The hyperphagic experience in obesity: a phenomenological study of French and Brazilian contexts

A experiência hiperfágica na obesidade: um estudo fenomenológico nos contextos francês e brasileiro

Abstract

This article aims to understand the hyperphagic experience in the obesity of patients in the French and Brazilian contexts. Using the critical phenomenological method, twenty subjects were interviewed in health services in Paris and in Fortaleza. We note an objectification and expropriation of the body often experienced in the hyperphagic experience in obesity. We highlight the emphasis on health in the French context and on form and aesthetics in the Brazilian context. In Fortaleza, there seems to be a more evidenced discrimination in relation to obesity and a pathological discourse, whereas in Paris this pathologization is viewed from a critical position regarding the treatments. We conclude that the hyperphagic experience in obesity reveals a subject who is often lost in his/her way of being and having a body, and that clinical work must involve the re-appropriation of this body and the recovery of the condition of the autonomous subject.

Keywords
Eating disorders; Hyperphagia; Psychopathology

Resumo

Este artigo tem como objetivo compreender a experiência hiperfágica na obesidade de pacientes nos contextos francês e brasileiro. Utilizando o método fenomenológico crítico, 20 sujeitos foram entrevistados em serviços de saúde de Paris e de Fortaleza. São evidenciadas a objetificação e a desapropriação do corpo frequentemente vividas na experiência hiperfágica na obesidade. No contexto francês, destaca-se a ênfase na saúde e, no contexto brasileiro, a forma corporal e a estética. Em Fortaleza parece haver uma discriminação em relação à obesidade mais evidenciada e um discurso em direção à patologização dessa experiência, enquanto que em Paris essa patologização é revestida por uma posição crítica em relação aos tratamentos. Conclui-se que a experiência hiperfágica na obesidade revela um sujeito, muitas vezes, perdido em seu modo de ser e de ter um corpo e que o trabalho clínico deve envolver a reapropriação desse corpo e a recuperação de sua condição de sujeito autônomo.

Palavras-chave
Hiperfagia; Psicopatologia; Transtornos alimentares

Eating disorders have become an increasingly important issue in public health worldwide. According to the Diagnostic and Statistical Manual of Mental Disorders (5^th edition), the main clinical entities defined by psychiatry and frequently used as references are: anorexia nervosa, bulimia nervosa, pica, rumination disorder, Avoidant/Restrictive Food Intake Disorder and binge eating disorder (hyperphagia) (American Psychiatric Association, 2015). Considered the most common eating disorder (Guerdjikova, Mori, Casuto, & McElroy, 2017), hyperphagia can be characterized by loss of food control and significant food intake. Hyperphagic episodes may be present in anorexia, bulimia, obesity and also occur in isolation without necessarily meaning any pathological condition. However, systematic repetition associated with guilt after overeating leads to the diagnosis and is only officially recognized in the Diagnostic and Statistical Manual of Mental Disorders (5^th edition). It is an experience marked by intense and repeated acts related to food and refers to a subject who cannot not eat (Bloc, Pringuey, & Wolf-Fedida, 2018).

In obese patients with hyperphagia, there is a tendency of responding to emotional states by eating, as well as feeling suffering and distress in relation to the body image, manifestations often absent in non-hyperphagic obese individuals. Therefore, hyperphagia appears as a subcategory of the obese population (Da Luz, Hay, Touyz, & Sainsbury, 2018). There is a propensity to increase the prevalence of hyperphagia in obese patients undergoing treatment for weight loss (Agüera et al., 2020; Villarejo et al., 2012). Although estimates in the prevalence of hyperphagia range from 4% to 8% in the general population, it can reach 30% in patients undergoing weight loss treatment, which makes obesity an important comorbidity (Da Luz et al., 2018). These two percentages above show that a very large number of people suffer from hyperphagia, which also urges us to take into account the different cultural contexts in which this experience is presented.

Obesity, a global public health problem (Poutier, Ung, Delhumeau, Hamidi, & Salle, 2017), is a complex and multifactorial phenomenon. According to a large study published in 2016, 13% of the world population is obese (NCD Risk Factor Collaboration, 2016). In the two cities where this research was carried out, the obesity indexes show a significant epidemiological difference. In Fortaleza, Brazil, the population’s obesity rate is 19.2% (Ministério da Saúde, 2017). In Paris, France, obesity is at 10.7%, a number below the world average (Matta et al., 2016). Hyperphagia associated with obesity presents a psychopathological dimension to this phenomenon which needs to be better investigated.

The purpose of this article is to understand the hyperphagic experience in the obesity of patients in the French (in Paris) and Brazilian (in Fortaleza) contexts. Using cross-cultural and phenomenological research, we aim to reveal, from a first-person perspective, the different meanings of the hyperphagic experience in obesity. To understand this experience as way of being, we use the contributions of phenomenological psychopathology and the phenomenological position that eating disorders are an epiphenomenon of a deeper change that involves the way in which people experience their own bodies and shape their personal identity (Castellini, Trisolini, & Ricca, 2014). The phenomenology of Merleau-Ponty serves both as inspiration for the methodological construction and as a contribution to understand the body dimension that undergoes the hyperphagic experience in obesity.

Method

The phenomenological method proposes to access the lived experience of the subject from the narrative of experience. We use the critical (or mundane) phenomenological method proposed by Moreira (2004, 2016), based on Merleau-Ponty’s phenomenology as a way of accessing hyperphagic experience in obesity.

Participants

Twenty interviews were conducted, ten with Brazilian citizens living in the city of Fortaleza or in the metropolitan region, and ten with people living in or around Paris. In Paris, the interviews were conducted at the Department of Obesity Medicine of the Pitié-Salpêtrière Hospital. In Chart 1, we present a brief description about each French participant and their eating experience.

Chart 1
Brief description of the participants in Paris

Name	Age	Brief description about the eating experience of participants in Paris (France)
Jacques	59	Jacques has had weight problems all his life. He feels unable to stop eating and recognizes that his eating behavior is a repetition of what he experienced with his family in his childhood.
Isabelle	52	Isabelle is married and gained weight after her second pregnancy. The act of eating is a way of compensating for the negative consequences that happened to her.
Karine	59	Karine says she forgets about her weight problems frequently. She admits to having accepted her physical condition but, at the same time, she desires to change her physique. She sometimes believes that she needs to lose control of her act of eating, which is seen as synonymous with freedom for her.
Anne	57	Anne has always had weight problems. She feels fat, but she sees herself as an obese person, because she thinks that obesity corresponds to a pathological dimension. The hyperphagic episodes occur frequently giving her some concern.
Lisa	47	After 25 years of obesity, Lisa considers that her weight gives her a status and it constitutes a kind of protection and strength – a way to face life. On the one hand, she says she gorges herself and on the other, she eats feel relief and to fill a kind of hole she has.
Marion	52	Marion started to gain weight after her first pregnancy. She recognizes that she has let herself go more and more, without paying any attention to herself, especially aesthetically. According to her, eating fills her, but then she feels very bad. She thinks she has an addiction due to her hunger, which constantly occurs.
Pierre	42	Pierre has presented obesity since his childhood. He was born in Portugal, where she lived all his childhood. He thinks he had a bad nutritional education. Nowadays, the malaise with his body is mainly related to consequences of obesity. According to him, his body presents a visible defect and causes a real “mental problem”.
Dominique	44	Dominique feels “substandard”. She lost confidence in herself and does not recognize herself in the image she reflects. She thinks gorging is a solution to cure her malaise and a way of hiding her suffering.
Marine	45	Marine went to the medical service because she gained weight. She finds comfort while eating and has difficulties in having contact with her own body, listening to it and recognizing her physical condition and the needs of her body. For her, it is a strange body with which she can not feel its limits. There is the sensation of an emptiness she tries to fulfill through food. During the binge eating episodes, she says she can eat even if she does not like something very much.
Louise	62	Louise emphasizes that questions of obesity, weight and the act of eating have always been problems for her since childhood. Her bariatric surgery in 2013 changed her eating habits and her body. The binge eating episodes are described as an invasion of her desire to eat followed by feelings of guilt. There is a difficulty to feel her body and a sensation of emptiness she tries to fulfill.

• Note: Pseudonyms have been used to preserve participants’ privacy.

In Fortaleza, five interviews were carried out at the Interdisciplinary Program on Nutrition for Eating Disorders and Obesity, a service created by the University of Fortaleza, and five at Treatment Center for Eating Disorders, which is based at the Federal University of Ceará. In Chart 2, we present a brief description about each Brazilian participant and their eating experience.

Chart 2
Brief description of the participants in Fortaleza

Name	Age	Brief description of eating experiences of participants in Fortaleza (Brazil)
Maria	65	Maria had an experience of abandonment by her husband who left her with two children. She associates her attachment to food to the experience of abandonment. For her, the act of eating is a way to release herself from something, “a shelter”. Nevertheless, food became a means of suffering as well.
Joaquim	28	Joaquim has presented obesity since childhood. He decided to start a treatment when he realized he was excluded from job interviews because of his bad mobility related to his excessive weight. He is conscious of his bad eating habits and binge eating episodes. He desires to change his eating habits very gradually, without adopting radical measures.
Claudia	40	Claudia started to suffer with her obesity when she felt disturbed by her appearance and the discriminatory looks from others. She became an anxious person. She tries to fulfill her emptiness and to relax while eating. Even if she feels well during mealtimes, she describes a feeling of guilt followed by excessive food intake and loss of control during the act of eating.
Nicolas	25	Nicolas did not see himself as an obese person before suffering clinical consequences of obesity. He thinks the act of eating is something so natural that he sometimes does not even realize that he is eating. He realized that he was having binge eating episodes only when there was no more food in front of him.
Helena	35	Helena feels bad about the looks from others, full of disregard. She feels a constant fatigue. She has a bad image of herself and suffers depression, which is treated with psychotropic medicines. Despite her reluctant relationship with food and her desire to lose weight, eating is an act which gives her pleasure and relief.
Sara	50	Sara associates her weight problem and excessive food intake with anxiety. When she feels anxious, she can eat “without realizing” and without having any control over food intake. She thinks she is “addicted” to food.
Laura	34	For Laura, food is the “whole” to which all feelings are directed. Concerning her malaise generated by the loss of control in eating, she says: “it’s something stronger, I can’t say no”. For her, she needs to feel a burden in the stomach so that she stops eating.
Monique	31	For Monique, obesity is a new experience. She talks about experiencing feelings of strangeness while her body undergoes its change and weight gain. She does not recognize her own body, but she says she is happy while eating and then feels sad with her physique.
Paula	40	Paula started to gain weight after the birth of her children. She also associates her weight gain with anxiety which started to be part of her life with motherhood. There are moments in which she eats in secret. She says she is: “eating to live”. She says there is an intense “force” that makes her eat as if there was another person inside her.
Rebeca	45	After a late pregnancy, Rebecca experienced major weight gain. She lived only for her son and she didn’t realize the change in her body. When she became conscious about her physique, she realized she lived in a body she didn’t recognize as her own body. Hyperphagic episodes were described as moments of despair. Eating is a kind of compensation and brings her a moment of happiness, but she feels guilty after food intake.

• Note: Pseudonyms have been used to preserve participants’ privacy.

Instruments

Semi-structured interviews were used with two basic questions which were asked in the search for the description of the experience: (1) What is it like for you to be obese? (2) What is it like for you to eat? The first question is about describing the experience of being considered obese, either by the patient or by others. The second question attempts to elucidate the actual experience of “eating”, how patients feel about this act, and to approach a possible description of the hyperphagic experience.

Procedures

For the selection of the sample, we adopted two strategies. The first was the dissemination of research to patients through interdisciplinary teams. The second was the indication of patients by professionals who, after being contacted, decided to participate in the research, and who used the following inclusion criteria: (1) to be over eighteen years old; (2) to be undergoing psychological and/or psychiatric treatment; and (3) actively participate in programs for the treatment of eating disorders or to be undergoing some kind of nutritional monitoring. As for exclusion criteria, we established the following: (1) pregnant women; and (2) patients ending treatment before the day of the interview or referred to another institution.

All the collaborating subjects spontaneously completed and signed the free and informed consent form. The interviews were all carried out in the institutions where the patients performed their treatments, by the same interviewer, in an adequate environment set aside for clinical interviews, each interview lasting an average of forty minutes. In regard to the ethical procedures of research with human beings, the guidelines of each institution and of each country were strictly followed. This research was approved by the Research Ethics Committee of University of Fortaleza in Brazil and is registered under the nº 59438216.6.0000.5052.

Data Analysis

The analysis of the interviews followed the phenomenological procedure proposed by Moreira (2004), with the research focused on psychopathology. The subsequent steps were followed: (1) Literal transcript of the interview; (2) Division of the transcribed interviews by themes using phenomenological reduction to put aside our own thoughts and interests, being open to any type of content or theme that could emerge in our research; (3) Descriptive analysis of the meanings emerging from the themes which are analyzed and structured around what we call phenomenological categories, divided into each context to facilitate understanding of the experience lived in each context studied; and (4) Comparative discussion, coming out of the phenomenological reduction: all ideas, prejudices and, in particular, the scientific discussions that we intend to leave aside are adopted with the aim of creating a dialogue of the experience of patients with the theoretical references. This discussion is made considering the two contexts investigated together, allowing a better understanding of the common and particular aspects of the hyperphagic experience in obesity lived in Brazil and France.

Results

The analysis of interview data conducted in Paris and Fortaleza allowed us to establish certain phenomenological categories about being obese and the hyperphagic experience. Chart 3 shows these categories and subcategories from clinical interviews in the two countries.

Chart 3
Categories and subcategories in France and Brazil

Categories and subcategories from clinical interviews in Paris (France)
Categories		Subcategories
1. Being obese: the body, the weight and the gaze of others		1.1. The “burden” and suffering of being obese 1.2. Body Experience in Obesity 1.3. Obesity as “visible defect”: the gaze of others
2. The Sense of Eating in the Hyperphagic Experience of Obesity		2.1. Eating for... 2.2.“After, we feel guilty” 2.3. Eating as an addiction
3. The experience of loss of control with eating 4. Hunger and Satiety 5. The family and the act of eating
Categories and subcategories from clinical interviews in Fortaleza (Brazil)
Categories		Subcategories
1. Being obese: malaise, suffering and (re)knowing the body		1.1. The malaise of being obese: the gaze of society and physical limitations
		1.2. “Being myself again”: estrangement and (non)acceptance of the body
2. The act of hyperphagic eating in obesity		2.1. Anxiety and the hyperphagic experience
		2.2. “Everything is in food”: roles in the act of eating
		2.3. “I cannot let myself be dominated by a plate of food”: excess and loss of control

From the interviews in Paris, five categories were built. In the first one, Being obese: the body, the weight and the gaze of others, the participants describe the body and its visible character, the gaze of others, weight and its consequences, as well as diets. The body is perceived, seen and judged. Having a “fat body” and “being obese” are two states that often produce suffering. In the second, The Sense of Eating in the Hyperphagic Experience of Obesity, we can see how the act of eating presents many meanings beyond its natural and everyday sense and we find an intersubjective way. The third, The experience of loss of control with eating, explores the meanings of hyperphagic episodes as an experience that exceeds the subject’s choice. In the fourth category, Hunger and satiety, the subjects interviewed talked a lot about body sensations and their changes as part of the hyperphagic experience. In the fifth category, The family and the act of eating, the participants in France mentioned how family relationships and their eating habits affect their current ways of eating. Chart 4 synthesizes these categories with some comments from the participants.

Chart 4
Examples of comments from clinical interviews in Paris (France)

Categories	Subcategories	Speeches
1. Being obese: the body, the weight and the gaze of others	1.1. The “burden” and suffering of being obese	“you cannot do what you want to do, you cannot move easily” (Isabelle).
		“it is mainly on the physical plane because, as I said, it unbalances everything, I feel very tired, this is mainly what irritates me, fatigue” (Marion).
		“Obesity seems really pathological […]. Heavy, negative, not having much character because it cannot resist temptations, weak, weak, very negative” (Anne).
		“I still have trouble pronouncing the word obese, because for me being obese actually represents a negative image” (Dominique).
	1.2. Body Experience in Obesity	“I gained weight so fast that it’s a new body, I do not recognize my body when I look at it. I don’t recognize it and I don’t think I accept it […]”the body has grown so much that I won’t necessarily be able to get through there”(Marine).
		“It’s strange, I know I’m fat, but I don’t feel it everyday, especially when I see photos” (Marion).
		“It makes me a statue, it strengthens me [...] I think it’s really a kind of protection” (Lisa).
	1.3. Obesity as “visible defect”: the gaze of others	“We all have a defect somewhere, mine is visible, my defect is seen. Most people have defects that you cannot see [...] my defect is visible” (Pierre).
		“It’s something that has weighed on me throughout my entire life, it’s been a daily suffering, the eyes of others, my own view of myself and, above all, the fact of being judged” (Louise).
2. The Sense of Eating in the Hyperphagic Experience of Obesity	2.1. Eating for...	“Sometimes it is necessary to fill, as if there was a great emptiness in me and a need to fill it by eating” (Marine).
		“It fills me, it fills me in a moment and then I do not feel good [...]. It’s just to stuff me, fill me up” (Marion).
		“the act of eating gives rhythm to the day. It is one of the points of passing, it is a social point of passing” (Jacques).
	2.2.“After, we feel guilty”	“After, we feel guilty, we tell ourselves, if you get fat, it’s your fault” (Marine).
		“And then, that guilt that also makes me see everything in a negative way. I say, “That’s it, I’m the worst of the worst, I’ve failed again, I’ve lost everything again, I’m worthless, I’m pitiful” (Louise).
		“Everything goes wrong because I feel guilty, but, at the same time, it is the only antidote I have found, it is the other side of the coin” (Dominique).
	2.3. Eating as an addiction	“Once I lapse, I have to finish. It’s addictive” (Anne).
		“It’s the worst addiction… It’s terrible because we have to eat to live, we don’t have the possibility of leaving it alone” (Lisa).
		“It’s a dependency, without a doubt [...]. You can control yourself for three days and then you can’t any more, there’s a more serious problem behind it” (Pierre).
	3. The experience of loss of control with eating	“I was completely out of control. Before, during, after... I was caught up by an irrepressible will to eat [...] all my thoughts were filled with what I’m going to eat” (Louise).
		“This emotion is stronger, this desire to eat, I have the impression that it is stronger than anything and I have the impression that it is uncontrollable”. She identifies it as an action that is due to her problems and negative thoughts. She is moved, or even hypnotized, by an irresistible urge to eat, like a zombie: “I’m so deep into my thoughts that I walk like a zombie practically [...] I’m so focused on my thoughts that the body does it automatically” (Marine).
		“During the act, in any way, I don’t feel that I can control myself by definition, I am not aware of it” (Jacques).
4. Hunger and Satiety		“I was never hungry. I’ve always eaten before, never been hungry. And I was never satisfied [...] I just felt like it, but hunger, I don’t know what it is. And eating enough, I don’t know what it is”. She continues, “I have always been a mass, a carcass, a mass. At the same time, a carcass and a mass, but never hungry [...] a block with a hole in the middle, an emptiness” (Louise).
		“my problem is the desire to eat, firstly, I’m often not hungry. My desire to eat, if I could spend my life eating, I think I would” (Pierre).
		“I ask myself: is it a craving for food or am I really hungry?” (Marine).
		“I think I had, that I have a problem, because I just do not feel any more, I have difficulty feeling hunger, satisfaction”. He believes that any improvement means going through the process of relearning to eat: “It is necessary that I relearn to eat again, I relearn my sensations, and so on. That’s really my goal” (Jacques).
5. The family and the act of eating		“It’s historic, because in my family, my father and mother had six children and have always loved family gatherings, table meetings, and when we go home they eat a lot [...] I think that we have, that there is a family relationship with food which is a little abnormal. It’s definitely an issue with my family” (Jacques).
		“For me, it’s usually almost a celebratory moment. And even when I was young, eating was the time to meet with the family” [...] “In my home it is also a time to find myself face to face with myself. I come from a family where everyone is very sporty and very skinny. Ultimately, I feel that I no longer belong to my family” (Marine).
		“In the family I’ve always been the ugly duckling, the one who’s not like the others [...] We were all around the table, the table was important to me because it was a way of getting together. When I went to Paris, I found myself alone” (Louise).

• Note: Pseudonyms have been used to preserve participants’ privacy.

The results of the clinical interviews in Fortaleza were organized into two categories. The first one, Being obese: malaise, suffering and (re)knowing the body, describes obesity as a way of being and is divided into two subcategories. The first one is based on the malaise that is experienced from the gaze of society and from the physical limitations related to obesity. The second one focuses on the strangeness of the obese body experience and the question of (un)acceptance of the body. The second category, The act of hyperphagic eating in obesity, focuses on the description of the eating experience. The participants mentioned the relation between anxiety and the hyperphagic experience. The act of eating was described as something in the center of their lives with different roles. They emphasized the excess and the loss of control of food intake as characteristics of their daily diet. Chart 5 shows some important statements from the interviewees.

Chart 5
Examples of comments from clinical interviews in Fortaleza (Brazil)

Categories	Subcategories	Speeches
1. Being obese: malaise, suffering and (re)knowing the body	1.1. The malaise of being obese: the gaze of society and physical limitations	“Society is very hard on anyone who doesn’t reach its standards, so the fat one is always the reference. Oh, he’s the third person after the fat man. Do you see that fat man there?”. She believes that everyone is looking at her: “To me, if I go out on the street, everyone is commenting: fatty” (Rebeca).
		“It’s very difficult, I wanted to sleep three days and wake up thin. For me, I would be the happiest woman”. Obesity is often seen by others as a simple phenomenon. Paula points to this simplification of obesity by others: “it is good for society to see, to look at fat people as though it is not a problem. Oh, she’s fat because she wants to be” (Paula).
		Claudia expresses her difficulty with the mirror and how she feels discriminated: “I don’t even like looking in the mirror sometimes, I try to see myself without looking. Because it is a terrible thing to be mistreated. So, today, at the University, I feel a little discriminated against” (Claudia).
		“I saw that really I was being excluded because of my weight” (Joaquim)
		“Everything we’re doing soon tires us out, doesn’t it? The body doesn’t react” (Helena).
		“What was bothering me, is not so much aesthetics but discomfort. So, I gained 30kg within a period of a year or so” (Laura).
	1.2. Being myself again: estrangement and (non)acceptance of the body	“I do not recognize myself, it’s not me. My picture is on my page… I didn’t realize I was getting fat... When I saw myself, and I saw myself at that size, it was like my head on another body, that day was shocking to me... I do not accept being fat, I do not accept buying clothes for myself” (Rebeca).
		“I wanted to at least accept myself. My family doesn’t know that I’m so angry with myself” (Paula).
		“When I started to have difficulty sleeping, I had difficulty breathing, I started to feel hypertensive, I noticed that any movement I made was slower, I felt pain in my joints, it was then that I realized that I was really obese”. For Nicolas, there is a long journey to “really accept yourself, until you seek help, know that it is a disorder” (Nicolas).
2. The act of hyperphagic eating in obesity	2.1. Anxiety and the hyperphagic experience	“I eat more from anxiety than from hunger. Properly from hunger, ah, am I starving? No, I eat because of anxiety, not because I’m hungry. To really fill something” (Claudia).
		“I think it’s due to anxiety. Some stop eating, in my case I eat a lot… I think anxiety, nervousness makes me eat more. I’m very anxious. The chest tightens, the heart accelerates” (Helena).
		“Anxiety causes me to eat without realizing it, without even really realizing it... The more I eat, the more I want to eat” (Sara).
		“When I have concerns, some anxiety, I am nervous, I can’t control myself” (Laura).
	2.2. “Everything is in food”: roles in the act of eating	“Everything I seek, I find in food. If I am nervous, I have some problems, I try to eat. If I feel weak, I try to eat, if I’m happy, I’ll eat too, everything is in food” (Laura).
		“Food is way of “getting rid of something, only I don’t know what it was”, but it also signals suffering: “I started to eat, to eat, to eat, to close off the world from myself, from there the suffering started” (Maria).
		“Eating for me is a refuge. If I’m sad I eat, if I’m scared I eat, if I’m alone I eat, I take out everything in food”. It is “a refuge, it is an escape. As if only there could I satisfy my desires” (Claudia).
		“The solution is food” (Monique).
		“From a certain time to now, I see it as the most important thing. I’m eating to live” (Paula).
	2.3. “I cannot let myself be dominated by a plate of food”: excess and loss of control	“It’s like I have no control. As much as I didn’t want it, I didn’t have the need, I have no control to say no, I can’t”. She is aware of what she does or even what she should not do, but she cannot control herself: “I am aware that I shouldn’t do it, but I am to blame that I can’t control myself, because I know it’s not good, I’m aware that it’s not good, but I blame myself” (Claudia).
		“I ate compulsively, I had no control ... It was every moment, I couldn’t wait to eat. It’s not even in large quantities, but several times a day, small portions” (Nicolas).
		“I feel bad, right? Uneasy, because then, I wonder, how can a small dish control an adult, right? It’s something stronger, I can’t say no, I don’t want to” (Laura).
		“I do not eat because I want to, it’s such a force that it feels like it’s somebody else. Sometimes I’m eating, ah, I’m only going to eat half, then I see that I’ve eaten everything” (Paula).
		“Before comes the mad will, the desire, I need, I want, eat, eat, it will not hurt you, eat, until I get up and get it. I eat a piece, I see some chocolate, a small square of 100g, I eat desperately in what seems like two seconds and want to eat another, then that’s it, then I want to eat another. At the time you put it in your mouth the feeling is wonderful, that feeling of ecstasy, eat, eat, it’s good, that’s delicious. Go on eating, Go on eating. When I looked, there was only the wrapper left. How could I have eaten a kilo of chocolate and not even felt it? Here comes the blame, damn I ate a kilo of chocolate, damn, how could I do this to myself?” (Rebeca).

• Note: Pseudonyms have been used to preserve participants’ privacy.

Discussion

In this discussion, we introduce theoretical elements that allow for a better understanding of the hyperphagic experience in obesity in France and Brazil. The first point highlights the suffering of being obese, based on their weight, (in)visible character and perceived discrimination as part of a culture that rejects obesity. This suffering is also discussed through the confusion expressed in the interviews between the being and the having of the obese body. In the second point, we discuss the meanings of the act of eating in the hyperphagic experience and the changes in the way that the patients seem to experience their bodies.

The suffering of being obese: weight, (in)visibility and discrimination

The presence of suffering in obesity seemed to be important in both contexts, as the categories Being obese: the body, the weight and the gaze of others and Being obese: malaise, suffering and (re)knowing the body showed. Patients interviewed in France and Brazil emphasized the fatigue and discomfort caused by being overweight, which affects their daily lives. It is considered that the way of seeing, and also of being seen, affects body experience in obesity. On the one hand, patients interviewed in France consider obesity as a kind of “visible defect” which is not well understood by society and that has the power to underline visibility, constant evaluation and control by others. On the other hand, the participants interviewed in Brazil strongly emphasized the prejudices and discriminations that they suffer. Body appearance and shape are challenged by the inability of the subjects to change the look of their body, seen by others as “outside of the norm”. Discrimination affects how obese people look upon themselves. Although the discrimination was more evoked by patients in Brazil, it was possible to notice a reduction of the subject with their body condition in both contexts.

We can see an iconic body that progressively becomes the foundation of self-esteem and presents itself as a place of suffering (Apfeldorfer, 2008). The person is seen as obese, a fat individual, unable to lose weight. The body is the target of the gaze of others and the obese individual is increasingly troubled by the look that identifies him/her as such, outside of the norm. This body is overlaid with aesthetic and health concerns and the obese individual should try to model themselves around it all. The desirable body must be beautiful and healthy and at the same time undergo a progressive medicalization of the aesthetics and aestheticization of medicine (Saint Pol, 2010). The suffering described directly and indirectly by patients in both contexts is presented through the ideals of beauty and health. These two elements, health and beauty, are interconnected and constitute the way of seeing, and even judging, obese people. For our participants these aspects seemed to be emphasized differently. In Brazil, the ideal of beauty was more evident in their discourse and the notion of health was more evoked as a concern for French participants.

The existence of the subject in the obese body is often neglected and it is one of the sources of suffering of the subjects interviewed. The person who lives in this body is not sufficiently taken into account and becomes “invisible” in the condition of subject. Merleau-Ponty’s words illustrate this: “Since I have a body, I can be reduced to an object before the eyes of others and no longer be considered as a person” (Merleau-Ponty, 1945/2010, p. 853, our translation)³. This reduction of the obese individual to their corporal condition was mentioned in both contexts. The subject is attached to his/her obese body, which is objectified and often the target of diets and of surgical procedures. In a society in which body worship is exacerbated, there is an attempt to match the body with the image that the individual wants for him/herself in the search of self-recognition and recognition from others.

The interviews in Brazil and in France show that the gaze of others is a source of suffering, which has an impact on the “way of being obese” experienced by patients. Fuchs (2003, p. 226) states that “the eyes of the other decentralize my world”. There is a power in the other’s gaze that can paralyze the lived body, petrify it during the experience of obesity, as Fuchs (2003) considers, alluding to the Medusa myth. The intersubjective dimension of the phenomenon must be taken into account. We also noticed the refusal, by some patients, of the “obese identity”. However, this refusal is not enough to avoid the suffering of the patient in the face of the intensity and power of the gaze of others. If one lives in a culture that overemphasizes body shape and thinness, the obese experience is therefore experienced as a “defect” of being fat, which hides what belongs to the subject. In both obesity and eating disorders, the focus on symptoms and body condition neglects what is relevant from the patient’s perspective (Stanghhellini, Daga, & Ricca, 2020).

If we consider culture as the intersection of meaning and experience (Kleinman & Good, 1985), we must examine the way in which French and Brazilian culture deal with the experience of obesity, and constitute it. This experience is described by the patients, as mentioned above, in the first categories of each context and shows how this suffering is present and has traces of the culture where they live. It is necessary to recognize the intrinsically dimensional nature of bodily concern and eating behavior, and, most importantly, to understand and recognize cultural diversity (Becker, 2007). In both contexts studied, even with certain particularities, there is clearly negative, discriminatory and moral ways of seeing obesity and the obese individual. The gaze of others is presented as a source of suffering and as a characteristic of Western culture that continues to produce negative and moral discourses in regard to obesity, with reference to both health and beauty. In obesity, the invasion of the gaze of others seems to be even more intense and marked by this visible body.

Throughout the interviews, we observe a certain confusion, a dissonance, between what patients experience and what they perceive as their body, between the body experienced as belonging to them and the body they have (Grangeard-Polard, 2008), between the being and the having of the obese body. The experience of being obese is strongly marked by the objectification of the body and by the imperative to change it. The “ideal” notions of bodily beauty dominate the way the obese see their body and health parameters, which tend to change the way of experiencing the body itself and induce the idea of a body that one should incessantly seek. In the context of an eating disorder in obesity and considering our results, we can perceive that there is a change that affects the sensitivity and the way these individuals see their own body (Castellini et al., 2014).

In the case of obesity, there is the emphasis of an objective character, mainly in relation to the visibility of the body, which leads to experiences of suffering and the reduction of the subject in his/her bodily condition. When obesity occurs with or from a hyperphagic experience, as in the both contexts developed, we see the further exacerbation of the body as an object. There seems to be a kind of “hyper” relationship established with food that is based on an altered bodily experience as a function of the imbalance between the body that one is and the body one has. According to Merleau-Ponty (1960, p. 166), “the distinction of subject and object is scrambled in my body”. The body opens us to possibilities, but a possible imbalance between the body that one “is” and the body one “has” can give rise to psychopathological experiences.

The experience of being obese and having an obese body is intersubjective. The way of experiencing one’s own body is impacted by others, by a world that dictates the ways of being-in-the-world. In the case of obesity, there is a discomfort experienced in this body that must be changed. There is an excessive objectification of the body that prevents effective appropriation by the subject. To the extent that this body is permanently identified, judged, and regarded as an object capable of change, the subject living in that body is cast aside and feels lost in this mode of the body’s being. There is a process of subjectivation centered excessively on the body as an object, distancing the subject from what he/she is and showing what he/she has.

Clinical work must revisit a body “that escapes the distinction between being and having, between subject and object, between oneself and another” (Castellini et al., 2014, p. 211), in a journey for the re-appropriation of the body from a first person perspective. It is necessary to allow for a process of subjectivation that is not reduced to the body as an object, allowing for the unveiling of a particular mode of being. We observe the tendency to evidence the “have” of the body and the difficulty of patients to be subjects of their own history, their own body. Treatments tend to focus on the excess of this body as an object and, sometimes, cast aside the subject living in that body.

The act of eating in the hyperphagic experience

In the hyperphagic experience described by the patients, the act of eating seems to occupy a singular place and is traversed by the way in which they experience their own body. Hunger and satiety seem to no longer be the main operators in the act of eating and there seems to be a change in the way of experiencing them. It should be noted that several participants highlighted that it was the desire to eat, not hunger, which leads to the act. The act of eating would not necessarily be preceded by hunger, but by this powerful will to eat. There is a difficulty in feeling their own body and, somehow, they are lost in the act of eating, without the sensation of hunger and satiety. The will to eat leads to the act of eating, but not just in the sense of finding pleasure in eating. It is above all the will attached to the action since the sensations are not always felt.

In the absence of the sensation of hunger, the action of eating is the objective and the choice of food becomes a secondary element. In the patient’s experience, the desire to “eat” leads to food. The main element, which conditions the will, is the fact that it can (and should) be eating. The French participants, who emphasized the difficulty of feeling these experiences, described the change in the way of experiencing hunger and satiety. This aspect was also discussed during the interviews in Brazil, but less frequently. During the interviews in Fortaleza, we observed a certain difficulty of the patients in describing their corporal experiences related to food. Our attention was also focused on the issues about the presence (or not) of hunger and the reasons for eating when this is absent. In addition, such a change in the experience of hunger and satiety may be an important aspect to establish the difference between the experience of obese patients with and without hyperphagia.

We were able to observe the patients’ difficulties in feeling their own body. Circumstances such as hunger, but also thirst and fatigue, enable the body to reappear or even just allow it not to be disregarded (Tatossian, 2016). In the case of patients with hyperphagia, the body is further sidelined in the face of the subjects difficulty to feel. If hunger and satiety are no longer the operators and are experienced in a different way, the participants give meaning to their hyperphagic experience from functions that go beyond these experiences. Eating to fill a void, compensating, lessening anxiety, finding refuge, and having a good time during the day are some of the meanings, as expressed in the categories The Sense of Eating in the Hyperphagic Experience of Obesity and The act of hyperphagic eating in obesity. It is an action that goes far beyond hunger and satiation as a source and is a way of organizing the act of eating.

The change in hunger and satiety seems to be one of the elements that contributes to the absence of control in the hyperphagic experience. It is marked by the loss of freedom of the subject who becomes, in a certain way, a “hostage” to the uncontrollable desire to eat. People who present hyperphagic episodes do not sufficiently feel their body and are controlled by the will, which cannot be managed. This experience reveals a real change of sensations that can no longer be easily experienced naturally. In a phenomenological study of eating disorders, Stanghellini et al. (2015) concluded that extraneous feelings from one’s own body are the feature that most differentiates clinical patients with eating disorders from nonclinical populations. In both contexts of our research, we observed a change in the way they feel their own bodies. It seems to be the strange body that loses control in face of food. The possibly addictive dimension of the act of eating was also mentioned, especially by French patients, as shown in the subcategory Eating as an addiction.

The act of eating presents several meanings that go beyond the “natural” and everyday sense. It is mainly a bodily experience, identificatory and existential (Durif-Bruckert, 2007). Although eating is essential for survival, eating is not restricted to the nutritional sense. Eating is often eating together, the relationship to food takes on a special emotional meaning, which connected to the family space. Commensality rediscovers links to family and childhood. These aspects, especially those linked to commensality, were mentioned in particular by patients in France who have repeatedly emphasized the social role of food as well as its importance in the family and in the construction of their habits, while Brazilians subjects have remained more focused on their symptoms and on the issues of health and aesthetics faced from obesity.

The act of eating can be seen as a habit, and this habit (Merleau-Ponty, 1945/2010) is always constructed with others, especially with the family, or those who play this role. Eating often involves an exchange, and hyperphagia can be seen as a mode of expression that takes place and grows within this exchange. This mode of expression carries a particular language, and what we perceived throughout the interviews was an attachment, sometimes excessive, to food, to the act of eating. There is a body marked by the habits and lifestyles that constitutes the particular use the individual makes of that body while keeping a record: “Whatever the time and place, the body keeps the imprint of the individual’s experience” (Saint Pol, 2010, p. 19). The hyperphagic experience is composed within a historical process, lived in relationships, and sometimes builds a problematic bond with food that assumes too large a role in the lives of patients.

In France, in the category or family and act of eating for example, we have clearly observed the role of the family in the constitution of the hyperphagic experience. There is a family space around food where it can have a friendly and emotional character but which also brings into play visibility and judgments related to the body and to the act of eating. Emotions and affects influence and are influenced by eating acts. Meanwhile, in the Brazilian interviews, the subjects-collaborators did not highlight family and commensality as an important point that intersects with how they eat. However, they did address the gaze of others and control when eating in particular. These looks seem aimed above all at the aesthetic dimension.

During the interviews in both contexts, we observed that the act of eating and the role of food play an even more central part in the daily lives of patients and they are presented as a true event. We emphasize the question of emptiness and the act of eating as a way of trying to fill this emptiness, as evoked by some patients. The act of eating would be the only event “summoned” as supposedly capable of filling this void. There is a lived experience of emptiness as a condition of possibility for the act of hyperphagic eating.

During the hyperphagic episodes, nothing but food matters. If the act of eating is the path that leads to an existence to be filled, it is also a sign of failure insofar as the subject realizes that this emptiness can never be completely filled and that there is overconsumption of food. During the action of hyperphagia, individuals are so focused on food that they lose their autonomy and their ability to control food intake. After eating without controlling food intake, they realize that everything they had swallowed was not effective. The act of eating is often the “everything”, the only possible alternative, which occupies the whole range of significance and direction of meaning of the individual. “Eating everything” means that the act of eating is experienced as the supposed moment capable of filling all the emptiness that is felt in the body, as an action capable of solving everything or of enabling the confrontation of all one’s problems. This symbolic whole embodies the act of eating. However, we can say that this “everything” results in emptiness, marked by a body that is hypnotized by the will to eat, by the condition of not being able to not eat and by the difficulty of feeling one’s own body.

In the hyperphagic experience, we may say that the act of eating makes it possible to change the senses and disorganize the subjects in their indispensable daily routine around food. The act of eating and its implications are central to the daily lives of patients. In addition, eating is sometimes an event that is linked to a destabilization related to an earlier event, or is actually destabilization of itself, according to its intensity and its possible consequences, such as obesity and guilt, which are often lived and was often mentioned by our participants. The subject is impacted and disturbed in his/her totality, which makes us think about the “choice” of the eating act as a way of expression.

Understanding the act of eating as an event implies a way of understanding that observes from an existential perspective, without necessarily limiting itself to a horizon of previous meanings, insofar as the event can disturb and reconfigure this horizon (Romano, 1998). The appreciation of meaning refers to the implications for our own existence of what is produced or what is said about what happens to us (Pachoud, 2005). The intentionality of the act of eating carries many meanings of the subject’s existence.

After eating, guilt appears through the other’s gaze. In hyperphagia, we can say that they live a way of being-in-the-world marked by a structure of action that is initiated by emptiness and that tries to reduce suffering or by the need to compensate for something, to have the conditions to search for an experience capable of filling or replacing these bad experiences. Nevertheless, guilt and, sometimes, the overwhelming gaze of others impact these experiences. There is real suffering for the hyperphagic individual. It is related to this daily dynamic that he/she desperately tries to escape in a conflict with him/herself, his/her body, his/her desires and with the world.

Conclusion

We can conclude that the boundaries between the two phenomena (hyperphagia and obesity) are not very clear. There is a mutual “interaction” that affects the subjects’ way of living. The hyperphagic experience in obesity is largely marked by a centralization of the body as an object that is a characteristic of our contemporary society. From the interviews, we observed a double incidence: (1) the obese body is the “enemy”, the extraordinary element that defines the subject until it can be changed and which is the target to fight; and (2) lost in his/her body, the subject experiences hyperphagic episodes oscillating between a desperate and unrestrained immersion into food followed by an overwhelming guilt after overeating. They seem to experience their own body as an object seen, judged, and evaluated by others. With obesity, this “massacre” due to the negative effect of the other’s gaze is very blatant. This effect is also found in the hyperphagic experience through concerns about body shape, guilt experienced by the subject and the attempt to respond to emotions through the food experience.

In relation to the two cultural contexts investigated, there seems to be more common elements than differences. Among the points in common, we can mention the social refusal of obesity that affects the way of living with the patient’s body condition, intense suffering linked to both obesity and hyperphagic experiences, changes in the way of experiencing the body itself as a result of the lived hyperphagic experience, and the centrality of the act of eating. The interviews conducted in France reveal habits around the chart that are very different from the Brazilian experience and highlight health as a major concern for the French in their hyperphagic experiences. The interviews conducted in Brazil seem to have revealed a more frequent discrimination of the obese individual than in France and are more focused on the aesthetic dimension. In addition, Brazilian participants often refer to other pathologies as part of their experience. We observed that in Brazil there is a more present pathological discourse, while the patients in France were more critical about this dimension.

Given the changes experienced in the body, our results indicate the importance of a clinical psychological work that involves the re-appropriation of this body by the individual and the consideration of the intersubjective character of the hyperphagic experience in obesity. These aspects can be useful in the treatment and prevention of both obesity and hyperphagia. This includes the search to recover the condition of the autonomous individual who can feel, choose, suffer and also (not) eat. This cross-cultural issue needs further studies which should include new cultural contexts.

• Support: Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Process n° 09998/14-1) and Conselho Nacional de Desenvolvimento Científico e Tecnológico (Project PQ-1D Fenomenologia Clínica da Intersubjetividade no mundo vivido – Lebenswelt – Psicopatológico – PQ – 1D).
• This article is based on the thesis of L. BLOC, entitled “Approche phénoménologique de l’expérience hyperphagique dans l’obésité: une étude dans les contextes français et brésilien”. Université Paris Diderot, 2018.

• 3
  In original: “En tant que j’ai un corps, je peux être réduit en objet sous le regard d’autrui et ne plus compter pour lui comme personne” (Merleau-Ponty, 1945/2010, p. 853).

How to cite this article

• Bloc, L., Ramalho, J. A. M., & Moreira, V. (2021). The hyperphagic experience in obesity: a phenomenological study of French and Brazilian contexts. Estudos de Psicologia (Campinas), 38, e200168. https://doi.org/10.1590/1982-0275202138e200168

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Publication Dates

• Publication in this collection
  02 June 2021
• Date of issue
  2021

History

• Received
  11 Aug 2020
• Reviewed
  15 Dec 2020
• Accepted
  05 Apr 2021