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Weight management

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9th Jul 2013

This Update looks at the psychology of food, eating, weight and body image.

Dr Rick Kausman MBBS

Principal, If not dieting Weight Management and Eating Behaviour Clinic; Director, Butterfly Foundation; Fellow of the Australian Society for Psychological Medicine; Author of If Not Dieting, Then What?

Conflicts: nothing to declare

Introduction

International research is clear that for many of the wealthier countries around the world, the number of people at a higher weight has reached, or at the very least is close to reaching, the highest level it has ever been.

While the current research is showing somewhat of a levelling off of this rising trend of the past few decades, this change has still happened very quickly.

It should come as no surprise that this change has occurred. The forces that have, and are continuing, to contribute to this situation are understandable and have become overwhelming.

Over the past 50 years or so, most people have been doing significantly less physical activity than at any other time in history. At the same time, in many countries, food is becoming more accessible, brilliantly marketed, processed, pre-made and pre-packaged, and available at a price that a lot of people can afford. Combined with this, life for many of us seems to be getting busier and busier.

These are all very good reasons why it is more likely, and even a common occurrence, that we purchase more pre-prepared and take away food.

In addition to this, many of us are doing a significant amount of eating that we are not physically hungry for. A number of years ago, I coined the term ‘non-hungry eating’ to describe this type of eating. It is normal and can even be helpful to do some non-hungry eating, but too much can be a key reason why many people end up becoming, and staying, above their most healthy weight.

There are many reasons why we may be eating a lot of the time when we are not feeling physically hungry, but for any one person, it is often due to a whole range of reasons. For example, we may be eating while doing other things (not eating mindfully), eating to finish off everything on our plate, eating due to life pressures, and we may be eating because of many different emotions.

These key factors — less movement, more food availability, less time/priority to prepare food, and a significant amount of non-hungry eating, combined with the human biological and genetic ability to store excess energy as fat — have largely contributed to the trend over the past decades of pushing more people to a higher weight.

At the same time, as the population weight gain has been evolving — incredibly and most unhelpfully — the cultural ideal of what size and shape is the most desirable has gone in the opposite direction.

So as the weight of populations has continued to go up, the ‘ideal’ cultural size and shape has continued to go down. This has led to a situation where almost all of us cannot possibly be at a size or shape that the culture says is ‘best’ or ‘ideal’ (whether we are above our most healthy weight or not). And significantly, for many of us, our size and shape is inextricably linked to how we feel about ourselves.

So within a relatively short period of time in human history, a particularly tricky combination of factors have come together: weight gain for a significant number of people in the community (with an association of some health risks from a population point of view), combined with a body cultural ideal that is nigh on impossible to achieve, accompanied by the feeling that we are not good enough as we are.

Can we tell if a patient is healthy by looking?

Research is now clearly showing that we can’t tell if an individual person is healthy simply by looking at them, weighing them, or measuring them. Many bigger-sized people are in fact simply a natural and healthy form of human diversity.

The latest research is showing that relative to ‘normal weight’ (BMI = 18.5—25), Grade 1 ‘obesity’ (BMI = 30—35) was not associated with higher mortality, and ‘overweight’ (BMI = 25—30) was associated with significantly lower all-cause mortality. 1

In addition to this research, there are now many journal articles discussing the so-called ‘obesity paradox’; that is, there are many situations and associations where heavier cohorts within a population are not at a higher health risk than their lower-weight cohorts (e.g. fat/fit versus thin/unfit).

This in no way discounts the research that shows there are some associations of a higher health risk such as for developing type 2 diabetes for a higher weight cohort. It simply highlights the complexity of the issue, that even among population cohorts, associations of a higher weight and health risk are unclear.

However, what is clear is that if there is confusion with regard to the association of health risk and weight within populations, it is simply impossible to extrapolate what health risk there might be when only considering an individual person’s weight.

Instead, it is vital that we focus on each individual patient on their own merit, irrespective of their weight.

In general, we have been focusing on the wrong ‘W’. We have been focusing on weight rather than wellbeing. While we want to encourage people to be the healthiest they can be, and as a result of that, the healthiest weight they can be for them, the helpful and appropriate message of being healthy and encouraging healthy habits, has become unhelpfully and inappropriately confused with the message that one should focus on being thinner and/or on losing weight.

So what are some key things we can do to help all our patients to be the healthiest they can be (irrespective of their weight, and without making weight the primary focus)?

Language

The word obese and obesity has slipped into everyday use for many practitioners. However, recent research shows that both women and men feel this terminology is negative, judgemental and pejorative.

Using this language can in fact get in the way of having a discussion about healthy habits. Not only that, research is also showing us that if women feel they are being judged for being a certain size, they are less likely to present for routine preventive health checks such as mammograms and Pap smears. I will never forget the day one of my patients told me that her doctor had called her ‘a beast’. I am confident the doctor didn’t call her ‘a beast’, but had called her ‘obese’, and unfortunately it sounded the same to her.

So what are our alternatives? I have found using more morally neutral language when talking about weight to be helpful. For example, talking about a person being above his/her most comfortable weight (range) has been beneficial for many of my patients. One of my patients described her experience as follows:

“For the first time in a long while I feel truly hopeful and optimistic about my ability to achieve the most comfortable, healthy weight I can be. Even that phrase itself gives me hope, because it’s a really positive phrase — it allows me hope.”

Dieting is not the answer

The research is now clear. The burgeoning commercial weight loss industry has actually contributed to the current health issue in many ways. Directly associated with the behemoth that is now the commercial weight loss industry, not only are more people at a higher weight compared with 20 years ago, but increasingly, people are developing difficulties with their relationship with food.

These difficulties can range from people feeling like they shouldn’t keep biscuits in their house for fear of eating all of them, all the way through to the development of disordered eating and eating disorders.

Mann and Tomiyama, in a review of 31 studies, found that “several studies indicate that dieting is actually a consistent predictor of future weight gain. One study found that both men and women who participated in formal weight-loss programs gained significantly more weight over a two-year period than those who had not participated in a weight-loss program”.

“[And] these studies show that one-third to two-thirds of dieters regain more weight than they lost on their diets and… these studies likely underestimate the extent to which dieting is counterproductive.” 2

Non-hungry eating ®

As previously mentioned, many people are doing a significant amount of non-hungry eating. When people are asked to estimate the percentage of non-hungry eating they may be doing, the answers can range from 30 to 40%, to anything up to 60 to 100% of their total eating.

If an individual patient is doing a significant amount of non-hungry eating, to assist their awareness, it can be very helpful to encourage them to ‘check in’ with their body before and after they have something to eat on a hunger-fullness, mindful eating scale (Figure 1). 3


Simply being more aware of hunger and fullness before and after we eat can quickly help people to decrease the amount of eating they are doing that they are not physically hungry for, and can increase the likelihood of being more aware of the reasons they might be eating when they are not physically hungry.

Research is now clearly showing the benefits of taking this mindful eating, non-dieting approach. Studies are showing people using this approach have improved physiological health (such as improved blood pressure, cholesterol and blood glucose levels), improvements in health behaviours (such as eating behaviours and physical activity levels), and psychological improvements (such as how people feel about themselves and their body image). Madden et al in a study of 1601 New Zealand women published in 2012 concluded that “eating in response to hunger and satiety signals is strongly associated with lower BMI in mid-age women”. 4 Gast et al in a study of US college students also published in 2012 concluded that “results showed being an intuitive eater [mindful eater] was associated with a lower body mass”. 5

Eating slowly

Many people find they eat quickly, and eat quickly a lot of the time. If people do eat quickly, it is likely they will end up eating more than what they really feel like, and more than what their body is asking for.

In this way, over time, our patients can’t help but eat more food than what is best for them. This behaviour can contribute to people becoming, and staying, above their most healthy weight. An increasing number of studies are showing the benefits of helping our patients to eat more slowly.

Sook Ling Leong et al found that faster eating was associated with higher BMI, and that BMI was significantly increased for each category increase in self-reported speed of eating. 6

Everyday and sometimes food

It is very common for many people to feel guilty about eating a range of different types, and amounts, of food. For many of us, it is actually very challenging not to feel guilty about eating. Within our culture, there are messages almost everywhere we go implying that we should feel guilty about eating.

So while it is very understandable that many of us are feeling unsettled and guilty about what we should be eating, it is extremely unhelpful to feel this way. Rather than talking about food as ‘good food’ and ‘junk food’, it is much more useful to use the terminology ‘everyday food’ and ‘sometimes food’.

Feeling unsettled and guilty about food is extremely unhelpful.

Clinical experience and research continues to show that when we feel guilty about food, rather than helping us to eat less, it actually increases the chances of us eating more. Fletcher et al said that “instead of helping people to eat more healthily, the negative affect… appears to have the opposite effect in that it can increase their desire for the very foods they are trying to avoid.”7

Self-compassion and body image

In my practice, when I ask people what they do to take care of themselves, I often get a range of responses, but almost always with a similar theme. A lot of blank looks, some embarrassed smiles and only occasionally do I hear a few things that seem to be truly supportive and nurturing of that person.

Rather than our patients being self-critical, it can be very helpful to encourage people to be more self-compassionate. Evolving research by Kristin Neff is showing how important self-compassion is for our wellbeing. With respect to eating behaviour, Adams and Leary found “self-compassion was associated with a lower tendency to eat as a way of coping with negative emotions”.8 Helping people to feel better about their body image is also a key aspect of helping people be the healthiest and the healthiest weight they can be.

Avalos and Tylka put it very well: “Although certain societal messages suggest that some degree of body dissatisfaction is healthy... our results provide an argument for the opposite. An appreciation of the body is more likely to be associated with intuitive eating. Because intuitive eating emphasises responding to internal hunger and satiety cues, individuals who eat intuitively on a regular basis are more likely to be at a weight that is appropriate for their body type, and have higher levels of psychological wellbeing.”9

New moves

With catchy, but mostly misleading messages such as ‘go hard or go home’ and ‘no pain, no gain’, we have, as a society, created further barriers for many people to increase their physical activity.

Even the word exercise has, for many of us, become a negative, disempowering word as it has often been associated with the incorrect concept of physical activity having to hurt to be worthwhile.

An overwhelming amount of research is showing that small amounts of physical activity is still helpful, and for many of our patients, it is clearly the best way of getting them started on increasing the amount of moving they are doing.

In addition, there may well be opportunities to discuss some changes in the type of food our patients eat. The total amount of food and the amount of non-hungry eating our patients have been doing is a major factor in being the healthiest they can be, and as a result of that, achieving and maintaining a healthy weight for them. Nevertheless, at the appropriate time, it can still be of benefit for some of our patients to discuss how they might be able to make some changes in the type of food they eat. A key message here is that when our patient is ready, it can be helpful for them to finetune what they are eating and drinking in a non-deprivational way.Text Box:  

References:

1.Flegal K et. al. Journal of the American Medical Association. January 2013, Vol 309, No. 1

2.Mann et. al. Medicare’s search for effective obesity treatments. Diets are not the answer. American Psychologist, Vol. 62 (3), 2007, 220-233.)

3.Kausman, R. If Not Dieting, Then What? Allen & Unwin. 2004

4.Madden EL, et al. Eating in response to hunger and satiety signals is related to BMI in a nationwide sample of 1601 mid-age New Zealand women. Public Health Nutrition, 2012, 15, pp 2272-2279. doi:10.1017/S1368980012000882.

5. Gast et. al., Are men more intuitive when it comes to eating and physical activity? American Journal of Men’s Health. 2012. Vol 6 (2) 164-171.

6.Leong SL, et al, Journal of the American Dietetic Association

Volume 111, Issue 8, August 2011, Pages 1192–1197

7. Fletcher et. al., How visual images of chocolate affect the craving and guilt of female dieters. Appetite. 48 (2007) 211-217.

8.Adams, Leary, Journal of Social and Clinical Psychology December, Vol. 26, No. 10, pp. 1120-1144

9.Avalos LC, Tylka TL. Exploring a model of intuitive eating with college women. Journal of Counseling Psychology, Vol 53(4), Oct 2006, 486-497.

 

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