Between precariousness and self-care: socioeconomic barriers to weight control treatment

Objectives

General objective: To analyze the socioeconomic barriers that some people with obesity and chronic degenerative diseases face in adhering to weight control treatment.

Specific objectives:

Identify the material conditions (income, employment, transportation, access to healthy food) that limit the acquisition and maintenance of healthy habits.

Describe the relationship between structural inequality and treatment abandonment.

Justification

This research aims to investigate how structural inequalities and socioeconomic precariousness hinder sustained adherence to treatment for weight control and chronic degenerative conditions in people with obesity, in order to understand how structural conditions influence health, the body, and self-care practices, prioritizing this dimension over psychological or cultural factors (Kaufer-Horwitz & Pérez-Hernández, 2022; Schmitz et al., 2020).

In Mexico, adult women postpone self-care because they face double or triple shifts, paid work, domestic work, and caregiving. This reality underscores the need to examine how social structures shape access to and the continuity of treatment, as ignoring them perpetuates clinical interventions that place responsibility solely on the patient, without considering their actual living conditions (Tettero et al., 2022).

On the other hand, González and Pérez (2022), Ramírez et al. (2022), and Smith et al. (2021) point out that emotions such as body shame, stigma, and hopelessness interact to reinforce abandonment, self-exclusion, and internalization of guilt, creating a vicious cycle of anxiety, overeating, and relapse. These emotions cannot be resolved solely with medical prescriptions, but require therapeutic support and spaces for containment. This work focuses on socioeconomic barriers due to their structuring capacity and their role in reproducing health inequalities. By focusing on these barriers, we aim to contribute elements that enable the design of more context-specific and sustainable interventions.

Obesity and its repercussions

Obesity is a chronic disease characterized by an abnormal or excessive accumulation of body fat that poses a health risk. From a biomedical perspective, its diagnosis is based on body mass index (BMI): a BMI of 25 or higher is considered overweight, and a BMI of 30 or higher is considered obese (WHO, 2021).

It is a multifactorial condition involving genetic, metabolic, behavioral, psychological, social, and environmental factors. These include energy imbalances, a diet high in ultra-processed foods, a sedentary lifestyle, chronic stress, and insufficient sleep. Socioeconomic inequalities, limited access to health services, and unhealthy environments also contribute (Teixeira et al., 2015; Sánchez-Carracedo, 2022).

The repercussions of obesity are felt at different levels. In medical terms, it is associated with an increased risk of developing chronic noncommunicable diseases such as type 2 diabetes, high blood pressure, dyslipidemia, sleep apnea, and certain types of cancer. In the psychosocial sphere, it can lead to low self-esteem, anxiety, depression, and stigmatization; economically, it increases healthcare costs and reduces labor productivity (WHO, 2021; Puhl & Heuer, 2010). However, in recent decades, obesity has gone from being conceived as a clinical-individual phenomenon to a social phenomenon linked to structural transformations, such as the growth of the food industry, changes in urban planning, the digitization of work, and the weakening of care networks, becoming an indicator of social inequality (Kaufer-Horwitz & Pérez-Hernández, 2022). Thus, obesity as a public health problem reflects the transition to a scenario in which caloric overfeeding predominates, in contrast to the malnutrition that marked previous decades.

Strategies for the prevention and treatment of obesity

In Mexico, the Ministry of Health implemented the National Strategy for the Prevention and Control of Overweight, Obesity, and Diabetes (2013), focused on ensuring access to healthy foods, regulating the consumption of ultra-processed products, and promoting physical activity (Ministry of Health, 2013). Its actions include front-of-package labeling (NOM-051,

2020) and campaigns such as "3xMiSalud" (3xMyHealth) and "Muévete y Métete en Cintura" (Get Moving and Get in Shape) (Barquera et al.,

2020; Rivera-Dommarco et al., 2020). Likewise, its comprehensive treatment (NOM-008-SSA32017) includes changes in diet, increased physical activity, behavioral modification, psychological support, medical follow-up, and, in some cases, pharmacological or surgical treatment. Treatment must be personalized and continuous, with multidisciplinary interventions that address the multiple dimensions that influence obesity (Ministry of Health, 2017).

The effectiveness of treatment depends on adherence, understood as "the degree to which a person's behavior (taking medication, following a diet, and lifestyle changes) corresponds to the recommendations agreed upon by a health professional" (WHO translation, 2003). In the case of obesity and other chronic degenerative conditions, adherence involves maintaining dietary and physical activity changes, ongoing medical monitoring, and, in some cases, pharmacological or surgical follow-up (Tettero et al., 2022). However, sustaining the changes required for long-term weight control is particularly complex due to social and economic factors that shape the ability to adopt healthy habits (Smith et al., 2021), as well as the psychological and subjective factors involved. Adherence cannot be reduced to simple individual discipline; it is a process influenced by structural conditions and social stigma toward the obese body, which reinforces feelings of guilt, low self-esteem, and distrust of the healthcare system (González and Pérez, 2022).

In addition to the above, low self-efficacy and fear of judgment in clinical settings trigger avoidance of medical follow-up, a cycle of relapse, and dietary dysregulation (Smith et al., 2021). In this sense, addressing obesity involves ensuring intersectoral public policies that articulate health, nutrition, decent work, and care networks, recognizing that this problem transcends BMI, diet, or exercise and constitutes the visible expression of profound inequalities that permeate the body, emotions, and daily life (Schrecker & Bambra, 2015).

Socioeconomic barriers

Social determinants of health (SDH) are "the circumstances in which people are born, grow up, work, live, and age" and explain how structural factors influence well-being (WHO, 2021). Socioeconomic barriers, understood as obstacles arising from material and structural conditions that limit equitable access to services, opportunities, and conditions necessary for health care, include insufficient income, precarious employment, food insecurity, lack of basic services or social protection, and hinder treatment adherence (Marmot et al., 2020; PAHO, 2022). These barriers not only manifest as practical limitations but also create a context that limits people's ability to sustain lifestyle changes and comply with medical instructions.

In Latin America, socioeconomic barriers to health care are reflected in high rates of poverty (29%), extreme poverty (11.2%), higher maternal and infant mortality, and deaths attributable to unsafe water and inadequate sanitation (PAHO, 2022). The persistence of these structural inequalities shows that material conditions affect people's actual ability to access healthy food, plan care, sustain lifestyle changes, and cover medical expenses. These barriers are exacerbated for vulnerable groups, such as women caregivers and informal workers, who have less access to support networks and less social security coverage (Schmitz et al., 2020; González & Pérez, 2022). Authors such as Funk, Foreman, and Smith (2022), Ramírez et al. (2022), and Smith et al. (2021) have identified that socioeconomic barriers, including informal employment, food insecurity, and a lack of reliable transportation, limit sustained access to treatment. They also note that social stigma and multiple work and family responsibilities affect continuity, underscoring the need for comprehensive, context-sensitive approaches.

Specific factors: poverty, employment, food, transportation, time, and care

Within the context of socioeconomic barriers, specific factors that interact with one another are identified. Poverty, understood as the deprivation of income, education, health, security, and fundamental human rights, limits access to healthy foods, thereby favoring dependence on more accessible but less healthy ultra-processed products (Haughton & Khandker, 2009; Funk et al., 2022). Informal employment and long working hours reduce the time available for physical activity and medical care, while food insecurity forces people to prioritize quantity over quality (Schmitz et al., 2020). In addition, the lack of safe and affordable public transportation limits attendance at medical appointments and community programs. Similarly, the burden of care, which falls mainly on women, pushes self-care into the background (Kaufer-Horwitz & Pérez-Hernández, 2022).

Material barriers directly affect the ability to sustain self-care practices, understood as the set of intentional decisions and actions to care for physical, mental, and social health, including hygiene, nutrition, and exercise, as well as emotional management and actively seeking medical care (WHO, 2021).

Although many people are aware of weight-loss recommendations, their living conditions make it difficult for them to implement them and encourage them to gradually abandon treatment (González and Pérez 2022; Tettero et al., 2022). Therefore, the responsibility for self-care cannot fall exclusively on the individual, but must be understood as a result of the material conditions that sustain or limit it.

Link to psycho-emotional and symbolic factors

Material conditions interact with symbolic and psycho-emotional factors that reinforce the difficulties of adherence. Symbolic factors include aesthetic ideals, social mandates on self-care, being disciplined, and the stigma associated with the obese body (Menéndez, 2003). Economic insecurity and work overload generate anxiety, hopelessness, and emotional exhaustion, lack of motivation, and low self-efficacy, while stigma and body shame increase self-criticism and self-exclusion, reinforcing patterns of abandonment (Ramírez et al., 2022; Smith et al., 2021).

Any strategy to improve adherence to treatment for weight control and chronic degenerative conditions must consider not only socioeconomic barriers but also emotional support and stigma reduction to strengthen patient resilience and motivation. Tettero et al. (2022) emphasize the need for sustained emotional support to promote lasting change in people facing multiple vulnerabilities.

Treatment Adherence

In recent years, factors that hinder treatment adherence for weight control in people with obesity and their interaction with barriers and impediments have been explored. Schmitz et al. (2020) identified structural barriers such as informal employment, food insecurity, poor community support, and lack of reliable transportation, while Smith et al. (2021) pointed out that the availability and advertising of ultra-processed foods and the absence of healthy markets in low-income urban environments constitute environmental barriers that hinder the adoption of healthy habits. In addition, Funk, Foreman, and Smith (2022) showed that social stigma, fear of discrimination in medical settings, and multiple family and work responsibilities affect treatment continuity, and they recommended an intersectional approach that considers gender, class, and life context. González and Pérez (2022) highlighted the need for a comprehensive view of obesity that recognizes structural factors and does not hold the patient solely responsible for treatment outcomes.

For their part, Morales, Álvarez, and Ribeiro (2024) highlight that subjective and emotional difficulties affect adherence, including deficiencies in the therapeutic relationship and the lack of recognition of psychological factors, which contribute to the persistence of discomfort in patients. Ramírez et al. (2022) emphasize the importance of emotional support, given that relapses and treatment abandonment are closely linked to negative emotional experiences during weight loss processes. Taken together, these studies show that sustaining lifestyle changes requires not only addressing socioeconomic and structural barriers, but also considering the symbolic, emotional, and psychological factors that permeate the patient's experience.

Design

This research takes a qualitative approach, which allows social phenomena to be understood from the perspective of the subjects who experience them, focusing on meanings, experiences, and contexts (Hernández-Sampieri et al., 2021). This work is part of a broader exploratory study with a phenomenological design, aimed at describing and understanding the lived experience of two participants with obesity regarding the barriers they face in adhering to treatment (Vargas, 2019).

Sample and sampling

The sample consists of two interviews with adult female patients diagnosed with chronic degenerative diseases and obesity who were treated at a public health institution. Non-probabilistic convenience sampling was used, employing a typical case strategy and selecting participants who represent common characteristics of the phenomenon under study (Patton, 1990).

Method for obtaining information

The information was obtained through semi-structured interviews, which allow for in-depth data collection without sacrificing flexibility (González & Rodríguez, 2020). The interviews were conducted with the prior informed consent of each participant and recorded for later transcription, with the approval of the corresponding Ethics Committee and in accordance with all ethical principles of confidentiality, autonomy, and non-maleficence.

Method of information analysis

A thematic content analysis was applied, identifying, coding, and categorizing units of meaning to construct interpretive patterns (Vargas, 2022, p. 155). Emerging categories (such as transportation, employment, food insecurity, and stigma) were recognized and organized around predefined axes such as self-care, health, and body, using comparative matrices and worksheets that facilitated the integration of the data with the reviewed literature.

Ethical considerations

This research was conducted in compliance with the fundamental ethical principles established in the Code of Ethics for Psychologists of the Mexican College of Psychology (Colegio Mexicano de Profesionistas de la Psicología, 2010), thereby guaranteeing the confidentiality, autonomy, and protection of participants' rights. Informed consent was obtained prior to participation, and it was ensured that the data would be used exclusively for academic, research, and training purposes, and that academic integrity would be maintained through the correct and transparent use of all sources consulted.

Informal employment and low income

Informal employment generates low income, economic instability, and a lack of social benefits, conditions that limit healthy eating and time for rest.

“I work from early in the morning until late at night, and sometimes I only have time to eat whatever I can find on the street... whatever I can get.”

Limited access to healthy foods

The interviews reveal difficulties in adhering to medical dietary recommendations, highlighting a contradiction between the nutritional ideal proposed by the health system and the realities of families living in precarious socioeconomic conditions.

“The doctor tells me to eat lettuce and vegetables, but that is expensive, and there are several of us at home.”

Food insecurity

The participants noted that sometimes there is not enough food in their homes, and they prioritize feeding their children, neglecting their own health. Low income and limited food support result in irregular access to adequate food, in terms of both quantity and quality.

“Sometimes there is not enough for everyone, so I prefer to let my children eat first, and then I will see what I can eat.”

Accessibility to public transportation

The interviewees reported long, expensive journeys that make it difficult for them to attend the health center where they receive regular treatment.

“To get there, I have to take two buses, and sometimes I do not have enough money, or it takes me too long. If I go, I do not have time to do anything else.”

Domestic and caregiving workload

Both women perform caregiving duties within their homes, which, added to their work activities, leaves them little room for self-care, maintaining healthy habits, or attending appointments.

“When I am not working, I am with my children or cleaning. Sometimes I do not even have the strength to think about myself.”

Lack of institutional support

The interviewees reported that, although they receive medical advice, they do not receive follow-up, emotional support, or accommodations for their economic reality. This ultimately weakens the therapeutic relationship and disrupts treatment continuity.

“Sometimes I feel like I go and they tell me the same thing, but they do not help me with how to do it with what I have.”

Symbolic and emotional factors (emerging category)

The participants expressed feelings of guilt, body shame, demotivation, and frustration at the difficulty of losing weight, demonstrating that treatment adherence is influenced by structural, symbolic, and emotional factors, not just individual willpower.

“I feel like I am failing... like I am not good at this. I do not want to go anymore because they scold me.”