The Thing About Research: Engendering Some Healthy Paranoia

People love to cite research. Take these fictitious examples: “This study showed that 80% of participants lost 10 or more pounds after taking these pills for one month.” “Another study showed that eating chocolate daily can lead to a long and painful death.” “Some research suggests that if you ingest fewer than 500 calories per day, you’ll live past 100.”

Let’s take a look at a real example: An AOL news item revealed recently that approximately 42% of French people (older than 15) have a “weight problem.” To start, the study was conducted by ObEpi-Roche, defined as a “drugs group” that “makes weight loss products,” such as Xenical. Hmm. . . think they might have a vested interest in showing exactly how fat the French are? How about the survey’s co-sponsors: Sanofi-Aventis and Abott Laboratoties (the manufactures of diet drugs Acomplia and Meridia, respectively)? The AOL article states that, “Campaigns were launched in France last year warning of the health dangers linked to obesity. . . .” It's always important to understand who is funding (either directly or indirectly) the research on obesity. In The Diet Myth, Paul Campos reports that many studies on obesity are conducted by physicians and weight-loss clinics intimately tied to the diet industry. By definition, this obfuscates the possibility of unbiased (read: ethical) research.

On August 27th, 2006, NBC exposed a similar problem in the cancer research arena. They revealed how cancer studies are often funded by pharmaceutical companies and that the drug companies play a large role in the research, often choosing what results will be reported and even writing the papers “authored” by scientists. That is, the researcher conducting the study doesn’t even write up the results (yet, his/her name is used for authorship). I’m concerned that researchers would allow ghost-writers to publish their results—as part of the American Psychological Association’s ethics code, for instance, I’m accountable to standards of practice that obligate me to, along with not publishing research that isn’t mine, avoid having sex with my patients! These are pretty big things.

Furthermore, many studies run multiple analyses as part of the research—in this way, researchers can get creative and choose to publish the results that support their hypotheses. . . and their products. As any amateur statistician can tell you, statistics are more an art than a science, and if you look hard enough (and run enough analyses), you’re bound to find something you hoped to see.

Next point: the study used BMI’s in order to define people as overweight or obese. Recent research has confirmed that the BMI is not an accurate and reliable indicator of weight-related health concerns. Should we still be using it as a measure? What measures do researchers employ in a study, and do instruments show adequate psychometric properties (i.e., are they valid and reliable)?

The informed consumer of research should consider other factors as well, when evaluating study claims. 1) How many participants were in the study? Generally, the more the better. Was it a diverse sample? Did the sample represent you? 2) Were all data used, and if not, how can we explain why certain data were tossed? 3) What types of statistical techniques were used? I won’t bore you here, but techniques can vary in their statistical power. 4) In a true experiment, were the participants and the researcher aware of the experimental hypotheses? If so, that may influence (and artificially inflate) the results. 5) How about that sneaky fellow, the placebo effect? 6) What other factors may contribute to what seems like a causal relationship described by study results? For example, let’s say one product (a diet pill) advertises itself to be proven effective for weight-loss in 90% of all patients. Let’s also say that taking said pill makes you really tired and you end up sleeping significantly more each night. Can we really say that the pill caused weight-loss? Or, did it maybe promote sleep, which on its own would have reduced food intake? Ever notice that (barring the Ambien-binge reports) you kind of eat less when you’re asleep? Insufficient sleep is also linked to disruptions in hunger hormones, such as leptin and ghrelin. Or, let’s look at happiness and exercise. If we find that people who exercise daily are happier, can we say that exercise leads to happiness? Not really. Maybe happy people are simply more inclined to hit the gym. 7) Where was the research published? Peer-review journals are best. Even research that’s really, really bad can be published in a sub-standard publication for a fee.

All kinds of factors need to be considered when evaluating weight-loss research. Unfortunately, the scientific value of studies is often obscured by the emotionality, funds, and media involved. Reading, and consequently citing, a study at face value is often not enough.

Velvet Aboveground

By now, you’ve probably heard about Velvet D'Amour, a 39-year-old model and actress who took Paris Fashion Week by storm. As part of his 30-year anniversary show, designer Jean-Paul Gaultier offered his unique spin on the recent Size-0 controversy in Spain (and in New York, where fall fashion week models were anecdotally judged to be more emaciated than ever before) by casting Velvet in his show. While the rest of his models donned workout gear (sweats, hoodies, etc.), Velvet, among a roaring crowd, pranced down the catwalk in a satin corset and negligee. None of this is really surprising, unless you’ve also heard about Velvet’s, um, weight. Reports indicate that voluptuous Velvet is 5’8”, weighs 291 pounds, and wears a Size 20 (see below). Velvet is decidedly plus-size.

By today’s standards, a plus-size model is defined as one who wears a dress size of 14 or higher (irony aficionados take note: that’s the average dress size of women in America). Emma Melissa Aronson is described as the first (barely) plus-sized model to gain widespread appeal. Really? Can you picture her? Funny thing about Emma—50% chance says she’s your size or smaller. But now, everyone seems to have a mental image of Velvet.

The model herself offers some perspective on the hoopla surrounding her recent job—Velvet’s quoted as saying: “If you tell me somebody's too thin, if you tell me somebody's too fat, you're still being prejudiced. The point is diversity.” That might not dampen the requisite backlash from those who haven’t gotten the point. In a New York Post article, Velvet is described as a “massive model” wearing a “barrel-sized corset and enough lace to outfit the entire Moulin Rouge.” A caption states: “The colossal catwalker at Jean Paul Gaultier’s Paris show looks as if she could swallow whole the stick-figure model [pictured next to her.]” Even removing the fat-is-bad lens from the equation, it’s still pretty far from praise. Hopefully, Velvet’s thick-skinned.

No one’s ever accused Gaultier of being subtle, but has he crossed the line, going overboard for publicity’s sake? Is Gaultier’s decision to use Velvet revolutionary, a pendulum-swinging act away from the disappearing model-star, or is she just the latest pawn in our global size wars?

The War on Fat

New York City: The Big Apple. Land of opportunity. Food, everywhere you look. Come December, the city’s restaurant menu may be partially revamped. Last week, health department officials proposed a new code that would force the city’s 20,000 restaurants to limit their use of trans fats, the hydrogenated oils found in French fries, pies, and other processed goods. Establishments, including the city’s umpteen McDonald’s, would have to switch to oils and shortenings that have fewer than .5 grams of trans fat per serving.

Why the proposal? Artery-clogging trans-fats have been linked to heart disease. "New Yorkers are consuming a hazardous, artificial substance without their knowledge or consent," says Health Commissioner, Thomas Frieden. Earlier this year, the FDA began requiring food manufactures to list trans fat content on product labels. Now, New York City restaurateurs are up in arms, arguing that such a ban would affect the taste of menu items and would also drive up costs. New York, which banned smoking in restaurants in 2003, would be the first city to attack trans fats, though Chicago may soon follow suit.

Thoughts?

From the Mailbag

Hello Dr. Stacey,
While reading your blog EDNOS, I began to think about the roots of thin body expectations for women. Where did it come from? When and how did it evolve? When was it decided that thinner looked better? Certainly this is a phenomenon that has been around a relatively short amount of time, judging from photos and portraits of women considered beautiful over a hundred years ago. Perhaps you addressed this in earlier posts. I will peruse...

Also, what other cultures are so wrapped up in this obsession? Are eating disorders cross-cultural? What do eating disorders look like in other parts of the world? Do they only exist in developing nations? Of course, many parts of the world do not have enough food and don't have the luxury.

Sometimes I feel incredibly guilty and disgusting for having an eating disorder when I realize so many people don't have enough food to sustain their health. How dare I not eat healthy when others don't even have that choice. I am filled with self and culture-loathing. But then I realize that this thinking, while true, doesn't help me or anyone else. Self-love. Self-love. Self-love.

Thanks for your BLOG and thanks for reading,
Shelley

“Thinner is better” is a relatively new phenomenon, as we see from artwork and archival data. Looking at the sizes of models, movie stars, Miss America contestants, and even Playboy centerfolds, we see pretty sharp decreases in weight during the second half of the 20th century. Even our mannequins have shrunk—here’s some information I found: In 1950, the hip measurement for store mannequins was 34 inches, reflecting the size of the average woman at the time. Forty years later, when heroic chic descended on the catwalk, the average hip measurement for real women climbed to 37 inches, while mannequins’ hips shrunk to 31 inches. If these mannequins were real, they (along with Barbie, who if her measurements were extrapolated to “real” size, would be 6 feet and 101 pounds) would be amenorrheic. So, as real women have grown, our standards have gotten smaller, and as such, the frequency of dieting and eating disorders has increased.

To answer your second question, eating disorders are cross-cultural. Eating disorder inventories have been translated into countless languages and what we see are many studies documenting disorders among, for example, people of various cultures living in Western countries, as well as in women living around the world. That said, what’s interesting to note is that while women around the world may struggle with disordered eating, the relative incidence may vary, particularly when you take into account the culture’s exposure to Western ideals (see above). Some studies, for instance, show that when developing nations are introduced to Western media (i.e., they first get television access), the incidence of eating disorders increases. Anyone who has watched a couple of hours of Western-influenced television may understand why, both from the programming and commercials. From this, one can argue that eating disorders, to some extent, are culture-bound phenomena. Even with exposure to Western media, however, there is usually an accompanying predisposition—in Western countries, not everyone develops an eating disorder (with the same exposure), so a combination of variables is likely present. This describes what we call the diathesis-stress model—the diathesis is some sort of genetic, biological, or psychological disposition and the stress could be exposure to media, family dynamics, etc.

True, plenty of people around the world don’t have sufficient access to food. David Landes, author and professor of economics and history writes: “This world is divided roughly into three kinds of nations: those that spend lots of money to keep their weight down; those whose people eat to live; and those whose people don't know where their next meal is coming from.” While this provides some perspective, I’m not sure, as you indicate that it’s helpful to compare your struggle with others’, as that leads to greater self-reproach (which can fuel the problem). There will always be someone who suffers more than you—what matters, from my perspective, is that we do what we can to understand and support ourselves and that, if we’re so inclined, we reach out to others with fewer resources.

Magazine Article

See here for an interesting article on celebrities and eating/body image, courtesy of People magazine.

Irony

Toward the end of World War II, a biologist by the name of Dr. Ancel Keys set out to determine some of the physiological and psychological effects of restricted food intake in what was known as “the Minnesota starvation study.” The motive, it seems, was to understand the mechanisms of starvation, in order to more adequately handle potential post-war, European famine. The study participants were 36 physically and psychologically healthy men, conscientious objectors to the war, who volunteered to participate in a diet-regimen that cut their normal caloric intake roughly in half for a period of six months. What followed was an unprecedented look into the science and psychology of malnutrition. (One participant, Lester Glick, chronicles some of his experiences here.)

As any observer of the Jewish holiday, Yom Kippur, or the Muslim period of Ramadan may tell you, fasting is a unique psychophysiological state, in which food becomes a primary focus. While religious or spiritual matters may be intended to take center stage, when told to not think about a white horse (or White Castle burger, as the case may be), that’s exactly what we can’t seem to do. Fasters may overindulge the night before, as they “stock up” for the fast, may similarly overindulge post-fast, and often report spending a great deal of time during the fast thinking about food, their hunger, and when they’ll eat again. From a dieting perspective, it’s likely that in the end, they’ve consumed more food than they would have without the fast, with the additional problem of having toyed (albeit briefly) with their metabolism.

In the Minnesota study, now captured by Todd Tucker in the new book, The Great Starvation Experiment, what we saw was a compromised humanity (and throwback to animal times), resulting from food restriction. As participants lost weight, and essentially began to starve, not only did they become incredibly and solely focused on food, but their hunger took on epic proportions—participants reported violent fantasies, contemplating suicide, murder, and ultimately, cannibalism.

A hot topic lately has been the significant increase in adult (and childhood) obesity—recent figures indicate, for example, that 64% of Americans (115 million) are considered overweight or obese. How do we explain this trend? While a number of factors may be involved, taking note from the Minnesota study, as well as the general research suggesting that (depending on which study you reference), 95-98% of all diets fail, it seems that perhaps the simple and repeated act of trying to restrict oneself has actually led to our expanding waistline. Trying to (unnaturally) tame an appetite can have quite a rebound effect, leading to both acute and chronic overeating, as compensation. While most self-imposed food restrictors thankfully do not arrive at the point of suicidal or homicidal ideation, what we can say is that the more weight we try to lose, the more we seem to gain. As a corollary, the more we grow our diet industry (now worth an estimated $40 billion), the more we grow ourselves, begging the question: Is it possible that we are obese simply because we are trying so hard not to be?

Miss Jackson

Janet Jackson. Amid wardrobe malfunctions and family drama, the woman still knows how to pick a man. In a recent issue of Britain’s Grazia magazine, Janet reports that despite her 68-pound weight-gain for a now defunct movie role, her music industry boyfriend, Jermaine Dupri, still worshipped her frame:

Not once did he make me feel uncomfortable. He'd grab me, pull me around the stomach, look me in the eyes and say, 'This needs love too!'

I thought that was the sweetest thing. I've never in my life had love that was so unconditional.

My weight never affected my sex life. Nothing changed, nothing!

40-year-old Janet is convinced she’s found “The One.” To know that while her weight may fluctuate, his attraction to (and love for) her remains constant produces one of the most monumental relationship exhales. And, isn’t that what partnership is all about? To quote Janet in song, “That’s the way love goes.”

Medifast Response

My August 29th post on Medifast appears to have hit a nerve. While I typically haven't commented on older posts, I feel it's important to address some of the reader comments that now appear on this post.

I am happy to hear that some readers have lost significant amounts of weight on Medifast and even happier that they report being healthier and feeling more energetic than they did before. I have consistently written that the subjects of eating and weight-loss are largely idiographic, and it makes perfect sense that different philosophies/approaches will work for different people. If Medifast has worked for you, feel free to stop reading here.

That said, as I wrote in an email to one reader, my personal experience working with patients (some of whom have had bariatric surgery, some of whom have clinical eating disorders, many of whom use food emotionally) is that there is very commonly a long and painful road of yo-yo dieting, which wreaks significant emotional havoc on them. By the time they see me (or my colleagues), they have tried numerous diets (some VLCD's), have lost weight, gained it back (plus some), and are absolutely dejected and demoralized. Through the years, I have also seen many patients who suffer from anorexia, bulimia, and EDNOS. This is the bulk of the readership of my blog (as judged by comments and emails to me). For these individuals, too, their relationship with food is an incredibly deep and emotional one and not one that can be addressed simply with a food plan or other behavioral measures. This does not, in any way, suggest that I believe that people cannot lose weight on Medifast. As some of you have reported, there is often a substantial weight-loss associated with VLCD's--and how could there not be?

To clarify a point on my post, I was not saying that Medifast allows only 167 calories per day. What I was saying is that in order to lose five pounds per week (as the Medifast website states is possible with the plan), you would have to have a deficit of 17,500 calories per week. You do the math. I have consulted with physicians and nutritionists on diets such as Medifast. As with everything, there are varying points of view. I will not, however, accept a doctor's approval of a diet plan as carte blanche to plow ahead. If you recall, Bextra/Vioxx/Celebrex, Fen-Phen, and even Thalidomide were once approved for use.

A couple of readers have questioned my credentials: I am a psychologist, with a master's degree in exercise science and a doctorate in clinical psychology (with an emphasis on health psychology). You're absolutely right that, outside of what's provided to me by the physicians and nutritionists with whom I consult, I do not claim to have specialized knowledge of specific nutritional programs. What I do claim to have knowledge and training in (and experience with) are the psychological factors that influence eating, dieting, and weight-loss cycles. In my experience, programs like Medifast are not a long-term solution to the psychological antecedents and sequelae of eating disorders. They may, however, work for you.

I do appreciate controversy. Without different (and often opposing) ideas, it is difficult for us to move forward as a science and a society. Attack my ideas as much as you'd like--I'm happy to provide a forum for you to do so; however, please, as I have advised before, challenge the ideas and not the writers. When attacks become personal, they are unnecessarily hurtful and obscuring of our ultimate goal.

Miss Scarlett in the Kitchen with the Wrench

In an In Touch magazine feature entitled, “I Won’t Starve Myself,” Scarlett Johannson reports, “‘I’m comfortable with my body.’” Aside from the obvious question (who wouldn’t be comfortable with Johansson’s body?), I’m happy to read such a body-positive statement, particularly from a star who hasn’t historically made the “skinny alert” reports. “‘I’m not one of those actresses who is going to stop eating. . . I like chocolate and I’m going to eat it!’”, Johansson says.

She seems to have arrived at a place that allows her to recognize her body is a factor in her work, but one that allows her to engage in healthy eating and body image practices. In a recent People feature, Johansson states: "I'm curvy – I'm never going to be 5' 11" and 120 pounds," she says. "But I feel lucky to have what I've got."

Johansson is currently parlaying her body positivism into the design of a new line for Reebok footwear and apparel, called “Scarlett Hearts Reebok.” The line, which debuts in the spring of 2007, has been described as “athletic inspired” and “fashion forward.” Johansson tells InStyle magazine that items are "fitted to my body. So I know they'll fit a regular person." Well, Scarlett, you’re not exactly a regular person, but you’re certainly a closer approximation than the waif. Every Woman Has an Eating Disorder hearts you for throwing a wrench in the celebrity culture of starvation and body distortion and for eating what you want and accepting yourself the way you are.

Pathways

In Overcoming Binge Eating, Dr. Christopher Fairburn describes a common pathway for how patients arrive at bulimic behavior:

Typically the person begins dieting and losing weight in the mid-teenage years, despite in many cases not having been overweight in the first place. When the weight loss is extreme, it leads to the development of anorexia nervosa. Eventually, after a varying amount of time, the person’s control over eating starts to break down and he or she begins to binge. Control progressively deteriorates, and the person’s weight gradually returns to near its original level.

Once bingeing begins, it may only be a matter of time before the fear of weight-gain escalates to the point of necessitating the purge.

Sound familiar?

Of course, anorexia is not a required stop in this journey—many people swing from dieting to binge eating without a descent into full-blown anorexia. In either case, one of the easiest points of intervention in this dieting-->anorexia (or not)-->binge eating-->bulimia cycle is the dieting stage. Dr. Fairburn talks about three forms of dieting, including:

1) Trying not to eat for long periods of time 2) Trying to restrict the overall amount eaten 3) Trying to avoid certain types of food

According to him, any of these restrictions can eventually lead to a binge. What I find interesting is how creative we are with our dieting attempts—we may think we’re not dieting because we’re not on a specific plan or because we eat three meals a day, but when you consider the restrictions above, it’s clear how the diet can cleverly masquerade as “I’m too busy to eat” or “I’m just being healthy.” Will dieting always segue into an eating disorder? No. But, for many it will, and it’s important to be aware of this outcome and to be on guard for the plunge into anorexic or binge-eating behavior.

Community

So, this is it—my 101st post! I still plan on posting regularly (aiming for twice a week), though will now turn more of my attention back to my clinical work, teaching, and getting this book proposal accepted.

For now, I’ve compiled (a la Barbara’s idea) a list of the blogs I know that link to me. Apologies if I got any of the addresses wrong—please feel free to correct or redirect in the comments section. Also, if you link to me but I don’t know it, please feel free to add your site. Thank you all for sending readers my way. Everyone else—check out these amazing blogs and the women who write them!

www.aweightyissue.blogsome.com
www.babblingcats2.blogspot.com
www.bexactually.blogspot.com
www.burntoday.com
www.cheatymonkey.com
www.dickundduenn.blogspot.com
www.donnainhouston.blogspot.com
www.fatnforty.wordpress.com
www.girladdicted.com
www.hollygoheavily.blogspot.com
www.idiet.blogspot.com
www.iendedupherehow.com
www.jens-ramblings.blogspot.com
www.kellyim10.blogspot.com
www.meltingmama.typepad.com
www.minusthirty.blogspot.com
www.nopenotanymore.blogspot.com
www.nourishyoursoul.blogspot.com
www.onbulimia.blogs.com
www.onceuponafatgirl.blogspot.com
www.opaat.blogspot.com
www.pathofmindfulness.blogspot.com
www.sizeate.blogspot.com
www.talesofafatgirl.blogspot.com
www.thechocholatebunny.blogspot.com
www.weightedlongenough.com

Motivation

Do you operate out of self-love or self-abuse? It’s something to consider, especially if you’d like to change something about yourself. I’d argue that no change can be made out of self-abuse. The self-loving part of you will always step in and sabotage the plan.

A big push in psychology (particularly with regard to eating disorders) is this concept of self-care. How do you comfort, soothe, and be kind to yourself? Are you compassionate, gentle, and patient, or harsh, punitive, and unyielding? What language do you use with yourself? Is it angry, hurtful, and condemning?

As someone who usually espouses the value of the continuum, I’m feeling pretty black-and-white on this one. It seems that so much of our behavior, particularly related to eating and our bodies, is either motivated by self-care or self-abuse. Eating when you’re hungry? Self-care. Exercising when you’re tired, or sick, or because you have to get rid of the fat? Self-abuse. Allowing yourself to have a food that you desire? Self-care. Eating when you’re stuffed? Self-abuse.

Making Weight

Dislike your job? It could be worse—The New York Post reported yesterday that two ex-waitresses of Manhattan’s Sutton Place Bar and Restaurant are suing the establishment (to the tune of $15 million) for tracking their weight and forcing them to hop on the scale at work. One of the plaintiffs, Kristen McRemond, 27, indicated that “she physically resisted when a beefy manager tried to pick her up to get her on the scale while another manager looked on.” It seems that only female employees were subjected to public weigh-ins (or criticized for their choice of foods when dining themselves). The Post reports that the “waitresses' individual weights were tracked on a computer spreadsheet - and the results placed on a Web site that tracked the weights of waitresses in other establishments in the city.”

McRemond, and her co-plaintiff, Alexandria Lipton, 25 (featured above), are accusing Sutton Place’s owners and managers of sexual harassment and illegal firing—both McRedmond and Lipton were axed after vocalizing disagreement about the weigh-ins. As you may imagine, the restaurant’s lawyer has denied these allegations, but has not provided explanation as to why McRemond and Lipton were let go.

While the allegations here are pretty straightforward, it begs the question of how many other workplaces engage in less-subtle (but still discriminatory) weight-related practices. I hope that the current suit raises consciousness about weight discrimination, particularly against women. A woman’s body is not a commodity, a product to be sold—and if the owners of this establishment disagree, then, clearly, they’re in the wrong business.

EDNOS

Eating Disorder Not Otherwise Specified (EDNOS) is a clinical eating disorder that captures eating-disordered thoughts, feelings, and behavior that do not meet full criteria for Anorexia Nervosa or Bulimia Nervosa. While no specific criteria distinguish this diagnosis, the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM IV-TR) offers the following examples of symptoms that would warrant a clinical diagnosis:

1. For females, all of the criteria for Anorexia Nervosa are met except that the individual has regular menses.
2. All of the criteria for Anorexia Nervosa are met except that, despite significant weight loss, the individual’s current weight is in the normal range.
3. All of the criteria for Bulimia Nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than twice a week or for a duration of less than three months.
4. The regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food (e.g., self-induced vomiting after the consumption of two cookies).
5. Repeatedly chewing and spitting out, but not swallowing, large amounts of food.
6. Binge-eating disorder: recurrent episodes of binge eating in the absence of the regularly use of inappropriate compensatory behaviors characteristic of Bulimia Nervosa.

DrStaceyny’s input (by number):
1. One of the required symptoms for a diagnosis of anorexia is that you present with amenorrhea (having no menstrual period for at least three months). So, if you meet all other criteria for anorexia (less than or equal to 85% of what you should weigh, fears of gaining weight, body-image disturbance), but are still getting your period, your diagnosis would likely be EDNOS.
2. The first criterion for anorexia is “refusal to maintain body weight at or above a minimally normal weight for age and height.” This is often translated to the 85% rule stated above. However, some people might have started out at a heavier weight, and thus, even if they lose lots of weight, they’re actually not below “normal” weight expectations.
3. Think of this one as less-frequent bulimia—there is bingeing and purging, but not at the same rate (or for the same duration) as what would be required for a bulimia diagnosis.
4. This example captures those who don’t, by definition, binge, but who still rely on compensatory strategies (vomiting, laxative use) following even small amounts of food consumption (sometimes referred to as “purging disorder”).
5. Pretty straight-forward.
6. Binge Eating Disorder is, as of now, what’s called a “criteria set.” The American Psychiatric Association has recognized the condition as one which warrants further empirical attention, and it’s quite possible, that by the next revision of the DSM (supposedly in 2010), Binge Eating Disorder will be recognized as its own diagnosable (read: reimbursable) condition. Other disorders similarly on deck include: Premenstrual Dysphoric Disorder (now coded under a type of depression), Mixed Anxiety-Depressive Disorder, and Caffeine Withdrawal.

The list of six examples given above is not intended to be a comprehensive list of all of the symptom constellations that might qualify as EDNOS. Symptom presentations, as individual, may vary, and it is important to recognize that for those who suffer from EDNOS, this is a serious condition no less painful, no less subjectively detrimental, no less of a personal hell than anorexia or bulimia. While it is likely that EDNOS is not as fatal as anorexia or bulimia, EDNOS can still cause substantial ruin. EDNOS can ruin your self-concept. It can ruin relationships. It can ruin your work and your interests. It can still ruin. . . you.

Score One for the Home Team

The rain in Spain falls mainly on the plain—well, not anymore, because (tiny) curves are in in Madrid! AOL News* reports that Spain’s hottest fashion show, Pasarela Cibeles, forbade a number of models from participating this year. . . because they were, oops, too thin. In a surprising example of how Body Mass Indexes can be an effective and reliable health/wellness tool after all, pageant officials calculated models’ indices and dropped each hopeful with a BMI shy of 18.

The show, which features primarily Spanish designers, decided to enact this measure following the aftermath of last year’s show, which featured “bone thin” models. Aghast feminists and medical professionals spoke up, recognizing how parading these forms on the catwalk can fuel national eating-disordered behavior, particularly among young girls. The decision to step in seems to be a collaborative effort of Madrid’s regional government and the Association of Fashion Designers of Spain. AOL readers, it seems, would likely offer their support, as well. In an on-line poll of over 55,000 voters (when I voted), 91% believed that the presence of “ultra-thin” models contributed to the development of eating disorders.

As New York City launches its fall fashion week, I wonder if the U.S. (and other countries) will follow in the Spaniards’ footsteps. After hearing the news, Ryan Brown, of the Elite Modeling Agency in New York, is quoted as saying: “I think it is great to promote health.” Time will tell how many fashion weeks will come and go before such a sentiment is turned into practice on American soil. As for now, Brown notes: “They don't want voluptuous girls any more,” though he adds: “It would be nice if fashion got back to that.” Yes, Mr. Brown, it would.

*thanks to the readers who sent this my way

Google Me This

Coming up on my last week of daily posts, I thought it would be interesting to explore how people found my blog, since when I started out, I only shared the site with a handful of colleagues, family, and friends. As such, I’ve been periodically tracking the Google searches that have landed readers here. Many of them relate to celebrity diet/weight concerns:

-Is Mandy Moore getting fat?
-Beyonce Knowles’ recent weight-loss secret
-Katherine Heigl bra size
-Jessica Alba eating disorder squats
-Jamie Sigler eating disorder
-Katie Couric fat arms

We also seem to be very interested in celebrity dress sizes, including the sizes of some of the aforementioned stars, as well as others.

One of the more popular searches that lands people at my site?

-Woman eating shit

So. . . uh. . . I have absolutely no idea what to say here.

Other searches focus on dieting and eating-disorder tips and techniques:

-What WW members eat
-Non-purging bulimia
-Starve and barf
-Bingeing restrictions
-How to hide an eating disorder

In fact, many are of the pro-ana/pro-mia variety. I can’t even count the number of searches for these terms. I also can’t imagine the disappointment in trying to find a pro-ana site and getting stuck with me. We seem, overall, to be very interested in anorexia and the disappearance of flesh.

-Anorexic 75-lb woman
-Freudian anorexic pregnancy
-Ballerina anorexic images
-47-pound anorexic ballerina
-Anorexic role models

And, the most harrowing query to date?

-How little can a woman weigh and still live

Parenting

A recent study conducted by Boston University’s School of Medicine, and appearing in the June issue of Pediatrics, revealed that children of authoritarian (strict disciplinarian) parents are five times more likely to be overweight by the first grade than those reared by more authoritative (democratic) parents. True, children of overly permissive and/or neglectful parents were even more likely to be overweight, but the question remains—why would kids raised by overly strict parents tend to be more overweight than those exposed to more flexible parenting?

The study’s lead author, Dr. Kyung Rhee, provides some clarity, suggesting that authoritarian parents may inhibit children from developing their self-regulatory abilities. Children instructed to eat brussel sprouts, for instance, instead of vegetables more palatable to them, lose their sense of autonomy and personal choice, which may, in turn, affect their abilities to “listen to their bodies about how full they are,” Rhee says.

Another factor, I’d add, is that children of excessively strict parents may soothe themselves with food in an effort to comfort themselves following (or preceding) frequent disciplining. Moreover, in a system where rigidity is key, children may rebel by overeating, sneaking food as an effort toward self-expression and/or separation from the family.

My Time in the Zone

The story, of which I have no recollection, goes something like this: When I was five, my mother served hamburgers one night for dinner. Always inquisitive, I posed a question to her: “Mommy, how does the cow make the hamburger?” My mother, not wanting to mislead me, replied, “Stacey, this is the cow.” I pushed my plate away.

While I did go on to eat meat again, fast forward about twelve years, and, fueled by burgeoning ideas about animal ethics, as well as a general unrest about chewing animal flesh, I became a full-fledged vegetarian.

A few months before beginning this book, I went on my first organized diet. I wasn’t really trying to lose weight (ok, maybe a few pounds), but was more interested in healthy eating and balancing protein and carbs, as the media told me I should be doing. As a vegetarian, I’m often asked, “Do you get enough protein?” Truth is, I’m not sure I do.

One of the Zone-Diet inspired plans had recently unveiled a vegetarian program, so I decided to give it a go. My go involved about eight servings of tofu a day. I had tofu for breakfast, lunch, and dinner, and tofu before bed. As I write this, I stand firm (though, not extra firm) in my belief that tofu is not a breakfast food, no matter how closely it resembles a sausage link.

During my trial, I’m really, really hungry and am not sure they figured in my active lifestyle when calculating my portion sizes. A couple of days into the program, I go to the gym and realize my effort is about 50%. I’m tired, and can’t run far. The next time I try to run, I’m even more exhausted. I barely make it home from the gym, dizzy, faint, and unsure of what to do. My normal blood pressure is 90/60, and I can tell I’m south of that. I consider going to the closest E.R. Meanwhile, I plant myself at the computer, and search the panacea for all things medical, the web, where I learn that such diets (particularly for the uninitiated) often create electrolyte imbalances and that salt ingestion is a quick and effective cure. I grab some crackers and slowly begin to feel better, more myself. I toss the remaining meals, feeling slightly rebellious, but healthy and liberated. About a week later, I get a call from a program rep, who asks me how the diet went. I explain how hungry and tired and sick I became, detailing my near emergency-room excursion. His response: “I’m sorry to hear that. We’re offering a discount for the monthly program, which would be only $36.95 a day. Would you like to enroll?”

Gambling on Life

The Hollywood Gossip is a celebrity site that devotes an entire category of posts to eating-disorder gossip. On the site, recently, I found this poll:

Which emaciated star will disappear first?
1) Nicole Richie
2) Kate Bosworth
3) Mischa Barton
4) Paris Hilton
5) Ashlee Simpson

Games: Simon Says, Monopoly, Spades
Not Games: Taking bids on people’s lives

Body Innocence

A while back, I posed the question, “How far back do you have to go to arrive at a time when you weren’t aware of your body?” To frame the question differently, I’m curious when we lose, what I call, our “body innocence.” Body innocence has to do with knowing what your body can do, knowing what you look like, but not being “aware” of your body—not judging your appearance, not worrying about what you’re eating, not checking yourself in the mirror, or weighing yourself repeatedly. Body innocence is accompanied by cognitive innocence of all things diet and weight-related. Becoming body aware (versus innocent) does not necessarily lead to an eating disorder; however, this is often the first step down a windy, insidious path.

What causes us to lose our body innocence? A starting, and certainly not comprehensive, list:
1) An unsuspecting comment by a family member, friend, or peer
2) A purposely cruel comment by a family member, friend, or peer
3) Losing some weight unintentionally and being consequently reinforced by
others
4) Realizing ourselves that we’re not as skinny as other children
5) Being involved in a weight-dependent activity, such as ballet, gymnastics,
cheerleading, or ice skating (let’s not even say, “figure skating”)
6) Exposure to constant media messages about unnaturally thin celebrities
7) Exposure to constant media messages about the dangers of being
overweight
8) Exposure to constant media messages that promote diet pills, plans, and procedures
9) Exposure to family members, friends, or peers, who aren’t body innocent
10) Abuse