Brazil is a huge, diverse country with significant social disparities. People are commonly judged and stigmatized due to their social class, race, education, gender, and body characteristics. Weight, particularly high weight, is one of the body characteristics that is used to stigmatize parts of the population, often intersecting with race and class. Similar to other parts of the world, the fat body in Brazil is seen as synonymous with ‘failure,’ ‘lack of control,’ ‘laziness,’ and ‘ignorance.’ Low-income classes believe that weight gain is related to heredity or stress, while high-income classes, especially those who are not fat, blame ‘poor’ diet and exercise choices. In reaction to this last point, the Brazilian government has propagated strategies to combat weight gain based on self-control, seeking to ‘teach’ people (especially low-income groups) how to eat, live, and be healthier.
In late 2020, the Brazilian Ministry of Health started developing a new clinical protocol for ‘obesity,’ the “Clinical Protocol and Therapeutic Guidelines for Overweight and Obesity in Adults” (Protocolos Clínicos e Diretrizes Terapêuticas para Sobrepreso e Obesidade em adultos). In an updated version, the protocol was the first to address weight stigma, its impact on the health of individuals, and the responsibility of health professionals in promoting weight stigma. This was a legitimate and innovative move, given that the previous protocols had never addressed stigma and were rather interested in individual responsibility.
As a nutritionist, I knew the importance of these clinical protocols (also called ‘guidelines’) in the day-to-day processes of health services and in the education/training of health professionals and students. Guidelines are a raw expression of how the biomedical field understands and approaches certain conditions/diseases; they have a great impact on the way patients are treated in health services. So, when I saw that a clinical protocol for ‘obesity’ was being written, I started to follow its development process, looking for possible controversies that could arise along this production.
The development of a clinical protocol has several phases and involves different actors. Internal areas of the Ministry of Health evaluate the need for the protocol and then order the production of the document. In this first phase, the questions that guide the research and the content of the protocol are defined, as well as the technologies (drugs and other treatments) that must be evaluated for a possible incorporation into the health system. Social participation is a fundamental point in Brazilian public health, so these guiding questions are published on a website so that the public (patients, health professionals, medical associations, companies, among others) can give their opinion and suggest modifications. This step is also known as public consultation and occurs at different stages in the development of a health policy. After the questions are defined, research begins, technologies are evaluated, and a preliminary text is written. This preliminary text goes through another public consultation, where the contributions are read by a committee, which decides whether to incorporate the modifications or not. After this step, the document is redrafted, to be discussed in a meeting of the ministry and, finally, published.
During this process, I observed two main controversies: the first was related to the pathologization of fatness and the use of the Body Mass Index (BMI) as an appropriate diagnostic criterion. The second was related to the rejection of weight-loss drugs by the Ministry of Health. In order to study the controversies, I analyzed the contributions made by healthcare professionals and patients on the protocol during the public consultation phase. In addition, the controversies are also based on the different perspectives and aims of biomedicine on the one side, and Fat Studies and Critical Weight Studies on the other side.
The clinical protocol in question chooses to define ‘obesity’ as a chronic condition that can be easily diagnosed through the BMI. The BMI, according to the protocol, is an “easily applicable and low-cost method” that allows the “classification of the nutritional status and the definition of therapeutic measures,” used as a “substitute measure of body fat in clinical practice” (translations are provided by the author). The BMI, however, is strongly criticized; Fat Studies scholars and healthcare professionals have discussed its questionable source and point out its limitations. Consequently, its use is not a consensual practice in healthcare. This became clear during the public consultation phase. After health professionals pointed out the limitations of this diagnostic tool during public consultation, the committee added a note saying that health professionals should make a “careful judgment of the meaning of this measure” to the final version of the protocol. Yet, they don’t say how this “careful judgement” should be done in practice.
During the protocol development process, the writers adopted the BMI because it is a fully established practice in medicine and healthcare. Similarly, the doctors and patients consulted in this process never questioned its use in a significant way. Despite the growing criticism of the pathologization of fatness and the BMI, those who operate in the biomedical field – the dominant system of determining health – cannot imagine any other way of looking at the fat body. The authors of the protocol propose the “careful judgment” of the BMI because they know the limitations of the index, yet they still choose to use it, leaving the responsibility of interpreting this data to health professionals. It is clear that the writers don’t know how to judge carefully; judgment is still a classification that reinforces weight stigma.
The second controversy is related to the use of weight-loss drugs to ‘treat’ fatness. Brazil has a long history of using weight-loss drugs. For many years now, these drugs have been going through a political and regulatory up and down: They are sometimes released for sale and sometimes banned from the market. This happens mainly because of the political pressure that medical associations and parliamentarians apply on the decisions of the Ministry of Health, which is against the commercialization of these drugs.
During the first meetings of the protocol committee, the members chose to evaluate the safety and efficacy of two drugs – sibutramine and orlistat – for a possible incorporation into Brazilian healthcare. If incorporated, these drugs would be available for free. After an extensive evaluation, the Ministry of Health decided not to incorporate or recommend them, considering their low efficacy and safety, which left health professionals, medical institutions, and some pharmaceutical companies very dissatisfied. As a result, these groups carried out campaigns to promote the public consultations, so that the public (patients and doctors) could comment in support of the use of these drugs. These comments, in general, were against the decision not to recommend drugs for weight loss, arguing that their use is safe and that this decision ultimately harms the healthcare system. The Ministry of Health maintained its position to not recommend the drugs, but is currently under strong pressure from medical associations and parliamentarians to change this decision and recommend the drugs.
These two controversies show that the development of a clinical protocol is expressive of social power structures and can lead to disputes based on the participants’ knowledge. The great majority of the participants in the public consultation phase were health professionals: white residents of the Brazilian Southeast – a wealthy area of the country. Despite consulting the population, the committee ended up listening to those who are responsible for promoting fat stigma and prejudice. Other ways of understanding fatness were not considered. Instead, the authors only superficially promoted an anti-stigma discourse by admitting to the impact of stigma on the health of fat individuals, in order to avoid their own responsibility in maintaining the stigma. In reality, effective changes against weight stigma are not offered in the protocol. In the future, the medical community will have to invite fat people to participate in the development of these protocols in order to actually offer humanized and integral healthcare, two very important values in the Brazilian public health system.