Psychology of Nutrition and Health

A causal model

The view that mental factors may affect health has long been enshrined in the notion of psychosomatic illness. Asthma, ulcers and migraine are examples of conditions in which psychological causative factors are presumed to dominate. However, this division into somatic and psychosomatic disguises what is increasingly regarded as the true picture.

It is now fair to say that the role of psychological factors in health is conceived very much more broadly, to the extent that the somewhat mechanical, largely physical approach to health and illness that characterises the medical profession looks increasingly out dated.

Totman (1979, 1982) proposes the “social functioning” of the individual is crucial to health. For example, the focus on the importance of life events for health, and the role of social networks in sustaining recovery from psychiatric illness, illustrate the importance of adequate interpersonal and social relationships to both physical and mental health. Life events like taking a new job or moving house are associated with subsequent ill health, both physical (Dohrenwend and Dohrenwend, 1974) and psychiatric (Brown and Harris, 1978).

Within a given social network, people agree on what they would like individually to achieve and they know in what way it is appropriate for them to attain these goals. This set of knowledge, Totman refers to as “social rules”. However, not everyone abides by and conforms to social rules. Inconsistencies in the co­ operation of all society to support and socialise increase susceptibility to illness particularly mental health illness, whereby individuals can be ostracized by society: Illness, on this view, is facilitated by social breakdown.

Behaviourally induced coronary heart disease (CHD)

The working environment contains many potential stressors, that is, factors that can cause individuals to feel under pressure create tension, anxiety, poor performance, and consequent ill health. Physical conditions, unrelenting job demands, role conflict and intergroup conflict have all been shown to cause symptoms of stress. Although it should be noted that people vary in their responsiveness to such externally induced demands (Altman, Valens and Hodgets, 1985). There is, in addition, good evidence that suggests excessive internally induced demands may predispose ill health and CHO in particular.

Friedman and Rosenman (1959) defined a coronary “type A” behaviour pattern, which apparently was strongly associated with the incidence of CHO. Matthews et al (1977) suggest that the key coronary prone behaviours are low frustration threshold, irritability and hostility, impatience, competitiveness and energetic voice style. The significant fact about coronary prone individuals is, according to Totman’s analysis, that they are out of line with their fellow counterparts in society and they make demands on themselves, which make a socially integrated life difficult to attain. They suffer chronically that sense of failure, which is reflected in their tendency to evoke physiological changes, such as high blood pressure.

Dembroski and Macdougall (1982) suggest, however, that changes in attitudes and behaviour in type A people towards a less competitive and abrasive life style are effective in reducing the risk of ill health, at least to the extent that physiological measures associated with CHO are responsive to changes in the perceived quality of social relationships

There are of course many problems and flawed methodology associated in trying to assess the levels of stress or ill health upon individuals that can be induced from external forces. However, there are certain effects upon one’s mental and physical health.

general apathy toward physical activity, new strategies have been introduced to try to encourage active participation in a variety of activities.

It is clear that a variety of factors can influence our lifestyle, food choices and habits, but none more so than the media.

PSYCHOLOGICAL FACTORS THAT INFLUENCE BEHAVIOUR IN RELATION TO DIETARY INTAKE. MEDIA

The media seek to inform us, persuade us, entertain us, and change us. The media also seeks to engage large groups of people so that advertisers can sell them products or services by making them desirable. Other institutions such as Governments also engage the public via the media to make ideas and values desirable. Institutions from politics to corporations can use the media to influence our behaviour. There are multitudinous ways in which information passes to us especially with the increase in sophisticated media providers, such as email and the internet. The argument about whether the media shape society or merely reflect current or nascent trends is constantly under debate.

There is no doubt that the ideal body size, as reflected in the style icons promoted in the media, is getting thinner. This ideal body size epitomised by ‘Gerri Halliwell’, ‘Posh Spice’ or’ Ally Mcbeal’ is unrealistically thin, their BMI (Body Mass Index} is on the borders of what a clinician would regard as anorexic. Due to the proliferation of food in our culture, people are getting bigger, fatter, and maturing younger and younger as the years pass by. The gap between actual body sizes and the cultural ideal is getting wider, and giving rise to anxiety among almost all women, although it is the most vulnerable who are most affected by this.

So is the media to blame? It is hard to separate the influence of the media in the development of eating disorders. Various studies point to the correlation between low self-esteem in young girls and high scores on eating distress measures as they grow.          —

Self-esteem is a dynamic construct, which is influenced by a whole variety of factors such as parenting, childhood experiences, core personality and body image (a person links their self-esteem with how they look physically}, especially in girls. Thus influences on body image will affect self-esteem and promote the risk of developing an eating disorder as a person turns to the control of their body in order to feel acceptable. In this respect the media may contribute to low self-esteem by promoting slenderness as the pathway to gaining love, acceptance and respect while at the same time reflecting a trend in society to demonise fat. When women are asked what they fear most in life, most will cite the possibility of gaining weight. When women are asked what they least like about themselves, most will describe a part of their body (usually stomach, thighs, legs) rather than no physical attributes like laziness or low confidence. Men conversely are more likely to mention non-physical attributes. When women are asked what men find attractive in them, most mention physical appearance. Women thus feel judged by their looks rather than their other resources and feel pressure from many sides to control their weight, from the media, from their peers, from boyfriends, from parents and from the fashion shops that carry clothes in ranges and sizes that suit only the smallest among them.

It is not only in the desire for thinness that the media influences us. You cannot pick up a magazine or paper without there being some article on nutrition, health, what foods are good for you, what foods are bad for you and so forth, even if there is scientific fact to prove it or not. We cannot escape the influence of the media as it both steers and reflects our cultural obsession with how we look and what we put into our mouths.

Eating disorders

What is anorexia nervosa?

Anorexia Nervosa (anorexia) is a state in which the sufferer, usually female, refuses to eat enough to maintain her normal body weight for her height. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV 1994) defines an eating disorder as characterised by:-

The DSM-IV has four criteria:

1. Refusal to maintain body weight over a minimal normal weight for age and height.
2. An intense fear of gaining weight or becoming fat, even though underweight.
3. A disturbance in the way one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation; or denial of the seriousness of the current low body weight.
4. In females, absence of at least three consecutive menstrual cycles when otherwise expected to occur (American Psychiatric Association, 1994).

Anorexia is specifically associated with other feelings and behaviours related to the fear of fatness.

These feelings include: –

• Poor body image
• Fear of fatness
• Under eating
• Excessive loss of weight
• Vigorous exercise
• Monthly periods stop
• Missing meals, eating very little and avoiding fattening foods
• Avoiding eating in public, secret eating
• Becoming preoccupied with food; cooking for others
• Going to the bathroom or toilet immediately after meals
• Using laxatives and vomiting to control weight.

CULTURAL INFLUENCES

Anorexia hardly exists in third world countries where there is barely enough food for survival and where fatness is regarded as a sign of affluence.

Anorexia is rare in countries which have sufficient food but which do not place a value on slimness as a sign of sexual attractiveness.

In the developed world there is a tendency to associate fatness with negative attributes such as lower social or economic status.

Personal inadequacy. This exists together with an overvalued set of positive values toward slimness. Rates of anorexia would appear to increase in such societies in direct proportion to the gap, which emerges between the culturally defined ideal body size and the actual size achieved by its population.

Anorexia is predominantly a female condition, with only one in every 50 sufferers being male. It typically begins in the adolescent girl at or just after puberty, although it can start at any age and can last for many years. It is said that the incidence of anorexia is greater in the higher social groups but it is not confined to these areas.

WHAT IS BULIMIA NERVOSA?

The DSM-IV has four criteria:

• Recurrent episodes of binge eating, characterised by:
• Eating, in a discrete period of time an amount of food that is larger than most people would eat during a similar period or under similar circumstances and a sense of lack of control over eating during the episode.
• Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self­ induced vomiting, misuse of laxatives, diuretics, enemas, or other medications, fasting or excessive exercise.
• The binge eating and inappropriate compensatory behaviours both occur, on average, at least twice a week for three months.
• Self-evaluation is unduly influenced by body shape and weight. (American Psychiatric Association, 1994).

Bulimia Nervosa (bulimia) therefore describes an illness with very specific behaviours. Typically there are regular episodes of binge eating, usually in private, of foods believed to be fattening and therefore in some way forbidden to someone conscious of needing to control her weight. Foods typically eaten during a binge will include biscuits, crisps, chips, sweets, chocolate, ice cream and toast and butter. Eating continues until the urge to eat had stopped, tension is reduced; physical satiation is reached, often to the point of pain, or the person is interrupted.

Food is often eaten quickly without tasting, accompanied by feelings of guilt, anxiety and remorse. Following a binge, but not always immediately afterwards, there will be an attempt to get rid of the calories consumed by either making oneself sick and/or taking laxatives. Some bulimics try to contain their weight by indulging in excessive exercise and additionally starving for periods of time.

Severe bulimics can have devastating effects on their health; the bulimic can eat vast amounts to the point of rupturing the stomach, followed by self-induced vomiting to the point of causing life threatening chemical imbalance. The cycle of binging and purging can occur up to twelve times a day, thus completely taking over one’s life.

Most bulimics see their condition as a breakdown of self-control indicating that they are at best morally weak – lacking will power, and at worst mentally ill. This is likely to be felt most powerfully by people who either dieted very successfully in the past, or who were anorexic and who therefore felt totally in control around food. In most people the emergence of a binge-eating problem is directly related to the effects of dieting because food restriction has far reaching consequences both for the body and mind. Some people respond to the breakdown of control with great dismay and may attempt to vomit after a particular binge, or they try it because ‘they have heard about it’. Vomiting if successful becomes a way of dealing with the guilt one feels after a binge episode.

Professional competence and limitations must be at the forefront of your mind if working with a client with an eating disorder; it is important to put the best interests of your client first, and not try to experiment with your client on unfounded notions of how to “get them better”. So, how do you proceed with your client?

Firstly you may not be certain that your client has an eating disorder; how do you broach the subject? What if you get it wrong and offend your client?

Approach your client from the point of view “I am concerned about your well-being”, or “I feel that your eating and exercise routine may not be helping you to achieve your goals”. This language lets them know you care, but doesn’t say you know how they feel.

Get an “ok” to proceed. Ask your client if they would be receptive to looking at solutions together. This may include a referral to another professional; this does not mean that you have to stop working with your client; on the contrary, clients with an eating disorder need help from a variety of professionals, such as counsellors, nutritionists, and exercise professionals. This is where working in conjunction with other agencies and professionals proves extremely beneficial to the client and extremely rewarding for you.

Your key is to remember your boundaries and know your remit. Do not try to tackle issues that you are not qualified or experienced in; by doing so you may end up causing more harm than good and damaging your reputation as a fitness or health professional.

Managing users with suspected eating disorders

If someone with an eating disorder has managed to become a member of your club and avoided a pre­ activity health screening, or developed an eating disorder once they have become a member, then they are your responsibility.

Do not be afraid to approach someone who you suspect has an eating disorder; it is for their benefit. Even if you are sure that someone has an eating disorder they may not admit this and will probably react badly.

Do not use aggressive language or threaten to take their membership away. Do not ‘try to make them see’ that they are too thin. Do not comment on their weight or appearance. These sorts of actions will undermine feelings of self-worth and reinforce notions of imperfection and poor body image.

Do reinforce their self-worth. Make it known that you are there to support them. Encourage them to contact their GP or to call one of the numbers at the end of this guide. Do not try to take on the role of a therapist or counsellor that is not your job. If the individual is in serious danger then it may be permissible to suspend membership and only return it with a doctor’s approval.

Advise a participant with an eating disorder to contact ABC advice.

• Helpline – 01934 710645
• Website – www.anorexiabulimiacare.co.uk

OBESITY

Without doubt obesity is one of the fastest growing problems within Western society, and it is accelerating at an alarming rate.

Overweight is defined via the body mass index (BMI). The classification for how overweight you are is defined as follows:-

Since 1960 overweight and obesity have increased across all ages, genders and racial and ethnic groups. It is reported that 54.9% of all American adults are now overweight or obese. Perhaps the most worrying factor in overweight and obesity is its advancement in children.

It is commonly reported that huge changes in the Western diet, increasing portion sizes, and the ease of take away and fast foods, are contributory factors in this growing epidemic. If you are overweight or obese the risks to your health are even more prevalent than in persons of normal weight.

HEALTH RISKS ASSOCIATED WITH OBESITY

• Non-insulin dependent Diabetes
• Surgical risk
• Various cancers
• Bone and joint disorders
• Gallbladder stones
• Skin disorders
• Hypertension
• High Cholesterol
• CHO
• Pulmonary disease
• Depression/ Psychological problems
• Pregnancy risk
• Early death

However, labelling overweight and obese people as “overeaters”, or “greedy” or “lacking control” is an extremely simplistic and ignorant attitude to take. Obesity is now being more widely recognised as an eating disorder of some form, for whatever reason.

Experts subscribe to one or other of two theories of weight increase, which we can identify as either the PUSH or PULL theories. The PULL theory suggests that weight is regulated by factors inside the body which pulls food in, for example, lots of hungry fat cells are waiting to be filled – OR the PUSH theory suggests there is something external in the family or the culture which pushes food in.

There is a lot of evidence for the PUSH theory. After all, we live in a culture which celebrates food. Holidays are centred on eating. If you want to celebrate something you don’t take your family to a salad bar. In our culture there are countless opportunities to eat together with countless messages telling you that you will be lacking something important – happiness even – if you do not eat. In addition, we are much more sedentary than we used to be; research states that our sedentary lifestyle compared to that of thirty years ago, accounts for a weight gain of 5-10 lb each year.

There is an evolutionary benefit conferred on people who are able to store fat. In olden times when food was scarce, it was fatter people – those who were able to store fat – who would survive illness and scarcity. Obesity would be rare in those times since periodic shortages made it impossible for weight to be gained progressively. However, although we live in the 21st century our bodies, are still “in the caves” so to speak, because culture has galloped ahead of our biological response to culture. This means that our bodies have not adapted to an environment in which there is plenty of food, therefore weight gain is the resulting factor.

On the family level, the PUSH theory may operate. Some families foster overeating for emotional or cultural reasons, or simply from ignorance. Parents might teach bad habits, like forcing children to clear everything on their plates, eating quickly, or tie-in eating to relaxation such as watching television.

Research indicates that eating in front of the TV may contribute to storing more calories because metabolism slows down when people are in a mild trance state and food energy is less likely to be converted to heat.

Stress is another factor in the external world which might lead to weight gain. It is well known that obese binge eaters are more likely than thin people to eat in response to stress, loneliness or anger. This suggests a “personality led” response to push factors in the environment, and indeed stress driven overeating is more common among deniers/ avoiders. Overeating however is not a symptom of emotional distress – because if this were true the remedy would be to root it out. There are many people with emotional problems who are not overweight; similarly there are many overweight people who try psychotherapy who remain overweight despite addressing their emotional issues. Obviously something else is going on.

EVIDENCE FOR THE PULL THEORY

Fat cell biology

Considerable research is being conducted on the biology of fat cells. Researchers in Sweden recently discovered that people tended to drop out of weight loss programmes – not when they had attained their target weight but when their fat cells had reached normal size. For two people of the same height, this could occur at greatly different weights. This might be so because one person might have more fat cells than the other.

Overweight children and very obese adults are known to have more fat cells than usual. This is called hyperplastic obesity. Fat cells are usually formed at two critical periods of a person’s life – in early childhood and at puberty. We now know that new fat cells can be formed at any time of life if weight is gained rapidly or if fat cells grow to over 50% of their normal size.

Similarly if people try to reduce their weight to the point where their fat cells shrink below their normal size they start to behave as if they are starving (even if they eat fairly well) and they display all the usual symptomology of people with eating disorders – cravings, obsessional behaviour, performing rituals, etc. So there is obviously some kind of biological pressure to keep fat cells at approximately their normal size, even if technically this means that a person may be culturally “overweight”. This provides evidence for the Set Point Theory.

Set point theory

Further support for the PULL effect comes-from the set weight theory. One question that researchers have asked is whether or not we have a biological mechanism which determines what weight we are going to be stable at; and this mechanism will pull food into our mouths (that is by our biological responses to evoke hunger) until we have attained that weight? Also, what of the people who appear on the front covers of slimming magazines reporting they have lost huge amounts of weight? It is well documented that 97% of these people regain all the weight they have lost, “magically” settling to more or less the weight they were before they started dieting. Good evidence for set weight or not? Perhaps, but our environment has a huge effect upon our genetic levels of control, if the food was not available, the weight could not be gained, so is it biology or is it psychology?

Well, undeniably behaviour plays an important part, but research does suggest that we do have a physiological mechanism residing in our fat cells that under normal circumstances keeps our body weight and body fat fairly close to our genetic set point. This mechanism can easily cope with day-to-day fluctuations in our eating habits, very quickly restoring the balance after a weekend of overindulgence or a day of semi-starvation. It has recently been discovered that fat cells produce a hormone called LEPTIN.

Leptin appears to have two main effects:-

• Together with other hormones it helps to regulate our metabolic rate by speeding it up.
• It controls our appetite by acting as a suppressant.

So, when our fat cells are as full as they are genetically set to be, and therefore producing exactly the right amount of leptin, our metabolic rate and our appetite will be normal. When the amount of fat in our fat cells increases they produce more leptin which leads to an increase in metabolic rate, a decrease in appetite and very quickly a restoration of normal levels (that are genetically pre-set) of body fat.

Conversely, when we lose a little weight, even after a day of not eating very much, the amount of fat in our fat cells decreases. They produce less leptin which leads to a decrease in metabolic rate, an increase in appetite and again a return to normal. It seems that this mechanism works well when we listen to our bodies and only eat when we feel hungry. However, as we know, only eating when we are “hungry” does not always occur. We have behavioural control over our eating habits and can easily over-ride physiological signals. We eat for all sorts of reasons that have nothing to do with biological necessity.

When we over-eat over an extended period of time our bodies will continually over-produce leptin. Remember that its purpose is to decrease our appetite and speed up our metabolic rate. If we ignore leptin then our body will soon stop responding to its signals and we will settle down at our new larger body size. What this means is that in order to restore normal desirable body weight we have to do far more than just eat less. We have to:

• Address any underlying psychological problems that made us use eating as comfort or control.
• Re-establish healthy diet and lifestyle patterns that are sustainable for the rest of our lives.
• Learn to listen to our body’s natural signals and messages.

It is clear that there is strong evidence for the set weight theory, but many experts now feel that it is not an exact level of weight that is “set”, but rather a broad band, and the position we take on that band will be affected by our lifestyle, food choices, exercise levels, our age and our gender.

Metabolism

Overweight people often claim that they have a slow metabolism, which we could ascribe to the PULL theory. Food is pulled in but it cannot be utilised (burned). Metabolism is the rate at which we burn energy and is also affected by age, gender, body musculature and exercise levels. There is also a very important component of metabolism that is influenced by the food we eat and by our dieting history. Although there is evidence that overweight children can burn energy at a slower level than slim children (perhaps because slim children feel more comfortable at running around), overweight adults do NOT have slower metabolisms – they have higher metabolic levels consistent with their additional body weight. Note that exercise has a profound effect on metabolism mostly due to changes in cell response to insulin and dieting has a strong effect on metabolic rate.

Genes

Another possible PULL factor is in the genes. Is overweight hereditary? Well yes, it does run in families. 80% of children with overweight parents, will be overweight themselves, compared to only 20% of children with parents who are not obese. But, could it simply be bad eating habits being passed on? Possibly; an adoption study conducted in Denmark compared the weight of adoptees compared to their natural and their adoptive parents. The weight of children as they grew corresponded most closely to their natural parents. Even more interesting were the studies done with identical twins raised apart. Thin separated twins grew up identical in size and weight. Overweight separated twins grew up overweight but there was much more variability in their body size, corresponding to other factors such as environment. From these studies it was estimated that genetics accounts for up to 70% as an influence upon obesity.

GLANDS

Are they a PULL factor? Glandular problems account for less than 5% of cases of obesity.

After looking at all these factors, while we cannot be specific about the causes of weight gain, we can at least dismiss some of the myths about fat people, namely:

• “Fat people are greedy”. There is no evidence that fat people are greedy. Fat people need to eat more than thin people to support higher energy needs due to their additional weight. What is true is that fat people are more likely to turn to food in times of stress than thin people; this may be due to personality factors but we can speculate that due to cultural and social pressures which lead fat people to feel bad about themselves they may be driven into ways of thinking which supports this kind of avoidance behaviour.
• “Fat people are lazy”. Many fat people do not exercise due to feelings of embarrassment and / or discomfort, not simply because they are lazy.
• “Fat people are responsible for their condition”. This kind of thinking is unfair and misplaced.
• Obesity is a complex issue. As is clear from the above discussion there are lots of different reasons and theories for obesity and its cause. It has different physiological and psychological manifestations and cannot be explained by a single label such as “gluttony”. There are no single guaranteed treatment programmes for obesity and individuals must be matched to treatments. Any programme undertaken must be sensitive to personal motivation and the personal factors which affect long term commitment. Without doubt though, a structured low fat diet, an activity and exercise programme, coupled with huge amounts of motivation can prove successful for some overweight and obese people.