Thesis Literature Review Part I

Table of Contents:

Introduction

In discussions about the theories, common problems, and treatment of repeat dieters or those dealing with issues of weight preoccupation, obesity and dieting are often interrelated. There are physical, psychological and social aspects to the problems of obese. This is why the social work profession is ideally suited to understanding the problems and provide effective intervention.

Some controversy surrounds whether obesity is considered an "eating disorder." Stunkard (1994) has defined Night Eating Syndrome and Binge Eating Disorder as eating disorders that contribute to obesity. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV (TM)) (American Psychiatric Association, 1994) characterizes eating disorders as severe disturbances in eating behavior. It does not include simple obesity as an eating disorder because it is not consistently associated with a psychological or behavioral syndrome. Labeling obesity as an eating disorder that needs to be "cured" implies a focus on physical or psychological processes and does not include recognition of the social factors that may also have a contributive impact. Weight preoccupation and dieting behaviors will certainly have some aspects of an eating disorder and its psychological implications such as inappropriate eating behaviors or disturbances in body perception. In this paper, neither obesity or weight preoccupation are considered to be eating disorders. Labeling these as eating disorders does not provide any useful clinical or functional purpose and only serves to further stigmatize the obese and weight-preoccupied.

What is Obesity?

It is difficult to find an adequate or clear definition of obesity. Many sources discuss obesity in terms of percentage above normal weight using weight and height as parameters. Sources vary in their definitions as to what is considered "normal" or "ideal" versus "overweight" or "obese." Sources range in defining a person who is 10% above ideal as obese to 100% above ideal as obese (Bouchard, 1991; Vague, 1991). Even ideal weight is difficult to define. Certainly not all people of a certain height should be expected to weigh the same. Determining obesity by poundage alone is not always indicative of a weight problem.

Bailey (1991) has suggested that the use of measuring tools such as fat calipers or water submersion techniques where the percentage of fat is determined and considered within acceptable or non-acceptable standards is a better indicator of obesity. Waist-hip ratio measurements are also considered to be a better determination of risk factors due to obesity. The waist-hip ratio takes into account the distribution of fat on the body. If fat distribution is mainly concentrated at the stomach or abdomen (visceral obesity), the health risks for heart disease, high blood pressure, and diabetes increase. If fat distribution is concentrated at the hips (femoral or saggital obesity), there is considered to be somewhat less of a physical health risk (Vague, 1991).

Currently, the most common measurement of obesity is through the use of the Body Mass Index (BMI) scale. The BMI is based on the ratio of weight over height squared (kg/MxM). The BMI gives a broader range of weight that may be appropriate for a specific height. A BMI of 20 to 25 is considered to be within ideal body weight range. A BMI between 25 to 27 is somewhat at a health risk and a BMI above 30 is considered at significant health risk due to obesity. Most medical sources define a BMI of 27 or higher to be "obese." Although the BMI scale does not take into account musculature or fat distribution, it is the most convenient and presently most widely understood measure of obesity risk (Vague, 1991). For the purposes of this study, a BMI of 27 and above is considered to be obese. The terms obese or overweight are used interchangeably throughout this thesis and refer to those with a BMI of 27 or higher.

Obesity and Dieting Demographics

Berg (1994) reported that the most recent National Health and Nutrition Examination Survey (NHANES III) revealed that the average body mass index of American adults has risen from 25.3 to 26.3. This would indicate an almost 8 pound increase in the average weight of adults over the past 10 years. These statistics indicate that 35 percent of all women and 31 percent of men have BMIs over 27. The gains extend across all ethnic, age, and gender groups. Canadian statistics indicate that obesity is prevalent in the Canadian adult population. The Canadian Heart Health Survey (Macdonald, Reeder, Chen, & Depres, 1994) showed that 38% of adult males and 80% of adult females had BMIs of 27 or higher. This statistic has remained relatively unchanged over the past 15 years. Therefore, it clearly indicates that in North America, approximately one-third of the adult population is considered to be obese.

The NHANES III study reviewed the possible causes of the pervasiveness of obesity and took into consideration such issues as an increasing American sedentary lifestyle and the prevalence of eating food outside the home. It is interesting to note that in an era in which dieting has become almost the norm and profits from the diet industry are high, overall weight is increasing! This could this lend some credibility to the notion that dieting behaviors lead to increased weight gain.

In the Canadian survey, approximately 40% of men and 60% of women who were obese stated that they were trying to lose weight. It was estimated that 50% of all women are dieting at any one time and Wooley and Wooley (1984) estimated that 72% of adolescents and young adults were dieting. In Canada, it was striking to note that one third of women who had a healthy BMI (20-24) were trying to lose weight. It was disturbing to note that 23% of women in the lowest weight category (BMI under 20) wanted to further reduce their weight.

Physical Risks of Obesity and Dieting

There is evidence that suggests obesity is linked to increased sickness and death rates. The physical risks to the obese have been described in terms of increased risks of hypertension, gall bladder disease, certain cancers, elevated levels of cholesterol, diabetes, heart disease and stroke, and some associative risks with conditions such as arthritis, gout, abnormal pulmonary function, and sleep apnea (Servier Canada, Inc.,1991; Berg, 1993). However, increasingly there have been conflicting opinions about the health risks of being overweight. Vague (1991) suggests that the health risks of being overweight may be more determined by genetic factors, fat location, and chronic dieting. Obesity may not be a major risk factor in heart disease or premature death in those who do not have pre-existing risks. In fact, there are some indications that moderate obesity (about 30 pounds overweight) may be healthier than thinness (Waaler, 1984).

It has been hypothesized that it is not the weight that causes the physical health symptoms found in the obese. Ciliska (1993a) and Bovey (1994) suggest the physical risks manifested in the obese are a result of the stress, isolation and prejudice that are experienced from living in a fat-phobic society. In support for this contention, Wing, Adams-Campbell, Ukoli, Janney, and Nwankwo (1994) studied and compared African cultures which exhibited increased acceptance of higher levels of fat distribution. She found that there were no significant increases in health risks where obesity was an accepted part of the cultural composition.

The health risks of obesity are usually well known to the general public. The public is often less well informed about the health risks of dieting and other weight loss strategies such as liposuction or gastroplasty. Dieters have been known to experience a wide variety of health complications including cardiac disorders, gallbladder damage, and death (Berg, 1993). Diet-induced obesity has been considered a direct result of weight cycling due to the body regaining more and more weight after each diet attempt such that there is a resultant net gain (Ciliska, 1990). Therefore, the physical risks of obesity may be attributed to the repetitive pattern of dieting that created the obesity through a gradual net gain of weight after each diet attempt. It is believed that the physical health risk in people who repeatedly go through weight losses followed by weight gains is likely greater than if they were to stay the same weight "above" ideal (Ciliska, 1993b)

Causes of Obesity

The underlying causes of obesity are largely unknown (National Institute of Health [NIH], 1992). The medical community and general public hold the strongly entrenched belief that most obesities are caused by an excessive amount of caloric intake with low energy expenditure. Most treatment models assume the obese eat considerably more than the non-obese and that daily food intake must be restricted in order to ensure weight loss. This belief is directly opposed by Stunkard, Cool, Lindquist, and Meyers (1980), and Garner and Wooley (1991) who contend that most obese people do NOT eat more than the general population. There is often no difference in the amount of food consumed, speed of eating, bite size or total calories consumed between obese people and the general population. There is a great deal of controversy to these beliefs. On the one hand, overweight people often state that they do not eat more than their thin friends. However, many overweight people will self report that they do eat considerably more than they need. For many of the obese, dieting behaviors may have created a dysfunctional relationship with food such that they may have learned to turn to food increasingly to meet many of their emotional needs. (Bloom & Kogel, 1994).

It is not entirely clear whether normal weight people who are not weight preoccupied are able to tolerate or adapt to varying amounts of food in a more efficient fashion or whether the obese who have attempted calorie restricted diets may indeed have a food intake that is too high for their daily needs (Garner & Wooley, 1991). Through repeated dieting, dieters may be unable to read their own satiety signals and therefore will eat more than others (Polivy & Herman, 1983). The very act of dieting results in binge eating behaviors. It is known that the onset of binge behaviors occurs only after the experience of dieting. It is believed that dieting creates binge eating behavior that is difficult to stop even when the person is no longer on a diet (NIH, 1992).

Therefore, the evidence would suggest that obesity is caused by a multitude of factors that are difficult to determine. There may be genetic, physiologic, biochemical, environmental, cultural, socioeconomic, and psychological conditions. It is important to recognize that being overweight is not simply a problem of will power as it is commonly assumed (NIH, 1992).

Physiological Aspects of Dieting and Obesity

Physiological explanations of obesity look to such areas as genetic predispositions to weight gain, set point theory, different ranges of metabolism and the issue of "diet induced obesity." Some physiological evidence may indicate that obesity is more a physical rather than psychological issue. Mouse studies undertaken by Zhang, Proenca, Maffei, Barone, Leopold, and Freidman (1994) and twin studies conducted by Bouchard (1994) indicate that there may indeed be a genetic predisposition for obesity and fat distribution.

Metabolic rates are determined by genetic inheritance and have often been discussed in relation to obesity. It has been hypothesized that overweight people may alter their metabolism and weight through caloric restriction. At the onset of a calorie reduced diet the body loses weight. However, slowly, the body recognizes it is in "famine" conditions. Metabolism slows down considerably so that the body is able to maintains itself on fewer calories. In evolution, this was a survival technique that ensured a population, particularly the females, could survive in times of famine. Today, the ability for one's metabolism to slow with dieting means that weight loss efforts through dieting will usually not be effective (Ciliska, 1990).

Set point theory also relates to issues of metabolism. If one's metabolic rate is reduced to ensure survival, fewer calories are needed. The "set point" is lowered. Therefore, one will gain more weight when the diet stops ensuring a subsequent weight gain on fewer calories. This phenomena is often found in women who have endured a very low calorie liquid protein diet (VLCD) that consists of 500 calories per day. Weight is lost initially, stabilizes and when calories are increased to just 800 per day, weight is GAINED. It is believed that the set point is lowered and a resultant net gain occurs (College of Physicians and Surgeons of Alberta, 1994).

There has been discussion that the process of prolonged and repeated dieting puts the body at physical risk. Yo-yo dieting or weight cycling is the repeated loss and regain of weight. Brownell, Greenwood, Stellar, and Shrager (1986) suggested that repeat dieting will result in increased food efficiency that makes weight loss harder and weight regain easier. The National Task Force on the Prevention and Treatment of Obesity (1994) concluded that the long term health effects of weight cycling were largely inconclusive. It recommended that the obese should continue to be encouraged to lose weight and that there were considerable health benefits in remaining at a stable weight. This is an ironic suggestion in that most dieters do not intentionally try to regain weight once it has been lost.

Garner and Wooley (1991) have discussed how the prevalence of high fat foods in western society has challenged the adaptive capacity of the gene pool such that there is an increasing amount of obesity found in western populations. The belief that it is only the obese who overeat is sustained by stereotypical assumptions that non-obese individuals eat less. Normal weight individuals who eat a great deal will usually attract little or no attention to themselves. As Louderback (1970) wrote, "A fat person munching on a single stalk of celery looks gluttonous, while a skinny person wolfing down a twelve-course meal simply looks hungry."

Psychological Aspects of Dieting and Obesity

While stating that the physical consequences of weight cycling were unclear but likely not as serious as some would assume, the National Task Force on the Prevention and Treatment of Obesity (1994) stated that the psychological impact of weight cycling was in need of further investigation. The study did not address the devastating emotional impact that repeat dieters universally experience when they repeatedly attempt diets that result in failure. The psychological damage that has been attributed to dieting include depression, diminishment of self esteem, and the onset of binge eating and eating disorders (Berg, 1993).

People may overeat compulsively due to psychological reasons that may include sexual abuse, alcoholism, a dysfunctional relationship with food, or genuine eating disorders such as bulimia (Bass & Davis, 1992). Such individuals are believed to use food to cope with other issues or feelings in their lives. Bertrando, Fiocco, Fascarini, Palvarinis, and Pereria (1990) discuss the "message" that the overweight person may be trying to send. The fat may be a symptom or signal representative of the need for protection or a hiding place. It has been suggested that overweight family members are often found having family therapy issues as well. Dysfunctional family relationships have been known to be manifested in such areas as parent-child struggles involving eating disorders. I believe that similar issues can also be recognized in families where there are family members who are perceived to be overweight regardless as to the accuracy of this perception.

Self Esteem and Body Image

Studies suggest that obese women will have significantly lower self esteem and negative body image than normal weight women (Campbell, 1977; Overdahl, 1987). When individuals fail to lose weight, issues of low self esteem, repeated failures, and the feeling that they "didn't try hard enough" come into play. Embarking on a diet that ultimately results in failure or even a higher rebound weight will have a significant negative impact on self esteem and body image. Contempt of oneself and disturbance of body image are often seen in those that struggle with weight control issues (Rosenberg, 1981). Wooley and Wooley (1984) have stated that concern over weight leads to "a virtual collapse" of self esteem.

Body image is the picture a person has of her body, what it looks like to her and what she thinks it looks like to others. This can be accurate or inaccurate and is often subject to change. The relationship between body image and self esteem is complicated. Often dual feelings that "I am fat" and "therefore I am worthless" go hand in hand (Sanford & Donovan, 1993). Both body image and self esteem are perceptions that are actually independent of physical realities. Improving body image involves changing the way one thinks about one's body rather than undergoing physical change (Freedman, 1990). To improve body image and therefore improve self esteem, it is important for women to learn to like themselves and to take care of themselves through healthy lifestyle choices that do not emphasize weight loss as the only measure of good health.

Relationship With Food

Repeat dieters often learn to use food to cope with their emotions. Women's experiences with emotional eating have often been neglected, trivialized and misunderstood (Zimberg, 1993). Polivy and Herman (1987) contend that dieting often results in distinctive personality traits such as "passivity, anxiety and emotionality." It is interesting to note that these are characteristics often used to describe women in stereotypical ways.

Food is often used to feed or nurture oneself for both physical and psychological hunger. Food is used to literally swallow emotions. I believe that when people become weight or diet preoccupied, it is often "safer" to focus on food and eating than on underlying emotional issues. It is important for people to look closely at their relationship with food. Through repeated experiences of dieting, people will develop a skewed relationship with food. Food should not be a moral judgment as to whether or not you have been "good" or "bad" depending on what has been consumed. Similarly, a person's self worth should not be measured on the bathroom scale.

There is often the belief that if one can make "peace" with food, then the logical result will be that weight will then be lost (Roth, 1992). While it is important to look at one's relationship with food and have it become a less powerful influence in life, this will not necessarily lead to weight loss. Studies that have utilized a non-dieting approach resulting in food disempowerment have shown that weight remained approximately stable (Ciliska, 1990). It may be considered a positive result for a person to be able to resolve a distorted relationship with food and then be able to maintain a stable weight without the gains and losses that repeat dieters often undergo.

I believe that when people become weight or diet preoccupied, it is often "safer" to focus on food and eating than on emotional issues. That is, for some people it may be easier to focus on their weight than to focus on the overwhelming feelings that they have learned to cope with through eating behaviors. People use food to nurture themselves or to literally "swallow" their emotions. Food is often used to cope with emotions such as grief, sadness, boredom, and even happiness. If food loses its power to aid in distracting or avoiding difficult situations, it may be quite overwhelming to confront the issues that were previously avoided through weight preoccupation or abnormal eating. Additionally, the excessive focus on concerns about body weight and dieting may also serve as a functional distraction to other overwhelming life issues.

Social Impact of Dieting and Obesity

From a young age, a woman is often given the message that she must be beautiful to be worthy. Attractive people are not only seen as more attractive, they are seen as smarter, more compassionate and morally superior. Cultural ideals of beauty are often transient, unhealthy and impossible for most women to live up to. Women are encouraged to be delicate, frail or "waif-like." There is a very narrow range of what is considered to be "acceptable" body size. Shapes that are not within this range are met with discrimination and prejudice (Stunkard & Sorensen, 1993). Women are taught early in life to be wary of what they eat and to fear getting fat. Trusting one's body often evokes tremendous fear for most women. Our society teaches women that eating is wrong (Friedman, 1993). Young women have long been taught to control their bodies and appetites, both sexually and with food (Zimberg, 1993). Women are expected to constrain their appetites and pleasures (Schroff, 1993).

We live in an age where women are seeking equality and empowerment, yet are starving themselves through diet and weight preoccupation while assuming that they can keep up with their better fed (male) counterparts. The strong social pressure to be thin began after World-War II (Seid, 1994). Magazines began showing thinner images of models as both pornography and the women's movement increased (Wooley, 1994). Faludi (1991) states that when society makes women conform to such a thin standard, it becomes a form of oppression towards women and a way of ensuring their inability to compete on equal grounds. The emphasis on thinness in our culture not only oppresses women, it also serves as a form of social control (Sanford & Donovan, 1993).

The stereotypical view of the overweight held by society is that they are unfeminine, antisocial, out of control, asexual, hostile and aggressive (Sanford & Donovan, 1993). Zimberg (1993) questions whether weight preoccupation would be a problem for women if it did not exist alongside society's clear prejudice against fat people. "Public derision and condemnation of fat people is one of the few remaining social prejudices... allowed against any group based solely on appearance" (Garner & Wooley, 1991). It is assumed that the obese willingly bring their condition on themselves through lack of will power and self control. The discriminatory implications of being overweight are well known and are often accepted as "truths" in western society. Fat oppression, the fear and hatred of fat is so commonplace in Western cultures that it is rendered invisible (MacInnis, 1993). Obesity is seen as a danger sign in moralistic terms that may imply personality faults, weak wills and laziness.

The obese face discriminatory practices such as having lower acceptance rates in high ranking colleges, a reduced likelihood of being hired for jobs and a lower possibility of movement to a higher social class through marriage. These effects are more severe for women than men. Obese women are not a strong social force and are likely to be of lower status in income and occupation (Canning & Mayer,1966; Larkin & Pines, 1979). "Prejudice, discrimination, contempt, stigmatization and rejection are not only sadistic, fascist and intensely painful for fat people. These things have a serious effect on physical, mental and emotional health; an effect which is real, and must not be trivialized." (Bovey, 1994)

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