Transcript PsY 472 Psychology of Food - Buffalo State College Faculty

Many Areas within Psychology
Sensation and perception
 Cognition
 Social
 Clinical
 Health
 Developmental

History of Healthy Eating
 1824—The
Family Oracle of Good
Health—United Kingdom
 US in 1800s
 Boer War Parent education classes
about healthy diet
 Great
 WWII
Depression in US
Healthy Eating
Food is divided into
different groups
Fruit and
vegetables
Bread, pasta, other
cereals, potatoes
Meat, fish, and
alternatives
Milk and dairy
products
Fatty and sugary
foods
Additional Recommendations
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Balancing Calories
Enjoy your food, but eat less.
 Avoid oversized portions.
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Foods to Increase
 Make half your plate fruits and vegetables.
 Make at least half your grains whole grains.
 Switch to fat-free or low-fat (1%) milk.
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Foods to Reduce
 Compare sodium in foods like soup, bread, and
frozen meals and choose the foods with lower
numbers.
 Drink water instead of sugary drinks.
The Role of Diet in Contributing
to Illness

Diet and coronary heart disease
 Incidence increased steadily from 1925 to
1977 (except for a dip in WWII)
 Remains single largest cause of death in US
 CHD involves three stages
○ Atherscerlosis—narrowing of arteries
○ Thrombosis—a blood clot—may result in sudden
death, heart attack, angina
○ State of the myocardium—the impact of the clot
depends on this
Diet and Blood Pressure
Hypertension is one of the main risk factors for
coronary heart disease and is linked with heart
attacks, angina, and strokes
 Salt
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 Recommend salt intake of less than 6g per day
 59% of salt that we consume is used in the processing of
food
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Alcohol
 Heavy drinkers have higher rates of hypertension
 Some benefits to drinking in light to moderate
consumption
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Micronutrients
 Components of diet hypothesized to lower bp
Diet and Cancer
Diet accounts for more variance in cancer
than any other factor, even smoking
 Two theories
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 Foods contain nonnutrients that trigger cancer
(cause mutations)
 Poor diets weaken defense mechanisms
Esophogeal cancer
Stomach cancer
Large intestine cancer
 Breast cancer
 Fiber and soy are protective
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Role of Diet in Treating Illness
 Coronary
Heart Disease
 Lifestyle changes
 Diabetes
 Diet is central to both Type 1 and Type 2
 But improving self-care is difficult task
 Social cognition theories are being used
in interventions
Children’s Diet
Correlations between children’s diet and
diets later on
 Also linked with later adult health
 Western Hemisphere
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 Nicklas, 1995—majority of 10 year olds exceed
American Heart Association recommendations
for total fat, saturated fat, and dietary cholesterol
 Other studies find inadequate intake of fruits and
veggies—only 5% of kids exceed recommended
intake
 About 10% of kids in US are malnourished
 Internationally, it is about 18%, with 30% in subSaharan Africa
Young Adults
Eating habits are established in childhood
 Wardle et al, 1997
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 16,000 male and female students 18-24 in
Europe
○ 39% try to avoid fat
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2001 study in UK aged 19-24
 98% ate less than 5 portions of fruit and veggies
daily
 Averaged 8-9 cans of soft drinks per week, up
from 3-4 in 1986-1987
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Similar results seen in adults and the elderly
Measuring Food Intake
 Three
primary ways:
 In the laboratory
 Self-report measures
 “How often do you eat X?”
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Observational methods
Food Choice
Why do people eat what they eat?
 Three basic ways to look at this today:
 Developmentally
 Cognitively
 Psychophysiologically
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Developmental Models: Early
Work
 Davis,
1928, 1939
 Studied infants and young children in a
peds ward
○ Had a strict feeding regimen
○ Offered 10-12 healthy foods and kids were
free to eat what they chose
○ Children selected diet consistent with growth
and health
○ Generated a theory of the “wisdom of the
body”
Developmental Models:
Exposure
Need to consume variety of foods for a balanced
diet
 Yet show a fear or avoidance of novel foods-neophobia
 This is the omnivore’s paradox
 Mere exposure to novel foods can change
preferences
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 Birch &Marlin (1982) gave 2 year olds novel foods over 6
weeks
 Williams et al 2008
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Learned safety
 Studies show just looking at novel foods is not enough to
change preference—must taste
Developmental Models: Social
Learning
 Peers
○ Duncker, 1938—social suggestion
○ Birch, 1980
○ Salvy, 2007
 Parents
○ Adolescents are more likely to eat breakfast if their
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parents do
Correlation between child and parent emotional eating
Children select different foods when watched by their
parents
Correlation between mothers’ and preschool kids’ food
intakes for most nutrients
Not always in line with each other
 Wardle, 1995—parents reported health as more important for
kids than for themselves
 Dieting mothers may feed more of the foods they are denying
themselves to their children
Developmental Models: Social
Learning
 The
media
 Radnitz et al, 2009
○ Analyzed nutritional content of food on tv
programs aimed at kids under 5
 Eyton The Plan F Diet
 Halford et al, 2004
○ Lean, overweight, and obese children were
shown a series of food-related and non-food
related ads
○ All children ate more after exposure to ads
Developmental Models:
Associative Learning
 Rewarding food choice
○ Giving food in association with positive attention
increases food preference
 Food as a reward
○ If you’re well behaved, you can have a cookie
○ Food acceptance increased if food was presented
as a reward
○ But not food preference…
 Food and control
○ Restricting access and forbidding foods makes
foods more attractive—Birch, 1999
 Food and physiological consequences
Cognitive Models
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Most research focuses on social cognition
 Some of these look at behavioral intention;
others at actual behavior
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In general, the models incorporate
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Attitude toward a given behavior
Risk perception
Perceptions of severity of the problem
Costs and benefits of a behavior
Self-efficacy
Past behavior
Social norms
Intention-Behavior Gap
Attitudes are the best predictors of
things like eating in fast food
restaurants, use of table salt, healthy
eating
 Perceived behavioral control
 Other factors like nutritional knowledge,
perceived social support, and
descriptive norms don’t add much to the
model
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Psychophysiological Models
 Hunger—a
state that follows food
deprivation and reflects a motivation
or drive to eat
 Satiety—the polar opposite
 This approach looks at cognitions,
behavior and physiology
Metabolic Models
 Homeostasis—beginning
of 19th
century
 Walter Cannon
 Biological variables are regulated within
defined limits
 Maintained via a negative feedback loop—
we adjust behavior to meet needs
 Set
point
 More recently—cellular energy
Hypothalamus
 Area
of brain associated with feeding
 Early clues—patients with tumors of
the basal hypothalamus who became
obese
 Experimentally induced lesions to
hypothalamus in animals
Neurotransmitters and drugs
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Neurotransmitters that increase intake
 Norepinephrine
 Neuropeptide Y
 Galanin
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Neurotransmitters that decrease intake
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Serotonin
Bombesin
Corticotropin-releasing hormone (CRH)
Cholecystokinin (CCK)
Psychopharmacological drugs
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Nicotine
Amphetamine
Marijuana
Alcohol
Antipsychotic drugs
Tricyclics
SSRIs
Analgesics
Food and Cognition
Caffeine
 Carbohydrates
 Chocolate
 Stress and eating
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 Some research shows stress causes a
reduction in food intake
 Some research shows an increase in eating
by females but not males
 Mindless eating
○ Can be good if used to encourage healthy eating
The Meaning of Food
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This includes…
 Food classification systems
 Food as a statement of the self
 Food as a social interaction
 Food as cultural identity
Food Classification Systems
Levi-Strauss (1965) and Douglas (1966) argued
that food can be understood as a deep
underlying structure—common across cultures
 Helman (1984)—5 types of food classification
systems
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Food vs. nonfood—what is edible and what is not
Sacred vs. profane food
Parallel food classifications
Food as medicine, medicine as food
Social foods
Alternatively, -- meaning of individual foods
Food and Gender and
Sexuality
•Cooking
as a traditional female
activity
•Lots of animal and food related
words have meanings related to
sex and men/women
•Lots of double meanings in
food-related activities
•Cecil (1929)—
•19th and early 20th centuries
Low-meat diets were
recommended to
discourage masturbation
in males
Food and Gender
 Eating
versus denial
 Charles & Kerr (1986, 1987)
○ Studied 200 mothers in northern England
 Silverstein et al, 1986
○ Studied images in magazines
 Men’s—10 food ads, 10 sweet ads, 1 diet food ads
 Women’s –1,179 food ads, 359 food ads, 63 diet
food ads
Food and Guilt, and Self-Control
Some foods are
associated with
conflict between
pleasure and guilt
 Food and selfcontrol
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 Fasting as a
religious act
 19th century—
hunger artists
 Anorexia
Food as a Social Interaction
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Dinner table is often
the only place where
the family gets
together
Tool for
communication—
Forum for sharing
experiences
Sense of group
identity
The meal as love
Power relations
Food as Cultural Identity
 Food
as religious identity
 Rituals of food preparation provide a
sense of holiness in daily domestic work
 Food
as social power
 Powerful individuals eat well and are fed
well by others
 Statement of social status

Hunger strikes
Marketing of Food
Exposure to food advertisements
 FTC reported that average child (2-11)
sees 15 television food ads per day
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 5500 per year
 Adolescents see about 5% fewer
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Powell et al, 2007
 About 28% of ads viewed by African
American kids and 25% of ads viewed by
white kids are for food.
Children’s Food and Beverage
Advertising Initiative
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2004—marketers vowed decrease
2006---Children’s Food and Beverage Advertising
Initiative (CFBAI),
 Abstain from advertising or to advertise only “better- for-you”
foods to children under the age of 12 years.
Some loopholes exist
In 2008, results indicated that food advertising to
children was down about 4% (1/2 ad) from 2002,
and down 13% from 2004 peak
 An update in 2010 showed increases in many of
the ads that were on the decline in 2008
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Better for You Foods
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Kid Cuisine Deep Sea Adventure Fish
Sticks
Kid Cuisine KC’s Primo Pepperoni
Double Stuffed Pizza
Chef Boyardee Microwave Bowls Bite Size Beef Ravioli
Chef Boyardee Two Pepperoni Pizza
Kit
Peter Pan Creamy Peanut Butter
Peter Pan Crunchy Peanut Butter
Cinnamon Toast Crunch
Cocoa Puffs
Cookie Crisp
Honey Nut Cheerios
Chocolate Lucky Charms
Reese’s Puffs
Trix
Yoplait Go-Gurt Fruit Flavors
Fruit Roll-Ups
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McDonalds , USA
Chicken Nuggets Happy Meal
 4 Piece Chicken McNuggets
 Apple Dippers with Low-Fat
Caramel Apple Dip
 1% Low-Fat White Milk
Hamburger Happy Meal
 Hamburger
 Apple Dippers with Low-Fat
Caramel Apple Dip
 1% Low-Fat White Milk
Kellogg’s Frosted Flakes® (all flavors)
Froot Loops® (all flavors except
marshmallow)
Apple Jacks®
Rice Krispies® (all flavors)
Cocoa Krispies®
Eggo® Waffles (all flavors except
Chocolate Chip)
Gripz® Cookies
What do parents think? (Rudd
Center, 2010)
Low awareness of food marketing and its
impacts on kids
 Believe that limiting exposure to food
marketing is a parents job
 Some positive attitudes toward marketing.
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 Enjoyed seeing idealized families in ads
 Believed that advertising can be fun and
informative
 Some advertising promotes foods that are
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But…annoyed that marketing often makes
their children demand certain foods
Public Perceptions (Rudd Center,
2009)
Reported that children saw marketing for
unhealthy foods less often than they do
and for healthy foods more often than they
do
 Reported that children saw food marketing
on television most frequently, followed by
characters on packages, logos on other
products, and product placements, and
least frequently through text messages.
 Underreported how frequently children saw
this marketing
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Solutions Elsewhere
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Solutions at the Government Level:
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Ban advertising to children in general
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Ban TV advertisements during breaks for
all programs
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Ban junk food advertisements during
children’s TV programs (age 16 and under)
Ban TV advertisements in general during Austria Norway Denmark
children’s programs
Belgium Sweden
Ban TV advertisements right before and
Belgium
after children’s programs
Sweden
Create a law indicating that advertisements France
for unhealthy foods must accompany
nutrition message disclaimers
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Countries that have
already implemented the
particular solution
Sweden (under age 12)
Quebec (under age 13)
Denmark
France (on state-owned
channels)
Britain
How does this affect children’s
behavior?
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Messages in food ads
 Snacking at nonmeal times in 58% of ads
 Only 11% of food ads are set in kitchen, dining
room, or restaurant
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Effects of food marketing exposure
 Increases preferences for foods and requests to
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parents for those foods
Increases consumption in the short term
Most studies are on television ads
Often in lab settings, for example…
Quebec
Indirect effects
Mechanisms of Food Marketing
Effects
 Generally
assumed to follow an
information-processing approach
 Marketing effects follow a path from
exposure to behavior
 Mediated by preferences, attitudes, and
beliefs about the products
 Related—greater cognitive maturity
reduces the effects as kids become able
to defend against marketing messages
This Model is Limited
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But these ideas were developed in
1970s, and times have changed
 For example, marketers work to create
brand images and associations, not only to
create the belief that their product is superior
 Associations are developed over a long time
 Food marketing may also serve as an
environmental cue
 Old assumptions about the age of children
and the effect of ads may also be wrong
The Meaning of Size
Media Representations
 Paek et al 2011—Study of television ads across 7
countries
 Males featured in prominent auditory and visual roles
 Women still generally in stereotypical roles
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Glascock & Preston-Schreck, 2004
 Studied 50 comic strips over a month
 Gender roles –stereotypical
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Newspapers
Television—Desmond and Danielewicz, 2010
 Female reporters—more likely to present human interest
and health-related stories
 Male reporters—more likely to present political stories
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Magazines—Spees and Zimmerman, 2002
 Belief that boys are stronger/more athletic in 41%
 Belief that appearance is important for girls in 54%
Images of Female Body Size and
Shape
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Ideal woman’s
body has become
smaller over the
past century
 Rubenesque—
1600s—
reproductive figure
 1800s—Courbet
 Manet’s Olympia of
1863—
Modern History
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Current preference goes back to flapper look of 1920s
Some respite after WWII—Marilyn Monroe, Jane Russell
End of 1950s—Audrey Hepburn, Grace Kelly
1960s—Twiggy
Spitzer et al 1999
○ Compared mean body mass indices from 18-24 yo from 11
national health surveys to Miss America and Playboy models and
Playgirl models
○ From 1950s to 1990s
○ Over decades, body sizes of Miss American decreased
significantly, Playboy models were below normal weight
○ Playgirl models increased—due to muscularity
 If the average woman wanted to look like Barbie, she
would have to be 24 inches taller, make her chest 5
inches bigger, her neck 3.2 inches longer, and decrease
her waist by 6 inches
Images of Male Body Size and
Shape
Greek and Roman art
 Male body does not exist quite as much
as an object of idealization until fairly
recently
 Male models are increasingly hairless,
well toned, and narrow hipped
 To be Ken, be 20 inches taller, chest 11
inches larger, neck 7.9 inches thicker
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The Meaning of Sex
 Classic
work on sex stereotypes
 1960s and 1970s
 Clear consistency about what a
hypothetical man or woman should be
like
 Women—warm, expressive, sensitive
 Man—active, objective, independent,
aggressive, direct
Meaning of Size: Quantitative
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Cross-cuturally, people of all ages and both sex
stigmatize and discriminate against obese
people
Rated as more unattractive, lacking in selfdiscipline, unpopular
Less active, intelligent, hardworking, successful,
athletic, or popular
Fat women are judged more negatively than fat
men
Stereotypes are independent of the body size of
the person doing the rating
Associations develop at a young age
 Hansson and Rasmussen, 2010
Meaning of Size: Qualitative
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Control
 Ability to control self indicates will power, resisting
temptation
 Control of inner world over consumerism
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Freedom
 Thinness provides some freedom from class
 Freedom from reproduction
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Success
 Not consistent across cultures
○ Mco, Dick, &Steyn, 1999—Cape Town, South Africa
 Studied overweight poor black women
 Placed high value on food—food was often scarce, so voluntarily
regulating food would be unacceptable
 Overweight kids seen as a sign of health
○ Similar findings in other poor countries
Why are the obese and overweight
judged so negatively in the West?
Viewed as fault of person
 Obese may be viewed as overweight to
compensate for other problems
 Simply gluttonous
 Women are viewed more positively if
they eat lightly in public
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Body Dissatisfaction
 Body
image
 The picture of our own body which we
form in our mind
 Body
dissatisfaction
 As a distorted body image
 As a discrepancy from the ideal
 As a negative response to the body
Who is dissatisfied with their
bodies?
Women
 Normal weight women prefer an ideal size that
is smaller than their own
 Women show more body dissatisfaction than
men
 Most dissatisfied with stomach, thighs,
buttocks, and hips
 Surveys show that between 50 and 80% or
more of women are dissatisfied with their
weight
 This dissatisfaction starts at a young age—
kids as young as 6 or 7
Who is dissatisfied with their
bodies?
Men
 Compared to women, men’s satisfaction is
higher
 But men also show dissatisfaction
 Up to 75% show discrepancy between
perceived ideal and actual size
Most dissatisfied with biceps, shoulders,
chest
 Many want to be more muscular
 Gay men tend to report more dissatisfaction
than straight men
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Causes of Body Dissatisfaction
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Media
 Most commonly held belief in lay (and
professional) community
 Thin ideal
 Social comparison
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Culture
The Family
 Mothers who are dissatisfied with their own
bodies communicate this to the their daughters,
resulting in daughters’ body dissatisfaction
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Psychological factors
 Perfectionism
Consequences of Body
Dissatisfaction
Women
 Dieting—about 40% diet at any one
time, up to 70% or more in lifetime
 Exercise
 Women exercise less than men
 Exercise more than they used to
 Cosmetic
surgery
Consequences of Body
Dissatisfaction
Men
 Less likely to diet
 More likely to engage in both team
and solo sports
 Main motivators for men for exercise:
 Social contact and enjoyment
 Most
men want to develop muscle
mass and attain mesomorphic ideal
Putting Dieting into Context
For as long as records have been kept, the
female figure (in particular) has been
viewed as something to control and
master
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Foot-binding
Female genital mutilation
Wearing corsets or bustles
Breast-binding
Feet, breasts, waists, thighs, bottoms have
been either too big or too small
Demographics of Dieting
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Age
 Compared to adult women, adolescent girls report slightly higher
levels of dieting
 Increases between 11 and 16
 Average age of starting to diet is around 12 and 13
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Geography
 Some, but not all, studies show prevalence of dieters to be lower
in Europe than US
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Body weight
 Overweight women are 4x as likely to try to lose weight
 But not all
○ There are more normal weight dieters than there are obese dieters
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SES
 Inverse relationship between SES and dieting in adults but not
adolescents
 American white adolescents are twice as likely to diet as African
American adolescents
Keys to Studying Dieting
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Uncertainty over self-report data
Researchers specify the variety of behaviors
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Limiting the amount eaten at meals
Avoiding fats and fatty foods
Avoiding eating between meals
Avoiding sweets and sweet drinks
These behaviors distinguish dieters from non-dieters
There are also unhealthy dieting behaviors
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Skipping meals
Fasting
Vomiting
Taking laxatives
Diet pills
Smoking to lose weight
Around 20% of women report using one of these in the past year
Early Experimental Work on
Dieting
 WWII—Keys and colleagues
 Conscientious objectors who agreed to
undergo experimental starvation
 Went down to about 75% of initial body
weight
 Starving COs were
○ Unable to concentrate
○ More distractible
○ Thinking more about food
○ More irritable, emotionally volatile
Research on Chronic Dieters
Think more about food
 Remember more weight and foodrelated information about other people
than do non-dieters
 On tests like the Stroop, restrained
eaters tend to be more disrupted by food
or body-shape words
 Dieters tend to think about food as more
black and white and eat that way
 More irritable and emotionally volatile
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Food Intake and Body Weight
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Weight loss and taste perception—early study
 Experimenters dieted to lose 10%
○ Did not experience negative alliesthesia
○ This may have an effect on how dieters choose to eat
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Studies show, as you might expect, that dieters
report eating less over a typical day than nondieters
 However, prospective studies show
○ Large fluctuations over time
○ Little, if any, decrease in weight
 This seems to be because dieters replace internally-
regulated (hunger-driven) eating with planned
(cognitively-driven) eating
Eating Behavior of Chronic
Dieters
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Experimental starvation studies and prisoners of war
○ Frequently followed by bouts of overeating or binge eating
 More recent lab investigations
○ Normal eaters follow a period of overeating by minimizing later intake
○ Dieters don’t
 This is called counterregulation
 Once they become disinhibited, they also get worse at reporting intake and
underestimate it considerably
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Other factors
 Dieters who are emotionally distressed, lonely, dysphoric
○ Eat more and snack more than non-distressed dieters or distressed non-
dieters
○ One hypothesis—eating temporarily lifts the dysphoria
○ Another hypothesis—the distress moves their focus to external cues (like
taste)
 Dieters report greater levels of cravings for foods
 Thus, occasional bouts of overeating cancel out accumulated
caloric deficits
Negative Associations of Dieting
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Associated with other maladaptive behaviors
Implicated in both anorexia nervosa and bulimia
nervosa
Lower self-esteem than unrestrained eaters
Score higher on Ellis’s irrational thoughts measure
Unrealistic expectations about self-improvement
following weight loss
Expect eating to reduce negative affect
Have mothers who rate them as being less attractive
than other girls
Appear to be more suggestible than unrestrained
eaters
Popular Diets
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Calculated calorie deficit approach
 Energy deficits of 500 calories per day will cause a
loss of about 1 pound of fat tissue per week
 Deficits greater than 500 calories are not
recommended without medical initiation and
supervision
 To calculate: Energy intake=Energy needs –
500kcal/day
 Energy needs for maintenance
○ Calculate resting metabolic rate (RMR)
 Men: 900 + 10 (weight in pounds/2.2)
 Women: 700 + 7 (weight in pounds/2.2)
○ Multiply the resting RMR by estimate for physical activity
level
 1.2 –very sedentary
 1.4—moderately active
 1.8—very active
Popular Diets
 Fixed
low-calorie reducing diets
 Gram counting, etc
 Moderate hypocaloric plans
 Low calorie diets
 Very low calorie diets
 Total fasting is inappropriate for
everyone
Consumer Issues
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Costs and effectiveness are not necessarily related
Good popular diet should
 Healthful, nutritious diet plan
 Physical activity and exercise
 Behavior modification in both weight loss and
maintenance phases
 Physician monitoring if
○ Medication is used
○ Comorbidities are present

In general, the best diets are




Low fat
High fiber
High carbohydrate
Physically active
Commercial and Self-Help Weight
Loss Programs
Actions of the federal trade commission
 1990—Congressman Ron Wyden
 FTC stepped up monitoring of programs
 1997 FTC assembled a plane to explore
voluntary guidelines
 Partnership for Healthy Weight Management
○ Provides consumer with the following information to
help them identify the best program for them:




Staff qualification and central components of the program
Risks associated with overweight and obesity
Risks associated with the provider’s product or program
Program costs
Types of Programs Available

Nonmedical Weight Loss Programs
 Weight Watchers, Jenny Craig, LA Weight Loss

Supermarket Self-Help
 Slim Fast
Web-based programs
 Self-Help Approaches

 TOPS, Overeaters Anonymous or books


Residential Programs
Medically-base Proprietary Programs
 Optifast, Health Management Resources

Alli and Xenical
What is Obesity?


Populations means
Body Mass Index







Normal—18.5-24.9
Overweight (Grade 1): 25-29.9
Clinically obese (Grade 2): 30-39.9
Severe obesity (Grade 3): 40 or more
Doesn’t allow for differences between muscle and fat
Waist circumference
Percentage body fat
 Most basic—assessing skinfold thickness with
calipers
 Water tank
 Bioelectrical impedence
How Common is Obesity?


1959 Metropolitan Life Insurance Company
Factors associated with obesity










Older
Female
Racial and ethnic minorities
Low SES
Children of obese parents
Married
Multiparous women
Ex-smokers
Chronically exceeding energy intake over energy
expenditure
In US, about 1/5 non-Hispanic whites and about 1/3
non-Hispanic blacks and Hispanics are obese
Obesity around the World
Australia
Brazil
Canada
China
Japan
Kuwait
Netherlands
Samoa (rural)
Samoa (urban)
United States
Men
12
6
15
.4
2
32
8
42
58
20
Women
13
13
15
.9
3
44
8
59
77
25
Causes of Obesity
 Physiological
theories
 Genetics
 Fat cell theories
 Appetite regulation
 Leptin
 Genetic disorders
Causes continued

Obesogenic environment
 Food industry
 Environmental factors that encourage us to
be sedentary

Behavioral theories
 Physical activity
○ Extension phones—about an extra mile of walking
each year
○ Obese exercise less
○ Even when doing activities, are less active
 Eating behavior
○ Overresponsive to external cues
Health Risks

Diabetes mellitus
 BMI 25.0-26.9 risk of diabetes increase 2.2x in men
 BMI 29.0-30 risk increases 6.7x
 BMI greater 35 increases 42x








Hypertension
Dyslipidemia
Cardiovascular disease
Gallbladder disease
Respiratory disease
Cancer
Arthritis and gout
In children
 70% of obese children become obese adults
Stigma and Discrimination

Employment discrimination
 Studies have manipulated perceived body weight of fictional
employees
○ Perceived to be lazy, sloppy, less competent
 Overweight women receive less pay for the same job than
average weight women

Medical and health care discrimination





Documented among physicians, nurses, and medical students
Viewed as unintelligent, weak-willed, lazy
May lead to poor medical care
BMI is positively related to appointment cancellation
Educational discrimination
 Peer rejection
 College admissions
 Average weight students receive more financial support from
their parents than overweight students
Psychological Consequences

First generation of studies
 Compared obese and nonobese groups on single variables

Second generation of studies
 Examine psychological consequences within the obese




population
Looks at factors likely to place an overweight individual at risk
Binge eating
Weight cycling
Potential demographic risk factors
○ Female
○ Adolescent
○ Being severely overweight
 Depressed obese individuals may be more likely to seek
treatment for obesity

Third generation of research
 These factors that have been identified need to be studied in
concert
 Establish causal links
Should Obesity Be Treated at All?
Belief that body size and shape are
changeable can result in victim blaming
 Costs of treatment

 Psychological problems and obesity treatment
 Physical problems
○ Weight variability

Benefits of treatment
 Weight loss is associated with elation, self-
confidence and increased feelings of well-being
 Health benefits of weight loss that sticks
Goals of Obesity Treatment
(Brownell & Stunkard, 2002)
Treatment Negotiation
 Provider and patient need to agree on goals of
treatment
 When patient is unrealistic…
 This may result in lowered expectations
about weight loss
Ultimate Goal
 Improve health and well-being




Weight loss is only one part of this
Healthy diet
Increased activity
Changes in psychosocial domains
Goals continued
Initial Considerations
 Whether to attempt weight loss
 Ideally, could assess for prognosis
 But….Best we can do is suggest honesty
 Practitioners have to talk about
○ Level of readiness
○ Financial costs
○ Time required
○ Need to be physically active
○ Altered eating habits
 Therapy to resolve barriers to treatment
Weight Loss Goals


Ideal weight flaw
Establishing weight goals








Dream weight
Happy weight (less than dream but still satisfying)
Acceptable weight (not satisfying but reasonable)
Disappointing weight (better than nothing)
Focus on short term goals
Modification of assumptions about body image
Behavioral and psychosocial goals
Maintenance goals
Behavioral Treatment

Behavioral Weight Loss








Groups
4 to 6 months of weekly sessions
Self-monitoring
Self-regulation
Cognitive restructuring
Interpersonal relationships addressed
Moderate calorie restriction
Evaluation of treatment outcome
 Short-term--Results are consistent and well-established
 Long-term
○ On average, patients regain 1/3 of treatment-induced weight loss at 1 year
follow-up
○ A minority keep the weight off over 4 yrs.
○ Better long term results for children

Limits of behavioral treatment
Exercise in the Management of
Obesity

Health Benefits of Physical Activity
 Significant benefits regardless of body size
 Fit but obese men had lower death rates than lean but unfit men
in a longitudinal study of over 20,000 men (Blair & Holder, 2002)

Lifestyle vs. Traditional Physical Activity
 Most weight programs use prescriptive approaches
 New guidelines—accumulate 30 minutes of physical activity on
most days
○ As effective as traditional

Overview of Lifestyle Approach





Cognitive and behavioral strategies
Daily-life routines at home and work
Using stairs instead of taking the elevator
Hand delivering messages at work instead of using email
Goal-setting, self-monitoring, problem solving regarding barriers
to physical activity, traditional cognitive-behavioral skills
Surgery



Only proven effective treatment for morbid obesity
BMI >40 or BMI>35 if comorbities
Contraindications







High operative risk
Unresolved substance abuse
Depression or suicidal attempts
Failure to understand the procedure
Unrealistic expectations from the operation
Variety of surgical procedures
Weight losses average 50 percent of excess weight in one
year
 After 8 years, weight loss of surgical group remained high

Psychological effects of surgery
 Improved quality of life in surgical patients compared to control
subjects
 Paradox of control
Characteristics of Successful
Weight Maintainers

Prevalence of weight loss maintenance
 1959—Strunkard and McLaren-Home
○ More recent—13-22% maintain weight loss of
>= 5 kg at 5 years

National Weight Loss Registry
○ 55% had assistance, 45% lost it on their own
○ 90% had previously tried and failed to lose weight

Behavior Changes Associated with
Successful Weight Loss Maintenance
 Physical activity
 Dietary factors
 Behavioral strategies
Psychological Consequences of
Maintaining Weight Loss




More confident
Self-assured
Capable of handling their problems
85% of maintainers report weight loss and
maintenance had improved






Quality of life
Energy
Physical mobility
General mood
20% reported more time thinking about weight
14% more time thinking about food
History of Anorexia Nervosa



For centuries, voluntary abstinence from food was not
pathological
End of 17th century, physician Richard Morton described
“nervous consumption”
Distinct clinical entity in second half of 19th century
 1873—Lasegue—“anorexie hysterique” (likely not translated in
time to affect Gull’s thoughts)
 1874—Gull—anorexia nervosa



For a time, some thought that it might be a pituitary disorder.
This was debunked by WWII
Some psychoanalytic work post WWII, but not much
1960 Hilda Bruch
 Focused on distorted body image and lack of self-esteem
 Added two features to understanding
○ Relentless pursuit of thinness
○ Disturbance of body image
History of Bulimia Nervosa
Bulimia may come from two places
 Historically known as





Kynorexia
Fames canina
Originally, abnormalities of the stomach were thought to be the cause
19th century—some accounts of hysterical vomiting, but not looked at as a
specific disorder
 Until well into 20th century, some internists considered it a sign of gastric
dysfunction

Modern conceptualization emerged within context of anorexia
nervosa


Originally viewed as a variation of anorexia
1970s on
○
○
○
○
○

Discrete cluster of symptoms emerged
Copious amounts of food
Vomiting or laxatives
Lots of names proposed
1979 Gerald Russell coined bulimia nervosa
1980—DSM III—initially only “bulimia”
○
Bulimia nervosa in DSM IIIR
Characteristics of Anorexia
Nervosa





Refusal to maintain body weight at or above
minimally normal weight for age and height
Intense fear of gaining weight or becoming
fat, even though underweight
Disturbance of body image; denial of
seriousness of low body weight
Amenorrhea—but many women with
anorexia continue to menstruate and some
don’t begin menstruating again when
symptoms are abated
Subtypes: Restricting and Bingeeating/purging
Additional Characteristics










Mortality: 3-21%--about 12x higher than other females age 15-24
Normal awareness of hunger, but terrified of giving in to impulse to
eat.
Distorted perception of satiety.
Excessive activity.
90-95 % of cases are in females
Peak onset between 14-18
.5-2% prevalence in clinical populations. Higher rates of behaviors
when we use an epidemiological approach.
Males tend to fall in a few specific groups—jockeys, wrestlers,
models
Most common among high achieving hs students—middle and
upper middle class, but it is found everywhere. So called Golden
Girls disease.
Most common in industrialized nations (highest rates are here) but
increasingly found everywhere.
Medical Complications










Hair and nails thin and become brittle
Dry skin
Lanugo
Yellowish tinge to skin
Cold all the time
Low bp
Kidney damage
Heart arrhythmias
Electrolyte imbalances
Osteoporosis
Outcome

Varied
 May be a single, relatively mild disturbance






or chronic
40%-50% totally recover
30% considerably improve
20% unimproved, seriously impaired
Remainder die
Early onset—more favorable prognosis
Poor prognosis—chronicity, pronounced
family difficulties, poor vocational
adjustment
Bulimia Nervosa

Recurrent episodes of binge eating. Episode of binge eating
is characterized by
 Eating more in a discrete period of time than most people would
eat under similar circumstances
 A sense of lack of control over the eating during the episode





Recurrent inappropriate compensatory behavior in order to
prevent weight gain, such as self-induced vomiting, misuse
of laxatives, diuretics, enemas, or other medications ,
fasting, or excessive exercise
Must occur at least twice a week for 3 months
Self-evaluation is unduly influenced by body shape and
weight
Disturbance does not occur exclusively during anorexia
nervosa
Two types—purging and non-purging
Characteristics of Bulimia
Nervosa










Typical picture: white female begins overeating around
18 and purging a year later, generally vomiting
May be over or underweight, typically about average
Family hx often includes obesity or alcoholism
Prevalence about 1-3 %, higher rates when we look at #
with behavior
>90% are female
Preoccupied with food, eating, and vomiting so that
concentration on other subjects is impaired.
May steal food (increased food costs assoc. with binging)
Less time socializing, more time alone than non-bulimics
Terrified of losing control over eating—all or none thinking
Lots of shame, guilt, self-deprecation, and efforts at
concealment
Personality and Bulimia
Different picture than anorexics
More extroverted
More likely to abuse ETOH, steal, attempt suicide
More affectively unstable than depressed
Difficulty with self-regulation
Some evidence of hx of pica
More sexually active than controls, but less interested
in sex and enjoy it less
 Hx of childhood maladjustment; alienated from family
 Higher rates of borderline
 50-75% show full recovery







Health Risks
Electrolyte imbalances
 Hypokalemia (low potassium) leading to heart
problems
 Damage to heart muscle
 Calluses on hands
 Tears to the throat
 Mouth ulcers and cavities
 Small red dots around eyes
 Swollen salivary glands

Eating Disorders in Males












Similar diagnostic criteria to females
Instead of amenorrhea, see lowered testosterone happening gradually
Similar comorbid conditions, especially mood and personality disorders
Males are more severely afflicted by osteoporosis
Also see “Muscle Dysmorphia”
Only 10% of cases of anorexia
Bulimia is uncommon
Binge eating appears about the same
Men are clearly exposed to less general sociocultural pressure about thinness
About 20% of male eating disorder patients are gay
Treatment
Basic treatment is about the same





Restoration of weight leads to increased testerone


Restoring normal weight
Interrupting abnormal behaviors
Treating comorbid conditions
Helping them think differently about the value of weight loss and shape changes
10-20% are left with testicular abnormality
Pre-illness sexual fantasy of behavior improves prognosis
Risk Factors for Eating Disorders




Biological factors
Risk of anorexia for relatives is 11.4X greater than controls—
concordance for MZ twins is about 50%, DZ twins about 5%
Risk of bulimia is 3.7x greater
Sociocultural factors
 Peer and media influences
○ Objectification theory (Frederickson and Roberts, 1997)
 Family influences
○ 1/3 of pts report that family dysfunction contributed to dev of anorexia
○ Bulimia—high parental expectations, other family members’ dieting,
critical comments about shape, weight, or eating

Individual risk factors




Fat spurt
Internalizing the thin ideal
Perfectionism—more common in women
Sexual abuse in bulimia and binge-eating
Ineffective or Weak Treatments
Nutritional counseling
 Psychoanalytic therapy, both individual
and group
 12 step
 Medications alone
 Behavioral contracts

Self-Help Books/Internet
Bulimia
 A few studies have investigated this
 Many students, in both clinic and community
studies, report reduction in symptoms

Anorexia
 Self-help is not recommended
 Pro-Ana sites are a concern
Eating Disorders Services
Program should be multidisciplinary
Program should follow up-to-date published
treatment guidelines
 Program should provide evidence-based care


 Not just a program that is supported in the literature,
but also a program that evaluates its own efficacy

Program should provide care that is cost
effective
 Least intensive, least costly interventions should be
given to the largest number of patients initially
 Stepped care
Clinical Components of Stepped
Care








Systematic and comprehensive initial
evaluation
Brief psychoeducational program
Outpatient psychotherapy
Nutritional counseling
An intensive day hospital treatment program
An inpatient therapy
An aftercare and chronic care program
Specialized interventions for subgroups of
patients
Cognitive Behavioral Therapy for
Bulimia Nervosa

Cognitive disturbance is a prominent feature






Binges don’t happen randomly
Negative self-evaluations
Characteristic extreme concerns about shape and weight
Perfectionism and dichotomous thinking
Usually 15-20 sessions over 5 months
Over 50 randomized clinical trials





Dropout rate is about 15-20% (less than meds)
Substantial effect on binge eating
Appear to be maintained over 6-12 months
More effective than pharmacotherapy
Brief versions also show promise for use in primary care
Cognitive Behavioral Therapy for
Anorexia Nervosa
Usually 1-2 years
 Involves managing eating and weight
 Modifying beliefs about weight and food
 Modifying views of the self
 Empirical evidence

 Fewer patients in CBT terminate early
 More meet criteria for good outcome than in
nutritional counseling (44% vs 6%)
 Appears to yield comparable improvements
to family therapy and behavioral therapy
Family Therapy
 Critical
for treatment of adolescents
and children
 Good evidence for efficacy with
adolescents
 More chronic patients, more severe,
later onset—family therapy is less
effective
 Strong focus on helping parents
manage symptomatic behavior
Pharmacological Treatment

Anorexia
 SSRIs may be of some benefit in preventing relapse
 Antianxiety meds may help with distress around meals
 Most research indicates meds are not that useful for
anorexia
 Med use is not dictated by diagnosis but by other clinical
features

Bulimia
 Meds are much more effective for bulimia
 Antidepressants, esp SSRIs, most effective
 But only a minority achieve remission during med use
alone
 And relapse is possible, even with continued med use
Public Health vs. Medical Models

Medical models
 Treat obesity and eating disorders as individual
conditions
 Examination of causal variables
○ Biology
○ Psychology
○ Behavior

Public health
 View these in terms of the population
 Examination of causal variables
○ Individual differences as above and…
○ Factors outside the individual
Changes in BMI Over Time

http://yaleruddcenter.org/resources/uplo
ad/docs/what/industry/FoodIndustryBrownell.pdf
Models of Intervention

Disseminating information and
behavioral skills training have not been
that effective in preventing obesity
 General population is aware of obesity

Targeting the Environment






Modifying environmental abuse potential
Controlling advertising
Controlling sales conditions
Controlling prices
Improving environmental controls
Improving public health education
Public Policy and the Prevention
of Obesity
Enhance opportunities for physical
activity
 Regulate food advertising aimed at
children
 Prohibit fast foods and soft drinks from
schools
 Restructure school lunch programs
 Subsidize the sale of healthy foods
 Tax foods with poor nutritional value
