Arya M. Sharma, MD

At the 1st National Summit on Weight Bias and Discrimination organized by the Canadian Obesity Network in Toronto almost exactly a year ago, I learnt that weight-based bullying is one of the most common and pervasive forms of bullying experience by children and youth.

This topic is further examined by Obesity Network Bootcamper Atif Kukaswadia and colleagues from Queens University, Kingston, Ontario in a paper just published in OBESITY FACTS.

The researchers report on their findings in a longitudinal analysis of the Health Behaviour in School-Age Children Survey conducted in 2006 and then again in 2007, which included 1,738 youths from 17 Ontario high schools.

Based on self-reports, excess adiposity preceded bullying involvement and obese and overweight males reported 2-fold increases in both physical and relational victimization, while obese females reported 3-fold increases in perpetration of relational bullying over the observation period.

In addition, among those free of bullying at baseline (2006), significant increases in perpetration of relational bullying were reported by obese females in 2007 relative to normal-weight females (14.8 vs. 3.8% among normal-weight girls).

These findings support previous findings on the increased risk for bullying faced by overweight and obese youth and certainly suggest that this problem, if anything, is getting worse.

Given the many deleterious (and often lasting) effects of bullying on mental and physical health, this issue is certainly something that should concern us all.

Thus, it is certainly not surprising that one of the strategic priorities identified at CON’s Weight-Bias Summit was to “address weight-bias and discrimination in education settings”.

A full report of the Summit is available here.

AMS
Edmonton, Alberta

Kukaswadia A, Craig W, Janssen I, & Pickett W (2011). Obesity as a determinant of two forms of bullying in ontario youth: a short report. Obesity facts, 4 (6), 469-72 PMID: 22248998

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In a follow up to yesterday’s post on why parents are often reluctant to seek professional help to deal with their kid’s excess weight, I want to draw my readers’ attention to an article by Jillon Vander Wal and Elisha Mitchell from Saint Louis University, MO, just published in Pediatric Clinics of North America.

The paper gives a succinct overview of the many psychological and behavioural problems that can be associated with excess weight (or weight gain) in kids and adolescents: body dissatisfaction, symptoms of depression, loss-of-control eating, unhealthy and extreme weight control behaviors, impaired social relationships, obesity stigma, and decreased health-related quality of life.

The authors note the importance of recognizing and addressing psychosocial issues in overweight kids - they point out that:

“ecological models that take into consideration individual, psychosocial, physical, and macrolevel environments are best suited for understanding the associations between child obesity and psychosocial difficulties”

They discuss how such approaches can be important determinants of successful interventions:

“Consistent with the bioecological theory, these interventions addressed the more immediate family social context, but also the broader peer environment. These findings highlight the importance of addressing these issues before the initiation of weight loss treatment or, at the very least, concurrently. The addition of social facilitation and skills building may prove to be a core improvement to lifestyle intervention programs.”

While noting that:

“The topics of weight and mental health issues must be approached with care and consideration.”

the authors also point out that:

“Physicians must objectively evaluate psychological complications among overweight youth and not assume maladjustment.”

A number of non-threatening and non-judgemental ‘conversation starters’ for assessing mental health concerns are suggested (e.g. Does your child express concerns regarding appearance?, Does your child worry a lot?).

The paper also provides practitioners with a list of standardized and validated assessment tools that can help explore a wide range of important dimensions like emotional functioning, physical functioning, teasing/marginalization, positive social attributes, mealtime challenges, and school functioning (e.g. Sizing Me Up).

As the authors point out:

“More comprehensive screenings for high-risk populations are also available and should be used by appropriately trained professionals, preferably in multidisciplinary treatment settings. These tools are most applicable for high-risk children, such as children with BMIs of 40 or greater or for youth presenting for professional weight loss services.“

Ideally, if significant psychosocial concerns are identified, the family can be referred to an experienced psychologist for further consultation and management:

“Pediatricians may consider referral to psychologists who can assess for a broad range of physical and mental health conditions and aid in their treatment, as well as associated psychosocial difficulties.Further, psychologists can intervene from a systems-level approach to promote the individual, family, and social-level change needed to promote and maintain weight loss. A psychologist intervening at a systemic level works not only with the child, but with the child’s family to promote healthy eating practices, engage in opportunities for physical activity, and establish positive peer interactions at home, with external caretakers, in the child’s school, and in the surrounding community. “

As the authors conclude:

“Addressing psychological complications associated with pediatric obesity is an important component of treatment success.”

I would certainly like to hear from any of my readers, who have had positive and helpful interactions with health professionals regarding their kids’ excess weight.

AMS
Edmonton, Alberta

Vander Wal JS, & Mitchell ER (2011). Psychological complications of pediatric obesity. Pediatric clinics of North America, 58 (6), 1393-401 PMID: 22093858

I always thought that the three most important determinants of food choices for most people are taste, cost and convenience. (interestingly, health benefits feature much further down this list than most people think).

Now a fascinating article by Matthew Ruby and Steven Heine from the University of British Columbia, just published in APPETITE, suggests food choices also have to do with factors like virtue and masculinity.

In Western societies, people who chose to be vegetarian most often do so for reasons that are widely perceived as virtuous: concern for animal welfare, concern for the environment, and concern for health ( a fourth reason is disgust at the sensory qualities of meat - but this often develops after people have been vegetarian for a while). This raises the issue of whether or not vegetarians themselves are less tolerant of omnivorous diets.

But choosing to eat meat or go vegetarian may not just be about perceived morality or virtue. As the authors point out, in many societies, meat consumption is associated with manhood, power, and virility:

“In contemporary North American society, meat is often viewed as an archetypal food for men, with many men not considering a meal without meat to be a “real” meal, and the concept of the strong and hearty “meat and potatoes man” abounds.”

In their paper, the authors report the results of two studies that looked at people’s perceptions of others who follow omnivorous and vegetarian diets, controlling for the perceived healthiness of the diets in question.

In both studies, subjects were asked to rate targets who were presented in brief identical vignettes - the only differences being the targets’ reported dietary preferences, omnivorous or vegetarian - with regard to three scales: virtue, masculinity and health.

In both studies, omnivorous participants rated the vegetarian targets as significantly more virtuous and rated vegetarian men as less masculine. Ratings of female targets’ masculinity did not differ according to their dietary status.

Thus, the authors conclude:

“Taken together, the two studies support the notion that, above and beyond the previously found effects of diet healthiness, people infer a stronger sense of virtue and morality in those who abstain from eating meat. Especially for male targets, participants perceived vegetarians as less masculine than omnivores….Through purposefully abstaining from meat, a widely established symbol of power, status, and masculinity, it seems that the vegetarian man is perceived as more principled, but less manly, than his omnivorous counterpart.”

These findings may have important implications for dietary counseling. Thus, recommendations to reduce meat consumption (or even to just eat more vegetables) may be less likely to appeal to men, who may perceive this (or fear that others may perceive this) as a loss of masculinity and therefore socially unacceptable.

Indeed, I can easily picture the men, who would happily forgo taste, cost and convenience just to prove to themselves (and whoever else may care) that ‘real’ men eat meat.

On the other hand I can also see why the well-meaning dietary advise from the ‘holier-than-thou’ vegetarian may be ill received by individuals (not just men), who resent the moral and judgmental undertones implied in such advise (especially if it is unsolicited).

Suddenly, the title of Carol Adams’ seminal work, “The Sexual Politics of Meat”, makes so much more sense.

AMS
Edmonton, Alberta

Ruby MB, & Heine SJ (2011). Meat, morals, and masculinity. Appetite, 56 (2), 447-50 PMID: 21256169

In my interactions with patients, I always ask them to tell me when their weight problems began and what they believe contributed to their weight gain.

Broadly speaking, there are two categories: people, who were big (or were considered big by others) as long as they can remember and those, who can often clearly pinpoint when their weight problem started. Individuals in the latter group can often recall a specific event or situation that led to their weight gain (e.g. when I miscarried, when I entered puberty, after my second child, when I moved to Canada, etc.).

After hearing hundreds of such stories, common themes emerge, which in the past have led me to make statements such as, “Many roads lead to obesity” or, “Obesity can happen to anyone - no one is immune”.

So how exactly do people with obesity tend to explain their excess weight and do men and women differ in their explanations?

This fascinating topic was now explored by Louise Smith and Lotte Holm from the University of Copenhagen, in a paper just published in the Scandinavian Journal of Public Health.

The researchers conducted extensive in-depth interviews of 20 Danish middle-aged men and women who had experienced obesity, randomly selected from a representative nationwide dietary survey.

While some of the participants had lost weight, others were weight stable. Some reported being overweight from childhood, others reported steady or sudden weight gain later in life.

Most interestingly, there were clear gender differences in the explanations offered for weight gain between men and women.

In men, the following central themes emerged: Firstly (and most commonly), men reported life-course transitions (usually from youth to adulthood), whereby they perceived education or work-related obstacles that prevented or reduced physical activity levels as most relevant. Men also frequently referred to injuries that reduced their physical activity.

Some men reported eating for comfort or due to personal problems, most often related to work, unemployment, or financial concerns - rarely to social or relationship problems.

Some men also mentioned work environments that promoted overeating (e.g. when I began work as a cook).

The stories that women told were strikingly different. Although women also presented “life-course” explanations, these were less frequently related to shifting living conditions or social obligations, but rather to transitions in the female biological cycle such as puberty, pregnancy, and menopause.

The second theme in women was related to changes in social relationships (e.g. when I met my husband, when we moved in together, etc.).

The third theme in women was overeating related to personal problems, in all cases related to intimate social relationships (e.g. I did not receive adequate love in my childhood, I was brought up in a family with an alcoholic father, etc.).

The fourth theme in women was related to the use of psychopharmaca (e.g. for depression, when I began having lithium, etc.).

As the authors point out, it is perhaps not all that surprising that women are more likely to relate the beginning of their weight problems to their biology (which is clearly far more striking and eventful in women than in men) and to problems in their intimate and personal relationships.

In contrast, men look at both life-transitions and emotional stressors more in the context of work (e.g. new job, retirement, unemployment, financial trouble) or blame injury or other circumstance for reduced activity levels.

Thus, as previous research has shown, when it comes to overeating, women typically invoke family obligations, whereas men allude to obligations outside the family.

The fact that the use of psychopharmaca came up as a distinct theme in women but not in men, may be related to the fact (as the authors suggest) that these drugs are far more commonly used in women than in men.

These gender differences are not only striking but may also have important implications for addressing obesity both in populations and in individuals.

Firstly, nowhere in this discourse of life stories, did “lack of knowledge” come up as a driver of weight gain. Thus, it is perhaps not at all surprising, that the public health strategies focussing on “educating” the public on healthy eating and activity, have thus far had virtually no impact on obesity rates.

Rather, based on their findings, the authors suggest that obesity prevention strategies need to target men and women differently and must take into account their very different life histories:

In women, obesity prevention strategies are perhaps best focussed at key times during their biological lifecycles (e.g. at puberty, around pregnancies and menopause) and emotional eating may be best dealt with by addressing and improving coping skills in personal relationships (i.e. at home, within families, etc.).

In men, obesity prevention efforts are perhaps best targeted at periods of educational or professional transition. Emotional eating in men may be best dealt with by addressing social stressors related to work and livelihood and are probably best offered in the workplace.

Certainly a lot for the public health folks to chew on.

In light of these findings I cannot but help emphasize just how important it is to engage and listen to the people who actually have the problem, which we as researchers and health professionals are trying to help solve.

This is exactly the intention of the Canadian Obesity Awareness and Control initiative for Health (COACH), which I blogged about earlier this week.

If you have not yet taken the COACH survey but would like support this initiative, please take three minutes to complete this survey now.

Click here to take survey

As always, I would love to hear from my readers as to whether or not they can relate to these findings - Copenhagen may not be as far away as we think.

AMS
Edmonton, Alberta

Hat tip to Nathalie for bringing the study to my attention.

Smith LH, & Holm L (2011). Obesity in a life-course perspective: An exploration of lay explanations of weight gain. Scandinavian journal of public health PMID: 21270139

While the phenomenon of depression during and following pregnancy in women is widely appreciated (and often associated with weight gain and/or antenatal weight retention), the effect of pregnancy on mood of fathers is less appreciated.

A recent study by James Paulson and Sharnail Bazemore from the Virginia Medical School, Norfolk, VA, just published in the Journal of the American Medical Association, throws new light on this interesting issue.

The researchers performed a meta-analysis of 43 studies that documented depression in fathers between the first trimester and the first postpartum year involving 28 004 participant.

Although there was substantial heterogeneity between the rates of paternal depression between studies, the average rate of paternal depression in the antenatal period (during pregnancy) was abour 10% but increased to about 25% during the 3 to 6-month postpartum period (after birth).

While paternal depression was more likely in the presence of maternal depression, this was by no means a strong predictor of paternal mood disorder.

These findings have important implications.

Not only is it important to also be wary of mood disorders in expecting and new fathers (especially if the mother has mood problems), but these mood disorders in fathers may need to be addressed.

This is of particular importance given the emerging evidence that paternal depression may have substantial emotional, behavioural and developmental effects on the infant.

Furthermore, it may well be that paternal peripartum depression could contribute to weight gain in dads.

Thus, prevention, screening and interventions for depression should likely be focussed on the couple rather than on the individual parent.

AMS
Oslo, Norway

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Paulson JF, & Bazemore SD (2010). Prenatal and postpartum depression in fathers and its association with maternal depression: a meta-analysis. JAMA : the journal of the American Medical Association, 303 (19), 1961-9 PMID: 20483973