Dieting and Risk for Eating Disorders
Garner, D.M. (2008). Women and dieting. (pp. 801-805). In K. Keller (ED.), Encyclopedia of Obesity, Sage Publications, Inc.
The impetus for dieting among women appears to have several key sources. First is the concern regarding the increasing prevalence of overweight and obesity and associated health risks observed in many countries. This source has led to public health campaigns to remedial or prevention efforts by recommending limiting caloric intake. The second motivation is the pursuit of improved health. A third, more pernicious, motive is the mounting pressure on women to be thin in order to meet cultural ideals for physical attractiveness. The mass media’s emphasis on ultra-thinness as a standard for beauty in Western culture has been linked to the high prevalence of body dissatisfaction and restrictive dieting among adolescent girls and women. It is well documented that individuals who are dissatisfied with their body weight are at a significantly higher risk of developing eating disorders. Along with the pervasiveness and risks of dieting, there is also evidence that weight-loss efforts may backfire by leading to mental and physical and health problems as well as higher weights over time. Ironically, rather than a solution to obesity, dieting may actually be one of the causes. Since restrictive dieting is the standard treatment recommendation for overweight and obese individuals, consideration of the potential risks of dieting is of utmost importance in a comprehensive volume on the topic of obesity.
The term “dieting” can have different meanings. It can refer to attempts to limit certain types of foods for medical or health reasons (e.g. dairy products in lactose intolerance) with no intent of weight loss, or it can denote restricting amount eaten for the purpose of weight loss. Dieting can refer to behaviors designed to lose weight or, “cognitive restraint,” where the individual has a clear intent to lose weight, but this may not be evident in specific behaviors. Finally, dieting in an attempt to lose weight can be defined as “healthy,” such as moderate limitation of food intake, or “unhealthy,” such as fasting, vomiting, etc. The term “dieting” will be used in this chapter to denote the intent to restrict food intake in order to reduce body weight without designating whether or not the behavior is “healthy” or whether or not it actually results in weight loss unless these factors are specifically relevant to the topic of discussion.
Dieting and Culture
One of the strongest predictors of dieting in preadolescents, adolescents and adult women is body dissatisfaction. Body dissatisfaction and dieting behaviors have been fostered by a clash between unrealistic cultural imperatives to be thin and biological realities that preclude most women from ever achieving the shape standards portrayed in popular women’s magazines. In the past 50 years, the perceived cultural ideals of feminine beauty have become even thinner with the burgeoning dieting and weight loss industry successfully marketing the vision that ultra-thin shape ideals are attainable. This is evidenced by the industry’s annual revenues in North America, which are estimated between $35 and $50 billion. There is compelling evidence that women in Western culture increasingly have been socialized to view their body weight or shape as a marker for attractiveness, self-esteem, social desirability and competence. The impact of Westernization and globalization has propagated the gaunt standard of beauty to non-Western countries and has, coincidentally, led to the proliferation of dieting and dieting disorders. Studies have shown that as young women from other more weight-tolerant cultures (e.g., Egyptian, Japanese, and Chinese) are assimilated into “thinness-conscious” Western culture, weight concerns and dieting behaviors in the previously weight-tolerant cultures increase.
Pervasiveness of Dieting
The pervasiveness of body dissatisfaction and dieting among adolescent girls and women in Western culture is remarkable because it reflects normative discontentment with an aspect of physical appearance that has also been shown as integral to feelings of self-worth. Research has shown that body dissatisfaction and weight-control behaviors are more prevalent in girls than in boys, and that these attitudes and behaviors peak during adolescence when girls experience conspicuous changes in body fat and shape. Studies indicate that 70%-85% of female adolescents and college students want to lose weight. Almost 50% of 14-year-old girls compared to about 20% of boys are actively trying to lose weight. These seeds of discontentment begin even earlier with studies documenting body dissatisfaction in children as young as 6 years old, an age much before they reach pubertal milestones. Then, rather than subsiding in adulthood, concerns about body weight appear to intensify; however, there is some evidence that actual attempts to lose weight may diminish over time along with a decline in disordered eating patterns.
Body Mass Index (BMI) and Dieting
BMI is one of the most robust predictors of body dissatisfaction and dieting among women. High levels of weight concern are reported in almost 60% of women with a BMI of 25 or higher compared to about 25% of women with a BMI between 19 and 24.9. Also of interest, more than 10% of women with a BMI less than 19 report very high levels of weight concern. Studies indicate that between 40% and 60% of high school and college women tried to lose weight in the previous year. Dieting is not uncommon among women who are in the normal weight range and is reported among the 10%-15% of college students who are objectively underweight (BMI less than 19). Interestingly, more than 10% of women who report being contented with their weight still indicate they are trying to lose weight. Several studies have found that perceived weight status is a better predictor of extreme dieting methods than actual body weight. It is important to emphasize that measures of body dissatisfaction and dieting have different clinical significance for individuals at different weights. For example, patients with anorexia nervosa and nonclinical college women report similar levels of body dissatisfaction on standardized measures; however, the patients are emaciated compared to the average college student. Although a significant proportion of both groups describe being relatively satisfied with their weight, the anorexia nervosa patients are satisfied with a clearly aberrant body weight. Nevertheless, the potential clinical significance of high levels of body dissatisfaction and obsessive dieting among women at the heavier end of the weight spectrum should not be dismissed, since these behaviors may be associated with clinical levels of emotional distress.
Dieting and Eating Disorder Risk
It could be argued that the high percentage of women who are dieting may reflect that this behavior is relatively benign. However, the evidence does not support this view. Prospective studies indicate that body dissatisfaction and restrictive dieting are powerful predictors of the development of full-blown eating disorders as well as partial syndromes characterized by dangerous weight-controlling behaviors such as self-induced vomiting, fasting and laxative abuse. The magnitude of this risk is considerable. 15-year-old girls classified as “dieters” have an eight times higher risk of developing an eating disorder compared to “non-dieters,” and the risk is about 18 times higher for those classified as “severe dieters.” The starting point for risk can be traced to maternal eating behavior. Prospective studies of mothers and their newborns indicate that maternal dieting and eating disorder symptoms are strong predictors of the development of early childhood eating disturbances.
However, we should be aware of the risk of oversimplifying the relationship between body dissatisfaction, dieting and eating disorders. Other variables such as media exposure to thin-ideal body stereotypes, internalization of the thin ideal, social comparison, low self-esteem, lack of family support and perfectionism have been shown to improve the prediction of both body dissatisfaction and dieting. For example, perfectionistic women who perceive themselves as overweight engage in extreme dieting and bulimic symptoms more often if they have low self-esteem. They seem to doubt their ability to achieve their high standards. In contrast, perfectionistic women with high self-esteem seem to be protected from severe dieting and bulimic symptoms. Studies of Eating Attitudes Test (EAT-26) results from normal twin pairs have also provided evidence for a substantial genetic contribution to body dissatisfaction and eating concerns.
Finally, understanding the role of dieting as a risk factor for eating disorders must reconcile the fact that trying to lose weight is endemic to young women in Western culture; however, it leads to the expression of eating disorders in only a small fraction of the population. This observation could also be used to minimize the risks associated with dieting, but rather is should be equated to the association between cigarette smoking and cancer. The risks of dieting are real and should be treated as such.
Epidemiological studies of dieting have consistently found that body dissatisfaction is more common among women than men. Moreover, the form, substance, and behavioral correlates of body dissatisfaction appear to be different in men and women. Men are concerned with muscularity as well as body size and many men who are dissatisfied with their weight want to gain weight rather than lose. Men who do perceive themselves as overweight tend to use exercise and healthier dieting patterns than women. Nevertheless, there is evidence that body dissatisfaction and unhealthy dieting patterns are becoming more common among adolescent boys and adult men.
Racial and Ethnic Differences
Research has indicated that there are racial and ethnic differences in body dissatisfaction and dieting in Western culture. Historically, weight concerns, dieting and eating disorders have been attributed to primarily white, middle class women; however, it is now well recognized that the pattern of racial and ethnic associations is more complex. Although generalizations must be made with caution, weight concerns appear to be less common among African Americans than among Caucasian and Hispanic women. Asian women show the fewest concerns and Native Americans show the most. The same pattern of findings applies for dieting. Of interest, although African American women report less body dissatisfaction and dieting than other groups, they report binge eating more often. While racial and ethnic differences in body dissatisfaction and dieting do exist, it is important to be mindful of generalizations that could minimize the significance of attitudes and behavior reported by minorities.
Emerging research has shown that body image may be improving, possibly decreasing the risk of unhealthy dieting behaviors. In an article published by Cash and colleagues, it is suggested that body image in college-aged women is currently evolving positively. The study spanned nineteen years and evaluated body image using several different measures. Using the data collected, it was determined that although there was a significant decline in body satisfaction from the early 1980s until the mid 1990s, this decline began to reverse in the mid 1990s, causing an overall increase in body satisfaction at the last point of evaluation.
Prevention of Eating Disorder Risk
There are a number of promising programs found to decrease risk factors for eating disorders such as body dissatisfaction and dieting. In general there are more positive findings for programs that are interactive versus didactic, multisession versus single session, and with participants older than 15 years of age with high levels of weight and shape concerns. Barr Taylor and colleagues report impressive results from an 8-week, Internet-based cognitive-behavioral intervention, and the improvements remained significant at one-year follow-up.
Ineffectiveness of Dieting
The steadily increasing prevalence of obesity in developed countries continues to be a major health concern. The promotion of various forms of dieting as a solution to obesity has remained popular in the absence of evidence for long-term effectives except for a small minority of cases. Participation in weight loss programs usually results in small to moderate amounts of weight loss followed by regain. Moreover, continued participation in weight loss programs is associated a pattern of weight loss and regain (“weight cycling”). The health effects of weight cycling remains controversial; however, animal studies have indicated that weight cycling may increase metabolic efficiency, insulin resistance, blood pressure, and the consumption of dietary fat. Epidemiological studies of humans have linked weight cycling to increased mortality risk. Even in the absence of serious health consequences, it would be imprudent to underestimate the effects of guilt, shame and self-disparagement following failed attempts to maintain weight loss as well as the significance of the economic burden associated with participation in weight loss programs.
The high prevalence of dieting, weight concerns and obesity among adolescents as well as their potentially serious physical and psychological consequences, has raised questions regarding the possible effects of dieting on unintentional weight gain. Again, this is a controversial area with inconsistent findings across studies. However, more recent longitudinal research has found that dieting not only is associated with the development of severe weight control behaviors but also with weight gain. A recent 5-year follow-up study by Dianne Neumark-Sztainer and colleagues found that dieting and particularly unhealthy weight control behaviors predicted subsequent weight gain, overweight status, binge-eating, extreme weight control behaviors, and the onset of eating disorders. Moreover, even behaviors commonly recommended as part of healthful weight management (e.g. increasing fruit and vegetable consumption and physical activity) were not predictive of greater weight control five years later. More than half of female adolescents and one quarter of male adolescents were dieting at the onset of the study. The pervasiveness of serious health consequences and the paradoxical association with weight gain over time rather than weight loss mean that dieting cannot be considered as either innocuous or as a “conservative” approach to health. Taken together, these findings suggest the need for a major shift in thinking about the advisability of recommending dieting for weight control.
Alternatives to Dieting
If chronic restrictive dieting has untoward effects, what are the alternatives for those with obesity or eating disorders? Details of the available alternatives go beyond the scope of this chapter; however, alternatives to the restrictive dieting approach to obesity have moved from the unorthodox (described by David Garner and Susan Wooley in 1991) to the mainstream (National Institute of Diabetes and Digestive and Kidney Diseases publications available at http://win.niddk.nih.gov/publications/index.htm). The new paradigm for the management of obesity more recently described a special issue of the Journal of Social Issues in 1999 and introduced by Jeanine Cogan and Paul Earnsberger emphasizes trying to improve the health and well-being of individuals who are obese without requiring restrictive dieting or weight loss. The main principles involve increasing activity and making healthful food choices within the context of “fat acceptance” (see Miriam Berg, this volume).
Individuals with eating disorders typically engage in an extreme form of dietary restraint characterized by rigid dietary rules that constitute extreme interpretations of sensible dietary guidelines. For instance, red meat may be excluded altogether, not just minimized; dietary fat and sugar may be totally eliminated rather than reduced; only food considered “not fattening” is permitted; food intake is limited to 800 Calories a day; food will not be consumed after 7:00 p.m. Deviating from these highly restrictive dieting rules is usually met with intense anxiety. Psycho-education may be used to correct these nutritional myths; however, a form of structured meal planning is usually required to assist in graded exposure to fears associated with eating certain types and amounts of food. Meal planning involves a detailed written plan specifying meal times as well as the exact types and amounts of food to be consumed. It is an important first step in assisting those with eating disorders to overcome highly restrictive eating patterns.
Jeanine C. Cogan and Paul Earnsberger (1999). Dieting, Weight, and Health: Reconceptualizing Research and Policy. Journal of Social Issues, 22(2), 187-2
C. Barr Taylor, et al (2007). Prevention of Eating Disorders in At-Risk College-Age Women. Arch Gen Psychiatry, 63, 881-888.
Alison E. Field, Todd F. Heatherton, Pamela Keel, Fary Mahamedi and Meg Striepe (1997). A 10-Years Longitudinal Study of Body Weight, Dieting, and Eating Disorder Symptoms. Journal of Abnormal Psychology, 106 , 1-9.
Thomas F. Cash, Joshua I. Hrabosky, Jennifer A. Morrow, and April A. Perry (2004). How Has Body Image Changed? A Cross-Sectional Investigation of College Women and Men From 1983 to 2001. Journal of Consulting and Clinical Psychology, 72, 1080-1089.
David J. Dorer, Todd F. Heatherton, Thomas E. Joiner, Pamela K. Keel, and Alyson K. Zalta (2006). Point prevalence of bulimia nervosa in 1982, 1992, and 2002. Psychological Medicine, 36, 119-127.
Lyn Y. Abramson, Anna M. Bardone, Thomas E. Joiner, Jr., and Kathleen D. Vohs (1999). Perfectionism, Perceived Weight Status, and Self-Esteem Interact to Predict Bulimic Symptoms: A Model of Bulimic Symptom Development. Journal of Abnormal Psychology, 108(4), 695-700.
Jeff Gau, Katherine Presnell, Heather Shaw, and Eric Stice (2007). Testing Mediators of Intervention of Effects in Randomized Controlled Trials; An Evaluation of Two Eating Disorder Prevention Programs. Journal of Consulting and Clinical Psychology, 75, 20-32.
Marla Eisenberg, Jess Haines, Dianne Neumark-Sztainer, Mary Story, and Melanie Wall (2006). Obesity , Disordered Eating, and Eating Disorders in a Longitudinal Study of Adolescents: How do Dieters Fare 5 Years Later? Journal of the American Dietetic Association, 106, 559-568.
Corinna Jacobi, Chris Hayward, Martina de Zwann, Helena C. Kraemer and W. Stewart Agras, d (2004). Coming to Terms with Risk Factors for Eating Disorders: Application of Risk Terminology and Suggestions for a General Taxonomy. Psychological Bulletin, 130, 19-65.
Active at Any Size National Institute of Diabetes and Digestive and Kidney Diseases NIH Pub No. 04-4352 available at http://win.niddk.nih.gov/publications/active.htm
David M. Garner Psychoeducational Principles in Treatment. In David M. Garner & Paul E. Garfinkel (Eds.), Handbook of Treatment for Eating Disorders (pp. 145-177), New York: Guilford Press.
David M. Garner and Susan C. Wooley, S.C. (1991). Confronting the Failure of Behavioral and Dietary Treatments for Obesity. Clinical Psychology Review, 11, 729-780.
Dianne Nuemark-Sztainer, Melanie Wall, Mary Story, Jess Haines and Marla Eisenberg. Obesity, Disordered Eating, and Eating Disorders in a Longitudinal Study of Adolescents: How do Dieters Fare 5 Years Later. Journal of the American Dietetic Association, 2006, 106, 59-568.
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