PsY 472 Psychology of Food

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PsY 472 Psychology of Food
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Many Areas within Psychology

• Sensation and perception
• Cognition
• Social
• Clinical
• Health
• Developmental

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History of Healthy Eating

• 1824The Family Oracle of Good HealthUnited
  Kingdom
• US in 1800s
• Boer War Parent education classes about healthy
  diet
• Great Depression in US
• WWII

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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

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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.

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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
• Atherscerlosisnarrowing of arteries
• Thrombosisa blood clotmay result in sudden
  death, heart attack, angina
• State of the myocardiumthe impact of the clot
  depends on this

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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

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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

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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

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Childrens Diet

• Correlations between childrens diet and diets
  later on
• Also linked with later adult health
• Western Hemisphere
• Nicklas, 1995majority 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 veggiesonly 5 of kids exceed recommended
  intake
• About 10 of kids in US are malnourished
• Internationally, it is about 18, with 30 in
  sub-Saharan Africa

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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

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Measuring Food Intake

• Three primary ways
• In the laboratory
• Self-report measures
• How often do you eat X?
• Observational methods

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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

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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 omnivores 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 preferencemust taste

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Developmental Models Social Learning

• Peers
• Duncker, 1938social 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, 1995parents 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

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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

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Developmental Models Associative Learning

• Rewarding food choice
• Giving food in association with positive
  attention increases food preference
• Food as a reward
• If youre 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 attractiveBirch, 1999
• Food and physiological consequences

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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

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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
  dont add much to the model

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Psychophysiological Models

• Hungera state that follows food deprivation and
  reflects a motivation or drive to eat
• Satietythe polar opposite
• This approach looks at cognitions, behavior and
  physiology

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Metabolic Models

• Homeostasisbeginning of 19th century
• Walter Cannon
• Biological variables are regulated within defined
  limits
• Maintained via a negative feedback loopwe adjust
  behavior to meet needs
• Set point
• More recentlycellular energy

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Hypothalamus

• Area of brain associated with feeding
• Early cluespatients with tumors of the basal
  hypothalamus who became obese
• Experimentally induced lesions to hypothalamus in
  animals

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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

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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

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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

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Food Classification Systems

• Levi-Strauss (1965) and Douglas (1966) argued
  that food can be understood as a deep underlying
  structurecommon across cultures
• Helman (1984)5 types of food classification
  systems
• Food vs. nonfoodwhat 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

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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

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Food and Gender

• Eating versus denial
• Charles Kerr (1986, 1987)
• Studied 200 mothers in northern England
• Silverstein et al, 1986
• Studied images in magazines
• Mens10 food ads, 10 sweet ads, 1 diet food ads
• Womens 1,179 food ads, 359 food ads, 63 diet
  food ads

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Food and Guilt, and Self-Control

• Some foods are associated with conflict between
  pleasure and guilt
• Food and self-control
• Fasting as a religious act
• 19th centuryhunger artists
• Anorexia

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Food as a Social Interaction

• Dinner table is often the only place where the
  family gets together
• Tool for communicationForum for sharing
  experiences
• Sense of group identity
• The meal as love
• Power relations

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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

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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.

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Childrens Food and Beverage Advertising
Initiative

• 2004marketers vowed decrease
• 2006---Childrens 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

• Kid Cuisine Deep Sea Adventure Fish Sticks
• Kid Cuisine KCs 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
• Reeses 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
• Kelloggs 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

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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
• Butannoyed that marketing often makes their
  children demand certain foods

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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

• Solutions at the Government Level Countries
  that have already implemented the
  particular solution
• Ban advertising to children in general Sweden
  (under age 12)
• Quebec (under age 13)
• Ban TV advertisements during breaks for Denmark
• all programs France (on state-owned
  channels)
• Ban junk food advertisements during Britain
• childrens TV programs (age 16 and under)
• Ban TV advertisements in general during
  Austria Norway Denmark
• childrens programs Belgium Sweden
• Ban TV advertisements right before and Belgium
• after childrens programs Sweden
• Create a law indicating that advertisements
  France
• for unhealthy foods must accompany
• nutrition message disclaimers

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How does this affect childrens 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

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Mechanisms of Food Marketing Effects

• Generally assumed to follow an information-process
  ing approach
• Marketing effects follow a path from exposure to
  behavior
• Mediated by preferences, attitudes, and beliefs
  about the products
• Relatedgreater cognitive maturity reduces the
  effects as kids become able to defend against
  marketing messages

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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

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The Meaning of Size

• Media Representations
• Paek et al 2011Study 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
• TelevisionDesmond and Danielewicz, 2010
• Female reportersmore likely to present human
  interest and health-related stories
• Male reportersmore likely to present political
  stories
• MagazinesSpees and Zimmerman, 2002
• Belief that boys are stronger/more athletic in
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• Belief that appearance is important for girls in
  54

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Images of Female Body Size and Shape

• Ideal womans body has become smaller over the
  past century
• Rubenesque1600sreproductive figure
• 1800sCourbet
• Manets Olympia of 1863

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Modern History

• Current preference goes back to flapper look of
  1920s
• Some respite after WWIIMarilyn Monroe, Jane
  Russell
• End of 1950sAudrey Hepburn, Grace Kelly
• 1960sTwiggy
• 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 increaseddue 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

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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
• Womenwarm, expressive, sensitive
• Manactive, objective, independent, aggressive,
  direct

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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
  self-discipline, 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

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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, 1999Cape Town, South Africa
• Studied overweight poor black women
• Placed high value on foodfood was often scarce,
  so voluntarily regulating food would be
  unacceptable
• Overweight kids seen as a sign of health
• Similar findings in other poor countries

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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

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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 agekids
  as young as 6 or 7

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Who is dissatisfied with their bodies?

• Men
• Compared to women, mens 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

• 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

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Consequences of Body Dissatisfaction

• Women
• Dietingabout 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

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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

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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

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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

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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

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Early Experimental Work on Dieting

• WWIIKeys 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

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Research on Chronic Dieters

• Think more about food
• Remember more weight and food-related 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

• Weight loss and taste perceptionearly 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
  non-dieters
• 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

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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 dont
• 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 hypothesiseating temporarily lifts the
  dysphoria
• Another hypothesisthe 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

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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 Elliss 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

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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 intakeEnergy 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
• 1.4moderately active
• 1.8very active

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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

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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

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Commercial and Self-Help Weight Loss Programs

• Actions of the federal trade commission
• 1990Congressman 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 providers product or
  program
• Program costs

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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

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What is Obesity?

• Populations means
• Body Mass Index
• Normal18.5-24.9
• Overweight (Grade 1) 25-29.9
• Clinically obese (Grade 2) 30-39.9
• Severe obesity (Grade 3) 40 or more
• Doesnt allow for differences between muscle and
  fat
• Waist circumference
• Percentage body fat
• Most basicassessing skinfold thickness with
  calipers
• Water tank
• Bioelectrical impedence

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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

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Obesity around the World

• Men Women
• Australia 12 13
• Brazil 6 13
• Canada 15 15
• China .4 .9
• Japan 2 3
• Kuwait 32 44
• Netherlands 8 8
• Samoa (rural) 42 59
• Samoa (urban) 58 77
• United States 20 25

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Causes of Obesity

• Physiological theories
• Genetics
• Fat cell theories
• Appetite regulation
• Leptin
• Genetic disorders

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Causes continued

• Obesogenic environment
• Food industry
• Environmental factors that encourage us to be
  sedentary
• Behavioral theories
• Physical activity
• Extension phonesabout an extra mile of walking
  each year
• Obese exercise less
• Even when doing activities, are less active
• Eating behavior
• Overresponsive to external cues

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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

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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

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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

78
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

79
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

80
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

81
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

82
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

83
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 guidelinesaccumulate 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

84
Surgery

• Only proven effective treatment for morbid
  obesity
• BMI gt40 or BMIgt35 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

85
Characteristics of Successful Weight Maintainers

• Prevalence of weight loss maintenance
• 1959Strunkard and McLaren-Home
• More recent13-22 maintain weight loss of gt 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

86
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

87
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
• 1873Lasegueanorexie hysterique (likely not
  translated in time to affect Gulls thoughts)
• 1874Gullanorexia 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

88
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 centurysome 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
• 1980DSM IIIinitially only bulimia
• Bulimia nervosa in DSM IIIR

89
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
• Amenorrheabut many women with anorexia continue
  to menstruate and some dont begin menstruating
  again when symptoms are abated
• Subtypes Restricting and Binge-eating/purging

90
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
  groupsjockeys, wrestlers, models
• Most common among high achieving hs
  studentsmiddle 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.

91
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

92
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 onsetmore favorable prognosis
• Poor prognosischronicity, pronounced family
  difficulties, poor vocational adjustment

93
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 typespurging and non-purging

94
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
• gt90 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 eatingall or
  none thinking
• Lots of shame, guilt, self-deprecation, and
  efforts at concealment

95
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

96
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

97
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
• Restoring normal weight
• Interrupting abnormal behaviors
• Treating comorbid conditions
• Helping them think differently about the value of
  weight loss and shape changes
• Restoration of weight leads to increased
  testerone
• 10-20 are left with testicular abnormality
• Pre-illness sexual fantasy of behavior improves
  prognosis

98
Risk Factors for Eating Disorders

• Biological factors
• Risk of anorexia for relatives is 11.4X greater
  than controlsconcordance 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
• Bulimiahigh parental expectations, other family
  members dieting, critical comments about shape,
  weight, or eating
• Individual risk factors
• Fat spurt
• Internalizing the thin ideal
• Perfectionismmore common in women
• Sexual abuse in bulimia and binge-eating

99
Ineffective or Weak Treatments

• Nutritional counseling
• Psychoanalytic therapy, both individual and group
  
• 12 step
• Medications alone
• Behavioral contracts

100
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

101
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

102
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

103
Cognitive Behavioral Therapy for Bulimia Nervosa

• Cognitive disturbance is a prominent feature
• Binges dont 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

104
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

105
Family Therapy

• Critical for treatment of adolescents and
  children
• Good evidence for efficacy with adolescents
• More chronic patients, more severe, later
  onsetfamily therapy is less effective
• Strong focus on helping parents manage
  symptomatic behavior

106
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

107
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

108
Changes in BMI Over Time

• http//yaleruddcenter.org/resources/upload/docs/wh
  at/industry/FoodIndustry-Brownell.pdf

109
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

110
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