Abstracts

Introduction

Obesity has been seen as one of the main and most challenging problems in today’s health. It involves a systemic and multi-sectorial approach for transforming eating atmospheres and health practice. However, this challenge is still far from being faced. Increased obesity has become a worldwide concern due the costs involved and the subsequent effects on health, reduced life expectancies and high prevalence rates¹1 Agha M, Agha R. The rising prevalence of obesity: part A: impact on public health. Int J Surg Oncol. 2017; 2(7):e17. Doi: https://doi.org/10.1097/IJ9.0000000000000017.
https://doi.org/10.1097/IJ9.000000000000... ^,22 Kudel I, Jefferson S, Alves T, Gonçalves TM, Kull K, Emil N. The association between body mass index and health and economic outcomes in the United States. J Occup Environ Med. 2015; 57(10):1047-1054.. Bariatric surgery has been seen as the main treatment for severe obesity, since it can lead to important weight losses in one year and guarantees that comorbidities are reduced³3 Schauer PR, Bhatt DL, Kirwan JP, Wolski K, Aminian A, Brethauer SA, et al. Bariatric surgery versus intensive medical therapy for diabetes – 5 years outcomes. N Engl J Med. 2017; 376(7):641-651.. With this data at hand, we can see that the number of procedures has increased in Brasil⁴4 Oliveira MA, Costa SZ, Costa IS, Batalha Júnior NJP. Bariatric surgeries performed in the unique Brazilian health system between 2010 and 2019. Res Soc Dev. 2021; 10(1):e47510111985. Doi: https://doi.org/10.33448/rsd-v10i1.11982.
https://doi.org/10.33448/rsd-v10i1.11982... , but not to the point of addressing the increased demand. From the day when the person entered the line until surgery has been carried out may mean a wait of up to five years⁵5 Rego ALC, Cruz GKP, Carvalho DPSRP, Azevedo IC, Vitor AF, Ferreira Júnior MA. Tempo de espera de pacientes em fila para realização de cirurgia bariátrica e complicações relacionadas. Rev Enferm UFPE on line. 2017; 11 Supl 2:1025-1031..

The long wait for bariatric surgeries requires an effective educational process to mitigate the effects of excessive weight on the quality of life. We are also aware of the complications of obesity, that can lead to early death. Care for severe obesity is complex and challenging, and health professionals everywhere seek better methods for achieving effectiveness, including control over comorbidities and other methods for promoting weight loss⁵5 Rego ALC, Cruz GKP, Carvalho DPSRP, Azevedo IC, Vitor AF, Ferreira Júnior MA. Tempo de espera de pacientes em fila para realização de cirurgia bariátrica e complicações relacionadas. Rev Enferm UFPE on line. 2017; 11 Supl 2:1025-1031.

6 Tapsell LC, Thorne R, Batterham M, Russell J, Ciarrochi J, Peoples G, et al. Feasibility of a community-based interdisciplinary lifestyle intervention trial on weight loss (the Health Track study). Nutr Diet. 2016; 73(4):321-328.^-77 Malik S, Mitchell JE, Engel S, Crosby R, Wonderlich S. Psychopathology in bariatric surgery candidates: a review of studies using structured diagnostic interviews. Compr Psychiatry. 2014; 55(2):248-259..

Educational action in health, based on a problematizing, participative approach to eating and nutrition, has been an important strategy to promote greater bonds between professionals and patients. It is aimed at transforming reality, and provides better self-perception when patients are getting sick and/or caring for illness⁸8 Brasil. Ministério do Desenvolvimento Social e Combate à Fome. Marco de referência de educação alimentar e nutricional para as políticas públicas. Brasília: Ministério do Desenvolvimento Social e Combate à Fome, Secretaria Nacional de Segurança Alimentar e Nutricional; 2012..

This article is an attempt to analyze the perceptions of bariatric patients who experienced an educational process in an outpatient clinic of a university hospital, as compared with perceptions of bariatric patients who did not have the same educational experience.

Method

Subjects of the study

This article presents a qualitative analysis of the perceptions of patients who were accompanied during one year while on the waiting list for bariatric surgery. They were recruited at the general surgery outpatient clinic of the University Hospital of São José do Rio Preto, State of São Paulo, Brazil⁹9 Evangelista MM, Crisp AH, Rossato SL, Vieira CM, Bossa R, Oliveira MRM. Randomized controled trial protocol: a quanti-quali approach for analyzing the results of an intervention on the waiting list for bariatric surgery. Rev Nutr. 2019; 32:e180234. Doi: https://doi.org/10.1590/1678-9865201932e180234.
https://doi.org/10.1590/1678-9865201932e... . The present article is derived from a larger study which involved 88 patients, who had been divided into two large blocks, with 44 patients in each. The first block was referred to as the “educational groups” and the second was referred to as the “non-educational groups”.

To hold the meetings of the block known as the “educational group”, the patients were divided into four smaller groups, each one containing 11 participants. The “educational groups” held 18 meetings between February, 2018 and February, 2019. At these meetings the patients were evaluated and monitored on their clinical, physical, nutritional, and psychological conditions over the period of one year, and an educational experience was carried out at the same meetings.

The members of the “non-educational group” were also evaluated and monitored in their clinical, physical, nutritional, and psychological conditions over the period of one year, but no educational process was carried out.

All those patients who agreed to participate voluntarily in the study signed the informed consent form. The study was approved by the Research Ethics Committee (FCF-Unesp, n. 2289208), and the Brazilian Register of Clinical Trials (ReBEC) RBR – 775y3d was carried out.

The focus group technique (FG) was applied in order to understand the perceptions of the patients regarding their experiences while waiting in line for bariatric surgery. The proposal was to compare the perceptions of the patients who participated in the educational encounters with the perceptions of those who had not participated. Therefore, an encounter was held with ten representatives of the educational block (chosen at random), and another encounter with representatives of the non-educational block. These two encounters, carried out at the end of a year of monitoring, were carried out in the FG format, as a research method to compare the different perceptions about living in the waiting line for those who had been through the educational experience, and those who had received only clinical monitoring (Figure 1).

The researchers decided on the FG technique because it gives positive results in evaluating qualitative research. It also allows analysts to note various perceptions by the group while respecting the differences of each participant¹⁰10 Backes DS, Colomé JS, Erdmann RH, Lunardi VL. The focal group as a technique for data collection and analysis in qualitative research. Mundo Saude. 2011; 35(4):438-442.^,1111 Vieira CA, Santiago LS, Tavares PCW, Brandt A, Oliveira MRM. Aplicação da técnica de grupo focal em pesquisa da Rede-SANS sobre as ações de alimentação e nutrição na atenção básica em saúde. Cad Saude Colet. 2013; 21(4):407-413..

The two FGs were held in the outpatient environment. According to the FG method, the participants sat in circles in order to promote interaction among the members¹²12 Lino FS, Schoninger RRZV, Sartori AS. A técnica do grupo focal em pesquisa sobre Educomunicação: construindo ecossistemas comunicativos. Rev Tematica. 2018; 14(4):16-28. and each FG meeting lasted an hour and a half. In order to apply the FG technique, a team that had had no previous contact with any of the patients was formed, consisting of a trained mediator, an adviser and an observer of non-verbal expressions¹³13 Leny A, Bomfim T. Grupos focais: conceitos, procedimentos e reflexões baseadas em experiências com o uso da técnica em pesquisas de saúde. Physis. 2009; 19(3):777-796.. According to Figure 1, they used a script with questions concerning the area of bariatric surgery. The recorded material was transcribed to a Word archive for later analysis. The written phrases spoken during the meetings were repeated several times so that the researchers could organize the data in order to identify flows of meaning and categories of analysis.

To identify the subjects’ phrases that are presented in the section on results and discussion, the following letter codes were used: 1 - REG means representative of the educational groups and, 2 - RNEG means representative of the non-educational groups.

The educational process

The educational process was aimed at promoting general care in order to guarantee integration of the fields of knowledge and relationships among the patients. This was seen as a way to broaden their viewpoints and promote more complete care¹⁴14 World Health Organization. Framework for action on interprofessional education and collaborative practice. Geneva: WHO; 2010..

The meetings of the groups of patients were held once every two weeks during the first semester of 2018, and monthly during the second semester, always on the same day of the month and at the same time and place. The educational meetings lasted for 60 minutes. A round of initial conversation was held, in order to come up with topics of interest to the patients, and these topics were dealt with during the meetings.

The educational process was coordinated by the interdisciplinary team, which included a nutritionist, a physiotherapist, a physical education professional and a psychologist. The professionals who participated in this study worked in an interdisciplinary way, with similar actions of welcoming, establishing of bonds, group promotion and qualified listening to the groups’ demands. The areas operated together, gathering knowledge and sharing information and perceptions. However, specific practices of each profession were called upon to promote behavior changes in synchronized and broader ways in the different areas of knowledge. The approaches carried out by each area of knowledge are described in Frame 1.

The educational process was based on the active method of learning. Topics and problematizing questions favored dialogue and the exchange of knowledge among the dynamic singularities and differences of each group. This educational practice is highly recommended in the literature because it is based on learning through problems and on meaningful learning. It is organized into small groups, since this aspect is considered essential to guarantee the broadest possible learning¹⁵15 Brasil. Ministério da Saúde. Perspectivas e desafios no cuidado às pessoas com obesidade no sus: resultados do laboratório de inovação no manejo da obesidade nas redes de atenção à saúde. Brasília: Ministério da Saúde; 2014..

The educational process of the professionals took place as a permanent space of reflection and perfection of the project that was being developed with the educational groups of patients. All these professionals had participated in an educational process for one year and eight months (between June, 2017, and February, 2019), in partnership with an educational institute, in order to guarantee a process of reflection on the practices being recommended.

The education was designed to reflect on practices jointly with health professionals and thus establish a line of care for obesity, focusing on Food Security and Nutrition. The purpose of all this was to discover links between teaching and action, with the objective of supporting the experience that was being developed concurrently with groups of patients.

Results and discussion

The analysis of the discourse used by the patients in the FG was grouped into four analytic categories, distributed in the following way: 1 - Patients’ perception of bariatric surgery; 2 - Self-image: reflection in the mirror and its judgment; 3 - Triggers and barriers regarding obesity; and, 4 - Changes perceived by the participants of the educational group.

Perception of patients about bariatric surgery

This category shows the perceptions of the patients about bariatric surgery as a clinical procedure and the difficulties that they imagine they will have in this process. A number of doubts and uncertainties were observed in the group that had not been through the educational process:

An analysis of the narratives made it possible to identify differences in the perceptions about the surgery between the two focal groups. Both groups presented feelings of fear of the unknown and anxiety in relation to the results, but the patients that had not gone through the educational process showed a more expressive idealization in relation to bariatric surgery, and transformed it into a “magic” formula to resolve obesity, just like all of life’s other problems.

The unrealistic expectations for bariatric surgeries are frequently referred to in the literature, which reinforces the importance of detailed accompaniment of patients and he construction of legitimate post-surgical benefits¹⁶16 Homer CV, Tod AM, Thompson AR, Goyder PAE. Expectations and patients’ experiences of obesity prior to bariatric surgery: a qualitative study. BMJ Open. 2016; 6:e009389. Doi: https://doi.org/10.1136/bmjopen-2015-009389.
https://doi.org/10.1136/bmjopen-2015-009... . In the reports presented by the group that went through the educational strategies, it could be observed how valuable the educational activities had been as strategies for broadening and changing the paradigm.

Self-image: reflection in the mirror and judging it

This category refers to the self-perceptions of the patients about their bodies stop and the challenges of being obese in a society that sees the body as something idealized. Living with the stigma makes patients feel sad, or even furious at themselves, with important impacts on their mental health.

The meetings in the educational group could not deconstruct this deep view from the cultural and social context. Despite the promising results attained in the group meeting of the educational process, like self-perception and its treatment, some barriers against changes in comportment were chosen by the patients of both groups. They were motivated by aspects of each one’s personal life, through prejudices and social barriers.

In this sense, the two groups of patients presented similar views about their bodies and showed that they see bariatric surgeries as a strategy for them to be “fixed” and therefore accepted by today’s aesthetic patterns.

The participants of both groups brought up situations of everyday life where they were very embarrassed and this generated feelings that were hard to handle. As they said in the literature, they are situations that make you stay away from your own social world. They cause you to have low self-esteem and feelings of impotence, uselessness, anxiety and depression¹⁷17 Chugh M, Friedman AM, Clemow LP, Ferrante JM. Women weigh in: obese African-American and white women’s perspectives on physicians’ roles in weight management. J Am Board Fam Med. 2013; 26(4):421-428.

18 Macedo T, Portela PP, Palamira CS, Mussi FC. Obese people’s perception of their own bodies. Esc Anna Nery Rev Enferm. 2015; 19(3):505-510.^-1919 Megías A, González-Cutre D, Beltrán-Carrillo VJ, Gomis-Díaz JM, Cervelló E, Bartholomew KJ. The impact of living with morbid obesity on psychological need frustration: a study with bariatric patients. Stress Health. 2018; 34(4):509-522..

The preference to stay-at-home was seen in both groups. A justification for this position was their adaptation to the home as where there are fewer offenses and prejudices¹⁷17 Chugh M, Friedman AM, Clemow LP, Ferrante JM. Women weigh in: obese African-American and white women’s perspectives on physicians’ roles in weight management. J Am Board Fam Med. 2013; 26(4):421-428.. However, this choice can favor a very sedentary life, which was mentioned by the participants in this study that did not undergo educational intervention. This situation was worse when there are economic difficulties, lack of time, diseases leading to obesity and the difficulty of going to a gym²⁰20 Marcelino LF, Patrício ZM. A complexidade da obesidade e o processo de viver após a cirurgia bariátrica: uma questão de saúde coletiva. Cienc Saude Colet. 2011; 16(12):4767-4776..

However, despite the barriers and rigidity found in the social context, we heard a voice of resistance in the group that participated in the educational process, although it was very timid. It was an invitation to perceive oneself beyond the aesthetic body, like an individual with the right to love and respect.

In this study, it was evident that the perception of obesity by the patients is understood as something bad, ugly and awful, a reflex of social imagination. Along the same line, a review of the literature noted the negative effect of the stigma and how such contacts centralize the obese patient as the guilty one. In this way, the individual is pointed out as responsible for his or her body, thus minimizing other dimensions, such as emotional and social aspects. Even health professionals who are caring for obese patients are sometimes responsible²¹21 Tarozo M, Pessa RP. Impacto das consequências psicossociais do estigma do peso no tratamento da obesidade: uma revisão integrativa da literatura. Psicol Cienc Prof. 2020; 40(1):1-16..

Triggers and barriers in obesity

Everyday episodes interfere in the process of obesity, such as triggers for gaining weight or barriers against losing weight. Perceptions of triggers and barriers were mentioned by the participants of both focal groups in the reports about the difficulties when facing day-to-day life.

Aspects of personal life, prejudices and social obstacles, such as the lack of accessibility and public places, can be a barrier against any change in behavior. Similar results are seen in communities in Australia and New Zealand, where they concluded that the main barriers to change are directly connected to unreal expectations, low intrinsic motivation and unfavorable environmental aspects²²22 Kozica SL, Lombard CB, llic D, Ng S, Harrison CL, Teede HJ. Acceptability of delivery modes for lifestyle advice in a large scale randomised controlled obesity prevention trial. BMC Public Health. 2015; 15(1):699..

Situations like these can be psychologically stressing and affect one’s humor, emotional state and eating behavior, causing changes in eating choices. The preferred options are the tastiest, and “comfort foods” are consumed to minimize negative feelings²³23 Minati S. Mood, food and obesity. Front Psychol. 2014; 5:925. Doi: https://doi.org/10.3389/fpsyg.2014.00925.
https://doi.org/10.3389/fpsyg.2014.00925... .

Also, about triggers, the study made by Porto et al.²⁴24 Marcus CVP, Brito TC, Calfa AD, Amoras M, Villela NB. Perfil do obeso classe III do ambulatório de obesidade de um hospital universitário de Salvador, Bahia. Arq Bras Endocrinol Metab. 2002; 46(6):668-673. showed that patients can mention motives for starting to get fat, such as anxiety, eating too much, taking birth control medicines, hereditary traits, pregnancy, getting married, surgery and others. But there are some who cannot say when they started putting on weight²⁴24 Marcus CVP, Brito TC, Calfa AD, Amoras M, Villela NB. Perfil do obeso classe III do ambulatório de obesidade de um hospital universitário de Salvador, Bahia. Arq Bras Endocrinol Metab. 2002; 46(6):668-673..

Changes in posture perceived by patients in the educational group

The perceptions of participants in the focal group made up of patients that had been through the educational process are that they began to change their posture in relation to being very sedentary, as well as changing everyday eating practices and paying less attention to mental health. The patients in this group showed a positive change in their narratives:

In a qualitative study carried out by Sharman et al.²⁵25 Sharman MJ, Venn AJ, Jose KA, Williams D, Hensher M, Palmer AJ, et al. The support needs of patients waiting for publicly funded bariatric surgery – implications for health service planners. Clin Obes. 2017; 7(1):46-53. on participants who were on a waiting list for bariatric surgery, it was noted that the participants of the groups with health education spoke positively about the support that they received. They also noted how important it was to exchange ideas and experiences with other participants. The educational space given for exchanging experiences emotions and support was recognized by the patients of the educational group, and this is the basis of the process of changes referred to by them:

On the contrary, patients waiting for surgery who didn’t go through an educational process found it hard to establish new positions to face the prejudices about fat bodies in the social context:

The study carried out by Krukowski supports what we have been saying²⁶26 Krukowski RA, West DS, Priest J, Ashikaga T, Naud S, Harvey JR. The impact of the interventionist – participants relationship on treatment adherence and weight loss. Transl Behav Med. 2019; 9(2):368-372., that, over time, the bond between professionals and participants favors the loss of weight of the patients. Other studies also show positive results of educational processes in preparing for bariatric operations, whether they are for long²⁷27 Lerdal A, Gay CL, Bonsaksen T, Fagermoen MS. Predictors of physical and mental health in persons with morbid obesity attending a patient education course – a two-year follow-up study. Health Qual Lifes Outcomes. 2017; 15(1):103. Doi: https://doi.org/10.1186/s12955-017-0675-z.
https://doi.org/10.1186/s12955-017-0675-... or for short periods²⁸28 Barros LM, Carneiro FN, Galindo Neto NM, Araújo MFM, Moreira RAN, Barbosa LP, et al. Intervenção Educativa e Indicadores de Obesidade de candidatos à Gastroplastia: um estudo quase-experimental. Acta Paul Enferm. 2020; 33(1):1-13.. They provide tools that give the patients the strength to change behaviors.

Participative educational processes that involve qualified listening are important because they provide patients with the possibility to abandon the condition of victim of obesity. In other words, they see that fat bodies cannot make everyday changes in eating practices, body movements and emotional balance.

Conclusion

The perceptions of the participants of the two different groups were not unanimous, but they came close to one another on some points, such as their approaches regarding bariatric surgery. Both of the groups realized the benefits presented by educational procedures and they maximize the advantages. They were able to identify that the stigma of self-images, prejudices, everyday difficulties and social isolation carry a certain weight for the patients of both groups. It was also easy to note that they all expressed themselves as a living presence in society that carries with it considerable prejudices to mental health. This is because the prejudice against fat bodies and obesity are cultural constructions that make change and self-care difficult.

The perceptions regarding the barriers against changing behavior and their positive view of the encounters in educational groups were seen as potential social support. This helped at moments of emotional difficulty based on the sharing of information, strengthening of bonds and resolution of problems that are characteristic of the pre-operative period. In this sense, the contribution of the educational space for the decision not to give up treatment in view of critical situations was referred to by some patients. The fact that people are obese in our society is challenging in general, but it can be even more difficult for those who are in line for surgery.

The life of an obese person in our society is a challenge in general. But it can become even more difficult for those who are in line for bariatric surgery, because the long wait involves emotional suffering, an increase in comorbidities and even the risk of death. Educational spaces that are participative and that promote autonomy also reaffirm the strength of preventive action to bring about changes in the behavior of patients with serious obesity, as shown by this study, as it compares the perceptions of the two different focal groups.

Acknowledgments

Universidade Estadual Paulista “Júlio de Mesquita Filho” - Unesp e FUNFARME/Hospital de base.

References

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History