University of Colorado, BoulderCU Scholar

Undergraduate Honors Theses Honors Program

Spring 2013

Understanding the Cultural, Social, and BiologicalEnvironment Where Eating Disorders ThrivePoper Rose McMillinUniversity of Colorado Boulder

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Recommended CitationMcMillin, Poper Rose, "Understanding the Cultural, Social, and Biological Environment Where Eating Disorders Thrive" (2013).Undergraduate Honors Theses. Paper 439.

UnderstandingtheCultural,Social,andBiologicalEnvironment

WhereEatingDisordersThrive

PiperRoseMcMillin

April1,2013

Advisor:HeatherWilliams,Anthropology

CommitteeMembers:

DougBamforth,AnthropologyRyanBachtell,PsychologyandNeuroscience

McMillin 1

AbstractInaworldofimmensevarietyanddramaticdifferenceinphysicalbeauty,western

culturalconceptionsofattractivenesshavegoneagainstthegrainbyshunningthosewhoseappearancefallsoutsideofthenarrowlydefinedideals.Slender,tonedbodies,well‐definedjawlines,andstrongfeaturesrepresentattractivenessinthiscultureandarepropagatedthroughconstantremindersinpopularmedia.Inthisenvironment,apersonwhomeetsthehighstandardsofbeautyandbodysizealsodemonstratesgoodhealth,self‐control,moralintegrity,drive,andanumberofotherqualitiesthatarepraisedanddesiredinthisculture.Ironically,theincreaseinglorificationofanultrathin,tonedbodycoincideswithanincreaseinaveragebodyweightandcaloricintake,duetoindustrialization,economicchanges,andmassproductionofcheap,unhealthy,caloriedensefoods.Thisincongruitybetweenwhatisbeingdemandedandwhatisbeingconsumedhasledmanyindividualstobecomefullyimmersedinobsessionoverfood,appearance,andmechanismsthroughwhichtheycancontroltheirbodies.Forsome,thisobsessionleadstohealthyeatingandincreasedactivitylevels,forothersitbecomesarevolvingdoorofcrashdietsandweight‐lossmedication,andinextremecaseseatingdisorders.

Withinthispaper,Isuggestthatinanenvironmentwherebeingphysicallyattractivemeanseverything,theremaybeabiologicalprecursorthatdrivesapersontoeatingdisorderpathologies.Researchsuggeststhatprevalenceratesforsomeotherdisorders,suchasmood,anxiety,andpersonalitydisturbances,arerelativelyhighinpersonswitheatingdisordersandviseversa.Whilethesemaladaptivepracticeshavenotbeenrestrictedtolate20thcenturywesternculture,theyarecontainedinareaswherethesehighstandardsofbeautyperpetuate.Unfortunately,inthewakeofaglobalizedculture,dietingbehaviorsandeatingdisordersemergeinternationally.

McMillin 2

Introduction

Theunderstandingofmentaldisorderhasbeenofmedicalimportanceforovera

centuryinAmericanhistory.AccordingtotheAmericanPsychiatricAssociation,

classificationofpsychologicaldisordersbeganbeforetheWorldWarsbecauseofits

importanceingatheringstatisticalinformation.In1952,theAmericanPsychiatric

AssociationCommitteeonNomenclatureandStatisticspublishedthefirsteditionofthe

DiagnosticandStatisticalManual:MentalDisorders(DSM­I).Thispublicationprovided

informationtomedicalpersonnelonthedescriptions,andcriteriafordiagnosisofmany

mentaldisorders.Sincethattime,theDSMhasgonethroughanumberofrevisions,which

changedcriteria,addeddisorders,andclassifiedmoreoftheunknown(American

PsychiatricAssociation).

IntheinitialpublicationoftheDSM,anorexiaandbulimiaservedassupplementary

termsforpsychologicaldisturbancesthataffectedthedigestivesystem.Atthisstage,the

DSMdescribedanorexiaasthelossofappetiteandbulimiaasanexcessiveappetite.

However,thesedefinitionshavechangedandthemostcurrentversionoftheDSM(DSM‐

IV‐tr)containsspecificdefiningcriteriaforeatingdisorders,morespecificallyknowas:

anorexianervosa(AN),bulimianervosa(BN),andeatingdisordersotherwisenotspecified

(EDNOS).Ingeneral,thesymptomsofpatientswitheatingdisordersareabnormalpatterns

ofconsumption(noteating,eatingtoomuch,vomitingupwhattheyareeating,etc.),anda

recurrentmentalobsessionwithwhattheyareorarenoteatingandhowtheirbodylooks

(AmericanPsychiatricAssociation2000).

Althoughtherearesimilaritiesacrosstherangeofeatingdisorders,thedifferences

aremoreimportantintheirclassificationwithintheDSM.Foradiagnosisofeitheranorexia

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nervosaorbulimianervosa,apatientmeetsthespecificcriteriaofthatdisorder.Whena

patientdisplayspartsofadisorder,forexamplebingeeatingwithoutpurging,theyreceive

anEDNOSdiagnosis(Costin2007).AstheDSMgoesintoitsmostrecentrevision,duefor

releaseinSpring2013,thecriteriawillagainchangetobemoreencompassingofthemany

variationsofthesedisorders.Thisrevisionisextremelyimportanttotheunderstandingof

eatingdisordersbecauseitwillexpandtheknowledgebaseandresearchpool.Thiswillbe

accomplishedthroughthediagnosisofmorepatientswithanorexianervosaorbulimia

nervosaandreductionofthenumberofEDNOSdiagnoses.

EatingDisordersinHistory

Inordertounderstandmoderneatingdisordersonemustalsounderstandtheir

origins,andtheenvironmentinwhichtheythrive.Fastingandexpellingfoodfromthe

bodyarenotnewphenomena.InAncientGreece,religiouspracticesusedfastingfor

contactingsupernaturalforcesandavoidingentryofevilforces(Kerndt1982).Inancient

Egyptthepeoplewouldlimittheirfoodintakethroughfastingorvomitingtomaintaintheir

health(SiculusandHerodotusinHaslam);andintheChristiantradition,fastinghasbeen

usedasamethodforbringingpeopletogether,pavingthewaytoagreatfeast,healing,and

expellingdemons(Russell2005).Patternsoffoodandbeverageconsumptionandpatterns

ofabnormaleatingbehaviorsinhistoryareimportantbecausetheyevolveandoccurfor

varyingreasons,whichareoftensituatedintimeandspace.

Forexample,oneoftheearliestrecordingsofabnormaleatingandpsychological

disturbanceoccurredin1694.Inhisdescription,RichardMortonwroteaboutan18year‐

oldpatient,whohediagnosedwithnervousatrophy/nervousconsumption.Hersymptoms,

whichincludedalackofappetite,upsetdigestion,faintingfits,andextremethinness

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closelymirroredthecurrentDSMcriteriaforanorexianervosa.However,henever

discussedthementalfixationofthispatientonweightorpersonalworthinregardstoher

weight,becauseofthisitishardtoclassifyherwithmodernanorecticsofwesternculture

(Morton1720,Costin2007).Regardless,thiscaseprovidesinsightintothevastcomplexity

andvariationofthesymptomsthroughouthistory,situations,andinspecificcases

In1933,EllenWest,attheageof33,tookherlife.Beforethistragicending,shewas

checkedintoBinswanger’sBellevueAsyluminSwitzerlandinanattempttoputhermental

tormentatbay.Atthistime,Dr.Binswangertreatedherforschizophrenia.WhenEllendid

notrespondtohistreatmentDr.Binswangerreleasedheras‘incurable’andlefthertoher

owndevices,andalmostinevitabledeath.Yearsafterpublishingthedoctor’sanalysisalong

withherdiaries,medicalprofessionalswereabletoreclassifyherdisorder.InDr.Albrecht

Hirschmüller’sEllenWest:EinePatientinLudwigBinswangerszwischenKreativitatund

destruktivemLedien(2004),hecomposedanewdiagnosisofhermentaldisorder.

Understandinghersymptomsofpreoccupationwiththinness,fearofweightgain,and

rapidweightlosshemadeadiagnosisofanorexianervosa.Thishallmarkcasemayvery

wellmarkthebeginningofanerawherepeoplestruggleagainsttheirnaturalbodyand

mind,inpursuitofanunrealisticandnotnecessarilyhealthyversionofthemselves.

DriversforEatingDisordersandDietingBehavior

Determininghoweatingdisordersandcompulsionstowardfoodandweightfitinto

societyandhumantendencyisakeyfactorinrecognizingthecauses.SheilaReaves’essay

“RethinkingVisualEthics:Evolution,SocialComparison,andtheMedia’sMono‐Bodyinthe

GlobalRiseofEatingDisorders”(2011),describesquiteeloquentlythecorrelationbetween

adaptivehumannatureandtherecentincreaseinbelittlingbeliefsofpersonalappearance

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andworth.Inshort,shestatesthathumanshaveabiologicalinclinationtobeinconstant

selectionmodebecauseofbrainactivityresponsestoobjectregistration;thiscauses

humanstoattendtoselectedmediaimages.Theancienthumanbrainevolvedandadapted

tobeabletoreadthefaceandbodyforcuesthatdetermineanotherperson’sdemeanor,

emotions,andstatus.Reavessuggeststhatthismechanismplaysamajorroleinthecurrent

tendencytocompareandjudgeoneselfbasedonthequalitiesofanother.Theoutcomeof

couplingthisevolutionaryhabitwithothersocio‐environmentalfactorsthatenhance

comparisoncanhavenegativeconsequences.

Onesuchsocio‐environmentalfactorischanginggenderexpectations,especiallyin

theUnitedStates.Thisshiftoverthelastcenturymayalludetotheincreasedfocuson

attractiveness.Earlierinhistory,thefamilyunitdeterminedstatus,andwomenwere

marriedofftoanappropriatesuitorinordertoincreasethefamily’sstanding.Duetosocial

andtechnologicalshifts,thispracticedissolvedandapracticewhereindividualscould

accumulatepersonalstatusandchoosetheirfuturepartnerreplacedit(Littlewood2004).

Thisindividualizedfocusonsuccessandprosperitygavemenandwomentheabilityto

createtheirownstory,aslongasitfellwithintheconfinesoftheculture.Intheexpanding

industrialsocietyoftheearly20thcentury,menmadeupthemajorityofthelaborforceand

womentookovertheworkwithinthedomesticsphere.Nevertheless,thiswasacrucial

turningpointinwomen’srolewithinsociety(Harrison1997).AftertheGreatDepression,

morewomenjoinedtheirmalecounterpartsinpaidwork.DuringWWII,thisnumbergrew

substantiallyaswomencameintocoverthejobsthattroopsleftbehind.However,when

thesemenreturnedhome,theytookbacktheirjobsandwomenreturnedtothehome

(Harrison1997).

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The1950’sclassic‘LeaveItToBeaver,’showedanall‐AmericanfamilywithJune,

cladinpearls,vacuumingthelivingroomandcookingdinnerforherlovinghusbandWard,

whohadjustreturnedhomefromalongdayattheoffice.Inthisera,culturalexpectations

ofmaintainingahomeandafamilyrestrictedwomen.Nevertheless,therewereculturally

acceptablejobsunmarriedwomencouldhold,butthesewerelimitedtonurse,stewardess,

andreceptionist.TheSecondWaveFeministMovementofthe1960sand1970sbrought

abouttheEqualEmploymentOpportunityCommission,whichopenedupaworldof

potentialforwomen.However,withthisalsocameareconstructionofsocialrelationships

andanincreaseinexpectationsforwomen.Notonlymustwomenmaintainthehome,but

theymustalsochallengetheoriginalgenderrestrictionsbyhavingajob(Littlewood2004).

ThisquotefromSusanBordo’sbookUnbearableWeighthighlightsthecontradictoryidea

presentedduringandfollowingthesesocialchanges:

Ontheonehand,theleanbodyrepresentsarejectionofthefiftiesidealofcuddly,reproductivewomanhood,andanassertionofapost‐feminist,non‐domesticidentity.Ontheotherhand,thesteadilyshrinkingspacepermittedthefemalebodyseemedexpressiveofdiscomfortwithgreaterfemalepowerandpresence.”(xxi:2003)

Women’semergenceinthepublicsphereoccurredatthesametimeasnew

techniquesforprocessingfoodsdeveloped.Thistechnologicalshiftresultedindrastic

changesinthetypesandamountsoffoodconsumed.Whenmenabandonedthefarmto

workinindustrializedsupercenters,theyreplacedtheirself‐sufficientsubsistencewith

commercialagriculture,foodproducedbythefewforthemany.Theintroductionof

governmentfarmsubsidiesintheyearsfollowingtheFirstWorldWarallowedfarmersto

produceandinvestinhigherproductivity(Delpeuchetal.2009),andmanyfarmers

producedextremesurpluses.Inordertogetthesesurplusesofftheshelfandintothe

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consumer’scart,advertisingworkedtosparkthedesireofthebuyer.Bycompactingthe

surplusesintocaloriedensecommoditiestheindustryandadvertisersdrewtheconsumers

in(Delpeuchetal.2009,Pollan2003).AsAmericagraduallyincreasedtheintakeofthese

conveniencefoodsandcalories—anapproximate10%caloriegaininthelastfourdecades

(Pollan2003)—weightsacrossthecountryanddemographicsincreased.Accordingtothe

CenterforDiseaseControlandPrevention,inthelastfortyyearstheaverageweightofan

Americanhasincreasedby25pounds,andthe2009‐10censusreportedthat35.7%ofU.S.

adultsareobese.AlthoughthesestatisticsarespecifictotheUnitedStates,thisproblemis

notsolelyanAmericanone.TheWorldHealthOrganizationreportsthat,“obesity

prevalenceisincreasingworldwideatanalarmingrateinbothdevelopedanddeveloping

countries.Inmanydevelopingcountries,obesitycoexistswithundernutrtion.Itisstill

morerelativelyuncommoninAfricanandAsiancountries,butismoreprevalentinurban

populationsthaninruralpopulations.”(16:2000)

Evenasobesityratesincreaseandoverweightbecomesthenorm,thegolden

standardbodyweightremainslow.Personalworthcanbedeterminedinconcordancewith

howonemeasuresupcomparedtootherssurroundingthem,andwithhowtheymeasure

upinsociety.Thus,otherscharacterizepeoplebasedontheirweightandexteriorstrengths

ratherthantheirinternalcapabilities.Obesitythen,representsacharacterflawnotjustan

aestheticmisalignment(Spitzack1990).Westernculturehaslinkedobesitywith

undesirabletraitssuchaslackofself‐control,laziness,stupidity,andfailure(Ogden2010).

Ingeneral,peopletrytoescapethesestereotypesbyaligningwithsocietalexpectations.

Thedesiretomeetsometimesunrealisticgoalsandstandardshasresultedinbooming

industriessurroundingdieting,cosmeticsurgery,andweightlossingeneral.

McMillin 8

Thisenvironmentfuelslowself‐esteem,constantself‐judgment,anddegrading

beliefs.Forindividualswhohavepsychologicalimbalances,thisenvironmentandthese

societalpressuresmaytriggereatingdisorders.Avastamountofresearchexploresthe

comorbidityratesofeatingdisorderswithanumberofotherpsychologicaldisorders,such

aspersonality,anxiety,mood,andsubstanceabusedisorders.Ananalyticalreviewby

KarinaO’BrienandNorahVincent(2003)lookedthroughmanystatisticsoncomorbidityof

differentpsychologicalsyndromeswithDSM‐IVanorexianervosaandbulimianervosa.In

theiressay,theyconclude,“apossiblyinheritedsusceptibilitytoOCDand/ormajor

depression,maycombinetofacilitatetheexpressionofaneatingdisorder,”(2003:68).

TheirresearchalsolookedattheexistenceofAxisIIpersonalitydisorders,asdefinedby

theDSM‐IV,andsubstanceabuseineatingdisorderpatientsandfoundhigherpercentages

ofwomenwitheatingdisorderspresentingcomorbiditywithanotherpsychological

disorderthanwithwomeninacontrolgroup.Althoughtheirstudydidnotlookatthe

prevalenceofcomorbidpsychologicaldisordersinpatientswithBingeEatingDisorder

otherresearchonthisideareportssimilarresults.Dr.WalterKayealsosuggeststhis

possibilityinhisNIHarticleontheneurobiologyofanorexiaandbulimianervosa.

“SymptomsmaybeasusceptibilityfactorthatmakepeoplevulnerabletodevelopinganED.

Malnutrititiontendstoexaggeratepremorbidbehavioraltraits,notcausethem.”(3:2008)

Hesuggeststhatthesusceptibilityfactoristheprevalenceofobsessivecompulsive

disorderorbehaviors,perfectionism,andanxiety.Theresearchoncomorbiditywillbe

lookedatingreaterdepthlateron.

Throughexaggeratedsocialmediaandothermassmediaoutletsbroadcasting,the

frequencyofslenderidealsandeatingdisordersincreases.Theglobalizationofwestern

McMillin 9

cultureandmediathatglorifiesphysicalattractivenesswhileperpetuatingthenegative

stigmaaroundexcessweightdemonstratesthisincidence.Theliteraturecommonlyrefers

toFijiasanexampleoftheglobalizationofslenderidealsandtheincreasingprevalenceof

dietingbehaviorsandeatingdisordersbecauseoftheconvincingevidence.InAnne

Becker’sessay,“Television,DisorderedEating,andYoungWomeninFiji”(2004),she

lookedataruralpopulationduringtheintroductionofwesternmediaconcurrentwitha

timeofsocialandeconomicchange.Inshort,shesuggeststhatregardlessoflongstanding

culturalsupportoflargerbodies,theyounggirlssawthewesternimagesandquiterapidly

showedashiftinaestheticideals.However,shealsosuggeststhatthedriveforthinness

differedfromthatinwesternculture.Insteadofdesiringthinnessasameansofprocuring

successandavoidingnegativestigma,Fijiangirlsweredrivenbythedesiretoimprove

domesticproductivityandincreaseFijianimpactintheglobaleconomy.Byplacingher

researchintotimeandspace,shewasabletousetheshiftingculturetounderstandwhy

themediaimageswereplayingsucharole.Herworkisnotaloneintheunderstandingof

theacculturationofglorifiedthinnessandnegativeperceptionof“fat,”studiesonthistopic

havebeendoneallovertheworldwithsimilarresults.

Anthropologically,itisveryimportanttounderstandtherelationshipbetween

socio‐culturalenvironmentandbiologyanditsimpactonpeople,thedietingindustry,and

eatingdisorders.Thisunderstandingbringstolightthetroublewithpromotingamono‐

bodyimageinthemediaandasaculture,aswellasthehypersensitivitytoappearanceand

stereotypesaboutcharacterbasedonphysicalappearance.Globally,thestigmatizationof

obesityandfatisspreading.AlexisBrewisandherteamcollecteddatafromurbanareasin

tencountriesaroundtheworld,theirfindingsreportanacculturatedideaofbodyweight

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asabasisfor“judgingthesocialandpersonalqualitiesoftheindividual,”(273:2011).In

addition,researchmustkeepinmindthatneithersciencenorsocialunderstandingalone

cananswerallofthequestionssurroundingdisorderedeating,andtheanswerswillcome

fromamorecomprehensiveapproach.Understandingthesepathologieswithinthecultural

contextmaygrantgreaterpotentialforpreventionandtreatment.Furthercollaborative

researchinthefieldofeatingdisorderstudiesisextremelynecessaryduetothehigh

mortalityrateofindividualsafflictedwiththemandpreventionbeingaclearpossibility.

EatingDisordersClinicallyDefined TheNationalEatingDisordersAssociationreportsthat10millionfemalesandone

millionmalesintheUnitedStatessufferfromanorexianervosa(AN)orbulimianervosa

(BN),andmillionsmoresufferfromotherdisorderedeatingpathologies.Furthermore,the

associationstatesthatalargemajorityofthesesuffererswillnotseekorreceivetreatment.

Inadditiontostaggeringlyhighratesofmorbidity,Birminghametal.(2005)reporthigh

mortalityratesassociatedwitheatingdisorders.Inthisstudy,theyreport25deathsoutof

954patientsoveran8.7‐yearperiod;seventeenofthesedeathswereofpatientsdiagnosed

withAN,andtragicallysevenendedwithsuicide.Reportedly,ANhasthehighestmortality

rateofallmentalillnessesbecauseofbothmedicalandpsychologicaldisturbances

(Sullivan1995).Giventheseverehealthcomplicationsandsuicidaldeathsassociatedwith

eatingdisorders,itisextremelyimportanttoimproveourunderstandingofthese

disorders,includingthesymptoms,andunderlyingsocio‐culturalandbiologicalcauses.

Beforeaddressingtheunderlyingcausesofdisorderedeating,itisfirstimportantto

definewhatismeantbythetermeatingdisorderfromaclinicalperspective.Thecurrent

DiagnosticandStatisticalManualofMentalDisordersDSM­IV­TRFourthEditionhasbeenin

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usebycliniciansandpsychiatristssince2000.Allrecognizedmentalhealthdisordersare

classifiedwithinfivedifferentcategories:AxisI:ClinicalSyndromes,AxisII:Personality

andMentalRetardation,AxisIII:MedicalConditions,AxisIV:Psychosocialand

EnvironmentalProblems,AxisV:GlobalAssessmentofFunctioning.Thecriteriaforeating

disorderdiagnosesarefoundunderAxisI:ClinicalSyndromes.

Threesub‐groupsmakeupthelargercategoryofeatingdisorders;theseinclude

anorexianervosa307.1,bulimianervosa307.50,andEDNOS307.51.“Tobeofficially

diagnosedwithaneatingdisorder,onehastomeettheclinicaldiagnosticcriteria

delineatedinthecurrenteditionoftheDiagnosticandStatisticalManualforMental

DisordersIVTR(2000),butthespecificdefinitionsthereindonotencompassallofthe

syndromeshealthprofessionalstreat.”(Costin2007:4)Disorderedeatingcomesinmany

forms,andsymptomsofthesementaldisorderscanmanifestthemselvesinwaysthatare

notincludedinthecurrentcriteria.Table1providesthefulllistofcriteriafordiagnosesas

presentedintheDSM‐IV‐TR.

AnorexiaNervosa307.1

TheDSM‐IV‐TRclassificationofanorexianervosa(AN)restrictsthediagnosisof

individualstothosewhodemonstratethefollowingsymptoms:weightfallsbelow85%of

whatisexpectedforthatindividual’sageandheight,intensefearofgainingweight,

distortedperceptionofhowone’sbodylooksorisexperienced,andmissingmenstrual

periodinfemalesofappropriateage(basedoffofthreeconsecutivemissedperiods).

Withinthisdiagnosis,therearetwotypes,therestrictivetypeandthebinge‐purgetype.A

restrictivetypewillrefrainfromcalorieconsumptioninordertoloseorkeepweightoff,

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whereas,abinge‐purgetypewillregularlyover‐consumeandthenuseinappropriate

behaviorstoremovefoodbeforeabsorptioncanoccur.

BulimiaNervosa307.51

TheDSM‐IV‐TRdiagnosisofbulimianervosa(BN)isrestrictedtoindividualswith

thefollowingsymptomsoccurringtwotimesaweekforthreemonths:episodesofbinge‐

eatingwithlossofcontrol,episodesarecharacterizedbyeatingunusuallylargeamountsin

shortperiodsoftime,andarefollowedbyinappropriatemethodsofcompensation,

includingforcedvomiting,laxativeanddiureticuse,fasting,excessiveexerciseetc.A

patientwithBNassessesthemselvesthroughtheirperceptionoftheirweightandbody,

andtendstojudgetheirselfworthbasedontheirshape.Bulimianervosaalsocomesintwo

formsthefirsttypeutilizespurging,i.e.self‐inducedvomiting,laxatives,diuretics,or

enemas,thesecondtypeutilizesalternativeformsofcaloriecompensation,i.e.excessive

exerciseorfasting.

EDNOS307.50

TheDSM‐IV‐TRdiagnosisofEatingDisordersOtherwiseNotSpecified(EDNOS)

coversaverylargerangeofsymptoms.Thisclassificationisusedforpatientsthatdisplay

eatingdisorderpathologiesthatlieoutsideofthespecificcriteriaforANandBN,ordisplay

onlysomeoftheANorBNsymptoms.Thesesymptomsinclude,butarenotlimitedto:all

criteriaofANexceptamenorrhea(missedperiod),allcriteriaofANexceptnormalweight

andregularmenses,allcriteriaofBNexceptbehaviorsoccurlessfrequentthantwotimes

perweekforadurationofthreemonths,usinginappropriatemethodstoexpelsmall

amountsoffood,andchewingandspittingoutfoodsoastoavoidnormalcalorieintake.

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AlsodefinedwithintheEDNOScategoryisBingeEatingDisorder(BED),patients

withthisdisorderendurereoccurringepisodesofbinge‐eating,withasenseoflostcontrol,

butdonotuseinappropriatemethodsofcompensation.Increasedcuriosityonthis

disorderflagsitasoneinneedoffurtherstudy,andresearchsurroundingitisimportant.

ProblemswithClinicalDefinitionsandDiagnosis

Although,thenarrowrequirementsoftheDSM‐IV‐TRcanbeadvantageousthrough

preventionofoverdiagnosis,theycanalsocauseproblemsinidentificationofmildor

moderatedisorders,aswellascreateagapinresearch.Severalcriteriathatcanbe

problematicwithanorexianervosacurrentlyincludetherequirementofamenorrheaand

weightbelownormal.Withbulimianervosathecriteriaarenolessproblematicincluding

issueswiththeilldefinitionof‘binge’andthetimerequirementforrecurrenceofepisodes

(Wilfleyetal.2007:125).Asaresultofthenarrowdefinitionsofanorexianervosaand

bulimianervosaalargemajority,approximately50‐70%(WalshandSysko2009:1),of

patientsreceiveEDNOSdiagnoses.Thisstatisticistroublesomebecauseresearchis

typicallyonlydoneusingpatientswhoreceiveANorBNdiagnoses.Also,EDNOSismuch

toovagueandcoverstoolargearangeofsymptoms(WalshandSysco2009:1).For

instance,awomanwhomeetsallofthecriteriaforAN,butmaintainsnormalmenses,falls

intothesamecategoryasamanwhobinge‐eats,withlostcontrol,fivenightsaweek.

ThenegativeramificationsofthelimitsoftheDSM‐IV‐TReatingdisorderdiagnoses

haveledtoanefforttoredefineandreorganizethedisorders.Insearchofmore

encompassingcategoriesforuseintheDSM‐V,TimothyWalsh,MDandRobynSysko,PhD,

utilizedcurrentstudiestoreclassifythedisordersintotheBroadCategoriesforthe

DiagnosisofEatingDisorders(BCD‐ED).Theysuggestthatthenewdiagnosesincludeall

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personswho“meetthefundamentalconceptualdefinitionofaneatingdisorder,”(2011:4).

Theirproposaltakesintoconsiderationthefactthatthesedisordersareextremely

complex,varybetweenpersons,andoccurindifferentseverities.Table2.showsthe

lengthydefinitionsforAN,BN,BED,andEDNOSassuggestedbySyskoandWalsh.

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Table1.DSM‐IV‐TRCriteriaforEatingDisorders1.AnorexianervosaTheDSM‐IVTRDiagnosticCriteriafor307.1SymptomsofAnorexiaNervosaA.Refusaltomaintainbodyweightatoraboveaminimallynormalweightforageandheight(e.g.,lessthan85percentofthatexpectedorfailuretomakeexpectedweightgainduringperiodofgrowthleadingtobodyweightlessthan85percentofthatexpected)B.Intensefearofgainingweightorbecomingfat,eventhoughunderweight.C.Disturbanceinthewayinwhichone’sbodyweightorshapeisexperienced,undueinfluenceofbodyweightorshapeonself‐evaluation,ordenialoftheseriousnessofthecurrentlowbodyweight.D.Inpostmenarchealfemales,amenorrhea,i.e.,theabsenceofatleastthreeconsecutivemenstrualcycles.(Awomanisconsideredtohaveamenorrheaifherperiodsoccuronlyfollowinghormone,e.g.,estrogen,administration)RestrictingType:duringthecurrentepisodeofAnorexiaNervosa,thepersonhasnotregularlyengagedinbingeeatingorpurgingbehavior(i.e.,self‐inducedvomitingorthemisuseoflaxatives,diuretics,orenemas).Binge­Eating/PurgingType:duringthecurrentepisodeofAnorexiaNervosathepersonhasregularlyengagedinbinge‐eatingorpurgingbehavior(i.e.,self‐inducedvomitingorthemisuseoflaxatives,diuretics,orenemas).

2.BulimianervosaTheDSM‐IVTRDiagnosticcriteriafor307.51SymptomsofBulimiaNervosaA.Recurrentepisodesofbingeeatingcharacterizedbyboth:‐Eating,inadiscreteperiodoftime(e.g.,withinany2‐hourperiod),anamountoffoodthatisdefinitelylargerthanmostpeoplewouldeatduringasimilarperiodoftimeandundersimilarcircumstances‐Asenseoflackofcontrolovereatingduringtheepisode(e.g.,afeelingthatonecannotstopeatingorcontrolwhatorhowmuchoneiseating),B.Recurrentinappropriatecompensatorybehaviorinordertopreventweightgain,suchasselfinducedvomiting;misuseoflaxatives,diuretics,enemas,orothermedications;fasting;orexcessiveexercise.C.Thebingeeatingandotherinappropriatecompensatorybehaviorsbothoccur,ontheaverage,atleasttwiceaweekforthreemonths.D.Self‐evaluationisundulyinfluencedbybodyshapeandweight.E.ThedisturbancedoesnotoccurexclusivelyduringepisodesofAnorexiaNervosa.PurgingType:DuringthecurrentepisodeofBulimiaNervosa,thepersonhasregularlyengagedinself‐inducedvomitingorthemisuseoflaxatives,diuretics,orenemas.Non­purgingType:DuringthecurrentepisodeofBulimiaNervosa,thepersonhasusedotherinappropriatecompensatorybehavior,suchasexcessiveexercisingorfasting,buthasnotregularlyengagedinself‐inducedvomitingormisusedlaxatives,diuretics,orenemas.

3.EDNOSDSM‐IVTRDiagnosticcriteriafor307.50EatingDisorderNotOtherwiseSpecifiedTheEDNOScategoryisfordisordersofeatingthatdonotmeetthecriteriaforanyspecificEatingDisorder.ExamplesInclude:1.Forfemales,allofthecriteriaforAnorexiaNervosaaremetexceptthattheindividualhasregularmenses.1. AlloftheCriteriaforAnorexiaNervosaaremetexceptthat,despitesignificantweightloss,theindividual’scurrentweightisinthenormalrange.2. AllofthecriteriaforBulimiaNervosaaremetexceptthatbingeeatingandinappropriatecompensatorymechanismsoccuratafrequencyoflessthantwiceaweekorforadurationoflessthanthreemonths.3. Theregularuseofinappropriatecompensatorybehaviorbyanindividualofnormalbodyweightaftereatingsmallamountsoffood(e.g.,self‐inducesvomitingaftertheconsumptionoftwocookies).4. Thepatientengagesinrepeatedlychewingandspittingout,butnotswallowing,largeamountsoffood.5. Binge‐eatingdisorder:recurrentepisodesofbingeeatingintheabsenceofregularinappropriatecompensatorybehaviorcharacteristicofBulimiaNervosa.

(FromDiagnosticandStatisticalManuelofMentalDisordersDSM‐IV‐TR2000)

McMillin 16

Table2.BCD‐EDCategoriesforconsiderationinDSM‐Vclassificationnnn.1AnorexiaNervosaandBehaviorallySimilarDisorders(AN‐BSD)DiagnosticCriteriaforAN­BSD1.Severerestrictionoffoodintakerelativetocaloricrequirementsleadingtothemaintenanceofaninappropriatelylowbodyweightfortheindividualtakingintoaccounttheirageandheight.2.Clinicallysignificantdistressorfunctionalimpairmentrelatedtotheeatingdisturbance.3.NotbetteraccountedforbyanotherAxisIdisorderorageneralmedicalcondition.

nnn.2BulimiaNervosaandBehaviorallySimilarDisorders(BN‐BSD)DiagnosticCriteriaforBN­BSD1.Recurrentoutofcontroleatingandtherecurrentuseofinappropriatepurgingbehaviorsaftereatingtocontrolweightorshapeand/ortheabsorptionoffood.2.Clinicallysignificantdistressorfunctionalimpairmentrelatedtothesebehaviors.3.NotbetteraccountedforbyanotherAxisIdisorderofageneralmedicalcondition.4.Doesnotmeetcriteriafornnn.1.

nnn.3BingeEatingDisorderandBehaviorallySimilarDisordersDiagnosticCriteriaforBED­BSD1.Recurrentepisodesofoutofcontroleating,duringwhichtheindividualfeelsasifhe/shecannotcontroleatingbehavior.2.Clinicallysignificantdistressorfunctionalimpairmentrelatedtothesebehaviors.3.NotbetteraccountedforbyanotherAxisIdisorderorageneralmedicalcondition.4.Doesnotmeetcriteriafornnn.1ornnn.2.

nnn.11TypicalAnorexiaNervosaA.Severerestrictionoffoodintakerelativetocaloricrequirementsleadingtomaintenanceofbodyweightbelowaminimallynormalweightforanindividualtakingintoaccountageandheight(e.g.,85%ofthatexpected).B.Evidenceofintensefearofgainingweightorbecomingfat,eventhoughunderweight.C.Disturbanceinthewayinwhichone’sbodyweightorshapeisexperienced,undueinfluenceofbodyshapeorweightonself‐evaluation,ordenialoftheseriousnessofcurrentlowbodyweight.Note:amenorrheaisnotrequired

nnn.21TypicalBulimaNervosaA.Recurrentepisodesofbingeeating(theconsumptionofalargeamountoffoodinadiscreteperiodoftimeaccompaniedbyasenseoflossofcontrol.)B.Recurrentinappropriatecompensatorypurgingbehaviorafterbingeeatingtopreventweightgain(self‐inducedvomiting,abuseoflaxatives,diuretics,orenemas).C.Thebingeeatingandinappropriatepurgingbehavioroccur,onaverage,atleastonceaweekforthreemonths.D.Selfevaluationisundulyinfluencedbybodyshapeandweight.E.Doesnotmeetcriteriafornnn.1

nnn.31TypicalBingeEatingDisorderA.Recurrentepisodesofbingeeating(largeamountoffoodinadiscreteperiodoftimeaccompaniedbyasenseoflossofcontrol).B.Thebingeeatingoccurs,onaverage,atleastonceaweekforthreemonths.C.Doesnotmeetcriteriafornnn.1ornnn.2

nnn.12AnorexiaNervosa,withoutEvidenceofDistortionsRelatedtoBodyShapeandWeightA.Severerestrictionoffoodintakerelativetocaloricrequirementsleadingtomaintenanceofbodyweight

nnn.22BulimiaNervosa,LowFrequencyA.Recurrentepisodesofbingeeating(largeamountoffoodinadiscreteperiodoftimeaccompaniedbyasenseoflossofcontrol).B.Recurrentinappropriatecompensatorypurging

nnn.32BingeEatingDisorder,LowFrequencyA.Recurrentepisodesofbingeeating(largeamountoffoodinadiscreteperiodoftimeaccompaniedbyasenseoflossofcontrol).B.Doesnotmeetcriteriafornnn.1ornnn.2ornnn.31.

McMillin 17

belowaminimallynormalweightforanindividualtakingintoaccountageandheight(e.g.,85%ofthatexpected)B.Evidenceofintensefearofgainingweightorbecomingfat,eventhoughunderweight.C.Doesnotmeetcriteriafornnn.11Note:amenorrheaisnotrequired

behaviortopreventweightgain(self‐inducedvomiting,abuseoflaxatives,diuretics,orenemas).C.Selfevaluationisundulyinfluencedbybodyshapeandweight.D.Doesnotmeetthecriteriafornnn.1ornnn.21.

nnn.13AN­BSD,withSignificantWeightLossatoraboveaMinimallyAcceptableWeightA.Severerestrictionoffoodintakerelativetocaloricrequirementsinordertoavoidweightgain.B.Evidenceofintensefearofgainingweight.C.Disturbanceinthewayinwhichone’sbodyweightorshapeisexperiencedorundueinfluenceofbodyshapeorweightonself‐evaluation.D.Bodyweightatoraboveminimallynormalforanindividualtakingintoaccountageandheight.E.Doesnotmeetcriteriafornnn.11ornnn.12.

nnn.23PurgingDisorderA.Recurrentinappropriatecompensatorypurgingbehaviorfollowingoutofcontroleating.B.Selfevaluationisundulyinfluencedbybodyshapeandweight.C.Doesnotmeetcriteriafornnn.1ornnn.21.

nnn.33SubjectiveBingeEatingA.Recurrentepisodesofoutofcontroleatingthatdonotinvolvetheconsumptionofobjectivelylargeamountsoffood.B.Doesnotmeetcriteriafornnn.1ornnn.2ornnn.31ornnn.32

nnn.14DisordersBehaviorallySimilartoAnorexianorotherwiseClassifiedA.Severerestrictionoffoodintakerelativetocaloricrequirementsleadingtomaintenanceofbodyweightbelowaminimallynormalweightforanindividualtakingintoaccountageandheight(e.g.,85%ofthatexpected)B.Doesnotmeetcriteriafornnn.11,nnn.12,ornnn.13.

nnn.24DisordersBehaviorallySimilartoBulimiaNervosanotOtherwiseClassifiedA.Recurrentoutofcontroleating.B.Recurrentuseofinappropriatebehaviorstocontrolweightorshapeand/ortheabsorptionoffood.C.Doesnotmeetthecriteriaofnnn.21,nnn.22,nnn.23

nnn.34DisordersBehaviorallySimilartoBingeEatingDisorderNotOtherwiseClassified(BED­BSD­NOS)A.Recurrentepisodesofoutofcontroleating,duringwhichtheindividualfeelsasifhe/shecannotstoporcontroleatingbehavior.B.Doesnotmeetcriteriafornnn.1,nnn.2,ornnn.31‐33.

nnn.4EatingDisordersNotOtherwiseSpecified(EDNOS)Eachbroadcategoryforclinicallysignificanteatingdisordernotmeetingcriteriaforoneofthecategoriesabove.Possibleexample:recurrentchewingandspittingoffood,nighteatingsyndrome.(FromWalshandSyskoBroadCategoriesfortheDiagnosisofEatingDisorders(BCD‐ED)2009)

McMillin 18

BCD­EDAnorexiaNervosa WalshandSysko’sredefinedcategoryofanorexianervosawouldcoverallpersons

whorestrictfoodintakeandasaresultmaintainverylowbodyweightrelativetoheight

(approx.85%ofexpected).UnlikethecurrentDSM‐IVcriteria,theysuggestdroppingthe

requirementforamenorrhea.Thisreconsiderationisextremelyimportantasithelps

removethegenderedassumptionscurrentlyheldbytheDSM‐IV,andopensupthe

diagnosistowomenwhohavenotreachedthatseverityintheirowndisorder.The

extensionoftheircategoriesalsowidenstoincludepersonswhodonothavethesame

mentaldisturbances,fearofweightgainand/orbodydismorphia,butpracticethesame

behaviorsoffoodrestriction.

BCD­EDBulimiaNervosa

WalshandSysko’sorganizationofbulimianervosaissimilartoDSM‐IVinthe

requirementforrecurrentepisodesofout‐of‐controleatingandcompensatorymethodsfor

alteringabsorptionoffood.However,theirreclassificationwouldalsoincludeindividuals

whoseoutofcontroleatingmaynotbeclassifiedasbinging,aswellascaseswherethe

individualdisplaysbulimicbehaviorswithoutthementaldisturbance.

BCD­EDBingeEatingDisorder

BecausetheDSM‐IVdoesnotdistinctlyclassifyBingeEatingDisorderandit

currentlymakesupalargepercentageofpatientsfallingintotheEDNOScategory,the

suggestionsonthisdisorderareveryimportant.WalshandSysko’sBEDdiagnosisincludes

individualswhoengageinrecurrentepisodesofout‐of‐controleating,withouttheuseof

compensatorybehaviors.Theirsuggestiondoesnotspecifyhowmuchfoodanindividual

consumesinanepisodeofout‐of‐controleatingorforhowlongtheypracticethebehavior

todiagnoseBED.Beyondthis,theyalsodefineaNightEatingSyndrome,whichconsistsof

McMillin 19

eatinganunusuallylargeamountoffoodafterdinner(25%ofthedayscalories);practicing

thisbehaviorhelpsonetosleep.

DSM­V

Thoughnotyetreleased,thefifthversionoftheDiagnosticandStatisticalManual

willcontainrevisedcriteriaforANandBN,aswellasanewclassificationforBingeEating

Disorder.Thesechangescomefromassessmentsofpublishedworkswithinthe

InternationalJournalofEatingDisorders(Keel2011:553).Withthenewclassification,

professionalswillbeabletogiveagreaternumberofindividualsdiagnosesandreducethe

numberofEDNOSdiagnoses.Toreiterate,theimportanceofreducingthenumberof

EDNOSdiagnosesliesinopeninguptheresearchtoabroaderspectrumofsymptomsand

diagnoses.Inaddition,itwillgiveprofessionalswiderguidelinesthroughwhichtheycan

understandapatientandtheirsymptoms.

Classificationofthesedisorderscanbequitecomplexwiththevaryingmental

disturbances,severities,andindividual’sexpressions.Understandingthatthecauseis

deeplyrootedinaninteractionofsocio‐culturalenvironmentandanindividual’sbiology,

genetics,andexperiencesmayindicatewhytheyexpressthemselvesthewaytheydo,how

totreatthem,orbetteryethowtopreventthem.

UnderstandingNutrition,HumanBiology,andFoodImplications

Thegrowingfieldofnutritionstudyhasbroughtaboutawealthofknowledgeon

howandwhatpeopleshouldandshouldnoteatinordertolivelongandhealthylives.The

verycomplexfoodsystemintheWesternworldcreatesanumberofcontradictionsabout

consumptionoffoodsandbeverages;manyofwhichtheeatingdisorderpatientbattles

witheveryday.Atthemostbasiclevel,eatingdisorderstemperwiththebodiesneedsfor

McMillin 20

energyandnutrientstofunctionproperly.Beyondthat,theyfacilitatetheculturaldemand

tomaintainaslenderphysiqueandcontrolone’sintake,andultimatelytheirlife.

NutritionandHumanBiology

Foodandbeveragesprovideenergyandnutrientsessentialtogrowth,development,

andmaintenanceofbodilyfunctions.However,thetypesoffoodsandbeveragespeople

consumevaryaccordingtonecessity,availability,preference,digestibility,etc.Actual

energyandnutrientrequirementsaredeterminedbyage,size,activitylevel,reproductive

state,andgenetics.Evidencebasedrecommendationsformeetingtheserequirementshave

beenestablishedbyTheFoodandNutritionBoardoftheInstituteofMedicine(IOM),and

arepublishedastheDietaryReferenceIntakes(DRI).Everyfiveyears,theyupdateand

reviewtheserecommendations.Adequatedietsmeettheminimumrecommendationsand

aredefinedas,“theamountofnutrientsrequiredbyanindividualtopreventsignsof

clinicaldeficiency,”(Barasi2003:41).

Thefoodsandbeveragesthatmakeuphumandietsarecomposedoftwocategories

ofnutrients:macronutrientsandmicronutrients.Thesenutrientsallowthebodyto

performallofthecrucialfunctions.Macronutrientsincludecarbohydrates(starchand

sugar),fat,protein,andalcohol,andmakeupthelargestcomponentofthedietbecause

theyprovideenergy(Eastwood2003).Theenergycontentofafoodordrinkismeasuredin

calories,theamountofheatrequiredtoraiseonegramofwateronedegreeCelsius

(Eastwood2003),andvariesaccordingtothequantityofeachmacronutrientinits

makeup.Micronutrientsincludeallvitaminsandminerals,andwhiletheyareonly

requiredinverysmallamounts,theyplayacrucialroleinanumberofbiologicalprocesses

includingbutnotlimitedtoimmunefunction,brainfunction,andeyesight(Eastwood

McMillin 21

2003).Bothmacronutrientsandmicronutrientsareessentialtoanadequatediet,andthey

arehighlyinterdependent.Thus,individualsmustkeepsufficientamountsofallnutrients

inthebody(Eastwood2003).

Evenwithadequateenergyintakes,itispossibleforapersontosufferfrom

nutrientimbalances.Whennutrientconsumptionisunbalanced,individualscansuffer

frommalnutrition,eitherbyconsumingtoomuchofaparticularnutrient(overnutrition)or

notconsumingenough(undernutrition).Imbalancesresultingfrommalnutritioncanlead

toanumberofpoorhealthoutcomesincluding:obesityandobesityrelateddiseases

(excessmacronutrientintakes),rickets(VitaminDdeficiency)andblindness(VitaminA

deficiency)(Barasi2003).Giventheadverseeffectsassociatedwithmalnutrition,

understandingtheappropriateamountsofnutrientsandtheimportanceofkeepingthem

inbalance,forbothimmediateuseandstoragerequirements(Eastwood2003:52),has

beenamajorfocusofmedicalresearchinrecentdecades,andhasledtoanexpanding

knowledgeinthefield.

Aspreviouslymentioned,theDietaryReferenceIntakes(DRI)publishedbytheFood

andNutritionBoard,“comprisesasetofreferencevaluesforspecificnutrients,andeach

categoryofwhichhasspecialuses.”(DRI21)Thesetofreferencevaluesinclude:

RecommendedDailyAllowance(RDA),EstimatedAverageRequirement(EAR),Upper

TolerableLimit(UL),AdequateIntake(AI),andEstimatedEnergyRequirement(EER).An

RDAistheestimatedamountofnutrientsfor97‐98percentoftheindividualsofacertain

ageandgender.CalculationofastandarddeviationoftheEstimatedAverageRequirement

(EAR)reportsthesenumbers.TheDRIdefinesanEARas“theintakevaluethatisestimated

tomeettherequirement,asdefinedbythespecifiedindicatororcriterionofadequacy,in

McMillin 22

halfoftheapparentlyhealthyindividualsinalifestageorgendergroup,”(23).Nutrients

thatdonothaveenoughscientificdataforanRDAreceiveanAIvalueproposalbasedon

requirementsofhealthyindividuals.Thetolerableupperintakeleveldemarcatesthe

greatestamountofcertainvitaminsandmineralsapersoncanconsumewithoutadverse

effects.Thesevaluesaretypicallyusedforfat‐solublevitaminsbecausethefatandbody

storethem,whichmakethemmorelikelytoreachtoxiclevels.

Theestimatedenergyrequirement(EER)establishesnumbersthatachieve

equilibriumbetweenenergyintakeandenergyexpenditure(i.e.energybalance).The

energyintakepartofenergybalancereferstotheamountofenergyconsumedfrom

macronutrientsinfoodsandbeverages.Theenergyexpenditurepartofenergybalance

referstototaldailyenergyexpenditure(TDEE);thisisthesumamountofenergyexpended

ina24‐hourperiodthroughthethreecomponentsofenergyexpenditure:BasalMetabolic

Rate,thermiceffectoffood,andphysicalactivity.BasalMetabolicRate(BMR)istheamount

ofenergyrequiredtoperformallbasicmetabolicfunctionsinapost‐absorptive,resting

state.Bodysize,bodycomposition,age,gender,nutritionalstate,andvariabilityin

hormoneproductioninfluenceBMR(InstituteofMedicine2005).Thethermiceffectof

food(TEF)isthemetaboliccostnecessarytodigest,handle,andstoreingestednutrients,

andcontributestoabout10%oftotalenergyexpenditure.Physicalactivityistheamountof

energyusedformovingthebodyaround.Thisisthemostvariablecomponentofenergy

expenditure,andcanfluctuatebetweenindividualsanddaytoday.Forexample,ina

sedentaryindividual,physicalactivitymayonlycontributeto1/3oftotalenergy

expenditure.Ontheotherhand,inahighlyactiveindividualenergyexpenditurecanbetwo

timesashighbecauseofphysicalactivity(InstituteofMedicine2005).

McMillin 23

Whentheamountofcaloriesin(energyintake)doesnotequaltheamountof

caloriesout(energyexpenditure)thereisanenergyimbalance.Consumptionofmore

caloriesthanneededresultsinpositiveenergybalance,thiscausestheextracaloriestobe

convertedtoadiposetissue,akafat(Barasi2003,DRI2005,Eastwood2003).Theenergy

excessstoredinfatservesasabackupsupplyinperiodsofinadequateintakeforsurvival

overthecourseofseveralmonthsofdeprivationdependingontheamountstored(DRI

111).Negativeenergybalanceresultsfromfewercaloriesconsumedthanused.Inthis

situation,thebodyreliesonstoredenergytocompensatefortheimbalanceandkeepthe

bodyrunning.Thissystemofenergybalanceistheresultofalonghistoryofevolutionin

timeswhenresourceswerenotalwayspredictableandperiodsofscarcityfollowedperiods

ofplenty(Haslam2007).Inmoderntimes,theseimbalancesaccountformostpeoples

weightgainandloss.

TheDRIalsoprovidesrecommendationsforintakesofmicronutrientsandwater.

These,likemacronutrients,varyaccordingtotheindividualandaccordingtothenutrient.

Themostimportantpiecetobenotedaboutvitaminsandmineralsisunlikeexcessenergy

whichisstoredasfatanduseablebythebodyintimesofneedanumberoftheessential

micronutrients,onesthatmustbeobtainedthroughthediet,arenotstoredwiththebody

sotheymustbeconsumedonaregularbasis(Eastwood2003).Theseareknownaswater‐

solublebecausetheywatercarriesthemthroughandoutofthebody.Consumingthese

nutrientslessoftenincreasesthelikelihoodofprocuringadeficiency.

NutritionandSideEffectsofEatingDisorders

Withthisbriefdescriptionofhumannutritionalrequirements,anumberofphysical

sideeffectscausedbyeatingdisorderscanbeclearlyseen.Forinstance,apersonwith

McMillin 24

restricting‐typeanorexianervosaisnotconsumingenoughcaloriestomaintainenergy

balance,thus,resultinginweightloss.Also,thissameindividualmaynotbegetting

adequateamountsofdailyvitaminsandminerals,whichcanleadtodeficiencyandthe

resultingcomplications.Beyondthenutritionalsideeffects,womenwhohaveANmaylose

theirregularmensesbecauseoflowbodyweight(Copelandetal.1995).

Apersonwhohasbulimianervosa(BN)mayexperiencebingeswherethey

consumemorethanadequateamountsofvitamins,minerals,andmacronutrients.

However,apurgefollowingthisbehaviorcanexcretealargeamountoftheconsumption.It

isimportanttopointoutthatanindividualwithBNislikelytobeofnormalweightor

aboveweight,whichsuggeststhatpersistentlowenergyintakesarenotacommon

behavior,butself‐inducedvomiting,laxatives,anddiureticsarecommon.Theseparticular

behaviorscanhavemanycomplicationsoftheirown;including,butnotlimitedto,

dehydration,electrolyteimbalances,andacidicerosionofteethoresophagus(Romeand

Ammerman2003).LasaterandMehler(2001)reportdifferencesbetweenBNpatients

basedonthemethodforcompensation,orpurging.BNpatientswhopurgethroughself‐

inducedvomitingmayexperienceadirectlossofpotassium,chlorideions,andgastricacid;

whereasindividualswhopurgethroughlaxativeuselosepotassiumandbicarbonate.

InindividualswhosufferBingeEatingDisorder,orperhapsBNcompensatedwith

exerciseorself‐deprivation,itislikelytheyconsumetoomanycaloriesandpossiblytoo

manyvitaminsandminerals.Mostofthesepeoplewillseedrasticincreasesinweightdue

toexcessenergyintakeunmatchedbyenergyoutput.Inaddition,becausethenatureofa

bingeepisodediffersfromovereatinginthatitoccursinashortamountoftime,these

individualsmayreachtoxiclevelsoffat‐solublevitamins.Asthenewsandmassmediahave

McMillin 25

popularized,therearemajorhealthcomplicationsthataccompanyextremeweightgain

includingincreasedriskfordiabetes,coronaryheartdisease,andsleepapnea(Haslam

2007).

Withsuchdangeroussideeffects,thetacticsofeatingdisordersdemonstratethe

disconnectbetweenhumanbiology,includingthenecessityofcertainmacroand

micronutrients,andthewayhumansperceiveconsumption.Foodandbeverageplayan

importantroleinhumancultureandthisroledoesnotalwaysmatchupwiththebiological

necessity.Thesedifferencesmayaccountforwhypeoplearoundtheglobetreatfoodand

consumptioninamultitudeofways.Itmayalsobringlighttosomeofthereasonsforthe

developmentofeatingdisordersinwesternculture.

TheShiftfrom‘EattoLive’to‘LivetoEat’

Mostanimalseatpurelyasameanstosurvive;humans,however,havechangedthe

connotationofsubsistence.Amonghumans,foodandfoodconsumptionpatternshave

social,culturalandeconomicsignificance.Throughouthumanhistory,peoplehaveused

eatinganddrinkingtosignifytimesofday,status,hegemony,identity,andalargerangeof

otherculturalimplications.

AncientEgypt,duringthereignofKingDjoser,enduredaseven‐yeardroughtduring

whichtimethekingwasabletodisplayhisauthorityandprominencebyprovidingthe

peoplefoodfromasurplusheobtainedandcontrolled(Shaw2000).Thisdisplayofpower

occurredallovertheancientworldandisnotunknowntoday.Inmodern‐dayJapan,

womenandchildrendemonstratetheirsubserviencetosocietybycreatingandeating

obentos.Thesebeautifullycraftedlunchesareanobligationofmothersthatprovetheir

maternalabilities,andserveasaplatformforjudgmentbyauthoritativefigures.Forthe

McMillin 26

children,theselunches,whichmustbefinishedinatimelymanneratthetablewithallof

theotherchildren,prepyoungstersforthesocietytheywillbeentering.Thus,these

lunchesserveapurposethatgoeswellbeyondbiologyandcontroltheactionsofmany

membersofthepopulation(Allison1991).

InRichardLee’sarticleEatingChristmasintheKalahari(1969),hediscussesthe

practiceofundervaluinglargekillsofhuntersinordertopreventegoandhierarchyinthe

¡KungSanBushmen.Evenifakillisverylargeandwillsustainthepopulationforalong

periodoftime,theydenythehunterorproviderthisglorificationbecausetheydonotwant

tofacilitatethegrowthofhispride.Inthishunter‐gatherer,egalitariansociety,thepeople

denouncekillstoavoidobtainingstatusthroughhuntingsuccess.Inothercultures,food

candojusttheopposite.Forinstance,caviarisnotespeciallyenergeticallypotentwhich

makesitbiologicallyorevolutionarilylow‐cost.However,Westerncultureascribesvery

highvaluetocaviarandasaresultitmarkspersonalstatus.

Aculturalcreationthatappearsbiologicalistheassertionofcertaintimesintheday

whenfoodiseaten.IntheUnitedStates,morningisassociatedwithbreakfast,noonwith

lunch,andeveningwithdinner,andthesemealsrollaroundregardlessofapersons

nutritionalrequirementsorappetite.Peoplesensehungerduetocuesfromtheirbrainand

thereleaseofsignalinghormones,butthisreactionisnotalwaysbecauseoftruebodily

needforprovisions.Rather,itisduetothecreationofhabitsoranotheroutside

stimulation(Barasi2003).IntheUnitedStates,patternsoffoodandbeverageconsumption

resideinawebofculturalmeaningspunfromhistorical,social,andbiologicalequations.

Throughoutsocietiesthisdichotomybetweenbiologicalvalueandculturalvalueshowsup

invaryingdegrees.

McMillin 27

“Fat”intheUnitedStates

InthetwoandahalfcenturyhistoryoftheUnitedStates,trendsindietary

consumptionandlifestylehaveseenanumberofchangesastheresultofsocial,political,

economic,andbiologicalfactors.Outliningtheseshiftsallowsforageneralunderstanding

oftheincreasingAmericanbodyweights,thesocialconcernforthisepidemic,andthe

disgraceofbeing“fat”intheUnitedStates.

ChangesinProductionandConsumption

Inthe1850’s,thenumberoffarmsonAmericansoilwasaroundoneandahalf

millionandgrewquicklyonintothe1930’swhereitpeakedatnearlysevenmillion.Farms

atthistimedidnotincreasemuchinsizeandaveragedoutaround150acres(figure1).

However,followingthe1930’sthenumberoffarmsdrasticallydecreasedandthesizeof

thefarmsincreased.TheUSDAreportsanincreaseinfarmsholding500+acresfromthe

late1800’swellintothelate

1900’s.Concurrently,the

numbersoffarmswith

acreagefrom1‐49and50‐

499sawincreasesuntil

1935andhavesince

experiencedsteady

decrease.Thesenumbers

suggestthattherapidly

increasingAmericanpopulation

reliedonadecreasingnumberof

Figure1.Farmsizeinacresandnumberoffarmsfrom1850‐1997.(From:USDAAgriculturalFactBook2003)

McMillin 28

farmstoprovidethemwithsustenance.

Theagriculturalperiodbetweenthelate1700’sandearly‐mid1800’sutilizedthe

earliestcropsofcorn,wheat,barley,tobacco,andothersforanycommercialuse,butalso

dependedonsmallergardenplotsforsubsistence(Schlebecker1975).However,asthe

populationexpandedwestward,travelroutesimproved,andnewfarmingtechnologies

wereintroduced,thewaysofmanyAmericanfarmerschanged.Thenineteenthcentury

broughtwithitanumberofequipmentimprovementsthatloweredcostsofproduction,

boostedagriculturalproductivity,reducedtheuseofhiredlabor(Post1997).The

introductionofenhancedplantingtechniques,likeDickey’sImprovedPatentedCorn

PlanterandtheGraindrillplanter,allowedformoreefficiencyandlesshandplantingof

crops(Schlebecker1975).Anotherimplementofgreatmagnitudeduringthistimewas

mechanizedharvestingandprocessing.Afterthemidnineteenthcentury,farmersadopted

reaperstocutandbundlethegrainandthreshingmachinestocleanit;theseinventions

drasticallydecreasedthenumberofman‐hoursrequiredforthesameamountofreturn

(Schlebecker1975).Thedesireforcommodities,increasedlandholdings,andpayingoff

accumulateddebts,promptedtheespousalofthesetechnologiesbyfamilyfarmers(Post

1997).

Whenindustriesstarteddevelopinginthenineteenthcenturyanddemanded

employeesfromtheruralfarminglands,thepopulationdensitiesofurbancentersboomed.

By1860,over30%ofthepeoplelivingincities(classifiedbyhaving2,500peopleormore)

madeupcitiesofover100,000people,andby1890,35.1percentoftheUnitedStates

populationlivedinacity(USCensusBureau).Thelaborchangefrommanualfarmingto

industriallineworkencasedaverydramaticlifestyleshift;mostlineworkdidnotentail

McMillin 29

thesameamountofphysicalactivitythatfarmworkoncehad,workhoursranfrom9‐5,

andtheyatelunchonthejob(Delpeuchetal.2009).WhenAmericajoinedtheworld

markethavingenoughenergytosustainagrowingpopulationthatwouldincrease

productivityinthefactoriesbecameveryimportant(Grigg1987).Aswasstandardforthe

time,agriculturalgiantsandindustrializedtechniquesreplacedthesmallproductionfarms,

andtheself‐sufficientsystemdwindled.

Withsteadyincomeandlessworkputintoafarm,menandfamiliesstartedtorely

moreonoutsidesourcesoffood.Farmsandtheiroutputgrewexponentially,butwith

changingeconomicsituationsanddietarypreferences,themarketwasinconstantflux.As

aresult,presidentsHoover(1929‐33)andRoosevelt(1933‐45)bothintroducedprograms

thatwouldcollecttaxesforthesubsidizingoffarmers(Folsom2006).Initiationofthese

subsidiesfreedfarmersofconcernsaboutcropfailureorcommercialvariabilityandthe

moneyprovidedbygovernmenttofarmersallowedfortheproductionoffoodsurplusand

thefeedingofthenation'smasses(Delpeuch2009)..

TheAmericandietquicklyembracedtheearlycropsofcorn,cerealgrains,andsugar

beetsproducedbyindustrializedfarms(Schlebecker1975).AstheSecondWorldWar

beganintheearliestpartofthe1940’s,Americawasstruckwithconcernaboutkeepingthe

industrylaborersandsoldierssufficientlyfueled(Levenstein2003).Thisdemandoffood

forUSsoldiersandtheAllies,andchangingproductivityledtogovernmentestablishment

ofrationsandfoodinsecurities(Schlebecker1975).Theyearsthatfollowedpost‐warsaw

anincreaseinblackmarketsalesofbutter,sugar,andmeats(Levenstein2003);thedesire

forthesefoodsonlygrewaftertheyearsofuncertaintyandfluctuationofWWII.

McMillin 30

WhenthemarketwasabletorebootandAmerica’sfarmersoutproducedtheneeds

ofthepopulation,thepricesofthecropsdroppedandtheindustryhadtoomuchfood.

Muchofthesurpluswasexportedtotheworldmarketandsubsidizedforcountries

sufferingdepressioninthepost‐warera(Schlebecker1975).However,therewasalsoan

increaseinconsumptionofanimalmeatproductsandadecreaseinfreshfruitand

vegetableconsumptionatthistime(Schlebecker1975).Accordingly,therewasarisein

productionofcaloriedenseconveniencefoods,agrowingvarietyoffoodstobefoundat

thelocalsupermarket,andmoremeatthaneverbefore,allaccompaniedbyarelative

decreaseinpricepercalorie.

TheAmericanhouseholdconsumedmanyacommoditypostwar;however,eating

home‐cookedmealsdidnotloseimportance.Mothersconcoctedbeautifuldinners

spendingabouttwicethetimebothcookingandcleaningthantheydotoday(Cutleretal.

2003).ThisislikelybecausetheaverageAmericandinnerconsistedofastarch,meat,a

vegetable,asalad,andadesert(Levenstein2003).Yet,aswomenmovedfromdomestic

worktotheworkforce,timetopreparethese

extravagantmealsdecreased,leadingto

dependenceoneasierandquickercalorie

sources(Delpeuchetal.2009),seefigure2.

Figure2.showsanadvertisementforGoldMedalFlour

from1953.Thispieceappealstowomenasdeliciouscook

andhomemaker,whilealsohighlightingthedecreasedeffortnecessaryforpreparationandcleanup.Noticethenumberedsectionstating“1.Onlyonebowltowash!2.Onerising!Rightinthebakingban!3.Nokneading!No

punchingdown!4.BetterthanaMix!”

McMillin 31

Divergencefromwholefoodsources(i.e.:freshfruits,vegetables,andlessfattymeat

cuts)toconvenientfrozen,premade,packaged,andfastfoodsresultedinexploitationof

thatdemandbythecapitalisteconomy.The1950’ssawanincreaseintheproductionof

packagedcereals,cakemixes,frozendinners,instantcoffee,andpreparedentréesallladen

withcompactedcalories(Tillotson2003).Foodsconsumedprior,including:wholeor

mashedpotatoes,vegetables,andmeatwouldconstitutealowercaloriecontentthantheir

condensedcounterparts.However,theeaseofreadybakelasagna,frozenvegetables,and

GeneralMills©dinnerrollsmadethemalluringprospectsformanyhomes.Yet,thedesire

foreasierfoodswasnotrestrictedtohomemadedinners.

Thepeoplesoondemandedinstantsnacksandfastermealsforthequickeningpace

oftheirlives.ManfredGarhammer’spaper“PaceofLifeandEnjoymentofLife,”(2002)

outlinestheevidenceforincreasingtimepressureandhasteningpaceoflifeinmodern

societies.Hisworkbringsattentiontothenotionthatpeopleinmodernizedcountries

appeartobehappyandsatisfiedintheirlives,however40%offulltimeAmerican

employeessaidtheyalwaysfeltrushed,asdid46%ofemployedGermans.Garhammer

pointsoutthatthetime‐crunchsensationpeoplearefeelingmaybetheresultofmulti‐

taskinginordertogeteverythingdoneinacertaintimeframe.Inorderforpeopletogetall

ofthetasksofthedaydoneinareasonablemanner,timeforcertainactivitieshastobecut

short.Relianceonfasterfoodproductionandconsumptionallowspeople,especially

women,toallocatemoreoftheirtimetoothercomponentsoftheirlife.

Unfortunately,withmassandfastproductioncomeunintendedconsequences.

Foodsprovidedinthismannermustbeproducedmoreinexpensively,thus,thereisan

increaseinfatcontentandadecreaseinmicronutrients(Delpeuchetal.2009).Inthe

McMillin 32

1980’s,therelativepriceforenergyrichfoodsfell,andthepricesofvegetables,fish,fruit,

andmilkincreased(Levenstein2003).Becauseofthisshift,productionofenergydense

productslikehamburgers,potatochips,andsugarybeveragescanoccurinlargequantities

forlowprices(Delpeuchetal.2009).Thelasthalfofthecenturysawanexpansioninthe

amountofproducerstakingadvantageofcheapcaloriesandthisamountcontinuestogrow

today.

ConvenienceFoodsintheUnitedStates

WhenevaluatingAmericatodayitissafetosaythatthelargemajorityconsumes

conveniencefoods.InastudybyHarrisandShiptsovatheyfoundthatthenumberofnew

convenienceproductsintroducedbetween1987and2002totheAmericanmarketwas

overthreethousand,andthisnumberdoesnotrepresenteveryitemineverynewflavor

(2007).Ofthesenewitems,meals,entrees,pizza,hotsnacks,andsandwichesmakeup26.4

percent,7.9percentsoups,and7.8percentpastaandpastasidedishes.Theyalso

approximatethattheaverageAmericanconsumes71frozendinnersayear.Theirresearch

suggeststhatnominaldollarsalesonconveniencefoodsincreased53percentfrom1987‐

1998andcontinuestogrow.From1977to1996theamountofcaloriesconsumedathome

fromsaltysnacksincreasedfrom127cal‐206cal;asimilarpatternwasalsoseenin

desserts,302cal‐324cal,sodas130cal‐158cal,andpizza493cal‐628cal(Nielsenetal.2003).

Theincreaseofathomeconveniencefoodandcalorieintakeisaccompaniedby

growingratesoffastfood,take‐out,anddine‐inconsumptionaswell.Approximately50%

ofthemoneyfamiliesallocatetofoodisspentoneatingout,andoneinfiveAmerican’seat

fast‐fooddaily(Holdsworth2009).AccordingtoastudybyNielsenetal.(2003),American

adolescents(12‐18yearsold)inthelate1970’swereeating74.1percentoftheirmealsat

McMillin 33

homewithonly6.5percentoftheircalorieseatenatarestaurantorfastfoodjoint.Even

thegenerationofyoungadultsatthistime,19‐29yearsold,wasonlyconsuming14.3

percentoftheirenergyfromrestaurantsorfastfood.By1996,thepercentagesofcalories

eateninthehomedecreasedforbothgroups,adolescentsate64.8percentathome,and

youngadultsate54percent.Anincreaseinrestaurant/fastfoodcalorieconsumption

accompaniedthisforbothgroupsby10.9percentand21.3percentrespectively.

Nowadays,peoplecanfindfastfoodchainsandrestaurantsinallcornersofthe

world.McDonald’salonehaslocationsin118countries,over34,000restaurants,andthey

claimtoprovidefoodto69millionpeople(McDonalds.com).Whenlookingatanaverage

AmericanMcDonald’smealthereareanumberofverycheapcaloriesourcesutilized.For

example,aBigMac©hasabunproducedwithenrichedflour(cerealgrains),highfructose

cornsyrup(corn),andsoybeanand/orcanolaoil(soy/rapeseed),toppedwitha100%

beefpatty,pasteurizedprocessedAmericancheese,BigMacsauce,shreddedlettuce,pickle

slices,andsliveredonions(McDonald’singredientslist).Thesandwichaloneamountsto

550calories,whichisactuallyonthelowerendfortheirburgers.Whenthisispairedwith

amediumFrenchfryandCokethemealtotalis1140kcal,accountingforoverhalfofthe

averageperson’sdailycalorierequirement.Therelativecostofthismealpercalorieis

inexpensive,especiallywhencomparedtoasaladorvegetabledishmadeathome,and

acquiring/enjoyingrequireslittletimeandeffort.Aconsumerculturethatpromotes

indulgencefuelsthedesireforeasyfoodsthatappealtothetastebuds(Bordo2003).

Advertisingthatstimulatesthesensesandpromptsdesirebombardspeople.Thisscenario

doesgreatthingsforboostingtheeconomyoffoodandbeverages,butmaycomeatthe

costofpeople’shealth.However,thecaloriedensefoodisnotsolelytoblame.

McMillin 34

Ifthepopulationwereconsumingthesefoodsinamountsthatdidnotreachtheir

caloricintakenecessitythentherewouldbelessdramaticweightgain.Thiscanbeseenin

aruralAmazonianpopulationoflowerclasswomenwherethereisanincreasing

dependenceonanimalprotein,fats,andconveniencefoodsanddecreasingconsumptionof

traditionalfruits,vegetables,legumes,andtubers.Overthecourseofaseven‐yearstudy,

thispopulationsawanincreaseinpercentageoffoodspurchasednotproduced,butalso

sawadecreaseinaveragedailycalorieintake(Piperata2011).

IntheUnitedStates,wherethemajorityofpeoplepurchasetheirsustenanceand

enjoyalargevarietyofsalty,sweet,fattycaloriedensecommodities,theyhaveatendency

toconsumetoomanycalories.Overthelastfortyyearscalorieconsumptionandportion

sizehasincreasednotonlyatrestaurantsandfast‐foodplacesbutinthehomeaswell

(Nielsenetal.2003).TheUSDAreportsthatin2000approximately3,800calorieswere

producedandsuppliedperpersonperdaywithanapproximate1,100calorieslostto

waste,leavingtheaverageconsumptionat2,700calories.Thisnumberisup24.5percent

fromtheaveragedconsumptionofthe1970’s,whichhadalreadyseenanincreasefromthe

1950’s(USDA2003).Thisincreaseincalorieconsumptiondoesnotmatchanincreasein

physicalactivityormetabolicdemand.Thus,thebodystorestheexcessenergyasfat.

Recentresearchsuggeststhatthedesireforfattyfoodsmayactuallybea

neurobiologicalresponsesimilartoaddiction.NoraVolkowpreformedastudyat

BrookhavenNationallablookingintodopaminelevelsinpeopleclassifiedasobese.She

foundthattheirlevelsofdopaminewerelowerinresponsetothefattyfoodsandmoreof

thefoodwasrequiredtogetasimilarneurotransmitterresponse;thesefindingsmimicthe

responseanaddicthastotheirchosenremedy(NutritionActionHealthLetter2012).A

McMillin 35

projectheadedbyEricSticeoftheOregonResearchInstitute’sEatingDisordersand

ObesityPreventionLabcomparedratsfedadiethighinfatandsugarwithratsfedthe

sameamountofcalories,butlowersugarandfatcontent.Theyreportthatthedopamine

responseinmicefedahighfathighsugardietwaslowerthaninthosefedalowerfatand

sugardiet(NutritionAction2012).Inaseparatestudy,donebyMarkGoldattheUniversity

ofFlorida,animalsgivenhighfatfoodsforanhourofthedaywouldbingeonthemeven

thoughotherfoodswereavailablealldaylong(Bell2012).Theresultsofsuchtestssuggest

thattheremaybeabiologicalreasonfordesireofhighfatandsugarfoodsinincreasing

quantities.Itisafairconclusionthatanumberofthingscontributetooverconsumption

notjustasingletrigger.

ObesitybytheNumbers

Since1985,theaveragecalorieintakebyAmericanshasincreasedbyapproximately

300calories,withgrains,fats,andaddedsugarsmakingup93%ofthesecalories(Putnam

etal.2002).Aswasstatedinthesectiononnutrition,fats,carbohydrates,andprotein

provideenergy;whenafoodistakenfromitsoriginalstate,thepotatoforinstance,andis

thenprocessedwithaddedoils(fats)andsugars(carbohydrates)thecaloriecontent

increases.Thisincreasedcalorieconsumptionalongsideadecreasedcalorieexpenditure,

likelyrelatedtotransportationandsedentaryjobs,resultedinthelooseningofbeltsacross

thecountry.

TheCenterforDiseaseControlandPrevention(CDC)reportsfromtheearly1960’s

show31.5%oftheUSpopulationages20‐74asoverweight,13.4%asobese,andjustless

than1%asextremelyobese.ThesestatisticsarebasedoffBodyMassIndexreference

rangesof25‐30,over30,andover40respectively.Injust50years,asreportedfor2009‐

McMillin 36

2010,thesenumbershavejumpedto33%

overweight,

35.7%obese,

and6.3%

extremely

obese.Figure3

showstheCDC

statisticsthat

trackthe

progression

from1960‐62through2009‐10.

AlldemographicsofAmericapresentgrowingpercentagesofindividualsclassified

asoverweight,obese,ormorbidlyobese.Ogdenetal.(2012)reportontheNationalHealth

andNutritionExaminationSurvey(NHANES)from2009‐2010showsthatinchildrenand

adolescentsages2‐19,highBMIsareprevalentinHispanicpopulations,MexicanAmerican

populations,non‐Hispanicwhitepopulations,andnon‐Hispanicblackpopulations.Intotal,

theyreport16.9percentofU.S.minorswereobesein2009‐10,with31.8percent

maintainingaBMIthatsuggestsastatusofoverweightorobese.AnearlierstudybyFlegal

etal.(2010)lookedattheNHANEStorecordobesityandoverweightprevalenceinadult

populationsoftheUnitedStates.Asof2007‐2008,obesityclassified33.8percentofUS

adultsover20and68percentofthepopulationiseitheroverweightorobese.

Interestingly,thestudyalsoreportsthatfrom1999‐2008thepercentageofthepopulation

Figure3.CDCTrackingforthepercentageofpeoplewithinatestpopulationthatareoverweight,obese,orextremelyobese.

McMillin 37

withBMIinobesityrangehadnotincreasedatthesameratethatithadintheprevious

studiescovering1988‐2000.

Sincethegreatestincreasehascomeinthepercentageofpeoplethatareobese,it

warrantsconcern.However,theincreaseinphysicalweightisnottheonlysideeffectof

cheapcalories.Theburdenalsomanifestsinsocialandculturalreaction.

TheCulturalandSocialResponse

Intheearlyyearsofprocessedsnacks,conveniencemeals,andhighcalorie

commoditiesobesityanditssideeffectswerenotmajorcauseforworry.However,inthe

recentexpansionofknowledgeaboutnutritionscience,anumberofmedicalissues

associatedwiththesetypesoffoodsanddietarypatternshavebecomeanareaofmajor

socialandpublichealthconcern(Tillotson2003).Asanation,decreasingthenumberof

peopleclassifiedasobeseisofgraveimportance.Thesereasonscomeinmanyforms

includinghealth,aesthetics,andmoralwell‐being.Ideasaboutobesityculminateand

becomeengrainedintheculturewiththehelpofthescientificworld,media,andpopular

opinion.

Scientifically,theresearchsaysthatbearingextraweightisdamagingtotheheart,

joints,bloodstream,etc.(Haslam2007).Thebasicunderstandingoftherelationship

betweenobesityandchronicdiseasehasalsobecomeembeddedwithinconsumer

knowledgethrougheveryadvertisingmethodimaginable.

BodyMassIndex(BMI),calculatedusingweightandheight,isameasurecommonly

usedtoidentifyoverweightandobesepatientsandpopulations;thismeasureconsidersan

individualwithaBMIover30obese.Doctorsalloverthecountryfrequentlyencounter

patientswithhighBMIs,whoarefacingmanyofthemedicalcomplicationsofobesity.

McMillin 38

Thesecomplicationscanincludebutarenotlimitedto:type‐2diabetes,coronaryheart

disease,stroke,andsleepapnea(Kopelman2007).Obesityrelatedhealthcomplications

couldbelifethreatening,andtendtobetheresultofnotonlyhighcaloriediets,but

sedentarylifestylesaswell.However,controversysurroundingthescienceonobesityand

weightgainhasgottenattentioninrecentyears.

Inordertodiscussthesefearsandthecontroversies,itisimportanttobriefly

describesomeoftheobesityrelatedconditions,whichunderlietheseperceptions.Type‐2

diabetesorinsulinresistancehasrecentlybecomeamajorpublichealthconcernandhas

beenthefocusofagreatdealofresearch.Theconditionistheresultoftoomuchadipose

tissue,akafat,producingfactorsthatcontributetothedevelopmentofinsulinresistancein

largeamounts(Kahnetal.2006).Insulin,producedbythepancreas,helpsthebodyto

regulatethelevelsofsugarintheblood,whenapersonisinsulinresistantortype2

diabetictheirbodycannotcontroltheselevels(Kahnetal.2006).Apersonwithtype‐2

diabetesmayrequiredailydosage(s)ofinsulininordertocontroltheirbloodsugarand

avoidthepotentialfornegativehealthresponses.

Cardiovasculardiseaseisalsoamajorconcern.Theheartcanbeverytroubledby

increasedweightbecauseithastosupplyoxygenatedbloodtoalargeramountofarea

coveredbyleantissuemassandmetabolicallyactiveadiposetissue(Kopelman2007).

Compensationfortherestofthebodysendstheheartintooverdrive.Thisputsstresson

thewallsoftheheart,causeschangeintheintakeandoutputpressures,andleadstothe

leftsidemassincreasing(Kopelman2007).Notsurprisingly,thiscanresultinheartfailure,

stroke,andultimatelydeath.

McMillin 39

Sleepapneaisanailmentwheretheexcessweightsittingontopofthechestwhile

sleepingleadstoareducedlungcapacityandalterstheamountofforceneededtogetair

intoandoutofthelungs.Thispressurecanresultinstoppingofbreathingduringsleep,

whichleadstodecreasedoxygenconcentrationinblood,akahypoxia(Kopelman2007).

Howeverrealtheseproblemsmaybe,thereissomedisagreementintheair.Inher

articleObesity:HowBigaProblem?,Wickelgrenarguesthatobesityandhealth

complicationsmaynotnecessarilybeacauseforworryforeverypersonwhocarriesextra

weight.Rather,shearguesthattherearefactorsbeyondaperson’sBMIthatdetermine

healthandpredictpotentialhealthrisks.Someofthesefactorsinclude:locationof

additionalfatandfitnesslevel.AnumberofstudiessuggestthathavingalowerBMI

attributestolowermortalityrates,butthesestudiesmaynottakeintoaccountfactors

outsideofweightsuchasactivitylevel,habitswithvice,otherillnesses,andbodyshape

(Wickelgren1998).Also,itisimportanttopointoutthatthedegreetowhichsomeoneis

overweightmaydeterminehisorherriskforassociatedillness.

MikeMitka’sarticleObesity’sRoleinHeartDiseaseRequiresApplesandPears

Comparison,discussesthepotentialforbodyshapeasanindicatorofhealthrisks

associatedwithobesity.Thisargumentstatesthatpersonswhogainweightaroundtheir

mid‐section,inandaroundtheirorgans,maybeatahigherriskforcardiovasculardisease

thanapersonwhoispearshapedandcarriesexcessfataroundtheirhipsandthighs.He

endshisarticlebyunderliningthefactthatthisisstillatopicfordebate,andwilllikely

continue.Thepropositionthatlocationofbodyfatisimportantindeterminingthehealth

consequencesisalsohighlightedinastudybyKahnetal.(2006),whichstatesthatlean

individualswhohavemorefatintheabdominalandchestareaaremorelikelytobeinsulin

McMillin 40

sensitivethanleanindividualswithfatlocatedperipherally.Theygoontosuggestthatthis

discrepancymaybetheresultofgeneticcodesinintra‐abdominalfat,whichcuethe

secretionofproteinsthatinfluenceinsulinresistanceandtype‐2diabetes.

Theassociationbetweenweightandhealthoutcomesisverycommoninthe

medicalworldandcanoftenleadtopotentialbiasfromhealthcareproviders.Forexample,

inRobertDarryl’sdocumentary,AmericatheBeautiful2,awomanwhocarriesexcess

weightvisitedamedicalprofessionalwhodescribedherasunfitandatpotentialriskfor

disease.However,thiswomaninparticularwashighlyactive,dancingmanyhoursaday

andhadnonegativehealthcomplications.Thisexampledemonstrateshowconcernsabout

obesityandweightgaingobeyondstrictclinicaldefinitionsandcaninfluencehealthcare

providersintheirrecommendationsordiagnoses.

Beyondthemedicalprofession,ideasaboutobesityandstereotypesassociatedwith

differentbodysizesandshapesaredeeplyembeddedinwesternculture,andthese

perceptionsoftendevelopatearlyagesandremainintoadulthood.Forexample,when

askingnine‐year‐oldchildrentodescribefourdifferentsilhouettesAJHill(1995)found

thattheyweremorelikelytoassigntheoverweightbodyshapedescriptionsofpoorhealth,

diet,andlackoffitness.Alongwiththesephysicalattributes,thechildrenrecognized

societaldeterminantssuchaslowersocialrankingandpoorereducationalsuccess.

Furthermore,itisnotuncommonforpeoplewithhighBMIsoroflargebodysizetobe

stereotypedaslazy,overindulgent,unintelligent,unhygienic,unattractive,andlackingin

self‐discipline(Puhletal.2007).Many,ifnotall,ofthesetraitsareconsideredundesirable

withinwesterncultureandcanbeseeninthewayspeopleareregardedinsocial

McMillin 41

situations,theworkplace,andinlove.Obviously,noteveryindividualineverystateof

theirlifeholdstheseideas,buttheyarewidespreadenoughtocausedistressandresponse.

Beinginsecureaboutone’sbodyisnotanunusualfeelingformostAmericans.

Smolak(1996)suggeststhatasmanyas80%ofwomenaredissatisfiedwiththeir

appearance.Oneresultoftheseperceptionsandanxietiesaboutweighthasbeenthelong‐

standingpopularityofdiets,whichclaimtoresultinrapidandexcessiveweightloss.

Dietingfadsbegantogrowinpopularityatthebeginningofthe20thcentury,andcontinues

today.Inthe1920’swiththemovementof“Flapper”styleattire,womanbegandesiring

moreslenderfigures,andtheconsumereconomycapitalizedonthis.Advertiserssolicited

alltypesofslimmingtechniquesfromstimulatingbeltstoreducingbrushestopackaged

dietsandlaxativeseachofwhichwoulddecreaseherweightandincreaseherhappiness

(Fraser1997).Marketingschemesplayedculturalstigmasagainstwomentoincreasetheir

vulnerabilityandindulgetheirinsecurities.

Yet,withchangingtimesandchangingfashionscomechangingidealsandstandards.

IntheyearsfollowingtheSecondWorldWarwomeninthemediaspotlightdemonstrated

increasinglycurvaceousbodieswithfewimperfections.MissAmerica’sdimensionswent

frombeing32‐25‐35inthe1920’sto35‐25‐35inthefiftiesandsixties(Fraser1997).

Theselargebreastedwomenwithslenderwaistsandroundhipsweretheepitomeof

beautyemphasizedinfigureslikeMarilynMonroeandJayneMansfield.However,the

standardsfellquiteadistancefromAmericanaverages.Basedon1988measurementsof

U.S.Armyfemalerecruitstheaveragewomanmeasured36‐31‐38,wellabovethe

measurementsofMissAmericaonlyseveraldecadesearlier(UrlaandSwedland1995).

Withthebarsetsohighwomentakedrasticmeasurestoreachit.

McMillin 42

Recenttrendsindietculturelurescustomerswithguilt.Whenpeopleindulgein

culturallyorsociallyunacceptabledietarybehaviors,itresultsinguiltandthedietindustry

offersreliefforthatsensation(Stearns1997).Inadditiontoguiltrelief,thedietindustry

offerspromisesofquickweightlossbysimplyavoidingcertainfoods,orrestricting

consumptiontospecialfoodsorasinglefoodtype.Health.comandeverydiet.orgprovidea

briefglimpseintothehistoryofdietingintheUSaswellasthecharacterizationsofsomeof

themostpopular,or“fad”diets.Inthe1930’s,theGrapefruitdietcaughtfireinHollywood

andquicklyspread.Thisdietcalledforgrapefruitateverymeal,accompaniedbymeatand

vegetableswithverylimitedcarbohydrates.Behindthisdietwastheideathatgrapefruit

hadpropertieswhichspedupdigestion,andincreasedmetabolism;nevertheless,itisalso

verylowcaloriewithmostofthecaloriescomingfromtheproteinandfatofthemeatand

somecarbohydratesandproteinfromthefruitandvegetables.Inthe1950’s,anewdiet

calledthecabbagesoupdietbecamepopular.Thedietsuggestedalossof10to15pounds

inaweek,whichresultedfromeatingacabbagesoupmadeoffibrousvegetablesandonion

soup‐mixoccasionallypairedwithfruitsorsomeothervegetables.In1975,Dr.Siegalof

FloridadesignedtheCookiediet.Heprescribedsixcookiesaday,whichweresupposedto

helpabatehungerandmanageappetite.Thedietalsorecommendedadinnerhighin

proteinfromwhitemeatorfishandacupofvegetables.In1977,Slim‐Fast,ameal

replacementshakewasdeveloped.Thebenefitofthisdietwasthatitrewardedthebuyer

withsweetnessfortwomeals(theshakes)followedbyaproperdinner.Evenmore

recently,in1992Dr.Atkinspublishedhistakeonahighprotein‐lowcarbohydratediet.All

ofthesedietspromiseweight‐lossiftheuserfollowstherule;however,theproblemwith

allofthemistheytendtoprovideverylowdailycalorieconsumptionandlowvariety,thus

McMillin 43

resultinginlimitednutritionalbenefitandunintendedfailure.However,Americansare

attractedtothequickfixandthedietingindustryprovidesthesecurestypicallywithout

regardforthelong‐termhealthofthecustomer(Spitzack1990).

Inadditionto“crashdiets,”apopulartrendhasbeenthedevelopmentofmore

holisticdietplanslikeWeightWatchers,JennyCraig,andTheSouthBeachDiet.These,

althoughlessextreme,stillpromiseresultswhenfollowedproperly.Thekeyhereis

followingproperly,inordertoobtainthefreedomofweightlossandslendernessonemust

beself‐disciplined,controlled,andateasewithdeprivation;failureinthesedepartments

attributestothefailureofdieting(Spitzack1990,Bordo2003).

Althoughmuchoftheresearchinthepastdemonstratesthisasanissueprimarily

seenamongwomeninwesternculture,thereisincreasingevidencethatmoreandmore

menalsoholdanxietyaboutweightaswell.Culturalexpectationsformalephysique

representthemostattractivemalesasonesthatareslender,andmuscular,butnotoverly

muscular(Grogan1999).Thisbodytyperepresentstheculturalvaluesofmenasstrong,

active,daring,hardworking,etc.(Grogan1999).Menmaysenseslightlydifferentbody

insecuritiesthanwomen,forexample,menmaydesiretogainweightormusculaturein

ordertoachievethetonedandslenderbodytypethatisdeemedmostattractive.

Regardless,meetingthestandardisthegoalforbothgenders.

FrankMortpointsoutthattheculturalchange,whichbringslighttothemalebody

asarepresentationofhim,maybetheresultofadvertisingaimedatmenandtheincreased

consciousnessofthemselvesincomparisontoothers(Grogan1999).Forexample,there

arealargenumberofcommercialsontelevisiondirectedspecificallyatmenforweightloss

andmusclebuilding.Onesuchcommercial,NutrisystemforMenshowstwoprominentmale

McMillin 44

figuresofAmericanculture,footballplayersTerryBradshawandDanMarinobothof

whomwereverytalentedandlucrativemembersoftheNFL,anddiscussestheirsuccessat

getting“skinny”,orbackdownto“playingweight.”Thisassociationofsuccesswithaligning

tosocietaldemandsforachievingattractivenessstandardsdemonstratesthediminishing

lineofgenderedexpectationinmaintainingacertainphysique.

Otherindustrieshavealsotakenadvantageoftheculturalimportanceofweight‐

lossandmaintainingaparticularbodysize,shape,andappearance.Someofthese

industriesincludethosethatpromoteintenseexerciseregimens,plasticsurgery,andeven

thehealthfoodpush.Inrecentdecades,withscientificandmedicaldevelopment,cosmetic

surgeryhasblossomedintoa$1.75billionayearindustrywith1.5millionpeople

undergoingproceduresannually(Bordo2003).Thesesurgeriesrangefromliposuctionto

breastimplants,tocalfimplantsandbeyond,eachofthemunderstoodasanelective

processforimprovingtheiraestheticappeal.

Despitetheubiquityandpopularityoffaddiets,notallprogramshavecalledupon

unhealthyorunnaturalmethodstoaccomplishedweight‐lossgoals.In1982,JaneFonda

releasedherexercisevideoWorkout:StarringJaneFonda,asamajorplayerinthemedia

spotlightshegainedanenormousfollowingandreallygottoballrollingforphysical

activity(Spitzack1990);thejazzercisecrazefollowedshortlythereafter(Health.com).The

mostcurrenttrendhasbeenthedevelopmentofeasilyaccessibleorinexpensivegyms,

recreationcenters,orexercisestudios,whichpromotethebenefitsofphysicalactivity.

Whendrivingdowntheroadthrougharecentlydevelopedurbanorsuburbanarea,itisnot

unusualtospota24‐HourFitnessjustdownthestreetfromtheYMCAandthelocal

McMillin 45

recreationcenter.PeoplealloverthecountryaresigningupforBikramyoga,kickboxing,

andspinclassestogettheirheartratesup,theirlegstoned,andtheirbelliesincheck.

Therehasalsobeenashifttowardtheanti‐diet,whichrestsonthebeliefthatlosing

weightisnotadietbutalifestyleandattitudechange(Spitzack1990).Acrossthecountry,

thehealthfoodindustryoforganics,pesticidefree,hormonefree,andwholefoodcanbe

seen.RetailerssuchasWholeFoods,Sprouts,andTraderJoesprovideconsumerswith

healthyalternativestosupplementanimprovedlifestyleandpotentialweightloss.Ona

nationalandgovernmentalscale,theUSDAandtheCenterforNutritionPolicyand

PromotionhasprovidedAmericanswithapamphletoutliningthebasicsforabalanced

diet.Theysuggestthatpeoplerequireavarietyoffoods,usingfatsandoilssparingly,2‐3

servingsofdairyandmeat,3‐5servingsofvegetables,2‐4servingsoffruit,and6‐11

servingsofwholegrainsdaily.

Althoughsciencereportsthatbeingoverweightputspeopleatriskforgreater

healththreatsitisnottheonlyprecursorforweight‐loss.Apersonmaintainingaweight

thatfallswithintherangeofhealthyBMI,18.5‐24.9,providedbytheNationalInstituteof

Health,maystilldesiretoloseweight.Thisdesiremaybepromptednotbyhealth,but

ratheryearningtoachieveanappealingappearanceandincreasedsuccess,asdefined

withinalocalornationalcontext.Inourconsumerculture,increasedsuccessisassociated

withappearance,relationships,andmonetaryvalue.Bymaintainingamoreslender,fit

body,anindividualisnotonlyconsideredtobehealthier,butisalsoviewedasmore

attractive,morecontrolled,moredriven,andultimatelyworthmore.Massmediaoutlets

maintainthisbeliefbykeepingslender,beautiful,successful,highrankingindividualsinthe

socialspotlight.Itisnotuncommontowalkbythenewsstandandseeamagazinebashing

McMillin 46

theweightgainorcelebratingtheweightlosssuccessofacelebrityandtheseimagesmay

becomeimprinted.

Recently,JudgeandCable(2010)comparedbodyweighttoaverageincome.They

foundthatwomenwhoweighed30poundslessthanthenational164poundaverage,

made$10,000moreannuallythanwomenwhowere30poundsovertheaveragedid.In

fact,theheavierwomennotonlyhadalowerincomethanthelowerweightwomen,they

earnedlessthanthe$40,000yearlyaverageincomeforwomenintheUnitedStates.In

contrast,menwithlowerthanaveragebodyweightearnedbelowaverageincomes,and

therewasnoassociation

betweenobesityandpay

decreases.However,height

seemstohaveastronger

associationwithincomeamong

menthanwomen.In2005,the

FederalReserveBankofSt.Louis

reportedtheaverageheightof

CEO’sinFortune500companies

atthreeinchestallerthanthe

Americanaverageand30%of

themmeasuredatleast6’2.The

importancehere,isnotweightorheight,itisthatthesestudiesreflectthestrongemphasis

placedonaestheticsintheworkplaceasopposedtoworkperformance.Thus,thebodyacts

asarepresentationofthepersonasawholeandallowsforinstantperceptionbyanother.

Figure4.JennieGarthastarofpopulartvseries90210shareswiththepublichersecretsonhowshelost30lbsafteradivorcefromhusbandPeterFacinelliintheOctober2012issueofPeopleMagazine.http://www.people.com/people/article/0,,20635433,00.html

McMillin 47

AccordingtotheSocialComparisonTheory,comparingone’sperceptionofthe

physicalattributesofanothertotheirownisanadaptationthatmayhavedevelopedoutof

necessityforbeingabletosize‐upacompetitorandpropeltheselfandthegroup(Gilbert

etal1995).Thetendencyforpeopletocomparethemselvestotheirneighboror

competitormaythengobeyondjustculturalshaping,andreflectaninnatehuman

characteristic.Inthisculture,beingthinisassumedadvantageous.Massmediaandcultural

standardsfurtherthisassumptionandhavesetahighbarforindividuals.Meetingthese

highstandardscomeswithmany

benefits,

includinghigher

socialstatus,

popularity

withinasocial

circle,andin

manycases

increased

income.Thus,it

is

understandable

whytheweightlossindustryhasboomedinrecentdecades.Besides,whodoesn'twantto

loseweightand“gettheirlifeback”?(SeeFigures4and5)

Figure5.Lap‐Band“Theadjustablegastricband,whichisplacedaroundtheupperpartofthestomach,isasiliconeringcomprisedofsoft,pre‐curvedindividualsections,filledwithsalinetoallowadjustabilityofthebandandincreasedordecreasedrestriction.Thiscreatesanew,smallerstomachpouchandreducestheamountoffoodthatthepatient'sstomachcanhold.”Lap‐BandProductDescriptionMagazineAdhttp://myboonehealth.com/tag/lap‐band/

McMillin 48

WhenCultureandBiologyClash

Humanbehaviorhasaddedconnotationstoeating,cuisine,andphysicalappearance

foraverylongtime.Inwesternculture,agreatamountofattentionisplacedon

maintainingaslenderbodyandmeetingculturalstandardsofappearance.Giventhis

emphasisonphysicalappearance,itisnothardtounderstandwhymillionsofpeople

devotecountlesshoursandthoughtstopreparinghealthymeals,goingtothegym,taking

weight‐lossenhancers,undergoingsurgeries,etc.However,manypeopletakeweightloss

andachievingaslenderappearancetotheextremethroughtheuseofdisorderedeating

behaviors.Theseindividualshaveatendencytoresorttoallmeanstoloseweightor

changetheirappearance,regardlessofthehealthconsequences.Thisisexacerbatedbythe

abundanceofeasilyaccessibleanddetailedinformationaboutdangerousweightloss

techniquesthatisavailabletopeoplewhomaybesusceptibletoeatingdisorders.The

situationspeoplecreatethrougheatingdisordersarenotidealandcanresultinlong‐term

orpermanentbiologicalandpsychologicaldamage,thusmakingitimportanttounderstand

themmorefully.

Ithasbeensuggestedthateatingdisordersareculturallycreatedandculturally

boundsyndromes.Thisisassumedbecausetheprevalenceofdietingbehaviorandeating

disordersoutsideofwesternculture,especiallyindevelopingcountrieswherefood

resourcesarenotalwaysreliable,arelow(BarlowandDurand2009).However,ifeating

disorderswerepurelyasymptomofculturalstressthenthequestionofwhyonlysome

peopleexperiencethemwouldbemoreeasilyanswered.Theetiology,orcausation,

questionhasbeenraisedofteninconsiderationofeatingdisordersbecauseoftheratesat

McMillin 49

whichtheyappearinsocietyandtheirtendencytobeculturallysituated(Littlewood

2004).

Seeingaseatingdisordersareverycomplexandaffectindividualsdifferently,a

multidimensionalapproach,utilizingsocio‐culturalandbiologicaldrives,seemstobethe

mostaccuratewaytoanswerthisquestion.Thisapproachisanthropologicalbecauseit

analyzeshowculture,biology,andsocialsituationsworktoshapeeachother,butitapplies

topsychologyaswell.InBarlowandDurand’sbookAbnormalPsychology,theyutilizethe

integrativeapproach,whichanalyzespsychological,biological,andsocialaspectsofa

personinordertounderstandtheirbehavior.Incaseswherebehaviorisnot“normal,”a

personmaybequalifiedforadiagnosisofpsychologicaldisorder.Inordertomeetthe

requirementsforpsychologicaldisorderabehaviordemonstratesa“psychological

dysfunctionwithinanindividualthatisassociatedwithdistressorimpairmentin

functioningandaresponsethatisnottypicalorculturallyexpected.”(BarlowandDurand

2009:2).

Inthecaseofeatingdisorders,“thedistressorimpairmentinfunctioning”tendsto

comefromeatingandbodyshape,andthe“responsethatisnottypicalorculturally

expected”isthementalfixationonfood,onworthbasedonbodyshape,andthemany

dangerouscopingmechanisms.Thesuggestionthateatingdisordersarearesultofmulti‐

factorialinfluencesisnotunusual.However,theresearchonabiologicaltriggerforeating

disordersisverybroadandcoversmanyideas,andisnotoftencoupledwithsocial

influences.Forexample,Lawsonetal.(2011)suggeststhatwomenwitheatingdisorders

showincreasedlevelsofcortisolandpeptideYY,bothhormonesengagedinappetite

regulation,regardlessofBMI.Thisstudysuggeststhatthehormonesmaybetriggering

McMillin 50

eatingdisorders,ortheymaybeoutofwhackasabodilyreactiontotheeatingdisorder.

AnothersuggestionmadebyMichikoetal.(2012)proposesthatthelevelofbrain‐derived

neurotrophicfactor,whichisinvolvedinbrainaugmentationduringdevelopment,are

relativelylowerinpatientswitheatingdisordersandthusareinvolved.Neitherofthese

studieslooksathowthecultureinteractswiththebiology,whichmayprovidegreater

insight.

Here,itissuggestedthatpredispositionto,ormorbidityofapsychological

disturbancemaybethebiologicalorgeneticpiecethatisshapedbythecultural

environmenttoresultindisorderedeatingbehaviors.Duetohighratesofcomorbidity,

morbiditybeingthestateoflivingwithdisease,ofeatingdisorderswithother

psychologicaldisordersitseemsplausiblethattheculturalenvironment,wherepeopleare

constantlybombardedwithreasonstodesiretobethinner,cuesapsychological

dysfunctionofamooddisorder,anxietydisorder,orsomethingelse,toresultinatypical

eatingbehaviorandmentalperception.

Toreiterate,individualswitheatingdisorderspracticebehaviorsthatarenot

normalwhenitcomestoeatinganddrinking.Someavoidfoodatallcosts;somelose

controlwhentheyeatandloseconnectionwithbiologicalresponsestoeating;others

inducevomitingorotherformsofpurgingbehaviorafteroverconsumption(DSM‐IV‐TR

2000).Beyondthephysicalbehaviors,personswitheatingdisorderstendtospend

countlesshoursobsessingoverfood,theirbody,comparisonswithothers,etc(Costin

2007).

Therehasbeenavastamountofresearchcompletedonthepresenceofcomorbidity

ofotherpsychologicaldisorderswitheatingdisorders.OnestudybyBlinderetal.2006

McMillin 51

reportsthatof436patientswithanorexianervosasubtypebinge‐purge98%presented

anothercomorbidpsychologicaldisorderatsomepointintheirlife(Table4).Another

studybyYanovskietal.(1993)reportedthat60%ofobesepatientswithBEDhadanother

psychologicaldisorderintheirlife.Theprevalenceratesrangeacrossthedifferenteating

disorders(AN,BN,BED,andEDNOS)anddifferentpsychologicaldisorders,butthe

frequencyisundoubtedlyelevated.

Tables3,4,and5showtheprevalenceratesfromfourstudiesofeachanorexia

nervosa,bulimianervosa,andBingeEatingDisorderwithoneormoreAxisIaffective

disorder.Theseincludemooddisorders,specificallymajordepressivedisorder(MDD);

anxietydisorders,specificallypanicdisorder,specificphobia,socialphobia,obsessive‐

compulsivedisorder(OCD),andpost‐traumaticstressdisorder(PTSD);andsubstance

abuse/dependencedisorders,specificallyalcoholandgeneraldrugabuseanddependence.

Althoughthesearetheonlypsychiatricdisturbancesnotedhere,theyarenottheonlyones

reportedintheliterature.However,thesedisordersseemtobethemostoftenfoundinthe

studiesandtypicallyhavethehighestcomorbidityrateswitheatingdisorders.Other

disordersfoundintheliteraturearebipolardisorder,generalizedanxietydisorder,

impulsecontroldisorder,attentiondeficit/hyperactivitydisorder,andpersonality

disorders(Halmi2010).

Inthemajorityofthestudiesexaminedhere,themostcommoncomorbiditywithan

eatingdisorderwasmajordepressivedisorder.InthestudiesonBingeEatingDisorder,

lifetimeprevalencecomorbidityratesofatleastoneothercomorbiditywere46.8%(Grilo

etal.2009),51%(Zeltichetal.1993),32.3%(Hudsonetal.2007),and58%(Wilfleyetal.

2000).Theanorexianervosastudiesreportedsimilarlifetimerateswith39.1%(Hudsonet

McMillin 52

al.2007),40%AN‐Restrictive(ANR)50%AN‐Binge‐Purge(ANBP)(Blinderetal.2006),

63%(Jordanetal.2008),and32.4%ANR72.7%ANBP(Braun1994).Thestudieson

bulimianervosaagainreportedelevatedlifetimecomorbidpsychologicaldisorderrates

with50.1%(Hudsonetal.2007),46%(Blinderetal.2006),51%(Jordanetal.2008),and

45.1%(Braun1994).

Theliteratureshowedsomepatternswithinthedifferenteatingdisordersandthe

differentpsychologicalcomorbidities.MostofthestudiesreportedhighratesofANand

OCD:29%ANR28%ANBP(Blinderetal.2006),21%(Jordanetal.2008),and3%ANR

13.6%ANBP(Braun1994).Withbulimianervosa,severalofthestudiesreportedrelatively

highratesofcomorbiditywithspecificandsocialphobias,aswellasPTSD.Hudsonetal.

2007reported50.1%ofBNpatientshadcomorbidspecificphobia,41.3%socialphobia,

and45.4%PTSD.Blinder’s(2006)studyreportedthat23%ofBNpatientspresentedPTSD

comorbidity,butonly3%socialphobiacomorbidity.Finally,theJordanetal.(2008)study

reported30%oftheBNparticipantshadcomorbidsocialphobiaand27%specificphobia.

Studyingthesepatternsinthefuturecouldprovideinsightsintoeatingdisorderetiology,

duration,andseverity.

Onthewhole,thestudiesshouldprobablynotbeusedtosuggestasinglenumberor

ratebecausetherearemanydifferencesintheexperiments.Betweenthestudies,the

researchpremiseissimilarintryingtoidentifythenumberofpatientswhohaveeating

disordersthatalsohaveanothermorbidpsychiatricdisorder.However,theycoverabroad

rangeofdemographics,includingageranges,symptomseverities,socio‐economicstatus,

biologicalsexes,etc.,andtheydonotallcomparethecomorbidityfindingstoacontrol

group.Nevertheless,thediscrepancyinratesobservedamongstthedemographicsandthe

McMillin 53

disordersmayprovidevaluableinformationinunderstandingcorrelationandcausation.

Forexample,Blinderetal.(2006)reportthat28%of436patientstreatedforanorexia

nervosasub‐typebingepurgehadcomorbidobsessive‐compulsivedisorder.Thisnumber

wasrelativelyhigherthanthe16%of882patientsreceivingtreatmentforbulimianervosa.

Whatcausesanindividualwithbinge‐purgebehaviortolosetheextraweightandfallinto

thecategoryofANasopposedtoBN?

Thelackofdatarecordingonsetagesforeachofthedisorderspresentsanother

problem.Ultimately,havingthisinformationmorereadilyavailablecouldhighlighttrends

inthemorbiddisordersandanswerquestionssuchas:whichdisorder(s)appearfirst?At

whatagedoesthedisordermostcommonlystart?Couldonebeaprecursorfortheother?

Couldoneinfluencethecreatingorseverityofthesymptomsoftheother?

Havingmoreuniformcriteriaacrossstudiesinthefuturemaybenefitthestudyof

eatingdisordersasawhole.Ifthereismassinformationrecordingtheageofonset,the

duration,thesocio‐economicstatus,thedifferencebetweensexes,andthecomparisontoa

controlgroupofpersonswithouteatingdisorders,thepatternswillbemoreeasilyspotted

andcouldshedlightonsomeofthecurrentuncertainties.

ItshouldbenotedthatthesuggestionofAxisIdisorders,oraspecificdisorder,as

thecauseoforpreconditionforeatingdisordersisnotuniquetothispaper(Pallister2008,

O’BrienandVincent2003,Kayeetal.2004,Garcia2009,andothers).Also,severalstudies

discountthisidea.InaliteraturereviewbyGodartetal.(2007),theteamexamined55

studiesoncomorbiditybetween1985‐2006.Theirresearchdismissesthesuggestiondue

tothelackofcontrolgroupsinthemajorityofthestudies,demographicinconsistencies,

McMillin 54

Table3.BingeEatingDisorder Griloetal.

2009Lifetime/Current

Yanovskietal.1993Lifetime

Hudsonetal.2007Lifetime

Wilfleyetal.2000Lifetime/Current

AnyAxisI 73.8%/42.8% 60% 78.9% 77%/‐‐AllMoodDisorders

54.2%/26% ‐‐ 46.4% 61%/22%

MajorDepressiveDisorder

46.8%/18% 51% 32.3% 58%/16%

AllAnxietyDisorders

37.1%/24.5% 65.1% 29%/16%

PanicDisorder 15.3%/3.7% 9% 13.2% 13%/1%SocialPhobia 9.2%/6.2% 5% 31.9% 6%/4%OCD 2.7%/2.2% 2% 8.2% 1%/1%PTSD 6.7%/4.0% 0% 26.3% ‐‐SpecificPhobia 9.9%/8.9% ‐‐ 37.1% 10%/7%SubstanceDependence/AbuseDisorder

24.8%/2.7% 12% 23.1% 33%/4%

AlcoholAbuse/Dependence

20.3%/1.5% 9% 21.4% 23%/3%

DrugAbuse/Dependence

14.6%/1.2% 7% 19.4% 18%/1%

DSM‐VersionNUMBERS/DEMOGRAPHICS/CONTROLS/

DSM‐IV94Maleand310Femalepatientsaverageage4582%Caucasian84%attendedcollegenocontrol

DSM‐III‐RandDSM‐IV33ObeseFemales10ObeseMalesAges18‐49BothAfrican‐AmericanandCaucasianparticipantsComparedagainstcontrolgroupof56FwithoutBEDand29MwithoutBEDControlused

DSM‐IVAndICD‐102980MaleandFemaleParticipantsofNationalComorbiditySurveyages18+nocontrol

DSM‐III‐Ron28Maleand134FemalePatientsAgesbetween18‐6593%Caucasian60%MarriedOverallwelleducated,meanincomeof$40K‐$50kannuallyNocontrol

McMillin 55

Table4.AnorexiaNervosa Hudson

etal.2007Lifetime

Blinderetal.2006LifetimeRestricting/Binge‐Purge

Jordanetal.2008Lifetime

Braun1994LifetimeRestricting/Binge‐Purge

AnyAxisIDisorder

56.2% 96%/98% ‐‐ ‐‐

AllMoodDisorders

42.1% 93%/95% 68% 41.2%/81.1%

MajorDepressiveDisorder

39.1% 40%/50% 63% 32.4%/72.7%

AllAnxietyDisorders

47.9% 55%/59% 55% 35.3%/40.9%

PanicDisorder 3% 3%/6% 25% 11.8%/13.6%SocialPhobia 24.8% 4%/2% 30% 3%/13.6%OCD 0 29%/28% 21% 20.6%/18.2%PTSD 12% 10%/25% ‐‐ ‐‐SpecificPhobia 26.5% ‐‐ 30% 0/13.6%SubstanceDependence/AbuseDisorder

27% 5%/20% 34% 5.9%/11.8%

AlcoholAbuse/Dependence

24.5% 3%/14% 24% ‐‐

DrugAbuse/Dependence

17.7% ‐‐ ‐‐ ‐‐

DSM‐VersionNUMBERS/DEMOGRAPHICS/CONTROLS/

DSM‐IV94Maleand310Femalepatients(examinedforalldisorders)averageage4582%Caucasian84%attendedcollegeNoControl

DSM‐IVfemalepatients520withAN‐Rand436AN‐BP95%Caucasian<1%AfricanAmerican2.8%Hispanic<Highschool‐45%Highschool/college‐55%Nocontrol

DSM‐IV56femalepatientsages17‐40nocontrol

AN‐R34femalesAN‐B22FemalesDiagnosedwithSCID16+yearsoldmeanageAN‐R24.8andAN‐B24.2nocontrol

McMillin 56

Table5.BulimiaNervosa Hudsonetal.

2007Lifetime

Blinderetal.2006Lifetime

Jordanetal.2008Lifetime

Braun1994Lifetime

AnyAxisIDisorder 94.5% 97% ‐‐ ‐‐

AllMoodDisorders 70.7% 94% 71% 64.5%

MajorDepressiveDisorder

50.1% 46% 51% 45.1%

AllAnxietyDisorders

80.6% 55% 50% 29%

PanicDisorder 16.2% 4% 11% 9%

SocialPhobia 41.3% 3% 30% 16.1%

OCD 17.4% 16% 3% 12%PTSD 45.4% 23% ‐‐ ‐‐SpecificPhobia 50.1% ‐‐ 27% 0%

SubstanceDependence/AbuseDisorder

36.8% 34% 49% 41.9%

AlcoholAbuse/Dependence

33.7% 26% 46% ‐‐

DrugAbuse/Dependence

26.0% ‐‐ ‐‐ ‐‐

DSM‐VersionNUMBERS/DEMOGRAPHICS/CONTROLS

DSM‐IV94Maleand310Femalepatients(examinedforalldisorders)averageage4582%Caucasian84%attendedcollegeNoControl

DSM‐IV882femalepatients95%Caucasian<1%AfricanAmerican2.8%Hispanic<Highschool‐45%Highschool/college‐55%NoControl

DSM‐IV132femalepatientsage17‐40NoControl

DSM‐III‐R31Females16+yearsoldAverageagewas25DidlookatonsetagesforalldisordersNoControl

McMillin 57

aswellasscarceandconflictingresults.AsecondreportbyStroberandKatz(1987)

suggeststhatalthoughaffectivedisordersmaypredisposeadolescentstoeatingdisorders

itisalsopossiblethatdepressionandotheraffectivedisorderscouldbetheresultof

starvationandcatecholaminefunctioningeneticriskforeatingdisorder.Thesearguments

arevalid.Regardless,thecauseofeatingdisordersisverycomplex,andunderstandingthat

therearecultural,environmental,biologicalfactorsthatplayintotheiretiologyis

important.

Currently,thereappearstobeagapintheresearch,whichwouldbridgethecultural

causationandthebiologicalpsychologicalpredispositiontoeatingdisorders.Inorderto

moveforwardwitheatingdisorderresearchamultidisciplinarycooperationwillbe

necessary.Thesedisordersaremultidimensional;theyariseinareaswhereculture

promotesslendernessasameansforbeauty,success,andcontrolandtheymanifestinto

psychologicaldisturbancesthatcandisruptandtaketheenjoymentfromlife.Questions

thatneedtobeaskedandmaybeansweredthroughaninterdisciplinaryapproachinclude:

Whydoesthecultureonlyinfluencethesebehaviorsincertainindividuals?Whydon’t

someindividualswhohaveabiologicalpredispositiondevelopaneatingdisorderinthis

environment?Howcantreatmentbemoresuccessfulwiththeunderstandingofunderlying

biologicalpredispositions?

Finally,treatmentofthesedisorderscanbeverydifficultbecausetheyare

rewarding.Ifanindividuallosesweightitisrewarding;iftheyovereatandexperienceguilt,

itisrewardingtorelievethatguiltthroughpurging;iftheythinknegativelyabout

themselvestheymaytemporarilyrelieveitthroughexcessiveconsumption.Thus,this

researchpointsouttheneedforsocio‐culturalchangebecausechangingbiologymaynot

McMillin 58

bepossible.Solicitingtheideaofthebodyasavectorforthemindandnotarepresentation

ofworthcouldbringsocialchangethatresultsindecreasingprevalenceofeatingdisorders

anddietingbehavioraswellasincreasinghealthacrosstheboard.

GlobalizationandDieting/EatingDisorders

Lookingatpopulationsacrosstheglobethatdidnotexpressconcernsaboutbody

slendernessuntilwesternculturereacheditsshorescansupporttheproposalthateating

disordersareaculturallyboundsyndrome.

Inthe1990’s,AnneBeckerdidoneofthemostcommonlyreferencedworkson

dieting,eatingdisorders,andglobalization.HerresearchtookplaceinWesternFijiwhere

sheanalyzedtheeffectsofwesterntelevisionandmediaonadolescentsandwomenliving

inthisruralarea.In1989shefoundthatwomenwhenaskedquestionslike“Howwelldo

youlikeyourbody?”“Wouldyouliketotradeyourbodyforanother?”and“Howcriticalare

youofyourshape?Othersshape?”reportedhighnumbersforappreciationoftheirbody,

prideintheirbody,lowercriticismoftheirshapeandothersbodies.Whensheutilized

thesequestionsnineyearslater,andthreeyearsaftertheintroductionofwestern

television,shefoundthatwomenhadalowerappreciationoftheirbody,andweremore

criticaloftheirownandothersbodies(2002).Duringthetimeofherstudy,shealso

reportedhigherratesofoverweightandobesitywithinthe1998sample.Thesenumbers

shesuggestsarerepresentativeofpopulationthatareseeingculturalshiftsfrom

appreciatingamorerobustshapetoacknowledgingthepossibilityofreshapingthebody

andmotivatingFijianstomaintainbodyweight.AsecondstudyAnneBecker(2004)led

wasontheimpactofwesterntelevisiononadolescentFijianschoolgirls,inthisstudyshe

reportsthatgirlsaredemonstratingapreoccupationwithweightandbodyshape,purging

McMillin 59

behaviortocontrolweight,andbodydissatisfactionallofwhichwerenotexperiencedto

thisextentpriortoexposure.

OutsideofFijitherearemanyotherpeoplefacingsimilareffectsfromglobalization

andapromotedidealofslenderbodyshape.SarahTrainer’sarticle“BodyImage,Health,

andModernity:Women’sPerspectivesandExperiencesintheUnitedArabEmirates”

(2010)discussestheincreaseinoverweightandobesityintheUAE,andthecoping

mechanismswomeninthisareaemploytodealwithallofthechangesassociatedwithit.

Shestatesthatthewomenareoftencriticizedforstickingtothetraditionalwaysby

ignoringthehealthrisksassociatedwithexcessivebodyweight.However,thereis

contradictorypressure“because‘beingmodern’isequatedwithconsumptionoffastfood,

employmentofservants,useofcars,andsoon,butontheotherhand,theyareincreasingly

exposedtoWesternideasaboutbodyimageandweight.”(Trainer2010:61S).This

contradictionshowsaculturalconstructionofthesameparadoxfacingWestern

civilizations.TheresultsofherstudyshowthatyoungEmiratiwomen,inhersampling,

understandthinasbeinganindicationofbeauty,andthatbeing‘fat’wasnolongera

positivereflectionofaperson,likeithadbeenintheirgrandparentsera.Thisculturalshift

maybeassociatedwiththesocioeconomicchangestheUAEhasbeenundergoing,including

growingdispensableincoming,changingrolesforwomen,betterhealthcare,andinclusion

inthegrowingglobalmarket.

AnotherstudybyVirenSwamiandMartinTovéelookedatacross‐cultural

comparisonoffemalephysicalattractivenessinBritainandMalaysia(2004).Their

conclusionstatesthatBMIisareliablesourcefordeterminingphysicalattractivenessin

areas.However,theyalsofoundlowerBMIsrepresentattractivenessinindustrialized

McMillin 60

areasofsociety.Conversely,insemi‐industrializedorruralsocietiestheBMIsseenasmost

attractivetendedtobeslightlyhigher.Theysuggestthisdifferencecouldbedueto

preferredBMIincertainenvironments,forcertainhealthoutcomes,andcultural

definitions(2004:123).Theindustrializedareas,wheresocialchangeisrampant,mayhave

experiencedgreaterexposuretowesternizedideasandstandardssuchasdemandsto

striveforcareeraccomplishmentandmaintenanceofphysicalattractiveness(2004:125).

Althoughthisstudydidnotdoexplicitresearchontheeffectofwesternization,itdoes

suggesttheimpositionofsimilaridealsonwomeninindustrialized,globalmarketareas.

ToddJacksonandHongChen(2007)completedanotherinterestingstudyto

consideringlobalizationandthecausesofeatingdisorders.Theirresearchcomparedthe

experienceofsocialpressure,comparison,teasing,andconcernwithfacialfeaturesin

Chineseadolescentsandyoungadultswitheatingdisordersymptomstosimilaraged

participantswithnoEDsymptoms.Theirresultsdemonstratedthatparticipantswith

eatingdisordersreportedgreatersocialpressure,moreteasing,morecomparisonofand

concernwithappearanceandfacialappearance.Theysuggestthatthesocialpressurein

thePeople’sRepublicofChinaplacesstressinfacialappearance,asopposedtothemore

Westernfocusonbodyshapeandweight.Thisdemonstrateshowsocietyshapesand

assimilatesthesymptomsofeatingdisordersthroughthespecificculturaldemandsand

standardsofappearance.

Finally,insupportofpsychologicaldisorderspredisposingindividualstoeating

disorders,researchbyLeeetal.(2005)demonstratesthatevenacrossculturespersons

witheatingdisordersalsodisplaycomorbiddisorders.Thisstudylookedat126casesof

anorexianervosainChinese,Malay,andIndianindividualsbeingtreatedataneating

McMillin 61

disorderclinicoveraneight‐yearperiod.TheresearchreportedthatthenumberofAN

casesfrom1994to2002increaseddramatically,andinthesepatients25.4%presented

depression.Otherpatientspresentedwithobsessive‐compulsivedisorder,and/oranxiety

disorder.TheyalsonotethattheincidenceofANishigherintheChinesethaninMalayor

Indianpopulations,contrarytotheresultsofanationalhealthsurveythatreportedthe

highestratesofobesityinMalays(2005:278).Socio‐culturalprotectionthroughaless

emphasizedthinidealorlackofknowledgeaboutthedisorderslendshandtothis

discrepancy(2005).

Theincreasingprevalenceofthesepotentiallyfataldisordersacrosstheglobe

shouldbecauseforconcernandacknowledgementoftheculturalforcethatiscreatingan

environmentwherethesedisordersthrive.Theincreasingglobalizationandworldmarket

hasmanypositiveeffects,suchascreatingjobs,changingsocialrequirements,and

enhancingmanylivingconditions.However,aswithanychangethereareorcanbe

unforeseenconsequences,andthepreoccupationwithweight,bodyshape,dieting,and

eatingdisordersmaybepartoftheseconsequences.

Conclusion

Throughoutthispaper,IhavesuggestedthatWesternsocieties,throughalensof

theUnitedStates,havefacedanumberofdrasticchangesinthelastcentury;thesechanges

havecomeinmanysocial,economic,cultural,andbiologicalshapes.Becauseofthese

changesWesterner’sandonanincreasingscaleglobally,therehasbeenadramatic

increaseinthenumberofpeoplewhoareclassifiedasoverweightandobese.Alongwith

thisnumericalincrease,therehasbeenanegativesocialstigmatizationofbodyweightand

aboominggrowthinthedietingandfitnessindustries.Culturalandmediadepictionsof

McMillin 62

bodyweightasadirectrepresentationofaperson’sintegrity,morality,andpotentialfor

success,pairedwithaneconomythatinsistsuponindulgenceresultsinanenvironmentof

inconsistencyandconstantbattle.

Thisenvironmentactsastheperfectbreedinggroundsforlowself‐esteem,body

dissatisfaction,self‐denigration,andeatingdisorders.Thecreatingofdisorderedeating

pathologyappearstobeculturallyrestrained,butisaveryrampantproblemafflicting

millionsofpeopleglobally.Afflictionofonlysomeindividualsinthepopulationwitheating

disorderssuggestsacausethatgoesbeyondjustsocialdistress.HereIsuggestthe

possibilitythatpeoplewhodevelopeatingdisorderpathologiesdosobecausetheyhave

existing,orpredispositionsto,otherpsychologicaldisorders.Theevidenceprovidedcould

notconcludethatthisisanabsolute;rather,itdemonstratesthattherearehighlevelsof

comorbiditywitheatingdisordersandaffectivedisorders,suchasdepressionandOCD,

andthisisanavenueofresearchindemandofmoreinformation.

Furtherinvestigationofthepsychologicaldisordercomorbiditywitheating

disordershasatleasttwopotentialavenuesthatcaneachprovidedifferentinsights.One

routeexploresmorespecificandindividualizedinformationamongstthedisorders.The

complexityanddiversitybetweeneachindividualsexperiencewithaneatingdisorderand

anotherpsychologicaldisturbancemayprovideinformationonwhytheirdisorders

manifestthewaytheydo,whytheystartedwhentheydid,whytheywerepossiblymore

susceptibletoaneatingdisorder,etc.Byunderstandingthedisordersonamorespecific

levelitcouldopenupnewformsoftreatmentandcopingmechanisms.Asecondavenueof

researchcanbedonetocollectmorelarge‐scale,generalizeddata.Thiswouldtake

demographicsfromallspectrumsofthedisordersanddeterminepatternswithinthe

McMillin 63

diagnoses.Thistypeofstudycouldshedlightonthepossibilitythatonepsychological

disorderismorecommonlyassociatedwitheacheatingdisorder,oreatingdisorder

behavior.

Itwouldalsobeveryinterestingtoexaminetheprevalenceofeatingdisordersand

comorbidpsychologicaldisordersinothersocieties.Thesestudieswouldhavetotakeinto

considerationthedifferencesinexpressionofthesedisordersbasedontheircultural

situation,likethestudybyJacksonandChenthatreportsonfacialfeaturesandthetiesto

eatingdisordersinChineseadolescentgirls.Otherculturesmayexperiencethesedisorders

throughtheshapingofdifferentsocietalpressuresandthecriteriamustfit.Cross‐cultural

comparisonandsimilarelevatedratesofpsychologicalcomorbiditywitheatingdisorders

couldserveasevidenceinsupportofthehypothesisthatinitialdisorderstriggereating

disorders.

Althoughthispaperfocusesprimarilyonfemalesocialandattitudechanges,thisis

notstrictlyafemaleissue.Thenumberofmalesafflictedwitheatingdisordersinthe

UnitedStatesreportedbytheNationalEatingDisordersAssociationisonemillion,

however,thesenumbersmaynotreportthetruescaleoftheproblem.Withthereleaseof

theDSM‐Vinthespringof2013,theremayevenbeahigherincidencerateofeating

disordersinmenbecauseoftheadditionofBingeEatingDisorder,thelessrestricting

criteriaofanorexianervosa,andpotentiallyfewercasesreceivingEDNOSdiagnoses.

Understandingtheetiologyofeatingdisordersisimportantbecauseitwill

potentiallyencouragetheexpansionofknowledgeonprevention,treatment,andcure.It

seemstobeawellspreadperceptionthatthemediaandculturalviewofextreme

slendernesscanbebothunreasonableanddetrimental.However,thepushtochangethese

McMillin 64

standardshasbeenonlysomewhatsuccessful.TheDove®CampaignforRealBeauty

launchedin2004releasedadvertisementswithfleshywomenthaturgedviewersto

“ImagineaWorldWhereBeautyisaSourceofConfidence,NotAnxiety.”Theirshiftto

seeingbeautyinwomenofallshapesandsizeshasevolvedintoamovementforself‐

esteem,whichisgearedtowardsinspiringandmotivatingconfidenceinwomenalloverthe

world(Dove®SocialMission).Bodydissatisfaction,alongwithpreoccupationsabout

weightorshape,canserveasveryrestrictivementalblocks;dismissalofthesebarrierscan

bringfreedomandlendtimetomoreproductiveandrewardingthoughtsandbehaviors.

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