Oregon researchers develop counseling approaches that reduce anorexia, bulimia and obesity among young women — apparently for years.
If an alien were to tune in to an Earth television broadcast, it would gain an impression of humans as very thin yet very muscular, with prominent cheekbones and jaw lines, sculpted torsos and long, shapely legs. If the alien then landed on the street of nearly any American city, it would be in for the shock of loose clothing and guts peeking out from under T-shirt hems. This extreme discrepancy — between the norm of form and figure and what our culture and media offer up as the ideal — is the source of much emotional pain and huge social costs.
The conventional wisdom is that fatness is a simple function of the first law of thermodynamics: There must be a balance between energy intake (food) and energy expenditure (exercise). And in America, it is deeply and widely held that anybody out of balance on the intake side is a slovenly weakling. Thin people must be stronger, smarter and more disciplined than the fat. As the saying goes, "You can never be too thin or too rich."
Experts know, though, that many factors influence the thermodynamic equation, including mood, self-image, genetics, chemical exposure, brain chemistry and cultural norms. And there is a connection, not yet fully understood, between the pressure to be thin and the perception of being fat. In some people, primarily young women, negative body images give rise to extreme attempts to conform to the "thin ideal of female beauty."
Science has thus far failed to find preventions or cures for obesity or eating disorders. But a simple and inexpensive treatment may transform the landscape. Clinical psychologist Eric Stice and his colleagues at the Oregon Research Institute in Eugene have developed two group-counseling interventions that reduce the risk for eating disorders and obesity. If the interventions can be refined and widely disseminated, Stice says, "we could reduce the health care expenses in America by a very big amount."
The ORI study recruited 481 female high school and college students who felt dissatisfaction with their bodies — a purposely nonspecific criterion — but who did not have an eating disorder and were not obese. As reported in the April Journal of Consulting and Clinical Psychology, the participants were divided into four groups. In one of two experimental groups — called the healthy-weight intervention — the subjects learned about metabolism, nutrition and exercise and were encouraged to think carefully about what they ate, rather than taking an easy but unhealthy option (such as having a pizza delivered to the dorm instead of going to the cafeteria salad bar).
In the other experimental group — known as the dissonance intervention — counselors led participants through a script designed to induce cognitive dissonance. A technique in widespread clinical use as a treatment for a number of psychological disorders, cognitive dissonance is a mental state in which a person realizes that there is a logical conflict between a belief and a behavior. Thus, if girls aspire to the thin ideal but simultaneously understand that is actually unattainable and will not make them happy, they run head-on into cognitive dissonance. For this study, the dissonance-group participants came up with arguments against the thin ideal; role-played a conversation they might have with a younger girl to dissuade her from trying to attain the thin ideal; and took a variety of actions related to society's judgment of thinness, such as placing anti-thin-ideal posters in school bathrooms and confronting peers who bullied or teased others about fatness. There were also two control groups in the experiment whose activities were not designed to control obesity or eating disorders directly.
Each of the four groups met for only three one-hour sessions, with follow-up interviews at six months and then annually for three years. Participants' current behaviors and emotional states, as well as their risk of developing an eating disorder, were evaluated in the follow-up interviews via standardized psychological tests. Even after three years both experimental groups showed striking differences from the controls: In the healthy-weight group, there was a 61 percent reduction in the risk of developing an eating disorder and a 55 percent reduction in the risk of obesity; in the dissonance group, there was a 60 percent reduction in the risk of developing an eating disorder.
Anorexics starve themselves. Binge eaters overeat to an extreme degree. Bulimics binge and then purge by vomiting or using laxatives. Although not everyone who is obese has an eating disorder, binge eating, Stice says, is a "huge driving force of obesity." Anorexia, bulimia and obesity all pose huge health risks and exact huge health costs from the economy.
According to the World Health Organization, in 2005, there were approximately 1.6 billion overweight adults worldwide, including 400 million obese adults. Obesity is a risk factor for most of the killer diseases of modern industrialized nations, including cardiovascular problems, cancers and diabetes.
About 3 percent of the U.S. population — that is, some 9 million people — are binge eaters, 1 to 3 percent are bulimic and 0.3 to 1 percent are anorexic, according to the Academy for Eating Disorders, a nonprofit professional organization based in Deerfield, Ill. The percentage of the population with subclinical and/or intermittent manifestations of these disorders is unknown but estimated to be much higher. Up to 20 percent of young women engage in "unhealthy patterns of dieting, purging and binge-eating," the academy says. Left untreated, about 20 percent of people with serious eating disorders die, according to Anorexia Nervosa and Related Eating Disorders Inc.
While eating-disorder therapies seek to relieve sufferers of the shame and excessive sense of guilt for what appears to be compulsive behavior, the underlying theory still relies on that pesky law of thermodynamics. The field has yet to address emerging evidence that environmental exposures, especially in the womb, can affect appetite and metabolism. "The bottom line is if you're overweight, you're not balancing input and output," Stice says.
Yet a number of studies have shown that prenatal chemical exposures can lead to adult-onset obesity independent of energy intake and expenditure. For example, a study by Retha Newbold, a researcher in the Laboratory of Molecular Toxicology of the National Institute of Environmental Health Sciences, found that mice exposed to diethylstilbestrol in the womb or as newborns became obese even though they ate and exercised as much as the control mice. And molecular biologist Bruce Blumberg of the University of California, Irvine has shown that prenatal exposure to the hormone-disrupting chemical tributyltin produces a propensity toward obesity in mice.
These studies have convinced Blumberg that exposure to certain environmental chemicals or estrogen "permanently alters the way an individual processes calories such that there is a predisposition to weight gain." Failing to account for the profound effects of such environmental influence on an individual's weight fate is "to put one's head in the sand," Blumberg says.
Some psychologists and psychiatrists, meanwhile, are exploring brain chemistry to identify mechanisms driving the painful emotional states of people with eating disorders. In brain imaging studies, Walter Kaye, a psychiatrist at the University of California, San Diego and a board member of the National Eating Disorders Association, has found that serotonin receptors in brain regions involved with the experience of reward may be faulty in people with eating disorders. Stice also has data from a functional magnetic resonance imaging study now under peer review that shows obese subjects are deficient in the neurotransmitter dopamine, which regulates motivation, emotion and the experience of pleasure.
With the chemical and theoretical underpinnings in flux, many mental health professionals believe that proving the causes of compulsive eating behaviors and obesity is less important than finding ways to stop them. The cognitive dissonance approach appears to be extremely effective. Moreover, the protocol for facilitating a dissonance group is easy to learn. According to Stice, the dissonance program has been replicated in seven other labs and been administered by school nurses. "Real world school staff can recruit (participants) and lead this intervention, and it seems to work," Stice says.
Carolyn becker, an associate professor of psychology at Trinity University in San Antonio, Texas, has taught the dissonance protocol to undergraduates who have successfully led interventions with peers who have eating disorders. She has also hit upon an effective method of distributing the treatment to the adolescent and young adult women at highest risk of developing eating disorders: She's taught it in sororities. First she worked with sororities at Trinity University; the response was so positive that some of them now require the training every year for new pledges. About three years ago, the national organization of Delta Delta Delta (Tri-Delt) became interested in the intervention and now runs the program at a dozen chapters across the country.
Becker sees sororities as an ideal network for distribution of the dissonance method of preventing eating disorders, not because sororities are full of women with anorexia and bulimia but because they are strongly bonded national networks that encourage members to serve the wider community. The Tri-Delts are contemplating deploying members trained in the program to high schools to intervene earlier against the thin ideal and warn young women about the torment of body image shame. One 16-year-old girl liked her experience in the ORI dissonance group because "they were trying to tell girls it's OK to be who they are, and they don't need to be super skinny. I think a lot more people should (experience the intervention) if they have any concerns."
Although further research will presumably refine and clarify the way the healthy-weight and dissonance interventions exert their apparently long-lasting effects, Stice confesses to feeling very excited about his results to date. "There's reason for optimism with regard to preventing the onset of obesity and eating disorders," he says. "Three years ago, I had a lot less confidence in that ever working out."
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