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Saúde e Sociedade

Print version ISSN 0104-1290On-line version ISSN 1984-0470

Saude soc. vol.29 no.4 São Paulo  2020  Epub Nov 18, 2020

https://doi.org/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 discriminations1

“É lá, perto da moça gorda”: estudo qualitativo sobre as percepções de mulheres gordas acerca de seus corpos e discriminações relacionadas ao peso corporal

aUniversidade de São Paulo. Faculdade de Saúde Pública. Departamento de Nutrição. São Paulo, SP, Brazil. E-mail: m.dimitrov@usp.br E-mail: pri.sato@gmail.com E-mail: fer.tini@hotmail.com E-mail: isabel.perez_11@hotmail.com E-mail: luiz.aburad@gmail.com E-mail: andretvessoni@gmail.com E-mail: fernanda.scagliusi@gmail.com

bUniversidade de São Paulo. Grupo de Pesquisa em Fisiologia Aplicada e Nutrição. São Paulo, SP, Brazil. E-mail: ana.pinto@usp.br E-mail: fabenatti@gmail.com E-mail: desirecoelho@gmail.com E-mail: brunogualano@yahoo.com.br

cUniversidade Estadual de Campinas. Faculdade de Ciências Aplicadas. Limeira, SP, Brazil. E-mail: patlcamp@gmail.com

dUniversidade Estadual de Campinas. Faculdade de Educação Física. Campinas, SP, Brazil. E-mail: roble@fef.unicamp.br

eUniversidade Federal de São Paulo. Instituto de Saúde e Sociedade. Santos, SP, Brazil. E-mail: ramirofunsain@yahoo.co.uk


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

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% 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 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 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).
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 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) 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.

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 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 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 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.

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.

References

ANDREYEVA, T.; PUHL, R.; BROWNELL, K. Changes in perceived weight discrimination among Americans, 1995-1996 through 2004-2006. Obesity, Silver Spring, v. 16, n. 5, p. 1129-1134, 2008. [ Links ]

ARAÚJO, K. L.; PENA, P. G.; FREITAS, M. C. S. Sofrimento e preconceito: trajetórias percorridas por nutricionistas obesas em busca do emagrecimento. Ciência & Saúde Coletiva, Rio de Janeiro, v. 20, n. 9, p. 2787-2796, 2015. [ Links ]

ARAÚJO, K. L. et al. Estigma do nutricionista com obesidade no mundo do trabalho. Revista de Nutrição, Campinas, v. 28, n. 6, p. 569-579, 2015. [ Links ]

ARAÚJO, L. S. et al. Discriminação baseada no peso: representações sociais de internautas sobre a gordofobia. Psicologia em Estudo, Maringá, v. 23, p. e34502, 2018. [ Links ]

BAILEY, P. H.; TILLEY, S. Storytelling and the interpretation of meaning in qualitative research. Storytelling and the interpretation of meaning in qualitative research. Journal of Advanced Nursing, Hoboken, v. 38, p. 574-583, 2002. [ Links ]

BERNARD, R.; RYAN, G. W. Analyzing qualitative data: systematic approaches. Thousand Oaks: Sage, 2010. [ Links ]

BOERO, N. Killer fat: media, medicine, and morals in the American “obesity epidemic”. New Brunswick: Rutgers University Press, 2012. [ Links ]

BREWIS, A. et al. Body norms and fat stigma in global perspective. Current Anthropology, Chicago, v. 52, n. 2, p. 269-276, 2011. [ Links ]

BREWIS, A. et al. Publically misfitting: extreme weight and the everyday production and reinforcement of felt stigma. Medical Anthropology Q, Washington, DC, v. 31, n. 2, p. 257-276, 2016. [ Links ]

BROWN, I. et al. Management of obesity in primary care: nurses? Practices, beliefs and attitudes. Journal of Advanced Nursing, Oxford, v. 54, n. 4, p. 329-341, 2007. [ Links ]

CAMPOS, S. S. et al. Num relance de olhar… A estigmatização das pessoas gordas: do passado aos dias de hoje. Revista HUPE, Rio de Janeiro, v. 14, n. 3, p. 90-96, 2015. [ Links ]

CARR, D.; FRIEDMAN, M. Is obesity stigmatizing? Body weight, perceived discrimination, and psychological well-being in the United States. Journal of Health and Social Behavior, Thousand Oaks, v. 46, n. 3, p. 344-259, 2005. [ Links ]

COHEN, J. A coefficient of agreement for nominal scales. Educational and Psychological Measurement, Thousand Oaks, v. 20, n. 1, p. 37-46, 1960. [ Links ]

CRUZ, C. A. G.; BASTOS, L. C. Histórias de uma obesa: a teoria dos posicionamentos e a (re)construção discursiva das identidades. Linguagem em (Dis)curso, v. 15, n. 3, p. 367-384, 2015. [ Links ]

DEGHER, D.; HUGHES, G. The adoption and management of a “fat” identity. In: SOBAL, J.; MAURER, D. Interpreting weight: the social management of fatness and thinness. Nova York: Aldine de Gruyter, 1999. p. 11-27. [ Links ]

DRESSLER, W. W. et al. How culture shapes the body: Cultural consonance and body mass in urban Brazil. American Journal of Human Biology, Nova York, v. 24, n. 3, p. 325-331, 2012. [ Links ]

DUNCAN, M. The politics of women’s body images and practices: Foucault, the panopticon, and shape magazine. Journal of Sport and Social Issues, Thousand Oaks, v. 18, n. 1 p. 48-65, 1994. [ Links ]

EDMONDS, A. Pretty modern: beauty, sex, and plastic surgery in Brazil. Durham: Duke University Press, 2010. [ Links ]

FLINT, S. W. Obesity stigma: prevalence and impact in healthcare. British Journal of Obesity, [S.l.], n. 1, p. 14-18, 2015. [ Links ]

FONTE, C. A. A narrativa no contexto da ciência psicológica sob o aspecto do processo de construção de significados. Psicologia: teoria e prática, São Paulo, v. 8, n. 2, p. 123-131, 2006. [ Links ]

FOUCAULT, M. Vigiar e punir: o nascimento das prisões. Petrópolis: Vozes; 1977. [ Links ]

GOFFMAN, E. Estigma: notas sobre a manipulação da identidade deteriorada. Nova York: Simon & Shuster, 1983. [ Links ]

GOLDENBERG, M. Corpo e envelhecimento: diferenças de gênero na cultura brasileira. Educere et Educare, Cascavel, v. 9, n. 17, p. 231-242, 2014. [ Links ]

GRACIA-ARNAIZ, M. Fat bodies and thin bodies. Cultural, biomedical and market discourses on obesity. Appetite, Londres, v. 55, n. 2, p. 219-255, 2010. [ Links ]

HEBL, M.; XU, J.; MASON, M. Weighing the care: patients’ perceptions of physician care as a function of gender and weight. International Journal of Obesity, Hampshire, v. 27, n. 2, 2003. [ Links ]

HILBERT, A.; RIEF, W.; BRAEHLER, E. Stigmatizing attitudes toward obesity in a representative population-based sample. Obesity, Silver Spring, v. 16, n. 7, p. 1529-1534, 2008. [ Links ]

HUIZINGA, M. et al. Physician respect for patients with obesity. Journal of General Internal Medicine, Filadélfia, v. 24, n. 11, p. 1236-1239, 2009. [ Links ]

JANSSEN, I. et al. Associations between overweight and obesity with bullying behaviors in school-aged children. Pediatrics, Springfield, v. 113, n. 5, p. 1187-1194, 2004. [ Links ]

LEWIS, S. et al. “I don’t eat a hamburger and large chips every day!” A qualitative study of the impact of public health messages about obesity on obese adults. BMC Public Health, Berlim, v. 10, n. 309, 2010. [ Links ]

MACEDO, T. T. S. D. et al. Percepção de pessoas obesas sobre seu corpo. Escola Anna Nery, Rio de Janeiro, v. 19, n. 3, p. 505-510, 2015. [ Links ]

MACLEAN, L. et al. Obesity, stigma and public health planning. Health Promotion International, Oxford, v. 24, n. 1, p. 88-93, 2009. [ Links ]

MALTERUD, K.; ULRIKSEN, K. “Norwegians fear fatness more than anything else” - A qualitative study of normative newspaper messages on obesity and health. Patient Education and Counseling, Princeton, v. 81, n. 1, p. 47-52, 2010. [ Links ]

MCCULLOUGH, M. B.; HARDIN, J. A. Reconstructing obesity: the meaning of measures and the measure of meanings. Nova York: Berghahn, 2013. [ Links ]

NG, M. et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet, Londres, v. 384, n. 9945, p. 766-781, 2014. [ Links ]

PATTON, M. Q. Qualitative research and evaluation methods. 3. ed. Thousand Oaks: Sage , 2002. [ Links ]

PETERSEN, A.; BUNTON, R. Foucault, health, and medicine. Nova York: Routledge, 1997. [ Links ]

PINTO, M. S.; BOSI, M. L. M. Muito mais do que pe(n)sam: percepções e experiências acerca da obesidade entre usuárias da rede pública de saúde de um município do Nordeste do Brasil. Physis, Rio de Janeiro, v. 20, n. 2, p. 443-457, 2010. [ Links ]

POULAIN, J. P. Sociologie de l’obésité. Paris: Puf; 2009. [ Links ]

PUHL, R.; HEUER, C. The stigma of obesity: a review and update. Obesity, Silver Spring, v. 17, n. 5, p. 941-964, 2009. [ Links ]

PUHL, R.; HEUER, C. Obesity stigma: important considerations for public health. American Journal of Public Health, Nova York, v. 100, n. 6, p. 1019-1028, 2010. [ Links ]

PUHL, R.; ANDREYEVA, T.; BROWNELL, K. Perceptions of weight discrimination: prevalence and comparison to race and gender discrimination in America. International Journal of Obesity, Londres, v. 32, n. 6, p. 992-1000, 2008. [ Links ]

SANTOS, A. T. et al. A história de pessoas com obesidade mórbida: uma experiência no sul do Brasil. Enfermagem em Foco, Brasília, DF, v. 1, n. 3, p. 109-113, 2010. [ Links ]

SOBAL, J. Sociological analysis of the stigmatisation of obesity. In: GERMOV, J.; WILLIAMS, L. A sociology of food & nutrition: the social appetite. Oxford: Oxford University Press, 2000. p. 187-204. [ Links ]

STEARNS, P. N. The turning point. In: STEARNS, P. N. Fat bodies: bodies and beauty in the modern west. Nova York: New York University Press, 2002. p. 3-24. [ Links ]

TRAINER, S.; WUTICH, A.; BREWIS, A. Eating in the panopticon: surveillance of food and weight before and after bariatric surgery. Medical Anthropology, Thousand Oaks, v. 36, n. 5, p. 500-514, 2017. [ Links ]

ULIAN, M. D. et al. The design and rationale of an interdisciplinary, non-prescriptive, and Health at Every Size®-based clinical trial: the “Health and Wellness in Obesity” study. Nutrition and Health, Berkhamsted, v. 23, n. 4, p. 261-270, 2017. [ Links ]

VESTER, K. Regime change: gender, class, and the invention of dieting in post-bellum America, United States. Journal of Social History, Pittsburgh, v. 44, n. 1, p. 39-70, 2010. [ Links ]

YAMAMIYA, Y. et al. Women’s exposure to thin-and-beautiful media images: body image effects of media-ideal internalization and impact-reduction interventions. Body Image, Amsterdã, v. 2, n. 1, p. 74-80, 2005. [ Links ]

1We 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.

2We understand “experiences” by situations lived continuously by someone, who is thus, able to give in depth details about it (Patton, 2002).

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”)

4Available from: <https://www.sizediversityandhealth.org/>. Access on: July 6, 2020.

Received: February 20, 2019; Revised: March 16, 2020; Accepted: June 26, 2020

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.

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.

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