I'll have a cheeseburger and some self-loathing, please

So I'm going along quite well, holding on to the idea that I love and accept and approve and forgive myself, and then I wake up this morning - and something's different.

As I consider it, I remember a number of little things happened yesterday - to be more accurate, a number of little things didn't happen yesterday. I didn't work as hard as I planned to, I didn't follow my eating plan as well as I wanted to, I didn't do a few things that I said I would do, I got a little apprehensive about the future, and I didn't sleep that well last night. Basically, I had set some small goals for myself, some of which were not really within my control, and then I had not met those goals.

So this morning dawns and I'm feeling not so great about myself. I've lost that lovin' feelin'.

I got on the scale this morning. It was a conscious choice, but in retrospect I see now that I created another expectation for myself, in this case an unrealistic expectation. I had lost weight, just not as much as I wanted to. The scale accurately reflected my "loosened" commitment to my eating plan over the last two weeks.

Of course, it added to all the other evidence that, for all my talk about loving myself, I was a failure and flawed and undeserving of self-love.

Like a subtle headache, the cloudiness descended, just a little, and I could tell that my mood was flat. A non-love hangover.

With a sense of resolve, I jumped back to my eating plan, ate the breakfast I planned, and it was good. But there was residual dust in the air of my consciousness. Like crumbs on a counter after making a sandwich, or smoke hanging overhead.

I had NOT loved, approved and forgiven myself this morning. I was, in fact, feeling "bad." I had done bad things (actually, I had not done good things), and it was as if the barometric pressure had changed.

In my "less than" state, I was less patient with our new teenage kitty, and barked at her for doing something that was just about her natural curiosity. Her nature. It is her nature to investigate - she's a curious cat - yet I was "in a bad mood" and so I reacted more harshly than I might have were I in a good mood.

In a bad mood - interesting - actually, my mood reflects my self-perception as bad. I'm bad, and I'm moody. I'm in a bad mode. AHA!

So now I sit at my desk and I started writing this because I felt there was an opportunity here to get clear about what was going on for me.

Those of us who are new to the idea of loving, approving and forgiving ourselves (newbies) can be quite detached from what we REALLY are thinking, feeling, reacting to.

It kinda takes the joy out of devouring an entire lotza meatza pizza when you accurately identify the motivator. "I don't love myself, so I'm doing a self-destructive thing to confirm my low opinion of myself. I'm eating this pizza because I get a momentary sensory pleasure in a life devoid of other pleasures, followed by a pervasive sense of depression, desperation, sadness, punishing physical pain, and relentless self-loathing. I get to have my clothes feel tighter tomorrow morning. As an added bonus, I get to exacerbate an ongoing health problem and possibly precipitate a medical crisis. I might even die. Hell - make that an extra large!!" How many orders for Ruin Your Life Pizza do you think Domino's would get?

Ben & Jerry's Pity Party Ice Cream
McDonald's Supersize Disgustie McNuggies
Tillamook Extra Frustrated Sharp Cheddar
Wendy's Inferiority Complex Chili
KFC Bucket O' Bile
Jack-in-the-Box Jumbo Self-Destructo
Starbuck's Venti Depresso

The aisles of the supermarket could be divided into moods and feelings instead of food categories. "I think I'll take a stroll down the Self-Contempt aisle - oh look, they're having a sale on Loathio's!"

I sat down in front of the computer this morning, and I know I'll be leaving the house later to go to the bank, and I had the fleeting thought, "Hmmmmm. I could get a breakfast burrito while I'm out."

Here's the progression of thoughts and feelings from that one little seed:

I'll be out and it'll be easy to hit a drive-through.
I'm not really hungry but I'm feeling kinda empty.
I'm feeling anxious this morning - kinda jumpy. I need to eat something.
I don't know why, but I want to be "bad."
I could have a breakfast burrito.
That wouldn't be so bad.
Probably 500 calories.
Tortilla, cheese, eggs, sausage pieces, salsa - mmmmmm.
They make a good one at Checkers.
I'll probably just slam it down in 30 seconds.
Sounds good.
Maybe I sould get two burritos.
I could slam the first one down really fast, just to relieve the pressure, you know, just get it out of the way, then savor the second one.
I'll need to get a drink, too, because I'll probably choke from eating so fast.
And I'll need to throw away the wrappings somewhere while I'm out so that nobody finds out I cheated.
It's fun thinking about being bad.
As long as I'm cheating - maybe I should get some of those tasty tater tots they have.
Or maybe I should go to a burger place instead.
Oh man, a big greasy burger on a big bun, dripping with cheese - that would be good!
Then I could also get a big chocolate shake!
As long as I'm being bad, I might as well go for it.
Fries, too, of course.
Oh, and maybe a hot apple pie! Two. They're two for a buck, need to order two.
I haven't tried their Tuscan mushroom chicken burger yet - I wonder what that's like.
How much money do I have in my wallet? Oh good, I've got a twenty. Phew.
Oh, I know - I'll get one breakfast burrito from Checkers, slam it down, then go to the burger place and get just one big superduper burger or whatever and a strawberry shake, and then park somewhere and really enjoy it.
I feel a sense of relief making that plan.
There's enough food to make me really feel like shit for cheating - I'll REALLY feel bad after I eat all that - and I'll also feel uncomfortably full, painfully full. I might even be light-headed from the insulin reaction to the shake.
I'm gonna feel like total shit.
Good.
I need to punish myself.
I NEED to wallow in my unhappiness, my unloveability.
There's no alternative.
There's nothing I can do - I'm going to be running that errand, and I'll be driving right in front of both those places.
Oh, KFC is there, too!
Maybe I could get one of those 8-piece family specials with a big potato salad and a big mac n cheese. Neither of those are that good, and the extra crispy is so damned salty, but I'll REALLY feel uncomfortable. But wait, what about something sweet? I need to have salty, greasy, spicy, crispy, sweet, creamy, chewy - all the sensations - I have to have a festival in my mouth if I expect this binge to work. You know, work - make me feel like total shit.
KFC doesn't have anything that good as far as sweet is concerned.
Hmmm, I like the idea of a strawberry shake.
I could get a couple of those small dollar burgers and a shake at the burger place, then hit KFC for the rest of it.
Yeah!
Now we're talking!
That's a good plan.
Phew! I feel a sense of relief, and a tingly sensation about the upcoming badness.
I'm also energized - time to get dressed and get out there!
Oh crap, it's almost noon.
I'll be hitting the lunch traffic.
That's not so good.
I'll wait until around 1:30 to go out.
Is there anything around here I could eat that would tide me over until I went out?
I know there's two ramens.
I could make the ramens and put a big chunk of butter on them.
Just slam those down now, and take the pressure off, then go get the "good" stuff.
Well, if I have the ramens now, maybe I want something different?
What would be really good would be to go to the drive-through BBQ place and get a pound of beef ribs.
Yummmmmmmm!
Those things are damned good. Dripping with grease and caramelized BBQ sauce.
And they go so well with ramen.
Mmmmm!
The BBQ place is kinda far away - definitely not on the way to the bank - it's in the opposite direction, actually.
But man, it's so worth it.
And I've got twenty in my wallet, I can afford it.
Their sweet potato pie is really good, too.
The burger place is on the way to the BBQ place.
Ramen with butter now.
Pick up one of those Tuscan chicken sandwiches and a great big Pepsi for the ride over to the BBQ place.
Get a big honkin pile of those delicious beef ribs.
Park somewhere, cover myself with paper towels (those ribs are messy!) and go to town.
Oh, and there's that open dumpster down the road I can throw all the trash in.
All right!
Now we're talking!
Gotta be almost 4000 cals there.
Whooee!
I'll feel so bad when I'm done!
My belly will be extended.
I'll totter on my feet.
I'll be sweating and greasy and that wonderful combination of light-headed and completely disgusted with myself.
And tonight, when Ande gets home, I'll have to make a "regular" dinner and eat it, because I don't want her to know.
But I'll probably be in a crappy mood.
And I'll spend the night reliving eating all those gorgeous ribs, and I'll be itching to tell her about it. If I tell her, she will chastize me. God knows, I'll deserve it.
I won't even tell her about the ramen and the chicken burger and the shake - just telling her about the ribs will be plenty bad enough.
I'm kinda smiling right now, thinking about it.
Thinking about her disappointment with me.
Thinking about the disappointment with myself.
Afterward, I'll have to make big promises to her, and to myself, which I won't keep.
And I'll have even more reason to feel bad.
I'll be curiously hungry at bedtime.
You'd think, with all that food, I wouldn't want to eat more, but I will.
Those breakfast burritos are really good cold.
I could just get one, leave it in the car, and then sneak out tonight after Ande goes to bed and scarf it down.
I should probably also have something sweet - after all, it's bedtime.
Something that will last awhile as I eat it.
That's what's so good about a pint of ice cream.
It's like thirty spoonfuls.
I could just scrap the whole plan and go to the supermarket and and get twenty bucks worth of food - a pint of ice cream, maybe a big steak, a pound of cheese, a box of crackers - mmmmm!
Twenty might not be enough, but I could get some cash out.
I could get some BBQ sauce to dip the steak in.
That would be good.
But not as good as the ribs.
Hmmm.
What to do - what to do.

Funny.
All this thought about eating and I don't feel anxious anymore.
Somehow, planning to be bad - imagining being bad - and writing it all down so I could see the self-deceipt and self-destruction in it - has squelched the actual need to be bad.
There was a moment there where I woulda just jumped in the car and gone for it.
But now I'm thinking I could do the errand to the bank and not get any food.
If I put some of my skinless chicken thighs into the oven right now, they'll be done by the time I go, and I'll have them when I return. That's on my eating plan. I can make the bok choy, too, and theres one serving of brown rice left in the fridge.
That would be a great lunch, and tasty - and nutritious.
It would take the pressure off, because I would KNOW that it was waiting for me when I got home, and I wouldn't have to go to a fast food place at all.
Honestly, there's nothing I really could get "out there" that would be both delicious and on my plan.
I like following the plan.
It's a good feeling to know I can move out of the desire to hurt myself.
I can reaffirm my newborn sense of love, approval and forgiveness for myself.
I can let the haze lift.
I feel better.
I really feel better!
Amazing.

If it was crystal clear to me exactly WHAT I was really doing when I choose to eat, I wonder how often I'd go ahead and eat that burger when it came drenched in self-loathing?

Some relevant quotes

To know all is to forgive all.
Learning to love yourself is the greatest love of all.
Love is the answer.
Love thy neighbor as you love yourself.
Forgive and forget.
The power to change is in the present moment.
Love heals everything.
Let there be peace on earth, and let it begin with me.

Self-esteem is the real magic wand that can form a child’s future. A child’s self-esteem affects every area of her existence, from friends she chooses, to how well she does academically in school, to what kind of job she gets, to even the person she chooses to marry.
ATTRIBUTION:	Stephanie Martson (20th century), U.S. family therapist, author. The Magic of Encouragement, ch. 1 (1990).

Self-esteem creates natural highs. Knowing that you’re lovable helps you to love more. Knowing that you’re important helps you to make a difference to to others. Knowing that you are capable empowers you to create more. Knowing that you’re valuable and that you have a special place in the universe is a serene spiritual joy in itself.
ATTRIBUTION:	Louise Hart (20th century), U.S. psychologist, educator. The Winning Family, ch. 4 (1987).

Self-esteem is as important to our well-being as legs are to a table. It is essential for physical and mental health and for happiness.
ATTRIBUTION:	Louise Hart (20th century), U.S. psychologist, educator. The Winning Family, ch. 20 (1987).

”But most of all respect thyself.”—A precept of the Pythagoreans.

In order to feel good about himself, a child must be successful in his own eyes, not just in your eyes. Self-esteem is an inner feeling: Sometimes it corresponds with outer reality, and sometimes it doesn’t.
ATTRIBUTION:	Stanley I. Greenspan (20th century), U.S. clinical professor of psychiatry, behavioral sciences, pediatrics, and author. Playground Politics, ch. 3 (1993).

Sonnet LXII.

“Sin of self-love possesseth all mine eye”

SIN of self-love possesseth all mine eye
And all my soul and all my every part;
And for this sin there is no remedy,
It is so grounded inward in my heart.
Methinks no face so gracious is as mine,	5
No shape so true, no truth of such account;
And for myself mine own worth do define,
As I all other in all worths surmount.
But when my glass shows me myself indeed,
Beated and chopp’d with tann’d antiquity,	10
Mine own self-love quite contrary I read;
Self so self-loving were iniquity.
’Tis thee, myself,—that for myself I praise,
Painting my age with beauty of thy days.

William Shakespeare

A low self-love in the parent desires that his child should repeat his character and fortune; an expectation which the child, if justice is done him, will nobly disappoint. By working on the theory that this resemblance exists, we shall do what in us lies to defeat his proper promise and produce the ordinary and mediocre. I suffer whenever I see that common sight of a parent or senior imposing his opinion and way of thinking and being on a young soul to which they are totally unfit. Cannot we let people be themselves, and enjoy life in their own way? You are trying to make another man you. One’s enough.

ATTRIBUTION:

Ralph Waldo Emerson (1803–1882), U.S. essayist, poet, philosopher. “Education,” Lectures and Biographical Sketches (1883, repr. 1904).

Self-love, my liege, is not so vile a sin As self-neglecting.
ATTRIBUTION:	William Shakespeare (1564–1616), British dramatist, poet. Dauphin, in Henry V, act 2, sc. 4, l. 74-5.

Self-love depressed becomes self-loathing.
ATTRIBUTION:	Sally Kempton (b. 1943), U.S. author. “Cutting Loose,” Esquire (New York, July 1970).

As a character disorder, narcissism is the very opposite of strong self-love. Self-absorption does not produce gratification, it produces injury to the self; erasing the line between self and other means that nothing new, nothing “other,” ever enters the self; it is devoured and transformed until one thinks one can see oneself in the other—and then it becomes meaningless. This is why the clinical profile of narcissism is not of a state of activity, but of a state of being. There are erased the demarcations, limits, and forms of time as well as relationship. The narcissist is not hungry for experiences, he is hungry for Experience. Looking for an expression or reflection of himself in Experience, he devalues each particular interaction or scene, because it is never enough to encompass who he is. The myth of Narcissus neatly captures this: one drowns in the self—it is an entropic state.

ATTRIBUTION:

Richard Sennett (b. 1943), U.S. social historian. “The Actor Deprived of His Art,” The Fall of the Public Man, Cambridge University Press (1977).

Had we not loved ourselves at all, we could never have been obliged to love anything. So that self-love is the basis of all love.
ATTRIBUTION:	Thomas Traherne (1636–1674), British clergyman, poet, mystic. “Fourth Century,” no. 55, Centuries (written c. 1672, publ. 1908).

I am a feminist, and what that means to me is much the same as the meaning of the fact that I am Black: it means that I must undertake to love myself and to respect myself as though my very life depends upon self-love and self-respect.
ATTRIBUTION:	June Jordan (b. 1939), U.S. poet, civil rights activist. Address, 1978, to the Black Writers’ Conference, Howard University. “Where Is the Love?” Moving Towards Home: Political Essays (1989).

Addiction, obesity, starvation (anorexia nervosa) are political problems, not psychiatric: each condenses and expresses a contest between the individual and some other person or persons in his environment over the control of the individual’s body.
ATTRIBUTION:	Thomas Szasz (b. 1920), U.S. psychiatrist. “Control and Self-control,” The Second Sin (1973).

Success matters very much to the under-six age group. These children want so desperately to be able to hold their heads high. They sound exceedingly boastful: “I can count up to five....” “I can tie my shoes....” “I know how old I am. Do you want to see...?” Each child maintains his own public relations office. He is continuously concerned with getting his name and his skill and his knowledge and his power into the “headlines.” But we mustn’t be misled by this drumbeating. The bombast is as much for the child’s benefit as for ours—he can’t quite believe his own importance.

ATTRIBUTION:

James L. Hymes, Jr. (20th century), U.S. child development specialist, author. Teaching the Child Under Six, ch. 2 (1968).

QUOTATION:	Success is a process, a quality of mind and way of being, an outgoing affirmation of life.
ATTRIBUTION:	Alex Noble, “In Touch with the Present” Christian Science Monitor 6 Mar 79

Benefits of Being Self-Destructive

"I just don't see how someone could DO THAT to themselves!"
"I would NEVER let myself go like that."
"Why would someone want to kill themselves like that?"
"Why would anyone start smoking/get fat/cut themselves/gamble away their retirement?"
"Don't they know the pain they are causing themselves and their family?"
"How can they look themselves in the mirror?"
"How can you kill/rape/molest/injure/rob/abuse/harrass someone?"
"How can they live like that?"
"Why don't they just stop?"
"Why don't they just hide?"

Because. Because there are benefits to being self-destructive.

Huh? What-the? Benefits? No way.

Way.

Self-destructive behavior gives you:
A built-in excuse whenever you don't live up to a promise, expectation or goal.
A rationale for not trying something difficult or new.
An opportunity to blame others or circumstances instead of taking responsibility.
An automatic "off-the-hook" card.

Self-destructive behavior is:
A substitute for something more/less dangerous/legal.
Soothing.
Upsetting.
Mollifying.
Agitating.
Empowering.
Strengthening.
Weakening.
Manipulative.
Painful.
Painless.
Relaxing.
Energizing.
Fun.
Agonizing.
Expense.
Cheap.
Legal.
Illegal.
A time killer.
A day waster.
A life waster.

You engage in self-destructive behavior:
To generate sympathy, compassion, pity, and understanding.
To get attention.
To create obstacles.
To create obstacles so you then have something to overcome.
To explain.
To wipe the slate clean.
To right past wrongs.
To make wrong past rights.
To self-punish.
To punish others.
To send a signal to the world that there's a problem.
To wallow.
To face your fears.
To hide from your fears.
To comfort.
To distress.
To pleasure.
To pain.
To fulfill your own opinion of yourself.
To fulfill others' opinions of you.
To hit rock bottom.
To get help.
To have a place to progress from.
To negate all progress.
To improve.
To fail.
To "show them."
To block out.
To black out.
To remember.
To forget.
To indicate.
To learn.
To grow.
To change.
To prove something.
To disprove something.
To relieve.
To cause pressure.
To make right.
To make wrong.
To feel sad.
To feel depressed.
To feel elated.
To protect.
To expose.
To loosen inhibitions.
To tighten inhibitions.
To feel sorry for yourself.
To feel sorry for your parents.
To make your parents feel sorry for you.
To kill yourself.
To not kill yourself.
To mock someone.
To fly in the face of conventional wisdom.
To ignore warnings.


Because you were dared.
Because you spit on other people's feelings.
Because you want to be the drunkest, fattest, baddest.
Because God told you to.
Because the Pope told you to.
Because the Pope told you not to.
Because you are smart.
Because you are stupid.
Because you are healthy.
Because you are sick.
Because you are young.
Because you are old.
Because you have brothers and sisters.
Because you don't have brothers and sisters.
Because you're creative.
Because you're not creative.
Because you want what you can't have.
Because you have what you don't want.
Because you are who you don't want to be.
Because of something you did.
Because of something you didn't do.
Because you murdered/raped/molested/abused/attacked/hurt/robbed someone.
Because you were raped/molested/abused/attacked/hurt/robbed.
Because it's Monday.
Because it's not Monday.
Because it's hot.
Because it's cold.
Because it's sunny.
Because it's raining.
Because you live in America.
Because you live in Somalia.
Because you used to live in America and now live in Somalia.
Because your parents disappointed you.
Because your parents loved you.
Because your parents didn't love you.
Because you never knew your dad.
Because your dad abused you.
Because your dad molested you.
Because your dad neglected you.
Because your dad is just the most wonderful dad in the world.
Because your dad was just the most wonderful dad in the world until your brother was born.
Because your dad was just the most wonderful dad in the world, and now he's dead.
Because your mom died.
Because your dog died.
Because your plant died.
Because your foot is tingling.
Because you're constipated.
Because you wet the bed when you were a child.
Because you still wet the bed.
Because you got a D in math.
Because you got an A in math.
Because you're unique.
Because you're just like everyone else.
Because you're human.
Because you're inhuman.
Because you drive a Mercedes.
Because you don't drive a Mercedes.
Because you need to do the laundry.
Because you finished the laundry.
Because your mother did your laundry.
Because you want to make your mother cry.
Because you want to block out the memory of your mother crying.
Because it's been an hour since you last did something self-destructive.
Because you haven't been sober in over a year.
Because you've been sober for 634 days, 12 hours and 45 minutes.
Because it's cool.
Because it's not cool.
Because you're white.
Because you're black.
Because you want to go to prison/rehab.
Because you want to stay up.
Because you want to sleep.
Because it's there.
Because it's not there.
Because it makes sense.
Because it makes no sense.

Because, like everything else in life, there are a million reasons/motivators/rationalizations/excuses.

Why?
Because.

Fat Bias in Fat People

The influence of the stigma of obesity on overweight individuals

S S Wang1, K D Brownell1 and T A Wadden2

1Department of Psychology, Yale University, New Haven, CT, USA 2University of Pennsylvania School of Medicine, USA

Correspondence to: Dr S Wang, Department of Psychology, Yale University, 2 Hillhouse Avenue, P.O. Box 208205, New Haven, CT 06520, USA. E-mail: shirley.s.wang@yale.edu

OBJECTIVE: To investigate the internalization of anti-fat bias among overweight individuals across a variety of attitudes and stereotypes. DESIGN: Two studies were conducted using the Implicit Association Test (IAT), a performance-based measure of bias, to examine beliefs among overweight individuals about 'fat people' vs 'thin people'. Study two also contained explicit measures of attitudes about obese people. SUBJECTS: Study 1 participants were 68 overweight patients at a treatment research clinic (60 women, 8 men; mean Body Mass Index (BMI) of 37.1±3.9 kg/m2). Study 2 involved 48 overweight participants (33 women, 15 men) with a BMI of 34.5±4.0 kg/m2. RESULTS: Participants exhibited significant anti-fat bias on the IAT across several attributes and stereotypes. They also endorsed the explicit belief that fat people are lazier than thin people. CONCLUSION: Unlike other minority group members, overweight individuals do not appear to hold more favorable attitudes toward ingroup members. This ingroup devaluation has implications for changing the stigma of obesity and for understanding the psychosocial and even medical impact of obesity on those affected. International Journal of Obesity (2004) 28, 1333-1337. doi:10.1038/sj.ijo.0802730 Published online 27 July 2004

Fat Bias in the Medical Profession

'Fat Bias': A Barrier to the Treatment of Obesity

Tarayn Grizzard Photo by Jeff Cleary

In this brave new century, it is less likely than in the past that people will hear a shockingly sexist remark in the workplace, a blatantly racist comment on TV, or a pointedly anti-Semitic statement anywhere in a public forum. This relative dearth is a wonderful statement on the progress that has been made since the dark days of the turn of the last century when such comments were commonplace and acceptable. In fact, between political correctness, dawning rationality, and a litigious society, there seem to be few prejudices left that are considered socially appropriate to act upon.

Of those remaining biases, fat bias is perhaps the most prominently featured in media, work, and social life in the U.S. The size, shape, romantic prospects, and eating habits of obese people are the focus of many a comedy sketch and movie plot (last year's upsettingly successful Shallow Hal, for instance), and they are a source of insult and torment on the playground and in the boardroom. This phenomenon has been so widespread that prejudice against obese people has been called "the last socially acceptable form of prejudice" by some scholars.

This discrimination occurs despite nearly one fourth of Americans being obese according to federal guidelines on body mass index (BMI). Obese and overweight individuals typically report marked discrimination in daily life with teasing, slurs, petty violence, and isolation. A study attempting to quantify this stigmatization showed that of nearly 1,000 men and women enrolled in weight-gain prevention programs, 22 percent of women and 17 percent of men reported discrimination and prejudice related to their size. The mistreatment was positively associated with BMI. Other research has shown that excess body weight is associated with discrimination. A study of 57 subjects before and after surgery for morbid obesity reported significant prejudice and discrimination at work, within the family, and in public places prior to surgery and little or no discrimination after surgically induced weight losses of 100 lbs. or more.

A Health Care Gap

Within the social schema of obesity-related discrimination, one of the most consistently documented arenas has been health care, with substantial evidence for the presence of "fat bias" among health care workers. In a survey of nurses, 28 percent reported repulsion at the sight of an obese person, while another survey of 438 Michigan physicians showed that obesity was the fifth most negative patient characteristic. The American Academy of Family Physicians surveyed 324 members and found that 39 percent believed that obese patients were lazy, and two thirds thought that obese patients lacked self-control. Other surveys of physicians' attitudes showed that physicians often described their obese patients as "weak-willed," "ugly," and "awkward."

A majority of candidates referred for gastric bypass surgery reported being treated disrespectfully by their physicians because of their weight. Ill treatment of this type has been linked to delays or avoidance of medical care by obese women, in particular; 12.7 percent in one survey reported avoiding or delaying medical appointments because of weight-related concerns such as stigmatization.

Such discrimination within the medical community is particularly damaging due to the health effects of obesity and a subsequent increased need for medical attention. The well-known increased incidence of chronic progressive diseases such as diabetes mellitus, osteoarthritis, and cardiovascular disease in obese people make delays and avoidance of care dangerous. Obesity-related conditions result in 300,000 deaths per year in the U.S. according to the American Heart Association, many of which could be prevented with weight loss and proper medical management. The inadequate treatment of these diseases also adds a significant burden on the health care system. The management of obesity-related medical conditions made up 9.4 percent of U.S. health care expenditures in 1999. The social and fiscal costs of obesity on society--and on the individual--are enormous, and these costs are compounded by negative attitudes toward obese people among health care workers.

Consequences of Inadequate Care

Despite the high cost of obesity, it is often undertreated, possibly colored by physician biases with an ensuing impact on clinical decision-making and health care. The prevalence of childhood obesity is rapidly increasing, with one out of five children being considered obese today. Childhood obesity has been associated with increased rates of diabetes, cardiovascular disease, and adult obesity. However, a recent study of pediatrician referral patterns for failure to thrive/underweight and obesity at the University of Colorado found that pediatricians who referred children for nutritional work-ups referred mostly mildly underweight children and severely obese children. This suggests that moderately obese and overweight children may not be referred for medical treatment until their health status has deteriorated to severely obese. This problem with insufficient treatment is only compounded by the relative lack of reimbursement for pediatric obesity. One study found that only 11 percent of pediatrician-ordered treatments for obesity were reimbursed, particularly when Medicaid was the third-party payer.

Adults face similar problems with inadequate weight-control counseling. In a telephone survey of 12,835 obese U.S. adults, it was found that only 42 percent had been counseled about weight loss by a primary care physician in the past year. Those counseled were significantly more likely to report attempts at weight loss than those who were not. These statistics were in line with an unpublished 1995 National Ambulatory Medical Care Survey in which physicians reported counseling obese patients about weight reduction during 56 percent of general medical visits. This inadequate counseling is particularly problematic because initiation of the more successful therapies for weight loss typically must begin in the primary care setting. Without the advice of physicians, patients may not be aware of the dangers of their excess weight or of the most effective ways to treat them--and may not receive the behavioral and psychosocial support of any clinician should they choose to attempt weight loss.

These issues with inadequate treatment point to a common problem in philosophy, that is, that many physicians view obesity as a primarily behavioral problem as opposed to a medical disorder. In the face of mounting evidence to the contrary, this philosophical position on obesity has remained and continues to impair clinical decision-making, often resulting in prolonged ill health in obese patients--with disastrous consequences for the individual and for society on the whole. In order to ameliorate the effects of societally condoned biases in medical practice, obesity must be actively taught as a biological construct--a medical disorder--to best help patients and the health of our nation.

Obesity sensitivity should be emphasized in medical school classes and in residency training programs, with the purpose of making the medical environment comfortable for obese patients. Formal education on proper, National Institutes of Health-regulated treatment algorithms for treating obesity and counseling obese patients should be mandatory in residency and in medical school. Creating formal constructs to teach students and residents how to deal appropriately with obese patients and provide them the best care possible would begin to override the medical establishment's bias against them and, one hopes, to eradicate the deleterious effects of this highly popular bias.

2002
--Tarayn Grizzard, a third-year medical student at HMS

The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.

Spirituality and Weight Management

Popkess-Vawter, S., Yoder, E. and Gajewski, B. "The role of spirituality in holistic weight management." Clinical Nursing Research 14, no. 2 (May 2005): 158-174.

SUMMARY: The authors describe at the outset the "obesity epidemic" which is the context for their study: "More than 64% of the adults in the U.S. are overweight, with 15% to 25 % obesity prevalence in 50 states compared to only 4 states in 1991." They assert, "Failure to help people sustain healthy weights may be partly due to health care professionals' not addressing the psychological, sociocultural, and spiritual influences of weight gain" [p. 159]. This is a descriptive, feasibility study of 34 adults (out of a convenience sample of 104) who had received health care from the principal investigator. Sue Popkess-Vawter (a practicing clinical nurse specialist as well as a professor at the School of Nursing, University of Kansas Medical Center), had generally observed in her practice:

Patients demonstrated that long-term weight management failures might be linked to spiritual distress, poor self-esteem grounded in past negative beliefs about self, and less than favorable quality of life. Patients' stories indicated lack of healthy attention to themselves and prevalence of underlying beliefs about not being worthy of spending the time, effort, and money necessary to be successful in long-term weight management. [p. 162]

In light of these personal observations, the intention of the study was...

...to explore weight management patients' views of spirituality and whether they saw a link between spirituality and weight management. Measures of spiritual assessment [Spirituality Assessment Scale, (1992, unpublished)], spiritual well-being [Paloutzian & Ellison's Spirituality Well-Being Scale (1982)], self esteem [the Rosenberg Self-Esteem Scale (1965)], and quality of life [Quality of Life Short Form 12 (1996)] were administered to explore the relationships among the concepts. [p. 163]

Patients were mailed questionnaire packets which contained both the quantitative measures and demographic questionnaires including open-ended questions about spirituality. Definitions of spirituality were offered by 32 of the 34 respondents, with the most common themes being "a belief in, a connection with, or giving control to a Higher Power or God," but other prominent themes were "a sense of peace, prayer, purpose, or meaning in life and spiritual nurturing of self" [p. 169]. Regarding a relationship between spirituality and weight management, 3 respondents did not see a connection and 4 were not sure, but most described...

...a positive connection in which a Higher Power was a source of help for them to improve their health. Spirituality was perceived as an inner source of strength, power, peace, and comfort needed to live life in a healthy way. Some reported that spirituality increased their self-awareness and positive view of self for success. A few mentioned that overeating was gluttony, which was considered "bad" from a religious context. [p. 169]

Quantitative analysis of the formal measures indicated that "spiritual well-being was significantly related to self-esteem" [p. 170]. After linear regression analysis, "approximately 47%...of the variance for self-esteem was accounted for by its linear relationship with spiritual well-being," and scores on the Existential Spirituality subscale of Paloutzian & Ellison's Spirituality Well-Being Scale "accounted for 68% of the variance for self-esteem" [p 170]. The same subscale also "accounted for 35% of the variance for quality of life" [p. 170], though the total scores on the Spirituality Assessment Scale and Spirituality Well-Being Scale to quality of life did not show a significant relationship to the quality of life scores.

The authors note that their theoretical perspective is rooted in Aaron T. Beck's cognitive theory, particularly that "when people assess underlying personal beliefs and cognitions that lead to negative emotions and actions, they can learn to reevaluate and challenge basic assumptions about their self worth" [p. 163]. With this in mind, Popkess-Vawter and her colleagues believe that their findings may support the "cognitive restructuring strategies" of spiritual nurturance and spiritual coping as clinical interventions.

Spiritual nurturance--practicing daily interconnections with self, others, nature, and a Higher Power--is aimed at expanding inner reserves to "buildup resistance" to negative cognitions. Spiritual coping is cognitive restructuring aimed at tapping into inner reserves as a source of guidance and strength when confronted with negative situations and thoughts. [p. 163]

They state in the discussion of their findings:

Spiritual intervention strategies are needed to support spiritual nurturance and spiritual coping and to dispel any biases that self-care for the mind, body, and spirit is selfish and self-serving. ...Negative emotions (anger, resentment, feelings of abandonment, loneliness, fear) originating from negative beliefs and negative cognitions can potentially be corrected using spiritual cognitive restructuring strategies, which can bolster cognitive cognitions of self-esteem and quality of life. [p. 171]

However, the authors do caution against the practical application of such cognitive restructuring strategies with weight management patients until further research is conducted. In the meantime, they suggest to nurses that they "can follow Nightingale's general directive...to use spirituality as a potent source of healing. Asking about, listening to, and supporting patients' spiritual beliefs generally can promote wellness" [p. 172].

BRIEF COMMENT: This article presents a constructive association between spirituality and healthy weight management, in terms of the reports of participants as well as the authors' theoretical take on the potential place of spirituality in cognitive restructuring strategies. As such, this research may be an affirmative invitation for chaplains to become more involved in clinical programs and studies regarding weight management, ranging from diet modification to (increasingly popular) bariatric surgery. Research on the relationship of spirituality/religion to weight management remains scarce and could benefit from the practical perspective of chaplains on the range of ways that religion may play out in the lives of people with weight management issues. For example, a patient may find in religious teachings strong motivation to care for her body as the "temple of the soul" or as the vehicle for work in the world. Certainly, some formal religious dietary regulations may promote healthy eating. This would be in line with the sense of this month's article. However, a patient may also struggle with religiously-based guilt about his excessive weight, may come to come to identify himself as a "glutton," and may resort to unhealthy behaviors to purge himself of his sinfulness. (As a chaplain myself, I have encountered this in a number of patients.) A patient may also have conflicted feelings about the role of food in her religious social life, such as the place of "church suppers" and eating as part of a "fellowship hour" after worship when food becomes rather ironically mixed with the very settings to which the patient looks for social support. The relationship between spirituality/religion and weight management seems complex but also quite investigable, since some outcomes could be easily measured and since patients' self-reports about their motivation and experience may be especially valuable. The subject appears also be well suited for interventional studies, and that is said to be the immediate plan for the principal investigator in this case [see p. 172]. Future studies, however, will likely benefit from more recently developed measures of spirituality and from a variety of population samples representing different religious traditions.

Suggestions for the Use of the Article for Discussion in CPE:

This month's study is a good example of a research approach that combines qualitative and quantitative methodologies, and students may see how each yields insights that might go undiscovered if only one of the methodologies had been employed. Students new to research could be challenged to think about each methodology's potential for insights and for blind spots. Also, students may wish to discuss the authors' ideas about interventions, especially "spiritual nurturance" and its possible relationship to pastoral interventions. Of course, the article could easily open a general discussion of the role of spirituality/religion in weight management and the place of food and eating in religious traditions.

Rosenberg Self-Esteem Scale

The Rosenberg Self-Esteem Scale is perhaps the most widely-used self-esteem measure in social science research. Dr. Rosenberg was professor of Sociology at the University of Maryland from 1975 until his death in 1992. He received his Ph.D. from Columbia University in 1953, and held a variety of positions, including at Cornell University and the National Institute of Mental Health, prior to coming to Maryland. Dr. Rosenberg is the author or editor of numerous books and articles, and his work on the self-concept, particularly the dimension of self-esteem, is world-renowned.

Dr. Florence Rosenberg, Manny's wife, has given permission to use the Self-Esteem Scale for educational and professional research. There is no charge associated with the use of this scale in your professional research. However, please be sure to give credit to Dr. Rosenberg when you use the scale by citing his work in publications, papers and reports. We would also appreciate receiving copies of any published works resulting from your research at the University of Maryland address listed below.

SELF-ESTEEM: WHAT IS IT?

Self-esteem is a positive or negative orientation toward oneself; an overall evaluation of one's worth or value. People are motivated to have high self-esteem, and having it indicates positive self-regard, not egotism. Self-esteem is only one component of the self-concept, which Rosenberg defines as "totality of the individual's thoughts and feelings with reference to himself as an object." Besides self-esteem, self-efficacy or mastery, and self-identities are important parts of the self-concept.

Because of its widespread popularity in everyday parlance and in popular psychology, the concept of self-esteem may be subject to distortion and misuse. Thus, it is recommended that that those using the scale be familiar with the scientific study of this concept and its complexities. Rosenberg's books are a good starting point. Note that there are other definitions and measures of self-esteem in the social sciences, as well as thousands of empirical studies and theoretical analyses of this concept in the academic literature.

Much of Rosenberg's work examined how social structural positions like racial or ethnic statuses and institutional contexts like schools or families relate to self-esteem. Here, patterned social forces provide a characteristic set of experiences which are actively interpreted by individuals as the self-concept is shaped. At least four key theoretical principles -- reflected appraisals, social comparisons, self-attributions, and psychological centrality -- underlie the process of self-concept formation.

In addition to examining self-esteem as an outcome of social forces, self-esteem is often analyzed as an independent or intervening variable. Note that self-esteem is generally a stable characteristic of adults, so it is not easily manipulated as an outcome in experimental designs. Blascovich and Tomaka (1993) indicate that "experimentally manipulated success or failure is unlikely to have any measurable impact when assessed against a lifetime of self-evaluative experiences" (p. 117). It is also unrealistic to think that self-esteem can be "taught"; rather, it is developed through an individual's life experiences.

USING THE ROSENBERG SELF-ESTEEM SCALE

Below you will find a copy of the scale, along with brief instructions for scoring it. A full description of the original scale may be found in the Appendix of Rosenberg's Society and the Adolescent Self-Image (see below for full citation). PLEASE NOTE: The Department of Sociology does not have the resources to answer individual queries about the scale and its use. However, the information below, including the references, should address your questions.

General Information for Using the Rosenberg Self-Esteem Scale (SES):

1. While designed as a Guttman scale, the SES is now commonly scored as a Likert scale. The 10 items are answered on a four point scale ranging from strongly agree to strongly disagree.

2. The original sample for which the scale was developed in the 1960s consisted of 5,024 high school juniors and seniors from 10 randomly selected schools in New York State and was scored as a Guttman scale. The scale generally has high reliability: test-retest correlations are typically in the range of .82 to .88, and Cronbach's alpha for various samples are in the range of .77 to .88 (see Blascovich and Tomaka, 1993 and Rosenberg, 1986 for further detail). Studies have demonstrated both a unidimensional and a two-factor (self-confidence and self-deprecation)structure to the scale. To obtain norms for a sample similar to your own, you must search the academic literature to find research using similar samples.

3. To score the items, assign a value to each of the 10 items as follows:

   • For items 1,2,4,6,7: Strongly Agree=3, Agree=2, Disagree=1, and Strongly Disagree=0.

   • For items 3,5,8,9,10 (which are reversed in valence, and noted with the asterisks** below): Strongly Agree=0, Agree=1, Disagree=2, and Strongly Disagree=3.

4. The scale ranges from 0-30, with 30 indicating the highest score possible. Other scoring options are possible. For example, you can assign values 1-4 rather than 0-3; then scores will range from 10-40. Some researchers use 5- or 7-point Likert scales, and again, scale ranges would vary based on the addition of "middle" categories of agreement.

Present the items with these instructions. Do not print the asterisks on the sheet you provide to respondents.

BELOW IS A LIST OF STATEMENTS DEALING WITH YOUR GENERAL FEELINGS ABOUT YOURSELF. IF YOU STRONGLY AGREE, CIRCLE SA. IF YOU AGREE WITH THE STATEMENT, CIRCLE A. IF YOU DISAGREE, CIRCLE D. IF YOU STRONGLY DISAGREE, CIRCLE SD.

		1. STRONGLY AGREE	2 AGREE	3. DISAGREE	4. STRONGLY DISAGREE
1.	I feel that I'm a person of worth, at least on an equal plane with others.	SA	A	D	SD
2.	I feel that I have a number of good qualities.	SA	A	D	SD
3.	All in all, I am inclined to feel that I am a failure.**	SA	A	D	SD
4.	I am able to do things as well as most other people.	SA	A	D	SD
5.	I feel I do not have much to be proud of.**	SA	A	D	SD
6.	I take a positive attitude toward myself.	SA	A	D	SD
7.	On the whole, I am satisfied with myself.	SA	A	D	SD
8.	I wish I could have more respect for myself.**	SA	A	D	SD
9.	I certainly feel useless at times.**	SA	A	D	SD
10.	At times I think I am no good at all.**	SA	A	D	SD

References with further characteristics or discussion of the scale and its derivatives:

Blascovich, Jim and Joseph Tomaka. 1993. "Measures of Self-Esteem." Pp. 115-160 in J.P. Robinson, P.R. Shaver, and L.S. Wrightsman (eds.), Measures of Personality and Social Psychological Attitudes. Third Edition. Ann Arbor: Institute for Social Research.

Owens, Timothy J. 1994. "Two Dimensions of Self-Esteem: Reciprocal Effects of Positive Self-Worth and Self-Deprecation on Adolescent Problems." American Sociological Review. 59:391-407.

Owens, Timothy J. 1993. "Accentuate the Positive - and the Negative: Rethinking the Use of Self-Esteem, Self-Deprecation, and Self-Confidence." Social Psychology Quarterly. 56:288-99.

Owens, Timothy J. 2001. Extending Self-Esteem Theory and Research. Cambridge: University Press.

Rosenberg, Morris. 1965. Society and the Adolescent Self-Image. Princeton, New Jersey: Princeton University Press. (Chapter 2 discusses construct validity.)

Rosenberg, Morris. 1986. Conceiving the Self. Krieger: Malabar, FL.

Silber, E. and Tippett, Jean 1965. "Self-esteem: Clinical assessment and measurement validation." Psychological Reports, 16, 1017-1071. (Discusses multitrait-multimethod investigation using RSE).

Wells, L. Edward and Gerald Marwell. 1976. Self-Esteem: Its Conceptualization and Measurement. Beverly Hills: Sage.

Wylie, Ruth C. 1974. The Self-Concept (especially pp. 180-189.) Revised Edition. Lincoln, Nebraska: University of Nebraska Press

FAQ (Frequently Asked Questions)
Related Links: Frequently Asked Questions (FAQs)

May I have permission to use the Rosenberg Self-Esteem Scale in my research?

Dr. Florence Rosenberg, Manny's wife, has given permission to use the Self-Esteem Scale for educational and professional research. There is no charge associated with the use of this scale in your professional research. However, please be sure to give credit to Dr. Rosenberg when you use the scale by citing his work in publications, papers and reports. We would also appreciate receiving copies of any published works resulting from your research at the University of Maryland address listed below.

How do I cite the scale?

You should cite the scale according to the standards of your discipline. The most appropriate citation is:

Rosenberg, Morris. 1989. Society and the Adolescent Self-Image. Revised edition. Middletown, CT: Wesleyan University Press.

Are there foreign language versions of the scale available?

The Rosenberg Self-Esteem Scale is perhaps the most widely-used self-esteem measure in social science research. The scale has been translated into many languages; unfortunately, the University of Maryland is not a repository for such scales. Please refer to the scholarly literature in the language which you are using.

Can you tell me what the scale cut-offs are for high and low self-esteem?

There are no discrete cut-off points to delineate high and low self-esteem.

It is recommended that you consult the literature relevant to the population you are interested in studying. By examining this literature you should be able learn more about the norms of a specific population.

The Rosenberg SES may be used without explicit permission.
The author's family, however, would like to be kept informed of its use.
Send information about how you have used the scale, or send published research resulting from its use, to the address below:

The Morris Rosenberg Foundation c/o Dept. Of Sociology University of Maryland 2112 Art/Soc Building College Park, MD 20742-1315

Chronic Dieters and Body Image

The Centre for the Study of Curriculum and Instruction, Faculty of Education, University of British Columbia, 309-2125 Main Mall, Vancouver, BC, V6T 1Z4, Canada. jgingras@interchange.ubc.ca

This study was conducted to determine the body image of a group of female chronic dieters. Participants were asked to complete a body image questionnaire, and their results were compared with age- and sex-matched reference norms.

Chronic dieters possessed significantly lower appearance evaluation, lower body satisfaction, and higher self-classified vs actual body weight compared with reference norms. Body image dissatisfaction may prevent individuals from incorporating beneficial lifestyle behaviors, and thus it is important to address body image dissatisfaction with chronic dieters for the best chance at improving health, regardless of body size.

Eating disorders and childhood obesity: Who are the real gluttons?

by Joan M. Johnston, a family physician in Edmonton, Alberta
Published in the Canadian Journal of Medicine, December 2004

I recently received a package in the mail intended as part of an obesity-awareness campaign aimed at family physicians and pediatricians. The materials included body mass index (BMI) charts, worksheets, handouts and a poster. These materials urged me to calculate the BMI of every child in my practice and, for those over the 85th percentile, to set up an "intervention" to give advice and counselling to parents and child — delivered empathically and uncritically, of course.

An apparently limitless supply of these printed materials is available to physicians in my province, the bill being footed by government and professional agencies. The monetary cost of the campaign makes me shudder, but the human cost makes me angry.

As a physician and recovered anorexic who has worked with patients with eating disorders for the past 12 years, I am disgusted by the cavalier disregard for eating disorders exhibited in the medico-cultural war against obesity. The resource materials I received contained not a word about eating disorders. Why this massive blind spot? Are we to believe that obesity is an isolated phenomenon unrelated to eating disorders? Or is the reason more sinister? Are physicians the pawns of a $50-billion a year diet and fitness industry?¹ Or are we being manipulated by health care policy-makers' myopic focus on the bottom line? (As an elected politician recently remarked to me, "In 10 years we will not be able to afford to treat type 2 diabetes in this province!")

It is common knowledge that there is a mounting incidence of obesity in our population. The reasons are many and complex; as we all know, diet and sedentary lifestyles play a part. Virtually every patient I see in my family practice already possesses a surfeit of information about these issues. How could they not, given the obsessive media attention given to diet, exercise and body type?

Is it unreasonable to expect physicians to take a broader and more insightful approach to the problem of obesity than do the publishers of Cosmopolitan, Elle or Men's Fitness? Can we not for a moment stop to consider the implications for our patients if we jump on the weight-loss bandwagon?

Childhood obesity is not unconnected to eating disorders. Indeed, many overweight youngsters are already suffering from an eating disorder (typically binge eating) as the primary cause of their abnormal weight gain. This is known in common parlance as "compulsive overeating" and is characterized by the use of food as a drug to soothe disturbing emotions such as anger, fear or sadness (not unexpected feelings for anyone growing up in today's world). For such individuals, launching a frontal assault on the symptom (obesity) instead of dealing with the underlying cause (the eating disorder) may simply catalyze the transformation of their disorder into anorexia or bulimia nervosa. Diet clubs and exercise facilities are filled with people who for most of their lives have been trying to control their bodies without ever being diagnosed as having an eating disorder. Their physicians are as oblivious or deluded as they are.

For young people who are overweight because of lifestyle factors or underlying metabolic or genetic conditions, this campaign also completely ignores the reality that most cases of anorexia and bulimia originate in early or mid-adolescence in individuals with a fragile sense of self and a core belief that life is uncontrollable (which it is). Food, exercise and body weight then become the arena in which they can establish a feeling of control over their lives. Too late, they discover that this "control" is mere illusion, that they have lost all power of choice over their eating and exercise behaviours and simply cannot stop. Up to 20% of them will die from their eating disorder,² a number far higher than the risk of death from diabetes or heart disease related to obesity.

Undoubtedly, childhood obesity is a serious problem in our country that needs to be addressed — but with creativity and imagination, not with reflexive and heavy-handed strategies. Einstein once said, "Imagination is more important than knowledge."³ Until we dare to imagine the real causes of this multifaceted problem, until we stop racing for a quick fix and instead tune in to the personal unhappiness, the profound dissatisfaction with life, that lies at its root, then we are doomed to go on seeing the problem as a mathematical equation in which the variables are caloric intake and expenditure.

I can't think of a better way to damage the self-esteem of children than to tell them, tactfully or otherwise, that their bodies are overfed or underexercised. By adding the official voice of family physicians and pediatricians to the consumerist messages already bombarding them about diet and exercise, we will be endorsing the exploitative purveyors of these messages. We will be telling our kids that they are not okay, and we will drive many of them into the waiting arms of anorexia and bulimia.

Theologian and historian Matthew Fox has characterized our society as one that "devours its youth."⁴ This is a strange cultural pathology indeed.

1. The Eating Disorder Education Organization, www.edeo.org (accessed 2004 Nov 15).
2. Ratnasuryi RH, Eisler I, Szmukler GI, Russell GFM. Anorexia nervosa: outcome and prognostic facts. Br J Psych 1991;158:495-502.[Abstract]
3. Desroches L. Allow the water. Toronto: Dunamis Publishers; 1996. p. 172.
4. Fox M. The coming of the cosmic Christ. San Francisco: HarperCollins; 1988. p. 181.

Study: Obesity and Self-Reported Maltreatment

Childhood maltreatment in extremely obese male and female bariatric surgery candidates.

Grilo CM, Masheb RM, Brody M, Toth C, Burke-Martindale CH, Rothschild BS.

Department of Psychiatry, Yale Psychiatric Research, Yale University School of Medicine, P.O. Box 208098, 301 Cedar Street, New Haven, CT 06520, USA. carlos.grilo@yale.edu

OBJECTIVE: To examine rates of self-reported childhood maltreatment in extremely obese bariatric surgery candidates and to explore associations with sex, eating disorder features, and psychological functioning. RESEARCH METHODS AND PROCEDURES: Three hundred forty (58 men and 282 women) extremely obese consecutive candidates for gastric bypass surgery completed a questionnaire battery. The Childhood Trauma Questionnaire was given to assess childhood maltreatment. RESULTS: Overall, 69% of patients self-reported childhood maltreatment: 46% reported emotional abuse, 29% reported physical abuse, 32% reported sexual abuse, 49% reported emotional neglect, and 32% reported physical neglect. Except for higher rates of emotional abuse reported by women, different forms of maltreatment did not differ significantly by sex. Different forms of maltreatment were generally not associated with binge eating, current BMI, or eating disorder features. At the Bonferonni-corrected significance level, emotional abuse was associated with higher eating concerns and body dissatisfaction, and emotional neglect was associated with higher eating concerns. In terms of psychological functioning, at the Bonferonni-corrected level, emotional abuse and emotional neglect were associated with higher depression and lower self-esteem, and physical abuse was associated with higher depression.

DISCUSSION: Extremely obese bariatric surgery candidates reported rates of maltreatment comparable with those reported by clinical groups and roughly two to three times higher than normative community samples. Reported experiences of maltreatment differed little by sex and were generally not significantly associated with current BMI, binge eating, or eating disorder features. In contrast, maltreatment-notably emotional abuse and neglect-were significantly associated with higher depression and lower self-esteem.

The National Weight Control Registry

This is from a "Success Story" posted on the National Weight Control Registry, a project to compile information about thousands of people who have lost significant amounts of weight and kept it off for years. Little by little, the researchers are gathering statistical and anecdotal information from these successful people through detailed questionnaires, interviews, and yearly follow-ups.

Michal Eakin was significantly overweight throughout childhood, adolescence, and early adulthood. By the early 1980’s, numerous unsuccessful dieting attempts had left her feeling frustrated and hopeless. It wasn’t until 1984, when Michal changed her mindset and her priorities, that she successfully lost over 60 pounds. She has maintained this weight loss ever since.

"It took refusing to continue enslaving my life to bingeing and obesity, as well as recognizing my own unique irreplaceable value. From there, I learned to make my health un-negotiably important. Following that, it took little to no effort to apply what I had known all along but was unable to persist in doing.”

This fills my heart with joy and gladness. This is exactly what I'm talking about here.

The official website: http://www.nwcr.ws/default.htm

Diet - The First Five Days

The impulse to start a diet (in PC terms, "a program") usually starts with a moment of deep self-hate - you feel fat, disgusting, and ugly, your clothes don't fit anymore, maybe someone has said or done something to hurt you, maybe a doctor has given you a dire warning about the risks of being fat, and in that moment of dread and fear and self-loathing, you throw your hand up like Scarlett O'Hara in the turnip field and say, "As God is my witness, I'll never be fat again!" In that moment, all the "truths" about how fat you really are, all the ways that you've been able to avoid your own reality become crystal clear. You pass a plate glass mirror and truly "see" yourself, and it's horrible, it's shocking - "I'm even fatter and more disgusting than thought!" You're aware of the shortness of breath at the top of the stairs, and the feeling of fullness in your belly shows itself to be uncomfortable. Maybe your child's friend looks at you like you're a freak, and you're overwhelmed with despair.

At the same moment you're feeling so awful, you see a celebrity on Access Hollywood whose recent weight loss has everybody buzzing, and you think to yourself, "If Kirstie Allie can succeed, then so can I." So you go out and buy a book or a piece of exercise equipment or get a gym membership or order some amazing weight-loss supplement or get the 10-CD set of motivational lectures or you join Jenny Craig or you may decide to consult with a surgeon about gastric by-pass surgery or prescription drugs. You devour the materials about the new diet sensation the way you would normally devour a pint of ice cream. You examine the before and after pictures of people your size and read about how they lost 50 - 100 - 150 pounds and 20 - 40 - 60 inches, and just ran a marathon, and how that now have perfectly flat abs, and you read their stories and think, "They were where I am now, and look at them! In a year they lost all that weight and they say it was easy!"

So you clear the decks for the big diet. It's Friday, and you've decided to start the program on Monday (of course), so you have a weekend to eat all the things you know you can't have when you're on the diet. Friday night becomes lasagna binge night, and Saturday is maybe the last time you can make a big pancake and bacon breakfast for the family, so you pull out all the stops and get the 100% pure maple syrup and real creamery butter and the thick-cut, applewood-smoked gourmet bacon, and you have a feast. You eat the food with a sense of "This is it - the last piece of bacon I'll ever eat" and you make a list in your mind of all the other things you need to eat before Monday morning - nachos, pizza, ice cream, eggs benedict, a grilled cheese sandwich or two, barbecue spareribs, chocolate candy, peanut brittle, rice pudding, a dozen krispy kremes, a couple of Big Macs, maybe a bucket of KFC, and the list goes on. By Sunday night, there's a half of a quadruple-mighty-meaty sausage pepperoni deep dish pizza sitting in its box on the kitchen counter and one more pint of Haagen-Daz in the freezer. You're absolutely bloated, but this is your last chance - tomorrow starts the regime, so you somehow find a position (probably lying down, on your side) where you can finish off the pizza and ice cream before popping five or six Rolaids (the acid reflux is horrible) , maye a few Tylenol PMs, and drift to sleep.

The morning dawns, and BOY are you excited about starting the new plan! There's a spring in your step and an energy that makes you feel invincible. "This won't be so hard at all!" you think, and it's true, that first day is no problem, because you're still full from the day before. "I'm not hungry, even though I just ate half a grapefruit and half a piece of dry toast for breakfast! This really is the breakthrough diet I've been dreaming of! I already feel thinner!"
You jump on the scale that morning and, oh my, it's even higher than you figured, but you think, "Whew! thank God I'm starting now - on the track I was on I would've topped 300 pounds by the new year." In the back of your head you realize that you're carrying about five pounds of waste product in your intestines from your "last weekend" but it's kinda neat that your starting weight is so high - it just adds more drama to your story, and makes the number of total pounds you lose more impressive.

You've managed to clear the decks so the new diet can take its proper place as the number one item on your agenda. I mean, that's what it takes - it has to be number one in your thoughts, because as soon as it's on the back burner, as soon as you're distracted, as soon as you're not giving it your complete and total attention, it fails (or should I say YOU fail) and the weight comes back. Knock on wood, things are calm at work, your husband isn't grousing about his own stupid concerns, and your teen daughter has stayed out of trouble since last summer. There hasn't been a terrorist attack in months, the weather is bright and sunny, your car is working pretty good, and your mother isn't driving you crazy.

You've also managed to prepare the environment for this exciting new undertaking. All the stale Oreos and leftover Halloween candy has been cleared out of the pantry, your husband has been coached on what to say and what to do to support you, the $200 treadmill you bought from QVC ten years ago, the one that's been stored under the guest room bed, is pulled out, dusted off, and placed front and center in the living room. There's no way you can just flop on the sofa at night anymore when the treadmill blocks your view of the TV. You've gone to the supermarket and bought all the things you'll need for that first week: instant nonfat oatmeal, three heads of cauliflower, skinless chicken breast, Pam, Chinese dieter's tea, six green peppers, rice cakes, some sugarfree, fat-free, chocolate-free cocoa mix, a huge container of peeled garlic (this is the secret amazing discovery the diet guru based her whole program on), a dozen lemons, and some cardamom (turns out cardamom, in combination with garlic, has amazing powers to kill appetite and is what the monks in Tibet drink to keep meditating when they should be starving). Oh, and don't forget the chromium piccolinate, the distillate of cayenne and enough Crystal Lite to make fifty quarts of sugarfree pink lemonade.

Maybe you've gone to your closet and pulled out the ugliest, biggest pair of tacky polyester stretch jeans you own and said to yourself, "These are the jeans I'm gonna hold up in my 'after' pictures when I've lost 100 pounds!" Maybe you find, in the back of your closet, a favorite outfit you haven't been able to wear for years, and you check the label - "Hmm. Size 6. If I lose five pounds a week like the program says I will, I should be able to fit into this and wear it to my daughter's graduation!" Maybe you put the outfit in the front of your closet to act as motivator.

You've called your sister back East and told her all about how miserable you are to be fat and how you've found this amazing new diet and you say, "This is it. I can't be fat anymore. "I refuse to let my life be ruined by my eating behavior. I'm doing this for me. I'm tired of putting everybody else first. This time I'm going to succeed, and nothing is going to stop me." You both shed a few tears together, and your sister tells you how much she loves you and how proud she is of you that you're doing this, and offers to help in any way she can, even if it's just to keep Mom from bothering you. Maybe you confess that that the reason you didn't visit last year was because you were embarrassed by your weight, but that you'll be sure to visit next year when you're thin. Maybe your sister told you that she loves you no matter what your weight is, but you think to yourself, "Yeah, yeah, yeah, maybe - but I feel so much better about myself when I'm not the FAT sister, when I'm the same size, or even thinner, than she is, and besides, we have more fun when I'm thin - I can't go to Dollywood and ride the log chute with everybody when my ass is so big." You say, "Thanks, Sis, I sure do appreciate your support."

You might even have sworn off TV or fast-food places for the duration. You've certainly compiled a list of all the foods you ABSOLUTELY CAN'T EAT anymore. You've gone to Lane Bryant and purchased a jaunty verticle-striped exercise outfit to wear to the gym. You've dug up a perky pink scrunchie to hold your hair back when you're in step aerobics class. You've put a cooler in the back seat of your car with a few of those blue ice packs and some containers of sugar-free Jell-O, baby carrots and other "emergency" foods just in case (in case? I mean, when) you're tempted to go off your diet.

"This is it, oh my God, here we go, I can't believe it, finally, FINALLY, I'll pulling myself together, I'm headed in the right direction, my priorities are in order, I have all the tools I need, I'm feeling confident, I'm feeling excited, I'm SOOOOOOOOOO ready for this! Get ready for the new me, world!!! I'm on my way!!"

The second day of the diet goes really well, too - you're light headed and have diarrhea, which of course is a sure sign you're losing weight. Are you imagining it, but are your clothes feeling looser? Incredible! You feel like a wave of energy has washed over you and you're proud of the phenomenal workout you had. And you didn't stop off at Wendy's on the way home! The food you've been eating isn't so delicious, and there's such a tiny amount of it, but that's okay, it's totally worth it to lose weight and feel good about yourself again. You check the mirror: can you tell? Have you lost weight? You postpone getting on the scale for a week so the number of pounds lost is more dramatic. Five pounds? Six? Ten? Sure, some of it is water weight, we know that, but a LOT of it is ugly, disgusting FAT and it's melting off of you!

The third day is pretty hard, because now you're feeling hungry. All the food you ate over the weekend has passed through your system and the first hunger pain you've felt in years makes its presence known. Used to dealing with any sort of discomfort immediately (pop a pill, eat a meal, put your feet up), you're a little panicked about the hunger pain - it's a pang, really, not that bad, but you're not really in control of it, and the solution that presents itself to you (EATING!) is not allowed. So you look nervously around, maybe pop in the DVD that came with your regime, and hope it gives you some ideas about what to do. Drink water - sometimes hunger is really thirst - hmmm! So you chug down a half-gallon of Crystal Lite. Yup, seemed to work! About a half hour later the pang "knocks" again. You quickly flip through the diet guidebook. The guru says that you shouldn't be feeling hungry because the amazig combination of garlic and cardamom kill your appetite. "It's not hunger you're feeling." the author says, "It's just the sensation of having an empty stomach. Relax - it's okay!" And you think, "Yeah, I know the diet is working now! I'm hungry and I'm anxious. This is good!"

You pull through Wednesday (it was a challenge, though, and you give yourself lots of pats on the back for holding on to your willpower and your steely resolve) and Thursday is definitely easier. Your stomach has calmed down a bit. You ache from head to toe from that big workout you had a couple of days ago, but you get to the gym as planned and put in another herculean workout.

That night, you have six ounces of snapper instead of four, and two tiny red potatoes instead of one, but you skip the unsweetened apple sauce and make yourself a big steaming mug of satisfying herbal tea, so it's okay. It doesn't bother you when your husband comes home late from work, and you smell it before you see it - he's carrying a Carls Jr bag containing a double SuperStar with cheese, monster fries and a chocolate "frostie". All smiles, you get out a plate and put the burger and fries onto it for him. You cut the burger in half, then you sip your tea while he eats. The crunch and smell of the greasy food doesn't tempt you. You feel victorious, proud of yourself, and your paints feel looser. "Wow, I've really changed! I'm doing it! This is fantastic! I'm not tempted one bit to eat that burger. Or one of those hot salty fries. In fact, I used to love them but now they look disgusting to me. I think I'll flip through the Victoria's Secret catalog tonight!"

Friday dawns, and excitedly you jump out of bed, take a long pee (and a crap if you're lucky), get naked and weigh yourself. Five pounds! Five pounds! That's so much in just five days! Secretly you're disappointed that it isn't more, but still it's a good beginning, and at the rate of a pound a day, you'll be in a bikini by July! You tell your husband the great news and, having been well coached, he says, "That's so great, honey! I'm so proud of you!" and he smiles. His eyes travel to your hips to see if there's a noticeable change, and his expression betrays to you that he can't "tell" yet if your ass is smaller, but you smile, too, and think, "Wait till I call my sister - SHE will know what an amazing achievement this is!"

You call your sister. She's not home, so you try her on her cell. She's not picking up. You leave a message: "Call me! I've got something really exciting to tell you!" A few minutes later you text message her: "GR8 411; Call ASAP!" Obviously she's really busy.

You go to work. You tell your co-workers that you've lost five pounds already (maybe you even say you've lost six - it's really closer to six - it sounds even more impressive and you can always subract a pound from next week's total). You get reactions everywhere from totally delighted to cautiously optimistic. After all, you've been in this place before, and they've watched while you put back on all the weight you lost. One of your work friends tries to let you know that they're happy for you but that they like you regardless of your size, and you smile and think, "She's thinking I'm going to gain back this weight like I did the last four times I tried a new program, but this time it's different - this time I'm REALLY going to do it - this time I won't have anything come up in my life that distracts me from staying on track. I'm not going to let her negative thoughts sabotage me. She's trying to enable my fatness by telling me she like me regardless of my size. Well, I'll show her - she'll see, she'll see!"

The morning passes excruciatingly slowly. You haven't heard from your sister and you're preoccupied with thoughts about what your co-worker said. "The diet guru said there would be people who were jealous about my success and would be out to get me. I never thought Doris was like that, but obviously she is. What the hell is my sister doing? Couldn't she pick up the phone? She KNOWS I'm on a diet and how important it is to have her support! It's already 10:30 - I'll go ahead and eat my lunch now - it's a little early, but it's only a small green salad with nonfat ranch dressing and two rice cakes. Wouldn't hurt to eat early. I'll go for a brisk stroll at lunch hour - that's it - I'll go window shopping for clothes! Damn that Doris for shaking my confidence like that! Well, that's the last time somebody's gonna try to sabotage my progress. What is hell is my sister doing that she can't call me back?"

By noon, you still haven't heard from your sister, and you're out in the sun, window shopping. You pass by a guy selling hot pretzels. Man, they look good, but they're on the "NEVER EAT" list. You keep going and spot a table with two Girl Scouts selling cookies. "I can't believe it - I started a diet program the same week as the Girl Scouts do their big annual cookie campaign! Oh, they have a new low-fat version of the thin mints. They're my favorite. I really should walk right by, but look at how cute those girls are, how eager little salespeople they are! It's a good cause to support them, I've supported them every year. After all, I was a Girl Scout once! Maybe I could just read the nutrition label and see how many calories and carbs and fat grams they have. Hmmmm, a box has twelve servings (two cookies each) at 70 calories per serving. Very low fat grams! Quite a lot of carbs, though. What're the main ingredients? Oh, high fructose corn syrup solids, then sugar, then glucose. But still - I skipped the apple sauce yesterday, and I still have 400 calories to go on today's regime - maybe I can just eat 2 servings (4 cookies) and it'll be just fine." After all this rational thought, you give yourself permission to "cheat" a tiny bit and have four measly little diet cookies.

Your heart beating rapidly in excitement, you buy two boxes of cookies. ("I know, I'll buy two boxes instead of one. It's two for five bucks anyway - you save a dollar by getting two - and I'll bring the second box back to the office and let everyone else eat them - they'll see how strong I am, how I'm able to resist temptation.")

Just steps from the card table, you quickly tear open one of the boxes and the plastic inner wrapping. The first one melts in your mouth. The sensation is just heavenly. You haven't had sugar in five days and your tongue is practically having an orgasm. "It's so creamy and it's LOW FAT!" You pop another cookie in your mouth. You close your eyes in ecstasy and almost slam into a lamppost. The third and fourth ones disappear almost without consciously being aware of eating them.

The cookies come in rows of five - there's one little cookie left in the first row, like a lone poker chip. Without much thought you pop the fifth cookie in your mouth and stride purposefully over to the trash can. You're going to throw away the rest of the opened box of cookies. You hesitate - seems like such a waste - but you go ahead and throw them away, and you feel so proud of yourself! "Wow, I coulda eaten that entire box of cookies but I only had four - I mean five - and threw the rest away! Amazing! I'm just so strong! I REALLY have turned a corner in my life now. I gotta tell my sis. Why the HELL hasn't she called me yet?"

Back at the office, you pull out the remaining box and, with quite a bit of fanfare, present it to "the girls." They each gingerly take one or two. One of the girls (a skinny one, of course) taps her trim belly and says no thanks, it's not on their diets. You try to persuade them to have just one but they smilingly refuse, and you think, "That bitch - it's just one little low fat cookie, for heaven's sake. What's her problem?" You're flooded with jealousy - and contempt - for her.

You leave the half-eaten box of cookies on the countertop outside your office, then call your sister again. This time she answers. She sounds really tired, definitely not very peppy, but you go ahead with your news. Using a big cheery singsong voice, you say, "Hey Sis! Guess what? I lost SIX pounds in the first five days!" You've actually forgotten by now that you really lost five pounds, but what's the difference. Your sister tries to sound excited for you - she says, "Great going! Wow! Incredible! Good for you! Fantastic!" But somehow she sounds less than thrilled. "What's going on?" you ask her. "Oh, nothing much, really." Seems you need to prod her to tell you. "C'mon, Sis, tell me." "Oh all right - I heard from Lisa last night and she's pregnant." Lisa is your problem neice. Lisa's been through hell and back in her nineteen short years on Earth. Lisa's the one who got a tattoo at 12, seven piercings at 13, and ran away with some biker in 10th grade. "Oh, don't worry about it, Sis," you say. "You know how Lisa is. She's always been a troublemaker. I'm sure things will work out." "I know," says your sister, "But this time I'm really concerned because that guy she's been dating seems like such a loser." Her voice starts to crack and she quietly sniffles. "Cheer up, Sis - come on, it'll all be okay." After another round of compliments from your sister about your weight loss, you hang up.

Before you know it, you're on your feet and out the door of your office, feeling kinda fidgety and distracted. You think, "That damned Lisa, always stealing the spotlight - this was supposed to be my big day!" And you spot the leftover cookies on the counter. "No! NO! I will NOT eat any more cookies!!"

You decide to make yourself a cup of tea. Coming back from the microwave, you pass the cookies again and notice now there's just three left. There's some crumbs on the counter. It's two o'clock. You stride quickly past the cookies, your head held high, and return to your office. You start doing the weekly back-up on your PC, a very boring job you do every friday. Usually you munch on some fritos and sip a Coke during back-up and flip through a Vogue or something. It takes an hour to finish backing up your PC. You've been sipping your tea and organizing your paper clips into two piles - plastic covered and plain. You've been thinking how unsupportive your sister is to allow her petty little concern get in the way of showing you the support you need to keep on track with this difficult, difficult program. You remember Doris's remarks this morning and that skinny little bitch who didn't eat one damned cookie, and you think, "The whole world wants to keep me fat, I just know it, it's a conspiracy!"

At 3 pm, you spot the Girl Scout cookie box on the counter. Now there's just two left. Plus some crumbs.