Eating at the crossroads: intersectional contributions to an Expanded and Implicated Clinical Nutrition

This essay, which brings posthumous contributions from the first author, starts from the understanding of intersectionality as a theoretical-methodological tool and analytical offering that shows how multiple systems of subordination and discrimination, their consequences and structural dynamics, relate between two or more axes of social oppression. We propose an epistemological approximation between this understanding and the field of Eating and Nutrition, which contributes to thinking an intersectional eating and nutritional care and an integral praxis. Corroborating the intersection (and crossroads) metaphor, we state that several axes of power – race, gender, sexuality, ethnicity, age, class, body size, (dis)abilities, among others – shape the avenues that structure the field of health care, including eating and nutritional care. Among such avenues and crossroads, we outline an initial proposal of an Extended and Implicated Clinical Nutrition. Among the proposed implications, we highlight reflexivity and action in power and oppression relations, placing the nutritionist as a political agent, involved with emancipatory, participatory, and socially referenced praxis. Intersectionality, therefore, is treated here as a strategy for social justice work, including eating and nutrition. We deal with relationships under construction, constituting reflective practices, the composition of meanings in the act of living eating and nutrition work.


Prologue
This text could not have been woven anywhere other than the crossroads in its trajectory of multiple paths.However, returning and presenting these paths to those who read them is required.First, this is a posthumous text since the first author, Fran Demétrio, passed away in 2021.Therefore, it is imperative that the second author remembers Fran beyond her words and highlights the additions that she could not read.In this way, the singular person and italic font will be used when referring to her thoughts, which emerged after the article written with Fran, and the plural person and regular font will be used when bringing what they intellectually weaved together.
Fran was a trans, transvestite, black woman, daughter of a single mother, of poor origin, from the Northeast, father, university professor, activist, transfeminist, and daughter of Oxum. 2 I, without a doubt, due to several social privileges that I have, as a cis, white, upper-middle class woman from São Paulo, among others, do not occupy the same standpoint as Fran.I come, with great simplicity and humility, to take the standpoint of an admirer, colleague, and friend of Fran, who was the most brilliant and revolutionary academic I have ever met, the one who had, within her, everything to change everything.In his work of fiction, "The Sandman: Endless Nights, "Neil Gaiman wrote "You lived what anybody gets: You got a lifetime" (Gaiman, 2005).Fran's life was so powerful and, at the same time, so fleeting.She meant so much to so many of us in that short time.She was a beacon and an anchor for those who felt suffocated by racism, elitism, and cis-heteropatriarchy in academia, such an exclusionary environment.She was an inspiration and a foundation for thinking about other food and nutritional care avenues.She built new epistemes and praxis from the "Human (co)Laboratory of Transdisciplinary Studies, Research and Extension in Comprehensiveness and Intersectionality of Health Care and Nutrition, Genders, and Sexualities" which she coordinated. 3Furthermore, going so far beyond what she could have imagined, it was astonishing when she did a postdoctorate in philosophy and researched epistemic human rights.4Furthermore, she was always an aggregating friend, sweet, sensitive, beautiful, and provocative.
I would now like to rewind this prologue to talk about how I met her.Many of my encounters with Fran Demétrio, especially the initial ones, were unusual.I knew her through her words.In March 2011, I was asked to give an opinion on a scientific article that proposed Expanded Clinical Nutrition, written by her and her collaborators.At this time, however, Fran had not started what she called the "gender transgression process" (the first author's original terms), using the name Franklin Demétrio.I remember that, when reading the text, I thought it was the best article I had ever read in the Nutrition area.In my opinion, I considered this reflective essay as highly innovative, interdisciplinary, well-written, and thought-provoking, with an excellent theoretical framework, and it presented an urgent discussion for the field of Clinical Nutrition, which, however, did not find much space in the hegemonic discourse at the time.(and I believe this remains).Opinion sent, cut the scene.In April 2012, at the World Nutrition Congress in Rio de Janeiro, I looked for a seat in the packed audience to listen to Rosa Wanda Diez-Garcia, Raul Lody, and Claude Fischler.During the questions, a person stands behind me and introduces himself as Franklin Demétrio, who worked with Expanded Clinical Nutrition.I could not contain myself.I introduced myself, and we had a round of celebratory shouts as we figured out who we were, as Franklin also only knew me through my words.I broke the ethics of confidentiality (and I do not regret it) and told him I had been one of the reviewers.More screams, laughter, hugs, and toasts at the conference closing party.Cut the scene.In 2017, I was helping to make up the panel for a competition in which Expanded Clinical Nutrition was a crucial point.I suggested inviting Franklin, who already worked at the Federal University of Recôncavo da Bahia, and I tried to find his CV to see if he had completed a doctorate.I did not find it, so I wrote to his institutional email.She responded that two years ago, she had started the "gender transgression process," recognizing and identifying herself as a transgender woman, adopting the social and scientific name Fran Demétrio.We connected a lot when she came to the competition and planned several joint projects.Then, our friendship and the intense learning she generously provided me began to take shape.We published, with Professor Bárbara Lourenço, a book chapter in 2019 (Lourenço;Demétrio;Scagliusi, 2019).That same year, Fran and I began working on an essay entitled "Do fetiche fisiometabólico à interseccionalidade: inquietações e (re)construções para a práxis da nutrição clínica ampliada e implicada."Due to personal health issues that affected us at different times, we did not finalize and submit the article.In July 2021, Fran passed away.
Our text was kept until the Scientific Committee of the XXVII Brazilian Nutrition Congress, in 2022, invited me to give a lecture on "fem-homage"5 to Fran.I retrieved the written article and read its core points in the lecture "Do Fetiche Fisiometabólico à Interseccionalidade: Caminhos para uma Nutrição Ampliada e Implicada.Contribuições de Fran Demétrio para a Nutrição em Saúde Coletiva."Still in the same October 2022, I read the text on World Food Day at the School of Public Health of the University of São Paulo.Indeed, these occasions were some of the greatest honors I have ever had in my life.At the same time, I felt afraid, not knowing the public's reaction to the text itself and to its presentation made by me, who was far from Fran concerning my social context and standpoint.The reception was extremely warm and emotional/exciting.Many people asked for the text itself, and this motivated me to submit it for publication, with Fran Demétrio as the first author, although, unfortunately, posthumously.I hope Fran's absolutely original contributions resonate across time and space.

Intersectionality and its place in food and nutritional care
Intersectionality is a theoretical-methodological framework coined by American black feminist and jurist Kimberlé Crenshaw in the context of anti-discrimination laws at the academic crossroads of social studies of gender and race (Akotirene, 2018;Crenshaw, 2002).It is a theoretical-methodological tool and an analytical offering highlighting their consequences and structural dynamics as multiple systems of subordination and discrimination and how they associate and interact between two or more axes of subalternization and social oppression (Akotirene, 2018;Crenshaw, 2002).According to Crenshaw (2002, p. 7; our translation), intersectionality: […] specifically addresses how racism, patriarchy, class oppression, and other discriminatory systems create fundamental inequalities that structure the relative positions of women, races, ethnicities, classes, and others.Furthermore, intersectionality addresses how specific actions and policies generate oppressions that flow along such axes, constituting dynamic or active aspects of disempowerment.Crenshaw (2002) also highlighted that, in feminist studies and movements, white women spoke for all women, just as, in anti-racism studies and movements, black men spoke for all black people.There was an intersectional oppressive structure that made black women and their experiences as such disappear.The author also highlighted that it was not the sum of two distinct oppressions (being a woman and being black) but rather the unique experience of a black woman.This experience derives from the association and interaction between discriminatory systems (such as racism, patriarchy, and class oppression), which create inequalities that structure social positions.Crenshaw (2002) was essential for the gathering and institutional incorporation of diverse ideas coming from the fundamental social activism of previous decades, such as actions, speeches, and manifestos by black women, such as Frances Beal and Sojourner Truth; activists from the Black Women's Movement in Brazil, which included essential names such as Lélia Gonzalez and Sueli Carneiro, among others; and the Combahee River Collective (Collins;Bilge, 2020).Cho, Crenshaw, and McCall (2013) stated that intersectionality is best portrayed -or structured -as a sensitivity or analytical disposition to consider the problem of similarities and differences and their power relationships.They emphasized, therefore, that this provision conceives the categories of social differentiation (such as race, ethnicity, gender, social class, and sexuality, among others) not as distinct but somewhat fluid, mutant, and permeable by other categories, always in the process of being created by power dynamics, as well as creating them.In this sense, Collins and Bilge (2020) defined intersectionality as a perspective that: […] investigates how intersecting power relations influence social relations across diverse societies as well as individual experiences in everyday life.As an analytical tool, intersectionality views categories of race, class, gender, sexuality, class, nation, ability, ethnicity, and age -among othersas interrelated and mutually shaping one another.Intersectionality is a way of understanding and explaining complexity in the world, in people, and in human experiences.
Collins and Bilge (2020) also reflected on the specificities of the Global South and North, highlighting that when the Global North "introjects" intersectionality into the Global South, from top to bottom, it is common to silence the people who produce knowledge and erase not only this knowledge but also the local resistance praxis.This is different from when groups in different parts of the world claim versions of intersectionality, as the black feminist movement in Brazil has done.An attempt would be made to rethink Global North's approaches to democratizing the social construction of knowledge.
Carla Akotirene (2018), a cis, black Brazilian woman, author, researcher, and activist, brought renewing twists and theoretical turns to intersectional thinking in the Global South.For her: Intersectionality aims to give theoretical-methodological instrumentality to the structural inseparability of racism, capitalism, and cis heteropatriarchy -producers of identity avenues in which black women are repeatedly affected by the crossing and overlapping of gender, race, and class, modern colonial apparatuses (Akotirene, 2018, p. 14; our translation).
The terms "twists" and "theoretical turns" are used here because the author placed intersectionality on another plane-theoretical, political, and metaphysicalwhen she proposed that: It is opportune to decolonize hegemonic perspectives on the intersectionality theory and adopt the Atlantic as a locus of crossed oppressions.I believe that this territory of waters fundamentally reflects the history and forced migration of African women and men.The waters, moreover, heal colonial wounds caused by Europe, manifested in ethnicities trafficked as commodities, in drowned cultures, in identity binaries, and human and non-human contrasts.In the Atlantic Sea, we have the knowledge of a salty memory of slavery, and ancestral energies protest tears under the ocean (Akotirene, 2018, p. 15; our translation).
As a result of these turns and twists, through her feminist diasporic method, she aimed to "increase dialogues with the epistemes of colonized peoples, encompass the theoretical crossings of sailing bodies, swayed by ethnic waters, Indic memories, polysemic cultures and transatlantic positionalities" (Akotirene, 2018, p. 64;our translation).
Carla Akotirene had a significant influence on Fran Demétrio.Akotirene (2018) reminds us that Exu is the lord of the crossroads and recognizes him as the lord of intersectionality.According to Bueno and Anjos (2021), it is precisely through the figure of crossroads that black female Brazilian researchers put knowledge, sensibilities, and political powers into flux.Hence, I like to think that Fran Demétrio now walks along the crossroads and, considering her legacy in the scientific field of Food and Nutrition, eats there, too.
Starting from this crossroads, we propose an epistemological approach with the theoretical framework of intersectionality to think and produce intersectional food and nutritional care and an integral praxis, the latter already recommended by the National Humanization Policy (Brasil, 2006).The idea of thinking about and producing intersectional food and nutritional care arose from the critical and experiential experience of the first author who, as a trans, transvestite and black woman, professor and researcher of Nutrition and Public Health at a public university located in a city in the interior of Northeastern Brazil, found herself excluded and discriminated against due to the methods, techniques and clinical and scientific parameters of anthropometric and nutritional assessment and other contexts and forms of care in the health services she sought.
Supporting the metaphor of the intersection and the crossroads, we affirm that several axes of power-race, gender, sexuality, ethnicity, class, body size, age, (dis)abilities, among others-shape the avenues and paths that structure the terrain of care in health, including food and nutrition.We intend, with intersectionality, to highlight how food and nutritional care can generate inequalities in attention to health demands and people, in their aesthetic and existential multiplicities, when the aforementioned structuring structures of power are not considered as social marks that carry oppression and generate serious consequences for the health of socio-historically subordinated subjects, such as poor people, Black people, fat people, women, Indigenous people, trans people, transvestites, lesbians, gays, bisexuals and intersex people, older people, and people with physical disabilities.Such effects can be derived from the interaction of different axes of social oppression and impact differently on the health, food, and nutrition conditions of these populations that were/are socio-historically marginalized and discriminated.We advocate the inclusion of this debate in approaches to food and nutritional care, aiming to expand its methods, techniques, and epistemologies of assessment and care, seeking humanization, comprehensiveness, and involvement with people's singularities in the context of clinical-nutritional care.Thus, based on dialogue with intersectionality, we evolved from "Expanded Clinical Nutrition" (Demétrio et al., 2011) to "Expanded and Implicated Clinical Nutrition." In this new proposal, we clearly mark epistemic and political divergences with the behavioral approaches that have been a major focus of attention in Nutrition and were very well discussed critically by Seixas et al. (2020).We will briefly address some of these divergences.We noted, in these approaches, little articulation with Brazilian historical, sociocultural, economic, and political contexts and subservience to capital, neoliberalism, and the commodification of health.Issues related to poverty and food insecurity, so pressing today, are generally neglected.Often, the figure of the "patient/client" who has already been on countless diets and can make new choices is used.Padrão, Aguiar, and Barão (2017, p. 674; our translation) state that […] When one argues that man is free by nature and that they express this freedom through their capacity and possibility of choice, without evaluating in which situations or options are placed for their choice, it seems that this decision is also free.In other words, everyone can choose what they want on equal terms.This idea of freedom as an equal right to choose is the idea of freedom of the bourgeoisie and not the historical-social reality of freedom.
Such criticisms seem pertinent to behavioral approaches.For example, Satter (2007), in the food skills approach, highlights that people of low socioeconomic status are concerned with food sufficiency and not specific nutrients.Consequently, she suggests encouraging these people to eat energetically dense foods, rich in fat and sugar, citing ultra-processed foods such as margarine and instant noodles, so as not to enter into dietary restrictions-linking it to voluntary diets and not to poverty, positioning themselves against the first and not the last one.We argue that such suggestions and positions violate the constitutional human right to adequate food and ignore a fundamental struggle to reduce poverty and improve living and food conditions for people of lower socioeconomic status.Going in the opposite direction, we will assume our involvement in this struggle and others that break hegemonic and intersecting oppressions.

Expanded and Implicated Clinical Nutrition -an embryo
To embryo Expanded and Implicated Clinical Nutrition, we retrieved from Ayres (2004, p. 22) the notion of care as a "therapeutic activity that actively seeks its existential meaning" and that of qualified listening in an encounter as something that affects affections and changes everyone who participates in it.The process of encounter-listening-dialogue-food and nutritional care brings to light the identity of the nutritionist, their life background, their existential stance, and not only their set of scientific knowledge and techniques.There is a permeability from the technical (contextualized in political, economic, and sociocultural terms) to the non-technical (duly anchored in reflexivity), which can create therapeutic heterodoxies (Ayres, 2004).An example of this heterodoxy can be found in Frutuoso (2017), who, in the exercise of interprofessional training, built fields of relationships sensitive to complexity and singularity, constituting a living work in action.
However, what makes this proposal an implicated nutrition?Firstly, recognizing the power relations in producing knowledge, public policies, food phenomenon, and care relationships and practices.We adopt a constructivist and relational position, understanding knowledge as socially constructed and historically derived, valuing lived experience and inter and transdisciplinary epistemic foundations encompassing food's complexity (Gringas et al., 2014;Demetrio, 2014).We are also committed to the right to health and adequate food, which presupposes macro and microstructural actions to achieve them.This also supports our alignment with the Unified Health System (SUS) principles as a democratic, ethical, and human project and against the commodification of health, food, and nutrition.
Another implication is to bring historical, sociocultural, human, political, and economic issues -or "the world that perpetuates nutrition problems" -to professional training and practice (Gringas et al., 2014).From now on, we are committed to understanding the relationships and interactions between food, race, ethnicity, social class, genders, sexualities, and body sizes, among other distinct body aesthetics, acting against their intersecting oppressions, which affect both the nutritionist and the subject, placing them as a political agent and no longer as a closed professional in the clinical universe.We advocate, in this sense, that the construction of food and nutritional care proposals with/for trans and transvestite people represents an implication with the lives of these people and with the transformation of their social realities, starting with the elimination of discriminatory and stigmatizing barriers in the food, nutritional and health care context6 .Therefore, we propose the integration of the intersectional analytical disposition in clinical practice, understanding that this disposition reveals not only the oppression suffered by socio-historically subalternized groups but also their powers and forms of resistance.Such challenges call for reflexivity as a critical consciousness supported by complex thinking, promoting a nutritionist who recognizes their singularities and subjectivities and constitutes an engaged and socially and politically implicated subject (Gringas et al., 2014).Bosi and Teixeira (2016) propose, for example, a political space in food and nutritional education aimed at women medically classified as obese and binge eating, which questions ideologies that cause privileges and injustices related to the complex eating practices of this group.
There is an implication with the breaking of norms and the continuous (re)production of docile bodies, a concept that we brought from Foucault (2004) to rethink the nutritional clinic.Briefly, his concept of biopower -the regulatory practices of modern States, which control, subjugate, and manage the existence of bodies and populations in their daily lives, making them docile, controllable, and productive -is clearly reflected in some foundations of the biomedical model, such as the "knowledge-regulation" of the disease and the body-object (Demétrio, 2014).It is also reflected in the dissymmetrical power relationship between the healthcare professional and the user and formats "life practices into abstract models, with their manuals on the 'art' of living well and living at any cost" (Maia;Osorio, 2004, p. 72;our translation).From a Foucauldian perspective, Seixas and Birman (2012, p. 24; our translation) state that "the obese body as bare life exposes the precariousness of a field open to new interventions, a valueless body, killable by anyone who wishes to intervene on it."This body becomes, in Nutrition, the locus of the exercise of biopower and technical-scientific constructions for its regulation, which does not avoid exclusion.Contrary to this exclusion, we commit ourselves to bring this body and other dissident bodies close, inside, to the side, fighting for social justice while we practice.
Thus, within the clinic, we engage in symmetrical relationships by recognizing a valid interlocutor, someone from a different universe, as an ethical and political proposal (Seixas et al., 2019).We are committed to the subject of the care, "considering their inescapable subjectivities, vicissitudes, idiosyncrasies, weaknesses, and strengths" (Lourenço;Scagliusi, 2019, p. 283;our translation).Such implications require an existential stance of openness to the new and the other, which will not find a didactic path in rigid models and protocols.This stance is linked to the principle of comprehensiveness, made possible by the solid practice of relational technologies, such as listening to others and oneself, and by the freedom of joint construction of the (diet)therapeutic project by uniting singularities and needs of the subject to live work in health, food, and nutrition (Franco; Mehry, 2012; Demétrio et al., 2011).
In this sense, Fieldhouse (2011) critically analyzed, in a way aligned with complexity and social and human sciences, the idea of "adherence to nutritional treatment," pointing out that people's ability to exert agency over their eating practices is strongly restricted by different forms of domination and control (social, political, economic, among others).When the nutritionist proposes to hold the subject of care entirely responsible, even understanding this as autonomy, without addressing the conditioning structures of eating practices, an individualizing and, consequently, blaming bias can be generated.Like Fieldhouse (2011), we see people as social actresses/actors involved in systems of domination and dispute, which must be faced so that eating is an emancipatory process in which people eat well on their own terms.Following Ayres (2004), instead of adherence, we glimpse this actress/social actor who appropriates the encounter with the nutritionist and their food, making them their own and (re)constructing them within their life projects and happiness.Therefore, we are involved with these reconstructions and with the proposition of Seixas et al. (2019) of twisting the idea of adherence "from the user to the treatment" to "from the team to the project of the other," recognizing that the centrality in the other must not forget the structures and become individualizing.We are involved in (re) constructions and transformations to promote emancipatory, participatory, and socioculturally referenced praxis that aim at social justice (Gringas et al., 2014).
Advancing further, such (re)constructions and transformations consider that structural racism permeates in Brazil the "health-illness processes of black and indigenous people in our country and how this is expressed in therapeutic interactions and health care practices" (Borret, 2022, p. 3970).This consideration is far from banal and has many implications.The "life and happiness projects" themselves, advocated above, may not be able to account for the health of people whose ancestries, aesthetics, epistemes, subjectivities, and individualities are denied and delegitimized, as occurs among black people.If there is, in fact, an implication with social justice, there must also be an implication with the proposition of "emancipation and freedom projects," as proposed by Borret (2022).
Epistemic vigilance and continuous reflection on professional practice are necessary to prevent dogmas and power relations that generate technical, oppressive, discriminatory, exclusionary food and nutritional care not involved in human and social transformations.Intersectionality, therefore, is transvested here as a strategy for social justice work, including health, food, and nutrition.
In short, we do not advocate the complete rejection of new nutritional approaches based on behavioral theories, the abandonment of the biomedical model, or a hegemonic status for Expanded and Implicated Clinical Nutrition.We deal with a field of relationships under construction, constituting reflective practices, whose hermeneutics of care will occur through the composition of meanings in the act of living work and the production of (other) epistemologies in each encounter and dialogue.
My part in this work, however, is simple.It was Fran who, based on her critical and embodied experience of the axes and CIStems of oppression, set out to bring intersectionality to Food and Nutrition.It was she who, in yet another of her brilliant phrases, wrote that this was an introductory and embryonic presentation for which we intended to fertilize, generate, and give birth to this discussion in future theoretical or empirical work.With Fran on another plane now, I ask Oxum that this fertilization, gestation, and birth may prosper in all the people who read this text.
Here, I return to Fran and Exu at the crossroads.In African-based religions, crossroads are absolutely powerful places, as they indicate the opening of countless paths, some of them hitherto unexplored.Imbued with this power, Fran's intersectional thinking, "latent, powerful, black, poetry"7 (Emicida, 2019a), has the epistemological power to become a great and necessary theoretical framework in Food and Nutrition.