RESEARCH ARTICLES

Body perception among women with diabetes mellitus and obesity

Valmir Aparecido de Oliveira^I; Manoel Antônio dos Santos^II; Nájela Hassan Saloum de Andrade^III; Carla Regina de Souza Teixeira^IV; Flávia Fernanda Luchetti Rodrigues^V; Maria Lúcia Zanetti^VI

^I Psychologist, Master's Degree in Science of School of Nursing of Ribeirão Preto, University of São Paulo. Ribeirão Preto, São Paulo, Brasil. E-mail: valoliveir@usp.br
^II Psychologist, Associate Professor of Faculty of Philosophy, Sciences and Letters of Ribeirão Preto, University of São Paulo. Ribeirão Preto, São Paulo, Brasil. E-mail: masantos@ffclrp.usp.br
^III Nurse, PhD in Nursing of School of Nursing of Ribeirão Preto, University of São Paulo. Ribeirão Preto, São Paulo, Brasil. E-mail: najela@usp.br
^IV Nurse, Associate Professor of School of Nursing of Ribeirão Preto, University of São Paulo.Ribeirão Preto, São Paulo, Brasil. E-mail: carlarst@eerp.usp.br
^V Nurse, PhD in Nursing Student of School of Nursing of Ribeirão Preto, University of São Paulo. Ribeirão Preto, São Paulo, Brasil. E-mail: flavialuchetti@gmail.com
^VI Nurse, Associate Professor of School of Nursing of Ribeirão Preto, University of São Paulo. Ribeirão Preto, São Paulo, Brasil. E-mail: zanetti@.eerp.usp.br

ABSTRACT

This qualitative study aimed to understand how obese women with diabetes mellitus perceive their body. The eight participants were interviewed at a primary health care service in Ribeirão Preto, São Paulo, between March and July 2009. The Merleau-Ponty perspective on body perception was used as a theoretical framework. The category developed from analysis of the testimonies was: the obese body endowed with meaning and intentionality, comprising three subcategories: the body as something shameful, uncomfortable, limiting, a living hell; the body as a means of expressing feelings and of defending against affect; and the obese body is perceived through clothes, pains and tiredness. The data reveal that participants attribute intentionality and negative meanings to the body. This points to the health professional's role in favoring a way of seeing that approximates the participants to self-care, strengthening their sense of autonomy and responsibility towards their own bodies, enabling them to take ownership of their 'phenomenal body'. Keywords: Diabetes mellitus; obesity; perception; qualitative research.

INTRODUCTION

Advances and investments, both clinical and behavioral, have increased strategies for controlling diabetes mellitus (DM)^1-2. However, people who live with the disease are at greater risk for social isolation and difficulties in maintaining daily activities; they often perceive life as something threatening and build disruptive social relations, which may disintegrate due to stress triggered by the management of the disease. The disease tends to reduce the ability of afflicted individuals develop and maintain a network of encouraging social relations, modify perceptions and behaviors in daily life ^3-6.

Another difficulty in the control of DM refers to the maintenance or reduction of body weight⁷. This difficulty is related to inappropriate eating habits and to lifestyle, which are influenced by psychological factors. Therefore, such factors are crucial for the development of risk factors associated with both obesity and DM⁸. The presence of DM may lead to alterations in body perception and, when attended by other comorbidities, such as obesity, this result can be maximized, bringing consequences for self-care.

In the literature review in nursing and psychology areas, studies on the understanding of body awareness in people suffering from DM have been identified. They warn about the need to change the focus on health, embracing the man in full and able to make the adaptations according to the needs raised by the disease^9-13.

However, there are still few studies that address this perception in people who, besides presenting DM are obese. It is known that women have a higher risk of developing overweight and obesity compared to men¹⁴.

When considering the experience of the authors of this study, as members of the multidisciplinary team, which showed the need to include the perception of the body as part of the care of people with DM aiming comprehensive care, the present study aimed to understand how women with type 2 DM (T2DM) and obesity perceive their body. It is hoped that this study will bring contributions for the health care providers to incorporate other dimensions of health care, in addition to pathophysiological issues, to women with DM and obesity.

THEORETICAL REFERENCE

To understand how women with T2DM who are obese perceive their body, the theoretical reference of the Phenomenology of Perception Merleau-Ponty was chosen. For this author, human being perceives things through their body. It is through an immediate awareness of its own body that a human being exists outside the self. The human being does not have a body, but he is a body, an interaction of being that goes beyond the body-mind dichotomy and the relativity of being seen as an object¹⁵. The body is understood as a structure that has meanings and intentions are not merely the result of a mechanistic procedure of cause and effect. Thus, for Merleau-Ponty it is necessary to consider the intentionality of the body and its relations with the environment and experience the original creator of meanings. The perception of body underlies all reflexive activity of human knowledge; it is through bodily experience that the relationship between the world, human beings in the world and the body in the world is understood from its facticity¹⁶.

In this perspective, T2DM and obesity can be included as facticities that promote significant changes in the daily lives of people who did not choose to experience these diseases. In these situations, the body must not be understood as a mere organic object and receptacle of ideas in the world, but as the lived body¹⁶. In this sense, the body is space and time, it is sensitivity, expression, speech, it is language. It is through the body – and hence the language – that human beings, before its facticities, remain in constant contact with each other, i.e., is a being-in-world-with-others ^17-18.

METODOLOGY

This is a qualitative study using the phenomenological framework. To investigate the phenomenon of how women with T2DM and obesity perceive their body, we focused on the perspective of those who experience it. Thus it was aimed to unveil the universe of meanings, motives, aspirations, beliefs, values ​​and attitudes that women attach to their body. According Phenomenology, when working with certain phenomenon, it is considered that the object under study does not exist in itself, but always in relation to the subject who experiences it¹⁹.

The study setting was a Primary Health Care Service in São Paulo state, Brazil, in 2009. This service attended 43 adult women with T2DM, and eight women who met the inclusion criteria of the study were interviewed. The inclusion criteria were: to present Body Mass Index BMI>30 kg/m^2,20 and preserved ability to establish dialogue and communication.

Phenomenological interview resources were used as instrument for data collection. It was an open interview with the following guiding question: "How do you feel about your body?" Demographic and clinical data were obtained from the health record. A first contact was made, and two participants were invited by phone and six through personal approach. Participants were informed about the nature and objectives of the study, the assurance of confidentiality and anonymity, and after signing the Informed Consent Form, data collection began.

The open interviews were conducted individually, in face to face situation, in a private room of that service, from March to July 2009, according to participants' availability. The interviews were audio recorded and the mean duration was 46 minutes. As the assumptions of phenomenological investigation, it was sought to apprehend, in every interview, beyond speech, non-verbal language in its complexity as well as the expressivity of gestures, the tone of voice and silences¹⁹. So it was from the unique experience of each participant that the reports that composed the analysis corpus were obtained.

The interviews were transcribed verbatim, respecting the lines, pauses, expressions and intonations. Subsequently, reports were identified with sequential numbering of interviews (E1, E2 ... and so on), in order to preserve anonymity. Following transcription of each interview, it was held the stage of phenomenological analysis of statements¹⁷ with a thorough reading of all the testimonies of the participants, identifying meaning units, preparation of synthesis by constructing thematic categories and the interpretation of them through the lens of Merleau-Ponty's Phenomenology of Perception ¹⁹.

The research project was approved by the Research Ethics Committee of the School of Nursing of Ribeirão Preto, University of São Paulo, Brazil, in compliance with Resolution 196 of the National Health Council, protocol number 0871/2008.

RESULTS AND DISCUSSION

The women were aged between 40 and 60 years old; four were married, two were single, one widow and one divorcee; the predominant schooling was completed elementary school; four performed paid activities, two were retired and three were housewives; family income ranged from one to six minimum wages. The time since diagnosis ranged from one to 18 years, with the majority of participants having no more than 10 years. Three took insulin, six took oral antidiabetic medicines (of these, three used insulin and oral medication combined), and one was not taking medication for DM control.

The analysis of the empirical material enabled the elaboration of thematic category: The obese body endowed with meaning and intentionality, comprising three subcategories: The body as shameful, uncomfortable, limiting, disproportionate, hell in life; The body as a means of expressing feelings and defense in relation to the affections; The obese body is perceived through the clothes, the pains and tiredness . These subcategories point to the perception of the body of women with T2DM and obesity.

Next, we present the analysis of each subcategory drawn from the testimonies of women with T2DM and obesity.

The body as shameful, uncomfortable, limiting, disproportionate, hell in life

In this subcategory, the lines reflect an intentionality and meaning of the body that are incongruent with the lived body, as follows:

I do not like fat, no. Even in this situation, I have never got used, ok? [gives laughter] But I say: fall sick with a disease to get bony? (E1)

The speech of the participant can be understood as a result of the internalization of aversion to obesity, leading to the rejection of its lived body. The presented testimony reminds us of the difficulty of getting used to the fat body, incorporating it into the body schema. For Merleau-Ponty¹⁶ get used to is to install something and make it part of our body schema – in this study, it involves taking possession of the obese body. Habits show the ability of the Being to expand in the world or to change existence incorporating to the body new instruments or potential¹¹. This paradox between idealized and habitual body points to the existential movement, need to adapt to current obese body, seeking its own ways of inhabiting the world.

On the other hand, the testimony of E1 reveals discomfort generated by fear of thinness as an expression of the disease process. The perception that the participant has obesity leads to the reflection that the body becomes problematic when it is perceived as an object, something belonging to the external world in which one lives, and not being itself.

In this direction, the lines below show the perception of the body as something shameful, uncomfortable, limiting, heavy, tired, poor, disproportionate, disturbing, a hell in the lives of participants:

Because the only thing I feel unhappy in my life is with this body. With this hell. [...] Today I do not even like to put some lipstick. It is the number one women's vanity. I think that if I put it, I get fatter, you know? In my heart I have this complex. (E2)

I do not wear dress. Shame, right? I'm 17 kg overweight. So it is already a lot to me, is not it? I feel bad, I do not even like to look at myself in the mirror. I think I'm out ... with a huge, disproportional trunk. (E3)

[...] but I do not like being fat. Fat leaves us heavy, without coordination to do things, very tired. (E1)

The testimonies of the participants unveil the ignorance that every body carries the markings that tell its life story, i.e., a drama which can express itself in words, actions, feelings, sensations and contacts. Several plots coexist inside the body. These plots were enrolled over processes and biological, psychological and social pathways that give meaning to the experiences of pleasure and displeasure, unity and fragmentation, destruction and repair. When these experiences are not integrated, the body becomes ignorance and is systematically denied²¹. The participants expressed the perception of their own body through the use of words with strongly negative connotation – embarrassing, uncomfortable, limiting, heavy, fatigued, disproportionate, disturbing, producer of unhappiness in life. These negative expressions depreciate their physical and psychological integrity, referring to threatening experiences that elicit feelings of unhappiness, helplessness and depreciation, which helps to consolidate a low self-esteem.

The process of knowledge construction necessarily involves the body. Thus, obese women with T2DM grasp the world through a body perceived as uncomfortable, limiter and disproportionate, of which she is ashamed. Considering that our existence is eminently bodily, subjectivity of these participants is built supported on a strongly rejected body that raises sufferings, instead of being perceived as a source of pleasure and contact with the surrounding world. Health professionals should be aware of this uniqueness in the construction of corporeality, identifying their strengths and limitations, their gains and losses at different stages of life cycle, i.e., should help women to realize their body from what it was, what is ceasing to be and how they would like it to be²².

It is inferred that the feelings expressed by the participants may reveal a lack of projects in their lives. In this scenario, body care is regarded as irrelevant in their experiential processes. In phenomenological framework, the body is the vehicle of being in the world. To a being, having a body is to join a defined environment, to be involved with certain projects and strive continuously on its behalf¹⁴. Thus, the process of bounding to its own projects will enable the participants to find the anchorage of its integrity, becoming aware of its body connected to the world.

The body as a means of expressing feelings and defense in relation to the affections

The lines below show that the body is also perceived as a means of expression or defense in relation to the affections. So, it is meant as part of themselves and a means of protection against the outside world.

Because being fat at the time of adolescence or young adulthood was a protection. It was a way to protect myself from the world, people, is not it? (E4)

It became a fellow of affectivity [speaks very low]. This is, well ... it is [...]. At first, you start to think it is a defense. It involves us with no truce... (E5)

The speeches of the participants unveil that their relationship with the obese body has meanings and intentions, including its dual role of serving both as a vehicle for expression of feelings as protective shield regarding affections. These meanings and intentions are unique, belonging only to each participant and thus each participant satisfies, in its own way, the need for expressiveness of their body before the unique situations they have to face. Thus, there is the essentially body notion of the expression, in which body expresses a body behavior and, at the same time creates its direction by means of a practical intention, thereby performing communication with the world in which it lives²³.

Body is space and time, and also producer and conductor of meanings and senses. It is through the body that the participants inhabit the world, conceiving themselves as a body in the world. The subject of perception is the body, not the consciousness conceived separately from lived experience anymore ¹³. The body is perceived as a source of senses and significance of the relationships of the subject in the world and in its structures with the things around the subject. In Merleau-Ponty's Phenomenology of Perception framework¹⁹, this relationship with the world is viscerally corporeal and always significant¹⁶. Words have corporeality, since the language is understood as a means of communication whose signs reflect the culture of which the being is impregnated.

Thus, body needs to adopt a language as a form of expression that is established early, before the acquisition of own speech. Much more than just occupy a space in time, the body of participating causes and reflects a range of brands and implied lines, which refer to a mesh of meanings²⁴. The expressions of the meanings referring to the body reveal its relations with the world, as being in the world and with each other in the world. I.e., the body articulates an implied speech, as an expression of affection and defense. In this direction, the body can translate the experience of participants facing adversities of the disease as part of their being in the world.

The obese body is perceived through the clothes, the pains and tiredness

On the speech of the participants, the body is perceived through the clothes – whose measures no longer adjust to new forms as well as through the pains and tiredness, denouncing the existence of a mismatch in the way of experiencing the usual body.

I see the clothes I used to have. There is a difference of an inch. They do not fit me, it is horrible, sad, very sad. I feel bad to get dressed, there are no clothes. (E3)

Because, on the one hand, the weight was there, it was terrible for me to get dressed. [...] This obese body today is a hindrance to my health. (E4)

In my heart I have this complex. And every time I will try an outfit in a store, then I make it an exact month regime. [...] I get so disgusted with the clothes, nothing fits well. (E2)

All you do is tiring. I feel pain in the legs. Pain everywhere... (E5)

It is noted a painful realizing that there was a progressive change in weight and body shape over the course of years, without the participants have been able to get used to this new condition. Thus, it is not possible to (re)elaborate life. An adaptation to the phenomenal body can happen in a positive or negative way. Realizing the obese body, the person verifies that lost its previous world and can react with authenticity or inauthenticity. By denying its possibilities, trivializing everyday life and excluding perspectives for a better future, the person is moving away from itself and from the possibility of introducing a true and full meaning of existence. In this posture the person can build their own sense of being-in-world-with-a-disease, which allows it to take ownership of its new body and develop a new sense of the world which can be inhabited¹⁶.

The limitations imposed by the fat body also impose barriers in loving relationships and in professional and personal projects. This may limit efforts to renew its strength in spirit¹⁶. The new perceptions replace the old ones, as well as the emotions. But this renovation concerns only the content of the experience and not its structure, because the impersonal time continues to flow, while personal time is retained¹⁶. Each individual chooses in its past that which allows them to make sense of the present. Merleau-Ponty emphasizes that each subject assigns a meaning to its life and it is not designed or premeditated, but comes spontaneously from the past and present in their coexistence. The body needs to understand the factuality of weight gain to enable human existence through another existential movement to get used to this new body, so the subject can incorporate new habits and change its lifestyle. Habit is to show that the body learns and expresses a form of body automatism. Our body is open to real and imaginary situations. The habit starts an existential movement that is at the same time, bodily and spiritual¹⁶.

The perceived limitations in the body are endowed with meanings that reflect the mind-body dichotomy that is, the dualism of cultivating the desire to have a slim body, but hardly mobilize to achieve this goal - it requires tolerance to frustration and adoption of disciplined habits life. Thus, the participants face the dilemma between the desire to have a slim body and a lack of willingness to adopt behavior changes that would achieve their goals. For the person with diabetes, the body is often interpreted and presents itself to consciousness as a mechanistic body, experienced as merely a reflection of physiological or material processes. A body-machine, which would act as a sophisticated laboratory of biophysical processes. From the point of view of Merleau-Ponty framework, the body is only perceived by the sensation it provides each person. This sensation is only noticeable in terms of individuality, and nobody else has access to that process and to the concrete experiences that every body performs. Thus, the awareness one has of its own body is inaccessible to the other, as well as impervious to representing how the other feels its own body²⁵.

It is noticed in the reports that the bodies of participants, aggregate meanings and intentions that lead to an experience dissociated between body and mind. Such meanings are expressed by psychic movements that reveal their particular body perception, in which the body is a source of intense displeasure and distress. Before this process, it is the multidisciplinary health care professionals obligation to keep an open eye to the perception of corporeality revealed by women with T2DM and obesity in order to help them realize the body as a source of pleasure and supporter of its being in the world, through the emotional, professional and personal relationships.

CONCLUSION

Data analysis allowed the elaboration of three thematic subcategories: The body as shameful, uncomfortable, limiting, disproportionate, hell in life; The body as a means of expressing feelings and defense in relation to the affections; The obese body is perceived through the clothes, the pains and tiredness . These subcategories in turn, make up the thematic category: The obese body endowed with meaning and intentionality.

The results revealed that participants perceive the body with obesity from their own meanings. The corporeality is constructed within its space and time, laden with ambiguities that will permeate its very existence as corporeality inscribed in the world. Thus, the body is sometimes perceived as a means of contact with the surrounding world and vehicle of expression of feelings, and sometimes it is experienced as a protective barrier in relation to disruptive emotions. It is through the spatiality of their body that participants understand the actions that are processed inside it, opening up to a new attitude to life after illness or closing itself for new possibilities presented by the very existence. This can lead women with T2DM to adopt attitudes towards or distance in relation to treatment. As the body is perceived as an object – external to the self, self-care actions can be compromised.

Understanding women with T2DM and obesity demands understanding them in particular how they constitute their corporeality. The lack of understanding of corporeality by health professionals perpetuates the dichotomy body and mind in the health-disease-care process, leading to reduced perception of the person as a self-limited, fragmented, mortified and carrier (in the sense of mere receptacle) of a body chronic disease. In this direction, the body is taken care by health professionals as the host of a disease that inhabits a person. It is no longer seen as a lived body, but as an object-body, full of illness.

In this context, the healthcare team can (re)define their attitudes in order to implement practices that intensify the appreciation of the meanings, feelings and body language. In the scenario of diabetes care, professionals need to recognize the internal psycho processes of women with obesity, approximating them of self-care practices that enhance the acquisition of autonomy and responsibility for their own bodies. Thus, the appropriation of the phenomenal body by women would be facilitated. In the dialogue between participants and health professional, when speaking and listening are incorporated as part of the bonding process, this can constitute fruitful path towards change in care in diabetes.

The limitations of the study consists the fact that this investigation was carried out in a restricted scenario of a single Primary Health Care Service, considering that the sample could be extended to contexts of private services and other cities, enabling grasp how obese women with T2DM from different social classes and geographic location, with or without access to health plans, perceive their body.

It is hoped that this study will foster reflection of nurses in order to broaden perspectives in relation to the perception of the body of women with diabetes and obesity, moving the body as strictly biological object to the lived body.

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