
“discriminatory” and “stereotypical” perceptions of
stigmatized individuals as examples of negative attitudes
toward these people (Allison, 1995). The ATOP, described by
Allison (1995), utilizes a Likert-type scale with
reliability coefficient alphas ranging from .80 to .84,
reflecting good internal consistency for reliability in
various samples. These samples consisted of 514 members of
the National Association to Advance Fat Acceptance and 124
college and graduate students.

The second survey is listed in Appendix E, “Attitudes
Toward Obese Adult Patients” and was developed by Bagley et
al. (1995) to assess nurses' attitudes toward obese
patients. This questionnaire also uses a Likert-type scale,
consisting of two scales, “Nursing Management" (15 items)
and “Personality and Lifestyle” (13 items). These two scales

were found to correlate .75 with each other (Allison, 1995),

36

indicating that a negative attitude toward caring for obese
patients is associated with a negative attitude toward obese
persons in general. Reliability data were not provided.
Construct validity was assessed in a sample of 107 nurses.
Scores on the two scales were associated in expected
directions (r values ranging between .54 and .64) with
various semantic differential ratings of “an obese adult.”
Scoring instructions are not given for “The Attitudes Toward
Obese Adult Patients Scale,” although high scores indicate
favorable attitudes and low scores indicate unfavorable
attitudes (Bagley et al., 1995). For the purposes of this
project, a sum score will be used.

The third survey (see Appendix F), “Fat Phobia Scale
(FPS),” was developed based on a theoretical model of
Robinson, Bacon, and O’Reilly, (1995). This model affirms
that “fat phobia” refers to a pathological fear of fatness
which is most often manifested as negative attitudes and
stereotypes about fat people (Robinson et al., 1995). Fat
phobia is defined as dislike of, hatred for, or disgust for
fat people and a fear of becoming fat oneself (Allison,
1995). Robinson et al. (1995) reported an alpha coefficient
of .92 for the Fat Phobia Scale showing very high internal
consistency reliability for a sample of people who entered a
motor vehicle license bureau in a Minnesota suburb (exact
number not reported). Robinson et al. (1995) stated that
their method of item development demonstrates that the scale

has “content validity,” as evidenced by a quasi-experimental

37

study. It showed that a treatment designed to improve
attitudes toward obese persons did demonstrate significantly
improved attitudes as measured by the total FPS.

After completion, the surveys would be sent back to the
administrator (preferable arrangement is for someone else to_
collect/analyze for protection of confidentiality), for
computation and recording of the results. Data regarding
attitudes would be gathered using a pre-test/post-test
descriptive survey design. It would be important for these
surveys to be repeated after the entire educational module
was completed by the APNs to compare results showing
evidence that the incorporation of this new knowledge
improved their attitudes toward clients who present with
weight-related concerns. Further evaluation would be
important to see what effect this project had on patient
clinical outcomes.

IMPLICATIONS FOR.ADVANCED NURSING PRACTICE

There are many goals for primary care, among which are
promoting wellness and healthy lifestyle behaviors. APNs are
in the pivotal position to accomplish this. What other
health-related issue is better for APNs to be involved in
than with weight-related issues? However, to be maximally
therapeutic, APNs in general must become knowledgeable about
the new weight paradigm and change their own behavior and
attitudes toward clients who present with weight-related

concerns in primary care.

38

When introducing a new paradigm, it is important to
show what is being done differently 29w that is an
improvement over the old paradigm (Robison, 1997). First is
the enhancement in the quality of care as a result of APN’s
increased knowledge of the new weight paradigm. The APN
utilizes the teaching/coaching/counseling role that will
assist them in developing positive interventions to empower
their patients to make positive changes in their health,
facilitating a productive path to self-care.

Another potential improvement as a result of APNs
embracing the new weight paradigm and utilizing the role of
the teacher, coach, and counselor, is lower costs of health
care. Because weight itself is not the focus, the client
would be more likely to return to the primary care provider
for preventive care. Studies have shown in the literature
that patients, especially women, put off preventive care as
they fear the embarrassment of being weighed (Adams et al.,
1993). Instead of continuing to work on diet failures and
weight loss, time would be better spent on health promotion
techniques. This is so important when the literature states
that there is a 95% plus failure rates of diets (National
Institutes of Health, 1992). Furthermore, the improvement of
self acceptance and increased self-esteem as a positive
clinical outcome would result in less depression which would
result, too, in lower health care costs.

The project can also serve as a starting point to

further research. The APN is qualified to design and

39

implement research projects based on implementation of the
assessment tool. Success in intervening with clients with
weight-related concerns has much room for improvement.
Research conducted and published by the APN is needed to
better understand the nature of the clinical problem and to
test nursing theory to advance nursing knowledge for
clinical practice. The knowledge development that can be
generated with this project is a publishable assessment of
APN’s attitudes toward weight. To date there has been
limited research in this area with published attitude
assessments having been conducted only with dietitians and
physicians.

Another potential area for research is the development
of a framework for APNs to assess where patients are in
regard to readiness for behavior change. This Would be a
helpful tool for formulating interventions for the new
weight paradigm to promote healthy lifestyle regardless of
weight status. This research is essential in order to
document the APN’s positive interventions on client
outcomes.

This project reports development of an assessment of
APN’s attitudes toward clients who present to primary care.
It represents the first step in a comprehensive educational
module for APNs to be introduced to the new weight paradigm.
This tool can serve as a springboard for the APN for future

nursing research, education, and practice.

40

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49

APPENDICES

APPENDIX A

GLOSSARY

10.

ll.

GLOSSARY

.Actual caring occasion-a particular type of event
and is the result of a transpersonal caring
relationship (Watson, 1985; Fawcett, 1993).

Attitude-a learned tendency that can change with new
information (Pender, 1996).

Body Mass Index (BMI)-Weight (in kilograms) divided by
height (in meters) squared; the medical standard used
to define weight status (Thomas, 1995).

Carative Factors-intervention processes or modalities
used in a transpersonal caring relationship (Watson,
1985).

Current weight Paradigmra paradigm that teaches that
there is a lean optimal body weight for all persons

to maintain and achieve. This paradigm argues that
diets are necessary because the incidence of disease
and premature death increases in direct proportion to
body weight; also termed “old paradigm,"

“traditional paradigm,” or “dieting paradigm” (Kratina
et al., 1996).

Empathy-the capacity to understand other's feelings as
if they were their own, while remaining fully aware of
their own identity (Wheeler & Barrett, 1994).

Event-an outcome that occurs when two people with their
unique histories and phenomenal fields engage in a
human care transaction (Watson, 1985).

Fat-a complicated word that many large people are
offended by as it brings back memories of childhood
taunts like “fatso” and “fatty” (Kratina et al., 1996).

Fat Oppression-bias against overweight people;
synonymous with “fatism” (Berg, 1995).

Fatism— bias against overweight people; synonymous with
“fat oppression” (Berg, 1995).

Human Care-human to human contact which becomes a way
of knowing the self and the other (Watson, 1985).

50

12.

13.

14.

15.

l6.

17.

18.

19.

Knowledge-information acquired through learning or the
condition of being aware of something (Merriam-Webster,
1994).

Obesity-an excess of body fat; a BMI of 35 or heavier
(Gaesser, 1996).

Overweight-a BMI of 27 to 30; sometimes termed as
“mildly obese” by some researchers (Gaesser, 1996).

New Weight Paradigm—a paradigm that focuses on a
healthy lifestyle regardless of weight status; a
holistic, nondiet View that recognizes many dimensions
of personal health, including its physical, emotional,
mental, and spiritual aspects; also termed
“nondieting paradigm” (Kratina et al., 1996).

Paradigms-the theoretical frameworks by which
professional practices are formulated, evaluated, and
adapted (Robison, 1997).

Phenomenal Field-the subjective experience of the
person; one's frame of reference and can only be known
by others indirectly through empathetic understanding
(Watson, 1985).

Self—the ideal self that the person would like to be,
and also the spiritual self which is synonymous with
the geist or soul of the person (Watson, 1985).

Transpersonal Caring Relationship-a specific type of
professional human-to-human contact having the goal of
restoring the patient's experience of inner harmony
(Watson, 1985).

51

APPENDIX B

PROCHASKA’ 8 MODEL

APPENDIX B

A.Spiral Model of the Stages of Change starts with
precontemplation, moving through a series of attempts, until
maintenance and termination is reached (Prochaska,

DiClemente, and Norcross, 1992).

Termination
Maintenance
.0
79"”
Precontemplation Contemplation Preparatio
0
fa
Precontemplation Contemplation Preparation

52

APPENDIX C

WATSON ’ S CARAT IVE FACTORS

10.

.APPENDIX C

Watson's ten carative factors

Formation of a humanistic-altruistic system of
values

Instillation of faith-hope

Cultivation of sensitivity to one’s self and to
others

Development of a helping-trusting, human care
relationship

Promotion and acceptance of the expression of
positive and negative feelings

Systematic use of a creative problem-solving
caring process

Promotion of transpersonal teaching-learning
Provision for a supportive, protective, and/or
corrective mental, physical, societal, and
spiritual environment

.Assistance with gratification of human needs
Allowance for existential-phenomenological-

spiritual forces

53

APPENDIX D

ATTITUDES TOWARD OBESE
PERSONS SCALE
(ATOP)

Attitudes Toward Obese Persons Scale (ATOP)

Please mark each statement below in the left margin. according to how much you
agree or disagree with it. Please do not leave any blank. Write a +1. +2. +3. 0r -1. -2.
—3, according to the scale below.

+3 = I strongly agree

+2 2 l moderately agree
+1 = I slightly agree

-1 = I slightly disagree

-2 = I moderately disagree
-3 = I strongly disagree

 

a—a
O

Obese people are as happy as nonobese people.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Most obese people feel that they are nm as good as other people.
3. Most obese people are more self-conscious than other people.
4. Obese workers cannot be as successful as other workers.
5. Most nonobese people would not want to marry anyone who is obese.
6. Severely obese people are usually untidy.
7. Obese people are usually sociable.
8. Most obese people are not dissatisfied with themselves.
9. Obese people are just as self-confident as other people.
10. Most people feel uncomfortable when they associate with obese people.
11. Obese people are often less aggressive than nonobese people.
12. Most obese people have different personalities than nonobese people.
13. Very few obese people are ashamed of their weight.
14. Most obese people resent normal weight people.
15. Obese people are more emotional than other people.
16. Obese people should not expect to lead normal lives.
17. Obese people are just as healthy as nonobese people.
18. Obese people are just as sexually attractive as nonobese people.
19. Obese people tend to have family problems.
20. One of the worst things that could happen to a person would be for him

 

to become obese.

(Yuker & Block, p. 106-107, 1995).

54

Scoring instructions for AT OP.
Step 1: Multiply the response to the following items by -l (i.e., reverse

the direction of scoring):

- Item 2 through Item 6, Item 10 through Item 12, Item 14
through Item 16,1tem 18 through Item 20

Step 2: Add up the responses to all items.

Step 3: Add 60 to the value obtained in Step 2. This value is the ATOP
score. Higher numbers indicate more positive attitudes.

(Yuker & Block, pp. 106-107, 1995)

55

APPENDIX E

ATTITUDES TOWARD OBESE
ADULT PATIENTS SCALE’

Attitudes Toward Obese Adult Patients

Note: All statements (items) are scored using a 1-5 liken-type scale:
1 I StronglyAgree
2‘593
3 - Unsure
4 I Disagree
5 - Strongly Disagree

 

. Obesityinadultscsnbeprevensedbyself-controul’lthl
. Mostobeseadultshavepoorfoodselection.(P&L)
. ObeseadultsshouldbeputonadietwheninhospitaHNM)

. Mostobeseadultsalcpushyandaggressivefltl.)

_

 

N

U

 

 

 

 

 

 

4

S.__Caringforanobeseadultisphysicallyezhaustin¢.(NMl

6. Nurses oftenfeeluncomfortablewhenearingforobeseadult patients.
(NM)

7. Obeseadultseaperiencelesssueeessinlife.(P&L)

8. ltisunlikelythstanadultofnormalweidltwuldmtmmmm
obeseadultfl’tll

9. Weightlosshonlyamatter ofehangiugoue's lifestyle. (PatM)

lo. CaringforaaobesepatieutismessquNM)

11.__Caringforanobeseadultpatientusuallyrepulsesme.(NMl

12. .mMadubmmdemandthomapaWINM)

 

13. CaringforanoboeadultpatientbemodonaflydnhtingINM)
14.___ IoftenfielhnpatientwhenearingforanobeseadultpatientJNM)

15. Mostnunesfinditdificulttoobtainthecooperationofobeseadult
patientsJNM)

lé.__Mostobeseadultslackself—oonfidenoe.(PatLl

17.___Iffimfiedohmustnurseswouldprefernottoeareforanobese

adultpatientmu)
18.___I'dtathernottouchanobeseadult.(NMl
19. ItisdificultmfielempatbyforanobeseadultJNM)

 

20.__Mostobeaeadultsareoverindulgent.(P&L)

21. It does not hurt to apply 'seare' tactics to obtain the compliance of the
obeseadult patient. (NM)

22. _._ Mostobeseadultsareunhempt. (PltL)
23._Obeseadultsnrelyeapresstheirtruefeelings.(P&Ll

 

 

24. Obese adult patients require a firm approach. (NM)
25. __ Most obese adults can lose weight if they change their eating habits.
(NIL)

26. __ I feel disgust when I am caring for an obese adult patient. (NM)
27. __ Most obese adults experience unresolved anger. (Pain
28. __ Most obese adults are lazy. (PatL)

(Bagley et al., pp. 109-110, 1995).

56

.APPENDIX E

EAT PHOBIA.SCALE
(FPS)

Pat Phobia Scale (FPS)

Listed below are adjectives sometimes used to describe obese or fat people. Please indi-
cate your beliefs about what fat people are like on the following items by placing an X
on the line that best describes your feelings and beliefs.

h

- lazy

810m
disgusting
friendly
nonassertive
. no willpower
artistic

creative

assesses!»

warm
depressed
. smart
. reads a lot

mourns-I
UNt—p

. unambitious

.-a
Q

. easytotalltto

pd
UI

. unattractive

.—
G

. miserable

. selfish

t—ns—
”\l

. poor self-control

p—a
'0

. inconsiderate of others

.good

N
O

 

 

(Robinson, Bacon, 8. O'Reilly, pp. 117-118, 1995).

57

(Robinson,

. popular

. important
. slow

. inefiective
. careless

. having endurance

. nice complexion

. tries to please people
. humorous/funny

. ineficient

. strong

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bacon, & O’Reilly, pp. 117-118,

58

unpopular
insisnificant

fast

effective

careful

having no endurance
active

bad complexion
doesn’t try to please people
humorless/not funny
eficient

weak

not individualistic
not pitiful
mquan

irritable
self-sacrificing
aggressive

direct

dislikes food

clean

veryattentive
toownappearanoe

uptisht

1995) .

Scoring instructions for the FPS.

Step 1: For items 4, 7-9, ll-12, 14, 20-22, 26, 28-30, 32-33, 35-36, and 43,
score the FPS as follows:

12.145.

Step 2: For items 1-3, 5-6, 10, 13, 15-19, 23-25, 27, 31, 34, 37-42, and 44-
50, score the FPS as follows: 4

51221

Step 3: Add up the score for each item to get the total score for the FPS.
The range of scale is 50-250.

- High score = more “fat phobia”
— Low score = less “fat phobia”

(Robinson, Bacon, & O'Reilly, pp. 117-118, 1995).

59