THE ENCYCLOPEDIA OF

OBESITY AND EATING DISORDERS

THE ENCYCLOPEDIA OF

OBESITY AND EATING DISORDERS

Third Edition

Dana K. CassellDavid H. Gleaves, Ph.D.

The Encyclopedia of Obesity and Eating Disorders, Third Edition

Copyright © 2006, 2000, 1994 by Dana CassellForeword copyright © 2006, 2000 David H. Gleaves, Ph.D.

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CONTENTS

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

Acknowledgments xi

Introduction xiii

A–Z Entries 1

Appendixes 301

Bibliography 341

Index 347

Never before has so much attention been paid towhat might be called the disorders of eating

and/or weight regulation. Not coincidentally, soci-ety is currently preoccupied with thinness, dieting,beauty and health, and a great industry has arisento take advantage of the fear of fatness that hasspread through developed nations and is beginningto spread throughout others. No-calorie or low-calorie foods and drinks, sugarless sweeteners andpills sold as appetite suppressants pour onto themarket. Writers make fortunes propagating newdiets, and health clubs and the makers of exercisemachines sell people the presumed benefits of”working out.”

The Eating Disorders category of the currentDiagnostic and Statistical Manual of Mental Disorders(DSM), published by the American PsychiatricAssociation, includes the two best-known eatingdisorders, anorexia and bulimia nervosa, as well asa residual category called “eating disorder not oth-erwise specified.” A provisional diagnostic categorycalled “binge eating disorder” was added to themost recent version of the DSM. Obesity, althoughtechnically not an eating disorder, is a much morecommon problem, affecting at least one-third ofthe American population; this prevalence hasincreased from about one-quarter of the popula-tion since the mid-1980s.

The literal definition of anorexia nervosa is lossof appetite (anorexia) of nervous, or emotional,origin (nervosa). Bulimia can be literally definedas “ox hunger,” with the term nervosa againimplying that it (bulimia nervosa) has an emo-tional origin. However, both of these terms are

probably misnomers, because the typical anorexicmay not experience a loss of appetite (and, in fact,may be preoccupied with food), and for the suf-ferer of bulimia, the most frustrating part of thedisorder may be that he or she binge eats evenwhen not hungry.

In terms of invariable clinical observations withthese disorders, both anorexia and bulimia ner-vosa are characterized by gross disturbances in eat-ing behavior and highly characteristic extremeconcerns about shape and weight. In both disor-ders, self-esteem is influenced to a great degree bybody weight and shape. These similarities have ledsome researchers to suggest that the disorders aresimply variations on a common theme; however,according to the DSM, the disorders are classifiedas distinct categories, and there are two subtypesof each. With anorexia nervosa, there are therestricting and binge-eating/purging subtypes.With bulimia nervosa, there are purging and non-purging subtypes.

Binge-eating disorder is characterized by out-of-control binge eating in the absence of any compen-satory behaviors. Obesity is a state rather than aneating disorder per se, although a sizable propor-tion of obese individuals may engage in binge eat-ing, and may even meet the diagnostic criteria forbinge-eating disorder. Conversely, most peoplewith binge-eating disorder are clinically obese.

In addition to the core eating and body image-related psychopathology of the eating disorders andobesity, a variety of additional problems, includingdepression, anxiety, obsessive-compulsive behavior,post-traumatic stress disorder and substance use,

FOREWORD

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viii The Encyclopedia of Obesity and Eating Disorders

have been described in the literature. Interpersonaland family problems as well as personality disordersare also common.

Despite earliest attempts to find strictly biologicalor intrapsychic explanations, the recently devel-oped understanding of the role of cultural factors inthe development and maintenance of eating disor-ders leads one to wonder whether the proper sub-ject for treatment is the individual or society as awhole. However, it is still the case that only aminority of people actually develop full-blown eat-ing disorders, despite the fact that almost all areexposed to and are aware of the aforementionedsociocultural thinness standards. There is thus aneed to understand who internalizes these stan-dards and who is at risk (possibly because of bio-logical factors) for developing additional problemsas a consequence. The most popular etiologicalexplanation of eating disorders and obesity, knownas the biopsychosocial model, thus attempts to inte-grate these biological, psychological and social fac-tors. According to this model, there is no simplisticsingle factor explanation for any of these problems.Particularly when such multiple problems exist,such as those described above, it is often difficult todisentangle cause and effect. For example, aredepression and anxiety causes or effects of an eat-ing problem, or are there some other mechanisms(biological, psychological or social) that somehowexplain the comorbidity? Answering this questionis one of the ongoing challenges in the field.

Just as the etiology of eating and weight disor-ders may be complex and multiply determined, somay the treatment need to be complex and multi-faceted. In other words, most successful treatmentsintegrate features that address biological (includingnutritional), psychological and social factors. Thedegree to which treatment of each factor is neces-sary may depend both on the disorder and the indi-vidual. However, in recent years there has alsobeen a move toward a transdiagnostic psychologi-cal approach to treatment; that is, a more unifiedtherapy based on the similarities among peoplewith eating problems.

For years scientific literature on eating disordersand obesity was regrettably separated. The obesityfield had been dominated by perspectives frommedicine and health risk concerns, whereas the

eating disorders field had its roots in the social sci-ences. As a consequence of this division, personsworking in the fields had very few shared interestsand had different conceptualizations of the etiol-ogy, assessment and treatment of these arguablyrelated conditions. This gap in the literature hasfortunately begun to close since the 1990s. Testa-ments to this closure include the publication ofBrownell and Fairburn’s Eating Disorders and Obesity:A Comprehensive Handbook (1995), the journal Eat-ing and Weight Disorders: Studies on Anorexia, Bulimia,and Obesity and The Encyclopedia of Obesity and EatingDisorders (first published in 1994). This, the thirdedition of the last-named book, is meant to furtherbridge the gap between the literature on obesityand eating disorders. It is also meant to bring anunderstanding to subjects on which expertresearchers both have and have not been able toagree. Under these circumstances it seems that theencyclopedia approach is especially useful, forwhereas an encyclopedia cannot give exhaustiveinformation about any subject, it can bring crucialquestions about that subject into focus, give thereader a reasonably accurate “bottom line” and listfurther reading for those who want to know more.

Since the publication of the second edition ofthe encyclopedia, there have been numerousdevelopments in the obesity and eating disordersfield. These have been in the areas of epidemiology,etiology, treatment, long-term outcome and pre-vention; some developments have been positive,others negative. Use of antiobesity medicationsexploded, only to be followed in many cases bydrugs being banned due to harmful physical effects.The low-carbohydrate diet was resurrected, alongwith an associated marketing explosion. Recentresearch has questioned the assumed continuitymodels of eating disorders (that eating disordersoccur on a continuum and are simply extreme vari-ants of normal dieting, eating and weight concerns)and suggested that the subtypes of bulimia andanorexia nervosa should be organized differently.There has also been new research on the biologicalbases of anorexia and bulimia and increased atten-tion to eating and body image problems (suchas muscle dysmorphia) among males and amongpersons of diverse cultural groups. Recently amuch better understanding of the effectiveness of

eating disorder prevention programs has beengained. As a testament of the amount of profes-sional knowledge and interest that now existsregarding these disorders, there are now approxi-mately a dozen journals devoted exclusively to thestudy, prevention and/or treatment of eatingand/or weight disorders, and several others focusedon related problems.

As technology (particularly the Internet) hascontinued to develop, it has substantially affectedthe obesity and eating disorders field. As with otherdevelopments, some have been positive and othersnegative. On the positive side, Internet-based treat-ment programs have been developed and imple-mented for both obesity and eating disorders,numerous Internet support groups have been cre-ated and the availability of information about thetopics for the consumer and professional has grownamazingly. On the negative side, some of the infor-mation on the Internet is of questionable accuracy,and some of the “support groups” (such as pro-anorexia sites) actually purposefully support main-

tenance of eating disorders. Increased use of theInternet and computers may also lead to furtherdecreases in activity level and an increased preva-lence of obesity. Technology is evolving so fast thatit is difficult to even keep up with developmentsand to predict its future effect on the field.

This third edition is therefore timely and valu-able. It aims to be helpful to students, clinicians,researchers, parents, the eating disorder sufferer insearch of knowledge and referral information andthe prospective consumer of a vast variety of goodsand services that purport to change eating patternsor transform bodies (in many cases without chang-ing eating patterns). The authors hope that TheEncyclopedia of Obesity and Eating Disorders, Third Edi-tion will provide insights and accurate resources tothose in need. And last but not least, readers areurged to consult the references included through-out the book and the numerous appendixes.

—David H. Gleaves, Ph.D.

University of Canterbury

Foreword ix

ACKNOWLEDGMENTSNo work of this size could be completed withoutassistance from many sources. In preparing thisvolume, we have reviewed books, journal andmass media articles, monographs and studies bythe score to distill current opinion and researchfindings. Of particular help in the 21st century isthe wonderful World Wide Web, with its vast trea-sure trove of information, sources, communities,statistics and explanations. Toward the end of ourresearch for this edition, we were able to takeadvantage of the new database of NIH-fundedresearch articles published in scientific and medicaljournals now available to the public at no cost.Acknowledgment of this important initiative isintended not only as a “thank-you,” but also tobring it to the attention of our readers, who will beable to benefit from it as well. (The database islocated at http://www.pubmedcentral.nih.gov.)Hidden behind the endless waves of Web pages are

real people who gather and post that informationfor the use of the medical community, patients,researchers and the general public. Without all thatwork being done behind the scenes, this bookwould have been much more difficult to write.

Throughout this book, we have been especiallycareful to provide full attribution to authors andresearchers whose work we have consulted. Theyhave all contributed significantly to the field—andthus indirectly to the success of this book—and weare grateful to them.

Finally, a note of appreciation to James Cham-bers, our editor—not only for his editing help, butalso for his topic suggestions to make this andother books in the series more comprehensiveand valuable.

—Dana K. Cassell

David H. Gleaves, Ph.D.

Fashions shift in human beauty as they do inclothes and architecture, a fact pointed out by

Anne Scott Beller in her natural history of obesity,Fat & Thin. Physical proportions strived for and glo-rified during one era or generation are avoided, evenstigmatized, in another.

HILDE BRUCH, while describing the historical andsociocultural perspectives in Eating Disorders, notedthat the oldest known representation of the humanform, the “Venus of Willendorf” (Paleolithic period[20,000 to 30,000 B.C.], found in Willendorf, Aus-tria), is the figure of “an extremely obese womanwith large breasts and an enormous abdomen.”Other Paleolithic figures represent similar fatwomen. The idealization of obesity in women con-tinued into the Neolithic period. Prehistoric Greek,Babylonian and Egyptian sculptures also “indicatepreference or artistic admiration for women withlarge abdomens and heavy hips and thighs,”according to Bruch.

It is not known, Bruch added, whether thesearchaeological “Venuses” are representations ofwomen’s actual appearances or whether theyreflect a cultural ideal; they have usually beentaken as symbolic representations of abundanceand fertility at periods in human history whenfamine was an ever-present possibility (thoughsome researchers have surmised that these figureswere based on actual models). In any case, Bruchexplained, in every age and in every land people

have starved, and typically during hard times, obe-sity has emerged as a kind of cultural goal or desir-able state.

In very poor societies, sufficient food is consis-tently available only to a privileged few. Thus obe-sity may become a prestigious and admiredcharacteristic. Bruch discovered during her anthro-pological research that in some Polynesian culturesit was considered a sign of great distinction to be sowell nourished as to become fat. “Malayan kingswere very large and fat; they were treated withspecial massages and exercises to keep them ingood health.”

Anthropologists tell us that in conditions ofgeneral scarcity, gluttony was conceived of as apractice to be aspired to, as in expressions fromboth South Pacific and southern African culturesabout anticipated feasts: “We shall be glad, weshall eat until we vomit.” “We shall eat until outbellies swell out and we can no longer stand.” Weare told that the southern African’s dream was tobe fat himself as well as to have a fat wife and chil-dren and fat cattle.

Bruch added that ancient travelers reportedAfrican cultures in which young girls at pubertywere sent to fattening houses to make them readyfor marriage. The fatter a girl grew, the more beau-tiful she was considered, although the men wereexpected to remain athletic and slim. The king’smother and his wives competed with one another

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INTRODUCTIONA HISTORY OF OBESITY AND EATING DISORDERS

xiv The Encyclopedia of Obesity and Eating Disorders

as to who should be the fattest. They took no exer-cise and were carried in litters when going fromplace to place.

The attitude that “bigger is better” prevailedduring hard times earlier in this century amongAmerica’s immigrants. Having suffered hungerduring their own early years, poor mothers saw fatchildren as symbols of success. These children werenot called fat; they were “solid” or “hefty.” AuthorHarry Golden, who grew up in that environment,related, “I, too, was a husky kid and when I wor-ried about it my mother consoled me with theobservation, ‘ In America, the fat man is the bossand the skinny man is the bookkeeper.’ ”

Paradoxically, Bruch said, during prosperoustimes and in affluent societies obesity is commonlyassociated with poverty and lower-class status.Now the ideal is to be thin, and there is much con-cern about obesity. The privileged classes of theWestern world have been preoccupied through thiscentury with the question of how to stay slim inthe face of abundance.

The ancient Greeks of the classical age enviedtheir cultural predecessors, the Cretans, for havingknown of a drug that permitted them to stay slimwhile eating as much as they wanted. Leaders inSparta were stern taskmasters in their attitudetoward obesity. Young people were examined inthe nude once a month, and those who had gainedweight were forced to exercise. The Athenians alsofrowned upon obesity. Socrates is said to havedanced every morning in order to keep slim, andPlato was forgiven his fatness only on account ofhis brilliance. Hippocrates described obesity ingreat detail and made observations that are stillpertinent today.

The Romans disliked obesity as much as theGreeks; ladies of the upper class literally starved tomake themselves look slim as reeds. Yet, as withthe Greeks, there were also famous Romans whowere fat, and exact descriptions have been pre-served of some of their eating habits. It is knownthat Marius, the defender of Rome, enjoyed enor-mous quantities of food. Horace, the poet, wasfamous for the extraordinary variety and elegantpreparation of his meals.

During the Middle Ages also, there were con-flicting views on obesity. On the one hand, glut-

tony was counted among the venial sins. But obe-sity was also considered a sign of the grace of God.In Lochner’s painting The Last Judgment, the sinnersbeing dragged into Hell are stout, and the blessedbeing led into Paradise are slender.

Ron Van Deth and Walter Vandereycken, Dutchmedical historians, have noted that despite theenormous number of scientific publications onanorexia nervosa, research into its history is still inits infancy. Believing that historical studies wouldshed light on the sociocultural genesis of anorexianervosa, they began research some years ago. Theyhave pointed out that although the medical con-cept of anorexia is little more than 100 years old,self-starvation has been known in various formsfor centuries.

The less severe symptoms of lack of appetite andaversion to food have appeared in a variety of psy-chiatric illnesses. Also symptomatic have beenmore serious disorders associated with hysteria,melancholy, lovesickness, chlorosis (greensickness)and atrofia nervosa (nervous consumption).

Of these, Van Deth and Vandereycken considerthe only one resembling modern-day anorexia ner-vosa to be atrofia nervosa, which was described byBritish physician Richard Morton (1689) as “delib-erate starvation due to an ill and morbid state ofthe spirits.” The disorder was accompanied by alack of appetite and indigestion and was difficult tocure. His two detailed case histories described suchsymptoms as amenorrhea, constipation, hyperac-tivity, extreme emaciation and indifference towardboth condition and cure, classic symptoms oftoday’s anorexic. But even this description lacksany reference to what is a central feature of mod-ern anorexia: the relentless pursuit of thinness.

According to Joan Brumberg in Fasting Girls,Simone Porta of Genoa, Italy, wrote the first med-ical account of anorexia in 1500. A very few simi-lar cases were described in medical literature overthe next several hundred years.

But the relative silence in pre-1850 medical lit-erature about a disorder with such remarkable anddramatic manifestations is striking, add Van Dethand Vandereycken. They consider it improbablethat anorexia nervosa did exist but went unnoticedbecause of the low general standard of living, assome authors have suggested.

xv

The observable features and complications ofsevere anorexia usually are too obvious, if nothorrifying, to go unnoticed, even when a majorityof the population is underfed. Furthermore,physicians in previous centuries were rather keenobservers; they had to rely almost exclusively onclinical examination. Among social classes wherepeople did not suffer from undernutrition andmedical consult[ation] could be afforded, possiblecases of anorexia nervosa were scarcely men-tioned either.

While anorexia nervosa may be a relativelymodern phenomenon, self-starvation has beenaround throughout history. But our ancestors didnot consider it to involve a disease.

Extreme fasting was a practice of many piousChristians throughout history, especially in the lateMiddle Ages among deeply religious women.Although reports of contemporaries claim these“saints” sometimes ate nothing but the consecratedhost for years, these reports are subject to misinter-pretation and exaggeration. As Van Deth and Van-dereycken explained, “Hagiographers (biographersof saints) showed more zeal in demonstrating theholiness of the candidate-saint than in providingtruthful historical facts. . . . [T]hey did not writea historically reliable biography or medical report.”

Beginning with the 16th century, “miraculousmaids” or “fasting girls” moved self-starvation intoa more secular atmosphere. While considered bythe pious a sign of God’s presence on earth becausethey could eat virtually nothing yet stay alive, theywere regarded by most more as curiosities than asdivine manifestations. The popular media of theday publicized them. Thousands of people, includ-ing kings and other dignitaries, visited them, evenoffering them money, in the process turning theminto tourist attractions.

Physicians of the day took on the task of inves-tigating these cases for their validity rather than forthe purpose of treating them or discovering causesfor their starvation. Many of these girls wereunmasked as frauds and imprisoned or killed, butnot all.

By the 17th and 18th centuries, according toBrumberg, religious reform and changes of attitudeled to prolonged fasting’s being taken as the work ofSatan rather than God. “Women who exhibited

anorexic symptoms were said to be possessed by thedevil and persecuted as witches.” During the 19thcentury, the alleged extended fasts and the deceit ofthe maids were both labeled by physicians as signs ofhysteria. From this point on, most self-starvation waslooked upon as a medical-psychological problem.

It was not until 1873 that anorexia nervosa wasestablished as a clinical diagnosis. In that year, E.C. Lasègue, professor of clinical medicine at theUniversity of Paris, claimed that “anorexie hys-terique” was caused by emotional disturbances thatthe patient tended to disguise or conceal. He men-tioned the patient’s “state of quietude—I mightalmost say a condition of contentment trulypathological. Not only does she not sigh for recov-ery, but she is not ill-pleased with her condition,notwithstanding all the unpleasantness it isattended with.”

About that same year Sir William W. Gull, one ofLondon’s most respected physicians, first used theterm “anorexia nervosa” in a paper submitted tothe London Clinical Society. He explained, “Wemight call the state hysterical. . . . I prefer, how-ever, the more general term, ‘nervosa,’ since thedisease occurs in males as well as females, and isprobably rather central than peripheral.” He didnote that young girls were especially prone to thedisease. Lasègue and Gull were familiar with eachother’s work and recognized they were dealingwith “the same maladie.” They both insisted thatanorexia was a mental rather than an organic dis-ease and achieved a small degree of success bytreating it with “rest, nourishment, separation fromfamily and supportive therapy.”

In 1879 a French physician, J. Naudeau, pub-lished a lengthy description of a fatal case withsignificant similarities to modern anorexia.Another French doctor, H. Huchard, differentiatedbetween “anorexie gastrique” and “anorexie men-tale” in 1883. Six years later J. M. Charcot, thefamous French neurologist and teacher of Freud,recommended removal of his anorexic patientsfrom their families. Although still relatively rare,the puzzling malady anorexia nervosa hadbecome a recognized disorder affecting mainly themiddle and upper classes.

Recognition, however, did not slow the debatesas to the disease’s causes; was it a physical disease

Introduction xv

xvi The Encyclopedia of Obesity and Eating Disorders

or a mental disease? During the early 1900s, med-ical experts for the most part considered all diseaseto stem from abnormal variation of the body’s cellsor organs. In the case of anorexia nervosa, this the-ory found strong support when Morris Simmonds,a pathologist at the University of Hamburg,described pituitary cachexia in 1914. During anautopsy, Simmonds had observed lesions on thepituitary gland of a severely emaciated womanwho had shown signs of pituitary failure and died.For the next 15 years, though anorexia might bementioned in the literature, virtually all casesinvolving unexplained weight loss were diagnosedand treated as “Simmonds’ disease.”

Then in 1930, John Mayo Berkman of the MayoClinic in Rochester, Minnesota, published the firstlong-term report on large numbers of anorexiacases. His report outlined treatment of 117 patientsat the clinic during a 10-year period. Even thoughthe clinic treated anorexia as a metabolic disorderand rarely administered any kind of psychiatrictreatment, researchers have credited Berkman with“rediscovery” of anorexia as a separate disorder.

In 1942 R. F. Escamilla and H. Lisser searchedmedical literature worldwide to review casesreported as Simmonds’ disease. In their report(Journal of Clinical Endocrinology 2, 1942), theydetermined that 494 of the 595 reported caseswere, in all probability, cases of anorexia nervosaand not pituitary disease.

During the 1940s the theory that anorexia ner-vosa was a psychological disorder began to gainsupport, although disagreement as to its exactcauses ran rampant for the next 20 years. Thesepsychological theories ranged from fantasies tofears of oral impregnation to emotional disturbanceto psychosexual dysfunction.

The start of the modern era in the treatment ofanorexia nervosa has been credited to a paperdelivered by Hilde Bruch in 1961 and published inPsychosomatic Medicine 24:2 (1962): “Perceptual andConceptual Disturbances in Anorexia Nervosa.” AsPatricia A. Neuman and Patricia A. Halvorsonexplain (Anorexia Nervosa and Bulimia). “Bruch dif-ferentiated between ‘primary anorexia nervosa’(the classic form as described by Morton and Gull)and ‘atypical anorexia nervosa’ (self-starvation dueto other psychiatric illnesses).”

The classic or true form, according to Bruch, ischaracterized by severe disturbances in body image(the way subjects see themselves); misinterpreta-tions of internal and external stimuli, particularlyof hunger; and a paralyzing underlying sense ofineffectuality, the subjects’ conviction of beinghelpless to change anything about their lives.

Prior to the 1960s, reports of anorexia nervosawere rare, but since then they have been occurringat a rapidly increasing rate. In addition, anorexiahas increased its geographic spread. Cases havebeen reported in countries as far apart as the for-mer Soviet Union and Australia, Sweden and Italy,England and the United States. Mara Selvini-Palaz-zoli, an Italian pioneer in the psychiatric study ofanorexia nervosa, reported no cases at all at herclinic during World War II when dire food short-ages occurred; yet after the war, as the Italian econ-omy improved and food became plentiful,hospitalizations did occur for anorexia nervosa.Studies in both the United States and Switzerlandhave indicated that the incidence of anorexia ner-vosa has doubled since 1960. During the early1960s, for example, the University of WisconsinHospital typically admitted one anorexic a year; in1982 more than 70 cases were admitted. It is socommon today that it represents a substantialproblem in high schools and colleges.

But anorexia nervosa has not only become morewidespread among its traditional young whitefemale model; in recent years researchers havenoted a spreading of the disorder to other ethnicgroups and to males. Since 2000, studies have pro-vided evidence that males had likely been under-represented in both epidemiologic and clinicalstudies. Instead of the previously believed ratio of10 females to one male suffering with anorexia,recent research has indicated a more likely ratio ofthree or four females to one male. Also, numerousrecent studies have documented a high rate of eat-ing disorder behaviors and risk factors, includingbody dissatisfaction, among African-Americanwomen. Also underrepresented in earlier eating-disorder studies were males and females of Asianheritage, not only because researchers focused onwhite American girls, but also because many AsianAmericans equate psychological problems withweakness and shame and thus avoid seeking treat-

xvii

ment. Yet one study of more than 900 middleschool girls in northern California found that AsianAmerican girls reported greater body dissatisfactionthan white girls. That and other cultural factorsmay contribute to disordered eating.

Another change Bruch observed over the yearswas a difference in the way patients approached theillness. Formerly no anorexic had ever heard of thecondition; each thought she had invented a form ofindependence and control. Today most patientshave read or heard about anorexia nervosa; someeven compare their illness with textbook examples.Moreover, occurrence of anorexia is now often agroup phenomenon. It is not unusual for ananorexic to be aware of others in her school classeswith the same problem, and to use the others tomeasure her “success.” Indeed, the growth of Inter-net “pro-ana,” sites has extended the “group reach”globally. With the increase in media attention,anorexia nervosa has become a fashionable diseaseamong affluent adolescent and young adult womenwho are particularly susceptible to peer influence. Ithas been estimated that as many as 30 percent of allcurrent cases are what Bruch once called “me-too”anorexics.

In 1994 Vandereycken and Van Deth wrote,“Anorexia nervosa has become a fashionable disor-der: television producers smell sensation, women’smagazines see a subject for their advisory columns,publishers dream of autobiographical bestsellers.Often the illness is presented as ‘mysterious’:physicians are desperately seeking an ultimateexplanation and self-help organizations do notknow which ‘in’ therapy to recommend.”

Just as the incidence of anorexia nervosa hassurged since the 1960s, bulimia has also emergedas an increasingly common psychophysiologicaldisorder, so much so that there is a widespread mis-conception that it is of quite recent origin. In fact,bulimia has an extensive history.

Episodic overeating has been a common prac-tice. Primitive peoples dependent on hunting wenton one- or two-day binges before spoilage couldoccur after successful expeditions, in attempts tocompensate for long periods of famine.

Two early English references to bulimia wereSteven Blankaart’s Physical Dictionary (1708) andJohn Quincy’s Dictionary (1726). Both discuss

excessive appetite, but Blankaart refers to an extra-ordinary appetite usually accompanied by a “defec-tion of the spirits.”

In 1743 James, in A Medicinal Dictionary, cred-ited the Greek physician Galen (A.D. 130–200)with defining the origins of boulimus, or the “greathunger.” Galen considered it a digestive dysfunc-tion, the primary symptom of which was a desirefor food “at very short intervals.” This, he said, wasoften coupled with fainting, loss of color, coldnessin the extremities, oppressive feeling in the stom-ach, and weak pulse. According to Galen,boulimus was probably caused by an acidic“humor” lodged in the stomach, causing intensebut false hunger signals. In addition, he suspectedthat the disorder was associated with the too-rapiddigestion of food, resulting in inadequate nourish-ment and chronic hunger.

James added to Galen’s and other writers’descriptions in an effort to distinguish boulimousfrom similar conditions associated with worms,ulcers and normal pregnancy. He noted that short-ness of breath and an intense preoccupation withfood may be symptoms of true boulimus. He furtherdistinguished between true boulimus and a variantof it complicated by vomiting, “caninus appetitus.”

In the caninus appetitus, there is a desire aftermuch food and great quantities are eaten, whichoppressing the stomach, are again discharged byvomit. The patient thus being relieved, his appetitereturns, which having gratified, he finds himselfobliged to ease his stomach again, like a dog, byvomiting.

In the true boulimis [sic], there is a ravenoushunger and eating, but instead of vomiting, thepatient suffers from lipothymy [fainting spells].

Motherby, in 1785, differentiated three types ofbulimia. The first two were bulimia of the purehunger type and bulimia in which hunger was ter-minated by vomiting. In the third form, hungerwas associated with “swooning.”

In 1797 the Encyclopaedia Britannica included anentry for bulimia under the heading “Bulimy”: “adisease in which the patient is affected with aninsatiable and perpetual desire of eating; and unlessindulged, he often falls into fainting fits.”

Introduction xvii

xviii The Encyclopedia of Obesity and Eating Disorders

In the early 1800s, dictionaries describedbulimia as featuring violent appetite, vomiting,fainting and canine appetite and occurring mostoften in hysteria and pregnancy.

During the 19th century Gull acknowledgedthat anorexia patients occasionally displayedextremely voracious appetites, quite the oppositeof their usual starvation tactics in their pursuit ofthinness. Researchers have suggested that Gull’snotation of such variations in symptoms, variationsalso seen by clinicians through the years, probablycontributed to the idea of classifying bulimia simplyas a subtype of anorexia nervosa.

However, in 1869 in France, P. F. Blanchez iden-tified “boulimie” as a distinct syndrome, whileadmitting that it might occur as an accessory toanother disorder. He described boulimie symptomsas food being an obsession and major preoccupation,yet with hunger sometimes continuing even afterenormous quantities of food are eaten. He describedthe patient as becoming lethargic after a binge untilthe intense hunger returns a few hours later.

Then in 1894, in Germany, O. Soltmann posited“nutritional neuroses” such as “hyperorexia,” ofwhich bulimia was taken to be a symptom.According to Soltmann, hyperorexia, a syndrome,might be partly neurotic and partly biological inorigin, affecting “over-excited, hysterical chloroticyoung girls.”

Purging is also not a recent phenomenon. Theancient Egyptians thought all diseases originated infood and thus purged their bodies every month.Tilmann Habermas writes that “vomiting was oneof the most popular nonspecific symptoms in thenineteenth century, so its absence was often notedin cases of anorexia. On the other hand, it wasrather unexpected that patients might intentionallyinduce vomiting.”

Many of the physicians reporting on anorexicpatients from the 1800s on included among the ill-ness phases purging of some kind to get rid ofunwanted food. Some patients learned to vomitimmediately after swallowing; at least one wasreported to use “a kind of hose to empty her stom-ach” (Habermas). During the early 1900s, abuse oflaxatives or thyroid medication for the purpose ofweight control was first mentioned, although vine-gar had been drunk as a laxative for centuries.

Bulimia among individuals who did not havehistories of weight disorders was first observed in1976 by Marlene Boskind-White, who coined theterm “bulimarexia” to describe this group. Bulimiaofficially became a distinct diagnostic entity in1980 with the publication of the third edition ofthe Diagnostic and Statistical Manual of Mental Disor-ders of the American Medical Association. DSM-IIIsuggested that episodic binge eating is not only anisolated symptom but an essential component of aspecific syndrome of disordered eating.

With the DSM-III-R (as well as the DSM-IV ), thediagnosis of bulimia was changed to bulimia ner-vosa and the category narrowed to include onlypersons who both binged and engaged in someform of compensatory behaviors. Persons whoengaged in binge eating but without compensatorybehaviors no longer met the diagnostic criteria.With the DSM-IV, there was consideration of addinga new diagnostic category of binge eating disorderthat would encompass this latter group of individ-uals. The category was added to the appendix as adiagnosis needing further study.

And, as with anorexia nervosa, recent studieshave determined that bulimia nervosa is occurringincreasingly in diverse ethnic and socioculturalgroups. For example, research has shown thatbinge eating and purging is at least as commonamong African-American women as white women.

If eating disorders had become “fashionable” bythe mid-1990s, obesity has become de rigueursince then among the global population, and writ-ten about everywhere from scientific literature todaily newspapers. Noting that the past 10 years hadbeen described as the “golden age” of obesityresearch, Blackman wrote, “In that time,researchers have worked on a smorgasbord of mol-ecules involved in body weight regulation viamany overlapping systems and pathways.”

The impetus for all this research and media cov-erage has been an unexpected rise in overweightand obesity, not only in the United States, whereoverindulgence has long been blamed for manysocial ills, but worldwide. According to a Centersfor Disease Control and Prevention (CDC) reportissued in October 2004, American adults are nearly25 pounds heavier on average than they were in1960. Children ages six to 11 average nine pounds

xix

heavier, and adolescents are 12 pounds (girls) and16 pounds (boys) heavier on average. From 1986to 2000, the prevalence of Americans with a bodymass index of 40 or above quadrupled, from aboutone in 200 to one in 50. Because of these currenttrends in obesity, Olshansky et al. concluded in2005 that the steady rise in life expectancy duringthe 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 Statesnow overweight and 31 percent obese, according tothe CDC—up from 55 percent at the time the Ency-clopedia of Obesity and Eating Disorders, Second Editionwas written in 1999—several key areas and issueshave been added or significantly expanded.

Within the alphabetical body of the third editionare topics related to the economic, sociological,legal, psychological and medical aspects of obesityand eating disorders—nearly 150 of them new tothis edition. With increased multicultural study inboth eating disorders and obesity, new informationhas been added to reflect their ramifications over awider range of the population. For example, thisedition now has extensive entries on AfricanAmericans and eating disorders, African Americansand obesity, American Indians/Alaska Natives andeating disorders, American Indians/Alaska Nativesand obesity, Asians/Pacific Islander Americans andeating disorders, Asians/Pacific Islander Americansand obesity and Hawaiian Natives and obesity.

Along with the increase in obesity has come aphenomenal growth in bariatric surgery proceduressince the second edition. Similarly, the potential forprofits has spurred pharmacological research to bet-ter understand obesity in the hope of developingeffective drug treatment. This edition includes manynew entries to reflect these trends; among these areantiobesity drugs, appetite hormones, bariatricsurgery, belt lipectomy, biliopancreatic diversion,gastric bypass, ghrelin, implantable gastric stimula-tor, interleukin-6, malabsorptive operations, pan-niculectomy, rimonabant and others.

Another new entry is “orthorexia nervosa”—anunhealthy obsession with healthy eating. Althoughnot yet an official eating disorder, it has been cov-

ered in the Journal of American Medical Associationand described as “increasingly an area of concern”by the National Eating Disorders Association.

Several dozen topics have been completelyrevised—some totally rewritten—to reflect currentkey research and trends. Among these major revi-sions are: anorexia nervosa, research, antidepres-sants, antipsychotics, childhood obesity, depressionand eating disorders, diabetes and eating disorders,diet centers and programs, over-the-counter dietpills, employee health costs and obesity, exercise,fad diets, fraudulent products, gastric bubble, gas-tric restriction procedures, gastroplasty, genetic fac-tors in obesity, jejunoileal bypass, liposuction, maleanorexics, metabolism, obesity, overweight bulimianervosa, pharmacotherapy, pregnancy and obesity,psychotherapy, satiety and size discrimination. Andnearly every other topic from the second editionhas been updated.

Any terms used within a listing that have theirown separate listings are designated with smallcapital letters to make them easy to find. Also,many topics end with references to articles andbooks cited in the entry.

The appendixes include new lists of organiza-tions and groups that offer information and sup-port, 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 comprehensiveoverview of obesity and eating disorders, with in-depth treatment of current issues, in an easy-to-access format, and with plenty of assistance on whereto go next for additional information on these topics.

REFERENCESBell, 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, andthe Person Within. New York: Basic Books, 1973.

Brumberg, Joan Jacobs. Fasting Girls: The Emergence ofAnorexia Nervosa as a Modern Disease. Cambridge, Mass.:Harvard University Press, 1988.

Introduction xix

xx The Encyclopedia of Obesity and Eating Disorders

Bynum, C. W. Holy Feast and Holy Fast: The Religious Signifi-cance of Food to Medieval Women. Berkeley and Los Ange-les: University of California Press, 1987.

Habermas, Tilmann. “The Psychiatric History of Anorexiaand Bulimia: Weight Fears and Bulimic Symptoms inEarly Cases.” International Journal of Eating Disorders 8,no. 3 (1989); reprinted in BASH Magazine (December1989).

Neuman, Patricia A., and Patricia A. Halvorson. AnorexiaNervosa and Bulimia. A Handbook for Counselors and Thera-pists. New York: Van Nostrand Reinhold, 1983.

Olshansky, S. Jay, et. al. “A Potential Decline in LifeExpectancy in the United States in the 21st Century.”The New England Journal of Medicine 352, no. 11 (March17, 2005): 1,138-1,145.

Van Deth, R., and W. Vandereycken. From Miraculous Fasts toMorbid Pursuit of Thinness: Anorexia Nervosa in HistoricalPerspective. Amsterdam: Boompers, 1988.

Vandereycken, Walter, and Ron Van Deth. From FastingSaints to Anorexic Girls: The History of Self-Starvation. NewYork: New York University Press, 1994.

A–Z ENTRIES

Aabdominoplasty A shaping of the abdominalarea by surgery, popular since the 1960s. Fre-quently referred to as a “tummy tuck,” this surgerygets rid of stomach fat and tightens flabby musclesand loose abdominal skin. The surgeon cuts sevento 15 inches across the body at the bikini line, liftsthe skin, uses sutures to tighten the abdominalmuscles and tissue, pulls the skin back down overthe tightened area, cuts off excess skin and thencloses the incision, sometimes making a new “bellybutton” in the process. The length of the incisiondepends upon the looseness of the skin. There issome pain and a scar, which usually fades to a thinline within a year. Total costs generally rangebetween $5,000 and $9,000. Once an indulgenceof the wealthy, such surgery is now advertised tothe public, with monthly payment plans oftenavailable. According to the American Society ofPlastic Surgeons (ASPS), performance ofabdominoplasty procedures increased 500 percentbetween 1990 and 2003. The ASPS reported101,228 such procedures in 2003.

Abdominoplasties are not always without prob-lems. When fat above the incision is not com-pletely removed, bulges can occur above the scarline. These bulges can also appear if circulation isimpaired during surgery, resulting in an accumula-tion of fluid. Because removing fat from the upperpart of the abdomen can lead to bleeding and inter-fere with the skin’s blood supply, fat is frequentlyleft in this upper area, giving unsatisfactory resultswith the upper abdomen sticking out over themore flattened lower abdomen.

These complications have led to a more fre-quent use of LIPOSUCTION for abdominal fatremoval. However, because successful liposuctiondepends upon normal elasticity to shrink the skinafter surgery, this procedure isn’t always satisfac-

tory either where there is excess skin or loose mus-cle. In many such cases, surgeons first use liposuc-tion to remove the fat and then follow withabdominoplasty to tighten the abdominal musclesand remove excess skin.

See also BELT LIPECTOMY, PANNICULECTOMY.

Academy for Eating Disorders (AED) A multi-disciplinary professional organization founded in1993 that focuses on anorexia nervosa, bulimianervosa, binge eating disorder and related disor-ders. A guiding principle of the organization is thateffective treatment for eating disorder patientsrequires that professionals from various disciplineswork together. The AED brings these professionalstogether to: 1) promote the effective treatment andcare of patients with eating disorders and associ-ated problems; 2) develop and advance initiativesfor the prevention of eating disorders; 3) dissemi-nate knowledge regarding eating disorders tomembers of the Academy, other professionals andthe general public; 4) stimulate and supportresearch in the field; 5) promote multidisciplinaryexpertise within the Academy’s membership; 6)advocate on behalf of patients, the public and eat-ing disorder professionals; 7) assist in the develop-ment of guidelines for training, practice andprofessional conduct within the field; and 8) iden-tify and reward outstanding achievement and serv-ice in the field.

See also APPENDIX III, SOURCES OF INFORMATION.

accommodating the obese Obesity has causedhospitals and other emergency services to rethinktheir purchasing and practices. A May 2004 ChicagoTribune article noted, “Throughout a nation sud-denly acknowledging its mounting obesity epi-demic, hospitals are adding new units, retrofitting

1

their buildings, or simply investing in items such asheavy-duty wheelchairs, extra-strength toilets andeven waiting-room chairs that can handle peopleweighing up to 1,000 pounds. Staff members areheading to sensitivity training.”

A 2003 survey by Novation, the largest U.S.group purchasing organization for hospitals andhealth care institutions, found that additional costsassociated with treating or accommodating theseverely 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, needlesand syringes; larger gowns; wider and reinforcedwheelchairs; remodeled rooms and bathrooms(including floor-mounted commodes to replacewall-mounted models); large beds; special lifts;scales with 800-pound capacities; operating tablesable to withstand 1,000 pounds; and wider doorsand hallways. Patient lift systems that can handle600 pounds are becoming standard in the healthcare industry. Novation, which had sold $847,000worth of patient lifts in 2001, sold $3 million worthin 2003.

A Texas company that sells specialty hospitalbeds and mattresses for obese patients realized a 6percent increase in sales in 2003 over the yearbefore. A rental company in Nevada that special-izes in medical equipment for the obese said itsbusiness has grown 15 percent to 20 percent ayear. Surgical Products reported on the recent intro-duction of “Bariatric Table Extensions with nopinch points or articulation obstructions, whichextend the surgical tables’ widths from 20 to 28inches.” Other bariatric table accessories includepower assist leg holders, specially designed legboots, and extra-long restraint straps.

The move to accommodate obese patients stemsnot only from a desire to make them feel comfort-able and ease any embarrassment, but also toreduce injuries. In an article explaining how theincreasing number of obese patients has affectedIndiana emergency workers, Richards explained,“Their weight can shift, causing cots or stretchersto tip over and possibly injuring both the patientand paramedics.” In the past, it would take eight to

10 firefighters using canvas tarps or mattresses totransport patients weighing 500 pounds or more.Today’s heavy-duty cots that can hold in the rangeof 650 pounds require only two to three firefight-ers. One hospital clinical materials resource man-ager was quoted in a Milwaukee Journal Sentinelarticle as saying, “Today, 85 percent of the backinjuries suffered by hospital staffs are related to thecare of heavy patients.”

A researcher, noting that the prevalence of clin-ically severe obesity is increasing much faster thanobesity, wrote: “Accommodating severely obesepatients will no longer be a rare event, andproviders have to prepare to treat such patients ona regular basis.” The National Institute of Diabetesand Digestive and Kidney Diseases of the NationalInstitutes of Health suggests that health careproviders create an accessible and comfortableoffice environment by doing the following:

• Provide sturdy, armless chairs and high, firmsofas in waiting rooms.

• Provide sturdy, wide examination tables that arebolted to the floor to prevent tipping

• Provide extra-large examination gowns.

• Install a split lavatory seat and provide a speci-men collector with a handle.

• Use large adult blood pressure cuffs or thighcuffs on patients with an upper-arm circumfer-ence greater than 34 cm.

• Have extra-long phlebotomy needles, tourni-quets, 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 sit-uations that arise for people who are obese. TheJob Accommodation Network, a service of theOffice of Disability Employment Policy, U.S.Department of Labor, offers the following commonaccommodations for obese employees:

• Climbing steps: An individual who is obese canbenefit from an elevator or a large-rated stair liftor large-rated wheelchair lift.

• Sitting: Large-rated ergonomic chairs are avail-able as options.

2 accommodating the obese

• Seat belt extenders: Seat belt extenders areavailable for some vehicles and industrial equip-ment.

• Using safety products: Specially designed laddersand harnesses are available.

• Walking: A large-rated wheelchair or scootermay accommodate this limitation.

Beyond medical and work facilities, rising obe-sity has led to the need for other “ample” products,from long-handled nail clippers to household fur-niture to clothing to caskets. Even the standardbathroom scale of a few years ago no longeraccommodates the growing number of Americansover 300 or 350 pounds. Not only is the plus-sizedclothing business booming, but stores are offeringoversized doorways, dressing rooms and mirrors toaccommodate obese customers.

The width of a typical casket has grown from 21inches to 24 inches, with casket makers nowadding 28- and 30-inch-wide caskets to their regu-lar offerings. Vaults, mausoleums and even ceme-tery plots are being enlarged to accommodate theseverely obese.

National Institute of Diabetes and Digestive and KidneyDiseases. “Medical Care for Obese Patients.” Weight-control 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 MovingObese Patients.” The Daily Journal, July 11, 2004, p.A1.

Ritsma, Rich. “Tools to Make the Bigger Better.” SurgicalProducts 23, no. 5 (May 2004): 20–21.

Sturm, R. “Increases in Clinically Severe Obesity in theUnited States, 1986–2000.” Archives of Internal Medi-cine 163, no. 18 (October 13, 2003): 2,146–2,148.

Worland, Gayle. “Obesity Epidemic Makes HospitalsRethink, Retool.” Chicago Tribune, May 4, 2004, p. 1.

Active Living by Design (ALbD) A national pro-gram of the Robert Wood Johnson Foundation anda part of the School of Public Health at the Univer-sity of North Carolina. The program defines “activeliving” as a way of life that integrates physicalactivity into daily routines. The program’s purposeis to establish and evaluate innovative approachesto increase physical activity through community

design, public policies and communications strate-gies. Recent studies have shown that people wholive in the most sprawling counties are the mostlikely to be overweight, and vice versa; and thatpeople who live where stores and other businessesare within easy walking distance are significantlyless likely to be overweight, primarily because theywalk more and drive less.

Among the strategies for promoting active livingrecommended by ALbD: Communicate the impor-tance of active living in a variety of built, natural,and social environments, and create programs thatincrease the demand for physical activity in thecommunity by including parks, trails, bikeways,and sidewalks. The target is for all people to accu-mulate at least 30 minutes of activity each day.ALbD funds “partnership” projects that help com-munities become more pedestrian friendly. Eachpartnership receives a $200,000 grant in additionto technical assistance to address communitydesign, land use, transportation, architecture,trails, parks and other issues that influence health-ier lifestyles. The 25 ALbD community partner-ships are located in: Oakland, Sacramento, andSanta 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 Hamp-shire and Vermont; Albuquerque, New Mexico;the Bronx and Buffalo, New York; Chapel Hill,North Carolina; Cleveland, Ohio; Portland, Ore-gon; Wilkes-Barre, Pennsylvania, Charleston,South Carolina; Nashville, Tennessee; and Seattle,Washington.

The National Institute of Environmental HealthSciences, a branch of the National Institutes ofHealth, will conduct follow-up examinations of theprogram’s impact on physical activity, obesity andother health indicators.

See also APPENDIX III, SOURCES OF INFORMATION.

acupressure A technique similar to and derivedfrom ACUPUNCTURE, this treatment involves theapplication of manual pressure to the body ratherthan the insertion of needles. Acupressure hasbeen recommended by some practitioners to con-

acupressure 3

trol APPETITE. It is administered by applying pres-sure with the ball of the thumb and sometimes thefingers to specific points on the body. The mainpressure point is on the upper lip; a point midwaybetween the breastbone and navel is said to con-trol HUNGER. Other points on the elbow and theknee are said by practitioners to control the emo-tions that lead to overeating. Not an instanta-neously effective treatment, according tospecialists, it is said to take three days for thereflex passages to the brain to become pro-grammed by acupressure. Acupressure is even lesswell documented and scientifically tested thanacupuncture. A review of four such studies, pub-lished in the January 1997 Austrian journalWiener Klinische Wochenschrift, reported that noneof these studies is without significant flaws, andthat their results are contradictory.

acupuncture An ancient practice, used especiallyby the Chinese, of piercing the skin with extremelyfine needles at strategic places on the body to treatdisease or relieve pain. Acupuncturists believe thatvital energy (chi) flows through the body along 12main pathways (channels or meridians) connectedto internal organs and systems like the kidney andrespiratory system. They believe that diseaseoccurs when there is an imbalance of energy inone of these systems, and that acupuncture nee-dles inserted at specific points (numbering morethan 1,000) on the body correct the flow of energythrough the channel and help the body to healitself. Some medical doctors speculate thatacupuncture may produce a state of painlessnesspartly by stimulating the release of endorphins(natural painkillers). Acupuncture as a treatmenthas some respectability based on empirical obser-vations, but almost no scientific basis for accept-ance. A very few medical doctors use acupunctureto supplement standard treatment.

The origin of acupuncture is unknown, but it isbelieved to have been practiced in China for morethan 3,000 years. When acupuncture is used tohelp lose weight, the needle is placed in the area ofthe external ear known as the concha. The vagusnerve, which extends from the brain down theneck and chest to the stomach, branches to theconcha. When the sharp point of the needle finds

this branch of the vagus nerve, it acts to inhibit thecontractions of the stomach.

The acupuncture treatment to the ear does notitself cause a person to lose weight. Rather, itcauses the person to feel less HUNGER. Doctors inthe United States have used staples and small nee-dles, which are left in the ear to be jiggled whenthe patient feels the urge to overeat.

Published studies evaluating acupuncture as atreatment for obesity have thus far been inconclu-sive. In one, the author claimed a good response from75 percent of 1,030 patients, but few details weregiven. In another study of 120 volunteers, it wasreported that 70 percent treated at the “hunger”point experienced decreased appetite, compared withonly 20 percent who had a stud (needle) in anotherpart of the ear. And in a study of 350 obese subjectstreated with acupuncture, 66 percent of them lostweight after seven treatment sessions. However, sub-jects had a variable number of courses of treatment ofvarious duration. There were also no control subjectsfor comparison, so no final conclusions could bedrawn. However, researchers Richards and Marleydid use a control group in a study involving 60 over-weight subjects. Of those who responded, 95 percentof the active group noticed suppression of APPETITE,whereas none of the control group noticed such achange. After reviewing several studies, Vincent andRichardson concluded that even though there are noclear indications for or against the use of acupunc-ture, an individual patient might derive less tangiblepsychological benefit from belief in the treatment.

Giller, R. M. “Auricular Acupuncture and Weight Reduc-tion: A Controlled Study.” American Journal ofAcupuncture 3, no. 2 (April–June 1975): 151–153.

Ishida, Yasuo. “Acupuncture Today.” Southern MedicalJournal 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 AuricularAcupuncture Points in Weight Loss.” Australian Fam-ily Physician 109, Suppl. 2 (July 1998): 573–577.

Sacks, L. L. “Drug Addiction, Alcoholism, Smoking, Obe-sity, Treated by Auricular Staple Puncture.” AmericanJournal of Acupuncture 3 (1975): 147+.

Vincent, C. A., and P. H. Richardson. “Acupuncture forSome Common Disorders: A Review of EvaluativeResearch.” Journal of the Royal College of General Practi-tioners 37, no. 295 (February 1987): 77–81.

4 acupuncture

addiction A term that, in the scientific andpopular literature, may refer to a wide range ofdifferent behaviors. In strictest scientific terms,an addiction requires the development of toler-ance (a need for more of a substance to achievethe same effect) and/or withdrawal (characteris-tic physiological effects associated with termina-tion of the use of a substance). A similar term inthe scientific literature is substance dependence,and highly “addictive” substances include nico-tine, alcohol, cocaine, and opium derivatives. Inthe popular literature, the term addiction is oftenapplied to unwanted habits that are hard tobreak (e.g., shopping) or to substances (e.g.,chocolate) that do not elicit the core characteris-tics of addiction (i.e., tolerance and withdrawal).Addictions such as smoking and alcoholismshare characteristics with binge eating and purg-ing, but the eating-disordered person is addictedto the illness itself rather than to a substance.Food is the agent the addicted eating-disorderedperson uses to cover up or forget a weight prob-lem (either real or imagined), fear of losing control over eating or other behavior, distorted body image, negative self-image, dissatisfactionin sexual or interpersonal relationships or lack of independence.

There is great controversy over whether or notthe eating disorders are a form of addiction.According to Vandereycken, addiction-like behav-iors exhibited by bulimics include “craving, preoc-cupation with obtaining the substance, loss ofcontrol, adverse social and medical consequences,ambivalence towards treatment, and risk ofrelapse.” In addition, persons with eating disordersoften have comorbid substance use disorders (i.e.,alcohol or drug abuse). If eating disorders are con-sidered addictions, the substance or behavior towhich the person is addicted is unclear. Somewould argue that it is food, others specific types offood (e.g., sugars, white flour), and others that per-sons with eating disorders are addicted to dieting,exercising, and/or purging.

Overall, regarding the question of whether ornot eating disorders are a form of addiction, itappears that we are dealing with an issue of “par-tial similarity” in that some characteristics areshared and others are not. Certainly eating disor-

dered individuals have cravings and preoccupa-tions with food, dieting, or exercise. However, ifone uses the strictest scientific definition, the phe-nomena of tolerance and withdrawal are not pres-ent. Furthermore, the treatment implications thatfollow from the addiction model are in markedcontrast with those that follow from cognitivebehavioral models (those treatments with the mostempirical support). That is, most treatmentapproaches that follow an addiction model empha-size abstinence (from certain foods, types of foods,or behaviors) and often include a rigid model of“relapse” similar to that taken with AlcoholicsAnonymous or similar programs. In contrast, cog-nitive behavioral treatments attempt to get theindividual to stop avoiding “forbidden foods” andto change the rigid all-or-nothing way of thinkingassociated with relapse.

The self-starving anorexic’s behavior may alsoinclude alcoholism, although the binge eater ismore likely to be addicted to alcohol or drugs.The way in which bulimics and anorexics (seeBULIMIA and ANOREXIA NERVOSA) often tackleexercise and schoolwork also resembles addic-tion. Alcohol, over-the-counter diet pills, caf-feine, barbiturate and amphetamine addictionshave been noted by many researchers to be com-monly associated with bulimia. In a 1981 studydone at the University of Minnesota Adult Out-patient Psychiatric Clinic, bulimic womenreported using alcohol to avoid depression associ-ated with binge-purging, to relax and to delay orprevent overeating.

In a 1984–85 survey of 1,100 patients atHazelden, a Minnesota chemical dependencytreatment center, approximately 7 percent offemale patients and 3 percent of males reportedenough symptoms to be classified as bulimic underDSM criteria.

A later Hazelden report stated that 30–40 per-cent of the women in residential treatment foralcohol and other drug dependence have an activeeating disorder or one in remission. Among men,the incidence is about 5 percent.

Hazelden reported in the 1980s that its bulimicfemale patients experienced more adolescentbehavior problems and self-destructive behaviorthan nonbulimic patients. The typical chemically

addiction 5

dependent female bulimic at Hazelden is morelikely to “be a polydrug user; have had adolescentbehavior problems such as school suspension orexpulsion, stealing, and fighting; exhibit self-destructive tendencies through self-inflicted injury,suicide attempts, or suicidal thoughts during treat-ment; have had outpatient or inpatient mentalhealth treatment or medication.”

A 2002 Yale University School of Medicinereview of the extent and co-occurrence of eatingdisorders and substance abuse disorders concluded:“Alcoholism and eating disorders frequently co-occur and often co-occur in the presence of otherpsychiatric and personality disorders. Althoughsuch diagnostic co-occurrence suggests the possi-bility of shared factors in the etiology or mainte-nance of these problems, research has notestablished such links. The clinical reality that eat-ing and alcohol use disorders frequently co-occurhas important implications for assessment, treat-ment, and research. Comprehensive assessment isnecessary for good treatment. Research on meth-ods of treating people with co-occurring alcoholand eating problems represents a major need.”

In December 2003, the National Center onAddiction and Substance Abuse (CASA) at Colum-bia University released a report, “Food forThought: Substance Abuse and Eating Disorders,”that revealed that up to one-half of individualswith eating disorders abuse alcohol or illicit drugs,compared to 9 percent of the general population.Conversely, up to 35 percent of alcohol or illicitdrug abusers have eating disorders compared to 3percent of the general population.

The CASA report named anorexia nervosa andbulimia nervosa as the eating disorders most com-monly linked to substance abuse, and found thatbecause health professionals often overlook thelink between substance abuse and eating disorders,treatment options are virtually nonexistent forthese co-occurring conditions. Wandler noted that“dual-diagnosis patients are challenging; theirsymptoms interact and may lead to dangerousmedical sequelae.”

Because of the strong association betweenaddictions and eating disorders, Hazelden presentlyconducts a comprehensive assessment for eatingdisorders for all its addiction patients.

While clinicians agree that both chemical andfood disorders must be treated in order for eitherillness to be treated successfully, disagreementsexist over whether to treat them together or sepa-rately. Hazelden quotes Elke Eckert, M.D., profes-sor of psychiatry and director of the EatingDisorders Clinic at the University of Minnesota, asbelieving the chemical dependency must be treatedfirst, then the eating disorder.

In addition to chemical addiction, eating disor-dered patients can also exhibit a general tendencytoward addiction to running and level of runningintensity. Estok and Rudy found that 25 percent ofthe women studied who ran more than 30 miles aweek indicated a high risk for anorexia.

See also ADDICTION MODEL OF EATING DISORDERS;ANOREXIA ATHLETICA.

Davis, C., and G. Claridge. “The Eating Disorders asAddiction: A Psychobiological Perspective.” AddictiveBehaviors 23, no. 4 (July/August 1998): 463–475.

Estok, P. J., and E. B. Rudy. “The Relationship betweenEating Disorders and Running in Women.” Research inNursing and Health 19, no. 5 (October 1996): 377–387.

Grilo, Carlos M., Rajita Sinha, and Stephanie S. O’Mal-ley. “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 November2002.

Pyle, Richard L. “The Subtle, Puzzling Affinity of Drugsand Bulimia.” BASH Magazine (September 1989).

“Study Suggests Some Bulimia Manageable duringChemical Dependency Treatment.” Hazelden Profes-sional Update (September 1988).

Vandereycken, Walter. “The Addiction Model in EatingDisorders: Some Critical Remarks and a Selected Bib-liography.” International Journal of Eating Disorders 9(1990): 95–101.

Wandler, K. “Eating Disorders and Substance Use: BeAware of This Dual Diagnosis.” Behavioral HealthcareTomorrow 12, no. 6 (December 2003): 8, 11.

Welch, S. L., and C. G. Fairburn. “Impulsivity or Comor-bidity in Bulimia Nervosa: A Controlled Study ofDeliberate Self-Harm and Alcohol and Drug Abuse ina Community Sample.” British Journal of Psychiatry169, no. 4 (October 1996): 451–458.

addiction model of eating disorders Treatingeating disorders as addictive disease by applying the12-step program of Alcoholics Anonymous as an

6 addiction model of eating disorders

adjunct to counseling and treatment for those whosuffer from compulsive overeating and bulimia.

See also ADDICTION.

Trotzky, A. S. “The Treatment of Eating Disorders asAddiction among Adolescent Females.” InternationalJournal of Adolescent Medicine and Health 14, no. 4(October–December 2002): 269–274.

Wilson, G. T., and J. D. Latner. “Eating Disorders andAddiction.” In Food Cravings and Addiction, edited byM. Hetherington, pp. 585–605. Surrey, U.K.: Leather-head, 2001.

adipose tissue Also called fat tissue; composed ofadipocytes or fat cells, connective tissue cells,nerves, blood and collagen. A layer of fat lying justunder the skin and around many internal organs(e.g., the heart and kidneys) to protect them frominjury. This tissue acts as a shock absorber, cush-ioning areas such as the heels and buttocks againstthe frequent and sudden jolts they receive. Adi-pose tissue also functions as an insulating thermalblanket, keeping body heat inside. Because adiposetissue accumulates from eating more food thannecessary for the body’s immediate needs, it storestriglycerides as energy for future needs. Whenmore adipose tissue is accumulated than is neededfor cushioning, insulation and energy reserves,OBESITY results.

In 2001 researchers from the University of Cali-fornia at Los Angeles and the University of Pitts-burgh first reported that adult stem cells could beisolated from adipose tissue. Adult stem cells areprimitive cells that can self-renew and are capableof becoming the major cell types in the tissue ororgan that harbors them. The primary roles ofadult stem cells are to maintain and repair the tis-sue in which they are found.

Research has indicated that when exposed tospecific laboratory growth conditions, adipose-derived stem cells can demonstrate various charac-teristics suggestive of cells from tissues such as fat,bone, cartilage, nerve, muscle and blood vessels,with the potential for regenerating damagedhearts, reconnecting severed nerves and recon-structing breasts following cancer surgery.

More than 300,000 LIPOSUCTION procedures areperformed in the United States each year, produc-ing about 150,000 gallons of discarded liposuc-

tioned fat. In a typical liposuction procedure, suchas for the buttocks, about one to three quarts of fatcan be removed. In just one day, plastic surgeonscan remove more than 30 pounds of fat perform-ing between two and five tummy tucks (seeABDOMINOPLASTY) in gastric bypass patients whohave lost significant weight. It is estimated thathundreds of millions of stem cells can be obtainedfrom one liposuction patient. One pint of liposuc-tioned fat or one pound of whole fat removed in atummy tuck, for example, can yield up to 200 mil-lion stem cells, which in culture can be expandedby 10 times over the course of two weeks.

See also SUBCUTANEOUS FAT; VISCERAL FAT.

adjustable gastric banding (AGB) Commonlyreferred to as the LapBand or laparascopicadjustable gastric banding. Adjustable gastric band-ing is a restrictive bariatric surgical procedure inwhich a hollow band made of special material isplaced around the stomach near its upper end,which divides the stomach in two portions, creatinga small pouch at the top of the stomach where foodenters from the esophagus. The LapBandAdjustable Gastric Banding System (BioEntericsCorp.) was the first AGB device to receive FDAapproval, which it did in 2001. The approval wasfor use in weight reduction for severely obesepatients with a BODY MASS INDEX (BMI) of at least 40or a BMI of at least 35 with one or more severecomorbid conditions, or those who are 100 poundsor more over their ideal weight. Prospectivepatients must have attempted and failed more con-servative weight-reduction alternatives, such asdiet, exercise, and behavior modification programs.Patients who elect to have this procedure mustmake the commitment to accept significant changesin their eating habits for the rest of their lives.

The LapBand system is a long-term implantabledevice intended to induce weight loss in morbidlyobese patients by limiting food consumption(restrictive rather than malabsorption). The deviceis surgically implanted, using either a laparoscopicor open procedure, to create a restricted opening(stoma) and a small gastric pouch to limit foodconsumption and induce early satiety. The maincomponents of the device are the silicone elas-tomer band, the access port and kink-resistant tub-

adjustable gastric banding 7

ing used to connect the other two components.The inner surface of the silicone band, which isplaced around the stomach, is inflatable and con-nected by the tubing to the access port (a remoteinjection site). The access port is placed in or on therectus muscle to permit nonsurgical, percutaneousadjustments to the band and thus, the stoma diam-eter, using sterile saline.

Initially, the pouch holds about one ounce offood and later expands to two to three ounces. Thelower outlet of the pouch usually has a diameter ofonly about three-quarters of an inch. This smalloutlet delays the emptying of food from the pouchand causes a feeling of fullness. The band is theninflated by injecting a salt solution into a smallreservoir placed under the skin at the time of sur-gery and connected to the band by intravenous (IV)tubing. It can be tightened or loosened over time tochange the size of the passage by increasing ordecreasing the amount of salt solution to regulatethe amount of food that can get through the pas-sage. As a result of this surgery, most people losethe ability to eat large amounts of food at one time.After an operation, the person usually can eat onlythree-quarters to one cup of food without discom-fort or nausea. Also, food has to be well chewed.

Advantages: No cutting or stapling of the stom-ach is required, making adjustable gastric bandingsimple and relatively safe. It usually prevents thepatient from overeating because doing so is painfuland leads to vomiting. Food follows the normaldigestive process. The band can be adjusted toincrease or decrease the amount of food allowed asthe patient’s weight reduction dictates. The recov-ery period is very short; the major complicationrate is low. The surgery can be reversed, allowingrestoration of the normal stomach, as there is noalteration of normal anatomy.

Disadvantages: Some patients are unable to adjusttheir eating habits and fail to lose the desired weight.Successful results depend on the patient’s willingnessto adopt a long-term plan of healthy eating and reg-ular physical activity. A common risk is vomiting,which is caused when the small stomach is overlystretched by food particles that have not beenchewed well. Deep infection is possible. Band ero-sion and migration, deep infection, and saline leak-age have been reported after adjustable gastric

banding; with such complications reported in 10 to22 percent of patients. When complications do occur,additional surgery to correct the problem is likely.Overall, there is a 5 percent failure rate. Adjustablegastric banding is not permanent; replacement orremoval will be necessary eventually.

Brown et al. reviewed medical literature onadverse events with silicone adjustable gastricbanding systems, as well as all adverse events,including deaths and serious injuries, reported tothe FDA through August 8, 2002. They found that“the FDA received 556 reports of adverse eventsrelated to the use of adjustable silicone gastricbands. Two of these reports were for deaths, oneduring surgery and the other as a result of an ero-sion of the gastric band into the stomach nineweeks after implantation. Forty-four reports werefor injuries including band erosions, slippage, andinfection. The most common type of report (499)was for device malfunction, and of these, 485 (97.2percent) described a leak at or near the port. Of the485 leaks reported as malfunctions, 99.4 percentwere treated surgically. The majority of reportswere related to disconnection, breakage, and leak-age at or near the access port.”

Chebli points out that early slippage rates of 15percent “were a reflection of the perigastric tech-nique in which the band was deployed flush withthe stomach. More recently, the most commonlyemployed technique is the pars flaccida approach.This involves placing the band around the stomachas well as tissue surrounding the stomach, whichreduces likelihood of the band migrating. This newerapproach has dropped the slip rate to 3 percent.”

After reviewing eight years of AGB procedures,Weiner et al. noted, “After the learning curve ofthe surgeon, results are markedly improved.” Oth-ers have suggested that surgeons who have per-formed at least 100 procedures have noticeablybetter results.

According to the FDA, adjustable gastric bandingshould not be used for people who are poor candi-dates for surgery, have certain stomach or intestinaldisorders, have an infection, have to take aspirinfrequently or are addicted to alcohol or drugs. Itshould not be used on patients who are not able orwilling to follow the rules for eating and exercisethat are recommended by the doctor after surgery.

8 adjustable gastric banding

In 2004 fees for laparoscopic adjustable bandsurgeries 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. “AdjustableSilicone Gastric Banding Adverse Events Reported tothe Food and Drug Administration.” Journal of Long-term Effects of Medical Implants 13, no. 6 (January2003): 509–517.

Chebli, Joseph E. “Why the LAP-BAND Has Not Hit theMainstream in the United States.” WLS Lifestyles 2, no.1 (winter 2004): 20–21.

Weiner, R. et al. “Outcome after Laparoscopic AdjustableGastric Banding—8 Years Experience.” Obesity Surgery13, no. 3 (June 2003): 427–434.

adolescent obesity During the early years of ado-lescence, as their bodies are undergoing dramaticphysical growth and biological change, some individ-uals become plump and may think of themselves as“too fat.” But once the growth stops and the biolog-ical change is completed, the weight of most will nat-urally level off until they regain slimmer proportions.

For some, adolescent obesity is a temporarycondition. For others, it is the beginning of a life-time of obesity compounded with severe emo-tional and personality problems, since experiencesduring adolescence play such an important role inpsychological development.

Just as other segments of America’s populationare becoming increasingly obese (see OBESITY),there is a growing national health problem of trueobesity among young people. According to theCenters for Disease Control and Prevention (CDC),the percent of adolescents (ages 12–19) who areoverweight is 16 percent (1999–2000), an increaseof 11 percent since 1976–80. An additional 14.9percent of adolescents are at risk for overweight.And a 2002 National Center for Health Statisticsstudy found nearly 6 million American childrenages six to 17 years to be severely overweight—triple the prevalence of the 1960s.

Some obese adolescents are simply continuing ahistory of childhood obesity, becoming even heav-ier during puberty. Some have not been over-weight until adolescence. Others go from extremethinness to obesity during these years.

This period of rapid growth is usually accompa-nied by an increase in APPETITE, especially for high-calorie foods, and some adolescent obesity iscaused by an apparent inability to restrict foodintake. While some adolescents burn off theseextra calories in vigorous physical activities, othersappear unwilling to exercise. They choose insteadto treat their fatness as a “disability,” refusing tojoin in normally active and boisterous adolescentgames and activities. Frequently, this refusal toparticipate derives from feelings of inferiority andshame brought on by taunting and name-callingby their peers. Further exacerbating their difficultymay be parents and teachers who lecture themabout their unhealthy weight and social nonpartic-ipation. It soon becomes easy for them to blame alltheir failures or disappointments on their obesity.

Such feelings, demoralizing at any age but dev-astating during adolescence, can have serious long-term consequences. Thus, adolescent obesity mayoften contribute to lifelong behavioral and psycho-logical problems.

When obese adolescents do not receive—oraccept—help, whether in losing weight or dealingpositively and maturely with their weight andemotional problems, they usually withdraw evenfurther from social life. They frequently then turnto food for solace, causing them to put on evenmore weight.

Obesity in adolescence is also frequently blamedfor problems with sexual adjustment. Althoughbeing fat can prevent a person from being consid-ered “attractive” in our weight-conscious society,HILDE BRUCH cautioned that “it is not the weightexcess itself but the attitude toward it, or more cor-rectly toward oneself, that interferes with any per-sonal relationships, most of all in the sexual area.”Studies of adolescent obesity have described fre-quent cases of provocativeness and uncontrolledsexual behavior, even to the point of promiscuity.

Adolescents with severe personality problemswho are desperately unhappy about being fat areespecially easy prey for FAD DIETS and NOVELTIES. Thepromise and dream of changing a boring, unevent-ful life to one of exciting activity and romance makethe advertised products appear magical.

Members of the American Society of BariatricPhysicians have reported little success in treating

adolescent obesity 9

younger children for obesity, but they have hadincreased success with adolescents at about the ageof puberty. Emerging interest in the opposite sexand a developing maturity level contribute to themotivation to follow eating restrictions.

Because the adolescent body undergoes so manyenergy-requiring physical changes, “average” calo-rie requirement tables are of little use for obese ado-lescents dieting to lose weight. Following typicalcalorie requirement tables is likely to result in anunhealthy low calorie intake. Diets are particularlydifficult for boys around the age of 15, when theircalorie intake may increase five times or more. Ado-lescent dieting can also be stressful socially becauseso much of teenage social life revolves around eat-ing. Well-meaning but nagging parents may add tothis stress, especially given adolescents’ growingindependence. 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 havebeen performed successfully on adolescents; how-ever, surgery for adolescents is usually consideredonly when severe medical conditions are presentthat can improve with the surgery.

Barlow adds, “An adolescent who has contin-ued rapid weight gain during organized attemptsat weight management has obviously not suc-ceeded, but this failure may reflect an eating oremotional disorder that requires psychologicaltreatment, not surgery.”

Writing in Diabetes and Primary Care (March 22,2004), Dr. John J. Reilly of the University of Glas-gow, says, “There is still a widespread belief amongadolescents, their parents and healthcare profes-sionals that obesity is a relatively minor healthproblem, or even a largely cosmetic problem withno significant health impact. In fact, there is a rap-idly accumulating body of evidence that obesity inadolescents will have major health consequences inthe short term (for the adolescent) and the longerterm (for the adult who was an obese adolescent).”

Baur and O’Connor add, “The current epidemic(of child and adolescent obesity) is due to massiveenvironmental change over the past few decadesleading to a rise in sedentary pursuits, a decrease inphysical activity and increased energy intake.Effective management requires a family-focused,developmentally sensitive, behavioral manage-

ment approach that addresses, for example, eatinghabits, incidental activity and television viewing.”

See also BARIATRIC SURGERY.

Barlow, Sarah E. “Bariatric Surgery in Adolescents: ForTreatment Failures or Health Care System Failures?”Pediatrics 114, no. 1 (July 2004): 252–253.

Baur, L. A., and J. O’Connor. “Special Considerations inChildhood and Adolescent Obesity.” Clinics in Derma-tology 22, no. 4 (July/August 2004): 338–344.

Bruch, Hilde. “Obesity in Adolescence.” In Eating Disor-ders: 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 Sociocul-tural Perspective.” In Eating Disorders: Effective Care andTreatment, 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 FatTest.” New Jersey Medicine 94, no. 6 (June 1997): 49–51.

adoption and eating disorders There is someinterest in discovering how adoption and the inci-dence of eating disorders may correlate, since bothanorexia and the internal conflicts faced byadoptees manifest themselves in early adolescenceand around puberty. However, reports on anorexianervosa in adopted children are sparse.

A case was reported in 1985 in which three bio-logically unrelated individuals in one family hadsevere anorexia: a father, his adopted daughter andan unrelated person living with them. This casesuggests the possible importance of environmentalfactors in the generation of anorexia nervosa andalso reveals the special problems underlying thedevelopment of the condition in adoptees.

In 1997 Hewitt called for twin, family and adop-tion studies to help delineate which causes of eatingdisorders can be inherited and which are due tofamily circumstances or individual environments.

In their review of the findings concerning theheritability and the contributing genes of anorexianervosa (AN), Ben-Dor et al. concluded, “Althoughthere is a strong familial component in AN, so farthe search for candidate genes has not been fruitfuland further large scale prospective and adoptionstudies are needed to confirm genetic factors.”

See also TWIN STUDIES AND EATING DISORDERS.

10 adoption and eating disorders

Ben-Dor, D. H., et al. “Heritability, Genetics and Associa-tion Findings in Anorexia Nervosa.” Israel Journal ofPsychiatry and Related Sciences 4, no. 39 (2002):262–270.

Fry, Richard, and Arthur H. Crisp. “Adoption and Iden-tity: A Case of Anorexia.” British Journal of Medical Psy-chology 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 aboutthe age of 25, usually from overeating (especiallyof high-calorie snack foods) and frequentlybecause of emotional frustration, stress or bore-dom. It is generally seen in people who did nothave weight problems as children. Some of themore common emotion charged events that canlead to first-time obesity in adults include leavinghome for college or career, marriage, pregnancy,divorce, death of a close family member, extendedillness or serious injury. In one study, 68 percent ofobese adults related the onset of their weight prob-lems to inactivity because of injury or illness; fre-quently these traumatic events result in unusuallyexcessive eating of high-calorie foods combinedwith long periods of inactivity. Because theserather common and relatively sudden increases inweight frequently remain even after the stress andthe excessive eating stop, one theory suggests thatthere may be a resetting of the set-point mecha-nism during these eating/exercise pattern changes.

See also SET-POINT THEORY.

advertising and obesity Advertising has comeunder increased scrutiny as health organizationsand lawmakers have stepped up efforts to stem theobesity epidemic. Researchers and clinicians havetargeted the multimillion-dollar advertising cam-paigns that promote candy-like cereals and calorie-dense snack foods to children as significantcontributors to the tripling of overweight childrensince the 1970s.

In 1992 the American Academy of Pediatricssuggested that televised food advertising aimed atchildren be completely eliminated because “chil-dren are unprepared to make appropriate foodchoices and do not understand the relationship offood choices to health maintenance and diseaseprevention.” More recently, the American Psycho-

logical Association has recommended governmentrestrictions on advertising to children youngerthan seven or eight because they are unable “torecognize advertising’s persuasive intent.”

Although absolute consensus has yet to bereached on the impact of advertising on childrenand adolescents, many experts agree that televi-sion has a unique capacity to influence children’sminds and behavior. And advertising to children isincreasing along with the obesity. Children arenow exposed to 40,000 TV ads a year, up from20,000 in the 1970s, according to a report by theHenry J. Kaiser Family Foundation. The Kaiserreport cited studies stating that the majority of adstargeted to children are for food: primarily candy(32 percent of all children’s ads), cereal (31 per-cent), and fast food (9 percent). Ads for high-fat,high-salt foods have more than doubled since the1980s, while commercials for fruits and vegetablesremain in short supply.

In a British study to discover how televisioncommercials might affect children’s eating behav-ior and health, the overall snack food intake of theobese and overweight children was significantlyhigher than the lean children in the control (non-food advertising) condition. The consumption ofall the food offered increased following food com-mercials with the exception of the low-fat savorysnack. The authors concluded that obese childrenhave heightened alertness to food-related cues,and exposure to such cues induces increased foodintake in all children.

The advertising industry has vigorously refutedany direct links between advertising and obesity. Ina New York Times article in 2004, leaders of adver-tising trade associations called the Kaiser findingsthat advertising may be part of the obesity problem“a huge leap in judgment.” They also noted thatrestrictions on advertising food to children in othercountries have not reduced obesity. Corroboratingthis, Ashton wrote, “Experience of advertising bansin Quebec and Sweden suggests that the measurewas completely inefficient in combating childhoodobesity.” In Quebec, obesity rates are no differentfrom those in other Canadian provinces, despite a1980 ban on advertising food to children. A similarban in Sweden, which prohibits advertising to chil-dren under age 12, has not affected obesity.Swedish children are as obese as those in compara-

advertising and obesity 11

ble countries. Even countries with virtually nomarketing to children, such as Egypt, are seeingrises in obesity.

According to Broadcasting & Cable, a media tradepublication, the number of television food com-mercials has actually declined during the yearsobesity increased by 15 percent among eighth-graders. Media executives argued, “Yes, kids arespending more time slouched in front of screens.But increasingly, those screens aren’t TVs. Instead,young people are turning to computers, DVD play-ers, and game players that don’t run commercials.”

Advertisers tend to place the childhood obesityproblem on parents who allow their children toovereat and to become “couch potatoes.” Oppo-nents counter that blaming parents “fails to recog-nize the extent of advertising and marketingsurrounding families.” At the June 2004Time/ABC News Obesity Summit, the chairman ofthe Federal Trade Commission asserted that ban-ning advertising to children would be unconstitu-tional and would not end the obesity problem. Henoted, “Even our dogs and cats are fat and it’s notbecause they’re watching too much advertising.”Proponents of restricting or even eliminatingadvertising of fat-laden foods to children note thattobacco and alcohol advertising is restricted, thusthe precedent exists. Some have even comparedRonald McDonald with Joe Camel.

The psychology behind advertising high-fatfoods to adults has also received complaints fromthe medical community; one example was Her-shey’s 2002 ad equating chocolate bars with happi-ness. Newsweek quoted Thomas Warden, director ofthe Weight and Eating Disorders Program at theUniversity of Pennsylvania, as saying, “If you havecommercials like this, which are inviting people toeat in order to feel happy, the likelihood is that therates of obesity will just continue to increase.” Oth-ers accused Hershey of capitalizing on people’sunhealthy connection with high-fat foods.

In June 2004 congressional testimony regardinggovernment’s role in combating obesity, Lester M.Crawford, acting commissioner of the FDA, statedthat the Centers for Disease Control and Preven-tion (CDC) will “conduct a comprehensive reviewof the effects of advertising and marketing on chil-dren’s behavior in general, and specifically on chil-dren’s dietary patterns and health status. The

project will include all aspects of marketing: prod-uct, promotion, placement, and pricing. Addition-ally, CDC will review policies and practices fromother countries. Results from these efforts willinform the development of new social marketingstrategies designed to promote more healthfulnutrition behavior among youth.”

False or Deceptive Advertising

A September 2002 Federal Trade Commission(FTC) report on weight-loss advertising concludedthat, despite vigorous FTC law enforcement andconsumer education efforts, fraudulent and mis-leading weight-loss advertising was widespreadand on the rise. Between 1990 and 2002, the FTCbrought 97 lawsuits against companies it accusedof marketing phony weight-loss products, winning$50 million in restitution to consumers as well asother financial remedies. Public workshop panelssponsored by the FTC found that claims that pro-mote substantial weight loss without reducingcaloric intake or increasing exercise are not scien-tifically feasible at the current time. The reviewconsidered nonprescription drugs, dietary supple-ments, creams, wraps, devices, and patches. Thepanels also looked at ways to improve industryself-regulation of weight-loss advertising anddetermined that further guidance would assist themedia in screening out these bogus claims.

In December 2003 the FTC issued guidelines thatidentified seven common weight-loss claims that theagency called “scientifically unfeasible.” They are:

• Causes weight loss of two pounds or more perweek for a month or more without dieting orexercise

• Causes substantial weight loss, no matter whator how much the consumer eats

• Causes permanent weight loss even when theconsumer stops using the product

• Blocks the absorption of fat or calories to enableconsumers to lose substantial weight

• Safely enables consumers to lose more thanthree pounds per week for more than fourweeks

• Causes substantial weight loss for all users

• Causes substantial weight loss by wearing it onthe body or rubbing it into the skin

12 advertising and obesity

The FTC called on newspapers, magazines, andtelevision networks to voluntarily screen andreject all advertisement for products that makeany of these claims. According to obesity experts,such misleading ads only make the obesity prob-lem worse. Not only do the quick weight-lossplans not work, but they can set up nutritionaldeficiencies, which in the long run may lead tomore health problems.

American Academy of Pediatrics Committee on Commu-nications. “The Commercialization of Children’s Tele-vision.” Pediatrics 89 (1992): 343–344.

Ashton, David. “Food Advertising and Childhood Obe-sity.” Journal of the Royal Society of Medicine 97, no. 2(February 2004): 51–52.

Halford, Jason C. G., et al. “Effect of Television Adver-tisements for Foods on Food Consumption in Chil-dren.” Appetite 42, no. 2 (April 2004): 221–225.

Ives, Nat. “A Report on Childhood Obesity.” The New YorkTimes, February 25, 2004, section 6, p. 3.

Kaiser Family Foundation. “The Role of Media in Child-hood 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 theheart and lungs by increasing the efficiency of oxy-gen intake by the body, usually through an activityin which oxygen reaches the muscles at the samerate at which it is used up. This type of physicalactivity is also recommended for weight controland body conditioning. Such exercise involves thelarge muscles of the upper body, arms and legs, andto be effective it should be continued for periods ofat least 20 minutes at least three times a week.Typical aerobic exercise is not too strenuous andcan be performed slowly for a long period of time.Such exercise includes walking, jogging, swim-ming, bicycling, ice-skating, roller-skating, rowing,aerobic dancing, ballroom dancing, rope skippingand cross-country skiing.

Aerobic exercise is effective for weight reduc-tion because it increases the muscles’ ability to useoxygen to burn energy from stored fat. Although

the exercise itself may seemingly expend few calo-ries, the expenditures is cumulative and continuesafter exercise ends.

The effectiveness of aerobic exercise in reducingfat deposits depends upon several elements,including body weight and the frequency, intensityand duration of exercise. According to the ExercisePhysiology Laboratory at the University of Massa-chusetts Medical School, the average 150-poundperson burns approximately 100 calories walking amile. Its tests have shown that the average personwho takes a brisk 45-minute walk four times aweek for a year and does not increase food intakewill burn enough calories to lose 18 pounds. Virtu-ally all of this weight loss will be fat, because regu-lar aerobic exercise preserves muscle mass.

Usually, aerobic exercise tends to decreaseappetite. Some fitness experts claim that exercisingaerobically during the lunch hour reduces appetitesufficiently that a bowl of soup or a cold drink willsatisfy hunger, and that some people have lost asmuch as 20 pounds within five weeks.

See also ANAEROBIC EXERCISE.

Cooper, Kenneth H. The Aerobics Program for Total Wellbe-ing: 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 Casesof eating disorders among African Americans areoften underreported because studies typically donot include ethnically diverse populations. Thatsaid, more is known about eating disorders amongAfrican Americans than any ethnic and culturalgroup other than white Americans. Although fewstudies examine the incidence or prevalence ratesfor eating disorders in the African-American pop-ulation, a 1996 review of the research literaturerelated to eating behaviors and disturbancesamong American minority groups did provideclinical accounts of eating disorders in African-American women, albeit less frequently thanamong the white population. A later review of theliterature published by the Association of Black

African Americans and eating disorders 13

Nursing Faculty noted that a significant study con-ducted at a large midwestern university identified2 percent of African-American women as eatingdisordered and 23 percent of the non-eating-disor-dered as symptomatic. Because African Americansrepresent only 11 percent of all undergraduates,the author asks, “If the African American womensurveyed sought to assume the values, attributes,and behavior of their Caucasian peers in order tobecome accepted members of the culture, in thiscase the university, then how can a true preva-lence of the eating disorders among the AfricanAmerican subgroup be identified? (They) mayhave been influenced by the activities of their Cau-casian peers who are eating disordered.”

Numerous other studies have documented ahigh rate of eating disorder behaviors and risk fac-tors, including body dissatisfaction among African-American women. More specifically, researchdemonstrates that binge-eating and purging is atleast as common among African-American womenas white women. Some researchers believe thatracial prejudice and discrimination toward AfricanAmericans result in a sense of isolation that maycontribute to binge-eating.

The National Women’s Health Information Ser-vice (U.S. Department of Health and Human Ser-vices) states in its Eating Disorders InformationSheet: “Unfortunately, little work has been under-taken regarding differences in presentation ofsymptoms, cultural-specific risk factors, and effec-tive treatment methods for African Americans.”The commonly held belief that African-Americanwomen do not experience eating disorders hascontributed to the lack of identification of theireating disorder problems. And because early detec-tion of an eating disorder is critical for its success-ful treatment, this misperception can result inserious health problems for African-American girls.

Similar to their white counterparts, as black girlsapproach adolescence, they become concernedwith thinness. Studies indicate that when African-American girls experience social pressure to bethin, they express the same type of body dissatis-faction and drive for thinness as white girls. Ado-lescents from middle-class African-Americanfamilies may be particularly vulnerable to theinfluence of the white beauty ideal. Essence, a mag-azine that caters to African-American women, reg-

ularly runs stories on body size anxiety and eatingdisorders. A survey of its readers indicated thatAfrican-American women appear to have at leastequal levels of abnormal eating attitudes andbehaviors as white women. Studies indicate thatblacks who identify with mainstream cultureexhibit more eating problems, including dietingand fear of fat.

Media targeting African American and otherracial and ethnic and cultural groups in theUnited States are increasingly embracing thebeauty as thinness ideal. Black female stars in themusic, film, and fashion industries are just as thinas their white counterparts. The influence of theserole models may contribute to body dissatisfactionand weight control behaviors among African-American girls.

The first large-scale epidemiological study ofrecurrent binge-eating in black American womenindicated that black women were as likely as whitewomen to report that they had engaged in binge-eating and self-induced vomiting. More specifi-cally, a greater number of black women than whitewomen reported that they had used laxatives,diuretics or fasting to control their weight. Almosttwice as many black women as white women wereidentified as probably having eating disorders.

Crago, M., C. M. Shisslak, and L. S. Estes. “Eating Dis-turbances among American Minority Groups: AReview.” International Journal of Eating Disorders 19,no. 3 (April 1996): 239–248.

Pumariega, A. J. et al. “Eating Attitudes in African-American Women: The Essence Eating Disorders Sur-vey.” Eating Disorders: The Journal for Treatment andPrevention 2, no. 1 (1994): 5–16.

Striegel-Moore, R. H., et al. “Recurrent Binge Eating inBlack American Women.” Archives of Family Medicine9, no. 1 (January 2000): 83–87.

Tyler, Indira D. “A True Picture of Eating Disordersamong African American Women: A Review of Liter-ature.” ABNF Journal 14, no. 3 (May–June 2003):73–74.

African Americans and obesity The prevalenceof obesity is high among African Americans, par-ticularly African-American women. In the period1999–2000, 50 percent of non-Hispanic blackwomen 20–74 years of age were obese, comparedwith 30 percent of non-Hispanic white women.

14 African Americans and obesity

Obesity among black women increased more than60 percent since the period 1976–80, from 31 per-cent. Poor African Americans have an even higherrate of obesity: one in three. The incidence of over-weight and obesity is even higher—69 percentuntil age 60, when it declines. About 36 percent ofAfrican-American children six to 10 years old areoverweight (compared to 30 percent of all U.S.children), and 20 percent are obese (compared to15 percent of all U.S. children).

Black girls are not likely to be heavier thanwhite girls during childhood, but after adolescencetheir BODY MASS INDEX (BMI) surpasses that ofwhite adolescent girls. This increase may be par-tially due to metabolic differences, as black womenand girls tend to have lower resting expendituresthan their white counterparts. African-Americanwomen tend to experience weight gain earlier inlife than Caucasians and Asians. African-Americanmen tend to develop obesity later in life than His-panic men.

James Gavin, M.D., president of the MorehouseSchool of Medicine, suggests that African Ameri-cans may be genetically predisposed to being over-weight. “Many of us have what is called a thriftygene (it’s really a cluster of genes) that protectedour ancestors in time of famine or too little food.We get a lot of miles out of the food we eat. Whenpeople with the thrifty gene eat too much foodevery day for years, we become obese.”

Experts caution that as a hybrid populationformed from a mixture of African, Native Ameri-can and European-American ethnic groups, blackAmericans have different eating and exercisebehaviors, as well as different attitudes about bodysize, than their African ancestors. One reasongiven for the higher rate of obesity among low-income African Americans is their traditionallyhigh-fat diet, which some studies show to be par-ticularly followed in southern states. According tothe National Women’s Health Information Service(U.S. Department of Health and Human Services),black women and girls are less likely to exercisethan their white counterparts. Although the AMER-ICAN OBESITY ASSOCIATION (AOA) says overweightaffects African Americans regardless of economicstatus, statistics show that black women moreoften 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 African-American neighborhoods than in other communi-ties. Studies have found that many overweightAfrican Americans feel they cannot walk in theirneighborhoods for fear of their own safety, andblack men are often hesitant to walk or jog any-where out of fear of being considered a criminal.African-American women also report exercisingless as they get older, according to the AOA.

But economics and exercise do not appear toplay the only roles in the obesity race disparity.Researchers at Rush University Medical Center inChicago followed 2,017 women for four years aspart of the Study of Women’s Health across theNation (SWAN). The study was designed to test theeffects of race and socioeconomic status on bodymass index (BMI) by examining a diverse group ofwomen. They found that, although women of bothraces with only high school education had similarBMI levels (31.4 for blacks versus 31.1 for whites),the BMI of Caucasian women with college educa-tion was lower than the BMI of similar African-American women (27.1 for whites versus 30.7 forblacks). In fact, the weight difference grew withadditional education. More studies are needed todetermine the reason behind these provocativefindings, but researchers suggest that factors mightinclude cultural differences (being overweight hashistorically carried less stigma for lower economicblack women than for white), or the increasedstress the black women reported from perceiveddiscrimination as they climbed the career ladder.Previous research has associated stress withweight gain.

Researchers from the Children’s Hospital ofPhiladelphia reported in 2003 that African Ameri-cans who gained weight more rapidly than theirpeers in the first four months of life were morethan twice as likely to be obese 20 years later thansubjects without rapid early infant weight gain.Nicolas Stettler, M.D., the lead author of the study,said, “Our results suggest that early infant weightgain is a critical period for the establishment ofobesity. This may lead to new hypotheses to originsof obesity and to new approaches for obesity pre-vention.” He noted that further research is needed.

Several studies have reported an associationbetween low birth weight and a risk for later obe-

African Americans and obesity 15

sity and diabetes, with African Americans experi-encing much higher prevalence of low birth ratesthan others. The average low-birth rate for AfricanAmericans is 13.2 percent, for African-born blacks7.1 percent and for white Americans, 4.3 percent.Rates improve for higher income groups, but thedisparity remains: 7.5 percent for black Americans,3.6 percent for black Africans and 2.4 percent forwhite Americans.

Another area where the connection betweenobesity and African Americans has been studied isin television shows. Tirodkar and Jain comparedfour of the most popular sitcoms viewed by thegeneral public with four sitcoms most watched byAfrican-American audiences. A much higherprevalence of obesity was found in the shows tar-geting African Americans than in those designedfor the public at large (27 percent vs. 2 percent),and there were more food commercials overallduring the African-American shows (4.8 vs. 2.9per half-hour show). However, the Kaiser FamilyFoundation noted in its issue brief The Role of Mediain Childhood Obesity, “Exactly what effect seeingobese characters on these shows has on the preva-lence of obesity among African Americans in reallife is not clear.”

Generally, overweight and obese African-American girls express satisfaction with their phys-ical appearance, with reports showing as high as40 percent considering their figures to be attractiveor very attractive. However, studies of African-American women who have moved to highersocioeconomic status have shown increased levelsof poor self-image along with increased BMI.

Freedman et al. examined both ethnic differ-ences and differences between college and commu-nity samples in male preferences for ideal body sizeand shape in women. They found that African-American men were more likely to choose heavierfigures as ideal than white American men did. Bothethnic groups chose figures with a low waist-to-hipratio (WHR), but African-American men weremore likely to choose a very low WHR as ideal. Theauthors stated, “The findings replicate and extendresearch showing weight to be a more importantcue than WHR in the mate-selection process andsupport the theory that African-American men’spreferences may serve as a protective factor against

eating and body image pathology in African-American women.”

Several studies show little or no associationbetween overweight and the risk of death forAfrican Americans, especially women. In an analy-sis of American Cancer Society data on more than1 million U.S. adults, the heaviest black women(BMI greater than 35) had a smaller increase inrisk of death from all causes (increase was 20 per-cent to 30 percent) than did the heaviest whitewomen with the same BMI (increase was 75 per-cent to 100 percent). Black men who were over-weight showed an increased risk, but it was verysmall. Researchers have no explanation for thisdisparity, and they do not know whether risks arethe same for people of African descent elsewherebecause no large studies exist in other parts of theworld to compare with those done in the UnitedStates. Another reason for not considering thesefindings final is that only about 12,000 of the studyparticipants were African Americans—too few tobe statistically meaningful or to establish a cleartrend. But other studies have also shown thatAfrican Americans may live longer if they are inthe overweight but not obese category. If AfricanAmericans do indeed suffer fewer consequences ofmodest weight gain, experts speculate that differ-ences in body fat distribution might be part of thereason, according to an article in USA Today. “Fat isthought to be most dangerous if it is packedaround the internal organs. This kind of fat is mostbiologically active, throwing off cholesterol levelsand forcing up insulin levels. Overweight blackstend to have lower levels of harmful triglyceridesand higher amounts of protective HDL than dosimilar-size whites, and this might be due to wheretheir fat is deposited. Blacks tend to carry a largerproportion of their fat in a layer under the skinrather than deep in the belly.”

However, African-American women do havehigher rates of obesity-related diseases such as dia-betes, hypertension and breast cancer; thus someexperts say the higher obesity rates in AfricanAmericans may indirectly be connected to theoverall higher mortality rate among blacks.

See also THRIFTY GENE.

Associated Press. “Is Weight Gain Less Hazardous forBlacks than Whites?” Available online. URL:

16 African Americans and obesity

http://www.USATODAY.com/news/health/2004-06-07-blacks-weight_x.htm. Downloaded on September15, 2005.

Calle, Eugenia E., et al. “Body-Mass Index and Mortalityin a Prospective Cohort of U.S. Adults.” The New Eng-land Journal of Medicine 341, no. 15 (October 7, 1999):1097–1105.

Freedman, Rachel E. K., et al. “Ethnic Differences inPreferences for Female Weight and Waist-to-HipRatio: A Comparison of African-American and WhiteAmerican College and Community Samples.” EatingBehaviors 5, no. 3 (July 2004): 191–198.

Freid, V. M., et al. 2003 Chartbook on Trends in the Health ofAmericans. Hyattsville, Md.: National Center forHealth Statistics, 2003.

Gavin, James R., with Sherrye Landrum. Dr. Gavin’sHealth Guide for African Americans. Alexandria, Va.:Small Steps Press, 2004.

Kaiser Family Foundation. “The Role of Media in Child-hood Obesity.” Available online. URL:http://www.kff.org/entmedia/7030.cfm. Posted onFebruary 24, 2004.

Tirodkar, M., and A. Jain. “Food Messages on AfricanAmerican Television Shows.” American Journal of Pub-lic Health 93, no. 3 (March 2003): 439–441.

air pollution and obesity Harvard School of Pub-lic Health researchers studied 611 Boston-areafourth- and fifth-grade students to determine theshort-term affects of air pollution. They reported tothe American Thoracic Society International Con-ference in 2004 that when air pollution levels wentup, associations between air pollution and lungfunction were two to five times stronger for obesechildren than for normal-weight children. Themore obese a child was, the stronger the effect wasof the previous day’s air pollution on his or herlung function. Increases in air levels of nitrogendioxide produced the greatest disparity. Theschoolchildren were an ethnically diverse group,with about 58 precent classified as white, 18 per-cent as black, 14 percent as Hispanic and 10 per-cent as other. The researchers speculated thatbecause fatty tissue is known to release chemicalsinvolved in inflammation, and because air pollu-tion also leads to inflammation of the airways,there may be a multiplier effect that makes obesechildren more sensitive to air pollution. In anotherstudy that followed these children through 12thgrade, the same researchers found that long-term

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

alexithymia Difficulty in describing or recogniz-ing one’s emotions; confusion about one’s feelings,or an apparent lack of thought and concern aboutone’s personal experiences. This disturbance isvery common in anorexia nervosa. When asked todescribe their sensations of SATIETY, anorexics oftenrespond with such statements as “I feel like I haveeaten”; “I don’t like it”; “I feel guilty.” Inquiriesabout their emotions may result in defensive orhostile responses to what is viewed as an intrusioninto an area they do not understand.

A Canadian study of 95 subjects supportednumerous reports of the presence of a high degreeof alexithymia in the obese. One theory is thatsome people have difficulty coping psychologicallywith stressful, emotionally intense situations andrelieve their anxiety through physical action. Eat-ing, already associated with satisfaction and therelief of stress, is by far the most common device.

A British study concluded that eating disorderpatients are considerably more alexithymic thannormal controls. It also found that alexithymia maybe a trait in bulimia nervosa requiring psychologicaltreatment to encourage the expression of emotion.

A French study of 169 obese women, publishedin 2003, found that alexithymia was the predictorof emotional eating in those obese subjects whoalso had BINGE-EATING DISORDER, while perceivedstress and depression were the predictors in thosesubjects without binge-eating disorder.

Legoretta, Gabriela; Robert H. Bull; and Margaret C.Kiely. “Alexithymia and Symbolic Function in theObese.” Psychotherapy and Psychosomatics 50, no. 2(1988): 88–94.

Pinaquy, Sandrine, et al. “Emotional Eating, Alex-ithymia, and Binge-Eating Disorder in ObeseWomen.” Obesity Research 11, no. 2 (February 2003):195–201.

Schmidt, V., A. Jiwany and J. Treasure. “A ControlledStudy of Alexithymia in Eating Disorders.” Compre-hensive Psychiatry 34, no. 1 (January/February 1993):54–58.

Alzheimer’s disease risk and obesity Becauseobesity is closely associated with vascular diseases

Alzheimer’s disease risk and obesity 17

(diabetes, coronary heart disease and hyperten-sion), and all of these have been implicated as riskfactors in Alzheimer’s disease, researchers havelong contemplated the possibility of a linkbetween obesity and Alzheimer’s disease. How-ever, any such link had been difficult to connectbecause weight loss frequently occurs prior tosymptoms of Alzheimer’s.

This problem was overcome when scientists inSweden were able to follow nearly 400 people for 18years, from age 70 or older. At the end of the 18years, 93 of the participants were found to haveAlzheimer’s disease. Women in the study who devel-oped Alzheimer’s disease between the ages of 79 and88 were significantly more likely to have been over-weight at age 70, as well as at 75 and 79. Their bodymass index (BMI) averaged 3.6 units higher thanthat of women who did not become demented. Forevery unit increase (approximately five to sevenpounds) in BMI at age 70, the risk of developingAlzheimer’s disease increased by 36 percent.

An important side note to the study: Thosewomen who did not develop Alzheimer’s diseasewere not superthin; their average BMI was 25, theborderline between healthy and overweight. Theauthors noted, “These results suggest that evenmoderate, common-sense weight control may helplower risk of Alzheimer’s disease.”

This study did not find a connection betweenexcess weight and Alzheimer’s disease in men,largely because few male participants lived longinto the study, and thus few developed dementia.The researchers said it is also possible that theremay be some physiological basis for the difference,such as a metabolic factor or a different pattern ofbody fat distribution in men and women. Moremen will have to be included in future studies tobetter determine any differences.

In two previous Alzheimer’s studies, oneSwedish and one Finnish, obesity also appeared tobe a factor. As 2,000 people aged in one study,those with a BMI greater than 30 (obese) whenthey were middle-aged had a 3.5 times greater riskof developing dementia than those of normalweight. In the other study of 1,449 Finns, risk ofany dementia, and Alzheimer’s in particular,roughly doubled with a BMI of more than 30 atage 50. The risk was six times higher when those

who were obese also suffered from high choles-terol and high blood pressure.

Although the findings point to important publichealth implications (women older than 50 are thefastest-growing age group in Western societies),the Alzheimer’s Association (which helped sponsorthe 18-year Swedish study with a grant) cautionedthat more work needs to be done. Among thequestions scientists will be trying to answer is howexcess weight might lead to Alzheimer’s disease orother forms of dementia.

Experts had already projected the number ofAlzheimer’s cases in the United States to rise from4.5 million today to as many as 16 million by 2050;however, a spokesperson for the National Instituteon Aging was quoted as saying that number “prob-ably doesn’t take into account the nation’s bur-geoning weight problem.” The World HealthOrganization has predicted nearly 29 milliondemented people in both developed and develop-ing countries by the year 2020. Should obesityprove out to indeed have a definitive link toAlzheimer’s disease, the numbers projected arelikely to be grossly underestimated, a problem thathas been called “scary.”

Gustafson, Deborah, et al. “An 18-Year Follow-up ofOverweight and Risk of Alzheimer Disease.” Archivesof Internal Medicine 163, no. 13 (July 14, 2003):1,524–1,528.

amenorrhea A suppression or absence of men-struation. It is considered normal after meno-pause, during pregnancy and during lactation(secretion of milk after childbirth). Primary amen-orrhea is failure of menstruation to occur atpuberty; secondary amenorrhea is cessation ofmenstruation after its establishment. Among thecauses of abnormal amenorrhea are metabolic dis-orders (diabetes or those stemming from OBESITY ormalnutrition) and emotional disorders (ANOREXIA

NERVOSA or those stemming from excitement,shock, fright or hysteria).

When the amount of fat drops below a criticalpercentage of body weight (20 percent) for anyreason, hormonal release is affected, which in turnresults in amenorrhea. Because of this, it is gener-ally considered to be a symptom of anorexia ner-

18 amenorrhea

vosa. Although drastic weight reduction generallyleads to amenorrhea, there have been cases inwhich amenorrhea has occurred prior to weightloss. In many of these cases, the amenorrhea con-tinues even after the weight has been regained,sometimes for years. For this reason, some suggestthat amenorrhea is a response to psychic stress orindicative of an underlying hypothalamic (bodytemperature) disorder. Others suggest that perhapspoor nutrition or abnormal psychological develop-ment can affect hormonal functions and causethese different results.

However, many persons who are at anextremely low body weight do not develop amen-orrhea and sometimes persons who are actuallyoverweight develop amenorrhea while losingweight. Thus, the exact relationship between bodyweight, weight loss and menstrual irregularities isunclear. Currently amenorrhea (defined as theabsence of at least three menstrual cycles) is one ofthe required diagnostic criteria for anorexia ner-vosa. However, because of the problems notedabove, many researchers have recommended thatit be eliminated as a criterion.

Irregular menstrual cycles and amenorrhea inbulimic women have been reported by nearly adozen authors in medical journals, with irregularmenstrual cycles reported in as many as 50 percentof cases studied and amenorrhea in 7 to 20 percentof cases studied.

See also BULIMIA NERVOSA.

Garfinkel, Paul E., et al. “Should Amenorrhea Be Neces-sary for the Diagnosis of Anorexia Nervosa?” BritishJournal 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 dis-orders For statistical purposes, the U.S. govern-ment and various health agencies group NativeAmericans and Alaska Natives into one populationsegment they call American Indian/Alaska Native(AI/AN). Eating disorders among American Indi-ans and Alaska Natives are often not diagnosedappropriately, possibly because cases have not beenreported as often among ethnically diverse popula-

tions and thus are not expected. Some authors sug-gest that incorrect diagnoses may also come fromthe widely accepted false belief that eating disor-ders affect only middle-class to upper-middle-classwhite adolescent women. However, recent studiesindicate that American Indian and Alaska Nativeadolescents are increasingly exhibiting disturbedeating behaviors and using unhealthy practices tocontrol their weight. Disordered eating has beenshown to occur more often among this group thanamong white, Hispanic, African-American or Asiangirls, according to the National Women’s HealthInformation Center:

In a large study involving 545 Hispanic, AmericanIndian, and white high school students, AmericanIndians consistently scored the highest on each ofseven items representing disturbed eating behav-iors and attitudes. This study, which included 129American Indians, also found very high rates ofself-induced vomiting and binge eating among thisgroup. Other small studies of American Indianadolescents also indicate high rates of disorderedeating, including dieting and purging.

The largest and most comprehensive surveyundertaken to date on the health status of NativeAmerican youths living on or near reservationsinvolved 13,454 American Indians and AlaskaNatives in grades 7 through 12. Approximately41 percent of the adolescents reported feelingoverweight, 50 percent were dissatisfied withtheir weight, and 44 percent worried about beingoverweight.

Among American Indian youth, body dissatis-faction is associated with unhealthy weight controlbehaviors. In the Indian Adolescent Health Studymentioned above, almost half of the girls and one-third of the boys had been on weight loss diets inthe past year, with 27 percent reporting self-induced vomiting and 11 percent reporting the useof diet pills. Girls who reported feeling overweightwere more likely to engage in unhealthy weightcontrol practices.

Increased contact with the mainstream cul-ture that equates thinness with beauty seems tocontribute to higher rates of disordered eatingamong American Indian girls. In one study,anorexic Navajo girls from Arizona were morelikely to come from upwardly mobile familieswho moved off the reservation. In a secondstudy, child and adolescent members of a tribewere much more likely to prefer thinner body

American Indians/Alaska Natives and eating disorders 19

sizes than elder tribe members. Eating distur-bances have also been associated with racism,social isolation, low self-worth, and pressure tolook a certain way, which may increase vulnera-bility to developing eating disorders.

Fitzgibbon and Stolley came to similar conclusions:“Among Native American populations, the scantavailable information suggests that aberrant eatingpatterns more often strike heavier individuals andthat purging behaviors such as vomiting and laxa-tive abuse are used to control weight. Research hasalso noted that younger women with higher levelsof education, as well as those who have moved offreservations and are assimilating into western cul-ture, are at increased risk.”

Fitzgibbon, Marian, and Melinda Stolley. “MinorityWomen: The Untold Story.” Nova Online: Dying to BeThin. Available online. URL: http:/www.pbs.org/wgbh/nova/thin/minorities.html. Updated in December2000.

National Women’s Health Information Center. “EatingDisorders Information Sheet: American Indian andAlaska Native Girls.” Office on Women’s Health, U.S.Department of Health and Human Services. Availableonline. URL: http://www.4woman.gov/BodyImage/Bodywise/uf/AmericanIndianGirls.pdf. DownloadedAugust 30, 2004.

American Indians/Alaska Natives and obesityIncreasing rates of obesity have been measured inmany American Indian and Alaska Native commu-nities, with the current rate of obesity for thesegroups twice that of the non-Hispanic white popu-lation. Eighty percent of American Indians withdiabetes are obese. In Pima Indians, the mostwidely studied American Indian group, 95 percentof those with diabetes are overweight.

The study of obesity and energy metabolism inPima Indians has not identified exact causes buthas revealed that Pima Indian families share thetrait of low metabolic rate. This trait is consideredpredictive of weight gain and development of type2 diabetes. A THRIFTY GENE is also thought to causea genetic predisposition to obesity, although thisgene has not been identified.

American Indians have a high prevalence ofobesity in all age groups and both sexes. Becausechildren who are obese are at risk for developing

eating disorders and for becoming obese adults,health services have called for a focus on the pre-vention and treatment of obesity in AmericanIndian adolescents. A U.S. government initiativecalled Healthy People 2010: Objectives for Improv-ing Health, released in January 2000, lists amongits goals: Reduce overweight to a prevalence of nomore than 30 percent among American Indiansand Alaska Natives.

Dabelea, D., et al. “Increasing Prevalence of Type II Dia-betes in American Indian Children.” Diabetologia 41,no. 8 (August 1998): 904–910.

American Obesity Association (AOA) A non-profit 501(c)(4) educational and lobbying organiza-tion founded in 1995. Its funding primarily comesfrom pharmaceutical companies, weight loss firms,and health care organizations. AOA’s focus is onchanging public policy and perceptions about obe-sity. Its mission is to change the perception of obe-sity from one of individual failure to recognition asa complex disease involving more than personalbehavior, such as the environment and genetic her-itage, and to fashion appropriate strategies to dealwith the epidemic. To achieve these objectives,AOA acts as an advocate before Congress, theWhite House and executive branch agencies anddepartments for policies that will be beneficial, plusdevelops educational materials to explain its posi-tions. AOA’s program areas include education,research, prevention, treatment, consumer protec-tion, discrimination and stigma and childhood andadolescent obesity. In addition, AOA has createdand participated in several coalitions and studies.

See also APPENDIX III, SOURCES OF INFORMATION.

amitriptyline A tricyclic ANTIDEPRESSANT that hasbeen used to treat bulimic patients for depressionand BINGE-EATING behavior. In one study,amitriptyline (trade name Elavil) was testedagainst a PLACEBO in a sample of 32 bulimic sub-jects. Even though it was discovered that as manyas half the subjects receiving amitriptyline mayhave been inadequately treated, amitriptyline stillproved to be significantly superior to the placeboon one rating scale for anxiety and depression, butnot significantly superior on another rating scale.

20 American Indians/Alaska Natives and obesity

Other studies have reported less favorableresults in treating ANOREXIA NERVOSA. Becauseamitriptyline has been shown to produce carbohy-drate cravings in nonanorexics, researchersGarfinkel and Garner cautioned that there may bea significant risk of triggering BULIMIA in anorexics(see CARBOHYDRATES and CRAVINGS). In a 1985study comparing the effects of amitriptyline andplacebo on weight gain, depression, eating atti-tudes and obsessive-compulsive tendency over afive-week period, no significant differences favor-ing amitriptyline were found in any of the out-come variables.

Side effects include increased appetite and thirstand 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 stimu-lants whose effects resemble those of the naturallyoccurring substance adrenalin. They have the tem-porary effect of increasing energy and apparentmental alertness. Until recent years amphetamineswere widely prescribed by physicians for obesitybecause they lessen the appetite.

Amphetamines were originally formulated in aGerman laboratory in 1887 but were largelyignored until they were rediscovered in 1932 byGordon Alles of the University of California, whotransferred his patents to the pharmaceutical firmof Smith, Kline & French (SKF) Laboratories. By1937, amphetamines were being recommended forcertain patients whose obesity was accompaniedby low-level depression, on the grounds that apatient whose mood improved would no longerneed to overeat and thus would lose weight. Itwasn’t long before amphetamines were beinghailed as a painless way to lose weight throughappetite suppression. By the time the federal gov-ernment stepped in to control the manufactureand sale of amphetamines, SKF was selling $30 mil-lion worth each year. (See APPETITE SUPPRESSANTS

and OBESITY.)Their use does initially reduce appetite and

increase energy levels. Because they induce condi-tions 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 forenergy. Some practitioners believe this theoryshows that weight loss from amphetamines is theresult of a lowering of the set point rather thanappetite suppression (see SET-POINT THEORY). It hasalso been suggested that the anorexic effect ofthese drugs is a consequence of their inhibition ofthe salivary glands, which causes dry mouth,makes food less palatable and results in a loss ofappetite. Amphetamines are frequently misused byanorexics, who experience intense hunger on theone hand yet terror on the other at giving in to theimpulse to eat. Amphetamine abusers have experi-enced difficulty in swallowing, an extreme way tosuppress the appetite.

All of these appetite-control mechanisms haveonly temporary effects. The body soon draws on itsimmense recuperative powers, learns to adapt tothe chemical and restores digestion, salivation andappetite to normal, thus preventing any more lossof tissue. Those who adhere to the lowered-set-point theory also say that the resultant weight lossis temporary: after use of the drug is stopped, theset point returns to its previous level, so weightalso rises to its previous level, or higher.

The American Medical Association (AMA) hasevaluated amphetamines as hazardous because oftheir undesirable effects, including a tendency toproduce psychic and, occasionally, physicallydependence when used indiscriminately and inlarge doses. The AMA suggests that physicians pre-scribe them only for temporary use of four to sixweeks. The Food and Drug Administration affirmsthat these common drugs are of limited usefulnessand that their use for prolonged periods in thetreatment of obesity can lead to drug dependenceand abuse and must be avoided. Phentermine (oneof the ingredients of fen-phen) is an amphetamine(see FEN-PHEN/REDUX).

Because of the high potential for abuse andaddiction, amphetamines are now reserved forlimited treatment of attention-deficit hyperactivitydisorder (ADHD), narcolepsy and Parkinson’s dis-ease. The most common trade names are Adderall,Desoxyn, Dexedrine, Dexedrine Spansule andDextroStat. All are closely related chemically.Some brands are not approved for medical use andare manufactured illegally.

amphetamines 21

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. 2nded. New York: Facts On File, 1992.

amylin A recently (1987) isolated hormone dis-covered in high levels in the pancreas of Type II(non-insulin-dependent) diabetics. It appears to beresponsible for the obesity, the reduced insulinsecretion and the reduced effectiveness of insulinobserved in Type II diabetes. Until this discovery,obesity had been considered by many to be a majorcontributor to the disease rather than a result of it.

anaclitic depression Also called anaclitic reac-tion. A state of reduced spontaneity and expres-siveness in an infant resulting from lack of maternalresponsiveness to the infant’s demands. Althoughthere is no scientific proof of the theory, someresearchers have attributed the sense of emptinessand loss experienced by anorexics to an anacliticdepression that develops because of maternal over-or underinvolvement. During the child’sexploratory phase of development, the motherneeds to allow and encourage freedom in order topromote the illusion of self-sufficiency, but sheshould also be available for emotional support.When the mother offers either too much or too lit-tle assistance, she can hinder the toddler’s develop-ment of self-reliance. One theory is that the motherof an anorexic overprotects her daughter ratherthan encourages her to explore, or is emotionallyunavailable for support when her daughter returnsfor comfort or reassurance. This lack of dependableand consistent maternal responsiveness inhibits thedaughter’s normal striving for autonomy and slowsher separation-individuation process.

This school of thought theorizes that it is specifi-cally because the anorexic’s mother had difficulty inallowing or promoting independent behavior in herdaughter that the anorexic is later unable to matureand separate. During adolescence, when separationand independence develop, the anorexic’s depend-ency again surfaces, along with the latent psy-chopathology originating in her infancy.

Anaclitic depression is not a DSM-IV diagnosis.

anaerobic exercise Exercise that demands briefspurts of intense effort, such as calisthenics orweight training. Anaerobic exercise is so intensethat the oxygen supplied to the muscles by theblood is insufficient, forcing the muscle cells towork without it. For this reason, it does not burn asmany calories as AEROBIC EXERCISE does. Anaerobicexercise is important to include in an overall fitnessprogram because it helps to improve flexibility, ton-ing and firming of the muscles, but it will not con-tribute a great deal to a weight reduction program.

anorexia athletica Also called obligatory exer-cise. Compulsive exercising to the point of obses-sion; an addiction to exercising. Anorexia athleticais not a recognized distinct disease, but it is beingincreasingly referred to by researchers. Althoughsome refer to it as a “new” disorder, others callsuch a distinction unreasonable and say it is simplya possible symptom of anorexia nervosa.

Eating disorder treatment centers such as theWillough at Naples, Florida, include it in theirinformation sheets “because many people who arepreoccupied with food and weight exercise com-pulsively in attempts to control weight. The realissues are not weight and performance excellencebut rather control and self-respect.”

Fitness club owners have reported that typicallythe person is a woman in her 20s or 30s who uses thefacilities for several hours a day, sometimes workingout at more than one center during the day, and wholoses so much weight that other club membersexpress concern. Some will lose so much body fatthat the workouts will burn muscle, “which gives offa distinct, foul odor.” The exercise-addicted personwill work out not for enjoyment but rather becauseshe feels obligated to do so—with nothing stoppingthe workout, not illness nor injury. According toobservers, female gymnasts, cross-country runnersand swimmers are most likely to succumb to this be-havior; about 5 percent of young male athletes, usu-ally wrestlers or cross-country runners, develop it.

While acknowledging that anorexia athletica isnot a recognized diagnosis, the National EatingDisorder Information Centre (Canada) lists the fol-lowing symptoms:

• Exercising beyond the requirements for goodhealth

22 amylin

• Being fanatical about weight and diet

• Stealing time from work, school, and relation-ships to exercise

• Focusing on challenge and forgetting that phys-ical activity can be fun

• Defining self-worth in terms of performance

• Rarely or never being satisfied with athleticachievements

• Always pushing on to the next challenge

• Justifying excessive behavior by defining self asan athlete or insisting that their behavior ishealthy

Researchers have suggested that further study isneeded to delineate and define the unique charac-teristics of those with purported subclinical eatingdisorders such as anorexia athletica, as well aswhich criteria need to be met if it is to be desig-nated a separate disorder.

Goodman, Brenda. “Stop That Treadmill: Is CompulsiveExercising 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 physiciansduring the High Middle Ages to describe “miracu-lously inspired” loss of appetite. This was a fairlycommon occurrence in medieval Europe, espe-cially between 1200 and 1500. It was consideredmiraculous when women survived prolongedperiods of fasting; many insisted they were actu-ally unable to eat normal “earthly fare.” Fastingwas critical to female sainthood during this time,given medieval culture’s association of the femalebody and food. Catherine of Siena (1347–80)restricted her diet to a daily handful of herbs;whenever she did partake of other food, shewould cause herself to vomit by forcing a stickdown her throat. Other female saints became ill orfelt their throats close up around food, fasted fordays at a time, ate only orange seeds, and evendied of starvation. Anorexia mirabilis, unlikeanorexia nervosa, was not restricted to adolescentor young adult women. And today’s anorexicstrives for the modern ideal of physical perfection

or beauty rather than the medieval ideal of spiri-tual perfection or beauty.

As the Protestant Reformation revolutionizedmedieval culture, prolonged fasting became a neg-ative practice; it was considered a work of the devilrather than of God. Where fasting females wereonce venerated as saints, they were nowdenounced as evil, possessed by the devil or insane.

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

anorexia nervosa A serious psychological disor-der characterized by intense fear of gaining weight.Anorexics refuse to maintain even a minimal bodyweight and are pathologically preoccupied withfood and dieting. Anorexia literally means “lack ofappetite” and thus is actually a misnomer, but it isthe generally accepted name for the condition.Anorexics do experience hunger, but they simplyrefuse to give in to it for fear of becoming fat.Anorexia nervosa affects chiefly young women intheir teens and twenties.

Anorexia nervosa has always been overwhelm-ingly a disorder of upper-class adolescents (the usualage range is from 12 to 25), but studies by Garfinkeland Garner show it to be increasing in older womenand in other social classes. Ninety to 95 percent ofanorexics are female; in 85 percent of patients, onsetoccurs between the ages of 13 and 20.

It is estimated that in the United States, one ofevery 200 females in late adolescence and earlyadulthood is starving herself (source: Diagnostic andStatistical Manual of Mental Disorders, 4th ed., TextRevision, Washington, D.C.: American PsychiatricAssociation). The Anorexia Nervosa and RelatedEating Disorders (ANRED) organization estimatesthat approximately one in every 100 femalesbetween the ages of 10 and 20 suffers fromanorexia. For girls over 16 in private schools or inuniversities, the figure may be as high as one in 10.No reliable statistics exist for younger children orolder adults, but cases in these age groups do occur.Until recently, anorexia was rare among AfricanAmericans, the cause explained by experts as lessconcern among this population with dieting andbeing thin. They correlate the recent increase inanorexia in black women to their assimilation of theideals of middle- and upper-class Western culture.

anorexia nervosa 23

In their review of the literature, Hoek andHoeken found an average prevalence rate foryoung females of 0.3 percent and an incidence ofeight cases per 100,000 population per year. Polivyand Herman noted that “Precise estimates of inci-dence and prevalence vary wildly, perhaps becausethose who suffer from these disorders are oftenreluctant to reveal their condition. Prevalence esti-mates tend to range from about 3 percent to 10percent of at-risk females (those between 15 and29 years of age).”

Of those patients being treated for anorexia, asmany as 20 of every 100 will actually die. Of theremainder only half will recover to lead normallives; the rest are likely to relapse. Arthur H. Crisphas reported patients relapsing after being in remis-sion for 50 years. (See ELDERLY, EATING DISORDERS IN

THE.) Morbidity and mortality rates in anorexia ner-vosa are among the highest recorded for psychiatricdisorders. According to the American PsychiatricAssociation Work Group on Eating Disorders(2000), the mortality rate at five years is 5 percent,increasing to 20 percent at 20-year follow-up, giv-ing anorexia nervosa the highest mortality rate ofany psychiatric disorder.

Authors, researchers and journals have referredto the “dramatic increase in diagnosed cases ofanorexia nervosa in the last 20 years,” but actualnumbers have been difficult to come by. This is duepartly to a lack of a system for collecting and inter-preting data and partly to a lack of standardizationin diagnostic criteria. However, there is evidencethat such an increase has occurred. Two measure-ments used have been hospital admissions and casereportings around the country. The University ofWisconsin Hospital, for example, showed an aver-age of fewer than one anorexic patient admissionper year prior to the 1960s; in 1982, it admittedmore than 70. In Monroe County, New York, thenumber of reported anorexia nervosa cases dou-bled between 1960 and 1976.

A number of reasons have been given for thisapparent surge in diagnosed cases of anorexia ner-vosa: (1) Both the professional and popular presshave published numerous articles and reports onthe disorder. This has resulted in both the medicalprofession and the general population becomingmore familiar with the disorder, thereby exposing

more cases. (2) There has been a history of inade-quate recordkeeping in anorexia cases and lack ofagreement criteria for diagnosis. This leaves somequestion as to the actual incidence of the disorderin years past. (3) Because anorexics do not admitto their illness or even complain about it, there isa belief that many cases prior to the recentincrease in press coverage were never brought tothe attention of doctors. (4) Some psychologistsestimate that as many as 30 percent of today’scases are “copycat” anorexics, responding to a peergroup phenomenon rather than suffering trueanorexia nervosa.

Although estimates of the incidence of anorexianervosa in western Europe and the United Stateshave suggested a great increase since 1950 andperhaps even since 1930, a study conducted by theMayo Clinic showed no significant trend in ratesover time. The study was population based andspanned the years from 1935 through 1984; it con-sisted of a survey of the medical records of resi-dents of Rochester, Minnesota. The incidence ratesfor females were high during 1935–49, relativelylow during 1950–54 and high again during1980–84. The difference in rates over time,although not statistically significant, wasaccounted for by changing rates for 10- to 19-year-old girls. For women 20 years of age and older andfor females there was no change in the rates overtime. The lifetime prevalence rate for anorexia ner-vosa among Rochester residents was 269.9 per100,000 population for females and 22.5 per100,000 population for males.

Polivy and Herman, writing in 2001, noted thatthe incidence of anorexia nervosa has “increasedmarkedly during the past 50 years.” Hoek andHoeken concluded that “the incidence of anorexianervosa increased over the past century, until the1970s,” and that “only a minority of people whomeet stringent diagnostic criteria for eating disor-ders are seen in mental health care.”

The person with anorexia nervosa typicallybegins dieting with a simple goal of losing weight,but over time the achievement of that goalbecomes a manifestation of mastery, control andvirtue. The anorexic may find dieting easy andrewarding from the start, or at least discover that ina sense she is good at it. Typically, she ends up by

24 anorexia nervosa

continuing to diet despite having gone past hertarget weight. The desire for slenderness becomessecondary to the need for control and mastery overthe body and develops into a real fear of fatnessand a drive to remain small and childlike.

Because anorexia nervosa patients do not seethemselves as abnormal, they do not want anyhelp in reversing their weight loss. When told theycannot live on such a small amount of food, theywill insist that they feel better as they become thin-ner. Because they do not suffer, they must be well.This denial of illness is an important feature earlyin the disorder. The clinical picture of anorexianervosa centers on a three-fold denial—denial ofhunger, of thinness and of fatigue.

Even if they admit to some weight loss, anorex-ics will feel that while they may have lost weightgenerally, some particular part of their body is stilltoo large. When family pressures or social obliga-tions force anorexics to eat, most will use decep-tion to hide their extreme dieting. They’ll slip foodto the dog, flush it down the toilet or throw it intothe garbage. Teenagers will tell parents, “I’m nothungry; I ate at a friend’s house.” Many will inducevomiting after meals. When undergoing treatment,anorexics will resort to all kinds of deceptions tolead doctors to believe they are gaining weight.Among those that have been documented aredrinking enormous amounts of water before beingweighed, recalibrating scales and inserting weightsin the rectum and vagina.

Anorexia nervosa has been said to developonly in the face of plenty, that it exists only wherefood is abundant. However, today’s researchersare beginning to discover that the stereotype isinaccurate and that it may have come aboutbecause such a large proportion of the studiesdone were of college students and patients whocould afford treatment. In a 1989 survey of morethan 2,000 adolescent girls and their mothers,University of Michigan psychologist AdamDrewnowski discovered that the frequency of eat-ing disorders was the same in lower-income com-munities near Detroit as it was in the city’swealthy suburbs—about 2 percent.

Gordon, Richard A. Anorexia and Bulimia: Anatomy of aSocial Epidemic. Malden, Mass.: Blackwell Publishers,1990.

Herzog, David B., and Paul M. Copeland. “MedicalProgress: Eating Disorders.” New England Journal ofMedicine 313, no. 5 (August 1, 1985): 295–303.

Herzog, W., H.-C. Deter, and W. Vandereycken, eds. TheCourse of Eating Disorders: Long-term Studies of Anorexiaand Bulimia Nervosa. New York: Springer-Verlag.

Hoek, H. W., and D. van Hoeken. “Review of the Preva-lence and Incidence of Eating Disorders.” InternationalJournal 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 ofAnorexia Nervosa in Rochester, Minn.” AmericanJournal of Psychiatry 148, no. 7 (July 1991):917–922.

Orbach, Susie. Hunger Strike: The Anorectic’s Struggle as aMetaphor for Our Age. New York: W. W. Norton, 1986.

Polivy, Janet, and C. Peter Herman. “Causes of EatingDisorders.” Annual Review of Psychology 53 (January2002): 187–213.

Sullivan, P. F. “Mortality in Anorexia Nervosa.” AmericanJournal of Psychiatry 152, no. 7 (July 1995):1,073–1,074.

Causes

There is no known specific cause of anorexia. Sev-eral theories do exist, but they are based on indi-vidual clinical observations and histories, so nonehas been accepted as definitive. Researchers doagree that anorexia nervosa is probably a negativeresponse to a number of psychological, environ-mental and physiological factors rather than a dis-ease that can be traced to a single cause. Althoughthese influencing factors affect virtually all indi-viduals, the anorexic appears to lack the skills nec-essary to cope with them. Neuman and Halvorsonhave identified several potential causes ofanorexia nervosa:

Stressful life situations These may range frommajor developments such as family conflict, achange in schools (especially transitions from jun-ior high to high school or from high school to col-lege), a family move, the loss of a boyfriend orgirlfriend or a serious illness, to less obvious diffi-culties such as a casual remark made by an athleticcoach or dance instructor about “dropping a fewpounds,” teasing by classmates or siblings or arejection, which may be real or perceived. Manystressful situations are caused by or lead to change,and change in general is difficult for an anorexic to

anorexia nervosa 25

handle. One possible explanation for this is theanorexic’s obsession with perfection and the fearthat she may not be able to achieve her goal in newcircumstances. Change may well trigger over-whelming fear that things are out of control.

Adolescence One hypothesis is that anorexianervosa is a rejection of female sexuality broughton by the physical development associated withpuberty. Neuman and Halvorson explain this as“an attempt to retain ‘little girl’ status by wardingoff the adolescent’s physical development.” HILDE

BRUCH described in Eating Disorders several of herpatients who had had active fantasies as childrenabout being boys—until puberty put a shockingend to them. Other professionals argue that it isthe entire role of an adult that is being rejected: theresponsibilities, decision making, sexual intimacyand so on. To support this, they point out thatanorexics avoid intimacy, largely because of theirfear of rejection over “mistakes” they might make.Even sexually active anorexics have beendescribed by therapists as withholding feelings andthoughts from partners. It has been suggested thatanorexics’ sexual activity happens at all onlybecause of their inability to be assertive in thatarena—to say no.

Culture Another reason some feel anorexia isa rejection of the adult female role is that the ado-lescent of recent years has no clear-cut road to fol-low into adulthood. Neuman and Halvorsonexplain that the anorexic adolescent typically hasmastered the role of being a “good little girl.” Butthe criteria for being a “good woman” are no longerwell defined; in fact, the social messages, thesetherapists feel, are confusing to the anorexic. Nolonger do the wedding and first pregnancy define“growing up.” Today’s adolescent is also encour-aged to “be something” or “somebody,” at the sametime that biological changes may be reminding herof more traditional roles. And because anorexics areusually good students, they are frequently steeredinto academic and career paths rather than down amore traditional female road. So, being unassertiveand evading decisions, they may retreat into thefamiliar “child” role where they already masteredthe well-defined “rules.”

Anorexia nervosa was once believed to be a dis-order of Western culture, a belief recently recon-

sidered by researchers. A 1996 Chinese Universityof Hong Kong study determined that Western pat-terns of body dissatisfaction and disordered eatingattitudes are common among Chinese adolescentfemales. One theory is these attitudes are nowgrounded in the “transnational culture of moder-nity” due to increased affluence in rapidly urbaniz-ing parts of the world. In most Western societies, astrong cultural emphasis is placed on individualsuccess. Neuman and Halvorson explain that untilrecently Western women’s social success wasjudged by their affiliations—by whose daughter orwife they were. Today’s woman has new demands.“Thus many maturing females find themselvescaught up in the ‘Superwoman’ syndrome, tryingto be all things to all people.” And, they add, girlswho are already perfectionists and not good atmaking decisions can become overwhelmed byfeelings of powerlessness. College-age anorexicsespecially have reported to Neuman and Halvorsonthese feelings of confusion and being out of controlof their own future.

Other cultural factors influencing the recent riseof anorexia nervosa include the growing concernabout nutrition and physical fitness and a nationalobsession with calorie counting and being thin.Television, magazine and newspaper messagesbombard women and girls with advice on how tolose weight more quickly, exercise more and eatless in order to be thinner. The messages blatantlystate that being thin will make a woman moreattractive, improve her popularity, lead to successon the job and snag her an ideal mate because shewill then be sexier and more desirable. Fashionmodels display small waists and busts, narrow hipsand thin thighs. This has resulted in a cultural focuson the physical being more than on the inner per-son. Small wonder, experts say, that some girls inthe highly vulnerable adolescent and young adultyears take these “thin-or-sorry” messages to heartand carry their responses to them to extremes.

Discussing the remarkable emergence of eatingdisorders in countries where they were once thoughtto be culturally incompatible, Gordon writes, “Onetheme that seems to unite these disparate geographicand cultural regions is that they are either highlydeveloped economies (such as Hong Kong and Sin-gapore) or they are witnessing rapid market changes

26 anorexia nervosa

and their associated impact on the status of women.The impact of a global consumer culture, with pow-erful mandates for the cultivation of a certain type ofbody ideal, appears to play a significant role. Equallyimportant, however, are the contradictory pressuresthat emerge when women begin to have access on amass level to education and a role in public life, andstruggles about sexual equality come to the fore-ground. This may be especially problematic in soci-eties in which the transition to a new female role isespecially sudden and conflicts sharply with tradi-tional forces that demand deference to one’s familyand submissiveness to men.”

See CULTURAL INFLUENCES ON APPEARANCE andCULTURAL INFLUENCES ON EATING DISORDERS.

Gordon, Richard A. “Eating Disorders and West: A Culture-Bound Syndrome Unbound.” In Eating Disor-ders and Cultures in Transition, edited by Mervat Nasserand Melanie A. Katzman, chapter 1, pages 1–16. NewYork: Brunner-Routledge, 2001.

Keel, P. K., and K. L. Klump. “Are Eating Disorders Cul-ture-Bound Syndromes? Implications for Conceptual-izing Their Etiology.” Psychological Bulletin 129, no. 5(September 2003): 747–769.

Lee, A. M., and S. Lee. “Disordered Eating and Its Psy-chosocial Correlates among Chinese AdolescentFemales in Hong Kong.” International Journal of EatingDisorders 20, no. 2 (September 1996): 177–183.

Lee, S. “Reconsidering the Status of Anorexia Nervosa asa Western Culture-Bound Syndrome.” Social Scienceand Medicine 42, no. 1 (January 1996): 21–34.

Lee, S., et al. “Rationales for Food Refusal in ChinesePatients with Anorexia Nervosa.” International Journalof Eating Disorders, 29, no. 2 (March 2001): 224–229.

Simpson, K. J. “Anorexia Nervosa and Culture.” Journalof Psychiatric & Mental Health Nursing. 9, no. 1 (Febru-ary 2002): 65–71.

Biological predisposition While research hasshown that women are far more likely than meneither to eat more or to lose appetite in response tostress, Neuman and Halvorson suggest that appetitefluctuation in women may also be a learnedresponse. Women have also been found to be moreprone to “holding in” negative feelings, which canlead to increased stress. It has been suggested thatthis stress, in the presence of a biological predispo-sition to eat more or less because of it, may lead toa greater likelihood of anorexia nervosa.

Family dynamics It has been noted that thereis a greater risk of a person’s developing anorexianervosa when another member of the family hashad the disorder or when a parent is either verythin or obese. What has not been established iswhether this risk is genetic. Studies reported in1998 from Toronto (Ontario) Hospital, in Canada,and the University of Pittsburgh School of Medi-cine concluded that genetic factors may influencepredisposition to eating disorders but do not provesuch a familial vulnerability exists. Because a fewsets of identical twins have been found in whichboth twins succumbed to anorexia, and becauseseveral cases are known of adopted family mem-bers matching the patterns of their biological fam-ilies’ histories, this family tendency is believed tobe more environmental than inherited. However,research in this area has been sparse; much moreneeds to be learned.

Anorexics do tend to come from families placingstrong emphasis on food. Neuman and Halvorsonexplain that “this concern may be the result of thespecial dietary needs of a family member, anemphasis on nutrition, and/or previous powerstruggles over eating. The family may also haveused food for purposes other than nourishment.Eating may be used when members face problemsor unpleasantness, as a sign of love and caring forthe providers, to fill time, or to keep the familytogether and ‘happy.’ ”

Clinicians have found that certain personalitytypes seem to appear frequently among parents ofanorexics. Mothers are often found to be domi-neering, intruding in the anorexic’s hour-to-hourlife. Mothers of anorexics also frequently sufferfrom depression, and fathers are described as “aloofor passive.” Alcoholism and other addictions, of oneor both parents, are not uncommon. However,none of these patterns is always present; some caseseven show the exact opposite family dynamics.

But there are medical experts who still insistthat family dynamics play an important role ingenerating the disorder. They cite those family fea-tures most likely to encourage anorexia asenmeshment (entanglement in one another’saffairs), rigidity, overprotectiveness and inability toresolve conflict within the family. Margo Maine,assistant clinical director of the Eating Disorders

anorexia nervosa 27

Service at Newington Children’s Hospital in Con-necticut, suggests that a father’s emotional or phys-ical absence from the family may be a majorinfluence on both anorexia nervosa and bulimia inadolescent girls. Thirty-six of 39 young femalepatients questioned by Maine described theirfathers as emotionally distant.

See also FAMILY THERAPY.

Lilenfeld, L. R., et al. “A Controlled Family Study ofAnorexia and Bulimia Nervosa.” Archives of GeneralPsychiatry 55, no. 7 (July 1998): 603–610.

Woodside, D. B., et al. “Specificity of Eating DisordersDiagnoses in Families of Probands with AnorexiaNervosa and Bulimia.” Comprehensive Psychiatry 39, no.5 (September–October 1998): 261–264.

Peer Relationships The tendency of anorexicsnot to develop or keep close longterm friendshipsoutside the family group has been theorized to bean important factor in the development of the dis-order. Neuman and Halvorson note that whenrelationships are developed by anorexics, they areusually with only one person at a time, and eventhen they are short-lived. Arthur H. Crisp notedthat male anorexics have been found to be inhib-ited, nonassertive loners—even during their teenyears when a group or “gang” affiliation is usual.

Therapists such as Neuman and Halvorsonbelieve that during adolescence peer relationshipsare essential for the move from a family-centeredexistence to an adult existence in a social environ-ment. According to Delores Jones, “the anorexicwho is overly involved with and dependent uponher family to the exclusion of outside relationshipsis at a distinct disadvantage. Because she has nopeer group to help her make the transition, she iseffectively imprisoned within the family.” How-ever, her increasingly adult size as she matureselicits social pressure on her for more independentbehavior. Jones speculated that the anorexicresolves this conflict by losing weight so that interms of size and biological functioning, shebecomes a child again and can legitimately remainwithin the family.

In their summation of the various proposedcauses for anorexia nervosa, Polivy and Hermansay, “As with other psychological problems, we mayhave to be satisfied with recognizing contributory

risk factors and devising therapies to help alleviatethe discomfort, without conclusive proof of exactlywhat causes the disorder in any individual.”

Byrne, Katherine. A Parent’s Guide to Anorexia andBulimia: Understanding and Helping Selfstarvers andBinge/Purgers. New York: Schocken Books, 1987.

Jones, Delores. “Structural Discontinuity and the Devel-opment 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 inChinese?” British Journal of Psychiatry 154 (May 1989):683–688.

Neuman, Patricia A., and Patricia A. Halvorson. AnorexiaNervosa and Bulimia: A Handbook for Counselors andTherapists. New York: Van Nostrand Reinhold, 1983.

Polivy, Janet, and C. Peter Herman. “Causes of EatingDisorders.” Annual Review of Psychology 53 (January2002): 187–213.

Clinical Features

The central feature of anorexia nervosa is the over-riding pursuit of thinness. This may seem to begininnocently with ordinary adolescent self-con-sciousness—dieting to lose extra pounds put onduring puberty’s growth spurts. But after severalmonths, the restrictor anorexic will stubbornlyrefuse to eat normal amounts of food. Typically shelimits her intake to about 600–800 calories per day,resulting in a loss of 25 percent or more of bodyweight. In extreme cases, the loss may be as highas 50 percent.

When questioned about her loss of weight, ananorexic will deny that she is too thin or that thereis anything wrong with her. This denial can be anobstacle for doctors during diagnosis and assess-ment. Because they don’t perceive themselves as illor abnormal, anorexics refuse help. Denial is a typ-ical characteristic of anorexia nervosa and is seenas an early sign of the disorder.

One of the fundamental characteristics ofanorexia nervosa is a disturbance in body image,“feeling fat” even when emaciated. During treat-ment, the anorexic claims that her body is largerthan it really is. She seems genuinely unaware ofher changed body proportions. Even though herbody may appear starved, she may stubbornlyinsist she is not as thin as another anorexic who isas thin or thinner than she; yet she will recognize

28 anorexia nervosa

the other anorexic as too thin. A few will admit totheir emaciated state and even recognize thehealth dangers, but they will still refuse to eat.Many anorexics argue that their thin bodies arestill too fat. Others consider their stick-figure legsand arms to be attractive and “just right.”

Overestimation of body size may indicategreater severity of disorder with less hope of recov-ery. In studies, patients who most grossly overesti-mated were also those who were the mostmalnourished, were previous treatment failures,indicated a greater loss of appetite, had a greatertendency to deny their illness, vomited, were moredepressed and in general exhibited more symp-toms of anorexia nervosa as measured by the EAT-ING ATTITUDES TEST.

In addition to the misperception of body size,the anorexic’s body image disturbance can involveher attitude toward her body. Frequently she man-ifests self-loathing, particularly of her developingfemale body parts, such as the normal slight curveof stomach or rounding of hips or buttocks.

HUNGER is usually denied, even in the presenceof stomach pains. When she does eat a small bit offood, an anorexic will complain about ensuingacute discomfort.

In contrast to starving nonanorexics, who gen-erally attempt to conserve energy by reducingactivity and who usually show symptoms of list-lessness and indifference, anorexics are oftenhyperactive, tending to indulge in heavy or pro-longed exercise. Instead of being exhausted whilestarving, these young women enjoy boundlessenergy until late in their illness. The anorexicbegins exercising in order to burn up calories andlose additional weight. As with dieting, however,exercising over time becomes an issue of self-disci-pline and control; anorexics cannot allow them-selves to miss even one day of the highlystructured regimen they have assigned themselves.

If an anorexic was already involved in a sport,she will likely become driven, almost obsessed toexcel at it. Anorexics may appear to be in perpet-ual motion; constantly busy, moving about rest-lessly until late into the night, almost never sittingdown. Studies have shown that anorexics walk anaverage of 6.8 miles a day compared with the aver-age of 4.0 miles walked by women of normal

weight. This hyperactivity is not generally presentbefore the onset of anorexic illness. Just as theanorexic denies hunger, she will deny any diffi-culty in sitting still and attending to her work.

Often compulsive behavior is exhibited in exces-sive orderliness, cleaning and studying. As Neumanand Halvorson explain, “Anything less than perfec-tion is upsetting to the anorexic, and everythingundertaken seems to be done in excess.”

A few years ago anorexia was generally inter-preted as reflecting a wish not to grow up, toreturn to a prepubertal stage; therapists now saythat many anorexics appear anxious to exerciseauthority and to control their lives through regula-tion of body weight.

Anorexics have been described as suffering froma “weight phobia.” Regardless of the original rea-son for dieting, subsequent weight gain by theanorexic causes severe anxiety and weight lossreduces it. This “phobia” about “normal” bodyweight appears to intensify as the patient becomesthinner. She weighs herself frequently, becominganxious if the scales show an increase over theprevious reading. In her mind, each drop in weightbecomes a new barometer; next time she mustweigh less to be normal. Anorexics seem to have agreater fear of becoming obese than of dying fromstarvation. As the anorexic’s weight drops, her fearbecomes 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 andso deletes them from her diet. Soon she systemati-cally eliminates fats and other foods until only afew vegetables and fruits remain. She also controlsfood portions rigidly; she must restrict intake to aspecific number of pieces or bites a day. If she doesexceed her allotted daily portion, the anorexic suf-fers severe anxiety and sets about to control hereating even more severely.

Some researchers maintain that the core psy-chopathology of anorexia nervosa is cognitive.That is, such individuals have extremely distortedways of thinking and distorted and irrationalbeliefs about food, themselves and the world. Theymay have completely irrational ideas regarding thecaloric content of foods. One of the authors

anorexia nervosa 29

encountered a woman who was worried aboutgaining weight from licking a stamp. Such individ-uals may also have very all-or-nothing beliefsabout eating, for example believing that eating onepiece of candy is as bad as eating the whole box.Regarding beliefs about the self, the anorexia indi-vidual may equate self-worth with physicalappearance. To put on weight means to be worth-less. Similarly, the anorexic individual may haveattitudes about the world and others, such asbelieving that others evaluate them only in termsof body size and shape. It is worth noting that,although this latter belief is distorted, it is merelyan exaggeration of some of the attitudes that areshaped by the popular media.

Anorexic patients often become experts indevious behavior. They will conceal their eatinghabits by lying about what, when and where theyeat. Usually they do not like to eat in front of oth-ers and come up with excuses to avoid eating withthe family, partly to avoid the food itself and partlyto avoid confrontations about their eating habitsand their appearance. Because of family pressureto eat, they may take food onto their plate, sur-reptitiously slipping it to the dog under the tableor hiding it in their napkins to flush down the toi-let or throw away later. Many pathological behav-iors occur in secret: hiding food, self-inducedvomiting, laxative and/or diuretic abuse andexcessive exercising.

Constipation and abdominal distress typicallyresult from restricted food intake and the starva-tion state. These in turn lead to further symptomsof bloating and reduced dietary intake. Long-termlaxative abuse can produce permanent damage tothe colon resulting in malabsorption and loss ofability to evacuate naturally.

Also accompanying anorexia nervosa is delayedpsychosexual development. According to Neumanand Halvorson, “Boyfriends may be desired butusually only in a fairytale sense—to live ‘happilyever after.’ ” Anorexics exhibit virtually no sexualinterest, with low estrogens in female anorexicsand low output of testosterone in males. Duringtherapy, anorexics cannot even talk about sex,“not out of embarrassment, but because it is soforeign: anorexics are totally out of touch with thesexual part of their being.” (See SEXUALITY AND

EATING DISORDERS.)

Anorexics also gradually narrow their inter-ests. Many entirely restrict their activities to exer-cise, schoolwork and dieting, and all otheractivities fall by the wayside. Most girls lose inter-est in their friends early in their dieting; this lossis considered a most important early signal of theproblem. By the time the weight loss has pro-gressed to the point of requiring medical atten-tion, an anorexic may be totally isolated fromothers. This isolation results in loneliness and asense of social inadequacy.

Other warning signals include dizziness andfainting spells, nervousness around mealtime,excuses during mealtime for not eating, cuttingfood into small pieces or playing with it, anincreased interest in collecting recipes and cookingfor others, weighing frequently and wearing mul-tiple layers of clothing (anorexics are frequentlycold as a result of the loss of fat and muscle tissue).In some cases obsessive interest in food will resultin an anorexic’s insisting on cooking for, and over-feeding, her immediate family. Anorexics havebeen reported to hoard and conceal food, includ-ing food that is rotten or moldy, while refusingfresh food.

Another established feature of anorexia isAMENORRHEA (absence or suppression of menstrua-tion). In a high percentage of cases; this is the firstsign of the disorder, appearing before any notice-able loss of weight. Ultimately, it occurs in nearlyall cases as weight plummets.

Anorexics have frequent mood swings; whenthey are most hungry and their blood sugar levelsthe lowest, they may become quite irritable. Theyalso will sometimes demonstrate an inability toconcentrate, and this may be coupled with con-fused thinking. Initially they will deny all prob-lems, including mood changes; anorexics displaya stubborn defiance about most matters, alongwith a noticeable lack of concern for personalproblems. They tend to be highly perfectionistic,particularly about physical appearance, as well ashighly self-critical. They tend to be overachievers.They will frequently seem angry, irritable, indeci-sive, stubborn, tense or overly sensitive. Depres-sion or obsession is common when the disorderbecomes chronic.

When asked to describe their anorexic daugh-ters as children, parents refer to most of them as

30 anorexia nervosa

“model children,” using terms like introverted,conscientious and well behaved. They are usuallynonassertive, reacting passively to others. Butalthough an anorexic may appear outwardly smil-ing and happy and is usually a highly competentpeople pleaser, she may actually be miserable.Neuman and Halvorson stress that while a passivepersonality has been found to be consistentlyamong the most common of anorexics’ traits, it isnot always present. Anorexics can display irritabil-ity, indecisiveness, stubbornness and defiance.

Neuman, Patricia A., and Patricia A. Halvorson. AnorexiaNervosa and Bulimia: A Handbook for Counselors andTherapists. New York: Van Nostrand Reinhold, 1983.

Complications

Most of the medical complications of anorexia arethose caused by starvation. The body defends itsvital organs, the heart and brain, against a lack ofnutrients by slowing down: menstrual periodsstop; breathing, pulse and blood pressure ratesdrop; and thyroid function slows.

Particularly critical are the fluid and electrolyte(sodium, potassium, hydrogen, etc.) imbalancesthat commonly occur, especially among anorexicswho induce vomiting or use laxatives extensively.Potassium deficiency can lead to muscle weakness,abdominal bloating, nervous irritability, apathy,fatigue, drowsiness, dizziness, mental confusionand irregular heartbeat. Death from kidney orheart failure may occur. Such electrolyte imbal-ances are not always outwardly apparent; the per-son suffering from them may appear to be inrelatively good health.

Studies have also raised questions about thepossibility of ZINC DEFICIENCY in anorexia nervosa.In 1987, Rebecca Katz et al. reported in the Journalof Adolescent Health Care that their evaluation ofanorexic adolescents suggested that individualswith anorexia nervosa may be at risk for zinc defi-ciency, which can impair taste, appetite and physi-cal growth, cause hair loss and delay sexualdevelopment. But C. J. M. van Binsbergen et al.reported in the European Journal of Clinical Nutritionin 1988 that no significant difference was found inthe concentration of zinc in plasma between 20female anorexics and 20 lean to normal-weightfemale control subjects.

Mild anemia, swelling joints (from edema),reduced muscle mass, dizziness and light-headednessare also results of anorexia. If the disorder becomessevere, osteoporosis, kidney failure, irregular heartrhythm and heart failure can occur. The anorexicwho turns to purging to limit weight is in particulardanger; the abuse of drugs to stimulate vomiting(see IPECAC SYRUP), bowel movements and urina-tion increases the risk of heart failure. In addition,there is a possibility of temporary or even perma-nent edema (accumulation of fluid in the body’scells, tissues or cavities) once the use of diuretics asan aid to weight reduction is stopped.

Osteoporosis (a loss of bone mass accompaniedby mineralization of the remaining bone) isanother consequence of anorexia nervosa. A studyof anorexics by Anne Klibanski and other Massa-chusetts General Hospital researchers involvingseven adolescent girls and 26 women found thatadults with anorexia nervosa had bone density thatwas 30 percent lower than normal. Those whosemenstruation stopped before age 18 had evenweaker bones—20 percent weaker than the bonesof the older anorexia victims.

A report in the journal Clinical Endocrinologystates that in 24 anorexic patients who wereseverely malnourished, the ovaries were small andshapeless, and some hormone levels were very low.

In addition to an emaciated appearance, ananorexic usually has dry, cracking skin and may losesome hair from her scalp. Her nails become brittle. Afine downy growth of fetal-like hair (lanugo) overthe cheeks, neck, forearms and thighs is common.Yet she will keep her pubic and underarm hair aswell as the shape of her breasts, thus ruling out glan-dular insufficiency as the root cause of her symp-toms. The anorexic’s hands and feet usually have abluish tinge, which may also appear on her nose andears. Other likely results of anorexia include a slowheartbeat, low blood pressure (hypotension) and alow basal metabolic rate. An anorexic may also havetrouble sleeping when the loss of fat tissue paddingmakes sitting or lying down uncomfortable.

Those anorexics who frequently and over a longperiod resort to vomiting as a way to control foodintake can develop a variety of dental problems,including loss of enamel, decay and enlarged sali-vary glands.

See also DENTAL CARIES.

anorexia nervosa 31

Depression, weakness and obsession with foodalso accompany starvation. Personality changescan occur. Outbursts of hostility and anger or socialwithdrawal may surprise those who have becomeused to the typical “good girl” anorexic. Othercomplications can include amnesia, generalizedfatigue, lowered body temperature (hypothermia),low blood sugar, low white blood cell count andlack of energy.

To determine the range and severity of medicalcomplications encountered in younger patients, astudy was made of the medical records of 65 ado-lescents and preadolescents in the Eating DisordersClinic of the Children’s Hospital at Stanford Uni-versity. A total of 55 percent of anorexic patientsrequired hospitalization for medical reasons duringthe study period.

George Patton reported in the British MedicalJournal (July 15, 1989) that in an assessment of481 anorexia nervosa patients, half of those whodied killed themselves, either accidentally or inten-tionally through drug overdoses. This challengesthe earlier view that death in anorexia nervosa isalways a direct consequence of malnutrition.

There have been no clear, consistent predictorsof worsening conditions without eventual improve-ment in anorexia nervosa cases, but factors mostoften found in these cases include extremely lowweight, long periods with the illness, older age atonset, and disturbed family relationship.

Treatment

Various treatments have been suggested for anorexianervosa, including psychoanalysis, PSYCHOTHERAPY,simple supportive therapy, isolation, ACUPUNCTURE,lobotomy, FAMILY THERAPY, BEHAVIOR MODIFICATION,COGNITIVE THERAPY, TUBE FEEDING, FORCED FEEDING,bed rest HYPERALIMENTATION, PHARMACOTHERAPY, elec-troshock, psychosurgery and SELF-HELP GROUPS.

Because anorexics and their families tend todeny the presence of the disorder or its severity,the results of treatment of anorexia have beenamong the most unsatisfactory in clinical medi-cine. Even patients in treatment tend to resist pre-scribed medical and psychiatric care; because theydon’t consider themselves to be ill or because theydon’t want their efforts to lose weight thwarted,they make those trying to help them “the enemy.”

Virtually every type of therapy known to psy-chiatry has been proposed and tried at some timein the treatment of anorexics, but no one has beenfound distinctly effective or definitive. Part of thereason for this is the lack of agreement about therelationship between food and its “host.” We knowvery little of the chemical processing of food by thebody and how dieting and purging may affect theappetite center of the brain. To make mattersworse, there is body image distortion and an inte-roceptive (internal sensory receptor) problem. (SeeINTEROCEPTIVE DISTURBANCE.) In addition, the treat-ment needs of different patients can vary widely;considerable flexibility is necessary.

Because anorexia nervosa patients differ widelyin psychological, social, behavioral and biologicalfunctioning, treatment centers most frequentlyoffer integrated and multifaceted programs. Boththe physical and psychological aspects of the disor-der have to be addressed: The physical aspects takeprecedence when the weight is low and the starva-tion strategy is most dominant, and the psycholog-ical aspects take precedence later, after weightconcerns have been addressed and eating habitshave been stabilized. Ideally, internists, nutrition-ists, individual or group therapists, psychopharma-cologists, psychiatrists and family therapists may allbe involved in treatment.

Weight gain must occur if psychological treat-ment is to be meaningful. Researchers Garfinkeland Garner explain that there are two reasons forthis. First, the effects of starvation must be reducedfor the patient truly to benefit from psychotherapy,a learning process that cannot proceed well whena patient’s mental functioning is impaired. Second,patients have developed a phobic attitude towardweight and must learn to face it as a preconditionfor dealing with underlying psychological issues.“As long as a low weight is maintained throughrigid dieting, the phobia is being reinforced, as isthe avoidance of dealing realistically with signifi-cant life problems.”

The concept of weight phobia has been ques-tioned by experts such as Arthur H. Crisp, whoargues that what a patient dreads is facing herselfat a normal weight. He believes that what is beingreinforced when weight is kept very low is the“advantage” of being prepubertally thin so this

32 anorexia nervosa

dread doesn’t become an actuality. Otherresearchers have concluded that modern Westernanorexia nervosa with weight phobia is clearly dis-tinct from other groups of cases of extreme fastingwithout weight phobia.

The most difficult and critical factor in treat-ment is engaging the patient in therapy. The prob-lem here is that many anorexics deny their illness;they insist there is nothing wrong with them ifonly others would leave them alone. They mistrustthemselves and especially mistrust medical peoplethey think are interested only in getting them togain weight, or who represent parental authority.Anorexics feel that treatment represents a betrayalof their trust, fearing a return to being what theyconsider overweight.

Although controversy has surrounded almostevery means of weight restoration, the issue ofhospitalization has been far less controversial. His-torically, hospital admission has been advocatedboth to allow the physician to control the situation,and to separate the patient from her parents.

Hospitalization should be considered if there arenumerous physical complications, if the patient issuicidal or extremely unmotivated, and/or if thereis no outpatient treatment available. When weightloss is 40 percent or more from the norm, emer-gency action is required. The urgency of hospital-ization depends on several factors, includingweight loss greater than 30 percent of body weightover three months, severe metabolic disturbance,severe depression or suicide risk, severe purging,psychosis, family crisis or symptoms of severe star-vation. Hospitalization is also suggested when out-patient treatment has failed.

Frequently, even when emergency care is notnecessary, several days of unstructured hospitalrest are ordered to give physicians and psychiatristsa chance to observe the patient. The treatmentteam can thus learn whether she is a starver or avomiter, whether she hoards food or secretlythrows it away, whether she drinks water or notbefore weigh-in. They also observe how muchwalking and exercising she does, and whether hos-pitalization has resulted in her becoming agitatedand manipulative or passive and withdrawn.

Length of hospitalization usually varies betweentwo and four months. Brief hospitalization of 10

days to two weeks can be helpful for anorexicswho are not severely malnourished but who sufferfrom laxative withdrawal (e.g., dependence on thelaxative drug in place of normal bowel action) oruncontrollable binge eating and vomiting.

Application of EXPOSURE AND RESPONSE PREVEN-TION treatment principles to anorexia nervosarequires a patient to face the twin fears of eatingand gaining weight. Reports have shown that psy-chological improvement does occur with weightgain; to realize it, several approaches to treatmentmay be effective, including forced feedings andstructured diets.

Response prevention can be used to treatanorexic “rituals” such as vomiting after meals,food fads, use of laxatives, compulsive exercisingand frequent weighing. Response preventionentails forced avoidance of these rituals; for exam-ple, the patient might agree to delay vomiting foran increasing amount of time after meals in ordereventually to stop vomiting altogether.

In general, it is felt that patients must retain asmuch control as possible as long as the desired resultis achieved. Patients discharged from the hospitalwhile the medical staff is still in control via struc-tured enforced diets or tube feeding usually relapse.

Those patients better motivated to change willsometimes benefit from outpatient treatment. Edu-cation about the effects of starvation and applica-tion of the principles of exposure and responseprevention, coupled with simple support, some-times will produce weight gain. Individual psy-chotherapy is the approach most commonlyprescribed for outpatient treatment, especiallywhen the patient has stable relationships and ade-quate self-esteem.

Also beneficial can be the use of behavioral tech-niques that the patient can apply herself: keepingrecords of food intake, using structured meal plansand practicing “non-anorexic” eating. In cases inwhich certain foods are feared, it is recommendedthat these be left out of the diet initially but intro-duced later. Eventual exposure to feared foods isimportant; to avoid it would be to reinforce anorexicbehavior. Cognitive behavioral therapy is designedto help the patient gain control of unhealthy eatingbehaviors and to alter the distorted and rigid think-ing that perpetuates the syndrome.

anorexia nervosa 33

The goals of individual therapy are to help thepatient regain physical health, reduce symptoms,increase self-esteem and proceed with personaland social development. Long-term individualtherapy may be indicated when the patient has amild personality disorder, such as irritability, anxi-ety, depression, mood swings or sleep disturbance.

Group therapy can be helpful to motivatedanorexics, allowing them to feel less alone withtheir symptoms, to get feedback from their peersand to build their social skills. It has been founduseful to have patients at varying stages ofimprovement in a group. The role modeling doneby recovering anorexics, as well as the support andappropriate confrontation by an entire group, hasproven to be quite powerful.

Family therapy attempts to establish moreappropriate eating patterns, facilitate communica-tion and permit family members to feel moreconnected with one another. It may be helpfuleven if a patient is able to achieve only a limiteddegree of autonomy, because of disturbed familyrelationships.

Anorexics often retreat into denial when expe-riencing anxiety in therapy and may flee treatmentearly on.

Many drug therapies have been tried either asthe major focus of treatment or as adjuncts to gen-eral support and psychological therapies. Amongthese have been CYPROHEPTADINE, CHLORPROMAZINE,AMITRIPTYLINE, METOCLOPRAMIDE, nalaxone, PROZAC,and Zoloft. In one trial, dietary zinc supplementa-tion for anorexic adolescents was followed by adecrease in the levels of depression and anxiety.

The primary aim of such treatment has been topromote food intake and weight restoration.Although drug treatments do have a place in themanagement of eating disorders, they have not yetattained a high enough degree of effectiveness tobe considered as useful as they are in the treatmentof such disorders as mania or depression.

Reiterating that drugs are not the treatment ofchoice for anorexia nervosa, Brewerton noted that“although a number of agents have been found inrandomized controlled trials to be beneficial, theyare by and large insufficient as stand-alone treat-ments.” He referred to ANTIDEPRESSANTS as beingtheoretically sound, but cautioned, “results fromrandomized controlled trials have been dismal.”

This was echoed by Grilo et al. of Yale Univer-sity, who wrote, “Pharmacological treatments havegenerally been found to have little effect onanorexia nervosa either as the primary approach oras an augmentation approach, although the anti-depressant fluoxetine was found to decrease fre-quency of relapse in one study.”

In a 10-year follow-up of 76 anorexic women inIowa and Minnesota who had been treated in hos-pitals and released at normal weight, Cornell Uni-versity Medical College researchers found that onlythree women kept their weight within normalrange during the 10-year study period. Thirty-oneof the 76 women were still below minimumweight for their age and height at the 10-yearmark. Five women in the study had died; theiraverage weight at death was 58 pounds.

Anderson, Arnold E. “Inpatient and Outpatient Treat-ment of Anorexia Nervosa.” In Handbook of Eating Dis-orders, edited by Kelly D. Brownell and John Foreyt.New York: Basic Books, 1986.

Brewerton, Timothy D. “Pharmacotherapy for Patientswith Eating Disorders.” Psychiatric Times 21, no. 6(May 2004): 59–68.

Garfinkel, Paul E., and David M. Garner. Anorexia Ner-vosa: A Multidimensional Perspective. New York: Brun-ner/Mazel, 1982.

Grilo, Carlos M., Sinha Rajita, and Stephanie S. O’Mal-ley. “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. PostedNovember 2002.

Habermas, T. “In Defense of Weight Phobia as the Cen-tral Organizing Motive in Anorexia Nervosa.” Interna-tional Journal of Eating Disorders 19, no. 4 (May 1996):317–334.

Levitt, John L. “Treating Adults with Eating Disorders byUsing an Inpatient Approach.” Health and Social Work11, no. 2 (Spring 1986): 133–140.

Neuman, Patricia A., and Patricia A. Halvorson. AnorexiaNervosa and Bulimia: A Handbook for Counselors andTherapists. New York: Van Nostrand Reinhold, 1983.

Recovery

Recovery from anorexia nervosa does occur, but itisn’t always the same for every patient—or forevery authority or clinic. Generally, recoveryinvolves many factors and may vary from partial tofull recovery. The criteria most usually associated

34 anorexia nervosa

with recovery are weight gain, resumption of men-struation and social/emotional maturity. Becausedifferent criteria are used by different researchersto indicate recovery, and because different treat-ment centers select different types of patients,studies reporting recovery rates can be confusingand contradictory.

It is tempting, because it is so noticeable, to con-sider only weight gain as a measure of recovery, butweight restoration alone is not always a goodbarometer. Returning a patient to normal weight iscertainly important, but it is relatively easy toaccomplish simply by hospitalizing the patient andcontrolling her food intake. The critical and moredifficult task is to get the patient to maintain thehigher weight in her normal environment. For thisreason, the length of time reported in studiesbetween “recovery” and follow-up is important.The longer the time from treatment to follow-up,the higher the reported mortality rates, the morefrequent the rehospitalizations, the greater the con-tinuing psychological problems, the more inade-quate the marital and social adjustments and thelower the recovery rates. However, researchershope that newer treatment methods, along withearlier detection (due to educational efforts andpublicity), will result in more permanent recoveries.

In terms of nutrition, Neuman and Halvorsoncorrelated various studies to determine that 50 per-cent of diagnosed and treated anorexics can beexpected to recover completely within two to fiveyears. When those anorexics who demonstratesome nutritional improvement are included, therate of recovery increases to 66 percent. Approxi-mately 90 percent of treated anorexics go on tobecome employed. Between 50 and 87 percent ofthese anorexics resume menstruation, usually ayear or more after body weight has stabilized. Neu-man and Halvorson add, “Even for those anorexicswho do not experience the return of menstrualperiods, the possibility of bearing children remains,since ovaries may still be active.”

On the other hand, recovered anorexics maycontinue to experience problems relating to theirdisorder. Anorexia can become chronic. In theirresearch, Neuman and Halvorson found that asmany as half those affected have a relapse, and upto 38 percent may have to be rehospitalizedwithin two years. But rehospitalization can actu-

ally be a step toward recovery; sometimes severalsetbacks occur before real progress is apparent.Nevertheless, approximately 18 percent of diag-nosed anorexics do remain ill and unchanged.Death from complications of the disorder or fromsuicide has been estimated to occur in anywherefrom 3 to 25 percent of cases. Psychologically,approximately 50 percent of anorexia victims, onfollow-up, show problems with phobias, depres-sion and social adjustment.

A comparison of several studies indicates thatrecovery rates may be predicted when body weightis low at the time treatment begins; the older theage at the onset of the disorder the longer theduration of the illness. Other predictors are dis-turbed family relationships, binge eating and/orpurging or a history of previous psychiatric treat-ment or childhood adjustment problems.

Castro et al. analyzed the variables related torehospitalization 12 months after total weightrecovery in 101 adolescents, aged 11–19 years, withanorexia nervosa. Twenty-five of the subjectsrequired readmission after complete weight recov-ery and 76 did not. Duration of disorder, weight loss,body mass index at first admission, and global bodyimage distortion were similar in the two groups. Theauthor wrote, “The variables most clearly related toreadmission were young age, abnormal eating atti-tudes, and a low rate of weight gain.”

In a small study of 35 anorexic patients two anda half years following assessment, Clausen con-cluded that “In spite of different treatments andsymptoms between patients, the results supportthe notion of a common pattern in the process ofchange including a long and stepwise course.”

Castro, J., et al. “Predictors of Rehospitalization afterTotal Weight Recovery in Adolescents with AnorexiaNervosa.” International Journal of Eating Disorders 36,no. 1 (July 2004): 22–30.

Clausen, L. “Time Course of Symptom Remission in Eat-ing Disorders.” International Journal of Eating Disorders36, no. 3 (November 2004): 296–306.

Neuman, Patricia A., and Patricia A. Halvorson. AnorexiaNervosa and Bulimia: A Handbook for Counselors andTherapists. New York: Van Nostrand Reinhold, 1983.

Szmukler, George I., and Gerald F. M. Russell. “Outcomeand Prognosis of Anorexia Nervosa.” In Handbook ofEating Disorders, edited by Kelly D. Brownell and JohnP. Foreyt. New York: Basic Books, 1986.

anorexia nervosa 35

anorexia nervosa: research Historically, therehave been many barriers to conducting research oninterventions in anorexia nervosa (AN), includingsmall sample sizes (due to low base rate of the dis-order in combination with the difficulty of enteringparticipants into treatment), high attrition ratesand minimal long-term follow-up assessments.Most of this research has been uncontrolled stud-ies, single case designs or case reports.

Given the limited progress in identifying effec-tive treatments for anorexia nervosa, a workshopcosponsored by the National Institutes of Health(NIH) Office of Rare Diseases and the NationalInstitute of Mental Health, brought together inSeptember 2002 a group of scientists and NIH staffto: 1) update what is known about the treatmentof anorexia nervosa, 2) address the barriers associ-ated with conducting research in this area and 3)make recommendations about how these impedi-ments can be overcome, so that improved inter-ventions can be developed and implemented.

Among the workshop’s findings: Additionalinformation is needed regarding the most effectivetypes of interventions, the most appropriateapproaches for different age groups and the bestsystems for delivery. Psychosocial and pharmaco-logical treatments should be studied across differ-ent settings (e.g., inpatient, outpatient, daytreatment) and should target both the short andlong-term phases of the illness, including the pre-vention of relapse. Given that the overwhelmingmajority of participants in research have been Cau-casian females, there is a need to evaluate special-ized intervention strategies for ethnic minoritygroups and for males. Developmentally informedinterventions specifically targeting youths shouldalso be examined. Clinical observations and limitedepidemiological research have also suggested thatpersons with AN are at greater risk for suicidalbehavior and death. Improved research approachesfor better assessment and management of suicidalrisk among persons with this disorder are needed.

To address these challenges, the NIH establishedthe Research on Interventions for Anorexia Ner-vosa (RIAN) network of committed investigatorswith access to patients with AN, noting, “The RIANnetwork will have the capacity to improve samplesize, accelerate recruitment, and increase popula-

tion diversity and representation beyond whatcould be accomplished at a single site.” In Novem-ber 2003, NIH solicited participants in the network,with awards to be announced in late 2004. Theawards were to total approximately $1,250,000 tofund the one network, and an applicant couldrequest a project period of up to five years, mean-ing the results of this research could be announcedas early as 2010. In January 2005, NIH reissued aRequest for Applications (RFA), and stated theintent now was to commit $1,500,000 in fiscal year2005 to fund one research network.

anorexic behavior A term used by Garfinkel andGarner to describe the behavior of young womenwho have weight concerns that interfere with theirpsychological well-being but do not have full-blown anorexia nervosa. Garfinkel and Garnerspeculate that these women may be using weightcontrol to deal with issues similar to those ofanorexics—the regulation and expression of self,autonomy and self-control; they correspond toBruch’s THIN FAT PEOPLE. Among the features of so-called anorexic behavior are intense preoccupationwith food, food fads, mixing unusual food combi-nations 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 asanorexia nervosa, binge eating/purging type. Accordingto DSM-IV, most anorexics who binge engage inthese behaviors at least weekly, but sufficient infor-mation is not available to justify the specification ofa minimum frequency. Anorexia accompanied byBINGE EATING and purging has been found to affectolder age groups more frequently than adolescents.

Bingeing anorexics display less self-disciplineand act more impulsively than RESTRICTOR ANOREX-ICS. They also have greater incidence of MULTICOM-PULSIVE behavior such as alcohol and drug abuseand shoplifting, as well as more SUICIDE and SELF-MUTILATION attempts. There is also more VOMITING

and LAXATIVE ABUSE among bingers.In comparing anorexic bingers and non-

bingers, Neuman and Halvorson referred to a

36 anorexia nervosa: research

1980 study by Casper et al., reported in the scien-tific journal Archives of General Psychiatry 37, thatfound that anorexic patients who binge tend to bemore depressed, anxious, guilt ridden and preoc-cupied with food than nonbingers. Anorexicbingers also complain more about aches and painsand have more trouble sleeping, resulting in morecomplaints of fatigue. Bingers also tend to bemore outgoing and sensitive to others. In theCasper study, 86 percent of the anorexic bingerswere described as outgoing as children in contrastto only 57 percent of the anorexic nonbingers.Besides being more outgoing, anorexic bingers areoften sexually active and concerned with physicalattractiveness and attention from the oppositesex, in marked contrast to the restrictor, whodenies or avoids sexual feelings. Perhaps not coin-cidentally, poor father-child relationships havebeen reported more often in the lives of anorexicbingers than non-bingers.

While restrictor anorexics are able to ignore andeven deny hunger, bingers report strongerappetites that are more difficult to control. Possiblybecause of this feeling of lack of control, the bingeris more likely to seek treatment. Yet anorexiaaccompanied by bingeing is more difficult to treat,since it occurs intermittently and persistently overa longer period of time.

In a study of 120 adolescents undergoing stan-dardized assessment for an eating disorder, Geist etal. also concluded that patients with binge/purgesymptoms exhibit significantly more behavioraldisorders and have a higher frequency of depres-sive disorders than restrictors.

DaCosta, M., and K. A. Halmi. “Classifications ofAnorexia Nervosa: Questions of Subtypes.” Interna-tional Journal of Eating Disorders 11, no. 3 (November1992): 305–313.

Geist, R., R. Davis, and R. Heinmoa. “Binge/Purge Symp-toms and Comorbidity in Adolescents with EatingDisorders.” Canadian Journal of Psychiatry 43, no. 5(June 1998): 507–512.

Neuman, Patricia A., and Patricia A. Halvorson. AnorexiaNervosa and Bulimia: A Handbook for Counselors andTherapists. New York: Van Nostrand Reinhold, 1983.

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

organization founded in 1979, that collects infor-mation about eating disorders and distributes it toanorexics, bulimics, families, school personnel,students and medical and mental health profes-sionals. The ANRED staff leads workshops andseminars across the United States, helping peopleidentify and understand anorexia nervosa andbulimia. ANRED also participates in professionalconferences, helping physicians, psychotherapistsand other human services personnel learn effectiveways of working with eating-disordered people.

ANRED is affiliated with the NATIONAL EATING DIS-ORDERS ASSOCIATION (NEDA).

See also APPENDIX III.

anticonvulsant treatment Anticonvulsants aredrugs that suppress convulsions. First-generation(meaning older drugs) anticonvulsants included:phenytoin (Dilantin), carbamazepine (Tegretol,Carbatrol), phenobarbital and valproate(Depakote). Second-generation anticonvulsantswere developed mostly during the 1990s. Theyinclude: topiramate (Topamax), gabapentin (Neu-rontin), lamotrigine (Lamictal), tiagabine (Gabi-tril), levetiracetam (Keppra), oxcarbazepine(Trileptal), ethosuximide (Zarontin), zonisamide(Zonegran) and primidone (Mysoline). They areused in the treatment of epilepsy and in psy-chomotor (muscular action resulting from mentalactivity) and myoclonic (involuntary twitching orspasms of muscles) seizures.

A relationship between binge eating and seizuredisorders has been suggested because binge eaterstypically describe their binges as episodic anduncontrollable. Binge episodes are also frequentlypreceded by a change in mental state that could beinterpreted as an aura (flashes of light, unusualsmells, increased tension or fear), a phenomenonthat sometimes occurs in nervous disorders. Anumber of compulsive eaters have had abnormali-ties of their electroencephalogram (EEG) pattern(an EEG measures electric current generated in thebrain). Because of these findings, some doctors hadtreated bulimic patients with first generation anti-convulsant drugs and had reported success. How-ever, others had found these drugs to be of no use,and there has not been sufficient compelling evi-dence to support the hypothesis that bulimia is aform of seizure disorder.

anticonvulsant treatment 37

More recently, newer anticonvulsants such astopiramate and zonisamide have been shown effec-tive in treating obesity and are sometimes used totreat binge eating disorder (BED). In one study, top-iramate reduced binge-eating frequency, obsessive-compulsive features of binge-eating and bodyweight more effectively than placebo in a 14-weekstudy of 61 obese patients with BED. These effectswere maintained across 48 weeks in an open-labelextension trial. Zonisamide produced similar resultsduring a prospective open-label 12-week trial in 15patients with BED. In an open-label study (alsocalled unblinded), the patient, the researcher andthe evaluator all know what the treatment is.

Following their 10-week, randomized, double-blind, placebo-controlled trial to examine the effi-cacy of topiramate in the treatment of bulimianervosa, Hedges et al. concluded that “topiramatetreatment improves multiple behavioral dimensionsof bulimia nervosa. Binge and purge behaviors arereduced, and treatment is associated with improve-ments in self-esteem, eating attitudes, anxiety, andbody image. These results support topiramate as aviable therapeutic option for the treatment ofbulimia nervosa.” However, they cautioned, addi-tional longer-term multicenter trials are indicated.

Kotwal et al. suggest several reasons that binge eat-ing disorder may respond to anticonvulsant therapy:

• Some anticonvulsants are effective in treatingbipolar disorder, which may occur with BED.

• Some anticonvulsants have shown benefit inconditions associated with pathologic impulsiv-ity, such as substance abuse, impulse-controland cluster B disorders. (The DSM-IV-TR groupsthe personality disorders into three clustersbased on descriptive similarities: Cluster A disor-ders are marked by odd or eccentric behaviorsand include the paranoid, schizoid and schizo-typal disorders. Cluster B disorders are charac-terized by dramatic, emotional or erraticbehaviors, and include the antisocial, borderline,histrionic and narcissistic disorders. Cluster Cdisorders are characterized by anxious or fearfulbehaviors, and include the avoidant, dependentand obsessive-compulsive disorders.)

• Growing evidence shows that bulimia nervosa andBED may be associated with pathologic impulsivity.

Others caution that it takes several positive double-blind studies, or one with at least several hundredpatients in it, to prove that a drug is effective for agiven condition.

Hedges, D. W., et al. “Treatment of Bulimia Nervosa withTopiramate in a Randomized, Double-Blind, Placebo-Controlled Trial, Part 2: Improvement in PsychiatricMeasures.” Journal of Clinical Psychiatry 64, no. 12(December 2003): 1,449–1,454.

Kotwal, Renu, et al. “Binge-Eating Disorder.” Current Psy-chiatry 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 ofBinge Eating Disorder Associated with Obesity: ARandomized, Placebo-Controlled Trial.” AmericanJournal of Psychiatry 160, no. 2 (February 2003):255–261.

McElroy, S. L., et al. “Zonisamide in the Treatment ofBinge-Eating Disorder: An Open-Label, ProspectiveTrial.” Journal of Clinical Psychiatry 65, no. 1 (January2004): 50–56.

antidepressants Drugs originally developed forthe treatment of depression that are now used fora variety of psychiatric and nonpsychiatric condi-tions. They are among the most commonly usedpsychotropic (affecting the mind) agents in thetreatment of eating disorders in the United States.Three types of antidepressants have been com-monly used in this country: tricyclics, monoamineoxidase (MAO) inhibitors and selective serotoninreuptake inhibitors (SSRI). They all boost theaction of the neurotransmitters SEROTONIN andnorepinephrine, two of the chemicals that transmitimpulses through the nervous system. Tricyclicsand MAO inhibitors prolong the active life of thesechemicals. Trazodone (Deseryl) is an antidepres-sant structurally unrelated to other antidepres-sants; it has a strong sedative effect.

Anorexia nervosa Antidepressant use foranorexia nervosa is usually determined only afterweight gain has been successfully achieved, andwhen the psychological effects of malnutrition areof less concern. At that time, antidepressants maybe considered for the prevention of relapse or totreat associated features of anorexia nervosa, suchas depression or obsessive-compulsive problems.SSRIs such as fluoxetine (Prozac) are often consid-

38 antidepressants

ered for such treatment. Tricyclics are used onlywith caution because of the greater risks of cardiaccomplications like arrhythmias and hypotension.

Kaplan notes that the scientific literature intotal describes “only five randomized, placebo-controlled trials with antidepressants, and onlyone of these had more than 40 patients. Addition-ally, most of the trials were conducted in a hospi-tal environment designed to encourage weightgain among the patients, which is not really agood environment to determine the effectivenessof the drug.”

Bulimia nervosa Antidepressants are some-times effective as one component of an initialtreatment for bulimia nervosa. SSRIs are currentlyconsidered to be the safest antidepressants andmay be especially helpful for patients with fre-quent disturbed eating behaviors as well as signifi-cant symptoms of depression, anxiety, obsession orcertain impulse disorder symptoms, or for thosepatients who have had poor response to previouspsychosocial therapy. Other classes of antidepres-sants can reduce the symptoms of binge eating andpurging and may help prevent relapse amongpatients in remission.

According to Deshmukh and Franco, “The onlymedication approved by the Food and Drug Admin-istration for bulimia nervosa is fluoxetine (Prozac).”(It was approved in November 1996.) “Several stud-ies have demonstrated efficacy of serotonin-reup-take inhibitors; e.g., sertraline (Zoloft), paroxetine(Paxil) and citalopram (Celexa); tricyclic antidepres-sants, e.g., imipramine (Tofranil), nortriptyline(Pamelor) and desipramine (Norpramin); andmonoamine oxidase inhibitors (MAOI). Doses of tri-cyclic antidepressants and MAOI antidepressantsparallel those used to treat depression, but higherdoses of fluoxetine (up to 60 or 80 mg/day) may beneeded to treat bulimia nervosa.”

Although tricyclics and MAOIs can be used totreat bulimia nervosa, treatment guidelines urgecaution when tricyclics are given to patients with ahigh risk for suicide attempts, and warn thatMAOIs should be avoided for patients with chaoticbinge eating and purging. Deshmukh and Francoadd that “bupropion (Wellbutrin) has been associ-ated with seizures in purging bulimic patients andits use is not recommended.”

Binge-eating disorder Cautioning that cognitive-behavioral therapy is still the treatment of choice,Brewerton notes that randomized controlled trialssuggest bingeing to be reduced by the SSRIs fluox-etine, fluvoxamine, sertraline (Zoloft) and citalo-pram (Celexa).

See also DEPRESSION.

Brewerton, Timothy D., “Pharmacotherapy for Patientswith Eating Disorders.” Psychiatric Times 21, no. 6(May 2004). Available online. URL: http://www.psychiatrictimes.com/p040559.html.

Deshmukh, Rashmi, and Kathleen Franco. “Eating Dis-orders.” The Cleveland Clinic. Available online. URL:http://www.clevelandclinicmeded.com/diseasemanagement/psychiatry/eating/eating.htm. Postedon January 21, 2003, and reviewed on December 22,2003.

Kaplan, Arline. “Treating Eating Disorders: The Pitfallsand Perplexities.” Psychiatric Times 21, no. 9 (August2004). Available online. URL: http://www.psychiatrictimes.com/p040804.html.

anti-fat attitudes See OBESITY, ATTITUDES TOWARD.

antiobesity drugs For more than 100 years, peo-ple have searched for the magic pill that wouldmelt excess pounds of fat off their overweight bod-ies. Around the 1900s, according to the FederalTrade Commission, popular weight-loss drugsincluded animal-derived thyroid, laxatives and thepoisons arsenic and strychnine; eventually eachwas shown to cause weight loss only temporarily,and usually to be unsafe to use. In the 1930s, doc-tors prescribed dinitrophenol, a synthetic insecti-cide and herbicide that increases humanmetabolism so drastically that organs fail, causingblindness and other health problems. The hor-mone human chorionic gonadotropin (HCG)became popular in the 1950s for weight loss, andresurfaced recently, even though the FDA exposedit decades ago as effective only to treat Fröhlich’ssyndrome, a particular genetic imbalance occur-ring only in boys.

Currently only two prescription drugs—Meridia (sibutramine) and Xenical (orlistat)—areapproved for long-term obesity treatment. Sibu-tramine works by making a person feel full. Itsside effects include a rise in blood pressure and

antiobesity drugs 39

heart rate, and possible dry mouth, headaches andconstipation. Orlistat works by eliminating fatsfrom the body before they are digested. Its sideeffects include stomachaches, diarrhea and inade-quate absorption of some vitamins. Both drugs areapproved for use for up to two years. Xenical wasshown in one study to prevent heart attacks inthose people taking it to help lose weight. Themodest efficacy of both drugs in short-term weightloss and long-term weight maintenance has beendocumented in randomized controlled trials, butattrition rates are high.

A third approved obesity drug, phentermine, issold under several brand names, including Adipex-P and Fastin. Although not an amphetamine,phentermine is chemically similar to AMPHETA-MINES and may show up positive in urine screeningtests for amphetamines. It works in much the sameway that sibutramine does, but can be taken foronly eight weeks. Because this is not enough formost obese people to lose satisfactory weight,many doctors do not prescribe it.

A handful of drugs intended for other purposesbut which appear to have some weight-loss bene-fits are used off-label for weight control; meaningthey were approved by the FDA, but not asantiobesity drugs. One example is bupropion, anantidepressant sold under the brand name of Well-butrin, which makes users feel less hungry. Onestudy found that 14 percent of those people whotook the drug every day lost about five pounds ineight weeks. However, some people experienceside effects including anxiety, constipation andnausea. Another example is metformin, sold asGlucophage, which is approved to treat type 2 dia-betes. Although diabetics taking the drug haveoften been found to lose weight, nondiabetics tak-ing it often do not experience the same amount ofweight loss. Off-label medications such as thesealso have their own side effects.

Although the search for obesity-controllingdrugs had been low-key in recent years, it has nowescalated. Woods et al. explain:

Obesity is now recognized as a chronic disorderwith biologic causes that may require chronicmedical therapy, much as is the case for hyperten-sion or diabetes mellitus. Prior to this change ofpolicy, antiobesity drugs approved by the Federal

Drug Administration were expected to induceweight loss that was sustained even after drugtreatment was discontinued. Consequently, therewas little interest on the part of pharmaceuticalcompanies in the development of new drugs forthe treatment of obesity. Fortunately, commonsense and the weight of medical evidence pre-vailed and led to a reassessment. A major conse-quence of this new policy is the potential for newopportunities for the pharmaceutical industry,which once again has turned its attention (andimmense resources) toward the development ofantiobesity drugs and their lucrative market.

In order to be approved by the U.S. Food andDrug Administration, new drugs generally mustshow two years of proven safety data, plus long-term effectiveness. A major impediment to devel-oping satisfactory antiobesity treatments is thetendency so far for potential drugs to be effectiveduring the first six months of treatment, only tolose effectiveness as the patients taking themdevelop resistance.

One experimental drug undergoing testing thatshows promise is Acomplia (rimonabant), devel-oped by the French pharmaceutical companySanofi-Aventis. In one two-year test involving3,040 Americans and Canadians, those participantswho took Acomplia averaged 19 pounds lost thefirst year, and kept the weight off the second year.About 12 percent of the trial’s participants had todrop out because of nausea and dizziness. Also,participants in the trial who were switched after ayear from Acomplia to a placebo tended in the sec-ond year to regain the weight they had lost; thus,proof of safety and tolerability over an unlimitedtreatment period will be a major consideration forapproval. Acomplia is not intended to replace diet-ing and exercise, but to supplement them by block-ing receptors in the brain that trigger cravings. Ifthe drug receives FDA approval it could be on themarket as early as 2006, and industry experts say itcould become one of the best-selling drugs ever.

Another challenge facing antiobesity drugdevelopment, according to Park, is that weight“represents the sum of a bewildering network ofoverlapping metabolic pathways, all designed toprotect the body from starvation by packing on asmany pounds as possible. In addition, not every-body gains weight the same way, so a drug target-

40 antiobesity drugs

ing one pathway will probably not work for alloverweight people.”

A pharmaceutical company executive hasstated that using drugs to treat obesity likely willrequire a combination of medicines hitting differ-ent targets that tell the body to lose weight.Researchers are studying signals in the brain thatmake people hungry and others in the gut that tellthe brain the stomach is full. Other approachesinclude trying to block absorption of certain foodsor stimulating metabolism.

Weigel is optimistic about the outlook for effectiveantiobesity drugs. “Our growing understanding ofperipheral signals and central nervous system (CNS)pathways involved in the regulation of adipositymakes it very likely that effective new drugs willbecome available to treat obesity in the near future.”

See also DIET PILLS; GHRELIN; INTERLEUKIN-6; LEPTIN.

Cleland, Richard, et al. “Weight-Loss Advertising: AnAnalysis of Current Trends.” Washington, D.C.: Fed-eral Trade Commission, 2002.

Park, Alice. “Pills in the Pipeline: Drug Treatments forObesity May Not Be Far Off, but Don’t Expect OnePrescription 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 ClinicalEndocrinology & Metabolism 88, no. 6 (June 2003):2,462–2,469.

Woods, Stephen C., et al. “Food Intake and the Regula-tion of Body Weight.” Annual Review of Psychology no.51 (2000): 255–277.

antipsychotics Also called neuroleptics, a groupof drugs used to treat psychoses (mental disorderscharacterized by loss of contact with reality). Theywere introduced into psychiatry during the early1950s. The first antipsychotic compound, approvedfor the treatment of the symptoms of schizophre-nia, was CHLORPROMAZINE (Largactil, Thorazine) in1953. During the 1960s, chlorpromazine was usedby some clinicians for treating anorexia nervosa,but the overall results were not satisfactory. Walshand Devlin explain: “A series of early studiesreported that chlorpromazine, sometimes in com-bination with insulin to further stimulate hunger,produced more rapid weight gain and earlier hos-pital discharge. However, unwanted side effects

included the onset of binge eating and seizures,and follow-up studies showed no benefit. Placebo-controlled studies of the higher-potency antipsy-chotics pimozide and sulpiride provided littleevidence of clinical utility. Therefore, althoughparticular patients may benefit from treatmentwith antipsychotic medications, existing studies donot support their routine use.” Long-term antipsy-chotic therapy in patients with anorexia nervosa,as in other patients, can lead to the development oftardive dyskinesia (involuntary jerky movementsof the face, tongue, jaws, trunk and limbs, usuallydeveloping as a late side effect of prolonged treat-ment with antipsychotic drugs).

First-generation antipsychotic drugs are nowcommonly referred to as typical antipsychotics. Inthe 1990s several atypical antipsychotic drugs werefirst introduced, and they are believed to have alower incidence of side effects. According to ArnoldE. Andersen, M.D., of the University of Iowa Schoolof Medicine, “A number of trials are underwayusing atypical neuroleptics such as risperidone andolanzapine. The hope is that they will have an effecton the core psychopathology of anorexia nervosarather than merely stimulating weight gain, as wasthe case with chlorpromazine in the 1960s.”

Powers and Santana also describe antipsychoticsas possibly suitable treatment for anorexia nervosa.“The medications currently being most widelystudied are the atypical antipsychotics, particularlyolanzapine. Emerging evidence suggests that someanorexia nervosa patients have psychotic symp-toms that may respond to antipsychotic agents.There are promising case reports and open-labelstudies of the atypical antipsychotics, but as yet, norandomized, placebo-controlled, double-blindstudies have been reported.”

Powers, P. S., and C. Santana. “Available Pharmacologi-cal Treatments for Anorexia Nervosa.” Expert Opinionon Pharmacotherapy 5, no. 11 (November 2004):2,287–2,292.

Walsh, B. Timothy, and Michael J. Devlin. “Psychophar-macology of Anorexia Nervosa, Bulimia Nervosa, andBinge Eating.” Psychopharmacology—The Fourth Genera-tion of Progress, The American College of Neuropsy-chopharmacology. Available online. URL: http://www.acnp.org/g4/gn401000153/ch149.html. Down-loaded on October 28, 2004.

antipsychotics 41

anxiety A feeling of uneasiness, apprehension ordread often characterized by tension, increasedpulse and sweating. Most persons find healthyways to deal with their anxiety, such as socialactivities, hobbies, music, reading, and sports.Anxiety can even be a positive signal, alerting theindividual to a situation or event that requirespreparation to overcome, such as the anxiety thatmotivates a student to study for an exam. Some,however, respond in negative or inappropriateways, having insomnia or recurrent headaches,overindulging in alcohol or drugs, overeating orexperiencing a loss of appetite, for example.

Instead of using anxiety as a signal to prepare tocope with some perceived stress, eating-disorderedpersons see anxiety as a signal of impending doom,a warning that whatever is coming will be emo-tionally overwhelming. They react to anxiety bytrying to get rid of it rather than by heeding it. Inthem, anxiety is likely to set off a binge or, inanorexics, to further restrict eating.

Some researchers, such as Don Williamson haveproposed an anxiety model of bulimia nervosa.According to this model, anxiety about gainingweight is the central feature of the disorder andbinge eating triggers an increase in such anxiety.The anxiety is then reduced by vomiting or someother purgative activity. The reduction in anxietythen negatively reinforces the purgative behavior.

Psychophysiological research supports this anx-iety model of bulimia nervosa.

The central theme of the PSYCHODYNAMIC

APPROACH TO OBESITY is that anxiety precedes andtriggers the overweight person’s overeatingresponse. The anxiety that results in overeating isproduced by internal emotional conflicts ratherthan external stimuli. Eating often serves tem-porarily to make a person feel better. Becausemuch internal conflict is believed to take place inthe subconscious, an individual may often not beaware of the source of the anxiety. Studies haveshown that uncontrollable anxiety increases eat-ing in obese individuals, but controllable anxietydoes not. Some therapists see the use of food ascompensating for life’s upsets, replacing whatseems to be missing in life and soothing, calmingand covering up daily stresses and anxiety. Theo-ries in opposition to this include the EXTERNALITY

APPROACH TO OBESITY.

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

appetite An emotional and physical impulse ordesire or urge to eat, regardless of nutritionalneeds. Appetite is psychological, dependent onmemory and associations (social learning), unlikeHUNGER, which is physiologically aroused by thebody’s need for food. Appetite is a complex mech-anism involving the METABOLISM, gastric juices, thehypothalamus and the cerebral cortex. It is stimu-lated by the sight, smell or thought of food andaccompanied by the flow of saliva in the mouthand gastric juice in the stomach. Appetite maystimulate a person to eat when no hunger signalsare present or to continue eating after physiologi-cal SATIETY has been achieved. When appetite isdisturbed, an individual consumes more caloriesthan he uses up and thus gains weight.

For many years it was presumed that the stom-ach held the primary role in appetite control. Assurgical techniques developed and gastrectomy(removal of the stomach) became possible, itbecame apparent that this is not so. Ultimate con-trol of feeding lies in the brain. There are also sev-eral mechanisms by which the small intestine isthought to bring about satiety.

appetite hormones Hormones that stimulate orsuppress hunger; they include GHRELIN, LEPTIN andPYY (Peptide YY3-36). Appetite hormones arereceiving more attention as researchers strive tosolve the mystery of why some people becomeobese. Researchers do not expect appetite hor-mones by themselves to provide any “magic bullet”to stop obesity, but they believe a better under-standing of how these hormones work togethermay prove useful in the development of drugs thatmimic the action of the appetite hormones. A med-ical device called an IMPLANTABLE GASTRIC STIMULA-TOR (IGS) has shown in trials to stimulate theappetite hormones to create a feeling of fullness.

appetite-stimulating drugs Although patientswith anorexia nervosa do not have a reducedappetite, a number of researchers have triedappetite-stimulating drugs in the hope that they

42 anxiety

might induce anorexic patients to eat and gainweight. Only one of these drugs, an antihista-mine called CYPROHEPTADINE, has actually beenstudied in detail, and it has been found generallyto be useless.

appetite suppressants Drugs such as AMPHETA-MINES, BULKING AGENTS and topical painkillers thatlessen or eliminate appetite by slowing gastricemptying, and possibly by increasing a “full” feel-ing following eating. They can also maintain a feel-ing of fullness long enough to help a patient limitthe size of the next meal. Many clinicians stronglyadvise against the use of any appetite suppressantfor bulimics or compulsive overeaters.

One theory suggests that appetite suppressantstemporarily lower the set point rather than sup-press the appetite and that because of this anyweight lost while using suppressants is usually rap-idly regained once the dieter stops taking them.(See SET-POINT THEORY.)

Appetite suppression by a modest amount ofreadily assimilable energy, such as a caloric sweet-ener (“diet candy”), is not likely to last longer thanan hour. Some appetite suppressants use the topi-cal painkiller BENZOCAINE to reduce sensation in themouth and make eating a less rewarding activity.

According to the National Institutes of HealthWeight-control Information Network (WIN) pro-gram, most studies show that the majority ofpatients who stop taking appetite suppressant med-ications regain the weight they had lost. Appetitesuppressant medications may be appropriate forcarefully selected patients who are at significantmedical risk because of their obesity, but they arenot recommended for use by people who are onlymildly overweight unless they have health prob-lems that are made worse by their weight. Thesemedications should not be used only to improveappearance. Although NIH says long-term use ofprescription appetite suppressant medications maybe helpful for carefully selected individuals, its factsheet cautions that little information is available onthe safety and effectiveness of these medicationswhen used for more than one year.

Because any appetite-reducing effect from thesemedications tends to decrease after a few weeks,they are usually prescribed only during the first

few weeks of a weight-loss program. Thus, manyfind them most useful as an early weight-loss boostwhile learning new ways to eat and to exercise forreal long-term weight reduction.

See also ANTIOBESITY DRUGS, DIET PILLS, EPHEDRA,HERBAL FEN-PHEN, PHENYLPROPANOLAMINE.

Weight-Control Information Network (WIN). “Prescrip-tion Medications for the Treatment of Obesity FactSheet.” National Institute of Diabetes and Digestiveand Kidney Diseases, October 1997.

art therapy An outgrowth of work therapy andactivation therapies, which serve to foster activityand thus rehabilitation by encouraging some formof occupation. Also referred to as creative therapy,art therapy is an attempt to stimulate patientsthrough the creation of art and design and then totransfer this creativity or expressiveness to thereshaping of the patient’s life.

Work created during art therapy is not evalu-ated for aesthetic merit or artistic skill but for itsvalue in psychotherapeutic exploration. Artisticproductions can be interpreted by experienced psy-chotherapists in the context of a therapy, as withfree association, or as is done in psychoanalysiswith dreams.

Art therapy has existed in various forms sincethe 1940s. It has been used alone or to augmentother forms of treatment with both individuals andgroups. Although the field has been gainingacceptance as a legitimate form of psychotherapy,critics say it has lagged behind other therapies indocumenting and evaluating its effectiveness. Arttherapy is thought to be especially helpful in thecase of young children who may express graphi-cally what they cannot yet communicate verbally.

Diamond-Raab and Orrell-Valente noted thatadolescent anorexia nervosa and bulimia nervosapatients typically have trouble talking about them-selves. “Traditional group therapy that focuses onverbal therapy is often not effective, particularly inthe acute stages of the diseases. A group therapyapproach that integrates art therapy, PSY-CHODRAMA, and verbal therapy offers an innova-tive alternative to traditional group therapy.”

In the treatment of eating disorders, art therapycan provide anorexics with an opportunity tobecome more sensitive to their inner selves. They

art therapy 43

create artwork that originates within themselvesand is not under the control of others. Anorexicsconvey their emotional needs through the use of“body language” (by starving themselves), that is,engaging in a nonverbal form of symbolic commu-nication. Drawing and painting are also forms ofnonverbal communication; through these mediathey can express their emotional conflicts andenhance their self-awareness.

Levitt and Sansone explain, “An extremelyimportant part of treatment is to provide an oppor-tunity for clients to identify their own body expe-riences more accurately (e.g., size and proportion,body image, relation to others). For example,clients estimate body size during art therapy andcompare this with their actual body size, which istraced onto paper.”

In art therapy, anorexics are encouraged to rep-resent themselves, their families, their feelings,their view of treatment and so on. Interpretation ofsuch work can provide an opportunity to beginmore formal PSYCHOTHERAPY.

Diamond-Raab, L., and J. K. Orrell-Valente. “Art Ther-apy, Psychodrama, and Verbal Therapy. An Integra-tive Model of Group Therapy in the Treatment ofAdolescents with Anorexia Nervosa and Bulimia Ner-vosa.” Child and Adolescent Psychiatric Clinics of NorthAmerica 11, no. 2 (April 2002): 343–364.

Levitt, John L., and Randy A. Sansone. “The Treatmentof Eating Disorder Clients in a Community-Based Par-tial Hospitalization Program.” Journal of Mental HealthCounseling 25, no. 2 (April 2003): 140+.

arthritis link to obesity Obesity is associatedwith increased risk of osteoarthritis (OA), and bothoverweight and obesity increase the severity ofarthritis. Population-based studies have consis-tently shown a link between overweight or obesityand arthritis in the knees, according to Bartlett.“Data from the first National Health and NutritionExamination Survey (HANES I) indicated thatobese women had nearly four times the risk ofknee OA as compared with non-obese women; forobese men, the risk was nearly five times greater.In a study from Framingham, Mass., overweightindividuals in their thirties who did not have kneeOA were at greater risk of later developing the dis-ease. Other investigations, which also performed

repeated x-rays over time, have found that beingoverweight significantly increases the risk of devel-oping knee OA.”

In 2004 researchers from two large, ongoingCanadian studies (the Canadian CommunityHealth Survey and the National Population HealthSurvey) reported that obesity increases the odds ofdeveloping arthritis by 60 percent, and being over-weight increases a woman’s chances of developingarthritis by 30 percent, but does not seem to havean immediate impact on men’s joints.

According to the U.S. Department of Health andHuman Services, for every two-pound increase inweight, the risk of developing arthritis is increasedby 9 to 13 percent. Symptoms of arthritis canimprove with weight loss, yet Mehrota et al.reported that in a survey of adults from 35 states,among those obese adults with arthritis who hadroutine checkups within the past 12 months, only43 percent were advised to lose weight by theirphysicians. However, those who did receive suchadvice were more likely to attempt to lose weight,pointing to the need for health care professionalsto make overweight and obese patients moreaware of the link between obesity and arthritis.

Clinicians have noted that severely obese mentend to die of heart attacks at a young age, butwomen live longer and develop severe arthritis intheir knees, not allowing them to move muchbeyond their beds or chairs.

The link between obesity and arthritis is compli-cated by the natures of the diseases. For example,doctors have expressed concern that meals inretirement homes and assisted care facilities areoften lavish, large and high-calorie, but becauseresidents so frequently suffer from arthritis, manyhave difficulty participating in enough exercise toburn off those calories—thereby leading to moreweight gain and worsened arthritis.

Bartlett, Susan. “Osteoarthritis and Body Weight.” JohnsHopkins Arthritis Presents the Role of Body Weight inOsteoarthritis. Available online. URL: http://www.hopkins-arthritis.som.jhmi.edu/mngmnt/osteoandweight.html#obesity. Downloaded Septem-ber 27, 2004.

Mehrotra, C., et al. “Arthritis, Body Mass Index, and Pro-fessional Advice to Lose Weight: Implications for Clin-ical Medicine and Public Health.” American Journal ofPreventive Medicine 27, no. 1 (July 2004): 16–21.

44 arthritis link to obesity

artificial sweeteners Sugar substitutes with fewor no calories. According to the Calorie ControlCouncil, a sugar-substitute industry group based inAtlanta, approximately 85 percent of adult Ameri-cans consume foods or beverages containing artifi-cial sweeteners, with 63 percent of thoseconsumers not on diets. A teaspoon of sugar con-tains about 16 calories, and sugar substitutes ofequal sweetness contain one calorie or less. Nutri-tionists caution that just because a food or drink issweetened with a substitute does not necessarilymean it is low in calories. Artificially sweetened icecream, for example, often has nearly as many calo-ries as regular ice cream sweetened with sugarbecause it has more fats.

Artificial sweeteners are regulated by the U.S.Food and Drug Administration (FDA), which hasapproved five different sweeteners:

• Saccharin, sold as Sweet ’N Low and Sugar Twin,among others, was discovered in 1879, so it didnot go through the same testing as later sweet-eners. In 1977, after animal studies linked sac-charin to bladder cancer, the FDA consideredbanning it; however, it has since been deemednot a major risk for bladder cancer in humans.However, some scientists continue to dispute theFDA approval.

• Aspartame, sold as NutraSweet, Equal, Natra-Taste, Sugar Twin and others, was approved bythe FDA in 1981. Although users have com-plained of headaches, industry-funded studieshave concluded that aspartame does not causeheadaches. Schardt cautions that an independ-ent test in 1994 found the sweetener to belinked to symptoms in the 11 (out of 26 people)who were “very sure” they were sensitive. “Thatsuggests that some people react to aspartame,though fewer than the number who believe theydo.” He adds that charges of aspartame beinga cancer risk have never been proved, and“there’s no foundation to claims floating aroundon the Internet that aspartame causes every-thing from Alzheimer’s disease to multiple scle-rosis.” Aspartame-containing foods must displaya warning that people with phenylketonuria(PKU) should avoid it because they cannotmetabolize an amino acid found in aspartame.

Consumer Reports on Health (January 2005) notedthat aspartame has been a “lightning rod” for thesafety debates since its approval, and althoughopponents have claimed it causes brain tumors,severe allergic reactions, and other problems,“more than 500 studies have produced no con-vincing evidence of any harmful effects in theaverage person.” However, many health profes-sionals remain concerned about aspartame andthe fact that industry-funded studies conclude itto be harmless do not reassure them.

• Sucralose, sold as Splenda, is sucrose (sugar)chemically combined with chlorine. In its gran-ular state, it can be substituted equally for sugarin baking and cooking. According to the Inter-national Food Information Council, sucralosewas discovered in 1976, and “more than 100 sci-entific studies conducted over a 20-year periodhave conclusively demonstrated that sucralose issafe for consumption.” In 1991 Canada’s HealthProtection Branch became the first national reg-ulatory agency to endorse sucralose safety andpermit its use in foods and beverages. In 1998,the United States FDA approved the use ofsucralose in 15 food and beverage categories—the broadest initial approval ever given to a foodadditive. Then, in August 1999, the FDAextended the approval by permitting sucraloseuse as a general-purpose sweetener in all foods,beverages, dietary supplements and medicalfoods. In January 2004 the European Unionamended its Sweeteners Directive to permit theuse of sucralose in a broad range of food andbeverage products. By September 2004 Splendawas reported to be the leading branded sweet-ener in U.S. homes, with sales surpassing evenDomino Sugar. Some 5 billion Splenda packetsare consumed each year; it is approved in 79countries, and it is used in more than 4,000products worldwide.

• Acesulfame-K, sold as Sunett and Sweet One, wasapproved for use in 2003. It is used in hundredsof products and can be used in baked goods.Although the FDA says its safety is backed bymore than 90 studies, consumer groups insist itneeds more testing to answer a few early tests inwhich rats developed cancer tumors.

artificial sweeteners 45

• Neotame is not yet available in any product inthe United States. The most recently approvedartificial sweetener, it is made by the same com-pany that produces NutraSweet. Because it ismetabolized differently from aspartame, prod-ucts containing it will not be required to carrythe PKU warning.

Low-calorie sweeteners known as sugar alco-hols or polyols are found in packaged goods andlisted in the ingredients as sorbitol, mannitol, xyl-itol, erythritol and D-tagatose. According to Har-vard Women’s Health Watch, sugar alcohols havelittle caloric effect because they are absorbedslowly and incompletely by the intestines. “How-ever, this property can also cause gas and diarrheaif you consume too much, for example, more than50 grams per day of sorbitol or 20 grams per dayof mannitol.”

Although consumption of artificially sweetenedfoods and drinks soared to 180 million in 2004 from68 million in 1986, obesity reached epidemic pro-portions during that period. A Purdue Universitystudy reported by Davidson and Swithers found thatrats fed artificial sweeteners ate three times morecalories than rats given sugar; thus the authors sug-gest sugar-free foods may play a role in the obesityepidemic. They hypothesize that artificial sweetenersmay disrupt the body’s natural ability to use sweettaste and viscosity to gauge caloric content of foodsand beverages, so may be fooled into thinking aproduct sweetened with artificial sweetener has nocalories and, therefore, people overeat. Other scien-tists, however, have dismissed the hypothesis, argu-ing that studies on people do not indicate that at all.

Referring to a different study, St-Onge andHeymsfield of the Obesity Research Center atColumbia University wrote, “Subjects supplement-ing their diets with artificially sweetened foods lostweight, whereas those consuming high-sucrosefoods gained weight. This review sheds some lighton the controversy regarding the effects of artificialsweeteners in body weight control.” Other authorshave noted that studies showing replacement ofadded sugar with low-energy sweeteners to resultin reduced body weight have been short-termstudies, and they caution that long-term conclu-sions cannot be drawn without long-term testing.

See also STEVIA.

“Artificial Sweeteners: Okay in Moderation.” HarvardWomen’s Health Watch 11, no. 11 (July 2004): 2–3.

Davidson, Terry L., and Susan E. Swithers. “A PavlovianApproach to the Problem of Obesity.” InternationalJournal of Obesity 28, no. 7 (July 2004): 933–935.

Schardt, David. “Sweet Nothings: Not All Sweeteners AreEqual.” Nutrition Action Healthletter, May 1, 2004:8–11. Available online. URL: http://www.cspinet.org/nah/05_04/sweet_nothings.pdf. Downloaded on Sep-tember 9, 2005.

St-Onge, M. P., and Heymsfield, S. B. “Usefulness of Arti-ficial Sweeteners for Body Weight Control.” NutritionReviews 61, no. 6 part 1 (June 2003): 219–221.

Asians/Pacific Islander Americans and eating dis-orders Also called Asian American/PacificIslander, this group comprises more than 7 millionpeople from 28 Asian countries and 25 PacificIsland cultures in the United States. The largestsubgroups are Chinese, Filipinos, Japanese, AsianIndians, Koreans and Vietnamese. Hawaiians com-prise the largest subgroups of Pacific Islanders (58percent), followed by residents of Samoa, Guamand Tonga. Each subgroup has its own history, lan-guage and culture.

Studies typically do not include ethnicallydiverse populations; therefore, cases of eating disor-ders among diverse racial ethnic groups, includingAsian Americans, are often underreported. In addi-tion, many Asian Americans equate psychologicalproblems with weakness and shame; therefore,women and girls may avoid seeking treatment. Inone study of more than 900 middle-school girls innorthern California, Asian-American girls reportedgreater body dissatisfaction than white girls. Amongthe leanest 25 percent of girls, Asian girls reportedsignificantly more dissatisfaction than white girls.Recent research on Asian Americans suggests thatbody dissatisfaction is increasing due to the promo-tion of the Western beauty ideal.

Asian Americans are often perceived as “modelminorities” and are expected to be successful andhigh achieving. Asian-American girls may try toseek power and identity through the pursuit of aphysically ideal body. The drive to become the“perfect Asian woman” can lead to perfectionism,which is linked to eating disorders, particularlyanorexia. In addition, the cultural value of “savingface,” which promotes a facade of control, may alsocontribute to disordered eating or eating disorders.

46 Asians/Pacific Islander Americans and eating disorders

Adapting to a new culture creates a set of stres-sors that for Asian-American and immigrant girlsmay cause confusion about identity, includinggender roles. For example, an adolescent girlraised by her family to be obedient and demuremay experience emotional turmoil in a Westernculture that prizes independence and individual-ism. For Asian-American girls, acculturation canlead to feelings of isolation, low self-esteem andthe devaluation of native cultural identity, whichcan increase their vulnerability to eating disorders.Highly acculturated Chinese-American femalesare more likely to report bulimic behaviors and adrive for thinness than those who stay closer totheir family values. One report found that themore acculturated Asian-American girls were atgreatest risk for adopting the “dysfunctional”behaviors of white American society, includingpoor eating habits and accepting media messagesregarding standards of beauty.

Noting that not enough is known about eatingdisorders among Asian-American and PacificIslander women, Fitzgibbon and Stolley wrote,“Available research, which has focused on adoles-cents or college students, appears to indicate that eat-ing disorders are less prevalent in Asian-Americanfemales than in white females. Asian-Americanwomen report less binge-eating, dieting and bodydissatisfaction, and fewer weight concerns. But tocome to any firm conclusions about eating disorderswithin this ethnic group, researchers need to gathermore information across different ages, levels ofacculturation and Asian subgroups (e.g., Japanese,Chinese, Indian).

Fitzgibbon, Marian, and Melinda Stolley. “MinorityWomen: The Untold Story.” Nova Online: Dying to BeThin. Available online. URL: http://www.pbs.org/wgbh/nova/thin/minorities.html. Updated in December 2000.

Asians/Pacific Islander Americans and obesityAsian American/Pacific Islanders (APIA) representone of the fastest-growing and most diverse popu-lations in the United States. Asian Americans repre-sent a number of groups, including people ofVietnamese, Korean, Asian Indian, Japanese, Fil-ipino, Cambodian, Laotian and Chinese descent.Among Pacific Islanders are Hawaiians, Samoans,Guamanians, Tongans and Fijians. Some of thesepeople are fourth- or fifth-generation Asian Amer-

icans; 75 percent are recent immigrants andrefugees. Native Hawaiians and American Samoansare considered part of the Asian-American popula-tion, although they are native to the United States.

Data from the Racial and Ethnic Approaches toCommunity Health (REACH) 2010 Risk Factor Sur-vey conducted 2001–02 showed a median preva-lence of obesity among APIA men and women of2.9 percent and 3.6 percent, respectively—farbelow that of other racial and ethnic groups. Inter-views were conducted in 21 communities located in14 states. However, those findings did not includeNative Hawaiians and American Samoans, who areamong the most obese people in the world.

Also, research reported at a national medicalconference held in California in 2004 disclosed thatthe percentage of low-income Asian and PacificIslander children in California who are overweightmore than doubled between 1994 and 2003, from7 percent to 15 percent. Noting that the traditionalAsian diet is high in fiber and vitamins, while lowin saturated and total fat, one of the study’sauthors said that many of the participantsexpressed a sense of powerlessness over the influ-ence of television and food advertising and theschool environment on their children.

assessment of body fat As early as 1908, therewere reports that the obese had a greater suscepti-bility than the lean to caisson disease, the decom-pression sickness now called the bends, suffered byunderwater workers and caused by too-rapiddecrease in atmospheric pressure. In 1935 it wasconfirmed that rapid changes in atmospheric pres-sure did result in more severe attacks of the bendsamong the obese than the lean. This held practicalsignificance for deep-sea diving and aviation and ledto the military’s practice of rejecting people whoseweight was more than 15 percent above that recom-mended by the standard body weight/height charts.

But the use of standard body weight/heightratios has limitations for assessment of body fat.Muscular football players have been rejected formilitary service because they were over the limiteven though thy were not obese. And there areindividuals who have extremely large skeletons.

More recently, SKIN FOLD MEASUREMENTS

emerged as a tool to improve the assessment ofbody fat for the general population. Newer tests

assessment of body fat 47

use high-tech methods such as bioelectrical imped-ance, ultrasound, X-ray and near-infrared spec-trophotometry. According to a Web article postedby Sports Doctor, Inc., “Body-fat testing is a grow-ing business. Many health clubs offer it as a freeservice to new members, and to the general publicfor a fee, usually between $10 and $30. Coachesand trainers often include it in routine fitness eval-uations. At least one popular diet program comeswith a set of calipers to measure body fat.”

But researchers have expressed concern thatstudies for various measurement methods have nottaken into account possible differences betweengenders, age categories and ethnic groups. Accord-ing to Heyward, “The skinfold method is appropri-ate for estimating body fat of children (6–17 years)and body density of adults (18–60 years) fromdiverse ethnic groups. Likewise, bioimpedance iswell suited for estimating the fat-free mass of chil-dren (10–19 years) as well as American Indian,black, Hispanic, and white adults. Anthropometricprediction equations that use a combination of cir-cumferences and bony diameters are recom-mended for older adults (up to 79 years of age), aswell as obese men and women.”

See also BODY FAT.

Heyward, V. H. “Practical Body Composition Assessmentfor Children, Adults, and Older Adults.” InternationalJournal 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 releasedin 1998 and 1999 linked obesity to asthma, a med-ical condition occurring when the bronchial tubesswell up and go into a spasm, blocking the passageof air in and out of the lungs. In a presentation tothe 1998 American Lung Association/AmericanThoracic Society International Conference, CarlosA. Camargo, Jr., an epidemiologist at Brigham andWomen’s Hospital in Boston and an instructor atHarvard Medical School, suggested that obese peo-ple are more susceptible to asthma than people ofaverage weight. Prior to this study of more than100,000 nurses, the general assumption was that

asthma patients were prone to putting on weightbecause their breathing problems limited exercise.But Camargo’s research showed that obesity pre-ceded the diagnosis of asthma. Other expertsdescribed the study as good preliminary researchbut cautioned that more study needed to be done.Among the possible reasons for the link suggestedby Camargo and others is that sedentary peoplemay not take as many deep breaths as more activepeople, with the more frequent shallow breathingleading to the asthma symptoms. Or the extrapounds obese people carry may somehow affecttheir airways. Or there may be a genetic linkbetween asthma and obesity.

In a study of 171 children between the ages offour and 16 at an urban community health center,pediatrician Jennifer Gennuso and her colleaguesat the State University of New York at Buffaloreported that children and teenagers with asthmaare significantly more likely than those withoutasthma to be obese.

In London Dr. Sheif Shaheen and colleaguesstudied health histories of 9,000 people born dur-ing the same week in 1970, then monitored themthroughout their lives. They found that the preva-lence of asthma fell as birth weight increased. Withboth asthma and obesity increasing in recent years,researchers have searched for any cause-and-effectrelationship between the two diseases. However,the process of looking for such linkage is compli-cated, especially determining which comes first,the asthma or the obesity. Not only is it possiblethat weight gain might lead to asthma, but peoplewho already have asthma may experience moreweight gain simply because the asthma can restricttheir ability to exercise and burn off calories.Among the findings so far:

• A multi-university study sponsored by theNational Heart, Lung, and Blood Institute fol-lowed 4,547 African-American and white menand women, ages 18 to 30, for up to 10 years, andconcluded that gain in body mass index predis-poses young women to new asthma diagnoses,but decreased physical activity does not explainthe association of weight gain with asthma.

• A study looked at girls who were between theages of six and 11, and who subsequently gainedenough weight to be classified as overweight or

48 asthma link to obesity

obese. After the weight gain, these girls werenearly seven times more likely as their normal-weight peers to develop asthma symptoms.

• In a study of children who had asthma, thosewho were also obese used more asthma medica-tion, reported wheezing more frequently andreported more visits to emergency rooms.

• Researchers at the University of Southampton,United Kingdom, investigated the effects of post-natal weight gain on the lung function of 131healthy newborns. Infants who gained weightrapidly in the weeks following birth were foundto have worse respiratory function than thosewho gained weight at a normal rate.

• Data gathered as part of the Children’s HealthStudy of Southern California, involving 3,792youngsters ages seven to 18, revealed thatbeing overweight is associated with anincreased risk of new-onset asthma in boys andin nonallergic children.

• In their review of the literature over a 10-yearperiod, Zametkin et al. noted, “Recent researchon asthma and child obesity has demonstratedmixed results, and most findings suggest no cor-relation between the two disorders.”

• In a Harvard School of Public Health study of85,911 female registered nurses, weight gainafter age 18 strongly predicted development ofadult-onset asthma. Women who gained 22 to44 pounds were nearly one and a half timesmore likely to develop asthma. Women whogained more than 55 pounds were at two and ahalf times the risk.

• Stanten reported on a three-year French studyof 67,229 women that found that those whogained about 22 pounds from the time theybegan menstruating to the time they reachedadulthood were at 66 percent greater risk ofdeveloping asthma. The researchers suggestedthat higher levels of estrogen and higher levelsof the hormone LEPTIN, both associated withextra weight, may boost inflammation and inter-fere with the functioning of smith muscle cellslining the airways of the lungs.

• Ackerman et al. reviewed medical records at aninner-city academic asthma center to helpdetermine any relationship between obesity and

asthma. They found that prevalence of obesityincreases with increasing asthma severity inadults. “The association of asthma severity withobesity suggests that obesity may be a poten-tially modifiable risk factor for asthma orasthma-like symptoms.”

• Working for the Air Pollution and RespiratoryHealth Branch, Centers for Disease Control andPrevention, King et al. studied peer-reviewed lit-erature from 1994 to 2004 to determine whatfactors predict the development of asthma inboth children and adults. They found 40 studiesin this area, with 36 providing some estimate ofasthma incidence for the total sample and or aspecific subgroup. Among both children andadults, having a higher body mass index (BMI)and significant weight gain were both found toprecede the diagnosis of asthma in at least somesegments of the studied population. Duringadulthood, obesity and smoking were thestrongest risk factors for asthma. The authorsconcluded, however, that “before specific publichealth recommendations can be made, additionallongitudinal research is needed to better charac-terize target populations and identify appropriatesettings for multifaceted asthma interventions.”

However, not everyone is quick to link over-weight or obesity with asthma. In the June 2004Chest, Elamin M. Elamin, M.D., associate professorof medicine and director of critical care medicine inthe Division of Pulmonary and Critical Care Medi-cine at Southern Illinois University, wrote, “Thequestion remains whether the relation of asthmato obesity is a real connection or just a casual asso-ciation. Large prospective studies and randomizedpopulation-based studies are needed to determinethe prevalence of such an association.” Such stud-ies, Elamin added, “might support the counteropinion that . . . asthma might be overdiagnosed inthe portion of the population that is overweight.”

Plus, there is always a concern about makingcausal interpretation from correlational data. Theeffect could just as easily be the reverse (of theAkerman et al. study): People with asthma mightexercise less and thus be at a higher risk for obesity.

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

asthma link to obesity 49

The Journal of Asthma 41, no. 5 (August 2004):521–526.

Beckett, William S. “Asthma Is Associated with WeightGain in Females but Not Males, Independent of Phys-ical Activity.” American Journal of Respiratory and Criti-cal 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 betweenAsthma and Obesity in Urban Minority Children andAdolescents.” Archives of Pediatrics and Adolescent Medi-cine 152, no. 12 (December 1998): 1197–2000.

Gilliland, F. D., et al. “Obesity and the Risk of NewlyDiagnosed Asthma in School-Age Children.” AmericanJournal of Epidemiology 158, no. 5 (September 1,2003): 406–415.

King, M. E., D. M. Mannino, and F. Holguin. “Risk Fac-tors for Asthma Incidence. A Review of RecentProspective Evidence.” Panminerva Medica 46, no. 2(June 2004): 97–110.

Shaheen, Sheif, et al. “Birth Weight, Body Mass Indexand Asthma in Young Adults.” Thorax 54, no. 5 (May1999): 396–402.

Stanten, Michele. “Slim Women Breathe Easier.” Preven-tion 56, no. 2 (February 2004): 42.

Zametkin, A. J., et al. “Psychiatric Aspects of Child andAdolescent Obesity: A Review of the Past 10 Years.”Journal of the American Academy of Child and AdolescentPsychiatry 43, no. 2 (February 2004): 134–150.

athletes Athletes who compete in certain sportsin which body thinness is stressed along with highperformance expectations, such as gymnastics,wrestling, swimming and figure skating, haveshown frequent symptoms of eating disorders, ashave dancers (see BALLET DANCERS). Likewise,bulimia and other drastic weight-control measureshave been described as common among jockeys,who must meet low weight requirements.

Female cheerleaders often experience pressure toattain and maintain weight that is lower than otheradolescents of the same height. A study reported in1986 by Lundholm and Littrell examined cheerlead-ers’ desire for thinness in relationship to disorderedeating and weight-control behaviors. A total of 751high school cheerleaders from the Midwest weretested. Cheerleaders who expressed a strong desirefor thinness had significantly higher scores on sevenof eight eating-disorder scales. The greater the desirefor thinness, the more likely the tendency to report

disordered eating and weight-control behaviorsassociated with bulimia.

A 1989 Associated Press story stated that an“alarming number” of women athletes at the Uni-versity of Texas had eating disorders, with the prob-lem especially prevalent among members of theswimming team. According to the report, during aperiod of 18 months, one of every 10 female athletesat the university, a total of 12, had been diagnosedas having a serious eating disorder. Another 20 to 30percent had shown symptoms of an eating disorder,and 50 to 60 percent expressed above-average con-cern about their weight. Current and former swim-mers blamed the pressure to meet weight guidelinesfor their routine fasting, induced vomiting, laxativeand diuretic abuse and excessive exercising. TiffanyCohen, a swimmer who won two Olympic goldmedals in 1984, was quoted as saying that her fearof being overweight when reporting to workouts ledher into bulimic cycles of binges and purges thatresulted in a nine-week hospitalization. And manywomen on the professional tennis circuit have beenknown to suffer from eating disorders, includingZina Garrison and Carling Bassett-Seguso.

According to a 1992 American College of SportsMedicine Study, eating disorders affected 62 per-cent of females in sports such as figure skating andgymnastics. Olympic gymnasts who have admittedto eating disorders include Nadia Comaneci, KathyJohnson and Cathy Rigby. In 1976 the averagegymnast weighed 105 pounds, and in 1992 theaverage dropped to 88 pounds.

Effects of eating disorders on athletes includestress fractures, fatigue, iron deficiency anemia,electrolyte imbalances and cardiacarrhythmias.Because athletes are already putting above-averagepressure on their bodies, they are at a greater riskthan nonathlete patients for these complications.

A 1997 study of NCAA student-athletes in 11sports disclosed that binge eating occurred at leastweekly in 13 percent of male student-athletes and10 percent of female student-athletes.

Ferraro focused on sports that had not beenwell represented in past research. “Results suggestthat speed-focused athletes, whose success insports depends on time as well as talent, do notfeel more concern about weight and body sizedespite being involved in sports that require leanbuilds. Instead, women not involved in sports of

50 athletes

any kind seem to have the greatest dissatisfactionwith their bodies and see themselves as heavierthan both groups of athletes.”

Some coaches may be contributing to the devel-opment of eating disorders in their athletes by put-ting too much pressure on them to achieve a presetweight or body form without taking the individual’scondition into consideration. Many coaches and ath-letes estimate optimal body weight to be much lowerthan what researchers believe to be healthy, and con-sider a well-formed and graceful body to be muchleaner than the medically defined healthy body.

Ferraro suggested that future studies might“examine program and coaching characteristicsthat encourage healthy attitudes and behavior; andstudies of female athletes and non-athletes at sev-eral points in time may bring a greater under-standing of the relationships between women’sbody attitudes and eating behaviors and their par-ticipation or nonparticipation in athletics.”

Deutsch, Nancy. “National Eating Disorders ScreeningProgram.” Sports Sciences Newsletter, October 1997.

“Eating Disorders Soar among College Team Swimmers.”BASH Magazine, November 1989.

Ferraro, F. Richard. “The Relationship between Types ofFemale Athletic Participation and Female Body Type.”The Journal of Psychology 138, no. 2 (March 2004):115–128.

Hahn, Cindy. “Why Eating Disorders Pervade Women’sTennis.” Tennis, December 1990.

Lundholm, J. K., and J. M. Littrell. “Desire for Thinnessamong High School Cheerleaders: Relationship toDisordered Eating and Weight Control Behaviors.”Adolescence 21, no. 83 (fall 1986): 573–579.

Perrone, Vinnie. “Pound for Pound, a Most DangerousSport.” Washington Post, April 28, 1991.

Rucinski, Ann. “Relationship of Body Image and DietaryIntake of Competitive Ice Skaters.” Journal of the Ameri-can 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 YorkCity cardiologist and pioneer in holistic medicinewho advocated the natural healing arts as an alter-native to and complement to pharmaceutical drugsand surgery for many illnesses, including heart dis-ease, diabetes and obesity. A graduate of the Uni-versity of Michigan and Cornell University Medical

College, he founded the Atkins Center for Comple-mentary Medicine. But Atkins’s major impact onhealth and diet was his high-protein, low-carbohy-drate diet plan, which he introduced in 1972 in abest-selling book, Dr. Atkins’ Diet Revolution (DavidMcKay Company, New York). A later book, Dr.Atkins’ New Diet Revolution (M. Evans and Com-pany, 1992) went through several revisions andsold more than 10 million copies worldwide. In all,Atkins was author of eight best-selling books ondiet and nutrition, which sold more than 45 mil-lion copies. As the New York Times wrote in hisobituary, “The market for weight-loss plans andproducts is $35 billion a year, and Dr. Atkinstapped it with scores of products, including cook-books, energy bars and diet-oriented oceancruises.” Although many in the medical field havebeen critical of his diet plan, his “diet revolution”became known simply as the ATKINS DIET, whichgained such popularity that it also revolutionizedthe food industry and spawned several imitators.Atkins died on April 18, 2003, from head injuriesreceived 10 days earlier when he fell on an icysidewalk 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 world-wide. Since the body burns both carbohydrates andfat for energy, Atkins contended that, by limitingone’s carbohydrate intake, the body would burnmore fat, thereby increasing weight loss. Consum-ing a high level of carbohydrates causes increasedlevels of insulin and metabolic changes, accordingto Atkins, leading to increased hunger and weightgain. The Atkins Diet allows large amounts of pro-tein, including meats, eggs and cheese, and severelylimits foods containing carbohydrates, such aspasta, bread and fruit. A major criticism is that theencouraged consumption of saturated fats may leadto heart disease, diabetes and other health prob-lems. Although short-term trials have shown cho-lesterol readings to be the same or even better thanconventional diets, medical experts caution thatlonger-term studies are needed to evaluate any car-diovascular risk factors with the Atkins Diet.

In 2003, research sponsored by the NationalCenter for Complementary and Alternative Medi-

Atkins Diet 51

cine (NCCAM) concluded and reported on aground-breaking one-year multicenter clinical trialof obese persons to evaluate the effects of theAtkins Diet on weight loss and risk factors for car-diovascular disease. As published in the New Eng-land Journal of Medicine, the study compared weightloss and cardiovascular risks of 33 severely obesepeople (12 men, 21 women) on the Atkins Diet,with 30 others (eight men, 22 women) who con-sumed a conventional high-carbohydrate, low-fat,energy-deficit diet. After six months, those on theAtkins Diet had lost significantly more weight(approximately 4 percent more) than those on theconventional diet. Those on this low-carbohydratediet also experienced improvements in certain riskfactors for coronary heart disease such as levels ofblood lipids. After one year, there was no longerevidence of a significant difference in weight lossbetween the two groups of dieters, leading investi-gators to call for additional research, involvinglonger-term studies and more participants, to accu-rately assess the longer-term risks and benefits oflow-carbohydrate, high-fat diets.

Similarly, a Danish team’s review of some 60studies on the Atkins and other low-carbohydratediets, published in The Lancet, concluded thatweight loss achieved through Atkins-type diets isassociated with the duration of the diet andrestriction of energy intake, but not with restric-tion of carbohydrates. The authors expressed con-cern that side effects such as headaches, muscleweakness and diarrhea, which were reportedmore frequently by Atkins dieters than by thoseon more conventional weight-loss diets, may sig-nal that the diet is not healthy in the long term.Other experts have reported less concern, suggest-ing that such side effects cannot be too severebecause, in most observations, Atkins dieters stickto the regime longer than people following otherdiets. Because these side effects have beenreported at the beginning of the Atkins Diet aswell as further along, it has been suggested thatthey may be due to dehydration.

With the low-carb diet craze in general, and theAtkins Diet in particular, losing popularity follow-ing Atkins’s death, Atkins Nutritionals Inc. filed forbankruptcy court protection in August 2005.

See also LOW-CARB DIETS.

Astrup, Arne, Larsen T. Meinert, and A. Harper. “Atkinsand Other Low-Carbohydrate Diets: Hoax or an Effec-tive 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-car-bohydrate Diet for Obesity.” New England Journal ofMedicine 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 lossoccurs because of various symbolic misinterpreta-tions of the eating function, rather than because ofa preoccupation with weight.

One example Bruch describes is the relationshipof eating to the symbolization of pregnancy fan-tasies. Although this theory of the fear of oralimpregnation had been considered, in the early1940s, the cornerstone in the mental and emo-tional processes underlying anorexia nervosa,Bruch found this preoccupation only in excep-tional cases and thus came to rate patients withthis preoccupation as atypical. Others she classifiedas atypical include those who refuse to eat for fearof abdominal pain or vomiting, those who refusefood because they feel unworthy and those who donot eat in response to events in their lives. Lee etal. found that stomach bloating was the most com-mon rationale for food refusal among non-fat-pho-bic patients.

Patients with atypical anorexia nervosa andthose with the genuine disorder look deceptivelyalike, particularly after the condition has existedfor some time. In contrast to genuine anorexics,however, in whom relentless pursuit of thinnessand denial of their condition, even of acute emaci-ation, are key symptoms, atypical anorexics com-plain about weight loss and do not want to staythin, or value thinness only secondarily, as ameans of manipulating others. Inability to eat isthe leading symptom in the atypical group. Oftenthere is an unacknowledged desire to stay sick inorder to remain in a dependent role, in contrast tothe struggle for an independent identity thatoccurs in genuine, or primary, anorexics. Bruchdescribed these patients as displaying variousdegrees of neurotic and hysterical symptoms.

52 attitudes toward obesity

Patients diagnosed as atypical do not display thepeculiar features of the primary disorder: pursuit ofthinness as a struggle for an independent identity,delusional denial of thinness, preoccupation withfood, hyperactivity and striving for perfection.

Of 60 female patients Bruch reported on withthe diagnosis of anorexia nervosa, there were 15(25 percent) diagnosed as atypical. She found few ifany differences in the descriptive data between theatypical and genuine group. Weight loss was of thesame order of magnitude, age of onset in the atyp-ical group was slightly higher and amenorrhea wasnot present as frequently with the atypical group.Both groups proved equally resistant to treatment.

Bruch found the one common characteristicamong atypical anorexia patients to be a severesense of inadequacy and discontent with theirlives. Eating difficulties developed when thedemands of reality became overpowering and theirfragile sense of self was further undermined.

In a 15-year study, Strober et al. found that com-pared to patients with pure cases of anorexia ner-vosa, atypical patients were less likely to drop weightafter discharge, recovered more rapidly and hadlower cumulative risk for developing binge-eating.

A 1995 study of eating-disordered children andadolescents over the previous three decades sug-gested that bulimia nervosa and atypical eating dis-order are not replacing the traditional category ofanorexia nervosa. Rather, the authors concluded,eating disorders are becoming more widespreadand dissimilar.

See also PSYCHOGENIC MALNUTRITION.

Ash, J. B., and E. Piazza. “Changing Symptomatology inEating Disorders.” International Journal of Eating Disor-ders 18 (July 1995).

Lee, S., et al. “Rationales for Food Refusal in ChinesePatients with Anorexia Nervosa.” International Journalof Eating Disorders 29, no. 2 (March 2001): 224–229.

Bruch, Hilde. “Psychogenic Malnutrition and AtypicalAnorexia Nervosa.” In Eating Disorders: Obesity,Anorexia Nervosa, and the Person Within. New York:Basic Books, 1973.

Strober, M., R. Freeman, and W. Morrell. “AtypicalAnorexia Nervosa: Separation from Typical Cases inCourse and Outcome in a Long-Term ProspectiveStudy.” International Journal of Eating Disorders 25, no.2 (March 1999): 135–142.

aversion therapy A type of behavioral therapybased on the experiments of Ivan Pavlov(1849–1936), a Russian scientist who workedextensively in the field of conditioned reflexes.Typically, an aversive experience (a foul odor, anelectric shock) is administered to a patient at cer-tain times in order to create a negative reactiontoward certain foods or behaviors. This therapywas among the first techniques employed in thetreatment of obesity. Repeated pairings of aversiveexperience with certain foods were assumed toresult in decreasing palatability of those foodsthrough a process of “Pavlovian” behavioral condi-tioning; this shift in preference was assumed tofacilitate control over eating and, thus, weightreduction. Taste aversions develop most easily tonovel and less preferred foods and often persist formany years. One limitation of this therapy is therelative difficulty in establishing aversions to famil-iar, preferred foods, which are the very ones towhich dieters may wish to develop aversions.Results with overweight patients have been poor,whether the unpleasant stimuli have been foulsmells, electric shocks or unpleasant images.

Although aversion therapy has been used quitefrequently in the treatment of patients who areoverweight because of compulsive eating, fewreports deal specifically with patients identified asbulimic. It is now considered an outdated treatment.

In a 1996 study of 172 overweight women sub-jects who received aversion therapy and HYP-NOTHERAPY lost more weight than subjectsreceiving only hypnotic therapy, but the differ-ences were not significant.

See also BEHAVIOR MODIFICATION.

Avicenna (980–1037) An 11th-century Persianphysician and philosopher, called the “Prince ofPhysicians,” who was the first to write aboutanorexia nervosa. He described the case of amelancholic young prince who was successfullytreated for the disorder. He was the author ofmore than 100 works, of which his Canon of Medi-cine was the most important and was used for cen-turies as a medical reference in both the Christianand Islamic worlds.

Avicenna 53

Bballet dancers According to various reports inmedical literature, between 7 and 38 percent offemale dancers in competitive settings have beenfound to have serious eating problems. Classicalballet demands the same high standards of techni-cal proficiency of its dancers as competitive sportsdo of first-class athletes. And as in wrestling, gym-nastics and swimming, the right body shape andweight are primary concerns. Because ballet isbasically nonaerobic and has a low caloric expen-diture, weight reduction cannot be achieved andlow weight maintained through dancing alone.

In a study of 49 female dancers who performedin national ballet companies in the United Statesand in the Republic of China (Taiwan), 11 percentof the Americans and 24 percent of the Chinesereported that they had an eating problem. Thosedancers chosen from general auditions exhibitedsignificantly more anorexic behaviors and had ahigher incidence of eating problems, with 46 per-cent reporting anorexia nervosa, bulimia or purg-ing behavior, than those taken from a companyschool such as the School of American Ballet (11percent), where a strict selection process over anumber of years weeds out those who do not meetthe rigid body shape and weight requirements. Thestudy’s authors contend that companies choosingby audition, who do not control the early selectionprocess of their dancers, “may be choosing womenwho have more difficulty maintaining the lowbody weight demanded by this profession, and soare more at risk for developing eating-related prob-lems than dancers selected from company schools,who may be less susceptible to the development ofeating problems because they are more naturallysuited to the thin ideal required by this profession.”This has been suggested as the reason for the widedisparity of eating disorders reported in differentstudies of ballet dancers.

In a 1996 study comparing ballet dancers andstudents, the dancers were more preoccupied withthoughts of eating and body weight, used andabused laxatives for weight control and reporteddisordered eating more than the students—eventhough the dancers were at lower body weight andhad less body fat.

Analysis of 10 female members of a professionalballet company in 1998 indicated a high distortionof body image among these dancers. Although eat-ing disorders are frequent among elite performers,Ravaldi et al. noted that little is known about non-professional performers. They evaluated 113female non-elite ballet dancers, 54 female gymna-sium users, 44 male noncompetitive body builders,105 female controls and 30 male controls, usingseveral standard tests. Among these groups, non-elite ballet dancers reported the highest prevalenceof eating disorders (anorexia nervosa 1.8 percent;bulimia nervosa 2.7 percent; eating disorders nototherwise specified 22.1 percent).

See also ANOREXIA ATHLETICA; ATHLETES.

Abraham, S. “Eating and Weight Controlling Behavioursof Young Ballet Dancers.” Psychopathology 29, no. 4(1996): 218–222.

Hamilton, Linda H., et al. “The Role of Selectivity in thePathogenesis 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 Imageamong Elite Female Dancers.” Perceptual and MotorSkills 87 (December 1998): 769–770.

Ravaldi, C., et al. “Eating Disorders and Body ImageDisturbances among Ballet Dancers, GymnasiumUsers and Body Builders.” Psychopathology 36, no. 5(September–October 2003): 247–254.

Schnitt, Diana. “Psychological Issues in Dancers—AnOverview.” Journal of Physical Education, Recreation andDance 61, no. 9 (November/December 1990): 32–34.

55

Banting, William (1797–1878) The “Father ofDieting”; a 19th-century English mortician whoseweight began climbing during his late thirties. Whenhis doctor advised him to exercise to lose weight andsuggested 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 hun-gry; he went home and ate even more.

By age 50 he had become so obese that he couldnot bend to tie his shoes; he could hardly exert anyenergy without difficulty in breathing. He continuedto eat and gain weight. As he wrote later, his bodyfell into a “low and impoverished state.” When hisdoctor suggested that he sweat off some pounds inTurkish baths, he took 90. They did not work.

By this time, Banting was 65 years old, stoodfive feet five inches tall and weighed 230 pounds.Walking down stairs caused such strain on his legsthat he had to navigate the stairs backward.Finally, in 1862, he consulted another physician,William Harvey.

Harvey was one of the few scientists and physi-cians of the day who studied the effects of dietingon general health. Until then, weight-controlmethods had included bleeding from the arm orjugular vein, applying leeches to the arms, eatingvegetables with vinegar, taking hot baths or salt-water baths, staying awake most of the night, tak-ing sea voyages, eating soap, pricking the fleshwith needles, walking with naked feet and surgi-cally removing fatty tissue with a scalpel.

Dr. Harvey put Banting on a high-protein, low-carbohydrate diet of 1,200 calories per day. Bant-ing was willing to try anything, and it worked. Thefirst week he lost two pounds, the next weekthree, and the third week four pounds. After ayear he had lost a total of 46 pounds and 141/2

inches around his waist. Even his hearing andvision improved.

Banting was so pleased that he decided to tellothers about his good fortune. In 1863 he wrote apamphlet called Letter on Corpulence, Addressed to thePublic, the first diet book. He gave away the first2,500 copies, and it became the talk of London.The third edition sold 50,000 copies. By the fourthedition, it had grown from its original 25 pages to100 pages, with the addition of letters and testimo-nials praising Banting’s success and his diet.

Banting became famous, frequently lecturingwhile wearing the clothes he had worn when hehad weighed 230 pounds. The clothes would fallaround him, and he would tell his audiences thatthis is what a proper diet should do for them.

Several doctors dismissed Banting as a fraud andas the “prototype hypochondriac.” Some evenstarted rumors that Banting was dying because ofhis diet. On two occasions in 1864, Banting foundit necessary to write to the Times of London to denythat he was dying.

During Banting’s lifetime, “Bantingism” and “tobant” 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 withthe causes, prevention and treatment of obesityand its associated conditions. There are 1,100members of the American Society of BariatricPhysicians. The term came into use in the 20thcentury, and was derived from the Greek baros(weight) and iatrics (medical treatment).

bariatric surgery Surgery performed on the stom-ach and/or intestines to help severely obese peoplelose weight; also called gastrointestinal surgery. Thefirst such surgery in the United States was performedin 1953. Bariatric surgery restricts stomach sizeand/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, butmany do not. According to the Orlando Sentinel, “Anational employee health benefits survey, pub-lished in December 2003 by Mercer HumanResource Consulting, found that 48 percent oflarge companies (500 or more employees) pro-vided coverage for bariatric surgery, but less thanone-fourth of all companies did.”

Bariatric surgery results in substantial weightloss, which in many cases is sustained over thelong term. In addition, this weight loss results incomplete resolution or marked improvement inmany obesity-related comorbid conditions (exist-ing simultaneous with the obesity). In their reviewof all scientific articles on bariatric surgery pub-

56 Banting, William

lished in the English language between 1990 and2003, Buchwald et al. found that “a substantialmajority of patients with diabetes, hyperlipidemia,hypertension, and obstructive sleep apnea experi-enced complete resolution or improvement.”

However, surgical treatment is appropriate onlyfor those with extreme obesity, and carries with itthe possibility of significant complications (includ-ing death), as well as the need for lifelong medicalfollowup. It is recommended when expectedweight loss from behavior change alone may notbe sufficient to have a major impact on health andis unlikely to be sustained. Rabin cautions thatguidelines developed by the New York State HealthPlan Association “recommend using hospitals thatspecialize in bariatric surgery. Such centers shouldperform more than 200 cases a year and have ateam led by a surgeon who spends most of his orher professional time in bariatric surgery.”

People who may consider gastrointestinal sur-gery include those with a body mass index (BMI)above 40—about 100 pounds of overweight formen and 80 pounds for women. People with a BMIbetween 35 and 40 who suffer from type 2 diabetesor life-threatening cardiopulmonary problemssuch as severe sleep apnea or obesity-related heartdisease may also be candidates for surgery.

Once viewed as suitable only for adults, bariatricsurgery is now being considered for adolescents.Inge et al. suggest the following considerationswhen evaluating adolescents for surgery: Adoles-cents must have attempted but failed at organizedweight-loss attempts for at least six months, andmust have met certain anthropometric, medical,and psychologic criteria. They should be veryseverely obese (defined by the World Health Orga-nization as a body mass index of 40), have attaineda majority of skeletal maturity (generally 13 yearsof age for girls and 15 years of age for boys), andhave comorbidities related to obesity that might beremedied with durable weight loss. Potential can-didates for bariatric surgery should be referred tocenters with multidisciplinary weight managementteams that have expertise in meeting the uniqueneeds of overweight adolescents. Surgery shouldbe performed in institutions that are equipped tomeet the tertiary care needs of severely obesepatients and to collect long-term data on the clini-cal outcomes of these patients.

The concept of gastrointestinal surgery to controlobesity grew out of results of operations for canceror severe ulcers that removed large portions of thestomach or small intestine. Because patients under-going these procedures tended to lose weight aftersurgery, some physicians began to use such opera-tions to treat severe obesity. The first operation thatwas widely used for severe obesity was the intes-tinal bypass. This operation produced weight loss bycausing malabsorption. The idea was that patientscould eat large amounts of food, which would bepoorly digested or passed along too fast for the bodyto absorb many calories. The problem with this sur-gery was that it caused a loss of essential nutrientsand its side effects were unpredictable and some-times fatal. The original form of the intestinalbypass operation is no longer used.

Today’s bariatric operations promote weight lossby closing off parts of the stomach to make itsmaller. Operations that only reduce stomach sizeare known as RESTRICTIVE OPERATIONS because theyrestrict the amount of food the stomach can hold.Restrictive operations for obesity includeADJUSTABLE GASTRIC BANDING (AGB) and VERTICAL

BANDED GASTROPLASTY (VBG). Some operationscombine stomach restriction with a partial bypassof the small intestine. These procedures create adirect connection from the stomach to the lowersegment of the small intestine, literally bypassingportions of the digestive tract that absorb caloriesand nutrients. These are known as MALABSORPTIVE

OPERATIONS, and are the most common bariatricsurgeries for weight loss. Malabsorptive operationsfor 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 andDigestive and Kidney Diseases of the National Insti-tutes of Health, offers the following benefits and risksto consider before undergoing bariatric surgery:

Benefits

• Right after surgery, most patients lose weightquickly and continue to lose for 18 to 24 monthsafter the procedure. Although most patientsregain 5 to 10 percent of the weight they lost,many maintain a long-term weight loss of about100 pounds.

bariatric surgery 57

• Surgery improves most obesity-related condi-tions. For example, in one study blood sugar lev-els of 83 percent of obese patients with diabetesreturned to normal after surgery. Nearly allpatients whose blood sugar levels did not returnto normal were older or had lived with diabetesfor a long time.

Risks

• Ten to 20 percent of patients who have weight-loss surgery require follow-up operations to cor-rect complications. Abdominal hernia was themost common complication requiring follow-upsurgery, but laparoscopic techniques seem tohave solved this problem. In laparoscopy, thesurgeon makes one or more small incisionsthrough which slender surgical instruments arepassed. This technique eliminates the need for alarge incision and creates less tissue damage.Patients who are superobese (more than 350pounds) or have had previous abdominal sur-gery may not be good candidates forlaparoscopy, however. Less common complica-tions include breakdown of the staple line andstretched stomach outlets.

• Some obese patients who have weight-loss surgery develop gallstones. Gallstones areclumps of cholesterol and other matter thatform in the gallbladder. During rapid or substantial weight loss, a person’s risk of devel-oping gallstones increases. Taking supplemen-tal bile salts for the first six months aftersurgery can prevent gallstones.

• Nearly 30 percent of patients who haveweight-loss surgery develop nutritional defi-ciencies such as anemia, osteoporosis andmetabolic bone disease. These deficiencies usu-ally can be avoided if vitamin and mineralintakes are high enough.

• Women of childbearing age should avoid preg-nancy until their weight becomes stable becauserapid weight loss and nutritional deficiencies canharm a developing fetus.

Long-term data for bariatric surgery are stillneeded. One of the most extensive looks at long-term results was a Swedish study of 1,703 individ-uals who had undergone one of several types of

bariatric surgery two years prior and 4,047 peoplewho had surgery a decade prior. Both groups werecompared to a group of obese people who had notundergone surgery. After two years, the weight ofpeople in the control group had increased by 0.1percent, while in the surgery group it haddecreased by 23.4 percent. After 10 years, theweight of those in the control group had increasedby 1.6 percent. Those in the surgery group sawtheir weight decrease to an overall total of 16.1percent, meaning that individuals did gain someweight back. People in the surgery group also con-sumed fewer calories and were more physicallyactive than those in the control group. At both twoand 10 years, the surgery participants had higherrates of recovery from related health risks. Expertsnoted that the surgeons involved were consideredvery experienced.

Buchwald, Henry. “Bariatric Surgery: A SystematicReview and Meta-Analysis.” Journal of the AmericanMedical Association. 292, no. 14 (October 13, 2004):1,724–1,737.

Gardner, Amanda. “Obesity Surgery Shows BenefitsYears 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 Over-weight Adolescents: Concerns and Recommenda-tions.” 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 Cardiovas-cular Risk Factors 10 Years after Bariatric Surgery.”New England Journal of Medicine 351, no. 26 (Decem-ber 23, 2004): 2,683–2,693.

Wessel, Harry. “Workplace Insurance Covers Weight LossSurgery.” The Orlando Sentinel, September 8, 2004,page G-1.

basal metabolic rate (BMR) The rate at whichenergy (fuel, the fat and glucose obtained fromfood) is used by an individual at complete physicaland mental rest for basic body functioning(breathing, heart activity, nervous system activityand various other essential organ functions). It isusually measured in the morning when a personis relaxed and has not eaten since the precedingevening. In an average person, this functioningaccounts for approximately 70 percent of total

58 basal metabolic rate

energy expenditure. The remaining 30 percent islargely a reflection of one’s level of physical activ-ity. The BMR varies according to age, sex andweight. It is highest in children and begins todecline in young adults after age 24, droppingapproximately 5 to 7 percent each decade after age20, making it more difficult to lose weight as onegets older. BMR is also lower in hypothyroidismand higher in hyperthyroidism.

The wide variance in basal metabolic rate amongindividuals is one reason why different peoplerespond differently to identical diet and exerciseprograms. People with high basal metabolic ratestend to remain slim even while eating largeamounts of high-calorie food; those with lowerBMRs seem to gain weight merely “looking” at food.The BMR actually decreases when caloric intake isseverely 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 behaviortherapy in which the changing of human behavioris achieved through conditioning and operanttechniques. In behavior modification therapy, afterdetermining what behaviors are dysfunctional orself-destructive, therapeutic techniques are used toalter or eliminate them.

These techniques are grounded in the theoriesof the behavioral school of psychology, whichholds that human behavior consists almost entirelyof responses to physiological stimuli, and dismissessuch concepts as the subconscious or the uncon-scious and in general, nonphysiological causationof behavior. Therapists of many schools, however,have found techniques developed by behavioriststo be useful in their own practices.

Techniques often used include exposing thepatient gradually to the presumed cause of his dis-tress while teaching him to cope with anxiety;flooding the patient with anxiety-producing stim-uli and preventing him from responding in theusual manner until feelings of anxiety eventuallydisappear; and modeling by performing the anxiety-provoking activity for the patient to copy.

Advocates of behavior-modification therapy saythat it is a more efficient mode of treatment thanpsychoanalytic or other psychotherapeutic

approaches, which often take years and may neverproduce clear and unambiguous results. Oppo-nents argue that it treats only the symptoms of adisorder and does not engage the profound causes,so that symptoms frequently reappear.

In Anorexia and Bulimia

Use of behavior modification for treatment ofanorexia and bulimia was first advocated in 1972.Change is achieved through a reward-and-punish-ment system. Behavior leading to weight gain isrewarded, or “positively reinforced,” by access todesirable activities, and behavior not leading toweight gain is punished by making things unpleas-ant. Proponents of behavior modification claim itachieves weight gain more rapidly than other meth-ods. Detractors express concern that it often provokesserious psychological damage by increasing the innerturmoil and sense of helplessness in patients who feeltricked into losing control over their bodies. HILDE

BRUCH condemned it, pointing out that weight gainin itself is not a cure for anorexia nervosa.

Follow-up observations have shown that weightgain achieved through behavior modification isoften short-lived. Some hospitalized patientsrespond to the therapy in order to gain enoughweight to obtain release from the hospital—andthen freely resume their noneating behavior pat-tern. It has been most successful with patients whocome to it voluntarily and who make a “contract”to gain weight. Overall, behavior modification byitself may be an inadequate treatment, but may bean integral part of a comprehensive treatment.(See EATING HABITS MONITORING.)

Numerous controlled treatment trials haveshown behavior therapy to be as effective or moreso than any other bulimia nervosa treatment towhich it has been compared. Although behaviortherapy also seems to be effective for binge-eatingdisorder, research is in a preliminary stage.

In Obesity

When behavior modification is used in treatmentfor obesity, the therapist first analyzes the patient’scurrent eating habits. Usually this involves thepatient’s maintaining a detailed food diary. Notedin the diary are the types and amounts of foodeaten at various times of the day, where the foodis eaten (at his desk, dining room table, living

behavior modification 59

room, in his car, etc.), activities involved in at thesame time eating takes place (e.g., reading, watch-ing television, listening to the radio, etc.), thedegree of hunger at each time food is eaten andthe mood the patient is in when he or she decidesto eat. The food diary helps identify particular eat-ing patterns or situations in which the patient islikely to overeat.

After a thorough analysis of eating behavior hasbeen made and recurring patterns identified, otherbehaviors are substituted for eating when a partic-ular situation arises. For example, if the patientregularly snacks while watching television, hecould substitute some other behavior such aschewing gum or sipping on a glass of water. If thepatient routinely eats candy when she feels angryor depressed, she can instead do 10 repetitions of asimple exercise or go for a walk or express herthoughts on paper. In this way, a new habit is sub-stituted for the established eating response to cer-tain situations.

If the eating pattern analysis shows that thepatient has poor eating habits, such as eating toorapidly, behavior modification is used to alter andcontrol them. New eating patterns might includeusing smaller dishes, putting the fork downbetween bites and carefully chewing before swal-lowing in order to stretch out a meal and allowstimulation of the SATIETY mechanisms, substitut-ing low-calorie foods like fruits and vegetablesfor high-calorie snacks, eating meals at regulartimes or avoiding distractions such as televisionduring meals.

A central element of most obesity behavior-modification programs is slowing down the act ofeating. It was initially though that doing so wouldinterrupt the “chaining” of behaviors involved ineating: putting food on the fork, lifting it to themouth and so on, which occurred largely outside aperson’s awareness. But it has since been foundthat slowing down the act of eating has an addi-tional benefit because a larger proportion of themeal remains uneaten at the time when the stom-ach and intestine have begun to absorb nutrients,thus producing the physiological signals of fullness.These signals add to the effect of the techniquesused to eat less.

There are specific techniques to help peopleslow their rate of eating, enabling them to become

aware of all its components and gain control overthem. The most frequently suggested one is settingdown one’s fork or spoon between bites. Anotheris to count each mouthful, chew or swallow. Thosepatients who have trouble slowing their eating rateare told to stop eating for one minute late in a mealwhen a delay is more readily tolerated. They arethen instructed to increase the number and dura-tion of delays and begin them earlier.

Patients are also urged to make meals a time ofcomfort and relaxation and to avoid argumentsand the rehashing of problems at the dinner table.They are encouraged to learn to savor food as theyeat it, to make a conscious effort to become awareof it as they are chewing and to enjoy the act ofswallowing and the feeling of warmth and fullnessin their stomach. To the extent that they succeedwith this, they may eat less and enjoy it more.

A system of rewards (positive reinforcement) isthe key element in a behavioral therapy program.Although the ultimate reward is an improvementin health, personal appearance and self-esteem,interim rewards are important in encouragingfaithful adherence to the program. Examplesinclude treating oneself to a movie after a three-pound weight loss or going on a trip after success-fully shedding 10 pounds. Charts recording weightloss and changes in body measurements also pro-vide positive reinforcement.

Brownell and Kramer write that

behavior modification is practiced so widely, thereis a tendency to believe that it consists of littlemore than a series of techniques or tricks such asrecord-keeping and slowing eating. This is mis-taken. a modern day, comprehensive program issophisticated and involves systematic work, notonly on eating behavior, but on exercise, attitudes,social relationships, nutrition, and other factors.The better behavioral programs now are producingweight losses in the range of 25 to 30 pounds.

For many people, adherence to a behavior-modification program is easier if it is administeredin a group setting. Lay groups devoted to weightloss 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-

60 behavior modification

ally moderate. Even though the goal of behaviormodification is a lifelong change in eating habits,many people gradually return to their old eatingbehavior and regain the lost weight.

See also AVERSION THERAPY; EXTERNAL CONTROL

THERAPY.

Brownell, Kelly D., and P. M. Kramer. “Behavioral Man-agement of Obesity.” Medical Clinics of North America73, no. 1 (January 1989): 185–201.

Brownell, Kelly D., and Thomas A. Wadden. “BehaviorTherapy for Obesity: Modern Approaches and BetterResults.” In Handbook of Eating Disorders, edited byKelly D. Brownell and John P. Foreyt. New York:Basic Books, 1986.

Foreyt, J. P., and W. S. Poston. “What Is the Role ofCognitive-Behavior Therapy in Patient Manage-ment?” Obesity Research 6, suppl. 1 (April 1998):185–225.

———. “The Role of the Behavioral Counselor in ObesityTreatment.” Journal of the American Dietetic Association10, suppl. 2 (October 1998): 527–530.

Lewandowski, L. M., et al. “Meta-Analysis of Cognitive-Behavioral Treatment Studies for Bulimia.” Clinical Psy-chology Review 17, no. 7 (November 1997): 703–718.

O’Brien, Robert, and Morris Chafetz. The Encyclopedia ofUnderstanding Alcohol and Other Drugs. New York: FactsOn File, 1999.

behavior therapy Broadly speaking, the applica-tion of cognitive and behavioral science to humanproblems. In general, with behavior therapy, thereis an emphasis on changing behavior, but the mostimportant emphasis is on the application of scien-tific principles to clinical research and therapy.Depending on whose definition one uses, cognitiveinterventions may or may not be considered a partof behavior therapy. Overall, there is more empiri-cal research on behavior therapy or cognitivebehavior therapy for the eating disorders than anyother treatment modality.

Behavior therapy has acquired greaterrespectability in recent years, particularly for thetreatment of bulimia nervosa. Behavioral tech-niques to prevent binge eating include eatingslowly by putting the fork down between eachbite, and always eating with other people.Although results with behavior therapy have beenencouraging during initial treatment, some physi-cians questions its long-term effect. It is most likely

to be effective when the patient anticipates anoncoming desire or need to binge eat. “Automatic”binge eating is not as effectively treated withbehavior therapy.

belly fat Common term for abdominal fat; alsoreferred to as a beer belly, beer gut, potbelly orspare tire. Men especially tend to accumulate fatdeposits in their abdomen, and it often accumu-lates in both men and women as they age. Peoplewhose fat is mostly distributed around the middleare said to be apple-shaped, and are at greaterhealth risk than those who are pear-shaped, withtheir fat located mainly across the hips and thighs.Health writer Nanci Hellmich explains that scien-tists have “discovered that people with wide girthsare more likely to have large amounts of deep-hidden belly fat around their organs. It might bethe most dangerous kind of fat and could increasea person’s risk of diabetes, heart disease, stroke, andsome types of cancer.” This deep abdominal fat iscalled VISCERAL FAT, and a large amount of it is oneof the prime risk factors for METABOLIC SYNDROME.

Studies presented at a 2004 American HeartAssociation meeting showed that having a big bellymay be a prime indicator of future heart attack orserious heart disease. One study of 7,000 middle-aged police officers who died of heart attacks orother sudden heart problems between 1967 and1984 showed that those with potbellies were morelikely to die suddenly, with the risk of suddendeath increasing with abdominal density. Thosewith higher BODY MASS INDEX were not any morelikely to die suddenly—unless they also hadnoticeable belly fat. In the case of men, a 40-inchwaist appeared to be the dangerous cut-off point;for women, the risk begins at 35 inches.

Another study of 2,000 adults 45 years andolder took several measurements of fatness,including waist circumference, neck circumfer-ence, body mass index and skin-fold thickness onthe arms and waist. That study also found thatpeople who had fat in the abdominal area of thebody were more likely to have specific heart symp-toms called left ventricular dysfunction and dias-tolic dysfunction—measures of how well the heartis pumping. When the researchers looked at whodied over five years, those who had poor diastolic

belly fat 61

function and who had large waists were muchmore likely to have died.

People who eat a lot of refined grains like whitebread seem to have paunchier bellies, researchersfrom Tufts University have reported. In their stud-ies, those who consumed the most white bread(four to five daily servings) saw their waistlinesexpand three times as much as those who ate oneserving or less, even when calories were equal.Some of the people the researchers tracked over athree-year period inched up into a larger size ofpants. “Waist circumference was very much associ-ated with this high-refined-grains pattern,” accord-ing to Katherine Tucker, one of the study’s authors.The team is trying to figure out why refined grainsappear to send calories straight to the midsection.One theory is that they appear to be more sensitiveto insulin, which tends to store the calories as fat.

Most experts state that exercise alone will notget rid of belly fat; it takes a combination of exer-cise and eating fewer calories, especially those fromfat. Walking has been shown in tests to be espe-cially helpful in losing belly fat, with some sayingthat the dangerous visceral fat may be the first togo with vigorous exercise like walking.

A few individual small studies have shown thatsubjects lose belly fat when they cut back on eatingsaturated fat, eat three servings of fat-free yogurt aday, add at least 12 grams of fiber to their daily dietor lower their stress levels. Researchers at Washing-ton University in St. Louis reported in 2004 thattaking a supplement that boosts the hormone DEHY-DROEPIANDROSTERONE (DHEA) significantly reducedabdominal fat in a small group of elderly patients.However, no long-term research has definitivelydiscovered a secret to losing belly fat that is any eas-ier or quicker than vigorous exercise and a sensibleweight-loss diet. Even when these are followed,some people resort to LIPOSUCTION in order to get ridof most or all of their subcutaneous belly fat.

See also ADIPOSE TISSUE; BODY FAT DISTRIBUTION.

Hellmich, Nanci. “Belly Full of Danger.” USA Today, Feb-ruary 25, 2003. Available online. URL: http://www.usatoday.com/news/health/2003-02.25-bellyfat-usat_x.htm.

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

body lift and circumferential lipectomy. The proce-dure is basically an ABDOMINOPLASTY (tummy tuck)that is extended around the back when the excessfat and skin involves not only the belly, but also thehips, back, buttocks and outer thighs. Belt lipec-tomy is considered major surgery and, although it isnot offered at many hospitals, it has gained popu-larity as more patients undertake BARIATRIC SUR-GERY. The prime candidates have lost more than100 pounds of weight, resulting in hanging skinand fat beyond the abdomen to include the fulltrunk area. This loose, baggy skin is not onlyunsightly, but can lead to rashes, yeast infections,sores in the skin folds, pain from the sheer weightof the skin and even a faulty center of gravity.

According to Al Aly, M.D., at the University ofIowa Hospitals, where many belt lipectomies areperformed, “Infection, bleeding, and seroma for-mation are the most frequent complications of beltlipectomy. Wound separation is another possiblerisk.” Costs for a belt lipectomy can range from$6,000 to $8,000.

See also PANNICULECTOMY.

Aly, Al, and Zlatko Anguelov. “Belt Lipectomy for Cir-cumferential Truncal Excess.” University of IowaHealth Care. Currents 3, no. 4 (fall 2002). Availableonline. URL: http://www.uihealthcare.com/news/currents/vol3issue4/04belt.html.

benzocaine A crystalline compound used inointments as a mild local anesthetic. When usedin a diet pill, it is supposed to deaden the tastebuds and thereby lessen the craving for food.It is often used in “miracle” pills and weight-reducing candies in combination with methyl cel-lulose, which expands by absorbing water fromthe stomach to give a false sense of fullness.Researchers are divided over whether benzocaineis such small doses (7.5 mg per tablet) actually hasa numbing effect on the salivary glands. But, asEdwin Bayrd wrote in The Thin Game (1987) thatargument “is quite beside the point, for the sali-vary glands are a part of the mouth and the pillsare already in the stomach.”

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

62 belt lipectomy

that are digested together. The first week allowsonly fruit; the second adds a few other items. Anupdated version called The New Beverly Hills Diet(Health Communications) appeared in 1996, andadvocated “conscious combining”—eating fruitalone, eating protein with other protein and/or eat-ing carbohydrates with other carbs. Fats can becombined with either protein or carbohydrates, butnot with fruit. A registered dietitian who reviewedthe book for USA Today said, “If people lose weighton this plan, it’s not because of the food combiningbut because the program is low in calories.”

In Journal of School Health (August 1988),M. Elizabeth Collins stated that the original Bev-erly Hills Diet marked the first time an eatingdisorder—anorexia nervosa—was marketed as acure 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 EatingDisorders Clinic at the University of CincinnatiCollege of Medicine) as yet another symptom of ‘aweight-obsessed culture in which no price is toohigh for thinness, including health.’ ”

P. Wright also condemned the Beverly Hills Diet:“[It] actually advocates a form of bulimia in whichdieters are advised to counteract an eating binge byconsuming large amounts of raw fruit in order toproduce diarrhea.”

Hellmich, Nanci. “New Beverly Hills Diet Slim on Scien-tific Data.” USA Today, December 5, 1996.

Wright, P., “The Psychology of Eating and Eating Disor-ders,” in Psychology Survey 6, edited by Halla Beloff andAndrew M. Colman, 140–165. Cambridge, Mass.: MITPress, 1987.

biliopancreatic diversion (BPD) A complicatedMALABSORPTIVE OPERATION for obesity developed inthe 1970s in Italy, in which portions of the stom-ach are removed. The small pouch that remains isconnected directly to the final segment of the smallintestine, completely bypassing the duodenum andthe jejunum. Although this procedure successfullyleads to weight loss, it is less frequently used thanother types of surgery because of the high risk fornutritional deficiencies. BPD is typically used forpersons with severe obesity who have a BODY MASS

INDEX of 50 or more.

A variation of BPD includes a duodenal switch.This leaves a larger portion of the stomach intact,including the pyloric valve, which regulates therelease of stomach contents into the small intes-tine. It also keeps a small part of the duodenum inthe digestive pathway.

Nutritional deficiencies can occur because mostiron and calcium are absorbed in the duodenumand jejunum. Menstruating women may developanemia because not enough vitamin B12 and ironare absorbed. Decreased absorption of calcium mayalso bring on osteoporosis and metabolic bone dis-ease. Patients are required to take nutritional sup-plements that usually prevent these deficiencies.Patients who have the biliopancreatic diversionsurgery must also take fat-soluble (dissolved by fat)vitamins A, D, E and K supplements.

BPD operations may also cause DUMPING SYN-DROME. Because the duodenal switch operationkeeps the pyloric valve intact, it may reduce thelikelihood of dumping syndrome.

The more extensive the bypass, the greater therisk for complications and nutritional deficiencies.Patients with extensive bypasses of the normal diges-tive process require close monitoring and lifelong useof special foods, supplements and medications.

According to a news item in Obesity Management(January 2005), an analysis of 22,094 patientsundergoing some sort of bariatric surgery between1990 and 2003 showed a mean percentage of excessweight loss to be 61.2 percent for all procedures,with a BPD or duodenal switch resulting in thehighest percentage of weight loss (70.1 percent).“However, this procedure had the highest operativemortality (1.1 percent) for a 30-day or less period.”

Compared to other bariatric surgeries, BPDoffers quicker weight loss (within three to fiveyears) and a better chance to maintain weight losswhile eating larger quantities of food. On the neg-ative side, however, in addition to a greater chanceof nutritional deficiencies, is more likelihood ofchronic diarrhea, stomal ulcers and foul-smellingstools and gas. In a study of 132 morbidly obesepatients who underwent BPD in Italy from Febru-ary 1995 to April 2001, the incidence of complica-tions was higher in those more than 55 years old.

binge-eating Rapid consumption of largeamounts of food during a short period of time. A

binge-eating 63

binge is usually defined as the consumption of2,000 calories or more during the span of one totwo hours. An average binge lasts from 60 to 75minutes, with 3,400 calories consumed (an entirepecan pie, for instance).

A joint Swiss-German-American study pub-lished in 2003 suggested that the melanocortin 4receptor gene, which makes protein that helpsstimulate appetite, may lead some people to bingeeat when it makes too little protein. In the study,“all mutation carriers reported binge eating, ascompared with 14.2 percent of obese subjectswithout mutations and 0 percent of the normal-weight subjects without mutations.” Armstrongquoted scientists as saying that the challenge is tofigure out a way to bypass the receptor in thosepeople with the mutant gene. However, any magicpills to do this are likely years away. According tothe National Institutes of Health, binge eatingstrikes as many as 4 million Americans.

Branson, R., et al. “Binge Eating as a Major Phenotype ofMelanocortin 4 Receptor Gene Mutations.” New Eng-land Journal of Medicine 348, no. 12 (March 20, 2003):1,096–1,103.

binge-eating disorder (BED) Prior to the designa-tion of binge-eating disorder, persons engaging inbinge eating without compensatory behaviors hadreceived a variety of labels, including binge-eatersand compulsive overeaters. Binge-eating is definedin exactly the same way for both BULIMIA NERVOSA

and for binge-eating disorder (BED). The differencebetween bulimia and BED is that BED is character-ized by recurrent episodes of binge eating withoutthe regular use of inappropriate compensatorybehaviors (such as vomiting and laxatives). This isnot to say that people with BED will not on occasionengage in purging behaviors such as compulsiveexercise or vomiting, but they will not do it regularly.

Binge-eating disorder also differs from obesity.Unlike obesity, BED is a psychiatric disorder andshould be treated as such. Because people with BEDbinge on high-calorie foods and do not regularlyengage in purging behavior, most of them are over-weight; however, this does not mean that all over-weight or obese people have binge-eating disorder.

BED was not added to DSM-IV as an officialtype of eating disorder, but rather was added in the

appendix as a disorder needing further evaluation.As defined in DSM-IV, essential features of binge-eating disorder include

• Recurrent episodes of binge eating. A “binge” iswhen one eats more food than most peoplewould eat during a similar time period andunder similar circumstances, plus exhibits a lackof control during the bingeing episode (cannotstop eating or cannot control what or how muchone is eating).

• The binge-eating episodes must be associatedwith at least three of the following: 1. Eatingmuch more rapidly than normal 2. Eating pastthe feeling of “full,” until uncomfortable 3. Eat-ing large amounts of food even though not hun-gry 4. Eating in secret due to shame andembarrassment over the amount being eaten. 5.Feeling distressed, depressed, disgusted and/orguilty after overeating.

• Suffering distress over one’s binge eating in general.

• Binges occur at least twice a week for approxi-mately six months minimum.

• No regular purging.

Medical complications with BED include heartdisease, respiratory problems and psychologicalproblems; frequently substance abuse problemsalso exist. Approximately 50 percent of obese bingeeaters suffer from depression, compared with only5 percent of obese people who do not binge.

If BED is considered an eating disorder, then itis more common than either anorexia or bulimianervosa. The prevalence in the United States,Canada and the United Kingdom has beenreported between 0.7 and 4 percent of the popu-lation. A 1991 study reported 8 percent of womenwho were overweight suffered from BED. Inweight control programs, anywhere from 15 to 50percent of the people suffer from BED. BED usu-ally begins in late adolescence or the early 20s,but onset can be as early as age seven or in the30s and 40s.

It has been reported to be a chronic condition,but little is known about the long-term course ofbinge-eating disorder. In a study of 68 BEDpatients after six years of treatment, the majorityshowed no major DSM-IV eating disorder, while

64 binge-eating disorder

5.9 percent still had BED, 7.4 percent had shiftedto purging type bulimia nervosa, 7.4 percent wereclassified with unspecified eating disorders and onehad died.

Researchers are still trying to find the treatmentthat is the most helpful in controlling binge eating dis-order, and in the meantime BED treatment regimensusually follow those of bulimia nervosa. Antidepres-sants and appetite suppressants have been foundto be reasonably effective in controlling binge eatingfor some. In a randomized, double-blind, placebo-controlled study of patients who met the DSM-IV cri-teria for binge-eating disorder as well as the definitionof obesity based on their body mass index, SIBU-TRAMINE was found to be an effective and safe treat-ment of obese patients with BED over 12 weeks.Another randomized control trial found the anticon-vulsant topiramate to be effective in reducing bingeeating as well as weight. Psychotherapy treatment, inparticular cognitive-behavioral therapy, appears tohave longer-lasting effects than do medications.

Appolinario, J. C., et al. “A Randomized, Double-Blind,Placebo-Controlled Study of Sibutramine in the Treat-ment of Binge-Eating Disorder.” Archives of GeneralPsychiatry 60, no. 11 (November 2003): 1,109–1,116.

Fichter, M. M. “Binge Eating Disorder: Treatment over a6-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. “Empir-ical Classification of Eating Disorder NOS: Support forDSM-IV Changes.” Journal of Psychopathology and Behav-ioral Assessment 14, no. 2 (June 2002): 201–216.

Binge Eating Scale (BES) A self-test developed in1982 by Gormally, Black, Daston and Rardin to assessbinge-eating among the obese. The BES contains 16items designed to measure the behavioral compo-nents of the binge-eating syndrome and the feelingsor 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 withthoughts about food. I feel like I live to eat.

Because I feel so helpless about controlling my eat-ing, I have become very desperate about trying to get incontrol.

Binge Scale A self-test developed in 1980 byHawkins and Clements. It contains nine itemsdesigned to measure binge-eating behavior (e.g.,frequency, duration, rate of eating) and attitudesassociated with BULIMIA. The scale was developed toparallel the diagnostic criteria described in DSM III.

Sample item from the Binge Scale:

How often do you binge?

A. SeldomB. Once or twice a monthC. Once a weekD. Almost every day

biofeedback A technique that seeks to controlcertain emotional states, such as ANXIETY or DEPRES-SION, by modifying, with the aid of electronicdevices, involuntary body functions such as bloodpressure or heartbeat.

This technique has been used with some successin the treatment of eating disorders. Its basic bene-fit is the teaching of relaxation techniques to coun-teract the typically high activity level of anorexics,who tend to deny fatigue and typically are unableto relax. They pursue their activities compulsively,producing excessive levels of automatic arousal(heart, blood pressure and so on), which can leadto psychophysiological stress reactions.

Through connection to the biofeedbackmachines by muscle or temperature sensors, thepatients learn to become active participants in theprocess of relaxation training. Patients find it diffi-cult to deny their condition when the evidence canbe seen on a sound or light monitor. Biofeedbackmay make it easier for the therapist to breakthrough the denial process of anorexic patients.

Pop-Jordanova reported on a small study com-prising obese and anorexic girls, as well as ahealthy control group, in which multimodal ther-apy included a biofeedback relaxation systembased on electrodermal response (EDR). “The EDRbiofeedback was shown to be an effective supportfor mitigation of eating disorders in preadolescents,with better results for anorexic girls.”

The MANDOMETER TREATMENT, developed in Swe-den, has claimed a 75 percent success rate amongthose with eating disorders, including anorexia andbulimia. This nutritional program teaches patients to

biofeedback 65

eat normally and recognize natural feelings of satietyusing a patented computer-based biofeedback system.

In 2003 the National Center for Complementaryand Alternative Medicine, a part of the National Insti-tutes of Health, awarded funds to explore possibletherapies, such as the Flexyx Neurotherapy System(FNS), which is a new form of biofeedback using elec-troencephalograph (EEG) or brainwave information.Neurotherapy is a type of EEG biofeedback treatment,and is used at the Mirasol eating disorders treatmentcenter in Tucson, Arizona (see APPENDIX IV).

Gross, Meir. “Anorexia Nervosa—Treatment Perspec-tives.” In Eating Disorders: Effective Care and Treatment,edited by Félix E. F. Larocca. St. Louis: IshiyakuEuroAmerica, 1986.

Pop-Jordanova, N. “Psychological Characteristics andBiofeedback Mitigation in Preadolescents with EatingDisorders.” Pediatrics International 42, no. 1 (February2000): 76–81.

biopsychosocial model of eating disorders Theprevailing conceptualization of the etiology(causes) of eating disorders and/or obesity. Accord-ing to the model, rather than there being a singlecause, these disorders/conditions are more likelythe product of a complex combination of biologi-cal, psychological and social factors. The precisecontribution of each of these factors may vary,depending on the disorder and the individual.

Johnson, C. and M. E. Connors. The Etiology and Treatmentof Bulimia Nervosa: A Biopsychosocial Perspective. NewYork: Basic Books, 1987.

biotech foods Crops produced by utilizing themodern techniques of biotechnology. Although allcrops have been genetically modified through tradi-tional plant breeding for more than 100 years, withthe tools developed from biotechnology a gene canbe inserted into a plant to give it a specific new char-acteristic instead of mixing all of the genes from twoplants and seeing what comes out. Once in the plant,the new gene does what all genes do: It directs theproduction of a specific protein that makes the plantuniquely different. This technology provides muchmore control over, and precision to, what character-istic breeders give to a new plant. It also allows thechanges to be made much faster than ever before.

Most biotech products are drugs, but the biotechindustry hopes to help fight the global obesity epi-demic by developing healthier varieties of food oilswith fewer calories, as well as new flavor enhancersthat could replace some of the excessive sugar, saltand fats in packaged foods with substances that bothtantalize the taste buds and make foods healthier.For instance, Crabtree explains, “Devising a mole-cule that enhances the sweet taste might allow foodcompanies to make cookies and soft drinks thatrequire less sugar without sacrificing flavor.”

The issue of biotech foods has raised some con-troversy and protests. According to the Food andDrug Administration (FDA), “All labeling for afood product must be truthful and not misleading.If a bioengineered food is significantly differentfrom its conventional counterpart—if the nutri-tional value changes or it causes allergies—it mustbe labeled to indicate that difference.”

Crabtree, Penni. “Weapons for a Food Fight: Firm’s Fla-vor Enhancers May Help in Battle on Obesity.” TheSan Diego Union-Tribune, October 1, 2004. Availableonline. URL: http://www.signonsandiego.com/union-trib/20041001/news_1b1senomyx.html.

Thompson, Larry. “Are Bioengineered Foods Safe?” FDAConsumer, vol. 34, no. 1, January/February 2000.Available online. URL: http://www.fda.gov/fdac/2000/100_bio.html.

body dysmorphic disorder (BDD) Defined bythe DSM-IV as a preoccupation with some imag-ined defect in physical appearance or a gross exag-geration of a slight physical anomaly, thispreoccupation with appearance is excessively timeconsuming and causes significant distress orimpairment in functioning. Symptoms of dissatis-faction with body shape and size that are a func-tion of an eating disorder are exclusionary criteriafor BDD. The most common complaints are aboutfeatures involving the head and body hair, facialfeatures, skin blemishes, thighs, stomach, breasts,buttocks and genitals. It appears that a majority ofpatients have multiple dysmorphic symptoms. Theexact connection between BDD and eating disor-ders is unclear, but Rosen has argued that both arebasically disorders of body image.

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

66 biopsychosocial model of eating disorders

ment, and Treatment Strategies.” Clinical PsychologyReview 21, no. 6 (August 2001): 949–970.

Rosen, James C. “Body Dysmorphic Disorder: Assess-ment and Treatment.” Body Image, Eating Disorders, andObesity. Ed. J. Kevin Thompson. Washington, D.C.:American Psychological Association, 1996, pp.149–170.

body fat Body fat is a reservoir of available fuelfor energy needs. When CALORIES are eaten inexcess of immediate needs, the body converts thisfuel into a storable form (FAT). When an insuffi-cient number of calories are eaten, the body takessome of the stored fat and metabolizes it into avail-able fuel. (See METABOLISM.)

Some body fat is desirable. For example, fatcushions the balls of the feet and protects the bonystructure. Fat insulates the organs from cold duringwinter months and protects them against damagefrom outside the body. Too-low body fat reducesresistance to viral infection.

Excess body fat, however, is harmful. Excess fatrequires the heart to pump harder and at higherpressures simply because the arterial circuit islonger. Fat also chokes down the available pas-sageways, forcing the heart to pump still harder.This extra strain significantly increases the risk ofheart attacks, strokes, hypertension and other car-diovascular diseases. In addition, excess fat putsundue strain on other body organs and has provento significantly increase the risk of diabetes andeven certain types of cancers.

Dutch researchers have reported that internalfat deposits can physically compress the kidneys,cramping their ability to control the flow of fluidthrough the body, resulting in a build-up ofblood pressure.

Compare a five-foot seven-inch football playerweighing 200 pounds and a sedentary executive ofthe same height and weight. The athlete may have6 to 7 percent body fat (at the low end of the rec-ommended range), while the executive may have25 percent (over the recommended maximum).The theoretical maximum percentage of body fat is68 percent. What is recommended? According tothe University California Wellness Letter (January1991), the ideal amount of body fat varies fromperson to person, depending on age, sex, fitnesslevel and genetic makeup. It can also vary accord-

ing to who sets the standards. Many researcherssuggest a desirable range for men of between 11and 18 percent; for women, between 16 and 23percent. Others say that up to 23 percent is accept-able for men and up to 30 percent for women.

Recent data indicate that simple DIETING reduceslean body material (muscle) and predisposes the indi-vidual to regain lost weight with even higher per-centages of body fat (see YO-YO DIETING). However,simultaneous dieting and exercise retains and evenincreases muscle, initially at the expense of water,then fatty tissue. Studies are under way exploringtechniques that could increase thermogenesis andpermit obese people to burn off their excess fat.

During World War II the U.S. Navy sought sub-mariners with low body fat for their greater abilityto withstand nitrogen uptake and discharge, whichprotected them against the “bends.” Thus beganthe search for a reliable means to measure bodyfat. Until recently, the methods most often usedwere hydrostatic testing (water pressure), SKIN

FOLD MEASUREMENT, blood analysis and impedancemeasurements (sound waves).

The direct method for measuring body fat isthrough biopsies. However, other measurementshave been developed and are now used more fre-quently. Densitometric analysis (hydrostaticweighing) compares regular weight with underwa-ter weight in calculating the amount of lean bodymass and body fat. (Because fat weighs less thanwater, a fatter person weighs proportionately lessunderwater than a lean one.) This method hasbecome the “control” against which other fat-measuring methods are compared and standard-ized. However, equipment to perform these testscan usually be found only at certain hospitals oruniversity labs.

Anthropometric measurements such as bodycircumference and thickness of skin fold providemore practical assessments for measuring body fat.In particular, caliper measurements of skin foldshave been advocated for use in behavioralresearch. In this procedure, calipers are used tomeasure the thickness of skin and underlying fat atseveral locations on the body, with results calcu-lated in an equation. However, some researchershave found measurement of height and weight tohave a smaller standard deviation than skin folds,so they are frequently the anthropometric meas-

body fat 67

urements of choice in assessing fatness. In addi-tion, some clinicians have found height and weightmeasurements more convenient, practical and reli-able in treatment than the caliper assessments.

Recently developed instruments offer the abilityto determine an accurate measurement of body fatand lean body mass with no discomfort, withresults in seconds. These fitness and body fat ana-lyzers are based on a technology developed by theU.S. Department of Agriculture. By touching thebiceps, a fiber-optic wand emitting infrared lightsenses a spectrum change (because fat absorbsmore light than muscle or bone) and displays anaccurate body-fat percentage on a digital readout.

Still another development is the bioelectricalimpedance analysis (BIA). This sends a mild elec-trical current through electrodes attached to thefoot and hand; the greater the resistance to elec-tricity, the more body fat. Researchers do not agreeabout the reliability of the BIA and infrared tests.

More recent methods developed for the deter-mination of body fat analysis include ultrasound,computed tomography, dual energy X-ray absorp-tiometry (DEXA), Bod Pod and magnetic reso-nance imaging (MRI).

Ultrasound machines frequently show up athealth fairs, schools and health clubs. An ultra-sound beam radiates through the body area (thebiceps, for example), with the speed it takes to hitthe bone and bounce back determining body fatpercentage. Experts question its accuracy, whichdepends greatly on the expertise of the technicianoperating the machine.

Computed tomography shoots a beam of lowintensity X-rays through a body area, then senses thestrength of the remainder beam after it goes throughthe area. The machine rotates a degree and the pro-cess repeats. Once the scanner collects several of thesereadings, its computer processes the information andproduces a graphical representation of the area.

Dual energy X-ray absorptiometry, a techniquecurrently used to study osteoporosis, has beendemonstrated as a reliable tool for measuring bodyfat. It works by scanning the body from head totoe, using a filter to split the X-ray beam into twoenergy 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 casesfor research rather than for clinical purposes.

The Bod Pod, an orb-shaped body-enclosingchamber, differentiates fat and lean tissue throughcomputerized pressure sensors that determinebody density by measuring the quantity of air dis-placed by the person sitting inside the chamber.Developed with a grant from the National Insti-tutes of Health, more than 100 Bod Pods are in usenationwide. Its accuracy has been reported to cor-relate to that of hydrostatic weighing. Costs for ameasurement may be $50 to $75 or more.

Magnetic resonance imaging (MRI), the latestmethod of testing for body fat, is currently under study.In a 1998 report, Thomas et al. found that the largevariation in individual internal fat content cannot bepredicted from either indirect methods or direct imag-ing techniques, such as MRI or computed tomogra-phy, on the basis of a single-slice sampling strategy.

See also ASSESSMENT OF BODY FAT.

Eliakim, A., et al. “Fitness, Fatness and the Effect ofTraining Assessed by Magnetic Resonance Imagingand Skinfold-Thickness Measurements in HealthyAdolescent Females.” American Journal of ClinicalNutrition 66, no. 2 (August 1997): 223–231.

Gray, D. S. “Skinfold Thickness Measurements in ObeseSubjects.” American Journal of Clinical Nutrition 51, no.4 (April 1990): 571–577.

Lehmann, Annie. “Machine Measures Body Fat byDeducting 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 TheirAccuracy.” Seattle Times, October 2, 1996, Living section.

Mayo Clinic. “New Ways to Measure Body Fat.” MayoHealth Oasis (June 5, 1996).

Thomas, E. L., et al. “Magnetic Resonance Imaging ofTotal 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 Per-centage from Total Body Density or Skinfold-Thick-ness Measurements.” American Journal of ClinicalNutrition 49, no. 11 (November 1989): 1,104–1,115.

body fat distribution The pattern of fat distribu-tion on a person’s body can have as direct a rela-tionship to health and mortality as the totalamount of body fat. For example, in women,upper-body fat may be associated with a higherrisk of diabetes than lower-body fat accumulation.In both men and women, abdominal obesity is

68 body fat distribution

associated with an increased risk of heart disease.Thus, knowledge of body composition and fat dis-tribution is increasingly recognized as an essentialcomponent of an overall nutritional assessment.

A relative predominance of fat in the abdominalregion (called the apple shape) as well as the shoul-ders and neck is found more often in men and isstrongly related to metabolic disturbances such asdiabetes mellitus, hypertriglyceridemia and hyper-tension. In women, gluteal-femoral (buttocks-hip-thigh) obesity is more common, but when they dohave body fat concentrated in the stomach, theyhave a six-times-greater chance of developing breastcancer than women with flat stomachs, according toa study conducted by Dr. David V. Schapira, associ-ate professor of medicine at the University of SouthFlorida College of Medicine. Researchers compared216 women newly diagnosed with breast cancerwith 432 women who were tested but did not havecancer. They found that the cancer patients hadmore abdominal and upper-body fat than those notdiagnosed with cancer. Schapira reported that thewomen with fat in the stomach area had lower lev-els of a protein called sex hormone binding globulin,which leads to increased levels of free estrogen.Increased free estrogen levels are thought to con-tribute to the development of breast cancer. Whenthe women lost weight in the abdominal region,levels of the protein increased.

In another study, conducted at Washington Uni-versity School of Medicine, researchers discoveredthat people with beefy hips and trim waists (pearshaped) have higher levels of a protective form ofcholesterol called HDL than do those who areapple shaped. This is believed to be a possibleexplanation of why people with fat posteriors tendto have healthier hearts than those with big bellies.

Body fat distribution has been related not only tomorbidity and mortality of obesity but also to adi-pose tissue cellularity. That is, in abdominal obesityfat cell size is relatively enlarged, whereas in gluteal-femoral obesity the number of fat cells is increased.

While gender differences are the most obviousinfluences of distribution of body fat, age isanother significant factor; the body changes shapeas it grows and ages. A National Institute on Agingstudy of 1,179 men and women aged 17 to 96showed progressive trends toward increasedupper- and central-body fat deposits with age. In

women there tends to be a postmenopausal accel-eration of this trend.

A Yale University study determined the degree ofweight occupation and body dissatisfaction in 77women between the ages of 21 and 50. Women withthe greatest distribution of their fat in the hips andbuttocks, relative to the abdomen and waist, werethe most eating-disordered and saw attaining the“right” weight as more central to their sense of self.

Individual differences in fat distribution arelargely determined by hereditary factors. Environ-mental factors, including diet and exercise habits,determine the extent to which individual geneticpredispositions are fulfilled.

Underwood and Adler point out that a TuftsUniversity study illustrated how the source of calo-ries might make some difference in where theyend up. In the study, “participants ate roughly thesame number of calories, but those who consumedmore white bread, rice, pasta and other refinedcarbohydrates tended to add fat disproportionatelyaround the middle, even without a big change inweight. Other foods produced little change in waistmeasurements. These good foods included wholegrains, beans, fruits and vegetables.”

Weight loss does not guarantee that inches willbe shed from desired areas. On the contrary, suc-cess as measured on the bathroom scale is oftennot translated into the reality of a more shapelybody as visualized in the imagination. Recent stud-ies have confirmed that some areas of the bodytend to be resistant to slimming.

British researchers have documented the resist-ance of the thighs to weight loss regimens. Mea-surements of women’s waists and thighs were usedto compute a “fat distribution score,” a ratiobetween abdominal and thigh circumferences.Increasing thigh size relative to waist circumfer-ence yielded a lower ratio and vice versa. Follow-ing completion of a weight reduction regimen, fatdistribution scores showed little change, indicatingthat fat was shed proportionately from both areasof the body without altering their proportions rel-ative to each other. This study is consistent withthe experiences and frustrations of many dieterswho, despite weight loss, are unable to achievetheir primary goal, improvement in body shape.

A Boston study reported in the May 1991 Amer-ican Journal of Clinical Nutrition indicated that when

body fat distribution 69

smokers start putting on fat, they are slightly morelikely than nonsmokers to deposit it around theabdomen. Because people with abdominal obesityare more likely to develop heart disease, this find-ing may offer one partial explanation for smokers’higher risk of this disease.

A study presented by the Wake Forest Univer-sity Baptist Medical Center in North Carolina at theannual meeting of the North American Associationfor the Study of Obesity in November 2004 sug-gests that accumulation of fat in the abdominalarea in middle age may increase the risk of disabil-ity in later years. The study followed more than9,000 African-American and white men andwomen age 45 to 64 years for nine years. Hugginsexplained, “Overall, disability risk increased alongwith increasing abdominal fat, and this was oftentrue even among normal-weight study partici-pants. The greatest risk of disability, however, wasfound among those in both the highest body massindex and the highest abdominal fat categories.”

See also ADIPOSE TISSUE; BODY FAT; METABOLIC

SYNDROME.

Huggins, Charnicia. “Too Much Belly Fat May up LaterDisability Risk.” Reuters Health, November 17, 2004.

Underwood, Anne, and Jerry Adler. “What You Don’tKnow about Fat.” Newsweek 144, no. 8 (August 23,2004): 40–47.

Body Image: An International Journal of ResearchA peer-reviewed journal that began publication in2004, and publishes research on body image andhuman physical appearance. It is published by Else-vier, and the editor is Thomas F. Cash, Ph.D.,Department of Psychology, Old Dominion Univer-sity, Norfolk, VA 23529; bodyimage@odu.edu;http://www.elsevier.com or http://www.body-images.com/research/journal.html

body image assessment (BIA) The BIA, originallydeveloped by Williamson and colleagues, is a sim-ple procedure for assessment of body image distur-bance. The test consists of nine silhouettes rangingfrom very small to very large. A research participantor client is asked to select the card that best repre-sents her current body size and her ideal body size.The difference between the two is conceptualized asthe degree of body dissatisfaction. Williamson and

colleagues demonstrated that, when comparedwith same-size controls, persons with bodyanorexia and bulimia nervosa choose a larger cur-rent 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 Validityof a Group Administered Version of the Body ImageAssessment.” Assessment 8, no. 1 (March 2001): 37–46.

Williamson, D. A., et al. “Development of a Simple Pro-cedure for Assessing Body Image Disturbance,” Behav-ioral Assessment 11 (1998): 433–446.

body image disturbance A term that has beenused to describe numerous phenomena but gener-ally refers to a disturbance in the way one thinks,feels, or perceives one’s body or how one behavesregarding such thoughts, feelings or perceptions. Asimplied in this definition, body image disturbance isgenerally conceptualized as having several compo-nents or dimensions: a) a perceptual component thatrefers to how accurately someone can estimate his/her own body size, b) a subjective/attitudinal com-ponent that refers to attitudes, feelings, and thoughtsabout one’s body, and c) a behavioral componentthat refers to avoidance of situations that may causesomeone to experience dysphoria due to body imageconcerns. It has been found that body image distur-bance and body dissatisfaction are associated witheating disordered attitudes and behaviors and thatbody image disturbance likely plays a causal role inthe development of eating disorder symptoms.

Currently, some aspect of body image distur-bance is included as a diagnostic criterion for bothanorexia and bulimia nervosa. For anorexia ner-vosa, the criterion reads that there is a “Distur-bance in the way in which one’s body weight orshape is experienced, undue influence of bodyweight or shape on self-evaluation, or denial of theseriousness of the current low body weight.” Forbulimia nervosa the criterion simply reads that“self evaluation is unduly influenced by bodyshape and weight.” Both of these criteria havesomewhat decreased the emphasis of perceptualbody image and indeed much research suggeststhat the effective body image (i.e., how one feelsabout one’s body) may be most important withregard to eating disorders. However, research byWilliamson, Gleaves and colleagues suggests that

70 Body Image: An International Journal of Research

the perceptual component should not be aban-doned because it may contribute to one’s overallfeelings about one’s body may be equivalent foranorexia and bulimia nervosa.

Experiencing body image disturbance (or dis-torted body image) is like booking into a funhousemirror: You see yourself as fatter than you are. Forthe ANOREXIA NERVOSA patient, misperceptionreaches quasi-delusional proportions and is evidentin the anorexic’s lack of concern about, stubborndefense of or inability to recognize an emaciatedcondition. Some patients display a variation of thisdisturbance in which their misperception isrestricted to a particular part or parts of the body.Stomach or thighs are magnified in a patient’s mindand seem disproportionate to the rest of the body.These patients will acknowledge that in general theyappear emaciated but believe that further dieting isnecessary to eliminate a protruding belly or someother perceived unattractive feature. HILDE BRUCH

first recognized body image disturbance to be anessential characteristic of anorexia nervosa, and sheconsidered its correction necessary for recovery.

An analysis of multiple ethnic groups by the Uni-versity of South Florida showed Caucasian and His-panic Americans exhibiting more weight-relatedbody image disturbance than African Americansand Asian Americans. African Americans had themost positive general appearance body image.

Many obese individuals perceive themselves aslarger than they are and have very negative atti-tudes toward their body. Patients who have beenobese as children or adolescents and who subse-quently lose weight often retain a distorted per-ception of themselves as very obese. In a 1996study, obese individuals with binge-eating disorderreported significantly greater body image distur-bance than obese non-binge-eating participants

See also OBESITY; CHILDHOOD OBESITY; ADOLES-CENT OBESITY.

Altabe, M. “Ethnicity and Body Image: Quantitative andQualitative Analysis.” International Journal of EatingDisorders 23, no. 2 (March 1998): 153–159.

Ben-Tovim, David I. “Body Size Estimates: Body Imageor Body Attitude Measures.” International Journal ofEating Disorders 9, no. 1 (1990): 57–67.

Gleaves, David H., et al. “Clarifying Body Image Distur-bance: Testing a Multidimensional Model Using Struc-tural Modeling. Journal of Personality Assessment 64, no.3 (June 1995): 478–493.

Mussell, M. P., et al. “Differences in Body Image andDepression among Obese Women with and withoutBinge Eating Disorder.” Obesity Research 4, no. 5 (Sep-tember 1996): 431–439.

Rucinski, Ann. “Relationship of Body Image and DietaryIntake of Competitive Ice Skaters.” Journal of the Ameri-can Dietetic Association 89, no. 1 (January 1989): 98–100.

Steiger, H., Fraenkel, L. and P. P. Leichner. “Relationshipof Body-Image Distortion to Sex-Role Identifications,Irrational Cognitions, and Body Weight in Eating-dis-ordered Females.” Journal of Clinical Psychology 45, no.1 (January 1989): 61–65.

Thompson, J. K., and S. Tantleff-Dunn. “Assessment ofBody Image Disturbance in Obesity.” Obesity Research6, no. 5 (September 1998): 375–377.

Williamson, D. A., B. A. Cubic, and D. H. Gleaves.“Equivalence of body image disturbance in anorexiaand bulimia nervosa.” Journal of Abnormal Psychology102, no. 1 (February 1993): 177–180.

body mass index (BMI) A way of measuringbody mass, defined as weight in kilograms dividedby height in meters squared. BMI is the measure-ment of choice for many physicians andresearchers studying obesity. In June 1998, theNational Institutes of Health adopted the BMI stan-dard in the dietary guidelines issued earlier by theDepartment of Agriculture. Under those guide-lines, a BMI under 19 is underweight, BMI 19 to25 is healthy weight, BMI 25 to 29.9 is overweight,BMI 30 to 39 is obese and BMI 40 and above ismorbidly obese. A BMI cutoff of 17.5 or less is usedfor defining anorexia in the International Classifi-cation of Diseases, Tenth Revision (ICD-10).According to the guidelines, a BMI of 30 is about30 pounds overweight and is equivalent to 221pounds in a six-foot-tall person and to 186 poundsin someone who is five feet six inches tall. The BMInumbers apply to both men and women.

The BMI measurement poses some of the sameproblems as the weight/height tables. Doctorsdon’t agree on the cutoff points for “healthy” ver-sus “unhealthy” BMI ranges. BMI also does notprovide information on a person’s percentage ofbody fat. Some very muscular people may have ahigh BMI without health risks. Also, BMI mayunderestimate body fat in older persons and otherswho have lost muscle mass. However, like theweight-for-height table, BMI is a useful generalguideline (also known as Quetelet’s index).

A shortcut to estimating BMI is to multiply one’sweight (in pounds) by 704.5, then divide the result

body mass index 71

by height in inches, then divide again by height ininches. The result should be close to one’s BMI.The National Institutes of Health offers a Web pagethat does the computing at http://www.nhlbisupport.com/bmi/bmicalc.htm.

See also WAIST-TO-HIP RATIO.

Greil, H., and U. Trippo. “Physique and Body Composi-tion: Comparisons of Methods and Results.” CollegiumAntropologicum 22, no. 2 (December 1998).

body types Typologizing the human body, or clas-sifying bodies by shape and size, has been proposedsince Hippocrates, who described the basic Greekphysiques as phthisic (linear and vertical) andapoplectic (broad and horizontal). ErnstKretschmer, a 19th-century psychiatrist, divided thepopulation into pyknics (short and round) andasthenics (lean and long legged), with athletesfalling somewhere in between. After analyzingthousands of specially posed photographs, WilliamSheldon devised a three-part classification of bodytypes in 1940. He named them ENDOMORPHS (soft,round, fleshy, light boned, well padded), MESO-MORPHS (muscular, square, broad shouldered,sturdy) and ECTOMORPHS (long legged, fragile, thin,skeletal, linear) Sheldon also claimed that body typeis an unalterable inheritance, demonstrating by hiselaborate measurement system that people retainedthe same basic body type after weight changes of asmuch as 100 pounds. He demonstrated that evenafter subjects underwent semi-starvation for sixmonths and changed outward signs of body type,they all returned to their original shapes within twoyears. Forced-weight-gain tests produced similarresults. Kretschmer’s and Sheldon’s studies are notconsidered scientifically sound today.

body wrapping A technique claimed by huck-sters on late-night television, in magazine ads andon the Internet to cause layers of fat to disappearwithout dieting. Common body-wrapping devicesin the past have included sauna suits or heatedbelts strapped to the waist or stomach or whateverarea needed reduction. The heat produced by suchgadgets, either alone or when used in conjunctionwith exercise, supposedly melts away fat much asa hot stove burner melts lard or butter in asaucepan. The advertisements do not explain how

the body can withstand temperatures high enoughto melt deposited fat, or how the melted fat will beeliminated from the body.

Current popular body wraps include plastic orcotton cloths soaked in herbal products. Some-times the cream, gel or lotion is applied to theskin before the wrap is worn. Body wraps tem-porarily cause a loss of inches and sometimespounds due to fluid loss or perspiration. The fluid,along with the inches or pounds, is soon replacedby drinking or eating. Experts consider bodywraps to be potentially dangerous because theycan bring about severe dehydration, personalinjury from circulatory constriction or cardiacincident while exercising.

See also FRAUDULENT PRODUCTS.

McCurdy, John A., Jr. Sculpturing Your Body: Diet, Exerciseand Lipo (Fat) Suction. Hollywood, Fla.: Frederick FellPublishers, 1987.

borderline personality disorder A personality dis-order characterized by instability in numerous areasof one’s life, impulsiveness and fears of abandon-ment. Research suggests that borderline personalitydisorder is the personality disorder most frequentlyassociated with eating disorders. However, some ofthis comorbidity may be due to an overlap in the cri-teria. For example, the binge eating of a person withbulimia nervosa would also meet the impulsivenesscriteria for borderline personality disorder.

brain activity and obesity In recent years, scien-tists have been working at deciphering the con-nections between human brain activity andobesity. Antonio Tataranni, a nutrition expert atthe National Institutes of Health’s branch office inPhoenix, found that six different regions in thebrains of 55 volunteers responded in differentways depending on whether the subjects werehungry or full, fat or thin. According to Boyd,“Tataranni took PET (positron emission tomogra-phy) scans of the volunteers after they had gonewithout food for 36 hours, and again after theywere fed a hearty meal. He discovered significantchanges in the way six different sites in the vol-unteers’ brains responded to hunger and full-ness.” Tataranni explained that different regionsof the brain work in concert to orchestrate nor-

72 body types

mal eating behaviors and conspire to produceobesity and other eating disorders. He noted that11 people in the study were of special interestbecause they were formerly obese and their brainscans resembled those of fat people more thanthin people. “We are now working on the vastlymore important and complicated questions ofwhich of these neural differences may cause obe-sity in the first place.”

An earlier study suggested that reduced brainactivity of dopamine, a naturally occurring substancethat modulates feelings of pleasure, may contribute toobesity as well as drug addiction. The National Insti-tute on Drug Abuse (NIDA) funded study led by Gene-Jack Wang, M.D., of the U.S. Department of Energy’sBrookhaven National Laboratory found that thebrains of obese individuals have relatively few of thenerve cell components called D2 receptors throughwhich dopamine acts to stimulate pleasurable feel-ings from basic activities such as eating and sex. Indi-viduals with this deficiency may need to overeat toget feelings of gratification from food, the researcherssay. Because a deficit of the same receptor has beenimplicated in addiction to cocaine, heroin and otherdrugs of abuse, the researchers suggest that it may belinked to a range of compulsive behaviors.

A later NIH study also led by Wang revealed thatthe parts of the brain responsible for sensation inthe mouth, lips and tongue are more active inobese people than in normal-weight control sub-jects. This enhanced sensitivity could at least par-tially account for the powerful appeal andsignificance that food has for obese individuals.

Tataranni and colleagues at Good SamaritanMedical Center in Phoenix, Arizona, took picturesof the brains of 21 obese and 20 lean, hungry sub-jects, both before and after tasting a liquid meal(Ensure Plus) following a 36-hour fast. Their find-ings were presented at the 2004 annual meeting ofthe Endocrine Society. The researchers found sig-nificantly elevated activity in the brain regions thatare activated in response to the sensory and emo-tional aspects of food ingestion in the obese sub-jects. “Abnormally high activity in the insularcortex region of the brain, which responds to thesensory experience of food, may put people at anincreased risk for developing obesity. Continuedresearch in this area could help us understand whysome people consistently overeat and are suscepti-

ble to gaining weight.” It is unknown whether thebrains of obese people are especially sensitive tofood stimuli or if other aspects of being obesechange the way the brain responds to any stimu-lus, noted the researchers.

Boyd, Robert S. “Researchers Use Brain Activity as Mar-keting Tool, Obesity Clue.” Knight Ridder/TribuneNews Service, June 25, 2004.

Mathias, Robert. “Pathological Obesity and Drug Addic-tion Share Common Brain Characteristics.” NIDANotes 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 mostimportant meal of the day, recent research is show-ing that breakfast may have more influence onobesity than scientists had realized. A study thatfollowed nearly 4,000 healthy people ages 25 to37, who answered surveys, found that people whoeat breakfast are significantly less likely to be obesethan those who frequently skip the morning meal.The risk reduction for obesity was consistent forwhite men and women and for black men, but notfor black women, a difference the researchers arecontinuing to study. The study was limited, how-ever, because researchers cannot determine causeand effect from a self-reporting study.

Another study of 499 people over a year’s timealso found that skipping breakfast was associated withincreased prevalence of obesity—this study showed4.5 times greater risk—as was greater frequency ofeating breakfast or dinner away from home.

Because of findings such as these, researchersare beginning to look more closely at what peopleeat for breakfast. A study funded by Kellogg USAand conducted by UC Berkeley researchers investi-gated the relationship between breakfast type,energy intake and body mass index (BMI). Theanalyzed breakfast categories were breakfast skip-pers, meat/eggs, ready-to-eat cereal, cooked cereal,breads, quick breads, fruits/vegetables, dairy,fats/sweets and beverages. Breakfast skippers andfruit/vegetable eaters had the lowest daily energyintake. The meat/egg eaters had the highest dailyenergy intake and one of the highest BMIs. The

breakfast and obesity 73

authors concluded, “This analysis provides evi-dence that skipping breakfast is not an effectiveway to manage weight. Eating cereal (ready-to-eator cooked cereal) or quick breads for breakfast isassociated with significantly lower body massindex compared to skipping breakfast or eatingmeats and/or eggs for breakfast.”

Cho, S., et al. “The Effect of Breakfast Type on Total DailyEnergy Intake and Body Mass Index: Results from theThird National Health and Nutrition ExaminationSurvey (NHANES III).” Journal of the American Collegeof Nutrition 22, no. 4 (August 2003): 296–302.

Ma, Yunsheng, et al. “Association between Eating Pat-terns and Obesity in a Free-Living US Adult Popula-tion.” American Journal of Epidemiology 158, no. 1 (July2003): 85–92.

brown fat A type of tissue named for its brownishcolor, caused by the numerous blood vessels thatcourse through it. In humans, thermogenesis takesplace in brown fat tissue. Thermogenesis is a process,induced by food intake or by cold temperatures,whereby calories are converted to heat. An impair-ment in thermogenesis can result in greater efficiencyin energy storage, which could lead to excess fat.

Abundant in newborn infants, brown fat can befound under the arms, across the back, near thekidneys and around large blood vessels in thechest. Research suggests that defective brown fatcells might be the cause of obesity in some people.Heavy people appear to have less brown fat thanaverage-weight people, and what they do haveseems to work inefficiently. All this is conjecture,with nothing proven scientifically.

Bruch, Hilde (1904–1984) A practicing psychi-atrist and professor of psychiatry at Baylor Collegeof Medicine in Houston. In the years followingWorld War II, she was the most influential personin the United States in shaping the conception ofeating disorders as psychiatric illnesses and in for-mulating psychotherapeutic approaches to theirtreatment. Throughout her work Bruch stressedthe formation of individual personality and factorswithin the family that precondition victims ofthese disorders to respond to certain kinds of prob-lems by self-starvation or overeating.

Bruch did not regard obesity as a single condi-tion but distinguished three main forms: in some

individuals obesity is due to physical factors, andtheir weight has no association with emotionalproblems. Others have “reactive obesity,”brought about by overeating in situations of psy-chological stress. The third type, “developmentalobesity,” has its onset in childhood and is associ-ated with a disturbance in the maturation of theindividual’s personality.

Bruch was one of the first to stress that manycognitive defects in anorexics are directly related tostarvation. Therefore, a meaningful psychiatricevaluation is possible only after the worst effects ofmalnutrition have been corrected.

Bruch’s principal works include Eating Disorders:Obesity, Anorexia Nervosa, and the Person Within (NewYork: Basic Books, 1973); The Golden Cage: TheEnigma of Anorexia Nervosa (Cambridge, Mass.: Har-vard University Press, 1978; New York: VintageBooks, 1979); Conversations with Anorexics/HildeBruch, edited by Danita Czyzewski and MelanieA. Sur (New York: Basic Books, 1988).

bulimarexia A term coined in 1976 by MarleneBoskind-White to cover the compulsive practice ofbingeing and purging; at the time BULIMIA was offi-cially described as bingeing without purging (DSM-II). Bulimarexia was called a “nomenclatureatrocity” by HILDE BRUCH. Though still used by someresearchers and clinicians as interchangeable with“bulimia” or “bulimia nervosa,” in the current DSM,this term would be best captured under the diagno-sis of anorexia nervosa, binge eating/purging type.

Boskind-White, Marlene, and William C. White Jr. “Buli-marexia: A Historical-Sociocultural Perspective.” InHandbook of Eating Disorders, edited by Kelly D. Brownelland John P. Foreyt. New York: Basic Books, 1986.

bulimia The word bulimia literally means “oxhunger” or gorging. It refers to the compulsivepractice of binge eating. The term has been used invarious ways by different medical authors, forexample, to describe a subgroup of patients withanorexia nervosa who also binge eat. In the DSM-III, bulimia was an official diagnostic category.However, with the DSM-III-R and DSM-IV, the cri-teria were refined and the name changed toBULIMIA NERVOSA. Today, although some researchersand/or clinicians use the terms bulimia and bulimia

74 brown fat

nervosa interchangeably, it is more appropriate touse the term bulimia to refer to the symptom ofbinge eating and bulimia nervosa to refer to thecurrent disorder as defined in the DSM-IV.

bulimia nervosa An eating disorder character-ized by recurrent binge-eating followed by somecompensatory behavior (e.g., vomiting or use oflaxatives). Also characteristic of the disorder is anintense preoccupation with body size and shape. Itis not known to be caused by any physical illness;genetic and neurochemical factors have beenimplicated in its cause. It usually begins in adoles-cence or early adult life and is 10 times more com-mon in females than in males.

A number of terms have been used to describethis disorder, but the term bulimia nervosa intro-duced by GERALD F. M. RUSSELL, is the most widelyaccepted and frequently used because it implies alink to ANOREXIA NERVOSA and differentiates thesyndrome from simple binge-eating (bulimia). Inmoments of stress, bulimics turn toward food, notaway from it as anorectics do. Bulimic patients areusually more distressed and humiliated by theirbehavior than anorectics, swinging betweenintense feelings of self-control while dieting andtotal self-loathing when bulimic.

Sometimes eating behavior becomes bizarre. Ayoung woman from a financially secure back-ground may search through garbage for food.Another may shoplift food or steal money fromfriends and family to buy it. The behavior that sup-ports the “habit” of recurring bulimia can resemblethat of alcoholism, and its cost may also be similar.

Bulimics usually control their eating while busywith other things, but during solitary leisure timethey may eat to the point of exhaustion. Enormousamounts of food may be eaten at one time, as manyas 20,000 calories a day. Some studies have shownthe average binge to last slightly less than 11/4

hours and to include slightly more than 3,400 calo-ries. However, research also demonstrates thatthere is great variability (in terms of size) in whatpersons with bulimia nervosa call a binge. Whatseems to be the most salient feature is the feelingof lack of control during the eating episode. Never-theless, the DSM-IV does now specify that, in orderto meet the diagnostic criteria for the disorder, theperson does have to engage in objectively large

binges at least twice per week. This bingeing will befollowed by purging via vomiting (induced by gag-ging, emetics or simply willing it), diuretics or lax-atives (from 50 to 100 or more tablets at one time).

Although it is common in most industrializedcountries, bulimia nervosa is said to be epidemic inthe United States. It is harder to detect thananorexia because there is no obvious physical evi-dence such as emaciation, and thus the extent ofbulimia nervosa is less clear than that of anorexia,but medical experts estimate that as many as 16 to30 percent of all women may have practiced bulimicbehaviors to some degree. The condition usuallybecomes symptomatic between ages 13 and 20.According to DSM-IV, the prevalence of bulimianervosa among adolescents and young adultfemales is 1–3 percent. When Drewnowski, Yee andKrahn of the University of Michigan conducted asurvey of college freshman in 1988, they found theincidence of bulimia nervosa to be 4.2 cases per 100women per year. The rate remained stable (2.9–3.3percent) as new cases were offset by partial remis-sions. Some women continued bulimic behaviorswithout meeting full diagnostic criteria. In a surveyconducted of 1,728 10th-grade students, 13 percentreported purging behavior. Female purgers outnum-bered male two to one. Until recently, anorexia wasmore common, but bulimia became the eating dis-order of the 1980s, achieving almost celebrity status.

Yet David E. Schotte and Albert J. Stunkardreported in 1987 in the Journal of the American MedicalAssociation a different view of the “sweeping epi-demic” of bulimia. They interviewed a sample of1,965 students at the University of Pennsylvania,using a 15-item self-report questionnaire. Only 1.3percent of the female and 0.1 percent of the malerespondents met diagnostic criteria for bulimia. Fromthis study they determined that whether there is anepidemic of bulimia on the college campus or notdepends on the definition of bulimia. “If bulimia isdefined as self-reported overeating, or even as self-reported overeating in combination with occasionalpurging, then the answer is an emphatic ‘yes.’ If, how-ever, the term ‘bulimia’ is restricted to the diagnosisof a clinically significant disorder, the answer is ‘no.’ ”

Bulimia has been called the disease of successbecause the typical bulimic is a professionalwoman in her mid- to late-twenties, college edu-cated, single and working and living in a big city—

bulimia nervosa 75

an overachiever. Increasing numbers of men arebeing reported with bulimia nervosa, estimated atbetween 5 and 10 percent of adult males, althoughit is theorized that there are many more who donot reveal their bulimic activities because of its per-ceived status as a “woman’s disease.”

Many of these men form a bona fide subgroup ofovereaters and compulsive exercisers. Rather thanfollowing the typical binge/purge cycle, they arepreoccupied with physical activity. After exercisingfor hours, they will become ravenously hungry andeat uncontrollably. Sometimes the food will be areward for the frantic workout, but afterward thethought of the calories ingested will cause them tobegin the cycle again with even more exercising.

The disorder can go undetected for years, even byclose family members. Both the gorging and purgingare carried out in secret, with all evidence destroyed.Because the bulimic appears outwardly to be quitesuccessful in school or career, no one suspects thatshe does not feel as good as she may appear to be. Itis not unusual for a diagnosis not to be made until apatient is well into her thirties or forties.

Bulimia typically begins during the late teens orearly twenties, after the patient has unsuccessfullytried to lose weight via several reducing diets,especially when restrictive dieting results inhunger. The hunger is satisfied by bingeing. Eitherthrough reading about it or hearing a fellow stu-dent or coworker talk about it, the patient learnsthat self-induced VOMITING or laxative use will getrid of the extra calories, thereby relieving feelingsof guilt brought on by the binge eating. However,self-induced vomiting leads to further hunger. Ulti-mately, a vicious cycle is established, perpetuatedby emotional disturbances and the continuingdesire to lose weight. Some bulimics begin withvomiting after regular meals to lose weight andonly binge eat later when their hunger and crav-ings increase because of the lowered energy intake.During a binge, bulimics typically eat foods high inCARBOHYDRATES, foods they would normally not beallowed to eat on healthy or weight-reductiondiets, setting aside time each day for solitary, secretbinge eating. However, therapists have reportedpatients eating salads, vegetables, cheese, meat andyogurt during a binge.

University of Alabama researchers report thatmore women who were college freshmen in the

mid-1960s are engaging in extreme weight-controlmeasures such as bulimia-like behavior today thanthey did in their high school and college years.Bulimia-like behaviors reported in the studyincluded the use of DIET PILLS, laxatives and diuret-ics, self-induced vomiting, FASTING and bingeing.This study was conducted to determine if theincrease in bulimia-like behaviors reported by psy-chologists was real or just a reflection of greaterawareness of such problems. Results showed thatthere is indeed a real increase and that those at riskare not just college women overly concerned withdating and appearance but older women as well.

The researchers surveyed 159 women, rangingin age from 35 to 45, who were college freshmen in1964. Subjects were asked about their weight-con-trol practices during high school, college and today.Most reported an increase in the use of extremeweight-control measures (diet pills, fasting, laxa-tives, etc.) during the years since high school. Forexample, 84.7 percent said that they had neverused diet pills when they were in college, but thatfigure has dropped to 77.4 percent today.

Comparing these results with those of a similarstudy in 1983, researchers found that a large pro-portion of both age groups saw themselves asheavier than they were, a problem that is linked tobulimia, anorexia and other eating disorders. (SeeBODY IMAGE DISTURBANCE.) The study indicates thatolder women, as well as adolescents, are feelingmore pressure about their weight. Researchersrelated this to the fact that we live in a very youth-oriented society and that cultural pressures to bethin are great. Many women are trying to conformto an ideal body image that is almost impossible toobtain without these extreme unhealthy measures.

A study released in February 1999 adds evi-dence that bulimia springs at least in part from achemical malfunction in the brain and not merelyfrom exercising desire to remain thin. Women whohad suffered from bulimia and recovered weremore affected psychologically than other womanby being deprived of tryptophan, which plays anindirect role in appetite regulation.

The role of the family is also being looked atclosely by researchers attempting to determine thecauses or origins of bulimia nervosa and other eat-ing disorders. A 1989 study comparing 50 bulimicwomen with 40 non-eating-disordered women, all

76 bulimia nervosa

from the same geographic area, revealed no signif-icant differences between the two groups in socialclass, family size, birth position or sibling sex ratio,but the parents of bulimic women were found tohave been significantly older than those of thecontrol group at the time of birth of their daugh-ters. An earlier study (1983) had found no signifi-cant difference in this area. Researchersdetermined that further study is needed in order todetermine what significance these later findingsmay have. According to DSM-IV, several studieshave suggested an increased frequency of bulimianervosa in the first-degree biological relatives ofindividuals with bulimia nervosa.

Drewnowski, A., D. K. Yee, and D. D. Krahn. “Bulimia inCollege 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 SweepingEpidemic?” Journal of the American Medical Association258, no. 9 (September 1987): 1213–1215.

Clinical Features

Typical physical signs of bulimia nervosa includedark circles under the eyes, tooth decay, puffinessaround the face (eyes and below cheeks), facialpallor, red knuckles, dull and lifeless hair and lossof hair. In many bulimics, the menstrual cyclebecomes irregular. Bulimics may be—but rarelyare—emaciated; they are most usually of normalweight but sometimes are overweight.

Bulimic behavior is to be suspected wherethere is evidence of consumption of unusuallylarge amounts of high-calorie foods, especially ifconsumed alone or secretly. A diagnosis ofbulimia nervosa requires binge eating at leasttwice a week for three months. Other signsinclude excessive exercise or fasting, a preoccupa-tion with food, weight and bodily concerns, fre-quent weight fluctuations due to alternativebinges and fasts or purges, increased time spentalone and less with family and friends, theft ofmoney for binges and frequent trips to the bath-room, especially after meals. Sexual interest mayalso diminish, but not always.

Emotionally, bulimic patients have feelings ofdepression and self-loathing after eating binges,feel unable to control eating behavior and may

appear embarrassed, angry, tense and oversensi-tive. COGNITIVE DISTORTIONS may also exist:

• Denial Bulimics seek acceptable reasons forunacceptable behavior. Whereas others say obe-sity results from a simple lack of willpower, thebulimic will have excuses or even lie about hisovereating (“I eat because . . .”) (“I don’t knowwhy I’m fat . . . I never eat.”). Bulimics hide theirpurging by using breath sprays, mints and chew-ing gum. They will often seek “magic” cures fortheir problems (depression or obesity) throughsuch 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 thanthey actually are or may base their self worth ontheir body size and shape. (See BODY IMAGE DIS-TURBANCE.)

• Fictional Finalism Bulimics often believe thatthere is a “magic” weight, and that once theyattain it, they will have happiness and success(“If I were 120 pounds, everything would beperfect”). They usually find that everything isthe same except that they do not have food as abar against reality.

• Rigidity and Inflexibility Bulimics develop an atti-tude of intransigence, characterized by an air of“I’m right and you’re not.” This is most obviousin their refusal to try suggested cures or in theirrigid persistence with diets that do not work.

Psychologists Barbara Bauer and WayneAnderson have identified nine irrational beliefscommonly held by bulimics that are related tothese emotional distortions: (1) Becoming over-weight 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 isworthless. (5) Everyone is aware of, and interestedin, what I am doing. (6) Everyone must love me andapprove of what I do. (7) External validation is cru-cial to me. (8) As soon as a particular event such asgraduation or marriage occurs, my bulimic behaviorwill disappear. (9) I must be dependent and sub-servient yet competitive and aggressive.

bulimia nervosa 77

The most universal belief, and the one most dif-ficult to modify, appears to be the fear of becomingfat and the failure it represents. Bulimics obsessabout and belittle themselves over the slightestweight gain. Although not everyone with bulimiaholds all these beliefs, therapists say all are likely tobelieve in some of them.

A bulimic’s weight may fluctuate but not neces-sarily to the dangerously low levels seen in anorex-ics. Also unlike anorexics, bulimics are commonlyupset by their actions and willing to accept help;they frequently join self-help groups or even seekmedical help. Furthermore, they are usually out-going and have developed attachments, whereasanorexics 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 fea-tures in common with drug or alcohol addicts. Theymay spend $50 or more a day on food to supporttheir habitual bingeing and often resort to stealingmoney or shoplifting food. (See MULTICOMPULSIVE.)

A California School of Professional Psychologystudy in 1987 compared two groups of bulimicwomen: bulimics who compensate for binges bypurging through laxatives, diuretics, vomiting andspitting out food, and bulimics who compensate byfasting. These two groups were compared with eachother and with a third group of nonbulimic womenfor self-esteem and self-role concept. All were ofnormal weight and were selected from a nonclini-cal population of undergraduate college students.

Prior to the study, researchers hypothesized thatthe three groups would differ on self-esteem, withthe purging group having the lowest; that thegroups would differ on components of gender-related behavior patterns, with the purging grouphaving the lowest score on real-self “femininity”and the highest on ideal-self and imagined male-ideal “femininity”; and that low self-esteem wouldrelate to discrepancies between components ofgender-related behavior patterns.

Contrary to expectations, although the bulimicgroups combined had lower self-esteem than thenonbulimic group, when the two bulimic groupswere examined separately, only the fasting grouphad lower self-esteem than the nonbulimic group.Moreover, while results indicated that low self-esteem correlates with certain discrepancies for

nonbulimics, and that in both fasting bulimics andnonbulimics high self-esteem correlates with a real-self sex-role concept incorporating masculine andfeminine gender characteristics, no correlation wasfound among these variables for purging bulimics.

Bauer, Barbara, and Wayne Anderson. “Bulimic Beliefs:Food for Thought.” Journal of Counseling and Develop-ment 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 40percent of bulimics; for those whose weight fallsbelow 92 percent of ideal body weight, there is anincreased likelihood of AMENORRHEA. RepeatedVOMITING dissolves tooth enamel and makes thegums recede, can tear the esophagus and stomachand may cause the salivary glands to swell. BINGE

EATING can overload the stomach, causing it toexpand and even rupture. Low potassium in theblood can lead to heart problems and death andcan upset the body’s balance of electrolytes(sodium, magnesium, potassium and calcium),causing fatigue, seizures, muscle cramps, irregularheartbeat and decreased bone density (seeOSTEOPENIA). Other complications include diges-tive problems, bursting blood vessels in the eyesand cheeks, headaches, rashes, swelling aroundthe eyes, ankles and feet, weakness, kidney failureand heart failure. Bulimia can also cause scarringon the backs of hands when fingers are pusheddown the throat to induce vomiting. For diabetics,bingeing on high-carbohydrate foods and sweets isparticularly hazardous, because their pancreasmay not be able to metabolize properly thestarches and sugars.

Bulimics speak of being “hooked” on certainfoods (particularly CARBOHYDRATES) and needing tofeed their “habit.” This so-called addictive tendencyseems to carry over into other areas, includingabuse of drugs and alcohol and KLEPTOMANIA (com-pulsive stealing). (See MULTICOMPULSIVE.) Manybulimics suffer from serious DEPRESSION, which,combined with their impulsive tendencies, placesthem at increased risk for SUICIDE. Depression is aproblem especially among bulimic students, whoseself-esteem plummets when they engage in these

78 bulimia nervosa

extreme behaviors. When they get depressed, theirgrades fail and they lose their self-confidence.

To determine the range and severity of medicalcomplications encountered in younger patients,researchers reviewed the medical records of 65adolescents and preadolescents in the Eating Disor-ders Clinic of the Children’s Hospital at StanfordUniversity. Twenty-two percent of bulimic patientsrequired hospitalization for medical reasons duringthe study period.

Treatment

Although bulimic patients are for the most part morelikely than anorexics to accept, even seek, treatment,they usually expect quick solutions and become frus-trated if treatment does not produce immediate reliefof their symptoms. They may deal with their frustra-tion and anxiety in therapy through increased bingeeating and may also leave treatment prematurely.GROUP THERAPY is particularly useful for bulimics whofeel isolated by their symptoms.

The psychological treatments that have beenstudied the most are behavior and cognitive behav-ioral approaches. These treatments use behavioralinterventions such as self-monitoring and stimuluscontrol to normalize eating behavior and use cog-nitive interventions to challenge the distortedthinking and belief systems of the individual.Research suggests that these treatments can bevery effective, as effective as the antidepressants(see below) and more effective when one consid-ers follow-up. Another psychological treatmentthat has recently been found to be effective forbulimia nervosa is interpersonal psychotherapy(see INTERPERSONAL PSYCHOTHERAPY).

Because of the lack of understanding of the bio-logical bases of normal and abnormal eatingbehavior, development of effective pharmacologictreatment for bulimia nervosa has been slow. ANTI-DEPRESSANT medication has been used in treatmentfor bulimia. The three classes of antidepressantdrugs most commonly used in the treatment ofbulimia have been the monoamine oxidaseinhibitors, the serotonin reuptake inhibitors (flu-oxetine, clomipramine) and the tricyclics. Somecontrolled studies of antidepressants in bulimiahave been promising; IMIPRAMINE and phenelzinehave been shown to be significantly successful inreducing bulimic and depressive symptoms.

During controlled testing, the tricyclic antide-pressant imipramine produced, on average, a 70percent reduction in binge frequency. A similardrug, desipramine, resulted in a mean reduction of91 percent in binge frequency. A third tricyclic anti-depressant, AMITRIPTYLINE, was associated with a 72percent reduction in binge frequency. A controlledtrial of phenelzine, a monoamine oxidase inhibitor,found a 66 percent reduction in binge frequency.

In a multicenter-controlled, double-blind study offluoxetine, those patients receiving fluoxetine experi-enced a 45 percent decrease in the median number ofbinges and a 29 percent decrease in the median num-ber of purges. Patients receiving higher doses of med-ication had decreases of 67 percent and 56 percent.

In their review of the psychopharmacology treat-ment literature, Mitchell et al. found that “the agentsmost commonly used are the antidepressants, withparticular focus on the selective serotonin reuptakeinhibitors including fluoxetine hydrochloride. Theseagents clearly impact significantly on the frequencyof abnormal eating behaviors such as binge eatingand purging. However, subjects treated with thesedrugs rarely achieve remission.”

Whittal et al. analyzed four treatment outcomes,and found that the people given cognitive behav-ioral therapy (CBT) did significantly better thanthose given medication and apparently better thanthose who received other psychosocial treatments.

In a multidimensional meta-analysis of psy-chotherapy trials for bulimia nervosa publishedbetween 1980 and 2000, Thompson-Brenner et al.wrote, “The data point to four conclusions. First,psychotherapy leads to large improvements frombaseline. Approximately 40 percent of patientswho complete treatment recover completely,although 60 percent maintain clinically significantposttreatment symptoms. Second, individual ther-apy shows substantially better effects than grouptherapy for the therapies tested. Third, additionalapproaches or treatment parameters (e.g., numberof sessions) need to be tested for the substantialnumber of patients who enter treatment and donot recover. Finally, the utility of meta-analysescan be augmented by including a wider range ofoutcome metrics, such as recovery rates and post-treatment symptom levels.”

The long-term outcome of drug treatment forbulimia remains unknown. Medication has proved

bulimia nervosa 79

useful when a bulimic patient also has an associ-ated mood disorder and has failed to respond toPSYCHOTHERAPY. Treatment for bulimia nervosa ismost successful when medical therapy and psy-chotherapy are combined.

Fairburn, C. G., and P. J. Cooper. “Eating disorders.” InCognitive Behaviour Therapy for Psychiatric Problems: APractical Guide, edited by K. Hawton, et al. New York:Oxford Medical Publications, 1996.

Levitt, John L. “Treating Adults with Eating Disorders byUsing an Inpatient Approach.” Health and Social Work11, no. 2 (Spring 1986): 133–140.

Mitchell, J. E., M. de Zwaan, and J. L. Roerig. “DrugTherapy for Patients with Eating Disorders.” CurrentDrug Targets. CNS and Neurological Disorders 2, no. 1(February 2003): 17–29.

Neuman, Patricia A., and Patricia A. Halvorson. AnorexiaNervosa and Bulimia: A Handbook for Counselors andTherapists. 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. “AMultidimensional Meta-Analysis of Psychotherapyfor Bulimia Nervosa Clinical Psychology.” Science &Practice 10, no. 3 (fall 2003): 269–287.

Whittal, M. L., W. S. Agras, and R. A. Gould. “BulimiaNervosa: A Meta-Analysis of Psychosocial and Phar-macological Treatments.” Behavior Therapy 30, no. 1(winter 1999): 117–135.

Bulimia Test Revised (BULIT-R) A revision of theBulimia self-test originally developed in 1984 byM. S. Smith and M. H. Thelen, but updated to beconsistent with the DSM-III-R criteria for bulimianervosa. The BULIT is a 32-item multiple-choicescale designed to identify individuals with symp-toms of bulimia.

Sample items from the BULIT:

I prefer to eat:

A. At home aloneB. At home with othersC. In a public restaurantD. At a friend’s homeE. Doesn’t matter

What is the most weight you’ve lost in onemonth?

A. Over 20 poundsB. 12–20 poundsC. 8–11 poundsD. 4–7 poundsE. Less than 4 pounds

Thelen, M. H., J. Farmer, S. Wonderlich, and M. Smith.“A Revision of the Bulimia Test: The BULIT-R.” Psy-chological Assessment 3 (1991): 119–124.

bulking agents APPETITE SUPPRESSANTS made fromfood fiber, taken before meals because they swell upin the stomach, creating a sense of fullness that is sup-posed to inhibit excess eating. Some doctors disputethe effectiveness and discourage the use of these.

Stephen Barrett, M.D., chairman of Quackwatch,Inc., and vice president of the National CouncilAgainst Health Fraud, describes bulking agents as“indigestible, non-caloric substances that absorbwater during digestion and supposedly trick the stom-ach into thinking it is full. The substances include al-ginic acid, carboxymethylcellulose, carrageenan, guargum, karaya gum, methylcellulose, psyllium, kelp,and xanthan gum.” Barrett notes that X-rays haveshown that methylcellulose “does not actually fill thestomach but quickly passes into the small intestine.”

Bulk producers or fillers come in a number offorms: powders, capsules or pills. One such productis glucomannan, which is processed from the rootsof the konjac plant. The Food and Drug Adminis-tration has stated that the use of bulk producers aresafe, but their value in reducing weight has notbeen established. At most, the FDA says, bulk pro-ducers absorb liquid and swell the stomach, therebyreducing HUNGER. There is no proof that they areany more effective than ordinary bulking foodssuch as whole grains, apples, carrots and sprouts, allof which can provide the same feeling of fullness.

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

bypass surgery See BARIATRIC SURGERY; GASTRIC

BYPASS.

80 Bulimia Test Revised

caffeine An alkaloid found naturally in coffeeand tea that is a central nervous system stimulantand a diuretic. About 100 to 150 milligrams arefound in a strong cup of tea or coffee.

When researchers at King’s College, Universityof London administered caffeine orally to humanvolunteers in single doses of 100 milligrams, itincreased the resting metabolic rate of both leanand postobese subjects by 3 to 4 percent over aperiod of 150 minutes. (See METABOLISM.) It alsoimproved the diet-induced defective thermogene-sis observed in the postobese subjects. Measure-ments of energy expenditure indicated thatrepeated caffeine administration at two-hour inter-vals over a 12-hour day increased the energyexpenditure of both subject groups by 8 to 11 per-cent during that period but had no influence onthe subsequent 12-hour night energy expenditure.The net effect was a significant increase in dailyenergy expenditure of 150 calories in the lean sub-jects and 79 calories in the postobese. Theresearchers feel that caffeine at commonly con-sumed doses can have a significant influence onenergy balance and may promote thermogenesis inthe treatment of obesity.

Robert O’Brien and Sidney Cohen, writing in TheEncyclopedia of Understanding Alcohol and Other Drugs(New York: Facts On File, 1999), cautioned that reg-ular use of 350 milligrams or more of caffeine a dayresults in a form of physical dependence. Regularuse of more than 600 milligrams a day may causechronic insomnia, breathlessness, persistent anxietyand depression, mild delirium and stomach upset.Heavy caffeine use is also suspected of associationwith heart disease and some forms of cancer.

Although a few studies have indicated that largeamounts of caffeine may slightly enhance weight lossin people who exercise and maintain a low-fat diet,

the Mayo Clinic cautions that even as many as sixcups of coffee a day have not proven to greatlyincrease the body’s ability to burn calories, nor has itresulted in significant loss of body fat. Because coffeeis a diuretic, any weight loss is more likely to be fromwater loss. No studies indicate that weight loss fromlarge amounts of caffeine is significant or permanent.

Caffeine is sometimes abused by persons with eat-ing disorders in an attempt to control their weight.

Dulloo, A. G., et al. “Normal Caffeine Consumption:Influence on Thermogenesis and Daily EnergyExpenditure in Lean and Postobese Human Volun-teers.” American Journal of Clinical Nutrition 49, no. 1(January 1989).

Hamilton, Kim. “The Weight-Loss Perk.” Health (July1989).

calcium A Purdue University study presented in1999 by Dorothy Teegarden, an assistant professorof foods and nutrition, showed that increased lev-els of calcium appeared to help women lose bodyfat but only if overall calorie consumption was lim-ited. The study, which was partly financed by theNational Dairy Council, tracked 54 women overtwo years; the women followed no particular diet.Those women who consumed fewer than 1,900calories a day along with a daily calcium intake ofat least 780 milligrams, either did not increasebody fat, or they lost fat. Those women who tookin 1,000 milligrams of calcium a day decreasedbody weight by up to seven pounds, all of whichwas in the form of body fat. Those who used dairyproducts as their calcium source lost more body fatthan those who got their calcium from leafy veg-etables or supplements. Those women with 500 orfewer milligrams of calcium intake per day actuallyshowed an increase in body fat. Because of thehigh fat content in many dairy products, Teegarden

81

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suggested that people needing to lower their bodyfat get calcium from yogurt or skim milk, whichare both low fat and low calorie. Other sources ofcalcium include broccoli, cabbage and sardines.

Katherine Tallmadge, a nutritionist, noted,“Since 2000, observational and clinical studies ofmen, women and children have consistentlyshown that people eating diets containing cal-cium’s recommended dietary allowance of 1,000 to1,300 milligrams per day have lower body weightsand lower body fat. In fact, it’s been calculated thatwith 300 more milligrams of calcium daily, adultswill weigh about seven pounds lighter than theywould without the calcium.”

Michael Zemel and his team of researchers at theUniversity of Tennessee reported in several journalsin 2004 on their studies using both mice and humansubjects, which continued to show calcium’s influ-ence on weight loss. Explaining their beliefs on whycalcium, especially when in milk products, appearsto help take off unwanted pounds and body fat, par-ticularly in the trunk region, Zemel told Tallmadgethat it has to do with the body’s natural instinct toprevent starvation when it thinks food is scarce. Andone of the things that makes the body think food isscarce 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 mak-ing more fat, and also slows down the process of fatbreakdown and oxidation. Thus, a low-calorie dietthat includes low levels of calcium causes fat to dothe opposite of what is expected. Because the aver-age American consumes only half the daily calciumrequirement, weight loss is harder for many.“Higher-calcium intakes (in which the body senses,rightly or wrongly, that there is plenty of foodaround) cause lower calcitriol levels and increasedfat breakdown.”

Most American adults take in only 600 mil-ligrams of calcium a day. Until age 50, adults shouldtake in 1,000 milligrams; after age 50 for women orafter age 65 for men, the recommended amount is1,200–1,500. According to Dr. Zemel’s research, cal-cium from supplements or from other calcium-richfoods have an effect on fat loss, but calcium fromdairy products seems to work best. Other foodsources of calcium include dark greens such as broc-coli and kale; beans; canned salmon and sardineswith bones; and calcium-fortified orange juice.

Data from a study funded by the Canadian Insti-tutes of Health Research (CIHR) called the QuebecFamily Study indicate that people who consume lesscalcium have a greater tendency to be overweight orobese. Although the mechanism is unclear, Dr.Angelo Tremblay of Laval University says calciumintake may bring about an increase in fat oxidation,in the amount of calories burned as fat.

Tallmadge, Katherine. “Counting Calcium” WashingtonPost, June 30, 2004, page F01.

Zemel, Michael B. “Role of Calcium and Dairy Productsin Energy Partitioning and Weight Management.”American Journal of Clinical Nutrition 79, no. 5 (May2004): 907S–912S.

Zemel, Michael B., and S. L. Miller. “Dietary Calcium andDairy Modulation of Adiposity and Obesity Risk.”Nutrition Reviews 62, no. 4 (April 2004): 125–131.

Zemel, Michael B., et al. “Calcium and Dairy Accelera-tion of Weight and Fat Loss during Energy Restrictionin Obese Adults.” Obesity Research 12, no. 4 (April2004): 582–590.

calorie A unit of measurement of heat. One large,or great, calorie (kilogram calorie) is the amount ofheat required to raise the temperature of one kilo-gram (2.2046 pounds) of water by one degree Celsius(1.8 degrees Fahrenheit); this is the calorie commonlyused in metabolic studies. One small calorie (gramcalorie) is the amount of heat required to raise thetemperature of one gram of water one degree Celsius.In writings on human nutrition the large or kilogramcalorie is used. In medical literature, it is occasionallycapitalize in order to distinguish it from a small calo-rie; sometimes it is abbreviated as keal.

It is possible to calculate the amount of energycontained in a certain food by measuring theamount of heat units, or calories, in that food. (SeeCALORIMETRY.) Every bodily process—the buildingup of cells, motion of the muscles, the mainte-nance of body temperature—requires energy, andthe body derives this energy from the food it con-sumes. Digestive processes reduce food to usable“fuel,” which the body “burns” in the complexchemical reactions that sustain life.

“From its daily intake of energy converted fromfood, the body uses only the amount it needs forcurrent activity. The remainder is stored as FAT. If aperson consumes more calories than necessary fordaily bodily processes, he or she will gain weight. If

8282 calorie

a person consumes fewer than necessary, the bodywill supplement it by drawing on energy stored asfat, and he or she will lose weight.

Bonnie Liebman, director of nutrition at theCenter for Science in the Public Interest, Washing-ton, D.C., told Boardroom Reports (May 15, 1989)that all calories are not alike.

Nutritionists used to say that a calorie was a calo-rie no matter what kind of food it was—protein,fat or carbohydrate. It didn’t matter whether oneate 3,000 calories of fat or 3,000 calories of carbo-hydrates, the calories the body didn’t use wereturned into fat. Thus, calorie-counting was the keyto dieting. But a growing body of scientific evi-dence shows that, once inside the body, caloriesare not treated alike. Fat is handled very differ-ently from protein and carbohydrates, with the fatcalories being the most problematic.

Studies conducted by biochemist Jean-Pierre Flattat the University of Massachusetts Medical Schoolshowed that fewer calories are required for the bodyto turn food fat into body fat than to turn PROTEINS

and CARBOHYDRATES into body fat. In the case of foodfat, only 3 percent of the calories taken in are burnedoff in the process of storing it as body fat. In the caseof complex carbohydrates, 23 percent of the caloriesare used up in converting it to body fat.

It is also more difficult for the body to turn pro-teins and carbohydrates into fat, doing so onlywhen massive amounts have been ingested andusing a great amount of energy to do so. The bodycan store about 1,500 calories’ worth of carbohy-drates and protein (the rest are burned), but it canstore 100,000 to 200,000 calories’ worth of fat,according to Flatt. Whereas the normal bodyattempts to use food fat as energy before storing itin fat cells, the bodies of formerly obese peopleappear to put fat calories directly into storage,thereby contributing to their weight problem.

Researchers at Harvard Medical School studied141 women aged 34 to 59 and found no correla-tion between caloric intake and body weight. Thefattest women did not necessarily eat the most. Theresearchers did find, however, that the womenwhose diets were highest in fat, particularly satu-rated fats from red meat and dairy products, werethe most overweight regardless of the number ofcalories they consumed.

Americans today are heavier than ever but con-sume fewer calories than at the turn of the cen-tury. One of the reasons given for this is that wehave become a more sedentary society. But it hasalso been noted that while we may eat less thanour ancestors did, the percentage of fats in ourdiets is 31 percent greater today than it used to be.

Experts argue that total calories nevertheless docount, even those not derived from fat. They pointto a recent National Health and Nutrition Exami-nation Survey, which showed total caloric intakeby adults increasing from 1,969 calories in 1978 to2,200 in 1990.

Putnam et al., agricultural economists with theFood and Rural Economics Division, EconomicResearch Service, USDA, reported that averagedaily calorie consumption in 2000 was 12 percent,or roughly 300 calories, above the 1985 level. In anearlier review, Putnam had written that calorieconsumption per capita increased 21 percentbetween 1970 and 1994. Three-quarters of thatincrease occurred between 1984 and 1994.

Similar findings reported by the Centers for Dis-ease Control and Prevention showed that the aver-age calories taken in by men grew from 2,450 in1971 to 2,618 in 2000. For women, caloric intakegrew from 1,542 calories to 1,877 calories duringthe same time. The government recommendsabout 1,600 daily calories for women and 2,200 formen, with more for very active people.

Studies have shown that taking in 100 fewercalories a day or burning 100 more calories a daythrough increased physical activity can stop weightgain. From that point, increasing activity ordecreasing calorie intake works toward weight loss.A study by the Human Nutrition Research Centerin Maryland found that six out of seven womenunderreported how much they ate in a day’s timeby an average of 621 calories; and six out of 10 menunderreported 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/DEC2002/frvol25i3a.pdf.

83calorie 83

calorie restriction diet (CR diet) An eating regi-men with a goal to achieve a longer life by eatingas few calories as possible while maintaining ade-quate nutrition. The Calorie Restriction Society(http://www.calorierestriction.org) states, “Exten-sive scientific research has shown that a CR dietimproves the health and extends the lifespan ofevery species so far tested, including worms, spi-ders, rodents, dogs, cows and monkeys. We believethat people who adopt a CR diet will see the sameresults—longer life and better health.”

Although people following a CR diet (usually30–50 percent fewer calories than recommended) donot have a primary goal of losing weight (some arethin when they begin the CR lifestyle), most eventu-ally lose enough weight to look gaunt. They prima-rily eat raw vegetables, fruit and nuts, then augmenttheir diet with any missing vitamins and minerals.

Calorie restriction first came under observationin the 1930s when Clive McCay, a nutritionist atCornell University, discovered by chance thatunderfed rats not only maintained a more youth-ful appearance than those on a regular diet, butlived up to one-third longer. Similar results havebeen obtained with monkeys, dogs and any num-ber of other species. However, there is no concreteevidence that CR helps people live longer.

Short trials to test CR’s effect on human bodysystems are in progress, but any definitive trialswould be too lengthy and difficult because of thelonger lifespan of humans. Bee noted, “Few doc-tors oppose the principles of calorie reduction perse, especially since CR members ensure ‘optimalnutrition,’ including essential vitamins and miner-als, from what little food they do eat. Crucially, thisis what sets CR apart from eating disorders such asanorexia, which restrict all food, and therefore allessential nutrients, to a point where the body isunable to function in a normal way.”

Lawson interviewed an avid male follower ofCR (80 percent of CR followers are men), whoadmitted to food obsession for the first year, as wellas a virtual disappearance of sexual desire from alowering testosterone. Answering a question aboutthe amount of discussion of anorexia on the CRSociety Web site, he replied, “There are certainlyanorexics who at least claim to practice CR. But Idon’t know of anyone who was not anorexic and

who became one after starting CR.” Researchershave reported seeing no eating disorders amongtheir CR subjects.

However, Layton noted that investigators at theAmerican Federation for Aging Research questionthe diet. “A calorie-restricted diet will produceweight loss, to the point that most adherentsappear ill . . . CR followers are generally cold andalways hungry. Because they lose so much bodyfat, they lose cushions that protect their bones, sothat sitting or walking can become painful. And it’ssimply not sustainable for most people. Very fewpeople can lose 30 percent of their body weightand 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 onPromise—Hard-Core Followers Want to Live to Be100.” The Record, October 24, 2004. Available online.URL: http://www.myhealth.com/features/05-01-low-cal.htm.

calorimetry A method of measuring the amountof energy (CALORIE) value in food via a burningprocess. First a small amount of food is weighed andplaced in a sealed container, called a bomb calorime-ter. Then the food is set on fire with an electric fuse.The calorimeter is then submerged in a premea-sured amount of water. The rise in the temperatureof the water when the food item is completelyburned measures the calorie value of that amountand kind of food. This calorie value is then used tocalculate the number of calories in a typical serving.

cancer links to obesity Since the 1970s, numer-ous epidemiological studies have indicated thatobesity contributes to the increased incidenceand/or death from cancers of the colon and rec-tum, breast and uterus and cervix and ovaries (inpostmenopausal women), kidney, esophagus andgall 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. evaluated900,000 people, who were cancer-free when the

8484 calorie restriction diet

study began, over 16 years. The researchers con-cluded that excess body weight may contribute to14 percent of all cancer deaths in men and 20 per-cent of all cancer deaths in women. This accountsfor about 90,000 cancer deaths each year, accord-ing to the American Cancer Society.

Explaining the relationship between cancer andobesity, George Blackburn, M.D., writes, “Cancer-ous tumors seem to thrive on certain normallyoccurring hormones, including estrogens, andro-gens, and insulin. Unfortunately, obese people pro-duce excess amounts of these and othercancer-stimulating hormones, so they are morelikely to die from cancer.”

There are other suggested reasons for the closelink between obesity and cancer death. Forinstance, obesity makes cancer more difficult todiagnose and treat; the proper amount ofchemotherapy is difficult to determine accuratelyin the obese because fat tissue sometimes absorbsthe chemicals, and many obese people avoid regu-lar doctor visits.

In 2002 about 41,000 new cases of cancer in theUnited States were estimated to be due to obesity.This means that about 3.2 percent of all new can-cers are linked to obesity. On a more positive note,University of Minnesota researchers who followednearly 22,000 women over seven years found thatoverweight or obese women who lost 20 or morepounds cut their cancer risk 21 percent.

See also PROSTATE CANCER AND OBESITY.

Blackburn, George L. “The Skinny on Obesity and Can-cer: Obesity Increases the Risk of Death from Cancer,but Being Overweight Isn’t Inescapable.” Health News9, no. 6 (June 2003): 3.

Calle, Eugenia, et al. “Overweight, Obesity, and Mortal-ity from Cancer in a Prospectively Studied Cohort ofU.S. Adults.” New England Journal of Medicine 348, no.17 (April 24, 2003): 1625–1638.

carbohydrate addict’s diet A popular diet intro-duced in 1991 by Rachel and Richard Heller in abest-selling book series. The theory is that somepeople are biologically predisposed to developunmanageable cravings for carbohydrates, andwhen this occurs, it can often lead to weight gain.The authors believe that this condition results froman overproduction of insulin, impairing glucose

metabolism, and an insufficient rise of brain sero-tonin, which is responsible for the feeling of sati-ety. The purpose of the diet is to control insulinrelease by minimizing the carbohydrate consump-tion that triggers it. The basic diet consists of twocarbohydrate-restricted meals and one “reward”meal, which must be consumed within 60 min-utes, but at which the person may eat absolutelyanything. Foods at the restricted meals includestandard proportions of such foods as eggs, fish,meat, cheese, salads and most nonstarchy vegeta-bles. Allowable foods contain no more than fourgrams of carbohydrate per standard serving.Although there is little or no scientific evidence forthe theory behind the diet, some nutritionistsaccept the diet per se as healthy if the dieter selectsappropriate foods.

See also ADDICTION.

carbohydrates A group of chemical substancesthat make up one of the three sources of nutrients(the others are proteins and fats) and contain onlycarbon, oxygen and hydrogen. Usually the ratio ofhydrogen to oxygen is 2:1. The most common car-bohydrates are sugar and starches; others includeglycogen, dextrins and celluloses.

Carbohydrates are formed by green plants,which utilize sunlight energy to combine carbondioxide and water in forming them. Carbohy-drates are a basic source of energy. (See CALORIE.)One gram yields approximately four calories. Car-bohydrate is stored in the body as glycogen (apolysaccharide consisting of sugar molecules) invirtually all tissues, but principally in the liver andmuscles, where it becomes a source of reserveenergy. Whole grains, vegetables, legumes (peasand beans), tubers (potatoes), fruits, honey andrefined sugar are all excellent sources of carbohy-drates. Calories derived from sugar and candy,however, have been termed “empty” caloriesbecause these foods lack essential amino acids,vitamins and minerals.

Foods whose carbohydrates are digested andabsorbed quickly are said to have a high glycemicindex (GI), which a Tufts University study showedmay trigger overeating several hours later.Researchers fed a group of 12 obese teenage boyshigh- medium- or low-glycemic breakfasts and

85carbohydrates 85

lunches on different days. The low-GI breakfastsincluded foods such as a spinach omelet and fruit;the medium-GI meals included slowly digestinggrains such as Irish oatmeal (which is less processedthan American oatmeal) with milk and sugar; andthe high-GI breakfasts included foods such as bagelsand cream cheese, muffins, donuts, waffles withsyrup or instant oatmeal. In the afternoon, the boyswere encouraged to select snacks from a large plat-ter of food if they felt hungry. Those who ate thehigh-GI meals ate almost twice as many snacks asthose who had eaten low-GI meals that day.

Studies such as this help to explain why peoplewho cut back on refined carbohydrates and sugaroften find it easier to control and even lose weight.Nutritionists contend that refined starches andsugars—which are a significant part of high-GIfoods—are a completely unnecessary part of theAmerican diet.

Amersbach, Gabriele. “In a Low-Fat World, Why AreAmericans Getting Fatter?” Tufts Nutrition, Fall 1999.Available online. URL: http://nutrition.tufts.edu/magazine/1999fall/roberts.html.

Carpenter, Karen (1950–1983) A popularsinger and recording star (with her brotherRichard) during the 1970s, who died in 1983 at theage of 32 as a consequence of cardiomyopathy, sec-ondary to the effects of the toxic substance eme-tine. She suffered from ANOREXIA NERVOSA, possiblywith bulimic episodes, and abused IPECAC SYRUP.Building up over time, the alkaloid emetine in theipecac irreversibly damaged her heart muscle,eventually leading to her death by cardiac arrest.Because of her popularity, her death brought moreattention to eating disorders than anything beforeor since. A TV movie, The Karen Carpenter Story, wasfirst shown January 1, 1989.

cataracts and obesity Cataracts are the third lead-ing cause of preventable blindness in the UnitedStates. A cataract is a clouding of the eye’s lens, aclear protein structure located behind the pupil. In ahealthy eye, the lens bends light and focuses it on theretina, which converts the light to signals that thebrain processes and organizes into images. A cataractdevelops when the lens thickens to the point that it

is no longer able to reflect light. Proteins coagulateinto an opaque mass resembling something like anegg white, which prevents light from entering.

According to research by the Tufts UniversityLaboratory for Nutrition and Vision Research, obesewomen are two and a half times more likely to geta specific type of cataract—posterior subscapular(PSC) opacity—than healthy-weight women. Work-ing with scientists from the Harvard Nurses’ HealthStudy, the researchers conducted eye examinationsof 466 Boston-area women aged 53–73 who werewithout previously diagnosed cataracts. Both bodymass index and waist circumference were used tomeasure overweight and abdominal adiposity.Those who were 30 to 40 pounds overweight werethe most likely to develop a PSC opacity—a cataractparticularly damaging to sight. Also, those who hadwaistlines larger than 35 inches developed cataractsat a much earlier age than the women whose waistsmeasured less than 31.5 inches.

Jacques, P. F., et al. “Weight Status, Abdominal Adiposity,Diabetes, and Early Age-Related Lens Opacities.” TheAmerican Journal of Clinical Nutrition 78, no. 3 (Sep-tember 2003): 400–405.

cellulite A term first used in the 1950s to refer tothe tenacious FAT and fibrous tissue that formsbumps and ridges on thighs, hips and buttocks, giv-ing them a dimpled or “cottage cheese” look. It isespecially common in women. According toMichael O’Shea, founder and chairman of theSports Training Institute in New York City, thelumpiness is caused by fat deposits located directlybeneath the skin pushing up between the tiny lig-aments running from the skin’s surface throughthe fat layer to the muscles underneath. When thefat cells increase in size, as they do during weightgain, they cause the fat deposits to bulge, givingthe skin a dimpled look.

Edwin Bayrd, author of The Thin Game, wrotehowever, that “this dimpling is a result of agingrather than overindulgence. It manifests itselfwhen the subdermal connective tissue that forms asort of honeycomb around the body’s adipose cellsbegins to lose its elasticity and shrinks with age.When this happens, the overlying skin also con-tracts—and if the encased fat cells cannot shrink,they cannot help but pucker.”

8686 Carpenter, Karen

In its February 2004 issue, the Johns HopkinsHealth after 50 newsletter stated that cellulite“seems to develop when small blood vessels inthe layer of fatty tissue under the skin becomedamaged, perhaps from inflammation. The circu-lation of blood and lymph slows. As fluid accu-mulates, the fat layer expands and puckers,resulting in a dimpled appearance.”

Early promoters of cellulite “therapy” claimedthat cellulite is caused by a thickening of the con-nective tissue, which then traps fluids and “toxicmaterials” in that fat itself, causing the lumpy look.They promoted a variety of treatments and gim-micks to “melt” these fatty pockets, includingbalms, creams, lotions, injections, plastic wraps,massage, mineral baths, air hoses and wrappings ofcheesecloth soaked in paraffin.

None of these “cures” proved consistently suc-cessful for a number of reasons. Primary amongthese is the very protective nature of the skin,which prevents penetration of most salves, oint-ments and other substance applied to its surface.Even if one of these “miracle extracts” were able tobreak through the skin and break down fat stores,this would not necessarily lead to the eliminationof fat from the body. Fat cells constantly dispensefat into the bloodstream and simultaneously resyn-thesize triglyceride (storage fat) from circulatingfatty acids. Circulating fat will be burned only ifmuscle of other tissue extracts it from the blood-stream. If the tissues do not need fuel, circulatingfat is redeposited in fat cells.

Grapefruit diet pills have been promoted to“burn off cellulite” while allowing consumers toeat as much food as they want. Ingredients in thesepills vary. In addition to grapefruit extract, somehave contained a diuretic, and some, glucomannan(see BULKING AGENTS). Others may combine anappetite suppressant with herbs or other ingredi-ents. The Food and Drug Administration has notapproved any grapefruit pill for cellulite treatment.

There is no scientific evidence to support cel-lulite therapies or the theories on which they arebased. Studies have found no detectable differencebetween so-called cellulite and fat in other areas.

The Johns Hopkins newsletter suggests exerciseand losing weight as the best way to “minimize”cellulite. “Squats, lunges, and step exercises with

light weights are particularly effective for increas-ing muscle tone in the buttocks and thighs. Asmuscle builds, the skin feels and looks firmer. Cel-lulite cannot be eliminated with liposuction.”

See also FRAUDULENT PRODUCTS; LIPOSUCTION.

Bayrd, Edwin. The Thin Game. New York: NewsweekBooks, 1978.

Frey, Jennifer. “Lumpy Bumpy, Dimpled: Living off theFat of the Land.” Washington Post, March 27, 1999.

McCurdy, John A., Jr. Sculpturing Your Body: Diet, Exerciseand Lipo (Fat) Suction. Hollywood, Fla.: Frederick FellPublishers, 1987.

Centers for Obesity Research and Education(CORE) An education program formed in 1998to provide guidance and training for health careproviders on how to manage their obese patients.CORE includes eight of the leading centersinvolved in the management of overweight andobesity in the United States. These centers worktogether to conduct monthly interactive work-shops to help physicians, nurses, and other healthcare providers better identify, understand and treatoverweight and obesity in their practices. TheirWeb site is at http://www.uchsc.edu/core.

chemical dependency and bulimia In a surveyof 1,100 patients at Hazelden, a Minnesota chemi-cal dependency treatment center, approximately 7percent of female patients and 3 percent of malesreported enough symptoms to be classified asbulimic under DSM-III criteria.

An audit of treatment files of bulimic femalepatients revealed that they had experienced moreadolescent behavior problems and self-destructivebehavior than their nonbulimic peers. The typicalfemale chemical-dependent bulimic patient atHazelden differed markedly from her asympto-matic peers. She was more likely to be a polydruguser; to have had adolescent behavior problemssuch as school suspension or expulsion, stealingand fighting; to have exhibited self-destructive ten-dencies through self-inflicted injury, suicideattempts or suicidal thoughts during treatment;and to have had outpatient or inpatient mentalhealth treatment or medication.

Although a group of patients with these prob-lems could be expected to have difficulty in treat-

87chemical dependency and bulimia 87

ment, the course of treatment for both groups wassimilar in most areas of comparison. Bulimicsrequired the same length of stay in treatment,were discharged with staff approval at similar rates,had about the same number of conflicts with peersduring treatment and saw their counselors withthe same frequency as asymptomatic patients.Bulimic patients did use mental health services atHazelden slightly more than nonbulimics.

While cautioning that recent changes in thediagnostic criteria for bulimia and in Hazelden’spretreatment assessment methods make the data“tentative,” researchers concluded that researchand clinical experience demonstrate that it is pos-sible to work with manageable eating disorders inchemical dependency treatment.

According to DSM-IV, chemical abuse ordependence occurs in about one-third of individu-als with bulimia nervosa. Such stimulant use oftenbegins in an attempt to control appetite and weight.

childhood anorexia Anorexia nervosa has beenreported in children as early as age four; it is esti-mated that 3 percent of reported anorexia casesoccur before the age of puberty. Because prepuber-tal children, especially girls, have less body fat thanadolescent, they become emaciated more quicklythan older anorexics. GERALD F. M. RUSSELL exam-ined a series of 20 girls whose anorexia nervosabegan before their first menstrual period (menar-che), concluding that anorexia nervosa can bedevastating to physical development. There is pro-longed delay of puberty (late menarche) and inter-ference with grown in stature and breastdevelopment. Young children with anorexia haveexhibited clinging behavior upon entering school,difficulty in maintaining peer relations, physicaland psychological immaturity, depression and aninability to translate feelings into words. Also,according to DSM-IV, there are suggestions that theseverity of associated mental disturbance may begreater among prepubertal individuals whodevelop the illness.

Blinder, Barton J., and Stanley L. Goodman. “AtypicalEating Disorders.” In Eating Disorders, edited by FélixE. F. Larocca. San Francisco: Jossey-Bass, 1986.

childhood obesity Childhood obesity is a grow-ing concern among physicians and researchers.Results from the 1999–2002 National Health andNutrition Examination Survey (NHANES), usingmeasured heights and weights, indicate that anestimated 16 percent of children and adolescentsages six to 19 years are overweight. This representsa 45 percent increase from the overweight esti-mates of 11 percent obtained from NHANES III(1988–94).

To assess changes in overweight that haveoccurred, prevalence estimates for participants inthe 1999–2002 NHANES were compared with esti-mates for those who participated in earlier surveys.The NHANES surveys used a stratified, multistageprobability sample of the civilian noninstitutional-ized U.S. population. A household interview and aphysical examination were conducted for each sur-vey participant. During the physical examination,conducted in mobile examination centers, heightand weight were measured as part of a more com-prehensive set of body measurements. These meas-urements were taken by trained healthtechnicians, using standardized measuring proce-dures and equipment. Observations for personsmissing a valid height or weight measurementwere not included in the data analysis.

When the overweight definition (greater thanor equal to 95th percentile of the age- and sex-spe-cific body mass index, or BMI) is applied to datafrom earlier national health examination surveys,overweight in children and adolescents was rela-tively stable from the 1960s to 1980. However,from NHANES II (1976–80) to NHANES III, theprevalence of overweight nearly doubled amongchildren. In the time interval between NHANES IIand III, the prevalence of overweight among chil-dren ages six to 11 years increased from an esti-mated 7 percent to 11 percent. One of thenational health objectives for 2010 is to reducethe prevalence of overweight from the NHANESIII baseline of 11 percent. However, the NHANES1999–2002 overweight estimates suggest thatsince 1994, overweight in youths has not leveledoff or decreased, and is increasing to even higherlevels. The 1999–2002 findings for children andadolescents suggest the likelihood of another gen-eration of overweight adults who may be at risk

8888 childhood anorexia

for subsequent overweight and obesity-relatedhealth conditions.

Recent findings among preschoolers indicatethat children’s weight problems are beginningmuch earlier than school age. The American HeartAssociation’s 2004 annual statistical report onheart disease and stroke showed more than 10 per-cent of U.S. children ages two to five were over-weight in 2002 (the most recent year for whichstatistics were available), an increase from 7 per-cent in 1994. It was expected that the situation waseven worse in 2004.

Because parents frequently think their smallchildren will “outgrow their baby fat” or that achubby child is a healthy child, most of them donot believe their children have a medical problem.But one study in England showed a definite corre-lation between weight at six months of age andadult weight.

According to Richard Strauss, the increasingprevalence of obesity can be explained by the factthat few children today engage in regular physicalactivity. Others have similarly blamed the signifi-cant erosion of physical education and recreationprograms in schools. CDC researchers have placedblame for increased preschooler obesity on high-calorie convenience foods rather than lack of phys-ical activity. Parental obesity is also a strongpredictor of childhood obesity.

Torgan says there are many causes of childhoodobesity. “While there’s no doubt genetics plays arole, genes alone can’t account for the hugeincrease in rates over the past few decades. Themain culprits are the same as those for adult obe-sity: eating too much and moving around too little.Almost half of children aged 8–16 years watchthree to five hours of television a day. Kids whowatch the most hours of television have the high-est incidence of obesity.”

Physical Health Effects

Along with the rise in childhood obesity, theAmerican Obesity Association reports an increasein the incidence and prevalence of medical condi-tions in children and adolescents that had beenrare in the past. Pediatricians and childhood obe-sity researchers are reporting more frequent casesof obesity-related diseases such as type 2 diabetes,

asthma, cancer and hypertension that once wereconsidered adult conditions.

Kendall et al. elaborate: “Many risk factorsassociated with these diseases, such as high cho-lesterol, blood pressure and triglyceride levels,can be followed from childhood to adulthood.This points to a potential link between childhoodhealth and long-term adult health. Overweightchildren are more than two times likely to havehigh levels of cholesterol. Aortic fatty streaks, thefirst stages of atherosclerosis, begin to appear inchildhood, maybe even as early as three years old.Also, children with triceps skinfolds greater thanthe 70th percentile have significantly higherblood pressures.”

Torgan brings up another consequence of child-hood obesity. “Perhaps more devastating to anoverweight child than the health problems is thesocial discrimination. Children who are teased a lotcan develop low self-esteem and depression.”

Psychological Effects

Because of the psychological trauma of feeling dif-ferent, inferior, laughed-at, unattractive andashamed, obese children tend to withdraw frompeer group situations and social activities. Testshave shown that personality characteristics ofobese girls are similar to those of people who havebeen subjected to intense discrimination because oftheir race or ethnic origin: passivity, obsessive con-cern with self-image and expectation of rejection.These lead to awkwardness in social situations,social isolation and actual rejection, and thus lessactivity outside the home, increased eating and,consequently greater obesity. Obese girls also con-sider obesity—and hence their own bodies—unde-sirable and in extreme cases repulsive. Theyconsider obesity to be a handicap and the reasonfor all their disappointments.

When an adolescent feels inferior in group sit-uations, he or she tends to withdraw to solitaryand usually sedentary activities, such as TV view-ing and eating. Food has been described as a “feel-good drug” for the apathetic and unsureadolescent, whose appetite is also increasing toaccompany normal physical growth. Coupled withless-than-normal exercise, this usually leads toeven more excess fat and often to severe obesity in

89childhood obesity 89

adulthood. In extreme cases, the obese child mayalso suffer from depression, leading to total isola-tion and an incapacity to become emotionallyattached to other persons.

Routine and necessary activities like shoppingfor clothes can upset obese adolescents. Clothesmade for “typical” children don’t begin to covertheir frames. In order to locate pants that fitaround his waist, the fat boy must shop in themen’s department. But the rest of these pants arefar out of proportion, creating a humiliating situa-tion for already self-conscious children.

Rimm noted that in a survey of 5,400 third-through eighth-graders from suburban, urban andrural schools in 18 states, compared with normal-weight kids, heavy children were:

• Five times more likely to have low self-confi-dence

• Four times more likely to be lonely

• Three times more likely to worry about theirfutures

• Two times more likely to consider themselves“not smart enough.”

Childhood Teasing

Overweight children are more prone to ridiculeand teasing, which makes them sensitive abouttheir bodies and prime candidates for later prob-lems. When Arkansas adopted legislation in 2003to involve its schools in curtailing childhood obe-sity, the Arkansas Center for Health Improvement,which implemented the program statewide,trained school nurses to be sensitive to issuesrelating to body image and teasing. Childrenstepped on the scale backward so they could notsee their own weight.

Writing in Psychiatric Times, Stunkard et al.noted not only the connection between childhoodteasing and depression but also its escalation. “Arecent study has shown that the stigma of obesity,already severe in 1960, has increased measurablyin the past 43 years. An instructive three-yearprospective study of adolescents demonstratedhow teasing mediated the relationship betweenobesity and later levels of depression. The obesitystatus of these adolescents elicited teasing, which,

in turn, elicited depression through theirincreased dissatisfaction with their appearance.Jackson et al. also reported that obese womenwith binge-eating disorder (BED) who experi-enced teasing about their appearance developedbody dissatisfaction and depression.”

Treatment

Childhood obesity is usually found to be accompa-nied by one or more other physical or psychologi-cal disorders. Thus it is often treated mostsuccessfully by a combination of therapies, includ-ing low-calorie diet, behavior modification, nutri-tion education and increased physical activity.

Children as young as three months have beenplaced on diets intended to control weight gain.Doctors at the Clinical Research Center of Mt. SinaiHospital in New York have hospitalized obese chil-dren aged two through 11 and successfully treatedthem with a diet of 400 calories a day, togetherwith iron and vitamin supplements. The diet con-sists of 46 grams of carbohydrates, 28 grams of pro-tein and 12 grams of fat.

The premise underlying behavioral approachesto obesity—that effective weight control requiresmajor changes in eating behavior—is consideredby some to be even more important for childrenthan for adults because it is usually easier tochange the habits of children than those ofadults, who are more set in their ways. (SeeBEHAVIOR MODIFICATION.) These behavioral tech-niques involve the manipulation of the physicaland social environment to decrease the probabil-ity of overeating. This is achieved in the case ofdiet by keeping track of what is eaten, notingvarious internal and external cues that lead toeating, immediate positive reinforcements ofdesirable behaviors, dissociation of eating fromother experiences and, in some cases, emphasison eating styles. Behavior therapy in combina-tion with diet restrictions, has been shown instudies to be superior to diet alone, and mainte-nance of weight loss has been more successful. Itis most helpful for those with one or more “obeseeating style” problems: rapid eating, few butlarge bites, short-duration meals, exaggeratedsensitivity to external stimuli.

A child’s level of involvement in a weight lossprogram depends, in large part, on his or her level

9090 childhood obesity

of mental development. Leonard H. Epstein hasoutline four age ranges as a guideline for placingincreasing responsibility for weight control on achild. At ages one to five, any weight programmust rely on parental control. A child is generallynot able to read or write and thus is unable tokeep track of calories consumed, burned throughexercise and so on. Motivation to lose weight isabsent. During this time, parents are the majorinfluences on a child’s eating and activity habits.At ages five to eight, a child’s ability to monitorcalorie consumption/expenditure and eating pat-terns is still limited, although simple diet controlcan begin. Children at this age can start learningnutritionally sound eating habits and can betrained to handle social situations in which foodis offered. In addition, these children can alsobegin learning to solicit praise and encourage-ment for healthy eating from adults close tothem. Parents will still be involved significantly.At ages eight to 12, a child can set goals and self-monitor. Peer pressure may provide motivation tolose weight; however, children at this age stillbenefit substantially from parental involvement.From age 13 on, children can use programs simi-lar to those of adults, though they may be helpedthrough social groups. At this stage of develop-ment, children are becoming independent of theirparents, and too much parental guidance or inter-ference may be counterproductive.

In the attempt to monitor and control types andamounts of food intake, color coding of foods toshow calorie amounts can be understood by chil-dren as young as age five. The nutritionally bal-anced TRAFFIC LIGHT DIET developed by Epstein in1978 separates premeasured food portions intored, yellow and green categories corresponding totraffic signals (stop eating reds, be careful of theamounts of yellows, and go ahead and eat lots ofgreens). With young children, colored stars corre-sponding to foods eaten may then be exchangedfor reinforcers. This method of encouraginghealthy low-calorie eating by obese children hasbeen shown to be useful in school as well as homesettings. The New American Eating Guide, a color-coded poster similar in concept to the Traffic LightDiet, and the Nutrition Scoreboard (Center for Sci-ence in the Public Interest, 1977) have also been

useful in programs of weight control and eating-habit change for children. The Food ExchangeDiet prepared by the American Dietetic Associa-tion is also applicable to children, with help fromadults in learning the procedures. Pediatricianshave used colored tokens to represent the foodexchanges in this diet; tokens are transferred fromone plastic box to another following consumptionof food in their color groups. These color-codedsystems provide effective visual representation ofdiet for children too young to read and write. Pre-measured portions also eliminate the need forcalorie counting.

Numerous food-related factors influence achild’s eating pattern and treatment for obesity:the parents’ food-buying habits, another familymember’s eating disorder, contradictory messagesto the child regarding eating, the child’s attitudetoward diet and exercise change and his knowl-edge of nutrition.

Although exercise is an important componentin assessing and treating childhood obesity, someevidence suggests that it may be less importantthan diet in maintaining weight loss. Some authorsrecommend “lifestyle” exercise (walking, cycling,etc.) with little structure or intensity over struc-tured aerobic exercise in weight-loss programs forchildren, for two reasons. First, if caloric expendi-ture and not aerobic fitness is the goal of the pro-gram, lifestyle exercise will accomplish that goal.More important, studies have found that lifestyleexercise is more likely to be adhered to, and lack ofadherence is recognized as a major obstacle toeffective treatment.

Parents’ involvement in children’s weight lossprograms has been found to be a barometer oftheir success. Some programs have achieved theirbest initial weight losses when parents wereactive participants, especially when the parentswere obese and also involved in losing weight.Interestingly, the effectiveness of these parent-child treatments may be greater when the parentand children are worked with separately ratherthan together.

For older children, there is some evidence sug-gesting that maintenance of weight loss is mostreadily achieved when they engage in self-regula-tion of food intake and exercise, self-reinforcement

91childhood obesity 91

and self-imposed restrictions in tempting situa-tions. For younger children, treatment may beenhanced by teaching self-control skills and inchanging attitudes toward diet and exercise thatmay undermine self-control, since parents cannotcontrol what children eat all of the time. As chil-dren mature, more responsibility for weight losscan be shifted to them.

Bar-Or, O., et al. “Physical Activity, Genetic, and Nutri-tional Considerations in Childhood Weight Manage-ment.” 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 Dietfor Children. Boston: Little, Brown, 1988.

Jackson, T. D., C. M. Grilo, and R. M. Masheb. “TeasingHistory, Onset of Obesity, Current Eating DisorderPsychopathology, Body Dissatisfaction, and Psycho-logical Functioning in Binge Eating Disorder. ObesityResearch 8, no. 6 (2000): 451–458.

Kendall, P., K. Wilken, and E. Serrano. “Childhood Obe-sity.” Colorado State University Cooperative Exten-sion. Available online. URL: http://www.ext.colostate.edu/pubs/foodnut/09317.html. Updated on August24, 2004.

Latner, J. D. and A. J. Stunkard. “Getting Worse: TheStigmatization of Obese Children.” Obesity Research 11,no. 3 (2003): 452–456.

Marin, Roselyn. Helping Obese Children. Montreal andHolmes Beach, Fla.: Learning Publications, 1990.

Mei, Z., et al. “Increasing Prevalence of OverweightAmong U.S. Low-Income Preschool Children.” Pedi-atrics 101, no. 1 (January 1998): 103–105.

Meisels, Samuel J., and Jack P. Shonkoff, ed. Handbook ofEarly Childhood Intervention. 2nd ed. Cambridge andNew York: Cambridge University Press, 2000.

Rimm, Sylvia. Rescuing the Emotional Lives of OverweightChildren. New York: Rodale Books, 2004.

Rotatori, Anthony F., and Robert A. Fox, comps. Obesityin Children and Youth: Measurement, Characteristics,Causes, and Treatment. Springfield, Ill.: C. C. Thomas,1989.

Strauss, Richard. “Childhood Obesity.” Current Problemsin 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). Availableonline. URL: http://www.psychiatrictimes.com/p041081.html.

Thompson J. K., et al. “Development of Body Image, Eat-ing Disturbance, and General Psychological Function-ing in Female Adolescents: Covariance StructureModeling and Longitudinal Investigations.” Interna-tional Journal of Eating Disorders 18, no. 3 (November1995): 221–236.

Torgan, Carol. “Childhood Obesity on the Rise.” Word onHealth, National Institutes of Health, June 2002.Available online. URL: http://www.nih.gov/news/WordonHealth/jun2002/childhoodobesity.htm.

Chipley, William Stout (1810–1880) Chiefmedical officer of the Eastern Lunatic Asylum ofKentucky, who published the first Americandescription of SITOMANIA in 1859 in the AmericanJournal of Insanity. His observations were based onhis clinical experience at the asylum, where anumber of young girls who would not eat werefinally brought by their desperate families, alwaysafter treatment by their family doctors had failed.Chipley’s commentary was significant because ofhis identification of a specific type of food refuserand because it called attention to the behavior ofadolescent girls. He strongly believed that theirrefusal to eat was an intentional attempt to drawattention, elicit sympathy and exert power withina small circle of friends and family.

chlorpromazine A tranquilizing drug used dur-ing the 1960s in conjunction with insulin to treatanorexia nervosa. Garfinkel and Garner wrote thatit reduced a patient’s initial anxiety and resistanceto eating and weight gain. It also sometimes sedatedthe patient enough to help her tolerate bed rest orother enforced reduction of activity. Although thisresulted in rapid weight gain, there were a numberof serious problems, including lowered blood pres-sure and reduced body temperature.

In a comparison of two similar groups of hospi-talized anorexic patients, one group treated withchlorpromazine and insulin and the other grouptreated without chlorpromazine, the patientstreated with chlorpromazine gained weight sub-stantially faster and left the hospital significantlysooner. After two years, 33 percent of each grouprequired readmission. However, 45 percent of the

9292 Chipley, William Stout

patients treated with chlorpromazine had devel-oped bulimia, compared with 12 percent of thepatients treated without it. Furthermore, the chlor-promazine treatment was associated with signifi-cant side effects, including grand mal seizures.

Chlorpromazine was sometimes recommendedonly for patients who showed marked anxietyabout food and an inability to eat after general sup-portive measures had been attempted. Insulintherapy with chlorpromazine is not used today.

Garfinkel, Paul E., and David M. Garner. Anorexia Ner-vosa: A Multidimensional Perspective. New York: Brunner/Mazel, 1982.

cholecystokinin (CCK) A hormone releasedfrom the intestine within five minutes after eating,which stimulates gallbladder contraction and pan-creatic secretion. First isolated more than 60 yearsago, it is now said also to send a signal from thestomach to the brain when the stomach is full. Allmammals have CCK in varying amounts. In a U.S.Agriculture Department study, scientists discov-ered that they can block the hormone in pigs byinjecting them with a vaccine that makes theirappetite insatiable, in effect producing bigger pigs.In less than three months, the injected animalsconsumed an average of 22 more pounds of cornand soybean meal than untreated pigs, while put-ting on 11 pounds, of mostly meat rather than fat.

Medical researchers and psychiatrists are moni-toring the animal experiments to see if the princi-ple could help anorexics. Studies are also underway to develop drugs to block the CCK hormone inthe hope of curbing food cravings.

In 1988 Thomas D. Geracioto, Jr., a clinical neu-roendocrinologist at the National Institute of Men-tal Health, and Rodger A. Liddle of the University ofCalifornia at San Francisco released results of astudy on bulimia in which they compared severalmeasurements of cholecystokinin in both bulimicsand control subjects. They found that, on average,the bulimics secreted half as much cholecystokininas the controls did, indicating that bulimics may notreach a reasonable satiety level.

Since CCK is produced in the intestine and inthe brain, scientists are searching to discover whichparts of SATIETY are physiological and which are

psychological, and how they interconnect. Doctorshave discovered that certain ANTIDEPRESSANT drugs,which help bulimics to stop binge eating, also raisetheir CCK levels.

In pill form CCK has no effect because thechemical cannot survive in the digestive track. TheFood and Drug Administration (FDA) considersCCK pills promoted for weight loss to be a drugrequiring FDA premarket approval. The FDA hasnot yet received requested substantiation ofweight-loss claims from CCK manufacturers.

Chase, Marilyn, “Pigs May Provide Hints for Humans onNot Being Hogs.” Wall Street Journal, December 8,1988, p. A1.

Geracioti, Thomas D., Jr., and Liddle, Rodger A.“Impaired Cholecystokinin Secretion in Bulimia Ner-vosa.” New England Journal of Medicine 319, no. 11(September 15, 1988): 683–688.

Moore, Beth O., and J. A. Deutsch. “An Antiemetic IsAntidotal to Satiety Effects of Cholecystokinin.”Nature (May 23, 1985), page 321–322.

cholesterol A pearly white crystalline substancethat is found in all foods derived from animals. It isan essential building block of our cells, but whenpresent in high levels in the blood, it can lead toatherosclerosis (impeded blood flow due to thick-ening of the arteries). Cholesterol helps carry fatsin the bloodstream to tissues throughout the body.Most cholesterol in the blood is made by the liverfrom saturated fats (see FATS, SATURATED); some isabsorbed directly from cholesterol-rich foods suchas egg yolks.

cognitive behavior therapy See BEHAVIOR THER-APY; COGNITIVE THERAPY.

cognitive distortions Illogical, faulty thinkingand irrational beliefs. Neuman and Halvorsondetermined from their studies of medical literaturethat one of the most critical tasks facing therapistsand anorexics is the correction of cognitive distor-tions, which are numerous in anorexics. These dis-tortions include an inability to perceive their bodyshapes and sizes accurately and may even affecttheir understanding of the body’s biological func-tions. (“For instance, anorexics often have strange

93cognitive distortions 93

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 common-ly found in anorexics. Burns gives the fol-lowing patterns for illogical or distorted thought in perfectionists:

• Dichotomous Thinking All-or-nothing thinkingin which perfectionists evaluate their experi-ences in a dichotomous manner, seeing thingsin black-or-white terms. (“If I don’t choose amajor before school starts, I’ll probably end upjust being a bum,” or “If I gain any weight, I’llbe fat.”)

• Overgeneralization Perfectionists tend to jumpdogmatically to the conclusion that a negativeevent will be repeated endlessly. An anorexicmay have a small lapse in her eating and con-clude, “I’ll never get better, my eating willnever improve.”

• “Should” Statements When perfectionists fallshort of a goal, they berate themselves (“Ishouldn’t have goofed up! I ought to do better! Imustn’t do that again!”).

Two other reasoning errors were identified byGarner and Bemis as common to victims ofanorexia: superstitious thinking and personaliza-tion. Superstitious thinking assumes a cause-effectrelationship of unrelated events. This kind ofthinking may play a part in the emergence ofanorexic behavior, with the anorexic believing thatweight loss will solve other problems in her life.Superstitious thinking can also lead to otherbizarre behavior rituals. Personalization involvesseeing oneself as the focus of other people’s atten-tion and taking events and comments personallywhether or not they are so intended. (“Two peoplelaughed and whispered something to each otherwhen I walked by. They were probably saying thatI looked unattractive. I have gained three pounds.’)

Burns, D. “The Perfectionist’s Script for Self-Denial.” Psy-chology Today (November 1980).

Neuman, Patricia A., and Patricia A. Halvorson. AnorexiaNervosa and Bulimia: A Handbook for Counselors andTherapists. New York: Van Nostrand Reinhold, 1983.

Polivy, Janet, Peter C. Herman, and David M. Garner.“Cognitive Assessment.” In Assessment of AddictiveBehaviors, edited by Dennis M. Donovan and G. AlanMarlatt. New York: Guilford Press, 1988.

Garner, D. M., and K. M. Bemis. “A Cognitive BehavioralApproach to Anorexia Nervosa.” Cognitive Therapy andResearch 6, no. 2 (1982): 123–150.

Cognitive Factors Scale (CFS) A self-test devel-oped in 1982 by Gormally, Black, Daston andRardin containing 14 items designed to assess spe-cific dieting problems. The scale measures two fac-tors: Strict Dieting Standards and Self-EfficacyExpectations to Sustain a Diet. In general, cogni-tive factors play a crucial role in leading from anisolated slip (just one piece of pie) to a full-blownrelapse (an all-out binge).

Sample items from the CFS:

When I start a diet, I say to myself that I will haveabsolutely no “forbidden foods.”

I don’t persist very long on diets I set for myself.

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

cognitive therapy A treatment method for men-tal disorders founded on the premise that the waywe think about the world and ourselves affects ouremotions and behavior. Therapists work withpatients’ thoughts, senses, memories and percep-tions, as expressed in their internal monologuesabout their behavior.

For example, internal monologues about weightreduction can play a critical role in the mainte-nance and control of obesity. An internal mono-logue may say, “It’s taking me so long to lose theweight.” A therapist will counsel the patient toreplace that negative thought with the more posi-tive, “But I am losing it. And this time I’m learninghow to keep it off.” Simple repetition of counter-statements over a period of time helps to changepeople’s views of themselves, even if they do notcompletely believe them at the outset.

In a British study, a cognitive-behavioralapproach was applied to the individual treatmentof 11 bulimic women. First the binge-purge cycle

9494 Cognitive Factors Scale

was interrupted, and then cognitive strategies weretaught for self-control. Next the patients werehelped to modify abnormal attitudes toward food,eating and body weight and shape. Normallyrestricted foods, such as carbohydrates, were grad-ually introduced into the diet to lessen the desire tobinge on these foods. Patients were also helped toidentify situations in which loss of controloccurred. Finally, patients were prepared for futurerelapse events. Duration of treatment was sevenmonths. Nine of the 11 patients reduced theirbinge eating and vomiting from three times dailyto less than once a month. Anxiety and depressiondecreased, as did dysfunctional attitudes concern-ing shape and weight. At one-year follow-up of sixof the patients, one had stopped bingeing andvomiting completely, four reported that thesebehaviors occurred two to three times a month,and one showed no improvement. Follow-up datawere not available for the other five patients. Theresearch team later reported that subsequent expe-rience with more than 50 patients has confirmedthat the majority do indeed benefit from the cog-nitive therapy approach, with most remaining welland requiring no further treatment.

Researcher David Garner has written thatbecause attitude change is an important element inrecovery of ANOREXIA NERVOSA, cognitive therapyhas promise as a valuable treatment strategy for it.Currently there is more empirical support for theuse of cognitive and/or cognitive behavior therapywith bulimia nervosa than any other treatment.

Fairburn, Christopher. “Binge Eating and Its Manage-ment.” British Journal of Psychiatry 141 (December1982): 631–633.

Garner, David M. “Cognitive Therapy for Anorexia Ner-vosa.” In Handbook of Eating Disorders, edited by KellyD. Brownell and John P. Foreyt. New York: BasicBooks, 1986.

Wilson, G. Terence. “Cognitive-Behavioral and Pharma-cological Therapies for Bulimia.” In Handbook of EatingDisorders, edited by Kelly D. Brownell and John P.Foreyt. New York: Basic Books, 1986.

college students and eating disorders Accordingto the National Institutes of Mental Health, 10 per-cent of college-age women have a clinical or near-clinical eating disorder. Experts believe the

prevalence may be higher, because the secretivenature of eating disorders and the shame involvedprevent many cases from being reported.

Also of concern are the even larger numbers ofat-risk students. In addition to full-blown BULIMIA

NERVOSA, for example, symptoms of bulimia, suchas occasional episodes of binge eating and purging,occur in up to 40 percent of college women. Onestudy found that 35 percent of female and 10 per-cent of male college athletes were at risk forANOREXIA NERVOSA, and 58 percent of female and 38percent of male college athletes at risk for bulimianervosa. These rates are significantly higher thanthose in the general college population.

In a study of 1,620 college students by Hoerr etal., 10.9 percent of women overall were at risk foreating disorders; while among African Americans,8.3 percent of women were at risk. One group ofwomen who lived separately in a social sororityhad the highest risk—15 percent. Students at riskfor disordered eating reported weight concernsinterfering with their academic performance.

In a small study of college students, Kitsantas etal. discovered that students with eating disordersreported more self-regulated strategies for manag-ing their weight, a lower level of life satisfactionand higher levels of negative feelings than did at-risk students or individuals with normal weights.Among the most frequently cited reasons for thehigh incidence of eating disorders or disorderedeating among college students:

• The Freshman 15 Those 15 pounds a collegefreshman is said to put on during the first yearaway from parental supervision, when increasedamounts of junk food and fast food tend toreplace balanced family meals. Once the weightgain becomes apparent, the student oftenengages in peer-encouraged disordered eatingpractices in an attempt to take off the extrapounds. Some criticism of this concept has beenpublished. Weight gain is probably less than that,although some students do gain a lot.

• New Pressures With the added stress of livingapart from family for the first time, meetingheavy academic demands, and wanting tobelong, college students can feel lonely, sad,tired, overwhelmed, depressed, scared or con-

95college students and eating disorders 95

fused. Too often, they turn to food as a source ofcomfort. When they binge, all the negative feel-ings they are experiencing disappear. Later, theyeither feel guilty about the bingeing or fearfulthey will gain weight, so they are likely to purgeor exercise compulsively. Because the food helpsthem feel better only temporarily, the binge/purge cycle continues.

• Weight-conscious society College counselors saythat the pressure to look and remain thin seemsto be at an all-time high on college campuses.According to the Baldwin-Wallace College(Berea, Ohio) counseling services, “Advertise-ments [and] magazine covers at college book-stores are portraying young women as beingbeautiful only if they are slender, with long legsand thin arms. Men are portrayed as desirable ifthey are tall, have broad shoulders and are thinat the waist. College students across the countryare on a mission to attain an ‘ideal figure’ that isunrealistic for many and dangerous for some.”

Hoerr, S. L., et al. “Risk for Disordered Eating Relates toBoth 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. “CollegeWomen with Eating Disorders: Self-Regulation, LifeSatisfaction, and Positive/Negative Affect.” Journal ofPsychology 137, no. 4 (July 2003): 381–395.

comfort food University of California–SanFrancisco researchers identified a biochemicalfeedback system in rats that could explain whysome people crave “comfort foods” such as choco-late chip cookies and greasy cheeseburgers whenthey are chronically stressed, and why such peopleare apt to gain weight in the abdomen.

Their finding focuses on a glucocorticoid steroidhormone (corticosterone in rats, CORTISOL inhumans) that plays a key role in the stressresponse system. In their study, Dallman et al.determined that 24 hours after activation of thechronic stress system—which stimulates a flood ofhormonal signaling from the hypothalamus to theadrenal glands—glucocorticoids prompt rats toengage in pleasure-seeking behaviors, which

include eating high-energy foods (sucrose andlard). The animals develop abdominal obesity, andthe negative aspects of the chronic stress responsesystem, otherwise ushered in by the glucocorti-coids, are blunted. The researchers suspect that themetabolic signal to inhibit the stress system comesdirectly from fat depots.

The finding offers an explanation into howchronic stress can be inhibited or curbed. While thebody’s acute response to stress—say, to being cutoff in traffic by a speeding car—diminishes througha naturally occurring inhibitory feedback mecha-nism of the adrenal stress system, its chronicresponse to stress—in which a barrage of threats,scares or frustrations occur over days, weeks ormonths—becomes chronically excited. Over time,the elevated stress level can initiate a host of dele-terious effects on the body—a loss or gain ofweight, depression, obesity (associated with type 2diabetes, cardiovascular disease and stroke), and aloss of brain tissue.

“Our studies suggest that comfort food appliesthe brakes on a key element of chronic stress,” saysstudy coauthor Norman Pecoraro. And it couldexplain, he says, why solace is often sought in suchfoods by people with stress, anxiety or depression.It also could help to explain bulimic and night-binging eating disorders. Dallman, who has spentyears studying the regulation of the stress responsesystem, developed the new model of chronic glu-cocorticoid feedback.

Evolutionarily, the drive to eat comfort foodsmakes sense, says Pecoraro. The animal kingdom isan “eat or be eaten” world, and a body under con-stant, or chronic, stress may preferentially eathigh-energy foods to stay in the game. Under themodel that the research team has proposed, gluco-corticoids would both prompt vigilance to threatsand send a signal to the brain of a chronicallystressed animal to seek high-energy food. If it weresuccessful in finding such food, stress and its atten-dant feelings would be terminated.

In regions of the world where people strugglewith wars, epidemics of disease and chronic foodshortage, the need to seek out high-energy foodswould be great, as well. In the developed world,where stress is more often found in a commutingoffice worker, for example, people seem to be seek-

9696 comfort food

ing the same solution—and finding it at everystreet corner, says Pecoraro.

“If, after the near-miss on the freeway, you getinto work and almost lose your job during anargument with your boss, and have a fight athome that night—and these types of events arerelentless—you’re going to have chronically ele-vated adrenal hormones (i.e., chronic stress),” hesays. There has to be a brake on the system, and,for some, it is chocolate.

However, there are other ways to treat chronicstress—exercise, yoga, meditation, sex and bathsall stimulate neurochemicals that activate regionsof the brain that stimulate pleasure. Relaxationtechniques may work by reducing the psychologi-cal drives on stress output, which can be the rootcauses of stress. (Drugs and alcohol do not providesufficient metabolic feedback, and may even stim-ulate further stress and its attendant compulsionsfor pleasure.)

As for the use of food, there are serious healthconsequences of a diet high in fat and sugars:abdominal obesity (which can lead to cardiovascu-lar disease, type 2 diabetes and stroke), and cardio-vascular disease itself.

“In the short term, if you’re chronically stressedit might be worth eating and sleeping a little moreto calm down, perhaps at the expense of gaining afew pounds,” says Pecoraro. “But seeking a long-term solution in comfort foods—rather than fixingthe source of the stress or your relationship to thesource of the stress—is going to be bad for you.”

Stress is a strategy that evolved to enable thebody to deal with threats, ranging from thecrouched lion ready to pounce to the possibility oflosing a job. It promotes quick, though somewhatinflexible, physical and mental responses, vigilanceand attention. It the immediate response to a per-ceived danger, the body experiences the familiar“adrenaline rush,” in which the adrenal glands ini-tiate a flood of hormonal signals that quicken theheart rate, constrict the vasculature to preventbleeding to death and provide energy to the mus-cles. Minutes later, a slightly slower response isorchestrated by hormones from another region ofthe adrenal glands, providing such defenses as ananti-inflammatory function. Once an acute threathas subsided, these hormones are shut off throughan inhibitory feedback system.

During chronic stress, however, the system doesnot turn off, and glucocorticoids, which were for-merly inhibitory, have an overriding excitatoryeffect on brain stress networks. Glucocorticoids inthe system remain elevated, maintaining high lev-els of corticotropin releasing factor, which in turnregulates adrenocorticotropin—both key incitinghormones in the chronic stress response system.This creates a positive feedback loop between thestress systems of the body and brain.

From their studies, the researchers concludedthat rats with chronically elevated glucocorticoidsdeveloped pleasure-seeking/or compulsive behav-iors that included drinking sucrose (rather thansaccharine), eating lard, running on the wheel andtaking a drug. They then observed changes thattook place in the stress response system in theaftermath of eating the comfort food: an increasein abdominal fat and an end to corticotropin-releasing factor and adrenocorticotropin secretion.They also observed an inverse relationshipbetween abdominal fat and the expression of genesin the motor zone of the hypothalamus, where thestress response is initiated.

“This seems to be the body’s way of telling thebrain, ‘It’s ok, you can relax, you’re refueled withhigh-energy food,’” says Pecoraro. The message isclearly being transmitted in the middle-aged manor woman with a gut. “This body type representsthe classic distribution of fat from stress.”

The new model may explain why losing weightis notoriously difficult, he says. Losing weight is lit-erally stressful, which makes a person feel anxious,and stress hormones make a person crave high-energy foods, which blunt the feelings of stress andmake one feel better.

Dallman, Mary F., et al. “Chronic Stress and Obesity: ANew View of ‘Comfort Food.’ ” Proceedings of theNational Academy of Sciences 100, no. 20 (September30, 2003): 11,696–11,701.

complement factors Immune system proteinsbelieved to play a role in obesity; they are so calledbecause they are necessary to complete certainhemolytic reactions (the removal of hemoglobinfrom red blood corpuscles). The term derives fromthe Latin compere, “to fill up.”

97complement factors 97

Findings in a 1989 study of mice conducted by ateam of researchers from the Harvard MedicalSchool and the University of Alabama confirmedwhat scientists had suspected for some time: thesystem that helps an animal defend itself againstinfarction (death of tissue from lack of blood sup-ply) may influence how it stores and burns energy.These results are helping researchers investigatethe causes of obesity in animals and humans.

The researchers reported that families of obesemice had unusually low levels of complement fac-tors. Human and mouse complement factorsappear to be very similar, so researchers believeobese people may show similar deficiencies. Thiswas the first time anybody had established the pos-sibility of a connection between complements andenergy metabolism.

Most complement factors—humans have 30—are proteins produced and secreted by the liver.Many of these proteins circulate in the blood likeroaming security guards and provide an immediatedefense against invading bacteria or viruses. Othercomplements cannot mobilize until the body pro-duces antibodies, the molecules that recognize andbind to foreign bodies.

The first evidence for a link between comple-ments and the metabolic system appeared severalyears ago when doctors discovered that human fatcells secrete a protein named Complement FactorD, also called adipsin, or ADN.

In humans, Factor D is among those comple-ments that do not need to unite with antibodiesbefore activating. As the bottleneck in the series ofreactions that trigger inflammation, Factor D helpsregulate the first response to an attack on theimmune system.

The research team compared a mouse comple-ment factor, adipsin, with human Factor D. Like thehuman protein, adipsin is secreted primarily by themouse fat cells. Earlier research had shown that 60percent of adipsin’s structure is identical to that ofFactor D. When they compared the levels of adipsinin normal and obese mice, they found that obesemice had dramatically less circulating adipsin.

Because human Factor D so closely resemblesthe mouse protein, scientists suspect that peoplewith certain kinds of obesity will also show FactorD deficiency.

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

compulsive eating Also referred to as compul-sive overeating or binge eating. An eating patterncharacterized by symptoms similar to those ofbulimia nervosa, but without the purging. (SeeBINGE-EATING DISORDER.) Much of the compulsiveeater’s life is centered on food, what she (most arewomen) can or cannot eat, what she will or willnot eat, what she has or has not eaten and whenshe will or will not eat next. Typically, she eats con-tinuously from morning until night, much of thetime in secret. Her obsession with food is coupledwith self-disgust, loathing and shame because ofher total lack of self-control around food. Fre-quently a compulsive eater thinks that if she doesnot have access to food, she will be all right, andshe will therefore keep her home almost bare offood, except for the “health food” variety. But hercompulsion will drive her out even in the night tolook for food to satisfy her uncontrollable urges.Typically, she will continue to eat long after she isfull. She eats not because she’s hungry or evenbecause she enjoys it but to satisfy an unacknowl-edged psychological need.

Not all compulsive eaters are obese; some con-trol their weight by constant EXERCISE, FASTING fora few days at a time or even dieting. There arecompulsive eaters at all levels of society, from shopfloor to executive suite.

Because many compulsive eaters do haveweight problems, they run a high risk of hyperten-sion, heart disease and diabetes. And they usuallyingest high levels of fat, cholesterol and sugar,which increase their risk of heart disease, cancerand iron-deficiency anemia.

So-called cures, ranging from hypnosis to hospi-talization, do not help many compulsive eaters. Mosthelpful thus far have been clinics, both inpatient andoutpatient, that address both physical and psycho-logical aspects of the problem. Such treatment cen-ters work on the premise that compulsive eating isan addiction similar to drug or alcohol addictions.

Unlike anorexia or bulimia, compulsiveovereating generally has a more gradual begin-ning, according to Siegel, Brisman and Weinshel.

9898 compulsive eating

They explain that it often starts in early childhoodwhen eating patterns are being formed. Sometimesa family focuses on food as a retreat from feelings,as a way to feel good or as an activity to fill other-wise empty time. Eating patterns that do not causeproblems for growing children can cause them inadulthood. When compulsive overeating starts inyoung adulthood, it is often at times of stress whenyoung people are ill prepared to handle certainkinds of frustration and emotion. Soon they beginto use food inappropriately (often against their bet-ter judgment) and eventually become addicted toit, losing control over the amounts of food they eat.HILDE BRUCH says that compulsive eaters often eatmore when they feel worried or tense, and theyfeel less effective and competent when they try tocontrol their food intake; she referred to their com-pulsion as a “neurotic need for food.”

Bruch, Hilde. Eating Disorders. New York: Basic Books,1973.

Ghiy, L., and J. C. Chrisler. “Compulsive Eating, Obses-sive Thoughts of Food, and Their Relation toAssertiveness and Depression in Women.” Journal ofClinical Psychology 51, no. 4 (July 1995): 491–499.

Hirschmann, Jane R., and Carol H. Munter. OvercomingOvereating. New York: Fawcett, 1998.

Siegel, Michele, Judith Brisman, and Margot Weinshell.Surviving an Eating Disorder. Rev. ed. New York: Peren-nial Currents, 1997.

compulsive eating scale (CES) A self-testdesigned by Dunn and Ondercin to assess emo-tional states related to eating and specific aspects ofbinge behavior. The CES includes 32 items andprovides data related to degree of compulsive eat-ing. In addition, it assesses general informationabout the frequency of binges, alternations ofBINGE EATING with FASTING and DIETING, and emo-tional 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 los-ing weight.

Dunn, P. K., and P. Ondercin. “Personality Variables Relatedto Compulsive Eating in College Women.” Journal ofClinical Psychology 37, no. 1 (January 1981): 43–49.

conjugated linoleic acid (CLA) A naturallyoccurring compound found in the fat of beef,turkey and dairy products. According to Mar-tineau, “Increasing clinical evidence is provingthat CLA decreases body fat and promotes weightloss, without causing any serious side effects. Thecompound appears to reduce fat by regulatingenzymes in fat cells, which reduces the rate atwhich the body deposits fat. Moreover, CLA pro-motes calorie burning by increasing metabolism.Supplements made from the compound are sold asfat blockers.”

Prior studies of CLA’s effect on humans had beentoo short to be definitive, but a yearlong Norwegianstudy concluded that CLA reduces body fat mass inoverweight but otherwise healthy adults by as muchas 9 percent. The randomized, double-blind placebo-controlled study is the first to document the long-term safety and efficacy of CLA supplementationover a 12-month period without additional lifestyleor dietary restrictions. This long-term clinical trialsupports earlier research that found CLA improvesbody composition by promoting body fat reductionand maintaining lean muscle mass.

One hundred eighty healthy men and women,aged 18 to 65, with a body mass index (BMI) of25–30 (thus, overweight) were randomized toreceive capsules containing either 4.5 gramsTonalin CLA-free fatty acid, 4.5 grams TonalinCLA-triglycerides or 4.5 grams of olive oil(placebo). Subjects were then monitored for 12months, and weight, BMI and adverse events wererecorded every three months. Body compositionand blood samples were analyzed at regular inter-vals throughout the study.

At baseline, there was no difference betweenthe groups for either weight, BMI, body fat mass orlean body mass. After six months, individuals tak-ing either form of Tonalin CLA experienced a sig-nificant reduction in body fat mass, while those inthe placebo group saw no change. Compared to theplacebo group, those who took CLA lost about 9percent of body fat on average, plus increased leanbody mass, making weight loss minimal.

Daily calorie intake and exercise did not differbetween groups either at zero or 12 months andthus most likely did not play a role in body com-position changes observed in the CLA groups.

99conjugated linoleic acid 99

Both forms of CLA were equally effective inbody fat mass reduction and considered safewhen used for one year in healthy, overweightadults. The researchers concluded that CLA“administered either in the triglyceride or freefatty acid form, in healthy, overweight adults forone year, results in a significant decrease of bodyfat mass.”

Scientists do not know precisely how CLAworks, but suspect it may decrease the amount offat stored after eating and help the body use exist-ing fat for energy. Although CLA is not a “magicpill,” it may prove to enhance diet and exercise incontrolling weight gain.

Gaullier, Jean-Michel, et al. “Conjugated Linoleic Acid(CLA) Supplementation for One Year Reduces Body FatMass in Healthy, Overweight Humans.” American Journalof Clinical Nutrition 79, no. 6 (June 2004): 1,118–1,125.

Martineau, William. “What’s the Skinny?” CanadianChemical News 56, no. 7 (July–August 2004): 23–25.

continuity/discontinuity models of eating disor-ders This is a common model in the eating disor-ders literature. The idea is that eating disordersoccur on a continuum with normal dieting andweight concerns. When someone’s behavior,thoughts and/or feelings are far enough on thecontinuum, we consider this pathological and inthis case, and eating disorder. The continuum orcontinuity model of eating disorders can be con-trasted with the discontinuity model, whichassumes that the experiences of persons with eat-ing disorders are qualitatively different from thoseof persons with common dieting and weight con-cerns. Although the continuum model is com-monly accepted and some research does support it,very recent research utilizing statistical methodsdesigned to distinguish continuities from disconti-nuities have supported the discontinuity model ofbulimia nervosa and anorexia nervosa, binge eat-ing/purging type.

See also TAXON.

Gleaves, D. H., M. R. Lowe, A. C. Snow, B. A. Green, andK. P. Murphy-Eberenz. “The Continuity and Disconti-nuity Models of Bulimia Nervosa: A TaxometricInvestigation.” Journal of Abnormal Psychology 109, no.1 (February 2000): 56–58.

Gleaves, D. H., J. D. Brown, and C. S. Warren. “The Con-tinuity/Discontinuity Models of Eating Disorders: AReview of the Literature and Implications for Assess-ment, Treatment, and Prevention.” Behavior Modifica-tion 28, no. 6 (November 2004): 739–762.

Stice, E., et al. “Support for the Continuity Hypothesis ofBulimic Pathology.” Journal of Consulting and ClinicalPsychology 66, no. 5 (October 1998): 784–790.

control group A group used as a basis of com-parison with an experimental group. In a study ofthe effectiveness of a drug, the experimental groupwould take the drug, and the control group wouldtake either nothing or a PLACEBO.

See also DOUBLE-BLIND STUDY.

CortiSlim A dietary supplement heavily adver-tised beginning in August 2003. According to theFederal Trade Commission (FTC), which filed suitin September 2004, the marketers promoted corti-sol control as “the answer” for anyone who wantsto lose weight, especially abdominal weight.According to the FTC’s complaint, the defendants’broadcast ads, print ads and Web sites claimed thatpersistently elevated levels of cortisol, which theycalled the “stress hormone,” are the underlyingcause of weight gain and weight retention andalso claimed that CortiSlim effectively reduces andcontrols cortisol levels and thereby causes sub-stantial weight loss. The FTC alleges that thedefendants claimed that CortiSlim: (1) causesweight loss of 10 to 50 pounds for virtually allusers; (2) causes users to lose as much as four to10 pounds per week over multiple weeks; (3)causes users to lose weight specifically from theabdomen, stomach and thighs; (4) causes rapidand substantial weight loss; (5) causes long-termor permanent weight loss; and (6) causes weightloss. The FTC also alleges that the defendantsclaimed that the effectiveness of CortiSlim and itsingredients is demonstrated by more than 15 yearsof scientific research. According to the FTC’s com-plaint, these claims are false or unsubstantiated.

When asked by a reader about CortiSlim, the UCBerkeley Wellness Letter, May 2004, “Ask theExperts” editor said, “We could not find even onepublished study on CortiSlim.”

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

100100 continuity/discontinuity models of eating disorders

ceutically as hydrocortisone. Also referred to as thestress hormone.

A good deal of study has been devoted to corti-sol levels, particularly as they relate to depression.Recently, scientists have been able to show that theexcess of cortisol in both depressed and anorexicpeople is due to a problem that occurs in a region ofthe brain near or in the hypothalamus. The hypo-thalamus regulates many bodily functions—hor-monal secretions, temperature, water balance andsugar and fat metabolism; thus, it is certain thatthere is a link between abnormality in the hypo-thalamus and the problems associated with eatingdisorders. Questions remain about cause and effect.Some scientists believe that prolonged stress causesthe neurotransmitter/hormone imbalances, whichthen “drive” the eating disorder.

One of the functions of cortisol is to help thebody produce blood sugar (glucose) from proteins.Excess glucose is then used for lipogenesis (fat pro-duction). Thus, researchers have linked over secre-tion of cortisol with obesity and increased fatstorage 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 whosecreted higher levels of cortisol while under stresshad a much greater tendency to snack on high-fatfoods than did women who did not secrete as muchcortisol in reaction to the same stressful event.

See also STRESS AND WEIGHT GAIN.

costs to treat eating disorders Not only doesanorexia nervosa have one of the highest mortalitycosts among psychiatric conditions, but the chronicnature of eating disorders generally lead to hightreatment costs over time. Agras explains, “Thecosts of therapy for anorexia nervosa are higherthan those for schizophrenia. Although somewhatless chronic, bulimia nervosa and binge-eating dis-order are costly conditions to treat, similar to ormore expensive than the costs for the treatment ofobsessive compulsive disorder. Although antide-pressant medication seems to be the most cost-effective treatment in the short term, given thehigher relapse rates with antidepressants, it seemsthat, in the end, cognitive-behavioral therapy maybe the most cost-effective approach to the treat-

ment of bulimia nervosa. It is possible that similarfigures would occur for binge-eating disorder.”

Agras, W. S. “The Consequences and Costs of the EatingDisorders.” Psychiatric Clinics of North America 24, no. 2(June 2001): 371–379.

costs to treat obesity Obesity has been called notonly a health problem but also “an economic phe-nomenon.”

• Annual U.S. obesity-attributable medical expen-ditures are estimated at $75 billion in 2003 dol-lars, and approximately one-half of theseexpenditures are financed by Medicare andMedicaid, according to research done by thenonprofit group RTI International and the Cen-ters for Disease Control and Prevention. State-level estimates range from $87 million(Wyoming) to $7.7 billion (California). Obesity-attributable Medicare estimates range from $15million (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 tooverweight and obesity amounted to $117 bil-lion in 2000, according to The Surgeon General’sCall to Action to Prevent and Decrease Overweight andObesity report issued in December 2001.

• Obese men spend as much as 3.5 times that ofnormal-weight men on prescription drugs,according to a Mayo Clinic study presented atthe American Heart Association’s Scientific Ses-sions 2004. Researchers studied 328 male exec-utives, average age 47, and found that obesemen spent an average of $80.31 per month ondrugs, overweight men spent an average of$39.27 per month, and normal-weight menspent an average of $22.84 per month. “Theseare what we call ‘real and immediate costs.’These are not the costs associated with an oper-ation or serious event like a heart attack thatmight happen at some time in the future.Rather, this is what the men, or their employers,spend month after month on their prescriptiondrugs,” said Thomas G. Allison, lead author.

• Researchers at Beth Israel Deaconess MedicalCenter and Harvard Medical School found obese

101costs to treat obesity 101

adults had significantly higher medication andoffice visit spending than did people with lowerBMIs. Mean annual per person spending forhealth care overall was (in 2003 dollars) $2,127for a typical normal-weight white woman aged35 to 44 years; $2,358 for women with BMIs of25 to 29.9; $2,873 for women with BMIs of 30 to34.9; $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 dramati-cally among white and older adults but notamong blacks or those younger than 35 years.

Finkelstein, Eric A., Ian C. Fiebelkorn, and GuijingWang. “State-Level Estimates of Annual MedicalExpenditures Attributable to Obesity.” Obesity Research12, no. 1 (January 2004): 18–24.

Wee, C. C. “Health Care Expenditures Associated withOverweight and Obesity among U.S. Adults: Impor-tance of Age and Race.” American Journal of PublicHealth 95, no. 1 (January 2005): 159–165.

Council on Size and Weight Discrimination, Inc.An organization formed in 1991 to influence pub-lic policy and opinion in order to fight discrimina-tion based on body weight, size or shape. It is anonprofit project oriented advocacy group with aboard of directors rather than a membershiporganization. It depends on contributions andgrants to support its efforts. Its projects includenegotiations with architects’ groups over the stan-dard size of theater seats, testimony before regula-tory agencies dealing with diet fraud anddiscussions with writers and editors of medicaltextbooks on what the next generation of doctorswill be taught concerning weight and dieting.

The council also presents the perspective of thelarge-size health consumer at meetings of the sci-entific, medical, and research communities.

See also APPENDIX III, SOURCES OF INFORMATION.

couples therapy Psychological therapy involvingboth a patient and another person with whom thepatient has a uniquely close relationship; thoseinvolved may be a patient’s parent or his or herspouse or life partner. Couples therapy is used in avariety of settings and is recommended for treatingeating disorders when there is significant conflict

in a couple’s relationship. The conflict may becaused by the personalities involved, the eatingdisorder itself or a combination. The purpose ofcouples therapy is to strengthen the relationshipand to assist couples in problem solving and suc-cessfully 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 uncontrol-lable desire to consume a particular food, such aschocolate, or foods from a specific group, such asstarches. Consumption of this food gives both aphysical and psychological sense of well-being andsatisfaction. Research on both animals and humanshas demonstrated that cravings can be caused bybiochemical needs. A food craving may be thebody’s signal that something is out of balance.Although eating foods one craves makes one feelbetter for the moment, the resulting “high” even-tually is followed by fatigue, depression,headaches, moodiness, unclear or confused think-ing and the weight problems that frequentlyaccompany the abuse of any food. Cravings havesometimes been found to be caused by nutritionaldeficiencies, food allergies or diseases.

Studies have shown that overweight people tendto crave fatty foods; the fatter people are, the morethey prefer the taste of fat. In studies, when given achoice of milk shakes made with varying amountsof cream and sugar, overweight people have chosenfattier shakes than their lean counterparts. Over-weight people report eating no more calories thanothers, but more of those calories come from fat.

The effect of fatty foods on the brain—and theway people think about fats—undermine Ameri-cans’ attempts to stay trim, according to one schoolof thought. When the brain gets used to the sud-den rush of fat/sugar mixtures, a physical cravingdevelops similar to opiate drug addiction, accord-ing to research conducted at the University ofMichigan. New research indicates that a drug foropiate overdoses can also block craving for suchfoods as cookies and candy, but it is not a practicalor proven treatment.

Writing for Scientific American (January 1989),two researchers from the Massachusetts Institute

102102 Council on Size and Weight Discrimination, Inc.

of Technology, R. J. Wurtman and J. J. Wurtman,classified carbohydrate craving obesity as a distinctbehavioral disorder. They named as symptomsdepression, lethargy and an inability to concen-trate, combined with episodic bouts of overeatingand excessive weight gain. They also found thesecravings to be cyclic, occurring usually in the lateafternoons or evenings. They say it appears thatthis disorder is affected by biochemical distur-bances in the neurotransmitter serotonin, whichregulates appetite for carbohydrate-rich foods.

Many women experience apparently physio-logical-based cravings during pregnancy and men-struation. Researchers note that appetite increasespremenstrually and thus say it is possible (but notproven) that food cravings are a source of theextra appetite.

Cepeda-Benito and colleagues have recentlydeveloped a multidimensional assessment measureof food cravings. The instrument has both a traitand state version and has been validated in bothEnglish and Spanish.

Baker, Emily. “Food Cravings.” Scripps Howard NewsService, September 12, 1998.

Cepeda-Benito, A., D. H. Gleaves, T. L. Williams, andS. A. Erath. “The Development and Validation of theState and Trait Food Cravings Questionnaires,” Behav-ior Therapy 31, no. 1 (winter 2000): 151–173.

Cepeda-Benito, A., et al. “The Development and Valida-tion of Spanish Versions of the State and Trait FoodCravings Questionnaires,” Behaviour Research andTherapy 38, no. 11 (November 2000): 1,125–1,138.

creeping obesity A term used by someresearchers to describe the gradual but frequentweight gain affecting people in middle age. Accord-ing to proponents of the theory that creeping obesityis a specific form of obesity, the average Americangains one-half to one pound per year between theages of 20 and 60. One of the major causes of thiscreeping obesity, they say, is the lack of physicalactivity. They support their argument by noting thatit affects many residents of industrialized nations.

On the other side of the debate, HILDE BRUCH

writes,

In my own experience with this age group therehas not been one instance in which obesity had

developed in this gradual way. Whenever adetailed history was taken, weight increases werefound to be related to certain events or changes inlife patterns. This weight then became stable untilsome new event precipitated a new increase, suchas incapacitating illness, surgery, or states of emo-tional dissatisfaction. The increase at any one timemay not have been large, usually in the five to tenpound range. But these episodic increases addedup to “overweight.”

crystal methamphetamine An illegal appetite-suppressing amphetamine.

See also ICE.

cultural influences on appearance Attitudestoward physical appearance and standards ofbeauty and desirability have varied over time andfrom culture to culture. In prerevolutionary China,for example, tiny feet represented the ideal forwomen of the upper classes, leading to widespreaddeformities caused by the practice of foot binding.In Greek and Roman representations of the ideal inthe form of sculpted gods and goddesses, womenoften have ample thighs, hips and waists. Duringthe Renaissance, full-bodied women were also theideal. Plumpness was admired; in some cultures itwas an appealing sexual characteristic. But in the19th century, corsets were invented to enablewomen to achieve the then-ideal hourglassappearance. It became rude, among the genteel, toeat heartily. It was even glamorous, in some quar-ters, to look sickly. Because tuberculosis wasthought especially to afflict artists and other cre-ative people, a tubercular appearance came to sig-nify a romantic personality. Men preferreddelicate, pale women, and women used whiteningpowders rather than rouge.

In Western society during the early 20th cen-tury, a buxom appearance was preferred. Then the“flat-chested” flappers became the ideal in the1920s. Bustiness and the hourglass figure returnedin the 1950s. This was followed once again by thestill-current ideal of thinness. Researchers havedocumented recent shifts in our cultural image ofwomen by using data from Playboy magazine cen-terfolds and statistics from Miss America Pageantcontestants. The average weight of centerfold mod-

103cultural influences on appearance 103

els in 1960 was approximately 90 percent ofexpected average weight, based on the Society ofActuaries 1959 norm; in 1978, it was approxi-mately 83 percent. This decline occurred evenwhile the expected averages of weight and heightfor young women were increasing. Today a thinlook denotes self-control and success; the desire toconform to this slim physical model is one of thesocial variables that may lead to anorexia.

The culturally generated compulsion to be thinis also reflected in the proliferation of articles aboutdieting in magazines published principally forwomen. Fear of being fat, fear of losing controlover eating and fear of not being as slim as possibleare important social concerns. As far back as 1966,studies found that 70 percent of high school girlswere unhappy with their bodies and wanted tolose weight. Particularly for women, thinness hasbecome synonymous with attractiveness.

Studies examining changing standards of attrac-tiveness for men and women portrayed in 20th-century media indicated that female televisioncharacters are more likely to be slim and less likelyto be fat than male characters; that womenreceived more messages through magazine articlesand advertisements to be slim and stay in shapethan did men; that the prominence of curvaceousfemales portrayed in popular women’s magazinesdecreased dramatically since 1901; and that thestandard of bodily attractiveness of movie actressesbecame significantly thinner during the last 50years of the century.

Not all researchers believe that “ideal” appear-ances have changed in Western culture. HillelSchwartz, author of Never Satisfied: A Cultural His-tory of Diets, Fantasies, and Fat, says that the image ofbeauty in the United States has not changed muchover the years. He claims that for men and womenalike the ideal woman has long been thin, with along, thin neck, long arms, thin wrists, a very thinwaist and thin ankles. These proportions have alsobeen desirable for young men. (It was only around1850 that a plump, full-faced look became theideal for children. Before then, the image of ahealthy young child was thin as well.)

Not only slim proportions were considered beau-tiful for women; as the popular 1890s image of theGibson girls shows, it was also considered desirable

for them to be assertive and athletic, too. This led tothe belief that even as people age, they must retaintheir youthfulness and remain thin, although thebody does not naturally keep these proportions.This belief, Schwartz asserts, rather than health orfashion, is at the root of our dieting problems.

Pervasive cultural images linking slendernesswith beauty and health have convinced many normal-weight young children into believing that they areoverweight. Some start dieting before they are outof elementary school. A Canadian study found thatbetween the ages of five and seven, children beginto apply adult standards of attractiveness to them-selves and to one another—and to view fat nega-tively. By that age they start relating to fat peopledifferently. and the difference is markedly moresignificant with girls than with boys. They seeimages equating slenderness with health andbeauty, thin adult models in magazines and on tel-evision, and they perceive themselves to be fatbecause they have plump little faces and hands.

Collins reported that most people who worryabout their weight are women, and the currentstandard of beauty is so thin that, almost withoutexception, they consider themselves “overweight.”

In a 1998 British study, Hill and Franklin con-curred with earlier research that mothers play arole in the transmission of cultural values regardingweight, shape and appearance to their daughters.

It has also been observed that wherever andwhenever food is scarce or not sufficient for all,obesity becomes a symbol of success and is viewedwith admiration; where and when food is plentiful,thinness becomes the goal and dieting common-place. Sobal concludes: “Levels of obesity must beseen within their cultural and historical contexts,with each particular society and time period estab-lishing broad conditions within which body weightlevels occur for the population. In specific timesand places, the social demographics of individualsare important influences on body weight patterns.

“Understanding social patterns is useful forthose who deal with weight in their professionalroles. Assessing and considering social factors helpsto establish the social risks for obesity in individualclients or populations. When professionals decidewhether to deal with body weight issues andwhich interventions to use, it is crucial to consider

104104 cultural influences on appearance

cultural, historical, and social factors. Targetingchanges to specific audiences also requires consid-ering 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 BodyWeight: Helping Adolescents Balance the CulturalPressure for Thinness.” Journal of School Health 58, no.6 (August 1988): 227–231.

Hill, A. J., and J. A. Franklin. “Mothers, Daughters andDieting.” British Journal of Clinical Psychology 37, part 1(February 1998): 3–13.

Mazur, A. “U.S. Trends in Feminine Beauty and Over-adaptation.” 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 Influenceson 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 Peoplewith eating disorders have come mostly fromwhite middle- or upper-class families, leadingresearchers to determine that higher socioeco-nomic status is an important risk factor. Interna-tional studies offer further evidence to support thisnotion: Eating disorders have increased dramati-cally in industrialized nations during the last 20years, while remaining practically unheard of indeveloping countries. “Thinness” is not an idealamong people whose hunger is not a matter ofchoice. Concern over the shape of one’s body is anindulgence of the affluent.

The shift toward a thinner ideal body shape inWestern societies has been marked by the increas-ingly pervasive practice of dieting, especially amongwomen. An estimated 90 percent of the customersof the “diet” industry are women. Though the ben-efits of slenderness have been extolled by healthprofessionals, the potentially harmful side effects ofdieting have received considerably less attention.Several researchers have connected the culturalpursuit of thinness with eating disorders:

• Data presented by Polivy and Herman indicatethat dieting usually precedes binge eating; thusthey speculate that dieting is the disorder inneed of cure.

• Similarly, Garner states that bulimia may becomea problem in psychologically normal individualsafter a period of intensive caloric restriction.

• Katz identifies weight loss by itself as a precipi-tate for the appearance of anorexia nervosa invulnerable individuals.

• Mazur identifies anorexia nervosa and bulimia,as well as extreme diet and exercise regimensamong “normal” women, as examples of oftendangerous attempts to match the ever-changingideal of feminine beauty.

In addition, Japanese researchers have reportedthat during the past 25 years, a slim body hasbecome increasingly desirable for young women asa sign of beauty and success in Japan; dieting isnow common among them. Research suggests thatthis dieting is a factor contributing to bulimiaamong young women in Japan.

Giddens et al. suggest cultural influences affectthe female/male ratio: “Women suffer more oftenfrom eating disorders than men for a number ofreasons. First, our social norms put more emphasison physical attractiveness for women. Second, thesocially defined desirable body image for women isskinny, not muscular. Third, women are moreactive in public, social life than they used to be, butthey are still judged as much by their appearanceas by their accomplishments. Eating disorders arerooted in feelings of shame about the body.”

While Garner and his team reiterated that cul-tural influences do not cause eating disorders andthat culture is mediated by the psychology of theindividual as well as the social context of the fam-ily, Collins cautioned that the potential impact ofthe media in establishing identifiable role modelsshould not be underestimated.

Collins, M. Elizabeth. “Education for Healthy BodyWeight: Helping Adolescents Balance the CulturalPressure for Thinness.” Journal of School Health, 58, no.6 (August 1988): 227–231.

Feldman, W., E. Feldman, and J. Y. Goodman. “Cultureversus Biology: Children’s Attitudes toward Thinness

105cultural influences on eating disorders 105

106

and Fatness.” Pediatrics 81, no. 2 (February 1988):190–194.

Garner, David M. “Psychoeducational Principles in Treat-ment.” In Handbook of Treatment for Eating Disorders,2nd edition, edited by David M. Garner and Paul E.Garfinkel, chapter 8, 145–177. New York: GuilfordPress, 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 EatingDisorders: On the Need for Humility.” InternationalJournal of Eating Disorders 4 (1985): 617–626.

Mazur, A. “U.S. Trends in Feminine Beauty and Over-adaptation.” Journal of Sexual Research 22 (1986):281–303.

Polivy, J., and Herman, C. P. “Dieting and Binging: ACausal Analysis.” American Psychologist 40, no. 2 (Feb-ruary 1985): 193–201.

Cushing’s disease A disease caused by overactiv-ity of the pituitary gland, which influences growth,metabolism and other glands. The disease is char-acterized by a form of obesity and muscular weak-ness. It is much more common in women than inmen. Obesity is confined almost exclusively to thetrunk; any obesity involving the upper arms andthe upper thighs is disproportionately small.Patients with Cushing’s disease frequently havehypertension and are more susceptible to infec-tion. There may be minor hirsutism in women,particularly on the upper lip and chin, and some inthe periareolar region of the breast. Increased hairgrowth also often occurs over the lower abdomen,extending up from the pubic region.

cyproheptadine An appetite-stimulating anti-histamine used primarily for the treatment ofallergic conditions.

An early study in Peru found that cyprohepta-dine caused anorexics to gain significant weight,but two subsequent studies in the United Statesfailed to replicate this result. In one, there was adifferential drug effect related to the presence ofbulimia, so that cyproheptadine significantlyincreased treatment efficiency in the nonbulimicpatients and impaired treatment efficiency in thebulimic patients.

There are indications that cyproheptadine inrelatively large doses may have some mild effect inpromoting weight gain and relieving depression inanorexia nervosa. One major advantage of cypro-heptadine is that it appears to have few side effectseven in relatively large doses.

Morley lists cyproheptadine among the “numer-ous drugs utilized to treat the anorexia of agingwith varying success.” In their review of currentdrug treatments for anorexia nervosa, Powers andSantana state, “Although cyproheptadine has somemodest benefit during the weight restorationphase, it is not widely used.”

Morley. J. E. “Anorexia in Older Persons: Epidemiologyand Optimal Treatment.” Drugs and Aging 8, no. 2(February 1996): 134–155.

Powers, P. S., and C. Santana. “Available Pharmacologi-cal Treatments for Anorexia Nervosa.” Expert Opinionon Pharmacotherapy 5, no. 11 (November 2004):2,287–2,292.

106 Cushing’s disease

dairy foods and weight loss Since University ofTennessee researcher Dr. Michael Zemel beganreporting a link between CALCIUM and decreasedbody fat in the 1980s, several other studies havealso suggested that dairy food may help burn offbody fat.

In one of those studies, presented at the Ameri-can Heart Association’s 44th Annual Conferenceon Cardiovascular Disease Epidemiology and Pre-vention (2004), Lynn Moore, an epidemiologistfrom Boston University’s School of Medicine, andher colleagues analyzed the dietary habits of 106families, all with children three to five years of age.After following the children for 12 years, theresearchers found that the children who consumedthe least amount of dairy foods per day gained themost weight. Moore also noted that during theyears, childhood obesity has risen dramatically,while children’s milk consumption has fallen andsoda consumption has risen by 300 percent.

Researchers in Canada found that eating less fat,more whole fruits and dairy foods, specifically fatfree and low-fat milk, was associated with lessweight gain over time, and may be helpful inweight loss or weight maintenance.

In another study of food consumption patterns,which analyzed the diets of 459 healthy men andwomen, results suggest that a pattern rich inreduced-fat dairy products and high-fiber foodsmay lead to smaller gains in body mass index(BMI) in women and smaller gains in waist cir-cumference in both women and men.

Zemel noted that his and others’ studies “indi-cate that diets that include three or more dailyservings of dairy products result in significantreductions in adipose tissue mass in obese humansin the absence of caloric restriction, and markedlyaccelerate weight and body fat loss secondary to

caloric restriction compared with diets low in dairyproducts. These data indicate an important role fordairy products in both the prevention and treat-ment of obesity.”

However, not every scientist is ready to buy intothe “dairy foods equals weight loss” propositionwithout further studies. The October 2004 issue ofTufts University Health & Nutrition Newsletter cautionsthat Dr. Zemel “holds a patent on treating obesitywith a high-calcium regimen. He also has a bookout that discusses how calcium is a ‘revolutionarydiet discovery’ for losing weight faster. The scien-tific community becomes concerned when the per-son doing the research stands to gain financiallydepending on the result.” Others point out thatmost of the studies to date have been funded atleast in part by the dairy industry.

And even a National Dairy Council–fundedstudy failed to confirm some of the earlier findings.The study leader told WebMD, “When we got ourresults, it was quite disappointing that there wereno differences between the high- and low-dairygroups in our study. It may be that a low-calorie,high-dairy diet may offer just two pounds moreweight loss than a low-calorie, low-dairy diet. Butit is not going to be a magic bullet.”

Scientists caution that even if more extensiveand independent studies in the future do confirm alink between dairy foods and weight loss, simplyadding dairy foods to an existing diet will not leadto weight loss. It is more likely that replacing high-fat foods with low-fat dairy products while reduc-ing calories generally will be the key.

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

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Drapeau, V., et al. “Modifications in Food-Group Con-sumption Are Related to Long-Term Body-WeightChanges.” American Journal of Clinical Nutrition 80, no.1 (July 2004): 29–37.

Newby, P. K., et al. “Food Patterns Measured by FactorAnalysis and Anthropometric Changes in Adults.”American Journal of Clinical Nutrition 80, no. 1 (July2004): 504–513.

Zemel, Michael B. “Role of Calcium and Dairy Productsin Energy Partitioning and Weight Management.”American Journal of Clinical Nutrition 79, no. 5 (May2004): 907S–912S.

dehydroepiandrosterone (DHEA) A naturalhormone produced in the body by the adrenalgland. Also available as a dietary supplement.DHEA levels are at their highest around age 20,then gradually diminish with aging until only about20 percent remains around age 70. Because thesupplement reduces abdominal fat and preventsinsulin resistance in laboratory animals, Villarealand Holloszy, researchers at Washington Universityin St. Louis, enrolled 56 elderly persons in a ran-domized placebo-controlled trial to test whethersimilar effects would hold true in humans: If DHEAlevels in elderly people were returned to the levelsof their youth, could they reverse some of themetabolic complications of aging?

Using highly sensitive MRI measurements of theamount of abdominal fat, the researchers foundthat compared with placebo, DHEA supplementa-tion resulted in a decrease in VISCERAL FAT (withinthe abdomen) of 10.2 percent in the women and7.4 percent in the men. DHEA therapy alsoresulted in a decrease in subcutaneous abdominalfat (below the skin surface) averaging 6 percent inboth the women and the men. The researchersfound no adverse effects from DHEA therapy.

At the end of the study, patients receiving DHEAhad significantly lower insulin levels during oralglucose tolerance tests than at the start of thestudy. Their glucose levels remained unchanged,and these results indicate an improvement ininsulin action. The degree of improvement ininsulin action correlated closely to the amount ofdecrease in visceral fat.

The researchers then began a larger and longerfollow-up study on the effects of DHEA replace-ment. Doctors caution that more data is neededbefore people should begin taking DHEA outside of

medical supervision. Not only is the DHEA cur-rently sold as a supplement unregulated and thuswith no assurance of quality, but because it is ahormone, DHEA could be harmful for persons witha history of hormone-sensitive cancers, such asbreast and prostate tumors.

Villareal, Dennis T., and John O. Holloszy. “Effect ofDHEA on Abdominal Fat and Insulin Action inElderly Women and Men: A Randomized ControlledTrial.” Journal of the American Medical Association 292,no. 18 (November 10, 2004): 2,243–2,248.

dental caries (or cavities) Tooth decay; the pro-gressive destruction of the hard tissues of the teeththrough a process initiated by bacterially producedacids at the tooth surface. Dental caries are seenextensively in patients with eating disorders. Thisis due to an excessive CARBOHYDRATE intake, poororal hygiene and changes that occur in the saliva.

During binge periods (see BINGE EATING), hugeamounts of sugar can be consumed, followed bysugar drinks, often used to relieve thirst after vom-iting. Thus, bulimics tend to have higher sugarintake than anorexics, whose diet is limited. Butanorexics under the care of physicians also are sus-ceptible to dental caries, because some medicationsgiven to them, such as dextrose tablets, dietarysupplements, and vitamin C drinks, contain sugar.

Neglect of oral hygiene can be seen in bothanorexic and bulimic patients, due mainly to theupset in daily routine. Their eating habits get mostof their attention. Meticulous oral hygiene is anecessity in these patients, because of excess acidpresent in the oral cavity, excess sugar intake anddisturbances in the saliva.

Anorexics have been found to have decreasedsalivary pH and decreased buffering action, withthe low pH contributing to the occurrence of den-tal caries. Patients with anorexia typically havedecreased salivary flow as well. Fear and DEPRES-SION decrease salivary flow and affect its composi-tion, thus potentially contributing to the formationof caries. Often this decreased flow of saliva is mul-tiplied by the misuse of laxatives and diuretics (seeDIURETIC ABUSE, LAXATIVE ABUSE) or by ANTIDEPRES-SANT drugs. These drugs decrease total fluid vol-umes and affect electrolyte balance, causing aneven further diminished salivary flow. Anorexic

108108 dehydroepiandrosterone

patients, with virtually no natural defense againstcarries, have monumental decay problems.

Bulimics and anorexics who vomit repeatedly(see VOMITING) to purge themselves of consumedfood risk erosion of the enamel of their teeth, par-ticularly on the inner surfaces, from hydrochloricacid in the vomit. This erosion may result in severegum disease, cavities and tooth loss. The dentistmay be the first to encounter actual indications ofbulimia. The dental manifestations—although notlife threatening and not evident until the laterstages of illness—are effects of eating disorders thatcannot be reversed.

Faine noted, “Young women with bulimia ner-vosa and anorexia nervosa may seek dental carebefore seeking medical treatment because they areconcerned about their appearance. Early identifi-cation of oral changes by the dental practitionerand referral to medical and psychiatric therapistscan reduce the risk of further physical damage tothe body or greater loss of tooth surface enamel.Home care instructions will be followed when thereasons for timing of toothbrushing, rinsing aftervomiting, and use of fluoride are explained. Care-ful selection of beverages and snacks will helpreduce the risk of further erosion and dental caries.Comprehensive dental procedures should not beundertaken until significant improvement in vom-iting behavior or complete recovery has occurred.”

Dalin, Jeffrey B., D.D.S. “Oral Manifestations of EatingDisorders.” In Eating Disorders: Effective Care and Treat-ment. St. Louis: Ishiyaku EuroAmerica, 1986.

Faine, M. P. “Recognition and Management of EatingDisorders in the Dental Office.” Dental Clinics of NorthAmerica 47, no. 2 (April 2003): 395–410.

depression and eating disorders A mental statecharacterized by sad mood, lack of hope and a gen-eral loss of interest in life. It is distinguished fromgrief, which is a response to a real loss and gener-ally proportionate to its importance. Symptomsvary with the severity of the illness. With milddepression, the main symptoms are anxiety, moodchanges and sometimes inexplicable crying spells.Serious depression is usually accompanied byappetite and sleep disturbances, social withdrawal,increasingly poor performance in school, at homeor at work, lack of energy and loss of concentra-

tion. Severely depressed persons may wish fordeath or even consider SUICIDE, exhibit phobiasand dwell on thoughts of guilt or worthlessness.

In bulimics, depression may be obvious, evi-denced by apathy, lethargy, joylessness, suicidalthoughts, sleep disturbances and general lack ofpleasure in life. The severity of depressive symp-toms in bulimics is similar to that of patients withMAJOR AFFECTIVE DISORDER.

The relationship between depression and eatingdisorders has been under considerable study. Manypeople with eating disorders also appear to sufferfrom depression, and scientists have wonderedwhether depression could trigger an eating disorder.There are similarities in neurochemical abnormalitiesin both disorders. Low levels of SEROTONIN and nor-epinephrine are associated with depressive disordersas well as eating disorders, and ANTIDEPRESSANT med-ications may help some people with eating disorders,particularly bulimics. In addition, both the depressedand anorexic tend to have higher than normal levelsof the hormone CORTISOL, which is released inresponse to stress. Depression is commonly seen inpatients with bulimia; it is unclear, however, whetherthe depression leads to bulimia or vice versa.

According to DSM-IV, there is an increased fre-quency of depressive symptoms or mood disorders(particularly dysthymic disorder and major depres-sive disorder) in individuals with bulimia nervosa.In most cases, the mood disturbance begins at thesame time as or following the development ofbulimia nervosa, with some patients blaming theirmoods on their bulimia. In others, however, themood disturbance clearly precedes the develop-ment of bulimia nervosa.

Gucciardi et al. noted, “In 2000, the prevalenceof depression among women who were hospital-ized with a diagnosis of anorexia (11.5 percent) orbulimia (15.4 percent) was more than twice therate of depression (5.7 percent) among the generalpopulation of Canadian women. The highest inci-dence of depression was found in women aged 25to 39 years for both anorexia and bulimia.”

Noting that although research on adults hasfound the comorbidity between depression and eat-ing disorders to exceed the comorbidity of any otherclinical disorder and eating disorders, Perez et al.found that few studies have investigated the specificassociations of major depression versus dysthymia

109depression and eating disorders 109

with eating disorders. Their research followed 937adolescents until age 24, and determined that dys-thymia had a stronger association with bulimia thanmajor depression, concluding that the presence ofdysthymia in adolescence might be a possible riskfactor for the development of bulimia nervosa.

Casper. R. C. “Depression and Eating Disorders.” Depres-sion and Anxiety 8, suppl. 1 (1998).

Gucciardi, E., et al. “Eating Disorders.” BMC Women’sHealth no. 4, suppl. 1 (August 25, 2004): S21.

Perez, M., T. E. Joiner, Jr., and P. M. Lewinsohn. “Is MajorDepressive Disorder or Dysthymia More StronglyAssociated with Bulimia Nervosa?” International Jour-nal of Eating Disorders 36, no. 1 (July 2004): 55–61.

depression and obesity Research on the rela-tionship of obesity to depression is in the earlystages, according to the American Obesity Associa-tion. Stunkard et al. suggest the need to betterunderstand why these disorders co-occur in certainindividuals and how to develop more effectivetreatments when they do occur together. Theywrite, “For years it was assumed that any relation-ship of depression to obesity in the general popula-tion was largely coincidental. Research in therecent past, however, has uncovered a large num-ber of moderating and mediating variables thatrelate depression and obesity. Depression influ-ences obesity under some circumstances and obe-sity influences depression under others.”

Rosmond suggests that obesity and depressionmay represent different manifestations of the samedisease process. “Our understanding of the systemsof the brain related to energy balance has increasedover the last decade. As a result, drugs most com-monly used today in the management of obesityhave their primary effect in modulating the balancebetween monoaminergic neurotransmitters,among other serotonin. Serotonin is believed to beinvolved in the complex process of integratingphysiological and behavioral systems gearedtowards energy balance. However, gradual weightgain seen in most people suggests that the regula-tory system may not be sufficient under all circum-stances. An insufficient serotoninergic neuronalfunction in the central nervous system has beenshown in many studies to occur in patients withdepression. In such serotonin-deficient patients,treatment with drugs increasing the concentration

of serotonin at serotoninergic synapses gives afavorable clinical response. Taken together, thissuggests to a certain extent a common pathophysi-ology between obesity and depression.”

Others have noted that although most individualswho are extremely obese have normal psychologicalfunctioning, a significant minority do suffer fromdepression or other emotional complications thatmay need treatment prior to bariatric surgery. John-son et al. found that obesity increases the risk ofdepression by more than 40 percent after controllingfor other factors, concluding, “More studies areneeded to ascertain the mechanism by which obesityand depression could be related and the significanceof this relation for the prevention and treatment ofboth obesity and depression. Given the effects of de-pression, we suggest that health professionals shouldassess their obese patients for risk of depression be-fore embarking on a weight management protocol.”

Johnston, E., et al. “The Relation of Body Mass Index toDepressive Symptoms.” Canadian Journal of PublicHealth 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). Availableonline. URL: http://www.psychiatrictimes.com/p041081.html.

diabetes and eating disorders People who com-bine disordered eating with diabetes face signifi-cantly more health risks than nondiabetics withsimilar eating patterns in the general population.

Rodin et al. reviewed studies from the previousdecade regarding the association of type I diabetesmellitus and eating disorders, noting that “althoughthere has been much debate regarding the speci-ficity of this association, a recent large multisitecase-controlled study demonstrated that the preva-lence rates of both full syndrome and subthresholdeating disorders among adolescent and young adultwomen with diabetes are twice as high as in theirnondiabetic peers. Further, a four-year follow-upstudy showed that disordered eating behavior inyoung women with diabetes often persists and isassociated with a threefold increase in the risk ofdiabetic retinopathy. These eating disturbances tend

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to be associated with impaired family functioningand with poor diabetes management.”

The diabetic’s necessary focus on food, his or herdeprivation of certain foods, his guilt over nonad-herence to the prescribed diet, unhealthy relation-ship with food, and rebelliousness toward dietaryrestrictions can all provoke a disordered eating pat-tern. The starvation of anorexia nervosa and thepurging of bulimia can both lead to serious hypo-glycemia (deficiency of sugar in the blood). Andbinge eating can lead to seriously elevated bloodglucose levels and diabetic ketoacidosis.

Recent reports have cautioned health careproviders to be aware of the possible associationbetween eating disturbances and diabetes, and alsothe types of behavior, particularly insulin omissionfor weight loss, that are common in eating disorderpatients who also have diabetes.

Rodin et al., for example, advise, “Health careprofessionals should maintain a high index of suspi-cion for the presence of an eating disturbance amongyoung women with diabetes, particularly amongthose with persistently poor metabolic controland/or weight and shape concerns. Screening forsuch disturbances should begin during the prepuber-tal period among girls with diabetes. A brief psy-choeducational intervention leads to a reduction indisturbed eating attitudes and behavior but is notsufficient to improve metabolic control. More inten-sive treatment approaches, which should include afamily-based component, may be needed to improvemetabolic control. The evaluation of these and othertreatment approaches is indicated in view of the seri-ous short- and long-term health risks associated witheating disorders in young women with diabetes.”

If insulin-dependent patients develop anorexia,their extremely low weight may appear to controlthe diabetes for a while. Eventually, however, ifthey fail to take insulin and regain weight, thesepatients will die.

Herpertz and Nielsen note that considerably lessresearch has been done on the comorbidity of type2 diabetes and eating disorders. Pointing out thatstudies have shown a predominance of bulimianervosa in type I diabetes and binge eating disorderin type 2 diabetes, they add, “Contrary to type 1diabetes, nearly 90 percent of type 2-diabeticpatients developed an eating disorder before themetabolic illness was diagnosed. . . . By being over-

weight and obese, binge eating may lead to type 2diabetes in some patients.”

Herpetz, Stephen, and Soren Nielsen. “Comorbidity ofDiabetes Mellitus and Eating Disorders.” In Handbookof Eating Disorders, 2nd Ed., edited by Janet Treasure,Ulrike Schmidt, and Eric van Furth, 400–414. WestSussex, U.K.: John Wiley & Sons Ltd., 2003.

Rodin, G., et al. “Eating Disorders in Young Women withType 1 Diabetes Mellitus.” Journal of PsychosomaticResearch 53, no. 4 (October 2002): 943–949.

diabetes and obesity Diabetes mellitus is a chronicdisease in which blood glucose (sugar) levels are toohigh. Cells in the body break down glucose in orderto provide energy for movement, growth and repair.The hormone insulin is responsible for regulatingglucose levels in the blood. Abnormally high levels ofglucose can damage the small and large blood ves-sels, leading to diabetic blindness, kidney disease,amputations of limbs, stroke and heart disease.

There are three common types of diabetes. Type1 diabetes is usually (but not always) diagnosed inchildren and young adults, and is an autoimmunedisease. Persons with Type 1 diabetes make noinsulin and must take insulin every day. Type 2diabetes is usually (but not always) diagnosed inadults over the age of 45. In Type 2 diabetes, eitherthe person is not making enough insulin or thebody is resistant to insulin and cannot use it prop-erly. More than 80 percent of people with Type 2diabetes are overweight. Gestational diabetesoccurs during pregnancy: 2–4 percent of all preg-nant women have gestational diabetes. If a womanhas gestational diabetes, she has about a 40 percentchance of having Type 2 diabetes later in her life.

Type 2 diabetes, which until recently was com-monly referred to as adult-onset diabetes, isincreasingly turning up in children—a primaryreason for its now being more often called Type 2.In 2000, an estimated 30 percent of boys and 40percent of girls born in the United States were atrisk for being diagnosed with Type 2 diabetes atsome point in their lives. Several studies havelinked Type 2 diabetes in children with obesity, andaccording to the Institute of Medicine, approxi-mately 9 million children over six years of age arenow obese: “Since the 1970s, the prevalence (orpercentage) of obesity has more than doubled for

111diabetes and obesity 111

preschool children aged 2–5 years and adolescentsaged 12–19 years, and it has more than tripled forchildren aged 6–11 years.”

In a study published in the January 1, 2003, issueof the Journal of the American Medical Association(JAMA), the Centers for Disease Control and Pre-vention (CDC) of the U.S. Department of Health andHuman Services reported that 44 million Americansare considered obese by BODY MASS INDEX (BMI),reflecting an increase of 74 percent since 1991. Dur-ing the same time frame, diabetes increased by 61percent, reflecting the strong correlation betweenobesity and development of diabetes.

Prevalence of both diagnosed diabetes and obe-sity varied widely among states. Mississippi had thehighest rate of obesity (25.9 percent) and Coloradohad the lowest (14.4 percent). Alabama had thehighest rate of diagnosed diabetes (10.5 percent)and Minnesota the lowest (5.0 percent). Comparedto adults with healthy weight (BMI values from18.5 to 24.9), those with a body mass index of 40or higher had a 7.37 times greater risk of beingdiagnosed with diabetes.

Other study results found that African Ameri-cans had the highest rates of both obesity (31.1percent) and diabetes (11.2 percent) comparedwith other ethnic groups. People with less than ahigh school education had higher rates of bothobesity (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 CDCresearchers found that overweight diabetic adultstrying to lose weight have a reduced risk of mortal-ity, independent of whether they lose weight.Actual weight loss is associated with increased mor-tality only if the weight loss is unintentional.

Also, findings from the Diabetes Prevention Pro-gram (DPP), a major clinical trial funded by theNational Institutes of Health involving 3,234 peo-ple with impaired glucose tolerance, a conditionthat often precedes diabetes, showed that Ameri-cans at high risk for Type 2 diabetes can sharplylower their chances of getting the disease throughdiet and exercise. Participants randomly assignedto intensive lifestyle intervention reduced their riskof getting Type 2 diabetes by 58 percent. On aver-age, this group maintained their physical activity at30 minutes per day, usually with walking or othermoderate intensity exercise, and lost 5–7 percent

of their body weight. Participants randomized totreatment with the oral diabetes drug metformin(Glucophage) reduced their risk of getting Type 2diabetes by 31 percent. Smaller studies in Chinaand Finland have also shown that diet and exercisecan delay Type 2 diabetes in at-risk people.

Gregg, Edward W., et al. “Trying to Lose Weight, LosingWeight, and 9-Year Mortality in Overweight U.S.Adults with Diabetes.” Diabetes Care 27, no. 3 (March2004): 657–662.

“Overview of the IOM’s Childhood Obesity PreventionStudy.” Preventing Childhood Obesity: Health in the Bal-ance, 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 pat-tern that occurs with numerous psychological dis-orders and commonly among the eating disorders.Dichotomous reasoning involves thinking inextreme, absolute, all-or-none terms and is typi-cally applied to food, eating and weight. The patientdivides food into good (low calorie) and bad (fat-tening) categories. A one-pound weight gain maybe equated with incipient obesity. Breaking a rigideating routine produces panic because it means acomplete loss of control. Rigid attitudes and behav-iors are not restricted to food and weight but extendto the pursuit of sports, studies and careers.

See also COGNITIVE DISTORTIONS.

dietary fiber The edible but indigestible fibrouscomponents of plants. Fiber adds bulk to the dietand can aid normal bowel function by enabling thelarge intestine to work effectively and by helpingregulate the absorption of nutrients in the smallintestine. Dietary fiber is not a single substance,and there are significant differences in the physio-logical effects of the various fibers. A Recom-mended Dietary Allowance has not beenestablished; however, an adequate amount can beobtained by eating several servings daily of whole-grain breads and cereals, fruits, root vegetables,legumes and nuts.

A report of the Council on Scientific Affairs ofthe American Medical Association stated that somescientists believe that excessive energy (caloric)intake may be inevitable when diets are low in

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fiber, with high-fiber diets possibly reducing energyintake, even when more food is eaten. Studies sug-gest that when people are allowed to eat unlimitedamounts of high-fiber food, but not foods contain-ing sugar and other refined carbohydrates, theamount eaten decreases significantly, and appetitesare satisfied. Although fiber has no magical effectsin promoting weight loss, it can be an importantpart of a balanced but low-calorie diet. High-fiberdiets are also beneficial because they help preventconstipation, a common result of reduced foodintake. Limited data from clinical trials that suggestthat fiber supplements or high-fiber diets are usefulfor weight reduction are contradictory. Dietary fibermay have a limited role as an adjunct in the treat-ment of obesity, but controlled, long-term trials areneeded before this can be established.

dietary supplements Products taken by mouththat contain a “dietary ingredient” intended to sup-plement the diet, as defined by the Dietary Supple-ment Health and Education Act (DSHEA) of 1994.The dietary ingredients in these products mayinclude: vitamins, minerals, herbs or other botani-cals, amino acids and substances such as enzymes,organ tissues, glandulars and metabolites. Dietarysupplements can also be extracts or concentrates,and may be found in many forms such as tablets,capsules, softgels, gelcaps, liquids or powders. Theycan also be in other forms, such as a bar, but if theyare, information on their label must not representthe product as a conventional food or a sole item ofa meal or diet. Whatever their form may be,DSHEA places dietary supplements in a special cat-egory under the general umbrella of “foods,” notdrugs, and requires that every supplement belabeled a dietary supplement. Unlike medications,dietary supplements are presumed to be safe untilthe U.S. Food and Drug Administration (FDA)receives multiple reports of adverse effects.

Generally, manufacturers do not need to registertheir products with the FDA nor get FDA approvalbefore producing or selling dietary supplements.Manufacturers must make sure that product labelinformation is truthful and not misleading.

In November 2004 the FDA announced initia-tives to further implement and enforce DSHEA. Theinitiatives include a regulatory plan and a draft

guidance document for industry. The regulatoryplan includes monitoring product safety, assuringproduct quality and evaluating product labeling. Thedraft guidance for industry describes the amount,type and quality of evidence the FDA recommendsa manufacturer have to substantiate a claim.

A five-state survey of 14,679 adults in 1998found that 7 percent of adults used over-the-counter weight-loss supplements, with the greatestuse noted among young obese women (28 per-cent). Retail sales of weight-loss supplements wereestimated to be more than $1.3 billion in 2001.

Although many dietary supplements promiseweight loss, few if any have been shown to defi-nitely help with weight loss. In general, peoplewho have lost weight while taking these supple-ments also had eaten less and increased their phys-ical activity. However, some supplements are beingstudied to see whether they are safe and effective.

Blanck, H. M., L. K. Khan, and M. K. Serdula. “Use ofNonprescription Weight Loss Products: Results from aMultistate Survey.” Journal of the American MedicalAssociation 286, no. 8 (August 22–29, 2001): 930–935.

diet centers and programs The frustration ofcontinuously striving to achieve the elusive “ideal”weight is a prime motivator for the overweight toturn to other “sufferers,” seeking help, under-standing, empathy. And when those other suffer-ers number about 130 million people, according tothe National Center for Health Statistics, it is smallwonder that an entire industry of diet centers,clubs and programs bringing these obsessive dieterstogether has flourished. According to some reports,50 million Americans go on diets each year—which approximates $30 billion in spending ondiet foods, diet sodas, books, videos, cassettes, fit-ness clubs and related services.

Some diet centers, like TOPS (Take Off Pounds Sen-sibly) and OVEREATERS ANONYMOUS, are nonprofitorganizations; others, like WEIGHT WATCHERS, andJENNY CRAIG are commercial enterprises. Diet centersprovide dietary advice and social support and areespecially helpful for those people who find that theonly way to lose weight is to have others pushing andpulling them along toward their goals. Diet centersprovide psychological motivation and “good exam-ples” of others who have succeeded, as well as super-

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vised diet programs with step-by-step daily routines,exercises, menus, weigh-ins and so on. One analysisof such diet centers found that short-term outcomesare at least equivalent to medically prescribed thera-pies. The average length of membership is about 26weeks and the mean weight loss about 20 pounds.Little is known about long-term results. The reducingdiet, group pressures, BEHAVIOR MODIFICATION tech-niques, a supportive group and financial commit-ments all play a part in accounting for their success.

Scientific interest in dieting for obesity began inthe mid-1800s with the Harvey-Banting Diet (seeBANTING, WILLIAM). The novel aspect of Harvey’s dietwas the emphasis on meat, the “strong food,” whichhad just been recognized as being less fattening thanthe “innocent” foodstuffs, such as breads and sweets.Proteins were considered necessary for restoration ofbody substances, carbohydrates for the acute com-bustion process.

With Harvey’s diet program achieving popularsuccess, other metabolism experts quickly devel-oped their own diets. Ebstein’s method (high fatcontent) and the Dancel-Oertel cure (fluid restric-tion and systematic exercise) also proved popularduring the 1880s.

But there were difficulties with all three programs,with unsuccessful cases being attributed to their“mechanical” application; presumably more flexibil-ity would have led to success. Despite better under-standing of metabolic processes, most of the sameproblems remain unsolved by today’s programs.

HILDE BRUCH wrote:

every “new” diet program uses the hook of offer-ing nutrient essentials in an unexpected, interest-ing, and convenient combination so that weightconscious people become curious, follow it for aweek or two, and proudly proclaim its effective-ness. An important factor in the diet game is pub-licity and packaging; scientifically designed dietsare taken over by commercial enterprises andadvertising, and then become highly successful.

She used as examples a fluid low-protein dietdesigned for in-hospital metabolic studies, whichbecame the “Metrecal” diet; and a high-proteindiet prescribed for years by the New York CityHealth Department in its obesity clinic, a diet thatbecame the basis of a multimillion-dollar businesscalled Weight Watchers.

In recent years, the use of celebrities to endorsediet products has helped revolutionize the promo-tion of weight reduction programs. Elliott Gould, EdKoch, Susan St. James, Sarah Ferguson, MonicaLewinsky, Lynn Redgrave, Oprah Winfrey andTommy Lasorda are a few celebrities who haveearned many thousands of dollars a year touting dietproducts and programs. Their endorsements haveboosted diet company sales by up to 100 percent; thepowdered-diet portion of the industry alone hasreached the billion-dollar mark in annual sales.

Yet it was reported in The Washington Post thatSlim-Fast sales fell 27 percent in 2003 to $290 mil-lion, while Jenny Craig sales were flat or declinedfor the previous five years, and Weight Watchersshowed a 3.1 percent drop in membership in fourth-quarter 2003, with product sales dropping 8 percent.The reason given: a struggle to compete with low-carb 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 weightby yourself or with a group of like-minded othersthrough support groups or worksite- or commu-nity-based programs fits in the “do-it-yourself”category. Individuals using such a program relyon their own judgment, group support and prod-ucts such as diet books for advice.

• Nonclinical Programs These programs may or maynot be commercially operated, such as through aprivately owned weight-loss chain. They often usebooks and pamphlets that are prepared by healthcare providers. These programs use counselors(who usually are not health care providers andmay or may not have training) to provide servicesto you. Some programs require participants to usethe program’s food or supplements.

• Clinical Programs This type of program may ormay not be commercially owned. Services areprovided in a health care setting, such as a hos-pital, by licensed health professionals, such asphysicians, nurses, dietitians and/or psycholo-gists. In some clinical programs, a health profes-sional works alone; in others, a group of healthprofessionals works together to provide servicesto patients. Clinical programs may offer you

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services such as nutrition education, medicalcare, behavior change therapy and physicalactivity. Clinical programs may also use otherweight-loss methods, such as very low-caloriediets, prescription weight-loss drugs and surgery,to treat severely overweight patients.

In February 1999 a coalition of government,academic and commercial weight-loss organiza-tions announced new guidelines to provide con-sumers with better information on the risks, costsand track records of commercial diet programs.Participants in the new agreement (Partnership forHealthy Weight Management), including WeightWatchers International and Jenny Craig, agreed toabide by provisions aimed at helping dieters tocomparison-shop among programs. Among theseprovisions, programs must disclose the qualifica-tions of their staff, and they must outline all costsof their regimens, including payments for propri-etary diet foods.

WIN suggests that anyone contemplating join-ing a diet center or enrolling in a diet programgather as much information as possible first. WINsays providers of weight-loss programs should beable to answer these questions:

• What does the weight-loss program consist of?

• Does the program offer individual counselingand/or group classes?

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

• Do participants have to purchase special food,drugs or supplements?

• Does the program encourage participants to bephysically active, follow a specific physical activ-ity plan or provide exercise instruction?

• Does the program provide information on howto make positive and healthy behavior changes?

• Is the program sensitive to participants’ lifestyleand cultural needs?

• What are the staff qualifications?

• Who supervises the program?

• What type of weight management training,experience, education and certification does thestaff have?

• Are there risks related to following the pro-gram’s eating or exercise plans?

• Are there risks related to using recommendeddrugs or supplements?

• Do participants talk with a medical professional?

• Does a medical professional oversee the pro-gram?

• Will the program providers work with a partici-pant’s personal health care provider if he or shehas a medical condition or takes prescribed med-ications?

• What is the total cost of the program?

• Are there recurring costs such as weekly atten-dance fees, costs of food and supplement pur-chases?

• Are there additional fees for a follow-up pro-gram or to reenter the program for follow-upafter weight loss?

• Are there additional fees for medical tests?

• How much weight do average participants loseand how long have they kept off all or part oftheir weight?

• Can the program provide references?

Finally, WIN suggests that anyone interested inlocating a local weight-loss program ask their healthcare provider for a referral or contact a local hospital.

See also FAD DIETS.

dieter’s teas Herbal teas containing senna, aloe,buckthorn and other plant-derived laxatives.When consumed in excessive amounts, they cancause diarrhea, vomiting, nausea, stomach cramps,chronic constipation, fainting or perhaps death. Inrecent years, the Food and Drug Administration(FDA) has received “adverse event” reports,including the deaths of four young women, inwhich dieter’s teas may have been a contributingfactor. As a result, the FDA has issued consumeradvisories. These teas, which are usually bought inhealth food stores, through mail-order catalogs andover the Internet, often are used for weight lossbased on the belief that increased bowel move-ments will prevent absorption of calories. How-ever, the FDA concluded in 1995 thatlaxative-induced diarrhea does not significantly

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reduce absorption of calories because the laxativesdo not work on the small intestine, where caloriesare absorbed, but rather on the colon, the lowerend of the bowel. Unless sweetened, dieter’s teasprovide essentially no nutrients and no calories.

Kurtzweil, Paula. “Dieter’s Brews Make Tea Time a Dan-gerous Affair.” FDA Consumer (July/August 1997).

dieting A word generally used to refer to restric-tion or alteration of food intake. Counting CALO-RIES and restricting food intake has become anobsession with Americans. DIET CENTERS AND PRO-GRAMS, “slimnastics” classes, weight reduction sup-port groups and “figure salons” can be found inmost neighborhoods. In fact, dieting has beencalled the fastest-growing industry in the UnitedStates. According to a Calorie Control CouncilNational Consumer Survey in 2004, 33 percent ofU.S. adults (71 million people) are currently diet-ing. That is an increase from 2001, when an NPDGroup survey found 26 percent (30 percentwomen and 22 percent men) to be dieting year-round. In 2003, the NPD Group, which tracks con-sumer behavior for industry, reported that adultsdieting by month were as follows: January, 25 per-cent; February, 29 percent; March, 30 percent;April, 29 percent; May, 29 percent; June, 28 per-cent; July, 28 percent; August, 28 percent; Sep-tember, 27 percent; October, 26 percent;November, 28 percent; December, 26 percent.Americans spend more than $40 billion a year ondieting and diet-related products.

And dieting is no longer practiced only byadults. A study of fourth-grade girls in Californiafound that 80 percent said they were dieting. Thepractice of young girls’ dieting to get from a sizeeight to a size seven can establish patterns of dep-rivation, BINGE EATING and weight gain that willhaunt them all their lives. The director of one hos-pital eating-disorders unit estimates that more than50 percent of the patients there—mostly women intheir late teens and early twenties—began dietingbefore they were teenagers. A survey in Londonrevealed that girls as young as 12 felt too fat,attempted to restrict food intake and expressedguilt about eating. Even non-obese girls of ages fiveand six express concern about their body imageand fear gaining weight. In extreme cases, chil-

dren’s attempts at dieting can actually stunt theirgrowth: if they occur just before the main growthspurt of early adolescence, they can jeopardize theincrease in height that would automatically rectifyan obesity problem. Zinc deficiencies and anemiaalso can result from improper dieting.

A national survey of 11,631 high school stu-dents conducted by the national Centers for Dis-ease Control and Prevention found that more than43 percent of the girls reported they were on adiet—and a quarter of these dieters did not thinkthey were overweight.

When Calderon et al. surveyed 10th-grade maleand female students at a multiethnic urban publichigh school in the Los Angeles area, 26.6 percent ofthe students had a body mass index greater than 25and were therefore at risk of being overweight. Yet60 percent had made conscious efforts to loseweight—36.5 percent of the boys and 73.6 percent ofthe girls. Of those who had tried dieting, 54.7 percentoften dieted to control their weight. Limiting portionsize was practiced by about 34 percent of those whohad tried dieting techniques. In addition, countingcalories and counting grams of fat were reported by31.4 percent and 41.9 percent of these students,respectively. Approximately 44 percent of these stu-dents used meal skipping to control their weight.

One unconfirmed, and possibly unconfirmable,hypothesis is that dieting may begin accidentallyduring infancy, when dieting mothers uninten-tionally put their infants on and off diets byattempting to limit the children’s food intake whenthey themselves are dieting and by becoming morelenient when they are not dieting. This theoryderives from a single study in which mothers whoreported the strongest inclination to diet were mostlikely to interpret tape-recorded episodes of ababy’s crying as a reflection of hunger. The samestudy showed that fat mothers preferred thinnerbabies and planned to make more efforts to pre-vent obesity by limiting intake than thin mothers.

Remedies for obesity have always been a part ofAmerican culture. But while there are fad diets, inthe United States dieting itself is not a fad; rather,it is a culturally embedded practice, a permanentsocial feature. Hillel Schwartz explains that

fashion will not bring a diet to popularity, but ratherdieting and fashion evolve from society’s and theindividual’s desires. The history of dieting is a com-

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bination of the way we see our bodies and the waysociety sees our body, and of our fantasies and fearsabout ourselves, and desires for our society.

The growing weight-consciousness of Americansociety became evident with the appearance of thefirst public penny scales during the 1890s. These hadbells that rang and music that played when peoplestepped on them; the faces were large so that any-one could see the weight. Then charts began toappear with the scales. These initially showed theaverage weight for a given height, and later the sug-gested weight. As scales and weight-consciousnessbecame more widespread, the faces shrunk. Soon,public scales were out of vogue and bathroom scalesbecame popular—one could weigh in private andwithout 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 themain source of help, combined with programs ofregular weighing and counseling, they generallylose weight—while attending. One study reporteda mean loss of 25 pounds over an average 24weeks of treatment. Long-term results are rarelyreported. VERY LOW-CALORIE DIETS, whether com-posed of ordinary or specially prepared food,achieve losses similar in size to those produced bystarvation, but being safer, they can be employedwith outpatients. However, studies of the long-term effects of very low calorie diets have foundfairly rapid replacement of lost weight. Within twoto five years, 40 percent of people who lose weightactually end up heavier than when they started.Jane R. Hirshmann, coauthor with Carol H.Munter of Overcoming Overeating, has been quotedas saying, “Every single diet results in a binge. Itdoesn’t matter what you’re on. Everyone who isinvolved with them knows they don’t work.”

The increasing evidence is that weight lossachieved exclusively through diet restriction can“prime” for future weight gain. This is because adecrease in the resting metabolic rate occurs whenenergy intake is reduced, possibly as a result of theloss of lean body mass. A repeated cycle of weight lossand gain may lower the resting metabolic rate, andpersons with a history of weight cycling may requiresignificantly fewer calories than persons without sucha history. (See SET-POINT THEORY; YOYO DIETING.)

But a later study reported by the University ofPennsylvania Medical School disputes this “starva-tion response” theory. Researchers tracked 18 diet-ing obese women for 48 weeks, all of whom alsoincreased their levels of physical activity. Half thewomen ate 1,200 calories daily; the other half took420-calories-a-day OPTIFAST for 16 weeks, graduallyreturning to solid food. The Optifast patients had amean loss of 47 pounds, the others 22. The restingmetabolism dropped dramatically for the very-low-calorie dieters early in the program, but it was onlyslightly lower by the end because of a reduction inlean body mass. The study determined that whendieters lose weight, they lose both fat and lean bodymass; thus, for every 25 pounds lost, the dieter needsto decrease calorie intake by 100 calories a day.

There is some evidence that by dieting, theobese may actually shorten their life span. Japan-ese men in Hawaii who were heavy at age 25 butsucceeded in losing weight by middle age had ahigher mortality than those who maintained ahigh and steady weight. On the other hand, menwho had been lean at age 25 and became eventhinner fared no worse than those who maintaineda low steady weight. Weight reduction was associ-ated with a near doubling of mortality for fat menbut was not nearly as hazardous for thin men.Nearly identical results have been obtained in stud-ies of French government workers and Harvardalumni. In an American Cancer Society Study, per-sons who reported having lost weight by intentprior to entering the study were more likely to dieof stroke and coronary artery disease over theensuing five years of follow-up. In another study,victims of myocardial infarction who successfullylost 10 pounds or more were twice as likely to dieas those who maintained stable weights. And in aDutch survey, obese women who were dieting tolose weight reported an average of 12 health com-plaints, whereas nondieters reported an average ofonly eight. These findings have raised questionsabout the widespread assumption that dieting forweight loss improves health.

Janet Polivy, professor of psychology at the Uni-versity of Toronto, has been studying dieting formore than 30 years. She is convinced that dietingto lose weight can be as much of a problem as theone it is supposed to alleviate. Her research sug-gests that attempts to lose weight may result in

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both weight gain and poorer health, mental as wellas physical. She and her research team have, viatheir 10-item RESTRAINT SCALE, developed a pictureof the chronic dieter as someone who is easilyupset and easily distracted, who is obsessed withweight and eating, who is eager to please and gen-erally has lower than normal self-esteem.

Polivy has also cautioned that fatigue, weak-ness, dizziness, irritability, changes in texture ofhair and skin and occasionally more severe prob-lems resulting from malnutrition occur as a resultof inadequate caloric intake during dieting.

In addition to these physical effects, psychologicalaspects of dieting also are being studied by healthprofessionals. A University of Vermont studyattempted to correlate the daily and major life stress,psychological symptoms and dieting behavior in 143adolescent girls aged 14 to 18 over a four-monthperiod. The results of this study indicate that there isa correlation between stress and dieting behavior inadolescents, which was also found to be the case inprevious studies of adults. The Vermont study alsosupported the idea that dieting behavior is related tocertain psychological symptoms in adolescents.

The association between dieting and eating dis-orders, especially bulimia nervosa, has recentlybeen called into question. Michael Lowe and col-leagues studied several groups of women withbulimia nervosa and found that the majority werenot currently dieting to lose weight. It may be thatdieting is more important in the development ofbulimia nervosa than in its maintenance.

Hillel Schwartz noted that the reason mostdieters fail to lose weight or keep it off is that theyare dieting in order to change their personalities,and when their personalities do not change, theylose confidence and return to their earlier habits.He stresses that being happy with one’s body andhaving a beautiful body has little to do with weightor fat and more with physical grace.

Weight-Loss Strategies: Questions

Considerable attention has been devoted to theidentification of behavioral changes that facilitateshort-term and long-term weight loss. Thisresearch has largely concentrated on the interven-tions of clinical practitioners in nutrition, medicineand psychology. Most efforts to lose weight, how-ever, are made by individuals independently of

professional supervision and counseling and with-out physical aids such as drugs or surgery.

Dieting has become an informal institutiondeeply embedded in Western culture and econ-omy. The media, official bodies and product mar-keters ply the public with information, sometimesinaccurate, about ways to reduce weight. On thebasis of such information, as well as from personalexperience, many people construct personal pro-grams of eating practices and physical activity withthe intention of losing weight. They also continuesome of these practices, perhaps conceived as gen-erally healthful eating and exercise, when they areno longer trying to lose weight.

Recent research has attempted to relate people’sknowledge of diet and nutrition to issues of healthand weight control. One study, for example, foundthat good knowledge of nutrition seldom corre-lated with good weight control in the overweight.Others have found differences between men andwomen in their use of dieting strategies. Womenhave been found to be more likely than men to useboth physical activity and food-restriction strate-gies. However, another study, while noting thatwomen more often used reduced-calorie diets thanmen, found that men engaged in physical activityfor weight control more frequently than women.

A British research team led by Alan Blairreported in Psychology and Health on a study of therelationship between professed beliefs about dietingand reported body weight before and after dieting.Among respondents to their questionnaire, strate-gies of increasing exercise, avoiding alcohol and cut-ting down on fat were positively correlated withsuccess in reducing weight. General avoidance ofcalories between meals was positively correlatedwith success in maintaining weight loss. Amongpractices whose use was not correlated with weightloss were conventional slimming strategies such asfasting, skipping meals, using liquid meal replace-ments and attending diet centers. In addition, effec-tive weight control was directly related to highexpectations of success, no matter the weight lossstrategy. The researchers suggested that adjustmentsmay be called for in the content of educational mes-sages and clinical therapy for the overweight.

Other studies have reexamined the relation-ships between nutrient intake and overweight. Inone, researchers found that high BODY MASS INDEX

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was most strongly associated with low bread con-sumption and use of low-fat milk. Another foundthat average daily alcohol consumption was unre-lated to adiposity, and still another reported evi-dence that fat intake may contribute to overweightindependently of total energy intake.

One researcher has hypothesized, on the basisof satiety physiology and surveys of sugar use, thatcalories in and with drinks consumed after andbetween meals make a major contribution to diffi-culties in weight control.

The American Heart Association does not rec-ommend high-protein diets for weight loss, espe-cially those restricting healthful foods that provideessential nutrients and fail to include the variety offoods needed to adequately meet nutritionalneeds. People who remain on these diets long-termmay be at risk for inadequate vitamin and mineralintake as well as other health risks. Others havenoted that weight loss appears to be associatedwith decreased caloric intake, which can beachieved through a well-balanced diet rather thanvia reduced carbohydrate content.

In Sculpturing Your Body: Diet, Exercise and Lipo (Fat)Suction, John A. McCurdy says, “The most effectivemethod to assist in sculpturing your body by diet isto formulate a plan that is balanced but utilizessmaller portions of all basic food groups. If a diet is tobe skewed in the direction of any one nutrient, itshould be constructed to be high in complex carbo-hydrates because of the many benefits provided bythese substances.” He cited a study on a college cam-pus that showed that overweight students effectivelyreduced on a diet requiring 12 slices of low-calorie,high-fiber bread per day in addition to virtually any-thing else they wished (except alcoholic beverages),including between-meals snacks. The high-fiber bulkof the bread appeared to reduce the intake of otherhigh-calorie foods, presumably by increasing satietyor the feeling of fullness.

The National Heart, Lung, and Blood Institute(NHLBI) guidelines recommend beginning a weight-loss diet by lowering one’s usual caloric intake by 500to 1,000 calories per day. This type of reduction typ-ically results in a loss of one to two pounds per weekand has been shown to reduce total body weight byan average of 8 percent over three months to a year.

In a representative sample of 100 adult dietersin the English Midlands, only reduction of fatty

foods was associated with a decrease in weightafter intensive dieting. Exercise was also associatedwith weight loss. In fact, because traditional treat-ments for overweight/obesity that focus onrestricting energy (cutting calories) show poorlong-term maintenance of weight loss, non-dietingapproaches such as exercising to expend moreenergy are increasingly advocated.

Many questions, therefore, remain about whichenergy-related strategies facilitate weight loss inthe short term, and, more important, for the rest ofone’s life.

Weight Loss: A Sensible Approach

The U.S. Department of Health and Human Servicessuggests the following “sensible approach” to dieting:

Before embarking on any weight loss program,would-be dieters should consult their physicians tobe sure there are no underlying medical problemsand that the diet and exercise program they are con-templating is right for them. Talking to a registereddietitian or qualified nutritionist can also be helpful.

Women should be aware that they face more ofa challenge in losing weight than men do. Becausethey generally need fewer calories than men simplyto maintain their weight, women have to reducecalories to a lower level in order to lose. For exam-ple, most men can lose one to two pounds a weekconsuming 1,500 to 1,600 calories a day, whereasmany women may have to cut down to 1,000 to1,200 calories a day to achieve the same result.

Because she is consuming fewer calories, afemale dieter needs to pay especially close attentionto the nutrient value of the foods she eats. Anyone,male or female, considering a diet of 1,000 caloriesor less should discuss with a physician whether avitamin-mineral supplement at the level of U.S.Recommended Daily Allowances is advisable.

Although women may have more of a battlethan men when it comes to weight loss, the samebasic principles apply to both:

• Consult a physician and, if possible, a dietitianbefore embarking on a very restricted diet.

• Aim for a moderate weight loss of one or twopounds a week. Research has shown that lossesin excess of this tend to be losses not of body fatbut of water and lean muscle.

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• Reduce portion sizes, but maintain a balanceddiet from the four basic food groups: grains andcereals; eggs and dairy products; fruits and veg-etables; 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 calo-ries in order to keep track of how much they’retaking in. It also can be helpful to eat severalsmaller meals, rather than three large meals a day.

Calderon, L. L., C. K. Yu, and P. Jambazian. “DietingPractices in High School Students.” Journal of theAmerican Dietetic Association 104, no. 9 (September2004): 1,369–1,374.

Lowe, M. R., D. H. Gleaves, and K. P. Eberenz. “On theRelation 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 Con-sumer (May 1997).

Polivy, Janet. “Is Dieting Itself an Eating Disorder?” BASHMagazine (July 1989).

Schwartz, Hillel. Never Satisfied: A Cultural History of Diets,Fantasies, and Fat. New York: Free Press, 1986.

diet pills—OTC Nonprescription weight-controlpills sold over the counter (OTC) and promoted asa way to lose weight. In their examination of theprevalence of specific weight-loss practices amongU.S. adults trying to lose weight, Kruger et al.,researchers with the Centers for Disease Controland Prevention, found that 2 percent of men and 3percent of women were taking diet pills.

In the earlier Indian Adolescent Health Study, 11percent of American Indian adolescents reported theuse of diet pills. According to another study of 2,629girls in grades nine through 12, 12 percent reportedusing diet pills during the previous 30 days. A surveyby the National Center on Addiction and SubstanceAbuse (CASA) at Columbia University in 2003 indi-cated that girls and young women who drink coffeewith caffeine are significantly likelier than those whodo not to take diet pills to help them control theirweight (15.7 percent versus 6 percent). The data also in-dicated that girls and young women who take diet pillsto help them control their weight drink coffee morefrequently than those who do not take diet pills.

According to the market research firm KaloramaInformation, the OTC diet aids industry declinedabout $100 million in 2003 from nearly $900 mil-lion in 2002, in part due to the controversy overEPHEDRA and lingering suspicions from previousproblem ingredients such as PHENYLPROPANOLAMINE

(PPA), which made consumers more wary. TheKalorama report noted that major companies in theindustry have come up with ephedra-free versionsof their most popular products.

In November 2000 the FDA issued a publichealth advisory concerning PPA, which had beenfound in both nonprescription cold medicationsand diet pills for decades, after a Yale study sug-gested it caused 200–500 strokes a year. Because ofthe PPA advisory and ephedra ban, manufacturersare now using herbal supplements, vitaminsand/or caffeine. Pharmacists caution that, not onlydoes the FDA not regulate herbal supplements, butdosages of the product may be different from whatis stated on the label, and often such ingredientscan have dangerous interactions if taken with pre-scription medications. The bottom line, accordingto the FDA, is that no OTC diet pill has proved tobe effective. In addition, medical experts haveexpressed concern that newer diet pills often con-tain Citrus aurantium, or synephrine, also known asbitter orange, which may cause some of the sameside effects as ephedra.

Since 1990, FTC cases challenging deceptiveclaims for diet pills, potions, patches and programshave resulted in administrative or federal districtcourt orders requiring companies or individuals topay more than $48 million to consumers.

See also APPETITE SUPPRESSANTS.

Kruger, J., et al. “Attempting to Lose Weight: SpecificPractices among U.S. Adults.” American Journal of Pre-ventive Medicine 26, no. 5 (June 2004): 401–406.

dissociation A term generally referring to a dis-connection of mental processes that are normallyintegrated. Dissociation can be pathological andnon-pathological. Non-pathological dissociationgenerally refers to daydreaming, absorption andimaginative involvement. Pathological dissociationgenerally refers to amnesia, depersonalization,derealization, identity confusion and identity alter

120120 diet pills—OTC

ation. The most extreme form of the dissociativedisorders is dissociative identity disorder (formallyknown as multiple personality disorder).

For years there has been a debate regarding theassociation between eating disorders and dissociativephenomena or disorders. Persons with eating disor-ders frequently describe a variety of dissociativeexperiences and some persons may have full blowndissociative disorders. Some researchers and/or clini-cians have hypothesized that there may be some sortof dissociative mechanism that is central to the eatingdisorders. However, the results of a recent study byKatz and Gleaves suggest that the elevated dissocia-tive symptomatology sometimes seen in persons witheating disorders may simply be an artifact of a comor-bid dissociative disorder. Regardless of this latter find-ing, dissociative experiences may be an importantclinical variable to consider as part of treatment:

Katz, B. E., and D. H. Gleaves, “Dissociative Symptomsamong Patients with Eating Disorders: AssociatedFeature or Artifact of a Comorbid Dissociative Disor-der,” 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, butcan also be common substances such as tea, coffeeand water, that help remove excess water from thebody by stimulating the flow of urine. Diureticdrugs interfere with normal kidney action bychanging the amount of water, potassium, sodiumand waste products removed from the blood-stream. Normally, most of the potassium, sodiumand water are returned to the bloodstream duringthe normal filtration process, but small amountsare expelled from the body along with waste prod-ucts in the urine. Some diuretics reduce theamount of sodium and water taken back into theblood; others increase blood flow through the kid-neys and thus the amount of water they filter andexpel in the urine. They are often irresponsiblygiven by diet doctors so a patient can experience aquick weight loss. Any such weight loss is tempo-rary and a consequence of the dehydrating effect.

Because diuretics are available in a wide variety ofover-the-counter formulations as well as by prescrip-tion, the exact rate of diuretic use or abuse is unknown.

Patients who abuse diuretics obtain them from sev-eral sources: over the counter; appropriate prescrip-tions for medical conditions; multiple prescriptionsfrom two or more physicians, each unaware of thereal amount of the drug the patient is using; pre-scriptions meant for another person; misappropria-tion from workplaces, including nursing homes,hospitals, pharmacies and pharmaceutical distributors.

Researchers at the University of MinnesotaMedical School evaluated 14 symptomatic femalevolunteers between the ages of 18 and 40 whoused diuretics on a regular basis for nonmedicalreasons. Seven (50 percent) were diagnosed ashaving a current or past eating disorder, and nine(64 percent) were diagnosed as having a current orpast AFFECTIVE DISORDER. The results of this pilotstudy suggest that chronic diuretic use by youngwomen signals the possibility of an unrecognizedeating problem and/or affective disorder.

The three groups of prescription diuretics mostoften abused by patients with eating disorders arethe thiazides, loop diuretics and potassium-sparingdiuretics. Thiazides, including chlorothiazide andhydrochlorothiazide, cause depletion of potassiumand other electrolytes. Adverse consequences ofHYPOKALEMIA (extreme potassium depletion) includecardiac conduction defects, arrhythmias and muscu-lar weakness or paralysis. Common symptomsinclude weakness, nausea, palpitations, excessiveurination, excessive thirst, constipation and abdom-inal pain. Other potential side effects of thiazideabuse include abnormal blood levels of sodium,sugar, uric acid, fat, zinc, magnesium and calcium.

Loop diuretics include furosemide andethacrynic acid. Excessive potassium loss and fluiddepletion occur frequently, especially when usedin larger-than-recommended doses. Other sideeffects of these agents include hyperuricemia,hypocalcemia, magnesium depletion, ototoxicityand cross-reaction in sulfa-allergic patients.

Potassium-sparing diuretics include spironolac-tone and triamterene. In contrast to the thiazides andloop diuretics, these agents result in a mild loss ofpotassium. In addition, triamterene nephrolithiasisand acute renal failure are potential adverse effects.

Most bulimic patients who misuse or abusediuretics use over-the-counter preparations. Com-monly available over-the-counter diuretics includePremsyn-PMS, Midol-PMS, Diurex-MPR, Pamprin

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Menstrual Relief, Aqua-Ban and Diurex Water Pill.Most of them contain one of three ingredientslisted by the U.S. Food and Drug Administration asdiuretics (Category I) effective in menstrual drugproducts: pamabrom, ammonium chloride and caf-feine. In addition, the FDA has found that pyril-amine maleate (an antihistamine) is an appropriateadjunct to any of the Category I diuretics.

Ammonium chloride is the active diuretic ingredi-ent in one of the most widely used over-the-counterformulations. It is considered safe in a dosage rangeof one to three grams daily in divided oral doses forperiods of up to six days. Ammonium chlorideresults in formation of sodium chloride from sodiumbicarbonate in the body, but the effect lasts onlyabout four or five days. Nausea, vomiting and gas-trointestinal distress are potential side effects.

CAFFEINE is considered by the FDA to be a safeand effective diuretic for over-the-counter use indoses of 100 to 200 milligrams every three to fourhours. As a diuretic, caffeine acts by increasing theglomerular filtration rate in the kidneys. Sleepless-ness is a potential side effect.

Pamabrom is considered by the FDA to be a safeand effective diuretic for relief of water accumulationduring menstrual cycles. Recommended dosage is notmore than 50 milligrams per dose and 200 milligramsin 24 hours.

The effects of these over-the-counter diureticson individuals with eating disorders who may haveother metabolic abnormalities owing to vomitingor LAXATIVE ABUSE can have severe consequenceson renal function and fluid and electrolyte balance.

Huynh-Do and Frey noted, “An acute cessationof diuretic intake causes renal sodium retentionwith formation of edema due to diuretic-inducedsecondary hyperaldosteronism. Therefore, diuret-ics should be tapered over weeks or even monthsin these patients.”

Huynh-Do, U., and F. J. Frey. “[Potential dangers ofdiuretics . . .]” Therapeutische Umschau 57, no. 6 (June2000): 408–411.

Mitchell, J. E., et al. “Diuretic Use as a Marker for EatingProblems and Affective Disorders among Women,”Journal of Clinical Psychiatry 49, no. 7 (July 1988):267–270.

Pomeroy, Claire, et al. “Prescription Diuretic Abuse inPatients with Bulimia Nervosa.” Journal of Family Prac-tice 27, no. 5 (November 1988): 493–496.

double-blind study A study in which neither theresearchers nor the participants know which groupis the experimental group and which the controlgroup. The purpose is to eliminate any expecta-tions, conscious or unconscious, that might affectthe outcome of the study or trial.

DSM-IV The fourth and most recent edition of theDiagnostic and Statistical Manual of Mental Disorders,published by the American Psychiatric Associationin 1994. DSM-IV provides criteria for classifyingpsychological disorders for physicians making diag-noses and researchers compiling statistics. This man-ual is considered the standard for the profession.

Diagnostic and Statistical Manual of Mental Disor-ders, Fourth Edition, Text Revision (DSM-IV-TR),released in 2000, incorporates information culledfrom a comprehensive literature review of researchabout mental disorders published since DSM-IVwas completed. Updated information is includedabout the associated culture, age and gender fea-tures, prevalence, course and familial pattern ofmental disorders, including eating disorders.

dumping syndrome A side effect that may resultfrom ROUX-EN-Y GASTRIC BYPASS (RGB) and BILIOPAN-CREATIC DIVERSION (BPD) operations. It means thatstomach contents move too rapidly through thesmall intestine. Blackwood explains, “The foodenters the small intestine rapidly and without the aidof partial digestion by gastric juices.” Symptomsinclude nausea, vomiting, weakness, sweating, faint-ness, a bloated sensation and sometimes cramps anddiarrhea after eating that last for about 20 to 30 min-utes. It is especially triggered by eating sweets or car-bohydrates or large amounts of foods. Although theresults can be extremely unpleasant, it is not consid-ered a serious health risk; in fact, some consider it abenefit because it controls the intake of less healthyand calorie-laden foods. Some patients are unable toeat any form of sweets following such surgery.

Blackwood, Hilary S. “Obesity: A Rapidly ExpandingChallenge.” Nursing Management 35, no. 5 (May2004): 27–36.

dysfunctional behavior patterns Abnormal,inadequate or impaired functioning. According to

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Polivy, Herman and Garner in Assessment of Addic-tive Behaviors (New York: Guilford Press, 1988),many of the dysfunctional behavior patterns char-acterizing eating-disordered patients are directlyrelated to perceptions that perpetuate the eatingdisorder. Although the negative self-concept repre-sented by the sense of worthlessness, overcompli-ancy, lack of trust and excessive perfectionism doesnot necessarily correspond to particular behaviorproblems, it does constrain an individual andinhibits normal interactions and relationships. Theflight from maturity or femininity often creates (orexacerbates) problems with sexual behavior:patients may either avoid sex completely or act ina promiscuous but unsatisfying (and often person-ally distasteful) manner. The positive value per-ceived in symptoms such as weight loss andstarvation in anorexics, binge eating and purging

in bulimics and inappropriate (i.e., non-hunger-induced) eating in the obese makes it particularlydifficult to substitute more acceptable behaviors.

Misperceptions about food and calories, lack ofself-awareness, DICHOTOMOUS REASONING, obsessionwith food and eating and excessively high valuationof thinness all contribute to the chaotic eating behav-iors of these patients. When patients cannot distin-guish emotion from hunger, or cannot determinewhether they are hungry or sated (see HUNGER andSATIETY), it becomes more likely that they will eat inresponse to inappropriate (e.g., emotional) internalsensations. The desire for thinness leads to DIETING,which in turn may trigger BINGE EATING. A dichoto-mous thinking style can promote binge-or-starveeating. Misperceptions regarding food and calories,and obsessions with food, are associated in obviousways with disordered eating patterns.

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early satiety Bulimics who practice frequentvomiting often complain that they feel “full” fol-lowing consumption of a relatively small amountof food, a characteristic referred to as early satiety.

Eating and Weight Disorders: Studies onAnorexia, Bulimia and Obesity A quarterly jour-nal that first appeared at the end of 1996, it isdevoted to research on eating disorders andobesity. Published in Italy, the editor is MassimoCuzzolaro, and the publisher is Edrice Kurtis.

See APPENDIX VIII for contact information.

Eating Attitudes Test (EAT-26) A self-test devisedby Paul E. Garfinkel and David M. Garner to meas-ure the broad range of symptoms characteristic ofanorexia nervosa. A high score on the EAT-26 doesnot necessarily reflect anorexia nervosa, nor does alow score invariably rule it out, since people may notrespond honestly on a self-report questionnaire.However, in practice, the EAT-26 has been shown tobe quite accurate in discriminating anorexics fromcontrol subjects. It is most useful as a screeningdevice; diagnoses of anorexia nervosa must be con-firmed in clinical interviews. EAT-26 scores can alsoserve as an index of anorexic patients’ improvement.

The EAT-26 appears on the Web sites of many eat-ing disorder groups and medical and educationalWeb sites, including Penn State’s at http://www.sa.psu.edu/uhs/healthinformation/eatingattitudes.cfm.Site visitors can take the test quickly, submit itanonymously and receive an instant score.

Schmolling, Paul. “Eating Attitude Test Scores in Rela-tion to Weight Socioeconomic Status, and Family Sta-bility.” Psychological Reports 63 (1988).

Eating Behaviors An international scientificjournal publishing research on the etiology, pre-

vention and treatment of obesity, binge eating andeating disorders in adults and children. Contentincludes studies related to the promotion ofhealthy eating patterns to treat or prevent medicalconditions (e.g., hypertension, diabetes mellitusand cancer); descriptive studies establishing func-tional relationships between eating behaviors andsocial, cognitive, environmental, attitudinal, emo-tional or biochemical factors; and clinical outcomeresearch evaluating the efficacy of prevention ortreatment protocols. It is published by Elsevier Ltd.

See APPENDIX VIII for contact information.

eating disorder not otherwise specified (EDNOS)A diagnostic category described in DSM-IV for vari-ants of disordered eating that do not meet the diag-nostic criteria for anorexia nervosa or bulimianervosa. The international Eating Disorder ReferralOrganization cautions, “These are still eating disor-ders requiring necessary treatment. A substantialnumber of individuals with eating disorders fit intothis category.” Examples include females who meetcriteria for anorexia nervosa but continue to men-struate, individuals who regularly purge but do notbinge-eat and individuals who meet criteria forbulimia nervosa but binge-eat less than twiceweekly. Disordered eating patterns also fit into thiscategory, such as BINGE-EATING DISORDER (BED),and repeatedly chewing and spitting out, but notswallowing large amounts of food.

International Eating Disorder Referral Organization.“Other Eating Disorders.” Available online. URL:http://www.edreferral.com/othered.htm. Down-loaded on December 14, 2004.

Eating Disorders Awareness Week (EDAW) In1988 the last week of April was designated EatingDisorders Awareness Week by Congress. Currently,

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Eating Disorders Awareness Week is held each yearduring February. Its sevenfold purpose:

1. To increase efforts to prevent the developmentof eating disorders.

2. To educate the public and professional commu-nities regarding warning signs and appropriateinterventions.

3. To increase awareness of treatment programsand support services.

4. To encourage development of healthy attitudestoward psychological and physical develop-ment, body image and self-esteem by influen-tial individuals (i.e., parents, educators andhealth professionals).

5. To challenge cultural attitudes regarding thin-ness, perfection, achievement and expression ofemotion that contribute to the increasing inci-dence of eating disorders.

6. To improve the ability of professionals of all disci-plines to provide effective treatment and support.

7. To promote a compassionate, nonjudgmental,public understanding of eating disorders.

eating disorders inventory (EDI) A 64-item self-test designed in 1983 by Garner, Olmstead andPolivy to differentiate bulimics, extreme dieters andparticular subgroups of anorexic patients. The EDIevaluates an individual on a number of differentsubscales including drive for thinness, body dissat-isfaction, sense of ineffectiveness, perfectionism,interpersonal distrust and fears of maturity—psychological and behavioral components commonto anorexia and bulimia. This test was intendedto augment the EAT, which focuses primarily ondieting- and eating-related symptoms. It is one ofvery few tests for anorexia, bulimia and bulimia ner-vosa that measure not only symptoms but also psy-chological characteristics believed to be central inthese disorders. The EDI has been used experimen-tally to discriminate individuals with eating disordersfrom nonpathological weight-preoccupied women.

The test has been revised (and is now called theEDI-2) with the addition of three new scales and 17items. However although recent research has con-tinued to support the reliability and validity of theeight original subscales, the reliability and validityof the three new subscales appears questionable.

Eberenz, K. P., and D. H. Gleaves. “An Examination of theInternal Consistency and Factor Structure of the Eat-ing Disorder Inventory-2 in a Clinical Sample.” Inter-national Journal of Eating Disorders, 16 (1994): 371–379.

Welch, Garry, Anne Hall, and Claes Norring. “The FactorStructure of the Eating Disorder Inventory in aPatient Setting.” International Journal of Eating Disor-ders 9, no. 1 (January 1988).

Welch, G., A. Hall, and F. Walkey. “The Factor Structureof the Eating Disorder Inventory.” Journal of ClinicalPsychology 44, no. 1 (January 1988).

Eating Disorders: The Journal of Treatment andPrevention A scientific journal devoted exclu-sively to the eating disorders; published since 1992,five issues per year. It is published by Taylor andFrancis and edited by Leigh Cohn. The journal is verypractice 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 orbony body type. Ectomorphs are characterized bylong, thin arms and legs and a narrow trunk, con-veying a rather trim, thin appearance.

Theories linking body types to emotional or psy-chological characteristics are not considered scien-tifically sound.

See also BODY TYPES; ENDOMORPH; MESOMORPH.

ego state therapy A treatment approach apply-ing various techniques from group and family ther-apy to the resolution of internal conflict in a singleindividual. In this therapy, the individual psyche isassumed to be made up of various parts that havedifferent functions and constitute the whole.

Torem, Moshe S. “Eating Disorders and Dissociative States.”In Eating Disorders: Effective Care and Treatment, edited byFélix E. F. Larocca. St. Louis: Ishiyaku EuroAmerica, 1986.

Watkins, John G., with Helen H. Watkins. Ego States: The-ory and Therapy. New York: W. W. Norton, 1997.

elderly and eating disorders Although eatingdisorders are most commonly thought of as occur-ring during adolescence, the process of aging bringsmany changes that can influence such illnesses asanorexia nervosa and bulimia. After the age of 50,

126126 eating disorders inventory

physical changes such as a decrease in the basalmetabolic rate, a decrease in lean body mass andan increase in percentage of body fat combine withcommon changes in psychosocial conditions toaffect nutrition. For instance, decreasing financialresources and increasing social isolation may pro-mote 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 ofwhat their bodies require. Life stresses and traumamay also have an effect on the development of eat-ing disorders in the elderly. For example, researchindicates that women who are newly grieving overthe deaths of their husbands are likely to skipmeals and resort to junk food.

As with adolescents, there is an increase in bodyfat in those over 50. Changes in the body’s energyrequirements may coincide with changes in dailyroutine due to such events as illness, relocation orretirement. If physical activity is decreased but theamount of food consumed is not, there will be again in weight, another common variable inalready changing bodies.

Along with a decline in metabolism, the agingprocess brings changes in nearly all other body sys-tems. The aging may experience changes in sightand hearing, as well as declining sensitivity to tem-perature, touch and taste gustatory villae [tastebuds] begin to atrophy in women in their early for-ties and men in their early fifties). The neurologicalsystem, especially the brain, the digestive systemand the musculoskeletal system are all noticeablyaffected. Such physiological changes affect the bodyimages of aging individuals, and body image is oftenan important variable in the initiation of dietingbehaviors that may lead to eating disorders.

Clinicians at Northeastern Ohio Universityhave reported three case histories of onset ofanorexia nervosa in geriatric patients. Geriatricresearch has demonstrated neurotransmitterchanges that may predispose the aging populationto anorexia. These include a decline in norepi-nephrine as well as B-endorphin levels; thesechanges are also seen in anorexia.

Some researchers have theorized that eatingdisorders are becoming more common among theelderly for two reasons. First, there has been a dra-matic increase in the incidence of eating disorders

in the last three decades. Since at least 20 percentof patients become chronic, and not all of themshed their illness as they age, some are likely toremain anorexic or bulimic into old age. Second, itis possible that even elderly women are beginningto succumb to the social pressures to be slim, andsome may use vomiting to control their weight.

Lending credibility to the first theory, Arthur H.Crisp reported in the British Journal of Psychiatry in1990 that an 80-year-old woman had a relapse ofanorexia nervosa after being in remission for 50years. Symptoms of the disease graduallyreemerged after her husband died. Investigatorsconsidered the relapse an attempt to use a previ-ously discovered coping strategy to keep the nega-tive emotions of depression and grief at bay.

Allen quotes the medical director of an eatingdisorders treatment center as saying that he hasnoticed an increase in the number of olderpatients—30 of his 200 patients in 2003 (15 per-cent) were age 65 or older. “Some patients havehad a disorder all their lives, and never grow out ofit. Others are predisposed to a disorder and somelife-altering event—the last child leaving home orthe death of a spouse—triggers the latent condi-tion. Some act on a lifelong distorted body image.”

Another eating disorders center doctor toldAllen that “triggers for a disorder in an older per-son can include a ‘greater discomfort with gettingolder. 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 geri-atric medicine at St. Louis University MedicalSchool, depression is the most common cause ofweight loss and anorexia in older persons.

Experts do caution that age-related anorexia is aterm frequently used to describe the loss ofappetite among elderly individuals, and is not nec-essarily 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.” Amer-ican Journal of Psychiatry 146, no. 2 (February 1989).

Morley, John E. “Anorexia in Older Persons: Epidemiol-ogy and Optimal Treatment.” Drugs and Aging 8 (Feb-ruary 1996).

127elderly and eating disorders 127

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 agegroup least likely to be overweight, but physiciansare reporting increased incidence of obesity amongthis age group, particularly those in retirementcommunities and assisted-care facilities. Amongthe reasons suggested for the increase are threelarge high-calorie meals a day, little exercise andthe dynamic of eating in group settings.

A report compiling data from 12 federal agen-cies, Older Americans 2004: Key Indicators of Well-Being, showed the increase in the prevalence ofoverweight and obesity among older adults to bedramatic. In the period 1999–2002, 69 percent ofAmericans age 65 and older were overweight orobese. In the prior two decades, the increasesamong those ages 65–74 have been especiallystriking. In the periods 1976–80 and 1999–2002,the percentage of people ages 65–74 who wereoverweight or obese rose from 57 percent to 73percent; the percentage who were obese doubledfrom 18 percent to 36 percent.

Arterburn et al. calculate that the number ofobese adults over age 60 will rise from 14.6 millionin 2000 to 20.9 million in 2010, an increase of 43percent, “challenging healthcare delivery andfinancing systems in the United States.”

BODY MASS INDEX (BMI) is considered by some tobe a less valid indicator of obesity among the eld-erly, who tend to have a shift of fat from peripheralto central sites along with an increase in waist-to-hip ratio at the same level of BMI. Also, becausethe elderly lose muscle mass, BMI can underesti-mate their body fat. Also, the elderly may be in thehealthy-weight category according to their BMI,yet actually have reduced nutritional reserves.Normally, total body fat decreases after age 70, andpercentage of body fat may decline slightly inextreme old age. However, abdominal and intra-muscular fat increases with age.

In 2004 United Press International surveyed 84specialists for a 15-part series on the causes, conse-quences and costs of the global obesity epidemic.One feature discussed the negative results of diet-ing for the elderly: “In seniors, inadequate nutri-tion poses a particularly perilous problem. An

alarming 16 percent of the 65-plus set nibblesfewer than 1,000 calories a day, setting the stagefor malnutrition, illness and early demise.” Expertspoint out that “almost every study shows thatintentional and unintentional weight loss in theelderly results in premature death.”

Steven J. Milloy, publisher of JunkScience.comand an adjunct scholar at the Cato Institute, wrotein September 2004, “Studies have generallyreported that the risk of death associated with obe-sity actually declines with increasing age. A 1998review of seven studies on bodyweight and mor-tality in elderly persons reported that only two ofthose studies reported a statistical correlationbetween bodyweight and premature death—and ofthose two studies, one reported no association forthose aged 75 years or over. The other five studieseither found no correlation or a strong negativecorrelation. Researchers are not sure why, but ithas been suggested that in old age, the protectiveeffects of obesity might counterbalance some neg-ative effects.” National Center for Health Statisticsresearchers speculate that “The protective effects ofobesity include greater nutritional reserves in timesof stress, lower rates of injury from falls and lowerrates of osteoporosis.”

On the other hand, Bartlett notes thatresearchers have concluded that in elderly persons,if obese men were to lose enough weight to fall intothe overweight category, and men in the over-weight category were to lose enough weight tomove into the normal weight category, kneeosteoarthritis (OA) would decrease by 21.5 percent.“Similar changes in weight category by womenwould result in a 33 percent decrease in knee OA.A handful of studies have indicated that weight losssubstantially reduced reports of pain as well.”

Because of the negative aspects of dieting for theelderly, experts suggest that only the morbidly obeseelderly diet to lose weight, and others over the ageof 60 who may be overweight or even obese stick toexercise in their attempts to lower their weight.

Some experts downplay the importance of wor-rying about obesity among the elderly, arguing thatit is much more critical to address obesity amongthe young, because the overall health damage hasalready been done in obese geriatric patients. YetOlder Americans 2004 reported that the conse-

128128 elderly and obesity

quences of obesity among the elderly includeincreased risk of diabetes, heart and lung disease,breast and colon cancer, arthritis and disability. Inthe same decades that obesity doubled, deathsamong the elderly from diabetes increased 43 per-cent, according to the report. Experts estimate thatweight-related illnesses for older adults cost thenation an estimated $30 billion to $40 billion ayear in medical bills and contribute to escalatingout-of-pocket costs among the elderly.

See also ALZHEIMER’S DISEASE RISK AND OBESITY.

Arterburn, David E., Paul K. Crane, and Sean D. Sulli-van. “The Coming Epidemic of Obesity in ElderlyAmericans.” Journal of the American Geriatric Society 52,no. 11 (November 2004): 1,907–1,912.

Bartlett, Susan. “Osteoarthritis and Body Weight.” JohnsHopkins University. Available online. URL:http://www.hopkins-arthrit is .som.jhmi.edu/mngmnt/osteoandweight.html. Downloaded onDecember 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 evi-dence-based practices, evidence-based therapy orempirically validated treatments. Treatment thathas been clearly specified and found to be sup-ported by scientific evidence as having been exten-sively studied using rigorous scientific methodsand that has been found to work well.

Mussell et al. set out to “assess the primarymethods used by psychotherapists in treating indi-viduals with eating disorders and to determine theextent to which certain empirically supported psy-chotherapies (i.e., cognitive behavioral therapyand interpersonal psychotherapy) are used in clin-ical settings.” They found that while evidence-based therapies are frequently reported as beingused, most of the psychotherapists they surveyedidentified something else as their primaryapproach. “In addition, the majority of respon-dents indicated not having received training in theuse of manual-based, empirically supported treat-ment approaches for working with individualswith eating disorders, although most reported adesire to obtain such training.”

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

empirical research Research based on observa-tion and actual experience rather than from theoryor belief or scientific principles.

employee health costs and obesity The obesityrate among American workers of all ages grewfrom 20 percent to 29 percent in the periods1988–94 and 1999–2000, leading to serious reper-cussions in the workplace, according to a PfizerInc. study. Robin Hertz, the study’s author, com-mented, “The damage caused by obesity is clear—employers face growing costs for insurancepremiums, as well as lost productivity, andemployees face serious work and health concerns.”Among the study’s findings: Obese workers havethe highest prevalence of work limitations (6.9percent versus 3.0 percent among normal-weightworkers), hypertension (35.3 percent versus 8.8percent), high cholesterol (36.4 percent versus22.1 percent), type 2 diabetes (11.9 percent versus3.2 percent) and metabolic syndrome (53.6 per-cent versus 5.7 percent). The study also foundincreased prevalence rates among those classifiedas overweight.

Other research has also found obese employeesto be costly. Examples:

• A University of Michigan study examined therelationship between physical activity andhealth care costs in different weight groups. Thestudy sample consisted of 23,490 active employ-ees grouped into normal weight, overweight,and obese categories. Physically moderatelyactive (one to two times per week) and veryactive (three or more times per week) employ-ees had approximately $250 less paid healthcare costs annually than sedentary employees(no time per week) across all weight categories.The difference was approximately $450 in theobese subpopulation. The maximum possiblesavings was estimated to be 1.5 percent of thetotal health care costs if all obese sedentaryemployees would adapt a physically active

129employee health costs and obesity 129

lifestyle. Study authors Wang et al. determinedthat as a strategy to control escalating healthcare costs, wellness programs should facilitateengagement in moderate physical activity of atleast one to two times a week among sedentaryobese people and help them to maintain thismore active lifestyle.

• In congressional testimony in June 2004, StuartTrager, M.D., Medical Director of Atkins Nutri-tionals, Inc., stated, “Within the workplace, esti-mates suggest that $20–30 billion per year arelost in productivity to lost time due to theincreased medical problems linked to obesity.Employees lost 39.3 million workdays in 1994due to obesity-related medical conditions, repre-senting a 50% increase since 1988.”

• An employee who is significantly overweightcan have a benefit expense more than 20 per-cent higher than a person who is not, accordingto research reported in The Wall Street Journal.

• The American Obesity Association has reportedthat obesity is associated with a greater tendencyto be absent from work due to illness. The costassociated with absenteeism from obesity hasbeen reported to be approximately $387,800 for1,000 employees per year. The cost differencebetween obese and lean employees due toabsenteeism is approximately $128,600.

• As the national obesity problem escalated, busi-ness appeared to pay less attention to it. Areview of the Healthy People 2000 objectives,established in 1990 by the Department of Healthand Human Services, showed that the propor-tion of worksites with 50 or more employeesthat offer nutrition/weight management pro-grams for employees increased from 15 percentin 1985 to 24 percent in 1992, then dropped to14 percent in 1995.

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

As corporations have become more concernedabout how employee obesity and its related prob-lems are affecting their bottom lines, some are nowproviding wellness centers and weight-loss coun-seling or even allowing employees to use onlinediet programs during work hours. Some are going

a step further by changing the physical environ-ment. Among the strategies being implemented orconsidered by various companies:

• Slowing down elevators to make using the stairsmore attractive

• Placing parking lots farther from the work building

• Paying employees a cash award for maintainingan exercise regimen

• Offering health coaching to employees who arebattling heart disease, high cholesterol, highblood pressure, diabetes or other obesity-relatedchronic illness

• Issuing pedometers to employees to encourageregular exercise

• Offering employees discounts to sporting goodsstores and healthy restaurants

Hertz, Robin P. et al. “The Impact of Obesity on WorkLimitations and Cardiovascular Risk Factors in theU.S. Workforce.” Journal of Occupational and Environ-mental Medicine 46, no. 12 (December 2004):1,196–1,203.

Wang, F. “Relationship of Body Mass Index and PhysicalActivity to Health Care Costs among Employees.”Journal of Occupational and Environmental Medicine 46,no. 5 (May 2004): 428–436.

employees with eating disorders According toRemuda Ranch, an eating disorders treatment cen-ter in Phoenix (see APPENDIX IV), the overall med-ical and mental health costs to U.S. businesses in2001 for all eating disorders totaled more than $3.8billion. “Statistics show 40 percent of women witheating disorders function poorly at work and one-third are frequently absent from work.”

Even when an anorexic employee’s health sta-tus allows him or her to work, the disease may stillaffect both the employee and his or her coworkers,according to Gleaves and Cepeda-Benito.

The employee’s job performance may sufferbecause of the cognitive and emotional effects ofthe self-induced starvation, and social activitiesmay be negatively affected secondary to the avoid-ance of food-related activities or secondary to acomorbid personality disorder. The eating-relatedproblems may, in some cases, be easily recognized

130130 employees with eating disorders

by fellow employees. It is even possible that theemployee’s eating problem may become a sourceof conflict among fellow employees, if several rec-ognize a need for possible intervention but none isclear on the best approach.

In contrast, bulimia nervosa appears to be aclandestine disorder. People with the disorder aretypically of average weight and, because of theshame associated with the disorder, may not dis-close to others that a problem exists. Only in themore severe cases are physiological and/or cogni-tive deficits likely to affect a person’s work per-formance. However, the various types of comorbidpsychopathology—such as depression, borderlinepersonality disorder, and substance abuse—mayhave more substantive work-related impact.

As with anorexia nervosa, binge-eating disor-der may be recognizable by coworkers, notbecause of the disorder per se, but rather becauseof the commonly occurring obesity. Binge eatingdisorder most likely has the least workplace impactof the three disorders. However, the constant pre-occupation with food as well as time spent plan-ning and engaging in eating binges may markedlyaffect quality of life, reducing social relationshipsand leaving little time for other interests. Recur-rent bingeing may even cause financial problemsfor the afflicted individual because of the moneyspent on food (a problem that may occur withbulimia nervosa as well as binge-eating disorder).

Stressing that early identification and treatmentcan help reduce these problems in the workplace,Remuda suggests the following when talking to anemployee about an eating disorder:

• Plan your approach first: Think about what you will sayand 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 thatsomeone has a problem, bring up the topic in an open-ended manner as a possibility that emerges from yourconcern. Keep asking questions until you are satisfiedthat you understand what is happening.

• Show concern: Be compassionate and nonjudgmentalat all times. Listen carefully to the person. Acknowl-edge their fears. Say, “I understand your feelings. Atherapist can help you overcome those fears.”

• State the problem for the company: Be clear that theproblems are affecting the individual’s work, and statehow. Do so in a non-blaming manner.

• State your goal: Your goal is for the person to get pro-fessional help so that they can recover from their eating

disorder and improve work performance. Don’t acceptthe employee’s claim that they can overcome the prob-lem on their own. Eating disorders require treatment.

• Offer solutions: Have viable treatment options andreferrals on hand to offer the person. Since specializedknowledge and skills are needed to effectively treat eat-ing disorders, rely only on treatment providers who spe-cialize in eating disorders and who use evidence-basedand multi-disciplinary team approaches to treatment.

• Be persistent: The person may reject your efforts atfirst. Return at a later time and try again. If theyattempt treatment and don’t succeed, continue toencourage them because a different therapist or treat-ment method will eventually work.

Gleaves and Cepeda-Benito add, “Perhaps the mostsignificant workplace accommodation may simply bethe ability to have time off for treatment. Theamount of time necessary here will obviously dependon the intensity of the treatment. Outpatient psycho-logical treatment for bulimia nervosa may be twoappointments per week for a period of several weeks.These may occur in the evening, which would notaffect the employee’s work schedule. With anorexiaand a need for hospitalization, the employee mayneed an extended leave from work. If an employee isinvolved in a day treatment program, a flexible workschedule may allow the person to continue workingand receive treatment at the same time.”

Gleaves, David H., and Antonio Cepeda-Benito. “EatingDisorders.” 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 endocrineglands produce hormones that regulate the body’srate of METABOLISM, growth and sexual develop-ment and functioning. “Glands” have often beenblamed by individuals for their obesity, but obesitycaused by endocrine alterations are uncommon,and the increase in body weight observed withacute endocrine disease is usually limited. Hypothy-roidism, adrenal hyperplasia and hypogonadism areendocrine alterations that result in modest obesity.

endomorph A person with a body type charac-terized by a tendency toward roundness and sub-stantial fat deposits. Endomorphs have wide trunks

131endomorph 131

and shorter-than-average arms and legs, makingthem appear to be somewhat fat. People with sig-nificant endomorphy gradually fill out until latemiddle age, when they generally shrink a little.

Theories linking body types to emotional or psy-chological characteristics are not considered scien-tifically sound.

See also ECTOMORPH; MESOMORPH; BODY TYPES.

ephedra A naturally occurring substance thatcomes from botanicals. The principal active ingre-dient, ephedrine, is an amphetamine-like com-pound that can powerfully stimulate the nervoussystem and heart. Ephedrine alkaloids are foundnaturally in a number of plants, including theephedra species (also known by the traditionalChinese medicine name, ma huang, or called Chi-nese ephedra or epitonin). In recent years, ephedraproducts have been marketed as dietary supple-ments to promote weight loss and increase energyand enhance athletic performance.

The Food and Drug Administration (FDA) hadwarned consumers against the use of dietary sup-plements containing ephedra since June 1997, andfinally banned these products in April 2004.Ephedra was the first federal ban of a dietary sub-stance in the United States.

After a review of the available evidence aboutthe risks and benefits of ephedra in supplements,the FDA found that these supplements presentedan unreasonable risk of illness or injury to con-sumers. The data showed little evidence ofephedra’s effectiveness, except for short-termweight loss, while confirming that the substanceraises blood pressure and stresses the heart. Theincreased risk of heart problems and strokesnegates any benefits of weight loss. Prior to its ban,ephedra was blamed for as many as 100 deaths. Italso had been known to cause hypertension,tachycardia, arrhythmias, stroke, seizures andmyocardial infarction.

In April 2004, after a Utah-based NutraceuticalInternational Corporation challenged the FDA ban,claiming that ephedra “has been safely consumed”for hundreds of years, the U.S. District Court forthe District of Utah overturned the ban and sentthe matter back to the FDA “for further rulemak-ing consistent with the court’s opinion.”

epidemiological research Research that looks at(1) the natural course of diseases in a particulargroup of people; (2) relationships between peopleand their health habits, lifestyles and environment;(3) risk factors for certain diseases. It involves thestudy of the incidence and distribution of diseases inlarge populations. Epidemiological researchers alsoconduct investigations into the causes of chronic dis-eases such as eating disorders and obesity.

The International Food Information Council cau-tions that “epidemiological studies may suggest rela-tionships between two factors, but do not providethe basis for conclusions about cause and effect. Pos-sible associations inferred from epidemiologicalresearch can turn out to be coincidental. Epidemio-logical studies are observational in nature and theoutcomes need further study through other types ofresearch such as intervention or clinical studies.”

International Food Information Council. “Epidemiologi-cal Research: Roots, Roles and Real-Life Limitations.”Food Insight, July/August 2002. Available online. URL:http://www.ific.org/foodinsight/2002/ja/epidemresfi402.cfm.

exercise Physical exertion for improvement ormaintenance of health and fitness, as well asweight loss. Exercise alone is not usually pre-scribed as a weight loss method, but physical activ-ity is a key to any weight control program. It burnsCALORIES, speeds METABOLISM and helps offset thedreaded “plateau” stage in which weight loss slowsor stops temporarily. (See SET-POINT THEORY.) Peo-ple who exercise and diet lose more fat and lessmuscle than people who only diet.

Racette et al. summed it up this way: “Exercisegenerally does not produce considerable weightloss when used independently, but is a very impor-tant adjunct to a weight-reducing diet because itincreases energy expenditure, enhances loss of adi-pose tissue, and improves dietary adherence.Although aerobic exercise has been used most fre-quently for weight loss and control because of thecaloric expenditure required, strength training hasnumerous benefits and may help to preserve fat-free mass during diet-induced weight loss.”

Achieving a negative energy balance—that is,using up more calories than one takes in—by exer-

132132 ephedra

cise alone has been shown to cause some weightloss. The mean weight loss achieved over a meanduration of 19 weeks, in seven studies, was 16pounds. No long-term follow-ups are available.Although changes of exercise (energy output)and/or altered metabolic efficiency can causeweight loss when one is over- or under-weight, theamount is usually not significant unless accompa-nied by lowered food intake.

Most studies have shown that vigorous exercis-ers consume more calories than sedentary individ-uals, but they also weigh approximately 20 percentless on average. There are no data supporting thecontention that moderate activity of short durationused in weight loss programs stimulates APPETITE.In fact, for many people, moderate exercise tendsto have an appetite-suppressing effect. For this rea-son, many experts recommend that daily exercisebe performed prior to the main meal of the day.

Researchers at Mt. Sinai Hospital in New Yorkhave reported that whereas fat people burn offmore calories if they eat after exercising, thin peo-ple burn off more if they eat before. Theresearchers believe that fat people’s cells are lesssensitive to insulin, the hormone that admits fuelinto body cells. Intense exercise, they say, mayimprove the insulin sensitivity of fat people.

Studies at Stanford University comparing foodintake and weight of long-distance runners (thosewho run approximately 40 miles per week) withthose of randomly selected sedentary adults of sim-ilar age show that despite ingesting an average of600 more calories per day (2,959 vs. 2,361), therunners weighed 25 percent less than the seden-tary group, evidence strongly suggesting that exer-cise lowers the set point. Numerous studies havedocumented the observation that a program ofmoderate exercise reduces body fat levels whilepreserving or increasing lean body mass. Animalstudies show that exercise produces a specific fat-burning effect and that the animals maintain thenew body fat levels, demonstrating that the setpoint has been lowered.

But the older we get, the more difficult it is forour muscles to burn fat, according to researchers atthe Washington University School of Medicine andthe University of Texas Medical Branch in Galve-ston. Their study found that fat oxidation in oldersubjects (average age 73) was 25–30 percent lower

than in younger subjects. The older people weremore likely to burn carbohydrates during exercise.

Many experts have concluded that exercise is asimportant in preventing weight gain as it is inweight loss, and thus have emphasized its value inmaintaining current weight and diet programs.Donnelly et al. sum it up: “The available evidenceindicates that exercise is an important componentof weight loss and perhaps the best predictor ofweight maintenance.” They recommend at least 30minutes a day of moderate intensity aerobic exer-cise per day for weight loss and maintenance.

But 30 minutes a day may not be enough to con-tinue losing weight, according to Spake. “This is alevel that can reduce cardiovascular disease, dia-betes, and other serious chronic illnesses. To loseweight or maintain a large weight loss, it takesmore: The Institute of Medicine recommends accu-mulating 60 minutes of activity each day to achievea healthy weight. The key word here is accumulate.You don’t have to do all 30 minutes—or 60—atonce. You can do three (or six) 10-minute bouts.”

The evidence establishing regular exercise as animportant factor in weight control has convincedmany health care professionals that one of themajor causes of CREEPING OBESITY is the lack ofphysical activity, largely as the result of sedentarystyles of life. The average American man between35 and 45 years of age weighed six pounds more in1980 than in 1960 (the average American womanof similar age showed an eight-pound weightincrease) despite a 10 percent reduction in caloricintake over this period.

Too Much Exercise Is Not a Good Thing

Today’s emphasis on fitness and athletics has hada negative as well as positive effect on health,especially for adolescent girls. Encouraged to exer-cise for their looks rather than their health, girlsare often told that exercise is “nature’s bestmakeup.” Researchers have found that slimness ofhips is the most sought-after feature among ado-lescents aged 12 to 16. Dissatisfaction with hipmeasurement only increases during this periodwhen hips show the most change from naturalhormonal influences. Some adolescents are sointent on changing their appearance that theybecome obsessed with exercise.

133exercise 133

Eating-disordered patients often use exercise asa means of purging themselves of unwanted calo-ries—a practice that causes additional health prob-lems, such as vitamin and mineral deficiencies thatcan cause damage to bones, AMENORRHEA and car-diac arrest from low potassium levels and elec-trolyte imbalances. Excessive exercising canbecome a dangerous habit and one that is difficultto break. One exercise machine maker advertises“No pain, no gain,” but pain is a warning to thebody that something is wrong. For anorexics andbulimics, exercise buffers some of the pain theyshould be feeling; they are numbing their bodies’warnings to stop their destructive behavior.

Breaking an exercise addiction can be as difficultas overcoming an eating disorder. While the effectsof anorexia can be measured on a bathroom scale,the “fitaholic’s” problem is not so easily defined.Truly compulsive exercisers let their workoutsdominate their existence to the detriment of family,job and social life. Obsessive runners may be taughtrelaxation techniques and other ways of copingwith stress that can help them become less depend-ent on exercise for their sense of well-being.

Donnelly, J. E., et al. “The Role of Exercise for WeightLoss and Maintenance.” Best Practice and Research. Clin-ical Gastroenterology 18, no. 6 (December 2004):1,009–1,029.

Molé, Paul, et al. “Exercise Reverses Depressed MetabolicRate Produced by Severe Caloric Restriction.” Medicineand Science in Sports and Exercise 21, no. 1 (February1989): 29–33.

Racette, Susan B., Susan S. Deusinger, and Robert H.Deusinger. “Obesity: Overview of Prevalence, Etiol-ogy, 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 (January1989): 217–236.

Spake, Amanda. “26. Exercise, A Little,” in “50 Ways toFix 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. “MetabolicResponses to Intense Exercise in Lean and Obese Sub-jects.” Journal of Clinical Endocrinology and Metabolism68, no. 2 (February 1989): 438–445.

exposure and response prevention (ERP) Atreatment method originally used in treating pho-

bic and obsessive-compulsive disorders, in whichthe patient is exposed to whatever is triggering hisor her abnormal behavior, with the abnormalbehavior then forcibly restrained. The treatment hasto cause significant anxiety in order for it to work.

ERP has also been adapted to treatment of bulimianervosa. For example, clinicians have described howa bulimic woman was made to wait increasinglengths of time between stages of the disorderedbehavior that culminated in vomiting. After eightweeks her vomiting, which had occurred roughlyfour times a day prior to treatment, ceased.

Explaining why ERP works, Rosen and Leiten-berg wrote that “binge eating and self-inducedvomiting seem linked in a vicious circle by anxi-ety.” Eating (especially BINGE EATING) elicits the fearof weight gain; vomiting reduces it. “Once an indi-vidual has learned that vomiting following foodintake leads to anxiety reduction, rational fears nolonger inhibit overeating.” Thus, if the end-resultvomiting is delayed longer and longer after eachbinge-eating session, the binge eating needed tostimulate it is delayed until it no longer is needed(because the vomiting that counters it is no longeroccurring). So “the driving force of this disordermay be vomiting, not bingeing.”

Later reviews of the treatment of bulimia ner-vosa do not conclude that ERP adds anything tothe effectiveness of cognitive behavioral treat-ments. Following a trial with 135 women who hadbulimia nervosa, Bulik et al. concluded, “ERP forbulimia nervosa is an expensive and logisticallycomplicated treatment that does not appear tooffer any significant additive benefits that are pro-portional to the amount of effort required toimplement the treatment.”

American Academy of Child and Adolescent Psychiatry(AACAP). “Practice Parameters for the Assessmentand Treatment of Children and Adolescents withDepressive Disorders.” Journal of the American Academyof Child & Adolescent Psychiatry 40, suppl. 7 (July 2001):45–235.

Bulik, C. M. “The Role of Exposure with Response Pre-vention in the Cognitive-Behavioural Therapy forBulimia Nervosa.” Psychological Medicine 28, no. 3(May 1998): 611–623.

Rosen, J. C., and H. Leitenberg. “Bulimia Nervosa: Treat-ment with Exposure and Response Prevention.”Behavior Therapy 13 (1982): 117–124.

134134 exposure and response prevention

externality approach to obesity One of twomajor types of treatment for obesity (the other isthe PSYCHODYNAMIC APPROACH TO OBESITY). Exter-nality focuses on salient food-related cues inpatients’ environment and attempts to controltheir responses to them. This approach developedfrom experiments at Columbia University per-formed in 1974 by social psychologist StanleySchachter. Schachter’s group found that obese peo-ple are more likely to eat when a clock says it ismealtime or when food is put onto a plate thanwhen their bodies signal HUNGER.

This approach assumes that what obese peopleneed is to change their responses to these externalcues, and that by allowing themselves to eat onlywhen truly hungry, they will lose weight naturally.It has spawned a number of behavioral therapytechniques, such as putting food on smaller platesso the amount looks larger, eating only in a partic-ular room and so on.

Some externalists’ patients have achievedremarkable results (one group lost an average of 40pounds each in a single year), but these resultshave not consistently been replicated by others.Not only have patients not lost 40 pounds, theyhave tended to gain back what they have lost.

See also EATING HABITS MONITORING.

extreme eating A term used by the InternationalFood Information Council to describe the eatinghabits of teens who seem to have lost their balancewhen it comes to choosing an appropriate diet.Going overboard in one or more areas of the diet suchas cutting out entire food groups, fervently followingthe latest fad diet or weight loss plan, or regularlyconsuming a single type of food to excess could all becharacterized as extreme eating behaviors.

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

extreme obesity The National Institutes of Health(NIH) identifies extreme obesity as Class III, or hav-ing a BODY MASS INDEX (BMI) of 40 or greater, suchas a person five feet, six inches tall who weighs 250pounds. It is also known as severe or morbid obe-sity, although doctors who treat the condition tendto discourage use of “morbid obesity” because it ismisleading and has negative connotations.

The NIH Obesity Research Task Force reportedthat while obesity and overweight have risen inthe population in general, the greatest increasesobserved over approximately the past two decadeshave been in the prevalence of extreme obesity. Agovernment report containing data from theNational Health and Nutrition Examination Surveyin the periods 1999–2000 and 2001–02 showedextreme obesity rates rising from 4.7 percent to 5.1percent. From 1988 to 2000, the prevalence ofextreme obesity increased from 2.9 to 4.7 percent;in 1960 it was 0.8 percent. During the periodbetween 1986 and 2000, those with a BMI of 50 ormore multiplied over five times.

An article appearing in the Group Practice Journalby HMO Kaiser Northwest researchers in May 2004revealed that people with extreme obesity have 78percent higher medical costs than members withnormal weight. In a University of Pennsylvania studyof 2,100 people in a sample of 482 nuclear families,extreme obesity was associated with an increasedrisk 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 bethe most effective therapy for people who haveextreme obesity.

Dong, C., L. E. Sanchez, and R. A. Price. “Relationship ofObesity to Depression: A Family-Based Study.” Inter-national Journal of Obesity and Related Metabolic Disorders28, no. 6 (June 2004): 790–795.

135extreme obesity 135

fad diets Diets that achieve widespread, thoughshort-lived, popularity, usually as a result of heav-ily promoted “best-selling” books and/or popularmagazine or tabloid features.

But diets that promise such easy results and the“magic bullet” are not really effective, according toDiane Quagliani, a spokesperson for the AmericanDietetic Association, who told the InternationalFood Information Council (IFIC) Foundation: “Faddiets are a short-term, quick-fix approach to weightloss that don’t work over the long haul. These dietstend to over-promise results but don’t deliver. Foodchoices are often monotonous, and caloric intakemay be very restricted, so that once the noveltywears off, so does the motivation to continue.”

The IFIC notes that there is a dire lack of scien-tific research to corroborate the theoriesexpounded in the majority of diet books currentlyon the market. Most promise weight-loss programsthat are easy, allow favorite foods or foods tradi-tionally limited in weight-loss diets and do notrequire a major shift in exercise habits. Often, addsSachiko St. Jeor, director of the Nutrition Educa-tion and Research Program at the University ofNevada School of Medicine, “Fad diet book authorstake a scientific half-truth that is complex and usethat as the basis for their arguments.” Authors maysimplify or expand upon biochemistry and physiol-ogy in an effort to help support their theories andprovide a plethora of scientific jargon that peopledo not understand but that seems to make sense.And few, if any, offer solid scientific support fortheir claims in the form of published research stud-ies. Instead, most evidence is based on anecdotalfindings, theories and testimonials of short-termresults.

Katz noted that despite claims of success, “Evi-dence that weight loss is enhanced by means other

than caloric restriction is lacking. Also lacking isevidence that fad diets produce sustainable weightloss. Most important, fad diets generally ignore orrefute what is known about fundamental associa-tions between dietary pattern and human health.”

Other medical experts caution that althoughmany fad diets may result in some weight loss,they invariably do so at the expense of good nutri-tion, which if continued long-term could exacer-bate any health problems stemming from beingoverweight or obese. Studies have found some faddiets no more effective than losing weight the old-fashioned way—working it off with exercise.

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 ofNutritional 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 chil-dren, which in many cases may be a combinationof both biologic and psychologic complications thatrequire treatment. Bassali and Benjamin explain:

Failure to thrive is a descriptive term and not a spe-cific diagnosis. Although definitions vary, mostauthors use this term only when growth has beennoted to be low or to have decreased over time. Forinstance, some authors define FTT as height orweight less than the third to fifth percentiles for ageon more than one occasion. Other authors citeheight or weight measurements falling two majorpercentile lines using the standard growth charts ofthe National Center for Health Statistics (NCHS).Still others state that true malnutrition (weight lessthan 80 percent of ideal body weight for age)

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F

should be present to state a child is failing to thrive.All authorities agree that only by comparing heightand weight on a growth chart over time can FTT beassessed accurately. Although measurements ofhead circumference are important in the evalua-tion of infants and toddlers, failure of the head togrow is not part of the FTT entity.

Krugman and Dubowitz explain further that inmost children with FTT, the condition has mixedcauses or origins: “A child may have a medical dis-order that causes feeding problems and familystress. The stress can compound the feeding prob-lem and aggravate FTT. A more useful classificationsystem is based on pathophysiology—inadequatecaloric intake, inadequate absorption, excess meta-bolic demand, or defective utilization. This classifi-cation leads to a logical organization of the manyconditions that cause or contribute to FTT.”

Failure to thrive is now included in the Ameri-can Psychiatric Association’s Diagnostic and Statisti-cal Manual of Mental Disorders (DSM-IV) as FEEDING

DISORDER OF INFANCY OR EARLY CHILDHOOD.

Bassali, Reda W., and John Benjamin. “Failure toThrive.” eMedicine Pediatrics, updated August 11, 2004.Available online. URL: http://www.emedicine.com/ped/topic738.htm.

Krugman, Scott D., and Howard Dubowitz. “Failure toThrive.” 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 aneating-disordered patient and family members eatmeals together with a therapist, who helps themidentify dysfunctional communication patternswithin the family that perpetuate the patient’s dis-order. Unsubstantiated claims of dramatic recoveryhave been made by proponents of this technique.

Rockwell, W. J. Kenneth. “A Critique of TreatmentMethods 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 inwhich a therapist works with a patient and her

family together; sometimes called familizationtherapy. Generally, a family therapy group consistsof one therapist and three or more family mem-bers. In working with a family, a therapist canassess the impact of the individual’s behavior onthe family and observe the handling of conflicts,family roles, family decision making and commu-nication patterns and family values. This therapy ismeant to teach all members of a family how toexpress and fulfill their needs and change old pat-terns that have been mutually unsatisfactory. Itcan help both patients and their families bringpainful emotions to the surface and understandthem. The duration of family therapy varies withindividual cases. Family therapy can be especiallyuseful in treating eating disorders of adolescentsand may be helpful to young adults struggling withseparation from their original families.

European treatment of eating disorders, prima-rily anorexia nervosa, has traditionally favored fam-ily therapy, following precepts established in Italy byMara Selvini-Palazzoli. But family therapy alone hasyet to provide universally the kind of spectacularoutcome that was once hoped for and publicly pre-dicted. The current trend in most European centerstreating eating disorders is, as in the United States,toward a “multidimensional” approach, with familytherapy included in treatment.

Vanderlinden and Vandereycken, of the Univer-sity Psychiatric Center, Kortenberg, Belgium, havesuggested that neglect of the family in bulimiatreatment by many therapists may be attributed tothe attitude of the bulimics themselves, who tendto conceal their problem from the world. And, theyadd, the absence of consideration of family contextin the literature of bulimia may be explained bythe 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 usuallyidentifiable as family illnesses. Families often get assick as addicts or eating-disordered patients.Bulimics use food as a way of dealing with stressand problems of daily living, but families have nosuch outlet and often face the problems withoutknowledge, understanding or coping skills. In mostcases, family members fail to recognize theunhealthy relationships and behaviors that have

138138 fake fat

brought them so much discontent. They aretrapped in an unhealthy family equilibrium, exac-erbating and prolonging the problem.

Women with anorexia or bulimia often comefrom families that have difficulty with conflict andcommunication. Sometimes the families have longhistories of conflict. As children, the patients mayhave experienced abuse or rejection or grown upwith an alcoholic parent. Members of these fami-lies may have had difficulty communicating andrecognizing one another’s feelings. The parents,having perhaps grown up in such families them-selves, may never have learned how to handleproblems, thus experiencing frightening difficultiesin their own marriages or with their children.

In the face of unresolved family conflict, daugh-ters may focus on how they can make things better.Frequently, they feel that their parents want themto be good and not cause trouble. They may thinkthat if they stay out of the way and do everythingright, things will get better. They see their role aspeacemakers. When conflict arises, they may feelthey must make it better for everyone. This can leadto their discounting their own feelings and needs.Like their parents, they have not had the opportu-nity to learn how to deal with their emotions. Theymay develop eating disorders as a way to cope. Onthe surface, it may seem that they are able to han-dle things, but they still need nurturing and support.

A daughter in this situation may not feel recog-nized by her family as being a helpful negotiator. Fora young woman with bulimia, feeding herself is away of covering up painful feelings and giving her-self the nurturing she needs. PURGING functions as away to release tension and sometimes bury feelings.

Bulimia and anorexia are commonly found infamilies that are excessively protective of members’feelings. Eating-disordered individuals may havedifficulty learning from mistakes because they haverarely been allowed to make any. Lack of control intheir lives may compel them to start controllingtheir weight; their bodies are among the few thingsover which they feel they have any authority.

Bulimics and anorexics may also come fromfamilies that have problems expressing unpleasantemotions and strive to present themselves as “per-fectly” well adjusted. Everything appears to be finein this type of family. Under the surface are prob-lems that no one in the family can or wants to

acknowledge. A daughter, also afraid of expressingher feelings, may deal with them through food.She, like the rest of the family, has extreme diffi-culty admitting that they have any problems. Sheis very out of touch with her feelings and may havelittle idea why she binge eats or restricts. (SeeBINGE-EATING DISORDER; RESTRICTOR ANOREXICS.)

In one report, more than 90 percent of the eat-ing-disordered patients described their fathers asemotionally distant. Common characteristics of thedaughters were low self-esteem, confusion, loneli-ness, sexual fears, DEPRESSION and a general inabil-ity to master developmental tasks. With theabsence of emotional support from the fathers,daughters try more to support themselves synthet-ically, deriving a superficial sense of self-worthfrom their control over their appearance and theirachievement of conformity to an exaggerated idealof beauty.

Bulimia is also often associated with dysfunc-tional families. In a family that must face difficultissues such as alcoholism, drug addiction, mentalillness or abuse, a daughter may respond by devel-oping an eating disorder.

A 1995 Wayne State University study ofanorexia treatments demonstrated that structuredtherapies for adolescent anorexia do impact familyrelations, even when the family is never seen as aunit during the therapy.

After treating more than 550 cases of bulimiawith family therapy, the Renfrew Center inPhiladelphia has seen another family type emerge.This one usually centers on the daughter. She mayfeel guilty about the excessive influence she has onhow the family functions and about the attentionshe gets, especially from her father. She turns tofood to help relieve the guilt.

At Renfrew, a residential facility, a family ther-apist is assigned to each resident. If family mem-bers have come at admission, the first familysession is held that day. During treatment, five toeight sessions are usually held. Although familymembers are always encouraged to attend in per-son, some sessions may be conducted by confer-ence phone call, to accommodate geographicallydistant family members. Treatment typically lastsseven to nine weeks.

In their review of family therapy for treatingeating disorders, Eisler et al. agreed that it can be

139family therapy 139

an effective treatment for anorexia on an outpa-tient basis, even for those adolescents seriously ill.In addition, they determined that (1) Family inter-ventions are best viewed as treatments that mobi-lize family resources rather than treat familydysfunction (for which they say there is littleempirical evidence); and (2) Brief, intensive multi-ple family interventions provide an importantalternative to engaging families in treatment andare viewed very positively by families.

Family Treatment of Obesity

Family intervention has proven very helpful, also, intreating OBESITY. In one study, spouses of obesepatients were instructed in the behavioral principlesof weight control and were told how to demonstrategood eating habits themselves, to reinforce appropri-ate eating behavior in their partners. Husbands andwives attended sessions together and were encour-aged to make a collaborative effort. Weight losses forpatients with involved spouses were superior tothose with uninvolved spouses and were, in fact,greater than those in any previous study.

Parents can exert an even stronger influence ontheir children than spouses can on each other. Theyhave an unsurpassed degree of control over the foodintake of their young children. Even among older chil-dren, the capability of parents to foster new patterns ofeating behavior and discourage old ones is substantial.

“Family” can extend beyond spouses and par-ents to relatives, friends, neighbors and evencoworkers. All or any of these represent potentialallies or foes in the treatment process. Althoughactive encouragement of failure in treatment isinfrequent, subtle discouragement by others mayreduce treatment effectiveness. For example, “sab-otaging” spouses of obese patients have acknowl-edged that they feared weight loss would improvetheir partners’ attractiveness, leading to extramar-ital affairs. In other couples in which both partnersare obese, husbands and wives may subtly encour-age each other to overeat and not to follow thetreatment procedures at home, in order to helpthem rationalize their own poor eating habits.

Family therapy is often useful in ending thisprocess. In it the entire family unit is designated asthe “patient” and treated as a whole. As one mem-ber changes, the whole unit must change becauseof the need for equilibrium in the family. The goal

of therapy becomes that of developing new healthyrelationships to support the entire family.

Depending on their analysis of family function-ing and its evolution during treatment, therapistsmay decide to work with whole families or meetonly with separate subgroups (parents, children,with or without patients).

Brownell, Kelly D., and Albert J. Stunkard. “BehavioralTreatment of Obesity in Children.” In Childhood Obe-sity. New York: Warner Books, 1986.

Eisler, Ivan, Daniel le Grange, and Eia Asen. “Family Inter-ventions.” In Handbook of Eating Disorders, 2nd Ed.,edited by Janet Treasure, Ulrike Schmidt, and Eric vanFurth, 291–310. West Sussex, U.K.: John Wiley &Sons Ltd., 2003.

Ganley, Richard M. “Eating Disorders Are FamilyAffairs.” Renfrew Perspective (Spring 1988).

Karpell, Merrily. “The Fear of Stepping out of Line.” Ren-frew Perspective (Fall 1988).

Robin, A. L., et al. “Family Versus Individual Therapy forAnorexia: Impact on Family Conflict.” InternationalJournal of Eating Disorders 17 (May 1995): 313–322.

Stierlin, Helm, and Gunthard Weber. Unlocking the FamilyDoor: A Systemic Approach to the Understanding and Treat-ment of Anorexia Nervosa. New York: Brunner/Mazel,1989.

Vandereycken, W., E. Kog, and J. Vanderlinden. The Fam-ily Approach to Eating Disorders: Assessment and Treatmentof Anorexia Nervosa and Bulimia. New York: PMA, 1989.

Vanderlinden, Johan, and Walter Vandereycken. “FamilyTherapy in Bulimia Nervosa.” Paper presented at theInternational Symposium on Eating Disorders in Ado-lescents and Young Adults, Jerusalem, May 26–28,1987; reprinted in BASH Magazine.

famous eating-disorder patients In recent yearsseveral well-known athletes and entertainers havecome forward to discuss their eating-disorder prob-lems. The death in 1983 of KAREN CARPENTER, apopular singer, brought on by anorexia, inspiredmany of these women to make public their ownbouts with anorexia and bulimia in the hope ofinfluencing young people into seeking treatment.Olympic gymnast Cathy Rigby had been bulimicfor four years when she retired at age 19, and herproblem continued when she started her newcareer in sports broadcasting and commercials. Shewas 28 before she started getting professional help.

Ballerina Gelsey Kirkland starved herself peri-odically while a teenager and later began to vomit

140140 famous eating-disorder patients

in an attempt to keep her weight down. In herautobiography, Dancing on My Grave (Garden City,N.Y.: Doubleday, 1986), she talks about her pursuitof the body beautiful.

Cherry Boone O’Neill, daughter of singer PatBoone, described her bout with anorexia in herbook Starving for Attention (New York: Continuum,1982). Actress and political activist Jane Fonda wasbulimic for many years. Actress Ally Sheedy wasboth bulimic and anorexic.

John Lennon, the late Beatle, has beendescribed by biographer Albert Goldman (The Livesof John Lennon, New York: William Morrow, 1988)as being anorexic for most of his adult life. Gold-man says that Lennon starved himself to achievewhat he perceived as perfection. The onset of hisdisorder can be traced to 1965, Goldman writes,“when some fool described him in print as the ‘fatBeatle.’ That phrase struck such a blow to his frag-ile ego that the wound never healed.”

In 1995 it was revealed that Britain’s PrincessDiana had been treated for bulimia nervosa.

In 1999 actor Billy Bob Thornton said he devel-oped anorexia after he lost 59 pounds for a movierole—then could not stop losing. He reported howhe denied his eating problem to himself and others.At the time he acknowledged his problem, he saidhe had gotten it under control.

International fashion model Magali Amadeiwent on a national tour of high schools to speak onher struggle with bulimia, which began at age 14,before she was a model. At her worst, she bingedand purged seven times a day and swallowed 40laxative pills. Now she is using her celebrity toencourage others to recognize and treat their eat-ing disorders early. Actress Jamie-Lynn Sigler, whoplayed Meadow Soprano on HBO’s The Sopranos,wrote about her “exercise bulimia” as a teenager inher book, Wise Girl (Pocket Books, 2002). In June2004, actress Mary-Kate Olsen’s publicist said theactress had entered a treatment center for an eat-ing disorder. Although he did not disclose the cen-ter or the specific disease, newspapers and tabloidshad reported it to be anorexia nervosa, basedmainly on her emaciated appearance in recentmonths. The disclosure brought eating disordersback into the spotlight, with magazines, televisionnews shows, and newspapers providing warningsigns and information on the diseases.

fasting Abstaining from food for a period of time.During the 1960s, several clinics began to useshort-term fasts to bring about rapid weight reduc-tion. One reason they became so popular is thatfasters no longer feel hungry after the first fewdays of starvation. However, the severe conse-quences of the nutritional deficiencies and exten-sive loss of lean body mass that characterizesclinical starvation prompted investigators to find asafer and more effective dieting treatment. As aresult, VERY LOW-CALORIE DIETS were developed.

Supervised fasting is one of the simplest methodsof weight reduction, but it is best carried out in amedical setting because of the significant risk of com-plications, and even of sudden death. Risks associ-ated with fasting include hypoglycemia and impairedglucose tolerance, KETOSIS, lactic acidosis, hyper-uricemia, loss of nitrogen and lean tissue, hypoala-ninemia and hair loss; loss of potassium, sodium,calcium, magnesium and phosphate; reduced kidneyfunction, edema, anuria, hypotension, anemia, alter-ations in liver function, decreased serum iron bind-ing capacity, gastrointestinal tract changes, nauseaand vomiting, alterations in thyroxine metabolismand impaired serum triglyceride metabolism.

In 15 studies, the mean length of treatment was17 weeks, with mean weight loss of 77 pounds.Few studies report follow-up, and in those that dothe results are poor. Supervised fasting is a veryexpensive technique with poor long-term results.

Health experts have expressed concern aboutthe harmful effects religious fasts, such as YomKippur, can have for people with eating disorderssuch as anorexia and bulimia. Religious leadersand therapists have urged people not to fast duringthese times, saying that Jewish people (for exam-ple) should live by traditions, not die by them.Clinicians at the RENFREW CENTERS have counseledpatients in recovery not to use religious fasts as jus-tification for their restrictive eating behavior.

Female fasting, in the manner of ANOREXIA NER-VOSA, is not a new behavior. There is a long historyof food-refusing behavior and appetite control bywomen dating from medieval times, practiced forreasons of mystical piety rather than physical van-ity, as in the life of St. Catherine of Siena(1347–80) and her imitators. A more recognizablymodern version of the phenomenon became wide-spread in the 19th century (see FASTING GIRLS).

141fasting 141

Duhamel, Denise. “Holding Fast.” American Health (May1990).

Graham, Janis. “Food File: Is Fasting Worth It?” Health(July 1991).

Segal, Marian. “A Sometime Solution to a Weighty Prob-lem.” FDA Consumer (April 1990).

Thompson, Trisha, and Laura Flynn McCarthy. “TheFasting Controversy.” Harper’s Bazaar (January 1992).

fasting girls The term used by Victorians on bothsides of the Atlantic to describe cases of prolongedabstinence from food by girls or young women, inwhich there was uncertainty about the reasons forfasting and the intentions of the fasters. The termwas used jokingly by some and disparagingly by oth-ers. Doctors generally spoke of fasting girls withskepticism. The controversy over fasting girls intensi-fied the arguments about the relationship betweenmind and body that were central to the Victoriandebate about religion and science. Reports of fastinggirls appeared in the American press as late as 1910.Sustained food refusal was still regarded by most as areligious or supernatural phenomenon rather than apsychological disorder; it fed on a strain of religiouspiety and supernatural belief more common thenthan now. The “fasting girls” phenomenon was ofwidespread interest, drawing the attention of theeducated and the uneducated, the elite and the ordi-nary. But the character of society was changing, andduring this time refusal of food changed from an actof personal piety to a symptom of a disorder; physi-cians changed their diagnoses from anorexiamirabilis to anorexia nervosa.

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

fat blockers Antiobesity drugs that work byblocking 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 materialthat lies under the skin. When an excessive amountaccumulates, it tends to build up in the thigh, hip,abdomen or neck areas. The resultant bulges aregenerally considered both unhealthy and unattrac-tive. Once accumulated, these fat deposits fre-quently remain a permanent part of the body, as

only a few people have the patience, willpower andenergy to diet and exercise them away.

About 95 percent of body fat is stored in theform of triglycerides, composed of fatty acidsbound to glycerol. When required for energyMETABOLISM, triglycerides are broken down withinfatty cells. The fatty acid component then attachesto a specific protein in the blood (lipoprotein) fortransport to the muscles. Fat cells are constantlyactive, dispensing fat into the bloodstream fortransport to the body tissues needing energy, andextracting other circulating molecules for conver-sion into fat to replenish the storage deposits.

Evolving research suggests that the size and num-ber of fat cells (adipocytes) may play a role in the pre-disposition to obesity. Obese individuals have slightlylarger and significantly more fat cells than normal-weight individuals. A greater number of fat cells isparticularly characteristic of juvenile-onset obesity.

There are two important periods of develop-ment when the number of fat cells is affected:infancy (up to two years of age) and the preado-lescent years (from nine to 12). A correlation isbelieved to exist between the number of fat cellsand the rapidity of weight gain. Once fat cells haveformed, they cannot be eliminated, so they mustbe shrunk—depleted of lipids—before an obeseindividual can reach normal weight. Individualswho have been obese since childhood regain lostweight more rapidly after dieting.

Once produced, fat cells do not die. Whenweight is lost by diminishing fat stores, existing fatcells shrink, but they are primed to manufactureand store fat more efficiently once a normal diet isresumed. This is the reason for the “yo-yo” effect ofrapid weight loss and gain experienced by so manydieters (see YO-YO DIETING).

According to John A. McCurdy, Jr., the evolu-tionary process has favored survival of those whoare able efficiently to convert food into fat for stor-age. Some bodies are better at storing fat than oth-ers. Stored fat is available for use as an energysource during times of food deprivation—famine,pestilence and other disasters that have often besethumanity. But in societies like ours, where food isreadily available, the body seldom has an opportu-nity to call on its fat reserves and gradually accu-mulates additional fat in its storage deposits, aphenomenon sometimes called CREEPING OBESITY.

142142 fasting girls

When these fat reserves are used during dieting,the body naturally becomes more “fuel efficient,”lowering its metabolic rate and decreasing sponta-neous activity in order to conserve the fat that, inancient times, enhanced the ability to survive.

The body can increase the amount of body fat inonly two ways: by producing more fat cells, or bystoring more fat in the existing fat cells. But fatcells can expand just so far and then can reachtheir capacity of stored fat. At one time,researchers believed that a body’s number of fatcells was set by puberty. It is now known that thenumber of fat cells can continue to increase, doingso when existing fat cells fill to their capacity.

The body cannot eliminate existing fat cells,either through dieting or exercise; they simplyshrink in size. The only way researchers have dis-covered to eliminate fat cells is through surgery.After years of removing fat surgically from variousareas of the body, and after observing injuries inwhich fat tissue has been lost, doctors have deter-mined that fat is usually not redeposited in thetreated areas as long as diet and exercise are suffi-cient to keep the number of fat cells from increasing.

See also ADIPOSE TISSUE; BODY FAT; BODY FAT DIS-TRIBUTION; LIPOSUCTION; SET-POINT THEORY.

“Body Fat: The Hormone Factor.” Science News, June 15,1991.

Hirsch, J., et al. “The Fat Cell.” Medical Clinics of NorthAmerica 73, no. 1 (January 1989): 83–96.

McCurdy, John A., Jr. Sculpturing Your Body: Diet, Exerciseand Lipo (Fat) Suction. New York: Kensington Publish-ing Corp., 1990.

“fat” doctors A derisive term given by the med-ical profession during the 1960s to certain “reduc-ing” doctors who, together with drug companies,created an entire industry devoted to treating obe-sity with “rainbow pills,” various combinations ofdrugs (since prohibited by the Food and DrugAdministration), offered in different colors, to beused at different times of day. In 1968, followingthe death of several patients from indiscriminateprescription of such diet pills, Life magazine pub-lished an exposé of these practices.

To research the exposé, a reporter, a youngwoman who at five feet five inches and 123 poundshad never had a weight problem, visited 10 doctors in

different parts of the United States who were nation-ally or locally known for their easy reducing proce-dures. In each instance she was either put through ameaningless routine examination or just measuredand weighed, and then was given varying numbersof multicolored pills. The pills contained variouscombinations of AMPHETAMINES, thyroid and digitalisand were prescribed with the recommendation thatthey be purchased at the doctors’ own drug counters.A Kansas City doctor simply handed her a box of 140pink, brown, tan and gray pills, charged her $10 andtold her to return in one month. A Virginia doctorgave her 150 amphetamine-thyroid-barbituratecombination pills. And a Miami Beach doctor gaveher a similar combination plus diuretics and laxa-tives, told her she could now eat 4,000 calories a dayand lose weight, and asked her to return in a week.

There was no consensus among the fat doctorsconcerning diets; some advised that with these pillsshe could eat anything she wanted, and othersoffered elaborate restricted diets. The doctors alsoall prescribed varying degrees of exercise and liq-uid consumption.

With the FDA crackdown on doctors—bothlegitimate and fraudulent—who engage in suchpractices, the lucrative business of selling diet pillsexpanded into mail order, which is more difficultto regulate. In the late 1980s, Susan Gilbert foundit flourishing. “Eat all day and still lose weight” wasthe 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 ava-lanche of media stories and books during the 1990sstressing the health dangers of too much fat in thediet. Nutritionist Ann C. Grandjean (Center forHuman Nutrition, Omaha, Nebraska) was quotedin a USA Today article as saying, “Fat phobia is thebiggest diet problem I see among young athletes.I’m talking about these young people who are eat-ing only 6% of their calories from fat.” She goes onto say that people are following horrendous dietsin the name of low fat. While many Americans doeat too much fat, some have cut their fat intakeback way too far.

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The Henry Ford Health System cautions thateven though a diet high in fat is unhealthy, going inthe other direction can be equally bad. “In a studyfrom the University of Washington, 30 percent ofthe people placed on a low fat diet actually increasedtheir risk of heart disease.” Also, “A very low-fat dietmay be too high in carbohydrates for some patientswith diabetes. In both cases, the risk of future heartattack actually increase with the low-fat diet.”

In another context, fat phobia also is used todescribe “excessive fear and dislike of fat in oneselfand in others,” which Areton explains “is a rela-tively new phenomenon, born during the 20thcentury.” This term has also been operationalizedby Robinson, Bacon and O’Reilly to reflect antifatattitudes and negative stereotypes about fat people.

See also FATS; FEAR OF FAT SYNDROME.

Areton, Lilka Woodward. “Background of the Problem ofFat Phobia.” Chapter 3 in “Factors in the Sexual Sat-isfaction of Obese Women in Relationships.” ElectronicJournal 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, January4, 1999, page 9D.

Henry Ford Health System. “Fat Phobia.” Avail-able 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-fatAttitudes.” International Journal of Eating Disorders 14,no. 4 (December 1993): 467–480.

fat power A term used by advocates of a move-ment toward greater social acceptance for theoverweight, reflecting a nationwide trend ofchanging attitudes. “Fat power” advocates point tothe commercial success of products, services andmedia personalities as evidence of this shift. Thereare now dating services for overweight people,magazines and clothing being designed for thelarge-sized by such well-known names as PierreCardin. Among the euphemisms for obesity pro-moted by pro-fat groups are “size positive,” “fat-positive” and “plus-sized.”

See also CULTURAL INFLUENCES ON APPEARANCE.

fat recycling Also called fat grafting; the tech-nique of removing fat cells from one part of the

body and using them in another. It is a furtherrefinement of liposuction.

Fat recycling is a relatively new and still-evolvingcosmetic surgery technique in which fat removed dur-ing liposuction can be injected into the hollows be-tween chin and cheek, for example, during face-lifts.

Hilton quotes pioneer plastic surgeon Ian T.Jackson, M.D.: “There are practitioners now whoare really excellent at fat grafting and have per-fected details that make it truly a viable alternativefor contour defect correction and for contouringareas that have been damaged by disease, radia-tion, or over-aggressive cosmetic surgery.”

See also COSMETIC SURGERY; LIPOSUCTION.

Hilton, Lisette. “Approach Provides Alternative for FatGrafting in Patients with Radiation Defects.” CosmeticSurgery Times 5, no. 5 (June 2002): 8.

fats One of the three main classifications ofnutrients (see CARBOHYDRATES and PROTEINS), fatsbelong to a class of compounds known as lipids.They are derived from both animal and plantfoods, but they differ chemically from each. Thoseoriginating from animal sources are saturated fats;fats from plants are usually unsaturated fats (seeFATS, SATURATED; FATS, UNSATURATED). Exceptionsare tropical vegetable oils, including coconut oiland palm oil which are highly saturated and arewidely used in food processing, particularly coffeecreamers and baked goods. Both saturated andunsaturated fats have the same caloric value, aboutnine calories per gram, more than twice that ofcarbohydrates and proteins (four calories pergram). (Some studies indicate that fat may have upto 11 calories per gram.)

Fat serves as the body’s major store of energy,and METABOLISM of this substance supplies approx-imately 90 percent of energy requirements duringprolonged EXERCISE. The higher caloric value of fatmakes it a more efficiently convertible source ofenergy for storage than protein or carbohydrate.

The American Heart Association recommendslimiting calories eaten as fat to the 20 to 30 percentrange instead of the 40 to 50 percent typical of mostAmericans. Diets consisting of less than 20 percentfat generally lack sufficient taste and palatability forfaithful adherence; much below 10 percent for aprolonged period could cause serious health prob-

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lems or even death. Some fat must be included in adiet because fat serves as a carrier for several impor-tant vitamins including A, D, E and K. Very low fatdiets may result in deficiency of these “fat-soluble”vitamins. Nevertheless, dedicated fat-free puristsstrive to eliminate all fats from their diets.

See also FAT PHOBIA; TRANS FATS.

fats, saturated Fats whose chemical compositionincludes the maximum possible quantity of hydro-gen. They come primarily from animals and areusually solid at room temperature. They tend toraise blood cholesterol levels. According to HarvardHealth Letter, saturated fats are associated with amodest increase in heart disease, with some evi-dence pointing to a link to prostate and colon can-cer. Examples of saturated fats are butter, fats inwhole milk, cheese, lard, meat fat, solid shorten-ing, palm oil, cocoa butter and coconut oil.

From a nutritional standpoint, some saturated fatis essential for proper growth and metabolism; a defi-ciency 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 acidswhose chemical composition includes some siteson the carbon atom unoccupied by hydrogen.When many sites are vacant, they are calledpolyunsaturated. Unsaturated fats are capable ofabsorbing additional hydrogen. They are alsoknown as free fatty acids because of their freebonds that allow them to take on more hydrogenatoms. They usually come from plants and are liq-uid at room temperature. Examples of polyunsatu-rated fats are vegetable oils such as corn,cottonseed, sunflower, safflower and soybean.Monounsaturated fats include olive, peanut andcanola oils. Unsaturated fats tend to lower bloodcholesterol levels.

According to Harvard Health Letter, monounsatu-rated fats lower “bad” LDL cholesterol while raising“good” HDL cholesterol, and may have protectiveeffects against cancer. Some polyunsaturated fats—specifically omega-3 oils such as fish, flaxseed oil,walnuts and canola oil—lower the risk for heartarrhythmias, lower triglycerides (blood fats) and

may help with depression. Other polyunsaturatedfats—specifically corn, soybean and sunfloweroils—lower LDL while raising HDL, and mayreduce risk for heart disease and diabetes.

See also CHOLESTEROL; FATS; FATS, SATURATED;TRANS FATS.

“Dietary Fat.” Harvard Health Letter, January 2004, p. 5.

fat substitutes Artificial fat replacement sub-stances first developed by major food processingand manufacturing companies during the late1980s and early 1990s. SIMPLESSE (NutraSweet), alow-calorie milk-protein-and-egg-white substance,was the first all-natural substitute to win approvalfrom the Food and Drug Administration. InitialFDA approval for Simplesse was for use only infrozen dessert products. OLESTRA, a cooking-oilreplacement developed by Procter & Gamble, is, onthe other hand, heat resistant and can be used inbaked goods, fried foods and snacks. According tothe company, Olestra is “almost a carbon copy ofregular fat, but with a molecule of sugar at its coreinstead of glycerine, and up to eight fatty acidsattached to the core instead of customary three.”

Since these two products were introduced, thefat replacement field has become quite crowded;supermarket shelves are bulging with productsaimed at what is anticipated to be a billion-dollarannual market. Among these additional fat substi-tutes have been Stellar, made from cornstarch byA. E. Staley Manufacturing, and Slendid, made outof pectin extracted from citrus peels, developed byHercules Inc. Procter & Gamble developedCaprenin, a low-calorie fat that replaced cocoa but-ter in candy bars such as the Milky Way II bar.Caprenin had only five calories a gram instead ofthe nine calories a gram in other fats. Its “secret”ingredient was behenic acid, a substance not easilymetabolized by the body. Because Capreninappeared to increase serum cholesterol slightly, theMilky Way II was withdrawn from the market.

No one fat replacer is ideal for all uses—flavor,texture, lubrication, bulk or heat transfer. In somecases, a single fat replacer may do the job; in others,a combination of fat replacers may be necessary.

The Calorie Control Council explains, “The typeof fat replacer(s) used in a product depends largelyon which of the complex and diverse properties of

145fat substitutes 145

fat are being duplicated. In addition to flavor,palatability and creaminess, fats provide an essen-tial lubricating action. In fried foods, fats and oilstransmit heat rapidly and uniformly and providecrisping. Thus, the particular desired functions offat needed to produce an acceptable product—fla-vor/texture, lubrication, volume/bulk, or heattransfer—determine which ingredient(s) and pro-cessing techniques are employed.

“The ideal fat replacer(s) recreates all the attrib-utes of fat, while also significantly reducing fat andcalorie content. The challenge for food processorsis to identify the fat replacer(s) that works best fora given product.

“Fat replacement may require several ingredientsto replace the functionality of fat. A ‘systemsapproach’ is, therefore, sometimes employed. In thesystems approach, a variety of synergistic componentsare used to achieve the functional and sensory char-acteristics of the full-fat product. Combinations ofingredients are used to compensate for specific func-tions of the fat being replaced. These combinationsmay include proteins, starches, dextrins, maltodex-trins, fiber, emulsifiers and flavoring agents. Some fatreplacers are now available that are themselves acombination or blend of ingredients (for example, oneingredient currently in use is a combination of whey,emulsifiers, modified food starch, fiber and gum).”

Some analysts say that the use of these low- ornonfat substitutes will revolutionize the food pro-cessing industry, dramatically increasing sales andconsumption. But others feel that fat-substituteproducts will only take sales from existingprocessed food products.

The medical community has been cautiousabout the introduction of these fake fats. It willtake some time before adequate studies are com-pleted; to date, however, no data show that eatinga fat substitute will help lower or even maintainbody weight—unless overall calories are cut.

In fact, some concern is expressed that peoplewill eat even more calories because of the fake fat.For example, a piece of fat-free cake that has 160calories is more “fattening” than an apple that hasonly 65 calories and is also fat free. But nutrition-ists fear that a population addicted to sugar andchocolate will now feel the fat-free cake gives theman excuse to indulge.

See also APPENDIX V.

Calorie Control Council. “Fat Replacers: Food Ingredi-ents for Healthy Eating.” Available online. URL:http://www.caloriecontrol.org/fatrepl.html. Down-loaded 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 insome people. When the virus is given to animals,their body fat increases 50 percent or more—evenquadrupling weight gain, even though they haveeaten the same amount as animals not given thevirus. Recently, scientists have tested humans forthe virus, and found that 30 percent of obese peo-ple showed their blood had been exposed to thevirus, while only 11 percent of nonobese personshad been exposed.

Among the theories of how AD 36 may lead toobesity, according to Squires: “One theory is thatinfection prompts fat cells to pull more triglyc-erides and cholesterol from the blood—an idea thatfits with the lower levels of these substances in theblood of those who have had the virus. Otherresearch points to the possibility that infectionmight significantly reduce the amount of leptinproduced by fat cells. Still more studies suggest thatAD 36 might prompt fat cells to mature morequickly and start storing fat.”

Scientists caution that a “fat virus” is only a the-ory at this point, and “extremely unlikely” and“fringe”—although interesting.

Atkinson, Richard L. “Human Adenovirus-36 Is Associ-ated with Increased Body Weight and ParadoxicalReduction of Serum Lipids.” International Journal ofObesity and Related Metabolic Disorders, December 2004.

Squires, Sally. “A Question from the Edge: Is Fat Conta-gious?” The Washington Post, August 3, 2004, p. HE01.

fear of fat syndrome Behavior resulting from anexaggerated concern about gaining weight, notclassifiable as a serious disorder such as BULIMIA oranorexia. Fear of fat syndrome is much morecommon than ANOREXIA NERVOSA and affectsyounger children.

There are both boys and girls as young as sevenwho experience fear of fat and on occasion dietand skip meals. They are not anorexic—they do

146146 fat virus

not have an obsessive wish to be thinner—but theyare obsessed with not gaining weight. This dietingbefore their bodies are fully formed can lead tostunted growth, a stunting of development of heartmuscle and delaying of puberty. If children stopdieting, damage is usually temporary; but if theydiet strenuously for more than six months, theyare not likely to grow that year. Frequently thisfear of fat is seen in children who are not fat tobegin with.

Often the extra baby fat that appears rightbefore puberty inspires panic dieting. Because thisbaby fat is not extra calories stored as fat, it doesnot respond well to dieting, which only increasesanxiety, producing more rigorous attempts to diet.Children will frequently conceal this dieting,explaining that they are not eating dinner becausethey have to go somewhere, or that they ate at afriend’s house or on the way home.

One study evaluated disturbed eating behaviorsand attitudes among 326 adolescent girls attendingan upper-middle-class parochial high school. Thestudents reported an exaggerated concern withobesity regardless of body weight or knowledge ofnutrition. Underweight, normal-weight and over-weight girls were dieting to lose weight andreported frequent self-weighing. As many as 51percent of the underweight adolescents describedthemselves as extremely fearful of being over-weight, and 36 percent were preoccupied withbody fat. The frequency of BINGE EATING and VOM-ITING behaviors was similar in the three weight cat-egories. The data suggested that fear of fat andinappropriate eating behaviors are pervasiveamong adolescent girls regardless of body weightor nutrition knowledge.

University studies of college-age women haverevealed this same fear of fat syndrome. Eightypercent of the 1,335 female students in a Univer-sity of Florida study said they had dieted during thepast year; the average respondent was five feet fiveinches tall and weighed 122 pounds, well withinthe low-to-normal weight range. An Ohio StateUniversity study found that 67 percent of thefemale respondents had some kind of disorderedeating pattern.

Fear of fat appears to be deeply ingrained in oursociety; we have cultural preoccupation with slim-

ness. Television, magazines and even the classroompromote the goal of thinness for reasons of bothbeauty and health. Even medical doctors and otherexpert sources promote a “healthier” dietaryintake. This social phenomenon not only has animpact on adult and adolescent eating habits butmay also influence those of young children.Notions regarding body weight and appearance areformed very early in life. In fact, elementary schoolchildren have been shown to perceive obesity asbeing worse than being handicapped or disabled.

See also CULTURAL INFLUENCES ON EATING DISOR-DERS; DIETING; FAT PHOBIA; GOLDFARB FEAR OF FAT

SCALE.

Moses, Nancy, Mansour-Max Banilivy, and Fima Lifshitz.“Fear of Obesity among Adolescent Girls.” Pediatrics83 (March 1989): 393–398.

feeding disorder of infancy or early childhoodTerm used in the American Psychiatric Associa-tion’s Diagnostic and Statistical Manual of Mental Dis-orders (DSM-IV) for the more commonly knownFAILURE TO THRIVE.

DSM describes the condition as a persistent fail-ure to eat adequately, as reflected by significantweight loss or a failure to gain weight over at leastone month. The feeding disturbance is not due toan associated gastrointestinal or other generalmedical condition. Plus, the feeding disturbance isnot better accounted for by another mental disor-der or by lack of available food. Onset of the disor-der must be before age six years.

According to DSM-IV, of all pediatric hospitaladmissions, 1 to 5 percent are for failure to gainadequate weight, and up to one-half of those maybe attributed to feeding disturbances without anyapparent predisposing medical condition. Althoughfeeding disorder of infancy or early childhood usu-ally occurs during the infant’s first year, it maybegin as late as two to three years of age. Themajority of children have improved growth aftervariable lengths of time.

feminist psychotherapy for eating disordersFeminist psychotherapy (FP) involves a multifac-eted approach, one that does not follow a unifieddoctrine, but can be incorporated into extant

147feminist psychotherapy for eating disorders 147

approaches such as cognitive-behavior therapy orpsychodynamic treatment for eating disorders. Inconceptualizing the etiology of eating disorders,feminist psychotherapists focus on issues of genderinequality, sociocultural media influences, fashionand diet food industries and the cultural idealiza-tion of thinness.

Some general principles of feminist psychother-apy include an emphasis on a consciousness-rais-ing approach to treatment, an open exploration ofpower differentials between clients and therapistwith a commitment toward minimizing this hierar-chy, a recognition of women’s strengths andrephrasing of weaknesses as strengths and advo-cating social action among clients to empowerwomen and promote social change. Further, femi-nist therapists value client autonomy and need forconnections with others, and they encourageclients to change rather than adapt to socially pre-scribed conflicting sex roles. Perhaps most funda-mental, however, is the FP belief that psychologicaldistress stems from internal and external sources,thus creating a need to view problems within asociocultural framework and emphasize systemicchange through therapy.

Feminist psychotherapists employ strategiessuch as problem solving, skills training, psychoed-ucation, sex role and power analyses, assertivenesstraining, consciousness-raising groups, bibliother-apy, reframing to recognize contributions of theexternal environment and demystification,wherein therapists provide information aboutchange processes and tools for clients to monitorand evaluate their own progress.

From a more psychodynamic perspective, femi-nist psychotherapists may argue that women aresocialized to pursue the potentially conflicting cul-tural ideals of independence and nurturance, with-out attention to interdependence. Further, womenare led to develop their identities in the context ofand in comparison to others, learning to tie theirself-worth to their interpersonal abilities and suc-cesses. Indeed, eating disorder clients have hadmuch experience with so-called false relationships;consequently, one important goal of feminist psy-chodynamic psychotherapy is to help the clientrecognize and validate her perceptions of priorfalse relationships, and to learn that engagementdoes not necessarily lead to a loss of a separate self.

HILDE BRUCH cautioned that attempts at inter-pretation may seem to the anorexia nervosa (AN)client to be reminiscent of earlier experiences inwhich the client was told what to think by some-one more powerful; this may then further con-tribute to the client’s lack of confidence andself-awareness. With regard to client response, theAN client may identify the female therapist withher own intrusive mother, thereby leading to fearsof being taken over and ambivalence towardsprogress. During early sessions, the therapistshould accept the AN client’s negative responseswithout retaliating or interpreting the behaviors(which may be misconstrued as manipulative), toteach the client that a relationship can be support-ive in her self-learning. Other countertransferenceimplications relate to the therapist’s personal biasesand attitudes toward body weight. Fodor, forinstance, recommended that feminist psychothera-pists working with eating disorder clients reevalu-ate their definitions of overweight, questioningassumptions such as the existence of set weightsfor individuals, the unhealthiness and unattrac-tiveness of moderate overweight and the ease ofself-control over weight.

Bruch, Hilde. “Psychotherapy in Primary Anorexia Ner-vosa.” Journal of Nervous and Mental Diseases 150, no. 1(January 1970): 51–66.

Fodor, Iris G. “Cognitive Behavior Therapy: Evaluation ofTheory and Practice for Addressing Women’s Issues.”In Feminist Psychotherapies: Integration of Therapeutic andFeminist Systems, edited by M. A. Dutton-Douglas andL. E. A. Walker, 91–117. Westport, Conn.: Ablex Pub-lishing Corp., 1988.

Sesan, Robin. “Feminist Inpatient Treatment for EatingDisorders: An Oxymoron?” In Feminist Perspectives onEating 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. “Empowermentand the Eating-Disordered Client.” In Feminism andPsychotherapy: Reflections on Contemporary Theories andPractices. 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, NewModels of Therapy: The Psychology of Women andthe Treatment of Eating Disorders.” In PsychodynamicTreatment of Anorexia Nervosa and Bulimia, edited by C.L. Johnson, 225–244. New York: Guilford Press, 1991.

148148 feminist psychotherapy for eating disorders

Striegel-Moore, Ruth H. “A Feminist Perspective on theEtiology of Eating Disorders.” In Eating Disorders andObesity: 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 Treat-ment of Eating Disorders: A Gender Perspective.” InPsychodynamic Treatment of Anorexia Nervosa andBulimia, edited by C. L. Johnson, 245–294. New York:Guilford Press, 1991.

Worell, Judith, and Pam Remer. Feminist Perspectives inTherapy: An Empowerment Model for Women. West Sus-sex, U.K.: John Wiley & Sons Ltd., 1992.

Zerbe, Kathryn J. “Feminist Psychodynamic Psychother-apy of Eating Disorders: Theoretic Integration Inform-ing Clinical Practice.” The Psychiatric Clinics of NorthAmerica 19, no. 4 (December 1996): 811–827.

fen-phen/Redux Fen-phen refers to the com-bined use of the drugs fenfluramine (brand namePondimin) and phentermine. Redux is the brandname for dexfenfluramine. Phentermine wasapproved by the Food and Drug Administration in1959 and fenfluramine in 1973, both as appetitesuppressants for the short-term (a few weeks)management of obesity. Dexfenfluramine wasapproved in 1996 for use as an appetite suppres-sant in the management of obesity. Based largelyon a study by Weintraub, some physicians begandescribing fenfluramine or dexfenfluramine incombination with phentermine, often for extendedperiods of time, for use in weight-loss programs. In1996 physicians had written 18 million prescrip-tions for fen-phen. Use of drugs in ways other thandescribed in the FDA-approved label is called “off-label use.” In the case of fen-phen and dexfen/phen, no studies were presented to the FDA todemonstrate either the effectiveness or safety ofthe drugs taken in combination.

When the Mayo Clinic and other treatmentfacilities reported more than 200 patients develop-ing heart valve disease after taking fen-phen, theFDA notified doctors and drug makers on Septem-ber 12, 1997, to withdraw fenfluramine anddexfenfluramine from the market. (There werealso reports of cases of heart valve disease inpatients taking only fenfluramine or dexfenflu-ramine, but no cases meeting FDA’s definition inpatients taking phentermine alone.)

Weintraub, M., J. D. Hasday, A. I. Mushlin, and D. H.Lockwood. “A Double-Blind Clinical Trial in WeightControl. Use of Fenfluramine and Phentermine Aloneand in Combination.” Archives of Internal Medicine 144,no. 6 (1984): 1143–1148.

Weintraub, M. “Long-Term Weight Control Study: Con-clusions,” Clinical Pharmacology and Therapeutics 51, no.5 (May 1992): 642–646.

Wellman, P. J., and Maher, T. J. “Synergistic Interactionsbetween Fenfluramine and Phentermine.” Interna-tional Journal of Obesity and Related Metabolic Disorders23, no. 7 (July 1999): 723–732.

fiber An edible, but indigestible, part of certainfoods. Fiber is important in the diet as roughage, orbulk. Fiber is found in starches, breads, vegetablesand fruit.

See also DIETARY FIBER.

food addiction Some popular writings on thesubject of food have postulated the existence of adisorder they call “food addiction.” Loosely con-strued, the concept of addiction might be said toapply to compulsive or disordered eating of certainfoods, most commonly those high in sugar orstarch content, but there is no scientific basis forbelieving that any ordinary food substance is liter-ally physiologically addictive in the same sense as anarcotic drug. So-called food addiction is moreplausibly understood as an expression of a psycho-logical disorder, response to an unacceptablyintense condition of emotional deprivation, anxi-ety or tension. In other words, the idea of foodaddiction is not medically or scientifically valid.

Some authors classify “addictive” foods asfoods that trigger cravings and compulsive eatingor drinking.

Scientists at Brookhaven National Laboratoryhave found that the mere display of food—wherein food-deprived subjects are allowed tosmell and taste their favorite foods without actu-ally eating them—causes a significant elevation inbrain dopamine, a neurotransmitter associatedwith feelings of pleasure and reward. This activa-tion of the brain’s dopamine motivation circuits isdistinct from the role the brain chemical playswhen people actually eat, and may be similar towhat addicts experience when craving drugs.

149food addiction 149

Brookhaven scientists have done extensiveresearch showing that addictive drugs increasethe levels of dopamine in the brain, and thataddicts have fewer dopamine receptors than non-addicts. Previously, in an effort to understand therelationship of the dopamine system to obesity,the scientists had found that obese individualsalso had fewer dopamine receptors than normalcontrol subjects.

Several University of Florida (UF) studies havealso presented new evidence linking overeating,obesity and addiction, and could have treatmentimplications for people struggling with weightproblems, alcoholism or drug use, according toMark Gold, M.D., chief of addiction medicine atUF’s College of Medicine. Nordlie explains: “Gold,an early proponent of the food-as-drug model, saidthe medical community considered the idea radicala decade ago, but many addiction specialists nowgive it serious consideration. Advances in imagingtechnology, neurochemistry and other fields haveenabled basic science researchers to map rodents’brain pathways and show how food and drugsevoke similar responses. At the same time, clinicalresearchers such as Gold have begun investigatingthe relationship between food-seeking and drug-seeking behaviors in people.”

See also ADDICTION; ADDICTION MODEL OF EATING

DISORDERS; CRAVING.

Gold, Mark S., ed. Eating Disorders, Overeating, andPathological Attachment to Food: Independent or Addic-tive Disorders? Binghamton, N.Y.: Haworth Press,2004.

James, G. Andrew, Mark S. Gold, and Yijun J. Liu.“Interaction of Satiety and Reward Response to FoodStimulation.” Journal of Addictive Diseases 23, no. 3(July 2004): 23–37.

Nordlie, Tom. “UF College of Medicine ResearchersReport Link between Overeating, Obesity and Addic-tion.” Available online. URL: http://www.news.health.ufl.edu/stories/2004/July/070804_Nordlie.shtml. Posted July 8, 2004.

Volkow, Nora D., et al. “Nonhedonic Food Motivation inHumans Involves Dopamine in the Dorsal Striatumand Methylphenidate Amplifies This Effect.” Synapse44, no. 3 (June 1, 2002): 175–180.

food nutrition labels Beginning in 1994, theU.S. government began requiring manufacturers to

put information about nutritional value on foodlabels. The first significant change was the recentrequirement that beginning January 1, 2006, man-ufacturers must list the amount of unhealthy transfatty acids, or TRANS FAT, directly under the line forsaturated fat.

Then in March 2004, U.S. Health and HumanServices (HHS) secretary Tommy Thompsonunveiled a strategy for the Food and Drug Admin-istration (FDA) to fight American obesity, whichincluded changing the Nutrition Facts panel onfood labels. Specifically, the initiative includes thefollowing recommendations for FDA:

• Give more prominence to calorie content onfood labels, such as increasing the font size forthe calories line item, including a percent dailyvalue column for total calories and/or eliminat-ing the listing for calories from fat.

• Authorizing health claims on certain foods thatmeet FDA’s definition of “reduced calorie” or“low calorie.” For example, FDA may considerallowing a health claim such as “Diets low incalories may reduce the risk of obesity, which isassociated with type 2 diabetes, heart diseaseand certain cancers.”

• Publish a proposed rule to provide for nutrientcontent claims related to carbohydrate contentof foods and provide guidance for the use of “netcarb” claims.

• Encourage food manufacturers to label as a sin-gle serving those food packages for which theentire content of the package “can reasonably beconsumed at a single eating occasion.” FDA givesthe example that a 20-ounce bottle of soda, cur-rently labeled as 110 calories per serving and 2.5servings per bottle, could be labeled as contain-ing 275 calories per bottle. In addition, FDA mayenhance enforcement of inaccurate labeling ofserving sizes.

Most of the FDA’s recommendations are vol-untary, which received complaints from con-sumer advocates.

The National Institute of EnvironmentalHealth Sciences (NIEHS) suggests watching labelsfor the following:

150150 food nutrition labels

• Pay close attention to serving sizes.

• Products labeled “light” or “lite” must have one-third fewer calories or one-half the fat of thefoods to which they are compared. “Light” alsocan 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 lesssugar.

• Use the “percentage of daily values” section ofthe label as a guide for daily planning.

• The amount of calories a person needs each daydepends on many factors, including exercise.

Center for Food Safety and Applied Nutrition. “How toUnderstand and Use the Nutrition Facts Label.” Avail-able online. URL: http://vm.cfsan.fda.gov/~dms/food-lab.html. Posted July 2000; updated July 2003 andNovember 2004.

forbidden foods A term used by clinicians andeating disordered individuals to refer to foods thatthe person feels that he or she should not eat, usu-ally because they are high in calories and the per-son believes that he or she would not be able tostop eating them. Not coincidently, “forbiddenfoods” are also the foods on which persons witheating disorders usually binge. Although someapproaches to treatment of eating disordersencourage the individual to abstain from these“forbidden foods,” the most effective treatmentshelp the individual learn to eat the food withoutlosing control (i.e., without bingeing and purg-ing). Thus at the end of treatment for an eatingdisorder, a person would no longer have any for-bidden foods.

forced feeding Feeding accomplished throughinvasive tubes in the nose or by a process calledtotal parenteral nutrition.

Forced feeding is the most dramatic treatmentfor anorexia. In severe cases, in which bodyweight falls to dangerous levels, parents andphysicians may decide to admit an anorexic to ahospital for forced feeding on the grounds that itwill prevent her death and restore her to a mentalstate that will make meaningful therapeutic inter-action possible. In these critical cases physicians

recommend “renourishment” or “refeeding”because they believe that the biological effects ofstarvation create a psychological prison fromwhich patients cannot escape. In this view, theanorexic must gain a certain amount of weightbefore she can progress in psychotherapy or makerational decisions about treatment.

See also HYPERALIMENTATION.

fraudulent products With a reported 65 percentof Americans overweight or obese, it is littlewonder that unscrupulous promoters prey onthose looking for miracle cures. But the Fed-eral Trade Commission (FTC) warns that despiteclaims to the contrary, there are no magic bulletsor effortless ways to burn off fat. The only wayto lose weight is to lower caloric intake andincrease physical activity. Claims for diet productsor programs that promise weight loss withoutsacrifice or effort are bogus. And some can evenbe dangerous.

These facts do not keep fraudulent advertisersfrom preying on consumers and reaping billions ofdollars each year. While the scams may vary (forexample, pills, patches, clips, body wraps, insolesor “diet teas”), the claims are almost always thesame—dramatic, effortless weight loss without dietor exercise.

The FTC warns consumers to watch out for thefollowing 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!

• Revolutionary European Method! Ancient ChineseSecret!

• 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 usethe following techniques:

151fraudulent products 151

• Extravagant claims of dramatic, rapid weight loss

• Testimonials from “famous” doctors, researchersor other medical experts

• Dramatic before-and-after photos depicting sub-stantial weight loss

• Ads that tout the latest trendy ingredient in theheadlines

• A footnote hidden somewhere in an ad noting“diet and exercise required”

The FTC reminds consumers that an otherwisemisleading ad or a fleeting video “super” (a flash-ing message superimposed over the video) cannotbe “cured” with a buried “disclosure”.

Further, the FTC identifies seven commonweight-loss claims made for products availableover the counter, including nonprescription drugs,dietary supplements, creams, wraps, devices andpatches that are scientifically infeasible at the cur-rent time. These claims include:

• Causes weight loss of two pounds or more aweek for a month or more without dieting orexercise

• Causes substantial weight loss, no matter whator how much the consumer eats

• Causes permanent weight loss (even when theconsumer stops using the product)

• Blocks the absorption of fat or calories to enableconsumers to lose substantial weight

• Safely enables consumers to lose more than threepounds per week for more than four weeks

• Causes substantial weight loss for all users

• Causes substantial weight loss by wearing it onthe body or rubbing it into the skin

Fraudulent weight loss product claims can bereported to the state attorney general, local con-sumer protection office, or Better Business Bureau.

free fatty acids Free fatty acids (FFA) in theblood originate from the release of ADIPOSE TISSUE

triglycerides. They represent virtually the onlyroute by which these fat stores can be transferredto nonfat tissue for net loss via oxidation. Free fattyacid metabolism in obesity has therefore been the

subject of many studies over the last 30 years.Unfortunately, conflicting confusions regardingseveral aspects of FFA metabolism have appeared,including the antilipolytic (lipolysis: the chemicalbreakdown of fat) effectiveness of insulin in obe-sity, the relationship of FFA release to the amountof body fat and the lipolytic responsiveness ofobese individuals to catecholamines (secretions).

To determine whether differences in DISTRIBU-TION OF BODY FAT result in specific abnormalities offree fatty acid metabolism, researchers conductedstudies of women of varying body fat distribution.They concluded that the basal release of FFA fromadipose tissue to meet lean body mass energyneeds is greater in upper-body obese women thanlower-body obese or non-obese women. The netlipolytic response to epinephrine (a hormone thatacts as a stimulant to several metabolic processes)is reduced in upper-body obese women comparedwith lower-body obese and non-obese women.Their results may explain many of the conflictingreports in the literature regarding FFA metabolismin human obesity and emphasize the need to char-acterize the type of obesity being studied beforeinvestigations of FFA metabolism in humans.

Freshman 15 A term used since at least the mid-1980s to explain the added pounds college fresh-men typically put on when they go away to collegefor the first time. The propensity to put on weighthas been attributed to several things, includingdiets of pizza and sweets, midnight munchies,stress-related eating binges and alcohol calories.According to the Kansas State University Housingand Dining Services, “More and more the Fresh-man 15 is being replaced with 20–25 pounds ofweight gain.”

Although the Freshman 15 is largely a myth,researchers at Cornell University found that stu-dents in their study did gain an average of fourpounds during the first 12 weeks of their freshmanyear. This was a rate of gain 11 times higher thanthe typical weight gain for 17- and 18-year-olds.

Not everyone is destined to gain the full Fresh-man 15, though. A multiyear study by researchersat Tufts University found that while students do gainweight during their first year, the average is aboutsix pounds for men and 4.5 pounds for women.

152152 free fatty acids

Graham and Jones investigated whether theperception that freshman gain 15 pounds duringtheir first year of college is related to either actualor perceived weight gain. Their findings revealedno significant weight gain at the end of the year.The Freshman 15 myth was found to play animportant role in perpetuating negative attitudestoward weight. Freshmen who were concernedabout gaining 15 pounds were more likely tothink about their weight, have a poorer bodyimage than others and categorize themselves asbeing overweight.

In their study of 135 college freshmen, Andersonet al. found that statistically significant (but modest)weight increases did occur for the majority of par-ticipants during their freshman year in college, withone-quarter of them gaining at least five poundsduring their first semester—resulting in the propor-tion of students classified as overweight or obese toincrease markedly from September to December.“The percentage of participants defined as over-weight or obese from September to May virtuallydoubled. For this subset of participants, the fresh-man year of college could be considered a criticalperiod 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 CriticalPeriod for Weight Gain: An Initial Evaluation.” EatingBehaviors 4, no. 4 (November 2003): 363–367.

Graham, M. A., and A. L. Jones. “Freshman 15: ValidTheory or Harmful Myth?” Journal of American CollegeHealth 50, no. 4 (January 2002): 171–173.

fructose as a contributor to obesity The Inter-national Food Information Council (IFIC) Founda-tion explains that fructose is a single sugar unit,like glucose, and is sometimes referred to as “fruitsugar” because it is the sugar that occurs naturallyin fruits, vegetables and honey. Fructose and glu-cose are combined in equal amounts in table sugar(sucrose). Similarly, fructose and glucose occur inalmost equal amounts in high fructose corn syrup(HFCS). HFCS is primarily found in two formula-tions in the United States: “HFCS 55,” which is 55percent fructose and is used to sweeten beverages,and “HFCS 42,” which is 42 percent fructose andused mostly in baked goods.

The interchangeable use of the words fructoseand HFCS in some media and even scientific docu-ments is potentially misleading to consumers, whomay assume that the two are identical. They are,however, quite different in both their structure anduses in the food supply. Although research usingfructose alone has led to assumptions about HFCS,as a sweetener pure fructose is rarely consumedalone. It is generally consumed as a component oftable sugar or of HFCS.

A scientific debate has emerged over whetherAmerica’s increased use of high fructose corn syrupis contributing to or responsible for the increasingrates of obesity. Among the points made recentlyby scientists and food groups:

• Bray et al. analyzed food consumption patternsby using U.S. Department of Agriculture foodconsumption tables from 1967 to 2000, andfound that consumption of HFCS increased morethan 1,000 percent between 1970 and 1990, farexceeding the changes in intake of any other foodor food group. Noting that calorically sweetenedbeverages may enhance caloric overconsump-tion, the authors suggested that the increase inconsumption of HFCS has a temporal relation tothe epidemic of obesity, and the overconsump-tion of HFCS in calorically sweetened beveragesmay play a role in the epidemic of obesity.

• Earlier in 2004 the American Dietetic Associationpublished a report that found, on the basis of cur-rent scientific evidence, that consumers can safelyenjoy a range of caloric and noncaloric sweeten-ers. They noted that this statement is valid whensuch sweeteners are consumed as part of a dietthat is guided by current nutrition recommenda-tions, such as those in the U.S. Dietary Guidelinesfor Americans and the Dietary Reference Intakes,as well as individual health goals. This includesfructose from HFCS or from table sugar.

• IFIC says the primary factor driving the allegedconnection between fructose and obesity is theincreased availability of HFCS since its introduc-tion in the 1970s. “Availability” refers to thetotal amount delivered into the food supply. Thisamount is greater than actual consumption,since waste and other losses are not accountedfor. The proportion of HFCS as a percentage of

153fructose as a contributor to obesity 153

154

all caloric sweeteners (added sugars and sweet-eners) available in the U.S. food supply hasincreased from less than 0.5 percent in 1970 to42 percent in 2001. Although the increasedavailability of HFCS appears dramatic, it must benoted that as the availability of HFCS hasincreased, the availability of table sugar hasdecreased at nearly the same rate. Although theincreased availability of HFCS parallels theincreasing prevalence of obesity, that correlationalone does not prove causality. Further researchin this area is warranted.

Some researchers have concluded that caloriesingested in liquid form do not contribute to satiety.This theory is cited to support the fructose-obesityconnection. However, it is difficult to separate thepossible effects because there are different physio-logical mechanisms for digesting food versus bev-erages, there are different roles that foods andbeverages have in the diet and there are otherpotential differences in cognitive cues.

Other studies have shown that the body com-pensates for calories from beverages depending on

the degree of blood glucose rise and time betweenbeverage consumption and test meal. The majorityof studies have shown that sucrose solutions sup-press food intake if the time between ingesting thesolution and consuming the test meal is less than60 minutes. Stemming from differences in theexperimental designs of the various studies thathave been performed, the overall data in this areaare inconclusive. Because nearly identical amountsof glucose and fructose are found in sucrose andthe HFCS used in beverages, similar results wouldbe expected with the types of HFCS commonlyused in soft drinks. This remains to be tested.

American Dietetic Association. “Position of the AmericanDietetic Association: Use of Nutritive and Nonnutri-tive Sweeteners.” Journal of the American Dietetic Associ-ation 104, no. 2 (February 2004): 255–275.

Bray, George A., S. J. Nielsen, and B. M. Popkin. “Con-sumption of High-Fructose Corn Syrup in BeveragesMay Play a Role in the Epidemic of Obesity.” AmericanJournal of Clinical Nutrition 79, no. 4 (April 2004):537–543.

IFIC Foundation. “What Do We Know about Fructose andObesity?” Food Insight, July/August 2004, pp. 1, 4, 5.

154 fructose as a contributor to obesity

gallstones Stonelike masses that form in the gall-bladder. Gallstones form when cholesterol crystal-lizes after mixing with acids from the liver. Theircause is unknown, although there is evidence of aconnection between gallstones and obesity. Leanwomen have a better chance of avoiding gall-stones; obese men and women trying to loseweight may be more likely to develop them, espe-cially if they resort to severe forms of dieting, sincefasting reduces the amount of other acids in thebody that dissolve cholesterol. Those are the find-ings of separate studies that strengthen the associ-ation between weight and gallstones.

Even a woman who is moderately overweight—15 to 20 pounds—doubles her risk of developinggallstones, and her risk increases as she puts onmore weight, according to a study by the Brighamand Women’s Hospital in Boston. A woman who is75 to 100 pounds overweight is approximately sixtimes more likely to develop gallstones than awoman of normal weight.

Obese people trying to lose weight throughextreme and often unhealthy measures such asextended FASTING or caloric restriction may be put-ting themselves at risk for developing gallstones,according to a University of California at SanFrancisco study. Thirteen of 51 obese male dieters(25.5 percent) who consumed no more than 500calories a day for eight weeks developed choles-terol gallstones, and three had a buildup of cho-lesterol that leads to formation of the stones, thestudy showed. None of the 26 nondieting controlsdeveloped gallstones.

The University of Texas Health Science Centerstudied 1,202 Mexican Americans and 908 non-Hispanic whites from 1979 to 1982. They selectedMexican Americans for this study of the role ofobesity and body fat distribution in gallbladder dis-

ease specifically because, statistically, MexicanAmericans have a higher incidence of gallbladderdisease and also have greater overall adisposity andan unfavorable body fat distribution (upper-bodyand central adiposity) relative to non-Hispanicwhites. Their findings showed central body fat dis-tribution to be a risk factor for clinical gallbladderdisease in women, independent of age, ethnicgroup and overall adiposity.

Abdominal fat was also found to significantlyraise the risk for gallstones among men in a studyof 29,847 male health professionals who were fol-lowed for 11 years by Harvard researchers. Thosemen whose waist circumference (after adjustmentfor height) was at least 40.4 inches had nearlytriple the risk of gallstones as those whose waistcircumference was less than 34 inches. The study’sauthors concluded that abdominal circumferenceand waist-to-hip ratio predict the risk of develop-ing gallstones independently of body mass index.

Bankhead, Charles D. “Plummeting Pounds GainBlame.” Medical World News (July 1990).

Haffner, Steven, et al. “Central Adiposity and GallbladderDisease in Mexican Americans.” American Journal ofEpidemiology 129 (March 1989): 587–595.

Maclure, Malcolm, et al. “Weight, Diet, and the Risk ofSymptomatic 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. “AProspective Study of Hospitalization with GallstoneDisease among Women: Role of Dietary Factors, Fast-ing Period, and Dieting.” American Journal of PublicHealth 81, no. 7 (July 1991): 880–884.

Tsai, C. J., et al. “Prospective Study of Abdominal Adi-posity and Gallstone Disease in U.S. Men.” AmericanJournal of Clinical Nutrition 80, no. 1 (July 2004):38–44.

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G

gamma butyrolactone (GBL) A chemicalincluded in products sold as dietary supplements,claimed to have such effects as building muscles,enhancing sexual performance and reducingstress. One of the products containing GBL,Revivarant, has been sold as a liquid in 32-ouncebottles and as Revivarant G in pill form, and pro-moted as a diet drug. Because the Food and DrugAdministration (FDA) received reports of serioushealth problems—some of them life-threatening—associated with the use of products containingGBL, the FDA in January 1999 advised consumersto dispose of any products of this type in their pos-session and requested that sellers voluntarilywithdraw the products from market.

gastric banding See ADJUSTABLE GASTRIC BANDING.

gastric bubble Also called the Garren-EdwardsGastric Bubble (GEGB); a procedure introducedin the mid-1980s. During the operation, a balloondevice was placed inside the stomach which,when inflated, acted as “artificial food,” creatinga sensation of fullness. The FDA initiallyapproved it as a temporary adjunct to diet andbehavior modification for a maximum use of 14weeks. Subsequent complications with thedevice, including spontaneous deflation, passageinto the small bowel with small bowel obstruc-tion, erosion through the stomach and regainof lost weight upon removal of the bubble, ledthe FDA to withdraw its approval except for re-search purposes.

Duke Weight Loss Surgery Center. “Obesity as a HealthCare Problem.” Available online. URL: http://duke-health1.org/obesity/problem.asp. Downloaded onDecember 28, 2004.

gastric bypass Specifically, a type of surgical pro-cedure that can be used to cause significant weightloss if one has EXTREME OBESITY. The surgeryreduces the body’s intake of calories because thestomach is made smaller; thus, the person feels fullfaster and must reduce the amount eaten at anygiven time. Part of the stomach and small intes-tines are literally bypassed (skipped over) so thatfewer calories are absorbed.

According to the Association of Perioperative Reg-istered Nurses (AORN), Edward E. Mason, M.D., pro-fessor of surgery at the University of Iowa, introducedgastric bypass in 1966. “Dr. Mason developed the pro-cedure based on the observation that women whohad undergone partial gastrectomy for peptic ulcerdisease tended to remain underweight after the sur-gery and that it was difficult to achieve weight gain inthis patient population. He applied the principles ofpartial gastrectomy to women who were obese andfound that they lost weight. Using surgical staples, hecreated a partition across the upper stomach andanastomosed this pouch to the small intestine. Com-plications of the early gastric bypass procedures led tothe further development and refinement of gastro-plasty in the late 1960s and early 1970s.”

Generally, the term gastric bypass is commonlyused for any number of weight-reduction operations.

See also ADJUSTABLE GASTRIC BANDING; BARIATRIC

SURGERY; BILIOPANCREATIC DIVERSION; GASTROPLASTY;MALABSORPTIVE OPERATIONS; RESTRICTIVE OPERA-TIONS; ROUX-EN-Y GASTRIC BYPASS; STOMACH STA-PLING; VERTICAL BANDED GASTROPLASTY.

Association of Perioperative Registered Nurses. “AORNBariatric Surgery Guideline.” AORN Journal 79, no. 5(May 2004): 1,026–1,040.

gastric restriction procedures Also called “restric-tive operations” or “restrictive procedures.” Thesebariatric surgeries serve only to restrict food intakeand do not interfere with the normal digestiveprocess. To perform the surgery, doctors create asmall pouch at the top of the stomach where foodenters from the esophagus. Initially, the pouch holdsabout one ounce of food; later it expands to two tothree ounces. The lower outlet of the pouch usuallyhas a diameter of only about three-quarters of aninch. This small outlet delays the emptying of foodfrom the pouch and causes a feeling of fullness.

As a result of this surgery, most people lose theability to eat large amounts of food at one time.After an operation, the person usually can eat onlythree-quarters to one cup of food without discom-fort or nausea. Also, food has to be well chewed.

Restrictive procedures lead to significant weightloss in almost all patients, although it is possible to“eat through” the procedure—meaning to con-

156156 gamma butyrolactone

sume as many high calorie foods as one wants byeating or drinking slowly—and consequentlyregain some of the lost weight.

Although restrictive operations lead to weightloss in almost all patients, they are less successfulthan MALABSORPTIVE OPERATIONS in achieving sub-stantial long-term weight loss.

Restrictive operations for obesity includeADJUSTABLE GASTRIC BANDING (AGB) and VERTICAL

BANDED GASTROPLASTY (VBG).

gastrointestinal surgery for obesity SeeBARIATRIC SURGERY.

gastroplasty An operation in which the stomachis sectioned; the term encompasses all proceduresthat divide the stomach into an upper and lowergastric pouch with a stapling device but that do notdivide the upper and lower gastric remnants.

See also VERTICAL BANDED GASTROPLASTY.

genetic factors in eating disorders There is evi-dence that eating disorders run in families. Femalesare particularly vulnerable, and there have been anumber of reports of identical twins both developinganorexia nervosa. In some cases, imitative behaviormay be a factor. Comparisons of families of anorex-ics and bulimics with families without eating disor-ders have found some differences: families ofbulimics report more hostile interactions; families ofanorexics are as warm and supportive of their chil-dren as nondisordered families but have more mari-tal problems. Some mental health specialists theorizethat anorexic children serve as “lightning rods” forfamilies who cannot face or resolve their problems.However, most evidence is capable of other explana-tions, so until more scientifically controlled studiesare carried out, a genetic factor in generating eatingdisorders must remain speculative.

One study showed that the parents of bulimicand anorexic subjects tended to have particularpersonality characteristics. Fathers of bulimicswere more impulsive and mothers were moredepressed, and both reported more dissatisfactionwith family relationships than the parents ofrestrictor anorexics. There was also greater inci-dence of affective disorder reported in the familiesof bulimic anorexics.

Walsh noted, “The available data strongly sug-gest that the genetic influences on susceptibility (toeating disorders) reside in multiple genes, and pre-sumably reflect an interaction between multiplegenes and the environment. The technical chal-lenges to identifying such polygenic patterns ofinheritance are impressive, as witnessed by the dif-ficulty of identifying genes which increase the riskfor illnesses such as schizophrenia and manic-depressive illness. It is likely that what is inheritedis not a disorder, but risk factors for the develop-ment of a disorder, such as, perhaps, a tendencytoward obsessionality. Thus, even if a gene orgenes is identified, it will probably not be a genefor an eating disorder but a gene for a related fac-tor. These notions are consistent with the findingsof the family and twin studies which typicallyobserve more robust patterns of transmission forbroadly defined eating disturbances than for thefull blown diagnostic categories.”

Researchers at the University of PittsburghSchool of Medicine, led by Walter H. Kaye, M.D.,and Bernie Devlin, Ph.D., have undertaken thefirst government-funded genetic study ofanorexia nervosa. The study, funded by theNational Institute of Mental Health, is a five-yeargrant with more than $10 million in funding. Itbrings together 11 groups of researchers fromNorth America and Europe (10 clinical centersand one to analyze data) to find regions of thehuman genome that contain genes that influencerisk for anorexia. To find these regions, theresearchers are recruiting families with two ormore members, mainly siblings, who have or hadanorexia nervosa, and analyzing the DNA fromthe participants.

The research will build on recent genetic studiessupported by the Price Foundation, a private Euro-pean foundation that has already pointed to fourregions of the genome to look for genes affectingsusceptibility to anorexia.

Bulik, Cynthia, et al. “Heritability of Binge-Eating andBroadly Defined Bulimia Nervosa.” Biological Psychia-try 44, no. 12 (December 12, 1998): 1,208–1,209.

Kaye, Walter H., Bernie Devlin, et al. “Genetic Analysisof Bulimia Nervosa: Methods and Sample Descrip-tion.” International Journal of Eating Disorders 35, no. 4(May 2004): 556–570.

157genetic factors in eating disorders 157

Lilenfeld, L. R., et al. “A Controlled Family Study ofAnorexia Nervosa and Bulimia Nervosa: PsychiatricDisorders in First-degree Relatives and Effects ofProband Comorbidity,” Archives of General Psychiatry55, no. 7 (1998): 603–610.

Schepank, H. “Genetic Determinants in Anorexia Ner-vosa: Results of Twin Studies.” Psychosomatic MedicinePsychoanalysis 37, no. 3 (1991): 265–281.

Strober, Michael. “Family-Genetic Studies of Eating Dis-orders.” Journal of Clinical Psychiatry 52, suppl. 10(October 1991): 9–12.

Walsh, B. Timothy. “The Future of Research on EatingDisorders.” Appetite 42, no. 1 (February 2004): 5–10.

Woodside, D. B., et al. “Specificity of Eating DisordersDiagnoses in Families of Probands with AnorexiaNervosa and Bulimia Nervosa.” Comprehensive Psychia-try 39, no. 5 (September–October 1998): 261–264.

genetic factors in obesity Obesity often followsfamily lines, and evidence from twin studies andother family studies, although not completely con-sistent, have for some time implied inheritance.

A recent St. Louis University study examinedthe genetics of adult-onset weight change in mid-dle-aged male-male twins controlling for weight inearly adulthood, lifetime history of tobacco use andalcohol dependence, and aimed to estimate theproportion of genetic factors that influence weightchange between early adulthood and middle age inwhite middle-class males. The resultant data indi-cated that more than half of the change in bodymass index (BMI) from early adulthood to middleage remains heritable. No shared environmentalfactors were identified, thus the remainder of thevariance was accounted for by nonshared, orunique, environmental factors and error.

Marti et al. concluded that both genes andeveryday life environmental factors such ascultural- and social-mediated food intake andreduced domestic and living work activities areinvolved in the obesity pandemia. The occurrenceof gene x gene and gene x environmental factorsinteractions makes it more difficult to interpret thespecific roles of genetics and lifestyle in obesity risk.

Some experts have downplayed the role ofgenetics in obesity simply because of the current“pandemic,” arguing that people have the samegenes as their forebears, who did not have today’sprevalence of obesity. But Ellis and Harman sought

to determine if genetic factors might be contribut-ing to the increases in the proportions of NorthAmericans who are obese and overweight. “TheBMI for a large sample of two generations ofUnited States and Canadian subjects was correlatedwith family fertility indicators. Small but highlysignificant positive correlations were foundbetween the BMIs of family members and theirreproduction rates, especially in the case ofwomen. For instance, mothers in the sample (mostof whom were born in the 1940s and 50s) whowere in the normal or below normal range had anaverage of 4.3 siblings and 3.2 children, comparedwith 4.8 siblings and 3.5 children for mothers whowere overweight or obese. When combined withevidence from twin and adoption studies indicat-ing that genes make substantial contributions toobesity, this study suggests that recent increases inobesity are partially the result of overweight andobese women having more children than is truefor average and underweight women. It is specu-lated that improvements in medical treatments forconditions associated with obesity—particularlydiabetes and heart disease—are making it possiblefor overweight women to live longer and to bemore fertile than was true historically.”

Other recent findings and reports that haveindicated genetic factors play at least a small rolein obesity:

• A Stanford University study found that havingoverweight parents is the biggest risk factor forchildhood obesity. Nearly half—48 percent—ofchildren with overweight parents became over-weight themselves, compared to only 13 percentof children who had parents of normal weight.

• More than 200 gene markers for obesity havebeen identified.

• Evidence from twin, adoption, and family stud-ies strongly suggests that biological relativesexhibit similarities in the maintenance of bodyweight. Some children seem to be geneticallyimmune to the effects of overeating. Others con-tinue to gain weight no matter how hard theytry to shed the extra pounds. Some experts pointout that these situations are the minority andoccur only “under the right environmental orlifestyle conditions.”

158158 genetic factors in obesity

Dr. Jeffrey Friedman, a molecular geneticist atthe Rockefeller University in New York, told Timemagazine, “There are genes in the population thatpredispose to obesity. Obviously, there’s an envi-ronmental contribution, but no one questions thatgenes are involved.”

Ellis, L., and D. Haman. “Population Increases in ObesityAppear to Be Partly Due to Genetics.” Journal of Bioso-cial Science 36, no. 5 (September 2004): 547–559.

Kluger, Jeffrey, Christine Gorman, and Alice Park. “WhyWe Eat.” Time 163, no. 23 (June 7, 2004): 72–76.

Marti, A., et al. “Genes, Lifestyles and Obesity.” Interna-tional Journal of Obesity and Related Metabolic Disorders28, suppl. 3 (November 2004): S29–36.

Romeis, J. C., et al. “The Genetics of Middle-Age Spreadin Middle-Class Males.” Twin Research 7, no. 6(December 2004): 596–602.

geophagia A condition in which the patient eatschalk or earth or clay; a type of PICA (the desire toeat inedible substances). After surveying the litera-ture, Isolde Prince concluded that in many culturesgeophagia is a common, acceptable, benign prac-tice without psychological implications. In fact,geophagia occurring among nutritionally deprivedpopulations is looked at differently than pica in theWestern world, where nutrition is much morelikely to be at a satisfactory level.

Although still subject to considerable debate, innutritionally deprived populations geophagia prob-ably fulfills nutritional needs for elements impor-tant for growth and development. Thesenutritional factors are particularly important dur-ing childhood and pregnancy. The main debatablepoint is whether clay eating provides elementssuch as iron, zinc and calcium and is a significanttreatment for anemia, or whether clays removethese elements from food and give rise to anemia.

An important paradox in the geophagia litera-ture is that even though populations consumeearth in significant quantities with impunity, forsome individuals earth eating is pathological andeven lethal. It has been proposed that this paradoxcan be resolved by attributing the malignant formto the co-occurrence of sickle-cell anemia. In thisinterpretation, the malignant cachexia africana andperhaps pobough lang are not caused by earth eat-ing, 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-CulturalPerspective.” Transcultural Psychiatric Research Review26, no. 3 (1989): 167–197.

Simon, S. L. “Soil Ingestion by Humans: A Review of His-tory, Data, and Etiology.” Health Physics 74, no. 6(June 1998): 647–672.

ghrelin A hormone in the digestive system thatregulates appetite. Ghrelin is produced in thestomach and upper intestine in the absence of foodin the digestive system and stimulates appetite justbefore meals. Although it is primarily secreted bythe stomach, ghrelin is also produced in the brain.In recent studies, increased levels of ghrelin werefound in obese individuals following diet-inducedweight loss—with a resulting increase in appetite—providing a potential explanation for the difficultypeople experience in maintaining weight loss.Also, researchers have recently discovered thatghrelin levels are suppressed by some forms ofBARIATRIC SURGERY. Blocking the action of ghrelin isthus a potentially attractive target for drug devel-opment according to the National Institutes ofHealth Obesity Task Force.

Because ghrelin is made primarily in the stom-ach, and because there are receptors (“dockingsites”) for ghrelin in the brain, this hormone wasthought to be a signal from the gut to the brain toindicate when it was time to start a meal. Taking thisinformation as a potential clue that there may beanother pathway for ghrelin’s actions, a team of sci-entists has further explored the brain’s production ofghrelin. Many cells in the brain have been shown tobe involved in energy balance. However, by study-ing the brains of rodents, the scientists discoveredthat ghrelin is made by a group of brain cells notpreviously known to influence energy balance.Intriguingly, these ghrelin-producing cells arelocated adjacent to brain cells that produce a proteincalled NPY, which functions to increase appetite—and which has also been known to help mediate theeffects of ghrelin. The scientists also found that ghre-lin can stimulate the activity of NPY-producing cells.Based on these results and several other experi-

159ghrelin 159

ments, the scientists proposed that the brain’s ownindigenous source of ghrelin may activate the pro-duction of NPY by neighboring brain cells, thus lead-ing to increased appetite. By uncovering what maybe a previously unknown brain regulatory circuit,these studies provide further insights into the body’scomplex regulation of energy balance.

National Institutes of Health. A Report of the NIH ObesityResearch Task Force: Strategic Plan for NIH ObesityResearch, 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 WorldHealth Organization (WHO) to describe the world-wide “epidemic” of obesity and overweight. WHOestimates that more than 1 billion adults world-wide are overweight, defined as a body mass index(BMI) greater than 25; 300 million are consideredobese, with a BMI greater than 30—up from 200million in 1995.

According to WHO, current obesity levels rangefrom below 5 percent in China, Japan and certainAfrican nations, to more than 75 percent in urbanSamoa. But even in relatively low-prevalencecountries like China, rates are almost 20 percent insome cities.

Childhood obesity is already epidemic in someareas and on the rise in others. An estimated 17.6million children under age five are estimated to beoverweight worldwide. The problem increasinglyextends into the developing world; for example, inThailand the prevalence of obesity in five-to-12-year-old children rose from 12.2 percent to 15.6percent in just two years.

Obesity accounts for 2–6 percent of totalhealth care costs in several developed countries;some estimates put the figure as high as 7 per-cent. The true costs are undoubtedly muchgreater as not all obesity-related conditions areincluded in the calculations.

glycemic index (GI) A lab tool developed in1981 to help people (especially diabetics and ath-letes) maintain stable blood sugar levels. It

describes the degree to which blood glucose risesafter a meal. Refined, starchy foods, like bread,cereal and potatoes and concentrated sugars have ahigh glycemic index, whereas most vegetables,legumes and fruits have a low GI. Studies haveshown that after a high GI index meal, blood glu-cose and insulin levels generally rose higher thanafter the low-GI meal. A few hours after the highGI meal, blood glucose and fatty acids decreased torelatively low levels and epinephrine rosemarkedly. These metabolic changes are associatedwith increased hunger, and subjects are found toeat 80 percent more calories after the high GI mealversus the low GI meal. Thus, a low GI diet mayhelp decrease hunger and promote weight loss—which serves as the main theory behind the effec-tiveness of LOW-CARB DIETS.

Although some experts champion the glycemicindex as a way of judging which foods may be fuel-ing the epidemics of obesity and diabetes, othersdisagree. Spake writes:

The problem with this theory, says Xavier Pi Sun-yer, director of the New York Obesity ResearchCenter, is that carbohydrates have not been asso-ciated with a high frequency of diabetes. “Asianstraditionally ate a high-carbohydrate diet with ahigh glycemic index—lots of rice, low in proteinand fat, and they had low rates of diabetes, heartdisease, and obesity,” he says. Others agree thatthe evidence is mixed at best. Says nutritionistJames Kenney of the Pritikin Longevity Center:“The No. 1 reason for diabetes is overweight. Peo-ple who have lost weight and kept it off do not eata low glycemic index diet—they eat a low-fat dietand exercise a lot.” Whether the GI concept willplay a major part in reversing obesity is unclear.

The International Food Information Council(IFIC) cautions that although the GI is often usedas a research tool, it may be difficult to use it as ameasure on which to base dietary recommenda-tions for the general population, because of itswide variability depending on the ripeness of afood, the degree to which a food is cooked, as wellas other factors:

“Ranking and eating foods according to theirglycemic index has a number of problems. First, aperson’s blood sugar response to eating a food canvary from day to day and also according to how the

160160 globesity

food was prepared. Even something as simple asripeness in the case of bananas can affect theglycemic index (the riper the banana, the higher itsglycemic index). Second, once a food is combinedwith other foods (such as cereal and milk orpeanut butter and bread), the glycemic index ofthe meal will be very different from that of eitherfood alone. Finally, the amount of food eaten tomeasure the glycemic index is often different fromthe amount of food eaten in a typical serving. Cre-ating a diet based solely on glycemic index canresult in an eating plan that may exclude somenutrient-rich foods, in addition to being less palat-able overall.”

IFIC Foundation. “Questions and Answers aboutGlycemic Index.” Available online. URL: http://ific.org/publications/qa/glycemicqa.cfm. Posted September2002.

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-itemassessment device for use with bulimic clients tomeasure a person’s fear of becoming fat. Answersare rated on a four-point scale, ranging from “verytrue” to “very untrue.” Higher scores indicate agreater fear of fat. GFFS significantly differentiatesbetween bulimics, repeat dieters and nondietingwomen, according to the authors. Thus, they con-clude, “The GFFS may be utilized clinically as a diag-nostic tool and indicator of change, which may assistin the early identification of bulimic individuals.”

Goldfarb, L. A., E. M. Dykens, and M. Gerrard. “TheGoldfarb Fear of Fat Scale.” Journal of PersonalityAssessment 49, no. 3 (June 1985): 329–332.

gonads obesity Obesity caused by hypogonadism(abnormally low functioning of the gonads, withconsequences for growth and development); it ismarked by a concentration of fat tissue in thepelvic and breast regions. Other features mayinclude poor beard growth in men, decreasedgrowth of pubic hair and lack of development ofthe genitalia. Many obese females with this dis-ease have mild hirsutism, irregular menses orAMENORRHEA. Young obese girls sometimes have

premature or early menarche (first menstrualperiod in puberty).

government role in combating obesity As obesity-related health costs soar, government policymakers have explored ways in which both federaland state legislation or programs might help providesolutions. In September 2004 Ed Thompson, M.D.,chief of public health practice for the Centers for Dis-ease Control and Prevention, Department of Healthand Human Services (HHS), addressed a congression-al subcommittee on the role of government in com-bating the obesity epidemic. Among his comments:

Overweight and obesity represent a major long-term public health crisis: If it is not reversed, thegains in life expectancy and quality of life seen inrecent decades will erode, and more health-relatedcosts will burden the Nation.

Eating a healthy diet and increasing physicalactivity reduces weight which is shown to reducethe risk for many chronic diseases. Often smallchanges—such as physical activity for 30 minutesa day or consuming 100 fewer calories a day—canresult in large health benefits. Individuals musthave the right information to empower theirlifestyle choices.

The government can support individual actionby doing the following:

• Providing leadership;

• Establishing a framework for understanding issuesrelated to overweight and obesity;

• Coalescing and coordinating efforts to address the issues;

• Developing clear, coherent and effective health mes-sages to ensure that consumers have accurate andadequate information to make informed decisionsabout improving their health;

• Identifying and addressing research gaps;

• Synthesizing research findings to identify effectivepolicies and programs;

• Bringing diverse stakeholders together to address theepidemic (e.g., food industry, consumer organizationsand the medical community);

• Coordinating private/public campaigns;

• Providing training and education materials to addressthe epidemic; and,

161government role in combating obesity 161

• Working to improve the health-promoting nature ofthe environments in which individuals make theirdecisions. Current initiatives include programs ineducation, communication and outreach, interven-tion, diet and nutrition, physical activity and fitness,disease surveillance, research, clinical preventiveservices and therapeutics, and policy and web-basedtools. These programs target a variety of populationsincluding infants and breastfeeding mothers, childrenand adolescents, women, minorities, the elderly, thedisabled, rural, and the general population.

• Monitoring the problem and programs to address theproblem so that we can better understand its causes,consequences, and how it changes over time;

• Developing and disseminating tools to help schoolsand community-based organizations implement effec-tive policies and programs; and

• Helping national, state, and local agencies and organi-zations implement effective programs.

Several states have passed or are in the process ofpassing new nutritional requirements for vending-machine food in schools or introducing legislation toban the sale of vending-machine food during schoolhours in an effort to combat childhood obesity. Andthe National Institute of Medicine has called on stateand local governments to establish zoning require-ments that encourage the construction of more side-walks, bike paths and recreational areas.

Hurst, Marianne. “Momentum Builds to Confront ChildObesity.” Education Week 24, no. 7 (October 13, 2004): 5.

group therapy A form of psychotherapy in whichdiscussion takes place among a therapist and anumber of patients rather than between a therapistand a single individual. Studies show that grouptherapy can be as effective as individual therapyand, in some cases, even more effective. In somecases, the two are used in combination. Typically, atherapy group comprises six to eight patients and atherapist leader, who guides the discussion and pro-vides professional insight when needed.

Since 1980, group therapy has become a com-mon form of treatment for both anorexia andbulimia. Group treatment for support groups pro-vide an arena for demystifying the eating disorder,diminishing feelings of isolation and secrecy, fos-tering realistic goal setting, sharing successful tech-

nique, expressing feelings and obtaining feedback.PSYCHOTHERAPY groups are most effective in thetreatment of bulimia. They may be open-ended orhave a time limit, membership may be closed orparticipants may join at any time and the durationand frequency of sessions may vary. The focus is onindividual dynamics and group process.

Belgian researchers studied the progress of 53eating-disordered patients during inpatient grouptreatment by comparing the changes in perception ofeach patient by the patients themselves, the othergroup members and the therapeutic team. Remark-able differences were found among these judgments.Patients tend to deny problems or to evaluate theirprogress rather optimistically, while fellow patientsand staff members are all more skeptical in theirevaluations. The research team concluded that theevaluation procedure may have more value as atherapeutic tool than as an assessment method.

Although group therapy is now frequently usedas a component of eating-disorders treatments,subsequent outcome studies indicate that its effec-tiveness remains problematic.

One school of thought holds that group therapy isa good model for understanding female developmentissues. The theory behind this is that women are gen-erally socialized to function cooperatively in groupsand that therefore the social dynamics of group ther-apy mimic or parallel the processes of female social-ization. Because the majority of eating-disorderpatients are female, it is possible that the success ofgroup therapy for such patients may be related to this.

A setting such as that found in group therapy ora self-help group provides eating-disordered womena social format in which they can express opinionsdiffering from the social consensus yet remain a partof the group (and the larger culture). As groupmembers feel increasingly confident expressingthoughts and concerns that do not support thinnessas an ideal, they are practicing skills of autonomywithin a framework of social relationships and min-imizing their fear of rejection and isolation.

Many issues can thus be explored in group ses-sions, from “what if” questions to actual experi-ences (“What happened to you when you quitpurging?”). Group therapy can also help an indi-vidual to initiate serious treatment. Many patientshave a difficult time beginning individual psy-

162162 group therapy

163

chotherapy but may be less defensive and resistantto recovery in a group setting. A patient may acceptconfrontation from peers in a group more readilyand in a more positive light than from a therapist.

Group therapy does not, however, represent apanacea. Many eating-disorder patients will denythat they have problems or will deny any feelingsabout their condition. This can keep them fromdeveloping the openness toward the group that isessential to allow the group to function fully. Thegroup format helps decrease this resistance to trust,but there is no guarantee of success.

In a review of the literature on the outcome ofgroup therapy for bulimia nervosa, McKisack andWaller found no obvious advantage attached toany single therapeutic orientation or to the genderof therapists. However, they determined thatlonger, more intensively scheduled groups realizedgreater success, as did the addition of other treat-ment components, such as individual work.

Goodner, Sherry. “Group Therapy for Eating Disorders.”BASH Magazine (1987).

McKisack, C., and G. Waller. “Factors Influencing theOutcome of Group Psychotherapy for Bulimia Ner-vosa.” International Journal of Eating Disorders 22, no. 1(July 1997): 1–13.

Piazza, Eugene U., and Catherine Steiner-Adair. “RecentTrends in Group Therapy in Anorexia Nervosa andBulimia.” In Eating Disorders: Effective Care and Treat-ment, edited by Félix E. F. Larocca. St. Louis: IshiyakuEuroAmerica, 1986.

growth hormone in obesity Growth hormone isa substance secreted in the anterior lobe of the pitu-itary gland that directly influences protein, carbo-hydrate and fat METABOLISM and controls the rate ofskeletal and visceral growth. Compared with nor-mal-weight subjects, obese subjects have impairedgrowth hormone secretion. Their plasma growthhormone responses to provocative stimuli, such asinsulin-induced hypoglycemia, L-dopa, arginineinfusion, glucagen, exercise, opioid administrationand sleep, are blunted. The deranged growth hor-mone regulation is related to obesity itself, and inobese subjects who lost weight, growth hormone

secretion becomes normal promptly. Conversely,overfed lean subjects have a weight-related impair-ment in growth hormone secretion.

Production of growth hormone is modulated bymany factors, including stress, exercise, nutrition,sleep and growth hormone itself. One of its pri-mary controllers is GHRELIN.

Cordido, Fernando, Felipe F. Casanueva, and CarlosDieguez. “Cholinergic Receptor Activation by Pyri-dostigmine Restores Growth Hormone (GH) Respon-siveness to GH-Releasing Hormone Administration inObese Subjects.” Journal of Clinical Endocrinology andMetabolism 68, no. 2 (February 1989).

Bowen, R. A. “Growth Hormone.” Colorado State Uni-versity. 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 usesvisualization techniques to relax the patient andstrengthen the patient’s connection with his or herinner consciousness. The theory behind it is thatonce relaxed and comforted, the patient will haveless stress, which will enhance the healing process.In a study of 50 bulimia nervosa patients, guidedimage treatment substantially reduced bingeingand purging episodes. Guided imagery also demon-strated improvement on measures of attitudes con-cerning eating, dieting and body weight.

Esplen, M. J., et al. “A Randomized Controlled Trial ofGuided Imagery in Bulimia Nervosa.” PsychologicalMedicine 28, no. 6 (November 1998): 1,347–1,357.

Gull, Sir William Withey (1816–1890) An emi-nent London physician of the 19th century whowas one of the first to use the term anorexia nervosa.He worked and lived for many years at Guy’s Hos-pital in London and treated Queen Victoria and herfamily. Gull described anorexia nervosa as a diseasedistinct from starvation among the insane andunrelated to organic diseases such as tuberculosis,diabetes or cancer. Most important, he observedthat this disorder specifically affected youngwomen between the ages of 16 and 23.

Gull, Sir William Withey 163

Hawaiian Natives and obesity Being overweightis a problem for Native Hawaiians, who are among themost obese people in the world. The Waianae CoastComprehensive Health Center tracked obesity amongits 24,000 patients and found that more than 55 percentof adults between ages 20 and 59 are obese. NativeHawaiians have the highest prevalence rate of over-weight and obesity (69.4 percent), a rate that is 38percent higher than that for the total state population(50.2 percent). The study also found that the averageNative Hawaiian and Samoan patient is morbidlyobese and in serious risk of major medical problems.

But Native Hawaiians have not always beenobese. Wergowske and Blanchette explain, “Thereports of Captain Cook’s first contact with NativeHawaiians described strong, healthy-looking, mus-cular natives. On subsequent voyages, the popula-tion had declined and the natives looked sicker.Obesity was rare. Today, obesity is a common prob-lem, to the extent that it is considered the norm forboth men and women.”

Experts place much of the blame for today’s obe-sity problem on the move away from native foods.Tavares and Timm explain, “For hundreds of years,Hawaiians maintained a fairly consistent diet thatwas high in weight, low in calories and fat whencompared to a typical American meal. A switch to amore westernized diet has decreased food weight,which leads to less volume and distention of stom-ach, therefore decreasing satiety. Hawaiians there-fore ate a higher volume of food (which containedhigher calories) than their ancestors. Genes influ-ence how the body burns calories for energy orstores of fat. Hawaiian genes, having been exposedto a fairly stable diet over hundreds of years, werenot ‘equipped’ to deal with this dramatic increase incaloric intake, predisposing them to obesity.”

Illustrating how food “weight” as well as caloriesand fat differ between the Hawaiian and Americandiets, the authors break down a typical meal for each:

TYPICAL HAWAIIAN MEAL

Weight Calories Fat(oz.) (gm)

Taro 4 161 0.12Poi 8 151 0.3Sweet potato 8 314 1.2Taro greens (cooked) 7 42 0.5Mountain apple 5 81 0.5Fish 2 75 0.7Seaweed 1 13 0.2Total 35 837 3.5

TYPICAL AMERICAN MEAL

Weight Calories Fat(oz.) (gm)

Cheeseburger 8.5 677 40French fries 4.3 400 22Total 12.8 1077 62

A local doctor has created the “Hawaiian Diet,” en-couraging the state’s natives to return to their ances-tors’ traditional, and more healthful, eating habits.

Tavares, Damien, III, and Robert Timm III. “CommunityCultural Rounds Legacy Project: Hawaiians Dealingwith Obesity.” Ho’olokahi Program: Waianae CoastComprehensive Health Center, April 15, 2003.

Wergowske, Gilbert, and Patricia Lanoie Blanchette.“Health and Health Care of Elders from Native Hawai-ian and Other Pacific Islander Backgrounds.” StanfordUniversity. Available online. URL: http://www.stanford.edu/group/ethnoger/nativehawaiian.html.Downloaded on January 2, 2005.

HCG A hormone (human chorionic gonadotropin)extracted from the urine of pregnant women, onceused in treating obesity. It was typically administereddaily by injection.

165

H

The rationale for this treatment was that weightchange during pregnancy is likely to be long lasting;therefore, by mimicking pregnancy and simultane-ously inducing weight loss, a permanent changemay be accomplished. In the mid-1930s, injectionsof HCG did seem to help reduce accumulations offat on hips, buttocks and thighs that make boyswith Froelich’s syndrome look like girls. The hor-mone was described as seeming to “melt away” thisfat. With the “melting” fat as a major source ofnourishment, the boys were able to survive on only500 calories a day. Thus, although HCG alone didnot reduce weight, it did make drastic calorie cur-tailment possible. Follow-up studies, however,have not demonstrated that HCG patients stay thinany longer than patients in other programs.

Because there had been no scientifically adequatecontrolled clinical studies to establish the safety andeffectiveness of HCG in the treatment of obesity, theU.S. Food and Drug Administration (FDA) in 1974began requiring that HCG carry a warning label:“There is no substantial evidence that it increasesweight loss beyond that resulting from caloric restric-tion, that it causes a more attractive or ‘normal’ dis-tribution of fat, or that it decreases the hunger anddiscomfort associated with calorie-restricted diets.”In 1975 the FDA declared HCG ineffective.

Clinicians who agree with the FDA’s findings cau-tion that in addition to patients’ having to sufferthrough repeated injections of HCG, any benefitsappearing to come from it are actually attributable tothe strict low-calorie, high-protein diet (and diureticpills) usually prescribed along with the shots.

This treatment is no longer in use by the medicalprofession, although Belluscio and Ripamonte sug-gest that oral administration of HCG via a VERY LOW

CALORIE diet may be useful for obesity treatment.

Belluscio, Daniel O., and Leonor E. Ripamonte. “Utilityof an Oral Formulation of HCG for Obesity Treatment:A Double-Blind Study.” Indexmedico. Available online.URL: http://indexmedico.com/obesity/hcg.htm. Down-loaded on January 25, 2005.

HEED Foundation HEED (Helping End Eating Dis-orders) is a not-for-profit organization started in1996. The foundation“s mission is to promote aware-ness and prevention of eating disorders, as well as totreat those who are already affected. Programs andservices offered include free weekly support groups,

a help line, information and treatment referrals,speakers for schools and community groups, educa-tional workshops, lecture series and an annual eatingdisorder symposium. Headquartered in Plainview,New York, HEED Foundation also has offices inManhattan, Brooklyn and upstate New York.

See also APPENDIX III, SOURCES OF INFORMATION.

high fructose corn syrup (HFCS) The primaryindustrial sweetener found in many preparedfoods. It is six times sweeter and cheaper to usethan cane sugar.

See also FRUCTOSE AS A CONTRIBUTOR TO OBESITY.

Hispanics/Latinos and eating disorders The termsHispanic or Latino encompass diverse groups whoimmigrated to the United States, with Hispanic oftenreferring to people from the Caribbean region andSouth America and Latino to those from Mexico andSouth America. However, the terms are often usedinterchangeably and those geographic definitions arenot absolute. Among the largest U.S. Hispanic/Latinopopulations are Mexican Americans, Puerto Ricansand Cuban Americans. The Hispanic population isgrowing faster than any other ethnic group in thiscountry; it has more than doubled in the past 20years. It is estimated that Hispanics will be the largestminority group in the United States by the year2020. Hispanics are predominantly young, withmore than one in three being under the age of 18.

Several studies have found eating disorders inthe United States to be experienced about the sameamong Hispanics and non-Hispanic whites. TheOffice on Women’s Health (OWH) in the Depart-ment of Health and Human Services (HHS) cau-tions that because studies typically do not includeethnically diverse populations, cases of eating dis-orders among Hispanics are often underreported.Although research on eating disorders amongLatina girls is limited, recent studies indicate thatLatina girls are expressing the same concerns aboutbody weight as non-Hispanic white girls and thatmany are engaging in disordered eating behaviors,including dieting and purging, to lose weight.

Studies show that Latinas express the same orgreater concerns about their body shape and weightas white females. In a study of more than 900middle-school girls in northern California, Hispanicgirls reported levels of body dissatisfaction higher

166166 HEED Foundation

than any other group. Among the leanest 25 percentof girls, Hispanic girls reported significantly more dis-satisfaction than white girls. Media targeting Latinas,including Hispanic television and magazines, areincreasingly reinforcing the ideal of thinness asbeauty. For example, although Mexicans have tradi-tionally preferred a larger body size for women,many Mexican American women are idealizing anddesiring a thinner figure than the one they currentlyhave. For all racial and ethnic groups, body dissatis-faction is strongly linked with eating disorders.

Some transcultural anthropology and psychiatrystudies have shown eating disorders to have a veryimportant cultural factor affecting Hispanics, and tobe linked to migration stress. Beitman et al. write:

Silber noted that the Hispanic females had high per-sonal ideals. Being raised in a more traditional Latinculture, they may have had difficulty when expectedto assimilate into the American culture, where thin-ness and academic achievement were highly valued.In addition, they had to contend with contrastingsexual attitudes, which may have exacerbated theirown conflicts. Development of anorexia nervosa, withits regression to a prepubertal psychological struc-ture, served as a maladaptive attempt to cope withissues of identity and cultural and sexual conflict.

The OWH also notes that acculturation can havean impact on body size preference and body image.

Heaviness is seen as a sign of affluence and successin some traditional Hispanic cultures; but as His-panics acculturate to the standards of beauty in thiscountry, they may seek to achieve thinner bodies.Hispanic women born in the U.S. are more likely toprefer a smaller body size. Those who immigrateafter age 17 are less likely to desire a thin body.High levels of acculturation are associated not onlywith a drive for thinness but also with less healthyeating behaviors. As a result, second and third gen-eration Hispanic adolescents are more likely to beobese than their first generation peers.

Some experts have expressed concern that His-panic girls, because of their greater prevalence anddegree of overweight, may be at greater risk thanCaucasian girls for the development of bulimia ner-vosa and binge eating disorder. According to theOWH, Latina girls seem to be particularly at risk fordieting and purging. Latinas have been found to uselaxatives more frequently than girls from other

racial groups. Vander Wal writes, “Future researchshould incorporate instruments more sensitive todisorders of overeating and investigate how eatingdisorder development differs among girls from var-ious racial and ethnic backgrounds.”

Beitman, Bernard D., Barton J. Blinder, Michael E.Thase, and Debra L. Safer. Integrating Psychotherapy andPharmacotherapy: Dissolving the Mind-Brain Barrier. NewYork: W. W. Norton, 2003.

Silber, T. J. “Anorexia Nervosa in Blacks and Hispanics.”International Journal of Eating Disorders 5, no. 1 (July1986): 121–128.

Vander Wal, J. S. “Eating and Body Image Concernsamong Average-weight and Obese African Americanand Hispanic Girls.” Eating Behaviors 5, no. 2 (May2004): 181–187.

Hispanics/Latinos and obesity Hispanics, asreported by numerous studies, generally have higherBODY MASS INDEX (BMI) than non-Hispanic whites.According to the National Institutes of Health, theage-adjusted prevalence of combined overweightand obesity (BMI greater than 25) in racial/ethnicminorities—especially minority women—is gener-ally 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 hasincreased dramatically in the United States in recentyears, the prevalence of overweight among Hispanicchildren has increased disproportionately comparedwith non-Hispanic whites. Recent data from anationally representative sample of U.S. childrenaged four to 12 years reported that within a 12-yearperiod, the prevalence of overweight increased to21.8 percent among Hispanics and 12.3 percentamong non-Hispanic whites. In a 2004 study ofArkansas public school students, 46 percent of His-panic students were considered overweight or at risk,compared to 37 percent of Caucasian youths.

In their attempt to describe the trends in over-weight and obesity occurring in the Mexican-

167Hispanics/Latinos and obesity 167

American population in the United States, Flegalet al. found that in 1999–2002, 73 percent of Mex-ican-American adults were overweight and 33percent were obese. Obesity increased in the peri-ods 1988–94 and 1999–2002, from 24 percent to27 percent for men and from 35 percent to 38 per-cent for women. Increases were also seen for chil-dren and adolescents. “The Mexican-Americanpopulation in the United States, both children andadults, is showing trends in overweight and obe-sity over time that are similar to those seen inother segments of the U.S. population and indeedin many countries.”

The Office on Women’s Health (OWH) in theDepartment of Health and Human Services (HHS)reports that Hispanic children consume the most fastfood of all ethnic groups. Research has shown thathigh-fat diets greatly contribute to the high rates ofobesity among low-income Hispanic families.

Obesity is also a risk factor for binge eating. In astudy of 31 middle schools and high schools inMinnesota, binge eating was more prevalentamong Hispanic girls than among those of othercultural backgrounds.

Flegal, K. M., C. L. Ogden, and M. D. Carroll. “Prevalenceand Trends in Overweight in Mexican-AmericanAdults and Children.” Nutrition Reviews 62, no. 7, pt. 2(July 2004): S144–148.

homosexuality and eating disorders When psy-chiatrist Joel Yager of the University of California,Los Angeles found that nearly 50 percent of themen who enter treatment for anorexia nervosadescribe themselves as homosexual, he questionedwhether there might be a link between homosex-uality and anorexia or bulimia. In a comparisonstudy he conducted of homosexual with primarilyheterosexual males, the gay men were more fear-ful of being fat and were more likely to feel fatdespite others’ perceptions. They also reported ahigher incidence of BINGE EATING and PURGING. Thehomosexual men also scored higher on the EATING

DISORDERS INVENTORY scales for drive for thinness,INTEROCEPTIVE DISTURBANCE, BULIMIA, body dissatis-faction, maturity fears and ineffectiveness.

Yager also found that gay men had a differentbody image preference. While heterosexual menpreferred a more muscular or “macho” physique,the gay men Yager studied preferred being slender.

Yager speculated that homosexual men may bemore likely to develop eating disorders because ofthis concern with slim bodies, a traditionally femi-nine attitude, at least in recent history.

A 1996 study of 203 lesbians by the RutgersUniversity Eating Disorders Clinic to assess bulimianervosa was similar to that of heterosexualwomen, but binge-eating disorder was more fre-quent. Lesbians were not significantly differentfrom heterosexual women in attitudes concerningweight, appearance or dieting.

Then, in 1997, a Massachusetts General Hospi-tal study concluded that while most characteristicsof males and females with eating disorders are sim-ilar, homosexuality/bisexuality appears to be a spe-cific risk factor for males, especially for those whodevelop bulimia nervosa. The authors said thatfuture research on the link between sexual orien-tation and eating disorders would help guide pre-vention and treatment strategies.

In her interview with the authors of MakingWeight: Men’s Conflicts with Food, Weight, Shape andAppearance (Gürze, 2000), Goode wrote:

Some studies have suggested that homosexuals areover represented among men with anorexia andbulimia who do seek treatment, perhaps becausethey are more willing to identify themselves ashaving an eating disorder or because gay male cul-ture puts a premium on trimness and physicalappearance. “There is nothing about gayness itselfthat increases eating disorders,” Dr. (Arnold)Andersen said, “but there is a lot in the fact thatthe community has highly stereotyped norms forwhat is attractive.” Other researchers have foundno relationship between homosexuality and eatingdisorders, and the association remains debated.

Four years later, authors were reporting thesame findings. For example, Ray stated, “The rela-tionship between sexual identity and eating disor-ders remains unclear; however, several studiesposit that male homosexuals are at increased riskfor developing eating disorders.” He mentionedstudies that found a significantly higher prevalenceof homosexuality among anorexic and bulimicmales than that of the general male population.

In one of those studies, Russell and Keel foundthat homosexual men had more pathological scoreson the Beck Depression Inventory (BDI), Rosen-berg Self-Esteem Scale (RSE), Bulimia Test-Revised

168168 homosexuality and eating disorders

(BULIT-R), Eating Attitudes Test (EAT-26) andBody Shape Questionnaire (BSQ). They concludedthat future research may benefit from exploringaspects of homosexuality that may contributespecifically to risk for disordered eating in men.

But Austrian researchers concluded that both gayand straight men have unrealistic expectationswhen it comes to their bodies. Hausmann et al.found that gay men did not differ significantly fromheterosexual men on measures of body image.“These unexpected findings cast doubt on the wide-spread belief that gay men experience greater body-image dissatisfaction than heterosexual men. If ourfindings are valid, it follows that some previousstudies of body image in gay men may possibly havebeen influenced by selection bias.”

Carlat, D. J., et al. “Eating Disorders in Males: A Reporton 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 Dissatisfactionin Gay Versus Heterosexual Men: Is There Really aDifference?” Journal of Clinical Psychiatry 65, no. 11(November 2004): 1,555–1,558.

Hefferman, K. “Eating Disorders and Weight ConcernAmong Lesbians.” International Journal of Eating Disor-ders 19 (March 1996).

Ray, Shannon, L. “Eating Disorders in AdolescentMales.” Professional School Counseling October 1, 2004.

Russell, C. J., and P. K. Keel. “Homosexuality as a SpecificRisk Factor for Eating Disorders in Men.” InternationalJournal of Eating Disorders 31, no. 3 (April 2002): 300–306.

hunger An urge to eat prompted by an immediatephysical need for food. In healthy people, hungerand APPETITE usually coincide. Opportunities to eat,however, may arouse appetite even in the absenceof real hunger, and some experiences can be sounsettling or traumatic that they can cause loss ofappetite even in the presence of hunger.

Some researchers have distinguished two kinds ofhunger: stomach hunger and mouth hunger. Stom-ach, or physiological, hunger derives from the phys-iological need to refuel. Compulsive eaters rarelyexperience it; they eat from mouth hunger. Mouth,or psychological, hunger has nothing to do with sus-taining life. Mouth-hungry people eat “just becauseit’s there,” “because you have to put something into

your mouth,” “because it tastes good,” “because itlooks so delicious,” “because it’s time for breakfast/lunch/dinner,” “because someone went to the trou-ble to prepare it,” “because it would be a shame tothrow it away,” “because I feel lonely/anxious/depressed” or “because I feel happy/excited/like cel-ebrating.” Mouth hunger is what you feel pullingyou toward the refrigerator as soon as you sit downto work or what compels you to leave your house at11:30 P.M. in search of an all-night ice cream stand.Mouth hunger is what continues to send spoon afterspoon of ice cream to your mouth long after you’vebegun to feel ill. Mouth hunger is the hunger weattempt to control with diets.

HILDE BRUCH emphasized that the inability to rec-ognize hunger is a trait that is of fundamental sig-nificance for the development of severe eatingdisturbances. Bruch also noted that obese childrenare routinely fed when they cry for reasons otherthan hunger. Consequently, their “real” hunger isresponded to inappropriately, with under- or over-feeding. Eventually, these children’s ability to differ-entiate accurately between hunger and emotionalstates becomes undermined. Emotional distress isconfused with hunger, and these potentially obesechildren may overeat in response to virtually anyinternal arousal state. As obese adults, they sufferfrom a deficit in hunger awareness. Studies haveshown that obese subjects are relatively insensitiveto stimuli typically associated with hunger and donot 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. OvercomingOvereating. Reading, Mass.: Addison-Wesley, 1988.

hunger hormones A recently identified andstudied class of hormones. Over the past severaldecades, about a dozen hunger hormones producedby the human body have been discovered that affecteating and weight control by regulating appetite andmetabolism. Some of them are attractin, bombesin(BN), GHRELIN, LEPTIN, melanocortin (melanin-con-centrating hormone [MCH]), melanin-stimulatinghormone (MSH), neuropeptide Y (NPY), orexin,PYY3-36 and UNCOUPLING PROTEINS (UCP).

Experts suspect even more hormones affectinghunger and appetite are yet to be discovered. Thechallenge, they say, will be to determine which are

169hunger hormones 169

the most critical in controlling weight gain, thenfiguring out how to control them via medications.

However, others caution that controllinghunger hormones will not be the magic formulafor ending obesity. People who continue to eateven when not hungry, or even worse, when full,would continue to put on weight. Also, controllinghunger hormones could help people from puttingon weight, but would not necessarily help themlose weight unless they reduced overall calorieintake and/or increased caloric expenditure.

hyperactivity Increased or excessive activity. Theterm commonly refers to manifestations of disturbedbehavior, mostly in children, characterized by con-stant movement, distraction, impulsiveness, inabilityto concentrate and aggressiveness. It is also charac-teristic of anorexics; many are usually active, with atendency to exercise even when emaciated. Somerarely stay still; even when confined to bed, theyhave been known to perform isometric exercisesunder the blankets. This preoccupation with physicalfitness is closely related to the consuming desire forthinness. The apparently unusual capacity for physi-cal exertion is not evidence of special physical tough-ness; it is an indicator of a determination to be activedespite the actual state of physical health. Sometimesanorexics will push themselves to the point of col-lapse, causing them finally to seek or be taken formedical treatment. Physical overactivity can alsoserve to distract attention from hunger.

HILDE BRUCH wrote that hyperactivity is rarelycomplained of, or even mentioned, by the parentsof anorexics but that it will be found with greatregularity if looked for. Hyperactivity usuallydevelops before the noneating phase. It may takemany forms. Sometimes an existing interest in ath-letics and sports becomes intensified. Sometimesanorexics may engage in activities that seem to beaimless, walking for miles, doing chinning and bend-ing exercises, refusing to sit down or literally runningaround in circles. Some may roam around at night,too restless to sleep, or they will do housework,cooking and cleaning by the hour. They themselvesdo not feel that they exercise too much, and parentsdo not notice or are not alarmed. Anorexics, andtheir parents, can therefore deny hyperactivity.

The relationship between hyperactivity and dis-ordered eating has been corroborated via animalresearch. One of the common findings in animal

studies of the effect of restricting food intake is anincrease in restlessness and spontaneous motion.When rats are placed on a limited feeding sched-ule, they increase the number of times they spintheir exercise wheels. After a few days of increasedactivity, however, adult rats will alter their cyclesso that most of their activity occurs during thehour or two before feeding, and the total numberof revolutions of the wheels per day will be some-what lower than during times when they are feed-ing at their own pleasure. Prepubertal rats, on theother hand, do not adjust their activity in this wayand will literally run themselves to death if feedingis not increased. This suggests that the heightenedenergy output that frequently accompanies dietingmay be biologically determined.

Recent clinical studies suggest that physicalactivity plays a more central role in the develop-ment and maintenance of eating disorders thanhad previously been thought, according to Davis.

Davis, C. “Eating Disorders and Hyperactivity: A Psy-chobiological Perspective.” Canadian Journal of Psychi-atry 42 (March 1997).

hyperalimentation Also known as total parenteralnutrition (TPN): intravenous feeding. It involves theinfusion of a protein solution made up ofhydrolysate, glucose, electrolytes, minerals and vita-mins at a constant rate through a catheter that hasbeen surgically placed in a major blood vessel such asthe subclavian or jugular vein. Helpful in the treat-ment of anorexia nervosa, it avoids the argumentsabout FORCED FEEDING. While it prevents patients’surreptitiously disposing of food, vomiting and othertricks, inventive anorexics find ways of interferingwith the flow; they even manage to turn themachinery off. But by bringing about a rapid correc-tion of poor nutrition, hyperalimentation makespatients more accessible to psychotherapy. Hyperali-mentation is considered to be a drastic treatmentmeasure and is regarded negatively by many whocite possible infections and overhydration, as well asunwise control over patients who are already strug-gling to escape feelings of powerlessness.

hypercellularity The condition of having toomany cells.

It appears that the number of fat cells in thebody cannot be decreased. However, during peri-

170170 hyperactivity

ods of rapid growth, a proliferation of cells can beslowed or stopped. Thus it is believed that chang-ing nutrition at the proper time may modify therate of cell development. This is especially impor-tant in treating obesity-prone children.

See also FAT CELLS.

hypergymnasia A term used by Adel Eldahmy,medical director of the Long Beach (California) Eat-ing Disorders Clinic, to describe the excessive exer-cising an increasing number of bulimic patientsturn to once they have stopped PURGING. Instead ofvomiting or using laxatives, they go to a gym sevendays a week, two or three hours a day, to burn offcalories. They’ve been scared sufficiently to stoppurging, but they don’t see anything wrong withexercising until they’re dangerously dehydrated.

See also EXERCISE; HYPERACTIVITY.

hyperphagia Abnormally increased appetite forand consumption of food; eating excessively beforefeeling full. Hyperphagia can be a symptom of vari-ous disorders, including anxiety, bulimia nervosa,depression, diabetes mellitus, Graves’ disease, hyper-thyroidism, hypoglycemia, Parkinson’s disease,Prader-Willi syndrome, premenstrual syndrome, sea-sonal affective disorder, schizophrenia and sleep dis-orders. Certain medications and drugs such ascorticosteroids, cyproheptadine, tricyclic antidepres-sants and marijuana can also cause hyperphagia.

hyperplastic obesity A severe, lifelong type of obe-sity that is anatomically generalized (not concen-trated in any area or areas of the body) and resistantto therapy. It is further characterized by an increasednumber 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 arterialwalls); usually defined as a condition in which rest-ing systolic pressure is consistently greater than 160millimeters of mercury and diastolic pressure isover 90 millimeters.

Data from the National Health and NutritionExamination Survey (NHANES) show that the age-adjusted prevalence of high blood pressure increasesprogressively 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 is38.4 percent for men and 32.2 percent for women,respectively, compared with 18.2 percent for menand 16.5 percent for women with BMI less than 25.The direct and independent association betweenblood pressure and BMI or weight has been shownin numerous cross-sectional studies.

In August 2004 the National Heart, Lung, andBlood Institute (NHLBI) announced that a newanalysis of the prevalence of high blood pressure inthe United States showed a striking increase overthe previous 10 years in the number of adults withthis condition.

According to this study, there are about 65 millionhypertensive adults in the United States, or about athird of U.S. adults (age 18 and older). This number,based on survey and examination data from 1999 to2000, contrasts with data from 1988 to 1994, whichfound that about 50 million adults had hypertension.

This new analysis shows that the proportion ofthe population with hypertension grew by about 8percent in the past decade. In terms of absolutenumbers, the study found a 30 percent increase inthe total number of adults with hypertension.

Barbara Alving, M.D., acting director ofNHLBI, commented, “High blood pressure is amajor risk factor for heart disease and the chiefrisk factor for stroke and heart failure, and alsocan lead to kidney damage. The hypertensiontrend is not unexpected given the increase in obe-sity and an aging population. Obesity contributesto the development of hypertension and the cur-rent epidemic of overweight and obesity in theU.S. has set the stage for an increase in high bloodpressure. We also know that high blood pressurebecomes more common as people get older. Atage 55, those who do not have high blood pres-sure have a 90 percent chance of developing it atsome point in their lives.”

Myers writes, “The reasons that obesity causeshypertension are multiple, but it appears that theexcess adipose (fat) tissue secretes substances thatare acted on by the kidneys, resulting in hyperten-sion. Additionally, with obesity there are generallyhigher amounts of insulin produced (because ofthe excess adipose tissue) and this excess insulinalso elevates blood pressure.”

Michael D. Myers, M.D. “Hypertension (High Blood Pres-sure)” Available online. URL: http://www.weight.com/hypertension.asp. Updated May 28, 2004.

171hypertension 171

hyper trophic obesity Adult-onset obesity. It ismore amenable to therapy than childhood obesityor obesity caused by or associated with a patholog-ical condition. Physiologically, it is characterized bythe increased size, but not number, of fat cells.

See also HYPERPLASTIC OBESITY.

hypnotherapy The use of hypnosis in the treat-ment of psychological problems. It has multipleusers, including stress reduction, substitution ofmore problematic with less problematic behaviors,and at times helping patients remember and cometo terms with disturbing memories or emotions thatthey have dissociated. However, using hypnosis tohelp remember traumatic events is quite controver-sial, and numerous psychological/psychiatric ormedical organizations have issued warnings aboutthe use of hypnosis for this purpose.

According to the American Medical Association,scientific studies regarding the effectiveness of hyp-notherapy are lacking. Hypnosis has been usedeffectively as part of a therapeutic strategy foranorexia nervosa. Hypnotherapeutic intervention ismost effective when symptoms such as hyperactiv-ity, distorted body image, feelings of inadequacy andperfectionistic tendencies are present. It may alsohelp patients to overcome resistance to therapy.

Hypnotic suggestion has been used to increasepatients’ awareness of hunger by associating it withthe pleasure of eating. Hypnoanalysis has been usedfor uncovering psychodynamic conflicts behindanorexic symptoms. A combination of behavior ther-apy and hypnosis has been used to associate foodand appetite with pleasant memories and to helppatients ventilate feelings of aggression and hostility.

Hypnosis has also been used in treatment pro-grams for weight loss, but with mixed results.According to recent reviews of weight-loss studies,the addition of hypnosis to other treatment has notaffected outcome to any significant degree.

Allison, D. B., and M. S. Faith. “Hypnosis as an Adjunct toCognitive-Behavioral Psychotherapy for Obesity.” Jour-nal of Consulting and Clinical Psychology 64 (June 1996).

Gross, Meir. “Use of Hypnosis in Eating Disorders.” InEating Disorders, edited by Félix E. F. Larocca. SanFrancisco: Jossey-Bass, 1986.

Johnson, D. L., and R. T. Karkut. “Participation in Multi-component Hypnosis Treatment Programs for

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

hypokalemia A potassium deficiency often resultingfrom chronic vomiting because of the loss of salt, min-erals and other nutrients. It commonly results in car-diac dysrhythmia (lack of rhythm) and, if severe, maylead to sudden death. When accompanying malnu-trition, hypokalemia also adversely affects the renaland gastrointestinal systems. Hypokalemia also resultsin specific injury to the kidney tubules, affecting theirability to concentrate urine. The resulting clinicalmanifestations are frequent urination and increasedthirst. Its effects on the gastrointestinal system includegastric fullness, regurgitation of food, heartburn, constipation and exacerbation of external hemorrhoids.

hypothalamic disease A disease, trauma or tumorthat affects the APPETITE center located in the hypo-thalamus (a part of the brain controlling functions ofthe autonomic nervous system), resulting in obesity.Individuals suffering from this condition usually havean insatiable appetite, eating compulsively day andnight. Their obesity advances relentlessly, and even-tually they become massive in size. In some instancesthere is a decrease in normal brain function.

Patients diagnosed as having hypothalamic dis-ease often have a history of brain damage caused bytrauma or inflammation. Such cases show a gener-alized type of obesity with no areas of the bodybeing spared. Excess ADIPOSE TISSUE tends to con-centrate in the face and neck region as well as theupper arms, upper legs and pelvis. In men theremay be a retraction of the testes, and in youngwomen development of secondary sexual charac-teristics may be delayed. Diagnosis is based on thesephysical findings, as well as on brain scans and thy-roid function tests. The prescribed treatment for thisdisease is weight reduction as well as treatment ofintracerebral lesions. Early death may result fromextreme obesity and complications of stasis pneu-monia 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 BodyWeight to the Lateral Hypothalamic Feeding Syn-drome.” Journal of Comparative Physiological Psychology70 (1970).

172172 hyper trophic obesity

Iice The slang term for an appetite-suppressingdrug sold illegally on the streets, which is 98 per-cent pure crystal methamphetamine. Its appear-ance resembles frozen ice water. It is as addictiveand dangerous as crack cocaine. USA Todayreported in 1989, that “ice” was at that time beingused by dieters in Hawaii and California and hadspread as far east as Oklahoma. Experts said mostusers are women, some of whom use it for weightloss. The trend continued, as the Record (BergenCounty, New Jersey) reported in 2004: “Over thelast 15 years, authorities have watched with con-cern as crystal meth worked its way from the WestCoast—grabbing hold of the rich and low-income,urbanites, and even rural dwellers.”

Although it does cause weight loss for a shorttime, addiction and toxic problems soon set in. TheDrug Enforcement Administration, National Insti-tute on Drug Abuse, warns that ice can lead to vio-lent behavior, anxiety, confusion, insomnia,auditory hallucinations, delusions and paranoia. Itcan also cause brain damage similar to Alzheimer’sdisease. High doses can elevate body temperatureto dangerous, sometimes fatal, levels.

Ice can be smoked, snorted or injected; isdomestically produced; is comparable in price tocrack; and gives the user a high—and suppressesappetite—for eight to 24 hours. A crack high lastsan average of 15 minutes.

Kelley, Jack. “ ‘Ice Age’ May Dwarf Crack Crisis.” USAToday, December 26, 1989, p. A3.

Vadarevu, Raghuram. “N.J. Police Alarmed by Rising Useof Crystal Meth—Highly Addictive Drug BeingLikened to Crack.” The Record, May 31, 2004, n.p.

imipramine The first true ANTIDEPRESSANT, inuse since the 1950s under the commercial name

Tofranil. A tricyclic antidepressant, it has beenused by millions of people and has an establishedrecord of long-term safety when used as pre-scribed. Imipramine has some side effects, amongthem dry mouth, light-headedness on standing up(which usually disappears after a week or two)and sleepiness. It has many more side effects thanthe newer selective serotonin reuptake inhibitors(e.g., Prozac). It has been used successfully in thetreatment of bulimia, with patients receiving itreducing their binge frequency about 75 percent.However, long-term maintenance is a problem, asthere is a high probability of relapse after thedrugs are discontinued.

immigrants and obesity Immigrants are thefastest-growing segment of the U.S. population,and although people arrive in the United Stateswith low rates of obesity, their acculturation to newfoods, new eating patterns and larger portions iscausing their weight to become Americanized alongwith language and lifestyles. In a study of 32,374respondents, prevalence of obesity was 8 percentamong immigrants living in the United States forless than one year, but 19 percent among those liv-ing in the United States for at least 15 years.

A Time magazine article on obesity pointed toseveral reasons for the increase in immigrants’weight gain.

Among immigrants, particularly those coming tothe U.S., the obesity problem has become a full-blown crisis. Even the stubbornest new arrivals mayfind that their food practices are impossible to main-tain in a new environment, where familiar ingredi-ents aren’t available, old-world holidays aren’tobserved and the Mediterranean tradition of theheavy lunch must yield to the less healthy practiceof postponing the big meal until the end of the day.

173

Goel, Mita Sanghavi et al. “Obesity among U.S. Immi-grant Subgroups by Duration of Residence.” The Jour-nal of the American Medical Association 292, no. 23(December 15, 2004): 2,860–2,867.

Kluger, Jeffrey, Christine Gorman, and Alice Park. “WhyWe Eat.” Time 163, no. 23 (June 7, 2004): 72–76.

immune function and dieting Scientists have dis-covered that fat tissue is more than just fat. Steindescribes it as “a complex amalgamation thatincludes key immune system cells calledmacrophages. Macrophages and fat cells producepowerful substances called tumor necrosis factor-alpha and interleukin-6, which help regulate theimmune system. Fat probably evolved a close con-nection to immune function because the body needsenergy when it is fending off threats, scientists say.”

Studies have shown that a woman’s immunefunction decreases in relation to the number oftimes she attempts to lose weight; and when awoman stays at the same weight for many years,she has higher natural-killer-cell activity, a meas-urement of the immune system.

Shade, E. D., et al. “Frequent Intentional Weight Loss IsAssociated with Lower Natural Killer Cell Cytotoxic-ity in Postmenopausal Women: Possible Long-TermImmune Effects.” Journal of the American Dietetic Associ-ation 104, no. 6 (June 2004): 903–912.

Stein, Rob. “Decoding the Surprisingly Active Life of FatCells.” Washington Post, July 12, 2004, p. A01.

implantable gastric stimulator (IGS) A pacemaker-like device about the size of a pocket watch thathas been found to be effective in inducing andmaintaining weight loss. The IGS has electrodesthat connect to the wall of the stomach, deliveringmild electrical impulses to the stomach that trick itinto feeling full. The device has been approved andused in Europe, but is still undergoing clinical tri-als in the United States, with approval projected foras early as 2006.

A Tufts–New England Medical Center surgeondoing some of the testing told the Boston Globe thatit is not clear exactly how the device works. “Itmay be stimulating nerves that go to the appetitecenters of the brain or affecting the production ofcertain hormones responsible for appetite.” Hecautioned that although some patients “respond

very well, others do not,” simply because they con-tinue to eat even when they feel full.

In small initial trials, the average weight losswas 18 percent. If the effectiveness and safetyprove out in larger studies, it will be considered asan alternative to the riskier BARIATRIC SURGERY.

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

infant eating disorders Several categories offeeding and eating disorders of infancy aredescribed in the American Psychiatric Association’sDiagnostic and Statistical Manual of Mental Disorders(DSM-IV). Characterized by persistent feeding andeating 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 aspoverty, parent psychopathology, child abuse orneglect and parental misinformation. A Children’sNational Medical Center study in 2004 demon-strated that psychosocial factors, such as mother-toddler interactions, maternal education level andsocioeconomic status level, are related to the cogni-tive development of toddlers with feeding problemsand explain more unique variance in Mental Devel-opment Index (MDI) scores than nutritional status.

See also FAILURE TO THRIVE.

Chatoor, Irene, et al. “Failure to Thrive and CognitiveDevelopment in Toddlers with Infantile Anorexia.”Pediatrics 113, no. 5 (May 2004): e440–447.

infant obesity The incidence of obesity in infantshas not been determined, but it appears to beincreasing. Studies suggest that two trends in infantfeeding may account for some of this increase—thetrend toward bottle feeding rather than breast feed-ing, and the trend toward earlier introduction ofsolids. Whether bottle feeding contributes to thedevelopment of obesity is controversial.

Although several recent studies have indicatedan association between breast-feeding and as greatas 20 percent reduced risk of obesity later in life,others have found no evidence to suggest thatbreast-feeding protects babies against becomingoverweight. Some researchers have suggested that

174174 immune function and dieting

breast-feeding may show less risk for infant obesitysimply because women who are overweight orobese before pregnancy breast-feed for shorterdurations than do normal-weight women—and areeven less likely to breast-feed at all. Also, breast-fedbabies are less likely to overfeed than bottle-fedbabies. Dewey concluded that any associationbetween breast-feeding and later obesity is probablysmall compared to other factors that influence childobesity, such as parental overweight.

Although infants are able to take solids at veryearly ages without apparent harm, they receive nodesirable nutrients that cannot be provided by milkformula. Instead, such feedings usually result inthe ingestion of more calories and protein than arerequired for optimum growth.

The Feeding Infants and Toddlers Study, commis-sioned by baby-food maker Gerber Products Co. andpresented in 2003, suggested that the rise in infantobesity may be attributable to the same cause asmuch of today’s adult obesity epidemic—ingestingtoo many “junk food” calories. Infants ages sevenmonths to 11 months were taking in a 20 percentdaily caloric surplus over normal requirements, andchildren ages one to two years, an excess of nearly30 percent. Among the study’s other findings: Sodais being served to infants as young as seven months.French fries are the most commonly consumed veg-etable for toddlers age 15–24 months. By 19–24months, most toddlers consumed sweets, desserts orsalty snacks at least once a day.

It is generally recommended that obese infantsnot be made to lose weight but that their weight becontrolled. An obese infant’s rate of weight gainshould be slowed to parallel his or her lineargrowth. Recommended is a limitation of 50 to 55calories per pound of body weight per day duringthe first six months of life, and 41 to 46 calories perpound of body weight per day from six to 12months of age. Substituting skim milk for formulais not recommended, but water may be offeredperiodically in its place. Researchers believe thatthirst is often mistaken for hunger.

An opposite concern of many dietitians is thatfat-phobic parents who, caught up in the low-fatcraze, will cut too much fat from their infants’ andtoddlers’ diets. They have reported many cases inwhich babies have been hospitalized for FAILURE TO

THRIVE because parents have eliminated too muchfat from their diet.

A number of studies have claimed that rapidityof weight gain in infancy is a better guide to the riskof being overweight at the age of six or eight thanis the weight of the parents. For example, in onestudy, adults whose obesity appeared to have begunin infancy had a higher number of fat cells than agroup of equally fat adults whose obesity was ofmore recent origin. In addition, psychological prob-lems encountered in attempting to lose weight havebeen more pronounced in patients with early-onsetobesity. An infant who becomes obese usuallyremains obese as an adolescent and as an adult.

Researchers at the University of Edinburghinvestigated the learning experiences involved inHUNGER and SATIETY in early infancy, and their rela-tion to eventual obesity and other eating disorders.Findings appeared to contradict an earlier theorythat there might exist a critical period in earlydevelopment when the number of FAT CELLS

becomes fixed and predisposes a fat infant tobecome a fat child and ultimately a fat adult.

In 1999 a study by the National Institute ofChild Health and Human Development said thatbabies who are undernourished in the womboften are fed too much when they are young tocompensate, giving them excess fat to go withdiminished muscle mass. Other babies born smallreact by storing more fat than the body needs. Theresult is small babies often grow into obese adults.The solution, lead author Mary L. Hedinger said, isfor parents to talk to their pediatrician about anexercise program for infants to increase blood flowand muscle.

Baker, J. L., et al. “Maternal Prepregnant Body MassIndex, Duration of Breastfeeding, and Timing of Com-plementary Food Introduction Are Associated withInfant Weight Gain.” American Journal of Clinical Nutri-tion 80, no. 6 (December 2004): 1,579–1,588.

Dewey, K. G. “Is Breastfeeding Protective against ChildObesity?” Journal of Human Lactation 19, no. 1 (Febru-ary 2003): 9–18.

Eriksson, J. et al. “Obesity from Cradle to Grave.” Inter-national Journal of Obesity and Related Metabolic Disorders27, no. 6 (June 2003): 722–727.

Grummer-Strawn, L. M., and Z. Mei. “Does Breastfeed-ing Protect against Pediatric Overweight? Analysis ofLongitudinal Data from the Centers for Disease Con-

175infant obesity 175

trol and Prevention Pediatric Nutrition SurveillanceSystem.” Pediatrics 113, no. 2 (February 2004):e81–86.

infertility and obesity Overweight and obesewomen have a high incidence of irregular men-strual periods and lower ovulation rates, making itmore difficult for them to get pregnant. Physicianshave reported as high as 10 to 15 percent of theirpatients having weight-related infertility, withweight a contributing factor in others trying toconceive. Also, women given fertility treatmentsoften need higher doses of drugs and for a longertime in order to spur ovulation. A large proportionof infertile women have POLYCYSTIC OVARY SYN-DROME (PCOS), which is also linked with increasedrisk of obesity and other metabolic irregularities.

Although infertility in obese women has longbeen documented, a new study presented at ameeting of the American Society for ReproductiveMedicine in October 2004 showed that obesewomen also are less likely to become pregnanteven when embryos are fertilized in lab dishes andplaced in their wombs. Associated Press medicalwriter Marilynn Marchione quoted Dr. DavidRyley of Beth Israel Deaconess Medical Center inBoston as saying, “Among the severely obese, wesaw significantly reduced implantation and preg-nancy rates.” The study involved 5,847 attempts atin vitro fertilization.

Although doctors have seen women get preg-nant after BARIATRIC SURGERY, they caution that notenough data is in yet to say whether it improvespregnancy rates.

See also PREGNANCY AND OBESITY; STERILITY AND

OBESITY.

Linne, Y. “Effects of Obesity on Women’s Reproductionand Complications During Pregnancy.” Obesity Review5, no. 3 (August 2004): 137–143.

Norman, R. J., et al. “Improving Reproductive Perfor-mance in Overweight/Obese Women with EffectiveWeight Management.” Human Reproduction Update,10, no. 3 (May–June 2004): 257–280.

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

sleep patterns and insomnia and use BINGE-EATING

as a kind of sleeping pill. Sleep disturbance is a reg-ular complication of starvation. Insomnia, espe-cially premature early morning awakening, affectsmany anorexics and depressed people.

insurance coverage for eating disorders Treat-ment for eating disorders is frequently either notcovered or only partially covered by hospitalizationpolicies. Many health insurance companies do notprovide the same coverage for treating mental ill-ness as they do for physical illness, making itharder for some eating-disorder patients to com-plete 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 insuranceproblems. Their statement:

Many health insurance policies do not cover ade-quate or appropriate care for people with eating dis-orders. Those who struggle with eating disordersmay be forced to pay out-of-pocket for their life-saving treatment. Appropriate therapy may be hun-dreds of miles away, or in another state. Because ofthe lack of a coordinated federal response to eatingdisorders, Americans are left to fight with their owninsurance companies, or to spend tens of thousandsof dollars chasing a limited number of treatmentprograms. In Simon v. Blue Cross and Blue Shield ofGreater New York, a New York State appeals court in1988 held that hospitalization of a person foranorexia nervosa is medical, not psychiatric, careand therefore is not subject to insurance policy lim-itations on psychiatric coverage. The physician whoexamined the patient at the time of her first hospi-talization asserted that because of rapid weight lossthe patient was “emaciated, malnourished, dehy-drated, and hypotensive. She required immediatemedical treatment for these conditions.”

This case is covered in Hospital and CommunityPsychiatry (June 1989), page 662, reprinted inBASH Magazine (August 1989, page 223).

insurance coverage for obesity The obesity “epi-demic” coupled with the national and state gov-ernment initiatives on fighting obesity are causinghealth insurance companies to rethink their cover-age of overweight- and obesity-related treatments.

176176 infertility and obesity

Also instrumental has been the need for employersto deal with billions of dollars in costs due to obeseemployees. Today, insurance providers and healthmaintenance organizations are increasingly subsi-dizing weight control programs such as WeightWatchers and providing other incentives for peopleto lose weight, such as nutrition programs andhealth club memberships. However, employeeswho are significantly overweight can have benefitcosts as much as 20 percent higher than those ofnormal weight employees.

Citing safety and efficacy concerns along withmounting costs from the recent sharp increase inBARIATRIC SURGERY, a growing number of insurancecompanies have discontinued paying for the oper-ations, which cost close to $3 billion a year. Somestates, such as Virginia, Georgia, Indiana andMaryland, require that all insurance plans in theirstates cover surgeries that treat morbid obesity.

In response to the many complaints from con-sumers about the complexity of health insurancecoverage for obesity treatment, New York Statepublished an online consumer guide in November2004 called “Focus On: Overcoming Obesity.” It isavailable at http://www.oag.state.ny.us.

A priority for the AMERICAN OBESITY ASSOCIATION

is expanding access for individuals with obesity toreceive health insurance and weight loss andweight maintenance services provided by healthinsurance programs. “Many individuals with obe-sity cannot obtain health insurance due to theirweight. When they do gain access, most insuranceprograms do not reimburse them for weight loss orweight maintenance services including surgery andpharmacy benefits even though they cover the co-morbid conditions. We expect to use obesity as aleading health indicator to draw attention to theneed to rectify this inequitable situation.”

Stein, Rob. “As Obesity Surgeries Soar, So Do Safety, CostConcerns.” 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 andobese 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) pro-duction.

Because of its diverse effects, IL-6 has potentialas a therapeutic drug in treating such metabolic dis-orders as obesity, type 2 diabetes and atherosclero-sis. Although it is naturally released by musclesduring exercise, research has found that it can beinjected into a human body to reduce body fat by asmuch as 20 percent. Scientists say it will take sev-eral years of research before its potential as a med-ical treatment to reduce obesity is fully explored.

International Journal of Eating Disorders Ajournal founded in 1981 to foster and publishresearch on anorexia nervosa, bulimia, obesity andother atypical patterns of eating behavior and bodyweight regulation. The editor is Michael Strober,and it is published by John Wiley & Sons Inc.

International Journal of Obesity A journaldevoted to publishing research related to obesityand the official journal of the International Associ-ation for the Study of Obesity. The editors are Dr.Richard L. Atkinson and Ian Macdonald, and it ispublished by Nature Publishing Group, the scien-tific publishing arm of Macmillan Publishers Ltd.

International Size Acceptance Association (ISAA)An activist group whose mission is to promote sizeacceptance and fight size discrimination throughoutthe world. ISAA’s primary purpose is to end size dis-crimination and bigotry against fat children andadults. ISAA defines size discrimination as any actionthat places people at a disadvantage simply becauseof their size, and size acceptance as acceptance of selfand others without regard to weight or body size.

See also APPENDIX III, SOURCES OF INFORMATION.

interoceptive disturbance An inability to iden-tify accurately internal sensations such as HUNGER,SATIETY, fatigue, cold and sexual feelings. HILDE

BRUCH suggested that both anorexia nervosa andjuvenile obesity are fundamentally related to thisdisturbed awareness. Anorexic patients oftendescribe extreme confusion about their bodily sen-sations; sometimes they appear devoid of thoughts

177interoceptive disturbance 177

178

and feelings reflecting personal experiences. Rarelycan they focus on and accurately describe theiremotional and physical states.

interpersonal psychotherapy (IPT) A form ofpsychotherapy that has been found to be an effec-tive treatment for bulimia nervosa. The focus ofthe therapy is on resolving relationship issues andproblems rather than on eating problems per se.That IPT has been found to be an effective treat-ment for bulimia nervosa is an interesting andimportant finding because it demonstrates that atreatment that does not directly target eatingbehavior can be effective in altering such behavior.

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

Interview for the Diagnosis of Eating Disorders-IV The IDED is a structured interview designedfor the purpose of determining diagnoses inresearch and clinical settings specializing in theeating disorders. Research has shown the instru-ment to have good psychometric properties.

Kutlesic, V., D. A. Williamson, D. H. Gleaves, J. Barbin,and K. P. Eberenz. “The Interview for the Diagnosis ofEating Disorders-IV: Application to DSM-IV Diagnos-tic Criteria,” Psychological Assessment 10, no. 1 (March1998): 41–48.

ipecac syrup A drug derived from the dried rootof the ipecacuanha, a plant grown in Brazil, thatinduces vomiting. Ipecac syrup is sold over thecounter and for many years was used by hospitalsin emergencies to treat people who had ingestedpoisons. Families were long advised to keep a one-ounce bottle in their first-aid kits to use shouldtheir young children swallow household poison-ous substances.

Eating-disordered patients, especially those withbulimia, have long used ipecac syrup to purge their

bodies of food. When abused in this manner,ipecac syrup can have many side effects, both shortterm and long term, including dizziness, nausea,stomach cramps, respiratory difficulties, fast orirregular heartbeat, seizures and pneumonia. If theipecac is not vomited or an individual overdoses, itcan cause serious heart problems and even death.The late recording artist KAREN CARPENTER, ananorectic who used syrup of ipecac to induce vom-iting, died after build-up of the drug irreversiblydamaged her heart.

A Yale University study evaluated 851 consecu-tive outpatients at a suburban eating disorder clinicfor current or past ipecac abuse. Of these, 7.6 per-cent reported some use or experimentation withipecac for purging; 4.7 percent had experimentedwith it briefly; 3.1 percent (8.8 percent of subjectsmeeting criteria for bulimia) had chronicallyabused ipecac; and 1.1 percent (1.5 percent of sub-jects meeting criteria for bulimia) were regularlyabusing ipecac at the time of intake. Chronic ipecacabusers were more likely to have been hospital-ized. Subjects who experimented briefly withipecac had a longer duration of illness. Bothchronic ipecac abusers and experimenters weremore prone to abuse other substances for purgingand to report alcohol abuse in an immediate fam-ily member. In a later study, reported in 2001,adults were more likely than adolescents to have ahistory of ipecac abuse.

In 2003 the American Academy of Pediatricsrecommended that families no longer routinelyuse syrup of ipecac to treat accidental poisoning.Their research had found no benefits for childrentreated with ipecac; plus, that ipecac was beingimproperly administered by parents and was beingabused by people with eating disorders.

Also, most emergency rooms have stopped usingipecac following toxic ingestions in favor of acti-vated charcoal and whole bowel irrigation, whichhave proved more effective and better tolerated.

Greenfeld, D., et al. “Ipecac Abuse in a Sample of Eating-Disordered Outpatients.” International Journal of EatingDisorders 13, no. 4 (May 1993): 411–414.

178 interpersonal psychotherapy

Janet, Pierre (1859–1947) A French psychia-trist and researcher specializing in the study of hys-teria. He was the first to describe in modernmedical terms the symptoms of BULIMIA. In hisbook Les Obsessions et la psychasthénie (1903), hewrote about a young woman who developed com-pulsive eating binges, many of them in secret.

jaw wiring Wiring the jaws together to preventthe eating of solid foods and allowing only liquidnutrition directly restricts calorie intake. Weightreduction usually occurs during this time; as muchas 70 and 80 pounds have been lost when jawshave been left wired for long periods of time. How-ever, much of this is regained once they areunwired. Some patients find the conspicuousnessand the claustrophobic qualities of jaw wiring to berather unpleasant.

This procedure has been used primarily to helpcompulsive eaters. Once a week the braces areloosened so the teeth can be brushed.

jejunocolonic bypass An intestinal bypass pro-cedure developed in the 1960s that was intendedto aid weight loss; it is no longer performed, how-ever, because of detrimental side effects (severediarrhea, uncontrolled weight loss, malnutrition,liver dysfunction) during the postoperativemonths. Patients did lose much weight, but as sideeffects worsened, surgeons had to reconnect theirintestines. Subsequently, all lost weight wasregained. Regained weight proved that the bypasswas the cause of weight reduction, however, andthis experience provided the impetus for continuedinvestigation into surgical weight control.

See also BYPASS SURGERY.

jejunoileal bypass An early MALABSORPTIVE

OPERATION for weight loss in patients with severeobesity until it was replaced by procedures such asthe ROUX-EN-Y GASTRIC BYPASS, which use a lesserdegree of malabsorption combined with gastricrestriction to induce and maintain weight loss.Although jejunoileal bypass was effective in pro-ducing weight loss (an average of 100 pounds fiveyears after surgery), its side effects and complica-tions were substantial. They included intractablediarrhea, nutrient deficiencies, kidney stones andliver failure. The jejunoileal bypass no longer is arecommended bariatric surgical procedure.

Boon, A. P., H. Thompson, and R. M. Baddeley. “Use ofHistological Examination to Assess Ultrastructure ofLiver in Patients with Long Standing JejunoilealBypass for Morbid Obesity.” Journal of Clinical Pathol-ogy 41 (December 1988).

Powers, Pauline S., and Alexander Rosemurgy. “CurrentTreatment of Obesity.” In Eating Disorders: Effective Careand Treatment, edited by Félix E. F. Larocca. St. Louis:Ishiyaku EuroAmerica, 1986.

Yetiv, Jack Z., Popular Nutritional Practices: A ScientificAppraisal. Toledo, Ohio: Popular Medicine Press,1986.

Jenny Craig Program A diet program combiningfrozen and prepackaged shelf foods with one-on-one counseling, independent homework andgroup classes on behavior modification. In thebeginning, participants buy most of their foodsfrom the Jenny Craig company. As the diet pro-gresses, more and more regular foods are incorpo-rated into the diet, with the Jenny Craig food uselessening. The idea behind the plan is to teach por-tion control and how to make healthy foodchoices, as well as to encourage exercise.

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kaolin Also known as white dirt, chalk or whiteclay. The ingestion of kaolin is a relatively commontype of PICA found in the central Georgia Piedmontarea. Although GEOPHAGIA (earth eating) has beenobserved and documented in many areas of theworld, the specific preference for consuming kaolinis less well known. After reviewing the literature,researchers determined that kaolin ingestionappears to be a culturally transmitted form of pica,not selectively associated with other psychopathol-ogy, and appears to meet the DSM-IV criteria for a“culture-bound” syndrome.

ketogenic diet A diet that produces elevated lev-els of acetone or ketone bodies, accompanied bymild acidosis or ketoacidosis. In this kind of dietthe ratio of calories derived from fat to those fromcarbohydrates is three or four to one.

The combustion of fatty acids in the bloodstreamproduces ketones, which eventually are brokendown into carbon dioxide and water by the liverand other tissues of the body. Under abnormal con-ditions such as diabetes mellitus, starvation or a dietcomposed almost entirely of fat, the breakdown offatty acids may be halted at the ketone stage, caus-ing increasing levels of ketone bodies in the bloodand body tissues. Ketones are powerful appetitesuppressants 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 Englishsurgeon, first experimented with high-protein,low-carbohydrate, ketone-producing diets in themid-1800s. The diet he developed is generallyknown as the Banting Diet (see BANTING,WILLIAM), after an early patient of Harvey who wasso delighted by the effects of the doctor’s weightloss program that he published a pamphlet in

praise of it. Since that time versions of the BantingDiet, with minor modifications, have appeared atregular intervals: as the Pennington or Dupont Dietin 1953, the Air Force Diet in 1960, the DrinkingMan’s Diet in 1965, the Stillman and Atkins Dietsin the 1970s, and later the Zone, Protein Powerand South Beach.

Elevated levels of ketones are potentially dan-gerous (see KETOSIS).

See also LOW-CARB DIETS.

ketosis A condition in which excessive amountsof ketones accumulate in the body. Ketones arechemicals the body makes when there is notenough glucose in the blood and it must breakdown fat for its energy. When this occurs, fattyacids are released into the blood; these fatty acidsare then converted to ketones. Ketones can poisonand even kill body cells. Ketones that build up inthe body for a long time can lead to serious illnessand coma. Symptoms include a “fruity” odor to thebreath, loss of appetite, nausea, vomiting andabdominal pain. Ketosis can be diagnosed by a testto detect ketones in the urine. FASTING can causeketosis. Treatment in this case is a gradual reintro-duction of a nutritious diet.

Ketosis also occurs in uncontrolled diabetesmellitus, because carbohydrates are not properlyutilized. In these cases, it is treated with either dietchange or insulin.

kidney stones and obesity Researchers at Univer-sity of Texas Southwestern Medical Center at Dal-las, working with doctors at the University ofChicago, studied more than 5,000 patients andfound a direct link between body weight and uricacid kidney stones. Kidney stones form when wastematerials in urine do not dissolve completely. Over

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time, these microscopic particles form into stones.Uric acid kidney stones form when the level of acidin the urine is too high. These kinds of stones arefound in about 5 percent of kidney stone patients.

Eating too much animal protein can raise acidlevels in urine, but the researchers found thatoverweight people had highly acidic urine, no mat-ter what they ate. Uric acid kidney stones are alsoassociated with insulin resistance and type 2 dia-

betes. A study author said that researchers nowneed to find whether or not losing weight orimproving insulin sensitivity will help people keepfrom forming kidney stones.

Maalouf, N. M., et al. “Association of Urinary Ph withBody Weight in Nephrolithiasis.” Kidney International65, no. 4 (April 2004): 1,422–1,425.

182 kidney stones and obesity

Lap Band See ADJUSTABLE GASTRIC BANDING.

laporoscopic adjustable gastric banding SeeADJUSTABLE GASTRIC BANDING.

Lasègue, Charles (1816–1883) A French psy-chiatrist who was one of the first to publish adetailed description of anorexia nervosa. In 1873he described the disorder as a variant of hysteria.While his contemporary, the Englishman SIR

WILLIAM WITHEY GULL, concentrated on the med-ical aspects of anorexia, Lasègue emphasized itspsychological aspects. He confirmed what Gull hadsuggested, that anorexic women came from fami-lies willing and able to spend emotional and finan-cial resources on them. He was the first physicianto suggest that refusal of food constitutes a form ofconflict between a maturing girl and her parents.

laxative abuse Misuse of laxatives is a fairlycommon problem among bulimic women, and lax-atives appear to be the type of drug most com-monly abused by anorexic patients. This misuseusually involves the ingestion of many times theamounts recommended by the manufacturer.

In their study, Kovacs and Palmer noted, “Laxa-tive abuse appears to be associated with especiallysevere psychopathology and low self-esteemamong subjects with anorexia nervosa.”

In a University of Kansas study of women witheating disorders, more than one-half of the womenhad abused laxatives at some point. And in a surveyof 2,400 North Carolina middle school students, near-ly 10 percent of the girls and 4 percent of the boysreported vomiting or using laxatives to lose weight.

Researchers have found that patients who useself-induced VOMITING for weight control tend toeat significantly more during binges yet weigh lessthan those who use laxatives, suggesting that laxa-

tive abuse is relatively ineffective for this purposeand that dietary restraint is responsible for anyweight loss among laxative abusers. One studyfound that the weight loss experienced by patientsfollowing ingestion of laxatives resulted from tem-porary fluid loss; the amount of caloric absorptionprevented by laxative use was minimal.

Laxatives containing stimulant compounds arefavored by those with eating disorders becausethese agents will reliably produce a watery diar-rhea fairly promptly, and a sense of weight loss, ifsufficient amounts are ingested. Most laxativeabuse is practiced independently, but laxatives areoften prescribed by diet doctors in an effort tospeed food through the intestines so nutrients arenot absorbed and turned to fat.

Physicians warn that taking laxatives is moredangerous than it may appear. As the body adjusts,patients often go from three laxatives to 50 to 100laxatives a day. Then if they stop taking them,severe swelling and constipation occurs. The bow-els get addicted and have to be weaned off. Com-plications of laxative abuse include:

• Constipation These drugs produce a reflex hypo-functioning (decreased functioning) of the colon,resulting in constipation. Constipation becomes aparticular problem during laxative withdrawal.

• Cathartic Colon Patients who have taken stimulant-type laxatives for long periods of time can developpermanent dysfunctioning of the colon, accompa-nied by radiographic and microscopic changes inthe bowel.

• Bleeding Chronic recurrent use of stimulant-typelaxatives can result in gastrointestinal bleedingand hidden or obvious blood loss.

• Dehydration Stimulant-type laxatives promotefluid loss through the intestine, which can resultin volume depletion and lead to a secondary

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hyperaldosteronism, a condition caused bysecretion of excessive amounts of the elec-trolyte-regulating hormone aldosterone by theadrenal cortex; this is turn results in reflexperipheral edema (swelling), which is a particu-lar problem during laxative withdrawal. Thisreflex fluid retention can be quite dramatic.

• Electrolyte Abnormalities Laxative-induced diar-rhea markedly elevates the electrolyte content ofthe feces. HYPOKALEMIA and acidosis may result.

• Other medical complications that have beendescribed include the development of steatorrhea(excessive fat in the feces) and protein-losing gas-troenteropathy (disease of the digestive tract), pan-creatic dysfunction, osteomalacia (softening ofbone), pseudofractures, hypocalcemia (reductionof calcium in the blood) and hypomagnesemia(abnormally low level of magnesium in the blood).

In California, laxative sales restrictions havebeen imposed by legislators. It is thought by manythat some restrictions should be placed on the saleof over-the-counter laxatives because thousands ofyoung women are overdosing on laxatives in theirquest for weight loss.

Bankhead, Charles D. “Myths Fueling Widespread Abuseof OTC Laxatives.” Medical World News, January 8, 1990.

Kovacs, D., and R. L. Palmer. “The Associations betweenLaxative Abuse and Other Symptoms among Adultswith Anorexia Nervosa.” International Journal of EatingDisorders 36, no. 2 (September 2004): 224–228.

Krowchuk, D. P., et al. “Problem Dieting Behaviors amongYoung Adolescents.” Archives of Pediatrics and AdolescentMedicine 152, no. 9 (September 1998): 884–888.

Moriarty, K. J., and D. B. Silk. “Laxative Abuse.” DigestiveDiseases 6, no. 1 (1988): 15–29.

Pryor, T., et al. “Laxative Abuse among Women with Eat-ing Disorders: An Indication of Psychopathology?”International Journal of Eating Disorders 20, no. 1 (July1996): 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 helpsthe body regulate its amount of fat. Leptin is pro-duced by fat tissue and signals the brain when oneis full and to stop eating. A mutation in the genesthat code for leptin would prevent signaling andthe person would continue to eat, thus gainingweight. Park explains further:

Leptin helps manage just how much fat you storearound your organs and under your skin througha complex feedback loop. If your fat deposits startto shrink—for example, when you lose weight—the amount of leptin in your body falls, a situationthat the brain interprets as a result of starvation.The whole system of chemicals and neurologicalimpulses shifts in an attempt to get the body toburn fewer calories so that it can regain theweight. The greater the weight loss, the strongerthe signals to eat more and replenish fat stores.

Scientists had hoped leptin could be used as anantiobesity drug, but they later discovered thatmost obese people are not deficient in leptin; theirbodies are simply resistant to its messages. For indi-viduals with a rare from of obesity caused by adeficiency in leptin, it would be extremely difficultto achieve weight loss through lifestyle interven-tions alone, and some drug therapies would beunlikely to work well, if at all. However, replacingtheir missing hormone, leptin, through injectionsis extremely effective not only in helping them loseweight but also in reversing the other negativehealth consequences of this missing hormone.

Researchers in one study found that levels of leptinwere significantly higher in the obese volunteers andthe levels spiked at night, yet they remained steady forthe lean volunteers. Other recent research has founda link between lack of sleep and the risk of weightgain, with sleep being a major regulator of leptin.

Research published in January 2005 found thata single brain region is sufficient for normal controlof blood sugar and activity level by leptin. Thesame region also exerts significant, though moremodest, control over leptin’s effects on bodyweight. The findings in mice provide insight intopotential mechanisms underlying type 2 diabetesand suggest new avenues for treatment, accordingto the researchers. The new results suggest thatleptin signaling acts directly on the brain regionknown as the hypothalamic arcuate nucleus(ARH) to control insulin and glucose levels in thebloodstream. Leptin receptors in the ARHaccounted for approximately 22 percent of thehormone’s effects on body weight, the researchersreported, suggesting that other brain regions arealso important to this hormonal function.

Coppari, Roberto, et al. “The Hypothalamic ArcuateNucleus: A Key Site for Mediating Leptin’s Effects on

184184 leptin

Glucose Homeostasis and Locomotor Activity.” CellMetabolism 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 inthe storage of body fat. Its activity varies in differentparts of the body, being very active in abdominal fatand less active in hip fat. Studies have shown thatobese people may have difficulty achieving a normallevel of lipoprotein lipase. A University of Coloradostudy reported that obese people, in comparisonwith people and normal weight, produce too muchof the enzyme and that even after weight loss theirenzyme activity had not fully returned to normal.

Levels of lipoprotein lipase in ADIPOSE TISSUES

affect the maintenance of fat-cell size, body weightand obesity. Genetic and diet-induced obesity havebeen found to be associated with increases inlipoprotein lipase levels in the adipose tissue ofhumans and rodents after overnight fasting. Pro-gressive increases in body mass index in humansare associated with increases in adipose tissuelipoprotein lipase. Most evidence suggests than anincrease in levels of lipoprotein lipase in adiposetissue preserves rather than causes obesity.

One study found that people who had main-tained a large weight loss for eight or more yearsstill produced too much of the enzyme. But as soonas those obese people who have lost weight startregaining it, their enzyme level drops.

In more recent studies, Perreault et al. found thatafter three to four hours of exercise, muscle and adi-pose tissue LPL activity increased significantly inmen, whereas LPL activity remained unchanged inwomen. And Berman et al. determined that despiteimproving lipoprotein lipid profiles in obese post-menopausal women, weight loss does not affect theregulation of regional fat metabolism.

Berman, D. M., et al. “Regulation of Lipolysis andLipoprotein Lipase after Weight Loss in Obese, Post-menopausal Women.” Obesity Research 12, no. 1 (Jan-uary 2004): 32–39.

Eckel, Robert H. “Lipoprotein Lipase.” New England Jour-nal of Medicine 320, no. 16 (April 20, 1989):1,060–1,068.

Perreault, L., et al. “Gender Differences in LipoproteinLipase Activity after Acute Exercise.” Obesity Research12, no. 2 (February 2004): 241–249.

liposuction A surgical procedure pioneered inEurope in the 1970s to remove localized deposits ofexcess fat; also called liposculpture, lipoplasty orlipectomy. The surgeon inserts a long, thin, hollowblunt-edged tube called a cannula through a quarter-inch incision. This tube is attached via another hol-low tube to a machine with a powerful vacuumapparatus that sucks out subcutaneous (beneath theskin) fat. The collecting tube is transparent, allowingthe surgeon to see the tissue being removed. Lipo-suction has been referred to as “maid service for yourfat: The surgeon vacuums the areas you didn’t havethe time or energy to clean up yourself.” Thoughonce controversial, it has become one of the mostcommon types of cosmetic surgery today.

Giorgio Fischer, a surgeon in Rome, was the firstto devise an instrument to remove fat by suctionand the first to perform liposuction surgery. Theoriginal procedure removed fat almost totally fromthe suctioned area, creating a large cavity thatfilled with body fluids. Because the skin overlyingit did not shrink correspondingly, the procedureleft an unsatisfactory result.

To combat this problem, Yves-Gérard Ilouz, aFrench surgeon, devised a method for dissecting fatwith a blunt tube (cannula) that removed fat in aregular series of tunnels created sequentially byprobing the fat deposit to be treated. In this newprocedure, both the adjacent fat and the small bloodvessels running through the area remained intact,allowing continuous contact between the skin andthe underlying tissue. This helped the skin to shrinkslowly and regularly over the newly contoured area,with less likelihood of developing ripples anddepressions. Keeping original blood vessels in thearea helped fluids that leak into it during the post-operative period to be more easily absorbed into thebody. This shortened the prolonged wound drainagethat characterized earlier suction procedures.

Liposuction was developed to remove from ahealthy, normal-weight person localized geneticallyderived fat deposits that do not respond to diet orexercise. It is not intended to be a treatment for obe-sity. The most frequently treated areas include thehips and thighs and the abdomen. Liposuction canalso be done on the neck, face, arms and legs.

Losing body fat through liposuction does notappear to improve health risks associated withoverweight and obesity as it does when losing itthrough dieting and exercise. A Washington Uni-

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versity (St. Louis) study published in 2004 evalu-ated the effect of large-volume abdominal liposuc-tion on metabolic risk factors for coronary heartdisease in women with abdominal obesity, andfound that risk factors for heart disease—bloodpressure, lipid levels and insulin sensitivity—remained unchanged 12 weeks following surgery.

Results

While fluid shifts restricted fat removal to abouttwo pounds during a single liposuction in the earlydays, recent advances in liposuction techniques,such as tumescent liposuction, allow doctors tosafely take out three to four times that amount andto remove up to 15 inches off a person’s girth.Tumescent liposuction injects the area to be suc-tioned with a special fluid-anesthesia combinationprior to suctioning. The fluid constricts the sur-rounding blood vessels, making the procedurenearly bloodless while minimizing the pain.

Not all fat is removed from a location. The sur-geon leaves some fat cells behind because fat cellsgrow and shrink, depending on nutrition and theage of the patient. Removing all the fat cells wouldresult in a disproportionately flat area.

Not everyone achieves satisfactory results,mainly because there is no control over how theskin will contract over suctioned areas. Somepatients end up with “dents” and more unevenskin and sagging than they had before surgery.Others have dropped two full clothing sizes.

Liposuction surgery differs from fat loss throughdieting and exercise. When fat is lost in those ways,FAT CELLS become smaller, though their numberthroughout the body remains constant. These“starved” fat cells send messages to the brain indi-cating their depleted state, stimulating HUNGER.When they receive extra CALORIES, these cells onceagain store fat for future needs. Liposuction, in con-trast, actually removes fat cells from the treatedarea. These are not replaced unless there is a subse-quent weight gain large enough to fill the remain-ing cells to their capacity. For this reason, patientswho have undergone liposuction surgery mustmonitor their caloric intake to maintain positiveresults. It should be noted that reaccumulated fat isnot necessarily deposited in the same locations thathave been suctioned. This new fat generally tendsto spread itself evenly throughout the body.

Liposuction also removes fat from specific, tar-geted areas, but diet and exercise may reduce non-preferred areas while leaving other areas virtuallyintact. Women with large thighs, for instance, areoften frustrated by the persistence of this phenom-enon even when their diet and exercise regimeslead to virtual emaciation of their faces and upperbodies. And men with “spare tires” around theirmiddles are often unable to eliminate thementirely by dieting despite considerable weight loss.

Limitations

Liposuction surgery is not the ultimate answer todieters’ prayers, though. The procedure does havedistinct limitations.

Good skin tone is important for continued suc-cess, because once fat is removed, the skin mustshrink to fit a new contour. Assuming that prolongedaccumulation and drainage of body fluids does notoccur, skin that is sufficiently elastic will heal with-out dimples, dents or ripples. But skin that has lost itselasticity may not contract as rapidly or satisfactorily.

Liposuction can be performed under local orgeneral anesthesia. At the present time, the sur-gery is commonly performed on an outpatientbasis in an office surgical suite or ambulatory sur-gical facility. However, medical opinions differabout whether the procedure should be done in anoffice or in a hospital. Dr. Pierre F. Fournier, a pastpresident of the International Academy of Cos-metic Surgery, has stated that “anyone who isgoing to have a large amount of fat removedshould be operated on in a hospital and observedovernight. Such patients will probably need intra-venous fluids and may need blood transfusions.”

Liposuction surgery is a body-contouring opera-tion, not a weight loss procedure. Only smallamounts of fat in terms of weight, one-half to twopounds, are actually removed during an operation,and this fat is considerably lighter than the solutionsadministered intravenously during the surgery. It isnot uncommon for a patient actually to observe aweight gain of several pounds in the first few daysfollowing surgery because of this fluid replacement.But the kidneys rapidly eliminate excess fluid, andbody weight soon returns to its preoperative level.Most patients with small to moderate fat bulges loseonly a few pounds but may drop two to three cloth-ing sizes. Many patients, however, report continuing

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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 doc-tors and used the results to project national averagesfor 23,000 medical specialists. Results of that surveyshowed that from 2002 to 2003, there was a 20 per-cent increase in the total number of cosmetic proce-dures. The top surgical cosmetic procedure in 2003was liposuction (384,626, up 3 percent from 2002).

The American Society of Plastic Surgeons(ASPS) showed liposuction to be the second mostfrequently performed cosmetic surgery in 2003,with 320,022 procedures, and the most often cho-sen by women. The 35–50 age group made up 40percent of all cosmetic plastic surgery, with lipo-suction being their most popular procedure.

Complications

Early reports of problems, including loss of limbs anda dozen deaths, led to investigations of liposuctionprocedures by the American Society of Plastic andReconstructive Surgeons. In 1987 the society issueda report stating that “suction-assisted lipectomy isnormally safe and effective” when performed by aproperly trained, experienced surgeon with boardcertification in plastic surgery and a proven trackrecord of success in liposuction. Legally, any surgeoncan perform liposuction. This fact was brought outduring a 1989 hearing held by the U.S. House ofRepresentatives Small Business Committee’s Sub-committee on Regulation and Business Opportuni-ties. Chairman Ron Wydan (D-Oregon) concludedthat a liposuction surgeon “can buy $4,000 worth ofequipment on Monday morning, do two proceduresin 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 morethan 5,000 cases performed through 1983 showedonly six complications, most minor (loss of skin andlimbs was blamed on untreated infection; deathsoccurred when liposuction was performed alongwith other surgery, or by unqualified surgeons).

Liposuction is major surgery and, as such, car-ries all the inherent risks, including potential prob-lems with anesthesia, infection, discomfort,recovery time, side effects, complications and, ofcourse, high cost. Minor complications associated

with liposuction can include bruising, swelling andlocal sensory changes. Some complications can bepermanent, such as bodily lumps, craters, asym-metry and permanent creases and furrows wherethe fat is removed. If the suction occurs too close tothe skin’s surface, it may tug at the skin tissue,causing it to ripple. The worst complications areexcessive bleeding and loss of body fluids. Patientswho have large amounts of fat removed (two litersor more) run the risk of shock if fluids are not ade-quately replenished during the surgery.

Bleeding was the most common complicationfollowing liposuction surgery in its early days.Removal of large amounts of fat can still result inmoderate blood loss, but for the routine liposuc-tion, these problems today are unusual. Most seri-ous complications today are associated withlarge-volume (more than 10 pounds) liposuction.

As with any procedure involving incisions in theskin, liposuction does leave scars. Usually these aresmall, about one-quarter inch, and are camou-flaged by placement within natural skin lines.However, surgeons caution that persons predis-posed to “over-active” scars need to discuss thisproblem with their doctor prior to surgery.

Early complaints of dents, depressions and skinwaviness were blamed on the uneven removal of fatduring liposuction. Today’s specialists claim to havesolved most of the problem by leaving a pad of fat onthe undersurface of the skin and confining fatremoval to deeper areas. Most surgeons now usesmaller cannulas to make smaller, more numeroustunnels 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, whereskin does not contract as well as skin in other areas.

When uneven contours do exist after swelling hasgone down, a second liposuction procedure is usuallyperformed under local anesthesia. Surgeons say it isfar easier to remove small amounts of excess fat thanto fill in depressions caused by excessive fat removal.

The U.S. Food and Drug Administration (FDA)cautions, “Some of the studies indicate that the riskof death due to liposuction is as low as three deathsfor every 100,000 liposuction operations performed.However, other studies indicate that the risk ofdeath is between 20 and 100 deaths per 100,000liposuction procedures. One study suggests that the

187liposuction 187

death rate is higher in liposuction surgeries in whichother surgical procedures are also performed at thesame time. In order to understand the size of therisk, one paper compares the deaths from liposuc-tion to that for deaths from car accidents (16 per100,000). It is important to remember that liposuc-tion is a surgical procedure and that there may beserious complications, including death.”

Cost of liposuction surgery can range between$1,000 and $5,000 depending on the length andcomplexity of the procedure. The average sur-geon’s fee for liposuction was reported in 2004 tobe $2,224. Liposuction is not covered by mostinsurance plans because it is considered elective.

A liposuction technique called ultrasonic liposuc-tion (or ultrasound-assisted lipoplasty, UAL) wasintroduced in the United States in 1994 andapproved by the Food and Drug Administration in1996. UAL uses sound waves to liquefy the fat so itcan be vacuumed out of the body faster than itmight with other methods. There is less trauma tothe body with UAL, plus the ultrasound leaves bloodvessels and nerves intact, so there is significantly lessbleeding and postoperative pain. The FDA does notethat “during ultrasound assisted liposuction, theultrasound probe may become very hot and cancause burns.” UAL is rapidly becoming the preferredmethod of fat removal by plastic surgeons, althoughit is not appropriate in all situations. Often it is usedin conjunction with other techniques. Long-termeffects of ultrasound liposuction are not known, andextensive research and clinical trials are needed toestablish fully the safety and efficacy of UAL.

New techniques are being developed that areimproving results and reducing risks. Among themore recent:

• German plastic surgeon A. Ziah Taufig, M.D., hasintroduced an alternative method to tumescentliposuction that he believes is superior to its pred-ecessor, because it allows controlled and selectiveremoval of fat tissue via water-jet dissection—anapproach that has been shown to be safer thanthe circulation of a local anesthetic. According toKapes, water jet liposuction is becoming knownfor its improved process and results, shorter oper-ating times and increased safety for patients.

• In 2004 the FDA approved the Erchonia 4L laserfor use during liposuction. The painless laser

treatment is administered a few minutes prior toliposuction and works by liquefying the fat. As aresult, fat removal is made easier and quicker.There is less post-op pain and bruising and aspeedier recovery time. In addition, less painmedication is required. At the time of approval,the Erchonia laser was being used by approxi-mately 100 cosmetic and plastic surgeons.

Albin, R., and de Campo, T. “Large-Volume Liposuctionin 181 Patients.” Aesthetic Plastic Surgery 23, no. 1 (Jan-uary/February 1999): 5–15.

Kapes, Beth. “Jetting Water Curtails Liposuction Risks:Improved Process Enhances Results.” Cosmetic SurgeryTimes 7, no. 10 (November–December 2004): 6, 9.

Klein, Samuel, et al. “Absence of an Effect of Liposuctionof Insulin Action and Risk Factor for Coronary HeartDisease.” New England Journal of Medicine 350, no. 25(June 17, 2004): 2,549–2,557.

Lillis, Patrick J., and Coleman, William P., III, ed. “Lipo-suction.” Dermatologic Clinics 8, no. 3 (July 1990).

McCurdy, John A., Jr. Sculpturing Your Body: Diet, Exerciseand Lipo (Fat) Suction. New York: Kensington Publish-ing Corp., 1990.

liquid formulas A number of commercial dietsupplement drinks promoted since the 1970s, theearliest and most highly publicized of which wasRobert Linn’s “Prolinn,” described as “a formulacomposed of all the amino acids needed to form aprotein molecule.” Such liquids have been used byhospitals 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 Dietand Multi-Protein Slim, appeared.

The first liquid protein supplements were with-drawn when the Centers for Disease Control andPrevention attributed 60 deaths to their use. Theprotein in these early supplements was collagenbased; their inadequate amino acid compositionled to dangerous loss of lean muscle mass, includ-ing heart muscle. In addition, these early diets didnot provide adequate potassium, which may haveresulted in serious disturbances of heart rhythm.

Then, during the mid-1980s, a new generationof liquid protein diets was developed. Made fromhigh-quality protein, with adequate vitamins, min-erals and electrolytes to maintain health, some ofthem are even intended for use in programs of

188188 liquid formulas

medical monitoring, nutrition education, behaviormodification, exercise and support groups spon-sored by the manufacturers. Three widely used pro-grams Optifast (Sandoz were Nutrition), Medifast(Jason Pharmaceuticals) and Ultrafast (NationalCenter for Nutrition). In November 1988 thesereformatted liquid protein diet programs received acommercial boost when the popular TV talk-showhost Oprah Winfrey revealed that the loss of nearly70 pounds that she had experienced was the resultof following the Optifast liquid diet program.

Formula diets come in dry form as mixtures ofessential nutrients; water must be added before use.Prepared in two to six servings, most of these dietsprovide milk or egg (not vegetable) protein and varyingproportions of carbohydrate and fat. The addition ofcarbohydrate decreases ketosis, hyperuricemia, elec-trolyte depletion and loss of lean tissue proteins. Fatimproves palatability and provides essential fatty acids.

Users who stay with the program usually lose fourto 10 pounds during the first week of the formuladiet and two to five pounds per week thereafter.Twelve-week programs usually result in a loss of 22to 33 pounds. One study evaluated 4,026 morbidlyobese patients who showed interest in the Optifastdiet program. Ten percent failed to join or did notmeet entry criteria; one-fourth of those remainingleft the program within the fist three weeks; amongthe 2,717 remaining patients, one-third reached thedesired weight during treatment, but fewer than halfof these remained within 10 pounds of that weightwhen examined 18 months later. In other words, 80to 90 percent of patients who wanted to lose weightwere ultimately unsuccessful.

Fabricatore and Wadden note that liquid mealreplacements provide another method of facilitat-ing adherence to a low-calorie diet, pointing to onestudy in which patients who replaced two meals aday with a shake lost 8 percent of initial weightduring three months of treatment, whereas thosewho were prescribed the same 1,200–1,500 caloriesper day but consumed a self-selected diet of con-ventional foods lost only 1.5 percent of initialweight. They add that meal replacements may alsofacilitate the maintenance of weight loss. Patients inthe same study who continued to replace one mealand one snack a day with shakes or snack barsmaintained an 8 percent weight loss at 51 months.

These programs are recommended only for thosepeople who are at least 30 percent or 50 pounds

above desired body weight. Liquid diets may causegingivitis and other dental problems, along with thenormal adverse effects of rapid weight loss. Accord-ing to the Federal Trade Commission (FTC), theseprograms require professional supervision becausethere is evidence that patients on liquid diets riskdeveloping gallstones. Also to be considered are thehigh costs (generally between $1,400 and $2,800),time needed for medical monitoring and group sup-port, and social restrictions when dinnertime comes.Episodes of sudden death (sometimes associatedwith myocardial abnormalities) like those thatoccurred with older liquid protein preparations havenot been reported with current diet formulas.

However, even these newer liquid formulascame under attack. In October 1991 the FTCcharged marketers of Optifast 70, Medifast 70 andUltrafast with making deceptive claims that theirprograms are safe and effective over the long term.As a result, liquid formula diet promoters mustback up their claims of weight loss with more sub-stantial 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 Diabetes21, no. 2 (April 2003): 67–72.

Longitudinal Assessment of Bariatric Surgery(LABS) Originally known as the Bariatric SurgeryClinical Research Consortium and first funded inSeptember 2003, LABS is a National Institutes ofHealth (NIH)–funded consortium of six clinical cen-ters and a data-coordinating center working incooperation with NIH scientific staff to plan, developand conduct coordinated clinical, epidemiologicaland behavioral research in BARIATRIC SURGERY.

LABS has brought together experts in bariatricsurgery, obesity research, internal medicine, endo-crinology, behavioral science, outcomes research, epidemiology and other relevant fields to plan andconduct studies that will analyze the risks and ben-efits of bariatric surgery and its impact on thehealth and well-being of patients with extremeobesity, and identify the kinds of patients who aremost likely to benefit. Full information is providedat the NIH Web site at http://win.niddk.nih.gov/publications/labs.htm.

189Longitudinal Assessment of Bariatric Surgery 189

low-carb diets Fad diets that restrict carbohy-drates. Low-carb diets have enjoyed popularity peri-odically since the 1800s, taking turns with LOW-FAT

DIETS as the current dieting standard. Spurred by arevision of the ATKINS DIET in the mid-1990s, restrict-ing carbohydrates became a craze, affecting the foodand restaurant industries as well as the book indus-try, which turned out several best-selling titles suchas Dr. Atkins’ New Diet Revolution, Enter the Zone, TheSouth Beach Diet, Protein Power, and The CarbohydrateAddict’s Diet. Restaurants had to devise sandwicheswithout bread, and reportedly some bakers literallyhad to close up shop during the low-carb craze. InAugust 2004, a reported 44 million Americans wereeither on a low-carb diet or watching their carbintake. NPD Group, an independent marketing infor-mation company, reported that the percentage ofAmerican adults on any low-carb diet peaked at 9.1percent in February 2004, but dropped to 4.9 percentin November 2004, signaling a possible end to thelow-carb “diet wars.” On July 31, 2005, Atkins Nutri-tionals filed for bankruptcy protection; other low-carb businesses either cut back or folded during 2005.

Several studies have shown that low-carb dietsmay cause more weight loss in the short term thanconventional reduced-calorie, low-fat diets, butafter a year there appears to be no difference.Some people have lost as much as 50 and 60pounds on low-carb diets, only to eventually go offthe diet and regain some of the weight, citing a“tiresome” and “monotonous” diet as the reasons.

The medical community is divided about thesafety of a low-carb diet. Some studies suggest it issafe; others suggest it is potentially dangerous. In theJune 2004 issue of The Costco Connection, for example,two nutritionist authors argued opposite viewpointson whether low-carb diets are a healthy choice. Dr.Howard Shapiro said, “People on strict low-carbdiets miss out on health-giving nutrients and take inhealth-harming substances.” Dr. Fred Pescatore said,“Recent studies show that low-carb dieting has pos-itive health outcomes in the treatment of heart dis-ease by lowering all of the associated risk factors,lowering risk for diabetes and decreasing risks forcertain cancers when done properly.”

In their study of both low-carbohydrate dietersand low-fat dieters, Yancy et al. concluded, “Low-carbohydrate diets seem to be effective and relativelysafe. However, people on this diet must be moni-tored for harmful elevations of bad cholesterol.”

Health experts caution that low-carb does notmean no carbs. But people who restrict carbohy-drates, especially those who take the diet to itsextreme, may miss out on key nutrients, such as Bvitamins (found in bread, pasta and cereal), vitaminC (found in orange juice), and calcium. The Ameri-can Cancer Society expresses concern about therestriction of milk and yogurt, which are “importantsources of calcium. As a result, many low-carb dietplans recommend taking a multivitamin/mineralsupplement with calcium.”

Scientists also warn that because the foods pro-hibited or restricted by low-carb diets (bread, pasta,breakfast cereals and orange juice) are fortified withfolic acid, a micronutrient essential to the neurolog-ical development of fetuses, women should avoidlow-carb diets during their reproductive years.

The Berkeley Wellness Newsletter also cautionsagainst paying extra for low-carb foods: Sleight-of-hand can distract you from an accurate comparisonbetween low-carb foods and conventional ones.Here are two examples:

• A slice of “low-carb” Atkins bread, for instance, has 60calories and 8 grams of total carbs, though it claims tohave only 3 “net impact” carbs. A slice of a conven-tional “diet” bread typically has 50 calories and 10grams of carbs. That isn’t significant difference.

• A 1-ounce low-carb chocolate bar has 155 calories and12 grams of fat, but no sugar; it claims to have only 1“net impact” carb. A regular bar has 150 calories and10 grams of fat. (Some choice!) Low-carb candies areactually pretty much the same as the sugar-free can-dies that have been on the market for years.

The FDA has no definition of “low-carbohydrate”and has never approved any low-carb labels. Anyfood can be so labeled.

Gaesser, Glenn A., and Karin Kratina. It’s the Calories, Notthe Carbs. Toronto: Trafford Publishing, 2004.

University of California, Berkeley. “Low-carb Foods: LessThan 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, KetogenicDiet versus a Low-Fat Diet to Treat Obesity and Hyper-lipidemia: A Randomized, Controlled Trial.” Annals ofInternal Medicine 140, no. 10 (May 18, 2004): 769–777.

low-fat diet Whether dietary fat intake plays animportant role in the rising prevalence of over-

190190 low-carb diets

weight and obesity has long been a matter of con-troversy among weight-loss experts. According to areview of 28 studies investigating the relationshipbetween fat intake and weight, people who switchto a low-fat diet but eat as much as they like stilldecrease their calorie intake by 11 to 30 percent.Findings suggest that the incidence of obesity hasincreased in nations where fat intake has risen butremained steady in countries where the populationhas continued to follow a low-fat diet.

From these findings, Bray and Popkin contend thatbecause low-fat diets pack comparatively fewer calo-ries into the same amount of food, they can fill peo-ple up before they eat too many calories and are thusmore satisfying. Because these diets are more satisfy-ing, people are more likely to stick with them for thelong term, and not only lose weight, but keep it off.

The researchers estimate that the average personcould expect to lose a pound or more a month simplyby lowering their fat intake by 10 percent. They addthat by combining lowered-fat intake with increasedexercise, people can lose considerably more weight.

But not all experts agree with this review andconclusion, criticizing the researchers’ choice ofstudies and their analysis. They argue that thedegree of effect of dietary fat intake on body fatneeds long-term trials to be determined.

In a later study, Bray et al. argue, “In animals,increasing dietary fat increases body fat, and it isunlikely that humans escape this important biolog-ical rule. In epidemiological studies, increasingdietary fat is associated with increased prevalenceof obesity probably by increasing the intake ofenergy dense foods.” They illustrate thus:

The relation of dietary fat is most evident whenphysical activity is low. The speed of adaptation todietary fat is increased by exercise. When dietaryfat is reduced, weight is lost, but weight loss even-tually plateaus. The rate of weight loss during theinitial phase is about 1.6 g/day for each 1 percentdecrease in fat intake. When dietary fat is replacedwith olestra to reduce fat intake from 33 percent to25 percent in obese men, weight loss continues forabout 9 months reaching a maximum of nearly 6percent of body weight and a loss of 18% of initialbody fat. In the control group with a 25 percentreduced-fat diet, weight loss stopped after threemonths and was regained over the next six

months, indicating the difficulty of adhering to aconventional low-fat diet. Thus, dietary fat is animportant contributor to obesity in some people.

In comments to the FDA Obesity Working Group inDecember 2003, representatives of the Weston A.Price Foundation, a nonprofit organization dedi-cated to exploring the scientific validation of dietary,agricultural and medical traditions throughout theworld, made the following recommendation:

Over the long term, low-fat diets have been shownto be disadvantageous for preventing the diseasesthey have been recommended for. Most people areat risk for lowered intakes of the important fat-sol-uble vitamins and other fat-soluble nutrientswhen they consume low-fat diets for any length oftime. So it would seem that the fat content of nat-ural fats that our ancestors used, with an averageof 35–40 percent of energy as fat, makes sense.

In her review of weight-loss strategies, Arnst writes,

The medical Establishment particularly favors low-fat diets for their proven ability to help preventheart disease. Also note that the National WeightControl Registry, which has collected data on morethan 3,000 people who maintained a loss of 30pounds or more for at least one year, found thatthe majority of successful dieters in the registryfollowed a low-fat program.

Keep in mind, though, that successful dietersare few and far between. It’s tough to cut fat with-out feeling hungry all the time, and many peopleend up replacing fat calories with carb or sugarcalories. Besides, some fats, such as nuts and oliveoil, can be good for you.

Arnst, Catherine. “How to Weigh the Competing Claimsof All Those Weight-Loss Plans.” Business Week,August 30, 2004. Available online. URL: http://www.businessweek.com/magazine/content/04_35/b3897442.htm. Downloaded on September 15, 2005.

Bray, G. A., S. Paeratakul, and B. M. Popkin. “Dietary Fatand Obesity: A Review of Animal, Clinical and Epi-demiological Studies.” Physiology & Behavior 83, no. 4(December 30, 2004): 549–555.

Bray, George A., and Barry Popkin, “Dietary Fat IntakeDoes Affect Obesity!” American Journal of ClinicalNutrition 68, no. 6 (December 1998): 1,157–1,173.

191low-fat diet 191

ma huang See EPHEDRA.

malabsorptive operation Obesity surgery thatcreates a direct connection from the stomach to thelower segment of the small intestine, bypassingportions of the digestive tract that absorb caloriesand nutrients. Although such operations doinvolve some reduction in the size of the stomach,most of their success results from shortening thegastrointestinal tract so that food passes throughwithout being broken down and absorbed by thebody. The most commonly performed malabsorp-tive procedures today are BILIOPANCREATIC DIVER-SION (BPD) and ROUX-EN-Y GASTRIC BYPASS (RGB).

Malabsorptive operations produce more weightloss than restrictive operations, and are more effec-tive in reversing the health problems associatedwith severe obesity. Patients who have malabsorp-tive operations generally lose two-thirds of theirexcess weight within two years.

In addition to the risks of restrictive surgeries,malabsorptive operations also carry greater risk fornutritional deficiencies because the procedurecauses food to bypass the duodenum and jejunum,where most iron and calcium are absorbed. Men-struating women may develop anemia because notenough vitamin B12 and iron are absorbed.Decreased absorption of calcium may also bring onosteoporosis and metabolic bone disease. Patientsare required to take nutritional supplements thatusually prevent these deficiencies.

Woodard says that following this surgery, abilityto become pregnant is improved because weightloss often allows for a normalization of sex hor-mones, but adds, “However, the nutrition chal-lenges brought about by the surgery may have aprofound impact on maternal health and preg-nancy outcome. Deficiencies in iron, vitamin B12,

folate, and calcium can result in maternal compli-cations, such as severe anemia, and in fetal com-plications, such as neural tube defect, intrauterinegrowth restriction, and failure to thrive. Nutrientsupplementation following bariatric surgery andclose supervision before, during, and after preg-nancy can help prevent nutrition-related compli-cations and improve maternal and fetal health.”

Fujioka cautions that nutrients lost due to mal-absorptive procedures may present long-termproblems. “Over the next several years, the num-ber of patients who will have had bariatric surgeryfor morbid obesity will reach close to a million.Several well-described nutritional problems suchas B12 and iron deficiency will be noted in thesepatients. Many of these patients will be lost to theoriginal surgeon and will now be in the care of the‘other physicians.’ If these problems are left undi-agnosed, severe and irreparable problems canresult. Long-term problems, such as changes inbone metabolism, will need to be monitored. Ifsome of these long-term problems are notaddressed in a timely fashion, then eventual treat-ment becomes much more difficult.”

See also BARIATRIC SURGERY; GASTRIC RESTRICTION

PROCEDURES.

Fujioka, K. “Follow-Up of Nutritional and MetabolicProblems 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 dodevelop anorexia nervosa, but much less com-monly than girls and young women. It is believedby many experts in the field that this conditionmay be more common in males than it seems to be

193

M

but not readily recognized by doctors because of itsreputation as a female disorder. Recent estimatesare 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 menare affected by eating disorders.

In 2003 Andersen wrote, “A recent large epi-demiologic study has substantiated that males areprobably underrepresented in both epidemiologicand clinical studies. While earlier studies reportedratios of as many as 10 females to one male, a ratioof one male to three or four females may be moreaccurate. This raises concerns that males areunderrepresented in clinical programs, and calls forbetter understanding of the factors that may bekeeping them from seeking treatment.”

Many experts feel that the spread of lean malebody images in men’s magazines in recent yearshas contributed to the increasing number of malesbeing diagnosed with anorexia. Goode explains:

Women with eating disorders may be driven bytheir desire to be thin, but men often express theirpreoccupation in different terms. Instead of a lowbody weight, they seek well-defined muscles,sleek abs and sculptured pecs. Achieving this goal,however, usually means excising every strayounce of fat. If the anorexic or bulimic woman’snightmare is being told that she has “a little meaton her thighs,” many men live in fear of being toldthat they “still have a little fat on those delts.”

Agliata and Tantleff-Dunn found that men whowatched TV commercials featuring muscular actorsfelt unhappy about their own physiques. This “cul-ture of muscularity” can be linked to eating disor-ders, the researchers said.

Studies of male anorexics tend to agree that ingeneral the behavior of males resembles closelythat of their female counterparts, with a fewexceptions. One is that males who becomeanorexic tend to do so on average at an earlier agethan females. In addition, relatively more malescome from working-class homes. Some studieshave found that a family history of anorexia ner-vosa is particularly common in male cases. Theanorexic male tends to be obese before becomingemaciated. Finally, there is an impression that maleanorexics respond to treatment less well and may

be more likely to become chronic or drop out oftreatment programs.

HILDE BRUCH wrote that male anorexia “occursin youngsters who seemingly were doing well butwhose accomplishments were a facade, an expres-sion of compliance, and not of self-initiated andself-directed goals. In their desperate struggle tobecome ‘somebody’ and to establish a sense of dif-ferentiated identity, they become overambitious,hyperactive, and perfectionistic.”

Families of boys aged nine to 12 who developanorexia are often described as psychologically dis-turbed or distressed, with the child having anunsatisfactory relationship with both parents.

Most males with anorexia begin weight lossduring adolescence. These boys are more oftenmildly to moderately obese before onset than girlswho become ill at the same age. Many, but not all,adolescent boys with anorexia show confusionabout sexual identity. In personality tests theypresent a spectrum of disorders from perfectionis-tic and obsessive to borderline personalities notcapable of maintaining stable relationships, anddisplay rapid and inappropriate mood changes.

Restrictive male anorexics (see RESTRICTOR

ANOREXICS) show complete impotence and absenceof sexual activity and interest. When they regainweight, they experience a gradual return of normalsexual feeling.

Fichter and Krenn note that not only homosex-uality but also asexuality or sexual anxieties andinhibition have been documented in males suffer-ing from anorexia nervosa. “Fichter and Daserfound males to be significantly more anxiousregarding sexuality, with 95 percent having tried tosuppress their sexual drive and feeling relieved byloss of libido secondary to weight loss.” That studyconcluded that males with atypical gender rolebehavior have an increased risk for developinganorexia nervosa or bulimia in adolescence.

Noting that males and females show substantialsimilarities during the acute illness phase of eatingdisorders, Fichter and Krenn say, “Before and afterthe acute phase of illness, differences betweengenders in respect to biological and social learningprocesses and gender role identity come to bear.Future research has to focus on these phases.There is still very little data on possible biological

194194 males and anorexia nervosa

vulnerability factors (genetic, neurochemical,neuroendocrine, etc.) in males suffering from eat-ing disorders.”

Because few suspect eating disorders amongteenage boys and men, the problems often goundiagnosed and untreated for many years. Whenfinally recognized, the disorders are often faradvanced and that much more difficult to treat.

Andersen has noted that understanding thelower frequency of eating disorders in males maylead to more effective means of protecting girlsfrom these disorders and the culturally induceddistress about normal body size and shape thatburdens adolescent development and adult life.

See also MUSCLE DYSMORPHIA.

Agliata, Daniel, and Stacey Tantleff-Dunn. “The Impactof Media Exposure on Males’ Body Image.” Journal ofSocial and Clinical Psychology 23, no. 1 (February 2004):7–22.

Andersen, Arnold E. “Anorexia Nervosa: 11 Areas ofAdvancement.” Eating Disorders Review 14, no. 2(March/April 2003): 1.

Andersen, Arnold E. “Anorectic Behavior Isn’t Quite theSame 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 Eat-ing Disorders: Challenges for Treatment andResearch.” Psychopharmacology Bulletin 33, no. 3(1997): 391–397.

Fichter, M. M., and C. Daser. “Symptomatology, Psycho-sexual Development and Gender Identity in 42Anorexic Males.” Psychological Medicine 17, no. 2 (May1987): 409–418.

Fichter, Manfred, and Heidelinde Krenn, “Eating Disor-ders in Males.” In Handbook of Eating Disorders, 2nd Edi-tion, edited by Janet Treasure, Ulrike Schmidt, andEric van Furth, 369–383. West Sussex, U.K.: JohnWiley & 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

EATING on high-calorie, easily ingested foods maybe done by as many as 30 percent of male collegestudents, according to studies. The percentage ofmales meeting the DSM-IV criteria for BULIMIA

NERVOSA, however, is approximately 1–3 percent.In one report, male students reporting to a univer-

sity psychiatric clinic represented 10 percent ofpatients diagnosed as bulimic.

The figures could be artificially low. In tests,men have freely acknowledged “frequent con-sumption of large quantities of food at times otherthan during meals”; unlike women, however, theytended not to label this behavior as binge eating.

Generally, men have been found to be morecomfortable with their weight and perceive lesspressure to be thin than women. However, formale bodybuilders, long-distance runners andhomosexuals, emphasis on body and physicalappearance approaches the levels seen generally inwomen in our culture and puts these men athigher risk for developing eating disorders.

A past history of obesity is another risk factor formales. Obese young males, being a minority in oursociety, are often targets of cruel verbal and physi-cal taunting. They might easily become preoccu-pied with their body and their physical appearance.

In some bulimia studies, the rare men with thediagnosis of bulimia nervosa all had a history ofdieting from their mid- or late teens; indeed, thiswas all they had in common—only some had beenanorexic, only some obese.

According to Root, Fallon and Friedrich inBulimia: A Systems Approach to Treatment, “it appearsmore difficult for the male bulimic to seek help,perhaps because the socialization of men discour-ages help-seeking and because bulimia has beendescribed as a ‘woman’s problem.’ ”

Through their comparison of men with eatingdisorders to men in the general population, Wood-side et al. found that men with eating disorderswere more likely to have other mental disordersand were less satisfied with their lives. Dr. Wood-side said that these differences could result fromside effects of the disorders. Gleaves and Cepeda-Benito also noted that males with bulimia nervosahave a later disorder onset than do women.

In a Massachusetts General Hospital study of 135males with eating disorders, 62 were bulimic. Ofthese, 42 percent were identified as either homosex-ual or bisexual. The study concluded that while mostcharacteristics of males and females with eating dis-orders are similar, homosexuality/bisexuality appearsto be a specific risk factor for males, especially forthose who develop bulimia nervosa.

195males and bulimia nervosa 195

Carlat, David J., Carlos A. Camargo, Jr., and David B.Herzog. “Eating Disorders in Males: A Report on 135Patients.” American Journal of Psychiatry 154, no. 8(August 1997): 1,127–1,132.

Gleaves, David H., and Antonio Cepeda-Benito. “EatingDisorders.” In Handbook of Mental Health in the Work-place, 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.” Inter-national Journal of Eating Disorders 22, no. 2 (Septem-ber 1997): 131–138.

Woodside, D. Blake, et al. “Comparisons of Men withFull or Partial Eating Disorders, Men without EatingDisorders, and Women with Eating Disorders in theCommunity.” American Journal of Psychiatry 158, no. 4(April 2001): 570–574.

malnutrition Poor nourishment resulting fromimproper diet or from some defect in metabolismthat prevents the body from digesting or absorb-ing food properly. Extreme malnutrition may leadto starvation.

Eating disorders sometimes result in malnutri-tion. While intentional malnutrition is the hallmarkof anorexia nervosa, it represents a significant med-ical complication of bulimia in 20 percent of cases.Principal manifestations of malnutrition involvefive body organ systems: endocrine (amenorrheaand estrogen deficiency), cardiovascular (loweredblood pressure and reduced heart rate), neuromus-cular (osteoporosis), renal (kidney stones and renalfailure) and gastrointestinal (gastritis and decreasedacid secretion).

mammography and obesity Researchers at theUniversity of Washington analyzed 100,622 screen-ing mammography examinations performed onmembers of a nonprofit health plan, and found thatobese women had more than a 20 percent increasedrisk of having false-positive mammography resultscompared with underweight and normal-weightwomen. False-positive means that their mammo-grams were interpreted as abnormal, but follow-uptesting did not find cancer. Being overweight (butnot obese) raised a woman’s risk for false-positiveresults by 14 percent.

Although the study did not find any differenceamong women of varying weights in the ability of

mammograms to detect cancer, the false-positivesrequiring more tests can cause severe anxiety andstress, as well as added health care costs.

Noting that achieving a normal weight mayimprove screening mammography performance,the study’s authors suggest in the meantime thatoverweight and obese women return to the samefacilities for each mammogram so the radiologistcan compare the current test to previous ones.

Elmore, Joann G., et al. “The Association between Obesityand Screening Mammography Accuracy.” Archives ofInternal Medicine 164, no. 10 (May 2004): 1,140–1,147.

Mandometer Treatment A system developed inSweden that is being used in Stockholm, Amster-dam, and San Diego to treat eating disorders. Itallows simultaneous recording of eating rate andsatiety, and in small studies has shown a 75 percentremission rate compared to the more usual 50 per-cent rate with other treatment options.

Mandometer is a nutritional program thatteaches patients to eat normally and recognize nat-ural feelings of satiety using a patented computer-based biofeedback system. First, the rate at which anormal person would eat a meal and the amounteaten to become satiated is programmed into theMandometer. Over time, patients learn to eat nor-mally using this feedback and adapt eating speedand satiety to curves displayed on the computermonitor. Treatment time averages about 12months and according to the San Diego company,“published research studies” show 93 percent ofpatients in Sweden “remain well for a minimum ofone year.” No studies on the Mandometer appearon a PubMed database search.

In 2004 the Mandometer was reported to beundergoing further development at the University ofBristol, Great Britain, for use as a treatment for child-hood obesity. It was targeted to be ready in two years.

Bergh, Cecilia, et al. “Randomized Controlled Trial of aTreatment for Anorexia and Bulimia Nervosa.” Pro-ceedings of the National Academy of Sciences 99, no. 14(July 9, 2002): 9,486–9,491.

marriage and eating disorders Some womenmarry while anorexic, even though they are likely tobe infertile. The anorexic will often choose a partner

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who suits her as the kind of person she has becomerather than as she was before becoming anorexic.For instance, the husband may be quiet and sexuallyundemanding, or alternatively superficially glam-orous but privately wary of personal or sexualinvolvement. The marriage may be stable while thewife remains anorexic, but it will often be strainedand tested if and when a process of recovery begins.

Many bulimics vow to give up BINGE EATING andPURGING once they are married, hoping that mar-riage itself will magically transform their lives.Researcher Marlene Boskind-White has found thatthis does happen for some, but others resume theirhabit in secret, feeling more guilty and ashamedthat ever. Bulimics have been known to keep theirbehavior a total secret from their husbands for aslong as 15 years. But the deception often destroysa marriage. Some husbands conclude that theirwives must be carrying on affairs because of theirexaggerated sense of privacy. When they finally dofind out that it’s “only” an eating problem, they arerelieved and often don’t realize that it is even moresignificant than the affair they had suspected.

A Canadian study examined the intimacy aspectof couples in which one member has an eating dis-order, before and after intensive day hospital treat-ment for the disorder. Patients generally improvedin terms of their eating disorder symptoms duringthe treatment. Spousal ratings showed satisfactoryratings of intimacy at the start of treatment and didnot change during treatment.

Woodside, D. B., J. B. Lackstrom, and L. Shekter-Wolf-son. “Marriage in Eating Disorders Comparisonsbetween Patients and Spouses and Changes over theCourse of Treatment.” Journal of Psychosomatic Research49, no. 3 (September 2000): 165–168.

marriage and weight gain Researchers only cor-roborate what many couples have learned—thatmarriage leads to increased body weight and, inmany cases, obesity. Sobal includes marriageamong the many cultural and social factors thatinfluence body weight. Drawing from numerousstudies conducted since the 1970s, he cites severalfindings to illustrate how marriage is related tobody weight and obesity: “Obese people enter mar-riage later and marry heavier partners. Marriedmen, but not necessarily women, weigh more than

unmarried individuals. People tend to gain weightafter entering marriage. People who terminatetheir marriages tend to lose weight. Overall, enter-ing into marriage is more difficult for obese people,being married is associated with higher bodyweight, and terminating marriage is associatedwith weight loss. Marriage structures people’slives, provides social obligations for eating andactivities, and includes normative perceptionsabout body weight and shape. Marital status is apredictor of body weight levels, and effective inter-ventions to change or maintain body weights canbe structured around marital partners.”

Jeffery and Rick found that BODY MASS INDEX

(BMI) did not predict the likelihood of marriage ordivorce. However, in their study, marriage wasassociated with a significant two-year weight gainand divorce with a significant two-year weightloss. “The results suggest that spouse similarity inBMI is at least partly due to shared environment.The observed effects of marriage and divorce onweight may be due to the influence of marriage oninducements to eat (e.g., shared meals) or on moti-vation for weight control.”

Even patients with eating disorders have beenreported to gain weight following marriage.Among the reasons proposed is that when peoplewith eating disorders live alone, they are able tocontrol the amount of food in their homes and theamount of food they eat. But when they begin liv-ing with a marriage partner, more food is likely tobe in the home, meals are less apt to be eaten aloneand the partner more prone to encourage the eat-ing disordered person to eat more food.

Jeffery, R. W., and A. M. Rick. “Cross-Sectional and Lon-gitudinal Associations between Body Mass Index andMarriage-Related Factors.” Obesity Research 10, no. 8(August 2002): 809–815.

Sobal, Jeffery. “Cultural, Historical, and Social Influenceson Body Weight.” Cornell Cooperative Extension.Available online. URL: http://www.cce.cornell.edu/food/expfiles/topics/sobal/sobaloverview.html. Down-loaded on February 12, 2005.

media influence on eating disorders Numerousstudies during the past several decades havepointed to mass media—print advertisements, tel-evision commercials, images of stick-thin models—

197media influence on eating disorders 197

as exerting some influence upon the rate of eatingdisorders, perhaps even a strong impact. Amongthe findings have been the following:

• One out of every 3.8 commercials send somesort of “attractiveness message” telling viewerswhat is or is not attractive, with the average ado-lescent seeing more than 5,260 attractivenessmessages per year.

• According to the National Eating Disorders Asso-ciation, a study of one teen adolescent magazineover the course of 20 years found that in articlesabout fitness or exercise plans, 74 percent cited“to become more attractive” as a reason to startexercising and 51 percent noted the need to loseweight or burn calories.

• Today’s adolescents have been exposed toextreme thinness as a standard of attractivenessfor their entire lives.

• In a survey of more than 500 girls in grades fivethrough 12, 69 percent of the girls reported mag-azine pictures influencing their idea of the perfectbody shape, and 47 percent reported wanting tolose weight because of the magazine pictures.

• Duggan and McCreary found that viewing andpurchasing of muscle and fitness magazines cor-related positively with levels of body dissatisfac-tion for both gay and heterosexual men.

Several authors have also recently written on theconnection between the media and eating disorders:

• Andrist wrote, “The media holds an awesomepower to influence young women, bombardingthem with images of abnormally thin modelswho seem to represent the ideal. When themajority of adolescents inevitably fail to achievethe extremely thin image they crave, body dis-satisfaction results, and disordered eating canbegin. Emerging research in the pediatric andadolescent literature demonstrates that childrenas young as 5 are already anxious about theirbodies, and want to be thinner.”

• Agliata and Tantleff-Dunn noted that althoughmass media are believed to be a pervasive forcein shaping physical appearance ideals and havebeen shown to negatively impact females’ bodyimage, little research has addressed the effects of

media exposure on males’ body image. Theirresearch “exposed 158 males to television adver-tisements containing either ideal male images orneutral images that were inserted. Results indi-cated that participants exposed to ideal imageadvertisements became significantly moredepressed and had higher levels of muscle dis-satisfaction than those exposed to neutral ads.”

Others have placed less emphasis on the role ofmedia in perpetuating eating disorders. Gordonwrites, “Whether such (increasingly thin and rela-tively less curvaceous in shape) media images playa causal role in eating disorders or whether theymerely reflect the standards of the wider culture isa matter of some controversy, but there seems lit-tle doubt that there has been an increasingly strin-gent expectation for thinness in women.”

Polivy and Herman write: “Exposure to themedia is so widespread that if such exposure werethe cause of [eating disorders], then it would bedifficult to explain why anyone would not be eat-ing-disordered. Furthermore, as Tiggemann &Picketing noted upon discovering that among girls,body dissatisfaction and drive for thinness wereassociated with increased exposure to certain typesof TV shows, ‘although it is tempting to concludethat watching a large dose of thin idealized imageson television leads to dissatisfaction with one’sbody, a correlation cannot determine causality. Analternative scenario, for example, might be thatthose most dissatisfied with their bodies or wishingto be thinner, seek out or are more interested inparticular types of television.’ ”

Dr. Lou Rappaport, eating disorders expert andassociate dean at the school of psychology andbehavioral science at Argosy University in SanFrancisco, told the Boston Herald, “I think market-ing of a certain body image and clothing is part andparcel of eating disorders. It doesn’t fully explainthe problem, but I am sure it’s a part of it.”

Agliata, Daniel, and Stacey Tantleff-Dunn. “The Impactof Media Exposure on Males’ Body Image.” Journal ofSocial and Clinical Psychology 23, no. 1 (February 2004):7–22.

Andrist, L. C. “Media Images, Body Dissatisfaction, andDisordered Eating in Adolescent Women.” MCN: TheAmerican Journal of Maternal Child Nursing 28, no. 2(March–April 2003): 119–123.

198198 media influence on eating disorders

Duggan, S. J., and D. R. McCreary. “Body Image, EatingDisorders, and the Drive for Muscularity in Gay andHeterosexual Men: The Influence of Media Images.”Journal of Homosexuality 47, no. 3–4: 45–58.

Falcone, Lauren Beckham. “Will Skinny Screen StarsSpawn Wave of ‘Manorexia’?” The Boston Herald, Feb-ruary 1, 2005, page 31.

Polivy, Janet, and C. Peter Herman. “Causes of EatingDisorders.” Annual Review of Psychology 53 (February2002): 187–213.

Tiggemann, M., and Pickering, A. S. “Role of Televisionin Adolescent Women’s Body Dissatisfaction andDrive for Thinness.” International Journal of Eating Dis-orders 20, no. 2 (September 1996): 199–203.

Medicare and obesity Services, procedures andmedications covered by Medicare change continu-ally, so it is always advisable to check with the Cen-ters for Medicare and Medicaid Services (CMS) toverify what is currently allowed. The Web page fordoing this is located at http://www.cms.hhs.gov/coverage.

As of October 1, 2004, the CMS posted the fol-lowing policies:

Obesity may be caused by medical conditions suchas hypothyroidism, Cushing’s disease, and hypo-thalamic lesions, or can aggravate a number of car-diac and respiratory diseases as well as diabetesand hypertension. Services in connection with thetreatment of obesity are covered when such serv-ices are an integral and necessary part of a courseof treatment for one of these medical conditions.However, program payment may not be made fortreatment of obesity unrelated to such a medicalcondition since treatment in this context has notbeen determined to be reasonable and necessary.In addition, supplemented fasting is a type of verylow calorie weight reduction regimen used toachieve rapid weight loss. The reduced calorieintake is supplemented by a mixture of protein,carbohydrates, vitamins, and minerals. Seriousquestions exist about the safety of prolongedadherence for 2 months or more to a very lowcalorie weight reduction regimen as a generaltreatment for obesity, because of instances of car-diopathology and sudden death, as well as possibleloss of body protein. Services performed in con-nection with the treatment of obesity are coveredby Medicare when such services are an integraland necessary part of a course of treatment for dis-eases such as hypothyroidism, Cushing’s disease,

hypothalamic lesions, cardiovascular diseases, res-piratory diseases, diabetes, and hypertension.

The treatment of obesity unrelated to such amedical condition (see above) is not consideredreasonable and necessary and is not covered underthe Medicare program.

Supplemented fasting is not covered under theMedicare program as a general treatment for obesity.

Where weight loss is necessary before surgeryin order to ameliorate the complications posed byobesity when it coexists with pathological condi-tions such as cardiac and respiratory diseases, dia-betes, or hypertension (and other moreconservative techniques to achieve this end arenot regarded as appropriate), supplemented fast-ing with adequate monitoring of the patient is eli-gible for local coverage determination throughindividual contractor discretion. The risks associ-ated with the achievement of rapid weight lossmust be carefully balanced against the risk posedby the condition requiring surgical treatment.

In 2005 the CMS was reevaluating policies forcoverage of various BARIATRIC SURGERY proceduressuch as intestinal bypass surgery. At that time,“gastric bypass surgery for extreme obesity [was]covered under the program if (1) it is medicallyappropriate for the individual to have such sur-gery; and (2) the surgery is to correct an illnesswhich caused the obesity or was aggravated bythe obesity.”

Mediterranean Diet A popular diet developed in1995 by a team that included the Harvard Schoolof Public Health and the World Health Organiza-tion. It is based on research led by pioneering med-ical scientist Ancel Keys, which investigated thelink between diet and heart disease, and in theprocess discovered that people living in Crete,other parts of Greece and southern Italy livedlonger and had very low rates of heart disease andcertain cancers.

The Mediterranean Diet emphasizes fruits, veg-etables, nuts and whole grains, with olive oil themain source of dietary fat, and includes regularconsumption of red wine. It includes some fish andpoultry, but very little red meat and dairy products(mainly cheese and yogurt).

Several studies have validated that such a diet isassociated with reduced risk of heart disease, obe-

199Mediterranean Diet 199

sity, gallstones, diabetes and certain cancers. Aftermuch debate about which component of the dietaccounts for the benefits, researchers who fol-lowed more than 22,000 healthy Greeks for anaverage of four years determined that no singlepart of the Mediterranean diet played a significantrole; rather, the cumulative effect of all these foods,perhaps interacting, was substantial.

An Australian study found the MediterraneanDiet to be very effective for weight loss both in theshort term and at 15 months follow-up. “Longterm follow-up of this diet program is at least aseffective as any diet or diet and drug therapy pub-lished. Individuals completing the recommended12-week program seem to have more effectivelong-term weight loss.”

Flynn, G., and D. Colquhoun. “Successful Long-TermWeight Loss with a Mediterranean Style Diet in a Pri-mary Care Medical Centre.” Asia Pacific Journal of Clin-ical Nutrition 13 (2004): S139.

Willett, Walter C. Eat, Drink, and Be Healthy: The HarvardMedical School Guide to Healthy Eating. New York: FreePress, 2001.

menopause and weight gain Menopause is thatperiod marking the natural and permanent cessa-tion of menstruation, occurring usually betweenthe ages of 45 and 55. During the years immedi-ately prior to the onset of menopause (pre-menopausal or perimenopausal) and followingmenopause (postmenopausal), many womenexperience increases in body weight and total bodyfat, as well as alterations in body fat distribution,with an increase in abdominal fat. One studyshowed premenopausal women between 42 and50 years of age to gain an average of five pounds inthree years, with 20 percent of these women gain-ing at least 10 pounds.

Racette et al. wrote, “Based on the NHANES IIIdata set, approximately 70 percent of womenbetween 45 and 54 years of age are overweight orobese. Although increasing adiposity appears to becommon after menopause, a great deal of evidencesuggests that this phenomenon is neither desirablenor necessarily inevitable.” Among that evidence isthe Women’s Healthy Lifestyle Project, whichshowed that reducing saturated fat and cholesterolconsumption and preventing weight gain by

decreased caloric and fat intake and increasedphysical activity would prevent the rise in LDLcholesterol and weight gain in women during per-imenopause to postmenopause.

Also, Sternfeld et al. examined the relations ofaging, menopausal status and physical activity toweight and waist circumference in 3,064racially/ethnically diverse women aged 42–52 yearsat baseline who were participating in the Study ofWomen’s Health Across the Nation (SWAN), anobservational study of the menopausal transition.They concluded, “Although midlife women tendto experience increases in weight and waist cir-cumference over time, maintaining or increas-ing participation in regular physical activitycontributes to prevention or attenuation ofthose gains.”

Lovejoy emphasizes the importance of womenpreventing weight gain during the menopausalyears: “Changes in body composition atmenopause may be caused by the decrease in cir-culating estrogen, and, for fat distribution shifts,the relative increase in the androgen-estrogen ratiois likely to be important. Clinicians need to beaware of the likelihood of weight gain during theperimenopausal and postmenopausal yearsbecause behavioral strategies for weight loss can beeffectively used in this population. Weight loss orprevention of weight gain is likely to have signifi-cant health benefits for older women.”

Kuller, L. H., et al. “Women’s Healthy Lifestyle Project, aRandomized Clinical Trial: Results at 54 Months.” Cir-culation 103, no. 1 (January 2, 2001): 32–37.

Lovejoy, J. C. “The Menopause and Obesity.” PrimaryCare 30, no. 2 (June 2003): 317–325.

Racette, Susan B., Susan S. Deusinger, and Robert H.Deusinger. “Obesity: Overview of Prevalence, Etiol-ogy, and Treatment.” Physical Therapy 83, no. 3(March 2003): 276–288.

Sternfeld, et al. “Physical Activity and Changes in Weightand Waist Circumference in Midlife Women: Findingsfrom the Study of Women’s Health across theNation.” American Journal of Epidemiology 160, no. 9(November 1, 2004): 912–922.

menstrual dysfunction Abnormal functioning ofthe menstrual cycle in females. Menstrual dysfunc-tion is a common condition accompanyingANOREXIA NERVOSA and BULIMIA NERVOSA. Early

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studies emphasized the role of weight loss andlean/fat ratio in AMENORRHEA. But later studiesconducted at the University of Rochester MedicalCenter, Rochester, New York to determine the inci-dence of menstrual abnormalities in a group ofwomen with abnormal eating attitudes but with-out obvious eating disorder symptoms found that93.4 percent (compared with 15.0 percent of theCONTROL GROUP) reported an abnormal menstrualhistory. These data suggest that menstrual dysfunc-tion often occurs in women with abnormal eatingbehavior but without weight loss or diagnosableeating pathology.

Crow et al. examined menstrual and reproduc-tive function in 173 bulimia nervosa patients ret-rospectively, with 10–15-year follow-ups, andconcluded that while menstrual irregularities arecommon, bulimia nervosa appears to have littleimpact on later ability to achieve pregnancy.

Regarding anorexics, Mitan wrote, “Psychologi-cal recovery may be as important as weight forreturn of menses. Weight-recovered patients withpersistent amenorrhea restrict fat intake more andscore higher on ‘anorexic’ measurements such aspreoccupation with the nutritional value of foodand distorted perception of body depth than domenstruating peers. Depression, a common dualdiagnosis in anorexia nervosa patients, has alsobeen linked to amenorrhea.”

Crow, S. J., et al. “Long-Term Menstrual and Reproduc-tive 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 andSubclinical Eating Disorders: A Preliminary Report.”Psychosomatic Medicine 51, no. 1 (January–February1989): 81–86.

Mitan, L. A. “Menstrual Dysfunction in Anorexia Ner-vosa.” Journal of Pediatric and Adolescent Gynecology 17,no. 2 (April 2004): 81–85.

Meridia See SIBUTRAMINE.

mesomorph A person whose body type is squareand muscular. Mesomorphs have an athleticphysique characterized by a broad trunk andshoulders with well-proportioned muscular armsand legs.

Theories linking body types to emotional or psy-chological characteristics are not considered scien-tifically sound.

See also ECTOMORPH; ENDOMORPH; BODY TYPES.

mesotherapy An alternative treatment devel-oped in France in the 1950s for a variety of ail-ments ranging from tennis elbow to arthritis tomigraine headaches and including the reductionand removal of fat and cellulite, via microinjec-tions. Although the technique is used by 15,000physicians in Europe and South America, it is notwidely accepted by the U.S. medical communitybecause no long-term studies have proven itssafety or efficacy.

Conventional or homeopathic medicationand/or vitamins and amino acids are injected intothe mesoderm, or middle layer of skin, whichappears to accelerate the breakdown of fat storedin fat cells. A primary concern of dermatologistsand plastic surgeons in the United States is that theconventional drugs used are intended for otherpurposes and thus may lead to unknown compli-cations. A USA Today article quoted a derma-sur-geon as saying, “No one says exactly what they putinto the [syringe]. One drug they often use, phos-phatidylcholin, is unpredictable and causesextreme inflammation and swelling whereinjected. It is not a benign drug.” Proponents arguethat the biggest side effect is bruising.

The procedure is intended primarily for healthypatients of normal weight or who have already lostweight through conventional means, but whohave small areas of fatty deposits they wantremoved largely for cosmetic purposes. As withliposuction, tissue contoured by mesotherapy canreaccumulate the fatty deposits without proper dietand exercise. Mesotherapy treatments cost $300 to$500 and up per treatment, with 10 to 15 treat-ments common.

Kelly, Katy. “Pinpoint Fat Relief?” U.S. News & WorldReport, March 10, 2003, p. 56.

Puente, Maria. “Critics Say Mesotherapy Offers SlimChance.” USA Today, August 4, 2004, p. D1.

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

201metabolic equivalent 201

sity of certain activities is commonly characterizedas light, moderate or vigorous, many activities canbe classified in any one or all three categories sim-ply on the basis of the level of personal effortinvolved in carrying out the activity (i.e., how hardone is working to do the activity). For example, onecan bicycle at intensities ranging from very light tovery vigorous. This unit is used to estimate theamount of oxygen used by the body during physi-cal activity. One MET equals the energy (oxygen)used by the body as a person sits quietly, perhapswhile talking on the phone or reading a book. Theharder the body works during an activity, thehigher the MET. Any activity that burns three to sixMETs is considered moderate-intensity physicalactivity. Any activity that burns more than six METsis considered vigorous-intensity physical activity.

metabolic syndrome Also called syndrome X orinsulin resistance syndrome, metabolic syndromeis not a single disease but a cluster of particularmedical problems, including obesity, insulin resist-ance, high blood pressure and hyperlipidemia(high lipid levels), that appear in varying combina-tions, and that put people at increased risk forheart attacks, stroke and type 2 diabetes and itscomplications. Obesity is considered a driving forcefor the condition.

Metabolic syndrome is diagnosed when a per-son has three or more of the following conditions:abdominal obesity (a waist measuring at least 40inches for men and 35 inches for women); highlevels (at least 150 milligrams per deciliter) oftriglycerides (fats that circulate in the blood); lowhigh-density lipoprotein (HDL) cholesterol (lessthan 40 milligrams in men and less than 50 mil-ligrams in women); high blood pressure (at least135/85); and high fasting glucose levels (bloodsugar) of at least 110 milligrams.

Although experts had long suspected the syn-drome was common, its prevalence was uncertainuntil a Centers for Disease Control and Prevention(CDC) study in 2002 provided hard numbers. TheCDC team analyzed data from a cross-sectionalsample of 8,814 men and women who participatedin the Third National Health and Nutrition Exami-nation Survey (1988–94). Although the unad-justed and age-adjusted prevalences of metabolic

syndrome were only 21.8 percent and 23.7 per-cent, respectively, the prevalence increased from6.7 percent among participants aged 20 through 29years to 43.5 percent and 42.0 percent for partici-pants aged 60 through 69 years and aged at least70 years, respectively. Mexican Americans had thehighest age-adjusted prevalence of the metabolicsyndrome (31.9 percent). The age-adjusted preva-lence was similar for men (24.0 percent) andwomen (23.4 percent). However, among AfricanAmericans, women had about a 57 percent higherprevalence than men did; and among MexicanAmericans, women had about a 26 percent higherprevalence than men did. Using 2000 census data,researchers determined that about 47 million U.S.residents have metabolic syndrome.

Dietary approaches to treating and preventingmetabolic syndrome vary, but nearly all expertsagree that clinical parameters are greatly improvedby reducing body weight by as little as 10 percentand increasing one’s level of physical activity. Ahigh-carbohydrate diet can raise the risk of heartdisease for those who have metabolic syndrome.For these people, too much carbohydrate will raiselevels of triglycerides and lower levels of HDL(good) cholesterol.

Ford, E. S., W. H. Giles, and W. H. Dietz. “Prevalence ofthe Metabolic Syndrome among U.S. Adults: Findingsfrom the Third National Health and Nutrition Exami-nation Survey.” Journal of the American Medical Associa-tion 287, no. 3 (January 16, 2002): 356–359.

IFIC Foundation. “Metabolic Syndrome: Lifestyle StrikesAgain.” Food Insight, May/June 2002, pp. 2–3.

metabolism The sum of all chemical and physi-cal processes by which the body transforms foodand keeps itself alive. Metabolism is a two-phaseprocess: catabolic and anabolic. In the catabolic, ordestructive, phase, the body breaks down foodsinto simpler chemical substances. During thisprocess, energy is released in the form of heat. Theanabolic, or constructive, phase uses these sub-stances to create new cells or mend damage. Per-sons with a high metabolism can eat more withoutgaining weight.

The rate of metabolism can be increased byexercise; by elevated body temperature (as in ahigh fever), which can more than double the

202202 metabolic syndrome

metabolic rate; by hormonal activity, such as thatof thyroxine, insulin and epinephrine; and by spe-cific dynamic action that occurs following theingestion of a meal. Reduction of caloric intake, onthe other hand, will lower the rate of metabolism.Studies with animals have shown that the ratemay drop during starvation to 60 percent ofprestarvation levels. The lower the normal meta-bolic rate, the more, and the more quickly, it dropsin response to caloric restriction.

Obese patients with the lowest metabolic ratesprior to a diet lose the least amount of weight. Ithas been estimated that a dieter can expect to losean average of 40 grams (1.5 ounces) per day for thefirst month if calories are cut from 2,000 to 1,500per day. During the second month, expectedweight loss would be half that amount—20 gramsper day; during the third month, 10 grams per day;after that, no loss at all. Such evidence indicatesthat the metabolism adapts to caloric restriction bybecoming more efficient.

Studies on metabolism as it relates to obesityhave led to several findings, including the following:

• Metabolic rate naturally slows as people age.However, a study funded by the USDA Agricul-tural Research Service showed that older peoplemay regain some of their youthful resting meta-bolic rate by regular muscle-building exercises.Increasing muscle mass would help seniors getoff the “slow boat to obesity,” according to theresearchers.

• In starvation studies of animals, during therefeeding period following the fasting, thegreater the amount of weight lost during fasting,the greater the weight gain per calorie eatenduring refeeding. In one study, rats starved to 20percent below normal weight gained 29.6 gramsduring the refeeding period while eating lessfood than controls—representing an 18-foldincrease in metabolic efficiency.

• People who become overweight tend to burnfewer calories than those who do not, eitherbecause they use food calories more efficientlyor because they are less active. Studies suggestthat once metabolism adjusts to increasedweight, “normal” weight for obese people maybe quite different from normal weight for thin

people. Adults who gained more than 22 poundsover four years were burning an average of 87fewer calories a day than people who did notgain that much weight. The same study showedthat slow metabolism tends to run in families.

Periodically, magazine ads and televisioninfomercials will promote supplements purportedto boost metabolism and thereby stimulate weightloss without cutting calorie consumption orincreasing energy expenditure through exercise. InDecember 2003 the Federal Trade Commission(FTC) provided a summary and analysis of theFTC’s public workshop called Deception in Weight-Loss Advertising. Expert panelists at that workshopreported the following regarding such claims:

Theoretically, products purporting to cause weightloss without diet or exercise would either need tocause malabsorption of calories or to increasemetabolism (so-called thermogenic drugs). Theeffect of purported metabolism boosters appears tobe very limited. For example, a study of green teaextract found only a four percent increase in metab-olism. Ephedrine [ephedra], usually sold in combi-nation with caffeine, has been one of the mostpopular thermogenic agents marketed over the pastfive years. It appears to produce only modest weightloss, mostly due to its appetite suppression effect.

The significance of the small amount of weightthat can be lost through increased metabolism isdebatable. It is clear, however, that as the amountof claimed weight loss increases, the likelihood thatsuch weight loss can be achieved without restrict-ing caloric intake or increasing exercise decreasesdramatically. For example, weight loss in the rangeof two pounds per week over periods of timebeyond four weeks (eight or more pounds permonth) would require a net caloric deficit of 7,000calories per week, or a 1,000 calories per day, overan extended period of time. That would amount to40 percent of the total calories consumed per weekon a 2,500 calorie per day diet. The staff is unawareof any scientific literature suggesting that 40 per-cent increases in metabolism can be achieved with-out producing toxic effects on the body.

In summary, the amount of weight loss that canbe achieved through the use of nonprescriptionproducts without reducing caloric intake orincreasing exercise is likely to be no more thanone-fourth to one-third of a pound per week, withadditional weight loss being attributable to reduced

203metabolism 203

caloric intake. Accordingly, weight loss in the rangeof two pounds per week over periods of timebeyond four weeks (eight or more pounds permonth) without restricting caloric intake orincreasing exercise is not now scientifically feasible.

See also EPHEDRA; MALABSORPTION; THERMOGENIC

DRUGS.

metoclopramide A drug that increases the speedwith which fluid and food pass from the stomach;it is often used prior to surgery. Metoclopramidehas been prescribed to relieve the bloating com-plained of by many ANOREXIA NERVOSA patientsafter meals. However, the use of metoclopramidehas been associated with significant depression andwith hormonal changes, limiting its potential usein treating anorexia nervosa.

Mexican Americans and obesity See HISPAN-ICS/LATINOS AND OBESITY.

mind hunger Also written as mind-hunger. A non-scientific term used to describe emotional eating—eating because one is angry, stressed, bored, sad orlonely, or simply to satisfy cravings or because theclock says it is time to eat, as opposed to eating tosatisfy physical or body hunger. Geneen Roth,author of Breaking Free from Emotional Eating (PlumeBooks, 2003), explains, “Mind hunger is endless,bottomless, erratic. You pass a bakery and suddenlyhave to have an éclair, even though you ate break-fast 10 minutes ago.” When eating to satisfy mindhunger is not kept under control, weight gain andobesity can result over time.

Roth, Geneen. “Satisfying Mind Hunger.” Prevention, Feb-ruary 2004, pp. 81–84.

molecular liposuction A therapy developed byscientists at the University of Texas’s M. D. Ander-son Cancer Center that destroys blood vessels thatsupport accumulation of fat, causing it to rapidlybreak down and disappear. Thus far, the treatmenthas undergone only animal testing, but the mice inthe study had nearly doubled in weight from ahigh-calorie diet, and after treatment returned tonormal size in four weeks. None of the mice used in

the experiment were genetically altered or prone toobesity prior to treatment; they gained weightbecause they ate a high-fat diet. The scientists whoconducted the study noted that there were no toxicside effects to the treatment. They cautioned thatfurther studies are needed to ensure that such treat-ment will not damage other vital tissues or vascularsystems and that it will work on humans.

Kolonin, Mikhail G. “Reversal of Obesity by TargetedAblation of Adipose Tissue.” Nature Medicine 10, no. 6(June 2004): 625–632.

mood disorders and eating disorders Mood dis-orders are disorders of feelings or emotions, usu-ally involving depression or elation or moodswings between them. They are sometimes relateddirectly to another physical or mental illness. Themood disorders of depression, premenstrual syn-drome (PMS) and seasonal affective disorder(SAD) share similar features with eating disorders,including symptoms and development, a genetic orfamilial tie and neuroendocrinological evidence,and receive similar treatments.

One symptom common to all these disorders isweight fluctuation. Depressed patients and SADpatients usually gain or lose weight as a result ofincreased or decreased appetite; PMS patients mayretain water, causing weight gain, or they maycrave foods high in CARBOHYDRATES—and as theirsnacking increases, so does their weight. Markedweight gain or loss is also often a key sign to diag-nosing eating disorders.

Additional evidence that mood and eating disor-ders are related is that 20 to 30 percent of all eating-disorder patients are also depressed, and many ofthem have a family history of depression as well.Patients with anorexia nervosa may also manifestsigns of mania such as euphoria and hyperactivity, aswell as feelings of sadness, thoughts of suicide andsuicidal behavior. In one study 27 out of 94 anorexicpatients were depressed following treatment. Threeothers had committed suicide. Several other studieshave reported incidence of depression among formeranorexic patients in the 40 to 45 percent range.

Researchers have also found a biological linkbetween eating and mood disorders. APPETITE iscontrolled by the same endorphins (hormones

204204 metoclopramide

secreted in the brain) that control the sense ofwell-being, pain tolerance levels, irritability, mem-ory, ability to concentrate and other feelings andfunctions. The hormone melatonin, which affectsappetite, aggression and sex drive, may be one cul-prit in the cases of SAD, PMS and bulimia. Bothexposure to light and darkness and premenstrualchanges in the body determine the levels of mela-tonin produced. Disproportionate levels of mela-tonin seem to be a problem in bulimics andcompulsive overeaters, causing them to eat moreat certain times of the day. In women with pre-menstrual syndrome, melatonin may cause heav-ier eating before the period; in SAD patients it maycause them to eat more at other times. Victims ofthese disorders often find that after ingesting car-bohydrates, they are in a better mood, can concen-trate more easily and are less irritable. This theoryis being studied more thoroughly, since a cravingfor carbohydrates, which bring melatonin to morenormal levels, is common to all these disorders.

Another problem area may be SEROTONIN, a NEU-ROTRANSMITTER, which also affects frame of mind,appetite, and sex drive. Low levels of serotonin canalso cause craving for carbohydrates.

A study conducted by Toner, Garfinkel and Garnerinvestigated the incidence of mood and anxiety dis-orders in women who had been diagnosed withanorexia nervosa five to 14 years earlier. Results indi-cated that these disorders developed frequently, regard-less of the outcome of the anorexia nervosa. Majordepression and anxiety disorders developed beforethe eating disorder in more than half of these cases.

A genetic or familial tie between eating and mooddisorders has also been noted in several studies. Inone, a group of 26 anorexic patients had two fathers,15 mothers and six siblings diagnosed as havingmood disorders. In another study, 25 anorexia ner-vosa patients were compared with 25 nonanorexics.The relatives of those with anorexia had a 22 percentincidence of mood disorder, whereas only 10 percentof the relatives of the control group had such histo-ries. And a University of Minnesota study reportedthat among patients with bulimia, 34 to 60 percenthad first-degree relatives with mood disorders. Aswith the relatives of the patients with anorexia ner-vosa, the predominant type of mood disorder amongthem was major depressive disorder. And treatments

specifically for eating disorders have been found toalleviate depression.

Noting that few studies have investigated the spe-cific associations of major depression versus dys-thymia (a mood disorder characterized by milddepression) with eating disorders, Perez et al. fol-lowed 937 adolescents until the age of 24. “Theywrote: Analyses revealed that dysthymia was astronger correlate with bulimia than major depres-sion, even while controlling for other mood disordersand a history of depression and dysthymia. The pres-ence of dysthymia in adolescence might be a possiblerisk factor for the development of bulimia nervosa.”

Polivy and Herman sum up the connection: “Theco-occurrence of eating disorders and mood disor-ders (particularly depression) has been frequentlynoted and may reflect primary mood disturbance ineating disorders, mood disorders secondary to eat-ing disorders, or common third variables (biologicalor psychosocial) leading to both, such as genetic orfamilial transmission. The lack of a well-organizedbody- and self-image is unique to eating disorders,however. Some evidence supports the primacy ofthe eating disorder; eating disorder symptoms anddietary restraint predicted subsequent depression ininitially nondepressed individuals. Some studiesfind that eating disorder onset follows that of mooddisorder, whereas still others suggest that depres-sion and anxiety are more state-dependent featuresthat resolve when eating disorder symptoms remit.Actually inducing negative affect increases bodydissatisfaction and body-size perception in bulimianervosa patients, suggesting that whichever isprimary, negative affect can contribute to eatingdisorder symptoms.” (See also DEPRESSION AND

EATNG DISORDERS.)Evidence against a connection between eating

disorders and mood disorders is that eating disor-ders and mood disorders have different patterns ofrecovery; treatments that work for depression donot always work for eating disorders. And accord-ing to Dr. Moises Gaviria, professor of psychiatry atthe University of Illinois at Chicago, at five-yearfollow-up, only 3 percent of depressed adolescentsare eating-disordered, and their chances of devel-oping an eating disorder in their lifetime is only 2percent. The chances of their developing anothermood disorder are 6 to 10 percent.

205mood disorders and eating disorders 205

Goldbloom, D. S., and P. E. Garfinkel. “The SerotoninHypothesis of Bulimia Nervosa: Theory and Evi-dence,” 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 Disor-ders?” 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 Depres-sion: A Review of the Affective Variant Hypothesis.Psychological Bulletin 102, no. 1 (July 1987): 150–158.

Jewell, Regina. “Affective, Eating Disorders: Their Com-mon Ground.” BASH Magazine, November 1989.

Munoz, Rodrigo A. “The Basis for the Diagnosis ofAnorexia Nervosa.” In The Psychiatric Clinics of NorthAmerica, 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 MajorDepressive Disorder or Dysthymia More StronglyAssociated with Bulimia Nervosa?” International Jour-nal of Eating Disorders 36, no. 1 (July 2004): 55–61.

Polivy, Janet, and C. Peter Herman. “Causes of EatingDisorders.” Annual Review of Psychology 53 (February2002): 187–213.

Toner, Brenda B., Paul E. Garfinkel, and David M. Garner.“Affective and Anxiety Disorders in the Long-TermFollow-up of Anorexia Nervosa.” International Journalof Psychiatry in Medicine 18, no. 4 (1988): 357–364.

mortality rate The number of deaths that occurper year in a particular population divided by the sizeof the population at that time. Mortality rates relatedto obesity and eating disorders include the following:

• Mortality rates for BARIATRIC SURGERY are “scantyand wildly inconsistent” according to a Newsday(May 26, 2004) article: “The InternationalBariatric Surgery Registry estimates the mortalityrate a month after surgery is one in 300 patients,while the American Society for Bariatric Sur-geons says the death rate is one in 200 patientsand a University of Washington study estimatesone in 50 patients dies after surgery.”

• A 12-year study of 750,000 individuals found thatmortality rates increased approximately twofoldfor men and women who weighed 50 percentmore 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 23percent lower mortality rate than those whoreported not trying to lose weight. This associa-tion was as strong for those who failed to loseweight as for those who succeeded in losingweight. Trying to lose weight was beneficial foroverweight (BODY MASS INDEX [BMI] of 25–30)individuals but not for obese (BMI greater than30) individuals.

• A study published in The Archives of Surgery con-cluded that obesity, as an independent risk factor,carries a nearly six-fold increase in mortality rate.

• In a review of the literature, Munson noted, “A50-year follow-up to the Harvard Growth Study of1922 to 1935 showed that obese adolescent boysages 13 to 18 experienced twice the mortality ratefrom cardiovascular disease in adulthood. Beingobese as an adolescent was a better predictor ofoverall mortality than being obese as an adult.”

• Anorexia nervosa has the highest mortality ratesof all psychological disorders: estimates rangefrom 12 to 18 percent.

• Gleaves and Cepeda-Benito note that mortalityrates for binge-eating disorder may be higherthan with bulimia nervosa because of the associ-ated obesity.

Gleaves, David H., and Antonio Cepeda-Benito. “EatingDisorders.” In Handbook of Mental Health in the Work-place, edited by Jay C. Thomas and Michael Hersen,311–329. Thousand Oaks, Calif.: Sage Publications,2002.

Munson, Suzanne. “Psychiatric Aspects of Child andAdolescent Obesity: A Review of the Past 10 Years.”Journal of the American Academy of Child and AdolescentPsychiatry 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. Apsychotherapeutic treatment method based on thepremise that the way we move is intrinsically con-nected to our thoughts and feelings. Dance, asspontaneous body movement, has been usedalmost from the beginning of history to expressfeelings and attitudes. The American Dance Ther-

206206 mortality rate

apy Association defines movement/dance therapyas “the psychotherapeutic use of movement as aprocess which furthers the emotional, cognitive,social and physical integration of the individual.” Itis a technique that uses nonverbal interactionbetween people as the primary means for accom-plishing therapeutic goals.

The premise behind movement therapy is thatthe body and mind are interrelated, thus mentaland emotional problems can result in muscle ten-sion and constrained movement patterns com-pounding the original condition. Conversely, thestate of the body can affect mental and emotionalwell-being both positively and negatively.

Levitt and Sansone explained further howmovement therapy works with eating-disorderedpatients: “An extremely important part of treat-ment is to provide an opportunity for clients toidentify their own body experiences more accu-rately (e.g., size and proportion, body image, rela-tion to others). Art, music, and movementtherapies are used in this process. For example,experiencing one’s body in motion during move-ment therapy develops an improved awareness ofthe spatial feel of the body self. For many, identify-ing internal experiences is difficult.”

Wennerstrand added, “Dance/movement thera-pists help clients to name and modulate strongemotions. That is, by attending to a bodily felt sen-sation, the individual can start to notice differentintensities of the sensation and through attentionto breath and movement, notice what changesoccur. Many patients are then better able to self-soothe anxiety and other feeling states on theirown outside of the therapy session.”

The tendency of women with eating disorders toblock their emotions and to fear loss of control isseen in blocked, split, rigid and restricted movementstyles. Their self-esteem problems are demonstratedprimarily in significant body image distortions. Theyseem to lack healthy boundaries in relationships andhave either a rigid or an unclear sense of their kine-sphere (personal body space). They tend to usemore gestural than postural movements and lackthe natural fluidity of movement.

At the end of movement therapy, eating disor-dered patients seem more comfortable watchingthemselves in the mirror and their body image is less

distorted and more acceptable to them. They gener-ally seem more self-accepting and sure of themselves.

Levitt, John L., and Randy A. Sansone. “The Treatmentof Eating Disorder Clients in a Community-Based Par-tial Hospitalization Program.” Journal of Mental HealthCounseling 25, no. 2 (April 2003): 140+.

Wennerstrand, Anne L. “Dance/Movement Therapy inthe Treatment of Eating and Body Image Problems.”International Eating Disorder Referral Organization.Available online. URL: http://www.edreferral.com/movement_therapy.htm. Downloaded on February10, 2005.

multicompulsive Also referred to as multi-impulsive. Having more than one compulsionsimultaneously. Ten percent of bulimics arereported to display compulsive behavior in otherareas, such as alcohol, drugs, stealing and sex.Multicompulsive behavior is very difficult to treat.

Bulimics and anorexics sometimes becomeinvolved with drugs such as cocaine, methamphet-amine, CAFFEINE and over-the-counter DIET PILLS asthey learn about and experiment with theirappetite-suppressing qualities. As their eating dis-orders worsen, substances such as alcohol, mari-juana, barbiturates and so on become an enticinganodyne for painful reality.

Eating-disordered women may actually convincethemselves that their substance abuse in some wayhelps lessen the severity of their eating disorders. Butin reality, substance abuse tends only to exacerbatetheir effects. For example, a bulimic woman whoalso abuses cocaine will extol the drug’s tendency tooffset food binges and decrease her appetite. Uponfurther discussion, however, she will be less enthusi-astic about addressing her BINGE EATING and PURGING

as she copes with the DEPRESSION and despair that setin after the cocaine has worn off. An eating-disor-dered marijuana abuser may insist that her use of thedrug 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 particularlyvulnerable to substance abuse when they areattempting to break away from bulimic or anorexicbehavior. As uncomfortable feelings and memoriesbegin to surface, they may seek intoxication as ameans to numb their feelings without resorting to

207multicompulsive 207

compulsive behavior toward food. Richard L. Pyle, aclinician with the Department of Psychiatry of theUniversity of Minnesota, reported that at least 2 per-cent of the women coming to his clinic for evaluationwere also abusing alcohol and that one in five hadhad previous treatment for chemical dependency.

Bulimic women who abuse alcohol present spe-cial problems. Perhaps the most significant problemis the high frequency of SUICIDE attempts. In onestudy, 32 percent of bulimic women who had a his-tory of alcohol abuse reported suicide attempts,compared with none by non-alcohol-abusingbulimics and 26 percent by a third group of bulimicwomen with a history of major depression. In addi-tion, bulimic women who had a history of chemicaldependency had an older age of onset; significantlymore DIURETIC ABUSE and LAXATIVE ABUSE; worsefunctioning in social, financial and work areas; ahigher incidence of stealing both before and afterthe onset of their eating disorder; and, more often,a history of previous inpatient treatment forbulimia (56 percent vs. 4 percent).

Daily substance abuse produces sufficient loss ofcontrol that outpatient treatment of bulimia ner-vosa is often unsuccessful. Inpatient care may berequired to treat the chemical dependency, eitherconcurrently with or preceding outpatient care forbulimia nervosa. Many clinicians also believe thata history of substance abuse in bulimia nervosa isassociated with negative treatment outcome.

However, a two- to five-year follow-up study byDr. Pyle’s clinic indicated that, after treatment in anintensive outpatient group psychotherapy pro-gram, 24 patients who had a history of chemicalabuse did as well as 65 who did not. In both groups67 percent of the patients were symptom free atfollow-up, and 25 percent were virtuallyunchanged. Only one of the 24 women with a his-tory of chemical dependency required chemicaldependency treatment during the follow-up,which averaged three and a half years, and three of65 bulimic women without a history of chemicalabuse required chemical dependency treatment.Therefore, Dr. Pyle summarized, a history of chem-ical abuse does not necessarily influence outcomenegatively; and following successful treatment,patients with a history of alcohol abuse are nomore at risk for chemical dependency than thosewith no history of alcohol abuse.

Doctors are also reporting a new trend of girlsand young women using highly addictive cocaineand crack to lose weight. Drug dealers even pro-mote these drugs with weight loss in mind, tellinggirls as young as 10 that boys like only thin girlsand that crack (or cocaine) will help them loseweight. Crack, which is cheaper, is used mainly bypoorer users, whereas cocaine is the drug of choicefor the wealthier. Crack and cocaine suppressHUNGER by stimulating the central nervous system.Users feel no need to eat or sleep.

In a potentially important recent study by Gleavesand Eberenz, the authors found that a large propor-tion of bulimic patients who displayed multi-impul-sive characteristics also reported a history of sexualabuse. The authors speculated that many of thebehaviors observed among this subgroup of patientsmay be part of a chronic posttraumatic stress reac-tion. The authors also noted that treatments mayneed to address the posttraumatic condition beforedirectly attempting to change eating behavior.

Gleaves, D. H., and Eberenz, K. P. “Sexual-Abuse Histo-ries among Treatment-Resistant Bulimia NervosaPatients.” International Journal of Eating Disorders 15,no. 3 (April 1994): 227–231.

Mitchell, James E., Richard L. Pyle, et al. “A 2–5 YearFollow-Up Study of Patients Treated for Bulimia.”International Journal of Eating Disorders 8, no. 2 (March1989): 157–165.

Pyle, Richard L. “The Subtle, Puzzling Affinity of Drugsand Bulimia.” BASH Magazine, September 1989.

multidimensional/multifactorial models Cur-rently, the psychopathology of eating disorders isbelieved to be multidimensional in nature, and aseries of factor analytic studies have identifiedwhat the various dimensions are for both anorexiaand bulimia nervosa. Generally consistent acrossstudies, the dimensions or features appear to be 1)bulimic behaviors (i.e., bingeing and purging); 2)restrictive eating; 3) body dissatisfaction/fear of fat-ness; 4) affective disturbance; and 5) personalitydisturbance. Some studies have found the lattertwo dimensions to be a single dimension.

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

208208 multidimensional/multifactorial models

———. “Validating a Multidimensional Model of the Psy-chopathology of Bulimia Nervosa.” Journal of ClinicalPsychology 51, no. 2 (March 1995): 181–189.

Gleaves, D. H., D. A. Williamson, and S. E. Barker. “Con-firmatory Factor Analysis of a MultidimensionalModel of Bulimia Nervosa.” Journal of Abnormal Psy-chology 102, no. 1 (February 1993): 173–176.

Multifactorial Assessment of Eating DisorderSymptoms (MAEDS) MAEDS is a brief self-reportinstrument designed to be used to evaluate treat-ment outcome for anorexia and bulimia nervosa.The instrument has six scales empirically and theo-retically 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 andValidation of a Multiaxial Treatment of OutcomeMeasure for Eating Disorders.” Assessment, 6, no. 1(March 1999): 7–20.

muscle dysmorphia Also called muscle dysmor-phic disorder and bigorexia, this disorder is theopposite of anorexia nervosa. People with muscledysmorphia obsess about being small and undevel-oped, rather than too large; they worry that theirmuscles are inadequate. They may spend hours inthe gym, abuse supplements or steroids in order tobecome larger and withdraw from social situationsin order to pursue their fitness goals. Choi et al.noted, “In addition to a desire for greater muscu-larity, they are very concerned not to gain fat.”

The term was first used by Pope and his col-leagues (McLean Hospital/Harvard) in 1997. Theauthors interviewed 24 men (18–30 years old) withmuscle dysmorphia and 30 comparison weightlifters,recruited from gymnasiums in the Boston area, usinga battery of demographic, psychiatric and physicalmeasures. Data showed that the men with muscledysmorphia differed significantly from comparisonweightlifters on measures such as body dissatisfac-tion, eating attitudes, prevalence of anabolic steroidsuse and lifetime prevalence of DSM-IV mood, anxi-ety and eating disorders. Men with muscle dysmor-phia frequently described shame, embarrassmentand impairment of social and occupational function-ing in association with their condition. By contrast,ordinary weightlifters displayed little pathology.

Although males make up the majority of peopleidentified as having muscle dysmorphia, Gruber andPope, who performed psychiatric and medical evalu-ations of 75 dedicated women athletes, found amongthem several unusual psychiatric syndromes, such as“rigid dietary practices (which we have termed ‘eat-ing disorder, bodybuilder type’), nontraditional gen-der roles and chronic dissatisfaction and pre-occupation with their physiques (a syndrome whichwe have termed ‘muscle dysmorphia’).”

Choi, P. Y., H. G. Pope, Jr., and R. Olivardia. “Muscle Dys-morphia: A New Syndrome in Weightlifters.” BritishJournal of Sports Medicine 36, no. 5 (October 2002):375–377.

Gruber, A. J., and H. G. Pope, Jr. “Psychiatric and Med-ical Effects of Anabolic-Androgenic Steroid Use inWomen.” Psychotherapy and Psychosomatics 69, no. 1(2000): 19–26.

Olivardia, R., H. G. Pope, and A. J. Hudson. “Muscle Dys-morphia in Male Weightlifters: A Case ControlStudy.” American Journal of Psychiatry 157, no. 8(August 2000): 1,291–1,296.

Pope, Harrison G., et al. “Muscle Dysmorphia: An Under-recognized Form of Body Dysmorphic Disorder.” Psy-chosomatics 38, no. 6 (November–December 1997):548–557.

music Slow music reduces APPETITE, according toJohns Hopkins University research led by MariaSimonson. Researchers counted the number ofbites people took during meals while listening tomusic. Subjects who listened to no music took 3.9bites per minute, with a third asking for secondhelpings. Those who listened to lively music ate anaverage of 5.1 bites per minute, with almost halfrequesting second helpings. But subjects listeningto soothing flute instrumentals ate only 3.2 bitesper minute, and none requested seconds. Most ofthe slow-music diners left about a quarter of thefood on their plates and said they were full. Theyalso had fewer digestive complaints and said theirfood tasted better. Researchers speculated thatheightened taste occurred because chewing forcesair from the throat to the nose, allowing the noseto smell the food. Because odor is an importantelement in the sense of taste, slower chewing givesa heightened sense of flavor.

See also EATING HABITS MONITORING; TASTE.

209music 209

NNAAFA (National Association to Advance FatAcceptance) Formerly known as the NationalAssociation to Aid Fat Americans, this nonprofit,tax-exempt organization formed in 1969 seeks toincrease the happiness and well-being of fat people.

Its basic purposes are to assist the large numberof people regarded by the medical profession as“persistently or incurably overweight” to adapt tothemselves and increase their self-confidence; topromote social tolerance toward fat people; toserve as a forum in which important problemsaffecting heavy people can be openly discussed; todisseminate knowledge pertaining to the sociolog-ical, psychological, medical and physiologicalaspects of obesity; and to sponsor research con-cerning these aspects of obesity. NAAFA is con-cerned with the general issues of fat people’s lives,such as job discrimination, individual psychologicalproblems and difficulties with respect to socialacceptance and mobility. Its goal is to remedy thesedifficulties rather than to make members leaner. Itsquarterly publication is the NAAFA Newsletter.

narcissistic personality disorder As defined inDSM-IV, the essential feature of narcissistic person-ality disorder is a pervasive pattern of grandiosity,need for admiration and lack of empathy thatbegins by early adulthood and is present in a vari-ety of contexts. Many theories attribute anorexiaand bulimia nervosa to “pathological narcissism.”To evaluate this conception, Steiger, et al., com-pared narcissism scores of 90 eating disorder suf-ferers with 90 control subjects. Narcissism scores ofeating-disordered patients consistently exceededthose of the control cases.

In a Canadian study, Lehoux et al. concluded,“Narcissism may be a common trait characteristic

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

Lehoux, P. M., H. Steiger, and S. Jabalpurlawa.“State/Trait Distinctions in Bulimic Syndromes.” Inter-national Journal of Eating Disorders 27, no. 1 (January2000): 36–42.

Steiger, H., et al. “A Controlled Study of Trait Narcissismin Anorexia and Bulimia Nervosa.” International Jour-nal 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 theUnited States working to prevent eating disordersand provide treatment referrals to those sufferingfrom anorexia, bulimia and binge-eating disorderand those concerned with body image and weightissues. NEDA was formed in 2001, when EatingDisorders Awareness and Prevention (EDAP)joined forces with the American Anorexia BulimiaAssociation (AABA), merging the largest and old-est eating disorders prevention and advocacyorganizations in the world. Headquartered in Seat-tle, Washington, with an office in New York City,the organization is staffed by 10 full-time employ-ees and many dedicated volunteers. NEDA’s mis-sion is to expand public understanding of eatingdisorders and promote access to quality treatmentfor those affected along with support for their fam-ilies through education, advocacy and research. Toachieve this, they develop prevention programs fora wide range of audiences, publish and distributeeducational materials, and operate a toll-free eat-ing disorders information and referral help line.

See also APPENDIX III.

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National Eating Disorders Screening Program(NEDSP) An educational and two-stage screen-ing program designed to detect potentially clini-cally significant disordered eating attitudes andbehaviors and offer referrals for further evaluationwhen warranted. The first National Eating Disor-ders Screening Program was conducted on morethan 400 college campuses in 1996.

The goal of the screening event is to reduce thestigma attached to eating disorders and let studentsknow that help is available, according to Screeningfor Mental Health, the nonprofit organization thatsponsors the NEDSP. The program offers educationand screening to help students stop unhealthy eat-ing habits before they evolve into full-blown eatingdisorders. As part of the program, students hear aneducational presentation, complete a written self-assessment and have the opportunity to talk pri-vately with a health professional about theirscreening results. If appropriate, students may bereferred to the counseling center for a completeevaluation. Colleges across the United States offerthis program in conjunction with Eating DisordersAwareness Week.

Assessing the impact of the NEDSP on partici-pants, Becker et al. determined that while suchprograms may be a promising strategy for second-ary prevention of eating disorders, mere awarenessof the risks of disordered eating and available treat-ment may not be sufficient to motivate individualsto adhere to recommendations to seek treatment.

Studies of the first NEDSP also suggest that cli-nician bias may be an important barrier to care foreating disorder symptoms in ethnic minority pop-ulations. “Even after controlling for severity of self-reported eating disorder symptoms, both Latinoand Native American participants in the NEDSPwere significantly less likely than Whites to receivea recommendation or referral for further evalua-tion or care. Ethnic minority subjects with self-acknowledged eating and weight concerns werealso significantly less likely than non-minority par-ticipants to have been asked by a doctor about eat-ing disorder symptoms. Only one marginallysignificant difference was found between ethnicminority and non-minority respondents withrespect to their help-seeking behaviors, namely,ethnic minority subjects were less likely (at the

level of a trend) to seek eating disorders treatmentwithin 1(1/2)-2 years following the NEDSP.”

Becker, A. E., et al. “Ethnicity and Differential Access toCare for Eating Disorder Symptoms.” InternationalJournal of Eating Disorders 33, no. 2 (March 2003):205–212.

Becker, A. E., et al. “Secondary Prevention for EatingDisorders: The Impact of Education, Screening, andReferral in a College-Based Screening Program.”International Journal of Eating Disorders 36, no. 2 (Sep-tember 2004): 157–162.

National Weight Control Registry (NWCR) ANational Institutes of Health–funded researchstudy of individuals who have managed to loseweight successfully over the long term. It wasdeveloped by Rena Wing, Ph.D., of Brown Univer-sity and the University of Pittsburgh, and JamesHill, Ph.D., at the University of Colorado, to studyweight loss and weight maintenance strategies.The registry includes more than 4,000 adults whohave each lost an average of 60 pounds or moreand maintained their weight loss for an average of5.5 years—some longer than 10 years.

NWCR is an ongoing study that solicits partici-pants who are at least 18 years of age, have lost atleast 30 pounds, and have maintained a weightloss of at least 30 pounds for one year or more.Individuals enrolling in the registry are periodi-cally asked to complete questionnaires about theirsuccess at losing weight, current weight mainte-nance strategies and other health-related behav-iors. There is no cost to enter the registry andparticipants receive no compensation. All namesare kept confidential. Further information is avail-able on the Web site (http://www.nwcr.ws) or bycalling 1-800-606-NWCR (6927).

The researchers have reported a number offindings from the study’s data. Among them:

• Medical events or conditions are often reportedas “triggers” for weight loss (other triggersinclude psychological and environmental fac-tors), meaning that, they can initiate weight loss.Participants with medical triggers were olderthan those with nonmedical triggers or no trig-ger, had a higher initial BODY MASS INDEX (BMI)at entry into the NWCR, and were more likely to

212 National Eating Disorders Screening Program

be male. Participants with medical triggersreported greater initial weight loss than thosewith nonmedical triggers or no trigger. Partici-pants with medical triggers also gained lessweight over two years of follow-up than thosewith nonmedical triggers or no trigger.

• Although successful weight losers continued tomaintain a large percentage of their weightlosses over two years, recovery from even minorweight regain was uncommon.

• Participants who reported a consistent diet dur-ing the week were 1.5 times more likely tomaintain their weight within five pounds overthe subsequent year than participants whodieted more strictly on weekdays. A similar rela-tionship emerged between dieting consistentlyacross the year and subsequent weight regain.

• Data from the NWRC indicate that moderatingdietary fat intake is a key strategy for long-termmanagement of body weight.

• A large proportion of NWCR subjects (78 per-cent) reported regularly eating breakfast everyday of the week. Only 4 percent reported nevereating breakfast. Thus, eating breakfast may be afactor in the success of people who maintainweight loss over time.

• Although approaches to weight loss differ widelyamong the NWCR participants, strategies forweight loss maintenance are similar—includingeating a diet low in fat, frequent self-monitoringof body weight and food intake and high levelsof regular physical activity.

Gorin, A. A., et al. “Promoting Long-Term Weight Con-trol: Does Dieting Consistency Matter?” InternationalJournal of Obesity and Related Metabolic Disorders 28, no.2 (February 2004): 278–281.

Gorin, A. A., et al. “Medical Triggers Are Associated withBetter 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 Suc-cessful Weight Maintainers.” American Journal of Clini-cal Nutrition 78, no. 6 (December 2003): 1,079–1,084.

Wing, Rena R., and James O. Hill. “Successful WeightLoss Maintenance.” Annual Review of Nutrition 21(2001): 323–341.

Native Americans and eating disorders SeeAMERICAN 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 tothose carbohydrates having an effect on bloodsugar and insulin. Under a Food and Drug Associa-tion food labeling agreement in 2001, net carbohy-drates can be calculated from a food source bysubtracting sugar alcohols and fiber (which areshown to have no effect on blood sugar level) fromtotal carbohydrates. But the concept of net carbs iscontroversial. Ellison writes, “Is the term a reliablenutritional designation or a dubious marketingtool? Even the Food and Drug Administration isstill debating the definition of the term, while itattempts to come up with standards for ‘low-carb.’ ” Although the number of products listing netcarbs on their labels continues to grow, nutritionexperts say the science behind these claims is fuzzy,and it is unclear whether counting net carbs willhelp or hurt weight loss efforts. Some experts ques-tion the accuracy of net-carb counts on food labels.

Ellison, Sarah. “Blood Sugar, Sugar Alcohol and theFDA.” Wall Street Journal, July 26, 2004, pp. B1, B6.

neurotransmitters Chemicals that transmit elec-trical impulses or “messages” from one neuron(nerve cell) to another or to a muscle cell.

Much scientific study has been directed at keychemical messengers in the brain that play a majorrole in regulating hormone production.Researchers have found anorexics and bulimics tohave abnormal levels of certain neurotransmitters.For example, low levels of the neurotransmitterSEROTONIN are linked to bulimia, as well as themood disorders, depression and impulsive behav-ior associated with bulimia. Low serotonin levelsmay contribute to bulimics’ binge eating of foodhigh in carbohydrates.

In anorexia, lower-than-normal levels of norepi-nephrine are found in the spinal fluid. Because thenorepinephrine levels are low in anorexic patientswho have regained weight, it is possible that this

neurotransmitters 213

neurotransmitter abnormality precedes weight lossand may, in fact, indicate a genetic connection to theeating disorder. But the same biochemical conditionalso could result from anorexics’ starvation practices.

night eating syndrome (NES) The name given byAlbert J. Stunkard in 1959 to an eating patternin which an obese person succeeds in keeping hiseating-disordered behavior under control duringthe day, in the interest of normal functioning, butis unable to resist it at night when alone. HILDE

BRUCH described such a patient:

She was quite efficient in her work, although hersevere obesity became increasingly a handicap.When she was alone at night, the tension and anx-iety became unbearable. “I think then that I amravenously hungry and I do my utmost not to eat.My body becomes stiff in my effort to control myhunger. If I want to have any rest at all, I’ve got toget up and eat. Then I go to sleep like a newbornbaby.” Patients with Night Eating Syndrome areunable to adhere to any dietary regimen as long astheir problems and conflicts are unresolved, or aslong as they remain in an anxiety- and rage-pro-voking environment. They can reduce without dif-ficulty in a hospital but will regain as soon as theyreturn to the old setting.

In a study reported in 1996, Stunkard and histeam concluded that the frequency of night eatingsyndrome is comparable to that of binge-eating dis-order. This was followed in 1997 by a University ofFlorida study that found prevalence of night eatingsyndrome to be higher among postoperative obe-sity patients than among a randomly selected sam-ple of adults, but within the range reported forbinge-eating disorder. They concluded that nighteating syndrome may warrant consideration as adistinct eating disorder.

Tanofsky-Kraff and Yanovski argue, however,that it is yet unclear whether night eating syndromeas currently defined should be a distinct patient sub-group. “We propose that a distinction be madebetween ‘eating disorders’ and ‘non-normative’ eat-ing patterns without associated distress or impair-ment. Although non-normative eating patterns maynot be considered mental disorders, they may bevery important in terms of their impact on bodyweight and health. More precise behavioral and

metabolic characterization of subgroups with eatingdisorders and non-normative eating behaviors hasimportant implications for understanding the etiol-ogy, pathophysiology, and treatment of obesity. Ulti-mately, better understanding of the many pathwaysto increased energy intake may lead to targetedstrategies for prevention of overweight and obesityin at-risk individuals and populations.

In a comparison of obese and nonobese personswho have NES, Marshall et al. found very little dif-ference between the two groups, except that thenormal-weight NES subjects were considerablyyounger, leading the authors to conclude, “Thestriking similarity in the characteristics betweenobese and nonobese subjects with the NES indi-cates that this disorder, considered until now tooccur primarily among obese persons, also occursamong nonobese persons. The younger age of thenonobese subjects suggests that the NES may con-tribute to the development of obesity.”

Striegel-Moore et al. attempted to describe theprevalence of night eating in a community cohortof black and white girls, using different definitionsof night eating as described in the literature. Theyfound that frequency of night eating variedtremendously depending on how the behavior wasdefined. Thus, they concluded, “A standard defini-tion of night eating behavior is needed to advancethe field. An agreed-on operationalized definitionthat includes time of day, amount of calories con-sumed, and a frequency criterion would enablecross-study comparisons and encourage the exam-ination of developmental and clinical considera-tions of night eating behavior.

Stunkard and Allison noted in 2003 that “Stud-ies of treatment for NES are in their infancy butselective serotonin reuptake inhibitors (SSRI)show promise.” Stunkard has found NES in 6 to 7percent of people in weight-loss programs and upto 28 percent of those seeking gastric-bypass sur-gery. In their book, Overcoming Night Eating Syn-drome, Allison et al. put the disease in perspectivewith the following facts:

• Of people seen in clinics for treatment of obesity,9 percent also suffer from NES.

• Approximately a third or more of individualswho are extremely overweight, ranging from 27to 42 percent, also have NES.

214 night eating syndrome

• About 40 percent of all people with NES aremen; about 60 percent are women.

• NES usually develops in people in their 20sand 30s, but for some it may develop earlier orlater because of a strong genetic component intheir eating behaviors or in response to astressful life situation.

Allison, Kelly C., Albert J. Stunkard, and Sara L. Thier.Overcoming Night Eating Syndrome: A Step-by-Step Guideto Breaking the Cycle. Oakland, Calif.: New HarbingerPublications, 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 amongNonobese Persons.” International Journal of Eating Dis-orders 35, no. 2 (March 2004): 217–222.

Rand, C. S., et al. “The Night Eating Syndrome in theGeneral Population and among Postoperative ObesitySurgery Patients.” International Journal of Eating Disor-ders 22 (July 1997).

Striegel-Moore, R. H., et al. “Definitions of Night Eatingin Adolescent Girls.” Obesity Research 12, no. 8 (August2004): 1,311–1,321.

Stunkard, Albert J., et al. “Binge Eating Disorder andNight Eating Syndrome.” International Journal of Obe-sity and Related Metabolic Disorders 20 (January 1996).

Stunkard, Albert J., and Kelly C. Allison. “Two Forms ofDisordered Eating in Obesity: Binge Eating and NightEating.” International Journal of Obesity and RelatedMetabolic Disorders 27, no. 1 (January 2003): 1–12.

Tanofsky-Kraff, M., and S. Z. Yanovski. “Eating Disorderor Disordered Eating? Non-normative Eating Patternsin Obese Individuals.” Obesity Research 12, no. 9 (Sep-tember 2004): 1,361–1,366.

Niños Activos, Familias Sanas (Active Children,Healthy Families) A Centers for Disease Controland Prevention (CDC) campaign launched in sum-mer 2004 to encourage Hispanic/Latino parents toget their children ages nine to 13 involved in phys-ical activity for at least 60 minutes every day as away to reduce childhood obesity. The campaignused various communications channels to conveyculturally relevant messages in Spanish. In addi-tion to TV, radio and print, a 26-week event tourvisited various events across the country. Commu-nity and corporate partnerships help to ensure thatthese efforts are sustained and adopted by other

organizations interested in affecting the futurehealth and well-being of Hispanic children acrossthe United States.

nocturnal sleep-related eating disorder SeeSLEEP-RELATED EATING DISORDER.

nonexercise activity thermogenesis (NEAT)Physical activity associated with fidgeting, restless-ness, stretching, maintenance of posture, movingaround and other activities of daily life. In a MayoClinic study in which 16 people volunteered tostuff themselves with 1,000 extra calories a day foreight weeks, some gained as much as 16 pounds,while others gained as little as two pounds. The dif-ference, according to the researchers, was due toincreased total daily energy expenditure throughincreased NEAT. Those people who had the great-est increase in NEAT gained the least fat, and thosewho had the least change gained the most. Theseresults suggest that as humans overeat, activationof NEAT dissipates excess energy to preserve lean-ness and that failure to activate NEAT may result inready fat gain.

In a later study Levine et al. examined NEAT’srole in obesity by measuring volunteers’ body pos-tures and movements every half-second for 10days. Obese individuals were seated, on average,two hours longer per day than lean individuals.Posture allocation did not change when the obeseindividuals lost weight or when lean individualsgained weight, suggesting, the authors concluded,that it is biologically determined. “If obese individ-uals adopted the NEAT-enhanced behaviors oftheir lean counterparts, they might expend anadditional 350 calories (kcal) per day.”

Levine, James A., N. L. Eberhardt, and M. D. Jensen.“Role of Nonexercise Activity Thermogenesis in Resis-tance to Fat Gain in Humans.” Science 283, no. 5399(January 8, 1999): 212–214.

Levine, James A., et al. “Interindividual Variation in Pos-ture Allocation: Possible Role in Human Obesity.” Sci-ence 307, no. 5709 (January 28, 2005): 584–586.

novelties for weight loss Commercial items,usually useless for any practical purpose, designedto appear useful or amusing. Some novelties are

novelties for weight loss 215

devices contrived to be taken seriously by peopleinterested in losing weight or becoming trim, forinstance, by appearing capable of reshaping a per-son’s body while he or she remains completely pas-sive. Such items are sold in health food stores,drugstores, special clinics and salons, as well asthrough the mail and over the Internet.

A few of these, like “appetite-suppressing” eye-glasses with colored lenses that are supposed toproject an image to the retina that dampens thedesire to eat, are or border on the ridiculous. Yethundreds, even thousands, of overweight peopleallow their unhappiness with their condition tooverride their common sense and are duped bysuch products regularly.

One weight reduction novelty, BODY WRAPPING,was invented in France. Areas of the body to bereduced are smeared with a cream, which maycontain such ingredients as sea salt, herbs and codliver oil, and wrapped in special bandages or gar-ments. The intent is to “melt” or “burn” fat, espe-cially CELLULITE, right off the body. The creams,gels, wraps, belts and sweatsuits are said to reducebody dimensions by removing fluids—that is, theuser sweats it off. This is a very temporary lossbecause the fluid is regained when the person eatsor drinks. Moreover, rapid and excessive fluid lossis potentially dangerous because it can causesevere dehydration and chemical imbalance. TheU.S. Food and Drug Administration has taken legalaction against several promoters of these productsfor making unsubstantiated weight loss claims.

Other French techniques for fighting celluliteare more aggressive, and some are potentially dan-gerous. Machines massage a woman’s legs withpowerful jets of air or administer a barrage of “fat-dispersing” injections.

A reducing machine that delivers slight electri-cal shocks to selected muscles, causing them tocontract and supposedly do the client some good,has achieved some degree of popularity. A 35-minute session with the machine is supposed to beequivalent to 1,500 push-ups or sit-ups withoutthe unpleasant aches and pains required from suchstrenuous exercise.

The electrical muscle stimulator has legitimateuses in physical therapy but is useless for weightloss or figure firming. Claims that stimulation from

these devices has the figure-toning effect of asmany as 3,000 sit-ups, for example, are withoutany scientific basis. Further, these devices, oftenpromoted through mail order for home use, can bedangerous if not handled correctly. There havebeen reports of electrical shocks and burns, and thedevices can be particularly hazardous to pregnantwomen and to people with heart problems, pace-makers or epilepsy.

Hillel Schwartz believes that the popularity ofthese novelties lies in the key word for Americandieting: secrecy. He says that although dieters wantto have others notice weight loss, most do notwant others to know they are dieting. Thus, suchimplements of fat destruction as girdles, corsetsand wooden roller belts (the forerunners of today’svibrating machines) became popular because theycould 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, vita-mins, minerals and water. Carbohydrates, fats andproteins provide energy, and vitamins and miner-als are essential for the METABOLISM that uses thisenergy. Water, composing 60 percent of our totalbody weight, provides the medium in which chem-ical reactions take place.

The combination of processes by which thebody takes in and uses food containing these nutri-ents, which includes digestion and metabolism, iscalled nutrition.

Nutrient-dense foods are those that providesubstantial amounts of vitamins and minerals andrelatively fewer calories, such as fruits and vegeta-bles. The opposite of nutrient dense is caloriedense, which describes foods that mainly supplycalories and relatively few nutrients. They are typ-ically high in fat and/or sugar, such as white bread,pastries, ice cream or chocolate candy.

The Dietary Guidelines for Americans, released bythe U.S. Department of Health and Human Ser-vices (HHS) and the U.S. Department of Agricul-ture (USDA) every five years, are the federalgovernment’s science-based advice designed to

216 nutrients

help Americans choose diets that will meet nutri-ent requirements. The 2005 guidelines warnedthat many Americans consume more calories thanthey need without meeting recommended intakesfor a number of nutrients.

Nutritional intake is of particular importance inadolescence because of rapid growth and develop-ment during this period, but several governmentand private studies have shown that while obesityamong American children is escalating, consump-tion of Recommended Daily Allowance of criticalfoods and nutrients is on the decline. Adolescentswith anorexia nervosa also rob their bodies ofessential nutrients.

While anorexics do not take in enough food toprovide adequate nutrients, people with binge-eat-ing disorder usually eat large amounts of fats andsugars, which do not have a lot of vitamins or min-erals, so they also may not get the right nutrients.The overweight or obese need to be wary of faddiets, which may not provide all of the nutrientsthe body needs.

U.S. Department of Health and Human Services, U.S.Department of Agriculture. Dietary Guidelines for Amer-icans 2005. Washington: U.S. Government PrintingOffice, 2005. Available online. URL:http://www.health.gov/dietaryguidelines/dga2005/document.Downloaded on August 15, 2005.

nutritional counseling Frequently recommendedin the treatment of eating disorders. As physiciansMichele Siegel and Judith Brisman and MargotWeinshel explain in their book Surviving an EatingDisorder, “Some people with eating disorders haveextremely chaotic eating patterns or have noteaten a ‘meal’ in years. Nutritionists, who aretrained to assess nutritional imbalances anddevelop dietary programs, can help recoveringclients correct nutritional deficits and develophealthy eating habits, perhaps for the first time.”The authors say that counseling is most successfulafter binge eating, purging or starving behaviorshave decreased, when food is no longer used as acoping mechanism and eating is a response tophysiological, not psychological, hungers.

Professor P. J. V. Beumont, presenting a paperon “Dietary Advice” at the BASH VII International

Conference in April 1989, stated that nutritionalcounseling is an important component of the treat-ment of all bulimic patients and is usually essentialif therapy is to be effective. He gave the followingreasons why nutritional guidance is so important:

• Eating behavior is often so erratic in bulimicsthat patients need to regain control of theirhabits before they become involved in otherforms of treatment such as PSYCHOTHERAPY.

• Bulimics view their problem as one of overeat-ing and do not understand that gorging is aresponse to prior restrained eating practices.

• Bulimics have many fears and misconceptionsabout food and weight control that need to beidentified and corrected. (They firmly believethat if they eat regular meals or high-energyfoods, they will inevitably get fat.)

• Bulimic patients have had disordered eatinghabits for so long that they need to learn to rec-ognize when they are hungry and when theyare satisfied.

Sometimes nutritional counseling is recom-mended in order to provide an appropriate diet.But a diet is not always the answer to an eating dis-order. Many eating-disordered people are actuallyexperts on diet and nutrition. They know whatthey should be eating. Eating disturbances are notdue to lack of knowledge or information but to thepsychological disorders that keep people fromusing them. Thus nutritional counseling worksbest, some experts feel, after psychological treat-ment has progressed.

In fact, nutritional counseling by itself has notbeen proven effective for anorexia nervosa. Pike etal. compared nutritional counseling with cognitive-behavioral therapy (CBT) for anorexia nervosaand found the overall treatment failure rate(relapse and dropping out combined) was signifi-cantly higher for nutritional counseling (73 per-cent) than for CBT (22 percent). Experts havenoted that this points to the need for nutritionalcounseling along with CBT when treatinganorexia nervosa.

Nutritional counseling is also important whentreating obesity, and critical following BARIATRIC

nutritional counseling 217

SURGERY, according to experts. Proper nutritionalcounseling may prevent long-term nerve damagefollowing weight-loss surgery. A program ofbehavioral treatment and nutritional counseling,designed to help make long-term changes in one’sdiet and physical activity, is also important forpatients taking appetite suppressant medications.

Some insurance companies now provide nutri-tional counseling in an effort to encourage theobese to lose weight, and people of normal weightto maintain good health.

Beumont, P. J. V. “Diet Guide for Bulimics.” BASH Maga-zine, June 1989.

Pike, K. M., et al. “Cognitive Behavior Therapy in thePosthospitalization Treatment of Anorexia Nervosa.”American Journal of Psychiatry 160, no. 11 (November2003): 2,046–2,049.

Siegel, Michele, Judith Brisman, and Margot Weinshel.Surviving an Eating Disorder. Rev. ed. New York: Peren-nial Currents, 1997.

218 nutritional counseling

Oobesity Body weight in excess of biological needs;excessive fatness.

The first federal guidelines on the identification,evaluation and treatment of overweight and obesityin adults were released on June 17, 1998, by theNational Heart, Lung, and Blood Institute (NHLBI),in cooperation with the National Institute of Diabetesand Digestive and Kidney Diseases (NIDDK), bothpart of the National Institutes of Health (NIH).

These clinical practice guidelines were designed tohelp physicians in their treatment of overweight andobesity, a growing public health problem that nowaffects 129.6 million American adults (over 20 yearsold), or 64.5 percent of the population. Womencomprise 64.5 million (61.9 percent) and men com-prise 65.1 million (67.2 percent). Nearly one-third ofU.S. adults are obese—61.3 million (30.5 percent).Women comprise 34.7 million (33.4 percent) andmen 26.6 million (27.5 percent) of the total.

Overweight and obese individuals are at increasedrisk of illness from hypertension, lipid disorders, TypeII diabetes, heart disease, stroke, gallbladder disease,osteoarthritis, sleep apnea and respiratory problems,and certain cancers (uterine, breast, colorectal, kid-ney and gallbladder). Obesity is also associated withhigh blood cholesterol, complications of pregnancy,menstrual irregularities, hirsutism (presence ofexcess body and facial hair), stress incontinence(urine leakage caused by weak pelvic floor muscles),psychological disorders such as depression andincreased surgical risk. A recent Swedish study alsofound that obese people are twice as likely to developdementia. The total costs attributable to obesity-related disease are $117 billion annually, $61 billiondirect costs and $56 billion indirect costs.

The NIH guidelines no longer utilize the traditionalheight/weight charts for defining obesity that insur-ance companies had relied on for years. According tocurrent guidelines, assessment of overweight involves

evaluation of three key measures: BODY MASS INDEX

(BMI), waist circumference and a patient’s risk factorsfor diseases and conditions associated with obesity.

The body mass index equals a person’s weight inkilograms divided by his or her height in meterssquared. Because BMI describes body weight relativeto height, it is strongly correlated with total body fatcontent in adults. To estimate BMI using pounds andinches, one divides the weight in pounds by the heightin inches squared and multiplies the result by 704.5.The multiplier 704.5 is used by the National Insti-tutes of Health. Other organizations may use a slightlydifferent multiplier; for example, the AmericanDietetic Association suggests multiplying by 700. Thevariation 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 cut-off points are a guide for definitions of overweightand obesity and are useful for comparative purposesacross populations and over time; however, thehealth risks associated with overweight and obesity areon a continuum and do not necessarily correspond torigid cutoff points. For example, an overweight indi-vidual with a BMI of 29 does not acquire additionalhealth consequences associated with obesity simplyby crossing the BMI threshold of 30. However, healthrisks generally increase with increasing BMI.

The definitions or measurement characteristics foroverweight have varied over time, from study tostudy, and from one part of the world to another. Thevaried definitions affect prevalence statistics andmake it difficult to compare data from different studies.

Excess fat accumulation is associated withincreased FAT CELL size; in extremely obese individ-uals, the number of fat cells is also increased. In thesimplest terms, obesity is an imbalance betweenintake of food and expenditure of energy. Theexcess taken in is stored in fat deposits, resulting inan increase in body weight.

219

Possible Causes

Why this imbalance occurs remains uncertain.Although genetic influences appear to be the mostlikely factor in explaining a tendency toward obe-sity, the precise trigger for its development isunknown. As a result, there is a variety of methodsfor treating obesity, with results that also vary.

Until recently, obesity was considered to be causedsimply by eating too much, as a result of psychologicalproblems with food: using food to deal with DEPRES-SION, anxiety, boredom, even happiness. The prevail-ing theory was that to lose weight an obese personneeded only to eat less. Recent studies have shown,however, that tendency to overweight is biologicalrather than psychological or diet driven. Some stud-ies have shown that thin people, as a group, tend toeat more than obese people. People with identical dietand exercise programs may become, or remain, fat orthin. The difference is now believed to be genetic.

Other research has demonstrated that obesitytends to occur in families. One large study, which col-lected data from approximately 10,000 individuals,revealed that hereditary factors accounted for 11 per-cent of the variance in the incidence of obesity, andfamily environment for 35 percent. Because familiesusually share diet and lifestyle habits that may con-tribute to obesity, the separation of pure genetic fac-tors from family environment is a challenge.

Jeffrey, Dawson and Wilson wrote that metabolicdeterminants of obesity have gained increasingattention from researchers. In a year’s time, theyexplain, the average person of normal weight con-sumes more than one million calories, but there islittle variation in body weight because a comparablenumber of calories is used in bodily maintenanceand activity. Taking in 10 percent more calories orexpending 10 percent less energy would lead to a30-pound weight gain within a year. Researchersconclude that in normal-weight individuals, bodyweight is regulated with extraordinary accuracy.Moreover, research suggests that the hypothalamusis directly linked to weight regulation, containing afeeding center that controls appetite and SATIETY andmaintains body weight. Leptin, a protein producedby fat cells, has been identified as playing a role inregulating body fat, and may signal body fat levels tothe hypothalamus. Individual differences in leptinproduction or resistance to leptin at its site of actionmay result in differing patterns of energy use and

eating behavior. However, more research must bedone in this area. Some studies have shown that,rather than causing obesity, metabolic andendocrinological anomalies actually result from it.

Jeffrey et al. also list social learning processes asplaying a major etiological role in most cases of obesity:

A social learning theory of obesity is based on theconcept of energy balance and the assumption thatour eating and physical activity habits, good orbad, are mostly acquired patterns of behavior.Thus, social learning theory specifically focuses onthe acquisition and maintenance of behaviors thatresult from environmental factors. This conceptu-alization has clear implications in the assessmentand subsequent treatment of an eating disorder.

Rodin et al. stated that the role of psychologicalvariables in the etiology of obesity is still not fullyunderstood. The etiologic significance of many fac-tors once thought to be important—lack of impulsecontrol, inability to delay gratification, or faulty eat-ing habits—has not been supported by experimentalevidence. Other factors, depression and dysphoria,for example, appear to be consequences rather thancauses of obesity, although they may serve to main-tain and intensify weight-related problems. Dietingin response to weight concerns appears, perversely,to be implicated in increasing overweight. Responseto food cues in the environment may also play acausal role in some cases of obesity. Among the“environmental” causes, researchers have suggestedincreased consumption of corn syrup (see FRUCTOSE

AS A CONTRIBUTOR TO OBESITY; HIGH FRUCTOSE CORN

SYRUP), a more sedentary lifestyle due to labor-sav-ing tools and increased television and computer use,junk foods in schools, suburban sprawl leading tomore automobile travel and less walking, less physicalactivity in schools and larger servings at restaurants.

Some illnesses can lead to obesity or a tendencyto gain weight. These include hypothyroidism,Cushing’s syndrome, depression and certain neuro-logical problems that can lead to overeating. Also,drugs such as steroids and some antidepressantsmay cause weight gain. A doctor can tell whetherthere are underlying medical conditions that arecausing weight gain or making weight loss difficult.

Emotional Overeating

Some people, when they are nervous, tense, angry,frustrated or upset, often indulge in overeating

220 obesity

because food has become an emotional outlet forthem. It acts as a sedative, giving them a feeling ofwell-being and security. Overindulgence in foodhelps to control the emotional stress they experi-ence. Many of these people show signs of otherexaggerated oral activity, such as excessive talking,laughing, giggling or nail biting.

Physicians have categorized four major types ofemotional overeating:

• Overeating as a response to tension, anger,upset, loneliness or boredom.

• Overeating as a substitute gratification for lack ofsex or love, or when faced with an intolerable lifesituation such as the hostility of a parent or spouse.

• Overeating due to addiction to food. (See BINGE-EATING, COMPULSIVE EATING and CRAVING.)

• Overeating as a symptom of an underlyingdepression and hysteria.

HILDE BRUCH believed that obesity is an essentialand desirable state for a considerable number ofemotional overeaters. These people use their exces-sive fat like a security blanket—as a protective bar-rier against the world. For these people, loss ofweight is fraught with psychological danger andmay result in serious psychological consequences.

Risk Factors

Obesity is the most common chronic medical con-dition in America today and affects all age groups,according to the National Center for Health Statis-tics. For example, one-year-old children today typ-ically weigh 50 percent more than one-year-oldchildren of a generation ago.

In 1993 the deputy assistant secretary forhealth, J. Michael McGinnis, and the formerdirector of the Centers for Disease Control andPrevention (CDC), William Foege, coauthored ajournal article, “Actual Causes of Death in theU.S.” They concluded that a combination ofdietary factors and sedentary activity patternsaccounts for at least 300,000 deaths each year,making obesity the second leading cause of pre-ventable death in the United States (tobaccobeing the first). In 1995 the Institute of Medicineissued a report that expressed concern about thegrowing prevalence of overweight and obesity inthe United States.

In 2004 Mokdad et al. used published causes ofdeath for the year 2000, relative risks and prevalenceestimates from published literature to update actualcauses of death in the United States, determiningthat preventable deaths from obesity-related factorshad risen to 400,000 per year. However, about a yearlater, the authors stated that “through an error in ourcomputations, we overestimated the number ofdeaths caused by poor diet and physical inactivity.Our principal conclusions, however, remainunchanged: tobacco use and poor diet and physicalinactivity contributed to the largest number of deaths,and the number of deaths related to poor diet andphysical inactivity is increasing.” Using methods sim-ilar to those used by earlier investigators, the authorscorrected the estimate to 365,000 deaths per year inthe United States attributable to poor nutrition com-bined with physical inactivity. Then, in April 2005,another team of CDC scientists and NIH researchers,using mortality data from several major federalhealth surveys, attributed 111,909 deaths each yearto obesity. They also found that people who are over-weight but not obese have no added risk of death.McKay wrote, “In fact, for people classified as merelyoverweight but not obese, there was an unexpectedpositive effect in comparison with persons of normalweight—namely, 86,000 fewer deaths.” Theresearchers then subtracted the benefits of beingmodestly overweight and arrived at 25,814 deaths ayear attributable to obesity—ranking it as the sev-enth leading cause of death in the United States.Among the proposed explanations for the lowermortality rate among overweight are improvementsin public health and medical care, plus a decliningrate of high cholesterol and some other risk factorsfor cardiovascular disease among the overweight.The vast majority of obesity-related deaths occurredin people with a body mass index of at least 35.

The prevalence of overweight and obesity hassteadily increased over the years among both gen-ders, all ages, all racial/ethnic groups, all educationallevels and all smoking levels. From 1960 to 2000 theprevalence of overweight increased from 31.5 to 33.6percent in U.S. adults aged 20 to 74. The prevalenceof obesity during this same time period more thandoubled from 13.3 to 30.9 percent, with most of thisrise occurring in the past 20 years. From 1988 to 2000the prevalence of extreme obesity increased from 2.9

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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. By2000 every state except Colorado had an obesity rateof 15 percent or more, and 22 states had an obesityrate of 20 percent or more. The prevalence of over-weight and obesity generally increases with advanc-ing age, then starts to decline among people over 60.

The age-adjusted prevalence of combined over-weight and obesity (BMI greater than 25) in racial/ethnic minorities—especially minority women—isgenerally 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 definitionfor obesity as distinct from overweight in childrenand adolescents, the prevalence of overweight isincreasing for children and adolescents in theUnited States. Approximately 15.3 percent of chil-dren (ages six to 11) and 15.5 percent of adoles-cents (ages 12–19) were overweight in 2000. Anadditional 15 percent of children and 14.9 percentof adolescents were at risk for overweight (BMI forage between the 85th and 95th percentile).

Women in the United States with low incomes orlow education are more likely to be obese than thoseof higher socioeconomic status; the association ofsocioeconomic status with obesity is less consistent inmen. Obesity is less common after age 70 amongboth men and women, possibly due to a progressivedecrease in BMI with increasing age past the fifthdecade or to an excess in mortality associated withincreasing BMI in the presence of increasing age.

Several conditions are recognized as placing anindividual at risk for developing obesity:

Heredity Recent studies have confirmed pre-vious findings that heredity is involved in thedevelopment of obesity. Doctors and scientistshave examined different families and found thatobesity is more common in some than in others.Some researchers have gone so far as to call “fam-ily” the most important risk factor for obesity, cit-

ing a 1965 study that found that 80 percent of thechildren of two obese parents will be obese, 40 per-cent of the children of one obese parent will beobese and 10 percent of the children of two leanparents will be obese. In foster families with over-weight parents, the natural children tend to bemore overweight than the foster children.

A “biological clock” factor refers to genetic char-acteristics that influence adolescent growth andamount of body fat. Throughout childhood, theobese as a group develop faster not only withrespect to weight and height but also in terms ofoverall size, skeletal and dental maturation. This isparticularly evident among those obese frominfancy. This lends support to the notion that thegrowth of ADIPOSE TISSUE is not completely inde-pendent of the growth and maturation of other tis-sues, and that each may influence the other.

Morphology of fat tissue In general, thoseadults with a childhood history of obesity display themost marked degree of adipose tissue hyperplasia(abnormally high number of cells), and obese chil-dren begin to differ significantly with respect to sizeand number of fat cells as early as age two. Innonobese children, fat cell size and number increaseduring the prepubescent and adolescent periods,after remaining relatively stable from the age of two.In contrast, massively obese children have achievedadult cell size by age two, and after that time theyshow a constant increase in cell numbers.

Early dietary excess There is evidence that fatcell size expands in the first 12 months of life and fatcell number increases up to 12–18 months of age.Using various weight-based indices, some researchershave attributed obesity to infant feeding practices.

Family environment Theories based on fam-ily-centered learning emphasize the psychosocialinteractions in the social environment of the fam-ily as important factors in the development of obe-sity. In some cases this may involve majordisruptive events, such as long separation from themother or an overly protective family environ-ment, but these causes are considered much lesscommon than a family disinclination to physicalactivity and exercise, or a social, emotional andphysical environment within the family that favorsoverindulgence. Family eating habits are oftenblamed for childhood obesity.

222 obesity

Social learning theory There is reason to sus-pect that, at least for adult-onset obesity, factorsinvolving social learning after the early years withinthe family are very much involved. The effectivenessor frequency of attempts to lose weight is thought tovary, especially by social class, even as early as ado-lescence. Social learning also influences knowledgeof weight control techniques and of nutrition.

Psychological time-bomb theory Theories ofobesity as resulting from neuroticism or excessiveemotional reaction to adolescent stress have beenlargely ruled out by recent studies. The evidence forthem is considered less convincing than that formore sociologically and culturally oriented explana-tions. However, numerous studies suggest that obesepeople, once they have become obese, may developpsychological symptoms and that these may becomeparticularly apparent during weight reductionefforts. They are especially pronounced among thosewith an earlier age of onset and a greater degree ofobesity. Such individuals are generally very sensitiveabout their condition. Because obese adolescents arediscriminated against both in employment and inhigh-ranking college admissions, it has been sug-gested that these social selection factors, felt moststrongly in late adolescence, tend to encourage obeseadolescents into social environments more permis-sive of obesity; thus they become even fatter.

Affluent sedentary society In our highly mech-anized, automated society, most people expend littleenergy in muscular work. Children and adolescentsare more sedentary than formerly, and energy outputis even lower among adults. The obese are generallyless active than others. The widespread availability ofpalatable, cheap (and commercially promoted) food-stuffs is another characteristic of the affluent societyin Western countries today. Given such abundance,food and eating not only may be used to satisfy phys-iological needs but also are readily available meansfor coping with various emotional states. Food cuesin the physical and electronic environment also favoroverindulgence if the propensity for it is there.Recent studies emphasize the importance of thesocial environment in these respects.

Health Complications

Many studies have found that obesity either con-tributes 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. Sci-entists also report that obesity may foretell certaindiseases, such as breast and uterine cancer. Aspounds are added, more cells divide, increasing theodds that they will divide abnormally and developinto tumors. Animal studies show that eating fewercalories reduces colon and breast cancer risk regard-less of dietary fat levels. Cancer risk was alsoreduced in rats that ate as much as they wanted butmaintained lean body mass with exercise.

Severe childhood obesity increases the risk of anumber of diseases. An immediate danger is defor-mation of the spine or the long bones of the limbs.These changes in the skeletal system may be par-ticularly pronounced if obesity is accompanied byvitamin D and calcium deficiency.

A low hemoglobin blood count is quite commonin obese children, making them more susceptible totonsillitis and respiratory infections and prolongingtheir duration. Obese children also tend to have sig-nificantly higher levels of glucose, cholesterol andtriglycerides, putting them more at risk for develop-ing atherosclerosis (vascular fat deposits), whichcan lead to heart attacks and strokes.

Several studies have shown that the risk of liverand kidney damage from surgical anesthesia withhalogenated anesthetic agents is greater than nor-mal for patients who are obese.

Women with a high concentration of abdominalfat seem to be at higher risk for diabetes mellitus,cardiovascular disease, mental disorders and psy-chosomatic disease than other women, accordingto a study of 1,492 Swedish women.

Benefits of Obesity?

Not all clinicians subscribe to the supposition thatall obesity is harmful. There have been critics ofprevailing views on obesity for nearly 50 years,some asserting that obesity is more of an aestheticand moral problem than one of physical health.Some researchers have even proposed that theremay be advantages, medical and other, to being fat.

One detailed study of the effects of weight onmortality followed nearly the entire population ofNorway for 10 years after an initial physical exam-ination. Optimal life expectancy occurred atweights 10–30 percent above actuarial standards.Weights slightly less than standard were far morehazardous than those slightly more.

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The fact that obese persons have a normal lifeexpectancy presents a paradox, since the incidenceof a number of serious risk factors is increased in obe-sity. Paul Ernsberger, a biomedical researcher at Cor-nell University Medical School and a leadingproponent of the theory that obesity is not necessar-ily hazardous, suggests that the solution to this puz-zle is that there are advantages as well asdisadvantages to being heavy. He states that obesepersons are less likely to develop cancer, citingnumerous studies. The obese, he says, are also pro-tected against infectious diseases, chronic obstructivepulmonary disease, osteoporosis, mitral valve pro-lapse, intermittent claudication, renovascular hyper-tension, eclampsia, premature birth, anemia,diabetes Type I, peptic ulcer, scoliosis and suicide.These health benefits of obesity might potentiallyoffset its hazards.

Obesity is also associated with improved survivalin several diseases. Ernsberger states that heavypersons with hypertension, diabetes Type II andhyperlipidemia have a more favorable prognosisthan thin people with these same ailments. Obesehypertensives have been shown to outlive leanhypertensives in 15 separate controlled studies.

Although hypertension, diabetes and hyperlipi-demia have reduced complications and mortalityin heavy persons, this does not mean these condi-tions are benign in obesity, nor does it mean thatdiabetics and hypertensives should be encouragedto gain weight, since this may worsen their condi-tion. However, Ernsberger suggests that the threatto the health and longevity of fat people posed bydiabetes and hypertension may be overestimated,owing to the failure to take into account the ame-liorating influence of obesity on these conditions.

Janet Polivy of the University of Toronto andToronto General Hospital, who has researched obe-sity and eating disorders for more than 20 years,stresses that it is unclear whether obesity is a “prob-lem” in any but the social sense. She says the so-called health hazards of obesity have been grosslyoverstated. While medical disorders do result fromexcessive body weight, many of the diseases blamedon overweight are not a simple result of excessweight per se. More often, they are caused byovereating, by large and rapid weight fluctuationsand possibly most often by dieting. Specifically, shecites heart attacks usually blamed on obesity, butactually caused by diet pills and inadequate diets.

Researchers at the University of Nebraska Med-ical Center analyzed 8,428 adult hospital admis-sions and reported their findings in the May 1988Journal of Gerontology. Obesity was associated withhigher mortality only when subjects were 100 per-cent or more overweight; being at or below idealweight was usually associated with increased mor-tality. The lowest mortality occurred at moderateoverweight. Underweight seemed to be a moreimportant predictor of mortality than overweightin older hospitalized subjects.

Psychological Effects

Not all medical professionals believe that child-hood psychological problems are at the root ofadult obesity. In his book The Dieter’s Dilemma,William Bennett suggests that although there arepeople who overeat in a desperate attempt to han-dle inner conflicts, they are probably a small frac-tion of fat people. In fact, he says, fat people as agroup are mentally quite healthy, considering whatthey must put up with. They are not more neuroticthan thin people and, in some ways, less so, sincethey have maintained their mental health throughdecades of well-intentioned but ineffective effortsto explain and “improve” them.

Yet Jeffrey, Dawson and Wilson say,

Unpleasant affective responses and overeatingcommonly occur together. Negative feelings suchas anger, resentment, anxiety, or loneliness, whenhandled by eating, lead to continued obesity and tothe development and maintenance of maladaptivebehavior. Thus, some individuals learn to use foodto escape from tension or boredom or to assuagepain or depression. On the other hand, food andovereating also appear to be frequently associatedwith social occasions, fun, and self-gratification.

Treatment

The fundamental treatment for obesity is caloricreduction combined with increased caloric expendi-ture (i.e., exercise). The traditional view has been thatweight loss depends on reducing the total number,rather than the kind, of calories consumed. Whilesome popular FAD DIETS concentrate on certain typesof calorie intake, there is very little evidence of thesuperiority of such diets to more conventional, calo-rie-restricted but balanced diets. The degree of caloricrestriction required to lose weight depends on the

224 obesity

degree of obesity, age, sex, physical activity and gen-eral health of the patient. Except for unusually activeindividuals, it would be difficult to lose weight whileconsuming more than 1,200 calories per day. Dra-matic weight losses commonly result from VERY LOW

CALORIE DIETS of fewer than 800 calories; side effectsinclude hypotension, constipation and occasionaldizziness. Although initial losses may be impressive,these diets have not effectively encouraged perma-nent weight loss. Polivy cautions that self-imposeddieting often results in eating binges once food isavailable and in psychological preoccupation withfood and eating. She recommends instead healthfuland balanced eating without specific food restrictions.

Physical training is widely used for reduction ofbody fat, although it frequently does not result in anet weight loss because of a parallel increase inmuscle mass. With continued training, though, thedecrease in body fat generally exceeds the increasein muscle mass so that a net loss in body weight doesoccur. Studies have shown that at least eight weeksof three-per-week sessions, each lasting a minimumof 30 minutes, is required to reduce fat tissue meas-urably. Studies have also shown that the initial six toeight months of a training program are character-ized by a decline in BODY FAT, after which most indi-viduals reach a plateau in total body weight and inpercentage of body fat. One other result of physicaltraining is a general HUNGER-reducing effect ofintensive EXERCISE. For most, exercise is more effec-tive in preventing rather than treating obesity.

In recent years there has been increased interestin BEHAVIOR MODIFICATION for the treatment of obe-sity. Such techniques as slowing the rate of eating,limiting access to cues that signal eating behaviorand keeping records have all resulted in short-termbenefits. According to the 1998 NHLBI ClinicalGuidelines, behavioral strategies to reinforce changesin diet and physical activity can produce a weightloss in obese adults of 10 percent over four monthsto one year. Most patients return to original weightsin the absence of continued behavior modification.Newer studies have emphasized spouse training andteaching self-control. Individual therapy rather thangroup therapy is best used for the person lacking inself-esteem, the immature individual who has haddifficulty separating from the mother and thesocially isolated person who had little or no contactwith his or her mother. GROUP THERAPY is quite effec-

tive in treating CHILDHOOD OBESITY, primarilybecause of the enormous peer pressure among chil-dren. It is used with patients who have stronger egosthan those who are suitable for individual therapy.Teenage children respond very well to counselinggiven in groups. They are accustomed to learning ingroups, and learning about their diet comes mostreadily when they are with friends who have simi-lar problems. Most effective with teenagers is aleader who is knowledgeable in the field of nutritionand obesity, who genuinely likes children and wantsto help children with this problem. When the causeof childhood obesity is related to family pathology,FAMILY THERAPY is called for. This treatment tends tofocus on areas of conflict within the family that fos-ter certain eating habits and patterns.

As reported in the NHLBI Clinical Guidelines,drug therapy has undergone radical changes in thelast few years. With the publication of the trialswith phentermine and fenfluramine conductedover a period of 210 weeks by Weintraub in 1992,drug therapy began to change from short-term tolong-term use. Both dexfenfluramine and fenflu-ramine alone, as well as the combination of phen-termine and fenfluramine, were used long term;however, concerns about reported unacceptableside effects, such as valvular lesions of the heartcausing significant insufficiency of the valves, ledto the withdrawal of the drugs dexfenfluramineand fenfluramine from the market in September1997. No drugs remained that were approved bythe Food and Drug Administration (FDA) for uselonger than three months. In November 1997 theFDA approved SIBUTRAMINE for use in obesity, andin April 1999 approved ORLISTAT for long-term use.

In November 1997 the FDA approved SIBU-TRAMINE for use in obesity, and in April 1999approved ORLISTAT for long-term use. Unlike otherobesity drugs, orlistat prevents enzymes in the gas-trointestinal tract from breaking down dietary fatsinto smaller molecules that can be absorbed by thebody. Absorption of fat is decreased by about 30percent. Since undigested triglycerides are notabsorbed, the reduced caloric intake may have apositive effect on weight control.

The drugs used to promote weight loss had beenanorexiants or appetite suppressants. These drugs areeffective but modest in their ability to produceweight loss. Net weight loss attributable to drugs gen-

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erally has been reported to be in the range of 4.4 to22 pounds, although some patients lose significantlymore weight. Most of the weight loss usually occursin the first six months of therapy. Weight-loss med-ications are recommended only for patients who areat increased medical risk because of their weight andshould not be used for cosmetic weight loss. Thepotential for side effects from the use of weight-lossdrugs is of great concern. (See ANTIOBESITY DRUGS.)

Surgical treatment of obesity has escalated inrecent years, with the number of procedures nearlyquadrupling since 2001. BARIATRIC SURGERY is theonly option today that effectively treats extreme obe-sity in people for whom more conservative measuressuch as diet, exercise and medication have failed. AnAgency for Healthcare Research and Quality (AHRQ)Evidence Report concluded, “Surgical treatment ismore effective than nonsurgical treatment for weightloss and the control of some comorbidities in patientswith a body mass index of 40 or greater. More dataare needed to confirm or refute the relative efficacyof surgery for less severely obese persons. Periopera-tive (occurring during surgery) mortality rates of lessthan one percent have been achieved by some sur-geons and surgical centers. The perioperative mortal-ity rates in other settings may be higher. Surgicaltreatment is associated with a substantial number ofcomplications and adverse events, although most ofthese are minor.”

The AHRQ report also found that “clearly, RYGBresults in greater weight loss than vertical bandedgastroplasty. All three procedures for which wefound data—RYGB; VBG; and laparoscopicadjustable band procedures—report substantiallong-term weight loss.”

As noted by the report, a variety of approaches tobariatric surgery exist, but all procedures are eitherMALABSORPTIVE OPERATIONS, GASTRIC RESTRICTION

PROCEDURES or a combination of the two. Malab-sorptive procedures change the way the digestivesystem works. Restrictive procedures are those thatseverely reduce the size of the stomach to hold lessfood, but the digestive functions remain intact.

Although the general opinion has been that peopleover the age of 60 would not be good candidates forobesity surgery, surgeons at the Mayo Clinic in Scotts-dale, Arizona, examined the operative outcomes,weight loss, reduction of comorbidities, and medica-tion requirements in patients older than 60 years

compared with those younger than 60 years under-going laparoscopic ROUX-EN-Y GASTRIC BYPASS, andconcluded that patients of advanced age can safelyundergo stomach bypass surgery with operativeresults nearly identical to those of younger patients.

The American Medical Association’s Council onScientific Affairs 2004 informational report states,“In 2003, the U.S. Preventive Services Task Forceconcluded that data were sufficient to recommendthat physicians screen all adult patients for obesityand offer intensive counseling and behavioral inter-ventions to promote sustained weight loss for obeseadults. Other sets of clinical recommendationsdirected at adult and childhood obesity have alsobeen developed recently by national organizationsand experts. In a recent systematic review of the lit-erature, researchers concluded that the lack of qual-ity studies limits recommendations for improvinghealth professionals’ management of obesity. How-ever, reminder systems, brief training interventions,shared care, inpatient care, and dietitian-led treat-ments provided promise and warrant further study.”

See also VERTICAL BANDED GASTROPLASTY.

Clinical Guidelines on the Identification, Evaluation, and Treat-ment of Overweight and Obesity in Adults—The EvidenceReport. National Institutes of Health, 1998.

Ernsberger, P., and Haskew, P. “Health Implications ofObesity: An Alternative View.” Journal of Obesity andWeight Regulation 6 (1987).

Flegal, Katherine M., et al. “Excess Deaths Associatedwith Underweight, Overweight, and Obesity.” Journalof the American Medical Association 293, no. 15 (April20, 2005): 1,861–1,867.

“Health Implications of Obesity.” NIH Consensus Develop-ment Conference Statement 5, no. 9.

Jeffrey, D. Balfour, Brenda Dawson, and Gregory L. Wil-son. “Behavioral and Cognitive-Behavioral Assess-ment.” In Assessment of Addictive Behaviors, edited byDennis Donovan and G. Alan Marlatt. New York:Guilford Press, 1988.

McKay, Betsy. “New Study Further Downplays Obesity’sDeadliness.” The Wall Street Journal, April 20, 2005,p. D4.

Mokdad, Ali H., James S. Marks, Donna F. Stroup, andJulie L. Gerberding. “Actual Causes of Death in theUnited States, 2000.” Journal of the American MedicalAssociation 291, no. 10 (March 10, 2004): 1,238–1,245.

Mokdad, A. H., et al. “Correction: Actual Causes of Deathin the United States, 2000.” Journal of the AmericanMedical Association 293, no. 3 (January 19, 2005):293–294.

226 obesity

Polivy, Jane. “Psychological Consequences of FoodRestriction.” Journal of the American Dietetic Association96 (June 1996).

Report 8 of the Council on Scientific Affairs (A-04) FullText, “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 ofNorth America 73 (January 1989).

Shekelle, P. G., S. C. Morton, M. Maglione et al. “Phar-macological and Surgical Treatment of Obesity. Sum-mary, Evidence Report/Technology Assessment:Number 103.” AHRQ Publication Number 04-E028-1,July 2004. Agency for Healthcare Research and Qual-ity, 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 HealthBenefits after Laparoscopic Gastric Bypass.” Archives ofSurgery 140, no. 2 (February 2005): 165–168.

obesity, attitudes toward It has been suggestedthat public derision and condemnation of fat peo-ple is one of the few remaining sanctioned socialprejudices against any group based solely onappearance. There is evidence that obese peopleare denied educational opportunities, jobs, promo-tions and housing because of their weight.

Dennis E. Clayson and Michael L. Klassen statedthat “there is considerable evidence to suggest thatobese persons are perceived negatively by others.This negative perception seems to be heightenedbecause, unlike many other stereotyped persons,obese persons are seen as personally responsiblefor their condition.” Clayson and Klassen foundthat obese persons are characterized as lazy,unkempt, lacking self-discipline and self-respect,unhealthy and insecure. (Paradoxically, they arealso seen as jolly.) An obese person may be seen aspurposely violating a cultural value.

Disdain toward the obese begins before adult-hood. Several studies have documented what mostpeople know from experience—that grade schoolchildren consistently attribute negative qualities tolarger body shapes.

Children appear to develop attitudes about fat at avery early age. They are told repeatedly by parentsand physical education teachers that fatness is notonly unattractive but leads to sickness, and these atti-tudes persist throughout their lives. Studies confirm

that chubby children are regarded by their peers asugly, stupid, mean, sloppy, lazy and dishonest andare frequently teased. Samples of adults have ratedobese children as less likable than children with avariety of handicaps, disfigurements and deformities.

A recent study that assessed familial links in fatstereotypes and predictors of stereotypes amongnine-year-old girls and their parents found that boththe girls and their parents exhibited fat stereotypes.Specifically, the following characteristics were signif-icantly more likely to be attributed to thin peoplethan fat people: having lots of friends (girls), happy(girls, parents), smart (girls), good looking (girls,parents) and the general statement that it is good tobe thin (girls, parents). Fathers who were more edu-cated and had a higher family income were morelikely to endorse fat stereotypes, as were mothersand fathers with a high investment in their physicalappearance. Although no associations were foundbetween girls’ and parents’ fat stereotypes, girlswere more likely to endorse fat stereotypes wheninteractions with parents and peers focused on bodyshape and weight loss. Girls were also more likely tosupport fat stereotypes when they reported higherlevels of maladaptive eating.

One study included a preference test to seewhether two- to five-year-olds preferred a thin ora fat rag doll. Fifty-three out of 56 children asyoung as two years of age picked the thin doll.Similar results occurred using drawings of fat andthin children. The team conducting the test hadplanned to use photographs but were unable toobtain photos of fat children. They visited shoppingcenters, amusement parks and similar places andasked every parent who passed by to let them pho-tograph their children. No parent of a thin childrefused; no parent of a fat child ever consented.Some parents permitted a thin child to be pho-tographed while hiding a fat one behind them. Theteam ended up with hundreds of photographs ofchildren, and not one of them was fat.

This prejudice is neither natural nor universal.Obesity has been valued highly in many cultures atvarious periods of history. Some African peopleshave been known to lock pubescent females in fat-tening huts where they are denied exercise andreceive extra rations of food for as long as twoyears. This practice produces an overweight womanwho symbolizes the well-to-do status of her family.

obesity, attitudes toward 227

Other cultures discriminate in their preferencefor 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, somequite harmful, to alter their natural physique.

Corsets and waist cinches have caused fainting,rib fractures and permanent damage to the respira-tory system. Around the turn of the century, somewomen had ribs removed (a practice not unknowntoday among fashion models) in order to achievean hour-glass figure. More recently, cosmetic sur-gery, silicone injections and breast implants havereplaced the padded bra and bustle in the relentlesspursuit of “beauty.”

The NPD Group, a Chicago research firm, hasfound some signs that as Americans grow in girth,they are becoming less critical of overweight peo-ple. In 1984, 55 percent of respondents to theirattitudes tracking survey agreed with the state-ment “People who are not overweight look a lotmore attractive”; by 1988, that figure had droppedto 42 percent; and in 1996 it had plummeted to 28percent. It is possible that because of increased sen-sitivity to such comments, some responders to thesurvey may have provided “politically correct”answers rather than what they truly believed.

In fact, not all research points to progress in thisarea. In a 1998 Cornell University study, Sobal andBursztyn found that 74 percent of male studentsand 60 percent of female students were uncom-fortable 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 ofcaregivers, but the obese patients reported signifi-cantly more negative attitudes of caregivers thandid the nonobese patients.”

Similarly, Schwartz et al. concluded that “Evenprofessionals whose careers emphasize research orthe clinical management of obesity show verystrong weight bias, indicating pervasive and pow-erful stigma.”

See also CULTURAL INFLUENCES ON APPEARANCE.

Clayson, Dennis E., and Michael L. Klassen. “Perceptionof Attractiveness by Obesity and Hair Color.” Perceptualand 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 (January2004): 86–94.

Garner, C. M., and G. T. Nicol. “Comparison of Male andFemale Nurses’ Attitudes toward Obesity.” PerceptualMotor Skills 86, no. 3, pt. 2 (June 1998): 1,442.

Schwartz, Marlene B., Heather O’Neal Chambliss, KellyD. Brownell, Steven N. Blair, and Charles Billington.“Weight Bias among Health Professionals Specializingin Obesity.” Obesity Research 11, no. 9 (September2003): 1,033–1,039.

Sobal, Jeffery, and Mark Bursztyn. “Dating People withAnorexia and Bulimia Nervosa: Attitudes and Beliefsof University Students.” Women and Health 27, no. 3(1998): 71–87.

obesity as a class issue With the World HealthOrganization describing obesity as an internationalhealth crisis, researchers and writers around theworld have endeavored to identify the causes forthe pandemic. Carma International, global mediaanalysts, reported, “The UK and Continental mediashared a perception either wholly absent or thicklyveiled in the US media—namely, that obesity is aclass issue and often linked to poverty. ‘This obesitydebate is full of humbug and denial. Fat is a classissue, but few like to admit that most of the seri-ously obese are poor,’ wrote The Observer (May 30,2004). In Germany, Frankfurter Rundschau statedthat ‘children from poor background are specifi-cally prone to obesity.’ (April 3, 2004).”

The Week, a British publication, reported on June14, 2003, “As the gap between rich and poor widens,Britain has become divided into an ‘overweightunderclass and a super-healthy elite.’ Working-classchildren live on cheap, calorific diets of pizza andchips. Middle-class children, by contrast, have lunch-boxes packed with wholewheat sandwiches and sal-ads, and go to schools with good playing fields. Theirparents, too, have the time and money to cookdecent meals and join a gym. Fitness has become a‘badge of financial as well as physical virility.’ ”

On May 31, 2004, the International Herald Tribunequoted London’s The Guardian as reporting, “Fat is aclass issue, but few like to admit that most of theseriously obese are poor. It is inequality and disre-spect that makes people fat: People will only getthinner when they are included in things that areworth staying thin for. Offer self-esteem, respect,jobs or some social status and the pounds wouldstart to fall away. The inequality/obesity link is mir-

228 obesity as a class issue

rored internationally. America has by far the mostunequal society and by far the fattest. Britain andAustralia come next. Europe is better and the Scan-dinavian countries best of all. No doubt there arealso social policy reasons for this: The best socialdemocracies pick up family problems earliest andoffer most support, putting people back on theirfeet, preventing social exclusion. But the narrowerthe status and income gap between high and low,the narrower the waistbands.”

In his review of the various suggested causes forthe rise in obesity, Crespo wrote:

Some researchers have suggested that the preva-lence of obesity is related to social class. Extremeobesity is most prevalent among African-Americanwomen (15.1 percent), while the prevalence ofextreme obesity in the rest of the other racial andethnic groups was less than 5.5 percent.

Other important indicators of social class areeducation and income, and these factors seem toinfluence obesity differently. Education is typicallyrelated 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 incomeare related to obesity, the prevalence of obesitywas tallied in different strata of social classes usingnine mutually exclusive categories of educationand income. Among women, the highest preva-lence of obesity was among those who had lessthan a high school education and earned less than$20,000 a year. Among men, the prevalence ofobesity was highest among those in the highestincome category but who had less than highschool education. Invariably, obesity is lowestamong those who have more than a high schooleducation, regardless of income.

Poverty and lower educational attainment areconsistently associated with obesity, independentof ethnicity, and therefore affect more persons inminority populations than in white populations.Thus, minorities may be at higher risk for obesitybecause of their increased poverty rate and lowereducational attainment. Our understanding of howand why obesity develops should involve the inte-gration of social, behavioral, environmental, cul-tural, physiologic, metabolic, and genetic factors.

In May 2005 University of Iowa researchersreported to the American Heart Association on astudy that showed obesity to be growing fastest

among affluent Americans. Using U.S. governmentdatabases, they found that while the percentage ofobese people with incomes below $25,000 had risen10 percent between the 1970s and 2002; the per-centage of obese people with incomes above$60,000 had jumped 17 percent. The investigatorssuggested that perhaps longer commutes plus longerworking hours since the 1970s have resulted in lesstime to prepare home cooked meals, more frequenteating in restaurants and less time for physical activ-ity. But others cautioned that since the 1970s, ratesof extreme obesity have ballooned among lower-income groups, something the study did not address.

Crespo, Carlos J. “Obesity in the United States: A Worri-some Epidemic.” The Physician and Sportsmedicine 31,no. 11 (November 2003): 23–28.

obesity-hypoventilation syndrome (OHS) Alsocalled pickwickian syndrome, Pickwick syndromeand obstructive sleep apnea/hypoventilation. This isa condition related to obstructive sleep apnea, inwhich a very obese person does not breathe a suffi-cient amount of oxygen during sleep or whileawake. However, OHS can occur separately fromobstructive sleep apnea. The cause of OHS inunknown, but it is likely to involve a combination ofa disorder of the brain’s control over breathing andthe effects of massive obesity on the chest wall. Withthe excess weight of massive obesity, the muscles ofthe chest wall can have difficulty expanding the tho-rax enough to exchange air efficiently. This resultsin a decreased ability to oxygenate the blood andretention of carbon dioxide. Affected individualssuffer from chronic fatigue brought on by sleep loss,poor sleep quality and decreased blood oxygen. OHSaffects 5 percent of morbidly obese individuals. Theterm pickwickian syndrome was first used in 1956 forOHS patients because they resemble the messengerboy, Joe, in Charles Dickens’s The Pickwick Papers.

Berg et al. found that OHS patients were muchmore likely to have cardiovascular disease, a his-tory of metabolic disease (e.g., diabetes orhypothyroidism) and osteoarthritis, concluding,“OHS patients are heavy users of health-careresources for several years prior to the evaluationand treatment of their sleep breathing disorder,and there is a substantial reduction in days hospi-talized once treatment is instituted.”

obesity-hypoventilation syndrome 229

Berg, Greg, et al. “The Use of Health-Care Resources inObesity-Hypoventilation Syndrome.” Chest 120, no. 2(August 2001): 377–383.

Kessler, Romain, et al. “The Obesity-HypoventilationSyndrome Revisited: A Prospective Study of 34 Con-secutive Cases.” Chest 120, no. 2 (August 2001):369–376.

obesity in the workplace The obesity epidemicin the general population has meant not only anincrease in the numbers of overweight and obeseworkers, but also an increase in those workers’girth. As one newspaper business writer reported,“Sales of sturdy, large office chairs accommodatingoffice workers of up to 400 pounds are booming.”

Insurance companies have linked workplace junkfood to workplace obesity and increased absen-teeism. A 2004 Harris Interactive survey reportedthat 83 percent of those who have vendingmachines in their workplace say they mostly containsnacks such as potato chips, cookies and candy bars.Yet 80 percent of workers say they would favoradding nutritional information, such as calories andfat content, to menus at restaurants and workplacecafeterias to help consumers make informed choices.

Although research has found obese workers tobe costly to employers (see EMPLOYEE HEALTH COSTS

AND OBESITY), Baum and Ford conclude that obe-sity is also costly to the workers themselves. UsingNational Longitudinal Survey of Youth (NLSY)data to examine the effects of obesity on wages bygender, the economists found “that both men andwomen experience a persistent obesity wagepenalty over the first two decades of their careers.”Noting that standard socioeconomic and familialvariables do not explain these wage penalties, theysuggest that “other variables—including job dis-crimination, health-related factors and/or obeseworkers’ behavior patterns—may be the channelsthrough which obesity adversely affects wages.” Intheir research, Baum and Ford found that wages ofobese workers average 2.5 percent less than wagesof thinner employees, with the wage penalty muchgreater 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 WeightDiscrimination, such discrimination against obesemen does not kick in until they are severely obese,while women employees encounter weight dis-crimination for being just 30 pounds overweight.

Baum, Charles L., II, and William F. Ford. “The WageEffects of Obesity: A Longitudinal Study.” Health Eco-nomics 13, no. 9 (September 2004): 885–899.

Obesity Management A medical journal firstpublished in September 2003; its purpose is tooffer physicians and health care professionalseffective options and strategies to help overweightpatients. The publisher is Mary Ann Liebert, Inc.;the editor in chief is James O. Hill, Ph.D., profes-sor of pediatrics and medicine, and director of theCenter for Human Nutrition, University of Col-orado Health Sciences Center. Each issue providespractice-oriented information and resources.

See also APPENDIX VIII.

obesity virus See FAT VIRUS.

Obesity Working Group (OWG) In August 2003the U.S. Food and Drug Administration (FDA)established the Obesity Working Group (OWG) toadvise the agency on innovative ways to deal withthe increase in obesity and to identify ways to helpconsumers lead healthier lives through better nutri-tion. On March 12, 2004, the OWG released areport, Calories Count, to reexamine the FDA’sresponsibilities for reducing obesity. The group’slong- and short-term proposals were based on thescientific fact that weight control is mainly a func-tion of caloric balance—calories in must equal calo-ries out. Recommended actions included:

• Enhancing food labels to display calorie count moreprominently and to use meaningful serving sizes

• Initiating a consumer education campaign focus-ing on the “Calories Count” message

• Encouraging restaurants to provide nutritionalinformation to consumers

• Stepping up enforcement actions concerningaccuracy of food labels

• Revising FDA guidance for developing drugs totreat obesity

• Working cooperatively with other governmentagencies, nonprofits, industry, and academia onobesity research.

Obesity Working Group. “Calories Count: Report of theWorking Group on Obesity.” Available online. URL:

230 obesity in the workplace

http://www.cfsan.fda.gov/~dms/owg-toc.html.Posted on March 12, 2004.

obesophobic Having a fear of being fat. A termused by some clinicians to describe people judgedunderweight by standard measurements but whostill think they are too fat and who are preoccupiedwith their weight.

See also FEAR OF FAT SYNDROME.

olestra The generic name for a no-calorie fatsubstitute developed by Procter & Gamble in 1989after nearly 20 years of research and marketedunder the brand name Olean. It is intended for usein shortenings and oils and in the preparation ofcertain fried snacks, like potato chips. It tastes,feels and, in cooking, functions like fat but is notin any sense a food and is not found naturally inany food.

Olestra is not absorbed into the bloodstreamand therefore, according to Procter & Gamble,should likely produce fewer complications thanother food substitutes such as aspartame, a sugarsubstitute known to cross into the bloodstream. Inone study by the company, 10 obese people werefed with up to 60 grams of olestra in their diet for20 days, so that their caloric intake was reducedby 23 percent and fat intake by 50 percent. Onaverage, the patients lost eight pounds each.Patients on the olestra diet did not crave addi-tional food to make up for their calorie loss.Olestra satiates the desire to gorge, as does foodmade with conventional fats.

Olestra has remained under review by the Foodand Drug Administration (FDA) since 1987.Although Procter & Gamble maintains that Olestrais safe for humans, some scientists have questionedit. Rats in some tests have developed tumors andleukemia, among other diseases, according to theCenter for Science in the Public Interest, a con-sumer advocacy group.

The FDA concluded on January 25, 1996, thatolestra was safe for use in savory snacks (potato chips,corn chips) but required that fat-soluble vitamins lostthrough absorption be added back to olestra.

Although Procter & Gamble has effectively dealtwith a number of criticisms of olestra from consumergroups, some of these criticisms reappear from timeto 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 nolonger need to include the label statement requiredsince olestra’s approval in 1996. The statementinforms consumers that olestra may cause abdomi-nal cramping and loose stools in some people, that itinhibits the body’s absorption of vitamins A, D, E andK and other nutrients, and that these vitamins havebeen added to compensate for olestra’s effects onthese nutrients. Consumption studies of productscontaining olestra showed the fat substitute causedonly infrequent, mild gastrointestinal effects inamounts that reflected typical dietary habits. How-ever, the FDA will require manufacturers to continueadding vitamins A, D, E and K to such products.

Levine et al. examined the association betweenauthors’ published positions on the safety and effi-cacy in assisting with weight loss of olestra and theirfinancial relationships with the food and beverageindustry. “Supportive authors were significantlymore likely than critical or neutral authors to havefinancial relationships with P&G (80 percent vs 11percent and 21 percent, respectively). All authorsdisclosing an affiliation with P&G were supportive.”

In a recent review of studies involving dietaryfat, Bray et al. found, “When dietary fat is replacedwith olestra to reduce fat intake from 33 percent to25 percent in obese men, weight loss continues forabout nine months, reaching a maximum of nearly6 percent of body weight and a loss of 18 percentof initial body fat.”

See also FAT SUBSTITUTES.

Bray, G. A., S. Paeratakul, and B. M. Popkin. “Dietary Fatand Obesity: A Review of Animal, Clinical and Epi-demiological 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 andBeverage Industry and Their Published Positions onthe Fat Substitute Olestra.” American Journal of PublicHealth 93, no. 4 (April 2003): 664–669.

Nestle, M. “The Selling of Olestra.” Public Health Report113, no. 6 (November/December 1998): 508–520.

Prince, D. M., and M. A. Welschenbach. “Olestra: A NewFood Additive.” Journal of the American Dietetic Associa-tion 98, no. 5 (May 1998): 565–569.

online dieting Also called cyberdieting; plans andprograms offered over the Web to help individuals

online dieting 231

lose weight. Internet dieting services, which firstappeared in the mid-1990s, have expanded andproliferated recently as an estimated 15 millionpeople now turn to the Internet every month forweight-loss information. By 2005 the most populardiet brands were introducing food and activityguides that users download from the Internet,which are designed for use with handheld devicesand personal digital assistants so that users cansearch food and activity lists and track their eatingand exercise when in a restaurant, at the grocerystore or even on vacation.

Psychologist Thomas Wadden, director of theWeight and Eating Disorders Program at the Univer-sity of Pennsylvania in Philadelphia, who hasresearched the effectiveness of online dieting, statedon USAToday.com on January 4, 2005, “OnlineInternet programs can be helpful to people if theykeep a record of their daily food intake, calories, andphysical activity.” The University of PennsylvaniaSchool of Medicine study compared results ofwomen who enrolled in an eDiets.com onlineweight-loss program available to the public withthose of women who followed a weight loss manual(LEARN Program for Weight Control 2000). Bothgroups followed similar weight-loss techniques,including reducing calories and increasing exercise.The dieters using the Internet service lost 1.5 poundsafter 16 weeks and 1.8 pounds after one year. Thoseusing the self-help manual lost 6.6 pounds after 16weeks and 7.3 pounds after a year. Explaining thelow online dieting results, Wadden said, “This wasbecause people did not log on frequently enough orkeep records of their food intake.”

Harvey-Berino et al. evaluated 255 overweightand obese men in a six-month behavioral weightcontrol program conducted over the Internet. Afterthis program, participants were placed into one ofthree groups (frequent in-person support, minimalin-person support or Internet support) as part of a 12-month weight maintenance phase. The participantsassigned to the Internet-based weight maintenanceprogram lost about the same amount of weight over18 months as those who met with counselors. Otherstudies have also found similar results betweenonline dieting and other diet center programs.

According to Market Trends: The Online Weight Lossand Dieting Services Market, a 2005 report from mar-ket research publisher Packaged Facts, employees’

use of approved health and dieting Web sites in theworkplace is expected to help U.S. employersincrease health awareness as well as boostemployee productivity and overall morale. Adop-tion by corporate America should help the growthpath of online weight loss and dieting services over-all. Currently valued at $280 million and expectedto post annual growth of 30 percent over the nextfew years, Packaged Facts estimates that by 2013the 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 Mainte-nance of Weight Loss.” Obesity Research 12, no. 2 (Feb-ruary 2004): 320–329.

Tsai, A. G., and T. A. Wadden. “Systematic Review: AnEvaluation of Major Commercial Weight Loss Pro-grams in the United States.” Annals of Internal Medicine142, no. 1 (January 4, 2005): 56–66.

Womble, L. G., T. A. Wadden, et al. “A Randomized Con-trolled Trial of a Commercial Internet Weight LossProgram.” 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 tel-evision talk show host Oprah Winfrey announced in1988 that she had lost 67 pounds on the Optifast pro-gram. After this announcement, the Optifast com-pany received hundreds of thousands of calls fromconsumers desperate to lose weight. Sales boomed aspeople paid $3,000 to $5,000 each to participate inthe program. But 18 months later, as reports surfacedabout the dangers of VERY LOW-CALORIE DIETS, bothOprah and the majority of the Optifast users hadregained much of their lost weight (plus addedpoundage), and the company had cut back on satel-lite clinics. Today company promotions focus moreon the fact that Optifast is a physician-supervisedprogram and less on the weight loss results.

oral contraceptives Although many women andclinicians believe that oral contraceptive use canlead to weight gain, keeping some women fromstarting hormonal contraception or leading to pre-mature quitting, there is no evidence supportingthis belief according to recent research. Gallo et al.reviewed 42 studies on the subject and found no

232 Optifast

evidence of appreciable weight gain from combina-tion estrogen/progestin contraceptive use. If anysuch effect does exist, it is small and may be due toshort-term water retention.

However, obese and overweight women aremore likely to experience a failure in the use oforal contraception than are women in lowerweight categories, according to a University ofWashington study. Among all oral contraceptiveusers, when compared with women having a bodymass index (BMI) of 27.3 or less, the risk of preg-nancy was nearly 60 percent higher in womenwith BMI greater than 27.3 and more than 70 per-cent higher in women with BMI greater than 32.2.Among consistent users (women who missed nopills in reference month), the risk of pregnancymore than doubled in women with BMI greaterthan 27.3.

Gallo, M. F., D. A. Grimes, K. F. Schulz, and F. M.Helmerhorst. “Combination Estrogen-Progestin Con-traceptives and Body Weight: Systematic Review ofRandomized Controlled Trials.” Obstetrics and Gynecol-ogy 103, no. 2 (February 2004): 359–373.

Holt, V. L., et al. “Body Mass Index, Weight, and OralContraceptive Failure Risk.” Obstetrics and Gynecology105, no. 1 (January 2005): 46–52.

oral nutritional supplements Nutrients in liquidform; the least invasive way of supplementing ananorexic patient’s food intake during hospitalization.

Because a nutritional supplement is considered amedication, its use is charted in a patient’s files andthe patient is required to drink it in the presence ofa nurse. Not considering it as food helps avoid con-flicts with the patient over eating or not eating.

oral soft tissues Periodontal tissues, gingival tissues,the lining of the mouth, pharynx and esophagus, thelips and tongue and the salivary glands, are all areasof the oral cavity that can be affected by anorexia ner-vosa and bulimia. Tissue health is impaired by drymouth and the resulting reduction of the saliva’smembrane-lubricating effects. As a result of drynessand poor oral hygiene, gingivitis, or inflammation ofthe gums, is quite common in eating-disorderedpatients. If untreated, this inflammation spreads intothe supporting structures of the teeth, causes boneloss and eventually results in loss of the teeth. Vita-

min deficiencies from poor diets have very markedeffects on soft tissues, including scurvy, inflammationof the tongue and a burning sensation in the tongue.Bulimic patients sometimes evidence abrasions of thelining of the throat due to use of the fingers or foreignobjects to induce vomiting. The caustic gastric acidbrought up during the purging process inflamesesophageal, pharyngeal and salivary gland tissues.Salivary gland enlargement is not an uncommonoccurrence in patients with eating disorders.

See also DENTAL CARIES; PERIMYLOLYSIS.

Dalin, Jeffrey B. “Oral Manifestations of Eating Disor-ders.” In Eating Disorders: Effective Care and Treatment,edited by Félix E. F. Larocca. St. Louis: IshiyakuEuroAmerica, 1986.

orlistat The first in a new class of drugs known aslipase inhibitors, compounds that block the absorp-tion (digestion) of roughly a third of the fat that theuser consumes. In clinical trials, patients who tookXenical (trade name of orlistat) lost about 10 percentof their body weight, more than three times theamount lost by those who took a placebo. Most ofthe patients taking orlistat reported such side effectsas intestinal cramping, gas, and oily or loose stools,but they usually were mild and lasted only a fewweeks. The drug can also interfere with the body’sability to absorb vitamins A, D, E, K and beta-carotene. Approval of Xenical by the Food and DrugAdministration was delayed because one studyshowed an increase in cases of breast cancer, butresearchers determined that many of those cancerswere preexisting and that the breast cancer incidentswere a statistical fluke. A large-scale follow-up studyshowed no increase risk of breast cancer. With thisquestion settled, final FDA approval was granted onApril 26, 1999. The drug is intended for treatment ofsevere obesity only. One concern, in addition to theside effects, is that people will quickly regain theweight they lost once they stop taking the drug.Almost everyone in the study did gain back theirweight when they stopped taking the drug, so peo-ple may need to take it for life—at a cost of around$1,500 a year; however, orlistat has not been studiedfor safety or efficacy beyond two years. Also, thestudy’s high dropout rate (66 percent) suggests thatpatients will be unlikely to take the drug long term.

orlistat 233

In 2004, researchers in Brazil reported that orli-stat, especially in combination with a diet rich inoxalate (a salt found in certain plants) alone orassociated with fat, seems to contribute to the for-mation of kidney stones in rats, suggesting thatpeople who have had kidney stones should be cau-tious with orlistat. Also, those taking the drugshould also avoid foods rich in oxalate, such asspinach, rhubarb and parsley.

Davidson, Michael H., et al. “Weight Control and RiskFactor Reduction in Obese Subjects Treated for 2Years with Orlistat.” Journal of the American MedicalAssociation 281, no. 3 (January 20, 1999): 235–242.

Ferraz, R. R., H. G. Tiseliu, and I. P. Heilberg. “Fat Mal-absorption Induced by Gastrointestinal LipaseInhibitor Leads to an Increase in Urinary OxalateExcretion.” Kidney International 66, no. 2 (August2004): 676–682.

Hellmich, Nanci. “Fat Blocker Weighs in a Drug forObese.” USA Today, January 20, 1999.

———. “New Fat-Blocking Obesity Drug Approved.”USA Today, April 27, 1999.

Klein, S. “Long-Term Pharmacotherapy for Obesity.” Obe-sity Research 12 (December 2004): 163S–166S.

orthorexia nervosa (ON) A term used by someeating disorder specialists and authors to describe anunhealthy—even obsessive—worry about eatingimpure or unsatisfactory foods. The word orthorexiacomes from the Greek words orthos (straight, proper)and orexia (appetite). Although it is not an officialeating disorder diagnosis, orthorexia has beenacknowledged as a serious problem by supportgroups. The name was first used by Steven Bratman,M.D., in “Health Food Junkie” (Yoga Journal, October31, 1997): “This transference of all of life’s value intothe act of eating makes orthorexia a true disorder. Inthis essential characteristic, orthorexia bears manysimilarities to the two well-known eating disordersanorexia and bulimia. Where the bulimic andanorexic focus on the quantity of food, the orthorexicfixates on its quality. All three give food an excessiveplace in the scheme of life.” Orthorexia has also beendefined as “a maniacal obsession for healthy foods.”

People with this disorder allegedly feel superiorto others who eat improper food, which mightinclude nonorganic or junk foods and items foundin regular grocery stores, as opposed to health foodstores. Orthorexics obsess over what to eat, how

much to eat, how to prepare food properly andwhere to obtain pure and proper foods. Eating theright food becomes an important, or even the pri-mary, focus of life. One’s worth or goodness is seenin terms of what one does or does not eat. Personalvalues, relationships, career goals and friendshipsbecome less important than the quality and timingof what is consumed. Orthorexia sometimesinvolves severe weight loss.

Catalina et al. explain further, “Orthorexic patientsexclude foods from their diets that they consider to beimpure because they have herbicides, pesticides orartificial substances and they worry in excess aboutthe techniques and materials used in the food elabo-ration. This obsession leads to loss of social relation-ships 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 dietbecomes the most important part of their lives.”

Donini et al. found a higher prevalence in menand in those with a lower level of education.Strand cautions that not all experts believeorthorexia to be a clinically useful diagnosis, saying“in terms of treatment, it differs from anorexiaonly in the finer points.”

Bratman, Steven, and David Knight. Health Food Junkies:Overcoming the Obsession with Healthful Eating. NewYork: Broadway Books, 2000.

Catalina, M., B. Bote, F. Garcia, and B. Rios. “OrthorexiaNervosa: A New Eating Behavior Disorder?” ActasEspanolas de Psiquiatria 33, no. 1 (January–February2005): 66–68.

Donini, L. M., et al. “Orthorexia Nervosa: A PreliminaryStudy with a Proposal for Diagnosis and an Attemptto Measure the Dimension of the Phenomenon.” Eat-ing and Weight Disorders 9, no. 2 (June 2004): 151–157.

Strand, Erik. “A New Eating Disorder?” Psychology Today37, no. 5 (September–October 2004): p. 16.

osteopenia A general term referring to loss ofbone, regardless of cause. Bone loss may be due to anumber of disorders, the most common of which areosteoporosis, osteomalacia and osteitis fibrosa. Thereare various causes for these conditions, and treat-ment and prevention strategies vary accordingly.

Osteoporosis is a condition in which bone massbecomes demineralized, less dense and brittle. It isassociated with aging. This is the most common

234 orthorexia nervosa

form of osteopenia and has received the most pub-licity. It accounts for the fragility of the bones inelderly women. A progressive condition, it gener-ally begins at menopause or when there is any lossof hormones. Women are more susceptible toosteoporosis than men for a number of reasons,including their smaller size and lower dietary cal-cium intake. Other hormones and certain drugsalso contribute to the development of osteoporosis.

Osteomalacia is the softening of the bones, char-acterized by an accumulation of newly createdbone mass that has not become mineralized. Hard-ening of bone mass requires both calcium andphosphorus and will be affected negatively by adeficiency of these minerals or by the presence ofcertain hormones or drugs. Persons with osteoma-lacia frequently suffer from generalized bone paineven in the absence of fractures.

Osteitis fibrosa is a condition in which bonedegenerates, or is resorbed, very rapidly. It usuallyresults from excessive production of certain sub-stances such as parathyroid hormone or thyroidhormone. In these cases, bone is diminished fasterthan new bone mass can be formed.

Osteopenia has been recognized as a seriouscomplication of anorexia nervosa. In 1983 E. R.McAnarney and her colleagues reported a case ofpathological rib fracture in a 25-year-old anorexic.Since then there have been many other reportsdocumenting pathological fractures in anorexicsincluding ribs, vertebrae and hips. In one instance,successful treatment of anorexia nervosa resultedin improvement of the patient’s bone density,although she continued to have mild osteopenia.

Reduced bone densities are found in someanorexics, caused by reduced calcium intake and adrop in estrogen levels from self-starvation.Although, in general, a certain level of activity isnecessary to promote adequate bone growth, thekind of excessive activity that characterizes someanorexics (such as 1,000 sit-ups a night) may over-stress already-weakened bone and lead to fractures.

Rigotti et al. reported on a study of the radialbone density of 18 anorexic and 28 normalwomen, which indicated that the anorexics had alower bone density. But anorexics having a highlevel of physical activity had a bone density similarto that of active or inactive nonanorexics, whichwas greater than that of low-activity anorexics.

Insufficient calcium for bone growth may resultfrom a number of factors besides poor dietary intake.Production of high levels of serum cortisol duringFASTING may increase the loss of calcium from thebody. PURGING practices such as self-induced VOMIT-ING and LAXATIVE ABUSE can also cause unnecessaryelimination by the kidney of essential chemicalsrequired in bone formation. Consequently, eating-disordered patients may have reduced bone mass ormay predispose themselves to the future develop-ment of osteoporosis through their restrictive dietarypractices and purging their behaviors.

In a study to determine the effect of prolongedanorexia nervosa on lumbar spine bone mineral den-sity (BMD) and to determine whether oral estrogenadministration prevents bone loss in women withthis disorder, Munoz et al. concluded that (1) Estro-gen replacement alone cannot prevent progressiveosteopenia in young women with anorexia nervosa;and (2) Other factors, such as the loss of weight, theduration of the amenorrhea and the low levels oftotal insulin-like growth factor I could contribute tothe loss of bone mass in women with this disorder.

One study of anorexic women who had beengiven either calcium or estrogen and who hadgained weight showed that bone loss was haltedbut not reversed. Physical exercise and calciumand estrogen treatments did not affect bonerestoration. From this, it was concluded that aperiod of severe weight loss in young women maybe a risk factor for premature osteoporosis.

The few reports on recovery have been conflict-ing, with some studies suggesting the restoration ofnormal bone mass with recovery from anorexianervosa, while others suggest that the improve-ment may only be partial.

Estrogen replacement alone does not generallyappear to reverse osteoporosis or osteopenia, andunless there is weight gain, it does not prevent fur-ther bone loss. A German trial reported in 2002concluded that dietary treatment including anindividually determined high caloric intake, cal-cium and vitamin D supplementation improvedbone metabolism. “After 15 weeks we found a sig-nificant increase of the bone formation markerPICP. Thus dietary treatment seems to be a promis-ing tool to counteract bone loss in these patients.”

Brotman, A. W., and T. A. Stern. “Osteoporosis andPathological Fractures in Anorexia Nervosa.” Ameri-

osteopenia 235

can Journal of Psychiatry 142, no. 4 (April 1985):495–496.

Carmichael, Kim. “How Self-Starvation Damages BoneStructure.” BASH Magazine, January 1990.

Grinspoon, S., D. Herzog, and A. Klibanski. “Mechanismsand Treatment Options for Bone Loss in AnorexiaNervosa.” Psychopharmacology Bulletin 33, no. 3(1997): 399–404.

McAnarney, E. R. et al. “Rib Fractures and Anorexia Ner-vosa.” Journal of Adolescent Health Care 4 (1983).

Mika, C., I. Grzella, B. Herpertz-Dahlmann, and M. Heer.“Dietary Treatment Enhances Bone Formation inMalnourished Patients.” Journal of Gravitational Physi-ology 9, no. 1 (July 2002): 331–332.

Munoz, M. T., et al. “The Effects of Estrogen Administra-tion on Bone Mineral Density in Adolescents withAnorexia Nervosa.” European Journal of Endocrinology146, no. 1 (January 2002): 45–50.

Rigotti, N. A., S. R. Nussbaum, D. B. Herzog, and R. M.Neer, “Osteoporosis in Women with Anorexia Ner-vosa.” New England Journal of Medicine 311, no. 25(December 20, 1984): 1,601–1,606.

Ward, A., N. Brown, and J. Treasure, “PersistentOsteopenia after Recovery from Anorexia Nervosa.”International Journal of Eating Disorders 22, no. 1 (July1997): 71–75.

Overeaters Anonymous (OA) A nonprofit self-help group formed in 1960 that follows many of theprinciples of Alcoholics Anonymous; membership isbased on freewill donations. OA promotes the beliefthat “compulsive eating is a progressive illness thatcan’t be cured but can be arrested.” Like AlcoholicsAnonymous, this group has a 12-step recovery pro-gram, based on acceptance of the premise that anovereater is powerless over food and that only aPower greater than oneself can restore one to san-ity. New members are encouraged to call theirsponsors each day to discuss weight loss efforts.

In their review of weight loss programs, Tsai etal. found no studies of the efficacy of OA forweight loss; however, they suggested encourage-ment of its use by patients “given that [the pro-grams] pose minimal financial or physical risks.”They concluded that “OA seems to be most appro-priate for patients who seek intensive emotionalsupport to facilitate weight loss. Because each OAchapter apparently has its own character, patientsshould sample several groups to find the best fit.”

In their analysis of data collected from 26women who met the criteria for bulimia nervosa,

Wasson and Jackson found that those participantsused five OA skills or strategies. “These included:(1) OA meeting attendance and participation, (2)interaction with a sponsor, (3) processing (i.e., writ-ing and journaling), (4) spirituality (i.e., prayer andmeditation), and (5) adherence to a food plan.”

See also APPENDIX III.

Wasson, Diane H., and Mary Jackson. “An Analysis ofthe Role of Overeaters Anonymous in Women’sRecovery from Bulimia Nervosa.” Eating Disorders: theJournal of Treatment & Prevention 12, no. 4 (Winter2004): 337–356.

Tsai, Adam Gilden, et al. “Commercial and Self-Help Pro-grams for Weight Control.” Psychiatric Clinics of NorthAmerica 28, no. 1 (March 2005): 171–192.

over-the-counter diet pills See DIET PILLS—OTC.

overweight bulimia Noting that “patients whohave bulimia nervosa and are overweight havereceived little attention in the medical literature,”Mitchell et al. contrasted 25 overweight bulimianervosa patients with a sample of 25 patients withbulimia nervosa who were within 10 percent oftheir ideal body weight. “Members of the over-weight bulimia nervosa group were binge-eatingand vomiting less frequently than the comparisongroup but were more likely to be abusing laxatives,and to report a history of self-injurious behaviorand suicide attempt(s). Both groups reported fre-quent binge-eating.”

Mitchell, J. E., et al. “Bulimia Nervosa in OverweightIndividuals.” The Journal of Nervous and Mental Disease178, no. 5 (May 1990): 324–327.

overweight bulimia nervosa Although normal-weight bulimics are the most common, there aresubstantial numbers of overweight bulimics, whorun into difficulties when seeking appropriate treat-ment. For example, because they binge-eat andpurge, they are often grouped by providers of ther-apy with emaciated bulimics or anorexics; or theyare classified simply as obese individuals. Overweightbulimics vehemently reject these classifications andthe treatment approaches that go with them.

236 Overeaters Anonymous

pagophagia The craving to eat ice. Kushner et al.said it is “one of the most common forms of picaand is closely associated with the development ofiron-deficiency anemia. Although this conditionhas been well described among pregnant womenand malnourished children, particularly in develop-ing countries, it has not been previously reported tooccur following gastric bypass surgery for treatmentof severe obesity.” The authors present two cases ofwomen who experienced a recurrence of pagopha-gia following gastric bypass surgery, along with anupdated review of the literature.

See also PICA.

Kushner, R. F., B. Gleason, and V. Shanta-Retelny“Reemergence of Pica Following Gastric BypassSurgery for Obesity: A New Presentation of an OldProblem.” Journal of the American Dietetic Association104, no. 9 (September 2004): 1,393–1,397.

pancreatic polypeptide (PP) A peptide contain-ing 36 amino acids that is produced in the pancreasand is released following ingestion of food, withage and in disease states. It is thought to be a SATI-ETY hormone that is deficient in children withhereditary forms of morbid obesity. A lack of pan-creatic polypeptide has been associated with theobese syndrome in rats and mice. Whether PP defi-ciency is the cause of obesity or just a marker is notclear. Administration of pancreatic polypeptide willdecrease food intake, although the doses requiredare believed to be above safe levels.

panniculectomy Surgical removal of the large“apron” (abdominal panniculus or pannus) ofexcess fat and skin that hangs down from thelower abdomen on a severely obese person or on aperson who has experienced massive weight loss.An abdominal apron can weigh as much as 100

pounds. ABDOMINOPLASTY and panniculectomy aretwo different procedures. Abdominoplasty dealswith muscle as well as skin and fat, whereas a pan-niculectomy deals only with excess skin and fat. Apanniculectomy can be performed alone, in con-junction with an abdominoplasty or along withanother abdominal surgery, such as hysterectomy.

The fat and skin apron is graded according toits size and extent. The higher the grade, themore extensive the operation and the greaterthe complications.

The Abdominal Panniculus Grading System isas follows:

• Grade 1. Pannus apron reaches hairline andmons pubis, but not the private areas.

• Grade 2. Pannus apron reaches private areaslevel with the upper thigh crease.

• Grade 3. Pannus apron reaches upper thigh.

• Grade 4. Pannus apron reaches mid thigh.

• Grade 5. Pannus apron reaches knees.

Panniculectomy is not always performed forcosmetic reasons. In certain circumstances it ismedically necessary in order to perform indicatedmajor gynecologic intra-abdominal surgery.

Generally, if a panniculectomy is performed on anobese person, it requires a hospital stay because of theextensive nature of the surgery as well as the needfor more medical attention during recovery. The hos-pital stay may be from one to three weeks or longer.Complete wound healing may take several months.

Gallagher lists the following signs and symptomsof complications: “respiratory compromise, deepvein thrombosis (DVT), skin injury, infection,atelectasis (total or partial collapse of the lung), andbleeding. Prolonged surgery and hypothermia dur-ing the procedure increase the risk of complica-

237

P

tions. Elderly patients, smokers, and hypertensivepatients are especially vulnerable, as are patientswith chronic illnesses, such as diabetes.” She alsocautions that “fatty tissue that wasn’t excised canbecome devitalized, causing necrosis and infection.”

Insurance companies will usually not cover pan-niculectomy when it is performed solely for cos-metic purposes, but will cover it when medicallynecessary for such problems as uncontrollableinfections, hernia or interference with mobility.

Gallagher, Susan. “Panniculectomy: More than a TummyTuck.” Nursing 34, no. 12 (December 2004): 48–50.

parental factors in anorexia nervosa The degreeto which parents influence the development of ordirectly cause anorexia nervosa had not been firmlyestablished, although theories abound. Parents ofanorexics have been described in various studies asneurotic, obsessive, rigid or passive. However, thereported incidence of these behaviors in parents ofanorexics has varied greatly, ranging from 10 to 40percent. Controlled research in this area has beensparse, but a few studies of parents have indicatedthe presence of emotional disturbance. Usually par-ents do blame themselves for a daughter’s anorexia.

HILDE BRUCH suggested that anorexia nervosadevelops in a family setting in which the child is notallowed to assume the responsibilities associatedwith the normal maturational process. She describesthese parents as overprotective, overambitious andoverconcerned. Consequently, these children oftendevelop unrealistic expectations of themselves. Onearea of such perfectionism is the body.

See also FAMILY THERAPY.

passive exercise machines Devices that deliverelectrical shocks to muscles, forcing involuntarycontractions, which supposedly takes the place ofactive exercise. A recent fad in weight-reducinggadgetry, these machines are supposed to tone thestimulated muscles, thus firming and trimmingobjectionable bulges. A forerunner to these latestexercise machines was the Relaxicisor, a devicethat was banned by a federal court in 1970.

John A. McCurdy wrote that such electrical stim-ulation is used to maintain muscle tone and flexibil-ity in patients who have suffered localized paralysis

from strokes, or who are unable to exercise activelybecause of coma or other neurological conditions.While properly performed electrical stimulation canenhance muscle tone in healthy people, mostresearches in this field feel that the machines uti-lized in “passive exercise” clinics are not sufficientlysophisticated (and personnel operating thesemachines not well enough trained) to offer the indi-vidual variability necessary to deliver the proper fre-quency, magnitude and duration of electricalstimulation required for efficient muscle toning.And unfortunately, muscle toning has no effect onoverlying fat deposits that usually contribute thebulk of the objectionable figure deformity.

In the 1990s the Federal Trade Commission (FTC)warned consumers about any effort-free motorizedtable, equipment or device that supports bodyweight and is capable of continuously moving iso-lated groups of muscles through as a range of motionin a manner requiring little or no effort. Examplesinclude toning tables and motorized calisthenicstables. Such devices have gained great popularity athealth clubs, spas, tanning salons and weight lossand fitness centers. The appeal is an easy exercisesolution. The FTC brought charges against one com-pany, Slender You, Inc., for making false and unsub-stantiated weight loss claims for the continuouspassive motion exercise tables it manufactures andsells to health and fitness centers. “In marketing tocenters and spas, Slender You has a strong appeal inprofitability, promising a full return on investmentwithin six months, and more than double theirmoney in profit by the end of the first year.” Passivemotion tables are used legitimately for rehabilitationin physical therapy and following orthopedic surgeryby helping to increase flexibility of joints. However,these devices simply do not reduce body fat or bodyweight, and do not firm muscles or increase fitness.

See also FRAUDULENT PRODUCTS; NOVELTIES FOR

WEIGHT LOSS.

McCurdy, John A., Jr. Sculpturing Your Body: Diet, Exerciseand Lipo (Fat) Suction. Hollywood, Fla.: Frederick FellPublishers, 1987.

pathophysiology The study of abnormal functionas related to body structure.

The late physiologist William Sheldon specu-lated that a genetic trait common to the overweight

238238 parental factors in anorexia nervosa

is a long intestinal tract. He estimated that in long,thin body types, ECTOMORPHS, the length is about 20feet; thus food reaches the colon in a matter ofhours, before many calories can be absorbed. HeavyENDOMORPHS, however, might have up to 40 feet ofintestine, which gives them additional absorptivesurface and more time to absorb and store every bitof fat and sugar. Sheldon believed that MESOMORPHS

have about 30 feet of bowel and tend to be neitherfat nor thin. Sheldon’s theories are not consideredvalid, although the terms associated with them fre-quently appear in books and articles.

perfectionism Extreme or obsessive striving forperfection; a trait often exhibited by young peoplewith eating disorders. One definition of perfection-istic thinking is that it involves the setting of unreal-istic standards, rigid and indiscriminate adherence tothese standards and the equating of self-worth andperformance. Others go a step further and argue fora distinction between “normal” perfectionism, auseful characteristic, and neurotic perfectionism, adysfunctional or self-defeating one. The latter ischaracteristic of those who are predisposed towarddeveloping an eating disorder, according to Slade.

For perfectionists, eating disorders are anotherside of the “all-or-nothing” mind set. The more theyfocus on being perfect, the more aware they becomeof their faults. Feelings of worthlessness set in. Espe-cially if they think they are being dominated inother areas of their life—family, school, work—theymay decide to take charge of at least one area: eat-ing. Controlling and monitoring their food intake issomething within their power. Other areas of per-fectionistic tendencies have also been documented.In one study of 20 anorexics, school achievementwas found to be significantly greater than would bepredicted by standard tests. Many women with eat-ing disorders also admit to feeling pressured to be“the perfect person.” Often they share low SELF-ESTEEM and a deep fear of making mistakes.

Serpell and Troop add, “There is a high level ofperfectionism in both anorexia nervosa (AN) andbulimia nervosa (BN) and most studies have foundthat different eating-disordered subtypes do notdiffer in levels of perfectionism. Recent studieshave suggested that perfectionistic traits remainhigh after recovery from AN, adding to evidence

that such traits are stable features rather than sim-ply due to the effects of the illness (e.g. starvation).There is also evidence from retrospective reports ofhigh levels of perfectionism prior to onset.”

Striegel-Moore and Smolak suggest, “Prospec-tive studies are needed to clarify the etiological roleof perfectionism in eating disorders. Several studieshave found ethnic and cross-cultural differences inperfectionism. Whether heightened levels of per-fectionism serve as a risk factor for the developmentof eating disorders in ethnic groups needs to bestudied. Internalized pressure to be a ‘model’minority, aspiration to ‘move up’ in socioeconomicstatus, or a desire to be an exemplary representativeof one’s ethnic group may result in increased risk ifthe means by which such ‘acculturation’ is thoughtto be possible involve pursuit of thinness. A recentstudy found that perfectionism was associated withbulimic symptoms only in those women who feltthat they were overweight, but not in women whodid not perceive themselves to be overweight. Theauthors concluded that striving to achieve highstandards only results in negative outcomes whenthe particular standards go unmet.”

See also DICHOTOMOUS REASONING.

Serpell, Lucy, and Nicholas Troop. “Psychological Factors.”In Handbook of Eating Disorders, 2nd Ed., edited by JanetTreasure, Ulrike Schmidt, and Eric van Furth, 151–167.West Sussex, U.K.: John Wiley & Sons, Ltd., 2003.

Slade, Peter D. “The Misery That Neurotic PerfectionismCan Create.” BASH Magazine, July 1989.

Striegel-Moore, Ruth H., and Linda Smolak. “The Influ-ence of Ethnicity on Eating Disorders in Women.” InHandbook of Gender, Culture and Health, edited byRichard M. Eisler and Michel Hersen, 227–253. Mah-wah, N.J.: Lawrence Erlbaum Associates, 2000.

perimylolysis A loss of enamel and dentin fromthe surfaces of the teeth as a result of repeated con-tact with regurgitated gastric acids, rubbed in bymovements of the tongue. Destruction can rangefrom slight (smooth and polished surface of theteeth) to extremely severe (the complete dissolu-tion of tooth structure through to the nerve). Inmore severe cases, all surfaces of the teeth areaffected by acid erosion. This decay can be causedby a number of factors, but once other problemsare ruled out, the patient can be assumed to havean eating disorder.

239perimylolysis 239

Perimylolysis is generally seen in the bulimic orbulimic/anorexic patient and not in the patientexhibiting restrictive anorexia alone, since the lat-ter does not usually vomit to purge. The chronicvomiting characteristic of bulimics (sometimes fiveto 10 or more times daily) brings gastric acids intothe oral cavity; these acids dissolve tooth structure.Enamel will not usually erode until repeated regur-gitation has occurred for two years. The surfacesmost commonly affected are the lingual, or tongue-side parts of the upper teeth. The other teeth areprotected by the position of the tongue, lips andcheeks. It has been suggested that acidic gastricjuices accumulate among the papillae of the tongueand that tongue movement continually deposits theacid on the lingual surfaces of the teeth.

See also DENTAL CARIES; ORAL SOFT TISSUES.

Dalin, Jeffrey B. “Oral Manifestations of Eating Disor-ders.” In Eating Disorders: Effective Care and Treatment,edited by Félix E. F. Lacorra. St. Louis: IshiyakuEuroAmerica, 1986.

personalities of eating-disordered individualsBulimics and anorexics sometimes differ in personal-ity. People who succumb to bulimia (including thosewith bulimic anorexia, which is now more com-monly referred to as anorexia, binge eating–purgingsubtype) are more impulsive and more likely to abusealcohol and drugs than anorexics, restricting type,who tend to be “too good to be true.” They rarely dis-obey, keep their feelings to themselves and tend to beperfectionists, good students and good athletes.

Bulimics and anorexics, however, do share feel-ings of helplessness, a lack of SELF-ESTEEM and fearof fat (see FEAR OF FAT SYNDROME). In both disor-ders, eating behaviors seem to develop as a way ofhandling stress and anxieties. The bulimic personconsumes 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 dis-tinction is between bingeing and nonbingeing dis-orders. The anorexic restricts food, particularlycarbohydrates, to gain a sense of control in her life.Having followed the wishes of others, for the mostpart, she has not learned to cope with the problemsof adolescence and growing up. Impulsive behav-ior is a common personality trait in persons withBINGE-EATING DISORDER.

Noting that previous studies of personalitycharacteristics in women with eating disorders pri-marily had focused on women who are acutely ill,Klump et al. compared personality characteristicsamong women who are ill with eating disorders,recovered from eating disorders, and those with-out eating or other clinical disorder, such as mood,anxiety, or sleep disorders. They concluded,“Women with eating disorders in both the ill andrecovered state show higher levels of harm avoid-ance and lower self-directedness and cooperative-ness scores than normal control women. Althoughfindings suggest that disturbances may be trait-related and contribute to the disorders’ pathogen-esis, additional research with more representativecommunity controls, rather than our pre-screened, normal controls, is needed to confirmthese impressions.”

See also ANXIETY; MULTICOMPULSIVE; PARENTAL

FACTORS IN ANOREXIA NERVOSA; PERFECTIONISM.

Aronson, H., Marla Fredman, and Marsha Gabriel. “Per-sonality Correlates of Eating Attitudes in a Nonclini-cal Sample.” International Journal of Eating Disorders 9,no. 1 (1990).

Klump, K. L., et al. “Two-Year Prospective Study of Per-sonality Disorders in Adults with Longstanding EatingDisorders.” International Journal of Eating Disorders 37,no. 2 (March 2005): 112–118.

personality disorder According to the DSM-IV,personality disorders are enduring patterns ofinner experience and behaviors that deviatemarkedly from the expectations of the individual’sculture, are pervasive and inflexible, have an onsetin adolescence or early childhood, are stable overtime and lead to distress or impairment.

Research has found personality disorders to be apossible risk factor for bulimia. Joel Yager et al.administered the Personality Diagnostic Question-naire (PDQ) to 628 eating-disordered women: 300with normal-weight bulimia, 15 with anorexianervosa with bulimic features and 313 with subdi-agnostic eating disorders. Three-quarters of sub-jects with normal-weight bulimia had personalitydisorder diagnoses, compared with 50 percent ofthose with subdiagnostic eating disorders. Themost common PDQ diagnoses were schizotypal,histrionic and borderline disorders, but avoidantand dependent personality features also occurred.

240240 personalities of eating-disordered individuals

In another study Yates et al., of the University ofIowa College of Medicine, compared 30 bulimicpatients with 30 age- and sex-matched controls(see CONTROL GROUP) on DSM-III personality meas-ures. The bulimic patients were more likely to dis-play cluster B (histrionic, narcissistic, antisocial andborderline) personality abnormalities and cluster C(avoidant, dependent, compulsive and passive-aggressive) personality abnormalities than werethe controls.

Carlat et al. found personality disorder presentin 26 percent of male eating-disordered patients,particularly among bulimics.

In some cases, the eating disorder may be a sec-ondary symptom to an underlying personality dis-order; in others, the personality disorder may besecondary to the eating disorder. Also, according toWatson et al., the comorbid personality disorderthat often accompanies an eating disorder may addto the denial of illness and unwillingness to seektreatment. Gleaves and Cepeda-Bonito noted thatthe effect on workplace behavior of associated per-sonality disorders may be as great as that of theeating disorder per se.

Up to 50 percent of women with bulimia havesome type of personality disorder. In 2003, theNational Center on Addiction and SubstanceAbuse (CASA) at Columbia University released areport, “Food for Thought: Substance Abuse andEating Disorders,” which found, “Bulimic womenwho are alcohol dependent report a higher rate ofsuicide attempts, anxiety disorders, personality dis-orders, conduct disorder and other substancedependence than bulimic women who are notalcohol dependent.”

In addition, the CASA report said, “Patients witheating disorders frequently suffer from personalitydisorders such as histrionic, obsessive-compulsive,avoidant, dependent or borderline personality dis-orders. Likewise, there is a high rate of co-occur-rence of personality disorders—particularlyantisocial personality disorder and borderline per-sonality disorder—and substance use disorders bothin the general population and in clinical settings.”

A Norwegian study investigated whether recov-ered patients had lower frequency of personalitydisorders than patients at admission. At admission,77 percent of patients had one or more personalitydisorders; whereas 57 percent had one or more per-

sonality disorders at two-year follow-up. No statis-tically significant differences in frequencies of per-sonality disorders among patients with anorexianervosa, bulimia nervosa, and EATING DISORDER NOT

OTHERWISE SPECIFIED (EDNOS) were found.In their study of 668 patients, Grilo et al. deter-

mined that certain personality disorders may notbe specific to certain eating disorders.

Carlat, Daniel J., Carlos A. Camargo, Jr., and David B.Herzog. “Eating Disorders in Males: A Report on 135Patients.” American Journal of Psychiatry 154, no. 8(August 1997): 1,127–1,132.

Gleaves, David H., and Antonio Cepeda-Benito. “EatingDisorders.” In Handbook of Mental Health in the Work-place, 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-occurwith Personality Disorders? Comparison Groups Mat-ter.” 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 Disordersin Adults with Longstanding Eating Disorders.” Inter-national Journal of Eating Disorders 37, no. 2 (March2005): 112–118.

Watson, Tureka, Wayne Bowers, and Arnold Andersen.“Involuntary Treatment of Patients with Eating Disor-ders.” Eating Disorders Review, March/April 2001, p. 1.

Yager, Joel, John Landsverk, Carole K. Edelstein, andSteven E. Hyler, “Screening for Axis II PersonalityDisorders in Women with Bulimic Eating Disorders.”Psychosomatics 30, no. 3 (Summer 1989): 255–262.

Yates, William R., Bruce Sieleni, James Reich, and ClintBrass. “Comorbidity of Bulimia Nervosa and Person-ality Disorder.” Journal of Clinical Psychiatry 50, no. 2(February 1989): 57–59.

pharmacotherapy The use of drugs in the treat-ment of psychological disorders. An outgrowth ofresearch in the neurobiological sciences, pharma-cotherapy has made great inroads in the treatmentof psychological disorders and psychiatric illness.

Although pharmacotherapy has not been foundefficacious during the initial weight-gaining stageof treating anorexia nervosa (AN), a few medica-tions have demonstrated some efficacy in reducingrelapse after weight restoration has occurred, withsome evidence that the use of selective serotoninreuptake inhibitors may help in preventing relapse

241pharmacotherapy 241

in weight restored patients. Gleaves and Cepeda-Bonito explain, “With AN, a variety of drugs havebeen tried, but no medication has been shown totreat the anorexia per se. Medications such as anti-depressants are usually aimed at treating thecomorbid psychopathology and should not be con-sidered specific treatments for the AN. In contrast,several types of antidepressants have been foundto be effective in reducing the bingeing and purg-ing associated with bulimia nervosa (BN) or thebingeing with binge-eating disorder (BED). Theselective serotonin reuptake inhibitors (SSRIs)(e.g., fluoxetine) may be the drugs of choice forBN; the data are less clear for BED. A significantlimitation of pharmacological interventions is thattheir effectiveness may be temporary. That is,relapse may occur when the drugs are discontin-ued, and there is a lack of evidence that the drugsremain effective over extended periods of time,even while use continues. Dropout rates may alsobe higher than with psychological interventions.”

In his overview of pharmacological treatment ofeating disorders, Brewerton concludes, “Withoutweight restoration in anorexia nervosa, antide-pressants are essentially useless for this condition,while olanzapine shows some promise in openstudies. There is a strong case for the use of fluox-etine as an adjunct in the treatment of BN, butremission rates are low in comparison to the effectsof cognitive-behavioral therapy. Other SSRIs maybe helpful for BED, while topiramate appears to beeffective in both BN and BED. Despite its expense,ondansetron can be useful in refractory BN, as cannaltrexone with or without SSRIs.”

Grilo et al. caution, “Studies generally find, par-ticularly for fluoxetine, that high doses arerequired to produce effects. Unfortunately, surveyshave revealed that most patients with BN treatedwith pharmacotherapy by community practition-ers received inadequate dosing.”

Noting that pharmacotherapy research in BED isstill in its preliminary stages, Appolinario and McEl-roy report that some drugs have been shown to bepromising agents: “Currently, three main classes ofdrugs have been studied in double-blind, placebocontrolled trials in BED: antidepressants, anti-obe-sity agents, and anticonvulsants. SSRIs are the beststudied medications. Thus, fluoxetine, fluvoxamine,

sertraline and citalopram have been shown to mod-estly but significantly reduce binge eating frequencyand body weight in BED over the short term. Morerecently, the anti-obesity agent sibutramine and theanticonvulsant topiramate have been shown to sig-nificantly reduce binge eating behavior and bodyweight in BED associated with obesity.”

Pharmacology has also had mixed results in thetreatment of obesity, as explained by Waitman andAronne: “Pharmacological treatments for obesityhave been tried over the years. Older therapieswere associated with side effects, abuse, andrelapse despite ongoing treatment—characteristicsthat have led most practitioners to steer clear ofprescribing them. Newer treatments have pro-duced more promising results. These are not habit-uating, have been studied long term, and havedemonstrated proven health benefits. Neverthe-less, they are not yet accepted by practitionersbecause they produce a 5 percent placebo-sub-tracted weight loss—less than desired—and are notuniformly reimbursed by insurance companies.”

The future holds promise for pharmacologicaltreatment of obesity and eating disorders, accord-ing to Bruna and Fogteloo: “New developmentswithin the field of pharmacotherapy make it likelythat the number of trials (for anorexia nervosa)will increase in the coming years. Much is stillunknown about the way in which specific drugscontribute to the cessation of bingeing. The questfor new medication which is both more specificand more effective is ongoing and promising. Inthe treatment of obesity, the long-term results ofpharmacotherapy have been disappointing. How-ever, new developments suggest a more promisingrole for medication in the treatment of obesity.”

Appolinario, J. C., and S. L. McElroy. “PharmacologicalApproaches in the Treatment of Binge Eating Disor-der.” Current Drug Targets 5, no. 3 (April 2004):301–307.

Brewerton, Timothy D. “Pharmacotherapy for PatientsWith Eating Disorders.” Psychiatric Times 21, no. 6(May 2004): 59–68.

Bruna, Tijs, and Jaap Fogteloo. “Drug Treatments.” InHandbook of Eating Disorders, 2nd Ed., edited by JanetTreasure, Ulrike Schmidt, and Eric van Furth,311–323. West Sussex, U.K.: John Wiley & Sons Ltd.,2003.

242242 pharmacotherapy

Gleaves, David H., and Antonio Cepeda-Benito. “EatingDisorders.” In Handbook of Mental Health in the Work-place, 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’Mal-ley. “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. PostedNovember 2002.

Waitman, Jonathan A., and Louis J. Aronne. “Pharma-cotherapy of Obesity.” Obesity Management 1, no. 1(January 2005): 15–19.

phen-Pro A combination of the diet drug phen-termine and Prozac, an antidepressant (fluoxetine).Phentermine has been used as a diet drug since1959, but only since the mid-1990s has it been cou-pled with Prozac. The combination works by stimu-lating noradrenaline and serotonin, which makesthe body feel full. In a Georgetown University study,28 percent of patients taking phen-Pro reached theirideal body weight, 50 percent lost a lot of weight butthen plateaued, and 1 percent gained weight. Possi-ble side effects include sleep disturbance, agitation,dry mouth and constipation—typical side effects ofsome antidepressants. Experts also say it may takeseveral weeks to start working. Prozac’s maker, EliLilly & Co., said, in 1998, it did not support combin-ing Prozac with phentermine, but some doctors con-tinue to prescribe the combination.

Few studies have been conducted on phen-Pro,according to Norton. “A 1999 study by Eli Lillywas based on an independent review of recordsfrom the private practices of [three physicians].No cases of primary pulmonary hypertension orcardiac valvulopathy were found in 711 obesepatients treated with phentermine 30 mg (mil-ligrams) and either 10 mg or 20 mg of fluoxetineonce a day, or in a control group of 154 patientsgiven phentermine 30 mg alone. The phen-Progroup lost an average of 11 percent of their start-ing weight by 18 months, and 20 percent reacheda body mass index of 25 kg/m2. On average,patients in the phentermine-only group lost 3 per-cent of their weight during the first six months oftherapy, but by the end of the study they hadreturned to baseline and had even gained weight.”

Norton, Patrice G. W. “Phentermine + Prozac May OfferSafe Obesity Tx.” Family Practice News, February 15,2004, p. 81.

phenylpropanolamine (PPA) An AMPHETAMINE-like agent available without prescription andapproved for sale as an APPETITE SUPPRESSANT. It isused in over-the-counter diet products like Dietac,Dexatrim and Acutrim. PPA is also the deconges-tant in such cold remedies as Contac, RobitussinCF and Vicks Formula 44D. It is potentially harm-ful for those with high blood pressure.

PPA works by stimulating a type of adrenalinereceptor to fool the body into thinking it’s full.According to the Food and Drug Administration,even the best studies show only about a half-pound greater weight loss per week using PPAcombined with diet and exercise.

physical activity and obesity Cardiologist JamesRippe, considered the father of the walkingmovement in the United States, says the countryis facing two major lifestyle-related epidemicsthat are intricately linked: an epidemic of obesityand an epidemic of inactivity. Among his manypoints, he states:

Multiple interactions exist between lack of physicalactivity and obesity. Increased physical activitylowers the risk of obesity, may favorably influencedistribution of body weight, and confers a varietyof health-related benefits even in the absence ofweight loss. Physical activity is important forachieving proper energy balance, which is neededto prevent or reverse obesity. Not only is energyexpended during physical activity, physical activityalso has a positive effect on resting metabolic rate.Regular physical activity can improve body compo-sition. Properly designed programs of physicalactivity may preserve or even increase lean musclemass during weight loss. Physical activity has alsobeen strongly associated with maintenance ofweight loss. Physical activity that expends 1,500 to2,000 kcal a week appears necessary to maintainweight loss. Numerous studies have shown that thecombination of proper nutrition and regular phys-ical activity is the most effective intervention forweight loss and maintenance of weight loss. Walk-ing is the most convenient and logical way for mostobese persons to increase their physical activity.

243physical activity and obesity 243

A new analysis of health habits of U.S. adultsreleased February 25, 2004, by the Centers for Dis-ease Control and Prevention’s National Center forHealth Statistics showed only about one-fourth ofadults engaged in light to moderate physical activ-ity and about one in 10 engaged in vigorous activ-ity at least five times per week.

Also, according to the Weight-control Informa-tion Network, an information service of theNational Institute of Diabetes and Digestive andKidney Diseases (NIDDK):

• Less than one-third (31.8 percent) of U.S. adultsget regular leisure-time physical activity(defined as light or moderate activity five timesor more per week for 30 minutes or more eachtime and/or vigorous activity three times ormore per week for 20 minutes or more eachtime). About 10 percent of adults do no physicalactivity at all in their leisure time.

• About 25 percent of young people (ages 12–21years) participate in light to moderate activity(e.g., walking, bicycling) nearly every day.About 50 percent regularly engage in vigorousphysical activity. Approximately 25 percentreport no vigorous physical activity, and 14 per-cent report no recent vigorous or light to mod-erate physical activity.

Rippe, James M., and S. Hess. “The Role of PhysicalActivity in the Prevention and Management of Obe-sity.” Journal of the American Dietetic Association 98, no.10, suppl. 2 (October 1998): 531–538.

physiological arousal Physical response to stim-uli; for instance, the development of a feeling ofhunger in response to the sight of food.

Although several studies have suggested thatphysiological arousal is an important factor inovereating by obese persons, a 1988 study byGardner et al. of the University of Southern Col-orado found no differences in arousal betweenweight groups. They examined differences inarousal between obese and normal-weight personswhile exposed to food stimuli, during eating andduring exposure to visual imagery of both food andnonfood stimuli.

The only sex differences in arousal occurredduring the auditory presentation of food imagery;men displayed higher arousal than women. Signif-icant sex differences were not present during anyof the other intervals.

The study concluded that there is no support forthe notion that obese subjects are differentiallyaroused by food-related stimuli. Although thepresentation and eating of pizza did produce signif-icant changes in arousal, there was no differentialarousal between the obese and normal-weight per-sons. Both food and nonfood imagery tasks provedineffective in increasing arousal in both obese andnormal-weight persons.

Gardner, Rick M., Tracy Espinoza, and Renee Martinez.“Physiological Responses of Obese Subjects to Exter-nal Stimuli.” Perceptual Motor Skills 66, no. 1 (February1988): 69–70.

pica Ingestion of strange or repulsive substancesnot normally considered suitable for food. The phe-nomenon occurs throughout the world and hasbeen recorded for centuries. The most commonexplanation is that those who evidence pica areseeking trace minerals or inorganic minerals miss-ing from their diet and desperately needed by theirbodies. However, there is a lack of evidence for thisexplanation. Pica is seen most often in young chil-dren, in children and adults with mental retarda-tion, or in persons with severe psychiatric disorders.

Pica is also not uncommon in pregnant women.Corbett et al. found that “Pica exists, and might bemore common than healthcare providers assume.Although this study did not show specific pregnancycomplications associated with pica, other studies haveshown anemia and lead poisoning among womenwho practice pica. It is not clear that patients volun-teer information about pica, so it would be helpful ifnurses queried patients at each prenatal visit regard-ing pica practice. Discussion of pica practices shouldbe based on a nonjudgmental model, for pica mayhave strong cultural implications, and may be prac-ticed for cultural reasons unknown to the nurse.”

In an earlier review of the literature for the period1950 through 1990, Homer et al. also concluded thatpica is more prevalent among pregnant women thancommonly believed. “The prevalence of pica among

244244 physiological arousal

pregnant women in high-risk groups declinedbetween the 1950s and the 1970s but now remainssteady, affecting about one fifth of high-risk women.Women at high risk of pica are more likely to beblack, to live in rural areas, and to have a positivechildhood and family history of pica. The clinical pic-ture of the disorder during pregnancy is not welldescribed. The evidence suggests that pica duringpregnancy results in anemia, but it is not definitive.”

In order for the eating of nonnutritive sub-stances to be diagnosed as pica, it must persist for aperiod of at least one month; it must not be devel-opmentally appropriate; it must not be consideredan acceptable practice in the person’s culture; and,if the eating behavior exists only during the courseof another mental disorder, it must be deemed seri-ous enough to warrant independent clinical atten-tion. The most common forms of pica areGEOPHAGIA and PAGOPHAGIA.

Corbett, R. W., C. Ryan, and S. P. Weinrich. “Pica inPregnancy: Does It Affect Pregnancy Outcomes?”MCN: The American Journal of Maternal Child Nursing28, no. 3 (May–June 2003): 183–189; quiz 190–191.

Horner, Ronnie D., et al. “Pica Practices of PregnantWomen.” Journal of the American Dietetic Association 91,no. 1 (January 1991): 34–38.

pickwickian syndrome See OBESITY-HYPOVENTILATION

SYNDROME.

pimozide An antipsychotic medication. In aDutch study, anorexia nervosa patients treatedwith pimozide gained weight faster than anothergroup administered PLACEBO, but overall the differ-ence from placebo was not statistically significant.There was also no significant difference in thepimozide patients’ attitudes.

pituitary obesity The pituitary gland influencesmost body functions and is particularly importantin growth, sexual maturity and reproduction. Itdoes this through the release of hormones (thyroid,adrenals and gonads). Pituitary obesity may resultfrom a disorder of the pituitary, including the loss ofmore than one of these pituitary hormones.

The major cause of pituitary obesity is CUSHING’SDISEASE, caused by an excess of ACTH (which stim-

ulates the adrenal glands to secrete hormones,with multiple effects on metabolism); it is alsoassociated with hypothyroidism. Pituitary obesityis slow to develop, is of a generalized type and canbe diagnosed by a dryness of the skin, shortenedgrowth of the eyebrows and diminished functionof the reflexes. Other characteristics that suggest apituitary disorder include pallor, a generalized obe-sity and, in both sexes, lack of fully developed sex-ual characteristics. In men with this disorder thereis a tendency for the adipose tissue to concentratein the pelvic region. Secretion of the growth hor-mone becomes sluggish in the obese, comparedwith people of normal weight. Yet it returns to nor-mal with weight reduction, indicating that this isthe result rather than the cause of the obesity.When pituitary obesity is treated by correcting thebasic disorder, it is possible for the patient to loseweight by restricting calories.

Frawley, Thomas F., “Obesity and the Endocrine Sys-tem.” In The Psychiatric Clinics of North America, vol. 7,no. 2: Symposium on Eating Disorders, edited by FélixLarocca. Philadelphia: W. B. Saunders, 1984.

placebo A harmless inactive substance (or inef-fective procedure) given to a CONTROL GROUP in astudy as if it were an effective treatment, used as acomparison for the substance or procedure beingtested. A placebo substance is made to look andtaste identical to the active preparation; subjectsare not told which they are taking.

polycystic ovary syndrome (PCOS) Also knownas Stein-Leventhal syndrome, it is the most com-mon cause of female infertility. Researchers esti-mate that 5 percent to 10 percent of women in theUnited States have PCOS. Women with PCOS mayalso have other health problems, such as abnor-mally high levels of insulin, obesity, high bloodpressure and heart disease. A small number ofthese women will also gain weight and notice anincrease in their hair growth.

Symptoms of PCOS include: infrequent men-strual periods, no menstrual periods and/or irregu-lar bleeding; infertility or inability to get pregnantbecause of not ovulating; increased growth of hairon the face, chest, stomach, back, thumbs or toes;

245polycystic ovary syndrome 245

acne, oily skin or dandruff; pelvic pain; weight gainor obesity, usually around the waist; type 2 diabetes;high cholesterol; high blood pressure; male-patternbaldness or thinning hair; patches of thickened anddark brown or black skin on the neck, arms, breastsor thighs; skin tags (tiny excess flaps of skin in thearmpits or neck area); sleep apnea/excessive snoringand breathing stops at times while asleep.

No one knows the exact cause of PCOS. Womenwith PCOS frequently have a mother or sister withPCOS, but there is not yet enough evidence toindicate a genetic link to this disorder. Manywomen with PCOS have a weight problem, soresearchers are looking at the relationship betweenPCOS and the body’s ability to make insulin.Insulin is a hormone that regulates the change ofsugar, starches and other food into energy for thebody’s use or for storage. Since some women withPCOS make too much insulin, it is possible that theovaries react by making too many male hormones,called androgens. This can lead to acne, excessivehair growth, weight gain and ovulation problems.

Treatments for PCOS are based on the symp-toms each patient is having and whether she wantsto conceive or needs contraception, and includebirth control pills, diabetes medications, fertilitymedications, medicine for increased hair growth orextra male hormones and surgery. Maintaining ahealthy weight is another way women can helpmanage PCOS. Because obesity is common withPCOS, a healthy diet and physical activity helpmaintain a healthy weight, which will help thebody lower glucose levels and use insulin moreefficiently, and may help restore a normal period.Even loss of 10 percent of her body weight canhelp make a woman’s cycle more regular.

Although PCOS has become a much-discussedtopic among the eating disorders community,research is finding no cause or effect betweenPCOS and either eating disorders or obesity. WhenMichelmore et al. investigated the reported associ-ation between PCOS and bulimia nervosa among230 women ages 18–25, they did not find any evi-dence that “bulimia nervosa or other binge-eatingdisorders occur more commonly in women withpolycystic ovaries or PCOS. In addition, womenwith polycystic ovaries do not demonstrate signifi-cantly higher scores for dieting and other features

of shape and weight concern when compared withwomen with normal ovaries.”

Key et al. wrote, “Low weight anorectic womenwith multifollicular ovaries have frequently beenmisdiagnosed as having PCOS, despite the twoconditions being morphologically distinct.” Refer-ring to suggested theories of a connection betweenbulimia nervosa and PCOS, they elaborated,“These include the suggestion that bingeing andrestricting are associated with insulin resistanceand this precipitates manifestations of PCOS orthat the two disorders share a predisposing factor.If disordered eating perpetuates PCOS and dietingworsens bulimic symptomatology, then the recom-mendation for weight loss in an individual withPCOS is likely to exacerbate the condition.”

Noting that previous authors had speculatedabout the contribution of dietary intake to obesityin PCOS, Wright et al. compared dietary data from91 PCOS cases to that of 80 controls and found that“dietary intake and physical activity alone are notsufficient to explain differences in weight betweenwomen with and without PCOS. Women withPCOS may tend to restrict significantly energyintake in order to maintain a normal weight.”

Key, Adrienne, Helen Mason, and Jim Bolton. “Repro-duction and Eating Disorders: A Fruitless Union.”European Eating Disorders Review 8, no. 2 (March2000): 98–107.

Michelmore, K. F., A. H. Balen, and D. B. Dunger. “Poly-cystic Ovaries and Eating Disorders: Are TheyRelated?” Human Reproduction 16, no. 4 (April 2001):765–769.

Wright, C. E., et al. “Dietary Intake, Physical Activity, andObesity in Women with Polycystic Ovary Syndrome.”International Journal of Obesity & Related Metabolic Disor-ders 28, no. 8 (August 2004): 1,026–1,032.

polyphagia Excessive craving for all types offood; very great HUNGER.

ponderosity Body weight relative to height. Indi-vidual differences in ponderosity are importantdeterminants of health status. In a family study byBurns, Moll and Lauer reported in American Journal ofEpidemiology (May 1989), the researchers determinedthat if the specific environmental exposure associatedwith differences in ponderosity could be identified,

246246 polyphagia

strategies could be devised to prevent the develop-ment of excess ponderosity in high-risk children andto reduce the risk of development of chronic diseasesassociated with obesity in adulthood.

portion and serving sizes Although much of thedramatic increase in prevalence of obesity in recentdecades has been largely attributed to a culturethat promotes increased caloric intake and physicalinactivity, another contributing factor has been anincrease in the sizes of food portions served notonly in restaurants but also in the home. Largerfood portions have more calories, and eating morecalories than one needs may lead to weight gain.

As Young and Nestle write, “Most marketplaceportions exceed standard serving sizes by at least afactor of 2 and sometimes 8-fold. Portions haveincreased over time; those offered by fast-foodchains, for example, often are 2 to 5 times largerthan the original size. The discrepancy betweenmarketplace portions and standard servings suggeststhe need for greater emphasis on the relationship ofportion size to energy intake as a factor in weightmaintenance.” In an earlier study these researchersfound that “portion sizes began to grow in the1970s, rose sharply in the 1980s, and have contin-ued in parallel with increasing body weights.”

Other studies have reported similar findings,such as:

• Food portion sizes in France, where the obeseadult population is one-third that of the UnitedStates, are about half the size of those in Amer-ica. (French plate sizes are nine inches, com-pared to the 11- or 13-inch plates typical in theUnited States).

• When served oversized portions ranging from largeto enormous, few participants finished even thelarge servings, but those given the largest portionsconsumed on average 30 percent more calories.

• Even cookbooks have increased portion sizes.Revisions published in the last 10 years havelowered the number of servings per recipe butkept the amount of food the same.

• According to the National Institutes of Healthinteractive “Portion Distortion!” quiz posted in2004, a muffin 20 years ago weighed 1.5 ounces

and had 210 calories. Today’s five-ounce muffinhas 500 calories. The comparison quiz is locatedat http://hin.nhlbi.nih.gov/portion.

Young, L. R., and M. Nestle. “Expanding Portion Sizes inthe US Marketplace: Implications for Nutrition Coun-seling.” Journal of the American Dietetic Association 103,no. 2 (February 2003): 231–214.

Young, L. R., and M. Nestle. “The Contribution ofExpanding Portion Sizes to the US Obesity Epidemic.”American Journal of Public Health 92, no. 2 (February2002): 246–249.

post-traumatic effect A specific form of ANXIETY

that appears following a stressful or frighteningevent. There have been numerous cases recorded ofanorexia nervosa and bulimia apparently precipitatedby physical trauma such as surgery, an automobileaccident, rape or sexual abuse. Trauma resulting ineither temporary or permanent body disfigurementmay in turn bring on or make worse DEPRESSION,BODY IMAGE DISTURBANCE, family or social stresses andmay possibly affect hypothalamic function, therebycontributing to the onset of eating disorders.

See also STRESS AND EATING DISORDERS.

Prader-Willi syndrome (PWS) A birth defectwhose victims are always hungry and do not knowhow to stop gorging. About one child in 10,000 to15,000 is born with this incurable syndrome, iden-tified in 1956 by Swiss doctors. Characteristicsinclude short stature, unusually small hands andfeet, hyperphasia (excessive talkativeness), hypog-onadism (retarded sexual development) and somedegree of learning disability or mental retardation.Unless people with this syndrome are strictlysupervised, their compulsion to gorge (hyperpha-gia) can cause them to swell two or three timestheir ideal weight. That can lead to heart or respi-ratory problems and early death. At the First Inter-national Scientific Conference on Prader-WilliSyndrome and Other Chromosome 15 DeletionDisorders (The Netherlands, 1991), specialistsnoted that hyperphagia is first manifested betweenages one and six, and that while victims do reachSATIETY, it is only after consuming three times morecalories than controls. Their hunger also returnsmore quickly. Many patients develop diabetes dur-ing adult life.

247Prader-Willi syndrome 247

pregnancy and eating disorders In a study of 66women who had a history of anorexia nervosa and98 randomly selected community controls, neithergroup differed on rate of pregnancy, mean numberof pregnancies per woman or age at first preg-nancy. But the women with anorexia nervosa hadsignificantly more miscarriages and cesarean deliv-eries, and their offspring were significantly morelikely to be born prematurely and of lower birthweight than the offspring of controls were. Therewere no differences between women with activeversus remitted anorexia nervosa on any of thesemeasures; however, the offspring of anorexicwomen with no history of bulimia nervosa had sig-nificantly lower body weight than the offspring ofanorexic women with a lifetime history of bulimianervosa did.

In another study of women with current or pastanorexia or bulimia nervosa, children of womenwith eating disorders also had significantly lowerbirth weights and lengths than control childrenhad. There were no differences observed in child-hood temperament or mothers’ satisfaction withchildren’s appearance. But mothers with eatingdisorders did have more difficulty maintainingbreast-feeding, and they made significantly fewerpositive comments about food and eating thancontrol mothers during mealtime observations.

Yet a 1998 Australian study of 88 women deliv-ering low birth-weight infants determined thatwomen with a past history of an eating disorderhad no greater risk of delivering a low birth-weightinfant. Women delivering infants who were smallfor their gestational age did report elevated eatingdisorder psychopathology after delivery and moreeating disturbances before and during pregnancy.

Benton-Hardy and Lock suggested that preg-nancy could be a possible contributor to the devel-opment of anorexia in a predisposed person. Theywrote that “although [the subject, a 17-year-oldgirl] has other factors associated with the develop-ment of anorexia, the psychological and physicalchanges of pregnancy appear to be the crucialchanges which precipitated anorexia nervosa.”

In a study of 48 women 10 or more followinginitial treatment of bulimia nervosa, short-termepisodes of bulimic-free behavior were associatedwith pregnancy and breast-feeding on some preg-

nancies. The prevalence of miscarriage and postna-tal depression was greater among women who hadnot recovered from their eating disorder at thetime of their pregnancy.

The results of a Swedish study reported in 2005confirm that fetal outcome may be compromisedin women with a past or active eating disorder.Twenty-two percent of the patients had a verifiedrelapse in eating disorders during pregnancy.Women with past or current eating disorders wereat increased risk of severe vomiting and deliveredinfants with significantly lower birth weight andsmaller head circumference as compared with con-trols. They were also at greater risk of deliveringinfants with microcephaly (abnormally smallheads) and small for gestational age infants.

Abraham, S. “Sexuality and Reproduction in BulimiaNervosa Patients over 10 Years.” Journal of Psychoso-matic Research 44, nos. 3–4 (March–April 1998):491–502.

Benton-Hardy, L. R., and Lock, J. “Pregnancy and EarlyParenthood: Factors in the Development of AnorexiaNervosa?” International Journal of Eating Disorders 24,no. 2 (September 1998): 223–226.

Bulik, C. M., et al. “Fertility and Reproduction in Womenwith Anorexia: A Controlled Study.” Journal of ClinicalPsychiatry 60, no. 2 (February 1999): 130–137.

Conti, J., S. Abraham, and A. Taylor. “Eating Behaviorand Pregnancy Outcome.” Journal of PsychosomaticResearch 44, nos. 3–4 (March—April 1998):465–477.

Kouba, S., T. Hallstrom, C. Lindholm, and A. L.Hirschberg. “Pregnancy and Neonatal Outcomes inWomen with Eating Disorders.” Obstetrics and Gynecol-ogy 105, no. 2 (February 2005): 255–260.

Waugh, E., and C. M. Bulik. “Offspring of Women withEating Disorders.” International Journal of Eating Disor-ders 25, no. 2 (March 1999): 123–133.

pregnancy and obesity In her studies, HILDE

BRUCH found that obesity that develops during orafter pregnancy often develops in response to stress(see REACTIVE OBESITY). Some women gain weightafter each pregnancy, some only after one. Bruch’sstudies determined that the most frequent causesof stress underlying obesity following pregnancyare disappointment with the marriage, unfulfilled,unrealistic expectations about what the childmight do for the mother or frank envy of the care

248248 pregnancy and eating disorders

the child receives and resentment about thedemands it makes.

Though noting that “much has been writtenabout obesity indicating a desire for pregnancy,”Bruch argued against this theory. While agreeingthat 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 neverreceived quite enough [attention]. They will resortto overeating to combat their anger and jealousyand to compensate themselves for what they feelthey are missing.

The more children a person has, the greater therisk he or she will become obese, according to astudy from Duke University Medical Center. Froman analysis of a large database of middle-agedAmericans, researchers found women faced anaverage 7 percent increased risk of obesity perchild and men an average 4 percent increased riskper child. Researchers attribute the weight gain toa busier lifestyle that may include a diet of morefast food and leave less time for exercise.“Increased risk of obesity in both men and womensuggests a substantial portion of the effect of obe-sity related to parenthood has to be social, culturalor psychological,” said Lori Bastian, M.D., a studycoauthor. “It’s difficult to imagine a physiologicalmechanism through which men could gain weightduring pregnancy or after childbirth. Further stud-ies are needed to isolate cause and effect so we canmore accurately suggest target groups for obesityprevention and research.”

Pre-pregnancy maternal obesity more than dou-bled the risk of stillbirth and neonatal death in aDanish study of 24,505 pregnancies. No statisticallysignificant increased risk of stillbirth or neonataldeath was found among underweight or over-weight (but not obese) women. Countering thatwas a recent American study of 2,910 women thatfound obesity before pregnancy to be associatedwith a lower rate of spontaneous preterm birth.

European research to determine whether mor-bidly obese women have an increased risk of preg-nancy complications and adverse perinatal

outcome compared 2,472 women with morbidobesity (body mass index greater than 40) withnormal-weight women. There was an increasedrisk of the following outcomes: gravidic hyperten-sion, preeclampsia, gestational diabetes, cesareandelivery and macrosomia. However, the authorsnoted “a lower rate of prematurity in the obesegroup (0 vs 11%). Even when morbidly obesewomen with preexisting diabetes and chronichypertension were excluded from the analysis,significant differences in the perinatal outcomesstill persisted.”

Diets to control weight during pregnancy mustaccount for the increased need for protein, iron,folic acid and most other minerals and vitamins.For this reason, during pregnancy weight is bestcontrolled through small decreases in calorieintake, with increased energy expenditure throughexercise. VERY LOW-CALORIE DIETS are to be avoidedduring pregnancy unless specifically prescribed bya physician.

Until recently, few studies had been done onpregnancy weight gain and its effect on maternalhealth. Physiological psychologist Jennifer Lovejoyhas been researching the disparity betweenwomen’s chance of gaining weight and men’s(women’s is about double) and believes pregnancymay be a factor. Studies show that the averagewoman retains two to five pounds after ninemonths of carrying a baby, far above the normalpace related to aging. Many women end up 20 ormore pounds heavier long after childbirth.

Siega-Riz et al. call for more studies on theeffect of pregnancy weight gain. “Past research onmaternal weight gain during pregnancy hasfocused on determinants and consequences ofinadequate weight gain with concerns for thehealth of the infant. However, with the risingprevalence of obesity among women of child-bearing ages and the high proportion of womenwho are gaining in excess of recommendations, ashift in research focus must occur to include con-sideration of the mother’s long-term health sta-tus. The few studies that have examineddeterminants of excessive weight gain and post-partum weight retention in this country were notcomprehensive in assessing diet, physical activityand psychosocial factors and suffer from small

249pregnancy and obesity 249

sample sizes. Information is lacking concerningpregnant women’s perceptions about eating andgaining weight, what they actually eat, how con-sumption and exercise relate to weight gain, andhow psychosocial factors influence these behav-iors during pregnancy. Likewise, little is knownconcerning these same attitudes and behaviorsduring the postpartum period that may con-tribute to weight retention.”

See also ORAL CONTRACEPTIVES.

Grossetti, E., et al. “Morbid Obesity and Perinatal Com-plications.” Journal of Gynecology, Obstetrics, and Repro-ductive Biology (Paris) 33, no. 8 (December 2004):739–744.

Hendler, I., et al. “The Preterm Prediction Study: Associ-ation between Maternal Body Mass Index and Spon-taneous and Indicated Preterm Birth.” AmericanJournal of Obstetrics and Gynecology 192, no. 3 (March2005): 882–886.

Kristensen, J., et al. “Pre-pregnancy Weight and the Riskof Stillbirth and Neonatal Death.” BJOG 112, no. 4(April 2005): 403–408.

Lovejoy, Jennifer C. “The Influence of Sex Hormones onObesity Across the Female Life Span.” Journal ofWomen’s Health 7 (December 1998).

Siega-Riz, A. M., K. R. Evenson, and N. Dole. “Pregnancy-Related Weight Gain—A Link to Obesity?” NutritionReviews 62, no. 7, pt. 2 (July 2004): S105–111.

Weng, H. H., L. A. Bastian, et al. “Number of ChildrenAssociated with Obesity in Middle-Aged Women andMen: Results from the Health and Retirement Study.”Journal of Women’s Health 13, no. 1 (January–February2004): 85–91.

pro-ana movement Also referred to as pro-ED. Asubculture that promotes anorexia and bulimia,which has flourished in Internet chat rooms andon message boards where groups of mostly teenagegirls support one another in their quest for the ulti-mate thinness. Experts note that eating-disorderedindividuals banding together to share tips on fast-ing, avoiding detection and losing weight is not anew phenomenon—dancers, wrestlers and modelshave done it for years; but the power of the Inter-net has made it more pervasive.

These online communities encourage “anas”(anorexics) and “mias” (bulimics) by posting “thin-spiration” photo galleries of waif-thin models andfamous celebrities reported to have eating disor-

ders like Mary-Kate Olsen and KAREN CARPENTER

along with photos of obese women to warn whatthey will look like if they do not stick with theirfasting and/or purging. A recent addition to thecommunity has been the marketing of coloredbracelets to be worn on the eating wrist—usuallyred for anorexics, blue or purple for bulimics orblack or black-and-blue for self injury—as botha “secret” sign of pro-ana membership and self-motivation not to eat.

Health professionals have expressed concernthat the pro-ana culture is hijacking preventionand recovery efforts and helping eating disorders tospread. Because some Web hosting companieshave been convinced to shut down these sites,more are “going underground” and requiring pass-words for entry.

Pollack, Deborah. “Pro-Eating Disorder Websites: WhatShould Be the Feminist Response?” Feminism & Psy-chology 13, no. 2 (May 2003): 246–251.

prostate cancer and obesity Of the more than35 studies on prostate cancer risk, most concludethat there is no association with obesity. Somereport that obese men are at higher risk than menof healthy weight, particularly for more aggressivetumors. Recently, obesity has been associated withmore aggressive prostate cancer at diagnosis andhigher recurrence rates after patients undergo sur-gery to remove the entire prostate. One studyfound an increased risk among men with highwaist-to-hip ratios, suggesting that abdominal fatmay be a more appropriate measure of body size inrelation to prostate cancer. Studies examining bodymass index (BMI) and prostate cancer mortalityhave had conflicting results. However, in a recentreview of the literature, Presti concluded, “A grow-ing body of evidence suggests that obesity mayimpact upon risk, detection and outcome withregard to prostate cancer.”

Also, a study by researchers from the Universityof Texas Health Science Center at San Antonioraises the possibility that the most common test forprostate cancer might be of less benefit to menwho are overweight or obese. Ian M. ThompsonJr., M.D., and Jacques G. Baillargeon, Ph.D., wereamong the authors on a study of the relationship

250250 pro-ana movement

between BMI and the prostate-specific antigen(PSA) test. The study in 2,779 men showed thatPSA values were lower as BMI increased.

Some researchers theorize that obese menmight have elevated hormone levels, possiblyexplaining their lower PSA scores. An alternativetheory, studied by the Health Science Center team,is that PSA may be less sensitive in obese men. Thisis important because it might mean that obese menare having their cancers diagnosed later, resultingin poorer overall survival.

Baillargeon, J., et al. “The Association of Body-Mass Indexand Prostate-Specific Antigen in a Population-BasedStudy.” Cancer 103, no. 5 (March 2005): 1,092–1,095.

Presti, J. C., Jr. “Obesity and Prostate Cancer.” CurrentOpinion in Urology 15, no. 1 (January 2005): 13–16.

proteins One of the three major types of nutri-ents (see CARBOHYDRATES and FATS) found in food.Proteins constitute about 20 percent of the body’scell mass. They are necessary for the building andrepair of all kinds of body tissues, especially ofmuscles and organs such as the heart, liver andkidneys. Skin, hair, ligaments, tendons, muscle andnails are composed of protein. Major sources ofprotein are animal products such as meat, eggs,fish and milk.

Digestion breaks down protein into its compo-nent elements, amino acids, which pass into theblood, some to be used as structural proteins forthe building of body tissues, others to be used asenzymes and the rest to be carried to various partsof the body as a reserve. Because they are drawnon directly as a source of energy, there is nonoticeable weight gain when high-protein foodsare eaten in reasonable amounts. Proteins provideabout four CALORIES per gram.

Protein deficiency manifests itself in weakness,poor resistance to disease and swelling of body tis-sues due to accumulation of fluid in the tissuespaces. When eaten in large amounts, protein-richfoods can cause constipation, kidney dysfunctionand heart failure.

protein-sparing modified fast (PSMF) A diet reg-imen designed to be safer than formula diets and toproduce loss primarily of fat tissue rather than leanbody tissue by adding PROTEINS and electrolytes to

the FASTING regimen. It was developed by pioneerssuch as Bistrian and Blackburn, who defined theconceptual framework and nutritional profile of adiet that produces rapid and significant fat loss whileminimizing or eliminating many of the adversehealth consequences of the earlier LIQUID FORMULAS.

The PSMF is recommended for the moderatelyobese (see OBESITY) when undertaken under closemedical supervision. It is not recommended for themildly obese because the risk from the treatmentoutweighs the risk from mild obesity; nor for themorbidly obese, because they are more safely andeffectively treated with BARIATRIC SURGERY; nor forchildren and adolescents, because there is some lossof lean body mass, which may interfere with growth.

No data suggest that the PSMF diet reliablyimproves obesity in the long term. The diet gener-ally prescribes a total energy intake of 600–800kcal daily for 12 weeks, followed by a maintenancediet. One study reported a weight loss of about 25pounds after 10 weeks, which was substantiallymore than that achieved by less restrictive meas-ures, but at the 15-month follow-up, the weightloss achieved by the two groups was similar.

Bristrian, B. R. “Clinical Use of a Protein-Sparing Modi-fied Fast.” Journal of the American Medical Association240 (1978).

Lindner, P. G., and G. L. Blackburn. “MultidisciplinaryApproach to Obesity Utilizing Fasting Modified byProtein Sparing Therapy.” Obesity/Bariatric Medicine 5(1976).

Prozac Proprietary name for fluoxetine, a long-lasting ANTIDEPRESSANT drug that acts by selectivelyand effectively blocking the reuptake (reabsorp-tion) of the neurotransmitter SEROTONIN into nerveterminals in the brain. It was introduced in theUnited States early in 1988 and within a yearbecame one of the most widely prescribed antide-pressants in the country.

Experiments on more than 1,000 patientsshowed that fluoxetine works at least as quicklyand effectively as IMIPRAMINE and other tricyclicantidepressants. The main side effects, according toresearchers, are nausea and vomiting, insomniaand nervousness. It is less likely than other antide-pressants to cause constipation, dry mouth,drowsiness, sexual difficulties or urinary problems.

251Prozac 251

Obese patients given fluoxetine at fairly high doseslost eight to 10 pounds in two months withoutdieting, even when the drug caused no nausea orupset stomach.

Although Prozac has been used to treat anorexianervosa (AN), Brewerton writes, “Prozac has beenshown to have absolutely no effect on weight, bodyimage, anxiety or mood in low-weight patientswith AN. However, once patients are weight-recov-ered, one controlled trial indicated that relapse(which is common) can be significantly reducedwith fluoxetine in comparison to placebo, presum-ably due to its antiobsessional effects.”

In their review, Rossi et al. wrote, “The meta-analysis available on the use of fluoxetine in thetreatment of bulimia nervosa shows that the drugis as effective as other agents with fewer patientsdropping out of treatment.”

Similarly, Walsh et al. had concluded that “a two-stage medication intervention using fluoxetine addsmodestly to the benefit of psychological treatment.”

See also ANTIDEPRESSANTS; PHEN-PRO.

Brewerton, Timothy D. “Pharmacotherapy for Patientswith 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: AReview on Evidence Based Medicine.” Annals of Gen-eral Hospital Psychiatry 3, no. 1 (February 12, 2004): 2.

Walsh, B. T., et al. “Medication and Psychotherapy in theTreatment of Bulimia Nervosa.” American Journal ofPsychiatry 154, no. 4 (April 1997): 523–531.

psychodrama A form of GROUP THERAPY in whichpatients act out their responses to difficult or con-flicted situations from their daily lives. Psy-chodrama was developed by a psychiatrist, J. L.Moreno (1890–1974) during the 1930s to liberatethe “spontaneous” self from the constrictions ofVictorian social morality. Today, psychodramaoffers adolescents and adults whose “real self” ishiding from hurtful or shameful traumas of thepast to reenact these scenes that have led to thedisordered behavior of the present. It’s a noncon-frontational format intended to make it possible forpatients to gain insight into their own conflicted orself-defeating behavior. Psychodrama has beenused as treatment for eating disorders.

Veronica O. Bowlan, a psychodrama consultant,explains that psychodrama is not merely role-play-ing and not acting class.

In psychodrama, a patient gets a chance to dealwith people and events in her past, present, orfuture. She gets a chance to begin to resolve unset-tled or hidden feelings and often learns new waysof handling conflicts in real situations.

Psychodrama . . . [uses] action rather than talk-ing to help patients deal with difficult feelings. Thepatient creates and actually steps into a situationto confront the problem and her feelings about it.It is difficult, but it is also very real and power-ful . . . [she] demonstrates to each player how thecharacter should behave. She does this throughoutthe whole drama. This is called role reversal.Reversing roles gives her a chance to see the situ-ation from other perspectives and discover newsolutions or ways of interacting.

Diamond-Raab and Orrell-Valente suggest thatpsychodrama is especially useful when treating ado-lescents. “Anorexia nervosa and bulimia nervosatypically afflict individuals in adolescence. Given theintractability of these diseases in combination withthe natural recalcitrance of adolescence, treatmentwith this population presents a daunting challenge.Traditional group therapy that focuses on verbaltherapy is often not effective with this population,particularly in the acute stages of the diseases. Agroup therapy approach that integrates art therapy,psychodrama, and verbal therapy offers an innova-tive alternative to traditional group therapy.”

Eating Disorder Center of Denver offers a psy-chodrama treatment group: “This is an experientialtherapy which focuses upon action based learning.Group members are encouraged to enact scenes fromtheir lives to identify and explore emotions and tobuild skills to increase their effectiveness in daily life.”

See also ART THERAPY.

Baaklini, George. “Psychodrama: A Timely TherapeuticProcedure.” Renfrew Perspective (Fall 1992).

Bowlan, Veroncia O. “Psychodrama: Taking Action toDiscover Feelings.” Renfrew Perspective (Fall 1992).

Diamond-Raab, L., and J. K. Orrell-Valente. “Art Ther-apy, Psychodrama, and Verbal Therapy. An Integra-tive Model of Group Therapy in the Treatment ofAdolescents with Anorexia Nervosa and Bulimia Ner-vosa.” Child and Adolescent Psychiatric Clinics of NorthAmerica 11, no. 2 (April 2002): 343–364.

252252 psychodrama

Hudgins, Kate. “Using Psychodrama as a TherapeuticTool.” Addiction Letter, October 1990.

psychodynamic approach to obesity An under-standing of obesity on the belief that overweightpeople eat in response to stress-engendered emo-tional states, especially ANXIETY and DEPRESSION,rather than simply to internal HUNGER cues. Thestress is due to conditions such as marital or workproblems, mother-daughter conflict and PERSONAL-ITY DISORDERS.

The eating response recurs because it works: itrelieves emotional distress. Psychodynamic theo-rists discuss overeating as a means of diminishinganxiety, achieving pleasure, relieving frustrationand 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 obe-sity, due largely to diminished SELF-ESTEEM from thediscrimination obese people experience today.

psychogenic malnutrition Weight loss from psy-chological causes; the noneating associated with itis incidental. The term covers a wide range of psy-chiatric disorders including chronic schizophrenia,acute catatonic schizophrenia, mental retardationand schizophrenic disorganization and forms ofDEPRESSION. Cases of this type have sometimesbeen included in anorexia nervosa literature butdo not qualify as a true anorexia eating disorder.

Habermas has argued that eliminating the fear offat criterion (as recommended by Sing Lee) wouldresult in anorexia nervosa being confused withother reasons for eating problems (e.g., depression).

Habermas, T. “In Defense of Weight Phobia as the Cen-tral Organizing Motive in Anorexia Nervosa: Histori-cal and Cultural Arguments for a Culture-SensitivePsychological Conception.” International Journal of Eat-ing Disorders 19, no. 4 (May 1996): 317–334.

psychogenic vomiting Vomiting due to someemotional or psychological reason, but not due toan eating disorder. That is, the person is not vomit-ing because of fear of weight gain but rather due tonausea from some psychological/emotional origin.

psychosomatic medicine A field of medicinebegun in the 1930s; Joan Brumberg describes it as“the scientific study of emotion and the bodilychanges that accompany different emotionalstates.” She continues,

Psychosomatic medicine involved practitionersfrom many different specialty areas, not just psy-chiatry. Followers of the psychosomatic movementshared a common interest in a more integratedapproach to etiology and therapy. Body (soma)and mind (psyche) were considered as one.

Brumberg added that anorexia nervosa was par-ticularly suited to psychosomatic research becauseof “the manner in which bodily changes accompa-nied neurotic mechanisms,” but the attempt toexplain it with a simple, single formula was ulti-mately doomed because of the complexity of thedisorder. After World War II HILDE BRUCH led theway to a broader and more complex view of thesignificance of food behavior and its relation toindividuals’ lives.

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

psychotherapy Treatment of mental and emo-tional disorders by any of various means involvingcommunication between trained therapists andpatients. It includes counseling, psychoanalysis,cognitive therapy and interpersonal therapy,among others. Through psychotherapy, patientsare helped to understand why they have followedcertain behavior patterns and to change those pat-terns. Psychotherapy aims to help individual suf-fering from eating disorders achieve a morecompetent, less painful way of handling their prob-lems. It may involve patients singly or in COUPLES

THERAPY, FAMILY THERAPY or GROUP THERAPY.Individual psychotherapy is generally recom-

mended for all eating-disorder patients and usuallyforms the foundation for all other treatment. Ini-tially, individuals begin to accept their eating disor-ders as attempts to solve psychological dilemmas,and they explore attitudes about weight, food andbody image. As a feeling of trust is establishedthrough the therapists’ acknowledgement of thepatients’ pain, the patient begin to recognize the

253psychotherapy 253

multiple origins and influences of disorder (social,psychopathologic, genetic, biological, behavioraland familial). Through psychotherapy, individualscan explore concerns, test new behaviors andreceive constructive and nonjudgmental commen-tary. It provides an opportunity for them todevelop self-confidence, self-esteem and feelings ofpower and control. Therapy also helps conquerDEPRESSION, guilt, ANXIETY and STRESS, alleviatingthe need to turn to, or away from, food to dealwith problems. Effective psychotherapy avoidssimplistic explanations and solutions. Someanorexics and bulimics will terminate psychother-apy prematurely, unable to relinquish their owncontrol or to see it as a problem.

After HILDE BRUCH and ARTHUR H. CRISP,among others, concluded that traditional insight-directed psychotherapeutic approaches aimed atpersonality reorganization had failed to deliver apermanent resolution of the eating disordersdilemma, others advocated a cognitive-behavioralapproach, in which misstatements and miscon-ceptions are challenged in a systematic way. Thistechnique is useful, though it has not proven themost effective approach.

A 2003 report, Food for Thought: Substance Abuseand Eating Disorders (The National Center on Addic-tion and Substance Abuse, Columbia University)states, “After being stabilized medically, an eatingdisorder patient typically undergoes a regimen ofpsychotherapy. Cognitive-behavior therapy (CBT),an approach most commonly used with bulimicpatients, attempts to correct unhealthy or distortedthinking patterns as a means of influencing emo-tions and behaviors. CBT is a short-term psy-chotherapy that involves active collaborationbetween patient and therapist to help the patientunderstand how certain thinking patterns cause orexacerbate mental health problems and how tolearn to think more clearly and resolve problemsmore effectively. Although far more expensive andtime consuming, some experts argue that long-termindividual psychotherapy that examines underlyingcauses of the illness, helps patients develop moreadaptive coping mechanisms, strengthens patients’self-image and identity and teaches them how toadaptively express their feelings or emotions is thebest route to long-lasting recovery.”

Psychotherapy plays a central role in inpatientand outpatient treatment, according to Winstonand Webster: “Appropriate psychological inter-ventions enable the patient to gain weight and,conversely, weight gain generates further psycho-logical issues which need to be addressed in ther-apy. However, patients who are severelyunderweight have evidence of cognitive impair-ment which may reduce their ability to make useof psychotherapy. Individual psychotherapy dur-ing the early stages of treatment may thereforeneed to be focused primarily on the developmentof a therapeutic alliance and exploration about thepatient’s anxieties about change.”

Outpatient psychotherapy is sometimes recom-mended, according to Gleaves and Cepeda-Benito.“If the client’s medical condition is not critical,and/or if his or her psychosocial functioning is notseverely impaired by the disorder, outpatient treat-ment may be the optimal referral choice. Thistreatment may be individual or group therapy andmay be based on a variety of approaches. Cognitivebehavioral and interpersonal therapies havereceived the most empirical support. Outpatienttreatment may vary considerably in level of inten-sity. Fairly typical would be group or individualtwice per week. However, many agencies nowhave what they call intensive outpatient programsthat may meet as often as every night during theweek. With outpatient eating disorder treatmentsin general, attention needs to be given to possiblesigns that a treatment of more intensity is needed.If weight gain cannot be initiated for the anorexicpatient, or if bingeing and purging are not con-trolled, outpatient treatment may be determined tobe inadequate.”

Gleaves and Cepeda-Benito add that very fewcontrolled outcome studies exist for anorexia ner-vosa “largely because of the ethical problems asso-ciated with putting people who are physically atrisk in a ‘no treatment’ or wait-list control group.Data are clearer for bulimia nervosa becausenumerous controlled and/or comparative outcomestudies have now been conducted. Treatments thathave received the most empirical research are CBTand interpersonal psychotherapy (IPT).”

In a recent study of psychotherapies foranorexia nervosa, McIntosh et al. found that “non-

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specific supportive clinical management was supe-rior to interpersonal psychotherapy, while cogni-tive behavior therapy was intermediate, neitherworse than nonspecific supportive clinical man-agement nor better than interpersonal psychother-apy. For the women completing therapy,nonspecific supportive clinical management wassuperior to the two specialized therapies.”

Wilfley et al. note that IPT is the only psycho-logical treatment for bulimia nervosa that hasdemonstrated long-term outcomes comparable toCBT, but that several key areas are in need of fur-ther investigation. “Data from ongoing clinical tri-als will be critical to determine whether IPT can beeffective for anorexia nervosa. Further research isneeded regarding the mechanisms by which IPTexerts its effects, predictors of treatment outcome,and dissemination of IPT for eating disorders inclinical settings outside of controlled trials.”

Sobel wrote that when treating eating disorders,psychotherapy primarily addresses issues of chaoticeating, hunger, inadequate calorie intake, condi-tioned response and profound fear of expressingimpulses and feelings, especially those of anger andsadness.

Gleaves, David H., and Antonio Cepeda-Benito. “EatingDisorders.” 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 Psychotherapiesfor Anorexia Nervosa: A Randomized, ControlledTrial.” American Journal of Psychiatry 162, no. 4 (April2005): 741–747.

Sobel, Stephen V. “What’s New in the Treatment ofAnorexia Nervosa and Bulimia?” Mescape Women’sHealth 1, no. 9 (September 1996).

Wilfley, Denise, Rick Stein, and Robinson Welch. “Inter-personal Psychotherapy.” In Handbook of Eating Disor-ders, 2nd Ed., edited by Janet Treasure, Ulrike Schmidt,and Eric van Furth, 253–270. West Sussex, U.K.: JohnWiley & Sons, Ltd., 2003.

Winston, Anthony, and Peter Webster. “Inpatient Treat-ment.” In Handbook of Eating Disorders, 2nd Ed., editedby Janet Treasure, Ulrike Schmidt, and Eric vanFurth, 349–367. West Sussex, U.K.: John Wiley &Sons, Ltd., 2003.

psychotropic drugs Drugs that affect psycholog-ical functioning and/or experience, sometimes

used in the treatment of eating disorders. Theseinclude the phenothiazine-derivative tranquilizers(Compazine, Phenergan, Stelazine, Temeral, Tho-razine), ANTIDEPRESSANTS (Elavil, Nardil, Tofranil,Triavil, Prozac, Zoloft) and other hallucinogenic,sedative, tranquilizing and antipsychotic drugs.

The use of psychotropic medication is not theprimary approach for treating eating disorders.This is because such medication usually accountsfor only a temporary reduction in symptoms andthus is generally considered an addition to inten-sive psychotherapy.

One exception is the case of women who have,one way or another, dealt with issues likely to havebeen among the most significant causes of theireating disorders but who are unable to controltheir symptoms. With a medication-relateddecrease in symptoms, they may be able to gainmore from PSYCHOTHERAPY and eventually be ableto control the symptoms without medication.

Illegal drugs (e.g., marijuana, LSD, cocaine,morphine and its derivatives) are all psychotropicdrugs too.

puberty The stage of physical developmentwhen secondary sex characteristics develop andsexual reproduction becomes possible. It usuallyoccurs between the ages of 10 and 12 in girls andbetween 12 and 14 in boys. However, the onset ofpuberty has been shown to be more closely relatedto weight and percentage of BODY FAT than tochronological age. In the United States, the meanweight of girls at menarche (first menstrual cycle)is 105 pounds (and about 22 percent body fat),according to studies. Delayed menarche oftenoccurs with dieting, exercise and extreme thinnessand can be as late as age 19 or 20 for athletes andballet dancers.

public policy and obesity While some writerssay that obesity is a matter of personal responsibilityand ought to be a matter of private concern and notpublic policy, others insist that federal and state gov-ernments need to set public policies to combat it. Forexample, Calle and Kaaks argue, “The tobacco controlexperience has taught us that policy and environ-mental changes are crucial to achieving changes inindividual behavior. Purposeful changes in public pol-

255public policy and obesity 255

icy are needed to provide access to healthful foodsand safe environments for physical activity in schools,worksites and communities. Such change will requiremultiple strategies and bold action, ranging from theimplementation of community and work-site health-promotion programs to policies that affect commu-nity planning, transportation, school-based physicaleducation, and food services. The World Health Orga-nization global strategy proposes such action and, indoing so, strengthens the potential for individualbehavior change and positive health outcomes.”

Connolly noted that by August 2003, state law-makers had filed more than 140 bills aimed at obe-sity, nearly double the 72 filed the previous year.“Many . . . appoint commissions to study the prob-lem; others impose physical education standards inthe schools.”

Calle, Eugenia E., and Rudolf Kaaks. “Overweight, Obe-sity and Cancer: Epidemiological Evidence and Pro-posed Mechanisms.” Nature Reviews Cancer 4, no. 8(August 2004): 579–591.

Connolly, Ceci. “Public Policy Targeting Obesity.” Wash-ington Post, August 10, 2003, p. A1.

purging A term used to cover the forced expul-sion of ingested foods by bulimics. Purging has beencalled a purification rite for bulimics, a means ofovercoming self-loathing by gaining self-control.Having regained their self-discipline, they once againfeel like “good” persons who are fresh and clean.

Self-induced VOMITING is the most commonmethod of purging. The Diagnostic and StatisticalManual of Mental Disorders now restricts the termpurging to vomiting, laxatives, diuretics or enemas.

PYY (Peptide YY3–36) Peptide tyrosine tyrosineis a hormone involved in appetite regulation; ittells the brain to stop eating when the stomach isfull. Researchers have discovered that people whoare obese do not produce enough PYY. The resultscould help explain why some obese people need toeat more food to feel full.

London researchers provided a series of different-sized meals to 20 obese and 21 lean individuals tofind out whether obese people experience a PYYdeficiency. The researchers measured the release ofPYY for 180 minutes after the meal and asked par-ticipants to record how full they felt. While bothgroups experienced an increase in PYY levels atmeals of each size, the obese subjects had a lowerlevel of PYY and recorded lower levels of fullnessfor meals of every size, compared with the leangroup. Obese people needed a meal twice as large toachieve the same blood levels of PYY as the leangroup. In a second part of the study, the researcherscompared the effects of PYY infusion on appetiteand food intake in 12 obese and 12 lean subjects ina double-blind placebo-controlled crossover study.Caloric intake during a buffet lunch offered twohours after the infusion of PYY decreased by 30percent in the obese subjects and 31 percent in thelean subjects. PYY infusion also caused a significantdecrease in the cumulative 24-hour caloric intakein both obese and lean subjects. The researcherspropose that reduced PYY levels in obese people fol-lowing a meal could contribute to a reduced feelingof fullness and a larger-sized next meal.

The Tufts University Health & Nutrition Letter(November 2003) noted that the overweight peo-ple in the study had less PYY in their intestinaltracts to being with, but also noted “It’s unclearwhether they become obese because their bodiesnaturally make less PYY, or if they started makingless PYY once they became overweight.”

Several companies are developing PYY drugs forobesity, including a nasal spray designed to deliverPYY directly to the bloodstream. However, it willtake some time before long-term PYY infusion canbe tested for safety and effectiveness.

Batterham, R. L., et al. “Inhibition of Food Intake inObese Subjects by Peptide YY3–36.” New England Jour-nal of Medicine 349, no. 10 (September 4, 2003):941–948.

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reactive obesity An increase in body weightresulting from overeating as a response to stressfullife events. It is widely accepted that all aspects ofhuman growth, development and disease are con-ditioned by social and interpersonal environment,and case reports and surveys suggest that obesity isno exception. Obesity has been found to followstressful experiences such as financial reverses,hospitalization, instances of social or intellectualfailure, marriage, failure of marriage, childbirth, ill-ness or death of parents or close relatives.

There are numerous references in the medical lit-erature to obesity as a possible symptom of nervousdisturbance since the 19th century. These includewomen who, grieving over the loss of their lovedones during World War I, were observed to put onweight that could not be accounted for otherwise.Similarly, during World War II there were manyinstances of severe obesity in young women whohad been exposed to bombing or other hardships.HILDE BRUCH observed frequent cases of newly devel-oped obesity following the deaths of family mem-bers, separations from home, breakups of love affairsor other situations involving fear and loneliness.

Bruch observed that reactive obesity occurred morecommonly in adults and infrequently in children.

See also COMPULSIVE EATING; NIGHT EATING SYN-DROME; PREGNANCY AND OBESITY.

religion and eating disorders Because there hadbeen no consensus among researchers on the etiol-ogy of the anorexia syndrome, a 1987 Loyola Uni-versity of Chicago study attempted to examinecritically the background from which anorexiadevelops. Because medical literature places greatemphasis on family environmental factors in thedevelopment of anorexia, a primary focus of this

study was on rituals in the family, particularly of areligious nature.

Conclusions reached were that religion func-tioned as a reinforcer in developing a personalityprofile that reflected poor SELF-ESTEEM and thatreligion was found to be associated with the instil-lation of guilt feelings. Fear of offending God inhib-ited the subjects from doing things in their ownbest interest. It was also found that even though allrespondents had left their childhood religions,those who adopted new religions committed them-selves to more formalized, structured and control-ling belief systems. Consistently, God wasportrayed as a controller, a protector and a judge.

In their review of how culture affects eatingdisorders, Keel and Klump discussed the religiousimplications. “Given both current (as well as his-torical) plurality in motivations behind self-starva-tion, Rieger, Touyz, Swain, and Beumont (2001)recommended requiring ego-syntonic emaciationrather than weight phobia to differentiateanorexia nervosa (AN) from other conditions thatlead to weight loss. The authors noted that cases ofAN are uniform in the extent to which self-starva-tion is deliberate and the responses to resultingemaciation range from indifference to pride. Theirproposition offers a solution to differentiating fast-ing to convey religious devotion that is commonto most religions and that displayed in holyanorexia. Moreover, ritualistic religious fasting istime-limited and tends to focus on avoiding spe-cific foods entirely or not eating during specifictime intervals and thus does not typically result inemaciation. It lacks the persistent and pervasivenature of food refusal that characterizes the formof fasting observed in medieval religious asceticsor modern-day AN.”

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Nobakht and Dezhkam listed religious fasting asone of the weight control behaviors practiced byTehran students that were unique to this culture.

Lavallee, Patricia Anne. “Religiosity, Rituals and Patternsin Anorexic and Bulimic Families.” Ph.D. dissertation,Loyola University of Chicago, 1987.

Keel, Pamela K., and Kelly L. Klump. “Are Eating Disor-ders Culture-Bound Syndromes? Implications forConceptualizing Their Etiology.” Psychological Bulletin129, no. 5 (September 2003): 747–769.

Nobakht, Minoo, and Mahmood Dezhkam. “An Epi-demiological Study of Eating Disorders in Iran.” Inter-national Journal of Eating Disorders 28, no. 3(November 2000): 265–271.

religion and obesity A Purdue University studyof religion and body weight found that religiouspeople are more likely to be overweight than arenonreligious people. Analyzing data collected intwo national surveys, Ferraro found the correla-tion between being overweight and being religiouswas statistically significant regardless of a person’schoice of faith. Baptists and fundamentaliststended to be the heaviest, with Jewish, Muslimand Buddhist groups the least overweight.

Among the reasons suggested for any linkbetween religion and obesity or overweight:

• Overweight people may find comfort in religioussettings. Temples, synagogues and churches mayprovide an important source of acceptance in themidst of a society that highly values fit bodies.

• Food has become a staple of religious worship,with potluck dinners and doughnuts as commonas hymnals.

• Restrictions on alcohol and drugs may have leftthe religious with one spiritually acceptablevice: food.

• Pastors might not want to embarrass membersby preaching about weight when obesity is soeasily identifiable.

In a later Cornell University national study, Kimet al. found no significant relationships betweenreligion and body weight in women, but religiousdenomination was related to body weight in men.“Other dimensions of religiosity showing a rela-tionship with higher body mass index appeared to

be because of the lower rates of smoking amongmore religious individuals.”

In a study of a single county in upstate NewYork, Kim and Sobal found few relationshipsbetween religion, fat intake and physical activity,“suggesting that in contemporary U.S. society reli-gion may play a small role in the context of howdiet and exercise are developed and maintained.The limited range of religiosity in the sample, how-ever, may have underestimated the role of religion.Significant relationships between religion andphysical activity in woman suggest that furtherresearch is needed to more clearly delineate reli-gion’s relationship with health behaviors.”

Ferraro, Kenneth F. “Firm Believers? Religion, BodyWeight, and Well-Being.” Review of Religious Research39, no. 3 (March 1998): 224–244.

Kim, K. H., J. Sobal, and E. Wethington. InternationalJournal of Obesity and Related Metabolic Disorders 27, no.4 (April 2003): 469–477.

Kim, K. H., and J. Sobol. “Religion, Social Support, FatIntake and Physical Activity.” Public Health Nutrition 7,no. 6 (September 2004): 773–781.

Tubbs, Sharon. “Miracle Weight Loss?” St. PetersburgTimes, July 11, 2004, n.p.

Remuda Ranch A residential treatment center inArizona that is devoted to the needs of womenand girls suffering from anorexia and bulimia.Ward Keller founded and developed the center asa result of helping his daughter in her battle withanorexia. All aspects of treatment are integratedwith a Christian-centered perspective. Remudaoffers a multidisciplinary team approach, witheach resident treated by a team of professionals,including a psychiatric and primary care provider,psychologist, registered dietitian, registered nurseand masters-level therapist.

See also APPENDIX IV.

Renfrew Centers The country’s first residentialfacility exclusively devoted to the treatment ofwomen with eating disorders. It was founded bySamuel E. Menaged, an attorney, and Allen R.Davis, administrator of a private psychiatric clinic.They bought the Renfrew farm in 1984 andsecured a license making it a Community Residen-tial Rehabilitation Service. The center received

258258 religion and obesity

$2.9 million in funding from banking and privatesources. In June 1985, when the Philadelphia pro-gram opened, its philosophy of respect for andempowerment of women and its location in aserene 27-acre environment contrasted sharplywith hospital-based, coercive programs offered inpsychiatric units or drug and alcohol facilities. In1990, Renfrew opened a second residential facilityin Coconut Creek, South Florida. The RenfrewCenter also has facilities in New York City, north-ern New Jersey and Connecticut. The centers treatpatients on both outpatient and residence bases.

The largest treatment outcome study ever pub-lished on residential treatment for bulimia wasconducted at the Renfrew Center.

See also APPENDIX IV.

Gleaves, David H. et al. “A Report of 497 Women Hospi-talized for Treatment of Bulimia Nervosa.” Eating Dis-orders: The Journal of Treatment and Prevention 1 (1993):134–146.

restaurant eating and obesity Young adults whoeat frequently at fast-food restaurants gain moreweight and have a greater increase in insulin resist-ance in early middle age, according to a large mul-ticenter study funded by the National Heart, Lung,and Blood Institute (NHLBI). After 15 years, thosewho ate at fast-food restaurants more than twiceeach week compared to less than once a week hadgained an extra 10 pounds and had a twofoldgreater increase in insulin resistance, a risk factorfor type 2 diabetes.

One reason for the weight gain may be that a sin-gle meal from one of these restaurants often containsenough calories to satisfy a person’s caloric require-ment for an entire day. Participants were asked dur-ing the physical examinations given as part of thestudy how often they ate breakfast, lunch or dinnerat fast-food restaurants. Researchers found that theadverse impact on participants’ weight and insulinresistance was seen in both blacks and whites whoate frequently at fast-food restaurants, even afteradjustment for other lifestyle habits.

In an earlier study, researchers from the Univer-sity of Massachusetts Medical School also foundthat eating in restaurants appears to play a role inobesity. People who frequently ate breakfast ordinner 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 andhigher in fat, and people tend to overindulge whenthey eat in restaurants. Everything is supersized, soyou 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 Pat-terns and Obesity in a Free-Living US Adult Popula-tion.” American Journal of Epidemiology 158, no. 1 (July1, 2003): 85–92.

Pereira, Mark, et al. “Fast-Food Habits, Weight Gain, andInsulin Resistance (The CARDIA Study): 15-YearProspective Analysis.” The Lancet (January 1, 2005):36–42.

Restraint Scale A test administered by cliniciansin the form of a questionnaire, the results of whichare used to measure “restrained eating” or chronicdieting. It was composed originally in 1980 byJanet Polivy and Peter Herman in the attempt toassess the tendency toward COMPULSIVE EATING inchronically dieting female college students. How-ever, the scope of the testing soon expandedbeyond eating behavior itself to encompass atti-tudes and other indices of chronic dieting. By ana-lyzing results, clinicians are able to assess attitudesand evaluate the resulting behaviors and the fluc-tuations in weight accompanying them.

Restrained eaters have been shown to differ fromunrestrained eaters in a number of respects, display-ing greater emotionality, distractibility and salivaryresponsiveness as well as different eating patterns.In addition, restrained eaters seem to be more likelyto be or become bulimic, and patients with anorexianervosa score significantly above average on theRestraint Scale, particularly if they are also bulimic.A high score on the Restraint Scale may thus indi-cate 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 Eat-ing Questionnaire to Measure Dietary Restraint andHunger.” Journal of Psychosomatic Research 29, no. 1(1985): 71–83.

259Restraint Scale 259

restrictive operations See GASTRIC RESTRICTION

PROCEDURES.

restrictor anorexics In the nomenclature ofthe Diagnostic and Statistical Manual of MentalDisorders, anorexia nervosa, restricting type. So-called pure anorexics who restrict their intake offood rather than binge-eat or purge.

See also ANOREXIA NERVOSA.

rimonabant A new class of drugs that is beingtested as a possible new treatment for obesity.Researchers at sites around the United States ran-domized 287 subjects (both men and womenbetween the ages of 18 and 65 with a body massindex of 29 to 41) to receive five, 10 or 20 mg ofrimonabant or a placebo, while on a moderately lowcalorie diet. After 16 weeks, patients who tookrimonabant lost an average of two to four times (fiveto eight pounds) more weight than the patients onthe placebo. In addition, waist circumference in thepatients taking rimonabant also decreased frommore than twice as much as the placebos. In anotherstudy, overweight and obese people lost nearly 20pounds when taking rimonabant for a year. The drugworks by blocking receptors in the brain that affectcravings, and also acting directly on fat cells to play arole in metabolism and prevent weight gain.

In a North American study of 3,040 obese peo-ple reported in 2004, those given the higher of twodoses of the drug lost about 19 pounds and kept itoff for up to two years, compared with only fivepounds for those given placebos. Then in March2005, a second study, in Europe involving 1,507severely obese people, confirmed these findings.

The French company Sanofi-Aventis SA hopes tosell rimonabant under the brand name Acomplia,and these studies set the stage for the company toseek approval to sell it in the United States.Researchers hope that rimonabant may help pro-vide an option for the growing number of peoplewho suffer from obesity but do not respond to tradi-tional weight loss options such as diet and exercise.

However, the excitement and optimism for thenew drug has been tempered by caution from themedical community, many of whom are concernedabout possible side effects, such as depression, anx-iety and miscarriages. While Sanofi-Aventis pro-

jected that Acomplia would be on the market inthe United States in 2006, some experts suggestedthat FDA concern over side effects may make thistimetable a bit optimistic.

Roux-en-Y gastric bypass (RGB) The most com-mon and successful malabsorptive surgery for obe-sity; it has been called “the gold standard in weightreduction.” A 2004 report issued by the Healthand Human Services Agency for HealthcareResearch and Quality found that Roux-en-Y gas-tric bypass surgery results in greater weight loss—an average of 20 pounds—than doesVERTICAL-BANDED GASTROPLASTY.

First, a small stomach pouch is created to restrictfood intake. Next, a Y-shaped section of the smallintestine is attached to the pouch to allow food tobypass the lower stomach, the duodenum (the firstsegment of the small intestine) and the first por-tion of the jejunum (the second segment of thesmall intestine). This bypass reduces the amount ofcalories and nutrients the body absorbs.

A five-year imaging study led by radiologistElmar Merkle, M.D., followed patients at the Uni-versity Hospitals of Cleveland after Roux-en-Y gas-tric bypass surgery. Among the 335 patients whoparticipated in the study, radiological imagingrevealed 57 complications from the surgeries—many of them multiple problems in the samepatients, including suture tears and leaks, pul-monary embolism, pneumonia and infection.

“Severely obese patients are at high risk for anytype of surgery because of other conditions relatedto their weight,” explained Merkle. “In addition,there is a wide spectrum of procedure-specificcomplications following Roux-en-Y gastricbypass.” According to Merkle, the results empha-size that the procedure should be a last resort afterall other interventions, such as diet and exercise,have been attempted. The findings also highlightthe importance of radiological imaging in diagnos-ing surgical complications in severely obesepatients following gastric bypass, he added.

In addition to its complications, the procedurealso requires patients to undergo major lifestylechanges. Following the surgery, patients mustrestrict their eating habits and rely on vitamin sup-plements for adequate nutrition. Regardless of

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these negatives, proponents say it is one of the fewtreatments that result in dramatic long-termweight loss.

rumination The voluntary regurgitation of par-tially digested food into the mouth, where it is sub-sequently rechewed and reswallowed. The humansyndrome is named after a normal digestiveprocess carried out by ruminant animals, such ascattle, sheep and goats, which results in improveddigestibility of ingested material. One of the lesscommonly recognized of the eating disorders, itoccurs much more frequently in young infants andmentally retarded children and adults than it doesin adults of normal intelligence. However, rumina-tion does plague a number of bulimics. It is oftenunrecognized by victims or professionals and isoften diagnosed as a “digestive problem,” second-ary to bulimic behaviors.

Rumination in infants typically developsbetween three and six months of age, althoughcases developing as late as 12 months have beenreported. It is believed to be a psychosomatic ill-ness resulting from a poor mother-infant relation-ship. Mothers of ruminating infants are oftencharacterized as having difficulty in enjoying theirbabies and in sensing what gives the baby satisfac-tion, resulting in the infant’s turning to self-stimu-lating behavior. The appearance of infants duringrumination has been described as “withdrawn andself-absorbed,” as though they were deriving grat-ification from the process.

Because rumination can lead to growth failure,weight loss to the point of emaciation, electrolyteimbalances and dehydration, it is considered a seri-ous medical condition. Because of the electrolyteimbalance, ruminating children can die early in lifefrom cardiac and other complications. The condi-tion is often overlooked initially as the primarycause of weight loss, because rumination usuallyoccurs when infants are left alone and the behav-ior is not observed. Once established, it is difficultto interrupt. Treatments attempted with minorsuccess have included behavioral, medical and sur-gical. The most effective treatment has been shownto be increased social stimulation and reestablish-ment of a positive interaction between the motherand infant.

Rumination in mentally normal adults isincreasingly being recognized as a distinct clinicalsyndrome. There appear to be two types of adultruminators: those in whom the behavior developsduring childhood and apparently persists withoutsevere negative consequences, and those in whomrumination is associated with bulimia nervosa.

In one study of patients with bulimia nervosa, asmall but significant proportion were found toruminate. Because this behavior is often performedin secret, diagnosis, especially in bulimics, can bevery difficult and is frequently missed.

Comparisons of ruminating bulimics with non-ruminating bulimics have found a higher incidenceof history of anorexia nervosa and previous psy-chiatric treatment for an eating disorder among theruminators. Most of the patients have reported theactivity as being “soothing,” regardless of whetherthey felt the practice was shameful or innocuous.

Bulimic ruminators display a greater tendencyto spit out, rather than reswallow, the regurgitatedfood in an attempt to reduce the amount of foodabsorbed. The medical consequences of ruminationin bulimics can be very similar to those in bulimicswho induce VOMITING, which adds to the difficultyof making a correct diagnosis. The most seriousconsequence is probably electrolyte depletion. Thepresence of digestive acids, mixed with undigestedfood, in the mouth can also affect the mucosalmembranes and the teeth. A ruminator can alsodevelop esophageal ulcers as a result of the passageup and down of hydrochloric acid. In the chronicruminator, the salivary glands become quiteenlarged. There is a tendency in adult ruminationfor weight loss because food is not properlydigested and the nutrient value is reduced.

Rumination occurs throughout the day, notspecifically after meals. Patients have reportedruminating from five or six times a day to as manyas 30 times a day. One who ruminated all the timeconsumed dozens of mints and used toothpaste tohide the smell. The process is not unconscious atall; ruminators can bring the undigested food intothe mouth at will.

Treatment of rumination in adults can be verydifficult, owing to the apparent pleasure derivedfrom it. Patients have described a sense of reliefduring the reswallowing. For those with bulimia

261rumination 261

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nervosa, treatment resulting in reestablishment ofcontrol over eating has led to cessation of rumina-tion. In nonbulimics, behavioral treatment directedat training them to relax before and after meals haslargely proven unsatisfactory, mostly because thereis less incentive than for bulimics to stop thebehavior. In two reported cases of pharmacologictreatment, administration of paregoric prior to eat-ing completely inhibited after-meal rumination;and premeal administration of dopamine-blockingagents reduced after-meal rumination. In othercases, paregoric at first had a PLACEBO effect, withpatients feeling a beneficial impact, but it soonwore off. More successful has been a combinationof COGNITIVE THERAPY and ANTIDEPRESSANTS.

Olden wrote, “The management of patientswith rumination needs to be accomplished in ahighly individualized manner. Children with infantrumination syndrome often have symptomsrelated to significant defects in bonding with theirmother. Thus, problems of mother-child bondingin pediatric patients with rumination syndromeshould be identified and appropriately addressed.The management of adult patients with develop-mental disabilities or neurologic impairments whoruminate focuses mainly on behavioral modalities,including adversive conditioning and contingencymanagement. The healthy adult who ruminatesand has no evidence of neurologic or developmen-tal disability is best seen as someone with a habit.Management in these patients is directed towardsadjunctive therapies (i.e., the use of proton pumpinhibitors or H2 receptor antagonists to decreaseacid injury to the esophagus) as well as identifyingsituations and emotions that trigger the patient’s

symptoms. Randomized controlled trials of varioustreatment modalities need to be undertaken; like-wise, the evaluation strategy needed to best diag-nose rumination is yet to be well defined.”

Fairburn, C. G., and P. G. Cooper. “Rumination inBulimia Nervosa.” British Medical Journal 288, no.6420 (1984): 826–827..

Larocca, Félix E. F., and Mary Anne Della-Fera. “Rumi-nation: Its Significance in Adults with Bulimia Ner-vosa.” Psychosomatics 27 (March 1986): 209–212.

Malcolm, A., et al. “Rumination Syndrome.” Mayo ClinicProceedings 72, no. 7 (July 1997): 646–652.

Olden, Kevin W. “Rumination.” Current Treatment Optionsin Gastroenterology 4, no. 4 (August 2001): 351–358.

Russell, Gerald F. M. (1928– ) Emeritus pro-fessor of psychiatry and director of eating disordersat Hayes Grove Priory Hospital, Hayes, Kent, Eng-land. Dr. Russell in 1979 published the first exten-sive description of an “ominous new variant ofanorexia nervosa,” which he named BULIMIA NER-VOSA. At the time, Dr. Russell was a professor inthe Academic Department of Psychiatry at RoyalFree Hospital in London.

Russell’s principal works include “AnorexiaNervosa: Its Identity as an Illness and its Treat-ment,” in Modern Trends in Psychological Medicine,edited by John Harding Price (London: Butter-worths, 1970); “Anorexia Nervosa and BulimiaNervosa,” in Handbook of Psychiatry, vol. 4, The Neu-roses and Personality Disorders, edited by G. F. M.Russell and L. A. Hersov (Cambridge: CambridgeUniversity Press, 1984); and “Bulimia Nervosa: AnOminous Variant of Anorexia Nervosa,” Psychologi-cal Medicine 9 (1979).

262 Russell, Gerald F. M.

satiety The feeling of fullness to or beyond satis-faction, along with disappearance of APPETITE aftereating. Factors that may lead to a person eatingbeyond satiety include taste of the food, stress orother emotional state and hormones. Various hor-mones have been implicated in conveying the feel-ing of satiety to the brain. LEPTIN increases onsatiety, and GHRELIN increases when the stomach isempty. According to King, “Biologically we feelhunger more acutely than feeling satiety.”

In one series of studies, scientists are exploringdietary manipulation to decrease caloric consump-tion and increase satiety. Over the short term,decreases in the energy density of foods (caloriesper gram of food) were found to lead to decreasedfood intake, independent of fat content. Long-termstudies are needed, but these results suggest a pos-sible strategy for reducing food intake.

Liquids generally have lower satiety value thansolid foods; yet despite high water content, soupshave been reported to be more satiating. In his studyof this contradiction, Mattes found, “The soups led toreductions of hunger and increases of fullness thatwere comparable to the solid foods. The beveragehad the weakest satiety effect. Daily energy intaketended to be lower on days of soup ingestion com-pared to the solid foods or no-load days and washighest with beverage consumption. Thus, thesedata support the high satiety value of soups. It is pro-posed that cognitive factors are likely responsible.”

In a clinical trial of patients treated with anIMPLANTABLE GASTRIC STIMULATOR (IGS), whichcauses early satiety, researchers reported a 15 per-cent change in appetite before meals, a 60 percentchange in satiety between meals and a 90 percentchange in satiety at the end of a meal.

King writes, “The pharmacological potential ofseveral endogenous peripheral peptides released

prior to, during and/or after feeding are beingexplored. Short-term signal hormones includingcholecystokinin (CCK), ghrelin, PYY (peptide YY3-36) and glucagon-like peptide 1 (GLP-1) controlmeal size via pathways converging on the hypo-thalamus. Long-term regulation is provided by themain circulating hormones leptin and insulin.These systems among others, implicated in hypo-thalamic appetite regulation all provide potential‘drugable’ targets by which to treat obesity.”

SIBUTRAMINE, a reuptake inhibitor of noradrena-line, serotonin and, to a lesser extent, dopamine inthe brain, has been studied long term. It reducesfood intake by enhancing satiety.

However, speeding up satiety may not be thekey to controlling obesity, according to a CornellUniversity study that concluded that the amount offood on a plate or bowl increases intake more thanthe feeling of fullness. “It seems that people usetheir eyes to count calories and not their stom-achs,” the authors concluded.

See also CHOLECYSTOKININ; PYY.

Hitt, Emma. “Implantable Gastric Stimulator May BeEffective against Morbid Obesity.” Medscape MedicalNews, October 16, 2003. Available online. URL:http://www.medscape.com/viewartic1e/463062.

King, P. J. “The Hypothalamus and Obesity.” Current DrugTargets 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. “BottomlessBowls: Why Visual Cues of Portion Size May Influ-ence Intake.” Obesity Research 13, no. 1 (January2005): 93–100.

schools and obesity In The Surgeon General’s Callto Action to Prevent and Decrease Overweight and Obe-sity (2001), schools were identified as “a key setting

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for public health strategies to prevent and decreasethe prevalence of overweight and obesity. Mostchildren spend a large portion of time in school.Schools provide many opportunities to engagechildren in healthy eating and physical activity andto reinforce healthy diet and physical activity mes-sages. Public health approaches in schools shouldextend beyond health and physical education toinclude school policy, the school physical andsocial environment, and links between schools andfamilies and communities.”

The importance of schools in the battle againstchildhood obesity was echoed three years later bySothern: “Schools should be primary targets forefforts to educate parents concerning the reduc-tion of TV, computer games, and unhealthysnacks. Schools should be encouraged to adoptvending machine policies that promote healthydrinks and food in appropriate portion sizes anddiscouraged from providing unhealthy food asrewards for positive behavior or academic accom-plishment. Schools should provide daily physicaleducation and frequent periods of unstructuredplay in young children.”

In light of the alarming increase in childhoodobesity and lack of evidence for the effectiveness ofschool programs, Veugelers and Fitzgerald studiedthe effects of school programs in regard to prevent-ing excess body weight. “In 2003, we surveyed5,200 grade 5 students. [Those] students fromschools participating in a coordinated program thatincorporated recommendations for school-basedhealthy eating programs exhibited significantlylower rates of overweight and obesity, had health-ier diets, and reported more physical activities thanstudents from schools without nutrition programs.”

Although two national polls released in Decem-ber 2003 showed 92 percent of teachers and 91 per-cent of parents favoring only healthful foods anddrinks in school vending machines, nearly everyhigh school and more than half of elementaryschools had sodas, candy and other high-sugar,high-fat snacks in their machines. Also, requiringphysical education in school every day at everygrade level won the endorsement of 85 percent ofparents and 81 percent of teachers, yet only 8 per-cent of elementary schools and 5.8 percent of highschools offered physical education in all grades.

Sothern, M. S. “Obesity Prevention in Children: PhysicalActivity and Nutrition.” Nutrition 20, no. 7–8(July–August 2004): 704–708.

Veugelers, P. J., and A. L. Fitzgerald. “Effectiveness ofSchool Programs in Preventing Childhood Obesity: AMultilevel Comparison.” American Journal of PublicHealth 95, no. 3 (March 2005): 432–435.

SCOFF Questionnaire A screening tool developedin Britain that can identify patients who require amore detailed assessment for eating disorders.

The acronym SCOFF is formed from the initialletter of the core concept of each question (Sick,Control, One, Fat, Food). The questions, whichaddress the central features of anorexia nervosaand bulimia nervosa, are:

• Do you make yourself sick because you feeluncomfortably full?

• Do you worry you have lost control over howmuch 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 otherssay you are too thin?

• Would you say that food dominates your life?

One point is awarded for each “yes” response. Ascore greater than two indicates a likely case ofanorexia or bulimia.

Because the SCOFF test has a 12.5 percent false-positive rate, it is not considered to be sufficientlyaccurate for diagnosing eating disorders, but it isconsidered an appropriate screening tool.

Luck, A. J., J. F. Morgan, et al. “The SCOFF Question-naire and Clinical Interview for Eating Disorders inGeneral Practice: Comparative Study.” British MedicalJournal 325, no. 7367 (October 5, 2002): 755–756.

Morgan, J. F., F. Reid, and J. H. Lacey. “The SCOFF Ques-tionnaire: Assessment of a New Screening Tool forEating Disorders.” British Medical Journal 319, no.7223 (December 4, 1999): 1467–1468.

secondary amenorrhea Cessation of menstrua-tion after menarche (the first menstrual period of agirl in PUBERTY), a condition most common inanorexics but not uncommon among bulimics, par-

264264 SCOFF Questionnaire

ticularly those who rely heavily on FASTING and/orextreme DIETING as means of PURGING. In manyinstances it is attributed to undernourishment. Inaddition, the menstrual cycle can be interrupted byenvironmental 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 dis-orders. People with eating disorders feel inadequate,and this adversely affects their recovery.

A 1987 study conducted by Debra LorraineMandel of the California School of Professional Psy-chology in Los Angeles compared two groups ofbulimic women—those who compensate for bingesby means of laxatives/diuretics, vomiting and/orspitting out food (B-L) and bulimics who compen-sate by fasting (B-F)—with each other and with athird group of nonbulimic women (NB) on self-esteem and self-role concept. All women were ofnormal weight and were selected from a nonclini-cal population of undergraduate college students.

Self-esteem was assessed using the CoopersmithSelf Esteem Inventory. Three components of sex-role concept, real self (RS), ideal self (IS) and imag-ined male ideal (IMI), were assessed using the SexRole Attribute Inventory. It was hypothesized thatthe three groups would differ on self-esteem withthe B-L group measuring lowest; that the groupswould differ on each component of sex role with B-L measuring lowest on RS femininity and highest onIS and IMI femininity; and that low-esteem inbulimics would correlate with discrepanciesbetween components of sex role. Contrary to expec-tations, however, although the bulimic groups com-bined averaged lower self-esteem measurementsthan the NB group, only the B-F group had lowerself-esteem than the NB group. In addition, whileresults indicated that low self-esteem is related to anRS sex-role concept (incorporating both masculineand feminine characteristics) for B-F and NB, norelationship was found between RS sex-role conceptand self-esteem measurements for B-L.

Self-esteem is also considered a factor in adoles-cent obesity. In a 1988 University of Arkansasstudy, the Rosenberg Self-esteem Scale was admin-istered to 550 14- to 16-year-old girls. Self-esteemscores were categorized by weight and by height.

Results indicated that self-esteem of adolescentgirls is related to their weight. As obesity increased,self-esteem decreased. These results tend to con-firm the observation that adolescent girls do inter-nalize social attitudes about body size, which resultin continued low self-esteem in overweight girls.

In a later French study of 102 severely obeseadolescents, Isnard et al. reported that binge-eatingsymptoms were frequent and the binge-eatingdimension was related to high levels of anxiety anddepression, as well as to low levels of self-esteemand body-esteem. And Weiss noted that someobese patients, even after weight loss, continue tosuffer from problems related to self-esteem.

Isnard, P., et al. “Binge Eating and Psychopathology inSeverely Obese Adolescents.” International Journal ofEating Disorders 34, no. 2 (September 2003): 235–243.

Martin, Sue, et al. “Self-Esteem of Adolescent Girls asRelated to Weight.” Perceptual and Motor Skills 67, no.3 (December 1988): 879–884.

Weiss, F. “Group Psychotherapy with Obese Disordered-eating Adults with Body-image Disturbances: AnIntegrated Model.” American Journal of Psychotherapy58, no. 3 (2004): 281–303.

self-help groups Therapy groups that rely ontheir members to supply one another with sup-port, assistance and positive influence, so thatindividual members do not have to try to helpthemselves in isolation.

The “ideal” self-help (or mutual-aid) group doesnot involve professionals. In practice, however, themost stable groups do involve them. Although anassociation with professionals appears to infringe onthe self-help premise of “equal-status” relationships, when groups are formed without such assis-tance, they tend eventually to deteriorate intounproductive complaint sessions, which may erodethe members’ motivation. Some authors also sug-gest that the poor interpersonal and leadership skillsof many anorexics and bulimics prevent long-termcommitment to such groups. Professional therapistscan assist by acting as organizers, teachers of socialskills, role models and consultants and can providea structure for meetings without infringing on theprimary purpose of groups, mutual support. Groupsthat maintain connections with professionals havethe potential to train group leaders capable of facil-

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itating constructive group interaction. These “lay”leaders may be parents of anorexics or bulimics whoare motivated to help other parents, or individualswho have themselves recovered, or who are recov-ering, from eating disorders.

Various attempts have been made to study theeffectiveness of self-help groups, since such groupsmay divert people from seeking professional help.A 1976 study demonstrated that the degree of dis-tress felt by a person is inversely related to thenumber of people in his or her social network whoprovide frequent emotional support. Self-helpgroups extend members’ social networks. Theymay thus discourage them from seeking profes-sional help, but they may also refer them to it.

A 1979 study examined help-seeking behaviorin members of self-help groups and in individualswho enter PSYCHOTHERAPY. It concluded that socialnetworks and self-help groups share the followingfeatures: they buffer the experience of stress; theyobviate the need for professional assistancethrough provision of instrumental and affectivesupport; they act as screening and referral agenciesfor professional services; and they transmit atti-tudes about values and norms of help-seeking.

A 1998 British study evaluated self-help pro-grams for binge-eating disorder on 72 women.Both pure self-help and guided self-help had a sub-stantial and sustained impact, with almost half theparticipants ceasing to binge eat.

In 2001, University of Minnesota researchersevaluated the longer-term outcome of three groupcognitive-behavioral therapy (CBT) delivery mod-els for the treatment of binge-eating disorder(BED): therapist-led group discussion; partial self-help, with participants viewing a psychoeduca-tional videotape followed by a therapist-leddiscussion; and structured self-help with partici-pants watching the videotape and then leadingtheir own discussion. Reductions in binge-eatingepisodes and associated symptoms were observedfor all three treatments at post, one-month, six-month and one-year follow-up, with no significantdifferences among the three conditions.

For people trying to lose weight, Tsai et al. con-cluded there is “little scientific evidence to recom-mend 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 helpingoneself without the assistance of others. In thecontext of multidimensional treatments of eatingdisorders, the term is really misleading. Membersof a “true” self-help group become interdependentfor support, understanding and acceptance as theygradually grow to trust one another and share feel-ings and experiences.

Families of members also benefit from thesegroups. The setting reduces social isolation and pro-vides a noncritical environment for issue explo-ration. Through shared experiences, parents canlearn how to cope with their children’s problemsand their own feelings. In groups that mix parentsand children of different families, the greater emo-tional distance can sometimes enable the older gen-eration to hear and appreciate better what theyounger generation has to say. For previously unre-sponsive therapy patients, the contact with peoplewho have “been there” and found themselves capa-ble of changing has proven particularly beneficial.

Self-help groups are not a substitute for otherforms of treatment. They differ significantly fromindividual or group therapy, whose purpose is to freepatients from disabling forms of psychological disor-der by developing insight into and understanding ofunderlying causes, eventually enabling changes indysfunctional behavior. But one valuable functiongroups often perform is to refer individuals to quali-fied professional treatment. Some groups are parts ofmultimodal treatment programs. Self-help groupssometimes are also the preferred resource of anorexicsand their families for financial reasons or by personalchoice, especially if they fear professionals or havehad previous unsuccessful encounters with them.

Because self-help groups for eating disordershave originated so recently, no standardizednationwide procedures have been developed.Effective guidelines based on the successful experi-ence of existing groups, however, are beginning toemerge. According to recent social science litera-ture on self-help, the ideal mutual-aid group pro-vides members with information (factualknowledge and referrals to appropriate profession-als); opportunity to share and learn from oneanother’s experience; mutual support; positiveassociation (members can identify with groupgoals); collective willpower; and benefit from theexchange itself.

266266 self-help groups

See also ANOREXIA NERVOSA; BULIMIA NERVOSA;OBESITY; GROUP THERAPY; PSYCHOTHERAPY.

Carter, J. C., and C. G. Fairburn. “Cognitive-BehavioralSelf-Help for Binge Eating Disorder: A ControlledEffectiveness Study.” Journal of Consulting Clinical Psy-chology 66, no. 4 (August 1998): 616–623.

Larocca, Félix E. F., with Nancy J. Kolodny. Facilitator’sTraining Manual. St. Louis: Midwest Medical Publica-tions, 1983.

Peterson, C. B., et al. “Self-Help versus Therapist-LedGroup Cognitive-Behavioral Treatment of Binge Eat-ing Disorder at Follow-Up.” International Journal ofEating Disorders 30, no. 4 (December 2001): 363–374.

Rubel, Jean A. “The Function of Self-Help Groups inRecovery from Anorexia Nervosa and Bulimia.” Psy-chiatric Clinics of North America 7, no. 2 (June 1984):381–394.

Tsai, Adam Gilden, et al. “Commercial and Self-Help Pro-grams for Weight Control.” Psychiatric Clinics of NorthAmerica 28, no. 1 (March 2005): 171–192.

self-monitoring Also referred to as eating habitsmonitoring. The process of keeping a careful recordof one’s own body weight, food intake and itscaloric value, physical activity and, in some cases,the circumstances (time, place, occasion, com-pany) of eating. Self-monitoring is a key elementin almost all BEHAVIOR MODIFICATION programs andtypically the first behavior change requirement. Inobesity treatment, it is frequently prescribed beforeany attempts to diet or increase exercise are made.Originally intended strictly as an information-gath-ering tool, it has proven to have other value.

Monitoring eating habits affects eating behaviorin a number of ways. First, the very act of recordingcan force awareness of previously unconscious pat-terns of behavior. For example, because snackingusually becomes a routine, automatic behavior, mostpeople express surprise at the amount of food—andcalories—they discover they eat in a day. This aware-ness can be a first and necessary step in their efforts tocontrol how much they eat. It can also reveal behav-iors likely to have defeated previous attempts to loseweight or keep it off. Second, self-monitoring providesspecific information that allows eating-disorderedpersons to evaluate their progress and then rewardor punish accordingly. Third, records of eatingbehavior can provide information useful to therapistsin assisting the obese to make behavior changes.

Therapists suggest that self-monitoring is mosteffective and successful when patients have conven-ient forms for recording the information, whenbehavior is recorded soon, or immediately, after itoccurs and when feelings, degree of HUNGER and con-current problems are also noted. Stewart explained,“Self-monitoring usually includes aspects such asthoughts, emotions, and behaviors elicited by a body-related situation. Through self-monitoring, individu-als begin to identify salient patterns and themes intheir thinking, behaviors, and emotional reactions.”

Although researchers have found self-monitor-ing to be an essential component of treatment foreating disorders, Anderson et al. note that there is“some controversy over the reliability and validityof self-reported binge/purge episodes of foodintake.” Among the problems they cite: Largeerrors in food consumption are extremely com-mon; some individuals deliberately minimize ordeny eating pathology on self-report forms; andthere is no standard format for self monitoring,with procedures varying from professional to pro-fessional, which potentially limits their reliability.“Despite these shortcomings, however, self-moni-toring can be a useful tool in assessing dietaryrestraint, binge eating, and purgative behavior ifviewed with appropriate caution and should beroutinely collected during treatment.”

When treating the obese patient, Fabricatore andWadden wrote, “Careful self-monitoring of calorieintake is crucial to the success of low-calorie diets.Obese individuals underestimate their intake by30–50 percent. Thus, patients must be instructed inreading food labels, measuring portion sizes, andrecording their food intake as soon as possible aftereating. The more self-monitoring records patientscomplete each week, the more weight they lose.”

Garner and Stuht added, “Research shows thatsome form of cognitive constraint or self-monitor-ing in the form of activity or food logs is a charac-teristic of people who have been successful atlosing and maintaining weight long-term.”

Anderson, Drew A., et al. “Assessment of Eating Disor-ders: 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 Diabetes21, no. 2 (April 2003): 67–72.

267self-monitoring 267

Garner, Sara, and Jennifer Stuht. “CORE Tools andPatient Information.” Obesity Management 1, no. 1(January 2005): 24–26.

Stewart, Tiffany M. “Light on Body Image Treatment:Acceptance through Mindfulness.” Behavior Modifica-tion 28, no. 6 (November 2004): 783–811.

self-mutilation Also called self-injury; self-inflicted violence. The act of deliberately injuringoneself. Mutilation of one’s own or another’s bodyhas always been a part of human existence andcontinues to be a normal part of some cultureseven today. Many cultures have long used mutila-tion of the body in religious or other social rituals,such as circumcision (of both sexes), tattooing orscarring the skin during rites of passage into adult-hood or the binding of feet to make women moreattractive. These forms of mutilation or self-muti-lation are not meant to be harmful; on the con-trary, they often signify strength or rebirth.

In our culture, self-mutilation generally is notan attempt to commit SUICIDE but a way of dealingwith anxieties and stress. Many self-mutilators findbleeding to be comforting and scarring a welcomesign of healing.

The mentally retarded may do things that resultin injury to themselves, and psychotics sometimesperform drastic acts such as poking out their eyesor cutting off extremities. The most common casesof mutilation are more subtle in nature. Typicallythey involve cutting or burning parts of the bodyor interfering with the healing of wounds.

Patients with eating disorders are at high risk forself-mutilation, and vice versa, according toArmando R. Favazza, who has studied this areaextensively. He and his colleagues write, “Evidencefor this linkage comes from a literature review, frompatient interviews, from responses to an instrumentwe have developed (the Self-Harm Behavior Sur-vey), and from three instructive case reports.”

Favazza reported on some of his own cases of self-mutilators who also suffered from eating disorders.One patient developed a fear of becoming over-weight after being treated on an outpatient basis forself-mutilation at age 16. After this treatment hermutilating behaviors decreased; however, at 19,when she was hospitalized for her eating disorder,the self-mutilating behaviors intensified. After oneyear in treatment, both behaviors stopped; but when

events in her life became stressful, she relapsed onceagain into the eating disorder. For another of hispatients with a history of alcohol abuse, eating disor-der and self-mutilation, the three behaviors were“interchangeable ways of hurting myself.”

According to Favazza, an impulse-control prob-lem seems to be the basis for self-mutilation, eatingdisorders and substance abuse; he feels that a goodnumber of those with one of these problems mayalso be affected by another.

Self-mutilation is one of the most commonlyidentified issues of risk in bulimia nervosa, accord-ing to Treasure and Schmidt. “Repeated self-harmthrough cutting, burning and overdosing is com-mon and occurs in approximately 15–25 percent ofclinic samples. This is often associated with otherhigh-risk behaviors such as alcohol or substanceabuse, unprotected casual sex or repeated shoplift-ing. These impulsive behaviors have been found topredict poorer outcome for review.”

In a study of Japanese subjects with habitualself-mutilation, Matsumoto et al. found results tobe consistent with those in Western studies. “Habit-ual self-mutilation is likely to coexist with depres-sion, bulimia, and dissociation. Such patientsfrequently have clinical features similar to those of‘multi-impulsive bulimia.’ Evidence supports theassociation between habitual self-mutilation andsexual/childhood physical abuse in Japan.”

Although psychotherapeutic treatment is cur-rently available for self-mutilators, researchers are nowspeculating that a deficiency of SEROTONIN, a neuro-transmitter that influences HUNGER, SATIETY, sexualdrive and pain response, among other feelings, maybe a biological contributor to self-mutilation.

Favazza, A. R., and K. Conterio. “Female Habitual Self-Mutilators.” Acta Psychiatrica Scandinavica 79, no. 3(March 1989): 283–289.

Favazza, A. R., L. DeRosear, and K. Conterio. “Self-Muti-lation and Eating Disorders.” Suicide & Life ThreateningBehavior 19, no. 4 (Winter 1989): 352–361.

Matsumoto, T. “Habitual Self-Mutilation in Japan.” Psy-chiatry and Clinical Neurosciences 58, no. 2 (April 2004):191–198.

Treasure, Janet, and Ulrike Schmidt. “TreatmentOverview.” In Handbook of Eating Disorders, 2nd Ed.,edited by Janet Treasure, Ulrike Schmidt, and Ericvan Furth, 207–217. West Sussex, U.K.: John Wiley &Sons Ltd., 2003.

268268 self-mutilation

serotonin One of a family of NEUROTRANSMITTERS

that mediate the passing of impulses through thenervous system. The chemical is produced in thebrain when an impulse passes between two nerveendings. Most is then reabsorbed by the nerves.

A link between eating disorders and serotonin isassumed, since eating CARBOHYDRATES stimulates theproduction of serotonin in the brain. It paves the wayfor other neurotransmitters that stimulate an appetitefor protein and fat. It is thought that bulimics, whosuffer from diminished serotonin activity, becomedepressed as their serotonin level drops. As a resultthey develop a CRAVING for foods that trigger produc-tion of the substance, as if they were using pasta andsugar as a “natural” antidepressant (see ANTIDEPRES-SANTS). Animal behavior tests are being used to betterunderstand pharmacologic intervention of drugs reg-ulating serotonin. However, any existing serotoninimbalance may also be caused by chronic dieting,especially restriction of carbohydrates. Furthermore,there is evidence that dieting changes serotonergicfunctioning in women but not men, which may par-tially explain why there is a much higher incidenceof bulimia among women than men.

Gurenlian notes that studies of serotonin in indi-viduals with anorexia nervosa have yet to clarify ifchanges in this chemical represents a cause or aconsequence of the disorder. “Increases in the neuro-transmitter serotonin lead to reductions in foodintake, while decreases in brain serotonin functionare associated with depression and suicide attempts.Levels of serotonin are low in underweight individ-uals with anorexia, but will rise to normal levels inindividuals who have recovered. A disturbance inserotonergic function may be a risk factor for thedevelopment of anorexia. Conversely, high levels ofserotonin can be associated with perfectionism andrigidity, characteristics that are often seen in indi-viduals with anorexia before the illness develops.”

Gurenlian, Jo Ann R. “Eating Disorders.” Journal of Den-tal Hygiene 76, no. 3 (June 2002): 219–238.

set-point theory There is persuasive evidencethat animals and humans naturally maintain, andthus will always return to, a constant weight range,just as the body naturally returns to its own tem-perature level following illness or external influ-

ence. This weight level is referred to as the body’s setpoint. It is clear that the human body attempts tomaintain a state of homeostasis. However, the termset point is probably an inaccurate descriptor for thisprocess because it is not a specific point, but rather arange of possible weights that the body attempts tomaintain. In support of this theory, studies haveshown that once “starved” volunteers are given freeaccess to food, they eat ravenously until theirweight returns to its normal level, when appetiteand caloric intake level off at prediet amounts. Sim-ilarly, after experimental forced feeding to increaseweight as much as 25 percent, weight rapidlyreturns to normal levels when volunteers are onceagain allowed to eat whatever they want, with noattempt to control weight in either direction.

It is this set point, proponents say, that explainswhy dieters invariably return to their prediet weightonce they cease to restrict food intake. An individ-ual’s set point can vary as much as 10 to 20 poundsover 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 belowthe set point, HUNGER increases and the body burnsfewer CALORIES until weight once again stabilizes.

Lambert explains further, “The hypothalamusseems to control body weight, triggering severalhomeostatic mechanisms to maintain weight at afixed set point. A lack of blood sugar stimulatessecretion of hormones such as ghrelin (an appetitestimulant) and leptin (an appetite suppressant) thatcascade to trigger a desire to eat. If you lose fat, lep-tin decreases and ghrelin increases, causing you toeat more—and you gain weight back. The body equi-librates. Hormones like leptin regulate the set point.”

Because the basal metabolism rate (BMR)increases with lean body mass, Lambert adds, activ-ities that build and tone muscle will burn morecalories and perhaps lower one’s set-point as well.

Noting that while “the existence of a set-pointfor homeostatic control of human body weight isuncertain,” Macias concludes that “Investigation ofthe human body weight set-point is vital in under-standing obesity.”

See also GHRELIN; LEPTIN.

Lambert, Craig. “The Way We Eat Now.” Harvard Maga-zine 106, no. 5 (May–June 2004): 50.

269set-point theory 269

Macias, A. E. “Experimental Demonstration of HumanWeight Homeostasis: Implications for UnderstandingObesity.” British Journal of Nutrition 91, no. 3 (March2004): 479–484.

sexual abuse and eating disorders There is anincreasing awareness that many survivors of sexualabuse develop eating disorders. Root et al. reportedthat 60 percent of 172 bulimics studied had beensexually and/or otherwise physically victimized,and other authors have indicated an even higherrate. Studies at the RENFREW CENTER also revealedthe high correlation between sexual abuse and eat-ing disorders—61 of a sample of 100 women hadbeen sexually abused before the age of 18. Of these,24 were victims of incest, 47 were molested byacquaintances and 18 by strangers. Realizing thatthis 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 asbulimia or anorexia is a logical response to the emo-tional experiences and messages received through-out the abused child’s formative years. As the youngchild moves into adolescence and young adulthood,she turns to food as a means of comfort and a toolfor avoiding feelings. Fasting, or bingeing and thenpurging, both help create an illusion of being incontrol—while also reinforcing her shame andfeeding the desperate need to isolate [herself].

Using data from 190 university women, a 1996study found that women with histories of assaultsfrom within the family were more likely to suffer aserious eating problem (47 percent) than womenwho had no history of sexual assault (21 percent)and women who reported only assaults from out-side the family (36 percent).

However, not all researchers support the con-nection between sexual abuse and eating disor-ders. Pope and Hudson, for example, reviewed thescientific literature on childhood sexual abuse as arisk factor for the development of bulimia nervosa.They concluded that “controlled studies generallydid not find that bulimic patients show a signifi-cantly higher prevalence of childhood sexual abusethan control groups. Furthermore, neither con-

trolled nor uncontrolled studies of bulimia nervosafound higher rates of childhood sexual abuse thanwere found in studies of the general populationthat used comparable methods.”

More recently, Rayworth et al. found thatamong 732 women between the ages of 36 and 44,those who said they were physically abused inchildhood were at twice the risk of having either afull-blown eating disorder or at least some symp-toms of one. Women who reported both physicaland sexual abuse during childhood had three timesthe odds of developing eating disorder symptomsand nearly four times the odds of meeting DSM-IVcriteria for an eating disorder. The authors notedthat abuse can make victims feel powerless, andeating disorders are thought to arise, in part, froma desire to take control of one aspect of life.

Waller found that bulimics were substantiallymore likely to report a history of unwanted sexualexperience than anorexics. He suggested that sex-ual abuse may not cause eating disorders but maydetermine the nature of those disorders when theyhave been prompted by other factors.

Perhaps a more important question is notwhether or not sexual abuse is a risk factor for eat-ing disorders, but rather in what way is it impor-tant when it is present. Gleaves and Eberenzexamined this question among a group of hospital-ized eating disordered individuals and found that,although sexual abuse was unrelated to severity ofeating disorder symptoms, it was highly related toadditional problems such as suicide attempts, alco-hol problems, and self-injurious behaviors.

Gustafson and Sarwer note that relatively fewstudies have examined the relationship betweenchildhood sexual abuse and adult obesity. “Thesestudies suggest at least a modest relationshipbetween the two. Potential explanations for therelationship have focused on the role of disorderedeating, particularly binge eating, as well as the pos-sible ‘adaptive function’ of obesity in childhoodsexual abuse survivors. Nevertheless, additionalresearch on the relationship between childhoodsexual abuse and obesity is clearly needed, notonly to address the outstanding empirical issuesbut also to guide clinical care.”

Baldo, T. D., et al. “Effects of Intrafamilial Sexual Assaulton Eating Behaviors.” Psychological Reports 79 (October1996).

270270 sexual abuse and eating disorders

Gleaves, D. H., and Eberenz, K. P. “Eating Disorders andAdditional Psychopathology in Women: The Role ofPrior Sexual Abuse.” Journal of Child Sexual Abuse 2(1993): 71–80.

Gustafson, T. B., and D. B. Sarwer. “Childhood SexualAbuse and Obesity.” Obesity Review 5, no. 3 (August2004): 129–135.

Pope, Harrison G., Jr., and James I. Hudson. “Is Child-hood Sexual Abuse a Risk Factor for Bulimia Ner-vosa?” American Journal of Psychiatry 149, no. 4 (April1992): 455–463.

Rayworth, B. B., L. A. Wise, and B. L. Harlow. “Child-hood 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 Dis-orders.” British Journal of Psychiatry 159 (November1991): 664–671.

sexuality and eating disorders Restricting anorex-ics demonstrate significant immaturity and inhibi-tion in sexual and social experience; however, in theirattempt to meet all social expectations, they some-times present a facade of good social adjustment.

Bulimic women, on the other hand, although lesssexually and socially mature than borderlinewomen, are more so than anorexic women. Butbulimia usually results in a sharp decrease in sexualdesire, attributed to both psychological and physio-logical causes. Even when bulimia sufferers are sex-ually active, they will have times of withdrawingfrom their partners and ceasing sexual behavior.Bulimic patients often have irregular menstrualcycles, pointing to disruption of the pattern of sex-hormone secretion. Their obsession with food leavesthem little time to think about other aspects of life,and they characteristically feel worthless and flawed.They also often fear that if anyone becomes closelyinvolved with them, they will learn their secret.Likewise, psychiatrists contend than many peopleovereat to cover up feelings of sexual inadequacy. Ifthey do not seem attractive to the opposite sex, theywill avoid occasions of stress and humiliation.

However, it is not unusual for those bulimicswho lack control over their impulses to participatein sexual promiscuity and extramarital affairs.

Nielsen and Bará-Caril write, “Many eating-dis-ordered patients have problems with sexuality ingeneral and consequently with procreation.” To

illustrate, they cite findings from several studies;among these: (1) fertility reduced to one-third ofthe expected numbers among a cohort of 140 for-mer female anorexia nervosa patients, and none ofthe 11 male patients had offspring; (2) a twofoldincrease in miscarriage rate was reported for abulimic population in a controlled study; (3) pleas-urable sexual relationships were reported in 67percent of an anorexia nervosa group and in 84percent of the comparison group; however, theindividuals with anorexia nervosa tended to havefewer and less satisfactory romantic relationships.

In a British study of 11 women with anorexia ner-vosa, Morgan et al. concluded, “An increase in sex-ual drive accompanies weight restoration in patientswith anorexia nervosa, which is consistent with psy-chological and physiological explanations of alteredsexuality. Transient depression is also associated withweight gain. Changes in sexuality should be consid-ered in both recovery and treatment failure.”

Abed has suggested that eating disorder syn-dromes, together with the phenomenon of thepursuit of thinness, are manifestations of femaleintrasexual competition. The contention is thateating disorders originate in the human female’spsychological adaptation of concern about physicalattractiveness, which is an important componentof female “mate attraction” and “mate retention”strategies. Abed argues that the present-day envi-ronment of Western countries presents a range ofconditions that have led to the overactivation orthe disruption of the archaic female sexual strategyof maximizing “mate value.” The predictions theo-rized by Abed need to be tested.

Abed, R. T. “The Sexual Competition Hypothesis for Eat-ing 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 duringWeight Restoration.” Psychosomatic Medicine 61, no. 4(July–August 1999): 541–545.

Nielsen, Søren, and Núria Bará-Caril. “Family, Burden ofCare and Social Consequences.” In Handbook of EatingDisorders, 2nd Ed., edited by Janet Treasure, UlrikeSchmidt, and Eric van Furth, 191–206. West Sussex,U.K.: John Wiley & Sons Ltd., 2003.

sexuality and obesity Obesity is significantlyassociated with sexual quality of life for men and

271sexuality and obesity 271

women, Duke University Medical Center research-ers found. Obese people report sexual problems suchas lack of desire, lack of enjoyment, avoiding sex andperformance difficulty at a much higher rate thanpeople of normal weight—in some cases, they are 25times more likely to report problems, according tothe Duke study. Overall, women experienced moredifficulties than did men among both weight groups,but the gender differences were small compared tothe disparity between the obese and normal-weightstudy populations. Martin Binks, Ph.D., and RonetteKolotkin, Ph.D., were co-investigators of the study;results were presented at the November 15, 2004,annual meeting of the North American Associationfor the Study of Obesity.

Of the 1,210 study participants, 506 obese peo-ple seeking treatment were drawn from the DukeDiet and Fitness Center; 422 obese and 282 nor-mal-weight people who were not seeking to loseweight were recruited from the community. Theaverage BODY MASS INDEX (BMI) of the obesegroups was 41 for the treatment-seekers and 40 forthe non-treatment seekers. The normal weightgroup had an average BMI of 22.

The average age of the groups was 48 for treat-ment seekers, 45 for non-treatment-seekers and 35for normal-weight people. The balance between menand women varied between the groups. About 53percent of the obese treatment seekers were women,rising to 67 percent in the obese nontreatment groupand 71 percent in the normal-weight group.

The Duke University findings differed somewhatfrom a recent Swedish study, in which researchersalso investigated whether there is any associationbetween obesity and sexual satisfaction in a normalpopulation. They interviewed a representative sam-ple of 2,810 subjects about sexual satisfaction andother areas. The answers from normal weight, over-weight and obese participants were compared. Theolder group of obese men (50 to 74 years) reported agreater decrease of sexual desire compared with fiveyears prior than normal-weight men. The oldergroup of overweight men reported participation insexual activities, not out of desire, but at the initia-tion of their partner more often than normal-weightmen. Overweight and obese groups seemed to bediverse with respect to sexual satisfaction. No signif-icant differences were detected between BMI groups.

Adolfsson et al. wrote, “It is conceivable that theexpectations of what is needed for satisfaction islower among overweight and obese persons com-pared with subjects of normal weight.” They continued,“Critical attitudes toward obese people are prevalent.Some obese people internalize the negative socialmessages. This may be the cause of self-imposedrestrictions on important aspects of life, such asenjoying a sexual relationship . . . [for] obese people—or even people of normal weight who feel obese.”

A common problem for obese men is erectiledysfunction. Around 30 million American mensuffer from some degree of impotence, and morethan half of all men over the age of 40 have somecomponent of erectile dysfunction, but four out ofevery five men who report sexual dysfunction areeither overweight or obese. In their study of therelationship between obesity and various diseasesand health complaints, Patterson et al. reportedthat men with a BMI of 35 or greater were threetimes more likely to report impotence.

Italian researchers investigated how healthylifestyle changes might help improve erectile dys-function in obese middle-aged men who did nothave heart disease, diabetes, hypertension or otherconditions known to cause erectile dysfunction. “Inour study, about one-third of obese men with erec-tile dysfunction regained their sexual function aftertwo years of adopting healthy behaviors, mainlyregular exercise and reducing weight.” They con-cluded, “Sedentary men may be able to reduce theirrisk of erectile dysfunction by adopting regular phys-ical activity at a level of at least 200 calories a day,which corresponds to walking briskly for two miles.”

However, an accompanying editorial cautionedthat diet and exercise alone are not likely to solvethe impotence problem for everyone. “The popula-tion studied may differ from obese patients typi-cally seen in primary care clinics in that thesepatients did not have known coronary heart dis-ease, diabetes, or hypertension, all commonly seenin obese patients in practice. The presence of thesediseases may lessen the impact of the effect ofexercise 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 Associ-ated with Obesity? A Population-Based Study.” Obe-sity Research 12, no. 10 (October 2004): 1,702–1,709.

272272 sexuality and obesity

Esposito, Katherine, et al. “Effect of Lifestyle Changes onErectile Dysfunction in Obese Men: A RandomizedControlled Trial.” Journal of the American Medical Asso-ciation 291, no. 24 (June 23, 2004): 2,978–2,984.

Patterson, Ruth E., Laura L. Frank, Alan R. Kristal, andEmily White. “A Comprehensive Examination ofHealth Conditions Associated with Obesity in OlderAdults.” American Journal of Preventive Medicine 27, no.5 (December 2004): 385–390.

Saigal, Christopher S. “Obesity and Erectile Dysfunction:Common Problems, Common Solution?” Journal ofthe American Medical Association 291, no. 24 (June 23,2004): 3011–3012.

sialadenosis Swelling of the salivary glands,most evident in the parotid glands; frequently seenin bulimics. “Puffy cheeks” may be an indication ofthis problem.

sibutramine An obesity drug approved by theFood and Drug Administration (FDA) in November1997. Sibutramine works to suppress appetite pri-marily by inhibiting the reuptake of the neurotransmitters norepinephrine and serotonin. Ani-mal studies have shown that it also increases ther-mogenesis (expending of energy). Unlikedexfenfluramine (see FEN-PHEN/REDUX) sibu-tramine does not cause an increase in release ofserotonin from the nerve cell. In clinical trials,patients taking sibutramine while on a reduced-calorie diet, lost 10 to 15 pounds over six months.The average weight loss in persons on only thereduced-calorie diet was 3.5 pounds. The mostcommon side effects associated with sibutramineinclude dry mouth, headache, constipation andinsomnia. It can raise blood pressure, so the FDArecommends regular blood pressure evaluationsfor patients taking sibutramine. Sibutramine ismanufactured and distributed by Abbott Laborato-ries under the brand name Meridia.

See also ANTIOBESITY DRUGS.

Simplesse A FAT SUBSTITUTE developed byNutraSweet. It can replace fat, and thus reduce calo-ries, in such foods as frozen desserts, mayonnaise,salad dressing and margarine. One of dozens of fatsubstitutes being developed by food manufacturers,Simplesse is composed of proteins from milk and eggwhites, which are heated and whipped to create tiny

spheres one-tenth the size of a grain of powderedsugar. On the tongue, Simplesse particles taste andfeel like cream. The first product made with Simp-lesse to be marketed to the American public wasSimple Pleasures, an ice “cream” with half the calo-ries of the real thing and virtually no fat.

sitomania (sitophobia) Interchangeable termsincluded as diagnostic categories in American medicaldictionaries during the mid-1850s to describe a“phase of insanity” characterized by “intense dread offood.” Sitophobics were not classified among theFASTING GIRLS of that period. They claimed no specialpowers, and no public pronouncements were madeabout the duration of the fasting or the patients’miraculous inspiration. Sitophobic girls came frommiddle-class families, well educated and well situated.No organic explanation could be found for their noteating. In Fasting Girls, Joan Jacobs Brumberg refersto sitomania as a “prehistory of anorexia nervosa.”

size discrimination Systematic restrictions inemployment, housing, child adoption and otherareas based on weight rather than ability, trainingor other qualifications.

Murray described the scope of the size discrimi-nation problem:

Among the greatest social problems encountered bypeople who are obese are prejudice and discrimina-tion at work, in public, and in interpersonal rela-tionships. In affluent Western societies, slendernessgenerally is associated with youth, success, happi-ness, and social acceptability. One study found thatprejudice against obesity begins in children asyoung as six years of age. In the study, a classroomof six-year-old children used terms such as “lazy,”“dirty,” “lack of willpower,” and “ugly” to describesilhouettes of children who were obese. In anotherstudy, individuals who were obese who underwentsimulated job interviews were rated less qualifiedfor jobs and viewed as having poorer work habits,as well as more emotional and interpersonal prob-lems than participants in a control group.

In contrast to other chronic physical condi-tions, such as asthma, diabetes, and musculoskele-tal deformities, obesity often results in negativeeconomic and social consequences, such as lowerincome levels and marriage rates. People who areobese are less likely to be admitted to prestigious

273size discrimination 273

schools or enter desirable professions. Physiciansand other health professionals also often havenegative perceptions of people who are obese.

Puhl and Brownell reviewed information on dis-criminatory attitudes and behaviors against obeseindividuals. “Clear and consistent stigmatization, andin some cases discrimination, can be documented inthree important areas of living: employment, educa-tion, and health care. Among the findings are that 28percent of teachers in one study said that becomingobese is the worst thing that can happen to a person;24 percent of nurses said that they are ‘repulsed’ byobese persons; and, controlling for income andgrades, parents provide less college support for theiroverweight than for their thin children. There arealso suggestions but not yet documentation of dis-crimination occurring in adoption proceedings, juryselection, housing, and other areas.”

In an Indiana University School of Nursingstudy to explore what it is like for individuals andfamily members to live with obesity as a chronicillness, the participants revealed frequent experi-ences of stigmatization and discrimination on thebasis of their obesity. The authors found that“those who are obese are reminded through theireveryday encounters with family members, peers,healthcare providers, and strangers, that they’rebeing deviates from social norms, and that they areinferior to those who are not obese. Obese subjectsexperience a pattern of denigration and condem-nation that is so pervasive as to constitute whatHarvey has called civilized oppression.”

Size discrimination can be especially onerous onthe job. Grossman writes, “A national phone surveyof 603 full- and part-time workers conducted for theEmployment Law Alliance [in October 2003] revealsthat workers are cognizant of the undercurrent ofdiscrimination in their midst. Nearly half of thosepolled (47 percent) believe obese workers suffer dis-crimination, 32 percent think these workers aregiven less respect and are taken less seriously, and 30percent think overweight workers are less likely to behired or promoted. Size discrimination ranges fromsubtle to overt, but it’s a huge issue—comparable inscope to age discrimination in the United States.”

According to NAAFA, the only state statute underwhich the obese may seek redress for discrimina-tion is Michigan’s 1976 Elliott-Larsen Civil Rights

Act, which prohibits employment discriminationon the basis of height and weight. Local statutesinclude a Santa Cruz, California, ordinance thatprohibits discrimination in employment, housing,and public accommodations on the basis of heightand weight or physical characteristics, and an ordi-nance in Washington, D.C., that prohibits discrim-ination based on personal appearance.

See also OBESITY IN THE WORKPLACE.

Grossman, Robert J. “Countering a Weight Crisis.” HRMagazine 49, no. 3 (March 2004): 42–51.

Puhl, R. M., and K. D. Brownell. “Bias, Discrimination,and Obesity.” Obesity Research 9, no. 12 (December2001): 788–805.

Murray, Donna. “Morbid Obesity—Psychosocial Aspectsand 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 inNursing Science 27, no. 4 (October–December 2004):301–315.

skin fold measurement The thickness of a fold ofskin at a selected body site, usually the upper armor triceps, the subscapular region (on the back nearthe shoulder blade), the calf, or the upperabdomen. The measurements are used to calculatebody fat, in order to evaluate nutritional status.

In the National Health Survey, 1960–62, theaverage right arm skin fold measured over themiddle of the triceps muscle was 11 millimeters formale subjects 18 to 24 years and 14 millimeters formales 25 to 34 years. In the same study, the aver-age triceps skin fold for women was 22 millimeters.Between 18 and 24 years, the average skin foldmeasurement was 18 millimeters, 21 millimetersbetween 25 and 34, and increased to 25 millime-ters between 55 and 64, after which there was aslight drop to 24 millimeters between 65 and 74years. There are no statistical differences betweentriceps skin folds measured on either arm.

Triceps skin fold measurements are based on theassumption that 50 percent of the fat is subcuta-neous. The midpoint between the shoulder andelbow process is located, with the arm folded. Theperson making the measurement pinches up a fullfold of skin and subcutaneous tissue with the thumband forefinger of the left hand at a distance 1 cmabove the site at which the measurement is to be

274274 skin fold measurement

taken. The fold is pulled away from the underlyingmuscle. The pressure on the fold is exerted by thecalipers and not the fingers. The dial of the calipers isread to the nearest 0.5 millimeters, after releasing thehandle and applying pressure to the skin fold. Skinfold measurements are then translated into percent-age of body fat by means of standard equations.

When carefully used, skin fold measurementsprovide a good indication of body fatness. (SeeBODY FAT.) They are most accurate when applied tohealthy subjects who are not either grossly obeseor severely underweight. Measurements are moreaccurate when extremes in temperature areavoided. Extreme heat can cause skin foldswelling. Edema, which in severe cases can cause agreat increase in body weight, can cause errors inskin fold measurements. Recent weight loss mayalso have an effect on tissue tension or the patternof subcutaneous fat thickness.

sleep deprivation and weight gain A growingbody of research is pointing to a possible connec-tion between obesity and lack of sleep. In an EastVirginia Medical School study of 1,001 participants,obese and overweight patients reported sleepingless than their peers with normal body massindexes (BMIs). The researchers found that totalsleep time decreased as BMI increased, except inthe severely obese group. The difference in totalsleep time between patients with a normal BMI andthe other patients was 16 minutes per day, reaching112 minutes, or 1.86 hours, during a week.

The authors commented, “Our findings suggestthat major extensions of sleep time may not benecessary, as an extra 20 minutes of sleep per nightseems to be associated with a lower BMI. We cau-tion that this study does not establish a cause-and-effect relationship between restricted sleep andobesity. Investigations demonstrating success inweight loss via extensions of sleep would helpgreatly to establish such a relationship.”

In another study, at the Stanford UniversitySchool of Medicine, researchers found that sleep lossleads to higher levels of GHRELIN, a hormone that trig-gers appetite; lower levels of LEPTIN, a hormone thattells the body it is full; and an increased body massindex. These findings documented for the first timethe relationship between sleep and metabolic hor-mones in the general population, tracking how hormon-

al changes are consistent with obesity. The investiga-tors noted, “In Western societies, where chronicsleep restriction is common and food is widely avail-able, changes in appetite regulatory hormones withsleep curtailment may contribute to obesity.”

A third study, although involving only 12 sub-jects and not measuring energy expenditure,showed sleep restriction to be associated withdecreased leptin levels, increased ghrelin levels andincreased hunger and appetite, especially for calorie-dense foods with high carbohydrate content. Dr. EveVan Cauter, one of the investigators and director ofthe University of Chicago Research Laboratory onSleep, Chronobiology and Neuroendocrinology, wasquoted in the Tufts University Health & Nutrition Letter(April 2005) as saying, “If you run a sleep debt, payit. If you are sleep-deprived, you will crave high-carb foods and will need an iron will to resist.”

The findings in these studies were reinforced bySteven Heymsfield, M.D., of Columbia Universityand St. Luke’s–Roosevelt Hospital in New York, andJames Gangwisch, Ph.D., a Columbia epidemiolo-gist, who presented results of their study at a meet-ing of the North American Association for the Studyof Obesity in November 2004. They used informa-tion on about 18,000 adults participating in the fed-eral government’s National Health and NutritionExamination Survey (NHANES) throughout the1980s. The survey includes long-term follow-upinformation on health habits, and researchersadjusted it to take into account other things thataffect the odds of obesity, like exercise habits, so thatthe effects of sleep could be isolated. The researchersdiscovered that those who got less than four hoursof sleep a night were 73 percent more likely to beobese than those who got the recommended sevento nine hours of rest. Those who averaged five hoursof sleep had 50 percent greater risk, and those whogot six hours had 23 percent more.

Spiegel, K., et al. “Brief Communication Sleep Curtail-ment in Healthy Young Men Is Associated withDecreased Leptin Levels, Elevated Ghrelin Levels, andIncreased Hunger and Appetite.” Annals of InternalMedicine 141, no. 11 (December 7, 2004): 846–850.

Taheri, S., et al. “Short Sleep Duration Is Associated withReduced Leptin, Elevated Ghrelin, and IncreasedBody Mass Index.” Public Library of Science: Medicine 1,no. 3 (December 2004): e62. Available online. URL:http://medicine.plosjournals.org.

275sleep deprivation and weight gain 275

Vorona, Robert D., et al. “Overweight and Obese Patientsin a Primary Care Population Report Less Sleep thanPatients with a Normal Body Mass Index.” Archives ofInternal Medicine 165, no. 1 (January 10, 2005): 25–30.

sleep-related eating disorder (SRED) Also callednocturnal sleep-related eating disorder. A syndromefirst officially described in 1991, in which peoplewake in the night and binge-eat but do not alwaysremember doing it. In one of the few studies pub-lished in this disorder, 83 percent of the patientswere female, and for most of them the condition hadbegun in adolescence and had been chronic—suffer-ing from it for an average of 15.8 years before it wasdiagnosed. Thirty-five percent of those studied alsohad a lifetime eating disorder (anorexia, bulimia orbinge-eating). Nearly all the patients reported eatingone to six times on a nightly basis, and all episodesfollowed a period of sleep. All patients described theireating as out of control. Many reported being totallyasleep during these episodes and could not recallthem; only a messy kitchen, food in the bedroom, ortestimony from another family member convincedthem it was happening. Those who could recall thesleep eating episodes said they were half-awake,half-asleep during them.

Foods eaten during these sleep-related eatingepisodes have been reported to run toward high-fat, high-sugar foods that people have restrainedthemselves from eating while awake. Bizarre com-binations and ingestion of nonfood items have alsobeen reported.

SRED is considered by some to be a sleep disor-der, not an eating disorder. According to ANRED,“One to three percent of the general population (3to 9 million people) seems to be subject to this dis-order, and ten to fifteen percent of people with eat-ing disorders are affected. The problem may bechronic or appear once or twice and then disap-pear. Many of these people are severely stressed,anxious individuals who are dismayed and angryat themselves for their nocturnal loss of control.Their behaviors may pave the way to depressionand weight gain.”

Hellmich noted that “Experts are researchingtreatments, including recommending basic behav-ioral changes in eating and exercise habits. In threedifferent studies, University of Pennsylvaniaresearchers are prescribing the antidepressant

Zoloft to patients with the disorder.” AlthoughZoloft does yield good results, the researchers cau-tion, “Of course, it’s not a magic bullet for every-one. Other drug treatments may work; they justhaven’t been studied yet.”

Topiramate, a second-generation anticonvulsantmedication approved in the United States in 1997,has been used successfully to treat both SRED andNIGHT EATING SYNDROME.

Hellmich, Nanci. “The Loneliness of the NighttimeSnacker; Syndrome Tied to Obesity, Moodiness, Lackof Sleep.” USA Today, November 15, 2004, p. D1.

Manni, R., et al. “Nocturnal Eating: Prevalence and Fea-tures 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 PolysomnographicFeatures of Sleep-Related Eating Disorder.” Journal ofClinical Psychiatry 59, no. 1 (January 1998): 14–19.

Winkelman, John W. “Treatment of Nocturnal EatingSyndrome and Sleep-Related Eating Disorder withTopiramate.” Sleep Medicine 4, no. 3 (May 2003):243–246.

smoking cessation and weight gain Cigarettesmokers have a lower average body weight thannonsmokers, and the fear of weight gain is a bar-rier to quitting in some smokers, particularly inwomen. Studies suggest that women gain an aver-age of 20 pounds and men 17 pounds followingsmoking cessation. In a Canadian study of under-graduate college students, dieters who were formersmokers reported considerably more weight gainthan nondieters. A Japanese study found thatalthough heavy smokers may experience largeweight gain and weigh more than nonsmokers inthe early years following smoking cessation, theythen lose weight until they are at the same level asthe nonsmokers. Light and moderate smokers gainweight up to the nonsmoker level once they stopsmoking, but not any amounts beyond that level.In a double-blind trial, fluoxetine appeared to fore-stall weight gain following cessation of smoking,allowing time for the weight-conscious smoker tofocus on quitting smoking rather than on prevent-ing weight gain.

276276 sleep-related eating disorder

Eastern Michigan University researchers com-mented, “Although there is empirical support forthe association between smoking, disordered eat-ing, and subsequent weight gain upon smokingcessation, there have been no prospective studiesto track changes in eating patterns during smokingabstinence and explore underlying biobehavioralprocesses.” Their findings suggest that “low-BMIwomen may be less prone to weight gain duringearly [smoking] abstinence, possibly because theycompensate for metabolic changes induced bynicotine washout by eating less. Craving increasesexperienced by high-BMI women during absti-nence under conditions of food deprivation maycontribute to difficulty quitting in these women.”

Borelli, B., et al. “Weight Suppression and WeightRebound 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 CessationUnderestimated.” 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 Cessationin Women: The Impact on Dieting Status.” Interna-tional Journal of Eating Disorder 24, no. 1 (July 1998):53–64.

Saules, K. K., et al. “Effects of Disordered Eating andObesity on Weight, Craving, and Food Intake duringAd Libitum Smoking and Abstinence.” Eating Behavior5, no. 4 (November 2004): 353–363.

social factors in obesity In industrialized soci-eties obesity is more prevalent in lower socialclasses, whereas the reverse pattern has beenobserved elsewhere, as in rural India. Stunkardwrote that social mobility has also accompaniedchanges in the incidence of OBESITY; in America,upward mobility has been associated with decreas-ing obesity, and downward mobility is associatedwith increasing obesity. In New York City, incidenceof obesity has been found to be seven times higherin the lowest than in the highest social class. Therealso is a tendency for slim women to move up thesocial scale and overweight women to move down.

In their review, Zametkin et al. write, “Social fac-tors associated with obesity include neglect, abuse,and generally nonsupportive home environments.

Neglected children are nine times more likely thanothers to become obese. Adults seeking treatmentfor obesity demonstrate a fourfold increase in theprevalence of childhood sexual abuse, as well as atwofold increase in nonsexual abuse compared witha control population. One psychosomatic theory ofobesity is that food provides comfort and thereforethat eating serves as a compensatory mechanism forchildren who have survived traumatic experiencesor who live in difficult environments. Thus, obesechildren may overeat as a consequence of environ-mental deprivation or as a result of depression, som-atization, or familial abuse.”

See also CULTURAL INFLUENCES ON APPEARANCE.

Goldblatt, P. B., M. E. Moore, and A. J. Stunkard. “SocialFactors in Obesity.” Journal of the American MedicalAssociation 192 (1965): 1,039–1,044.

Stunkard, Albert J. “The Control of Obesity: Social andCommunity Perspectives.” In Handbook of Eating Disor-ders, edited by Kelly D. Brownell and John P. Foreyt.New York: Basic Books, 1986.

Zametkin, A. J., et al. “Psychiatric Aspects of Child andAdolescent Obesity: A Review of the Past 10 Years.”Journal of the American Academy of Child and AdolescentPsychiatry 43, no. 2 (February 2004): 134–150.

Sociocultural Attitudes Towards AppearanceScale-3 (SATAQ-3) First developed in 1995, theSATAQ, now in its third version, is a widely usedmeasure of societal influences on body image andeating disturbances. The SATAQ was developed toassess women’s recognition and acceptance of soci-etally sanctioned standards of appearance thathave been developed due to media exposure. Itconsists of statements such as:

• Women who appear in TV shows and movies proj-ect 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 betteryou look in clothes

• I wish I looked like a swimsuit model

Participants indicate their recognition/aware-ness of each influence on a five-point scale rangingfrom 1 (completely disagree) to 5 (completelyagree). The SATAQ has been adapted for othergroups, such as middle-school children and men.

277Sociocultural Attitudes Towards Appearance Scale-3 277

Heinberg, L. J., J. K. Thompson, and S. Stormer. “Devel-opment and Validation of the Sociocultural Attitudestowards Appearance Questionnaire.” InternationalJournal of Eating Disorders 17, no. 1 (January 1995):81–89.

Thompson, J. Kevin, et al. “Sociocultural Attitudestowards Appearane Scale-3 (SATAQ-3): Developmentand Validation.” International Journal of Eating Disorders35, no. 3 (April 2004): 293–304.

sodium pump A metabolic process that main-tains balance in the concentrations of sodium andpotassium ions inside and outside cell walls. It hasbeen shown that obese people have lower pressuredifferentials across cell membranes than do normalweight subjects. This means that the sodium pumpconsumes less ENERGY in obese people, who there-fore survive on fewer CALORIES.

South Beach Diet A popular low-carbohydratediet plan proposed by Florida cardiologist ArthurAgatston in his best-selling book The South BeachDiet (Rodale, 2003). It restricts foods with highGLYCEMIC INDEX, but is less restrictive than theATKINS DIET, allowing more whole grains, fruits andvegetables, so may be easier for followers to main-tain over time. Gaesser and Kratina caution, “Thebook relies exclusively on anecdotal testimonies.There is no published evidence this diet is sustain-able and will result in permanent weight loss.”

Gaesser, Glenn A., and Karin Kratina. It’s the Calories, Notthe Carbs. Toronto: Trafford Publishing, 2004.

spinal cord injury and obesity An estimated250,000 people in the United States live withspinal cord injuries—82 percent of them are men,with roughly 11,000 additional Americans sustain-ing a spinal cord injury every year. About 60 per-cent of people with spinal cord injuries areobese—double the national rate of obesity amongthe general population.

The struggle against obesity is even more dra-matic for people with spinal cord injury, accordingto researchers at the University of Michigan HealthSystem (UMHS), who are looking at how peoplewith spinal cord injury burn calories and how thatis affected by their muscle mass and body weight.The goal is to make better recommendations to

people with spinal cord injury, but the researchwill also translate into greater understanding ofobesity in the general population as well.

“Individuals with spinal cord injury have signif-icantly less bone mass and muscle mass. As aresult, their body weight is comprised of muchmore fat and less muscle or bone than you wouldsee in an able-bodied individual,” says David Gater,M.D., Ph.D., director of Spinal Cord Injury Medi-cine at UMHS and director of the Spinal CordInjury Research Center at the Veterans Adminis-tration Ann Arbor Healthcare System.

Muscle burns calories even when the body is atrest. For someone with a spinal cord injury—whohas less muscle mass—resting metabolism can beas low as half that of a person without a spinal cordinjury. And that means that even when peoplewith spinal cord injury exercise, they burn signifi-cantly fewer calories. Burning calories at a reducedrate combined with limitations on physical activitycontributes not just to obesity but to all the associ-ated health problems: high cholesterol, coronaryartery disease, diabetes and cancer.

Splenda See ARTIFICIAL SWEETENERS.

spot reducing Exercising a particular group ofmuscles such as those of the stomach or upperarms in order to lose weight, tone muscles orreduce fat in that area.

Exercising specific muscles does tighten andincrease the tone of these muscles but does not pref-erentially mobilize fat from storage cells overlyingthese muscles. AEROBIC EXERCISE is required for mobi-lization of fat; the sequence of mobilization from var-ious areas of the body varies from person to person.

starch blockers Substances derived from con-centrated protein from certain beans that inhibitdigestion of starch by preventing complete METAB-OLISM of CARBOHYDRATES. They are marketed asaids in weight reduction.

Any weight loss that starch blockers may effectis due to the malnutrition this process causes,along with flatulence and gastric upset. In 1984,starch blockers were taken off the market pendingFood and Drug Administration approval. Thosecurrently available are effective only in preventing

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breakdown of complex carbohydrates and have noeffect on the digestion of the simple sugars abun-dant in the American diet.

The FDA has cautioned consumers to beware ofstarch blockers, saying they “promise to block orimpede starch digestion. Not only is the claimunproven, but users have complained of nausea,vomiting, diarrhea, and stomach pains.”

starvation syndrome Studies have shown thatstarvation influences behavior and reasoning,from preoccupation with food to mood swings tosocial isolation. Garfinkel and Kaplan wrote thatall the symptoms described in studies of starvingpeople are also prominent in anorexia nervosa.“That they result from starvation per se and notfrom a pathophysiological process unique toanorexia nervosa has allowed greater diagnosticspecificity and more emphasis on weight gain as acritical aspect of treatment.”

Berg, Frances S. “The Starvation Syndrome.” HealthyWeight Network (September 1998).

Garfinkel, Paul E., and Kaplan, Allan S. “Anorexia Ner-vosa: Diagnostic Conceptualizations.” In Handbook ofEating Disorders, edited by Kelly D. Brownell and JohnP. Foreyt. New York: Basic Books, 1986.

steatopygia Having abnormal fatness of the but-tocks; it is seen to an extreme in certain parts ofAfrica. Location of this excess fat accumulation inthe buttocks apparently represents an evolutionaryadaptation to a very hot climate. If this fat werespread throughout the subcutaneous tissue, nor-mal cooling of the skin would be severely limited.

Stein-Leventhal syndrome See POLYCYSTIC OVARY

SYNDROME.

sterility and obesity While obesity has long beenknown to be an infertility factor in females, recentresearch shows that obese males may also be at riskfor sterility. Obesity appears to affect a man’s fertil-ity by causing lower levels of the hormone testos-terone, a diminished sex drive and less ability toproduce sperm.

After hypothesizing that obesity affects hypo-thalamic and gonadal function in men, which inturn negatively affects fertility, Dr. Eric Pauli and

doctors at Pennsylvania State University College ofMedicine investigated fertility markers, such asreproductive history, inhibin B levels, testosteroneand semen analysis, in 87 adult males with a rangeof body mass index (BMI) levels. Results showedlower testosterone, free testosterone and folliclestimulating hormone (FSH) levels, which indicatesmild hypogonadotropic hypogonadism in menwith a higher BMI. Additionally, men with chil-dren had a lower BMI. “These results indicate thatobesity is an infertility factor in men as well aswomen,” noted Dr. Pauli. The findings were pre-sented at ENDO 2004, the 86th Annual Meeting ofthe Endocrine Society.

Also in 2004, Danish scientists examined therelationship between BMI and semen qualityamong 1,558 young men from the general popula-tion. Men with a BMI of less than 20 had a reduc-tion in sperm concentration and total sperm countof 28.1 percent, and men with a BMI greater than25 had a reduction in sperm concentration andtotal sperm count of 21.6 percent, compared tomen with a healthy BMI between 20 and 25. Per-centages of normal spermatozoa were reduced,although not significantly, among men with highor low BMI. Semen volume and percentage ofmotile spermatozoa were not affected by BMI.

What is not known is what causes this differ-ence in sperm quality. Among the suggestions is apossible alteration in hormonal values. Men pro-duce and need a certain amount of the female hor-mone estrogen. Fat cells produce estrogen, so toomuch or too little of it may be a problem.

See also INFERTILITY AND OBESITY.

Jensen T. K., et al. “Body Mass Index in Relation toSemen Quality and Reproductive Hormones among1,558 Danish Men.” Fertility & Sterility 82, no. 4 (Octo-ber 2004): 863–870.

stevia Also referred to as stevioside or steviol. Asweetening product 250 to 300 times sweeter thansugar; in effect it is calorie-free because the body doesnot metabolize it. Stevia is an extract from the leavesof a South American shrub and has been used forhundreds of years to sweeten a green-tea-like drinknative to Brazil and Paraguay called yerba maté.

To date, the FDA has not approved it for use as asweetener in the United States, but stevia may be

279stevia 279

sold as a dietary supplement (supplement rules areless stringent than those for food additives). It isavailable in either liquid or powered form as Stevitaand Sweet Leaf. Researchers have found that themain chemical in stevia can be converted in the lab-oratory to a compound that causes changes ingenes. More study is needed to learn whether thesame changes, which might lead to cancer, couldoccur in people. Some scientists believe that usingstevia in small amounts once or twice a day is prob-ably safe. According to reports, Japanese drinkmanufacturers have been adding stevia for morethan 30 years with no known health effects. Con-sumer Reports on Health (January 2005) does not rec-ommend its use due to insufficient data: “Animalevidence suggests high intake may reduce spermcount and cause fewer and smaller offspring.”

stimulus control A BEHAVIOR MODIFICATION tech-nique, also called cue elimination, stimulus controlattempts to alter the circumstances that may trig-ger the impulse to eat, while also including meas-ures used in traditional weight reductionprograms. Every effort, for instance, is made tolimit the amount of high-calorie food kept in thehouse and to limit accessibility to the food that iskept. Foods that require preparation replace thosethat require none. Spare change is kept to a mini-mum to decrease the likelihood of impulse buyingof candy or snacks. Eating is confined to scheduledmealtimes and places.

At the same time, new stimuli for eating areestablished. For example, the obese adult mightrestrict all eating to special table settings or unusu-ally colored place mats and napkins—anything tomake the eating process special and intentional (asdistinct from habitual, almost subconscious snack-ing). Emphasis is put on the eating process ratherthan the amount of food eaten.

stomach stapling A general term used for about20 surgical operations that create artificiallysmaller stomachs out of portions of the originalstomachs. Usually the stomach is closed off with astaple gun, although other means are sometimesused, such as the insertion of plastic mesh. Someinvolve GASTRIC BYPASS, in which the intestine issevered and reattached to a hole punched in thestomach pouch. These operations cause weight loss

by limiting food intake; as soon as a few mouthfulsare eaten, the person feels nauseated and muststop eating to avoid vomiting.

When the procedures were first developed, thestomach was reduced from its original capacity ofmore than a quart to five ounces. Currently, a two-ounce capacity is most common; one-half ounce isnot uncommon.

See also BARIATRIC SURGERY.

stress and eating disorders Some eating-disor-der patients use their eating-disordered behaviorsas a way to relieve stress or anxiety. A British studyconcluded that women with eating disorders areless effective in coping with stress than womenwithout eating disorders are.

The precise role stress plays in the developmentof eating disorders remains unclear, however. Onetheory is that biological changes within the bodythat occur during times of stress may promote thedevelopment of eating disorders. Another is thatpsychological changes accompanying life stressesmay affect the response to such stresses.

Stress may influence the development of eatingdisorders because of the effect it can have on variousbiochemical systems within the body, especiallythose that govern APPETITE. Changes may occurwithin the hypothalamic-pituitary-adrenal axis,within the endorphin system. Because the body is acomplex system of biochemical processes, there maybe changes in one or all of these systems as a resultof stress. Therefore, the exact relationship betweenstress and eating disorders remains unknown. It isevident, however, that stress requires a response ofsome type from the organism. As Thomas P. Dono-hoe, of the University of Nottingham, England con-cludes, “Psychosocial stress may combine withdieting behavior to produce changes in hypothala-mic function or other systems to generate or shapethe symptoms of anorexia nervosa.”

In 1986 Michael Rutter (professor of child andadolescent psychiatry, University of London, Eng-land) examined the work of Adolf Meyer(1866–1950; professor of psychiatry at the JohnsHopkins University; introduced the concept of psy-chobiology) to understand the role of life experi-ences as stressors and the effect they have onpersonality development. Although he acknowl-edged that certain negative life experiences could

280280 stimulus control

have such “an impact on psychological function . . .that in some circumstances they play a part in thegenesis of psychiatric disorder,” he also acknowledgedthat perspective was an essential factor. Individualsrespond in a variety of ways to life experiences,depending on their point of view and previous his-tory. A particular life experience may be viewed asnegative by one individual and positive by another.

Some researchers suspect that it is this perspec-tive on the life experience that actually determinesthe degree of stress involved. Physiologically, phys-ical illness is more stressful for some individualsthan for others and can play a role in the develop-ment of an eating disorder. For example, becauseof the many physical changes accompanying theaging process, older adults more often succumb tophysical illness and may experience more stressfrom them than they would if they were younger.And following the Gulf War, the Washington, D.C.health commissioner announced that war-relatedanxiety had caused an increase in eating disorders,as well as drug and alcohol abuse.

The stress of fear is also being studied for itseffect on eating disorders. Research suggests thatfilm-induced negative affect (exposure to a fright-ening film) may prompt overeating in persons whoare attempting to restrict their caloric intake.

In a University of Pittsburgh study, women withbulimic symptoms did not generally eat morewhen exposed to stress. However, both bulimicand control women increased their consumptionof carbohydrates following the stressor.

Schmidt et al. reanalyzed previously publisheddata to examine differences between womenwhose eating disorder did or did not develop inresponse to stress. They concluded, “There are nodifferences between women whose eating disorderdevelops in response to stress and those who donot. Women presenting for treatment withanorexia nervosa of the binge-purge subtype areunlikely to have developed their illness in responseto a severe provoking agent.”

More recently, an Italian study assessedwhether a stressful situation would reveal an asso-ciation between perfectionism, low self-esteem,worry and body mass index (BMI) and measures ofeating disorder symptoms in female high schoolstudents. “Low self-esteem, worry, and parentalcriticism (a dimension of perfectionism) were asso-

ciated with the measures of eating disorders onlyduring the stressful situation, whereas concernover mistakes (another dimension of perfection-ism) was associated in both stressful and non-stressful situations. The results suggest that innonclinical female individuals, stress might bringout a previously absent association between somepsychological predisposing factors for eating disor-ders and an actual desire or plan to lose weight.Such a finding suggests that stress may stimulatebehaviors related to eating disorders in a predis-posed personality.”

Although the precise role of stress and DIETING

in the development of eating disorders remainsunknown, that they can be precipitating factors isnot in doubt. Concerns about body image or phys-ical changes affecting peer group approval canoften be sources of stress. Social emphasis on thin-ness may also be accentuated in peer groups,regardless of age, encouraging further self-con-sciousness and dieting behaviors. Issues of social orfinancial independence may become chronicstrains for older persons. Such stresses may pro-mote dieting to regain a sense of control but maylead to the development of an eating disorder.

Donohoe, T. P. “Stress-Induced Anorexia: Implicationsfor Anorexia Nervosa.” Life Sciences 34, no. 3 (January16, 1984): 203–218.

Levine, M. D., and M. D. Morcus. “Eating Behavior Fol-lowing Stress in Women with and without BulimicSymptoms.” Annals of Behavioral Medicine 19, no. 2(Spring 1997): 132–138.

Rutter, M. “Meyerian Psychobiology, Personality Devel-opment, and the Role of Life Experiences.” AmericanJournal of Psychiatry 143, no. 9 (1986): 1,077–1,087.

Sassaroli, S., and G. M. Ruggiero. “The Role of Stress inthe Association between Low Self-esteem, Perfection-ism, Worry, and Eating Disorders.” International Jour-nal of Eating Disorders 37, no. 2 (March 2005):135–141.

Schmidt, V. H., et al. “Events and the Onset of Eating Dis-orders: Correcting an Age-Old Myth.” InternationalJournal of Eating Disorders 25, no. 1 (January 1999):83–88.

Schotte, David, Joseph Cools, and Richard McNally.“Film-Induced Negative Affect Triggers Overeating inRestrained Eaters.” Journal of Abnormal Psychology 99,no. 3 (August 1990): 317–320.

Troop, N. A., and J. L. Treasure. “Psychosocial Factors inthe Onset of Eating Disorders: Responses to Life

281stress and eating disorders 281

Events and Difficulties.” British Journal of Medical Psy-chology 70, pt. 4 (December 1997): 373–385.

Troop, N. A., et al. “Stress, Coping, and Crisis Support inEating Disorders.” International Journal of Eating Disor-ders 24, no. 2 (September 1998): 157–166.

stress and weight gain Stress-related obesity iscaused in large part by excess secretion of the hor-mone CORTISOL, which occurs under prolongedstress. Too much cortisol triggers cravings for high-fat, high-sugar “comfort” foods. It also stimulatesfat production, particularly in the abdomen. Epel etal. found that high levels of stress-induced cortisolare linked to excessive abdominal fat even in peo-ple who are not otherwise overweight. Stress is themost commonly reported trigger of binge-eating.

However, a University of Pittsburgh Cancer Insti-tute study partially contradicts this, suggesting that amajor stressor, such as a child’s diagnosis of cancer,is associated with weight gain. In their comparisonof 49 parents of healthy children and 49 parents ofcancer patients, the parents of cancer patients weremore likely to gain weight, and they experiencedsignificantly greater weight gain over the threemonths than parents of healthy children. The par-ents of the cancer patients actually ate less inresponse to stress. They gained weight because theiractivity level decreased even more than their caloricintake decreased. Thus, it is not automatic that peo-ple eat more in response to stress or that they gainweight because they eat more. The authors con-cluded, “Further research is needed to determinehow long these weight gains persist and whetherother types of stress also produce weight gains. Suchstudies should focus not only on the effect of stresson eating behavior but also on physical activity.”

Epel, Elissa S., et al. “Stress and Body Shape: Stress-induced Cortisol Secretion Is Consistently Greateramong Women with Central Fat.” Psychosomatic Medi-cine 62, no. 5 (September–October 2000): 623–632.

Smith, A. W., A. Baum, and R. R. Wing. “Stress andWeight Gain in Parents of Cancer Patients.” Interna-tional Journal of Obesity 29, no. 2 (February 2005):244–250.

subcutaneous fat The layer of fat that lies justunder the skin. This is the fat that forms a “sparetire” around the waist and can be easily pinched.

Subcutaneous fat is removed during LIPOSUCTION.The subcutaneous fat layer cushions the sensitiveconnective tissue layer of the skin from underlyingtissues such as muscle and bones. It is also believedto act an insulation to conserve body heat.

See also VISCERAL FAT.

sugar A sweet-tasting simple CARBOHYDRATE con-taining carbon and hydrogen usually in the ratio of1:2. The food known as sugar is refined from sug-arcane, but sugars are found universally in plantsand animal tissues. In 2003 Americans consumedan average 141.7 pounds of sugar from all sources;61.7 pounds were from cane and sugar beet sugarsand 79.2 pounds were from corn sweeteners. Thatcompares to about 40 pounds total per personworldwide. Contrary to popular belief, there are nonutritional differences among sugars. The humanbody uses all types of sugars in the same way.

Sugar is not the leading cause of obesity. Eatingmore calories than one uses is the basic problem,and for most people most excess calories comefrom FAT, not sugar. So concluded two studies inthe American Journal of Clinical Nutrition, whichfound that lean people tend to eat more sugar andless fat than obese people. Not only does fat havemore calories than sugar (about 36 versus 16 calo-ries per teaspoon), but studies have also suggestedthat dietary fat may be more efficiently convertedto body fat than carbohydrates (sugars) are.

People often blame sugary foods for weight gain,forgetting that cakes, ice cream, chocolate and cook-ies 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 sweet-eners keep people from gaining weight, much lesshelp them lose significant amounts. One problem isthat instead of eating artificially sweetened foods inplace of high-calorie ones, many people simply addthem to their diet. Moreover, artificial sweeteners donot suppress appetite—they may even increase it.

Some obesity experts argue that studies show-ing sugar not to lead to obesity have been fundedby the sugar industry, and thus could be less thanthe final word. Waldholz writes, “Some are con-vinced that a major culprit for the obesity epi-demic is the explosion of sugar in the foods weconsume . . . with ‘added sugar’ often the largest

282282 stress and weight gain

single ingredient in packaged foods and commer-cial beverages.”

Sugar can lead to tooth decay; however, so canall forms of carbohydrates if decay-producing bac-teria are also present. Between-meal sugary snacksplay a bigger role in dental caries than sugar eatenduring a meal, according to studies.

Sugar is not a cause of diabetes. It—along withother simple carbohydrates, total caloric intake orstress—can contribute to a rise in blood glucoselevels in persons who already have diabetes. Theeditors of HealthNews explain,

Simple sugars are quickly converted to glucose,the form of sugar our cells use for energy. Conse-quently, eating a candy bar or other confectiontypically causes rapid, short-lived surges in bothblood sugar and insulin, the hormone that allowsglucose to penetrate cells. The body compensatesfor those sugar and insulin spikes by secreting hor-mones that counteract the effects of insulin and byramping up processes that store sugar as fat. Thesecompensatory efforts often cause blood sugar andinsulin 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 OurDiets.” Wall Street Journal, February 20, 2003, p. D3.

suicide Suicide has been estimated to comprisehalf the deaths in anorexia. Suicidal behavior(attempts and threats) is common with bulimia;several researchers report that approximately one-third of their samples have attempted suicide. Oth-ers report lower but still significant rates. In onestudy of 142 bulimic women, researchers foundthat 49 percent of their sample had suicidalthoughts and 20 percent had attempted suicide.

In an Italian study of 495 eating-disordered out-patients, 13 percent of the patients reported at leastone suicide attempt and 29 percent reported cur-rent suicidal thoughts; 26 percent of attemptersreported multiple attempts. A history of suicideattempt was more prevalent among binge-eat-ing/purging anorexics and among purging bulimicsthan in the other subgroups. In patients with

anorexia nervosa, suicide attempters were older,had a longer illness duration, weighed less, hadmore often used drugs and/or alcohol and tendedto be more obsessive than nonattempters. Inpatients with bulimia nervosa, attempters pre-sented with more psychiatric symptoms and hadmore frequently been sexually abused.

A French study to estimate the lifetime fre-quency of suicide attempts by eating-disorderedpatients and to compare demographic and clinicalcharacteristics of those who had attempted suicideand those who had not assessed a total of 295women (202 with bulimia nervosa purging type,68 with bulimia nervosa nonpurging type, and 25with anorexia nervosa binge-eating/purging type).Suicide attempts were frequent (27.8 percent ofwomen), often serious and/or multiple. Womenwho had attempted suicide differed significantlyfrom those who had not for earlier onset of psy-chopathology, higher severity of depressive andgeneral symptoms and more impulsive disorderedconducts, but not for the core symptoms or sever-ity of bulimia nervosa.

Two recent studies looked at indicators of poten-tial suicidal behavior in eating-disorder patients.Researchers at the Harvard Eating Disorders Centerinterviewed women diagnosed with either DSM-IVanorexia nervosa or bulimia nervosa and assessedfor suicide attempts and suicidal intent every six to12 months over 8.6 years. Significantly moreanorexic (22.1 percent) than bulimic subjects (10.9percent) made a suicide attempt. The unique pre-dictors of suicide attempts for anorexia nervosaincluded the severity of both depressive symptomsand drug use over the course of the study. Forbulimia nervosa, a history of drug use disorder atintake and the use of laxatives during the studysignificantly predicted suicide attempts.

In a study of 150 patients at an outpatient eatingdisorder clinic in Israel, 48 patients (32 percent)had a history of parasuicide (i.e., suicide attempts,self-injury, or both). A significantly greater percent-age of parasuicidal patients than nonparasuicidalpatients had eating disorders with bingeing/pursingsymptomatology, used more than one type of purg-ing method and had a lifetime history of a drug usedisorder, impulse control problems and bipolar dis-order, as well as a more extensive outpatient andinpatient treatment history.

283suicide 283

Corcos, M., et al. “Suicide Attempts in Women withBulimia Nervosa: Frequency and Characteristics.”Acta Psychiatrica Scandinavica 106, no. 5 (November2002): 381–386.

Favaro, A., and P. Santonastaso. “Suicidality in EatingDisorders: Clinical and Psychological Correlates.” ActaPsychiatrica Scandinavica 95, no. 6 (June 1997):508–514.

Franko, D. L., et al. “What Predicts Suicide Attempts inWomen with Eating Disorders?” Psychological Medicine34, no. 5 (July 2004): 843–853.

Stein, D., et al. “Attempted Suicide and Self-Injury inPatients Diagnosed with Eating Disorders.” Compre-hensive Psychiatry 45, no. 6 (November 2004):447–451.

sulpiride An antipsychotic medication experi-mented with in treating anorexia. In a 1984study there was a slight trend favoring the drugcompared with a PLACEBO, but no statistically sig-nificant effect was demonstrated either onweight gain or on patient attitudes or behavior.Walsh and Devlin later wrote, “Placebo-con-trolled studies of the higher-potency antipsy-chotics pimozide and sulpiride provided littleevidence of clinical utility.”

Vandereycken, W. “Neuroleptics in the Short-Term Treat-ment of Anorexia Nervosa: A Double-blind Placebo-Controlled Study with Sulpiride.” British Journal ofPsychiatry 144 (1984).

Walsh, B. Timothy, and Michael J. Devlin. “Psychophar-macology of Anorexia Nervosa, Bulimia Nervosa, andBinge Eating.” The American College of Neuropsychophar-macology. Available online. URL: http://www.acnp.org/g4/gn401000153/ch149.html. Downloaded on April21, 2005.

superobesity See EXTREME OBESITY.

superstitious (or magical) thinking Thinkingbased on a belief that there is a cause-and-effectrelationship between unrelated events, a beliefcommon among anorexic patients, according toGarner and Garfinkel. They found that anorexicsoften assume that every last calisthenic in theirexercise regimen must be completed or they willgain weight: “One patient developed an elaborateset of exercise rituals in which various situationsrequired her to perform specific rigorous exercise

routines. Passing post boxes or street lamps had tobe followed by jogging for one block.”

As with superstitious behavior in general, the rit-uals are designed to avoid or mitigate either specificor, more often, obscure but ominous consequences.This behavior is so powerfully controlled by thebelief in bizarre internal relationships and contin-gencies that it is hardly affected even by extremelypunishing external consequences. Like other avoid-ance behavior, superstitious rituals are resistant tocritical examination because the beliefs governingthem insulate the believer from acknowledging con-tradictory information and experience.

In a more recent study of 3,261 Finnish studentsby Aarnio and Lindeman, “The average personmaintaining magical food and health (MFH) beliefswas a woman and a vegetarian, thought in a moreintuitive way, demonstrated more eating-disor-dered thinking, relied more on alternative medi-cine, and to a smaller degree, had experiencedmore negative life events than the average nonbe-liever. The believers reported their MFH beliefs toserve a value-expressive function more than any ofthe other functions. The second most importantfunctions were those of control, utilitarianism, andself-esteem, while the social identity and defensivefunctions were reported less frequently.”

Aarnio, Kia, and Marjaana Lindeman. “Magical Food andHealth Beliefs: A Portrait of Believers and Functions ofthe Beliefs.” Appetite 43, no. 1 (August 2004): 65–74.

Garner, David M., and Paul E. Garfinkel. Handbook of Psy-chotherapy for Anorexia Nervosa and Bulimia. New York:Guilford Press, 1985.

support groups A term sometimes used inter-changeably with SELF-HELP GROUPS. Generally, sup-port groups are free of charge and members mayenter or leave at any time. Support groups are con-sidered an adjunct to therapy, not a substitute forprofessional treatment. They are useful for profes-sional treatment. They are useful because they pro-vide a social network, emotional support, self-helptechniques and information.

surgery for obesity See BARIATRIC SURGERY.

syndrome X See METABOLIC SYNDROME.

284284 sulpiride

tagatose Also known as D-tagatose and Natur-lose. A low-calorie sugar alternative determined tobe a Generally Recognized As Safe (GRAS) sub-stance in the United States by the FDA in late 2001,permitting its use in foods and beverages. Schardtdescribes tagatose as a “mirror-image form of sugarthat’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 assweet as sucrose, has 1.5 calories per gram, does notcause cavities and it does not cause glucose spikes,which means that it can be used in diabetic foodsbecause it controls blood glucose levels. Tagatosecan be used in the production of nearly all foodsthat require sugar including bread, chocolates, hardcandy, soft candy, chewing gum, soda, juices, cakes,ice cream and other general food products.”

Schardt adds, “Unlike sugar, tagatose can’t bedigested by enzymes in the intestines. Most passesthrough the body unabsorbed. Because tagatose isn’twell-absorbed, consuming large amounts can causeflatulence, 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).” NutraceuticalsWorld. Available online. URL: http://www.nutraceuticalsworld.com/jan021.htm. Downloadedon April 22, 2005.

Schardt, David. “Sweet Nothings: Not All Sweeteners AreEqual.” Nutrition Action Healthletter, May 1, 2004, 8–11.

taste The bodily sense that distinguishes flavors;it is dependent on sense organs located on the sur-face of the tongue. These organs, called taste buds,when appropriately stimulated, produce one or a

combination of the four fundamental taste sensa-tions: sweet, bitter, sour and salty.

Both anorexic and bulimic women tested forperception or taste quality and intensity exhibitedimpaired sensitivity in estimating the magnitude ofhigher concentrations of all four different tastequalities, with bitter and sour tastes most severelyaffected. Bulimics’ cravings for sweets have beenhypothesized as the outcome of an impaired senseof taste. One mechanism for this change in gusta-tory sensitivity may be the saliva, because saliva isimportant for taste perception and becauseendocrinological changes occurring in eating disor-ders influence the composition of saliva. No data,however, support this hypothesis.

Results of testing by a Yale University researchteam headed by Judith Rodin provided evidence ofa taste disturbance in bulimia nervosa, most likelycaused by the acid in vomit damaging palate recep-tors. Rodin suggested that, because of this taste dis-turbance, bulimics may be less responsive to thetaste of vomit as the disorder progresses, whichcould prolong its existence. Rodin stressed that thisresearch does not reveal whether bulimics’ tastedisturbances are consequences of, or predisposingfactors to, bulimia nervosa, but she suspects theyare the result of bulimia nervosa.

Researchers at Rutgers University have foundthrough several studies that people especially sensi-tive to a bitter compound called PROP, found infoods such as broccoli and brussels sprouts, tend tobe thinner than others. Their studies have involvedmen, women and children, and all produced similarfindings. Although some scientists are skeptical ofany association between sensitivity to PROP andbody size, researchers at Yale University and theUniversity of Connecticut have produced resultssimilar to those at Rutgers. An Associated Press arti-

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cle reported, “Another scientist reported nearly fourdecades ago that people extremely sensitive to thebitter tastes of PROP tended to be lean, while non-tasters were built like football players. Little furtherresearch was done until the 1990s. Now numerousstudies are investigating the connection.”

Jirik-Babb, P., and J. L. Katz. “Impairment of Taste Per-ception in Anorexia Nervosa and Bulimia.” Interna-tional Journal of Eating Disorders 7 (1988): 353–360.

Johnson, Linda A. “Sensitivity to Bitter Taste Linked toLower-Weight.” Associated Press, October 28, 2004.Available online. URL: http://msnbc.msn.com/id/6355259.

Keller, K. L., and B. J. Tepper. “Inherited Taste Sensitiv-ity to 6-n-propylthiouracil in Diet and Body Weight inChildren.” Obesity Research 12, no. 6 (June 2004):904–912.

Rodin, Judith, et al. “Bulimia and Taste: Possible Interac-tions.” Journal of Abnormal Psychology 99, no. 1 (Feb-ruary 1990): 32–39.

Tepper, B. J., and N. V. Ullrich. “Influence of GeneticTaste Sensitivity to 6-n-propylthiouracil (PROP),Dietary Restraint and Disinhibition on Body MassIndex in Middle-Aged Women.” Physiology and Behav-ior 75, no. 3 (March 2002): 305–312.

tax deductions In 2000 the IRS began allowingthe cost of weight-loss programs as a medicalexpense. However, the deduction does not includeweight-loss programs followed only for the pur-pose of maintaining general good health. It mustbe “treatment for a specific disease (including obe-sity) diagnosed by a doctor.” Generally, allowabletreatments include behavioral counseling, nutri-tional counseling, pharmacology and surgery. Also,even allowable weight-loss expenses would fallunder the general medical expense requirement,meaning only those that exceed 7.5 percent ofone’s adjusted gross income (AGI) would bedeductible. Tax laws change every year, so themost current IRS guidelines need to be checked forany possible allowable deduction.

taxon A technical term for a latent class, type ordiscontinuity. The term relates to an ongoing debatein psychopathology and personality research regard-ing whether there are discrete classes or types ofpersonality or psychological disorders versus there

being only various dimensions or continua (e.g.,Meehl, 1992). The question has also been applied tothe eating disorders and recent research suggeststhat there may be a taxon for bulimia nervosa.

See also CONTINUITY/DISCONTINUITY MODELS OF

EATING DISORDERS.

Gleaves, D. H., M. R. Lowe, A. C. Snow, B. A. Green, andK. P. Murphy-Eberenz. “The Continuity and Disconti-nuity Models of Bulimia Nervosa: A TaxometricInvestigation.” Journal of Abnormal Psychology 109, no.1 (February 2000): 56–68.

Meehl, P. E. “Factors and Taxa, Traits and Types, Differ-ences of Degree and Differences in Kind.” Journal ofPersonality 60, no. 1 (March 1992): 117–174.

tea See DIETER’S TEAS.

teenage obesity See ADOLESCENT OBESITY.

television and obesity With television watchingthe nation’s most time-consuming activity aftersleeping and working, the role it plays in the devel-opment of health-related attitudes and behaviors isof growing interest. Studies of this powerfulmedium suggest that many health messages areconveyed to viewers but that the information issometimes unrealistic, distorted and misleading,particularly regarding food, nutrition and obesity.

William Feldman, medical professor at the Uni-versity of Ottawa and author of a report in Pedi-atrics on children’s attitudes toward weight, blamestelevision for most girls’ belief that they are fatterthan they really are. On television shows duringthe prime evening viewing hours, he said, womenin prestigious positions are typically thin. Ubiqui-tous television imagery delivers the message thatthinness equates with beauty and the good life.

Although many of these “lessons” to whichAmericans are regularly exposed promote miscon-ceptions that may lead to unhealthy eating habits,television’s primary offense may be simply its veryexistence, which has profoundly altered Americanleisure. When the TV is on, activity ceases; timespent exercising is reduced significantly. The heartand other muscles are not strengthened, and CALO-RIES are not expended beyond the resting METABO-LISM level during television viewing.

286286 tax deductions

When Larry A. Tucker (then of Auburn Univer-sity in Alabama) examined the relation betweentelevision viewing and physical fitness, he foundthat, among 379 high school males, as TV watch-ing increased, multiple measures of physical fit-ness decreased markedly and systematically.Similarly, other researchers have shown that asTV viewing increases among children, obesityincreases substantially.

Tucker and Glenn M. Friedman measured theextent of the association between TV viewing andobesity among adult males. Study subjects were6,138 adult male employees of more than 50 differ-ent companies. Those who viewed TV more thanthree hours a day were twice as likely to be obeseas those who viewed less than one hour per day.

In a sample of 78 undergraduate students (64females, 14 males), the participants ate more oftenon days when they ate with the television on—almost one additional meal (3.53 versus 2.76meals). Although the meals with TV on weresmaller, the net effect was an increase in calorieswhen eating with the television on.

Tucker and Friedman caution that with thegrowth of cable television, home video recordingand video games, television viewing is likely toincrease in the coming years. The findings of theirstudy and other recent research show that theimpact of television on fitness and health (espe-cially obesity) cannot be ignored.

When William Dietz, head of nutrition at theCenters for Disease Control and Prevention (CDC),spoke at an American Medical Association confer-ence, he warned that television also affects chil-dren’s eating behaviors: “The more children watchtelevision, the more they tend to consume what’sadvertised on television, and the more they tend toconsume foods while watching television.”

A policy profile prepared by Prevention Institutefor the Center for Health Improvement confirmsthis: “Studies on the behavioral effects of advertis-ing find that television has a major effect on theproducts children ask for and that increased televi-sion watching leads to increased requests foradvertised products. In addition, television adver-tising creates misperceptions among children aboutthe nutritional values of foods and how to main-tain positive health. Health experts believe that

constant promotion of high-calorie food is con-tributing to the epidemic of childhood obesity inthe United States by encouraging preferences forjunk food and contributing to poor eating habits.”

Prevention Institute. “Restricting Television Advertisingto Children.” Available online. URL: http://www.preventioninstitute.org/CHI_food_advertising.html.Downloaded on April 22, 2005.

Stroebele, Nanette, and John M. de Castro. “TelevisionViewing Is Associated with an Increase in Meal Fre-quency in Humans.” Appetite 42, no. 1 (February2004): 111–113.

Tucker, Larry A. “The Relationship of Television Viewingto Physical Fitness and Obesity.” Adolescence 21, no. 84(winter 1986): 797–806.

Tucker, Larry A., and Friedman, Glenn M. “TelevisionViewing and Obesity in Adult Males.” American Jour-nal of Public Health 79, no. 4 (April 1989): 516–518.

Tenuate A prescription only appetite suppressantchemically related to amphetamine. Its activeingredient is diethylpropion. When used in a pro-gram that includes a low-fat diet and regular exer-cise, it can increase the diet/exercise weight loss byan additional 10 percent. On average, patients loseabout 15 pounds over three months. Possible sideeffects of Tenuate include nervousness, insomnia,irritability, sweating, tension, dry mouth, nausea,constipation and headaches. Because Tenuate ishighly addictive, it is not recommended for individ-uals with a history of drug dependency or abuse,and is prescribed for a maximum of several weeks.

therapy Any treatment designed to mitigate ofeliminate disease or disorder, physical or psycholog-ical. Among the therapies often used in treating eat-ing-disordered persons are individual PSYCHOTHERAPY,FAMILY THERAPY, GROUP THERAPY and various physicaltreatments. Which type of therapy or combinationof therapies to use depends upon the age, needs andliving situation of the person seeking treatment.

In individual psychotherapy, patients meet withtherapists alone, usually at least once a week for 45minutes to an hour at a time. Patients in therapywork to understand the role that eating or PURGING

has served in their lives and to find replacementsfor destructive behaviors while developing health-ier coping mechanisms.

287therapy 287

In family therapy, sessions include not just eat-ing-disordered persons but members of their fami-lies. 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 trou-bled, not just the persons with the eating disorders.

A therapy group usually consists of five to 12people who meet with a therapist weekly. Thegroup therapy approach is particularly helpful incountering feelings of isolation, of being all alonewith the problem. Groups can provide feedbackand support for those attempting to change theireating patterns. They are also safe places for mem-bers to learn new ways of relating, to express feel-ings and to develop trusting relationships of thekind whose absence led in the first place to theirself-destructive relationship to food.

thermodynamic approach to obesity From thisperspective, obesity is understood in terms ofenergy balance. Since the law of conservation ofenergy must be preserved, obesity is the outcomeof energy (food) intake in excess of energy (heat)output. HILDE BRUCH described this as a limitedapproach because it does not consider the under-lying reasons for this disturbed energy balance,such as possible endocrine and biochemical fac-tors. The reasons for variations in energy needs,and the underlying mechanisms, remain a matterof controversy.

thermogenic drugs Drugs that enhance restingmetabolic activity. These compounds increaseenergy expenditure, which is important becauseweight loss is associated with metabolic readjust-ment to reduce energy output (see OBESITY). Thus,metabolic enhancers ensure that energy expendi-ture is maintained when food intake is reduced.See also ANTIOBESITY DRUGS; SIBUTRAMINE.

thin fat people A term used by HILDE BRUCH todescribe obese people who succeed in becomingand staying thin but whose problems are far fromsolved by having lost weight. On the contrary, theirdifficulties now have a chance to flourish, sinceobesity no longer prevents them from putting theirunrealistic dreams to the test. She was referring to

those people who blame all their difficulties onbeing fat and who hope that their lives will changewhen they get thin. Such people, though no longerobese, are far from transformed.

The term was originated by Heckel, who stated in1911 that a fat person cannot be considered curedeven though he has lost weight, unless all othersymptoms of dysfunction have also disappeared.

Heckel, P. Les grandes et petites obésités. Paris: Mason et Cie,1911.

thrifty genes Vestiges from times when food wasscarce, and those who ate more and stored fat mostefficiently survived. As the National Institutes ofHealth Obesity Research Force explained, “Aninteresting view that has been expressed regardingthe genetic basis for more common forms of obe-sity is the ‘thrifty gene hypothesis.’ That is, it isthought that because our ancestors lived in envi-ronments with more risk of starvation fromfamine, and greater need for physical exertion tosurvive, a genetic predisposition to efficient storingof fat (and hence, energy) was actually advanta-geous. In a current environment in which calorie-rich food is plentiful and life can be moresedentary, the ability to accumulate fat efficiently isno longer beneficial.”

Italian researchers investigating the effect of fatmass reduction on adipose tissue gene expressionfollowing BILIOPANCREATIC DIVERSION surgery con-cluded, “The degree of fat mass loss seems to inter-fere with SREBP-1c gene suppression to preservean adequate amount of fat storage, in accordancewith the thrifty genotype hypothesis.”

Cummings et al. offer “a speculative model ofghrelin as a thrifty gene product that evolved tohelp animals consume and store fat well, therebyincreasing their chances of survival during timesof 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. Over-duin. “Ghrelin and Energy Balance: Focus on CurrentControversies.” Current Drug Targets 6, no. 2 (March2005): 153–169.

288288 thermodynamic approach to obesity

Gniuli, D., et al. “Changes in Fat Mass Influence SREBP-1c and UCP-2 Gene Expression in Formerly ObeseSubjects.” Obesity Research 13, no. 3 (March 2005):567–573.

NIH Obesity Research Task Force. Strategic Plan For NIHObesity Research. U.S. Department of Health andHuman Services, National Institutes of Health, NIHPublication No. 04-5493, August 2004.

thymoleptic medications Medications effectivein the treatment of major DEPRESSION or bipolardisorder; ANTIDEPRESSANTS. These have been usedin treating bulimia on the theory that it may beclosely related to major affective disorder—thefamily of psychiatric illnesses that includes depres-sion and manic-depressive illness.

thyroid disease (hypothyroidism) A deficiencyof thyroid gland activity, resulting in underproduc-tion of the hormone thyroxine. Among its conse-quences are a lowered BASAL METABOLIC RATE andweight gain.

Probably nothing has been blamed more oftenas the cause of obesity than hypothyroidism, butstudies show that thyroid function in obese peopleis usually within normal limits. Thyroid disease isnot diagnosed unless there is strong laboratory evi-dence of reduced thyroid function accompanied byfindings of classic physical symptoms and a medicalhistory that includes a long-standing goiter, thy-roiditis or thyroid surgery. Weight gain developsinsidiously rather than suddenly. Associated fea-tures include some coarsening of scalp hair, dry-ness of skin, yellowing of palms, generalizedobesity, some thinning of the eyebrows and slug-gish and delayed reflexes. Hypothyroid patientsfrequently complain of constipation. Menstrualperiods are usually characterized by excessivebleeding; a history of dysfunctional bleeding maybe the earliest clue to thyroid disease. In cases inwhich thyroid disease is the true cause of obesity,weight control is achieved in over 90 percent ofthese cases through treatment with thyroxine (seeTHYROID HORMONE).

thyroid hormone (thyroxine) Prescribed forpatients suffering from hypothyroidism (see THYROID

DISEASE), whose thyroid glands produce it in insuffi-

cient amounts; it raises the basal metabolic rate (seeMETABOLISM), causing more calories to be burned.

It is also the metabolic medication most com-monly prescribed and marketed as a weight reduc-tion agent, even to people whose thyroid glandsare in good working order. But for overweight peo-ple without thyroid disease, thyroxine is of novalue. Thyroid hormones are especially dangerousfor people with heart disease.

According to some authors, use of this hormoneincreases breakdown of muscle protein rather thanfat. In addition, the body quickly adapts to theadministration of extra thyroid hormone by reduc-ing its natural production of this hormone, thusreturning metabolism to its normal rate. Excessthyroid hormone causes anxiety, irritability, sweat-ing, rapid heartbeat and other possible side effects.

Bruna and Fogteloo add, “Many well-knowncompounds (thyroxine, caffeine or ephedrine) do infact increase the total energy expenditure but arenot acceptable as prescription drugs because of their(mainly cardiac) side-effects or addictive properties.”

Bruna, Tijs, and Jaap Fogteloo. “Drug Treatments.” InHandbook of Eating Disorders, 2nd Ed., edited by JanetTreasure, Ulrike Schmidt, and Eric van Furth, 311–323.West Sussex, U.K.: John Wiley & Sons Ltd., 2003.

TOPS (Take Off Pounds Sensibly) A nonprofitsupport organization for overweight peoplefounded in 1948 that incorporates some of the prin-ciples of behavior therapy into its program. Thereare almost 300,000 members in nearly 12,000chapters throughout the United States, Canada andnumerous other countries. It is patterned afterAlcoholics Anonymous and employs group dynam-ics, competition and recognition (for those whohave achieved greatest weight loss) to aid the over-weight. There are weekly meetings with weigh-ins;programs vary, but all in some way provide mem-bers with motivation and reinforcement. TOPS ismedically oriented and asks members to obtaintheir individual weight goals and dietary regimensfrom their personal physicians. The organizationhas had an active research program for severalyears, headquartered at the Medical College of Wis-consin in Milwaukee. Areas of study have includedthe relative importance of heredity and environ-ment in the development of obesity, psychosocial

289TOPS (Take Off Pounds Sensibly) 289

differences between those successful and thoseunsuccessful in losing weight, the effect of obesityon pregnancy and the relationship of overweight toinfertility and various diseases.

See also APPENDIX III.

total parenteral nutrition (TPN) See HYPERALI-MENTATION.

Traffic Light Diet A simplified diet developed forchildren. It divides food into three colors, like thosein traffic lights: green, yellow and red.

Epstein et al. explain that it is used particularlyfor preschool and preadolescent children. “Thetraffic-light diet is a structured eating plan (900 to1,300 kcal) used to guide participants’ eating pat-terns to meet age recommendations of the basicfour 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 unlimitedquantities; yellow foods (caution) have averagenutritional value for the foods within their foodgroup; and red foods (stop) provide less nutrientdensity per calorie because of high fat or simplecarbohydrate content.”

See also CHILDHOOD OBESITY.

Epstein, Leonard H., et al. “Treatment of Pediatric Obe-sity.” 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 isformed when liquid oils are made into solid fatslike shortening and hard margarine. However, asmall amount of trans fat is found naturally, pri-marily in some animal-based foods. Essentially,trans fat is made when hydrogen is added to veg-etable oil, a process called hydrogenation. Hydro-genation increases the shelf life and flavor stabilityof foods containing these fats. Trans fat, like satu-rated fat and dietary cholesterol, raises the LDL (or“bad”) cholesterol that increases one’s risk for CHD(coronary heart disease). Trans fat can often befound in processed foods made with partiallyhydrogenated vegetable oils such as vegetableshortenings, some margarines (especially mar-

garines that are harder), crackers, candies, cookies,snack foods, fried foods and baked goods.

The Food and Drug Administration (FDA) nowrequires food manufacturers to list trans fat onNutrition Facts and some Supplement Facts panelson food labels. The FDA has created a Web site withhelpful background on trans fat and how to use thenew labeling to plan a healthful diet; it can be seenat http://www.cfsan.fda.gov/~dms/transfat.html.

trichophagia The (compulsive) habit of eating hairor wool, considered to be a variant of PICA. It alsocould be considered a perilous disorder, as trichobe-zoars (hairballs) can form and obstruction of thebowel may occur, requiring surgical intervention.

tube feeding Forced feeding through a nasogas-tric tube is a method sometimes used to supplementnutrition and replace body fluids in anorexicpatients. Authors such as Paul Garfinkel and DavidGarner have advised limited use of tube feedingwhile noting several disadvantages: It represents adirect intrusion into the gastrointestinal tract ofsomeone who is already preoccupied with (and mis-guided about) bodily functions; it may be perceivedas an assault or act of hostility that will only serve toconfirm the patient’s sense of her own worthless-ness; it is done with minimal patient cooperationand may lead to increased mistrust; and the physio-logical side effects are not insignificant.

At REMUDA RANCH, Zuercher et al. reviewed thecases of 381 female anorexia nervosa inpatients, with155 receiving tube feeding and oral refeeding, and226 receiving oral refeeding alone. “When severity-of-illness and caloric intake differences betweenpatients with and without tube feeding were con-trolled, patients who received tube feeding gainedsignificantly more weight per treatment week thanthose who received oral kilocalories alone. Patientswho received tube feeding for at least one-half theirlength of stay gained 1 kg/week versus 0.77 kg/weekfor patients receiving oral refeeding alone. Tube-fedpatients evidenced no differences in recovery fromanorexia’s psychological aspects, satisfaction withtreatment, or medical complication frequency.”

Zuercher, J. L., et al. “Efficacy of Voluntary NasogastricTube Feeding in Female Inpatients with Anorexia

290290 total parenteral nutrition

291

Nervosa.” Journal of Parenteral and Enteral Nutrition 27,no. 4 (July–August 2003): 268–276.

tummy tuck The commonly used name for anABDOMINOPLASTY.

twin studies and eating disorders Data fromstudies of twins in the past decade have begun tosuggest that heritable factors make a significantcontribution to the risk of developing eating disor-ders. In twin studies, researchers compare the fre-quency with which both members of the twin pairhave the same disorder or the trait of interest, thencompare those frequency rates in identical and fra-ternal twins. In their review, Bulik et al. con-cluded, “Twin studies confirm that bulimia nervosa

is familial and reveal significant contributions ofadditive genetic effects and of unique environmen-tal factors in liability to bulimia nervosa.” Becauseof small sample sizes, estimates obtained from twinstudies of anorexia nervosa are not considered asreliable as those from bulimia nervosa. Walshexplains, “The substantially higher incidence ofbulimia makes the analysis of twin data for this dis-order more powerful.”

See also GENETIC FACTORS IN EATING DISORDERS.

Bulik, Cynthia M., et al. “Twin Studies of Eating Disor-ders: A Review.” International Journal of Eating Disor-ders 27, no. 1 (January 2000): 1–20.

Walsh, B. Timothy. “The Future of Research on EatingDisorders.” Appetite 42, no. 1 (February 2004): 5–10.

twin studies and eating disorders 291

vegetarian diet and eating disorders A Universityof Minnesota study raised the concern that teenvegetarians are more likely to have eating disordersthan nonvegetarians. The study, which surveyednearly 5,000 middle school and high school stu-dents, found that adolescent vegetarians were moreweight- and body-conscious, more likely to havebeen told by a doctor that they had an eating disor-der and more likely to have tried a variety ofhealthy and unhealthy weight control practices,including diet pills, laxatives and vomiting. Theauthors concluded that vegetarianism among ado-lescents may be a signal for preventive intervention.

Perry, Cheryl L., et al. “Characteristics of Vegetarian Ado-lescents in a Multiethnic Urban Population.” Journalof Adolescent Health 29, no. 6 (December 2001):406–416.

vertical banded gastroplasty (VBG) A restrictiveoperation (see GASTRIC RESTRICTION PROCEDURES)for weight control that was more popular in the1980s, but is being replaced by ADJUSTABLE GASTRIC

BANDING (AGB). In VBG procedures, both a bandand staples are used to create a small stomachpouch. Risks of VBG include wearing away of theband and breakdown of the staple line. In a smallnumber of cases, stomach juices may leak into theabdomen, requiring an emergency operation. Inless than 1 percent of all cases, infection or deathfrom complications may occur. One study showedthat patients with vertical banded gastroplastymaintained a loss of 40 percent of their excessweight for three years after surgery. A five-yearfollow-up showed equally satisfactory results.

very low-calorie diet (VLCD) A program forachieving rapid weight loss through eating fewer

than 800 calories per day. These diets can result inserious side effects, the most common of which areinability to tolerate cold, dizziness, diarrhea, con-stipation, dry skin, hair loss and gout. Moodchanges ranging from elation to DEPRESSION mayoccur, and acute psychosis has been reported.

Most VLCDs are not tailored for individualneeds. Fatter people, for instance, can toleratemore drastic cuts in calorie consumption than lessobese individuals. The best VLCDs are closelysupervised and monitored by physicians, behav-ioral psychologists and dietitians. VLCDs have beenrecommended as viable treatment for peoplewhose obesity puts them at risk for such problemsas diabetes, hypertension and heart disease (BODY

MASS INDEX [BMI] greater than 30).VLCDs are accomplished by consuming pow-

dered protein mixes available by prescription only.According to the University of California BerkeleyWellness Letter, they contain 33 to 75 grams of egg-or milk-derived protein, varying amounts of carbo-hydrate and RDA (recommended daily allowance)levels of most other nutrients. The formulas, mixedwith liquid, are taken three to five times a day atmeal and snack times. Usually nothing else otherthan water is allowed; a few programs do allowraw vegetables. In addition to the formula, patientsreceive regular electrocardiograms and blood andurine tests and regularly visit their doctors. Thisregimen is augmented by required exercise, nutri-tion education and participation in support groups.

These programs can cost more than $2,000including weigh-ins and clinic visits and usuallylast three months, followed by a gradual “refeed-ing” phase. Some include a maintenance phase ofup to 18 months devoted to educating patients inlong-term weight-management techniques. Forpersons with medically significant obesity, a very

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low calorie diet yields an average weight loss ofgreater than 44 pounds and a significant reductionin health risks in 12 weeks.

One argument against the formula VLCD is thatit teaches reliance on patented products, not onsound, lifelong eating habits. The permanency ofthe results of VLCDs is not dissimilar to that ofother types of diet.

A San Diego State University study found thatwhile people who actually completed a VLCD pro-gram (45 percent of those enrolled) lost an averageof 84 percent of their excess weight, they regained59 to 82 percent of it within 30 months. Althoughintensive BEHAVIOR THERAPY MODIFICATION can helpreduce the dropout rate to one-third, three-year fol-low-up checks show that by then 40 percent ofpatients have regained all their excess weight. Thosewho do not return for retreatment gain back, onaverage, all but 10 pounds of the weight they’ve lost.

A three-year study reported in 1986 comparedlong-term results after a low calorie diet, a con-ventional 1,200-calorie diet plus behavior modifi-cation and a very low calorie diet plus behaviormodification. In the initial therapeutic phase,patients lost an average of 31.1, 31.5 and 42.6pounds respectively. Three years later, averageweight had returned to within 8.4, 10.6 and 14.3pounds of prediet weights.

In a 54-month trial of the Optifast program,men initially lost an average of 22 percent of theiroriginal weight, and women lost 18.8 percent. Butat the programs end, the average maintained lossof both men and women was only 4.3 percent oftheir original weight.

Assessing VLCD Programs

According to the American College of HealthcareExecutives, an adequate obesity treatment pro-gram that uses a very low calorie diet must include:

• Mandatory medical supervision provided by amultidisciplinary team of well-trained healthcare professionals (physicians, dietitians, nurses,behaviorists and exercise physiologists). Trainingof professional staff is critical to the success of anobesity treatment program.

• A high-quality nutritional beverage with ade-quate protein and calories and with an appropri-

ate nutrient composition. The dietary beverageshould have a high nutritional profile, meetingthe protein recommendation of 1.5 grams ofprotein per kilogram (2.2046 pounds) of idealbody weight. Studies show that at this proteinlevel, lean body mass is preserved and subjectsquickly attain nitrogen balance. Lower proteinlevels are not adequate for the calorie deficit ofthe modified fasting state, and the addition ofCARBOHYDRATE is not an equivalent protein-spar-ing replacement for protein. Some products arenutritionally incomplete, requiring vitamin andmineral supplementation in addition to the bev-erage. This can place patients who neglect totake their supplements at nutritional risk.

• A comprehensive educational program thatemphasizes behavior change and long-termweight maintenance. Without doubt, it is thecomprehensive educational program, in conjunc-tion with the diet, that determines long-termweight maintenance. The components of a com-prehensive program include nutrition education,behavior modification (e.g., planned behaviorchange and cognitive restructuring) and EXERCISE.

Very little information exists regarding the use ofVLCDs in older people. Because people over age 50already experience normal depletion of lean bodymass, use of VLCD may not be warranted. Also,people over 50 may not tolerate the side effectsassociated with VLCDs because of preexisting med-ical conditions or need for other medications.

See also DIETING; LIQUID FORMULAS; PROTEIN-SPARING MODIFIED FAST.

“Very-Low-Calorie Diets.” NIH Publication 03-3894, Jan-uary 2003.

Wadden, Thomas A., Theodore B. Van Itallie, and GeorgeL. Blackburn. “Responsible and Irresponsible Use ofVery-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-MonthEvaluation of a Popular Very Low Calorie Diet Pro-gram.” Journal of Family Practice 41, no. 3 (September1995): 231–236.

vibrator belts Gadgets sold as a means of elimi-nating localized fat deposits, based on the premise

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that localized stimulation breaks down fat cells,releasing fat stores into the bloodstream so thatthey can be effectively eliminated from the body.The localized vibration also stimulates blood circu-lation in the treated area, thus purportedlyenhancing the transport of released fat. There is noscientific evidence to support this concept.

See also FRAUDULENT PRODUCTS; NOVELTIES FOR

WEIGHT LOSS.

visceral fat Intra-abdominal fat; it increases therisk for diabetes and cardiovascular disease and canraise insulin levels, which promotes the growth ofcancer cells. People who have high levels of intra-abdominal fat may not even know it because it ishidden, deposited around organs within theabdomen. Visceral fat is what women tend to storeafter menopause. The only accurate way to deter-mine the presence of intra-abdominal fat is withimaging procedures such as CT or MRI scans. Littledata exists on intra-abdominal obesity because theseprocedures are so costly. Waist circumference iscommonly used as a surrogate measure for abdomi-nal visceral fat. One observational study showed sig-nificant decreases in visceral fat with a mean weightloss of 28.4 pounds. A Yale University School ofMedicine 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 Intra-Abdominal Body Fat in Postmenopausal Women: ARandomized Controlled Trial.” Journal of the AmericanMedical Association 289, no. 3 (January 15, 2003):323–330.

vitamin deficiency An insufficiency of vitaminsin the diet, a form of malnutrition that can resultfrom malabsorption of fat by the intestines ofbulimics (caused by abuse of laxatives) or fromself-starvation by anorexics. Vitamin deficiencycan also result from taking drugs that have sideeffects of reducing absorption of vitamins in theintestines. When physicians prescribe these drugs,they will frequently also prescribe vitamin supple-ments to correct the situation. A high-protein, lowfat diet can also cause depletion of vitamin A andvitamin D reserves.

A Southern Illinois University School of Medi-cine study found that vitamin D levels were 57percent lower in obese adults than in lean individ-uals due to the vitamin D getting trapped in fat.

Wortsman, Jacobo, et al. “Decreased Bioavailability ofVitamin D in Obesity.” American Journal of ClinicalNutrition 72, no. 3 (September 2000): 690–693.

vocational bulimics Some of the best-knownbulimics are those who started PURGING becausethinness is important to them vocationally. In thiscategory are models, actresses, athletes and dancerswho use VOMITING or laxatives (see LAXATIVE ABUSE)as a means of weight control and become depend-ent on it. Vocational bulimics present a specialobstacle to treatment, because it would be unrea-sonable to try to convince a dancer, for instance,that she does not have to weigh 90 pounds if that isthe current standard for dancers.

See also ATHLETES; BALLET DANCERS.

vomiting Forcible ejection of contents of thestomach through the mouth. Self-induced vomit-ing is the most dramatic, quickest and most com-mon method employed by eating disorderedindividual who think they can eliminate unwantedCALORIES before the calories “take effect.” Butresearch has actually demonstrated that a sizableproportion of calories are absorbed even whenvomiting occurs almost immediately after eating. Italso provides instant relief for the painfully over-stuffed stomachs of bulimics. Vomiting can also be“justified” as a means of getting rid of what isregarded as protrusion of the stomach.

To induce vomiting, many patients use“starters” such as Q-tips; they are effective andhave been described as less “disgusting” than fin-gers. Drinking large amounts of liquids makes thevomiting easier. Eventually, most patients canvomit at will.

Patients have reported self-induced vomiting asfrequently as 18 times a day or more. Vomiting hasled to severe tearing and bleeding in and around theesophagus, hiatal hernias and severely infected sali-vary glands, not to mention serious electrolyte dis-turbances. Also, there may be a loss of control overthe vomit reflex as a consequence. That is, some

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severe patients get to the point that they vomitspontaneously even when they don’t want to.

According to Neuman and Halvorson, there is asubgroup of anorexics consisting of individualswho resort to vomiting regardless of whether theyalso restrict their food intake or binge. Otherauthors have theorized that vomiting may be thedriving force in bulimia nervosa rather thanBINGE-EATING. They feel that binge-eating mightnot occur if the person could not vomit afterward,citing cases in which once bulimic individualsbegin to vomit, they binge-eat more frequently.These patients also discover that it is easier tovomit after eating a lot and therefore prolongtheir binges. Some patients report that the onlyreason they binge-eat is to make it physically eas-ier to vomit.

Repeated vomiting leads to physical complica-tions from hypokalemic/hypochloremic alkalosis,as described by Downs et al. “Low levels of potas-sium can lead to fatigue, generalized muscle weak-

ness, seizures, heart arrhythmias, and kidney dam-age. Abnormalities in sodium may lead to convul-sions, particularly in individuals who consumelarge quantities of alcohol in their binges. Deathfrom aspirated vomitus can occur; and there maybe fractures. Vomiting leads to gastric andesophageal irritation and bleeding, and some maydevelop hiatus hernia with abdominal pain.Repeated vomiting may cause esophageal or gastricdilatation and can result in a fatal rupture. Largebinges may produce pancreatic dysfunction, lead-ing to pancreatitis, and there may be immune sys-tem compromise.”

Downs, Susan, with Charmian Lewis. “Psychiatry.” InNausea and Vomiting: Overview, Challenges, PracticalTreatments 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. AnorexiaNervosa and Bulimia. New York: Van Nostrand Rein-hold, 1983.

296 vomiting

waist-to-hip ratio (WHR) A comparison of waistand hip circumferences, which is an indicator ofthe amount of fat a person carries and the propor-tion of intra-abdominal fat (see VISCERAL FAT). Peo-ple with a higher ratio are at increased risk ofdeveloping diseases associated with overweight. Todetermine one’s waist-to-hip ratio, a measuringtape is used to measure the circumference of thehips at the widest part of the buttocks. Then thewaist is measured at the smaller circumference ofthe natural waist, usually just above the belly but-ton. The waist measurement is then divided by thehip measurement. For example, a woman with awaist measurement of 30 inches and a hip meas-urement of 40 inches would have a waist-to-hipratio of 0.75. Generally, men with a waist-to-hipratio of greater than 1.0 and women with a ratiogreater than 0.8 are considered to have an excessaccumulation of fat in their abdomens. In onestudy, women with a ratio greater than 0.76 hadtwice the risk of developing coronary disease thanthose whose ratio was 0.75 or lower.

Rexrode, Kathryn M., et al. “Abdominal Adiposity andCoronary Heart Disease in Women.” Journal of theAmerican Medical Association 280, no. 21 (December 2,1998): 1,843–1,848.

water According to Donald S. Robertson, abariatric physician and author of The Snowbird Diet(Warner Books, 1986), drinking at least 64 ouncesof water a day can actually cause fat deposits todecrease. He explains that when the kidneys donot receive enough water, they do not functionproperly, resulting in some of their workload trans-ferring to the liver. When the liver then performssome of the kidney’s work, the liver cannot effec-tively perform one of its primary functions: to

metabolize stored fat into usable energy for thebody. As a result, it metabolizes less fat and morefat remains stored in the body; weight loss stops.

A small German study found that drinkingwater boosts the metabolic rate by 30 percent forabout an hour. The researchers estimate thatdrinking an extra 34 ounces a day would burnabout 17,400 calories a year, leading to a possibleloss of about five pounds. However, experts warnthat people already drinking a lot of water who addadditional water consumption risk reaching anelectrolyte imbalance.

Nutritionists caution that there is no evidencethat water curbs APPETITE. A director of science atthe Pritikin Longevity Center has been quoted innewspaper articles as saying the body is engineeredto get water through food—in soups, fruits and veg-etables, which are almost all water; whereas waterthat is drunk goes right through the body, into thestomach and then out. Along that same line, othershave suggested that because so much of the body’sdaily water intake comes from food, feeling hungrymay be a signal that the body needs more water.

weekend calories Analyzing data from thenationally representative Continuing Survey ofFood Intakes by Individuals, a University of NorthCarolina study found that the average Americanolder than two years of age consumes 82 extracalories per day on each weekend day (Fridaythrough Sunday) than on weekdays (Mondaythrough Thursday). Further, for the 19- to 50-year-old age group, the weekend day increase (vs.weekday) is 115 calories per day. The increasedproportions of energy from fat and alcohol con-sumed on weekends are greater for this adult agegroup by 0.7 percent and 1.4 percent, respectively,whereas the proportion of energy from carbohy-

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drates decreases 1.6 percent. The authors stated,“The effects of weekend days on nutrient intakeare substantial and should be considered in futureclinical and population-based interventions and indietary monitoring and research in the U.S.”

Haines, Pamela S., Mary Y. Hama, David K. Guilkey, andBarry M. Popkin. “Weekend Eating in the UnitedStates Is Linked with Greater Energy, Fat, and AlcoholIntake.” Obesity Research 11, no. 8 (August 2003):945–949.

weight phobia Fear of gaining weight. A termcoined by Arthur H. Crisp to describe the anorexic’sattitude toward being of a normal body weight.

Some authors have questioned whether or notweight phobia should be considered a central partof anorexia. Hsu and Lee, for example, write, “Sev-eral reviews of the history of anorexia nervosahave concluded that weight phobia, a basic diag-nostic criterion for the disorder, did not emerge asa predominant motive for food refusal until around1930. In addition, investigators have reported casesof self-starvation without apparent weight phobiain non-Western cultures. Three explanations havebeen proposed for these findings: 1) patients whodo not demonstrate a definite weight phobia are infact suffering from an eating disorder not other-wise specified, 2) weight phobia has been over-looked or concealed, and 3) there has been atransformation in the content of anorexia nervosain the West and an analogous situation may beoccurring in the developing countries.”

Crisp, Arthur H. “Diagnosis and Outcome of AnorexiaNervosa: The St. George’s View.” Proceedings of theRoyal Society of Medicine 70, no. 7 (1977).

Hsu, L. George, and Sing Lee. “Is Weight Phobia AlwaysNecessary for a Diagnosis of Anorexia Nervosa?”American Journal of Psychiatry 150, no. 10 (October1993): 1,466–1,471.

Weight Watchers A commercial corporation thatmarkets a line of packaged, reduced-calorie “diet”foods, meant to be used according to a company-sponsored diet and BEHAVIOR MODIFICATION plan.Weight Watchers also sponsors fee-collecting sup-port groups. The company was purchased in 1978

by H. J. Heinz, which took control of both the dietprogram and a prepackaged food line. In 1999 itwas acquired by a European investment firm.

In their review of weight loss programs, Wither-spoon and Rosenzweig wrote: “The benefits of theWeight Watchers program are its accessibility, groupsupport, emphasis on making good choices usingstandard foods, incorporation of physical activity,and relatively inexpensive upfront fee to join. Thelimitations are the cost of weekly meetings, thegroup perceived as intimidation, and the potentialfor disordered eating using the food point system.”

In their review of self-help weight control pro-grams. Tsai et al. wrote, “Among nonmedical pro-grams, Weight Watchers is the only one that hassponsored a randomized trial. Participants in theirlargest study lost 5.3 percent of initial weight at 12months and maintained a loss of 3.2 percent at twoyears.” According to these authors, “WeightWatchers costs approximately $167 for 12 weeks.This includes a $35 membership fee and a $12weekly fee, pay-as-you-go.”

Tsai, Adam Gilden, et al. “Commercial and Self-Help Pro-grams for Weight Control.” Psychiatric Clinics of NorthAmerica 28, no. 1 (March 2005): 171–192.

Witherspoon, Barbara, and Margaret Rosenzweig.“Industry-Sponsored Weight Loss Programs: Descrip-tion, Cost, and Effectiveness.” Journal of the AmericanAcademy of Nurse Practitioners 16, no. 5 (May 2004):198–205.

wound healing Wound healing can present spe-cial problems for obese patients. High risk factorsinclude infection, swelling and incision ruptures.Charlebois and Wilmoth explain, “The skin of per-sons who are obese is at high risk for breakdownand delayed wound healing. Persons with obesityhave many intertriginous folds (opposing skin sur-faces touching) that become moist and harbor bac-teria and yeast. Because of the poor vascularsupply to adipose tissue, these skin folds are proneto breakdown and can quickly ulcerate.”

Charlebois, Donna, and Debbie Wilmoth. “Critical Careof Patients with Obesity.” Critical Care Nurse 24, no. 4(August 2004): 19–27; 28–29.

298 weight phobia

Xenical Trade name of ORLISTAT, an obesity drugapproved in 1999.

yo-yo dieting Also called weight cycling. A habit-ual cycle of weight loss by dieting followed byweight regain; an inability to maintain weight loss.Studies have shown that yo-yo dieting increasesbody fatness and may ultimately result in an inabil-ity to lose weight even on a very low caloric intake.

People who get caught up in the yo-yo cycle takeprogressively longer each time to shed pounds andgain them back progressively faster. Kelly Brownell,a psychologist then at the University of Pennsylva-nia, found in 1986–87 that yo-yo dieting increasedthe activity of lipoprotein lipase, an enzyme thatpromotes the storage of body fat. And because fattissue is metabolically less active than muscle, witheach diet cycle the daily caloric needs dropped andweight was gained on fewer calories. Dr. Brownellconcluded that yo-yo dieting increases the body’sefficiency in using food for fuel and may ultimatelymake weight loss impossible.

In agreement with this is David A. Booth, a psy-chologist at the University of Birmingham, Eng-land, who says that yo-yo dieting “may havephysiological and psychological consequenceswhich would make weight loss more difficult whenit became medically more important.” A constantlyrepeated yo-yo dieting cycle has been shown to bemore of a health risk than remaining at a stableweight, even if high, particularly for those who aregenetically predisposed toward obesity.

In a 1989 report in the American Journal of Clini-cal Nutrition, Djoeke can Dale and Wim H. M. Sarisof the University of Limburg, the Netherlands com-pared body composition (fat to lean ratio), restingmetabolism rate and conversion of fats into fatty

acids among those with a history of yo-yo dietingwith those of dieters without such a history. After14 weeks, significant differences in weight loss andfat loss were revealed between dieting-only anddiet-and-exercise groups, but not between yo-yoand non-yo-yo dieters. Resting metabolic ratedecreased in all groups, but there was a significantlysmaller decline after 14 weeks for the diet-exercisegroups. No effects of frequent dieting or exercise onbasal and fat-burning activity were observed.

Evidence continues to mount that yo-yo diet-ing makes subsequent weight loss more difficult.In the Van Dale and Saris study, researchersexamined the weight loss patterns of obesepatients participating in a university weight lossprogram for the second time. The dieters had alllost weight on the program but had regained atleast 20 percent—more typically 120 percent—oftheir lost weight in the intervening years. Thoughthey were placed on the same weight loss regi-men, and compliance was monitored by a batteryof laboratory tests, the dieters lost significantlyless weight the second time. The researchersspeculate that chronic dieting leads to a slow-down in METABOLISM, which sets the stage forweight gain and makes future attempts at weightloss more difficult.

Later, Dr. Brownell, now at Yale University, leda research team that studied and analyzed data col-lected from 3,200 participants in the Framingham(Mass.) Heart Study over a period of 32 years. Themuch-heralded results of the study were reportedin the June 27, 1991 New England Journal of Medi-cine. Among the conclusions: “Persons whose bodyweight fluctuates often or greatly have a higherrisk of coronary heart disease and death than dopersons with relatively stable body weights.” Con-

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troversy remained because the study did notaddress the issue to whether weight fluctuationsare more dangerous than obesity.

Recent research has found similar connectionsbetween yo-yo dieting and binge-eating. In a Har-vard Medical School study of 2,476 young andmiddle-aged women, “weight cycling was associ-ated with greater weight gain, less physical activity,and a higher prevalence of binge eating. Low lev-els of activity and binge eating may be partiallyresponsible for the large amount of weightregained by weight cyclers.”

An Italian study of 1,889 treatment-seeking obesesubjects found that “Weight cycling is associatedwith psychological distress, and binge eating inde-pendently increases the risk, but cannot be used topredict cycling. Also, obese patients who do notexperience overeating as a loss of control discon-tinue treatment or regain weight following therapy.”

Earlier, Friedman et al. had examined the psy-chological effects of weight fluctuation associatedwith repeated dieting; their findings suggested that“an individual’s perception of being a weight cyclermay be more related to psychological problems

than the actual number of pounds lost andregained over time.”

Field, A. E., et al. “Association of Weight Change, WeightControl Practices, and Weight Cycling among Womenin the Nurses’ Health Study II.” International Journalof Obesity and Related Metabolic Disorders 28, no. 9(September 2004): 1,134–1,142.

Friedman, Michael A., Marlene B. Schwartz, and KellyD. Brownell. “Differential Relation of PsychologicalFunctioning with the History and Experience ofWeight Cycling.” Journal of Consulting & Clinical Psy-chology 66, no. 4 (August 1998): 646–650.

Marchesini, G., et al. “Weight Cycling in Treatment-Seeking Obese Persons: Data from the QuovadisStudy.” International Journal of Obesity and Related Meta-bolic Disorders 28, no. 11 (November 2004):1,456–1,462.

zinc deficiency Zinc is necessary in the body insmall amounts. A shortage of zinc, the result ofmalnutrition or starvation, can greatly alter tasteperception and may play a role in the bizarre foodcombinations eaten by starving anorexics. It alsoleads to hair loss, brittle nails and anemia.

300 zinc deficiency

I. Chronology

II. Tables

III. Sources of Information

IV. Obesity and Eating Disorder Treatment

Centers/Weight Reduction Camps

V. Glossary of Fat Replacers

VI. Web Sites of Interest

VII. Audiovisual Materials

APPENDIXES

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1873The term anorexia nervosa is first used in England byphysician Sir William Gull, who described thesymptoms in several young upper-middle-classEnglish girls. In a speech in 1868 he described thesymptoms of a “peculiar form of disease,” which hethen called “apepsia hysterica,” later deciding“anorexia” was a more appropriate term.

Charles Lasègue, a French neurologist, pub-lishes a paper, “On Hysterical Anorexia,” whichdetails the symptoms of anorexia nervosa, whichhe refers to as a form of hysteria.

1900C. Von Noorden classifies obesity into two types:exogenous, due to overeating and under-exercising;and endogenous, due to metabolism.

1920sBehavioral science pioneers Ivan Pavlov, EdwardThorndike and B. F. Skinner each begin importantbehavioral studies relating to eating responses.

1921Skinfold test to measure obesity is introduced, inwhich the thickness of a “pinched” fold of skinindicates the ratio of body fat to muscle tissue.

1929Invention of constant-tension calipers by R. Frazenimproves accuracy of skinfold obesity test.

1933Reducing drug called dinitro-ortho-creso is intro-duced by Drs. E. C. Dobbs and J. D. Robertson.

1935Surgeons in Budapest, Hungary remove 93pounds of fat from 379-pound poultry dealerby making many small surgical incisions onhis body.

1936Hormone Lipocaic, which controls utilization offat, is discovered by Drs. L. R. Dragstedt, J. van Pro-haska and H. P. Harms.

1947Dr. H. E. Richardson advocates treating non-glan-dular obesity in women as neurosis.

1948Scientists at Brown University link obesity toheredity.

1950Dr. H. Millman reports on emotional factors inobesity.

E. H. Rynearson reports on “emotional factorsin overeating” and recommends formation of anorganization to be called “Calories Anonymous.”

1951Metropolitan Life Insurance Company starts driveto curb obesity and promote sound nutrition.

1953Dorset Foods begins marketing canned foods withcalorie information printed on label. Knicker-bocker Hospital in New York establishes obesitytreatment center.

APPENDIX ICHRONOLOGY*

*Adapted from Library in a Book: Eating Disorders, by John R. Matthews. Copyright 1991 by FactsOn File.

Appendix I 303

1954Dr. W. S. Kroger patents weight reducing belt thatchecks hunger pangs by pressing against upper partof stomach.

Pituitary hormone adipoteinin is studied for itsfat burning properties.

J. Wolpe, in describing “avoidance condition-ing,” attempts to treat overeating with classicalaversion methods using electric shock.

1957Hilde Bruch postulates that obesity is consequenceof personality defects in which body size becomesexpressive of underlying psychological conflicts.

U.S. House subcommittee holds hearings onmisleading remedies for weight loss. Better Busi-ness Bureau says Americans spent $100 millionin 1956 on worthless remedies. The drug Phenylpropanolamine in reducing pills is declaredharmful.

1959J. M. Strang reclassifies Von Noorden’s metabolicobesity type, endogenous, to include breakdownsin the physiological or psychological regulation offood intake, and a type related to variousendocrinological dysfunctions.

First Metropolitan Life Insurance Companyheight and weight tables are published.

In a criminal case in New York, the DistrictAttorney calls Regimen brand reducing tabletsfraudulent, raids office and seizes ads and televi-sion commercials. Later in a criminal trial in1965, the drug company, its ad agency and theirexecutives are found guilty and fined: the adagency is fined $50,000; the drug company presi-dent is given an 18-month prison sentence andfined $50,000; and the drug company is fined$53,000.

Dr. Albert Stunkard and Mavis McLaren-Humecomplete watershed analysis of obesity research,setting forth criteria for evaluating obesity researchand reducing to eight the vast number of researchstudies that met criteria.

1960The Federal Trade Commission (FTC) chargesStauffer Labs with false claims of weight loss from“magic couch.”

Milk companies begin to market skim milk asdiet food.

Federal Drug Administration (FDA) seizesfalsely labeled diet mixes.

1961Yale doctors find link between tendency to gainweight and heart problems.

1962Major study is published by U.S. Public Health Ser-vice (PHS) of weight, height and body dimensionsof adults throughout the United States.

The Midtown Manhattan Study, directed by Dr.Lee Srole, establishes relation of obesity to socialstatus, showing greater obesity in the lower socio-economic classes.

W. L. Laurence reports new synthetic ACTH(pituitary hormone) compound that breaks downfat tissue into liquids.

Reducing drug phenmetrazine (Preludin) causesdeformities in newborns in Germany.

1964French women discover “cellulite” and rush to spasand salons for treatment.

1965First intestinal bypass operation for weight loss isreported by American College of Surgeons.

1966M. Mendelson, in a pioneer study, delineates acontinuum of the range of psychological distur-bance in obesity causes.

New York State appellate court upsets RegentsBoard’s 1964 censure of Dr. Walter Sherman fornegligence in treating obesity patients. Dr. Sher-man, who specialized in treatment of obesity, over-looked conditions such as diabetes and prescribedamphetamine sulphate, desiccated whole thyroidand phenobarbital.

The U.S. Public Health Service (PHS) reports onobesity as a major health problem and finds dietsare of limited value and urges exercise. The reportrejects height and weight charts for tests for obesityand recommends skinfold pinch test instead.

PHS publishes nationwide study of adult heightsand weights and finds males are seven pounds and

females 11 pounds heavier than found in the 1959Metropolitan Life charts.

New York state superior court awards ElizabethOstopowitz $1,205,000 for injuries caused by tak-ing anti-cholesterol drug Mer-29 to lose weight.The drug was withdrawn from the market in 1962by 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 studyfinds that colleges discriminate against obese inadmissions.

NAAFA (National Association to Aid Fat Amer-icans) is founded.

1967Dr. Herman Taller, author of Calories Don’t Count, ischarged in federal court in Brooklyn with mailfraud and making false claims in promoting hisbook along with safflower oil diet pills marketedby Cove Vitamins and Pharmaceuticals. Taller isconvicted and fined $7,000; charges against thebook’s publisher, Simon & Schuster, and its adagency are dropped.

Professor A. Feinstein, on American PhysiciansCollege panel, asserts that being mildly obese posesno health risks.

Scientists at Iowa University Medical Collegereport that people who become obese, especiallyearly in life, activate internal biological mechanismsthat tend to keep them obese. The report hypothe-sizes an alternative pathway for disposing of excessglucose intake. Studies of obese children found thatthey produced low levels of the hormone dehy-droepiandrosterone (DHA), which regulates theprocess of disposing of the excess glucose.

Senator Philip A. Hart’s (D., Michigan) subcom-mittee begins probe into diet pill industry, chargingthat manufacturers recruit doctors to promotedrugs and also charges that obesity specialists usemass production procedures in treating patients.

Dr. Alvan Feinstein at a meeting of the Ameri-can College of Physicians proposes that otherwisehealthy, slightly obese persons not diet and citesharm of fad dieting. Dr. Jules Hirsch of RockefellerUniversity reiterates his contention on lack of sci-entific knowledge about obesity.

Dr. Jean Mayer of Harvard reports on researchto locate the seat of hunger and satiation signals inthe brain. He describes the hypothalamus, a tinyregion at the base of the brain. Studies show ani-mals with an injured hypothalamus display confu-sion about hunger and satiation signals andconsequently overeat.

1968Senator Philip A. Hart’s (D-Michigan) subcommit-tee hearings produce evidence of indiscriminatedispensing of dangerous diet drugs containing thy-roid extract, digitalis, amphetamines, barbituratesand prednisone at about 1,000 clinics across theUnited States. Two companies, Western ResearchLabs and Lanpar Company, are charged. Compa-nies are ordered to cease marketing pills containingamphetamines and digitalis. In a related investiga-tion, Illinois Narcotics Control Division probesdeath of nurse who died from amphetamine accu-mulation in her body after taking reducing pills.

Dr. J. Hirsch of Rockefeller University claimsthat some persons with chronic obesity continue to“remember” and think of themselves as fat evenafter reducing.

Hypnosis cure for obesity becomes briefly popular.J. Knittle et al. conduct a series of studies show-

ing that adipose cells remain constant throughoutlife and that by adulthood increases in body sizeare caused by increase in cell size, not cell number.

1969Drs. I. B. Perlstein, B. N. Premachandra and H. T.Blumenthal report to the American TherapeuticSociety on study showing that some obese peopleproduce antibodies against their own thyroid hor-mone, and gain weight because of the resultingmetabolic imbalance.

A study by R. Half Personnel Agency finds thathigher-paid executives are thinner than lower-ech-elon employees.

In a study on metabolism at Lankenau Hospitalin Philadelphia it was found that the metabolic ratein a well-fed obese person and a starving lean per-son are similar because they both burn relativelymore fat and less blood sugar than normal persons,and it is thought that this is a vestige of earlyhuman behavior similar to some wild animals.

304 The Encyclopedia of Obesity and Eating Disorders

1970February 8: Two slightly overweight mothers, aged24 and 27, in Monroe County, New York, arereported to have died after taking diet pills contain-ing thyroid hormones, digitalis and amphetamines.

July 30: National Research Council criticizespractice of limiting weight gain by pregnantwomen and recommends weight gains of 20–25pounds during pregnancy, plus diet supplements.

August 6: FDA proposes limiting the manufac-ture of amphetamines, an important ingredient indiet pills.

September 13: Research report indicates over-feeding children produces excess of fat cells, whichremain for life, hampering future weight loss.

November 17: Drug industry promotions to doc-tors of reducing drugs is linked by the Narcoticsand Dangerous Drugs Bureau of the U.S. JusticeDepartment to increasing drug abuse.

1971January 20: Weight Watchers International, Inc.launches Operation HOPE in New York City tohelp people unable to leave home or function nor-mally because of extreme obesity.

September 7: Dr. J. L. Knittle, National Institutesof Health researcher, finds that adult obesity can bepredicted by age two because number of fat cells inbody can be closely determined by that age.

September 12: Weight loss fad Hot Pants, prod-uct name for inflatable shorts that allegedly reduceweight by increasing expenditure of energy, isinvestigated by the U.S. Postal Service. Test showsno weight loss by using the product.

1972Joseph Cautela introduces “covert conditioning” intreatment of obesity, which is based on “escape-avoidance” paradigm that punishes particular eat-ing responses and reinforces responses antagonisticto eating.

September 28: The Better Business Bureau ofMetropolitan New York mounts campaign againstmedical quackery relating to obesity control. Itclaims that Americans spend between $2 billion and$10 billion annually on useless gadgets and pills.

October 11: FDA reports on study it undertookto test claims of diet pills; study reveals that diet

pills are no aid in weight reduction. It recommendsimposing manufacturing quotas on amphetamines.

November 14: British study reports that babiesborn underweight suffer from educational andbehavioral problems by the time they reach schoolage. Dr. N. Butler, director of the study, says effectswere found in all social classes but most pro-nounced in lower socioeconomic levels.

December 14: The FDA moves to restrict harm-ful diet pills. FDA director E. Simmons mails bul-letins to 600,000 health professionals warning ofhazards of diet pills. In defending FDA’s originalaction in permitting prescribing of diet pills forweight loss, Simmons said that a small number ofpeople are able to lose weight taking the pills, andbecause the treatment of obesity is so difficult andincludes high rates of failure, they believe thatphysicians should have use of all therapeutic aids.

December 14: In testimony before Senator Gay-lord Nelson’s (D-Wisconsin) subcommittee, Drs.Jean Mayer, J. Tepperman and T. E. Prout accusethe medical profession and drug companies of pan-dering to public misbeliefs about obesity andweight loss. Dr. Mayer cites diets such as “DrinkingMan’s Diet,” rice diet, Mayo and Atkins diets asextreme and dangerous.

December 26: The $220 million salon and healthspa industry is said to be permeated with fraud.Consumer agency investigators focus on deceptiveads, high pressure sales pitches and long-term con-tracts to attract customers. Health clubs run byJack LaLanne and Nu-Dimensions are target ofprobe. Complaints include misleading ads, promiseof improbable weight loss, dirty and overcrowdedfacilities and untrained instructors.

1973February 7: A federal grand jury in Newark, NewJersey, indicts G. Maisonet, E. Axel, D. Bradwelland V. Lynch for selling $1.1 million in phony dietpills by mail.

February 8: The Federal Office on ConsumerAffairs warns against inflated claims and high pres-sure sales tactics used by spa and salons. The FederalTrade Commission (FTC) investigates sales tacticsand claims of health clubs and spas; recommendslimiting contracts to $500 rather than $1,000 andforbidding sellers to assign contracts to banks or oth-

Appendix I 305

ers, and recommends triple damages to buyers whobring successful deceptive-practices suits.

March 9: AMA in warning against the book Dr.Atkins’ Diet Revolution says the diets are unscientificand potentially dangerous; book recommends dietthat activates fat-mobilizing hormone, convertingstored fat to carbohydrates; advocates unlimitedintake of fats and cholesterol rich foods.

March 14: New York County Medical Societycalls Atkins Diet unscientific, unbalanced andpotentially dangerous to persons prone to kidney orheart disease and gout; it is called especially dan-gerous to pregnant women and unborn children.Dr. Atkins claims diet is based on clinical observa-tion of 10,000 obese subjects over nine years.

March 21: U.S. District Judge F. B. Lacey askspostal service to begin probe of mail order sales ofdiet pills and upheld postal service’s right to with-hold mail delivery to Baslee Products Corporationof Bayonne, New Jersey, which had been foundguilty in nine counts of false advertising relating tosales of the diet pill Marvex.

March 22: Dr. Atkins, author of Dr. Atkins’ DietRevolution, is sued for $7.5 million in suit claiminghis diet is responsible for heart attack as result ofnegligence and malpractice. Superior Court namesAtkins, his associate I. Mason and publisher DavidMcKay Company as codefendants.

March 31: O. N. Miller, associate director ofbiological research for Hoffman–La Roche,granted patent for obesity control product usingnicotinic acid to inhibit growth of fatty substancesknown as lipids. Hoffman–La Roche is testingproduct on animals.

April 2: The FDA and Bureau of Narcotics andDangerous Drugs recall diet drugs containingamphetamines. Action includes injectable amphet-amines and closely related chemicals and all com-bination diet pills that contain amphetamines andother ingredients such as sedatives or vitamins.

April 9: New York City Consumer AffairsDepartment passes regulation prohibiting noncan-cellable contracts for “future service” aimed espe-cially at reducing salons and spas.

June 7: American Chemical Society in a studyconducted at Loyola University’s Stritch School ofMedicine in Maywood, Illinois, reports on fat-reducing agent FMS (fat-mobilizing substance)

found in urine of those who are fasting. It isthought to play a role in rapid breakdown of fatduring starvation. FMS appears to stimulate therelease of a form of adenosine monophosphateknown as cyclic-AMP, which promotes theenzyme lipase that breaks down fats. The chemicalstructure of FMS is unknown, but it is thought tobe a protein.

June 14: Bureau of Narcotics of the JusticeDepartment places restrictions of prescription non-amphetamine diet pills that include ingredients suchas benzphetamine, fenfluramine and phendime-trazine, and are sold under many trade names asappetite suppressants. Illicit drug world beginsunderground sales in an effort to replace lost salesbecause of unavailability of amphetamines.

August 7: E. Axel pleads guilty of conspiring tocommit mail fraud in the sales of $1.1 million in dietpills advertised as Slim-Tabs 33 slenderizing tabletsand admits to being principal of Stanford ResearchCorp., arranging “fronts” as corporate officers.

August 21: Cassette tape recording designed tohelp in weight loss is marketed by Accomplish-ment Dynamics Company and narrated by Dr. R.E. Parrish, who says tape uses technique similarto hypnosis.

September 22: D. R. Salata receives patent forRollslim, massaging device consisting of tworollers, for overweight women.

October 19: Liberty Life Insurance Companyannounces hospitalization program with premiumrates based on insured’s weight; overweight per-sons will pay higher premiums.

October 21: A Brooklyn College study involvingmice finds that overweight mice live only half as longas normal-weight mice, and many of the overweightdevelop diabetes, become sluggish, inactive andalmost sterile, and have low sex drive; process isreversed by reducing mice’s weight. Professor G. H.Fired says experiment corroborates accepted theoriesabout proper exercise and nutrition. Study is basedon more than 1,000 mice over a 10-year period.

November 11: National nutritional study ofmore than 20,000 Canadians finds more than halfthe population is overweight and attributes causeto sedentary lifestyle rather than overeating.

November 26: Drug Guild Distributors, manu-facturer of X-11 Reducing Plan Tablets, agrees to

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Appendix I 307

discontinue misleading and harmful advertising.Tablets are considered by medical authorities aspotentially harmful to those suffering from heartdisease, high blood pressure, diabetes or thyroiddisease, despite ad statement that they are safe foreveryone.

December 27: Dr. J. Hirsch and J. Knittle andcolleagues report on people who have been fatsince childhood and have larger than normal num-ber of fat cells and claim that either in life obesitybegins, the larger the number of fat cells.

December 27: Dr. Jean Mayer says persons ofparticular body type—slender ectomorphs withlong, narrow hands and feet—are unlikely tobecome fat; other researchers note that infant feed-ing practices lead to overfeeding, which in turn cre-ates a greater number of fat cells. Researchers foundthat mothers of fat children tend to respond to theirinfants’ distress by feeding; later these childrenreact to emotional stress or frustration by eating.

1974January 23: Operator of weight reducing productscompany, Raymond Carapella, pleads guilty tomail fraud in multimillion dollar per year sales ofdiet pills and bust-developing products.

May 6: The FTC begins New York regionalinvestigation of sales of future service contracts byreducing salons.

June 15: Brewster Produce, a mail order house,admits in federal court in Newark, New Jersey, thatit sold almost $2 million worth of phony diet pills.

August 31: Patent is issued for mirror devicethat shows how an obese person will look afterconsiderable weight loss.

September 15: Woman on fast weight loss dietdies of heart attack after fasting for four days.

September 16: Several weight loss clinics are thesubject of federal investigation into fraudulentpractices for falsely advertising medical supervisionand using unapproved drugs. Chain-operated clin-ics charge fees of $175 to $500 for 21- to 40-daytreatment consisting of low calorie diet and dailyinjections of hormone HCG (human chorionicgonadotropin) obtained from urine of pregnantwomen, which clinics admit may be worthless.

November 10: Citing studies showing anorexianervosa as having a fatality rate higher than any

other psychiatric disorder, the Philadelphia ChildGuidance Clinic claims 100 percent cure rate forchildren who remain in treatment.

December 12: U.S. Postal Service bars mailing offraudulent products Slimmer Shake and Joe Wei-der’s Weight Loss Formula XR-7, made by WeiderDistributors Inc. of Norwood, New Jersey.

December 15: FDA announces that drugs con-taining hormone HCG must be labeled as worthlessfor weight loss.

1975March 27: Jack Fried, operator of Phase Method, isindicted in Newark, New Jersey, on mail fraudcharges for selling weight reduction plans based onclients’ handwriting samples. Fried is later con-victed and sentenced to three years in prison.

April 4: Pillsbury Company announces it willacquire Weight Watchers International Inc. for$43 million.

May 14: Slim-Tabs Slenderizing Tablets pro-ducer Arnold Mandell pleads guilty to mail fraud,admitting pills are worthless.

December 15: Federal Trade Commission (FTC)prohibits Stuart Frost Inc. from advertising bodywrapping devices called Slim-Quick or servicesused for weight reducing.

1976March 3: Americans for Democratic Action issue areport attacking the weight reducing industry, cit-ing $90 million annually wasted by consumers.

March 26: A study is published showing thatearly puberty and menstruation of girls is associatedwith stoutness and late menstruation with thinness.

June 9: FTC Judge Daniel H. Hanscom rules thatPorter & Dietsch Inc., makers of X-11 Diet Tablets,and its ad agency, Kelly Ketting Furth, falselyadvertised that users could lose weight while eat-ing as much as they wanted.

December 4: Two government employees patenta method of controlling obesity with purified “mir-acle fruit” grown in West Africa.

1977March 12: Because of saccharin’s role in causingcancer, the FDA announces plans to classify sac-charin as a drug instead of a food additive.

April 11: Dr. John E. Farley, Jr., head of theRhode Island Medical Society drug abuse commis-sion, announces his organization’s opposition to theuse of amphetamines in treating obesity; Utah Med-ical Association also opposes amphetamine use.

June 21: In the first major malpractice suitunder a new Pennsylvania law, Marlene Baumiller,who underwent intestinal bypass operation forweight loss, is awarded $100,000 from Dr. RobertCassella, who accidentally punctured her spleenand had to remove it; $25,000 from PittsburghPodiatry Hospital; and $225,000 from Medical Pro-fessional Liability Catastrophe Loss Fund.

July 21: The FDA opposes strict rules for label-ing foods as low calorie.

August 29: At annual American PsychologicalAssociation meeting Dr. Judith Rodin says over-weight people secrete more insulin when stimu-lated by food sights and smells. Increased insulinsecretion increases hunger, leading to overeating.

September 20: In Porter County, Indiana, supe-rior court, Cora Staniger is awarded $50,000 indamages from doctors who put her on a proteindeficient diet during her pregnancy, causing men-tal retardation of her daughter.

November 3: The FDA and Centers for DiseaseControl (CDC) begin inquiry into 12 deaths sus-pected to be caused by liquid protein diet formula,which supplies 300 calories per day in a liquidmade of fibrous protein collagen from animal tis-sue. Investigators suspect it may deprive users ofpotassium. FDA names a panel to investigate.

November 24: Federal Centers for Disease Con-trol reports 10 more deaths suspected tied to crashdieting with predigested liquid proteins. FDA Com-missioner Donald Kennedy requests 35 manufac-turers of product to label compounds as hazardousunder some conditions. Senator Charles Percyurges FDA to reclassify these diet products as pre-scription drugs.

December 1: At an American Heart Associationmeeting, California heart specialists claim that liq-uid protein diets can result in death even if usedunder strict medical supervision.

December 21: Figures from National Health Sta-tistics Center show that American adults weigh anaverage of about four pounds more than in theprevious decade.

December 29: At a House Subcommittee onHealth and Environment hearing about liquid pro-tein diets, Dr. Robert Linn, author of The LastChance Diet, questions the accuracy of the govern-ment report linking the diet to deaths.

1978January 27: FDA asks 800,000 professionalhealth workers to report cases of liquid-protein-caused death problems; 46 deaths and 200injuries from product are to be investigated. Salesof the product plummet.

February 12: Luciano Pavarotti, having lost 90pounds on diet, disproves myth that obesity helpsopera singers project strong voices.

March 12: Fat Liberation Front announcesdrive to free fat people from stigma and claimsthat no health problems result from obesity. Dr.Robert Sherwin of Yale comments that organiza-tions such as the Fat Liberation Front help theobese psychologically but warns that obesity stillneeds to be treated.

April 22: Dr. Feridun Gundy of Queens, NewYork is convicted in federal court of illegally dis-pensing $2.5 million worth of amphetamines toobese patients.

May 16: Dr. George Blackburn, whose researchwas partially the basis for liquid protein diets, warnsthat the diets dangerously deplete essential nutrients.

May 16: H. J. Heinz Company announces that itwill acquire Weight Watchers International Inc. forover $71 million.

September 22: Drs. Arthur Hartz and AlfredTimm, and mathematician Eldred Geifer announcethat research at the Medical College of Wisconsinshows that environment is more important thanheredity in determining tendency to obesity, dis-puting previous studies showing heredity as moreimportant. Study observed behavior among natu-ral and adopted siblings with overweight mothers,who were selected from weight reduction organi-zation TOPS (Take Off Pounds Sensibly).

October 15: Substantial decline in sales of liquidprotein diets is reported; decline is attributed toFDA findings of deaths by users of products. Alldeaths reported were of women who all died ofmyocarditis, inflammation of heart tissue.

December 17: Survey by British shirt manufac-turer shows that fewer than 20 percent of women

308 The Encyclopedia of Obesity and Eating Disorders

are attracted to skinny men, while 34 percent pre-fer men to have “slight suggestion of a paunch and31 percent like a bit more of a paunch.”

December 30: FDA revises order for warninglabels on liquid protein diets and now requireswarning on all protein products that provide morethan 50 percent of a person’s calories and are pro-moted for weight loss or as a food supplement.

1979February 20: New research study challengesheredity-caused theories on obesity; the new studyshows overeating as primary cause.

May 13: FDA panel headed by Dr. John W. Nor-cross reports that phenylpropanolamine and ben-zocaine, found in several nonprescription diet aids,may help some dieters; calls for further study onother ingredients; and reports that dozens of othersare worthless.

July 1: FDA requirements for strict labeling ofdiet foods goes into effect. Foods labeled “low calo-rie” are required to contain no more than 40 calo-ries per serving and must be lower in calories thanfood normally found in grocery stores. Foods labeled“reduced calorie” must contain at least one-thirdfewer calories than similar products for which it issubstituted. Comparisons must be shown on label.

July 17: FDA proposes crackdown on illegalamphetamine use by banning their use in weightreduction. FDA says ban would reduce pill produc-tion by 80 to 90 percent. Some 3.3 million pre-scriptions for amphetamines were written in 1978.

December 15: A study is reported in medicaljournal Lancet claiming that bypass surgery is safeand quick way to loose weight. Lancet editorialquestions validity of study, criticizing researchdesign and calling project ethically unsound.

1980February 10: Essex County, New Jersey, chapter ofNOW (National Organization for Women) sponsorsprogram called Food, Fat and Feminism, whichexplores reactions to fat and fat people, and foodand diet.

May 1: Five drug companies agree to FDArequest to stop shipments of new nonprescriptiondiet products containing twice the current legallimits of phenylpropanolamine hydrochloride(PPA), an appetite suppressant drug. FDA deter-

mines that recalls are not necessary because pillsare not considered a health risk.

May 4: A study is reported that finds thatalthough death rates are higher for people who areabove average weight, death rates are higher stillfor those weighing less than average.

May 29: A report by the Food and NutritionBoard of the National Academy of Sciences sayshealthy Americans need not worry about fat andcholesterol and admits its stand dissents fromother major organizations that urge curbs on fatand cholesterol. Government experts criticize thereport, saying board members ignored importantscientific data.

July 5: Diet preparation that suppresses appetitefor calories but not proteins is patented by RichardJ. Wurtman, Judith J. Wurtman and John D. Fern-strom and licensed for production by Massachu-setts Institute of Technology.

September 28: Research linking stress to obesityis reported. Rats reportedly overate when theirtails were pinched, but their appetites abated whengiven naloxone, an opiate antagonist. This researchhas implications for understanding stress-relatedovereating.

October 30: A study is reported showing evi-dence that obese people have a biochemical defectinvolving enzyme adenosine triphosphatase(ATPase), which helps pump sodium and potas-sium across the membranes of the body cells.ATPase may be responsible for 10 to 50 percent ofthe body’s heat energy production. The amount ofATPase in the red cells on the obese group was 22percent lower than in the nonobese in the study.

December 12: A study by Drs. EugeneLowenkopf and L. M. Vincent finds that 15 percentof students in professional ballet schools sufferfrom anorexia nervosa and many others are bor-derline. The study attributes dancer’s obsessionwith body weight to the ballet profession’s empha-sis on thinness.

1981August 4: New York State passes law makingamphetamine prescription for sole purpose ofweight loss illegal.

August 11: Study by Drs. Linda Craighead,Albert Stunkard and Richard M. O’Brien finds that

Appendix I 309

appetite suppressant drugs may be counterproduc-tive to long-term weight loss.

October 31: Psychotherapists report thatbulimia nearly always begins with stringentweight loss diet.

November 16: An AMA Journal report criticizesthe book The Beverly Hills Diet saying it is filled withmedical inaccuracies.

1982February 13: A report is published saying 10,000poisoning cases per year result from taking PPA(phenylpropanolamine).

March 9: Study by Richard Weindruch and RoyL. Walford finds that undernutrition begun in mid-dle 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 andmust be removed from market. Bio-Tech Laborato-ries, manufacturer of the pills, sues FDA to preventdefining starch blockers as drug.

August 22: Federal judge in Chicago deniesrequest by FDA for ban on starch blockers despitea report of 75 illnesses related to the pills.

October 10: Federal court classifies starchblocker diet aids as drugs and ends all sales untildetermination of their safety can be made.

October 24: Gastroplasty, new operation thatseals off most of stomach, is reported.

November 22: Suction lipectomy, new surgerythat removes body fat by suction, is reported.

1983March 2: Metropolitan Life Insurance Companypublishes new height and weight tables showingideal weights have increased for men by two to 13pounds and three to eight pounds for women.

April 28: Dr. Edward R. Woodward warns oflife-threatening side effects resulting fromjejunoileal bypass, a surgical procedure to loseweight by bypassing small intestine.

July 5: Cornell University study finds exerciseafter eating is the best way to get rid of extra calo-ries and finds exercise crucial in maintaining stableweight when daily caloric intake fluctuates.

July 23: Dr. Thomas R. Knapp of the Universityof Rochester recommends people abandon con-cept of “ideal weight” because it is based on incon-sistent data.

1984December 16: A new eating disorders program isreported at Phelps Memorial Hospital in SleepyHollow, New York, that treats anorexic and bulimicpatients who require extensive care.

December 16: Pump therapy for anorexicpatients is reported to pump up to 2,000 calories aday into severely underweight patients.

December 21: A study at Massachusetts GeneralHospital by Dr. Nancy A. Rigotti finds that womenwith anorexia nervosa often have weak bones butcan be treated with exercise.

1985February 14: A National Institutes of Health paneldefines obesity as a disease and says it shouldreceive the same medical attention as high bloodpressure, smoking and other factors that cause seri-ous illness and premature death, and that over-weight should be treated when it reaches 20percent above “desirable” weight.

March 19: A study reported in Journal of Abnor-mal Psychology finds that women have negativelydistorted view of their bodies; men also have dis-torted image of their bodies, but it is more positive.

March 22: Physicians and psychotherapists spe-cializing in anorexia nervosa and bulimia treat-ment ask FDA to ban over-the-counter sales ofsyrup 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 NewEngland Medical Center, and Dr. Steven Gort-maker, of the Harvard School of Public Health,finds that children who watch lots of televisionexercise less, eat more and become obese.

August 6: Dr. Reubin Andres challenges Metro-politan Life height and weight tables, sayingweight ranges given in tables do not reflect idealweights.

September 2: First free-standing residential facil-ity in United States devoted exclusively to treat-ment of anorexia nervosa and bulimia, RenfrewCenter in Philadelphia, is reported.

1986May 22: Scientists report that anorexia nervosasufferers have high levels of cortisone, hormoneexcreted by adrenals in response to fear.

310 The Encyclopedia of Obesity and Eating Disorders

1987March 24: Dr. George Blackburn, an obesity spe-cialist at Harvard Medical School, comments onstudy on causes of obesity and finds that dieting isineffective for many people because when theyreduce food intake, their metabolic rate drops toprotect them from starvation.

1988February 11: A study of Dr. William Feldman ofOttawa University reports that girls come tobelieve thin is beautiful as early as age seven andlinks that attitude to rising incidence of eating dis-orders in young girls.

February 25: Two studies are published show-ing evidence of genetic causes of obesity: one studywas of Pima Indians in Arizona, the other ofinfants in Britain. These studies confirm theories ofDr. Jules Hirsch of Rockefeller University, who haspromoted the idea for over two decades.

March 22: Doctors specializing in bulimia reportthat use of antidepressant drugs can help somepatients reduce binge-eating and purging, butwarn that they cannot replace psychotherapyneeded to get to the root problems.

April 17: Wilkins Center for Eating Disorders inGreenwich, Connecticut, survey says amonganorexics and bulimics, number of those who are12 years old or younger has doubled in the last twoyears from 3 to 7 percent and says rise indicatesincreasing social pressure for thinness.

1989January 3: Researchers at Rockefeller Universityannounce discovery that abnormally low levels ofprotein adipsin, which is secreted directly into thebloodstream by fat cells, may be linked to tendencyto 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 isreleased that finds American women aged 18 to 34have been getting fatter over past several decades;black and poor women and women with low edu-cation levels show the greatest weight gains.

March 18: Ronald T. Stunko patents chemicalmethod of preventing fat formation in humans.

July 1: Pharmacologist Mark Hohenwarterpatents biamine, chemical for treating addictionssuch as food or cocaine. Biamine works by replen-ishing certain neurotransmitters in the brain.

September 16: Cardiologists Jackie R. See andWilliam E. Shell patent “Fat Magnets” diet pills,made from bovine bile, that prevents the bodyfrom absorbing some fat and cholesterol in food.

October 3: Merck Sharp & Dohme announcesdiscovery of manner in which hormone cholecys-tokinin triggers brain to tell body when to stop eat-ing. They also discovered two chemicals that blockhormone’s action.

1990January 3: Nationwide survey by Calorie ControlCouncil finds that pounds almost always returnafter dieting and that only fundamental changes ineating behavior will keep them off. Survey alsofound a 26 percent drop in the number of peopleon diets.

February: Simplesse, the first fake fat with thetaste and texture of the real thing but withouthigh calories, was marketed as an ice cream calledSimple Pleasures.

March 20: Research team led by DavidWilliamson of the Centers for Disease Controlannounces findings that people are most likely togain weight as young adults and that black womenare especially vulnerable; women of all races aretwice as likely as men to gain large amounts ofweight; and women from 25 to 44 who were over-weight at the beginning of the study gained themost weight of all subjects.

March 28: Representative Ron Wyden (D., Ore-gon) chairman of the House of Regulation, Busi-ness Opportunities and Energy Subcommitteeopened hearings into questionable practices of theweight-loss industry amid charges that healthrisks, false advertising and profiteering are“bedrock” in the industry.

April 1: Five-year study by Dr. Thomas Waddenshows that 98 percent of all dieters regain theirweight within five years.

April 1: New York Times story says recent studiessuggest that formula diets can lead to psychologicaland physiological burdens that limit diets’ long-term effectiveness; some people develop fear offood and become dependent on formula diets,while others binge and suffer humiliating weightgains, while few maintain their lower weights.

May 8: New York Times story reports on the mostcomprehensive study of diet and disease ever

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312 The Encyclopedia of Obesity and Eating Disorders

undertaken—a survey of 6,500 Chinese—led byDr. T. Colin Campbell of Cornell University and Dr.Chen Junshi of the Chinese Institute of Nutritionand Food Hygiene. One of the first findings is thatobesity is related more to what people eat than tohow much.

May 24: New England Journal of Medicine reportson multiple studies that confirm that body weightis determined more by heredity than by diet. Thefindings do not go so far as to suggest that the roleof diet can be dismissed completely; what one eatsstill makes some difference.

August 8: Los Angeles Times reports that a Stan-ford University study shows overweight men whodieted but did not exercise had suppressed meta-bolic rates, while those who lost weight throughexercise but did not diet had no reduction in meta-bolic rates.

November 27: Medical World News reports thatweight loss is a $33 billion business this year, up 10percent from 1988.

1991January: University of Minnesota study of nearly5,000 workers in upper Midwest reports a lifetimeprevalence of dieting to lose weight of 47 percentin men and 75 percent in women.

March 28: Panel of experts convened by theNational Institutes of Health endorses gastroin-testinal surgery to treat severe obesity but recom-mends that patients first try nonsurgicalweight-loss techniques, such as diet, exercise andbehavior modification.

April 10: Physicians Committee for Responsi-ble Medicine, a nonprofit organization, asks U.S.Department of Agriculture (USDA) to abandonthe traditional four food groups—meat, fish andpoultry; grains; dairy products; and fruits andvegetables—and to replace them with a radicalnew grouping of foods: fruits, legumes, grains andvegetables becoming the primary group, withmeat and dairy products becoming minor optionslimited to three ounces a day.

May: British study led by Dr. Christopher Fair-burn suggests that cognitive behavior therapy ismore effective in treating bulimia nervosa thanboth interpersonal psychotherapy and a simplebehavior therapy.

September: Columbia University study led byDr. B. Timothy Walsh reports serious limitationsover the long term of a single antidepressant med-ication in treating bulimia nervosa.

1992January: Survey of 50 physicians and scientistsinvolved in obesity research shows disparate viewson causes and treatment of obesity among differentgenders, age groups and regional locations. Theonly overall agreements are that genetic factors arethe most important cause of obesity and that theusefulness of serotonergic and thermogenic drugsas effective treatments will increase during thenext 10 years.

May: Syracuse University report led by Dr. T. A.Wadden offers a multicenter evaluation of a pro-prietary weight reduction program after congres-sional hearings begun in March revealed that the$10 billion a year weight-loss industry is subject tominimal regulation by federal agencies. Becauseno proprietary program has provided an assess-ment of its short- and long-term treatment results,consumers are forced to rely on advertisements.

May 5: International No-Diet Day begins whenMary Evans Young of London, England, and hergroup, Diet Breakers, hold a no-diet picnic inHyde Park.

September 4: American Academy of Pediatricsrecommends that all American children over theage of two follow the lower-fat diet recommendedfor adults.

November 5: New England Journal of Medicinereports on a study spanning more than 60 yearsthat indicates that being overweight during theteenage years can lead to life-threatening chronicdisease in adulthood, even if the youngster latersheds the excess weight.

1993January: Citing the Framingham Heart Study, Har-vard Heart Letter reports that yo-yo dieting maycause more harm than good suggesting that ifdieters are not able to maintain their weight loss, itmay be better for their cardiovascular health toremain a little overweight.

January 17: A study by the Institute for Aero-bics Research (Dallas) based on analysis of 12,866men, finds that overweight men whose weight

remains constant over a period of six or sevenyears had lower heart attack risk than both menwhose weight cycled up and down and men wholost weight.

March: Newsletter of the American Anorexia-Bulimia Association, Inc., announces that theDSM-IV manual of psychiatric disorders willinclude the new term binge-eating disorder, therebyofficially recognizing compulsive overeaters ashaving an eating disorder.

April: Nutrition Today report suggests that obe-sity should be regarded as a chronic condition.

July 14: New York Times reports that a new drug(orlistat) that blocks fat absorption from the stom-ach and intestine is being tested in the UnitedStates and Europe.

August: Environmental Nutrition reports that the11 percent of total calories normally consumedfrom sugar poses no threat to health except bycausing cavities. The frequent pairing of sugar withfat in foods is a problem; sugar alone does not gen-erally cause weight gain.

October 1: Annals of Internal Medicine report sug-gests that more special attention be given to obe-sity as it occurs in and affects ethnic minorities inthe United States. In most of these groups, theprevalence of obesity is substantially higher than inwhites, especially among women.

1994March 29: Washington Post reports on a study of 202obese men and women that finds that weightcycling (yo-yo dieting) does not affect body com-position or metabolic efficiency or increase cardio-vascular risk.

June: Dr. James Hill concludes in EnvironmentalNutrition that there is no evidence that yo-yo diet-ing alters body composition or metabolic rates. Heconcedes that the stress involved with repeat diet-ing may contribute to reports of heart disease andpremature death.

August: A National Institutes of Health work-shop on pharmacologic treatment of obesity con-cludes that drugs may be effective in reducing bodyweight over an extended period of time.

November: Centers for Disease Control and Pre-vention (CDC) releases two new studies showingthat adolescents are more overweight and are

exercising less than their counterparts of a decadeago. Cause is probably related to large amount oftelevision watched by teenagers.

December 1: New York Times reports that scien-tists have isolated and cloned a gene that makesmice obese, and they have found a nearly identicalgene in human fat tissue.

December: Tuffs University Diet & Nutrition Letterreports that the National Task Force on the Preven-tion and Treatment of Obesity maintains there is noevidence that such a thing as weight cycling, or yo-yo dieting, exists. Panel members made their state-ment after reviewing three decades of research.

1995February: Economic Research Service (ERS) of theU.S. Department of Agriculture (USDA) issues areport that provides information on the incidence,prevalence and costs of health conditions com-monly associated with poor diets. Diet-relatedhealth conditions cost Americans an estimated$250 billion yearly.

July 21: Research Alert reports that sales of dietaids in 1994 reached $419 million.

December: U.S. Navy introduces a new height-weight chart that replaces an old standard ofunknown origin that placed especially stringent lim-its on women and certain minority groups who aregenetically programmed to add weight as they age.

1996January 2: U.S. Department of Agricultureannounces a new version of the official DietaryGuidelines, which says that meatless diets canmeet the Recommended Dietary Allowances(RDA) for nutrients as long as the variety andamounts of food consumed are adequate.

May 7: Washington Post reports on approval ofnew weight-loss drug, dexfenfluramine, by theFood and Drug Administration, to be marketedunder the name Redux. It works by slowing thedepletion of a brain chemical called serotonin andis recommended only for those patients with abody mass index (BMI) of 30 or higher.

May 28: Scientists from Ligand Pharmaceuticals,Inc., and the Institute Pasteur de Lille report theyhave discovered the DNA sequence responsible forcontrolling the expression of the human obesitygene, also called the leptin gene.

Appendix I 313

October 11: Knoll Pharmaceutical Companyannounces it has received an approval letter from theU.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 totreat bulimia.

1997September 12: Food and Drug Administrationremoves from sale the widely used antiobesitydrugs fenfluramine (Pondimin) and dexfenflu-ramine (Redux) because of more than 100 cases ofheart valve abnormalities attributed to their use.

November 24: Knoll Pharmaceutical Companyannounces it has received clearance from the U.S.Food and Drug Administration to market Meridia(sibutramin) capsules, pending U.S. Drug Enforce-ment Administration scheduling. Meridia will beindicated for the management of obesity, includingweight loss and maintenance of weight loss, whenused in conjunction with a reduced-caloric diet.

1998June 17: The National Heart, Lung, and Blood Insti-tute (NHLBI), in cooperation with the NationalInstitute of Diabetes and Digestive and Kidney Dis-eases (NIDDK), releases the first federal guidelineson the identification, evaluation and treatment ofoverweight and obesity in adults. These clinicalguidelines are designed to help physicians.

September 16: The National Institutes of Health(NIH) Office of Research on Women’s Health holdsa seminar on “Eating Disorders: Fad and Facts,”presenting the latest research on the biological,genetic and psychological factors associated withthese disorders, and discusses treatments.

December 2: The Journal of the American MedicalAssociation publishes research by Dr. KathrynRexrode and colleagues of Harvard Medical Schoolthat reports women with a waist measurement of30 inches or more have twice the risk of coronaryheart disease than their slimmer counterparts.

1999January 6: The Office of Dietary Supplements(ODS) at the National Institutes of Health

announces the launch of its new International Bib-liographic Information on Dietary Supplements(IBIDS) database. IBIDS database consists of pub-lished, international, scientific literature and isavailable to the public free of charge through theODS Internet home page (http://dietary-supple-ments.info.nih.gov).

May 13: The New England Journal of Medicinereports on five deaths of patients undergoing lipo-suction, raising questions about the safety of thecountry’s most popular kind of cosmetic surgery.

July 14: Researchers in Britain and the UnitedStates announce the discovery of the SLC-1 receptor,a key receptor molecule for an appetite-stimulatinghormone, which could herald the development ofnew treatments for obesity and anorexia nervosa.

July 23: The University of Minnesota publishesa study showing that weight and blood pressureare increasing among children between the ages of10 and 14.

August 29: Dr. Jeffrey Koplan, director of theU.S. Centers for Disease Control and Prevention,says in the Dallas Morning News, “We are facing areal epidemic of obesity. All segments of the popu-lation are getting fatter, but the highest increase isamong the younger ages.”

September 29: Artal Luxembourg S. A., a privateEuropean investment firm, acquires WeightWatchers International Inc. for $735 million.

2000January 25: Health and Human Services secretaryDonna E. Shalala and Assistant Secretary forHealth and Surgeon General David Satcher releasethe Healthy People 2010 initiative, a statement ofnational health objectives designed to identify themost significant preventable threats to health andto establish national goals to reduce these threats.Among the objectives to reduce overweight andobesity in the United States are to increase the pro-portion of adults who are at a healthy weight to 60percent by 2010 and reduce the proportion ofadults who are obese to 15 percent by 2010.

January 25: David Satcher, M.D., the U.S. assis-tant secretary for health and surgeon general,announces that overweight and obesity have beennamed to a list of 10 U.S. health priorities calledLeading Health Indicators (LHIs).

314 The Encyclopedia of Obesity and Eating Disorders

July 1: The American Psychiatric Association(APA) publishes a Revised Practice Guideline for Treat-ing Eating Disorders. The original guideline on eatingdisorders was published in 1993.

October 13: A Rand Health study published inthe Archives of Internal Medicine reports that the pro-portion of Americans who suffer from clinicallysevere obesity—defined as those who are 100 ormore pounds overweight—is rising twice as fast asthe proportion of those who are simply obese.

June 5: The LapBand Adjustable Gastric Band-ing System receives FDA approval.

November 15: Weight Watchers International,Inc., announces that it has completed its initialpublic offering of 17.4 million shares of commonstock at a price of $24 per share.

December 13: The U.S. Department of Healthand Human Services releases a report, The SurgeonGeneral’s Call to Action to Prevent and Decrease Over-weight and Obesity, outlining strategies that com-munities can use in helping to address healthproblems resulting from overweight and obesity.Those options include requiring physical educa-tion at all school grades, providing more healthyfood options on school campuses and providingsafe and accessible recreational facilities for resi-dents of all ages.

2002September 17: The Federal Trade Commissionreleases “Report on Weight-Loss Advertising: AnAnalysis of Current Trends.” The report concludesthat false or misleading claims, such as exaggeratedweight loss without diet or exercise, are wide-spread in ads for weight-loss products, and appearto have increased over the last decade.

September 26: A group of scientists and NationalInstitutes of Health staff meet to develop researchpriorities for the treatment of anorexia nervosa.

December 30: The Centers for Disease Controland Prevention reports that obesity climbed from19.8 percent of American adults to 20.9 percentof American adults between 2000 and 2001, anddiagnosed diabetes (including gestational dia-betes) increased from 7.3 percent to 7.9 percentduring the same one-year period. The increaseswere evident regardless of sex, age, race and edu-cational status.

2003December 9: The Federal Trade Commissionannounces its “Red Flag” education campaign toassist media outlets voluntarily to screen outweight-loss product ads containing claims that aretoo good to be true.

2004January 16: The Centers for Disease Control andPrevention announces that in 2000, the total costof obesity was estimated to be $117 billion. Of thisamount, $61 billion was due to direct medical costsand $56 billion to lost productivity.

February 5: The Centers for Disease Control andPrevention announces that Americans are con-suming more calories than they did 30 years ago,and the rate of increase is three times greater inwomen than men.

February 24: The Henry J. Kaiser Family Foun-dation announces that the percentage of childrenages six to 11 who were overweight in 1999 and2000 was more than triple the average from 1963to 1970.

July 15: Health and Human Services secretaryTommy G. Thompson announces that the Centersfor Medicare and Medicaid Services is removinglanguage in Medicare’s coverage manual that statesobesity is not an illness. By doing so, Medicareopens the door to expanded coverage of obesitytreatments such as gastric bypass surgery, but treat-ment first must be shown to improve health.

October 20: Trust for America’s Health releases anew report, F as in Fat: How Obesity Policies Are Fail-ing in America, which says adult obesity exceeds 20percent in 41 states and the District of Columbia,and all states are expected to fail the national goalof reducing the proportion of adults who are obeseto 15 percent or lower by the year 2010.

October 27: The Centers for Disease Controland Prevention releases a report, “Mean BodyWeight, Height, and Body Mass Index (BMI)1960–2002: United States,” which says adult menand women are roughly an inch taller than theywere in 1960, but are nearly 25 pounds heavier onaverage as well.

January 12: Health and Human Services secre-tary Tommy G. Thompson and USDA secretaryAnn M. Veneman release Dietary Guidelines for

Appendix I 315

316 The Encyclopedia of Obesity and Eating Disorders

Americans 2005. The guidelines provide authorita-tive advice about how good dietary habits can pro-mote health and reduce risk for major chronicdiseases in people two years and older. They serveas the basis for federal food and nutrition educa-tion programs. In light of the growing number ofoverweight and obese Americans, a major focus ofthe new guidelines is providing guidance to thepublic on maintaining a healthy weight and creat-ing lifestyles that balance the number of calorieseaten with the number of calories expended.

April 19: Agriculture secretary Mike Johannsunveils MyPyramid, a new symbol and interactivefood guidance system. “Steps to a Healthier You,”MyPyramid, which replaces the Food Guide Pyra-mid introduced in 1992, is part of an overall foodguidance system that emphasizes the need for amore individualized approach to improving dietand lifestyle. In addition to the multicolored bandsrepresenting the different food groups, the newsymbol emphasizes the need for “activity,” which isrepresented by steps and a person climbing them.

Table 1. Physical Manifestations of AnorexiaNervosa and Bulimia

Table 2. DSM-IV Criteria for DiagnosingAnorexia Nervosa, Bulimia Nervosa andBinge-Eating Disorder

Table 3. Possible Medical Complications ofCommonly Used Weight Regulation/Weight-Loss Methods

Table 4. Danger Signals

Table 5. How to Handle theAnorexic/Bulimic Child in the Family

Table 6. Food-Related Behaviors or BehaviorPatterns

Table 7. Body Mass Index Table

APPENDIX IITABLES

317

TABLE 1

PHYSICAL MANIFESTATIONS OF ANOREXIA NERVOSA AND BULIMIA

Manifestation Anorexia Nervosa Bulimia

Endocrine/metabolic Amenorrhea Menstrual irregularitiesOsteoporosisEuthyroid sick syndromeDecreased norepinephrine secretionDecreased somatomedinElevated growth hormoneDecreased or erratic vasopressin secretionAbnormal temperature regulationHypercarotenemia

Cardiovascular Bradycardia Ipecac poisoningHypotensionArrhythmias

Renal Increased blood urea nitrogen Hypokalemia (diuretic induced)Renal calculiEdema

Gastrointestinal Decreased gastric emptying Acute gastric dilation, ruptureConstipation Parotid enlargementElevated hepatic enzymes Dental-enamel erosion

EsophagitisMallory-Weiss tears,esophageal ruptureHypokalemia (laxative induced)

Hematologic AnemiaLeukopeniaThrombocytopenia

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.

318 The Encyclopedia of Obesity and Eating Disorders

TABLE 2

DSM-IV CRITERIA FOR DIAGNOSING ANOREXIA NERVOSA, BULIMIA NERVOSA AND BINGE-EATING DISORDER

Anorexia Nervosa

1. Refusal to maintain normal body weight2. Intense fear of gaining weight or becoming fat3. Disturbance of body image4. Amenorrhea in menstruating females

Specific type:Restricting Type: Has not regularly engaged in binge-eating or purging behaviorBinge-Eating/Purging Type: Has regularly engaged in binge-eating or purging behavior

Bulimia Nervosa

1. Recurrent episodes of binge eating2. Repeated attempts to prevent weight gain through self-induced vomiting; laxative, diuretic or medication mis-use; or excessive exercise3. Both of the above occur at least twice a week for three months4. Poor self-image due to body shape and weight5. Disturbance does not occur only during episodes of anorexia

Specific type:Purging Type: Has regularly engaged in self-induced vomiting or laxative/diuretic abuseNonpurging Type: Fasts or does excessive exercise to lose weight, but has not regularly engaged in self-inducedvomiting or abuse of laxatives, diuretics or enemas

Binge-Eating Disorder

1. Recurrent episodes of binge eating2. At least three of the following:

a. eating much more rapidly than normalb. eating until feeling uncomfortably fullc. eating large amounts of food when not hungryd. eating alone because of embarrassment of how much being eatene. feeling disgusted, depressed or very guilty after overeating

3. Marked distress over binge eating4. Binge eating occurs on average at least two days a week for six months5. 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.

Appendix II 319

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 cavitiesTears in esophagusChronic esophagitisChronic sore throatDifficulty swallowingStomach crampsDigestive problemsAnemiaElectrolyte imbalance

Diuretic Abuse

Hypokalemia (low potassium): fatigue; diminished reflexes; if severe, possible cardiac arrhythmia; if chronic,serious kidney damageFluid loss: dehydration, lightheadedness, thirst

Laxative Abuse

Nonspecific abdominal complaints, cramping, constipationSluggish 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.

320 The Encyclopedia of Obesity and Eating Disorders

TABLE 4

DANGER SIGNALS

Eating disorders may be prevented or more readily treated if they are detected early. A person who has several ofthe 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 move-

ments 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.

Appendix II 321

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 ifnecessary. Your involvement with the child’s eating is her tool for manipulating parents. Take this tool out of herhands.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 itpossible 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 illnessand destroy the family. The anorexic must be made aware by your actions and attitudes that she is important toyou, but no more important than every other member of the family. Do not commiserate; this only confirms thechild 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 becomesobvious that her continued presence is undermining the emotional health of the family. The final separation isdeath; 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 areflection of your esteem for her. Do not ask questions such as, “How are you feeling,” or “How is your sociallife?” 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, allideals are just that . . . only ideals. In practice we fall short, too; our own behavior is adulterated with self-servingrewards.3. Do everything to encourage her initiative, independence and autonomy. Be aware though, that anorexics tendto be perfectionists, so that they are never satisfied with themselves. Perfectionism justifies their dissatisfactionwith themselves.4. Be aware of the long-term nature of the illness. Anorexics do get better; many get completely well, very fewdie. But families must face months and sometimes years of treatment and anxiety. There are no counselors or psy-chiatrists with the same answer to every case. A support group such as a parents self-help group may make a sig-nificant 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.

322 The Encyclopedia of Obesity and Eating Disorders

TABLE 6

FOOD-RELATED BEHAVIORS OR BEHAVIOR PATTERNS

The following guidelines were published in BASH Magazine, April 1989, for identifying and monitoring the eatinghabits 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 makeit 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, arerestricted.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. Normal to large bites of food.2. May mix foods together.3. Eats rapidly with shortened chewing time before swallowing.4. Prefers large containers of food.5. Dislikes being responsible for food waste and will overeat or hoard food for an isolated binge experience.6. Vomits to control food absorption by inducing vomiting, spontaneous rumination or regurgitation.

Source: BASH Magazine, April 1989.

Appendix II 323

BODY MASS INDEX (BMI) TABLE

BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

Height Weight (in pounds)

4’10” (58”) 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 1674’11” (59”) 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 1735’ (60”) 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 1795’1” (61”) 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 1855’2” (62”) 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 1915’3” (63”) 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 1975’4” (64”) 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 2045’5” (65”) 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 2105’6” (66”) 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 2165’7” (67”) 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 2235’8” (68”) 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 2305’9” (69”) 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 2365’10” (70”) 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 2435’11” (71”) 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 2506’ (72”) 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 2586’1” (73”) 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 2656’2’ (74”) 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 2726’3’ (75”) 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279

Source: Evidence Report of Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity inAdults, 1998. NIH/National Heart, Lung, and Blood Institute (NHLBI).

324 The Encyclopedia of Obesity and Eating Disorders

Academy for Eating Disorders60 Revere DriveSuite 500Northbrook, IL 60062-1577(847) 498-4274(847) 480-9282 (fax)http://www.aedweb.orginfo@aedweb.org

Active Living by Design400 Market StreetSuite 205Chapel Hill, NC 27516(919) 843-ALBD(919) 843-3083 (fax)http://www.activelivingbydesign.orginfo@active1ivingbydesign.org

American Anorexia and Bulimia Association ofPhiladelphia

P.O. Box 1287Langhorne, PA 19047(215) 221-1864(215) 702-8944 (fax)http://www.aabaphila.org

American Board of Medical Specialties1007 Church StreetSuite 404Evanston, IL 60201-5913(866) ASK-ABMS(847) 491-9091(847) 328-3596 (fax)http://www.abms.org

American Dietetic Association Headquarters120 South Riverside PlazaSuite 2000Chicago, IL 60606(800) 877-1600

(312) 899-0040http://www.eatright.org

American Obesity Association1250 24th Street NWSuite 300Washington, DC 20037(202) 776-7711(202) 776-7712 (fax)http://www.obesity.orgpr@obesity.org

American Psychiatric Association1000 Wilson BoulevardArlington, VA 22209-3901(202) 682-6000http://www.psych.orgapa@psych.org

American Society for Bariatric Surgery100 Southwest 75th StreetSuite 201Gainesville, FL 32607(352) 331-4900(352) 331-4975 (fax)http://www.asbs.orginfo@asbs.org

American Society of Bariatric Physicians2821 South Parker RoadSuite 625Aurora, CO 80014-2735(303) 770-2526(303) 779-4834 (fax)http://www.asbp.orginfo@asbp.org

American Society of Plastic Surgeons444 East Algonquin RoadArlington Heights, IL 60005(847) 228-9900

APPENDIX IIISOURCES OF INFORMATION

325

http://www.plasticsurgery.orgmedia@plasticsurgery.org

Anorexia Nervosa and Related EatingDisorders, Inc. (ANRED)

(affiliated with National Eating Disorders Association)http://www.anred.com

Center for Science in the Public Interest1875 Connecticut Avenue NWSuite 300Washington, DC 20009(202) 332-9110(202) 265-4954 (fax)http://www.cspinet.orgcspi@cspinet.org

Council on Size and Weight Discrimination, Inc.P.O. Box 305Mt. Marion, NY 12456(845) 679-1209(845) 679-1206 (fax)http://www.cswd.orginfo@cswd.org

Eating Disorders Anonymous (EDA)780 West Hackberry DriveChandler, AZ 85248http://www.eatingdisordersanonymous.orginfo@eatingdisordersanonymous.org

Eating Organization of New Jersey721 Executive DrivePrinceton, NJ 08540(800) 522-2230(609) 252-0202(609) 252-0184 (fax)

HEED (Helping End Eating Disorders)Foundation

205 South Service RoadPlainview, NY 11803(516) 694-1054http://www.heedfoundation.orginfo@heedfoundation.org

Human Ecology Action League, Inc. (HEAL)P.O. Box 29629Atlanta, GA 30359-0629(404) 248-1898(404) 248-0162 (fax)

http://members.aol.com/HEALNatnlHEALNatnl@aol.com

International Size Acceptance AssociationP.O. Box 82126Austin, TX 78758(512) 371-4307http://www.size-acceptance.orgdirector@size-acceptance.org

Massachusetts Eating Disorder Association92 Pearl StreetNewton, MA 02458(609) 252-0202http://www.medainc.org

National Association to Advance FatAcceptance (NAAFA)

P.O. Box 22510Oakland, CA 94609http://naafa.orgmembership@naafa.org

National Eating Disorders Association603 Stewart StreetSuite 803Seattle, WA 98101(206) 382-3587(206) 829-8501 (fax)http://www.NationalEatingDisorders.orginfo@NationalEatingDisorders.org

National Eating Disorders Association–LongIsland

(formerly Eating Disorder Council of Long Island)50 Charles Lindbergh BoulevardSuite 400Uniondale, NY 11553(718) 962-2778

National Institute of Mental Health (NIMH)Information Resources and Inquiries Branch5600 Fishers LaneRoom 7C-02Rockville, MD 20857FACTS ON DEMAND: (301) 443-5158http://www.nimh.nih.gov

Overeaters Anonymous (OA)P.O. Box 44020Rio Rancho, NM 87174-4020(505) 891-2664

326 The Encyclopedia of Obesity and Eating Disorders

(505) 891-4320 (fax)http://www.oa.orginfo@oa.org

TOPS (Take Off Pounds Sensibly) Club4575 South Fifth StreetP.O. Box 070360Milwaukee, WI 53207-0360(414) 482-4620http://www.tops.org

Weight Watchers International, Inc.175 Crossways Park WestWoodbury, NY 11797-2055(800) 651-6000(516) 390-1400(516) 390-1334 (fax)http://www.weightwatchers.com

Appendix III 327

ARIZONA

Mirasol7650 East BroadwaySuite 303Tucson, AZ 85710-3773(888) 520-1700information@mirasol.nethttp://www.mirasol.net

Remuda RanchOne East Apache StreetWickenburg, AZ 85390(800) 455-1900(928) 684-3913http://www.remudaranch.cominfo@remudaranch.com

Rosewood Ranch: Women’s Center for EatingDisorders

36075 South Rincon RoadWickenburg, AZ 85390(800) 845-2211(928) 684-9594http://www.rosewoodranch.cominfo@rosewoodranch.com

CALIFORNIA

Center for Eating and Weight Disorders at SanDiego State University

6495 Alvarado RoadSuite 200San Diego, CA 92120(619) 594-3254

Eating Disorder Center of California27162 Sea Vista DriveMalibu, CA 90265(facility located in Brentwood, CA)(310) 457-9958

http://www.edcca.cominfo@edcca.com

Healthy Within, Inc.5665 Oberlin DriveSuite 206San Diego, CA 92121(858) 622-0221http://www.healthywithin.com

Oak Knoll Family Therapy Center12307 Oak Knoll RoadSuite OPoway, CA 92064(858) 748-4323http://www.oakknollftc.com

Rader Eating Disorder Treatment ProgramsPacific Shores Hospital2130 North Ventura RoadOxnard, CA 93036(800) 841-1515http://www.raderprograms.comrader@raderprograms.com

COLORADO

Eating Disorder Center of Denver950 South Cherry StreetSuite 300Denver, CO 80246(866) 771-0861 (toll-free)(303) 771-0861http://www.edcdenver.cominfo@edcdenver.com

CONNECTICUT

Wilkens Center7 Riversville RoadGreenwich, CT 06831

APPENDIX IVOBESITY AND EATING DISORDER

TREATMENT CENTERS

328

(203) 531-1909http://www.wilkinscenter.com

Yale Center for Eating and Weight Disorders405 Temple StreetP.O. Box 208205New Haven, CT 06520-8205(203) 432-4610http://www.yale.edu/ycewdycewd@yale.edu

FLORIDA

Eating Disorders Treatment Specialists of MiamiMiami location:7325 Southwest 63rd AvenueSuite 101South Miami, FL 33143(305) 284-1143Palm Beach location:600 Sandtree DriveSuite 203-CPalm Beach Gardens, FL 33403(561) 626-8070http://www.ereassoc.comereassoc@aol.com

Family Behavioral Center5850 West Atlantic AvenueSuite 101Delray Beach, FL 33484(888) 870-8484(561) 637-2592http://www.familybehavioralcenter.com

The Renfrew Center of South Florida7700 Renfrew LaneCoconut Creek, FL 33073(800) RENFREW(954) 698-9222http://www.renfrewcenter.com

The Willough at Naples9001 Tamiami Trail EastNaples, FL 34113(800) 722-0100http://thewilloughatnaples.cominfo@thewilloughatnaples.com

ILLINOIS

Weight and Eating Disorders Program atNorthwestern University

Feinberg School of Medicine303 East Chicago AvenueChicago, IL 60611-3008(312) 695-2269http://www.eatingdisorders.northwestern.edu

MINNESOTA

University of Minnesota Eating DisordersResearch Program

Department of Psychiatry606 24th Avenue SouthSuite 602Minneapolis, MN 55454http://www.tc.umn.edu/~crowx002/progeds.html

MISSOURI

Castlewood Treatment Center800 Holland RoadSt. Louis, MO 63021(888) 822-8938http://www.castlewoodtc.cominfo@castlewoodtc.com

NEBRASKA

Eating Disorders Program at Children’sHospital

8200 Dodge StreetOmaha, NE 68114(800) 642-8822(402) 955-6190http://www.chsomaha.org

NEW JERSEY

The Rutgers Eating Disorders ClinicRutgers, The State University of New Jersey41 Gordon RoadSuite CPiscataway, NJ 08854-5972(732) 445-2292http://gsappweb.rutgers.edu/EDC

NEW YORK

Adolescent Eating Disorders ProgramGolisano Children’s Hospital at StrongAdolescent Medicine

Appendix IV 329

601 Elmwood Avenue, Box 690Rochester, NY 14642(585) 275-2964http://www.stronghealth.com/services/childrens/

PatientCare/eatingdisordersprogram.cfm

Avalon Eating Disorder Center346 Harris Hill RoadWilliamsville, NY 14221(866) 814-0999 (toll-free)(716) 839-0999http://www.avalon-eatingdisorders.com

Eating Disorders Clinic(New York State Psychiatric Institute and Columbia

University Medical Center)1051 Riverside DriveUnit 98New York, NY 10032(212) 543-5739http://www.columbia.edu/~ea12EDRU@pi.cpmc.columbia.edu

The Renfrew Center of New York11 East 36th StreetNew York, NY 10016(800) RENFREWhttp://www.renfrewcenter.com

NORTH CAROLINA

Duke Diet and Fitness Center804 West Trinity AvenueDurham, NC 27701(800) 235-3853http://www.dukedietcenter.orgdfcinfo@dukedietcenter.org

OKLAHOMA

Rader Eating Disorder Treatment ProgramsBrookhaven Hospital201 South GarnettTulsa, OK 74128-1800(800) 841-1515rader@raderprograms.comhttp://www.raderprograms.com

PENNSYLVANIA

The Renfrew Center of Philadelphia475 Spring Lane

Philadelphia, PA 19128(800) RENFREWhttp://www.renfrewcenter.com

Weight and Eating Disorders Program at theUniversity of Pennsylvania

Department of Psychiatry3535 Market StreetSuite 3108Philadelphia, PA 19104(215) 898-7314http://www.med.upenn.edu/weightweight@uphsnet.med.upenn.edu

Western Psychiatric Institute and Clinic(University of Pittsburgh Medical Center)3811 O’Hara StreetPittsburgh, PA 15213(412) 624-5420http://wpic.upmc.com/EatingDisorderSvcs.htm

RHODE ISLAND

Lifespan Weight Management Programs atMiriam Hospital Center

164 Summit AvenueProvidence, RI 02906(401) 444-4800http://www.lifespan.org/Services/BMed/Wt_loss/

about.htm

SOUTH CAROLINA

Medical University of South Carolina WeightManagement Center

IOP South67 President StreetSuite 410Charleston, SC 29425(800) 553-7489(843) 792-2273http://www.muschealth.com/weight

TEXAS

The Menninger Clinic Eating DisordersPrograms

2801 Gessner DriveP.O. Box 809045Houston, TX 77280-9045(713) 275-5000

330 The Encyclopedia of Obesity and Eating Disorders

(800) 351-9058http://www.menningerclinic.com/p-eatingdisorders

Shades of Hope402-A Mulberry StreetP.O. Box 639Buffalo Gap, TX 79508(800) 588-HOPE(325) 572-3843(325) 572-3405 (fax)http://www.shadesofhope.cominfo@shadesofhope.com

UTAH

Avalon Hills7852 West 600 NorthPetersboro, UT 84325(800) 330-0490(435) 753-3686http://www.avalonhills.orginfo@avalonhills.org

Center for Change1790 North State StreetOrem, UT 84057(888) 224-8250(801) 224-8255http://www.centerforchange.cominfo@centerforchange.com

VERMONT

Green Mountain at Fox RunFox Lane, Box 164Ludlow, VT 05149(800) 448-8106(802) 228-8885http://www.fitwoman.cominfo@fitwoman.com

WASHINGTON

The Center for Counseling and HealthResources, Inc.

P.O. Box 700547 DaytonEdmonds, WA 98020(888) 771-5166(425) 771-5166http://www.aplaceofhope.com

WEIGHT REDUCTION CAMPS

CALIFORNIA

Western Wellspring Adventure CampAcademy of the Sierras42675 Road 44Reedley, CA 93654(866) 364-0808 (toll-free)(559) 638-4570http://www.westernadventurecamp.comadmissions@wellspringcamps.com

MASSACHUSETTS

Camp KingsmontHampshire College893 West StreetAmherst, MA 01002Winter address:Camp Kingsmont195 Main StreetGreat Barrington, MA 01230(800) 854-1377(413) 528-8474http://www.campkingsmont.com

NEW YORK

Camp ShaneSeptember 10–June 5:134 Teatown RoadCroton on Hudson, NY 10520(914) 271-4141June 6–September 9:302 Harris RoadFerndale, NY 12734(845) 292-4644http://www.campshane.comoffice@campshane.com

Wellspring CampsHealthy Living Academies17777 Center Court DriveSuite 300Cerritos, CA 90703(866) 364-0808 (toll-free)(562) 467-5578 (fax)http://www.wellspringcamps.comadmissions@wellspringcamps.com

Appendix IV 331

NORTH CAROLINA

Wellspring Adventure CampHealthy Living Academies17777 Center Court DriveSuite 300Cerritos, CA 90703(866) 364-0808 (toll-free)(562) 467-5578 (fax)http://www.wellspringadventurecamp.comadmissions@wellspringcamps.com

PENNSYLVANIA

Camp PennbrookP.O. Box 100Pennsburg, PA 18073(800) 442-7366Winter address:P.O. Box 5Leonia, NJ 07605-0005(212) 354-CAMPhttp://www.camppennbrook.cominfo@camppennbrook.com

332 The Encyclopedia of Obesity and Eating Disorders

Food technologists are investigating a wide rangeof ingredients and processes to replace fat in foodsand beverages. The following is a list of fat replac-ers currently in use or which have research effortsin place to develop them.

PROTEIN-BASED FAT REPLACERS

Microparticulated Protein (Simplesse)Reduced-calorie (1–2 calorie/gram) ingredientmade from whey protein or milk and egg protein.Digested as a protein. Many applications, includingdairy products (e.g., ice cream, butter, sour cream,cheese, yogurt), salad dressing, margarine- andmayonnaise-type products, as well as baked goods,coffee creamer, soups and sauces.

Modified Whey Protein Concentrate(Dairy-Lo)Controlled thermal denaturation results in a func-tional protein with fat-like properties. Applicationsinclude milk/dairy products (cheese, yogurt, sourcream, ice cream), baked goods, frostings, as wellas salad dressing and mayonnaise-type products.

Other (K-Blazer, ULTRA-BAKE, ULTRA-FREEZE, Lita)One example is a reduced-calorie fat substitutebased on egg white and milk proteins. Similar tomicroparticulated protein but made by a differentprocess. Another example is a reduced-calorie fatreplacer derived from a com protein. Some blendsof protein and carbohydrate can be used in frozendesserts and baked goods.

CARBOHYDRATE-BASED FAT REPLACERS

Cellulose (Avicel cellulose gel, Methocel,Solka-Floc)

Various forms are used. One is a noncaloric puri-fied form of cellulose ground to microparticles,which when dispersed, form a network of particleswith mouthfeel and flow properties similar to fat.Cellulose can replace some or all of the fat indairy-type products, sauces, frozen desserts andsalad dressings.

Dextrins (Amylum, N-Oil)Four calorie/gram fat replacers that can replace allor some of the fat in a variety of products. Foodsources for dextrins include tapioca. Applicationsinclude salad dressings, puddings, spreads, dairy-type products and frozen desserts.

Fiber (Opta, Oat Fiber, Snowite, Ultracel, Z-Trim)Fiber can provide structural integrity, volume,moisture-holding capacity, adhesiveness and shelfstability in reduced-fat products. Applicationsinclude baked goods, meats, spreads and extrudedproducts.

Gums (KELCOGEL, KELTROL, Slendid)Also called hydrophilic colloids or hydrocolloids.Examples include guar gum, gum arabic, locustbean gum, xanthan gum, carrageenan and pectin.Virtually noncaloric, provide thickening, some-times gelling effect; can promote creamy texture.Used in reduced-calorie, fat-free salad dressingsand to reduce fat content in other formulatedfoods, including desserts and processed meats.

Inulin (Raftiline, Fruitafit, Fibruline)Reduced-calorie (1–1.2 calorie/gram) fat and sugarreplacer, fiber and bulking agent extracted fromchicory root. Used in yogurt, cheese, frozendesserts, baked goods, icings, fillings, whippedcream, dairy products, fiber supplements andprocessed meats.

APPENDIX VGLOSSARY OF FAT REPLACERS

333

Maltodextrins (CrystaLean, Lorelite,Lycadex, MALTRIN, Paselli D-LITE, PaselliEXCEL, Paselli SA2, STAR-DRI)Four calorie/gram gel or powder derived fromcarbohydrate sources such as com, potato, wheatand tapioca. Used as fat replacer, texture modi-fier or bulking agent. Applications includebaked goods, dairy products, salad dressings,spreads, sauces, frostings, fillings, processedmeat, frozen desserts, extruded products andbeverages.

Nu-TrimA beta-glucan-rich fat replacer made from oat andbarley using an extraction process that removescoarse fiber components. The resulting product canbe used in foods and beverages such as bakedgoods, milk, cheese and ice cream, yielding prod-ucts that are both reduced in fat and high in beta-glucan. (The soluble fiber beta-glucan has beencited as the primary component in oats and barleythat is responsible for beneficial reduction in car-diovascular risk factors.)

Oatrim—Hydrolyzed Oat Flour (Beta-Trim,Trim-Choice)A water-soluble form of enzyme-treated oat flourcontaining beta-glucan soluble fiber and used as afat replacer, bodying and texturizing ingredients.Reduced calorie (1–4 calories/gram) as used inbaked goods, fillings and frostings, frozen desserts,dairy beverages, cheese, salad dressings, processedmeats and confections.

Polydextrose (Litesse, Sta-Lite)Reduced-calorie (1 calorie/gram) fat replacer andbulking agent. Water-soluble polymer of dextrosecontaining minor amounts of sorbitol and citricacid. Approved for use in a variety of productsincluding baked goods, chewing gums, confections,salad dressings, frozen dairy desserts, gelatins andpuddings.

Polyols (Many Brands Available)A group of sweeteners that provide the bulk ofsugar, without as many calories as sugar (1.6–3.0calories per gram, depending on the polyol). Due

to their plasticizing and humectant properties,polyols also may be used to replace the bulk of fatin 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) fatreplacers, bodying agents, texture modifiers. Canbe derived from potato, corn, oat, rice, wheat ortapioca starches. Can be used together with emul-sifiers, proteins, gums and other modified foodstarches. Applications include processed meats,salad dressings, baked goods, fillings and frost-ings, sauces, condiments, frozen desserts anddairy products.

Z-TrimA calorie-free fat replacer made from insoluble fiberfrom oat, soybean, pea and rice hulls or corn or wheatbran. 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- anddiglyceride emulsifiers, which can with waterreplace all or part of the shortening content incake mixes, cookies, icings, and numerous veg-etable dairy products. Same caloric value as fat (9calories/gram) but less is used, resulting in fat andcalorie reduction. Sucrose fatty acid esters alsocan be used for emulsification in products such asthose listed above. Additionally, emulsion systemsusing soybean oil or milk fat can significantlyreduce fat and calories by replacing fat on a one-to-one basis.

Salatrim (Benefat)Short- and long-chain acid triglyceride molecules.A 5 calorie/gram family of fats that can be adaptedfor use in confections, baked goods, dairy andother applications.

334 The Encyclopedia of Obesity and Eating Disorders

* Appears as cornstarch on the ingredient statement, others appear as food starch modified

Lipid (Fat/Oil) Analogs

Esterified Propoxylated Glycerol (EPG)**Reduced-calorie fat replacer. May partially or fullyreplace fats and oils in all typical consumer andcommercial applications, including formulatedproducts, baking and frying.

Olestra (Olean)Calorie-free ingredient made from sucrose and edi-ble fats and oils. Not metabolized and unabsorbedby the body. Approved by the FDA for use inreplacing the fat used to make salty snacks andcrackers. Stable under high-heat food applicationssuch as frying. Has the potential for numerousother food applications.

Sorbestrin**Low-calorie, heat-stable, liquid fat substitute com-posed of fatty acid esters of sorbitol and sorbitolanhydrides. Has approximately 1.5 calories/gramand is suitable for use in all vegetable oil applica-tions including fried foods, salad dressing, mayon-naise and baked goods.

NOTE: Brand names are shown in parentheses asexamples.

Copyright © 2000 Calorie Control Council, 5775Peachtree-Dunwoody Rd., Suite 500, Atlanta, GA30342; telephone: (404) 252-3663; e-mail: ccc@assnhq.com; Internet: www.caloriecontrol.org.

Appendix V 335

** May require FDA approval

Amplestuffhttp://www.amplestuff.com

Offers products for men and women who are plus orsupersize. Some products are plus-sized versions ofitems that are readily available to average-sized peo-ple, such as fanny packs, socks or hospital gowns.Other products—such as airline seatbelt extendersand size-positive books and videos—are designedespecially for larger people.

Eating Disorder Referral and InformationCenter

http://www.edreferral.com

Provides information and treatment resources for allforms of eating disorders.

Eating Disorders—Find Eating DisorderTreatment

http://www.eating-disorder.com

Find a treatment center by patients’ condition, bytype of facility or by state.

Eating Disorders Onlinehttp://eatingdisordersonline.com

Information about eating disorders, anorexia,bulimia, binge-eating disorder, compulsive overeat-ing and overexercising. Also offers a list of treatmentoptions around the world, current news, informationon recovery and a forum for online support.

Eating Disorders Resourceshttp://edr.org.uk

Formerly Lucy Serpell’s Eating Disorders Resources(since 1994), a clearinghouse for eating disordersnews, research, reports, conferences and opinions.

Food and Nutrition Information Center at theNational Agricultural Library

http://www.nal.usda.gov/fnic

Provides a directory to credible, accurate and practi-cal food and human nutrition information resourcesfor consumers, nutrition and health professionals,educators and government personnel.

HealthyPlace.com Eating Disorders Centerhttp://www.concernedcounseling.com/Communi-

ties/Eating_Disorders/index.asp

Provides comprehensive information on eating disor-ders from both patient and expert points of view.Offers active chat rooms, hosted support groups,educational information and professional resourcessuch as the online Eating Attitudes Test (EAT-26).

InteliHealthhttp://www.intelihealth.com

In 2000, Harvard Medical School became the con-tent partner for this site, which provides medicalnews, research, disease information, discussionboards, a drug resource center, medical dictionaryand section for weight management.

Mayo Clinichttp://www.mayoclinic.com/invoke.cfm?id=DS00314

Provides articles on obesity and weight loss, as wellas a BMI calculator and daily calorie calculator.

National Institutes of Health (NIH)http://www.nih.gov

Provides health information, grants and fundingopportunities, research training and scientificresources, and an NIH search engine.

New York Online Access to Health (NOAH)http://www.noah-health.org/en/mental/disorders/

eating

Provides in-depth information on anorexia nervosa,binge-eating, bulimia nervosa, compulsive eating,night eating syndrome and pica.

APPENDIX VIWEB SITES OF INTEREST

336

Obesity Helphttp://www.obesityhelp.com

Dedicated to the education, empowerment and sup-port of all individuals affected by obesity, along withothers (friends, employers, physicians) concerned.Their stated goal is to defeat ignorance, isolation anddiscrimination against the clinical disease of obesity.

PubMedhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi

A service of the National Library of Medicine,PubMed includes more than 15 million citations forbiomedical articles back to the 1950s. These citationsare from the MEDLINE database and life sciencejournals. PubMed includes links to many sites pro-viding full text articles and other related resources.

Shape Up America!http://www.shapeup.org

A national nonprofit initiative to promote healthyweight and increased physical activity in America.

SuperSizeWorldhttp://www.supersizeworld.com

Sells products for plus-sized people, such as high-capacity scales, huge towels, toenail clippers,XXXXXL life jackets, airline seat belt extenders andbig bicycle seats.

USDA/ARS Children’s Nutrition ResearchCenter

http://www.kidsnutrition.org

A cooperative venture between Baylor College ofMedicine, Texas Children’s Hospital and the U.S.Department of Agriculture/Agricultural Research

Service (USDA/ARS), offering a nutrition newsletter,weight management brochures, interactive nutritioncalculators and research articles.

The Weight-control Information Networkhttp://win.niddk.nih.gov/index.htm

Provides the general public, health professionals, themedia and Congress with up-to-date, science-basedinformation on weight control, obesity, physicalactivity and related nutritional issues.

ONLINE DIET CENTERSThe following Internet weight loss programs weredesigned by registered dietitians and are recom-mended by such groups as the American MedicalAssociation:

http://www.cyberdiet.com

Owned by dietwatch.com, features very similar con-tent and services.

http://www.dietwatch.com

Comprehensive site with meal plans, shopping lists,“meditation room” and message boards.

http://www.ediets.com

Focuses on individualized eating plans, with a recipeclub, shopping lists and chef.

http://www.fitday.com

Focus on food and activity tracking tools.

http://www.shapeup.org

Not-for-profit site has meal plans and nutritioninformation and facts.

Appendix VI 337

Big as Life: Obesity in America(DVD-R or VHS, 51 minutes, 2002)

Investigates the causes and health implications ofobesity in America while seeking to destigmatize adi-posity. Interviews with doctors, scientists, adults andchildren shed light on issues including size accept-ance, body image bias, and weight discriminationwhile considering health risks, genetic influencesand surgical interventions.

Cambridge Educational2572 Brunswick PikeLawrenceville, NJ 08648(800) 468-4227

Body Image for Boys(DVD-R or VHS, 18 minutes, 2002)

Discussion by experts are interspersed with clips ofyoung patients grappling with problems such assteroid abuse, eating disorders, exercise addictionand phony food supplements.

Films for the Humanities and SciencesP.O. Box 2053Princeton, NJ 08543(800) 257-5126

Body Image: Let’s Get Real(DVD-R or VHS, 48 minutes, 2000)

Explores the unhealthy impact of media, peer pres-sure and family opinions on adolescents’ perceptionsof their bodies. Individual testimony on mediastereotyping, eating disorders, self-esteem, balancednutrition and sexuality.

Films for the Humanities and SciencesP.O. Box 2053Princeton, NJ 08543(800) 257-5126

Childhood Obesity: Reversing the Trend(DVD-R or VHS, 29 minutes, 2003)

Presents two hospital-based programs that are helpingchildren lose weight and keep the pounds off by settingrealistic goals based on good health, not appearance.Patients talk about what it is like, from a child’s point ofview, to be overweight. From The Doctor Is In series.

Cambridge Educational2572 Brunswick PikeLawrenceville, NJ 08648(800) 468-4227

Eating Disorders: The Inner Voice(DVD-R or VHS, 30 minutes, 2000)

Four young women and men from a variety of eth-nic backgrounds share their stories of the physicalpain and emotional torment caused by eating disor-ders. Medical, psychological and nutritional expertsexplain the causes, risks and treatment options.

Cambridge Educational2572 Brunswick PikeLawrenceville, NJ 08648(800) 468-4227

Fad Diets: The Weight Loss Merry-Go-Round(DVD-R or VHS, 16 minutes, 1997)

With the help of nutrition experts, clarifies the dan-gers and frustrations of fad diets and diet pills whileshowing how healthy eating habits can lead toreaching and maintaining an ideal weight for life.

Films for the Humanities and SciencesP.O. Box 2053Princeton, NJ 08543(800) 257-5126

Fat Like Me: How to Win the Weight War(DVD-R or VHS, 43 minutes, 2003)

APPENDIX VIIAUDIOVISUAL MATERIALS

338

Nutritionists, psychologists, pediatricians and otherexperts explore the causes of obesity, the physicaland emotional damage it can do and how parentsand schools can team up to help kids improve theirhealth.

Cambridge Educational2572 Brunswick PikeLawrenceville, NJ 08648(800) 468-4227

Food Fight: Childhood Obesity and the FoodIndustry

(DVD-R or VHS, 23 minutes, 2003)

In this ABC News program, John Donovan examinesthe food industry’s marketing strategies to see if andto what extent they are responsible for America’sepidemic of childhood obesity.

Cambridge Educational2572 Brunswick PikeLawrenceville, NJ 08648(800) 468-4227

Hungry Hearts: Recognizing and Preventing EatingDisorders

(VHS, 30 minutes, 2003)

Teens present the truth about eating disorders, defin-ing them and outlining their consequences andwarning signs.

Aquarius Health Care Videos18 North Main StreetSherborn, MA 01770(888) 440-2963

It’s Not about the Food: Preventing Eating Disorders(VHS, 30 minutes, 2003)

Helps adults understand the nature of eating disordersamong young people so they can reach out to themearly, before the misuse of food spirals out of control.

Aquarius Health Care Videos18 North Main StreetSherborn, MA 01770(888) 440-2963

Managing Your Weight(DVD-R or VHS, 29 minutes, 1998)

Examines the role of exercise, dieting and otherweight control strategies in attaining optimal health

while skewering fad diets and risky or useless prod-ucts that undermine healthy weight management.Young adults explore the dynamics of body imageand the issues involved in eating disorders.

Cambridge Educational2572 Brunswick PikeLawrenceville, NJ 08648(800) 468-4227

Morbid Obesity: A Probable Cure?(DVD-R or VHS, 48 minutes)

Three people seek answers about gastric bypass sur-gery. Medical professionals explain the physiology ofobesity and argue the effectiveness of the procedure,and weight-loss surgery advocates analyze the socialstigmas against obese people.

Films for the Humanities and SciencesP.O. Box 2053Princeton, NJ 08543(800) 257-5126

Overcoming Eating Disorders(DVD-R or VHS, 22 minutes, 2000)

Highlights how eating disorders are not just about foodbut also about struggling with loss of emotional control.

Aquarius Health Care Videos18 North Main StreetSherborn, MA 01770(888) 440-2963.

Treating Obesity(DVD-R or VHS, 28 minutes, 2003)

Three case studies illustrate a spectrum of treatmentapproaches for obesity: medical-center-based plansemphasizing exercise, education, portion control andpeer support; medicines that suppress the appetiteand promote weight loss; and bariatric surgery. FromThe Doctor Is In series.

Films for the Humanities and SciencesP.O. Box 2053Princeton, NJ 08543(800) 257-5126

Understanding Fat(DVD-R or VHS, 48 minutes, 2002)

Explores what fat is and how the human body isengineered to use it. Nutritionists and health experts

Appendix VII 339

discuss the overriding physiological reasons whydiets fail. Obesity researchers explain the geneticbasis for normal and abnormal body weight, andsurgeons illustrate the life-saving potential of gastricbypass surgery for the morbidly obese.

Cambridge Educational2572 Brunswick PikeLawrenceville, NJ 08648(800) 468-4227

Voices of Recovery(VHS, 20 minutes, 2003)

Insights from individuals who have recovered fromeating disorders are interspersed with explanationsby experts, with discussion questions to be used bygroups of individuals who need guidance. Includes afacilitator’s guide with reproducible handouts.

Gurze BooksP.O. Box 2238Carlsbad, CA 92018(800) 756-7533

Weight Control: A Sane Approach(DVD-R or VHS, 52 minutes, 2000)

Host Kat Carney describes her personal quest to loseweight and maintain a healthier lifestyle. Doctorsand dietitians explain what fat is and which typesare good and bad, demonstrate how to determinebody fat percentage, evaluate the four major types ofdiets and discuss the risks of excess fat.

Films for the Humanities and SciencesP.O. Box 2053Princeton, NJ 08543(800) 257-5126

340 The Encyclopedia of Obesity and Eating Disorders

ARTICLES IN JOURNALS

EATING DISORDERS

Becker, A. E., et al. “Ethnicity and DifferentialAccess to Care for Eating Disorder Symptoms.”International Journal of Eating Disorders 33, no. 2(March 2003): 205–212.

Brehm, Bonnie J., and John J. Steffen. “RelationBetween Obligatory Exercise and Eating Disor-ders.” American Journal of Health Behavior 22, no.2 (March–April 1998): 108–119.

Brody, M. L., R. M. Masheb, and C. M. Grilo.“Treatment Preferences of Patients with BingeEating Disorder.” International Journal of EatingDisorders 37, no. 4 (May 2005): 352–356.

Butryn, M. L., and T. A. Wadden. “Treatment ofOverweight in Children and Adolescents: DoesDieting Increase the Risk of Eating Disorders?”International Journal of Eating Disorders 37, no. 4(May 2005): 285–293.

Cachelin, F. M., et al. “Barriers to Treatment forEating Disorders among Ethnically DiverseWomen.” International Journal of Eating Disorders30, no. 3 (November 2001): 269–278.

Cartwright, M. M. “Eating Disorder Emergencies:Understanding the Medical Complexities of theHospitalized Eating Disordered Patient.” CriticalCare Nursing Clinics of North America 16, no. 4(December 2004): 515–530.

Cororve, M. B., and D. H. Gleaves. “Body Dysmor-phic Disorder: A Review of Conceptualizations,Assessment, and Treatment Strategies.” ClinicalPsychology Review 21 no. 6 (August 2001):949–970.

Cotrufo, P., A. Gnisci, and I. Caputo. “Brief Report:Psychological Characteristics of Less SevereForms of Eating Disorders: An Epidemiological

Study among 259 Female Adolescents.” Journalof Adolescence 28, no. 1 (February 2005):147–154.

Currin, L., et al. “Time Trends in Eating DisorderIncidence.” British Journal of Psychiatry 186 (Feb-ruary 2005): 132–135.

Debate, R. D., L. A. Tedesco, and W. E. Ker-schbaum. “Knowledge of Oral and PhysicalManifestations of Anorexia and Bulimia Ner-vosa among Dentists and Dental Hygienists.”Journal of Dental Education 69, no. 3 (March2005): 346–354.

Decaluwe, V., and C. Braet. “The Cognitive Behav-ioural Model for Eating Disorders: A DirectEvaluation in Children and Adolescents withObesity.” Eating Behaviors 6, no. 3 (June 2005):211–220.

Fassino, S., et al. “Hormonal and MetabolicResponses to Acute Ghrelin Administration inPatients with Bulimia Nervosa.” Psychoneuroen-docrinology 30, no. 6 (July 2005): 534–540.

Fichter, M. M., and N. Quadflieg. “Twelve-yearCourse and Outcome of Bulimia Nervosa.” Psy-chological Medicine 34, no. 8 (November 2004):1,395–1,406.

Gleaves, D. H., J. D. Brown, and C. S. Warren. “TheContinuity/Discontinuity Models of Eating Dis-orders: A Review of the Literature and Implica-tions for Assessment, Treatment, andPrevention.” Behavior Modification 28, no. 6(November 2004): 739–762.

Godart, N. T., et al. “Predictive Factors of SocialDisability in Anorexic and Bulimic Patients.”Eating and Weight Disorders 9, no. 4 (December2004): 249–257.

Granillo, T., G. Jones-Rodriguez, and S. C. Carva-jal. “Prevalence of Eating Disorders in LatinaAdolescents: Associations with Substance Use

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341

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Lock, J., and D. le Grange. “Family-based Treat-ment of Eating Disorders.” International Journalof Eating Disorders 37, suppl. 1 (2005): S64–67.

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342 The Encyclopedia of Obesity and Eating Disorders

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OBESITY

Baker, S., et al. “Overweight Children and Adoles-cents: A Clinical Report of the North AmericanSociety for Pediatric Gastroenterology, Hepatologyand Nutrition.” Journal of Pediatric Gastroenterologyand Nutrition 40, no. 5 (May 2005): 533–543.

Blackburn, G. L., and B. A. Waltman. “Expandingthe Limits of Treatment—New Strategic Initia-tives.” Journal of the American Dietetic Association105, no. 5, pt. 2 (May 2005): 131–135.

Bloom, S., K. Wynne, and O. Chaudhr. “GutFeeling—The Secret of Satiety?” Clinical Medicine5, no. 2 (March–April 2005): 147–152.

Braunschweig, C. L., et al. “Obesity and Risk Fac-tors for the Metabolic Syndrome among Low-income, Urban, African American School-children: The Rule Rather than the Exception?”American Journal of Clinical Nutrition 81, no. 5(May 2005): 970–975.

Bray, G. A., and C. M. Champagne. “BeyondEnergy Balance: There Is More to Obesity thanKilocalories.” Journal of the American Dietetic Asso-ciation 105, no. 5, pt. 2 (May 2005): 17–23.

Christian, V. J., and W. H. Polonsky. “Overcomingthe Psychological Challenge to Weight Loss.”Diabetes Forecast 58, no. 4 (April 2005): 54–58.

Couzin, J. “Public Health: A Heavyweight Battleover CDC’s Obesity Forecasts.” Science 308, no.5723 (May 6, 2005): 770–771.

Crosnoe, R., and C. Muller. “Body Mass Index,Academic Achievement, and School Context:Examining the Educational Experiences of Ado-lescents at Risk of Obesity.” Journal of Health andSocial Behavior 45, no. 4 (December 2004):393–407.

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Dietl, J. “Maternal Obesity and Complications Dur-ing Pregnancy.” Journal of Perinatal Medicine 33,no. 2 (2005): 100–105.

Faith, M. S. “Development and Modification ofChild Food Preferences and Eating Patterns:Behavior Genetics Strategies.” International Jour-nal of Obesity and Related Metabolic Disorders 29,no. 6 (June 2005): 549–556.

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Ford, E. S., and D. M. Mannino. “Time Trends inObesity among Adults with Asthma in theUnited States: Findings from Three NationalSurveys.” Journal of Asthma 42, no. 2 (March2005): 91–95.

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Hawn, M. T., et al. “Impact of Obesity on ResourceUtilization for General Surgical Procedures.”Annals of Surgery 241, no. 5 (May 2005):821–828.

Horgan, S., et al. “Laparoscopic Adjustable GastricBanding for the Treatment of Adolescent Mor-bid Obesity in the United States: A Safe Alterna-tive to Gastric Bypass.” Journal of PediatricSurgery 40, no. 1 (January 2005): 86–91.

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EATING DISORDERS

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Maine, Margo. Father Hunger: Fathers, Daughters andthe Pursuit of Thinness. 2nd ed. Carlsbad, Calif.:Gurze Books, 2004.

Maisel, Richard, David Epston, and Ali Borden. Bit-ing the Hand That Starves You: Inspiring Resistanceto Anorexia/Bulimia. New York: W. W. Norton,2004.

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Michel, Deborah, and Susan G. Willard. WhenDieting Becomes Dangerous: A Guide to Under-standing and Treating Anorexia and Bulimia.New Haven, Conn.: Yale University Press, 2003.

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Gavin, James R., with Sherrye Landrum. Dr.Gavin’s Health Guide for African Americans.Alexandria, Va.: Small Steps Press, 2004.

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346 The Encyclopedia of Obesity and Eating Disorders

INDEX

347

Aabdominal fat 61–62, 68–70, 155,295

Abdominal Panniculus Grading Sys-tem 237

abdominoplasty 1, 7, 62, 237, 291Abed, R. T. 271Academy for Eating Disorders 1, 325accommodating the obese 1–3acesulfame-K 45Ackerman, M. J. 49Acomplia 40, 260Active Living by Design 3, 325actresses 295“Actual Causes of Death in the U.S.”(McGinnis and Foege) 221

acupressure 3–4acupuncture 4addiction 4–5

food 149–150addiction model of eating disorders6–7, 78–79

adipose tissue 7adipsin (ADN) 98adjustable gastric banding (AGB)7–9, 57, 226, 293

Adler, Jerry 69adolescent(s)

African American 14anorexia nervosa in 23, 26, 28appetite of 9bariatric surgery in 10, 57calorie requirements of 10dieting by 116media influences on 198sexual adjustment of 9vegetarian, eating disorders in 293

adolescent obesity 9–10Adolfsson, B. 272

adoption, and eating disorders10–11, 27

adult onset obesity 11advertising

and eating disorders 26, 197-199false or deceptive 12–13, 151–152,203–204

and obesity 11–13AED (Academy for Eating Disorders)1, 325

aerobic exercise 13African American(s)

body fat distribution in 16body image of 16body mass index of 15diabetes in 112eating disorders in xvi, 13–14, 23economics of 15exercise by 15low birth weight of 15–16mate selection and preferences of16

mortality rate of 16obesity in 14–17, 112, 222televised images of 16thrifty gene in 15

age-related anorexia 127aging

and eating disorders 126–128and obesity 128–129

Agliata, Daniel 194, 198Agras, W. S. 101Air Force Diet 181air pollution, and obesity 17ALbD (Active Living by Design) 3,325

Alcoholics Anonymous 6–7, 236alcoholism 4–5, 27, 207–208alexithymia 17Allison, Kelly C. 214–215

Alving, Barbara 171Aly, Al 62Alzheimer’s disease, obesity and17–18

Amadei, Magali 141amenorrhea 18–19, 30, 78, 200–201

primary 18secondary 18, 264–265

American Anorexia and BulimiaAssociation of Philadelphia 325

American Board of Medical Special-ties 325

American Cancer Society, on low-carb diets 190

American Dance Therapy Association206–207

American Dietetic Association Head-quarters 325

American Dietetic Association Wash-ington Office 325

American Indians/Alaska Nativesbody image of 19–20eating disorders in 19–20, 212Healthy People 2010 goals for 20obesity in 20thrifty gene in 20

American Medical Associationon amphetamine use 21obesity guidelines of 226

American Obesity Association (AOA)20, 177, 325

American Psychiatric Association 325American Society for BariatricSurgery 325

American Society of Bariatric Physi-cians 9–10, 56, 325

American Society of Plastic Surgeons326

amitriptyline 20–21, 79ammonium chloride 122

amphetamines 21–22, 43amylin 22anaclitic depression 22anaerobic exercise 22Andersen, Arnold E. 41, 194–195Anderson, Drew A. 267Anderson, Wayne 77Andres, Reubin 310Andrist, L. C. 198anemia 31, 58, 193, 237Anorexia and Bulimia (Neuman andHalvorson) xvi

anorexia athletica 22–23anorexia mirabilis 23anorexia nervosa 23–36

as addiction 4–5in adolescents 23, 26, 28adoption and 10–11, 27in African Americans 23amphetamine use in 21anaclitic depression and 22antidepressants for 21, 34, 38–39,241–242, 252

antipsychotics for 41, 92–93, 245,284

art therapy for 43–44in Asian/Pacific Islander Americans46–47

in athletes 50–51atypical 52–53Avicenna on 53in ballet dancers 55beginnings of 24–25behavioral therapy for 33behavior modification for 59binge eating/purging type 36–37biofeedback therapy for 65–66biological predisposition to 27bloating in 204body image in 28–29, 70–71causes of 25–28childhood 88clinical features of 28–31, 318cognitive distortions in 93–94cognitive psychopathology of29–30

cognitive therapy for 33, 95in college students 95–96complications of 31–32compulsive behavior in 29costs of 101cultural influences in 26–27danger signals for 321denial in 25, 30, 33–34denial of hunger in 25, 29dental problems in 31, 108–109,239–240

depression in 109–110, 204DSM-IV criteria for vii, 319in elderly 126–128emotional expression in 17, 27employees with 130–131epidemiology of 23–24exercise in 22–23, 29exposure and response preventionfor 33

family dynamics and 27–28,138–140, 238, 322

family therapy for 34, 138–140famous patients with 140–141feminist psychotherapy for147–148

food phobia in 29food preferences in 323food-related behaviors in 323forced feeding in 151, 290genetic factors in 157–158, 291group therapy for 34, 162–163Gull on xv, xviii, 163, 302history of xiii–xxhomosexuality and 168–169hospitalization for 33hyperactivity in 170, 204hypnotherapy for 172increase in diagnosed cases of 24individual therapy for 34interoceptive disturbance in 32,177–178

isolation in 30Lasègue on xv, 183, 302laxative abuse in 30, 183–184in males 28, 168–169, 193–195malnutrition in 196mania in 204marriage and 196–197menstrual dysfunction in 18–19,30, 200–201, 264–265

in “model children” 30–31mood in 30, 32mortality in 24, 206multicompulsive behavior in207–208

multidimensional/multifactorialmodels of 208–209

narcissism and 211neurotransmitters in 213–214, 269nutritional counseling for 217in older women 23oral soft tissues in 233osteopenia/osteoporosis in 31, 235parental factors in 238, 322peer relationships and 28personality changes in 32personality disorder and 240–241

personality traits in 30–31, 157,211, 239–240

pharmacotherapy for 34, 241–242physical manifestations of 318and pregnancy 248prognosis in 24, 34promotion of 250psychodrama for 252psychosomatic medicine in 253psychotherapy for 253–255pursuit of thinness in 25, 28recovery from 34–35religion and 257–258research in 36sexual abuse and 270sexuality in 30, 271skin and hair in 31socioeconomic status and 23, 25starvation in 31–32, 279stress and 25–26, 281–282suicide in 32, 36, 204, 283taste in 285treatment of 32–34weight phobia in 29, 32–33, 298zinc deficiency in 31, 34, 300

Anorexia Nervosa and Related EatingDisorders (ANRED) 23, 37, 326

anorexic behavior 36anorexic bingers 36–37ANRED (Anorexia Nervosa andRelated Eating Disorders) 23, 37,326

anthropometric measurements 67–68anticonvulsant treatment 37–38,242

antidepressants 38–39amitriptyline 20–21, 79for 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 93and dental caries 108–109imipramine 173Prozac 251–252for rumination 262for sleep-related eating disorder276

thymoleptic medications 289antiobesity drugs 39–41, 225–226,242, 260, 273

antipsychotics 41, 92–93pimozide 245sulpiride 284

anxiety 42, 205, 247

348 Index

AOA (American Obesity Association)20, 177, 325

apoplectic body type 72appearance, cultural influences onxiii–xx, 26–27, 103–105, 227–228,277–278

appetite 42acupressure and 3–4acupuncture and 4adolescence and 9hypothalamic disease and 172mood disorders and 204–205music and 209stress and 280

appetite hormones 42, 159–160,169–170, 184–185, 256, 263, 275

appetite-stimulating drugs 42–43cyproheptadine 43, 106

appetite suppressants 43, 225–226amphetamines 21–22for binge-eating disorder 65bulking agents 80crystal methamphetamine (ice)103, 173

fen-phen/Redux 149phenylpropanolamine 120, 243,309–310

sibutramine 39–40, 65, 225, 242,263, 273, 314

Tenuate 287apple shape 61–62, 69Appolinario, J. C. 242Areton, Lilka Woodward 144Arizona programs 328Arnst, Catherine 191Aronne, Louis J. 242arousal, physiological 244Arterburn, David E. 128arthritis link to obesity 44artificial sweeteners 45–46, 282art therapy 43–44Ashton, David 11Asians/Pacific Islander Americans

eating disorders in xvi–xvii, 46–47obesity in 47

aspartame 45Assessment of Addictive Behaviors(Polivy, Herman, and Garner)122–123

asthenic body type 72asthma link to obesity 48–50athletes 50–51, 295Atkins, Robert C. 51, 306Atkins Diet 51–52, 114, 181, 190,213, 305–306

attitudes toward obesity 227–228,273–274

attractin 169atypical anorexia nervosa 52–53audiovisual materials 338–340aversion therapy 53Avicenna 53Axel, E. 305–306

Bbaby fat 89Baillargeon, Jacques G. 250–251ballet dancers 50, 55, 140–141, 295Banting, William 56Banting diet 56, 114, 181Bará-Caril, Núria 271bariatric(s) 56bariatric surgery 56–58, 226

accommodations for 2adjustable gastric banding 7–9, 57,226, 293

in adolescents 10, 57benefits of 57–58biliopancreatic diversion 57, 63,122, 193

costs of 56definition of 56and dumping syndrome 63, 122gastric bypass 156indications for 57insurance coverage for 56, 177jejunocolic bypass 179jejunoileal bypass 179longitudinal assessment of 189malabsorptive 57, 63, 179, 193,226

Medicare coverage of 199mortality rate in 206, 226nutritional counseling after217–218

in older patients 226and pregnancy 58, 193restrictive 7–9, 57, 156–157, 226,260–261, 293

risks of 58Roux-en-Y gastric bypass 57, 122,193, 226, 260–261

stomach stapling 280vertical banded gastroplasty 57,226, 293

Bariatric Surgery Clinical ResearchConsortium 189

Barlow, Sarah E. 10Barrett, Stephen 80Bartlett, Susan 44, 128basal metabolic rate (BMR) 58–59Bassett-Seguso, Carling 50Bauer, Barbara 77

Baum, Charles L., II 230Baumiller, Marlene 308Baur, L. A. 10Bayrd, Edwin 62, 86Becker, A. E. 212behavior modification 59–61, 267,280for anorexia nervosa 59for bulimia nervosa 59for obesity 59–61, 225

behavior therapy 53, 61for anorexia nervosa 33for bulimia nervosa 61, 79for childhood obesity 90

Beller, Anne Scott xiiiBelluscio, Daniel O. 166belly fat 61–62, 68–70, 155, 295belt lipectomy 62Bemis, K. M. 94Ben-Dor, D. H. 10Bennett, William 224Benton-Hardy, L. R. 248benzocaine 43, 62Berg, Greg 229Berkman, John Mayo xviBeumont, P. J. V. 217Beverly Hills Diet 62–63, 310bigorexia 209biliopancreatic diversion (BPD) 57,63, 122, 193

binge-eating 63–64in African Americans 14in American Indians/Alaska Natives19–20

in anorexia nervosa 36–37antidepressants for 20–21in ballet dancers 55behavior therapy for 61in bulimia nervosa 75, 78and dental caries 108–109genetics of 64in Hispanics/Latinos 168by males 195marriage and 197seizure disorders and 37–38sleep disorders and 176in sleep-related eating disorder 276

binge-eating disorder (BED) 64–65anticonvulsants for 37–38, 242antidepressants for 39, 65, 242body image in 71versus bulimia nervosa 64complications of 64DSM-IV criteria for vii, xviii, 64,319

emotional expression and 17long-term course of 64–65

Index 349

mortality in 206versus obesity 64personality traits in 240pharmacotherapy for 65, 242prevalence of 64self-help groups for 266treatment of 65

Binge Eating Scale (BES) 65Binge Scale 65Binks, Martin 272bioelectrical impedance analysis 68biofeedback 65–66biopsychosocial model of eatingdisorders viii, 66

biotech foods 66birth control pills 232–233Blackburn, George 85, 308, 311Blackman, Stuart xviiiBlair, Alan 118Blanchette, Patricia Lanoie 165Blanchez, P. F. xviiiBlankaart, Steven xviiblood pressure, elevated 171Blumenthal, H. T. 304BMI. See body mass indexBod Pod 68bodybuilders 194–195, 209body dysmorphic disorder (BDD)66–67

body fat 67–68assessment of 47–48, 67–68,274–275, 302

brown 74cellulite 86–87conjugate linoleic acid and 99–100desirable range of 67dieting and 67excess 67immune function and 174low 67storage of 67, 185visceral 295

body fat distribution 61–62, 68–70in African Americans 16age differences in 69calorie source and 62, 69environmental factors in 69and gallstones 155gender differences in 68–69hereditary differences in 69smoking and 69–70waist-to-hip ratio of 297weight loss and 69

body image 66–67of African Americans 16of American Indians/AlaskanNatives 19–20

in anorexia nervosa 26–29, 70–71art therapy and 43–44of ballet dancers 55in binge-eating disorder 71in bulimia nervosa 70–71, 76–77cultural influences on xiii–xx,26–27, 103–105, 277–278

of Hispanics/Latinos 166–167of homosexuals 168of males 168, 194–195, 209media influences on 197–199movement therapy and 206–207in obesity 71

Body Image: An International Journal ofResearch 70

body image assessment (BIA) 70body image disturbance 70–71body mass index (BMI) 71–72, 324

of African Americans 15and Alzheimer’s disease 18as bariatric surgery guideline 7, 57education level and 15of elderly 128genetic factors and 157–158of Hispanics/Latinos 167and hypertension 171in obesity 71–72, 219and sudden death 61

body types 72, 126, 131–132, 201,238–239

body wrapping 72, 216bone loss 234–236Booth, David A. 299borderline personality disorder 72Boskind-White, Marlene xviii, 74,197

bottle-feeding 174–175Bowlan, Veronica O. 252Bradwell, D. 305brain activity and obesity 72–73Bratman, Steven 234Bray, G. A. 153, 191breakfast and obesity 73–74Breaking Free from Emotional Eating(Roth) 204

breast cancer detection, obesity and196

breast-feeding 174–175Brewerton, Timothy D. 34, 242, 252Brisman, Judith 99–100, 217Brown, S. L. 8Brownell, K. D. viii, 60, 274,299–300

brown fat 74Bruch, 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, 253Bruna, Tijs 242Bulik, Cynthia M. 134, 291bulimarexia 74bulimia 74–75Bulimia: A Systems Approach to Treat-ment (Root, Fallon and Friedrich)195

bulimia nervosa 75–80as addiction 4–5addiction model of 6–7, 78–79alcoholism in 4–5, 207–208anticonvulsants for 37–38, 242antidepressants for 20–21, 39, 79,109, 173, 242, 252, 289

anxiety model of 42art therapy for 43–44in athletes 50–51in ballet dancers 55beginnings of 76behavior modification for 59behavior therapy for 61, 79versus binge-eating disorder 64binge-eating patterns in 75, 78biofeedback therapy for 65–66body image in 70–71, 76–77chemical dependency and 87–88,207–208

clinical features of 77–78, 318cognitive distortions in 77–78cognitive therapy for 79, 94–95,254

in college students 95–96complications of 78–79compulsive behavior in 78costs of 101danger signals for 321denial in 77dental problems in 108–109, 233,239–240

depression in 78–79, 109–110diet pill use in 76as disease of success 75–76diuretic abuse in 75, 121–122DSM-IV criteria for vii, 319early satiety in 125emotional expression and 17employees with 130–131epidemic of 75epidemiology of 75exposure and response preventionfor 134

family dynamics in 76–77,138–140, 322

family therapy for 138–140

350 Index

famous patients with 140–141fictional finalism in 77food preferences in 323food-related behaviors in 323genetic factors in 157–158, 291group therapy for 79, 162–163history of xiii–xxhomosexuality and 168–169, 195interpersonal psychotherapy for79, 178, 254–255

ipecac syrup use in 178Janet on 179laxative abuse in 75–76, 183–184in males 76, 168–169, 195–196malnutrition in 196marriage and 197menstrual dysfunction in 78,200–201, 264–265

mortality in 206multicompulsive behavior in207–208

multidimensional/multifactorialmodels of 208–209

narcissism and 211neurotransmitters in 213–214nutritional counseling for 217oral soft tissues in 233overweight 236personality disorder and 240–241personality traits in 157, 211,239–240

pharmacotherapy for 79–80, 242physical manifestations of 318polycystic ovary syndrome and246

and pregnancy 248promotion of 250psychodrama for 252psychotherapy for 253–255rigidity and inflexibility in 77rumination in 261–262Russell on 262secrecy of 76seizure disorders and 37–38self-esteem in 78, 265sexual abuse and 208, 270sexuality in 78, 271sleep disorders in 176stress and 281suicide in 78, 208, 283taste in 285thymoleptic medications for 289treatment of 79–80vocational 295vomiting in 76, 78, 295–296

Bulimia Test Revised (BULIT-R) 80bulking agents 43, 80

bupropion 39–40Bursztyn, Mark 228Butler, N. 305bypass surgery. See bariatric surgery

Ccachexia africana 159caffeine 81, 122calcitriol 82calcium 81–82, 107, 235Calderon, L. L. 116California programs 328, 331Calle, Eugenia E. 255–256calorie(s) 82–83

weekend 297–298calorie restriction diet 84Calories Count (Obesity WorkingGroup) 230–231

Calories Don’t Count (Taller) 304calorimetry 84Camargo, Carlos A., Jr. 48Campbell, T. Colin 311–312camps 331–332cancer links to obesity 84–85, 223,250–251

Canon of Medicine (Avicenna) 53Caprenin 145Carapella, Raymond 307carbamazepine 37Carbatrol 37carbohydrate(s) 85–86

net 213carbohydrate addict’s diet 85, 190carbohydrate craving 102–103Carlat, Daniel J. 241Carpenter, Karen 86, 140, 178, 250Cash, Thomas F. 70Cassella, Robert 308Castro, J. 35Catalina, M. 234cataracts and obesity 86cathartic colon 183Catherine of Siena 23, 141Cautela, Joseph 305Celexa 39, 242cellulite 86–87, 216Centers for Obesity Research andEducation (CORE) 87

Centers for Science in the PublicInterest 326

Cepeda-Benito, Antonio 103,130–131, 195, 206, 241–242, 254

Charcot, J. M. xvCharlebois, Donna 298Chebli, Joseph E. 8cheerleaders 50

chemical dependency and bulimia87–88, 207–208

childhood anorexia 88childhood obesity 88–92

epidemiology of 88–89, 222group therapy for 225physical health effects of 89psychological effects of 89–90schools and 263–264teasing about 90treatment of 90–92

Chipley, William Stout 92chlorothiazide 121chlorpromazine 41, 92–93Choi, P. Y. 209cholecystokinin (CCK) 93, 263cholesterol 93, 202choreotherapy 206–207chronology of eating disorders andobesity 302–316

citalopram (Celexa) 39, 242Citrus aurantium 120class issue, obesity as 222, 228–229,277

Clausen, L. 35Clayson, Dennis E. 227clinical weight-loss programs114–115

cocaine use 207–208cognitive distortions 77–78, 93–94Cognitive Factors Scale (CFS) 94cognitive therapy 94–95, 254

for anorexia nervosa 33, 95for bulimia nervosa 79, 94–95versus nutritional counseling 217for obesity 94for rumination 262

Cohen, Sidney 81Cohen, Tiffany 50Cohn, Leigh 126college students

eating disorders in 95–96weight gain of 95, 152–153

Collins, M. Elizabeth 63, 104Colorado programs 328Comaneci, Nadia 50comfort food 96–97, 282complement factors 97–98compulsive behavior 29, 36, 78,207–208

compulsive eating 98–99compulsive eating scale (CES) 99computed tomography 68conjugate linoleic acid (CLA) 99–100Connecticut programs 328–329Connolly, Ceci 256constipation 30, 183

Index 351

continuity/discontinuity models ofeating disorders 100

control group 100Conversations with Anorexics/Hilde Bruch(Czyzewski and Sur, eds.) 74

Coopersmith Self Esteem Inventory265

Copeland, Paul 78CORE (Centers for Obesity Researchand Education) 87

CortiSlim 100cortisol 96, 100–101, 109, 235, 282Council on Size and Weight Discrimi-nation, Inc. 102, 326

couples therapy 102covert conditioning 305Crabtree, Penni 66crack cocaine 208Craighead, Linda 309–310craving 102–103Crawford, Lester M. 12creative therapy 43–44creeping obesity 103, 133, 142Crespo, Carlos J. 229Crisp, Arthur H. 24, 28, 32–33, 127,254, 298

Crow, S. J. 201crystal methamphetamine 103, 173cultural influence(s)

on appearance xiii–xx, 26–27,103–105, 227–228, 277–278

on dieting 116–117on eating disorders viii, 26–27,105–106, 167

Cummings, D. E. 288Cushing’s disease 106, 199, 220Cuzzolaro, Massimo 125cyberdieting 231–232, 337cyproheptadine 43, 106

Ddairy foods and weight loss 81–82,107–108

dancers 50, 55, 140–141, 295dance therapy 206–207Dancing on My Grave (Kirkland) 141danger signals 321Davidson, Terry L. 46Davis, Allen R. 258Dawson, Brenda 220, 224Deception in Weight-Loss Advertising203–204

deceptive advertising 12–13,151–152, 203–204

dehydration, laxative abuse and183

dehydroepiandrosterone (DHEA) 62,108, 304

denialin anorexia nervosa 25, 30, 33–34in bulimia nervosa 77

densitometric analysis 67dental caries (cavities) 108–109

in anorexia nervosa 31, 108–109dental problems 31, 108–109, 233,239–240

Depakote 37depression

anaclitic 22in anorexia nervosa 109–110, 204in bulimia nervosa 78–79, 109–110and eating disorders 109–110,204–206, 240

and obesity 110, 220Deseryl 38Deshmukh, Rashmi 39desipramine 39developmental obesity 74Devlin, Bernie 157Devlin, Michael J. 41dexfenfluramine 149, 225, 313–314Dezhkam, Mahmood 258diabetes

in African Americans 112amylin in 22and eating disorders 110–111gestational 111and obesity 22, 89, 111–112sugar and 283Type 1 111Type 2 111

Diagnostic and Statistical Manual of Men-tal Disorders vii, xviii, 64, 122, 319

Diamond-Raab, L. 43, 252Diana, Princess 141dichotomous reasoning 94, 112Dickens, Charles 229diet(s)

Air Force 181Atkins 51–52, 114, 181, 190, 213,305–306

Banting 56, 114, 181Beverly Hills 62–63, 310and body fat 67calorie restriction 84carbohydrate addict’s 85, 190for children 90–92Drinking Man’s 181Dupont 181fad 137, 224Hawaiian 165ketogenic 181liquid formula 188–189, 232, 251

low-carb 51–52, 85, 190low-fat 190–191Mediterranean 199–200Pennington 181Protein Power 181, 190protein-sparing modified fast 232,251

Snowbird 297South Beach 114, 181, 190, 278Traffic Light 91, 290very low-calorie 225, 232,293–294

Zone 181, 190dietary fiber 112–113, 149Dietary Guidelines for Americans 2005216–217, 315–316

Dietary Supplement Health and Edu-cation Act (DSHEA) 113

dietary supplements 113diet centers and programs 113–115Dieter’s Dilemma, The (Bennett) 224dieter’s teas 115–116dieting 116–120, 224–225

by adolescents 116cultural influences on 116–117immune function and 174and mortality 117by mothers and infants 116online 231–232, 337during pregnancy 249sensible approach in 119–120starvation response in 117stress and 281vicious cycle of 117–118weight-loss strategies in 118–119by young girls 116yo-yo 299–300

diet pill(s)benzocaine in 62in bulimia nervosa 76grapefruit 87over the counter (OTC) 120

Dietz, William 287, 310Dilantin 37dissociation 120–121diuretic abuse 121–122

by African Americans 14in bulimia nervosa 75, 121–122complications of 320

Dobbs, E. C. 302do-it-yourself weight-loss programs114

Donini, L. M. 234Donohoe, Thomas P. 280dopamine 73, 149–150, 263double-blind study 122Downs, Susan 296

352 Index

Dragstedt, L. R. 302Drewnowski, Adam 25, 75Drinking Man’s Diet 181drug therapy 241–243. See also specific

disordersDSM-III xviiiDSM-IV vii, 64, 122, 319D-tagatose 285dual energy X-ray absorptiometry(DEXA) 68

Dubowitz, Howard 138Duggan, S. J. 198dumping syndrome 63, 122Dunn, P. K. 99Dupont Diet 181dysfunctional behavior patterns122–123

Eearly satiety 125Eating and Weight Disorders: Studies onAnorexia, Bulimia and Obesity viii,125

Eating Attitudes Test (EAT-26) 29,125

Eating Behaviors 125eating disorder(s). See also specific types

as addiction 4–5addiction model of 6–7, 78–79adoption and 10–11, 27in African Americans xvi, 13–14,23

in American Indians/Alaska Natives19–20, 212

art therapy for 43–44in Asians/Pacific Islander Ameri-cans xvi–xvii, 46–47

in athletes 50–51in ballet dancers 50, 55, 140–141,295

biofeedback therapy for 65–66biopsychosocial model of viii, 66chronology of 302–316in college students 95–96continuity/discontinuity models of100

costs to treat 101cultural influences on viii, 26–27,105–106, 167

danger signals for 321depression and 109–110, 204–206,240

diabetes and 110–111in elderly 126–128employees with 130–131family generation of 138–140

family therapy for 138–140famous patients with 140–141feminist psychotherapy for147–149

genetic factors in 27, 157–158, 291group therapy for 162–163in Hispanics/Latinos 166–167, 212history of xiii–xxhomosexuality and 168–169infant 174insurance coverage for 176marriage and 196–197media influence on 197–199mood disorders and 204–206movement therapy for 206–207multidimensional/multifactorialmodels of 208–209

not otherwise specified (EDNOS)vii, 125

personalities of individuals with240

pregnancy and 248promotion of 250psychotherapy for 253–255religion and 257–258sexual abuse and 270–271sexuality and 271sleep-related 276stress and 280–282twin studies of 291vegetarian diet and 293

Eating Disorders and Obesity: A Compre-hensive Handbook (Brownell and Fair-burn) viii

Eating Disorders Anonymous (EDA)326

Eating Disorders Awareness Week(EDAW) 125–126

Eating Disorders Coalition forResearch, Policy and Action 176eating disorders inventory (EDI)126

Eating Disorders: Obesity, Anorexia, andthe Person Within (Bruch) xiii, 26, 74

Eating Disorders: The Journal of Treat-ment and Prevention 126

eating habits monitoring 267–268Eating Organization of New Jersey326

Eberenz, K. P. 208, 270Eckert, Elke 6ectomorph 72, 126, 239ego state therapy 126Eisler, Ivan 139Elamin, Elamin M. 49Elavil 20–21, 79Eldahmy, Adel 171

elderlyeating disorders in 126–128obesity in 128–129

electrodermal response (EDR) 65electroencephalograph (EEG)

in biofeedback therapy 66in compulsive eaters 37

electrolyte imbalancein anorexia nervosa 31laxative abuse and 184

Elliott-Larsen Civil Rights Act (Michi-gan) 274

Ellis, L. 158Ellison, Sarah 213emergency services, accommodatingobesity in 2

emotional eating 204emotional expression, and eating dis-orders 17, 27

emotional overeating 220–221empirically supported therapy 129empirical research 129employees

with eating disorders 130–131obesity in 230

health costs of 129–130Encyclopaedia Britannica xviiEncyclopedia of Understanding Alcoholand Other Drugs, The (O’Brien andCohen) 81

endocrine factors in obesity 131endomorph 72, 131–132, 239ephedra 120, 132epidemiological research 132Epstein, Leonard H. 91, 290Erchonia 4L laser 188Ernsberger, P. 224Escamilla, R. F. xviEssence 14Estok, P. J. 6ethacrynic acid 121ethosuximide (Zarontin) 37European treatment, of eating disor-ders 138

exercise 132–134aerobic 13by African Americans 15anaerobic 22in anorexia nervosa 22–23, 29excessive 133–134and obesity 91, 225, 243–244obligatory (anorexia athletica)22–23

spot reducing 278exercise machines, passive 238exposure and response prevention(ERP) 33, 134

Index 353

externality approach to obesity 42,135

extreme eating 135extreme obesity 135

FFabricatore, Anthony N. 189, 267Factor D 98fad diets 137, 224failure to thrive (FTT) 137–138, 147,175

Faine, M. P. 109Fairburn, Christopher viii, 312fake fat 138. See also fat substitutesfalse advertising 12–13family dynamics 138–140

and anorexia nervosa 27–28,138–140, 238, 322

and bulimia nervosa 76–77, 322and obesity 222

family meal 138family therapy 138–140, 288

for anorexia nervosa 34, 138–140for bulimia nervosa 138–140for obesity 140

famous eating-disorder patients140–141

Farley, John E., Jr. 308F as in Fat: How Obesity Policies Are Fail-ing America 315

fasting 141–142in bulimia nervosa 76and gallstones 155and osteopenia 235religious xv, 23, 141, 257–258

fasting girls xv, 142Fasting Girls (Brumberg) xivfat(s) 144–145

body. See body fatrestricted, in low-fat diet 190–191saturated 145trans 150, 290unsaturated 145

Fat & Thin (Beller) xiiifat blockers 142fat cells 142–143, 175, 219, 222“fat” doctors 143Fat Liberation Front 308fat-mobilizing substance (FMS) 306fat phobia 143–144fat power 144fat recycling 144fat substitutes 138, 145–146, 231,273, 333–335

fat tissue 7morphology of, and obesity 222

fat virus 146Favazza, Armando R. 268fear of fat syndrome 146–147, 240,253

Federal Trade Commission (FTC)on advertising 12–13on fraudulent products 151–152,202–203

on liquid programs 189on passive exercise machines 238

feeding disorder of infancy or earlychildhood 147

Feeding Infants and Toddlers Study175

Feinstein, Alvan 304Feldman, William 286, 311feminist psychotherapy for eating dis-orders 147–149

fenfluramine 149, 225, 314fen-phen/Redux 149, 225, 313–314Fernstrom, John D. 309Ferraro, F. Richard 50–51Ferraro, Kenneth F. 258fiber, dietary 112–113, 149Fichter, M. M. 194–195fictional finalism 77figure skaters 50Fired, G. H. 306Fischer, Giorgio 185Fitzgerald, A.L. 264Fitzgibbon, Marian 20, 47Flatt, Jean-Pierre 83Flexyx Neurotherapy System (FNS)66

Florida programs 329fluid imbalance, in anorexia nervosa31

fluoxetine. See Prozacfluvoxamine 39, 242Foege, William 221Fogteloo, Jaap 242Fonda, Jane 141food(s)

biotech 66comfort 96–97, 282dairy, and weight loss 81–82,107–108

forbidden 151solid, and infant obesity 174–175

food addiction 149–150food advertising 11–13Food and Drug Administration (FDA)

on ephedra 132on liposuction 187–188on nutrition labeling 150on starch blockers 278–279

Food Exchange Diet 91

Food for Thought: Substance Abuse andEating Disorders 254

“Food for Thought: Substance Abuseand Eating Disorders” 6

food nutrition labels 150–151food phobia 29food preferences, in anorexia andbulimia nervosa 323

food pyramid 316food-related behavior, in anorexiaand bulimia nervosa 323

forbidden foods 151forced feeding 151, 290–291Ford, William F. 230Franco, Kathleen 39Franklin, J. A. 104fraudulent products 151–152,202–203

Frazen, R. 302Freedman, Rachel E. K. 16free fatty acids 152Freshman 15 95, 152–153Frey, F. J. 122Fried, Jack 307Friedman, Glenn M. 287Friedman, Jeffrey 159Friedman, Michael 300Fröhlich’s syndrome 39fructose as contributor to obesity153–154, 166

Fujioka, K. 193furosemide 121

Ggabapentin 37Gabitril 37Gaesser, Glenn A. 278Galen xviiGallagher, Susan 237–238gallstones 58, 155gamma butyrolactone (GBL) 156Gangwisch, James 275Garfinkel, Paul E. 32, 36, 125, 205,279, 284, 290

Garner, C. M. 228Garner, David M. 32, 36, 94–95, 105,122–123, 125, 205, 284, 290

Garner, Sara 267Garren-Edwards Gastric Bubble(GEGB) 156

Garrison, Zina 50gastric banding, adjustable 7–9, 57,226, 293

gastric bubble 156gastric bypass 156, 280

Roux-en-Y 57, 122, 193, 226,260–261

354 Index

gastric restriction procedures 7–9, 57,156–157, 226, 260–261, 293

gastric stimulator, implantable 42,174, 263

gastrointestinal bleeding, laxativeabuse and 183

gastrointestinal surgery for obesity.See bariatric surgery

gastroplasty 157Gater, David 278Gavin, James 15Gaviria, Moises 205Geifer, Eldred 308genetic factors

in binge-eating 64in bulimia nervosa 157–158, 291in eating disorders 10, 27,157–158, 291

in obesity 158–159, 220, 222Gennuso, Jennifer 48geophagia 159, 181, 245Geracioto, Thomas D., Jr. 93ghrelin 42, 159–160, 163, 169, 263,275, 288

Giddens, Anthony 105Gleaves, David H. 70–71, 121,130–131, 195, 206, 208, 241–242,254, 270

globesity 160glucagon-like peptide 1 (GLP-1) 263glucocorticoids 96–97Glucophage (metformin) 40, 112glycemic index (GI) 160–161Gold, Mark 150Golden, Harvey xivGolden Cage, The: The Enigma ofAnorexia Nervosa (Bruch) 74

Goldfarb Fear of Fat Scale (GFFS) 161Goldman, Albert 141gonads obesity 161Goode, Erica 168, 194Gordon, Richard A. 26–27Gortmaker, Steven 310government role in combating obesity161–162

Graham, M. A. 153Grandjean, Ann C. 143grapefruit diet pills 87Grilo, Carlos M. 34, 242Grossman, Robert J. 274group therapy 162–163, 288

for anorexia nervosa 34, 162–163for bulimia nervosa 79, 162–163for obesity 225psychodrama 252

growth failure 137–138growth hormone in obesity 163

Gucciardi, E. 109guided image therapy 163Gull, Sir William Withey xv, xviii,163, 183, 302

Gundy, Feridun 308Gurenlian, Jo Ann R. 269Gustafson, T. B. 270gymnasts 50, 140

HHabermas, Tilmann xviii, 253hair, in anorexia nervosa 31Halvorson, Patricia A. xvi, 26–31,35–37, 296

Hanscom, Daniel H. 307Harman, D. 158Harms, H. P. 302Hart, Philip A. 304Hartz, Arthur 308Harvey, William 56, 181Harvey-Banting Diet 56, 114, 181Harvey-Berino, J. 232Hausmann, Armand 169Hawaiian Diet 165Hawaiian Natives, obesity in 165Hazelden 5–6, 87–88HCG 39, 165–166, 307Healthy People 2010: Objectives forImproving Health 20, 314

Heckel, P. 288Hedinger, Mary L. 175HEED (Helping End Eating Disorders)Foundation 166, 326

Heller, Rachel 85Heller, Richard 85Hellmich, Nanci 61, 276Herman, C. Peter 24, 28, 105,122–123, 198, 205, 259

Herpetz, Stephen 111Hertz, Robin 129Herzog, David 78Hewitt, J. K. 10Heymsfield, Steven 46, 275Heyward, V. H. 48high fructose corn syrup (HFCS)153–154, 166

Hill, A. J. 104Hill, James O. 212, 230, 313Hilton, Lisette 144Hirsch, J. 304, 307, 311Hirshmann, Jane R. 117Hispanics/Latinos

eating disorders in 166–167, 212obesity in 167–168, 215, 222

history of obesity and eating disordersxiii–xx

Hoek, H. W. 24Hoerr, S. L. 95Hohenwarter, Mark 311homeostasis 269homosexuality and eating disorders168–169, 195

hormones, appetite 42, 159–160,169–170, 184–185, 256, 263, 275

hospitalization, for anorexia nervosa 33hospitals, accommodating obesity in1–3

Huchard, H. xvHudson, James I. 270Huggins, Charnicia 70human chorionic gonadotropin(HCG) 39, 165–166, 307

Human Ecology Action League, Inc.(HEAL) 326

hunger 169. See also appetitedenial of, in anorexia nervosa 25, 29infant experiences in 175mind 204stomach versus mouth 169

hunger hormones 42, 159–160,169–170, 184–185, 256, 263, 275

Huynh-Do, U. 122hydrochlorothiazide 121hydrostatic weighing 67hyperactivity 170, 204hyperalimentation 170hypercellularity 170–171hypergymnasia 171hyperphagia 171hyperplastic obesity 171hypertension 171hypertrophic obesity 172hypnotherapy 53, 172hypokalemia 121, 172hypothalamic disease 172, 199hypothyroidism 289

Iice (illegal drug) 103, 173ice, craving to eat 237Illinois programs 329Ilouz, Yves-Gérard 185imipramine 39, 79, 173immigrants, obesity in 173–174immune function and dieting 174implantable gastric stimulator (IGS)42, 174, 263

infant(s)eating disorders in 174feeding disorder of 147obesity in 174–176rumination in 261

Index 355

infertilityeating disorders and 196obesity and 176, 279

inflexibility, in bulimia nervosa 77Inge, Thomas H. 57insomnia 176insulin resistance syndrome 202insurance coverage

for bariatric surgery 56, 177for eating disorders 176for obesity 176–177for panniculectomy 238

interleukin-6 (IL-6) 174, 177International Journal of Eating Disorders177

International Journal of Obesity 177International Size Acceptance Associ-ation 326

interoceptive disturbance 32,177–178

interpersonal psychotherapy 79, 178,254–255

Interview for the Diagnosis of EatingDisorders (IDED) 178

ipecac syrup 31, 178iron deficiency 193, 237isolation, in anorexia nervosa 30

JJackson, Ian T. 144Jackson, Mary 236Jackson, T. D. 90Janet, Pierre 179jaw wiring 179Jeffery, R. W. 197Jeffrey, D. Balfour 220, 224jejunocolic bypass 179jejunoileal bypass 179Jenny Craig Program 113–115, 179Job Accommodation Network 2–3jockeys 50Johanns, Mike 316Johnson, Kathy 50Jones, A. L. 153Jones, Delores 28Junshi, Chen 311–312

KKaaks, Rudolf 255–256kaolin 181Kaplan, Allan S. 279Kaplan, Arline 39Katz, B. E. 121Katz, D. L. 137Katz, J. L. 105

Katz, Rebecca 31Kaye, Walter H. 157Keel, Pamela K. 168–169, 257Keller, Ward 258Kendall, P. 89Kennedy, Donald 308Keppra (levetiracetam) 37ketogenic diet 181ketosis 181Key, Adrienne 246kidney stones and obesity 181–182Kim, K. H. 258King, M. E. 49King, P. J. 263Kirkland, Gelsey 140–141Kitsantas, A. 95–96Klassen, Michael L. 227kleptomania 78Klibanski, Anne 31Klump, Kelly L. 240, 257Knapp, Thomas R. 310Knittle, J. L. 304–305, 307Kolotkin, Ronette 272Koplan, Jeffrey 314Kotwal, Renu 38Krahn, D. D. 75Kramer, P. M. 60Kratina, Karin 278Krenn, Heidelinde 194–195Kretschmer, Ernst 72Kroger, W. S. 303Krugman, Scott D. 138Kushner, R. F. 237

Llabels, food nutrition 150–151Lacey, F. B. 306LaLanne, Jack 305Lambert, Craig 269lamotrigine 37LapBand 7–9, 57, 226, 293Largactil 41, 92–93Lasègue, Charles xv, 183, 302Laurence, W. L. 303Lawson, Willow 83–84laxative abuse 183–184

by African Americans 14by American Indians/AlaskaNatives 19–20

in anorexia nervosa 30, 183–184in anorexic bingers 36by ballet dancers 55in bulimia nervosa 75–76, 183–184complications of 183–184, 320by Hispanics/Latinos 167and osteopenia 235vocational 295

Layton, Mary Jo 84Leitenberg, H. 134Lennon, John 141leptin 42, 169, 184–185, 220, 263,275

lesbians, eating disorders in168–169

Letter of Corpulence, Addressed to thePublic (Banting) 56

levetiracetam 37Levine, James A. 215Levitt, John L. 43, 207Liebman, Bonnie 83Linn, Robert 188, 308linoleic acid, conjugate 99–100lipase inhibitors 233–234lipectomy, belt 62lipocaic 302lipoprotein lipase (LPL) 185liposuction 1, 7, 62, 185–188, 282

complications of 187–188cost of 188FDA caution on 187–188laser liquifying in 188limitations of 186–187molecular 204new techniques in 188results of 186ultrasonic 188water-jet dissection in 188

liquid formulas 188–189, 232, 251Lisser, H. xviLittrell, J. M. 50Lives of John Lennon, The (Goldman)141

Lock, J. 248Longitudinal Assessment of BariatricSurgery (LABS) 189

loop diuretics 121Lovejoy, Jennifer 249low birth weight, in African Ameri-cans 15–16

low-carb diets 51–52, 85, 190Lowenkopf, Eugene 309low-fat diet 190–191Lundholm, J. K. 50Lynch, V. 305

MMacias, A. E. 269Madley, Rebecca H. 285magical thinking 284magnetic resonance imaging 68ma huang (ephedra) 120, 132Maine, Margo 27–28Maisonet, G. 305

356 Index

Making Weight: Men’s Conflicts withFood, Weight, Shape and Appearance(Gürze) 168

malabsorptive operations 57, 63,179, 193, 226

malesanorexia nervosa in 28, 168–169,193–195

body image of 168, 194–195, 209bulimia nervosa in 76, 195–196homosexual, eating disorders in168–169

muscle dysmorphia in 209sterility in, obesity and 279

malnutrition 196psychogenic 253

mammography, obesity and 196Mandel, Debra Lorraine 265Mandell, Arnold 307Mandometer Treatment 65–66, 196Market Trends: The Online Weight Lossand Dieting Services Market 232

Marley, J. 4marriage

and eating disorders 196–197and weight gain 197

Marshall, H. M. 214Marti, A. 158Martineau, William 99Mason, Edward E. 156Massachusetts programs 326, 331Matsumoto, T. 268Mattes, R. 263Mayer, Jean 304–305, 307Mazel, Judy 62Mazur, A. 105McAnarney, E. R. 235McCay, Clive 84McCreary, D. R. 198McCurdy, John A. 119, 142, 238McElroy, S. L. 242McGinnis, J. Michael 221McIntosh, Virginia V. W. 254–255McKay, Betsy 221McKisack, C. 163McLaren-Hume, Mavis 303media influence on eating disorders197–199

Medicare and obesity 199A Medicinal Dictionary (James) xviiMedifast 189Mediterranean Diet 199–200Mehrota, C. 44melanin-stimulating hormone (MSH)169

melanocortin 64, 169melatonin 205

Menaged, Samuel E. 258Mendelson, M. 303menopause and weight gain 200menstrual dysfunction 18–19,200–201, 264–265

Meridia. See sibutramineMerkle, Elmar 260mesomorph 72, 201, 239mesotherapy 201metabolic equivalent (MET)201–202

metabolic rate, basal 58–59metabolic syndrome 61, 202metabolism 202–204metformin 40, 112metoclopramide 204Metrecal diet 114Mexican Americans. SeeHispanics/Latinos

Meyer, Adolf 280–281Michelmore, K. F. 246Midtown Manhattan Study 303Miller, O. N. 306Millman, H. 302Milloy, Stephen J. 128mind hunger 204Minnesota programs 329Mirasol 66, 328Missouri programs 329Mitan, L. A. 201Mitchell, J. E. 79, 236“model children,” anorexia nervosa in30–31

models 295Mokdad, A. H. 221molecular liposuction 204monoamine oxidase inhibitors(MAOIs) 38–39

mood disorders. See also depressionand eating disorders 204–206

Moore, Lynn 107Moreno, J. L. 252Morgan, John F. 271Morley, J. E. 106mortality rate 206, 221

in African Americans 16in anorexia nervosa 24, 206in bariatric surgery 206, 226dieting and 117in obesity 206, 221, 224

Morton, Richard xivmouth hunger 169movement therapy 206–207multicompulsive behavior 36, 78,207–208

multidimensional/multifactorial mod-els 208–209

Multifactorial Assessment of EatingDisorder Symptoms (MAEDS) 209

Munson, Suzanne 206Munter, Carol H. 117Murray, Donna 273–274muscle dysmorphia 209music 209Mussell, M. P. 129Myers, Michael D. 171MyPyramid 316Mysoline 37

NNAAFA (National Association toAdvance Fat Acceptance) 211, 326

naltrexone, for bulimia nervosa 242narcissistic personality disorder 211National Association to Advance FatAcceptance (NAAFA) 211, 326

National Center on Addiction andSubstance Abuse (CASA) 6

National Eating Disorders Association(NEDA) 211, 326

National Eating Disorders Associa-tion-Long Island (NEDA-LI) 326

National Eating Disorders ScreeningProgram (NEDSP) 212

National Health and Nutrition Exami-nation Survey (NHANES) 88–89

National Institute of EnvironmentalHealth Sciences (NIEHS), nutritionlabeling recommendations of150–151

National Institute of Mental Health(NIMH) 326

National Institutes of Health (NIH)obesity guidelines of 219research efforts of 36

National Weight Control Registry(NWCR) 212–213

Native Americans. See American Indi-ans/Alaska Natives

Naturlose 285Naudeau, J. xvNebraska programs 329NEDA (National Eating DisordersAssociation) 211, 326

NEDSP (National Eating DisordersScreening Program) 212

Nelson, Gaylord 305neotame 46Nestle, M. 247net carbs 213Neuman, Patricia A. xvi, 26–31,35–37, 296

neuroleptics 41

Index 357

Neurontin 37neuropeptide Y (NPY) 159–160, 169neurotransmitters 213–214Never Satisfied: A Cultural History ofDiets, Fantasies, and Fat (Schwartz)104

New American Eating Guide 91New Jersey programs 329New York programs 329–331Nicol, G. T. 228Nielsen, Soren 111, 271night eating syndrome (NES)214–215

Niños Activos, Familias Sanas (ActiveChildren, Healthy Families) 215

Nobakht, Minoo 258nonexercise activity thermogenesis(NEAT) 215

Norcross, John W. 309norepinephrine 213–214, 243, 273Norpramin (desipramine) 39North Carolina programs 330, 332nortriptyline 39novelties 215–216nutrients 216–217nutritional counseling 217–218Nutrition Scoreboard 91NWCR (National Weight Control Reg-istry) 212–213

OOA (Overeaters Anonymous) 113,236, 327

obesity 219–227accommodation of 1–3adolescent 9–10adult onset 11advertising and 11–13affluent sedentary society and 223in African Americans 14–17, 112,222

air pollution and 17alexithymia and 17and Alzheimer’s disease 17–18AMA guidelines in 226in American Indians/AlaskanNatives 20

anticonvulsants for 38arthritis link to 44in Asians/Pacific Islander Ameri-cans 47

asthma link to 48–50attitudes toward 227–228,273–274

behavior modification for 59–61,225

benefits of 223–224versus binge-eating disorder 64biological clock factor in 222body image in 71body mass index in 71–72, 219brain activity and 72–73breakfast and 73–74Bruch’s classification of 74cancer links to 84–85, 223,250–251

and cataracts 86causes of 220childhood. See childhood obesitychronology of 302–316class and 222, 228–229, 277cognitive therapy for 94complement factors and 97–98conditions associated with 219

costs to treat 101–102craving and 102–103creeping 103, 133, 142depression and 110, 220developmental 74diabetes and 22, 89, 111–112diet therapy for. See diet(s); dietingearly dietary excess and 222emotional overeating and 220–221employee health costs of 129–130endocrine factors in 131externality approach to 42, 135extreme 135family environment and 222family therapy for 140fat virus and 146fructose as contributor to 153–154,166

genetic factors in 158–159, 220,222

global epidemic of 160gonads 161government role in combating161–162

group therapy for 225growth hormone in 163in Hawaiian Natives 165hCG therapy for 39, 165–166, 307health complications of 223in Hispanics/Latinos 167–168, 215,222

hyperplastic 171hypertrophic 172hypnotherapy for 172hypothalamic disease and 172in immigrants 173–174infant 174–176and infertility 176, 279insurance coverage for 176–177

interoceptive disturbance in177–178

and kidney stones 181–182life expectancy in 223–224and mammography 196marriage and 197Medicare and 199menopause and 200and metabolic syndrome 202metabolism in 203morphology of fat tissue and 222mortality in 206, 221, 224nutritional counseling for 217–218oral contraceptive use in 232–233pharmacotherapy for 39–41,225–226, 242, 260, 273, 299

physical activity and 225, 243–244pituitary 245polycystic ovary syndrome and246

portion/serving sizes and 247pregnancy and 248–250prevalence of 221–222and prostate cancer 250–251psychodynamic approach to 42,253

psychological effects of 224psychological time-bomb theory of223

public policy and 255–256PYY and 256reactive 74, 257religion and 258restaurant eating and 259risk factors for 221–223schools and 263–264self-esteem and 265sexuality and 271–273social factors in 277social learning theory of 220, 223spinal cord injury and 278and sterility 279sugar and 282–283surgery for 56–58, 226. See alsobariatric surgery

television and 286–287thermodynamic approach to 288thrifty gene hypothesis of 15, 20,288

treatment of 224–228in workplace 230wound healing in 298

obesity-hypoventilation syndrome(OHS) 229–230

Obesity Management 230Obesity Working Group (OWG)230–231

358 Index

obesophobic 231obligatory exercise 22–23O’Brien, Richard M. 309–310O’Brien, Robert 81Obsessions et la psychasthénie, Les(Janet) 179

obstructive sleep apnea/hypoventila-tion 229–230

O’Connor, J. 10Oklahoma programs 330olanzapine 242Olden, Kevin W. 262Older Americans 2004: Key Indicators ofWell-Being 128–129

olestra 145, 231, 335Olsen, Mary-Kate 141, 250Olshansky, S. Jay xixondansetron 242Ondercin, P. 99O’Neill, Cherry Boone 141online dieting 231–232, 337online promotion of eating disorders250

online resources ix, 336–337Optifast 117, 189, 232oral contraceptives 232–233oral nutritional supplements 233oral soft tissues 233orexin 169orlistat 39–40, 225, 233–234, 299Orrell-Valente, J. K. 43, 252orthorexia nervosa (ON) 234O’Shea, Michael 86osteitis fibrosa 235osteomalacia 235osteopenia 31, 234–236osteoporosis 234–236Ostopowitz, Elizabeth 304OTC diet pills 120Overcoming Night Eating Syndrome(Stunkard, Allison and Thier)214–215

Overcoming Overeating (Hirshmann andMunter) 117

Overeaters Anonymous (OA) 113,236, 326

overeating, emotional 220–221overgeneralization 94overweight, definition of 219overweight bulimia nervosa 236oxcarbazepine 37

Ppagophagia 237, 245pamabrom 122Pamelor 39

pancreatic polypeptide (PP) 237panniculectomy 237–238parental factors

in anorexia nervosa 26–27,138–140, 238, 322

in bulimia nervosa 76–77, 322in obesity 222

Park, Alice 40–41, 184paroxetine 39Parrish, R. E. 306Partnership for Healthy Weight Man-agement 115

passive exercise machines 238pathophysiology 238–239Patterson, Ruth E. 272Patton, George 32Pauli, Eric 279Pavarotti, Luciano 308Pavlov, Ivan 53, 302Paxil 39pear shape 61Pecoraro, Norman 96–97peer relationships

and anorexia nervosa 28of obese children 89–90

Pennington Diet 181Pennsylvania programs 330, 332Percy, Charles 308perfectionism 239perimylolysis 239–240Perlstein, I. B. 304personalities of eating-disorderedindividuals 30–32, 157, 211, 239,240

personality disorder 240–241narcissistic 211

personalization 94Pescatore, Fred 190pharmacotherapy 241–243. See also

specific disordersphenelzine, for bulimia nervosa 79phenmetrazine 303phenobarbital 37phen-Pro 243phentermine 21, 40, 149, 225

with fluoxetine (phen-Pro) 243phenylpropanolamine (PPA) 120,243, 309–310

phenytoin 37phthisic body type 72physical activity and obesity 225,243–244

Physical Dictionary (Blankaart) xviiphysiological arousal 244pica 159, 181, 237, 244–245Pickering, A. S. 198pickwickian syndrome 229–230

Pike, K. M. 217Pima Indians 20pimozide 41, 245, 284pituitary obesity 245placebo 245pobough lang 159Polivy, Janet 24, 28, 105, 117–118,122–123, 198, 205, 224, 259

polycystic ovary syndrome (PCOS)176, 245–246

polyphagia 246ponderosity 246–247Pondimin 149, 225, 314Pope, Harrison G. 209, 270Pop-Jordanova, N. 65Popkin, B. M. 191portion and serving sizes 247positron emission tomography (PET),in obesity 72–73

post-traumatic effect 247potassium deficiency 31, 121, 172potassium-sparing diuretics 121Powers, P. S. 41Prader-Willi syndrome (PWS) 247pregnancy

bariatric surgery and 58, 193dieting during 249and eating disorders 248and obesity 248–250pica in 244–245

Preludin (phenmetrazine) 303Premachandra, B. N. 304premenstrual syndrome 204–205primidone 37pro-ana movement 250pro-ED 250Prolinn 188PROP 285–286prostate cancer, and obesity 250–251Protein Power Diet 181, 190proteins 251protein-sparing modified fast (PSMF)232, 251

Prout, T. E. 305Prozac 251–252, 314

for anorexia nervosa 34, 38–39,252

for binge-eating disorder 39, 242for bulimia nervosa 39, 79, 242mechanism of action 251with phentermine (phen-Pro) 243side effects of 251–252in smoking cessation 276

psychodrama 43, 252–253psychodynamic approach to obesity42, 253

psychogenic malnutrition 253

Index 359

psychogenic vomiting 253psychological time-bomb theory, ofobesity 223

psychosomatic medicine 253psychotherapy 253–255, 287–288.See also specific types

psychotropic drugs 255puberty 255public policy and obesity 255–256Puhl, R. M. 274purging 256. See also bulimia nervosaPutnam, Judy 83pyknic body type 72Pyle, Richard L. 208PYY (peptide YY3-36) 42, 169, 256,263

QQuagliani, Diane 137Quincy, John xvii

Rrace. See specific racesRacette, Susan B. 132, 200Rappaport, Lou 198Ravaldi, C. 55Ray, Shannon L. 168Rayworth, B. B. 270reactive obesity 74, 257Redux 149, 225, 313–314Reilly, John J. 10religion

and eating disorders 257–258and obesity 258

religious fasting xv, 23, 141, 257–258Remuda Ranch 130–131, 258, 290,328

Renfrew Centers 139, 258–259, 270,329–330

researchin anorexia nervosa 36empirical 129epidemiological 132

Research on Interventions forAnorexia Nervosa (RIAN) 36

restaurant eating and obesity 259Restraint Scale 259restraint scale 118restrictive operations 7–9, 57,156–157, 226, 260–261, 293

restrictor anorexics 36–37, 260Revivarant 156Rexrode, Kathryn 314Rhode Island programs 330Richards, Dean 4

Richardson, H. E. 302Richardson, P. H. 4Rick, A. M. 197Rigby, Cathy 50, 140rigidity, in bulimia nervosa 77Rigotti, Nancy A. 235, 310rimonabant 40, 260Ripamonte, Leonor E. 166Rippe, James 243Robertson, Donald S. 297Robertson, J. D. 302Robert Wood Johnson Foundation 3Rodin, G. 110–111Rodin, Judith 220, 285, 308Role of Media in Childhood Obesity, The16

Rosen, James C. 66, 134Rosenzweig, Margaret 298Rosmond, R. 110Rossi, A. 252Roth, Geneen 204Roux-en-Y gastric bypass 57, 122,193, 226, 260–261

Rudy, E. B. 6rumination 261–262runners 134, 195Russell, C. J. 168–169Russell, Gerald F. M. 75, 88, 262Rutter, Michael 280–281Ryley, David 176Rynearson, E. H. 302

Ssaccharin 45, 307St. Jeor, Sachiko 137Salata, D. R. 306Sansone, Randy A. 43, 207Santana, C. 41Saris, Wim H. M. 299Satcher, David 314satiety 263

cholecystokinin and 93early 125infant experiences in 175pancreatic polypeptide and 237

saturated fats 145Sawrer, D. B. 270Schachter, Stanley 135Schapira, David V. 69Schardt, David 285Schmidt, V. H. 281schools and obesity 263–264Schotte, David E. 75Schwartz, Hillel 104, 116–118, 216Schwartz, Marlene B. 228SCOFF Questionnaire 264

Sculpturing Your Body: Diet, Exercise andLipo (Fat) Suction (McCurdy) 119

seasonal affective disorder (SAD)204–205

secondary amenorrhea 18, 264–265See, Jackie R. 311seizures, and eating disorders 37–38selective serotonin reuptake inhibitors38–39, 241–242

self-esteem 78, 240, 265self-help groups 265–267self-monitoring 267–268self-mutilation 36, 268Selvini-Palazzoli, Mara xvi, 138serotonin 38, 109, 205, 213, 243,268, 269, 273

Serpell, Lucy 239sertraline 39, 242, 276serving sizes 247set point

amphetamines and 21appetite suppressants and 43

set-point theory 269–270Sex Role Attribute Inventory 265sexual abuse

and eating disorders 208, 270–271and multicompulsive behavior 208

sexualityin anorexia nervosa 30, 271in bulimia nervosa 78, 271and eating disorders 271of males with eating disorders168–169, 194

and obesity 271–273Shaheen, Sheif 48Shalala, Donna 314Shapiro, Howard 190Sheedy, Ally 141Sheldon, William 72, 238–239Shell, William E. 311Sherman, Walter 303Sherwin, Robert 308“should” statements 94Shure, Jane 270sialadenosis 273sibutramine 39–40, 65, 225, 242,263, 273, 314

Siega-Riz, A. M. 249–250Siegel, Michele 99–100, 217Sigler, Jamie-Lynn 141Simmonds, Morris xviSimmonds’ disease xviSimmons, E. 305Simone Porta xivSimonson, Maria 209Simon v. Blue Cross and Blue Shield ofGreater New York 176

360 Index

Simplesse 145, 273, 311, 333sitomania (sitophobia) 92, 273size discrimination 273–274skin, in anorexia nervosa 31skin fold measurement 47–48,67–68, 274–275, 302

Skinner, B. F. 302Slade, Peter D. 239sleep deprivation and weight gain275

sleep-related eating disorder (SRED)276

Slim-Fast 114Smith, M. S. 80smoking, and body fat distribution69–70

smoking cessation, and weight gain276–277

Smolak, Linda 239Snowbird Diet, The (Robertson) 297Sobal, Jeffery 104–105, 228, 258Sobel, Stephen V. 255social factors in obesity 277social learning theory, of obesity 220,223

Sociocultural Attitudes TowardsAppearance Scale-3 (SATAQ-3)277–278

socioeconomic statusand anorexia nervosa 23, 25and obesity 222, 228–229, 277

sodium pump 278solid foods, and infant obesity174–175

Soltmann, O. xviiiSothern, M. S. 264South Beach Diet 114, 181, 190, 278South Carolina programs 330Spake, Amanda 133, 160spinal cord injury and obesity 278spironolactone 121Splendid (fat substitute) 145spot reducing 278Squires, Sally 146Srole, Lee 303Staniger, Cora 308Stanten, Michele 49starch blockers 278–279starvation, in anorexia nervosa31–32

starvation response, in dieting 117starvation syndrome 279Starving for Attention (O’Neill) 141steatopygia 279Stein, Rob 174Stein-Leventhal syndrome. See poly-cystic ovary syndrome (PCOS)

Stellar (fat substitute) 145sterility, and obesity 279Stettler, Nicolas 15stevia 279–280Stewart, Tiffany M. 267Stillman Diet 181stimulus control 280Stolley, Melinda 20, 47stomach hunger 169stomach stapling 280St-Onge, M. P. 46Strand, Erik 234Strang, J. M. 303Strauss, Richard 89stress

and anorexia nervosa 25–26,281–282

comfort food and 96–97, 282cortisol release in 100–101, 282and eating disorders 280–282and weight gain 282

Striegel-Moore, Ruth H. 214, 239Strober, M. 53Study of Women’s Health across theNation (SWAN) 15, 200

Stuht, Jennifer 267Stunkard, Albert J. 75, 90, 110,214–215, 277, 303, 309–310

Stunko, Ronald T. 311subcutaneous fat 282substance dependence 4–5, 87–88,207–208

sucralose 45sugar 282–283sugar substitutes 45–46, 279–280,282, 285

suicide 283–284in anorexia nervosa 32, 36, 204,283

in bulimia nervosa 78, 208, 283substance abuse and 208

sulpiride 41, 284superstitious thinking 94, 284Superwoman syndrome 26support groups 285Surgeon General’s Call to Action to Pre-vent and Decrease Overweight and Obe-sity, The 263–264, 315

Surviving an Eating Disorder (Siegel,Brisman, and Weinshel) 217

sweeteners, artificial 45–46, 282swimmers 50Swithers, Susan E. 46symbolization, in atypical anorexianervosa 52–53

syndrome X 61, 202synephrine 120

Ttagatose 285Taller, Herman 304Tallmadge, Katherine 82Tanofsky-Kraff, M. 214Tantleff-Dunn, Stacey 194, 198taste 285–286Tataranni, Antonio 72–73Taufig, A. Ziah 188Tavares, Damien, III 165tax deductions 286taxon 286teas, dieter’s 115–116teasing, of obese children 90Teegarden, Dorothy 81–82Tegretol 37television and obesity 286–287Tenuate 287Tepperman, J. 305Texas programs 330–331Thelen, M. H. 80therapy 287–288. See also specific typesthermodynamic approach to obesity288

thermogenesis, nonexercise activity215

thermogenic drugs 288thiazide diuretics 121thin fat people 36, 288Thin Game, The (Bayrd) 62, 86thinness, ideal of 103–106Thompson, Ed 161–162Thompson, Ian M. 250–251Thompson, Tommy G. 150, 315–316Thompson-Brenner, H. 79Thorazine 41, 92–93Thorndike, Edward 302Thornton, Billy Bob 141thrifty genes 15, 20, 288thymoleptic medications 289thyroid disease 289thyroid hormone (thyroxine) 289tiagabine 37Tiggemann, M. 198Time/ABC News Obesity Summit 12Timm, Alfred 308Timm, Robert, III 165Tofranil 39, 79, 173Toner, Brenda B. 205topiramate (Topamax) 37–38, 242,276

TOPS (Take Off Pounds Sensibly) 60,113, 289–290, 308, 327

Torgan, Carol 89total parenteral nutrition (TPN) 151,170

Index 361

Traffic Light Diet 91, 290Trager, Stuart 130trans fat 150, 290trazodone (Deseryl) 38treatment centers 328–331Tremblay, Angelo 82triamterene 121trichophagia 290tricyclic antidepressants 38–39Trileptal 37Troop, Nicholas 239Tsai, Adam Gilden 236, 266, 298tube feeding 151, 290–291Tucker, Katherine 62Tucker, Larry A. 287tummy tuck 1, 7, 291tumor necrosis factor-alpha 17412-step programs 6–7, 236twin studies of eating disorders 10,27, 291

UUltrafast 189ultrasonic liposuction (UAL) 188ultrasound 68uncoupling proteins (UCPs) 169Underwood, Anne 69unsaturated fats 145Utah programs 331

Vvalproate 37van Binsbergen, C. J. M. 31Van Cauter, Eve 275Van Dale, Djoeke 299Vandereycken, Walter xvii, xiv–xv, 5,138

Vanderlinden, Johan 138Vander Wal, J. S. 167Van Deth, Ron xvii, xiv–xvvan Hoeken, D. 24van Prohaska, J. 302vegetarian diet and eating disorders293

Veneman, Ann M. 315–316Venus of Willendorf xiiiVermont programs 331vertical banded gastroplasty (VBG)57, 226, 293

very low-calorie diet (VLCD) 225,232, 293–294

Veugelers, P. J. 264vibrator belts 294–295vicious cycle, of dieting 117–118

Vincent, C. A. 4Vincent, L. M. 309visceral fat 61, 295vitamin deficiency 295vocational bulimics 295vomiting 256, 295–296

in anorexic bingers 36in bulimia nervosa 76, 78,295–296

complications of 296, 320and dental caries 109and hypokalemia 172ipecac syrup-induced 31, 178and osteopenia 235psychogenic 253

Von Noorden, C. 302–303

WWadden, Thomas A. 189, 232, 267,311–312

waist-to-hip ratio (WHR) 297Waitman, Jonathan A. 242Walford, Roy L. 310Waller, G. 163, 270Walsh, B. Timothy 41, 157, 252, 312Wang, Gene-Jack 73Warden, Thomas 12Washington programs 331Wasson, Diane H. 236water 297Watson, Tureka 241Webster, Peter 254weekend calories 297–298Weigel, David S. 41weight cycling 299–300weight gain. See also obesity

by college students 95, 152–153marriage and 197menopause and 200mood disorders and 204oral contraceptives and 232–233pregnancy and 248–250sleep deprivation and 275smoking cessation and 276–277stress and 282sugar and 282–283thyroid disease and 289

weightlifters 194–195, 209weight loss. See diet(s); dietingweight phobia 29, 32–33, 298weight reduction camps 331–332Weight Watchers 60, 113–115, 298,305, 327

Weindruch, Richard 310Weiner, R. 8

Weinshel, Margot 99–100, 217Weintraub, M. 149Wellbutrin 39Wennerstrand, Anne L. 207Wergowske, Gilbert 165Whittal, M. L. 79Wilfley, Denise 255Williamson, David 311Williamson, Don 42Williamson, Donald 70–71Wilmoth, Debbie 298Wilson, Gregory L. 220, 224Winfrey, Oprah 189, 232Wing, Rena 212Winston, Anthony 254Witherspoon, Barbara 298Wolpe, J. 303Women’s Healthy Lifestyle Project 200Woodard, C. B. 193Woods, Stephen C. 40Woodside, D. Blake 195Woodward, Edward R. 310workplace, obesity in 230wound healing 298wrestlers 50Wright, C. E. 246Wright, P. 63Wurtman, Judith J. 102–103, 309Wurtman, Richard J. 102–103Wyden, Ron 311

XXenical 39–40, 225, 233–234, 299

YYager, Joel 168, 240Yancy, W. S., Jr. 190Yanovski, S. Z. 214Yates, William R. 241Yee, D. K. 75Young, L. R. 247Young, Mary Evans 312yo-yo dieting 299–300

ZZametkin, A. J. 49, 277Zarontin 37Zemel, Michael 82, 107zinc deficiency 31, 34, 300Zoloft 39, 242, 276Zone diet 181, 190zonisamide (Zonegran) 37–38Zuercher, J. L. 290

362 Index