Arya M. Sharma, MD

The mantra about the benefits of weight loss seem to be gospel in most discussions about solutions to the obesity epidemic.

It was therefore quite refreshing to follow the presentations and discussions at yesterday’s session on weight bias and discrimination at the Journées annuelles de santé publique (Québec).

One of the most innovative presentations was in fact a review of the many programs and initiatives by ÉquiLibre, a Québec non-profit organization with the mission:

“to prevent and reduce problems related to weight and body image in the population, through actions encouraging and facilitating the adoption of healthy lifestyle and developing a positive body image.”

For the past 20 years, this organization has been providing “Choose to Lose Weight?“, a program for women concerned about their weight, that focusses on size acceptance and ending the cycle of ‘yo-yo’ dieting.

For people fluent in French, the site provides ample advise on myths regarding weight loss, the potential risks of dieting and weight obsession, and tips on how to recognize ‘ethical’ weight management programs.

The ÉquiLibre site also links to an most interesting interactive site called ‘Behind the Mirror” aimed at youth, that most engagingly challenges weight and appearance stereotypes.

For non-French speaking readers, I recommend exploring the site in the Google translation mode, which does a remarkably efficient job of translating the content of these pages.

French speakers should of course browse the original site for information on ÉquiLibre.

I’d love to hear from anyone, who has participated in their courses.

AMS
Montreal, QC

As mentioned yesterday, this week, I am attending a Scientific Symposium called “Recovery From Addiction“, organised as part of the Alberta Family Wellness Initiative of the Norlien Foundation.

One of the most fascinating and thought-provoking presentations yesterday, was a talk by Garrett O’Connor, Medical Director of the Professional Recovery Program at the Betty Ford Center, one of the leading US addiction treatment hospitals, on the topic of shame.

As Garrett pointed out, shame is not only a taboo topic but also leads to isolation, guilt, denial, secrets, silence, hidings and cover-ups - all issues related to addictions (and often obesity, I may add).

It seems that the phenomenon of shame is deeply ingrained in our biology and probably evolved to keep our reptilian brains in check.

Garrett described shame as, “A sudden decrease in self-esteem, an uncomfortable nanosecond in which we are revealed to ourselves as being something less than we wanted to believe“.

The emotions associated with shame can result in shyness, embarrassment, humiliation, alienation, or even mortification (shame can kill). Shame is the affect of inferiority, failure, mediocracy, inadequacy, dependency, unworthiness, abandonment, and expulsion.

There is a wide range of experiences that can result in shame, including witnessing or experiencing physical, mental or sexual abuse, witnessing domestic violence, mental illness, substance abuse, or criminality in the family, parental separation or divorce.

“Healthy” shame protects and motivates the self in a positive direction by deeply disturbing our sense of self or who we think we are.

In contrast “malignant” shame attacks and wounds the self, slices through the ego, and can express itself by rage and self-loathing. Often, malignant shame manifests itself as fear and terror of being judged negatively, or found wanting by a person or institution with real or imagined power and authority over you. It may lead people to evolve a false persona to conceal the “worthless person” hidden behind the mask of shame. In many cases malignant shame turns to despair - blocks feelings and connectedness.

Garrett spoke about how shame can cascade down through generations as it runs in families or even, as in the case of historical shame, can affect entire populations or societies.

When both personal and cultural shame come together, things can really go wrong. One example of malignant shame, discussed by Garrett, was the collective shame experienced by Germany after losng WW 1, which led to subsequent embracement of the Third Reich with projection of the shame into Jews, thereby making it appear “legitimate” to exterminate them in the holocaust. Clearly, the Nazis lacked “healthy” shame, which may well have have prevented these atrocities.

In North America, alcohol and other measures were used to induce malignant shame in the native populations resulting in much of the problems that these populations still face today (poverty, alcoholism, addiction, obesity, etc.).

Referring to his own experience with alcoholism, Garrett described how 25 years of shame, fear, remorse, despair, humiliation and dehumanisation were compounded by recognition of his own moral and spiritual bankruptcy with intermittent bouts of suicidal ideation.

I could not help but wonder, how often malignant shame plays a role in weight management. Many of my patients have experienced deep shame - shame about experiences or circumstances in their lives, but also shame about their failure to conquer their weight. For patients who chose bariatric surgery, shame can even come from appearing to have taken the “easy way out”.

Unfortunately, there is no easy way to deal with malignant shame. It appears, that as with addictions, the 12-steps approach may be the most effective.

Perhaps, as often, the first step on the path to healing is to simply acknowledge and accept shame as part of the problem. Anyone practicing in bariatric medicine or surgery should be sensitive to shame and learn to address this issue in a sensitive and constructive manner.

AMS
Banff, Alberta

A couple of days ago I asked readers of my new FaceBook Page whether or not they preferred exercising in front of a mirror?

The response was mixed: for some definitely no mirrors, for some definitely yes, and for some the answer depends on the exercise (weights: yes; aerobic: no).

So what does research have to say on this?

A Canadian study to address this issue was done by Kathleen Martin Ginis and colleagues from McMaster University, Hamilton, Ontario published back in 2003 in Health Psychology.

The researchers examined body image concerns on changes in exercise-induced feelings and self-efficacy in 58 young sedentary women, who were randomised to perform a 20-min bout of solitary exercise in front of either a mirrored or a nonmirrored wall.

The results clearly indicated that regardless of their level of body image concern, the women in the mirrored condition felt significantly worse after exercising than the women in the unmirrored condition.

The authors note that these findings are entirely consistent with predictions of the objective self-awareness theory proposed by Duval and Wicklund in 1972. According to this theory:

“…any stimulus that causes focus on the self, such as the presence of a mirror, can lead to a state of increased self-awareness. This state is characterized by a greater awareness of internal sensations and the elicitation of a self-evaluation process whereby individuals compare themselves with standards or ideals that are salient in the situation. When the self-evaluation process results in a perceived discrepancy between the actual and the ideal self, negative self-evaluations and negative affect will occur.”

As noted by the authors, this theory is supported by numerous studies showing that gazing at oneself in a mirror increases self-focus and can lead to increased negative mood, particularly among women.

Not surprisingly, the authors conclude that these findings have important implications for physical activity and exercise recommendations:

“Our findings suggest that mirrored exercise environments may not just prevent sedentary women from deriving the mood-enhancing benefits of exercise but may actually cause mood decrements.

This raises the possibility that mirrored fitness facilities are a deterrent to exercise participation among sedentary women. Certainly if a woman leaves the gym feeling even worse than when she arrived, she will not be particularly motivated to continue exercising in the future.

As such, the recommended practice of placing mirrors in exercise centers may need to be reconsidered, especially in centers that are trying to attract exercise initiates.”

As far as I can tell by the abundance of mirrored walls in fitness centres, five years later, these findings have yet to be widely translated into practice.

I wonder what my readers have to say about this? Are there actually gyms out there that offer mirror-free exercise rooms?

AMS
Edmonton, Alberta

Martin Ginis KA, Jung ME, & Gauvin L (2003). To see or not to see: effects of exercising in mirrored environments on sedentary women’s feeling states and self-efficacy. Health psychology : official journal of the Division of Health Psychology, American Psychological Association, 22 (4), 354-61 PMID: 12940391

Being overweight or obese has been associated with a poor body image and a lower quality of life specially in females, but the impact on males is less clear.

This relationship was now examined by Saloumi and Plourde from McGill University, Montreal, in a paper just published in Psychology, Health & Medicine.

The analysis was based on data from the nationally representative Canadian Community Health Survey, which included 25,246 males and females aged 15-29 years.

As expected, both satisfaction with their looks and satisfaction with life were inversely associated with excess weight in females.

In contrast, excess weight in older men was associated with greater satisfaction with life (body image in men was not examined).

While older overweight men were less likely to smoke, excess weight was associated with higher rates of smoking, particularly in younger women.

Both men and women with excess weight reported avoiding food because of caloric content and an attempt to control their weight.

Although most males and females with excess weight acknowledged the fact that they were overweight, 20.4, 29.6, and 36.1% of males with excess weight in the age group of 15-19, 20-24, and 25-29, respectively, seemed to think that their weight is “just about right”.

In contrast less than 10% of females with excess weight in all three age groups thought that their weight is “just about right”.

The study points to important differences in how young men and women perceive their excess weight and the strategies that they may adopt to control it.

The authors explain their interesting finding that overweight men appear more satisfied with life than do overweight women with the notion that while men associate excess weight with being “big and strong”, women tend to associate excess weight with being “fat”, something both sexes appear to fear.

Previous researchers have also suggested that while men may avoid high-caloric foods for health reasons, women tend to do so primarily to control their weight.

These differences have important implications both for public health messaging as well as for individual counseling of men and women with excess weight.

I am guessing that distinctly different strategies will be needed to address excess weight in men and women.

I look forward to any ideas my readers may have on how to better convince men that some of that “big and strong” may actually be a significant health risk.

AMS
Edmonton, Alberta

p.s. Join my new Facebook page for more posts and links on obesity prevention and management

Saloumi C, & Plourde H (2010). Differences in psychological correlates of excess weight between adolescents and young adults in Canada. Psychology, health & medicine, 15 (3), 314-25 PMID: 20480435

In most countries the ratio of obesity between men and women is approximately equal. Yet, the clients in most obesity clinics and weight loss centres are mainly women.

So what is with the guys?

This question was now examined by Jane deVille-Almond and colleagues from the UK in a paper just published online in the American Journal of Men’s Health.

For this study, 266 male drivers were randomly recruited from motorway service stations and asked about body weight perception and awareness of the relation between adiposity and diabetes as well as weight loss attempts.

The median age of participants was 52 years, and 46% were obese based on BMI and 73% based on waist circumference.

Of participants with normal BMI, 18% thought they were overweight, whereas 26% of overweight participants thought they were “just right” and only 19% of obese participants recognized their obesity.

Based on WC, 30% of participants with normal waist circumference thought they were obese and 9% of obese participants realized they were obese.

Only 25% and 42% of participants recognized that diabetes is associated with large waistlies and obesity, respectively.

A total of 81% of overweight and 62% of obese participants (based on BMI) believed that they were not at increased risk of diabetes.

Perhaps not surprisingly, self-perception of adiposity in men was only a weak predictor weight loss attempts.

I guess a lot more has to be done to bring obesity awareness to menfolk’s attention - especially given that their risk for metabolic complications and early infarcts associated with excess weight is as high if not higher than that of women.

AMS
Edmonoton, Alberta

p.s. check out my new Page on Facebook

Deville-Almond J, Tahrani AA, Grant J, Gray M, Thomas GN, & Taheri S (2010). Awareness of Obesity and Diabetes: A Survey of a Subset of British Male Drivers. American journal of men’s health PMID: 20413385