doi: 10.56294/saludcyt2023425

 

REVIEW

 

Fatphobia: the challenges of humanized care for patients with metabolically unhealthy obesity

 

Gordofobia: los retos de la atención humanizada a pacientes con obesidad metabólicamente insana

 

Solanche Stefany Molinas Franco1  *, Dayssy Franco1  *, Andrea Elizabeth López Ramirez1 *, Moisés Silva Campos1  *, Kátia Christina Rodrigues Souza e Silva1  *, Lidiana dos Santos Penha1  *, Livia Cavalcanti Moret1  *, Paloma Iracema Banak Zilch1  *, Anna Luisa Silva de Oliveira1  *, Camila Barros Araújo1  *, Ester Vitória Costa1  *, Gabriel Batista de Souza1   *, Gabriella Patricia Rodrigues de Oliveira1  *, Rebeca Marins Arantes1  *, Stênio Vasconcelos de Farias Filho1  *, Sthephany Caroliny Santos De Jesus1   *, Wilgner Itiel Teixeira Souza1  *

 

1Universidad Central del Paraguay. Asunción, Paraguay.

 

Cite as: Molinas Franco SS, Franco D, López Ramirez AE, Rodrigues Souza e Silva KC, dos Santos Penha L, Cavalcanti Moret L, Banak Zilch PI, Silva de Oliveira AL, Barros Araújo C, Vitória Costa E, Batista de Souza G, Rodrigues de Oliveira GP, Marins Arantes R, de Farias Filho SV, Santos De Jesus SC, Teixeira Souza WI. Gordofobia: los retos de la atención humanizada a pacientes con obesidad metabólicamente insana. Salud, Ciencia y Tecnología. 2023; 3:425. https://doi.org/10.56294/saludcyt2023425

 

Submitted: 01-05-2023                       Revised: 28-07-2023                                       Accepted: 12-11-2023                       Published: 13-11-2023

 

Editor: Dr. William Castillo González

 

ABSTRACT

 

Obesity is characterized by being a chronic disease deriving from the accumulation of excessive fat, used by the body as an energy reserve. It is determined by body mass index and, according to data collected from the Pan American Health Organization (PAHO), there are over a billion obese people worldwide, of all age groups. Despite the high number, the fat body became the target of prejudice, directly reaching the self-image of the obese in a negative way. The demand for the “ideal body” has intensified, and with this situation, there has been a gradual growth by medical specialists. The lack of sensitivity of the professional in question allows discriminatory acts to occur in medical consultations. It is also observed the increase in mobilizations to combat obesity, where the fat person has the obligation to lose weight, discussing serious topics such as obesity and fat phobia, overcoming this theme. Thinking about it, this article sought to analyze how the management of care with obese people occurs and verify the ability of the newly graduated physician to conduct with empathy and professionalism the care of obese patients, preserving moral integrity, physical health and mental illness of the patient in the face of fat phobia. Thus, it was verified that the practice of medical fat phobia occurs in three categories being in the professional relationship in the infrastructure and in the diagnosis and treatment. It is of a lot of importance to stimulate doctor-patient empathy, as it encompasses the emotional, ethical, intellectual and behavioral, in addition to fostering relationship, trust and respect, generating a reciprocal connection that allows benefits, such as improvement and satisfaction in the results of the health treatments of this patient, being an essential conduct for the therapeutic plan.

 

Keywords: Obesity; Fatphobia; Disease; Metabolically Healthy Obesity; Metabolically Unhealthy Obesity.

 

RESUMEN

 

La obesidad se caracteriza por ser una enfermedad crónica resultante de la acumulación excesiva de grasa, utilizada por el organismo como reserva energética. Se determina por el índice de masa corporal y, según datos recogidos por la Organización Panamericana de la Salud (OPS), hay más de mil millones de obesos en todo el mundo, de todos los grupos de edad. A pesar del elevado número, el cuerpo gordo se ha convertido en blanco de prejuicios, afectando directamente a la autoimagen de los obesos de forma negativa. La búsqueda del “cuerpo ideal” se ha intensificado y, como consecuencia, se ha producido un aumento gradual del número de médicos especialistas. La falta de sensibilidad por parte del profesional en cuestión permite que se produzcan actos discriminatorios durante las consultas médicas. Teniendo esto en cuenta, este artículo buscó analizar cómo se maneja la atención a personas obesas y verificar la capacidad del médico recién titulado para conducir la atención con empatía y profesionalismo, preservando la integridad moral y la salud física y mental del paciente frente a la gordofobia. Así, se constató que la práctica de la gordofobia médica ocurre en tres categorías: en la relación profesional de salud-paciente; en la infraestructura y en el diagnóstico-tratamiento. Es de suma importancia fomentar la empatía en la relación médico-paciente, ya que ésta abarca los aspectos emocionales, éticos, intelectuales y conductuales, además de fomentar las relaciones, la confianza y el respeto, generando una conexión recíproca que permita obtener beneficios, como la mejoría y satisfacción en los resultados de los tratamientos de salud del paciente, siendo una conducta esencial para el plan terapéutico.

 

Palabras clave: Obesidad; Gordofobia; Enfermedad; Obesidad Metabólicamente Sana; Obesidad Metabólicamente Insana.

 

 

 

INTRODUCTION

Obesity is a chronic disease caused by the accumulation of adiposity in quantities that damage the health of the individual. Thus, the World Health Organization (WHO) considers the value of the Body Mass Index (BMI) greater than or equal to 30kg/m² as a determinant for this disease.(1) In addition, this high level of tissue fatness has as a consequence the development of metabolic dysfunctions and diseases such as type 2 diabetes mellitus (DM2), cardiovascular diseases (CVD), dyslipidemia and, mainly, psychological pathologies.(2)

According to data from the Pan-American Health Organization (PAHO), more than one billion people in the world are obese, including children, youth and adults.(3) Thus, the search for health professionals is more and more frequent. Therefore, the difficulty of doctors in caring for fat people stands out, in which a lack of sensitivity of the specialists is perceived, which leads to the occurrence of discriminatory attacks in medical consultations identified as "Fatphobia" - preconception and dehumanization used to defame obese people.(4)

Consequently, the inability of the newly-trained physician to conduct a healthy doctor-patient relationship, the lack of adequate equipment and the associated lack of support structure for fat patients are hindrances to the effectiveness of treatment for the diagnosed obese patient and, indirectly, also a major cause of fatphobia.(5)

In this context, situations of discrimination with the patient's weight become more common, as was published in the partner media by Thaís Carla, influencer, who suffered prejudice during a medical care. On the other hand, it was reinforced by the physician Monalisa Nunes, that there is medical fatphobia in diagnosis and treatment, and that these professionals presume that any symptom presented by the patient comes from accumulated fat, thus preventing a fair clinical analysis.(6)

In view of the above, the objective of this scientific study is to analyze how the management of care for obese people occurs, to verify the ability of the newly trained physician to conduct the care with empathy and professionalism, preserving the moral integrity, physical and mental health of the patient in the face of the preconception of fat people.

 

Theoretical Reference

Obesidade Metabolicamente Saudável (ObMS)

Obesity is a risk factor for the development of metabolic dysfunctions and diseases such as cancer, cardiovascular diseases, type 2 diabetes, hypertension and dyslipidemias.(2) Given the risks, in 2013, the American Medical Association began to consider obesity as a disease and, corroborating this, the World Health Organization (WHO) defined obesity and overweight as an abnormal or excessive accumulation of fat that can be harmful to health.(7)

The accumulation of adipocytes has multifactorial foundations that occur in the relationship of genetic, physiological, habitual and sociocultural factors. It is, therefore, a chronic disease characterized by an excess of body fat. Constantly, it correlates with aggravation of caloric intake, establishing a risk for the health of the individual.(8)

Currently, the definition is clear, however, in the mid 1980s, after some years of observations, it was suggested that obesity for some individuals was not a risk factor and could even be an advantage. These individuals were classified as a subgroup, which would be protected against cardiometabolic alterations associated with obesity, called Obesidade Metabolicamente Saudável (ObMS).(2)

After the emergence of descriptions of what exactly is ObMS, Duque(9) emphasizes that there is still no consensus on the criteria for its definition. There are more than 30 different types of definition, already used in several studies. This is also due to the fact that there is heterogeneity in the number of metabolic risk factors allowed in the definition of this phenotype.(2)

However, despite the changes in the classification of obesity, ObMS is still being discussed as a phenotype of low cardiometabolic risk, due to the absence of factors that are associated with metabolic syndromes, such as hypertension, type 2 diabetes mellitus or insulin resistance.(9)

With all the counterpoints about metabolically healthy obesity and its difficult classification, it is considered that it is not a harmless state of obesity, but rather a transitory state in which about 20 % of individuals with 13 years of age transited to an unhealthy state until the age of 24 years.(2)

In this regard, Pinto reports the prevalence of ObMS, which was evaluated in different years and in different concepts. In 2014, prevalence was reported between 6 %-75 %; in 2015, through a meta-analysis, it was estimated that the prevalence of ObMS in the general population was 7,27 % and, finally, in 2017, this percentage was classified as 35 %. This lack of consensus led to discrepancies that make it impossible to use the term metabolically healthy obesity.(2)

This means that from the moment the individual presents more than two components of the metabolic syndrome, such as elevated generalized anxiety disorder, low HDL cholesterol levels (HDL-C) or elevated blood glucose levels, he enters a state of metabolically unhealthy obesity (ObMNS).(2)

Thus, Pinto affirms that some individuals classified as obese are not really healthy, but only present fewer components of metabolic syndrome than those necessary to be classified as metabolically unhealthy obesity.(2)

In 2020, the Brazilian Ministry of Health reported that obesity rates have almost tripled since 1975 and increased almost five times among children and adolescents. Obesity can affect people of all ages and from any social group, whether in developed or developing countries. Among Brazilians, according to the National Health Survey conducted in 2020, the incidence of obesity increased 54 % between 2006 and 2012.(7)

With the considerable increase in the number of medical conditions related to obesity and its prominence on the international agenda as a public health issue, the term "epidemic" has come to be used to treat obesity. Despite the word being generally associated with contagious diseases, this growing increase was called the obesity epidemic in 2016. As such, obesity would be the first non-infectious epidemic in history, reflecting the idea that anyone can "catch it".(5)

The immoderate representation of considering obesity as an epidemic could be justified due to the fact that the economic impact of obesity on health systems demands more public money, being this one of the biggest problems of health systems, which generates a feeling of burden coming from the obese person.(5)

According to Nilson, the total costs of treating hypertension, diabetes and obesity in SUS reached 3,45 billion reais (R$) (95% CI: 3,15 to 3,75) in 2018, or more than US$890 million. Considering separately obesity as a risk factor for hypertension and diabetes, the costs attributable to that disease reached R$1,42 billion (95% CI: 0,98 to 1,87), or 41 % of the total costs.(10)

Thus, the focus on behavioral actions is intensified, and public health comes to emphasize even more the individual responsibility and self-discipline in the process of weight loss of obese people. Therefore, there is evidence that there is an application of simplistic solutions to complex phenomena, and this is used in the moral regulation by health professionals to judge healthy individuals as responsible and those who suffer as irresponsible.(5)

In addition to the susceptibility to metabolic alterations, these individuals are also predisposed to suffer fat-phobic oppressions that have as main target the image and appearance of a body, since the preconception about the life habits and practices of fat individuals is given from a first glance that identifies the person as being fat or not.(11)

In this sense, Schmitz(12) reports that many of these individuals are discriminated against, which is an incentive for weight loss. The insistence on losing weight and the stigma in which the individual often feels blamed becomes a risk factor in relation to wellbeing and health.(5)

Criticism of the inadequacy and damage caused by this traditional approach is not limited to the academic literature; on the contrary, it can be found in the social media, where it is possible to find various allegations of discrimination against fat people by society in general and by medical professionals.(4)

Jimenez mentions that "when a body is not within the standard", that is, a lean body, considered beautiful and healthy, it is stigmatized, considered ugly, ugly, bad, abnormal, sick, frail, sad and, therefore, socially excluded. This discrimination is known as fatphobia. Such stigma is structural and cultural, transmitted in many and diverse spaces and social contexts".(13)

To refer to this discrimination and neglect, Lazzari describes the term "fat phobia", definition: "the term 'fat phobia' refers to a pathological fear of fatness often manifested as negative attitude and stereotypes about fat people".(4)

The lack of motivation of health professionals involved in the follow-up of obese patients occurs due to the negative perception that these professionals have about obesity. It is important to highlight that, due to indifference in medical consultations, the physician ignores the patient's main complaints, attributing them only to excess weight, which can, in addition to humanely harming the individual and his or her rights of access to health, prevent a diagnosis.(15)

In the medical field, fatphobia is classified according to the following parameters: 1) Medical fatphobia in the relationship between health professional and patient: which occurs when the patient is treated or spoken rudely or disrespectfully; 2) Medical fatphobia in the infrastructure: which occurs when there are no equipment, medicines, machinery, tools and, finally; 3) Medical fatphobia in diagnosis and treatment: malicious or negligent refusal to diagnose or failure to treat symptoms because the person is fat.(4)

Therefore, it is understood that it is necessary to evaluate the practices harmful to the obese body, as suggested by the medical class, what accompanies this course to reach the body considered healthy and the possible counterproductive effects of this approach to health recovery focused on weight loss and individual behavioral change.(5)

For this, it is necessary to understand the reasons for the importance of discussing fatphobia, especially in the field of medicine. For this, the three bases of Lazzari were chosen, which are: 1) obesity affects many individuals, in a growing way; 2) the allegations of fatphobia are being repeated in a numerous way in social networks, being possible to characterize it as relevant to public interest; and 3) fatphobia directly affects constitutional rights to health and dignity of the human being.(4)

 

A gordofobia na sociedade pós-moderna: do belo ao feio

Excess weight" was not always a stigmatized characteristic. At certain times in history, as in ancient times, the standard of beauty was already to have rounded, flabby and prominent forms. It was from 1890 to 1910 that the so-called turning point occurred, where obesity became abruptly discriminated against. The so-called "moral failure" was attributed to the obese and persists to this day, with frequent use of cartoons and cartoons ridiculing those who are overweight.(16)

The designation of fatphobia has come to be used in recent years, mainly in the social media, being used to denominate the preconception, stigmatization and aversion encompassed by means of a structural oppression in society that affects fat people. Thus, it is a form of discrimination structured and disseminated in the most varied sociocultural contexts, consisting in the devaluation, stigmatization and harassment of fat people and their bodies.(5)

Such stigmatization, as discussed by Tavares da Silva, feeds a process of dehumanization, in which the person is completely reduced to his or her stigma from a superficial judgment that generalizes the life habits of individuals who possess such social marker. The author adds that this process of dehumanization relies on social, media, cultural and medical devices to perpetuate models of acceptable bodies (lean or hypertrophic).(11)

As mentioned above, the fat body became marginalized - which generated a constant search for methods of weight loss, as well as a commercialization of weight control tools. "As strong as the fashion and commercialization of weight control, was the growth of the belief and/or perception that fatness, obesity, was negative. Quickly, a powerful stigma began to be created around obesity, deeply affecting people's self-image and behavior".(11)

The search for leanness and for the ideal body has become progressively more intense. The inadequacy between the ideal of a lean body, widely accepted in society, and the way in which adolescents perceive their own body, leads them to perform extreme and harmful attitudes to lose or maintain their weight, such as inducing vomiting or ingesting laxatives, or even taking medication or formulas without medical supervision.(16)

In addition, such extreme attitudes are also related to the continuous increase in the number of aesthetic surgeries, which according to data from the International Society of Aesthetic Plastic Surgery (ISAPS)(17) , were estimated at 33,3 % in the last four years. However, it is necessary to understand the problem behind this search for the ideal body, which can lead to an incessant body dissatisfaction and social isolation.(5)

To understand this problem, it is necessary to talk about what the ideal body is. The subject does not only have a body, the body is not only his dwelling place, it is not something he can say goodbye to, get rid of, but it is the body itself, his body that makes the opening of the self to the world, placing him in a situation: "The body is our general means of having a world".(18)

"Throughout human development, the body continues to have a strong relationship with the psyche. The external pressure of beauty standards ends up mobilizing the subject in his perception of himself and, concomitantly, in his self-esteem. It is a communicator of our emotions and a translator of our thoughts and desires. The body movement speaks, expresses and reveals the most intimate desires. Through it - and with it - we discover the world and our sensations. However, many times, it reveals something that one does not want to show, or it is even different, not corresponding to expectations".(18)

According to Soares and Barbosa, the way of looking at oneself and self-conceit may be intimately linked to the demands of a sociological norm of form and appearance, which are learned in society and culture. Self-esteem, whatever the level, is an intimate experience, a state of being that is not at war with oneself or with others.(18)

The lack of awareness of your true potential can lead to an imbalance between what I am and what I would like to be,(18) and can even cause tragedies, as is the case of the death of the digital influencer Liliane Amorim, 26, after undergoing liposuction, which shocked the country and reactivated the debate about the limits of the search for the 'perfect body'. Liliane was hospitalized in a private hospital since January 15, six days after suffering complications during the surgical procedure.(19)

According to Cocolo, studies point out that the mortality rate for liposuction is 19 for every 100,000 surgeries performed. Thus, the problem of beauty standards makes the body become an object of consumption, which legitimizes the alterations suffered by it.(20)

Therefore, the body is understood as a mutable and/or mutant construction, susceptible to interventions related to scientific development and technological evolution through cultural promotion.(18)

 

The legal partnership between doctor and patient in the treatment of obesity

Despite all the moral damage caused by the practice of fatphobia, it is known that fatphobia is still not recognized as an oppression, since it is considered a health issue and, therefore, becomes acceptable and legitimate from the medical point of view.(5)

According to Lazzari, the allegations of fatphobia become relevant from the legal point of view from the moment in which they refer to rights of constitutional status, which refers to the right to health, provided as a social right by article 6 of the Constitution of 1988. With this, Lazzari concludes that medical fatphobia is an affront to the dignity of the human person and should be debated from the moment it affects millions of people in their individual sphere.(4)

However, according to Ortolan, this conduct is condemned by Article 23 of the Code of Medical Ethics "... it is forbidden for a specialist to treat a human being without civility or consideration, to disrespect his dignity or to discriminate against him in any way or under any pretext". Therefore, specialists who engage in such "conduct" are subject to incrimination and penalties by the bodies that regulate the work of physicians.(21)

Finally, how should the doctor-patient relationship be in the face of obesity conditions? What would be the limit between medical care with the health of obese people and fatphobia? Is it the doctor's duty to guarantee equity in the admission of fat people to the basic health unit? What is the importance of a doctor-patient relationship without social stigmas ?(4)

Objectifying this point, and placing doctors as the main characters of this criticism, we can perceive the lack of wisdom and empathy towards patients, because nowadays there are stories of medical fatphobia, mainly spread through the Internet.(11)

Formerly, the figure of the physician, was something that approached a divinity, however, thoughts like that, increased his sovereignty and polluted his mind, whose purpose is to provide a state of relief and peace for his patient, as said by Hippocrates: "I will apply regimes for the good of the patient according to my power and understanding, never to cause harm or evil to anyone". Thus, the physician must have the knowledge to bring comfort through his words.(22)

It is also important to emphasize that the academic training of future physicians is of great importance in the doctor-patient relationship. There is a deficiency in learning due to the use of unattractive teaching methodologies for this purpose, not awakening the student's interest in the subject, as highlighted by a medical student: "I think that, when we have these classrooms of collective health that talk about empathy at the beginning of the course, we do not give value, they are not attractive [...]".(23)

In addition, because it is an elitist course, when in contact with more needy patients, some medical students go through a "reality shock" which, according to them: "My reality is not that, here you see yourself in a reality completely different from yours, and you do not know how to deal with it". However, this makes it difficult for them to recognize other realities, for which they are not prepared, which hinders learning and the development of skills related to empathy in doctor-patient care.(23)

Finally, it is understood that the importance of emotional and relational aspects in the deliberation and resolution of ethical conflicts is gradually being taken into account, as well as the value of narrative medicine and its relationship with ethics, and this is also reflected in relation to the treatment of obese patients.(24)

With this in mind, it is essential to have an adequate approach to the patient in primary care, as well as awareness of possible complications. This understanding is important to promote prevention, adherence to treatment, and protocols and guidelines for the best possible care of obese patients.(24)

 

METHODS

An exploratory literature review was conducted in the Google Scholar database, with the following indexes: obesity, metabolically healthy obesity, metabolically unhealthy obesity, fatphobia, medical fatphobia, cultural factors of fatphobia.

After the research, 29 articles were found, being that they were criteria for inclusion: they were published in Portuguese, Spanish and English, available in full and free texts, which permeated the objective of this research; survey made of the articles between the period of 10 years, from the date of publication, to the current year.

The analysis of the selected bibliographic material was carried out in depth in order to select the information and texts that fit with the objective of this study.

 

RESULTS AND DISCUSSION

The increase in obesity brings with it great concern and is already considered a pandemic by the World Health Organization (WHO), which estimates one billion obese people in the world by 2030. In addition to the risks associated with individual health, the problem will also affect the economic sector, as revealed by the Atlas of Obesity 2022, published by the World Obesity Federation, highlighting that if obesity continues to grow at this rate, the economic impact will increase tenfold in the next 40 years, reaching 3,3 % of global GDP.(25)

To systematize the information collected for discussion, we present the relevant articles in table 1.

 

Table 1. Articles analyzed for discussion

Title

Authors

Year

Type of study

Main results

Conclusion

Training humanistic do physician

Isaias Pessotti

1996

Revisão

Bibliographic

Apontar or social role do medical and com reflection of evolution of medical na history of civilização.

The changes historical not meaning social and ethical da atividade medical and na Philosophy Humanistic tornam difficult propor um conteúdo ideological for the formation

humanistic do physician.

Perceptions about ''being obese'' under otic do patient and two profissionais da health

Danitielle K. Marques Grejanin, Tiago H. Pezzo,

Valéria Nastri, Virginia P. Paula Sanches, Debora D. Gonçalves do Nascimento, Michele P. Quevedo

2007

Study exploratory and description of cut qualitative

Perceptions two professionals about you patients obese e a percepção dos patients obese about if they are their own.

Foram demonstrated perceptions of both of you groups that or obese is a pessoa infeliz, doente, com baixa self-esteem, embora seja reconhecida a  ossible success of treatment.

The standard of body beauty on the female body by means of BMI

Clara Maria Silveira Monteiro de Freitas, Ricardo Bezerra Torres Lima, António Silva Costa, Ademar Lucena Filho

2010

Qualitative-quantitative research, descriptive format

To define a standard of beauty of the female body with a scientific character, which is the body mass index (BMI).

Women are more dissatisfied with their body image, and society, both laypersons and physical education professionals, associate the beautiful female body as a "beautiful body", lean body.

Is medical empathy born or made?

Evolution of empathy in medical students.

Montse Esquerda, Oriol Yuguero, Joan Vinas, Josep Pifarré

2016

Observational cross-sectional study

To measure the degree of empathy of the medical students of a certain faculty, comparing with sociodemographic variables and the evolution of the students during the progress of the medical course.

Some variables showed that the degree of empathy of the medical student may be higher due to being female, being in contact with or even suffering from serious diseases, advancing in the course and doing voluntary activities.

Custos atribuíveis à obesidade, hipertensão e diabetes no Sistema Único de Saúde, Brasil, 2018.

Eduardo Augusto Fernandes Nilson, Rafaella da Costa Santin Andrade, Daniela Aquino de Brito, Michele Lessa de Oliveira

2018

Etiology study

To estimate the costs attributed to arterial hypertension, diabetes and obesity in the Sistema Único de Saúde (SUS).

The costs attributed to obesity as a risk factor for hypertension and diabetes reached 41 % of the total.

The feminine in search of the ideal body: a reading of the Frankfurt School.

Jénnefer Lorena de Oliveira Ramos, Valter Rodrigues Alberto

2018

Bibliographic Review

Elucidate the sociocultural factors that impose on women an ideal and perfect body.

There is a need, hidden by social pressure, to fit into a standardized beauty, generating a feeling of frustration and distress when this is not achieved. objective.

Learning of Empathy in the Doctor-Patient Relationship: a Qualitative Study among Internship Students of Medical Schools in Northeastern Brazil.

Nildo Alves Batista, Simone Schwartz Lessa

2019

Coverage study

To understand at what stage is the development of empathy among medical students who have already completed most of their training curriculum and who will soon be able to exercise their profession.

It was observed that students do not recognize or identify relevant teaching moments during their training, and when they do mention them, they relate them more to theory than to the medical practice.

From the pathologization of the fat body to bariatric surgery: reflections from the debate on fatphobia

Barbara Mariano

2019

Conclusion Work

to identify theoretical-critical elements of the debate on fatphobia in Brazil in relation to health services and bariatric surgery.

The debate on fatphobia becomes necessary and urgent, which affects the reflection about the care of obese people from non-stigmatized and non-stigmatized professional guidelines. não-discriminat orias.

Analysis of Brazilian obesity guidelines: pathologization of the fat body, approach focused on weight loss and fatphobia

Marina Bastos Paim, Douglas Francisco Kovaleski

2020

Bibliographic Review

Analysis of the Brazilian Obesity Guidelines on the field of obesity, their influence on professional practice, the type of treatment encouraged and the decision-making process in relation to obesity. fat bodies.

What we observe in the Guidelines is the defense of health in relation to lean bodies and stereotypes related to the fat body that link health to weight loss.

The ideal body: representation of the body in subjectivity and contemporaneity.

Marcela Dupont Soares, Josefa Ferreira Barbosa

2020

Bibliographic Review

To approach the relationship between the subject and the image he has of his body, covering the influence received by the media, of communication, print media, television and advertising campaigns.

Possible evils are listed below and psychological consequences of an excessive search for the ideal body.

Evaluation of the autonomic profile in metabolically healthy obese people.

Alice Pereira Duque

2021

Course conclusion work

To demonstrate that ObMS predisposes to autonomic alterations.

These findings suggest that, even in the absence of metabolic syndrome, the presence of BMS predisposes to subclinical autonomic disturbances, placing these individuals at greater risk of autonomic dysfunction and, therefore, at greater risk of cardiovascular.

Indemnification for pain and suffering damages in cases of fatphobia: A study of the understanding of the court of justice of São Paulo.

Lara Estrela, Baldo Silva

2022

Course conclusion work

Discussion of the concepts of fatphobia and moral damages, in Brazilian Law, in order to corroborate or not with the hypothesis of application of compensation for moral damages in cases of fatphobia.

Fat people have been living on the margins of society for a long time, due to a process of stigmatization that intensified at the end of the 19th century and that, in the current second decade of the 21st century, is only gaining more força.

Factors associated with sociocultural attitudes in relation to appearance in medical students.

Karolina De Souza Cardoso, Rogério José de Almeida

2022

Course conclusion work

To analyze sociocultural factors in relation to appearance in medical students.

The medical student many times, due to the influence of both the university and family environment, is subjected to unattractive standards. This can lead to prejudices to their mental health.

Is there fatphobia in nutrition?

Uma Análise estigma do peso e nutricionistas

Luiza Moura Tavares da Silva

2022

Course conclusion work

To analyze the fatphobia referring to the field of the health professional, especially the nutritionist.

Confirmed the presence of fatphobia among nutrition professionals and ratified the need for various educational and guidance measures in the course of the training course, profissional.

Metabolic Healthy Obesity: a temporary state of metabolic health?

Ana Maria Covas Pinto

2022

Thematic review

Expor facts about Metabolic Healthy Obesity and report its durability based on recent studies.

According to existing definitions, individuals with ObMS are considered obese (BMI ≥ 30 kg/m2) with zero, one, or two metabolic abnormalities. BMI is an indirect measure of body composition and does not provide information on the distribution of body fat and lean mass. 

The use of this definition can lead to the incorrect classification of this phenotype. The use of other anthropometric and body composition parameters can help to identify ObMS in a more accurate way.

Profile of obese adults with Healthy and Unhealthy Metabolic Phenotypes

Eduardo Schmitz

2022

Course conclusion work

To describe the metabolic phenotype of adults with obesity.

With the studies, a large population of metabolically healthy individuals was presented, concluding that obesity is a complex, multifactorial and challenging disease in terms of treatment, depending very much on the phenotype of the população.

Aristotelian Rhetoric and Medical fatphobia

George Schinestzki Lazzari

2022

Review

To endorse speeches against medical fatphobia.

A Medical fatphobia can be considered as a generalized injustice and violates the provisions of the legal.

 

Estimates of the cost of the main chronic diseases associated with malnutrition show that these diseases impose a large economic burden on the country’s health system. The data show that integrated and interagency policies that prioritize the prevention and control of hypertension, diabetes and obesity are necessary and can support interventions such as advocacy for physical and regulatory measures to achieve the goals of the United Nations Decade of Action on Nutrition.(10)

Since 1997, obesity has been recognized by the World Health Organization as an important public health problem and a global epidemic, associated with increased risks for cardiovascular diseases, cancer and diabetes. Although this increase in risk factors for other diseases is known and described, in the 1980s, at the same time that we have studies showing that obesity began to be discussed as a public health issue, other studies began to discuss a benign phenotype of obesity called Metabolically Healthy Obesity (MSO).(5,9)

The literature suggests that 30 % of obese patients have a healthy metabolic phenotype. Therefore, identifying characteristics associated with reduced risk factors for the main obesity-related diseases can help to maintain the health of obese patients. Thus, it is noted that phenotypic metabolic alterations exist even in obese adult populations and are associated with sociodemographic, behavioral and health variables, which may be of great importance in the clinical and epidemiological context of obesity.(14)

We can also see studies that report that this subgroup of people would be protected against obesity-related cardiometabolic diseases or would present a significantly lower risk than normal, described between high Body Mass Index (BMI) and cardiometabolic risk. This phenotype feeds the scientific debate, in the sense of understanding that, in some way, these people are really at lower risk of triggering cardiometabolic disorders, or if this is just a transitory state of metabolic health.(2)

Fatphobia is a type of discrimination that reinforces stereotypes and generates segregation. It is present in various aspects of today’s society due to the nutritional transition experienced by modernity and even as a result of the social income of the citizen. Thus, it is highlighted the stigmatization of the fat body in society and how this factor negatively influences life, making it impossible to live a full and healthy life mentally and physically. In addition, this problem is duly expanded and explored in the field of the health professional, specifically the nutritionist.(5)

Through several data and researches, it was ratified the presence of this preconception with the fat body among professionals who should at all costs help the patient in need of care and attention who, unfortunately, end up handling the situation in a very negligent and superfluous way. However, the nutritionists themselves who have fat bodies are not free from this situation, being victims of fatphobia from their own patients, who consider them “not professionally competent”.(5,12)

Based on the research conducted by Grejanin, where the thinking of health professionals and obese people in relation to the fat body was evaluated, it was revealed that many negative and negative thoughts are related, which results in a difficulty in the adequate treatment and, many times, a deterioration in the patient’s health framework.(14)

Thus, the presence of preconceived ideas about the fat body in the health area is fully visible.(14) As written by Mariano, “it is observed that the stigmatization of the fat body is at the base of the triggering of comorbidities and aggravates the clinical course, as it reveals itself as a potential factor of vulnerability to the deterioration of self-image”. The fat body tends to be judged as incapable and sedentary, causing the person himself to doubt or question his abilities.(26)

The preconceit with the obese patient can trigger several problems, among them depression. It is up to the physician to listen to the main complaints of the patients and together with him/her approach a therapeutic plan to improve their quality of life. The health system should approach this population with respect and dignity, promoting a welcoming and humanized environment.(5,27)

In this sense, we observe that fatphobia is socially validated in favor of concerns about health, well-being and self-esteem, and it is notoriously the female body that suffers most from the results of the marginalization caused by the preconception of fat. According to some studies, the female body has always been adapted to an aesthetic standard, largely as a result of the patriarchal and sexist society in practically a large part of the world.(16,26)

These marginalizations, many times, are warned by the health professionals themselves. Such medical conduct towards fat patients is reported by Jimenez, who stood by the side of women who had their claims silenced, as well as demonstrating in her book “lute como uma gorda” such medical negligence.(13)

Ramos makes a better deepening, together with the thinkers of the Frankfurt School, exploring much more the way of mass media and the cultural burden that is expressed to society that a woman is only attractive if she possesses a lean and standardized body.(13)

In addition, it is clear how this unhappiness of not reaching such a "perfect" aesthetic standard causes great personal dissatisfaction in the citizen, which can evolve into a depressive state and, in the best of hypotheses, a suicide, which in some way is beneficial to social health as a whole - which is in harmony with Durkheim's concept of social anomie, a phenomenon that is highly detrimental to sociocultural lifestyles.(16,26)

From Lazzari's point of view, we can divide medical fatphobia into three categories: in the health professional-patient relationship; in infrastructure, when there are no adequate equipment and devices for fat people; and in diagnosis and treatment, when there is a pre-conception and judgment that the diagnosis and treatment is wrong or neglected because the patient is fat.(4)

This means a great periculosity of medical fatphobia, and that this often leads to negligence on the part of health professionals, because, according to Schmitz, "a fat person, when he enters a doctor's office to complain about any pain or symptom, is automatically diagnosed as obese and the recommendation is always to lose weight".(12)

It is notorious that the first medical diagnosis has been correlated with obesity. Therefore, in order to obtain a reliable diagnosis of the patient's symptoms, preserve psychological health and maintain professional ethics, the physician should perform a good anamnesis and a thorough examination based on the patient's complaints, in order to consequently detect the possible disease early and correctly to which the patient refers to.(4,12)

Both fatphobia and bad medical conduct when treating obese patients can be considered as a violation of the law, since they offend human dignity and the principle of equity, and go against what is guaranteed by the constitution. In addition, the doctor who commits fatphobia is also violating the code of medical ethics, which states that everyone has the right to quality medical care, at the right time and with the right to continuity of treatment.(4)

The social and ethical significance of medical activity and the historical changes in humanistic philosophy make it difficult to propose the ideological content of the humanistic training of physicians. This formation is a product of the personal experience of each individual and implies an awareness of his or her own value system, which also implies an awareness of the patient as a follower and creator of values. His response to clinical treatment also depends on his understanding of the disease, life and medicine.(22)

A good doctor-patient relationship should be considered an essential factor for patient care, in which empathy is one of the main pillars of this relationship. The establishment of empathic relationships implies not only greater patient satisfaction, but also greater satisfaction of the health professionals themselves. It strengthens bonds, promotes better adherence to treatment and reduces complaints and legal proceedings against the professional.(23)

In this sense, some studies relate better empathy with better clinical competence, as well as better communication and doctor-patient relationship. Doctor-patient empathy encompasses emotional, ethical, intellectual and behavioral aspects, and is extremely important because it strengthens the relationship, trust and respect, generating a reciprocal connection that allows benefits such as improvement and satisfaction in the results of the patient's health treatments, being an essential conduit for the therapeutic plan.(28)

 

Final Considerations

Besides the issue of medical treatment, the fat body suffers from social stigmas that accompany it from the moment of leaving home, even bus barriers that do not allow its passage, seats in public places that do not accommodate its size and difficulties in finding clothes that fit - considering that every day they have smaller shapes and that coincide with what would be the ideal body: that is, lean and small.

Thinking about the individuals who go through daily constricting situations, over the last years, there has been the appearance of "free body" movements, which help in the reconstruction of the fat person's self-esteem, reaffirming that not only bodies within the current standard should be respected and considered worthy.

Among the people who command this internet movement is the influencer Thais Carla, who tells her daily life and the preconceptions suffered in current situations. However, there are controversial opinions regarding the guidelines that are raised by her, since there may be a tenuous line between body acceptance movement and obesity romanticization.

At the same time that the movement is considered of extreme importance for the recovery of fat people's self-esteem, it is not able to counteract the preconception that they suffer on a daily basis. Thus, it is perceived that sociocultural factors are determinant to the practices of fatphobia by society and, also, by the medical community.

It is very difficult for recently-trained physicians to adapt to the needs of their patients, considering that they still see obesity as a preconceived concept and do not analyze the disease itself, making diagnosis difficult and even neglecting them.

It is worth emphasizing that the construction of a healthy relationship between the two can improve the patient's life conditions, whether physical or psychological. Therefore, this statement makes us reflect and observe how important is the physician's action in the search for more knowledge about obesity, fatphobia and the social stigma it brings with it, in order to practice empathy and fairness, helping the population and their patients in the search for information about this issue, thus avoiding the spread not only of social problems, but also physical and psychological ones.

 

REFERENCES

1. Drozdz D, Alvarez-Pitti J, Wójcik M, Borghi C, Gabbianelli R, Mazur A, et al. Obesity and Cardiometabolic Risk Factors: From Childhood to Adulthood. Nutrients. 2021 Nov 22;13(11):4176. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8624977/. Accessed 2023 Feb 23.

 

2. Pinto AMC. Obesidade Metabolicamente Saudável: um estado temporário de saúde metabólica? Porto: Universidade do Porto; 2022.

 

3. Organização Pan-Americana da Saúde. Dia Mundial da Obesidade 2022: acelerar ação para acabar com a obesidade [Internet]. [cited 2023 Feb 25]. Available from: https://www.paho.org/pt/noticias/4-3-2022-dia-mundial-da-obesidade-2022-acelerar-acao-para-acabar-com-obesidade.

 

4. Lazzari GS. Retórica aristotélica e gordofobia médica. Rio de Janeiro: Universidade Federal do Rio de Janeiro; 2022.

 

5. Paim MB, Kovaleski DF. Análise das diretrizes brasileiras de obesidade: patologização do corpo gordo, abordagem focada na perda de peso e gordofobia. Saúde e Sociedade. 2020;29(1). Available from: https://www.scielo.br/j/sausoc/a/pBvf5Zc6vtkMSHytzLKxYJH/abstract/?lang=pt. Accessed 2023 Feb 24.

 

6. Lepez CO, Simeoni IA. Pedagogical experience with Public Health campaigns from the design of socio-educational projects with insertion in the local territory. Community and Interculturality in Dialogue 2023;3:74–74. https://doi.org/10.56294/cid202374.

 

7. Ministério da Saúde Brasil - Secretaria de Atenção Primária à Saúde. Excesso de peso e obesidade [Internet]. [cited 2023 Feb 25]. Available from: https://aps.saude.gov.br/ape/promocaosaude/excesso.

 

8. Tavares TB, Nunes SM, Santos MO. Obesidade e qualidade de vida: revisão de literatura. Revista Médica de Minas Gerais. 2010 Aug 18. [cited 2023 Mar 1]. Available from: https://rmmg.org/artigo/detalhes/371#.

 

9. Duque AP. Avaliação do perfil autônomo em obesos metabolicamente saudáveis. Rio de Janeiro: Instituto Nacional de Cardiologia; 2021.

 

10. Nilson EAF, Andrade RCS, Brito DA, Oliveira ML. Custos atribuíveis a obesidade, hipertensão e diabetes no Sistema Único de Saúde, Brasil, 2018. Revista Panamericana de Saúde Pública. 2020;44:e32. Available from: https://iris.paho.org/handle/10665.2/51945. Accessed 2023 Feb 23.

 

11. Tavares da Silva LM. Há Gordofobia na Nutrição? Uma análise sobre estigma do peso e nutricionistas. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2022.

 

12. Schmitz E. Perfil de adultos com obesidade com Fenótipos Metabólico Saudável e Não Saudável. Florianópolis: Universidade Federal de Santa Catarina; 2022.

 

13. Jimenez MLJ. Lute como uma gorda: gordofobia, resistências e ativismos. Cuiabá: Universidade Federal do Mato Grosso; 2020.

 

14. Grejanin DKM, Pezzo TH, Nastri V, Sanches VPP, Nascimento DDG, Quevedo MP. As percepções sobre o “ser obeso” sob a ótica do paciente e dos profissionais da saúde. Revista Brasileira de Crescimento e Desenvolvimento Humano. 2007;17(3):37-47. Available from: http://pepsic.bvsalud.org/pdf/rbcdh/v17n3/04.pdf. Accessed 2023 Feb 25.

 

15. Ramos JLO, Alberto VR. O feminismo em busca do corpo ideal: uma leitura da escola de Frankfurt. [Internet]. 2018. [cited 2023 Feb 24]. Available from: http://encontroregionalsul2014.abrapso.org.br/resources/anais/18/1483989554_ARQUIVO_ARTIGOFRANKFURT.pdf.

 

16. Silva LEB. A Indenização por Danos Morais nos Casos de Gordofobia: um estudo no entendimento do tribunal de justiça do Estado de São Paulo. Franca: Universidade Estadual Paulista Júlio de Mesquita Filho; 2022.

 

17. International Society of Aesthetic Plastic Surgery (ISAPS). A mais recente pesquisa global da ISAPS demonstra aumento significativo em cirurgias estéticas em todo o mundo [Internet]. [cited 2023 Feb 20]. Available from: https://www.prnewswire.com/news-releases/a-mais-recente-pesquisa-global-da-isaps-demonstra-aumento-significativo-em-cirurgias-esteticas-em-todo-o-mundo-892357510.html.

 

18. Soares MD, Barbosa JF. O corpo ideal: representação de corpo na subjetividade e contemporaneidade. Doxa: Revista Brasileira de Psicologia e Educação. 2020 Sep 11;22(1):238-54. [cited 2023 Feb 27]. Available from: https://periodicos.fclar.unesp.br/doxa/article/view/14131.

 

19. Téllez FC, Gimenez M, González C. Education for the control of arterial hypertension in older adults: An effective approach. Community and Interculturality in Dialogue 2021;1:3–3. https://doi.org/10.56294/cid20213.

 

20. Universidade Federal de São Paulo - Departamento de Comunicação Institucional. O lado obscuro da beleza [Internet]. [cited 2023 Feb 20]. Available from: http://www.unifesp.br/reitoria/dci/revista-unifesp/o-lado-obscuro-da-beleza.

 

21. Academia Médica. Sobre gordofobia - na sociedade e na medicina [Internet]. 2022 [cited 2023 Feb 28]. Available from: https://academiamedica.com.br/blog/sobre-gordofobia-na-sociedade-e-na-medicina.

 

22. Pessotti I. A formação humanística do médico. Portal de Revistas da USP [Internet]. 1996 Dec 30;29(4):440-8. [cited 2023 Feb 27]. Available from: https://www.revistas.usp.br/rmrp/article/view/788.

 

23. Batista NA, Lessa SS. Aprendizagem da Empatia na Relação Médico-Paciente: um olhar qualitativo entre estudantes do internato de escolas médicas no nordeste do Brasil. Revista Brasileira de Educação Médica [Internet]. 2019 [cited 2023 Feb 28]. Available from: https://www.scielo.br/j/rbem/a/JRf8vKxXWhxm8vpsbJ3d4Ps/?lang=pt.

 

24. Esquerda M, Yuguero O, Viñas J, Pifarré J. La empatía médica, ¿nace o se hace? Evolución de la empatía en estudiantes de medicina. Revista Elsevier, Atención Primaria [Internet]. 2016; 8-14. ISSN 0212-6567. [cited 2023 Feb 26]. Available from: https://www.sciencedirect.com/science/article/pii/S021265671500058X.

 

25. World Obesity Atlas 2022. One Billion People Globally Estimated to be Living with Obesity by 2030 [Internet]. [cited 2023 Mar 01]. Available from: https://www.worldobesity.org/resources/resource-library/world-obesity-atlas-2022.

 

26. Mariano B. Da patologização do corpo gordo à cirurgia bariátrica: reflexões a partir do debate sobre gordofobia. Florianópolis: Universidade Federal de Santa Catarina; 2019. Trabalho de conclusão de residência integrada multiprofissional em saúde.

 

27. Freitas CMSM, Lima RBT, Costa AS, Lucena Filho A. O padrão de beleza corporal sobre o corpo feminino mediante o IMC. Revista brasileira de Educação Física Esporte [Internet]. São Paulo. 2010 Jul/Sep;24(3):389-404. [cited 2023 Feb 27]. Available from: https://www.scielo.br/j/rbefe/a/rMpVx4jWKSSJmm9zsGT6fjh/abstract/?lang=pt.

 

28. Cardoso KS, Ritter GP, Almeida RJ. Fatores associados à atitudes socioculturais em relação à aparência em estudantes de medicina. Goiânia: Pontifícia Universidade Católica de Goiás; 2022. Trabalho de conclusão de curso de Medicina.

 

29. World Health Organization. Obesity and its roots [Internet]. [cited 2023 Feb 25]. Available from: https://www.who.int/news-room/events/detail/2020/03/04/default-calendar/world-obesity-day.

 

FINANCING

The authors did not receive financing for the development of this research.

 

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest.

 

AUTHORSHIP CONTRIBUTION

Conceptualization: Solanche Stefany Molinas Franco, Dayssy Franco, Andrea Elizabeth López Ramirez, Moisés Silva Campos, Kátia Christina Rodrigues Souza e Silva, Lidiana dos Santos Penha, Livia Cavalcanti Moret, Paloma Iracema Banak Zilch, Anna Luisa Silva de Oliveira, Camila Barros Araújo, Ester Vitória Costa, Gabriel Batista de Souza, Gabriella Patricia Rodrigues de Oliveira, Rebeca Marins Arantes, Stênio Vasconcelos de Farias Filho, Sthephany Caroliny Santos De Jesus, Wilgner Itiel Teixeira Souza.

Research: Solanche Stefany Molinas Franco, Dayssy Franco, Andrea Elizabeth López Ramirez, Moisés Silva Campos, Kátia Christina Rodrigues Souza e Silva, Lidiana dos Santos Penha, Livia Cavalcanti Moret, Paloma Iracema Banak Zilch, Anna Luisa Silva de Oliveira, Camila Barros Araújo, Ester Vitória Costa, Gabriel Batista de Souza, Gabriella Patricia Rodrigues de Oliveira, Rebeca Marins Arantes, Stênio Vasconcelos de Farias Filho, Sthephany Caroliny Santos De Jesus, Wilgner Itiel Teixeira Souza.

Methodology: Solanche Stefany Molinas Franco, Dayssy Franco, Andrea Elizabeth López Ramirez, Moisés Silva Campos, Kátia Christina Rodrigues Souza e Silva, Lidiana dos Santos Penha, Livia Cavalcanti Moret, Paloma Iracema Banak Zilch, Anna Luisa Silva de Oliveira, Camila Barros Araújo, Ester Vitória Costa, Gabriel Batista de Souza, Gabriella Patricia Rodrigues de Oliveira, Rebeca Marins Arantes, Stênio Vasconcelos de Farias Filho, Sthephany Caroliny Santos De Jesus, Wilgner Itiel Teixeira Souza.

Writing - original draft: Solanche Stefany Molinas Franco, Dayssy Franco, Andrea Elizabeth López Ramirez, Moisés Silva Campos, Kátia Christina Rodrigues Souza e Silva, Lidiana dos Santos Penha, Livia Cavalcanti Moret, Paloma Iracema Banak Zilch, Anna Luisa Silva de Oliveira, Camila Barros Araújo, Ester Vitória Costa, Gabriel Batista de Souza, Gabriella Patricia Rodrigues de Oliveira, Rebeca Marins Arantes, Stênio Vasconcelos de Farias Filho, Sthephany Caroliny Santos De Jesus, Wilgner Itiel Teixeira Souza.

Writing - proofreading and editing: Solanche Stefany Molinas Franco, Dayssy Franco, Andrea Elizabeth López Ramirez, Moisés Silva Campos, Kátia Christina Rodrigues Souza e Silva, Lidiana dos Santos Penha, Livia Cavalcanti Moret, Paloma Iracema Banak Zilch, Anna Luisa Silva de Oliveira, Camila Barros Araújo, Ester Vitória Costa, Gabriel Batista de Souza, Gabriella Patricia Rodrigues de Oliveira, Rebeca Marins Arantes, Stênio Vasconcelos de Farias Filho, Sthephany Caroliny Santos De Jesus, Wilgner Itiel Teixeira Souza.