Chantal Petitclerc

This weekend I spoke Montreal at the 2010 Annual Meeting of the Dietitians of Canada. The closing presentation of the conference was given by Chantal Petitclerc, Canada’s elite Paralympic wheel chair racing champion.

In a moving presentation, Chantal spoke about how, after losing the use of her legs in a farm accident at age 13, she eventually discovered wheel chair racing, which set her off on a ride of Olympic proportions. Since winning her first bronze medals in Barcelona in 1992, she officially ended her Paralympic racing career with winning golden medals in all five wheel chair racing distances at the Beijing Paralympics in 2008.

Of all her twentyone Paralympic medals, the one she is particularly proud of, is the one she got for beating her two closest Chinese competitors by covering 100 metres in around 16 seconds for a spectacular finish in front of 91 thousand cheering spectators at Beijing’s Olympic stadium.

But while the actual race may have taken just a few seconds, Chantal cleverly notes that it actually took her 20 years of hard work and perseverance to win that race - years of training, four hours daily, six days a week, 11 months a year, with all the ups and downs, highs and lows, wins and losses.

Clearly, Chantal is also a world champion in cognitive restructuring. Not only did she have to restructure her thoughts after her accident to realise that her life was not over but also had to constantly overcome all the psychological barriers inherent in a career as an elite athlete.

Certainly, there was no place for any “all or nothing thinking”, “shoulds and musts”, “excuses and rationalisations” or “catastrophising”, typical mistakes we often make that stop us from persevering with our goals and quickly recovering from setbacks.

Learning how to avoid and restructure negative thoughts is critical for long-term behaviour change and should therefore be a key element of any evidence-based weight management program.

If Chantal had given up after blowing a training day, had not constantly changed and adapted her training strategy to deal with changing circumstances, had made excuses for or rationalised her setbacks, had given in to thoughts that any race lost was the end of her career, she would not have ended up where she did.

Thinking you blew your “diet” because you took a bite of the “wrong” food, thinking you “should” or “must” reach a certain weight, always blaming your setbacks on others, or thinking that any pound regained is just the first step to gaining it all back again, are all surefire ways to failure.

Fortunately, with professional help, negative thinking and thought distortions can be overcome. As Chantal pointed out, she would probably not have won her 100 m Gold metal in Beijing had she not regularly Skyped with her sport psychologist.

Successfully maintaing weight loss is like training for the olympics - one day at a time!

AMS
Edmonton, Alberta

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Hay PP, Bacaltchuk J, Stefano S, & Kashyap P (2009). Psychological treatments for bulimia nervosa and binging. Cochrane database of systematic reviews (Online) (4) PMID: 19821271

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

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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

Dr. John Blundell

Yesterday, I had the pleasure of hosting John Blundell, at the Research in Progress seminar series at the Alberta Diabetes Institute.

Dr. Blundell is Professor of bio-psychology at the University of Leeds, UK, and is certainly one of the preeminent authorities on the bio-psychology of ingestive behaviour.

His presentation with the rather provocative title, “Will exercise make you fat?”, started with a broadside at the media, which lately has been quite active in promoting this notion.

However, as Blundell pointed out, this simplistic message is far from accurate in that the relationship between physical activity and its impact on ingestive behaviour and body weight is anything but straightforward.

For one, although short-term studies (days) do often show an increase in appetite, this is by no means regularly observed in longer-term studies (weeks).

In a paper he recently published in the Journal of Clinical Endocrinology and Metabolism, Blundell recently examined the effects of medium-term exercise on fasting and post-prandial levels of appetite-related hormones and subjective appetite sensations in overweight and obese individuals.

The study included 22 sedentary individuals who took part in a 12-wk supervised exercise programme (five times per week, 75% maximal heart rate) and were requested not to change their food intake during the study.

Not only did exercise result in a significant, albeit modest (~3 Kg), reduction in body weight and fasting insulin and an increase in ghrelin plasma levels but also in a reduction in fasting hunger sensations.

A significant reduction in postprandial insulin plasma levels and a tendency toward an increase in the delayed release of glucagon-like peptide-1 (90-180 min) and a greater suppression of postprandial ghrelin.

Thus, although exercise-induced weight loss was associated with physiological and biopsychological changes towards an increased drive to eat in the fasting state, this compensatory effect seems to be balanced by an improved satiety response to a meal and improved sensitivity of the appetite control system.

However, as Blundell pointed out, these mean changes hide the immense diversity between individuals.

Based on these studies it appears impossible to predict in advance how individuals will respond: Some people, in response to exercise, will be hungry and may overeat – others may find that they are much better in controlling their food intake.

Importantly, all subjects, irrespective of their body weight, showed a reduction in their amount of body fat and improvements in risk markers like physical fitness and blood pressure.

Thus, Blundell concludes, exercise does reduce body fat (even in people who do not lose weight) and has beneficial effects on important health parameters.

The answer therefore clearly is: no, exercise does not make you fat, but don’t expect to lose a lot of weight.

The many important benefits of exercise can, unfortunately, not be measured on a scale.

AMS
Edmonton, Alberta

Martins C, Kulseng B, King NA, Holst JJ, & Blundell JE (2010). The effects of exercise-induced weight loss on appetite-related peptides and motivation to eat. The Journal of clinical endocrinology and metabolism, 95 (4), 1609-16 PMID: 20150577

Recent population surveys show that as many as two out of three women will report trying to lose weight in the past year.

Obviously, this answer does not really tell us much about what women are actually doing, as the types of diets and weight loss strategies seem virtually countless - some perhaps healthier than others.

Now a study by Stephanie Lanza and colleagues from Pennsylvania State University, published in the latest issue of OBESITY, suggests that women’s weight loss strategies can be divided into four common strategies and that simple questions can help predict these behaviours.

The study used a statistical method called latent class analysis (LCA) to identify subgroups of individuals who shared similar patterns of weight-control strategies amongst 197 non-Hispanic white women living in central Pennsylvania by analysing their response to 14 commonly used healthy and unhealthy weight-loss strategies.

Four groups were identified:

“No Weight Loss Strategies” (10%): individuals in this group are characterized by a low probability of reporting any weight-control strategy.

“Dietary Guidelines” (26.5%): individuals in this group have a high probability of reporting use of strategies consistent with healthy practices present in current guidelines, such as increased fruits and vegetables intake, increased exercise, decreased fat intake, eliminating certain foods, and reducing calories.

“Guidelines+Macronutrient” (39.4%): individuals in this group, in addition to the healthy practices of the guideline users, also have a high probability of reporting trying a low-carbohydrate diet.

“Guidelines+Macronutrient+Restrictive” (24.2%): individuals in this group report having tried nearly all weight-loss strategies, including both healthy and unhealthy strategies. This is the only subgroup of individuals who were likely to report skipping meals; use of appetite suppressants/liquid diets/diet pills; reducing alcohol consumption; and fasting.

Perhaps not surprisingly, women with weight concerns, the desire to be thinner, and dietary restraint were far more likely (in fact 10 to 30 fold more likely) to be in the “Guidelines+Macronutrient+Restrictive” class than in the “No Weight Loss Strategy” class.

The relationship between disinhibition and behaviour was more complex: disinhibition increased the odds of engaging in any weight-loss strategy when restraint was low; whereas, disinhibition increased the odds of engaging in unhealthy compared to healthy weight-loss strategies when restraint was high.

The authors interpret these findings to suggest that being both highly restrained and disinhibited may be a strong predictor of unhealthy, extreme weight-loss behavior that may ultimately be counterproductive.

As a clinician, I wonder if the identification of these behavioural classes will help better manage patients in these classes or even provide reasonable predictors of attrition and outcomes in clinical weight management programs. My guess is that individuals in the “Guidelines+Macronutrient+Restrictive” will pose a far greater clinical challenge than individuals in any of the other classes.

Clearly, in the same manner that obesity is not a homogeneous disorder, weight control behaviours come in different flavours - something that should perhaps never be forgotten in counseling.

AMS
New York, New York

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Lanza ST, Savage JS, & Birch LL (2010). Identification and prediction of latent classes of weight-loss strategies among women. Obesity (Silver Spring, Md.), 18 (4), 833-40 PMID: 19696754

Yesterday, I presented Grand Rounds at the Holy Cross Pain Centre in Calgary. As regular readers will recall, pain is a common consequence and/or cause of weight gain and very often a major barrier to weight management.

Not only is obesity commonly associated with conditions such as fibromyalgia, back pain, osteoarthritis, or plantar fasciitis but also migraines and other forms of headaches.

In the same manner that obesity is a complex syndrome that has a multitude of psychosocial and biological determinants, so is chronic pain. It was therefore not surprising to see that many of the principles of interdisciplinary pain management used at the Holy Cross Pain Centre are not very different from the principles we use in the Weight Wise program.

The team at the Pain Centre is fortunate to have the support of physio- and occupational therapists, nurses, psychologists, pharmacists, dietitians and other allied health professionals as well as a wide range of physician consultants working at their centre.

This complement of health professional is indeed very similar to what we have in our obesity clinic.

There are other important similarities: managing patient expectations, emphasis on self-management, focus on functional goals, attrition rates, and other characteristics of chronic disease management programs.

As I have often blogged, obesity is not really different – it just takes the same approach and resources to manage as other chronic conditions – no more, but also no less!

AMS
Calgary, Alberta