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Transcript
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 Balancing Calories Enjoy your food, but eat less. Avoid oversized portions. 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. 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 Recommend salt intake of less than 6g per day 59% of salt that we consume is used in the processing of food Alcohol Heavy drinkers have higher rates of hypertension Some benefits to drinking in light to moderate consumption 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 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 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 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 16,000 male and female students 18-24 in Europe ○ 39% try to avoid fat 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 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?” Observational methods Food Choice Why do people eat what they eat? Three basic ways to look at this today: Developmentally Cognitively Psychophysiologically 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 Birch &Marlin (1982) gave 2 year olds novel foods over 6 weeks Williams et al 2008 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 ○ ○ ○ ○ 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 Most research focuses on social cognition Some of these look at behavioral intention; others at actual behavior In general, the models incorporate 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 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 Neurotransmitters that increase intake Norepinephrine Neuropeptide Y Galanin Neurotransmitters that decrease intake Serotonin Bombesin Corticotropin-releasing hormone (CRH) Cholecystokinin (CCK) Psychopharmacological drugs Nicotine Amphetamine Marijuana Alcohol Antipsychotic drugs Tricyclics SSRIs Analgesics Food and Cognition Caffeine Carbohydrates Chocolate Stress and eating 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 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 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 Fasting as a religious act 19th century— hunger artists Anorexia Food as a Social Interaction 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 5500 per year Adolescents see about 5% fewer 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 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 Better for You Foods 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 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. Enjoyed seeing idealized families in ads Believed that advertising can be fun and informative Some advertising promotes foods that are 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 Solutions Elsewhere Solutions at the Government Level: Ban advertising to children in general Ban TV advertisements during breaks for all programs 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 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? 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 Effects of food marketing exposure Increases preferences for foods and requests to 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 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 Glascock & Preston-Schreck, 2004 Studied 50 comic strips over a month Gender roles –stereotypical 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 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 Ideal woman’s body has become smaller over the past century Rubenesque— 1600s— reproductive figure 1800s—Courbet Manet’s Olympia of 1863— Modern History 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 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 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 Control Ability to control self indicates will power, resisting temptation Control of inner world over consumerism Freedom Thinness provides some freedom from class Freedom from reproduction 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 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 Causes of Body Dissatisfaction Media Most commonly held belief in lay (and professional) community Thin ideal Social comparison Culture The Family Mothers who are dissatisfied with their own bodies communicate this to the their daughters, resulting in daughters’ body dissatisfaction 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 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 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 Geography Some, but not all, studies show prevalence of dieters to be lower in Europe than US 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 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 Uncertainty over self-report data Researchers specify the variety of behaviors 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 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 Food Intake and Body Weight 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 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 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 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 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 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 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