Abstract(resumo):

Weight stigma and discrimination occur daily, especially among healthcare professionals, leading to repercussions on physical and mental health. This study aimed to examine the content of discussions associated with a video about judging a healthcare professional's competence based on their physical appearance on an Instagram profile. The comments linked to the post were analyzed using thematic content analysis and grouped into two themes: 1) "We cannot judge anyone": A fat body is not an incapable body, and 2) "Those who have an image sell more": The stigmatization of healthcare professionals. It was observed that judging professional competence based on body shape led to divergent opinions. The negative ones had elements of fatphobia and weight stigma and associated a fat individual with laziness, asserting that, as healthcare professionals, they should set an example. The positive ones conveyed messages of empathy and support.

Keywords(palavra-chave):

Weight stigma, Obesity, Instagram®

Content(conteúdo):

Introduction

Considering the broad cultural and historical development context of society, it is notable to observe the transformations in social patterns, including beauty standards, over time¹. Appreciation of beauty was once associated with a larger body, interpreted at the time as indicative of abundance and high social status. However, over the years and in response to significant sociocultural changes, these standards have shifted, and a larger body, which once symbolized abundance, wealth, and plenty, is now rejected and stigmatized2.
Stigma is defined by Goffman3 as a devaluing attribute that makes an individual different, with a disadvantage and a decrease in their moral standing compared to others in society. The process of stigma occurs when an individual has or believes they have a characteristic or attribute that is in some way devalued in the social context4. Although stigma and discrimination are seen as threats to fundamental values of inclusion and equality in contemporary society, some types of stigma, such as weight stigma, seem to be more easily propagated and tolerated5,6.
Weight stigma is manifested through social stigma assigned to a person with a larger body, based on various stereotypes predetermined by society that attribute moral characteristics and negative judgments based on weight6,7. These stereotypes label individuals with overweight or obesity as lazy, lacking willpower, without self-control, unsuccessful, low in intelligence, and unable to adhere properly to weight loss treatments due to supposed lack of discipline8. These stereotypes extend into various aspects of social life, such as in the workplace, healthcare settings, universities, media, and even interpersonal relationships9. Fat, which should be seen as a common component of the human body, has become synonymous with hate and self-hate, deeply connected to aversion, self-aversion, and negative thoughts10.
Weight stigma also resonates in professional areas, affecting the daily life of workers. Individuals with obesity or excess weight have lower market insertion, greater difficulty finding employment, and when employed, face discrimination11. A larger body often results in feelings of distrust from peers regarding the professional capabilities of individuals with obesity12, with nutritionists and physical education professionals being the most affected. These professionals often do not feel that they belong or are worthy of performing their roles; they are underestimated in terms of their technical skills, as contemporary society believes that these professionals should have a body that aligns with the “principles” of their profession to gain professional recognition13. As a result of this stigma, these professionals are frequently undervalued regarding their technical abilities and may face difficulties in being recognized in their careers13.
Nutritionists with larger bodies have a higher chance of being stigmatized, especially in clinical settings14. A study interviewed nutritionists with larger bodies, and they reported experiencing stigma at work and suffering in interpersonal relationships due to their bodies representing an inversion of normative values of nutrition, combined with a weight-phobic society that disapproves of obesity or being overweight14.
This stigmatization of healthcare professionals is exacerbated by social media, as it appears to play a significant role in the construction and dissemination of idealized body standards15, with potential negative repercussions on body image, body satisfaction, and weight stigma. The Instagram community develops the ideal body image (Instabody), disseminates, and promotes adherence to these practices as a result of social and psychological factors that pressure users to conform to the imposed body standard16.
In this context, it is evident how social media, especially Instagram, impacts the personal and professional lives of individuals through weight stigma. From this perspective, the objective of the present study was to examine the content of discourses associated with an Instagram video about assessing a healthcare professional’s capability based on their physical appearance.

Method
This is an exploratory study conducted with a qualitative focus and a cross-sectional approach. The choice of qualitative research is justified by the complexity of the phenomenon studied, which is social in nature and not suitable for quantification17.



Procedures

This study analyzed the comments on a video made by users of the social media platform Instagram®. The video is 54 seconds long and features an influencer discussing his perception of evaluating a professional's competence based on their body shape.
The selection of both the profile and the video in question was done intentionally. Specifically, a public Instagram profile maintained by a professional health influencer, who has 7.7 million followers, was chosen. The content regularly shared by this influencer includes topics related to sports medicine, training routines, and dietary guidelines.
The inclusion criteria for the comments consisted of their relevance to the theme of weight-related stigma. In contrast, the exclusion criteria included: (I) comments unrelated to the theme; (II) mentions of other users; (III) the use of emojis; and (IV) secondary responses to previous comments.

Data Analysis

The comments extracted from the video up to February 2023 were subjected to thematic content analysis according to Braun and Clarke18, which comprises the following steps: pre-analysis, exploration of the material, data processing, and interpretation. In the pre-analysis, all comments were thoroughly read ("floating reading") to ensure that the authors became fully familiar with the content of the data. This allowed initial impressions and hypotheses related to the theme to emerge. At this stage, comments that were friend tags, emojis, or unrelated to the video's theme were excluded. After this, the entire data set was manually coded; these codes described the common characteristics of the data. The codes were then grouped into thematic axes, defined a posteriori. This organization provided a condensed, simplified representation of the raw data, facilitating the understanding of the messages obtained from the comments. During this process, the first authors worked with the last author, who has experience in conducting, collaborating, and supervising qualitative research. The authors met frequently to discuss the coding of themes and subthemes. This discussion included referring back to and reviewing the analyzed comments to ensure that the analysis remained grounded in and justified by the data, thus making it reliable and plausible. Subsequently, messages with common characteristics were grouped into categories based on this organized content. Scientific articles relevant to the theme were used to support the discussion and interpretation of the results.

Results and Discussion

The analyzed video received 4,085 comments as of February 2023. Of these, 3,161 comments were excluded, including: 1,055 comments that were unrelated to the theme, 927 sub-comments, 834 comments containing only emojis and lacking discursive characteristics, and 345 comments that were just tags, leaving a total of 924 comments that comprised the corpus of the present study. Among the included comments, 585 had a negative tone (Figure 1).

The comment analysis generated 17 initial codes: 1. Knowledge, 2. Intelligence, 3. Ability, 4. Judgment, 5. Labels, 6. Prejudice, 7. Body (imposed standard), 8. Professional, 9. Showcase, 10. Doctor vs. Nutritionist vs. Physical Educator, 11. Example, 12. Morality, 13. Trust, 14. Health (time/care), 15. Laziness, 16. Work, 17. Credibility. In an effort to group these codes, two thematic axes were developed: 1) "We cannot judge anyone": A fat body is not an incapable body; and 2) "Those who have an image sell more": The stigmatization of healthcare professionals. Each thematic axis was divided into subthemes, which can be viewed in Figure 2.

The positive thematic axis 1 includes subthemes that address body standards in contemporary Society, the way these body standards are intrinsically linked to healthcare professions, and the stereotypes generated for each profession. The negative thematic axis 2 portrays the impacts of body image on a professional's credibility and field of work, the challenges faced by professionals "outside the standard" in entering the job market, and contemporary discussions about health and aesthetics.

Thematic axis 1 – "We cannot judge anyone": a fat body is not an incapable body

Body standards are shaped by cultural, social, and economic dimensions of Society. Thus, they are mutable, subjective, and entirely dependent on various factors such as gender, sexual orientation, age, and culture, among others19-,22. Disseminated by Society through art in paintings, sculptures, music, and literature and reinforced through the commercialization of products and treatments that value certain body parts or physical attributes, the idealized body shape is directly related to beauty, happiness, and individual success. This favors and reinforces the marginalization of the natural body, with the appreciation of beauty depending on the individual's ability to adhere to the standards set by Society23.
Contemporary Society promotes the valuation and romanticization of a slim body while stigmatizing the fat body, thereby instigating an incessant quest for the ideal body, which comes to represent acceptance or rejection of the individual in various spheres of life. This results in the hierarchization of groups, culminating in the marginalization of individuals with characteristics distinct from the established standard, frequently labeling them as atypical2. However, interest in and dissemination of positive body image are currently growing. Positive body image is defined by the ability to appreciate one's own body, accepting and valuing its abilities24.
Cohen et al.25 conducted a study with 195 female individuals aged 18 to 30 and exposed participants to three common types of social media exposure: (1) body-positive posts, (2) thin ideal posts, and (3) neutral appearance posts. In each condition, participants viewed 20 posts for at least 10 seconds each and then completed questionnaires on body self-objectification, mood, body satisfaction, and appreciation. The study found that exposure to body-positive posts encouraged changes in ideas about the ideal body and weight bias and had a positive effect on body image, improving self-esteem, mood, and acceptance of different body types. In this context, positive body image surpasses appearance evaluation24. This is evidenced in the comments, where the importance of physical appearance seems to lose strength compared to human abilities:

"[...] Even today, humanity is focused solely on physical appearance; human values have ceased to have an effect in this Society."
"[...] I completely agree with the video. Just like most people think that everyone who goes to the gym is obligated to have a perfect body or follow a stereotype that they might not achieve for various reasons, and then they don’t realize why people are mentally unhealthy—precisely because of such judgment and comparison!"
"[...] What was missing was the possibility for us to love ourselves this way, to choose to have and present this 'aesthetic,' without it being associated with neglect, laziness, or poor habits, because it is possible to have health and a healthy lifestyle in different body sizes [...]".

The individual with obesity is characterized as atypical, and the representation of obesity as a state of health/illness generates a series of complications in various aspects of these individuals' lives, such as social exclusion due to loss of personal confidence and deterioration of their social identity, contributing to "disability" for work26. There is a social disadvantage to being obese, which creates stigma and impacts the professional lives of healthcare professionals who are seen as incompetent. The social environment influences the physical body, potentially improving or reducing its health5.
Media, including traditional media and new communication technologies, have prioritized appearance over knowledge and ability. The exaggerated value placed on having and the minimization of being impacts not only interpersonal relationships but also the teaching-learning field, as educational content, which is part of being, becomes irrelevant when considering appearance and body size. This leads to increased devaluation of professions/careers, as professionals are considered less relevant in the social sphere due to not meeting the appearance expectations set by the market27.
Obesity is characterized by employers and internalized as a deviation from the imposed standard norm, which cannot be accepted by Society. Weight stereotypes and stigma are experienced in various life situations, such as public transportation, the job market, family environments, social events, and commercial establishments. People who suffer from stigma and prejudice quickly become aware of how they are perceived by others. Aesthetic-based discrimination disrespects human principles and values and is frequently observed in work environments, such as unequal job opportunities for not meeting the definitions of beauty, normality, and socially accepted beauty standards, with strong discrimination both in job interviews and in the workplace28,14. However, despite the overvaluation of the ideal body as a marker of professional competence, our findings suggest a potential change in the way professionals who do not fit the current body standard are perceived:

"[...] There are people who are professionals but, for a hundred reasons, are taking care of themselves while taking care of others. It is not possible to judge people's professional ability by their appearance, is it?"
"[...] Is a good professional the only one who is slim? Can you guarantee that they are a good professional with just that requirement? And what about the time the person spent in college? Did they waste that time then?"
"[...] We cannot say that a personal trainer without a great physique cannot train as well as one who does; not always will the person helping you achieve a goal have the same plan for their own life. We cannot measure anyone's ability by their appearance."
"[...] Society, and especially the internet, increasingly defend less empathy. We need to put ourselves in others' shoes; we don't know about others' lives, and we cannot judge a book by its cover. Everyone knows they shouldn't judge, but most people do."
"[...] A large part didn't understand anything he said in the video. I believe it is a lack of maturity. If we analyze it, Glen Mills wouldn't be able to train Usain Bolt because he doesn't have the physique of a runner and doesn't go through what his champion goes through. In the end, appearance during training has always mattered more than the essence, and in the 21st century, it shouldn't be any different. All the years of study, all the specialization courses, and hours of dedication are reduced to the size of our abdominal circumference."
"[...] A nutritionist is a health professional, not an aesthetic one. Health is a broad concept that goes far beyond weight and body. Everyone has their own choices and life priorities; if you lose weight, congratulations, but that doesn’t need to be the professional’s goal."
"[...] Similarly, a plus-sized physical education professional will be able to teach you the same techniques as a slim one. They are there to provide knowledge and help, not to be the reflection of your goal [...]".

In contemporary Society, individuals shape their identity and essence by configuring their bodies, which is driven by a culture that promotes the idealization of slimness. Health professionals undergo a social evaluation process where demonstrating their competencies is crucial. For those working in health fields, such as nutritionists and physical educators, this task may be easier if they maintain a weight considered healthy or eutrophic. Additionally, the construction of professional identity is influenced by body image perception, creating a shared scenario among these professionals29.
The role of a nutritionist involves constantly connecting theoretical knowledge learned during their training to practice, understanding dietary norms, and guiding the relationship between individuals and food, including its implications for health. This should determine their dietary choices and regulate their body. However, access to scientific information does not guarantee to have a slim body and using nutritionists' practices solely to meet ideal body standards disregards the socio-economic and cultural context in which individuals are situated. This creates a disconnection from societal life, resulting in discrimination and making these professionals feel inadequate in their field. It is not a requirement for a nutritionist to present a slim body. The stigma associated with the profession has compromised the physical and mental health of professionals, who feel the need to be respected by a society that imposes rules and creates suffering in social relationships due to body shape, with the "panic" caused by a larger body being seen as a "blemish" in the profession that needs to be "cleaned" from the workplace14. However, despite the literature highlighting the significant stigmatization faced by health professionals daily, the comments from users reflect empathy and support for these professionals:

"You can't judge anyone in the end; it's a rational thought. Each person has been shaped by the circumstances of life, and it's impossible to 'put yourself in someone else's shoes' because we don't understand the infinite factors involved [...]"
"Let's say a nutritionist or physical educator, who were great professionals and maintained a fit body, has recently experienced emotional problems, losses, grief, or depression. The nutritionist gained weight, and the physical educator lost their physique. Does that mean they've lost all their knowledge and excellence as professionals?"
"Exactly! Before becoming professionals, they are human beings who are vulnerable to their environment. We don't know everything; no matter how dedicated we are to our profession, there's still much to learn, especially not to measure someone else's life by our own standards."
"It makes a lot of sense, Muzy. I believe there's excessive pressure on these professions [...] Having knowledge doesn’t mean a person will apply it to their own life or that they can put it into practice given their own routine. Being out of shape doesn’t mean a person is a bad professional [...]"
"Two factors need to be considered here: 1. Nutritionists and physical education professionals are among those who suffer the most from eating disorders, particularly binge eating, as a trigger is precisely the excessive pressure for aesthetics! 2. Obesity is a metabolic disease of adipose tissue, not just a choice! Thus, judgment is not appropriate. They are human beings going through problems just like anyone else and might have issues far more complex than focus and discipline."
"Take someone who works, wakes up at 5 in the morning, works all day, returns at 6 in the evening, and then studies. How can they take care of themselves 100%? Their world is different from others [...]"
"[...] We are all fighting battles in our lives; we shouldn’t judge anyone."

Thematic Axis 2 – "Image Sells More": The Stigmatization of Healthcare Professionals

Contemporary culture values thinness, supported by biomedical discourse, and turns fat into a symbol of moral failure. This has serious consequences for individuals who cannot conform to this ideal body, such as body image distortion, internalization of weight, and an incessant desire for a thin body30. According to Bosi et al.31, the thin body ideal imposed by Society prevails and is intrinsically linked to healthcare professionals such as physical educators and nutritionists, who experience dissatisfaction with their body image and constantly wish to alter it to fit social standards, often resorting to unhealthy weight loss methods. In this context, obesity becomes a continuous torment. Failing to adapt to this norm, a fat body is seen as synonymous with failure, incapacity, low self-esteem, and an inability to be happy32.
This aversion and rejection of fat bodies make it difficult for healthcare professionals with fat bodies to interact with their patients. This personal perception can affect their self-confidence and their ability to provide adequate care, which can result in psychological consequences33. The formation of professional identity and competence is a dynamic and constantly evolving process that is partly influenced by cultural stereotypes. This process is cyclically fed by the media, which often portrays professions in a stereotypical manner. This can lead to the promotion of unfavorable attitudes and beliefs about professionals in certain fields, such as the nutritionist, who is associated with the need to be thin, or the physical educator, linked to the need to have a muscular body. These stereotypes tend to completely ignore the complexity of the lives and identities of the professionals involved, as well as the different social realities in which they are embedded, allowing these professionals to be characterized as careless and lazy, contributing to the internalization of such stereotypes by the professionals themselves34,35.
Stereotypes and internalizations not only hinder professional choices and market entry but also interpersonal relationships. Furthermore, they undermine workers' self-perception and professional capabilities. The value attributed to one's work depends on the social image built around the profession, which can either enhance or diminish the value of these professionals' work35. Often, these professionals are stigmatized even by other professionals with thin bodies, labeling them as lazy and less effective in providing patient care. Patients believe that thin healthcare professionals seem healthier and project a better image, making it easier and more consistent to follow the advice given by these professionals33. All these elements are evident in the following comments:

"[...] the body is like a quick proof: 'if he can do it for himself, he can do it for me.' So, unfortunately, right or wrong, those with the image sell more."
"[...] everything that involves the body, what sells is the image."
"[...] I disagree! Appearance is part of a professional's presentation [...] in any professional environment, appearance is important."
"[...] Actually, it doesn't convey any credibility, and it will always be like that. If you work in something related to aesthetics and don't have a good appearance, you lack credibility."
"[...] I don't agree, but I respect the opinion. There are exceptions. I know several nutritionists or sports doctors who are financially and mentally successful but aren't in shape purely out of laziness. Most patients seek out professionals because they are inspired by them, whether in training or diet. So, if you want to be a professional in this field, you at least have to set an example! Again, I respect opposing opinions."
"[...] I usually look for professionals with more experience in their career, and if they don't even take care of themselves, how can I believe they will 'take care' of me and help me reach my goal?"
"That said: the shoemaker's son always goes barefoot. A professional (nutritionist, physical educator) who doesn't practice what they preach to their patients doesn't convey credibility."
"[...] in this case, it's impossible not to judge the professional because the body is entirely linked to the 'product' they are selling. I wouldn't find it strange if a dentist is overweight because they don't sell weight loss, but I would find it strange if they had bad, ugly teeth."
"[...] people want to romanticize and shirk responsibility, right? Business is unforgiving; image is fundamental; only the lazy deny that. No one in shape thinks image doesn't matter."
"[...] 'The guy is overweight because he didn't have time, studied a lot, etc.' really isn't convincing. If they're not physically well, it's because they never took the time to adjust their diet and exercise; it's negligence in that area."
"[...] I usually agree with everything you say, but unfortunately, I can't agree with this. I would never go to an overweight personal trainer who doesn't look the part; I would never go to a dentist with bad teeth, and I would never go to a nutritionist who doesn't even take care of their own diet. If the professional can't take care of themselves, unfortunately, they can't take care of others, and so on."
"[...] You can't judge anyone by their appearance, but a professional whose work is in the health field and isn't healthy, someone who prescribes everything about healthy eating and helps people change their physique, someone who spent 3 or 4 years studying physical education and doesn't put it into practice, it doesn't make sense."
"The victimhood rhetoric to please sounds good on social media, but in real life, credibility is indeed associated with certain standards. A fat nutritionist or an overweight personal trainer doesn't convey credibility. This is inherent to the profession, whether you like it or not."

These comments reinforce the stigmatization that healthcare professionals face daily, as also seen in the study conducted by Araújo, Pena, and Freitas14, where the authors interviewed overweight nutritionists who reported experiencing stigma in the workplace and suffering in interpersonal relationships due to their bodies representing an inversion of the normative values of nutrition and a fatphobic society.
A study conducted by Siqueira et al.36 highlighted the stigma experienced by healthcare professionals in training, as can be observed in the following comments:

“(...) "I went to enroll, and I swear I started rethinking it... I kept thinking, like, I said, 'I'll study animal science, lose weight, and then try nutrition again,' but when I joined, I saw it wasn't like that at all; there are all kinds of people..."
"Sometimes I find it difficult, especially when it comes to nutrition, right? 'You study nutrition,' I feel like we are obligated to have an 'appropriate' body, so to speak, because how is my patient going to see me? I still think about that a lot."
"We need to see what can be done to change this, right? After all, I'm learning that it's impossible for me not to handle it... if I can't do it for myself, how could I possibly do it for others, right?"

The fat body, which in the past was associated with positive concepts of health, fertility, wealth, and abundance, has undergone a redefinition in contemporary times. Today, the fat body is equated with poor health and neglect37 (Júnior & Rocha, 2023). The pathologization of the fat body is a consolidated discourse grounded in the ideas of overweight and obesity, which produces a social norm. When an individual fails to meet this norm and threatens the ideal body type, their attitude is perceived as negligence38. Conversely, the thin body is seen as synonymous with health. This notion of health merely fuels the discourse of 'the thinner, the better,' where even bodies with weights below a healthy range are considered healthy. In this context, the value placed on the thin body is evident, regardless of how far it is from a 'normal' weight, as the ideal is to be as thin as possible38.
This discourse involving obesity as a disease has been solidified mainly due to concerns about what is morally acceptable, disguised under a health narrative39. The discourse on health that permeates individuals' lives is often used merely to mask the real reason behind the desire for a thin body, which is to fit into Society and be accepted within a social context. Individuals tend to give health-related justifications, as people often provide socially acceptable responses, tending to deny behaviors that would be socially disapproved2. In this context, obesity is now treated as a socially acceptable form of prejudice; individuals with obesity are the only ones who can be discriminated against with full impunity, as illustrated in the following comments:

“[...] if you're selling health, a healthy lifestyle, and you're not healthy... something is wrong.”
"[...] Sensational, everything sounds great, but in practice, it's not like that [...] nobody wants a nutritionist who's overweight; it's a kind of unintentional automatic prejudice."
"[...] 99% of the time, it's just a lack of discipline. I only believe in teaching through example [...]."
“[...] It's not about being prejudiced; it's about the fact that if you're telling others to do something, you should at least set an example. If you have a nutritionist who tells you to adjust your diet for health reasons, and they don't even do it themselves, they don't believe in what they're selling. Period.”
"[...] I do label and judge because the person is selling health—how can they sell a product they don't even use themselves."
"[...] There are no excuses for selling health and wellbeing with an appearance that contradicts what you're selling. You're automatically sabotaging your profession [...]"
“[...] I disagree, mate! Obesity is a lack of care for one's own health.”

These findings highlight that weight stigma is prevalent at all stages of life, from childhood to adulthood, and that individuals with larger bodies are labeled and discriminated against daily, whether among friends or within their professional fields. Social media plays a significant role in this stigmatization, labeling, and discrimination of individuals with larger bodies within Society.
Given this scenario, we know that the internet has a high flow of content and that exposure to negative or positive content influences individuals' attitudes and opinions. Through the thematic content analysis conducted in this study, it was possible to identify that most of the comments analyzed were negative and that the majority contained fatphobic and weight-stigmatizing sentiments, with statements associating larger-bodied individuals with laziness and suggesting that they should present a good image to be in the profession of a nutritionist or physical educator. A smaller portion of the comments was positive and served as a source of motivation and support for individuals with obesity.
In light of this, it is of utmost urgency to reflect on the phenomenon of fatphobia and weight stigma to support individuals and healthcare professionals who face stigma and prejudice daily. In this context, it becomes evident that there is a need and importance for the dissemination and use of diverse body sizes in campaigns and various media segments to raise public awareness and combat weight stigma and fatphobia.

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