FEELINGS AND LIVING EXPERIENCES OF INDIVIDUALS TAKING PART IN A SUPPORT GROUP FOR CONTROL OF OBESITY: AN EXPLORATORY STUDY

Aliny de Lima Santos1, Rafaela Pasquali², Sonia Silva Marcon³

1, 2 State University of Maringá;3 Paranaense University -UNIPAR.

ABSTRACT

Introduction: Obesity is considered a stigmatizing illness, often associated to prejudice, personal dissatisfaction with a self-image, and a feeling of social inadequacy, factors which make difficult its control. Objective: to know the meanings of "coping with obesity" for participants of a self-help group for obese, as well as to identify his/her perception regarding participation in the group. Methodology: Exploratory study with qualitative approach, accomplished with 14 participants of a self-help group for obese from the city of Maringá-PR. Data was collected from September to December 2010, through semi-structured interview, observation and recording of the meetings. Data analysis was carried out according to the content analysis. The study followed the guidelines of Resolution 196/96. Results: Reports showed feelings of prejudice, self-bias, discouragement and social inadequacy, generating insecurity, social escape and difficulties to carry on a relationship.  Participants stated they are taking part in the group to search for support, understanding and rapport with individuals that are sympathetic to their problems, evidencing changes in their lives due to that participation. Implications for the nursing: The work with groups reduces costs and time in the rendered assistance, besides providing greater opportunities of conviviality among professionals and clients, reducing the vertical relationship among them and facilitating the improvement of offer in healthcare.

Keywords: Self-help groups. Obesity. Body image. Self-care.

INTRODUCTION

Obesity has been defined as "the excessive accumulation of adipose tissue in the body"⁽¹⁾. Genetic, physical, psychological, environmental, behavioral and family factors may coexist and favor its appearance or even aggravate the situation. It has been seen as a clinical disorder associated with chronic diseases, especially the cardiovascular and premature death⁽²⁾.

Obesity can be classified in degrees I, II and III and its diagnosis is made from the Body Mass Index (BMI) determined by the relationship between weight and height⁽³⁾. Regardless, however, of the degree of obesity, the current standards in contemporary society place more emphasis on body image than on health and disease prevention that weight maintenance can provide, leading to dissatisfaction and discomfort with excessive weight⁽²⁾.

This "negative view of the body" makes obese individuals relate fitness with acceptance, social success and happiness. Emotional problems are generally perceived as consequences of obesity, although conflicts and psychological problems of self-concept may precede the development of it⁽¹⁾. Some psychological disorders such as depression, anxiety and difficulty in social adjustment, can be observed in obese individuals and act as cause or effect of the process of weight gain⁽²⁾.

The social avoidance behavior, in turn, affect the quality of life of individuals, so that the concern with the psychological aspects associated with obesity are increasingly common, especially those related to body image³. The term body image refers to an illustration that one has about the size, image or body shape, but also the feelings related to these characteristics, ie, it is the "mental picture" of one's physical appearance⁽²⁾.

For feeling stigmatized, obese people avoid social contact, give up the search for professional assistance and in some cases enter the process of "acceptance of obesity," resulting in the aggravation of this growing problem⁽⁵⁾. For individuals who experience this type of conflict and feel unable to reach resolution, support and encouragement from friends and family, and even the religious background, are essential to personal well-being and play an important role, but when performed in groups of the same kind, can become even more effective⁽⁶⁾.

The work with groups is characterized as a more cost-effective intervention, by the possibility of attending a larger number of clients simultaneously, resulting in more efficient use of time and energy on the part of professionals, and provide a better feedback among the client and health professional⁽⁷⁾. It usually constitutes an environment of motivation for the treatment by the sharing of difficulties and the search for alternatives to overcome them, in addition to building links, where each individual works as a support for others facing the same situation, trying to stimulate the participants to find resources to deal with the disease/problem and its effects on his life⁽⁷⁾.

Given the above, the study aims to know the meanings of "living with obesity" for participants in a self-help group for obese people, as well as identify their perception about the participation in this group.

METHODOLOGY

The study is exploratory and qualitative approach and was carried out among 14 participants in a self-help group for overweight people and it does not focus on profit or connection to any health institution. The group, called "Support Group Free to Lose Weight Thanks to God", was founded in a little more than a year, by a social worker in the city of Maringá - PR.

Meetings are held fortnightly in a private school, with an average duration of 60 to 90 minutes and are developed from verbalizations, reflections and discussions of problems and aspects of the life of participants and their relationship with obesity. There are also lectures and guidance by health volunteers on nutritional education, benefits of physical activity and health problems and complications associated with obesity, according to the request of participants. The group is open to people of both genders who wish to reduce weight, provided that they are overweight and over 18 years.

Data collection was conducted from September to December 2010, through observation and interview. The observation took place during seven sessions of self-help group. During data collection the group sessions were recorded by means of a digital device (MP3) and then transcribed for later analysis. At the beginning of the period of data collection all participants had their weight and height measured for the BMI calculation. In the following sessions at the request of the participants were also checked the weight, the capillary blood glucose and blood pressure. These activities have produced data which, although did not constitute an object of investigation, contributed to the smooth functioning of the group because they raised arguments and even encouraged the attendance to the meetings. The cutoff points proposed by the World Health Organization (WHO) were used as a diagnostic criterion of nutritional status. According to this criterion, those with BMI between 25 and 29.9 kg/m² are classified under the condition of overweight and those with BMI ≥ 30 as obese, as follows: BMI between 30.0 and 34.9 kg/m² is classified as grade I obesity, between 35.0 and 39.9 kg/m², class II obesity and BMI> 40.0 kg/m², obesity class III³.

The semi-structured interviews were conducted individually at the end of the last group session in a reserved room on school. They were recorded and the guiding question was: "Tell me how it was to join this group. Did something change in their lives due to participation in the group?".

Data analysis occurred through content analysis, using the following steps: 1) seizure of information from reading and rereading of meetings and interviews, 2) data encryption, 3) selection of codes for the process of living with obesity, 4) development of categories and 5) interpretation of the findings.

The development of the study was conducted in accordance with the ethical principles disciplined by Resolution 196/96 and its design was approved by the Permanent Committee of Ethics in Human Research of the State University of Maringá (Opinion No. 623/2010).

RESULTS

The participants were twelve women and two men, aged between 40 and 64 years and BMI ranging between 31.53 and 34.68. When analyzing the statements emerged two categories: 1) Living with obesity: feelings, concepts and prejudices, with the subcategory Knowledge about healthy eating, and 2) Experiencing the participation in a group of self-help: expectations and perceptions - also with a subcategory entitled Realizing Changes.

1) Living with obesity: feelings, concepts and prejudices.

In contemporary society it is a reality the requirement of a lean body, which is considered perfect and healthy and is highly valued.

 [...] I feel like nobody likes me being fat. I complain every day about it. (E1-92kg, 49 years)

 [...] I realize that my husband does not like me anymore, he thinks I´m ugly [...] it's very difficult to be so fat! Sometimes I feel very ashamed of myself and do not even want to go outside. (E1-92kg, 49 years)

It can be seen in this statement the presence of prejudice of this woman against herself. The interviewee believes she experiences a situation of judgment and distancing by the people of her conviviality and she relates it to the fact that "she is fat". During the meetings, it was easily observed by her speech that she associates her body image and her overweight to the difficulties in her married life, expressing the lack of feelings of her partner and blaming herself for it, because, by not being happy with her body, she believes she is not loved by her companion anymore.

In this case, we believe that prejudice and self-prejudice are more imaginary than real, since E1 reflects all the dissatisfaction with her weight and body image, in what she believes it to be a detachment and absence of support from her partner. Given the actual bias or its shadow, the individual dodges of his life, feels harassed and neglected by friends and family and even more so by people who do not know him.

[...]when a fat man goes on to the street he is always a benchmark for others, and they usually remember you saying: That fat lady, or say hello on the side of the fat lady [...] people have much prejudice.(E2-103kg, 62 years)

We observed in the testimony of E2 the perception of prejudice arising from the society in general.
It should also be considered that obesity has a strong influence on the development of daily activities and daily life, making changes and hindering the realization of activities related to lifestyle, due to excess weight or the associated pathologies. This fact was mentioned repeatedly during the meetings, especially by female participants, involving difficulties in performing household chores:

[...] being fat is a difficult thing! I cannot do many things, especially housekeeping. It is difficult for washing the dishes, laundry, and also cleaning the house, you know? ‘Cause I can't spend a lot of time standing, my legs hurt. I think it's because the body weighs a lot, isn't it? [Laughs] I know that when I was thinner it was easier to do everything. (E10-97kg, 48 years)

Obesity creates an enormous psychological burden and can be characterized as a negative effect of the disease, resulting in a bad perception in relation to your health and life in general. The participants consider their quality of life poor and recognize the association between obesity and other diseases of which it would be the cause or consequence:

[...] I consider my life awful! I have severe depression and sleep all day long; I have no willingness for doing anything, not even to cook to feed my family. Yet I'm still fat, even not eating almost anything. This is not life, you know! [...] (E3-98kg, 52 years)

 [...] I think my health is poor, really poor, and I think the result is hypertension, diabetes and fatness, because I work it off on the refrigerator, and eat until dawn. (E4-97kg, 54 years)

In the testimonies there is great dissatisfaction associated with obesity and chronic diseases arising from it. It is noteworthy that E3 reveals once again a situation of isolation and distance from her daily habits, such as cooking for the family due to his dissatisfaction with obesity, which in her statement she associates it with a process of depression. As for E4, dissatisfaction with her picture of obesity and other problems in her daily life result in greater consumption of food, increasing weight.

Knowledge about healthy eating

The formation of eating habits is processed gradually, forming the concepts of healthy eating that each individual has gotten for himself, concepts that are closely linked to the way he will conduct his food habits, which may be in accordance with or in the opposite direction of what would be good for his health.

[...] I don't know what truly means healthy eating to lose weight. I believe that a person only loses weight when they stop eating, that is, only if you fast, just like that. Since I cannot do that, I eat everything in can [laughs]. (E3-98kg, 52 years)

The belief that you only lose weight if you stop eating could be observed in this statement. Another relevant fact is that healthy eating is only associated with weight loss, not with health maintenance, demonstrating that reducing measures would be the only reason for E3 to adhere to changes in her eating routine. Faced with the desire of losing weight people end up removing foods that are part of a routine diet, making it difficult, in a progressive and systematic way, the continuity of the goal.

However, more suitable testimonies were also seen as it follows:

[...] Healthy eating, good for weight loss. I believe it should not be monotonous, but it should have a variety of fruits, vegetables, rice, beans, grilled meat and other more natural foods, also prepared in a more healthy way. We should eat correctly, isn't it? (E5-108kg, 42 years)

2) Experiencing the participation in a support group: expectations and perceptions

When trying to understand the meanings of group membership, we found that participants seek the group not only to solve the problem of weight, but also to seek support, understanding and rapport with individuals who know their problems closely¹³. We identified some expectations when they seek participation in the group, which involve, besides the desire to lose weight, to search for: motivation and support, improved self-esteem and overcoming their own difficulties:

[...] I started to join the group looking for motivation and support to lose weight. I think that if I meet people who have the same problems and share experiences, is very important for losing weight. We feel stronger [...] and these lectures and information that you provide help a lot, because then we know the best diet and lose weight faster [...] (E6-98kg, 58 years)

[...] I'm joining the group with the purpose of learning to love myself, and would like to improve my self-esteem with the support of the group [...] I know that here I will make it because here I see who is already making it. (E5-108kg, 42 years)

[...] I know I can control myself in the diet and lose weight, that I will be able not to compensate my anxiety and nervousness in the fridge, as I'm doing now [...] I want to have better health and lose weight, to be an example of overcoming for other people, and for me, and I know the group will help me. (E7-93kg, 46 years)

Even those who did not see the group as therapeutic and effective, would perceive it as useful by its social function. In these cases, the group acts as a support network, for its participants, not only discuss and listen to each other, but also maintain contacts outside the group, creating a large social support network:

[...] don't know if the group is gonna change anything in my life, if it's going to make me lose weight ... I don't know, I guess not! But I like coming. I feel welcome, meet people and I feel good, 'cause I see people like me. I have no friends, you know? I am always alone. Here at least I have someone to talk to. (E8-102kg, 64 years)

[...] Sometimes I get here sad, upset, discouraged, but with the conversations, with the friends I'm making here I go home with another spirit, I feel happy and hopeful, thinking that suddenly I can certainly lose weight (laughs ). (E7-93kg, 46 years)

Perceiving changes

When asked about the changes that had occurred in their lives after participation in the group, it was found that the participants felt changes and that the recognized them as important and satisfying not only for them, but also for their family, but it was not only the group that was mentioned as responsible for the satisfaction, but also the change in habits such as physical exercises:

Up to now I only came to two meetings, but I already see changes. As the use of brown rice and began to eat fruits and vegetables, which I could not stand. I really think that it's changing; now I'm the proud owner of my will, it's not my desire to eat that that is my mistress anymore. (E9-88kg, 53 years)

[...] When I first came, I confess I left the meeting full of hope and faith, confident that I could, not only lose weight , but also have better health. I realized that if I did not do that for me, nobody would and I should love myself more. So I'm changing my diet [...] not just mine, but everyone's at home too. (E4-97kg, 54 years)

[...] before coming to the group, cooking was an ordeal, and I always made a lot of fried stuff. Today I learned and understand the responsibility that I hold in my hands with the health of my family when I cook. Now I make a lot of salads and we eat healthier foods [...] before I slept all the time, now I exercise, walk every afternoon. In addition, I lost 13.2 pounds in one month, only with food, hiking and the group as well. (E6-98kg, 58 years)

The positive feelings related to the group show once again how valuable it is for those who participate in it, because in addition to promoting changes in the living habits, it was also associated with improvement of life.

DISCUSSION

Obesity is considered a multifactorial syndrome in which genetics, metabolism and environment interact, and it takes different clinical pictures in different socioeconomic realities. It is also related to various psychological aspects, generating feelings of dissatisfaction, anxiety, rejection, inadequacy and depression, which may constitute the major adverse effects of the disease⁽⁸⁾.

This feeling of inadequacy and dissatisfaction, closely linked to self-image disorders and caused by the weight gain, may cause a devaluation of the self in the obese, lowering his self-esteem and jeopardizing his relationship with others and with himself⁽⁹⁾. Factors such as those produce in the obese an uncomfortable social pressure and a feeling of inadequacy in relation to the current social patterns, causing relational difficulties, and often a shift away from social contact and the performance of some daily tasks. This feeling of inadequacy accompanied by feelings of worthlessness and an escape from the social, translated by isolation, is often at the root of depressive symptoms and relational difficulties⁽¹⁰⁾.

It is also seen in the results the presence of prejudice, which is considered as a routine in the life of obese individuals, whether real or imaginary, reflecting on how they face their illness, how they live together with the people around them and how they experience everyday life and changes for the maintenance, control and reduction of harm to obesity. In fact, obesity has been considered a stigmatized condition by the society and associated with negative characteristics, favoring increasing discrimination and the rise of feelings of social inadequacy, dissatisfaction with oneself, loneliness and isolation⁽⁵⁾.

As for social life, is not uncommon for overweight people to deal with excess weight as an aggravating factor in their relationships, believing they suffer discriminations that interfere in social and affective relations ⁽¹⁰⁾. This belief of social prejudice may lead to serious frustration, especially the isolation, stress and depression. It may also be associated with the "acceptance of the disease" as something not likely to change. As a chronic sufferer sees his condition as "karma or a curse", it becomes even more difficult their adherence to healthy behaviors⁽¹¹⁾.

The concept and interpretation that the individual attributes to important factors of the treatment and maintenance of a chronic situation, intervene directly in his adherence to self-care and changes in lifestyle⁽¹²⁾. Thus, life satisfaction and acceptance of his health condition/disease, as well as the awareness of the importance of changing habits and the possible problems that may evolve; are fundamental factors for the adherence to healthy practices, the early search for professional care and the consequent weight loss⁽¹²⁾. The further away of this awareness, the more difficult the path in search for a solution, even under professional guidance because of the professional guidelines will be followed only when the solution is perceived, i.e., when an individual believes that his case is subject to change⁽¹³⁾.

In short, for an individual to adopt and maintain changes in his life, it is necessary that he really believes that they may be held by him and that they will take effect on his condition. For that, again social, cultural, economic and behavioral factors work helping or hindering good relationship between the subject and the necessary changes⁽¹⁴⁾.

In this context, the group constitutes a space in which members can share their experiences and feelings with the certainty that they are understood by the other participants who experience the same situations and difficulties⁽¹⁵⁾. It works as a "hall of mirrors", resulting from a game of identifications. This expression reflects the therapeutic action of the group that is processed through the possibility of each one reflecting in one another and of being able to recognize in the mirror of others, his own aspects that are themselves denied⁽⁷⁾. Throughout the study these aspects were observed, as several participants, in informal conversations at the end of the meetings, reported how the group was being helpful to show them how to act and how not to act.

Within the group, it is possible to glimpse the universe of each participant, respecting their individuality and particularities. The self-help group for people with chronic diseases and of difficult confrontation, such as obesity, is a way of sharing knowledge and experiences in building a healthier living, because there is the possibility of forming a social support network, which will result in benefits for participants, as it promotes independence, enhances creativity, improves self-image and nurture free expression of feelings and knowledge, and encourages connections with people facing similar situations⁽¹⁵⁾.

We also observed that the group provided to individuals greater independence, confidence and belief in their power to change and improve their health/disease status. It allowed the exchange of experiences and promoted the interaction between participants, and it makes each participant find his way to tackle the problem. The meetings help combat social isolation, because the discussions provide a sense of universality, so that whoever feels different gets to live with those considered equal. Therefore, the group provides necessary support to its members, offering support for overcoming many of the problems faced⁽¹⁵⁾.

Teamwork also allowed the breaking of the vertical relationship that traditionally exists between health professionals and fellow recipient of their actions, being a facilitating strategy of expression of needs, expectations, fears and life circumstances⁽¹⁶⁾. This was observed during the course of the group, in which the discussions and reports of the participants occurred freely, with interference from health professionals only when requested in case of doubts, for clarification or inquiries.

Thus, considering that intervention works on the excess weight are rare and not very significant compared to the prevalence and complexity of the problem of obesity in our country⁽¹⁷⁾, and also the fact that having a chronic disease like obesity, tends to limit the social insertions, due to the way individuals perceive it in their lives, but even obese, when they have help and support of people of their social and family conviviality, may accept, live with and cope better with the disease and its limitations⁽¹⁸⁾.

FINAL CONSIDERATIONS

Obesity causes changes in the habits of the individual and the environment in which he lives and in many cases is associated with negative feelings such as dissatisfaction, avoidance of social interaction, loss of self-esteem, depression, and fear of prejudice; factors that influence motivation and ability to cope with his own body. Even aware of their situation and often holders of information about the importance of health care, not always these individuals are able to put them into practice. Changes in habits are only possible when one understands the genesis of obesity and the effect of different actions on him and he receives support, guidance and resources that enable him to promote these changes.

Thus, coping with obesity and feelings related to it and the way an obese person perceives himself in the world can occur more efficiently when in a group. The statements show that coexistence among obese people favors self-acceptance and the development of positive feelings towards the difficulties encountered in daily life and interpersonal relationships. This emotional understanding can promote greater security and improved self-image, acting directly on how this person sees the world and relates to people in his social environment.

Finally, it is noteworthy that group work is valid for nursing; because in addition to reducing costs and time to the care provided, it also offers greater opportunity for interaction between professional and client, reducing the vertical relationship between the two. These benefits are exaggerated in cases of chronic diseases, in which are required adherence to pharmacological treatments and changes in lifestyle and the way of perceiving the disease.

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Received: 05/14/2011

Approved: 10/27/2011