The Encyclopedia of Obesity and Eating Disorders

THE ENCYCLOPEDIA OF

OBESITY AND EATING DISORDERS

THE ENCYCLOPEDIA OF

OBESITY AND EATING DISORDERS Third Edition

Dana K. Cassell David H. Gleaves, Ph.D.

The Encyclopedia of Obesity and Eating Disorders, Third Edition Copyright © 2006, 2000, 1994 by Dana Cassell Foreword copyright © 2006, 2000 David H. Gleaves, Ph.D. All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage or retrieval systems, without permission in writing from the publisher. For information contact: Facts On File, Inc. An imprint of Infobase Publishing 132 West 31st Street New York NY 10001 Library of Congress Cataloging-in-Publication Data Cassell, Dana K. Encyclopedia of obesity and eating disorders / Dana Cassell, David H. Gleaves.—3rd ed. p. cm. Includes bibliographical references and index. ISBN 0-8160-6197-1 (alk. paper) 1. Eating disorders—Encyclopedias. 2. Obesity—Encyclopedias—English. 3. Eating disorders—Encyclopedias—English. I. Gleaves, David H. II. Title. RC552.E18C37 2006 616.85′26′003—dc22 2005051375 Facts On File books are available at special discounts when purchased in bulk quantities for businesses, associations, institutions, or sales promotions. Please call our Special Sales Department in New York at (212) 967-8800 or (800) 322-8755. You can find Facts On File on the World Wide Web at http://www.factsonfile.com Text and cover design by Cathy Rincon Printed in the United States of America VB FOF 10 9 8 7 6 5 4 3 2 1 This book is printed on acid-free paper.

CONTENTS Foreword by David H. Gleaves, Ph.D.

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Acknowledgments

xi

Introduction

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A–Z Entries

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Appendixes

301

Bibliography

341

Index

347

FOREWORD

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probably misnomers, because the typical anorexic may not experience a loss of appetite (and, in fact, may be preoccupied with food), and for the sufferer of bulimia, the most frustrating part of the disorder may be that he or she binge eats even when not hungry. In terms of invariable clinical observations with these disorders, both anorexia and bulimia nervosa are characterized by gross disturbances in eating behavior and highly characteristic extreme concerns about shape and weight. In both disorders, self-esteem is influenced to a great degree by body weight and shape. These similarities have led some researchers to suggest that the disorders are simply variations on a common theme; however, according to the DSM, the disorders are classified as distinct categories, and there are two subtypes of each. With anorexia nervosa, there are the restricting and binge-eating/purging subtypes. With bulimia nervosa, there are purging and nonpurging subtypes. Binge-eating disorder is characterized by out-ofcontrol binge eating in the absence of any compensatory behaviors. Obesity is a state rather than an eating disorder per se, although a sizable proportion of obese individuals may engage in binge eating, and may even meet the diagnostic criteria for binge-eating disorder. Conversely, most people with binge-eating disorder are clinically obese. In addition to the core eating and body imagerelated psychopathology of the eating disorders and obesity, a variety of additional problems, including depression, anxiety, obsessive-compulsive behavior, post-traumatic stress disorder and substance use,

ever before has so much attention been paid to what might be called the disorders of eating and/or weight regulation. Not coincidentally, society is currently preoccupied with thinness, dieting, beauty and health, and a great industry has arisen to take advantage of the fear of fatness that has spread through developed nations and is beginning to spread throughout others. No-calorie or lowcalorie foods and drinks, sugarless sweeteners and pills sold as appetite suppressants pour onto the market. Writers make fortunes propagating new diets, and health clubs and the makers of exercise machines sell people the presumed benefits of ”working out.” The Eating Disorders category of the current Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, includes the two best-known eating disorders, anorexia and bulimia nervosa, as well as a residual category called “eating disorder not otherwise specified.” A provisional diagnostic category called “binge eating disorder” was added to the most recent version of the DSM. Obesity, although technically not an eating disorder, is a much more common problem, affecting at least one-third of the American population; this prevalence has increased from about one-quarter of the population since the mid-1980s. The literal definition of anorexia nervosa is loss of appetite (anorexia) of nervous, or emotional, origin (nervosa). Bulimia can be literally defined as “ox hunger,” with the term nervosa again implying that it (bulimia nervosa) has an emotional origin. However, both of these terms are

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viii The Encyclopedia of Obesity and Eating Disorders have been described in the literature. Interpersonal and family problems as well as personality disorders are also common. Despite earliest attempts to find strictly biological or intrapsychic explanations, the recently developed understanding of the role of cultural factors in the development and maintenance of eating disorders leads one to wonder whether the proper subject for treatment is the individual or society as a whole. However, it is still the case that only a minority of people actually develop full-blown eating disorders, despite the fact that almost all are exposed to and are aware of the aforementioned sociocultural thinness standards. There is thus a need to understand who internalizes these standards and who is at risk (possibly because of biological factors) for developing additional problems as a consequence. The most popular etiological explanation of eating disorders and obesity, known as the biopsychosocial model, thus attempts to integrate these biological, psychological and social factors. According to this model, there is no simplistic single factor explanation for any of these problems. Particularly when such multiple problems exist, such as those described above, it is often difficult to disentangle cause and effect. For example, are depression and anxiety causes or effects of an eating problem, or are there some other mechanisms (biological, psychological or social) that somehow explain the comorbidity? Answering this question is one of the ongoing challenges in the field. Just as the etiology of eating and weight disorders may be complex and multiply determined, so may the treatment need to be complex and multifaceted. In other words, most successful treatments integrate features that address biological (including nutritional), psychological and social factors. The degree to which treatment of each factor is necessary may depend both on the disorder and the individual. However, in recent years there has also been a move toward a transdiagnostic psychological approach to treatment; that is, a more unified therapy based on the similarities among people with eating problems. For years scientific literature on eating disorders and obesity was regrettably separated. The obesity field had been dominated by perspectives from medicine and health risk concerns, whereas the

eating disorders field had its roots in the social sciences. As a consequence of this division, persons working in the fields had very few shared interests and had different conceptualizations of the etiology, assessment and treatment of these arguably related conditions. This gap in the literature has fortunately begun to close since the 1990s. Testaments to this closure include the publication of Brownell and Fairburn’s Eating Disorders and Obesity: A Comprehensive Handbook (1995), the journal Eating and Weight Disorders: Studies on Anorexia, Bulimia, and Obesity and The Encyclopedia of Obesity and Eating Disorders (first published in 1994). This, the third edition of the last-named book, is meant to further bridge the gap between the literature on obesity and eating disorders. It is also meant to bring an understanding to subjects on which expert researchers both have and have not been able to agree. Under these circumstances it seems that the encyclopedia approach is especially useful, for whereas an encyclopedia cannot give exhaustive information about any subject, it can bring crucial questions about that subject into focus, give the reader a reasonably accurate “bottom line” and list further reading for those who want to know more. Since the publication of the second edition of the encyclopedia, there have been numerous developments in the obesity and eating disorders field. These have been in the areas of epidemiology, etiology, treatment, long-term outcome and prevention; some developments have been positive, others negative. Use of antiobesity medications exploded, only to be followed in many cases by drugs being banned due to harmful physical effects. The low-carbohydrate diet was resurrected, along with an associated marketing explosion. Recent research has questioned the assumed continuity models of eating disorders (that eating disorders occur on a continuum and are simply extreme variants of normal dieting, eating and weight concerns) and suggested that the subtypes of bulimia and anorexia nervosa should be organized differently. There has also been new research on the biological bases of anorexia and bulimia and increased attention to eating and body image problems (such as muscle dysmorphia) among males and among persons of diverse cultural groups. Recently a much better understanding of the effectiveness of

Foreword ix eating disorder prevention programs has been gained. As a testament of the amount of professional knowledge and interest that now exists regarding these disorders, there are now approximately a dozen journals devoted exclusively to the study, prevention and/or treatment of eating and/or weight disorders, and several others focused on related problems. As technology (particularly the Internet) has continued to develop, it has substantially affected the obesity and eating disorders field. As with other developments, some have been positive and others negative. On the positive side, Internet-based treatment programs have been developed and implemented for both obesity and eating disorders, numerous Internet support groups have been created and the availability of information about the topics for the consumer and professional has grown amazingly. On the negative side, some of the information on the Internet is of questionable accuracy, and some of the “support groups” (such as proanorexia sites) actually purposefully support main-

tenance of eating disorders. Increased use of the Internet and computers may also lead to further decreases in activity level and an increased prevalence of obesity. Technology is evolving so fast that it is difficult to even keep up with developments and to predict its future effect on the field. This third edition is therefore timely and valuable. It aims to be helpful to students, clinicians, researchers, parents, the eating disorder sufferer in search of knowledge and referral information and the prospective consumer of a vast variety of goods and services that purport to change eating patterns or transform bodies (in many cases without changing eating patterns). The authors hope that The Encyclopedia of Obesity and Eating Disorders, Third Edition will provide insights and accurate resources to those in need. And last but not least, readers are urged to consult the references included throughout the book and the numerous appendixes. —David H. Gleaves, Ph.D. University of Canterbury

ACKNOWLEDGMENTS No work of this size could be completed without assistance from many sources. In preparing this volume, we have reviewed books, journal and mass media articles, monographs and studies by the score to distill current opinion and research findings. Of particular help in the 21st century is the wonderful World Wide Web, with its vast treasure trove of information, sources, communities, statistics and explanations. Toward the end of our research for this edition, we were able to take advantage of the new database of NIH-funded research articles published in scientific and medical journals now available to the public at no cost. Acknowledgment of this important initiative is intended not only as a “thank-you,” but also to bring it to the attention of our readers, who will be able to benefit from it as well. (The database is located at http://www.pubmedcentral.nih.gov.) Hidden behind the endless waves of Web pages are

real people who gather and post that information for the use of the medical community, patients, researchers and the general public. Without all that work being done behind the scenes, this book would have been much more difficult to write. Throughout this book, we have been especially careful to provide full attribution to authors and researchers whose work we have consulted. They have all contributed significantly to the field—and thus indirectly to the success of this book—and we are grateful to them. Finally, a note of appreciation to James Chambers, our editor—not only for his editing help, but also for his topic suggestions to make this and other books in the series more comprehensive and valuable. —Dana K. Cassell David H. Gleaves, Ph.D.

INTRODUCTION A HISTORY OF OBESITY AND EATING DISORDERS have starved, and typically during hard times, obesity has emerged as a kind of cultural goal or desirable state. In very poor societies, sufficient food is consistently available only to a privileged few. Thus obesity may become a prestigious and admired characteristic. Bruch discovered during her anthropological research that in some Polynesian cultures it was considered a sign of great distinction to be so well nourished as to become fat. “Malayan kings were very large and fat; they were treated with special massages and exercises to keep them in good health.” Anthropologists tell us that in conditions of general scarcity, gluttony was conceived of as a practice to be aspired to, as in expressions from both South Pacific and southern African cultures about anticipated feasts: “We shall be glad, we shall eat until we vomit.” “We shall eat until out bellies swell out and we can no longer stand.” We are told that the southern African’s dream was to be fat himself as well as to have a fat wife and children and fat cattle. Bruch added that ancient travelers reported African cultures in which young girls at puberty were sent to fattening houses to make them ready for marriage. The fatter a girl grew, the more beautiful she was considered, although the men were expected to remain athletic and slim. The king’s mother and his wives competed with one another

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ashions shift in human beauty as they do in clothes and architecture, a fact pointed out by Anne Scott Beller in her natural history of obesity, Fat & Thin. Physical proportions strived for and glorified during one era or generation are avoided, even stigmatized, in another. HILDE BRUCH, while describing the historical and sociocultural perspectives in Eating Disorders, noted that the oldest known representation of the human form, the “Venus of Willendorf” (Paleolithic period [20,000 to 30,000 B.C.], found in Willendorf, Austria), is the figure of “an extremely obese woman with large breasts and an enormous abdomen.” Other Paleolithic figures represent similar fat women. The idealization of obesity in women continued into the Neolithic period. Prehistoric Greek, Babylonian and Egyptian sculptures also “indicate preference or artistic admiration for women with large abdomens and heavy hips and thighs,” according to Bruch. It is not known, Bruch added, whether these archaeological “Venuses” are representations of women’s actual appearances or whether they reflect a cultural ideal; they have usually been taken as symbolic representations of abundance and fertility at periods in human history when famine was an ever-present possibility (though some researchers have surmised that these figures were based on actual models). In any case, Bruch explained, in every age and in every land people

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xiv The Encyclopedia of Obesity and Eating Disorders as to who should be the fattest. They took no exercise and were carried in litters when going from place to place. The attitude that “bigger is better” prevailed during hard times earlier in this century among America’s immigrants. Having suffered hunger during their own early years, poor mothers saw fat children as symbols of success. These children were not called fat; they were “solid” or “hefty.” Author Harry Golden, who grew up in that environment, related, “I, too, was a husky kid and when I worried about it my mother consoled me with the observation, ‘ In America, the fat man is the boss and the skinny man is the bookkeeper.’ ” Paradoxically, Bruch said, during prosperous times and in affluent societies obesity is commonly associated with poverty and lower-class status. Now the ideal is to be thin, and there is much concern about obesity. The privileged classes of the Western world have been preoccupied through this century with the question of how to stay slim in the face of abundance. The ancient Greeks of the classical age envied their cultural predecessors, the Cretans, for having known of a drug that permitted them to stay slim while eating as much as they wanted. Leaders in Sparta were stern taskmasters in their attitude toward obesity. Young people were examined in the nude once a month, and those who had gained weight were forced to exercise. The Athenians also frowned upon obesity. Socrates is said to have danced every morning in order to keep slim, and Plato was forgiven his fatness only on account of his brilliance. Hippocrates described obesity in great detail and made observations that are still pertinent today. The Romans disliked obesity as much as the Greeks; ladies of the upper class literally starved to make themselves look slim as reeds. Yet, as with the Greeks, there were also famous Romans who were fat, and exact descriptions have been preserved of some of their eating habits. It is known that Marius, the defender of Rome, enjoyed enormous quantities of food. Horace, the poet, was famous for the extraordinary variety and elegant preparation of his meals. During the Middle Ages also, there were conflicting views on obesity. On the one hand, glut-

tony was counted among the venial sins. But obesity was also considered a sign of the grace of God. In Lochner’s painting The Last Judgment, the sinners being dragged into Hell are stout, and the blessed being led into Paradise are slender. Ron Van Deth and Walter Vandereycken, Dutch medical historians, have noted that despite the enormous number of scientific publications on anorexia nervosa, research into its history is still in its infancy. Believing that historical studies would shed light on the sociocultural genesis of anorexia nervosa, they began research some years ago. They have pointed out that although the medical concept of anorexia is little more than 100 years old, self-starvation has been known in various forms for centuries. The less severe symptoms of lack of appetite and aversion to food have appeared in a variety of psychiatric illnesses. Also symptomatic have been more serious disorders associated with hysteria, melancholy, lovesickness, chlorosis (greensickness) and atrofia nervosa (nervous consumption). Of these, Van Deth and Vandereycken consider the only one resembling modern-day anorexia nervosa to be atrofia nervosa, which was described by British physician Richard Morton (1689) as “deliberate starvation due to an ill and morbid state of the spirits.” The disorder was accompanied by a lack of appetite and indigestion and was difficult to cure. His two detailed case histories described such symptoms as amenorrhea, constipation, hyperactivity, extreme emaciation and indifference toward both condition and cure, classic symptoms of today’s anorexic. But even this description lacks any reference to what is a central feature of modern anorexia: the relentless pursuit of thinness. According to Joan Brumberg in Fasting Girls, Simone Porta of Genoa, Italy, wrote the first medical account of anorexia in 1500. A very few similar cases were described in medical literature over the next several hundred years. But the relative silence in pre-1850 medical literature about a disorder with such remarkable and dramatic manifestations is striking, add Van Deth and Vandereycken. They consider it improbable that anorexia nervosa did exist but went unnoticed because of the low general standard of living, as some authors have suggested.

Introduction xv The observable features and complications of severe anorexia usually are too obvious, if not horrifying, to go unnoticed, even when a majority of the population is underfed. Furthermore, physicians in previous centuries were rather keen observers; they had to rely almost exclusively on clinical examination. Among social classes where people did not suffer from undernutrition and medical consult[ation] could be afforded, possible cases of anorexia nervosa were scarcely mentioned either.

While anorexia nervosa may be a relatively modern phenomenon, self-starvation has been around throughout history. But our ancestors did not consider it to involve a disease. Extreme fasting was a practice of many pious Christians throughout history, especially in the late Middle Ages among deeply religious women. Although reports of contemporaries claim these “saints” sometimes ate nothing but the consecrated host for years, these reports are subject to misinterpretation and exaggeration. As Van Deth and Vandereycken explained, “Hagiographers (biographers of saints) showed more zeal in demonstrating the holiness of the candidate-saint than in providing truthful historical facts. . . . [T]hey did not write a historically reliable biography or medical report.” Beginning with the 16th century, “miraculous maids” or “fasting girls” moved self-starvation into a more secular atmosphere. While considered by the pious a sign of God’s presence on earth because they could eat virtually nothing yet stay alive, they were regarded by most more as curiosities than as divine manifestations. The popular media of the day publicized them. Thousands of people, including kings and other dignitaries, visited them, even offering them money, in the process turning them into tourist attractions. Physicians of the day took on the task of investigating these cases for their validity rather than for the purpose of treating them or discovering causes for their starvation. Many of these girls were unmasked as frauds and imprisoned or killed, but not all. By the 17th and 18th centuries, according to Brumberg, religious reform and changes of attitude led to prolonged fasting’s being taken as the work of Satan rather than God. “Women who exhibited

anorexic symptoms were said to be possessed by the devil and persecuted as witches.” During the 19th century, the alleged extended fasts and the deceit of the maids were both labeled by physicians as signs of hysteria. From this point on, most self-starvation was looked upon as a medical-psychological problem. It was not until 1873 that anorexia nervosa was established as a clinical diagnosis. In that year, E. C. Lasègue, professor of clinical medicine at the University of Paris, claimed that “anorexie hysterique” was caused by emotional disturbances that the patient tended to disguise or conceal. He mentioned the patient’s “state of quietude—I might almost say a condition of contentment truly pathological. Not only does she not sigh for recovery, but she is not ill-pleased with her condition, notwithstanding all the unpleasantness it is attended with.” About that same year Sir William W. Gull, one of London’s most respected physicians, first used the term “anorexia nervosa” in a paper submitted to the London Clinical Society. He explained, “We might call the state hysterical. . . . I prefer, however, the more general term, ‘nervosa,’ since the disease occurs in males as well as females, and is probably rather central than peripheral.” He did note that young girls were especially prone to the disease. Lasègue and Gull were familiar with each other’s work and recognized they were dealing with “the same maladie.” They both insisted that anorexia was a mental rather than an organic disease and achieved a small degree of success by treating it with “rest, nourishment, separation from family and supportive therapy.” In 1879 a French physician, J. Naudeau, published a lengthy description of a fatal case with significant similarities to modern anorexia. Another French doctor, H. Huchard, differentiated between “anorexie gastrique” and “anorexie mentale” in 1883. Six years later J. M. Charcot, the famous French neurologist and teacher of Freud, recommended removal of his anorexic patients from their families. Although still relatively rare, the puzzling malady anorexia nervosa had become a recognized disorder affecting mainly the middle and upper classes. Recognition, however, did not slow the debates as to the disease’s causes; was it a physical disease

xvi The Encyclopedia of Obesity and Eating Disorders or a mental disease? During the early 1900s, medical experts for the most part considered all disease to stem from abnormal variation of the body’s cells or organs. In the case of anorexia nervosa, this theory found strong support when Morris Simmonds, a pathologist at the University of Hamburg, described pituitary cachexia in 1914. During an autopsy, Simmonds had observed lesions on the pituitary gland of a severely emaciated woman who had shown signs of pituitary failure and died. For the next 15 years, though anorexia might be mentioned in the literature, virtually all cases involving unexplained weight loss were diagnosed and treated as “Simmonds’ disease.” Then in 1930, John Mayo Berkman of the Mayo Clinic in Rochester, Minnesota, published the first long-term report on large numbers of anorexia cases. His report outlined treatment of 117 patients at the clinic during a 10-year period. Even though the clinic treated anorexia as a metabolic disorder and rarely administered any kind of psychiatric treatment, researchers have credited Berkman with “rediscovery” of anorexia as a separate disorder. In 1942 R. F. Escamilla and H. Lisser searched medical literature worldwide to review cases reported as Simmonds’ disease. In their report (Journal of Clinical Endocrinology 2, 1942), they determined that 494 of the 595 reported cases were, in all probability, cases of anorexia nervosa and not pituitary disease. During the 1940s the theory that anorexia nervosa was a psychological disorder began to gain support, although disagreement as to its exact causes ran rampant for the next 20 years. These psychological theories ranged from fantasies to fears of oral impregnation to emotional disturbance to psychosexual dysfunction. The start of the modern era in the treatment of anorexia nervosa has been credited to a paper delivered by Hilde Bruch in 1961 and published in Psychosomatic Medicine 24:2 (1962): “Perceptual and Conceptual Disturbances in Anorexia Nervosa.” As Patricia A. Neuman and Patricia A. Halvorson explain (Anorexia Nervosa and Bulimia). “Bruch differentiated between ‘primary anorexia nervosa’ (the classic form as described by Morton and Gull) and ‘atypical anorexia nervosa’ (self-starvation due to other psychiatric illnesses).”

The classic or true form, according to Bruch, is characterized by severe disturbances in body image (the way subjects see themselves); misinterpretations of internal and external stimuli, particularly of hunger; and a paralyzing underlying sense of ineffectuality, the subjects’ conviction of being helpless to change anything about their lives. Prior to the 1960s, reports of anorexia nervosa were rare, but since then they have been occurring at a rapidly increasing rate. In addition, anorexia has increased its geographic spread. Cases have been reported in countries as far apart as the former Soviet Union and Australia, Sweden and Italy, England and the United States. Mara Selvini-Palazzoli, an Italian pioneer in the psychiatric study of anorexia nervosa, reported no cases at all at her clinic during World War II when dire food shortages occurred; yet after the war, as the Italian economy improved and food became plentiful, hospitalizations did occur for anorexia nervosa. Studies in both the United States and Switzerland have indicated that the incidence of anorexia nervosa has doubled since 1960. During the early 1960s, for example, the University of Wisconsin Hospital typically admitted one anorexic a year; in 1982 more than 70 cases were admitted. It is so common today that it represents a substantial problem in high schools and colleges. But anorexia nervosa has not only become more widespread among its traditional young white female model; in recent years researchers have noted a spreading of the disorder to other ethnic groups and to males. Since 2000, studies have provided evidence that males had likely been underrepresented in both epidemiologic and clinical studies. Instead of the previously believed ratio of 10 females to one male suffering with anorexia, recent research has indicated a more likely ratio of three or four females to one male. Also, numerous recent studies have documented a high rate of eating disorder behaviors and risk factors, including body dissatisfaction, among African-American women. Also underrepresented in earlier eatingdisorder studies were males and females of Asian heritage, not only because researchers focused on white American girls, but also because many Asian Americans equate psychological problems with weakness and shame and thus avoid seeking treat-

Introduction xvii ment. Yet one study of more than 900 middle school girls in northern California found that Asian American girls reported greater body dissatisfaction than white girls. That and other cultural factors may contribute to disordered eating. Another change Bruch observed over the years was a difference in the way patients approached the illness. Formerly no anorexic had ever heard of the condition; each thought she had invented a form of independence and control. Today most patients have read or heard about anorexia nervosa; some even compare their illness with textbook examples. Moreover, occurrence of anorexia is now often a group phenomenon. It is not unusual for an anorexic to be aware of others in her school classes with the same problem, and to use the others to measure her “success.” Indeed, the growth of Internet “pro-ana,” sites has extended the “group reach” globally. With the increase in media attention, anorexia nervosa has become a fashionable disease among affluent adolescent and young adult women who are particularly susceptible to peer influence. It has been estimated that as many as 30 percent of all current cases are what Bruch once called “me-too” anorexics. In 1994 Vandereycken and Van Deth wrote, “Anorexia nervosa has become a fashionable disorder: television producers smell sensation, women’s magazines see a subject for their advisory columns, publishers dream of autobiographical bestsellers. Often the illness is presented as ‘mysterious’: physicians are desperately seeking an ultimate explanation and self-help organizations do not know which ‘in’ therapy to recommend.” Just as the incidence of anorexia nervosa has surged since the 1960s, bulimia has also emerged as an increasingly common psychophysiological disorder, so much so that there is a widespread misconception that it is of quite recent origin. In fact, bulimia has an extensive history. Episodic overeating has been a common practice. Primitive peoples dependent on hunting went on one- or two-day binges before spoilage could occur after successful expeditions, in attempts to compensate for long periods of famine. Two early English references to bulimia were Steven Blankaart’s Physical Dictionary (1708) and John Quincy’s Dictionary (1726). Both discuss

excessive appetite, but Blankaart refers to an extraordinary appetite usually accompanied by a “defection of the spirits.” In 1743 James, in A Medicinal Dictionary, credited the Greek physician Galen (A.D. 130–200) with defining the origins of boulimus, or the “great hunger.” Galen considered it a digestive dysfunction, the primary symptom of which was a desire for food “at very short intervals.” This, he said, was often coupled with fainting, loss of color, coldness in the extremities, oppressive feeling in the stomach, and weak pulse. According to Galen, boulimus was probably caused by an acidic “humor” lodged in the stomach, causing intense but false hunger signals. In addition, he suspected that the disorder was associated with the too-rapid digestion of food, resulting in inadequate nourishment and chronic hunger. James added to Galen’s and other writers’ descriptions in an effort to distinguish boulimous from similar conditions associated with worms, ulcers and normal pregnancy. He noted that shortness of breath and an intense preoccupation with food may be symptoms of true boulimus. He further distinguished between true boulimus and a variant of it complicated by vomiting, “caninus appetitus.” In the caninus appetitus, there is a desire after much food and great quantities are eaten, which oppressing the stomach, are again discharged by vomit. The patient thus being relieved, his appetite returns, which having gratified, he finds himself obliged to ease his stomach again, like a dog, by vomiting. In the true boulimis [sic], there is a ravenous hunger and eating, but instead of vomiting, the patient suffers from lipothymy [fainting spells].

Motherby, in 1785, differentiated three types of bulimia. The first two were bulimia of the pure hunger type and bulimia in which hunger was terminated by vomiting. In the third form, hunger was associated with “swooning.” In 1797 the Encyclopaedia Britannica included an entry for bulimia under the heading “Bulimy”: “a disease in which the patient is affected with an insatiable and perpetual desire of eating; and unless indulged, he often falls into fainting fits.”

xviii The Encyclopedia of Obesity and Eating Disorders In the early 1800s, dictionaries described bulimia as featuring violent appetite, vomiting, fainting and canine appetite and occurring most often in hysteria and pregnancy. During the 19th century Gull acknowledged that anorexia patients occasionally displayed extremely voracious appetites, quite the opposite of their usual starvation tactics in their pursuit of thinness. Researchers have suggested that Gull’s notation of such variations in symptoms, variations also seen by clinicians through the years, probably contributed to the idea of classifying bulimia simply as a subtype of anorexia nervosa. However, in 1869 in France, P. F. Blanchez identified “boulimie” as a distinct syndrome, while admitting that it might occur as an accessory to another disorder. He described boulimie symptoms as food being an obsession and major preoccupation, yet with hunger sometimes continuing even after enormous quantities of food are eaten. He described the patient as becoming lethargic after a binge until the intense hunger returns a few hours later. Then in 1894, in Germany, O. Soltmann posited “nutritional neuroses” such as “hyperorexia,” of which bulimia was taken to be a symptom. According to Soltmann, hyperorexia, a syndrome, might be partly neurotic and partly biological in origin, affecting “over-excited, hysterical chlorotic young girls.” Purging is also not a recent phenomenon. The ancient Egyptians thought all diseases originated in food and thus purged their bodies every month. Tilmann Habermas writes that “vomiting was one of the most popular nonspecific symptoms in the nineteenth century, so its absence was often noted in cases of anorexia. On the other hand, it was rather unexpected that patients might intentionally induce vomiting.” Many of the physicians reporting on anorexic patients from the 1800s on included among the illness phases purging of some kind to get rid of unwanted food. Some patients learned to vomit immediately after swallowing; at least one was reported to use “a kind of hose to empty her stomach” (Habermas). During the early 1900s, abuse of laxatives or thyroid medication for the purpose of weight control was first mentioned, although vinegar had been drunk as a laxative for centuries.

Bulimia among individuals who did not have histories of weight disorders was first observed in 1976 by Marlene Boskind-White, who coined the term “bulimarexia” to describe this group. Bulimia officially became a distinct diagnostic entity in 1980 with the publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Medical Association. DSM-III suggested that episodic binge eating is not only an isolated symptom but an essential component of a specific syndrome of disordered eating. With the DSM-III-R (as well as the DSM-IV ), the diagnosis of bulimia was changed to bulimia nervosa and the category narrowed to include only persons who both binged and engaged in some form of compensatory behaviors. Persons who engaged in binge eating but without compensatory behaviors no longer met the diagnostic criteria. With the DSM-IV, there was consideration of adding a new diagnostic category of binge eating disorder that would encompass this latter group of individuals. The category was added to the appendix as a diagnosis needing further study. And, as with anorexia nervosa, recent studies have determined that bulimia nervosa is occurring increasingly in diverse ethnic and sociocultural groups. For example, research has shown that binge eating and purging is at least as common among African-American women as white women. If eating disorders had become “fashionable” by the mid-1990s, obesity has become de rigueur since then among the global population, and written about everywhere from scientific literature to daily newspapers. Noting that the past 10 years had been described as the “golden age” of obesity research, Blackman wrote, “In that time, researchers have worked on a smorgasbord of molecules involved in body weight regulation via many overlapping systems and pathways.” The impetus for all this research and media coverage has been an unexpected rise in overweight and obesity, not only in the United States, where overindulgence has long been blamed for many social ills, but worldwide. According to a Centers for Disease Control and Prevention (CDC) report issued in October 2004, American adults are nearly 25 pounds heavier on average than they were in 1960. Children ages six to 11 average nine pounds

Introduction xix heavier, and adolescents are 12 pounds (girls) and 16 pounds (boys) heavier on average. From 1986 to 2000, the prevalence of Americans with a body mass index of 40 or above quadrupled, from about one in 200 to one in 50. Because of these current trends in obesity, Olshansky et al. concluded in 2005 that the steady rise in life expectancy during the past two centuries may soon come to an end.

What to Look for in the Third Edition With nearly two-thirds of adults in the United States now overweight and 31 percent obese, according to the CDC—up from 55 percent at the time the Encyclopedia of Obesity and Eating Disorders, Second Edition was written in 1999—several key areas and issues have been added or significantly expanded. Within the alphabetical body of the third edition are topics related to the economic, sociological, legal, psychological and medical aspects of obesity and eating disorders—nearly 150 of them new to this edition. With increased multicultural study in both eating disorders and obesity, new information has been added to reflect their ramifications over a wider range of the population. For example, this edition now has extensive entries on African Americans and eating disorders, African Americans and obesity, American Indians/Alaska Natives and eating disorders, American Indians/Alaska Natives and obesity, Asians/Pacific Islander Americans and eating disorders, Asians/Pacific Islander Americans and obesity and Hawaiian Natives and obesity. Along with the increase in obesity has come a phenomenal growth in bariatric surgery procedures since the second edition. Similarly, the potential for profits has spurred pharmacological research to better understand obesity in the hope of developing effective drug treatment. This edition includes many new entries to reflect these trends; among these are antiobesity drugs, appetite hormones, bariatric surgery, belt lipectomy, biliopancreatic diversion, gastric bypass, ghrelin, implantable gastric stimulator, interleukin-6, malabsorptive operations, panniculectomy, rimonabant and others. Another new entry is “orthorexia nervosa”—an unhealthy obsession with healthy eating. Although not yet an official eating disorder, it has been cov-

ered in the Journal of American Medical Association and described as “increasingly an area of concern” by the National Eating Disorders Association. Several dozen topics have been completely revised—some totally rewritten—to reflect current key research and trends. Among these major revisions are: anorexia nervosa, research, antidepressants, antipsychotics, childhood obesity, depression and eating disorders, diabetes and eating disorders, diet centers and programs, over-the-counter diet pills, employee health costs and obesity, exercise, fad diets, fraudulent products, gastric bubble, gastric restriction procedures, gastroplasty, genetic factors in obesity, jejunoileal bypass, liposuction, male anorexics, metabolism, obesity, overweight bulimia nervosa, pharmacotherapy, pregnancy and obesity, psychotherapy, satiety and size discrimination. And nearly every other topic from the second edition has been updated. Any terms used within a listing that have their own separate listings are designated with small capital letters to make them easy to find. Also, many topics end with references to articles and books cited in the entry. The appendixes include new lists of organizations and groups that offer information and support, Web sites providing resources and help; completely new bibliographies of books, articles, and videos; plus other lists and tables. Overall, the reader will find a comprehensive overview of obesity and eating disorders, with indepth treatment of current issues, in an easy-toaccess format, and with plenty of assistance on where to go next for additional information on these topics. REFERENCES Bell, R. M. Holy Anorexia. Chicago: University of Chicago Press, 1985. Beller, Anne Scott. Fat & Thin. New York: Farrar, Straus and Giroux, 1977. Blackman, Stuart. “The Enormity of Obesity.” The Scientist 18, no. 10 (May 24, 2004): 20–24. Bliss, Eugene L., and C. H. H. Branch. Anorexia Nervosa: Its History, Psychology and Biology. New York: P. B. Hoeber, 1960. Bruch, Hilde. Eating Disorders: Obesity, Anorexia Nervosa, and the Person Within. New York: Basic Books, 1973. Brumberg, Joan Jacobs. Fasting Girls: The Emergence of Anorexia Nervosa as a Modern Disease. Cambridge, Mass.: Harvard University Press, 1988.

xx The Encyclopedia of Obesity and Eating Disorders Bynum, C. W. Holy Feast and Holy Fast: The Religious Significance of Food to Medieval Women. Berkeley and Los Angeles: University of California Press, 1987. Habermas, Tilmann. “The Psychiatric History of Anorexia and Bulimia: Weight Fears and Bulimic Symptoms in Early Cases.” International Journal of Eating Disorders 8, no. 3 (1989); reprinted in BASH Magazine (December 1989). Neuman, Patricia A., and Patricia A. Halvorson. Anorexia Nervosa and Bulimia. A Handbook for Counselors and Therapists. New York: Van Nostrand Reinhold, 1983.

Olshansky, S. Jay, et. al. “A Potential Decline in Life Expectancy in the United States in the 21st Century.” The New England Journal of Medicine 352, no. 11 (March 17, 2005): 1,138-1,145. Van Deth, R., and W. Vandereycken. From Miraculous Fasts to Morbid Pursuit of Thinness: Anorexia Nervosa in Historical Perspective. Amsterdam: Boompers, 1988. Vandereycken, Walter, and Ron Van Deth. From Fasting Saints to Anorexic Girls: The History of Self-Starvation. New York: New York University Press, 1994.

A–Z ENTRIES

A tory either where there is excess skin or loose muscle. In many such cases, surgeons first use liposuction to remove the fat and then follow with abdominoplasty to tighten the abdominal muscles and remove excess skin. See also BELT LIPECTOMY, PANNICULECTOMY.

abdominoplasty

A shaping of the abdominal area by surgery, popular since the 1960s. Frequently referred to as a “tummy tuck,” this surgery gets rid of stomach fat and tightens flabby muscles and loose abdominal skin. The surgeon cuts seven to 15 inches across the body at the bikini line, lifts the skin, uses sutures to tighten the abdominal muscles and tissue, pulls the skin back down over the tightened area, cuts off excess skin and then closes the incision, sometimes making a new “belly button” in the process. The length of the incision depends upon the looseness of the skin. There is some pain and a scar, which usually fades to a thin line within a year. Total costs generally range between $5,000 and $9,000. Once an indulgence of the wealthy, such surgery is now advertised to the public, with monthly payment plans often available. According to the American Society of Plastic Surgeons (ASPS), performance of abdominoplasty procedures increased 500 percent between 1990 and 2003. The ASPS reported 101,228 such procedures in 2003. Abdominoplasties are not always without problems. When fat above the incision is not completely removed, bulges can occur above the scar line. These bulges can also appear if circulation is impaired during surgery, resulting in an accumulation of fluid. Because removing fat from the upper part of the abdomen can lead to bleeding and interfere with the skin’s blood supply, fat is frequently left in this upper area, giving unsatisfactory results with the upper abdomen sticking out over the more flattened lower abdomen. These complications have led to a more frequent use of LIPOSUCTION for abdominal fat removal. However, because successful liposuction depends upon normal elasticity to shrink the skin after surgery, this procedure isn’t always satisfac-

Academy for Eating Disorders (AED) A multidisciplinary professional organization founded in 1993 that focuses on anorexia nervosa, bulimia nervosa, binge eating disorder and related disorders. A guiding principle of the organization is that effective treatment for eating disorder patients requires that professionals from various disciplines work together. The AED brings these professionals together to: 1) promote the effective treatment and care of patients with eating disorders and associated problems; 2) develop and advance initiatives for the prevention of eating disorders; 3) disseminate knowledge regarding eating disorders to members of the Academy, other professionals and the general public; 4) stimulate and support research in the field; 5) promote multidisciplinary expertise within the Academy’s membership; 6) advocate on behalf of patients, the public and eating disorder professionals; 7) assist in the development of guidelines for training, practice and professional conduct within the field; and 8) identify and reward outstanding achievement and service in the field. See also APPENDIX III, SOURCES OF INFORMATION. accommodating the obese

Obesity has caused hospitals and other emergency services to rethink their purchasing and practices. A May 2004 Chicago Tribune article noted, “Throughout a nation suddenly acknowledging its mounting obesity epidemic, hospitals are adding new units, retrofitting

1

2 accommodating the obese their buildings, or simply investing in items such as heavy-duty wheelchairs, extra-strength toilets and even waiting-room chairs that can handle people weighing up to 1,000 pounds. Staff members are heading to sensitivity training.” A 2003 survey by Novation, the largest U.S. group purchasing organization for hospitals and health care institutions, found that additional costs associated with treating or accommodating the severely obese (at least 100 pounds overweight) can reach up to $500,000 per year per institution, with the additional cost per visit between $500 and $10,000. Among the items included in these costs: larger blood pressure cuffs; longer surgical gloves, laparoscopic surgical instruments, forceps, needles and syringes; larger gowns; wider and reinforced wheelchairs; remodeled rooms and bathrooms (including floor-mounted commodes to replace wall-mounted models); large beds; special lifts; scales with 800-pound capacities; operating tables able to withstand 1,000 pounds; and wider doors and hallways. Patient lift systems that can handle 600 pounds are becoming standard in the health care industry. Novation, which had sold $847,000 worth of patient lifts in 2001, sold $3 million worth in 2003. A Texas company that sells specialty hospital beds and mattresses for obese patients realized a 6 percent increase in sales in 2003 over the year before. A rental company in Nevada that specializes in medical equipment for the obese said its business has grown 15 percent to 20 percent a year. Surgical Products reported on the recent introduction of “Bariatric Table Extensions with no pinch points or articulation obstructions, which extend the surgical tables’ widths from 20 to 28 inches.” Other bariatric table accessories include power assist leg holders, specially designed leg boots, and extra-long restraint straps. The move to accommodate obese patients stems not only from a desire to make them feel comfortable and ease any embarrassment, but also to reduce injuries. In an article explaining how the increasing number of obese patients has affected Indiana emergency workers, Richards explained, “Their weight can shift, causing cots or stretchers to tip over and possibly injuring both the patient and paramedics.” In the past, it would take eight to

10 firefighters using canvas tarps or mattresses to transport patients weighing 500 pounds or more. Today’s heavy-duty cots that can hold in the range of 650 pounds require only two to three firefighters. One hospital clinical materials resource manager was quoted in a Milwaukee Journal Sentinel article as saying, “Today, 85 percent of the back injuries suffered by hospital staffs are related to the care of heavy patients.” A researcher, noting that the prevalence of clinically severe obesity is increasing much faster than obesity, wrote: “Accommodating severely obese patients will no longer be a rare event, and providers have to prepare to treat such patients on a regular basis.” The National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health suggests that health care providers create an accessible and comfortable office environment by doing the following: • Provide sturdy, armless chairs and high, firm sofas in waiting rooms. • Provide sturdy, wide examination tables that are bolted to the floor to prevent tipping • Provide extra-large examination gowns. • Install a split lavatory seat and provide a specimen collector with a handle. • Use large adult blood pressure cuffs or thigh cuffs on patients with an upper-arm circumference greater than 34 cm. • Have extra-long phlebotomy needles, tourniquets, and large vaginal speculae on hand. • Have a weight scale with adequate capacity (greater than 350 pounds) for obese patients. Employers have also begun to accommodate situations that arise for people who are obese. The Job Accommodation Network, a service of the Office of Disability Employment Policy, U.S. Department of Labor, offers the following common accommodations for obese employees: • Climbing steps: An individual who is obese can benefit from an elevator or a large-rated stair lift or large-rated wheelchair lift. • Sitting: Large-rated ergonomic chairs are available as options.

acupressure 3 • Seat belt extenders: Seat belt extenders are available for some vehicles and industrial equipment. • Using safety products: Specially designed ladders and harnesses are available. • Walking: A large-rated wheelchair or scooter may accommodate this limitation. Beyond medical and work facilities, rising obesity has led to the need for other “ample” products, from long-handled nail clippers to household furniture to clothing to caskets. Even the standard bathroom scale of a few years ago no longer accommodates the growing number of Americans over 300 or 350 pounds. Not only is the plus-sized clothing business booming, but stores are offering oversized doorways, dressing rooms and mirrors to accommodate obese customers. The width of a typical casket has grown from 21 inches to 24 inches, with casket makers now adding 28- and 30-inch-wide caskets to their regular offerings. Vaults, mausoleums and even cemetery plots are being enlarged to accommodate the severely obese. National Institute of Diabetes and Digestive and Kidney Diseases. “Medical Care for Obese Patients.” Weightcontrol Information Network. Available online. URL: http://www.niddk.nih.gov/health/nutrit/pubs/ medcare/medcare2.htm. Posted March 2003. Richards, Blythe. “Equipment Eases Strain of Moving Obese Patients.” The Daily Journal, July 11, 2004, p. A1. Ritsma, Rich. “Tools to Make the Bigger Better.” Surgical Products 23, no. 5 (May 2004): 20–21. Sturm, R. “Increases in Clinically Severe Obesity in the United States, 1986–2000.” Archives of Internal Medicine 163, no. 18 (October 13, 2003): 2,146–2,148. Worland, Gayle. “Obesity Epidemic Makes Hospitals Rethink, Retool.” Chicago Tribune, May 4, 2004, p. 1.

Active Living by Design (ALbD) A national program of the Robert Wood Johnson Foundation and a part of the School of Public Health at the University of North Carolina. The program defines “active living” as a way of life that integrates physical activity into daily routines. The program’s purpose is to establish and evaluate innovative approaches to increase physical activity through community

design, public policies and communications strategies. Recent studies have shown that people who live in the most sprawling counties are the most likely to be overweight, and vice versa; and that people who live where stores and other businesses are within easy walking distance are significantly less likely to be overweight, primarily because they walk more and drive less. Among the strategies for promoting active living recommended by ALbD: Communicate the importance of active living in a variety of built, natural, and social environments, and create programs that increase the demand for physical activity in the community by including parks, trails, bikeways, and sidewalks. The target is for all people to accumulate at least 30 minutes of activity each day. ALbD funds “partnership” projects that help communities become more pedestrian friendly. Each partnership receives a $200,000 grant in addition to technical assistance to address community design, land use, transportation, architecture, trails, parks and other issues that influence healthier lifestyles. The 25 ALbD community partnerships are located in: Oakland, Sacramento, and Santa Ana, California; Denver, Colorado; Orlando, Florida; Honolulu, Hawaii; Chicago, Illinois; Louisville, Kentucky; Somerville, Massachusetts; Jackson, Michigan; Isanti County, Minnesota; Columbia, Missouri; Omaha and Winnebago, Nebraska; the Upper Valley region of New Hampshire and Vermont; Albuquerque, New Mexico; the Bronx and Buffalo, New York; Chapel Hill, North Carolina; Cleveland, Ohio; Portland, Oregon; Wilkes-Barre, Pennsylvania, Charleston, South Carolina; Nashville, Tennessee; and Seattle, Washington. The National Institute of Environmental Health Sciences, a branch of the National Institutes of Health, will conduct follow-up examinations of the program’s impact on physical activity, obesity and other health indicators. See also APPENDIX III, SOURCES OF INFORMATION.

acupressure A technique similar to and derived from ACUPUNCTURE, this treatment involves the application of manual pressure to the body rather than the insertion of needles. Acupressure has been recommended by some practitioners to con-

4 acupuncture trol APPETITE. It is administered by applying pressure with the ball of the thumb and sometimes the fingers to specific points on the body. The main pressure point is on the upper lip; a point midway between the breastbone and navel is said to control HUNGER. Other points on the elbow and the knee are said by practitioners to control the emotions that lead to overeating. Not an instantaneously effective treatment, according to specialists, it is said to take three days for the reflex passages to the brain to become programmed by acupressure. Acupressure is even less well documented and scientifically tested than acupuncture. A review of four such studies, published in the January 1997 Austrian journal Wiener Klinische Wochenschrift, reported that none of these studies is without significant flaws, and that their results are contradictory.

acupuncture

An ancient practice, used especially by the Chinese, of piercing the skin with extremely fine needles at strategic places on the body to treat disease or relieve pain. Acupuncturists believe that vital energy (chi) flows through the body along 12 main pathways (channels or meridians) connected to internal organs and systems like the kidney and respiratory system. They believe that disease occurs when there is an imbalance of energy in one of these systems, and that acupuncture needles inserted at specific points (numbering more than 1,000) on the body correct the flow of energy through the channel and help the body to heal itself. Some medical doctors speculate that acupuncture may produce a state of painlessness partly by stimulating the release of endorphins (natural painkillers). Acupuncture as a treatment has some respectability based on empirical observations, but almost no scientific basis for acceptance. A very few medical doctors use acupuncture to supplement standard treatment. The origin of acupuncture is unknown, but it is believed to have been practiced in China for more than 3,000 years. When acupuncture is used to help lose weight, the needle is placed in the area of the external ear known as the concha. The vagus nerve, which extends from the brain down the neck and chest to the stomach, branches to the concha. When the sharp point of the needle finds

this branch of the vagus nerve, it acts to inhibit the contractions of the stomach. The acupuncture treatment to the ear does not itself cause a person to lose weight. Rather, it causes the person to feel less HUNGER. Doctors in the United States have used staples and small needles, which are left in the ear to be jiggled when the patient feels the urge to overeat. Published studies evaluating acupuncture as a treatment for obesity have thus far been inconclusive. In one, the author claimed a good response from 75 percent of 1,030 patients, but few details were given. In another study of 120 volunteers, it was reported that 70 percent treated at the “hunger” point experienced decreased appetite, compared with only 20 percent who had a stud (needle) in another part of the ear. And in a study of 350 obese subjects treated with acupuncture, 66 percent of them lost weight after seven treatment sessions. However, subjects had a variable number of courses of treatment of various duration. There were also no control subjects for comparison, so no final conclusions could be drawn. However, researchers Richards and Marley did use a control group in a study involving 60 overweight subjects. Of those who responded, 95 percent of the active group noticed suppression of APPETITE, whereas none of the control group noticed such a change. After reviewing several studies, Vincent and Richardson concluded that even though there are no clear indications for or against the use of acupuncture, an individual patient might derive less tangible psychological benefit from belief in the treatment. Giller, R. M. “Auricular Acupuncture and Weight Reduction: A Controlled Study.” American Journal of Acupuncture 3, no. 2 (April–June 1975): 151–153. Ishida, Yasuo. “Acupuncture Today.” Southern Medical Journal 81, no. 7 (July 1988): 885–887. Lewith, George T. “Acupuncture.” Practitioner 230, no. 1422 (December 1986): 1,053–1,054. Richards, Dean, and J. Marley. “Stimulation of Auricular Acupuncture Points in Weight Loss.” Australian Family Physician 109, Suppl. 2 (July 1998): 573–577. Sacks, L. L. “Drug Addiction, Alcoholism, Smoking, Obesity, Treated by Auricular Staple Puncture.” American Journal of Acupuncture 3 (1975): 147+. Vincent, C. A., and P. H. Richardson. “Acupuncture for Some Common Disorders: A Review of Evaluative Research.” Journal of the Royal College of General Practitioners 37, no. 295 (February 1987): 77–81.

addiction 5 addiction

A term that, in the scientific and popular literature, may refer to a wide range of different behaviors. In strictest scientific terms, an addiction requires the development of tolerance (a need for more of a substance to achieve the same effect) and/or withdrawal (characteristic physiological effects associated with termination of the use of a substance). A similar term in the scientific literature is substance dependence, and highly “addictive” substances include nicotine, alcohol, cocaine, and opium derivatives. In the popular literature, the term addiction is often applied to unwanted habits that are hard to break (e.g., shopping) or to substances (e.g., chocolate) that do not elicit the core characteristics of addiction (i.e., tolerance and withdrawal). Addictions such as smoking and alcoholism share characteristics with binge eating and purging, but the eating-disordered person is addicted to the illness itself rather than to a substance. Food is the agent the addicted eating-disordered person uses to cover up or forget a weight problem (either real or imagined), fear of losing control over eating or other behavior, distorted body image, negative self-image, dissatisfaction in sexual or interpersonal relationships or lack of independence. There is great controversy over whether or not the eating disorders are a form of addiction. According to Vandereycken, addiction-like behaviors exhibited by bulimics include “craving, preoccupation with obtaining the substance, loss of control, adverse social and medical consequences, ambivalence towards treatment, and risk of relapse.” In addition, persons with eating disorders often have comorbid substance use disorders (i.e., alcohol or drug abuse). If eating disorders are considered addictions, the substance or behavior to which the person is addicted is unclear. Some would argue that it is food, others specific types of food (e.g., sugars, white flour), and others that persons with eating disorders are addicted to dieting, exercising, and/or purging. Overall, regarding the question of whether or not eating disorders are a form of addiction, it appears that we are dealing with an issue of “partial similarity” in that some characteristics are shared and others are not. Certainly eating disor-

dered individuals have cravings and preoccupations with food, dieting, or exercise. However, if one uses the strictest scientific definition, the phenomena of tolerance and withdrawal are not present. Furthermore, the treatment implications that follow from the addiction model are in marked contrast with those that follow from cognitive behavioral models (those treatments with the most empirical support). That is, most treatment approaches that follow an addiction model emphasize abstinence (from certain foods, types of foods, or behaviors) and often include a rigid model of “relapse” similar to that taken with Alcoholics Anonymous or similar programs. In contrast, cognitive behavioral treatments attempt to get the individual to stop avoiding “forbidden foods” and to change the rigid all-or-nothing way of thinking associated with relapse. The self-starving anorexic’s behavior may also include alcoholism, although the binge eater is more likely to be addicted to alcohol or drugs. The way in which bulimics and anorexics (see BULIMIA and ANOREXIA NERVOSA) often tackle exercise and schoolwork also resembles addiction. Alcohol, over-the-counter diet pills, caffeine, barbiturate and amphetamine addictions have been noted by many researchers to be commonly associated with bulimia. In a 1981 study done at the University of Minnesota Adult Outpatient Psychiatric Clinic, bulimic women reported using alcohol to avoid depression associated with binge-purging, to relax and to delay or prevent overeating. In a 1984–85 survey of 1,100 patients at Hazelden, a Minnesota chemical dependency treatment center, approximately 7 percent of female patients and 3 percent of males reported enough symptoms to be classified as bulimic under DSM criteria. A later Hazelden report stated that 30–40 percent of the women in residential treatment for alcohol and other drug dependence have an active eating disorder or one in remission. Among men, the incidence is about 5 percent. Hazelden reported in the 1980s that its bulimic female patients experienced more adolescent behavior problems and self-destructive behavior than nonbulimic patients. The typical chemically

6 addiction model of eating disorders dependent female bulimic at Hazelden is more likely to “be a polydrug user; have had adolescent behavior problems such as school suspension or expulsion, stealing, and fighting; exhibit selfdestructive tendencies through self-inflicted injury, suicide attempts, or suicidal thoughts during treatment; have had outpatient or inpatient mental health treatment or medication.” A 2002 Yale University School of Medicine review of the extent and co-occurrence of eating disorders and substance abuse disorders concluded: “Alcoholism and eating disorders frequently cooccur and often co-occur in the presence of other psychiatric and personality disorders. Although such diagnostic co-occurrence suggests the possibility of shared factors in the etiology or maintenance of these problems, research has not established such links. The clinical reality that eating and alcohol use disorders frequently co-occur has important implications for assessment, treatment, and research. Comprehensive assessment is necessary for good treatment. Research on methods of treating people with co-occurring alcohol and eating problems represents a major need.” In December 2003, the National Center on Addiction and Substance Abuse (CASA) at Columbia University released a report, “Food for Thought: Substance Abuse and Eating Disorders,” that revealed that up to one-half of individuals with eating disorders abuse alcohol or illicit drugs, compared to 9 percent of the general population. Conversely, up to 35 percent of alcohol or illicit drug abusers have eating disorders compared to 3 percent of the general population. The CASA report named anorexia nervosa and bulimia nervosa as the eating disorders most commonly linked to substance abuse, and found that because health professionals often overlook the link between substance abuse and eating disorders, treatment options are virtually nonexistent for these co-occurring conditions. Wandler noted that “dual-diagnosis patients are challenging; their symptoms interact and may lead to dangerous medical sequelae.” Because of the strong association between addictions and eating disorders, Hazelden presently conducts a comprehensive assessment for eating disorders for all its addiction patients.

While clinicians agree that both chemical and food disorders must be treated in order for either illness to be treated successfully, disagreements exist over whether to treat them together or separately. Hazelden quotes Elke Eckert, M.D., professor of psychiatry and director of the Eating Disorders Clinic at the University of Minnesota, as believing the chemical dependency must be treated first, then the eating disorder. In addition to chemical addiction, eating disordered patients can also exhibit a general tendency toward addiction to running and level of running intensity. Estok and Rudy found that 25 percent of the women studied who ran more than 30 miles a week indicated a high risk for anorexia. See also ADDICTION MODEL OF EATING DISORDERS; ANOREXIA ATHLETICA. Davis, C., and G. Claridge. “The Eating Disorders as Addiction: A Psychobiological Perspective.” Addictive Behaviors 23, no. 4 (July/August 1998): 463–475. Estok, P. J., and E. B. Rudy. “The Relationship between Eating Disorders and Running in Women.” Research in Nursing and Health 19, no. 5 (October 1996): 377–387. Grilo, Carlos M., Rajita Sinha, and Stephanie S. O’Malley. “Eating Disorders and Alcohol Use Disorders.” National Institute on Alcohol Abuse and Alcoholism. Available online. URL: http://www.niaaa.nih.gov/ publications/arh26-2/151-160.htm. Posted November 2002. Pyle, Richard L. “The Subtle, Puzzling Affinity of Drugs and Bulimia.” BASH Magazine (September 1989). “Study Suggests Some Bulimia Manageable during Chemical Dependency Treatment.” Hazelden Professional Update (September 1988). Vandereycken, Walter. “The Addiction Model in Eating Disorders: Some Critical Remarks and a Selected Bibliography.” International Journal of Eating Disorders 9 (1990): 95–101. Wandler, K. “Eating Disorders and Substance Use: Be Aware of This Dual Diagnosis.” Behavioral Healthcare Tomorrow 12, no. 6 (December 2003): 8, 11. Welch, S. L., and C. G. Fairburn. “Impulsivity or Comorbidity in Bulimia Nervosa: A Controlled Study of Deliberate Self-Harm and Alcohol and Drug Abuse in a Community Sample.” British Journal of Psychiatry 169, no. 4 (October 1996): 451–458.

addiction model of eating disorders

Treating eating disorders as addictive disease by applying the 12-step program of Alcoholics Anonymous as an

adjustable gastric banding 7 adjunct to counseling and treatment for those who suffer from compulsive overeating and bulimia. See also ADDICTION. Trotzky, A. S. “The Treatment of Eating Disorders as Addiction among Adolescent Females.” International Journal of Adolescent Medicine and Health 14, no. 4 (October–December 2002): 269–274. Wilson, G. T., and J. D. Latner. “Eating Disorders and Addiction.” In Food Cravings and Addiction, edited by M. Hetherington, pp. 585–605. Surrey, U.K.: Leatherhead, 2001.

adipose tissue

Also called fat tissue; composed of adipocytes or fat cells, connective tissue cells, nerves, blood and collagen. A layer of fat lying just under the skin and around many internal organs (e.g., the heart and kidneys) to protect them from injury. This tissue acts as a shock absorber, cushioning areas such as the heels and buttocks against the frequent and sudden jolts they receive. Adipose tissue also functions as an insulating thermal blanket, keeping body heat inside. Because adipose tissue accumulates from eating more food than necessary for the body’s immediate needs, it stores triglycerides as energy for future needs. When more adipose tissue is accumulated than is needed for cushioning, insulation and energy reserves, OBESITY results. In 2001 researchers from the University of California at Los Angeles and the University of Pittsburgh first reported that adult stem cells could be isolated from adipose tissue. Adult stem cells are primitive cells that can self-renew and are capable of becoming the major cell types in the tissue or organ that harbors them. The primary roles of adult stem cells are to maintain and repair the tissue in which they are found. Research has indicated that when exposed to specific laboratory growth conditions, adiposederived stem cells can demonstrate various characteristics suggestive of cells from tissues such as fat, bone, cartilage, nerve, muscle and blood vessels, with the potential for regenerating damaged hearts, reconnecting severed nerves and reconstructing breasts following cancer surgery. More than 300,000 LIPOSUCTION procedures are performed in the United States each year, producing about 150,000 gallons of discarded liposuc-

tioned fat. In a typical liposuction procedure, such as for the buttocks, about one to three quarts of fat can be removed. In just one day, plastic surgeons can remove more than 30 pounds of fat performing between two and five tummy tucks (see ABDOMINOPLASTY) in gastric bypass patients who have lost significant weight. It is estimated that hundreds of millions of stem cells can be obtained from one liposuction patient. One pint of liposuctioned fat or one pound of whole fat removed in a tummy tuck, for example, can yield up to 200 million stem cells, which in culture can be expanded by 10 times over the course of two weeks. See also SUBCUTANEOUS FAT; VISCERAL FAT.

adjustable gastric banding (AGB) Commonly referred to as the LapBand or laparascopic adjustable gastric banding. Adjustable gastric banding is a restrictive bariatric surgical procedure in which a hollow band made of special material is placed around the stomach near its upper end, which divides the stomach in two portions, creating a small pouch at the top of the stomach where food enters from the esophagus. The LapBand Adjustable Gastric Banding System (BioEnterics Corp.) was the first AGB device to receive FDA approval, which it did in 2001. The approval was for use in weight reduction for severely obese patients with a BODY MASS INDEX (BMI) of at least 40 or a BMI of at least 35 with one or more severe comorbid conditions, or those who are 100 pounds or more over their ideal weight. Prospective patients must have attempted and failed more conservative weight-reduction alternatives, such as diet, exercise, and behavior modification programs. Patients who elect to have this procedure must make the commitment to accept significant changes in their eating habits for the rest of their lives. The LapBand system is a long-term implantable device intended to induce weight loss in morbidly obese patients by limiting food consumption (restrictive rather than malabsorption). The device is surgically implanted, using either a laparoscopic or open procedure, to create a restricted opening (stoma) and a small gastric pouch to limit food consumption and induce early satiety. The main components of the device are the silicone elastomer band, the access port and kink-resistant tub-

8 adjustable gastric banding ing used to connect the other two components. The inner surface of the silicone band, which is placed around the stomach, is inflatable and connected by the tubing to the access port (a remote injection site). The access port is placed in or on the rectus muscle to permit nonsurgical, percutaneous adjustments to the band and thus, the stoma diameter, using sterile saline. Initially, the pouch holds about one ounce of food and later expands to two to three ounces. The lower outlet of the pouch usually has a diameter of only about three-quarters of an inch. This small outlet delays the emptying of food from the pouch and causes a feeling of fullness. The band is then inflated by injecting a salt solution into a small reservoir placed under the skin at the time of surgery and connected to the band by intravenous (IV) tubing. It can be tightened or loosened over time to change the size of the passage by increasing or decreasing the amount of salt solution to regulate the amount of food that can get through the passage. As a result of this surgery, most people lose the ability to eat large amounts of food at one time. After an operation, the person usually can eat only three-quarters to one cup of food without discomfort or nausea. Also, food has to be well chewed. Advantages: No cutting or stapling of the stomach is required, making adjustable gastric banding simple and relatively safe. It usually prevents the patient from overeating because doing so is painful and leads to vomiting. Food follows the normal digestive process. The band can be adjusted to increase or decrease the amount of food allowed as the patient’s weight reduction dictates. The recovery period is very short; the major complication rate is low. The surgery can be reversed, allowing restoration of the normal stomach, as there is no alteration of normal anatomy. Disadvantages: Some patients are unable to adjust their eating habits and fail to lose the desired weight. Successful results depend on the patient’s willingness to adopt a long-term plan of healthy eating and regular physical activity. A common risk is vomiting, which is caused when the small stomach is overly stretched by food particles that have not been chewed well. Deep infection is possible. Band erosion and migration, deep infection, and saline leakage have been reported after adjustable gastric

banding; with such complications reported in 10 to 22 percent of patients. When complications do occur, additional surgery to correct the problem is likely. Overall, there is a 5 percent failure rate. Adjustable gastric banding is not permanent; replacement or removal will be necessary eventually. Brown et al. reviewed medical literature on adverse events with silicone adjustable gastric banding systems, as well as all adverse events, including deaths and serious injuries, reported to the FDA through August 8, 2002. They found that “the FDA received 556 reports of adverse events related to the use of adjustable silicone gastric bands. Two of these reports were for deaths, one during surgery and the other as a result of an erosion of the gastric band into the stomach nine weeks after implantation. Forty-four reports were for injuries including band erosions, slippage, and infection. The most common type of report (499) was for device malfunction, and of these, 485 (97.2 percent) described a leak at or near the port. Of the 485 leaks reported as malfunctions, 99.4 percent were treated surgically. The majority of reports were related to disconnection, breakage, and leakage at or near the access port.” Chebli points out that early slippage rates of 15 percent “were a reflection of the perigastric technique in which the band was deployed flush with the stomach. More recently, the most commonly employed technique is the pars flaccida approach. This involves placing the band around the stomach as well as tissue surrounding the stomach, which reduces likelihood of the band migrating. This newer approach has dropped the slip rate to 3 percent.” After reviewing eight years of AGB procedures, Weiner et al. noted, “After the learning curve of the surgeon, results are markedly improved.” Others have suggested that surgeons who have performed at least 100 procedures have noticeably better results. According to the FDA, adjustable gastric banding should not be used for people who are poor candidates for surgery, have certain stomach or intestinal disorders, have an infection, have to take aspirin frequently or are addicted to alcohol or drugs. It should not be used on patients who are not able or willing to follow the rules for eating and exercise that are recommended by the doctor after surgery.

adolescent obesity 9 In 2004 fees for laparoscopic adjustable band surgeries were in the range of $15,000 to $17,000. Health insurance plans do not always cover it. See also BARIATRIC SURGERY; VERTICAL BANDED GASTROPLASTY. Brown, S. L., M. H. Reid, and H. J. Duggirala. “Adjustable Silicone Gastric Banding Adverse Events Reported to the Food and Drug Administration.” Journal of Longterm Effects of Medical Implants 13, no. 6 (January 2003): 509–517. Chebli, Joseph E. “Why the LAP-BAND Has Not Hit the Mainstream in the United States.” WLS Lifestyles 2, no. 1 (winter 2004): 20–21. Weiner, R. et al. “Outcome after Laparoscopic Adjustable Gastric Banding—8 Years Experience.” Obesity Surgery 13, no. 3 (June 2003): 427–434.

adolescent obesity

During the early years of adolescence, as their bodies are undergoing dramatic physical growth and biological change, some individuals become plump and may think of themselves as “too fat.” But once the growth stops and the biological change is completed, the weight of most will naturally level off until they regain slimmer proportions. For some, adolescent obesity is a temporary condition. For others, it is the beginning of a lifetime of obesity compounded with severe emotional and personality problems, since experiences during adolescence play such an important role in psychological development. Just as other segments of America’s population are becoming increasingly obese (see OBESITY), there is a growing national health problem of true obesity among young people. According to the Centers for Disease Control and Prevention (CDC), the percent of adolescents (ages 12–19) who are overweight is 16 percent (1999–2000), an increase of 11 percent since 1976–80. An additional 14.9 percent of adolescents are at risk for overweight. And a 2002 National Center for Health Statistics study found nearly 6 million American children ages six to 17 years to be severely overweight— triple the prevalence of the 1960s. Some obese adolescents are simply continuing a history of childhood obesity, becoming even heavier during puberty. Some have not been overweight until adolescence. Others go from extreme thinness to obesity during these years.

This period of rapid growth is usually accompanied by an increase in APPETITE, especially for highcalorie foods, and some adolescent obesity is caused by an apparent inability to restrict food intake. While some adolescents burn off these extra calories in vigorous physical activities, others appear unwilling to exercise. They choose instead to treat their fatness as a “disability,” refusing to join in normally active and boisterous adolescent games and activities. Frequently, this refusal to participate derives from feelings of inferiority and shame brought on by taunting and name-calling by their peers. Further exacerbating their difficulty may be parents and teachers who lecture them about their unhealthy weight and social nonparticipation. It soon becomes easy for them to blame all their failures or disappointments on their obesity. Such feelings, demoralizing at any age but devastating during adolescence, can have serious longterm consequences. Thus, adolescent obesity may often contribute to lifelong behavioral and psychological problems. When obese adolescents do not receive—or accept—help, whether in losing weight or dealing positively and maturely with their weight and emotional problems, they usually withdraw even further from social life. They frequently then turn to food for solace, causing them to put on even more weight. Obesity in adolescence is also frequently blamed for problems with sexual adjustment. Although being fat can prevent a person from being considered “attractive” in our weight-conscious society, HILDE BRUCH cautioned that “it is not the weight excess itself but the attitude toward it, or more correctly toward oneself, that interferes with any personal relationships, most of all in the sexual area.” Studies of adolescent obesity have described frequent cases of provocativeness and uncontrolled sexual behavior, even to the point of promiscuity. Adolescents with severe personality problems who are desperately unhappy about being fat are especially easy prey for FAD DIETS and NOVELTIES. The promise and dream of changing a boring, uneventful life to one of exciting activity and romance make the advertised products appear magical. Members of the American Society of Bariatric Physicians have reported little success in treating

10 adoption and eating disorders younger children for obesity, but they have had increased success with adolescents at about the age of puberty. Emerging interest in the opposite sex and a developing maturity level contribute to the motivation to follow eating restrictions. Because the adolescent body undergoes so many energy-requiring physical changes, “average” calorie requirement tables are of little use for obese adolescents dieting to lose weight. Following typical calorie requirement tables is likely to result in an unhealthy low calorie intake. Diets are particularly difficult for boys around the age of 15, when their calorie intake may increase five times or more. Adolescent dieting can also be stressful socially because so much of teenage social life revolves around eating. Well-meaning but nagging parents may add to this stress, especially given adolescents’ growing independence. Experts suggest that, for this reason, parents may be most helpful in supportive roles. According to the American Obesity Association, surgical procedures such as gastric bypass have been performed successfully on adolescents; however, surgery for adolescents is usually considered only when severe medical conditions are present that can improve with the surgery. Barlow adds, “An adolescent who has continued rapid weight gain during organized attempts at weight management has obviously not succeeded, but this failure may reflect an eating or emotional disorder that requires psychological treatment, not surgery.” Writing in Diabetes and Primary Care (March 22, 2004), Dr. John J. Reilly of the University of Glasgow, says, “There is still a widespread belief among adolescents, their parents and healthcare professionals that obesity is a relatively minor health problem, or even a largely cosmetic problem with no significant health impact. In fact, there is a rapidly accumulating body of evidence that obesity in adolescents will have major health consequences in the short term (for the adolescent) and the longer term (for the adult who was an obese adolescent).” Baur and O’Connor add, “The current epidemic (of child and adolescent obesity) is due to massive environmental change over the past few decades leading to a rise in sedentary pursuits, a decrease in physical activity and increased energy intake. Effective management requires a family-focused, developmentally sensitive, behavioral manage-

ment approach that addresses, for example, eating habits, incidental activity and television viewing.” See also BARIATRIC SURGERY. Barlow, Sarah E. “Bariatric Surgery in Adolescents: For Treatment Failures or Health Care System Failures?” Pediatrics 114, no. 1 (July 2004): 252–253. Baur, L. A., and J. O’Connor. “Special Considerations in Childhood and Adolescent Obesity.” Clinics in Dermatology 22, no. 4 (July/August 2004): 338–344. Bruch, Hilde. “Obesity in Adolescence.” In Eating Disorders: Obesity, Anorexia Nervosa, and the Person Within. New York: Basic Books, 1973. Burch, Gwen Weber, and Paul H. Pearson. “Anorexia, Bulimia, and Obesity in Adolescence: The Sociocultural Perspective.” In Eating Disorders: Effective Care and Treatment, edited by Félix E. F. Larocca. St. Louis: Ishiyaku EuroAmerica, 1986. Collipp, Platon J., ed. Childhood Obesity. New York: Warner Books, 1986. Noonan, S. S. “Children and Obesity: Flunking the Fat Test.” New Jersey Medicine 94, no. 6 (June 1997): 49–51.

adoption and eating disorders There is some interest in discovering how adoption and the incidence of eating disorders may correlate, since both anorexia and the internal conflicts faced by adoptees manifest themselves in early adolescence and around puberty. However, reports on anorexia nervosa in adopted children are sparse. A case was reported in 1985 in which three biologically unrelated individuals in one family had severe anorexia: a father, his adopted daughter and an unrelated person living with them. This case suggests the possible importance of environmental factors in the generation of anorexia nervosa and also reveals the special problems underlying the development of the condition in adoptees. In 1997 Hewitt called for twin, family and adoption studies to help delineate which causes of eating disorders can be inherited and which are due to family circumstances or individual environments. In their review of the findings concerning the heritability and the contributing genes of anorexia nervosa (AN), Ben-Dor et al. concluded, “Although there is a strong familial component in AN, so far the search for candidate genes has not been fruitful and further large scale prospective and adoption studies are needed to confirm genetic factors.” See also TWIN STUDIES AND EATING DISORDERS.

advertising and obesity 11 Ben-Dor, D. H., et al. “Heritability, Genetics and Association Findings in Anorexia Nervosa.” Israel Journal of Psychiatry and Related Sciences 4, no. 39 (2002): 262–270. Fry, Richard, and Arthur H. Crisp. “Adoption and Identity: A Case of Anorexia.” British Journal of Medical Psychology 62, Part 2 (June 1989): 143–152. Hewitt, J. K. “Behavior Genetics and Eating Disorders.” Psychopharmacology Bulletin 33, no. 3 (1997): 355–358.

adult onset obesity Obesity that starts at about the age of 25, usually from overeating (especially of high-calorie snack foods) and frequently because of emotional frustration, stress or boredom. It is generally seen in people who did not have weight problems as children. Some of the more common emotion charged events that can lead to first-time obesity in adults include leaving home for college or career, marriage, pregnancy, divorce, death of a close family member, extended illness or serious injury. In one study, 68 percent of obese adults related the onset of their weight problems to inactivity because of injury or illness; frequently these traumatic events result in unusually excessive eating of high-calorie foods combined with long periods of inactivity. Because these rather common and relatively sudden increases in weight frequently remain even after the stress and the excessive eating stop, one theory suggests that there may be a resetting of the set-point mechanism during these eating/exercise pattern changes. See also SET-POINT THEORY. advertising and obesity Advertising has come under increased scrutiny as health organizations and lawmakers have stepped up efforts to stem the obesity epidemic. Researchers and clinicians have targeted the multimillion-dollar advertising campaigns that promote candy-like cereals and caloriedense snack foods to children as significant contributors to the tripling of overweight children since the 1970s. In 1992 the American Academy of Pediatrics suggested that televised food advertising aimed at children be completely eliminated because “children are unprepared to make appropriate food choices and do not understand the relationship of food choices to health maintenance and disease prevention.” More recently, the American Psycho-

logical Association has recommended government restrictions on advertising to children younger than seven or eight because they are unable “to recognize advertising’s persuasive intent.” Although absolute consensus has yet to be reached on the impact of advertising on children and adolescents, many experts agree that television has a unique capacity to influence children’s minds and behavior. And advertising to children is increasing along with the obesity. Children are now exposed to 40,000 TV ads a year, up from 20,000 in the 1970s, according to a report by the Henry J. Kaiser Family Foundation. The Kaiser report cited studies stating that the majority of ads targeted to children are for food: primarily candy (32 percent of all children’s ads), cereal (31 percent), and fast food (9 percent). Ads for high-fat, high-salt foods have more than doubled since the 1980s, while commercials for fruits and vegetables remain in short supply. In a British study to discover how television commercials might affect children’s eating behavior and health, the overall snack food intake of the obese and overweight children was significantly higher than the lean children in the control (nonfood advertising) condition. The consumption of all the food offered increased following food commercials with the exception of the low-fat savory snack. The authors concluded that obese children have heightened alertness to food-related cues, and exposure to such cues induces increased food intake in all children. The advertising industry has vigorously refuted any direct links between advertising and obesity. In a New York Times article in 2004, leaders of advertising trade associations called the Kaiser findings that advertising may be part of the obesity problem “a huge leap in judgment.” They also noted that restrictions on advertising food to children in other countries have not reduced obesity. Corroborating this, Ashton wrote, “Experience of advertising bans in Quebec and Sweden suggests that the measure was completely inefficient in combating childhood obesity.” In Quebec, obesity rates are no different from those in other Canadian provinces, despite a 1980 ban on advertising food to children. A similar ban in Sweden, which prohibits advertising to children under age 12, has not affected obesity. Swedish children are as obese as those in compara-

12 advertising and obesity ble countries. Even countries with virtually no marketing to children, such as Egypt, are seeing rises in obesity. According to Broadcasting & Cable, a media trade publication, the number of television food commercials has actually declined during the years obesity increased by 15 percent among eighthgraders. Media executives argued, “Yes, kids are spending more time slouched in front of screens. But increasingly, those screens aren’t TVs. Instead, young people are turning to computers, DVD players, and game players that don’t run commercials.” Advertisers tend to place the childhood obesity problem on parents who allow their children to overeat and to become “couch potatoes.” Opponents counter that blaming parents “fails to recognize the extent of advertising and marketing surrounding families.” At the June 2004 Time/ABC News Obesity Summit, the chairman of the Federal Trade Commission asserted that banning advertising to children would be unconstitutional and would not end the obesity problem. He noted, “Even our dogs and cats are fat and it’s not because they’re watching too much advertising.” Proponents of restricting or even eliminating advertising of fat-laden foods to children note that tobacco and alcohol advertising is restricted, thus the precedent exists. Some have even compared Ronald McDonald with Joe Camel. The psychology behind advertising high-fat foods to adults has also received complaints from the medical community; one example was Hershey’s 2002 ad equating chocolate bars with happiness. Newsweek quoted Thomas Warden, director of the Weight and Eating Disorders Program at the University of Pennsylvania, as saying, “If you have commercials like this, which are inviting people to eat in order to feel happy, the likelihood is that the rates of obesity will just continue to increase.” Others accused Hershey of capitalizing on people’s unhealthy connection with high-fat foods. In June 2004 congressional testimony regarding government’s role in combating obesity, Lester M. Crawford, acting commissioner of the FDA, stated that the Centers for Disease Control and Prevention (CDC) will “conduct a comprehensive review of the effects of advertising and marketing on children’s behavior in general, and specifically on children’s dietary patterns and health status. The

project will include all aspects of marketing: product, promotion, placement, and pricing. Additionally, CDC will review policies and practices from other countries. Results from these efforts will inform the development of new social marketing strategies designed to promote more healthful nutrition behavior among youth.” False or Deceptive Advertising A September 2002 Federal Trade Commission (FTC) report on weight-loss advertising concluded that, despite vigorous FTC law enforcement and consumer education efforts, fraudulent and misleading weight-loss advertising was widespread and on the rise. Between 1990 and 2002, the FTC brought 97 lawsuits against companies it accused of marketing phony weight-loss products, winning $50 million in restitution to consumers as well as other financial remedies. Public workshop panels sponsored by the FTC found that claims that promote substantial weight loss without reducing caloric intake or increasing exercise are not scientifically feasible at the current time. The review considered nonprescription drugs, dietary supplements, creams, wraps, devices, and patches. The panels also looked at ways to improve industry self-regulation of weight-loss advertising and determined that further guidance would assist the media in screening out these bogus claims. In December 2003 the FTC issued guidelines that identified seven common weight-loss claims that the agency called “scientifically unfeasible.” They are: • Causes weight loss of two pounds or more per week for a month or more without dieting or exercise • Causes substantial weight loss, no matter what or how much the consumer eats • Causes permanent weight loss even when the consumer stops using the product • Blocks the absorption of fat or calories to enable consumers to lose substantial weight • Safely enables consumers to lose more than three pounds per week for more than four weeks • Causes substantial weight loss for all users • Causes substantial weight loss by wearing it on the body or rubbing it into the skin

African Americans and eating disorders 13 The FTC called on newspapers, magazines, and television networks to voluntarily screen and reject all advertisement for products that make any of these claims. According to obesity experts, such misleading ads only make the obesity problem worse. Not only do the quick weight-loss plans not work, but they can set up nutritional deficiencies, which in the long run may lead to more health problems. American Academy of Pediatrics Committee on Communications. “The Commercialization of Children’s Television.” Pediatrics 89 (1992): 343–344. Ashton, David. “Food Advertising and Childhood Obesity.” Journal of the Royal Society of Medicine 97, no. 2 (February 2004): 51–52. Halford, Jason C. G., et al. “Effect of Television Advertisements for Foods on Food Consumption in Children.” Appetite 42, no. 2 (April 2004): 221–225. Ives, Nat. “A Report on Childhood Obesity.” The New York Times, February 25, 2004, section 6, p. 3. Kaiser Family Foundation. “The Role of Media in Childhood Obesity.” Available online. URL: http://www. kff.org/entmedia/7030.cfm. Posted on February 24, 2004. McConnell, Bill. “Bloated Agenda.” Broadcasting & Cable, June 14, 2004. Springen, Karen. “Taking a Bite out of Hershey’s.” Newsweek (November 4, 2004): 12.

aerobic exercise

Exercise that conditions the heart and lungs by increasing the efficiency of oxygen intake by the body, usually through an activity in which oxygen reaches the muscles at the same rate at which it is used up. This type of physical activity is also recommended for weight control and body conditioning. Such exercise involves the large muscles of the upper body, arms and legs, and to be effective it should be continued for periods of at least 20 minutes at least three times a week. Typical aerobic exercise is not too strenuous and can be performed slowly for a long period of time. Such exercise includes walking, jogging, swimming, bicycling, ice-skating, roller-skating, rowing, aerobic dancing, ballroom dancing, rope skipping and cross-country skiing. Aerobic exercise is effective for weight reduction because it increases the muscles’ ability to use oxygen to burn energy from stored fat. Although

the exercise itself may seemingly expend few calories, the expenditures is cumulative and continues after exercise ends. The effectiveness of aerobic exercise in reducing fat deposits depends upon several elements, including body weight and the frequency, intensity and duration of exercise. According to the Exercise Physiology Laboratory at the University of Massachusetts Medical School, the average 150-pound person burns approximately 100 calories walking a mile. Its tests have shown that the average person who takes a brisk 45-minute walk four times a week for a year and does not increase food intake will burn enough calories to lose 18 pounds. Virtually all of this weight loss will be fat, because regular aerobic exercise preserves muscle mass. Usually, aerobic exercise tends to decrease appetite. Some fitness experts claim that exercising aerobically during the lunch hour reduces appetite sufficiently that a bowl of soup or a cold drink will satisfy hunger, and that some people have lost as much as 20 pounds within five weeks. See also ANAEROBIC EXERCISE. Cooper, Kenneth H. The Aerobics Program for Total Wellbeing: Exercise, Diet, Emotional Balance. New York: M. Evans, 1982. Layman, Donald K., ed. Nutrition and Aerobic Exercise. Washington, D.C.: American Chemical Society, 1986. Rippe, James M. Fit for Success. New York: Prentice Hall, 1989.

African Americans and eating disorders

Cases of eating disorders among African Americans are often underreported because studies typically do not include ethnically diverse populations. That said, more is known about eating disorders among African Americans than any ethnic and cultural group other than white Americans. Although few studies examine the incidence or prevalence rates for eating disorders in the African-American population, a 1996 review of the research literature related to eating behaviors and disturbances among American minority groups did provide clinical accounts of eating disorders in AfricanAmerican women, albeit less frequently than among the white population. A later review of the literature published by the Association of Black

14 African Americans and obesity Nursing Faculty noted that a significant study conducted at a large midwestern university identified 2 percent of African-American women as eating disordered and 23 percent of the non-eating-disordered as symptomatic. Because African Americans represent only 11 percent of all undergraduates, the author asks, “If the African American women surveyed sought to assume the values, attributes, and behavior of their Caucasian peers in order to become accepted members of the culture, in this case the university, then how can a true prevalence of the eating disorders among the African American subgroup be identified? (They) may have been influenced by the activities of their Caucasian peers who are eating disordered.” Numerous other studies have documented a high rate of eating disorder behaviors and risk factors, including body dissatisfaction among AfricanAmerican women. More specifically, research demonstrates that binge-eating and purging is at least as common among African-American women as white women. Some researchers believe that racial prejudice and discrimination toward African Americans result in a sense of isolation that may contribute to binge-eating. The National Women’s Health Information Service (U.S. Department of Health and Human Services) states in its Eating Disorders Information Sheet: “Unfortunately, little work has been undertaken regarding differences in presentation of symptoms, cultural-specific risk factors, and effective treatment methods for African Americans.” The commonly held belief that African-American women do not experience eating disorders has contributed to the lack of identification of their eating disorder problems. And because early detection of an eating disorder is critical for its successful treatment, this misperception can result in serious health problems for African-American girls. Similar to their white counterparts, as black girls approach adolescence, they become concerned with thinness. Studies indicate that when AfricanAmerican girls experience social pressure to be thin, they express the same type of body dissatisfaction and drive for thinness as white girls. Adolescents from middle-class African-American families may be particularly vulnerable to the influence of the white beauty ideal. Essence, a magazine that caters to African-American women, reg-

ularly runs stories on body size anxiety and eating disorders. A survey of its readers indicated that African-American women appear to have at least equal levels of abnormal eating attitudes and behaviors as white women. Studies indicate that blacks who identify with mainstream culture exhibit more eating problems, including dieting and fear of fat. Media targeting African American and other racial and ethnic and cultural groups in the United States are increasingly embracing the beauty as thinness ideal. Black female stars in the music, film, and fashion industries are just as thin as their white counterparts. The influence of these role models may contribute to body dissatisfaction and weight control behaviors among AfricanAmerican girls. The first large-scale epidemiological study of recurrent binge-eating in black American women indicated that black women were as likely as white women to report that they had engaged in bingeeating and self-induced vomiting. More specifically, a greater number of black women than white women reported that they had used laxatives, diuretics or fasting to control their weight. Almost twice as many black women as white women were identified as probably having eating disorders. Crago, M., C. M. Shisslak, and L. S. Estes. “Eating Disturbances among American Minority Groups: A Review.” International Journal of Eating Disorders 19, no. 3 (April 1996): 239–248. Pumariega, A. J. et al. “Eating Attitudes in AfricanAmerican Women: The Essence Eating Disorders Survey.” Eating Disorders: The Journal for Treatment and Prevention 2, no. 1 (1994): 5–16. Striegel-Moore, R. H., et al. “Recurrent Binge Eating in Black American Women.” Archives of Family Medicine 9, no. 1 (January 2000): 83–87. Tyler, Indira D. “A True Picture of Eating Disorders among African American Women: A Review of Literature.” ABNF Journal 14, no. 3 (May–June 2003): 73–74.

African Americans and obesity

The prevalence of obesity is high among African Americans, particularly African-American women. In the period 1999–2000, 50 percent of non-Hispanic black women 20–74 years of age were obese, compared with 30 percent of non-Hispanic white women.

African Americans and obesity 15 Obesity among black women increased more than 60 percent since the period 1976–80, from 31 percent. Poor African Americans have an even higher rate of obesity: one in three. The incidence of overweight and obesity is even higher—69 percent until age 60, when it declines. About 36 percent of African-American children six to 10 years old are overweight (compared to 30 percent of all U.S. children), and 20 percent are obese (compared to 15 percent of all U.S. children). Black girls are not likely to be heavier than white girls during childhood, but after adolescence their BODY MASS INDEX (BMI) surpasses that of white adolescent girls. This increase may be partially due to metabolic differences, as black women and girls tend to have lower resting expenditures than their white counterparts. African-American women tend to experience weight gain earlier in life than Caucasians and Asians. African-American men tend to develop obesity later in life than Hispanic men. James Gavin, M.D., president of the Morehouse School of Medicine, suggests that African Americans may be genetically predisposed to being overweight. “Many of us have what is called a thrifty gene (it’s really a cluster of genes) that protected our ancestors in time of famine or too little food. We get a lot of miles out of the food we eat. When people with the thrifty gene eat too much food every day for years, we become obese.” Experts caution that as a hybrid population formed from a mixture of African, Native American and European-American ethnic groups, black Americans have different eating and exercise behaviors, as well as different attitudes about body size, than their African ancestors. One reason given for the higher rate of obesity among lowincome African Americans is their traditionally high-fat diet, which some studies show to be particularly followed in southern states. According to the National Women’s Health Information Service (U.S. Department of Health and Human Services), black women and girls are less likely to exercise than their white counterparts. Although the AMERICAN OBESITY ASSOCIATION (AOA) says overweight affects African Americans regardless of economic status, statistics show that black women more often face financial challenges than white women, and thus are not as likely to spend money on

weight loss programs or health clubs, which, authors have noted, are less common in AfricanAmerican neighborhoods than in other communities. Studies have found that many overweight African Americans feel they cannot walk in their neighborhoods for fear of their own safety, and black men are often hesitant to walk or jog anywhere out of fear of being considered a criminal. African-American women also report exercising less as they get older, according to the AOA. But economics and exercise do not appear to play the only roles in the obesity race disparity. Researchers at Rush University Medical Center in Chicago followed 2,017 women for four years as part of the Study of Women’s Health across the Nation (SWAN). The study was designed to test the effects of race and socioeconomic status on body mass index (BMI) by examining a diverse group of women. They found that, although women of both races with only high school education had similar BMI levels (31.4 for blacks versus 31.1 for whites), the BMI of Caucasian women with college education was lower than the BMI of similar AfricanAmerican women (27.1 for whites versus 30.7 for blacks). In fact, the weight difference grew with additional education. More studies are needed to determine the reason behind these provocative findings, but researchers suggest that factors might include cultural differences (being overweight has historically carried less stigma for lower economic black women than for white), or the increased stress the black women reported from perceived discrimination as they climbed the career ladder. Previous research has associated stress with weight gain. Researchers from the Children’s Hospital of Philadelphia reported in 2003 that African Americans who gained weight more rapidly than their peers in the first four months of life were more than twice as likely to be obese 20 years later than subjects without rapid early infant weight gain. Nicolas Stettler, M.D., the lead author of the study, said, “Our results suggest that early infant weight gain is a critical period for the establishment of obesity. This may lead to new hypotheses to origins of obesity and to new approaches for obesity prevention.” He noted that further research is needed. Several studies have reported an association between low birth weight and a risk for later obe-

16 African Americans and obesity sity and diabetes, with African Americans experiencing much higher prevalence of low birth rates than others. The average low-birth rate for African Americans is 13.2 percent, for African-born blacks 7.1 percent and for white Americans, 4.3 percent. Rates improve for higher income groups, but the disparity remains: 7.5 percent for black Americans, 3.6 percent for black Africans and 2.4 percent for white Americans. Another area where the connection between obesity and African Americans has been studied is in television shows. Tirodkar and Jain compared four of the most popular sitcoms viewed by the general public with four sitcoms most watched by African-American audiences. A much higher prevalence of obesity was found in the shows targeting African Americans than in those designed for the public at large (27 percent vs. 2 percent), and there were more food commercials overall during the African-American shows (4.8 vs. 2.9 per half-hour show). However, the Kaiser Family Foundation noted in its issue brief The Role of Media in Childhood Obesity, “Exactly what effect seeing obese characters on these shows has on the prevalence of obesity among African Americans in real life is not clear.” Generally, overweight and obese AfricanAmerican girls express satisfaction with their physical appearance, with reports showing as high as 40 percent considering their figures to be attractive or very attractive. However, studies of AfricanAmerican women who have moved to higher socioeconomic status have shown increased levels of poor self-image along with increased BMI. Freedman et al. examined both ethnic differences and differences between college and community samples in male preferences for ideal body size and shape in women. They found that AfricanAmerican men were more likely to choose heavier figures as ideal than white American men did. Both ethnic groups chose figures with a low waist-to-hip ratio (WHR), but African-American men were more likely to choose a very low WHR as ideal. The authors stated, “The findings replicate and extend research showing weight to be a more important cue than WHR in the mate-selection process and support the theory that African-American men’s preferences may serve as a protective factor against

eating and body image pathology in AfricanAmerican women.” Several studies show little or no association between overweight and the risk of death for African Americans, especially women. In an analysis of American Cancer Society data on more than 1 million U.S. adults, the heaviest black women (BMI greater than 35) had a smaller increase in risk of death from all causes (increase was 20 percent to 30 percent) than did the heaviest white women with the same BMI (increase was 75 percent to 100 percent). Black men who were overweight showed an increased risk, but it was very small. Researchers have no explanation for this disparity, and they do not know whether risks are the same for people of African descent elsewhere because no large studies exist in other parts of the world to compare with those done in the United States. Another reason for not considering these findings final is that only about 12,000 of the study participants were African Americans—too few to be statistically meaningful or to establish a clear trend. But other studies have also shown that African Americans may live longer if they are in the overweight but not obese category. If African Americans do indeed suffer fewer consequences of modest weight gain, experts speculate that differences in body fat distribution might be part of the reason, according to an article in USA Today. “Fat is thought to be most dangerous if it is packed around the internal organs. This kind of fat is most biologically active, throwing off cholesterol levels and forcing up insulin levels. Overweight blacks tend to have lower levels of harmful triglycerides and higher amounts of protective HDL than do similar-size whites, and this might be due to where their fat is deposited. Blacks tend to carry a larger proportion of their fat in a layer under the skin rather than deep in the belly.” However, African-American women do have higher rates of obesity-related diseases such as diabetes, hypertension and breast cancer; thus some experts say the higher obesity rates in African Americans may indirectly be connected to the overall higher mortality rate among blacks. See also THRIFTY GENE. Associated Press. “Is Weight Gain Less Hazardous for Blacks than Whites?” Available online. URL:

Alzheimer’s disease risk and obesity 17 http://www.USATODAY.com/news/health/2004-0607-blacks-weight_x.htm. Downloaded on September 15, 2005. Calle, Eugenia E., et al. “Body-Mass Index and Mortality in a Prospective Cohort of U.S. Adults.” The New England Journal of Medicine 341, no. 15 (October 7, 1999): 1097–1105. Freedman, Rachel E. K., et al. “Ethnic Differences in Preferences for Female Weight and Waist-to-Hip Ratio: A Comparison of African-American and White American College and Community Samples.” Eating Behaviors 5, no. 3 (July 2004): 191–198. Freid, V. M., et al. 2003 Chartbook on Trends in the Health of Americans. Hyattsville, Md.: National Center for Health Statistics, 2003. Gavin, James R., with Sherrye Landrum. Dr. Gavin’s Health Guide for African Americans. Alexandria, Va.: Small Steps Press, 2004. Kaiser Family Foundation. “The Role of Media in Childhood Obesity.” Available online. URL: http://www.kff.org/entmedia/7030.cfm. Posted on February 24, 2004. Tirodkar, M., and A. Jain. “Food Messages on African American Television Shows.” American Journal of Public Health 93, no. 3 (March 2003): 439–441.

air pollution and obesity Harvard School of Public Health researchers studied 611 Boston-area fourth- and fifth-grade students to determine the short-term affects of air pollution. They reported to the American Thoracic Society International Conference in 2004 that when air pollution levels went up, associations between air pollution and lung function were two to five times stronger for obese children than for normal-weight children. The more obese a child was, the stronger the effect was of the previous day’s air pollution on his or her lung function. Increases in air levels of nitrogen dioxide produced the greatest disparity. The schoolchildren were an ethnically diverse group, with about 58 precent classified as white, 18 percent as black, 14 percent as Hispanic and 10 percent as other. The researchers speculated that because fatty tissue is known to release chemicals involved in inflammation, and because air pollution also leads to inflammation of the airways, there may be a multiplier effect that makes obese children more sensitive to air pollution. In another study that followed these children through 12th grade, the same researchers found that long-term

exposure to air pollution had irreversible effects on lung function in obese children.

alexithymia

Difficulty in describing or recognizing one’s emotions; confusion about one’s feelings, or an apparent lack of thought and concern about one’s personal experiences. This disturbance is very common in anorexia nervosa. When asked to describe their sensations of SATIETY, anorexics often respond with such statements as “I feel like I have eaten”; “I don’t like it”; “I feel guilty.” Inquiries about their emotions may result in defensive or hostile responses to what is viewed as an intrusion into an area they do not understand. A Canadian study of 95 subjects supported numerous reports of the presence of a high degree of alexithymia in the obese. One theory is that some people have difficulty coping psychologically with stressful, emotionally intense situations and relieve their anxiety through physical action. Eating, already associated with satisfaction and the relief of stress, is by far the most common device. A British study concluded that eating disorder patients are considerably more alexithymic than normal controls. It also found that alexithymia may be a trait in bulimia nervosa requiring psychological treatment to encourage the expression of emotion. A French study of 169 obese women, published in 2003, found that alexithymia was the predictor of emotional eating in those obese subjects who also had BINGE-EATING DISORDER, while perceived stress and depression were the predictors in those subjects without binge-eating disorder. Legoretta, Gabriela; Robert H. Bull; and Margaret C. Kiely. “Alexithymia and Symbolic Function in the Obese.” Psychotherapy and Psychosomatics 50, no. 2 (1988): 88–94. Pinaquy, Sandrine, et al. “Emotional Eating, Alexithymia, and Binge-Eating Disorder in Obese Women.” Obesity Research 11, no. 2 (February 2003): 195–201. Schmidt, V., A. Jiwany and J. Treasure. “A Controlled Study of Alexithymia in Eating Disorders.” Comprehensive Psychiatry 34, no. 1 (January/February 1993): 54–58.

Alzheimer’s disease risk and obesity

Because obesity is closely associated with vascular diseases

18 amenorrhea (diabetes, coronary heart disease and hypertension), and all of these have been implicated as risk factors in Alzheimer’s disease, researchers have long contemplated the possibility of a link between obesity and Alzheimer’s disease. However, any such link had been difficult to connect because weight loss frequently occurs prior to symptoms of Alzheimer’s. This problem was overcome when scientists in Sweden were able to follow nearly 400 people for 18 years, from age 70 or older. At the end of the 18 years, 93 of the participants were found to have Alzheimer’s disease. Women in the study who developed Alzheimer’s disease between the ages of 79 and 88 were significantly more likely to have been overweight at age 70, as well as at 75 and 79. Their body mass index (BMI) averaged 3.6 units higher than that of women who did not become demented. For every unit increase (approximately five to seven pounds) in BMI at age 70, the risk of developing Alzheimer’s disease increased by 36 percent. An important side note to the study: Those women who did not develop Alzheimer’s disease were not superthin; their average BMI was 25, the borderline between healthy and overweight. The authors noted, “These results suggest that even moderate, common-sense weight control may help lower risk of Alzheimer’s disease.” This study did not find a connection between excess weight and Alzheimer’s disease in men, largely because few male participants lived long into the study, and thus few developed dementia. The researchers said it is also possible that there may be some physiological basis for the difference, such as a metabolic factor or a different pattern of body fat distribution in men and women. More men will have to be included in future studies to better determine any differences. In two previous Alzheimer’s studies, one Swedish and one Finnish, obesity also appeared to be a factor. As 2,000 people aged in one study, those with a BMI greater than 30 (obese) when they were middle-aged had a 3.5 times greater risk of developing dementia than those of normal weight. In the other study of 1,449 Finns, risk of any dementia, and Alzheimer’s in particular, roughly doubled with a BMI of more than 30 at age 50. The risk was six times higher when those

who were obese also suffered from high cholesterol and high blood pressure. Although the findings point to important public health implications (women older than 50 are the fastest-growing age group in Western societies), the Alzheimer’s Association (which helped sponsor the 18-year Swedish study with a grant) cautioned that more work needs to be done. Among the questions scientists will be trying to answer is how excess weight might lead to Alzheimer’s disease or other forms of dementia. Experts had already projected the number of Alzheimer’s cases in the United States to rise from 4.5 million today to as many as 16 million by 2050; however, a spokesperson for the National Institute on Aging was quoted as saying that number “probably doesn’t take into account the nation’s burgeoning weight problem.” The World Health Organization has predicted nearly 29 million demented people in both developed and developing countries by the year 2020. Should obesity prove out to indeed have a definitive link to Alzheimer’s disease, the numbers projected are likely to be grossly underestimated, a problem that has been called “scary.” Gustafson, Deborah, et al. “An 18-Year Follow-up of Overweight and Risk of Alzheimer Disease.” Archives of Internal Medicine 163, no. 13 (July 14, 2003): 1,524–1,528.

amenorrhea

A suppression or absence of menstruation. It is considered normal after menopause, during pregnancy and during lactation (secretion of milk after childbirth). Primary amenorrhea is failure of menstruation to occur at puberty; secondary amenorrhea is cessation of menstruation after its establishment. Among the causes of abnormal amenorrhea are metabolic disorders (diabetes or those stemming from OBESITY or malnutrition) and emotional disorders (ANOREXIA NERVOSA or those stemming from excitement, shock, fright or hysteria). When the amount of fat drops below a critical percentage of body weight (20 percent) for any reason, hormonal release is affected, which in turn results in amenorrhea. Because of this, it is generally considered to be a symptom of anorexia ner-

American Indians/Alaska Natives and eating disorders 19 vosa. Although drastic weight reduction generally leads to amenorrhea, there have been cases in which amenorrhea has occurred prior to weight loss. In many of these cases, the amenorrhea continues even after the weight has been regained, sometimes for years. For this reason, some suggest that amenorrhea is a response to psychic stress or indicative of an underlying hypothalamic (body temperature) disorder. Others suggest that perhaps poor nutrition or abnormal psychological development can affect hormonal functions and cause these different results. However, many persons who are at an extremely low body weight do not develop amenorrhea and sometimes persons who are actually overweight develop amenorrhea while losing weight. Thus, the exact relationship between body weight, weight loss and menstrual irregularities is unclear. Currently amenorrhea (defined as the absence of at least three menstrual cycles) is one of the required diagnostic criteria for anorexia nervosa. However, because of the problems noted above, many researchers have recommended that it be eliminated as a criterion. Irregular menstrual cycles and amenorrhea in bulimic women have been reported by nearly a dozen authors in medical journals, with irregular menstrual cycles reported in as many as 50 percent of cases studied and amenorrhea in 7 to 20 percent of cases studied. See also BULIMIA NERVOSA. Garfinkel, Paul E., et al. “Should Amenorrhea Be Necessary for the Diagnosis of Anorexia Nervosa?” British Journal of Psychiatry 168, no. 4 (April 1996): 500–506.

American Anorexia/Bulimia Association (AABA) See NATIONAL EATING DISORDERS ASSOCIATION.

American Indians/Alaska Natives and eating disorders For statistical purposes, the U.S. government and various health agencies group Native Americans and Alaska Natives into one population segment they call American Indian/Alaska Native (AI/AN). Eating disorders among American Indians and Alaska Natives are often not diagnosed appropriately, possibly because cases have not been reported as often among ethnically diverse popula-

tions and thus are not expected. Some authors suggest that incorrect diagnoses may also come from the widely accepted false belief that eating disorders affect only middle-class to upper-middle-class white adolescent women. However, recent studies indicate that American Indian and Alaska Native adolescents are increasingly exhibiting disturbed eating behaviors and using unhealthy practices to control their weight. Disordered eating has been shown to occur more often among this group than among white, Hispanic, African-American or Asian girls, according to the National Women’s Health Information Center: In a large study involving 545 Hispanic, American Indian, and white high school students, American Indians consistently scored the highest on each of seven items representing disturbed eating behaviors and attitudes. This study, which included 129 American Indians, also found very high rates of self-induced vomiting and binge eating among this group. Other small studies of American Indian adolescents also indicate high rates of disordered eating, including dieting and purging. The largest and most comprehensive survey undertaken to date on the health status of Native American youths living on or near reservations involved 13,454 American Indians and Alaska Natives in grades 7 through 12. Approximately 41 percent of the adolescents reported feeling overweight, 50 percent were dissatisfied with their weight, and 44 percent worried about being overweight. Among American Indian youth, body dissatisfaction is associated with unhealthy weight control behaviors. In the Indian Adolescent Health Study mentioned above, almost half of the girls and onethird of the boys had been on weight loss diets in the past year, with 27 percent reporting selfinduced vomiting and 11 percent reporting the use of diet pills. Girls who reported feeling overweight were more likely to engage in unhealthy weight control practices. Increased contact with the mainstream culture that equates thinness with beauty seems to contribute to higher rates of disordered eating among American Indian girls. In one study, anorexic Navajo girls from Arizona were more likely to come from upwardly mobile families who moved off the reservation. In a second study, child and adolescent members of a tribe were much more likely to prefer thinner body

20 American Indians/Alaska Natives and obesity sizes than elder tribe members. Eating disturbances have also been associated with racism, social isolation, low self-worth, and pressure to look a certain way, which may increase vulnerability to developing eating disorders.

Fitzgibbon and Stolley came to similar conclusions: “Among Native American populations, the scant available information suggests that aberrant eating patterns more often strike heavier individuals and that purging behaviors such as vomiting and laxative abuse are used to control weight. Research has also noted that younger women with higher levels of education, as well as those who have moved off reservations and are assimilating into western culture, are at increased risk.” Fitzgibbon, Marian, and Melinda Stolley. “Minority Women: The Untold Story.” Nova Online: Dying to Be Thin. Available online. URL: http:/www.pbs.org/wgbh/ nova/thin/minorities.html. Updated in December 2000. National Women’s Health Information Center. “Eating Disorders Information Sheet: American Indian and Alaska Native Girls.” Office on Women’s Health, U.S. Department of Health and Human Services. Available online. URL: http://www.4woman.gov/BodyImage/ Bodywise/uf/AmericanIndianGirls.pdf. Downloaded August 30, 2004.

American Indians/Alaska Natives and obesity Increasing rates of obesity have been measured in many American Indian and Alaska Native communities, with the current rate of obesity for these groups twice that of the non-Hispanic white population. Eighty percent of American Indians with diabetes are obese. In Pima Indians, the most widely studied American Indian group, 95 percent of those with diabetes are overweight. The study of obesity and energy metabolism in Pima Indians has not identified exact causes but has revealed that Pima Indian families share the trait of low metabolic rate. This trait is considered predictive of weight gain and development of type 2 diabetes. A THRIFTY GENE is also thought to cause a genetic predisposition to obesity, although this gene has not been identified. American Indians have a high prevalence of obesity in all age groups and both sexes. Because children who are obese are at risk for developing

eating disorders and for becoming obese adults, health services have called for a focus on the prevention and treatment of obesity in American Indian adolescents. A U.S. government initiative called Healthy People 2010: Objectives for Improving Health, released in January 2000, lists among its goals: Reduce overweight to a prevalence of no more than 30 percent among American Indians and Alaska Natives. Dabelea, D., et al. “Increasing Prevalence of Type II Diabetes in American Indian Children.” Diabetologia 41, no. 8 (August 1998): 904–910.

American Obesity Association (AOA)

A nonprofit 501(c)(4) educational and lobbying organization founded in 1995. Its funding primarily comes from pharmaceutical companies, weight loss firms, and health care organizations. AOA’s focus is on changing public policy and perceptions about obesity. Its mission is to change the perception of obesity from one of individual failure to recognition as a complex disease involving more than personal behavior, such as the environment and genetic heritage, and to fashion appropriate strategies to deal with the epidemic. To achieve these objectives, AOA acts as an advocate before Congress, the White House and executive branch agencies and departments for policies that will be beneficial, plus develops educational materials to explain its positions. AOA’s program areas include education, research, prevention, treatment, consumer protection, discrimination and stigma and childhood and adolescent obesity. In addition, AOA has created and participated in several coalitions and studies. See also APPENDIX III, SOURCES OF INFORMATION.

amitriptyline

A tricyclic ANTIDEPRESSANT that has been used to treat bulimic patients for depression and BINGE-EATING behavior. In one study, amitriptyline (trade name Elavil) was tested against a PLACEBO in a sample of 32 bulimic subjects. Even though it was discovered that as many as half the subjects receiving amitriptyline may have been inadequately treated, amitriptyline still proved to be significantly superior to the placebo on one rating scale for anxiety and depression, but not significantly superior on another rating scale.

amphetamines 21 Other studies have reported less favorable results in treating ANOREXIA NERVOSA. Because amitriptyline has been shown to produce carbohydrate cravings in nonanorexics, researchers Garfinkel and Garner cautioned that there may be a significant risk of triggering BULIMIA in anorexics (see CARBOHYDRATES and CRAVINGS). In a 1985 study comparing the effects of amitriptyline and placebo on weight gain, depression, eating attitudes and obsessive-compulsive tendency over a five-week period, no significant differences favoring amitriptyline were found in any of the outcome variables. Side effects include increased appetite and thirst and constipation. Corcos, M., et al. “Pharmacologic Treatment of Bulimia.” Encephale 22, no. 2 (March–April 1996): 133–142.

amphetamines

Commonly called “speed,” amphetamines are central nervous system stimulants whose effects resemble those of the naturally occurring substance adrenalin. They have the temporary effect of increasing energy and apparent mental alertness. Until recent years amphetamines were widely prescribed by physicians for obesity because they lessen the appetite. Amphetamines were originally formulated in a German laboratory in 1887 but were largely ignored until they were rediscovered in 1932 by Gordon Alles of the University of California, who transferred his patents to the pharmaceutical firm of Smith, Kline & French (SKF) Laboratories. By 1937, amphetamines were being recommended for certain patients whose obesity was accompanied by low-level depression, on the grounds that a patient whose mood improved would no longer need to overeat and thus would lose weight. It wasn’t long before amphetamines were being hailed as a painless way to lose weight through appetite suppression. By the time the federal government stepped in to control the manufacture and sale of amphetamines, SKF was selling $30 million worth each year. (See APPETITE SUPPRESSANTS and OBESITY.) Their use does initially reduce appetite and increase energy levels. Because they induce conditions in the body that mimic a state of alarm or

arousal, they may inhibit the digestive functions, causing the body to use fat rather than food for energy. Some practitioners believe this theory shows that weight loss from amphetamines is the result of a lowering of the set point rather than appetite suppression (see SET-POINT THEORY). It has also been suggested that the anorexic effect of these drugs is a consequence of their inhibition of the salivary glands, which causes dry mouth, makes food less palatable and results in a loss of appetite. Amphetamines are frequently misused by anorexics, who experience intense hunger on the one hand yet terror on the other at giving in to the impulse to eat. Amphetamine abusers have experienced difficulty in swallowing, an extreme way to suppress the appetite. All of these appetite-control mechanisms have only temporary effects. The body soon draws on its immense recuperative powers, learns to adapt to the chemical and restores digestion, salivation and appetite to normal, thus preventing any more loss of tissue. Those who adhere to the lowered-setpoint theory also say that the resultant weight loss is temporary: after use of the drug is stopped, the set point returns to its previous level, so weight also rises to its previous level, or higher. The American Medical Association (AMA) has evaluated amphetamines as hazardous because of their undesirable effects, including a tendency to produce psychic and, occasionally, physically dependence when used indiscriminately and in large doses. The AMA suggests that physicians prescribe them only for temporary use of four to six weeks. The Food and Drug Administration affirms that these common drugs are of limited usefulness and that their use for prolonged periods in the treatment of obesity can lead to drug dependence and abuse and must be avoided. Phentermine (one of the ingredients of fen-phen) is an amphetamine (see FEN-PHEN/REDUX). Because of the high potential for abuse and addiction, amphetamines are now reserved for limited treatment of attention-deficit hyperactivity disorder (ADHD), narcolepsy and Parkinson’s disease. The most common trade names are Adderall, Desoxyn, Dexedrine, Dexedrine Spansule and DextroStat. All are closely related chemically. Some brands are not approved for medical use and are manufactured illegally.

22 amylin Czerwinski, W. P. “Amphetamine-Related Disorders.” Journal of Louisiana State University Medical Society 150, no. 10 (October 1998): 491–499. Lukas, Scott E. and Solomon H. Snyder. Amphetamines: Danger in the Fast Lane. New York: Chelsea House, 1992. O’Brien, Robert et al. The Encyclopedia of Drug Abuse. 2nd ed. New York: Facts On File, 1992.

amylin A recently (1987) isolated hormone discovered in high levels in the pancreas of Type II (non-insulin-dependent) diabetics. It appears to be responsible for the obesity, the reduced insulin secretion and the reduced effectiveness of insulin observed in Type II diabetes. Until this discovery, obesity had been considered by many to be a major contributor to the disease rather than a result of it. anaclitic depression

Also called anaclitic reaction. A state of reduced spontaneity and expressiveness in an infant resulting from lack of maternal responsiveness to the infant’s demands. Although there is no scientific proof of the theory, some researchers have attributed the sense of emptiness and loss experienced by anorexics to an anaclitic depression that develops because of maternal overor underinvolvement. During the child’s exploratory phase of development, the mother needs to allow and encourage freedom in order to promote the illusion of self-sufficiency, but she should also be available for emotional support. When the mother offers either too much or too little assistance, she can hinder the toddler’s development of self-reliance. One theory is that the mother of an anorexic overprotects her daughter rather than encourages her to explore, or is emotionally unavailable for support when her daughter returns for comfort or reassurance. This lack of dependable and consistent maternal responsiveness inhibits the daughter’s normal striving for autonomy and slows her separation-individuation process. This school of thought theorizes that it is specifically because the anorexic’s mother had difficulty in allowing or promoting independent behavior in her daughter that the anorexic is later unable to mature and separate. During adolescence, when separation and independence develop, the anorexic’s dependency again surfaces, along with the latent psychopathology originating in her infancy. Anaclitic depression is not a DSM-IV diagnosis.

anaerobic exercise

Exercise that demands brief spurts of intense effort, such as calisthenics or weight training. Anaerobic exercise is so intense that the oxygen supplied to the muscles by the blood is insufficient, forcing the muscle cells to work without it. For this reason, it does not burn as many calories as AEROBIC EXERCISE does. Anaerobic exercise is important to include in an overall fitness program because it helps to improve flexibility, toning and firming of the muscles, but it will not contribute a great deal to a weight reduction program.

anorexia athletica

Also called obligatory exercise. Compulsive exercising to the point of obsession; an addiction to exercising. Anorexia athletica is not a recognized distinct disease, but it is being increasingly referred to by researchers. Although some refer to it as a “new” disorder, others call such a distinction unreasonable and say it is simply a possible symptom of anorexia nervosa. Eating disorder treatment centers such as the Willough at Naples, Florida, include it in their information sheets “because many people who are preoccupied with food and weight exercise compulsively in attempts to control weight. The real issues are not weight and performance excellence but rather control and self-respect.” Fitness club owners have reported that typically the person is a woman in her 20s or 30s who uses the facilities for several hours a day, sometimes working out at more than one center during the day, and who loses so much weight that other club members express concern. Some will lose so much body fat that the workouts will burn muscle, “which gives off a distinct, foul odor.” The exercise-addicted person will work out not for enjoyment but rather because she feels obligated to do so—with nothing stopping the workout, not illness nor injury. According to observers, female gymnasts, cross-country runners and swimmers are most likely to succumb to this behavior; about 5 percent of young male athletes, usually wrestlers or cross-country runners, develop it. While acknowledging that anorexia athletica is not a recognized diagnosis, the National Eating Disorder Information Centre (Canada) lists the following symptoms: • Exercising beyond the requirements for good health

anorexia nervosa 23 • Being fanatical about weight and diet • Stealing time from work, school, and relationships to exercise • Focusing on challenge and forgetting that physical activity can be fun • Defining self-worth in terms of performance • Rarely or never being satisfied with athletic achievements • Always pushing on to the next challenge • Justifying excessive behavior by defining self as an athlete or insisting that their behavior is healthy Researchers have suggested that further study is needed to delineate and define the unique characteristics of those with purported subclinical eating disorders such as anorexia athletica, as well as which criteria need to be met if it is to be designated a separate disorder. Goodman, Brenda. “Stop That Treadmill: Is Compulsive Exercising on the Rise?” Psychology Today 37, no. 3 (May/June 2004): 15. Sudi, K., et al. “Anorexia Athletica.” Nutrition 20, no. 7–8 (July–August 2004): 657–661.

anorexia mirabilis

The term used by physicians during the High Middle Ages to describe “miraculously inspired” loss of appetite. This was a fairly common occurrence in medieval Europe, especially between 1200 and 1500. It was considered miraculous when women survived prolonged periods of fasting; many insisted they were actually unable to eat normal “earthly fare.” Fasting was critical to female sainthood during this time, given medieval culture’s association of the female body and food. Catherine of Siena (1347–80) restricted her diet to a daily handful of herbs; whenever she did partake of other food, she would cause herself to vomit by forcing a stick down her throat. Other female saints became ill or felt their throats close up around food, fasted for days at a time, ate only orange seeds, and even died of starvation. Anorexia mirabilis, unlike anorexia nervosa, was not restricted to adolescent or young adult women. And today’s anorexic strives for the modern ideal of physical perfection

or beauty rather than the medieval ideal of spiritual perfection or beauty. As the Protestant Reformation revolutionized medieval culture, prolonged fasting became a negative practice; it was considered a work of the devil rather than of God. Where fasting females were once venerated as saints, they were now denounced as evil, possessed by the devil or insane. Brumberg, Joan Jacobs. Fasting Girls. Cambridge, Mass.: Harvard University Press, 1988.

anorexia nervosa A serious psychological disorder characterized by intense fear of gaining weight. Anorexics refuse to maintain even a minimal body weight and are pathologically preoccupied with food and dieting. Anorexia literally means “lack of appetite” and thus is actually a misnomer, but it is the generally accepted name for the condition. Anorexics do experience hunger, but they simply refuse to give in to it for fear of becoming fat. Anorexia nervosa affects chiefly young women in their teens and twenties. Anorexia nervosa has always been overwhelmingly a disorder of upper-class adolescents (the usual age range is from 12 to 25), but studies by Garfinkel and Garner show it to be increasing in older women and in other social classes. Ninety to 95 percent of anorexics are female; in 85 percent of patients, onset occurs between the ages of 13 and 20. It is estimated that in the United States, one of every 200 females in late adolescence and early adulthood is starving herself (source: Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision, Washington, D.C.: American Psychiatric Association). The Anorexia Nervosa and Related Eating Disorders (ANRED) organization estimates that approximately one in every 100 females between the ages of 10 and 20 suffers from anorexia. For girls over 16 in private schools or in universities, the figure may be as high as one in 10. No reliable statistics exist for younger children or older adults, but cases in these age groups do occur. Until recently, anorexia was rare among African Americans, the cause explained by experts as less concern among this population with dieting and being thin. They correlate the recent increase in anorexia in black women to their assimilation of the ideals of middle- and upper-class Western culture.

24 anorexia nervosa In their review of the literature, Hoek and Hoeken found an average prevalence rate for young females of 0.3 percent and an incidence of eight cases per 100,000 population per year. Polivy and Herman noted that “Precise estimates of incidence and prevalence vary wildly, perhaps because those who suffer from these disorders are often reluctant to reveal their condition. Prevalence estimates tend to range from about 3 percent to 10 percent of at-risk females (those between 15 and 29 years of age).” Of those patients being treated for anorexia, as many as 20 of every 100 will actually die. Of the remainder only half will recover to lead normal lives; the rest are likely to relapse. Arthur H. Crisp has reported patients relapsing after being in remission for 50 years. (See ELDERLY, EATING DISORDERS IN THE.) Morbidity and mortality rates in anorexia nervosa are among the highest recorded for psychiatric disorders. According to the American Psychiatric Association Work Group on Eating Disorders (2000), the mortality rate at five years is 5 percent, increasing to 20 percent at 20-year follow-up, giving anorexia nervosa the highest mortality rate of any psychiatric disorder. Authors, researchers and journals have referred to the “dramatic increase in diagnosed cases of anorexia nervosa in the last 20 years,” but actual numbers have been difficult to come by. This is due partly to a lack of a system for collecting and interpreting data and partly to a lack of standardization in diagnostic criteria. However, there is evidence that such an increase has occurred. Two measurements used have been hospital admissions and case reportings around the country. The University of Wisconsin Hospital, for example, showed an average of fewer than one anorexic patient admission per year prior to the 1960s; in 1982, it admitted more than 70. In Monroe County, New York, the number of reported anorexia nervosa cases doubled between 1960 and 1976. A number of reasons have been given for this apparent surge in diagnosed cases of anorexia nervosa: (1) Both the professional and popular press have published numerous articles and reports on the disorder. This has resulted in both the medical profession and the general population becoming more familiar with the disorder, thereby exposing

more cases. (2) There has been a history of inadequate recordkeeping in anorexia cases and lack of agreement criteria for diagnosis. This leaves some question as to the actual incidence of the disorder in years past. (3) Because anorexics do not admit to their illness or even complain about it, there is a belief that many cases prior to the recent increase in press coverage were never brought to the attention of doctors. (4) Some psychologists estimate that as many as 30 percent of today’s cases are “copycat” anorexics, responding to a peer group phenomenon rather than suffering true anorexia nervosa. Although estimates of the incidence of anorexia nervosa in western Europe and the United States have suggested a great increase since 1950 and perhaps even since 1930, a study conducted by the Mayo Clinic showed no significant trend in rates over time. The study was population based and spanned the years from 1935 through 1984; it consisted of a survey of the medical records of residents of Rochester, Minnesota. The incidence rates for females were high during 1935–49, relatively low during 1950–54 and high again during 1980–84. The difference in rates over time, although not statistically significant, was accounted for by changing rates for 10- to 19-yearold girls. For women 20 years of age and older and for females there was no change in the rates over time. The lifetime prevalence rate for anorexia nervosa among Rochester residents was 269.9 per 100,000 population for females and 22.5 per 100,000 population for males. Polivy and Herman, writing in 2001, noted that the incidence of anorexia nervosa has “increased markedly during the past 50 years.” Hoek and Hoeken concluded that “the incidence of anorexia nervosa increased over the past century, until the 1970s,” and that “only a minority of people who meet stringent diagnostic criteria for eating disorders are seen in mental health care.” The person with anorexia nervosa typically begins dieting with a simple goal of losing weight, but over time the achievement of that goal becomes a manifestation of mastery, control and virtue. The anorexic may find dieting easy and rewarding from the start, or at least discover that in a sense she is good at it. Typically, she ends up by

anorexia nervosa 25 continuing to diet despite having gone past her target weight. The desire for slenderness becomes secondary to the need for control and mastery over the body and develops into a real fear of fatness and a drive to remain small and childlike. Because anorexia nervosa patients do not see themselves as abnormal, they do not want any help in reversing their weight loss. When told they cannot live on such a small amount of food, they will insist that they feel better as they become thinner. Because they do not suffer, they must be well. This denial of illness is an important feature early in the disorder. The clinical picture of anorexia nervosa centers on a three-fold denial—denial of hunger, of thinness and of fatigue. Even if they admit to some weight loss, anorexics will feel that while they may have lost weight generally, some particular part of their body is still too large. When family pressures or social obligations force anorexics to eat, most will use deception to hide their extreme dieting. They’ll slip food to the dog, flush it down the toilet or throw it into the garbage. Teenagers will tell parents, “I’m not hungry; I ate at a friend’s house.” Many will induce vomiting after meals. When undergoing treatment, anorexics will resort to all kinds of deceptions to lead doctors to believe they are gaining weight. Among those that have been documented are drinking enormous amounts of water before being weighed, recalibrating scales and inserting weights in the rectum and vagina. Anorexia nervosa has been said to develop only in the face of plenty, that it exists only where food is abundant. However, today’s researchers are beginning to discover that the stereotype is inaccurate and that it may have come about because such a large proportion of the studies done were of college students and patients who could afford treatment. In a 1989 survey of more than 2,000 adolescent girls and their mothers, University of Michigan psychologist Adam Drewnowski discovered that the frequency of eating disorders was the same in lower-income communities near Detroit as it was in the city’s wealthy suburbs—about 2 percent. Gordon, Richard A. Anorexia and Bulimia: Anatomy of a Social Epidemic. Malden, Mass.: Blackwell Publishers, 1990.

Herzog, David B., and Paul M. Copeland. “Medical Progress: Eating Disorders.” New England Journal of Medicine 313, no. 5 (August 1, 1985): 295–303. Herzog, W., H.-C. Deter, and W. Vandereycken, eds. The Course of Eating Disorders: Long-term Studies of Anorexia and Bulimia Nervosa. New York: Springer-Verlag. Hoek, H. W., and D. van Hoeken. “Review of the Prevalence and Incidence of Eating Disorders.” International Journal of Eating Disorders 34, no. 4 (December 2003): 383–396. Knapp, Caroline. “Anorexia: My Story.” New Woman (March 1990). Lucas, A. R., et al. “50-Year Trends in the Incidence of Anorexia Nervosa in Rochester, Minn.” American Journal of Psychiatry 148, no. 7 (July 1991): 917–922. Orbach, Susie. Hunger Strike: The Anorectic’s Struggle as a Metaphor for Our Age. New York: W. W. Norton, 1986. Polivy, Janet, and C. Peter Herman. “Causes of Eating Disorders.” Annual Review of Psychology 53 (January 2002): 187–213. Sullivan, P. F. “Mortality in Anorexia Nervosa.” American Journal of Psychiatry 152, no. 7 (July 1995): 1,073–1,074.

Causes There is no known specific cause of anorexia. Several theories do exist, but they are based on individual clinical observations and histories, so none has been accepted as definitive. Researchers do agree that anorexia nervosa is probably a negative response to a number of psychological, environmental and physiological factors rather than a disease that can be traced to a single cause. Although these influencing factors affect virtually all individuals, the anorexic appears to lack the skills necessary to cope with them. Neuman and Halvorson have identified several potential causes of anorexia nervosa: Stressful life situations These may range from major developments such as family conflict, a change in schools (especially transitions from junior high to high school or from high school to college), a family move, the loss of a boyfriend or girlfriend or a serious illness, to less obvious difficulties such as a casual remark made by an athletic coach or dance instructor about “dropping a few pounds,” teasing by classmates or siblings or a rejection, which may be real or perceived. Many stressful situations are caused by or lead to change, and change in general is difficult for an anorexic to

26 anorexia nervosa handle. One possible explanation for this is the anorexic’s obsession with perfection and the fear that she may not be able to achieve her goal in new circumstances. Change may well trigger overwhelming fear that things are out of control. Adolescence One hypothesis is that anorexia nervosa is a rejection of female sexuality brought on by the physical development associated with puberty. Neuman and Halvorson explain this as “an attempt to retain ‘little girl’ status by warding off the adolescent’s physical development.” HILDE BRUCH described in Eating Disorders several of her patients who had had active fantasies as children about being boys—until puberty put a shocking end to them. Other professionals argue that it is the entire role of an adult that is being rejected: the responsibilities, decision making, sexual intimacy and so on. To support this, they point out that anorexics avoid intimacy, largely because of their fear of rejection over “mistakes” they might make. Even sexually active anorexics have been described by therapists as withholding feelings and thoughts from partners. It has been suggested that anorexics’ sexual activity happens at all only because of their inability to be assertive in that arena—to say no. Culture Another reason some feel anorexia is a rejection of the adult female role is that the adolescent of recent years has no clear-cut road to follow into adulthood. Neuman and Halvorson explain that the anorexic adolescent typically has mastered the role of being a “good little girl.” But the criteria for being a “good woman” are no longer well defined; in fact, the social messages, these therapists feel, are confusing to the anorexic. No longer do the wedding and first pregnancy define “growing up.” Today’s adolescent is also encouraged to “be something” or “somebody,” at the same time that biological changes may be reminding her of more traditional roles. And because anorexics are usually good students, they are frequently steered into academic and career paths rather than down a more traditional female road. So, being unassertive and evading decisions, they may retreat into the familiar “child” role where they already mastered the well-defined “rules.” Anorexia nervosa was once believed to be a disorder of Western culture, a belief recently recon-

sidered by researchers. A 1996 Chinese University of Hong Kong study determined that Western patterns of body dissatisfaction and disordered eating attitudes are common among Chinese adolescent females. One theory is these attitudes are now grounded in the “transnational culture of modernity” due to increased affluence in rapidly urbanizing parts of the world. In most Western societies, a strong cultural emphasis is placed on individual success. Neuman and Halvorson explain that until recently Western women’s social success was judged by their affiliations—by whose daughter or wife they were. Today’s woman has new demands. “Thus many maturing females find themselves caught up in the ‘Superwoman’ syndrome, trying to be all things to all people.” And, they add, girls who are already perfectionists and not good at making decisions can become overwhelmed by feelings of powerlessness. College-age anorexics especially have reported to Neuman and Halvorson these feelings of confusion and being out of control of their own future. Other cultural factors influencing the recent rise of anorexia nervosa include the growing concern about nutrition and physical fitness and a national obsession with calorie counting and being thin. Television, magazine and newspaper messages bombard women and girls with advice on how to lose weight more quickly, exercise more and eat less in order to be thinner. The messages blatantly state that being thin will make a woman more attractive, improve her popularity, lead to success on the job and snag her an ideal mate because she will then be sexier and more desirable. Fashion models display small waists and busts, narrow hips and thin thighs. This has resulted in a cultural focus on the physical being more than on the inner person. Small wonder, experts say, that some girls in the highly vulnerable adolescent and young adult years take these “thin-or-sorry” messages to heart and carry their responses to them to extremes. Discussing the remarkable emergence of eating disorders in countries where they were once thought to be culturally incompatible, Gordon writes, “One theme that seems to unite these disparate geographic and cultural regions is that they are either highly developed economies (such as Hong Kong and Singapore) or they are witnessing rapid market changes

anorexia nervosa 27 and their associated impact on the status of women. The impact of a global consumer culture, with powerful mandates for the cultivation of a certain type of body ideal, appears to play a significant role. Equally important, however, are the contradictory pressures that emerge when women begin to have access on a mass level to education and a role in public life, and struggles about sexual equality come to the foreground. This may be especially problematic in societies in which the transition to a new female role is especially sudden and conflicts sharply with traditional forces that demand deference to one’s family and submissiveness to men.” See CULTURAL INFLUENCES ON APPEARANCE and CULTURAL INFLUENCES ON EATING DISORDERS. Gordon, Richard A. “Eating Disorders and West: A Culture-Bound Syndrome Unbound.” In Eating Disorders and Cultures in Transition, edited by Mervat Nasser and Melanie A. Katzman, chapter 1, pages 1–16. New York: Brunner-Routledge, 2001. Keel, P. K., and K. L. Klump. “Are Eating Disorders Culture-Bound Syndromes? Implications for Conceptualizing Their Etiology.” Psychological Bulletin 129, no. 5 (September 2003): 747–769. Lee, A. M., and S. Lee. “Disordered Eating and Its Psychosocial Correlates among Chinese Adolescent Females in Hong Kong.” International Journal of Eating Disorders 20, no. 2 (September 1996): 177–183. Lee, S. “Reconsidering the Status of Anorexia Nervosa as a Western Culture-Bound Syndrome.” Social Science and Medicine 42, no. 1 (January 1996): 21–34. Lee, S., et al. “Rationales for Food Refusal in Chinese Patients with Anorexia Nervosa.” International Journal of Eating Disorders, 29, no. 2 (March 2001): 224–229. Simpson, K. J. “Anorexia Nervosa and Culture.” Journal of Psychiatric & Mental Health Nursing. 9, no. 1 (February 2002): 65–71.

Biological predisposition While research has shown that women are far more likely than men either to eat more or to lose appetite in response to stress, Neuman and Halvorson suggest that appetite fluctuation in women may also be a learned response. Women have also been found to be more prone to “holding in” negative feelings, which can lead to increased stress. It has been suggested that this stress, in the presence of a biological predisposition to eat more or less because of it, may lead to a greater likelihood of anorexia nervosa.

Family dynamics It has been noted that there is a greater risk of a person’s developing anorexia nervosa when another member of the family has had the disorder or when a parent is either very thin or obese. What has not been established is whether this risk is genetic. Studies reported in 1998 from Toronto (Ontario) Hospital, in Canada, and the University of Pittsburgh School of Medicine concluded that genetic factors may influence predisposition to eating disorders but do not prove such a familial vulnerability exists. Because a few sets of identical twins have been found in which both twins succumbed to anorexia, and because several cases are known of adopted family members matching the patterns of their biological families’ histories, this family tendency is believed to be more environmental than inherited. However, research in this area has been sparse; much more needs to be learned. Anorexics do tend to come from families placing strong emphasis on food. Neuman and Halvorson explain that “this concern may be the result of the special dietary needs of a family member, an emphasis on nutrition, and/or previous power struggles over eating. The family may also have used food for purposes other than nourishment. Eating may be used when members face problems or unpleasantness, as a sign of love and caring for the providers, to fill time, or to keep the family together and ‘happy.’ ” Clinicians have found that certain personality types seem to appear frequently among parents of anorexics. Mothers are often found to be domineering, intruding in the anorexic’s hour-to-hour life. Mothers of anorexics also frequently suffer from depression, and fathers are described as “aloof or passive.” Alcoholism and other addictions, of one or both parents, are not uncommon. However, none of these patterns is always present; some cases even show the exact opposite family dynamics. But there are medical experts who still insist that family dynamics play an important role in generating the disorder. They cite those family features most likely to encourage anorexia as enmeshment (entanglement in one another’s affairs), rigidity, overprotectiveness and inability to resolve conflict within the family. Margo Maine, assistant clinical director of the Eating Disorders

28 anorexia nervosa Service at Newington Children’s Hospital in Connecticut, suggests that a father’s emotional or physical absence from the family may be a major influence on both anorexia nervosa and bulimia in adolescent girls. Thirty-six of 39 young female patients questioned by Maine described their fathers as emotionally distant. See also FAMILY THERAPY. Lilenfeld, L. R., et al. “A Controlled Family Study of Anorexia and Bulimia Nervosa.” Archives of General Psychiatry 55, no. 7 (July 1998): 603–610. Woodside, D. B., et al. “Specificity of Eating Disorders Diagnoses in Families of Probands with Anorexia Nervosa and Bulimia.” Comprehensive Psychiatry 39, no. 5 (September–October 1998): 261–264.

Peer Relationships The tendency of anorexics not to develop or keep close longterm friendships outside the family group has been theorized to be an important factor in the development of the disorder. Neuman and Halvorson note that when relationships are developed by anorexics, they are usually with only one person at a time, and even then they are short-lived. Arthur H. Crisp noted that male anorexics have been found to be inhibited, nonassertive loners—even during their teen years when a group or “gang” affiliation is usual. Therapists such as Neuman and Halvorson believe that during adolescence peer relationships are essential for the move from a family-centered existence to an adult existence in a social environment. According to Delores Jones, “the anorexic who is overly involved with and dependent upon her family to the exclusion of outside relationships is at a distinct disadvantage. Because she has no peer group to help her make the transition, she is effectively imprisoned within the family.” However, her increasingly adult size as she matures elicits social pressure on her for more independent behavior. Jones speculated that the anorexic resolves this conflict by losing weight so that in terms of size and biological functioning, she becomes a child again and can legitimately remain within the family. In their summation of the various proposed causes for anorexia nervosa, Polivy and Herman say, “As with other psychological problems, we may have to be satisfied with recognizing contributory

risk factors and devising therapies to help alleviate the discomfort, without conclusive proof of exactly what causes the disorder in any individual.” Byrne, Katherine. A Parent’s Guide to Anorexia and Bulimia: Understanding and Helping Selfstarvers and Binge/Purgers. New York: Schocken Books, 1987. Jones, Delores. “Structural Discontinuity and the Development of Anorexia Nervosa.” Sociological Focus 14, no. 3 (August 1981). Lee, Sing, Helen F. K. Chiu, and Charnie Chen. “Anorexia Nervosa in Hong Kong: Why Not More in Chinese?” British Journal of Psychiatry 154 (May 1989): 683–688. Neuman, Patricia A., and Patricia A. Halvorson. Anorexia Nervosa and Bulimia: A Handbook for Counselors and Therapists. New York: Van Nostrand Reinhold, 1983. Polivy, Janet, and C. Peter Herman. “Causes of Eating Disorders.” Annual Review of Psychology 53 (January 2002): 187–213.

Clinical Features The central feature of anorexia nervosa is the overriding pursuit of thinness. This may seem to begin innocently with ordinary adolescent self-consciousness—dieting to lose extra pounds put on during puberty’s growth spurts. But after several months, the restrictor anorexic will stubbornly refuse to eat normal amounts of food. Typically she limits her intake to about 600–800 calories per day, resulting in a loss of 25 percent or more of body weight. In extreme cases, the loss may be as high as 50 percent. When questioned about her loss of weight, an anorexic will deny that she is too thin or that there is anything wrong with her. This denial can be an obstacle for doctors during diagnosis and assessment. Because they don’t perceive themselves as ill or abnormal, anorexics refuse help. Denial is a typical characteristic of anorexia nervosa and is seen as an early sign of the disorder. One of the fundamental characteristics of anorexia nervosa is a disturbance in body image, “feeling fat” even when emaciated. During treatment, the anorexic claims that her body is larger than it really is. She seems genuinely unaware of her changed body proportions. Even though her body may appear starved, she may stubbornly insist she is not as thin as another anorexic who is as thin or thinner than she; yet she will recognize

anorexia nervosa 29 the other anorexic as too thin. A few will admit to their emaciated state and even recognize the health dangers, but they will still refuse to eat. Many anorexics argue that their thin bodies are still too fat. Others consider their stick-figure legs and arms to be attractive and “just right.” Overestimation of body size may indicate greater severity of disorder with less hope of recovery. In studies, patients who most grossly overestimated were also those who were the most malnourished, were previous treatment failures, indicated a greater loss of appetite, had a greater tendency to deny their illness, vomited, were more depressed and in general exhibited more symptoms of anorexia nervosa as measured by the EATING ATTITUDES TEST. In addition to the misperception of body size, the anorexic’s body image disturbance can involve her attitude toward her body. Frequently she manifests self-loathing, particularly of her developing female body parts, such as the normal slight curve of stomach or rounding of hips or buttocks. HUNGER is usually denied, even in the presence of stomach pains. When she does eat a small bit of food, an anorexic will complain about ensuing acute discomfort. In contrast to starving nonanorexics, who generally attempt to conserve energy by reducing activity and who usually show symptoms of listlessness and indifference, anorexics are often hyperactive, tending to indulge in heavy or prolonged exercise. Instead of being exhausted while starving, these young women enjoy boundless energy until late in their illness. The anorexic begins exercising in order to burn up calories and lose additional weight. As with dieting, however, exercising over time becomes an issue of self-discipline and control; anorexics cannot allow themselves to miss even one day of the highly structured regimen they have assigned themselves. If an anorexic was already involved in a sport, she will likely become driven, almost obsessed to excel at it. Anorexics may appear to be in perpetual motion; constantly busy, moving about restlessly until late into the night, almost never sitting down. Studies have shown that anorexics walk an average of 6.8 miles a day compared with the average of 4.0 miles walked by women of normal

weight. This hyperactivity is not generally present before the onset of anorexic illness. Just as the anorexic denies hunger, she will deny any difficulty in sitting still and attending to her work. Often compulsive behavior is exhibited in excessive orderliness, cleaning and studying. As Neuman and Halvorson explain, “Anything less than perfection is upsetting to the anorexic, and everything undertaken seems to be done in excess.” A few years ago anorexia was generally interpreted as reflecting a wish not to grow up, to return to a prepubertal stage; therapists now say that many anorexics appear anxious to exercise authority and to control their lives through regulation of body weight. Anorexics have been described as suffering from a “weight phobia.” Regardless of the original reason for dieting, subsequent weight gain by the anorexic causes severe anxiety and weight loss reduces it. This “phobia” about “normal” body weight appears to intensify as the patient becomes thinner. She weighs herself frequently, becoming anxious if the scales show an increase over the previous reading. In her mind, each drop in weight becomes a new barometer; next time she must weigh less to be normal. Anorexics seem to have a greater fear of becoming obese than of dying from starvation. As the anorexic’s weight drops, her fear becomes more entrenched: the thinner she gets, the fatter she thinks she is. In addition to a phobic attitude toward weight, the anorexic develops another phobia toward food. At first, she fears only high-carbohydrate foods and so deletes them from her diet. Soon she systematically eliminates fats and other foods until only a few vegetables and fruits remain. She also controls food portions rigidly; she must restrict intake to a specific number of pieces or bites a day. If she does exceed her allotted daily portion, the anorexic suffers severe anxiety and sets about to control her eating even more severely. Some researchers maintain that the core psychopathology of anorexia nervosa is cognitive. That is, such individuals have extremely distorted ways of thinking and distorted and irrational beliefs about food, themselves and the world. They may have completely irrational ideas regarding the caloric content of foods. One of the authors

30 anorexia nervosa encountered a woman who was worried about gaining weight from licking a stamp. Such individuals may also have very all-or-nothing beliefs about eating, for example believing that eating one piece of candy is as bad as eating the whole box. Regarding beliefs about the self, the anorexia individual may equate self-worth with physical appearance. To put on weight means to be worthless. Similarly, the anorexic individual may have attitudes about the world and others, such as believing that others evaluate them only in terms of body size and shape. It is worth noting that, although this latter belief is distorted, it is merely an exaggeration of some of the attitudes that are shaped by the popular media. Anorexic patients often become experts in devious behavior. They will conceal their eating habits by lying about what, when and where they eat. Usually they do not like to eat in front of others and come up with excuses to avoid eating with the family, partly to avoid the food itself and partly to avoid confrontations about their eating habits and their appearance. Because of family pressure to eat, they may take food onto their plate, surreptitiously slipping it to the dog under the table or hiding it in their napkins to flush down the toilet or throw away later. Many pathological behaviors occur in secret: hiding food, self-induced vomiting, laxative and/or diuretic abuse and excessive exercising. Constipation and abdominal distress typically result from restricted food intake and the starvation state. These in turn lead to further symptoms of bloating and reduced dietary intake. Long-term laxative abuse can produce permanent damage to the colon resulting in malabsorption and loss of ability to evacuate naturally. Also accompanying anorexia nervosa is delayed psychosexual development. According to Neuman and Halvorson, “Boyfriends may be desired but usually only in a fairytale sense—to live ‘happily ever after.’ ” Anorexics exhibit virtually no sexual interest, with low estrogens in female anorexics and low output of testosterone in males. During therapy, anorexics cannot even talk about sex, “not out of embarrassment, but because it is so foreign: anorexics are totally out of touch with the sexual part of their being.” (See SEXUALITY AND EATING DISORDERS.)

Anorexics also gradually narrow their interests. Many entirely restrict their activities to exercise, schoolwork and dieting, and all other activities fall by the wayside. Most girls lose interest in their friends early in their dieting; this loss is considered a most important early signal of the problem. By the time the weight loss has progressed to the point of requiring medical attention, an anorexic may be totally isolated from others. This isolation results in loneliness and a sense of social inadequacy. Other warning signals include dizziness and fainting spells, nervousness around mealtime, excuses during mealtime for not eating, cutting food into small pieces or playing with it, an increased interest in collecting recipes and cooking for others, weighing frequently and wearing multiple layers of clothing (anorexics are frequently cold as a result of the loss of fat and muscle tissue). In some cases obsessive interest in food will result in an anorexic’s insisting on cooking for, and overfeeding, her immediate family. Anorexics have been reported to hoard and conceal food, including food that is rotten or moldy, while refusing fresh food. Another established feature of anorexia is AMENORRHEA (absence or suppression of menstruation). In a high percentage of cases; this is the first sign of the disorder, appearing before any noticeable loss of weight. Ultimately, it occurs in nearly all cases as weight plummets. Anorexics have frequent mood swings; when they are most hungry and their blood sugar levels the lowest, they may become quite irritable. They also will sometimes demonstrate an inability to concentrate, and this may be coupled with confused thinking. Initially they will deny all problems, including mood changes; anorexics display a stubborn defiance about most matters, along with a noticeable lack of concern for personal problems. They tend to be highly perfectionistic, particularly about physical appearance, as well as highly self-critical. They tend to be overachievers. They will frequently seem angry, irritable, indecisive, stubborn, tense or overly sensitive. Depression or obsession is common when the disorder becomes chronic. When asked to describe their anorexic daughters as children, parents refer to most of them as

anorexia nervosa 31 “model children,” using terms like introverted, conscientious and well behaved. They are usually nonassertive, reacting passively to others. But although an anorexic may appear outwardly smiling and happy and is usually a highly competent people pleaser, she may actually be miserable. Neuman and Halvorson stress that while a passive personality has been found to be consistently among the most common of anorexics’ traits, it is not always present. Anorexics can display irritability, indecisiveness, stubbornness and defiance. Neuman, Patricia A., and Patricia A. Halvorson. Anorexia Nervosa and Bulimia: A Handbook for Counselors and Therapists. New York: Van Nostrand Reinhold, 1983.

Complications Most of the medical complications of anorexia are those caused by starvation. The body defends its vital organs, the heart and brain, against a lack of nutrients by slowing down: menstrual periods stop; breathing, pulse and blood pressure rates drop; and thyroid function slows. Particularly critical are the fluid and electrolyte (sodium, potassium, hydrogen, etc.) imbalances that commonly occur, especially among anorexics who induce vomiting or use laxatives extensively. Potassium deficiency can lead to muscle weakness, abdominal bloating, nervous irritability, apathy, fatigue, drowsiness, dizziness, mental confusion and irregular heartbeat. Death from kidney or heart failure may occur. Such electrolyte imbalances are not always outwardly apparent; the person suffering from them may appear to be in relatively good health. Studies have also raised questions about the possibility of ZINC DEFICIENCY in anorexia nervosa. In 1987, Rebecca Katz et al. reported in the Journal of Adolescent Health Care that their evaluation of anorexic adolescents suggested that individuals with anorexia nervosa may be at risk for zinc deficiency, which can impair taste, appetite and physical growth, cause hair loss and delay sexual development. But C. J. M. van Binsbergen et al. reported in the European Journal of Clinical Nutrition in 1988 that no significant difference was found in the concentration of zinc in plasma between 20 female anorexics and 20 lean to normal-weight female control subjects.

Mild anemia, swelling joints (from edema), reduced muscle mass, dizziness and light-headedness are also results of anorexia. If the disorder becomes severe, osteoporosis, kidney failure, irregular heart rhythm and heart failure can occur. The anorexic who turns to purging to limit weight is in particular danger; the abuse of drugs to stimulate vomiting (see IPECAC SYRUP), bowel movements and urination increases the risk of heart failure. In addition, there is a possibility of temporary or even permanent edema (accumulation of fluid in the body’s cells, tissues or cavities) once the use of diuretics as an aid to weight reduction is stopped. Osteoporosis (a loss of bone mass accompanied by mineralization of the remaining bone) is another consequence of anorexia nervosa. A study of anorexics by Anne Klibanski and other Massachusetts General Hospital researchers involving seven adolescent girls and 26 women found that adults with anorexia nervosa had bone density that was 30 percent lower than normal. Those whose menstruation stopped before age 18 had even weaker bones—20 percent weaker than the bones of the older anorexia victims. A report in the journal Clinical Endocrinology states that in 24 anorexic patients who were severely malnourished, the ovaries were small and shapeless, and some hormone levels were very low. In addition to an emaciated appearance, an anorexic usually has dry, cracking skin and may lose some hair from her scalp. Her nails become brittle. A fine downy growth of fetal-like hair (lanugo) over the cheeks, neck, forearms and thighs is common. Yet she will keep her pubic and underarm hair as well as the shape of her breasts, thus ruling out glandular insufficiency as the root cause of her symptoms. The anorexic’s hands and feet usually have a bluish tinge, which may also appear on her nose and ears. Other likely results of anorexia include a slow heartbeat, low blood pressure (hypotension) and a low basal metabolic rate. An anorexic may also have trouble sleeping when the loss of fat tissue padding makes sitting or lying down uncomfortable. Those anorexics who frequently and over a long period resort to vomiting as a way to control food intake can develop a variety of dental problems, including loss of enamel, decay and enlarged salivary glands. See also DENTAL CARIES.

32 anorexia nervosa Depression, weakness and obsession with food also accompany starvation. Personality changes can occur. Outbursts of hostility and anger or social withdrawal may surprise those who have become used to the typical “good girl” anorexic. Other complications can include amnesia, generalized fatigue, lowered body temperature (hypothermia), low blood sugar, low white blood cell count and lack of energy. To determine the range and severity of medical complications encountered in younger patients, a study was made of the medical records of 65 adolescents and preadolescents in the Eating Disorders Clinic of the Children’s Hospital at Stanford University. A total of 55 percent of anorexic patients required hospitalization for medical reasons during the study period. George Patton reported in the British Medical Journal (July 15, 1989) that in an assessment of 481 anorexia nervosa patients, half of those who died killed themselves, either accidentally or intentionally through drug overdoses. This challenges the earlier view that death in anorexia nervosa is always a direct consequence of malnutrition. There have been no clear, consistent predictors of worsening conditions without eventual improvement in anorexia nervosa cases, but factors most often found in these cases include extremely low weight, long periods with the illness, older age at onset, and disturbed family relationship. Treatment Various treatments have been suggested for anorexia nervosa, including psychoanalysis, PSYCHOTHERAPY, simple supportive therapy, isolation, ACUPUNCTURE, lobotomy, FAMILY THERAPY, BEHAVIOR MODIFICATION, COGNITIVE THERAPY, TUBE FEEDING, FORCED FEEDING, bed rest HYPERALIMENTATION, PHARMACOTHERAPY, electroshock, psychosurgery and SELF-HELP GROUPS. Because anorexics and their families tend to deny the presence of the disorder or its severity, the results of treatment of anorexia have been among the most unsatisfactory in clinical medicine. Even patients in treatment tend to resist prescribed medical and psychiatric care; because they don’t consider themselves to be ill or because they don’t want their efforts to lose weight thwarted, they make those trying to help them “the enemy.”

Virtually every type of therapy known to psychiatry has been proposed and tried at some time in the treatment of anorexics, but no one has been found distinctly effective or definitive. Part of the reason for this is the lack of agreement about the relationship between food and its “host.” We know very little of the chemical processing of food by the body and how dieting and purging may affect the appetite center of the brain. To make matters worse, there is body image distortion and an interoceptive (internal sensory receptor) problem. (See INTEROCEPTIVE DISTURBANCE.) In addition, the treatment needs of different patients can vary widely; considerable flexibility is necessary. Because anorexia nervosa patients differ widely in psychological, social, behavioral and biological functioning, treatment centers most frequently offer integrated and multifaceted programs. Both the physical and psychological aspects of the disorder have to be addressed: The physical aspects take precedence when the weight is low and the starvation strategy is most dominant, and the psychological aspects take precedence later, after weight concerns have been addressed and eating habits have been stabilized. Ideally, internists, nutritionists, individual or group therapists, psychopharmacologists, psychiatrists and family therapists may all be involved in treatment. Weight gain must occur if psychological treatment is to be meaningful. Researchers Garfinkel and Garner explain that there are two reasons for this. First, the effects of starvation must be reduced for the patient truly to benefit from psychotherapy, a learning process that cannot proceed well when a patient’s mental functioning is impaired. Second, patients have developed a phobic attitude toward weight and must learn to face it as a precondition for dealing with underlying psychological issues. “As long as a low weight is maintained through rigid dieting, the phobia is being reinforced, as is the avoidance of dealing realistically with significant life problems.” The concept of weight phobia has been questioned by experts such as Arthur H. Crisp, who argues that what a patient dreads is facing herself at a normal weight. He believes that what is being reinforced when weight is kept very low is the “advantage” of being prepubertally thin so this

anorexia nervosa 33 dread doesn’t become an actuality. Other researchers have concluded that modern Western anorexia nervosa with weight phobia is clearly distinct from other groups of cases of extreme fasting without weight phobia. The most difficult and critical factor in treatment is engaging the patient in therapy. The problem here is that many anorexics deny their illness; they insist there is nothing wrong with them if only others would leave them alone. They mistrust themselves and especially mistrust medical people they think are interested only in getting them to gain weight, or who represent parental authority. Anorexics feel that treatment represents a betrayal of their trust, fearing a return to being what they consider overweight. Although controversy has surrounded almost every means of weight restoration, the issue of hospitalization has been far less controversial. Historically, hospital admission has been advocated both to allow the physician to control the situation, and to separate the patient from her parents. Hospitalization should be considered if there are numerous physical complications, if the patient is suicidal or extremely unmotivated, and/or if there is no outpatient treatment available. When weight loss is 40 percent or more from the norm, emergency action is required. The urgency of hospitalization depends on several factors, including weight loss greater than 30 percent of body weight over three months, severe metabolic disturbance, severe depression or suicide risk, severe purging, psychosis, family crisis or symptoms of severe starvation. Hospitalization is also suggested when outpatient treatment has failed. Frequently, even when emergency care is not necessary, several days of unstructured hospital rest are ordered to give physicians and psychiatrists a chance to observe the patient. The treatment team can thus learn whether she is a starver or a vomiter, whether she hoards food or secretly throws it away, whether she drinks water or not before weigh-in. They also observe how much walking and exercising she does, and whether hospitalization has resulted in her becoming agitated and manipulative or passive and withdrawn. Length of hospitalization usually varies between two and four months. Brief hospitalization of 10

days to two weeks can be helpful for anorexics who are not severely malnourished but who suffer from laxative withdrawal (e.g., dependence on the laxative drug in place of normal bowel action) or uncontrollable binge eating and vomiting. Application of EXPOSURE AND RESPONSE PREVENTION treatment principles to anorexia nervosa requires a patient to face the twin fears of eating and gaining weight. Reports have shown that psychological improvement does occur with weight gain; to realize it, several approaches to treatment may be effective, including forced feedings and structured diets. Response prevention can be used to treat anorexic “rituals” such as vomiting after meals, food fads, use of laxatives, compulsive exercising and frequent weighing. Response prevention entails forced avoidance of these rituals; for example, the patient might agree to delay vomiting for an increasing amount of time after meals in order eventually to stop vomiting altogether. In general, it is felt that patients must retain as much control as possible as long as the desired result is achieved. Patients discharged from the hospital while the medical staff is still in control via structured enforced diets or tube feeding usually relapse. Those patients better motivated to change will sometimes benefit from outpatient treatment. Education about the effects of starvation and application of the principles of exposure and response prevention, coupled with simple support, sometimes will produce weight gain. Individual psychotherapy is the approach most commonly prescribed for outpatient treatment, especially when the patient has stable relationships and adequate self-esteem. Also beneficial can be the use of behavioral techniques that the patient can apply herself: keeping records of food intake, using structured meal plans and practicing “non-anorexic” eating. In cases in which certain foods are feared, it is recommended that these be left out of the diet initially but introduced later. Eventual exposure to feared foods is important; to avoid it would be to reinforce anorexic behavior. Cognitive behavioral therapy is designed to help the patient gain control of unhealthy eating behaviors and to alter the distorted and rigid thinking that perpetuates the syndrome.

34 anorexia nervosa The goals of individual therapy are to help the patient regain physical health, reduce symptoms, increase self-esteem and proceed with personal and social development. Long-term individual therapy may be indicated when the patient has a mild personality disorder, such as irritability, anxiety, depression, mood swings or sleep disturbance. Group therapy can be helpful to motivated anorexics, allowing them to feel less alone with their symptoms, to get feedback from their peers and to build their social skills. It has been found useful to have patients at varying stages of improvement in a group. The role modeling done by recovering anorexics, as well as the support and appropriate confrontation by an entire group, has proven to be quite powerful. Family therapy attempts to establish more appropriate eating patterns, facilitate communication and permit family members to feel more connected with one another. It may be helpful even if a patient is able to achieve only a limited degree of autonomy, because of disturbed family relationships. Anorexics often retreat into denial when experiencing anxiety in therapy and may flee treatment early on. Many drug therapies have been tried either as the major focus of treatment or as adjuncts to general support and psychological therapies. Among these have been CYPROHEPTADINE, CHLORPROMAZINE, AMITRIPTYLINE, METOCLOPRAMIDE, nalaxone, PROZAC, and Zoloft. In one trial, dietary zinc supplementation for anorexic adolescents was followed by a decrease in the levels of depression and anxiety. The primary aim of such treatment has been to promote food intake and weight restoration. Although drug treatments do have a place in the management of eating disorders, they have not yet attained a high enough degree of effectiveness to be considered as useful as they are in the treatment of such disorders as mania or depression. Reiterating that drugs are not the treatment of choice for anorexia nervosa, Brewerton noted that “although a number of agents have been found in randomized controlled trials to be beneficial, they are by and large insufficient as stand-alone treatments.” He referred to ANTIDEPRESSANTS as being theoretically sound, but cautioned, “results from randomized controlled trials have been dismal.”

This was echoed by Grilo et al. of Yale University, who wrote, “Pharmacological treatments have generally been found to have little effect on anorexia nervosa either as the primary approach or as an augmentation approach, although the antidepressant fluoxetine was found to decrease frequency of relapse in one study.” In a 10-year follow-up of 76 anorexic women in Iowa and Minnesota who had been treated in hospitals and released at normal weight, Cornell University Medical College researchers found that only three women kept their weight within normal range during the 10-year study period. Thirty-one of the 76 women were still below minimum weight for their age and height at the 10-year mark. Five women in the study had died; their average weight at death was 58 pounds. Anderson, Arnold E. “Inpatient and Outpatient Treatment of Anorexia Nervosa.” In Handbook of Eating Disorders, edited by Kelly D. Brownell and John Foreyt. New York: Basic Books, 1986. Brewerton, Timothy D. “Pharmacotherapy for Patients with Eating Disorders.” Psychiatric Times 21, no. 6 (May 2004): 59–68. Garfinkel, Paul E., and David M. Garner. Anorexia Nervosa: A Multidimensional Perspective. New York: Brunner/Mazel, 1982. Grilo, Carlos M., Sinha Rajita, and Stephanie S. O’Malley. “Eating Disorders and Alcohol Use Disorders.” National Institute on Alcohol Abuse and Alcoholism (NIAAA). Available online. URL: http://www.niaaa. nih.gov/publications/arh26-2/151–160.htm. Posted November 2002. Habermas, T. “In Defense of Weight Phobia as the Central Organizing Motive in Anorexia Nervosa.” International Journal of Eating Disorders 19, no. 4 (May 1996): 317–334. Levitt, John L. “Treating Adults with Eating Disorders by Using an Inpatient Approach.” Health and Social Work 11, no. 2 (Spring 1986): 133–140. Neuman, Patricia A., and Patricia A. Halvorson. Anorexia Nervosa and Bulimia: A Handbook for Counselors and Therapists. New York: Van Nostrand Reinhold, 1983.

Recovery Recovery from anorexia nervosa does occur, but it isn’t always the same for every patient—or for every authority or clinic. Generally, recovery involves many factors and may vary from partial to full recovery. The criteria most usually associated

anorexia nervosa 35 with recovery are weight gain, resumption of menstruation and social/emotional maturity. Because different criteria are used by different researchers to indicate recovery, and because different treatment centers select different types of patients, studies reporting recovery rates can be confusing and contradictory. It is tempting, because it is so noticeable, to consider only weight gain as a measure of recovery, but weight restoration alone is not always a good barometer. Returning a patient to normal weight is certainly important, but it is relatively easy to accomplish simply by hospitalizing the patient and controlling her food intake. The critical and more difficult task is to get the patient to maintain the higher weight in her normal environment. For this reason, the length of time reported in studies between “recovery” and follow-up is important. The longer the time from treatment to follow-up, the higher the reported mortality rates, the more frequent the rehospitalizations, the greater the continuing psychological problems, the more inadequate the marital and social adjustments and the lower the recovery rates. However, researchers hope that newer treatment methods, along with earlier detection (due to educational efforts and publicity), will result in more permanent recoveries. In terms of nutrition, Neuman and Halvorson correlated various studies to determine that 50 percent of diagnosed and treated anorexics can be expected to recover completely within two to five years. When those anorexics who demonstrate some nutritional improvement are included, the rate of recovery increases to 66 percent. Approximately 90 percent of treated anorexics go on to become employed. Between 50 and 87 percent of these anorexics resume menstruation, usually a year or more after body weight has stabilized. Neuman and Halvorson add, “Even for those anorexics who do not experience the return of menstrual periods, the possibility of bearing children remains, since ovaries may still be active.” On the other hand, recovered anorexics may continue to experience problems relating to their disorder. Anorexia can become chronic. In their research, Neuman and Halvorson found that as many as half those affected have a relapse, and up to 38 percent may have to be rehospitalized within two years. But rehospitalization can actu-

ally be a step toward recovery; sometimes several setbacks occur before real progress is apparent. Nevertheless, approximately 18 percent of diagnosed anorexics do remain ill and unchanged. Death from complications of the disorder or from suicide has been estimated to occur in anywhere from 3 to 25 percent of cases. Psychologically, approximately 50 percent of anorexia victims, on follow-up, show problems with phobias, depression and social adjustment. A comparison of several studies indicates that recovery rates may be predicted when body weight is low at the time treatment begins; the older the age at the onset of the disorder the longer the duration of the illness. Other predictors are disturbed family relationships, binge eating and/or purging or a history of previous psychiatric treatment or childhood adjustment problems. Castro et al. analyzed the variables related to rehospitalization 12 months after total weight recovery in 101 adolescents, aged 11–19 years, with anorexia nervosa. Twenty-five of the subjects required readmission after complete weight recovery and 76 did not. Duration of disorder, weight loss, body mass index at first admission, and global body image distortion were similar in the two groups. The author wrote, “The variables most clearly related to readmission were young age, abnormal eating attitudes, and a low rate of weight gain.” In a small study of 35 anorexic patients two and a half years following assessment, Clausen concluded that “In spite of different treatments and symptoms between patients, the results support the notion of a common pattern in the process of change including a long and stepwise course.” Castro, J., et al. “Predictors of Rehospitalization after Total Weight Recovery in Adolescents with Anorexia Nervosa.” International Journal of Eating Disorders 36, no. 1 (July 2004): 22–30. Clausen, L. “Time Course of Symptom Remission in Eating Disorders.” International Journal of Eating Disorders 36, no. 3 (November 2004): 296–306. Neuman, Patricia A., and Patricia A. Halvorson. Anorexia Nervosa and Bulimia: A Handbook for Counselors and Therapists. New York: Van Nostrand Reinhold, 1983. Szmukler, George I., and Gerald F. M. Russell. “Outcome and Prognosis of Anorexia Nervosa.” In Handbook of Eating Disorders, edited by Kelly D. Brownell and John P. Foreyt. New York: Basic Books, 1986.

36 anorexia nervosa: research anorexia nervosa: research Historically, there have been many barriers to conducting research on interventions in anorexia nervosa (AN), including small sample sizes (due to low base rate of the disorder in combination with the difficulty of entering participants into treatment), high attrition rates and minimal long-term follow-up assessments. Most of this research has been uncontrolled studies, single case designs or case reports. Given the limited progress in identifying effective treatments for anorexia nervosa, a workshop cosponsored by the National Institutes of Health (NIH) Office of Rare Diseases and the National Institute of Mental Health, brought together in September 2002 a group of scientists and NIH staff to: 1) update what is known about the treatment of anorexia nervosa, 2) address the barriers associated with conducting research in this area and 3) make recommendations about how these impediments can be overcome, so that improved interventions can be developed and implemented. Among the workshop’s findings: Additional information is needed regarding the most effective types of interventions, the most appropriate approaches for different age groups and the best systems for delivery. Psychosocial and pharmacological treatments should be studied across different settings (e.g., inpatient, outpatient, day treatment) and should target both the short and long-term phases of the illness, including the prevention of relapse. Given that the overwhelming majority of participants in research have been Caucasian females, there is a need to evaluate specialized intervention strategies for ethnic minority groups and for males. Developmentally informed interventions specifically targeting youths should also be examined. Clinical observations and limited epidemiological research have also suggested that persons with AN are at greater risk for suicidal behavior and death. Improved research approaches for better assessment and management of suicidal risk among persons with this disorder are needed. To address these challenges, the NIH established the Research on Interventions for Anorexia Nervosa (RIAN) network of committed investigators with access to patients with AN, noting, “The RIAN network will have the capacity to improve sample size, accelerate recruitment, and increase popula-

tion diversity and representation beyond what could be accomplished at a single site.” In November 2003, NIH solicited participants in the network, with awards to be announced in late 2004. The awards were to total approximately $1,250,000 to fund the one network, and an applicant could request a project period of up to five years, meaning the results of this research could be announced as early as 2010. In January 2005, NIH reissued a Request for Applications (RFA), and stated the intent now was to commit $1,500,000 in fiscal year 2005 to fund one research network.

anorexic behavior A term used by Garfinkel and Garner to describe the behavior of young women who have weight concerns that interfere with their psychological well-being but do not have fullblown anorexia nervosa. Garfinkel and Garner speculate that these women may be using weight control to deal with issues similar to those of anorexics—the regulation and expression of self, autonomy and self-control; they correspond to Bruch’s THIN FAT PEOPLE. Among the features of socalled anorexic behavior are intense preoccupation with food, food fads, mixing unusual food combinations and dawdling over meals. Garfinkel, Paul E. and David M. Garner. Anorexia Nervosa: A Multidimensional Perspective. New York: Brunner/ Mazel, 1982.

anorexic bingers Technically referred to as anorexia nervosa, binge eating/purging type. According to DSM-IV, most anorexics who binge engage in these behaviors at least weekly, but sufficient information is not available to justify the specification of a minimum frequency. Anorexia accompanied by BINGE EATING and purging has been found to affect older age groups more frequently than adolescents. Bingeing anorexics display less self-discipline and act more impulsively than RESTRICTOR ANOREXICS. They also have greater incidence of MULTICOMPULSIVE behavior such as alcohol and drug abuse and shoplifting, as well as more SUICIDE and SELFMUTILATION attempts. There is also more VOMITING and LAXATIVE ABUSE among bingers. In comparing anorexic bingers and nonbingers, Neuman and Halvorson referred to a

anticonvulsant treatment 37 1980 study by Casper et al., reported in the scientific journal Archives of General Psychiatry 37, that found that anorexic patients who binge tend to be more depressed, anxious, guilt ridden and preoccupied with food than nonbingers. Anorexic bingers also complain more about aches and pains and have more trouble sleeping, resulting in more complaints of fatigue. Bingers also tend to be more outgoing and sensitive to others. In the Casper study, 86 percent of the anorexic bingers were described as outgoing as children in contrast to only 57 percent of the anorexic nonbingers. Besides being more outgoing, anorexic bingers are often sexually active and concerned with physical attractiveness and attention from the opposite sex, in marked contrast to the restrictor, who denies or avoids sexual feelings. Perhaps not coincidentally, poor father-child relationships have been reported more often in the lives of anorexic bingers than non-bingers. While restrictor anorexics are able to ignore and even deny hunger, bingers report stronger appetites that are more difficult to control. Possibly because of this feeling of lack of control, the binger is more likely to seek treatment. Yet anorexia accompanied by bingeing is more difficult to treat, since it occurs intermittently and persistently over a longer period of time. In a study of 120 adolescents undergoing standardized assessment for an eating disorder, Geist et al. also concluded that patients with binge/purge symptoms exhibit significantly more behavioral disorders and have a higher frequency of depressive disorders than restrictors. DaCosta, M., and K. A. Halmi. “Classifications of Anorexia Nervosa: Questions of Subtypes.” International Journal of Eating Disorders 11, no. 3 (November 1992): 305–313. Geist, R., R. Davis, and R. Heinmoa. “Binge/Purge Symptoms and Comorbidity in Adolescents with Eating Disorders.” Canadian Journal of Psychiatry 43, no. 5 (June 1998): 507–512. Neuman, Patricia A., and Patricia A. Halvorson. Anorexia Nervosa and Bulimia: A Handbook for Counselors and Therapists. New York: Van Nostrand Reinhold, 1983.

ANRED (Anorexia Nervosa and Related Eating Disorders, Inc.) A national 501(c)(3) nonprofit

organization founded in 1979, that collects information about eating disorders and distributes it to anorexics, bulimics, families, school personnel, students and medical and mental health professionals. The ANRED staff leads workshops and seminars across the United States, helping people identify and understand anorexia nervosa and bulimia. ANRED also participates in professional conferences, helping physicians, psychotherapists and other human services personnel learn effective ways of working with eating-disordered people. ANRED is affiliated with the NATIONAL EATING DISORDERS ASSOCIATION (NEDA). See also APPENDIX III.

anticonvulsant treatment

Anticonvulsants are drugs that suppress convulsions. First-generation (meaning older drugs) anticonvulsants included: phenytoin (Dilantin), carbamazepine (Tegretol, Carbatrol), phenobarbital and valproate (Depakote). Second-generation anticonvulsants were developed mostly during the 1990s. They include: topiramate (Topamax), gabapentin (Neurontin), lamotrigine (Lamictal), tiagabine (Gabitril), levetiracetam (Keppra), oxcarbazepine (Trileptal), ethosuximide (Zarontin), zonisamide (Zonegran) and primidone (Mysoline). They are used in the treatment of epilepsy and in psychomotor (muscular action resulting from mental activity) and myoclonic (involuntary twitching or spasms of muscles) seizures. A relationship between binge eating and seizure disorders has been suggested because binge eaters typically describe their binges as episodic and uncontrollable. Binge episodes are also frequently preceded by a change in mental state that could be interpreted as an aura (flashes of light, unusual smells, increased tension or fear), a phenomenon that sometimes occurs in nervous disorders. A number of compulsive eaters have had abnormalities of their electroencephalogram (EEG) pattern (an EEG measures electric current generated in the brain). Because of these findings, some doctors had treated bulimic patients with first generation anticonvulsant drugs and had reported success. However, others had found these drugs to be of no use, and there has not been sufficient compelling evidence to support the hypothesis that bulimia is a form of seizure disorder.

38 antidepressants More recently, newer anticonvulsants such as topiramate and zonisamide have been shown effective in treating obesity and are sometimes used to treat binge eating disorder (BED). In one study, topiramate reduced binge-eating frequency, obsessivecompulsive features of binge-eating and body weight more effectively than placebo in a 14-week study of 61 obese patients with BED. These effects were maintained across 48 weeks in an open-label extension trial. Zonisamide produced similar results during a prospective open-label 12-week trial in 15 patients with BED. In an open-label study (also called unblinded), the patient, the researcher and the evaluator all know what the treatment is. Following their 10-week, randomized, doubleblind, placebo-controlled trial to examine the efficacy of topiramate in the treatment of bulimia nervosa, Hedges et al. concluded that “topiramate treatment improves multiple behavioral dimensions of bulimia nervosa. Binge and purge behaviors are reduced, and treatment is associated with improvements in self-esteem, eating attitudes, anxiety, and body image. These results support topiramate as a viable therapeutic option for the treatment of bulimia nervosa.” However, they cautioned, additional longer-term multicenter trials are indicated. Kotwal et al. suggest several reasons that binge eating disorder may respond to anticonvulsant therapy: • Some anticonvulsants are effective in treating bipolar disorder, which may occur with BED. • Some anticonvulsants have shown benefit in conditions associated with pathologic impulsivity, such as substance abuse, impulse-control and cluster B disorders. (The DSM-IV-TR groups the personality disorders into three clusters based on descriptive similarities: Cluster A disorders are marked by odd or eccentric behaviors and include the paranoid, schizoid and schizotypal disorders. Cluster B disorders are characterized by dramatic, emotional or erratic behaviors, and include the antisocial, borderline, histrionic and narcissistic disorders. Cluster C disorders are characterized by anxious or fearful behaviors, and include the avoidant, dependent and obsessive-compulsive disorders.) • Growing evidence shows that bulimia nervosa and BED may be associated with pathologic impulsivity.

Others caution that it takes several positive doubleblind studies, or one with at least several hundred patients in it, to prove that a drug is effective for a given condition. Hedges, D. W., et al. “Treatment of Bulimia Nervosa with Topiramate in a Randomized, Double-Blind, PlaceboControlled Trial, Part 2: Improvement in Psychiatric Measures.” Journal of Clinical Psychiatry 64, no. 12 (December 2003): 1,449–1,454. Kotwal, Renu, et al. “Binge-Eating Disorder.” Current Psychiatry 3, no. 4 (April 2004). Available online. URL: http://www.currentpsychiatry.com/2004_04/0404_ binge_eating_disorder.asp. McElroy, S. L., et al. “Topiramate in the Treatment of Binge Eating Disorder Associated with Obesity: A Randomized, Placebo-Controlled Trial.” American Journal of Psychiatry 160, no. 2 (February 2003): 255–261. McElroy, S. L., et al. “Zonisamide in the Treatment of Binge-Eating Disorder: An Open-Label, Prospective Trial.” Journal of Clinical Psychiatry 65, no. 1 (January 2004): 50–56.

antidepressants Drugs originally developed for the treatment of depression that are now used for a variety of psychiatric and nonpsychiatric conditions. They are among the most commonly used psychotropic (affecting the mind) agents in the treatment of eating disorders in the United States. Three types of antidepressants have been commonly used in this country: tricyclics, monoamine oxidase (MAO) inhibitors and selective serotonin reuptake inhibitors (SSRI). They all boost the action of the neurotransmitters SEROTONIN and norepinephrine, two of the chemicals that transmit impulses through the nervous system. Tricyclics and MAO inhibitors prolong the active life of these chemicals. Trazodone (Deseryl) is an antidepressant structurally unrelated to other antidepressants; it has a strong sedative effect. Anorexia nervosa Antidepressant use for anorexia nervosa is usually determined only after weight gain has been successfully achieved, and when the psychological effects of malnutrition are of less concern. At that time, antidepressants may be considered for the prevention of relapse or to treat associated features of anorexia nervosa, such as depression or obsessive-compulsive problems. SSRIs such as fluoxetine (Prozac) are often consid-

antiobesity drugs 39 ered for such treatment. Tricyclics are used only with caution because of the greater risks of cardiac complications like arrhythmias and hypotension. Kaplan notes that the scientific literature in total describes “only five randomized, placebocontrolled trials with antidepressants, and only one of these had more than 40 patients. Additionally, most of the trials were conducted in a hospital environment designed to encourage weight gain among the patients, which is not really a good environment to determine the effectiveness of the drug.” Bulimia nervosa Antidepressants are sometimes effective as one component of an initial treatment for bulimia nervosa. SSRIs are currently considered to be the safest antidepressants and may be especially helpful for patients with frequent disturbed eating behaviors as well as significant symptoms of depression, anxiety, obsession or certain impulse disorder symptoms, or for those patients who have had poor response to previous psychosocial therapy. Other classes of antidepressants can reduce the symptoms of binge eating and purging and may help prevent relapse among patients in remission. According to Deshmukh and Franco, “The only medication approved by the Food and Drug Administration for bulimia nervosa is fluoxetine (Prozac).” (It was approved in November 1996.) “Several studies have demonstrated efficacy of serotonin-reuptake inhibitors; e.g., sertraline (Zoloft), paroxetine (Paxil) and citalopram (Celexa); tricyclic antidepressants, e.g., imipramine (Tofranil), nortriptyline (Pamelor) and desipramine (Norpramin); and monoamine oxidase inhibitors (MAOI). Doses of tricyclic antidepressants and MAOI antidepressants parallel those used to treat depression, but higher doses of fluoxetine (up to 60 or 80 mg/day) may be needed to treat bulimia nervosa.” Although tricyclics and MAOIs can be used to treat bulimia nervosa, treatment guidelines urge caution when tricyclics are given to patients with a high risk for suicide attempts, and warn that MAOIs should be avoided for patients with chaotic binge eating and purging. Deshmukh and Franco add that “bupropion (Wellbutrin) has been associated with seizures in purging bulimic patients and its use is not recommended.”

Binge-eating disorder Cautioning that cognitivebehavioral therapy is still the treatment of choice, Brewerton notes that randomized controlled trials suggest bingeing to be reduced by the SSRIs fluoxetine, fluvoxamine, sertraline (Zoloft) and citalopram (Celexa). See also DEPRESSION. Brewerton, Timothy D., “Pharmacotherapy for Patients with Eating Disorders.” Psychiatric Times 21, no. 6 (May 2004). Available online. URL: http://www. psychiatrictimes.com/p040559.html. Deshmukh, Rashmi, and Kathleen Franco. “Eating Disorders.” The Cleveland Clinic. Available online. URL: http://www.clevelandclinicmeded.com/disease management/psychiatry/eating/eating.htm. Posted on January 21, 2003, and reviewed on December 22, 2003. Kaplan, Arline. “Treating Eating Disorders: The Pitfalls and Perplexities.” Psychiatric Times 21, no. 9 (August 2004). Available online. URL: http://www.psychiatric times.com/p040804.html.

anti-fat attitudes antiobesity drugs

See OBESITY, ATTITUDES TOWARD.

For more than 100 years, people have searched for the magic pill that would melt excess pounds of fat off their overweight bodies. Around the 1900s, according to the Federal Trade Commission, popular weight-loss drugs included animal-derived thyroid, laxatives and the poisons arsenic and strychnine; eventually each was shown to cause weight loss only temporarily, and usually to be unsafe to use. In the 1930s, doctors prescribed dinitrophenol, a synthetic insecticide and herbicide that increases human metabolism so drastically that organs fail, causing blindness and other health problems. The hormone human chorionic gonadotropin (HCG) became popular in the 1950s for weight loss, and resurfaced recently, even though the FDA exposed it decades ago as effective only to treat Fröhlich’s syndrome, a particular genetic imbalance occurring only in boys. Currently only two prescription drugs— Meridia (sibutramine) and Xenical (orlistat)—are approved for long-term obesity treatment. Sibutramine works by making a person feel full. Its side effects include a rise in blood pressure and

40 antiobesity drugs heart rate, and possible dry mouth, headaches and constipation. Orlistat works by eliminating fats from the body before they are digested. Its side effects include stomachaches, diarrhea and inadequate absorption of some vitamins. Both drugs are approved for use for up to two years. Xenical was shown in one study to prevent heart attacks in those people taking it to help lose weight. The modest efficacy of both drugs in short-term weight loss and long-term weight maintenance has been documented in randomized controlled trials, but attrition rates are high. A third approved obesity drug, phentermine, is sold under several brand names, including AdipexP and Fastin. Although not an amphetamine, phentermine is chemically similar to AMPHETAMINES and may show up positive in urine screening tests for amphetamines. It works in much the same way that sibutramine does, but can be taken for only eight weeks. Because this is not enough for most obese people to lose satisfactory weight, many doctors do not prescribe it. A handful of drugs intended for other purposes but which appear to have some weight-loss benefits are used off-label for weight control; meaning they were approved by the FDA, but not as antiobesity drugs. One example is bupropion, an antidepressant sold under the brand name of Wellbutrin, which makes users feel less hungry. One study found that 14 percent of those people who took the drug every day lost about five pounds in eight weeks. However, some people experience side effects including anxiety, constipation and nausea. Another example is metformin, sold as Glucophage, which is approved to treat type 2 diabetes. Although diabetics taking the drug have often been found to lose weight, nondiabetics taking it often do not experience the same amount of weight loss. Off-label medications such as these also have their own side effects. Although the search for obesity-controlling drugs had been low-key in recent years, it has now escalated. Woods et al. explain: Obesity is now recognized as a chronic disorder with biologic causes that may require chronic medical therapy, much as is the case for hypertension or diabetes mellitus. Prior to this change of policy, antiobesity drugs approved by the Federal

Drug Administration were expected to induce weight loss that was sustained even after drug treatment was discontinued. Consequently, there was little interest on the part of pharmaceutical companies in the development of new drugs for the treatment of obesity. Fortunately, common sense and the weight of medical evidence prevailed and led to a reassessment. A major consequence of this new policy is the potential for new opportunities for the pharmaceutical industry, which once again has turned its attention (and immense resources) toward the development of antiobesity drugs and their lucrative market.

In order to be approved by the U.S. Food and Drug Administration, new drugs generally must show two years of proven safety data, plus longterm effectiveness. A major impediment to developing satisfactory antiobesity treatments is the tendency so far for potential drugs to be effective during the first six months of treatment, only to lose effectiveness as the patients taking them develop resistance. One experimental drug undergoing testing that shows promise is Acomplia (rimonabant), developed by the French pharmaceutical company Sanofi-Aventis. In one two-year test involving 3,040 Americans and Canadians, those participants who took Acomplia averaged 19 pounds lost the first year, and kept the weight off the second year. About 12 percent of the trial’s participants had to drop out because of nausea and dizziness. Also, participants in the trial who were switched after a year from Acomplia to a placebo tended in the second year to regain the weight they had lost; thus, proof of safety and tolerability over an unlimited treatment period will be a major consideration for approval. Acomplia is not intended to replace dieting and exercise, but to supplement them by blocking receptors in the brain that trigger cravings. If the drug receives FDA approval it could be on the market as early as 2006, and industry experts say it could become one of the best-selling drugs ever. Another challenge facing antiobesity drug development, according to Park, is that weight “represents the sum of a bewildering network of overlapping metabolic pathways, all designed to protect the body from starvation by packing on as many pounds as possible. In addition, not everybody gains weight the same way, so a drug target-

antipsychotics 41 ing one pathway will probably not work for all overweight people.” A pharmaceutical company executive has stated that using drugs to treat obesity likely will require a combination of medicines hitting different targets that tell the body to lose weight. Researchers are studying signals in the brain that make people hungry and others in the gut that tell the brain the stomach is full. Other approaches include trying to block absorption of certain foods or stimulating metabolism. Weigel is optimistic about the outlook for effective antiobesity drugs. “Our growing understanding of peripheral signals and central nervous system (CNS) pathways involved in the regulation of adiposity makes it very likely that effective new drugs will become available to treat obesity in the near future.” See also DIET PILLS; GHRELIN; INTERLEUKIN-6; LEPTIN. Cleland, Richard, et al. “Weight-Loss Advertising: An Analysis of Current Trends.” Washington, D.C.: Federal Trade Commission, 2002. Park, Alice. “Pills in the Pipeline: Drug Treatments for Obesity May Not Be Far Off, but Don’t Expect One Prescription to Fit All.” Time 163, no. 23 (June 7, 2004): 90. Weigle, David S. “Pharmacological Therapy of Obesity: Past, Present, and Future.” The Journal of Clinical Endocrinology & Metabolism 88, no. 6 (June 2003): 2,462–2,469. Woods, Stephen C., et al. “Food Intake and the Regulation of Body Weight.” Annual Review of Psychology no. 51 (2000): 255–277.

antipsychotics Also called neuroleptics, a group of drugs used to treat psychoses (mental disorders characterized by loss of contact with reality). They were introduced into psychiatry during the early 1950s. The first antipsychotic compound, approved for the treatment of the symptoms of schizophrenia, was CHLORPROMAZINE (Largactil, Thorazine) in 1953. During the 1960s, chlorpromazine was used by some clinicians for treating anorexia nervosa, but the overall results were not satisfactory. Walsh and Devlin explain: “A series of early studies reported that chlorpromazine, sometimes in combination with insulin to further stimulate hunger, produced more rapid weight gain and earlier hospital discharge. However, unwanted side effects

included the onset of binge eating and seizures, and follow-up studies showed no benefit. Placebocontrolled studies of the higher-potency antipsychotics pimozide and sulpiride provided little evidence of clinical utility. Therefore, although particular patients may benefit from treatment with antipsychotic medications, existing studies do not support their routine use.” Long-term antipsychotic therapy in patients with anorexia nervosa, as in other patients, can lead to the development of tardive dyskinesia (involuntary jerky movements of the face, tongue, jaws, trunk and limbs, usually developing as a late side effect of prolonged treatment with antipsychotic drugs). First-generation antipsychotic drugs are now commonly referred to as typical antipsychotics. In the 1990s several atypical antipsychotic drugs were first introduced, and they are believed to have a lower incidence of side effects. According to Arnold E. Andersen, M.D., of the University of Iowa School of Medicine, “A number of trials are underway using atypical neuroleptics such as risperidone and olanzapine. The hope is that they will have an effect on the core psychopathology of anorexia nervosa rather than merely stimulating weight gain, as was the case with chlorpromazine in the 1960s.” Powers and Santana also describe antipsychotics as possibly suitable treatment for anorexia nervosa. “The medications currently being most widely studied are the atypical antipsychotics, particularly olanzapine. Emerging evidence suggests that some anorexia nervosa patients have psychotic symptoms that may respond to antipsychotic agents. There are promising case reports and open-label studies of the atypical antipsychotics, but as yet, no randomized, placebo-controlled, double-blind studies have been reported.” Powers, P. S., and C. Santana. “Available Pharmacological Treatments for Anorexia Nervosa.” Expert Opinion on Pharmacotherapy 5, no. 11 (November 2004): 2,287–2,292. Walsh, B. Timothy, and Michael J. Devlin. “Psychopharmacology of Anorexia Nervosa, Bulimia Nervosa, and Binge Eating.” Psychopharmacology—The Fourth Generation of Progress, The American College of Neuropsychopharmacology. Available online. URL: http:// www.acnp.org/g4/gn401000153/ch149.html. Downloaded on October 28, 2004.

42 anxiety anxiety

A feeling of uneasiness, apprehension or dread often characterized by tension, increased pulse and sweating. Most persons find healthy ways to deal with their anxiety, such as social activities, hobbies, music, reading, and sports. Anxiety can even be a positive signal, alerting the individual to a situation or event that requires preparation to overcome, such as the anxiety that motivates a student to study for an exam. Some, however, respond in negative or inappropriate ways, having insomnia or recurrent headaches, overindulging in alcohol or drugs, overeating or experiencing a loss of appetite, for example. Instead of using anxiety as a signal to prepare to cope with some perceived stress, eating-disordered persons see anxiety as a signal of impending doom, a warning that whatever is coming will be emotionally overwhelming. They react to anxiety by trying to get rid of it rather than by heeding it. In them, anxiety is likely to set off a binge or, in anorexics, to further restrict eating. Some researchers, such as Don Williamson have proposed an anxiety model of bulimia nervosa. According to this model, anxiety about gaining weight is the central feature of the disorder and binge eating triggers an increase in such anxiety. The anxiety is then reduced by vomiting or some other purgative activity. The reduction in anxiety then negatively reinforces the purgative behavior. Psychophysiological research supports this anxiety model of bulimia nervosa. The central theme of the PSYCHODYNAMIC APPROACH TO OBESITY is that anxiety precedes and triggers the overweight person’s overeating response. The anxiety that results in overeating is produced by internal emotional conflicts rather than external stimuli. Eating often serves temporarily to make a person feel better. Because much internal conflict is believed to take place in the subconscious, an individual may often not be aware of the source of the anxiety. Studies have shown that uncontrollable anxiety increases eating in obese individuals, but controllable anxiety does not. Some therapists see the use of food as compensating for life’s upsets, replacing what seems to be missing in life and soothing, calming and covering up daily stresses and anxiety. Theories in opposition to this include the EXTERNALITY APPROACH TO OBESITY.

Williamson, Donald A., et al. “Psychophysiological Analysis of the Anxiety Model of Bulimia Nervosa.” Behavior Therapy 19 (1988): 1–9.

appetite An emotional and physical impulse or desire or urge to eat, regardless of nutritional needs. Appetite is psychological, dependent on memory and associations (social learning), unlike HUNGER, which is physiologically aroused by the body’s need for food. Appetite is a complex mechanism involving the METABOLISM, gastric juices, the hypothalamus and the cerebral cortex. It is stimulated by the sight, smell or thought of food and accompanied by the flow of saliva in the mouth and gastric juice in the stomach. Appetite may stimulate a person to eat when no hunger signals are present or to continue eating after physiological SATIETY has been achieved. When appetite is disturbed, an individual consumes more calories than he uses up and thus gains weight. For many years it was presumed that the stomach held the primary role in appetite control. As surgical techniques developed and gastrectomy (removal of the stomach) became possible, it became apparent that this is not so. Ultimate control of feeding lies in the brain. There are also several mechanisms by which the small intestine is thought to bring about satiety. appetite hormones

Hormones that stimulate or suppress hunger; they include GHRELIN, LEPTIN and PYY (Peptide YY3-36). Appetite hormones are receiving more attention as researchers strive to solve the mystery of why some people become obese. Researchers do not expect appetite hormones by themselves to provide any “magic bullet” to stop obesity, but they believe a better understanding of how these hormones work together may prove useful in the development of drugs that mimic the action of the appetite hormones. A medical device called an IMPLANTABLE GASTRIC STIMULATOR (IGS) has shown in trials to stimulate the appetite hormones to create a feeling of fullness.

appetite-stimulating drugs

Although patients with anorexia nervosa do not have a reduced appetite, a number of researchers have tried appetite-stimulating drugs in the hope that they

art therapy 43 might induce anorexic patients to eat and gain weight. Only one of these drugs, an antihistamine called CYPROHEPTADINE, has actually been studied in detail, and it has been found generally to be useless.

appetite suppressants

Drugs such as AMPHETAand topical painkillers that lessen or eliminate appetite by slowing gastric emptying, and possibly by increasing a “full” feeling following eating. They can also maintain a feeling of fullness long enough to help a patient limit the size of the next meal. Many clinicians strongly advise against the use of any appetite suppressant for bulimics or compulsive overeaters. One theory suggests that appetite suppressants temporarily lower the set point rather than suppress the appetite and that because of this any weight lost while using suppressants is usually rapidly regained once the dieter stops taking them. (See SET-POINT THEORY.) Appetite suppression by a modest amount of readily assimilable energy, such as a caloric sweetener (“diet candy”), is not likely to last longer than an hour. Some appetite suppressants use the topical painkiller BENZOCAINE to reduce sensation in the mouth and make eating a less rewarding activity. According to the National Institutes of Health Weight-control Information Network (WIN) program, most studies show that the majority of patients who stop taking appetite suppressant medications regain the weight they had lost. Appetite suppressant medications may be appropriate for carefully selected patients who are at significant medical risk because of their obesity, but they are not recommended for use by people who are only mildly overweight unless they have health problems that are made worse by their weight. These medications should not be used only to improve appearance. Although NIH says long-term use of prescription appetite suppressant medications may be helpful for carefully selected individuals, its fact sheet cautions that little information is available on the safety and effectiveness of these medications when used for more than one year. Because any appetite-reducing effect from these medications tends to decrease after a few weeks, they are usually prescribed only during the first MINES, BULKING AGENTS

few weeks of a weight-loss program. Thus, many find them most useful as an early weight-loss boost while learning new ways to eat and to exercise for real long-term weight reduction. See also ANTIOBESITY DRUGS, DIET PILLS, EPHEDRA, HERBAL FEN-PHEN, PHENYLPROPANOLAMINE. Weight-Control Information Network (WIN). “Prescription Medications for the Treatment of Obesity Fact Sheet.” National Institute of Diabetes and Digestive and Kidney Diseases, October 1997.

art therapy

An outgrowth of work therapy and activation therapies, which serve to foster activity and thus rehabilitation by encouraging some form of occupation. Also referred to as creative therapy, art therapy is an attempt to stimulate patients through the creation of art and design and then to transfer this creativity or expressiveness to the reshaping of the patient’s life. Work created during art therapy is not evaluated for aesthetic merit or artistic skill but for its value in psychotherapeutic exploration. Artistic productions can be interpreted by experienced psychotherapists in the context of a therapy, as with free association, or as is done in psychoanalysis with dreams. Art therapy has existed in various forms since the 1940s. It has been used alone or to augment other forms of treatment with both individuals and groups. Although the field has been gaining acceptance as a legitimate form of psychotherapy, critics say it has lagged behind other therapies in documenting and evaluating its effectiveness. Art therapy is thought to be especially helpful in the case of young children who may express graphically what they cannot yet communicate verbally. Diamond-Raab and Orrell-Valente noted that adolescent anorexia nervosa and bulimia nervosa patients typically have trouble talking about themselves. “Traditional group therapy that focuses on verbal therapy is often not effective, particularly in the acute stages of the diseases. A group therapy approach that integrates art therapy, PSYCHODRAMA, and verbal therapy offers an innovative alternative to traditional group therapy.” In the treatment of eating disorders, art therapy can provide anorexics with an opportunity to become more sensitive to their inner selves. They

44 arthritis link to obesity create artwork that originates within themselves and is not under the control of others. Anorexics convey their emotional needs through the use of “body language” (by starving themselves), that is, engaging in a nonverbal form of symbolic communication. Drawing and painting are also forms of nonverbal communication; through these media they can express their emotional conflicts and enhance their self-awareness. Levitt and Sansone explain, “An extremely important part of treatment is to provide an opportunity for clients to identify their own body experiences more accurately (e.g., size and proportion, body image, relation to others). For example, clients estimate body size during art therapy and compare this with their actual body size, which is traced onto paper.” In art therapy, anorexics are encouraged to represent themselves, their families, their feelings, their view of treatment and so on. Interpretation of such work can provide an opportunity to begin more formal PSYCHOTHERAPY. Diamond-Raab, L., and J. K. Orrell-Valente. “Art Therapy, Psychodrama, and Verbal Therapy. An Integrative Model of Group Therapy in the Treatment of Adolescents with Anorexia Nervosa and Bulimia Nervosa.” Child and Adolescent Psychiatric Clinics of North America 11, no. 2 (April 2002): 343–364. Levitt, John L., and Randy A. Sansone. “The Treatment of Eating Disorder Clients in a Community-Based Partial Hospitalization Program.” Journal of Mental Health Counseling 25, no. 2 (April 2003): 140+.

arthritis link to obesity Obesity is associated with increased risk of osteoarthritis (OA), and both overweight and obesity increase the severity of arthritis. Population-based studies have consistently shown a link between overweight or obesity and arthritis in the knees, according to Bartlett. “Data from the first National Health and Nutrition Examination Survey (HANES I) indicated that obese women had nearly four times the risk of knee OA as compared with non-obese women; for obese men, the risk was nearly five times greater. In a study from Framingham, Mass., overweight individuals in their thirties who did not have knee OA were at greater risk of later developing the disease. Other investigations, which also performed

repeated x-rays over time, have found that being overweight significantly increases the risk of developing knee OA.” In 2004 researchers from two large, ongoing Canadian studies (the Canadian Community Health Survey and the National Population Health Survey) reported that obesity increases the odds of developing arthritis by 60 percent, and being overweight increases a woman’s chances of developing arthritis by 30 percent, but does not seem to have an immediate impact on men’s joints. According to the U.S. Department of Health and Human Services, for every two-pound increase in weight, the risk of developing arthritis is increased by 9 to 13 percent. Symptoms of arthritis can improve with weight loss, yet Mehrota et al. reported that in a survey of adults from 35 states, among those obese adults with arthritis who had routine checkups within the past 12 months, only 43 percent were advised to lose weight by their physicians. However, those who did receive such advice were more likely to attempt to lose weight, pointing to the need for health care professionals to make overweight and obese patients more aware of the link between obesity and arthritis. Clinicians have noted that severely obese men tend to die of heart attacks at a young age, but women live longer and develop severe arthritis in their knees, not allowing them to move much beyond their beds or chairs. The link between obesity and arthritis is complicated by the natures of the diseases. For example, doctors have expressed concern that meals in retirement homes and assisted care facilities are often lavish, large and high-calorie, but because residents so frequently suffer from arthritis, many have difficulty participating in enough exercise to burn off those calories—thereby leading to more weight gain and worsened arthritis. Bartlett, Susan. “Osteoarthritis and Body Weight.” Johns Hopkins Arthritis Presents the Role of Body Weight in Osteoarthritis. Available online. URL: http:// www.hopkins-arthritis.som.jhmi.edu/mngmnt/ osteoandweight.html#obesity. Downloaded September 27, 2004. Mehrotra, C., et al. “Arthritis, Body Mass Index, and Professional Advice to Lose Weight: Implications for Clinical Medicine and Public Health.” American Journal of Preventive Medicine 27, no. 1 (July 2004): 16–21.

artificial sweeteners 45 artificial sweeteners Sugar substitutes with few or no calories. According to the Calorie Control Council, a sugar-substitute industry group based in Atlanta, approximately 85 percent of adult Americans consume foods or beverages containing artificial sweeteners, with 63 percent of those consumers not on diets. A teaspoon of sugar contains about 16 calories, and sugar substitutes of equal sweetness contain one calorie or less. Nutritionists caution that just because a food or drink is sweetened with a substitute does not necessarily mean it is low in calories. Artificially sweetened ice cream, for example, often has nearly as many calories as regular ice cream sweetened with sugar because it has more fats. Artificial sweeteners are regulated by the U.S. Food and Drug Administration (FDA), which has approved five different sweeteners: • Saccharin, sold as Sweet ’N Low and Sugar Twin, among others, was discovered in 1879, so it did not go through the same testing as later sweeteners. In 1977, after animal studies linked saccharin to bladder cancer, the FDA considered banning it; however, it has since been deemed not a major risk for bladder cancer in humans. However, some scientists continue to dispute the FDA approval. • Aspartame, sold as NutraSweet, Equal, NatraTaste, Sugar Twin and others, was approved by the FDA in 1981. Although users have complained of headaches, industry-funded studies have concluded that aspartame does not cause headaches. Schardt cautions that an independent test in 1994 found the sweetener to be linked to symptoms in the 11 (out of 26 people) who were “very sure” they were sensitive. “That suggests that some people react to aspartame, though fewer than the number who believe they do.” He adds that charges of aspartame being a cancer risk have never been proved, and “there’s no foundation to claims floating around on the Internet that aspartame causes everything from Alzheimer’s disease to multiple sclerosis.” Aspartame-containing foods must display a warning that people with phenylketonuria (PKU) should avoid it because they cannot metabolize an amino acid found in aspartame.

Consumer Reports on Health (January 2005) noted that aspartame has been a “lightning rod” for the safety debates since its approval, and although opponents have claimed it causes brain tumors, severe allergic reactions, and other problems, “more than 500 studies have produced no convincing evidence of any harmful effects in the average person.” However, many health professionals remain concerned about aspartame and the fact that industry-funded studies conclude it to be harmless do not reassure them. • Sucralose, sold as Splenda, is sucrose (sugar) chemically combined with chlorine. In its granular state, it can be substituted equally for sugar in baking and cooking. According to the International Food Information Council, sucralose was discovered in 1976, and “more than 100 scientific studies conducted over a 20-year period have conclusively demonstrated that sucralose is safe for consumption.” In 1991 Canada’s Health Protection Branch became the first national regulatory agency to endorse sucralose safety and permit its use in foods and beverages. In 1998, the United States FDA approved the use of sucralose in 15 food and beverage categories— the broadest initial approval ever given to a food additive. Then, in August 1999, the FDA extended the approval by permitting sucralose use as a general-purpose sweetener in all foods, beverages, dietary supplements and medical foods. In January 2004 the European Union amended its Sweeteners Directive to permit the use of sucralose in a broad range of food and beverage products. By September 2004 Splenda was reported to be the leading branded sweetener in U.S. homes, with sales surpassing even Domino Sugar. Some 5 billion Splenda packets are consumed each year; it is approved in 79 countries, and it is used in more than 4,000 products worldwide. • Acesulfame-K, sold as Sunett and Sweet One, was approved for use in 2003. It is used in hundreds of products and can be used in baked goods. Although the FDA says its safety is backed by more than 90 studies, consumer groups insist it needs more testing to answer a few early tests in which rats developed cancer tumors.

46 Asians/Pacific Islander Americans and eating disorders • Neotame is not yet available in any product in the United States. The most recently approved artificial sweetener, it is made by the same company that produces NutraSweet. Because it is metabolized differently from aspartame, products containing it will not be required to carry the PKU warning. Low-calorie sweeteners known as sugar alcohols or polyols are found in packaged goods and listed in the ingredients as sorbitol, mannitol, xylitol, erythritol and D-tagatose. According to Harvard Women’s Health Watch, sugar alcohols have little caloric effect because they are absorbed slowly and incompletely by the intestines. “However, this property can also cause gas and diarrhea if you consume too much, for example, more than 50 grams per day of sorbitol or 20 grams per day of mannitol.” Although consumption of artificially sweetened foods and drinks soared to 180 million in 2004 from 68 million in 1986, obesity reached epidemic proportions during that period. A Purdue University study reported by Davidson and Swithers found that rats fed artificial sweeteners ate three times more calories than rats given sugar; thus the authors suggest sugar-free foods may play a role in the obesity epidemic. They hypothesize that artificial sweeteners may disrupt the body’s natural ability to use sweet taste and viscosity to gauge caloric content of foods and beverages, so may be fooled into thinking a product sweetened with artificial sweetener has no calories and, therefore, people overeat. Other scientists, however, have dismissed the hypothesis, arguing that studies on people do not indicate that at all. Referring to a different study, St-Onge and Heymsfield of the Obesity Research Center at Columbia University wrote, “Subjects supplementing their diets with artificially sweetened foods lost weight, whereas those consuming high-sucrose foods gained weight. This review sheds some light on the controversy regarding the effects of artificial sweeteners in body weight control.” Other authors have noted that studies showing replacement of added sugar with low-energy sweeteners to result in reduced body weight have been short-term studies, and they caution that long-term conclusions cannot be drawn without long-term testing. See also STEVIA.

“Artificial Sweeteners: Okay in Moderation.” Harvard Women’s Health Watch 11, no. 11 (July 2004): 2–3. Davidson, Terry L., and Susan E. Swithers. “A Pavlovian Approach to the Problem of Obesity.” International Journal of Obesity 28, no. 7 (July 2004): 933–935. Schardt, David. “Sweet Nothings: Not All Sweeteners Are Equal.” Nutrition Action Healthletter, May 1, 2004: 8–11. Available online. URL: http://www.cspinet.org/ nah/05_04/sweet_nothings.pdf. Downloaded on September 9, 2005. St-Onge, M. P., and Heymsfield, S. B. “Usefulness of Artificial Sweeteners for Body Weight Control.” Nutrition Reviews 61, no. 6 part 1 (June 2003): 219–221.

Asians/Pacific Islander Americans and eating disorders Also called Asian American/Pacific Islander, this group comprises more than 7 million people from 28 Asian countries and 25 Pacific Island cultures in the United States. The largest subgroups are Chinese, Filipinos, Japanese, Asian Indians, Koreans and Vietnamese. Hawaiians comprise the largest subgroups of Pacific Islanders (58 percent), followed by residents of Samoa, Guam and Tonga. Each subgroup has its own history, language and culture. Studies typically do not include ethnically diverse populations; therefore, cases of eating disorders among diverse racial ethnic groups, including Asian Americans, are often underreported. In addition, many Asian Americans equate psychological problems with weakness and shame; therefore, women and girls may avoid seeking treatment. In one study of more than 900 middle-school girls in northern California, Asian-American girls reported greater body dissatisfaction than white girls. Among the leanest 25 percent of girls, Asian girls reported significantly more dissatisfaction than white girls. Recent research on Asian Americans suggests that body dissatisfaction is increasing due to the promotion of the Western beauty ideal. Asian Americans are often perceived as “model minorities” and are expected to be successful and high achieving. Asian-American girls may try to seek power and identity through the pursuit of a physically ideal body. The drive to become the “perfect Asian woman” can lead to perfectionism, which is linked to eating disorders, particularly anorexia. In addition, the cultural value of “saving face,” which promotes a facade of control, may also contribute to disordered eating or eating disorders.

assessment of body fat 47 Adapting to a new culture creates a set of stressors that for Asian-American and immigrant girls may cause confusion about identity, including gender roles. For example, an adolescent girl raised by her family to be obedient and demure may experience emotional turmoil in a Western culture that prizes independence and individualism. For Asian-American girls, acculturation can lead to feelings of isolation, low self-esteem and the devaluation of native cultural identity, which can increase their vulnerability to eating disorders. Highly acculturated Chinese-American females are more likely to report bulimic behaviors and a drive for thinness than those who stay closer to their family values. One report found that the more acculturated Asian-American girls were at greatest risk for adopting the “dysfunctional” behaviors of white American society, including poor eating habits and accepting media messages regarding standards of beauty. Noting that not enough is known about eating disorders among Asian-American and Pacific Islander women, Fitzgibbon and Stolley wrote, “Available research, which has focused on adolescents or college students, appears to indicate that eating disorders are less prevalent in Asian-American females than in white females. Asian-American women report less binge-eating, dieting and body dissatisfaction, and fewer weight concerns. But to come to any firm conclusions about eating disorders within this ethnic group, researchers need to gather more information across different ages, levels of acculturation and Asian subgroups (e.g., Japanese, Chinese, Indian). Fitzgibbon, Marian, and Melinda Stolley. “Minority Women: The Untold Story.” Nova Online: Dying to Be Thin. Available online. URL: http://www.pbs.org/wgbh/ nova/thin/minorities.html. Updated in December 2000.

Asians/Pacific Islander Americans and obesity Asian American/Pacific Islanders (APIA) represent one of the fastest-growing and most diverse populations in the United States. Asian Americans represent a number of groups, including people of Vietnamese, Korean, Asian Indian, Japanese, Filipino, Cambodian, Laotian and Chinese descent. Among Pacific Islanders are Hawaiians, Samoans, Guamanians, Tongans and Fijians. Some of these people are fourth- or fifth-generation Asian Amer-

icans; 75 percent are recent immigrants and refugees. Native Hawaiians and American Samoans are considered part of the Asian-American population, although they are native to the United States. Data from the Racial and Ethnic Approaches to Community Health (REACH) 2010 Risk Factor Survey conducted 2001–02 showed a median prevalence of obesity among APIA men and women of 2.9 percent and 3.6 percent, respectively—far below that of other racial and ethnic groups. Interviews were conducted in 21 communities located in 14 states. However, those findings did not include Native Hawaiians and American Samoans, who are among the most obese people in the world. Also, research reported at a national medical conference held in California in 2004 disclosed that the percentage of low-income Asian and Pacific Islander children in California who are overweight more than doubled between 1994 and 2003, from 7 percent to 15 percent. Noting that the traditional Asian diet is high in fiber and vitamins, while low in saturated and total fat, one of the study’s authors said that many of the participants expressed a sense of powerlessness over the influence of television and food advertising and the school environment on their children.

assessment of body fat

As early as 1908, there were reports that the obese had a greater susceptibility than the lean to caisson disease, the decompression sickness now called the bends, suffered by underwater workers and caused by too-rapid decrease in atmospheric pressure. In 1935 it was confirmed that rapid changes in atmospheric pressure did result in more severe attacks of the bends among the obese than the lean. This held practical significance for deep-sea diving and aviation and led to the military’s practice of rejecting people whose weight was more than 15 percent above that recommended by the standard body weight/height charts. But the use of standard body weight/height ratios has limitations for assessment of body fat. Muscular football players have been rejected for military service because they were over the limit even though thy were not obese. And there are individuals who have extremely large skeletons. More recently, SKIN FOLD MEASUREMENTS emerged as a tool to improve the assessment of body fat for the general population. Newer tests

48 asthma link to obesity use high-tech methods such as bioelectrical impedance, ultrasound, X-ray and near-infrared spectrophotometry. According to a Web article posted by Sports Doctor, Inc., “Body-fat testing is a growing business. Many health clubs offer it as a free service to new members, and to the general public for a fee, usually between $10 and $30. Coaches and trainers often include it in routine fitness evaluations. At least one popular diet program comes with a set of calipers to measure body fat.” But researchers have expressed concern that studies for various measurement methods have not taken into account possible differences between genders, age categories and ethnic groups. According to Heyward, “The skinfold method is appropriate for estimating body fat of children (6–17 years) and body density of adults (18–60 years) from diverse ethnic groups. Likewise, bioimpedance is well suited for estimating the fat-free mass of children (10–19 years) as well as American Indian, black, Hispanic, and white adults. Anthropometric prediction equations that use a combination of circumferences and bony diameters are recommended for older adults (up to 79 years of age), as well as obese men and women.” See also BODY FAT. Heyward, V. H. “Practical Body Composition Assessment for Children, Adults, and Older Adults.” International Journal of Sport Nutrition 8, no. 3 (September 1998): 285–307. Otis, Carol L. “Measuring Body Fat.” Sports Doctor Inc. Available online. URL: http://www.sportsdoctor.com/ articles/bodyfat.html. Downloaded on November 9, 2004.

asthma link to obesity

Several studies released in 1998 and 1999 linked obesity to asthma, a medical condition occurring when the bronchial tubes swell up and go into a spasm, blocking the passage of air in and out of the lungs. In a presentation to the 1998 American Lung Association/American Thoracic Society International Conference, Carlos A. Camargo, Jr., an epidemiologist at Brigham and Women’s Hospital in Boston and an instructor at Harvard Medical School, suggested that obese people are more susceptible to asthma than people of average weight. Prior to this study of more than 100,000 nurses, the general assumption was that

asthma patients were prone to putting on weight because their breathing problems limited exercise. But Camargo’s research showed that obesity preceded the diagnosis of asthma. Other experts described the study as good preliminary research but cautioned that more study needed to be done. Among the possible reasons for the link suggested by Camargo and others is that sedentary people may not take as many deep breaths as more active people, with the more frequent shallow breathing leading to the asthma symptoms. Or the extra pounds obese people carry may somehow affect their airways. Or there may be a genetic link between asthma and obesity. In a study of 171 children between the ages of four and 16 at an urban community health center, pediatrician Jennifer Gennuso and her colleagues at the State University of New York at Buffalo reported that children and teenagers with asthma are significantly more likely than those without asthma to be obese. In London Dr. Sheif Shaheen and colleagues studied health histories of 9,000 people born during the same week in 1970, then monitored them throughout their lives. They found that the prevalence of asthma fell as birth weight increased. With both asthma and obesity increasing in recent years, researchers have searched for any cause-and-effect relationship between the two diseases. However, the process of looking for such linkage is complicated, especially determining which comes first, the asthma or the obesity. Not only is it possible that weight gain might lead to asthma, but people who already have asthma may experience more weight gain simply because the asthma can restrict their ability to exercise and burn off calories. Among the findings so far: • A multi-university study sponsored by the National Heart, Lung, and Blood Institute followed 4,547 African-American and white men and women, ages 18 to 30, for up to 10 years, and concluded that gain in body mass index predisposes young women to new asthma diagnoses, but decreased physical activity does not explain the association of weight gain with asthma. • A study looked at girls who were between the ages of six and 11, and who subsequently gained enough weight to be classified as overweight or

asthma link to obesity 49 obese. After the weight gain, these girls were nearly seven times more likely as their normalweight peers to develop asthma symptoms. • In a study of children who had asthma, those who were also obese used more asthma medication, reported wheezing more frequently and reported more visits to emergency rooms. • Researchers at the University of Southampton, United Kingdom, investigated the effects of postnatal weight gain on the lung function of 131 healthy newborns. Infants who gained weight rapidly in the weeks following birth were found to have worse respiratory function than those who gained weight at a normal rate. • Data gathered as part of the Children’s Health Study of Southern California, involving 3,792 youngsters ages seven to 18, revealed that being overweight is associated with an increased risk of new-onset asthma in boys and in nonallergic children. • In their review of the literature over a 10-year period, Zametkin et al. noted, “Recent research on asthma and child obesity has demonstrated mixed results, and most findings suggest no correlation between the two disorders.” • In a Harvard School of Public Health study of 85,911 female registered nurses, weight gain after age 18 strongly predicted development of adult-onset asthma. Women who gained 22 to 44 pounds were nearly one and a half times more likely to develop asthma. Women who gained more than 55 pounds were at two and a half times the risk.

asthma. They found that prevalence of obesity increases with increasing asthma severity in adults. “The association of asthma severity with obesity suggests that obesity may be a potentially modifiable risk factor for asthma or asthma-like symptoms.” • Working for the Air Pollution and Respiratory Health Branch, Centers for Disease Control and Prevention, King et al. studied peer-reviewed literature from 1994 to 2004 to determine what factors predict the development of asthma in both children and adults. They found 40 studies in this area, with 36 providing some estimate of asthma incidence for the total sample and or a specific subgroup. Among both children and adults, having a higher body mass index (BMI) and significant weight gain were both found to precede the diagnosis of asthma in at least some segments of the studied population. During adulthood, obesity and smoking were the strongest risk factors for asthma. The authors concluded, however, that “before specific public health recommendations can be made, additional longitudinal research is needed to better characterize target populations and identify appropriate settings for multifaceted asthma interventions.”

• Stanten reported on a three-year French study of 67,229 women that found that those who gained about 22 pounds from the time they began menstruating to the time they reached adulthood were at 66 percent greater risk of developing asthma. The researchers suggested that higher levels of estrogen and higher levels of the hormone LEPTIN, both associated with extra weight, may boost inflammation and interfere with the functioning of smith muscle cells lining the airways of the lungs.

However, not everyone is quick to link overweight or obesity with asthma. In the June 2004 Chest, Elamin M. Elamin, M.D., associate professor of medicine and director of critical care medicine in the Division of Pulmonary and Critical Care Medicine at Southern Illinois University, wrote, “The question remains whether the relation of asthma to obesity is a real connection or just a casual association. Large prospective studies and randomized population-based studies are needed to determine the prevalence of such an association.” Such studies, Elamin added, “might support the counter opinion that . . . asthma might be overdiagnosed in the portion of the population that is overweight.” Plus, there is always a concern about making causal interpretation from correlational data. The effect could just as easily be the reverse (of the Akerman et al. study): People with asthma might exercise less and thus be at a higher risk for obesity.

• Ackerman et al. reviewed medical records at an inner-city academic asthma center to help determine any relationship between obesity and

Akerman, M. J., C. M. Calacanis, and M. K. Madsen. “Relationship between Asthma Severity and Obesity.”

50 athletes The Journal of Asthma 41, no. 5 (August 2004): 521–526. Beckett, William S. “Asthma Is Associated with Weight Gain in Females but Not Males, Independent of Physical Activity.” American Journal of Respiratory and Critical Care Medicine 164, no. 11 (December 2001): 2,045–2,050. Driscoll, Paul A. “Obesity May Increase Risk of Asthma.” Associated Press, April 25, 1998. Gennuso, Jennifer, et al. “The Relationship between Asthma and Obesity in Urban Minority Children and Adolescents.” Archives of Pediatrics and Adolescent Medicine 152, no. 12 (December 1998): 1197–2000. Gilliland, F. D., et al. “Obesity and the Risk of Newly Diagnosed Asthma in School-Age Children.” American Journal of Epidemiology 158, no. 5 (September 1, 2003): 406–415. King, M. E., D. M. Mannino, and F. Holguin. “Risk Factors for Asthma Incidence. A Review of Recent Prospective Evidence.” Panminerva Medica 46, no. 2 (June 2004): 97–110. Shaheen, Sheif, et al. “Birth Weight, Body Mass Index and Asthma in Young Adults.” Thorax 54, no. 5 (May 1999): 396–402. Stanten, Michele. “Slim Women Breathe Easier.” Prevention 56, no. 2 (February 2004): 42. Zametkin, A. J., et al. “Psychiatric Aspects of Child and Adolescent Obesity: A Review of the Past 10 Years.” Journal of the American Academy of Child and Adolescent Psychiatry 43, no. 2 (February 2004): 134–150.

athletes Athletes who compete in certain sports in which body thinness is stressed along with high performance expectations, such as gymnastics, wrestling, swimming and figure skating, have shown frequent symptoms of eating disorders, as have dancers (see BALLET DANCERS). Likewise, bulimia and other drastic weight-control measures have been described as common among jockeys, who must meet low weight requirements. Female cheerleaders often experience pressure to attain and maintain weight that is lower than other adolescents of the same height. A study reported in 1986 by Lundholm and Littrell examined cheerleaders’ desire for thinness in relationship to disordered eating and weight-control behaviors. A total of 751 high school cheerleaders from the Midwest were tested. Cheerleaders who expressed a strong desire for thinness had significantly higher scores on seven of eight eating-disorder scales. The greater the desire for thinness, the more likely the tendency to report

disordered eating and weight-control behaviors associated with bulimia. A 1989 Associated Press story stated that an “alarming number” of women athletes at the University of Texas had eating disorders, with the problem especially prevalent among members of the swimming team. According to the report, during a period of 18 months, one of every 10 female athletes at the university, a total of 12, had been diagnosed as having a serious eating disorder. Another 20 to 30 percent had shown symptoms of an eating disorder, and 50 to 60 percent expressed above-average concern about their weight. Current and former swimmers blamed the pressure to meet weight guidelines for their routine fasting, induced vomiting, laxative and diuretic abuse and excessive exercising. Tiffany Cohen, a swimmer who won two Olympic gold medals in 1984, was quoted as saying that her fear of being overweight when reporting to workouts led her into bulimic cycles of binges and purges that resulted in a nine-week hospitalization. And many women on the professional tennis circuit have been known to suffer from eating disorders, including Zina Garrison and Carling Bassett-Seguso. According to a 1992 American College of Sports Medicine Study, eating disorders affected 62 percent of females in sports such as figure skating and gymnastics. Olympic gymnasts who have admitted to eating disorders include Nadia Comaneci, Kathy Johnson and Cathy Rigby. In 1976 the average gymnast weighed 105 pounds, and in 1992 the average dropped to 88 pounds. Effects of eating disorders on athletes include stress fractures, fatigue, iron deficiency anemia, electrolyte imbalances and cardiacarrhythmias. Because athletes are already putting above-average pressure on their bodies, they are at a greater risk than nonathlete patients for these complications. A 1997 study of NCAA student-athletes in 11 sports disclosed that binge eating occurred at least weekly in 13 percent of male student-athletes and 10 percent of female student-athletes. Ferraro focused on sports that had not been well represented in past research. “Results suggest that speed-focused athletes, whose success in sports depends on time as well as talent, do not feel more concern about weight and body size despite being involved in sports that require lean builds. Instead, women not involved in sports of

Atkins Diet 51 any kind seem to have the greatest dissatisfaction with their bodies and see themselves as heavier than both groups of athletes.” Some coaches may be contributing to the development of eating disorders in their athletes by putting too much pressure on them to achieve a preset weight or body form without taking the individual’s condition into consideration. Many coaches and athletes estimate optimal body weight to be much lower than what researchers believe to be healthy, and consider a well-formed and graceful body to be much leaner than the medically defined healthy body. Ferraro suggested that future studies might “examine program and coaching characteristics that encourage healthy attitudes and behavior; and studies of female athletes and non-athletes at several points in time may bring a greater understanding of the relationships between women’s body attitudes and eating behaviors and their participation or nonparticipation in athletics.” Deutsch, Nancy. “National Eating Disorders Screening Program.” Sports Sciences Newsletter, October 1997. “Eating Disorders Soar among College Team Swimmers.” BASH Magazine, November 1989. Ferraro, F. Richard. “The Relationship between Types of Female Athletic Participation and Female Body Type.” The Journal of Psychology 138, no. 2 (March 2004): 115–128. Hahn, Cindy. “Why Eating Disorders Pervade Women’s Tennis.” Tennis, December 1990. Lundholm, J. K., and J. M. Littrell. “Desire for Thinness among High School Cheerleaders: Relationship to Disordered Eating and Weight Control Behaviors.” Adolescence 21, no. 83 (fall 1986): 573–579. Perrone, Vinnie. “Pound for Pound, a Most Dangerous Sport.” Washington Post, April 28, 1991. Rucinski, Ann. “Relationship of Body Image and Dietary Intake of Competitive Ice Skaters.” Journal of the American Dietetic Association 89, no. 1 (January 1989): 98–100. Thompson, Colleen. “Athletes and Eating Disorders.” Eating Disorders Shared Awareness, November 1998.

Atkins, Robert C. (1930–2003)

A New York City cardiologist and pioneer in holistic medicine who advocated the natural healing arts as an alternative to and complement to pharmaceutical drugs and surgery for many illnesses, including heart disease, diabetes and obesity. A graduate of the University of Michigan and Cornell University Medical

College, he founded the Atkins Center for Complementary Medicine. But Atkins’s major impact on health and diet was his high-protein, low-carbohydrate diet plan, which he introduced in 1972 in a best-selling book, Dr. Atkins’ Diet Revolution (David McKay Company, New York). A later book, Dr. Atkins’ New Diet Revolution (M. Evans and Company, 1992) went through several revisions and sold more than 10 million copies worldwide. In all, Atkins was author of eight best-selling books on diet and nutrition, which sold more than 45 million copies. As the New York Times wrote in his obituary, “The market for weight-loss plans and products is $35 billion a year, and Dr. Atkins tapped it with scores of products, including cookbooks, energy bars and diet-oriented ocean cruises.” Although many in the medical field have been critical of his diet plan, his “diet revolution” became known simply as the ATKINS DIET, which gained such popularity that it also revolutionized the food industry and spawned several imitators. Atkins died on April 18, 2003, from head injuries received 10 days earlier when he fell on an icy sidewalk outside his offices in Manhattan.

Atkins Diet

Named after diet pioneer Dr. ROBERT C. ATKINS, a low-carbohydrate, low-sugar diet, embraced by an estimated 20 million people worldwide. Since the body burns both carbohydrates and fat for energy, Atkins contended that, by limiting one’s carbohydrate intake, the body would burn more fat, thereby increasing weight loss. Consuming a high level of carbohydrates causes increased levels of insulin and metabolic changes, according to Atkins, leading to increased hunger and weight gain. The Atkins Diet allows large amounts of protein, including meats, eggs and cheese, and severely limits foods containing carbohydrates, such as pasta, bread and fruit. A major criticism is that the encouraged consumption of saturated fats may lead to heart disease, diabetes and other health problems. Although short-term trials have shown cholesterol readings to be the same or even better than conventional diets, medical experts caution that longer-term studies are needed to evaluate any cardiovascular risk factors with the Atkins Diet. In 2003, research sponsored by the National Center for Complementary and Alternative Medi-

52 attitudes toward obesity cine (NCCAM) concluded and reported on a ground-breaking one-year multicenter clinical trial of obese persons to evaluate the effects of the Atkins Diet on weight loss and risk factors for cardiovascular disease. As published in the New England Journal of Medicine, the study compared weight loss and cardiovascular risks of 33 severely obese people (12 men, 21 women) on the Atkins Diet, with 30 others (eight men, 22 women) who consumed a conventional high-carbohydrate, low-fat, energy-deficit diet. After six months, those on the Atkins Diet had lost significantly more weight (approximately 4 percent more) than those on the conventional diet. Those on this low-carbohydrate diet also experienced improvements in certain risk factors for coronary heart disease such as levels of blood lipids. After one year, there was no longer evidence of a significant difference in weight loss between the two groups of dieters, leading investigators to call for additional research, involving longer-term studies and more participants, to accurately assess the longer-term risks and benefits of low-carbohydrate, high-fat diets. Similarly, a Danish team’s review of some 60 studies on the Atkins and other low-carbohydrate diets, published in The Lancet, concluded that weight loss achieved through Atkins-type diets is associated with the duration of the diet and restriction of energy intake, but not with restriction of carbohydrates. The authors expressed concern that side effects such as headaches, muscle weakness and diarrhea, which were reported more frequently by Atkins dieters than by those on more conventional weight-loss diets, may signal that the diet is not healthy in the long term. Other experts have reported less concern, suggesting that such side effects cannot be too severe because, in most observations, Atkins dieters stick to the regime longer than people following other diets. Because these side effects have been reported at the beginning of the Atkins Diet as well as further along, it has been suggested that they may be due to dehydration. With the low-carb diet craze in general, and the Atkins Diet in particular, losing popularity following Atkins’s death, Atkins Nutritionals Inc. filed for bankruptcy court protection in August 2005. See also LOW-CARB DIETS.

Astrup, Arne, Larsen T. Meinert, and A. Harper. “Atkins and Other Low-Carbohydrate Diets: Hoax or an Effective Tool for Weight Loss?” The Lancet 364, no. 9437 (September 4, 2004): 897–899. Foster, Gary D., et al. “A Randomized Trial of a Low-carbohydrate Diet for Obesity.” New England Journal of Medicine 348, no. 21 (May 23, 2003): 2,082–2,090.

attitudes toward obesity

See

OBESITY, ATTI-

TUDES TOWARD.

atypical anorexia nervosa

A term used by HILDE BRUCH to describe a condition in which weight loss occurs because of various symbolic misinterpretations of the eating function, rather than because of a preoccupation with weight. One example Bruch describes is the relationship of eating to the symbolization of pregnancy fantasies. Although this theory of the fear of oral impregnation had been considered, in the early 1940s, the cornerstone in the mental and emotional processes underlying anorexia nervosa, Bruch found this preoccupation only in exceptional cases and thus came to rate patients with this preoccupation as atypical. Others she classified as atypical include those who refuse to eat for fear of abdominal pain or vomiting, those who refuse food because they feel unworthy and those who do not eat in response to events in their lives. Lee et al. found that stomach bloating was the most common rationale for food refusal among non-fat-phobic patients. Patients with atypical anorexia nervosa and those with the genuine disorder look deceptively alike, particularly after the condition has existed for some time. In contrast to genuine anorexics, however, in whom relentless pursuit of thinness and denial of their condition, even of acute emaciation, are key symptoms, atypical anorexics complain about weight loss and do not want to stay thin, or value thinness only secondarily, as a means of manipulating others. Inability to eat is the leading symptom in the atypical group. Often there is an unacknowledged desire to stay sick in order to remain in a dependent role, in contrast to the struggle for an independent identity that occurs in genuine, or primary, anorexics. Bruch described these patients as displaying various degrees of neurotic and hysterical symptoms.

Avicenna 53 Patients diagnosed as atypical do not display the peculiar features of the primary disorder: pursuit of thinness as a struggle for an independent identity, delusional denial of thinness, preoccupation with food, hyperactivity and striving for perfection. Of 60 female patients Bruch reported on with the diagnosis of anorexia nervosa, there were 15 (25 percent) diagnosed as atypical. She found few if any differences in the descriptive data between the atypical and genuine group. Weight loss was of the same order of magnitude, age of onset in the atypical group was slightly higher and amenorrhea was not present as frequently with the atypical group. Both groups proved equally resistant to treatment. Bruch found the one common characteristic among atypical anorexia patients to be a severe sense of inadequacy and discontent with their lives. Eating difficulties developed when the demands of reality became overpowering and their fragile sense of self was further undermined. In a 15-year study, Strober et al. found that compared to patients with pure cases of anorexia nervosa, atypical patients were less likely to drop weight after discharge, recovered more rapidly and had lower cumulative risk for developing binge-eating. A 1995 study of eating-disordered children and adolescents over the previous three decades suggested that bulimia nervosa and atypical eating disorder are not replacing the traditional category of anorexia nervosa. Rather, the authors concluded, eating disorders are becoming more widespread and dissimilar. See also PSYCHOGENIC MALNUTRITION. Ash, J. B., and E. Piazza. “Changing Symptomatology in Eating Disorders.” International Journal of Eating Disorders 18 (July 1995). Lee, S., et al. “Rationales for Food Refusal in Chinese Patients with Anorexia Nervosa.” International Journal of Eating Disorders 29, no. 2 (March 2001): 224–229. Bruch, Hilde. “Psychogenic Malnutrition and Atypical Anorexia Nervosa.” In Eating Disorders: Obesity, Anorexia Nervosa, and the Person Within. New York: Basic Books, 1973. Strober, M., R. Freeman, and W. Morrell. “Atypical Anorexia Nervosa: Separation from Typical Cases in Course and Outcome in a Long-Term Prospective Study.” International Journal of Eating Disorders 25, no. 2 (March 1999): 135–142.

aversion therapy A type of behavioral therapy based on the experiments of Ivan Pavlov (1849–1936), a Russian scientist who worked extensively in the field of conditioned reflexes. Typically, an aversive experience (a foul odor, an electric shock) is administered to a patient at certain times in order to create a negative reaction toward certain foods or behaviors. This therapy was among the first techniques employed in the treatment of obesity. Repeated pairings of aversive experience with certain foods were assumed to result in decreasing palatability of those foods through a process of “Pavlovian” behavioral conditioning; this shift in preference was assumed to facilitate control over eating and, thus, weight reduction. Taste aversions develop most easily to novel and less preferred foods and often persist for many years. One limitation of this therapy is the relative difficulty in establishing aversions to familiar, preferred foods, which are the very ones to which dieters may wish to develop aversions. Results with overweight patients have been poor, whether the unpleasant stimuli have been foul smells, electric shocks or unpleasant images. Although aversion therapy has been used quite frequently in the treatment of patients who are overweight because of compulsive eating, few reports deal specifically with patients identified as bulimic. It is now considered an outdated treatment. In a 1996 study of 172 overweight women subjects who received aversion therapy and HYPNOTHERAPY lost more weight than subjects receiving only hypnotic therapy, but the differences were not significant. See also BEHAVIOR MODIFICATION. Avicenna (980–1037)

An 11th-century Persian physician and philosopher, called the “Prince of Physicians,” who was the first to write about anorexia nervosa. He described the case of a melancholic young prince who was successfully treated for the disorder. He was the author of more than 100 works, of which his Canon of Medicine was the most important and was used for centuries as a medical reference in both the Christian and Islamic worlds.

B In a 1996 study comparing ballet dancers and students, the dancers were more preoccupied with thoughts of eating and body weight, used and abused laxatives for weight control and reported disordered eating more than the students—even though the dancers were at lower body weight and had less body fat. Analysis of 10 female members of a professional ballet company in 1998 indicated a high distortion of body image among these dancers. Although eating disorders are frequent among elite performers, Ravaldi et al. noted that little is known about nonprofessional performers. They evaluated 113 female non-elite ballet dancers, 54 female gymnasium users, 44 male noncompetitive body builders, 105 female controls and 30 male controls, using several standard tests. Among these groups, nonelite ballet dancers reported the highest prevalence of eating disorders (anorexia nervosa 1.8 percent; bulimia nervosa 2.7 percent; eating disorders not otherwise specified 22.1 percent). See also ANOREXIA ATHLETICA; ATHLETES.

ballet dancers

According to various reports in medical literature, between 7 and 38 percent of female dancers in competitive settings have been found to have serious eating problems. Classical ballet demands the same high standards of technical proficiency of its dancers as competitive sports do of first-class athletes. And as in wrestling, gymnastics and swimming, the right body shape and weight are primary concerns. Because ballet is basically nonaerobic and has a low caloric expenditure, weight reduction cannot be achieved and low weight maintained through dancing alone. In a study of 49 female dancers who performed in national ballet companies in the United States and in the Republic of China (Taiwan), 11 percent of the Americans and 24 percent of the Chinese reported that they had an eating problem. Those dancers chosen from general auditions exhibited significantly more anorexic behaviors and had a higher incidence of eating problems, with 46 percent reporting anorexia nervosa, bulimia or purging behavior, than those taken from a company school such as the School of American Ballet (11 percent), where a strict selection process over a number of years weeds out those who do not meet the rigid body shape and weight requirements. The study’s authors contend that companies choosing by audition, who do not control the early selection process of their dancers, “may be choosing women who have more difficulty maintaining the low body weight demanded by this profession, and so are more at risk for developing eating-related problems than dancers selected from company schools, who may be less susceptible to the development of eating problems because they are more naturally suited to the thin ideal required by this profession.” This has been suggested as the reason for the wide disparity of eating disorders reported in different studies of ballet dancers.

Abraham, S. “Eating and Weight Controlling Behaviours of Young Ballet Dancers.” Psychopathology 29, no. 4 (1996): 218–222. Hamilton, Linda H., et al. “The Role of Selectivity in the Pathogenesis of Eating Problems in Ballet Dancers.” Medicine and Science in Sports and Exercise 20, no. 6 (December 1988): 560–565. Pierce, E. F., and M. L. Daleng. “Distortion of Body Image among Elite Female Dancers.” Perceptual and Motor Skills 87 (December 1998): 769–770. Ravaldi, C., et al. “Eating Disorders and Body Image Disturbances among Ballet Dancers, Gymnasium Users and Body Builders.” Psychopathology 36, no. 5 (September–October 2003): 247–254. Schnitt, Diana. “Psychological Issues in Dancers—An Overview.” Journal of Physical Education, Recreation and Dance 61, no. 9 (November/December 1990): 32–34.

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56 Banting, William Banting, William (1797–1878) The “Father of Dieting”; a 19th-century English mortician whose weight began climbing during his late thirties. When his doctor advised him to exercise to lose weight and suggested rowing, Banting bought a small boat, which he took out onto the Thames each morning. But all this exercise and the fresh air made him hungry; he went home and ate even more. By age 50 he had become so obese that he could not bend to tie his shoes; he could hardly exert any energy without difficulty in breathing. He continued to eat and gain weight. As he wrote later, his body fell into a “low and impoverished state.” When his doctor suggested that he sweat off some pounds in Turkish baths, he took 90. They did not work. By this time, Banting was 65 years old, stood five feet five inches tall and weighed 230 pounds. Walking down stairs caused such strain on his legs that he had to navigate the stairs backward. Finally, in 1862, he consulted another physician, William Harvey. Harvey was one of the few scientists and physicians of the day who studied the effects of dieting on general health. Until then, weight-control methods had included bleeding from the arm or jugular vein, applying leeches to the arms, eating vegetables with vinegar, taking hot baths or saltwater baths, staying awake most of the night, taking sea voyages, eating soap, pricking the flesh with needles, walking with naked feet and surgically removing fatty tissue with a scalpel. Dr. Harvey put Banting on a high-protein, lowcarbohydrate diet of 1,200 calories per day. Banting was willing to try anything, and it worked. The first week he lost two pounds, the next week three, and the third week four pounds. After a year he had lost a total of 46 pounds and 141/2 inches around his waist. Even his hearing and vision improved. Banting was so pleased that he decided to tell others about his good fortune. In 1863 he wrote a pamphlet called Letter on Corpulence, Addressed to the Public, the first diet book. He gave away the first 2,500 copies, and it became the talk of London. The third edition sold 50,000 copies. By the fourth edition, it had grown from its original 25 pages to 100 pages, with the addition of letters and testimonials praising Banting’s success and his diet.

Banting became famous, frequently lecturing while wearing the clothes he had worn when he had weighed 230 pounds. The clothes would fall around him, and he would tell his audiences that this is what a proper diet should do for them. Several doctors dismissed Banting as a fraud and as the “prototype hypochondriac.” Some even started rumors that Banting was dying because of his diet. On two occasions in 1864, Banting found it necessary to write to the Times of London to deny that he was dying. During Banting’s lifetime, “Bantingism” and “to bant” became household words. He lived to be 81, dying on March 16, 1878, slim and trim to the end.

bariatrics A branch of medicine that deals with the causes, prevention and treatment of obesity and its associated conditions. There are 1,100 members of the American Society of Bariatric Physicians. The term came into use in the 20th century, and was derived from the Greek baros (weight) and iatrics (medical treatment). bariatric surgery Surgery performed on the stomach and/or intestines to help severely obese people lose weight; also called gastrointestinal surgery. The first such surgery in the United States was performed in 1953. Bariatric surgery restricts stomach size and/or results in decreased absorption of nutrients. Such procedures have nearly tripled in recent years, from 47,200 operations in 2001 to 103,200 in 2003, with some 144,000 operations expected in 2004. Costs for bariatric surgery average $26,000. Some health insurers cover bariatric surgery, but many do not. According to the Orlando Sentinel, “A national employee health benefits survey, published in December 2003 by Mercer Human Resource Consulting, found that 48 percent of large companies (500 or more employees) provided coverage for bariatric surgery, but less than one-fourth of all companies did.” Bariatric surgery results in substantial weight loss, which in many cases is sustained over the long term. In addition, this weight loss results in complete resolution or marked improvement in many obesity-related comorbid conditions (existing simultaneous with the obesity). In their review of all scientific articles on bariatric surgery pub-

bariatric surgery 57 lished in the English language between 1990 and 2003, Buchwald et al. found that “a substantial majority of patients with diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea experienced complete resolution or improvement.” However, surgical treatment is appropriate only for those with extreme obesity, and carries with it the possibility of significant complications (including death), as well as the need for lifelong medical followup. It is recommended when expected weight loss from behavior change alone may not be sufficient to have a major impact on health and is unlikely to be sustained. Rabin cautions that guidelines developed by the New York State Health Plan Association “recommend using hospitals that specialize in bariatric surgery. Such centers should perform more than 200 cases a year and have a team led by a surgeon who spends most of his or her professional time in bariatric surgery.” People who may consider gastrointestinal surgery include those with a body mass index (BMI) above 40—about 100 pounds of overweight for men and 80 pounds for women. People with a BMI between 35 and 40 who suffer from type 2 diabetes or life-threatening cardiopulmonary problems such as severe sleep apnea or obesity-related heart disease may also be candidates for surgery. Once viewed as suitable only for adults, bariatric surgery is now being considered for adolescents. Inge et al. suggest the following considerations when evaluating adolescents for surgery: Adolescents must have attempted but failed at organized weight-loss attempts for at least six months, and must have met certain anthropometric, medical, and psychologic criteria. They should be very severely obese (defined by the World Health Organization as a body mass index of 40), have attained a majority of skeletal maturity (generally 13 years of age for girls and 15 years of age for boys), and have comorbidities related to obesity that might be remedied with durable weight loss. Potential candidates for bariatric surgery should be referred to centers with multidisciplinary weight management teams that have expertise in meeting the unique needs of overweight adolescents. Surgery should be performed in institutions that are equipped to meet the tertiary care needs of severely obese patients and to collect long-term data on the clinical outcomes of these patients.

The concept of gastrointestinal surgery to control obesity grew out of results of operations for cancer or severe ulcers that removed large portions of the stomach or small intestine. Because patients undergoing these procedures tended to lose weight after surgery, some physicians began to use such operations to treat severe obesity. The first operation that was widely used for severe obesity was the intestinal bypass. This operation produced weight loss by causing malabsorption. The idea was that patients could eat large amounts of food, which would be poorly digested or passed along too fast for the body to absorb many calories. The problem with this surgery was that it caused a loss of essential nutrients and its side effects were unpredictable and sometimes fatal. The original form of the intestinal bypass operation is no longer used. Today’s bariatric operations promote weight loss by closing off parts of the stomach to make it smaller. Operations that only reduce stomach size are known as RESTRICTIVE OPERATIONS because they restrict the amount of food the stomach can hold. Restrictive operations for obesity include ADJUSTABLE GASTRIC BANDING (AGB) and VERTICAL BANDED GASTROPLASTY (VBG). Some operations combine stomach restriction with a partial bypass of the small intestine. These procedures create a direct connection from the stomach to the lower segment of the small intestine, literally bypassing portions of the digestive tract that absorb calories and nutrients. These are known as MALABSORPTIVE OPERATIONS, and are the most common bariatric surgeries for weight loss. Malabsorptive operations for obesity include ROUX-EN-Y GASTRIC BYPASS (RGB) and BILIOPANCREATIC DIVERSION (BPD). The Weight-control Information Network (WIN), a service of the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health, offers the following benefits and risks to consider before undergoing bariatric surgery: Benefits • Right after surgery, most patients lose weight quickly and continue to lose for 18 to 24 months after the procedure. Although most patients regain 5 to 10 percent of the weight they lost, many maintain a long-term weight loss of about 100 pounds.

58 basal metabolic rate • Surgery improves most obesity-related conditions. For example, in one study blood sugar levels of 83 percent of obese patients with diabetes returned to normal after surgery. Nearly all patients whose blood sugar levels did not return to normal were older or had lived with diabetes for a long time. Risks • Ten to 20 percent of patients who have weightloss surgery require follow-up operations to correct complications. Abdominal hernia was the most common complication requiring follow-up surgery, but laparoscopic techniques seem to have solved this problem. In laparoscopy, the surgeon makes one or more small incisions through which slender surgical instruments are passed. This technique eliminates the need for a large incision and creates less tissue damage. Patients who are superobese (more than 350 pounds) or have had previous abdominal surgery may not be good candidates for laparoscopy, however. Less common complications include breakdown of the staple line and stretched stomach outlets. • Some obese patients who have weight-loss surgery develop gallstones. Gallstones are clumps of cholesterol and other matter that form in the gallbladder. During rapid or substantial weight loss, a person’s risk of developing gallstones increases. Taking supplemental bile salts for the first six months after surgery can prevent gallstones. • Nearly 30 percent of patients who have weight-loss surgery develop nutritional deficiencies such as anemia, osteoporosis and metabolic bone disease. These deficiencies usually can be avoided if vitamin and mineral intakes are high enough. • Women of childbearing age should avoid pregnancy until their weight becomes stable because rapid weight loss and nutritional deficiencies can harm a developing fetus. Long-term data for bariatric surgery are still needed. One of the most extensive looks at longterm results was a Swedish study of 1,703 individuals who had undergone one of several types of

bariatric surgery two years prior and 4,047 people who had surgery a decade prior. Both groups were compared to a group of obese people who had not undergone surgery. After two years, the weight of people in the control group had increased by 0.1 percent, while in the surgery group it had decreased by 23.4 percent. After 10 years, the weight of those in the control group had increased by 1.6 percent. Those in the surgery group saw their weight decrease to an overall total of 16.1 percent, meaning that individuals did gain some weight back. People in the surgery group also consumed fewer calories and were more physically active than those in the control group. At both two and 10 years, the surgery participants had higher rates of recovery from related health risks. Experts noted that the surgeons involved were considered very experienced. Buchwald, Henry. “Bariatric Surgery: A Systematic Review and Meta-Analysis.” Journal of the American Medical Association. 292, no. 14 (October 13, 2004): 1,724–1,737. Gardner, Amanda. “Obesity Surgery Shows Benefits Years Later.” HealthDay. Available online. URL: http://www.healthfinder.gov/news/newsstory.asp? docID=52307. Downloaded on August 27, 2005. Inge, Thomas H. “Bariatric Surgery for Severely Overweight Adolescents: Concerns and Recommendations.” Pediatrics 114, no. 1 (July 2004): 217–223. Rabin, Roni. “A High-Risk Answer to Obesity.” Newsday, May 26, 2004, page A28. Sjöström, Lars, et al. “Lifestyle, Diabetes, and Cardiovascular Risk Factors 10 Years after Bariatric Surgery.” New England Journal of Medicine 351, no. 26 (December 23, 2004): 2,683–2,693. Wessel, Harry. “Workplace Insurance Covers Weight Loss Surgery.” The Orlando Sentinel, September 8, 2004, page G-1.

basal metabolic rate (BMR)

The rate at which energy (fuel, the fat and glucose obtained from food) is used by an individual at complete physical and mental rest for basic body functioning (breathing, heart activity, nervous system activity and various other essential organ functions). It is usually measured in the morning when a person is relaxed and has not eaten since the preceding evening. In an average person, this functioning accounts for approximately 70 percent of total

behavior modification 59 energy expenditure. The remaining 30 percent is largely a reflection of one’s level of physical activity. The BMR varies according to age, sex and weight. It is highest in children and begins to decline in young adults after age 24, dropping approximately 5 to 7 percent each decade after age 20, making it more difficult to lose weight as one gets older. BMR is also lower in hypothyroidism and higher in hyperthyroidism. The wide variance in basal metabolic rate among individuals is one reason why different people respond differently to identical diet and exercise programs. People with high basal metabolic rates tend to remain slim even while eating large amounts of high-calorie food; those with lower BMRs seem to gain weight merely “looking” at food. The BMR actually decreases when caloric intake is severely restricted by starvation or stringent diet. BMR increases as a function of activity level. See also SET-POINT THEORY.

behavior modification

A sub-branch of behavior therapy in which the changing of human behavior is achieved through conditioning and operant techniques. In behavior modification therapy, after determining what behaviors are dysfunctional or self-destructive, therapeutic techniques are used to alter or eliminate them. These techniques are grounded in the theories of the behavioral school of psychology, which holds that human behavior consists almost entirely of responses to physiological stimuli, and dismisses such concepts as the subconscious or the unconscious and in general, nonphysiological causation of behavior. Therapists of many schools, however, have found techniques developed by behaviorists to be useful in their own practices. Techniques often used include exposing the patient gradually to the presumed cause of his distress while teaching him to cope with anxiety; flooding the patient with anxiety-producing stimuli and preventing him from responding in the usual manner until feelings of anxiety eventually disappear; and modeling by performing the anxietyprovoking activity for the patient to copy. Advocates of behavior-modification therapy say that it is a more efficient mode of treatment than psychoanalytic or other psychotherapeutic

approaches, which often take years and may never produce clear and unambiguous results. Opponents argue that it treats only the symptoms of a disorder and does not engage the profound causes, so that symptoms frequently reappear. In Anorexia and Bulimia Use of behavior modification for treatment of anorexia and bulimia was first advocated in 1972. Change is achieved through a reward-and-punishment system. Behavior leading to weight gain is rewarded, or “positively reinforced,” by access to desirable activities, and behavior not leading to weight gain is punished by making things unpleasant. Proponents of behavior modification claim it achieves weight gain more rapidly than other methods. Detractors express concern that it often provokes serious psychological damage by increasing the inner turmoil and sense of helplessness in patients who feel tricked into losing control over their bodies. HILDE BRUCH condemned it, pointing out that weight gain in itself is not a cure for anorexia nervosa. Follow-up observations have shown that weight gain achieved through behavior modification is often short-lived. Some hospitalized patients respond to the therapy in order to gain enough weight to obtain release from the hospital—and then freely resume their noneating behavior pattern. It has been most successful with patients who come to it voluntarily and who make a “contract” to gain weight. Overall, behavior modification by itself may be an inadequate treatment, but may be an integral part of a comprehensive treatment. (See EATING HABITS MONITORING.) Numerous controlled treatment trials have shown behavior therapy to be as effective or more so than any other bulimia nervosa treatment to which it has been compared. Although behavior therapy also seems to be effective for binge-eating disorder, research is in a preliminary stage. In Obesity When behavior modification is used in treatment for obesity, the therapist first analyzes the patient’s current eating habits. Usually this involves the patient’s maintaining a detailed food diary. Noted in the diary are the types and amounts of food eaten at various times of the day, where the food is eaten (at his desk, dining room table, living

60 behavior modification room, in his car, etc.), activities involved in at the same time eating takes place (e.g., reading, watching television, listening to the radio, etc.), the degree of hunger at each time food is eaten and the mood the patient is in when he or she decides to eat. The food diary helps identify particular eating patterns or situations in which the patient is likely to overeat. After a thorough analysis of eating behavior has been made and recurring patterns identified, other behaviors are substituted for eating when a particular situation arises. For example, if the patient regularly snacks while watching television, he could substitute some other behavior such as chewing gum or sipping on a glass of water. If the patient routinely eats candy when she feels angry or depressed, she can instead do 10 repetitions of a simple exercise or go for a walk or express her thoughts on paper. In this way, a new habit is substituted for the established eating response to certain situations. If the eating pattern analysis shows that the patient has poor eating habits, such as eating too rapidly, behavior modification is used to alter and control them. New eating patterns might include using smaller dishes, putting the fork down between bites and carefully chewing before swallowing in order to stretch out a meal and allow stimulation of the SATIETY mechanisms, substituting low-calorie foods like fruits and vegetables for high-calorie snacks, eating meals at regular times or avoiding distractions such as television during meals. A central element of most obesity behaviormodification programs is slowing down the act of eating. It was initially though that doing so would interrupt the “chaining” of behaviors involved in eating: putting food on the fork, lifting it to the mouth and so on, which occurred largely outside a person’s awareness. But it has since been found that slowing down the act of eating has an additional benefit because a larger proportion of the meal remains uneaten at the time when the stomach and intestine have begun to absorb nutrients, thus producing the physiological signals of fullness. These signals add to the effect of the techniques used to eat less. There are specific techniques to help people slow their rate of eating, enabling them to become

aware of all its components and gain control over them. The most frequently suggested one is setting down one’s fork or spoon between bites. Another is to count each mouthful, chew or swallow. Those patients who have trouble slowing their eating rate are told to stop eating for one minute late in a meal when a delay is more readily tolerated. They are then instructed to increase the number and duration of delays and begin them earlier. Patients are also urged to make meals a time of comfort and relaxation and to avoid arguments and the rehashing of problems at the dinner table. They are encouraged to learn to savor food as they eat it, to make a conscious effort to become aware of it as they are chewing and to enjoy the act of swallowing and the feeling of warmth and fullness in their stomach. To the extent that they succeed with this, they may eat less and enjoy it more. A system of rewards (positive reinforcement) is the key element in a behavioral therapy program. Although the ultimate reward is an improvement in health, personal appearance and self-esteem, interim rewards are important in encouraging faithful adherence to the program. Examples include treating oneself to a movie after a threepound weight loss or going on a trip after successfully shedding 10 pounds. Charts recording weight loss and changes in body measurements also provide positive reinforcement. Brownell and Kramer write that behavior modification is practiced so widely, there is a tendency to believe that it consists of little more than a series of techniques or tricks such as record-keeping and slowing eating. This is mistaken. a modern day, comprehensive program is sophisticated and involves systematic work, not only on eating behavior, but on exercise, attitudes, social relationships, nutrition, and other factors. The better behavioral programs now are producing weight losses in the range of 25 to 30 pounds.

For many people, adherence to a behaviormodification program is easier if it is administered in a group setting. Lay groups devoted to weight loss have been proliferating throughout the world (two of the oldest and most successful are WEIGHT WATCHERS and TOPS (Take Off Pounds Sensibly). Weight loss with behavioral therapy is slow and undramatic, and the amount of weight lost is usu-

belly fat 61 ally moderate. Even though the goal of behavior modification is a lifelong change in eating habits, many people gradually return to their old eating behavior and regain the lost weight. See also AVERSION THERAPY; EXTERNAL CONTROL THERAPY. Brownell, Kelly D., and P. M. Kramer. “Behavioral Management of Obesity.” Medical Clinics of North America 73, no. 1 (January 1989): 185–201. Brownell, Kelly D., and Thomas A. Wadden. “Behavior Therapy for Obesity: Modern Approaches and Better Results.” In Handbook of Eating Disorders, edited by Kelly D. Brownell and John P. Foreyt. New York: Basic Books, 1986. Foreyt, J. P., and W. S. Poston. “What Is the Role of Cognitive-Behavior Therapy in Patient Management?” Obesity Research 6, suppl. 1 (April 1998): 185–225. ———. “The Role of the Behavioral Counselor in Obesity Treatment.” Journal of the American Dietetic Association 10, suppl. 2 (October 1998): 527–530. Lewandowski, L. M., et al. “Meta-Analysis of CognitiveBehavioral Treatment Studies for Bulimia.” Clinical Psychology Review 17, no. 7 (November 1997): 703–718. O’Brien, Robert, and Morris Chafetz. The Encyclopedia of Understanding Alcohol and Other Drugs. New York: Facts On File, 1999.

behavior therapy

Broadly speaking, the application of cognitive and behavioral science to human problems. In general, with behavior therapy, there is an emphasis on changing behavior, but the most important emphasis is on the application of scientific principles to clinical research and therapy. Depending on whose definition one uses, cognitive interventions may or may not be considered a part of behavior therapy. Overall, there is more empirical research on behavior therapy or cognitive behavior therapy for the eating disorders than any other treatment modality. Behavior therapy has acquired greater respectability in recent years, particularly for the treatment of bulimia nervosa. Behavioral techniques to prevent binge eating include eating slowly by putting the fork down between each bite, and always eating with other people. Although results with behavior therapy have been encouraging during initial treatment, some physicians questions its long-term effect. It is most likely

to be effective when the patient anticipates an oncoming desire or need to binge eat. “Automatic” binge eating is not as effectively treated with behavior therapy.

belly fat Common term for abdominal fat; also referred to as a beer belly, beer gut, potbelly or spare tire. Men especially tend to accumulate fat deposits in their abdomen, and it often accumulates in both men and women as they age. People whose fat is mostly distributed around the middle are said to be apple-shaped, and are at greater health risk than those who are pear-shaped, with their fat located mainly across the hips and thighs. Health writer Nanci Hellmich explains that scientists have “discovered that people with wide girths are more likely to have large amounts of deephidden belly fat around their organs. It might be the most dangerous kind of fat and could increase a person’s risk of diabetes, heart disease, stroke, and some types of cancer.” This deep abdominal fat is called VISCERAL FAT, and a large amount of it is one of the prime risk factors for METABOLIC SYNDROME. Studies presented at a 2004 American Heart Association meeting showed that having a big belly may be a prime indicator of future heart attack or serious heart disease. One study of 7,000 middleaged police officers who died of heart attacks or other sudden heart problems between 1967 and 1984 showed that those with potbellies were more likely to die suddenly, with the risk of sudden death increasing with abdominal density. Those with higher BODY MASS INDEX were not any more likely to die suddenly—unless they also had noticeable belly fat. In the case of men, a 40-inch waist appeared to be the dangerous cut-off point; for women, the risk begins at 35 inches. Another study of 2,000 adults 45 years and older took several measurements of fatness, including waist circumference, neck circumference, body mass index and skin-fold thickness on the arms and waist. That study also found that people who had fat in the abdominal area of the body were more likely to have specific heart symptoms called left ventricular dysfunction and diastolic dysfunction—measures of how well the heart is pumping. When the researchers looked at who died over five years, those who had poor diastolic

62 belt lipectomy function and who had large waists were much more likely to have died. People who eat a lot of refined grains like white bread seem to have paunchier bellies, researchers from Tufts University have reported. In their studies, those who consumed the most white bread (four to five daily servings) saw their waistlines expand three times as much as those who ate one serving or less, even when calories were equal. Some of the people the researchers tracked over a three-year period inched up into a larger size of pants. “Waist circumference was very much associated with this high-refined-grains pattern,” according to Katherine Tucker, one of the study’s authors. The team is trying to figure out why refined grains appear to send calories straight to the midsection. One theory is that they appear to be more sensitive to insulin, which tends to store the calories as fat. Most experts state that exercise alone will not get rid of belly fat; it takes a combination of exercise and eating fewer calories, especially those from fat. Walking has been shown in tests to be especially helpful in losing belly fat, with some saying that the dangerous visceral fat may be the first to go with vigorous exercise like walking. A few individual small studies have shown that subjects lose belly fat when they cut back on eating saturated fat, eat three servings of fat-free yogurt a day, add at least 12 grams of fiber to their daily diet or lower their stress levels. Researchers at Washington University in St. Louis reported in 2004 that taking a supplement that boosts the hormone DEHYDROEPIANDROSTERONE (DHEA) significantly reduced abdominal fat in a small group of elderly patients. However, no long-term research has definitively discovered a secret to losing belly fat that is any easier or quicker than vigorous exercise and a sensible weight-loss diet. Even when these are followed, some people resort to LIPOSUCTION in order to get rid of most or all of their subcutaneous belly fat. See also ADIPOSE TISSUE; BODY FAT DISTRIBUTION. Hellmich, Nanci. “Belly Full of Danger.” USA Today, February 25, 2003. Available online. URL: http://www. usatoday.com/news/health/2003-02.25-bellyfatusat_x.htm.

body lift and circumferential lipectomy. The procedure is basically an ABDOMINOPLASTY (tummy tuck) that is extended around the back when the excess fat and skin involves not only the belly, but also the hips, back, buttocks and outer thighs. Belt lipectomy is considered major surgery and, although it is not offered at many hospitals, it has gained popularity as more patients undertake BARIATRIC SURGERY. The prime candidates have lost more than 100 pounds of weight, resulting in hanging skin and fat beyond the abdomen to include the full trunk area. This loose, baggy skin is not only unsightly, but can lead to rashes, yeast infections, sores in the skin folds, pain from the sheer weight of the skin and even a faulty center of gravity. According to Al Aly, M.D., at the University of Iowa Hospitals, where many belt lipectomies are performed, “Infection, bleeding, and seroma formation are the most frequent complications of belt lipectomy. Wound separation is another possible risk.” Costs for a belt lipectomy can range from $6,000 to $8,000. See also PANNICULECTOMY. Aly, Al, and Zlatko Anguelov. “Belt Lipectomy for Circumferential Truncal Excess.” University of Iowa Health Care. Currents 3, no. 4 (fall 2002). Available online. URL: http://www.uihealthcare.com/news/ currents/vol3issue4/04belt.html.

benzocaine A crystalline compound used in ointments as a mild local anesthetic. When used in a diet pill, it is supposed to deaden the taste buds and thereby lessen the craving for food. It is often used in “miracle” pills and weightreducing candies in combination with methyl cellulose, which expands by absorbing water from the stomach to give a false sense of fullness. Researchers are divided over whether benzocaine is such small doses (7.5 mg per tablet) actually has a numbing effect on the salivary glands. But, as Edwin Bayrd wrote in The Thin Game (1987) that argument “is quite beside the point, for the salivary glands are a part of the mouth and the pills are already in the stomach.” Beverly Hills Diet

belt lipectomy

Also called a thigh buttock lift, torsoplasty, circumferential torsoplasty, central

A diet promoted in a 1980 book of the same name by Judy Mazel. The diet stresses combinations of similar kinds of foods

binge-eating 63 that are digested together. The first week allows only fruit; the second adds a few other items. An updated version called The New Beverly Hills Diet (Health Communications) appeared in 1996, and advocated “conscious combining”—eating fruit alone, eating protein with other protein and/or eating carbohydrates with other carbs. Fats can be combined with either protein or carbohydrates, but not with fruit. A registered dietitian who reviewed the book for USA Today said, “If people lose weight on this plan, it’s not because of the food combining but because the program is low in calories.” In Journal of School Health (August 1988), M. Elizabeth Collins stated that the original Beverly Hills Diet marked the first time an eating disorder—anorexia nervosa—was marketed as a cure for obesity. “The popularity of the book, which focuses on the reward of being ‘skinny’ and ‘perfect,’ is viewed by [Orland] Wooley and [Susan] Wooley (former directors of the Eating Disorders Clinic at the University of Cincinnati College of Medicine) as yet another symptom of ‘a weight-obsessed culture in which no price is too high for thinness, including health.’ ” P. Wright also condemned the Beverly Hills Diet: “[It] actually advocates a form of bulimia in which dieters are advised to counteract an eating binge by consuming large amounts of raw fruit in order to produce diarrhea.” Hellmich, Nanci. “New Beverly Hills Diet Slim on Scientific Data.” USA Today, December 5, 1996. Wright, P., “The Psychology of Eating and Eating Disorders,” in Psychology Survey 6, edited by Halla Beloff and Andrew M. Colman, 140–165. Cambridge, Mass.: MIT Press, 1987.

biliopancreatic diversion (BPD)

A complicated for obesity developed in the 1970s in Italy, in which portions of the stomach are removed. The small pouch that remains is connected directly to the final segment of the small intestine, completely bypassing the duodenum and the jejunum. Although this procedure successfully leads to weight loss, it is less frequently used than other types of surgery because of the high risk for nutritional deficiencies. BPD is typically used for persons with severe obesity who have a BODY MASS INDEX of 50 or more.

MALABSORPTIVE OPERATION

A variation of BPD includes a duodenal switch. This leaves a larger portion of the stomach intact, including the pyloric valve, which regulates the release of stomach contents into the small intestine. It also keeps a small part of the duodenum in the digestive pathway. Nutritional deficiencies can occur because most iron and calcium are absorbed in the duodenum and jejunum. Menstruating women may develop anemia because not enough vitamin B12 and iron are absorbed. Decreased absorption of calcium may also bring on osteoporosis and metabolic bone disease. Patients are required to take nutritional supplements that usually prevent these deficiencies. Patients who have the biliopancreatic diversion surgery must also take fat-soluble (dissolved by fat) vitamins A, D, E and K supplements. BPD operations may also cause DUMPING SYNDROME. Because the duodenal switch operation keeps the pyloric valve intact, it may reduce the likelihood of dumping syndrome. The more extensive the bypass, the greater the risk for complications and nutritional deficiencies. Patients with extensive bypasses of the normal digestive process require close monitoring and lifelong use of special foods, supplements and medications. According to a news item in Obesity Management (January 2005), an analysis of 22,094 patients undergoing some sort of bariatric surgery between 1990 and 2003 showed a mean percentage of excess weight loss to be 61.2 percent for all procedures, with a BPD or duodenal switch resulting in the highest percentage of weight loss (70.1 percent). “However, this procedure had the highest operative mortality (1.1 percent) for a 30-day or less period.” Compared to other bariatric surgeries, BPD offers quicker weight loss (within three to five years) and a better chance to maintain weight loss while eating larger quantities of food. On the negative side, however, in addition to a greater chance of nutritional deficiencies, is more likelihood of chronic diarrhea, stomal ulcers and foul-smelling stools and gas. In a study of 132 morbidly obese patients who underwent BPD in Italy from February 1995 to April 2001, the incidence of complications was higher in those more than 55 years old.

binge-eating

Rapid consumption of large amounts of food during a short period of time. A

64 binge-eating disorder binge is usually defined as the consumption of 2,000 calories or more during the span of one to two hours. An average binge lasts from 60 to 75 minutes, with 3,400 calories consumed (an entire pecan pie, for instance). A joint Swiss-German-American study published in 2003 suggested that the melanocortin 4 receptor gene, which makes protein that helps stimulate appetite, may lead some people to binge eat when it makes too little protein. In the study, “all mutation carriers reported binge eating, as compared with 14.2 percent of obese subjects without mutations and 0 percent of the normalweight subjects without mutations.” Armstrong quoted scientists as saying that the challenge is to figure out a way to bypass the receptor in those people with the mutant gene. However, any magic pills to do this are likely years away. According to the National Institutes of Health, binge eating strikes as many as 4 million Americans. Branson, R., et al. “Binge Eating as a Major Phenotype of Melanocortin 4 Receptor Gene Mutations.” New England Journal of Medicine 348, no. 12 (March 20, 2003): 1,096–1,103.

binge-eating disorder (BED)

Prior to the designation of binge-eating disorder, persons engaging in binge eating without compensatory behaviors had received a variety of labels, including binge-eaters and compulsive overeaters. Binge-eating is defined in exactly the same way for both BULIMIA NERVOSA and for binge-eating disorder (BED). The difference between bulimia and BED is that BED is characterized by recurrent episodes of binge eating without the regular use of inappropriate compensatory behaviors (such as vomiting and laxatives). This is not to say that people with BED will not on occasion engage in purging behaviors such as compulsive exercise or vomiting, but they will not do it regularly. Binge-eating disorder also differs from obesity. Unlike obesity, BED is a psychiatric disorder and should be treated as such. Because people with BED binge on high-calorie foods and do not regularly engage in purging behavior, most of them are overweight; however, this does not mean that all overweight or obese people have binge-eating disorder. BED was not added to DSM-IV as an official type of eating disorder, but rather was added in the

appendix as a disorder needing further evaluation. As defined in DSM-IV, essential features of bingeeating disorder include • Recurrent episodes of binge eating. A “binge” is when one eats more food than most people would eat during a similar time period and under similar circumstances, plus exhibits a lack of control during the bingeing episode (cannot stop eating or cannot control what or how much one is eating). • The binge-eating episodes must be associated with at least three of the following: 1. Eating much more rapidly than normal 2. Eating past the feeling of “full,” until uncomfortable 3. Eating large amounts of food even though not hungry 4. Eating in secret due to shame and embarrassment over the amount being eaten. 5. Feeling distressed, depressed, disgusted and/or guilty after overeating. • Suffering distress over one’s binge eating in general. • Binges occur at least twice a week for approximately six months minimum. • No regular purging. Medical complications with BED include heart disease, respiratory problems and psychological problems; frequently substance abuse problems also exist. Approximately 50 percent of obese binge eaters suffer from depression, compared with only 5 percent of obese people who do not binge. If BED is considered an eating disorder, then it is more common than either anorexia or bulimia nervosa. The prevalence in the United States, Canada and the United Kingdom has been reported between 0.7 and 4 percent of the population. A 1991 study reported 8 percent of women who were overweight suffered from BED. In weight control programs, anywhere from 15 to 50 percent of the people suffer from BED. BED usually begins in late adolescence or the early 20s, but onset can be as early as age seven or in the 30s and 40s. It has been reported to be a chronic condition, but little is known about the long-term course of binge-eating disorder. In a study of 68 BED patients after six years of treatment, the majority showed no major DSM-IV eating disorder, while

biofeedback 65 5.9 percent still had BED, 7.4 percent had shifted to purging type bulimia nervosa, 7.4 percent were classified with unspecified eating disorders and one had died. Researchers are still trying to find the treatment that is the most helpful in controlling binge eating disorder, and in the meantime BED treatment regimens usually follow those of bulimia nervosa. Antidepressants and appetite suppressants have been found to be reasonably effective in controlling binge eating for some. In a randomized, double-blind, placebocontrolled study of patients who met the DSM-IV criteria for binge-eating disorder as well as the definition of obesity based on their body mass index, SIBUTRAMINE was found to be an effective and safe treatment of obese patients with BED over 12 weeks. Another randomized control trial found the anticonvulsant topiramate to be effective in reducing binge eating as well as weight. Psychotherapy treatment, in particular cognitive-behavioral therapy, appears to have longer-lasting effects than do medications. Appolinario, J. C., et al. “A Randomized, Double-Blind, Placebo-Controlled Study of Sibutramine in the Treatment of Binge-Eating Disorder.” Archives of General Psychiatry 60, no. 11 (November 2003): 1,109–1,116. Fichter, M. M. “Binge Eating Disorder: Treatment over a 6-Year Course.” Journal of Psychosomatic Research 44, no. 3–4 (March–April 1998): 385–405. Williamson, D. A., D. A. Gleaves, and S. M. Savin. “Empirical Classification of Eating Disorder NOS: Support for DSM-IV Changes.” Journal of Psychopathology and Behavioral Assessment 14, no. 2 (June 2002): 201–216.

Binge Eating Scale (BES)

A self-test developed in 1982 by Gormally, Black, Daston and Rardin to assess binge-eating among the obese. The BES contains 16 items designed to measure the behavioral components of the binge-eating syndrome and the feelings or perceptions that precede or follow a binge. Sample items from the BES: I don’t think about food a great deal.

Most of my days seem to be preoccupied with thoughts about food. I feel like I live to eat. Because I feel so helpless about controlling my eating, I have become very desperate about trying to get in control.

Binge Scale A self-test developed in 1980 by Hawkins and Clements. It contains nine items designed to measure binge-eating behavior (e.g., frequency, duration, rate of eating) and attitudes associated with BULIMIA. The scale was developed to parallel the diagnostic criteria described in DSM III. Sample item from the Binge Scale: How often do you binge? A. Seldom B. Once or twice a month C. Once a week D. Almost every day

biofeedback

A technique that seeks to control certain emotional states, such as ANXIETY or DEPRESSION, by modifying, with the aid of electronic devices, involuntary body functions such as blood pressure or heartbeat. This technique has been used with some success in the treatment of eating disorders. Its basic benefit is the teaching of relaxation techniques to counteract the typically high activity level of anorexics, who tend to deny fatigue and typically are unable to relax. They pursue their activities compulsively, producing excessive levels of automatic arousal (heart, blood pressure and so on), which can lead to psychophysiological stress reactions. Through connection to the biofeedback machines by muscle or temperature sensors, the patients learn to become active participants in the process of relaxation training. Patients find it difficult to deny their condition when the evidence can be seen on a sound or light monitor. Biofeedback may make it easier for the therapist to break through the denial process of anorexic patients. Pop-Jordanova reported on a small study comprising obese and anorexic girls, as well as a healthy control group, in which multimodal therapy included a biofeedback relaxation system based on electrodermal response (EDR). “The EDR biofeedback was shown to be an effective support for mitigation of eating disorders in preadolescents, with better results for anorexic girls.” The MANDOMETER TREATMENT, developed in Sweden, has claimed a 75 percent success rate among those with eating disorders, including anorexia and bulimia. This nutritional program teaches patients to

66 biopsychosocial model of eating disorders eat normally and recognize natural feelings of satiety using a patented computer-based biofeedback system. In 2003 the National Center for Complementary and Alternative Medicine, a part of the National Institutes of Health, awarded funds to explore possible therapies, such as the Flexyx Neurotherapy System (FNS), which is a new form of biofeedback using electroencephalograph (EEG) or brainwave information. Neurotherapy is a type of EEG biofeedback treatment, and is used at the Mirasol eating disorders treatment center in Tucson, Arizona (see APPENDIX IV). Gross, Meir. “Anorexia Nervosa—Treatment Perspectives.” In Eating Disorders: Effective Care and Treatment, edited by Félix E. F. Larocca. St. Louis: Ishiyaku EuroAmerica, 1986. Pop-Jordanova, N. “Psychological Characteristics and Biofeedback Mitigation in Preadolescents with Eating Disorders.” Pediatrics International 42, no. 1 (February 2000): 76–81.

biopsychosocial model of eating disorders

The prevailing conceptualization of the etiology (causes) of eating disorders and/or obesity. According to the model, rather than there being a single cause, these disorders/conditions are more likely the product of a complex combination of biological, psychological and social factors. The precise contribution of each of these factors may vary, depending on the disorder and the individual.

Johnson, C. and M. E. Connors. The Etiology and Treatment of Bulimia Nervosa: A Biopsychosocial Perspective. New York: Basic Books, 1987.

biotech foods

Crops produced by utilizing the modern techniques of biotechnology. Although all crops have been genetically modified through traditional plant breeding for more than 100 years, with the tools developed from biotechnology a gene can be inserted into a plant to give it a specific new characteristic instead of mixing all of the genes from two plants and seeing what comes out. Once in the plant, the new gene does what all genes do: It directs the production of a specific protein that makes the plant uniquely different. This technology provides much more control over, and precision to, what characteristic breeders give to a new plant. It also allows the changes to be made much faster than ever before.

Most biotech products are drugs, but the biotech industry hopes to help fight the global obesity epidemic by developing healthier varieties of food oils with fewer calories, as well as new flavor enhancers that could replace some of the excessive sugar, salt and fats in packaged foods with substances that both tantalize the taste buds and make foods healthier. For instance, Crabtree explains, “Devising a molecule that enhances the sweet taste might allow food companies to make cookies and soft drinks that require less sugar without sacrificing flavor.” The issue of biotech foods has raised some controversy and protests. According to the Food and Drug Administration (FDA), “All labeling for a food product must be truthful and not misleading. If a bioengineered food is significantly different from its conventional counterpart—if the nutritional value changes or it causes allergies—it must be labeled to indicate that difference.” Crabtree, Penni. “Weapons for a Food Fight: Firm’s Flavor Enhancers May Help in Battle on Obesity.” The San Diego Union-Tribune, October 1, 2004. Available online. URL: http://www.signonsandiego.com/uniontrib/20041001/news_1b1senomyx.html. Thompson, Larry. “Are Bioengineered Foods Safe?” FDA Consumer, vol. 34, no. 1, January/February 2000. Available online. URL: http://www.fda.gov/fdac/ 2000/100_bio.html.

body dysmorphic disorder (BDD)

Defined by the DSM-IV as a preoccupation with some imagined defect in physical appearance or a gross exaggeration of a slight physical anomaly, this preoccupation with appearance is excessively time consuming and causes significant distress or impairment in functioning. Symptoms of dissatisfaction with body shape and size that are a function of an eating disorder are exclusionary criteria for BDD. The most common complaints are about features involving the head and body hair, facial features, skin blemishes, thighs, stomach, breasts, buttocks and genitals. It appears that a majority of patients have multiple dysmorphic symptoms. The exact connection between BDD and eating disorders is unclear, but Rosen has argued that both are basically disorders of body image.

Cororve, M. B., and D. H. Gleaves. “Body Dysmorphic Disorder: A Review of Conceptualizations, Assess-

body fat 67 ment, and Treatment Strategies.” Clinical Psychology Review 21, no. 6 (August 2001): 949–970. Rosen, James C. “Body Dysmorphic Disorder: Assessment and Treatment.” Body Image, Eating Disorders, and Obesity. Ed. J. Kevin Thompson. Washington, D.C.: American Psychological Association, 1996, pp. 149–170.

body fat Body fat is a reservoir of available fuel for energy needs. When CALORIES are eaten in excess of immediate needs, the body converts this fuel into a storable form (FAT). When an insufficient number of calories are eaten, the body takes some of the stored fat and metabolizes it into available fuel. (See METABOLISM.) Some body fat is desirable. For example, fat cushions the balls of the feet and protects the bony structure. Fat insulates the organs from cold during winter months and protects them against damage from outside the body. Too-low body fat reduces resistance to viral infection. Excess body fat, however, is harmful. Excess fat requires the heart to pump harder and at higher pressures simply because the arterial circuit is longer. Fat also chokes down the available passageways, forcing the heart to pump still harder. This extra strain significantly increases the risk of heart attacks, strokes, hypertension and other cardiovascular diseases. In addition, excess fat puts undue strain on other body organs and has proven to significantly increase the risk of diabetes and even certain types of cancers. Dutch researchers have reported that internal fat deposits can physically compress the kidneys, cramping their ability to control the flow of fluid through the body, resulting in a build-up of blood pressure. Compare a five-foot seven-inch football player weighing 200 pounds and a sedentary executive of the same height and weight. The athlete may have 6 to 7 percent body fat (at the low end of the recommended range), while the executive may have 25 percent (over the recommended maximum). The theoretical maximum percentage of body fat is 68 percent. What is recommended? According to the University California Wellness Letter (January 1991), the ideal amount of body fat varies from person to person, depending on age, sex, fitness level and genetic makeup. It can also vary accord-

ing to who sets the standards. Many researchers suggest a desirable range for men of between 11 and 18 percent; for women, between 16 and 23 percent. Others say that up to 23 percent is acceptable for men and up to 30 percent for women. Recent data indicate that simple DIETING reduces lean body material (muscle) and predisposes the individual to regain lost weight with even higher percentages of body fat (see YO-YO DIETING). However, simultaneous dieting and exercise retains and even increases muscle, initially at the expense of water, then fatty tissue. Studies are under way exploring techniques that could increase thermogenesis and permit obese people to burn off their excess fat. During World War II the U.S. Navy sought submariners with low body fat for their greater ability to withstand nitrogen uptake and discharge, which protected them against the “bends.” Thus began the search for a reliable means to measure body fat. Until recently, the methods most often used were hydrostatic testing (water pressure), SKIN FOLD MEASUREMENT, blood analysis and impedance measurements (sound waves). The direct method for measuring body fat is through biopsies. However, other measurements have been developed and are now used more frequently. Densitometric analysis (hydrostatic weighing) compares regular weight with underwater weight in calculating the amount of lean body mass and body fat. (Because fat weighs less than water, a fatter person weighs proportionately less underwater than a lean one.) This method has become the “control” against which other fatmeasuring methods are compared and standardized. However, equipment to perform these tests can usually be found only at certain hospitals or university labs. Anthropometric measurements such as body circumference and thickness of skin fold provide more practical assessments for measuring body fat. In particular, caliper measurements of skin folds have been advocated for use in behavioral research. In this procedure, calipers are used to measure the thickness of skin and underlying fat at several locations on the body, with results calculated in an equation. However, some researchers have found measurement of height and weight to have a smaller standard deviation than skin folds, so they are frequently the anthropometric meas-

68 body fat distribution urements of choice in assessing fatness. In addition, some clinicians have found height and weight measurements more convenient, practical and reliable in treatment than the caliper assessments. Recently developed instruments offer the ability to determine an accurate measurement of body fat and lean body mass with no discomfort, with results in seconds. These fitness and body fat analyzers are based on a technology developed by the U.S. Department of Agriculture. By touching the biceps, a fiber-optic wand emitting infrared light senses a spectrum change (because fat absorbs more light than muscle or bone) and displays an accurate body-fat percentage on a digital readout. Still another development is the bioelectrical impedance analysis (BIA). This sends a mild electrical current through electrodes attached to the foot and hand; the greater the resistance to electricity, the more body fat. Researchers do not agree about the reliability of the BIA and infrared tests. More recent methods developed for the determination of body fat analysis include ultrasound, computed tomography, dual energy X-ray absorptiometry (DEXA), Bod Pod and magnetic resonance imaging (MRI). Ultrasound machines frequently show up at health fairs, schools and health clubs. An ultrasound beam radiates through the body area (the biceps, for example), with the speed it takes to hit the bone and bounce back determining body fat percentage. Experts question its accuracy, which depends greatly on the expertise of the technician operating the machine. Computed tomography shoots a beam of low intensity X-rays through a body area, then senses the strength of the remainder beam after it goes through the area. The machine rotates a degree and the process repeats. Once the scanner collects several of these readings, its computer processes the information and produces a graphical representation of the area. Dual energy X-ray absorptiometry, a technique currently used to study osteoporosis, has been demonstrated as a reliable tool for measuring body fat. It works by scanning the body from head to toe, using a filter to split the X-ray beam into two energy levels to measure bone or tissue density. While the margin for error is only 2 to 3 percent, the high cost of a test restricts its use in most cases for research rather than for clinical purposes.

The Bod Pod, an orb-shaped body-enclosing chamber, differentiates fat and lean tissue through computerized pressure sensors that determine body density by measuring the quantity of air displaced by the person sitting inside the chamber. Developed with a grant from the National Institutes of Health, more than 100 Bod Pods are in use nationwide. Its accuracy has been reported to correlate to that of hydrostatic weighing. Costs for a measurement may be $50 to $75 or more. Magnetic resonance imaging (MRI), the latest method of testing for body fat, is currently under study. In a 1998 report, Thomas et al. found that the large variation in individual internal fat content cannot be predicted from either indirect methods or direct imaging techniques, such as MRI or computed tomography, on the basis of a single-slice sampling strategy. See also ASSESSMENT OF BODY FAT. Eliakim, A., et al. “Fitness, Fatness and the Effect of Training Assessed by Magnetic Resonance Imaging and Skinfold-Thickness Measurements in Healthy Adolescent Females.” American Journal of Clinical Nutrition 66, no. 2 (August 1997): 223–231. Gray, D. S. “Skinfold Thickness Measurements in Obese Subjects.” American Journal of Clinical Nutrition 51, no. 4 (April 1990): 571–577. Lehmann, Annie. “Machine Measures Body Fat by Deducting Displaced Air.” Detroit Free Press, March 24, 1998. Available online. URL: http://www.freep.com/ news/health/qbody/24.htm. Lytle, Lisa. “How Tests Measure Body Fat, and Their Accuracy.” Seattle Times, October 2, 1996, Living section. Mayo Clinic. “New Ways to Measure Body Fat.” Mayo Health Oasis (June 5, 1996). Thomas, E. L., et al. “Magnetic Resonance Imaging of Total Body Fat.” Journal of Applied Physiology 85, no. 5 (November 1998): 1,778–1,785. Westrate, J. A., et al. “Body Composition in Children: Proposal for a Method for Calculating Body Fat Percentage from Total Body Density or Skinfold-Thickness Measurements.” American Journal of Clinical Nutrition 49, no. 11 (November 1989): 1,104–1,115.

body fat distribution The pattern of fat distribution on a person’s body can have as direct a relationship to health and mortality as the total amount of body fat. For example, in women, upper-body fat may be associated with a higher risk of diabetes than lower-body fat accumulation. In both men and women, abdominal obesity is

body fat distribution 69 associated with an increased risk of heart disease. Thus, knowledge of body composition and fat distribution is increasingly recognized as an essential component of an overall nutritional assessment. A relative predominance of fat in the abdominal region (called the apple shape) as well as the shoulders and neck is found more often in men and is strongly related to metabolic disturbances such as diabetes mellitus, hypertriglyceridemia and hypertension. In women, gluteal-femoral (buttocks-hipthigh) obesity is more common, but when they do have body fat concentrated in the stomach, they have a six-times-greater chance of developing breast cancer than women with flat stomachs, according to a study conducted by Dr. David V. Schapira, associate professor of medicine at the University of South Florida College of Medicine. Researchers compared 216 women newly diagnosed with breast cancer with 432 women who were tested but did not have cancer. They found that the cancer patients had more abdominal and upper-body fat than those not diagnosed with cancer. Schapira reported that the women with fat in the stomach area had lower levels of a protein called sex hormone binding globulin, which leads to increased levels of free estrogen. Increased free estrogen levels are thought to contribute to the development of breast cancer. When the women lost weight in the abdominal region, levels of the protein increased. In another study, conducted at Washington University School of Medicine, researchers discovered that people with beefy hips and trim waists (pear shaped) have higher levels of a protective form of cholesterol called HDL than do those who are apple shaped. This is believed to be a possible explanation of why people with fat posteriors tend to have healthier hearts than those with big bellies. Body fat distribution has been related not only to morbidity and mortality of obesity but also to adipose tissue cellularity. That is, in abdominal obesity fat cell size is relatively enlarged, whereas in glutealfemoral obesity the number of fat cells is increased. While gender differences are the most obvious influences of distribution of body fat, age is another significant factor; the body changes shape as it grows and ages. A National Institute on Aging study of 1,179 men and women aged 17 to 96 showed progressive trends toward increased upper- and central-body fat deposits with age. In

women there tends to be a postmenopausal acceleration of this trend. A Yale University study determined the degree of weight occupation and body dissatisfaction in 77 women between the ages of 21 and 50. Women with the greatest distribution of their fat in the hips and buttocks, relative to the abdomen and waist, were the most eating-disordered and saw attaining the “right” weight as more central to their sense of self. Individual differences in fat distribution are largely determined by hereditary factors. Environmental factors, including diet and exercise habits, determine the extent to which individual genetic predispositions are fulfilled. Underwood and Adler point out that a Tufts University study illustrated how the source of calories might make some difference in where they end up. In the study, “participants ate roughly the same number of calories, but those who consumed more white bread, rice, pasta and other refined carbohydrates tended to add fat disproportionately around the middle, even without a big change in weight. Other foods produced little change in waist measurements. These good foods included whole grains, beans, fruits and vegetables.” Weight loss does not guarantee that inches will be shed from desired areas. On the contrary, success as measured on the bathroom scale is often not translated into the reality of a more shapely body as visualized in the imagination. Recent studies have confirmed that some areas of the body tend to be resistant to slimming. British researchers have documented the resistance of the thighs to weight loss regimens. Measurements of women’s waists and thighs were used to compute a “fat distribution score,” a ratio between abdominal and thigh circumferences. Increasing thigh size relative to waist circumference yielded a lower ratio and vice versa. Following completion of a weight reduction regimen, fat distribution scores showed little change, indicating that fat was shed proportionately from both areas of the body without altering their proportions relative to each other. This study is consistent with the experiences and frustrations of many dieters who, despite weight loss, are unable to achieve their primary goal, improvement in body shape. A Boston study reported in the May 1991 American Journal of Clinical Nutrition indicated that when

70 Body Image: An International Journal of Research smokers start putting on fat, they are slightly more likely than nonsmokers to deposit it around the abdomen. Because people with abdominal obesity are more likely to develop heart disease, this finding may offer one partial explanation for smokers’ higher risk of this disease. A study presented by the Wake Forest University Baptist Medical Center in North Carolina at the annual meeting of the North American Association for the Study of Obesity in November 2004 suggests that accumulation of fat in the abdominal area in middle age may increase the risk of disability in later years. The study followed more than 9,000 African-American and white men and women age 45 to 64 years for nine years. Huggins explained, “Overall, disability risk increased along with increasing abdominal fat, and this was often true even among normal-weight study participants. The greatest risk of disability, however, was found among those in both the highest body mass index and the highest abdominal fat categories.” See also ADIPOSE TISSUE; BODY FAT; METABOLIC SYNDROME. Huggins, Charnicia. “Too Much Belly Fat May up Later Disability Risk.” Reuters Health, November 17, 2004. Underwood, Anne, and Jerry Adler. “What You Don’t Know about Fat.” Newsweek 144, no. 8 (August 23, 2004): 40–47.

Body Image: An International Journal of Research A peer-reviewed journal that began publication in 2004, and publishes research on body image and human physical appearance. It is published by Elsevier, and the editor is Thomas F. Cash, Ph.D., Department of Psychology, Old Dominion University, Norfolk, VA 23529; [email protected]; http://www.elsevier.com or http://www.bodyimages.com/research/journal.html

body image assessment (BIA) The BIA, originally developed by Williamson and colleagues, is a simple procedure for assessment of body image disturbance. The test consists of nine silhouettes ranging from very small to very large. A research participant or client is asked to select the card that best represents her current body size and her ideal body size. The difference between the two is conceptualized as the degree of body dissatisfaction. Williamson and

colleagues demonstrated that, when compared with same-size controls, persons with body anorexia and bulimia nervosa choose a larger current body size and smaller ideal body size. Williams, T. L., D. H. Gleaves, A. Cepeda-Benito, S. A. Erath, and M. B. Cororve. “The Reliability and Validity of a Group Administered Version of the Body Image Assessment.” Assessment 8, no. 1 (March 2001): 37–46. Williamson, D. A., et al. “Development of a Simple Procedure for Assessing Body Image Disturbance,” Behavioral Assessment 11 (1998): 433–446.

body image disturbance

A term that has been used to describe numerous phenomena but generally refers to a disturbance in the way one thinks, feels, or perceives one’s body or how one behaves regarding such thoughts, feelings or perceptions. As implied in this definition, body image disturbance is generally conceptualized as having several components or dimensions: a) a perceptual component that refers to how accurately someone can estimate his/ her own body size, b) a subjective/attitudinal component that refers to attitudes, feelings, and thoughts about one’s body, and c) a behavioral component that refers to avoidance of situations that may cause someone to experience dysphoria due to body image concerns. It has been found that body image disturbance and body dissatisfaction are associated with eating disordered attitudes and behaviors and that body image disturbance likely plays a causal role in the development of eating disorder symptoms. Currently, some aspect of body image disturbance is included as a diagnostic criterion for both anorexia and bulimia nervosa. For anorexia nervosa, the criterion reads that there is a “Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.” For bulimia nervosa the criterion simply reads that “self evaluation is unduly influenced by body shape and weight.” Both of these criteria have somewhat decreased the emphasis of perceptual body image and indeed much research suggests that the effective body image (i.e., how one feels about one’s body) may be most important with regard to eating disorders. However, research by Williamson, Gleaves and colleagues suggests that

body mass index 71 the perceptual component should not be abandoned because it may contribute to one’s overall feelings about one’s body may be equivalent for anorexia and bulimia nervosa. Experiencing body image disturbance (or distorted body image) is like booking into a funhouse mirror: You see yourself as fatter than you are. For the ANOREXIA NERVOSA patient, misperception reaches quasi-delusional proportions and is evident in the anorexic’s lack of concern about, stubborn defense of or inability to recognize an emaciated condition. Some patients display a variation of this disturbance in which their misperception is restricted to a particular part or parts of the body. Stomach or thighs are magnified in a patient’s mind and seem disproportionate to the rest of the body. These patients will acknowledge that in general they appear emaciated but believe that further dieting is necessary to eliminate a protruding belly or some other perceived unattractive feature. HILDE BRUCH first recognized body image disturbance to be an essential characteristic of anorexia nervosa, and she considered its correction necessary for recovery. An analysis of multiple ethnic groups by the University of South Florida showed Caucasian and Hispanic Americans exhibiting more weight-related body image disturbance than African Americans and Asian Americans. African Americans had the most positive general appearance body image. Many obese individuals perceive themselves as larger than they are and have very negative attitudes toward their body. Patients who have been obese as children or adolescents and who subsequently lose weight often retain a distorted perception of themselves as very obese. In a 1996 study, obese individuals with binge-eating disorder reported significantly greater body image disturbance than obese non-binge-eating participants See also OBESITY; CHILDHOOD OBESITY; ADOLESCENT OBESITY. Altabe, M. “Ethnicity and Body Image: Quantitative and Qualitative Analysis.” International Journal of Eating Disorders 23, no. 2 (March 1998): 153–159. Ben-Tovim, David I. “Body Size Estimates: Body Image or Body Attitude Measures.” International Journal of Eating Disorders 9, no. 1 (1990): 57–67. Gleaves, David H., et al. “Clarifying Body Image Disturbance: Testing a Multidimensional Model Using Structural Modeling. Journal of Personality Assessment 64, no. 3 (June 1995): 478–493.

Mussell, M. P., et al. “Differences in Body Image and Depression among Obese Women with and without Binge Eating Disorder.” Obesity Research 4, no. 5 (September 1996): 431–439. Rucinski, Ann. “Relationship of Body Image and Dietary Intake of Competitive Ice Skaters.” Journal of the American Dietetic Association 89, no. 1 (January 1989): 98–100. Steiger, H., Fraenkel, L. and P. P. Leichner. “Relationship of Body-Image Distortion to Sex-Role Identifications, Irrational Cognitions, and Body Weight in Eating-disordered Females.” Journal of Clinical Psychology 45, no. 1 (January 1989): 61–65. Thompson, J. K., and S. Tantleff-Dunn. “Assessment of Body Image Disturbance in Obesity.” Obesity Research 6, no. 5 (September 1998): 375–377. Williamson, D. A., B. A. Cubic, and D. H. Gleaves. “Equivalence of body image disturbance in anorexia and bulimia nervosa.” Journal of Abnormal Psychology 102, no. 1 (February 1993): 177–180.

body mass index (BMI) A way of measuring body mass, defined as weight in kilograms divided by height in meters squared. BMI is the measurement of choice for many physicians and researchers studying obesity. In June 1998, the National Institutes of Health adopted the BMI standard in the dietary guidelines issued earlier by the Department of Agriculture. Under those guidelines, a BMI under 19 is underweight, BMI 19 to 25 is healthy weight, BMI 25 to 29.9 is overweight, BMI 30 to 39 is obese and BMI 40 and above is morbidly obese. A BMI cutoff of 17.5 or less is used for defining anorexia in the International Classification of Diseases, Tenth Revision (ICD-10). According to the guidelines, a BMI of 30 is about 30 pounds overweight and is equivalent to 221 pounds in a six-foot-tall person and to 186 pounds in someone who is five feet six inches tall. The BMI numbers apply to both men and women. The BMI measurement poses some of the same problems as the weight/height tables. Doctors don’t agree on the cutoff points for “healthy” versus “unhealthy” BMI ranges. BMI also does not provide information on a person’s percentage of body fat. Some very muscular people may have a high BMI without health risks. Also, BMI may underestimate body fat in older persons and others who have lost muscle mass. However, like the weight-for-height table, BMI is a useful general guideline (also known as Quetelet’s index). A shortcut to estimating BMI is to multiply one’s weight (in pounds) by 704.5, then divide the result

72 body types by height in inches, then divide again by height in inches. The result should be close to one’s BMI. The National Institutes of Health offers a Web page that does the computing at http://www.nhlbi support.com/bmi/bmicalc.htm. See also WAIST-TO-HIP RATIO. Greil, H., and U. Trippo. “Physique and Body Composition: Comparisons of Methods and Results.” Collegium Antropologicum 22, no. 2 (December 1998).

body types

Typologizing the human body, or classifying bodies by shape and size, has been proposed since Hippocrates, who described the basic Greek physiques as phthisic (linear and vertical) and apoplectic (broad and horizontal). Ernst Kretschmer, a 19th-century psychiatrist, divided the population into pyknics (short and round) and asthenics (lean and long legged), with athletes falling somewhere in between. After analyzing thousands of specially posed photographs, William Sheldon devised a three-part classification of body types in 1940. He named them ENDOMORPHS (soft, round, fleshy, light boned, well padded), MESOMORPHS (muscular, square, broad shouldered, sturdy) and ECTOMORPHS (long legged, fragile, thin, skeletal, linear) Sheldon also claimed that body type is an unalterable inheritance, demonstrating by his elaborate measurement system that people retained the same basic body type after weight changes of as much as 100 pounds. He demonstrated that even after subjects underwent semi-starvation for six months and changed outward signs of body type, they all returned to their original shapes within two years. Forced-weight-gain tests produced similar results. Kretschmer’s and Sheldon’s studies are not considered scientifically sound today.

body wrapping A technique claimed by hucksters on late-night television, in magazine ads and on the Internet to cause layers of fat to disappear without dieting. Common body-wrapping devices in the past have included sauna suits or heated belts strapped to the waist or stomach or whatever area needed reduction. The heat produced by such gadgets, either alone or when used in conjunction with exercise, supposedly melts away fat much as a hot stove burner melts lard or butter in a saucepan. The advertisements do not explain how

the body can withstand temperatures high enough to melt deposited fat, or how the melted fat will be eliminated from the body. Current popular body wraps include plastic or cotton cloths soaked in herbal products. Sometimes the cream, gel or lotion is applied to the skin before the wrap is worn. Body wraps temporarily cause a loss of inches and sometimes pounds due to fluid loss or perspiration. The fluid, along with the inches or pounds, is soon replaced by drinking or eating. Experts consider body wraps to be potentially dangerous because they can bring about severe dehydration, personal injury from circulatory constriction or cardiac incident while exercising. See also FRAUDULENT PRODUCTS. McCurdy, John A., Jr. Sculpturing Your Body: Diet, Exercise and Lipo (Fat) Suction. Hollywood, Fla.: Frederick Fell Publishers, 1987.

borderline personality disorder A personality disorder characterized by instability in numerous areas of one’s life, impulsiveness and fears of abandonment. Research suggests that borderline personality disorder is the personality disorder most frequently associated with eating disorders. However, some of this comorbidity may be due to an overlap in the criteria. For example, the binge eating of a person with bulimia nervosa would also meet the impulsiveness criteria for borderline personality disorder. brain activity and obesity

In recent years, scientists have been working at deciphering the connections between human brain activity and obesity. Antonio Tataranni, a nutrition expert at the National Institutes of Health’s branch office in Phoenix, found that six different regions in the brains of 55 volunteers responded in different ways depending on whether the subjects were hungry or full, fat or thin. According to Boyd, “Tataranni took PET (positron emission tomography) scans of the volunteers after they had gone without food for 36 hours, and again after they were fed a hearty meal. He discovered significant changes in the way six different sites in the volunteers’ brains responded to hunger and fullness.” Tataranni explained that different regions of the brain work in concert to orchestrate nor-

breakfast and obesity 73 mal eating behaviors and conspire to produce obesity and other eating disorders. He noted that 11 people in the study were of special interest because they were formerly obese and their brain scans resembled those of fat people more than thin people. “We are now working on the vastly more important and complicated questions of which of these neural differences may cause obesity in the first place.” An earlier study suggested that reduced brain activity of dopamine, a naturally occurring substance that modulates feelings of pleasure, may contribute to obesity as well as drug addiction. The National Institute on Drug Abuse (NIDA) funded study led by GeneJack Wang, M.D., of the U.S. Department of Energy’s Brookhaven National Laboratory found that the brains of obese individuals have relatively few of the nerve cell components called D2 receptors through which dopamine acts to stimulate pleasurable feelings from basic activities such as eating and sex. Individuals with this deficiency may need to overeat to get feelings of gratification from food, the researchers say. Because a deficit of the same receptor has been implicated in addiction to cocaine, heroin and other drugs of abuse, the researchers suggest that it may be linked to a range of compulsive behaviors. A later NIH study also led by Wang revealed that the parts of the brain responsible for sensation in the mouth, lips and tongue are more active in obese people than in normal-weight control subjects. This enhanced sensitivity could at least partially account for the powerful appeal and significance that food has for obese individuals. Tataranni and colleagues at Good Samaritan Medical Center in Phoenix, Arizona, took pictures of the brains of 21 obese and 20 lean, hungry subjects, both before and after tasting a liquid meal (Ensure Plus) following a 36-hour fast. Their findings were presented at the 2004 annual meeting of the Endocrine Society. The researchers found significantly elevated activity in the brain regions that are activated in response to the sensory and emotional aspects of food ingestion in the obese subjects. “Abnormally high activity in the insular cortex region of the brain, which responds to the sensory experience of food, may put people at an increased risk for developing obesity. Continued research in this area could help us understand why some people consistently overeat and are suscepti-

ble to gaining weight.” It is unknown whether the brains of obese people are especially sensitive to food stimuli or if other aspects of being obese change the way the brain responds to any stimulus, noted the researchers. Boyd, Robert S. “Researchers Use Brain Activity as Marketing Tool, Obesity Clue.” Knight Ridder/Tribune News Service, June 25, 2004. Mathias, Robert. “Pathological Obesity and Drug Addiction Share Common Brain Characteristics.” NIDA Notes 16, no. 4 (October 2001). Available online. URL: http://www.drugabuse.gov/NIDA_Notes/NNVol16N4/ pathological.html. Wang, Gene-Jack, et al. “Brain Dopamine and Obesity.” Lancet 357, no. 9253 (February 3, 2001): 354–357.

breakfast and obesity Long considered the most important meal of the day, recent research is showing that breakfast may have more influence on obesity than scientists had realized. A study that followed nearly 4,000 healthy people ages 25 to 37, who answered surveys, found that people who eat breakfast are significantly less likely to be obese than those who frequently skip the morning meal. The risk reduction for obesity was consistent for white men and women and for black men, but not for black women, a difference the researchers are continuing to study. The study was limited, however, because researchers cannot determine cause and effect from a self-reporting study. Another study of 499 people over a year’s time also found that skipping breakfast was associated with increased prevalence of obesity—this study showed 4.5 times greater risk—as was greater frequency of eating breakfast or dinner away from home. Because of findings such as these, researchers are beginning to look more closely at what people eat for breakfast. A study funded by Kellogg USA and conducted by UC Berkeley researchers investigated the relationship between breakfast type, energy intake and body mass index (BMI). The analyzed breakfast categories were breakfast skippers, meat/eggs, ready-to-eat cereal, cooked cereal, breads, quick breads, fruits/vegetables, dairy, fats/sweets and beverages. Breakfast skippers and fruit/vegetable eaters had the lowest daily energy intake. The meat/egg eaters had the highest daily energy intake and one of the highest BMIs. The

74 brown fat authors concluded, “This analysis provides evidence that skipping breakfast is not an effective way to manage weight. Eating cereal (ready-to-eat or cooked cereal) or quick breads for breakfast is associated with significantly lower body mass index compared to skipping breakfast or eating meats and/or eggs for breakfast.” Cho, S., et al. “The Effect of Breakfast Type on Total Daily Energy Intake and Body Mass Index: Results from the Third National Health and Nutrition Examination Survey (NHANES III).” Journal of the American College of Nutrition 22, no. 4 (August 2003): 296–302. Ma, Yunsheng, et al. “Association between Eating Patterns and Obesity in a Free-Living US Adult Population.” American Journal of Epidemiology 158, no. 1 (July 2003): 85–92.

brown fat

A type of tissue named for its brownish color, caused by the numerous blood vessels that course through it. In humans, thermogenesis takes place in brown fat tissue. Thermogenesis is a process, induced by food intake or by cold temperatures, whereby calories are converted to heat. An impairment in thermogenesis can result in greater efficiency in energy storage, which could lead to excess fat. Abundant in newborn infants, brown fat can be found under the arms, across the back, near the kidneys and around large blood vessels in the chest. Research suggests that defective brown fat cells might be the cause of obesity in some people. Heavy people appear to have less brown fat than average-weight people, and what they do have seems to work inefficiently. All this is conjecture, with nothing proven scientifically.

Bruch, Hilde (1904–1984)

A practicing psychiatrist and professor of psychiatry at Baylor College of Medicine in Houston. In the years following World War II, she was the most influential person in the United States in shaping the conception of eating disorders as psychiatric illnesses and in formulating psychotherapeutic approaches to their treatment. Throughout her work Bruch stressed the formation of individual personality and factors within the family that precondition victims of these disorders to respond to certain kinds of problems by self-starvation or overeating. Bruch did not regard obesity as a single condition but distinguished three main forms: in some

individuals obesity is due to physical factors, and their weight has no association with emotional problems. Others have “reactive obesity,” brought about by overeating in situations of psychological stress. The third type, “developmental obesity,” has its onset in childhood and is associated with a disturbance in the maturation of the individual’s personality. Bruch was one of the first to stress that many cognitive defects in anorexics are directly related to starvation. Therefore, a meaningful psychiatric evaluation is possible only after the worst effects of malnutrition have been corrected. Bruch’s principal works include Eating Disorders: Obesity, Anorexia Nervosa, and the Person Within (New York: Basic Books, 1973); The Golden Cage: The Enigma of Anorexia Nervosa (Cambridge, Mass.: Harvard University Press, 1978; New York: Vintage Books, 1979); Conversations with Anorexics/Hilde Bruch, edited by Danita Czyzewski and Melanie A. Sur (New York: Basic Books, 1988).

bulimarexia

A term coined in 1976 by Marlene Boskind-White to cover the compulsive practice of bingeing and purging; at the time BULIMIA was officially described as bingeing without purging (DSMII). Bulimarexia was called a “nomenclature atrocity” by HILDE BRUCH. Though still used by some researchers and clinicians as interchangeable with “bulimia” or “bulimia nervosa,” in the current DSM, this term would be best captured under the diagnosis of anorexia nervosa, binge eating/purging type. Boskind-White, Marlene, and William C. White Jr. “Bulimarexia: A Historical-Sociocultural Perspective.” In Handbook of Eating Disorders, edited by Kelly D. Brownell and John P. Foreyt. New York: Basic Books, 1986.

bulimia

The word bulimia literally means “ox hunger” or gorging. It refers to the compulsive practice of binge eating. The term has been used in various ways by different medical authors, for example, to describe a subgroup of patients with anorexia nervosa who also binge eat. In the DSMIII, bulimia was an official diagnostic category. However, with the DSM-III-R and DSM-IV, the criteria were refined and the name changed to BULIMIA NERVOSA. Today, although some researchers and/or clinicians use the terms bulimia and bulimia

bulimia nervosa 75 nervosa interchangeably, it is more appropriate to use the term bulimia to refer to the symptom of binge eating and bulimia nervosa to refer to the current disorder as defined in the DSM-IV.

bulimia nervosa

An eating disorder characterized by recurrent binge-eating followed by some compensatory behavior (e.g., vomiting or use of laxatives). Also characteristic of the disorder is an intense preoccupation with body size and shape. It is not known to be caused by any physical illness; genetic and neurochemical factors have been implicated in its cause. It usually begins in adolescence or early adult life and is 10 times more common in females than in males. A number of terms have been used to describe this disorder, but the term bulimia nervosa introduced by GERALD F. M. RUSSELL, is the most widely accepted and frequently used because it implies a link to ANOREXIA NERVOSA and differentiates the syndrome from simple binge-eating (bulimia). In moments of stress, bulimics turn toward food, not away from it as anorectics do. Bulimic patients are usually more distressed and humiliated by their behavior than anorectics, swinging between intense feelings of self-control while dieting and total self-loathing when bulimic. Sometimes eating behavior becomes bizarre. A young woman from a financially secure background may search through garbage for food. Another may shoplift food or steal money from friends and family to buy it. The behavior that supports the “habit” of recurring bulimia can resemble that of alcoholism, and its cost may also be similar. Bulimics usually control their eating while busy with other things, but during solitary leisure time they may eat to the point of exhaustion. Enormous amounts of food may be eaten at one time, as many as 20,000 calories a day. Some studies have shown the average binge to last slightly less than 11/4 hours and to include slightly more than 3,400 calories. However, research also demonstrates that there is great variability (in terms of size) in what persons with bulimia nervosa call a binge. What seems to be the most salient feature is the feeling of lack of control during the eating episode. Nevertheless, the DSM-IV does now specify that, in order to meet the diagnostic criteria for the disorder, the person does have to engage in objectively large

binges at least twice per week. This bingeing will be followed by purging via vomiting (induced by gagging, emetics or simply willing it), diuretics or laxatives (from 50 to 100 or more tablets at one time). Although it is common in most industrialized countries, bulimia nervosa is said to be epidemic in the United States. It is harder to detect than anorexia because there is no obvious physical evidence such as emaciation, and thus the extent of bulimia nervosa is less clear than that of anorexia, but medical experts estimate that as many as 16 to 30 percent of all women may have practiced bulimic behaviors to some degree. The condition usually becomes symptomatic between ages 13 and 20. According to DSM-IV, the prevalence of bulimia nervosa among adolescents and young adult females is 1–3 percent. When Drewnowski, Yee and Krahn of the University of Michigan conducted a survey of college freshman in 1988, they found the incidence of bulimia nervosa to be 4.2 cases per 100 women per year. The rate remained stable (2.9–3.3 percent) as new cases were offset by partial remissions. Some women continued bulimic behaviors without meeting full diagnostic criteria. In a survey conducted of 1,728 10th-grade students, 13 percent reported purging behavior. Female purgers outnumbered male two to one. Until recently, anorexia was more common, but bulimia became the eating disorder of the 1980s, achieving almost celebrity status. Yet David E. Schotte and Albert J. Stunkard reported in 1987 in the Journal of the American Medical Association a different view of the “sweeping epidemic” of bulimia. They interviewed a sample of 1,965 students at the University of Pennsylvania, using a 15-item self-report questionnaire. Only 1.3 percent of the female and 0.1 percent of the male respondents met diagnostic criteria for bulimia. From this study they determined that whether there is an epidemic of bulimia on the college campus or not depends on the definition of bulimia. “If bulimia is defined as self-reported overeating, or even as selfreported overeating in combination with occasional purging, then the answer is an emphatic ‘yes.’ If, however, the term ‘bulimia’ is restricted to the diagnosis of a clinically significant disorder, the answer is ‘no.’ ” Bulimia has been called the disease of success because the typical bulimic is a professional woman in her mid- to late-twenties, college educated, single and working and living in a big city—

76 bulimia nervosa an overachiever. Increasing numbers of men are being reported with bulimia nervosa, estimated at between 5 and 10 percent of adult males, although it is theorized that there are many more who do not reveal their bulimic activities because of its perceived status as a “woman’s disease.” Many of these men form a bona fide subgroup of overeaters and compulsive exercisers. Rather than following the typical binge/purge cycle, they are preoccupied with physical activity. After exercising for hours, they will become ravenously hungry and eat uncontrollably. Sometimes the food will be a reward for the frantic workout, but afterward the thought of the calories ingested will cause them to begin the cycle again with even more exercising. The disorder can go undetected for years, even by close family members. Both the gorging and purging are carried out in secret, with all evidence destroyed. Because the bulimic appears outwardly to be quite successful in school or career, no one suspects that she does not feel as good as she may appear to be. It is not unusual for a diagnosis not to be made until a patient is well into her thirties or forties. Bulimia typically begins during the late teens or early twenties, after the patient has unsuccessfully tried to lose weight via several reducing diets, especially when restrictive dieting results in hunger. The hunger is satisfied by bingeing. Either through reading about it or hearing a fellow student or coworker talk about it, the patient learns that self-induced VOMITING or laxative use will get rid of the extra calories, thereby relieving feelings of guilt brought on by the binge eating. However, self-induced vomiting leads to further hunger. Ultimately, a vicious cycle is established, perpetuated by emotional disturbances and the continuing desire to lose weight. Some bulimics begin with vomiting after regular meals to lose weight and only binge eat later when their hunger and cravings increase because of the lowered energy intake. During a binge, bulimics typically eat foods high in CARBOHYDRATES, foods they would normally not be allowed to eat on healthy or weight-reduction diets, setting aside time each day for solitary, secret binge eating. However, therapists have reported patients eating salads, vegetables, cheese, meat and yogurt during a binge. University of Alabama researchers report that more women who were college freshmen in the

mid-1960s are engaging in extreme weight-control measures such as bulimia-like behavior today than they did in their high school and college years. Bulimia-like behaviors reported in the study included the use of DIET PILLS, laxatives and diuretics, self-induced vomiting, FASTING and bingeing. This study was conducted to determine if the increase in bulimia-like behaviors reported by psychologists was real or just a reflection of greater awareness of such problems. Results showed that there is indeed a real increase and that those at risk are not just college women overly concerned with dating and appearance but older women as well. The researchers surveyed 159 women, ranging in age from 35 to 45, who were college freshmen in 1964. Subjects were asked about their weight-control practices during high school, college and today. Most reported an increase in the use of extreme weight-control measures (diet pills, fasting, laxatives, etc.) during the years since high school. For example, 84.7 percent said that they had never used diet pills when they were in college, but that figure has dropped to 77.4 percent today. Comparing these results with those of a similar study in 1983, researchers found that a large proportion of both age groups saw themselves as heavier than they were, a problem that is linked to bulimia, anorexia and other eating disorders. (See BODY IMAGE DISTURBANCE.) The study indicates that older women, as well as adolescents, are feeling more pressure about their weight. Researchers related this to the fact that we live in a very youthoriented society and that cultural pressures to be thin are great. Many women are trying to conform to an ideal body image that is almost impossible to obtain without these extreme unhealthy measures. A study released in February 1999 adds evidence that bulimia springs at least in part from a chemical malfunction in the brain and not merely from exercising desire to remain thin. Women who had suffered from bulimia and recovered were more affected psychologically than other woman by being deprived of tryptophan, which plays an indirect role in appetite regulation. The role of the family is also being looked at closely by researchers attempting to determine the causes or origins of bulimia nervosa and other eating disorders. A 1989 study comparing 50 bulimic women with 40 non-eating-disordered women, all

bulimia nervosa 77 from the same geographic area, revealed no significant differences between the two groups in social class, family size, birth position or sibling sex ratio, but the parents of bulimic women were found to have been significantly older than those of the control group at the time of birth of their daughters. An earlier study (1983) had found no significant difference in this area. Researchers determined that further study is needed in order to determine what significance these later findings may have. According to DSM-IV, several studies have suggested an increased frequency of bulimia nervosa in the first-degree biological relatives of individuals with bulimia nervosa. Drewnowski, A., D. K. Yee, and D. D. Krahn. “Bulimia in College Women: Incidence and Recovery Rates.” American Journal of Psychiatry 145, no. 6 (June 1988): 753–755. Schotte, D. E., and A. J. Stunkard. “Bulimia: A Sweeping Epidemic?” Journal of the American Medical Association 258, no. 9 (September 1987): 1213–1215.

Clinical Features Typical physical signs of bulimia nervosa include dark circles under the eyes, tooth decay, puffiness around the face (eyes and below cheeks), facial pallor, red knuckles, dull and lifeless hair and loss of hair. In many bulimics, the menstrual cycle becomes irregular. Bulimics may be—but rarely are—emaciated; they are most usually of normal weight but sometimes are overweight. Bulimic behavior is to be suspected where there is evidence of consumption of unusually large amounts of high-calorie foods, especially if consumed alone or secretly. A diagnosis of bulimia nervosa requires binge eating at least twice a week for three months. Other signs include excessive exercise or fasting, a preoccupation with food, weight and bodily concerns, frequent weight fluctuations due to alternative binges and fasts or purges, increased time spent alone and less with family and friends, theft of money for binges and frequent trips to the bathroom, especially after meals. Sexual interest may also diminish, but not always. Emotionally, bulimic patients have feelings of depression and self-loathing after eating binges, feel unable to control eating behavior and may

appear embarrassed, angry, tense and oversensitive. COGNITIVE DISTORTIONS may also exist: • Denial Bulimics seek acceptable reasons for unacceptable behavior. Whereas others say obesity results from a simple lack of willpower, the bulimic will have excuses or even lie about his overeating (“I eat because . . .”) (“I don’t know why I’m fat . . . I never eat.”). Bulimics hide their purging by using breath sprays, mints and chewing gum. They will often seek “magic” cures for their problems (depression or obesity) through such gimmicks as mail-order BODY WRAPPING. • Distorted Body Image Similar to anorexics, bulimics appear to have a distorted body image. They may believe themselves to be larger than they actually are or may base their self worth on their body size and shape. (See BODY IMAGE DISTURBANCE.) • Fictional Finalism Bulimics often believe that there is a “magic” weight, and that once they attain it, they will have happiness and success (“If I were 120 pounds, everything would be perfect”). They usually find that everything is the same except that they do not have food as a bar against reality. • Rigidity and Inflexibility Bulimics develop an attitude of intransigence, characterized by an air of “I’m right and you’re not.” This is most obvious in their refusal to try suggested cures or in their rigid persistence with diets that do not work. Psychologists Barbara Bauer and Wayne Anderson have identified nine irrational beliefs commonly held by bulimics that are related to these emotional distortions: (1) Becoming overweight is the worst thing that can happen to me. (2) There are good foods, such as vegetables and fish, and bad foods, such as sweets and carbohydrates. (3) I must have control over all of my actions to feel safe. (4) I must do everything perfectly or what I do is worthless. (5) Everyone is aware of, and interested in, what I am doing. (6) Everyone must love me and approve of what I do. (7) External validation is crucial to me. (8) As soon as a particular event such as graduation or marriage occurs, my bulimic behavior will disappear. (9) I must be dependent and subservient yet competitive and aggressive.

78 bulimia nervosa The most universal belief, and the one most difficult to modify, appears to be the fear of becoming fat and the failure it represents. Bulimics obsess about and belittle themselves over the slightest weight gain. Although not everyone with bulimia holds all these beliefs, therapists say all are likely to believe in some of them. A bulimic’s weight may fluctuate but not necessarily to the dangerously low levels seen in anorexics. Also unlike anorexics, bulimics are commonly upset by their actions and willing to accept help; they frequently join self-help groups or even seek medical help. Furthermore, they are usually outgoing and have developed attachments, whereas anorexics are isolated and asexual. (See SEXUALITY AND EATING DISORDERS.) According to Herzog and Copeland, bulimics often have a history of other compulsive behaviors, such as alcohol or drug abuse, and some have features in common with drug or alcohol addicts. They may spend $50 or more a day on food to support their habitual bingeing and often resort to stealing money or shoplifting food. (See MULTICOMPULSIVE.) A California School of Professional Psychology study in 1987 compared two groups of bulimic women: bulimics who compensate for binges by purging through laxatives, diuretics, vomiting and spitting out food, and bulimics who compensate by fasting. These two groups were compared with each other and with a third group of nonbulimic women for self-esteem and self-role concept. All were of normal weight and were selected from a nonclinical population of undergraduate college students. Prior to the study, researchers hypothesized that the three groups would differ on self-esteem, with the purging group having the lowest; that the groups would differ on components of genderrelated behavior patterns, with the purging group having the lowest score on real-self “femininity” and the highest on ideal-self and imagined maleideal “femininity”; and that low self-esteem would relate to discrepancies between components of gender-related behavior patterns. Contrary to expectations, although the bulimic groups combined had lower self-esteem than the nonbulimic group, when the two bulimic groups were examined separately, only the fasting group had lower self-esteem than the nonbulimic group. Moreover, while results indicated that low selfesteem correlates with certain discrepancies for

nonbulimics, and that in both fasting bulimics and nonbulimics high self-esteem correlates with a realself sex-role concept incorporating masculine and feminine gender characteristics, no correlation was found among these variables for purging bulimics. Bauer, Barbara, and Wayne Anderson. “Bulimic Beliefs: Food for Thought.” Journal of Counseling and Development 67 (March 1989): 416–419. Herzog, David, and Paul Copeland. “Eating Disorders.” New England Journal of Medicine, 315, no. 5 (August 1, 1985): 295–303.

Complications Menstrual irregularities occur in more than 40 percent of bulimics; for those whose weight falls below 92 percent of ideal body weight, there is an increased likelihood of AMENORRHEA. Repeated VOMITING dissolves tooth enamel and makes the gums recede, can tear the esophagus and stomach and may cause the salivary glands to swell. BINGE EATING can overload the stomach, causing it to expand and even rupture. Low potassium in the blood can lead to heart problems and death and can upset the body’s balance of electrolytes (sodium, magnesium, potassium and calcium), causing fatigue, seizures, muscle cramps, irregular heartbeat and decreased bone density (see OSTEOPENIA). Other complications include digestive problems, bursting blood vessels in the eyes and cheeks, headaches, rashes, swelling around the eyes, ankles and feet, weakness, kidney failure and heart failure. Bulimia can also cause scarring on the backs of hands when fingers are pushed down the throat to induce vomiting. For diabetics, bingeing on high-carbohydrate foods and sweets is particularly hazardous, because their pancreas may not be able to metabolize properly the starches and sugars. Bulimics speak of being “hooked” on certain foods (particularly CARBOHYDRATES) and needing to feed their “habit.” This so-called addictive tendency seems to carry over into other areas, including abuse of drugs and alcohol and KLEPTOMANIA (compulsive stealing). (See MULTICOMPULSIVE.) Many bulimics suffer from serious DEPRESSION, which, combined with their impulsive tendencies, places them at increased risk for SUICIDE. Depression is a problem especially among bulimic students, whose self-esteem plummets when they engage in these

bulimia nervosa 79 extreme behaviors. When they get depressed, their grades fail and they lose their self-confidence. To determine the range and severity of medical complications encountered in younger patients, researchers reviewed the medical records of 65 adolescents and preadolescents in the Eating Disorders Clinic of the Children’s Hospital at Stanford University. Twenty-two percent of bulimic patients required hospitalization for medical reasons during the study period. Treatment Although bulimic patients are for the most part more likely than anorexics to accept, even seek, treatment, they usually expect quick solutions and become frustrated if treatment does not produce immediate relief of their symptoms. They may deal with their frustration and anxiety in therapy through increased binge eating and may also leave treatment prematurely. GROUP THERAPY is particularly useful for bulimics who feel isolated by their symptoms. The psychological treatments that have been studied the most are behavior and cognitive behavioral approaches. These treatments use behavioral interventions such as self-monitoring and stimulus control to normalize eating behavior and use cognitive interventions to challenge the distorted thinking and belief systems of the individual. Research suggests that these treatments can be very effective, as effective as the antidepressants (see below) and more effective when one considers follow-up. Another psychological treatment that has recently been found to be effective for bulimia nervosa is interpersonal psychotherapy (see INTERPERSONAL PSYCHOTHERAPY). Because of the lack of understanding of the biological bases of normal and abnormal eating behavior, development of effective pharmacologic treatment for bulimia nervosa has been slow. ANTIDEPRESSANT medication has been used in treatment for bulimia. The three classes of antidepressant drugs most commonly used in the treatment of bulimia have been the monoamine oxidase inhibitors, the serotonin reuptake inhibitors (fluoxetine, clomipramine) and the tricyclics. Some controlled studies of antidepressants in bulimia have been promising; IMIPRAMINE and phenelzine have been shown to be significantly successful in reducing bulimic and depressive symptoms.

During controlled testing, the tricyclic antidepressant imipramine produced, on average, a 70 percent reduction in binge frequency. A similar drug, desipramine, resulted in a mean reduction of 91 percent in binge frequency. A third tricyclic antidepressant, AMITRIPTYLINE, was associated with a 72 percent reduction in binge frequency. A controlled trial of phenelzine, a monoamine oxidase inhibitor, found a 66 percent reduction in binge frequency. In a multicenter-controlled, double-blind study of fluoxetine, those patients receiving fluoxetine experienced a 45 percent decrease in the median number of binges and a 29 percent decrease in the median number of purges. Patients receiving higher doses of medication had decreases of 67 percent and 56 percent. In their review of the psychopharmacology treatment literature, Mitchell et al. found that “the agents most commonly used are the antidepressants, with particular focus on the selective serotonin reuptake inhibitors including fluoxetine hydrochloride. These agents clearly impact significantly on the frequency of abnormal eating behaviors such as binge eating and purging. However, subjects treated with these drugs rarely achieve remission.” Whittal et al. analyzed four treatment outcomes, and found that the people given cognitive behavioral therapy (CBT) did significantly better than those given medication and apparently better than those who received other psychosocial treatments. In a multidimensional meta-analysis of psychotherapy trials for bulimia nervosa published between 1980 and 2000, Thompson-Brenner et al. wrote, “The data point to four conclusions. First, psychotherapy leads to large improvements from baseline. Approximately 40 percent of patients who complete treatment recover completely, although 60 percent maintain clinically significant posttreatment symptoms. Second, individual therapy shows substantially better effects than group therapy for the therapies tested. Third, additional approaches or treatment parameters (e.g., number of sessions) need to be tested for the substantial number of patients who enter treatment and do not recover. Finally, the utility of meta-analyses can be augmented by including a wider range of outcome metrics, such as recovery rates and posttreatment symptom levels.” The long-term outcome of drug treatment for bulimia remains unknown. Medication has proved

80 Bulimia Test Revised useful when a bulimic patient also has an associated mood disorder and has failed to respond to PSYCHOTHERAPY. Treatment for bulimia nervosa is most successful when medical therapy and psychotherapy are combined. Fairburn, C. G., and P. J. Cooper. “Eating disorders.” In Cognitive Behaviour Therapy for Psychiatric Problems: A Practical Guide, edited by K. Hawton, et al. New York: Oxford Medical Publications, 1996. Levitt, John L. “Treating Adults with Eating Disorders by Using an Inpatient Approach.” Health and Social Work 11, no. 2 (Spring 1986): 133–140. Mitchell, J. E., M. de Zwaan, and J. L. Roerig. “Drug Therapy for Patients with Eating Disorders.” Current Drug Targets. CNS and Neurological Disorders 2, no. 1 (February 2003): 17–29. Neuman, Patricia A., and Patricia A. Halvorson. Anorexia Nervosa and Bulimia: A Handbook for Counselors and Therapists. New York: Van Nostrand Reinhold, 1983. Root, Maria P. P., Patricia Fallon, and William N. Friedrich. Bulimia: A Systems Approach to Treatment. New York: W. W. Norton, 1986. Thompson-Brenner, H., S. Glass, and Drew Western. “A Multidimensional Meta-Analysis of Psychotherapy for Bulimia Nervosa Clinical Psychology.” Science & Practice 10, no. 3 (fall 2003): 269–287. Whittal, M. L., W. S. Agras, and R. A. Gould. “Bulimia Nervosa: A Meta-Analysis of Psychosocial and Pharmacological Treatments.” Behavior Therapy 30, no. 1 (winter 1999): 117–135.

Bulimia Test Revised (BULIT-R) A revision of the Bulimia self-test originally developed in 1984 by M. S. Smith and M. H. Thelen, but updated to be consistent with the DSM-III-R criteria for bulimia nervosa. The BULIT is a 32-item multiple-choice scale designed to identify individuals with symptoms of bulimia. Sample items from the BULIT: I prefer to eat: A. At home alone B. At home with others C. In a public restaurant D. At a friend’s home E. Doesn’t matter What is the most weight you’ve lost in one month?

A. Over 20 pounds B. 12–20 pounds C. 8–11 pounds D. 4–7 pounds E. Less than 4 pounds Thelen, M. H., J. Farmer, S. Wonderlich, and M. Smith. “A Revision of the Bulimia Test: The BULIT-R.” Psychological Assessment 3 (1991): 119–124.

bulking agents

APPETITE SUPPRESSANTS made from food fiber, taken before meals because they swell up in the stomach, creating a sense of fullness that is supposed to inhibit excess eating. Some doctors dispute the effectiveness and discourage the use of these. Stephen Barrett, M.D., chairman of Quackwatch, Inc., and vice president of the National Council Against Health Fraud, describes bulking agents as “indigestible, non-caloric substances that absorb water during digestion and supposedly trick the stomach into thinking it is full. The substances include alginic acid, carboxymethylcellulose, carrageenan, guar gum, karaya gum, methylcellulose, psyllium, kelp, and xanthan gum.” Barrett notes that X-rays have shown that methylcellulose “does not actually fill the stomach but quickly passes into the small intestine.” Bulk producers or fillers come in a number of forms: powders, capsules or pills. One such product is glucomannan, which is processed from the roots of the konjac plant. The Food and Drug Administration has stated that the use of bulk producers are safe, but their value in reducing weight has not been established. At most, the FDA says, bulk producers absorb liquid and swell the stomach, thereby reducing HUNGER. There is no proof that they are any more effective than ordinary bulking foods such as whole grains, apples, carrots and sprouts, all of which can provide the same feeling of fullness.

Barrett, Stephen. “Bulking Agents and Weight Control.” Alternative Medicine: A Skeptical Look. Available online. URL: http://www.canoe.ca/HealthAlternative Columns/010726.html.

bypass surgery BYPASS.

See

BARIATRIC SURGERY; GASTRIC

C the Mayo Clinic cautions that even as many as six cups of coffee a day have not proven to greatly increase the body’s ability to burn calories, nor has it resulted in significant loss of body fat. Because coffee is a diuretic, any weight loss is more likely to be from water loss. No studies indicate that weight loss from large amounts of caffeine is significant or permanent. Caffeine is sometimes abused by persons with eating disorders in an attempt to control their weight.

caffeine

An alkaloid found naturally in coffee and tea that is a central nervous system stimulant and a diuretic. About 100 to 150 milligrams are found in a strong cup of tea or coffee. When researchers at King’s College, University of London administered caffeine orally to human volunteers in single doses of 100 milligrams, it increased the resting metabolic rate of both lean and postobese subjects by 3 to 4 percent over a period of 150 minutes. (See METABOLISM.) It also improved the diet-induced defective thermogenesis observed in the postobese subjects. Measurements of energy expenditure indicated that repeated caffeine administration at two-hour intervals over a 12-hour day increased the energy expenditure of both subject groups by 8 to 11 percent during that period but had no influence on the subsequent 12-hour night energy expenditure. The net effect was a significant increase in daily energy expenditure of 150 calories in the lean subjects and 79 calories in the postobese. The researchers feel that caffeine at commonly consumed doses can have a significant influence on energy balance and may promote thermogenesis in the treatment of obesity. Robert O’Brien and Sidney Cohen, writing in The Encyclopedia of Understanding Alcohol and Other Drugs (New York: Facts On File, 1999), cautioned that regular use of 350 milligrams or more of caffeine a day results in a form of physical dependence. Regular use of more than 600 milligrams a day may cause chronic insomnia, breathlessness, persistent anxiety and depression, mild delirium and stomach upset. Heavy caffeine use is also suspected of association with heart disease and some forms of cancer. Although a few studies have indicated that large amounts of caffeine may slightly enhance weight loss in people who exercise and maintain a low-fat diet,

Dulloo, A. G., et al. “Normal Caffeine Consumption: Influence on Thermogenesis and Daily Energy Expenditure in Lean and Postobese Human Volunteers.” American Journal of Clinical Nutrition 49, no. 1 (January 1989). Hamilton, Kim. “The Weight-Loss Perk.” Health (July 1989).

calcium A Purdue University study presented in 1999 by Dorothy Teegarden, an assistant professor of foods and nutrition, showed that increased levels of calcium appeared to help women lose body fat but only if overall calorie consumption was limited. The study, which was partly financed by the National Dairy Council, tracked 54 women over two years; the women followed no particular diet. Those women who consumed fewer than 1,900 calories a day along with a daily calcium intake of at least 780 milligrams, either did not increase body fat, or they lost fat. Those women who took in 1,000 milligrams of calcium a day decreased body weight by up to seven pounds, all of which was in the form of body fat. Those who used dairy products as their calcium source lost more body fat than those who got their calcium from leafy vegetables or supplements. Those women with 500 or fewer milligrams of calcium intake per day actually showed an increase in body fat. Because of the high fat content in many dairy products, Teegarden 81

82 calorie suggested that people needing to lower their body fat get calcium from yogurt or skim milk, which are both low fat and low calorie. Other sources of calcium include broccoli, cabbage and sardines. Katherine Tallmadge, a nutritionist, noted, “Since 2000, observational and clinical studies of men, women and children have consistently shown that people eating diets containing calcium’s recommended dietary allowance of 1,000 to 1,300 milligrams per day have lower body weights and lower body fat. In fact, it’s been calculated that with 300 more milligrams of calcium daily, adults will weigh about seven pounds lighter than they would without the calcium.” Michael Zemel and his team of researchers at the University of Tennessee reported in several journals in 2004 on their studies using both mice and human subjects, which continued to show calcium’s influence on weight loss. Explaining their beliefs on why calcium, especially when in milk products, appears to help take off unwanted pounds and body fat, particularly in the trunk region, Zemel told Tallmadge that it has to do with the body’s natural instinct to prevent starvation when it thinks food is scarce. And one of the things that makes the body think food is scarce is a low level of calcium. When that occurs, the body releases a hormone called calcitriol, which, among other “jobs,” prods the fat cells to start making more fat, and also slows down the process of fat breakdown and oxidation. Thus, a low-calorie diet that includes low levels of calcium causes fat to do the opposite of what is expected. Because the average American consumes only half the daily calcium requirement, weight loss is harder for many. “Higher-calcium intakes (in which the body senses, rightly or wrongly, that there is plenty of food around) cause lower calcitriol levels and increased fat breakdown.” Most American adults take in only 600 milligrams of calcium a day. Until age 50, adults should take in 1,000 milligrams; after age 50 for women or after age 65 for men, the recommended amount is 1,200–1,500. According to Dr. Zemel’s research, calcium from supplements or from other calcium-rich foods have an effect on fat loss, but calcium from dairy products seems to work best. Other food sources of calcium include dark greens such as broccoli and kale; beans; canned salmon and sardines with bones; and calcium-fortified orange juice.

Data from a study funded by the Canadian Institutes of Health Research (CIHR) called the Quebec Family Study indicate that people who consume less calcium have a greater tendency to be overweight or obese. Although the mechanism is unclear, Dr. Angelo Tremblay of Laval University says calcium intake may bring about an increase in fat oxidation, in the amount of calories burned as fat. Tallmadge, Katherine. “Counting Calcium” Washington Post, June 30, 2004, page F01. Zemel, Michael B. “Role of Calcium and Dairy Products in Energy Partitioning and Weight Management.” American Journal of Clinical Nutrition 79, no. 5 (May 2004): 907S–912S. Zemel, Michael B., and S. L. Miller. “Dietary Calcium and Dairy Modulation of Adiposity and Obesity Risk.” Nutrition Reviews 62, no. 4 (April 2004): 125–131. Zemel, Michael B., et al. “Calcium and Dairy Acceleration of Weight and Fat Loss during Energy Restriction in Obese Adults.” Obesity Research 12, no. 4 (April 2004): 582–590.

calorie

A unit of measurement of heat. One large, or great, calorie (kilogram calorie) is the amount of heat required to raise the temperature of one kilogram (2.2046 pounds) of water by one degree Celsius (1.8 degrees Fahrenheit); this is the calorie commonly used in metabolic studies. One small calorie (gram calorie) is the amount of heat required to raise the temperature of one gram of water one degree Celsius. In writings on human nutrition the large or kilogram calorie is used. In medical literature, it is occasionally capitalize in order to distinguish it from a small calorie; sometimes it is abbreviated as keal. It is possible to calculate the amount of energy contained in a certain food by measuring the amount of heat units, or calories, in that food. (See CALORIMETRY.) Every bodily process—the building up of cells, motion of the muscles, the maintenance of body temperature—requires energy, and the body derives this energy from the food it consumes. Digestive processes reduce food to usable “fuel,” which the body “burns” in the complex chemical reactions that sustain life. “From its daily intake of energy converted from food, the body uses only the amount it needs for current activity. The remainder is stored as FAT. If a person consumes more calories than necessary for daily bodily processes, he or she will gain weight. If

calorie 83 a person consumes fewer than necessary, the body will supplement it by drawing on energy stored as fat, and he or she will lose weight. Bonnie Liebman, director of nutrition at the Center for Science in the Public Interest, Washington, D.C., told Boardroom Reports (May 15, 1989) that all calories are not alike. Nutritionists used to say that a calorie was a calorie no matter what kind of food it was—protein, fat or carbohydrate. It didn’t matter whether one ate 3,000 calories of fat or 3,000 calories of carbohydrates, the calories the body didn’t use were turned into fat. Thus, calorie-counting was the key to dieting. But a growing body of scientific evidence shows that, once inside the body, calories are not treated alike. Fat is handled very differently from protein and carbohydrates, with the fat calories being the most problematic.

Studies conducted by biochemist Jean-Pierre Flatt at the University of Massachusetts Medical School showed that fewer calories are required for the body to turn food fat into body fat than to turn PROTEINS and CARBOHYDRATES into body fat. In the case of food fat, only 3 percent of the calories taken in are burned off in the process of storing it as body fat. In the case of complex carbohydrates, 23 percent of the calories are used up in converting it to body fat. It is also more difficult for the body to turn proteins and carbohydrates into fat, doing so only when massive amounts have been ingested and using a great amount of energy to do so. The body can store about 1,500 calories’ worth of carbohydrates and protein (the rest are burned), but it can store 100,000 to 200,000 calories’ worth of fat, according to Flatt. Whereas the normal body attempts to use food fat as energy before storing it in fat cells, the bodies of formerly obese people appear to put fat calories directly into storage, thereby contributing to their weight problem. Researchers at Harvard Medical School studied 141 women aged 34 to 59 and found no correlation between caloric intake and body weight. The fattest women did not necessarily eat the most. The researchers did find, however, that the women whose diets were highest in fat, particularly saturated fats from red meat and dairy products, were the most overweight regardless of the number of calories they consumed.

Americans today are heavier than ever but consume fewer calories than at the turn of the century. One of the reasons given for this is that we have become a more sedentary society. But it has also been noted that while we may eat less than our ancestors did, the percentage of fats in our diets is 31 percent greater today than it used to be. Experts argue that total calories nevertheless do count, even those not derived from fat. They point to a recent National Health and Nutrition Examination Survey, which showed total caloric intake by adults increasing from 1,969 calories in 1978 to 2,200 in 1990. Putnam et al., agricultural economists with the Food and Rural Economics Division, Economic Research Service, USDA, reported that average daily calorie consumption in 2000 was 12 percent, or roughly 300 calories, above the 1985 level. In an earlier review, Putnam had written that calorie consumption per capita increased 21 percent between 1970 and 1994. Three-quarters of that increase occurred between 1984 and 1994. Similar findings reported by the Centers for Disease Control and Prevention showed that the average calories taken in by men grew from 2,450 in 1971 to 2,618 in 2000. For women, caloric intake grew from 1,542 calories to 1,877 calories during the same time. The government recommends about 1,600 daily calories for women and 2,200 for men, with more for very active people. Studies have shown that taking in 100 fewer calories a day or burning 100 more calories a day through increased physical activity can stop weight gain. From that point, increasing activity or decreasing calorie intake works toward weight loss. A study by the Human Nutrition Research Center in Maryland found that six out of seven women underreported how much they ate in a day’s time by an average of 621 calories; and six out of 10 men underreported by an average of 581 calories. See also FAT CELLS; FATS; OBESITY. Putnam, Judy, Jane Allshouse, and Linda Scott Kantor. “U.S. Per Capita Food Supply Trends: More Calories, Refined Carbohydrates, and Fats.” FoodReview 25, no. 3 (December 2002). Available online. URL: http:// www.ers.usda.gov/publications/FoodReview/DEC 2002/frvol25i3a.pdf.

84 calorie restriction diet calorie restriction diet (CR diet)

An eating regimen with a goal to achieve a longer life by eating as few calories as possible while maintaining adequate nutrition. The Calorie Restriction Society (http://www.calorierestriction.org) states, “Extensive scientific research has shown that a CR diet improves the health and extends the lifespan of every species so far tested, including worms, spiders, rodents, dogs, cows and monkeys. We believe that people who adopt a CR diet will see the same results—longer life and better health.” Although people following a CR diet (usually 30–50 percent fewer calories than recommended) do not have a primary goal of losing weight (some are thin when they begin the CR lifestyle), most eventually lose enough weight to look gaunt. They primarily eat raw vegetables, fruit and nuts, then augment their diet with any missing vitamins and minerals. Calorie restriction first came under observation in the 1930s when Clive McCay, a nutritionist at Cornell University, discovered by chance that underfed rats not only maintained a more youthful appearance than those on a regular diet, but lived up to one-third longer. Similar results have been obtained with monkeys, dogs and any number of other species. However, there is no concrete evidence that CR helps people live longer. Short trials to test CR’s effect on human body systems are in progress, but any definitive trials would be too lengthy and difficult because of the longer lifespan of humans. Bee noted, “Few doctors oppose the principles of calorie reduction per se, especially since CR members ensure ‘optimal nutrition,’ including essential vitamins and minerals, from what little food they do eat. Crucially, this is what sets CR apart from eating disorders such as anorexia, which restrict all food, and therefore all essential nutrients, to a point where the body is unable to function in a normal way.” Lawson interviewed an avid male follower of CR (80 percent of CR followers are men), who admitted to food obsession for the first year, as well as a virtual disappearance of sexual desire from a lowering testosterone. Answering a question about the amount of discussion of anorexia on the CR Society Web site, he replied, “There are certainly anorexics who at least claim to practice CR. But I don’t know of anyone who was not anorexic and

who became one after starting CR.” Researchers have reported seeing no eating disorders among their CR subjects. However, Layton noted that investigators at the American Federation for Aging Research question the diet. “A calorie-restricted diet will produce weight loss, to the point that most adherents appear ill . . . CR followers are generally cold and always hungry. Because they lose so much body fat, they lose cushions that protect their bones, so that sitting or walking can become painful. And it’s simply not sustainable for most people. Very few people can lose 30 percent of their body weight and keep it off for any duration.” Bee, Peta. “Starve Yourself to Eternal Life.” The Guardian, September 25, 2004, p. 9. Lawson, Willow. “The Skinny on Calorie Restriction.” Psychology Today 37, no. 3 (May/June 2004): 16–19. Layton, Mary Jo. “Ultra-Low-Calorie Diet High on Promise—Hard-Core Followers Want to Live to Be 100.” The Record, October 24, 2004. Available online. URL: http://www.myhealth.com/features/05-01-lowcal.htm.

calorimetry

A method of measuring the amount of energy (CALORIE) value in food via a burning process. First a small amount of food is weighed and placed in a sealed container, called a bomb calorimeter. Then the food is set on fire with an electric fuse. The calorimeter is then submerged in a premeasured amount of water. The rise in the temperature of the water when the food item is completely burned measures the calorie value of that amount and kind of food. This calorie value is then used to calculate the number of calories in a typical serving.

cancer links to obesity Since the 1970s, numerous epidemiological studies have indicated that obesity contributes to the increased incidence and/or death from cancers of the colon and rectum, breast and uterus and cervix and ovaries (in postmenopausal women), kidney, esophagus and gall bladder, pancreas, liver, multiple myeloma, non-Hodgkin’s lymphoma, stomach and prostate (in men), and possibly other cancers. In a landmark study, Calle et al. evaluated 900,000 people, who were cancer-free when the

carbohydrates 85 study began, over 16 years. The researchers concluded that excess body weight may contribute to 14 percent of all cancer deaths in men and 20 percent of all cancer deaths in women. This accounts for about 90,000 cancer deaths each year, according to the American Cancer Society. Explaining the relationship between cancer and obesity, George Blackburn, M.D., writes, “Cancerous tumors seem to thrive on certain normally occurring hormones, including estrogens, androgens, and insulin. Unfortunately, obese people produce excess amounts of these and other cancer-stimulating hormones, so they are more likely to die from cancer.” There are other suggested reasons for the close link between obesity and cancer death. For instance, obesity makes cancer more difficult to diagnose and treat; the proper amount of chemotherapy is difficult to determine accurately in the obese because fat tissue sometimes absorbs the chemicals, and many obese people avoid regular doctor visits. In 2002 about 41,000 new cases of cancer in the United States were estimated to be due to obesity. This means that about 3.2 percent of all new cancers are linked to obesity. On a more positive note, University of Minnesota researchers who followed nearly 22,000 women over seven years found that overweight or obese women who lost 20 or more pounds cut their cancer risk 21 percent. See also PROSTATE CANCER AND OBESITY. Blackburn, George L. “The Skinny on Obesity and Cancer: Obesity Increases the Risk of Death from Cancer, but Being Overweight Isn’t Inescapable.” Health News 9, no. 6 (June 2003): 3. Calle, Eugenia, et al. “Overweight, Obesity, and Mortality from Cancer in a Prospectively Studied Cohort of U.S. Adults.” New England Journal of Medicine 348, no. 17 (April 24, 2003): 1625–1638.

carbohydrate addict’s diet A popular diet introduced in 1991 by Rachel and Richard Heller in a best-selling book series. The theory is that some people are biologically predisposed to develop unmanageable cravings for carbohydrates, and when this occurs, it can often lead to weight gain. The authors believe that this condition results from an overproduction of insulin, impairing glucose

metabolism, and an insufficient rise of brain serotonin, which is responsible for the feeling of satiety. The purpose of the diet is to control insulin release by minimizing the carbohydrate consumption that triggers it. The basic diet consists of two carbohydrate-restricted meals and one “reward” meal, which must be consumed within 60 minutes, but at which the person may eat absolutely anything. Foods at the restricted meals include standard proportions of such foods as eggs, fish, meat, cheese, salads and most nonstarchy vegetables. Allowable foods contain no more than four grams of carbohydrate per standard serving. Although there is little or no scientific evidence for the theory behind the diet, some nutritionists accept the diet per se as healthy if the dieter selects appropriate foods. See also ADDICTION.

carbohydrates

A group of chemical substances that make up one of the three sources of nutrients (the others are proteins and fats) and contain only carbon, oxygen and hydrogen. Usually the ratio of hydrogen to oxygen is 2:1. The most common carbohydrates are sugar and starches; others include glycogen, dextrins and celluloses. Carbohydrates are formed by green plants, which utilize sunlight energy to combine carbon dioxide and water in forming them. Carbohydrates are a basic source of energy. (See CALORIE.) One gram yields approximately four calories. Carbohydrate is stored in the body as glycogen (a polysaccharide consisting of sugar molecules) in virtually all tissues, but principally in the liver and muscles, where it becomes a source of reserve energy. Whole grains, vegetables, legumes (peas and beans), tubers (potatoes), fruits, honey and refined sugar are all excellent sources of carbohydrates. Calories derived from sugar and candy, however, have been termed “empty” calories because these foods lack essential amino acids, vitamins and minerals. Foods whose carbohydrates are digested and absorbed quickly are said to have a high glycemic index (GI), which a Tufts University study showed may trigger overeating several hours later. Researchers fed a group of 12 obese teenage boys high- medium- or low-glycemic breakfasts and

86 Carpenter, Karen lunches on different days. The low-GI breakfasts included foods such as a spinach omelet and fruit; the medium-GI meals included slowly digesting grains such as Irish oatmeal (which is less processed than American oatmeal) with milk and sugar; and the high-GI breakfasts included foods such as bagels and cream cheese, muffins, donuts, waffles with syrup or instant oatmeal. In the afternoon, the boys were encouraged to select snacks from a large platter of food if they felt hungry. Those who ate the high-GI meals ate almost twice as many snacks as those who had eaten low-GI meals that day. Studies such as this help to explain why people who cut back on refined carbohydrates and sugar often find it easier to control and even lose weight. Nutritionists contend that refined starches and sugars—which are a significant part of high-GI foods—are a completely unnecessary part of the American diet. Amersbach, Gabriele. “In a Low-Fat World, Why Are Americans Getting Fatter?” Tufts Nutrition, Fall 1999. Available online. URL: http://nutrition.tufts.edu/ magazine/1999fall/roberts.html.

Carpenter, Karen (1950–1983) A popular singer and recording star (with her brother Richard) during the 1970s, who died in 1983 at the age of 32 as a consequence of cardiomyopathy, secondary to the effects of the toxic substance emetine. She suffered from ANOREXIA NERVOSA, possibly with bulimic episodes, and abused IPECAC SYRUP. Building up over time, the alkaloid emetine in the ipecac irreversibly damaged her heart muscle, eventually leading to her death by cardiac arrest. Because of her popularity, her death brought more attention to eating disorders than anything before or since. A TV movie, The Karen Carpenter Story, was first shown January 1, 1989. cataracts and obesity Cataracts are the third leading cause of preventable blindness in the United States. A cataract is a clouding of the eye’s lens, a clear protein structure located behind the pupil. In a healthy eye, the lens bends light and focuses it on the retina, which converts the light to signals that the brain processes and organizes into images. A cataract develops when the lens thickens to the point that it

is no longer able to reflect light. Proteins coagulate into an opaque mass resembling something like an egg white, which prevents light from entering. According to research by the Tufts University Laboratory for Nutrition and Vision Research, obese women are two and a half times more likely to get a specific type of cataract—posterior subscapular (PSC) opacity—than healthy-weight women. Working with scientists from the Harvard Nurses’ Health Study, the researchers conducted eye examinations of 466 Boston-area women aged 53–73 who were without previously diagnosed cataracts. Both body mass index and waist circumference were used to measure overweight and abdominal adiposity. Those who were 30 to 40 pounds overweight were the most likely to develop a PSC opacity—a cataract particularly damaging to sight. Also, those who had waistlines larger than 35 inches developed cataracts at a much earlier age than the women whose waists measured less than 31.5 inches. Jacques, P. F., et al. “Weight Status, Abdominal Adiposity, Diabetes, and Early Age-Related Lens Opacities.” The American Journal of Clinical Nutrition 78, no. 3 (September 2003): 400–405.

cellulite

A term first used in the 1950s to refer to the tenacious FAT and fibrous tissue that forms bumps and ridges on thighs, hips and buttocks, giving them a dimpled or “cottage cheese” look. It is especially common in women. According to Michael O’Shea, founder and chairman of the Sports Training Institute in New York City, the lumpiness is caused by fat deposits located directly beneath the skin pushing up between the tiny ligaments running from the skin’s surface through the fat layer to the muscles underneath. When the fat cells increase in size, as they do during weight gain, they cause the fat deposits to bulge, giving the skin a dimpled look. Edwin Bayrd, author of The Thin Game, wrote however, that “this dimpling is a result of aging rather than overindulgence. It manifests itself when the subdermal connective tissue that forms a sort of honeycomb around the body’s adipose cells begins to lose its elasticity and shrinks with age. When this happens, the overlying skin also contracts—and if the encased fat cells cannot shrink, they cannot help but pucker.”

chemical dependency and bulimia 87 In its February 2004 issue, the Johns Hopkins Health after 50 newsletter stated that cellulite “seems to develop when small blood vessels in the layer of fatty tissue under the skin become damaged, perhaps from inflammation. The circulation of blood and lymph slows. As fluid accumulates, the fat layer expands and puckers, resulting in a dimpled appearance.” Early promoters of cellulite “therapy” claimed that cellulite is caused by a thickening of the connective tissue, which then traps fluids and “toxic materials” in that fat itself, causing the lumpy look. They promoted a variety of treatments and gimmicks to “melt” these fatty pockets, including balms, creams, lotions, injections, plastic wraps, massage, mineral baths, air hoses and wrappings of cheesecloth soaked in paraffin. None of these “cures” proved consistently successful for a number of reasons. Primary among these is the very protective nature of the skin, which prevents penetration of most salves, ointments and other substance applied to its surface. Even if one of these “miracle extracts” were able to break through the skin and break down fat stores, this would not necessarily lead to the elimination of fat from the body. Fat cells constantly dispense fat into the bloodstream and simultaneously resynthesize triglyceride (storage fat) from circulating fatty acids. Circulating fat will be burned only if muscle of other tissue extracts it from the bloodstream. If the tissues do not need fuel, circulating fat is redeposited in fat cells. Grapefruit diet pills have been promoted to “burn off cellulite” while allowing consumers to eat as much food as they want. Ingredients in these pills vary. In addition to grapefruit extract, some have contained a diuretic, and some, glucomannan (see BULKING AGENTS). Others may combine an appetite suppressant with herbs or other ingredients. The Food and Drug Administration has not approved any grapefruit pill for cellulite treatment. There is no scientific evidence to support cellulite therapies or the theories on which they are based. Studies have found no detectable difference between so-called cellulite and fat in other areas. The Johns Hopkins newsletter suggests exercise and losing weight as the best way to “minimize” cellulite. “Squats, lunges, and step exercises with

light weights are particularly effective for increasing muscle tone in the buttocks and thighs. As muscle builds, the skin feels and looks firmer. Cellulite cannot be eliminated with liposuction.” See also FRAUDULENT PRODUCTS; LIPOSUCTION. Bayrd, Edwin. The Thin Game. New York: Newsweek Books, 1978. Frey, Jennifer. “Lumpy Bumpy, Dimpled: Living off the Fat of the Land.” Washington Post, March 27, 1999. McCurdy, John A., Jr. Sculpturing Your Body: Diet, Exercise and Lipo (Fat) Suction. Hollywood, Fla.: Frederick Fell Publishers, 1987.

Centers for Obesity Research and Education (CORE) An education program formed in 1998 to provide guidance and training for health care providers on how to manage their obese patients. CORE includes eight of the leading centers involved in the management of overweight and obesity in the United States. These centers work together to conduct monthly interactive workshops to help physicians, nurses, and other health care providers better identify, understand and treat overweight and obesity in their practices. Their Web site is at http://www.uchsc.edu/core.

chemical dependency and bulimia

In a survey of 1,100 patients at Hazelden, a Minnesota chemical dependency treatment center, approximately 7 percent of female patients and 3 percent of males reported enough symptoms to be classified as bulimic under DSM-III criteria. An audit of treatment files of bulimic female patients revealed that they had experienced more adolescent behavior problems and self-destructive behavior than their nonbulimic peers. The typical female chemical-dependent bulimic patient at Hazelden differed markedly from her asymptomatic peers. She was more likely to be a polydrug user; to have had adolescent behavior problems such as school suspension or expulsion, stealing and fighting; to have exhibited self-destructive tendencies through self-inflicted injury, suicide attempts or suicidal thoughts during treatment; and to have had outpatient or inpatient mental health treatment or medication. Although a group of patients with these problems could be expected to have difficulty in treat-

88 childhood anorexia ment, the course of treatment for both groups was similar in most areas of comparison. Bulimics required the same length of stay in treatment, were discharged with staff approval at similar rates, had about the same number of conflicts with peers during treatment and saw their counselors with the same frequency as asymptomatic patients. Bulimic patients did use mental health services at Hazelden slightly more than nonbulimics. While cautioning that recent changes in the diagnostic criteria for bulimia and in Hazelden’s pretreatment assessment methods make the data “tentative,” researchers concluded that research and clinical experience demonstrate that it is possible to work with manageable eating disorders in chemical dependency treatment. According to DSM-IV, chemical abuse or dependence occurs in about one-third of individuals with bulimia nervosa. Such stimulant use often begins in an attempt to control appetite and weight.

childhood anorexia Anorexia nervosa has been reported in children as early as age four; it is estimated that 3 percent of reported anorexia cases occur before the age of puberty. Because prepubertal children, especially girls, have less body fat than adolescent, they become emaciated more quickly than older anorexics. GERALD F. M. RUSSELL examined a series of 20 girls whose anorexia nervosa began before their first menstrual period (menarche), concluding that anorexia nervosa can be devastating to physical development. There is prolonged delay of puberty (late menarche) and interference with grown in stature and breast development. Young children with anorexia have exhibited clinging behavior upon entering school, difficulty in maintaining peer relations, physical and psychological immaturity, depression and an inability to translate feelings into words. Also, according to DSM-IV, there are suggestions that the severity of associated mental disturbance may be greater among prepubertal individuals who develop the illness. Blinder, Barton J., and Stanley L. Goodman. “Atypical Eating Disorders.” In Eating Disorders, edited by Félix E. F. Larocca. San Francisco: Jossey-Bass, 1986.

childhood obesity

Childhood obesity is a growing concern among physicians and researchers. Results from the 1999–2002 National Health and Nutrition Examination Survey (NHANES), using measured heights and weights, indicate that an estimated 16 percent of children and adolescents ages six to 19 years are overweight. This represents a 45 percent increase from the overweight estimates of 11 percent obtained from NHANES III (1988–94). To assess changes in overweight that have occurred, prevalence estimates for participants in the 1999–2002 NHANES were compared with estimates for those who participated in earlier surveys. The NHANES surveys used a stratified, multistage probability sample of the civilian noninstitutionalized U.S. population. A household interview and a physical examination were conducted for each survey participant. During the physical examination, conducted in mobile examination centers, height and weight were measured as part of a more comprehensive set of body measurements. These measurements were taken by trained health technicians, using standardized measuring procedures and equipment. Observations for persons missing a valid height or weight measurement were not included in the data analysis. When the overweight definition (greater than or equal to 95th percentile of the age- and sex-specific body mass index, or BMI) is applied to data from earlier national health examination surveys, overweight in children and adolescents was relatively stable from the 1960s to 1980. However, from NHANES II (1976–80) to NHANES III, the prevalence of overweight nearly doubled among children. In the time interval between NHANES II and III, the prevalence of overweight among children ages six to 11 years increased from an estimated 7 percent to 11 percent. One of the national health objectives for 2010 is to reduce the prevalence of overweight from the NHANES III baseline of 11 percent. However, the NHANES 1999–2002 overweight estimates suggest that since 1994, overweight in youths has not leveled off or decreased, and is increasing to even higher levels. The 1999–2002 findings for children and adolescents suggest the likelihood of another generation of overweight adults who may be at risk

childhood obesity 89 for subsequent overweight and obesity-related health conditions. Recent findings among preschoolers indicate that children’s weight problems are beginning much earlier than school age. The American Heart Association’s 2004 annual statistical report on heart disease and stroke showed more than 10 percent of U.S. children ages two to five were overweight in 2002 (the most recent year for which statistics were available), an increase from 7 percent in 1994. It was expected that the situation was even worse in 2004. Because parents frequently think their small children will “outgrow their baby fat” or that a chubby child is a healthy child, most of them do not believe their children have a medical problem. But one study in England showed a definite correlation between weight at six months of age and adult weight. According to Richard Strauss, the increasing prevalence of obesity can be explained by the fact that few children today engage in regular physical activity. Others have similarly blamed the significant erosion of physical education and recreation programs in schools. CDC researchers have placed blame for increased preschooler obesity on highcalorie convenience foods rather than lack of physical activity. Parental obesity is also a strong predictor of childhood obesity. Torgan says there are many causes of childhood obesity. “While there’s no doubt genetics plays a role, genes alone can’t account for the huge increase in rates over the past few decades. The main culprits are the same as those for adult obesity: eating too much and moving around too little. Almost half of children aged 8–16 years watch three to five hours of television a day. Kids who watch the most hours of television have the highest incidence of obesity.” Physical Health Effects Along with the rise in childhood obesity, the American Obesity Association reports an increase in the incidence and prevalence of medical conditions in children and adolescents that had been rare in the past. Pediatricians and childhood obesity researchers are reporting more frequent cases of obesity-related diseases such as type 2 diabetes,

asthma, cancer and hypertension that once were considered adult conditions. Kendall et al. elaborate: “Many risk factors associated with these diseases, such as high cholesterol, blood pressure and triglyceride levels, can be followed from childhood to adulthood. This points to a potential link between childhood health and long-term adult health. Overweight children are more than two times likely to have high levels of cholesterol. Aortic fatty streaks, the first stages of atherosclerosis, begin to appear in childhood, maybe even as early as three years old. Also, children with triceps skinfolds greater than the 70th percentile have significantly higher blood pressures.” Torgan brings up another consequence of childhood obesity. “Perhaps more devastating to an overweight child than the health problems is the social discrimination. Children who are teased a lot can develop low self-esteem and depression.” Psychological Effects Because of the psychological trauma of feeling different, inferior, laughed-at, unattractive and ashamed, obese children tend to withdraw from peer group situations and social activities. Tests have shown that personality characteristics of obese girls are similar to those of people who have been subjected to intense discrimination because of their race or ethnic origin: passivity, obsessive concern with self-image and expectation of rejection. These lead to awkwardness in social situations, social isolation and actual rejection, and thus less activity outside the home, increased eating and, consequently greater obesity. Obese girls also consider obesity—and hence their own bodies—undesirable and in extreme cases repulsive. They consider obesity to be a handicap and the reason for all their disappointments. When an adolescent feels inferior in group situations, he or she tends to withdraw to solitary and usually sedentary activities, such as TV viewing and eating. Food has been described as a “feelgood drug” for the apathetic and unsure adolescent, whose appetite is also increasing to accompany normal physical growth. Coupled with less-than-normal exercise, this usually leads to even more excess fat and often to severe obesity in

90 childhood obesity adulthood. In extreme cases, the obese child may also suffer from depression, leading to total isolation and an incapacity to become emotionally attached to other persons. Routine and necessary activities like shopping for clothes can upset obese adolescents. Clothes made for “typical” children don’t begin to cover their frames. In order to locate pants that fit around his waist, the fat boy must shop in the men’s department. But the rest of these pants are far out of proportion, creating a humiliating situation for already self-conscious children. Rimm noted that in a survey of 5,400 thirdthrough eighth-graders from suburban, urban and rural schools in 18 states, compared with normalweight kids, heavy children were: • Five times more likely to have low self-confidence • Four times more likely to be lonely • Three times more likely to worry about their futures • Two times more likely to consider themselves “not smart enough.” Childhood Teasing Overweight children are more prone to ridicule and teasing, which makes them sensitive about their bodies and prime candidates for later problems. When Arkansas adopted legislation in 2003 to involve its schools in curtailing childhood obesity, the Arkansas Center for Health Improvement, which implemented the program statewide, trained school nurses to be sensitive to issues relating to body image and teasing. Children stepped on the scale backward so they could not see their own weight. Writing in Psychiatric Times, Stunkard et al. noted not only the connection between childhood teasing and depression but also its escalation. “A recent study has shown that the stigma of obesity, already severe in 1960, has increased measurably in the past 43 years. An instructive three-year prospective study of adolescents demonstrated how teasing mediated the relationship between obesity and later levels of depression. The obesity status of these adolescents elicited teasing, which,

in turn, elicited depression through their increased dissatisfaction with their appearance. Jackson et al. also reported that obese women with binge-eating disorder (BED) who experienced teasing about their appearance developed body dissatisfaction and depression.” Treatment Childhood obesity is usually found to be accompanied by one or more other physical or psychological disorders. Thus it is often treated most successfully by a combination of therapies, including low-calorie diet, behavior modification, nutrition education and increased physical activity. Children as young as three months have been placed on diets intended to control weight gain. Doctors at the Clinical Research Center of Mt. Sinai Hospital in New York have hospitalized obese children aged two through 11 and successfully treated them with a diet of 400 calories a day, together with iron and vitamin supplements. The diet consists of 46 grams of carbohydrates, 28 grams of protein and 12 grams of fat. The premise underlying behavioral approaches to obesity—that effective weight control requires major changes in eating behavior—is considered by some to be even more important for children than for adults because it is usually easier to change the habits of children than those of adults, who are more set in their ways. (See BEHAVIOR MODIFICATION.) These behavioral techniques involve the manipulation of the physical and social environment to decrease the probability of overeating. This is achieved in the case of diet by keeping track of what is eaten, noting various internal and external cues that lead to eating, immediate positive reinforcements of desirable behaviors, dissociation of eating from other experiences and, in some cases, emphasis on eating styles. Behavior therapy in combination with diet restrictions, has been shown in studies to be superior to diet alone, and maintenance of weight loss has been more successful. It is most helpful for those with one or more “obese eating style” problems: rapid eating, few but large bites, short-duration meals, exaggerated sensitivity to external stimuli. A child’s level of involvement in a weight loss program depends, in large part, on his or her level

childhood obesity 91 of mental development. Leonard H. Epstein has outline four age ranges as a guideline for placing increasing responsibility for weight control on a child. At ages one to five, any weight program must rely on parental control. A child is generally not able to read or write and thus is unable to keep track of calories consumed, burned through exercise and so on. Motivation to lose weight is absent. During this time, parents are the major influences on a child’s eating and activity habits. At ages five to eight, a child’s ability to monitor calorie consumption/expenditure and eating patterns is still limited, although simple diet control can begin. Children at this age can start learning nutritionally sound eating habits and can be trained to handle social situations in which food is offered. In addition, these children can also begin learning to solicit praise and encouragement for healthy eating from adults close to them. Parents will still be involved significantly. At ages eight to 12, a child can set goals and selfmonitor. Peer pressure may provide motivation to lose weight; however, children at this age still benefit substantially from parental involvement. From age 13 on, children can use programs similar to those of adults, though they may be helped through social groups. At this stage of development, children are becoming independent of their parents, and too much parental guidance or interference may be counterproductive. In the attempt to monitor and control types and amounts of food intake, color coding of foods to show calorie amounts can be understood by children as young as age five. The nutritionally balanced TRAFFIC LIGHT DIET developed by Epstein in 1978 separates premeasured food portions into red, yellow and green categories corresponding to traffic signals (stop eating reds, be careful of the amounts of yellows, and go ahead and eat lots of greens). With young children, colored stars corresponding to foods eaten may then be exchanged for reinforcers. This method of encouraging healthy low-calorie eating by obese children has been shown to be useful in school as well as home settings. The New American Eating Guide, a colorcoded poster similar in concept to the Traffic Light Diet, and the Nutrition Scoreboard (Center for Science in the Public Interest, 1977) have also been

useful in programs of weight control and eatinghabit change for children. The Food Exchange Diet prepared by the American Dietetic Association is also applicable to children, with help from adults in learning the procedures. Pediatricians have used colored tokens to represent the food exchanges in this diet; tokens are transferred from one plastic box to another following consumption of food in their color groups. These color-coded systems provide effective visual representation of diet for children too young to read and write. Premeasured portions also eliminate the need for calorie counting. Numerous food-related factors influence a child’s eating pattern and treatment for obesity: the parents’ food-buying habits, another family member’s eating disorder, contradictory messages to the child regarding eating, the child’s attitude toward diet and exercise change and his knowledge of nutrition. Although exercise is an important component in assessing and treating childhood obesity, some evidence suggests that it may be less important than diet in maintaining weight loss. Some authors recommend “lifestyle” exercise (walking, cycling, etc.) with little structure or intensity over structured aerobic exercise in weight-loss programs for children, for two reasons. First, if caloric expenditure and not aerobic fitness is the goal of the program, lifestyle exercise will accomplish that goal. More important, studies have found that lifestyle exercise is more likely to be adhered to, and lack of adherence is recognized as a major obstacle to effective treatment. Parents’ involvement in children’s weight loss programs has been found to be a barometer of their success. Some programs have achieved their best initial weight losses when parents were active participants, especially when the parents were obese and also involved in losing weight. Interestingly, the effectiveness of these parentchild treatments may be greater when the parent and children are worked with separately rather than together. For older children, there is some evidence suggesting that maintenance of weight loss is most readily achieved when they engage in self-regulation of food intake and exercise, self-reinforcement

92 Chipley, William Stout and self-imposed restrictions in tempting situations. For younger children, treatment may be enhanced by teaching self-control skills and in changing attitudes toward diet and exercise that may undermine self-control, since parents cannot control what children eat all of the time. As children mature, more responsibility for weight loss can be shifted to them. Bar-Or, O., et al. “Physical Activity, Genetic, and Nutritional Considerations in Childhood Weight Management.” Medicine and Science in Sports and Exercise 30, no. 1 (January 1998): 2–10. Collipp, Platon J., ed. Childhood Obesity. New York: Warner Books, 1986. Epstein, Leonard H. “Treatment of Childhood Obesity.” In Handbook of Eating Disorders, edited by Kelly D. Brownell and John P. Foreyt. New York: Basic Books, 1986. Epstein, Leonard H., and Sally Squires. The Stop-Light Diet for Children. Boston: Little, Brown, 1988. Jackson, T. D., C. M. Grilo, and R. M. Masheb. “Teasing History, Onset of Obesity, Current Eating Disorder Psychopathology, Body Dissatisfaction, and Psychological Functioning in Binge Eating Disorder. Obesity Research 8, no. 6 (2000): 451–458. Kendall, P., K. Wilken, and E. Serrano. “Childhood Obesity.” Colorado State University Cooperative Extension. Available online. URL: http://www.ext.colostate. edu/pubs/foodnut/09317.html. Updated on August 24, 2004. Latner, J. D. and A. J. Stunkard. “Getting Worse: The Stigmatization of Obese Children.” Obesity Research 11, no. 3 (2003): 452–456. Marin, Roselyn. Helping Obese Children. Montreal and Holmes Beach, Fla.: Learning Publications, 1990. Mei, Z., et al. “Increasing Prevalence of Overweight Among U.S. Low-Income Preschool Children.” Pediatrics 101, no. 1 (January 1998): 103–105. Meisels, Samuel J., and Jack P. Shonkoff, ed. Handbook of Early Childhood Intervention. 2nd ed. Cambridge and New York: Cambridge University Press, 2000. Rimm, Sylvia. Rescuing the Emotional Lives of Overweight Children. New York: Rodale Books, 2004. Rotatori, Anthony F., and Robert A. Fox, comps. Obesity in Children and Youth: Measurement, Characteristics, Causes, and Treatment. Springfield, Ill.: C. C. Thomas, 1989. Strauss, Richard. “Childhood Obesity.” Current Problems in Pediatrics 29, no. 1 (January 1999): 1–29. Stunkard, Albert, Myles S. Faith, and Kelly C. Allison. “Depression and Obesity: A Complex Relationship.”

Psychiatric Times 21, no. 11 (October 2004). Available online. URL: http://www.psychiatrictimes.com/ p041081.html. Thompson J. K., et al. “Development of Body Image, Eating Disturbance, and General Psychological Functioning in Female Adolescents: Covariance Structure Modeling and Longitudinal Investigations.” International Journal of Eating Disorders 18, no. 3 (November 1995): 221–236. Torgan, Carol. “Childhood Obesity on the Rise.” Word on Health, National Institutes of Health, June 2002. Available online. URL: http://www.nih.gov/news/ WordonHealth/jun2002/childhoodobesity.htm.

Chipley, William Stout (1810–1880)

Chief medical officer of the Eastern Lunatic Asylum of Kentucky, who published the first American description of SITOMANIA in 1859 in the American Journal of Insanity. His observations were based on his clinical experience at the asylum, where a number of young girls who would not eat were finally brought by their desperate families, always after treatment by their family doctors had failed. Chipley’s commentary was significant because of his identification of a specific type of food refuser and because it called attention to the behavior of adolescent girls. He strongly believed that their refusal to eat was an intentional attempt to draw attention, elicit sympathy and exert power within a small circle of friends and family.

chlorpromazine A tranquilizing drug used during the 1960s in conjunction with insulin to treat anorexia nervosa. Garfinkel and Garner wrote that it reduced a patient’s initial anxiety and resistance to eating and weight gain. It also sometimes sedated the patient enough to help her tolerate bed rest or other enforced reduction of activity. Although this resulted in rapid weight gain, there were a number of serious problems, including lowered blood pressure and reduced body temperature. In a comparison of two similar groups of hospitalized anorexic patients, one group treated with chlorpromazine and insulin and the other group treated without chlorpromazine, the patients treated with chlorpromazine gained weight substantially faster and left the hospital significantly sooner. After two years, 33 percent of each group required readmission. However, 45 percent of the

cognitive distortions 93 patients treated with chlorpromazine had developed bulimia, compared with 12 percent of the patients treated without it. Furthermore, the chlorpromazine treatment was associated with significant side effects, including grand mal seizures. Chlorpromazine was sometimes recommended only for patients who showed marked anxiety about food and an inability to eat after general supportive measures had been attempted. Insulin therapy with chlorpromazine is not used today. Garfinkel, Paul E., and David M. Garner. Anorexia Nervosa: A Multidimensional Perspective. New York: Brunner/ Mazel, 1982.

cholecystokinin (CCK)

A hormone released from the intestine within five minutes after eating, which stimulates gallbladder contraction and pancreatic secretion. First isolated more than 60 years ago, it is now said also to send a signal from the stomach to the brain when the stomach is full. All mammals have CCK in varying amounts. In a U.S. Agriculture Department study, scientists discovered that they can block the hormone in pigs by injecting them with a vaccine that makes their appetite insatiable, in effect producing bigger pigs. In less than three months, the injected animals consumed an average of 22 more pounds of corn and soybean meal than untreated pigs, while putting on 11 pounds, of mostly meat rather than fat. Medical researchers and psychiatrists are monitoring the animal experiments to see if the principle could help anorexics. Studies are also under way to develop drugs to block the CCK hormone in the hope of curbing food cravings. In 1988 Thomas D. Geracioto, Jr., a clinical neuroendocrinologist at the National Institute of Mental Health, and Rodger A. Liddle of the University of California at San Francisco released results of a study on bulimia in which they compared several measurements of cholecystokinin in both bulimics and control subjects. They found that, on average, the bulimics secreted half as much cholecystokinin as the controls did, indicating that bulimics may not reach a reasonable satiety level. Since CCK is produced in the intestine and in the brain, scientists are searching to discover which parts of SATIETY are physiological and which are

psychological, and how they interconnect. Doctors have discovered that certain ANTIDEPRESSANT drugs, which help bulimics to stop binge eating, also raise their CCK levels. In pill form CCK has no effect because the chemical cannot survive in the digestive track. The Food and Drug Administration (FDA) considers CCK pills promoted for weight loss to be a drug requiring FDA premarket approval. The FDA has not yet received requested substantiation of weight-loss claims from CCK manufacturers. Chase, Marilyn, “Pigs May Provide Hints for Humans on Not Being Hogs.” Wall Street Journal, December 8, 1988, p. A1. Geracioti, Thomas D., Jr., and Liddle, Rodger A. “Impaired Cholecystokinin Secretion in Bulimia Nervosa.” New England Journal of Medicine 319, no. 11 (September 15, 1988): 683–688. Moore, Beth O., and J. A. Deutsch. “An Antiemetic Is Antidotal to Satiety Effects of Cholecystokinin.” Nature (May 23, 1985), page 321–322.

cholesterol A pearly white crystalline substance that is found in all foods derived from animals. It is an essential building block of our cells, but when present in high levels in the blood, it can lead to atherosclerosis (impeded blood flow due to thickening of the arteries). Cholesterol helps carry fats in the bloodstream to tissues throughout the body. Most cholesterol in the blood is made by the liver from saturated fats (see FATS, SATURATED); some is absorbed directly from cholesterol-rich foods such as egg yolks. cognitive behavior therapy

See

BEHAVIOR THER-

APY; COGNITIVE THERAPY.

cognitive distortions Illogical, faulty thinking and irrational beliefs. Neuman and Halvorson determined from their studies of medical literature that one of the most critical tasks facing therapists and anorexics is the correction of cognitive distortions, which are numerous in anorexics. These distortions include an inability to perceive their body shapes and sizes accurately and may even affect their understanding of the body’s biological functions. (“For instance, anorexics often have strange

94 Cognitive Factors Scale ideas about what happens to the food they eat, imagining that it goes ‘directly’ to their thighs, hips, or abdomens.”) A perfectionistic way of thinking is commonly found in anorexics. Burns gives the following patterns for illogical or distorted thought in perfectionists:

Polivy, Janet, Peter C. Herman, and David M. Garner. “Cognitive Assessment.” In Assessment of Addictive Behaviors, edited by Dennis M. Donovan and G. Alan Marlatt. New York: Guilford Press, 1988. Garner, D. M., and K. M. Bemis. “A Cognitive Behavioral Approach to Anorexia Nervosa.” Cognitive Therapy and Research 6, no. 2 (1982): 123–150.

• Dichotomous Thinking All-or-nothing thinking in which perfectionists evaluate their experiences in a dichotomous manner, seeing things in black-or-white terms. (“If I don’t choose a major before school starts, I’ll probably end up just being a bum,” or “If I gain any weight, I’ll be fat.”)

Cognitive Factors Scale (CFS)

• Overgeneralization Perfectionists tend to jump dogmatically to the conclusion that a negative event will be repeated endlessly. An anorexic may have a small lapse in her eating and conclude, “I’ll never get better, my eating will never improve.” • “Should” Statements When perfectionists fall short of a goal, they berate themselves (“I shouldn’t have goofed up! I ought to do better! I mustn’t do that again!”). Two other reasoning errors were identified by Garner and Bemis as common to victims of anorexia: superstitious thinking and personalization. Superstitious thinking assumes a cause-effect relationship of unrelated events. This kind of thinking may play a part in the emergence of anorexic behavior, with the anorexic believing that weight loss will solve other problems in her life. Superstitious thinking can also lead to other bizarre behavior rituals. Personalization involves seeing oneself as the focus of other people’s attention and taking events and comments personally whether or not they are so intended. (“Two people laughed and whispered something to each other when I walked by. They were probably saying that I looked unattractive. I have gained three pounds.’) Burns, D. “The Perfectionist’s Script for Self-Denial.” Psychology Today (November 1980). Neuman, Patricia A., and Patricia A. Halvorson. Anorexia Nervosa and Bulimia: A Handbook for Counselors and Therapists. New York: Van Nostrand Reinhold, 1983.

A self-test developed in 1982 by Gormally, Black, Daston and Rardin containing 14 items designed to assess specific dieting problems. The scale measures two factors: Strict Dieting Standards and Self-Efficacy Expectations to Sustain a Diet. In general, cognitive factors play a crucial role in leading from an isolated slip (just one piece of pie) to a full-blown relapse (an all-out binge). Sample items from the CFS: When I start a diet, I say to myself that I will have absolutely no “forbidden foods.” I don’t persist very long on diets I set for myself.

Gormally, J. et al. “The Assessment of Binge Eating Severity among Obese Persons.” Addictive Behaviors 7, no. 1 (1982): 47–55.

cognitive therapy A treatment method for mental disorders founded on the premise that the way we think about the world and ourselves affects our emotions and behavior. Therapists work with patients’ thoughts, senses, memories and perceptions, as expressed in their internal monologues about their behavior. For example, internal monologues about weight reduction can play a critical role in the maintenance and control of obesity. An internal monologue may say, “It’s taking me so long to lose the weight.” A therapist will counsel the patient to replace that negative thought with the more positive, “But I am losing it. And this time I’m learning how to keep it off.” Simple repetition of counterstatements over a period of time helps to change people’s views of themselves, even if they do not completely believe them at the outset. In a British study, a cognitive-behavioral approach was applied to the individual treatment of 11 bulimic women. First the binge-purge cycle

college students and eating disorders 95 was interrupted, and then cognitive strategies were taught for self-control. Next the patients were helped to modify abnormal attitudes toward food, eating and body weight and shape. Normally restricted foods, such as carbohydrates, were gradually introduced into the diet to lessen the desire to binge on these foods. Patients were also helped to identify situations in which loss of control occurred. Finally, patients were prepared for future relapse events. Duration of treatment was seven months. Nine of the 11 patients reduced their binge eating and vomiting from three times daily to less than once a month. Anxiety and depression decreased, as did dysfunctional attitudes concerning shape and weight. At one-year follow-up of six of the patients, one had stopped bingeing and vomiting completely, four reported that these behaviors occurred two to three times a month, and one showed no improvement. Follow-up data were not available for the other five patients. The research team later reported that subsequent experience with more than 50 patients has confirmed that the majority do indeed benefit from the cognitive therapy approach, with most remaining well and requiring no further treatment. Researcher David Garner has written that because attitude change is an important element in recovery of ANOREXIA NERVOSA, cognitive therapy has promise as a valuable treatment strategy for it. Currently there is more empirical support for the use of cognitive and/or cognitive behavior therapy with bulimia nervosa than any other treatment. Fairburn, Christopher. “Binge Eating and Its Management.” British Journal of Psychiatry 141 (December 1982): 631–633. Garner, David M. “Cognitive Therapy for Anorexia Nervosa.” In Handbook of Eating Disorders, edited by Kelly D. Brownell and John P. Foreyt. New York: Basic Books, 1986. Wilson, G. Terence. “Cognitive-Behavioral and Pharmacological Therapies for Bulimia.” In Handbook of Eating Disorders, edited by Kelly D. Brownell and John P. Foreyt. New York: Basic Books, 1986.

college students and eating disorders

According to the National Institutes of Mental Health, 10 percent of college-age women have a clinical or nearclinical eating disorder. Experts believe the

prevalence may be higher, because the secretive nature of eating disorders and the shame involved prevent many cases from being reported. Also of concern are the even larger numbers of at-risk students. In addition to full-blown BULIMIA NERVOSA, for example, symptoms of bulimia, such as occasional episodes of binge eating and purging, occur in up to 40 percent of college women. One study found that 35 percent of female and 10 percent of male college athletes were at risk for ANOREXIA NERVOSA, and 58 percent of female and 38 percent of male college athletes at risk for bulimia nervosa. These rates are significantly higher than those in the general college population. In a study of 1,620 college students by Hoerr et al., 10.9 percent of women overall were at risk for eating disorders; while among African Americans, 8.3 percent of women were at risk. One group of women who lived separately in a social sorority had the highest risk—15 percent. Students at risk for disordered eating reported weight concerns interfering with their academic performance. In a small study of college students, Kitsantas et al. discovered that students with eating disorders reported more self-regulated strategies for managing their weight, a lower level of life satisfaction and higher levels of negative feelings than did atrisk students or individuals with normal weights. Among the most frequently cited reasons for the high incidence of eating disorders or disordered eating among college students: • The Freshman 15 Those 15 pounds a college freshman is said to put on during the first year away from parental supervision, when increased amounts of junk food and fast food tend to replace balanced family meals. Once the weight gain becomes apparent, the student often engages in peer-encouraged disordered eating practices in an attempt to take off the extra pounds. Some criticism of this concept has been published. Weight gain is probably less than that, although some students do gain a lot. • New Pressures With the added stress of living apart from family for the first time, meeting heavy academic demands, and wanting to belong, college students can feel lonely, sad, tired, overwhelmed, depressed, scared or con-

96 comfort food fused. Too often, they turn to food as a source of comfort. When they binge, all the negative feelings they are experiencing disappear. Later, they either feel guilty about the bingeing or fearful they will gain weight, so they are likely to purge or exercise compulsively. Because the food helps them feel better only temporarily, the binge/ purge cycle continues. • Weight-conscious society College counselors say that the pressure to look and remain thin seems to be at an all-time high on college campuses. According to the Baldwin-Wallace College (Berea, Ohio) counseling services, “Advertisements [and] magazine covers at college bookstores are portraying young women as being beautiful only if they are slender, with long legs and thin arms. Men are portrayed as desirable if they are tall, have broad shoulders and are thin at the waist. College students across the country are on a mission to attain an ‘ideal figure’ that is unrealistic for many and dangerous for some.”

Hoerr, S. L., et al. “Risk for Disordered Eating Relates to Both Gender and Ethnicity for College Students.” Journal of the American College of Nutrition 21, no. 4 (August 2002): 307–314. Kitsantas, A., T. D. Gilligan, and A. Kamata. “College Women with Eating Disorders: Self-Regulation, Life Satisfaction, and Positive/Negative Affect.” Journal of Psychology 137, no. 4 (July 2003): 381–395.

comfort food University of California–San Francisco researchers identified a biochemical feedback system in rats that could explain why some people crave “comfort foods” such as chocolate chip cookies and greasy cheeseburgers when they are chronically stressed, and why such people are apt to gain weight in the abdomen. Their finding focuses on a glucocorticoid steroid hormone (corticosterone in rats, CORTISOL in humans) that plays a key role in the stress response system. In their study, Dallman et al. determined that 24 hours after activation of the chronic stress system—which stimulates a flood of hormonal signaling from the hypothalamus to the adrenal glands—glucocorticoids prompt rats to engage in pleasure-seeking behaviors, which

include eating high-energy foods (sucrose and lard). The animals develop abdominal obesity, and the negative aspects of the chronic stress response system, otherwise ushered in by the glucocorticoids, are blunted. The researchers suspect that the metabolic signal to inhibit the stress system comes directly from fat depots. The finding offers an explanation into how chronic stress can be inhibited or curbed. While the body’s acute response to stress—say, to being cut off in traffic by a speeding car—diminishes through a naturally occurring inhibitory feedback mechanism of the adrenal stress system, its chronic response to stress—in which a barrage of threats, scares or frustrations occur over days, weeks or months—becomes chronically excited. Over time, the elevated stress level can initiate a host of deleterious effects on the body—a loss or gain of weight, depression, obesity (associated with type 2 diabetes, cardiovascular disease and stroke), and a loss of brain tissue. “Our studies suggest that comfort food applies the brakes on a key element of chronic stress,” says study coauthor Norman Pecoraro. And it could explain, he says, why solace is often sought in such foods by people with stress, anxiety or depression. It also could help to explain bulimic and nightbinging eating disorders. Dallman, who has spent years studying the regulation of the stress response system, developed the new model of chronic glucocorticoid feedback. Evolutionarily, the drive to eat comfort foods makes sense, says Pecoraro. The animal kingdom is an “eat or be eaten” world, and a body under constant, or chronic, stress may preferentially eat high-energy foods to stay in the game. Under the model that the research team has proposed, glucocorticoids would both prompt vigilance to threats and send a signal to the brain of a chronically stressed animal to seek high-energy food. If it were successful in finding such food, stress and its attendant feelings would be terminated. In regions of the world where people struggle with wars, epidemics of disease and chronic food shortage, the need to seek out high-energy foods would be great, as well. In the developed world, where stress is more often found in a commuting office worker, for example, people seem to be seek-

complement factors 97 ing the same solution—and finding it at every street corner, says Pecoraro. “If, after the near-miss on the freeway, you get into work and almost lose your job during an argument with your boss, and have a fight at home that night—and these types of events are relentless—you’re going to have chronically elevated adrenal hormones (i.e., chronic stress),” he says. There has to be a brake on the system, and, for some, it is chocolate. However, there are other ways to treat chronic stress—exercise, yoga, meditation, sex and baths all stimulate neurochemicals that activate regions of the brain that stimulate pleasure. Relaxation techniques may work by reducing the psychological drives on stress output, which can be the root causes of stress. (Drugs and alcohol do not provide sufficient metabolic feedback, and may even stimulate further stress and its attendant compulsions for pleasure.) As for the use of food, there are serious health consequences of a diet high in fat and sugars: abdominal obesity (which can lead to cardiovascular disease, type 2 diabetes and stroke), and cardiovascular disease itself. “In the short term, if you’re chronically stressed it might be worth eating and sleeping a little more to calm down, perhaps at the expense of gaining a few pounds,” says Pecoraro. “But seeking a longterm solution in comfort foods—rather than fixing the source of the stress or your relationship to the source of the stress—is going to be bad for you.” Stress is a strategy that evolved to enable the body to deal with threats, ranging from the crouched lion ready to pounce to the possibility of losing a job. It promotes quick, though somewhat inflexible, physical and mental responses, vigilance and attention. It the immediate response to a perceived danger, the body experiences the familiar “adrenaline rush,” in which the adrenal glands initiate a flood of hormonal signals that quicken the heart rate, constrict the vasculature to prevent bleeding to death and provide energy to the muscles. Minutes later, a slightly slower response is orchestrated by hormones from another region of the adrenal glands, providing such defenses as an anti-inflammatory function. Once an acute threat has subsided, these hormones are shut off through an inhibitory feedback system.

During chronic stress, however, the system does not turn off, and glucocorticoids, which were formerly inhibitory, have an overriding excitatory effect on brain stress networks. Glucocorticoids in the system remain elevated, maintaining high levels of corticotropin releasing factor, which in turn regulates adrenocorticotropin—both key inciting hormones in the chronic stress response system. This creates a positive feedback loop between the stress systems of the body and brain. From their studies, the researchers concluded that rats with chronically elevated glucocorticoids developed pleasure-seeking/or compulsive behaviors that included drinking sucrose (rather than saccharine), eating lard, running on the wheel and taking a drug. They then observed changes that took place in the stress response system in the aftermath of eating the comfort food: an increase in abdominal fat and an end to corticotropinreleasing factor and adrenocorticotropin secretion. They also observed an inverse relationship between abdominal fat and the expression of genes in the motor zone of the hypothalamus, where the stress response is initiated. “This seems to be the body’s way of telling the brain, ‘It’s ok, you can relax, you’re refueled with high-energy food,’” says Pecoraro. The message is clearly being transmitted in the middle-aged man or woman with a gut. “This body type represents the classic distribution of fat from stress.” The new model may explain why losing weight is notoriously difficult, he says. Losing weight is literally stressful, which makes a person feel anxious, and stress hormones make a person crave highenergy foods, which blunt the feelings of stress and make one feel better. Dallman, Mary F., et al. “Chronic Stress and Obesity: A New View of ‘Comfort Food.’ ” Proceedings of the National Academy of Sciences 100, no. 20 (September 30, 2003): 11,696–11,701.

complement factors Immune system proteins believed to play a role in obesity; they are so called because they are necessary to complete certain hemolytic reactions (the removal of hemoglobin from red blood corpuscles). The term derives from the Latin compere, “to fill up.”

98 compulsive eating Findings in a 1989 study of mice conducted by a team of researchers from the Harvard Medical School and the University of Alabama confirmed what scientists had suspected for some time: the system that helps an animal defend itself against infarction (death of tissue from lack of blood supply) may influence how it stores and burns energy. These results are helping researchers investigate the causes of obesity in animals and humans. The researchers reported that families of obese mice had unusually low levels of complement factors. Human and mouse complement factors appear to be very similar, so researchers believe obese people may show similar deficiencies. This was the first time anybody had established the possibility of a connection between complements and energy metabolism. Most complement factors—humans have 30— are proteins produced and secreted by the liver. Many of these proteins circulate in the blood like roaming security guards and provide an immediate defense against invading bacteria or viruses. Other complements cannot mobilize until the body produces antibodies, the molecules that recognize and bind to foreign bodies. The first evidence for a link between complements and the metabolic system appeared several years ago when doctors discovered that human fat cells secrete a protein named Complement Factor D, also called adipsin, or ADN. In humans, Factor D is among those complements that do not need to unite with antibodies before activating. As the bottleneck in the series of reactions that trigger inflammation, Factor D helps regulate the first response to an attack on the immune system. The research team compared a mouse complement factor, adipsin, with human Factor D. Like the human protein, adipsin is secreted primarily by the mouse fat cells. Earlier research had shown that 60 percent of adipsin’s structure is identical to that of Factor D. When they compared the levels of adipsin in normal and obese mice, they found that obese mice had dramatically less circulating adipsin. Because human Factor D so closely resembles the mouse protein, scientists suspect that people with certain kinds of obesity will also show Factor D deficiency.

Rosen, Barry S., et al. “Adipsin and Complement Factor D Activity: An Immune-related Defect in Obesity.” Science 244, no. 4911 (June 23, 1989): 1,483–1,487.

compulsive eating Also referred to as compulsive overeating or binge eating. An eating pattern characterized by symptoms similar to those of bulimia nervosa, but without the purging. (See BINGE-EATING DISORDER.) Much of the compulsive eater’s life is centered on food, what she (most are women) can or cannot eat, what she will or will not eat, what she has or has not eaten and when she will or will not eat next. Typically, she eats continuously from morning until night, much of the time in secret. Her obsession with food is coupled with self-disgust, loathing and shame because of her total lack of self-control around food. Frequently a compulsive eater thinks that if she does not have access to food, she will be all right, and she will therefore keep her home almost bare of food, except for the “health food” variety. But her compulsion will drive her out even in the night to look for food to satisfy her uncontrollable urges. Typically, she will continue to eat long after she is full. She eats not because she’s hungry or even because she enjoys it but to satisfy an unacknowledged psychological need. Not all compulsive eaters are obese; some control their weight by constant EXERCISE, FASTING for a few days at a time or even dieting. There are compulsive eaters at all levels of society, from shop floor to executive suite. Because many compulsive eaters do have weight problems, they run a high risk of hypertension, heart disease and diabetes. And they usually ingest high levels of fat, cholesterol and sugar, which increase their risk of heart disease, cancer and iron-deficiency anemia. So-called cures, ranging from hypnosis to hospitalization, do not help many compulsive eaters. Most helpful thus far have been clinics, both inpatient and outpatient, that address both physical and psychological aspects of the problem. Such treatment centers work on the premise that compulsive eating is an addiction similar to drug or alcohol addictions. Unlike anorexia or bulimia, compulsive overeating generally has a more gradual beginning, according to Siegel, Brisman and Weinshel.

conjugated linoleic acid 99 They explain that it often starts in early childhood when eating patterns are being formed. Sometimes a family focuses on food as a retreat from feelings, as a way to feel good or as an activity to fill otherwise empty time. Eating patterns that do not cause problems for growing children can cause them in adulthood. When compulsive overeating starts in young adulthood, it is often at times of stress when young people are ill prepared to handle certain kinds of frustration and emotion. Soon they begin to use food inappropriately (often against their better judgment) and eventually become addicted to it, losing control over the amounts of food they eat. HILDE BRUCH says that compulsive eaters often eat more when they feel worried or tense, and they feel less effective and competent when they try to control their food intake; she referred to their compulsion as a “neurotic need for food.” Bruch, Hilde. Eating Disorders. New York: Basic Books, 1973. Ghiy, L., and J. C. Chrisler. “Compulsive Eating, Obsessive Thoughts of Food, and Their Relation to Assertiveness and Depression in Women.” Journal of Clinical Psychology 51, no. 4 (July 1995): 491–499. Hirschmann, Jane R., and Carol H. Munter. Overcoming Overeating. New York: Fawcett, 1998. Siegel, Michele, Judith Brisman, and Margot Weinshell. Surviving an Eating Disorder. Rev. ed. New York: Perennial Currents, 1997.

compulsive eating scale (CES)

A self-test designed by Dunn and Ondercin to assess emotional states related to eating and specific aspects of binge behavior. The CES includes 32 items and provides data related to degree of compulsive eating. In addition, it assesses general information about the frequency of binges, alternations of BINGE EATING with FASTING and DIETING, and emotional reactions following a binge episode. Sample items from the CES: I eat when I’m not hungry. My weight varies and I am usually gaining or losing weight. Dunn, P. K., and P. Ondercin. “Personality Variables Related to Compulsive Eating in College Women.” Journal of Clinical Psychology 37, no. 1 (January 1981): 43–49.

conjugated linoleic acid (CLA) A naturally occurring compound found in the fat of beef, turkey and dairy products. According to Martineau, “Increasing clinical evidence is proving that CLA decreases body fat and promotes weight loss, without causing any serious side effects. The compound appears to reduce fat by regulating enzymes in fat cells, which reduces the rate at which the body deposits fat. Moreover, CLA promotes calorie burning by increasing metabolism. Supplements made from the compound are sold as fat blockers.” Prior studies of CLA’s effect on humans had been too short to be definitive, but a yearlong Norwegian study concluded that CLA reduces body fat mass in overweight but otherwise healthy adults by as much as 9 percent. The randomized, double-blind placebocontrolled study is the first to document the longterm safety and efficacy of CLA supplementation over a 12-month period without additional lifestyle or dietary restrictions. This long-term clinical trial supports earlier research that found CLA improves body composition by promoting body fat reduction and maintaining lean muscle mass. One hundred eighty healthy men and women, aged 18 to 65, with a body mass index (BMI) of 25–30 (thus, overweight) were randomized to receive capsules containing either 4.5 grams Tonalin CLA-free fatty acid, 4.5 grams Tonalin CLA-triglycerides or 4.5 grams of olive oil (placebo). Subjects were then monitored for 12 months, and weight, BMI and adverse events were recorded every three months. Body composition and blood samples were analyzed at regular intervals throughout the study. At baseline, there was no difference between the groups for either weight, BMI, body fat mass or lean body mass. After six months, individuals taking either form of Tonalin CLA experienced a significant reduction in body fat mass, while those in the placebo group saw no change. Compared to the placebo group, those who took CLA lost about 9 percent of body fat on average, plus increased lean body mass, making weight loss minimal. Daily calorie intake and exercise did not differ between groups either at zero or 12 months and thus most likely did not play a role in body composition changes observed in the CLA groups.

100 continuity/discontinuity models of eating disorders Both forms of CLA were equally effective in body fat mass reduction and considered safe when used for one year in healthy, overweight adults. The researchers concluded that CLA “administered either in the triglyceride or free fatty acid form, in healthy, overweight adults for one year, results in a significant decrease of body fat mass.” Scientists do not know precisely how CLA works, but suspect it may decrease the amount of fat stored after eating and help the body use existing fat for energy. Although CLA is not a “magic pill,” it may prove to enhance diet and exercise in controlling weight gain. Gaullier, Jean-Michel, et al. “Conjugated Linoleic Acid (CLA) Supplementation for One Year Reduces Body Fat Mass in Healthy, Overweight Humans.” American Journal of Clinical Nutrition 79, no. 6 (June 2004): 1,118–1,125. Martineau, William. “What’s the Skinny?” Canadian Chemical News 56, no. 7 (July–August 2004): 23–25.

continuity/discontinuity models of eating disorders This is a common model in the eating disorders literature. The idea is that eating disorders occur on a continuum with normal dieting and weight concerns. When someone’s behavior, thoughts and/or feelings are far enough on the continuum, we consider this pathological and in this case, and eating disorder. The continuum or continuity model of eating disorders can be contrasted with the discontinuity model, which assumes that the experiences of persons with eating disorders are qualitatively different from those of persons with common dieting and weight concerns. Although the continuum model is commonly accepted and some research does support it, very recent research utilizing statistical methods designed to distinguish continuities from discontinuities have supported the discontinuity model of bulimia nervosa and anorexia nervosa, binge eating/purging type. See also TAXON. Gleaves, D. H., M. R. Lowe, A. C. Snow, B. A. Green, and K. P. Murphy-Eberenz. “The Continuity and Discontinuity Models of Bulimia Nervosa: A Taxometric Investigation.” Journal of Abnormal Psychology 109, no. 1 (February 2000): 56–58.

Gleaves, D. H., J. D. Brown, and C. S. Warren. “The Continuity/Discontinuity Models of Eating Disorders: A Review of the Literature and Implications for Assessment, Treatment, and Prevention.” Behavior Modification 28, no. 6 (November 2004): 739–762. Stice, E., et al. “Support for the Continuity Hypothesis of Bulimic Pathology.” Journal of Consulting and Clinical Psychology 66, no. 5 (October 1998): 784–790.

control group

A group used as a basis of comparison with an experimental group. In a study of the effectiveness of a drug, the experimental group would take the drug, and the control group would take either nothing or a PLACEBO. See also DOUBLE-BLIND STUDY.

CortiSlim

A dietary supplement heavily advertised beginning in August 2003. According to the Federal Trade Commission (FTC), which filed suit in September 2004, the marketers promoted cortisol control as “the answer” for anyone who wants to lose weight, especially abdominal weight. According to the FTC’s complaint, the defendants’ broadcast ads, print ads and Web sites claimed that persistently elevated levels of cortisol, which they called the “stress hormone,” are the underlying cause of weight gain and weight retention and also claimed that CortiSlim effectively reduces and controls cortisol levels and thereby causes substantial weight loss. The FTC alleges that the defendants claimed that CortiSlim: (1) causes weight loss of 10 to 50 pounds for virtually all users; (2) causes users to lose as much as four to 10 pounds per week over multiple weeks; (3) causes users to lose weight specifically from the abdomen, stomach and thighs; (4) causes rapid and substantial weight loss; (5) causes long-term or permanent weight loss; and (6) causes weight loss. The FTC also alleges that the defendants claimed that the effectiveness of CortiSlim and its ingredients is demonstrated by more than 15 years of scientific research. According to the FTC’s complaint, these claims are false or unsubstantiated. When asked by a reader about CortiSlim, the UC Berkeley Wellness Letter, May 2004, “Ask the Experts” editor said, “We could not find even one published study on CortiSlim.”

cortisol An adrenal cortical hormone released in response to stress. It is usually referred to pharma-

costs to treat obesity 101 ceutically as hydrocortisone. Also referred to as the stress hormone. A good deal of study has been devoted to cortisol levels, particularly as they relate to depression. Recently, scientists have been able to show that the excess of cortisol in both depressed and anorexic people is due to a problem that occurs in a region of the brain near or in the hypothalamus. The hypothalamus regulates many bodily functions—hormonal secretions, temperature, water balance and sugar and fat metabolism; thus, it is certain that there is a link between abnormality in the hypothalamus and the problems associated with eating disorders. Questions remain about cause and effect. Some scientists believe that prolonged stress causes the neurotransmitter/hormone imbalances, which then “drive” the eating disorder. One of the functions of cortisol is to help the body produce blood sugar (glucose) from proteins. Excess glucose is then used for lipogenesis (fat production). Thus, researchers have linked over secretion of cortisol with obesity and increased fat storage deep within the abdomen, called VISCERAL FAT, which carries a higher risk of heart disease, diabetes and cancer than does subcutaneous fat. Researchers have also found that women who secreted higher levels of cortisol while under stress had a much greater tendency to snack on high-fat foods than did women who did not secrete as much cortisol in reaction to the same stressful event. See also STRESS AND WEIGHT GAIN.

costs to treat eating disorders

Not only does anorexia nervosa have one of the highest mortality costs among psychiatric conditions, but the chronic nature of eating disorders generally lead to high treatment costs over time. Agras explains, “The costs of therapy for anorexia nervosa are higher than those for schizophrenia. Although somewhat less chronic, bulimia nervosa and binge-eating disorder are costly conditions to treat, similar to or more expensive than the costs for the treatment of obsessive compulsive disorder. Although antidepressant medication seems to be the most costeffective treatment in the short term, given the higher relapse rates with antidepressants, it seems that, in the end, cognitive-behavioral therapy may be the most cost-effective approach to the treat-

ment of bulimia nervosa. It is possible that similar figures would occur for binge-eating disorder.” Agras, W. S. “The Consequences and Costs of the Eating Disorders.” Psychiatric Clinics of North America 24, no. 2 (June 2001): 371–379.

costs to treat obesity

Obesity has been called not only a health problem but also “an economic phenomenon.” • Annual U.S. obesity-attributable medical expenditures are estimated at $75 billion in 2003 dollars, and approximately one-half of these expenditures are financed by Medicare and Medicaid, according to research done by the nonprofit group RTI International and the Centers for Disease Control and Prevention. Statelevel estimates range from $87 million (Wyoming) to $7.7 billion (California). Obesityattributable Medicare estimates range from $15 million (Wyoming) to $1.7 billion (California), and Medicaid estimates range from $23 million (Wyoming) to $3.5 billion (New York). • The total direct and indirect costs attributed to overweight and obesity amounted to $117 billion in 2000, according to The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity report issued in December 2001. • Obese men spend as much as 3.5 times that of normal-weight men on prescription drugs, according to a Mayo Clinic study presented at the American Heart Association’s Scientific Sessions 2004. Researchers studied 328 male executives, average age 47, and found that obese men spent an average of $80.31 per month on drugs, overweight men spent an average of $39.27 per month, and normal-weight men spent an average of $22.84 per month. “These are what we call ‘real and immediate costs.’ These are not the costs associated with an operation or serious event like a heart attack that might happen at some time in the future. Rather, this is what the men, or their employers, spend month after month on their prescription drugs,” said Thomas G. Allison, lead author. • Researchers at Beth Israel Deaconess Medical Center and Harvard Medical School found obese

102 Council on Size and Weight Discrimination, Inc. adults had significantly higher medication and office visit spending than did people with lower BMIs. Mean annual per person spending for health care overall was (in 2003 dollars) $2,127 for a typical normal-weight white woman aged 35 to 44 years; $2,358 for women with BMIs of 25 to 29.9; $2,873 for women with BMIs of 30 to 34.9; $3,058 for women with BMIs of 35 to 39.9; and $3,056 for women with BMIs of 40 or higher. Expenditures related to higher BMI rose dramatically among white and older adults but not among blacks or those younger than 35 years.

Finkelstein, Eric A., Ian C. Fiebelkorn, and Guijing Wang. “State-Level Estimates of Annual Medical Expenditures Attributable to Obesity.” Obesity Research 12, no. 1 (January 2004): 18–24. Wee, C. C. “Health Care Expenditures Associated with Overweight and Obesity among U.S. Adults: Importance of Age and Race.” American Journal of Public Health 95, no. 1 (January 2005): 159–165.

Council on Size and Weight Discrimination, Inc. An organization formed in 1991 to influence public policy and opinion in order to fight discrimination based on body weight, size or shape. It is a nonprofit project oriented advocacy group with a board of directors rather than a membership organization. It depends on contributions and grants to support its efforts. Its projects include negotiations with architects’ groups over the standard size of theater seats, testimony before regulatory agencies dealing with diet fraud and discussions with writers and editors of medical textbooks on what the next generation of doctors will be taught concerning weight and dieting. The council also presents the perspective of the large-size health consumer at meetings of the scientific, medical, and research communities. See also APPENDIX III, SOURCES OF INFORMATION.

couples therapy Psychological therapy involving both a patient and another person with whom the patient has a uniquely close relationship; those involved may be a patient’s parent or his or her spouse or life partner. Couples therapy is used in a variety of settings and is recommended for treating eating disorders when there is significant conflict

in a couple’s relationship. The conflict may be caused by the personalities involved, the eating disorder itself or a combination. The purpose of couples therapy is to strengthen the relationship and to assist couples in problem solving and successfully resolving conflict. Root, Maria, Patricia Fallon, and William Friedrich. Bulimia: A Systems Approach to Treatment. New York: W. W. Norton, 1986.

craving A frequent compulsive and uncontrollable desire to consume a particular food, such as chocolate, or foods from a specific group, such as starches. Consumption of this food gives both a physical and psychological sense of well-being and satisfaction. Research on both animals and humans has demonstrated that cravings can be caused by biochemical needs. A food craving may be the body’s signal that something is out of balance. Although eating foods one craves makes one feel better for the moment, the resulting “high” eventually is followed by fatigue, depression, headaches, moodiness, unclear or confused thinking and the weight problems that frequently accompany the abuse of any food. Cravings have sometimes been found to be caused by nutritional deficiencies, food allergies or diseases. Studies have shown that overweight people tend to crave fatty foods; the fatter people are, the more they prefer the taste of fat. In studies, when given a choice of milk shakes made with varying amounts of cream and sugar, overweight people have chosen fattier shakes than their lean counterparts. Overweight people report eating no more calories than others, but more of those calories come from fat. The effect of fatty foods on the brain—and the way people think about fats—undermine Americans’ attempts to stay trim, according to one school of thought. When the brain gets used to the sudden rush of fat/sugar mixtures, a physical craving develops similar to opiate drug addiction, according to research conducted at the University of Michigan. New research indicates that a drug for opiate overdoses can also block craving for such foods as cookies and candy, but it is not a practical or proven treatment. Writing for Scientific American (January 1989), two researchers from the Massachusetts Institute

cultural influences on appearance 103 of Technology, R. J. Wurtman and J. J. Wurtman, classified carbohydrate craving obesity as a distinct behavioral disorder. They named as symptoms depression, lethargy and an inability to concentrate, combined with episodic bouts of overeating and excessive weight gain. They also found these cravings to be cyclic, occurring usually in the late afternoons or evenings. They say it appears that this disorder is affected by biochemical disturbances in the neurotransmitter serotonin, which regulates appetite for carbohydrate-rich foods. Many women experience apparently physiological-based cravings during pregnancy and menstruation. Researchers note that appetite increases premenstrually and thus say it is possible (but not proven) that food cravings are a source of the extra appetite. Cepeda-Benito and colleagues have recently developed a multidimensional assessment measure of food cravings. The instrument has both a trait and state version and has been validated in both English and Spanish. Baker, Emily. “Food Cravings.” Scripps Howard News Service, September 12, 1998. Cepeda-Benito, A., D. H. Gleaves, T. L. Williams, and S. A. Erath. “The Development and Validation of the State and Trait Food Cravings Questionnaires,” Behavior Therapy 31, no. 1 (winter 2000): 151–173. Cepeda-Benito, A., et al. “The Development and Validation of Spanish Versions of the State and Trait Food Cravings Questionnaires,” Behaviour Research and Therapy 38, no. 11 (November 2000): 1,125–1,138.

creeping obesity A term used by some researchers to describe the gradual but frequent weight gain affecting people in middle age. According to proponents of the theory that creeping obesity is a specific form of obesity, the average American gains one-half to one pound per year between the ages of 20 and 60. One of the major causes of this creeping obesity, they say, is the lack of physical activity. They support their argument by noting that it affects many residents of industrialized nations. On the other side of the debate, HILDE BRUCH writes, In my own experience with this age group there has not been one instance in which obesity had

developed in this gradual way. Whenever a detailed history was taken, weight increases were found to be related to certain events or changes in life patterns. This weight then became stable until some new event precipitated a new increase, such as incapacitating illness, surgery, or states of emotional dissatisfaction. The increase at any one time may not have been large, usually in the five to ten pound range. But these episodic increases added up to “overweight.”

crystal methamphetamine

An illegal appetite-

suppressing amphetamine. See also ICE.

cultural influences on appearance Attitudes toward physical appearance and standards of beauty and desirability have varied over time and from culture to culture. In prerevolutionary China, for example, tiny feet represented the ideal for women of the upper classes, leading to widespread deformities caused by the practice of foot binding. In Greek and Roman representations of the ideal in the form of sculpted gods and goddesses, women often have ample thighs, hips and waists. During the Renaissance, full-bodied women were also the ideal. Plumpness was admired; in some cultures it was an appealing sexual characteristic. But in the 19th century, corsets were invented to enable women to achieve the then-ideal hourglass appearance. It became rude, among the genteel, to eat heartily. It was even glamorous, in some quarters, to look sickly. Because tuberculosis was thought especially to afflict artists and other creative people, a tubercular appearance came to signify a romantic personality. Men preferred delicate, pale women, and women used whitening powders rather than rouge. In Western society during the early 20th century, a buxom appearance was preferred. Then the “flat-chested” flappers became the ideal in the 1920s. Bustiness and the hourglass figure returned in the 1950s. This was followed once again by the still-current ideal of thinness. Researchers have documented recent shifts in our cultural image of women by using data from Playboy magazine centerfolds and statistics from Miss America Pageant contestants. The average weight of centerfold mod-

104 cultural influences on appearance els in 1960 was approximately 90 percent of expected average weight, based on the Society of Actuaries 1959 norm; in 1978, it was approximately 83 percent. This decline occurred even while the expected averages of weight and height for young women were increasing. Today a thin look denotes self-control and success; the desire to conform to this slim physical model is one of the social variables that may lead to anorexia. The culturally generated compulsion to be thin is also reflected in the proliferation of articles about dieting in magazines published principally for women. Fear of being fat, fear of losing control over eating and fear of not being as slim as possible are important social concerns. As far back as 1966, studies found that 70 percent of high school girls were unhappy with their bodies and wanted to lose weight. Particularly for women, thinness has become synonymous with attractiveness. Studies examining changing standards of attractiveness for men and women portrayed in 20thcentury media indicated that female television characters are more likely to be slim and less likely to be fat than male characters; that women received more messages through magazine articles and advertisements to be slim and stay in shape than did men; that the prominence of curvaceous females portrayed in popular women’s magazines decreased dramatically since 1901; and that the standard of bodily attractiveness of movie actresses became significantly thinner during the last 50 years of the century. Not all researchers believe that “ideal” appearances have changed in Western culture. Hillel Schwartz, author of Never Satisfied: A Cultural History of Diets, Fantasies, and Fat, says that the image of beauty in the United States has not changed much over the years. He claims that for men and women alike the ideal woman has long been thin, with a long, thin neck, long arms, thin wrists, a very thin waist and thin ankles. These proportions have also been desirable for young men. (It was only around 1850 that a plump, full-faced look became the ideal for children. Before then, the image of a healthy young child was thin as well.) Not only slim proportions were considered beautiful for women; as the popular 1890s image of the Gibson girls shows, it was also considered desirable

for them to be assertive and athletic, too. This led to the belief that even as people age, they must retain their youthfulness and remain thin, although the body does not naturally keep these proportions. This belief, Schwartz asserts, rather than health or fashion, is at the root of our dieting problems. Pervasive cultural images linking slenderness with beauty and health have convinced many normalweight young children into believing that they are overweight. Some start dieting before they are out of elementary school. A Canadian study found that between the ages of five and seven, children begin to apply adult standards of attractiveness to themselves and to one another—and to view fat negatively. By that age they start relating to fat people differently. and the difference is markedly more significant with girls than with boys. They see images equating slenderness with health and beauty, thin adult models in magazines and on television, and they perceive themselves to be fat because they have plump little faces and hands. Collins reported that most people who worry about their weight are women, and the current standard of beauty is so thin that, almost without exception, they consider themselves “overweight.” In a 1998 British study, Hill and Franklin concurred with earlier research that mothers play a role in the transmission of cultural values regarding weight, shape and appearance to their daughters. It has also been observed that wherever and whenever food is scarce or not sufficient for all, obesity becomes a symbol of success and is viewed with admiration; where and when food is plentiful, thinness becomes the goal and dieting commonplace. Sobal concludes: “Levels of obesity must be seen within their cultural and historical contexts, with each particular society and time period establishing broad conditions within which body weight levels occur for the population. In specific times and places, the social demographics of individuals are important influences on body weight patterns. “Understanding social patterns is useful for those who deal with weight in their professional roles. Assessing and considering social factors helps to establish the social risks for obesity in individual clients or populations. When professionals decide whether to deal with body weight issues and which interventions to use, it is crucial to consider

cultural influences on eating disorders 105 cultural, historical, and social factors. Targeting changes to specific audiences also requires considering social patterns of body weight.” See also CULTURAL INFLUENCES ON EATING DISORDERS. Brumberg, Joan Jacobs. Fasting Girls. Cambridge, Mass.: Harvard University Press, 1988. Collins, M. Elizabeth. “Education for Healthy Body Weight: Helping Adolescents Balance the Cultural Pressure for Thinness.” Journal of School Health 58, no. 6 (August 1988): 227–231. Hill, A. J., and J. A. Franklin. “Mothers, Daughters and Dieting.” British Journal of Clinical Psychology 37, part 1 (February 1998): 3–13. Mazur, A. “U.S. Trends in Feminine Beauty and Overadaptation.” Journal of Sexual Research 22 (1986): 281–303. Schwartz, Hillel. Never Satisfied: A Cultural History of Diets, Fantasies, and Fat. New York: Free Press, 1986. Sobal, Jeffery. “Cultural, Historical, and Social Influences on Body Weight.” Cornell Cooperative Extension. Available online. URL: http://www.cce.cornell. edu/food/expfiles/topics/sobal/sobaloverview.html. Downloaded on December 3, 2004.

cultural influences on eating disorders

People with eating disorders have come mostly from white middle- or upper-class families, leading researchers to determine that higher socioeconomic status is an important risk factor. International studies offer further evidence to support this notion: Eating disorders have increased dramatically in industrialized nations during the last 20 years, while remaining practically unheard of in developing countries. “Thinness” is not an ideal among people whose hunger is not a matter of choice. Concern over the shape of one’s body is an indulgence of the affluent. The shift toward a thinner ideal body shape in Western societies has been marked by the increasingly pervasive practice of dieting, especially among women. An estimated 90 percent of the customers of the “diet” industry are women. Though the benefits of slenderness have been extolled by health professionals, the potentially harmful side effects of dieting have received considerably less attention. Several researchers have connected the cultural pursuit of thinness with eating disorders:

• Data presented by Polivy and Herman indicate that dieting usually precedes binge eating; thus they speculate that dieting is the disorder in need of cure. • Similarly, Garner states that bulimia may become a problem in psychologically normal individuals after a period of intensive caloric restriction. • Katz identifies weight loss by itself as a precipitate for the appearance of anorexia nervosa in vulnerable individuals. • Mazur identifies anorexia nervosa and bulimia, as well as extreme diet and exercise regimens among “normal” women, as examples of often dangerous attempts to match the ever-changing ideal of feminine beauty. In addition, Japanese researchers have reported that during the past 25 years, a slim body has become increasingly desirable for young women as a sign of beauty and success in Japan; dieting is now common among them. Research suggests that this dieting is a factor contributing to bulimia among young women in Japan. Giddens et al. suggest cultural influences affect the female/male ratio: “Women suffer more often from eating disorders than men for a number of reasons. First, our social norms put more emphasis on physical attractiveness for women. Second, the socially defined desirable body image for women is skinny, not muscular. Third, women are more active in public, social life than they used to be, but they are still judged as much by their appearance as by their accomplishments. Eating disorders are rooted in feelings of shame about the body.” While Garner and his team reiterated that cultural influences do not cause eating disorders and that culture is mediated by the psychology of the individual as well as the social context of the family, Collins cautioned that the potential impact of the media in establishing identifiable role models should not be underestimated. Collins, M. Elizabeth. “Education for Healthy Body Weight: Helping Adolescents Balance the Cultural Pressure for Thinness.” Journal of School Health, 58, no. 6 (August 1988): 227–231. Feldman, W., E. Feldman, and J. Y. Goodman. “Culture versus Biology: Children’s Attitudes toward Thinness

106 Cushing’s disease and Fatness.” Pediatrics 81, no. 2 (February 1988): 190–194. Garner, David M. “Psychoeducational Principles in Treatment.” In Handbook of Treatment for Eating Disorders, 2nd edition, edited by David M. Garner and Paul E. Garfinkel, chapter 8, 145–177. New York: Guilford Press, 1997. Giddens, Anthony, Mitchell Dunier, and Richard P. Appelbaum. Introduction to Sociology. 4th ed. New York: W. W. Norton, 2003. Katz, J. L. “Some Reflections on the Nature of the Eating Disorders: On the Need for Humility.” International Journal of Eating Disorders 4 (1985): 617–626. Mazur, A. “U.S. Trends in Feminine Beauty and Overadaptation.” Journal of Sexual Research 22 (1986): 281–303. Polivy, J., and Herman, C. P. “Dieting and Binging: A Causal Analysis.” American Psychologist 40, no. 2 (February 1985): 193–201.

Cushing’s disease

A disease caused by overactivity of the pituitary gland, which influences growth, metabolism and other glands. The disease is characterized by a form of obesity and muscular weakness. It is much more common in women than in men. Obesity is confined almost exclusively to the trunk; any obesity involving the upper arms and the upper thighs is disproportionately small. Patients with Cushing’s disease frequently have hypertension and are more susceptible to infection. There may be minor hirsutism in women, particularly on the upper lip and chin, and some in the periareolar region of the breast. Increased hair growth also often occurs over the lower abdomen, extending up from the pubic region.

cyproheptadine

An appetite-stimulating antihistamine used primarily for the treatment of allergic conditions. An early study in Peru found that cyproheptadine caused anorexics to gain significant weight, but two subsequent studies in the United States failed to replicate this result. In one, there was a differential drug effect related to the presence of bulimia, so that cyproheptadine significantly increased treatment efficiency in the nonbulimic patients and impaired treatment efficiency in the bulimic patients. There are indications that cyproheptadine in relatively large doses may have some mild effect in promoting weight gain and relieving depression in anorexia nervosa. One major advantage of cyproheptadine is that it appears to have few side effects even in relatively large doses. Morley lists cyproheptadine among the “numerous drugs utilized to treat the anorexia of aging with varying success.” In their review of current drug treatments for anorexia nervosa, Powers and Santana state, “Although cyproheptadine has some modest benefit during the weight restoration phase, it is not widely used.”

Morley. J. E. “Anorexia in Older Persons: Epidemiology and Optimal Treatment.” Drugs and Aging 8, no. 2 (February 1996): 134–155. Powers, P. S., and C. Santana. “Available Pharmacological Treatments for Anorexia Nervosa.” Expert Opinion on Pharmacotherapy 5, no. 11 (November 2004): 2,287–2,292.

D caloric restriction compared with diets low in dairy products. These data indicate an important role for dairy products in both the prevention and treatment of obesity.” However, not every scientist is ready to buy into the “dairy foods equals weight loss” proposition without further studies. The October 2004 issue of Tufts University Health & Nutrition Newsletter cautions that Dr. Zemel “holds a patent on treating obesity with a high-calcium regimen. He also has a book out that discusses how calcium is a ‘revolutionary diet discovery’ for losing weight faster. The scientific community becomes concerned when the person doing the research stands to gain financially depending on the result.” Others point out that most of the studies to date have been funded at least in part by the dairy industry. And even a National Dairy Council–funded study failed to confirm some of the earlier findings. The study leader told WebMD, “When we got our results, it was quite disappointing that there were no differences between the high- and low-dairy groups in our study. It may be that a low-calorie, high-dairy diet may offer just two pounds more weight loss than a low-calorie, low-dairy diet. But it is not going to be a magic bullet.” Scientists caution that even if more extensive and independent studies in the future do confirm a link between dairy foods and weight loss, simply adding dairy foods to an existing diet will not lead to weight loss. It is more likely that replacing highfat foods with low-fat dairy products while reducing calories generally will be the key.

dairy foods and weight loss

Since University of Tennessee researcher Dr. Michael Zemel began reporting a link between CALCIUM and decreased body fat in the 1980s, several other studies have also suggested that dairy food may help burn off body fat. In one of those studies, presented at the American Heart Association’s 44th Annual Conference on Cardiovascular Disease Epidemiology and Prevention (2004), Lynn Moore, an epidemiologist from Boston University’s School of Medicine, and her colleagues analyzed the dietary habits of 106 families, all with children three to five years of age. After following the children for 12 years, the researchers found that the children who consumed the least amount of dairy foods per day gained the most weight. Moore also noted that during the years, childhood obesity has risen dramatically, while children’s milk consumption has fallen and soda consumption has risen by 300 percent. Researchers in Canada found that eating less fat, more whole fruits and dairy foods, specifically fat free and low-fat milk, was associated with less weight gain over time, and may be helpful in weight loss or weight maintenance. In another study of food consumption patterns, which analyzed the diets of 459 healthy men and women, results suggest that a pattern rich in reduced-fat dairy products and high-fiber foods may lead to smaller gains in body mass index (BMI) in women and smaller gains in waist circumference in both women and men. Zemel noted that his and others’ studies “indicate that diets that include three or more daily servings of dairy products result in significant reductions in adipose tissue mass in obese humans in the absence of caloric restriction, and markedly accelerate weight and body fat loss secondary to

DeNoon, Daniel. “Dairy Food No Magic Bullet for Weight Loss.” WebMD Medical News. Available online. URL: http://my.webmd.com/content/Article/97/104180. htm. Posted November 19, 2004.

107

108 dehydroepiandrosterone Drapeau, V., et al. “Modifications in Food-Group Consumption Are Related to Long-Term Body-Weight Changes.” American Journal of Clinical Nutrition 80, no. 1 (July 2004): 29–37. Newby, P. K., et al. “Food Patterns Measured by Factor Analysis and Anthropometric Changes in Adults.” American Journal of Clinical Nutrition 80, no. 1 (July 2004): 504–513. Zemel, Michael B. “Role of Calcium and Dairy Products in Energy Partitioning and Weight Management.” American Journal of Clinical Nutrition 79, no. 5 (May 2004): 907S–912S.

dehydroepiandrosterone (DHEA) A natural hormone produced in the body by the adrenal gland. Also available as a dietary supplement. DHEA levels are at their highest around age 20, then gradually diminish with aging until only about 20 percent remains around age 70. Because the supplement reduces abdominal fat and prevents insulin resistance in laboratory animals, Villareal and Holloszy, researchers at Washington University in St. Louis, enrolled 56 elderly persons in a randomized placebo-controlled trial to test whether similar effects would hold true in humans: If DHEA levels in elderly people were returned to the levels of their youth, could they reverse some of the metabolic complications of aging? Using highly sensitive MRI measurements of the amount of abdominal fat, the researchers found that compared with placebo, DHEA supplementation resulted in a decrease in VISCERAL FAT (within the abdomen) of 10.2 percent in the women and 7.4 percent in the men. DHEA therapy also resulted in a decrease in subcutaneous abdominal fat (below the skin surface) averaging 6 percent in both the women and the men. The researchers found no adverse effects from DHEA therapy. At the end of the study, patients receiving DHEA had significantly lower insulin levels during oral glucose tolerance tests than at the start of the study. Their glucose levels remained unchanged, and these results indicate an improvement in insulin action. The degree of improvement in insulin action correlated closely to the amount of decrease in visceral fat. The researchers then began a larger and longer follow-up study on the effects of DHEA replacement. Doctors caution that more data is needed before people should begin taking DHEA outside of

medical supervision. Not only is the DHEA currently sold as a supplement unregulated and thus with no assurance of quality, but because it is a hormone, DHEA could be harmful for persons with a history of hormone-sensitive cancers, such as breast and prostate tumors. Villareal, Dennis T., and John O. Holloszy. “Effect of DHEA on Abdominal Fat and Insulin Action in Elderly Women and Men: A Randomized Controlled Trial.” Journal of the American Medical Association 292, no. 18 (November 10, 2004): 2,243–2,248.

dental caries (or cavities) Tooth decay; the progressive destruction of the hard tissues of the teeth through a process initiated by bacterially produced acids at the tooth surface. Dental caries are seen extensively in patients with eating disorders. This is due to an excessive CARBOHYDRATE intake, poor oral hygiene and changes that occur in the saliva. During binge periods (see BINGE EATING), huge amounts of sugar can be consumed, followed by sugar drinks, often used to relieve thirst after vomiting. Thus, bulimics tend to have higher sugar intake than anorexics, whose diet is limited. But anorexics under the care of physicians also are susceptible to dental caries, because some medications given to them, such as dextrose tablets, dietary supplements, and vitamin C drinks, contain sugar. Neglect of oral hygiene can be seen in both anorexic and bulimic patients, due mainly to the upset in daily routine. Their eating habits get most of their attention. Meticulous oral hygiene is a necessity in these patients, because of excess acid present in the oral cavity, excess sugar intake and disturbances in the saliva. Anorexics have been found to have decreased salivary pH and decreased buffering action, with the low pH contributing to the occurrence of dental caries. Patients with anorexia typically have decreased salivary flow as well. Fear and DEPRESSION decrease salivary flow and affect its composition, thus potentially contributing to the formation of caries. Often this decreased flow of saliva is multiplied by the misuse of laxatives and diuretics (see DIURETIC ABUSE, LAXATIVE ABUSE) or by ANTIDEPRESSANT drugs. These drugs decrease total fluid volumes and affect electrolyte balance, causing an even further diminished salivary flow. Anorexic

depression and eating disorders 109 patients, with virtually no natural defense against carries, have monumental decay problems. Bulimics and anorexics who vomit repeatedly (see VOMITING) to purge themselves of consumed food risk erosion of the enamel of their teeth, particularly on the inner surfaces, from hydrochloric acid in the vomit. This erosion may result in severe gum disease, cavities and tooth loss. The dentist may be the first to encounter actual indications of bulimia. The dental manifestations—although not life threatening and not evident until the later stages of illness—are effects of eating disorders that cannot be reversed. Faine noted, “Young women with bulimia nervosa and anorexia nervosa may seek dental care before seeking medical treatment because they are concerned about their appearance. Early identification of oral changes by the dental practitioner and referral to medical and psychiatric therapists can reduce the risk of further physical damage to the body or greater loss of tooth surface enamel. Home care instructions will be followed when the reasons for timing of toothbrushing, rinsing after vomiting, and use of fluoride are explained. Careful selection of beverages and snacks will help reduce the risk of further erosion and dental caries. Comprehensive dental procedures should not be undertaken until significant improvement in vomiting behavior or complete recovery has occurred.” Dalin, Jeffrey B., D.D.S. “Oral Manifestations of Eating Disorders.” In Eating Disorders: Effective Care and Treatment. St. Louis: Ishiyaku EuroAmerica, 1986. Faine, M. P. “Recognition and Management of Eating Disorders in the Dental Office.” Dental Clinics of North America 47, no. 2 (April 2003): 395–410.

depression and eating disorders A mental state characterized by sad mood, lack of hope and a general loss of interest in life. It is distinguished from grief, which is a response to a real loss and generally proportionate to its importance. Symptoms vary with the severity of the illness. With mild depression, the main symptoms are anxiety, mood changes and sometimes inexplicable crying spells. Serious depression is usually accompanied by appetite and sleep disturbances, social withdrawal, increasingly poor performance in school, at home or at work, lack of energy and loss of concentra-

tion. Severely depressed persons may wish for death or even consider SUICIDE, exhibit phobias and dwell on thoughts of guilt or worthlessness. In bulimics, depression may be obvious, evidenced by apathy, lethargy, joylessness, suicidal thoughts, sleep disturbances and general lack of pleasure in life. The severity of depressive symptoms in bulimics is similar to that of patients with MAJOR AFFECTIVE DISORDER. The relationship between depression and eating disorders has been under considerable study. Many people with eating disorders also appear to suffer from depression, and scientists have wondered whether depression could trigger an eating disorder. There are similarities in neurochemical abnormalities in both disorders. Low levels of SEROTONIN and norepinephrine are associated with depressive disorders as well as eating disorders, and ANTIDEPRESSANT medications may help some people with eating disorders, particularly bulimics. In addition, both the depressed and anorexic tend to have higher than normal levels of the hormone CORTISOL, which is released in response to stress. Depression is commonly seen in patients with bulimia; it is unclear, however, whether the depression leads to bulimia or vice versa. According to DSM-IV, there is an increased frequency of depressive symptoms or mood disorders (particularly dysthymic disorder and major depressive disorder) in individuals with bulimia nervosa. In most cases, the mood disturbance begins at the same time as or following the development of bulimia nervosa, with some patients blaming their moods on their bulimia. In others, however, the mood disturbance clearly precedes the development of bulimia nervosa. Gucciardi et al. noted, “In 2000, the prevalence of depression among women who were hospitalized with a diagnosis of anorexia (11.5 percent) or bulimia (15.4 percent) was more than twice the rate of depression (5.7 percent) among the general population of Canadian women. The highest incidence of depression was found in women aged 25 to 39 years for both anorexia and bulimia.” Noting that although research on adults has found the comorbidity between depression and eating disorders to exceed the comorbidity of any other clinical disorder and eating disorders, Perez et al. found that few studies have investigated the specific associations of major depression versus dysthymia

110 depression and obesity with eating disorders. Their research followed 937 adolescents until age 24, and determined that dysthymia had a stronger association with bulimia than major depression, concluding that the presence of dysthymia in adolescence might be a possible risk factor for the development of bulimia nervosa. Casper. R. C. “Depression and Eating Disorders.” Depression and Anxiety 8, suppl. 1 (1998). Gucciardi, E., et al. “Eating Disorders.” BMC Women’s Health no. 4, suppl. 1 (August 25, 2004): S21. Perez, M., T. E. Joiner, Jr., and P. M. Lewinsohn. “Is Major Depressive Disorder or Dysthymia More Strongly Associated with Bulimia Nervosa?” International Journal of Eating Disorders 36, no. 1 (July 2004): 55–61.

depression and obesity

Research on the relationship of obesity to depression is in the early stages, according to the American Obesity Association. Stunkard et al. suggest the need to better understand why these disorders co-occur in certain individuals and how to develop more effective treatments when they do occur together. They write, “For years it was assumed that any relationship of depression to obesity in the general population was largely coincidental. Research in the recent past, however, has uncovered a large number of moderating and mediating variables that relate depression and obesity. Depression influences obesity under some circumstances and obesity influences depression under others.” Rosmond suggests that obesity and depression may represent different manifestations of the same disease process. “Our understanding of the systems of the brain related to energy balance has increased over the last decade. As a result, drugs most commonly used today in the management of obesity have their primary effect in modulating the balance between monoaminergic neurotransmitters, among other serotonin. Serotonin is believed to be involved in the complex process of integrating physiological and behavioral systems geared towards energy balance. However, gradual weight gain seen in most people suggests that the regulatory system may not be sufficient under all circumstances. An insufficient serotoninergic neuronal function in the central nervous system has been shown in many studies to occur in patients with depression. In such serotonin-deficient patients, treatment with drugs increasing the concentration

of serotonin at serotoninergic synapses gives a favorable clinical response. Taken together, this suggests to a certain extent a common pathophysiology between obesity and depression.” Others have noted that although most individuals who are extremely obese have normal psychological functioning, a significant minority do suffer from depression or other emotional complications that may need treatment prior to bariatric surgery. Johnson et al. found that obesity increases the risk of depression by more than 40 percent after controlling for other factors, concluding, “More studies are needed to ascertain the mechanism by which obesity and depression could be related and the significance of this relation for the prevention and treatment of both obesity and depression. Given the effects of depression, we suggest that health professionals should assess their obese patients for risk of depression before embarking on a weight management protocol.” Johnston, E., et al. “The Relation of Body Mass Index to Depressive Symptoms.” Canadian Journal of Public Health 95, no. 3 (May–June 2004): 179–183. Rosmond, R. “Obesity and Depression: Same Disease, Different Names?” Medical Hypotheses 62, no. 6 (2004): 976–979. Stunkard, Albert, Myles S. Faith, and Kelly C. Allison. “Depression and Obesity: A Complex Relationship.” Psychiatric Times 21, no. 11 (October 2004). Available online. URL: http://www.psychiatrictimes.com/ p041081.html.

diabetes and eating disorders People who combine disordered eating with diabetes face significantly more health risks than nondiabetics with similar eating patterns in the general population. Rodin et al. reviewed studies from the previous decade regarding the association of type I diabetes mellitus and eating disorders, noting that “although there has been much debate regarding the specificity of this association, a recent large multisite case-controlled study demonstrated that the prevalence rates of both full syndrome and subthreshold eating disorders among adolescent and young adult women with diabetes are twice as high as in their nondiabetic peers. Further, a four-year follow-up study showed that disordered eating behavior in young women with diabetes often persists and is associated with a threefold increase in the risk of diabetic retinopathy. These eating disturbances tend

diabetes and obesity 111 to be associated with impaired family functioning and with poor diabetes management.” The diabetic’s necessary focus on food, his or her deprivation of certain foods, his guilt over nonadherence to the prescribed diet, unhealthy relationship with food, and rebelliousness toward dietary restrictions can all provoke a disordered eating pattern. The starvation of anorexia nervosa and the purging of bulimia can both lead to serious hypoglycemia (deficiency of sugar in the blood). And binge eating can lead to seriously elevated blood glucose levels and diabetic ketoacidosis. Recent reports have cautioned health care providers to be aware of the possible association between eating disturbances and diabetes, and also the types of behavior, particularly insulin omission for weight loss, that are common in eating disorder patients who also have diabetes. Rodin et al., for example, advise, “Health care professionals should maintain a high index of suspicion for the presence of an eating disturbance among young women with diabetes, particularly among those with persistently poor metabolic control and/or weight and shape concerns. Screening for such disturbances should begin during the prepubertal period among girls with diabetes. A brief psychoeducational intervention leads to a reduction in disturbed eating attitudes and behavior but is not sufficient to improve metabolic control. More intensive treatment approaches, which should include a family-based component, may be needed to improve metabolic control. The evaluation of these and other treatment approaches is indicated in view of the serious short- and long-term health risks associated with eating disorders in young women with diabetes.” If insulin-dependent patients develop anorexia, their extremely low weight may appear to control the diabetes for a while. Eventually, however, if they fail to take insulin and regain weight, these patients will die. Herpertz and Nielsen note that considerably less research has been done on the comorbidity of type 2 diabetes and eating disorders. Pointing out that studies have shown a predominance of bulimia nervosa in type I diabetes and binge eating disorder in type 2 diabetes, they add, “Contrary to type 1 diabetes, nearly 90 percent of type 2-diabetic patients developed an eating disorder before the metabolic illness was diagnosed. . . . By being over-

weight and obese, binge eating may lead to type 2 diabetes in some patients.” Herpetz, Stephen, and Soren Nielsen. “Comorbidity of Diabetes Mellitus and Eating Disorders.” In Handbook of Eating Disorders, 2nd Ed., edited by Janet Treasure, Ulrike Schmidt, and Eric van Furth, 400–414. West Sussex, U.K.: John Wiley & Sons Ltd., 2003. Rodin, G., et al. “Eating Disorders in Young Women with Type 1 Diabetes Mellitus.” Journal of Psychosomatic Research 53, no. 4 (October 2002): 943–949.

diabetes and obesity Diabetes mellitus is a chronic disease in which blood glucose (sugar) levels are too high. Cells in the body break down glucose in order to provide energy for movement, growth and repair. The hormone insulin is responsible for regulating glucose levels in the blood. Abnormally high levels of glucose can damage the small and large blood vessels, leading to diabetic blindness, kidney disease, amputations of limbs, stroke and heart disease. There are three common types of diabetes. Type 1 diabetes is usually (but not always) diagnosed in children and young adults, and is an autoimmune disease. Persons with Type 1 diabetes make no insulin and must take insulin every day. Type 2 diabetes is usually (but not always) diagnosed in adults over the age of 45. In Type 2 diabetes, either the person is not making enough insulin or the body is resistant to insulin and cannot use it properly. More than 80 percent of people with Type 2 diabetes are overweight. Gestational diabetes occurs during pregnancy: 2–4 percent of all pregnant women have gestational diabetes. If a woman has gestational diabetes, she has about a 40 percent chance of having Type 2 diabetes later in her life. Type 2 diabetes, which until recently was commonly referred to as adult-onset diabetes, is increasingly turning up in children—a primary reason for its now being more often called Type 2. In 2000, an estimated 30 percent of boys and 40 percent of girls born in the United States were at risk for being diagnosed with Type 2 diabetes at some point in their lives. Several studies have linked Type 2 diabetes in children with obesity, and according to the Institute of Medicine, approximately 9 million children over six years of age are now obese: “Since the 1970s, the prevalence (or percentage) of obesity has more than doubled for

112 dichotomous reasoning preschool children aged 2–5 years and adolescents aged 12–19 years, and it has more than tripled for children aged 6–11 years.” In a study published in the January 1, 2003, issue of the Journal of the American Medical Association (JAMA), the Centers for Disease Control and Prevention (CDC) of the U.S. Department of Health and Human Services reported that 44 million Americans are considered obese by BODY MASS INDEX (BMI), reflecting an increase of 74 percent since 1991. During the same time frame, diabetes increased by 61 percent, reflecting the strong correlation between obesity and development of diabetes. Prevalence of both diagnosed diabetes and obesity varied widely among states. Mississippi had the highest rate of obesity (25.9 percent) and Colorado had the lowest (14.4 percent). Alabama had the highest rate of diagnosed diabetes (10.5 percent) and Minnesota the lowest (5.0 percent). Compared to adults with healthy weight (BMI values from 18.5 to 24.9), those with a body mass index of 40 or higher had a 7.37 times greater risk of being diagnosed with diabetes. Other study results found that African Americans had the highest rates of both obesity (31.1 percent) and diabetes (11.2 percent) compared with other ethnic groups. People with less than a high school education had higher rates of both obesity (27.4 percent) and diabetes (13 percent) than people who had a high school education. The good news is that Gregg and his team of CDC researchers found that overweight diabetic adults trying to lose weight have a reduced risk of mortality, independent of whether they lose weight. Actual weight loss is associated with increased mortality only if the weight loss is unintentional. Also, findings from the Diabetes Prevention Program (DPP), a major clinical trial funded by the National Institutes of Health involving 3,234 people with impaired glucose tolerance, a condition that often precedes diabetes, showed that Americans at high risk for Type 2 diabetes can sharply lower their chances of getting the disease through diet and exercise. Participants randomly assigned to intensive lifestyle intervention reduced their risk of getting Type 2 diabetes by 58 percent. On average, this group maintained their physical activity at 30 minutes per day, usually with walking or other moderate intensity exercise, and lost 5–7 percent

of their body weight. Participants randomized to treatment with the oral diabetes drug metformin (Glucophage) reduced their risk of getting Type 2 diabetes by 31 percent. Smaller studies in China and Finland have also shown that diet and exercise can delay Type 2 diabetes in at-risk people. Gregg, Edward W., et al. “Trying to Lose Weight, Losing Weight, and 9-Year Mortality in Overweight U.S. Adults with Diabetes.” Diabetes Care 27, no. 3 (March 2004): 657–662. “Overview of the IOM’s Childhood Obesity Prevention Study.” Preventing Childhood Obesity: Health in the Balance, 2005, Institute of Medicine. Available online. URL: http://www.iom.edu/report.asp?id=22596. Posted on September 30, 2004.

dichotomous reasoning A faulty thinking pattern that occurs with numerous psychological disorders and commonly among the eating disorders. Dichotomous reasoning involves thinking in extreme, absolute, all-or-none terms and is typically applied to food, eating and weight. The patient divides food into good (low calorie) and bad (fattening) categories. A one-pound weight gain may be equated with incipient obesity. Breaking a rigid eating routine produces panic because it means a complete loss of control. Rigid attitudes and behaviors are not restricted to food and weight but extend to the pursuit of sports, studies and careers. See also COGNITIVE DISTORTIONS. dietary fiber The edible but indigestible fibrous components of plants. Fiber adds bulk to the diet and can aid normal bowel function by enabling the large intestine to work effectively and by helping regulate the absorption of nutrients in the small intestine. Dietary fiber is not a single substance, and there are significant differences in the physiological effects of the various fibers. A Recommended Dietary Allowance has not been established; however, an adequate amount can be obtained by eating several servings daily of wholegrain breads and cereals, fruits, root vegetables, legumes and nuts. A report of the Council on Scientific Affairs of the American Medical Association stated that some scientists believe that excessive energy (caloric) intake may be inevitable when diets are low in

diet centers and programs 113 fiber, with high-fiber diets possibly reducing energy intake, even when more food is eaten. Studies suggest that when people are allowed to eat unlimited amounts of high-fiber food, but not foods containing sugar and other refined carbohydrates, the amount eaten decreases significantly, and appetites are satisfied. Although fiber has no magical effects in promoting weight loss, it can be an important part of a balanced but low-calorie diet. High-fiber diets are also beneficial because they help prevent constipation, a common result of reduced food intake. Limited data from clinical trials that suggest that fiber supplements or high-fiber diets are useful for weight reduction are contradictory. Dietary fiber may have a limited role as an adjunct in the treatment of obesity, but controlled, long-term trials are needed before this can be established.

dietary supplements

Products taken by mouth that contain a “dietary ingredient” intended to supplement the diet, as defined by the Dietary Supplement Health and Education Act (DSHEA) of 1994. The dietary ingredients in these products may include: vitamins, minerals, herbs or other botanicals, amino acids and substances such as enzymes, organ tissues, glandulars and metabolites. Dietary supplements can also be extracts or concentrates, and may be found in many forms such as tablets, capsules, softgels, gelcaps, liquids or powders. They can also be in other forms, such as a bar, but if they are, information on their label must not represent the product as a conventional food or a sole item of a meal or diet. Whatever their form may be, DSHEA places dietary supplements in a special category under the general umbrella of “foods,” not drugs, and requires that every supplement be labeled a dietary supplement. Unlike medications, dietary supplements are presumed to be safe until the U.S. Food and Drug Administration (FDA) receives multiple reports of adverse effects. Generally, manufacturers do not need to register their products with the FDA nor get FDA approval before producing or selling dietary supplements. Manufacturers must make sure that product label information is truthful and not misleading. In November 2004 the FDA announced initiatives to further implement and enforce DSHEA. The initiatives include a regulatory plan and a draft

guidance document for industry. The regulatory plan includes monitoring product safety, assuring product quality and evaluating product labeling. The draft guidance for industry describes the amount, type and quality of evidence the FDA recommends a manufacturer have to substantiate a claim. A five-state survey of 14,679 adults in 1998 found that 7 percent of adults used over-thecounter weight-loss supplements, with the greatest use noted among young obese women (28 percent). Retail sales of weight-loss supplements were estimated to be more than $1.3 billion in 2001. Although many dietary supplements promise weight loss, few if any have been shown to definitely help with weight loss. In general, people who have lost weight while taking these supplements also had eaten less and increased their physical activity. However, some supplements are being studied to see whether they are safe and effective. Blanck, H. M., L. K. Khan, and M. K. Serdula. “Use of Nonprescription Weight Loss Products: Results from a Multistate Survey.” Journal of the American Medical Association 286, no. 8 (August 22–29, 2001): 930–935.

diet centers and programs

The frustration of continuously striving to achieve the elusive “ideal” weight is a prime motivator for the overweight to turn to other “sufferers,” seeking help, understanding, empathy. And when those other sufferers number about 130 million people, according to the National Center for Health Statistics, it is small wonder that an entire industry of diet centers, clubs and programs bringing these obsessive dieters together has flourished. According to some reports, 50 million Americans go on diets each year— which approximates $30 billion in spending on diet foods, diet sodas, books, videos, cassettes, fitness clubs and related services. Some diet centers, like TOPS (Take Off Pounds Sensibly) and OVEREATERS ANONYMOUS, are nonprofit organizations; others, like WEIGHT WATCHERS, and JENNY CRAIG are commercial enterprises. Diet centers provide dietary advice and social support and are especially helpful for those people who find that the only way to lose weight is to have others pushing and pulling them along toward their goals. Diet centers provide psychological motivation and “good examples” of others who have succeeded, as well as super-

114 diet centers and programs vised diet programs with step-by-step daily routines, exercises, menus, weigh-ins and so on. One analysis of such diet centers found that short-term outcomes are at least equivalent to medically prescribed therapies. The average length of membership is about 26 weeks and the mean weight loss about 20 pounds. Little is known about long-term results. The reducing diet, group pressures, BEHAVIOR MODIFICATION techniques, a supportive group and financial commitments all play a part in accounting for their success. Scientific interest in dieting for obesity began in the mid-1800s with the Harvey-Banting Diet (see BANTING, WILLIAM). The novel aspect of Harvey’s diet was the emphasis on meat, the “strong food,” which had just been recognized as being less fattening than the “innocent” foodstuffs, such as breads and sweets. Proteins were considered necessary for restoration of body substances, carbohydrates for the acute combustion process. With Harvey’s diet program achieving popular success, other metabolism experts quickly developed their own diets. Ebstein’s method (high fat content) and the Dancel-Oertel cure (fluid restriction and systematic exercise) also proved popular during the 1880s. But there were difficulties with all three programs, with unsuccessful cases being attributed to their “mechanical” application; presumably more flexibility would have led to success. Despite better understanding of metabolic processes, most of the same problems remain unsolved by today’s programs. HILDE BRUCH wrote: every “new” diet program uses the hook of offering nutrient essentials in an unexpected, interesting, and convenient combination so that weight conscious people become curious, follow it for a week or two, and proudly proclaim its effectiveness. An important factor in the diet game is publicity and packaging; scientifically designed diets are taken over by commercial enterprises and advertising, and then become highly successful.

She used as examples a fluid low-protein diet designed for in-hospital metabolic studies, which became the “Metrecal” diet; and a high-protein diet prescribed for years by the New York City Health Department in its obesity clinic, a diet that became the basis of a multimillion-dollar business called Weight Watchers.

In recent years, the use of celebrities to endorse diet products has helped revolutionize the promotion of weight reduction programs. Elliott Gould, Ed Koch, Susan St. James, Sarah Ferguson, Monica Lewinsky, Lynn Redgrave, Oprah Winfrey and Tommy Lasorda are a few celebrities who have earned many thousands of dollars a year touting diet products and programs. Their endorsements have boosted diet company sales by up to 100 percent; the powdered-diet portion of the industry alone has reached the billion-dollar mark in annual sales. Yet it was reported in The Washington Post that Slim-Fast sales fell 27 percent in 2003 to $290 million, while Jenny Craig sales were flat or declined for the previous five years, and Weight Watchers showed a 3.1 percent drop in membership in fourthquarter 2003, with product sales dropping 8 percent. The reason given: a struggle to compete with lowcarb diets like the Atkins and South Beach Diets. The Weight-Control Information Network (WIN), a service of the National Institutes of Health, describes three types of weight-loss programs: • Do-It-Yourself Programs Any effort to lose weight by yourself or with a group of like-minded others through support groups or worksite- or community-based programs fits in the “do-it-yourself” category. Individuals using such a program rely on their own judgment, group support and products such as diet books for advice. • Nonclinical Programs These programs may or may not be commercially operated, such as through a privately owned weight-loss chain. They often use books and pamphlets that are prepared by health care providers. These programs use counselors (who usually are not health care providers and may or may not have training) to provide services to you. Some programs require participants to use the program’s food or supplements. • Clinical Programs This type of program may or may not be commercially owned. Services are provided in a health care setting, such as a hospital, by licensed health professionals, such as physicians, nurses, dietitians and/or psychologists. In some clinical programs, a health professional works alone; in others, a group of health professionals works together to provide services to patients. Clinical programs may offer you

dieter’s teas 115 services such as nutrition education, medical care, behavior change therapy and physical activity. Clinical programs may also use other weight-loss methods, such as very low-calorie diets, prescription weight-loss drugs and surgery, to treat severely overweight patients. In February 1999 a coalition of government, academic and commercial weight-loss organizations announced new guidelines to provide consumers with better information on the risks, costs and track records of commercial diet programs. Participants in the new agreement (Partnership for Healthy Weight Management), including Weight Watchers International and Jenny Craig, agreed to abide by provisions aimed at helping dieters to comparison-shop among programs. Among these provisions, programs must disclose the qualifications of their staff, and they must outline all costs of their regimens, including payments for proprietary diet foods. WIN suggests that anyone contemplating joining a diet center or enrolling in a diet program gather as much information as possible first. WIN says providers of weight-loss programs should be able to answer these questions:

• Are there risks related to following the program’s eating or exercise plans? • Are there risks related to using recommended drugs or supplements? • Do participants talk with a medical professional? • Does a medical professional oversee the program? • Will the program providers work with a participant’s personal health care provider if he or she has a medical condition or takes prescribed medications? • What is the total cost of the program? • Are there recurring costs such as weekly attendance fees, costs of food and supplement purchases? • Are there additional fees for a follow-up program or to reenter the program for follow-up after weight loss? • Are there additional fees for medical tests? • How much weight do average participants lose and how long have they kept off all or part of their weight? • Can the program provide references?

• Does the program offer individual counseling and/or group classes?

Finally, WIN suggests that anyone interested in locating a local weight-loss program ask their health care provider for a referral or contact a local hospital. See also FAD DIETS.

• Do participants have to follow a specific meal plan or keep food records?

dieter’s teas

• What does the weight-loss program consist of?

• Do participants have to purchase special food, drugs or supplements? • Does the program encourage participants to be physically active, follow a specific physical activity plan or provide exercise instruction? • Does the program provide information on how to make positive and healthy behavior changes? • Is the program sensitive to participants’ lifestyle and cultural needs? • What are the staff qualifications? • Who supervises the program? • What type of weight management training, experience, education and certification does the staff have?

Herbal teas containing senna, aloe, buckthorn and other plant-derived laxatives. When consumed in excessive amounts, they can cause diarrhea, vomiting, nausea, stomach cramps, chronic constipation, fainting or perhaps death. In recent years, the Food and Drug Administration (FDA) has received “adverse event” reports, including the deaths of four young women, in which dieter’s teas may have been a contributing factor. As a result, the FDA has issued consumer advisories. These teas, which are usually bought in health food stores, through mail-order catalogs and over the Internet, often are used for weight loss based on the belief that increased bowel movements will prevent absorption of calories. However, the FDA concluded in 1995 that laxative-induced diarrhea does not significantly

116 dieting reduce absorption of calories because the laxatives do not work on the small intestine, where calories are absorbed, but rather on the colon, the lower end of the bowel. Unless sweetened, dieter’s teas provide essentially no nutrients and no calories. Kurtzweil, Paula. “Dieter’s Brews Make Tea Time a Dangerous Affair.” FDA Consumer (July/August 1997).

dieting

A word generally used to refer to restriction or alteration of food intake. Counting CALORIES and restricting food intake has become an obsession with Americans. DIET CENTERS AND PROGRAMS, “slimnastics” classes, weight reduction support groups and “figure salons” can be found in most neighborhoods. In fact, dieting has been called the fastest-growing industry in the United States. According to a Calorie Control Council National Consumer Survey in 2004, 33 percent of U.S. adults (71 million people) are currently dieting. That is an increase from 2001, when an NPD Group survey found 26 percent (30 percent women and 22 percent men) to be dieting yearround. In 2003, the NPD Group, which tracks consumer behavior for industry, reported that adults dieting by month were as follows: January, 25 percent; February, 29 percent; March, 30 percent; April, 29 percent; May, 29 percent; June, 28 percent; July, 28 percent; August, 28 percent; September, 27 percent; October, 26 percent; November, 28 percent; December, 26 percent. Americans spend more than $40 billion a year on dieting and diet-related products. And dieting is no longer practiced only by adults. A study of fourth-grade girls in California found that 80 percent said they were dieting. The practice of young girls’ dieting to get from a size eight to a size seven can establish patterns of deprivation, BINGE EATING and weight gain that will haunt them all their lives. The director of one hospital eating-disorders unit estimates that more than 50 percent of the patients there—mostly women in their late teens and early twenties—began dieting before they were teenagers. A survey in London revealed that girls as young as 12 felt too fat, attempted to restrict food intake and expressed guilt about eating. Even non-obese girls of ages five and six express concern about their body image and fear gaining weight. In extreme cases, chil-

dren’s attempts at dieting can actually stunt their growth: if they occur just before the main growth spurt of early adolescence, they can jeopardize the increase in height that would automatically rectify an obesity problem. Zinc deficiencies and anemia also can result from improper dieting. A national survey of 11,631 high school students conducted by the national Centers for Disease Control and Prevention found that more than 43 percent of the girls reported they were on a diet—and a quarter of these dieters did not think they were overweight. When Calderon et al. surveyed 10th-grade male and female students at a multiethnic urban public high school in the Los Angeles area, 26.6 percent of the students had a body mass index greater than 25 and were therefore at risk of being overweight. Yet 60 percent had made conscious efforts to lose weight—36.5 percent of the boys and 73.6 percent of the girls. Of those who had tried dieting, 54.7 percent often dieted to control their weight. Limiting portion size was practiced by about 34 percent of those who had tried dieting techniques. In addition, counting calories and counting grams of fat were reported by 31.4 percent and 41.9 percent of these students, respectively. Approximately 44 percent of these students used meal skipping to control their weight. One unconfirmed, and possibly unconfirmable, hypothesis is that dieting may begin accidentally during infancy, when dieting mothers unintentionally put their infants on and off diets by attempting to limit the children’s food intake when they themselves are dieting and by becoming more lenient when they are not dieting. This theory derives from a single study in which mothers who reported the strongest inclination to diet were most likely to interpret tape-recorded episodes of a baby’s crying as a reflection of hunger. The same study showed that fat mothers preferred thinner babies and planned to make more efforts to prevent obesity by limiting intake than thin mothers. Remedies for obesity have always been a part of American culture. But while there are fad diets, in the United States dieting itself is not a fad; rather, it is a culturally embedded practice, a permanent social feature. Hillel Schwartz explains that fashion will not bring a diet to popularity, but rather dieting and fashion evolve from society’s and the individual’s desires. The history of dieting is a com-

dieting 117 bination of the way we see our bodies and the way society sees our body, and of our fantasies and fears about ourselves, and desires for our society.

The growing weight-consciousness of American society became evident with the appearance of the first public penny scales during the 1890s. These had bells that rang and music that played when people stepped on them; the faces were large so that anyone could see the weight. Then charts began to appear with the scales. These initially showed the average weight for a given height, and later the suggested weight. As scales and weight-consciousness became more widespread, the faces shrunk. Soon, public scales were out of vogue and bathroom scales became popular—one could weigh in private and without clothes that added extra pounds. The Vicious Circle Dieting among the obese has a history of failure. When obese people are given dietary advice as the main source of help, combined with programs of regular weighing and counseling, they generally lose weight—while attending. One study reported a mean loss of 25 pounds over an average 24 weeks of treatment. Long-term results are rarely reported. VERY LOW-CALORIE DIETS, whether composed of ordinary or specially prepared food, achieve losses similar in size to those produced by starvation, but being safer, they can be employed with outpatients. However, studies of the longterm effects of very low calorie diets have found fairly rapid replacement of lost weight. Within two to five years, 40 percent of people who lose weight actually end up heavier than when they started. Jane R. Hirshmann, coauthor with Carol H. Munter of Overcoming Overeating, has been quoted as saying, “Every single diet results in a binge. It doesn’t matter what you’re on. Everyone who is involved with them knows they don’t work.” The increasing evidence is that weight loss achieved exclusively through diet restriction can “prime” for future weight gain. This is because a decrease in the resting metabolic rate occurs when energy intake is reduced, possibly as a result of the loss of lean body mass. A repeated cycle of weight loss and gain may lower the resting metabolic rate, and persons with a history of weight cycling may require significantly fewer calories than persons without such a history. (See SET-POINT THEORY; YOYO DIETING.)

But a later study reported by the University of Pennsylvania Medical School disputes this “starvation response” theory. Researchers tracked 18 dieting obese women for 48 weeks, all of whom also increased their levels of physical activity. Half the women ate 1,200 calories daily; the other half took 420-calories-a-day OPTIFAST for 16 weeks, gradually returning to solid food. The Optifast patients had a mean loss of 47 pounds, the others 22. The resting metabolism dropped dramatically for the very-lowcalorie dieters early in the program, but it was only slightly lower by the end because of a reduction in lean body mass. The study determined that when dieters lose weight, they lose both fat and lean body mass; thus, for every 25 pounds lost, the dieter needs to decrease calorie intake by 100 calories a day. There is some evidence that by dieting, the obese may actually shorten their life span. Japanese men in Hawaii who were heavy at age 25 but succeeded in losing weight by middle age had a higher mortality than those who maintained a high and steady weight. On the other hand, men who had been lean at age 25 and became even thinner fared no worse than those who maintained a low steady weight. Weight reduction was associated with a near doubling of mortality for fat men but was not nearly as hazardous for thin men. Nearly identical results have been obtained in studies of French government workers and Harvard alumni. In an American Cancer Society Study, persons who reported having lost weight by intent prior to entering the study were more likely to die of stroke and coronary artery disease over the ensuing five years of follow-up. In another study, victims of myocardial infarction who successfully lost 10 pounds or more were twice as likely to die as those who maintained stable weights. And in a Dutch survey, obese women who were dieting to lose weight reported an average of 12 health complaints, whereas nondieters reported an average of only eight. These findings have raised questions about the widespread assumption that dieting for weight loss improves health. Janet Polivy, professor of psychology at the University of Toronto, has been studying dieting for more than 30 years. She is convinced that dieting to lose weight can be as much of a problem as the one it is supposed to alleviate. Her research suggests that attempts to lose weight may result in

118 dieting both weight gain and poorer health, mental as well as physical. She and her research team have, via their 10-item RESTRAINT SCALE, developed a picture of the chronic dieter as someone who is easily upset and easily distracted, who is obsessed with weight and eating, who is eager to please and generally has lower than normal self-esteem. Polivy has also cautioned that fatigue, weakness, dizziness, irritability, changes in texture of hair and skin and occasionally more severe problems resulting from malnutrition occur as a result of inadequate caloric intake during dieting. In addition to these physical effects, psychological aspects of dieting also are being studied by health professionals. A University of Vermont study attempted to correlate the daily and major life stress, psychological symptoms and dieting behavior in 143 adolescent girls aged 14 to 18 over a four-month period. The results of this study indicate that there is a correlation between stress and dieting behavior in adolescents, which was also found to be the case in previous studies of adults. The Vermont study also supported the idea that dieting behavior is related to certain psychological symptoms in adolescents. The association between dieting and eating disorders, especially bulimia nervosa, has recently been called into question. Michael Lowe and colleagues studied several groups of women with bulimia nervosa and found that the majority were not currently dieting to lose weight. It may be that dieting is more important in the development of bulimia nervosa than in its maintenance. Hillel Schwartz noted that the reason most dieters fail to lose weight or keep it off is that they are dieting in order to change their personalities, and when their personalities do not change, they lose confidence and return to their earlier habits. He stresses that being happy with one’s body and having a beautiful body has little to do with weight or fat and more with physical grace. Weight-Loss Strategies: Questions Considerable attention has been devoted to the identification of behavioral changes that facilitate short-term and long-term weight loss. This research has largely concentrated on the interventions of clinical practitioners in nutrition, medicine and psychology. Most efforts to lose weight, however, are made by individuals independently of

professional supervision and counseling and without physical aids such as drugs or surgery. Dieting has become an informal institution deeply embedded in Western culture and economy. The media, official bodies and product marketers ply the public with information, sometimes inaccurate, about ways to reduce weight. On the basis of such information, as well as from personal experience, many people construct personal programs of eating practices and physical activity with the intention of losing weight. They also continue some of these practices, perhaps conceived as generally healthful eating and exercise, when they are no longer trying to lose weight. Recent research has attempted to relate people’s knowledge of diet and nutrition to issues of health and weight control. One study, for example, found that good knowledge of nutrition seldom correlated with good weight control in the overweight. Others have found differences between men and women in their use of dieting strategies. Women have been found to be more likely than men to use both physical activity and food-restriction strategies. However, another study, while noting that women more often used reduced-calorie diets than men, found that men engaged in physical activity for weight control more frequently than women. A British research team led by Alan Blair reported in Psychology and Health on a study of the relationship between professed beliefs about dieting and reported body weight before and after dieting. Among respondents to their questionnaire, strategies of increasing exercise, avoiding alcohol and cutting down on fat were positively correlated with success in reducing weight. General avoidance of calories between meals was positively correlated with success in maintaining weight loss. Among practices whose use was not correlated with weight loss were conventional slimming strategies such as fasting, skipping meals, using liquid meal replacements and attending diet centers. In addition, effective weight control was directly related to high expectations of success, no matter the weight loss strategy. The researchers suggested that adjustments may be called for in the content of educational messages and clinical therapy for the overweight. Other studies have reexamined the relationships between nutrient intake and overweight. In one, researchers found that high BODY MASS INDEX

dieting 119 was most strongly associated with low bread consumption and use of low-fat milk. Another found that average daily alcohol consumption was unrelated to adiposity, and still another reported evidence that fat intake may contribute to overweight independently of total energy intake. One researcher has hypothesized, on the basis of satiety physiology and surveys of sugar use, that calories in and with drinks consumed after and between meals make a major contribution to difficulties in weight control. The American Heart Association does not recommend high-protein diets for weight loss, especially those restricting healthful foods that provide essential nutrients and fail to include the variety of foods needed to adequately meet nutritional needs. People who remain on these diets long-term may be at risk for inadequate vitamin and mineral intake as well as other health risks. Others have noted that weight loss appears to be associated with decreased caloric intake, which can be achieved through a well-balanced diet rather than via reduced carbohydrate content. In Sculpturing Your Body: Diet, Exercise and Lipo (Fat) Suction, John A. McCurdy says, “The most effective method to assist in sculpturing your body by diet is to formulate a plan that is balanced but utilizes smaller portions of all basic food groups. If a diet is to be skewed in the direction of any one nutrient, it should be constructed to be high in complex carbohydrates because of the many benefits provided by these substances.” He cited a study on a college campus that showed that overweight students effectively reduced on a diet requiring 12 slices of low-calorie, high-fiber bread per day in addition to virtually anything else they wished (except alcoholic beverages), including between-meals snacks. The high-fiber bulk of the bread appeared to reduce the intake of other high-calorie foods, presumably by increasing satiety or the feeling of fullness. The National Heart, Lung, and Blood Institute (NHLBI) guidelines recommend beginning a weightloss diet by lowering one’s usual caloric intake by 500 to 1,000 calories per day. This type of reduction typically results in a loss of one to two pounds per week and has been shown to reduce total body weight by an average of 8 percent over three months to a year. In a representative sample of 100 adult dieters in the English Midlands, only reduction of fatty

foods was associated with a decrease in weight after intensive dieting. Exercise was also associated with weight loss. In fact, because traditional treatments for overweight/obesity that focus on restricting energy (cutting calories) show poor long-term maintenance of weight loss, non-dieting approaches such as exercising to expend more energy are increasingly advocated. Many questions, therefore, remain about which energy-related strategies facilitate weight loss in the short term, and, more important, for the rest of one’s life. Weight Loss: A Sensible Approach The U.S. Department of Health and Human Services suggests the following “sensible approach” to dieting: Before embarking on any weight loss program, would-be dieters should consult their physicians to be sure there are no underlying medical problems and that the diet and exercise program they are contemplating is right for them. Talking to a registered dietitian or qualified nutritionist can also be helpful. Women should be aware that they face more of a challenge in losing weight than men do. Because they generally need fewer calories than men simply to maintain their weight, women have to reduce calories to a lower level in order to lose. For example, most men can lose one to two pounds a week consuming 1,500 to 1,600 calories a day, whereas many women may have to cut down to 1,000 to 1,200 calories a day to achieve the same result. Because she is consuming fewer calories, a female dieter needs to pay especially close attention to the nutrient value of the foods she eats. Anyone, male or female, considering a diet of 1,000 calories or less should discuss with a physician whether a vitamin-mineral supplement at the level of U.S. Recommended Daily Allowances is advisable. Although women may have more of a battle than men when it comes to weight loss, the same basic principles apply to both: • Consult a physician and, if possible, a dietitian before embarking on a very restricted diet. • Aim for a moderate weight loss of one or two pounds a week. Research has shown that losses in excess of this tend to be losses not of body fat but of water and lean muscle.

120 diet pills—OTC • Reduce portion sizes, but maintain a balanced diet from the four basic food groups: grains and cereals; eggs and dairy products; fruits and vegetables; meat, poultry and fish. • Limit intake of fats, sweets and high-calorie foods. • Exercise regularly—increase exercise if possible. Some dieters also find it helpful to count calories in order to keep track of how much they’re taking in. It also can be helpful to eat several smaller meals, rather than three large meals a day. Calderon, L. L., C. K. Yu, and P. Jambazian. “Dieting Practices in High School Students.” Journal of the American Dietetic Association 104, no. 9 (September 2004): 1,369–1,374. Lowe, M. R., D. H. Gleaves, and K. P. Eberenz. “On the Relation of Dieting and Binging in Bulimia Nervosa.” Journal of Abnormal Psychology 107, no. 2 (May 1998): 263–271. Papazian, Ruth. “Should You Go on a Diet?” FDA Consumer (May 1997). Polivy, Janet. “Is Dieting Itself an Eating Disorder?” BASH Magazine (July 1989). Schwartz, Hillel. Never Satisfied: A Cultural History of Diets, Fantasies, and Fat. New York: Free Press, 1986.

diet pills—OTC Nonprescription weight-control pills sold over the counter (OTC) and promoted as a way to lose weight. In their examination of the prevalence of specific weight-loss practices among U.S. adults trying to lose weight, Kruger et al., researchers with the Centers for Disease Control and Prevention, found that 2 percent of men and 3 percent of women were taking diet pills. In the earlier Indian Adolescent Health Study, 11 percent of American Indian adolescents reported the use of diet pills. According to another study of 2,629 girls in grades nine through 12, 12 percent reported using diet pills during the previous 30 days. A survey by the National Center on Addiction and Substance Abuse (CASA) at Columbia University in 2003 indicated that girls and young women who drink coffee with caffeine are significantly likelier than those who do not to take diet pills to help them control their weight (15.7 percent versus 6 percent). The data also indicated that girls and young women who take diet pills to help them control their weight drink coffee more frequently than those who do not take diet pills.

According to the market research firm Kalorama Information, the OTC diet aids industry declined about $100 million in 2003 from nearly $900 million in 2002, in part due to the controversy over EPHEDRA and lingering suspicions from previous problem ingredients such as PHENYLPROPANOLAMINE (PPA), which made consumers more wary. The Kalorama report noted that major companies in the industry have come up with ephedra-free versions of their most popular products. In November 2000 the FDA issued a public health advisory concerning PPA, which had been found in both nonprescription cold medications and diet pills for decades, after a Yale study suggested it caused 200–500 strokes a year. Because of the PPA advisory and ephedra ban, manufacturers are now using herbal supplements, vitamins and/or caffeine. Pharmacists caution that, not only does the FDA not regulate herbal supplements, but dosages of the product may be different from what is stated on the label, and often such ingredients can have dangerous interactions if taken with prescription medications. The bottom line, according to the FDA, is that no OTC diet pill has proved to be effective. In addition, medical experts have expressed concern that newer diet pills often contain Citrus aurantium, or synephrine, also known as bitter orange, which may cause some of the same side effects as ephedra. Since 1990, FTC cases challenging deceptive claims for diet pills, potions, patches and programs have resulted in administrative or federal district court orders requiring companies or individuals to pay more than $48 million to consumers. See also APPETITE SUPPRESSANTS. Kruger, J., et al. “Attempting to Lose Weight: Specific Practices among U.S. Adults.” American Journal of Preventive Medicine 26, no. 5 (June 2004): 401–406.

dissociation

A term generally referring to a disconnection of mental processes that are normally integrated. Dissociation can be pathological and non-pathological. Non-pathological dissociation generally refers to daydreaming, absorption and imaginative involvement. Pathological dissociation generally refers to amnesia, depersonalization, derealization, identity confusion and identity alter

diuretic abuse 121 ation. The most extreme form of the dissociative disorders is dissociative identity disorder (formally known as multiple personality disorder). For years there has been a debate regarding the association between eating disorders and dissociative phenomena or disorders. Persons with eating disorders frequently describe a variety of dissociative experiences and some persons may have full blown dissociative disorders. Some researchers and/or clinicians have hypothesized that there may be some sort of dissociative mechanism that is central to the eating disorders. However, the results of a recent study by Katz and Gleaves suggest that the elevated dissociative symptomatology sometimes seen in persons with eating disorders may simply be an artifact of a comorbid dissociative disorder. Regardless of this latter finding, dissociative experiences may be an important clinical variable to consider as part of treatment: Katz, B. E., and D. H. Gleaves, “Dissociative Symptoms among Patients with Eating Disorders: Associated Feature or Artifact of a Comorbid Dissociative Disorder,” Dissociation, 9, no. 1 (March 1996): 28–36. Vanderlinden, Johan and Walter Vandereycken, Trauma, Dissociation, and Impulse Dyscontrol in Eating Disorders. Bristol, Pa.: Brunner/Mazel, 1997.

diuretic abuse

Diuretics are usually drugs, but can also be common substances such as tea, coffee and water, that help remove excess water from the body by stimulating the flow of urine. Diuretic drugs interfere with normal kidney action by changing the amount of water, potassium, sodium and waste products removed from the bloodstream. Normally, most of the potassium, sodium and water are returned to the bloodstream during the normal filtration process, but small amounts are expelled from the body along with waste products in the urine. Some diuretics reduce the amount of sodium and water taken back into the blood; others increase blood flow through the kidneys and thus the amount of water they filter and expel in the urine. They are often irresponsibly given by diet doctors so a patient can experience a quick weight loss. Any such weight loss is temporary and a consequence of the dehydrating effect. Because diuretics are available in a wide variety of over-the-counter formulations as well as by prescription, the exact rate of diuretic use or abuse is unknown.

Patients who abuse diuretics obtain them from several sources: over the counter; appropriate prescriptions for medical conditions; multiple prescriptions from two or more physicians, each unaware of the real amount of the drug the patient is using; prescriptions meant for another person; misappropriation from workplaces, including nursing homes, hospitals, pharmacies and pharmaceutical distributors. Researchers at the University of Minnesota Medical School evaluated 14 symptomatic female volunteers between the ages of 18 and 40 who used diuretics on a regular basis for nonmedical reasons. Seven (50 percent) were diagnosed as having a current or past eating disorder, and nine (64 percent) were diagnosed as having a current or past AFFECTIVE DISORDER. The results of this pilot study suggest that chronic diuretic use by young women signals the possibility of an unrecognized eating problem and/or affective disorder. The three groups of prescription diuretics most often abused by patients with eating disorders are the thiazides, loop diuretics and potassium-sparing diuretics. Thiazides, including chlorothiazide and hydrochlorothiazide, cause depletion of potassium and other electrolytes. Adverse consequences of HYPOKALEMIA (extreme potassium depletion) include cardiac conduction defects, arrhythmias and muscular weakness or paralysis. Common symptoms include weakness, nausea, palpitations, excessive urination, excessive thirst, constipation and abdominal pain. Other potential side effects of thiazide abuse include abnormal blood levels of sodium, sugar, uric acid, fat, zinc, magnesium and calcium. Loop diuretics include furosemide and ethacrynic acid. Excessive potassium loss and fluid depletion occur frequently, especially when used in larger-than-recommended doses. Other side effects of these agents include hyperuricemia, hypocalcemia, magnesium depletion, ototoxicity and cross-reaction in sulfa-allergic patients. Potassium-sparing diuretics include spironolactone and triamterene. In contrast to the thiazides and loop diuretics, these agents result in a mild loss of potassium. In addition, triamterene nephrolithiasis and acute renal failure are potential adverse effects. Most bulimic patients who misuse or abuse diuretics use over-the-counter preparations. Commonly available over-the-counter diuretics include Premsyn-PMS, Midol-PMS, Diurex-MPR, Pamprin

122 double-blind study Menstrual Relief, Aqua-Ban and Diurex Water Pill. Most of them contain one of three ingredients listed by the U.S. Food and Drug Administration as diuretics (Category I) effective in menstrual drug products: pamabrom, ammonium chloride and caffeine. In addition, the FDA has found that pyrilamine maleate (an antihistamine) is an appropriate adjunct to any of the Category I diuretics. Ammonium chloride is the active diuretic ingredient in one of the most widely used over-the-counter formulations. It is considered safe in a dosage range of one to three grams daily in divided oral doses for periods of up to six days. Ammonium chloride results in formation of sodium chloride from sodium bicarbonate in the body, but the effect lasts only about four or five days. Nausea, vomiting and gastrointestinal distress are potential side effects. CAFFEINE is considered by the FDA to be a safe and effective diuretic for over-the-counter use in doses of 100 to 200 milligrams every three to four hours. As a diuretic, caffeine acts by increasing the glomerular filtration rate in the kidneys. Sleeplessness is a potential side effect. Pamabrom is considered by the FDA to be a safe and effective diuretic for relief of water accumulation during menstrual cycles. Recommended dosage is not more than 50 milligrams per dose and 200 milligrams in 24 hours. The effects of these over-the-counter diuretics on individuals with eating disorders who may have other metabolic abnormalities owing to vomiting or LAXATIVE ABUSE can have severe consequences on renal function and fluid and electrolyte balance. Huynh-Do and Frey noted, “An acute cessation of diuretic intake causes renal sodium retention with formation of edema due to diuretic-induced secondary hyperaldosteronism. Therefore, diuretics should be tapered over weeks or even months in these patients.” Huynh-Do, U., and F. J. Frey. “[Potential dangers of diuretics . . .]” Therapeutische Umschau 57, no. 6 (June 2000): 408–411. Mitchell, J. E., et al. “Diuretic Use as a Marker for Eating Problems and Affective Disorders among Women,” Journal of Clinical Psychiatry 49, no. 7 (July 1988): 267–270. Pomeroy, Claire, et al. “Prescription Diuretic Abuse in Patients with Bulimia Nervosa.” Journal of Family Practice 27, no. 5 (November 1988): 493–496.

double-blind study

A study in which neither the researchers nor the participants know which group is the experimental group and which the control group. The purpose is to eliminate any expectations, conscious or unconscious, that might affect the outcome of the study or trial.

DSM-IV The fourth and most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association in 1994. DSM-IV provides criteria for classifying psychological disorders for physicians making diagnoses and researchers compiling statistics. This manual is considered the standard for the profession. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), released in 2000, incorporates information culled from a comprehensive literature review of research about mental disorders published since DSM-IV was completed. Updated information is included about the associated culture, age and gender features, prevalence, course and familial pattern of mental disorders, including eating disorders. dumping syndrome

A side effect that may result from ROUX-EN-Y GASTRIC BYPASS (RGB) and BILIOPANCREATIC DIVERSION (BPD) operations. It means that stomach contents move too rapidly through the small intestine. Blackwood explains, “The food enters the small intestine rapidly and without the aid of partial digestion by gastric juices.” Symptoms include nausea, vomiting, weakness, sweating, faintness, a bloated sensation and sometimes cramps and diarrhea after eating that last for about 20 to 30 minutes. It is especially triggered by eating sweets or carbohydrates or large amounts of foods. Although the results can be extremely unpleasant, it is not considered a serious health risk; in fact, some consider it a benefit because it controls the intake of less healthy and calorie-laden foods. Some patients are unable to eat any form of sweets following such surgery. Blackwood, Hilary S. “Obesity: A Rapidly Expanding Challenge.” Nursing Management 35, no. 5 (May 2004): 27–36.

dysfunctional behavior patterns

Abnormal, inadequate or impaired functioning. According to

dysfunctional behavior patterns 123 Polivy, Herman and Garner in Assessment of Addictive Behaviors (New York: Guilford Press, 1988), many of the dysfunctional behavior patterns characterizing eating-disordered patients are directly related to perceptions that perpetuate the eating disorder. Although the negative self-concept represented by the sense of worthlessness, overcompliancy, lack of trust and excessive perfectionism does not necessarily correspond to particular behavior problems, it does constrain an individual and inhibits normal interactions and relationships. The flight from maturity or femininity often creates (or exacerbates) problems with sexual behavior: patients may either avoid sex completely or act in a promiscuous but unsatisfying (and often personally distasteful) manner. The positive value perceived in symptoms such as weight loss and starvation in anorexics, binge eating and purging

in bulimics and inappropriate (i.e., non-hungerinduced) eating in the obese makes it particularly difficult to substitute more acceptable behaviors. Misperceptions about food and calories, lack of self-awareness, DICHOTOMOUS REASONING, obsession with food and eating and excessively high valuation of thinness all contribute to the chaotic eating behaviors of these patients. When patients cannot distinguish emotion from hunger, or cannot determine whether they are hungry or sated (see HUNGER and SATIETY), it becomes more likely that they will eat in response to inappropriate (e.g., emotional) internal sensations. The desire for thinness leads to DIETING, which in turn may trigger BINGE EATING. A dichotomous thinking style can promote binge-or-starve eating. Misperceptions regarding food and calories, and obsessions with food, are associated in obvious ways with disordered eating patterns.

E vention and treatment of obesity, binge eating and eating disorders in adults and children. Content includes studies related to the promotion of healthy eating patterns to treat or prevent medical conditions (e.g., hypertension, diabetes mellitus and cancer); descriptive studies establishing functional relationships between eating behaviors and social, cognitive, environmental, attitudinal, emotional or biochemical factors; and clinical outcome research evaluating the efficacy of prevention or treatment protocols. It is published by Elsevier Ltd. See APPENDIX VIII for contact information.

early satiety Bulimics who practice frequent vomiting often complain that they feel “full” following consumption of a relatively small amount of food, a characteristic referred to as early satiety. Eating and Weight Disorders: Studies on Anorexia, Bulimia and Obesity A quarterly journal that first appeared at the end of 1996, it is devoted to research on eating disorders and obesity. Published in Italy, the editor is Massimo Cuzzolaro, and the publisher is Edrice Kurtis. See APPENDIX VIII for contact information.

eating disorder not otherwise specified (EDNOS)

Eating Attitudes Test (EAT-26) A self-test devised by Paul E. Garfinkel and David M. Garner to measure the broad range of symptoms characteristic of anorexia nervosa. A high score on the EAT-26 does not necessarily reflect anorexia nervosa, nor does a low score invariably rule it out, since people may not respond honestly on a self-report questionnaire. However, in practice, the EAT-26 has been shown to be quite accurate in discriminating anorexics from control subjects. It is most useful as a screening device; diagnoses of anorexia nervosa must be confirmed in clinical interviews. EAT-26 scores can also serve as an index of anorexic patients’ improvement. The EAT-26 appears on the Web sites of many eating disorder groups and medical and educational Web sites, including Penn State’s at http://www.sa. psu.edu/uhs/healthinformation/eatingattitudes.cfm. Site visitors can take the test quickly, submit it anonymously and receive an instant score.

A diagnostic category described in DSM-IV for variants of disordered eating that do not meet the diagnostic criteria for anorexia nervosa or bulimia nervosa. The international Eating Disorder Referral Organization cautions, “These are still eating disorders requiring necessary treatment. A substantial number of individuals with eating disorders fit into this category.” Examples include females who meet criteria for anorexia nervosa but continue to menstruate, individuals who regularly purge but do not binge-eat and individuals who meet criteria for bulimia nervosa but binge-eat less than twice weekly. Disordered eating patterns also fit into this category, such as BINGE-EATING DISORDER (BED), and repeatedly chewing and spitting out, but not swallowing large amounts of food. International Eating Disorder Referral Organization. “Other Eating Disorders.” Available online. URL: http://www.edreferral.com/othered.htm. Downloaded on December 14, 2004.

Schmolling, Paul. “Eating Attitude Test Scores in Relation to Weight Socioeconomic Status, and Family Stability.” Psychological Reports 63 (1988).

Eating Disorders Awareness Week (EDAW)

In 1988 the last week of April was designated Eating Disorders Awareness Week by Congress. Currently,

Eating Behaviors

An international scientific journal publishing research on the etiology, pre-

125

126 eating disorders inventory Eating Disorders Awareness Week is held each year during February. Its sevenfold purpose: 1. To increase efforts to prevent the development of eating disorders. 2. To educate the public and professional communities regarding warning signs and appropriate interventions. 3. To increase awareness of treatment programs and support services. 4. To encourage development of healthy attitudes toward psychological and physical development, body image and self-esteem by influential individuals (i.e., parents, educators and health professionals). 5. To challenge cultural attitudes regarding thinness, perfection, achievement and expression of emotion that contribute to the increasing incidence of eating disorders. 6. To improve the ability of professionals of all disciplines to provide effective treatment and support. 7. To promote a compassionate, nonjudgmental, public understanding of eating disorders.

eating disorders inventory (EDI) A 64-item selftest designed in 1983 by Garner, Olmstead and Polivy to differentiate bulimics, extreme dieters and particular subgroups of anorexic patients. The EDI evaluates an individual on a number of different subscales including drive for thinness, body dissatisfaction, sense of ineffectiveness, perfectionism, interpersonal distrust and fears of maturity— psychological and behavioral components common to anorexia and bulimia. This test was intended to augment the EAT, which focuses primarily on dieting- and eating-related symptoms. It is one of very few tests for anorexia, bulimia and bulimia nervosa that measure not only symptoms but also psychological characteristics believed to be central in these disorders. The EDI has been used experimentally to discriminate individuals with eating disorders from nonpathological weight-preoccupied women. The test has been revised (and is now called the EDI-2) with the addition of three new scales and 17 items. However although recent research has continued to support the reliability and validity of the eight original subscales, the reliability and validity of the three new subscales appears questionable.

Eberenz, K. P., and D. H. Gleaves. “An Examination of the Internal Consistency and Factor Structure of the Eating Disorder Inventory-2 in a Clinical Sample.” International Journal of Eating Disorders, 16 (1994): 371–379. Welch, Garry, Anne Hall, and Claes Norring. “The Factor Structure of the Eating Disorder Inventory in a Patient Setting.” International Journal of Eating Disorders 9, no. 1 (January 1988). Welch, G., A. Hall, and F. Walkey. “The Factor Structure of the Eating Disorder Inventory.” Journal of Clinical Psychology 44, no. 1 (January 1988).

Eating Disorders: The Journal of Treatment and Prevention A scientific journal devoted exclusively to the eating disorders; published since 1992, five issues per year. It is published by Taylor and Francis and edited by Leigh Cohn. The journal is very practice oriented and designed mainly for clinicians. See APPENDIX VIII for contact information.

eating habits monitoring

See

SELF-MONITORING.

ectomorph A person with a thin and skeletal or bony body type. Ectomorphs are characterized by long, thin arms and legs and a narrow trunk, conveying a rather trim, thin appearance. Theories linking body types to emotional or psychological characteristics are not considered scientifically sound. See also BODY TYPES; ENDOMORPH; MESOMORPH. ego state therapy

A treatment approach applying various techniques from group and family therapy to the resolution of internal conflict in a single individual. In this therapy, the individual psyche is assumed to be made up of various parts that have different functions and constitute the whole.

Torem, Moshe S. “Eating Disorders and Dissociative States.” In Eating Disorders: Effective Care and Treatment, edited by Félix E. F. Larocca. St. Louis: Ishiyaku EuroAmerica, 1986. Watkins, John G., with Helen H. Watkins. Ego States: Theory and Therapy. New York: W. W. Norton, 1997.

elderly and eating disorders

Although eating disorders are most commonly thought of as occurring during adolescence, the process of aging brings many changes that can influence such illnesses as anorexia nervosa and bulimia. After the age of 50,

elderly and eating disorders 127 physical changes such as a decrease in the basal metabolic rate, a decrease in lean body mass and an increase in percentage of body fat combine with common changes in psychosocial conditions to affect nutrition. For instance, decreasing financial resources and increasing social isolation may promote the development of poor eating patterns. Favorite foods may be financially out of reach; boredom may lead to decreased interest in meals; aging people may simply lack understanding of what their bodies require. Life stresses and trauma may also have an effect on the development of eating disorders in the elderly. For example, research indicates that women who are newly grieving over the deaths of their husbands are likely to skip meals and resort to junk food. As with adolescents, there is an increase in body fat in those over 50. Changes in the body’s energy requirements may coincide with changes in daily routine due to such events as illness, relocation or retirement. If physical activity is decreased but the amount of food consumed is not, there will be a gain in weight, another common variable in already changing bodies. Along with a decline in metabolism, the aging process brings changes in nearly all other body systems. The aging may experience changes in sight and hearing, as well as declining sensitivity to temperature, touch and taste gustatory villae [taste buds] begin to atrophy in women in their early forties and men in their early fifties). The neurological system, especially the brain, the digestive system and the musculoskeletal system are all noticeably affected. Such physiological changes affect the body images of aging individuals, and body image is often an important variable in the initiation of dieting behaviors that may lead to eating disorders. Clinicians at Northeastern Ohio University have reported three case histories of onset of anorexia nervosa in geriatric patients. Geriatric research has demonstrated neurotransmitter changes that may predispose the aging population to anorexia. These include a decline in norepinephrine as well as B-endorphin levels; these changes are also seen in anorexia. Some researchers have theorized that eating disorders are becoming more common among the elderly for two reasons. First, there has been a dramatic increase in the incidence of eating disorders

in the last three decades. Since at least 20 percent of patients become chronic, and not all of them shed their illness as they age, some are likely to remain anorexic or bulimic into old age. Second, it is possible that even elderly women are beginning to succumb to the social pressures to be slim, and some may use vomiting to control their weight. Lending credibility to the first theory, Arthur H. Crisp reported in the British Journal of Psychiatry in 1990 that an 80-year-old woman had a relapse of anorexia nervosa after being in remission for 50 years. Symptoms of the disease gradually reemerged after her husband died. Investigators considered the relapse an attempt to use a previously discovered coping strategy to keep the negative emotions of depression and grief at bay. Allen quotes the medical director of an eating disorders treatment center as saying that he has noticed an increase in the number of older patients—30 of his 200 patients in 2003 (15 percent) were age 65 or older. “Some patients have had a disorder all their lives, and never grow out of it. Others are predisposed to a disorder and some life-altering event—the last child leaving home or the death of a spouse—triggers the latent condition. Some act on a lifelong distorted body image.” Another eating disorders center doctor told Allen that “triggers for a disorder in an older person can include a ‘greater discomfort with getting older. People are fearful of their changing bodies. This is one of the ways they can manage control.’ ” According to John E. Morley, a professor in geriatric medicine at St. Louis University Medical School, depression is the most common cause of weight loss and anorexia in older persons. Experts do caution that age-related anorexia is a term frequently used to describe the loss of appetite among elderly individuals, and is not necessarily the same as the disease anorexia nervosa. Allen, Rick. “Inner Turmoil—When It Strikes the Elderly, It Is More Deadly.” Ocala Star-Banner December 21, 2003, page 1A. Giannini, A. James, James I. Collins, and Denise Lewis. “Anorexia Nervosa in the Elderly—Case Studies.” American Journal of Psychiatry 146, no. 2 (February 1989). Morley, John E. “Anorexia in Older Persons: Epidemiology and Optimal Treatment.” Drugs and Aging 8 (February 1996).

128 elderly and obesity Morley, J. E., and A. J. Silver. “Anorexia in the Elderly.” Neurobiology of Aging 9 (September 1988): 9–16.

elderly and obesity The elderly are the one age group least likely to be overweight, but physicians are reporting increased incidence of obesity among this age group, particularly those in retirement communities and assisted-care facilities. Among the reasons suggested for the increase are three large high-calorie meals a day, little exercise and the dynamic of eating in group settings. A report compiling data from 12 federal agencies, Older Americans 2004: Key Indicators of WellBeing, showed the increase in the prevalence of overweight and obesity among older adults to be dramatic. In the period 1999–2002, 69 percent of Americans age 65 and older were overweight or obese. In the prior two decades, the increases among those ages 65–74 have been especially striking. In the periods 1976–80 and 1999–2002, the percentage of people ages 65–74 who were overweight or obese rose from 57 percent to 73 percent; the percentage who were obese doubled from 18 percent to 36 percent. Arterburn et al. calculate that the number of obese adults over age 60 will rise from 14.6 million in 2000 to 20.9 million in 2010, an increase of 43 percent, “challenging healthcare delivery and financing systems in the United States.” BODY MASS INDEX (BMI) is considered by some to be a less valid indicator of obesity among the elderly, who tend to have a shift of fat from peripheral to central sites along with an increase in waist-tohip ratio at the same level of BMI. Also, because the elderly lose muscle mass, BMI can underestimate their body fat. Also, the elderly may be in the healthy-weight category according to their BMI, yet actually have reduced nutritional reserves. Normally, total body fat decreases after age 70, and percentage of body fat may decline slightly in extreme old age. However, abdominal and intramuscular fat increases with age. In 2004 United Press International surveyed 84 specialists for a 15-part series on the causes, consequences and costs of the global obesity epidemic. One feature discussed the negative results of dieting for the elderly: “In seniors, inadequate nutrition poses a particularly perilous problem. An

alarming 16 percent of the 65-plus set nibbles fewer than 1,000 calories a day, setting the stage for malnutrition, illness and early demise.” Experts point out that “almost every study shows that intentional and unintentional weight loss in the elderly results in premature death.” Steven J. Milloy, publisher of JunkScience.com and an adjunct scholar at the Cato Institute, wrote in September 2004, “Studies have generally reported that the risk of death associated with obesity actually declines with increasing age. A 1998 review of seven studies on bodyweight and mortality in elderly persons reported that only two of those studies reported a statistical correlation between bodyweight and premature death—and of those two studies, one reported no association for those aged 75 years or over. The other five studies either found no correlation or a strong negative correlation. Researchers are not sure why, but it has been suggested that in old age, the protective effects of obesity might counterbalance some negative effects.” National Center for Health Statistics researchers speculate that “The protective effects of obesity include greater nutritional reserves in times of stress, lower rates of injury from falls and lower rates of osteoporosis.” On the other hand, Bartlett notes that researchers have concluded that in elderly persons, if obese men were to lose enough weight to fall into the overweight category, and men in the overweight category were to lose enough weight to move into the normal weight category, knee osteoarthritis (OA) would decrease by 21.5 percent. “Similar changes in weight category by women would result in a 33 percent decrease in knee OA. A handful of studies have indicated that weight loss substantially reduced reports of pain as well.” Because of the negative aspects of dieting for the elderly, experts suggest that only the morbidly obese elderly diet to lose weight, and others over the age of 60 who may be overweight or even obese stick to exercise in their attempts to lower their weight. Some experts downplay the importance of worrying about obesity among the elderly, arguing that it is much more critical to address obesity among the young, because the overall health damage has already been done in obese geriatric patients. Yet Older Americans 2004 reported that the conse-

employee health costs and obesity 129 quences of obesity among the elderly include increased risk of diabetes, heart and lung disease, breast and colon cancer, arthritis and disability. In the same decades that obesity doubled, deaths among the elderly from diabetes increased 43 percent, according to the report. Experts estimate that weight-related illnesses for older adults cost the nation an estimated $30 billion to $40 billion a year in medical bills and contribute to escalating out-of-pocket costs among the elderly. See also ALZHEIMER’S DISEASE RISK AND OBESITY. Arterburn, David E., Paul K. Crane, and Sean D. Sullivan. “The Coming Epidemic of Obesity in Elderly Americans.” Journal of the American Geriatric Society 52, no. 11 (November 2004): 1,907–1,912. Bartlett, Susan. “Osteoarthritis and Body Weight.” Johns Hopkins University. Available online. URL: http://www.hopkins-arthritis.som.jhmi.edu/ mngmnt/osteoandweight.html. Downloaded on December 18, 2004. Federal Interagency Forum on Aging-Related Statistics. Older Americans 2004: Key Indicators of Well-Being. Washington, D.C.: U.S. Government Printing Office, November 2004.

empirically supported therapy Also called evidence-based practices, evidence-based therapy or empirically validated treatments. Treatment that has been clearly specified and found to be supported by scientific evidence as having been extensively studied using rigorous scientific methods and that has been found to work well. Mussell et al. set out to “assess the primary methods used by psychotherapists in treating individuals with eating disorders and to determine the extent to which certain empirically supported psychotherapies (i.e., cognitive behavioral therapy and interpersonal psychotherapy) are used in clinical settings.” They found that while evidencebased therapies are frequently reported as being used, most of the psychotherapists they surveyed identified something else as their primary approach. “In addition, the majority of respondents indicated not having received training in the use of manual-based, empirically supported treatment approaches for working with individuals with eating disorders, although most reported a desire to obtain such training.”

Mussell, M. P., et al. “Utilization of Empirically Supported Psychotherapy Treatments for Individuals with Eating Disorders: A Survey of Psychologists.” International Journal of Eating Disorders 27, no. 2 (March 2000): 230–237.

empirical research Research based on observation and actual experience rather than from theory or belief or scientific principles. employee health costs and obesity The obesity rate among American workers of all ages grew from 20 percent to 29 percent in the periods 1988–94 and 1999–2000, leading to serious repercussions in the workplace, according to a Pfizer Inc. study. Robin Hertz, the study’s author, commented, “The damage caused by obesity is clear— employers face growing costs for insurance premiums, as well as lost productivity, and employees face serious work and health concerns.” Among the study’s findings: Obese workers have the highest prevalence of work limitations (6.9 percent versus 3.0 percent among normal-weight workers), hypertension (35.3 percent versus 8.8 percent), high cholesterol (36.4 percent versus 22.1 percent), type 2 diabetes (11.9 percent versus 3.2 percent) and metabolic syndrome (53.6 percent versus 5.7 percent). The study also found increased prevalence rates among those classified as overweight. Other research has also found obese employees to be costly. Examples: • A University of Michigan study examined the relationship between physical activity and health care costs in different weight groups. The study sample consisted of 23,490 active employees grouped into normal weight, overweight, and obese categories. Physically moderately active (one to two times per week) and very active (three or more times per week) employees had approximately $250 less paid health care costs annually than sedentary employees (no time per week) across all weight categories. The difference was approximately $450 in the obese subpopulation. The maximum possible savings was estimated to be 1.5 percent of the total health care costs if all obese sedentary employees would adapt a physically active

130 employees with eating disorders lifestyle. Study authors Wang et al. determined that as a strategy to control escalating health care costs, wellness programs should facilitate engagement in moderate physical activity of at least one to two times a week among sedentary obese people and help them to maintain this more active lifestyle.

a step further by changing the physical environment. Among the strategies being implemented or considered by various companies:

• In congressional testimony in June 2004, Stuart Trager, M.D., Medical Director of Atkins Nutritionals, Inc., stated, “Within the workplace, estimates suggest that $20–30 billion per year are lost in productivity to lost time due to the increased medical problems linked to obesity. Employees lost 39.3 million workdays in 1994 due to obesity-related medical conditions, representing a 50% increase since 1988.”

• Paying employees a cash award for maintaining an exercise regimen

• An employee who is significantly overweight can have a benefit expense more than 20 percent higher than a person who is not, according to research reported in The Wall Street Journal. • The American Obesity Association has reported that obesity is associated with a greater tendency to be absent from work due to illness. The cost associated with absenteeism from obesity has been reported to be approximately $387,800 for 1,000 employees per year. The cost difference between obese and lean employees due to absenteeism is approximately $128,600.

• Slowing down elevators to make using the stairs more attractive • Placing parking lots farther from the work building

• Offering health coaching to employees who are battling heart disease, high cholesterol, high blood pressure, diabetes or other obesity-related chronic illness • Issuing pedometers to employees to encourage regular exercise • Offering employees discounts to sporting goods stores and healthy restaurants

Hertz, Robin P. et al. “The Impact of Obesity on Work Limitations and Cardiovascular Risk Factors in the U.S. Workforce.” Journal of Occupational and Environmental Medicine 46, no. 12 (December 2004): 1,196–1,203. Wang, F. “Relationship of Body Mass Index and Physical Activity to Health Care Costs among Employees.” Journal of Occupational and Environmental Medicine 46, no. 5 (May 2004): 428–436.

• Unum Provident estimates obesity costs of $8,720 per employee per year.

employees with eating disorders According to Remuda Ranch, an eating disorders treatment center in Phoenix (see APPENDIX IV), the overall medical and mental health costs to U.S. businesses in 2001 for all eating disorders totaled more than $3.8 billion. “Statistics show 40 percent of women with eating disorders function poorly at work and onethird are frequently absent from work.” Even when an anorexic employee’s health status allows him or her to work, the disease may still affect both the employee and his or her coworkers, according to Gleaves and Cepeda-Benito.

As corporations have become more concerned about how employee obesity and its related problems are affecting their bottom lines, some are now providing wellness centers and weight-loss counseling or even allowing employees to use online diet programs during work hours. Some are going

The employee’s job performance may suffer because of the cognitive and emotional effects of the self-induced starvation, and social activities may be negatively affected secondary to the avoidance of food-related activities or secondary to a comorbid personality disorder. The eating-related problems may, in some cases, be easily recognized

• As the national obesity problem escalated, business appeared to pay less attention to it. A review of the Healthy People 2000 objectives, established in 1990 by the Department of Health and Human Services, showed that the proportion of worksites with 50 or more employees that offer nutrition/weight management programs for employees increased from 15 percent in 1985 to 24 percent in 1992, then dropped to 14 percent in 1995.

endomorph 131 by fellow employees. It is even possible that the employee’s eating problem may become a source of conflict among fellow employees, if several recognize a need for possible intervention but none is clear on the best approach. In contrast, bulimia nervosa appears to be a clandestine disorder. People with the disorder are typically of average weight and, because of the shame associated with the disorder, may not disclose to others that a problem exists. Only in the more severe cases are physiological and/or cognitive deficits likely to affect a person’s work performance. However, the various types of comorbid psychopathology—such as depression, borderline personality disorder, and substance abuse—may have more substantive work-related impact. As with anorexia nervosa, binge-eating disorder may be recognizable by coworkers, not because of the disorder per se, but rather because of the commonly occurring obesity. Binge eating disorder most likely has the least workplace impact of the three disorders. However, the constant preoccupation with food as well as time spent planning and engaging in eating binges may markedly affect quality of life, reducing social relationships and leaving little time for other interests. Recurrent bingeing may even cause financial problems for the afflicted individual because of the money spent on food (a problem that may occur with bulimia nervosa as well as binge-eating disorder).

Stressing that early identification and treatment can help reduce these problems in the workplace, Remuda suggests the following when talking to an employee about an eating disorder: • Plan your approach first: Think about what you will say and decide on a good time to approach the person— when they are calm and not distracted. Talk in private. • Get the facts: If you suspect, but are not sure that someone has a problem, bring up the topic in an openended manner as a possibility that emerges from your concern. Keep asking questions until you are satisfied that you understand what is happening. • Show concern: Be compassionate and nonjudgmental at all times. Listen carefully to the person. Acknowledge their fears. Say, “I understand your feelings. A therapist can help you overcome those fears.” • State the problem for the company: Be clear that the problems are affecting the individual’s work, and state how. Do so in a non-blaming manner. • State your goal: Your goal is for the person to get professional help so that they can recover from their eating

disorder and improve work performance. Don’t accept the employee’s claim that they can overcome the problem on their own. Eating disorders require treatment. • Offer solutions: Have viable treatment options and referrals on hand to offer the person. Since specialized knowledge and skills are needed to effectively treat eating disorders, rely only on treatment providers who specialize in eating disorders and who use evidence-based and multi-disciplinary team approaches to treatment. • Be persistent: The person may reject your efforts at first. Return at a later time and try again. If they attempt treatment and don’t succeed, continue to encourage them because a different therapist or treatment method will eventually work.

Gleaves and Cepeda-Benito add, “Perhaps the most significant workplace accommodation may simply be the ability to have time off for treatment. The amount of time necessary here will obviously depend on the intensity of the treatment. Outpatient psychological treatment for bulimia nervosa may be two appointments per week for a period of several weeks. These may occur in the evening, which would not affect the employee’s work schedule. With anorexia and a need for hospitalization, the employee may need an extended leave from work. If an employee is involved in a day treatment program, a flexible work schedule may allow the person to continue working and receive treatment at the same time.” Gleaves, David H., and Antonio Cepeda-Benito. “Eating Disorders.” In Handbook of Mental Health in the Workplace, edited by Jay C. Thomas and Michael Hersen, 311–329. Thousand Oaks, Calif.: Sage Publications, 2002.

endocrine factors in obesity The endocrine glands produce hormones that regulate the body’s rate of METABOLISM, growth and sexual development and functioning. “Glands” have often been blamed by individuals for their obesity, but obesity caused by endocrine alterations are uncommon, and the increase in body weight observed with acute endocrine disease is usually limited. Hypothyroidism, adrenal hyperplasia and hypogonadism are endocrine alterations that result in modest obesity. endomorph A person with a body type characterized by a tendency toward roundness and substantial fat deposits. Endomorphs have wide trunks

132 ephedra and shorter-than-average arms and legs, making them appear to be somewhat fat. People with significant endomorphy gradually fill out until late middle age, when they generally shrink a little. Theories linking body types to emotional or psychological characteristics are not considered scientifically sound. See also ECTOMORPH; MESOMORPH; BODY TYPES.

ephedra

A naturally occurring substance that comes from botanicals. The principal active ingredient, ephedrine, is an amphetamine-like compound that can powerfully stimulate the nervous system and heart. Ephedrine alkaloids are found naturally in a number of plants, including the ephedra species (also known by the traditional Chinese medicine name, ma huang, or called Chinese ephedra or epitonin). In recent years, ephedra products have been marketed as dietary supplements to promote weight loss and increase energy and enhance athletic performance. The Food and Drug Administration (FDA) had warned consumers against the use of dietary supplements containing ephedra since June 1997, and finally banned these products in April 2004. Ephedra was the first federal ban of a dietary substance in the United States. After a review of the available evidence about the risks and benefits of ephedra in supplements, the FDA found that these supplements presented an unreasonable risk of illness or injury to consumers. The data showed little evidence of ephedra’s effectiveness, except for short-term weight loss, while confirming that the substance raises blood pressure and stresses the heart. The increased risk of heart problems and strokes negates any benefits of weight loss. Prior to its ban, ephedra was blamed for as many as 100 deaths. It also had been known to cause hypertension, tachycardia, arrhythmias, stroke, seizures and myocardial infarction. In April 2004, after a Utah-based Nutraceutical International Corporation challenged the FDA ban, claiming that ephedra “has been safely consumed” for hundreds of years, the U.S. District Court for the District of Utah overturned the ban and sent the matter back to the FDA “for further rulemaking consistent with the court’s opinion.”

epidemiological research

Research that looks at (1) the natural course of diseases in a particular group of people; (2) relationships between people and their health habits, lifestyles and environment; (3) risk factors for certain diseases. It involves the study of the incidence and distribution of diseases in large populations. Epidemiological researchers also conduct investigations into the causes of chronic diseases such as eating disorders and obesity. The International Food Information Council cautions that “epidemiological studies may suggest relationships between two factors, but do not provide the basis for conclusions about cause and effect. Possible associations inferred from epidemiological research can turn out to be coincidental. Epidemiological studies are observational in nature and the outcomes need further study through other types of research such as intervention or clinical studies.”

International Food Information Council. “Epidemiological Research: Roots, Roles and Real-Life Limitations.” Food Insight, July/August 2002. Available online. URL: http://www.ific.org/foodinsight/2002/ja/epidem resfi402.cfm.

exercise

Physical exertion for improvement or maintenance of health and fitness, as well as weight loss. Exercise alone is not usually prescribed as a weight loss method, but physical activity is a key to any weight control program. It burns CALORIES, speeds METABOLISM and helps offset the dreaded “plateau” stage in which weight loss slows or stops temporarily. (See SET-POINT THEORY.) People who exercise and diet lose more fat and less muscle than people who only diet. Racette et al. summed it up this way: “Exercise generally does not produce considerable weight loss when used independently, but is a very important adjunct to a weight-reducing diet because it increases energy expenditure, enhances loss of adipose tissue, and improves dietary adherence. Although aerobic exercise has been used most frequently for weight loss and control because of the caloric expenditure required, strength training has numerous benefits and may help to preserve fatfree mass during diet-induced weight loss.” Achieving a negative energy balance—that is, using up more calories than one takes in—by exer-

exercise 133 cise alone has been shown to cause some weight loss. The mean weight loss achieved over a mean duration of 19 weeks, in seven studies, was 16 pounds. No long-term follow-ups are available. Although changes of exercise (energy output) and/or altered metabolic efficiency can cause weight loss when one is over- or under-weight, the amount is usually not significant unless accompanied by lowered food intake. Most studies have shown that vigorous exercisers consume more calories than sedentary individuals, but they also weigh approximately 20 percent less on average. There are no data supporting the contention that moderate activity of short duration used in weight loss programs stimulates APPETITE. In fact, for many people, moderate exercise tends to have an appetite-suppressing effect. For this reason, many experts recommend that daily exercise be performed prior to the main meal of the day. Researchers at Mt. Sinai Hospital in New York have reported that whereas fat people burn off more calories if they eat after exercising, thin people burn off more if they eat before. The researchers believe that fat people’s cells are less sensitive to insulin, the hormone that admits fuel into body cells. Intense exercise, they say, may improve the insulin sensitivity of fat people. Studies at Stanford University comparing food intake and weight of long-distance runners (those who run approximately 40 miles per week) with those of randomly selected sedentary adults of similar age show that despite ingesting an average of 600 more calories per day (2,959 vs. 2,361), the runners weighed 25 percent less than the sedentary group, evidence strongly suggesting that exercise lowers the set point. Numerous studies have documented the observation that a program of moderate exercise reduces body fat levels while preserving or increasing lean body mass. Animal studies show that exercise produces a specific fatburning effect and that the animals maintain the new body fat levels, demonstrating that the set point has been lowered. But the older we get, the more difficult it is for our muscles to burn fat, according to researchers at the Washington University School of Medicine and the University of Texas Medical Branch in Galveston. Their study found that fat oxidation in older subjects (average age 73) was 25–30 percent lower

than in younger subjects. The older people were more likely to burn carbohydrates during exercise. Many experts have concluded that exercise is as important in preventing weight gain as it is in weight loss, and thus have emphasized its value in maintaining current weight and diet programs. Donnelly et al. sum it up: “The available evidence indicates that exercise is an important component of weight loss and perhaps the best predictor of weight maintenance.” They recommend at least 30 minutes a day of moderate intensity aerobic exercise per day for weight loss and maintenance. But 30 minutes a day may not be enough to continue losing weight, according to Spake. “This is a level that can reduce cardiovascular disease, diabetes, and other serious chronic illnesses. To lose weight or maintain a large weight loss, it takes more: The Institute of Medicine recommends accumulating 60 minutes of activity each day to achieve a healthy weight. The key word here is accumulate. You don’t have to do all 30 minutes—or 60—at once. You can do three (or six) 10-minute bouts.” The evidence establishing regular exercise as an important factor in weight control has convinced many health care professionals that one of the major causes of CREEPING OBESITY is the lack of physical activity, largely as the result of sedentary styles of life. The average American man between 35 and 45 years of age weighed six pounds more in 1980 than in 1960 (the average American woman of similar age showed an eight-pound weight increase) despite a 10 percent reduction in caloric intake over this period. Too Much Exercise Is Not a Good Thing Today’s emphasis on fitness and athletics has had a negative as well as positive effect on health, especially for adolescent girls. Encouraged to exercise for their looks rather than their health, girls are often told that exercise is “nature’s best makeup.” Researchers have found that slimness of hips is the most sought-after feature among adolescents aged 12 to 16. Dissatisfaction with hip measurement only increases during this period when hips show the most change from natural hormonal influences. Some adolescents are so intent on changing their appearance that they become obsessed with exercise.

134 exposure and response prevention Eating-disordered patients often use exercise as a means of purging themselves of unwanted calories—a practice that causes additional health problems, such as vitamin and mineral deficiencies that can cause damage to bones, AMENORRHEA and cardiac arrest from low potassium levels and electrolyte imbalances. Excessive exercising can become a dangerous habit and one that is difficult to break. One exercise machine maker advertises “No pain, no gain,” but pain is a warning to the body that something is wrong. For anorexics and bulimics, exercise buffers some of the pain they should be feeling; they are numbing their bodies’ warnings to stop their destructive behavior. Breaking an exercise addiction can be as difficult as overcoming an eating disorder. While the effects of anorexia can be measured on a bathroom scale, the “fitaholic’s” problem is not so easily defined. Truly compulsive exercisers let their workouts dominate their existence to the detriment of family, job and social life. Obsessive runners may be taught relaxation techniques and other ways of coping with stress that can help them become less dependent on exercise for their sense of well-being. Donnelly, J. E., et al. “The Role of Exercise for Weight Loss and Maintenance.” Best Practice and Research. Clinical Gastroenterology 18, no. 6 (December 2004): 1,009–1,029. Molé, Paul, et al. “Exercise Reverses Depressed Metabolic Rate Produced by Severe Caloric Restriction.” Medicine and Science in Sports and Exercise 21, no. 1 (February 1989): 29–33. Racette, Susan B., Susan S. Deusinger, and Robert H. Deusinger. “Obesity: Overview of Prevalence, Etiology, and Treatment.” Physical Therapy 83, no. 3 (March 2003): 276–288. Segal, K. R., and F. X. Pi-Sunyer. “Exercise and Obesity.” Medical Clinics of North America 73, no. 1 (January 1989): 217–236. Spake, Amanda. “26. Exercise, A Little,” in “50 Ways to Fix Your Life.” U.S. News & World Report 137, no. 1 (December 27, 2004): 124–125. Yale, J. F., L. A. Leiter, and E. B. Marliss. “Metabolic Responses to Intense Exercise in Lean and Obese Subjects.” Journal of Clinical Endocrinology and Metabolism 68, no. 2 (February 1989): 438–445.

exposure and response prevention (ERP)

A treatment method originally used in treating pho-

bic and obsessive-compulsive disorders, in which the patient is exposed to whatever is triggering his or her abnormal behavior, with the abnormal behavior then forcibly restrained. The treatment has to cause significant anxiety in order for it to work. ERP has also been adapted to treatment of bulimia nervosa. For example, clinicians have described how a bulimic woman was made to wait increasing lengths of time between stages of the disordered behavior that culminated in vomiting. After eight weeks her vomiting, which had occurred roughly four times a day prior to treatment, ceased. Explaining why ERP works, Rosen and Leitenberg wrote that “binge eating and self-induced vomiting seem linked in a vicious circle by anxiety.” Eating (especially BINGE EATING) elicits the fear of weight gain; vomiting reduces it. “Once an individual has learned that vomiting following food intake leads to anxiety reduction, rational fears no longer inhibit overeating.” Thus, if the end-result vomiting is delayed longer and longer after each binge-eating session, the binge eating needed to stimulate it is delayed until it no longer is needed (because the vomiting that counters it is no longer occurring). So “the driving force of this disorder may be vomiting, not bingeing.” Later reviews of the treatment of bulimia nervosa do not conclude that ERP adds anything to the effectiveness of cognitive behavioral treatments. Following a trial with 135 women who had bulimia nervosa, Bulik et al. concluded, “ERP for bulimia nervosa is an expensive and logistically complicated treatment that does not appear to offer any significant additive benefits that are proportional to the amount of effort required to implement the treatment.” American Academy of Child and Adolescent Psychiatry (AACAP). “Practice Parameters for the Assessment and Treatment of Children and Adolescents with Depressive Disorders.” Journal of the American Academy of Child & Adolescent Psychiatry 40, suppl. 7 (July 2001): 45–235. Bulik, C. M. “The Role of Exposure with Response Prevention in the Cognitive-Behavioural Therapy for Bulimia Nervosa.” Psychological Medicine 28, no. 3 (May 1998): 611–623. Rosen, J. C., and H. Leitenberg. “Bulimia Nervosa: Treatment with Exposure and Response Prevention.” Behavior Therapy 13 (1982): 117–124.

extreme obesity 135 externality approach to obesity

One of two major types of treatment for obesity (the other is the PSYCHODYNAMIC APPROACH TO OBESITY). Externality focuses on salient food-related cues in patients’ environment and attempts to control their responses to them. This approach developed from experiments at Columbia University performed in 1974 by social psychologist Stanley Schachter. Schachter’s group found that obese people are more likely to eat when a clock says it is mealtime or when food is put onto a plate than when their bodies signal HUNGER. This approach assumes that what obese people need is to change their responses to these external cues, and that by allowing themselves to eat only when truly hungry, they will lose weight naturally. It has spawned a number of behavioral therapy techniques, such as putting food on smaller plates so the amount looks larger, eating only in a particular room and so on. Some externalists’ patients have achieved remarkable results (one group lost an average of 40 pounds each in a single year), but these results have not consistently been replicated by others. Not only have patients not lost 40 pounds, they have tended to gain back what they have lost. See also EATING HABITS MONITORING.

extreme eating

A term used by the International Food Information Council to describe the eating habits of teens who seem to have lost their balance when it comes to choosing an appropriate diet. Going overboard in one or more areas of the diet such as cutting out entire food groups, fervently following the latest fad diet or weight loss plan, or regularly consuming a single type of food to excess could all be characterized as extreme eating behaviors.

“Extreme Eating: Are Teens Compromising Their Health?” Food Insight, November/December 1998.

extreme obesity

The National Institutes of Health (NIH) identifies extreme obesity as Class III, or having a BODY MASS INDEX (BMI) of 40 or greater, such as a person five feet, six inches tall who weighs 250 pounds. It is also known as severe or morbid obesity, although doctors who treat the condition tend to discourage use of “morbid obesity” because it is misleading and has negative connotations. The NIH Obesity Research Task Force reported that while obesity and overweight have risen in the population in general, the greatest increases observed over approximately the past two decades have been in the prevalence of extreme obesity. A government report containing data from the National Health and Nutrition Examination Survey in the periods 1999–2000 and 2001–02 showed extreme obesity rates rising from 4.7 percent to 5.1 percent. From 1988 to 2000, the prevalence of extreme obesity increased from 2.9 to 4.7 percent; in 1960 it was 0.8 percent. During the period between 1986 and 2000, those with a BMI of 50 or more multiplied over five times. An article appearing in the Group Practice Journal by HMO Kaiser Northwest researchers in May 2004 revealed that people with extreme obesity have 78 percent higher medical costs than members with normal weight. In a University of Pennsylvania study of 2,100 people in a sample of 482 nuclear families, extreme obesity was associated with an increased risk for depression across gender and racial groups, even after controlling for chronic physical disease, familial depression and demographic risk factors. Experts have reported BARIATRIC SURGERY to be the most effective therapy for people who have extreme obesity. Dong, C., L. E. Sanchez, and R. A. Price. “Relationship of Obesity to Depression: A Family-Based Study.” International Journal of Obesity and Related Metabolic Disorders 28, no. 6 (June 2004): 790–795.

F than caloric restriction is lacking. Also lacking is evidence that fad diets produce sustainable weight loss. Most important, fad diets generally ignore or refute what is known about fundamental associations between dietary pattern and human health.” Other medical experts caution that although many fad diets may result in some weight loss, they invariably do so at the expense of good nutrition, which if continued long-term could exacerbate any health problems stemming from being overweight or obese. Studies have found some fad diets no more effective than losing weight the oldfashioned way—working it off with exercise.

fad diets

Diets that achieve widespread, though short-lived, popularity, usually as a result of heavily promoted “best-selling” books and/or popular magazine or tabloid features. But diets that promise such easy results and the “magic bullet” are not really effective, according to Diane Quagliani, a spokesperson for the American Dietetic Association, who told the International Food Information Council (IFIC) Foundation: “Fad diets are a short-term, quick-fix approach to weight loss that don’t work over the long haul. These diets tend to over-promise results but don’t deliver. Food choices are often monotonous, and caloric intake may be very restricted, so that once the novelty wears off, so does the motivation to continue.” The IFIC notes that there is a dire lack of scientific research to corroborate the theories expounded in the majority of diet books currently on the market. Most promise weight-loss programs that are easy, allow favorite foods or foods traditionally limited in weight-loss diets and do not require a major shift in exercise habits. Often, adds Sachiko St. Jeor, director of the Nutrition Education and Research Program at the University of Nevada School of Medicine, “Fad diet book authors take a scientific half-truth that is complex and use that as the basis for their arguments.” Authors may simplify or expand upon biochemistry and physiology in an effort to help support their theories and provide a plethora of scientific jargon that people do not understand but that seems to make sense. And few, if any, offer solid scientific support for their claims in the form of published research studies. Instead, most evidence is based on anecdotal findings, theories and testimonials of short-term results. Katz noted that despite claims of success, “Evidence that weight loss is enhanced by means other

IFIC. “Fad Diets: Look before You Leap.” Food Insight, March/April 2000. Available online. URL: http:// www.ific.org/foodinsight/2000/ma/faddietsfi200.cfm. Downloaded on August 8, 2005. Katz, D. L. “Pandemic Obesity and the Contagion of Nutritional Nonsense.” Public Health Review 31, no. 1 (January 2003): 33–44.

failure to thrive (FTT) Also called growth failure. Inadequate weight gain in infants and young children, which in many cases may be a combination of both biologic and psychologic complications that require treatment. Bassali and Benjamin explain: Failure to thrive is a descriptive term and not a specific diagnosis. Although definitions vary, most authors use this term only when growth has been noted to be low or to have decreased over time. For instance, some authors define FTT as height or weight less than the third to fifth percentiles for age on more than one occasion. Other authors cite height or weight measurements falling two major percentile lines using the standard growth charts of the National Center for Health Statistics (NCHS). Still others state that true malnutrition (weight less than 80 percent of ideal body weight for age)

137

138 fake fat should be present to state a child is failing to thrive. All authorities agree that only by comparing height and weight on a growth chart over time can FTT be assessed accurately. Although measurements of head circumference are important in the evaluation of infants and toddlers, failure of the head to grow is not part of the FTT entity.

Krugman and Dubowitz explain further that in most children with FTT, the condition has mixed causes or origins: “A child may have a medical disorder that causes feeding problems and family stress. The stress can compound the feeding problem and aggravate FTT. A more useful classification system is based on pathophysiology—inadequate caloric intake, inadequate absorption, excess metabolic demand, or defective utilization. This classification leads to a logical organization of the many conditions that cause or contribute to FTT.” Failure to thrive is now included in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as FEEDING DISORDER OF INFANCY OR EARLY CHILDHOOD. Bassali, Reda W., and John Benjamin. “Failure to Thrive.” eMedicine Pediatrics, updated August 11, 2004. Available online. URL: http://www.emedicine.com/ ped/topic738.htm. Krugman, Scott D., and Howard Dubowitz. “Failure to Thrive.” American Family Physician, September 1, 2003. Available online. URL: http://www.aafp.org/ afp/20030901/879.html.

fake fat

Popular name for all-natural FAT SUBSTITUTES.

family meal

A therapy technique in which an eating-disordered patient and family members eat meals together with a therapist, who helps them identify dysfunctional communication patterns within the family that perpetuate the patient’s disorder. Unsubstantiated claims of dramatic recovery have been made by proponents of this technique.

Rockwell, W. J. Kenneth. “A Critique of Treatment Methods for Anorexia Nervosa.” In Eating Disorders: Effective Care and Treatment, edited by Félix E. F. Larocca. St. Louis: Ishiyaku EuroAmerica, 1986.

family therapy

A form of GROUP THERAPY in which a therapist works with a patient and her

family together; sometimes called familization therapy. Generally, a family therapy group consists of one therapist and three or more family members. In working with a family, a therapist can assess the impact of the individual’s behavior on the family and observe the handling of conflicts, family roles, family decision making and communication patterns and family values. This therapy is meant to teach all members of a family how to express and fulfill their needs and change old patterns that have been mutually unsatisfactory. It can help both patients and their families bring painful emotions to the surface and understand them. The duration of family therapy varies with individual cases. Family therapy can be especially useful in treating eating disorders of adolescents and may be helpful to young adults struggling with separation from their original families. European treatment of eating disorders, primarily anorexia nervosa, has traditionally favored family therapy, following precepts established in Italy by Mara Selvini-Palazzoli. But family therapy alone has yet to provide universally the kind of spectacular outcome that was once hoped for and publicly predicted. The current trend in most European centers treating eating disorders is, as in the United States, toward a “multidimensional” approach, with family therapy included in treatment. Vanderlinden and Vandereycken, of the University Psychiatric Center, Kortenberg, Belgium, have suggested that neglect of the family in bulimia treatment by many therapists may be attributed to the attitude of the bulimics themselves, who tend to conceal their problem from the world. And, they add, the absence of consideration of family context in the literature of bulimia may be explained by the higher average age of bulimics than anorexics, so that many no longer live with their families. Family Generation of Eating Disorders Addictive diseases like eating disorders are usually identifiable as family illnesses. Families often get as sick as addicts or eating-disordered patients. Bulimics use food as a way of dealing with stress and problems of daily living, but families have no such outlet and often face the problems without knowledge, understanding or coping skills. In most cases, family members fail to recognize the unhealthy relationships and behaviors that have

family therapy 139 brought them so much discontent. They are trapped in an unhealthy family equilibrium, exacerbating and prolonging the problem. Women with anorexia or bulimia often come from families that have difficulty with conflict and communication. Sometimes the families have long histories of conflict. As children, the patients may have experienced abuse or rejection or grown up with an alcoholic parent. Members of these families may have had difficulty communicating and recognizing one another’s feelings. The parents, having perhaps grown up in such families themselves, may never have learned how to handle problems, thus experiencing frightening difficulties in their own marriages or with their children. In the face of unresolved family conflict, daughters may focus on how they can make things better. Frequently, they feel that their parents want them to be good and not cause trouble. They may think that if they stay out of the way and do everything right, things will get better. They see their role as peacemakers. When conflict arises, they may feel they must make it better for everyone. This can lead to their discounting their own feelings and needs. Like their parents, they have not had the opportunity to learn how to deal with their emotions. They may develop eating disorders as a way to cope. On the surface, it may seem that they are able to handle things, but they still need nurturing and support. A daughter in this situation may not feel recognized by her family as being a helpful negotiator. For a young woman with bulimia, feeding herself is a way of covering up painful feelings and giving herself the nurturing she needs. PURGING functions as a way to release tension and sometimes bury feelings. Bulimia and anorexia are commonly found in families that are excessively protective of members’ feelings. Eating-disordered individuals may have difficulty learning from mistakes because they have rarely been allowed to make any. Lack of control in their lives may compel them to start controlling their weight; their bodies are among the few things over which they feel they have any authority. Bulimics and anorexics may also come from families that have problems expressing unpleasant emotions and strive to present themselves as “perfectly” well adjusted. Everything appears to be fine in this type of family. Under the surface are problems that no one in the family can or wants to

acknowledge. A daughter, also afraid of expressing her feelings, may deal with them through food. She, like the rest of the family, has extreme difficulty admitting that they have any problems. She is very out of touch with her feelings and may have little idea why she binge eats or restricts. (See BINGE-EATING DISORDER; RESTRICTOR ANOREXICS.) In one report, more than 90 percent of the eating-disordered patients described their fathers as emotionally distant. Common characteristics of the daughters were low self-esteem, confusion, loneliness, sexual fears, DEPRESSION and a general inability to master developmental tasks. With the absence of emotional support from the fathers, daughters try more to support themselves synthetically, deriving a superficial sense of self-worth from their control over their appearance and their achievement of conformity to an exaggerated ideal of beauty. Bulimia is also often associated with dysfunctional families. In a family that must face difficult issues such as alcoholism, drug addiction, mental illness or abuse, a daughter may respond by developing an eating disorder. A 1995 Wayne State University study of anorexia treatments demonstrated that structured therapies for adolescent anorexia do impact family relations, even when the family is never seen as a unit during the therapy. After treating more than 550 cases of bulimia with family therapy, the Renfrew Center in Philadelphia has seen another family type emerge. This one usually centers on the daughter. She may feel guilty about the excessive influence she has on how the family functions and about the attention she gets, especially from her father. She turns to food to help relieve the guilt. At Renfrew, a residential facility, a family therapist is assigned to each resident. If family members have come at admission, the first family session is held that day. During treatment, five to eight sessions are usually held. Although family members are always encouraged to attend in person, some sessions may be conducted by conference phone call, to accommodate geographically distant family members. Treatment typically lasts seven to nine weeks. In their review of family therapy for treating eating disorders, Eisler et al. agreed that it can be

140 famous eating-disorder patients an effective treatment for anorexia on an outpatient basis, even for those adolescents seriously ill. In addition, they determined that (1) Family interventions are best viewed as treatments that mobilize family resources rather than treat family dysfunction (for which they say there is little empirical evidence); and (2) Brief, intensive multiple family interventions provide an important alternative to engaging families in treatment and are viewed very positively by families. Family Treatment of Obesity Family intervention has proven very helpful, also, in treating OBESITY. In one study, spouses of obese patients were instructed in the behavioral principles of weight control and were told how to demonstrate good eating habits themselves, to reinforce appropriate eating behavior in their partners. Husbands and wives attended sessions together and were encouraged to make a collaborative effort. Weight losses for patients with involved spouses were superior to those with uninvolved spouses and were, in fact, greater than those in any previous study. Parents can exert an even stronger influence on their children than spouses can on each other. They have an unsurpassed degree of control over the food intake of their young children. Even among older children, the capability of parents to foster new patterns of eating behavior and discourage old ones is substantial. “Family” can extend beyond spouses and parents to relatives, friends, neighbors and even coworkers. All or any of these represent potential allies or foes in the treatment process. Although active encouragement of failure in treatment is infrequent, subtle discouragement by others may reduce treatment effectiveness. For example, “sabotaging” spouses of obese patients have acknowledged that they feared weight loss would improve their partners’ attractiveness, leading to extramarital affairs. In other couples in which both partners are obese, husbands and wives may subtly encourage each other to overeat and not to follow the treatment procedures at home, in order to help them rationalize their own poor eating habits. Family therapy is often useful in ending this process. In it the entire family unit is designated as the “patient” and treated as a whole. As one member changes, the whole unit must change because of the need for equilibrium in the family. The goal

of therapy becomes that of developing new healthy relationships to support the entire family. Depending on their analysis of family functioning and its evolution during treatment, therapists may decide to work with whole families or meet only with separate subgroups (parents, children, with or without patients). Brownell, Kelly D., and Albert J. Stunkard. “Behavioral Treatment of Obesity in Children.” In Childhood Obesity. New York: Warner Books, 1986. Eisler, Ivan, Daniel le Grange, and Eia Asen. “Family Interventions.” In Handbook of Eating Disorders, 2nd Ed., edited by Janet Treasure, Ulrike Schmidt, and Eric van Furth, 291–310. West Sussex, U.K.: John Wiley & Sons Ltd., 2003. Ganley, Richard M. “Eating Disorders Are Family Affairs.” Renfrew Perspective (Spring 1988). Karpell, Merrily. “The Fear of Stepping out of Line.” Renfrew Perspective (Fall 1988). Robin, A. L., et al. “Family Versus Individual Therapy for Anorexia: Impact on Family Conflict.” International Journal of Eating Disorders 17 (May 1995): 313–322. Stierlin, Helm, and Gunthard Weber. Unlocking the Family Door: A Systemic Approach to the Understanding and Treatment of Anorexia Nervosa. New York: Brunner/Mazel, 1989. Vandereycken, W., E. Kog, and J. Vanderlinden. The Family Approach to Eating Disorders: Assessment and Treatment of Anorexia Nervosa and Bulimia. New York: PMA, 1989. Vanderlinden, Johan, and Walter Vandereycken. “Family Therapy in Bulimia Nervosa.” Paper presented at the International Symposium on Eating Disorders in Adolescents and Young Adults, Jerusalem, May 26–28, 1987; reprinted in BASH Magazine.

famous eating-disorder patients

In recent years several well-known athletes and entertainers have come forward to discuss their eating-disorder problems. The death in 1983 of KAREN CARPENTER, a popular singer, brought on by anorexia, inspired many of these women to make public their own bouts with anorexia and bulimia in the hope of influencing young people into seeking treatment. Olympic gymnast Cathy Rigby had been bulimic for four years when she retired at age 19, and her problem continued when she started her new career in sports broadcasting and commercials. She was 28 before she started getting professional help. Ballerina Gelsey Kirkland starved herself periodically while a teenager and later began to vomit

fasting 141 in an attempt to keep her weight down. In her autobiography, Dancing on My Grave (Garden City, N.Y.: Doubleday, 1986), she talks about her pursuit of the body beautiful. Cherry Boone O’Neill, daughter of singer Pat Boone, described her bout with anorexia in her book Starving for Attention (New York: Continuum, 1982). Actress and political activist Jane Fonda was bulimic for many years. Actress Ally Sheedy was both bulimic and anorexic. John Lennon, the late Beatle, has been described by biographer Albert Goldman (The Lives of John Lennon, New York: William Morrow, 1988) as being anorexic for most of his adult life. Goldman says that Lennon starved himself to achieve what he perceived as perfection. The onset of his disorder can be traced to 1965, Goldman writes, “when some fool described him in print as the ‘fat Beatle.’ That phrase struck such a blow to his fragile ego that the wound never healed.” In 1995 it was revealed that Britain’s Princess Diana had been treated for bulimia nervosa. In 1999 actor Billy Bob Thornton said he developed anorexia after he lost 59 pounds for a movie role—then could not stop losing. He reported how he denied his eating problem to himself and others. At the time he acknowledged his problem, he said he had gotten it under control. International fashion model Magali Amadei went on a national tour of high schools to speak on her struggle with bulimia, which began at age 14, before she was a model. At her worst, she binged and purged seven times a day and swallowed 40 laxative pills. Now she is using her celebrity to encourage others to recognize and treat their eating disorders early. Actress Jamie-Lynn Sigler, who played Meadow Soprano on HBO’s The Sopranos, wrote about her “exercise bulimia” as a teenager in her book, Wise Girl (Pocket Books, 2002). In June 2004, actress Mary-Kate Olsen’s publicist said the actress had entered a treatment center for an eating disorder. Although he did not disclose the center or the specific disease, newspapers and tabloids had reported it to be anorexia nervosa, based mainly on her emaciated appearance in recent months. The disclosure brought eating disorders back into the spotlight, with magazines, television news shows, and newspapers providing warning signs and information on the diseases.

fasting Abstaining from food for a period of time. During the 1960s, several clinics began to use short-term fasts to bring about rapid weight reduction. One reason they became so popular is that fasters no longer feel hungry after the first few days of starvation. However, the severe consequences of the nutritional deficiencies and extensive loss of lean body mass that characterizes clinical starvation prompted investigators to find a safer and more effective dieting treatment. As a result, VERY LOW-CALORIE DIETS were developed. Supervised fasting is one of the simplest methods of weight reduction, but it is best carried out in a medical setting because of the significant risk of complications, and even of sudden death. Risks associated with fasting include hypoglycemia and impaired glucose tolerance, KETOSIS, lactic acidosis, hyperuricemia, loss of nitrogen and lean tissue, hypoalaninemia and hair loss; loss of potassium, sodium, calcium, magnesium and phosphate; reduced kidney function, edema, anuria, hypotension, anemia, alterations in liver function, decreased serum iron binding capacity, gastrointestinal tract changes, nausea and vomiting, alterations in thyroxine metabolism and impaired serum triglyceride metabolism. In 15 studies, the mean length of treatment was 17 weeks, with mean weight loss of 77 pounds. Few studies report follow-up, and in those that do the results are poor. Supervised fasting is a very expensive technique with poor long-term results. Health experts have expressed concern about the harmful effects religious fasts, such as Yom Kippur, can have for people with eating disorders such as anorexia and bulimia. Religious leaders and therapists have urged people not to fast during these times, saying that Jewish people (for example) should live by traditions, not die by them. Clinicians at the RENFREW CENTERS have counseled patients in recovery not to use religious fasts as justification for their restrictive eating behavior. Female fasting, in the manner of ANOREXIA NERVOSA, is not a new behavior. There is a long history of food-refusing behavior and appetite control by women dating from medieval times, practiced for reasons of mystical piety rather than physical vanity, as in the life of St. Catherine of Siena (1347–80) and her imitators. A more recognizably modern version of the phenomenon became widespread in the 19th century (see FASTING GIRLS).

142 fasting girls Duhamel, Denise. “Holding Fast.” American Health (May 1990). Graham, Janis. “Food File: Is Fasting Worth It?” Health (July 1991). Segal, Marian. “A Sometime Solution to a Weighty Problem.” FDA Consumer (April 1990). Thompson, Trisha, and Laura Flynn McCarthy. “The Fasting Controversy.” Harper’s Bazaar (January 1992).

fasting girls

The term used by Victorians on both sides of the Atlantic to describe cases of prolonged abstinence from food by girls or young women, in which there was uncertainty about the reasons for fasting and the intentions of the fasters. The term was used jokingly by some and disparagingly by others. Doctors generally spoke of fasting girls with skepticism. The controversy over fasting girls intensified the arguments about the relationship between mind and body that were central to the Victorian debate about religion and science. Reports of fasting girls appeared in the American press as late as 1910. Sustained food refusal was still regarded by most as a religious or supernatural phenomenon rather than a psychological disorder; it fed on a strain of religious piety and supernatural belief more common then than now. The “fasting girls” phenomenon was of widespread interest, drawing the attention of the educated and the uneducated, the elite and the ordinary. But the character of society was changing, and during this time refusal of food changed from an act of personal piety to a symptom of a disorder; physicians changed their diagnoses from anorexia mirabilis to anorexia nervosa.

Brumberg, Joan Jacobs. Fasting Girls. Cambridge, Mass.: Harvard University Press, 1988.

fat blockers

Antiobesity drugs that work by blocking the absorption of some fat by the body. See also ORLISTAT.

fat cells

The fatty or ADIPOSE TISSUE of the body. Fat is a soft, solid, yellow, slightly greasy material that lies under the skin. When an excessive amount accumulates, it tends to build up in the thigh, hip, abdomen or neck areas. The resultant bulges are generally considered both unhealthy and unattractive. Once accumulated, these fat deposits frequently remain a permanent part of the body, as

only a few people have the patience, willpower and energy to diet and exercise them away. About 95 percent of body fat is stored in the form of triglycerides, composed of fatty acids bound to glycerol. When required for energy METABOLISM, triglycerides are broken down within fatty cells. The fatty acid component then attaches to a specific protein in the blood (lipoprotein) for transport to the muscles. Fat cells are constantly active, dispensing fat into the bloodstream for transport to the body tissues needing energy, and extracting other circulating molecules for conversion into fat to replenish the storage deposits. Evolving research suggests that the size and number of fat cells (adipocytes) may play a role in the predisposition to obesity. Obese individuals have slightly larger and significantly more fat cells than normalweight individuals. A greater number of fat cells is particularly characteristic of juvenile-onset obesity. There are two important periods of development when the number of fat cells is affected: infancy (up to two years of age) and the preadolescent years (from nine to 12). A correlation is believed to exist between the number of fat cells and the rapidity of weight gain. Once fat cells have formed, they cannot be eliminated, so they must be shrunk—depleted of lipids—before an obese individual can reach normal weight. Individuals who have been obese since childhood regain lost weight more rapidly after dieting. Once produced, fat cells do not die. When weight is lost by diminishing fat stores, existing fat cells shrink, but they are primed to manufacture and store fat more efficiently once a normal diet is resumed. This is the reason for the “yo-yo” effect of rapid weight loss and gain experienced by so many dieters (see YO-YO DIETING). According to John A. McCurdy, Jr., the evolutionary process has favored survival of those who are able efficiently to convert food into fat for storage. Some bodies are better at storing fat than others. Stored fat is available for use as an energy source during times of food deprivation—famine, pestilence and other disasters that have often beset humanity. But in societies like ours, where food is readily available, the body seldom has an opportunity to call on its fat reserves and gradually accumulates additional fat in its storage deposits, a phenomenon sometimes called CREEPING OBESITY.

fat phobia 143 When these fat reserves are used during dieting, the body naturally becomes more “fuel efficient,” lowering its metabolic rate and decreasing spontaneous activity in order to conserve the fat that, in ancient times, enhanced the ability to survive. The body can increase the amount of body fat in only two ways: by producing more fat cells, or by storing more fat in the existing fat cells. But fat cells can expand just so far and then can reach their capacity of stored fat. At one time, researchers believed that a body’s number of fat cells was set by puberty. It is now known that the number of fat cells can continue to increase, doing so when existing fat cells fill to their capacity. The body cannot eliminate existing fat cells, either through dieting or exercise; they simply shrink in size. The only way researchers have discovered to eliminate fat cells is through surgery. After years of removing fat surgically from various areas of the body, and after observing injuries in which fat tissue has been lost, doctors have determined that fat is usually not redeposited in the treated areas as long as diet and exercise are sufficient to keep the number of fat cells from increasing. See also ADIPOSE TISSUE; BODY FAT; BODY FAT DISTRIBUTION; LIPOSUCTION; SET-POINT THEORY. “Body Fat: The Hormone Factor.” Science News, June 15, 1991. Hirsch, J., et al. “The Fat Cell.” Medical Clinics of North America 73, no. 1 (January 1989): 83–96. McCurdy, John A., Jr. Sculpturing Your Body: Diet, Exercise and Lipo (Fat) Suction. New York: Kensington Publishing Corp., 1990.

“fat” doctors A derisive term given by the medical profession during the 1960s to certain “reducing” doctors who, together with drug companies, created an entire industry devoted to treating obesity with “rainbow pills,” various combinations of drugs (since prohibited by the Food and Drug Administration), offered in different colors, to be used at different times of day. In 1968, following the death of several patients from indiscriminate prescription of such diet pills, Life magazine published an exposé of these practices. To research the exposé, a reporter, a young woman who at five feet five inches and 123 pounds had never had a weight problem, visited 10 doctors in

different parts of the United States who were nationally or locally known for their easy reducing procedures. In each instance she was either put through a meaningless routine examination or just measured and weighed, and then was given varying numbers of multicolored pills. The pills contained various combinations of AMPHETAMINES, thyroid and digitalis and were prescribed with the recommendation that they be purchased at the doctors’ own drug counters. A Kansas City doctor simply handed her a box of 140 pink, brown, tan and gray pills, charged her $10 and told her to return in one month. A Virginia doctor gave her 150 amphetamine-thyroid-barbiturate combination pills. And a Miami Beach doctor gave her a similar combination plus diuretics and laxatives, told her she could now eat 4,000 calories a day and lose weight, and asked her to return in a week. There was no consensus among the fat doctors concerning diets; some advised that with these pills she could eat anything she wanted, and others offered elaborate restricted diets. The doctors also all prescribed varying degrees of exercise and liquid consumption. With the FDA crackdown on doctors—both legitimate and fraudulent—who engage in such practices, the lucrative business of selling diet pills expanded into mail order, which is more difficult to regulate. In the late 1980s, Susan Gilbert found it flourishing. “Eat all day and still lose weight” was the headline of a typical ad published in 1987. Bender, Arnold E. Health or Hoax? Buffalo, N.Y.: Prometheus Books, 1986. Gilbert, Susan. Medical Fakes and Frauds. New York: Chelsea House, 1989.

fat phobia A fear of eating fat caused by the avalanche of media stories and books during the 1990s stressing the health dangers of too much fat in the diet. Nutritionist Ann C. Grandjean (Center for Human Nutrition, Omaha, Nebraska) was quoted in a USA Today article as saying, “Fat phobia is the biggest diet problem I see among young athletes. I’m talking about these young people who are eating only 6% of their calories from fat.” She goes on to say that people are following horrendous diets in the name of low fat. While many Americans do eat too much fat, some have cut their fat intake back way too far.

144 fat power The Henry Ford Health System cautions that even though a diet high in fat is unhealthy, going in the other direction can be equally bad. “In a study from the University of Washington, 30 percent of the people placed on a low fat diet actually increased their risk of heart disease.” Also, “A very low-fat diet may be too high in carbohydrates for some patients with diabetes. In both cases, the risk of future heart attack actually increase with the low-fat diet.” In another context, fat phobia also is used to describe “excessive fear and dislike of fat in oneself and in others,” which Areton explains “is a relatively new phenomenon, born during the 20th century.” This term has also been operationalized by Robinson, Bacon and O’Reilly to reflect antifat attitudes and negative stereotypes about fat people. See also FATS; FEAR OF FAT SYNDROME. Areton, Lilka Woodward. “Background of the Problem of Fat Phobia.” Chapter 3 in “Factors in the Sexual Satisfaction of Obese Women in Relationships.” Electronic Journal of Human Sexuality 5 (January 15, 2002). Available online. URL: http://www.ejhs.org/ volume5/Areton/03Background.htm. Hellmich, Nanci. “Get Fit, Stay Fit.” USA Today, January 4, 1999, page 9D. Henry Ford Health System. “Fat Phobia.” Available online. URL: https://www.henryford.com/body. cfm?id=38355. Downloaded on December 26, 2004. Robinson, B. E., J. G. Bacon, and J. O’Reilly. “Fat Phobia: Measuring, Understanding, and Changing Anti-fat Attitudes.” International Journal of Eating Disorders 14, no. 4 (December 1993): 467–480.

fat power

A term used by advocates of a movement toward greater social acceptance for the overweight, reflecting a nationwide trend of changing attitudes. “Fat power” advocates point to the commercial success of products, services and media personalities as evidence of this shift. There are now dating services for overweight people, magazines and clothing being designed for the large-sized by such well-known names as Pierre Cardin. Among the euphemisms for obesity promoted by pro-fat groups are “size positive,” “fatpositive” and “plus-sized.” See also CULTURAL INFLUENCES ON APPEARANCE.

fat recycling

Also called fat grafting; the technique of removing fat cells from one part of the

body and using them in another. It is a further refinement of liposuction. Fat recycling is a relatively new and still-evolving cosmetic surgery technique in which fat removed during liposuction can be injected into the hollows between chin and cheek, for example, during face-lifts. Hilton quotes pioneer plastic surgeon Ian T. Jackson, M.D.: “There are practitioners now who are really excellent at fat grafting and have perfected details that make it truly a viable alternative for contour defect correction and for contouring areas that have been damaged by disease, radiation, or over-aggressive cosmetic surgery.” See also COSMETIC SURGERY; LIPOSUCTION. Hilton, Lisette. “Approach Provides Alternative for Fat Grafting in Patients with Radiation Defects.” Cosmetic Surgery Times 5, no. 5 (June 2002): 8.

fats One of the three main classifications of nutrients (see CARBOHYDRATES and PROTEINS), fats belong to a class of compounds known as lipids. They are derived from both animal and plant foods, but they differ chemically from each. Those originating from animal sources are saturated fats; fats from plants are usually unsaturated fats (see FATS, SATURATED; FATS, UNSATURATED). Exceptions are tropical vegetable oils, including coconut oil and palm oil which are highly saturated and are widely used in food processing, particularly coffee creamers and baked goods. Both saturated and unsaturated fats have the same caloric value, about nine calories per gram, more than twice that of carbohydrates and proteins (four calories per gram). (Some studies indicate that fat may have up to 11 calories per gram.) Fat serves as the body’s major store of energy, and METABOLISM of this substance supplies approximately 90 percent of energy requirements during prolonged EXERCISE. The higher caloric value of fat makes it a more efficiently convertible source of energy for storage than protein or carbohydrate. The American Heart Association recommends limiting calories eaten as fat to the 20 to 30 percent range instead of the 40 to 50 percent typical of most Americans. Diets consisting of less than 20 percent fat generally lack sufficient taste and palatability for faithful adherence; much below 10 percent for a prolonged period could cause serious health prob-

fat substitutes 145 lems or even death. Some fat must be included in a diet because fat serves as a carrier for several important vitamins including A, D, E and K. Very low fat diets may result in deficiency of these “fat-soluble” vitamins. Nevertheless, dedicated fat-free purists strive to eliminate all fats from their diets. See also FAT PHOBIA; TRANS FATS.

may help with depression. Other polyunsaturated fats—specifically corn, soybean and sunflower oils—lower LDL while raising HDL, and may reduce risk for heart disease and diabetes. See also CHOLESTEROL; FATS; FATS, SATURATED; TRANS FATS. “Dietary Fat.” Harvard Health Letter, January 2004, p. 5.

fats, saturated Fats whose chemical composition includes the maximum possible quantity of hydrogen. They come primarily from animals and are usually solid at room temperature. They tend to raise blood cholesterol levels. According to Harvard Health Letter, saturated fats are associated with a modest increase in heart disease, with some evidence pointing to a link to prostate and colon cancer. Examples of saturated fats are butter, fats in whole milk, cheese, lard, meat fat, solid shortening, palm oil, cocoa butter and coconut oil. From a nutritional standpoint, some saturated fat is essential for proper growth and metabolism; a deficiency can lead to eczema and other skin disorders. See also CHOLESTEROL; FATS; FATS, UNSATURATED; TRANS FATS. “Dietary Fat.” Harvard Health Letter, January 2004, p. 5.

fats, unsaturated Fats that include fatty acids whose chemical composition includes some sites on the carbon atom unoccupied by hydrogen. When many sites are vacant, they are called polyunsaturated. Unsaturated fats are capable of absorbing additional hydrogen. They are also known as free fatty acids because of their free bonds that allow them to take on more hydrogen atoms. They usually come from plants and are liquid at room temperature. Examples of polyunsaturated fats are vegetable oils such as corn, cottonseed, sunflower, safflower and soybean. Monounsaturated fats include olive, peanut and canola oils. Unsaturated fats tend to lower blood cholesterol levels. According to Harvard Health Letter, monounsaturated fats lower “bad” LDL cholesterol while raising “good” HDL cholesterol, and may have protective effects against cancer. Some polyunsaturated fats— specifically omega-3 oils such as fish, flaxseed oil, walnuts and canola oil—lower the risk for heart arrhythmias, lower triglycerides (blood fats) and

fat substitutes Artificial fat replacement substances first developed by major food processing and manufacturing companies during the late 1980s and early 1990s. SIMPLESSE (NutraSweet), a low-calorie milk-protein-and-egg-white substance, was the first all-natural substitute to win approval from the Food and Drug Administration. Initial FDA approval for Simplesse was for use only in frozen dessert products. OLESTRA, a cooking-oil replacement developed by Procter & Gamble, is, on the other hand, heat resistant and can be used in baked goods, fried foods and snacks. According to the company, Olestra is “almost a carbon copy of regular fat, but with a molecule of sugar at its core instead of glycerine, and up to eight fatty acids attached to the core instead of customary three.” Since these two products were introduced, the fat replacement field has become quite crowded; supermarket shelves are bulging with products aimed at what is anticipated to be a billion-dollar annual market. Among these additional fat substitutes have been Stellar, made from cornstarch by A. E. Staley Manufacturing, and Slendid, made out of pectin extracted from citrus peels, developed by Hercules Inc. Procter & Gamble developed Caprenin, a low-calorie fat that replaced cocoa butter in candy bars such as the Milky Way II bar. Caprenin had only five calories a gram instead of the nine calories a gram in other fats. Its “secret” ingredient was behenic acid, a substance not easily metabolized by the body. Because Caprenin appeared to increase serum cholesterol slightly, the Milky Way II was withdrawn from the market. No one fat replacer is ideal for all uses—flavor, texture, lubrication, bulk or heat transfer. In some cases, a single fat replacer may do the job; in others, a combination of fat replacers may be necessary. The Calorie Control Council explains, “The type of fat replacer(s) used in a product depends largely on which of the complex and diverse properties of

146 fat virus fat are being duplicated. In addition to flavor, palatability and creaminess, fats provide an essential lubricating action. In fried foods, fats and oils transmit heat rapidly and uniformly and provide crisping. Thus, the particular desired functions of fat needed to produce an acceptable product—flavor/texture, lubrication, volume/bulk, or heat transfer—determine which ingredient(s) and processing techniques are employed. “The ideal fat replacer(s) recreates all the attributes of fat, while also significantly reducing fat and calorie content. The challenge for food processors is to identify the fat replacer(s) that works best for a given product. “Fat replacement may require several ingredients to replace the functionality of fat. A ‘systems approach’ is, therefore, sometimes employed. In the systems approach, a variety of synergistic components are used to achieve the functional and sensory characteristics of the full-fat product. Combinations of ingredients are used to compensate for specific functions of the fat being replaced. These combinations may include proteins, starches, dextrins, maltodextrins, fiber, emulsifiers and flavoring agents. Some fat replacers are now available that are themselves a combination or blend of ingredients (for example, one ingredient currently in use is a combination of whey, emulsifiers, modified food starch, fiber and gum).” Some analysts say that the use of these low- or nonfat substitutes will revolutionize the food processing industry, dramatically increasing sales and consumption. But others feel that fat-substitute products will only take sales from existing processed food products. The medical community has been cautious about the introduction of these fake fats. It will take some time before adequate studies are completed; to date, however, no data show that eating a fat substitute will help lower or even maintain body weight—unless overall calories are cut. In fact, some concern is expressed that people will eat even more calories because of the fake fat. For example, a piece of fat-free cake that has 160 calories is more “fattening” than an apple that has only 65 calories and is also fat free. But nutritionists fear that a population addicted to sugar and chocolate will now feel the fat-free cake gives them an excuse to indulge. See also APPENDIX V.

Calorie Control Council. “Fat Replacers: Food Ingredients for Healthy Eating.” Available online. URL: http://www.caloriecontrol.org/fatrepl.html. Downloaded on December 26, 2004. Segal, Marian. “Fat Substitutes: A Taste of the Future?” FDA Consumer, December 1990.

fat virus

A human adenovirus known as AD 36, which researchers think may lead to obesity in some people. When the virus is given to animals, their body fat increases 50 percent or more—even quadrupling weight gain, even though they have eaten the same amount as animals not given the virus. Recently, scientists have tested humans for the virus, and found that 30 percent of obese people showed their blood had been exposed to the virus, while only 11 percent of nonobese persons had been exposed. Among the theories of how AD 36 may lead to obesity, according to Squires: “One theory is that infection prompts fat cells to pull more triglycerides and cholesterol from the blood—an idea that fits with the lower levels of these substances in the blood of those who have had the virus. Other research points to the possibility that infection might significantly reduce the amount of leptin produced by fat cells. Still more studies suggest that AD 36 might prompt fat cells to mature more quickly and start storing fat.” Scientists caution that a “fat virus” is only a theory at this point, and “extremely unlikely” and “fringe”—although interesting.

Atkinson, Richard L. “Human Adenovirus-36 Is Associated with Increased Body Weight and Paradoxical Reduction of Serum Lipids.” International Journal of Obesity and Related Metabolic Disorders, December 2004. Squires, Sally. “A Question from the Edge: Is Fat Contagious?” The Washington Post, August 3, 2004, p. HE01.

fear of fat syndrome Behavior resulting from an exaggerated concern about gaining weight, not classifiable as a serious disorder such as BULIMIA or anorexia. Fear of fat syndrome is much more common than ANOREXIA NERVOSA and affects younger children. There are both boys and girls as young as seven who experience fear of fat and on occasion diet and skip meals. They are not anorexic—they do

feminist psychotherapy for eating disorders 147 not have an obsessive wish to be thinner—but they are obsessed with not gaining weight. This dieting before their bodies are fully formed can lead to stunted growth, a stunting of development of heart muscle and delaying of puberty. If children stop dieting, damage is usually temporary; but if they diet strenuously for more than six months, they are not likely to grow that year. Frequently this fear of fat is seen in children who are not fat to begin with. Often the extra baby fat that appears right before puberty inspires panic dieting. Because this baby fat is not extra calories stored as fat, it does not respond well to dieting, which only increases anxiety, producing more rigorous attempts to diet. Children will frequently conceal this dieting, explaining that they are not eating dinner because they have to go somewhere, or that they ate at a friend’s house or on the way home. One study evaluated disturbed eating behaviors and attitudes among 326 adolescent girls attending an upper-middle-class parochial high school. The students reported an exaggerated concern with obesity regardless of body weight or knowledge of nutrition. Underweight, normal-weight and overweight girls were dieting to lose weight and reported frequent self-weighing. As many as 51 percent of the underweight adolescents described themselves as extremely fearful of being overweight, and 36 percent were preoccupied with body fat. The frequency of BINGE EATING and VOMITING behaviors was similar in the three weight categories. The data suggested that fear of fat and inappropriate eating behaviors are pervasive among adolescent girls regardless of body weight or nutrition knowledge. University studies of college-age women have revealed this same fear of fat syndrome. Eighty percent of the 1,335 female students in a University of Florida study said they had dieted during the past year; the average respondent was five feet five inches tall and weighed 122 pounds, well within the low-to-normal weight range. An Ohio State University study found that 67 percent of the female respondents had some kind of disordered eating pattern. Fear of fat appears to be deeply ingrained in our society; we have cultural preoccupation with slim-

ness. Television, magazines and even the classroom promote the goal of thinness for reasons of both beauty and health. Even medical doctors and other expert sources promote a “healthier” dietary intake. This social phenomenon not only has an impact on adult and adolescent eating habits but may also influence those of young children. Notions regarding body weight and appearance are formed very early in life. In fact, elementary school children have been shown to perceive obesity as being worse than being handicapped or disabled. See also CULTURAL INFLUENCES ON EATING DISORDERS; DIETING; FAT PHOBIA; GOLDFARB FEAR OF FAT SCALE. Moses, Nancy, Mansour-Max Banilivy, and Fima Lifshitz. “Fear of Obesity among Adolescent Girls.” Pediatrics 83 (March 1989): 393–398.

feeding disorder of infancy or early childhood Term used in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) for the more commonly known FAILURE TO THRIVE. DSM describes the condition as a persistent failure to eat adequately, as reflected by significant weight loss or a failure to gain weight over at least one month. The feeding disturbance is not due to an associated gastrointestinal or other general medical condition. Plus, the feeding disturbance is not better accounted for by another mental disorder or by lack of available food. Onset of the disorder must be before age six years. According to DSM-IV, of all pediatric hospital admissions, 1 to 5 percent are for failure to gain adequate weight, and up to one-half of those may be attributed to feeding disturbances without any apparent predisposing medical condition. Although feeding disorder of infancy or early childhood usually occurs during the infant’s first year, it may begin as late as two to three years of age. The majority of children have improved growth after variable lengths of time.

feminist psychotherapy for eating disorders Feminist psychotherapy (FP) involves a multifaceted approach, one that does not follow a unified doctrine, but can be incorporated into extant

148 feminist psychotherapy for eating disorders approaches such as cognitive-behavior therapy or psychodynamic treatment for eating disorders. In conceptualizing the etiology of eating disorders, feminist psychotherapists focus on issues of gender inequality, sociocultural media influences, fashion and diet food industries and the cultural idealization of thinness. Some general principles of feminist psychotherapy include an emphasis on a consciousness-raising approach to treatment, an open exploration of power differentials between clients and therapist with a commitment toward minimizing this hierarchy, a recognition of women’s strengths and rephrasing of weaknesses as strengths and advocating social action among clients to empower women and promote social change. Further, feminist therapists value client autonomy and need for connections with others, and they encourage clients to change rather than adapt to socially prescribed conflicting sex roles. Perhaps most fundamental, however, is the FP belief that psychological distress stems from internal and external sources, thus creating a need to view problems within a sociocultural framework and emphasize systemic change through therapy. Feminist psychotherapists employ strategies such as problem solving, skills training, psychoeducation, sex role and power analyses, assertiveness training, consciousness-raising groups, bibliotherapy, reframing to recognize contributions of the external environment and demystification, wherein therapists provide information about change processes and tools for clients to monitor and evaluate their own progress. From a more psychodynamic perspective, feminist psychotherapists may argue that women are socialized to pursue the potentially conflicting cultural ideals of independence and nurturance, without attention to interdependence. Further, women are led to develop their identities in the context of and in comparison to others, learning to tie their self-worth to their interpersonal abilities and successes. Indeed, eating disorder clients have had much experience with so-called false relationships; consequently, one important goal of feminist psychodynamic psychotherapy is to help the client recognize and validate her perceptions of prior false relationships, and to learn that engagement does not necessarily lead to a loss of a separate self.

HILDE BRUCH cautioned that attempts at interpretation may seem to the anorexia nervosa (AN) client to be reminiscent of earlier experiences in which the client was told what to think by someone more powerful; this may then further contribute to the client’s lack of confidence and self-awareness. With regard to client response, the AN client may identify the female therapist with her own intrusive mother, thereby leading to fears of being taken over and ambivalence towards progress. During early sessions, the therapist should accept the AN client’s negative responses without retaliating or interpreting the behaviors (which may be misconstrued as manipulative), to teach the client that a relationship can be supportive in her self-learning. Other countertransference implications relate to the therapist’s personal biases and attitudes toward body weight. Fodor, for instance, recommended that feminist psychotherapists working with eating disorder clients reevaluate their definitions of overweight, questioning assumptions such as the existence of set weights for individuals, the unhealthiness and unattractiveness of moderate overweight and the ease of self-control over weight. Bruch, Hilde. “Psychotherapy in Primary Anorexia Nervosa.” Journal of Nervous and Mental Diseases 150, no. 1 (January 1970): 51–66. Fodor, Iris G. “Cognitive Behavior Therapy: Evaluation of Theory and Practice for Addressing Women’s Issues.” In Feminist Psychotherapies: Integration of Therapeutic and Feminist Systems, edited by M. A. Dutton-Douglas and L. E. A. Walker, 91–117. Westport, Conn.: Ablex Publishing Corp., 1988. Sesan, Robin. “Feminist Inpatient Treatment for Eating Disorders: An Oxymoron?” In Feminist Perspectives on Eating Disorders, edited by P. Fallon, M. A. Katzman, and S. C. Wooley, 251–271. New York: Guilford Press, 1994. Sesan, Robin, and Melanie A. Katzman. “Empowerment and the Eating-Disordered Client.” In Feminism and Psychotherapy: Reflections on Contemporary Theories and Practices. Perspectives on Psychotherapy, edited by I. B. Seu and M. C. Heenan, 78–95. Thousand Oaks, Calif.: Sage Publishing, 1998. Steiner-Adair, C. “New Maps of Development, New Models of Therapy: The Psychology of Women and the Treatment of Eating Disorders.” In Psychodynamic Treatment of Anorexia Nervosa and Bulimia, edited by C. L. Johnson, 225–244. New York: Guilford Press, 1991.

food addiction 149 Striegel-Moore, Ruth H. “A Feminist Perspective on the Etiology of Eating Disorders.” In Eating Disorders and Obesity: A Comprehensive Handbook, edited by K. D. Brownell and C. G. Fairburn, 224–229. New York: Guilford Press, 1995. Wooley, S. C. “Uses of Countertransference in the Treatment of Eating Disorders: A Gender Perspective.” In Psychodynamic Treatment of Anorexia Nervosa and Bulimia, edited by C. L. Johnson, 245–294. New York: Guilford Press, 1991. Worell, Judith, and Pam Remer. Feminist Perspectives in Therapy: An Empowerment Model for Women. West Sussex, U.K.: John Wiley & Sons Ltd., 1992. Zerbe, Kathryn J. “Feminist Psychodynamic Psychotherapy of Eating Disorders: Theoretic Integration Informing Clinical Practice.” The Psychiatric Clinics of North America 19, no. 4 (December 1996): 811–827.

fen-phen/Redux Fen-phen refers to the combined use of the drugs fenfluramine (brand name Pondimin) and phentermine. Redux is the brand name for dexfenfluramine. Phentermine was approved by the Food and Drug Administration in 1959 and fenfluramine in 1973, both as appetite suppressants for the short-term (a few weeks) management of obesity. Dexfenfluramine was approved in 1996 for use as an appetite suppressant in the management of obesity. Based largely on a study by Weintraub, some physicians began describing fenfluramine or dexfenfluramine in combination with phentermine, often for extended periods of time, for use in weight-loss programs. In 1996 physicians had written 18 million prescriptions for fen-phen. Use of drugs in ways other than described in the FDA-approved label is called “offlabel use.” In the case of fen-phen and dexfen/ phen, no studies were presented to the FDA to demonstrate either the effectiveness or safety of the drugs taken in combination. When the Mayo Clinic and other treatment facilities reported more than 200 patients developing heart valve disease after taking fen-phen, the FDA notified doctors and drug makers on September 12, 1997, to withdraw fenfluramine and dexfenfluramine from the market. (There were also reports of cases of heart valve disease in patients taking only fenfluramine or dexfenfluramine, but no cases meeting FDA’s definition in patients taking phentermine alone.)

Weintraub, M., J. D. Hasday, A. I. Mushlin, and D. H. Lockwood. “A Double-Blind Clinical Trial in Weight Control. Use of Fenfluramine and Phentermine Alone and in Combination.” Archives of Internal Medicine 144, no. 6 (1984): 1143–1148. Weintraub, M. “Long-Term Weight Control Study: Conclusions,” Clinical Pharmacology and Therapeutics 51, no. 5 (May 1992): 642–646. Wellman, P. J., and Maher, T. J. “Synergistic Interactions between Fenfluramine and Phentermine.” International Journal of Obesity and Related Metabolic Disorders 23, no. 7 (July 1999): 723–732.

fiber

An edible, but indigestible, part of certain foods. Fiber is important in the diet as roughage, or bulk. Fiber is found in starches, breads, vegetables and fruit. See also DIETARY FIBER.

food addiction Some popular writings on the subject of food have postulated the existence of a disorder they call “food addiction.” Loosely construed, the concept of addiction might be said to apply to compulsive or disordered eating of certain foods, most commonly those high in sugar or starch content, but there is no scientific basis for believing that any ordinary food substance is literally physiologically addictive in the same sense as a narcotic drug. So-called food addiction is more plausibly understood as an expression of a psychological disorder, response to an unacceptably intense condition of emotional deprivation, anxiety or tension. In other words, the idea of food addiction is not medically or scientifically valid. Some authors classify “addictive” foods as foods that trigger cravings and compulsive eating or drinking. Scientists at Brookhaven National Laboratory have found that the mere display of food— wherein food-deprived subjects are allowed to smell and taste their favorite foods without actually eating them—causes a significant elevation in brain dopamine, a neurotransmitter associated with feelings of pleasure and reward. This activation of the brain’s dopamine motivation circuits is distinct from the role the brain chemical plays when people actually eat, and may be similar to what addicts experience when craving drugs.

150 food nutrition labels Brookhaven scientists have done extensive research showing that addictive drugs increase the levels of dopamine in the brain, and that addicts have fewer dopamine receptors than nonaddicts. Previously, in an effort to understand the relationship of the dopamine system to obesity, the scientists had found that obese individuals also had fewer dopamine receptors than normal control subjects. Several University of Florida (UF) studies have also presented new evidence linking overeating, obesity and addiction, and could have treatment implications for people struggling with weight problems, alcoholism or drug use, according to Mark Gold, M.D., chief of addiction medicine at UF’s College of Medicine. Nordlie explains: “Gold, an early proponent of the food-as-drug model, said the medical community considered the idea radical a decade ago, but many addiction specialists now give it serious consideration. Advances in imaging technology, neurochemistry and other fields have enabled basic science researchers to map rodents’ brain pathways and show how food and drugs evoke similar responses. At the same time, clinical researchers such as Gold have begun investigating the relationship between food-seeking and drugseeking behaviors in people.” See also ADDICTION; ADDICTION MODEL OF EATING DISORDERS; CRAVING. Gold, Mark S., ed. Eating Disorders, Overeating, and Pathological Attachment to Food: Independent or Addictive Disorders? Binghamton, N.Y.: Haworth Press, 2004. James, G. Andrew, Mark S. Gold, and Yijun J. Liu. “Interaction of Satiety and Reward Response to Food Stimulation.” Journal of Addictive Diseases 23, no. 3 (July 2004): 23–37. Nordlie, Tom. “UF College of Medicine Researchers Report Link between Overeating, Obesity and Addiction.” Available online. URL: http://www.news. health.ufl.edu/stories/2004/July/070804_Nordlie.sht ml. Posted July 8, 2004. Volkow, Nora D., et al. “Nonhedonic Food Motivation in Humans Involves Dopamine in the Dorsal Striatum and Methylphenidate Amplifies This Effect.” Synapse 44, no. 3 (June 1, 2002): 175–180.

food nutrition labels

Beginning in 1994, the U.S. government began requiring manufacturers to

put information about nutritional value on food labels. The first significant change was the recent requirement that beginning January 1, 2006, manufacturers must list the amount of unhealthy trans fatty acids, or TRANS FAT, directly under the line for saturated fat. Then in March 2004, U.S. Health and Human Services (HHS) secretary Tommy Thompson unveiled a strategy for the Food and Drug Administration (FDA) to fight American obesity, which included changing the Nutrition Facts panel on food labels. Specifically, the initiative includes the following recommendations for FDA: • Give more prominence to calorie content on food labels, such as increasing the font size for the calories line item, including a percent daily value column for total calories and/or eliminating the listing for calories from fat. • Authorizing health claims on certain foods that meet FDA’s definition of “reduced calorie” or “low calorie.” For example, FDA may consider allowing a health claim such as “Diets low in calories may reduce the risk of obesity, which is associated with type 2 diabetes, heart disease and certain cancers.” • Publish a proposed rule to provide for nutrient content claims related to carbohydrate content of foods and provide guidance for the use of “net carb” claims. • Encourage food manufacturers to label as a single serving those food packages for which the entire content of the package “can reasonably be consumed at a single eating occasion.” FDA gives the example that a 20-ounce bottle of soda, currently labeled as 110 calories per serving and 2.5 servings per bottle, could be labeled as containing 275 calories per bottle. In addition, FDA may enhance enforcement of inaccurate labeling of serving sizes. Most of the FDA’s recommendations are voluntary, which received complaints from consumer advocates. The National Institute of Environmental Health Sciences (NIEHS) suggests watching labels for the following:

fraudulent products 151 • Pay close attention to serving sizes. • Products labeled “light” or “lite” must have onethird fewer calories or one-half the fat of the foods to which they are compared. “Light” also can mean that salt has been reduced by one-half. • Look for foods with lower levels of saturated fats. • Look for products that have more fiber and less sugar. • Use the “percentage of daily values” section of the label as a guide for daily planning. • The amount of calories a person needs each day depends on many factors, including exercise. Center for Food Safety and Applied Nutrition. “How to Understand and Use the Nutrition Facts Label.” Available online. URL: http://vm.cfsan.fda.gov/~dms/foodlab.html. Posted July 2000; updated July 2003 and November 2004.

forbidden foods A term used by clinicians and eating disordered individuals to refer to foods that the person feels that he or she should not eat, usually because they are high in calories and the person believes that he or she would not be able to stop eating them. Not coincidently, “forbidden foods” are also the foods on which persons with eating disorders usually binge. Although some approaches to treatment of eating disorders encourage the individual to abstain from these “forbidden foods,” the most effective treatments help the individual learn to eat the food without losing control (i.e., without bingeing and purging). Thus at the end of treatment for an eating disorder, a person would no longer have any forbidden foods.

recommend “renourishment” or “refeeding” because they believe that the biological effects of starvation create a psychological prison from which patients cannot escape. In this view, the anorexic must gain a certain amount of weight before she can progress in psychotherapy or make rational decisions about treatment. See also HYPERALIMENTATION.

fraudulent products

With a reported 65 percent of Americans overweight or obese, it is little wonder that unscrupulous promoters prey on those looking for miracle cures. But the Federal Trade Commission (FTC) warns that despite claims to the contrary, there are no magic bullets or effortless ways to burn off fat. The only way to lose weight is to lower caloric intake and increase physical activity. Claims for diet products or programs that promise weight loss without sacrifice or effort are bogus. And some can even be dangerous. These facts do not keep fraudulent advertisers from preying on consumers and reaping billions of dollars each year. While the scams may vary (for example, pills, patches, clips, body wraps, insoles or “diet teas”), the claims are almost always the same—dramatic, effortless weight loss without diet or exercise. The FTC warns consumers to watch out for the following buzzwords: • No Diet! No Exercise! • Lose 30 Pounds in 30 Days • Eat Your Favorite Foods and Still Lose Weight • Shrinks Inches off Your Stomach, Waist and Hips • Scientists Announce Incredible Discovery!

forced feeding

Feeding accomplished through invasive tubes in the nose or by a process called total parenteral nutrition. Forced feeding is the most dramatic treatment for anorexia. In severe cases, in which body weight falls to dangerous levels, parents and physicians may decide to admit an anorexic to a hospital for forced feeding on the grounds that it will prevent her death and restore her to a mental state that will make meaningful therapeutic interaction possible. In these critical cases physicians

• Revolutionary European Method! Ancient Chinese Secret! • Turn on Your Body’s Fat Burning Process • Automatically Convert Fat to Lean Trim Muscle! • Absorbs Fat • Developed after Years of Secret Research • New Scientific/Medical Breakthrough Also, the FTC says fraudulent advertisers use the following techniques:

152 free fatty acids • Extravagant claims of dramatic, rapid weight loss • Testimonials from “famous” doctors, researchers or other medical experts • Dramatic before-and-after photos depicting substantial weight loss • Ads that tout the latest trendy ingredient in the headlines • A footnote hidden somewhere in an ad noting “diet and exercise required” The FTC reminds consumers that an otherwise misleading ad or a fleeting video “super” (a flashing message superimposed over the video) cannot be “cured” with a buried “disclosure”. Further, the FTC identifies seven common weight-loss claims made for products available over the counter, including nonprescription drugs, dietary supplements, creams, wraps, devices and patches that are scientifically infeasible at the current time. These claims include: • Causes weight loss of two pounds or more a week for a month or more without dieting or exercise • Causes substantial weight loss, no matter what or how much the consumer eats • Causes permanent weight loss (even when the consumer stops using the product) • Blocks the absorption of fat or calories to enable consumers to lose substantial weight • Safely enables consumers to lose more than three pounds per week for more than four weeks • Causes substantial weight loss for all users • Causes substantial weight loss by wearing it on the body or rubbing it into the skin Fraudulent weight loss product claims can be reported to the state attorney general, local consumer protection office, or Better Business Bureau.

free fatty acids

Free fatty acids (FFA) in the blood originate from the release of ADIPOSE TISSUE triglycerides. They represent virtually the only route by which these fat stores can be transferred to nonfat tissue for net loss via oxidation. Free fatty acid metabolism in obesity has therefore been the

subject of many studies over the last 30 years. Unfortunately, conflicting confusions regarding several aspects of FFA metabolism have appeared, including the antilipolytic (lipolysis: the chemical breakdown of fat) effectiveness of insulin in obesity, the relationship of FFA release to the amount of body fat and the lipolytic responsiveness of obese individuals to catecholamines (secretions). To determine whether differences in DISTRIBUTION OF BODY FAT result in specific abnormalities of free fatty acid metabolism, researchers conducted studies of women of varying body fat distribution. They concluded that the basal release of FFA from adipose tissue to meet lean body mass energy needs is greater in upper-body obese women than lower-body obese or non-obese women. The net lipolytic response to epinephrine (a hormone that acts as a stimulant to several metabolic processes) is reduced in upper-body obese women compared with lower-body obese and non-obese women. Their results may explain many of the conflicting reports in the literature regarding FFA metabolism in human obesity and emphasize the need to characterize the type of obesity being studied before investigations of FFA metabolism in humans.

Freshman 15 A term used since at least the mid1980s to explain the added pounds college freshmen typically put on when they go away to college for the first time. The propensity to put on weight has been attributed to several things, including diets of pizza and sweets, midnight munchies, stress-related eating binges and alcohol calories. According to the Kansas State University Housing and Dining Services, “More and more the Freshman 15 is being replaced with 20–25 pounds of weight gain.” Although the Freshman 15 is largely a myth, researchers at Cornell University found that students in their study did gain an average of four pounds during the first 12 weeks of their freshman year. This was a rate of gain 11 times higher than the typical weight gain for 17- and 18-year-olds. Not everyone is destined to gain the full Freshman 15, though. A multiyear study by researchers at Tufts University found that while students do gain weight during their first year, the average is about six pounds for men and 4.5 pounds for women.

fructose as a contributor to obesity 153 Graham and Jones investigated whether the perception that freshman gain 15 pounds during their first year of college is related to either actual or perceived weight gain. Their findings revealed no significant weight gain at the end of the year. The Freshman 15 myth was found to play an important role in perpetuating negative attitudes toward weight. Freshmen who were concerned about gaining 15 pounds were more likely to think about their weight, have a poorer body image than others and categorize themselves as being overweight. In their study of 135 college freshmen, Anderson et al. found that statistically significant (but modest) weight increases did occur for the majority of participants during their freshman year in college, with one-quarter of them gaining at least five pounds during their first semester—resulting in the proportion of students classified as overweight or obese to increase markedly from September to December. “The percentage of participants defined as overweight or obese from September to May virtually doubled. For this subset of participants, the freshman year of college could be considered a critical period for weight gain.” See also COLLEGE STUDENTS AND EATING DISORDERS. Anderson, Drew A., Jennifer R. Shapiro, and Jennifer D. Lundgre. “The Freshman Year of College as a Critical Period for Weight Gain: An Initial Evaluation.” Eating Behaviors 4, no. 4 (November 2003): 363–367. Graham, M. A., and A. L. Jones. “Freshman 15: Valid Theory or Harmful Myth?” Journal of American College Health 50, no. 4 (January 2002): 171–173.

fructose as a contributor to obesity

The International Food Information Council (IFIC) Foundation explains that fructose is a single sugar unit, like glucose, and is sometimes referred to as “fruit sugar” because it is the sugar that occurs naturally in fruits, vegetables and honey. Fructose and glucose are combined in equal amounts in table sugar (sucrose). Similarly, fructose and glucose occur in almost equal amounts in high fructose corn syrup (HFCS). HFCS is primarily found in two formulations in the United States: “HFCS 55,” which is 55 percent fructose and is used to sweeten beverages, and “HFCS 42,” which is 42 percent fructose and used mostly in baked goods.

The interchangeable use of the words fructose and HFCS in some media and even scientific documents is potentially misleading to consumers, who may assume that the two are identical. They are, however, quite different in both their structure and uses in the food supply. Although research using fructose alone has led to assumptions about HFCS, as a sweetener pure fructose is rarely consumed alone. It is generally consumed as a component of table sugar or of HFCS. A scientific debate has emerged over whether America’s increased use of high fructose corn syrup is contributing to or responsible for the increasing rates of obesity. Among the points made recently by scientists and food groups: • Bray et al. analyzed food consumption patterns by using U.S. Department of Agriculture food consumption tables from 1967 to 2000, and found that consumption of HFCS increased more than 1,000 percent between 1970 and 1990, far exceeding the changes in intake of any other food or food group. Noting that calorically sweetened beverages may enhance caloric overconsumption, the authors suggested that the increase in consumption of HFCS has a temporal relation to the epidemic of obesity, and the overconsumption of HFCS in calorically sweetened beverages may play a role in the epidemic of obesity. • Earlier in 2004 the American Dietetic Association published a report that found, on the basis of current scientific evidence, that consumers can safely enjoy a range of caloric and noncaloric sweeteners. They noted that this statement is valid when such sweeteners are consumed as part of a diet that is guided by current nutrition recommendations, such as those in the U.S. Dietary Guidelines for Americans and the Dietary Reference Intakes, as well as individual health goals. This includes fructose from HFCS or from table sugar. • IFIC says the primary factor driving the alleged connection between fructose and obesity is the increased availability of HFCS since its introduction in the 1970s. “Availability” refers to the total amount delivered into the food supply. This amount is greater than actual consumption, since waste and other losses are not accounted for. The proportion of HFCS as a percentage of

154 fructose as a contributor to obesity all caloric sweeteners (added sugars and sweeteners) available in the U.S. food supply has increased from less than 0.5 percent in 1970 to 42 percent in 2001. Although the increased availability of HFCS appears dramatic, it must be noted that as the availability of HFCS has increased, the availability of table sugar has decreased at nearly the same rate. Although the increased availability of HFCS parallels the increasing prevalence of obesity, that correlation alone does not prove causality. Further research in this area is warranted. Some researchers have concluded that calories ingested in liquid form do not contribute to satiety. This theory is cited to support the fructose-obesity connection. However, it is difficult to separate the possible effects because there are different physiological mechanisms for digesting food versus beverages, there are different roles that foods and beverages have in the diet and there are other potential differences in cognitive cues. Other studies have shown that the body compensates for calories from beverages depending on

the degree of blood glucose rise and time between beverage consumption and test meal. The majority of studies have shown that sucrose solutions suppress food intake if the time between ingesting the solution and consuming the test meal is less than 60 minutes. Stemming from differences in the experimental designs of the various studies that have been performed, the overall data in this area are inconclusive. Because nearly identical amounts of glucose and fructose are found in sucrose and the HFCS used in beverages, similar results would be expected with the types of HFCS commonly used in soft drinks. This remains to be tested. American Dietetic Association. “Position of the American Dietetic Association: Use of Nutritive and Nonnutritive Sweeteners.” Journal of the American Dietetic Association 104, no. 2 (February 2004): 255–275. Bray, George A., S. J. Nielsen, and B. M. Popkin. “Consumption of High-Fructose Corn Syrup in Beverages May Play a Role in the Epidemic of Obesity.” American Journal of Clinical Nutrition 79, no. 4 (April 2004): 537–543. IFIC Foundation. “What Do We Know about Fructose and Obesity?” Food Insight, July/August 2004, pp. 1, 4, 5.

G ease specifically because, statistically, Mexican Americans have a higher incidence of gallbladder disease and also have greater overall adisposity and an unfavorable body fat distribution (upper-body and central adiposity) relative to non-Hispanic whites. Their findings showed central body fat distribution to be a risk factor for clinical gallbladder disease in women, independent of age, ethnic group and overall adiposity. Abdominal fat was also found to significantly raise the risk for gallstones among men in a study of 29,847 male health professionals who were followed for 11 years by Harvard researchers. Those men whose waist circumference (after adjustment for height) was at least 40.4 inches had nearly triple the risk of gallstones as those whose waist circumference was less than 34 inches. The study’s authors concluded that abdominal circumference and waist-to-hip ratio predict the risk of developing gallstones independently of body mass index.

gallstones

Stonelike masses that form in the gallbladder. Gallstones form when cholesterol crystallizes after mixing with acids from the liver. Their cause is unknown, although there is evidence of a connection between gallstones and obesity. Lean women have a better chance of avoiding gallstones; obese men and women trying to lose weight may be more likely to develop them, especially if they resort to severe forms of dieting, since fasting reduces the amount of other acids in the body that dissolve cholesterol. Those are the findings of separate studies that strengthen the association between weight and gallstones. Even a woman who is moderately overweight— 15 to 20 pounds—doubles her risk of developing gallstones, and her risk increases as she puts on more weight, according to a study by the Brigham and Women’s Hospital in Boston. A woman who is 75 to 100 pounds overweight is approximately six times more likely to develop gallstones than a woman of normal weight. Obese people trying to lose weight through extreme and often unhealthy measures such as extended FASTING or caloric restriction may be putting themselves at risk for developing gallstones, according to a University of California at San Francisco study. Thirteen of 51 obese male dieters (25.5 percent) who consumed no more than 500 calories a day for eight weeks developed cholesterol gallstones, and three had a buildup of cholesterol that leads to formation of the stones, the study showed. None of the 26 nondieting controls developed gallstones. The University of Texas Health Science Center studied 1,202 Mexican Americans and 908 nonHispanic whites from 1979 to 1982. They selected Mexican Americans for this study of the role of obesity and body fat distribution in gallbladder dis-

Bankhead, Charles D. “Plummeting Pounds Gain Blame.” Medical World News (July 1990). Haffner, Steven, et al. “Central Adiposity and Gallbladder Disease in Mexican Americans.” American Journal of Epidemiology 129 (March 1989): 587–595. Maclure, Malcolm, et al. “Weight, Diet, and the Risk of Symptomatic Gallstones in Middle-Aged Women.” New England Journal of Medicine 321, no. 9 (August 31, 1989): 563–569. Sichieri, Rosely, James Everhart, and Harold Roth. “A Prospective Study of Hospitalization with Gallstone Disease among Women: Role of Dietary Factors, Fasting Period, and Dieting.” American Journal of Public Health 81, no. 7 (July 1991): 880–884. Tsai, C. J., et al. “Prospective Study of Abdominal Adiposity and Gallstone Disease in U.S. Men.” American Journal of Clinical Nutrition 80, no. 1 (July 2004): 38–44.

155

156 gamma butyrolactone gamma

butyrolactone (GBL) A chemical included in products sold as dietary supplements, claimed to have such effects as building muscles, enhancing sexual performance and reducing stress. One of the products containing GBL, Revivarant, has been sold as a liquid in 32-ounce bottles and as Revivarant G in pill form, and promoted as a diet drug. Because the Food and Drug Administration (FDA) received reports of serious health problems—some of them life-threatening— associated with the use of products containing GBL, the FDA in January 1999 advised consumers to dispose of any products of this type in their possession and requested that sellers voluntarily withdraw the products from market.

gastric banding

See ADJUSTABLE GASTRIC BANDING.

gastric bubble

Also called the Garren-Edwards Gastric Bubble (GEGB); a procedure introduced in the mid-1980s. During the operation, a balloon device was placed inside the stomach which, when inflated, acted as “artificial food,” creating a sensation of fullness. The FDA initially approved it as a temporary adjunct to diet and behavior modification for a maximum use of 14 weeks. Subsequent complications with the device, including spontaneous deflation, passage into the small bowel with small bowel obstruction, erosion through the stomach and regain of lost weight upon removal of the bubble, led the FDA to withdraw its approval except for research purposes.

Duke Weight Loss Surgery Center. “Obesity as a Health Care Problem.” Available online. URL: http://dukehealth1.org/obesity/problem.asp. Downloaded on December 28, 2004.

gastric bypass

Specifically, a type of surgical procedure that can be used to cause significant weight loss if one has EXTREME OBESITY. The surgery reduces the body’s intake of calories because the stomach is made smaller; thus, the person feels full faster and must reduce the amount eaten at any given time. Part of the stomach and small intestines are literally bypassed (skipped over) so that fewer calories are absorbed.

According to the Association of Perioperative Registered Nurses (AORN), Edward E. Mason, M.D., professor of surgery at the University of Iowa, introduced gastric bypass in 1966. “Dr. Mason developed the procedure based on the observation that women who had undergone partial gastrectomy for peptic ulcer disease tended to remain underweight after the surgery and that it was difficult to achieve weight gain in this patient population. He applied the principles of partial gastrectomy to women who were obese and found that they lost weight. Using surgical staples, he created a partition across the upper stomach and anastomosed this pouch to the small intestine. Complications of the early gastric bypass procedures led to the further development and refinement of gastroplasty in the late 1960s and early 1970s.” Generally, the term gastric bypass is commonly used for any number of weight-reduction operations. See also ADJUSTABLE GASTRIC BANDING; BARIATRIC SURGERY; BILIOPANCREATIC DIVERSION; GASTROPLASTY; MALABSORPTIVE OPERATIONS; RESTRICTIVE OPERATIONS; ROUX-EN-Y GASTRIC BYPASS; STOMACH STAPLING; VERTICAL BANDED GASTROPLASTY. Association of Perioperative Registered Nurses. “AORN Bariatric Surgery Guideline.” AORN Journal 79, no. 5 (May 2004): 1,026–1,040.

gastric restriction procedures

Also called “restrictive operations” or “restrictive procedures.” These bariatric surgeries serve only to restrict food intake and do not interfere with the normal digestive process. To perform the surgery, doctors create a small pouch at the top of the stomach where food enters from the esophagus. Initially, the pouch holds about one ounce of food; later it expands to two to three ounces. The lower outlet of the pouch usually has a diameter of only about three-quarters of an inch. This small outlet delays the emptying of food from the pouch and causes a feeling of fullness. As a result of this surgery, most people lose the ability to eat large amounts of food at one time. After an operation, the person usually can eat only three-quarters to one cup of food without discomfort or nausea. Also, food has to be well chewed. Restrictive procedures lead to significant weight loss in almost all patients, although it is possible to “eat through” the procedure—meaning to con-

genetic factors in eating disorders 157 sume as many high calorie foods as one wants by eating or drinking slowly—and consequently regain some of the lost weight. Although restrictive operations lead to weight loss in almost all patients, they are less successful than MALABSORPTIVE OPERATIONS in achieving substantial long-term weight loss. Restrictive operations for obesity include ADJUSTABLE GASTRIC BANDING (AGB) and VERTICAL BANDED GASTROPLASTY (VBG).

gastrointestinal

surgery

for

obesity

See

BARIATRIC SURGERY.

gastroplasty

An operation in which the stomach is sectioned; the term encompasses all procedures that divide the stomach into an upper and lower gastric pouch with a stapling device but that do not divide the upper and lower gastric remnants. See also VERTICAL BANDED GASTROPLASTY.

genetic factors in eating disorders There is evidence that eating disorders run in families. Females are particularly vulnerable, and there have been a number of reports of identical twins both developing anorexia nervosa. In some cases, imitative behavior may be a factor. Comparisons of families of anorexics and bulimics with families without eating disorders have found some differences: families of bulimics report more hostile interactions; families of anorexics are as warm and supportive of their children as nondisordered families but have more marital problems. Some mental health specialists theorize that anorexic children serve as “lightning rods” for families who cannot face or resolve their problems. However, most evidence is capable of other explanations, so until more scientifically controlled studies are carried out, a genetic factor in generating eating disorders must remain speculative. One study showed that the parents of bulimic and anorexic subjects tended to have particular personality characteristics. Fathers of bulimics were more impulsive and mothers were more depressed, and both reported more dissatisfaction with family relationships than the parents of restrictor anorexics. There was also greater incidence of affective disorder reported in the families of bulimic anorexics.

Walsh noted, “The available data strongly suggest that the genetic influences on susceptibility (to eating disorders) reside in multiple genes, and presumably reflect an interaction between multiple genes and the environment. The technical challenges to identifying such polygenic patterns of inheritance are impressive, as witnessed by the difficulty of identifying genes which increase the risk for illnesses such as schizophrenia and manicdepressive illness. It is likely that what is inherited is not a disorder, but risk factors for the development of a disorder, such as, perhaps, a tendency toward obsessionality. Thus, even if a gene or genes is identified, it will probably not be a gene for an eating disorder but a gene for a related factor. These notions are consistent with the findings of the family and twin studies which typically observe more robust patterns of transmission for broadly defined eating disturbances than for the full blown diagnostic categories.” Researchers at the University of Pittsburgh School of Medicine, led by Walter H. Kaye, M.D., and Bernie Devlin, Ph.D., have undertaken the first government-funded genetic study of anorexia nervosa. The study, funded by the National Institute of Mental Health, is a five-year grant with more than $10 million in funding. It brings together 11 groups of researchers from North America and Europe (10 clinical centers and one to analyze data) to find regions of the human genome that contain genes that influence risk for anorexia. To find these regions, the researchers are recruiting families with two or more members, mainly siblings, who have or had anorexia nervosa, and analyzing the DNA from the participants. The research will build on recent genetic studies supported by the Price Foundation, a private European foundation that has already pointed to four regions of the genome to look for genes affecting susceptibility to anorexia. Bulik, Cynthia, et al. “Heritability of Binge-Eating and Broadly Defined Bulimia Nervosa.” Biological Psychiatry 44, no. 12 (December 12, 1998): 1,208–1,209. Kaye, Walter H., Bernie Devlin, et al. “Genetic Analysis of Bulimia Nervosa: Methods and Sample Description.” International Journal of Eating Disorders 35, no. 4 (May 2004): 556–570.

158 genetic factors in obesity Lilenfeld, L. R., et al. “A Controlled Family Study of Anorexia Nervosa and Bulimia Nervosa: Psychiatric Disorders in First-degree Relatives and Effects of Proband Comorbidity,” Archives of General Psychiatry 55, no. 7 (1998): 603–610. Schepank, H. “Genetic Determinants in Anorexia Nervosa: Results of Twin Studies.” Psychosomatic Medicine Psychoanalysis 37, no. 3 (1991): 265–281. Strober, Michael. “Family-Genetic Studies of Eating Disorders.” Journal of Clinical Psychiatry 52, suppl. 10 (October 1991): 9–12. Walsh, B. Timothy. “The Future of Research on Eating Disorders.” Appetite 42, no. 1 (February 2004): 5–10. Woodside, D. B., et al. “Specificity of Eating Disorders Diagnoses in Families of Probands with Anorexia Nervosa and Bulimia Nervosa.” Comprehensive Psychiatry 39, no. 5 (September–October 1998): 261–264.

genetic factors in obesity

Obesity often follows family lines, and evidence from twin studies and other family studies, although not completely consistent, have for some time implied inheritance. A recent St. Louis University study examined the genetics of adult-onset weight change in middle-aged male-male twins controlling for weight in early adulthood, lifetime history of tobacco use and alcohol dependence, and aimed to estimate the proportion of genetic factors that influence weight change between early adulthood and middle age in white middle-class males. The resultant data indicated that more than half of the change in body mass index (BMI) from early adulthood to middle age remains heritable. No shared environmental factors were identified, thus the remainder of the variance was accounted for by nonshared, or unique, environmental factors and error. Marti et al. concluded that both genes and everyday life environmental factors such as cultural- and social-mediated food intake and reduced domestic and living work activities are involved in the obesity pandemia. The occurrence of gene x gene and gene x environmental factors interactions makes it more difficult to interpret the specific roles of genetics and lifestyle in obesity risk. Some experts have downplayed the role of genetics in obesity simply because of the current “pandemic,” arguing that people have the same genes as their forebears, who did not have today’s prevalence of obesity. But Ellis and Harman sought

to determine if genetic factors might be contributing to the increases in the proportions of North Americans who are obese and overweight. “The BMI for a large sample of two generations of United States and Canadian subjects was correlated with family fertility indicators. Small but highly significant positive correlations were found between the BMIs of family members and their reproduction rates, especially in the case of women. For instance, mothers in the sample (most of whom were born in the 1940s and 50s) who were in the normal or below normal range had an average of 4.3 siblings and 3.2 children, compared with 4.8 siblings and 3.5 children for mothers who were overweight or obese. When combined with evidence from twin and adoption studies indicating that genes make substantial contributions to obesity, this study suggests that recent increases in obesity are partially the result of overweight and obese women having more children than is true for average and underweight women. It is speculated that improvements in medical treatments for conditions associated with obesity—particularly diabetes and heart disease—are making it possible for overweight women to live longer and to be more fertile than was true historically.” Other recent findings and reports that have indicated genetic factors play at least a small role in obesity: • A Stanford University study found that having overweight parents is the biggest risk factor for childhood obesity. Nearly half—48 percent—of children with overweight parents became overweight themselves, compared to only 13 percent of children who had parents of normal weight. • More than 200 gene markers for obesity have been identified. • Evidence from twin, adoption, and family studies strongly suggests that biological relatives exhibit similarities in the maintenance of body weight. Some children seem to be genetically immune to the effects of overeating. Others continue to gain weight no matter how hard they try to shed the extra pounds. Some experts point out that these situations are the minority and occur only “under the right environmental or lifestyle conditions.”

ghrelin 159 Dr. Jeffrey Friedman, a molecular geneticist at the Rockefeller University in New York, told Time magazine, “There are genes in the population that predispose to obesity. Obviously, there’s an environmental contribution, but no one questions that genes are involved.” Ellis, L., and D. Haman. “Population Increases in Obesity Appear to Be Partly Due to Genetics.” Journal of Biosocial Science 36, no. 5 (September 2004): 547–559. Kluger, Jeffrey, Christine Gorman, and Alice Park. “Why We Eat.” Time 163, no. 23 (June 7, 2004): 72–76. Marti, A., et al. “Genes, Lifestyles and Obesity.” International Journal of Obesity and Related Metabolic Disorders 28, suppl. 3 (November 2004): S29–36. Romeis, J. C., et al. “The Genetics of Middle-Age Spread in Middle-Class Males.” Twin Research 7, no. 6 (December 2004): 596–602.

geophagia A condition in which the patient eats chalk or earth or clay; a type of PICA (the desire to eat inedible substances). After surveying the literature, Isolde Prince concluded that in many cultures geophagia is a common, acceptable, benign practice without psychological implications. In fact, geophagia occurring among nutritionally deprived populations is looked at differently than pica in the Western world, where nutrition is much more likely to be at a satisfactory level. Although still subject to considerable debate, in nutritionally deprived populations geophagia probably fulfills nutritional needs for elements important for growth and development. These nutritional factors are particularly important during childhood and pregnancy. The main debatable point is whether clay eating provides elements such as iron, zinc and calcium and is a significant treatment for anemia, or whether clays remove these elements from food and give rise to anemia. An important paradox in the geophagia literature is that even though populations consume earth in significant quantities with impunity, for some individuals earth eating is pathological and even lethal. It has been proposed that this paradox can be resolved by attributing the malignant form to the co-occurrence of sickle-cell anemia. In this interpretation, the malignant cachexia africana and perhaps pobough lang are not caused by earth eating, but earth eating is an attempt at cure by those

who are suffering from a severe, often lethal, hereditary anemia. See also KAOLIN. Prince, Isolde. “Pica and Geophagia in Cross-Cultural Perspective.” Transcultural Psychiatric Research Review 26, no. 3 (1989): 167–197. Simon, S. L. “Soil Ingestion by Humans: A Review of History, Data, and Etiology.” Health Physics 74, no. 6 (June 1998): 647–672.

ghrelin A hormone in the digestive system that regulates appetite. Ghrelin is produced in the stomach and upper intestine in the absence of food in the digestive system and stimulates appetite just before meals. Although it is primarily secreted by the stomach, ghrelin is also produced in the brain. In recent studies, increased levels of ghrelin were found in obese individuals following diet-induced weight loss—with a resulting increase in appetite— providing a potential explanation for the difficulty people experience in maintaining weight loss. Also, researchers have recently discovered that ghrelin levels are suppressed by some forms of BARIATRIC SURGERY. Blocking the action of ghrelin is thus a potentially attractive target for drug development according to the National Institutes of Health Obesity Task Force. Because ghrelin is made primarily in the stomach, and because there are receptors (“docking sites”) for ghrelin in the brain, this hormone was thought to be a signal from the gut to the brain to indicate when it was time to start a meal. Taking this information as a potential clue that there may be another pathway for ghrelin’s actions, a team of scientists has further explored the brain’s production of ghrelin. Many cells in the brain have been shown to be involved in energy balance. However, by studying the brains of rodents, the scientists discovered that ghrelin is made by a group of brain cells not previously known to influence energy balance. Intriguingly, these ghrelin-producing cells are located adjacent to brain cells that produce a protein called NPY, which functions to increase appetite— and which has also been known to help mediate the effects of ghrelin. The scientists also found that ghrelin can stimulate the activity of NPY-producing cells. Based on these results and several other experi-

160 globesity ments, the scientists proposed that the brain’s own indigenous source of ghrelin may activate the production of NPY by neighboring brain cells, thus leading to increased appetite. By uncovering what may be a previously unknown brain regulatory circuit, these studies provide further insights into the body’s complex regulation of energy balance. National Institutes of Health. A Report of the NIH Obesity Research Task Force: Strategic Plan for NIH Obesity Research, August 2004. Available online. URL: http://www.obesityresearch.nih.gov/about/Obesity_ EntireDocument.pdf. NIDDK. Recent Advances & Emerging Opportunities: Obesity, 2004. Available online. URL: http://www.niddk.nih.gov/ federal/advances/2004/obesity.pdf.

globesity

A new word coined by the World Health Organization (WHO) to describe the worldwide “epidemic” of obesity and overweight. WHO estimates that more than 1 billion adults worldwide are overweight, defined as a body mass index (BMI) greater than 25; 300 million are considered obese, with a BMI greater than 30—up from 200 million in 1995. According to WHO, current obesity levels range from below 5 percent in China, Japan and certain African nations, to more than 75 percent in urban Samoa. But even in relatively low-prevalence countries like China, rates are almost 20 percent in some cities. Childhood obesity is already epidemic in some areas and on the rise in others. An estimated 17.6 million children under age five are estimated to be overweight worldwide. The problem increasingly extends into the developing world; for example, in Thailand the prevalence of obesity in five-to-12year-old children rose from 12.2 percent to 15.6 percent in just two years. Obesity accounts for 2–6 percent of total health care costs in several developed countries; some estimates put the figure as high as 7 percent. The true costs are undoubtedly much greater as not all obesity-related conditions are included in the calculations.

glycemic index (GI) A lab tool developed in 1981 to help people (especially diabetics and athletes) maintain stable blood sugar levels. It

describes the degree to which blood glucose rises after a meal. Refined, starchy foods, like bread, cereal and potatoes and concentrated sugars have a high glycemic index, whereas most vegetables, legumes and fruits have a low GI. Studies have shown that after a high GI index meal, blood glucose and insulin levels generally rose higher than after the low-GI meal. A few hours after the high GI meal, blood glucose and fatty acids decreased to relatively low levels and epinephrine rose markedly. These metabolic changes are associated with increased hunger, and subjects are found to eat 80 percent more calories after the high GI meal versus the low GI meal. Thus, a low GI diet may help decrease hunger and promote weight loss— which serves as the main theory behind the effectiveness of LOW-CARB DIETS. Although some experts champion the glycemic index as a way of judging which foods may be fueling the epidemics of obesity and diabetes, others disagree. Spake writes: The problem with this theory, says Xavier Pi Sunyer, director of the New York Obesity Research Center, is that carbohydrates have not been associated with a high frequency of diabetes. “Asians traditionally ate a high-carbohydrate diet with a high glycemic index—lots of rice, low in protein and fat, and they had low rates of diabetes, heart disease, and obesity,” he says. Others agree that the evidence is mixed at best. Says nutritionist James Kenney of the Pritikin Longevity Center: “The No. 1 reason for diabetes is overweight. People who have lost weight and kept it off do not eat a low glycemic index diet—they eat a low-fat diet and exercise a lot.” Whether the GI concept will play a major part in reversing obesity is unclear.

The International Food Information Council (IFIC) cautions that although the GI is often used as a research tool, it may be difficult to use it as a measure on which to base dietary recommendations for the general population, because of its wide variability depending on the ripeness of a food, the degree to which a food is cooked, as well as other factors: “Ranking and eating foods according to their glycemic index has a number of problems. First, a person’s blood sugar response to eating a food can vary from day to day and also according to how the

government role in combating obesity 161 food was prepared. Even something as simple as ripeness in the case of bananas can affect the glycemic index (the riper the banana, the higher its glycemic index). Second, once a food is combined with other foods (such as cereal and milk or peanut butter and bread), the glycemic index of the meal will be very different from that of either food alone. Finally, the amount of food eaten to measure the glycemic index is often different from the amount of food eaten in a typical serving. Creating a diet based solely on glycemic index can result in an eating plan that may exclude some nutrient-rich foods, in addition to being less palatable overall.” IFIC Foundation. “Questions and Answers about Glycemic Index.” Available online. URL: http://ific.org/ publications/qa/glycemicqa.cfm. Posted September 2002. Spake, Amanda. “The Truth on Foods and Fats.” U.S. News & World Report, July 12, 2004, pp. 124, 126.

Goldfarb Fear of Fat Scale (GFFS) A 10-item assessment device for use with bulimic clients to measure a person’s fear of becoming fat. Answers are rated on a four-point scale, ranging from “very true” to “very untrue.” Higher scores indicate a greater fear of fat. GFFS significantly differentiates between bulimics, repeat dieters and nondieting women, according to the authors. Thus, they conclude, “The GFFS may be utilized clinically as a diagnostic tool and indicator of change, which may assist in the early identification of bulimic individuals.” Goldfarb, L. A., E. M. Dykens, and M. Gerrard. “The Goldfarb Fear of Fat Scale.” Journal of Personality Assessment 49, no. 3 (June 1985): 329–332.

gonads obesity Obesity caused by hypogonadism (abnormally low functioning of the gonads, with consequences for growth and development); it is marked by a concentration of fat tissue in the pelvic and breast regions. Other features may include poor beard growth in men, decreased growth of pubic hair and lack of development of the genitalia. Many obese females with this disease have mild hirsutism, irregular menses or AMENORRHEA. Young obese girls sometimes have

premature or early menarche (first menstrual period in puberty).

government role in combating obesity

As obesity-related health costs soar, government policy makers have explored ways in which both federal and state legislation or programs might help provide solutions. In September 2004 Ed Thompson, M.D., chief of public health practice for the Centers for Disease Control and Prevention, Department of Health and Human Services (HHS), addressed a congressional subcommittee on the role of government in combating the obesity epidemic. Among his comments: Overweight and obesity represent a major longterm public health crisis: If it is not reversed, the gains in life expectancy and quality of life seen in recent decades will erode, and more health-related costs will burden the Nation. Eating a healthy diet and increasing physical activity reduces weight which is shown to reduce the risk for many chronic diseases. Often small changes—such as physical activity for 30 minutes a day or consuming 100 fewer calories a day—can result in large health benefits. Individuals must have the right information to empower their lifestyle choices. The government can support individual action by doing the following:

• Providing leadership; • Establishing a framework for understanding issues related to overweight and obesity; • Coalescing and coordinating efforts to address the issues; • Developing clear, coherent and effective health messages to ensure that consumers have accurate and adequate information to make informed decisions about improving their health; • Identifying and addressing research gaps; • Synthesizing research findings to identify effective policies and programs; • Bringing diverse stakeholders together to address the epidemic (e.g., food industry, consumer organizations and the medical community); • Coordinating private/public campaigns; • Providing training and education materials to address the epidemic; and,

162 group therapy • Working to improve the health-promoting nature of the environments in which individuals make their decisions. Current initiatives include programs in education, communication and outreach, intervention, diet and nutrition, physical activity and fitness, disease surveillance, research, clinical preventive services and therapeutics, and policy and web-based tools. These programs target a variety of populations including infants and breastfeeding mothers, children and adolescents, women, minorities, the elderly, the disabled, rural, and the general population. • Monitoring the problem and programs to address the problem so that we can better understand its causes, consequences, and how it changes over time; • Developing and disseminating tools to help schools and community-based organizations implement effective policies and programs; and • Helping national, state, and local agencies and organizations implement effective programs.

Several states have passed or are in the process of passing new nutritional requirements for vendingmachine food in schools or introducing legislation to ban the sale of vending-machine food during school hours in an effort to combat childhood obesity. And the National Institute of Medicine has called on state and local governments to establish zoning requirements that encourage the construction of more sidewalks, bike paths and recreational areas. Hurst, Marianne. “Momentum Builds to Confront Child Obesity.” Education Week 24, no. 7 (October 13, 2004): 5.

group therapy

A form of psychotherapy in which discussion takes place among a therapist and a number of patients rather than between a therapist and a single individual. Studies show that group therapy can be as effective as individual therapy and, in some cases, even more effective. In some cases, the two are used in combination. Typically, a therapy group comprises six to eight patients and a therapist leader, who guides the discussion and provides professional insight when needed. Since 1980, group therapy has become a common form of treatment for both anorexia and bulimia. Group treatment for support groups provide an arena for demystifying the eating disorder, diminishing feelings of isolation and secrecy, fostering realistic goal setting, sharing successful tech-

nique, expressing feelings and obtaining feedback. groups are most effective in the treatment of bulimia. They may be open-ended or have a time limit, membership may be closed or participants may join at any time and the duration and frequency of sessions may vary. The focus is on individual dynamics and group process. Belgian researchers studied the progress of 53 eating-disordered patients during inpatient group treatment by comparing the changes in perception of each patient by the patients themselves, the other group members and the therapeutic team. Remarkable differences were found among these judgments. Patients tend to deny problems or to evaluate their progress rather optimistically, while fellow patients and staff members are all more skeptical in their evaluations. The research team concluded that the evaluation procedure may have more value as a therapeutic tool than as an assessment method. Although group therapy is now frequently used as a component of eating-disorders treatments, subsequent outcome studies indicate that its effectiveness remains problematic. One school of thought holds that group therapy is a good model for understanding female development issues. The theory behind this is that women are generally socialized to function cooperatively in groups and that therefore the social dynamics of group therapy mimic or parallel the processes of female socialization. Because the majority of eating-disorder patients are female, it is possible that the success of group therapy for such patients may be related to this. A setting such as that found in group therapy or a self-help group provides eating-disordered women a social format in which they can express opinions differing from the social consensus yet remain a part of the group (and the larger culture). As group members feel increasingly confident expressing thoughts and concerns that do not support thinness as an ideal, they are practicing skills of autonomy within a framework of social relationships and minimizing their fear of rejection and isolation. Many issues can thus be explored in group sessions, from “what if” questions to actual experiences (“What happened to you when you quit purging?”). Group therapy can also help an individual to initiate serious treatment. Many patients have a difficult time beginning individual psyPSYCHOTHERAPY

Gull, Sir William Withey 163 chotherapy but may be less defensive and resistant to recovery in a group setting. A patient may accept confrontation from peers in a group more readily and in a more positive light than from a therapist. Group therapy does not, however, represent a panacea. Many eating-disorder patients will deny that they have problems or will deny any feelings about their condition. This can keep them from developing the openness toward the group that is essential to allow the group to function fully. The group format helps decrease this resistance to trust, but there is no guarantee of success. In a review of the literature on the outcome of group therapy for bulimia nervosa, McKisack and Waller found no obvious advantage attached to any single therapeutic orientation or to the gender of therapists. However, they determined that longer, more intensively scheduled groups realized greater success, as did the addition of other treatment components, such as individual work. Goodner, Sherry. “Group Therapy for Eating Disorders.” BASH Magazine (1987). McKisack, C., and G. Waller. “Factors Influencing the Outcome of Group Psychotherapy for Bulimia Nervosa.” International Journal of Eating Disorders 22, no. 1 (July 1997): 1–13. Piazza, Eugene U., and Catherine Steiner-Adair. “Recent Trends in Group Therapy in Anorexia Nervosa and Bulimia.” In Eating Disorders: Effective Care and Treatment, edited by Félix E. F. Larocca. St. Louis: Ishiyaku EuroAmerica, 1986.

growth hormone in obesity

Growth hormone is a substance secreted in the anterior lobe of the pituitary gland that directly influences protein, carbohydrate and fat METABOLISM and controls the rate of skeletal and visceral growth. Compared with normal-weight subjects, obese subjects have impaired growth hormone secretion. Their plasma growth hormone responses to provocative stimuli, such as insulin-induced hypoglycemia, L-dopa, arginine infusion, glucagen, exercise, opioid administration and sleep, are blunted. The deranged growth hormone regulation is related to obesity itself, and in obese subjects who lost weight, growth hormone

secretion becomes normal promptly. Conversely, overfed lean subjects have a weight-related impairment in growth hormone secretion. Production of growth hormone is modulated by many factors, including stress, exercise, nutrition, sleep and growth hormone itself. One of its primary controllers is GHRELIN. Cordido, Fernando, Felipe F. Casanueva, and Carlos Dieguez. “Cholinergic Receptor Activation by Pyridostigmine Restores Growth Hormone (GH) Responsiveness to GH-Releasing Hormone Administration in Obese Subjects.” Journal of Clinical Endocrinology and Metabolism 68, no. 2 (February 1989). Bowen, R. A. “Growth Hormone.” Colorado State University. Available online. URL: http://arbl.cvmbs. colostate.edu/hbooks/pathphys/endocrine/hypopit/ gh.html. Updated on April 14, 2003.

guided image therapy A treatment that uses visualization techniques to relax the patient and strengthen the patient’s connection with his or her inner consciousness. The theory behind it is that once relaxed and comforted, the patient will have less stress, which will enhance the healing process. In a study of 50 bulimia nervosa patients, guided image treatment substantially reduced bingeing and purging episodes. Guided imagery also demonstrated improvement on measures of attitudes concerning eating, dieting and body weight. Esplen, M. J., et al. “A Randomized Controlled Trial of Guided Imagery in Bulimia Nervosa.” Psychological Medicine 28, no. 6 (November 1998): 1,347–1,357.

Gull, Sir William Withey (1816–1890) An eminent London physician of the 19th century who was one of the first to use the term anorexia nervosa. He worked and lived for many years at Guy’s Hospital in London and treated Queen Victoria and her family. Gull described anorexia nervosa as a disease distinct from starvation among the insane and unrelated to organic diseases such as tuberculosis, diabetes or cancer. Most important, he observed that this disorder specifically affected young women between the ages of 16 and 23.

H Hawaiian Natives and obesity Being overweight is a problem for Native Hawaiians, who are among the most obese people in the world. The Waianae Coast Comprehensive Health Center tracked obesity among its 24,000 patients and found that more than 55 percent of adults between ages 20 and 59 are obese. Native Hawaiians have the highest prevalence rate of overweight and obesity (69.4 percent), a rate that is 38 percent higher than that for the total state population (50.2 percent). The study also found that the average Native Hawaiian and Samoan patient is morbidly obese and in serious risk of major medical problems. But Native Hawaiians have not always been obese. Wergowske and Blanchette explain, “The reports of Captain Cook’s first contact with Native Hawaiians described strong, healthy-looking, muscular natives. On subsequent voyages, the population had declined and the natives looked sicker. Obesity was rare. Today, obesity is a common problem, to the extent that it is considered the norm for both men and women.” Experts place much of the blame for today’s obesity problem on the move away from native foods. Tavares and Timm explain, “For hundreds of years, Hawaiians maintained a fairly consistent diet that was high in weight, low in calories and fat when compared to a typical American meal. A switch to a more westernized diet has decreased food weight, which leads to less volume and distention of stomach, therefore decreasing satiety. Hawaiians therefore ate a higher volume of food (which contained higher calories) than their ancestors. Genes influence how the body burns calories for energy or stores of fat. Hawaiian genes, having been exposed to a fairly stable diet over hundreds of years, were not ‘equipped’ to deal with this dramatic increase in caloric intake, predisposing them to obesity.” Illustrating how food “weight” as well as calories and fat differ between the Hawaiian and American diets, the authors break down a typical meal for each:

TYPICAL HAWAIIAN MEAL

Taro Poi Sweet potato Taro greens (cooked) Mountain apple Fish Seaweed Total

Weight (oz.)

Calories

Fat (gm)

4 8 8 7 5 2 1 35

161 151 314 42 81 75 13 837

0.12 0.3 1.2 0.5 0.5 0.7 0.2 3.5

TYPICAL AMERICAN MEAL

Cheeseburger French fries Total

Weight (oz.)

Calories

8.5 4.3 12.8

677 400 1077

Fat (gm)

40 22 62

A local doctor has created the “Hawaiian Diet,” encouraging the state’s natives to return to their ancestors’ traditional, and more healthful, eating habits. Tavares, Damien, III, and Robert Timm III. “Community Cultural Rounds Legacy Project: Hawaiians Dealing with Obesity.” Ho’olokahi Program: Waianae Coast Comprehensive Health Center, April 15, 2003. Wergowske, Gilbert, and Patricia Lanoie Blanchette. “Health and Health Care of Elders from Native Hawaiian and Other Pacific Islander Backgrounds.” Stanford University. Available online. URL: http://www.stan ford.edu/group/ethnoger/nativehawaiian.html. Downloaded on January 2, 2005.

HCG A hormone (human chorionic gonadotropin) extracted from the urine of pregnant women, once used in treating obesity. It was typically administered daily by injection. 165

166 HEED Foundation The rationale for this treatment was that weight change during pregnancy is likely to be long lasting; therefore, by mimicking pregnancy and simultaneously inducing weight loss, a permanent change may be accomplished. In the mid-1930s, injections of HCG did seem to help reduce accumulations of fat on hips, buttocks and thighs that make boys with Froelich’s syndrome look like girls. The hormone was described as seeming to “melt away” this fat. With the “melting” fat as a major source of nourishment, the boys were able to survive on only 500 calories a day. Thus, although HCG alone did not reduce weight, it did make drastic calorie curtailment possible. Follow-up studies, however, have not demonstrated that HCG patients stay thin any longer than patients in other programs. Because there had been no scientifically adequate controlled clinical studies to establish the safety and effectiveness of HCG in the treatment of obesity, the U.S. Food and Drug Administration (FDA) in 1974 began requiring that HCG carry a warning label: “There is no substantial evidence that it increases weight loss beyond that resulting from caloric restriction, that it causes a more attractive or ‘normal’ distribution of fat, or that it decreases the hunger and discomfort associated with calorie-restricted diets.” In 1975 the FDA declared HCG ineffective. Clinicians who agree with the FDA’s findings caution that in addition to patients’ having to suffer through repeated injections of HCG, any benefits appearing to come from it are actually attributable to the strict low-calorie, high-protein diet (and diuretic pills) usually prescribed along with the shots. This treatment is no longer in use by the medical profession, although Belluscio and Ripamonte suggest that oral administration of HCG via a VERY LOW CALORIE diet may be useful for obesity treatment. Belluscio, Daniel O., and Leonor E. Ripamonte. “Utility of an Oral Formulation of HCG for Obesity Treatment: A Double-Blind Study.” Indexmedico. Available online. URL: http://indexmedico.com/obesity/hcg.htm. Downloaded on January 25, 2005.

HEED Foundation

HEED (Helping End Eating Disorders) is a not-for-profit organization started in 1996. The foundation“s mission is to promote awareness and prevention of eating disorders, as well as to treat those who are already affected. Programs and services offered include free weekly support groups,

a help line, information and treatment referrals, speakers for schools and community groups, educational workshops, lecture series and an annual eating disorder symposium. Headquartered in Plainview, New York, HEED Foundation also has offices in Manhattan, Brooklyn and upstate New York. See also APPENDIX III, SOURCES OF INFORMATION.

high fructose corn syrup (HFCS)

The primary industrial sweetener found in many prepared foods. It is six times sweeter and cheaper to use than cane sugar. See also FRUCTOSE AS A CONTRIBUTOR TO OBESITY.

Hispanics/Latinos and eating disorders

The terms Hispanic or Latino encompass diverse groups who immigrated to the United States, with Hispanic often referring to people from the Caribbean region and South America and Latino to those from Mexico and South America. However, the terms are often used interchangeably and those geographic definitions are not absolute. Among the largest U.S. Hispanic/Latino populations are Mexican Americans, Puerto Ricans and Cuban Americans. The Hispanic population is growing faster than any other ethnic group in this country; it has more than doubled in the past 20 years. It is estimated that Hispanics will be the largest minority group in the United States by the year 2020. Hispanics are predominantly young, with more than one in three being under the age of 18. Several studies have found eating disorders in the United States to be experienced about the same among Hispanics and non-Hispanic whites. The Office on Women’s Health (OWH) in the Department of Health and Human Services (HHS) cautions that because studies typically do not include ethnically diverse populations, cases of eating disorders among Hispanics are often underreported. Although research on eating disorders among Latina girls is limited, recent studies indicate that Latina girls are expressing the same concerns about body weight as non-Hispanic white girls and that many are engaging in disordered eating behaviors, including dieting and purging, to lose weight. Studies show that Latinas express the same or greater concerns about their body shape and weight as white females. In a study of more than 900 middle-school girls in northern California, Hispanic girls reported levels of body dissatisfaction higher

Hispanics/Latinos and obesity 167 than any other group. Among the leanest 25 percent of girls, Hispanic girls reported significantly more dissatisfaction than white girls. Media targeting Latinas, including Hispanic television and magazines, are increasingly reinforcing the ideal of thinness as beauty. For example, although Mexicans have traditionally preferred a larger body size for women, many Mexican American women are idealizing and desiring a thinner figure than the one they currently have. For all racial and ethnic groups, body dissatisfaction is strongly linked with eating disorders. Some transcultural anthropology and psychiatry studies have shown eating disorders to have a very important cultural factor affecting Hispanics, and to be linked to migration stress. Beitman et al. write: Silber noted that the Hispanic females had high personal ideals. Being raised in a more traditional Latin culture, they may have had difficulty when expected to assimilate into the American culture, where thinness and academic achievement were highly valued. In addition, they had to contend with contrasting sexual attitudes, which may have exacerbated their own conflicts. Development of anorexia nervosa, with its regression to a prepubertal psychological structure, served as a maladaptive attempt to cope with issues of identity and cultural and sexual conflict.

The OWH also notes that acculturation can have an impact on body size preference and body image. Heaviness is seen as a sign of affluence and success in some traditional Hispanic cultures; but as Hispanics acculturate to the standards of beauty in this country, they may seek to achieve thinner bodies. Hispanic women born in the U.S. are more likely to prefer a smaller body size. Those who immigrate after age 17 are less likely to desire a thin body. High levels of acculturation are associated not only with a drive for thinness but also with less healthy eating behaviors. As a result, second and third generation Hispanic adolescents are more likely to be obese than their first generation peers.

Some experts have expressed concern that Hispanic girls, because of their greater prevalence and degree of overweight, may be at greater risk than Caucasian girls for the development of bulimia nervosa and binge eating disorder. According to the OWH, Latina girls seem to be particularly at risk for dieting and purging. Latinas have been found to use laxatives more frequently than girls from other

racial groups. Vander Wal writes, “Future research should incorporate instruments more sensitive to disorders of overeating and investigate how eating disorder development differs among girls from various racial and ethnic backgrounds.” Beitman, Bernard D., Barton J. Blinder, Michael E. Thase, and Debra L. Safer. Integrating Psychotherapy and Pharmacotherapy: Dissolving the Mind-Brain Barrier. New York: W. W. Norton, 2003. Silber, T. J. “Anorexia Nervosa in Blacks and Hispanics.” International Journal of Eating Disorders 5, no. 1 (July 1986): 121–128. Vander Wal, J. S. “Eating and Body Image Concerns among Average-weight and Obese African American and Hispanic Girls.” Eating Behaviors 5, no. 2 (May 2004): 181–187.

Hispanics/Latinos and obesity Hispanics, as reported by numerous studies, generally have higher BODY MASS INDEX (BMI) than non-Hispanic whites. According to the National Institutes of Health, the age-adjusted prevalence of combined overweight and obesity (BMI greater than 25) in racial/ethnic minorities—especially minority women—is generally higher than in whites in the United States: • Non-Hispanic black women: 77.3% • Mexican American women: 71.9% • Non-Hispanic white women: 57.3% • Non-Hispanic black men: 60.7% • Mexican American men: 74.7% • Non-Hispanic white men: 67.4% As the prevalence of childhood overweight has increased dramatically in the United States in recent years, the prevalence of overweight among Hispanic children has increased disproportionately compared with non-Hispanic whites. Recent data from a nationally representative sample of U.S. children aged four to 12 years reported that within a 12-year period, the prevalence of overweight increased to 21.8 percent among Hispanics and 12.3 percent among non-Hispanic whites. In a 2004 study of Arkansas public school students, 46 percent of Hispanic students were considered overweight or at risk, compared to 37 percent of Caucasian youths. In their attempt to describe the trends in overweight and obesity occurring in the Mexican-

168 homosexuality and eating disorders American population in the United States, Flegal et al. found that in 1999–2002, 73 percent of Mexican-American adults were overweight and 33 percent were obese. Obesity increased in the periods 1988–94 and 1999–2002, from 24 percent to 27 percent for men and from 35 percent to 38 percent for women. Increases were also seen for children and adolescents. “The Mexican-American population in the United States, both children and adults, is showing trends in overweight and obesity over time that are similar to those seen in other segments of the U.S. population and indeed in many countries.” The Office on Women’s Health (OWH) in the Department of Health and Human Services (HHS) reports that Hispanic children consume the most fast food of all ethnic groups. Research has shown that high-fat diets greatly contribute to the high rates of obesity among low-income Hispanic families. Obesity is also a risk factor for binge eating. In a study of 31 middle schools and high schools in Minnesota, binge eating was more prevalent among Hispanic girls than among those of other cultural backgrounds. Flegal, K. M., C. L. Ogden, and M. D. Carroll. “Prevalence and Trends in Overweight in Mexican-American Adults and Children.” Nutrition Reviews 62, no. 7, pt. 2 (July 2004): S144–148.

homosexuality and eating disorders When psychiatrist Joel Yager of the University of California, Los Angeles found that nearly 50 percent of the men who enter treatment for anorexia nervosa describe themselves as homosexual, he questioned whether there might be a link between homosexuality and anorexia or bulimia. In a comparison study he conducted of homosexual with primarily heterosexual males, the gay men were more fearful of being fat and were more likely to feel fat despite others’ perceptions. They also reported a higher incidence of BINGE EATING and PURGING. The homosexual men also scored higher on the EATING DISORDERS INVENTORY scales for drive for thinness, INTEROCEPTIVE DISTURBANCE, BULIMIA, body dissatisfaction, maturity fears and ineffectiveness. Yager also found that gay men had a different body image preference. While heterosexual men preferred a more muscular or “macho” physique, the gay men Yager studied preferred being slender.

Yager speculated that homosexual men may be more likely to develop eating disorders because of this concern with slim bodies, a traditionally feminine attitude, at least in recent history. A 1996 study of 203 lesbians by the Rutgers University Eating Disorders Clinic to assess bulimia nervosa was similar to that of heterosexual women, but binge-eating disorder was more frequent. Lesbians were not significantly different from heterosexual women in attitudes concerning weight, appearance or dieting. Then, in 1997, a Massachusetts General Hospital study concluded that while most characteristics of males and females with eating disorders are similar, homosexuality/bisexuality appears to be a specific risk factor for males, especially for those who develop bulimia nervosa. The authors said that future research on the link between sexual orientation and eating disorders would help guide prevention and treatment strategies. In her interview with the authors of Making Weight: Men’s Conflicts with Food, Weight, Shape and Appearance (Gürze, 2000), Goode wrote: Some studies have suggested that homosexuals are over represented among men with anorexia and bulimia who do seek treatment, perhaps because they are more willing to identify themselves as having an eating disorder or because gay male culture puts a premium on trimness and physical appearance. “There is nothing about gayness itself that increases eating disorders,” Dr. (Arnold) Andersen said, “but there is a lot in the fact that the community has highly stereotyped norms for what is attractive.” Other researchers have found no relationship between homosexuality and eating disorders, and the association remains debated.

Four years later, authors were reporting the same findings. For example, Ray stated, “The relationship between sexual identity and eating disorders remains unclear; however, several studies posit that male homosexuals are at increased risk for developing eating disorders.” He mentioned studies that found a significantly higher prevalence of homosexuality among anorexic and bulimic males than that of the general male population. In one of those studies, Russell and Keel found that homosexual men had more pathological scores on the Beck Depression Inventory (BDI), Rosenberg Self-Esteem Scale (RSE), Bulimia Test-Revised

hunger hormones 169 (BULIT-R), Eating Attitudes Test (EAT-26) and Body Shape Questionnaire (BSQ). They concluded that future research may benefit from exploring aspects of homosexuality that may contribute specifically to risk for disordered eating in men. But Austrian researchers concluded that both gay and straight men have unrealistic expectations when it comes to their bodies. Hausmann et al. found that gay men did not differ significantly from heterosexual men on measures of body image. “These unexpected findings cast doubt on the widespread belief that gay men experience greater bodyimage dissatisfaction than heterosexual men. If our findings are valid, it follows that some previous studies of body image in gay men may possibly have been influenced by selection bias.” Carlat, D. J., et al. “Eating Disorders in Males: A Report on 135 Patients.” American Journal of Psychiatry 154 (August 1997). Goode, Erica. “Thinner: The Male Battle with Anorexia.” New York Times, June 25, 2000. Available online. URL: http://www.gurze.net/site12_5_00/nytimes.htm. Hausmann, Armand, et al. “Body-Image Dissatisfaction in Gay Versus Heterosexual Men: Is There Really a Difference?” Journal of Clinical Psychiatry 65, no. 11 (November 2004): 1,555–1,558. Hefferman, K. “Eating Disorders and Weight Concern Among Lesbians.” International Journal of Eating Disorders 19 (March 1996). Ray, Shannon, L. “Eating Disorders in Adolescent Males.” Professional School Counseling October 1, 2004. Russell, C. J., and P. K. Keel. “Homosexuality as a Specific Risk Factor for Eating Disorders in Men.” International Journal of Eating Disorders 31, no. 3 (April 2002): 300–306.

hunger

An urge to eat prompted by an immediate physical need for food. In healthy people, hunger and APPETITE usually coincide. Opportunities to eat, however, may arouse appetite even in the absence of real hunger, and some experiences can be so unsettling or traumatic that they can cause loss of appetite even in the presence of hunger. Some researchers have distinguished two kinds of hunger: stomach hunger and mouth hunger. Stomach, or physiological, hunger derives from the physiological need to refuel. Compulsive eaters rarely experience it; they eat from mouth hunger. Mouth, or psychological, hunger has nothing to do with sustaining life. Mouth-hungry people eat “just because it’s there,” “because you have to put something into

your mouth,” “because it tastes good,” “because it looks so delicious,” “because it’s time for breakfast/ lunch/dinner,” “because someone went to the trouble to prepare it,” “because it would be a shame to throw it away,” “because I feel lonely/anxious/ depressed” or “because I feel happy/excited/like celebrating.” Mouth hunger is what you feel pulling you toward the refrigerator as soon as you sit down to work or what compels you to leave your house at 11:30 P.M. in search of an all-night ice cream stand. Mouth hunger is what continues to send spoon after spoon of ice cream to your mouth long after you’ve begun to feel ill. Mouth hunger is the hunger we attempt to control with diets. HILDE BRUCH emphasized that the inability to recognize hunger is a trait that is of fundamental significance for the development of severe eating disturbances. Bruch also noted that obese children are routinely fed when they cry for reasons other than hunger. Consequently, their “real” hunger is responded to inappropriately, with under- or overfeeding. Eventually, these children’s ability to differentiate accurately between hunger and emotional states becomes undermined. Emotional distress is confused with hunger, and these potentially obese children may overeat in response to virtually any internal arousal state. As obese adults, they suffer from a deficit in hunger awareness. Studies have shown that obese subjects are relatively insensitive to stimuli typically associated with hunger and do not usually eat more in response to hunger cues. Bruch, Hilde. Eating Disorders: Obesity, Anorexia Nervosa, and the Person Within. New York: Basic Books, 1973. Hirschmann, Jane R., and Carol H. Munter. Overcoming Overeating. Reading, Mass.: Addison-Wesley, 1988.

hunger hormones A recently identified and studied class of hormones. Over the past several decades, about a dozen hunger hormones produced by the human body have been discovered that affect eating and weight control by regulating appetite and metabolism. Some of them are attractin, bombesin (BN), GHRELIN, LEPTIN, melanocortin (melanin-concentrating hormone [MCH]), melanin-stimulating hormone (MSH), neuropeptide Y (NPY), orexin, PYY3-36 and UNCOUPLING PROTEINS (UCP). Experts suspect even more hormones affecting hunger and appetite are yet to be discovered. The challenge, they say, will be to determine which are

170 hyperactivity the most critical in controlling weight gain, then figuring out how to control them via medications. However, others caution that controlling hunger hormones will not be the magic formula for ending obesity. People who continue to eat even when not hungry, or even worse, when full, would continue to put on weight. Also, controlling hunger hormones could help people from putting on weight, but would not necessarily help them lose weight unless they reduced overall calorie intake and/or increased caloric expenditure.

hyperactivity

Increased or excessive activity. The term commonly refers to manifestations of disturbed behavior, mostly in children, characterized by constant movement, distraction, impulsiveness, inability to concentrate and aggressiveness. It is also characteristic of anorexics; many are usually active, with a tendency to exercise even when emaciated. Some rarely stay still; even when confined to bed, they have been known to perform isometric exercises under the blankets. This preoccupation with physical fitness is closely related to the consuming desire for thinness. The apparently unusual capacity for physical exertion is not evidence of special physical toughness; it is an indicator of a determination to be active despite the actual state of physical health. Sometimes anorexics will push themselves to the point of collapse, causing them finally to seek or be taken for medical treatment. Physical overactivity can also serve to distract attention from hunger. HILDE BRUCH wrote that hyperactivity is rarely complained of, or even mentioned, by the parents of anorexics but that it will be found with great regularity if looked for. Hyperactivity usually develops before the noneating phase. It may take many forms. Sometimes an existing interest in athletics and sports becomes intensified. Sometimes anorexics may engage in activities that seem to be aimless, walking for miles, doing chinning and bending exercises, refusing to sit down or literally running around in circles. Some may roam around at night, too restless to sleep, or they will do housework, cooking and cleaning by the hour. They themselves do not feel that they exercise too much, and parents do not notice or are not alarmed. Anorexics, and their parents, can therefore deny hyperactivity. The relationship between hyperactivity and disordered eating has been corroborated via animal research. One of the common findings in animal

studies of the effect of restricting food intake is an increase in restlessness and spontaneous motion. When rats are placed on a limited feeding schedule, they increase the number of times they spin their exercise wheels. After a few days of increased activity, however, adult rats will alter their cycles so that most of their activity occurs during the hour or two before feeding, and the total number of revolutions of the wheels per day will be somewhat lower than during times when they are feeding at their own pleasure. Prepubertal rats, on the other hand, do not adjust their activity in this way and will literally run themselves to death if feeding is not increased. This suggests that the heightened energy output that frequently accompanies dieting may be biologically determined. Recent clinical studies suggest that physical activity plays a more central role in the development and maintenance of eating disorders than had previously been thought, according to Davis. Davis, C. “Eating Disorders and Hyperactivity: A Psychobiological Perspective.” Canadian Journal of Psychiatry 42 (March 1997).

hyperalimentation

Also known as total parenteral nutrition (TPN): intravenous feeding. It involves the infusion of a protein solution made up of hydrolysate, glucose, electrolytes, minerals and vitamins at a constant rate through a catheter that has been surgically placed in a major blood vessel such as the subclavian or jugular vein. Helpful in the treatment of anorexia nervosa, it avoids the arguments about FORCED FEEDING. While it prevents patients’ surreptitiously disposing of food, vomiting and other tricks, inventive anorexics find ways of interfering with the flow; they even manage to turn the machinery off. But by bringing about a rapid correction of poor nutrition, hyperalimentation makes patients more accessible to psychotherapy. Hyperalimentation is considered to be a drastic treatment measure and is regarded negatively by many who cite possible infections and overhydration, as well as unwise control over patients who are already struggling to escape feelings of powerlessness.

hypercellularity

The condition of having too many cells. It appears that the number of fat cells in the body cannot be decreased. However, during peri-

hypertension 171 ods of rapid growth, a proliferation of cells can be slowed or stopped. Thus it is believed that changing nutrition at the proper time may modify the rate of cell development. This is especially important in treating obesity-prone children. See also FAT CELLS.

hypergymnasia A term used by Adel Eldahmy, medical director of the Long Beach (California) Eating Disorders Clinic, to describe the excessive exercising an increasing number of bulimic patients turn to once they have stopped PURGING. Instead of vomiting or using laxatives, they go to a gym seven days a week, two or three hours a day, to burn off calories. They’ve been scared sufficiently to stop purging, but they don’t see anything wrong with exercising until they’re dangerously dehydrated. See also EXERCISE; HYPERACTIVITY. hyperphagia Abnormally increased appetite for and consumption of food; eating excessively before feeling full. Hyperphagia can be a symptom of various disorders, including anxiety, bulimia nervosa, depression, diabetes mellitus, Graves’ disease, hyperthyroidism, hypoglycemia, Parkinson’s disease, Prader-Willi syndrome, premenstrual syndrome, seasonal affective disorder, schizophrenia and sleep disorders. Certain medications and drugs such as corticosteroids, cyproheptadine, tricyclic antidepressants and marijuana can also cause hyperphagia. hyperplastic obesity

A severe, lifelong type of obesity that is anatomically generalized (not concentrated in any area or areas of the body) and resistant to therapy. It is further characterized by an increased number of fat cells of normal or of increased size. See also HYPERTROPHIC OBESITY.

hypertension

Chronic high blood pressure (excessive pressure of the blood against the arterial walls); usually defined as a condition in which resting systolic pressure is consistently greater than 160 millimeters of mercury and diastolic pressure is over 90 millimeters. Data from the National Health and Nutrition Examination Survey (NHANES) show that the ageadjusted prevalence of high blood pressure increases progressively with higher levels of BODY MASS INDEX (BMI) in men and women. The prevalence of high

blood pressure in adults with BMI greater than 30 is 38.4 percent for men and 32.2 percent for women, respectively, compared with 18.2 percent for men and 16.5 percent for women with BMI less than 25. The direct and independent association between blood pressure and BMI or weight has been shown in numerous cross-sectional studies. In August 2004 the National Heart, Lung, and Blood Institute (NHLBI) announced that a new analysis of the prevalence of high blood pressure in the United States showed a striking increase over the previous 10 years in the number of adults with this condition. According to this study, there are about 65 million hypertensive adults in the United States, or about a third of U.S. adults (age 18 and older). This number, based on survey and examination data from 1999 to 2000, contrasts with data from 1988 to 1994, which found that about 50 million adults had hypertension. This new analysis shows that the proportion of the population with hypertension grew by about 8 percent in the past decade. In terms of absolute numbers, the study found a 30 percent increase in the total number of adults with hypertension. Barbara Alving, M.D., acting director of NHLBI, commented, “High blood pressure is a major risk factor for heart disease and the chief risk factor for stroke and heart failure, and also can lead to kidney damage. The hypertension trend is not unexpected given the increase in obesity and an aging population. Obesity contributes to the development of hypertension and the current epidemic of overweight and obesity in the U.S. has set the stage for an increase in high blood pressure. We also know that high blood pressure becomes more common as people get older. At age 55, those who do not have high blood pressure have a 90 percent chance of developing it at some point in their lives.” Myers writes, “The reasons that obesity causes hypertension are multiple, but it appears that the excess adipose (fat) tissue secretes substances that are acted on by the kidneys, resulting in hypertension. Additionally, with obesity there are generally higher amounts of insulin produced (because of the excess adipose tissue) and this excess insulin also elevates blood pressure.” Michael D. Myers, M.D. “Hypertension (High Blood Pressure)” Available online. URL: http://www.weight.com/ hypertension.asp. Updated May 28, 2004.

172 hyper trophic obesity hyper trophic obesity Adult-onset obesity. It is more amenable to therapy than childhood obesity or obesity caused by or associated with a pathological condition. Physiologically, it is characterized by the increased size, but not number, of fat cells. See also HYPERPLASTIC OBESITY. hypnotherapy The use of hypnosis in the treatment of psychological problems. It has multiple users, including stress reduction, substitution of more problematic with less problematic behaviors, and at times helping patients remember and come to terms with disturbing memories or emotions that they have dissociated. However, using hypnosis to help remember traumatic events is quite controversial, and numerous psychological/psychiatric or medical organizations have issued warnings about the use of hypnosis for this purpose. According to the American Medical Association, scientific studies regarding the effectiveness of hypnotherapy are lacking. Hypnosis has been used effectively as part of a therapeutic strategy for anorexia nervosa. Hypnotherapeutic intervention is most effective when symptoms such as hyperactivity, distorted body image, feelings of inadequacy and perfectionistic tendencies are present. It may also help patients to overcome resistance to therapy. Hypnotic suggestion has been used to increase patients’ awareness of hunger by associating it with the pleasure of eating. Hypnoanalysis has been used for uncovering psychodynamic conflicts behind anorexic symptoms. A combination of behavior therapy and hypnosis has been used to associate food and appetite with pleasant memories and to help patients ventilate feelings of aggression and hostility. Hypnosis has also been used in treatment programs for weight loss, but with mixed results. According to recent reviews of weight-loss studies, the addition of hypnosis to other treatment has not affected outcome to any significant degree. Allison, D. B., and M. S. Faith. “Hypnosis as an Adjunct to Cognitive-Behavioral Psychotherapy for Obesity.” Journal of Consulting and Clinical Psychology 64 (June 1996). Gross, Meir. “Use of Hypnosis in Eating Disorders.” In Eating Disorders, edited by Félix E. F. Larocca. San Francisco: Jossey-Bass, 1986. Johnson, D. L., and R. T. Karkut. “Participation in Multicomponent Hypnosis Treatment Programs for

Women’s Weight Loss with and without Overt Aversion.” Psychological Reports 79 (October 1996).

hypokalemia A potassium deficiency often resulting from chronic vomiting because of the loss of salt, minerals and other nutrients. It commonly results in cardiac dysrhythmia (lack of rhythm) and, if severe, may lead to sudden death. When accompanying malnutrition, hypokalemia also adversely affects the renal and gastrointestinal systems. Hypokalemia also results in specific injury to the kidney tubules, affecting their ability to concentrate urine. The resulting clinical manifestations are frequent urination and increased thirst. Its effects on the gastrointestinal system include gastric fullness, regurgitation of food, heartburn, constipation and exacerbation of external hemorrhoids. hypothalamic disease A disease, trauma or tumor that affects the APPETITE center located in the hypothalamus (a part of the brain controlling functions of the autonomic nervous system), resulting in obesity. Individuals suffering from this condition usually have an insatiable appetite, eating compulsively day and night. Their obesity advances relentlessly, and eventually they become massive in size. In some instances there is a decrease in normal brain function. Patients diagnosed as having hypothalamic disease often have a history of brain damage caused by trauma or inflammation. Such cases show a generalized type of obesity with no areas of the body being spared. Excess ADIPOSE TISSUE tends to concentrate in the face and neck region as well as the upper arms, upper legs and pelvis. In men there may be a retraction of the testes, and in young women development of secondary sexual characteristics may be delayed. Diagnosis is based on these physical findings, as well as on brain scans and thyroid function tests. The prescribed treatment for this disease is weight reduction as well as treatment of intracerebral lesions. Early death may result from extreme obesity and complications of stasis pneumonia or septicemia from infected skin sites. Frawley, Thomas F. “Obesity and the Endocrine System.” Psychiatric Clinics of North America 7, no. 2 (June 1984). Powley, T. L., and R. Keesey. “Relationships of Body Weight to the Lateral Hypothalamic Feeding Syndrome.” Journal of Comparative Physiological Psychology 70 (1970).

I Tofranil. A tricyclic antidepressant, it has been used by millions of people and has an established record of long-term safety when used as prescribed. Imipramine has some side effects, among them dry mouth, light-headedness on standing up (which usually disappears after a week or two) and sleepiness. It has many more side effects than the newer selective serotonin reuptake inhibitors (e.g., Prozac). It has been used successfully in the treatment of bulimia, with patients receiving it reducing their binge frequency about 75 percent. However, long-term maintenance is a problem, as there is a high probability of relapse after the drugs are discontinued.

ice

The slang term for an appetite-suppressing drug sold illegally on the streets, which is 98 percent pure crystal methamphetamine. Its appearance resembles frozen ice water. It is as addictive and dangerous as crack cocaine. USA Today reported in 1989, that “ice” was at that time being used by dieters in Hawaii and California and had spread as far east as Oklahoma. Experts said most users are women, some of whom use it for weight loss. The trend continued, as the Record (Bergen County, New Jersey) reported in 2004: “Over the last 15 years, authorities have watched with concern as crystal meth worked its way from the West Coast—grabbing hold of the rich and low-income, urbanites, and even rural dwellers.” Although it does cause weight loss for a short time, addiction and toxic problems soon set in. The Drug Enforcement Administration, National Institute on Drug Abuse, warns that ice can lead to violent behavior, anxiety, confusion, insomnia, auditory hallucinations, delusions and paranoia. It can also cause brain damage similar to Alzheimer’s disease. High doses can elevate body temperature to dangerous, sometimes fatal, levels. Ice can be smoked, snorted or injected; is domestically produced; is comparable in price to crack; and gives the user a high—and suppresses appetite—for eight to 24 hours. A crack high lasts an average of 15 minutes.

immigrants and obesity

Immigrants are the fastest-growing segment of the U.S. population, and although people arrive in the United States with low rates of obesity, their acculturation to new foods, new eating patterns and larger portions is causing their weight to become Americanized along with language and lifestyles. In a study of 32,374 respondents, prevalence of obesity was 8 percent among immigrants living in the United States for less than one year, but 19 percent among those living in the United States for at least 15 years. A Time magazine article on obesity pointed to several reasons for the increase in immigrants’ weight gain. Among immigrants, particularly those coming to the U.S., the obesity problem has become a fullblown crisis. Even the stubbornest new arrivals may find that their food practices are impossible to maintain in a new environment, where familiar ingredients aren’t available, old-world holidays aren’t observed and the Mediterranean tradition of the heavy lunch must yield to the less healthy practice of postponing the big meal until the end of the day.

Kelley, Jack. “ ‘Ice Age’ May Dwarf Crack Crisis.” USA Today, December 26, 1989, p. A3. Vadarevu, Raghuram. “N.J. Police Alarmed by Rising Use of Crystal Meth—Highly Addictive Drug Being Likened to Crack.” The Record, May 31, 2004, n.p.

imipramine The first true ANTIDEPRESSANT, in use since the 1950s under the commercial name 173

174 immune function and dieting Goel, Mita Sanghavi et al. “Obesity among U.S. Immigrant Subgroups by Duration of Residence.” The Journal of the American Medical Association 292, no. 23 (December 15, 2004): 2,860–2,867. Kluger, Jeffrey, Christine Gorman, and Alice Park. “Why We Eat.” Time 163, no. 23 (June 7, 2004): 72–76.

very well, others do not,” simply because they continue to eat even when they feel full. In small initial trials, the average weight loss was 18 percent. If the effectiveness and safety prove out in larger studies, it will be considered as an alternative to the riskier BARIATRIC SURGERY.

immune function and dieting Scientists have discovered that fat tissue is more than just fat. Stein describes it as “a complex amalgamation that includes key immune system cells called macrophages. Macrophages and fat cells produce powerful substances called tumor necrosis factoralpha and interleukin-6, which help regulate the immune system. Fat probably evolved a close connection to immune function because the body needs energy when it is fending off threats, scientists say.” Studies have shown that a woman’s immune function decreases in relation to the number of times she attempts to lose weight; and when a woman stays at the same weight for many years, she has higher natural-killer-cell activity, a measurement of the immune system.

Kirsner, Scott. “In the Belly of a Killer: Opportunity.” The Boston Globe, May 17, 2004, p. C1.

Shade, E. D., et al. “Frequent Intentional Weight Loss Is Associated with Lower Natural Killer Cell Cytotoxicity in Postmenopausal Women: Possible Long-Term Immune Effects.” Journal of the American Dietetic Association 104, no. 6 (June 2004): 903–912. Stein, Rob. “Decoding the Surprisingly Active Life of Fat Cells.” Washington Post, July 12, 2004, p. A01.

implantable gastric stimulator (IGS)

A pacemakerlike device about the size of a pocket watch that has been found to be effective in inducing and maintaining weight loss. The IGS has electrodes that connect to the wall of the stomach, delivering mild electrical impulses to the stomach that trick it into feeling full. The device has been approved and used in Europe, but is still undergoing clinical trials in the United States, with approval projected for as early as 2006. A Tufts–New England Medical Center surgeon doing some of the testing told the Boston Globe that it is not clear exactly how the device works. “It may be stimulating nerves that go to the appetite centers of the brain or affecting the production of certain hormones responsible for appetite.” He cautioned that although some patients “respond

infant eating disorders

Several categories of feeding and eating disorders of infancy are described in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Characterized by persistent feeding and eating disturbances, they include PICA, RUMINATION DISORDER, and FEEDING DISORDER OF INFANCY AND EARLY CHILDHOOD. The cause of such disorders is unknown, but often results from a variety of factors such as poverty, parent psychopathology, child abuse or neglect and parental misinformation. A Children’s National Medical Center study in 2004 demonstrated that psychosocial factors, such as mothertoddler interactions, maternal education level and socioeconomic status level, are related to the cognitive development of toddlers with feeding problems and explain more unique variance in Mental Development Index (MDI) scores than nutritional status. See also FAILURE TO THRIVE. Chatoor, Irene, et al. “Failure to Thrive and Cognitive Development in Toddlers with Infantile Anorexia.” Pediatrics 113, no. 5 (May 2004): e440–447.

infant obesity The incidence of obesity in infants has not been determined, but it appears to be increasing. Studies suggest that two trends in infant feeding may account for some of this increase—the trend toward bottle feeding rather than breast feeding, and the trend toward earlier introduction of solids. Whether bottle feeding contributes to the development of obesity is controversial. Although several recent studies have indicated an association between breast-feeding and as great as 20 percent reduced risk of obesity later in life, others have found no evidence to suggest that breast-feeding protects babies against becoming overweight. Some researchers have suggested that

infant obesity 175 breast-feeding may show less risk for infant obesity simply because women who are overweight or obese before pregnancy breast-feed for shorter durations than do normal-weight women—and are even less likely to breast-feed at all. Also, breast-fed babies are less likely to overfeed than bottle-fed babies. Dewey concluded that any association between breast-feeding and later obesity is probably small compared to other factors that influence child obesity, such as parental overweight. Although infants are able to take solids at very early ages without apparent harm, they receive no desirable nutrients that cannot be provided by milk formula. Instead, such feedings usually result in the ingestion of more calories and protein than are required for optimum growth. The Feeding Infants and Toddlers Study, commissioned by baby-food maker Gerber Products Co. and presented in 2003, suggested that the rise in infant obesity may be attributable to the same cause as much of today’s adult obesity epidemic—ingesting too many “junk food” calories. Infants ages seven months to 11 months were taking in a 20 percent daily caloric surplus over normal requirements, and children ages one to two years, an excess of nearly 30 percent. Among the study’s other findings: Soda is being served to infants as young as seven months. French fries are the most commonly consumed vegetable for toddlers age 15–24 months. By 19–24 months, most toddlers consumed sweets, desserts or salty snacks at least once a day. It is generally recommended that obese infants not be made to lose weight but that their weight be controlled. An obese infant’s rate of weight gain should be slowed to parallel his or her linear growth. Recommended is a limitation of 50 to 55 calories per pound of body weight per day during the first six months of life, and 41 to 46 calories per pound of body weight per day from six to 12 months of age. Substituting skim milk for formula is not recommended, but water may be offered periodically in its place. Researchers believe that thirst is often mistaken for hunger. An opposite concern of many dietitians is that fat-phobic parents who, caught up in the low-fat craze, will cut too much fat from their infants’ and toddlers’ diets. They have reported many cases in which babies have been hospitalized for FAILURE TO

because parents have eliminated too much fat from their diet. A number of studies have claimed that rapidity of weight gain in infancy is a better guide to the risk of being overweight at the age of six or eight than is the weight of the parents. For example, in one study, adults whose obesity appeared to have begun in infancy had a higher number of fat cells than a group of equally fat adults whose obesity was of more recent origin. In addition, psychological problems encountered in attempting to lose weight have been more pronounced in patients with early-onset obesity. An infant who becomes obese usually remains obese as an adolescent and as an adult. Researchers at the University of Edinburgh investigated the learning experiences involved in HUNGER and SATIETY in early infancy, and their relation to eventual obesity and other eating disorders. Findings appeared to contradict an earlier theory that there might exist a critical period in early development when the number of FAT CELLS becomes fixed and predisposes a fat infant to become a fat child and ultimately a fat adult. In 1999 a study by the National Institute of Child Health and Human Development said that babies who are undernourished in the womb often are fed too much when they are young to compensate, giving them excess fat to go with diminished muscle mass. Other babies born small react by storing more fat than the body needs. The result is small babies often grow into obese adults. The solution, lead author Mary L. Hedinger said, is for parents to talk to their pediatrician about an exercise program for infants to increase blood flow and muscle. THRIVE

Baker, J. L., et al. “Maternal Prepregnant Body Mass Index, Duration of Breastfeeding, and Timing of Complementary Food Introduction Are Associated with Infant Weight Gain.” American Journal of Clinical Nutrition 80, no. 6 (December 2004): 1,579–1,588. Dewey, K. G. “Is Breastfeeding Protective against Child Obesity?” Journal of Human Lactation 19, no. 1 (February 2003): 9–18. Eriksson, J. et al. “Obesity from Cradle to Grave.” International Journal of Obesity and Related Metabolic Disorders 27, no. 6 (June 2003): 722–727. Grummer-Strawn, L. M., and Z. Mei. “Does Breastfeeding Protect against Pediatric Overweight? Analysis of Longitudinal Data from the Centers for Disease Con-

176 infertility and obesity trol and Prevention Pediatric Nutrition Surveillance System.” Pediatrics 113, no. 2 (February 2004): e81–86.

infertility and obesity

Overweight and obese women have a high incidence of irregular menstrual periods and lower ovulation rates, making it more difficult for them to get pregnant. Physicians have reported as high as 10 to 15 percent of their patients having weight-related infertility, with weight a contributing factor in others trying to conceive. Also, women given fertility treatments often need higher doses of drugs and for a longer time in order to spur ovulation. A large proportion of infertile women have POLYCYSTIC OVARY SYNDROME (PCOS), which is also linked with increased risk of obesity and other metabolic irregularities. Although infertility in obese women has long been documented, a new study presented at a meeting of the American Society for Reproductive Medicine in October 2004 showed that obese women also are less likely to become pregnant even when embryos are fertilized in lab dishes and placed in their wombs. Associated Press medical writer Marilynn Marchione quoted Dr. David Ryley of Beth Israel Deaconess Medical Center in Boston as saying, “Among the severely obese, we saw significantly reduced implantation and pregnancy rates.” The study involved 5,847 attempts at in vitro fertilization. Although doctors have seen women get pregnant after BARIATRIC SURGERY, they caution that not enough data is in yet to say whether it improves pregnancy rates. See also PREGNANCY AND OBESITY; STERILITY AND OBESITY. Linne, Y. “Effects of Obesity on Women’s Reproduction and Complications During Pregnancy.” Obesity Review 5, no. 3 (August 2004): 137–143. Norman, R. J., et al. “Improving Reproductive Performance in Overweight/Obese Women with Effective Weight Management.” Human Reproduction Update, 10, no. 3 (May–June 2004): 257–280.

sleep patterns and insomnia and use BINGE-EATING as a kind of sleeping pill. Sleep disturbance is a regular complication of starvation. Insomnia, especially premature early morning awakening, affects many anorexics and depressed people.

insurance coverage for eating disorders

Treatment for eating disorders is frequently either not covered or only partially covered by hospitalization policies. Many health insurance companies do not provide the same coverage for treating mental illness as they do for physical illness, making it harder for some eating-disorder patients to complete the treatment they need. The Eating Disorders Coalition for Research, Policy and Action is working in Washington, D.C., to educate policy makers about the insurance problems. Their statement: Many health insurance policies do not cover adequate or appropriate care for people with eating disorders. Those who struggle with eating disorders may be forced to pay out-of-pocket for their lifesaving treatment. Appropriate therapy may be hundreds of miles away, or in another state. Because of the lack of a coordinated federal response to eating disorders, Americans are left to fight with their own insurance companies, or to spend tens of thousands of dollars chasing a limited number of treatment programs. In Simon v. Blue Cross and Blue Shield of Greater New York, a New York State appeals court in 1988 held that hospitalization of a person for anorexia nervosa is medical, not psychiatric, care and therefore is not subject to insurance policy limitations on psychiatric coverage. The physician who examined the patient at the time of her first hospitalization asserted that because of rapid weight loss the patient was “emaciated, malnourished, dehydrated, and hypotensive. She required immediate medical treatment for these conditions.”

This case is covered in Hospital and Community Psychiatry (June 1989), page 662, reprinted in BASH Magazine (August 1989, page 223).

insurance coverage for obesity insomnia

Chronic inability to sleep, or consistent interruption of sleep by periods of wakefulness. Insomnia is not a disease but may be a symptom of many diseases. Bulimics frequently report troubled

The obesity “epidemic” coupled with the national and state government initiatives on fighting obesity are causing health insurance companies to rethink their coverage of overweight- and obesity-related treatments.

interoceptive disturbance 177 Also instrumental has been the need for employers to deal with billions of dollars in costs due to obese employees. Today, insurance providers and health maintenance organizations are increasingly subsidizing weight control programs such as Weight Watchers and providing other incentives for people to lose weight, such as nutrition programs and health club memberships. However, employees who are significantly overweight can have benefit costs as much as 20 percent higher than those of normal weight employees. Citing safety and efficacy concerns along with mounting costs from the recent sharp increase in BARIATRIC SURGERY, a growing number of insurance companies have discontinued paying for the operations, which cost close to $3 billion a year. Some states, such as Virginia, Georgia, Indiana and Maryland, require that all insurance plans in their states cover surgeries that treat morbid obesity. In response to the many complaints from consumers about the complexity of health insurance coverage for obesity treatment, New York State published an online consumer guide in November 2004 called “Focus On: Overcoming Obesity.” It is available at http://www.oag.state.ny.us. A priority for the AMERICAN OBESITY ASSOCIATION is expanding access for individuals with obesity to receive health insurance and weight loss and weight maintenance services provided by health insurance programs. “Many individuals with obesity cannot obtain health insurance due to their weight. When they do gain access, most insurance programs do not reimburse them for weight loss or weight maintenance services including surgery and pharmacy benefits even though they cover the comorbid conditions. We expect to use obesity as a leading health indicator to draw attention to the need to rectify this inequitable situation.” Stein, Rob. “As Obesity Surgeries Soar, So Do Safety, Cost Concerns.” Washington Post, April 11, 2004, p. A1.

interleukin-6 (IL-6) A protein that breaks down fat (lipolysis) in adipose tissue in the human body and obese animals. IL-6 has many biologic roles, including: • Activation/inhibition of metabolic genes • Induction of lipolysis, or the breakdown of fat

• Inhibition of insulin resistance, and • Suppression of tumor necrosis factor (TNF) production. Because of its diverse effects, IL-6 has potential as a therapeutic drug in treating such metabolic disorders as obesity, type 2 diabetes and atherosclerosis. Although it is naturally released by muscles during exercise, research has found that it can be injected into a human body to reduce body fat by as much as 20 percent. Scientists say it will take several years of research before its potential as a medical treatment to reduce obesity is fully explored.

International Journal of Eating Disorders

A journal founded in 1981 to foster and publish research on anorexia nervosa, bulimia, obesity and other atypical patterns of eating behavior and body weight regulation. The editor is Michael Strober, and it is published by John Wiley & Sons Inc.

International Journal of Obesity A journal devoted to publishing research related to obesity and the official journal of the International Association for the Study of Obesity. The editors are Dr. Richard L. Atkinson and Ian Macdonald, and it is published by Nature Publishing Group, the scientific publishing arm of Macmillan Publishers Ltd. International Size Acceptance Association (ISAA) An activist group whose mission is to promote size acceptance and fight size discrimination throughout the world. ISAA’s primary purpose is to end size discrimination and bigotry against fat children and adults. ISAA defines size discrimination as any action that places people at a disadvantage simply because of their size, and size acceptance as acceptance of self and others without regard to weight or body size. See also APPENDIX III, SOURCES OF INFORMATION.

interoceptive disturbance

An inability to identify accurately internal sensations such as HUNGER, SATIETY, fatigue, cold and sexual feelings. HILDE BRUCH suggested that both anorexia nervosa and juvenile obesity are fundamentally related to this disturbed awareness. Anorexic patients often describe extreme confusion about their bodily sensations; sometimes they appear devoid of thoughts

178 interpersonal psychotherapy and feelings reflecting personal experiences. Rarely can they focus on and accurately describe their emotional and physical states.

interpersonal psychotherapy (IPT)

A form of psychotherapy that has been found to be an effective treatment for bulimia nervosa. The focus of the therapy is on resolving relationship issues and problems rather than on eating problems per se. That IPT has been found to be an effective treatment for bulimia nervosa is an interesting and important finding because it demonstrates that a treatment that does not directly target eating behavior can be effective in altering such behavior.

Fairburn, C. G. et al. “Psychotherapy and Bulimia Nervosa: The Longer-Term Effects of Interpersonal Psychotherapy, Behaviour Therapy, and Cognitive Behaviour Therapy,” Archives of General Psychiatry, 50, no. 6 (June 1993): 419–428.

Interview for the Diagnosis of Eating DisordersIV The IDED is a structured interview designed for the purpose of determining diagnoses in research and clinical settings specializing in the eating disorders. Research has shown the instrument to have good psychometric properties. Kutlesic, V., D. A. Williamson, D. H. Gleaves, J. Barbin, and K. P. Eberenz. “The Interview for the Diagnosis of Eating Disorders-IV: Application to DSM-IV Diagnostic Criteria,” Psychological Assessment 10, no. 1 (March 1998): 41–48.

ipecac syrup

A drug derived from the dried root of the ipecacuanha, a plant grown in Brazil, that induces vomiting. Ipecac syrup is sold over the counter and for many years was used by hospitals in emergencies to treat people who had ingested poisons. Families were long advised to keep a oneounce bottle in their first-aid kits to use should their young children swallow household poisonous substances. Eating-disordered patients, especially those with bulimia, have long used ipecac syrup to purge their

bodies of food. When abused in this manner, ipecac syrup can have many side effects, both short term and long term, including dizziness, nausea, stomach cramps, respiratory difficulties, fast or irregular heartbeat, seizures and pneumonia. If the ipecac is not vomited or an individual overdoses, it can cause serious heart problems and even death. The late recording artist KAREN CARPENTER, an anorectic who used syrup of ipecac to induce vomiting, died after build-up of the drug irreversibly damaged her heart. A Yale University study evaluated 851 consecutive outpatients at a suburban eating disorder clinic for current or past ipecac abuse. Of these, 7.6 percent reported some use or experimentation with ipecac for purging; 4.7 percent had experimented with it briefly; 3.1 percent (8.8 percent of subjects meeting criteria for bulimia) had chronically abused ipecac; and 1.1 percent (1.5 percent of subjects meeting criteria for bulimia) were regularly abusing ipecac at the time of intake. Chronic ipecac abusers were more likely to have been hospitalized. Subjects who experimented briefly with ipecac had a longer duration of illness. Both chronic ipecac abusers and experimenters were more prone to abuse other substances for purging and to report alcohol abuse in an immediate family member. In a later study, reported in 2001, adults were more likely than adolescents to have a history of ipecac abuse. In 2003 the American Academy of Pediatrics recommended that families no longer routinely use syrup of ipecac to treat accidental poisoning. Their research had found no benefits for children treated with ipecac; plus, that ipecac was being improperly administered by parents and was being abused by people with eating disorders. Also, most emergency rooms have stopped using ipecac following toxic ingestions in favor of activated charcoal and whole bowel irrigation, which have proved more effective and better tolerated. Greenfeld, D., et al. “Ipecac Abuse in a Sample of EatingDisordered Outpatients.” International Journal of Eating Disorders 13, no. 4 (May 1993): 411–414.

J jejunoileal bypass

Janet, Pierre (1859–1947)

An early MALABSORPTIVE for weight loss in patients with severe obesity until it was replaced by procedures such as the ROUX-EN-Y GASTRIC BYPASS, which use a lesser degree of malabsorption combined with gastric restriction to induce and maintain weight loss. Although jejunoileal bypass was effective in producing weight loss (an average of 100 pounds five years after surgery), its side effects and complications were substantial. They included intractable diarrhea, nutrient deficiencies, kidney stones and liver failure. The jejunoileal bypass no longer is a recommended bariatric surgical procedure.

A French psychiatrist and researcher specializing in the study of hysteria. He was the first to describe in modern medical terms the symptoms of BULIMIA. In his book Les Obsessions et la psychasthénie (1903), he wrote about a young woman who developed compulsive eating binges, many of them in secret.

OPERATION

jaw wiring

Wiring the jaws together to prevent the eating of solid foods and allowing only liquid nutrition directly restricts calorie intake. Weight reduction usually occurs during this time; as much as 70 and 80 pounds have been lost when jaws have been left wired for long periods of time. However, much of this is regained once they are unwired. Some patients find the conspicuousness and the claustrophobic qualities of jaw wiring to be rather unpleasant. This procedure has been used primarily to help compulsive eaters. Once a week the braces are loosened so the teeth can be brushed.

Boon, A. P., H. Thompson, and R. M. Baddeley. “Use of Histological Examination to Assess Ultrastructure of Liver in Patients with Long Standing Jejunoileal Bypass for Morbid Obesity.” Journal of Clinical Pathology 41 (December 1988). Powers, Pauline S., and Alexander Rosemurgy. “Current Treatment of Obesity.” In Eating Disorders: Effective Care and Treatment, edited by Félix E. F. Larocca. St. Louis: Ishiyaku EuroAmerica, 1986. Yetiv, Jack Z., Popular Nutritional Practices: A Scientific Appraisal. Toledo, Ohio: Popular Medicine Press, 1986.

jejunocolonic bypass An intestinal bypass procedure developed in the 1960s that was intended to aid weight loss; it is no longer performed, however, because of detrimental side effects (severe diarrhea, uncontrolled weight loss, malnutrition, liver dysfunction) during the postoperative months. Patients did lose much weight, but as side effects worsened, surgeons had to reconnect their intestines. Subsequently, all lost weight was regained. Regained weight proved that the bypass was the cause of weight reduction, however, and this experience provided the impetus for continued investigation into surgical weight control. See also BYPASS SURGERY.

Jenny Craig Program

A diet program combining frozen and prepackaged shelf foods with one-onone counseling, independent homework and group classes on behavior modification. In the beginning, participants buy most of their foods from the Jenny Craig company. As the diet progresses, more and more regular foods are incorporated into the diet, with the Jenny Craig food use lessening. The idea behind the plan is to teach portion control and how to make healthy food choices, as well as to encourage exercise.

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K praise of it. Since that time versions of the Banting Diet, with minor modifications, have appeared at regular intervals: as the Pennington or Dupont Diet in 1953, the Air Force Diet in 1960, the Drinking Man’s Diet in 1965, the Stillman and Atkins Diets in the 1970s, and later the Zone, Protein Power and South Beach. Elevated levels of ketones are potentially dangerous (see KETOSIS). See also LOW-CARB DIETS.

kaolin

Also known as white dirt, chalk or white clay. The ingestion of kaolin is a relatively common type of PICA found in the central Georgia Piedmont area. Although GEOPHAGIA (earth eating) has been observed and documented in many areas of the world, the specific preference for consuming kaolin is less well known. After reviewing the literature, researchers determined that kaolin ingestion appears to be a culturally transmitted form of pica, not selectively associated with other psychopathology, and appears to meet the DSM-IV criteria for a “culture-bound” syndrome.

ketosis A condition in which excessive amounts of ketones accumulate in the body. Ketones are chemicals the body makes when there is not enough glucose in the blood and it must break down fat for its energy. When this occurs, fatty acids are released into the blood; these fatty acids are then converted to ketones. Ketones can poison and even kill body cells. Ketones that build up in the body for a long time can lead to serious illness and coma. Symptoms include a “fruity” odor to the breath, loss of appetite, nausea, vomiting and abdominal pain. Ketosis can be diagnosed by a test to detect ketones in the urine. FASTING can cause ketosis. Treatment in this case is a gradual reintroduction of a nutritious diet. Ketosis also occurs in uncontrolled diabetes mellitus, because carbohydrates are not properly utilized. In these cases, it is treated with either diet change or insulin.

ketogenic diet

A diet that produces elevated levels of acetone or ketone bodies, accompanied by mild acidosis or ketoacidosis. In this kind of diet the ratio of calories derived from fat to those from carbohydrates is three or four to one. The combustion of fatty acids in the bloodstream produces ketones, which eventually are broken down into carbon dioxide and water by the liver and other tissues of the body. Under abnormal conditions such as diabetes mellitus, starvation or a diet composed almost entirely of fat, the breakdown of fatty acids may be halted at the ketone stage, causing increasing levels of ketone bodies in the blood and body tissues. Ketones are powerful appetite suppressants that account for the loss of HUNGER occurring on the second day of any rigorous fast. Ketone-producing diets have been around for more than 100 years. William Harvey, an English surgeon, first experimented with high-protein, low-carbohydrate, ketone-producing diets in the mid-1800s. The diet he developed is generally known as the Banting Diet (see BANTING, WILLIAM), after an early patient of Harvey who was so delighted by the effects of the doctor’s weight loss program that he published a pamphlet in

kidney stones and obesity

Researchers at University of Texas Southwestern Medical Center at Dallas, working with doctors at the University of Chicago, studied more than 5,000 patients and found a direct link between body weight and uric acid kidney stones. Kidney stones form when waste materials in urine do not dissolve completely. Over

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182 kidney stones and obesity time, these microscopic particles form into stones. Uric acid kidney stones form when the level of acid in the urine is too high. These kinds of stones are found in about 5 percent of kidney stone patients. Eating too much animal protein can raise acid levels in urine, but the researchers found that overweight people had highly acidic urine, no matter what they ate. Uric acid kidney stones are also associated with insulin resistance and type 2 dia-

betes. A study author said that researchers now need to find whether or not losing weight or improving insulin sensitivity will help people keep from forming kidney stones. Maalouf, N. M., et al. “Association of Urinary Ph with Body Weight in Nephrolithiasis.” Kidney International 65, no. 4 (April 2004): 1,422–1,425.

L Lap Band

tive abuse is relatively ineffective for this purpose and that dietary restraint is responsible for any weight loss among laxative abusers. One study found that the weight loss experienced by patients following ingestion of laxatives resulted from temporary fluid loss; the amount of caloric absorption prevented by laxative use was minimal. Laxatives containing stimulant compounds are favored by those with eating disorders because these agents will reliably produce a watery diarrhea fairly promptly, and a sense of weight loss, if sufficient amounts are ingested. Most laxative abuse is practiced independently, but laxatives are often prescribed by diet doctors in an effort to speed food through the intestines so nutrients are not absorbed and turned to fat. Physicians warn that taking laxatives is more dangerous than it may appear. As the body adjusts, patients often go from three laxatives to 50 to 100 laxatives a day. Then if they stop taking them, severe swelling and constipation occurs. The bowels get addicted and have to be weaned off. Complications of laxative abuse include:

See ADJUSTABLE GASTRIC BANDING.

laporoscopic adjustable gastric banding

See

ADJUSTABLE GASTRIC BANDING.

Lasègue, Charles (1816–1883) A French psychiatrist who was one of the first to publish a detailed description of anorexia nervosa. In 1873 he described the disorder as a variant of hysteria. While his contemporary, the Englishman SIR WILLIAM WITHEY GULL, concentrated on the medical aspects of anorexia, Lasègue emphasized its psychological aspects. He confirmed what Gull had suggested, that anorexic women came from families willing and able to spend emotional and financial resources on them. He was the first physician to suggest that refusal of food constitutes a form of conflict between a maturing girl and her parents. laxative abuse Misuse of laxatives is a fairly common problem among bulimic women, and laxatives appear to be the type of drug most commonly abused by anorexic patients. This misuse usually involves the ingestion of many times the amounts recommended by the manufacturer. In their study, Kovacs and Palmer noted, “Laxative abuse appears to be associated with especially severe psychopathology and low self-esteem among subjects with anorexia nervosa.” In a University of Kansas study of women with eating disorders, more than one-half of the women had abused laxatives at some point. And in a survey of 2,400 North Carolina middle school students, nearly 10 percent of the girls and 4 percent of the boys reported vomiting or using laxatives to lose weight. Researchers have found that patients who use self-induced VOMITING for weight control tend to eat significantly more during binges yet weigh less than those who use laxatives, suggesting that laxa-

• Constipation These drugs produce a reflex hypofunctioning (decreased functioning) of the colon, resulting in constipation. Constipation becomes a particular problem during laxative withdrawal. • Cathartic Colon Patients who have taken stimulanttype laxatives for long periods of time can develop permanent dysfunctioning of the colon, accompanied by radiographic and microscopic changes in the bowel. • Bleeding Chronic recurrent use of stimulant-type laxatives can result in gastrointestinal bleeding and hidden or obvious blood loss. • Dehydration Stimulant-type laxatives promote fluid loss through the intestine, which can result in volume depletion and lead to a secondary

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184 leptin hyperaldosteronism, a condition caused by secretion of excessive amounts of the electrolyte-regulating hormone aldosterone by the adrenal cortex; this is turn results in reflex peripheral edema (swelling), which is a particular problem during laxative withdrawal. This reflex fluid retention can be quite dramatic. • Electrolyte Abnormalities Laxative-induced diarrhea markedly elevates the electrolyte content of the feces. HYPOKALEMIA and acidosis may result. • Other medical complications that have been described include the development of steatorrhea (excessive fat in the feces) and protein-losing gastroenteropathy (disease of the digestive tract), pancreatic dysfunction, osteomalacia (softening of bone), pseudofractures, hypocalcemia (reduction of calcium in the blood) and hypomagnesemia (abnormally low level of magnesium in the blood). In California, laxative sales restrictions have been imposed by legislators. It is thought by many that some restrictions should be placed on the sale of over-the-counter laxatives because thousands of young women are overdosing on laxatives in their quest for weight loss. Bankhead, Charles D. “Myths Fueling Widespread Abuse of OTC Laxatives.” Medical World News, January 8, 1990. Kovacs, D., and R. L. Palmer. “The Associations between Laxative Abuse and Other Symptoms among Adults with Anorexia Nervosa.” International Journal of Eating Disorders 36, no. 2 (September 2004): 224–228. Krowchuk, D. P., et al. “Problem Dieting Behaviors among Young Adolescents.” Archives of Pediatrics and Adolescent Medicine 152, no. 9 (September 1998): 884–888. Moriarty, K. J., and D. B. Silk. “Laxative Abuse.” Digestive Diseases 6, no. 1 (1988): 15–29. Pryor, T., et al. “Laxative Abuse among Women with Eating Disorders: An Indication of Psychopathology?” International Journal of Eating Disorders 20, no. 1 (July 1996): 13–18. Willard, S. G., et al. “Laxative Abuse in Eating Disorders.” Psychiatric Medicine 7, no. 3 (1989): 75–87.

leptin

A hormone discovered in 1994 that helps the body regulate its amount of fat. Leptin is produced by fat tissue and signals the brain when one is full and to stop eating. A mutation in the genes that code for leptin would prevent signaling and the person would continue to eat, thus gaining weight. Park explains further:

Leptin helps manage just how much fat you store around your organs and under your skin through a complex feedback loop. If your fat deposits start to shrink—for example, when you lose weight— the amount of leptin in your body falls, a situation that the brain interprets as a result of starvation. The whole system of chemicals and neurological impulses shifts in an attempt to get the body to burn fewer calories so that it can regain the weight. The greater the weight loss, the stronger the signals to eat more and replenish fat stores.

Scientists had hoped leptin could be used as an antiobesity drug, but they later discovered that most obese people are not deficient in leptin; their bodies are simply resistant to its messages. For individuals with a rare from of obesity caused by a deficiency in leptin, it would be extremely difficult to achieve weight loss through lifestyle interventions alone, and some drug therapies would be unlikely to work well, if at all. However, replacing their missing hormone, leptin, through injections is extremely effective not only in helping them lose weight but also in reversing the other negative health consequences of this missing hormone. Researchers in one study found that levels of leptin were significantly higher in the obese volunteers and the levels spiked at night, yet they remained steady for the lean volunteers. Other recent research has found a link between lack of sleep and the risk of weight gain, with sleep being a major regulator of leptin. Research published in January 2005 found that a single brain region is sufficient for normal control of blood sugar and activity level by leptin. The same region also exerts significant, though more modest, control over leptin’s effects on body weight. The findings in mice provide insight into potential mechanisms underlying type 2 diabetes and suggest new avenues for treatment, according to the researchers. The new results suggest that leptin signaling acts directly on the brain region known as the hypothalamic arcuate nucleus (ARH) to control insulin and glucose levels in the bloodstream. Leptin receptors in the ARH accounted for approximately 22 percent of the hormone’s effects on body weight, the researchers reported, suggesting that other brain regions are also important to this hormonal function. Coppari, Roberto, et al. “The Hypothalamic Arcuate Nucleus: A Key Site for Mediating Leptin’s Effects on

liposuction 185 Glucose Homeostasis and Locomotor Activity.” Cell Metabolism 1, no. 1 (January 2005): 63–72. Park, Alice. “Why We Eat.” Time 163, no. 23 (June 7, 2004): 72–76.

lipoprotein lipase (LPL)

An enzyme that aids in the storage of body fat. Its activity varies in different parts of the body, being very active in abdominal fat and less active in hip fat. Studies have shown that obese people may have difficulty achieving a normal level of lipoprotein lipase. A University of Colorado study reported that obese people, in comparison with people and normal weight, produce too much of the enzyme and that even after weight loss their enzyme activity had not fully returned to normal. Levels of lipoprotein lipase in ADIPOSE TISSUES affect the maintenance of fat-cell size, body weight and obesity. Genetic and diet-induced obesity have been found to be associated with increases in lipoprotein lipase levels in the adipose tissue of humans and rodents after overnight fasting. Progressive increases in body mass index in humans are associated with increases in adipose tissue lipoprotein lipase. Most evidence suggests than an increase in levels of lipoprotein lipase in adipose tissue preserves rather than causes obesity. One study found that people who had maintained a large weight loss for eight or more years still produced too much of the enzyme. But as soon as those obese people who have lost weight start regaining it, their enzyme level drops. In more recent studies, Perreault et al. found that after three to four hours of exercise, muscle and adipose tissue LPL activity increased significantly in men, whereas LPL activity remained unchanged in women. And Berman et al. determined that despite improving lipoprotein lipid profiles in obese postmenopausal women, weight loss does not affect the regulation of regional fat metabolism. Berman, D. M., et al. “Regulation of Lipolysis and Lipoprotein Lipase after Weight Loss in Obese, Postmenopausal Women.” Obesity Research 12, no. 1 (January 2004): 32–39. Eckel, Robert H. “Lipoprotein Lipase.” New England Journal of Medicine 320, no. 16 (April 20, 1989): 1,060–1,068. Perreault, L., et al. “Gender Differences in Lipoprotein Lipase Activity after Acute Exercise.” Obesity Research 12, no. 2 (February 2004): 241–249.

liposuction

A surgical procedure pioneered in Europe in the 1970s to remove localized deposits of excess fat; also called liposculpture, lipoplasty or lipectomy. The surgeon inserts a long, thin, hollow blunt-edged tube called a cannula through a quarterinch incision. This tube is attached via another hollow tube to a machine with a powerful vacuum apparatus that sucks out subcutaneous (beneath the skin) fat. The collecting tube is transparent, allowing the surgeon to see the tissue being removed. Liposuction has been referred to as “maid service for your fat: The surgeon vacuums the areas you didn’t have the time or energy to clean up yourself.” Though once controversial, it has become one of the most common types of cosmetic surgery today. Giorgio Fischer, a surgeon in Rome, was the first to devise an instrument to remove fat by suction and the first to perform liposuction surgery. The original procedure removed fat almost totally from the suctioned area, creating a large cavity that filled with body fluids. Because the skin overlying it did not shrink correspondingly, the procedure left an unsatisfactory result. To combat this problem, Yves-Gérard Ilouz, a French surgeon, devised a method for dissecting fat with a blunt tube (cannula) that removed fat in a regular series of tunnels created sequentially by probing the fat deposit to be treated. In this new procedure, both the adjacent fat and the small blood vessels running through the area remained intact, allowing continuous contact between the skin and the underlying tissue. This helped the skin to shrink slowly and regularly over the newly contoured area, with less likelihood of developing ripples and depressions. Keeping original blood vessels in the area helped fluids that leak into it during the postoperative period to be more easily absorbed into the body. This shortened the prolonged wound drainage that characterized earlier suction procedures. Liposuction was developed to remove from a healthy, normal-weight person localized genetically derived fat deposits that do not respond to diet or exercise. It is not intended to be a treatment for obesity. The most frequently treated areas include the hips and thighs and the abdomen. Liposuction can also be done on the neck, face, arms and legs. Losing body fat through liposuction does not appear to improve health risks associated with overweight and obesity as it does when losing it through dieting and exercise. A Washington Uni-

186 liposuction versity (St. Louis) study published in 2004 evaluated the effect of large-volume abdominal liposuction on metabolic risk factors for coronary heart disease in women with abdominal obesity, and found that risk factors for heart disease—blood pressure, lipid levels and insulin sensitivity— remained unchanged 12 weeks following surgery. Results While fluid shifts restricted fat removal to about two pounds during a single liposuction in the early days, recent advances in liposuction techniques, such as tumescent liposuction, allow doctors to safely take out three to four times that amount and to remove up to 15 inches off a person’s girth. Tumescent liposuction injects the area to be suctioned with a special fluid-anesthesia combination prior to suctioning. The fluid constricts the surrounding blood vessels, making the procedure nearly bloodless while minimizing the pain. Not all fat is removed from a location. The surgeon leaves some fat cells behind because fat cells grow and shrink, depending on nutrition and the age of the patient. Removing all the fat cells would result in a disproportionately flat area. Not everyone achieves satisfactory results, mainly because there is no control over how the skin will contract over suctioned areas. Some patients end up with “dents” and more uneven skin and sagging than they had before surgery. Others have dropped two full clothing sizes. Liposuction surgery differs from fat loss through dieting and exercise. When fat is lost in those ways, FAT CELLS become smaller, though their number throughout the body remains constant. These “starved” fat cells send messages to the brain indicating their depleted state, stimulating HUNGER. When they receive extra CALORIES, these cells once again store fat for future needs. Liposuction, in contrast, actually removes fat cells from the treated area. These are not replaced unless there is a subsequent weight gain large enough to fill the remaining cells to their capacity. For this reason, patients who have undergone liposuction surgery must monitor their caloric intake to maintain positive results. It should be noted that reaccumulated fat is not necessarily deposited in the same locations that have been suctioned. This new fat generally tends to spread itself evenly throughout the body.

Liposuction also removes fat from specific, targeted areas, but diet and exercise may reduce nonpreferred areas while leaving other areas virtually intact. Women with large thighs, for instance, are often frustrated by the persistence of this phenomenon even when their diet and exercise regimes lead to virtual emaciation of their faces and upper bodies. And men with “spare tires” around their middles are often unable to eliminate them entirely by dieting despite considerable weight loss. Limitations Liposuction surgery is not the ultimate answer to dieters’ prayers, though. The procedure does have distinct limitations. Good skin tone is important for continued success, because once fat is removed, the skin must shrink to fit a new contour. Assuming that prolonged accumulation and drainage of body fluids does not occur, skin that is sufficiently elastic will heal without dimples, dents or ripples. But skin that has lost its elasticity may not contract as rapidly or satisfactorily. Liposuction can be performed under local or general anesthesia. At the present time, the surgery is commonly performed on an outpatient basis in an office surgical suite or ambulatory surgical facility. However, medical opinions differ about whether the procedure should be done in an office or in a hospital. Dr. Pierre F. Fournier, a past president of the International Academy of Cosmetic Surgery, has stated that “anyone who is going to have a large amount of fat removed should be operated on in a hospital and observed overnight. Such patients will probably need intravenous fluids and may need blood transfusions.” Liposuction surgery is a body-contouring operation, not a weight loss procedure. Only small amounts of fat in terms of weight, one-half to two pounds, are actually removed during an operation, and this fat is considerably lighter than the solutions administered intravenously during the surgery. It is not uncommon for a patient actually to observe a weight gain of several pounds in the first few days following surgery because of this fluid replacement. But the kidneys rapidly eliminate excess fluid, and body weight soon returns to its preoperative level. Most patients with small to moderate fat bulges lose only a few pounds but may drop two to three clothing sizes. Many patients, however, report continuing

liposuction 187 weight loss for several months following liposuction, stabilizing at a loss of five to 10 pounds. The American Society of Aesthetic Plastic Surgeons (ASAPS) sent out a survey to more than 14,000 doctors and used the results to project national averages for 23,000 medical specialists. Results of that survey showed that from 2002 to 2003, there was a 20 percent increase in the total number of cosmetic procedures. The top surgical cosmetic procedure in 2003 was liposuction (384,626, up 3 percent from 2002). The American Society of Plastic Surgeons (ASPS) showed liposuction to be the second most frequently performed cosmetic surgery in 2003, with 320,022 procedures, and the most often chosen by women. The 35–50 age group made up 40 percent of all cosmetic plastic surgery, with liposuction being their most popular procedure. Complications Early reports of problems, including loss of limbs and a dozen deaths, led to investigations of liposuction procedures by the American Society of Plastic and Reconstructive Surgeons. In 1987 the society issued a report stating that “suction-assisted lipectomy is normally safe and effective” when performed by a properly trained, experienced surgeon with board certification in plastic surgery and a proven track record of success in liposuction. Legally, any surgeon can perform liposuction. This fact was brought out during a 1989 hearing held by the U.S. House of Representatives Small Business Committee’s Subcommittee on Regulation and Business Opportunities. Chairman Ron Wydan (D-Oregon) concluded that a liposuction surgeon “can buy $4,000 worth of equipment on Monday morning, do two procedures in the afternoon and make money all day Tuesday,” even if he or she lacks accreditation. But proponents of liposuction cite its safety record. John McCurdy, Jr., wrote that a compilation of more than 5,000 cases performed through 1983 showed only six complications, most minor (loss of skin and limbs was blamed on untreated infection; deaths occurred when liposuction was performed along with other surgery, or by unqualified surgeons). Liposuction is major surgery and, as such, carries all the inherent risks, including potential problems with anesthesia, infection, discomfort, recovery time, side effects, complications and, of course, high cost. Minor complications associated

with liposuction can include bruising, swelling and local sensory changes. Some complications can be permanent, such as bodily lumps, craters, asymmetry and permanent creases and furrows where the fat is removed. If the suction occurs too close to the skin’s surface, it may tug at the skin tissue, causing it to ripple. The worst complications are excessive bleeding and loss of body fluids. Patients who have large amounts of fat removed (two liters or more) run the risk of shock if fluids are not adequately replenished during the surgery. Bleeding was the most common complication following liposuction surgery in its early days. Removal of large amounts of fat can still result in moderate blood loss, but for the routine liposuction, these problems today are unusual. Most serious complications today are associated with large-volume (more than 10 pounds) liposuction. As with any procedure involving incisions in the skin, liposuction does leave scars. Usually these are small, about one-quarter inch, and are camouflaged by placement within natural skin lines. However, surgeons caution that persons predisposed to “over-active” scars need to discuss this problem with their doctor prior to surgery. Early complaints of dents, depressions and skin waviness were blamed on the uneven removal of fat during liposuction. Today’s specialists claim to have solved most of the problem by leaving a pad of fat on the undersurface of the skin and confining fat removal to deeper areas. Most surgeons now use smaller cannulas to make smaller, more numerous tunnels through the fat. The results in a smoother, more even shrinkage of skin over the suctioned area. The most troublesome area is the inner thigh, where skin does not contract as well as skin in other areas. When uneven contours do exist after swelling has gone down, a second liposuction procedure is usually performed under local anesthesia. Surgeons say it is far easier to remove small amounts of excess fat than to fill in depressions caused by excessive fat removal. The U.S. Food and Drug Administration (FDA) cautions, “Some of the studies indicate that the risk of death due to liposuction is as low as three deaths for every 100,000 liposuction operations performed. However, other studies indicate that the risk of death is between 20 and 100 deaths per 100,000 liposuction procedures. One study suggests that the

188 liquid formulas death rate is higher in liposuction surgeries in which other surgical procedures are also performed at the same time. In order to understand the size of the risk, one paper compares the deaths from liposuction to that for deaths from car accidents (16 per 100,000). It is important to remember that liposuction is a surgical procedure and that there may be serious complications, including death.” Cost of liposuction surgery can range between $1,000 and $5,000 depending on the length and complexity of the procedure. The average surgeon’s fee for liposuction was reported in 2004 to be $2,224. Liposuction is not covered by most insurance plans because it is considered elective. A liposuction technique called ultrasonic liposuction (or ultrasound-assisted lipoplasty, UAL) was introduced in the United States in 1994 and approved by the Food and Drug Administration in 1996. UAL uses sound waves to liquefy the fat so it can be vacuumed out of the body faster than it might with other methods. There is less trauma to the body with UAL, plus the ultrasound leaves blood vessels and nerves intact, so there is significantly less bleeding and postoperative pain. The FDA does note that “during ultrasound assisted liposuction, the ultrasound probe may become very hot and can cause burns.” UAL is rapidly becoming the preferred method of fat removal by plastic surgeons, although it is not appropriate in all situations. Often it is used in conjunction with other techniques. Long-term effects of ultrasound liposuction are not known, and extensive research and clinical trials are needed to establish fully the safety and efficacy of UAL. New techniques are being developed that are improving results and reducing risks. Among the more recent: • German plastic surgeon A. Ziah Taufig, M.D., has introduced an alternative method to tumescent liposuction that he believes is superior to its predecessor, because it allows controlled and selective removal of fat tissue via water-jet dissection—an approach that has been shown to be safer than the circulation of a local anesthetic. According to Kapes, water jet liposuction is becoming known for its improved process and results, shorter operating times and increased safety for patients. • In 2004 the FDA approved the Erchonia 4L laser for use during liposuction. The painless laser

treatment is administered a few minutes prior to liposuction and works by liquefying the fat. As a result, fat removal is made easier and quicker. There is less post-op pain and bruising and a speedier recovery time. In addition, less pain medication is required. At the time of approval, the Erchonia laser was being used by approximately 100 cosmetic and plastic surgeons. Albin, R., and de Campo, T. “Large-Volume Liposuction in 181 Patients.” Aesthetic Plastic Surgery 23, no. 1 (January/February 1999): 5–15. Kapes, Beth. “Jetting Water Curtails Liposuction Risks: Improved Process Enhances Results.” Cosmetic Surgery Times 7, no. 10 (November–December 2004): 6, 9. Klein, Samuel, et al. “Absence of an Effect of Liposuction of Insulin Action and Risk Factor for Coronary Heart Disease.” New England Journal of Medicine 350, no. 25 (June 17, 2004): 2,549–2,557. Lillis, Patrick J., and Coleman, William P., III, ed. “Liposuction.” Dermatologic Clinics 8, no. 3 (July 1990). McCurdy, John A., Jr. Sculpturing Your Body: Diet, Exercise and Lipo (Fat) Suction. New York: Kensington Publishing Corp., 1990.

liquid formulas A number of commercial diet supplement drinks promoted since the 1970s, the earliest and most highly publicized of which was Robert Linn’s “Prolinn,” described as “a formula composed of all the amino acids needed to form a protein molecule.” Such liquids have been used by hospitals for years to feed seriously ill patients. Once Linn’s formula was published, other brands, such as Winmill, GroLean, Ran-Tein, T-Amino, LPP, E.M.F., Pro-Fast, Nu-Trim/20, Bahamian Diet and Multi-Protein Slim, appeared. The first liquid protein supplements were withdrawn when the Centers for Disease Control and Prevention attributed 60 deaths to their use. The protein in these early supplements was collagen based; their inadequate amino acid composition led to dangerous loss of lean muscle mass, including heart muscle. In addition, these early diets did not provide adequate potassium, which may have resulted in serious disturbances of heart rhythm. Then, during the mid-1980s, a new generation of liquid protein diets was developed. Made from high-quality protein, with adequate vitamins, minerals and electrolytes to maintain health, some of them are even intended for use in programs of

Longitudinal Assessment of Bariatric Surgery 189 medical monitoring, nutrition education, behavior modification, exercise and support groups sponsored by the manufacturers. Three widely used programs Optifast (Sandoz were Nutrition), Medifast (Jason Pharmaceuticals) and Ultrafast (National Center for Nutrition). In November 1988 these reformatted liquid protein diet programs received a commercial boost when the popular TV talk-show host Oprah Winfrey revealed that the loss of nearly 70 pounds that she had experienced was the result of following the Optifast liquid diet program. Formula diets come in dry form as mixtures of essential nutrients; water must be added before use. Prepared in two to six servings, most of these diets provide milk or egg (not vegetable) protein and varying proportions of carbohydrate and fat. The addition of carbohydrate decreases ketosis, hyperuricemia, electrolyte depletion and loss of lean tissue proteins. Fat improves palatability and provides essential fatty acids. Users who stay with the program usually lose four to 10 pounds during the first week of the formula diet and two to five pounds per week thereafter. Twelve-week programs usually result in a loss of 22 to 33 pounds. One study evaluated 4,026 morbidly obese patients who showed interest in the Optifast diet program. Ten percent failed to join or did not meet entry criteria; one-fourth of those remaining left the program within the fist three weeks; among the 2,717 remaining patients, one-third reached the desired weight during treatment, but fewer than half of these remained within 10 pounds of that weight when examined 18 months later. In other words, 80 to 90 percent of patients who wanted to lose weight were ultimately unsuccessful. Fabricatore and Wadden note that liquid meal replacements provide another method of facilitating adherence to a low-calorie diet, pointing to one study in which patients who replaced two meals a day with a shake lost 8 percent of initial weight during three months of treatment, whereas those who were prescribed the same 1,200–1,500 calories per day but consumed a self-selected diet of conventional foods lost only 1.5 percent of initial weight. They add that meal replacements may also facilitate the maintenance of weight loss. Patients in the same study who continued to replace one meal and one snack a day with shakes or snack bars maintained an 8 percent weight loss at 51 months. These programs are recommended only for those people who are at least 30 percent or 50 pounds

above desired body weight. Liquid diets may cause gingivitis and other dental problems, along with the normal adverse effects of rapid weight loss. According to the Federal Trade Commission (FTC), these programs require professional supervision because there is evidence that patients on liquid diets risk developing gallstones. Also to be considered are the high costs (generally between $1,400 and $2,800), time needed for medical monitoring and group support, and social restrictions when dinnertime comes. Episodes of sudden death (sometimes associated with myocardial abnormalities) like those that occurred with older liquid protein preparations have not been reported with current diet formulas. However, even these newer liquid formulas came under attack. In October 1991 the FTC charged marketers of Optifast 70, Medifast 70 and Ultrafast with making deceptive claims that their programs are safe and effective over the long term. As a result, liquid formula diet promoters must back up their claims of weight loss with more substantial studies over a longer duration. See also DIETING; FAT DIETS; PROTEIN-SPARING MODIFIED FAST. Fabricatore, Anthony N., and Thomas A. Wadden. “Treatment of Obesity: An Overview.” Clinical Diabetes 21, no. 2 (April 2003): 67–72.

Longitudinal Assessment of Bariatric Surgery (LABS) Originally known as the Bariatric Surgery Clinical Research Consortium and first funded in September 2003, LABS is a National Institutes of Health (NIH)–funded consortium of six clinical centers and a data-coordinating center working in cooperation with NIH scientific staff to plan, develop and conduct coordinated clinical, epidemiological and behavioral research in BARIATRIC SURGERY. LABS has brought together experts in bariatric surgery, obesity research, internal medicine, endocrinology, behavioral science, outcomes research, epidemiology and other relevant fields to plan and conduct studies that will analyze the risks and benefits of bariatric surgery and its impact on the health and well-being of patients with extreme obesity, and identify the kinds of patients who are most likely to benefit. Full information is provided at the NIH Web site at http://win.niddk.nih.gov/ publications/labs.htm.

190 low-carb diets low-carb diets Fad diets that restrict carbohydrates. Low-carb diets have enjoyed popularity periodically since the 1800s, taking turns with LOW-FAT DIETS as the current dieting standard. Spurred by a revision of the ATKINS DIET in the mid-1990s, restricting carbohydrates became a craze, affecting the food and restaurant industries as well as the book industry, which turned out several best-selling titles such as Dr. Atkins’ New Diet Revolution, Enter the Zone, The South Beach Diet, Protein Power, and The Carbohydrate Addict’s Diet. Restaurants had to devise sandwiches without bread, and reportedly some bakers literally had to close up shop during the low-carb craze. In August 2004, a reported 44 million Americans were either on a low-carb diet or watching their carb intake. NPD Group, an independent marketing information company, reported that the percentage of American adults on any low-carb diet peaked at 9.1 percent in February 2004, but dropped to 4.9 percent in November 2004, signaling a possible end to the low-carb “diet wars.” On July 31, 2005, Atkins Nutritionals filed for bankruptcy protection; other lowcarb businesses either cut back or folded during 2005. Several studies have shown that low-carb diets may cause more weight loss in the short term than conventional reduced-calorie, low-fat diets, but after a year there appears to be no difference. Some people have lost as much as 50 and 60 pounds on low-carb diets, only to eventually go off the diet and regain some of the weight, citing a “tiresome” and “monotonous” diet as the reasons. The medical community is divided about the safety of a low-carb diet. Some studies suggest it is safe; others suggest it is potentially dangerous. In the June 2004 issue of The Costco Connection, for example, two nutritionist authors argued opposite viewpoints on whether low-carb diets are a healthy choice. Dr. Howard Shapiro said, “People on strict low-carb diets miss out on health-giving nutrients and take in health-harming substances.” Dr. Fred Pescatore said, “Recent studies show that low-carb dieting has positive health outcomes in the treatment of heart disease by lowering all of the associated risk factors, lowering risk for diabetes and decreasing risks for certain cancers when done properly.” In their study of both low-carbohydrate dieters and low-fat dieters, Yancy et al. concluded, “Lowcarbohydrate diets seem to be effective and relatively safe. However, people on this diet must be monitored for harmful elevations of bad cholesterol.”

Health experts caution that low-carb does not mean no carbs. But people who restrict carbohydrates, especially those who take the diet to its extreme, may miss out on key nutrients, such as B vitamins (found in bread, pasta and cereal), vitamin C (found in orange juice), and calcium. The American Cancer Society expresses concern about the restriction of milk and yogurt, which are “important sources of calcium. As a result, many low-carb diet plans recommend taking a multivitamin/mineral supplement with calcium.” Scientists also warn that because the foods prohibited or restricted by low-carb diets (bread, pasta, breakfast cereals and orange juice) are fortified with folic acid, a micronutrient essential to the neurological development of fetuses, women should avoid low-carb diets during their reproductive years. The Berkeley Wellness Newsletter also cautions against paying extra for low-carb foods: Sleight-ofhand can distract you from an accurate comparison between low-carb foods and conventional ones. Here are two examples: • A slice of “low-carb” Atkins bread, for instance, has 60 calories and 8 grams of total carbs, though it claims to have only 3 “net impact” carbs. A slice of a conventional “diet” bread typically has 50 calories and 10 grams of carbs. That isn’t significant difference. • A 1-ounce low-carb chocolate bar has 155 calories and 12 grams of fat, but no sugar; it claims to have only 1 “net impact” carb. A regular bar has 150 calories and 10 grams of fat. (Some choice!) Low-carb candies are actually pretty much the same as the sugar-free candies that have been on the market for years.

The FDA has no definition of “low-carbohydrate” and has never approved any low-carb labels. Any food can be so labeled. Gaesser, Glenn A., and Karin Kratina. It’s the Calories, Not the Carbs. Toronto: Trafford Publishing, 2004. University of California, Berkeley. “Low-carb Foods: Less Than Meets the Eye.” Wellness Letter, January 2004. Available online. URL: http://www.berkeleywellness.com/ html/wl/2004/wlFeatured0104.html. Yancy, W. S., Jr., et al. “A Low-Carbohydrate, Ketogenic Diet versus a Low-Fat Diet to Treat Obesity and Hyperlipidemia: A Randomized, Controlled Trial.” Annals of Internal Medicine 140, no. 10 (May 18, 2004): 769–777.

low-fat diet

Whether dietary fat intake plays an important role in the rising prevalence of over-

low-fat diet 191 weight and obesity has long been a matter of controversy among weight-loss experts. According to a review of 28 studies investigating the relationship between fat intake and weight, people who switch to a low-fat diet but eat as much as they like still decrease their calorie intake by 11 to 30 percent. Findings suggest that the incidence of obesity has increased in nations where fat intake has risen but remained steady in countries where the population has continued to follow a low-fat diet. From these findings, Bray and Popkin contend that because low-fat diets pack comparatively fewer calories into the same amount of food, they can fill people up before they eat too many calories and are thus more satisfying. Because these diets are more satisfying, people are more likely to stick with them for the long term, and not only lose weight, but keep it off. The researchers estimate that the average person could expect to lose a pound or more a month simply by lowering their fat intake by 10 percent. They add that by combining lowered-fat intake with increased exercise, people can lose considerably more weight. But not all experts agree with this review and conclusion, criticizing the researchers’ choice of studies and their analysis. They argue that the degree of effect of dietary fat intake on body fat needs long-term trials to be determined. In a later study, Bray et al. argue, “In animals, increasing dietary fat increases body fat, and it is unlikely that humans escape this important biological rule. In epidemiological studies, increasing dietary fat is associated with increased prevalence of obesity probably by increasing the intake of energy dense foods.” They illustrate thus: The relation of dietary fat is most evident when physical activity is low. The speed of adaptation to dietary fat is increased by exercise. When dietary fat is reduced, weight is lost, but weight loss eventually plateaus. The rate of weight loss during the initial phase is about 1.6 g/day for each 1 percent decrease in fat intake. When dietary fat is replaced with olestra to reduce fat intake from 33 percent to 25 percent in obese men, weight loss continues for about 9 months reaching a maximum of nearly 6 percent of body weight and a loss of 18% of initial body fat. In the control group with a 25 percent reduced-fat diet, weight loss stopped after three months and was regained over the next six

months, indicating the difficulty of adhering to a conventional low-fat diet. Thus, dietary fat is an important contributor to obesity in some people.

In comments to the FDA Obesity Working Group in December 2003, representatives of the Weston A. Price Foundation, a nonprofit organization dedicated to exploring the scientific validation of dietary, agricultural and medical traditions throughout the world, made the following recommendation: Over the long term, low-fat diets have been shown to be disadvantageous for preventing the diseases they have been recommended for. Most people are at risk for lowered intakes of the important fat-soluble vitamins and other fat-soluble nutrients when they consume low-fat diets for any length of time. So it would seem that the fat content of natural fats that our ancestors used, with an average of 35–40 percent of energy as fat, makes sense.

In her review of weight-loss strategies, Arnst writes, The medical Establishment particularly favors lowfat diets for their proven ability to help prevent heart disease. Also note that the National Weight Control Registry, which has collected data on more than 3,000 people who maintained a loss of 30 pounds or more for at least one year, found that the majority of successful dieters in the registry followed a low-fat program. Keep in mind, though, that successful dieters are few and far between. It’s tough to cut fat without feeling hungry all the time, and many people end up replacing fat calories with carb or sugar calories. Besides, some fats, such as nuts and olive oil, can be good for you. Arnst, Catherine. “How to Weigh the Competing Claims of All Those Weight-Loss Plans.” Business Week, August 30, 2004. Available online. URL: http://www. businessweek.com/magazine/content/04_35/b38974 42.htm. Downloaded on September 15, 2005. Bray, G. A., S. Paeratakul, and B. M. Popkin. “Dietary Fat and Obesity: A Review of Animal, Clinical and Epidemiological Studies.” Physiology & Behavior 83, no. 4 (December 30, 2004): 549–555. Bray, George A., and Barry Popkin, “Dietary Fat Intake Does Affect Obesity!” American Journal of Clinical Nutrition 68, no. 6 (December 1998): 1,157–1,173.

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folate, and calcium can result in maternal complications, such as severe anemia, and in fetal complications, such as neural tube defect, intrauterine growth restriction, and failure to thrive. Nutrient supplementation following bariatric surgery and close supervision before, during, and after pregnancy can help prevent nutrition-related complications and improve maternal and fetal health.” Fujioka cautions that nutrients lost due to malabsorptive procedures may present long-term problems. “Over the next several years, the number of patients who will have had bariatric surgery for morbid obesity will reach close to a million. Several well-described nutritional problems such as B12 and iron deficiency will be noted in these patients. Many of these patients will be lost to the original surgeon and will now be in the care of the ‘other physicians.’ If these problems are left undiagnosed, severe and irreparable problems can result. Long-term problems, such as changes in bone metabolism, will need to be monitored. If some of these long-term problems are not addressed in a timely fashion, then eventual treatment becomes much more difficult.” See also BARIATRIC SURGERY; GASTRIC RESTRICTION PROCEDURES.

EPHEDRA.

malabsorptive operation Obesity surgery that creates a direct connection from the stomach to the lower segment of the small intestine, bypassing portions of the digestive tract that absorb calories and nutrients. Although such operations do involve some reduction in the size of the stomach, most of their success results from shortening the gastrointestinal tract so that food passes through without being broken down and absorbed by the body. The most commonly performed malabsorptive procedures today are BILIOPANCREATIC DIVERSION (BPD) and ROUX-EN-Y GASTRIC BYPASS (RGB). Malabsorptive operations produce more weight loss than restrictive operations, and are more effective in reversing the health problems associated with severe obesity. Patients who have malabsorptive operations generally lose two-thirds of their excess weight within two years. In addition to the risks of restrictive surgeries, malabsorptive operations also carry greater risk for nutritional deficiencies because the procedure causes food to bypass the duodenum and jejunum, where most iron and calcium are absorbed. Menstruating women may develop anemia because not enough vitamin B12 and iron are absorbed. Decreased absorption of calcium may also bring on osteoporosis and metabolic bone disease. Patients are required to take nutritional supplements that usually prevent these deficiencies. Woodard says that following this surgery, ability to become pregnant is improved because weight loss often allows for a normalization of sex hormones, but adds, “However, the nutrition challenges brought about by the surgery may have a profound impact on maternal health and pregnancy outcome. Deficiencies in iron, vitamin B12,

Fujioka, K. “Follow-Up of Nutritional and Metabolic Problems after Bariatric Surgery.” Diabetes Care 28, no. 2 (February 2005): 481–484. Woodard, C. B. “Pregnancy Following Bariatric Surgery.” Journal of Perinatal & Neonatal Nursing 18, no. 4 (October–December 2004): 329–340.

males and anorexia nervosa Boys and men do develop anorexia nervosa, but much less commonly than girls and young women. It is believed by many experts in the field that this condition may be more common in males than it seems to be 193

194 males and anorexia nervosa but not readily recognized by doctors because of its reputation as a female disorder. Recent estimates are that 5 to 10 percent of all cases occur in males. Based on the number of those who seek treatment, experts estimate that as many as one million men are affected by eating disorders. In 2003 Andersen wrote, “A recent large epidemiologic study has substantiated that males are probably underrepresented in both epidemiologic and clinical studies. While earlier studies reported ratios of as many as 10 females to one male, a ratio of one male to three or four females may be more accurate. This raises concerns that males are underrepresented in clinical programs, and calls for better understanding of the factors that may be keeping them from seeking treatment.” Many experts feel that the spread of lean male body images in men’s magazines in recent years has contributed to the increasing number of males being diagnosed with anorexia. Goode explains: Women with eating disorders may be driven by their desire to be thin, but men often express their preoccupation in different terms. Instead of a low body weight, they seek well-defined muscles, sleek abs and sculptured pecs. Achieving this goal, however, usually means excising every stray ounce of fat. If the anorexic or bulimic woman’s nightmare is being told that she has “a little meat on her thighs,” many men live in fear of being told that they “still have a little fat on those delts.”

Agliata and Tantleff-Dunn found that men who watched TV commercials featuring muscular actors felt unhappy about their own physiques. This “culture of muscularity” can be linked to eating disorders, the researchers said. Studies of male anorexics tend to agree that in general the behavior of males resembles closely that of their female counterparts, with a few exceptions. One is that males who become anorexic tend to do so on average at an earlier age than females. In addition, relatively more males come from working-class homes. Some studies have found that a family history of anorexia nervosa is particularly common in male cases. The anorexic male tends to be obese before becoming emaciated. Finally, there is an impression that male anorexics respond to treatment less well and may

be more likely to become chronic or drop out of treatment programs. HILDE BRUCH wrote that male anorexia “occurs in youngsters who seemingly were doing well but whose accomplishments were a facade, an expression of compliance, and not of self-initiated and self-directed goals. In their desperate struggle to become ‘somebody’ and to establish a sense of differentiated identity, they become overambitious, hyperactive, and perfectionistic.” Families of boys aged nine to 12 who develop anorexia are often described as psychologically disturbed or distressed, with the child having an unsatisfactory relationship with both parents. Most males with anorexia begin weight loss during adolescence. These boys are more often mildly to moderately obese before onset than girls who become ill at the same age. Many, but not all, adolescent boys with anorexia show confusion about sexual identity. In personality tests they present a spectrum of disorders from perfectionistic and obsessive to borderline personalities not capable of maintaining stable relationships, and display rapid and inappropriate mood changes. Restrictive male anorexics (see RESTRICTOR ANOREXICS) show complete impotence and absence of sexual activity and interest. When they regain weight, they experience a gradual return of normal sexual feeling. Fichter and Krenn note that not only homosexuality but also asexuality or sexual anxieties and inhibition have been documented in males suffering from anorexia nervosa. “Fichter and Daser found males to be significantly more anxious regarding sexuality, with 95 percent having tried to suppress their sexual drive and feeling relieved by loss of libido secondary to weight loss.” That study concluded that males with atypical gender role behavior have an increased risk for developing anorexia nervosa or bulimia in adolescence. Noting that males and females show substantial similarities during the acute illness phase of eating disorders, Fichter and Krenn say, “Before and after the acute phase of illness, differences between genders in respect to biological and social learning processes and gender role identity come to bear. Future research has to focus on these phases. There is still very little data on possible biological

males and bulimia nervosa 195 vulnerability factors (genetic, neurochemical, neuroendocrine, etc.) in males suffering from eating disorders.” Because few suspect eating disorders among teenage boys and men, the problems often go undiagnosed and untreated for many years. When finally recognized, the disorders are often far advanced and that much more difficult to treat. Andersen has noted that understanding the lower frequency of eating disorders in males may lead to more effective means of protecting girls from these disorders and the culturally induced distress about normal body size and shape that burdens adolescent development and adult life. See also MUSCLE DYSMORPHIA. Agliata, Daniel, and Stacey Tantleff-Dunn. “The Impact of Media Exposure on Males’ Body Image.” Journal of Social and Clinical Psychology 23, no. 1 (February 2004): 7–22. Andersen, Arnold E. “Anorexia Nervosa: 11 Areas of Advancement.” Eating Disorders Review 14, no. 2 (March/April 2003): 1. Andersen, Arnold E. “Anorectic Behavior Isn’t Quite the Same in Males.” BASH Magazine (July 1989). ———. “Anorexia and Bulimia in Adolescent Males.” Pediatric Annals 13, no. 12 (1984). Andersen, Arnold E., and J. E. Holman. “Males with Eating Disorders: Challenges for Treatment and Research.” Psychopharmacology Bulletin 33, no. 3 (1997): 391–397. Fichter, M. M., and C. Daser. “Symptomatology, Psychosexual Development and Gender Identity in 42 Anorexic Males.” Psychological Medicine 17, no. 2 (May 1987): 409–418. Fichter, Manfred, and Heidelinde Krenn, “Eating Disorders in Males.” In Handbook of Eating Disorders, 2nd Edition, edited by Janet Treasure, Ulrike Schmidt, and Eric van Furth, 369–383. West Sussex, U.K.: John Wiley & Sons Ltd., 2003. Goode, Erica. “Thinner: The Male Battle with Anorexia.” New York Times, June 25, 2000, section 16, p. 8.

males and bulimia nervosa

Occasional BINGE on high-calorie, easily ingested foods may be done by as many as 30 percent of male college students, according to studies. The percentage of males meeting the DSM-IV criteria for BULIMIA NERVOSA, however, is approximately 1–3 percent. In one report, male students reporting to a univer-

EATING

sity psychiatric clinic represented 10 percent of patients diagnosed as bulimic. The figures could be artificially low. In tests, men have freely acknowledged “frequent consumption of large quantities of food at times other than during meals”; unlike women, however, they tended not to label this behavior as binge eating. Generally, men have been found to be more comfortable with their weight and perceive less pressure to be thin than women. However, for male bodybuilders, long-distance runners and homosexuals, emphasis on body and physical appearance approaches the levels seen generally in women in our culture and puts these men at higher risk for developing eating disorders. A past history of obesity is another risk factor for males. Obese young males, being a minority in our society, are often targets of cruel verbal and physical taunting. They might easily become preoccupied with their body and their physical appearance. In some bulimia studies, the rare men with the diagnosis of bulimia nervosa all had a history of dieting from their mid- or late teens; indeed, this was all they had in common—only some had been anorexic, only some obese. According to Root, Fallon and Friedrich in Bulimia: A Systems Approach to Treatment, “it appears more difficult for the male bulimic to seek help, perhaps because the socialization of men discourages help-seeking and because bulimia has been described as a ‘woman’s problem.’ ” Through their comparison of men with eating disorders to men in the general population, Woodside et al. found that men with eating disorders were more likely to have other mental disorders and were less satisfied with their lives. Dr. Woodside said that these differences could result from side effects of the disorders. Gleaves and CepedaBenito also noted that males with bulimia nervosa have a later disorder onset than do women. In a Massachusetts General Hospital study of 135 males with eating disorders, 62 were bulimic. Of these, 42 percent were identified as either homosexual or bisexual. The study concluded that while most characteristics of males and females with eating disorders are similar, homosexuality/bisexuality appears to be a specific risk factor for males, especially for those who develop bulimia nervosa.

196 malnutrition Carlat, David J., Carlos A. Camargo, Jr., and David B. Herzog. “Eating Disorders in Males: A Report on 135 Patients.” American Journal of Psychiatry 154, no. 8 (August 1997): 1,127–1,132. Gleaves, David H., and Antonio Cepeda-Benito. “Eating Disorders.” In Handbook of Mental Health in the Workplace, edited by Jay C. Thomas and Michael Hersen, 311–329. Thousand Oaks, Calif.: Sage Publications, 2002. Kinzl, J. F., et al. “Eating-Disordered Behavior in Males: The Impact of Adverse Childhood Experiences.” International Journal of Eating Disorders 22, no. 2 (September 1997): 131–138. Woodside, D. Blake, et al. “Comparisons of Men with Full or Partial Eating Disorders, Men without Eating Disorders, and Women with Eating Disorders in the Community.” American Journal of Psychiatry 158, no. 4 (April 2001): 570–574.

malnutrition Poor nourishment resulting from improper diet or from some defect in metabolism that prevents the body from digesting or absorbing food properly. Extreme malnutrition may lead to starvation. Eating disorders sometimes result in malnutrition. While intentional malnutrition is the hallmark of anorexia nervosa, it represents a significant medical complication of bulimia in 20 percent of cases. Principal manifestations of malnutrition involve five body organ systems: endocrine (amenorrhea and estrogen deficiency), cardiovascular (lowered blood pressure and reduced heart rate), neuromuscular (osteoporosis), renal (kidney stones and renal failure) and gastrointestinal (gastritis and decreased acid secretion). mammography and obesity Researchers at the University of Washington analyzed 100,622 screening mammography examinations performed on members of a nonprofit health plan, and found that obese women had more than a 20 percent increased risk of having false-positive mammography results compared with underweight and normal-weight women. False-positive means that their mammograms were interpreted as abnormal, but follow-up testing did not find cancer. Being overweight (but not obese) raised a woman’s risk for false-positive results by 14 percent. Although the study did not find any difference among women of varying weights in the ability of

mammograms to detect cancer, the false-positives requiring more tests can cause severe anxiety and stress, as well as added health care costs. Noting that achieving a normal weight may improve screening mammography performance, the study’s authors suggest in the meantime that overweight and obese women return to the same facilities for each mammogram so the radiologist can compare the current test to previous ones. Elmore, Joann G., et al. “The Association between Obesity and Screening Mammography Accuracy.” Archives of Internal Medicine 164, no. 10 (May 2004): 1,140–1,147.

Mandometer Treatment A system developed in Sweden that is being used in Stockholm, Amsterdam, and San Diego to treat eating disorders. It allows simultaneous recording of eating rate and satiety, and in small studies has shown a 75 percent remission rate compared to the more usual 50 percent rate with other treatment options. Mandometer is a nutritional program that teaches patients to eat normally and recognize natural feelings of satiety using a patented computerbased biofeedback system. First, the rate at which a normal person would eat a meal and the amount eaten to become satiated is programmed into the Mandometer. Over time, patients learn to eat normally using this feedback and adapt eating speed and satiety to curves displayed on the computer monitor. Treatment time averages about 12 months and according to the San Diego company, “published research studies” show 93 percent of patients in Sweden “remain well for a minimum of one year.” No studies on the Mandometer appear on a PubMed database search. In 2004 the Mandometer was reported to be undergoing further development at the University of Bristol, Great Britain, for use as a treatment for childhood obesity. It was targeted to be ready in two years. Bergh, Cecilia, et al. “Randomized Controlled Trial of a Treatment for Anorexia and Bulimia Nervosa.” Proceedings of the National Academy of Sciences 99, no. 14 (July 9, 2002): 9,486–9,491.

marriage and eating disorders

Some women marry while anorexic, even though they are likely to be infertile. The anorexic will often choose a partner

media influence on eating disorders 197 who suits her as the kind of person she has become rather than as she was before becoming anorexic. For instance, the husband may be quiet and sexually undemanding, or alternatively superficially glamorous but privately wary of personal or sexual involvement. The marriage may be stable while the wife remains anorexic, but it will often be strained and tested if and when a process of recovery begins. Many bulimics vow to give up BINGE EATING and PURGING once they are married, hoping that marriage itself will magically transform their lives. Researcher Marlene Boskind-White has found that this does happen for some, but others resume their habit in secret, feeling more guilty and ashamed that ever. Bulimics have been known to keep their behavior a total secret from their husbands for as long as 15 years. But the deception often destroys a marriage. Some husbands conclude that their wives must be carrying on affairs because of their exaggerated sense of privacy. When they finally do find out that it’s “only” an eating problem, they are relieved and often don’t realize that it is even more significant than the affair they had suspected. A Canadian study examined the intimacy aspect of couples in which one member has an eating disorder, before and after intensive day hospital treatment for the disorder. Patients generally improved in terms of their eating disorder symptoms during the treatment. Spousal ratings showed satisfactory ratings of intimacy at the start of treatment and did not change during treatment. Woodside, D. B., J. B. Lackstrom, and L. Shekter-Wolfson. “Marriage in Eating Disorders Comparisons between Patients and Spouses and Changes over the Course of Treatment.” Journal of Psychosomatic Research 49, no. 3 (September 2000): 165–168.

marriage and weight gain

Researchers only corroborate what many couples have learned—that marriage leads to increased body weight and, in many cases, obesity. Sobal includes marriage among the many cultural and social factors that influence body weight. Drawing from numerous studies conducted since the 1970s, he cites several findings to illustrate how marriage is related to body weight and obesity: “Obese people enter marriage later and marry heavier partners. Married men, but not necessarily women, weigh more than

unmarried individuals. People tend to gain weight after entering marriage. People who terminate their marriages tend to lose weight. Overall, entering into marriage is more difficult for obese people, being married is associated with higher body weight, and terminating marriage is associated with weight loss. Marriage structures people’s lives, provides social obligations for eating and activities, and includes normative perceptions about body weight and shape. Marital status is a predictor of body weight levels, and effective interventions to change or maintain body weights can be structured around marital partners.” Jeffery and Rick found that BODY MASS INDEX (BMI) did not predict the likelihood of marriage or divorce. However, in their study, marriage was associated with a significant two-year weight gain and divorce with a significant two-year weight loss. “The results suggest that spouse similarity in BMI is at least partly due to shared environment. The observed effects of marriage and divorce on weight may be due to the influence of marriage on inducements to eat (e.g., shared meals) or on motivation for weight control.” Even patients with eating disorders have been reported to gain weight following marriage. Among the reasons proposed is that when people with eating disorders live alone, they are able to control the amount of food in their homes and the amount of food they eat. But when they begin living with a marriage partner, more food is likely to be in the home, meals are less apt to be eaten alone and the partner more prone to encourage the eating disordered person to eat more food. Jeffery, R. W., and A. M. Rick. “Cross-Sectional and Longitudinal Associations between Body Mass Index and Marriage-Related Factors.” Obesity Research 10, no. 8 (August 2002): 809–815. Sobal, Jeffery. “Cultural, Historical, and Social Influences on Body Weight.” Cornell Cooperative Extension. Available online. URL: http://www.cce.cornell.edu/ food/expfiles/topics/sobal/sobaloverview.html. Downloaded on February 12, 2005.

media influence on eating disorders Numerous studies during the past several decades have pointed to mass media—print advertisements, television commercials, images of stick-thin models—

198 media influence on eating disorders as exerting some influence upon the rate of eating disorders, perhaps even a strong impact. Among the findings have been the following: • One out of every 3.8 commercials send some sort of “attractiveness message” telling viewers what is or is not attractive, with the average adolescent seeing more than 5,260 attractiveness messages per year. • According to the National Eating Disorders Association, a study of one teen adolescent magazine over the course of 20 years found that in articles about fitness or exercise plans, 74 percent cited “to become more attractive” as a reason to start exercising and 51 percent noted the need to lose weight or burn calories. • Today’s adolescents have been exposed to extreme thinness as a standard of attractiveness for their entire lives. • In a survey of more than 500 girls in grades five through 12, 69 percent of the girls reported magazine pictures influencing their idea of the perfect body shape, and 47 percent reported wanting to lose weight because of the magazine pictures. • Duggan and McCreary found that viewing and purchasing of muscle and fitness magazines correlated positively with levels of body dissatisfaction for both gay and heterosexual men. Several authors have also recently written on the connection between the media and eating disorders: • Andrist wrote, “The media holds an awesome power to influence young women, bombarding them with images of abnormally thin models who seem to represent the ideal. When the majority of adolescents inevitably fail to achieve the extremely thin image they crave, body dissatisfaction results, and disordered eating can begin. Emerging research in the pediatric and adolescent literature demonstrates that children as young as 5 are already anxious about their bodies, and want to be thinner.” • Agliata and Tantleff-Dunn noted that although mass media are believed to be a pervasive force in shaping physical appearance ideals and have been shown to negatively impact females’ body image, little research has addressed the effects of

media exposure on males’ body image. Their research “exposed 158 males to television advertisements containing either ideal male images or neutral images that were inserted. Results indicated that participants exposed to ideal image advertisements became significantly more depressed and had higher levels of muscle dissatisfaction than those exposed to neutral ads.” Others have placed less emphasis on the role of media in perpetuating eating disorders. Gordon writes, “Whether such (increasingly thin and relatively less curvaceous in shape) media images play a causal role in eating disorders or whether they merely reflect the standards of the wider culture is a matter of some controversy, but there seems little doubt that there has been an increasingly stringent expectation for thinness in women.” Polivy and Herman write: “Exposure to the media is so widespread that if such exposure were the cause of [eating disorders], then it would be difficult to explain why anyone would not be eating-disordered. Furthermore, as Tiggemann & Picketing noted upon discovering that among girls, body dissatisfaction and drive for thinness were associated with increased exposure to certain types of TV shows, ‘although it is tempting to conclude that watching a large dose of thin idealized images on television leads to dissatisfaction with one’s body, a correlation cannot determine causality. An alternative scenario, for example, might be that those most dissatisfied with their bodies or wishing to be thinner, seek out or are more interested in particular types of television.’ ” Dr. Lou Rappaport, eating disorders expert and associate dean at the school of psychology and behavioral science at Argosy University in San Francisco, told the Boston Herald, “I think marketing of a certain body image and clothing is part and parcel of eating disorders. It doesn’t fully explain the problem, but I am sure it’s a part of it.” Agliata, Daniel, and Stacey Tantleff-Dunn. “The Impact of Media Exposure on Males’ Body Image.” Journal of Social and Clinical Psychology 23, no. 1 (February 2004): 7–22. Andrist, L. C. “Media Images, Body Dissatisfaction, and Disordered Eating in Adolescent Women.” MCN: The American Journal of Maternal Child Nursing 28, no. 2 (March–April 2003): 119–123.

Mediterranean Diet 199 Duggan, S. J., and D. R. McCreary. “Body Image, Eating Disorders, and the Drive for Muscularity in Gay and Heterosexual Men: The Influence of Media Images.” Journal of Homosexuality 47, no. 3–4: 45–58. Falcone, Lauren Beckham. “Will Skinny Screen Stars Spawn Wave of ‘Manorexia’?” The Boston Herald, February 1, 2005, page 31. Polivy, Janet, and C. Peter Herman. “Causes of Eating Disorders.” Annual Review of Psychology 53 (February 2002): 187–213. Tiggemann, M., and Pickering, A. S. “Role of Television in Adolescent Women’s Body Dissatisfaction and Drive for Thinness.” International Journal of Eating Disorders 20, no. 2 (September 1996): 199–203.

Medicare and obesity

Services, procedures and medications covered by Medicare change continually, so it is always advisable to check with the Centers for Medicare and Medicaid Services (CMS) to verify what is currently allowed. The Web page for doing this is located at http://www.cms.hhs.gov/ coverage. As of October 1, 2004, the CMS posted the following policies: Obesity may be caused by medical conditions such as hypothyroidism, Cushing’s disease, and hypothalamic lesions, or can aggravate a number of cardiac and respiratory diseases as well as diabetes and hypertension. Services in connection with the treatment of obesity are covered when such services are an integral and necessary part of a course of treatment for one of these medical conditions. However, program payment may not be made for treatment of obesity unrelated to such a medical condition since treatment in this context has not been determined to be reasonable and necessary. In addition, supplemented fasting is a type of very low calorie weight reduction regimen used to achieve rapid weight loss. The reduced calorie intake is supplemented by a mixture of protein, carbohydrates, vitamins, and minerals. Serious questions exist about the safety of prolonged adherence for 2 months or more to a very low calorie weight reduction regimen as a general treatment for obesity, because of instances of cardiopathology and sudden death, as well as possible loss of body protein. Services performed in connection with the treatment of obesity are covered by Medicare when such services are an integral and necessary part of a course of treatment for diseases such as hypothyroidism, Cushing’s disease,

hypothalamic lesions, cardiovascular diseases, respiratory diseases, diabetes, and hypertension. The treatment of obesity unrelated to such a medical condition (see above) is not considered reasonable and necessary and is not covered under the Medicare program. Supplemented fasting is not covered under the Medicare program as a general treatment for obesity. Where weight loss is necessary before surgery in order to ameliorate the complications posed by obesity when it coexists with pathological conditions such as cardiac and respiratory diseases, diabetes, or hypertension (and other more conservative techniques to achieve this end are not regarded as appropriate), supplemented fasting with adequate monitoring of the patient is eligible for local coverage determination through individual contractor discretion. The risks associated with the achievement of rapid weight loss must be carefully balanced against the risk posed by the condition requiring surgical treatment.

In 2005 the CMS was reevaluating policies for coverage of various BARIATRIC SURGERY procedures such as intestinal bypass surgery. At that time, “gastric bypass surgery for extreme obesity [was] covered under the program if (1) it is medically appropriate for the individual to have such surgery; and (2) the surgery is to correct an illness which caused the obesity or was aggravated by the obesity.”

Mediterranean Diet

A popular diet developed in 1995 by a team that included the Harvard School of Public Health and the World Health Organization. It is based on research led by pioneering medical scientist Ancel Keys, which investigated the link between diet and heart disease, and in the process discovered that people living in Crete, other parts of Greece and southern Italy lived longer and had very low rates of heart disease and certain cancers. The Mediterranean Diet emphasizes fruits, vegetables, nuts and whole grains, with olive oil the main source of dietary fat, and includes regular consumption of red wine. It includes some fish and poultry, but very little red meat and dairy products (mainly cheese and yogurt). Several studies have validated that such a diet is associated with reduced risk of heart disease, obe-

200 menopause and weight gain sity, gallstones, diabetes and certain cancers. After much debate about which component of the diet accounts for the benefits, researchers who followed more than 22,000 healthy Greeks for an average of four years determined that no single part of the Mediterranean diet played a significant role; rather, the cumulative effect of all these foods, perhaps interacting, was substantial. An Australian study found the Mediterranean Diet to be very effective for weight loss both in the short term and at 15 months follow-up. “Long term follow-up of this diet program is at least as effective as any diet or diet and drug therapy published. Individuals completing the recommended 12-week program seem to have more effective long-term weight loss.” Flynn, G., and D. Colquhoun. “Successful Long-Term Weight Loss with a Mediterranean Style Diet in a Primary Care Medical Centre.” Asia Pacific Journal of Clinical Nutrition 13 (2004): S139. Willett, Walter C. Eat, Drink, and Be Healthy: The Harvard Medical School Guide to Healthy Eating. New York: Free Press, 2001.

menopause and weight gain Menopause is that period marking the natural and permanent cessation of menstruation, occurring usually between the ages of 45 and 55. During the years immediately prior to the onset of menopause (premenopausal or perimenopausal) and following menopause (postmenopausal), many women experience increases in body weight and total body fat, as well as alterations in body fat distribution, with an increase in abdominal fat. One study showed premenopausal women between 42 and 50 years of age to gain an average of five pounds in three years, with 20 percent of these women gaining at least 10 pounds. Racette et al. wrote, “Based on the NHANES III data set, approximately 70 percent of women between 45 and 54 years of age are overweight or obese. Although increasing adiposity appears to be common after menopause, a great deal of evidence suggests that this phenomenon is neither desirable nor necessarily inevitable.” Among that evidence is the Women’s Healthy Lifestyle Project, which showed that reducing saturated fat and cholesterol consumption and preventing weight gain by

decreased caloric and fat intake and increased physical activity would prevent the rise in LDL cholesterol and weight gain in women during perimenopause to postmenopause. Also, Sternfeld et al. examined the relations of aging, menopausal status and physical activity to weight and waist circumference in 3,064 racially/ethnically diverse women aged 42–52 years at baseline who were participating in the Study of Women’s Health Across the Nation (SWAN), an observational study of the menopausal transition. They concluded, “Although midlife women tend to experience increases in weight and waist circumference over time, maintaining or increasing participation in regular physical activity contributes to prevention or attenuation of those gains.” Lovejoy emphasizes the importance of women preventing weight gain during the menopausal years: “Changes in body composition at menopause may be caused by the decrease in circulating estrogen, and, for fat distribution shifts, the relative increase in the androgen-estrogen ratio is likely to be important. Clinicians need to be aware of the likelihood of weight gain during the perimenopausal and postmenopausal years because behavioral strategies for weight loss can be effectively used in this population. Weight loss or prevention of weight gain is likely to have significant health benefits for older women.” Kuller, L. H., et al. “Women’s Healthy Lifestyle Project, a Randomized Clinical Trial: Results at 54 Months.” Circulation 103, no. 1 (January 2, 2001): 32–37. Lovejoy, J. C. “The Menopause and Obesity.” Primary Care 30, no. 2 (June 2003): 317–325. Racette, Susan B., Susan S. Deusinger, and Robert H. Deusinger. “Obesity: Overview of Prevalence, Etiology, and Treatment.” Physical Therapy 83, no. 3 (March 2003): 276–288. Sternfeld, et al. “Physical Activity and Changes in Weight and Waist Circumference in Midlife Women: Findings from the Study of Women’s Health across the Nation.” American Journal of Epidemiology 160, no. 9 (November 1, 2004): 912–922.

menstrual dysfunction

Abnormal functioning of the menstrual cycle in females. Menstrual dysfunction is a common condition accompanying ANOREXIA NERVOSA and BULIMIA NERVOSA. Early

metabolic equivalent 201 studies emphasized the role of weight loss and lean/fat ratio in AMENORRHEA. But later studies conducted at the University of Rochester Medical Center, Rochester, New York to determine the incidence of menstrual abnormalities in a group of women with abnormal eating attitudes but without obvious eating disorder symptoms found that 93.4 percent (compared with 15.0 percent of the CONTROL GROUP) reported an abnormal menstrual history. These data suggest that menstrual dysfunction often occurs in women with abnormal eating behavior but without weight loss or diagnosable eating pathology. Crow et al. examined menstrual and reproductive function in 173 bulimia nervosa patients retrospectively, with 10–15-year follow-ups, and concluded that while menstrual irregularities are common, bulimia nervosa appears to have little impact on later ability to achieve pregnancy. Regarding anorexics, Mitan wrote, “Psychological recovery may be as important as weight for return of menses. Weight-recovered patients with persistent amenorrhea restrict fat intake more and score higher on ‘anorexic’ measurements such as preoccupation with the nutritional value of food and distorted perception of body depth than do menstruating peers. Depression, a common dual diagnosis in anorexia nervosa patients, has also been linked to amenorrhea.” Crow, S. J., et al. “Long-Term Menstrual and Reproductive Function in Patients with Bulimia Nervosa.” American Journal of Psychiatry 159, no. 6 (June 2002): 1,048–1,050. Kreipe, R. E., et al. “Menstrual Cycle Abnormalities and Subclinical Eating Disorders: A Preliminary Report.” Psychosomatic Medicine 51, no. 1 (January–February 1989): 81–86. Mitan, L. A. “Menstrual Dysfunction in Anorexia Nervosa.” Journal of Pediatric and Adolescent Gynecology 17, no. 2 (April 2004): 81–85.

Meridia

See

mesomorph

SIBUTRAMINE.

A person whose body type is square and muscular. Mesomorphs have an athletic physique characterized by a broad trunk and shoulders with well-proportioned muscular arms and legs.

Theories linking body types to emotional or psychological characteristics are not considered scientifically sound. See also ECTOMORPH; ENDOMORPH; BODY TYPES.

mesotherapy

An alternative treatment developed in France in the 1950s for a variety of ailments ranging from tennis elbow to arthritis to migraine headaches and including the reduction and removal of fat and cellulite, via microinjections. Although the technique is used by 15,000 physicians in Europe and South America, it is not widely accepted by the U.S. medical community because no long-term studies have proven its safety or efficacy. Conventional or homeopathic medication and/or vitamins and amino acids are injected into the mesoderm, or middle layer of skin, which appears to accelerate the breakdown of fat stored in fat cells. A primary concern of dermatologists and plastic surgeons in the United States is that the conventional drugs used are intended for other purposes and thus may lead to unknown complications. A USA Today article quoted a derma-surgeon as saying, “No one says exactly what they put into the [syringe]. One drug they often use, phosphatidylcholin, is unpredictable and causes extreme inflammation and swelling where injected. It is not a benign drug.” Proponents argue that the biggest side effect is bruising. The procedure is intended primarily for healthy patients of normal weight or who have already lost weight through conventional means, but who have small areas of fatty deposits they want removed largely for cosmetic purposes. As with liposuction, tissue contoured by mesotherapy can reaccumulate the fatty deposits without proper diet and exercise. Mesotherapy treatments cost $300 to $500 and up per treatment, with 10 to 15 treatments common.

Kelly, Katy. “Pinpoint Fat Relief?” U.S. News & World Report, March 10, 2003, p. 56. Puente, Maria. “Critics Say Mesotherapy Offers Slim Chance.” USA Today, August 4, 2004, p. D1.

metabolic equivalent (MET) A way of measuring physical activity intensity. Although the inten-

202 metabolic syndrome sity of certain activities is commonly characterized as light, moderate or vigorous, many activities can be classified in any one or all three categories simply on the basis of the level of personal effort involved in carrying out the activity (i.e., how hard one is working to do the activity). For example, one can bicycle at intensities ranging from very light to very vigorous. This unit is used to estimate the amount of oxygen used by the body during physical activity. One MET equals the energy (oxygen) used by the body as a person sits quietly, perhaps while talking on the phone or reading a book. The harder the body works during an activity, the higher the MET. Any activity that burns three to six METs is considered moderate-intensity physical activity. Any activity that burns more than six METs is considered vigorous-intensity physical activity.

metabolic syndrome

Also called syndrome X or insulin resistance syndrome, metabolic syndrome is not a single disease but a cluster of particular medical problems, including obesity, insulin resistance, high blood pressure and hyperlipidemia (high lipid levels), that appear in varying combinations, and that put people at increased risk for heart attacks, stroke and type 2 diabetes and its complications. Obesity is considered a driving force for the condition. Metabolic syndrome is diagnosed when a person has three or more of the following conditions: abdominal obesity (a waist measuring at least 40 inches for men and 35 inches for women); high levels (at least 150 milligrams per deciliter) of triglycerides (fats that circulate in the blood); low high-density lipoprotein (HDL) cholesterol (less than 40 milligrams in men and less than 50 milligrams in women); high blood pressure (at least 135/85); and high fasting glucose levels (blood sugar) of at least 110 milligrams. Although experts had long suspected the syndrome was common, its prevalence was uncertain until a Centers for Disease Control and Prevention (CDC) study in 2002 provided hard numbers. The CDC team analyzed data from a cross-sectional sample of 8,814 men and women who participated in the Third National Health and Nutrition Examination Survey (1988–94). Although the unadjusted and age-adjusted prevalences of metabolic

syndrome were only 21.8 percent and 23.7 percent, respectively, the prevalence increased from 6.7 percent among participants aged 20 through 29 years to 43.5 percent and 42.0 percent for participants aged 60 through 69 years and aged at least 70 years, respectively. Mexican Americans had the highest age-adjusted prevalence of the metabolic syndrome (31.9 percent). The age-adjusted prevalence was similar for men (24.0 percent) and women (23.4 percent). However, among African Americans, women had about a 57 percent higher prevalence than men did; and among Mexican Americans, women had about a 26 percent higher prevalence than men did. Using 2000 census data, researchers determined that about 47 million U.S. residents have metabolic syndrome. Dietary approaches to treating and preventing metabolic syndrome vary, but nearly all experts agree that clinical parameters are greatly improved by reducing body weight by as little as 10 percent and increasing one’s level of physical activity. A high-carbohydrate diet can raise the risk of heart disease for those who have metabolic syndrome. For these people, too much carbohydrate will raise levels of triglycerides and lower levels of HDL (good) cholesterol. Ford, E. S., W. H. Giles, and W. H. Dietz. “Prevalence of the Metabolic Syndrome among U.S. Adults: Findings from the Third National Health and Nutrition Examination Survey.” Journal of the American Medical Association 287, no. 3 (January 16, 2002): 356–359. IFIC Foundation. “Metabolic Syndrome: Lifestyle Strikes Again.” Food Insight, May/June 2002, pp. 2–3.

metabolism

The sum of all chemical and physical processes by which the body transforms food and keeps itself alive. Metabolism is a two-phase process: catabolic and anabolic. In the catabolic, or destructive, phase, the body breaks down foods into simpler chemical substances. During this process, energy is released in the form of heat. The anabolic, or constructive, phase uses these substances to create new cells or mend damage. Persons with a high metabolism can eat more without gaining weight. The rate of metabolism can be increased by exercise; by elevated body temperature (as in a high fever), which can more than double the

metabolism 203 metabolic rate; by hormonal activity, such as that of thyroxine, insulin and epinephrine; and by specific dynamic action that occurs following the ingestion of a meal. Reduction of caloric intake, on the other hand, will lower the rate of metabolism. Studies with animals have shown that the rate may drop during starvation to 60 percent of prestarvation levels. The lower the normal metabolic rate, the more, and the more quickly, it drops in response to caloric restriction. Obese patients with the lowest metabolic rates prior to a diet lose the least amount of weight. It has been estimated that a dieter can expect to lose an average of 40 grams (1.5 ounces) per day for the first month if calories are cut from 2,000 to 1,500 per day. During the second month, expected weight loss would be half that amount—20 grams per day; during the third month, 10 grams per day; after that, no loss at all. Such evidence indicates that the metabolism adapts to caloric restriction by becoming more efficient. Studies on metabolism as it relates to obesity have led to several findings, including the following: • Metabolic rate naturally slows as people age. However, a study funded by the USDA Agricultural Research Service showed that older people may regain some of their youthful resting metabolic rate by regular muscle-building exercises. Increasing muscle mass would help seniors get off the “slow boat to obesity,” according to the researchers. • In starvation studies of animals, during the refeeding period following the fasting, the greater the amount of weight lost during fasting, the greater the weight gain per calorie eaten during refeeding. In one study, rats starved to 20 percent below normal weight gained 29.6 grams during the refeeding period while eating less food than controls—representing an 18-fold increase in metabolic efficiency. • People who become overweight tend to burn fewer calories than those who do not, either because they use food calories more efficiently or because they are less active. Studies suggest that once metabolism adjusts to increased weight, “normal” weight for obese people may be quite different from normal weight for thin

people. Adults who gained more than 22 pounds over four years were burning an average of 87 fewer calories a day than people who did not gain that much weight. The same study showed that slow metabolism tends to run in families. Periodically, magazine ads and television infomercials will promote supplements purported to boost metabolism and thereby stimulate weight loss without cutting calorie consumption or increasing energy expenditure through exercise. In December 2003 the Federal Trade Commission (FTC) provided a summary and analysis of the FTC’s public workshop called Deception in WeightLoss Advertising. Expert panelists at that workshop reported the following regarding such claims: Theoretically, products purporting to cause weight loss without diet or exercise would either need to cause malabsorption of calories or to increase metabolism (so-called thermogenic drugs). The effect of purported metabolism boosters appears to be very limited. For example, a study of green tea extract found only a four percent increase in metabolism. Ephedrine [ephedra], usually sold in combination with caffeine, has been one of the most popular thermogenic agents marketed over the past five years. It appears to produce only modest weight loss, mostly due to its appetite suppression effect. The significance of the small amount of weight that can be lost through increased metabolism is debatable. It is clear, however, that as the amount of claimed weight loss increases, the likelihood that such weight loss can be achieved without restricting caloric intake or increasing exercise decreases dramatically. For example, weight loss in the range of two pounds per week over periods of time beyond four weeks (eight or more pounds per month) would require a net caloric deficit of 7,000 calories per week, or a 1,000 calories per day, over an extended period of time. That would amount to 40 percent of the total calories consumed per week on a 2,500 calorie per day diet. The staff is unaware of any scientific literature suggesting that 40 percent increases in metabolism can be achieved without producing toxic effects on the body. In summary, the amount of weight loss that can be achieved through the use of nonprescription products without reducing caloric intake or increasing exercise is likely to be no more than one-fourth to one-third of a pound per week, with additional weight loss being attributable to reduced

204 metoclopramide caloric intake. Accordingly, weight loss in the range of two pounds per week over periods of time beyond four weeks (eight or more pounds per month) without restricting caloric intake or increasing exercise is not now scientifically feasible.

See also EPHEDRA; MALABSORPTION; THERMOGENIC DRUGS.

metoclopramide

A drug that increases the speed with which fluid and food pass from the stomach; it is often used prior to surgery. Metoclopramide has been prescribed to relieve the bloating complained of by many ANOREXIA NERVOSA patients after meals. However, the use of metoclopramide has been associated with significant depression and with hormonal changes, limiting its potential use in treating anorexia nervosa.

Mexican Americans and obesity

See HISPAN-

ICS/LATINOS AND OBESITY.

mind hunger

Also written as mind-hunger. A nonscientific term used to describe emotional eating— eating because one is angry, stressed, bored, sad or lonely, or simply to satisfy cravings or because the clock says it is time to eat, as opposed to eating to satisfy physical or body hunger. Geneen Roth, author of Breaking Free from Emotional Eating (Plume Books, 2003), explains, “Mind hunger is endless, bottomless, erratic. You pass a bakery and suddenly have to have an éclair, even though you ate breakfast 10 minutes ago.” When eating to satisfy mind hunger is not kept under control, weight gain and obesity can result over time. Roth, Geneen. “Satisfying Mind Hunger.” Prevention, February 2004, pp. 81–84.

molecular liposuction A therapy developed by scientists at the University of Texas’s M. D. Anderson Cancer Center that destroys blood vessels that support accumulation of fat, causing it to rapidly break down and disappear. Thus far, the treatment has undergone only animal testing, but the mice in the study had nearly doubled in weight from a high-calorie diet, and after treatment returned to normal size in four weeks. None of the mice used in

the experiment were genetically altered or prone to obesity prior to treatment; they gained weight because they ate a high-fat diet. The scientists who conducted the study noted that there were no toxic side effects to the treatment. They cautioned that further studies are needed to ensure that such treatment will not damage other vital tissues or vascular systems and that it will work on humans. Kolonin, Mikhail G. “Reversal of Obesity by Targeted Ablation of Adipose Tissue.” Nature Medicine 10, no. 6 (June 2004): 625–632.

mood disorders and eating disorders Mood disorders are disorders of feelings or emotions, usually involving depression or elation or mood swings between them. They are sometimes related directly to another physical or mental illness. The mood disorders of depression, premenstrual syndrome (PMS) and seasonal affective disorder (SAD) share similar features with eating disorders, including symptoms and development, a genetic or familial tie and neuroendocrinological evidence, and receive similar treatments. One symptom common to all these disorders is weight fluctuation. Depressed patients and SAD patients usually gain or lose weight as a result of increased or decreased appetite; PMS patients may retain water, causing weight gain, or they may crave foods high in CARBOHYDRATES—and as their snacking increases, so does their weight. Marked weight gain or loss is also often a key sign to diagnosing eating disorders. Additional evidence that mood and eating disorders are related is that 20 to 30 percent of all eatingdisorder patients are also depressed, and many of them have a family history of depression as well. Patients with anorexia nervosa may also manifest signs of mania such as euphoria and hyperactivity, as well as feelings of sadness, thoughts of suicide and suicidal behavior. In one study 27 out of 94 anorexic patients were depressed following treatment. Three others had committed suicide. Several other studies have reported incidence of depression among former anorexic patients in the 40 to 45 percent range. Researchers have also found a biological link between eating and mood disorders. APPETITE is controlled by the same endorphins (hormones

mood disorders and eating disorders 205 secreted in the brain) that control the sense of well-being, pain tolerance levels, irritability, memory, ability to concentrate and other feelings and functions. The hormone melatonin, which affects appetite, aggression and sex drive, may be one culprit in the cases of SAD, PMS and bulimia. Both exposure to light and darkness and premenstrual changes in the body determine the levels of melatonin produced. Disproportionate levels of melatonin seem to be a problem in bulimics and compulsive overeaters, causing them to eat more at certain times of the day. In women with premenstrual syndrome, melatonin may cause heavier eating before the period; in SAD patients it may cause them to eat more at other times. Victims of these disorders often find that after ingesting carbohydrates, they are in a better mood, can concentrate more easily and are less irritable. This theory is being studied more thoroughly, since a craving for carbohydrates, which bring melatonin to more normal levels, is common to all these disorders. Another problem area may be SEROTONIN, a NEUROTRANSMITTER, which also affects frame of mind, appetite, and sex drive. Low levels of serotonin can also cause craving for carbohydrates. A study conducted by Toner, Garfinkel and Garner investigated the incidence of mood and anxiety disorders in women who had been diagnosed with anorexia nervosa five to 14 years earlier. Results indicated that these disorders developed frequently, regardless of the outcome of the anorexia nervosa. Major depression and anxiety disorders developed before the eating disorder in more than half of these cases. A genetic or familial tie between eating and mood disorders has also been noted in several studies. In one, a group of 26 anorexic patients had two fathers, 15 mothers and six siblings diagnosed as having mood disorders. In another study, 25 anorexia nervosa patients were compared with 25 nonanorexics. The relatives of those with anorexia had a 22 percent incidence of mood disorder, whereas only 10 percent of the relatives of the control group had such histories. And a University of Minnesota study reported that among patients with bulimia, 34 to 60 percent had first-degree relatives with mood disorders. As with the relatives of the patients with anorexia nervosa, the predominant type of mood disorder among them was major depressive disorder. And treatments

specifically for eating disorders have been found to alleviate depression. Noting that few studies have investigated the specific associations of major depression versus dysthymia (a mood disorder characterized by mild depression) with eating disorders, Perez et al. followed 937 adolescents until the age of 24. “They wrote: Analyses revealed that dysthymia was a stronger correlate with bulimia than major depression, even while controlling for other mood disorders and a history of depression and dysthymia. The presence of dysthymia in adolescence might be a possible risk factor for the development of bulimia nervosa.” Polivy and Herman sum up the connection: “The co-occurrence of eating disorders and mood disorders (particularly depression) has been frequently noted and may reflect primary mood disturbance in eating disorders, mood disorders secondary to eating disorders, or common third variables (biological or psychosocial) leading to both, such as genetic or familial transmission. The lack of a well-organized body- and self-image is unique to eating disorders, however. Some evidence supports the primacy of the eating disorder; eating disorder symptoms and dietary restraint predicted subsequent depression in initially nondepressed individuals. Some studies find that eating disorder onset follows that of mood disorder, whereas still others suggest that depression and anxiety are more state-dependent features that resolve when eating disorder symptoms remit. Actually inducing negative affect increases body dissatisfaction and body-size perception in bulimia nervosa patients, suggesting that whichever is primary, negative affect can contribute to eating disorder symptoms.” (See also DEPRESSION AND EATNG DISORDERS.) Evidence against a connection between eating disorders and mood disorders is that eating disorders and mood disorders have different patterns of recovery; treatments that work for depression do not always work for eating disorders. And according to Dr. Moises Gaviria, professor of psychiatry at the University of Illinois at Chicago, at five-year follow-up, only 3 percent of depressed adolescents are eating-disordered, and their chances of developing an eating disorder in their lifetime is only 2 percent. The chances of their developing another mood disorder are 6 to 10 percent.

206 mortality rate Goldbloom, D. S., and P. E. Garfinkel. “The Serotonin Hypothesis of Bulimia Nervosa: Theory and Evidence,” Canadian Journal of Psychiatry, 35, no. 9 (December 1990): 741–744. Hatsumaki, Dorothy K., James E. Mitchell, and Elke D. Eckert. “Eating Disorders: A Variant of Mood Disorders?” In The Psychiatric Clinics of North America, vol. 7, no. 2: Symposium on Eating Disorders, edited by Félix E. F. Larocca. Philadelphia: W. B. Saunders, 1984. Hinz, L. D., and D. A. Williamson. Bulimia and Depression: A Review of the Affective Variant Hypothesis. Psychological Bulletin 102, no. 1 (July 1987): 150–158. Jewell, Regina. “Affective, Eating Disorders: Their Common Ground.” BASH Magazine, November 1989. Munoz, Rodrigo A. “The Basis for the Diagnosis of Anorexia Nervosa.” In The Psychiatric Clinics of North America, vol. 7, no. 2: Symposium on Eating Disorders, edited by Félix E. F. Larocca. Philadelphia: W. B. Saunders, 1984. Perez, M., T. E. Joiner, Jr., and P. M. Lewinsohn. “Is Major Depressive Disorder or Dysthymia More Strongly Associated with Bulimia Nervosa?” International Journal of Eating Disorders 36, no. 1 (July 2004): 55–61. Polivy, Janet, and C. Peter Herman. “Causes of Eating Disorders.” Annual Review of Psychology 53 (February 2002): 187–213. Toner, Brenda B., Paul E. Garfinkel, and David M. Garner. “Affective and Anxiety Disorders in the Long-Term Follow-up of Anorexia Nervosa.” International Journal of Psychiatry in Medicine 18, no. 4 (1988): 357–364.

mortality rate The number of deaths that occur per year in a particular population divided by the size of the population at that time. Mortality rates related to obesity and eating disorders include the following: • Mortality rates for BARIATRIC SURGERY are “scanty and wildly inconsistent” according to a Newsday (May 26, 2004) article: “The International Bariatric Surgery Registry estimates the mortality rate a month after surgery is one in 300 patients, while the American Society for Bariatric Surgeons says the death rate is one in 200 patients and a University of Washington study estimates one in 50 patients dies after surgery.” • A 12-year study of 750,000 individuals found that mortality rates increased approximately twofold for men and women who weighed 50 percent more than the average weight for their height. • A Centers for Disease Control and Prevention (CDC) study of nine-year mortality rates found

that individuals trying to lose weight had a 23 percent lower mortality rate than those who reported not trying to lose weight. This association was as strong for those who failed to lose weight as for those who succeeded in losing weight. Trying to lose weight was beneficial for overweight (BODY MASS INDEX [BMI] of 25–30) individuals but not for obese (BMI greater than 30) individuals. • A study published in The Archives of Surgery concluded that obesity, as an independent risk factor, carries a nearly six-fold increase in mortality rate. • In a review of the literature, Munson noted, “A 50-year follow-up to the Harvard Growth Study of 1922 to 1935 showed that obese adolescent boys ages 13 to 18 experienced twice the mortality rate from cardiovascular disease in adulthood. Being obese as an adolescent was a better predictor of overall mortality than being obese as an adult.” • Anorexia nervosa has the highest mortality rates of all psychological disorders: estimates range from 12 to 18 percent. • Gleaves and Cepeda-Benito note that mortality rates for binge-eating disorder may be higher than with bulimia nervosa because of the associated obesity.

Gleaves, David H., and Antonio Cepeda-Benito. “Eating Disorders.” In Handbook of Mental Health in the Workplace, edited by Jay C. Thomas and Michael Hersen, 311–329. Thousand Oaks, Calif.: Sage Publications, 2002. Munson, Suzanne. “Psychiatric Aspects of Child and Adolescent Obesity: A Review of the Past 10 Years.” Journal of the American Academy of Child and Adolescent Psychiatry 43, no. 2 (February 2004): 151–153. Rabin, Roni. “A High-Risk Answer to Obesity.” Newsday, May 26, 2004, p. A28.

movement therapy

Also called dance therapy, dance movement therapy and choreotherapy. A psychotherapeutic treatment method based on the premise that the way we move is intrinsically connected to our thoughts and feelings. Dance, as spontaneous body movement, has been used almost from the beginning of history to express feelings and attitudes. The American Dance Ther-

multicompulsive 207 apy Association defines movement/dance therapy as “the psychotherapeutic use of movement as a process which furthers the emotional, cognitive, social and physical integration of the individual.” It is a technique that uses nonverbal interaction between people as the primary means for accomplishing therapeutic goals. The premise behind movement therapy is that the body and mind are interrelated, thus mental and emotional problems can result in muscle tension and constrained movement patterns compounding the original condition. Conversely, the state of the body can affect mental and emotional well-being both positively and negatively. Levitt and Sansone explained further how movement therapy works with eating-disordered patients: “An extremely important part of treatment is to provide an opportunity for clients to identify their own body experiences more accurately (e.g., size and proportion, body image, relation to others). Art, music, and movement therapies are used in this process. For example, experiencing one’s body in motion during movement therapy develops an improved awareness of the spatial feel of the body self. For many, identifying internal experiences is difficult.” Wennerstrand added, “Dance/movement therapists help clients to name and modulate strong emotions. That is, by attending to a bodily felt sensation, the individual can start to notice different intensities of the sensation and through attention to breath and movement, notice what changes occur. Many patients are then better able to selfsoothe anxiety and other feeling states on their own outside of the therapy session.” The tendency of women with eating disorders to block their emotions and to fear loss of control is seen in blocked, split, rigid and restricted movement styles. Their self-esteem problems are demonstrated primarily in significant body image distortions. They seem to lack healthy boundaries in relationships and have either a rigid or an unclear sense of their kinesphere (personal body space). They tend to use more gestural than postural movements and lack the natural fluidity of movement. At the end of movement therapy, eating disordered patients seem more comfortable watching themselves in the mirror and their body image is less

distorted and more acceptable to them. They generally seem more self-accepting and sure of themselves. Levitt, John L., and Randy A. Sansone. “The Treatment of Eating Disorder Clients in a Community-Based Partial Hospitalization Program.” Journal of Mental Health Counseling 25, no. 2 (April 2003): 140+. Wennerstrand, Anne L. “Dance/Movement Therapy in the Treatment of Eating and Body Image Problems.” International Eating Disorder Referral Organization. Available online. URL: http://www.edreferral.com/ movement_therapy.htm. Downloaded on February 10, 2005.

multicompulsive

Also referred to as multiimpulsive. Having more than one compulsion simultaneously. Ten percent of bulimics are reported to display compulsive behavior in other areas, such as alcohol, drugs, stealing and sex. Multicompulsive behavior is very difficult to treat. Bulimics and anorexics sometimes become involved with drugs such as cocaine, methamphetamine, CAFFEINE and over-the-counter DIET PILLS as they learn about and experiment with their appetite-suppressing qualities. As their eating disorders worsen, substances such as alcohol, marijuana, barbiturates and so on become an enticing anodyne for painful reality. Eating-disordered women may actually convince themselves that their substance abuse in some way helps lessen the severity of their eating disorders. But in reality, substance abuse tends only to exacerbate their effects. For example, a bulimic woman who also abuses cocaine will extol the drug’s tendency to offset food binges and decrease her appetite. Upon further discussion, however, she will be less enthusiastic about addressing her BINGE EATING and PURGING as she copes with the DEPRESSION and despair that set in after the cocaine has worn off. An eating-disordered marijuana abuser may insist that her use of the drug is not a problem, emphasizing its relaxing effect. But she may neglect to mention the subsequent “killer munchies” that trigger marathon binges. Eating-disordered women may be particularly vulnerable to substance abuse when they are attempting to break away from bulimic or anorexic behavior. As uncomfortable feelings and memories begin to surface, they may seek intoxication as a means to numb their feelings without resorting to

208 multidimensional/multifactorial models compulsive behavior toward food. Richard L. Pyle, a clinician with the Department of Psychiatry of the University of Minnesota, reported that at least 2 percent of the women coming to his clinic for evaluation were also abusing alcohol and that one in five had had previous treatment for chemical dependency. Bulimic women who abuse alcohol present special problems. Perhaps the most significant problem is the high frequency of SUICIDE attempts. In one study, 32 percent of bulimic women who had a history of alcohol abuse reported suicide attempts, compared with none by non-alcohol-abusing bulimics and 26 percent by a third group of bulimic women with a history of major depression. In addition, bulimic women who had a history of chemical dependency had an older age of onset; significantly more DIURETIC ABUSE and LAXATIVE ABUSE; worse functioning in social, financial and work areas; a higher incidence of stealing both before and after the onset of their eating disorder; and, more often, a history of previous inpatient treatment for bulimia (56 percent vs. 4 percent). Daily substance abuse produces sufficient loss of control that outpatient treatment of bulimia nervosa is often unsuccessful. Inpatient care may be required to treat the chemical dependency, either concurrently with or preceding outpatient care for bulimia nervosa. Many clinicians also believe that a history of substance abuse in bulimia nervosa is associated with negative treatment outcome. However, a two- to five-year follow-up study by Dr. Pyle’s clinic indicated that, after treatment in an intensive outpatient group psychotherapy program, 24 patients who had a history of chemical abuse did as well as 65 who did not. In both groups 67 percent of the patients were symptom free at follow-up, and 25 percent were virtually unchanged. Only one of the 24 women with a history of chemical dependency required chemical dependency treatment during the follow-up, which averaged three and a half years, and three of 65 bulimic women without a history of chemical abuse required chemical dependency treatment. Therefore, Dr. Pyle summarized, a history of chemical abuse does not necessarily influence outcome negatively; and following successful treatment, patients with a history of alcohol abuse are no more at risk for chemical dependency than those with no history of alcohol abuse.

Doctors are also reporting a new trend of girls and young women using highly addictive cocaine and crack to lose weight. Drug dealers even promote these drugs with weight loss in mind, telling girls as young as 10 that boys like only thin girls and that crack (or cocaine) will help them lose weight. Crack, which is cheaper, is used mainly by poorer users, whereas cocaine is the drug of choice for the wealthier. Crack and cocaine suppress HUNGER by stimulating the central nervous system. Users feel no need to eat or sleep. In a potentially important recent study by Gleaves and Eberenz, the authors found that a large proportion of bulimic patients who displayed multi-impulsive characteristics also reported a history of sexual abuse. The authors speculated that many of the behaviors observed among this subgroup of patients may be part of a chronic posttraumatic stress reaction. The authors also noted that treatments may need to address the posttraumatic condition before directly attempting to change eating behavior. Gleaves, D. H., and Eberenz, K. P. “Sexual-Abuse Histories among Treatment-Resistant Bulimia Nervosa Patients.” International Journal of Eating Disorders 15, no. 3 (April 1994): 227–231. Mitchell, James E., Richard L. Pyle, et al. “A 2–5 Year Follow-Up Study of Patients Treated for Bulimia.” International Journal of Eating Disorders 8, no. 2 (March 1989): 157–165. Pyle, Richard L. “The Subtle, Puzzling Affinity of Drugs and Bulimia.” BASH Magazine, September 1989.

multidimensional/multifactorial models

Currently, the psychopathology of eating disorders is believed to be multidimensional in nature, and a series of factor analytic studies have identified what the various dimensions are for both anorexia and bulimia nervosa. Generally consistent across studies, the dimensions or features appear to be 1) bulimic behaviors (i.e., bingeing and purging); 2) restrictive eating; 3) body dissatisfaction/fear of fatness; 4) affective disturbance; and 5) personality disturbance. Some studies have found the latter two dimensions to be a single dimension.

Gleaves, D. H., and K. P. Eberenz. “The Psychopathology of Anorexia Nervosa: A Factor Analytic Investigation.” Journal of Psychopathology and Behavioral Assessment 15, no. 2 (June 1993): 141–152.

music 209 ———. “Validating a Multidimensional Model of the Psychopathology of Bulimia Nervosa.” Journal of Clinical Psychology 51, no. 2 (March 1995): 181–189. Gleaves, D. H., D. A. Williamson, and S. E. Barker. “Confirmatory Factor Analysis of a Multidimensional Model of Bulimia Nervosa.” Journal of Abnormal Psychology 102, no. 1 (February 1993): 173–176.

Multifactorial Assessment of Eating Disorder Symptoms (MAEDS) MAEDS is a brief self-report instrument designed to be used to evaluate treatment outcome for anorexia and bulimia nervosa. The instrument has six scales empirically and theoretically related to eating disorders: depression, binge eating, purgative behavior, fear of fatness, restrictive eating and avoidance of forbidden foods. Anderson, D. A., D. A. Williamson, E. G. Duchmann, D. H. Gleaves, and J. S. Barbin. “Development and Validation of a Multiaxial Treatment of Outcome Measure for Eating Disorders.” Assessment, 6, no. 1 (March 1999): 7–20.

muscle dysmorphia Also called muscle dysmorphic disorder and bigorexia, this disorder is the opposite of anorexia nervosa. People with muscle dysmorphia obsess about being small and undeveloped, rather than too large; they worry that their muscles are inadequate. They may spend hours in the gym, abuse supplements or steroids in order to become larger and withdraw from social situations in order to pursue their fitness goals. Choi et al. noted, “In addition to a desire for greater muscularity, they are very concerned not to gain fat.” The term was first used by Pope and his colleagues (McLean Hospital/Harvard) in 1997. The authors interviewed 24 men (18–30 years old) with muscle dysmorphia and 30 comparison weightlifters, recruited from gymnasiums in the Boston area, using a battery of demographic, psychiatric and physical measures. Data showed that the men with muscle dysmorphia differed significantly from comparison weightlifters on measures such as body dissatisfaction, eating attitudes, prevalence of anabolic steroids use and lifetime prevalence of DSM-IV mood, anxiety and eating disorders. Men with muscle dysmorphia frequently described shame, embarrassment and impairment of social and occupational functioning in association with their condition. By contrast, ordinary weightlifters displayed little pathology.

Although males make up the majority of people identified as having muscle dysmorphia, Gruber and Pope, who performed psychiatric and medical evaluations of 75 dedicated women athletes, found among them several unusual psychiatric syndromes, such as “rigid dietary practices (which we have termed ‘eating disorder, bodybuilder type’), nontraditional gender roles and chronic dissatisfaction and preoccupation with their physiques (a syndrome which we have termed ‘muscle dysmorphia’).” Choi, P. Y., H. G. Pope, Jr., and R. Olivardia. “Muscle Dysmorphia: A New Syndrome in Weightlifters.” British Journal of Sports Medicine 36, no. 5 (October 2002): 375–377. Gruber, A. J., and H. G. Pope, Jr. “Psychiatric and Medical Effects of Anabolic-Androgenic Steroid Use in Women.” Psychotherapy and Psychosomatics 69, no. 1 (2000): 19–26. Olivardia, R., H. G. Pope, and A. J. Hudson. “Muscle Dysmorphia in Male Weightlifters: A Case Control Study.” American Journal of Psychiatry 157, no. 8 (August 2000): 1,291–1,296. Pope, Harrison G., et al. “Muscle Dysmorphia: An Underrecognized Form of Body Dysmorphic Disorder.” Psychosomatics 38, no. 6 (November–December 1997): 548–557.

music Slow music reduces APPETITE, according to Johns Hopkins University research led by Maria Simonson. Researchers counted the number of bites people took during meals while listening to music. Subjects who listened to no music took 3.9 bites per minute, with a third asking for second helpings. Those who listened to lively music ate an average of 5.1 bites per minute, with almost half requesting second helpings. But subjects listening to soothing flute instrumentals ate only 3.2 bites per minute, and none requested seconds. Most of the slow-music diners left about a quarter of the food on their plates and said they were full. They also had fewer digestive complaints and said their food tasted better. Researchers speculated that heightened taste occurred because chewing forces air from the throat to the nose, allowing the nose to smell the food. Because odor is an important element in the sense of taste, slower chewing gives a heightened sense of flavor. See also EATING HABITS MONITORING; TASTE.

N (persisting even after remission of bulimic symptoms) in those who develop bulimic eating syndromes.”

NAAFA (National Association to Advance Fat Acceptance) Formerly known as the National Association to Aid Fat Americans, this nonprofit, tax-exempt organization formed in 1969 seeks to increase the happiness and well-being of fat people. Its basic purposes are to assist the large number of people regarded by the medical profession as “persistently or incurably overweight” to adapt to themselves and increase their self-confidence; to promote social tolerance toward fat people; to serve as a forum in which important problems affecting heavy people can be openly discussed; to disseminate knowledge pertaining to the sociological, psychological, medical and physiological aspects of obesity; and to sponsor research concerning these aspects of obesity. NAAFA is concerned with the general issues of fat people’s lives, such as job discrimination, individual psychological problems and difficulties with respect to social acceptance and mobility. Its goal is to remedy these difficulties rather than to make members leaner. Its quarterly publication is the NAAFA Newsletter.

Lehoux, P. M., H. Steiger, and S. Jabalpurlawa. “State/Trait Distinctions in Bulimic Syndromes.” International Journal of Eating Disorders 27, no. 1 (January 2000): 36–42. Steiger, H., et al. “A Controlled Study of Trait Narcissism in Anorexia and Bulimia Nervosa.” International Journal of Eating Disorders 22, no. 2 (September 1997): 173–178.

nasal spray and obesity

See PYY.

National Eating Disorders Association (NEDA) The largest not-for-profit organization in the United States working to prevent eating disorders and provide treatment referrals to those suffering from anorexia, bulimia and binge-eating disorder and those concerned with body image and weight issues. NEDA was formed in 2001, when Eating Disorders Awareness and Prevention (EDAP) joined forces with the American Anorexia Bulimia Association (AABA), merging the largest and oldest eating disorders prevention and advocacy organizations in the world. Headquartered in Seattle, Washington, with an office in New York City, the organization is staffed by 10 full-time employees and many dedicated volunteers. NEDA’s mission is to expand public understanding of eating disorders and promote access to quality treatment for those affected along with support for their families through education, advocacy and research. To achieve this, they develop prevention programs for a wide range of audiences, publish and distribute educational materials, and operate a toll-free eating disorders information and referral help line. See also APPENDIX III.

narcissistic personality disorder

As defined in DSM-IV, the essential feature of narcissistic personality disorder is a pervasive pattern of grandiosity, need for admiration and lack of empathy that begins by early adulthood and is present in a variety of contexts. Many theories attribute anorexia and bulimia nervosa to “pathological narcissism.” To evaluate this conception, Steiger, et al., compared narcissism scores of 90 eating disorder sufferers with 90 control subjects. Narcissism scores of eating-disordered patients consistently exceeded those of the control cases. In a Canadian study, Lehoux et al. concluded, “Narcissism may be a common trait characteristic

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212 National Eating Disorders Screening Program National Eating Disorders Screening Program (NEDSP) An educational and two-stage screening program designed to detect potentially clinically significant disordered eating attitudes and behaviors and offer referrals for further evaluation when warranted. The first National Eating Disorders Screening Program was conducted on more than 400 college campuses in 1996. The goal of the screening event is to reduce the stigma attached to eating disorders and let students know that help is available, according to Screening for Mental Health, the nonprofit organization that sponsors the NEDSP. The program offers education and screening to help students stop unhealthy eating habits before they evolve into full-blown eating disorders. As part of the program, students hear an educational presentation, complete a written selfassessment and have the opportunity to talk privately with a health professional about their screening results. If appropriate, students may be referred to the counseling center for a complete evaluation. Colleges across the United States offer this program in conjunction with Eating Disorders Awareness Week. Assessing the impact of the NEDSP on participants, Becker et al. determined that while such programs may be a promising strategy for secondary prevention of eating disorders, mere awareness of the risks of disordered eating and available treatment may not be sufficient to motivate individuals to adhere to recommendations to seek treatment. Studies of the first NEDSP also suggest that clinician bias may be an important barrier to care for eating disorder symptoms in ethnic minority populations. “Even after controlling for severity of selfreported eating disorder symptoms, both Latino and Native American participants in the NEDSP were significantly less likely than Whites to receive a recommendation or referral for further evaluation or care. Ethnic minority subjects with selfacknowledged eating and weight concerns were also significantly less likely than non-minority participants to have been asked by a doctor about eating disorder symptoms. Only one marginally significant difference was found between ethnic minority and non-minority respondents with respect to their help-seeking behaviors, namely, ethnic minority subjects were less likely (at the

level of a trend) to seek eating disorders treatment within 1(1/2)-2 years following the NEDSP.” Becker, A. E., et al. “Ethnicity and Differential Access to Care for Eating Disorder Symptoms.” International Journal of Eating Disorders 33, no. 2 (March 2003): 205–212. Becker, A. E., et al. “Secondary Prevention for Eating Disorders: The Impact of Education, Screening, and Referral in a College-Based Screening Program.” International Journal of Eating Disorders 36, no. 2 (September 2004): 157–162.

National Weight Control Registry (NWCR)

A National Institutes of Health–funded research study of individuals who have managed to lose weight successfully over the long term. It was developed by Rena Wing, Ph.D., of Brown University and the University of Pittsburgh, and James Hill, Ph.D., at the University of Colorado, to study weight loss and weight maintenance strategies. The registry includes more than 4,000 adults who have each lost an average of 60 pounds or more and maintained their weight loss for an average of 5.5 years—some longer than 10 years. NWCR is an ongoing study that solicits participants who are at least 18 years of age, have lost at least 30 pounds, and have maintained a weight loss of at least 30 pounds for one year or more. Individuals enrolling in the registry are periodically asked to complete questionnaires about their success at losing weight, current weight maintenance strategies and other health-related behaviors. There is no cost to enter the registry and participants receive no compensation. All names are kept confidential. Further information is available on the Web site (http://www.nwcr.ws) or by calling 1-800-606-NWCR (6927). The researchers have reported a number of findings from the study’s data. Among them: • Medical events or conditions are often reported as “triggers” for weight loss (other triggers include psychological and environmental factors), meaning that, they can initiate weight loss. Participants with medical triggers were older than those with nonmedical triggers or no trigger, had a higher initial BODY MASS INDEX (BMI) at entry into the NWCR, and were more likely to

neurotransmitters 213 be male. Participants with medical triggers reported greater initial weight loss than those with nonmedical triggers or no trigger. Participants with medical triggers also gained less weight over two years of follow-up than those with nonmedical triggers or no trigger. • Although successful weight losers continued to maintain a large percentage of their weight losses over two years, recovery from even minor weight regain was uncommon. • Participants who reported a consistent diet during the week were 1.5 times more likely to maintain their weight within five pounds over the subsequent year than participants who dieted more strictly on weekdays. A similar relationship emerged between dieting consistently across the year and subsequent weight regain. • Data from the NWRC indicate that moderating dietary fat intake is a key strategy for long-term management of body weight. • A large proportion of NWCR subjects (78 percent) reported regularly eating breakfast every day of the week. Only 4 percent reported never eating breakfast. Thus, eating breakfast may be a factor in the success of people who maintain weight loss over time. • Although approaches to weight loss differ widely among the NWCR participants, strategies for weight loss maintenance are similar—including eating a diet low in fat, frequent self-monitoring of body weight and food intake and high levels of regular physical activity. Gorin, A. A., et al. “Promoting Long-Term Weight Control: Does Dieting Consistency Matter?” International Journal of Obesity and Related Metabolic Disorders 28, no. 2 (February 2004): 278–281. Gorin, A. A., et al. “Medical Triggers Are Associated with Better Short- and Long-Term Weight Loss Outcomes.” Preventive Medicine 39, no. 3 (September 2004): 612–616. Peters, J. C. “Dietary Fat and Body Weight Control.” Lipids 38, no. 2 (February 2003): 123–127. Phelan, S., et al. “Recovery from Relapse among Successful Weight Maintainers.” American Journal of Clinical Nutrition 78, no. 6 (December 2003): 1,079–1,084. Wing, Rena R., and James O. Hill. “Successful Weight Loss Maintenance.” Annual Review of Nutrition 21 (2001): 323–341.

Native Americans and eating disorders

See

AMERICAN INDIANS/ALASKA NATIVES.

Native Americans and obesity

See AMERICAN

INDIANS/ALASKA NATIVES.

net carbs Also called active carbs or impact carbs. A term introduced by the ATKINS DIET, it relates to those carbohydrates having an effect on blood sugar and insulin. Under a Food and Drug Association food labeling agreement in 2001, net carbohydrates can be calculated from a food source by subtracting sugar alcohols and fiber (which are shown to have no effect on blood sugar level) from total carbohydrates. But the concept of net carbs is controversial. Ellison writes, “Is the term a reliable nutritional designation or a dubious marketing tool? Even the Food and Drug Administration is still debating the definition of the term, while it attempts to come up with standards for ‘lowcarb.’ ” Although the number of products listing net carbs on their labels continues to grow, nutrition experts say the science behind these claims is fuzzy, and it is unclear whether counting net carbs will help or hurt weight loss efforts. Some experts question the accuracy of net-carb counts on food labels. Ellison, Sarah. “Blood Sugar, Sugar Alcohol and the FDA.” Wall Street Journal, July 26, 2004, pp. B1, B6.

neurotransmitters

Chemicals that transmit electrical impulses or “messages” from one neuron (nerve cell) to another or to a muscle cell. Much scientific study has been directed at key chemical messengers in the brain that play a major role in regulating hormone production. Researchers have found anorexics and bulimics to have abnormal levels of certain neurotransmitters. For example, low levels of the neurotransmitter SEROTONIN are linked to bulimia, as well as the mood disorders, depression and impulsive behavior associated with bulimia. Low serotonin levels may contribute to bulimics’ binge eating of food high in carbohydrates. In anorexia, lower-than-normal levels of norepinephrine are found in the spinal fluid. Because the norepinephrine levels are low in anorexic patients who have regained weight, it is possible that this

214 night eating syndrome neurotransmitter abnormality precedes weight loss and may, in fact, indicate a genetic connection to the eating disorder. But the same biochemical condition also could result from anorexics’ starvation practices.

night eating syndrome (NES)

The name given by Albert J. Stunkard in 1959 to an eating pattern in which an obese person succeeds in keeping his eating-disordered behavior under control during the day, in the interest of normal functioning, but is unable to resist it at night when alone. HILDE BRUCH described such a patient: She was quite efficient in her work, although her severe obesity became increasingly a handicap. When she was alone at night, the tension and anxiety became unbearable. “I think then that I am ravenously hungry and I do my utmost not to eat. My body becomes stiff in my effort to control my hunger. If I want to have any rest at all, I’ve got to get up and eat. Then I go to sleep like a newborn baby.” Patients with Night Eating Syndrome are unable to adhere to any dietary regimen as long as their problems and conflicts are unresolved, or as long as they remain in an anxiety- and rage-provoking environment. They can reduce without difficulty in a hospital but will regain as soon as they return to the old setting.

In a study reported in 1996, Stunkard and his team concluded that the frequency of night eating syndrome is comparable to that of binge-eating disorder. This was followed in 1997 by a University of Florida study that found prevalence of night eating syndrome to be higher among postoperative obesity patients than among a randomly selected sample of adults, but within the range reported for binge-eating disorder. They concluded that night eating syndrome may warrant consideration as a distinct eating disorder. Tanofsky-Kraff and Yanovski argue, however, that it is yet unclear whether night eating syndrome as currently defined should be a distinct patient subgroup. “We propose that a distinction be made between ‘eating disorders’ and ‘non-normative’ eating patterns without associated distress or impairment. Although non-normative eating patterns may not be considered mental disorders, they may be very important in terms of their impact on body weight and health. More precise behavioral and

metabolic characterization of subgroups with eating disorders and non-normative eating behaviors has important implications for understanding the etiology, pathophysiology, and treatment of obesity. Ultimately, better understanding of the many pathways to increased energy intake may lead to targeted strategies for prevention of overweight and obesity in at-risk individuals and populations. In a comparison of obese and nonobese persons who have NES, Marshall et al. found very little difference between the two groups, except that the normal-weight NES subjects were considerably younger, leading the authors to conclude, “The striking similarity in the characteristics between obese and nonobese subjects with the NES indicates that this disorder, considered until now to occur primarily among obese persons, also occurs among nonobese persons. The younger age of the nonobese subjects suggests that the NES may contribute to the development of obesity.” Striegel-Moore et al. attempted to describe the prevalence of night eating in a community cohort of black and white girls, using different definitions of night eating as described in the literature. They found that frequency of night eating varied tremendously depending on how the behavior was defined. Thus, they concluded, “A standard definition of night eating behavior is needed to advance the field. An agreed-on operationalized definition that includes time of day, amount of calories consumed, and a frequency criterion would enable cross-study comparisons and encourage the examination of developmental and clinical considerations of night eating behavior. Stunkard and Allison noted in 2003 that “Studies of treatment for NES are in their infancy but selective serotonin reuptake inhibitors (SSRI) show promise.” Stunkard has found NES in 6 to 7 percent of people in weight-loss programs and up to 28 percent of those seeking gastric-bypass surgery. In their book, Overcoming Night Eating Syndrome, Allison et al. put the disease in perspective with the following facts: • Of people seen in clinics for treatment of obesity, 9 percent also suffer from NES. • Approximately a third or more of individuals who are extremely overweight, ranging from 27 to 42 percent, also have NES.

novelties for weight loss 215 • About 40 percent of all people with NES are men; about 60 percent are women. • NES usually develops in people in their 20s and 30s, but for some it may develop earlier or later because of a strong genetic component in their eating behaviors or in response to a stressful life situation.

organizations interested in affecting the future health and well-being of Hispanic children across the United States.

nocturnal sleep-related eating disorder

See

SLEEP-RELATED EATING DISORDER.

nonexercise activity thermogenesis (NEAT) Allison, Kelly C., Albert J. Stunkard, and Sara L. Thier. Overcoming Night Eating Syndrome: A Step-by-Step Guide to Breaking the Cycle. Oakland, Calif.: New Harbinger Publications, 2004. Bruch, Hilde. Eating Disorders: Obesity, Anorexia Nervosa, and the Power Within. New York: Basic Books, 1973. Marshall, H. M., et al. “Night Eating Syndrome among Nonobese Persons.” International Journal of Eating Disorders 35, no. 2 (March 2004): 217–222. Rand, C. S., et al. “The Night Eating Syndrome in the General Population and among Postoperative Obesity Surgery Patients.” International Journal of Eating Disorders 22 (July 1997). Striegel-Moore, R. H., et al. “Definitions of Night Eating in Adolescent Girls.” Obesity Research 12, no. 8 (August 2004): 1,311–1,321. Stunkard, Albert J., et al. “Binge Eating Disorder and Night Eating Syndrome.” International Journal of Obesity and Related Metabolic Disorders 20 (January 1996). Stunkard, Albert J., and Kelly C. Allison. “Two Forms of Disordered Eating in Obesity: Binge Eating and Night Eating.” International Journal of Obesity and Related Metabolic Disorders 27, no. 1 (January 2003): 1–12. Tanofsky-Kraff, M., and S. Z. Yanovski. “Eating Disorder or Disordered Eating? Non-normative Eating Patterns in Obese Individuals.” Obesity Research 12, no. 9 (September 2004): 1,361–1,366.

Niños Activos, Familias Sanas (Active Children, Healthy Families) A Centers for Disease Control and Prevention (CDC) campaign launched in summer 2004 to encourage Hispanic/Latino parents to get their children ages nine to 13 involved in physical activity for at least 60 minutes every day as a way to reduce childhood obesity. The campaign used various communications channels to convey culturally relevant messages in Spanish. In addition to TV, radio and print, a 26-week event tour visited various events across the country. Community and corporate partnerships help to ensure that these efforts are sustained and adopted by other

Physical activity associated with fidgeting, restlessness, stretching, maintenance of posture, moving around and other activities of daily life. In a Mayo Clinic study in which 16 people volunteered to stuff themselves with 1,000 extra calories a day for eight weeks, some gained as much as 16 pounds, while others gained as little as two pounds. The difference, according to the researchers, was due to increased total daily energy expenditure through increased NEAT. Those people who had the greatest increase in NEAT gained the least fat, and those who had the least change gained the most. These results suggest that as humans overeat, activation of NEAT dissipates excess energy to preserve leanness and that failure to activate NEAT may result in ready fat gain. In a later study Levine et al. examined NEAT’s role in obesity by measuring volunteers’ body postures and movements every half-second for 10 days. Obese individuals were seated, on average, two hours longer per day than lean individuals. Posture allocation did not change when the obese individuals lost weight or when lean individuals gained weight, suggesting, the authors concluded, that it is biologically determined. “If obese individuals adopted the NEAT-enhanced behaviors of their lean counterparts, they might expend an additional 350 calories (kcal) per day.” Levine, James A., N. L. Eberhardt, and M. D. Jensen. “Role of Nonexercise Activity Thermogenesis in Resistance to Fat Gain in Humans.” Science 283, no. 5399 (January 8, 1999): 212–214. Levine, James A., et al. “Interindividual Variation in Posture Allocation: Possible Role in Human Obesity.” Science 307, no. 5709 (January 28, 2005): 584–586.

novelties for weight loss Commercial items, usually useless for any practical purpose, designed to appear useful or amusing. Some novelties are

216 nutrients devices contrived to be taken seriously by people interested in losing weight or becoming trim, for instance, by appearing capable of reshaping a person’s body while he or she remains completely passive. Such items are sold in health food stores, drugstores, special clinics and salons, as well as through the mail and over the Internet. A few of these, like “appetite-suppressing” eyeglasses with colored lenses that are supposed to project an image to the retina that dampens the desire to eat, are or border on the ridiculous. Yet hundreds, even thousands, of overweight people allow their unhappiness with their condition to override their common sense and are duped by such products regularly. One weight reduction novelty, BODY WRAPPING, was invented in France. Areas of the body to be reduced are smeared with a cream, which may contain such ingredients as sea salt, herbs and cod liver oil, and wrapped in special bandages or garments. The intent is to “melt” or “burn” fat, especially CELLULITE, right off the body. The creams, gels, wraps, belts and sweatsuits are said to reduce body dimensions by removing fluids—that is, the user sweats it off. This is a very temporary loss because the fluid is regained when the person eats or drinks. Moreover, rapid and excessive fluid loss is potentially dangerous because it can cause severe dehydration and chemical imbalance. The U.S. Food and Drug Administration has taken legal action against several promoters of these products for making unsubstantiated weight loss claims. Other French techniques for fighting cellulite are more aggressive, and some are potentially dangerous. Machines massage a woman’s legs with powerful jets of air or administer a barrage of “fatdispersing” injections. A reducing machine that delivers slight electrical shocks to selected muscles, causing them to contract and supposedly do the client some good, has achieved some degree of popularity. A 35minute session with the machine is supposed to be equivalent to 1,500 push-ups or sit-ups without the unpleasant aches and pains required from such strenuous exercise. The electrical muscle stimulator has legitimate uses in physical therapy but is useless for weight loss or figure firming. Claims that stimulation from

these devices has the figure-toning effect of as many as 3,000 sit-ups, for example, are without any scientific basis. Further, these devices, often promoted through mail order for home use, can be dangerous if not handled correctly. There have been reports of electrical shocks and burns, and the devices can be particularly hazardous to pregnant women and to people with heart problems, pacemakers or epilepsy. Hillel Schwartz believes that the popularity of these novelties lies in the key word for American dieting: secrecy. He says that although dieters want to have others notice weight loss, most do not want others to know they are dieting. Thus, such implements of fat destruction as girdles, corsets and wooden roller belts (the forerunners of today’s vibrating machines) became popular because they could be hidden under the dieter’s clothing. See also FRAUDULENT PRODUCTS. Schwartz, Hillel. Never Satisfied: A Cultural History of Diets, Fantasies and Fat. New York: Anchor Books, 1990.

nutrients Substances in food necessary for life. They include carbohydrates, fats, proteins, vitamins, minerals and water. Carbohydrates, fats and proteins provide energy, and vitamins and minerals are essential for the METABOLISM that uses this energy. Water, composing 60 percent of our total body weight, provides the medium in which chemical reactions take place. The combination of processes by which the body takes in and uses food containing these nutrients, which includes digestion and metabolism, is called nutrition. Nutrient-dense foods are those that provide substantial amounts of vitamins and minerals and relatively fewer calories, such as fruits and vegetables. The opposite of nutrient dense is calorie dense, which describes foods that mainly supply calories and relatively few nutrients. They are typically high in fat and/or sugar, such as white bread, pastries, ice cream or chocolate candy. The Dietary Guidelines for Americans, released by the U.S. Department of Health and Human Services (HHS) and the U.S. Department of Agriculture (USDA) every five years, are the federal government’s science-based advice designed to

nutritional counseling 217 help Americans choose diets that will meet nutrient requirements. The 2005 guidelines warned that many Americans consume more calories than they need without meeting recommended intakes for a number of nutrients. Nutritional intake is of particular importance in adolescence because of rapid growth and development during this period, but several government and private studies have shown that while obesity among American children is escalating, consumption of Recommended Daily Allowance of critical foods and nutrients is on the decline. Adolescents with anorexia nervosa also rob their bodies of essential nutrients. While anorexics do not take in enough food to provide adequate nutrients, people with binge-eating disorder usually eat large amounts of fats and sugars, which do not have a lot of vitamins or minerals, so they also may not get the right nutrients. The overweight or obese need to be wary of fad diets, which may not provide all of the nutrients the body needs. U.S. Department of Health and Human Services, U.S. Department of Agriculture. Dietary Guidelines for Americans 2005. Washington: U.S. Government Printing Office, 2005. Available online. URL:http://www. health.gov/dietaryguidelines/dga2005/document. Downloaded on August 15, 2005.

nutritional counseling Frequently recommended in the treatment of eating disorders. As physicians Michele Siegel and Judith Brisman and Margot Weinshel explain in their book Surviving an Eating Disorder, “Some people with eating disorders have extremely chaotic eating patterns or have not eaten a ‘meal’ in years. Nutritionists, who are trained to assess nutritional imbalances and develop dietary programs, can help recovering clients correct nutritional deficits and develop healthy eating habits, perhaps for the first time.” The authors say that counseling is most successful after binge eating, purging or starving behaviors have decreased, when food is no longer used as a coping mechanism and eating is a response to physiological, not psychological, hungers. Professor P. J. V. Beumont, presenting a paper on “Dietary Advice” at the BASH VII International

Conference in April 1989, stated that nutritional counseling is an important component of the treatment of all bulimic patients and is usually essential if therapy is to be effective. He gave the following reasons why nutritional guidance is so important: • Eating behavior is often so erratic in bulimics that patients need to regain control of their habits before they become involved in other forms of treatment such as PSYCHOTHERAPY. • Bulimics view their problem as one of overeating and do not understand that gorging is a response to prior restrained eating practices. • Bulimics have many fears and misconceptions about food and weight control that need to be identified and corrected. (They firmly believe that if they eat regular meals or high-energy foods, they will inevitably get fat.) • Bulimic patients have had disordered eating habits for so long that they need to learn to recognize when they are hungry and when they are satisfied. Sometimes nutritional counseling is recommended in order to provide an appropriate diet. But a diet is not always the answer to an eating disorder. Many eating-disordered people are actually experts on diet and nutrition. They know what they should be eating. Eating disturbances are not due to lack of knowledge or information but to the psychological disorders that keep people from using them. Thus nutritional counseling works best, some experts feel, after psychological treatment has progressed. In fact, nutritional counseling by itself has not been proven effective for anorexia nervosa. Pike et al. compared nutritional counseling with cognitivebehavioral therapy (CBT) for anorexia nervosa and found the overall treatment failure rate (relapse and dropping out combined) was significantly higher for nutritional counseling (73 percent) than for CBT (22 percent). Experts have noted that this points to the need for nutritional counseling along with CBT when treating anorexia nervosa. Nutritional counseling is also important when treating obesity, and critical following BARIATRIC

218 nutritional counseling SURGERY, according to experts. Proper nutritional counseling may prevent long-term nerve damage following weight-loss surgery. A program of behavioral treatment and nutritional counseling, designed to help make long-term changes in one’s diet and physical activity, is also important for patients taking appetite suppressant medications. Some insurance companies now provide nutritional counseling in an effort to encourage the obese to lose weight, and people of normal weight to maintain good health.

Beumont, P. J. V. “Diet Guide for Bulimics.” BASH Magazine, June 1989. Pike, K. M., et al. “Cognitive Behavior Therapy in the Posthospitalization Treatment of Anorexia Nervosa.” American Journal of Psychiatry 160, no. 11 (November 2003): 2,046–2,049. Siegel, Michele, Judith Brisman, and Margot Weinshel. Surviving an Eating Disorder. Rev. ed. New York: Perennial Currents, 1997.

O evaluation of three key measures: BODY MASS INDEX (BMI), waist circumference and a patient’s risk factors for diseases and conditions associated with obesity. The body mass index equals a person’s weight in kilograms divided by his or her height in meters squared. Because BMI describes body weight relative to height, it is strongly correlated with total body fat content in adults. To estimate BMI using pounds and inches, one divides the weight in pounds by the height in inches squared and multiplies the result by 704.5. The multiplier 704.5 is used by the National Institutes of Health. Other organizations may use a slightly different multiplier; for example, the American Dietetic Association suggests multiplying by 700. The variation in outcome (a few tenths) is insignificant. “Overweight” is defined as a BMI value of 25–29. “Obesity” is defined as a BMI of 30 or above BMI cutoff points are a guide for definitions of overweight and obesity and are useful for comparative purposes across populations and over time; however, the health risks associated with overweight and obesity are on a continuum and do not necessarily correspond to rigid cutoff points. For example, an overweight individual with a BMI of 29 does not acquire additional health consequences associated with obesity simply by crossing the BMI threshold of 30. However, health risks generally increase with increasing BMI. The definitions or measurement characteristics for overweight have varied over time, from study to study, and from one part of the world to another. The varied definitions affect prevalence statistics and make it difficult to compare data from different studies. Excess fat accumulation is associated with increased FAT CELL size; in extremely obese individuals, the number of fat cells is also increased. In the simplest terms, obesity is an imbalance between intake of food and expenditure of energy. The excess taken in is stored in fat deposits, resulting in an increase in body weight.

obesity

Body weight in excess of biological needs; excessive fatness. The first federal guidelines on the identification, evaluation and treatment of overweight and obesity in adults were released on June 17, 1998, by the National Heart, Lung, and Blood Institute (NHLBI), in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), both part of the National Institutes of Health (NIH). These clinical practice guidelines were designed to help physicians in their treatment of overweight and obesity, a growing public health problem that now affects 129.6 million American adults (over 20 years old), or 64.5 percent of the population. Women comprise 64.5 million (61.9 percent) and men comprise 65.1 million (67.2 percent). Nearly one-third of U.S. adults are obese—61.3 million (30.5 percent). Women comprise 34.7 million (33.4 percent) and men 26.6 million (27.5 percent) of the total. Overweight and obese individuals are at increased risk of illness from hypertension, lipid disorders, Type II diabetes, heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea and respiratory problems, and certain cancers (uterine, breast, colorectal, kidney and gallbladder). Obesity is also associated with high blood cholesterol, complications of pregnancy, menstrual irregularities, hirsutism (presence of excess body and facial hair), stress incontinence (urine leakage caused by weak pelvic floor muscles), psychological disorders such as depression and increased surgical risk. A recent Swedish study also found that obese people are twice as likely to develop dementia. The total costs attributable to obesityrelated disease are $117 billion annually, $61 billion direct costs and $56 billion indirect costs. The NIH guidelines no longer utilize the traditional height/weight charts for defining obesity that insurance companies had relied on for years. According to current guidelines, assessment of overweight involves

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220 obesity Possible Causes Why this imbalance occurs remains uncertain. Although genetic influences appear to be the most likely factor in explaining a tendency toward obesity, the precise trigger for its development is unknown. As a result, there is a variety of methods for treating obesity, with results that also vary. Until recently, obesity was considered to be caused simply by eating too much, as a result of psychological problems with food: using food to deal with DEPRESSION, anxiety, boredom, even happiness. The prevailing theory was that to lose weight an obese person needed only to eat less. Recent studies have shown, however, that tendency to overweight is biological rather than psychological or diet driven. Some studies have shown that thin people, as a group, tend to eat more than obese people. People with identical diet and exercise programs may become, or remain, fat or thin. The difference is now believed to be genetic. Other research has demonstrated that obesity tends to occur in families. One large study, which collected data from approximately 10,000 individuals, revealed that hereditary factors accounted for 11 percent of the variance in the incidence of obesity, and family environment for 35 percent. Because families usually share diet and lifestyle habits that may contribute to obesity, the separation of pure genetic factors from family environment is a challenge. Jeffrey, Dawson and Wilson wrote that metabolic determinants of obesity have gained increasing attention from researchers. In a year’s time, they explain, the average person of normal weight consumes more than one million calories, but there is little variation in body weight because a comparable number of calories is used in bodily maintenance and activity. Taking in 10 percent more calories or expending 10 percent less energy would lead to a 30-pound weight gain within a year. Researchers conclude that in normal-weight individuals, body weight is regulated with extraordinary accuracy. Moreover, research suggests that the hypothalamus is directly linked to weight regulation, containing a feeding center that controls appetite and SATIETY and maintains body weight. Leptin, a protein produced by fat cells, has been identified as playing a role in regulating body fat, and may signal body fat levels to the hypothalamus. Individual differences in leptin production or resistance to leptin at its site of action may result in differing patterns of energy use and

eating behavior. However, more research must be done in this area. Some studies have shown that, rather than causing obesity, metabolic and endocrinological anomalies actually result from it. Jeffrey et al. also list social learning processes as playing a major etiological role in most cases of obesity: A social learning theory of obesity is based on the concept of energy balance and the assumption that our eating and physical activity habits, good or bad, are mostly acquired patterns of behavior. Thus, social learning theory specifically focuses on the acquisition and maintenance of behaviors that result from environmental factors. This conceptualization has clear implications in the assessment and subsequent treatment of an eating disorder.

Rodin et al. stated that the role of psychological variables in the etiology of obesity is still not fully understood. The etiologic significance of many factors once thought to be important—lack of impulse control, inability to delay gratification, or faulty eating habits—has not been supported by experimental evidence. Other factors, depression and dysphoria, for example, appear to be consequences rather than causes of obesity, although they may serve to maintain and intensify weight-related problems. Dieting in response to weight concerns appears, perversely, to be implicated in increasing overweight. Response to food cues in the environment may also play a causal role in some cases of obesity. Among the “environmental” causes, researchers have suggested increased consumption of corn syrup (see FRUCTOSE AS A CONTRIBUTOR TO OBESITY; HIGH FRUCTOSE CORN SYRUP), a more sedentary lifestyle due to labor-saving tools and increased television and computer use, junk foods in schools, suburban sprawl leading to more automobile travel and less walking, less physical activity in schools and larger servings at restaurants. Some illnesses can lead to obesity or a tendency to gain weight. These include hypothyroidism, Cushing’s syndrome, depression and certain neurological problems that can lead to overeating. Also, drugs such as steroids and some antidepressants may cause weight gain. A doctor can tell whether there are underlying medical conditions that are causing weight gain or making weight loss difficult. Emotional Overeating Some people, when they are nervous, tense, angry, frustrated or upset, often indulge in overeating

obesity 221 because food has become an emotional outlet for them. It acts as a sedative, giving them a feeling of well-being and security. Overindulgence in food helps to control the emotional stress they experience. Many of these people show signs of other exaggerated oral activity, such as excessive talking, laughing, giggling or nail biting. Physicians have categorized four major types of emotional overeating: • Overeating as a response to tension, anger, upset, loneliness or boredom. • Overeating as a substitute gratification for lack of sex or love, or when faced with an intolerable life situation such as the hostility of a parent or spouse. • Overeating due to addiction to food. (See BINGEEATING, COMPULSIVE EATING and CRAVING.) • Overeating as a symptom of an underlying depression and hysteria. HILDE BRUCH believed that obesity is an essential and desirable state for a considerable number of emotional overeaters. These people use their excessive fat like a security blanket—as a protective barrier against the world. For these people, loss of weight is fraught with psychological danger and may result in serious psychological consequences. Risk Factors Obesity is the most common chronic medical condition in America today and affects all age groups, according to the National Center for Health Statistics. For example, one-year-old children today typically weigh 50 percent more than one-year-old children of a generation ago. In 1993 the deputy assistant secretary for health, J. Michael McGinnis, and the former director of the Centers for Disease Control and Prevention (CDC), William Foege, coauthored a journal article, “Actual Causes of Death in the U.S.” They concluded that a combination of dietary factors and sedentary activity patterns accounts for at least 300,000 deaths each year, making obesity the second leading cause of preventable death in the United States (tobacco being the first). In 1995 the Institute of Medicine issued a report that expressed concern about the growing prevalence of overweight and obesity in the United States.

In 2004 Mokdad et al. used published causes of death for the year 2000, relative risks and prevalence estimates from published literature to update actual causes of death in the United States, determining that preventable deaths from obesity-related factors had risen to 400,000 per year. However, about a year later, the authors stated that “through an error in our computations, we overestimated the number of deaths caused by poor diet and physical inactivity. Our principal conclusions, however, remain unchanged: tobacco use and poor diet and physical inactivity contributed to the largest number of deaths, and the number of deaths related to poor diet and physical inactivity is increasing.” Using methods similar to those used by earlier investigators, the authors corrected the estimate to 365,000 deaths per year in the United States attributable to poor nutrition combined with physical inactivity. Then, in April 2005, another team of CDC scientists and NIH researchers, using mortality data from several major federal health surveys, attributed 111,909 deaths each year to obesity. They also found that people who are overweight but not obese have no added risk of death. McKay wrote, “In fact, for people classified as merely overweight but not obese, there was an unexpected positive effect in comparison with persons of normal weight—namely, 86,000 fewer deaths.” The researchers then subtracted the benefits of being modestly overweight and arrived at 25,814 deaths a year attributable to obesity—ranking it as the seventh leading cause of death in the United States. Among the proposed explanations for the lower mortality rate among overweight are improvements in public health and medical care, plus a declining rate of high cholesterol and some other risk factors for cardiovascular disease among the overweight. The vast majority of obesity-related deaths occurred in people with a body mass index of at least 35. The prevalence of overweight and obesity has steadily increased over the years among both genders, all ages, all racial/ethnic groups, all educational levels and all smoking levels. From 1960 to 2000 the prevalence of overweight increased from 31.5 to 33.6 percent in U.S. adults aged 20 to 74. The prevalence of obesity during this same time period more than doubled from 13.3 to 30.9 percent, with most of this rise occurring in the past 20 years. From 1988 to 2000 the prevalence of extreme obesity increased from 2.9

222 obesity to 4.7 percent, up from 0.8 percent in 1960. In 1991, four states had obesity rates of 15 percent or higher, but none had an obesity rate above 16 percent. By 2000 every state except Colorado had an obesity rate of 15 percent or more, and 22 states had an obesity rate of 20 percent or more. The prevalence of overweight and obesity generally increases with advancing age, then starts to decline among people over 60. The age-adjusted prevalence of combined overweight and obesity (BMI greater than 25) in racial/ ethnic minorities—especially minority women—is generally higher than in whites in the United States: • Non-Hispanic black women: 77.3 percent • Mexican American women: 71.9 percent • Non-Hispanic white women: 57.3 percent • Non-Hispanic black men: 60.7 percent • Mexican American men: 74.7 percent • Non-Hispanic white men: 67.4 percent While there is no generally accepted definition for obesity as distinct from overweight in children and adolescents, the prevalence of overweight is increasing for children and adolescents in the United States. Approximately 15.3 percent of children (ages six to 11) and 15.5 percent of adolescents (ages 12–19) were overweight in 2000. An additional 15 percent of children and 14.9 percent of adolescents were at risk for overweight (BMI for age between the 85th and 95th percentile). Women in the United States with low incomes or low education are more likely to be obese than those of higher socioeconomic status; the association of socioeconomic status with obesity is less consistent in men. Obesity is less common after age 70 among both men and women, possibly due to a progressive decrease in BMI with increasing age past the fifth decade or to an excess in mortality associated with increasing BMI in the presence of increasing age. Several conditions are recognized as placing an individual at risk for developing obesity: Heredity Recent studies have confirmed previous findings that heredity is involved in the development of obesity. Doctors and scientists have examined different families and found that obesity is more common in some than in others. Some researchers have gone so far as to call “family” the most important risk factor for obesity, cit-

ing a 1965 study that found that 80 percent of the children of two obese parents will be obese, 40 percent of the children of one obese parent will be obese and 10 percent of the children of two lean parents will be obese. In foster families with overweight parents, the natural children tend to be more overweight than the foster children. A “biological clock” factor refers to genetic characteristics that influence adolescent growth and amount of body fat. Throughout childhood, the obese as a group develop faster not only with respect to weight and height but also in terms of overall size, skeletal and dental maturation. This is particularly evident among those obese from infancy. This lends support to the notion that the growth of ADIPOSE TISSUE is not completely independent of the growth and maturation of other tissues, and that each may influence the other. Morphology of fat tissue In general, those adults with a childhood history of obesity display the most marked degree of adipose tissue hyperplasia (abnormally high number of cells), and obese children begin to differ significantly with respect to size and number of fat cells as early as age two. In nonobese children, fat cell size and number increase during the prepubescent and adolescent periods, after remaining relatively stable from the age of two. In contrast, massively obese children have achieved adult cell size by age two, and after that time they show a constant increase in cell numbers. Early dietary excess There is evidence that fat cell size expands in the first 12 months of life and fat cell number increases up to 12–18 months of age. Using various weight-based indices, some researchers have attributed obesity to infant feeding practices. Family environment Theories based on family-centered learning emphasize the psychosocial interactions in the social environment of the family as important factors in the development of obesity. In some cases this may involve major disruptive events, such as long separation from the mother or an overly protective family environment, but these causes are considered much less common than a family disinclination to physical activity and exercise, or a social, emotional and physical environment within the family that favors overindulgence. Family eating habits are often blamed for childhood obesity.

obesity 223 Social learning theory There is reason to suspect that, at least for adult-onset obesity, factors involving social learning after the early years within the family are very much involved. The effectiveness or frequency of attempts to lose weight is thought to vary, especially by social class, even as early as adolescence. Social learning also influences knowledge of weight control techniques and of nutrition. Psychological time-bomb theory Theories of obesity as resulting from neuroticism or excessive emotional reaction to adolescent stress have been largely ruled out by recent studies. The evidence for them is considered less convincing than that for more sociologically and culturally oriented explanations. However, numerous studies suggest that obese people, once they have become obese, may develop psychological symptoms and that these may become particularly apparent during weight reduction efforts. They are especially pronounced among those with an earlier age of onset and a greater degree of obesity. Such individuals are generally very sensitive about their condition. Because obese adolescents are discriminated against both in employment and in high-ranking college admissions, it has been suggested that these social selection factors, felt most strongly in late adolescence, tend to encourage obese adolescents into social environments more permissive of obesity; thus they become even fatter. Affluent sedentary society In our highly mechanized, automated society, most people expend little energy in muscular work. Children and adolescents are more sedentary than formerly, and energy output is even lower among adults. The obese are generally less active than others. The widespread availability of palatable, cheap (and commercially promoted) foodstuffs is another characteristic of the affluent society in Western countries today. Given such abundance, food and eating not only may be used to satisfy physiological needs but also are readily available means for coping with various emotional states. Food cues in the physical and electronic environment also favor overindulgence if the propensity for it is there. Recent studies emphasize the importance of the social environment in these respects. Health Complications Many studies have found that obesity either contributes to or is associated with a number of diseases, including diabetes, high blood pressure, coronary

heart disease, complications of pregnancy, osteoarthritis and some cancers and infections. Scientists also report that obesity may foretell certain diseases, such as breast and uterine cancer. As pounds are added, more cells divide, increasing the odds that they will divide abnormally and develop into tumors. Animal studies show that eating fewer calories reduces colon and breast cancer risk regardless of dietary fat levels. Cancer risk was also reduced in rats that ate as much as they wanted but maintained lean body mass with exercise. Severe childhood obesity increases the risk of a number of diseases. An immediate danger is deformation of the spine or the long bones of the limbs. These changes in the skeletal system may be particularly pronounced if obesity is accompanied by vitamin D and calcium deficiency. A low hemoglobin blood count is quite common in obese children, making them more susceptible to tonsillitis and respiratory infections and prolonging their duration. Obese children also tend to have significantly higher levels of glucose, cholesterol and triglycerides, putting them more at risk for developing atherosclerosis (vascular fat deposits), which can lead to heart attacks and strokes. Several studies have shown that the risk of liver and kidney damage from surgical anesthesia with halogenated anesthetic agents is greater than normal for patients who are obese. Women with a high concentration of abdominal fat seem to be at higher risk for diabetes mellitus, cardiovascular disease, mental disorders and psychosomatic disease than other women, according to a study of 1,492 Swedish women. Benefits of Obesity? Not all clinicians subscribe to the supposition that all obesity is harmful. There have been critics of prevailing views on obesity for nearly 50 years, some asserting that obesity is more of an aesthetic and moral problem than one of physical health. Some researchers have even proposed that there may be advantages, medical and other, to being fat. One detailed study of the effects of weight on mortality followed nearly the entire population of Norway for 10 years after an initial physical examination. Optimal life expectancy occurred at weights 10–30 percent above actuarial standards. Weights slightly less than standard were far more hazardous than those slightly more.

224 obesity The fact that obese persons have a normal life expectancy presents a paradox, since the incidence of a number of serious risk factors is increased in obesity. Paul Ernsberger, a biomedical researcher at Cornell University Medical School and a leading proponent of the theory that obesity is not necessarily hazardous, suggests that the solution to this puzzle is that there are advantages as well as disadvantages to being heavy. He states that obese persons are less likely to develop cancer, citing numerous studies. The obese, he says, are also protected against infectious diseases, chronic obstructive pulmonary disease, osteoporosis, mitral valve prolapse, intermittent claudication, renovascular hypertension, eclampsia, premature birth, anemia, diabetes Type I, peptic ulcer, scoliosis and suicide. These health benefits of obesity might potentially offset its hazards. Obesity is also associated with improved survival in several diseases. Ernsberger states that heavy persons with hypertension, diabetes Type II and hyperlipidemia have a more favorable prognosis than thin people with these same ailments. Obese hypertensives have been shown to outlive lean hypertensives in 15 separate controlled studies. Although hypertension, diabetes and hyperlipidemia have reduced complications and mortality in heavy persons, this does not mean these conditions are benign in obesity, nor does it mean that diabetics and hypertensives should be encouraged to gain weight, since this may worsen their condition. However, Ernsberger suggests that the threat to the health and longevity of fat people posed by diabetes and hypertension may be overestimated, owing to the failure to take into account the ameliorating influence of obesity on these conditions. Janet Polivy of the University of Toronto and Toronto General Hospital, who has researched obesity and eating disorders for more than 20 years, stresses that it is unclear whether obesity is a “problem” in any but the social sense. She says the socalled health hazards of obesity have been grossly overstated. While medical disorders do result from excessive body weight, many of the diseases blamed on overweight are not a simple result of excess weight per se. More often, they are caused by overeating, by large and rapid weight fluctuations and possibly most often by dieting. Specifically, she cites heart attacks usually blamed on obesity, but actually caused by diet pills and inadequate diets.

Researchers at the University of Nebraska Medical Center analyzed 8,428 adult hospital admissions and reported their findings in the May 1988 Journal of Gerontology. Obesity was associated with higher mortality only when subjects were 100 percent or more overweight; being at or below ideal weight was usually associated with increased mortality. The lowest mortality occurred at moderate overweight. Underweight seemed to be a more important predictor of mortality than overweight in older hospitalized subjects. Psychological Effects Not all medical professionals believe that childhood psychological problems are at the root of adult obesity. In his book The Dieter’s Dilemma, William Bennett suggests that although there are people who overeat in a desperate attempt to handle inner conflicts, they are probably a small fraction of fat people. In fact, he says, fat people as a group are mentally quite healthy, considering what they must put up with. They are not more neurotic than thin people and, in some ways, less so, since they have maintained their mental health through decades of well-intentioned but ineffective efforts to explain and “improve” them. Yet Jeffrey, Dawson and Wilson say, Unpleasant affective responses and overeating commonly occur together. Negative feelings such as anger, resentment, anxiety, or loneliness, when handled by eating, lead to continued obesity and to the development and maintenance of maladaptive behavior. Thus, some individuals learn to use food to escape from tension or boredom or to assuage pain or depression. On the other hand, food and overeating also appear to be frequently associated with social occasions, fun, and self-gratification.

Treatment The fundamental treatment for obesity is caloric reduction combined with increased caloric expenditure (i.e., exercise). The traditional view has been that weight loss depends on reducing the total number, rather than the kind, of calories consumed. While some popular FAD DIETS concentrate on certain types of calorie intake, there is very little evidence of the superiority of such diets to more conventional, calorie-restricted but balanced diets. The degree of caloric restriction required to lose weight depends on the

obesity 225 degree of obesity, age, sex, physical activity and general health of the patient. Except for unusually active individuals, it would be difficult to lose weight while consuming more than 1,200 calories per day. Dramatic weight losses commonly result from VERY LOW CALORIE DIETS of fewer than 800 calories; side effects include hypotension, constipation and occasional dizziness. Although initial losses may be impressive, these diets have not effectively encouraged permanent weight loss. Polivy cautions that self-imposed dieting often results in eating binges once food is available and in psychological preoccupation with food and eating. She recommends instead healthful and balanced eating without specific food restrictions. Physical training is widely used for reduction of body fat, although it frequently does not result in a net weight loss because of a parallel increase in muscle mass. With continued training, though, the decrease in body fat generally exceeds the increase in muscle mass so that a net loss in body weight does occur. Studies have shown that at least eight weeks of three-per-week sessions, each lasting a minimum of 30 minutes, is required to reduce fat tissue measurably. Studies have also shown that the initial six to eight months of a training program are characterized by a decline in BODY FAT, after which most individuals reach a plateau in total body weight and in percentage of body fat. One other result of physical training is a general HUNGER-reducing effect of intensive EXERCISE. For most, exercise is more effective in preventing rather than treating obesity. In recent years there has been increased interest in BEHAVIOR MODIFICATION for the treatment of obesity. Such techniques as slowing the rate of eating, limiting access to cues that signal eating behavior and keeping records have all resulted in short-term benefits. According to the 1998 NHLBI Clinical Guidelines, behavioral strategies to reinforce changes in diet and physical activity can produce a weight loss in obese adults of 10 percent over four months to one year. Most patients return to original weights in the absence of continued behavior modification. Newer studies have emphasized spouse training and teaching self-control. Individual therapy rather than group therapy is best used for the person lacking in self-esteem, the immature individual who has had difficulty separating from the mother and the socially isolated person who had little or no contact with his or her mother. GROUP THERAPY is quite effec-

tive in treating CHILDHOOD OBESITY, primarily because of the enormous peer pressure among children. It is used with patients who have stronger egos than those who are suitable for individual therapy. Teenage children respond very well to counseling given in groups. They are accustomed to learning in groups, and learning about their diet comes most readily when they are with friends who have similar problems. Most effective with teenagers is a leader who is knowledgeable in the field of nutrition and obesity, who genuinely likes children and wants to help children with this problem. When the cause of childhood obesity is related to family pathology, FAMILY THERAPY is called for. This treatment tends to focus on areas of conflict within the family that foster certain eating habits and patterns. As reported in the NHLBI Clinical Guidelines, drug therapy has undergone radical changes in the last few years. With the publication of the trials with phentermine and fenfluramine conducted over a period of 210 weeks by Weintraub in 1992, drug therapy began to change from short-term to long-term use. Both dexfenfluramine and fenfluramine alone, as well as the combination of phentermine and fenfluramine, were used long term; however, concerns about reported unacceptable side effects, such as valvular lesions of the heart causing significant insufficiency of the valves, led to the withdrawal of the drugs dexfenfluramine and fenfluramine from the market in September 1997. No drugs remained that were approved by the Food and Drug Administration (FDA) for use longer than three months. In November 1997 the FDA approved SIBUTRAMINE for use in obesity, and in April 1999 approved ORLISTAT for long-term use. In November 1997 the FDA approved SIBUTRAMINE for use in obesity, and in April 1999 approved ORLISTAT for long-term use. Unlike other obesity drugs, orlistat prevents enzymes in the gastrointestinal tract from breaking down dietary fats into smaller molecules that can be absorbed by the body. Absorption of fat is decreased by about 30 percent. Since undigested triglycerides are not absorbed, the reduced caloric intake may have a positive effect on weight control. The drugs used to promote weight loss had been anorexiants or appetite suppressants. These drugs are effective but modest in their ability to produce weight loss. Net weight loss attributable to drugs gen-

226 obesity erally has been reported to be in the range of 4.4 to 22 pounds, although some patients lose significantly more weight. Most of the weight loss usually occurs in the first six months of therapy. Weight-loss medications are recommended only for patients who are at increased medical risk because of their weight and should not be used for cosmetic weight loss. The potential for side effects from the use of weight-loss drugs is of great concern. (See ANTIOBESITY DRUGS.) Surgical treatment of obesity has escalated in recent years, with the number of procedures nearly quadrupling since 2001. BARIATRIC SURGERY is the only option today that effectively treats extreme obesity in people for whom more conservative measures such as diet, exercise and medication have failed. An Agency for Healthcare Research and Quality (AHRQ) Evidence Report concluded, “Surgical treatment is more effective than nonsurgical treatment for weight loss and the control of some comorbidities in patients with a body mass index of 40 or greater. More data are needed to confirm or refute the relative efficacy of surgery for less severely obese persons. Perioperative (occurring during surgery) mortality rates of less than one percent have been achieved by some surgeons and surgical centers. The perioperative mortality rates in other settings may be higher. Surgical treatment is associated with a substantial number of complications and adverse events, although most of these are minor.” The AHRQ report also found that “clearly, RYGB results in greater weight loss than vertical banded gastroplasty. All three procedures for which we found data—RYGB; VBG; and laparoscopic adjustable band procedures—report substantial long-term weight loss.” As noted by the report, a variety of approaches to bariatric surgery exist, but all procedures are either MALABSORPTIVE OPERATIONS, GASTRIC RESTRICTION PROCEDURES or a combination of the two. Malabsorptive procedures change the way the digestive system works. Restrictive procedures are those that severely reduce the size of the stomach to hold less food, but the digestive functions remain intact. Although the general opinion has been that people over the age of 60 would not be good candidates for obesity surgery, surgeons at the Mayo Clinic in Scottsdale, Arizona, examined the operative outcomes, weight loss, reduction of comorbidities, and medication requirements in patients older than 60 years

compared with those younger than 60 years undergoing laparoscopic ROUX-EN-Y GASTRIC BYPASS, and concluded that patients of advanced age can safely undergo stomach bypass surgery with operative results nearly identical to those of younger patients. The American Medical Association’s Council on Scientific Affairs 2004 informational report states, “In 2003, the U.S. Preventive Services Task Force concluded that data were sufficient to recommend that physicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults. Other sets of clinical recommendations directed at adult and childhood obesity have also been developed recently by national organizations and experts. In a recent systematic review of the literature, researchers concluded that the lack of quality studies limits recommendations for improving health professionals’ management of obesity. However, reminder systems, brief training interventions, shared care, inpatient care, and dietitian-led treatments provided promise and warrant further study.” See also VERTICAL BANDED GASTROPLASTY. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—The Evidence Report. National Institutes of Health, 1998. Ernsberger, P., and Haskew, P. “Health Implications of Obesity: An Alternative View.” Journal of Obesity and Weight Regulation 6 (1987). Flegal, Katherine M., et al. “Excess Deaths Associated with Underweight, Overweight, and Obesity.” Journal of the American Medical Association 293, no. 15 (April 20, 2005): 1,861–1,867. “Health Implications of Obesity.” NIH Consensus Development Conference Statement 5, no. 9. Jeffrey, D. Balfour, Brenda Dawson, and Gregory L. Wilson. “Behavioral and Cognitive-Behavioral Assessment.” In Assessment of Addictive Behaviors, edited by Dennis Donovan and G. Alan Marlatt. New York: Guilford Press, 1988. McKay, Betsy. “New Study Further Downplays Obesity’s Deadliness.” The Wall Street Journal, April 20, 2005, p. D4. Mokdad, Ali H., James S. Marks, Donna F. Stroup, and Julie L. Gerberding. “Actual Causes of Death in the United States, 2000.” Journal of the American Medical Association 291, no. 10 (March 10, 2004): 1,238–1,245. Mokdad, A. H., et al. “Correction: Actual Causes of Death in the United States, 2000.” Journal of the American Medical Association 293, no. 3 (January 19, 2005): 293–294.

obesity, attitudes toward 227 Polivy, Jane. “Psychological Consequences of Food Restriction.” Journal of the American Dietetic Association 96 (June 1996). Report 8 of the Council on Scientific Affairs (A-04) Full Text, “AMA Actions on Obesity.” Available online. URL: http://www.ama-assn.org/ama/pub/category/ 13653.html. Last updated on December 12, 2004. Rodin, Judith, Diane Schank, and Ruth Striegel-Moore. “Psychological Features of Obesity.” Medical Clinics of North America 73 (January 1989). Shekelle, P. G., S. C. Morton, M. Maglione et al. “Pharmacological and Surgical Treatment of Obesity. Summary, Evidence Report/Technology Assessment: Number 103.” AHRQ Publication Number 04-E028-1, July 2004. Agency for Healthcare Research and Quality, Rockville, Md. Available online. URL: http://www. ahrq.gov/clinic/epcsums/obesphsum.htm. St. Peter, S. D., R. O. Craft, J. L. Tiede, and J. M. Swain. “Impact of Advanced Age on Weight Loss and Health Benefits after Laparoscopic Gastric Bypass.” Archives of Surgery 140, no. 2 (February 2005): 165–168.

obesity, attitudes toward It has been suggested that public derision and condemnation of fat people is one of the few remaining sanctioned social prejudices against any group based solely on appearance. There is evidence that obese people are denied educational opportunities, jobs, promotions and housing because of their weight. Dennis E. Clayson and Michael L. Klassen stated that “there is considerable evidence to suggest that obese persons are perceived negatively by others. This negative perception seems to be heightened because, unlike many other stereotyped persons, obese persons are seen as personally responsible for their condition.” Clayson and Klassen found that obese persons are characterized as lazy, unkempt, lacking self-discipline and self-respect, unhealthy and insecure. (Paradoxically, they are also seen as jolly.) An obese person may be seen as purposely violating a cultural value. Disdain toward the obese begins before adulthood. Several studies have documented what most people know from experience—that grade school children consistently attribute negative qualities to larger body shapes. Children appear to develop attitudes about fat at a very early age. They are told repeatedly by parents and physical education teachers that fatness is not only unattractive but leads to sickness, and these attitudes persist throughout their lives. Studies confirm

that chubby children are regarded by their peers as ugly, stupid, mean, sloppy, lazy and dishonest and are frequently teased. Samples of adults have rated obese children as less likable than children with a variety of handicaps, disfigurements and deformities. A recent study that assessed familial links in fat stereotypes and predictors of stereotypes among nine-year-old girls and their parents found that both the girls and their parents exhibited fat stereotypes. Specifically, the following characteristics were significantly more likely to be attributed to thin people than fat people: having lots of friends (girls), happy (girls, parents), smart (girls), good looking (girls, parents) and the general statement that it is good to be thin (girls, parents). Fathers who were more educated and had a higher family income were more likely to endorse fat stereotypes, as were mothers and fathers with a high investment in their physical appearance. Although no associations were found between girls’ and parents’ fat stereotypes, girls were more likely to endorse fat stereotypes when interactions with parents and peers focused on body shape and weight loss. Girls were also more likely to support fat stereotypes when they reported higher levels of maladaptive eating. One study included a preference test to see whether two- to five-year-olds preferred a thin or a fat rag doll. Fifty-three out of 56 children as young as two years of age picked the thin doll. Similar results occurred using drawings of fat and thin children. The team conducting the test had planned to use photographs but were unable to obtain photos of fat children. They visited shopping centers, amusement parks and similar places and asked every parent who passed by to let them photograph their children. No parent of a thin child refused; no parent of a fat child ever consented. Some parents permitted a thin child to be photographed while hiding a fat one behind them. The team ended up with hundreds of photographs of children, and not one of them was fat. This prejudice is neither natural nor universal. Obesity has been valued highly in many cultures at various periods of history. Some African peoples have been known to lock pubescent females in fattening huts where they are denied exercise and receive extra rations of food for as long as two years. This practice produces an overweight woman who symbolizes the well-to-do status of her family.

228 obesity as a class issue Other cultures discriminate in their preference for the location of fat deposits. In our own culture, the attempt to achieve the “right” proportions, those in vogue at given time or in given society, has led women to try a variety of devices, some quite harmful, to alter their natural physique. Corsets and waist cinches have caused fainting, rib fractures and permanent damage to the respiratory system. Around the turn of the century, some women had ribs removed (a practice not unknown today among fashion models) in order to achieve an hour-glass figure. More recently, cosmetic surgery, silicone injections and breast implants have replaced the padded bra and bustle in the relentless pursuit of “beauty.” The NPD Group, a Chicago research firm, has found some signs that as Americans grow in girth, they are becoming less critical of overweight people. In 1984, 55 percent of respondents to their attitudes tracking survey agreed with the statement “People who are not overweight look a lot more attractive”; by 1988, that figure had dropped to 42 percent; and in 1996 it had plummeted to 28 percent. It is possible that because of increased sensitivity to such comments, some responders to the survey may have provided “politically correct” answers rather than what they truly believed. In fact, not all research points to progress in this area. In a 1998 Cornell University study, Sobal and Bursztyn found that 74 percent of male students and 60 percent of female students were uncomfortable dating someone who is obese. Also, in their study of male and female nurses’ attitudes toward obesity, Garner and Nicol found “no sex differences in reported negative feelings of caregivers, but the obese patients reported significantly more negative attitudes of caregivers than did the nonobese patients.” Similarly, Schwartz et al. concluded that “Even professionals whose careers emphasize research or the clinical management of obesity show very strong weight bias, indicating pervasive and powerful stigma.” See also CULTURAL INFLUENCES ON APPEARANCE. Clayson, Dennis E., and Michael L. Klassen. “Perception of Attractiveness by Obesity and Hair Color.” Perceptual and Motor Skills 68, no. 1 (February 1989): 199–202. Davison, Kirsten Krahnstoever, and Leann Lipps Birch. “Predictors of Fat Stereotypes among 9-Year-Old Girls

and Their Parents.” Obesity Research 12, no. 1 (January 2004): 86–94. Garner, C. M., and G. T. Nicol. “Comparison of Male and Female Nurses’ Attitudes toward Obesity.” Perceptual Motor Skills 86, no. 3, pt. 2 (June 1998): 1,442. Schwartz, Marlene B., Heather O’Neal Chambliss, Kelly D. Brownell, Steven N. Blair, and Charles Billington. “Weight Bias among Health Professionals Specializing in Obesity.” Obesity Research 11, no. 9 (September 2003): 1,033–1,039. Sobal, Jeffery, and Mark Bursztyn. “Dating People with Anorexia and Bulimia Nervosa: Attitudes and Beliefs of University Students.” Women and Health 27, no. 3 (1998): 71–87.

obesity as a class issue With the World Health Organization describing obesity as an international health crisis, researchers and writers around the world have endeavored to identify the causes for the pandemic. Carma International, global media analysts, reported, “The UK and Continental media shared a perception either wholly absent or thickly veiled in the US media—namely, that obesity is a class issue and often linked to poverty. ‘This obesity debate is full of humbug and denial. Fat is a class issue, but few like to admit that most of the seriously obese are poor,’ wrote The Observer (May 30, 2004). In Germany, Frankfurter Rundschau stated that ‘children from poor background are specifically prone to obesity.’ (April 3, 2004).” The Week, a British publication, reported on June 14, 2003, “As the gap between rich and poor widens, Britain has become divided into an ‘overweight underclass and a super-healthy elite.’ Working-class children live on cheap, calorific diets of pizza and chips. Middle-class children, by contrast, have lunchboxes packed with wholewheat sandwiches and salads, and go to schools with good playing fields. Their parents, too, have the time and money to cook decent meals and join a gym. Fitness has become a ‘badge of financial as well as physical virility.’ ” On May 31, 2004, the International Herald Tribune quoted London’s The Guardian as reporting, “Fat is a class issue, but few like to admit that most of the seriously obese are poor. It is inequality and disrespect that makes people fat: People will only get thinner when they are included in things that are worth staying thin for. Offer self-esteem, respect, jobs or some social status and the pounds would start to fall away. The inequality/obesity link is mir-

obesity-hypoventilation syndrome 229 rored internationally. America has by far the most unequal society and by far the fattest. Britain and Australia come next. Europe is better and the Scandinavian countries best of all. No doubt there are also social policy reasons for this: The best social democracies pick up family problems earliest and offer most support, putting people back on their feet, preventing social exclusion. But the narrower the status and income gap between high and low, the narrower the waistbands.” In his review of the various suggested causes for the rise in obesity, Crespo wrote: Some researchers have suggested that the prevalence of obesity is related to social class. Extreme obesity is most prevalent among African-American women (15.1 percent), while the prevalence of extreme obesity in the rest of the other racial and ethnic groups was less than 5.5 percent. Other important indicators of social class are education and income, and these factors seem to influence obesity differently. Education is typically related to behaviors (e.g., diet, exercise, smoking), whereas income is related to things purchased (e.g,, health insurance, prescription medication). To better understand how education and income are related to obesity, the prevalence of obesity was tallied in different strata of social classes using nine mutually exclusive categories of education and income. Among women, the highest prevalence of obesity was among those who had less than a high school education and earned less than $20,000 a year. Among men, the prevalence of obesity was highest among those in the highest income category but who had less than high school education. Invariably, obesity is lowest among those who have more than a high school education, regardless of income. Poverty and lower educational attainment are consistently associated with obesity, independent of ethnicity, and therefore affect more persons in minority populations than in white populations. Thus, minorities may be at higher risk for obesity because of their increased poverty rate and lower educational attainment. Our understanding of how and why obesity develops should involve the integration of social, behavioral, environmental, cultural, physiologic, metabolic, and genetic factors.

In May 2005 University of Iowa researchers reported to the American Heart Association on a study that showed obesity to be growing fastest

among affluent Americans. Using U.S. government databases, they found that while the percentage of obese people with incomes below $25,000 had risen 10 percent between the 1970s and 2002; the percentage of obese people with incomes above $60,000 had jumped 17 percent. The investigators suggested that perhaps longer commutes plus longer working hours since the 1970s have resulted in less time to prepare home cooked meals, more frequent eating in restaurants and less time for physical activity. But others cautioned that since the 1970s, rates of extreme obesity have ballooned among lowerincome groups, something the study did not address. Crespo, Carlos J. “Obesity in the United States: A Worrisome Epidemic.” The Physician and Sportsmedicine 31, no. 11 (November 2003): 23–28.

obesity-hypoventilation syndrome (OHS)

Also called pickwickian syndrome, Pickwick syndrome and obstructive sleep apnea/hypoventilation. This is a condition related to obstructive sleep apnea, in which a very obese person does not breathe a sufficient amount of oxygen during sleep or while awake. However, OHS can occur separately from obstructive sleep apnea. The cause of OHS in unknown, but it is likely to involve a combination of a disorder of the brain’s control over breathing and the effects of massive obesity on the chest wall. With the excess weight of massive obesity, the muscles of the chest wall can have difficulty expanding the thorax enough to exchange air efficiently. This results in a decreased ability to oxygenate the blood and retention of carbon dioxide. Affected individuals suffer from chronic fatigue brought on by sleep loss, poor sleep quality and decreased blood oxygen. OHS affects 5 percent of morbidly obese individuals. The term pickwickian syndrome was first used in 1956 for OHS patients because they resemble the messenger boy, Joe, in Charles Dickens’s The Pickwick Papers. Berg et al. found that OHS patients were much more likely to have cardiovascular disease, a history of metabolic disease (e.g., diabetes or hypothyroidism) and osteoarthritis, concluding, “OHS patients are heavy users of health-care resources for several years prior to the evaluation and treatment of their sleep breathing disorder, and there is a substantial reduction in days hospitalized once treatment is instituted.”

230 obesity in the workplace Berg, Greg, et al. “The Use of Health-Care Resources in Obesity-Hypoventilation Syndrome.” Chest 120, no. 2 (August 2001): 377–383. Kessler, Romain, et al. “The Obesity-Hypoventilation Syndrome Revisited: A Prospective Study of 34 Consecutive Cases.” Chest 120, no. 2 (August 2001): 369–376.

obesity in the workplace The obesity epidemic in the general population has meant not only an increase in the numbers of overweight and obese workers, but also an increase in those workers’ girth. As one newspaper business writer reported, “Sales of sturdy, large office chairs accommodating office workers of up to 400 pounds are booming.” Insurance companies have linked workplace junk food to workplace obesity and increased absenteeism. A 2004 Harris Interactive survey reported that 83 percent of those who have vending machines in their workplace say they mostly contain snacks such as potato chips, cookies and candy bars. Yet 80 percent of workers say they would favor adding nutritional information, such as calories and fat content, to menus at restaurants and workplace cafeterias to help consumers make informed choices. Although research has found obese workers to be costly to employers (see EMPLOYEE HEALTH COSTS AND OBESITY), Baum and Ford conclude that obesity is also costly to the workers themselves. Using National Longitudinal Survey of Youth (NLSY) data to examine the effects of obesity on wages by gender, the economists found “that both men and women experience a persistent obesity wage penalty over the first two decades of their careers.” Noting that standard socioeconomic and familial variables do not explain these wage penalties, they suggest that “other variables—including job discrimination, health-related factors and/or obese workers’ behavior patterns—may be the channels through which obesity adversely affects wages.” In their research, Baum and Ford found that wages of obese workers average 2.5 percent less than wages of thinner employees, with the wage penalty much greater for women (2.3 percent to 6.2 percent) than men (0.7 percent to 2.6 percent). According to the Council on Size and Weight Discrimination, such discrimination against obese men does not kick in until they are severely obese, while women employees encounter weight discrimination for being just 30 pounds overweight.

Baum, Charles L., II, and William F. Ford. “The Wage Effects of Obesity: A Longitudinal Study.” Health Economics 13, no. 9 (September 2004): 885–899.

Obesity Management A medical journal first published in September 2003; its purpose is to offer physicians and health care professionals effective options and strategies to help overweight patients. The publisher is Mary Ann Liebert, Inc.; the editor in chief is James O. Hill, Ph.D., professor of pediatrics and medicine, and director of the Center for Human Nutrition, University of Colorado Health Sciences Center. Each issue provides practice-oriented information and resources. See also APPENDIX VIII. obesity virus

See

FAT VIRUS.

Obesity Working Group (OWG) In August 2003 the U.S. Food and Drug Administration (FDA) established the Obesity Working Group (OWG) to advise the agency on innovative ways to deal with the increase in obesity and to identify ways to help consumers lead healthier lives through better nutrition. On March 12, 2004, the OWG released a report, Calories Count, to reexamine the FDA’s responsibilities for reducing obesity. The group’s long- and short-term proposals were based on the scientific fact that weight control is mainly a function of caloric balance—calories in must equal calories out. Recommended actions included: • Enhancing food labels to display calorie count more prominently and to use meaningful serving sizes • Initiating a consumer education campaign focusing on the “Calories Count” message • Encouraging restaurants to provide nutritional information to consumers • Stepping up enforcement actions concerning accuracy of food labels • Revising FDA guidance for developing drugs to treat obesity • Working cooperatively with other government agencies, nonprofits, industry, and academia on obesity research. Obesity Working Group. “Calories Count: Report of the Working Group on Obesity.” Available online. URL:

online dieting 231 http://www.cfsan.fda.gov/~dms/owg-toc.html. Posted on March 12, 2004.

obesophobic Having a fear of being fat. A term used by some clinicians to describe people judged underweight by standard measurements but who still think they are too fat and who are preoccupied with their weight. See also FEAR OF FAT SYNDROME. olestra

The generic name for a no-calorie fat substitute developed by Procter & Gamble in 1989 after nearly 20 years of research and marketed under the brand name Olean. It is intended for use in shortenings and oils and in the preparation of certain fried snacks, like potato chips. It tastes, feels and, in cooking, functions like fat but is not in any sense a food and is not found naturally in any food. Olestra is not absorbed into the bloodstream and therefore, according to Procter & Gamble, should likely produce fewer complications than other food substitutes such as aspartame, a sugar substitute known to cross into the bloodstream. In one study by the company, 10 obese people were fed with up to 60 grams of olestra in their diet for 20 days, so that their caloric intake was reduced by 23 percent and fat intake by 50 percent. On average, the patients lost eight pounds each. Patients on the olestra diet did not crave additional food to make up for their calorie loss. Olestra satiates the desire to gorge, as does food made with conventional fats. Olestra has remained under review by the Food and Drug Administration (FDA) since 1987. Although Procter & Gamble maintains that Olestra is safe for humans, some scientists have questioned it. Rats in some tests have developed tumors and leukemia, among other diseases, according to the Center for Science in the Public Interest, a consumer advocacy group. The FDA concluded on January 25, 1996, that olestra was safe for use in savory snacks (potato chips, corn chips) but required that fat-soluble vitamins lost through absorption be added back to olestra. Although Procter & Gamble has effectively dealt with a number of criticisms of olestra from consumer groups, some of these criticisms reappear from time to time in the media, or have been the subject of fur-

ther studies. The FDA announced in the August 5, 2003, Federal Register that manufacturers will no longer need to include the label statement required since olestra’s approval in 1996. The statement informs consumers that olestra may cause abdominal cramping and loose stools in some people, that it inhibits the body’s absorption of vitamins A, D, E and K and other nutrients, and that these vitamins have been added to compensate for olestra’s effects on these nutrients. Consumption studies of products containing olestra showed the fat substitute caused only infrequent, mild gastrointestinal effects in amounts that reflected typical dietary habits. However, the FDA will require manufacturers to continue adding vitamins A, D, E and K to such products. Levine et al. examined the association between authors’ published positions on the safety and efficacy in assisting with weight loss of olestra and their financial relationships with the food and beverage industry. “Supportive authors were significantly more likely than critical or neutral authors to have financial relationships with P&G (80 percent vs 11 percent and 21 percent, respectively). All authors disclosing an affiliation with P&G were supportive.” In a recent review of studies involving dietary fat, Bray et al. found, “When dietary fat is replaced with olestra to reduce fat intake from 33 percent to 25 percent in obese men, weight loss continues for about nine months, reaching a maximum of nearly 6 percent of body weight and a loss of 18 percent of initial body fat.” See also FAT SUBSTITUTES. Bray, G. A., S. Paeratakul, and B. M. Popkin. “Dietary Fat and Obesity: A Review of Animal, Clinical and Epidemiological Studies.” Physiology & Behavior 83, no. 4 (December 2004): 549–555. Levine, J., J. D. Gussow, D. Hastings, and A. Eccher. “Authors’ Financial Relationships with the Food and Beverage Industry and Their Published Positions on the Fat Substitute Olestra.” American Journal of Public Health 93, no. 4 (April 2003): 664–669. Nestle, M. “The Selling of Olestra.” Public Health Report 113, no. 6 (November/December 1998): 508–520. Prince, D. M., and M. A. Welschenbach. “Olestra: A New Food Additive.” Journal of the American Dietetic Association 98, no. 5 (May 1998): 565–569.

online dieting

Also called cyberdieting; plans and programs offered over the Web to help individuals

232 Optifast lose weight. Internet dieting services, which first appeared in the mid-1990s, have expanded and proliferated recently as an estimated 15 million people now turn to the Internet every month for weight-loss information. By 2005 the most popular diet brands were introducing food and activity guides that users download from the Internet, which are designed for use with handheld devices and personal digital assistants so that users can search food and activity lists and track their eating and exercise when in a restaurant, at the grocery store or even on vacation. Psychologist Thomas Wadden, director of the Weight and Eating Disorders Program at the University of Pennsylvania in Philadelphia, who has researched the effectiveness of online dieting, stated on USAToday.com on January 4, 2005, “Online Internet programs can be helpful to people if they keep a record of their daily food intake, calories, and physical activity.” The University of Pennsylvania School of Medicine study compared results of women who enrolled in an eDiets.com online weight-loss program available to the public with those of women who followed a weight loss manual (LEARN Program for Weight Control 2000). Both groups followed similar weight-loss techniques, including reducing calories and increasing exercise. The dieters using the Internet service lost 1.5 pounds after 16 weeks and 1.8 pounds after one year. Those using the self-help manual lost 6.6 pounds after 16 weeks and 7.3 pounds after a year. Explaining the low online dieting results, Wadden said, “This was because people did not log on frequently enough or keep records of their food intake.” Harvey-Berino et al. evaluated 255 overweight and obese men in a six-month behavioral weight control program conducted over the Internet. After this program, participants were placed into one of three groups (frequent in-person support, minimal in-person support or Internet support) as part of a 12month weight maintenance phase. The participants assigned to the Internet-based weight maintenance program lost about the same amount of weight over 18 months as those who met with counselors. Other studies have also found similar results between online dieting and other diet center programs. According to Market Trends: The Online Weight Loss and Dieting Services Market, a 2005 report from market research publisher Packaged Facts, employees’

use of approved health and dieting Web sites in the workplace is expected to help U.S. employers increase health awareness as well as boost employee productivity and overall morale. Adoption by corporate America should help the growth path of online weight loss and dieting services overall. Currently valued at $280 million and expected to post annual growth of 30 percent over the next few years, Packaged Facts estimates that by 2013 the market will surpass $1 billion in revenue. Harvey-Berino, J., S. Pintauro, P. Buzzell, and E. C. Gold. “Effect of Internet Support on the Long-Term Maintenance of Weight Loss.” Obesity Research 12, no. 2 (February 2004): 320–329. Tsai, A. G., and T. A. Wadden. “Systematic Review: An Evaluation of Major Commercial Weight Loss Programs in the United States.” Annals of Internal Medicine 142, no. 1 (January 4, 2005): 56–66. Womble, L. G., T. A. Wadden, et al. “A Randomized Controlled Trial of a Commercial Internet Weight Loss Program.” Obesity Research 12, no. 6 (June 2004): 1,011–1,018.

Optifast

A commercial

PROTEIN-SPARING MODIFIED

FAST program, intended for use under medical super-

vision. This program achieved prominence when television talk show host Oprah Winfrey announced in 1988 that she had lost 67 pounds on the Optifast program. After this announcement, the Optifast company received hundreds of thousands of calls from consumers desperate to lose weight. Sales boomed as people paid $3,000 to $5,000 each to participate in the program. But 18 months later, as reports surfaced about the dangers of VERY LOW-CALORIE DIETS, both Oprah and the majority of the Optifast users had regained much of their lost weight (plus added poundage), and the company had cut back on satellite clinics. Today company promotions focus more on the fact that Optifast is a physician-supervised program and less on the weight loss results.

oral contraceptives Although many women and clinicians believe that oral contraceptive use can lead to weight gain, keeping some women from starting hormonal contraception or leading to premature quitting, there is no evidence supporting this belief according to recent research. Gallo et al. reviewed 42 studies on the subject and found no

orlistat 233 evidence of appreciable weight gain from combination estrogen/progestin contraceptive use. If any such effect does exist, it is small and may be due to short-term water retention. However, obese and overweight women are more likely to experience a failure in the use of oral contraception than are women in lower weight categories, according to a University of Washington study. Among all oral contraceptive users, when compared with women having a body mass index (BMI) of 27.3 or less, the risk of pregnancy was nearly 60 percent higher in women with BMI greater than 27.3 and more than 70 percent higher in women with BMI greater than 32.2. Among consistent users (women who missed no pills in reference month), the risk of pregnancy more than doubled in women with BMI greater than 27.3. Gallo, M. F., D. A. Grimes, K. F. Schulz, and F. M. Helmerhorst. “Combination Estrogen-Progestin Contraceptives and Body Weight: Systematic Review of Randomized Controlled Trials.” Obstetrics and Gynecology 103, no. 2 (February 2004): 359–373. Holt, V. L., et al. “Body Mass Index, Weight, and Oral Contraceptive Failure Risk.” Obstetrics and Gynecology 105, no. 1 (January 2005): 46–52.

oral nutritional supplements Nutrients in liquid form; the least invasive way of supplementing an anorexic patient’s food intake during hospitalization. Because a nutritional supplement is considered a medication, its use is charted in a patient’s files and the patient is required to drink it in the presence of a nurse. Not considering it as food helps avoid conflicts with the patient over eating or not eating. oral soft tissues

Periodontal tissues, gingival tissues, the lining of the mouth, pharynx and esophagus, the lips and tongue and the salivary glands, are all areas of the oral cavity that can be affected by anorexia nervosa and bulimia. Tissue health is impaired by dry mouth and the resulting reduction of the saliva’s membrane-lubricating effects. As a result of dryness and poor oral hygiene, gingivitis, or inflammation of the gums, is quite common in eating-disordered patients. If untreated, this inflammation spreads into the supporting structures of the teeth, causes bone loss and eventually results in loss of the teeth. Vita-

min deficiencies from poor diets have very marked effects on soft tissues, including scurvy, inflammation of the tongue and a burning sensation in the tongue. Bulimic patients sometimes evidence abrasions of the lining of the throat due to use of the fingers or foreign objects to induce vomiting. The caustic gastric acid brought up during the purging process inflames esophageal, pharyngeal and salivary gland tissues. Salivary gland enlargement is not an uncommon occurrence in patients with eating disorders. See also DENTAL CARIES; PERIMYLOLYSIS. Dalin, Jeffrey B. “Oral Manifestations of Eating Disorders.” In Eating Disorders: Effective Care and Treatment, edited by Félix E. F. Larocca. St. Louis: Ishiyaku EuroAmerica, 1986.

orlistat

The first in a new class of drugs known as lipase inhibitors, compounds that block the absorption (digestion) of roughly a third of the fat that the user consumes. In clinical trials, patients who took Xenical (trade name of orlistat) lost about 10 percent of their body weight, more than three times the amount lost by those who took a placebo. Most of the patients taking orlistat reported such side effects as intestinal cramping, gas, and oily or loose stools, but they usually were mild and lasted only a few weeks. The drug can also interfere with the body’s ability to absorb vitamins A, D, E, K and betacarotene. Approval of Xenical by the Food and Drug Administration was delayed because one study showed an increase in cases of breast cancer, but researchers determined that many of those cancers were preexisting and that the breast cancer incidents were a statistical fluke. A large-scale follow-up study showed no increase risk of breast cancer. With this question settled, final FDA approval was granted on April 26, 1999. The drug is intended for treatment of severe obesity only. One concern, in addition to the side effects, is that people will quickly regain the weight they lost once they stop taking the drug. Almost everyone in the study did gain back their weight when they stopped taking the drug, so people may need to take it for life—at a cost of around $1,500 a year; however, orlistat has not been studied for safety or efficacy beyond two years. Also, the study’s high dropout rate (66 percent) suggests that patients will be unlikely to take the drug long term.

234 orthorexia nervosa In 2004, researchers in Brazil reported that orlistat, especially in combination with a diet rich in oxalate (a salt found in certain plants) alone or associated with fat, seems to contribute to the formation of kidney stones in rats, suggesting that people who have had kidney stones should be cautious with orlistat. Also, those taking the drug should also avoid foods rich in oxalate, such as spinach, rhubarb and parsley. Davidson, Michael H., et al. “Weight Control and Risk Factor Reduction in Obese Subjects Treated for 2 Years with Orlistat.” Journal of the American Medical Association 281, no. 3 (January 20, 1999): 235–242. Ferraz, R. R., H. G. Tiseliu, and I. P. Heilberg. “Fat Malabsorption Induced by Gastrointestinal Lipase Inhibitor Leads to an Increase in Urinary Oxalate Excretion.” Kidney International 66, no. 2 (August 2004): 676–682. Hellmich, Nanci. “Fat Blocker Weighs in a Drug for Obese.” USA Today, January 20, 1999. ———. “New Fat-Blocking Obesity Drug Approved.” USA Today, April 27, 1999. Klein, S. “Long-Term Pharmacotherapy for Obesity.” Obesity Research 12 (December 2004): 163S–166S.

orthorexia nervosa (ON)

A term used by some eating disorder specialists and authors to describe an unhealthy—even obsessive—worry about eating impure or unsatisfactory foods. The word orthorexia comes from the Greek words orthos (straight, proper) and orexia (appetite). Although it is not an official eating disorder diagnosis, orthorexia has been acknowledged as a serious problem by support groups. The name was first used by Steven Bratman, M.D., in “Health Food Junkie” (Yoga Journal, October 31, 1997): “This transference of all of life’s value into the act of eating makes orthorexia a true disorder. In this essential characteristic, orthorexia bears many similarities to the two well-known eating disorders anorexia and bulimia. Where the bulimic and anorexic focus on the quantity of food, the orthorexic fixates on its quality. All three give food an excessive place in the scheme of life.” Orthorexia has also been defined as “a maniacal obsession for healthy foods.” People with this disorder allegedly feel superior to others who eat improper food, which might include nonorganic or junk foods and items found in regular grocery stores, as opposed to health food stores. Orthorexics obsess over what to eat, how

much to eat, how to prepare food properly and where to obtain pure and proper foods. Eating the right food becomes an important, or even the primary, focus of life. One’s worth or goodness is seen in terms of what one does or does not eat. Personal values, relationships, career goals and friendships become less important than the quality and timing of what is consumed. Orthorexia sometimes involves severe weight loss. Catalina et al. explain further, “Orthorexic patients exclude foods from their diets that they consider to be impure because they have herbicides, pesticides or artificial substances and they worry in excess about the techniques and materials used in the food elaboration. This obsession leads to loss of social relationships and affective dissatisfactions which, in turn, favors obsessive concern about food. In orthorexia, that patient initially wants to improve his/her health, treat a disease or lose weight. Finally, the diet becomes the most important part of their lives.” Donini et al. found a higher prevalence in men and in those with a lower level of education. Strand cautions that not all experts believe orthorexia to be a clinically useful diagnosis, saying “in terms of treatment, it differs from anorexia only in the finer points.” Bratman, Steven, and David Knight. Health Food Junkies: Overcoming the Obsession with Healthful Eating. New York: Broadway Books, 2000. Catalina, M., B. Bote, F. Garcia, and B. Rios. “Orthorexia Nervosa: A New Eating Behavior Disorder?” Actas Espanolas de Psiquiatria 33, no. 1 (January–February 2005): 66–68. Donini, L. M., et al. “Orthorexia Nervosa: A Preliminary Study with a Proposal for Diagnosis and an Attempt to Measure the Dimension of the Phenomenon.” Eating and Weight Disorders 9, no. 2 (June 2004): 151–157. Strand, Erik. “A New Eating Disorder?” Psychology Today 37, no. 5 (September–October 2004): p. 16.

osteopenia

A general term referring to loss of bone, regardless of cause. Bone loss may be due to a number of disorders, the most common of which are osteoporosis, osteomalacia and osteitis fibrosa. There are various causes for these conditions, and treatment and prevention strategies vary accordingly. Osteoporosis is a condition in which bone mass becomes demineralized, less dense and brittle. It is associated with aging. This is the most common

osteopenia 235 form of osteopenia and has received the most publicity. It accounts for the fragility of the bones in elderly women. A progressive condition, it generally begins at menopause or when there is any loss of hormones. Women are more susceptible to osteoporosis than men for a number of reasons, including their smaller size and lower dietary calcium intake. Other hormones and certain drugs also contribute to the development of osteoporosis. Osteomalacia is the softening of the bones, characterized by an accumulation of newly created bone mass that has not become mineralized. Hardening of bone mass requires both calcium and phosphorus and will be affected negatively by a deficiency of these minerals or by the presence of certain hormones or drugs. Persons with osteomalacia frequently suffer from generalized bone pain even in the absence of fractures. Osteitis fibrosa is a condition in which bone degenerates, or is resorbed, very rapidly. It usually results from excessive production of certain substances such as parathyroid hormone or thyroid hormone. In these cases, bone is diminished faster than new bone mass can be formed. Osteopenia has been recognized as a serious complication of anorexia nervosa. In 1983 E. R. McAnarney and her colleagues reported a case of pathological rib fracture in a 25-year-old anorexic. Since then there have been many other reports documenting pathological fractures in anorexics including ribs, vertebrae and hips. In one instance, successful treatment of anorexia nervosa resulted in improvement of the patient’s bone density, although she continued to have mild osteopenia. Reduced bone densities are found in some anorexics, caused by reduced calcium intake and a drop in estrogen levels from self-starvation. Although, in general, a certain level of activity is necessary to promote adequate bone growth, the kind of excessive activity that characterizes some anorexics (such as 1,000 sit-ups a night) may overstress already-weakened bone and lead to fractures. Rigotti et al. reported on a study of the radial bone density of 18 anorexic and 28 normal women, which indicated that the anorexics had a lower bone density. But anorexics having a high level of physical activity had a bone density similar to that of active or inactive nonanorexics, which was greater than that of low-activity anorexics.

Insufficient calcium for bone growth may result from a number of factors besides poor dietary intake. Production of high levels of serum cortisol during FASTING may increase the loss of calcium from the body. PURGING practices such as self-induced VOMITING and LAXATIVE ABUSE can also cause unnecessary elimination by the kidney of essential chemicals required in bone formation. Consequently, eatingdisordered patients may have reduced bone mass or may predispose themselves to the future development of osteoporosis through their restrictive dietary practices and purging their behaviors. In a study to determine the effect of prolonged anorexia nervosa on lumbar spine bone mineral density (BMD) and to determine whether oral estrogen administration prevents bone loss in women with this disorder, Munoz et al. concluded that (1) Estrogen replacement alone cannot prevent progressive osteopenia in young women with anorexia nervosa; and (2) Other factors, such as the loss of weight, the duration of the amenorrhea and the low levels of total insulin-like growth factor I could contribute to the loss of bone mass in women with this disorder. One study of anorexic women who had been given either calcium or estrogen and who had gained weight showed that bone loss was halted but not reversed. Physical exercise and calcium and estrogen treatments did not affect bone restoration. From this, it was concluded that a period of severe weight loss in young women may be a risk factor for premature osteoporosis. The few reports on recovery have been conflicting, with some studies suggesting the restoration of normal bone mass with recovery from anorexia nervosa, while others suggest that the improvement may only be partial. Estrogen replacement alone does not generally appear to reverse osteoporosis or osteopenia, and unless there is weight gain, it does not prevent further bone loss. A German trial reported in 2002 concluded that dietary treatment including an individually determined high caloric intake, calcium and vitamin D supplementation improved bone metabolism. “After 15 weeks we found a significant increase of the bone formation marker PICP. Thus dietary treatment seems to be a promising tool to counteract bone loss in these patients.” Brotman, A. W., and T. A. Stern. “Osteoporosis and Pathological Fractures in Anorexia Nervosa.” Ameri-

236 Overeaters Anonymous can Journal of Psychiatry 142, no. 4 (April 1985): 495–496. Carmichael, Kim. “How Self-Starvation Damages Bone Structure.” BASH Magazine, January 1990. Grinspoon, S., D. Herzog, and A. Klibanski. “Mechanisms and Treatment Options for Bone Loss in Anorexia Nervosa.” Psychopharmacology Bulletin 33, no. 3 (1997): 399–404. McAnarney, E. R. et al. “Rib Fractures and Anorexia Nervosa.” Journal of Adolescent Health Care 4 (1983). Mika, C., I. Grzella, B. Herpertz-Dahlmann, and M. Heer. “Dietary Treatment Enhances Bone Formation in Malnourished Patients.” Journal of Gravitational Physiology 9, no. 1 (July 2002): 331–332. Munoz, M. T., et al. “The Effects of Estrogen Administration on Bone Mineral Density in Adolescents with Anorexia Nervosa.” European Journal of Endocrinology 146, no. 1 (January 2002): 45–50. Rigotti, N. A., S. R. Nussbaum, D. B. Herzog, and R. M. Neer, “Osteoporosis in Women with Anorexia Nervosa.” New England Journal of Medicine 311, no. 25 (December 20, 1984): 1,601–1,606. Ward, A., N. Brown, and J. Treasure, “Persistent Osteopenia after Recovery from Anorexia Nervosa.” International Journal of Eating Disorders 22, no. 1 (July 1997): 71–75.

Overeaters Anonymous (OA)

A nonprofit selfhelp group formed in 1960 that follows many of the principles of Alcoholics Anonymous; membership is based on freewill donations. OA promotes the belief that “compulsive eating is a progressive illness that can’t be cured but can be arrested.” Like Alcoholics Anonymous, this group has a 12-step recovery program, based on acceptance of the premise that an overeater is powerless over food and that only a Power greater than oneself can restore one to sanity. New members are encouraged to call their sponsors each day to discuss weight loss efforts. In their review of weight loss programs, Tsai et al. found no studies of the efficacy of OA for weight loss; however, they suggested encouragement of its use by patients “given that [the programs] pose minimal financial or physical risks.” They concluded that “OA seems to be most appropriate for patients who seek intensive emotional support to facilitate weight loss. Because each OA chapter apparently has its own character, patients should sample several groups to find the best fit.” In their analysis of data collected from 26 women who met the criteria for bulimia nervosa,

Wasson and Jackson found that those participants used five OA skills or strategies. “These included: (1) OA meeting attendance and participation, (2) interaction with a sponsor, (3) processing (i.e., writing and journaling), (4) spirituality (i.e., prayer and meditation), and (5) adherence to a food plan.” See also APPENDIX III. Wasson, Diane H., and Mary Jackson. “An Analysis of the Role of Overeaters Anonymous in Women’s Recovery from Bulimia Nervosa.” Eating Disorders: the Journal of Treatment & Prevention 12, no. 4 (Winter 2004): 337–356. Tsai, Adam Gilden, et al. “Commercial and Self-Help Programs for Weight Control.” Psychiatric Clinics of North America 28, no. 1 (March 2005): 171–192.

over-the-counter diet pills

See

DIET PILLS—OTC.

overweight bulimia Noting that “patients who have bulimia nervosa and are overweight have received little attention in the medical literature,” Mitchell et al. contrasted 25 overweight bulimia nervosa patients with a sample of 25 patients with bulimia nervosa who were within 10 percent of their ideal body weight. “Members of the overweight bulimia nervosa group were binge-eating and vomiting less frequently than the comparison group but were more likely to be abusing laxatives, and to report a history of self-injurious behavior and suicide attempt(s). Both groups reported frequent binge-eating.” Mitchell, J. E., et al. “Bulimia Nervosa in Overweight Individuals.” The Journal of Nervous and Mental Disease 178, no. 5 (May 1990): 324–327.

overweight bulimia nervosa Although normalweight bulimics are the most common, there are substantial numbers of overweight bulimics, who run into difficulties when seeking appropriate treatment. For example, because they binge-eat and purge, they are often grouped by providers of therapy with emaciated bulimics or anorexics; or they are classified simply as obese individuals. Overweight bulimics vehemently reject these classifications and the treatment approaches that go with them.

P pagophagia

The craving to eat ice. Kushner et al. said it is “one of the most common forms of pica and is closely associated with the development of iron-deficiency anemia. Although this condition has been well described among pregnant women and malnourished children, particularly in developing countries, it has not been previously reported to occur following gastric bypass surgery for treatment of severe obesity.” The authors present two cases of women who experienced a recurrence of pagophagia following gastric bypass surgery, along with an updated review of the literature. See also PICA.

pounds. ABDOMINOPLASTY and panniculectomy are two different procedures. Abdominoplasty deals with muscle as well as skin and fat, whereas a panniculectomy deals only with excess skin and fat. A panniculectomy can be performed alone, in conjunction with an abdominoplasty or along with another abdominal surgery, such as hysterectomy. The fat and skin apron is graded according to its size and extent. The higher the grade, the more extensive the operation and the greater the complications. The Abdominal Panniculus Grading System is as follows:

Kushner, R. F., B. Gleason, and V. Shanta-Retelny “Reemergence of Pica Following Gastric Bypass Surgery for Obesity: A New Presentation of an Old Problem.” Journal of the American Dietetic Association 104, no. 9 (September 2004): 1,393–1,397.

• Grade 1. Pannus apron reaches hairline and mons pubis, but not the private areas. • Grade 2. Pannus apron reaches private areas level with the upper thigh crease. • Grade 3. Pannus apron reaches upper thigh.

pancreatic polypeptide (PP)

• Grade 4. Pannus apron reaches mid thigh.

A peptide containing 36 amino acids that is produced in the pancreas and is released following ingestion of food, with age and in disease states. It is thought to be a SATIETY hormone that is deficient in children with hereditary forms of morbid obesity. A lack of pancreatic polypeptide has been associated with the obese syndrome in rats and mice. Whether PP deficiency is the cause of obesity or just a marker is not clear. Administration of pancreatic polypeptide will decrease food intake, although the doses required are believed to be above safe levels.

• Grade 5. Pannus apron reaches knees. Panniculectomy is not always performed for cosmetic reasons. In certain circumstances it is medically necessary in order to perform indicated major gynecologic intra-abdominal surgery. Generally, if a panniculectomy is performed on an obese person, it requires a hospital stay because of the extensive nature of the surgery as well as the need for more medical attention during recovery. The hospital stay may be from one to three weeks or longer. Complete wound healing may take several months. Gallagher lists the following signs and symptoms of complications: “respiratory compromise, deep vein thrombosis (DVT), skin injury, infection, atelectasis (total or partial collapse of the lung), and bleeding. Prolonged surgery and hypothermia during the procedure increase the risk of complica-

panniculectomy Surgical removal of the large “apron” (abdominal panniculus or pannus) of excess fat and skin that hangs down from the lower abdomen on a severely obese person or on a person who has experienced massive weight loss. An abdominal apron can weigh as much as 100 237

238 parental factors in anorexia nervosa tions. Elderly patients, smokers, and hypertensive patients are especially vulnerable, as are patients with chronic illnesses, such as diabetes.” She also cautions that “fatty tissue that wasn’t excised can become devitalized, causing necrosis and infection.” Insurance companies will usually not cover panniculectomy when it is performed solely for cosmetic purposes, but will cover it when medically necessary for such problems as uncontrollable infections, hernia or interference with mobility. Gallagher, Susan. “Panniculectomy: More than a Tummy Tuck.” Nursing 34, no. 12 (December 2004): 48–50.

parental factors in anorexia nervosa The degree to which parents influence the development of or directly cause anorexia nervosa had not been firmly established, although theories abound. Parents of anorexics have been described in various studies as neurotic, obsessive, rigid or passive. However, the reported incidence of these behaviors in parents of anorexics has varied greatly, ranging from 10 to 40 percent. Controlled research in this area has been sparse, but a few studies of parents have indicated the presence of emotional disturbance. Usually parents do blame themselves for a daughter’s anorexia. HILDE BRUCH suggested that anorexia nervosa develops in a family setting in which the child is not allowed to assume the responsibilities associated with the normal maturational process. She describes these parents as overprotective, overambitious and overconcerned. Consequently, these children often develop unrealistic expectations of themselves. One area of such perfectionism is the body. See also FAMILY THERAPY. passive exercise machines

Devices that deliver electrical shocks to muscles, forcing involuntary contractions, which supposedly takes the place of active exercise. A recent fad in weight-reducing gadgetry, these machines are supposed to tone the stimulated muscles, thus firming and trimming objectionable bulges. A forerunner to these latest exercise machines was the Relaxicisor, a device that was banned by a federal court in 1970. John A. McCurdy wrote that such electrical stimulation is used to maintain muscle tone and flexibility in patients who have suffered localized paralysis

from strokes, or who are unable to exercise actively because of coma or other neurological conditions. While properly performed electrical stimulation can enhance muscle tone in healthy people, most researches in this field feel that the machines utilized in “passive exercise” clinics are not sufficiently sophisticated (and personnel operating these machines not well enough trained) to offer the individual variability necessary to deliver the proper frequency, magnitude and duration of electrical stimulation required for efficient muscle toning. And unfortunately, muscle toning has no effect on overlying fat deposits that usually contribute the bulk of the objectionable figure deformity. In the 1990s the Federal Trade Commission (FTC) warned consumers about any effort-free motorized table, equipment or device that supports body weight and is capable of continuously moving isolated groups of muscles through as a range of motion in a manner requiring little or no effort. Examples include toning tables and motorized calisthenics tables. Such devices have gained great popularity at health clubs, spas, tanning salons and weight loss and fitness centers. The appeal is an easy exercise solution. The FTC brought charges against one company, Slender You, Inc., for making false and unsubstantiated weight loss claims for the continuous passive motion exercise tables it manufactures and sells to health and fitness centers. “In marketing to centers and spas, Slender You has a strong appeal in profitability, promising a full return on investment within six months, and more than double their money in profit by the end of the first year.” Passive motion tables are used legitimately for rehabilitation in physical therapy and following orthopedic surgery by helping to increase flexibility of joints. However, these devices simply do not reduce body fat or body weight, and do not firm muscles or increase fitness. See also FRAUDULENT PRODUCTS; NOVELTIES FOR WEIGHT LOSS. McCurdy, John A., Jr. Sculpturing Your Body: Diet, Exercise and Lipo (Fat) Suction. Hollywood, Fla.: Frederick Fell Publishers, 1987.

pathophysiology The study of abnormal function as related to body structure. The late physiologist William Sheldon speculated that a genetic trait common to the overweight

perimylolysis 239 is a long intestinal tract. He estimated that in long, thin body types, ECTOMORPHS, the length is about 20 feet; thus food reaches the colon in a matter of hours, before many calories can be absorbed. Heavy ENDOMORPHS, however, might have up to 40 feet of intestine, which gives them additional absorptive surface and more time to absorb and store every bit of fat and sugar. Sheldon believed that MESOMORPHS have about 30 feet of bowel and tend to be neither fat nor thin. Sheldon’s theories are not considered valid, although the terms associated with them frequently appear in books and articles.

perfectionism Extreme or obsessive striving for perfection; a trait often exhibited by young people with eating disorders. One definition of perfectionistic thinking is that it involves the setting of unrealistic standards, rigid and indiscriminate adherence to these standards and the equating of self-worth and performance. Others go a step further and argue for a distinction between “normal” perfectionism, a useful characteristic, and neurotic perfectionism, a dysfunctional or self-defeating one. The latter is characteristic of those who are predisposed toward developing an eating disorder, according to Slade. For perfectionists, eating disorders are another side of the “all-or-nothing” mind set. The more they focus on being perfect, the more aware they become of their faults. Feelings of worthlessness set in. Especially if they think they are being dominated in other areas of their life—family, school, work—they may decide to take charge of at least one area: eating. Controlling and monitoring their food intake is something within their power. Other areas of perfectionistic tendencies have also been documented. In one study of 20 anorexics, school achievement was found to be significantly greater than would be predicted by standard tests. Many women with eating disorders also admit to feeling pressured to be “the perfect person.” Often they share low SELFESTEEM and a deep fear of making mistakes. Serpell and Troop add, “There is a high level of perfectionism in both anorexia nervosa (AN) and bulimia nervosa (BN) and most studies have found that different eating-disordered subtypes do not differ in levels of perfectionism. Recent studies have suggested that perfectionistic traits remain high after recovery from AN, adding to evidence

that such traits are stable features rather than simply due to the effects of the illness (e.g. starvation). There is also evidence from retrospective reports of high levels of perfectionism prior to onset.” Striegel-Moore and Smolak suggest, “Prospective studies are needed to clarify the etiological role of perfectionism in eating disorders. Several studies have found ethnic and cross-cultural differences in perfectionism. Whether heightened levels of perfectionism serve as a risk factor for the development of eating disorders in ethnic groups needs to be studied. Internalized pressure to be a ‘model’ minority, aspiration to ‘move up’ in socioeconomic status, or a desire to be an exemplary representative of one’s ethnic group may result in increased risk if the means by which such ‘acculturation’ is thought to be possible involve pursuit of thinness. A recent study found that perfectionism was associated with bulimic symptoms only in those women who felt that they were overweight, but not in women who did not perceive themselves to be overweight. The authors concluded that striving to achieve high standards only results in negative outcomes when the particular standards go unmet.” See also DICHOTOMOUS REASONING. Serpell, Lucy, and Nicholas Troop. “Psychological Factors.” In Handbook of Eating Disorders, 2nd Ed., edited by Janet Treasure, Ulrike Schmidt, and Eric van Furth, 151–167. West Sussex, U.K.: John Wiley & Sons, Ltd., 2003. Slade, Peter D. “The Misery That Neurotic Perfectionism Can Create.” BASH Magazine, July 1989. Striegel-Moore, Ruth H., and Linda Smolak. “The Influence of Ethnicity on Eating Disorders in Women.” In Handbook of Gender, Culture and Health, edited by Richard M. Eisler and Michel Hersen, 227–253. Mahwah, N.J.: Lawrence Erlbaum Associates, 2000.

perimylolysis

A loss of enamel and dentin from the surfaces of the teeth as a result of repeated contact with regurgitated gastric acids, rubbed in by movements of the tongue. Destruction can range from slight (smooth and polished surface of the teeth) to extremely severe (the complete dissolution of tooth structure through to the nerve). In more severe cases, all surfaces of the teeth are affected by acid erosion. This decay can be caused by a number of factors, but once other problems are ruled out, the patient can be assumed to have an eating disorder.

240 personalities of eating-disordered individuals Perimylolysis is generally seen in the bulimic or bulimic/anorexic patient and not in the patient exhibiting restrictive anorexia alone, since the latter does not usually vomit to purge. The chronic vomiting characteristic of bulimics (sometimes five to 10 or more times daily) brings gastric acids into the oral cavity; these acids dissolve tooth structure. Enamel will not usually erode until repeated regurgitation has occurred for two years. The surfaces most commonly affected are the lingual, or tongueside parts of the upper teeth. The other teeth are protected by the position of the tongue, lips and cheeks. It has been suggested that acidic gastric juices accumulate among the papillae of the tongue and that tongue movement continually deposits the acid on the lingual surfaces of the teeth. See also DENTAL CARIES; ORAL SOFT TISSUES. Dalin, Jeffrey B. “Oral Manifestations of Eating Disorders.” In Eating Disorders: Effective Care and Treatment, edited by Félix E. F. Lacorra. St. Louis: Ishiyaku EuroAmerica, 1986.

personalities of eating-disordered individuals Bulimics and anorexics sometimes differ in personality. People who succumb to bulimia (including those with bulimic anorexia, which is now more commonly referred to as anorexia, binge eating–purging subtype) are more impulsive and more likely to abuse alcohol and drugs than anorexics, restricting type, who tend to be “too good to be true.” They rarely disobey, keep their feelings to themselves and tend to be perfectionists, good students and good athletes. Bulimics and anorexics, however, do share feelings of helplessness, a lack of SELF-ESTEEM and fear of fat (see FEAR OF FAT SYNDROME). In both disorders, eating behaviors seem to develop as a way of handling stress and anxieties. The bulimic person consumes huge amounts of food, often junk food, in search of comfort and to ease stress. This BINGE EATING, however, brings guilt and depression. Relief comes only with PURGING. The critical distinction is between bingeing and nonbingeing disorders. The anorexic restricts food, particularly carbohydrates, to gain a sense of control in her life. Having followed the wishes of others, for the most part, she has not learned to cope with the problems of adolescence and growing up. Impulsive behavior is a common personality trait in persons with BINGE-EATING DISORDER.

Noting that previous studies of personality characteristics in women with eating disorders primarily had focused on women who are acutely ill, Klump et al. compared personality characteristics among women who are ill with eating disorders, recovered from eating disorders, and those without eating or other clinical disorder, such as mood, anxiety, or sleep disorders. They concluded, “Women with eating disorders in both the ill and recovered state show higher levels of harm avoidance and lower self-directedness and cooperativeness scores than normal control women. Although findings suggest that disturbances may be traitrelated and contribute to the disorders’ pathogenesis, additional research with more representative community controls, rather than our prescreened, normal controls, is needed to confirm these impressions.” See also ANXIETY; MULTICOMPULSIVE; PARENTAL FACTORS IN ANOREXIA NERVOSA; PERFECTIONISM. Aronson, H., Marla Fredman, and Marsha Gabriel. “Personality Correlates of Eating Attitudes in a Nonclinical Sample.” International Journal of Eating Disorders 9, no. 1 (1990). Klump, K. L., et al. “Two-Year Prospective Study of Personality Disorders in Adults with Longstanding Eating Disorders.” International Journal of Eating Disorders 37, no. 2 (March 2005): 112–118.

personality disorder According to the DSM-IV, personality disorders are enduring patterns of inner experience and behaviors that deviate markedly from the expectations of the individual’s culture, are pervasive and inflexible, have an onset in adolescence or early childhood, are stable over time and lead to distress or impairment. Research has found personality disorders to be a possible risk factor for bulimia. Joel Yager et al. administered the Personality Diagnostic Questionnaire (PDQ) to 628 eating-disordered women: 300 with normal-weight bulimia, 15 with anorexia nervosa with bulimic features and 313 with subdiagnostic eating disorders. Three-quarters of subjects with normal-weight bulimia had personality disorder diagnoses, compared with 50 percent of those with subdiagnostic eating disorders. The most common PDQ diagnoses were schizotypal, histrionic and borderline disorders, but avoidant and dependent personality features also occurred.

pharmacotherapy 241 In another study Yates et al., of the University of Iowa College of Medicine, compared 30 bulimic patients with 30 age- and sex-matched controls (see CONTROL GROUP) on DSM-III personality measures. The bulimic patients were more likely to display cluster B (histrionic, narcissistic, antisocial and borderline) personality abnormalities and cluster C (avoidant, dependent, compulsive and passiveaggressive) personality abnormalities than were the controls. Carlat et al. found personality disorder present in 26 percent of male eating-disordered patients, particularly among bulimics. In some cases, the eating disorder may be a secondary symptom to an underlying personality disorder; in others, the personality disorder may be secondary to the eating disorder. Also, according to Watson et al., the comorbid personality disorder that often accompanies an eating disorder may add to the denial of illness and unwillingness to seek treatment. Gleaves and Cepeda-Bonito noted that the effect on workplace behavior of associated personality disorders may be as great as that of the eating disorder per se. Up to 50 percent of women with bulimia have some type of personality disorder. In 2003, the National Center on Addiction and Substance Abuse (CASA) at Columbia University released a report, “Food for Thought: Substance Abuse and Eating Disorders,” which found, “Bulimic women who are alcohol dependent report a higher rate of suicide attempts, anxiety disorders, personality disorders, conduct disorder and other substance dependence than bulimic women who are not alcohol dependent.” In addition, the CASA report said, “Patients with eating disorders frequently suffer from personality disorders such as histrionic, obsessive-compulsive, avoidant, dependent or borderline personality disorders. Likewise, there is a high rate of co-occurrence of personality disorders—particularly antisocial personality disorder and borderline personality disorder—and substance use disorders both in the general population and in clinical settings.” A Norwegian study investigated whether recovered patients had lower frequency of personality disorders than patients at admission. At admission, 77 percent of patients had one or more personality disorders; whereas 57 percent had one or more per-

sonality disorders at two-year follow-up. No statistically significant differences in frequencies of personality disorders among patients with anorexia nervosa, bulimia nervosa, and EATING DISORDER NOT OTHERWISE SPECIFIED (EDNOS) were found. In their study of 668 patients, Grilo et al. determined that certain personality disorders may not be specific to certain eating disorders. Carlat, Daniel J., Carlos A. Camargo, Jr., and David B. Herzog. “Eating Disorders in Males: A Report on 135 Patients.” American Journal of Psychiatry 154, no. 8 (August 1997): 1,127–1,132. Gleaves, David H., and Antonio Cepeda-Benito. “Eating Disorders.” In Handbook of Mental Health in the Workplace, edited by Jay C. Thomas and Michael Hersen, 311–329. Thousand Oaks, Calif.: Sage Publications, 2002. Grilo, Carlos M., et al. “Do Eating Disorders Co-occur with Personality Disorders? Comparison Groups Matter.” International Journal of Eating Disorders 33, no. 2 (March 2003): 155–164. Ro, O., E. W. Martinsen, A. Hoffart, and J. Rosenvinge. “Two-Year Prospective Study of Personality Disorders in Adults with Longstanding Eating Disorders.” International Journal of Eating Disorders 37, no. 2 (March 2005): 112–118. Watson, Tureka, Wayne Bowers, and Arnold Andersen. “Involuntary Treatment of Patients with Eating Disorders.” Eating Disorders Review, March/April 2001, p. 1. Yager, Joel, John Landsverk, Carole K. Edelstein, and Steven E. Hyler, “Screening for Axis II Personality Disorders in Women with Bulimic Eating Disorders.” Psychosomatics 30, no. 3 (Summer 1989): 255–262. Yates, William R., Bruce Sieleni, James Reich, and Clint Brass. “Comorbidity of Bulimia Nervosa and Personality Disorder.” Journal of Clinical Psychiatry 50, no. 2 (February 1989): 57–59.

pharmacotherapy The use of drugs in the treatment of psychological disorders. An outgrowth of research in the neurobiological sciences, pharmacotherapy has made great inroads in the treatment of psychological disorders and psychiatric illness. Although pharmacotherapy has not been found efficacious during the initial weight-gaining stage of treating anorexia nervosa (AN), a few medications have demonstrated some efficacy in reducing relapse after weight restoration has occurred, with some evidence that the use of selective serotonin reuptake inhibitors may help in preventing relapse

242 pharmacotherapy in weight restored patients. Gleaves and CepedaBonito explain, “With AN, a variety of drugs have been tried, but no medication has been shown to treat the anorexia per se. Medications such as antidepressants are usually aimed at treating the comorbid psychopathology and should not be considered specific treatments for the AN. In contrast, several types of antidepressants have been found to be effective in reducing the bingeing and purging associated with bulimia nervosa (BN) or the bingeing with binge-eating disorder (BED). The selective serotonin reuptake inhibitors (SSRIs) (e.g., fluoxetine) may be the drugs of choice for BN; the data are less clear for BED. A significant limitation of pharmacological interventions is that their effectiveness may be temporary. That is, relapse may occur when the drugs are discontinued, and there is a lack of evidence that the drugs remain effective over extended periods of time, even while use continues. Dropout rates may also be higher than with psychological interventions.” In his overview of pharmacological treatment of eating disorders, Brewerton concludes, “Without weight restoration in anorexia nervosa, antidepressants are essentially useless for this condition, while olanzapine shows some promise in open studies. There is a strong case for the use of fluoxetine as an adjunct in the treatment of BN, but remission rates are low in comparison to the effects of cognitive-behavioral therapy. Other SSRIs may be helpful for BED, while topiramate appears to be effective in both BN and BED. Despite its expense, ondansetron can be useful in refractory BN, as can naltrexone with or without SSRIs.” Grilo et al. caution, “Studies generally find, particularly for fluoxetine, that high doses are required to produce effects. Unfortunately, surveys have revealed that most patients with BN treated with pharmacotherapy by community practitioners received inadequate dosing.” Noting that pharmacotherapy research in BED is still in its preliminary stages, Appolinario and McElroy report that some drugs have been shown to be promising agents: “Currently, three main classes of drugs have been studied in double-blind, placebo controlled trials in BED: antidepressants, anti-obesity agents, and anticonvulsants. SSRIs are the best studied medications. Thus, fluoxetine, fluvoxamine,

sertraline and citalopram have been shown to modestly but significantly reduce binge eating frequency and body weight in BED over the short term. More recently, the anti-obesity agent sibutramine and the anticonvulsant topiramate have been shown to significantly reduce binge eating behavior and body weight in BED associated with obesity.” Pharmacology has also had mixed results in the treatment of obesity, as explained by Waitman and Aronne: “Pharmacological treatments for obesity have been tried over the years. Older therapies were associated with side effects, abuse, and relapse despite ongoing treatment—characteristics that have led most practitioners to steer clear of prescribing them. Newer treatments have produced more promising results. These are not habituating, have been studied long term, and have demonstrated proven health benefits. Nevertheless, they are not yet accepted by practitioners because they produce a 5 percent placebo-subtracted weight loss—less than desired—and are not uniformly reimbursed by insurance companies.” The future holds promise for pharmacological treatment of obesity and eating disorders, according to Bruna and Fogteloo: “New developments within the field of pharmacotherapy make it likely that the number of trials (for anorexia nervosa) will increase in the coming years. Much is still unknown about the way in which specific drugs contribute to the cessation of bingeing. The quest for new medication which is both more specific and more effective is ongoing and promising. In the treatment of obesity, the long-term results of pharmacotherapy have been disappointing. However, new developments suggest a more promising role for medication in the treatment of obesity.” Appolinario, J. C., and S. L. McElroy. “Pharmacological Approaches in the Treatment of Binge Eating Disorder.” Current Drug Targets 5, no. 3 (April 2004): 301–307. Brewerton, Timothy D. “Pharmacotherapy for Patients With Eating Disorders.” Psychiatric Times 21, no. 6 (May 2004): 59–68. Bruna, Tijs, and Jaap Fogteloo. “Drug Treatments.” In Handbook of Eating Disorders, 2nd Ed., edited by Janet Treasure, Ulrike Schmidt, and Eric van Furth, 311–323. West Sussex, U.K.: John Wiley & Sons Ltd., 2003.

physical activity and obesity 243 Gleaves, David H., and Antonio Cepeda-Benito. “Eating Disorders.” In Handbook of Mental Health in the Workplace, edited by Jay C. Thomas and Michael Hersen, 311–329. Thousand Oaks, Calif.: Sage Publications, 2002. Grilo, Carlos M., Sinha Rajita, and Stephanie S. O’Malley. “Eating Disorders and Alcohol Use Disorders.” National Institute on Alcohol Abuse and Alcoholism (NIAAA). Available online. URL: http://www.niaaa. nih.gov/publications/arh26-2/151-160.htm. Posted November 2002. Waitman, Jonathan A., and Louis J. Aronne. “Pharmacotherapy of Obesity.” Obesity Management 1, no. 1 (January 2005): 15–19.

phen-Pro

A combination of the diet drug phentermine and Prozac, an antidepressant (fluoxetine). Phentermine has been used as a diet drug since 1959, but only since the mid-1990s has it been coupled with Prozac. The combination works by stimulating noradrenaline and serotonin, which makes the body feel full. In a Georgetown University study, 28 percent of patients taking phen-Pro reached their ideal body weight, 50 percent lost a lot of weight but then plateaued, and 1 percent gained weight. Possible side effects include sleep disturbance, agitation, dry mouth and constipation—typical side effects of some antidepressants. Experts also say it may take several weeks to start working. Prozac’s maker, Eli Lilly & Co., said, in 1998, it did not support combining Prozac with phentermine, but some doctors continue to prescribe the combination. Few studies have been conducted on phen-Pro, according to Norton. “A 1999 study by Eli Lilly was based on an independent review of records from the private practices of [three physicians]. No cases of primary pulmonary hypertension or cardiac valvulopathy were found in 711 obese patients treated with phentermine 30 mg (milligrams) and either 10 mg or 20 mg of fluoxetine once a day, or in a control group of 154 patients given phentermine 30 mg alone. The phen-Pro group lost an average of 11 percent of their starting weight by 18 months, and 20 percent reached a body mass index of 25 kg/m2. On average, patients in the phentermine-only group lost 3 percent of their weight during the first six months of therapy, but by the end of the study they had returned to baseline and had even gained weight.”

Norton, Patrice G. W. “Phentermine + Prozac May Offer Safe Obesity Tx.” Family Practice News, February 15, 2004, p. 81.

phenylpropanolamine (PPA)

An AMPHETAMINElike agent available without prescription and approved for sale as an APPETITE SUPPRESSANT. It is used in over-the-counter diet products like Dietac, Dexatrim and Acutrim. PPA is also the decongestant in such cold remedies as Contac, Robitussin CF and Vicks Formula 44D. It is potentially harmful for those with high blood pressure. PPA works by stimulating a type of adrenaline receptor to fool the body into thinking it’s full. According to the Food and Drug Administration, even the best studies show only about a halfpound greater weight loss per week using PPA combined with diet and exercise.

physical activity and obesity

Cardiologist James Rippe, considered the father of the walking movement in the United States, says the country is facing two major lifestyle-related epidemics that are intricately linked: an epidemic of obesity and an epidemic of inactivity. Among his many points, he states: Multiple interactions exist between lack of physical activity and obesity. Increased physical activity lowers the risk of obesity, may favorably influence distribution of body weight, and confers a variety of health-related benefits even in the absence of weight loss. Physical activity is important for achieving proper energy balance, which is needed to prevent or reverse obesity. Not only is energy expended during physical activity, physical activity also has a positive effect on resting metabolic rate. Regular physical activity can improve body composition. Properly designed programs of physical activity may preserve or even increase lean muscle mass during weight loss. Physical activity has also been strongly associated with maintenance of weight loss. Physical activity that expends 1,500 to 2,000 kcal a week appears necessary to maintain weight loss. Numerous studies have shown that the combination of proper nutrition and regular physical activity is the most effective intervention for weight loss and maintenance of weight loss. Walking is the most convenient and logical way for most obese persons to increase their physical activity.

244 physiological arousal A new analysis of health habits of U.S. adults released February 25, 2004, by the Centers for Disease Control and Prevention’s National Center for Health Statistics showed only about one-fourth of adults engaged in light to moderate physical activity and about one in 10 engaged in vigorous activity at least five times per week. Also, according to the Weight-control Information Network, an information service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK): • Less than one-third (31.8 percent) of U.S. adults get regular leisure-time physical activity (defined as light or moderate activity five times or more per week for 30 minutes or more each time and/or vigorous activity three times or more per week for 20 minutes or more each time). About 10 percent of adults do no physical activity at all in their leisure time. • About 25 percent of young people (ages 12–21 years) participate in light to moderate activity (e.g., walking, bicycling) nearly every day. About 50 percent regularly engage in vigorous physical activity. Approximately 25 percent report no vigorous physical activity, and 14 percent report no recent vigorous or light to moderate physical activity. Rippe, James M., and S. Hess. “The Role of Physical Activity in the Prevention and Management of Obesity.” Journal of the American Dietetic Association 98, no. 10, suppl. 2 (October 1998): 531–538.

physiological arousal

Physical response to stimuli; for instance, the development of a feeling of hunger in response to the sight of food. Although several studies have suggested that physiological arousal is an important factor in overeating by obese persons, a 1988 study by Gardner et al. of the University of Southern Colorado found no differences in arousal between weight groups. They examined differences in arousal between obese and normal-weight persons while exposed to food stimuli, during eating and during exposure to visual imagery of both food and nonfood stimuli.

The only sex differences in arousal occurred during the auditory presentation of food imagery; men displayed higher arousal than women. Significant sex differences were not present during any of the other intervals. The study concluded that there is no support for the notion that obese subjects are differentially aroused by food-related stimuli. Although the presentation and eating of pizza did produce significant changes in arousal, there was no differential arousal between the obese and normal-weight persons. Both food and nonfood imagery tasks proved ineffective in increasing arousal in both obese and normal-weight persons. Gardner, Rick M., Tracy Espinoza, and Renee Martinez. “Physiological Responses of Obese Subjects to External Stimuli.” Perceptual Motor Skills 66, no. 1 (February 1988): 69–70.

pica Ingestion of strange or repulsive substances not normally considered suitable for food. The phenomenon occurs throughout the world and has been recorded for centuries. The most common explanation is that those who evidence pica are seeking trace minerals or inorganic minerals missing from their diet and desperately needed by their bodies. However, there is a lack of evidence for this explanation. Pica is seen most often in young children, in children and adults with mental retardation, or in persons with severe psychiatric disorders. Pica is also not uncommon in pregnant women. Corbett et al. found that “Pica exists, and might be more common than healthcare providers assume. Although this study did not show specific pregnancy complications associated with pica, other studies have shown anemia and lead poisoning among women who practice pica. It is not clear that patients volunteer information about pica, so it would be helpful if nurses queried patients at each prenatal visit regarding pica practice. Discussion of pica practices should be based on a nonjudgmental model, for pica may have strong cultural implications, and may be practiced for cultural reasons unknown to the nurse.” In an earlier review of the literature for the period 1950 through 1990, Homer et al. also concluded that pica is more prevalent among pregnant women than commonly believed. “The prevalence of pica among

polycystic ovary syndrome 245 pregnant women in high-risk groups declined between the 1950s and the 1970s but now remains steady, affecting about one fifth of high-risk women. Women at high risk of pica are more likely to be black, to live in rural areas, and to have a positive childhood and family history of pica. The clinical picture of the disorder during pregnancy is not well described. The evidence suggests that pica during pregnancy results in anemia, but it is not definitive.” In order for the eating of nonnutritive substances to be diagnosed as pica, it must persist for a period of at least one month; it must not be developmentally appropriate; it must not be considered an acceptable practice in the person’s culture; and, if the eating behavior exists only during the course of another mental disorder, it must be deemed serious enough to warrant independent clinical attention. The most common forms of pica are GEOPHAGIA and PAGOPHAGIA.

ulates the adrenal glands to secrete hormones, with multiple effects on metabolism); it is also associated with hypothyroidism. Pituitary obesity is slow to develop, is of a generalized type and can be diagnosed by a dryness of the skin, shortened growth of the eyebrows and diminished function of the reflexes. Other characteristics that suggest a pituitary disorder include pallor, a generalized obesity and, in both sexes, lack of fully developed sexual characteristics. In men with this disorder there is a tendency for the adipose tissue to concentrate in the pelvic region. Secretion of the growth hormone becomes sluggish in the obese, compared with people of normal weight. Yet it returns to normal with weight reduction, indicating that this is the result rather than the cause of the obesity. When pituitary obesity is treated by correcting the basic disorder, it is possible for the patient to lose weight by restricting calories.

Corbett, R. W., C. Ryan, and S. P. Weinrich. “Pica in Pregnancy: Does It Affect Pregnancy Outcomes?” MCN: The American Journal of Maternal Child Nursing 28, no. 3 (May–June 2003): 183–189; quiz 190–191. Horner, Ronnie D., et al. “Pica Practices of Pregnant Women.” Journal of the American Dietetic Association 91, no. 1 (January 1991): 34–38.

Frawley, Thomas F., “Obesity and the Endocrine System.” In The Psychiatric Clinics of North America, vol. 7, no. 2: Symposium on Eating Disorders, edited by Félix Larocca. Philadelphia: W. B. Saunders, 1984.

pickwickian syndrome

See OBESITY-HYPOVENTILATION

SYNDROME.

pimozide An antipsychotic medication. In a Dutch study, anorexia nervosa patients treated with pimozide gained weight faster than another group administered PLACEBO, but overall the difference from placebo was not statistically significant. There was also no significant difference in the pimozide patients’ attitudes. pituitary obesity

The pituitary gland influences most body functions and is particularly important in growth, sexual maturity and reproduction. It does this through the release of hormones (thyroid, adrenals and gonads). Pituitary obesity may result from a disorder of the pituitary, including the loss of more than one of these pituitary hormones. The major cause of pituitary obesity is CUSHING’S DISEASE, caused by an excess of ACTH (which stim-

placebo

A harmless inactive substance (or ineffective procedure) given to a CONTROL GROUP in a study as if it were an effective treatment, used as a comparison for the substance or procedure being tested. A placebo substance is made to look and taste identical to the active preparation; subjects are not told which they are taking.

polycystic ovary syndrome (PCOS) Also known as Stein-Leventhal syndrome, it is the most common cause of female infertility. Researchers estimate that 5 percent to 10 percent of women in the United States have PCOS. Women with PCOS may also have other health problems, such as abnormally high levels of insulin, obesity, high blood pressure and heart disease. A small number of these women will also gain weight and notice an increase in their hair growth. Symptoms of PCOS include: infrequent menstrual periods, no menstrual periods and/or irregular bleeding; infertility or inability to get pregnant because of not ovulating; increased growth of hair on the face, chest, stomach, back, thumbs or toes;

246 polyphagia acne, oily skin or dandruff; pelvic pain; weight gain or obesity, usually around the waist; type 2 diabetes; high cholesterol; high blood pressure; male-pattern baldness or thinning hair; patches of thickened and dark brown or black skin on the neck, arms, breasts or thighs; skin tags (tiny excess flaps of skin in the armpits or neck area); sleep apnea/excessive snoring and breathing stops at times while asleep. No one knows the exact cause of PCOS. Women with PCOS frequently have a mother or sister with PCOS, but there is not yet enough evidence to indicate a genetic link to this disorder. Many women with PCOS have a weight problem, so researchers are looking at the relationship between PCOS and the body’s ability to make insulin. Insulin is a hormone that regulates the change of sugar, starches and other food into energy for the body’s use or for storage. Since some women with PCOS make too much insulin, it is possible that the ovaries react by making too many male hormones, called androgens. This can lead to acne, excessive hair growth, weight gain and ovulation problems. Treatments for PCOS are based on the symptoms each patient is having and whether she wants to conceive or needs contraception, and include birth control pills, diabetes medications, fertility medications, medicine for increased hair growth or extra male hormones and surgery. Maintaining a healthy weight is another way women can help manage PCOS. Because obesity is common with PCOS, a healthy diet and physical activity help maintain a healthy weight, which will help the body lower glucose levels and use insulin more efficiently, and may help restore a normal period. Even loss of 10 percent of her body weight can help make a woman’s cycle more regular. Although PCOS has become a much-discussed topic among the eating disorders community, research is finding no cause or effect between PCOS and either eating disorders or obesity. When Michelmore et al. investigated the reported association between PCOS and bulimia nervosa among 230 women ages 18–25, they did not find any evidence that “bulimia nervosa or other binge-eating disorders occur more commonly in women with polycystic ovaries or PCOS. In addition, women with polycystic ovaries do not demonstrate significantly higher scores for dieting and other features

of shape and weight concern when compared with women with normal ovaries.” Key et al. wrote, “Low weight anorectic women with multifollicular ovaries have frequently been misdiagnosed as having PCOS, despite the two conditions being morphologically distinct.” Referring to suggested theories of a connection between bulimia nervosa and PCOS, they elaborated, “These include the suggestion that bingeing and restricting are associated with insulin resistance and this precipitates manifestations of PCOS or that the two disorders share a predisposing factor. If disordered eating perpetuates PCOS and dieting worsens bulimic symptomatology, then the recommendation for weight loss in an individual with PCOS is likely to exacerbate the condition.” Noting that previous authors had speculated about the contribution of dietary intake to obesity in PCOS, Wright et al. compared dietary data from 91 PCOS cases to that of 80 controls and found that “dietary intake and physical activity alone are not sufficient to explain differences in weight between women with and without PCOS. Women with PCOS may tend to restrict significantly energy intake in order to maintain a normal weight.” Key, Adrienne, Helen Mason, and Jim Bolton. “Reproduction and Eating Disorders: A Fruitless Union.” European Eating Disorders Review 8, no. 2 (March 2000): 98–107. Michelmore, K. F., A. H. Balen, and D. B. Dunger. “Polycystic Ovaries and Eating Disorders: Are They Related?” Human Reproduction 16, no. 4 (April 2001): 765–769. Wright, C. E., et al. “Dietary Intake, Physical Activity, and Obesity in Women with Polycystic Ovary Syndrome.” International Journal of Obesity & Related Metabolic Disorders 28, no. 8 (August 2004): 1,026–1,032.

polyphagia

Excessive craving for all types of food; very great HUNGER.

ponderosity

Body weight relative to height. Individual differences in ponderosity are important determinants of health status. In a family study by Burns, Moll and Lauer reported in American Journal of Epidemiology (May 1989), the researchers determined that if the specific environmental exposure associated with differences in ponderosity could be identified,

Prader-Willi syndrome 247 strategies could be devised to prevent the development of excess ponderosity in high-risk children and to reduce the risk of development of chronic diseases associated with obesity in adulthood.

portion and serving sizes Although much of the dramatic increase in prevalence of obesity in recent decades has been largely attributed to a culture that promotes increased caloric intake and physical inactivity, another contributing factor has been an increase in the sizes of food portions served not only in restaurants but also in the home. Larger food portions have more calories, and eating more calories than one needs may lead to weight gain. As Young and Nestle write, “Most marketplace portions exceed standard serving sizes by at least a factor of 2 and sometimes 8-fold. Portions have increased over time; those offered by fast-food chains, for example, often are 2 to 5 times larger than the original size. The discrepancy between marketplace portions and standard servings suggests the need for greater emphasis on the relationship of portion size to energy intake as a factor in weight maintenance.” In an earlier study these researchers found that “portion sizes began to grow in the 1970s, rose sharply in the 1980s, and have continued in parallel with increasing body weights.” Other studies have reported similar findings, such as: • Food portion sizes in France, where the obese adult population is one-third that of the United States, are about half the size of those in America. (French plate sizes are nine inches, compared to the 11- or 13-inch plates typical in the United States). • When served oversized portions ranging from large to enormous, few participants finished even the large servings, but those given the largest portions consumed on average 30 percent more calories. • Even cookbooks have increased portion sizes. Revisions published in the last 10 years have lowered the number of servings per recipe but kept the amount of food the same. • According to the National Institutes of Health interactive “Portion Distortion!” quiz posted in 2004, a muffin 20 years ago weighed 1.5 ounces

and had 210 calories. Today’s five-ounce muffin has 500 calories. The comparison quiz is located at http://hin.nhlbi.nih.gov/portion. Young, L. R., and M. Nestle. “Expanding Portion Sizes in the US Marketplace: Implications for Nutrition Counseling.” Journal of the American Dietetic Association 103, no. 2 (February 2003): 231–214. Young, L. R., and M. Nestle. “The Contribution of Expanding Portion Sizes to the US Obesity Epidemic.” American Journal of Public Health 92, no. 2 (February 2002): 246–249.

post-traumatic effect

A specific form of ANXIETY that appears following a stressful or frightening event. There have been numerous cases recorded of anorexia nervosa and bulimia apparently precipitated by physical trauma such as surgery, an automobile accident, rape or sexual abuse. Trauma resulting in either temporary or permanent body disfigurement may in turn bring on or make worse DEPRESSION, BODY IMAGE DISTURBANCE, family or social stresses and may possibly affect hypothalamic function, thereby contributing to the onset of eating disorders. See also STRESS AND EATING DISORDERS.

Prader-Willi syndrome (PWS) A birth defect whose victims are always hungry and do not know how to stop gorging. About one child in 10,000 to 15,000 is born with this incurable syndrome, identified in 1956 by Swiss doctors. Characteristics include short stature, unusually small hands and feet, hyperphasia (excessive talkativeness), hypogonadism (retarded sexual development) and some degree of learning disability or mental retardation. Unless people with this syndrome are strictly supervised, their compulsion to gorge (hyperphagia) can cause them to swell two or three times their ideal weight. That can lead to heart or respiratory problems and early death. At the First International Scientific Conference on Prader-Willi Syndrome and Other Chromosome 15 Deletion Disorders (The Netherlands, 1991), specialists noted that hyperphagia is first manifested between ages one and six, and that while victims do reach SATIETY, it is only after consuming three times more calories than controls. Their hunger also returns more quickly. Many patients develop diabetes during adult life.

248 pregnancy and eating disorders pregnancy and eating disorders In a study of 66 women who had a history of anorexia nervosa and 98 randomly selected community controls, neither group differed on rate of pregnancy, mean number of pregnancies per woman or age at first pregnancy. But the women with anorexia nervosa had significantly more miscarriages and cesarean deliveries, and their offspring were significantly more likely to be born prematurely and of lower birth weight than the offspring of controls were. There were no differences between women with active versus remitted anorexia nervosa on any of these measures; however, the offspring of anorexic women with no history of bulimia nervosa had significantly lower body weight than the offspring of anorexic women with a lifetime history of bulimia nervosa did. In another study of women with current or past anorexia or bulimia nervosa, children of women with eating disorders also had significantly lower birth weights and lengths than control children had. There were no differences observed in childhood temperament or mothers’ satisfaction with children’s appearance. But mothers with eating disorders did have more difficulty maintaining breast-feeding, and they made significantly fewer positive comments about food and eating than control mothers during mealtime observations. Yet a 1998 Australian study of 88 women delivering low birth-weight infants determined that women with a past history of an eating disorder had no greater risk of delivering a low birth-weight infant. Women delivering infants who were small for their gestational age did report elevated eating disorder psychopathology after delivery and more eating disturbances before and during pregnancy. Benton-Hardy and Lock suggested that pregnancy could be a possible contributor to the development of anorexia in a predisposed person. They wrote that “although [the subject, a 17-year-old girl] has other factors associated with the development of anorexia, the psychological and physical changes of pregnancy appear to be the crucial changes which precipitated anorexia nervosa.” In a study of 48 women 10 or more following initial treatment of bulimia nervosa, short-term episodes of bulimic-free behavior were associated with pregnancy and breast-feeding on some preg-

nancies. The prevalence of miscarriage and postnatal depression was greater among women who had not recovered from their eating disorder at the time of their pregnancy. The results of a Swedish study reported in 2005 confirm that fetal outcome may be compromised in women with a past or active eating disorder. Twenty-two percent of the patients had a verified relapse in eating disorders during pregnancy. Women with past or current eating disorders were at increased risk of severe vomiting and delivered infants with significantly lower birth weight and smaller head circumference as compared with controls. They were also at greater risk of delivering infants with microcephaly (abnormally small heads) and small for gestational age infants. Abraham, S. “Sexuality and Reproduction in Bulimia Nervosa Patients over 10 Years.” Journal of Psychosomatic Research 44, nos. 3–4 (March–April 1998): 491–502. Benton-Hardy, L. R., and Lock, J. “Pregnancy and Early Parenthood: Factors in the Development of Anorexia Nervosa?” International Journal of Eating Disorders 24, no. 2 (September 1998): 223–226. Bulik, C. M., et al. “Fertility and Reproduction in Women with Anorexia: A Controlled Study.” Journal of Clinical Psychiatry 60, no. 2 (February 1999): 130–137. Conti, J., S. Abraham, and A. Taylor. “Eating Behavior and Pregnancy Outcome.” Journal of Psychosomatic Research 44, nos. 3–4 (March—April 1998): 465–477. Kouba, S., T. Hallstrom, C. Lindholm, and A. L. Hirschberg. “Pregnancy and Neonatal Outcomes in Women with Eating Disorders.” Obstetrics and Gynecology 105, no. 2 (February 2005): 255–260. Waugh, E., and C. M. Bulik. “Offspring of Women with Eating Disorders.” International Journal of Eating Disorders 25, no. 2 (March 1999): 123–133.

pregnancy and obesity

In her studies, HILDE BRUCH found that obesity that develops during or after pregnancy often develops in response to stress (see REACTIVE OBESITY). Some women gain weight after each pregnancy, some only after one. Bruch’s studies determined that the most frequent causes of stress underlying obesity following pregnancy are disappointment with the marriage, unfulfilled, unrealistic expectations about what the child might do for the mother or frank envy of the care

pregnancy and obesity 249 the child receives and resentment about the demands it makes. Though noting that “much has been written about obesity indicating a desire for pregnancy,” Bruch argued against this theory. While agreeing that some fat women have pregnancy fantasies, she cautioned that those who are not fat do also. “Occasionally,” Bruch added, a father may become fat after the birth of a child; this occurs in extremely dependent men who, even before the baby is born, feel that they never received quite enough [attention]. They will resort to overeating to combat their anger and jealousy and to compensate themselves for what they feel they are missing.

The more children a person has, the greater the risk he or she will become obese, according to a study from Duke University Medical Center. From an analysis of a large database of middle-aged Americans, researchers found women faced an average 7 percent increased risk of obesity per child and men an average 4 percent increased risk per child. Researchers attribute the weight gain to a busier lifestyle that may include a diet of more fast food and leave less time for exercise. “Increased risk of obesity in both men and women suggests a substantial portion of the effect of obesity related to parenthood has to be social, cultural or psychological,” said Lori Bastian, M.D., a study coauthor. “It’s difficult to imagine a physiological mechanism through which men could gain weight during pregnancy or after childbirth. Further studies are needed to isolate cause and effect so we can more accurately suggest target groups for obesity prevention and research.” Pre-pregnancy maternal obesity more than doubled the risk of stillbirth and neonatal death in a Danish study of 24,505 pregnancies. No statistically significant increased risk of stillbirth or neonatal death was found among underweight or overweight (but not obese) women. Countering that was a recent American study of 2,910 women that found obesity before pregnancy to be associated with a lower rate of spontaneous preterm birth. European research to determine whether morbidly obese women have an increased risk of pregnancy complications and adverse perinatal

outcome compared 2,472 women with morbid obesity (body mass index greater than 40) with normal-weight women. There was an increased risk of the following outcomes: gravidic hypertension, preeclampsia, gestational diabetes, cesarean delivery and macrosomia. However, the authors noted “a lower rate of prematurity in the obese group (0 vs 11%). Even when morbidly obese women with preexisting diabetes and chronic hypertension were excluded from the analysis, significant differences in the perinatal outcomes still persisted.” Diets to control weight during pregnancy must account for the increased need for protein, iron, folic acid and most other minerals and vitamins. For this reason, during pregnancy weight is best controlled through small decreases in calorie intake, with increased energy expenditure through exercise. VERY LOW-CALORIE DIETS are to be avoided during pregnancy unless specifically prescribed by a physician. Until recently, few studies had been done on pregnancy weight gain and its effect on maternal health. Physiological psychologist Jennifer Lovejoy has been researching the disparity between women’s chance of gaining weight and men’s (women’s is about double) and believes pregnancy may be a factor. Studies show that the average woman retains two to five pounds after nine months of carrying a baby, far above the normal pace related to aging. Many women end up 20 or more pounds heavier long after childbirth. Siega-Riz et al. call for more studies on the effect of pregnancy weight gain. “Past research on maternal weight gain during pregnancy has focused on determinants and consequences of inadequate weight gain with concerns for the health of the infant. However, with the rising prevalence of obesity among women of childbearing ages and the high proportion of women who are gaining in excess of recommendations, a shift in research focus must occur to include consideration of the mother’s long-term health status. The few studies that have examined determinants of excessive weight gain and postpartum weight retention in this country were not comprehensive in assessing diet, physical activity and psychosocial factors and suffer from small

250 pro-ana movement sample sizes. Information is lacking concerning pregnant women’s perceptions about eating and gaining weight, what they actually eat, how consumption and exercise relate to weight gain, and how psychosocial factors influence these behaviors during pregnancy. Likewise, little is known concerning these same attitudes and behaviors during the postpartum period that may contribute to weight retention.” See also ORAL CONTRACEPTIVES. Grossetti, E., et al. “Morbid Obesity and Perinatal Complications.” Journal of Gynecology, Obstetrics, and Reproductive Biology (Paris) 33, no. 8 (December 2004): 739–744. Hendler, I., et al. “The Preterm Prediction Study: Association between Maternal Body Mass Index and Spontaneous and Indicated Preterm Birth.” American Journal of Obstetrics and Gynecology 192, no. 3 (March 2005): 882–886. Kristensen, J., et al. “Pre-pregnancy Weight and the Risk of Stillbirth and Neonatal Death.” BJOG 112, no. 4 (April 2005): 403–408. Lovejoy, Jennifer C. “The Influence of Sex Hormones on Obesity Across the Female Life Span.” Journal of Women’s Health 7 (December 1998). Siega-Riz, A. M., K. R. Evenson, and N. Dole. “PregnancyRelated Weight Gain—A Link to Obesity?” Nutrition Reviews 62, no. 7, pt. 2 (July 2004): S105–111. Weng, H. H., L. A. Bastian, et al. “Number of Children Associated with Obesity in Middle-Aged Women and Men: Results from the Health and Retirement Study.” Journal of Women’s Health 13, no. 1 (January–February 2004): 85–91.

pro-ana movement Also referred to as pro-ED. A subculture that promotes anorexia and bulimia, which has flourished in Internet chat rooms and on message boards where groups of mostly teenage girls support one another in their quest for the ultimate thinness. Experts note that eating-disordered individuals banding together to share tips on fasting, avoiding detection and losing weight is not a new phenomenon—dancers, wrestlers and models have done it for years; but the power of the Internet has made it more pervasive. These online communities encourage “anas” (anorexics) and “mias” (bulimics) by posting “thinspiration” photo galleries of waif-thin models and famous celebrities reported to have eating disor-

ders like Mary-Kate Olsen and KAREN CARPENTER along with photos of obese women to warn what they will look like if they do not stick with their fasting and/or purging. A recent addition to the community has been the marketing of colored bracelets to be worn on the eating wrist—usually red for anorexics, blue or purple for bulimics or black or black-and-blue for self injury—as both a “secret” sign of pro-ana membership and selfmotivation not to eat. Health professionals have expressed concern that the pro-ana culture is hijacking prevention and recovery efforts and helping eating disorders to spread. Because some Web hosting companies have been convinced to shut down these sites, more are “going underground” and requiring passwords for entry. Pollack, Deborah. “Pro-Eating Disorder Websites: What Should Be the Feminist Response?” Feminism & Psychology 13, no. 2 (May 2003): 246–251.

prostate cancer and obesity Of the more than 35 studies on prostate cancer risk, most conclude that there is no association with obesity. Some report that obese men are at higher risk than men of healthy weight, particularly for more aggressive tumors. Recently, obesity has been associated with more aggressive prostate cancer at diagnosis and higher recurrence rates after patients undergo surgery to remove the entire prostate. One study found an increased risk among men with high waist-to-hip ratios, suggesting that abdominal fat may be a more appropriate measure of body size in relation to prostate cancer. Studies examining body mass index (BMI) and prostate cancer mortality have had conflicting results. However, in a recent review of the literature, Presti concluded, “A growing body of evidence suggests that obesity may impact upon risk, detection and outcome with regard to prostate cancer.” Also, a study by researchers from the University of Texas Health Science Center at San Antonio raises the possibility that the most common test for prostate cancer might be of less benefit to men who are overweight or obese. Ian M. Thompson Jr., M.D., and Jacques G. Baillargeon, Ph.D., were among the authors on a study of the relationship

Prozac 251 between BMI and the prostate-specific antigen (PSA) test. The study in 2,779 men showed that PSA values were lower as BMI increased. Some researchers theorize that obese men might have elevated hormone levels, possibly explaining their lower PSA scores. An alternative theory, studied by the Health Science Center team, is that PSA may be less sensitive in obese men. This is important because it might mean that obese men are having their cancers diagnosed later, resulting in poorer overall survival. Baillargeon, J., et al. “The Association of Body-Mass Index and Prostate-Specific Antigen in a Population-Based Study.” Cancer 103, no. 5 (March 2005): 1,092–1,095. Presti, J. C., Jr. “Obesity and Prostate Cancer.” Current Opinion in Urology 15, no. 1 (January 2005): 13–16.

proteins One of the three major types of nutrients (see CARBOHYDRATES and FATS) found in food. Proteins constitute about 20 percent of the body’s cell mass. They are necessary for the building and repair of all kinds of body tissues, especially of muscles and organs such as the heart, liver and kidneys. Skin, hair, ligaments, tendons, muscle and nails are composed of protein. Major sources of protein are animal products such as meat, eggs, fish and milk. Digestion breaks down protein into its component elements, amino acids, which pass into the blood, some to be used as structural proteins for the building of body tissues, others to be used as enzymes and the rest to be carried to various parts of the body as a reserve. Because they are drawn on directly as a source of energy, there is no noticeable weight gain when high-protein foods are eaten in reasonable amounts. Proteins provide about four CALORIES per gram. Protein deficiency manifests itself in weakness, poor resistance to disease and swelling of body tissues due to accumulation of fluid in the tissue spaces. When eaten in large amounts, protein-rich foods can cause constipation, kidney dysfunction and heart failure. protein-sparing modified fast (PSMF)

A diet regimen designed to be safer than formula diets and to produce loss primarily of fat tissue rather than lean body tissue by adding PROTEINS and electrolytes to

the FASTING regimen. It was developed by pioneers such as Bistrian and Blackburn, who defined the conceptual framework and nutritional profile of a diet that produces rapid and significant fat loss while minimizing or eliminating many of the adverse health consequences of the earlier LIQUID FORMULAS. The PSMF is recommended for the moderately obese (see OBESITY) when undertaken under close medical supervision. It is not recommended for the mildly obese because the risk from the treatment outweighs the risk from mild obesity; nor for the morbidly obese, because they are more safely and effectively treated with BARIATRIC SURGERY; nor for children and adolescents, because there is some loss of lean body mass, which may interfere with growth. No data suggest that the PSMF diet reliably improves obesity in the long term. The diet generally prescribes a total energy intake of 600–800 kcal daily for 12 weeks, followed by a maintenance diet. One study reported a weight loss of about 25 pounds after 10 weeks, which was substantially more than that achieved by less restrictive measures, but at the 15-month follow-up, the weight loss achieved by the two groups was similar. Bristrian, B. R. “Clinical Use of a Protein-Sparing Modified Fast.” Journal of the American Medical Association 240 (1978). Lindner, P. G., and G. L. Blackburn. “Multidisciplinary Approach to Obesity Utilizing Fasting Modified by Protein Sparing Therapy.” Obesity/Bariatric Medicine 5 (1976).

Prozac

Proprietary name for fluoxetine, a longlasting ANTIDEPRESSANT drug that acts by selectively and effectively blocking the reuptake (reabsorption) of the neurotransmitter SEROTONIN into nerve terminals in the brain. It was introduced in the United States early in 1988 and within a year became one of the most widely prescribed antidepressants in the country. Experiments on more than 1,000 patients showed that fluoxetine works at least as quickly and effectively as IMIPRAMINE and other tricyclic antidepressants. The main side effects, according to researchers, are nausea and vomiting, insomnia and nervousness. It is less likely than other antidepressants to cause constipation, dry mouth, drowsiness, sexual difficulties or urinary problems.

252 psychodrama Obese patients given fluoxetine at fairly high doses lost eight to 10 pounds in two months without dieting, even when the drug caused no nausea or upset stomach. Although Prozac has been used to treat anorexia nervosa (AN), Brewerton writes, “Prozac has been shown to have absolutely no effect on weight, body image, anxiety or mood in low-weight patients with AN. However, once patients are weight-recovered, one controlled trial indicated that relapse (which is common) can be significantly reduced with fluoxetine in comparison to placebo, presumably due to its antiobsessional effects.” In their review, Rossi et al. wrote, “The metaanalysis available on the use of fluoxetine in the treatment of bulimia nervosa shows that the drug is as effective as other agents with fewer patients dropping out of treatment.” Similarly, Walsh et al. had concluded that “a twostage medication intervention using fluoxetine adds modestly to the benefit of psychological treatment.” See also ANTIDEPRESSANTS; PHEN-PRO. Brewerton, Timothy D. “Pharmacotherapy for Patients with Eating Disorders.” Psychiatric Times 21, no. 6 (May 2004). Available online. URL: http://www. psychiatrictimes.com/p040559.html. Rossi, A., A. Barraco, and P. Donda. “Fluoxetine: A Review on Evidence Based Medicine.” Annals of General Hospital Psychiatry 3, no. 1 (February 12, 2004): 2. Walsh, B. T., et al. “Medication and Psychotherapy in the Treatment of Bulimia Nervosa.” American Journal of Psychiatry 154, no. 4 (April 1997): 523–531.

psychodrama A form of GROUP THERAPY in which patients act out their responses to difficult or conflicted situations from their daily lives. Psychodrama was developed by a psychiatrist, J. L. Moreno (1890–1974) during the 1930s to liberate the “spontaneous” self from the constrictions of Victorian social morality. Today, psychodrama offers adolescents and adults whose “real self” is hiding from hurtful or shameful traumas of the past to reenact these scenes that have led to the disordered behavior of the present. It’s a nonconfrontational format intended to make it possible for patients to gain insight into their own conflicted or self-defeating behavior. Psychodrama has been used as treatment for eating disorders.

Veronica O. Bowlan, a psychodrama consultant, explains that psychodrama is not merely role-playing and not acting class. In psychodrama, a patient gets a chance to deal with people and events in her past, present, or future. She gets a chance to begin to resolve unsettled or hidden feelings and often learns new ways of handling conflicts in real situations. Psychodrama . . . [uses] action rather than talking to help patients deal with difficult feelings. The patient creates and actually steps into a situation to confront the problem and her feelings about it. It is difficult, but it is also very real and powerful . . . [she] demonstrates to each player how the character should behave. She does this throughout the whole drama. This is called role reversal. Reversing roles gives her a chance to see the situation from other perspectives and discover new solutions or ways of interacting.

Diamond-Raab and Orrell-Valente suggest that psychodrama is especially useful when treating adolescents. “Anorexia nervosa and bulimia nervosa typically afflict individuals in adolescence. Given the intractability of these diseases in combination with the natural recalcitrance of adolescence, treatment with this population presents a daunting challenge. Traditional group therapy that focuses on verbal therapy is often not effective with this population, particularly in the acute stages of the diseases. A group therapy approach that integrates art therapy, psychodrama, and verbal therapy offers an innovative alternative to traditional group therapy.” Eating Disorder Center of Denver offers a psychodrama treatment group: “This is an experiential therapy which focuses upon action based learning. Group members are encouraged to enact scenes from their lives to identify and explore emotions and to build skills to increase their effectiveness in daily life.” See also ART THERAPY. Baaklini, George. “Psychodrama: A Timely Therapeutic Procedure.” Renfrew Perspective (Fall 1992). Bowlan, Veroncia O. “Psychodrama: Taking Action to Discover Feelings.” Renfrew Perspective (Fall 1992). Diamond-Raab, L., and J. K. Orrell-Valente. “Art Therapy, Psychodrama, and Verbal Therapy. An Integrative Model of Group Therapy in the Treatment of Adolescents with Anorexia Nervosa and Bulimia Nervosa.” Child and Adolescent Psychiatric Clinics of North America 11, no. 2 (April 2002): 343–364.

psychotherapy 253 Hudgins, Kate. “Using Psychodrama as a Therapeutic Tool.” Addiction Letter, October 1990.

psychodynamic approach to obesity

An understanding of obesity on the belief that overweight people eat in response to stress-engendered emotional states, especially ANXIETY and DEPRESSION, rather than simply to internal HUNGER cues. The stress is due to conditions such as marital or work problems, mother-daughter conflict and PERSONALITY DISORDERS. The eating response recurs because it works: it relieves emotional distress. Psychodynamic theorists discuss overeating as a means of diminishing anxiety, achieving pleasure, relieving frustration and emotional deprivation, expressing hostility (conscious or unconscious) and so forth (see ORAL FIXATION AND OBESITY). Opponents of this theory believe that these stress factors are consequences rather than causes of obesity, due largely to diminished SELF-ESTEEM from the discrimination obese people experience today.

psychogenic malnutrition

Weight loss from psychological causes; the noneating associated with it is incidental. The term covers a wide range of psychiatric disorders including chronic schizophrenia, acute catatonic schizophrenia, mental retardation and schizophrenic disorganization and forms of DEPRESSION. Cases of this type have sometimes been included in anorexia nervosa literature but do not qualify as a true anorexia eating disorder. Habermas has argued that eliminating the fear of fat criterion (as recommended by Sing Lee) would result in anorexia nervosa being confused with other reasons for eating problems (e.g., depression). Habermas, T. “In Defense of Weight Phobia as the Central Organizing Motive in Anorexia Nervosa: Historical and Cultural Arguments for a Culture-Sensitive Psychological Conception.” International Journal of Eating Disorders 19, no. 4 (May 1996): 317–334.

psychogenic vomiting

Vomiting due to some emotional or psychological reason, but not due to an eating disorder. That is, the person is not vomiting because of fear of weight gain but rather due to nausea from some psychological/emotional origin.

psychosomatic medicine A field of medicine begun in the 1930s; Joan Brumberg describes it as “the scientific study of emotion and the bodily changes that accompany different emotional states.” She continues, Psychosomatic medicine involved practitioners from many different specialty areas, not just psychiatry. Followers of the psychosomatic movement shared a common interest in a more integrated approach to etiology and therapy. Body (soma) and mind (psyche) were considered as one.

Brumberg added that anorexia nervosa was particularly suited to psychosomatic research because of “the manner in which bodily changes accompanied neurotic mechanisms,” but the attempt to explain it with a simple, single formula was ultimately doomed because of the complexity of the disorder. After World War II HILDE BRUCH led the way to a broader and more complex view of the significance of food behavior and its relation to individuals’ lives. Brumberg, Joan Jacobs. Fasting Girls. Cambridge, Mass.: Harvard University Press, 1988.

psychotherapy Treatment of mental and emotional disorders by any of various means involving communication between trained therapists and patients. It includes counseling, psychoanalysis, cognitive therapy and interpersonal therapy, among others. Through psychotherapy, patients are helped to understand why they have followed certain behavior patterns and to change those patterns. Psychotherapy aims to help individual suffering from eating disorders achieve a more competent, less painful way of handling their problems. It may involve patients singly or in COUPLES THERAPY, FAMILY THERAPY or GROUP THERAPY. Individual psychotherapy is generally recommended for all eating-disorder patients and usually forms the foundation for all other treatment. Initially, individuals begin to accept their eating disorders as attempts to solve psychological dilemmas, and they explore attitudes about weight, food and body image. As a feeling of trust is established through the therapists’ acknowledgement of the patients’ pain, the patient begin to recognize the

254 psychotherapy multiple origins and influences of disorder (social, psychopathologic, genetic, biological, behavioral and familial). Through psychotherapy, individuals can explore concerns, test new behaviors and receive constructive and nonjudgmental commentary. It provides an opportunity for them to develop self-confidence, self-esteem and feelings of power and control. Therapy also helps conquer DEPRESSION, guilt, ANXIETY and STRESS, alleviating the need to turn to, or away from, food to deal with problems. Effective psychotherapy avoids simplistic explanations and solutions. Some anorexics and bulimics will terminate psychotherapy prematurely, unable to relinquish their own control or to see it as a problem. After HILDE BRUCH and ARTHUR H. CRISP, among others, concluded that traditional insightdirected psychotherapeutic approaches aimed at personality reorganization had failed to deliver a permanent resolution of the eating disorders dilemma, others advocated a cognitive-behavioral approach, in which misstatements and misconceptions are challenged in a systematic way. This technique is useful, though it has not proven the most effective approach. A 2003 report, Food for Thought: Substance Abuse and Eating Disorders (The National Center on Addiction and Substance Abuse, Columbia University) states, “After being stabilized medically, an eating disorder patient typically undergoes a regimen of psychotherapy. Cognitive-behavior therapy (CBT), an approach most commonly used with bulimic patients, attempts to correct unhealthy or distorted thinking patterns as a means of influencing emotions and behaviors. CBT is a short-term psychotherapy that involves active collaboration between patient and therapist to help the patient understand how certain thinking patterns cause or exacerbate mental health problems and how to learn to think more clearly and resolve problems more effectively. Although far more expensive and time consuming, some experts argue that long-term individual psychotherapy that examines underlying causes of the illness, helps patients develop more adaptive coping mechanisms, strengthens patients’ self-image and identity and teaches them how to adaptively express their feelings or emotions is the best route to long-lasting recovery.”

Psychotherapy plays a central role in inpatient and outpatient treatment, according to Winston and Webster: “Appropriate psychological interventions enable the patient to gain weight and, conversely, weight gain generates further psychological issues which need to be addressed in therapy. However, patients who are severely underweight have evidence of cognitive impairment which may reduce their ability to make use of psychotherapy. Individual psychotherapy during the early stages of treatment may therefore need to be focused primarily on the development of a therapeutic alliance and exploration about the patient’s anxieties about change.” Outpatient psychotherapy is sometimes recommended, according to Gleaves and Cepeda-Benito. “If the client’s medical condition is not critical, and/or if his or her psychosocial functioning is not severely impaired by the disorder, outpatient treatment may be the optimal referral choice. This treatment may be individual or group therapy and may be based on a variety of approaches. Cognitive behavioral and interpersonal therapies have received the most empirical support. Outpatient treatment may vary considerably in level of intensity. Fairly typical would be group or individual twice per week. However, many agencies now have what they call intensive outpatient programs that may meet as often as every night during the week. With outpatient eating disorder treatments in general, attention needs to be given to possible signs that a treatment of more intensity is needed. If weight gain cannot be initiated for the anorexic patient, or if bingeing and purging are not controlled, outpatient treatment may be determined to be inadequate.” Gleaves and Cepeda-Benito add that very few controlled outcome studies exist for anorexia nervosa “largely because of the ethical problems associated with putting people who are physically at risk in a ‘no treatment’ or wait-list control group. Data are clearer for bulimia nervosa because numerous controlled and/or comparative outcome studies have now been conducted. Treatments that have received the most empirical research are CBT and interpersonal psychotherapy (IPT).” In a recent study of psychotherapies for anorexia nervosa, McIntosh et al. found that “non-

public policy and obesity 255 specific supportive clinical management was superior to interpersonal psychotherapy, while cognitive behavior therapy was intermediate, neither worse than nonspecific supportive clinical management nor better than interpersonal psychotherapy. For the women completing therapy, nonspecific supportive clinical management was superior to the two specialized therapies.” Wilfley et al. note that IPT is the only psychological treatment for bulimia nervosa that has demonstrated long-term outcomes comparable to CBT, but that several key areas are in need of further investigation. “Data from ongoing clinical trials will be critical to determine whether IPT can be effective for anorexia nervosa. Further research is needed regarding the mechanisms by which IPT exerts its effects, predictors of treatment outcome, and dissemination of IPT for eating disorders in clinical settings outside of controlled trials.” Sobel wrote that when treating eating disorders, psychotherapy primarily addresses issues of chaotic eating, hunger, inadequate calorie intake, conditioned response and profound fear of expressing impulses and feelings, especially those of anger and sadness. Gleaves, David H., and Antonio Cepeda-Benito. “Eating Disorders.” In Handbook of Mental Health in the Workplace, edited by Jay C. Thomas and Michael Hersen, 311–329. Thousand Oaks, Calif.: Sage Publications, 2002. McIntosh, Virginia V. W., et al. “Three Psychotherapies for Anorexia Nervosa: A Randomized, Controlled Trial.” American Journal of Psychiatry 162, no. 4 (April 2005): 741–747. Sobel, Stephen V. “What’s New in the Treatment of Anorexia Nervosa and Bulimia?” Mescape Women’s Health 1, no. 9 (September 1996). Wilfley, Denise, Rick Stein, and Robinson Welch. “Interpersonal Psychotherapy.” In Handbook of Eating Disorders, 2nd Ed., edited by Janet Treasure, Ulrike Schmidt, and Eric van Furth, 253–270. West Sussex, U.K.: John Wiley & Sons, Ltd., 2003. Winston, Anthony, and Peter Webster. “Inpatient Treatment.” In Handbook of Eating Disorders, 2nd Ed., edited by Janet Treasure, Ulrike Schmidt, and Eric van Furth, 349–367. West Sussex, U.K.: John Wiley & Sons, Ltd., 2003.

psychotropic drugs Drugs that affect psychological functioning and/or experience, sometimes

used in the treatment of eating disorders. These include the phenothiazine-derivative tranquilizers (Compazine, Phenergan, Stelazine, Temeral, Thorazine), ANTIDEPRESSANTS (Elavil, Nardil, Tofranil, Triavil, Prozac, Zoloft) and other hallucinogenic, sedative, tranquilizing and antipsychotic drugs. The use of psychotropic medication is not the primary approach for treating eating disorders. This is because such medication usually accounts for only a temporary reduction in symptoms and thus is generally considered an addition to intensive psychotherapy. One exception is the case of women who have, one way or another, dealt with issues likely to have been among the most significant causes of their eating disorders but who are unable to control their symptoms. With a medication-related decrease in symptoms, they may be able to gain more from PSYCHOTHERAPY and eventually be able to control the symptoms without medication. Illegal drugs (e.g., marijuana, LSD, cocaine, morphine and its derivatives) are all psychotropic drugs too.

puberty The stage of physical development when secondary sex characteristics develop and sexual reproduction becomes possible. It usually occurs between the ages of 10 and 12 in girls and between 12 and 14 in boys. However, the onset of puberty has been shown to be more closely related to weight and percentage of BODY FAT than to chronological age. In the United States, the mean weight of girls at menarche (first menstrual cycle) is 105 pounds (and about 22 percent body fat), according to studies. Delayed menarche often occurs with dieting, exercise and extreme thinness and can be as late as age 19 or 20 for athletes and ballet dancers. public policy and obesity While some writers say that obesity is a matter of personal responsibility and ought to be a matter of private concern and not public policy, others insist that federal and state governments need to set public policies to combat it. For example, Calle and Kaaks argue, “The tobacco control experience has taught us that policy and environmental changes are crucial to achieving changes in individual behavior. Purposeful changes in public pol-

256 purging icy are needed to provide access to healthful foods and safe environments for physical activity in schools, worksites and communities. Such change will require multiple strategies and bold action, ranging from the implementation of community and work-site healthpromotion programs to policies that affect community planning, transportation, school-based physical education, and food services. The World Health Organization global strategy proposes such action and, in doing so, strengthens the potential for individual behavior change and positive health outcomes.” Connolly noted that by August 2003, state lawmakers had filed more than 140 bills aimed at obesity, nearly double the 72 filed the previous year. “Many . . . appoint commissions to study the problem; others impose physical education standards in the schools.” Calle, Eugenia E., and Rudolf Kaaks. “Overweight, Obesity and Cancer: Epidemiological Evidence and Proposed Mechanisms.” Nature Reviews Cancer 4, no. 8 (August 2004): 579–591. Connolly, Ceci. “Public Policy Targeting Obesity.” Washington Post, August 10, 2003, p. A1.

purging

A term used to cover the forced expulsion of ingested foods by bulimics. Purging has been called a purification rite for bulimics, a means of overcoming self-loathing by gaining self-control. Having regained their self-discipline, they once again feel like “good” persons who are fresh and clean. Self-induced VOMITING is the most common method of purging. The Diagnostic and Statistical Manual of Mental Disorders now restricts the term purging to vomiting, laxatives, diuretics or enemas.

PYY (Peptide YY3–36)

Peptide tyrosine tyrosine is a hormone involved in appetite regulation; it tells the brain to stop eating when the stomach is full. Researchers have discovered that people who are obese do not produce enough PYY. The results could help explain why some obese people need to eat more food to feel full.

London researchers provided a series of differentsized meals to 20 obese and 21 lean individuals to find out whether obese people experience a PYY deficiency. The researchers measured the release of PYY for 180 minutes after the meal and asked participants to record how full they felt. While both groups experienced an increase in PYY levels at meals of each size, the obese subjects had a lower level of PYY and recorded lower levels of fullness for meals of every size, compared with the lean group. Obese people needed a meal twice as large to achieve the same blood levels of PYY as the lean group. In a second part of the study, the researchers compared the effects of PYY infusion on appetite and food intake in 12 obese and 12 lean subjects in a double-blind placebo-controlled crossover study. Caloric intake during a buffet lunch offered two hours after the infusion of PYY decreased by 30 percent in the obese subjects and 31 percent in the lean subjects. PYY infusion also caused a significant decrease in the cumulative 24-hour caloric intake in both obese and lean subjects. The researchers propose that reduced PYY levels in obese people following a meal could contribute to a reduced feeling of fullness and a larger-sized next meal. The Tufts University Health & Nutrition Letter (November 2003) noted that the overweight people in the study had less PYY in their intestinal tracts to being with, but also noted “It’s unclear whether they become obese because their bodies naturally make less PYY, or if they started making less PYY once they became overweight.” Several companies are developing PYY drugs for obesity, including a nasal spray designed to deliver PYY directly to the bloodstream. However, it will take some time before long-term PYY infusion can be tested for safety and effectiveness. Batterham, R. L., et al. “Inhibition of Food Intake in Obese Subjects by Peptide YY3–36.” New England Journal of Medicine 349, no. 10 (September 4, 2003): 941–948.

R study was on rituals in the family, particularly of a religious nature. Conclusions reached were that religion functioned as a reinforcer in developing a personality profile that reflected poor SELF-ESTEEM and that religion was found to be associated with the instillation of guilt feelings. Fear of offending God inhibited the subjects from doing things in their own best interest. It was also found that even though all respondents had left their childhood religions, those who adopted new religions committed themselves to more formalized, structured and controlling belief systems. Consistently, God was portrayed as a controller, a protector and a judge. In their review of how culture affects eating disorders, Keel and Klump discussed the religious implications. “Given both current (as well as historical) plurality in motivations behind self-starvation, Rieger, Touyz, Swain, and Beumont (2001) recommended requiring ego-syntonic emaciation rather than weight phobia to differentiate anorexia nervosa (AN) from other conditions that lead to weight loss. The authors noted that cases of AN are uniform in the extent to which self-starvation is deliberate and the responses to resulting emaciation range from indifference to pride. Their proposition offers a solution to differentiating fasting to convey religious devotion that is common to most religions and that displayed in holy anorexia. Moreover, ritualistic religious fasting is time-limited and tends to focus on avoiding specific foods entirely or not eating during specific time intervals and thus does not typically result in emaciation. It lacks the persistent and pervasive nature of food refusal that characterizes the form of fasting observed in medieval religious ascetics or modern-day AN.”

reactive obesity

An increase in body weight resulting from overeating as a response to stressful life events. It is widely accepted that all aspects of human growth, development and disease are conditioned by social and interpersonal environment, and case reports and surveys suggest that obesity is no exception. Obesity has been found to follow stressful experiences such as financial reverses, hospitalization, instances of social or intellectual failure, marriage, failure of marriage, childbirth, illness or death of parents or close relatives. There are numerous references in the medical literature to obesity as a possible symptom of nervous disturbance since the 19th century. These include women who, grieving over the loss of their loved ones during World War I, were observed to put on weight that could not be accounted for otherwise. Similarly, during World War II there were many instances of severe obesity in young women who had been exposed to bombing or other hardships. HILDE BRUCH observed frequent cases of newly developed obesity following the deaths of family members, separations from home, breakups of love affairs or other situations involving fear and loneliness. Bruch observed that reactive obesity occurred more commonly in adults and infrequently in children. See also COMPULSIVE EATING; NIGHT EATING SYNDROME; PREGNANCY AND OBESITY.

religion and eating disorders Because there had been no consensus among researchers on the etiology of the anorexia syndrome, a 1987 Loyola University of Chicago study attempted to examine critically the background from which anorexia develops. Because medical literature places great emphasis on family environmental factors in the development of anorexia, a primary focus of this 257

258 religion and obesity Nobakht and Dezhkam listed religious fasting as one of the weight control behaviors practiced by Tehran students that were unique to this culture. Lavallee, Patricia Anne. “Religiosity, Rituals and Patterns in Anorexic and Bulimic Families.” Ph.D. dissertation, Loyola University of Chicago, 1987. Keel, Pamela K., and Kelly L. Klump. “Are Eating Disorders Culture-Bound Syndromes? Implications for Conceptualizing Their Etiology.” Psychological Bulletin 129, no. 5 (September 2003): 747–769. Nobakht, Minoo, and Mahmood Dezhkam. “An Epidemiological Study of Eating Disorders in Iran.” International Journal of Eating Disorders 28, no. 3 (November 2000): 265–271.

religion and obesity

A Purdue University study of religion and body weight found that religious people are more likely to be overweight than are nonreligious people. Analyzing data collected in two national surveys, Ferraro found the correlation between being overweight and being religious was statistically significant regardless of a person’s choice of faith. Baptists and fundamentalists tended to be the heaviest, with Jewish, Muslim and Buddhist groups the least overweight. Among the reasons suggested for any link between religion and obesity or overweight: • Overweight people may find comfort in religious settings. Temples, synagogues and churches may provide an important source of acceptance in the midst of a society that highly values fit bodies.

• Food has become a staple of religious worship, with potluck dinners and doughnuts as common as hymnals. • Restrictions on alcohol and drugs may have left the religious with one spiritually acceptable vice: food. • Pastors might not want to embarrass members by preaching about weight when obesity is so easily identifiable. In a later Cornell University national study, Kim et al. found no significant relationships between religion and body weight in women, but religious denomination was related to body weight in men. “Other dimensions of religiosity showing a relationship with higher body mass index appeared to

be because of the lower rates of smoking among more religious individuals.” In a study of a single county in upstate New York, Kim and Sobal found few relationships between religion, fat intake and physical activity, “suggesting that in contemporary U.S. society religion may play a small role in the context of how diet and exercise are developed and maintained. The limited range of religiosity in the sample, however, may have underestimated the role of religion. Significant relationships between religion and physical activity in woman suggest that further research is needed to more clearly delineate religion’s relationship with health behaviors.” Ferraro, Kenneth F. “Firm Believers? Religion, Body Weight, and Well-Being.” Review of Religious Research 39, no. 3 (March 1998): 224–244. Kim, K. H., J. Sobal, and E. Wethington. International Journal of Obesity and Related Metabolic Disorders 27, no. 4 (April 2003): 469–477. Kim, K. H., and J. Sobol. “Religion, Social Support, Fat Intake and Physical Activity.” Public Health Nutrition 7, no. 6 (September 2004): 773–781. Tubbs, Sharon. “Miracle Weight Loss?” St. Petersburg Times, July 11, 2004, n.p.

Remuda Ranch A residential treatment center in Arizona that is devoted to the needs of women and girls suffering from anorexia and bulimia. Ward Keller founded and developed the center as a result of helping his daughter in her battle with anorexia. All aspects of treatment are integrated with a Christian-centered perspective. Remuda offers a multidisciplinary team approach, with each resident treated by a team of professionals, including a psychiatric and primary care provider, psychologist, registered dietitian, registered nurse and masters-level therapist. See also APPENDIX IV. Renfrew Centers

The country’s first residential facility exclusively devoted to the treatment of women with eating disorders. It was founded by Samuel E. Menaged, an attorney, and Allen R. Davis, administrator of a private psychiatric clinic. They bought the Renfrew farm in 1984 and secured a license making it a Community Residential Rehabilitation Service. The center received

Restraint Scale 259 $2.9 million in funding from banking and private sources. In June 1985, when the Philadelphia program opened, its philosophy of respect for and empowerment of women and its location in a serene 27-acre environment contrasted sharply with hospital-based, coercive programs offered in psychiatric units or drug and alcohol facilities. In 1990, Renfrew opened a second residential facility in Coconut Creek, South Florida. The Renfrew Center also has facilities in New York City, northern New Jersey and Connecticut. The centers treat patients on both outpatient and residence bases. The largest treatment outcome study ever published on residential treatment for bulimia was conducted at the Renfrew Center. See also APPENDIX IV. Gleaves, David H. et al. “A Report of 497 Women Hospitalized for Treatment of Bulimia Nervosa.” Eating Disorders: The Journal of Treatment and Prevention 1 (1993): 134–146.

restaurant eating and obesity

Young adults who eat frequently at fast-food restaurants gain more weight and have a greater increase in insulin resistance in early middle age, according to a large multicenter study funded by the National Heart, Lung, and Blood Institute (NHLBI). After 15 years, those who ate at fast-food restaurants more than twice each week compared to less than once a week had gained an extra 10 pounds and had a twofold greater increase in insulin resistance, a risk factor for type 2 diabetes. One reason for the weight gain may be that a single meal from one of these restaurants often contains enough calories to satisfy a person’s caloric requirement for an entire day. Participants were asked during the physical examinations given as part of the study how often they ate breakfast, lunch or dinner at fast-food restaurants. Researchers found that the adverse impact on participants’ weight and insulin resistance was seen in both blacks and whites who ate frequently at fast-food restaurants, even after adjustment for other lifestyle habits. In an earlier study, researchers from the University of Massachusetts Medical School also found that eating in restaurants appears to play a role in obesity. People who frequently ate breakfast or dinner in restaurants had about twice the risk of

being obese as those who ate these meals at home. The researchers explained the likely reason: “Restaurant meals tend to be higher in calories and higher in fat, and people tend to overindulge when they eat in restaurants. Everything is supersized, so you have a lot and you don’t want to waste food, so you eat what you’re given.” Ma, Yunsheng, et al. “Association between Eating Patterns and Obesity in a Free-Living US Adult Population.” American Journal of Epidemiology 158, no. 1 (July 1, 2003): 85–92. Pereira, Mark, et al. “Fast-Food Habits, Weight Gain, and Insulin Resistance (The CARDIA Study): 15-Year Prospective Analysis.” The Lancet (January 1, 2005): 36–42.

Restraint Scale A test administered by clinicians in the form of a questionnaire, the results of which are used to measure “restrained eating” or chronic dieting. It was composed originally in 1980 by Janet Polivy and Peter Herman in the attempt to assess the tendency toward COMPULSIVE EATING in chronically dieting female college students. However, the scope of the testing soon expanded beyond eating behavior itself to encompass attitudes and other indices of chronic dieting. By analyzing results, clinicians are able to assess attitudes and evaluate the resulting behaviors and the fluctuations in weight accompanying them. Restrained eaters have been shown to differ from unrestrained eaters in a number of respects, displaying greater emotionality, distractibility and salivary responsiveness as well as different eating patterns. In addition, restrained eaters seem to be more likely to be or become bulimic, and patients with anorexia nervosa score significantly above average on the Restraint Scale, particularly if they are also bulimic. A high score on the Restraint Scale may thus indicate a susceptibility or tendency to bulimia, although it is by no means a certain indicator. Herman, C. Peter, and Janet Polivy. “Restrained Eating.” In Obesity, edited by Albert J. Stunkard, 208–225. Philadelphia: Saunders, 1980. Stunkard, A. J., and S. Messick. “The Three-Factor Eating Questionnaire to Measure Dietary Restraint and Hunger.” Journal of Psychosomatic Research 29, no. 1 (1985): 71–83.

260 restrictive operations restrictive operations

See

GASTRIC RESTRICTION

PROCEDURES.

restrictor anorexics In the nomenclature of the Diagnostic and Statistical Manual of Mental Disorders, anorexia nervosa, restricting type. Socalled pure anorexics who restrict their intake of food rather than binge-eat or purge. See also ANOREXIA NERVOSA. rimonabant A new class of drugs that is being tested as a possible new treatment for obesity. Researchers at sites around the United States randomized 287 subjects (both men and women between the ages of 18 and 65 with a body mass index of 29 to 41) to receive five, 10 or 20 mg of rimonabant or a placebo, while on a moderately low calorie diet. After 16 weeks, patients who took rimonabant lost an average of two to four times (five to eight pounds) more weight than the patients on the placebo. In addition, waist circumference in the patients taking rimonabant also decreased from more than twice as much as the placebos. In another study, overweight and obese people lost nearly 20 pounds when taking rimonabant for a year. The drug works by blocking receptors in the brain that affect cravings, and also acting directly on fat cells to play a role in metabolism and prevent weight gain. In a North American study of 3,040 obese people reported in 2004, those given the higher of two doses of the drug lost about 19 pounds and kept it off for up to two years, compared with only five pounds for those given placebos. Then in March 2005, a second study, in Europe involving 1,507 severely obese people, confirmed these findings. The French company Sanofi-Aventis SA hopes to sell rimonabant under the brand name Acomplia, and these studies set the stage for the company to seek approval to sell it in the United States. Researchers hope that rimonabant may help provide an option for the growing number of people who suffer from obesity but do not respond to traditional weight loss options such as diet and exercise. However, the excitement and optimism for the new drug has been tempered by caution from the medical community, many of whom are concerned about possible side effects, such as depression, anxiety and miscarriages. While Sanofi-Aventis pro-

jected that Acomplia would be on the market in the United States in 2006, some experts suggested that FDA concern over side effects may make this timetable a bit optimistic.

Roux-en-Y gastric bypass (RGB) The most common and successful malabsorptive surgery for obesity; it has been called “the gold standard in weight reduction.” A 2004 report issued by the Health and Human Services Agency for Healthcare Research and Quality found that Roux-en-Y gastric bypass surgery results in greater weight loss— an average of 20 pounds—than does VERTICAL-BANDED GASTROPLASTY. First, a small stomach pouch is created to restrict food intake. Next, a Y-shaped section of the small intestine is attached to the pouch to allow food to bypass the lower stomach, the duodenum (the first segment of the small intestine) and the first portion of the jejunum (the second segment of the small intestine). This bypass reduces the amount of calories and nutrients the body absorbs. A five-year imaging study led by radiologist Elmar Merkle, M.D., followed patients at the University Hospitals of Cleveland after Roux-en-Y gastric bypass surgery. Among the 335 patients who participated in the study, radiological imaging revealed 57 complications from the surgeries— many of them multiple problems in the same patients, including suture tears and leaks, pulmonary embolism, pneumonia and infection. “Severely obese patients are at high risk for any type of surgery because of other conditions related to their weight,” explained Merkle. “In addition, there is a wide spectrum of procedure-specific complications following Roux-en-Y gastric bypass.” According to Merkle, the results emphasize that the procedure should be a last resort after all other interventions, such as diet and exercise, have been attempted. The findings also highlight the importance of radiological imaging in diagnosing surgical complications in severely obese patients following gastric bypass, he added. In addition to its complications, the procedure also requires patients to undergo major lifestyle changes. Following the surgery, patients must restrict their eating habits and rely on vitamin supplements for adequate nutrition. Regardless of

rumination 261 these negatives, proponents say it is one of the few treatments that result in dramatic long-term weight loss.

rumination

The voluntary regurgitation of partially digested food into the mouth, where it is subsequently rechewed and reswallowed. The human syndrome is named after a normal digestive process carried out by ruminant animals, such as cattle, sheep and goats, which results in improved digestibility of ingested material. One of the less commonly recognized of the eating disorders, it occurs much more frequently in young infants and mentally retarded children and adults than it does in adults of normal intelligence. However, rumination does plague a number of bulimics. It is often unrecognized by victims or professionals and is often diagnosed as a “digestive problem,” secondary to bulimic behaviors. Rumination in infants typically develops between three and six months of age, although cases developing as late as 12 months have been reported. It is believed to be a psychosomatic illness resulting from a poor mother-infant relationship. Mothers of ruminating infants are often characterized as having difficulty in enjoying their babies and in sensing what gives the baby satisfaction, resulting in the infant’s turning to self-stimulating behavior. The appearance of infants during rumination has been described as “withdrawn and self-absorbed,” as though they were deriving gratification from the process. Because rumination can lead to growth failure, weight loss to the point of emaciation, electrolyte imbalances and dehydration, it is considered a serious medical condition. Because of the electrolyte imbalance, ruminating children can die early in life from cardiac and other complications. The condition is often overlooked initially as the primary cause of weight loss, because rumination usually occurs when infants are left alone and the behavior is not observed. Once established, it is difficult to interrupt. Treatments attempted with minor success have included behavioral, medical and surgical. The most effective treatment has been shown to be increased social stimulation and reestablishment of a positive interaction between the mother and infant.

Rumination in mentally normal adults is increasingly being recognized as a distinct clinical syndrome. There appear to be two types of adult ruminators: those in whom the behavior develops during childhood and apparently persists without severe negative consequences, and those in whom rumination is associated with bulimia nervosa. In one study of patients with bulimia nervosa, a small but significant proportion were found to ruminate. Because this behavior is often performed in secret, diagnosis, especially in bulimics, can be very difficult and is frequently missed. Comparisons of ruminating bulimics with nonruminating bulimics have found a higher incidence of history of anorexia nervosa and previous psychiatric treatment for an eating disorder among the ruminators. Most of the patients have reported the activity as being “soothing,” regardless of whether they felt the practice was shameful or innocuous. Bulimic ruminators display a greater tendency to spit out, rather than reswallow, the regurgitated food in an attempt to reduce the amount of food absorbed. The medical consequences of rumination in bulimics can be very similar to those in bulimics who induce VOMITING, which adds to the difficulty of making a correct diagnosis. The most serious consequence is probably electrolyte depletion. The presence of digestive acids, mixed with undigested food, in the mouth can also affect the mucosal membranes and the teeth. A ruminator can also develop esophageal ulcers as a result of the passage up and down of hydrochloric acid. In the chronic ruminator, the salivary glands become quite enlarged. There is a tendency in adult rumination for weight loss because food is not properly digested and the nutrient value is reduced. Rumination occurs throughout the day, not specifically after meals. Patients have reported ruminating from five or six times a day to as many as 30 times a day. One who ruminated all the time consumed dozens of mints and used toothpaste to hide the smell. The process is not unconscious at all; ruminators can bring the undigested food into the mouth at will. Treatment of rumination in adults can be very difficult, owing to the apparent pleasure derived from it. Patients have described a sense of relief during the reswallowing. For those with bulimia

262 Russell, Gerald F. M. nervosa, treatment resulting in reestablishment of control over eating has led to cessation of rumination. In nonbulimics, behavioral treatment directed at training them to relax before and after meals has largely proven unsatisfactory, mostly because there is less incentive than for bulimics to stop the behavior. In two reported cases of pharmacologic treatment, administration of paregoric prior to eating completely inhibited after-meal rumination; and premeal administration of dopamine-blocking agents reduced after-meal rumination. In other cases, paregoric at first had a PLACEBO effect, with patients feeling a beneficial impact, but it soon wore off. More successful has been a combination of COGNITIVE THERAPY and ANTIDEPRESSANTS. Olden wrote, “The management of patients with rumination needs to be accomplished in a highly individualized manner. Children with infant rumination syndrome often have symptoms related to significant defects in bonding with their mother. Thus, problems of mother-child bonding in pediatric patients with rumination syndrome should be identified and appropriately addressed. The management of adult patients with developmental disabilities or neurologic impairments who ruminate focuses mainly on behavioral modalities, including adversive conditioning and contingency management. The healthy adult who ruminates and has no evidence of neurologic or developmental disability is best seen as someone with a habit. Management in these patients is directed towards adjunctive therapies (i.e., the use of proton pump inhibitors or H2 receptor antagonists to decrease acid injury to the esophagus) as well as identifying situations and emotions that trigger the patient’s

symptoms. Randomized controlled trials of various treatment modalities need to be undertaken; likewise, the evaluation strategy needed to best diagnose rumination is yet to be well defined.” Fairburn, C. G., and P. G. Cooper. “Rumination in Bulimia Nervosa.” British Medical Journal 288, no. 6420 (1984): 826–827.. Larocca, Félix E. F., and Mary Anne Della-Fera. “Rumination: Its Significance in Adults with Bulimia Nervosa.” Psychosomatics 27 (March 1986): 209–212. Malcolm, A., et al. “Rumination Syndrome.” Mayo Clinic Proceedings 72, no. 7 (July 1997): 646–652. Olden, Kevin W. “Rumination.” Current Treatment Options in Gastroenterology 4, no. 4 (August 2001): 351–358.

Russell, Gerald F. M. (1928– ) Emeritus professor of psychiatry and director of eating disorders at Hayes Grove Priory Hospital, Hayes, Kent, England. Dr. Russell in 1979 published the first extensive description of an “ominous new variant of anorexia nervosa,” which he named BULIMIA NERVOSA. At the time, Dr. Russell was a professor in the Academic Department of Psychiatry at Royal Free Hospital in London. Russell’s principal works include “Anorexia Nervosa: Its Identity as an Illness and its Treatment,” in Modern Trends in Psychological Medicine, edited by John Harding Price (London: Butterworths, 1970); “Anorexia Nervosa and Bulimia Nervosa,” in Handbook of Psychiatry, vol. 4, The Neuroses and Personality Disorders, edited by G. F. M. Russell and L. A. Hersov (Cambridge: Cambridge University Press, 1984); and “Bulimia Nervosa: An Ominous Variant of Anorexia Nervosa,” Psychological Medicine 9 (1979).

S prior to, during and/or after feeding are being explored. Short-term signal hormones including cholecystokinin (CCK), ghrelin, PYY (peptide YY336) and glucagon-like peptide 1 (GLP-1) control meal size via pathways converging on the hypothalamus. Long-term regulation is provided by the main circulating hormones leptin and insulin. These systems among others, implicated in hypothalamic appetite regulation all provide potential ‘drugable’ targets by which to treat obesity.” SIBUTRAMINE, a reuptake inhibitor of noradrenaline, serotonin and, to a lesser extent, dopamine in the brain, has been studied long term. It reduces food intake by enhancing satiety. However, speeding up satiety may not be the key to controlling obesity, according to a Cornell University study that concluded that the amount of food on a plate or bowl increases intake more than the feeling of fullness. “It seems that people use their eyes to count calories and not their stomachs,” the authors concluded. See also CHOLECYSTOKININ; PYY.

satiety

The feeling of fullness to or beyond satisfaction, along with disappearance of APPETITE after eating. Factors that may lead to a person eating beyond satiety include taste of the food, stress or other emotional state and hormones. Various hormones have been implicated in conveying the feeling of satiety to the brain. LEPTIN increases on satiety, and GHRELIN increases when the stomach is empty. According to King, “Biologically we feel hunger more acutely than feeling satiety.” In one series of studies, scientists are exploring dietary manipulation to decrease caloric consumption and increase satiety. Over the short term, decreases in the energy density of foods (calories per gram of food) were found to lead to decreased food intake, independent of fat content. Long-term studies are needed, but these results suggest a possible strategy for reducing food intake. Liquids generally have lower satiety value than solid foods; yet despite high water content, soups have been reported to be more satiating. In his study of this contradiction, Mattes found, “The soups led to reductions of hunger and increases of fullness that were comparable to the solid foods. The beverage had the weakest satiety effect. Daily energy intake tended to be lower on days of soup ingestion compared to the solid foods or no-load days and was highest with beverage consumption. Thus, these data support the high satiety value of soups. It is proposed that cognitive factors are likely responsible.” In a clinical trial of patients treated with an IMPLANTABLE GASTRIC STIMULATOR (IGS), which causes early satiety, researchers reported a 15 percent change in appetite before meals, a 60 percent change in satiety between meals and a 90 percent change in satiety at the end of a meal. King writes, “The pharmacological potential of several endogenous peripheral peptides released

Hitt, Emma. “Implantable Gastric Stimulator May Be Effective against Morbid Obesity.” Medscape Medical News, October 16, 2003. Available online. URL: http://www.medscape.com/viewartic1e/463062. King, P. J. “The Hypothalamus and Obesity.” Current Drug Targets 6, no. 22 (March 2005): 225–240. Mattes, R. “Soup and Satiety.” Physiology & Behavior 83, no. 5 (January 2005): 739–747. Wansink, B., J. E. Painter, and J. North. “Bottomless Bowls: Why Visual Cues of Portion Size May Influence Intake.” Obesity Research 13, no. 1 (January 2005): 93–100.

schools and obesity

In The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity (2001), schools were identified as “a key setting

263

264 SCOFF Questionnaire for public health strategies to prevent and decrease the prevalence of overweight and obesity. Most children spend a large portion of time in school. Schools provide many opportunities to engage children in healthy eating and physical activity and to reinforce healthy diet and physical activity messages. Public health approaches in schools should extend beyond health and physical education to include school policy, the school physical and social environment, and links between schools and families and communities.” The importance of schools in the battle against childhood obesity was echoed three years later by Sothern: “Schools should be primary targets for efforts to educate parents concerning the reduction of TV, computer games, and unhealthy snacks. Schools should be encouraged to adopt vending machine policies that promote healthy drinks and food in appropriate portion sizes and discouraged from providing unhealthy food as rewards for positive behavior or academic accomplishment. Schools should provide daily physical education and frequent periods of unstructured play in young children.” In light of the alarming increase in childhood obesity and lack of evidence for the effectiveness of school programs, Veugelers and Fitzgerald studied the effects of school programs in regard to preventing excess body weight. “In 2003, we surveyed 5,200 grade 5 students. [Those] students from schools participating in a coordinated program that incorporated recommendations for school-based healthy eating programs exhibited significantly lower rates of overweight and obesity, had healthier diets, and reported more physical activities than students from schools without nutrition programs.” Although two national polls released in December 2003 showed 92 percent of teachers and 91 percent of parents favoring only healthful foods and drinks in school vending machines, nearly every high school and more than half of elementary schools had sodas, candy and other high-sugar, high-fat snacks in their machines. Also, requiring physical education in school every day at every grade level won the endorsement of 85 percent of parents and 81 percent of teachers, yet only 8 percent of elementary schools and 5.8 percent of high schools offered physical education in all grades.

Sothern, M. S. “Obesity Prevention in Children: Physical Activity and Nutrition.” Nutrition 20, no. 7–8 (July–August 2004): 704–708. Veugelers, P. J., and A. L. Fitzgerald. “Effectiveness of School Programs in Preventing Childhood Obesity: A Multilevel Comparison.” American Journal of Public Health 95, no. 3 (March 2005): 432–435.

SCOFF Questionnaire A screening tool developed in Britain that can identify patients who require a more detailed assessment for eating disorders. The acronym SCOFF is formed from the initial letter of the core concept of each question (Sick, Control, One, Fat, Food). The questions, which address the central features of anorexia nervosa and bulimia nervosa, are: • Do you make yourself sick because you feel uncomfortably full? • Do you worry you have lost control over how much you eat? • Have you recently lost more than one stone (about 14 pounds) in a three-month period? • Do you believe yourself to be fat when others say you are too thin? • Would you say that food dominates your life? One point is awarded for each “yes” response. A score greater than two indicates a likely case of anorexia or bulimia. Because the SCOFF test has a 12.5 percent falsepositive rate, it is not considered to be sufficiently accurate for diagnosing eating disorders, but it is considered an appropriate screening tool. Luck, A. J., J. F. Morgan, et al. “The SCOFF Questionnaire and Clinical Interview for Eating Disorders in General Practice: Comparative Study.” British Medical Journal 325, no. 7367 (October 5, 2002): 755–756. Morgan, J. F., F. Reid, and J. H. Lacey. “The SCOFF Questionnaire: Assessment of a New Screening Tool for Eating Disorders.” British Medical Journal 319, no. 7223 (December 4, 1999): 1467–1468.

secondary amenorrhea

Cessation of menstruation after menarche (the first menstrual period of a girl in PUBERTY), a condition most common in anorexics but not uncommon among bulimics, par-

self-help groups 265 ticularly those who rely heavily on FASTING and/or extreme DIETING as means of PURGING. In many instances it is attributed to undernourishment. In addition, the menstrual cycle can be interrupted by environmental stress, a primary factor in bulimia. See also AMENORRHEA.

self-esteem

Belief in one’s own value: self-respect. Low self-esteem is often associated with eating disorders. People with eating disorders feel inadequate, and this adversely affects their recovery. A 1987 study conducted by Debra Lorraine Mandel of the California School of Professional Psychology in Los Angeles compared two groups of bulimic women—those who compensate for binges by means of laxatives/diuretics, vomiting and/or spitting out food (B-L) and bulimics who compensate by fasting (B-F)—with each other and with a third group of nonbulimic women (NB) on selfesteem and self-role concept. All women were of normal weight and were selected from a nonclinical population of undergraduate college students. Self-esteem was assessed using the Coopersmith Self Esteem Inventory. Three components of sexrole concept, real self (RS), ideal self (IS) and imagined male ideal (IMI), were assessed using the Sex Role Attribute Inventory. It was hypothesized that the three groups would differ on self-esteem with the B-L group measuring lowest; that the groups would differ on each component of sex role with BL measuring lowest on RS femininity and highest on IS and IMI femininity; and that low-esteem in bulimics would correlate with discrepancies between components of sex role. Contrary to expectations, however, although the bulimic groups combined averaged lower self-esteem measurements than the NB group, only the B-F group had lower self-esteem than the NB group. In addition, while results indicated that low self-esteem is related to an RS sex-role concept (incorporating both masculine and feminine characteristics) for B-F and NB, no relationship was found between RS sex-role concept and self-esteem measurements for B-L. Self-esteem is also considered a factor in adolescent obesity. In a 1988 University of Arkansas study, the Rosenberg Self-esteem Scale was administered to 550 14- to 16-year-old girls. Self-esteem scores were categorized by weight and by height.

Results indicated that self-esteem of adolescent girls is related to their weight. As obesity increased, self-esteem decreased. These results tend to confirm the observation that adolescent girls do internalize social attitudes about body size, which result in continued low self-esteem in overweight girls. In a later French study of 102 severely obese adolescents, Isnard et al. reported that binge-eating symptoms were frequent and the binge-eating dimension was related to high levels of anxiety and depression, as well as to low levels of self-esteem and body-esteem. And Weiss noted that some obese patients, even after weight loss, continue to suffer from problems related to self-esteem. Isnard, P., et al. “Binge Eating and Psychopathology in Severely Obese Adolescents.” International Journal of Eating Disorders 34, no. 2 (September 2003): 235–243. Martin, Sue, et al. “Self-Esteem of Adolescent Girls as Related to Weight.” Perceptual and Motor Skills 67, no. 3 (December 1988): 879–884. Weiss, F. “Group Psychotherapy with Obese Disorderedeating Adults with Body-image Disturbances: An Integrated Model.” American Journal of Psychotherapy 58, no. 3 (2004): 281–303.

self-help groups Therapy groups that rely on their members to supply one another with support, assistance and positive influence, so that individual members do not have to try to help themselves in isolation. The “ideal” self-help (or mutual-aid) group does not involve professionals. In practice, however, the most stable groups do involve them. Although an association with professionals appears to infringe on the self-help premise of “equal-status” relation ships, when groups are formed without such assistance, they tend eventually to deteriorate into unproductive complaint sessions, which may erode the members’ motivation. Some authors also suggest that the poor interpersonal and leadership skills of many anorexics and bulimics prevent long-term commitment to such groups. Professional therapists can assist by acting as organizers, teachers of social skills, role models and consultants and can provide a structure for meetings without infringing on the primary purpose of groups, mutual support. Groups that maintain connections with professionals have the potential to train group leaders capable of facil-

266 self-help groups itating constructive group interaction. These “lay” leaders may be parents of anorexics or bulimics who are motivated to help other parents, or individuals who have themselves recovered, or who are recovering, from eating disorders. Various attempts have been made to study the effectiveness of self-help groups, since such groups may divert people from seeking professional help. A 1976 study demonstrated that the degree of distress felt by a person is inversely related to the number of people in his or her social network who provide frequent emotional support. Self-help groups extend members’ social networks. They may thus discourage them from seeking professional help, but they may also refer them to it. A 1979 study examined help-seeking behavior in members of self-help groups and in individuals who enter PSYCHOTHERAPY. It concluded that social networks and self-help groups share the following features: they buffer the experience of stress; they obviate the need for professional assistance through provision of instrumental and affective support; they act as screening and referral agencies for professional services; and they transmit attitudes about values and norms of help-seeking. A 1998 British study evaluated self-help programs for binge-eating disorder on 72 women. Both pure self-help and guided self-help had a substantial and sustained impact, with almost half the participants ceasing to binge eat. In 2001, University of Minnesota researchers evaluated the longer-term outcome of three group cognitive-behavioral therapy (CBT) delivery models for the treatment of binge-eating disorder (BED): therapist-led group discussion; partial selfhelp, with participants viewing a psychoeducational videotape followed by a therapist-led discussion; and structured self-help with participants watching the videotape and then leading their own discussion. Reductions in binge-eating episodes and associated symptoms were observed for all three treatments at post, one-month, sixmonth and one-year follow-up, with no significant differences among the three conditions. For people trying to lose weight, Tsai et al. concluded there is “little scientific evidence to recommend the use of organized self-help programs. Rigorous efficacy studies are unlikely to occur, given these programs’ limited financial resources.”

In the literal sense, self-help means helping oneself without the assistance of others. In the context of multidimensional treatments of eating disorders, the term is really misleading. Members of a “true” self-help group become interdependent for support, understanding and acceptance as they gradually grow to trust one another and share feelings and experiences. Families of members also benefit from these groups. The setting reduces social isolation and provides a noncritical environment for issue exploration. Through shared experiences, parents can learn how to cope with their children’s problems and their own feelings. In groups that mix parents and children of different families, the greater emotional distance can sometimes enable the older generation to hear and appreciate better what the younger generation has to say. For previously unresponsive therapy patients, the contact with people who have “been there” and found themselves capable of changing has proven particularly beneficial. Self-help groups are not a substitute for other forms of treatment. They differ significantly from individual or group therapy, whose purpose is to free patients from disabling forms of psychological disorder by developing insight into and understanding of underlying causes, eventually enabling changes in dysfunctional behavior. But one valuable function groups often perform is to refer individuals to qualified professional treatment. Some groups are parts of multimodal treatment programs. Self-help groups sometimes are also the preferred resource of anorexics and their families for financial reasons or by personal choice, especially if they fear professionals or have had previous unsuccessful encounters with them. Because self-help groups for eating disorders have originated so recently, no standardized nationwide procedures have been developed. Effective guidelines based on the successful experience of existing groups, however, are beginning to emerge. According to recent social science literature on self-help, the ideal mutual-aid group provides members with information (factual knowledge and referrals to appropriate professionals); opportunity to share and learn from one another’s experience; mutual support; positive association (members can identify with group goals); collective willpower; and benefit from the exchange itself.

self-monitoring 267 See also

ANOREXIA NERVOSA; BULIMIA NERVOSA;

OBESITY; GROUP THERAPY; PSYCHOTHERAPY.

Carter, J. C., and C. G. Fairburn. “Cognitive-Behavioral Self-Help for Binge Eating Disorder: A Controlled Effectiveness Study.” Journal of Consulting Clinical Psychology 66, no. 4 (August 1998): 616–623. Larocca, Félix E. F., with Nancy J. Kolodny. Facilitator’s Training Manual. St. Louis: Midwest Medical Publications, 1983. Peterson, C. B., et al. “Self-Help versus Therapist-Led Group Cognitive-Behavioral Treatment of Binge Eating Disorder at Follow-Up.” International Journal of Eating Disorders 30, no. 4 (December 2001): 363–374. Rubel, Jean A. “The Function of Self-Help Groups in Recovery from Anorexia Nervosa and Bulimia.” Psychiatric Clinics of North America 7, no. 2 (June 1984): 381–394. Tsai, Adam Gilden, et al. “Commercial and Self-Help Programs for Weight Control.” Psychiatric Clinics of North America 28, no. 1 (March 2005): 171–192.

self-monitoring

Also referred to as eating habits monitoring. The process of keeping a careful record of one’s own body weight, food intake and its caloric value, physical activity and, in some cases, the circumstances (time, place, occasion, company) of eating. Self-monitoring is a key element in almost all BEHAVIOR MODIFICATION programs and typically the first behavior change requirement. In obesity treatment, it is frequently prescribed before any attempts to diet or increase exercise are made. Originally intended strictly as an information-gathering tool, it has proven to have other value. Monitoring eating habits affects eating behavior in a number of ways. First, the very act of recording can force awareness of previously unconscious patterns of behavior. For example, because snacking usually becomes a routine, automatic behavior, most people express surprise at the amount of food—and calories—they discover they eat in a day. This awareness can be a first and necessary step in their efforts to control how much they eat. It can also reveal behaviors likely to have defeated previous attempts to lose weight or keep it off. Second, self-monitoring provides specific information that allows eating-disordered persons to evaluate their progress and then reward or punish accordingly. Third, records of eating behavior can provide information useful to therapists in assisting the obese to make behavior changes.

Therapists suggest that self-monitoring is most effective and successful when patients have convenient forms for recording the information, when behavior is recorded soon, or immediately, after it occurs and when feelings, degree of HUNGER and concurrent problems are also noted. Stewart explained, “Self-monitoring usually includes aspects such as thoughts, emotions, and behaviors elicited by a bodyrelated situation. Through self-monitoring, individuals begin to identify salient patterns and themes in their thinking, behaviors, and emotional reactions.” Although researchers have found self-monitoring to be an essential component of treatment for eating disorders, Anderson et al. note that there is “some controversy over the reliability and validity of self-reported binge/purge episodes of food intake.” Among the problems they cite: Large errors in food consumption are extremely common; some individuals deliberately minimize or deny eating pathology on self-report forms; and there is no standard format for self monitoring, with procedures varying from professional to professional, which potentially limits their reliability. “Despite these shortcomings, however, self-monitoring can be a useful tool in assessing dietary restraint, binge eating, and purgative behavior if viewed with appropriate caution and should be routinely collected during treatment.” When treating the obese patient, Fabricatore and Wadden wrote, “Careful self-monitoring of calorie intake is crucial to the success of low-calorie diets. Obese individuals underestimate their intake by 30–50 percent. Thus, patients must be instructed in reading food labels, measuring portion sizes, and recording their food intake as soon as possible after eating. The more self-monitoring records patients complete each week, the more weight they lose.” Garner and Stuht added, “Research shows that some form of cognitive constraint or self-monitoring in the form of activity or food logs is a characteristic of people who have been successful at losing and maintaining weight long-term.” Anderson, Drew A., et al. “Assessment of Eating Disorders: Review and Recommendations for Clinical Use.” Behavior Modification 28, no. 6 (November 2004): 763–782. Fabricatore, Anthony N., and Thomas A. Wadden. “Treatment of Obesity: An Overview.” Clinical Diabetes 21, no. 2 (April 2003): 67–72.

268 self-mutilation Garner, Sara, and Jennifer Stuht. “CORE Tools and Patient Information.” Obesity Management 1, no. 1 (January 2005): 24–26. Stewart, Tiffany M. “Light on Body Image Treatment: Acceptance through Mindfulness.” Behavior Modification 28, no. 6 (November 2004): 783–811.

self-mutilation

Also called self-injury; selfinflicted violence. The act of deliberately injuring oneself. Mutilation of one’s own or another’s body has always been a part of human existence and continues to be a normal part of some cultures even today. Many cultures have long used mutilation of the body in religious or other social rituals, such as circumcision (of both sexes), tattooing or scarring the skin during rites of passage into adulthood or the binding of feet to make women more attractive. These forms of mutilation or self-mutilation are not meant to be harmful; on the contrary, they often signify strength or rebirth. In our culture, self-mutilation generally is not an attempt to commit SUICIDE but a way of dealing with anxieties and stress. Many self-mutilators find bleeding to be comforting and scarring a welcome sign of healing. The mentally retarded may do things that result in injury to themselves, and psychotics sometimes perform drastic acts such as poking out their eyes or cutting off extremities. The most common cases of mutilation are more subtle in nature. Typically they involve cutting or burning parts of the body or interfering with the healing of wounds. Patients with eating disorders are at high risk for self-mutilation, and vice versa, according to Armando R. Favazza, who has studied this area extensively. He and his colleagues write, “Evidence for this linkage comes from a literature review, from patient interviews, from responses to an instrument we have developed (the Self-Harm Behavior Survey), and from three instructive case reports.” Favazza reported on some of his own cases of selfmutilators who also suffered from eating disorders. One patient developed a fear of becoming overweight after being treated on an outpatient basis for self-mutilation at age 16. After this treatment her mutilating behaviors decreased; however, at 19, when she was hospitalized for her eating disorder, the self-mutilating behaviors intensified. After one year in treatment, both behaviors stopped; but when

events in her life became stressful, she relapsed once again into the eating disorder. For another of his patients with a history of alcohol abuse, eating disorder and self-mutilation, the three behaviors were “interchangeable ways of hurting myself.” According to Favazza, an impulse-control problem seems to be the basis for self-mutilation, eating disorders and substance abuse; he feels that a good number of those with one of these problems may also be affected by another. Self-mutilation is one of the most commonly identified issues of risk in bulimia nervosa, according to Treasure and Schmidt. “Repeated self-harm through cutting, burning and overdosing is common and occurs in approximately 15–25 percent of clinic samples. This is often associated with other high-risk behaviors such as alcohol or substance abuse, unprotected casual sex or repeated shoplifting. These impulsive behaviors have been found to predict poorer outcome for review.” In a study of Japanese subjects with habitual self-mutilation, Matsumoto et al. found results to be consistent with those in Western studies. “Habitual self-mutilation is likely to coexist with depression, bulimia, and dissociation. Such patients frequently have clinical features similar to those of ‘multi-impulsive bulimia.’ Evidence supports the association between habitual self-mutilation and sexual/childhood physical abuse in Japan.” Although psychotherapeutic treatment is currently available for self-mutilators, researchers are now speculating that a deficiency of SEROTONIN, a neurotransmitter that influences HUNGER, SATIETY, sexual drive and pain response, among other feelings, may be a biological contributor to self-mutilation. Favazza, A. R., and K. Conterio. “Female Habitual SelfMutilators.” Acta Psychiatrica Scandinavica 79, no. 3 (March 1989): 283–289. Favazza, A. R., L. DeRosear, and K. Conterio. “Self-Mutilation and Eating Disorders.” Suicide & Life Threatening Behavior 19, no. 4 (Winter 1989): 352–361. Matsumoto, T. “Habitual Self-Mutilation in Japan.” Psychiatry and Clinical Neurosciences 58, no. 2 (April 2004): 191–198. Treasure, Janet, and Ulrike Schmidt. “Treatment Overview.” In Handbook of Eating Disorders, 2nd Ed., edited by Janet Treasure, Ulrike Schmidt, and Eric van Furth, 207–217. West Sussex, U.K.: John Wiley & Sons Ltd., 2003.

set-point theory 269 serotonin

One of a family of NEUROTRANSMITTERS that mediate the passing of impulses through the nervous system. The chemical is produced in the brain when an impulse passes between two nerve endings. Most is then reabsorbed by the nerves. A link between eating disorders and serotonin is assumed, since eating CARBOHYDRATES stimulates the production of serotonin in the brain. It paves the way for other neurotransmitters that stimulate an appetite for protein and fat. It is thought that bulimics, who suffer from diminished serotonin activity, become depressed as their serotonin level drops. As a result they develop a CRAVING for foods that trigger production of the substance, as if they were using pasta and sugar as a “natural” antidepressant (see ANTIDEPRESSANTS). Animal behavior tests are being used to better understand pharmacologic intervention of drugs regulating serotonin. However, any existing serotonin imbalance may also be caused by chronic dieting, especially restriction of carbohydrates. Furthermore, there is evidence that dieting changes serotonergic functioning in women but not men, which may partially explain why there is a much higher incidence of bulimia among women than men. Gurenlian notes that studies of serotonin in individuals with anorexia nervosa have yet to clarify if changes in this chemical represents a cause or a consequence of the disorder. “Increases in the neurotransmitter serotonin lead to reductions in food intake, while decreases in brain serotonin function are associated with depression and suicide attempts. Levels of serotonin are low in underweight individuals with anorexia, but will rise to normal levels in individuals who have recovered. A disturbance in serotonergic function may be a risk factor for the development of anorexia. Conversely, high levels of serotonin can be associated with perfectionism and rigidity, characteristics that are often seen in individuals with anorexia before the illness develops.” Gurenlian, Jo Ann R. “Eating Disorders.” Journal of Dental Hygiene 76, no. 3 (June 2002): 219–238.

set-point theory

There is persuasive evidence that animals and humans naturally maintain, and thus will always return to, a constant weight range, just as the body naturally returns to its own temperature level following illness or external influ-

ence. This weight level is referred to as the body’s set point. It is clear that the human body attempts to maintain a state of homeostasis. However, the term set point is probably an inaccurate descriptor for this process because it is not a specific point, but rather a range of possible weights that the body attempts to maintain. In support of this theory, studies have shown that once “starved” volunteers are given free access to food, they eat ravenously until their weight returns to its normal level, when appetite and caloric intake level off at prediet amounts. Similarly, after experimental forced feeding to increase weight as much as 25 percent, weight rapidly returns to normal levels when volunteers are once again allowed to eat whatever they want, with no attempt to control weight in either direction. It is this set point, proponents say, that explains why dieters invariably return to their prediet weight once they cease to restrict food intake. An individual’s set point can vary as much as 10 to 20 pounds over time. It is believed that a combination of factors, including genetics, METABOLISM and number of FAT CELLS, work together to “set” a level of fat (weight) that’s “normal” for that person. If weight drops below the set point, HUNGER increases and the body burns fewer CALORIES until weight once again stabilizes. Lambert explains further, “The hypothalamus seems to control body weight, triggering several homeostatic mechanisms to maintain weight at a fixed set point. A lack of blood sugar stimulates secretion of hormones such as ghrelin (an appetite stimulant) and leptin (an appetite suppressant) that cascade to trigger a desire to eat. If you lose fat, leptin decreases and ghrelin increases, causing you to eat more—and you gain weight back. The body equilibrates. Hormones like leptin regulate the set point.” Because the basal metabolism rate (BMR) increases with lean body mass, Lambert adds, activities that build and tone muscle will burn more calories and perhaps lower one’s set-point as well. Noting that while “the existence of a set-point for homeostatic control of human body weight is uncertain,” Macias concludes that “Investigation of the human body weight set-point is vital in understanding obesity.” See also GHRELIN; LEPTIN. Lambert, Craig. “The Way We Eat Now.” Harvard Magazine 106, no. 5 (May–June 2004): 50.

270 sexual abuse and eating disorders Macias, A. E. “Experimental Demonstration of Human Weight Homeostasis: Implications for Understanding Obesity.” British Journal of Nutrition 91, no. 3 (March 2004): 479–484.

sexual abuse and eating disorders There is an increasing awareness that many survivors of sexual abuse develop eating disorders. Root et al. reported that 60 percent of 172 bulimics studied had been sexually and/or otherwise physically victimized, and other authors have indicated an even higher rate. Studies at the RENFREW CENTER also revealed the high correlation between sexual abuse and eating disorders—61 of a sample of 100 women had been sexually abused before the age of 18. Of these, 24 were victims of incest, 47 were molested by acquaintances and 18 by strangers. Realizing that this population had a need for specific treatment, the Renfrew Center of Florida, in June 1992, opened a program for survivors of abuse. Jane Shure, a consulting therapist at Renfrew, wrote that the development of an eating disorder such as bulimia or anorexia is a logical response to the emotional experiences and messages received throughout the abused child’s formative years. As the young child moves into adolescence and young adulthood, she turns to food as a means of comfort and a tool for avoiding feelings. Fasting, or bingeing and then purging, both help create an illusion of being in control—while also reinforcing her shame and feeding the desperate need to isolate [herself].

Using data from 190 university women, a 1996 study found that women with histories of assaults from within the family were more likely to suffer a serious eating problem (47 percent) than women who had no history of sexual assault (21 percent) and women who reported only assaults from outside the family (36 percent). However, not all researchers support the connection between sexual abuse and eating disorders. Pope and Hudson, for example, reviewed the scientific literature on childhood sexual abuse as a risk factor for the development of bulimia nervosa. They concluded that “controlled studies generally did not find that bulimic patients show a significantly higher prevalence of childhood sexual abuse than control groups. Furthermore, neither con-

trolled nor uncontrolled studies of bulimia nervosa found higher rates of childhood sexual abuse than were found in studies of the general population that used comparable methods.” More recently, Rayworth et al. found that among 732 women between the ages of 36 and 44, those who said they were physically abused in childhood were at twice the risk of having either a full-blown eating disorder or at least some symptoms of one. Women who reported both physical and sexual abuse during childhood had three times the odds of developing eating disorder symptoms and nearly four times the odds of meeting DSM-IV criteria for an eating disorder. The authors noted that abuse can make victims feel powerless, and eating disorders are thought to arise, in part, from a desire to take control of one aspect of life. Waller found that bulimics were substantially more likely to report a history of unwanted sexual experience than anorexics. He suggested that sexual abuse may not cause eating disorders but may determine the nature of those disorders when they have been prompted by other factors. Perhaps a more important question is not whether or not sexual abuse is a risk factor for eating disorders, but rather in what way is it important when it is present. Gleaves and Eberenz examined this question among a group of hospitalized eating disordered individuals and found that, although sexual abuse was unrelated to severity of eating disorder symptoms, it was highly related to additional problems such as suicide attempts, alcohol problems, and self-injurious behaviors. Gustafson and Sarwer note that relatively few studies have examined the relationship between childhood sexual abuse and adult obesity. “These studies suggest at least a modest relationship between the two. Potential explanations for the relationship have focused on the role of disordered eating, particularly binge eating, as well as the possible ‘adaptive function’ of obesity in childhood sexual abuse survivors. Nevertheless, additional research on the relationship between childhood sexual abuse and obesity is clearly needed, not only to address the outstanding empirical issues but also to guide clinical care.” Baldo, T. D., et al. “Effects of Intrafamilial Sexual Assault on Eating Behaviors.” Psychological Reports 79 (October 1996).

sexuality and obesity 271 Gleaves, D. H., and Eberenz, K. P. “Eating Disorders and Additional Psychopathology in Women: The Role of Prior Sexual Abuse.” Journal of Child Sexual Abuse 2 (1993): 71–80. Gustafson, T. B., and D. B. Sarwer. “Childhood Sexual Abuse and Obesity.” Obesity Review 5, no. 3 (August 2004): 129–135. Pope, Harrison G., Jr., and James I. Hudson. “Is Childhood Sexual Abuse a Risk Factor for Bulimia Nervosa?” American Journal of Psychiatry 149, no. 4 (April 1992): 455–463. Rayworth, B. B., L. A. Wise, and B. L. Harlow. “Childhood Abuse and Risk of Eating Disorders in Women.” Epidemiology 15, no. 3 (May 2004): 271–278. Root, Maria P. P., Patricia Fallon, and William N. Friedrich. Bulimia: A Systems Approach to Treatment. New York: W.W. Norton, 1986. Waller, Glenn. “Sexual Abuse as a Factor in Eating Disorders.” British Journal of Psychiatry 159 (November 1991): 664–671.

sexuality and eating disorders Restricting anorexics demonstrate significant immaturity and inhibition in sexual and social experience; however, in their attempt to meet all social expectations, they sometimes present a facade of good social adjustment. Bulimic women, on the other hand, although less sexually and socially mature than borderline women, are more so than anorexic women. But bulimia usually results in a sharp decrease in sexual desire, attributed to both psychological and physiological causes. Even when bulimia sufferers are sexually active, they will have times of withdrawing from their partners and ceasing sexual behavior. Bulimic patients often have irregular menstrual cycles, pointing to disruption of the pattern of sexhormone secretion. Their obsession with food leaves them little time to think about other aspects of life, and they characteristically feel worthless and flawed. They also often fear that if anyone becomes closely involved with them, they will learn their secret. Likewise, psychiatrists contend than many people overeat to cover up feelings of sexual inadequacy. If they do not seem attractive to the opposite sex, they will avoid occasions of stress and humiliation. However, it is not unusual for those bulimics who lack control over their impulses to participate in sexual promiscuity and extramarital affairs. Nielsen and Bará-Caril write, “Many eating-disordered patients have problems with sexuality in general and consequently with procreation.” To

illustrate, they cite findings from several studies; among these: (1) fertility reduced to one-third of the expected numbers among a cohort of 140 former female anorexia nervosa patients, and none of the 11 male patients had offspring; (2) a twofold increase in miscarriage rate was reported for a bulimic population in a controlled study; (3) pleasurable sexual relationships were reported in 67 percent of an anorexia nervosa group and in 84 percent of the comparison group; however, the individuals with anorexia nervosa tended to have fewer and less satisfactory romantic relationships. In a British study of 11 women with anorexia nervosa, Morgan et al. concluded, “An increase in sexual drive accompanies weight restoration in patients with anorexia nervosa, which is consistent with psychological and physiological explanations of altered sexuality. Transient depression is also associated with weight gain. Changes in sexuality should be considered in both recovery and treatment failure.” Abed has suggested that eating disorder syndromes, together with the phenomenon of the pursuit of thinness, are manifestations of female intrasexual competition. The contention is that eating disorders originate in the human female’s psychological adaptation of concern about physical attractiveness, which is an important component of female “mate attraction” and “mate retention” strategies. Abed argues that the present-day environment of Western countries presents a range of conditions that have led to the overactivation or the disruption of the archaic female sexual strategy of maximizing “mate value.” The predictions theorized by Abed need to be tested. Abed, R. T. “The Sexual Competition Hypothesis for Eating Disorders.” British Journal of Medical Psychology 71 (December 1998): 525–547. Morgan, John F., J. Hubert Lacey, and Fiona Reid. “Anorexia Nervosa: Changes in Sexuality during Weight Restoration.” Psychosomatic Medicine 61, no. 4 (July–August 1999): 541–545. Nielsen, Søren, and Núria Bará-Caril. “Family, Burden of Care and Social Consequences.” In Handbook of Eating Disorders, 2nd Ed., edited by Janet Treasure, Ulrike Schmidt, and Eric van Furth, 191–206. West Sussex, U.K.: John Wiley & Sons Ltd., 2003.

sexuality and obesity

Obesity is significantly associated with sexual quality of life for men and

272 sexuality and obesity women, Duke University Medical Center researchers found. Obese people report sexual problems such as lack of desire, lack of enjoyment, avoiding sex and performance difficulty at a much higher rate than people of normal weight—in some cases, they are 25 times more likely to report problems, according to the Duke study. Overall, women experienced more difficulties than did men among both weight groups, but the gender differences were small compared to the disparity between the obese and normal-weight study populations. Martin Binks, Ph.D., and Ronette Kolotkin, Ph.D., were co-investigators of the study; results were presented at the November 15, 2004, annual meeting of the North American Association for the Study of Obesity. Of the 1,210 study participants, 506 obese people seeking treatment were drawn from the Duke Diet and Fitness Center; 422 obese and 282 normal-weight people who were not seeking to lose weight were recruited from the community. The average BODY MASS INDEX (BMI) of the obese groups was 41 for the treatment-seekers and 40 for the non-treatment seekers. The normal weight group had an average BMI of 22. The average age of the groups was 48 for treatment seekers, 45 for non-treatment-seekers and 35 for normal-weight people. The balance between men and women varied between the groups. About 53 percent of the obese treatment seekers were women, rising to 67 percent in the obese nontreatment group and 71 percent in the normal-weight group. The Duke University findings differed somewhat from a recent Swedish study, in which researchers also investigated whether there is any association between obesity and sexual satisfaction in a normal population. They interviewed a representative sample of 2,810 subjects about sexual satisfaction and other areas. The answers from normal weight, overweight and obese participants were compared. The older group of obese men (50 to 74 years) reported a greater decrease of sexual desire compared with five years prior than normal-weight men. The older group of overweight men reported participation in sexual activities, not out of desire, but at the initiation of their partner more often than normal-weight men. Overweight and obese groups seemed to be diverse with respect to sexual satisfaction. No significant differences were detected between BMI groups.

Adolfsson et al. wrote, “It is conceivable that the expectations of what is needed for satisfaction is lower among overweight and obese persons compared with subjects of normal weight.” They continued, “Critical attitudes toward obese people are prevalent. Some obese people internalize the negative social messages. This may be the cause of self-imposed restrictions on important aspects of life, such as enjoying a sexual relationship . . . [for] obese people— or even people of normal weight who feel obese.” A common problem for obese men is erectile dysfunction. Around 30 million American men suffer from some degree of impotence, and more than half of all men over the age of 40 have some component of erectile dysfunction, but four out of every five men who report sexual dysfunction are either overweight or obese. In their study of the relationship between obesity and various diseases and health complaints, Patterson et al. reported that men with a BMI of 35 or greater were three times more likely to report impotence. Italian researchers investigated how healthy lifestyle changes might help improve erectile dysfunction in obese middle-aged men who did not have heart disease, diabetes, hypertension or other conditions known to cause erectile dysfunction. “In our study, about one-third of obese men with erectile dysfunction regained their sexual function after two years of adopting healthy behaviors, mainly regular exercise and reducing weight.” They concluded, “Sedentary men may be able to reduce their risk of erectile dysfunction by adopting regular physical activity at a level of at least 200 calories a day, which corresponds to walking briskly for two miles.” However, an accompanying editorial cautioned that diet and exercise alone are not likely to solve the impotence problem for everyone. “The population studied may differ from obese patients typically seen in primary care clinics in that these patients did not have known coronary heart disease, diabetes, or hypertension, all commonly seen in obese patients in practice. The presence of these diseases may lessen the impact of the effect of exercise and weight loss on erectile dysfunction.” See also STERILITY AND OBESITY. Adolfsson, B., S. Elofsson, S. Rossner, and A. L. Unden. “Are Sexual Dissatisfaction and Sexual Abuse Associated with Obesity? A Population-Based Study.” Obesity Research 12, no. 10 (October 2004): 1,702–1,709.

size discrimination 273 Esposito, Katherine, et al. “Effect of Lifestyle Changes on Erectile Dysfunction in Obese Men: A Randomized Controlled Trial.” Journal of the American Medical Association 291, no. 24 (June 23, 2004): 2,978–2,984. Patterson, Ruth E., Laura L. Frank, Alan R. Kristal, and Emily White. “A Comprehensive Examination of Health Conditions Associated with Obesity in Older Adults.” American Journal of Preventive Medicine 27, no. 5 (December 2004): 385–390. Saigal, Christopher S. “Obesity and Erectile Dysfunction: Common Problems, Common Solution?” Journal of the American Medical Association 291, no. 24 (June 23, 2004): 3011–3012.

sialadenosis Swelling of the salivary glands, most evident in the parotid glands; frequently seen in bulimics. “Puffy cheeks” may be an indication of this problem. sibutramine

An obesity drug approved by the Food and Drug Administration (FDA) in November 1997. Sibutramine works to suppress appetite primarily by inhibiting the reuptake of the neuro transmitters norepinephrine and serotonin. Animal studies have shown that it also increases thermogenesis (expending of energy). Unlike dexfenfluramine (see FEN-PHEN/REDUX) sibutramine does not cause an increase in release of serotonin from the nerve cell. In clinical trials, patients taking sibutramine while on a reducedcalorie diet, lost 10 to 15 pounds over six months. The average weight loss in persons on only the reduced-calorie diet was 3.5 pounds. The most common side effects associated with sibutramine include dry mouth, headache, constipation and insomnia. It can raise blood pressure, so the FDA recommends regular blood pressure evaluations for patients taking sibutramine. Sibutramine is manufactured and distributed by Abbott Laboratories under the brand name Meridia. See also ANTIOBESITY DRUGS.

Simplesse

A FAT SUBSTITUTE developed by NutraSweet. It can replace fat, and thus reduce calories, in such foods as frozen desserts, mayonnaise, salad dressing and margarine. One of dozens of fat substitutes being developed by food manufacturers, Simplesse is composed of proteins from milk and egg whites, which are heated and whipped to create tiny

spheres one-tenth the size of a grain of powdered sugar. On the tongue, Simplesse particles taste and feel like cream. The first product made with Simplesse to be marketed to the American public was Simple Pleasures, an ice “cream” with half the calories of the real thing and virtually no fat.

sitomania (sitophobia) Interchangeable terms included as diagnostic categories in American medical dictionaries during the mid-1850s to describe a “phase of insanity” characterized by “intense dread of food.” Sitophobics were not classified among the FASTING GIRLS of that period. They claimed no special powers, and no public pronouncements were made about the duration of the fasting or the patients’ miraculous inspiration. Sitophobic girls came from middle-class families, well educated and well situated. No organic explanation could be found for their not eating. In Fasting Girls, Joan Jacobs Brumberg refers to sitomania as a “prehistory of anorexia nervosa.” size discrimination

Systematic restrictions in employment, housing, child adoption and other areas based on weight rather than ability, training or other qualifications. Murray described the scope of the size discrimination problem: Among the greatest social problems encountered by people who are obese are prejudice and discrimination at work, in public, and in interpersonal relationships. In affluent Western societies, slenderness generally is associated with youth, success, happiness, and social acceptability. One study found that prejudice against obesity begins in children as young as six years of age. In the study, a classroom of six-year-old children used terms such as “lazy,” “dirty,” “lack of willpower,” and “ugly” to describe silhouettes of children who were obese. In another study, individuals who were obese who underwent simulated job interviews were rated less qualified for jobs and viewed as having poorer work habits, as well as more emotional and interpersonal problems than participants in a control group. In contrast to other chronic physical conditions, such as asthma, diabetes, and musculoskeletal deformities, obesity often results in negative economic and social consequences, such as lower income levels and marriage rates. People who are obese are less likely to be admitted to prestigious

274 skin fold measurement schools or enter desirable professions. Physicians and other health professionals also often have negative perceptions of people who are obese.

Puhl and Brownell reviewed information on discriminatory attitudes and behaviors against obese individuals. “Clear and consistent stigmatization, and in some cases discrimination, can be documented in three important areas of living: employment, education, and health care. Among the findings are that 28 percent of teachers in one study said that becoming obese is the worst thing that can happen to a person; 24 percent of nurses said that they are ‘repulsed’ by obese persons; and, controlling for income and grades, parents provide less college support for their overweight than for their thin children. There are also suggestions but not yet documentation of discrimination occurring in adoption proceedings, jury selection, housing, and other areas.” In an Indiana University School of Nursing study to explore what it is like for individuals and family members to live with obesity as a chronic illness, the participants revealed frequent experiences of stigmatization and discrimination on the basis of their obesity. The authors found that “those who are obese are reminded through their everyday encounters with family members, peers, healthcare providers, and strangers, that they’re being deviates from social norms, and that they are inferior to those who are not obese. Obese subjects experience a pattern of denigration and condemnation that is so pervasive as to constitute what Harvey has called civilized oppression.” Size discrimination can be especially onerous on the job. Grossman writes, “A national phone survey of 603 full- and part-time workers conducted for the Employment Law Alliance [in October 2003] reveals that workers are cognizant of the undercurrent of discrimination in their midst. Nearly half of those polled (47 percent) believe obese workers suffer discrimination, 32 percent think these workers are given less respect and are taken less seriously, and 30 percent think overweight workers are less likely to be hired or promoted. Size discrimination ranges from subtle to overt, but it’s a huge issue—comparable in scope to age discrimination in the United States.” According to NAAFA, the only state statute under which the obese may seek redress for discrimination is Michigan’s 1976 Elliott-Larsen Civil Rights

Act, which prohibits employment discrimination on the basis of height and weight. Local statutes include a Santa Cruz, California, ordinance that prohibits discrimination in employment, housing, and public accommodations on the basis of height and weight or physical characteristics, and an ordinance in Washington, D.C., that prohibits discrimination based on personal appearance. See also OBESITY IN THE WORKPLACE. Grossman, Robert J. “Countering a Weight Crisis.” HR Magazine 49, no. 3 (March 2004): 42–51. Puhl, R. M., and K. D. Brownell. “Bias, Discrimination, and Obesity.” Obesity Research 9, no. 12 (December 2001): 788–805. Murray, Donna. “Morbid Obesity—Psychosocial Aspects and Surgical Interventions.” AORN Journal 78, no. 6 (December 2003): 990–995. Rogge, M. M., M. Greenwald, and A. Golden. “Obesity, Stigma, and Civilized Oppression.” ANS: Advances in Nursing Science 27, no. 4 (October–December 2004): 301–315.

skin fold measurement The thickness of a fold of skin at a selected body site, usually the upper arm or triceps, the subscapular region (on the back near the shoulder blade), the calf, or the upper abdomen. The measurements are used to calculate body fat, in order to evaluate nutritional status. In the National Health Survey, 1960–62, the average right arm skin fold measured over the middle of the triceps muscle was 11 millimeters for male subjects 18 to 24 years and 14 millimeters for males 25 to 34 years. In the same study, the average triceps skin fold for women was 22 millimeters. Between 18 and 24 years, the average skin fold measurement was 18 millimeters, 21 millimeters between 25 and 34, and increased to 25 millimeters between 55 and 64, after which there was a slight drop to 24 millimeters between 65 and 74 years. There are no statistical differences between triceps skin folds measured on either arm. Triceps skin fold measurements are based on the assumption that 50 percent of the fat is subcutaneous. The midpoint between the shoulder and elbow process is located, with the arm folded. The person making the measurement pinches up a full fold of skin and subcutaneous tissue with the thumb and forefinger of the left hand at a distance 1 cm above the site at which the measurement is to be

sleep deprivation and weight gain 275 taken. The fold is pulled away from the underlying muscle. The pressure on the fold is exerted by the calipers and not the fingers. The dial of the calipers is read to the nearest 0.5 millimeters, after releasing the handle and applying pressure to the skin fold. Skin fold measurements are then translated into percentage of body fat by means of standard equations. When carefully used, skin fold measurements provide a good indication of body fatness. (See BODY FAT.) They are most accurate when applied to healthy subjects who are not either grossly obese or severely underweight. Measurements are more accurate when extremes in temperature are avoided. Extreme heat can cause skin fold swelling. Edema, which in severe cases can cause a great increase in body weight, can cause errors in skin fold measurements. Recent weight loss may also have an effect on tissue tension or the pattern of subcutaneous fat thickness.

sleep deprivation and weight gain

A growing body of research is pointing to a possible connection between obesity and lack of sleep. In an East Virginia Medical School study of 1,001 participants, obese and overweight patients reported sleeping less than their peers with normal body mass indexes (BMIs). The researchers found that total sleep time decreased as BMI increased, except in the severely obese group. The difference in total sleep time between patients with a normal BMI and the other patients was 16 minutes per day, reaching 112 minutes, or 1.86 hours, during a week. The authors commented, “Our findings suggest that major extensions of sleep time may not be necessary, as an extra 20 minutes of sleep per night seems to be associated with a lower BMI. We caution that this study does not establish a cause-andeffect relationship between restricted sleep and obesity. Investigations demonstrating success in weight loss via extensions of sleep would help greatly to establish such a relationship.” In another study, at the Stanford University School of Medicine, researchers found that sleep loss leads to higher levels of GHRELIN, a hormone that triggers appetite; lower levels of LEPTIN, a hormone that tells the body it is full; and an increased body mass index. These findings documented for the first time the relationship between sleep and metabolic hormones in the general population, tracking how hormon-

al changes are consistent with obesity. The investigators noted, “In Western societies, where chronic sleep restriction is common and food is widely available, changes in appetite regulatory hormones with sleep curtailment may contribute to obesity.” A third study, although involving only 12 subjects and not measuring energy expenditure, showed sleep restriction to be associated with decreased leptin levels, increased ghrelin levels and increased hunger and appetite, especially for caloriedense foods with high carbohydrate content. Dr. Eve Van Cauter, one of the investigators and director of the University of Chicago Research Laboratory on Sleep, Chronobiology and Neuroendocrinology, was quoted in the Tufts University Health & Nutrition Letter (April 2005) as saying, “If you run a sleep debt, pay it. If you are sleep-deprived, you will crave highcarb foods and will need an iron will to resist.” The findings in these studies were reinforced by Steven Heymsfield, M.D., of Columbia University and St. Luke’s–Roosevelt Hospital in New York, and James Gangwisch, Ph.D., a Columbia epidemiologist, who presented results of their study at a meeting of the North American Association for the Study of Obesity in November 2004. They used information on about 18,000 adults participating in the federal government’s National Health and Nutrition Examination Survey (NHANES) throughout the 1980s. The survey includes long-term follow-up information on health habits, and researchers adjusted it to take into account other things that affect the odds of obesity, like exercise habits, so that the effects of sleep could be isolated. The researchers discovered that those who got less than four hours of sleep a night were 73 percent more likely to be obese than those who got the recommended seven to nine hours of rest. Those who averaged five hours of sleep had 50 percent greater risk, and those who got six hours had 23 percent more. Spiegel, K., et al. “Brief Communication Sleep Curtailment in Healthy Young Men Is Associated with Decreased Leptin Levels, Elevated Ghrelin Levels, and Increased Hunger and Appetite.” Annals of Internal Medicine 141, no. 11 (December 7, 2004): 846–850. Taheri, S., et al. “Short Sleep Duration Is Associated with Reduced Leptin, Elevated Ghrelin, and Increased Body Mass Index.” Public Library of Science: Medicine 1, no. 3 (December 2004): e62. Available online. URL: http://medicine.plosjournals.org.

276 sleep-related eating disorder Vorona, Robert D., et al. “Overweight and Obese Patients in a Primary Care Population Report Less Sleep than Patients with a Normal Body Mass Index.” Archives of Internal Medicine 165, no. 1 (January 10, 2005): 25–30.

sleep-related eating disorder (SRED) Also called nocturnal sleep-related eating disorder. A syndrome first officially described in 1991, in which people wake in the night and binge-eat but do not always remember doing it. In one of the few studies published in this disorder, 83 percent of the patients were female, and for most of them the condition had begun in adolescence and had been chronic—suffering from it for an average of 15.8 years before it was diagnosed. Thirty-five percent of those studied also had a lifetime eating disorder (anorexia, bulimia or binge-eating). Nearly all the patients reported eating one to six times on a nightly basis, and all episodes followed a period of sleep. All patients described their eating as out of control. Many reported being totally asleep during these episodes and could not recall them; only a messy kitchen, food in the bedroom, or testimony from another family member convinced them it was happening. Those who could recall the sleep eating episodes said they were half-awake, half-asleep during them. Foods eaten during these sleep-related eating episodes have been reported to run toward highfat, high-sugar foods that people have restrained themselves from eating while awake. Bizarre combinations and ingestion of nonfood items have also been reported. SRED is considered by some to be a sleep disorder, not an eating disorder. According to ANRED, “One to three percent of the general population (3 to 9 million people) seems to be subject to this disorder, and ten to fifteen percent of people with eating disorders are affected. The problem may be chronic or appear once or twice and then disappear. Many of these people are severely stressed, anxious individuals who are dismayed and angry at themselves for their nocturnal loss of control. Their behaviors may pave the way to depression and weight gain.” Hellmich noted that “Experts are researching treatments, including recommending basic behavioral changes in eating and exercise habits. In three different studies, University of Pennsylvania researchers are prescribing the antidepressant

Zoloft to patients with the disorder.” Although Zoloft does yield good results, the researchers caution, “Of course, it’s not a magic bullet for everyone. Other drug treatments may work; they just haven’t been studied yet.” Topiramate, a second-generation anticonvulsant medication approved in the United States in 1997, has been used successfully to treat both SRED and NIGHT EATING SYNDROME. Hellmich, Nanci. “The Loneliness of the Nighttime Snacker; Syndrome Tied to Obesity, Moodiness, Lack of Sleep.” USA Today, November 15, 2004, p. D1. Manni, R., et al. “Nocturnal Eating: Prevalence and Features in 120 Insomniac Referrals.” Sleep 20, no. 9 (September 1997): 734–738. “Nocturnal Sleep-Related Eating Disorder.” ANRED (Anorexia Nervosa and Related Eating Disorders, Inc.); Available online. URL: http://www.anred.com/ nsred.html. Updated September 2004. Winkelman, John W. “Clinical and Polysomnographic Features of Sleep-Related Eating Disorder.” Journal of Clinical Psychiatry 59, no. 1 (January 1998): 14–19. Winkelman, John W. “Treatment of Nocturnal Eating Syndrome and Sleep-Related Eating Disorder with Topiramate.” Sleep Medicine 4, no. 3 (May 2003): 243–246.

smoking cessation and weight gain Cigarette smokers have a lower average body weight than nonsmokers, and the fear of weight gain is a barrier to quitting in some smokers, particularly in women. Studies suggest that women gain an average of 20 pounds and men 17 pounds following smoking cessation. In a Canadian study of undergraduate college students, dieters who were former smokers reported considerably more weight gain than nondieters. A Japanese study found that although heavy smokers may experience large weight gain and weigh more than nonsmokers in the early years following smoking cessation, they then lose weight until they are at the same level as the nonsmokers. Light and moderate smokers gain weight up to the nonsmoker level once they stop smoking, but not any amounts beyond that level. In a double-blind trial, fluoxetine appeared to forestall weight gain following cessation of smoking, allowing time for the weight-conscious smoker to focus on quitting smoking rather than on preventing weight gain.

Sociocultural Attitudes Towards Appearance Scale-3 277 Eastern Michigan University researchers commented, “Although there is empirical support for the association between smoking, disordered eating, and subsequent weight gain upon smoking cessation, there have been no prospective studies to track changes in eating patterns during smoking abstinence and explore underlying biobehavioral processes.” Their findings suggest that “low-BMI women may be less prone to weight gain during early [smoking] abstinence, possibly because they compensate for metabolic changes induced by nicotine washout by eating less. Craving increases experienced by high-BMI women during abstinence under conditions of food deprivation may contribute to difficulty quitting in these women.” Borelli, B., et al. “Weight Suppression and Weight Rebound in Ex-Smokers Treated with Fluoxetine.” Journal of Consulting and Clinical Psychology 67, no. 1 (February 1999): 124–131. Charnow, J. “Weight Gain after Smoking Cessation Underestimated.” MDX Health Digest 39, no. 20 (1998). Froom, P., et al. “Smoking Cessation and Weight Gain.” MDX Health Digest 46, no. 6 (1998). Jarry, J. L., et al. “Weight Gain after Smoking Cessation in Women: The Impact on Dieting Status.” International Journal of Eating Disorder 24, no. 1 (July 1998): 53–64. Saules, K. K., et al. “Effects of Disordered Eating and Obesity on Weight, Craving, and Food Intake during Ad Libitum Smoking and Abstinence.” Eating Behavior 5, no. 4 (November 2004): 353–363.

social factors in obesity In industrialized societies obesity is more prevalent in lower social classes, whereas the reverse pattern has been observed elsewhere, as in rural India. Stunkard wrote that social mobility has also accompanied changes in the incidence of OBESITY; in America, upward mobility has been associated with decreasing obesity, and downward mobility is associated with increasing obesity. In New York City, incidence of obesity has been found to be seven times higher in the lowest than in the highest social class. There also is a tendency for slim women to move up the social scale and overweight women to move down. In their review, Zametkin et al. write, “Social factors associated with obesity include neglect, abuse, and generally nonsupportive home environments.

Neglected children are nine times more likely than others to become obese. Adults seeking treatment for obesity demonstrate a fourfold increase in the prevalence of childhood sexual abuse, as well as a twofold increase in nonsexual abuse compared with a control population. One psychosomatic theory of obesity is that food provides comfort and therefore that eating serves as a compensatory mechanism for children who have survived traumatic experiences or who live in difficult environments. Thus, obese children may overeat as a consequence of environmental deprivation or as a result of depression, somatization, or familial abuse.” See also CULTURAL INFLUENCES ON APPEARANCE. Goldblatt, P. B., M. E. Moore, and A. J. Stunkard. “Social Factors in Obesity.” Journal of the American Medical Association 192 (1965): 1,039–1,044. Stunkard, Albert J. “The Control of Obesity: Social and Community Perspectives.” In Handbook of Eating Disorders, edited by Kelly D. Brownell and John P. Foreyt. New York: Basic Books, 1986. Zametkin, A. J., et al. “Psychiatric Aspects of Child and Adolescent Obesity: A Review of the Past 10 Years.” Journal of the American Academy of Child and Adolescent Psychiatry 43, no. 2 (February 2004): 134–150.

Sociocultural Attitudes Towards Appearance Scale-3 (SATAQ-3) First developed in 1995, the SATAQ, now in its third version, is a widely used measure of societal influences on body image and eating disturbances. The SATAQ was developed to assess women’s recognition and acceptance of societally sanctioned standards of appearance that have been developed due to media exposure. It consists of statements such as: • Women who appear in TV shows and movies project the type of appearance that I see as my goal • I believe that clothes look better on thin models • People think that the thinner you are, the better you look in clothes • I wish I looked like a swimsuit model Participants indicate their recognition/awareness of each influence on a five-point scale ranging from 1 (completely disagree) to 5 (completely agree). The SATAQ has been adapted for other groups, such as middle-school children and men.

278 sodium pump Heinberg, L. J., J. K. Thompson, and S. Stormer. “Development and Validation of the Sociocultural Attitudes towards Appearance Questionnaire.” International Journal of Eating Disorders 17, no. 1 (January 1995): 81–89. Thompson, J. Kevin, et al. “Sociocultural Attitudes towards Appearane Scale-3 (SATAQ-3): Development and Validation.” International Journal of Eating Disorders 35, no. 3 (April 2004): 293–304.

sodium pump A metabolic process that maintains balance in the concentrations of sodium and potassium ions inside and outside cell walls. It has been shown that obese people have lower pressure differentials across cell membranes than do normal weight subjects. This means that the sodium pump consumes less ENERGY in obese people, who therefore survive on fewer CALORIES. South Beach Diet A popular low-carbohydrate diet plan proposed by Florida cardiologist Arthur Agatston in his best-selling book The South Beach Diet (Rodale, 2003). It restricts foods with high GLYCEMIC INDEX, but is less restrictive than the ATKINS DIET, allowing more whole grains, fruits and vegetables, so may be easier for followers to maintain over time. Gaesser and Kratina caution, “The book relies exclusively on anecdotal testimonies. There is no published evidence this diet is sustainable and will result in permanent weight loss.” Gaesser, Glenn A., and Karin Kratina. It’s the Calories, Not the Carbs. Toronto: Trafford Publishing, 2004.

spinal cord injury and obesity

An estimated 250,000 people in the United States live with spinal cord injuries—82 percent of them are men, with roughly 11,000 additional Americans sustaining a spinal cord injury every year. About 60 percent of people with spinal cord injuries are obese—double the national rate of obesity among the general population. The struggle against obesity is even more dramatic for people with spinal cord injury, according to researchers at the University of Michigan Health System (UMHS), who are looking at how people with spinal cord injury burn calories and how that is affected by their muscle mass and body weight. The goal is to make better recommendations to

people with spinal cord injury, but the research will also translate into greater understanding of obesity in the general population as well. “Individuals with spinal cord injury have significantly less bone mass and muscle mass. As a result, their body weight is comprised of much more fat and less muscle or bone than you would see in an able-bodied individual,” says David Gater, M.D., Ph.D., director of Spinal Cord Injury Medicine at UMHS and director of the Spinal Cord Injury Research Center at the Veterans Administration Ann Arbor Healthcare System. Muscle burns calories even when the body is at rest. For someone with a spinal cord injury—who has less muscle mass—resting metabolism can be as low as half that of a person without a spinal cord injury. And that means that even when people with spinal cord injury exercise, they burn significantly fewer calories. Burning calories at a reduced rate combined with limitations on physical activity contributes not just to obesity but to all the associated health problems: high cholesterol, coronary artery disease, diabetes and cancer.

Splenda

See

ARTIFICIAL SWEETENERS.

spot reducing

Exercising a particular group of muscles such as those of the stomach or upper arms in order to lose weight, tone muscles or reduce fat in that area. Exercising specific muscles does tighten and increase the tone of these muscles but does not preferentially mobilize fat from storage cells overlying these muscles. AEROBIC EXERCISE is required for mobilization of fat; the sequence of mobilization from various areas of the body varies from person to person.

starch blockers Substances derived from concentrated protein from certain beans that inhibit digestion of starch by preventing complete METABOLISM of CARBOHYDRATES. They are marketed as aids in weight reduction. Any weight loss that starch blockers may effect is due to the malnutrition this process causes, along with flatulence and gastric upset. In 1984, starch blockers were taken off the market pending Food and Drug Administration approval. Those currently available are effective only in preventing

stevia 279 breakdown of complex carbohydrates and have no effect on the digestion of the simple sugars abundant in the American diet. The FDA has cautioned consumers to beware of starch blockers, saying they “promise to block or impede starch digestion. Not only is the claim unproven, but users have complained of nausea, vomiting, diarrhea, and stomach pains.”

starvation syndrome Studies have shown that starvation influences behavior and reasoning, from preoccupation with food to mood swings to social isolation. Garfinkel and Kaplan wrote that all the symptoms described in studies of starving people are also prominent in anorexia nervosa. “That they result from starvation per se and not from a pathophysiological process unique to anorexia nervosa has allowed greater diagnostic specificity and more emphasis on weight gain as a critical aspect of treatment.” Berg, Frances S. “The Starvation Syndrome.” Healthy Weight Network (September 1998). Garfinkel, Paul E., and Kaplan, Allan S. “Anorexia Nervosa: Diagnostic Conceptualizations.” In Handbook of Eating Disorders, edited by Kelly D. Brownell and John P. Foreyt. New York: Basic Books, 1986.

steatopygia Having abnormal fatness of the buttocks; it is seen to an extreme in certain parts of Africa. Location of this excess fat accumulation in the buttocks apparently represents an evolutionary adaptation to a very hot climate. If this fat were spread throughout the subcutaneous tissue, normal cooling of the skin would be severely limited. Stein-Leventhal syndrome

See

POLYCYSTIC OVARY

SYNDROME.

sterility and obesity

While obesity has long been known to be an infertility factor in females, recent research shows that obese males may also be at risk for sterility. Obesity appears to affect a man’s fertility by causing lower levels of the hormone testosterone, a diminished sex drive and less ability to produce sperm. After hypothesizing that obesity affects hypothalamic and gonadal function in men, which in turn negatively affects fertility, Dr. Eric Pauli and

doctors at Pennsylvania State University College of Medicine investigated fertility markers, such as reproductive history, inhibin B levels, testosterone and semen analysis, in 87 adult males with a range of body mass index (BMI) levels. Results showed lower testosterone, free testosterone and follicle stimulating hormone (FSH) levels, which indicates mild hypogonadotropic hypogonadism in men with a higher BMI. Additionally, men with children had a lower BMI. “These results indicate that obesity is an infertility factor in men as well as women,” noted Dr. Pauli. The findings were presented at ENDO 2004, the 86th Annual Meeting of the Endocrine Society. Also in 2004, Danish scientists examined the relationship between BMI and semen quality among 1,558 young men from the general population. Men with a BMI of less than 20 had a reduction in sperm concentration and total sperm count of 28.1 percent, and men with a BMI greater than 25 had a reduction in sperm concentration and total sperm count of 21.6 percent, compared to men with a healthy BMI between 20 and 25. Percentages of normal spermatozoa were reduced, although not significantly, among men with high or low BMI. Semen volume and percentage of motile spermatozoa were not affected by BMI. What is not known is what causes this difference in sperm quality. Among the suggestions is a possible alteration in hormonal values. Men produce and need a certain amount of the female hormone estrogen. Fat cells produce estrogen, so too much or too little of it may be a problem. See also INFERTILITY AND OBESITY. Jensen T. K., et al. “Body Mass Index in Relation to Semen Quality and Reproductive Hormones among 1,558 Danish Men.” Fertility & Sterility 82, no. 4 (October 2004): 863–870.

stevia

Also referred to as stevioside or steviol. A sweetening product 250 to 300 times sweeter than sugar; in effect it is calorie-free because the body does not metabolize it. Stevia is an extract from the leaves of a South American shrub and has been used for hundreds of years to sweeten a green-tea-like drink native to Brazil and Paraguay called yerba maté. To date, the FDA has not approved it for use as a sweetener in the United States, but stevia may be

280 stimulus control sold as a dietary supplement (supplement rules are less stringent than those for food additives). It is available in either liquid or powered form as Stevita and Sweet Leaf. Researchers have found that the main chemical in stevia can be converted in the laboratory to a compound that causes changes in genes. More study is needed to learn whether the same changes, which might lead to cancer, could occur in people. Some scientists believe that using stevia in small amounts once or twice a day is probably safe. According to reports, Japanese drink manufacturers have been adding stevia for more than 30 years with no known health effects. Consumer Reports on Health (January 2005) does not recommend its use due to insufficient data: “Animal evidence suggests high intake may reduce sperm count and cause fewer and smaller offspring.”

stimulus control A BEHAVIOR MODIFICATION technique, also called cue elimination, stimulus control attempts to alter the circumstances that may trigger the impulse to eat, while also including measures used in traditional weight reduction programs. Every effort, for instance, is made to limit the amount of high-calorie food kept in the house and to limit accessibility to the food that is kept. Foods that require preparation replace those that require none. Spare change is kept to a minimum to decrease the likelihood of impulse buying of candy or snacks. Eating is confined to scheduled mealtimes and places. At the same time, new stimuli for eating are established. For example, the obese adult might restrict all eating to special table settings or unusually colored place mats and napkins—anything to make the eating process special and intentional (as distinct from habitual, almost subconscious snacking). Emphasis is put on the eating process rather than the amount of food eaten. stomach stapling A general term used for about 20 surgical operations that create artificially smaller stomachs out of portions of the original stomachs. Usually the stomach is closed off with a staple gun, although other means are sometimes used, such as the insertion of plastic mesh. Some involve GASTRIC BYPASS, in which the intestine is severed and reattached to a hole punched in the stomach pouch. These operations cause weight loss

by limiting food intake; as soon as a few mouthfuls are eaten, the person feels nauseated and must stop eating to avoid vomiting. When the procedures were first developed, the stomach was reduced from its original capacity of more than a quart to five ounces. Currently, a twoounce capacity is most common; one-half ounce is not uncommon. See also BARIATRIC SURGERY.

stress and eating disorders

Some eating-disorder patients use their eating-disordered behaviors as a way to relieve stress or anxiety. A British study concluded that women with eating disorders are less effective in coping with stress than women without eating disorders are. The precise role stress plays in the development of eating disorders remains unclear, however. One theory is that biological changes within the body that occur during times of stress may promote the development of eating disorders. Another is that psychological changes accompanying life stresses may affect the response to such stresses. Stress may influence the development of eating disorders because of the effect it can have on various biochemical systems within the body, especially those that govern APPETITE. Changes may occur within the hypothalamic-pituitary-adrenal axis, within the endorphin system. Because the body is a complex system of biochemical processes, there may be changes in one or all of these systems as a result of stress. Therefore, the exact relationship between stress and eating disorders remains unknown. It is evident, however, that stress requires a response of some type from the organism. As Thomas P. Donohoe, of the University of Nottingham, England concludes, “Psychosocial stress may combine with dieting behavior to produce changes in hypothalamic function or other systems to generate or shape the symptoms of anorexia nervosa.” In 1986 Michael Rutter (professor of child and adolescent psychiatry, University of London, England) examined the work of Adolf Meyer (1866–1950; professor of psychiatry at the Johns Hopkins University; introduced the concept of psychobiology) to understand the role of life experiences as stressors and the effect they have on personality development. Although he acknowledged that certain negative life experiences could

stress and eating disorders 281 have such “an impact on psychological function . . . that in some circumstances they play a part in the genesis of psychiatric disorder,” he also acknowledged that perspective was an essential factor. Individuals respond in a variety of ways to life experiences, depending on their point of view and previous history. A particular life experience may be viewed as negative by one individual and positive by another. Some researchers suspect that it is this perspective on the life experience that actually determines the degree of stress involved. Physiologically, physical illness is more stressful for some individuals than for others and can play a role in the development of an eating disorder. For example, because of the many physical changes accompanying the aging process, older adults more often succumb to physical illness and may experience more stress from them than they would if they were younger. And following the Gulf War, the Washington, D.C. health commissioner announced that war-related anxiety had caused an increase in eating disorders, as well as drug and alcohol abuse. The stress of fear is also being studied for its effect on eating disorders. Research suggests that film-induced negative affect (exposure to a frightening film) may prompt overeating in persons who are attempting to restrict their caloric intake. In a University of Pittsburgh study, women with bulimic symptoms did not generally eat more when exposed to stress. However, both bulimic and control women increased their consumption of carbohydrates following the stressor. Schmidt et al. reanalyzed previously published data to examine differences between women whose eating disorder did or did not develop in response to stress. They concluded, “There are no differences between women whose eating disorder develops in response to stress and those who do not. Women presenting for treatment with anorexia nervosa of the binge-purge subtype are unlikely to have developed their illness in response to a severe provoking agent.” More recently, an Italian study assessed whether a stressful situation would reveal an association between perfectionism, low self-esteem, worry and body mass index (BMI) and measures of eating disorder symptoms in female high school students. “Low self-esteem, worry, and parental criticism (a dimension of perfectionism) were asso-

ciated with the measures of eating disorders only during the stressful situation, whereas concern over mistakes (another dimension of perfectionism) was associated in both stressful and nonstressful situations. The results suggest that in nonclinical female individuals, stress might bring out a previously absent association between some psychological predisposing factors for eating disorders and an actual desire or plan to lose weight. Such a finding suggests that stress may stimulate behaviors related to eating disorders in a predisposed personality.” Although the precise role of stress and DIETING in the development of eating disorders remains unknown, that they can be precipitating factors is not in doubt. Concerns about body image or physical changes affecting peer group approval can often be sources of stress. Social emphasis on thinness may also be accentuated in peer groups, regardless of age, encouraging further self-consciousness and dieting behaviors. Issues of social or financial independence may become chronic strains for older persons. Such stresses may promote dieting to regain a sense of control but may lead to the development of an eating disorder. Donohoe, T. P. “Stress-Induced Anorexia: Implications for Anorexia Nervosa.” Life Sciences 34, no. 3 (January 16, 1984): 203–218. Levine, M. D., and M. D. Morcus. “Eating Behavior Following Stress in Women with and without Bulimic Symptoms.” Annals of Behavioral Medicine 19, no. 2 (Spring 1997): 132–138. Rutter, M. “Meyerian Psychobiology, Personality Development, and the Role of Life Experiences.” American Journal of Psychiatry 143, no. 9 (1986): 1,077–1,087. Sassaroli, S., and G. M. Ruggiero. “The Role of Stress in the Association between Low Self-esteem, Perfectionism, Worry, and Eating Disorders.” International Journal of Eating Disorders 37, no. 2 (March 2005): 135–141. Schmidt, V. H., et al. “Events and the Onset of Eating Disorders: Correcting an Age-Old Myth.” International Journal of Eating Disorders 25, no. 1 (January 1999): 83–88. Schotte, David, Joseph Cools, and Richard McNally. “Film-Induced Negative Affect Triggers Overeating in Restrained Eaters.” Journal of Abnormal Psychology 99, no. 3 (August 1990): 317–320. Troop, N. A., and J. L. Treasure. “Psychosocial Factors in the Onset of Eating Disorders: Responses to Life

282 stress and weight gain Events and Difficulties.” British Journal of Medical Psychology 70, pt. 4 (December 1997): 373–385. Troop, N. A., et al. “Stress, Coping, and Crisis Support in Eating Disorders.” International Journal of Eating Disorders 24, no. 2 (September 1998): 157–166.

stress and weight gain Stress-related obesity is caused in large part by excess secretion of the hormone CORTISOL, which occurs under prolonged stress. Too much cortisol triggers cravings for highfat, high-sugar “comfort” foods. It also stimulates fat production, particularly in the abdomen. Epel et al. found that high levels of stress-induced cortisol are linked to excessive abdominal fat even in people who are not otherwise overweight. Stress is the most commonly reported trigger of binge-eating. However, a University of Pittsburgh Cancer Institute study partially contradicts this, suggesting that a major stressor, such as a child’s diagnosis of cancer, is associated with weight gain. In their comparison of 49 parents of healthy children and 49 parents of cancer patients, the parents of cancer patients were more likely to gain weight, and they experienced significantly greater weight gain over the three months than parents of healthy children. The parents of the cancer patients actually ate less in response to stress. They gained weight because their activity level decreased even more than their caloric intake decreased. Thus, it is not automatic that people eat more in response to stress or that they gain weight because they eat more. The authors concluded, “Further research is needed to determine how long these weight gains persist and whether other types of stress also produce weight gains. Such studies should focus not only on the effect of stress on eating behavior but also on physical activity.” Epel, Elissa S., et al. “Stress and Body Shape: Stressinduced Cortisol Secretion Is Consistently Greater among Women with Central Fat.” Psychosomatic Medicine 62, no. 5 (September–October 2000): 623–632. Smith, A. W., A. Baum, and R. R. Wing. “Stress and Weight Gain in Parents of Cancer Patients.” International Journal of Obesity 29, no. 2 (February 2005): 244–250.

subcutaneous fat

The layer of fat that lies just under the skin. This is the fat that forms a “spare tire” around the waist and can be easily pinched.

Subcutaneous fat is removed during LIPOSUCTION. The subcutaneous fat layer cushions the sensitive connective tissue layer of the skin from underlying tissues such as muscle and bones. It is also believed to act an insulation to conserve body heat. See also VISCERAL FAT.

sugar

A sweet-tasting simple CARBOHYDRATE containing carbon and hydrogen usually in the ratio of 1:2. The food known as sugar is refined from sugarcane, but sugars are found universally in plants and animal tissues. In 2003 Americans consumed an average 141.7 pounds of sugar from all sources; 61.7 pounds were from cane and sugar beet sugars and 79.2 pounds were from corn sweeteners. That compares to about 40 pounds total per person worldwide. Contrary to popular belief, there are no nutritional differences among sugars. The human body uses all types of sugars in the same way. Sugar is not the leading cause of obesity. Eating more calories than one uses is the basic problem, and for most people most excess calories come from FAT, not sugar. So concluded two studies in the American Journal of Clinical Nutrition, which found that lean people tend to eat more sugar and less fat than obese people. Not only does fat have more calories than sugar (about 36 versus 16 calories per teaspoon), but studies have also suggested that dietary fat may be more efficiently converted to body fat than carbohydrates (sugars) are. People often blame sugary foods for weight gain, forgetting that cakes, ice cream, chocolate and cookies derive most of their calories from fat, not sugar. Many a “sweet tooth” may actually be a “fat tooth.” Studies have failed to show that artificial sweeteners keep people from gaining weight, much less help them lose significant amounts. One problem is that instead of eating artificially sweetened foods in place of high-calorie ones, many people simply add them to their diet. Moreover, artificial sweeteners do not suppress appetite—they may even increase it. Some obesity experts argue that studies showing sugar not to lead to obesity have been funded by the sugar industry, and thus could be less than the final word. Waldholz writes, “Some are convinced that a major culprit for the obesity epidemic is the explosion of sugar in the foods we consume . . . with ‘added sugar’ often the largest

suicide 283 single ingredient in packaged foods and commercial beverages.” Sugar can lead to tooth decay; however, so can all forms of carbohydrates if decay-producing bacteria are also present. Between-meal sugary snacks play a bigger role in dental caries than sugar eaten during a meal, according to studies. Sugar is not a cause of diabetes. It—along with other simple carbohydrates, total caloric intake or stress—can contribute to a rise in blood glucose levels in persons who already have diabetes. The editors of HealthNews explain, Simple sugars are quickly converted to glucose, the form of sugar our cells use for energy. Consequently, eating a candy bar or other confection typically causes rapid, short-lived surges in both blood sugar and insulin, the hormone that allows glucose to penetrate cells. The body compensates for those sugar and insulin spikes by secreting hormones that counteract the effects of insulin and by ramping up processes that store sugar as fat. These compensatory efforts often cause blood sugar and insulin to plunge, producing fatigue and hunger.

See also

FRUCTOSE AS A CONTRIBUTOR TO OBESITY;

HIGH FRUCTOSE CORN SYRUP.

Editors, “Sugar’s Not-So-Sweet Revenge.” HealthNews, May 2003, p. 3. Waldholz, Michael. “Let’s Subtract ‘Added Sugar’ from Our Diets.” Wall Street Journal, February 20, 2003, p. D3.

suicide Suicide has been estimated to comprise half the deaths in anorexia. Suicidal behavior (attempts and threats) is common with bulimia; several researchers report that approximately onethird of their samples have attempted suicide. Others report lower but still significant rates. In one study of 142 bulimic women, researchers found that 49 percent of their sample had suicidal thoughts and 20 percent had attempted suicide. In an Italian study of 495 eating-disordered outpatients, 13 percent of the patients reported at least one suicide attempt and 29 percent reported current suicidal thoughts; 26 percent of attempters reported multiple attempts. A history of suicide attempt was more prevalent among binge-eating/purging anorexics and among purging bulimics than in the other subgroups. In patients with

anorexia nervosa, suicide attempters were older, had a longer illness duration, weighed less, had more often used drugs and/or alcohol and tended to be more obsessive than nonattempters. In patients with bulimia nervosa, attempters presented with more psychiatric symptoms and had more frequently been sexually abused. A French study to estimate the lifetime frequency of suicide attempts by eating-disordered patients and to compare demographic and clinical characteristics of those who had attempted suicide and those who had not assessed a total of 295 women (202 with bulimia nervosa purging type, 68 with bulimia nervosa nonpurging type, and 25 with anorexia nervosa binge-eating/purging type). Suicide attempts were frequent (27.8 percent of women), often serious and/or multiple. Women who had attempted suicide differed significantly from those who had not for earlier onset of psychopathology, higher severity of depressive and general symptoms and more impulsive disordered conducts, but not for the core symptoms or severity of bulimia nervosa. Two recent studies looked at indicators of potential suicidal behavior in eating-disorder patients. Researchers at the Harvard Eating Disorders Center interviewed women diagnosed with either DSM-IV anorexia nervosa or bulimia nervosa and assessed for suicide attempts and suicidal intent every six to 12 months over 8.6 years. Significantly more anorexic (22.1 percent) than bulimic subjects (10.9 percent) made a suicide attempt. The unique predictors of suicide attempts for anorexia nervosa included the severity of both depressive symptoms and drug use over the course of the study. For bulimia nervosa, a history of drug use disorder at intake and the use of laxatives during the study significantly predicted suicide attempts. In a study of 150 patients at an outpatient eating disorder clinic in Israel, 48 patients (32 percent) had a history of parasuicide (i.e., suicide attempts, self-injury, or both). A significantly greater percentage of parasuicidal patients than nonparasuicidal patients had eating disorders with bingeing/pursing symptomatology, used more than one type of purging method and had a lifetime history of a drug use disorder, impulse control problems and bipolar disorder, as well as a more extensive outpatient and inpatient treatment history.

284 sulpiride Corcos, M., et al. “Suicide Attempts in Women with Bulimia Nervosa: Frequency and Characteristics.” Acta Psychiatrica Scandinavica 106, no. 5 (November 2002): 381–386. Favaro, A., and P. Santonastaso. “Suicidality in Eating Disorders: Clinical and Psychological Correlates.” Acta Psychiatrica Scandinavica 95, no. 6 (June 1997): 508–514. Franko, D. L., et al. “What Predicts Suicide Attempts in Women with Eating Disorders?” Psychological Medicine 34, no. 5 (July 2004): 843–853. Stein, D., et al. “Attempted Suicide and Self-Injury in Patients Diagnosed with Eating Disorders.” Comprehensive Psychiatry 45, no. 6 (November 2004): 447–451.

sulpiride

An antipsychotic medication experimented with in treating anorexia. In a 1984 study there was a slight trend favoring the drug compared with a PLACEBO, but no statistically significant effect was demonstrated either on weight gain or on patient attitudes or behavior. Walsh and Devlin later wrote, “Placebo-controlled studies of the higher-potency antipsychotics pimozide and sulpiride provided little evidence of clinical utility.” Vandereycken, W. “Neuroleptics in the Short-Term Treatment of Anorexia Nervosa: A Double-blind PlaceboControlled Study with Sulpiride.” British Journal of Psychiatry 144 (1984). Walsh, B. Timothy, and Michael J. Devlin. “Psychopharmacology of Anorexia Nervosa, Bulimia Nervosa, and Binge Eating.” The American College of Neuropsychopharmacology. Available online. URL: http://www.acnp.org/ g4/gn401000153/ch149.html. Downloaded on April 21, 2005.

routines. Passing post boxes or street lamps had to be followed by jogging for one block.” As with superstitious behavior in general, the rituals are designed to avoid or mitigate either specific or, more often, obscure but ominous consequences. This behavior is so powerfully controlled by the belief in bizarre internal relationships and contingencies that it is hardly affected even by extremely punishing external consequences. Like other avoidance behavior, superstitious rituals are resistant to critical examination because the beliefs governing them insulate the believer from acknowledging contradictory information and experience. In a more recent study of 3,261 Finnish students by Aarnio and Lindeman, “The average person maintaining magical food and health (MFH) beliefs was a woman and a vegetarian, thought in a more intuitive way, demonstrated more eating-disordered thinking, relied more on alternative medicine, and to a smaller degree, had experienced more negative life events than the average nonbeliever. The believers reported their MFH beliefs to serve a value-expressive function more than any of the other functions. The second most important functions were those of control, utilitarianism, and self-esteem, while the social identity and defensive functions were reported less frequently.” Aarnio, Kia, and Marjaana Lindeman. “Magical Food and Health Beliefs: A Portrait of Believers and Functions of the Beliefs.” Appetite 43, no. 1 (August 2004): 65–74. Garner, David M., and Paul E. Garfinkel. Handbook of Psychotherapy for Anorexia Nervosa and Bulimia. New York: Guilford Press, 1985.

support groups

superobesity

See

EXTREME OBESITY.

superstitious (or magical) thinking

Thinking based on a belief that there is a cause-and-effect relationship between unrelated events, a belief common among anorexic patients, according to Garner and Garfinkel. They found that anorexics often assume that every last calisthenic in their exercise regimen must be completed or they will gain weight: “One patient developed an elaborate set of exercise rituals in which various situations required her to perform specific rigorous exercise

A term sometimes used interchangeably with SELF-HELP GROUPS. Generally, support groups are free of charge and members may enter or leave at any time. Support groups are considered an adjunct to therapy, not a substitute for professional treatment. They are useful for professional treatment. They are useful because they provide a social network, emotional support, self-help techniques and information.

surgery for obesity syndrome X

See

See

BARIATRIC SURGERY.

METABOLIC SYNDROME.

T combination of the four fundamental taste sensations: sweet, bitter, sour and salty. Both anorexic and bulimic women tested for perception or taste quality and intensity exhibited impaired sensitivity in estimating the magnitude of higher concentrations of all four different taste qualities, with bitter and sour tastes most severely affected. Bulimics’ cravings for sweets have been hypothesized as the outcome of an impaired sense of taste. One mechanism for this change in gustatory sensitivity may be the saliva, because saliva is important for taste perception and because endocrinological changes occurring in eating disorders influence the composition of saliva. No data, however, support this hypothesis. Results of testing by a Yale University research team headed by Judith Rodin provided evidence of a taste disturbance in bulimia nervosa, most likely caused by the acid in vomit damaging palate receptors. Rodin suggested that, because of this taste disturbance, bulimics may be less responsive to the taste of vomit as the disorder progresses, which could prolong its existence. Rodin stressed that this research does not reveal whether bulimics’ taste disturbances are consequences of, or predisposing factors to, bulimia nervosa, but she suspects they are the result of bulimia nervosa. Researchers at Rutgers University have found through several studies that people especially sensitive to a bitter compound called PROP, found in foods such as broccoli and brussels sprouts, tend to be thinner than others. Their studies have involved men, women and children, and all produced similar findings. Although some scientists are skeptical of any association between sensitivity to PROP and body size, researchers at Yale University and the University of Connecticut have produced results similar to those at Rutgers. An Associated Press arti-

tagatose

Also known as D-tagatose and Naturlose. A low-calorie sugar alternative determined to be a Generally Recognized As Safe (GRAS) substance in the United States by the FDA in late 2001, permitting its use in foods and beverages. Schardt describes tagatose as a “mirror-image form of sugar that’s manufactured from milk sugar (lactose).” Although the raw material for tagatose is lactose, the final product is 99.9 percent pure tagatose; thus, there is no lactose present in tagatose. According to Madley, “Tagatose is 90 percent as sweet as sucrose, has 1.5 calories per gram, does not cause cavities and it does not cause glucose spikes, which means that it can be used in diabetic foods because it controls blood glucose levels. Tagatose can be used in the production of nearly all foods that require sugar including bread, chocolates, hard candy, soft candy, chewing gum, soda, juices, cakes, ice cream and other general food products.” Schardt adds, “Unlike sugar, tagatose can’t be digested by enzymes in the intestines. Most passes through the body unabsorbed. Because tagatose isn’t well-absorbed, consuming large amounts can cause flatulence, rumbling noises, bloating, and nausea. Studies have raised no other safety concerns.” See also ARTIFICIAL SWEETENERS.

Madley, Rebecca H. “How Sweet It Is(n’t).” Nutraceuticals World. Available online. URL: http://www. nutraceuticalsworld.com/jan021.htm. Downloaded on April 22, 2005. Schardt, David. “Sweet Nothings: Not All Sweeteners Are Equal.” Nutrition Action Healthletter, May 1, 2004, 8–11.

taste The bodily sense that distinguishes flavors; it is dependent on sense organs located on the surface of the tongue. These organs, called taste buds, when appropriately stimulated, produce one or a 285

286 tax deductions cle reported, “Another scientist reported nearly four decades ago that people extremely sensitive to the bitter tastes of PROP tended to be lean, while nontasters were built like football players. Little further research was done until the 1990s. Now numerous studies are investigating the connection.”

being only various dimensions or continua (e.g., Meehl, 1992). The question has also been applied to the eating disorders and recent research suggests that there may be a taxon for bulimia nervosa. See also CONTINUITY/DISCONTINUITY MODELS OF EATING DISORDERS.

Jirik-Babb, P., and J. L. Katz. “Impairment of Taste Perception in Anorexia Nervosa and Bulimia.” International Journal of Eating Disorders 7 (1988): 353–360. Johnson, Linda A. “Sensitivity to Bitter Taste Linked to Lower-Weight.” Associated Press, October 28, 2004. Available online. URL: http://msnbc.msn.com/id/ 6355259. Keller, K. L., and B. J. Tepper. “Inherited Taste Sensitivity to 6-n-propylthiouracil in Diet and Body Weight in Children.” Obesity Research 12, no. 6 (June 2004): 904–912. Rodin, Judith, et al. “Bulimia and Taste: Possible Interactions.” Journal of Abnormal Psychology 99, no. 1 (February 1990): 32–39. Tepper, B. J., and N. V. Ullrich. “Influence of Genetic Taste Sensitivity to 6-n-propylthiouracil (PROP), Dietary Restraint and Disinhibition on Body Mass Index in Middle-Aged Women.” Physiology and Behavior 75, no. 3 (March 2002): 305–312.

Gleaves, D. H., M. R. Lowe, A. C. Snow, B. A. Green, and K. P. Murphy-Eberenz. “The Continuity and Discontinuity Models of Bulimia Nervosa: A Taxometric Investigation.” Journal of Abnormal Psychology 109, no. 1 (February 2000): 56–68. Meehl, P. E. “Factors and Taxa, Traits and Types, Differences of Degree and Differences in Kind.” Journal of Personality 60, no. 1 (March 1992): 117–174.

tax deductions

In 2000 the IRS began allowing the cost of weight-loss programs as a medical expense. However, the deduction does not include weight-loss programs followed only for the purpose of maintaining general good health. It must be “treatment for a specific disease (including obesity) diagnosed by a doctor.” Generally, allowable treatments include behavioral counseling, nutritional counseling, pharmacology and surgery. Also, even allowable weight-loss expenses would fall under the general medical expense requirement, meaning only those that exceed 7.5 percent of one’s adjusted gross income (AGI) would be deductible. Tax laws change every year, so the most current IRS guidelines need to be checked for any possible allowable deduction.

taxon A technical term for a latent class, type or discontinuity. The term relates to an ongoing debate in psychopathology and personality research regarding whether there are discrete classes or types of personality or psychological disorders versus there

tea

See

DIETER’S TEAS.

teenage obesity

See

ADOLESCENT OBESITY.

television and obesity With television watching the nation’s most time-consuming activity after sleeping and working, the role it plays in the development of health-related attitudes and behaviors is of growing interest. Studies of this powerful medium suggest that many health messages are conveyed to viewers but that the information is sometimes unrealistic, distorted and misleading, particularly regarding food, nutrition and obesity. William Feldman, medical professor at the University of Ottawa and author of a report in Pediatrics on children’s attitudes toward weight, blames television for most girls’ belief that they are fatter than they really are. On television shows during the prime evening viewing hours, he said, women in prestigious positions are typically thin. Ubiquitous television imagery delivers the message that thinness equates with beauty and the good life. Although many of these “lessons” to which Americans are regularly exposed promote misconceptions that may lead to unhealthy eating habits, television’s primary offense may be simply its very existence, which has profoundly altered American leisure. When the TV is on, activity ceases; time spent exercising is reduced significantly. The heart and other muscles are not strengthened, and CALORIES are not expended beyond the resting METABOLISM level during television viewing.

therapy 287 When Larry A. Tucker (then of Auburn University in Alabama) examined the relation between television viewing and physical fitness, he found that, among 379 high school males, as TV watching increased, multiple measures of physical fitness decreased markedly and systematically. Similarly, other researchers have shown that as TV viewing increases among children, obesity increases substantially. Tucker and Glenn M. Friedman measured the extent of the association between TV viewing and obesity among adult males. Study subjects were 6,138 adult male employees of more than 50 different companies. Those who viewed TV more than three hours a day were twice as likely to be obese as those who viewed less than one hour per day. In a sample of 78 undergraduate students (64 females, 14 males), the participants ate more often on days when they ate with the television on— almost one additional meal (3.53 versus 2.76 meals). Although the meals with TV on were smaller, the net effect was an increase in calories when eating with the television on. Tucker and Friedman caution that with the growth of cable television, home video recording and video games, television viewing is likely to increase in the coming years. The findings of their study and other recent research show that the impact of television on fitness and health (especially obesity) cannot be ignored. When William Dietz, head of nutrition at the Centers for Disease Control and Prevention (CDC), spoke at an American Medical Association conference, he warned that television also affects children’s eating behaviors: “The more children watch television, the more they tend to consume what’s advertised on television, and the more they tend to consume foods while watching television.” A policy profile prepared by Prevention Institute for the Center for Health Improvement confirms this: “Studies on the behavioral effects of advertising find that television has a major effect on the products children ask for and that increased television watching leads to increased requests for advertised products. In addition, television advertising creates misperceptions among children about the nutritional values of foods and how to maintain positive health. Health experts believe that

constant promotion of high-calorie food is contributing to the epidemic of childhood obesity in the United States by encouraging preferences for junk food and contributing to poor eating habits.” Prevention Institute. “Restricting Television Advertising to Children.” Available online. URL: http://www. preventioninstitute.org/CHI_food_advertising.html. Downloaded on April 22, 2005. Stroebele, Nanette, and John M. de Castro. “Television Viewing Is Associated with an Increase in Meal Frequency in Humans.” Appetite 42, no. 1 (February 2004): 111–113. Tucker, Larry A. “The Relationship of Television Viewing to Physical Fitness and Obesity.” Adolescence 21, no. 84 (winter 1986): 797–806. Tucker, Larry A., and Friedman, Glenn M. “Television Viewing and Obesity in Adult Males.” American Journal of Public Health 79, no. 4 (April 1989): 516–518.

Tenuate A prescription only appetite suppressant chemically related to amphetamine. Its active ingredient is diethylpropion. When used in a program that includes a low-fat diet and regular exercise, it can increase the diet/exercise weight loss by an additional 10 percent. On average, patients lose about 15 pounds over three months. Possible side effects of Tenuate include nervousness, insomnia, irritability, sweating, tension, dry mouth, nausea, constipation and headaches. Because Tenuate is highly addictive, it is not recommended for individuals with a history of drug dependency or abuse, and is prescribed for a maximum of several weeks. therapy

Any treatment designed to mitigate of eliminate disease or disorder, physical or psychological. Among the therapies often used in treating eating-disordered persons are individual PSYCHOTHERAPY, FAMILY THERAPY, GROUP THERAPY and various physical treatments. Which type of therapy or combination of therapies to use depends upon the age, needs and living situation of the person seeking treatment. In individual psychotherapy, patients meet with therapists alone, usually at least once a week for 45 minutes to an hour at a time. Patients in therapy work to understand the role that eating or PURGING has served in their lives and to find replacements for destructive behaviors while developing healthier coping mechanisms.

288 thermodynamic approach to obesity In family therapy, sessions include not just eating-disordered persons but members of their families. These may include parents and siblings, spouses and even grandparents or other relatives. In family therapy, the eating disorder is seen as a “red flag,” signaling that whole families are troubled, not just the persons with the eating disorders. A therapy group usually consists of five to 12 people who meet with a therapist weekly. The group therapy approach is particularly helpful in countering feelings of isolation, of being all alone with the problem. Groups can provide feedback and support for those attempting to change their eating patterns. They are also safe places for members to learn new ways of relating, to express feelings and to develop trusting relationships of the kind whose absence led in the first place to their self-destructive relationship to food.

thermodynamic approach to obesity

From this perspective, obesity is understood in terms of energy balance. Since the law of conservation of energy must be preserved, obesity is the outcome of energy (food) intake in excess of energy (heat) output. HILDE BRUCH described this as a limited approach because it does not consider the underlying reasons for this disturbed energy balance, such as possible endocrine and biochemical factors. The reasons for variations in energy needs, and the underlying mechanisms, remain a matter of controversy.

thermogenic drugs

Drugs that enhance resting metabolic activity. These compounds increase energy expenditure, which is important because weight loss is associated with metabolic readjustment to reduce energy output (see OBESITY). Thus, metabolic enhancers ensure that energy expenditure is maintained when food intake is reduced. See also ANTIOBESITY DRUGS; SIBUTRAMINE.

thin fat people

A term used by HILDE BRUCH to describe obese people who succeed in becoming and staying thin but whose problems are far from solved by having lost weight. On the contrary, their difficulties now have a chance to flourish, since obesity no longer prevents them from putting their unrealistic dreams to the test. She was referring to

those people who blame all their difficulties on being fat and who hope that their lives will change when they get thin. Such people, though no longer obese, are far from transformed. The term was originated by Heckel, who stated in 1911 that a fat person cannot be considered cured even though he has lost weight, unless all other symptoms of dysfunction have also disappeared. Heckel, P. Les grandes et petites obésités. Paris: Mason et Cie, 1911.

thrifty genes Vestiges from times when food was scarce, and those who ate more and stored fat most efficiently survived. As the National Institutes of Health Obesity Research Force explained, “An interesting view that has been expressed regarding the genetic basis for more common forms of obesity is the ‘thrifty gene hypothesis.’ That is, it is thought that because our ancestors lived in environments with more risk of starvation from famine, and greater need for physical exertion to survive, a genetic predisposition to efficient storing of fat (and hence, energy) was actually advantageous. In a current environment in which calorierich food is plentiful and life can be more sedentary, the ability to accumulate fat efficiently is no longer beneficial.” Italian researchers investigating the effect of fat mass reduction on adipose tissue gene expression following BILIOPANCREATIC DIVERSION surgery concluded, “The degree of fat mass loss seems to interfere with SREBP-1c gene suppression to preserve an adequate amount of fat storage, in accordance with the thrifty genotype hypothesis.” Cummings et al. offer “a speculative model of ghrelin as a thrifty gene product that evolved to help animals consume and store fat well, thereby increasing their chances of survival during times of famine. We suggest that ghrelin is a ‘saginary’ hormone, from the Latin, saginare, which means, ‘to fatten.’ ” See also GHRELIN. Cummings, D. E., K. E. Foster-Schubert, and J. Overduin. “Ghrelin and Energy Balance: Focus on Current Controversies.” Current Drug Targets 6, no. 2 (March 2005): 153–169.

TOPS (Take Off Pounds Sensibly) 289 Gniuli, D., et al. “Changes in Fat Mass Influence SREBP1c and UCP-2 Gene Expression in Formerly Obese Subjects.” Obesity Research 13, no. 3 (March 2005): 567–573. NIH Obesity Research Task Force. Strategic Plan For NIH Obesity Research. U.S. Department of Health and Human Services, National Institutes of Health, NIH Publication No. 04-5493, August 2004.

thymoleptic medications

Medications effective in the treatment of major DEPRESSION or bipolar disorder; ANTIDEPRESSANTS. These have been used in treating bulimia on the theory that it may be closely related to major affective disorder—the family of psychiatric illnesses that includes depression and manic-depressive illness.

thyroid disease (hypothyroidism) A deficiency of thyroid gland activity, resulting in underproduction of the hormone thyroxine. Among its consequences are a lowered BASAL METABOLIC RATE and weight gain. Probably nothing has been blamed more often as the cause of obesity than hypothyroidism, but studies show that thyroid function in obese people is usually within normal limits. Thyroid disease is not diagnosed unless there is strong laboratory evidence of reduced thyroid function accompanied by findings of classic physical symptoms and a medical history that includes a long-standing goiter, thyroiditis or thyroid surgery. Weight gain develops insidiously rather than suddenly. Associated features include some coarsening of scalp hair, dryness of skin, yellowing of palms, generalized obesity, some thinning of the eyebrows and sluggish and delayed reflexes. Hypothyroid patients frequently complain of constipation. Menstrual periods are usually characterized by excessive bleeding; a history of dysfunctional bleeding may be the earliest clue to thyroid disease. In cases in which thyroid disease is the true cause of obesity, weight control is achieved in over 90 percent of these cases through treatment with thyroxine (see THYROID HORMONE). thyroid hormone (thyroxine) Prescribed for patients suffering from hypothyroidism (see THYROID DISEASE), whose thyroid glands produce it in insuffi-

cient amounts; it raises the basal metabolic rate (see METABOLISM), causing more calories to be burned. It is also the metabolic medication most commonly prescribed and marketed as a weight reduction agent, even to people whose thyroid glands are in good working order. But for overweight people without thyroid disease, thyroxine is of no value. Thyroid hormones are especially dangerous for people with heart disease. According to some authors, use of this hormone increases breakdown of muscle protein rather than fat. In addition, the body quickly adapts to the administration of extra thyroid hormone by reducing its natural production of this hormone, thus returning metabolism to its normal rate. Excess thyroid hormone causes anxiety, irritability, sweating, rapid heartbeat and other possible side effects. Bruna and Fogteloo add, “Many well-known compounds (thyroxine, caffeine or ephedrine) do in fact increase the total energy expenditure but are not acceptable as prescription drugs because of their (mainly cardiac) side-effects or addictive properties.” Bruna, Tijs, and Jaap Fogteloo. “Drug Treatments.” In Handbook of Eating Disorders, 2nd Ed., edited by Janet Treasure, Ulrike Schmidt, and Eric van Furth, 311–323. West Sussex, U.K.: John Wiley & Sons Ltd., 2003.

TOPS (Take Off Pounds Sensibly) A nonprofit support organization for overweight people founded in 1948 that incorporates some of the principles of behavior therapy into its program. There are almost 300,000 members in nearly 12,000 chapters throughout the United States, Canada and numerous other countries. It is patterned after Alcoholics Anonymous and employs group dynamics, competition and recognition (for those who have achieved greatest weight loss) to aid the overweight. There are weekly meetings with weigh-ins; programs vary, but all in some way provide members with motivation and reinforcement. TOPS is medically oriented and asks members to obtain their individual weight goals and dietary regimens from their personal physicians. The organization has had an active research program for several years, headquartered at the Medical College of Wisconsin in Milwaukee. Areas of study have included the relative importance of heredity and environment in the development of obesity, psychosocial

290 total parenteral nutrition differences between those successful and those unsuccessful in losing weight, the effect of obesity on pregnancy and the relationship of overweight to infertility and various diseases. See also APPENDIX III.

total parenteral nutrition (TPN)

See

HYPERALI-

MENTATION.

Traffic Light Diet

A simplified diet developed for children. It divides food into three colors, like those in traffic lights: green, yellow and red. Epstein et al. explain that it is used particularly for preschool and preadolescent children. “The traffic-light diet is a structured eating plan (900 to 1,300 kcal) used to guide participants’ eating patterns to meet age recommendations of the basic four food groups, and now the food pyramid, thereby increasing the nutrient density of the diet. The traffic-light diet groups foods into categories: green foods (go) may be consumed in unlimited quantities; yellow foods (caution) have average nutritional value for the foods within their food group; and red foods (stop) provide less nutrient density per calorie because of high fat or simple carbohydrate content.” See also CHILDHOOD OBESITY.

Epstein, Leonard H., et al. “Treatment of Pediatric Obesity.” Pediatrics 101, no. 3, pt. 2 (March 1998): 554–570.

trans fat Common term for trans fatty acids. Unlike other fats, the majority of trans fat is formed when liquid oils are made into solid fats like shortening and hard margarine. However, a small amount of trans fat is found naturally, primarily in some animal-based foods. Essentially, trans fat is made when hydrogen is added to vegetable oil, a process called hydrogenation. Hydrogenation increases the shelf life and flavor stability of foods containing these fats. Trans fat, like saturated fat and dietary cholesterol, raises the LDL (or “bad”) cholesterol that increases one’s risk for CHD (coronary heart disease). Trans fat can often be found in processed foods made with partially hydrogenated vegetable oils such as vegetable shortenings, some margarines (especially mar-

garines that are harder), crackers, candies, cookies, snack foods, fried foods and baked goods. The Food and Drug Administration (FDA) now requires food manufacturers to list trans fat on Nutrition Facts and some Supplement Facts panels on food labels. The FDA has created a Web site with helpful background on trans fat and how to use the new labeling to plan a healthful diet; it can be seen at http://www.cfsan.fda.gov/~dms/transfat.html.

trichophagia

The (compulsive) habit of eating hair or wool, considered to be a variant of PICA. It also could be considered a perilous disorder, as trichobezoars (hairballs) can form and obstruction of the bowel may occur, requiring surgical intervention.

tube feeding

Forced feeding through a nasogastric tube is a method sometimes used to supplement nutrition and replace body fluids in anorexic patients. Authors such as Paul Garfinkel and David Garner have advised limited use of tube feeding while noting several disadvantages: It represents a direct intrusion into the gastrointestinal tract of someone who is already preoccupied with (and misguided about) bodily functions; it may be perceived as an assault or act of hostility that will only serve to confirm the patient’s sense of her own worthlessness; it is done with minimal patient cooperation and may lead to increased mistrust; and the physiological side effects are not insignificant. At REMUDA RANCH, Zuercher et al. reviewed the cases of 381 female anorexia nervosa inpatients, with 155 receiving tube feeding and oral refeeding, and 226 receiving oral refeeding alone. “When severityof-illness and caloric intake differences between patients with and without tube feeding were controlled, patients who received tube feeding gained significantly more weight per treatment week than those who received oral kilocalories alone. Patients who received tube feeding for at least one-half their length of stay gained 1 kg/week versus 0.77 kg/week for patients receiving oral refeeding alone. Tube-fed patients evidenced no differences in recovery from anorexia’s psychological aspects, satisfaction with treatment, or medical complication frequency.” Zuercher, J. L., et al. “Efficacy of Voluntary Nasogastric Tube Feeding in Female Inpatients with Anorexia

twin studies and eating disorders 291 Nervosa.” Journal of Parenteral and Enteral Nutrition 27, no. 4 (July–August 2003): 268–276.

tummy tuck

The commonly used name for an

ABDOMINOPLASTY.

twin studies and eating disorders Data from studies of twins in the past decade have begun to suggest that heritable factors make a significant contribution to the risk of developing eating disorders. In twin studies, researchers compare the frequency with which both members of the twin pair have the same disorder or the trait of interest, then compare those frequency rates in identical and fraternal twins. In their review, Bulik et al. concluded, “Twin studies confirm that bulimia nervosa

is familial and reveal significant contributions of additive genetic effects and of unique environmental factors in liability to bulimia nervosa.” Because of small sample sizes, estimates obtained from twin studies of anorexia nervosa are not considered as reliable as those from bulimia nervosa. Walsh explains, “The substantially higher incidence of bulimia makes the analysis of twin data for this disorder more powerful.” See also GENETIC FACTORS IN EATING DISORDERS. Bulik, Cynthia M., et al. “Twin Studies of Eating Disorders: A Review.” International Journal of Eating Disorders 27, no. 1 (January 2000): 1–20. Walsh, B. Timothy. “The Future of Research on Eating Disorders.” Appetite 42, no. 1 (February 2004): 5–10.

V than 800 calories per day. These diets can result in serious side effects, the most common of which are inability to tolerate cold, dizziness, diarrhea, constipation, dry skin, hair loss and gout. Mood changes ranging from elation to DEPRESSION may occur, and acute psychosis has been reported. Most VLCDs are not tailored for individual needs. Fatter people, for instance, can tolerate more drastic cuts in calorie consumption than less obese individuals. The best VLCDs are closely supervised and monitored by physicians, behavioral psychologists and dietitians. VLCDs have been recommended as viable treatment for people whose obesity puts them at risk for such problems as diabetes, hypertension and heart disease (BODY MASS INDEX [BMI] greater than 30). VLCDs are accomplished by consuming powdered protein mixes available by prescription only. According to the University of California Berkeley Wellness Letter, they contain 33 to 75 grams of eggor milk-derived protein, varying amounts of carbohydrate and RDA (recommended daily allowance) levels of most other nutrients. The formulas, mixed with liquid, are taken three to five times a day at meal and snack times. Usually nothing else other than water is allowed; a few programs do allow raw vegetables. In addition to the formula, patients receive regular electrocardiograms and blood and urine tests and regularly visit their doctors. This regimen is augmented by required exercise, nutrition education and participation in support groups. These programs can cost more than $2,000 including weigh-ins and clinic visits and usually last three months, followed by a gradual “refeeding” phase. Some include a maintenance phase of up to 18 months devoted to educating patients in long-term weight-management techniques. For persons with medically significant obesity, a very

vegetarian diet and eating disorders

A University of Minnesota study raised the concern that teen vegetarians are more likely to have eating disorders than nonvegetarians. The study, which surveyed nearly 5,000 middle school and high school students, found that adolescent vegetarians were more weight- and body-conscious, more likely to have been told by a doctor that they had an eating disorder and more likely to have tried a variety of healthy and unhealthy weight control practices, including diet pills, laxatives and vomiting. The authors concluded that vegetarianism among adolescents may be a signal for preventive intervention.

Perry, Cheryl L., et al. “Characteristics of Vegetarian Adolescents in a Multiethnic Urban Population.” Journal of Adolescent Health 29, no. 6 (December 2001): 406–416.

vertical banded gastroplasty (VBG) A restrictive operation (see GASTRIC RESTRICTION PROCEDURES) for weight control that was more popular in the 1980s, but is being replaced by ADJUSTABLE GASTRIC BANDING (AGB). In VBG procedures, both a band and staples are used to create a small stomach pouch. Risks of VBG include wearing away of the band and breakdown of the staple line. In a small number of cases, stomach juices may leak into the abdomen, requiring an emergency operation. In less than 1 percent of all cases, infection or death from complications may occur. One study showed that patients with vertical banded gastroplasty maintained a loss of 40 percent of their excess weight for three years after surgery. A five-year follow-up showed equally satisfactory results. very low-calorie diet (VLCD) A program for achieving rapid weight loss through eating fewer 293

294 vibrator belts low calorie diet yields an average weight loss of greater than 44 pounds and a significant reduction in health risks in 12 weeks. One argument against the formula VLCD is that it teaches reliance on patented products, not on sound, lifelong eating habits. The permanency of the results of VLCDs is not dissimilar to that of other types of diet. A San Diego State University study found that while people who actually completed a VLCD program (45 percent of those enrolled) lost an average of 84 percent of their excess weight, they regained 59 to 82 percent of it within 30 months. Although intensive BEHAVIOR THERAPY MODIFICATION can help reduce the dropout rate to one-third, three-year follow-up checks show that by then 40 percent of patients have regained all their excess weight. Those who do not return for retreatment gain back, on average, all but 10 pounds of the weight they’ve lost. A three-year study reported in 1986 compared long-term results after a low calorie diet, a conventional 1,200-calorie diet plus behavior modification and a very low calorie diet plus behavior modification. In the initial therapeutic phase, patients lost an average of 31.1, 31.5 and 42.6 pounds respectively. Three years later, average weight had returned to within 8.4, 10.6 and 14.3 pounds of prediet weights. In a 54-month trial of the Optifast program, men initially lost an average of 22 percent of their original weight, and women lost 18.8 percent. But at the programs end, the average maintained loss of both men and women was only 4.3 percent of their original weight. Assessing VLCD Programs According to the American College of Healthcare Executives, an adequate obesity treatment program that uses a very low calorie diet must include: • Mandatory medical supervision provided by a multidisciplinary team of well-trained health care professionals (physicians, dietitians, nurses, behaviorists and exercise physiologists). Training of professional staff is critical to the success of an obesity treatment program. • A high-quality nutritional beverage with adequate protein and calories and with an appropri-

ate nutrient composition. The dietary beverage should have a high nutritional profile, meeting the protein recommendation of 1.5 grams of protein per kilogram (2.2046 pounds) of ideal body weight. Studies show that at this protein level, lean body mass is preserved and subjects quickly attain nitrogen balance. Lower protein levels are not adequate for the calorie deficit of the modified fasting state, and the addition of CARBOHYDRATE is not an equivalent protein-sparing replacement for protein. Some products are nutritionally incomplete, requiring vitamin and mineral supplementation in addition to the beverage. This can place patients who neglect to take their supplements at nutritional risk. • A comprehensive educational program that emphasizes behavior change and long-term weight maintenance. Without doubt, it is the comprehensive educational program, in conjunction with the diet, that determines long-term weight maintenance. The components of a comprehensive program include nutrition education, behavior modification (e.g., planned behavior change and cognitive restructuring) and EXERCISE. Very little information exists regarding the use of VLCDs in older people. Because people over age 50 already experience normal depletion of lean body mass, use of VLCD may not be warranted. Also, people over 50 may not tolerate the side effects associated with VLCDs because of preexisting medical conditions or need for other medications. See also DIETING; LIQUID FORMULAS; PROTEINSPARING MODIFIED FAST. “Very-Low-Calorie Diets.” NIH Publication 03-3894, January 2003. Wadden, Thomas A., Theodore B. Van Itallie, and George L. Blackburn. “Responsible and Irresponsible Use of Very-Low-Calorie Diets in the Treatment of Obesity.” JAMA: Journal of the American Medical Association 263, no. 1 (January 5, 1990): 83–85. Walsh, Michael F., and Thomas J. Flynn. “A 54-Month Evaluation of a Popular Very Low Calorie Diet Program.” Journal of Family Practice 41, no. 3 (September 1995): 231–236.

vibrator belts

Gadgets sold as a means of eliminating localized fat deposits, based on the premise

vomiting 295 that localized stimulation breaks down fat cells, releasing fat stores into the bloodstream so that they can be effectively eliminated from the body. The localized vibration also stimulates blood circulation in the treated area, thus purportedly enhancing the transport of released fat. There is no scientific evidence to support this concept. See also FRAUDULENT PRODUCTS; NOVELTIES FOR WEIGHT LOSS.

visceral fat Intra-abdominal fat; it increases the risk for diabetes and cardiovascular disease and can raise insulin levels, which promotes the growth of cancer cells. People who have high levels of intraabdominal fat may not even know it because it is hidden, deposited around organs within the abdomen. Visceral fat is what women tend to store after menopause. The only accurate way to determine the presence of intra-abdominal fat is with imaging procedures such as CT or MRI scans. Little data exists on intra-abdominal obesity because these procedures are so costly. Waist circumference is commonly used as a surrogate measure for abdominal visceral fat. One observational study showed significant decreases in visceral fat with a mean weight loss of 28.4 pounds. A Yale University School of Medicine study showed that regular exercise alone, especially brisk walking, can reduce visceral fat. See also SUBCUTANEOUS FAT. Irwin, M. L. “Effect of Exercise on Total and IntraAbdominal Body Fat in Postmenopausal Women: A Randomized Controlled Trial.” Journal of the American Medical Association 289, no. 3 (January 15, 2003): 323–330.

vitamin deficiency

An insufficiency of vitamins in the diet, a form of malnutrition that can result from malabsorption of fat by the intestines of bulimics (caused by abuse of laxatives) or from self-starvation by anorexics. Vitamin deficiency can also result from taking drugs that have side effects of reducing absorption of vitamins in the intestines. When physicians prescribe these drugs, they will frequently also prescribe vitamin supplements to correct the situation. A high-protein, low fat diet can also cause depletion of vitamin A and vitamin D reserves.

A Southern Illinois University School of Medicine study found that vitamin D levels were 57 percent lower in obese adults than in lean individuals due to the vitamin D getting trapped in fat. Wortsman, Jacobo, et al. “Decreased Bioavailability of Vitamin D in Obesity.” American Journal of Clinical Nutrition 72, no. 3 (September 2000): 690–693.

vocational bulimics Some of the best-known bulimics are those who started PURGING because thinness is important to them vocationally. In this category are models, actresses, athletes and dancers who use VOMITING or laxatives (see LAXATIVE ABUSE) as a means of weight control and become dependent on it. Vocational bulimics present a special obstacle to treatment, because it would be unreasonable to try to convince a dancer, for instance, that she does not have to weigh 90 pounds if that is the current standard for dancers. See also ATHLETES; BALLET DANCERS. vomiting

Forcible ejection of contents of the stomach through the mouth. Self-induced vomiting is the most dramatic, quickest and most common method employed by eating disordered individual who think they can eliminate unwanted CALORIES before the calories “take effect.” But research has actually demonstrated that a sizable proportion of calories are absorbed even when vomiting occurs almost immediately after eating. It also provides instant relief for the painfully overstuffed stomachs of bulimics. Vomiting can also be “justified” as a means of getting rid of what is regarded as protrusion of the stomach. To induce vomiting, many patients use “starters” such as Q-tips; they are effective and have been described as less “disgusting” than fingers. Drinking large amounts of liquids makes the vomiting easier. Eventually, most patients can vomit at will. Patients have reported self-induced vomiting as frequently as 18 times a day or more. Vomiting has led to severe tearing and bleeding in and around the esophagus, hiatal hernias and severely infected salivary glands, not to mention serious electrolyte disturbances. Also, there may be a loss of control over the vomit reflex as a consequence. That is, some

296 vomiting severe patients get to the point that they vomit spontaneously even when they don’t want to. According to Neuman and Halvorson, there is a subgroup of anorexics consisting of individuals who resort to vomiting regardless of whether they also restrict their food intake or binge. Other authors have theorized that vomiting may be the driving force in bulimia nervosa rather than BINGE-EATING. They feel that binge-eating might not occur if the person could not vomit afterward, citing cases in which once bulimic individuals begin to vomit, they binge-eat more frequently. These patients also discover that it is easier to vomit after eating a lot and therefore prolong their binges. Some patients report that the only reason they binge-eat is to make it physically easier to vomit. Repeated vomiting leads to physical complications from hypokalemic/hypochloremic alkalosis, as described by Downs et al. “Low levels of potassium can lead to fatigue, generalized muscle weak-

ness, seizures, heart arrhythmias, and kidney damage. Abnormalities in sodium may lead to convulsions, particularly in individuals who consume large quantities of alcohol in their binges. Death from aspirated vomitus can occur; and there may be fractures. Vomiting leads to gastric and esophageal irritation and bleeding, and some may develop hiatus hernia with abdominal pain. Repeated vomiting may cause esophageal or gastric dilatation and can result in a fatal rupture. Large binges may produce pancreatic dysfunction, leading to pancreatitis, and there may be immune system compromise.” Downs, Susan, with Charmian Lewis. “Psychiatry.” In Nausea and Vomiting: Overview, Challenges, Practical Treatments and New Perspectives, edited by Richard H. Blum, W. LeRoy Heinrichs, and Andrew Herxheimer, 475–485. London: Whurr Publishers, Ltd., 2000. Neuman, Patricia A., and Halvorson, Patricia A. Anorexia Nervosa and Bulimia. New York: Van Nostrand Reinhold, 1983.

W metabolize stored fat into usable energy for the body. As a result, it metabolizes less fat and more fat remains stored in the body; weight loss stops. A small German study found that drinking water boosts the metabolic rate by 30 percent for about an hour. The researchers estimate that drinking an extra 34 ounces a day would burn about 17,400 calories a year, leading to a possible loss of about five pounds. However, experts warn that people already drinking a lot of water who add additional water consumption risk reaching an electrolyte imbalance. Nutritionists caution that there is no evidence that water curbs APPETITE. A director of science at the Pritikin Longevity Center has been quoted in newspaper articles as saying the body is engineered to get water through food—in soups, fruits and vegetables, which are almost all water; whereas water that is drunk goes right through the body, into the stomach and then out. Along that same line, others have suggested that because so much of the body’s daily water intake comes from food, feeling hungry may be a signal that the body needs more water.

waist-to-hip ratio (WHR)

A comparison of waist and hip circumferences, which is an indicator of the amount of fat a person carries and the proportion of intra-abdominal fat (see VISCERAL FAT). People with a higher ratio are at increased risk of developing diseases associated with overweight. To determine one’s waist-to-hip ratio, a measuring tape is used to measure the circumference of the hips at the widest part of the buttocks. Then the waist is measured at the smaller circumference of the natural waist, usually just above the belly button. The waist measurement is then divided by the hip measurement. For example, a woman with a waist measurement of 30 inches and a hip measurement of 40 inches would have a waist-to-hip ratio of 0.75. Generally, men with a waist-to-hip ratio of greater than 1.0 and women with a ratio greater than 0.8 are considered to have an excess accumulation of fat in their abdomens. In one study, women with a ratio greater than 0.76 had twice the risk of developing coronary disease than those whose ratio was 0.75 or lower.

Rexrode, Kathryn M., et al. “Abdominal Adiposity and Coronary Heart Disease in Women.” Journal of the American Medical Association 280, no. 21 (December 2, 1998): 1,843–1,848.

weekend calories Analyzing data from the nationally representative Continuing Survey of Food Intakes by Individuals, a University of North Carolina study found that the average American older than two years of age consumes 82 extra calories per day on each weekend day (Friday through Sunday) than on weekdays (Monday through Thursday). Further, for the 19- to 50-yearold age group, the weekend day increase (vs. weekday) is 115 calories per day. The increased proportions of energy from fat and alcohol consumed on weekends are greater for this adult age group by 0.7 percent and 1.4 percent, respectively, whereas the proportion of energy from carbohy-

water According to Donald S. Robertson, a bariatric physician and author of The Snowbird Diet (Warner Books, 1986), drinking at least 64 ounces of water a day can actually cause fat deposits to decrease. He explains that when the kidneys do not receive enough water, they do not function properly, resulting in some of their workload transferring to the liver. When the liver then performs some of the kidney’s work, the liver cannot effectively perform one of its primary functions: to 297

298 weight phobia drates decreases 1.6 percent. The authors stated, “The effects of weekend days on nutrient intake are substantial and should be considered in future clinical and population-based interventions and in dietary monitoring and research in the U.S.” Haines, Pamela S., Mary Y. Hama, David K. Guilkey, and Barry M. Popkin. “Weekend Eating in the United States Is Linked with Greater Energy, Fat, and Alcohol Intake.” Obesity Research 11, no. 8 (August 2003): 945–949.

weight phobia Fear of gaining weight. A term coined by Arthur H. Crisp to describe the anorexic’s attitude toward being of a normal body weight. Some authors have questioned whether or not weight phobia should be considered a central part of anorexia. Hsu and Lee, for example, write, “Several reviews of the history of anorexia nervosa have concluded that weight phobia, a basic diagnostic criterion for the disorder, did not emerge as a predominant motive for food refusal until around 1930. In addition, investigators have reported cases of self-starvation without apparent weight phobia in non-Western cultures. Three explanations have been proposed for these findings: 1) patients who do not demonstrate a definite weight phobia are in fact suffering from an eating disorder not otherwise specified, 2) weight phobia has been overlooked or concealed, and 3) there has been a transformation in the content of anorexia nervosa in the West and an analogous situation may be occurring in the developing countries.” Crisp, Arthur H. “Diagnosis and Outcome of Anorexia Nervosa: The St. George’s View.” Proceedings of the Royal Society of Medicine 70, no. 7 (1977). Hsu, L. George, and Sing Lee. “Is Weight Phobia Always Necessary for a Diagnosis of Anorexia Nervosa?” American Journal of Psychiatry 150, no. 10 (October 1993): 1,466–1,471.

Weight Watchers

A commercial corporation that markets a line of packaged, reduced-calorie “diet” foods, meant to be used according to a companysponsored diet and BEHAVIOR MODIFICATION plan. Weight Watchers also sponsors fee-collecting support groups. The company was purchased in 1978

by H. J. Heinz, which took control of both the diet program and a prepackaged food line. In 1999 it was acquired by a European investment firm. In their review of weight loss programs, Witherspoon and Rosenzweig wrote: “The benefits of the Weight Watchers program are its accessibility, group support, emphasis on making good choices using standard foods, incorporation of physical activity, and relatively inexpensive upfront fee to join. The limitations are the cost of weekly meetings, the group perceived as intimidation, and the potential for disordered eating using the food point system.” In their review of self-help weight control programs. Tsai et al. wrote, “Among nonmedical programs, Weight Watchers is the only one that has sponsored a randomized trial. Participants in their largest study lost 5.3 percent of initial weight at 12 months and maintained a loss of 3.2 percent at two years.” According to these authors, “Weight Watchers costs approximately $167 for 12 weeks. This includes a $35 membership fee and a $12 weekly fee, pay-as-you-go.” Tsai, Adam Gilden, et al. “Commercial and Self-Help Programs for Weight Control.” Psychiatric Clinics of North America 28, no. 1 (March 2005): 171–192. Witherspoon, Barbara, and Margaret Rosenzweig. “Industry-Sponsored Weight Loss Programs: Description, Cost, and Effectiveness.” Journal of the American Academy of Nurse Practitioners 16, no. 5 (May 2004): 198–205.

wound healing Wound healing can present special problems for obese patients. High risk factors include infection, swelling and incision ruptures. Charlebois and Wilmoth explain, “The skin of persons who are obese is at high risk for breakdown and delayed wound healing. Persons with obesity have many intertriginous folds (opposing skin surfaces touching) that become moist and harbor bacteria and yeast. Because of the poor vascular supply to adipose tissue, these skin folds are prone to breakdown and can quickly ulcerate.” Charlebois, Donna, and Debbie Wilmoth. “Critical Care of Patients with Obesity.” Critical Care Nurse 24, no. 4 (August 2004): 19–27; 28–29.

X–Z Xenical

Trade name of approved in 1999.

ORLISTAT,

acids among those with a history of yo-yo dieting with those of dieters without such a history. After 14 weeks, significant differences in weight loss and fat loss were revealed between dieting-only and diet-and-exercise groups, but not between yo-yo and non-yo-yo dieters. Resting metabolic rate decreased in all groups, but there was a significantly smaller decline after 14 weeks for the diet-exercise groups. No effects of frequent dieting or exercise on basal and fat-burning activity were observed. Evidence continues to mount that yo-yo dieting makes subsequent weight loss more difficult. In the Van Dale and Saris study, researchers examined the weight loss patterns of obese patients participating in a university weight loss program for the second time. The dieters had all lost weight on the program but had regained at least 20 percent—more typically 120 percent—of their lost weight in the intervening years. Though they were placed on the same weight loss regimen, and compliance was monitored by a battery of laboratory tests, the dieters lost significantly less weight the second time. The researchers speculate that chronic dieting leads to a slowdown in METABOLISM, which sets the stage for weight gain and makes future attempts at weight loss more difficult. Later, Dr. Brownell, now at Yale University, led a research team that studied and analyzed data collected from 3,200 participants in the Framingham (Mass.) Heart Study over a period of 32 years. The much-heralded results of the study were reported in the June 27, 1991 New England Journal of Medicine. Among the conclusions: “Persons whose body weight fluctuates often or greatly have a higher risk of coronary heart disease and death than do persons with relatively stable body weights.” Con-

an obesity drug

yo-yo dieting

Also called weight cycling. A habitual cycle of weight loss by dieting followed by weight regain; an inability to maintain weight loss. Studies have shown that yo-yo dieting increases body fatness and may ultimately result in an inability to lose weight even on a very low caloric intake. People who get caught up in the yo-yo cycle take progressively longer each time to shed pounds and gain them back progressively faster. Kelly Brownell, a psychologist then at the University of Pennsylvania, found in 1986–87 that yo-yo dieting increased the activity of lipoprotein lipase, an enzyme that promotes the storage of body fat. And because fat tissue is metabolically less active than muscle, with each diet cycle the daily caloric needs dropped and weight was gained on fewer calories. Dr. Brownell concluded that yo-yo dieting increases the body’s efficiency in using food for fuel and may ultimately make weight loss impossible. In agreement with this is David A. Booth, a psychologist at the University of Birmingham, England, who says that yo-yo dieting “may have physiological and psychological consequences which would make weight loss more difficult when it became medically more important.” A constantly repeated yo-yo dieting cycle has been shown to be more of a health risk than remaining at a stable weight, even if high, particularly for those who are genetically predisposed toward obesity. In a 1989 report in the American Journal of Clinical Nutrition, Djoeke can Dale and Wim H. M. Saris of the University of Limburg, the Netherlands compared body composition (fat to lean ratio), resting metabolism rate and conversion of fats into fatty

299

300 zinc deficiency troversy remained because the study did not address the issue to whether weight fluctuations are more dangerous than obesity. Recent research has found similar connections between yo-yo dieting and binge-eating. In a Harvard Medical School study of 2,476 young and middle-aged women, “weight cycling was associated with greater weight gain, less physical activity, and a higher prevalence of binge eating. Low levels of activity and binge eating may be partially responsible for the large amount of weight regained by weight cyclers.” An Italian study of 1,889 treatment-seeking obese subjects found that “Weight cycling is associated with psychological distress, and binge eating independently increases the risk, but cannot be used to predict cycling. Also, obese patients who do not experience overeating as a loss of control discontinue treatment or regain weight following therapy.” Earlier, Friedman et al. had examined the psychological effects of weight fluctuation associated with repeated dieting; their findings suggested that “an individual’s perception of being a weight cycler may be more related to psychological problems

than the actual number of pounds lost and regained over time.” Field, A. E., et al. “Association of Weight Change, Weight Control Practices, and Weight Cycling among Women in the Nurses’ Health Study II.” International Journal of Obesity and Related Metabolic Disorders 28, no. 9 (September 2004): 1,134–1,142. Friedman, Michael A., Marlene B. Schwartz, and Kelly D. Brownell. “Differential Relation of Psychological Functioning with the History and Experience of Weight Cycling.” Journal of Consulting & Clinical Psychology 66, no. 4 (August 1998): 646–650. Marchesini, G., et al. “Weight Cycling in TreatmentSeeking Obese Persons: Data from the Quovadis Study.” International Journal of Obesity and Related Metabolic Disorders 28, no. 11 (November 2004): 1,456–1,462.

zinc deficiency

Zinc is necessary in the body in small amounts. A shortage of zinc, the result of malnutrition or starvation, can greatly alter taste perception and may play a role in the bizarre food combinations eaten by starving anorexics. It also leads to hair loss, brittle nails and anemia.

APPENDIXES I. II. III. IV.

Chronology Tables Sources of Information Obesity and Eating Disorder Treatment Centers/Weight Reduction Camps V. Glossary of Fat Replacers VI. Web Sites of Interest VII. Audiovisual Materials

APPENDIX I CHRONOLOGY* 1935 Surgeons in Budapest, Hungary remove 93 pounds of fat from 379-pound poultry dealer by making many small surgical incisions on his body.

1873 The term anorexia nervosa is first used in England by physician Sir William Gull, who described the symptoms in several young upper-middle-class English girls. In a speech in 1868 he described the symptoms of a “peculiar form of disease,” which he then called “apepsia hysterica,” later deciding “anorexia” was a more appropriate term. Charles Lasègue, a French neurologist, publishes a paper, “On Hysterical Anorexia,” which details the symptoms of anorexia nervosa, which he refers to as a form of hysteria.

1936 Hormone Lipocaic, which controls utilization of fat, is discovered by Drs. L. R. Dragstedt, J. van Prohaska and H. P. Harms. 1947 Dr. H. E. Richardson advocates treating non-glandular obesity in women as neurosis.

1900 C. Von Noorden classifies obesity into two types: exogenous, due to overeating and under-exercising; and endogenous, due to metabolism.

1948 Scientists at Brown University link obesity to heredity.

1920s Behavioral science pioneers Ivan Pavlov, Edward Thorndike and B. F. Skinner each begin important behavioral studies relating to eating responses.

1950 Dr. H. Millman reports on emotional factors in obesity. E. H. Rynearson reports on “emotional factors in overeating” and recommends formation of an organization to be called “Calories Anonymous.”

1921 Skinfold test to measure obesity is introduced, in which the thickness of a “pinched” fold of skin indicates the ratio of body fat to muscle tissue.

1951 Metropolitan Life Insurance Company starts drive to curb obesity and promote sound nutrition.

1929 Invention of constant-tension calipers by R. Frazen improves accuracy of skinfold obesity test.

1953 Dorset Foods begins marketing canned foods with calorie information printed on label. Knickerbocker Hospital in New York establishes obesity treatment center.

1933 Reducing drug called dinitro-ortho-creso is introduced by Drs. E. C. Dobbs and J. D. Robertson.

*Adapted from Library in a Book: Eating Disorders, by John R. Matthews. Copyright 1991 by Facts On File.

302

Appendix I 303 1954 Dr. W. S. Kroger patents weight reducing belt that checks hunger pangs by pressing against upper part of stomach. Pituitary hormone adipoteinin is studied for its fat burning properties. J. Wolpe, in describing “avoidance conditioning,” attempts to treat overeating with classical aversion methods using electric shock. 1957 Hilde Bruch postulates that obesity is consequence of personality defects in which body size becomes expressive of underlying psychological conflicts. U.S. House subcommittee holds hearings on misleading remedies for weight loss. Better Business Bureau says Americans spent $100 million in 1956 on worthless remedies. The drug Phenyl propanolamine in reducing pills is declared harmful. 1959 J. M. Strang reclassifies Von Noorden’s metabolic obesity type, endogenous, to include breakdowns in the physiological or psychological regulation of food intake, and a type related to various endocrinological dysfunctions. First Metropolitan Life Insurance Company height and weight tables are published. In a criminal case in New York, the District Attorney calls Regimen brand reducing tablets fraudulent, raids office and seizes ads and television commercials. Later in a criminal trial in 1965, the drug company, its ad agency and their executives are found guilty and fined: the ad agency is fined $50,000; the drug company president is given an 18-month prison sentence and fined $50,000; and the drug company is fined $53,000. Dr. Albert Stunkard and Mavis McLaren-Hume complete watershed analysis of obesity research, setting forth criteria for evaluating obesity research and reducing to eight the vast number of research studies that met criteria. 1960 The Federal Trade Commission (FTC) charges Stauffer Labs with false claims of weight loss from “magic couch.”

Milk companies begin to market skim milk as diet food. Federal Drug Administration (FDA) seizes falsely labeled diet mixes. 1961 Yale doctors find link between tendency to gain weight and heart problems. 1962 Major study is published by U.S. Public Health Service (PHS) of weight, height and body dimensions of adults throughout the United States. The Midtown Manhattan Study, directed by Dr. Lee Srole, establishes relation of obesity to social status, showing greater obesity in the lower socioeconomic classes. W. L. Laurence reports new synthetic ACTH (pituitary hormone) compound that breaks down fat tissue into liquids. Reducing drug phenmetrazine (Preludin) causes deformities in newborns in Germany. 1964 French women discover “cellulite” and rush to spas and salons for treatment. 1965 First intestinal bypass operation for weight loss is reported by American College of Surgeons. 1966 M. Mendelson, in a pioneer study, delineates a continuum of the range of psychological disturbance in obesity causes. New York State appellate court upsets Regents Board’s 1964 censure of Dr. Walter Sherman for negligence in treating obesity patients. Dr. Sherman, who specialized in treatment of obesity, overlooked conditions such as diabetes and prescribed amphetamine sulphate, desiccated whole thyroid and phenobarbital. The U.S. Public Health Service (PHS) reports on obesity as a major health problem and finds diets are of limited value and urges exercise. The report rejects height and weight charts for tests for obesity and recommends skinfold pinch test instead. PHS publishes nationwide study of adult heights and weights and finds males are seven pounds and

304 The Encyclopedia of Obesity and Eating Disorders females 11 pounds heavier than found in the 1959 Metropolitan Life charts. New York state superior court awards Elizabeth Ostopowitz $1,205,000 for injuries caused by taking anti-cholesterol drug Mer-29 to lose weight. The drug was withdrawn from the market in 1962 by its maker, the Richardson-Merrell Corporation, after its toxic effects were discovered. Ostopowitz, who had Cushing’s disease, suffered from cataracts, baldness and scaling skin, caused by the drug. Harvard University Public Health School study finds that colleges discriminate against obese in admissions. NAAFA (National Association to Aid Fat Americans) is founded. 1967 Dr. Herman Taller, author of Calories Don’t Count, is charged in federal court in Brooklyn with mail fraud and making false claims in promoting his book along with safflower oil diet pills marketed by Cove Vitamins and Pharmaceuticals. Taller is convicted and fined $7,000; charges against the book’s publisher, Simon & Schuster, and its ad agency are dropped. Professor A. Feinstein, on American Physicians College panel, asserts that being mildly obese poses no health risks. Scientists at Iowa University Medical College report that people who become obese, especially early in life, activate internal biological mechanisms that tend to keep them obese. The report hypothesizes an alternative pathway for disposing of excess glucose intake. Studies of obese children found that they produced low levels of the hormone dehydroepiandrosterone (DHA), which regulates the process of disposing of the excess glucose. Senator Philip A. Hart’s (D., Michigan) subcommittee begins probe into diet pill industry, charging that manufacturers recruit doctors to promote drugs and also charges that obesity specialists use mass production procedures in treating patients. Dr. Alvan Feinstein at a meeting of the American College of Physicians proposes that otherwise healthy, slightly obese persons not diet and cites harm of fad dieting. Dr. Jules Hirsch of Rockefeller University reiterates his contention on lack of scientific knowledge about obesity.

Dr. Jean Mayer of Harvard reports on research to locate the seat of hunger and satiation signals in the brain. He describes the hypothalamus, a tiny region at the base of the brain. Studies show animals with an injured hypothalamus display confusion about hunger and satiation signals and consequently overeat. 1968 Senator Philip A. Hart’s (D-Michigan) subcommittee hearings produce evidence of indiscriminate dispensing of dangerous diet drugs containing thyroid extract, digitalis, amphetamines, barbiturates and prednisone at about 1,000 clinics across the United States. Two companies, Western Research Labs and Lanpar Company, are charged. Companies are ordered to cease marketing pills containing amphetamines and digitalis. In a related investigation, Illinois Narcotics Control Division probes death of nurse who died from amphetamine accumulation in her body after taking reducing pills. Dr. J. Hirsch of Rockefeller University claims that some persons with chronic obesity continue to “remember” and think of themselves as fat even after reducing. Hypnosis cure for obesity becomes briefly popular. J. Knittle et al. conduct a series of studies showing that adipose cells remain constant throughout life and that by adulthood increases in body size are caused by increase in cell size, not cell number. 1969 Drs. I. B. Perlstein, B. N. Premachandra and H. T. Blumenthal report to the American Therapeutic Society on study showing that some obese people produce antibodies against their own thyroid hormone, and gain weight because of the resulting metabolic imbalance. A study by R. Half Personnel Agency finds that higher-paid executives are thinner than lower-echelon employees. In a study on metabolism at Lankenau Hospital in Philadelphia it was found that the metabolic rate in a well-fed obese person and a starving lean person are similar because they both burn relatively more fat and less blood sugar than normal persons, and it is thought that this is a vestige of early human behavior similar to some wild animals.

Appendix I 305 1970 February 8: Two slightly overweight mothers, aged 24 and 27, in Monroe County, New York, are reported to have died after taking diet pills containing thyroid hormones, digitalis and amphetamines. July 30: National Research Council criticizes practice of limiting weight gain by pregnant women and recommends weight gains of 20–25 pounds during pregnancy, plus diet supplements. August 6: FDA proposes limiting the manufacture of amphetamines, an important ingredient in diet pills. September 13: Research report indicates overfeeding children produces excess of fat cells, which remain for life, hampering future weight loss. November 17: Drug industry promotions to doctors of reducing drugs is linked by the Narcotics and Dangerous Drugs Bureau of the U.S. Justice Department to increasing drug abuse. 1971 January 20: Weight Watchers International, Inc. launches Operation HOPE in New York City to help people unable to leave home or function normally because of extreme obesity. September 7: Dr. J. L. Knittle, National Institutes of Health researcher, finds that adult obesity can be predicted by age two because number of fat cells in body can be closely determined by that age. September 12: Weight loss fad Hot Pants, product name for inflatable shorts that allegedly reduce weight by increasing expenditure of energy, is investigated by the U.S. Postal Service. Test shows no weight loss by using the product. 1972 Joseph Cautela introduces “covert conditioning” in treatment of obesity, which is based on “escapeavoidance” paradigm that punishes particular eating responses and reinforces responses antagonistic to eating. September 28: The Better Business Bureau of Metropolitan New York mounts campaign against medical quackery relating to obesity control. It claims that Americans spend between $2 billion and $10 billion annually on useless gadgets and pills. October 11: FDA reports on study it undertook to test claims of diet pills; study reveals that diet

pills are no aid in weight reduction. It recommends imposing manufacturing quotas on amphetamines. November 14: British study reports that babies born underweight suffer from educational and behavioral problems by the time they reach school age. Dr. N. Butler, director of the study, says effects were found in all social classes but most pronounced in lower socioeconomic levels. December 14: The FDA moves to restrict harmful diet pills. FDA director E. Simmons mails bulletins to 600,000 health professionals warning of hazards of diet pills. In defending FDA’s original action in permitting prescribing of diet pills for weight loss, Simmons said that a small number of people are able to lose weight taking the pills, and because the treatment of obesity is so difficult and includes high rates of failure, they believe that physicians should have use of all therapeutic aids. December 14: In testimony before Senator Gaylord Nelson’s (D-Wisconsin) subcommittee, Drs. Jean Mayer, J. Tepperman and T. E. Prout accuse the medical profession and drug companies of pandering to public misbeliefs about obesity and weight loss. Dr. Mayer cites diets such as “Drinking Man’s Diet,” rice diet, Mayo and Atkins diets as extreme and dangerous. December 26: The $220 million salon and health spa industry is said to be permeated with fraud. Consumer agency investigators focus on deceptive ads, high pressure sales pitches and long-term contracts to attract customers. Health clubs run by Jack LaLanne and Nu-Dimensions are target of probe. Complaints include misleading ads, promise of improbable weight loss, dirty and overcrowded facilities and untrained instructors. 1973 February 7: A federal grand jury in Newark, New Jersey, indicts G. Maisonet, E. Axel, D. Bradwell and V. Lynch for selling $1.1 million in phony diet pills by mail. February 8: The Federal Office on Consumer Affairs warns against inflated claims and high pressure sales tactics used by spa and salons. The Federal Trade Commission (FTC) investigates sales tactics and claims of health clubs and spas; recommends limiting contracts to $500 rather than $1,000 and forbidding sellers to assign contracts to banks or oth-

306 The Encyclopedia of Obesity and Eating Disorders ers, and recommends triple damages to buyers who bring successful deceptive-practices suits. March 9: AMA in warning against the book Dr. Atkins’ Diet Revolution says the diets are unscientific and potentially dangerous; book recommends diet that activates fat-mobilizing hormone, converting stored fat to carbohydrates; advocates unlimited intake of fats and cholesterol rich foods. March 14: New York County Medical Society calls Atkins Diet unscientific, unbalanced and potentially dangerous to persons prone to kidney or heart disease and gout; it is called especially dangerous to pregnant women and unborn children. Dr. Atkins claims diet is based on clinical observation of 10,000 obese subjects over nine years. March 21: U.S. District Judge F. B. Lacey asks postal service to begin probe of mail order sales of diet pills and upheld postal service’s right to withhold mail delivery to Baslee Products Corporation of Bayonne, New Jersey, which had been found guilty in nine counts of false advertising relating to sales of the diet pill Marvex. March 22: Dr. Atkins, author of Dr. Atkins’ Diet Revolution, is sued for $7.5 million in suit claiming his diet is responsible for heart attack as result of negligence and malpractice. Superior Court names Atkins, his associate I. Mason and publisher David McKay Company as codefendants. March 31: O. N. Miller, associate director of biological research for Hoffman–La Roche, granted patent for obesity control product using nicotinic acid to inhibit growth of fatty substances known as lipids. Hoffman–La Roche is testing product on animals. April 2: The FDA and Bureau of Narcotics and Dangerous Drugs recall diet drugs containing amphetamines. Action includes injectable amphetamines and closely related chemicals and all combination diet pills that contain amphetamines and other ingredients such as sedatives or vitamins. April 9: New York City Consumer Affairs Department passes regulation prohibiting noncancellable contracts for “future service” aimed especially at reducing salons and spas. June 7: American Chemical Society in a study conducted at Loyola University’s Stritch School of Medicine in Maywood, Illinois, reports on fatreducing agent FMS (fat-mobilizing substance)

found in urine of those who are fasting. It is thought to play a role in rapid breakdown of fat during starvation. FMS appears to stimulate the release of a form of adenosine monophosphate known as cyclic-AMP, which promotes the enzyme lipase that breaks down fats. The chemical structure of FMS is unknown, but it is thought to be a protein. June 14: Bureau of Narcotics of the Justice Department places restrictions of prescription nonamphetamine diet pills that include ingredients such as benzphetamine, fenfluramine and phendimetrazine, and are sold under many trade names as appetite suppressants. Illicit drug world begins underground sales in an effort to replace lost sales because of unavailability of amphetamines. August 7: E. Axel pleads guilty of conspiring to commit mail fraud in the sales of $1.1 million in diet pills advertised as Slim-Tabs 33 slenderizing tablets and admits to being principal of Stanford Research Corp., arranging “fronts” as corporate officers. August 21: Cassette tape recording designed to help in weight loss is marketed by Accomplishment Dynamics Company and narrated by Dr. R. E. Parrish, who says tape uses technique similar to hypnosis. September 22: D. R. Salata receives patent for Rollslim, massaging device consisting of two rollers, for overweight women. October 19: Liberty Life Insurance Company announces hospitalization program with premium rates based on insured’s weight; overweight persons will pay higher premiums. October 21: A Brooklyn College study involving mice finds that overweight mice live only half as long as normal-weight mice, and many of the overweight develop diabetes, become sluggish, inactive and almost sterile, and have low sex drive; process is reversed by reducing mice’s weight. Professor G. H. Fired says experiment corroborates accepted theories about proper exercise and nutrition. Study is based on more than 1,000 mice over a 10-year period. November 11: National nutritional study of more than 20,000 Canadians finds more than half the population is overweight and attributes cause to sedentary lifestyle rather than overeating. November 26: Drug Guild Distributors, manufacturer of X-11 Reducing Plan Tablets, agrees to

Appendix I 307 discontinue misleading and harmful advertising. Tablets are considered by medical authorities as potentially harmful to those suffering from heart disease, high blood pressure, diabetes or thyroid disease, despite ad statement that they are safe for everyone. December 27: Dr. J. Hirsch and J. Knittle and colleagues report on people who have been fat since childhood and have larger than normal number of fat cells and claim that either in life obesity begins, the larger the number of fat cells. December 27: Dr. Jean Mayer says persons of particular body type—slender ectomorphs with long, narrow hands and feet—are unlikely to become fat; other researchers note that infant feeding practices lead to overfeeding, which in turn creates a greater number of fat cells. Researchers found that mothers of fat children tend to respond to their infants’ distress by feeding; later these children react to emotional stress or frustration by eating. 1974 January 23: Operator of weight reducing products company, Raymond Carapella, pleads guilty to mail fraud in multimillion dollar per year sales of diet pills and bust-developing products. May 6: The FTC begins New York regional investigation of sales of future service contracts by reducing salons. June 15: Brewster Produce, a mail order house, admits in federal court in Newark, New Jersey, that it sold almost $2 million worth of phony diet pills. August 31: Patent is issued for mirror device that shows how an obese person will look after considerable weight loss. September 15: Woman on fast weight loss diet dies of heart attack after fasting for four days. September 16: Several weight loss clinics are the subject of federal investigation into fraudulent practices for falsely advertising medical supervision and using unapproved drugs. Chain-operated clinics charge fees of $175 to $500 for 21- to 40-day treatment consisting of low calorie diet and daily injections of hormone HCG (human chorionic gonadotropin) obtained from urine of pregnant women, which clinics admit may be worthless. November 10: Citing studies showing anorexia nervosa as having a fatality rate higher than any

other psychiatric disorder, the Philadelphia Child Guidance Clinic claims 100 percent cure rate for children who remain in treatment. December 12: U.S. Postal Service bars mailing of fraudulent products Slimmer Shake and Joe Weider’s Weight Loss Formula XR-7, made by Weider Distributors Inc. of Norwood, New Jersey. December 15: FDA announces that drugs containing hormone HCG must be labeled as worthless for weight loss. 1975 March 27: Jack Fried, operator of Phase Method, is indicted in Newark, New Jersey, on mail fraud charges for selling weight reduction plans based on clients’ handwriting samples. Fried is later convicted and sentenced to three years in prison. April 4: Pillsbury Company announces it will acquire Weight Watchers International Inc. for $43 million. May 14: Slim-Tabs Slenderizing Tablets producer Arnold Mandell pleads guilty to mail fraud, admitting pills are worthless. December 15: Federal Trade Commission (FTC) prohibits Stuart Frost Inc. from advertising body wrapping devices called Slim-Quick or services used for weight reducing. 1976 March 3: Americans for Democratic Action issue a report attacking the weight reducing industry, citing $90 million annually wasted by consumers. March 26: A study is published showing that early puberty and menstruation of girls is associated with stoutness and late menstruation with thinness. June 9: FTC Judge Daniel H. Hanscom rules that Porter & Dietsch Inc., makers of X-11 Diet Tablets, and its ad agency, Kelly Ketting Furth, falsely advertised that users could lose weight while eating as much as they wanted. December 4: Two government employees patent a method of controlling obesity with purified “miracle fruit” grown in West Africa. 1977 March 12: Because of saccharin’s role in causing cancer, the FDA announces plans to classify saccharin as a drug instead of a food additive.

308 The Encyclopedia of Obesity and Eating Disorders April 11: Dr. John E. Farley, Jr., head of the Rhode Island Medical Society drug abuse commission, announces his organization’s opposition to the use of amphetamines in treating obesity; Utah Medical Association also opposes amphetamine use. June 21: In the first major malpractice suit under a new Pennsylvania law, Marlene Baumiller, who underwent intestinal bypass operation for weight loss, is awarded $100,000 from Dr. Robert Cassella, who accidentally punctured her spleen and had to remove it; $25,000 from Pittsburgh Podiatry Hospital; and $225,000 from Medical Professional Liability Catastrophe Loss Fund. July 21: The FDA opposes strict rules for labeling foods as low calorie. August 29: At annual American Psychological Association meeting Dr. Judith Rodin says overweight people secrete more insulin when stimulated by food sights and smells. Increased insulin secretion increases hunger, leading to overeating. September 20: In Porter County, Indiana, superior court, Cora Staniger is awarded $50,000 in damages from doctors who put her on a protein deficient diet during her pregnancy, causing mental retardation of her daughter. November 3: The FDA and Centers for Disease Control (CDC) begin inquiry into 12 deaths suspected to be caused by liquid protein diet formula, which supplies 300 calories per day in a liquid made of fibrous protein collagen from animal tissue. Investigators suspect it may deprive users of potassium. FDA names a panel to investigate. November 24: Federal Centers for Disease Control reports 10 more deaths suspected tied to crash dieting with predigested liquid proteins. FDA Commissioner Donald Kennedy requests 35 manufacturers of product to label compounds as hazardous under some conditions. Senator Charles Percy urges FDA to reclassify these diet products as prescription drugs. December 1: At an American Heart Association meeting, California heart specialists claim that liquid protein diets can result in death even if used under strict medical supervision. December 21: Figures from National Health Statistics Center show that American adults weigh an average of about four pounds more than in the previous decade.

December 29: At a House Subcommittee on Health and Environment hearing about liquid protein diets, Dr. Robert Linn, author of The Last Chance Diet, questions the accuracy of the government report linking the diet to deaths. 1978 January 27: FDA asks 800,000 professional health workers to report cases of liquid-proteincaused death problems; 46 deaths and 200 injuries from product are to be investigated. Sales of the product plummet. February 12: Luciano Pavarotti, having lost 90 pounds on diet, disproves myth that obesity helps opera singers project strong voices. March 12: Fat Liberation Front announces drive to free fat people from stigma and claims that no health problems result from obesity. Dr. Robert Sherwin of Yale comments that organizations such as the Fat Liberation Front help the obese psychologically but warns that obesity still needs to be treated. April 22: Dr. Feridun Gundy of Queens, New York is convicted in federal court of illegally dispensing $2.5 million worth of amphetamines to obese patients. May 16: Dr. George Blackburn, whose research was partially the basis for liquid protein diets, warns that the diets dangerously deplete essential nutrients. May 16: H. J. Heinz Company announces that it will acquire Weight Watchers International Inc. for over $71 million. September 22: Drs. Arthur Hartz and Alfred Timm, and mathematician Eldred Geifer announce that research at the Medical College of Wisconsin shows that environment is more important than heredity in determining tendency to obesity, disputing previous studies showing heredity as more important. Study observed behavior among natural and adopted siblings with overweight mothers, who were selected from weight reduction organization TOPS (Take Off Pounds Sensibly). October 15: Substantial decline in sales of liquid protein diets is reported; decline is attributed to FDA findings of deaths by users of products. All deaths reported were of women who all died of myocarditis, inflammation of heart tissue. December 17: Survey by British shirt manufacturer shows that fewer than 20 percent of women

Appendix I 309 are attracted to skinny men, while 34 percent prefer men to have “slight suggestion of a paunch and 31 percent like a bit more of a paunch.” December 30: FDA revises order for warning labels on liquid protein diets and now requires warning on all protein products that provide more than 50 percent of a person’s calories and are promoted for weight loss or as a food supplement. 1979 February 20: New research study challenges heredity-caused theories on obesity; the new study shows overeating as primary cause. May 13: FDA panel headed by Dr. John W. Norcross reports that phenylpropanolamine and benzocaine, found in several nonprescription diet aids, may help some dieters; calls for further study on other ingredients; and reports that dozens of others are worthless. July 1: FDA requirements for strict labeling of diet foods goes into effect. Foods labeled “low calorie” are required to contain no more than 40 calories per serving and must be lower in calories than food normally found in grocery stores. Foods labeled “reduced calorie” must contain at least one-third fewer calories than similar products for which it is substituted. Comparisons must be shown on label. July 17: FDA proposes crackdown on illegal amphetamine use by banning their use in weight reduction. FDA says ban would reduce pill production by 80 to 90 percent. Some 3.3 million prescriptions for amphetamines were written in 1978. December 15: A study is reported in medical journal Lancet claiming that bypass surgery is safe and quick way to loose weight. Lancet editorial questions validity of study, criticizing research design and calling project ethically unsound. 1980 February 10: Essex County, New Jersey, chapter of NOW (National Organization for Women) sponsors program called Food, Fat and Feminism, which explores reactions to fat and fat people, and food and diet. May 1: Five drug companies agree to FDA request to stop shipments of new nonprescription diet products containing twice the current legal limits of phenylpropanolamine hydrochloride (PPA), an appetite suppressant drug. FDA deter-

mines that recalls are not necessary because pills are not considered a health risk. May 4: A study is reported that finds that although death rates are higher for people who are above average weight, death rates are higher still for those weighing less than average. May 29: A report by the Food and Nutrition Board of the National Academy of Sciences says healthy Americans need not worry about fat and cholesterol and admits its stand dissents from other major organizations that urge curbs on fat and cholesterol. Government experts criticize the report, saying board members ignored important scientific data. July 5: Diet preparation that suppresses appetite for calories but not proteins is patented by Richard J. Wurtman, Judith J. Wurtman and John D. Fernstrom and licensed for production by Massachusetts Institute of Technology. September 28: Research linking stress to obesity is reported. Rats reportedly overate when their tails were pinched, but their appetites abated when given naloxone, an opiate antagonist. This research has implications for understanding stress-related overeating. October 30: A study is reported showing evidence that obese people have a biochemical defect involving enzyme adenosine triphosphatase (ATPase), which helps pump sodium and potassium across the membranes of the body cells. ATPase may be responsible for 10 to 50 percent of the body’s heat energy production. The amount of ATPase in the red cells on the obese group was 22 percent lower than in the nonobese in the study. December 12: A study by Drs. Eugene Lowenkopf and L. M. Vincent finds that 15 percent of students in professional ballet schools suffer from anorexia nervosa and many others are borderline. The study attributes dancer’s obsession with body weight to the ballet profession’s emphasis on thinness. 1981 August 4: New York State passes law making amphetamine prescription for sole purpose of weight loss illegal. August 11: Study by Drs. Linda Craighead, Albert Stunkard and Richard M. O’Brien finds that

310 The Encyclopedia of Obesity and Eating Disorders appetite suppressant drugs may be counterproductive to long-term weight loss. October 31: Psychotherapists report that bulimia nearly always begins with stringent weight loss diet. November 16: An AMA Journal report criticizes the book The Beverly Hills Diet saying it is filled with medical inaccuracies. 1982 February 13: A report is published saying 10,000 poisoning cases per year result from taking PPA (phenylpropanolamine). March 9: Study by Richard Weindruch and Roy L. Walford finds that undernutrition begun in middle age can lead to longer and healthier life for mice. July 2: FDA announces that starch blockers, sold as diet aids, are possibly dangerous drugs and must be removed from market. Bio-Tech Laboratories, manufacturer of the pills, sues FDA to prevent defining starch blockers as drug. August 22: Federal judge in Chicago denies request by FDA for ban on starch blockers despite a report of 75 illnesses related to the pills. October 10: Federal court classifies starch blocker diet aids as drugs and ends all sales until determination of their safety can be made. October 24: Gastroplasty, new operation that seals off most of stomach, is reported. November 22: Suction lipectomy, new surgery that removes body fat by suction, is reported. 1983 March 2: Metropolitan Life Insurance Company publishes new height and weight tables showing ideal weights have increased for men by two to 13 pounds and three to eight pounds for women. April 28: Dr. Edward R. Woodward warns of life-threatening side effects resulting from jejunoileal bypass, a surgical procedure to lose weight by bypassing small intestine. July 5: Cornell University study finds exercise after eating is the best way to get rid of extra calories and finds exercise crucial in maintaining stable weight when daily caloric intake fluctuates. July 23: Dr. Thomas R. Knapp of the University of Rochester recommends people abandon concept of “ideal weight” because it is based on inconsistent data.

1984 December 16: A new eating disorders program is reported at Phelps Memorial Hospital in Sleepy Hollow, New York, that treats anorexic and bulimic patients who require extensive care. December 16: Pump therapy for anorexic patients is reported to pump up to 2,000 calories a day into severely underweight patients. December 21: A study at Massachusetts General Hospital by Dr. Nancy A. Rigotti finds that women with anorexia nervosa often have weak bones but can be treated with exercise. 1985 February 14: A National Institutes of Health panel defines obesity as a disease and says it should receive the same medical attention as high blood pressure, smoking and other factors that cause serious illness and premature death, and that overweight should be treated when it reaches 20 percent above “desirable” weight. March 19: A study reported in Journal of Abnormal Psychology finds that women have negatively distorted view of their bodies; men also have distorted image of their bodies, but it is more positive. March 22: Physicians and psychotherapists specializing in anorexia nervosa and bulimia treatment ask FDA to ban over-the-counter sales of syrup of ipecac, a drug used to induce vomiting, because of its potential use by bulimics. May 6: A study of Dr. William Dietz, of the New England Medical Center, and Dr. Steven Gortmaker, of the Harvard School of Public Health, finds that children who watch lots of television exercise less, eat more and become obese. August 6: Dr. Reubin Andres challenges Metropolitan Life height and weight tables, saying weight ranges given in tables do not reflect ideal weights. September 2: First free-standing residential facility in United States devoted exclusively to treatment of anorexia nervosa and bulimia, Renfrew Center in Philadelphia, is reported. 1986 May 22: Scientists report that anorexia nervosa sufferers have high levels of cortisone, hormone excreted by adrenals in response to fear.

Appendix I 311 1987 March 24: Dr. George Blackburn, an obesity specialist at Harvard Medical School, comments on study on causes of obesity and finds that dieting is ineffective for many people because when they reduce food intake, their metabolic rate drops to protect them from starvation. 1988 February 11: A study of Dr. William Feldman of Ottawa University reports that girls come to believe thin is beautiful as early as age seven and links that attitude to rising incidence of eating disorders in young girls. February 25: Two studies are published showing evidence of genetic causes of obesity: one study was of Pima Indians in Arizona, the other of infants in Britain. These studies confirm theories of Dr. Jules Hirsch of Rockefeller University, who has promoted the idea for over two decades. March 22: Doctors specializing in bulimia report that use of antidepressant drugs can help some patients reduce binge-eating and purging, but warn that they cannot replace psychotherapy needed to get to the root problems. April 17: Wilkins Center for Eating Disorders in Greenwich, Connecticut, survey says among anorexics and bulimics, number of those who are 12 years old or younger has doubled in the last two years from 3 to 7 percent and says rise indicates increasing social pressure for thinness. 1989 January 3: Researchers at Rockefeller University announce discovery that abnormally low levels of protein adipsin, which is secreted directly into the bloodstream by fat cells, may be linked to tendency to gain weight when not enough adipsin is secreted. It may be a factor in genetic tendency to obesity. February 23: A University of Michigan study is released that finds American women aged 18 to 34 have been getting fatter over past several decades; black and poor women and women with low education levels show the greatest weight gains. March 18: Ronald T. Stunko patents chemical method of preventing fat formation in humans. July 1: Pharmacologist Mark Hohenwarter patents biamine, chemical for treating addictions such as food or cocaine. Biamine works by replenishing certain neurotransmitters in the brain.

September 16: Cardiologists Jackie R. See and William E. Shell patent “Fat Magnets” diet pills, made from bovine bile, that prevents the body from absorbing some fat and cholesterol in food. October 3: Merck Sharp & Dohme announces discovery of manner in which hormone cholecystokinin triggers brain to tell body when to stop eating. They also discovered two chemicals that block hormone’s action. 1990 January 3: Nationwide survey by Calorie Control Council finds that pounds almost always return after dieting and that only fundamental changes in eating behavior will keep them off. Survey also found a 26 percent drop in the number of people on diets. February: Simplesse, the first fake fat with the taste and texture of the real thing but without high calories, was marketed as an ice cream called Simple Pleasures. March 20: Research team led by David Williamson of the Centers for Disease Control announces findings that people are most likely to gain weight as young adults and that black women are especially vulnerable; women of all races are twice as likely as men to gain large amounts of weight; and women from 25 to 44 who were overweight at the beginning of the study gained the most weight of all subjects. March 28: Representative Ron Wyden (D., Oregon) chairman of the House of Regulation, Business Opportunities and Energy Subcommittee opened hearings into questionable practices of the weight-loss industry amid charges that health risks, false advertising and profiteering are “bedrock” in the industry. April 1: Five-year study by Dr. Thomas Wadden shows that 98 percent of all dieters regain their weight within five years. April 1: New York Times story says recent studies suggest that formula diets can lead to psychological and physiological burdens that limit diets’ longterm effectiveness; some people develop fear of food and become dependent on formula diets, while others binge and suffer humiliating weight gains, while few maintain their lower weights. May 8: New York Times story reports on the most comprehensive study of diet and disease ever

312 The Encyclopedia of Obesity and Eating Disorders undertaken—a survey of 6,500 Chinese—led by Dr. T. Colin Campbell of Cornell University and Dr. Chen Junshi of the Chinese Institute of Nutrition and Food Hygiene. One of the first findings is that obesity is related more to what people eat than to how much. May 24: New England Journal of Medicine reports on multiple studies that confirm that body weight is determined more by heredity than by diet. The findings do not go so far as to suggest that the role of diet can be dismissed completely; what one eats still makes some difference. August 8: Los Angeles Times reports that a Stanford University study shows overweight men who dieted but did not exercise had suppressed metabolic rates, while those who lost weight through exercise but did not diet had no reduction in metabolic rates. November 27: Medical World News reports that weight loss is a $33 billion business this year, up 10 percent from 1988. 1991 January: University of Minnesota study of nearly 5,000 workers in upper Midwest reports a lifetime prevalence of dieting to lose weight of 47 percent in men and 75 percent in women. March 28: Panel of experts convened by the National Institutes of Health endorses gastrointestinal surgery to treat severe obesity but recommends that patients first try nonsurgical weight-loss techniques, such as diet, exercise and behavior modification. April 10: Physicians Committee for Responsible Medicine, a nonprofit organization, asks U.S. Department of Agriculture (USDA) to abandon the traditional four food groups—meat, fish and poultry; grains; dairy products; and fruits and vegetables—and to replace them with a radical new grouping of foods: fruits, legumes, grains and vegetables becoming the primary group, with meat and dairy products becoming minor options limited to three ounces a day. May: British study led by Dr. Christopher Fairburn suggests that cognitive behavior therapy is more effective in treating bulimia nervosa than both interpersonal psychotherapy and a simple behavior therapy.

September: Columbia University study led by Dr. B. Timothy Walsh reports serious limitations over the long term of a single antidepressant medication in treating bulimia nervosa. 1992 January: Survey of 50 physicians and scientists involved in obesity research shows disparate views on causes and treatment of obesity among different genders, age groups and regional locations. The only overall agreements are that genetic factors are the most important cause of obesity and that the usefulness of serotonergic and thermogenic drugs as effective treatments will increase during the next 10 years. May: Syracuse University report led by Dr. T. A. Wadden offers a multicenter evaluation of a proprietary weight reduction program after congressional hearings begun in March revealed that the $10 billion a year weight-loss industry is subject to minimal regulation by federal agencies. Because no proprietary program has provided an assessment of its short- and long-term treatment results, consumers are forced to rely on advertisements. May 5: International No-Diet Day begins when Mary Evans Young of London, England, and her group, Diet Breakers, hold a no-diet picnic in Hyde Park. September 4: American Academy of Pediatrics recommends that all American children over the age of two follow the lower-fat diet recommended for adults. November 5: New England Journal of Medicine reports on a study spanning more than 60 years that indicates that being overweight during the teenage years can lead to life-threatening chronic disease in adulthood, even if the youngster later sheds the excess weight. 1993 January: Citing the Framingham Heart Study, Harvard Heart Letter reports that yo-yo dieting may cause more harm than good suggesting that if dieters are not able to maintain their weight loss, it may be better for their cardiovascular health to remain a little overweight. January 17: A study by the Institute for Aerobics Research (Dallas) based on analysis of 12,866 men, finds that overweight men whose weight

Appendix I 313 remains constant over a period of six or seven years had lower heart attack risk than both men whose weight cycled up and down and men who lost weight. March: Newsletter of the American AnorexiaBulimia Association, Inc., announces that the DSM-IV manual of psychiatric disorders will include the new term binge-eating disorder, thereby officially recognizing compulsive overeaters as having an eating disorder. April: Nutrition Today report suggests that obesity should be regarded as a chronic condition. July 14: New York Times reports that a new drug (orlistat) that blocks fat absorption from the stomach and intestine is being tested in the United States and Europe. August: Environmental Nutrition reports that the 11 percent of total calories normally consumed from sugar poses no threat to health except by causing cavities. The frequent pairing of sugar with fat in foods is a problem; sugar alone does not generally cause weight gain. October 1: Annals of Internal Medicine report suggests that more special attention be given to obesity as it occurs in and affects ethnic minorities in the United States. In most of these groups, the prevalence of obesity is substantially higher than in whites, especially among women.

exercising less than their counterparts of a decade ago. Cause is probably related to large amount of television watched by teenagers. December 1: New York Times reports that scientists have isolated and cloned a gene that makes mice obese, and they have found a nearly identical gene in human fat tissue. December: Tuffs University Diet & Nutrition Letter reports that the National Task Force on the Prevention and Treatment of Obesity maintains there is no evidence that such a thing as weight cycling, or yoyo dieting, exists. Panel members made their statement after reviewing three decades of research.

1994 March 29: Washington Post reports on a study of 202 obese men and women that finds that weight cycling (yo-yo dieting) does not affect body composition or metabolic efficiency or increase cardiovascular risk. June: Dr. James Hill concludes in Environmental Nutrition that there is no evidence that yo-yo dieting alters body composition or metabolic rates. He concedes that the stress involved with repeat dieting may contribute to reports of heart disease and premature death. August: A National Institutes of Health workshop on pharmacologic treatment of obesity concludes that drugs may be effective in reducing body weight over an extended period of time. November: Centers for Disease Control and Prevention (CDC) releases two new studies showing that adolescents are more overweight and are

1996 January 2: U.S. Department of Agriculture announces a new version of the official Dietary Guidelines, which says that meatless diets can meet the Recommended Dietary Allowances (RDA) for nutrients as long as the variety and amounts of food consumed are adequate. May 7: Washington Post reports on approval of new weight-loss drug, dexfenfluramine, by the Food and Drug Administration, to be marketed under the name Redux. It works by slowing the depletion of a brain chemical called serotonin and is recommended only for those patients with a body mass index (BMI) of 30 or higher. May 28: Scientists from Ligand Pharmaceuticals, Inc., and the Institute Pasteur de Lille report they have discovered the DNA sequence responsible for controlling the expression of the human obesity gene, also called the leptin gene.

1995 February: Economic Research Service (ERS) of the U.S. Department of Agriculture (USDA) issues a report that provides information on the incidence, prevalence and costs of health conditions commonly associated with poor diets. Diet-related health conditions cost Americans an estimated $250 billion yearly. July 21: Research Alert reports that sales of diet aids in 1994 reached $419 million. December: U.S. Navy introduces a new heightweight chart that replaces an old standard of unknown origin that placed especially stringent limits on women and certain minority groups who are genetically programmed to add weight as they age.

314 The Encyclopedia of Obesity and Eating Disorders October 11: Knoll Pharmaceutical Company announces it has received an approval letter from the U.S. Food and Drug Administration to market Meridia (sibutramine) capsules for the treatment of obesity. October 25: Eli Lilly announces that the U.S. Food and Drug Administration approves Prozac (fluoxetine) as the first drug specifically cleared to treat bulimia. 1997 September 12: Food and Drug Administration removes from sale the widely used antiobesity drugs fenfluramine (Pondimin) and dexfenfluramine (Redux) because of more than 100 cases of heart valve abnormalities attributed to their use. November 24: Knoll Pharmaceutical Company announces it has received clearance from the U.S. Food and Drug Administration to market Meridia (sibutramin) capsules, pending U.S. Drug Enforcement Administration scheduling. Meridia will be indicated for the management of obesity, including weight loss and maintenance of weight loss, when used in conjunction with a reduced-caloric diet. 1998 June 17: The National Heart, Lung, and Blood Institute (NHLBI), in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), releases the first federal guidelines on the identification, evaluation and treatment of overweight and obesity in adults. These clinical guidelines are designed to help physicians. September 16: The National Institutes of Health (NIH) Office of Research on Women’s Health holds a seminar on “Eating Disorders: Fad and Facts,” presenting the latest research on the biological, genetic and psychological factors associated with these disorders, and discusses treatments. December 2: The Journal of the American Medical Association publishes research by Dr. Kathryn Rexrode and colleagues of Harvard Medical School that reports women with a waist measurement of 30 inches or more have twice the risk of coronary heart disease than their slimmer counterparts. 1999 January 6: The Office of Dietary Supplements (ODS) at the National Institutes of Health

announces the launch of its new International Bibliographic Information on Dietary Supplements (IBIDS) database. IBIDS database consists of published, international, scientific literature and is available to the public free of charge through the ODS Internet home page (http://dietary-supplements.info.nih.gov). May 13: The New England Journal of Medicine reports on five deaths of patients undergoing liposuction, raising questions about the safety of the country’s most popular kind of cosmetic surgery. July 14: Researchers in Britain and the United States announce the discovery of the SLC-1 receptor, a key receptor molecule for an appetite-stimulating hormone, which could herald the development of new treatments for obesity and anorexia nervosa. July 23: The University of Minnesota publishes a study showing that weight and blood pressure are increasing among children between the ages of 10 and 14. August 29: Dr. Jeffrey Koplan, director of the U.S. Centers for Disease Control and Prevention, says in the Dallas Morning News, “We are facing a real epidemic of obesity. All segments of the population are getting fatter, but the highest increase is among the younger ages.” September 29: Artal Luxembourg S. A., a private European investment firm, acquires Weight Watchers International Inc. for $735 million. 2000 January 25: Health and Human Services secretary Donna E. Shalala and Assistant Secretary for Health and Surgeon General David Satcher release the Healthy People 2010 initiative, a statement of national health objectives designed to identify the most significant preventable threats to health and to establish national goals to reduce these threats. Among the objectives to reduce overweight and obesity in the United States are to increase the proportion of adults who are at a healthy weight to 60 percent by 2010 and reduce the proportion of adults who are obese to 15 percent by 2010. January 25: David Satcher, M.D., the U.S. assistant secretary for health and surgeon general, announces that overweight and obesity have been named to a list of 10 U.S. health priorities called Leading Health Indicators (LHIs).

Appendix I 315 July 1: The American Psychiatric Association (APA) publishes a Revised Practice Guideline for Treating Eating Disorders. The original guideline on eating disorders was published in 1993. October 13: A Rand Health study published in the Archives of Internal Medicine reports that the proportion of Americans who suffer from clinically severe obesity—defined as those who are 100 or more pounds overweight—is rising twice as fast as the proportion of those who are simply obese. June 5: The LapBand Adjustable Gastric Banding System receives FDA approval. November 15: Weight Watchers International, Inc., announces that it has completed its initial public offering of 17.4 million shares of common stock at a price of $24 per share. December 13: The U.S. Department of Health and Human Services releases a report, The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity, outlining strategies that communities can use in helping to address health problems resulting from overweight and obesity. Those options include requiring physical education at all school grades, providing more healthy food options on school campuses and providing safe and accessible recreational facilities for residents of all ages. 2002 September 17: The Federal Trade Commission releases “Report on Weight-Loss Advertising: An Analysis of Current Trends.” The report concludes that false or misleading claims, such as exaggerated weight loss without diet or exercise, are widespread in ads for weight-loss products, and appear to have increased over the last decade. September 26: A group of scientists and National Institutes of Health staff meet to develop research priorities for the treatment of anorexia nervosa. December 30: The Centers for Disease Control and Prevention reports that obesity climbed from 19.8 percent of American adults to 20.9 percent of American adults between 2000 and 2001, and diagnosed diabetes (including gestational diabetes) increased from 7.3 percent to 7.9 percent during the same one-year period. The increases were evident regardless of sex, age, race and educational status.

2003 December 9: The Federal Trade Commission announces its “Red Flag” education campaign to assist media outlets voluntarily to screen out weight-loss product ads containing claims that are too good to be true. 2004 January 16: The Centers for Disease Control and Prevention announces that in 2000, the total cost of obesity was estimated to be $117 billion. Of this amount, $61 billion was due to direct medical costs and $56 billion to lost productivity. February 5: The Centers for Disease Control and Prevention announces that Americans are consuming more calories than they did 30 years ago, and the rate of increase is three times greater in women than men. February 24: The Henry J. Kaiser Family Foundation announces that the percentage of children ages six to 11 who were overweight in 1999 and 2000 was more than triple the average from 1963 to 1970. July 15: Health and Human Services secretary Tommy G. Thompson announces that the Centers for Medicare and Medicaid Services is removing language in Medicare’s coverage manual that states obesity is not an illness. By doing so, Medicare opens the door to expanded coverage of obesity treatments such as gastric bypass surgery, but treatment first must be shown to improve health. October 20: Trust for America’s Health releases a new report, F as in Fat: How Obesity Policies Are Failing in America, which says adult obesity exceeds 20 percent in 41 states and the District of Columbia, and all states are expected to fail the national goal of reducing the proportion of adults who are obese to 15 percent or lower by the year 2010. October 27: The Centers for Disease Control and Prevention releases a report, “Mean Body Weight, Height, and Body Mass Index (BMI) 1960–2002: United States,” which says adult men and women are roughly an inch taller than they were in 1960, but are nearly 25 pounds heavier on average as well. January 12: Health and Human Services secretary Tommy G. Thompson and USDA secretary Ann M. Veneman release Dietary Guidelines for

316 The Encyclopedia of Obesity and Eating Disorders Americans 2005. The guidelines provide authoritative advice about how good dietary habits can promote health and reduce risk for major chronic diseases in people two years and older. They serve as the basis for federal food and nutrition education programs. In light of the growing number of overweight and obese Americans, a major focus of the new guidelines is providing guidance to the public on maintaining a healthy weight and creating lifestyles that balance the number of calories eaten with the number of calories expended.

April 19: Agriculture secretary Mike Johanns unveils MyPyramid, a new symbol and interactive food guidance system. “Steps to a Healthier You,” MyPyramid, which replaces the Food Guide Pyramid introduced in 1992, is part of an overall food guidance system that emphasizes the need for a more individualized approach to improving diet and lifestyle. In addition to the multicolored bands representing the different food groups, the new symbol emphasizes the need for “activity,” which is represented by steps and a person climbing them.

APPENDIX II TABLES Table 1. Physical Manifestations of Anorexia Nervosa and Bulimia

Table 4. Danger Signals Table 5. How to Handle the Anorexic/Bulimic Child in the Family

Table 2. DSM-IV Criteria for Diagnosing Anorexia Nervosa, Bulimia Nervosa and Binge-Eating Disorder

Table 6. Food-Related Behaviors or Behavior Patterns

Table 3. Possible Medical Complications of Commonly Used Weight Regulation/WeightLoss Methods

Table 7. Body Mass Index Table

317

318 The Encyclopedia of Obesity and Eating Disorders TABLE 1 PHYSICAL MANIFESTATIONS OF ANOREXIA NERVOSA AND BULIMIA Manifestation

Anorexia Nervosa

Bulimia

Endocrine/metabolic

Amenorrhea Osteoporosis Euthyroid sick syndrome Decreased norepinephrine secretion Decreased somatomedin Elevated growth hormone Decreased or erratic vasopressin secretion Abnormal temperature regulation Hypercarotenemia

Menstrual irregularities

Cardiovascular

Bradycardia Hypotension Arrhythmias

Ipecac poisoning

Renal

Increased blood urea nitrogen Renal calculi Edema

Hypokalemia (diuretic induced)

Gastrointestinal

Decreased gastric emptying Constipation Elevated hepatic enzymes

Acute gastric dilation, rupture Parotid enlargement Dental-enamel erosion Esophagitis Mallory-Weiss tears, esophageal rupture Hypokalemia (laxative induced)

Hematologic

Anemia Leukopenia Thrombocytopenia

Pulmonary

Aspiration pneumonia

Source: David B. Herzog and Paul M. Copeland. “Eating Disorders.” New England Journal of Medicine 313, no. 5 (August 1, 1985): 297.

Appendix II 319 TABLE 2 DSM-IV CRITERIA FOR DIAGNOSING ANOREXIA NERVOSA, BULIMIA NERVOSA AND BINGE-EATING DISORDER Anorexia Nervosa

1. Refusal to maintain normal body weight 2. Intense fear of gaining weight or becoming fat 3. Disturbance of body image 4. Amenorrhea in menstruating females Specific type: Restricting Type: Has not regularly engaged in binge-eating or purging behavior Binge-Eating/Purging Type: Has regularly engaged in binge-eating or purging behavior Bulimia Nervosa

1. Recurrent episodes of binge eating 2. Repeated attempts to prevent weight gain through self-induced vomiting; laxative, diuretic or medication misuse; or excessive exercise 3. Both of the above occur at least twice a week for three months 4. Poor self-image due to body shape and weight 5. Disturbance does not occur only during episodes of anorexia Specific type: Purging Type: Has regularly engaged in self-induced vomiting or laxative/diuretic abuse Nonpurging Type: Fasts or does excessive exercise to lose weight, but has not regularly engaged in self-induced vomiting or abuse of laxatives, diuretics or enemas Binge-Eating Disorder

1. Recurrent episodes of binge eating 2. At least three of the following: a. eating much more rapidly than normal b. eating until feeling uncomfortably full c. eating large amounts of food when not hungry d. eating alone because of embarrassment of how much being eaten e. feeling disgusted, depressed or very guilty after overeating 3. Marked distress over binge eating 4. Binge eating occurs on average at least two days a week for six months 5. Binge eating not associated with purging, fasting or excessive episode, and not occurring only through anorexia nervosa or bulimia nervosa Source: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, D.C.: American Psychiatric Association, 1994.

320 The Encyclopedia of Obesity and Eating Disorders TABLE 3 POSSIBLE MEDICAL COMPLICATIONS OF COMMONLY USED WEIGHT REGULATION/WEIGHT-LOSS METHODS Vomiting

Parotid gland enlargement (neck area) Erosion of tooth enamel and increased cavities Tears in esophagus Chronic esophagitis Chronic sore throat Difficulty swallowing Stomach cramps Digestive problems Anemia Electrolyte imbalance Diuretic Abuse

Hypokalemia (low potassium): fatigue; diminished reflexes; if severe, possible cardiac arrhythmia; if chronic, serious kidney damage Fluid loss: dehydration, lightheadedness, thirst Laxative Abuse

Nonspecific abdominal complaints, cramping, constipation Sluggish bowel functioning (“cathartic colon”) Malabsorption of fat, protein and calcium ( Combinations of these methods can dangerously affect potassium regulation and fluid balance.) Source: An Overview of Eating Disorders by the National Anorexic Aid Society Inc., copyright © 1991 by NAAS. Ohio.

Appendix II 321 TABLE 4 DANGER SIGNALS

Eating disorders may be prevented or more readily treated if they are detected early. A person who has several of the following signs may be developing or has already developed an eating disorder. Anorexia

The individual:

• • • • • • • • • • • •

Has lost a great deal of weight in a relatively short period. Continues to diet although bone-thin. Reaches diet goal and immediately sets another goal for further weight loss. Remains dissatisfied with appearance, claiming to feel fat, even after reaching weight loss goal. Prefers dieting in isolation to joining a diet group. Loses monthly menstrual periods. Develops unusual interest in food. Develops strange eating rituals and eats small amounts of food, e.g., cuts food into tiny pieces or measures everything before eating extremely small amounts. Becomes a secret eater. Becomes obsessive about exercising. Appears depressed much of the time. Begins to binge and purge (see below). Bulimia

The individual:

• Binges regularly (eats large amounts of food over a short period of time), and • Purges regularly (forces vomiting and/or uses drugs to stimulate vomiting, bowel movements and urination). • Diets and exercises often but maintains or regains weight. • Becomes a secret eater. • Eats enormous amounts of food at one sitting but does not gain weight. • Disappears into the bathroom for long periods of time to induce vomiting. • Abuses drugs or alcohol or steals regularly. • Appears depressed much of the time. • Has swollen neck glands. • Has scars on the back of hands from forced vomiting. Source: National Institute of Mental Health.

322 The Encyclopedia of Obesity and Eating Disorders TABLE 5 HOW TO HANDLE THE ANOREXIC/BULIMIC CHILD IN THE FAMILY Don’t

1. Do not urge your child to eat, or watch her eat, or discuss food intake or weight with her. Leave the room if necessary. Your involvement with the child’s eating is her tool for manipulating parents. Take this tool out of her hands. 2. Do not allow yourself to feel guilty. Most parents ask: “What have I done wrong?” There are no perfect parents. You have done the best you could. Once you have checked out physical condition with a physician and made it possible for her to begin counseling, getting well is her responsibility. It is her problem, not yours. 3. Do not neglect your marriage partner or other children. Focusing on the sick child can perpetuate her illness and destroy the family. The anorexic must be made aware by your actions and attitudes that she is important to you, but no more important than every other member of the family. Do not commiserate; this only confirms the child in her illness. She knows you love her. 4. Do not be afraid to have the child separated from you, either at school or in separate housing, if it becomes obvious that her continued presence is undermining the emotional health of the family. The final separation is death; don’t allow her to intimidate the family with threats of suicide. 5. Do not put down the child by comparing her to her more “successful” siblings or friends. Her self-esteem is a reflection of your esteem for her. Do not ask questions such as, “How are you feeling,” or “How is your social life?” She already feels inadequate, and questions only aggravate the feeling. Do

1. Love your child as you should love yourself. Love makes anyone feel worthwhile. 2. Trust your child to find her own values, ideals and standards, rather than insisting on yours. In any case, all ideals are just that . . . only ideals. In practice we fall short, too; our own behavior is adulterated with self-serving rewards. 3. Do everything to encourage her initiative, independence and autonomy. Be aware though, that anorexics tend to be perfectionists, so that they are never satisfied with themselves. Perfectionism justifies their dissatisfaction with themselves. 4. Be aware of the long-term nature of the illness. Anorexics do get better; many get completely well, very few die. But families must face months and sometimes years of treatment and anxiety. There are no counselors or psychiatrists with the same answer to every case. A support group such as a parents self-help group may make a significant difference to your family’s survival; it helps you to deal with yourself in relation to your anorexic child. You must make the child understand that your life is as important as hers. Source: American Anorexia/Bulimia Association, Inc.

Appendix II 323 TABLE 6 FOOD-RELATED BEHAVIORS OR BEHAVIOR PATTERNS

The following guidelines were published in BASH Magazine, April 1989, for identifying and monitoring the eating habits of eating-disordered patients. A. Food Preferences (Anorexia)

1. Restrictive in fat and protein in all food selections. 2. Consumes most vegetables and specific fruits to control weight gain. 3. Observable increase in the amount of noncaloric condiments used to alter the flavor of food, possibly to make it less appealing (cinnamon, mustard, vinegar). 4. Increased desire for diet drinks, coffee and/or tea. B. Food Preferences (Bulimia)

1. Polyphagic or carbohydrate specific during a binge; however, when not in a binge-purge cycle, specific “binge” foods, such as cereal, cakes, cookies, ice cream, bread, nuts, peanut butter, pasta, crackers and chips, are restricted. 2. Consumes easily purged foods to control weight gain, such as ice cream, cheese, eggs, vegetables, cereal, milk. 3. Craves foods that satisfy taste desires, usually for sweet or salty foods. 4. Increased desire for diet drinks, coffee and/or tea. 5. Consumes excess fluid to aid vomiting; attempts to suppress hunger and aid rehydration. C. Physical Experience (Anorexia)

1. Cuts food into small pieces. 2. Arranges food on plate. 3. Eats slowly, with prolonged chewing time before swallowing. 4. Prefers small containers of food. 5. Throws away or hides food to avoid consumption. 6. Does not self-induce vomiting to control food intake. (The exception is the bulimic anorexic.) D. Physical Experience (Bulimia)

1. 2. 3. 4. 5. 6.

Normal to large bites of food. May mix foods together. Eats rapidly with shortened chewing time before swallowing. Prefers large containers of food. Dislikes being responsible for food waste and will overeat or hoard food for an isolated binge experience. Vomits to control food absorption by inducing vomiting, spontaneous rumination or regurgitation.

Source: BASH Magazine, April 1989.

324 The Encyclopedia of Obesity and Eating Disorders BODY MASS INDEX (BMI) TABLE BMI

19

20

21

22

23

24

25

Height

4’10” (58”) 4’11” (59”) 5’ (60”) 5’1” (61”) 5’2” (62”) 5’3” (63”) 5’4” (64”) 5’5” (65”) 5’6” (66”) 5’7” (67”) 5’8” (68”) 5’9” (69”) 5’10” (70”) 5’11” (71”) 6’ (72”) 6’1” (73”) 6’2’ (74”) 6’3’ (75”)

26

27

28

29

30

31

32

33

34

35

143 148 153 158 164 169 174 180 186 191 197 203 209 215 221 227 233 240

148 153 158 164 169 175 180 186 192 198 203 209 216 222 228 235 241 248

153 158 163 169 175 180 186 192 198 204 210 216 222 229 235 242 249 256

158 163 168 174 180 186 192 198 204 211 216 223 229 236 242 250 256 264

162 168 174 180 186 191 197 204 210 217 223 230 236 243 250 257 264 272

167 173 179 185 191 197 204 210 216 223 230 236 243 250 258 265 272 279

Weight (in pounds)

91 94 97 100 104 107 110 114 118 121 125 128 132 136 140 144 148 152

96 99 102 106 109 113 116 120 124 127 131 135 139 143 147 151 155 160

100 104 107 111 115 118 122 126 130 134 138 142 146 150 154 159 163 168

105 109 112 116 120 124 128 132 136 140 144 149 153 157 162 166 171 176

110 114 118 122 126 130 134 138 142 146 151 155 160 165 169 174 179 184

115 119 123 127 131 135 140 144 148 153 158 162 167 172 177 182 186 192

119 124 128 132 136 141 145 150 155 159 164 169 174 179 184 189 194 200

124 128 133 137 142 146 151 156 161 166 171 176 181 186 191 197 202 208

129 133 138 143 147 152 157 162 167 172 177 182 188 193 199 204 210 216

134 138 143 148 153 158 163 168 173 178 184 189 195 200 206 212 218 224

138 143 148 153 158 163 169 174 179 185 190 196 202 208 213 219 225 232

Source: Evidence Report of Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, 1998. NIH/National Heart, Lung, and Blood Institute (NHLBI).

APPENDIX III SOURCES OF INFORMATION (312) 899-0040 http://www.eatright.org

Academy for Eating Disorders 60 Revere Drive Suite 500 Northbrook, IL 60062-1577 (847) 498-4274 (847) 480-9282 (fax) http://www.aedweb.org [email protected]

American Obesity Association 1250 24th Street NW Suite 300 Washington, DC 20037 (202) 776-7711 (202) 776-7712 (fax) http://www.obesity.org [email protected]

Active Living by Design 400 Market Street Suite 205 Chapel Hill, NC 27516 (919) 843-ALBD (919) 843-3083 (fax) http://www.activelivingbydesign.org [email protected]

American Psychiatric Association 1000 Wilson Boulevard Arlington, VA 22209-3901 (202) 682-6000 http://www.psych.org [email protected]

American Anorexia and Bulimia Association of Philadelphia P.O. Box 1287 Langhorne, PA 19047 (215) 221-1864 (215) 702-8944 (fax) http://www.aabaphila.org

American Society for Bariatric Surgery 100 Southwest 75th Street Suite 201 Gainesville, FL 32607 (352) 331-4900 (352) 331-4975 (fax) http://www.asbs.org [email protected]

American Board of Medical Specialties 1007 Church Street Suite 404 Evanston, IL 60201-5913 (866) ASK-ABMS (847) 491-9091 (847) 328-3596 (fax) http://www.abms.org

American Society of Bariatric Physicians 2821 South Parker Road Suite 625 Aurora, CO 80014-2735 (303) 770-2526 (303) 779-4834 (fax) http://www.asbp.org [email protected]

American Dietetic Association Headquarters 120 South Riverside Plaza Suite 2000 Chicago, IL 60606 (800) 877-1600

American Society of Plastic Surgeons 444 East Algonquin Road Arlington Heights, IL 60005 (847) 228-9900

325

326 The Encyclopedia of Obesity and Eating Disorders http://www.plasticsurgery.org [email protected]

http://members.aol.com/HEALNatnl [email protected]

Anorexia Nervosa and Related Eating Disorders, Inc. (ANRED) (affiliated with National Eating Disorders Association) http://www.anred.com

International Size Acceptance Association P.O. Box 82126 Austin, TX 78758 (512) 371-4307 http://www.size-acceptance.org [email protected]

Center for Science in the Public Interest 1875 Connecticut Avenue NW Suite 300 Washington, DC 20009 (202) 332-9110 (202) 265-4954 (fax) http://www.cspinet.org [email protected] Council on Size and Weight Discrimination, Inc. P.O. Box 305 Mt. Marion, NY 12456 (845) 679-1209 (845) 679-1206 (fax) http://www.cswd.org [email protected] Eating Disorders Anonymous (EDA) 780 West Hackberry Drive Chandler, AZ 85248 http://www.eatingdisordersanonymous.org [email protected] Eating Organization of New Jersey 721 Executive Drive Princeton, NJ 08540 (800) 522-2230 (609) 252-0202 (609) 252-0184 (fax) HEED (Helping End Eating Disorders) Foundation 205 South Service Road Plainview, NY 11803 (516) 694-1054 http://www.heedfoundation.org [email protected] Human Ecology Action League, Inc. (HEAL) P.O. Box 29629 Atlanta, GA 30359-0629 (404) 248-1898 (404) 248-0162 (fax)

Massachusetts Eating Disorder Association 92 Pearl Street Newton, MA 02458 (609) 252-0202 http://www.medainc.org National Association to Advance Fat Acceptance (NAAFA) P.O. Box 22510 Oakland, CA 94609 http://naafa.org [email protected] National Eating Disorders Association 603 Stewart Street Suite 803 Seattle, WA 98101 (206) 382-3587 (206) 829-8501 (fax) http://www.NationalEatingDisorders.org [email protected] National Eating Disorders Association–Long Island (formerly Eating Disorder Council of Long Island) 50 Charles Lindbergh Boulevard Suite 400 Uniondale, NY 11553 (718) 962-2778 National Institute of Mental Health (NIMH) Information Resources and Inquiries Branch 5600 Fishers Lane Room 7C-02 Rockville, MD 20857 FACTS ON DEMAND: (301) 443-5158 http://www.nimh.nih.gov Overeaters Anonymous (OA) P.O. Box 44020 Rio Rancho, NM 87174-4020 (505) 891-2664

Appendix III 327 (505) 891-4320 (fax) http://www.oa.org [email protected] TOPS (Take Off Pounds Sensibly) Club 4575 South Fifth Street P.O. Box 070360 Milwaukee, WI 53207-0360 (414) 482-4620 http://www.tops.org

Weight Watchers International, Inc. 175 Crossways Park West Woodbury, NY 11797-2055 (800) 651-6000 (516) 390-1400 (516) 390-1334 (fax) http://www.weightwatchers.com

APPENDIX IV OBESITY AND EATING DISORDER TREATMENT CENTERS http://www.edcca.com [email protected]

ARIZONA Mirasol 7650 East Broadway Suite 303 Tucson, AZ 85710-3773 (888) 520-1700 [email protected] http://www.mirasol.net

Healthy Within, Inc. 5665 Oberlin Drive Suite 206 San Diego, CA 92121 (858) 622-0221 http://www.healthywithin.com

Remuda Ranch One East Apache Street Wickenburg, AZ 85390 (800) 455-1900 (928) 684-3913 http://www.remudaranch.com [email protected]

Oak Knoll Family Therapy Center 12307 Oak Knoll Road Suite O Poway, CA 92064 (858) 748-4323 http://www.oakknollftc.com Rader Eating Disorder Treatment Programs Pacific Shores Hospital 2130 North Ventura Road Oxnard, CA 93036 (800) 841-1515 http://www.raderprograms.com [email protected]

Rosewood Ranch: Women’s Center for Eating Disorders 36075 South Rincon Road Wickenburg, AZ 85390 (800) 845-2211 (928) 684-9594 http://www.rosewoodranch.com [email protected]

COLORADO Eating Disorder Center of Denver 950 South Cherry Street Suite 300 Denver, CO 80246 (866) 771-0861 (toll-free) (303) 771-0861 http://www.edcdenver.com [email protected]

CALIFORNIA Center for Eating and Weight Disorders at San Diego State University 6495 Alvarado Road Suite 200 San Diego, CA 92120 (619) 594-3254 Eating Disorder Center of California 27162 Sea Vista Drive Malibu, CA 90265 (facility located in Brentwood, CA) (310) 457-9958

CONNECTICUT Wilkens Center 7 Riversville Road Greenwich, CT 06831

328

Appendix IV 329 (203) 531-1909 http://www.wilkinscenter.com Yale Center for Eating and Weight Disorders 405 Temple Street P.O. Box 208205 New Haven, CT 06520-8205 (203) 432-4610 http://www.yale.edu/ycewd [email protected]

FLORIDA Eating Disorders Treatment Specialists of Miami Miami location: 7325 Southwest 63rd Avenue Suite 101 South Miami, FL 33143 (305) 284-1143 Palm Beach location: 600 Sandtree Drive Suite 203-C Palm Beach Gardens, FL 33403 (561) 626-8070 http://www.ereassoc.com [email protected] Family Behavioral Center 5850 West Atlantic Avenue Suite 101 Delray Beach, FL 33484 (888) 870-8484 (561) 637-2592 http://www.familybehavioralcenter.com The Renfrew Center of South Florida 7700 Renfrew Lane Coconut Creek, FL 33073 (800) RENFREW (954) 698-9222 http://www.renfrewcenter.com The Willough at Naples 9001 Tamiami Trail East Naples, FL 34113 (800) 722-0100 http://thewilloughatnaples.com [email protected]

Feinberg School of Medicine 303 East Chicago Avenue Chicago, IL 60611-3008 (312) 695-2269 http://www.eatingdisorders.northwestern.edu

MINNESOTA University of Minnesota Eating Disorders Research Program Department of Psychiatry 606 24th Avenue South Suite 602 Minneapolis, MN 55454 http://www.tc.umn.edu/~crowx002/progeds.html

MISSOURI Castlewood Treatment Center 800 Holland Road St. Louis, MO 63021 (888) 822-8938 http://www.castlewoodtc.com [email protected]

NEBRASKA Eating Disorders Program at Children’s Hospital 8200 Dodge Street Omaha, NE 68114 (800) 642-8822 (402) 955-6190 http://www.chsomaha.org

NEW JERSEY The Rutgers Eating Disorders Clinic Rutgers, The State University of New Jersey 41 Gordon Road Suite C Piscataway, NJ 08854-5972 (732) 445-2292 http://gsappweb.rutgers.edu/EDC

NEW YORK ILLINOIS Weight and Eating Disorders Program at Northwestern University

Adolescent Eating Disorders Program Golisano Children’s Hospital at Strong Adolescent Medicine

330 The Encyclopedia of Obesity and Eating Disorders 601 Elmwood Avenue, Box 690 Rochester, NY 14642 (585) 275-2964 http://www.stronghealth.com/services/childrens/ PatientCare/eatingdisordersprogram.cfm Avalon Eating Disorder Center 346 Harris Hill Road Williamsville, NY 14221 (866) 814-0999 (toll-free) (716) 839-0999 http://www.avalon-eatingdisorders.com Eating Disorders Clinic (New York State Psychiatric Institute and Columbia University Medical Center) 1051 Riverside Drive Unit 98 New York, NY 10032 (212) 543-5739 http://www.columbia.edu/~ea12 [email protected] The Renfrew Center of New York 11 East 36th Street New York, NY 10016 (800) RENFREW http://www.renfrewcenter.com

NORTH CAROLINA Duke Diet and Fitness Center 804 West Trinity Avenue Durham, NC 27701 (800) 235-3853 http://www.dukedietcenter.org [email protected]

OKLAHOMA Rader Eating Disorder Treatment Programs Brookhaven Hospital 201 South Garnett Tulsa, OK 74128-1800 (800) 841-1515 [email protected] http://www.raderprograms.com

PENNSYLVANIA The Renfrew Center of Philadelphia 475 Spring Lane

Philadelphia, PA 19128 (800) RENFREW http://www.renfrewcenter.com Weight and Eating Disorders Program at the University of Pennsylvania Department of Psychiatry 3535 Market Street Suite 3108 Philadelphia, PA 19104 (215) 898-7314 http://www.med.upenn.edu/weight [email protected] Western Psychiatric Institute and Clinic (University of Pittsburgh Medical Center) 3811 O’Hara Street Pittsburgh, PA 15213 (412) 624-5420 http://wpic.upmc.com/EatingDisorderSvcs.htm

RHODE ISLAND Lifespan Weight Management Programs at Miriam Hospital Center 164 Summit Avenue Providence, RI 02906 (401) 444-4800 http://www.lifespan.org/Services/BMed/Wt_loss/ about.htm

SOUTH CAROLINA Medical University of South Carolina Weight Management Center IOP South 67 President Street Suite 410 Charleston, SC 29425 (800) 553-7489 (843) 792-2273 http://www.muschealth.com/weight

TEXAS The Menninger Clinic Eating Disorders Programs 2801 Gessner Drive P.O. Box 809045 Houston, TX 77280-9045 (713) 275-5000

Appendix IV 331 (800) 351-9058 http://www.menningerclinic.com/p-eatingdisorders Shades of Hope 402-A Mulberry Street P.O. Box 639 Buffalo Gap, TX 79508 (800) 588-HOPE (325) 572-3843 (325) 572-3405 (fax) http://www.shadesofhope.com [email protected]

WEIGHT REDUCTION CAMPS

CALIFORNIA Western Wellspring Adventure Camp Academy of the Sierras 42675 Road 44 Reedley, CA 93654 (866) 364-0808 (toll-free) (559) 638-4570 http://www.westernadventurecamp.com [email protected]

UTAH Avalon Hills 7852 West 600 North Petersboro, UT 84325 (800) 330-0490 (435) 753-3686 http://www.avalonhills.org [email protected] Center for Change 1790 North State Street Orem, UT 84057 (888) 224-8250 (801) 224-8255 http://www.centerforchange.com [email protected]

VERMONT Green Mountain at Fox Run Fox Lane, Box 164 Ludlow, VT 05149 (800) 448-8106 (802) 228-8885 http://www.fitwoman.com [email protected]

WASHINGTON The Center for Counseling and Health Resources, Inc. P.O. Box 700 547 Dayton Edmonds, WA 98020 (888) 771-5166 (425) 771-5166 http://www.aplaceofhope.com

MASSACHUSETTS Camp Kingsmont Hampshire College 893 West Street Amherst, MA 01002 Winter address: Camp Kingsmont 195 Main Street Great Barrington, MA 01230 (800) 854-1377 (413) 528-8474 http://www.campkingsmont.com

NEW YORK Camp Shane September 10–June 5: 134 Teatown Road Croton on Hudson, NY 10520 (914) 271-4141 June 6–September 9: 302 Harris Road Ferndale, NY 12734 (845) 292-4644 http://www.campshane.com [email protected] Wellspring Camps Healthy Living Academies 17777 Center Court Drive Suite 300 Cerritos, CA 90703 (866) 364-0808 (toll-free) (562) 467-5578 (fax) http://www.wellspringcamps.com [email protected]

332 The Encyclopedia of Obesity and Eating Disorders NORTH CAROLINA Wellspring Adventure Camp Healthy Living Academies 17777 Center Court Drive Suite 300 Cerritos, CA 90703 (866) 364-0808 (toll-free) (562) 467-5578 (fax) http://www.wellspringadventurecamp.com [email protected]

PENNSYLVANIA Camp Pennbrook P.O. Box 100 Pennsburg, PA 18073 (800) 442-7366 Winter address: P.O. Box 5 Leonia, NJ 07605-0005 (212) 354-CAMP http://www.camppennbrook.com [email protected]

APPENDIX V GLOSSARY OF FAT REPLACERS Food technologists are investigating a wide range of ingredients and processes to replace fat in foods and beverages. The following is a list of fat replacers currently in use or which have research efforts in place to develop them.

Various forms are used. One is a noncaloric purified form of cellulose ground to microparticles, which when dispersed, form a network of particles with mouthfeel and flow properties similar to fat. Cellulose can replace some or all of the fat in dairy-type products, sauces, frozen desserts and salad dressings.

PROTEIN-BASED FAT REPLACERS

Dextrins (Amylum, N-Oil) Four calorie/gram fat replacers that can replace all or some of the fat in a variety of products. Food sources for dextrins include tapioca. Applications include salad dressings, puddings, spreads, dairytype products and frozen desserts.

Microparticulated Protein (Simplesse) Reduced-calorie (1–2 calorie/gram) ingredient made from whey protein or milk and egg protein. Digested as a protein. Many applications, including dairy products (e.g., ice cream, butter, sour cream, cheese, yogurt), salad dressing, margarine- and mayonnaise-type products, as well as baked goods, coffee creamer, soups and sauces.

Fiber (Opta, Oat Fiber, Snowite, Ultracel, ZTrim) Fiber can provide structural integrity, volume, moisture-holding capacity, adhesiveness and shelf stability in reduced-fat products. Applications include baked goods, meats, spreads and extruded products.

Modified Whey Protein Concentrate (Dairy-Lo) Controlled thermal denaturation results in a functional protein with fat-like properties. Applications include milk/dairy products (cheese, yogurt, sour cream, ice cream), baked goods, frostings, as well as salad dressing and mayonnaise-type products.

Gums (KELCOGEL, KELTROL, Slendid) Also called hydrophilic colloids or hydrocolloids. Examples include guar gum, gum arabic, locust bean gum, xanthan gum, carrageenan and pectin. Virtually noncaloric, provide thickening, sometimes gelling effect; can promote creamy texture. Used in reduced-calorie, fat-free salad dressings and to reduce fat content in other formulated foods, including desserts and processed meats.

Other (K-Blazer, ULTRA-BAKE, ULTRAFREEZE, Lita) One example is a reduced-calorie fat substitute based on egg white and milk proteins. Similar to microparticulated protein but made by a different process. Another example is a reduced-calorie fat replacer derived from a com protein. Some blends of protein and carbohydrate can be used in frozen desserts and baked goods.

Inulin (Raftiline, Fruitafit, Fibruline) Reduced-calorie (1–1.2 calorie/gram) fat and sugar replacer, fiber and bulking agent extracted from chicory root. Used in yogurt, cheese, frozen desserts, baked goods, icings, fillings, whipped cream, dairy products, fiber supplements and processed meats.

CARBOHYDRATE-BASED FAT REPLACERS Cellulose (Avicel cellulose gel, Methocel, Solka-Floc)

333

334 The Encyclopedia of Obesity and Eating Disorders Maltodextrins (CrystaLean, Lorelite, Lycadex, MALTRIN, Paselli D-LITE, Paselli EXCEL, Paselli SA2, STAR-DRI) Four calorie/gram gel or powder derived from carbohydrate sources such as com, potato, wheat and tapioca. Used as fat replacer, texture modifier or bulking agent. Applications include baked goods, dairy products, salad dressings, spreads, sauces, frostings, fillings, processed meat, frozen desserts, extruded products and beverages. Nu-Trim A beta-glucan-rich fat replacer made from oat and barley using an extraction process that removes coarse fiber components. The resulting product can be used in foods and beverages such as baked goods, milk, cheese and ice cream, yielding products that are both reduced in fat and high in betaglucan. (The soluble fiber beta-glucan has been cited as the primary component in oats and barley that is responsible for beneficial reduction in cardiovascular risk factors.) Oatrim—Hydrolyzed Oat Flour (Beta-Trim, Trim-Choice) A water-soluble form of enzyme-treated oat flour containing beta-glucan soluble fiber and used as a fat replacer, bodying and texturizing ingredients. Reduced calorie (1–4 calories/gram) as used in baked goods, fillings and frostings, frozen desserts, dairy beverages, cheese, salad dressings, processed meats and confections. Polydextrose (Litesse, Sta-Lite) Reduced-calorie (1 calorie/gram) fat replacer and bulking agent. Water-soluble polymer of dextrose containing minor amounts of sorbitol and citric acid. Approved for use in a variety of products including baked goods, chewing gums, confections, salad dressings, frozen dairy desserts, gelatins and puddings. Polyols (Many Brands Available) A group of sweeteners that provide the bulk of sugar, without as many calories as sugar (1.6–3.0 calories per gram, depending on the polyol). Due

to their plasticizing and humectant properties, polyols also may be used to replace the bulk of fat in reduced-fat and fat-free products. Starch and Modified Food Starch (Amalean I & II, Fairnex VA15 & VA2O, Instant Stellar, N-Lite, OptaGrade*, Perfectamyl AC, AX-i & AX-2, PURE-GEL, STA-SLIM) Reduced-calorie (1–4 calories/gram as used) fat replacers, bodying agents, texture modifiers. Can be derived from potato, corn, oat, rice, wheat or tapioca starches. Can be used together with emulsifiers, proteins, gums and other modified food starches. Applications include processed meats, salad dressings, baked goods, fillings and frostings, sauces, condiments, frozen desserts and dairy products. Z-Trim A calorie-free fat replacer made from insoluble fiber from oat, soybean, pea and rice hulls or corn or wheat bran. It is heat stable and may be used in baked goods (where it can also replace part of the flour), burgers, hot dogs, cheese, ice cream and yogurt.

FAT-BASED FAT REPLACERS Emulsifiers (Dur-Lo, EC-25) Examples include vegetable oil-mono- and diglyceride emulsifiers, which can with water replace all or part of the shortening content in cake mixes, cookies, icings, and numerous vegetable dairy products. Same caloric value as fat (9 calories/gram) but less is used, resulting in fat and calorie reduction. Sucrose fatty acid esters also can be used for emulsification in products such as those listed above. Additionally, emulsion systems using soybean oil or milk fat can significantly reduce fat and calories by replacing fat on a oneto-one basis. Salatrim (Benefat) Short- and long-chain acid triglyceride molecules. A 5 calorie/gram family of fats that can be adapted for use in confections, baked goods, dairy and other applications.

* Appears as cornstarch on the ingredient statement, others appear as food starch modified

Appendix V 335 Lipid (Fat/Oil) Analogs Esterified Propoxylated Glycerol (EPG)** Reduced-calorie fat replacer. May partially or fully replace fats and oils in all typical consumer and commercial applications, including formulated products, baking and frying. Olestra (Olean) Calorie-free ingredient made from sucrose and edible fats and oils. Not metabolized and unabsorbed by the body. Approved by the FDA for use in replacing the fat used to make salty snacks and crackers. Stable under high-heat food applications such as frying. Has the potential for numerous other food applications.

** May require FDA approval

Sorbestrin** Low-calorie, heat-stable, liquid fat substitute composed of fatty acid esters of sorbitol and sorbitol anhydrides. Has approximately 1.5 calories/gram and is suitable for use in all vegetable oil applications including fried foods, salad dressing, mayonnaise and baked goods. NOTE: Brand names are shown in parentheses as examples. Copyright © 2000 Calorie Control Council, 5775 Peachtree-Dunwoody Rd., Suite 500, Atlanta, GA 30342; telephone: (404) 252-3663; e-mail: ccc@ assnhq.com; Internet: www.caloriecontrol.org.

APPENDIX VI WEB SITES OF INTEREST Provides a directory to credible, accurate and practical food and human nutrition information resources for consumers, nutrition and health professionals, educators and government personnel.

Amplestuff http://www.amplestuff.com Offers products for men and women who are plus or supersize. Some products are plus-sized versions of items that are readily available to average-sized people, such as fanny packs, socks or hospital gowns. Other products—such as airline seatbelt extenders and size-positive books and videos—are designed especially for larger people.

HealthyPlace.com Eating Disorders Center http://www.concernedcounseling.com/Communities/Eating_Disorders/index.asp

Eating Disorder Referral and Information Center http://www.edreferral.com

Provides comprehensive information on eating disorders from both patient and expert points of view. Offers active chat rooms, hosted support groups, educational information and professional resources such as the online Eating Attitudes Test (EAT-26).

Provides information and treatment resources for all forms of eating disorders.

InteliHealth http://www.intelihealth.com

Eating Disorders—Find Eating Disorder Treatment http://www.eating-disorder.com

In 2000, Harvard Medical School became the content partner for this site, which provides medical news, research, disease information, discussion boards, a drug resource center, medical dictionary and section for weight management.

Find a treatment center by patients’ condition, by type of facility or by state.

Mayo Clinic http://www.mayoclinic.com/invoke.cfm?id=DS00314

Eating Disorders Online http://eatingdisordersonline.com

Provides articles on obesity and weight loss, as well as a BMI calculator and daily calorie calculator.

Information about eating disorders, anorexia, bulimia, binge-eating disorder, compulsive overeating and overexercising. Also offers a list of treatment options around the world, current news, information on recovery and a forum for online support.

National Institutes of Health (NIH) http://www.nih.gov

Eating Disorders Resources http://edr.org.uk

Provides health information, grants and funding opportunities, research training and scientific resources, and an NIH search engine.

Formerly Lucy Serpell’s Eating Disorders Resources (since 1994), a clearinghouse for eating disorders news, research, reports, conferences and opinions.

New York Online Access to Health (NOAH) http://www.noah-health.org/en/mental/disorders/ eating

Food and Nutrition Information Center at the National Agricultural Library http://www.nal.usda.gov/fnic

Provides in-depth information on anorexia nervosa, binge-eating, bulimia nervosa, compulsive eating, night eating syndrome and pica.

336

Appendix VI 337 Obesity Help http://www.obesityhelp.com Dedicated to the education, empowerment and support of all individuals affected by obesity, along with others (friends, employers, physicians) concerned. Their stated goal is to defeat ignorance, isolation and discrimination against the clinical disease of obesity. PubMed http://www.ncbi.nlm.nih.gov/entrez/query.fcgi

Service (USDA/ARS), offering a nutrition newsletter, weight management brochures, interactive nutrition calculators and research articles. The Weight-control Information Network http://win.niddk.nih.gov/index.htm Provides the general public, health professionals, the media and Congress with up-to-date, science-based information on weight control, obesity, physical activity and related nutritional issues.

A service of the National Library of Medicine, PubMed includes more than 15 million citations for biomedical articles back to the 1950s. These citations are from the MEDLINE database and life science journals. PubMed includes links to many sites providing full text articles and other related resources.

ONLINE DIET CENTERS

Shape Up America! http://www.shapeup.org

http://www.cyberdiet.com

A national nonprofit initiative to promote healthy weight and increased physical activity in America.

The following Internet weight loss programs were designed by registered dietitians and are recommended by such groups as the American Medical Association:

Owned by dietwatch.com, features very similar content and services. http://www.dietwatch.com

SuperSizeWorld http://www.supersizeworld.com

Comprehensive site with meal plans, shopping lists, “meditation room” and message boards.

Sells products for plus-sized people, such as highcapacity scales, huge towels, toenail clippers, XXXXXL life jackets, airline seat belt extenders and big bicycle seats.

http://www.ediets.com

USDA/ARS Children’s Nutrition Research Center http://www.kidsnutrition.org

http://www.fitday.com

A cooperative venture between Baylor College of Medicine, Texas Children’s Hospital and the U.S. Department of Agriculture/Agricultural Research

Focuses on individualized eating plans, with a recipe club, shopping lists and chef.

Focus on food and activity tracking tools. http://www.shapeup.org Not-for-profit site has meal plans and nutrition information and facts.

APPENDIX VII AUDIOVISUAL MATERIALS Big as Life: Obesity in America (DVD-R or VHS, 51 minutes, 2002)

Childhood Obesity: Reversing the Trend (DVD-R or VHS, 29 minutes, 2003)

Investigates the causes and health implications of obesity in America while seeking to destigmatize adiposity. Interviews with doctors, scientists, adults and children shed light on issues including size acceptance, body image bias, and weight discrimination while considering health risks, genetic influences and surgical interventions.

Presents two hospital-based programs that are helping children lose weight and keep the pounds off by setting realistic goals based on good health, not appearance. Patients talk about what it is like, from a child’s point of view, to be overweight. From The Doctor Is In series.

Cambridge Educational 2572 Brunswick Pike Lawrenceville, NJ 08648 (800) 468-4227

Cambridge Educational 2572 Brunswick Pike Lawrenceville, NJ 08648 (800) 468-4227

Eating Disorders: The Inner Voice (DVD-R or VHS, 30 minutes, 2000)

Body Image for Boys (DVD-R or VHS, 18 minutes, 2002)

Four young women and men from a variety of ethnic backgrounds share their stories of the physical pain and emotional torment caused by eating disorders. Medical, psychological and nutritional experts explain the causes, risks and treatment options.

Discussion by experts are interspersed with clips of young patients grappling with problems such as steroid abuse, eating disorders, exercise addiction and phony food supplements.

Cambridge Educational 2572 Brunswick Pike Lawrenceville, NJ 08648 (800) 468-4227

Films for the Humanities and Sciences P.O. Box 2053 Princeton, NJ 08543 (800) 257-5126

Fad Diets: The Weight Loss Merry-Go-Round (DVD-R or VHS, 16 minutes, 1997)

Body Image: Let’s Get Real (DVD-R or VHS, 48 minutes, 2000)

With the help of nutrition experts, clarifies the dangers and frustrations of fad diets and diet pills while showing how healthy eating habits can lead to reaching and maintaining an ideal weight for life.

Explores the unhealthy impact of media, peer pressure and family opinions on adolescents’ perceptions of their bodies. Individual testimony on media stereotyping, eating disorders, self-esteem, balanced nutrition and sexuality.

Films for the Humanities and Sciences P.O. Box 2053 Princeton, NJ 08543 (800) 257-5126

Films for the Humanities and Sciences P.O. Box 2053 Princeton, NJ 08543 (800) 257-5126

Fat Like Me: How to Win the Weight War (DVD-R or VHS, 43 minutes, 2003)

338

Appendix VII 339 Nutritionists, psychologists, pediatricians and other experts explore the causes of obesity, the physical and emotional damage it can do and how parents and schools can team up to help kids improve their health.

Cambridge Educational 2572 Brunswick Pike Lawrenceville, NJ 08648 (800) 468-4227 Food Fight: Childhood Obesity and the Food Industry (DVD-R or VHS, 23 minutes, 2003) In this ABC News program, John Donovan examines the food industry’s marketing strategies to see if and to what extent they are responsible for America’s epidemic of childhood obesity.

Cambridge Educational 2572 Brunswick Pike Lawrenceville, NJ 08648 (800) 468-4227 Hungry Hearts: Recognizing and Preventing Eating Disorders (VHS, 30 minutes, 2003) Teens present the truth about eating disorders, defining them and outlining their consequences and warning signs.

Aquarius Health Care Videos 18 North Main Street Sherborn, MA 01770 (888) 440-2963

while skewering fad diets and risky or useless products that undermine healthy weight management. Young adults explore the dynamics of body image and the issues involved in eating disorders.

Cambridge Educational 2572 Brunswick Pike Lawrenceville, NJ 08648 (800) 468-4227 Morbid Obesity: A Probable Cure? (DVD-R or VHS, 48 minutes) Three people seek answers about gastric bypass surgery. Medical professionals explain the physiology of obesity and argue the effectiveness of the procedure, and weight-loss surgery advocates analyze the social stigmas against obese people.

Films for the Humanities and Sciences P.O. Box 2053 Princeton, NJ 08543 (800) 257-5126 Overcoming Eating Disorders (DVD-R or VHS, 22 minutes, 2000) Highlights how eating disorders are not just about food but also about struggling with loss of emotional control.

Aquarius Health Care Videos 18 North Main Street Sherborn, MA 01770 (888) 440-2963. Treating Obesity (DVD-R or VHS, 28 minutes, 2003)

Helps adults understand the nature of eating disorders among young people so they can reach out to them early, before the misuse of food spirals out of control.

Three case studies illustrate a spectrum of treatment approaches for obesity: medical-center-based plans emphasizing exercise, education, portion control and peer support; medicines that suppress the appetite and promote weight loss; and bariatric surgery. From The Doctor Is In series.

Aquarius Health Care Videos 18 North Main Street Sherborn, MA 01770 (888) 440-2963

Films for the Humanities and Sciences P.O. Box 2053 Princeton, NJ 08543 (800) 257-5126

Managing Your Weight (DVD-R or VHS, 29 minutes, 1998)

Understanding Fat (DVD-R or VHS, 48 minutes, 2002)

Examines the role of exercise, dieting and other weight control strategies in attaining optimal health

Explores what fat is and how the human body is engineered to use it. Nutritionists and health experts

It’s Not about the Food: Preventing Eating Disorders (VHS, 30 minutes, 2003)

340 The Encyclopedia of Obesity and Eating Disorders discuss the overriding physiological reasons why diets fail. Obesity researchers explain the genetic basis for normal and abnormal body weight, and surgeons illustrate the life-saving potential of gastric bypass surgery for the morbidly obese.

Gurze Books P.O. Box 2238 Carlsbad, CA 92018 (800) 756-7533

Cambridge Educational 2572 Brunswick Pike Lawrenceville, NJ 08648 (800) 468-4227

Weight Control: A Sane Approach (DVD-R or VHS, 52 minutes, 2000)

Voices of Recovery (VHS, 20 minutes, 2003) Insights from individuals who have recovered from eating disorders are interspersed with explanations by experts, with discussion questions to be used by groups of individuals who need guidance. Includes a facilitator’s guide with reproducible handouts.

Host Kat Carney describes her personal quest to lose weight and maintain a healthier lifestyle. Doctors and dietitians explain what fat is and which types are good and bad, demonstrate how to determine body fat percentage, evaluate the four major types of diets and discuss the risks of excess fat.

Films for the Humanities and Sciences P.O. Box 2053 Princeton, NJ 08543 (800) 257-5126

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ARTICLES IN JOURNALS

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BOOKS

EATING DISORDERS Allison, Kelly C., Albert J. Stunkard, and Sara L. Thier. Overcoming Night Eating Syndrome: A Stepby-Step Guide to Breaking the Cycle. Oakland, Calif.: New Harbinger Publications, 2004. Cooper, Myra. The Psychology of Bulimia Nervosa: A Cognitive Perspective. New York: Oxford University Press, 2003. Eivors, Alison, and Sophie Nesbitt. Hunger for Understanding: A Workbook for Helping Young People to Understand and Overcome Anorexia Nervosa. West Sussex, U.K.: John Wiley & Sons Ltd., The Atrium, 2005.

Bibliography 345 First, Michael, and Allan Tasman, eds. DSM-IV-TR Mental Disorders: Diagnosis, Etiology and Treatment. Washington, D.C.: American Psychiatric Association, 2004. Henning, Dennis, and Patricia Woods. Hiding under the Table. Albuquerque, N.Mex.: Americana Publishing, 2004. Kolodny, Nancy. The Beginner’s Guide to Eating Disorders Recovery. Carlsbad, Calif.: Gurze Books, 2004. Levitt, John L., Randy A. Sansone, and Leigh Cohn, eds. Self-Harm Behavior and Eating Disorders: Dynamics, Assessment, and Treatment. New York: Brunner-Routledge, 2004. Lock, James, and Daniel le Grange. Help Your Teenager Beat an Eating Disorder. New York: Guilford Press, 2005. Logue, Alexandra Woods. The Psychology of Eating and Drinking, 3rd ed. New York: BrunnerRoutledge, 2004. Lucas, Alexander R. Demystifying Anorexia Nervosa: An Optimistic Guide to Understanding and Healing. New York: Oxford University Press, 2004. Maine, Margo. Father Hunger: Fathers, Daughters and the Pursuit of Thinness. 2nd ed. Carlsbad, Calif.: Gurze Books, 2004. Maisel, Richard, David Epston, and Ali Borden. Biting the Hand That Starves You: Inspiring Resistance to Anorexia/Bulimia. New York: W. W. Norton, 2004. McCabe, Randi E., Traci L. McFarlane, and Marion P. Olmstead. Overcoming Bulimia: Your Comprehensive, Step-by-Step Guide to Recovery. Oakland, Calif.: New Harbinger Publications, 2004. McManus, Valerie Rainon. A Look in the Mirror: Freeing Yourself from the Body Image Blues. Washington, D.C.: Child & Family Press, 2004. Michel, Deborah, and Susan G. Willard. When Dieting Becomes Dangerous: A Guide to Understanding and Treating Anorexia and Bulimia. New Haven, Conn.: Yale University Press, 2003. Rabin, Mury. Art Therapy and Eating Disorders. New York: Columbia University Press, 2003. Riess, Helen, and Mary Dockray-Miller. Integrative Group Treatment for Bulimia Nervosa. New York: Columbia University Press, 2002. Smith, Gráinne. Anorexia and Bulimia in the Family: One Parent’s Practical Guide to Recovery. West Sus-

sex, U.K.: John Wiley & Sons Ltd., The Atrium, 2004. Tobin, David L. Coping Strategies Therapy for Bulimia Nervosa. Washington, D.C.: American Psychological Association, 2000. Treasure, Janet, Ulrike Schmidt, and Eric van Furth, eds. Handbook of Eating Disorders. 2nd ed. West Sussex, U.K.: John Wiley & Sons Ltd., The Atrium, 2003.

OBESITY Alvarez, Adrian O., et al., eds. Morbid Obesity: PeriOperative Management. New York: Cambridge University Press, 2004. Berg, Frances M. Underage and Overweight: America’s Childhood Obesity Epidemic—What Every Parent Needs to Know. Long Island City, N.Y.: Hatherleigh Press, 2004. Bray, George A. An Atlas of Obesity and Weight Control. Boca Raton, Fla.: CRC Press, 2002. Bray, George A., Claude Bouchard, and W. P. T. James, eds. Handbook of Obesity: Etiology and Pathophysiology. 2nd ed. New York: Marcel Dekker, 2004. Brownell, Kelly D., and Katherine Battle Horgen. Food Fight: The Inside Story of the Food Industry, America’s Obesity Crisis, and What We Can Do about It. New York: McGraw-Hill, 2003. Cooper, Zafra, Christopher G. Fairburn, and Deborah M. Hawker. Cognitive-Behavioral Treatment of Obesity: A Clinician’s Guide. New York: Guilford Press, 2004. Fairburn, Christopher G., and Kelly D. Brownell, eds. Eating Disorders and Obesity, Second Edition: A Comprehensive Handbook. New York: Guilford Press, 2002. Foster, Gary D., and Cathy A. Nonas, eds. Managing Obesity: A Clinical Guide. Chicago: American Dietetic Association, 2003. Gavin, James R., with Sherrye Landrum. Dr. Gavin’s Health Guide for African Americans. Alexandria, Va.: Small Steps Press, 2004. Koenig, Karen R. The Rules of “Normal Eating”: A Commonsense Approach for Dieters, Overeaters, Undereaters, Emotional Eaters, and Everyone in Between! Carlsbad, Calif.: Gurze Books, 2005.

346 The Encyclopedia of Obesity and Eating Disorders Kopelman, Peter G., ed. The Management of Obesity and Related Disorders. New York: Taylor & Francis Group, 2001. Liverman, Catharyn T., Vivica I. Kraak, and Jeffrey P. Koplan. Preventing Childhood Obesity: Health in the Balance. Washington, D.C.: National Academies Press, 2005. Martin, Louis F. Obesity Surgery. New York: McGraw-Hill Professional, 2003. May, Michelle, with Lisa Galper and Janet Carr. Am I Hungry? What to Do When Diets Don’t Work. Phoenix, Ariz.: Nourish Publishing, 2004. Okie, Susan. Fed Up! Winning the War against Childhood Obesity. Washington, D.C.: Joseph Henry Press, 2005.

Parizkova, Jana, and Andrew P. Hills. Childhood Obesity: Prevention And Treatment. 2nd ed. Boca Raton, Fla.: CRC Press, 2004. Rolls, Barbara, and Robert A. Barnett. The Volumetrics Weight-Control Plan: Feel Full on Fewer Calories. New York: HarperCollins, 2000. Shell, Ellen Ruppel. The Hungry Gene: The Science of Fat and the Future of Thin. New York: Atlantic Monthly Press, 2002. Wadden, Thomas A., and Albert J. Stunkard, eds. Handbook of Obesity Treatment. Updated edition. New York: Guilford Press, 2004. Willett, Walter C. Eat, Drink, and Be Healthy. New York: Free Press, 2001.

INDEX

A abdominal fat 61–62, 68–70, 155, 295 Abdominal Panniculus Grading System 237 abdominoplasty 1, 7, 62, 237, 291 Abed, R. T. 271 Academy for Eating Disorders 1, 325 accommodating the obese 1–3 acesulfame-K 45 Ackerman, M. J. 49 Acomplia 40, 260 Active Living by Design 3, 325 actresses 295 “Actual Causes of Death in the U.S.” (McGinnis and Foege) 221 acupressure 3–4 acupuncture 4 addiction 4–5 food 149–150 addiction model of eating disorders 6–7, 78–79 adipose tissue 7 adipsin (ADN) 98 adjustable gastric banding (AGB) 7–9, 57, 226, 293 Adler, Jerry 69 adolescent(s) African American 14 anorexia nervosa in 23, 26, 28 appetite of 9 bariatric surgery in 10, 57 calorie requirements of 10 dieting by 116 media influences on 198 sexual adjustment of 9 vegetarian, eating disorders in 293 adolescent obesity 9–10 Adolfsson, B. 272

adoption, and eating disorders 10–11, 27 adult onset obesity 11 advertising and eating disorders 26, 197-199 false or deceptive 12–13, 151–152, 203–204 and obesity 11–13 AED (Academy for Eating Disorders) 1, 325 aerobic exercise 13 African American(s) body fat distribution in 16 body image of 16 body mass index of 15 diabetes in 112 eating disorders in xvi, 13–14, 23 economics of 15 exercise by 15 low birth weight of 15–16 mate selection and preferences of 16 mortality rate of 16 obesity in 14–17, 112, 222 televised images of 16 thrifty gene in 15 age-related anorexia 127 aging and eating disorders 126–128 and obesity 128–129 Agliata, Daniel 194, 198 Agras, W. S. 101 Air Force Diet 181 air pollution, and obesity 17 ALbD (Active Living by Design) 3, 325 Alcoholics Anonymous 6–7, 236 alcoholism 4–5, 27, 207–208 alexithymia 17 Allison, Kelly C. 214–215

347

Alving, Barbara 171 Aly, Al 62 Alzheimer’s disease, obesity and 17–18 Amadei, Magali 141 amenorrhea 18–19, 30, 78, 200–201 primary 18 secondary 18, 264–265 American Anorexia and Bulimia Association of Philadelphia 325 American Board of Medical Specialties 325 American Cancer Society, on lowcarb diets 190 American Dance Therapy Association 206–207 American Dietetic Association Headquarters 325 American Dietetic Association Washington Office 325 American Indians/Alaska Natives body image of 19–20 eating disorders in 19–20, 212 Healthy People 2010 goals for 20 obesity in 20 thrifty gene in 20 American Medical Association on amphetamine use 21 obesity guidelines of 226 American Obesity Association (AOA) 20, 177, 325 American Psychiatric Association 325 American Society for Bariatric Surgery 325 American Society of Bariatric Physicians 9–10, 56, 325 American Society of Plastic Surgeons 326 amitriptyline 20–21, 79 ammonium chloride 122

348 Index amphetamines 21–22, 43 amylin 22 anaclitic depression 22 anaerobic exercise 22 Andersen, Arnold E. 41, 194–195 Anderson, Drew A. 267 Anderson, Wayne 77 Andres, Reubin 310 Andrist, L. C. 198 anemia 31, 58, 193, 237 Anorexia and Bulimia (Neuman and Halvorson) xvi anorexia athletica 22–23 anorexia mirabilis 23 anorexia nervosa 23–36 as addiction 4–5 in adolescents 23, 26, 28 adoption and 10–11, 27 in African Americans 23 amphetamine use in 21 anaclitic depression and 22 antidepressants for 21, 34, 38–39, 241–242, 252 antipsychotics for 41, 92–93, 245, 284 art therapy for 43–44 in Asian/Pacific Islander Americans 46–47 in athletes 50–51 atypical 52–53 Avicenna on 53 in ballet dancers 55 beginnings of 24–25 behavioral therapy for 33 behavior modification for 59 binge eating/purging type 36–37 biofeedback therapy for 65–66 biological predisposition to 27 bloating in 204 body image in 28–29, 70–71 causes of 25–28 childhood 88 clinical features of 28–31, 318 cognitive distortions in 93–94 cognitive psychopathology of 29–30 cognitive therapy for 33, 95 in college students 95–96 complications of 31–32 compulsive behavior in 29 costs of 101 cultural influences in 26–27 danger signals for 321 denial in 25, 30, 33–34 denial of hunger in 25, 29 dental problems in 31, 108–109, 239–240

depression in 109–110, 204 DSM-IV criteria for vii, 319 in elderly 126–128 emotional expression in 17, 27 employees with 130–131 epidemiology of 23–24 exercise in 22–23, 29 exposure and response prevention for 33 family dynamics and 27–28, 138–140, 238, 322 family therapy for 34, 138–140 famous patients with 140–141 feminist psychotherapy for 147–148 food phobia in 29 food preferences in 323 food-related behaviors in 323 forced feeding in 151, 290 genetic factors in 157–158, 291 group therapy for 34, 162–163 Gull on xv, xviii, 163, 302 history of xiii–xx homosexuality and 168–169 hospitalization for 33 hyperactivity in 170, 204 hypnotherapy for 172 increase in diagnosed cases of 24 individual therapy for 34 interoceptive disturbance in 32, 177–178 isolation in 30 Lasègue on xv, 183, 302 laxative abuse in 30, 183–184 in males 28, 168–169, 193–195 malnutrition in 196 mania in 204 marriage and 196–197 menstrual dysfunction in 18–19, 30, 200–201, 264–265 in “model children” 30–31 mood in 30, 32 mortality in 24, 206 multicompulsive behavior in 207–208 multidimensional/multifactorial models of 208–209 narcissism and 211 neurotransmitters in 213–214, 269 nutritional counseling for 217 in older women 23 oral soft tissues in 233 osteopenia/osteoporosis in 31, 235 parental factors in 238, 322 peer relationships and 28 personality changes in 32 personality disorder and 240–241

personality traits in 30–31, 157, 211, 239–240 pharmacotherapy for 34, 241–242 physical manifestations of 318 and pregnancy 248 prognosis in 24, 34 promotion of 250 psychodrama for 252 psychosomatic medicine in 253 psychotherapy for 253–255 pursuit of thinness in 25, 28 recovery from 34–35 religion and 257–258 research in 36 sexual abuse and 270 sexuality in 30, 271 skin and hair in 31 socioeconomic status and 23, 25 starvation in 31–32, 279 stress and 25–26, 281–282 suicide in 32, 36, 204, 283 taste in 285 treatment of 32–34 weight phobia in 29, 32–33, 298 zinc deficiency in 31, 34, 300 Anorexia Nervosa and Related Eating Disorders (ANRED) 23, 37, 326 anorexic behavior 36 anorexic bingers 36–37 ANRED (Anorexia Nervosa and Related Eating Disorders) 23, 37, 326 anthropometric measurements 67–68 anticonvulsant treatment 37–38, 242 antidepressants 38–39 amitriptyline 20–21, 79 for anorexia nervosa 21, 34, 38–39, 241–242, 252 for binge-eating disorder 39, 65, 242 for bulimia nervosa 20–21, 39, 79, 109, 173, 242, 252, 289 and cholecystokinin 93 and dental caries 108–109 imipramine 173 Prozac 251–252 for rumination 262 for sleep-related eating disorder 276 thymoleptic medications 289 antiobesity drugs 39–41, 225–226, 242, 260, 273 antipsychotics 41, 92–93 pimozide 245 sulpiride 284 anxiety 42, 205, 247

Index 349 AOA (American Obesity Association) 20, 177, 325 apoplectic body type 72 appearance, cultural influences on xiii–xx, 26–27, 103–105, 227–228, 277–278 appetite 42 acupressure and 3–4 acupuncture and 4 adolescence and 9 hypothalamic disease and 172 mood disorders and 204–205 music and 209 stress and 280 appetite hormones 42, 159–160, 169–170, 184–185, 256, 263, 275 appetite-stimulating drugs 42–43 cyproheptadine 43, 106 appetite suppressants 43, 225–226 amphetamines 21–22 for binge-eating disorder 65 bulking agents 80 crystal methamphetamine (ice) 103, 173 fen-phen/Redux 149 phenylpropanolamine 120, 243, 309–310 sibutramine 39–40, 65, 225, 242, 263, 273, 314 Tenuate 287 apple shape 61–62, 69 Appolinario, J. C. 242 Areton, Lilka Woodward 144 Arizona programs 328 Arnst, Catherine 191 Aronne, Louis J. 242 arousal, physiological 244 Arterburn, David E. 128 arthritis link to obesity 44 artificial sweeteners 45–46, 282 art therapy 43–44 Ashton, David 11 Asians/Pacific Islander Americans eating disorders in xvi–xvii, 46–47 obesity in 47 aspartame 45 Assessment of Addictive Behaviors (Polivy, Herman, and Garner) 122–123 asthenic body type 72 asthma link to obesity 48–50 athletes 50–51, 295 Atkins, Robert C. 51, 306 Atkins Diet 51–52, 114, 181, 190, 213, 305–306 attitudes toward obesity 227–228, 273–274

attractin 169 atypical anorexia nervosa 52–53 audiovisual materials 338–340 aversion therapy 53 Avicenna 53 Axel, E. 305–306

B baby fat 89 Baillargeon, Jacques G. 250–251 ballet dancers 50, 55, 140–141, 295 Banting, William 56 Banting diet 56, 114, 181 Bará-Caril, Núria 271 bariatric(s) 56 bariatric surgery 56–58, 226 accommodations for 2 adjustable gastric banding 7–9, 57, 226, 293 in adolescents 10, 57 benefits of 57–58 biliopancreatic diversion 57, 63, 122, 193 costs of 56 definition of 56 and dumping syndrome 63, 122 gastric bypass 156 indications for 57 insurance coverage for 56, 177 jejunocolic bypass 179 jejunoileal bypass 179 longitudinal assessment of 189 malabsorptive 57, 63, 179, 193, 226 Medicare coverage of 199 mortality rate in 206, 226 nutritional counseling after 217–218 in older patients 226 and pregnancy 58, 193 restrictive 7–9, 57, 156–157, 226, 260–261, 293 risks of 58 Roux-en-Y gastric bypass 57, 122, 193, 226, 260–261 stomach stapling 280 vertical banded gastroplasty 57, 226, 293 Bariatric Surgery Clinical Research Consortium 189 Barlow, Sarah E. 10 Barrett, Stephen 80 Bartlett, Susan 44, 128 basal metabolic rate (BMR) 58–59 Bassett-Seguso, Carling 50 Bauer, Barbara 77

Baum, Charles L., II 230 Baumiller, Marlene 308 Baur, L. A. 10 Bayrd, Edwin 62, 86 Becker, A. E. 212 behavior modification 59–61, 267, 280 for anorexia nervosa 59 for bulimia nervosa 59 for obesity 59–61, 225 behavior therapy 53, 61 for anorexia nervosa 33 for bulimia nervosa 61, 79 for childhood obesity 90 Beller, Anne Scott xiii Belluscio, Daniel O. 166 belly fat 61–62, 68–70, 155, 295 belt lipectomy 62 Bemis, K. M. 94 Ben-Dor, D. H. 10 Bennett, William 224 Benton-Hardy, L. R. 248 benzocaine 43, 62 Berg, Greg 229 Berkman, John Mayo xvi Beumont, P. J. V. 217 Beverly Hills Diet 62–63, 310 bigorexia 209 biliopancreatic diversion (BPD) 57, 63, 122, 193 binge-eating 63–64 in African Americans 14 in American Indians/Alaska Natives 19–20 in anorexia nervosa 36–37 antidepressants for 20–21 in ballet dancers 55 behavior therapy for 61 in bulimia nervosa 75, 78 and dental caries 108–109 genetics of 64 in Hispanics/Latinos 168 by males 195 marriage and 197 seizure disorders and 37–38 sleep disorders and 176 in sleep-related eating disorder 276 binge-eating disorder (BED) 64–65 anticonvulsants for 37–38, 242 antidepressants for 39, 65, 242 body image in 71 versus bulimia nervosa 64 complications of 64 DSM-IV criteria for vii, xviii, 64, 319 emotional expression and 17 long-term course of 64–65

350 Index mortality in 206 versus obesity 64 personality traits in 240 pharmacotherapy for 65, 242 prevalence of 64 self-help groups for 266 treatment of 65 Binge Eating Scale (BES) 65 Binge Scale 65 Binks, Martin 272 bioelectrical impedance analysis 68 biofeedback 65–66 biopsychosocial model of eating disorders viii, 66 biotech foods 66 birth control pills 232–233 Blackburn, George 85, 308, 311 Blackman, Stuart xviii Blair, Alan 118 Blanchette, Patricia Lanoie 165 Blanchez, P. F. xviii Blankaart, Steven xvii blood pressure, elevated 171 Blumenthal, H. T. 304 BMI. See body mass index Bod Pod 68 bodybuilders 194–195, 209 body dysmorphic disorder (BDD) 66–67 body fat 67–68 assessment of 47–48, 67–68, 274–275, 302 brown 74 cellulite 86–87 conjugate linoleic acid and 99–100 desirable range of 67 dieting and 67 excess 67 immune function and 174 low 67 storage of 67, 185 visceral 295 body fat distribution 61–62, 68–70 in African Americans 16 age differences in 69 calorie source and 62, 69 environmental factors in 69 and gallstones 155 gender differences in 68–69 hereditary differences in 69 smoking and 69–70 waist-to-hip ratio of 297 weight loss and 69 body image 66–67 of African Americans 16 of American Indians/Alaskan Natives 19–20

in anorexia nervosa 26–29, 70–71 art therapy and 43–44 of ballet dancers 55 in binge-eating disorder 71 in bulimia nervosa 70–71, 76–77 cultural influences on xiii–xx, 26–27, 103–105, 277–278 of Hispanics/Latinos 166–167 of homosexuals 168 of males 168, 194–195, 209 media influences on 197–199 movement therapy and 206–207 in obesity 71 Body Image: An International Journal of Research 70 body image assessment (BIA) 70 body image disturbance 70–71 body mass index (BMI) 71–72, 324 of African Americans 15 and Alzheimer’s disease 18 as bariatric surgery guideline 7, 57 education level and 15 of elderly 128 genetic factors and 157–158 of Hispanics/Latinos 167 and hypertension 171 in obesity 71–72, 219 and sudden death 61 body types 72, 126, 131–132, 201, 238–239 body wrapping 72, 216 bone loss 234–236 Booth, David A. 299 borderline personality disorder 72 Boskind-White, Marlene xviii, 74, 197 bottle-feeding 174–175 Bowlan, Veronica O. 252 Bradwell, D. 305 brain activity and obesity 72–73 Bratman, Steven 234 Bray, G. A. 153, 191 breakfast and obesity 73–74 Breaking Free from Emotional Eating (Roth) 204 breast cancer detection, obesity and 196 breast-feeding 174–175 Brewerton, Timothy D. 34, 242, 252 Brisman, Judith 99–100, 217 Brown, S. L. 8 Brownell, K. D. viii, 60, 274, 299–300 brown fat 74 Bruch, Hilde xvi–xvii, xiii–xiv, 9, 26, 36, 52–53, 59, 74, 114, 148, 169–170, 177–178, 194, 214, 221,

238, 248–249, 253–254, 257, 288, 303 Brumberg, Joan xiv–xv, 253 Bruna, Tijs 242 Bulik, Cynthia M. 134, 291 bulimarexia 74 bulimia 74–75 Bulimia: A Systems Approach to Treatment (Root, Fallon and Friedrich) 195 bulimia nervosa 75–80 as addiction 4–5 addiction model of 6–7, 78–79 alcoholism in 4–5, 207–208 anticonvulsants for 37–38, 242 antidepressants for 20–21, 39, 79, 109, 173, 242, 252, 289 anxiety model of 42 art therapy for 43–44 in athletes 50–51 in ballet dancers 55 beginnings of 76 behavior modification for 59 behavior therapy for 61, 79 versus binge-eating disorder 64 binge-eating patterns in 75, 78 biofeedback therapy for 65–66 body image in 70–71, 76–77 chemical dependency and 87–88, 207–208 clinical features of 77–78, 318 cognitive distortions in 77–78 cognitive therapy for 79, 94–95, 254 in college students 95–96 complications of 78–79 compulsive behavior in 78 costs of 101 danger signals for 321 denial in 77 dental problems in 108–109, 233, 239–240 depression in 78–79, 109–110 diet pill use in 76 as disease of success 75–76 diuretic abuse in 75, 121–122 DSM-IV criteria for vii, 319 early satiety in 125 emotional expression and 17 employees with 130–131 epidemic of 75 epidemiology of 75 exposure and response prevention for 134 family dynamics in 76–77, 138–140, 322 family therapy for 138–140

Index 351 famous patients with 140–141 fictional finalism in 77 food preferences in 323 food-related behaviors in 323 genetic factors in 157–158, 291 group therapy for 79, 162–163 history of xiii–xx homosexuality and 168–169, 195 interpersonal psychotherapy for 79, 178, 254–255 ipecac syrup use in 178 Janet on 179 laxative abuse in 75–76, 183–184 in males 76, 168–169, 195–196 malnutrition in 196 marriage and 197 menstrual dysfunction in 78, 200–201, 264–265 mortality in 206 multicompulsive behavior in 207–208 multidimensional/multifactorial models of 208–209 narcissism and 211 neurotransmitters in 213–214 nutritional counseling for 217 oral soft tissues in 233 overweight 236 personality disorder and 240–241 personality traits in 157, 211, 239–240 pharmacotherapy for 79–80, 242 physical manifestations of 318 polycystic ovary syndrome and 246 and pregnancy 248 promotion of 250 psychodrama for 252 psychotherapy for 253–255 rigidity and inflexibility in 77 rumination in 261–262 Russell on 262 secrecy of 76 seizure disorders and 37–38 self-esteem in 78, 265 sexual abuse and 208, 270 sexuality in 78, 271 sleep disorders in 176 stress and 281 suicide in 78, 208, 283 taste in 285 thymoleptic medications for 289 treatment of 79–80 vocational 295 vomiting in 76, 78, 295–296 Bulimia Test Revised (BULIT-R) 80 bulking agents 43, 80

bupropion 39–40 Bursztyn, Mark 228 Butler, N. 305 bypass surgery. See bariatric surgery

C cachexia africana 159 caffeine 81, 122 calcitriol 82 calcium 81–82, 107, 235 Calderon, L. L. 116 California programs 328, 331 Calle, Eugenia E. 255–256 calorie(s) 82–83 weekend 297–298 calorie restriction diet 84 Calories Count (Obesity Working Group) 230–231 Calories Don’t Count (Taller) 304 calorimetry 84 Camargo, Carlos A., Jr. 48 Campbell, T. Colin 311–312 camps 331–332 cancer links to obesity 84–85, 223, 250–251 Canon of Medicine (Avicenna) 53 Caprenin 145 Carapella, Raymond 307 carbamazepine 37 Carbatrol 37 carbohydrate(s) 85–86 net 213 carbohydrate addict’s diet 85, 190 carbohydrate craving 102–103 Carlat, Daniel J. 241 Carpenter, Karen 86, 140, 178, 250 Cash, Thomas F. 70 Cassella, Robert 308 Castro, J. 35 Catalina, M. 234 cataracts and obesity 86 cathartic colon 183 Catherine of Siena 23, 141 Cautela, Joseph 305 Celexa 39, 242 cellulite 86–87, 216 Centers for Obesity Research and Education (CORE) 87 Centers for Science in the Public Interest 326 Cepeda-Benito, Antonio 103, 130–131, 195, 206, 241–242, 254 Charcot, J. M. xv Charlebois, Donna 298 Chebli, Joseph E. 8 cheerleaders 50

chemical dependency and bulimia 87–88, 207–208 childhood anorexia 88 childhood obesity 88–92 epidemiology of 88–89, 222 group therapy for 225 physical health effects of 89 psychological effects of 89–90 schools and 263–264 teasing about 90 treatment of 90–92 Chipley, William Stout 92 chlorothiazide 121 chlorpromazine 41, 92–93 Choi, P. Y. 209 cholecystokinin (CCK) 93, 263 cholesterol 93, 202 choreotherapy 206–207 chronology of eating disorders and obesity 302–316 citalopram (Celexa) 39, 242 Citrus aurantium 120 class issue, obesity as 222, 228–229, 277 Clausen, L. 35 Clayson, Dennis E. 227 clinical weight-loss programs 114–115 cocaine use 207–208 cognitive distortions 77–78, 93–94 Cognitive Factors Scale (CFS) 94 cognitive therapy 94–95, 254 for anorexia nervosa 33, 95 for bulimia nervosa 79, 94–95 versus nutritional counseling 217 for obesity 94 for rumination 262 Cohen, Sidney 81 Cohen, Tiffany 50 Cohn, Leigh 126 college students eating disorders in 95–96 weight gain of 95, 152–153 Collins, M. Elizabeth 63, 104 Colorado programs 328 Comaneci, Nadia 50 comfort food 96–97, 282 complement factors 97–98 compulsive behavior 29, 36, 78, 207–208 compulsive eating 98–99 compulsive eating scale (CES) 99 computed tomography 68 conjugate linoleic acid (CLA) 99–100 Connecticut programs 328–329 Connolly, Ceci 256 constipation 30, 183

352 Index continuity/discontinuity models of eating disorders 100 control group 100 Conversations with Anorexics/Hilde Bruch (Czyzewski and Sur, eds.) 74 Coopersmith Self Esteem Inventory 265 Copeland, Paul 78 CORE (Centers for Obesity Research and Education) 87 CortiSlim 100 cortisol 96, 100–101, 109, 235, 282 Council on Size and Weight Discrimination, Inc. 102, 326 couples therapy 102 covert conditioning 305 Crabtree, Penni 66 crack cocaine 208 Craighead, Linda 309–310 craving 102–103 Crawford, Lester M. 12 creative therapy 43–44 creeping obesity 103, 133, 142 Crespo, Carlos J. 229 Crisp, Arthur H. 24, 28, 32–33, 127, 254, 298 Crow, S. J. 201 crystal methamphetamine 103, 173 cultural influence(s) on appearance xiii–xx, 26–27, 103–105, 227–228, 277–278 on dieting 116–117 on eating disorders viii, 26–27, 105–106, 167 Cummings, D. E. 288 Cushing’s disease 106, 199, 220 Cuzzolaro, Massimo 125 cyberdieting 231–232, 337 cyproheptadine 43, 106

D dairy foods and weight loss 81–82, 107–108 dancers 50, 55, 140–141, 295 dance therapy 206–207 Dancing on My Grave (Kirkland) 141 danger signals 321 Davidson, Terry L. 46 Davis, Allen R. 258 Dawson, Brenda 220, 224 Deception in Weight-Loss Advertising 203–204 deceptive advertising 12–13, 151–152, 203–204 dehydration, laxative abuse and 183

dehydroepiandrosterone (DHEA) 62, 108, 304 denial in anorexia nervosa 25, 30, 33–34 in bulimia nervosa 77 densitometric analysis 67 dental caries (cavities) 108–109 in anorexia nervosa 31, 108–109 dental problems 31, 108–109, 233, 239–240 Depakote 37 depression anaclitic 22 in anorexia nervosa 109–110, 204 in bulimia nervosa 78–79, 109–110 and eating disorders 109–110, 204–206, 240 and obesity 110, 220 Deseryl 38 Deshmukh, Rashmi 39 desipramine 39 developmental obesity 74 Devlin, Bernie 157 Devlin, Michael J. 41 dexfenfluramine 149, 225, 313–314 Dezhkam, Mahmood 258 diabetes in African Americans 112 amylin in 22 and eating disorders 110–111 gestational 111 and obesity 22, 89, 111–112 sugar and 283 Type 1 111 Type 2 111 Diagnostic and Statistical Manual of Mental Disorders vii, xviii, 64, 122, 319 Diamond-Raab, L. 43, 252 Diana, Princess 141 dichotomous reasoning 94, 112 Dickens, Charles 229 diet(s) Air Force 181 Atkins 51–52, 114, 181, 190, 213, 305–306 Banting 56, 114, 181 Beverly Hills 62–63, 310 and body fat 67 calorie restriction 84 carbohydrate addict’s 85, 190 for children 90–92 Drinking Man’s 181 Dupont 181 fad 137, 224 Hawaiian 165 ketogenic 181 liquid formula 188–189, 232, 251

low-carb 51–52, 85, 190 low-fat 190–191 Mediterranean 199–200 Pennington 181 Protein Power 181, 190 protein-sparing modified fast 232, 251 Snowbird 297 South Beach 114, 181, 190, 278 Traffic Light 91, 290 very low-calorie 225, 232, 293–294 Zone 181, 190 dietary fiber 112–113, 149 Dietary Guidelines for Americans 2005 216–217, 315–316 Dietary Supplement Health and Education Act (DSHEA) 113 dietary supplements 113 diet centers and programs 113–115 Dieter’s Dilemma, The (Bennett) 224 dieter’s teas 115–116 dieting 116–120, 224–225 by adolescents 116 cultural influences on 116–117 immune function and 174 and mortality 117 by mothers and infants 116 online 231–232, 337 during pregnancy 249 sensible approach in 119–120 starvation response in 117 stress and 281 vicious cycle of 117–118 weight-loss strategies in 118–119 by young girls 116 yo-yo 299–300 diet pill(s) benzocaine in 62 in bulimia nervosa 76 grapefruit 87 over the counter (OTC) 120 Dietz, William 287, 310 Dilantin 37 dissociation 120–121 diuretic abuse 121–122 by African Americans 14 in bulimia nervosa 75, 121–122 complications of 320 Dobbs, E. C. 302 do-it-yourself weight-loss programs 114 Donini, L. M. 234 Donohoe, Thomas P. 280 dopamine 73, 149–150, 263 double-blind study 122 Downs, Susan 296

Index 353 Dragstedt, L. R. 302 Drewnowski, Adam 25, 75 Drinking Man’s Diet 181 drug therapy 241–243. See also specific disorders DSM-III xviii DSM-IV vii, 64, 122, 319 D-tagatose 285 dual energy X-ray absorptiometry (DEXA) 68 Dubowitz, Howard 138 Duggan, S. J. 198 dumping syndrome 63, 122 Dunn, P. K. 99 Dupont Diet 181 dysfunctional behavior patterns 122–123

E early satiety 125 Eating and Weight Disorders: Studies on Anorexia, Bulimia and Obesity viii, 125 Eating Attitudes Test (EAT-26) 29, 125 Eating Behaviors 125 eating disorder(s). See also specific types as addiction 4–5 addiction model of 6–7, 78–79 adoption and 10–11, 27 in African Americans xvi, 13–14, 23 in American Indians/Alaska Natives 19–20, 212 art therapy for 43–44 in Asians/Pacific Islander Americans xvi–xvii, 46–47 in athletes 50–51 in ballet dancers 50, 55, 140–141, 295 biofeedback therapy for 65–66 biopsychosocial model of viii, 66 chronology of 302–316 in college students 95–96 continuity/discontinuity models of 100 costs to treat 101 cultural influences on viii, 26–27, 105–106, 167 danger signals for 321 depression and 109–110, 204–206, 240 diabetes and 110–111 in elderly 126–128 employees with 130–131 family generation of 138–140

family therapy for 138–140 famous patients with 140–141 feminist psychotherapy for 147–149 genetic factors in 27, 157–158, 291 group therapy for 162–163 in Hispanics/Latinos 166–167, 212 history of xiii–xx homosexuality and 168–169 infant 174 insurance coverage for 176 marriage and 196–197 media influence on 197–199 mood disorders and 204–206 movement therapy for 206–207 multidimensional/multifactorial models of 208–209 not otherwise specified (EDNOS) vii, 125 personalities of individuals with 240 pregnancy and 248 promotion of 250 psychotherapy for 253–255 religion and 257–258 sexual abuse and 270–271 sexuality and 271 sleep-related 276 stress and 280–282 twin studies of 291 vegetarian diet and 293 Eating Disorders and Obesity: A Comprehensive Handbook (Brownell and Fairburn) viii Eating Disorders Anonymous (EDA) 326 Eating Disorders Awareness Week (EDAW) 125–126 Eating Disorders Coalition for Research, Policy and Action 176 eating disorders inventory (EDI) 126 Eating Disorders: Obesity, Anorexia, and the Person Within (Bruch) xiii, 26, 74 Eating Disorders: The Journal of Treatment and Prevention 126 eating habits monitoring 267–268 Eating Organization of New Jersey 326 Eberenz, K. P. 208, 270 Eckert, Elke 6 ectomorph 72, 126, 239 ego state therapy 126 Eisler, Ivan 139 Elamin, Elamin M. 49 Elavil 20–21, 79 Eldahmy, Adel 171

elderly eating disorders in 126–128 obesity in 128–129 electrodermal response (EDR) 65 electroencephalograph (EEG) in biofeedback therapy 66 in compulsive eaters 37 electrolyte imbalance in anorexia nervosa 31 laxative abuse and 184 Elliott-Larsen Civil Rights Act (Michigan) 274 Ellis, L. 158 Ellison, Sarah 213 emergency services, accommodating obesity in 2 emotional eating 204 emotional expression, and eating disorders 17, 27 emotional overeating 220–221 empirically supported therapy 129 empirical research 129 employees with eating disorders 130–131 obesity in 230 health costs of 129–130 Encyclopaedia Britannica xvii Encyclopedia of Understanding Alcohol and Other Drugs, The (O’Brien and Cohen) 81 endocrine factors in obesity 131 endomorph 72, 131–132, 239 ephedra 120, 132 epidemiological research 132 Epstein, Leonard H. 91, 290 Erchonia 4L laser 188 Ernsberger, P. 224 Escamilla, R. F. xvi Essence 14 Estok, P. J. 6 ethacrynic acid 121 ethosuximide (Zarontin) 37 European treatment, of eating disorders 138 exercise 132–134 aerobic 13 by African Americans 15 anaerobic 22 in anorexia nervosa 22–23, 29 excessive 133–134 and obesity 91, 225, 243–244 obligatory (anorexia athletica) 22–23 spot reducing 278 exercise machines, passive 238 exposure and response prevention (ERP) 33, 134

354 Index externality approach to obesity 42, 135 extreme eating 135 extreme obesity 135

F Fabricatore, Anthony N. 189, 267 Factor D 98 fad diets 137, 224 failure to thrive (FTT) 137–138, 147, 175 Faine, M. P. 109 Fairburn, Christopher viii, 312 fake fat 138. See also fat substitutes false advertising 12–13 family dynamics 138–140 and anorexia nervosa 27–28, 138–140, 238, 322 and bulimia nervosa 76–77, 322 and obesity 222 family meal 138 family therapy 138–140, 288 for anorexia nervosa 34, 138–140 for bulimia nervosa 138–140 for obesity 140 famous eating-disorder patients 140–141 Farley, John E., Jr. 308 F as in Fat: How Obesity Policies Are Failing America 315 fasting 141–142 in bulimia nervosa 76 and gallstones 155 and osteopenia 235 religious xv, 23, 141, 257–258 fasting girls xv, 142 Fasting Girls (Brumberg) xiv fat(s) 144–145 body. See body fat restricted, in low-fat diet 190–191 saturated 145 trans 150, 290 unsaturated 145 Fat & Thin (Beller) xiii fat blockers 142 fat cells 142–143, 175, 219, 222 “fat” doctors 143 Fat Liberation Front 308 fat-mobilizing substance (FMS) 306 fat phobia 143–144 fat power 144 fat recycling 144 fat substitutes 138, 145–146, 231, 273, 333–335 fat tissue 7 morphology of, and obesity 222

fat virus 146 Favazza, Armando R. 268 fear of fat syndrome 146–147, 240, 253 Federal Trade Commission (FTC) on advertising 12–13 on fraudulent products 151–152, 202–203 on liquid programs 189 on passive exercise machines 238 feeding disorder of infancy or early childhood 147 Feeding Infants and Toddlers Study 175 Feinstein, Alvan 304 Feldman, William 286, 311 feminist psychotherapy for eating disorders 147–149 fenfluramine 149, 225, 314 fen-phen/Redux 149, 225, 313–314 Fernstrom, John D. 309 Ferraro, F. Richard 50–51 Ferraro, Kenneth F. 258 fiber, dietary 112–113, 149 Fichter, M. M. 194–195 fictional finalism 77 figure skaters 50 Fired, G. H. 306 Fischer, Giorgio 185 Fitzgerald, A.L. 264 Fitzgibbon, Marian 20, 47 Flatt, Jean-Pierre 83 Flexyx Neurotherapy System (FNS) 66 Florida programs 329 fluid imbalance, in anorexia nervosa 31 fluoxetine. See Prozac fluvoxamine 39, 242 Foege, William 221 Fogteloo, Jaap 242 Fonda, Jane 141 food(s) biotech 66 comfort 96–97, 282 dairy, and weight loss 81–82, 107–108 forbidden 151 solid, and infant obesity 174–175 food addiction 149–150 food advertising 11–13 Food and Drug Administration (FDA) on ephedra 132 on liposuction 187–188 on nutrition labeling 150 on starch blockers 278–279 Food Exchange Diet 91

Food for Thought: Substance Abuse and Eating Disorders 254 “Food for Thought: Substance Abuse and Eating Disorders” 6 food nutrition labels 150–151 food phobia 29 food preferences, in anorexia and bulimia nervosa 323 food pyramid 316 food-related behavior, in anorexia and bulimia nervosa 323 forbidden foods 151 forced feeding 151, 290–291 Ford, William F. 230 Franco, Kathleen 39 Franklin, J. A. 104 fraudulent products 151–152, 202–203 Frazen, R. 302 Freedman, Rachel E. K. 16 free fatty acids 152 Freshman 15 95, 152–153 Frey, F. J. 122 Fried, Jack 307 Friedman, Glenn M. 287 Friedman, Jeffrey 159 Friedman, Michael 300 Fröhlich’s syndrome 39 fructose as contributor to obesity 153–154, 166 Fujioka, K. 193 furosemide 121

G gabapentin 37 Gabitril 37 Gaesser, Glenn A. 278 Galen xvii Gallagher, Susan 237–238 gallstones 58, 155 gamma butyrolactone (GBL) 156 Gangwisch, James 275 Garfinkel, Paul E. 32, 36, 125, 205, 279, 284, 290 Garner, C. M. 228 Garner, David M. 32, 36, 94–95, 105, 122–123, 125, 205, 284, 290 Garner, Sara 267 Garren-Edwards Gastric Bubble (GEGB) 156 Garrison, Zina 50 gastric banding, adjustable 7–9, 57, 226, 293 gastric bubble 156 gastric bypass 156, 280 Roux-en-Y 57, 122, 193, 226, 260–261

Index 355 gastric restriction procedures 7–9, 57, 156–157, 226, 260–261, 293 gastric stimulator, implantable 42, 174, 263 gastrointestinal bleeding, laxative abuse and 183 gastrointestinal surgery for obesity. See bariatric surgery gastroplasty 157 Gater, David 278 Gavin, James 15 Gaviria, Moises 205 Geifer, Eldred 308 genetic factors in binge-eating 64 in bulimia nervosa 157–158, 291 in eating disorders 10, 27, 157–158, 291 in obesity 158–159, 220, 222 Gennuso, Jennifer 48 geophagia 159, 181, 245 Geracioto, Thomas D., Jr. 93 ghrelin 42, 159–160, 163, 169, 263, 275, 288 Giddens, Anthony 105 Gleaves, David H. 70–71, 121, 130–131, 195, 206, 208, 241–242, 254, 270 globesity 160 glucagon-like peptide 1 (GLP-1) 263 glucocorticoids 96–97 Glucophage (metformin) 40, 112 glycemic index (GI) 160–161 Gold, Mark 150 Golden, Harvey xiv Golden Cage, The: The Enigma of Anorexia Nervosa (Bruch) 74 Goldfarb Fear of Fat Scale (GFFS) 161 Goldman, Albert 141 gonads obesity 161 Goode, Erica 168, 194 Gordon, Richard A. 26–27 Gortmaker, Steven 310 government role in combating obesity 161–162 Graham, M. A. 153 Grandjean, Ann C. 143 grapefruit diet pills 87 Grilo, Carlos M. 34, 242 Grossman, Robert J. 274 group therapy 162–163, 288 for anorexia nervosa 34, 162–163 for bulimia nervosa 79, 162–163 for obesity 225 psychodrama 252 growth failure 137–138 growth hormone in obesity 163

Gucciardi, E. 109 guided image therapy 163 Gull, Sir William Withey xv, xviii, 163, 183, 302 Gundy, Feridun 308 Gurenlian, Jo Ann R. 269 Gustafson, T. B. 270 gymnasts 50, 140

H Habermas, Tilmann xviii, 253 hair, in anorexia nervosa 31 Halvorson, Patricia A. xvi, 26–31, 35–37, 296 Hanscom, Daniel H. 307 Harman, D. 158 Harms, H. P. 302 Hart, Philip A. 304 Hartz, Arthur 308 Harvey, William 56, 181 Harvey-Banting Diet 56, 114, 181 Harvey-Berino, J. 232 Hausmann, Armand 169 Hawaiian Diet 165 Hawaiian Natives, obesity in 165 Hazelden 5–6, 87–88 HCG 39, 165–166, 307 Healthy People 2010: Objectives for Improving Health 20, 314 Heckel, P. 288 Hedinger, Mary L. 175 HEED (Helping End Eating Disorders) Foundation 166, 326 Heller, Rachel 85 Heller, Richard 85 Hellmich, Nanci 61, 276 Herman, C. Peter 24, 28, 105, 122–123, 198, 205, 259 Herpetz, Stephen 111 Hertz, Robin 129 Herzog, David 78 Hewitt, J. K. 10 Heymsfield, Steven 46, 275 Heyward, V. H. 48 high fructose corn syrup (HFCS) 153–154, 166 Hill, A. J. 104 Hill, James O. 212, 230, 313 Hilton, Lisette 144 Hirsch, J. 304, 307, 311 Hirshmann, Jane R. 117 Hispanics/Latinos eating disorders in 166–167, 212 obesity in 167–168, 215, 222 history of obesity and eating disorders xiii–xx

Hoek, H. W. 24 Hoerr, S. L. 95 Hohenwarter, Mark 311 homeostasis 269 homosexuality and eating disorders 168–169, 195 hormones, appetite 42, 159–160, 169–170, 184–185, 256, 263, 275 hospitalization, for anorexia nervosa 33 hospitals, accommodating obesity in 1–3 Huchard, H. xv Hudson, James I. 270 Huggins, Charnicia 70 human chorionic gonadotropin (HCG) 39, 165–166, 307 Human Ecology Action League, Inc. (HEAL) 326 hunger 169. See also appetite denial of, in anorexia nervosa 25, 29 infant experiences in 175 mind 204 stomach versus mouth 169 hunger hormones 42, 159–160, 169–170, 184–185, 256, 263, 275 Huynh-Do, U. 122 hydrochlorothiazide 121 hydrostatic weighing 67 hyperactivity 170, 204 hyperalimentation 170 hypercellularity 170–171 hypergymnasia 171 hyperphagia 171 hyperplastic obesity 171 hypertension 171 hypertrophic obesity 172 hypnotherapy 53, 172 hypokalemia 121, 172 hypothalamic disease 172, 199 hypothyroidism 289

I ice (illegal drug) 103, 173 ice, craving to eat 237 Illinois programs 329 Ilouz, Yves-Gérard 185 imipramine 39, 79, 173 immigrants, obesity in 173–174 immune function and dieting 174 implantable gastric stimulator (IGS) 42, 174, 263 infant(s) eating disorders in 174 feeding disorder of 147 obesity in 174–176 rumination in 261

356 Index infertility eating disorders and 196 obesity and 176, 279 inflexibility, in bulimia nervosa 77 Inge, Thomas H. 57 insomnia 176 insulin resistance syndrome 202 insurance coverage for bariatric surgery 56, 177 for eating disorders 176 for obesity 176–177 for panniculectomy 238 interleukin-6 (IL-6) 174, 177 International Journal of Eating Disorders 177 International Journal of Obesity 177 International Size Acceptance Association 326 interoceptive disturbance 32, 177–178 interpersonal psychotherapy 79, 178, 254–255 Interview for the Diagnosis of Eating Disorders (IDED) 178 ipecac syrup 31, 178 iron deficiency 193, 237 isolation, in anorexia nervosa 30

J Jackson, Ian T. 144 Jackson, Mary 236 Jackson, T. D. 90 Janet, Pierre 179 jaw wiring 179 Jeffery, R. W. 197 Jeffrey, D. Balfour 220, 224 jejunocolic bypass 179 jejunoileal bypass 179 Jenny Craig Program 113–115, 179 Job Accommodation Network 2–3 jockeys 50 Johanns, Mike 316 Johnson, Kathy 50 Jones, A. L. 153 Jones, Delores 28 Junshi, Chen 311–312

K Kaaks, Rudolf 255–256 kaolin 181 Kaplan, Allan S. 279 Kaplan, Arline 39 Katz, B. E. 121 Katz, D. L. 137 Katz, J. L. 105

Katz, Rebecca 31 Kaye, Walter H. 157 Keel, Pamela K. 168–169, 257 Keller, Ward 258 Kendall, P. 89 Kennedy, Donald 308 Keppra (levetiracetam) 37 ketogenic diet 181 ketosis 181 Key, Adrienne 246 kidney stones and obesity 181–182 Kim, K. H. 258 King, M. E. 49 King, P. J. 263 Kirkland, Gelsey 140–141 Kitsantas, A. 95–96 Klassen, Michael L. 227 kleptomania 78 Klibanski, Anne 31 Klump, Kelly L. 240, 257 Knapp, Thomas R. 310 Knittle, J. L. 304–305, 307 Kolotkin, Ronette 272 Koplan, Jeffrey 314 Kotwal, Renu 38 Krahn, D. D. 75 Kramer, P. M. 60 Kratina, Karin 278 Krenn, Heidelinde 194–195 Kretschmer, Ernst 72 Kroger, W. S. 303 Krugman, Scott D. 138 Kushner, R. F. 237

L labels, food nutrition 150–151 Lacey, F. B. 306 LaLanne, Jack 305 Lambert, Craig 269 lamotrigine 37 LapBand 7–9, 57, 226, 293 Largactil 41, 92–93 Lasègue, Charles xv, 183, 302 Laurence, W. L. 303 Lawson, Willow 83–84 laxative abuse 183–184 by African Americans 14 by American Indians/Alaska Natives 19–20 in anorexia nervosa 30, 183–184 in anorexic bingers 36 by ballet dancers 55 in bulimia nervosa 75–76, 183–184 complications of 183–184, 320 by Hispanics/Latinos 167 and osteopenia 235 vocational 295

Layton, Mary Jo 84 Leitenberg, H. 134 Lennon, John 141 leptin 42, 169, 184–185, 220, 263, 275 lesbians, eating disorders in 168–169 Letter of Corpulence, Addressed to the Public (Banting) 56 levetiracetam 37 Levine, James A. 215 Levitt, John L. 43, 207 Liebman, Bonnie 83 Linn, Robert 188, 308 linoleic acid, conjugate 99–100 lipase inhibitors 233–234 lipectomy, belt 62 lipocaic 302 lipoprotein lipase (LPL) 185 liposuction 1, 7, 62, 185–188, 282 complications of 187–188 cost of 188 FDA caution on 187–188 laser liquifying in 188 limitations of 186–187 molecular 204 new techniques in 188 results of 186 ultrasonic 188 water-jet dissection in 188 liquid formulas 188–189, 232, 251 Lisser, H. xvi Littrell, J. M. 50 Lives of John Lennon, The (Goldman) 141 Lock, J. 248 Longitudinal Assessment of Bariatric Surgery (LABS) 189 loop diuretics 121 Lovejoy, Jennifer 249 low birth weight, in African Americans 15–16 low-carb diets 51–52, 85, 190 Lowenkopf, Eugene 309 low-fat diet 190–191 Lundholm, J. K. 50 Lynch, V. 305

M Macias, A. E. 269 Madley, Rebecca H. 285 magical thinking 284 magnetic resonance imaging 68 ma huang (ephedra) 120, 132 Maine, Margo 27–28 Maisonet, G. 305

Index 357 Making Weight: Men’s Conflicts with Food, Weight, Shape and Appearance (Gürze) 168 malabsorptive operations 57, 63, 179, 193, 226 males anorexia nervosa in 28, 168–169, 193–195 body image of 168, 194–195, 209 bulimia nervosa in 76, 195–196 homosexual, eating disorders in 168–169 muscle dysmorphia in 209 sterility in, obesity and 279 malnutrition 196 psychogenic 253 mammography, obesity and 196 Mandel, Debra Lorraine 265 Mandell, Arnold 307 Mandometer Treatment 65–66, 196 Market Trends: The Online Weight Loss and Dieting Services Market 232 Marley, J. 4 marriage and eating disorders 196–197 and weight gain 197 Marshall, H. M. 214 Marti, A. 158 Martineau, William 99 Mason, Edward E. 156 Massachusetts programs 326, 331 Matsumoto, T. 268 Mattes, R. 263 Mayer, Jean 304–305, 307 Mazel, Judy 62 Mazur, A. 105 McAnarney, E. R. 235 McCay, Clive 84 McCreary, D. R. 198 McCurdy, John A. 119, 142, 238 McElroy, S. L. 242 McGinnis, J. Michael 221 McIntosh, Virginia V. W. 254–255 McKay, Betsy 221 McKisack, C. 163 McLaren-Hume, Mavis 303 media influence on eating disorders 197–199 Medicare and obesity 199 A Medicinal Dictionary (James) xvii Medifast 189 Mediterranean Diet 199–200 Mehrota, C. 44 melanin-stimulating hormone (MSH) 169 melanocortin 64, 169 melatonin 205

Menaged, Samuel E. 258 Mendelson, M. 303 menopause and weight gain 200 menstrual dysfunction 18–19, 200–201, 264–265 Meridia. See sibutramine Merkle, Elmar 260 mesomorph 72, 201, 239 mesotherapy 201 metabolic equivalent (MET) 201–202 metabolic rate, basal 58–59 metabolic syndrome 61, 202 metabolism 202–204 metformin 40, 112 metoclopramide 204 Metrecal diet 114 Mexican Americans. See Hispanics/Latinos Meyer, Adolf 280–281 Michelmore, K. F. 246 Midtown Manhattan Study 303 Miller, O. N. 306 Millman, H. 302 Milloy, Stephen J. 128 mind hunger 204 Minnesota programs 329 Mirasol 66, 328 Missouri programs 329 Mitan, L. A. 201 Mitchell, J. E. 79, 236 “model children,” anorexia nervosa in 30–31 models 295 Mokdad, A. H. 221 molecular liposuction 204 monoamine oxidase inhibitors (MAOIs) 38–39 mood disorders. See also depression and eating disorders 204–206 Moore, Lynn 107 Moreno, J. L. 252 Morgan, John F. 271 Morley, J. E. 106 mortality rate 206, 221 in African Americans 16 in anorexia nervosa 24, 206 in bariatric surgery 206, 226 dieting and 117 in obesity 206, 221, 224 Morton, Richard xiv mouth hunger 169 movement therapy 206–207 multicompulsive behavior 36, 78, 207–208 multidimensional/multifactorial models 208–209

Multifactorial Assessment of Eating Disorder Symptoms (MAEDS) 209 Munson, Suzanne 206 Munter, Carol H. 117 Murray, Donna 273–274 muscle dysmorphia 209 music 209 Mussell, M. P. 129 Myers, Michael D. 171 MyPyramid 316 Mysoline 37

N NAAFA (National Association to Advance Fat Acceptance) 211, 326 naltrexone, for bulimia nervosa 242 narcissistic personality disorder 211 National Association to Advance Fat Acceptance (NAAFA) 211, 326 National Center on Addiction and Substance Abuse (CASA) 6 National Eating Disorders Association (NEDA) 211, 326 National Eating Disorders Association-Long Island (NEDA-LI) 326 National Eating Disorders Screening Program (NEDSP) 212 National Health and Nutrition Examination Survey (NHANES) 88–89 National Institute of Environmental Health Sciences (NIEHS), nutrition labeling recommendations of 150–151 National Institute of Mental Health (NIMH) 326 National Institutes of Health (NIH) obesity guidelines of 219 research efforts of 36 National Weight Control Registry (NWCR) 212–213 Native Americans. See American Indians/Alaska Natives Naturlose 285 Naudeau, J. xv Nebraska programs 329 NEDA (National Eating Disorders Association) 211, 326 NEDSP (National Eating Disorders Screening Program) 212 Nelson, Gaylord 305 neotame 46 Nestle, M. 247 net carbs 213 Neuman, Patricia A. xvi, 26–31, 35–37, 296 neuroleptics 41

358 Index Neurontin 37 neuropeptide Y (NPY) 159–160, 169 neurotransmitters 213–214 Never Satisfied: A Cultural History of Diets, Fantasies, and Fat (Schwartz) 104 New American Eating Guide 91 New Jersey programs 329 New York programs 329–331 Nicol, G. T. 228 Nielsen, Soren 111, 271 night eating syndrome (NES) 214–215 Niños Activos, Familias Sanas (Active Children, Healthy Families) 215 Nobakht, Minoo 258 nonexercise activity thermogenesis (NEAT) 215 Norcross, John W. 309 norepinephrine 213–214, 243, 273 Norpramin (desipramine) 39 North Carolina programs 330, 332 nortriptyline 39 novelties 215–216 nutrients 216–217 nutritional counseling 217–218 Nutrition Scoreboard 91 NWCR (National Weight Control Registry) 212–213

O OA (Overeaters Anonymous) 113, 236, 327 obesity 219–227 accommodation of 1–3 adolescent 9–10 adult onset 11 advertising and 11–13 affluent sedentary society and 223 in African Americans 14–17, 112, 222 air pollution and 17 alexithymia and 17 and Alzheimer’s disease 17–18 AMA guidelines in 226 in American Indians/Alaskan Natives 20 anticonvulsants for 38 arthritis link to 44 in Asians/Pacific Islander Americans 47 asthma link to 48–50 attitudes toward 227–228, 273–274 behavior modification for 59–61, 225

benefits of 223–224 versus binge-eating disorder 64 biological clock factor in 222 body image in 71 body mass index in 71–72, 219 brain activity and 72–73 breakfast and 73–74 Bruch’s classification of 74 cancer links to 84–85, 223, 250–251 and cataracts 86 causes of 220 childhood. See childhood obesity chronology of 302–316 class and 222, 228–229, 277 cognitive therapy for 94 complement factors and 97–98 conditions associated with 219 costs to treat 101–102 craving and 102–103 creeping 103, 133, 142 depression and 110, 220 developmental 74 diabetes and 22, 89, 111–112 diet therapy for. See diet(s); dieting early dietary excess and 222 emotional overeating and 220–221 employee health costs of 129–130 endocrine factors in 131 externality approach to 42, 135 extreme 135 family environment and 222 family therapy for 140 fat virus and 146 fructose as contributor to 153–154, 166 genetic factors in 158–159, 220, 222 global epidemic of 160 gonads 161 government role in combating 161–162 group therapy for 225 growth hormone in 163 in Hawaiian Natives 165 hCG therapy for 39, 165–166, 307 health complications of 223 in Hispanics/Latinos 167–168, 215, 222 hyperplastic 171 hypertrophic 172 hypnotherapy for 172 hypothalamic disease and 172 in immigrants 173–174 infant 174–176 and infertility 176, 279 insurance coverage for 176–177

interoceptive disturbance in 177–178 and kidney stones 181–182 life expectancy in 223–224 and mammography 196 marriage and 197 Medicare and 199 menopause and 200 and metabolic syndrome 202 metabolism in 203 morphology of fat tissue and 222 mortality in 206, 221, 224 nutritional counseling for 217–218 oral contraceptive use in 232–233 pharmacotherapy for 39–41, 225–226, 242, 260, 273, 299 physical activity and 225, 243–244 pituitary 245 polycystic ovary syndrome and 246 portion/serving sizes and 247 pregnancy and 248–250 prevalence of 221–222 and prostate cancer 250–251 psychodynamic approach to 42, 253 psychological effects of 224 psychological time-bomb theory of 223 public policy and 255–256 PYY and 256 reactive 74, 257 religion and 258 restaurant eating and 259 risk factors for 221–223 schools and 263–264 self-esteem and 265 sexuality and 271–273 social factors in 277 social learning theory of 220, 223 spinal cord injury and 278 and sterility 279 sugar and 282–283 surgery for 56–58, 226. See also bariatric surgery television and 286–287 thermodynamic approach to 288 thrifty gene hypothesis of 15, 20, 288 treatment of 224–228 in workplace 230 wound healing in 298 obesity-hypoventilation syndrome (OHS) 229–230 Obesity Management 230 Obesity Working Group (OWG) 230–231

Index 359 obesophobic 231 obligatory exercise 22–23 O’Brien, Richard M. 309–310 O’Brien, Robert 81 Obsessions et la psychasthénie, Les (Janet) 179 obstructive sleep apnea/hypoventilation 229–230 O’Connor, J. 10 Oklahoma programs 330 olanzapine 242 Olden, Kevin W. 262 Older Americans 2004: Key Indicators of Well-Being 128–129 olestra 145, 231, 335 Olsen, Mary-Kate 141, 250 Olshansky, S. Jay xix ondansetron 242 Ondercin, P. 99 O’Neill, Cherry Boone 141 online dieting 231–232, 337 online promotion of eating disorders 250 online resources ix, 336–337 Optifast 117, 189, 232 oral contraceptives 232–233 oral nutritional supplements 233 oral soft tissues 233 orexin 169 orlistat 39–40, 225, 233–234, 299 Orrell-Valente, J. K. 43, 252 orthorexia nervosa (ON) 234 O’Shea, Michael 86 osteitis fibrosa 235 osteomalacia 235 osteopenia 31, 234–236 osteoporosis 234–236 Ostopowitz, Elizabeth 304 OTC diet pills 120 Overcoming Night Eating Syndrome (Stunkard, Allison and Thier) 214–215 Overcoming Overeating (Hirshmann and Munter) 117 Overeaters Anonymous (OA) 113, 236, 326 overeating, emotional 220–221 overgeneralization 94 overweight, definition of 219 overweight bulimia nervosa 236 oxcarbazepine 37

P pagophagia 237, 245 pamabrom 122 Pamelor 39

pancreatic polypeptide (PP) 237 panniculectomy 237–238 parental factors in anorexia nervosa 26–27, 138–140, 238, 322 in bulimia nervosa 76–77, 322 in obesity 222 Park, Alice 40–41, 184 paroxetine 39 Parrish, R. E. 306 Partnership for Healthy Weight Management 115 passive exercise machines 238 pathophysiology 238–239 Patterson, Ruth E. 272 Patton, George 32 Pauli, Eric 279 Pavarotti, Luciano 308 Pavlov, Ivan 53, 302 Paxil 39 pear shape 61 Pecoraro, Norman 96–97 peer relationships and anorexia nervosa 28 of obese children 89–90 Pennington Diet 181 Pennsylvania programs 330, 332 Percy, Charles 308 perfectionism 239 perimylolysis 239–240 Perlstein, I. B. 304 personalities of eating-disordered individuals 30–32, 157, 211, 239, 240 personality disorder 240–241 narcissistic 211 personalization 94 Pescatore, Fred 190 pharmacotherapy 241–243. See also specific disorders phenelzine, for bulimia nervosa 79 phenmetrazine 303 phenobarbital 37 phen-Pro 243 phentermine 21, 40, 149, 225 with fluoxetine (phen-Pro) 243 phenylpropanolamine (PPA) 120, 243, 309–310 phenytoin 37 phthisic body type 72 physical activity and obesity 225, 243–244 Physical Dictionary (Blankaart) xvii physiological arousal 244 pica 159, 181, 237, 244–245 Pickering, A. S. 198 pickwickian syndrome 229–230

Pike, K. M. 217 Pima Indians 20 pimozide 41, 245, 284 pituitary obesity 245 placebo 245 pobough lang 159 Polivy, Janet 24, 28, 105, 117–118, 122–123, 198, 205, 224, 259 polycystic ovary syndrome (PCOS) 176, 245–246 polyphagia 246 ponderosity 246–247 Pondimin 149, 225, 314 Pope, Harrison G. 209, 270 Pop-Jordanova, N. 65 Popkin, B. M. 191 portion and serving sizes 247 positron emission tomography (PET), in obesity 72–73 post-traumatic effect 247 potassium deficiency 31, 121, 172 potassium-sparing diuretics 121 Powers, P. S. 41 Prader-Willi syndrome (PWS) 247 pregnancy bariatric surgery and 58, 193 dieting during 249 and eating disorders 248 and obesity 248–250 pica in 244–245 Preludin (phenmetrazine) 303 Premachandra, B. N. 304 premenstrual syndrome 204–205 primidone 37 pro-ana movement 250 pro-ED 250 Prolinn 188 PROP 285–286 prostate cancer, and obesity 250–251 Protein Power Diet 181, 190 proteins 251 protein-sparing modified fast (PSMF) 232, 251 Prout, T. E. 305 Prozac 251–252, 314 for anorexia nervosa 34, 38–39, 252 for binge-eating disorder 39, 242 for bulimia nervosa 39, 79, 242 mechanism of action 251 with phentermine (phen-Pro) 243 side effects of 251–252 in smoking cessation 276 psychodrama 43, 252–253 psychodynamic approach to obesity 42, 253 psychogenic malnutrition 253

360 Index psychogenic vomiting 253 psychological time-bomb theory, of obesity 223 psychosomatic medicine 253 psychotherapy 253–255, 287–288. See also specific types psychotropic drugs 255 puberty 255 public policy and obesity 255–256 Puhl, R. M. 274 purging 256. See also bulimia nervosa Putnam, Judy 83 pyknic body type 72 Pyle, Richard L. 208 PYY (peptide YY3-36) 42, 169, 256, 263

Q Quagliani, Diane 137 Quincy, John xvii

R race. See specific races Racette, Susan B. 132, 200 Rappaport, Lou 198 Ravaldi, C. 55 Ray, Shannon L. 168 Rayworth, B. B. 270 reactive obesity 74, 257 Redux 149, 225, 313–314 Reilly, John J. 10 religion and eating disorders 257–258 and obesity 258 religious fasting xv, 23, 141, 257–258 Remuda Ranch 130–131, 258, 290, 328 Renfrew Centers 139, 258–259, 270, 329–330 research in anorexia nervosa 36 empirical 129 epidemiological 132 Research on Interventions for Anorexia Nervosa (RIAN) 36 restaurant eating and obesity 259 Restraint Scale 259 restraint scale 118 restrictive operations 7–9, 57, 156–157, 226, 260–261, 293 restrictor anorexics 36–37, 260 Revivarant 156 Rexrode, Kathryn 314 Rhode Island programs 330 Richards, Dean 4

Richardson, H. E. 302 Richardson, P. H. 4 Rick, A. M. 197 Rigby, Cathy 50, 140 rigidity, in bulimia nervosa 77 Rigotti, Nancy A. 235, 310 rimonabant 40, 260 Ripamonte, Leonor E. 166 Rippe, James 243 Robertson, Donald S. 297 Robertson, J. D. 302 Robert Wood Johnson Foundation 3 Rodin, G. 110–111 Rodin, Judith 220, 285, 308 Role of Media in Childhood Obesity, The 16 Rosen, James C. 66, 134 Rosenzweig, Margaret 298 Rosmond, R. 110 Rossi, A. 252 Roth, Geneen 204 Roux-en-Y gastric bypass 57, 122, 193, 226, 260–261 Rudy, E. B. 6 rumination 261–262 runners 134, 195 Russell, C. J. 168–169 Russell, Gerald F. M. 75, 88, 262 Rutter, Michael 280–281 Ryley, David 176 Rynearson, E. H. 302

S saccharin 45, 307 St. Jeor, Sachiko 137 Salata, D. R. 306 Sansone, Randy A. 43, 207 Santana, C. 41 Saris, Wim H. M. 299 Satcher, David 314 satiety 263 cholecystokinin and 93 early 125 infant experiences in 175 pancreatic polypeptide and 237 saturated fats 145 Sawrer, D. B. 270 Schachter, Stanley 135 Schapira, David V. 69 Schardt, David 285 Schmidt, V. H. 281 schools and obesity 263–264 Schotte, David E. 75 Schwartz, Hillel 104, 116–118, 216 Schwartz, Marlene B. 228 SCOFF Questionnaire 264

Sculpturing Your Body: Diet, Exercise and Lipo (Fat) Suction (McCurdy) 119 seasonal affective disorder (SAD) 204–205 secondary amenorrhea 18, 264–265 See, Jackie R. 311 seizures, and eating disorders 37–38 selective serotonin reuptake inhibitors 38–39, 241–242 self-esteem 78, 240, 265 self-help groups 265–267 self-monitoring 267–268 self-mutilation 36, 268 Selvini-Palazzoli, Mara xvi, 138 serotonin 38, 109, 205, 213, 243, 268, 269, 273 Serpell, Lucy 239 sertraline 39, 242, 276 serving sizes 247 set point amphetamines and 21 appetite suppressants and 43 set-point theory 269–270 Sex Role Attribute Inventory 265 sexual abuse and eating disorders 208, 270–271 and multicompulsive behavior 208 sexuality in anorexia nervosa 30, 271 in bulimia nervosa 78, 271 and eating disorders 271 of males with eating disorders 168–169, 194 and obesity 271–273 Shaheen, Sheif 48 Shalala, Donna 314 Shapiro, Howard 190 Sheedy, Ally 141 Sheldon, William 72, 238–239 Shell, William E. 311 Sherman, Walter 303 Sherwin, Robert 308 “should” statements 94 Shure, Jane 270 sialadenosis 273 sibutramine 39–40, 65, 225, 242, 263, 273, 314 Siega-Riz, A. M. 249–250 Siegel, Michele 99–100, 217 Sigler, Jamie-Lynn 141 Simmonds, Morris xvi Simmonds’ disease xvi Simmons, E. 305 Simone Porta xiv Simonson, Maria 209 Simon v. Blue Cross and Blue Shield of Greater New York 176

Index 361 Simplesse 145, 273, 311, 333 sitomania (sitophobia) 92, 273 size discrimination 273–274 skin, in anorexia nervosa 31 skin fold measurement 47–48, 67–68, 274–275, 302 Skinner, B. F. 302 Slade, Peter D. 239 sleep deprivation and weight gain 275 sleep-related eating disorder (SRED) 276 Slim-Fast 114 Smith, M. S. 80 smoking, and body fat distribution 69–70 smoking cessation, and weight gain 276–277 Smolak, Linda 239 Snowbird Diet, The (Robertson) 297 Sobal, Jeffery 104–105, 228, 258 Sobel, Stephen V. 255 social factors in obesity 277 social learning theory, of obesity 220, 223 Sociocultural Attitudes Towards Appearance Scale-3 (SATAQ-3) 277–278 socioeconomic status and anorexia nervosa 23, 25 and obesity 222, 228–229, 277 sodium pump 278 solid foods, and infant obesity 174–175 Soltmann, O. xviii Sothern, M. S. 264 South Beach Diet 114, 181, 190, 278 South Carolina programs 330 Spake, Amanda 133, 160 spinal cord injury and obesity 278 spironolactone 121 Splendid (fat substitute) 145 spot reducing 278 Squires, Sally 146 Srole, Lee 303 Staniger, Cora 308 Stanten, Michele 49 starch blockers 278–279 starvation, in anorexia nervosa 31–32 starvation response, in dieting 117 starvation syndrome 279 Starving for Attention (O’Neill) 141 steatopygia 279 Stein, Rob 174 Stein-Leventhal syndrome. See polycystic ovary syndrome (PCOS)

Stellar (fat substitute) 145 sterility, and obesity 279 Stettler, Nicolas 15 stevia 279–280 Stewart, Tiffany M. 267 Stillman Diet 181 stimulus control 280 Stolley, Melinda 20, 47 stomach hunger 169 stomach stapling 280 St-Onge, M. P. 46 Strand, Erik 234 Strang, J. M. 303 Strauss, Richard 89 stress and anorexia nervosa 25–26, 281–282 comfort food and 96–97, 282 cortisol release in 100–101, 282 and eating disorders 280–282 and weight gain 282 Striegel-Moore, Ruth H. 214, 239 Strober, M. 53 Study of Women’s Health across the Nation (SWAN) 15, 200 Stuht, Jennifer 267 Stunkard, Albert J. 75, 90, 110, 214–215, 277, 303, 309–310 Stunko, Ronald T. 311 subcutaneous fat 282 substance dependence 4–5, 87–88, 207–208 sucralose 45 sugar 282–283 sugar substitutes 45–46, 279–280, 282, 285 suicide 283–284 in anorexia nervosa 32, 36, 204, 283 in bulimia nervosa 78, 208, 283 substance abuse and 208 sulpiride 41, 284 superstitious thinking 94, 284 Superwoman syndrome 26 support groups 285 Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity, The 263–264, 315 Surviving an Eating Disorder (Siegel, Brisman, and Weinshel) 217 sweeteners, artificial 45–46, 282 swimmers 50 Swithers, Susan E. 46 symbolization, in atypical anorexia nervosa 52–53 syndrome X 61, 202 synephrine 120

T tagatose 285 Taller, Herman 304 Tallmadge, Katherine 82 Tanofsky-Kraff, M. 214 Tantleff-Dunn, Stacey 194, 198 taste 285–286 Tataranni, Antonio 72–73 Taufig, A. Ziah 188 Tavares, Damien, III 165 tax deductions 286 taxon 286 teas, dieter’s 115–116 teasing, of obese children 90 Teegarden, Dorothy 81–82 Tegretol 37 television and obesity 286–287 Tenuate 287 Tepperman, J. 305 Texas programs 330–331 Thelen, M. H. 80 therapy 287–288. See also specific types thermodynamic approach to obesity 288 thermogenesis, nonexercise activity 215 thermogenic drugs 288 thiazide diuretics 121 thin fat people 36, 288 Thin Game, The (Bayrd) 62, 86 thinness, ideal of 103–106 Thompson, Ed 161–162 Thompson, Ian M. 250–251 Thompson, Tommy G. 150, 315–316 Thompson-Brenner, H. 79 Thorazine 41, 92–93 Thorndike, Edward 302 Thornton, Billy Bob 141 thrifty genes 15, 20, 288 thymoleptic medications 289 thyroid disease 289 thyroid hormone (thyroxine) 289 tiagabine 37 Tiggemann, M. 198 Time/ABC News Obesity Summit 12 Timm, Alfred 308 Timm, Robert, III 165 Tofranil 39, 79, 173 Toner, Brenda B. 205 topiramate (Topamax) 37–38, 242, 276 TOPS (Take Off Pounds Sensibly) 60, 113, 289–290, 308, 327 Torgan, Carol 89 total parenteral nutrition (TPN) 151, 170

362 Index Traffic Light Diet 91, 290 Trager, Stuart 130 trans fat 150, 290 trazodone (Deseryl) 38 treatment centers 328–331 Tremblay, Angelo 82 triamterene 121 trichophagia 290 tricyclic antidepressants 38–39 Trileptal 37 Troop, Nicholas 239 Tsai, Adam Gilden 236, 266, 298 tube feeding 151, 290–291 Tucker, Katherine 62 Tucker, Larry A. 287 tummy tuck 1, 7, 291 tumor necrosis factor-alpha 174 12-step programs 6–7, 236 twin studies of eating disorders 10, 27, 291

U Ultrafast 189 ultrasonic liposuction (UAL) 188 ultrasound 68 uncoupling proteins (UCPs) 169 Underwood, Anne 69 unsaturated fats 145 Utah programs 331

V valproate 37 van Binsbergen, C. J. M. 31 Van Cauter, Eve 275 Van Dale, Djoeke 299 Vandereycken, Walter xvii, xiv–xv, 5, 138 Vanderlinden, Johan 138 Vander Wal, J. S. 167 Van Deth, Ron xvii, xiv–xv van Hoeken, D. 24 van Prohaska, J. 302 vegetarian diet and eating disorders 293 Veneman, Ann M. 315–316 Venus of Willendorf xiii Vermont programs 331 vertical banded gastroplasty (VBG) 57, 226, 293 very low-calorie diet (VLCD) 225, 232, 293–294 Veugelers, P. J. 264 vibrator belts 294–295 vicious cycle, of dieting 117–118

Vincent, C. A. 4 Vincent, L. M. 309 visceral fat 61, 295 vitamin deficiency 295 vocational bulimics 295 vomiting 256, 295–296 in anorexic bingers 36 in bulimia nervosa 76, 78, 295–296 complications of 296, 320 and dental caries 109 and hypokalemia 172 ipecac syrup-induced 31, 178 and osteopenia 235 psychogenic 253 Von Noorden, C. 302–303

W Wadden, Thomas A. 189, 232, 267, 311–312 waist-to-hip ratio (WHR) 297 Waitman, Jonathan A. 242 Walford, Roy L. 310 Waller, G. 163, 270 Walsh, B. Timothy 41, 157, 252, 312 Wang, Gene-Jack 73 Warden, Thomas 12 Washington programs 331 Wasson, Diane H. 236 water 297 Watson, Tureka 241 Webster, Peter 254 weekend calories 297–298 Weigel, David S. 41 weight cycling 299–300 weight gain. See also obesity by college students 95, 152–153 marriage and 197 menopause and 200 mood disorders and 204 oral contraceptives and 232–233 pregnancy and 248–250 sleep deprivation and 275 smoking cessation and 276–277 stress and 282 sugar and 282–283 thyroid disease and 289 weightlifters 194–195, 209 weight loss. See diet(s); dieting weight phobia 29, 32–33, 298 weight reduction camps 331–332 Weight Watchers 60, 113–115, 298, 305, 327 Weindruch, Richard 310 Weiner, R. 8

Weinshel, Margot 99–100, 217 Weintraub, M. 149 Wellbutrin 39 Wennerstrand, Anne L. 207 Wergowske, Gilbert 165 Whittal, M. L. 79 Wilfley, Denise 255 Williamson, David 311 Williamson, Don 42 Williamson, Donald 70–71 Wilmoth, Debbie 298 Wilson, Gregory L. 220, 224 Winfrey, Oprah 189, 232 Wing, Rena 212 Winston, Anthony 254 Witherspoon, Barbara 298 Wolpe, J. 303 Women’s Healthy Lifestyle Project 200 Woodard, C. B. 193 Woods, Stephen C. 40 Woodside, D. Blake 195 Woodward, Edward R. 310 workplace, obesity in 230 wound healing 298 wrestlers 50 Wright, C. E. 246 Wright, P. 63 Wurtman, Judith J. 102–103, 309 Wurtman, Richard J. 102–103 Wyden, Ron 311

X Xenical 39–40, 225, 233–234, 299

Y Yager, Joel 168, 240 Yancy, W. S., Jr. 190 Yanovski, S. Z. 214 Yates, William R. 241 Yee, D. K. 75 Young, L. R. 247 Young, Mary Evans 312 yo-yo dieting 299–300

Z Zametkin, A. J. 49, 277 Zarontin 37 Zemel, Michael 82, 107 zinc deficiency 31, 34, 300 Zoloft 39, 242, 276 Zone diet 181, 190 zonisamide (Zonegran) 37–38 Zuercher, J. L. 290