Social media response to the introduction of the swallowable gastric balloon treatment for severe obesity in the NHS: A snapshot of public opinion

doi:10.21203/rs.3.rs-4814370/v1

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Research Article

Social media response to the introduction of the swallowable gastric balloon treatment for severe obesity in the NHS: A snapshot of public opinion

https://doi.org/10.21203/rs.3.rs-4814370/v1

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Background:

Swallowable gastric balloons are available in the UK to treat severe obesity. Our hospital introduced this treatment in 2023, the first to do so in the National Health Service (NHS). The event was featured by the British Broadcasting Corporation (BBC) on regional television and online by numerous news outlets in February 2024. Obesity and the treatment of obesity are often subject to stigma, prejudice and bias. The event gave an opportunity to observe and analyze public opinion in response to a new NHS-funded obesity treatment.

Methods:

Qualitative review of public comments made to articles about the introduction of swallowable gastric balloon therapy in the NHS. Comments were categorized as positive, neutral, or negative.

Results:

Out of 2364 comments reviewed from all sources, 16.6% were positive, 48.9% were neutral and 34.8% were negative. Obesity stigma was highly prevalent in the responses and included many derogatory and abusive comments, including towards the patients featured in the BBC articles.

Conclusions:

Obesity stigma is highly prevalent in those responding by social media and on news websites to a new treatment within the NHS. Negative stereotypes may be a barrier to obesity treatment within the NHS and need to be addressed.

Gastric balloon

obesity

obesity stigma

There was high engagement on social media in response to gastric balloons on the NHS.

There were more negative than positive comments in response to the news articles.

Stigmatizing and abusive comments were encountered frequently on social media.

Comments on news media were more likely to be negative than those on social media.

Swallowable gastric balloons are available in the UK on the NHS to treat severe obesity.
Obesity and the treatment of obesity are often subject to stigma, prejudice and bias.

‘What this study adds’

Obesity stigma was highly prevalent in the comments responding to the introduction of a novel obesity treatment on the NHS.
Our data suggest the UK media are not following guidelines on using non-stigmatizing language when moderating the comments published on their websites.
Strong role models from the NHS may be needed to interact with users on social media to help tackle negative stereotypes surrounding obesity treatment.

Obesity is a significant global public health challenge contributing to diseases such as type 2 diabetes (T2DM), cardiovascular disease, stroke, and certain cancer types. The Health Survey England 2021 reports that 26% of adults in England have obesity and 64% of adults have overweight ⁽¹⁾, rates amongst the highest in Europe. For those wishing treatment, metabolic bariatric surgery (MBS) is the most effective intervention. It leads to 25–35% weight loss, improves or reverses obesity-related comorbidities ^(2–4), reduces cancer risk ^(5,6), improves quality of life, anxiety and depression ^(7,8), and is safe ^(9,10). However, despite multiple national guidances ⁽¹¹⁾, access to secondary care weight management clinics, required in the pathway leading up to MBS, is severely limited in the UK National Health Service (NHS) ⁽¹²⁾, and less than 1% of those who could benefit receive MBS, far fewer than in many equivalent European countries ⁽¹³⁾. A possible reason for the very low volume of MBS in the NHS is stigma, prejudice and bias against people living with obesity (PLWO). There is a growing volume of literature that illustrates this ⁽¹⁴⁾, being present in healthcare professionals ⁽¹⁵⁾ as well as the general public ⁽¹⁶⁾.

Endoscopically placed intragastric balloon therapy has been available for several decades and leads to 10–15% weight loss. A new balloon that is swallowed and then inflated avoids two endoscopies and anesthetics for placement and removal, a potentially significant reduction in healthcare resources ⁽¹⁷⁾. Although not yet FDA-approved for use in the USA, it has been approved by the National Institute of Health and Care Excellence (NICE) ⁽¹⁸⁾ for short-term weight loss in the UK. The authors introduced it in ___________ in 2023, with a local press release as the first NHS hospital to do the procedure. The event attracted considerable media attention, featuring in a regional television report by the British Broadcasting Corporation (BBC), BBC national and regional radio interviews, regional commercial radio, and in national newspapers and social media ^(19,20). Analysis of the comments responding to the article online allowed a snapshot or barometer to be taken of current public views towards this treatment and the treatment of PLWO in the NHS. This study aimed to examine the public response. We intended to identify specifically the prevalence of weight stigma on social media and mainstream newspaper websites.

This qualitative study was conducted in _________________________ which has had over 15 years of experience placing endoscopic gastric balloons. The swallowable balloon (Allurion™) was introduced after local institutional approval. In response to the hospital press release, the BBC featured articles on 23rd January and 8th February 2024 reporting that the radiologically placed intragastric balloon was now available on the NHS ^(19,20). A comprehensive search of social and news media was carried out on 21st March 2024. This included the platforms TikTok, Instagram, Facebook, Reddit, YouTube and X, and all identified reports from major mainstream news media outlets. Search terms included the key terms ‘Allurion’, ‘weight-loss balloon’, ‘swallowable balloon’, ‘weight loss pill’, ‘non-surgical gastric balloon’, and ‘NHS’. Reports or posts on use in private practice were excluded and only publicly available comments were analyzed. Standards for reporting qualitative research (SRQR) ⁽²¹⁾ were used in the study design and in reporting.

Comments on all items were scrutinized by two authors (VG, PC) and any discrepancies were reviewed by the lead author. The comments identified on all platforms were then classified as positive, neutral or negative and recorded on an Excel dataset. All comments sampled were recorded to the dataset without details identifying the individual posting the comment.

Comments were considered positive if they supported a patient’s effort to lose weight, if they expressed that using the balloon was a legitimate part of a management strategy, if they said the person would be interested in trying the balloon, or when people praised the design. Comments were considered neutral if they tagged another person, asked questions about how the balloon worked, mentioned the cost, noted that the balloon looked like a breast implant, or disagreed with the treatment strategy of using a balloon. Comments were considered negative if they were overtly stigmatizing to PLWO, if they contained clearly untrue facts about obesity or obesity management as judged by the authors, if negative emojis, abusive content, or Graphics Interchange Format (GIFs) suggesting a response that was overtly stigmatizing. Two authors (_____) performed a thematic analysis of each set of comments. A sample of each ‘sentiment group’ was coded independently and then discussed to ensure inter-rater reliability. Principles of thematic analysis involved comments being read, and codes being generated and assigned to relevant excerpts within comments. Themes were then identified for each sentiment by grouping together similar codes which were analyzed in detail (Supplementary Table 1). The accuracy of the themes was checked through discussion with the senior author (__). Groups were compared using Fischer’s Exact Test. Statistical analysis was performed using GraphPad Prism Version 10.2.3 (GraphPad Software, San Diego, California USA, www.graphpad.com).

Fifteen media items that discussed the introduction of NHS funding for the swallowable intragastric balloon were identified. Eight mainstream news articles did not have comment facilities or had zero comments at the time of data collection. No items about this topic were found on searching Facebook, TikTok or Reddit.

Out of the remaining seven items, 2,364 comments were present on the search date. The majority (n = 2208) were in response to a BBC West’s Instagram Reel article that had over 11 million views and had been shared over 1,200 times. For comparison, the 20 BBC news reels before and after the intragastric balloon post received an average of 27,000 views (range 5069 − 224,000 views) and 9 shares (range 0–61 shares). The corresponding online article had no option for comments but was shared on the BBC West’s X account. Other media coverage included an Instagram Reel and YouTube video by ‘Talk TV’ (a ‘free-to-air’ British television and radio channel), articles by the ‘Daily Mail’, ‘Daily Mirror’ and ‘Welsh Guardian’ newspapers, and a YouTube video on ‘Channel 5 News’, a British news broadcaster.

After discrepancies between raters were resolved, sentiment analysis of comments found that 393 (16.6%) were ‘positive’, 1156 (48.9%) were ‘neutral’, and 815 (34.8%) were ‘negative’. The distribution of comments based on source media is shown (Fig. 1). The BBC West Instagram story had almost twice as many negative comments as positive comments.

Themes identified and supporting quotations summarized in Table 1 from ‘positive’ comments included: acceptance of being overweight, acknowledgement of obesity as a multifactorial disease (contradicting ideas of obesity as purely a function of overeating and lack of exercise), saving resources for the NHS in comparison to surgical methods of weight management, helping to address obesity-related diseases (e.g. type 2 diabetes, hypertension) and praising the advancement in technology within the field of bariatric surgery.

Table 1

Emergent themes for each sentiment and supporting quotations. Note, though prevalent during in the search, comments with vulgar language or strong abusive themes are excluded.
Sentiment	Theme	Supporting quotation
Positive	Acknowledgement of obesity as multifactorial process	‘All the hate here is disappointing. Many people have medical conditions that make it very difficult to lose weight. PCOS, thyroid issues are just some examples.’
	Acknowledgement of obesity as multifactorial process	‘As someone who at one time had lost over 100lbs/45kg, people that have not been significantly overweight don’t understand how hard it is to lose weight...I can’t imagine doing it with financial restrictions, stress or any other health problems.’
	Positive alternative to surgical management of obesity	‘I’m having gastric sleeve surgery soon. But by this short video I think I would much rather do this as a discipline than do the sleeve which I won’t ever be able to maybe eat a little more than normal and worry about damaging it.’
	Positive examples of the intra-gastric balloon	‘I’ve lost 32kg and kept the weight off. It’s been 2 yrs with this, I must say best decision ever’
	Addressing obesity-related diseases	‘If we could get people’s weight down we could save a fortune in treating the kinds of illnesses obesity brings. Well done!’
	Advancement in technology	‘how incredible. life changing technology for so many patients’
Neutral		‘What is it made of???’
		‘Being overweight is a nightmare for me. If I could ‘just stop’ don’t you think I would?’
		‘If it doesn't have a mother or grow from the ground, don't eat it.’
		‘It looks like a breast implant’
		‘That's some size to pass after!’
Negative	NHS funding better spent elsewhere	‘The NHS should not fund any such treatment...weight gain is psychological and weight loss should also be’
	NHS funding better spent elsewhere	‘people who have self control should not be forced to pay for those who do not.’
	Negative weight stigmatization	‘No not on the nhs.,.no way, join a gym, walk a friends dog...smaller portions on your plate, use your brain, they all want a quick fix’
		‘stop eating or sew your mouth up is the best option’
		‘how little determination must someone have to get this fitted, just eat less and exercise’
	Solution to obesity is diet/exercise alone	‘Stop swallowing this crap and learn to diet and exercise’
	Solution to obesity is diet/exercise alone	‘Anything to avoid gym’
	Personal attacks on obese patients	‘they'll just get fat again...they have zero morals, they refuse to control their flesh or physical urges. absolutely gross...the fact that anybody actually has to make science to help these cretens [sic] is ridiculous’

Thematic analysis of neutral comments was not performed but comments largely centered around misconceptions that the device would not deflate and be passed whole, that the balloon bore similarity to a breast implant, questions about the process or device, posts seeking personal help/advice, neutral emojis or alerting other users to content (tagging).

Themes identified from ‘negative’ comments included that NHS funding would be better spent on alternatives, including ear wax treatment, medical research, reducing waiting lists for secondary care treatment and staff retention. Negative weight stigmatization was identified such as comments on a person’s appearance and negative characterization of obesity (laziness, gluttony, shamelessness). Responsibility for obesity on an individual level was common, and there were many comments asserting that diet and exercise alone are the causes and solutions to obesity. There were also personal attacks on the patients featured in the news article and abusive, derogatory, and threatening messages directed towards PLWO. Two of the most engaged negative comments were “How about controlling what you put in your mouth?” (3712 likes) and “Or they could just stop feeding their face” (1994 likes). There were also more extreme comments unsuitable for publication.

There were significantly more negative than positive comments on the Daily Mail article when compared with the BBC Instagram story (p < 0.001). There was no statistical difference identified when the BBC Instagram story comments were compared with those on Talk TV, Daily Mirror, Welsh Guardian, or YouTube (Table 2).

Table 2

Summary of public response across social media, mainstream news articles and YouTube videos. Data is presented as a number of comments (% of total comments) per platform. P values indicate significance, ns = not significant.
	BBC West Instagram Post	Talk TV Instagram Post	BBC 'X' Post	Daily Mail Articles	Mirror Article	Welsh Guardian	Youtube videos
Positive	384 (17.3%)	1 (7%)	0	6 (6.4%)	0	0	2 (5.7%)
Neutral	1083 (49%)	11 (73%)	0	35 (37.2%)	1 (16.7%)	2 (40%)	24 (68.6%)
Negative	741 (33.6%)	3 (20%)	1 (100%)	53 (56.4%)	5 (83.3%)	3 (60%)	9 (25.7%)
P value	n/a	ns	n/a	< 0.0001	ns	ns	ns

To our knowledge, this study is the first to analyze public comments placed online in response to news reports about the introduction of a swallowable intragastric balloon. Categorizing comments into ‘positive, neutral or negative’, we found a high prevalence of negative attitudes across all media sources. The results show that prejudice and stigma are rife among the public towards a new treatment for obesity in the UK NHS.

Our finding that only 16.6% of comments were positive supports previous reports that weight stigma is prevalent and harmful on social media ⁽²²⁾. The data also demonstrate that obesity stigma is prominent on major news websites, with negative comments far more likely than positive ones. Some media outlets appeared to facilitate more negative opinions than others. For example, the proportion of negative comments on news website articles (56.4–83.3%) was far more compared to social media posts (20-33.6%) and YouTube videos (25.7%). It is possible that this reflects the demographics of newspaper readerships compared to Instagram and YouTube users. Some of the UK press is more likely to be conservative and right-leaning, and there is evidence that right-leaning publications more commonly report obesity as a personal responsibility rather than acknowledging it as a biomedical problem ^(23,24).

The frequency of reporting on obesity doubled in UK newspapers from 2008–2017 (23), and included portrayal of obesity stigma, focusing on individual responsibility which is considered more stigmatizing ^(23–25). As our study demonstrates that these themes also extend into the online user comments published on newspaper websites, the data suggest the UK media are not following guidelines on using non-stigmatizing language or moderating the comments published on their websites ^(26,27).

In 2022, 4.59 billion people, the majority of the world population, were using social media ⁽²⁸⁾ and it therefore has a critical influence in shaping beliefs and propagating harmful weight stigma ^(29,30). However, social media could become a valuable tool for public health bodies to promote body positivity, self-acceptance and advocacy. Specific training targeted to explain the importance of using people first language may also be helpful in reducing obesity stigma ⁽³¹⁾. Media campaigns in the form of short films can also reduce obesity bias amongst healthcare trainees ⁽³²⁾. Education should also include training healthcare professionals to make appropriate referrals into secondary care obesity services. An area of future research is to explore biases held by all stakeholders considering new obesity treatments. These should include examining the effectiveness of education programs for the general public to reduce bias against PLWO who choose public healthcare for the treatment of their obesity.

Strengths of the study include that the data specifically relate to the NHS, and therefore may be a barometer of views on a publicly funded service. The amount of media publicity and online comments was unexpected. However, the use of digital recording allows comments to be analyzed and quantified. To our knowledge, our results are the first to analyze public responses to a specific obesity treatment. This could have relevance for obesity services in other countries that are considering similar services.

The study has limitations. The choice of the three categories positive, neutral or negative was arbitrary, and therefore susceptible to interpretation bias, however inter-rater discrepancy between the two authors was low. Individuals commenting by social media to a news article may not be representative of the whole cohort of people viewing the article. Thus, the number of comments to the BBC _____ Instagram Reel indicated a response rate of only < 0.1% (2,000 to 11 million views). It is assumed that people with more extreme views, positive or negative, are more likely to offer comments. Another limitation is that it was not possible to know whether accounts and comments were created by bots, trolls or were the opinions of real people. Any comments that had been removed or were private posts were not captured. Therefore, it is possible that we have underestimated the degree of negative or neutral comments, as those reported or removed are more likely to have been extreme views or clear misinformation. Finally, we did not analyze ‘conversations’, but focused only on initial posts and comments.

Negative comments by the public to the introduction in the NHS of a new obesity treatment, a swallowable gastric balloon, were far more common than positive comments. There were many stigmatizing comments and misconceptions. We speculate that these could affect willingness to pay and be a barrier to developing effective services. A program of public education directed at identifying and addressing obesity stigma could increase acceptance that the public should pay for obesity services.

Financial support: None

Ethics: Not applicable

Author Contribution

Study design – PC, VG, RWData Collection – PC, VGData analysis – PC, VGData interpretation – PC, VG, RWWriting – PC, VG, RWCritical revision – PC, VG, RW, ZH, KL

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No competing interests reported.

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Social media response to the introduction of the swallowable gastric balloon treatment for severe obesity in the NHS: A snapshot of public opinion

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