Beyond Dieting

Psychoeducational Interventions For Chronically Obese Women

Donna Ciliska

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134851133
• Edition: 1
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

This book opens with an overview of dieting and its relationship to self-esteem and body image. Here, the author explores the negative and destructive side effects frequently experienced by obese women as a result of dieting. Alternative interventions to dieting are then explored and the weekly Beyond Dieting programme, the core of this volume, is introduced. Subsequent chapters present an evaluation of the Beyond Dieting program (purpose, analyses, comparisons and variables of outcome) and a discussion of the characteristics of the sample study. The overall effects of the intervention and implications of the findings provide an illuminating perspective on the treatment of obesity – one that suggests striving for positive self-image rather than thinness as the key to well-being for obese women. For the many health practitioners caring for obese women, this perspective, with its practical application, will prove to be an invaluable resource.

1

Is Dieting the Answer?

The development of ideas for this program came from the review of literature in several areas. These included definitions of the concepts of self-esteem and body image, and their theoretical underpinnings. Literature is presented here relating appearance to self-esteem, the current cultural drive for thinness, and the subsequent stigmatization of the obese. Gender and gender role differences in self-esteem are not fully examined.

Many health professionals treat the obese as though there were a standard for weight beyond which one is at high risk for the development of cardiovascular disease and Type II diabetes mellitus, and as though there were safe, effective means for all obese people to reduce weight. The basis for this belief is explored in this review, and the controversy surrounding the belief led to the inclusion of certain topics in the intervention: Is obesity a health risk? Is there an effective way to control weight? Are there any health risks involved in repeated cycles of calorie restriction followed by overeating? In order to develop these ideas, literature is included, but is not comprehensive, in the following areas: the measurement of obesity, its etiology, weight regulation, the health risks of obesity, treatments for obesity and their effectiveness, the effects of dieting, and alternative interventions to dieting for the obese.

SELF-ESTEEM, BODY IMAGE, AND THE CULTURAL DRIVE FOR THINNESS

Literature was reviewed regarding the concepts of self-esteem and body image, and the relationship of appearance to self-esteem. Our notion of standards of attractiveness are culturally determined. Thus, the cultural perspective of the current ideal of thinness in women is examined in relation to the subsequent stigmatization of those who do not meet the stringent standards of beauty and, again, the potential effect of this prejudice on the self-esteem of the obese.

Self-Esteem

A review by Wells and Marwell (1976) has shown that self-concept may be subdivided into three major domains: the specific content of the attitude toward the self (cognitive); judgment about that content relative to a standard (evaluative); and some feeling attached to that judgment (affective). Self-esteem is viewed as a subset of self-concept because it is related to the affective evaluative component. Content is considered important, but is generally thought to be secondary to the emotional tone or evaluative aspect of self-concept (Wells & Marwell, 1976, p. 59).

Many discrepant definitions of self-esteem are given by different theorists in the literature. Self-esteem has been considered to be a need (Maslow, 1954), an attitude (Coopersmith, 1967), a result of a certain level of competence (White, 1964), an index of mental health (Fitts, 1972), a moderating variable (Ziller, 1973), the purpose of all human activity (to enhance self-esteem) (Hayakawa, 1963), and an artifact, in that we cannot perceive of ourselves as objective entities (Lowe, 1961).

In keeping with the various different definitions of self-esteem, many theorists have written about the development of self-esteem from their particular theoretical framework. Freud (1923) regarded the ego in infancy and childhood to be, first, a body ego which evolves, through the process of separation-individuation, to body image. The body is, therefore, the first sense of self. Other major theorists who have considered the development of self-esteem include Adler (1929), Cooley (1956), Horney (1950), Kohut (1977) and Sullivan (1953). They have attributed the development of self-esteem to our interactions with significant others; moreover, they share the view that negative influences on the self may be minimized or reinforced by other people around us.

Cotton (1983) has synthesized several theoretical approaches in describing a developmental approach to self-esteem. During infancy, positive feelings of well-being arise from the relationship with a caregiver (usually a mother) who is responsive to the infant's needs; from the experience of one's own body which manages to effect change; and through incorporating parental behavior, personality, and the emotional milieu of the family into the sensorimotor self. The toddler develops self-esteem by differentiating the self from nonself through negativism, and by mastering motor, cognitive, and language skills. This stage involves expansion of the self through negotiation of the oral and anal stages and development of gender identity. Further skill development, parental approval, identification with parental qualities and roles, and expanded peer and teacher relationships all serve to develop self-esteem in the school-age child. Sexual identity and stronger peer relationships mark adolescence. The sense of personal identity is stronger and creates a more stable level of self-esteem.

For the purposes of this research, Rosenberg's social psychological approach (1965, 1981) to the self was used as an appropriate theoretical base for the study of obese women. Rosenberg (1965, p. 30) has defined self-esteem as a positive or negative attitude toward the self. He has developed a self-esteem scale to assess such attitudes—the extent to which individuals feel they are worthy and self-accepting, yet realistic in the sense of being aware of deficiencies and wanting to grow. While high self-esteem may connote that one thinks he or she is “good enough” or “very good,” low self-esteem implies self-rejection, self-dissatisfaction, and even self-contempt.

Rosenberg (1981) expanded on earlier theorists to develop his social-psychologic approach. He further elucidated the effect on the self of interpersonal interaction, social identity, social context, and social institutions. He hypothesized that, although self-concept is located in the inner world of thought and experience, social factors play a major role in its formation so that self-concept arises:

out of social experience and interaction; it both incorporates and is influenced by the individual's location in the social structure; it is formed within institutional systems, such as the family, school, economy, church; . . . and it is affected by immediate social and environmental contexts (p. 593).

Applying this social-psychological perspective to obese women, one can see how their self-esteem would be reduced by face-to-face interaction with people whom they judge as significant and who respond to them with the general disparagement accorded most obese in our society. “We come to see ourselves as we think others see us” (Rosenberg, 1981, p. 597), imagining our appearance to the other person, imagining the judgment he or she is making of that appearance, and formulating some sort of self-feeling as a result of that judgment. Rosenberg calls this principle of self-esteem formation “reflected appraisals.”

Expertise is an important basis for imputing credibility to another person. Generally, in our Western society, the medical community has seen obesity as a danger sign or in moralistic terms implying personality faults, weakness of will, or laziness in the lack of success at weight loss (Bennett & Gurin, 1982). Furthermore, the media are full of advertisements for commercial weight loss programs, diet books, and meal plans, all written and directed by the latest “expert.” In summary, there are many authoritative messages in day-to-day living that give the obese woman negative “reflected appraisal.”

The social context is such that interacting with people of average weight, or closer to the very thin ideal, results in a comparison that leaves obese women with even lower self-esteem. “If other people can maintain normal weight, why can't I?” This illustrates a second principle of self-esteem formation, that of “social comparison,” or learning about oneself by comparison to others (Rosenberg, 1981, p. 603).

In comparison to men, or to other women, obese women are not a strong social force. That may change as the clothing and fashion industry is just beginning to address the market for better quality large-size clothing. Furthermore, the National Association to Advance Fat Acceptance (NAAFA) has recently begun to give public education, to respond to offensive advertising, to raise awareness of discrimination, and to offer support groups. However, the obese are clearly not a strong political force except for a few such small vocal groups.

Self-esteem is also affected by social identity. The “obese woman” is likely to be lower in status both in terms of income and occupation (Canning & Mayer, 1966; Elder, 1969; Larkin & Pines, 1979). This social identity element represents a basis for social evaluation that, in turn, may influence self evaluation through inner experience or “self-attribution” (Rosenberg, 1981, p. 603). In addition, obesity in women is considered deviant behavior, given the cultural norm.

The social identity element may become so important that it overwhelms all others. The obese woman may agree that she is a good wife/mother/lawyer, but discount those positive elements of her identity for the primary element of “I am fat.” Self-esteem suffers when one negative part of identity is made the strongest. Rosenberg calls this aspect “psychological centrality,” and he defines it as the process through which one organizes a hierarchy of what is important to the self-concept.

Self-esteem is affected by levels of satisfaction with self-concept components to which one has attributed most importance. Rosenberg (1965) found support for the principle of centrality in a study of high-school students. He found significant correlations between self-esteem and satisfaction with such self-values as honest, likable, and dependable. He later found further support for this concept in a study of adults (Rosenberg, 1979): when a quality of social identity (such as social class, income, occupational status) was judged to be very important, its effect on self-esteem was greater than if it were judged to be less important. Centrality is an important concept for this study of the obese, and will be discussed further in this review as it relates to body image and body satisfaction.

Rosenberg emphasizes the importance of addressing the personal consequences of self-esteem levels as they influence the degree to which people will lead full lives. He summarizes the literature in the area by reviewing the evidence linking self-esteem and mental illness. There are consistent relationships between low self-esteem and depression, anxiety, somatic symptoms, aggression, negative affective states, and neurotic symptoms (Rosenberg, 1981, p. 614). Robson (1988) agrees that the literature demonstrates these associations, but cautions that a causal link between self-esteem and clinical disorders has yet to be clearly established. For example, low self-esteem generally accompanies depression, and may be a causative, maintaining, or consequent factor of the depression (Robson, 1988).

Body Image

Body image is the mental picture we have of the appearance of our bodies, as well as the associated attitudes and feelings (Garner, Garfinkel, Stancer & Moldofsky, 1976). As previously stated, one's body image contributes to self-esteem and, as such, has self-perceptive and affective components, both of which may be altered as a result of development, or in reaction to specific stimuli or a set of circumstances.

The self-perceptive aspect of body image has led to the development of several tools for its measurement. These tools were developed to explore and measure body image disturbance in the obese, and were later applied to eating disorder patients. The techniques vary from distorting mirrors (Traub & Orbach, 1964), photographs (Glucksman & Hirsch, 1969) and videos of the subject (Allbeck, Hallberg & Espmark, 1976) to techniques such as “draw a person” (McCrea, Summerfield & Rosen, 1982), an image-marker method (Askevold, 1975), and a visual size estimation apparatus (Slade & Russell, 1973). Measurement of body image has resulted in widely disparate findings. Anorexics have been reported as overestimating their size (Crisp & Kalucy, 1974; Garner et al., 1976; Slade & Russell, 1973) or underestimating their size (Garner et al., 1976); normal weight women have been reported as overestimating (Crisp & Kalucy, 1974; Garner et al., 1976; Pearlson, Flournoy, Simonson & Slavney, 1981), underestimating (Garner et al., 1976), and being accurate in the measurement of their body image (Garfinkel, Moldofsky, Garner, Stancer & Coscina, 1978; Shipman & Sohlkah, 1967; Slade & Russell, 1973).

Studies of body image measurement in obesity have also led to diverse conclusions. Using a flexible mirror apparatus, Shipman and Sohlkah (1967) found that the obese substantially overestimated the widths of their lower torso. In contrast, Glucksman and Hirsch (1969) used the distorting photograph technique and found that a small sample of superobese women slightly underestimated their size. However, following the onset of a reducing diet, the subjects overestimated their size. Moreover, the degree of overestimation increased with the amount of weight lost. The subjects consistently overestimated the size of other stimuli (a model and a vase) before, during, and after weight loss, leading the authors to conclude that the obese have a general perceptual distortion leading to overestimation. Similarly, Pearlson and colleagues (1981) found that obese people attending a weight loss clinic overestimated their size (using the visual size estimation apparatus) and disliked their bodies. Neither of these factors predicted success in weight loss. Age of onset of obesity was unrelated to degree of adult obesity or to the accuracy of estimation of body width. Garner and colleagues (1976) found overestimation of body size in obese subjects. Diverse conclusions regarding body size estimation may be explained by two factors: it is possible that different techniques measure different aspects of self perception (Garner et al., 1976) and that different perceptions result from different stages of weight loss, gain, or maintenance.

Regardless of how accurate or inaccurate women are in body size estimation, women today are often reported to have negative attitudes toward their bodies. Wooley and Kearney-Cooke (1986) have hypothesized that there are two cultural changes that have influenced contemporary young women to view their bodies more negatively than at any other time in history. One is that they are the first generation of women to be exposed from infancy to the preference for thin bodies, and to be raised by mothers who are rejecting of their own bodies. Moreover, these mothers are concerned about the size of their daughters’ bodies from birth. A survey of 33,000 women by “Glamour” magazine (Feeling fat, 1984) found that daughters who believed their mothers were critical of their bodies reported being more critical of their own bodies, showing poorer body image, greater use of severe dieting practices, and a higher incidence of bulimia.

This is the heritage of anxiety and self-loathing. Women reaching maturity have not had even the respite of childhood from concerns about body size and eating, and may approach puberty with a long history of negative body image, a problem which is intensified during adolescence (Wooley & Kearney-Cooke, 1986, p. 478).

The second cultural factor affecting women's views of their bodies relates to the apparent changing role of women. Wooley and Kearney-Cooke (1986) describe the widespread ambivalence of young women about which social roles to adopt. Although they identify themselves as female, they are rejecting of the mother's social role of housewife/mother and, with it, they reject the female body type associated with this traditional female role. They may be more accepting of the father's role of active involvement in the outside work world, and try to emulate the associated male body type. Both of these trends may have generated pressures to attain or maintain a thin physique. Other explanations for the symbolic meaning attached to the pursuit of thinness are found in Section 5.

Relationship of Satisfaction with Appearance to Self-Esteem

Dislike of one's body may have different effects on the level of self-esteem depending on the salience of body appearance to the person. To return to the issue of psychological centrality, central, rather than peripheral identity elements affect our self-esteem, that is, are seen as more salient to the self (Rosenberg, 1981, p. 607; Fleming & Watts, 1980). If appearance is considered more important to individuals than job performance and presence of good relationships, it will not matter to these individuals that they are highly skilled, in prestigious jobs, or having good relationships with co-workers, family, and friends. Their global self-esteem will be low because the judgments of their appearance are negative.

Clinical studies have described that contempt toward oneself and disturbance of body image are often seen in the obese (Glucksman, 1972; Glucksman & Hirsch, 1969; Stunkard & Mendelson, 1961). No general population studies were found in the literature which concluded that all overweight women have low self-esteem. However, there have been studies correlating body satisfaction and self-esteem that will be presented in this section. The underlying assumption of this study is that some obese women attribute their body size and appearance as salient, central factors in determining their self-esteem. Thus, their self-esteem would be lower than the self-esteem of obese women who have attributed only peripheral salience of body appearance to self-esteem. There is some support for this idea in the literature. Allen (1988), for example, conducted interviews with a small sample of women (n=37); some, but not the majority, believed that major consequences of being overweight were diminished self-image (40%) and unattractive appearance (36%). Thus, body size was not salient for most women in determining self-image or attractiveness, but was important for a significant minority.

Early research in this area, conducted by Secord and Jourard (1953), found a statistically significant relationship between self-esteem and satisfaction with one's body, which was slightly higher for females than for males. Musa and Roach (1973) later asked adolescents to rate their own appearance and that of other students in their class, and then asked students whether or not they were satisfied with how they looked. The researchers compared these ratings to a measure of self-concept. They found that there was a relationship between personal appearance and self-concept for females, but not for males. In fact, 47% of females who rated themselves equal to peers in appearance were high in ratings of self-concept, whereas 62.5% who rated themselves below their peers were low in self-concept. In a later study, attractiveness ratings were better predictors of self-concept in females, and effectiveness ratings were better predictors of self-concept in males (Lerner, Orlos & Knapp, 1976).

Satisfaction with 24 body parts has been found to be a moderate predictor of self-concept or self-esteem in college students of both sexes (Boldrick, 1983; Lerner, Karabenick & Stuart, 1973). These same two s...

Table of contents

• Front Cover
• Half Title
• Title Page
• Copyright
• Dedication
• Contents
• Acknowledgments
• Introduction
• 1. IS DIETING THE ANSWER?
• 2. OBESITY — DEFINITION, MEASUREMENT, ETIOLOGY, AND ATTEMPTS AT REGULATION
• 3. BEYOND DIETING: THE WEEKLY PROGRAM
• 4. EVALUATION OF THE PROGRAM
• 5. THE BEYOND DIETING PROGRAM: DISCUSSION AND IMPLICATIONS
• Appendix A. PARTICIPANT'S INFORMATION SHEET AND CONSENT FORMS
• Appendix B. ANALYSIS OF VARIANCE (ANOVA) TABLES
• Appendix C. CORRELATIONS OF SELF-ESTEEM WITH BODY DISSATISFACTION BY GROUP
• Appendix D. BEYOND DIETING—PROCESS EVALUATION
• Appendix E. ANNOTATED BIBLIOGRAPHY
• References
• Index