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Old 07-13-2009, 11:56 AM   #1
saucywench
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Default Does Stigma Motivate Weight Loss? The Science Says "No"

This is from WebMD's Medscape blog. Many of the doctors who left responses were quite empathetic, while some of them (no surprise) were absolute assholes. If you're interested in reading the responses, go to
http://www.medscape.com/public/blogs and scroll down to Public Health & Prevention.
P.S. This might get moved to the health board but seems like it belongs here.
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Sizable Issues
Does Stigma Motivate Weight Loss? The Science Says "No"

Posted By: rebecca puhl, , 12:56PM Jul 7

When giving lectures and seminars to health care professionals on the topic of weight stigma, I am sometimes asked the question, “Could stigma be helpful in motivating people to lose weight?” In response to this question, I often describe the mounting evidence demonstrating that weight bias may actually contribute to obesity through unhealthy eating behaviors and avoidance of physical activity, which are common coping strategies used by obese children and adults to cope with negative experiences of stigma and prejudice (1,2). From my own experience as a clinical psychologist treating obese patients, the thought of inducing stigma in patients as a way to provide incentive or motivation to lose weight seems unfathomable as an appropriate or ethical treatment approach.

To be fair though, the issue of whether stigma might serve as a tool to facilitate weight loss outcomes is an empirical question – and one that, until recently, hadn’t really been tested. But two studies were recently published in Annals of Behavioral Medicine, each which approached this issue differently, but both help to challenge this assumption and demonstrate the importance being sensitive to the issue of weight bias as providers counseling patients to lose weight.

The first is a study by Carels and colleagues(3) who studied a sample of overweight/obese treatment-seeking adults participating in a behavioral weight loss program. The authors examined the relationship between patients’ reported weight bias and (a) program attrition, (b) weight loss, (c) self-monitoring adherence, (d) daily exercise levels and overall caloric expenditure, (e) daily caloric intake, and (f) daily caloric deficit. The authors found that greater weight bias was associated with inconsistent self-monitoring, greater caloric intake, lower energy expenditure and exercise, higher program attrition, and a smaller percentage of weight loss. The study provides some of the first evidence that weight bias can interfere with patients’ ability to achieve optimal health through weight loss efforts.

The second study is a randomized treatment study by Lillis and colleagues (4), which showed that, compared to wait list controls, a brief one-day intervention that taught patients acceptance-based strategies to cope with obesity-related stigma resulted in greater improvements in body mass, quality of life, perceived weight-related stigma, and psychological distress at three-month follow-up. Thus, rather than using stigma as an incentive to lose weight, this study suggests that supporting individuals with adaptive ways to cope with weight stigma can facilitate weight loss outcomes. A model that can reduce the distress associated with stigma while simultaneously empowering weight control efforts seems like a worthwhile treatment approach to pursue.

Together, these studies add to the growing science on this issue and provide additional insight about the negative impact of weight bias on health for obese patients. While the topic of weight bias is unfortunately often ignored in discussions about obesity, my hope is that this evidence can help to dispel damaging assumptions about obese persons, and can promote an accurate understanding of the consequences of weight bias and the importance of approaching this issue with sensitivity in clinical practice.

References cited in this blog:

1. Puhl RM, Heuer CA. Weight bias: A review and update. Obesity 2009; 17: 941-964.
2. Puhl RM, Latner JD. Stigma, obesity, and the health of the nation's children. Psychol Bull 2007;133:557-580
3. Carels RA, Young KM, Coit CB, Harper J, Gumble A, Hobbs MW, et al. Internalized weight stigma and weight loss treatment outcomes in treatment-seeking adults. Ann Beh Med. 2009. In press.
4. Lillis J, Hayes SC, Bunting K, Masuda A. Teaching acceptance and mindfulness to improve the lives of the obese: A preliminary test of a theoretical model. Ann Beh Med 2009;37:58-69.
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About This Blog
Sizable Issues is a blog featuring timely research findings and provocative commentary about the stigma and prejudice related to obesity -- also known as "weight bias" -- and its implications for healthcare and quality of life for people struggling with weight.
  • rebecca puhl
    Rebecca Puhl, PhD is the Director of Research at the Rudd Center for Food Policy and Obesity at Yale University. She received her PhD in Clinical Psychology from Yale University. As a clinical psychologist, she has treated patients with eating disorders, binge-eating, and obesity. As a Research Scientist, Dr. Puhl has been studying weight bias for ten years, and has published studies on the prevalence and origins of weight stigma, interventions to reduce weight bias, and the impact of weight stigma on emotional and physical health. Dr. Puhl serves as chair of the Weight Bias Task Force of The Obesity Society (TOS), and is an editor of the book Weight Bias: Nature, Extent, and Remedies (Guilford Press, 2005).
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Old 07-13-2009, 03:44 PM   #2
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Interesting stuff! thanks for sharing saucywench!

The negative effects of stigma/stress/lowered self esteem on the health of "obese" people are supported somewhat by Linda Bacon's HAES findings (as I'm sure you're aware)
Bacon, L, VanLoan M , Stern JS, Keim N. Size Acceptance and Intuitive Eating Improves Health for Obese Female Chronic Dieters. Journal of American Dietetic Association. 2005;105:929-936.
http://www.lindabacon.org/HAESbook/
http://www.lindabacon.org/resources.html
http://nutrition.ucdavis.edu/faculty/bacon.html

And Peter Muennig goes further and suggests in this review http://www.biomedcentral.com/1471-2458/8/128
that stress due to societal stigma may in fact be causal for many of the health problems normally attributed to "obesity"... rather than obesity itself...
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Old 07-13-2009, 04:59 PM   #3
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I could've told them that, but I suppose a study is more relevant than one stubborn girl's experiences when it comes to supporting an argument. Thanks for posting!
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Old 07-13-2009, 05:43 PM   #4
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I could've told them that, but I suppose a study is more relevant than one stubborn girl's experiences when it comes to supporting an argument. Thanks for posting!
A lot of people totally trash anecdotes as evidence...
But if they are first hand they do represent a self-reported dataset...
Admittedly a dataset of just ONE....
So you just need a LOT of first hand anecdotes to form some sort of survey...
and although there's issues with self-reported experience too, it's still evidence of a sort!
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Old 07-13-2009, 06:20 PM   #5
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How whacky it is that a study is needed to convince health care professionals that verbally and/or physically abusing their patients would have the opposite desired affect.
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Old 07-20-2009, 06:38 AM   #6
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Shaking head....Someone's paying for these studies and I'm afraid it's my tax dollars.
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Old 07-20-2009, 07:51 AM   #7
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Originally Posted by joswitch View Post
A lot of people totally trash anecdotes as evidence...
But if they are first hand they do represent a self-reported dataset...
Admittedly a dataset of just ONE....
So you just need a LOT of first hand anecdotes to form some sort of survey...
and although there's issues with self-reported experience too, it's still evidence of a sort!
First hand experience is naturally biased. I listen a lot closer to the personal experiences of those who were directly affected than the conjecture of outsiders. In an atomic blast where people were maimed or killed, if among them a few people came out unscathed I would not be inclined to say the blast wasn't really a blast. I think sometimes these experts need to be told that things don't become true simply by repeating them loudly over and over in a white lab coat. I have to wonder who is most likely to have a bias between those two groups and for me the answer seems simple. I'm a simple person though.
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Old 07-20-2009, 08:20 AM   #8
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Default Rocket Science!

Quote:
Originally Posted by olwen View Post
How whacky it is that a study is needed to convince health care professionals that verbally and/or physically abusing their patients would have the opposite desired affect.
It's rocket science, I'm tellin' ya'. "They" could
never figure that out without a lot of PHD's (Piled
Higher and Deeper) and a lot of expensive research!

Education levels required for US Government Research
Study workers:

BS (Bull Shit)

MS (More the Same)

PHD (Piled Higher and Deeper)
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Old 07-20-2009, 10:23 AM   #9
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I know that this isn't exactly the same thing and I hate to say this, but Singapore's TAF program which is heavily based on shaming and stigmatizing overweight children actually yielded results when it came to weight loss, just at too horrible a cost. I wonder if it is cultural difference that made it possible?

Wiki link (more horrifying articles easily searchable):
Quote:
The Trim and Fit (TAF) program was a weight loss program that targeted child obesity in Singapore schools between 1992 and 2007. Introduced by the Ministry of Education, schoolchildren under the program were educated on nutrition, calorie control, and participated in intense physical exercise and activities.

Overview

Overall, the program was successful in reducing the obesity rate amongst schoolchildren from 14% to 9.8% by 2002. However, it came at a psychological cost of participants being stigmatized and in some cases, reportedly diagnosed with eating disorders.[1][2][3] The TAF program has since been replaced by the Holistic Health Framework (HHF) which includes all schoolchildren.

The program

The TAF program was introduced into schools in 1992 as part of the National Healthy Lifestyle Campaign. It was a result of a 1991 review of the nation's health plan by a national committee. Students aged 9 to pre-tertiary education were required to undergo annual BMI measurements and National Physical Fitness Award test (a precursor fitness test similar to Individual Physical Proficiency Test for National Servicemen). The country's population at that time was showing an increase in obesity that became associated with health problems and loss of manpower for male conscripts in National Service, which caused many conscripts to be deemed unfit for deployment into combat service.[4]

The program was deemed by observers as an interventionist measure, requiring students who were deemed overweight to be subject to additional intense exercises or physical activities for at least one and a half hours per week. These activities were organised during recess or at times set aside before or after lessons at schools' discretion. They were also issued with "calorie cash" - food ration coupons from which no more than a certain number of calories may be purchased and consumed in a recess break. The amount of calorie cash was inversely proportional to the child's obesity rate.[3][5] Children which exceeded the 160% of the ideal BMI were referred to the Health Promotion Board for follow-up action.

A direct impact of the TAF program was a reduction of the obesity rate of schoolchildren from 14% to 9.8% by 2002.[6] Worldwide public health experts have evaluated the TAF model for possible replication around the world.

A carrot-and-stick approach was adopted in putting pressure on schools to meet the targets of fitness and obesity set by the ministry. Cash incentives were awarded by the ministry to schools were that exceeded fitness targets and created new strategies to maintain students' obesity levels. Schools that failed had to face "consultation" sessions with ministry officials. Schools were also ranked annually based on how well targets were met at national level[5]. Schools were given a wide discretion in determining how TAF was to be implemented, which resulted in some schools going so far as to implement apartheid-like segregation - for instance, where children were grouped to sit at normal and overweight tables during recess.[3]

Psychological factors


Psychological motivation and peer pressure was emphasized in implementation of the program, which formed the bulk of criticism of the program as being insensitive and heavy-handed. Several TAF participants reported experiences of stigmatization, teasing, physiological stress and lower self-esteem as they found themselves being singled out for being obese.[5][7][8] It was also quickly pointed out that the name of the program contained a negative connotation, as its reverse acronym was 'FAT'.[1][8] Despite such criticism, education officials continually insisted that the program was not out to stigmatize overweight children.[5]

In 2005, a National University of Singapore study of 4,400 schoolgirls linked TAF to an increase in eating disorders. It found that girls were more likely to have poorer relationship with their parents and their female friends. The findings correlated to a Singapore General Hospital study released a week earlier which found that instances of anorexia nervosa and bulimia increased six-fold from 1994 to 2002.[1][2][9] The Ministry of Education quickly rejected these findings; claiming TAF was not a factor in the increase in anorexia.[10]

Two years later, in 2007, the Ministry of Education decided to replace TAF with the Holistic Health Framework (HHF). The HHF intended to ensure the fitness and health of all schoolchildren.[7][8][11]
I briefly experienced this program thanks to our lower BMI cut-off and the school's paranoia about putting "at risk" or "borderline overweight" children in the program. Most schools, keen to meet ministry standards were extremely harsh. Children in this club are frequently paraded in front of the entire school, cheers for those who lost and boos for those who dared to gain. We had to sit at a special table during breaks, given specific diets, vendors are instructed not to sell "junk" to us, peers encouraged to report those who dared sneak food and we spent at least three hours a week doing extra exercise. There were weekly public weighings, with weight, body fat and progress posted on a notice board for all to see and well, my peers and I generally did not last in this extremely humiliating and compulsory program. In fact, most of us lost weight at a dangerously fast rate (to great praise) and most "graduates" of that program (particularly males who have to serve an additional four months in our compulsory two-year National Service if they are overweight) did not regain the weight.
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Old 07-20-2009, 10:38 AM   #10
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Originally Posted by Cors View Post
I know that this isn't exactly the same thing and I hate to say this, but Singapore's TAF program which is heavily based on shaming and stigmatizing overweight children actually yielded results when it came to weight loss, just at too horrible a cost. I wonder if it is cultural difference that made it possible?

Wiki link (more horrifying articles easily searchable):


I briefly experienced this program thanks to our lower BMI cut-off and the school's paranoia about putting "at risk" or "borderline overweight" children in the program. Most schools, keen to meet ministry standards were extremely harsh. Children in this club are frequently paraded in front of the entire school, cheers for those who lost and boos for those who dared to gain. We had to sit at a special table during breaks, given specific diets, vendors are instructed not to sell "junk" to us, peers encouraged to report those who dared sneak food and we spent at least three hours a week doing extra exercise. There were weekly public weighings, with weight, body fat and progress posted on a notice board for all to see and well, my peers and I generally did not last in this extremely humiliating and compulsory program. In fact, most of us lost weight at a dangerously fast rate (to great praise) and most "graduates" of that program (particularly males who have to serve an additional four months in our compulsory two-year National Service if they are overweight) did not regain the weight.
Sweet Mary. I wonder what became of the 9.8% of kids who did not lose weight in this concentration camp? *shudders*
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Old 07-20-2009, 10:54 AM   #11
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Sweet Mary. I wonder what became of the 9.8% of kids who did not lose weight in this concentration camp? *shudders*
I dated a few women who "failed" the program (from ages 6 to 18 if you are unlucky) and it wasn't because they didn't try. They were all seriously traumatized by the experience and had severe body image issues.

I have a BHM flatmate who turned out okay though - the only one I know who seemed fine at least. He goes by the nickname "Fat", constantly jokes about his own weight but he is generally thick-skinned and apathetic.
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Old 07-20-2009, 01:52 PM   #12
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Originally Posted by Cors View Post
I know that this isn't exactly the same thing and I hate to say this, but Singapore's TAF program which is heavily based on shaming and stigmatizing overweight children actually yielded results when it came to weight loss, just at too horrible a cost. I wonder if it is cultural difference that made it possible?

Wiki link (more horrifying articles easily searchable):


I briefly experienced this program thanks to our lower BMI cut-off and the school's paranoia about putting "at risk" or "borderline overweight" children in the program. Most schools, keen to meet ministry standards were extremely harsh. Children in this club are frequently paraded in front of the entire school, cheers for those who lost and boos for those who dared to gain. We had to sit at a special table during breaks, given specific diets, vendors are instructed not to sell "junk" to us, peers encouraged to report those who dared sneak food and we spent at least three hours a week doing extra exercise. There were weekly public weighings, with weight, body fat and progress posted on a notice board for all to see and well, my peers and I generally did not last in this extremely humiliating and compulsory program. In fact, most of us lost weight at a dangerously fast rate (to great praise) and most "graduates" of that program (particularly males who have to serve an additional four months in our compulsory two-year National Service if they are overweight) did not regain the weight.
Holy hell! That's some horrifying shiz right there!
If I wasn't already set to be activizing against this kind of bullying this alone would be enough to do it!

Wow, Cors I'd read a lot of your posts about the weight-centered bullying you'd suffered but I didn't realize it was state-sponsored bullying! *hugs4u*
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Old 07-20-2009, 03:11 PM   #13
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That story from Singapore really is pretty chilling. Hell of a screwed up way to go about business, to say the least.

But yeah, none of this should come as a surprise; when a person acts out of fear and negative emotion, it's typically harder for them to accomplish something in a positive way. You've got people afraid of the "fat stigma" going on idiotic crash diets and unrealistic diet/exercise regiments that they could never hope to sustain (or worse, they develop eating disorders), or some who grow so afraid and hurt that they sort of crawl into a little space and just give up hope of ever accepting themselves.

Encouraging people to be active and to make some healthier choices along the way is fine by me, but attaching a specific stigma to something like fat is just disgusting, and while it shouldn't require a study for that to be obvious, I'm glad it's done and that there's now something on the books saying all but definitively that it doesn't work.

If you talk to somebody about health in a meaningful, realistic way, and explain that almost anyone at almost any size could live a healthy lifestyle, you're much, MUCH more likely to get that person to do positive things for themselves, even if it doesn't involve losing a single pound. Scaring them with a stigma will just engender negative and possibly destructive behavior.
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