Exploring self-compassion among men seeking weight loss: a thematic analysis

Weight stigma is a painful and distressing phenomenon experienced by many individuals with overweight and obesity around the world. Weight stigma, whether experienced from others, or internalised by individuals with overweight, is associated with a myriad of detrimental physical and mental health outcomes (Latner, Durso, & Mond, 2013; Papadopoulos & Brennan, 2015; Pearl, Puhl, & Dovidio, 2015; Puhl & Brownell, 2001). Given the widespread and negative impact of weight stigma, there is a need for strategies to alleviate the effects of weight stigma and assist individuals to better cope with stigmatising situations (Flint, Raisborough, & Hudson, 2020). Concurrently, there has been an increased interest in the field of self-compassion research, for which there is now compelling evidence highlighting that self-compassion is beneficial for mental health and well-being. Evidence shows that self-compassion is particularly important during times of suffering and distress, and can serve to buffer the effects of stigma for various populations, including marginalised groups (Fredrick, Williams, & LaDuke, 2019). Evidence demonstrating the advantages of self-compassion provides a persuasive rationale to argue that self-compassion has the potential to attenuate the negative effects of weight stigma. However, studies merging the fields of weight stigma and self-compassion research are limited, and the role of self-compassion within the context of weight stigma is an understudied area of investigation. Based on empirical evidence available from both fields, it is argued that self-compassion can serve as a protective factor in the lives of weight stigmatised individuals with overweight. It is further argued that a compassion focused method to alleviate the effects of weight stigma and develop the capacity for self-compassion offers an important empirical contribution to the field of weight stigma research, which has not been offered by the approaches currently available. This dissertation aimed to firstly present a review of empirical evidence across the fields of weight stigma and self-compassion. Following this, a series of studies aimed to identify and address gaps in the literature. Specifically, the research presented in this dissertation was designed to address three primary aims: 1) to investigate the role of internalised weight stigma and self-compassion in the relationship between weight stigma and outcomes of psychological distress, body shame, loneliness and life satisfaction; 2) develop a compassion-focused group intervention specifically designed to reduce the adverse effects of weight stigma; and 3) conduct a pilot study to examine the acceptability and feasibility of a compassion-focused group intervention for weight stigmatised women with overweight and obesity. This dissertation presents a compendium of three studies conducted to achieve these aims. Study 1 involved an empirical study that tested the relative contribution of both internalised weight stigma and self-compassion on weight stigma, as mediators in the relationship between weight stigma and outcomes of psychological distress, loneliness, body shame and life satisfaction. Results revealed that internalised weight stigma mediated the relationship between external weight stigma and body shame, while self-compassion mediated the relationship between external weight stigma and psychological distress, loneliness and satisfaction with life. Study 2 provided a detailed account of the development of a 2-day Compassion-Focused Therapy (CFT) intervention, designed to increase self-compassion, and reduce internalised weight stigma for women with overweight and obesity. Two case studies demonstrated improvements in the expected direction for self-compassion, internalised weight stigma, depression, body shame, loneliness, weight self-efficacy, body dissatisfaction, life satisfaction, as well as weight loss. Study 3 tested the feasibility/acceptability of the 2-day, Compassion-Focused Therapy (CFT) program for a group of weight stigmatised females with overweight and obesity in Australia. Significant group improvements were found from pre-treatment to post-treatment for self-compassion and internalised weight stigma, with gains maintained at 3-month follow-up. Significant improvements were also found for psychological distress, life satisfaction, eating self-efficacy, body dissatisfaction and loneliness at the post-treatment assessment. A non-significant trend of mean group weight loss from pre-treatment to three-month follow-up was also observed. Credibility ratings of the program were high. This compendium of research has advanced research knowledge in two main ways. Firstly, the research reported herein is the first to have demonstrated the unique roles of both self-compassion and internalised weight stigma as mechanisms through which experienced weight stigma can affect a range of adverse psychological consequences. Secondly, this dissertation has demonstrated the feasibility and acceptability of a 2-day CFT-based group program specifically designed to increase self-compassion and reduce internalised weight stigma for women with overweight and obesity. The current program has merged two important fields of self-compassion and weight stigma research, thus providing evidence for self-compassion as a promising strategy through which to assist individuals to better cope with the painful effects of weight stigma.

Self-compassion and body image in pregnancy and postpartum: A randomized pilot trial of a brief self-compassion meditation intervention

Social networking site (SNS) activities that entail exposure to idealised images of attractive women and men, or high investment in photo feedback through likes and comments, may reinforce feelings of inadequacy and negative body image. Given that young adults are the highest users of SNSs (Pew Research, 2019; Sensis, 2018), and that body dissatisfaction can increase further during the transition to young adulthood (Bucchianeri et al., 2013), the general purpose of this thesis was threefold. The first purpose was to identify pathways between appearance-related SNS use and negative body-related outcomes relevant to each gender, the second was to examine the mechanisms by which self-compassion affects the strength of these associations, and the third was to examine whether an intervention that aims to increase self-compassion helps reduce body concerns. Four studies were conducted to address four research aims. The studies were grounded in three main theoretical frameworks (a) objectification theory (Fredrickson & Roberts, 1997) (b) social comparison theory (Festinger, 1954), and (c) Neff’s (2003) conceptualisation of self-compassion. The first aim was to examine the associations between three appearance-related SNS uses (viewing or following of celebrity, fashion, beauty/grooming content [CFB/G], viewing or following of fitspiration content, and the importance placed on likes and comments [ILC]) and body concerns separately for each gender. Specifically, part one of the first aim was to test a revised objectification-social comparison model on the associations between the three appearance-related activities and body concerns (body dissatisfaction and drive for thinness) in women. Part two of the first aim was to test a revised objectification model on the same three SNS uses and two indices of men’s drive for muscularity (attitudes and behaviour). The second aim was to examine the six facets of self-compassion as potential moderators of the links between SNS use and body-related outcomes in each gender. The third aim was to qualitatively explore how trait self-compassion is used by this age group as a strategy to alleviate appearance-related distress. The fourth aim, given that body concerns are experienced differently, are more common, and more severe in young women than young men (Grogan, 2008; Murnen, 2011), was to evaluate the effectiveness of a brief Mindful Self-Compassion workshop (Neff & Germer, 2013), followed by a 2-week discussion group on the SNS platform, Facebook, on improving body image in young women. These aims were fulfilled by collecting data from three samples of young adult undergraduates aged 17–25 years. Study 1and 1a comprised 338 women, and Study 2 and 2a comprised 303 men. Study 3 comprised 30 selected participants from Studies 1 and 2, and Study 4 comprised 76 women (42 = intervention, 34 = waitlist control). In Study 1, structural equation modelling supported a serial mediation model that comprised significant paths from two SNS activities (CFB and ILC) through, in turn, upward appearance comparison, body surveillance, and social appearance anxiety, to drive for thinness and body dissatisfaction. A direct effect on body concerns was found for use of fitspiration. In Study 1a, the three compassionate facets were shown to buffer the effects of fitspiration use on drive for thinness, while self-kindness buffered the fitspiration and upward appearance comparison link. The uncompassionate facets of isolation and overidentification strengthened the link between ILC and upward appearance comparison, and fitspiration and body dissatisfaction. In Study 2, structural equation modelling supported a serial mediation model that comprised significant paths from CFG and ILC through, body surveillance, then social appearance anxiety, and finally to attitudinal drive for muscularity. Fitspiration use was directly associated with attitudinal and behavioural drive for muscularity. In Study 2a, the uncompassionate facets of self-judgement and overidentification strengthened the associations between CFG and ILC and body surveillance. In Study 3, descriptive/confirmative analyses revealed that, for participants with high trait self-compassion, only self-kindness was utilised to alleviate appearancerelated distress. Most participants with low trait self-compassion engaged in selfjudgement, with some expressing a fear of self-kindness. The concept of common humanity was acknowledged by all, but not used as an affect regulation strategy. Most participants engaged in forms of overidentification. In Study 4, a series of ANCOVAs showed that, relative to a waitlist control, the intervention group reported lower upward appearance comparison, social appearance anxiety, body dissatisfaction, and drive for thinness, and higher body appreciation and self-compassion, at posttest and 1-month follow-up. All effects, except those for body dissatisfaction, held at 3-month follow-up. Additionally, regression analysis showed that common humanity predicted gains in body appreciation from pretest to posttest. In sum, findings revealed gender similarities on the type of appearance-related SNS used and pathways through which these uses could lead to relevant body-related issues. However, gender differences regarding how the facets of self-compassion may be understood, and thus utilised in protective ways were revealed, suggesting further research is required in this area. Encouragingly, a brief Mindful Self-Compassion program complemented by a Facebook discussion group was shown to improve body image and self-compassion in young women, suggesting that the use of SNSs can be harnessed in constructive and supportive ways.

Body Image and Televised Images of Thinness and Attractiveness: A Controlled Laboratory Investigation

Improved self-esteem and body image, as well as reduced experiences of weight stigma are important patient-reported obesity treatment outcomes. However, more knowledge is needed about how individuals who have undergone metabolic and bariatric surgery (MBS) perceive themselves and their bodies and use different coping strategies in relation to body image and self-esteem long-term after MBS. In this qualitative study body image, self-esteem, weight stigma and coping strategies were explored among 18 individuals who underwent MBS more than 10 years ago when interviewed. Using reflexive thematic analysis, two primary themes were identified: 'Experiences of living with a stigmatised body' and 'Coping with weight stigma, body image and self-esteem', and eight sub-themes. Findings capture frequent experiences of weight stigma before bariatric surgery, the need for coping with stigma and body dissatisfaction before and after MBS, and how different coping strategies are related to participants' perceptions of their bodies and self-concepts. More adaptive coping strategies, such as confrontation and cognitive restructuring may facilitate more positive body image outcomes, than more ruminative and avoidant strategies. Understanding adaptive coping strategies can be useful to develop interventions to reduce negative consequences of weight stigma on body image and self-esteem.

Patient-Centered Care for Obesity: How Health Care Providers Can Treat Obesity While Actively Addressing Weight Stigma and Eating Disorder Risk

Fat Studies 101: Learning to Have Your Cake and Eat It Too

This study examined the relation between weight stigma, exercise motivation and exercise behavior. One hundred female undergraduates (BMIs [kg/m(2)] 17-38) completed measures of experiences with weight stigma, body dissatisfaction, self-esteem and exercise motivation, and reported on their exercise behavior. Stigma experiences were positively correlated with BMI and body dissatisfaction. Importantly, stigma experiences were related to increased desire to avoid exercise, even when controlling for BMI and body dissatisfaction. Exercise avoidance was in turn related to less frequent strenuous and moderate exercise. These findings suggest that weight stigma (through its impact on avoidance motivation) could potentially decrease physical activity levels.

Purpose: Obesity and associated healthcare-related issues continue to increase. The prevalence of obesity is on the rise, which has led many health professionals to find ways to improve health interventions. Health coaching can be a viable tool to reduce the obesity epidemic. The purpose of this quantitative study was to investigate the effects of an 8-weekhealth coaching intervention in obese individuals from Puerto Rico and to determine if self-esteem and body image influence weight managementself-efficacy. Method: A pretest-posttest design using a weight management self-efficacy scale helped the researcher evaluate the effectof the coaching sessions. In addition, body image was measured using the 9-figure Body Size Scale and self-esteem was analyzedwith the Rosenberg Self-esteem Scale. Forty Hispanic adult men and women participated in the study. Results: Health coaching had a statistically significant effect on weight management self-efficacy (t (39) = -6.58, p < .001). Additionally, body image and self-esteem affected weight management self-efficacy and positive health coaching outcomes were significant regardless of positive or negative perceived body image. Conclusions: These findings suggest that body image and self-esteem should be considered when creating programs for obesity and a health coaching program can be effective in increasing weight management self-efficacy.

Black women are at high risk for obesity and obesity-related health problems (1). Nearly 50% of black women compared to 30% of white women are obese (2,3). While many women who attempt to lose weight do so through caloric restriction and/or physical activity, smoking has been identified as an alternate strategy used for weight loss among black women with weight concerns or body image concerns (4). Nicotine's suppression of body weight facilitates initiation and maintenance of smoking among women (5,6,7). Despite the deadly health risks associated with tobacco use, 23.1% of women smoke (8). Female smokers are more likely to report smoking cigarettes to control weight (6,9) and less likely to quit smoking due to weight concern (10). Perkins et al. and Pirke and Laessle note that women tend to suffer more postcessation weight gain than men (as cited in Copeland) (11). Smoking cessation is less likely among women who fear postcessation weight gain or benefit from weight control when smoking. Additionally, women with the intention to control body weight by restrictive eating are more likely to smoke to control appetite and weight (12). Black women tend to have lower rates of smoking cessation and physical activity and higher dietary fat intake (13,14,15). Factors contributing to low prevalence of weight management among black women need to be identified for the development of appropriate interventions. Less reported social pressure to achieve thinness and greater perceived attractiveness at higher body weights may limit motivation for healthy weight management among many black women. The 2003–2008 National Health and Nutrition Examination Survey found weight control through physical activity or dietary change to be positively associated with weight perception (odds ratio women 3.74; 95% confidence interval 2.96, 4.73) (16). Several authors assert that historical black-white differences in ideal female body image (17) and acceptance of overweight (18) may contribute in part to explaining racial differences in weight loss efforts and modifiable weight management behaviors. It has been indicated that black women have a high prevalence of obesity partly because self-image is not strongly dependent on body size (19). Body shape perception often varies by race and gender with blacks generally perceiving their bodies as lighter than indicated by their BMI (20). An understanding of factors such as body image and their relationship to weight loss behaviors is necessary to promote healthier lifestyles. This review investigates the association between body image satisfaction and dietary behavior, physical activity, and smoking as tools for weight control among black women. Due to the paucity of literature focusing solely on black women, this article considers both the experiences of black women alone and with other groups. Studies were identified through computerized searches of biomedical and psychological databases, namely PubMed, CINAHL, Psych Abstracts, Science Direct, and Web of Science and manual searches of article bibliographies focusing on dietary behaviors, physical activity, and smoking/alternative weight control techniques since 1990. Searches were performed on recurring authors and in recurring journals for additional articles on the topics. Variations of the term "body image," including "body dissatisfaction," "satisfaction," and "esteem," as well as "size," "shape," and "weight" were sought. Searches included these terms in combination with the target health behaviors, namely diet, physical activity, and smoking. The search was limited to studies including black or African-American females. We did not restrict our search to only studies that investigated ethnic differences because it is our aim to understand body image as it relates to health behaviors among black women to determine whether it may be a factor to address in designing interventions. We were not specifically investigating racial differences in regards to body image. Additionally, we found that many studies did not distinguish results by race or ethnicity. Thirty-one articles have been cited in this article. The list may not be exhaustive. Some identified articles were excluded for several reasons. Studies investigating dietary disorders were omitted as well as those that did not evaluate body image in association with the health behaviors. Findings and critiques of the remaining articles follow. Over the last decade, several seminal papers have documented the positive association between components of body image dissatisfaction and dieting frequency or dieting status among US adults and adolescents. An accumulating body of research has directly evaluated the relationship between dimensions of body image and dieting behavior or dieting status specifically in black women (see Table 1). Two studies bear mentioning first as findings have acknowledged the importance of identifying potential within group variation among black women with respect to dieting and body image disturbance (see Table 1). Kumanyika and colleagues were among the first to begin to clarify the link between dieting and weight satisfaction in a large sample of black women from the Washington DC community (1). Results showed that less satisfaction with weight and a history of dieting were more likely among the overweight women. Similarly, among black female participants in the CARDIA multisite investigation, a positive relationship between dimensions of body dissatisfaction and dieting for weight reduction was evidenced across BMI tertiles despite women of greater BMI reporting poorer body image (19). It is unclear however, whether results varied by study site. A series of cross-sectional studies assessed body image (using diverse instrumentation) among multiethnic samples of self-identified dieters inclusive of appreciable numbers of black females (21,22,23,24,25,26). In both adults and adolescents few differences in body image disturbance were observed between black and white female dieters (Table 1). This parity was particularly evident when analyses were adjusted for covariates correlated with both dieting status and body image perceptions (e.g., age, BMI regardless of race (21,23,25). Only a few studies to date have examined these relationships including nondieting controls as a comparison (22,24). In one early report, adolescent dieters residing in the Midwest irrespective of race, gender, and actual overweight status typically endorsed more disturbed body image attitudes relative to nondieting peers (24). Similarly, in a more recent investigation conducted in Los Angeles, both black and white adult female chronic dieters exhibiting high dietary restraint reported greater distortions in aspects of body image than nondieting females and male chronic dieters (22). However, these results were not controlled for BMI, age, or socioeconomic status. Another series of cross-sectional investigations compared the relationship between dimensions of body image and dietary restraint/dieting in ethnically diverse groups of black and white adult and adolescent females. Again, it appears that in general, the correlations between these factors are robust independent of age and race in community (22,27,28,29,30) and in-patient (26) samples. Notable exceptions, however, were observed in a few instances where patterns of relationships between indicators of poor body image and dieting behavior differed between women of both racial groups (Table 1 and see refs. 26,28,29). Interestingly, the one investigation in which no significant relationship emerged between components of body dissatisfaction and dieting among black females was conducted in the southern US region (26). A few recent reports have begun to explore the association between measures of body image and various dietary consumption patterns among black females and others (Table 2; please see Ard et al., for a description of findings using qualitative methodology) (31). Dependent variables included frequency of skipping meals (32,33), fast food consumption (34), and composite measures of dietary weight control (35) in predominantly black or ethnically diverse samples spanning a spectrum of ages and US regions. Components of body image disturbance tended to covary positively with poorer nutritional content (35) and behavior patterns (36) and negatively correlated with healthy dietary intake (37) with some exceptions (38,39). However, BMI and other socioeconomic status variables were not consistently controlled in analyzing these relationships. There have been varied findings regarding the association between body satisfaction and participation in physical activity (see Table 3). One study identified body image as a motivating factor for engaging in physical activity (14). Taylor et al. (14) investigated reasons for adolescent girls' participating or not participating in physical activity. Focus groups of black and Latina girls revealed that concerns with body image facilitated physical activity. The girls reported that extra body fat and size affected how they felt about themselves. Some noted positive effects of exercise were "keeping your right size," "a flat stomach," and "losing weight" as well as the desire to be skinny like the people on the exercise programs on TV and to lift weights to give shape to your body. Although there is qualitative evidence of body image being a motivating factor for physical activity, several other studies have found that low body satisfaction is associated with low physical activity. In a 5-year longitudinal study of socioeconomically and ethnically diverse adolescents, Neumark-Sztainer and colleagues (40) found that lower body satisfaction predicted lower levels of physical activity among females. Separate findings for black and white females were not presented. However, results were weighted by ethnicity, race, and socioeconomic status of respondents. Similarly, Yancey et al. (41) found that overweight black women and men were less likely to perceive themselves to be overweight than overweight Latinos or whites. Average weight blacks and Latinos who perceived themselves as being overweight were more likely to be sedentary than their white counterparts. In subgroup analyses by race/ethnicity, black and Latina women were grouped together due to small numbers (41). In another study, adolescents who perceived themselves as overweight were less likely to engage in physical activity despite trying to lose weight. Exercising was the method more often reported by whites than by other racial and ethnic groups (32). Some studies support the notion of cultural acceptance of fatness suggesting that blacks are less likely to engage in weight loss behaviors due to acceptance of large body shapes (42,43). Kelly et al. (33,42) found that black girls were more likely than white girls to report high body satisfaction. Results suggested that adolescent girls with high body satisfaction were less likely to use healthy or unhealthy weight control behaviors, including exercise, eating more fruits and vegetables, and eating fewer sweets and high-fat foods (42). Similarly, Mabry and colleagues (43) found that black adolescent girls demonstrated more acceptance and self-esteem with regards to having a larger body size than their white peers. This acceptance was associated with less participation in physical activity (43). Although many investigators are concerned with the impact of body image satisfaction on engagement in physical activities, others have investigated the opposite relationship. Some studies have found participation in physical activity to lead to improved body image (20,44,45,46). In a convenience sample with 60% black women Smith and Michel found that pregnant women who participated in an aquatic aerobic program reported improved body image scores. While analyses were not stratified by race/ethnicity, the diversity of the sample suggested that this association was true across race and ethnic groups (44). Likewise, Miller and Levy found that female athletes exhibited significantly more positive body image self-concept than female nonathletes (45). Again, results were not stratified by race. In a biracial population of young adults aged 18.5–35 in Bogalusa, LA, physical activity was not found to be a significant predictor of body image perception (20). While both black women and white women expressed negative body image views that countered the cultural tolerance of fatness theory attributed to black women, these groups expressed differences in ideal weight-loss methods. White women emphasized physical activity whereas black women emphasized food characteristics with no mention of physical activity (46). Some studies investigated both body image and physical activity but did not assess the association between these two factors; however, racial/ethnic differences were noted. Studies suggest that there is no significant difference between blacks and whites over age 22, whereas white teens and college-aged women are more dissatisfied with their looks than black women at this age (47). Perry et al. found that white girls had greater physical activity whereas black girls had higher ideal body sizes and greater body satisfaction than white girls. There was no significant difference between black girls and Hispanic girls on body satisfaction or physical activity (48). Contrarily, another study found that black women had higher ideal body image and more sedentary behaviors than Latin-American women (49). While there is evidence of contrary findings of the relationship between body image and physical activity and differences by race/ethnicity, in general the association tends to vary by age. Several researchers have examined the relationship between body image and smoking among females. However, the sample sizes of many of these studies assessing the role of body image on decisions to start smoking or smoking cessation included few blacks. King (13) noted that researchers had not examined the role of tobacco use for weight management among black women. Several clinical trials regarding tobacco cessation have assessed the impact that body image or weight image has in influencing smoking patterns among females. The studies can be separated into two types—those examining smoking initiation or smoking cessation. Several cross-sectional studies examined whether perceptions of attractiveness influenced smoking behaviors (50,51,52). Findings suggest that women smokers felt less attractive and disliked their bodies more than nonsmokers (52) (Table 4). Women with weight concern were more likely to smoke to achieve a smaller figure. Knauss and colleagues (50) found that female smokers considered other smokers to be more attractive and rated smoking as appealing. Utilization of media (magazines and television) may encourage smoking among weight-concerned adolescents. Carson surveyed 967 12th graders to examine whether exposure to media and drive for thinness influenced smoking among this population. Teens who read fashion, entertainment, and gossip magazines were more likely to be current smokers. The authors asserted that smoking is used by these teens in order to maintain a thin figure (51). Among studies of smoking for weight management, few studies have assessed the use of smoking for weight management among black women (53). An earlier review of barriers to smoking cessation among minority women did not include weight control as a barrier to quitting smoking (13). Many prior studies included small numbers of blacks. However, four studies examined the relationships between smoking and weight concern among larger numbers of black females. Several clinical trials have assessed factors affecting smoking cessation among black females. One study examined smoking cessation among blacks with HIV/AIDS (54). Another examined smoking cessation among low-income blacks (55). Both found black females with less weight concern were more likely to smoke. Only one study has assessed the role of weight concerns in smoking initiation among black females (53). Whereas 5.6% of African-American women initiated smoking as a result of weight concern, 11.3% of white women felt that weight was an important factor in smoking initiation. Using data from the National Longitudinal Survey of Youth (NLSY97) Cawley and colleagues (56) found that adolescent females with a higher BMI who were trying to lose weight were more likely to initiate smoking than the females who did not consider themselves overweight. Results were not stratified by race. Several studies assessed whether weight concern reduced smoking cessation among black women. Pomerleau et al. (53) found that overweight black smokers were less willing to risk weight gain by quitting smoking and concluded that weight concerns may motivate black women as powerfully as white women to continue to smoke. Two studies found that the majority of black female smokers were not concerned about postcessation weight gain (54,57). Obese black females were least concerned about postcessation weight gain. In contrast, another study reported that black female smokers were concerned about postcessation weight gain (56). Concerns about body shapes or the fear of postcessation weight gain differ from those of white females, yet have influenced some black women's decisions about smoking cessation. Further efforts must be made to provide weight gain education and prevention among black females (57). Numerous studies have investigated the association between body image and modifiable weight-loss behaviors among black females. In general, body dissatisfaction was found to be associated with poorer health behaviors. Females who were dissatisfied with their bodies were more likely to practice poor nutritional behaviors and less likely to participate in physical activity or to stop smoking. There were variations in findings due to race, age, and overweight status. Notable aspects of some previous studies regarding body image and weight control measures were the use of diverse populations, longitudinal study designs, and the consideration of inverse relationships. Several studies of body image and dieting behavior are particularly noteworthy for their methodological rigor of executing prospective longitudinal study designs (34,57) and for strategically sampling from both traditionally underrepresented groups in health research (e.g., ethnically diverse female hospital workers in an urban locale: (55) and from large regional segments of the US adolescent population (36,58,59). With small numbers of black females generally included in body image studies, two studies on smoking cessation are also noteworthy for investigating large groups of black females (54,57). The women in these studies were low-income, and in one study, the black women were HIV-infected. The bidirectional association between components of body image and weight control behaviors was highlighted by physical activity studies which investigated the impact of body image satisfaction on participation in physical activity(14,40,41,42,43,60) as well as the inverse influence of physical activity on body satisfaction (38,39,40,42) to assess motivators and barriers to weight control. Contrary to the strengths of a few studies, many studies suffered from analytical, methodological, and inclusion deficiencies. Little is known about the bidirectional relationship between changes in specific weight control behaviors and shifts in how black females may perceive their bodies and whether these patterns correspond with those reported by white females in this country. Most studies were cross-sectional in nature and unable to infer a clear directional relationship. The variations in findings of the associations suggest the need for more longitudinal research to clarify the directionality of this association. Additionally, there was great variation in measures of body image and classifications for dieting and physical activity status and perception. Most studies utilized a measure of self-perceived body image or weight status. It has been found that black females tend to be more accepting of larger bodies and generally underestimate their actual weight status with those who are overweight less likely to perceive themselves as overweight compared to other races (41,61). Those who are overweight perceive themselves as normal weight, and the obese consider themselves overweight (61). This discrepancy suggests the need for more culturally tailored programs to increase self-awareness of weight status, health consequences, and healthy lifestyle changes. Many studies on body image were mainly conducted on white females. Unfortunately, only small percentages of black females were usually included in the studies, therefore making any efforts to test for the potential differential impact of race on the relationship between measures of body image and behaviors untenable. Most authors discussed general findings irrespective of race (59,62), used race simply as a sociodemographic control variable versus testing it as a possible effect modifier (35,58), or tended to prefer emphasizing differences observed due to gender (37,59) or to overweight status (58). Additionally, studies were performed on a broad range of age cohorts suggesting an influence of body image throughout the stages of development and the need for further studies at each age level. Further investigation into differences by race/ethnicity within various age groups is needed. To design appropriate interventions to reduce obesity among black females it is necessary to understand whether body image is gaining influence in promoting dietary, physical activity, and smoking changes within the context of weight control. Based on the review of the literature offered here, the current state of the evidence is insufficient to adequately address this question at present. There are several factors to consider in improving the quality of the research produced and therefore strengthening confidence in the validity and applicability of findings. Chief among these is the need for greater attention to designing prospective longitudinal studies that would provide a more robust test of how dimensions of body image may act as determinants of weight control behaviors among black females. Additionally, with perceived overweight as well as high satisfaction with body image both being associated with more sedentariness, this presents quite a challenge for identifying motivators for black females to engage in health-promoting activities. A central question to target in future efforts is: What factors may modify the impact of weight and body dissatisfaction on engaging in dieting, physical activity, and smoking cessation among black females? The current review has provided some preliminary clues that may be involved in further delineating important individual differences in this line of research. These include overweight status (1), level of acculturation to mainstream US culture (22), and likely regional variation in the value placed on weight loss and tuning into feelings about the body as a mechanism of change (35,39). It is our hope that this critique may serve as a preliminary roadmap for both existing and future qualitative and quantitative research in this area to be effectively translated into culturally attuned healthy weight management promotion efforts among ethnically diverse females. The authors declared no conflict of interest.

Living with body dissatisfaction can have a strong negative effect on wellbeing. This is especially relevant for women of midlife who are feeling pressure to maintain the societal expectations of beauty and the thin ideal. The persistent pressure by Western society for women of all ages to be thin is at odds with the natural biological changes experienced by most women during midlife. This study gives a voice to women aged 45-60 years, expanding on previous research, to explore and clarify the complexities of body image in midlife. An exploratory qualitative design was used. Twelve Australian women were interviewed using a semi-structured approach about their experience of body image. Data was analysed using reflexive thematic analysis. Four themes were identified: Rational body image versus emotional body image; Weight equals body satisfaction; Ever-present burden of body image; and Limitations of resilience and positive psychology. This study highlights the underlying discourse of societal expectations, the burden of normative discontent that persists with age, and the conflict between the rational desire to love one's body and the emotional body dissatisfaction that impacts women's lives. Findings provide a deeper understanding of the complex relationship between ageing and body image for women and offer avenues for education and intervention to ensure women can learn to live with greater resilience, undertake self-care and use positive psychology to improve quality of life and to age more optimistically.

Individuals with higher body weight are at a greater risk of having negative body image (Friedman & Brownell, 1995). Yet current body image interventions, such as Cognitive Behavioural Therapy (CBT), are largely tested with individuals with normal weight or individuals with eating disorders. Furthermore, cognitive restructuring, one of the key components of CBT for body image (Alleva et al., 2015), relies on the assumption that negative cognitions or appraisals regarding the body are unbalanced or distorted in some way. However, people with higher body weight are 50% more likely to experience major discrimination based on their weight status and thus may possess some “evidence” from lived experience of weight bias that would lend support to their negative body-related thoughts (Puhl & Brownell, 2001; 2006). The use of compassion-focused approaches might be particularly helpful in overcoming these obstacles. Self-compassion refers to the capacity for mindfully reflecting on one’s own perceived flaws, mistakes, or wrongdoings with kindness and with an appreciation for the inherent imperfection in everyone (Neff, 2013). The present study tested the impact of various thinking strategies for managing negative body image in women with higher body weight after getting on the scale, a commonly distressing body image trigger (Ogden & Evans, 1996). Participants (N = 79) were recruited from the community and screened for moderate body dissatisfaction. They were randomly assigned to receive a single training session in cognitive restructuring (CR), self-compassion (SC), or distraction (Control) strategies after being weighed. Participants in all three of the groups reported improvements in body dissatisfaction and negative affect immediately following the training. Relative to those in the Control group, those participants who received training in CR or SC strategies reported greater improvements in body image, body image flexibility, self-compassion, and cognitive distortions one week after the training. These findings suggest that CR and SC strategies may be helpful in improving the distress associated with being weighed among women with higher body weight. The results may have broader implications for the development of psychosocial interventions focused on improving body image among these individuals.

Individuals with higher body weight are at a greater risk of having negative body image (Friedman & Brownell, 1995). Yet current body image interventions, such as Cognitive Behavioural Therapy (CBT), are largely tested with individuals with normal weight or individuals with eating disorders. Furthermore, cognitive restructuring, one of the key components of CBT for body image (Alleva et al., 2015), relies on the assumption that negative cognitions or appraisals regarding the body are unbalanced or distorted in some way. However, people with higher body weight are 50% more likely to experience major discrimination based on their weight status and thus may possess some “evidence” from lived experience of weight bias that would lend support to their negative body-related thoughts (Puhl & Brownell, 2001; 2006). The use of compassion-focused approaches might be particularly helpful in overcoming these obstacles. Self-compassion refers to the capacity for mindfully reflecting on one’s own perceived flaws, mistakes, or wrongdoings with kindness and with an appreciation for the inherent imperfection in everyone (Neff, 2013). The present study tested the impact of various thinking strategies for managing negative body image in women with higher body weight after getting on the scale, a commonly distressing body image trigger (Ogden & Evans, 1996). Participants (N = 79) were recruited from the community and screened for moderate body dissatisfaction. They were randomly assigned to receive a single training session in cognitive restructuring (CR), self-compassion (SC), or distraction (Control) strategies after being weighed. Participants in all three of the groups reported improvements in body dissatisfaction and negative affect immediately following the training. Relative to those in the Control group, those participants who received training in CR or SC strategies reported greater improvements in body image, body image flexibility, self-compassion, and cognitive distortions one week after the training. These findings suggest that CR and SC strategies may be helpful in improving the distress associated with being weighed among women with higher body weight. The results may have broader implications for the development of psychosocial interventions focused on improving body image among these individuals.

Schools are crucial for preventing negative health outcomes in youth and are an ideal setting to address weight stigma and poor body image. The current study sought to examine and describe the nature of weight stigma and body image in adolescents, ascertain aspects of the school environment that affect body image, and identify recommendations for schools. We conducted 24 semi-structured interviews with students at 2 high schools in 2020. Qualitative data were analyzed using inductive coding and an immersion/crystallization approach. Students did not report weight discrimination or harmful body image messaging from teachers or administrators. Physical education (PE) class and dress codes were 2 instances where covert weight stigma appeared. The most common forms of peer weight stigma reported were weight-based teasing and self-directed appearance critiques. Students recommended that schools eliminate dress codes, diversify PE activities, address body image issues in school, and be cognizant of teasing within friend groups. Weight stigma presents itself in unique ways in high school settings. Schools can play a role in reducing experiences of weight stigma and negative body image. Weight-related teasing within friend groups was common and may not be captured in traditional assessments of bullying. More nuanced survey instruments may be needed.

This article examines the range of factors impacting on weight and type 2 diabetes management. As Dr Vanessa Snowdon-Carr highlights, failure to acknowledge these factors during assessment risks providing an intervention which may not meet the needs of the patient. Obesity is one of the primary risk factors for type 2 diabetes mellitus.1 There is a seven times greater risk of diabetes in obese people compared to those of healthy weight, with a three-fold increase in risk for overweight people.2 Both the management of diabetes and the management of obesity are time, energy and emotion intensive. Coping with the two together can be extremely hard. Within diabetes, failing to follow health care advice to the letter is so common it is considered as normal3 and so in order to optimise health and well-being we need to understand the factors which impact on the management of both conditions.4, 5 There are a number of psychological theories that help us to understand behaviours relevant to health conditions and help to explain why following health advice can be challenging. The Health Belief Model is extensively applied to health research as it focuses on the attitudes and beliefs of individuals. Table 1 highlights the six dimensions which determine health behaviour.6 The perception of severity, beliefs about the effectiveness of treatment and self-efficacy have all been found to influence behaviour and outcome in diabetes.7 While the Health Belief Model is used to predict health-related behaviours, other theories such as the Self-Regulatory Theory serve as an attempt to understand the dynamic processes which lead to achieving or not achieving a particular standard.8 Table 2 summarises the components involved with this model.9 Utilising these models to consider the interplay between diabetes and obesity is useful. Many people who believe they have little control over their obesity will assume they will develop type 2 diabetes at some point. This belief is often distressing but is associated with resigned helplessness. The belief in one's ability or capacity to influence change as highlighted in Table 1 is known as self-efficacy. Self-Efficacy Theory10 integrates cognitive and social learning frameworks. Table 3 summarises the way self-efficacy influences eating in people with type 2 diabetes.11 Coping style is important for obesity.12 As described in the introduction, obesity is not 'just' caused by eating too much. Holding such a reductionist approach will prevent us from properly understanding the people whom we are supporting. The following sections will be illustrated with typical statements used by patients. As children we are usually taught to eat our main meals three times per day. This becomes an over-learned behaviour we do automatically and secondary to other tasks of everyday life without even being aware of what we are doing.13 We are told when to eat regardless of whether we feel hungry, and typically we are encouraged to eat all of the food given to us. This pattern can lead to habitual overeating and correlates with weight gain, making obesity more difficult to control.14 'I was watching the TV and eating crisps. I didn't really notice I was eating them until I got to the bottom of the packet and realised they were all gone.' Emotional eating is often referred to as 'comfort eating' although this more popular term misrepresents the range of triggers to eat that are emotionally driven and the function of this eating. Learning to use food to cope with strong negative emotions can become a very powerful strategy15 to avoid or suppress thoughts and emotions which feel unbearable or uncomfortable. Over time this use of food as an 'anaesthetic' becomes habitual and automatic: 'I was so irritated with my partner… but there was nothing I could do about it. I picked at food all that evening. I don't know why…' The issue of whether restrictive eating can actually cause difficulties is contentious. Early research highlighted the impact, both physically and cognitively, of significant calorie restriction.16 Rigid restraint results in a person being less attentive to physiological cues to hunger and satiety, which can lead to overeating.17 Many people fall into the trap of trying to follow diets which are very different from their existing pattern of eating; this radical change can be hard to maintain both physiologically and behaviourally. If the diet plan is not followed it can lead to catastrophic thoughts of failure and undermine self-efficacy: 'Why did I eat that chocolate bar? I wasn't even hungry. I'm never going to be able to lose weight… I need to really be strict with myself now…' Followed by: 'What's the point? I've already messed the diet up for today. I'll start again tomorrow…' So a lapse can rapidly turn into a collapse and the diet is abandoned. Not being able to stick 'perfectly' to a diet plan will erode one's beliefs about the possibility of weight loss and create repeated cycles of loss and regain, increasing shame, self-blame, reducing self-efficacy and creating an unhelpful mix of dieting 'rules'. Flexible control over eating behaviour, however, is associated with better weight maintenance than rigid control.18 Binge eating disorder (BED) involves recurrent episodes of eating significantly larger than usual portions of food in a short period of time, alongside a subjective sense of loss of control over eating. There is no compensatory behaviour as found in bulimia nervosa (such as self-induced vomiting, fasting or laxative misuse). Within the general population, prevalence rates have been noted as 1.4%.19 However, within obese populations who are seeking treatment for their weight, the prevalence is considerably higher, up to 30%.20 Binge eating is an important consideration for impact on weight, mood and physical health. It is associated with weight gain, obesity onset and severity of obesity.21 It is also linked to weight cycling of loss and regain.22 Nearly 75% of a population of people who had BED also had at least one psychiatric disorder,23 with a significantly greater risk of developing metabolic syndrome over and above the risk attributable to obesity alone.24, 25 The prevalence rate for type 2 diabetes and BED has been observed at 5.6%, highlighting the need to screen for BED in people with type 2 diabetes.26 'I know perfectly well how to diet… I could write a book about calories… but I just can't seem to do it.' Weight stigma originates from the belief that weight can be controlled and therefore obesity represents character deficits (for example: greed, laziness). This belief is likely to be linked to the over-simplified messages about weight loss suggesting weight loss is easy if a person is motivated enough. People who are obese are far more likely to experience discrimination linked to their weight than their non-obese peers.27 Weight-based negative bias is found in employment and health care settings, within the media, interpersonal relationships and education.28 As BMI increases, the frequency of reported discrimination increases.29 Health care professionals are encouraged to provide health advice to their patients at every opportunity. The NHS 'Making Every Contact Count' initiative recommends that lifestyle advice be given priority – this includes encouraging individuals to: stop smoking; eat healthily; maintain a healthy weight; drink alcohol within the recommended daily limits; undertake the recommended amount of physical activity; and improve their mental health and wellbeing.30 However, many health providers dislike treating obesity, feel unprepared to do so and have little hope that patients will make lifestyle changes.31 Weight discrimination has been reported in health care settings, from clinicians in training32 through to qualified practitioners.33 There is a suggestion that weight-based stigma may encourage weight loss.34 However, overwhelmingly it has been found to leave people feeling berated and disrespected by their health care professional, upset by comments about their weight and worried that they will not be taken seriously and, as a consequence, reluctant to address weight concerns.35, 36 Weight stigma increases the risk of maladaptive eating patterns, eating disorder symptoms37 and binge eating.38 It has been linked to increased calorie intake and decreased perception of control of food.39 It has an impact on mood, with higher levels of depression reported and lower self-esteem.40 It interferes with people's ability to engage in physical activity, with poor body image and anxiety about discrimination compounding exercise avoidance.40 Internalised weight bias in individuals who are obese has been found to be associated with greater impairment in both physical and mental health related quality of life domains over and above age, BMI and medical comorbidity.41 Obesity stigma can act as a barrier to ongoing management of both conditions. Obese patients with type 2 diabetes may feel responsible not only for their weight but also their diabetes.42 Therefore, exploring weight stigma in education programmes for type 2 diabetes is recommended.43 Feelings of shame in obese individuals can result from weight stigma but also from the experience of repeatedly being unable to lose weight or prevent weight regain.44 Individuals who are seeking treatment for obesity have been found to experience high levels of shame, distress, eating disorder psychopathology and uncontrolled eating, with internal shame being of particular importance.45 Shame and guilt focusing on weight have been found to be positively associated with disengaging coping responses, such as avoidance, negative self-talk, crying and isolating oneself. These responses are likely to prevent active coping styles which may be more helpful for weight loss, such as problem-solving, confronting and seeking social support.46 Shame within type 2 diabetes has been less explicitly researched; however, more recently the proposal of the social stigma around diabetes has been investigated and highlighted shame experienced by patients who feel others blame them for developing type 2 diabetes.47 Identifying ways to reduce shame may be useful for supporting weight loss and preventing relapse,45 as well as exploring shame, stigma and type 2 diabetes. High levels of emotional distress are linked to obesity48 with a complex bidirectional relationship between the two. Little evidence has been found to link mood disorders with the general overweight and obese populations, but of those people seeking weight-loss treatment elevated rates of depression and bipolar disorders have been noted.49 A systematic review of obesity and depression concluded that the risk of developing depression over time for obese people was 55%, whereas those who were depressed had a 58% increased risk of becoming obese.50 In a recent Cochrane review,51 it was noted that people with severe mental illness are twice as likely to develop type 2 diabetes than those without severe mental illness, but also to develop anxiety, depression and diabetes-related stress.52 There are recognised links between psychiatric medication and weight gain, often associated with mood stabilisers, antipsychotics and antidepressants. Only a few weight neutral or weight loss producing psychotropics are available.53 Research has typically focused on the impact of depression and anxiety but more recently there has been interest in trauma. Experiencing post-traumatic stress disorder (PTSD) symptoms is associated with increased risk of becoming overweight or obese, and PTSD symptom onset alters BMI trajectories over time.54, 55 Clinical themes emerge around using the body (and weight) as a protection from unwanted intrusion. Stress is associated with obesity, and the neurobiology of stress overlaps significantly with that of appetite and energy regulation.56 There is also considerable evidence to suggest that there are physiological drives to eat particular foods under stress conditions.57 Chronic life stress seems to be associated with a greater preference for foods that are high in sugar and fat58 and a decrease in vegetables and whole-grain foods.59 There is an increased risk of type 2 diabetes in people: exposed to stressful working conditions or traumatic events; who have depression; with personality traits or mental health problems that put them in conflict with others; of low socioeconomic status, either currently or in childhood; and in racial/ethnic minority populations, independent of current socioeconomic status.60 'Our sense of self, which is part of our reality, is a subjective, emotion-laden, ongoing self-evaluation of worthiness, competence and social acceptability.'61 Struggling with self-esteem and self-worth is a pervasive theme noted within clinical practice for people who struggle significantly with their weight. Rather like depression, self-esteem occurs in both directions. People with low self-esteem may use food to care for themselves while at the same time weight stigma is having a deleterious effect on self-esteem. Self-esteem may also be very specific to weight; in other words, a person may have a good general sense of self-esteem but a very poor one in relation to body image and weight-related beliefs about self. Learning about the role of food and self-care will come from our primary caregivers. For example, children who have been offered food to compensate for all kinds of needs do not learn alternate strategies for coping and food becomes a long-term, central strategy. They may have experienced inadequate care in other aspects,62 or caregivers misinterpreted their needs. Those with secure attachment styles were found to participate in healthier preventive health behaviour and had higher self-esteem than those with insecure attachment styles.63 The relationship between self- esteem, self-care and self-worth and the impact on weight management has received little empirical attention. Cochrane61 has written about the importance of reframing the task from weight loss to self-care, suggesting that people with a healthy sense of self-worth consistently and conscientiously take care of their own health. Social support can assist in well-being by buffering against the negative effects of stress. It is considered to be a powerful means of enhancing outcome for weight loss but empirical evidence is mixed. This may be because 'social support' covers such a diverse range of interactions. Eating is a universal experience such that everyone will have their own ideas about what is required for weight loss and this will inform social support. Women who 'never' experienced family support were found to be less likely to lose weight compared to women who experienced frequent friend and family support. However, a paradoxical finding noted that women who had 'never' experienced friend support were the most likely of all to lose weight.64 This study highlights the complexity of what is meant and experienced as social support. Within clinical practice the variation of social support is noted with very different experiences between the approaches: encouraging support which enhances self-efficacy (for example, affirming of ability to make change) and/or supportive of healthy eating (for example, eating the same food) versus support which is perceived, even if not intended, as critical (for example, 'should you be eating that?'). Often support that is perceived as overly directive and critical is rejected and defended against which can prompt eating in secret driven by shame and/or a sense of rebellion. Mayberry and Osborn65 described two types of unhelpful support with type 2 diabetes: the first was sabotaging behaviours from family members who were not well informed about diabetes, and the second in which attempts to support resulted in conflict. Lower levels of adherence to diabetes medication were observed in people who reported non-supportive family interactions which were experienced as sabotaging of their efforts to engage in self-care/management behaviours. Integrating social support into interventions has potential benefit if there is understanding about how to enhance motivation and self-care rather than sabotaging.65 Interventions may also benefit from providing strategies for managing others' comments about weight, eating and diabetes. For complex obesity in which there is experience of weight cycling and low self-efficacy, simply concentrating on dietary change is not sufficient. Indeed, failing to acknowledge and explore the barriers discussed prevents an understanding of ambivalence. The following section will explore the main therapeutic approaches, the issues they can be most useful to target and their outcomes. Cognitive behaviour therapy (CBT)is an approach that aims to help people cope more effectively with problems by equipping them with a framework for thinking, feeling and behaviour.66 CBT is perhaps the most researched psychological intervention in the eating disorder and obesity field. It is versatile in terms of mode of delivery (self-help reading material, computerised, telephone, face-to-face individual and group), and different levels of intensity can be taught to a range of health professionals. Generally, CBT interventions are not considered to yield significant weight loss (average 9% weight loss).68 CBT has, however, been found to be more useful in reducing attrition69 and relapse70 and treating BED.71 Some studies have found limited impact for type 2 diabetes, noting improvements in long-term glycaemic control and psychological distress but no significant impact on weight control or blood glucose concentration;72 while others have noted that an adapted CBT intervention was an effective intervention for adherence, depression, and glycaemic control in people with depression.73 How we think and feel are profoundly important in terms of antecedents and consequences of targeting eating behaviours.74 Exploration of cognitive distortions and thinking errors can highlight extremely useful insights clinically, into rigidity around approaches to eating and weight loss, and yet empirical evidence does not support CBT on its own as an effective intervention for weight loss. Motivational interviewing is a therapeutic approach used extensively in physical health care. It is linked to the Transtheoretical Model of Change,75 which postulates that change is a process, not a discrete event. Motivational interviewing is used to work alongside an individual to explore and resolve their ambivalence about change, to support self-efficacy and enhance intrinsic motivation. It is considered to be a useful approach for weight management because people are generally aware of what they need to do to control their weight but they struggle with motivation to sustain these behaviours.76 Part of the difficulty in implementing behaviours to support weight loss is linked to ambivalence about whether the perceived costs (for example, focus on eating, increased activity etc) out-weigh the benefits.77 While motivational interviewing does appear to have an impact on weight reduction programmes, the effect size, however, is small.78 It is often statistical rather than clinical significance that is reported in studies, with as little as 1.47 kg weighted mean difference between motivational interviewing interventions versus control.78 Evidence suggests that motivational interviewing is a useful adjunct, effective for weight management when combined with physical activity, diet and other interventions.79 It can also be useful when specifically targeted to the individual's stage of change: Carels et al.80 found adding a component of motivational interviewing for people who were struggling to meet behavioural treatment goals resulted in increased weight loss and greater engagement in exercise than a matched group who did not receive motivational interviewing. Self-compassion allows for an acknowledgment of mistakes and shortcomings, enabling the individual to consider changing unhelpful behaviours and attempt new goals, rather than berating themselves for previous failures.81 Compassionate mind focused therapy is based on the premise that people with high levels of shame and self-criticism find it very difficult to be self-supporting or self-reassuring.82 This, therefore, fits well when working with external and internalised stigma about weight and previous unsuccessful weight loss attempts. Compassion-focused interventions have not been extensively researched in isolation for obesity, weight management or type 2 diabetes but an adaption for eating disorders addresses the associated high levels of shame and self-criticism.83 Research on women's motivation to exercise found that self-compassion was positively associated to intrinsic motivation and negatively related to introjected motivation (i.e. behaviours pressured by other forces).84 Mindfulness is defined as the ability to attend, in a non-judgemental way, to one's own physical and mental problems during ordinary, everyday tasks.85 Through practice it is possible to pay attention to what is happening in the present moment rather than being caught with worries about the past or future. Over the last few years, there has been a great deal of interest in mindfulness as applied to eating behaviour. The most promising results have been noted when mindfulness is adapted to target specific behaviours, rather than general mindfulness training. It has been found to potentially minimise the automatic and inattentive reactions to food and triggers which lead to emotional eating and overeating.86 It is a very useful approach to develop greater self-regulation, noticing cravings without acting on them therefore enabling weight loss87 and a reduction in binge eating.88 Specific programmes have been designed such as the Mindfulness Based Eating Awareness Training (MB-EAT)89 and the MB-EAT for Diabetes (MB-EAT-D).90 With diabetes specifically, mindfulness approaches have found a reduction in fasting glucose or HbA1c in some but not all studies.91 Developing both mindfulness and self-compassion appears more promising for weight loss than developing mindfulness alone or simply dieting.86 It is essential that psychological factors are considered to avoid prescriptive interventions for weight and type 2 diabetes which, rather than prompting change, can frequently lead to repeating cycles of lapse and relapse, reduced self- efficacy and increased shame. References are available in Practical Diabetes online at www.practicaldiabetes.com.