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Conteúdo (article):

Obesity, education and change: displacements of senses and meanings for primary care health professionals.


Carolina Gusmão Magalhães, Health Sciences Center - Federal University of the Recôncavo da Bahia,carol.magalhaes@ufrb.edu.br, ORCID: ORCID: 0000-0001-8040-0933
Virgínia Campos Machado, Department of Nutrition, Federal University of Bahia,virginia.campos@ufba.br, ORCID: 0000-0003-3568-7343
Ricardo Burg Ceccim, School of Education - Federal University of Rio Grande do Sul,burgceccim@gmail.com, ORCID: 0000-0003-0379-7310

Lígia Amparo-Santos, Department of Nutrition, Federal University of Bahia,ligiaamparo@gmail.com, ORCID: 0000-0002-6925-6421 | Federal University of Bahia | Department of Nutrition |

Verena Macedo Santos, Graduate Program in Food, Nutrition and Health, Federal University of Bahia,macedo.verena1@gmail.com, ORCID: 0000-0001-6185-2387

Ananda Ivie Dias Novais Cassimiro, Graduate Program in Food, Nutrition and Health, Federal University of Bahia,ivie.ananda@gmail.com, ORCID: 0000-0002-1315-9147

Poliana Cardoso Martins, Multidisciplinary Institute of Health - Federal University of Bahia,polic.martins@gmail.com, ORCID: 0000-0002-6698-0289

Mônica Leila Portela De-Santana, Department of Nutrition, Federal University of Bahia,monicalp@ufba.br, ORCID: 0000-0002-2706-8238


Abstract:
This article analyzed the possible shifts in the senses and meanings of obesity for primary care health professionals in Bahia after a health education initiative. A qualitative study was performed with 37 participants, which used a semistructured online questionnaire and triangulation method (free word association technique—prototypical analysis, open question–content analysis, and obesity development factor—descriptive statistical analysis), an essential strategy with careful analytical work capable of considering the different perspectives and perspectives on the same object. The Concept and Etiological Approaches categories revealed significant inflections in the senses and meanings of obesity, beyond the biological and biomedical model, in dialog with the ecological, syndemic, and multifactorial approaches, in addition to evoking anthropological perspectives and body diversity. They also revealed concerns about the prevalence and resolution of care practices, the uniqueness of obesity, and the limitation of the evaluation method by the body mass index, evidence that contributes to the reflection of health education in the structuring of curricula in light of the multifactorial nature and complexity of this phenomenon.
Keywords: obesity; health education; continuing education; primary health care.

Introduction

Epidemiological evidence accumulated in the last decade supports the definition of obesity as a “disease” of complex and multifactorial origin 1. From the perspective of the ecological approach to health2, it is characterized by the integration, interrelationship and interdependence of different dimensions (biological, genetic, behavioral, socioeconomic, political and environmental) 1 and needs to be analyzed according to anthropological and body diversity approaches 3. In parallel, there is a historical tendency to conceptualize obesity from a perspective more centered on the anatomoclinical (biomedical) paradigm, defining it as a chronic disease characterized by the abnormal or excessive accumulation of body fat that poses health risks 1,3.
Recently, obesity has been linked to malnutrition and climate change, thus integrating a global syndemic scenario. Considering the three central aspects of a syndemic, in addition to identifying the co-occurrence of public health problems, the essential interaction of contextual and social factors for the simultaneous emergence of diseases at the individual and population levels, as well as the consequences of adverse effects generated for the population, is important 4. This more comprehensive and integrated approach assumes a strategic place in the understanding of the problem and in the intervention proposals 5,6.
From the educational perspective, the nature of all action is equivalent to the nature of understanding 7. In this sense, as the organization of health curricula in Brazil is based mostly on the anatomoclinical model, the actions and understanding of health professionals are determined by this specific view, which conforms to an individualized approach to the health process—disease 8.
With respect to the care of people living with obesity, the reflections of this view are projected to present some challenges. Professionals working in primary care (PC) mention difficulties regarding (1) adherence to treatments and consequent feelings of frustration and helplessness; (2) acting in a multiprofessional team in complex settings of care; and (3) finding unpreparedness to address the complexity of the health‒disease process related to obesity 9. From the point of view of people living with obesity, the negative influences on involvement with PHC professionals stand out with respect to stigmatizing approaches, the attribution of all health problems to excess weight, barriers to the use of health care, and disregard for body diversity that affects mental health, among other factors 10.
In this complex “equation”, health education gains a place of privilege and responsibility in the reorganization of concepts, attitudes and practices of care for people with obesity. Thus, it should be performed on the basis of the social commitment of professionals, who, involved in the reflexive process of doing (action-reflection-action), can reconstruct their practices in sensitive relationships with reality and become involved with its transformation 11. This movement led to a dialog with health perspectives that considered the principles of integrality and intersectorality, in addition to the guidelines of multidisciplinary work and respect for food cultures and body diversity 12.
Educational initiatives aimed at training health professionals should encourage the construction of an interpretative network, supported by evidence, that questions professional perceptions (scientific convictions and thinking styles) and addresses the challenges faced by the population. This includes the processes of subjectivation and the particularities related to the body, desires and affective practices. Thus, we intend to build intervention plans that respond to human complexity, in addition to the causes mapped in an epidemiological–explanatory network 13. The present study aimed to analyze the possible shifts in the senses and meanings of obesity for primary care professionals in the state of Bahia, mobilized from an educational health initiative.

Method
This is an exploratory descriptive study with a qualitative method that uses the case study technique, document analysis and questionnaires as instruments for data production 14. The case studied was the Qualification of Care for People with Obesity course, whose objective was to strengthen the conceptual, methodological and strategic skills of professionals linked to the teams of the Expanded Nucleus of Family Health and Primary Care (eNASF-AB) and Primary Care to Health (PHC) 15.
The training included the optional participation of 182 primary care professionals, nominated by the managers of 77 municipalities that make up two macroregions of the state of Bahia. Initiated during the COVID-19 pandemic, the course was conducted entirely in a virtual learning environment (VLE), with a predominance of asynchronous activities. The participants, in their first access to the VLE, consented to the use of their educational activities for research purposes after ethical clarifications about the voluntary nature of their participation in the study.
The course was organized into phases, the first entitled “Obesities: different views, multiple expressions” and the second entitled “Management of care for people with obesity: thinking and acting”. Both were divided into three units, with those in phase 1 comprising (1) the phenomenon of obesity as a public health problem; (2) the responsibility of the subject to the syndemic approach: different narratives and ways of understanding the phenomenon of obesity; and (3) the phenomenon of obesity as a subjective experience. The units of phase 2 addressed the following topics: (1) (Re)thinking overweight and obesity from the structural and historical organization of public policies; (2) public policies and living networks of health workers in the context of overweight and obesity; and (3) planning interventions for the care of overweight and obese people in different territories 15. The evaluations were based on expanded discussions through forums, the elaboration of concept maps, evaluative activities contextualized to the participants’ reality and the construction of an “experimentation box”, following the methodology proposed by Permanent Education in Health (PHE) 15.
The data analyzed in the study were obtained through document analysis (course material) and a semistructured online questionnaire, which was self-completed by participants in the first week of the course (September 2020) and again at the end of the course (December 2020). 2020) via the SurveyMonkey platform. The study sample included 37 professionals who responded to the questionnaire at both application times.
The questionnaire was organized into two sections: “Sociodemographic and Occupational Data” and “Perceptions of professionals about obesity”. The first addressed variables such as sex, age, marital status, race/color, education, profession, participation in courses on overweight and obesity, performance in the area of care for overweight and obese people, sector of PHC activity, workload of work, time working in the service and type of employment relationship. The second section aimed at surveying the meanings attributed to obesity consisted of three questions: (i) Please write the first three words that come to your mind when you think of obesity, an open-ended question based on the Free Word Association Technique (TALP) 15; (ii) What is obesity for you?, an open question; and (iii) Factors in the development of obesity, a closed question supported by the Factors of Development of Obesity (FDO).
In TALP 16, a projective technique developed in the field of the study of social representations, the representational structures were identified on the basis of the criteria of frequency and average order of evocation (OME), anchored in central nucleus theory 17. In the ODF scale, which assesses beliefs about the causes of obesity, the factors adapted and translated in the studies by Harvey et al. were used. 18 and Foster 19, cited in the study by Obara 20.
For the analysis of sociodemographic and occupational data, descriptive statistics 21 were performed with the use of means and frequencies via STATA software, version 12, to characterize the study population. Data from the question “What is obese for you?” were analyzed via content analysis 22 via the atlas. TI software, version 9, was used for the preanalysis, material exploration, and treatment of the results. and interpretation 23. In TALP 16, the data were treated according to the semantic criteria grouping process 24, followed by prototypic analysis 24, via OpenEVOC software 25 - version 0.92. For this study, the general average frequency calculated by the software was considered. In the ODF, weights were assigned according to agreement or disagreement, generating a Likert scale, where the response options “unimportant” and “little important” were classified as “high stigma” and the responses “very important” and “extremely important” as “low stigma”. This classification followed some models of published studies 18,20,26. The causes considered more stigmatizing were maintained in the order of the ascending Likert scale, and the least stigmatizing or neutral causes were inverted. For this variable, descriptive analysis corresponding to the mean and frequency of the data was performed via STATA software.
The triangulation of techniques 14 was the procedure used to cross-reference the data, an important strategy with careful analytical work, both statistical and comprehensive, preceding the methodological and interdisciplinary guidelines 27. Two categories of analysis (Concept of obesity and Etiological approaches to obesity) were defined a priori to conduct this triangulation, corresponding to broad axes contemplated in the theoretical framework of the investigation, and to aggregate subcategories that emerged in the analysis 14 that support the understanding of the study. epistemological status of obesity.
The present study was approved by the Research Ethics Committee of the School of Nutrition – CEPNUT, Federal University of Bahia (n° 4,035,869). All the participants signed a free and informed consent form before they answered the questionnaire.

Results

The characteristics of the participants in this study are described in Table 1. Among the 37 study participants, 83.78% were female, and most were married (62.16%) and had attended some specialization course (70.27%). The self-reported mixed race predominated (32.43%), and the mean age was 36.11 years (standard deviation of +/-7.46). The participants from eight different categories composed the list of professionals in this study. The majority were nutritionists (37.83%) and statutory civil servants (64.83%) working in the eNASF-AB (62.16%) and in the care of overweight and obese people (91.89%), having never participated in the course with this central theme (83.78%). The participants had worked in these sectors for more than 4 years (54.05%) and 30 to 40 hours per week (72.97%).
Among the questions asked in the questionnaire, the questions based on the TALP presented, in both questionnaires, a total of 111 evocations each, without omitted cases, with the first 65 distinct words and the second 75 distinct words. After the grouping process by semantic criteria, with the standardization of words and expressions, 16 and 25 different words were identified in the first and second questionnaires, respectively. Table 2 presents the frequency results in order of recall before and after the course.
When the changes that occurred after the formative experience were analyzed, the word disease remained a constituent element of the central nucleus. However, previously, it was associated with the words fat and food. At the end of the course, this connection became more complex, and the word disease began to share this space with terms such as care, multifactoriality, mental health, complexity, imbalance, self-esteem and fat.
The first periphery, which suggests individual experiences and new conceptions, includes quality of life, mental health, stigma, sedentary lifestyle, self-esteem and health. After the course, the words “stigma” and “sedentary lifestyle” were maintained, and food, overcoming and some new words, such as risk factors and public policy, were provided. In the second periphery, which has elements less associated with the central nucleus, where only the words knowledge and body are present, after the course, some terms are displaced, leaving the words weight, health and quality of life and environments, with the addition of other terms such as syndemic, individuality, multiprofessionality and culture.
The second open-ended question, applied before and after the course, presented, after the data coding and categorization process, categories/subcategories that converged with the a priori categories of the study (Chart 1).
In the category concept of obesity, which analyzed the meanings for each participant after the course, the subcategory biomedical dimension lost its expressiveness to the ecological dimension when it was almost exclusive. The responses assigned to this category, for example, indicate a decrease in registration units linked to the biomedical dimension and a significant increase in those linked to the ecological dimension, such as multifactorial and social phenomena, multifactorial body conditions, multifactorial pandemics, multifactorial problems and multifactorial diseases.

A complex phenomenon, which is determined by socioeconomic and cultural dimensions, affects different genders, ethnicities and social classes. (P9)

It is a multifactorial pandemic that affects all social classes. (P22)

It is a body condition that encompasses several factors and affects the individual physically, mentally and emotionally. (P4)

After the course, there was also a semantic scope of the unit for recording health problems to public health problems, which proposes a conceptual expansion of the individual perspective to the collective, core of the work of primary care.

It is a public health problem and should receive more attention from the government, the secretary of health and health units. (P2)

Serious public health problems. (P37)

A similar situation applies to the example of the disease registry unit for multifactorial conditions, which suggests a significant shift toward a more ecologically friendly approach.
It is a multifactorial condition with a complex etiology and is difficult to treat since changes in lifestyle are necessary, in addition to multidisciplinary support. (P5)

In the category Etiological approaches to obesity, which presents the explanatory models found in the study, it was noted, after the course, that the subcategory Ecological approach starts to appear as the most significant approach to the research subjects. The multifactorial nature, after the course, gains expression in the approach to obesity category, representing the factor most indicated by professionals (43.75%).

It is a health problem in Brazil and worldwide and is influenced by psychological, biological, cultural, social, environmental and economic factors. (P13)

Obesity is much more common than the accumulation of body fat; it is a habit, it is a system, it is the environment, and it is the mind. (P30)

The expression of food/nutritional factors decreases over time, and genetic factors have gained relevance among the factors listed.

Disease acquired due to poor lifestyle habits and/or genetic and hormonal factors. (P28)

For me, obesity is a disease condition in which the human being is negatively influenced by the genetics that accompanies it, the environment in which they live and the people with whom they live and relate. (P14)

The syndemic factor, which was not recorded before the course, appeared after graduation and was the third most significant factor, together with the lifestyle factor.

This phenomenon, together with other pandemics, such as malnutrition and climate change, comprises the global obesity syndemic. (P32)

Obesity is a complex phenomenon in a syndemic context in which obesity is interrelated with malnutrition and climate change. (P24)

In the last category, emerging issues related to obesity, which are considered relevant to professionals, previously addressed the high prevalence of obesity and obesity stigma; however, after the course, they raised the concern of professionals with the various consequences in the person’s life, maintained the concern of high prevalence compared with low resolution, and highlighted obesity as a singular issue, the limitation of the body mass index (BMI) method and the need to broaden the look at care.

It is a bodily condition that (...) affects the individual physically, mentally and emotionally. (P4)

It is a multifactorial problem that is neglected and invisible worldwide; it only grows and does not evolve in terms of approach and prevention strategies. (P17)

This phenomenon is an important public health issue and, at the same time, a very private and subjective experience of each person who experiences this condition. (P24)

Obesity can be defined as the abnormal accumulation or excess of body fat, but the assessment of BMI alone cannot define obesity and its implications for the life of the individual, and it is necessary to take a broader view. (P3)

The Obesity Development Factors scale, with the results expressed in Table 3, compares the causes identified by professionals, in decreasing order of relevance, before and after the course. The persistence of the first factor, emotional and mood changes (depression, anxiety), was linked to psycho-emotional issues, but changes in the other factors were also observed. Physical inactivity is not relevant to the consumption of inappropriate foods. Next, extrinsic factors (family, friends, the environment, and media) gain expression in place of eating a greater amount than necessary. The following also appears among the first ten causes in the second moment: lack of knowledge about food and nutrition; unfavorable socioeconomic status; increased food availability; portions sold; and consumption of meals away from home.
Finally, Figure 1 shows the methodological design of the triangulation performed to understand the agreements and contradictions in the contextualization of empirical observations and theoretical articulations, increasing the credibility and, consequently, the reliability of this study.

Discussion
Profile of the participants
The profile of most participants was women; the predominant professions were nutritionists, nurses and physical educators; and skin color represented the majority of self-declared mixed races. This profile reveals clues for the attribution of senses and meanings to obesity that dialogs, for example, with intersectionality. Studies have shown that the intersection between the various types of oppression experienced by women, be they class, gender, and race/ethnicity, results in greater social regulation of their bodies, increasing the stigma of obesity 28. On the other hand, professional training in health care has historically been guided by curricula with a more instrumental and anatomoclinical approach, which may provide a bias toward meeting the aesthetic standards and healthy expression of disease tracers 8.
They also reveal the small investment that is made in the qualifications of professionals for care in this area 9, even though permanent health education is an important didactic-pedagogical strategy 29 that encourages and protects health services as a scenario of “situated learning” and “implied qualification” 30 and has the status of national policy in Brazil.

Obesity concept
From the educational perspective, the nature of every action is equivalent to the nature of understanding 7. In this sense, the actions outlined in care, education and public policies related to the phenomenon of obesity may influence perceptions about this condition, and vice versa. In this study, the distinct majority of evocation about obesity before the course was aligned with the anatomical-clinical perspective, widely disseminated in the areas of education 8, management and health care 31, and international agencies that regulate and legitimize global health actions 1.
Although recognizing the importance of the anatomical-clinical perspective in promoting access to treatment, in scientific research and in the development of important public policies for the world population 10, it is necessary to note that the criteria generally used for the diagnosis of this condition are not always fully met by many individuals and do not apply to all individuals. Therefore, defining only BMI thresholds to evaluate obese individuals may lead to a potential risk of misdiagnosis, highlighted by the inadequacy of current identification criteria 10,32.
After the research data are triangulated, to analyze possible conceptual shifts that occurred during the course, a dialog with different perspectives of obesity registration, such as multifactoriality (half of the registration units of the participants), care, mental health, complexity, imbalance and self-esteem, inspires both reflections of the training process and new perspectives on the phenomenon, as well as how complex is the interpretation and approach of obesity 31. These results show conceptual shifts in the direction of the discussions promoted by the social and human sciences, as well as the need to recognize the processes of subjectivation and differentiation that the bodies of people living with obesity demand in the current social context 31.
For Vygotsky 33, learning occurs both in the ascending direction, in which the action of spontaneous concepts paves the way for scientific concepts, and in the descending direction, in which scientific concepts influence the conception of everyday knowledge, providing the structures for ascending development. of the latter, always in a dialectical relationship 33. Thus, knowledge, both scientific and everyday, is a cultural production, and this means the genesis of the need that moves the individual in search of answers to the questions that afflict him 33.
The proposed educational initiative, with content and methodological strategies that promoted discussions about how complex the issue of obesity is, made it necessary to understand it as a phenomenon with a social character 31. From a procedural point of view, the conceptual shifts perceived after the course are probably the result of the alignment between the anxieties and experiences lived by the group in the daily practice of care for people living with obesity.

Etiological approaches to obesity

In an educational conception, the potentialities inherent to the condition of human beings who learn, therefore, are capable of critically apprehending the representations of things and facts that occur in empirical existence, in their subjective and contextual correlations, means that not only the reality as given, the phenomenon or the pure problematic situation, but it is precisely with the problem that the production of reality and our ability to interfere in it are captured 7. A dialogic practice or a practice of problematization confronts meanings and promotes meanings.
Although there is a scientific consensus on the multifactorial nature of the etiology of obesity 1, which involves all kinds of factors in a network, studies and public policies tend to focus on biological and behavioral factors 2. However, its increasing prevalence and the constant challenges faced in care suggest that this emphasis, to the detriment of the other determinants of the understanding of body diversity, needs to be revisited, requiring the use of actions and strategies that integrate but also combine this multidimensionality 31. In bodily diversity, the body is understood beyond a biological and social construction, as a cultural and technological product, within a linguistic dimension, the body is a broad territory to be explored, which acquires and produces social intelligibility, “in act”, political recognition and acceptability of human diversity in multiple aspects and singularities 3.
After triangulation of the research data, to analyze the possible changes that occurred during the course in the etiological approaches to obesity, the relevant scope regarding the ability to associate obesity with multifactoriality and multidimensionality stands out, in line with the approaches syndemic 5, comprehensive 9 and ecological 2 health care, reflex signs of a previous apprehension of “authentic causality” 6 and of the work developed by the course on the basis of the contents covered, especially in the first phase, which discussed different narratives and modes of understanding the phenomenon of obesity, as well as the phenomenon of obesity as a subjective experience 15,31.
This change also converges in the sense of what Edgar Morin 34 calls the paradigm of complexity, qualifying for an interdisciplinary and multireferenced approach in the construction of knowledge, in contrast to linear causality for approaching phenomena such as organic interference. This finding is also in line with the findings of the “Joint Declaration of International Consensus to End the Stigma of Obesity” 10, which suggests that recognition of the complex causes of obesity is associated with lower levels of weight bias and guilt, whereas internal, controllable or personal choices are more closely related to weight stigma 10.
The results show clues to such conceptual shifts that may signal the direction of other narratives about obesity, which are as follows: (1) the concern between the high prevalence and the low resolution of policies, programs and care practices strategies, reports that agree with records of other studies on the “frustration” of professionals arising from the population’s low adherence to therapeutic processes, impotence and unpreparedness to address the complexity of chronic diseases and obesity, in addition to the difficulties in working in a multidisciplinary team 9,35; (2) the issue of the uniqueness of obesity(ies), announcing the concern and importance of considering the subjectivity and specificities of each person in this condition in the practice of care 31; and (3) the limitation of the body mass index (BMI) assessment method, which cannot be considered exclusively for attributing the diagnosis to a person with obesity 10,32,35. The issues raised in these new narratives of the professionals were the subject of the themes and contents discussed in the course 15,31, which endorses the achievement of the objectives designed by the educational initiative researched.
We emphasize, above all, the importance of the displacements obtained in the face of the challenge of transforming care practices for obesity, closing the reflective circle starting from the data presented in the introduction in relation to the main challenges and problems faced in the organization of care practices that respect people and have repercussions for public health. As potential characteristics of the course developed that corroborated the results achieved, the methodological design oriented toward care within the scope of primary care of the SUS, integrating research, training and outreach, should be highlighted. The course was organized to promote social learning and situated training, addressing an analysis of the work situation of each course participant, the problematization of the conceptual framework on obesity, the construction of interventions related to the reality of each course participant and the evaluation of the educational process.
Conclusion
The present study, when analyzing the changes in the meaning and meaning of obesity that occurred during a health education initiative, revealed relevant inflections in the concepts and etiological approaches of obesity, beyond the anatomoclinical model, in dialog with the syndemic and ecological approaches and the field of social sciences and humanities, which are currently consolidated in the international scientific consensus. It also revealed clues to the conceptual shifts marked by concerns between the high prevalence and low resolution of care strategies and practices, the uniqueness of obesity, and the limitation of the method of evaluation by BMI in explaining the diagnosis or indication of therapies. It is inferred that such results may have been brought about by the themes and contents of the course but mainly by the discussions provided by it.
The use of sensitive and problematizing pedagogical and evaluative strategies (social cartography, experimentation boxes, concept maps and intervention-based learning), formulated in the context of continuing education in health, allowed for implicate analyses. In this sense, it was possible to mobilize reflections related to the appropriation of concepts and theories, the effects caused and the potential for promoting changes related to care.
There are many indications in the literature about the potential of health education for social change, as long as it is structured by critical and participatory projects. Therefore, it is important that the training and continuing education curricula in health can be revisited regarding the topic of obesity as a multifactorial, multidimensional and complex phenomenon, in an interdisciplinary and multiprofessional movement, to influence the way public policies, the training process of health professionals and, especially, care practices are structured.
Finally, it is noteworthy that the study presents triangulation as a strong point, a procedure that, by combining different methods, audiences and moments of the study, to consolidate its conclusions regarding the phenomenon of obesity, produces evidence capable of considering the various views and prisms on this same object, which has several sides and many ways to be contemplated. Given the limitations of this study, an evaluation of the sustainability of such changes in the meaning and meaning of obesity is presented since it does not scale this question.

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