Unit VII Ess
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Article1UnitVII.pdf
Saúde Soc. São Paulo, v.29, n.4, e180313, 2020 1 DOI 10.1590/S0104-12902020180313
Original articles
“It is over there, next to that fat lady”: a qualitative
study of fat women’s own body perceptions and
weight-related discriminations 1
“É lá, perto da moça gorda”: estudo qualitativo sobre as percepções
de mulheres gordas acerca de seus corpos e discriminações
relacionadas ao peso corporal
Correspondence
Mariana Dimitrov Ulian
Universidade de São Paulo, Faculdade de Saúde Pública, Departamento
de Nutrição. Av. Dr. Arnaldo, 715. São Paulo, SP, Brasil. CEP 01246-904.
Mariana Dimitrov Ulian a
https://orcid.org/0000-0001-7861-8597
E-mail: [email protected]
Priscila de Morais Sato a
https://orcid.org/0000-0001-9850-6859
E-mail: [email protected]
Ana Jéssica Pinto b
https://orcid.org/0000-0002-1363-7233
E-mail: [email protected]
Fabiana B. Benatti b
https://orcid.org/0000-0002-8320-7044
E-mail: [email protected]
Patricia Lopes de Campos-Ferraz c
https://orcid.org/0000-0003-0342-7790
E-mail: [email protected]
Desire Coelho b
https://orcid.org/0000-0001-5014-7762
E-mail: [email protected]
Odilon J. Roble d
https://orcid.org/0000-0003-1579-0116
E-mail: [email protected]
Fernanda Sabatini a
https://orcid.org/0000-0002-3037-4447
E-mail: [email protected]
Isabel Perez a
https://orcid.org/0000-0001-8992-5787
E-mail: [email protected]
Luiz Aburad a
https://orcid.org/0000-0002-1392-4339
E-mail: [email protected]
André Vessoni a
https://orcid.org/0000-0001-6027-6613
E-mail: [email protected]
Ramiro Fernandez Unsain e
https://orcid.org/0000-0003-3142-0561
E-mail: [email protected]
Bruno Gualano b
https://orcid.org/0000-0001-7100-8681
E-mail: [email protected]
Fernanda B. Scagliusi a
https://orcid.org/0000-0001-7590-4563
E-mail: [email protected]
a Universidade de São Paulo. Faculdade de Saúde Pública. Departamento de
Nutrição. São Paulo, SP, Brazil. b Universidade de São Paulo. Grupo de Pesquisa em Fisiologia Aplicada e
Nutrição. São Paulo, SP, Brazil. c Universidade Estadual de Campinas. Faculdade de Ciências Aplicadas.
Limeira, SP, Brazil. d Universidade Estadual de Campinas. Faculdade de Educação Física.
Campinas, SP, Brazil. e Universidade Federal de São Paulo. Instituto de Saúde e Sociedade. Santos,
SP, Brazil.
Abstract
We investigated fat women’s perceptions of their
own bodies and their experiences with weight-
related discriminations, and how these situations
affected their well-being. Thirty-nine obese women
were interviewed, and three axes of analysis were
identified: (1) repercussions of being fat, (2) living with a fat body, and (3) am I a person or just a fat body? These axes were composed of eight themes
which had similar meaning or complemented
each other. The results showed our participants
had mechanisms to diminish the magnitude of
their stigmatized bodies (e.g., attempting to lose weight and changing their current food choices). Participants also reported being fat had physical and
psychological consequences for them. Most notably,
their larger bodies influenced their self-evaluation, making them feel devalued, unlovable, incapable,
and incomplete. They reported stigmatizing
experiences in familiar situations, at the workplace
and in public spaces, and reported being stigmatized
by both close and unknown individuals, including
healthcare professionals. These professionals were
reported to treat patients disrespectfully, which
urges attention to health care inequalities for obese
people. Our results stress stigmatizing attitudes
towards fat people and their own considerations
about themselves have negative consequences in
their physical and mental well-being.
Keywords: Obesity; Stigmatization; Weight-Related
Discrimination; Self-Esteem; Physical Education.
1 We acknowledge the support by the Fundação de Amparo à Pesquisa do Estado de São Paulo (Fapesp), grant number 2015/03878-2. Finally, each author received a fellowship grant. Scagliusi was supported by the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) (grant numbers 311357/2015-6 and 309514/2018-5); Pinto, Sato, and Unsain by Fapesp (grant numbers 2015/26937-4, 2017/05651-0, and 2015/12235-8, respectively), Gualano has a productivity grant by CNPq and is also supported by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Capes) and Fapesp, and Ulian by Capes. The funding sources had no involvement in study design and in the collection, analysis and interpretation of data, writing of the article, and in the decision to submit it for publication.
Saúde Soc. São Paulo, v.29, n.4, e180313, 2020 2
Resumo
Investigamos a percepção de mulheres gordas
sobre seu próprio corpo e suas experiências com
discriminações relacionadas ao peso e como
essas situações afetavam seu bem-estar. Trinta
e nove mulheres obesas foram entrevistadas,
sendo identificados três eixos de análise: (1) repercussões de ser gorda, (2) vivendo com um corpo gordo, e (3) eu sou uma pessoa ou apenas um corpo gordo? Esses eixos eram compostos por
oito temas que se complementavam ou tinham
significado semelhante. Os resultados mostraram que nossas participantes utilizavam mecanismos
para diminuir a magnitude de seus corpos
estigmatizados (por exemplo, tentando perder peso e modificando suas escolhas alimentares
atuais). As participantes também relataram que ser gorda teve consequências físicas e psicológicas
para elas. É importante ressaltar que seus
corpos maiores influenciaram sua autoavaliação, fazendo com que se sentissem desvalorizadas,
incapazes, incompletas e sem possibilidade de
se sentirem amadas. Elas relataram experiências
estigmatizadoras em situações familiares, no local
de trabalho e em espaços públicos, e relataram
serem estigmatizadas por pessoas próximas e
desconhecidas, bem como por profissionais de
saúde. Foi relatado que esses profissionais tratam os pacientes com desrespeito, o que exige atenção
quanto às desigualdades na assistência à saúde de pessoas obesas. Nossos resultados enfatizam que atitudes estigmatizadoras em relação às pessoas
gordas e suas próprias considerações sobre si
mesmas têm consequências negativas para seu
bem-estar físico e mental.
Palavras-chave: Obesidade; Estigmatização;
Discriminação Relacionada ao Peso; Autoestima;
Educação Física.
Introduction
Throughout the last century, in Western
societies, body practices and attitudes towards
different body characteristics have undergone
changes. In the early 1900s, people experienced frequent periods of scarcity or famine, and thus,
having a robust body was a measure of health and
a desirable characteristic only possible for the
privileged strata of society. In contrast, a thin body would represent hunger, illness, and poverty (Gracia- Arnaiz, 2010). In the following decades, biomedicine started to understand excess of body weight as
pathological and associated it with worsened
health parameters, establishing mechanisms to
control it via recommendations of moderate food
consumption and standards of weight and height
(Gracia-Arnaiz, 2010; Stearns, 2002). Concomitantly, fashion, food, and pharmaceutical markets
started promoting thin bodies as the ideal shape,
attributing new meanings to thin and fat bodies.
While the first was associated with self-control, good health, and social distinction, the second
was associated with lack of self-control, illness,
and poverty (Brewis et al., 2011; Gracia-Arnaiz, 2010; Vester, 2010). These attributes were moral judgments, discrediting a corpulent body shape (Brewis et al., 2011). Consequently, a social obesity stigma was increasingly being framed (Goffman, 1983). Goffman (1983) describes stigma as a deeply discrediting attribute, disqualifying a person
from full social acceptance. This issue stems from
social interactions where the “deviant” is labeled
as the one who distances him/herself from those who are supposedly “normal.” Once assigned, the
stigmatizing feature legitimizes a series of social
discriminations, slanders, or exclusions.
Obesity has become a stigma, and negative
attitudes towards obese people have been constantly
observed (Puhl; Heuer, 2009). This reflects the priority of body weight in contemporary society, sidelining
people who are out of the established standard (i.e., people with slim bodies) (Sobal, 2000). A German study investigated stigmatizing attitudes towards obese
individuals and their determinants in a sample of 969 participants (431 men and 469 women), averaging 45.9 years old and 24.5 kg/m2 BMI. Results revealed 23.5%
Saúde Soc. São Paulo, v.29, n.4, e180313, 2020 3
of the participants had stigmatizing attitudes towards
obesity, attributing this condition to individual
behavior, less education, and older age (Hilbert; Rief; Braehler, 2008). This study shows how obese people are blamed for their body size and seen differently
from other people. In Brazil, it is also possible to observe stigmatizing attitudes towards fat people.
In 2014, a public contest for teachers in the state of São Paulo rejected 25% of the candidates because they were obese (Campos et al., 2015). Additionally, a Brazilian study investigated fat stigma by internet users (Araújo et al., 2018). The researchers selected the users’ comments on an article related to fat stigma
published in a national magazine. Results showed
the participants legitimized processes of prejudice and discrimination related to fat people. Moreover,
they expressed dissatisfaction with proposals aiming
equality between this group of people (e.g., quotas), ratifying the idea that to be socially respected, fat
people should adequate their body to the thin pattern
(Araújo et al., 2018). Over the past decade, it is estimated that the
prevalence of weight discrimination increased
60% (Andreyeva; Puhl; Brownell, 2008), which is now comparable to prevalence rates of racial
discrimination in the United States of America (USA) (Puhl; Andreyeva; Brownell 2008). Using data from the National Survey of Midlife Development
in the USA (1995-1996) Puhl, Andreyeva, and Brownell (2008) examined experiences2
of weight
discrimination. The sample consisted of 2,290 adults, and the results showed for adults with a BMI between 25 kg/m² and 30 kg/m², the percentage of weight discrimination ranged from 5% among men to 10% among women. For heavier individuals, those with a
BMI higher than 35 kg/m², the percentages were 28% for men and 45% for women. A study carried out in Florianópolis, Santa Catarina, Brazil, aimed to know the life story of people who underwent a bariatric
surgery (Santos et al., 2010). The interviewees perceived themselves socially excluded, avoided
social situations, and were called names because
of their fat bodies. This motivated their decision
to proceed with the surgery (Santos et al., 2010). Weight-related discriminations have serious impacts
on obese people, negatively affecting their access to
career and education, equality of payment, health
care assistance, and interpersonal relationships
(Carr; Friedman, 2005; Janssen et al., 2004; Poulain, 2009; Puhl; Heuer, 2009; Sobal, 2000).
Weight discrimination and obesity stigmatization
are important issues to be studied since they can be
partly responsible for health problems immediately
attributed to obesity (MacLean et al., 2009). Brazil is an important country to be studied since its
social context stands out for extreme weight-
related discriminations. Examples of that are the
evidences of studies showing how physical beauty
for Brazilian women is socially valued (Edmonds, 2010), and how failing to attend the thin-ideal causes high level of stress for them (Dressler et al., 2012). Internationally, some research has investigated weight-related discriminations in social
interactions (Brewis et al., 2011; Puhl; Heuer, 2009), healthcare professionals (Brown, 2007), media (Malterud; Ulriksen, 2010), public health actions (Lewis et al., 2010), everyday social relationships (Brewis et al., 2011), and social spaces (Brewis et al., 2016). Nationally, four qualitative studies have investigated obese women experiences in public
health facilities (Pinto; Bosi, 2010), with their bodies (Cruz; Bastos, 2015; Macedo et al., 2015), and of obese dietitians (Araújo; Pena; Freitas; 2015; Araújo et al., 2015).
In light of the evidence presented above, it seems there is a social and a historical consensus about
the negative effects of fat stigma to fat people
(Brewis et al., 2011; Carr; Friedman, 2005; Gracia- Arnaiz, 2010; Janssen et al., 2004; Poulain, 2009; Puhl; Heuer, 2009; Sobal, 2000). Nonetheless, only a limited number of national studies have
qualitatively examined how fat people describe
their own fat stigma experiences. Thus, little is
known about the consequences of fat stigma from
the perspective of fat people. The negative moral
meanings related to the fat body are increasing
and can also raise the number of people vulnerable
to this stigma, increasing the social consequences
of obesity. Investigate the different constructs of stigma and body image among fat women may be
2 We understand “experiences” by situations lived continuously by someone, who is thus, able to give in depth details about it (Patton, 2002).
Saúde Soc. São Paulo, v.29, n.4, e180313, 2020 4
important to help delineate novel and more effective
strategies of care, especially in a context in which
the prevalence of obesity is growing, such as Brazil (Ng et al., 2014). Therefore, we aimed to investigate, qualitatively, fat Brazilian women’s perceptions of their own bodies and their experiences with weight-
related discriminations, and how these experiences
affect their well-being.
Methods
Study design and participants
This study is part of a larger prospective,
randomized, controlled, mixed-method clinical trial,
“The Health and Wellness in Obesity Study,” whose full rationale and design are reported elsewhere
(Ulian et al., 2017). For this, only a baseline individual semi-structured interview of a sample of 39 women who were enrolled in the larger study and provided
information about weight stigma was included in
the data analysis. Participants were aged between
25 and 50 years and had a body mass index (BMI) ranging between 30 kg/m² and 39.9 kg/m². These participants lived in the city of São Paulo.
Qualitative research is based on the premise
that knowledge is relative, and a creation resulted
from the interaction between the researcher and the
participant. Some theories point out the meaning
attributed to a reality is not only subjective in nature but is essentially a constant construction of
individuals as they interact in a social environment.
These, when faced with a certain event or experience,
are led to successively reinterpret an earlier
reality (Fonte, 2006). Construction of meanings is not something permanent and immutable, on
the contrary, it is always transformed by new
experiences. Interpretation of the reality of a subject by the researcher is, therefore, a new construction
(Fonte, 2006). Thus, it is the meaning, not the truth, which the qualitative researcher seeks to understand
through data (Bailey; Tilley, 2002). The Ethics Committee of the concerned
institution approved the project. The participants signed the informed consent form, and all procedures
were in accordance with the Declaration of Helsinki, revised in 2008.
Data production and analysis
At the beginning of the intervention, an
individual semi-structured interview was conducted
with all participants. In this interview, participants were inquired whether and how their body
influenced day-by-day experiences, and whether they had faced prejudice or discrimination because of it, in addition to examples of such experiences.
All 39 participants were interviewed, and interviews lasted from 20 to 60 minutes, being audio-recorded and transcribed verbatim.
Through an exploratory content analysis,
the interviews were analyzed using an inductive
approach, which allowed for themes and codes to
emerge from the data. Two researchers read the
transcriptions separately and highlighted aspects
of the written material related to participants’
perceptions about their bodies and experiences with
weight-related discriminations. Then each researcher
identified relevant quotes and expressions to our objectives and grouped them into themes using the “cutting and sorting” approach (Bernard; Ryan, 2010). It is a process that identifies important quotes and expressions and then arranging them into piles
with similarities. Common factors between quotes
were identified, and these were used to formulate the themes. The themes identified were discussed between the coders and these sets of themes were
organized in a structured codebook. The codebook
included for each theme: short and detailed descriptions; inclusion and exclusion criteria; typical
and atypical quotes; and an exemplar classified as “close but no” (Bernard; Ryan, 2010). Two researchers discussed the codebook and applied independently to
the data set, using sentences as the unit of analysis.
Kappa coefficients for inter-rater reliability were calculated using the website GraphPad QuickCalcs, indicating satisfactory agreement between coders
(Cohen, 1960). The coding process generated the number of segments coded with each theme and an
array of excerpts of texts (quotes) for each theme. The themes were described as recommended by
Bernard and Ryan (2010) (i.e. considering both core and peripheral aspects, with attention to details). The software MAXQDA (Verbi, Berlin, Germany, 2015) supported the analysis. Themes that had a similar
Saúde Soc. São Paulo, v.29, n.4, e180313, 2020 5
meaning or complemented each other were grouped
in axes of analysis. Results of the exploratory content
analysis are presented with a detailed description,
direct quotes, and paraphrases (Bernard; Ryan, 2010). Participants’ speeches are identified as “P.”
Results
Participants’ mean age and BMI were 34.6 years (standard deviation = 7.5) and 34.8 kg/m2 (standard deviation = 2.7). Of these participants, 48.7% were single, 35.9% were married, 2.6% had a common-law
marriage, and 12.8% were divorced. Also, 7.7% of our participants graduated from high school, 64.1% graduated from college, 15.4% had some college graduation, and 12.8% had postgraduate-level studies. Eight themes emerged (Table 1), being described in Table 2. The strength of agreement between coders can be considered satisfactory by
Kappa values (Table 1) (Cohen, 1960). These themes highlighted three main body-related axes of analysis,
namely: (1) repercussions of being fat, (2) living with a fat body, and (3) Am I a person or just a fat body? They are presented below.
Table 1 – Theme kappa coefficients from initial individual interviews with participants of the “Health and Wellness in Obesity” study
Theme Kappa
Influences of a fat body 0.675
Attitudes about the participants’ own body 0.675
Prejudice against the participants’ fat body 0.836
Prejudice against someone else’s fat body 0.837
Discriminators of the participants’ fat body 0.836
Supportive attitudes 1.000
Fat as a curse 0.847
Indirect discriminatory comments 0.658
Kappa result is interpreted as follows: 0.61 to 0.80 as “good” agreement, and 0.81 to 1.00 as “very good” agreement (Cohen 1960).
Table 2 – Description of the themes considering their core and peripheral aspects, using direct quotes and
paraphrases
Theme Theme description
Influences of a fat body
The theme described obesity influences on participants’ actions. It included influences on how they dressed their bodies, on their physical disposal, on uncomfortable experiences in public spaces, and on
their personality. This quote exemplifies one of these influences: Dress, skirt, it’s been a while since I
don’t wear them because I can’t find a size that fits me, I don’t feel good wearing them, so it bothers
me a lot… Tight-fitting clothes I haven’t worn in a while too (P10).
Attitudes about
the participants’
own body
The theme described excerpts in which participants expressed attitudes towards their own bodies. It
included when they expressed how they felt about their bodies and how they related to their bodies.
Also, it included how they reacted and dealt with discriminatory situations, as observed in this quote: I
guess there are some looks, but then you realize the person is so stupid, so you feel pity and say “That
is fine…”. Or when you meet that aunt you have not seen for a while and she says, “How fat you are!,”
but then I can’t react (P16).
continued...
Saúde Soc. São Paulo, v.29, n.4, e180313, 2020 6
Theme Theme description
Prejudice against
the participants’
fat body
The theme described discriminatory attitudes of other people towards participants’ fat body.
It included when participants mentioned external expectations about how to attain a certain body and
interferences with their lifestyles, such as recommending eating changes or physical exercises. Finally,
it included examples of discriminatory experiences, as observed in the following quote: A friend of mine
said, “Don’t hug me too tightly, you’re so big that you can break my back!” (P26).
Prejudice against
someone else’s fat
body
The theme described discriminatory attitudes towards other people’s fat body than the participants.
It included someone else’s experiences regarding external expectations about how to attain a certain
body, such as recommending changes in their eating habits or physical exercises. Finally, it included
examples of other peoples’ discriminatory experiences, as observed in the following quote: In social
media, I constantly see this kind of comment, and even if it was not directed to me I feel offended. For
example, a friend of mine posted a photo of herself wearing a bikini, without any concern. And, in the
comments, people told her she should not wear a bikini and if she was not ashamed of her body marks.
I was offended because if they think this about her, they’ll definitely think the same about me (P27).
Discriminators of
the participants’
fat body
The theme described speeches where participants clearly define who were the people to make a discriminatory comment about the fat body. It included relatives, friends, unknown people, and healthcare
professionals. It also included when social media was used to mediate discriminatory comments. An
example can be observed in this excerpt: My dad told me, “Wow, you’re really fat!” (P35).
Supportive
attitudes
The theme described speeches in which participants mentioned positive and supportive attitudes of people
about their bodies. It included experiences in which participants were encouraged to engage in activities
or felt welcomed in a certain situation. This is exemplified in the following quote: I never faced prejudice
or realized it. On the contrary, the other day in my work we had an event and my colleagues said, “Let us
all use the same t-shirt”; and I said, “I’m not wearing a t-shirt at all, I’ll need a large one”; and they said,
“That’s nonsense, don’t mind about it!” So I’m always motivated by people around me (P28).
Fat as a curse
The theme described discriminatory attitudes that expressly involved cursing words about her body
condition, as exemplified in this quote: At school, my nickname was the killer whale, whale, and
sandbag (P37).
Indirect
discriminatory
comments
The theme described discriminatory experiences that involved indirect comments about their fat body.
It included experiences in which participants mentioned comments that did not have “the intention to
be discriminatory,” but they understood as if they were. The following excerpt exemplifies it: Sometimes
people don’t realize that I’m paying attention and they end up making some nasty comments (P27).
Repercussions of being fat
This axis of analysis is composed of the theme
“influences of a fat body.” The participants
mentioned several choices that seemed to be taken
to lessen the magnitude of their stigmatized bodies.
One of these choices was restricting their current
eating, which involved not eating or limiting the
consumption of foods with high percentage of fat,
carbohydrate, and sugar (e.g., chocolate, pizza, cakes, and candies), as exemplified in these quotes: I think I should restrict foods like cookies and cakes; I have stopped eating cake; I used to eat it more; I love pasta, bread, cakes, but I must [restrict myself] (P38).
They also reported that because of their body
condition they needed to deny their willingness to eat
something “less healthy” and eat less tasteful foods.
When they ate foods they considered “fattening,” they
described feeling guilty and repentant. For instance,
P30 mentioned that if she were determined to follow a diet but ate a chocolate, she would feel guilty.
Finally, participants shared a self-demand to eat
certain kinds of foods, such as salads, soups, fruits,
and avoid other kinds, such as ultra-processed foods.
Additionally, they reported being interested in some
foods because of their supposed health benefits, as observed in these quotes: Oat is good for lowering the cholesterol, so I eat it; Chia seeds reduce abdominal
Table 1 – Continuation
Saúde Soc. São Paulo, v.29, n.4, e180313, 2020 7
fat. Great! So I use it in my juice (P37). Another choice that participants shared, which seems to be related
to the stigmatization, was a plurality of attempts
to lose weight in the past. These attempts included
appointments with health professionals, namely
nutritionists, endocrinologists, and nutrologists;
the treatment included the prescription of restrictive
diets and medications. Participants also referenced
self-attempts, such as trying numerous commercial
diets (e.g., Weight Watchers, Dukan diet, soup diet, low carb diet, counting point diet), restricting eating or skipping meals, as exemplified in this
quote: When I was sixteen years old I started losing weight and I focused on my eating, which was not so ruled… I skipped dinner for several years (P30). They also mentioned engaging in physical exercises,
characterized by an intense routine (I went to the gym and I killed myself exercising – P28). Participants reported losing weight with these attempts, but
also regaining it in the long term. Moreover, they
reported difficulties to continue. Difficulties related to treatments prescribed by health professionals
included not being able to follow the restricted diets,
which resulted in negative emotional distress and
then discontinuity thereof. Also, the use of “anti-
obesity” drugs led them to show symptoms, such
as tachycardia, xerostomia, and bad temper. The
difficulties related to self-attempts included not liking a certain food, but insisting on it because of
the self-imposed diet (I’m not into meat, so it was a torture for me to eat that amount of meat [in the Dukan
diet] – P38), and having periods of starvation. Besides the expectations about changes in body weight per se,
other reasons were reported for losing weight such
as the fear of future health problems (e.g., diabetes, pregnancy-related issues).
Another repercussion of being fat that the
participants mentioned was related to physical and
psychological consequences. Physically, participants
revealed to feel constantly tired, discouraged
for day-by-day activities, and with less physical
resistance and agility. Moreover, they mentioned
numerous body pains, especially in the back, hip,
knees and legs, and plantar fasciitis. Psychologically,
participants mentioned low self-esteem, being
less active socially or exposing themselves less to
avoid judgments on their bodies. This affected their
relationships, interaction with people and workplace
performance, as exemplified in this quote: I need to recover my self-esteem because it is affecting me professionally. I often see myself repressed to say something because I don’t want to expose myself. I don’t want to be judged (P13). They also mentioned a dislike of their bodies and an avoidance to look at
it: I don’t like to look myself at a full-length mirror. When I do it, I don’t like what I see. I mean the full picture, I like from here up [her neck] (P37). Moreover, participants mentioned having difficulty to fit their bodies in certain situations: they reported fear of breaking chairs and not passing the bus turnstile.
Finally, a third influence was related to the dressing of their bodies. It involved not fitting in clothing sizes in most stores, which made shopping for
clothes a very unpleasant and frustrating activity.
Another dressing-related consequence mentioned
was having some “rules” to get dressed (Dress, skirt, I haven’t worn them for a while. Because I can’t find my size and I don’t feel well wearing them… Tight- fitting clothes… I don’t wear them for a while too –
P1), restricting the assortment of clothes they felt comfortable wearing (i.e., skirts, dresses, shorts), and feeling unmotivated to attend social appointments,
such as parties, given the lack of a suitable outfit.
Living with a fat body
This axis of analysis is composed of the theme
“attitudes of participants towards their own body.”
The most prominent characteristic they expressed
about living with their bodies referred to negative
perceptions. For some of them, a negative body
concept began during the childhood or adolescence,
when they started to compare themselves with other
girls and concluded they had a fat body, even when this
was not the case: I used to compare myself a lot with other girls and I thought I was fat. The other day, I saw a photograph of when I was eighteen and I said, “I was lean and I thought I was fat and huge” (P11). Since childhood, there was an association between
being fat and not feeling accepted for being out of
the beauty standard (i.e., being lean). When asked about the present time, most participants continued
expressing negative opinions about their bodies. It involved a desire to occupy less space in the world (P14)
Saúde Soc. São Paulo, v.29, n.4, e180313, 2020 8
and having the feeling of disturbing other people for
not having a good semblance. In addition, participants expressed having a hateful relationship with their
bodies. They reported not considering a fat body
beautiful or something that ought to be valued or
desired (sometimes I think my husband deserves a better body – P20) and disclosed negative adjectives about themselves, such as being distorted and
ugly. As a result, they voiced a willingness to lose
weight. Only nine participants mentioned positive
feelings about their bodies. It included valuing their appearance regardless of weight, feeling comfortable
about their sexuality, valuing their health status,
feeling comfortable to dress their bodies (e.g., wearing tighter-fitting clothes or bikinis), and seeing their bodies as a vehicle to give them strength to face the
world. Even so, some of these speeches were dual, as
the participants also expressed negative perceptions
about their bodies, as observed in this quote: There are moments when I say to myself, “It is all very good and that is it, don’t worry about it.” Other moments I look and I say, “Wow! You’re very fat,” and in that moment I want to break the mirror so I don’t see myself, so I have these two moments (P4). Finally, a different perception was related to some participants’ non-
recognition of their body size and feeling confused
about that, as exemplified in this excerpt: I don’t see myself with the weight that I have. For example, I wore a pair of pants and they were very tight, but I thought I would fit in those, you know? (P21).
Am I a person or just a fat body?
This axis of analysis comprises the themes
“prejudice against the participants’ fat body,” “prejudice against someone else’s fat body,” “discriminators of the participants’ fat body,”
“supportive attitudes,” “fat as a curse,” and
“indirect discriminatory comments.” Throughout
the interviews, participants were asked if they had
experienced prejudice or discrimination because of their fat bodies. Only four women mentioned not
facing it. The other participants mentioned facing
prejudice from different people and in different scenarios. The discriminatory comments were
expressed by unknown people and included referring
to them as a reference point (We are a reference point:
“It is over there, next to that fat lady” – P10), judging their eating (My lunchbox is smaller than this laptop, and while I was eating someone said, “Have you saved food for later? Is it in your drawer, right?,” and I answered “No, that is all I am eating,” and the person replied, “But with that size you should not eat only this” – P17), uncomfortably gazing at them, and discriminating and discrediting them in places
like clubs, workplaces, and clothing stores. Other
discriminatory situations involved experiences
with health professionals. For instance, physical
educators told them they could not perform a certain
exercise (before they even tried doing it or without these professionals explaining the reasons for such
restriction) or strongly recommended they should start a diet. Physicians, such as endocrinologists,
denied medical care unless they lost weight. Also,
some made discriminatory comments during
appointments, as observed in this quote: I went to the endocrinologist and he said “You’re here to lose weight, aren’t you? Because with this body it couldn’t be something else, right?” – then he saw that I was wearing my wedding ring and said, “Is your husband still interested in you or has he given up?” (P17). Friends and relatives also expressed discrimination
against their bodies. It included commenting on their body size, advising them to lose weight,
and saying what they should eat. Furthermore,
participants mentioned facing indirect comments
that, although they were not supposed to be noticed,
made them feel judged (I’ve overheard things like, “Let’s hide the cake because she’s coming” – P26). Also, they reported being called names because of
their bodies: One day, in traffic, a man stopped by my side and shouted, “You fat, hideous, whale” – P37). Finally, they reported being assumed as someone
with a “fun” personality. About participants’
reactions to these experiences, only two reported
confronting the person who discriminated them,
but the majority mentioned ignoring them. The “avoidance” of these situations led participants to
report feeling discomforted and desiring to have
confronted the person. Other than the experiences
highlighted above, three participants mentioned
having support from friends and family, who
encouraged them to engage in activities and make
them feel accepted.
Saúde Soc. São Paulo, v.29, n.4, e180313, 2020 9
Discussion
In this study, we aimed to contribute and promote advances in qualitative data addressing fat women’s
own perceptions about their bodies and how facing
discriminations against their large body influence their emotional and physical well-being. More specifically, our results advance the current knowledge by showing
how fat stigma negatively influences fat people
emotional and physical well-being by changing these
people attitudes, self-value, and healthcare assistance.
To our knowledge, this is the first national study to present such rich, detailed and varied information by
the eyes of people who directly face this stigma.
More and more sociocultural messages emphasize
a current standard for slimness and suggest body
weight can be easily modified (Puhl; Heuer, 2010). Examples of that are the instructions about how to
attain a thin body, which predominantly involves
restrictive diets and exercises. Yamamiya et al.
(2005) highlight two consequences of this exposure: an internalization of the thin-ideal and a process of
social comparison. In our study, our participants reported having countless attempts to lose weight
and expressed negative considerations about their
body condition, reinforcing the consequences
pointed by the above-mentioned authors (Yamamiya et al., 2005). Negative considerations about having a fat body were also observed in the Brazilian study of Macedo et al. (2015), which reflected a discomfort of the participants with their physical appearance.
Nonetheless, from our results, we can foresee other
consequences from constant practices to alter the
body shape that advance the current knowledge
on this matter. The negative considerations our
participants reported about themselves involved
not only reflections about their physical appearance, as was observed in the study of Macedo et al. (2015), but more importantly, about how they evaluated
themselves. The excerpt Sometimes I think my husband deserves a better body complemented by
the speeches in which participants disclosed feeling
ugly and distorted are alarming. This information
suggests being fat occupies a proportion of these
participants’ life, downgrading their many other
qualities. More than affecting these participants’
self-esteem, “being fat” seemed to disqualify them
to feel accepted, loved, desirable, and capable.
Being fat seemed to make these participants have doubts about their potentialities and to feel
incomplete as a person. Although they did not
state it, one may suggest living with such feelings
can be despairing, paralyzing, demotivating, and
emotionally draining. In addition, these feelings can limit ones’ potentialities, making them feel
powerless, valueless, and insecure.
If having a certain body characteristic can affect someone’s self-considerations in such profound
ways, it is not a surprise that wanting to change it is
a constant. Owning a different body (thinner) would represent having a different personality (better) – or even being able to be a person instead of a deviant
body – which would positively affect their function
and acceptance in the world. Our participants
suggested having a status quo belief they are not
worthy of a positive self-evaluation unless they are
thin, and that is worrisome given that many of them
might not achieve an “ideal weight.”
The ideas that our participants expressed
about their bodies might have roots in how the
body is symbolized in Brazil. Some authors suggest the Brazilian body is a capital (Edmonds, 2010; Goldenberg, 2014). Goldenberg (2014) and Edmonds (2010) argue that in the contemporary Brazilian culture attaining a certain body is a luxuriance, and perhaps the most desired luxury
among individuals with middle- and low-income,
of different generations, who perceive their bodies
as an important vehicle for social mobility. For
Brazilian women, body representations might be complex. While we are living one of the periods of
higher feminine independence and liberty, it is also
a period in which there is a high level of control
of the Brazilian female body (Goldenberg, 2014). The freedom of the Brazilian women’s body hides a “civilizer process” in which, presumably, the
aesthetical perfection is achievable and of individual
responsibility. This aesthetical perfection also
involves preventing the aging of the body. Thus, the
body, and all that it represents, stimulate Brazilian women to conform to a certain lifestyle and code of
conduct (Goldenberg, 2014). Although our sample did not reflect social and age gaps, the perceptions that our participants expressed about their bodies
Saúde Soc. São Paulo, v.29, n.4, e180313, 2020 10
might reflect the general body perception that seems to permeate Brazilian women’s experiences.
Besides that, our participants’ reports suggested that not corresponding to the current thin-ideal
reflected a discomfort about their current food
choices and in a constant willingness to change
their eating habits to a somehow idealized pattern
(i.e., an expectation to not eat “fattening” foods and eat only low-caloric and “healthy” foods). Showing self-discipline regarding eating – regardless of
body weight – is highly valued and accepted in
Western cultures, since it represents sociocultural
values of engagement, responsibility, integrity, and
good health (Boero, 2012; Petersen; Bunton, 1997; McCullough; Hardin, 2013). Both self-discipline attempts did not seem to be taken easily by our
participants but were agreed upon the idealization
of achieving a body shape that they believe would
be more socially acceptable. These attempts are
also in accordance with Goldenberg’s (2014) and Edmonds’ (2010) argumentation. In Brazil, where the body is notably seen as a source of distinction,
success, and social mobility, it seems conceivable to
understand that such self-transformation attempts
(“body works”) were vital to our participants to try and attain a body shape that has the value of
a capital in this culture. These beliefs, regarding
achieving a certain body standard, derivate
from cultural and social constructions but are
understood as something private and impressed in
someone’s perception. Duncan (1994) explained this ambiguousness using Foucault’s (1977) metaphor of the panopticon. The panopticon is a prison
structure in which a guard tower is at its center
and the prisoners are positioned in a circle around
the tower. With this arrangement, the guard has a
full vision of each prisoner, while the prisoner is
unable to see the guard. As a result, each prisoner
has a feeling of constant surveillance, and regardless
of the actual presence of a guard, each prisoner is
his/her own guard, feeling inhibited to commit a transgression. Metaphorically, women are exposed
to a panopticon gaze where the disciplinary power on
the female body is everywhere and nowhere and the
disciplinarian is immaterial, being everyone and no
one in particular. Thus, the panopticon corresponds
to a disciplinary power with methods that constantly
subject the strengths of the body, putting it in a position of docility and utility. The result of this is
that the body standard becomes actually a personal
standard. Lastly, this belief blames each woman for a conflicting relationship with their bodies, and not social institutions and public practices.
Stigmatizing examples about our participants’
obese bodies were clearly observed in different
scenarios, such as in family occasions, workplace,
and public spaces. Pinto and Bosi (2010) interviewed eight obese women attending a Family Health Center located in Fortaleza, Ceará, Brazil. One participant voiced fat people have no identity: “fat people have no name, you even lose your name, it is
fat, fat” (p. 451). Another participant shared she felt stigmatized even inside her house, saying she felt
her son wanted her to be slimmer (p. 452). Similar results were observed in the Brazilian study of Cruz and Bastos (2015). This study was conducted with only one fat woman and she related her depression
with the pejorative comments about her body that she received from different people. Despite the
fact we do not have information of these relatives’,
friends’, and acquaintances’ body weight, income and
age, their comments about fat people bodies suggest
body has a special cultural and moral significance to a myriad of social groups in Brazil, and not only to those whose body “deviate” from the norm.
Worrisomely, in our study, an expressive number
of participants reported having been stigmatized by
healthcare professionals (i.e., nutritionists, physical educators, and physicians), who offered poor health care and a disrespectful treatment. This information
supports studies showing stigmatizing and
discriminating attitudes from these professionals
towards obese people (Flint 2015; Hebl; Xu; Mason, 2003, Huizinga et al., 2009). In the study of Pinto and Bosi (2010), regarding the relationship between the participants and the physicians, one participant
shared that when she was diagnosed with obesity,
the doctor said she was “bichada.” 3 She said that this
3 “Bichada” is a Brazilian expression used informally and pejoratively when someone has a health or physical problem or is sick (something like “she has a bug”)
Saúde Soc. São Paulo, v.29, n.4, e180313, 2020 11
expression was painful for her to hear and she went
home feeling sad. In addition to complementing the information regarding physicians’ attitudes to fat
people, our results bring evidence of the postures
adopted by other health-care professionals. This
information urges attention regarding the quality
of advice and treatment obese people are receiving
nationally from health-care professionals, as well as
their health impacts. Also, the experiences that our
participants voiced with these professionals suggest
their attitudes towards obesity are more anchored in
the current social values regarding obesity than with
the real “problems” these professionals have faced
while dealing with obese patients. The formation
of these professionals can be a potent vehicle to
change the way they will deal with obese patients
in their future practice, being professionals that
will be a source of support and empathy, and not
of discouragement, disrespect, disapproval, and
frustration. Histories of the body and medicine in Brazil also seem to have particularities. They endure in the availability of the body to medical
experimentation and technological intervention
(Edmonds, 2010). In the ethnographical study of Edmonds (2010, p. 185) a participant living in a favela shared an experience with her gynecologist
after she gave birth: “he is accustomed to seeing me thin, and he said I was a cow.”. Another participant, also living in a favela, shared that after giving birth
her gynecologist said her belly would never go away
with exercise, only with plastic surgery. Such health-
care professionals’ comments elicit a culture (i.e., Brazilian) that sees the body as available for public scrutiny and intimacy, including experts’ comments.
Besides suffering stigmatization from relatives, coworkers, health-care professionals, and strangers,
our participants shared experiencing uncomfortable
situations in public spaces, which involved feeling
“misfit” in some places. In the study of Brewis et al. (2016), the participants shared ideas that were similar to those reported by our participants: It became more weight-related when was harder for me to get around and harder for me to find a chair that would fit my behind… I also know if I broke something, I’d feel bad. Brewis et al. (2016) propose the unavoidability of weight-related stigma lies in
the fact that public spaces are continuous sources of
stigmatizing environmental cues. Although it seems
clear this repetitive exposure is able to strengthen
someone’s weight-related stigma, the authors
consider this “misfitting” related to public spaces is not yet socially considered a form of fat stigma and
a relevant issue for urbanists and government. To
our knowledge, our results are the first, in a national sphere, to point fat stigma in public spaces as an
issue to be discussed.
By hearing our participants’ experiences, it became evident the number of external comments
about their bodies and the advice for them to lose
weight. As discussed by Trainer, Wutich, and
Brewis (2017), people with a fat body are usually seen as someone negligent, unable of exerting self-
discipline and self-surveillance properly; thereby,
external monitoring is not only socially accepted and
uncontested but is seen as imperative to “recover”
someone’s health, responsibility, and morality. In a Brazilian study, the obese participants shared they were told to be shameless and were given advices
such as to eat less and practice physical activities,
disregarding their actual eating and exercise habits
(Santos et al., 2010). In our study, most participants reported feeling irritated about these external
comments, but few expressed this discontentment,
choosing to ignore them instead. This can be
suggested as a strategy to minimize the pejorative characteristics associated with obesity identity,
called coping mechanism (Degher; Hughes, 1999). This mechanism can also be implied in the excerpts
quoted in our study when participants reported
how they exposed their bodies. Choosing a certain
outfit instead of another (e.g., a wide-fitting versus a tight-fitting blouse) may be a strategy to “hide” the fat body and avoid negative comments about it.
Also, we can infer that having to constantly “mask”
one’s body or discontentment might be emotionally
draining. In the long term, it is possible to suggest this process might lead to the development of other
health problems, such as depression or anxiety.
Our participants seemed little empowered to
protect themselves against pejorative comments about their bodies. It seems that strategies focusing on this empowerment are fundamental in interventions
tailored to a public with a large body. Examples of
such strategies in practice can include discussions
Saúde Soc. São Paulo, v.29, n.4, e180313, 2020 12
about the Heath at Every Size® approach principles.
One of these principles affirms body shape, size, and weight are not evidence of a particular way of eating,
level of physical activity, moral, or personality. 4
Another strategy could involve questioning the
current sociocultural assumptions associated with a
thin body, such as positive psychological and health-
related outcomes. These discussions might be critical
to strength obese participants’ inner resources and,
consequently, minimize how they are affected by
external comments. These are all relevant individual-
level approaches, but they might not be successful
if not combined with broader approaches. Given that obesity has psychological, environmental, and
socio-cultural influences, the focus must be given on multiple levels. Examples of actions that deal with
obesity could be proposing legal measures for the
issues overweight people face every day (such as laws to sue weight-related discrimination and prejudice, or surcharge ultra-processed food), besides proposing improvements in city planning, such as proper
building infrastructure and facilities to properly
welcome people with larger bodies, and provide fair
access to healthy food and recreational spaces. These
are some individual and multiple level actions that
could be important not only to prevent obesity but
also to include obese people in the society. These
courses of action might be potentially important
given the findings that some health problems might be triggered by the simple fact of feeling stigmatized
and subjected to a negative treatment, depriving this person of some experiences due to weight-related
issues. In addition to worsened health outcomes, it may lead to psychological distress and less interest
to engage in health-enhancing behaviors (Brewis et al., 2016). Thus, addressing stigma-related issues might be an important strategy to improve the health
of fat people.
One limitation of this study was that all
participants were women. Evidence on how
obese men are affected by their bodies in daily
experiences, and whether they have faced prejudice or discrimination related to obesity identity is still
lacking, warranting future studies with such focus.
Women are reported to be more discriminated and
judged because of their weight, perceiving more negatively their fat bodies compared to men (Sobal, 2000). In the study of Puhl, Andreyeva and, Brownell (2008), the results showed women were three times more likely to report weight discrimination than
men of a similar weight. In addition, although the interviewers attempted to provide a welcoming
environment, some participants might have felt
uncomfortable to share their personal experiences
about the topics investigated or to deepen their
explanations about some aspects. Despite that,
we could find different experiences and ideas
throughout the interviews, suggesting participants
felt comfortable to share their perceptions and
memories with us.
Final considerations
Our results showed several influences that a fat body exerted on our fat participants’ well-being. They
included mechanisms to diminish the magnitude of
their stigmatized bodies, such as making changes
in their current food choices and using strategies
to lose weight, regardless of their negative
consequences. Having a larger body was related to physical (e.g., body pains, unwillingness to perform activities) and psychological (e.g., low self-esteem, less social engagement) consequences. Furthermore, our participants voiced negative attitudes towards
themselves and a hateful relationship with their own
bodies. These negative feelings for having a larger
body stress how deeply negative assumptions made
about obesity can affect someone’s self-evaluation
and sense of self-worth. Finally, the interviewees
stressed facing prejudice from friends, family, and health-care professionals. From this last group, it
seems that healthcare inequalities for fat people
are real and need attention. Our results reinforce
the highly stigmatized characteristics attributed
to larger people, and the negative considerations
they have about themselves, both with negative
consequences for their physical and mental
well-being.
4 Available from: <https://www.sizediversityandhealth.org/>. Access on: July 6, 2020.
Saúde Soc. São Paulo, v.29, n.4, e180313, 2020 13
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Acknowledgement
The authors acknowledge the professors Dras. Nágila Raquel Teixeira
Damasceno e Marly Augusto Cardoso for technical support, the
professionals involved in the design of the intervention, the monitors
(Rafaela Faria Lemos, Jhessica Campos Victor, Victoria Lima, Felipe
Gregório, Stefan Tanabe, Leticia Pironato, Cristiane Siqueira), and
the colleagues Bruna Brito, Cristiane Siqueira, Fernanda Imamura,
Sabrina Moura Mercham de Santana, Thamires Guarnieri, and
Victoria Kupper Lima for helping with the interviews transcription.
Finally, we acknowledge the professor Dra. Sophie Deram and her
editor Christian Sperli for providing the book (Deram S. O peso das
dietas. 1st ed. São Paulo: Sensus; 2014) for material support.
Authors’ contribution
Ulian, Scagliusi, and Gualano conceived the presented idea. Sato,
Pinto, Benatti, Campos-Ferraz, Coelho, Roble, Sabatini, Perez,
Aburad, Vessoni, and Unsain contributed to the design and
implementation of the research. All authors contributed to the
analysis of the results and to the writing of the manuscript.
Received: 20/02/2019
Resubmitted: 16/03/2020
Approved: 26/06/2020
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