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21
Lessons from Eating Disorders

John P. Foreyt,1 G. Ken Goodrick, and Jean E. Nelson

Not Eating Enough, 1995

Pp. 393–409. Washington, D.C.

National Academy Press

INTRODUCTION

Anorexia nervosa, bulimia nervosa, and binge eating disorder are referred to as eating disorders because the most observable symptoms involve pathological behaviors, including binging, purging, and self-starvation. These disorders have seen a dramatic increase in prevalence over the last 25 years in the United States (Strober, 1986). The disorders usually begin in early to late adolescence and are most commonly found in females, although their prevalence in males is not as rare as was once believed. Today, approximately 5 to 10 percent of all eating-disordered patients are male (American Psychiatric Association, 1987). Characteristics of the disorders are the same for both sexes, and there does not appear to be a gender difference in the effects of treatment (Szmukler and Russell, 1986).

Evidence suggests that eating disorders are influenced by physiological factors, familial food habits, sociocultural influences, self-perception, familial interaction patterns, and emotional status (Bemis, 1978; Blundell and Hill,

1  

John P. Foreyt, Department of Medicine, Baylor College of Medicine, Houston TX 77030



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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations 21 Lessons from Eating Disorders John P. Foreyt,1 G. Ken Goodrick, and Jean E. Nelson Not Eating Enough, 1995 Pp. 393–409. Washington, D.C. National Academy Press INTRODUCTION Anorexia nervosa, bulimia nervosa, and binge eating disorder are referred to as eating disorders because the most observable symptoms involve pathological behaviors, including binging, purging, and self-starvation. These disorders have seen a dramatic increase in prevalence over the last 25 years in the United States (Strober, 1986). The disorders usually begin in early to late adolescence and are most commonly found in females, although their prevalence in males is not as rare as was once believed. Today, approximately 5 to 10 percent of all eating-disordered patients are male (American Psychiatric Association, 1987). Characteristics of the disorders are the same for both sexes, and there does not appear to be a gender difference in the effects of treatment (Szmukler and Russell, 1986). Evidence suggests that eating disorders are influenced by physiological factors, familial food habits, sociocultural influences, self-perception, familial interaction patterns, and emotional status (Bemis, 1978; Blundell and Hill, 1   John P. Foreyt, Department of Medicine, Baylor College of Medicine, Houston TX 77030

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations 1990; Brewerton et al., 1989; Bruch, 1973, 1977; Garner et al., 1982; Halmi et al., 1991; Pike and Rodin, 1991; Rosman et al., 1977; Strober, 1981; White and Boskind-White, 1981). Eating disorders may develop as the result of developmental processes that cause the individual to place an undue importance on physical appearance as a way to obtain love and to feel in control (Bruch, 1978). This emphasis on appearance is part of modern Western culture, and it is often reinforced by parents. The need to obtain love may be exaggerated by a rigid or nondemonstrative family of origin. The need for control may be exaggerated by the emphasis on control in a rigid family or by the inability to control other aspects of life (Bruch, 1973). The resulting focus on appearance leads to a fear of becoming fat. Along with this fear a distorted body image may develop, so that people with eating disorders perceive themselves to be fatter than they really are (Crisp and Kalucy, 1974; Warah, 1989). The fear of fat and body image distortion usually lead to dieting, which may lead to binging. Binging may lead to obesity with binging (binge eating disorder) or to a more normal weight with binging and purging (bulimia nervosa). Some dieters may be able to achieve a state of self-starvation, either with or without some binging (anorexia nervosa). Thus, while objective criteria for diagnosis remain observable eating and purging behaviors, the dynamics of the disorders involve self-esteem and body image. To complicate matters, the pathological behaviors may alter physiological functions, which in turn may affect emotional and cognitive functioning (Garfinkel and Garner, 1982; Mitchell et al., 1991). Therefore, both the diagnostic criteria and the dynamics of the eating disorder should be taken into account simultaneously so that the behavioral, cognitive, affective, and social manifestations of the disorder can be put into a conceptual whole. The eating disorder that will be emphasized here is anorexia nervosa, since the dynamics of anorexia nervosa most closely resemble the reduced energy intake manifested by military troops in field operations. The symptoms of anorexia nervosa may be experienced by ''normal" individuals but to a less serious degree and only for short periods of time. For example, most Americans have a fear of becoming fat or fatter and have a desire to feel in control of their eating. Most women and many men wish they were thinner. To the extent that normal troops have some of the same dynamics, a study of anorexia nervosa may provide lessons for preventing self-inflicted undernutrition in field situations. ASPECTS OF EATING DISORDERS Eating disorders vary in the criteria required for diagnosis; however, there are several common psychological themes. These include:

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations extreme fear or disgust of being fat; low self-esteem, exacerbated by a hypercritical body image, and failure to control eating habits and weight; the belief that self-worth hinges on bodily appearance; perceived blocks to developing interpersonal relationships due to negative self-image—the feeling of isolation associated with eating disorders; and the intrapunitive nature of exercise and other abusive purging techniques—the feeling that self-punishment is deserved for failure to control eating or weight (Garfinkel and Kaplan, 1986). Because anorexia, bulimia, and binge eating disorder all have overlapping symptoms and often occur in the same people (about half of all anorectics also have bulimia, and approximately 40 percent of bulimic patients have a history of anorexia [Eckert, 1985; Mitchell and Pyle, 1985]), the various causes of the disorders are also shared. Familial Factors Eating disorders are the products of multiple influences. One of the most important of them is the family, for it affects the individual's development of self-concept, values, food and eating patterns, and personal standards. Several studies involving first-degree relatives of anorectic women have suggested that eating disorders run in families. Specific ways in which the family may affect eating disorders have been suggested by various clinicians and theorists (e.g., Bruch, 1973, 1977; Pike and Rodin, 1991; Rosman et al., 1977; White and Boskind-White, 1981). In many families, the presymptomatic anorexic child is frequently perceived as the "pride and joy" of the brood, often characterized by parents as being well behaved, achieving, and perfectionistic (Halmi et al., 1977). Some researchers (e.g., Bruch, 1978; Rosman et al., 1977), however, suggest that many of the anorectic traits are engendered by the particular interactional patterns and values of the families involved. Bruch (1977) noted that among families of anorectic patients, parents tended to be overprotective, overconcerned, and overambitious. Within this setting, she noted that obedience and superior performance of the children were a concomitant expectation. Biological Factors Abnormalities in the production and regulation of the hormones and neurotransmitters in the brain that control appetite and food intake have been the subject of much research in recent years. Some studies have found low

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations concentrations of the metabolites of serotonin and norepinephrine in subjects with anorexia and low concentrations of serotonin in subjects with bulimia (Blundell and Hill, 1990; Brewerton et al., 1989). These neurotransmitter disturbances are similar to those found in clinically depressed subjects, and, indeed, antidepressant drugs that alter the effects of serotonin and nor epinephrine seem to decrease the frequency of binging in bulimic patients (Hughes et al., 1984; Pope et al., 1983; Stewart et al., 1984). It is estimated that women diagnosed with major depression have twice the average lifetime rate of bulimia and eight times the average rate of anorexia; from 40 to 80 percent of anorectic patients have been or are seriously depressed (Eckert, 1985). Behavior, Mood, and Personality Factors Behaviors are the external manifestation of the eating disorder; their nature and frequency largely define the severity of the problem. Examples of these behaviors include binge eating, vomiting, limited food intake, excessive exercise, and strange food-related rituals (e.g., order of food consumption, insistence on a specific place setting, lists of "forbidden foods," and regular departures to the bathroom after meals). Strober (1981) studied the etiology of bulimia in anorexia nervosa and found significant behavioral differences between bulimic and nonbulimic patients. Primarily, his results indicated that the family life of the bulimic anorexic is more tumultuous, conflict ridden, and negative in comparison to that of the nonbulimic. Bulimics also seem to have greater tendencies to impulsive behaviors: drug use, alcoholism, stealing, and self-mutilation (Casper et al., 1980; Garfinkel et al., 1980; Wilson, 1991). In contrast to the typical view of the anorectic as introverted, the bulimic variation is likely to be more socially and sexually active (Casper et al., 1980; Johnson, 1982; Russell, 1979). There appears to be a significant comorbidity of the affective and anxiety disorders with anorexia nervosa (Halmi et al., 1991). Although personality disorders, especially borderline personality disorder, have been though to be associated with bulimia nervosa, the relationship is not clear since personality trait scores may change so that such a diagnosis cannot be made after treatment for bulimia (Ames-Frankel et al., 1992). A recent study reported significantly higher rates of major depression, panic disorder, borderline personality disorder, and avoidant personality disorder among subjects with binge eating disorder (Yanovski et al., 1993). A number of psychological traits characterize the anorectic, including shyness, anxiety, and obsessive-compulsive behaviors (Bemis, 1978). These characteristics, although the source of much inner turmoil, are frequently manifested in outward behaviors such as orderliness and high achievement, which are viewed positively by family and friends.

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations Cognitive Factors Most, if not all, who suffer from an eating disorder have a structure of dysfunctional cognitions that exists in association with their aberrant eating behaviors. Body image in anorexia is one of the most powerful examples of how distorted cognitions can influence the cause and course of an eating disorder. The anorectic perceives his or her body as too large regardless of the degree of thinness achieved (Warah, 1989). Because this distortion does not diminish with weight loss, it persists as a relentless incentive. Bruch (1973) noted that this disorder is not "cured" until the body image misperception has been corrected, even if substantial weight gain has been achieved in therapy. Examples of cognitive distortions have been reported for anorexia nervosa (Garner et al., 1982), binge eating (Loro and Orleans, 1981), and obesity (Mahoney and Mahoney, 1976). Certain of these distortions are present in all persons with eating disorders, indicating the possibility of a cultural pattern gone awry. In some people, for example, staunch perfectionism is the cause of much distress and sometimes failure. These individuals proceed with substantial success on a diet until the first infraction occurs, no matter how minor. The inability to maintain a perfect record sends many into a binge that ends with self-recrimination and guilt. Perfectionism in the anorexic takes on an even more extreme form. Some carry this trait in all aspects of their life as well as in their anorexia. As indicated earlier, people with anorexia are often characterized by their friends and family as the "perfect one." Social Factors For many who have an eating disorder, social factors are associated both with the etiology and perpetuation of their problem (Garner et al, 1980). From a sociocultural perspective, eating disorders are likely to be a product of contemporary American society (i.e., a society that places inordinate value on slimness while simultaneously emphasizing the consumption of its abundant food supply). At the personal level, these societal traits are translated into interpersonal transactions that lead the susceptible into an eating disorder. For many young people, the most important social influence is the family, but other factors are important as well. In some cases of bulimia, for example, the idea of purging is obtained from an acquaintance or friend as an action to avoid the consequences of excessive eating. For the susceptible, it begins as a logical and apparently socially acceptable way to "have your cake and eat it too." Unfortunately, this rather innocent beginning can progress into a disturbing, all-encompassing compulsion. For anorectics, it is not unusual to find that their social activities or work or both are associated with their disorder (Eckert, 1985).

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations One of the phenomena frequently observed in individuals who suffer from an eating disorder is difficulty with interpersonal relationships (Mitchell and Pyle, 1985). Among bulimics, problems in this area are the frequent cause of a binge. Eating disorders may also be triggered by traumatic separations and losses (Garner et al., 1980; Kalucy et al., 1977; Strober, 1981). These situations may include the breakup of a home, death of a family member or friend, going away to college or the military, or family illness. ANOREXIA NERVOSA Anorexia nervosa is the eating disorder most noted for its severe course and consequences. It is the eating disorder that is more likely than the others to result in death, most often from complications arising from the state of starvation. Anorexia nervosa is a perplexing condition, for its most notable characteristic is self-imposed starvation in a country and culture blessed with an abundance of food. However, for anorectics, the apparent illogic of their actions is overridden by a psychological framework ruled by two powerful contingencies: the reward of weight loss and a morbid fear of fatness (Garner et al., 1982). Even at very low weights that are beyond the point of social desirability, attractiveness, and good health, anorectics deny that they are too thin and instead insist that they are too fat. Despite the literal meaning of the term anorexia nervosa, appetite loss of nervous origin, a diminished appetite is rare among people with this disorder (Bruch, 1986). Anorectics are often obsessed with food and may spend hours reading cookbooks, preparing meals, and serving food to others. They may develop rituals involving food, including cutting it into tiny pieces, hoarding it, weighing it, or hiding it and disposing of it at a later time. The Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 1993) diagnostic criteria for anorexia nervosa are: Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85 percent of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85 percent of that expected). Intense fear of gaining weight or becoming fat, even though underweight. Disturbance in the way in which 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.

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations In post-menarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.) In addition, the DSM-IV specifies two types of anorexia nervosa: Restricting type: During the episode of anorexia nervosa, the person does not regularly engage in binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives or diuretics). Binge Eating/Purging type: During the episode of anorexia nervosa, the person regularly engages in binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives or diuretics). There is evidence for increased comorbidity of affective and anxiety disorders with anorexia nervosa. Moreover, alcoholism and other psychiatric diagnoses, including other eating disorders, are more likely in first-degree relatives of anorectics (Halmi et al., 1991). Anorectics of the binge-eating/purging type tend to be heavier, with more lability of mood, impulsivity, and drug abuse (Mitchell and Pyle, 1985). The anorexic patient in a state of starvation may suffer cardiovascular and respiratory changes, problems with renal function, electrolyte imbalance, edema, hematological changes, gastrointestinal complications, and neurological changes (Garfinkel and Garner, 1982). Additional symptomatology includes low metabolic rate, loss of bone, cold intolerance, insomnia, alopecia, swollen joints, and dry skin (Bemis, 1978; Williamson, 1990). From 90 to 95 percent of anorectics are female (American Psychiatric Association, 1987). Such disproportionate representation of females indicates the strong cultural influences in the etiology of the disorder (Brownell, 1991). In the United States and many other Western nations, slenderness has become synonymous with attractiveness, and the achievement of both is an expectation more of women than of men. In Western cultures, males are more likely to be evaluated in terms of their actions, or what they do, whereas females tend to be judged in terms of their appearance, or how they look (Foreyt and McGavin, 1989). Anorexia is often seen as a response to the demands and expectations of adulthood and independence. Compulsive fasting may bring a sense of order to the patient's life by allowing her to exert some control over herself and her body. Her ability to lose weight may give her a sense of pride and achievement, and her rigid self-imposed rules governing food may serve as a substitute for genuine independence. The denial of her own needs through fasting may be a way of expressing that she will not allow other's demands to be imposed on her.

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations These dynamics of anorexia nervosa, involving self-imposed undereating as a way to establish feelings of self-control and independence and to reduce chaos, may be the most interesting to explore in their application to troops in the field. APPLICATION TO TROOP UNDERNUTRITION The dynamics of anorexia can be compared to the field situation when one considers the parallels between the anorexic's family and the "family" structure in the military. The majority of soldiers can be thought of as older adolescents in terms of their developmental stage. The officers serve in loco parentis to provide leadership and protection. Like the anorexic family, the military, especially in stressful field operations or combat, operates under conditions conducive to rigid rules for relationships, overprotectiveness, and enmeshment and high cohesion in the sense of close teamwork and buddy support. There is also a strong prohibition against intertroop conflict or expression of anger. Thus, the stage is set for the adolescent to develop a strong need for independence and autonomy; the natural way to cope with stress or combat is to try to make oneself into a self-sufficient individual. In this way the individual reduces feelings of vulnerability. At the same time, however, since a sense of mastery is not complete, there is a dependent turning toward authority to alleviate fear and confusion. This results in an inner, mostly subconscious, conflict between dependence and independence needs. One overt outcome of this conflict is that the individual develops a defiant and oppositional attitude toward authority. This defiance coincides with bonding with peers to reduce feelings of individual vulnerability and to maximize social acceptance. Thus norms develop among the troops that whatever comes down from authorities must be viewed with distaste as a way of communicating brotherhood with peers and defiance of parental figures. Thus, individuals may rate rations as acceptable in laboratory test situations, but they may shun the food in field situations when they are in the presence of their peers. Another related hypothesis is that when soldiers are in military field situations, there is very little they can do to control life. Most actions are the result of obeying commands with little sense of self-control. The act of not eating a recommended portion of rations may be a way of asserting personal control apart from the context of displaying to peers one's defiance of authority. The young anorexic female may enter into self-starvation as a way to convince herself that she is in control and achieving a perfect body; she has a vision of herself that she is trying to attain. The self-vision for a young soldier, male or female, may be along the lines of a "lean and mean fighting machine." The soldier may see undereating as a sign of toughness, sacrifice,

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations and machismo and eating full rations as a sign of self-indulgence. Being full of food may be perceived as preventing one from being on the fighting "edge." It is true that most people feel less alert after a full meal. Another aspect of control may involve in undereating to reduce the need for defecation, which may not be as easy or pleasant during field operations. Other considerations regarding underconsumption of rations are that under stressful conditions such as combat, appetite is reduced (Popper et al., 1989). Fear decreases gastric secretion and blood flow and inhibits gastric motility. This reaction is related to the release of corticotropin-releasing-hormone, which is the principal organizer of the stress response, leading to behavioral arousal, sympathetic stimulation, and a decrease in appetite due to increased glycolysis and blood glucose concentration (Ur and Grossman, 1992). One aspect of stress to consider is that some individuals are thrill seekers who seem to enjoy the mental activation caused by the stress response. These individuals would also be more likely to enjoy the alert feeling caused by undereating. Undereating is acutely associated with reduced availability of serotonin and opioids in the paraventricular nucleus (Norton et al., 1993). Low serotonin and opioids may cause agitation and enhanced alertness. This heightened state of alertness may alleviate feelings of boredom in noncombat field operations. RECOMMENDATIONS A discussion of the psychodynamics of self-imposed undernutrition displayed by troops in field operations in the light of eating disorders is speculative. To determine whether these dynamics are operative, research needs to focus on the attitudes and cognitions of troops. When this information is determined, then persuasive communications can be developed and tested to see if consumption of rations can be improved. Recommendations for future research include the following: Hold focus groups with troops to engage them in conversation about eating in the field. These groups would be led by nonmilitary personnel who would attempt to elicit responses that were not affected by the demand characteristics of military life (i.e., the need to look good in order to stay out of trouble). Use anonymous questionnaires to ask the troops about the topics that arose in focus groups and about the attitudes and beliefs that were discussed in the previous section. These topics include: (1) attitudes towards authority; (2) attitudes and preferences about the rations; (3) respondents' perceptions of their peers' views about the rations; (4) reasons why respondents do not eat fully; (5) reasons respondents believe their peers have for not eating fully; (6) how respondents feel physically and mentally when undereating versus eating fully and their perceptions about how eating might affect combat readiness; (7) how respondents' appetites have been affected by boredom, stress, or anxiety in premilitary life and in field and nonfield military life; (8) respondents' beliefs about the ability of the rations to cause weight gain; (9) respondents' attitudes about peers who always eat everything they can; (10) respondents' attitudes about full eating and defecation in the field; and (11) respondents' tendency toward thrill seeking.

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations An analysis of data from the focus groups and questionnaire would be the basis for developing persuasive communications designed to increase ration consumption. If the aspect of control-defiance appears operative, then communications would be designed to emphasize the self-nurturing aspect of full nutrition, rather than the subordinate-obedience aspect of complying with full eating orders. ACKNOWLEDGMENT This chapter was supported by grant DK43109 from the National Institute of Diabetes and Digestive and Kidney Diseases. REFERENCES American Psychiatric Association 1987. Diagnostic and Statistical Manual of Mental Disorders, 3d ed., rev. Washington, D.C.: American Psychiatric Association. 1993. DSM-IV draft criteria. Washington, D.C.: American Psychiatric Association. Ames-Frankel, J., M.J. Devlin, B.T. Walsh, T.J. Strasser, C. Sadik, J.M Oldham, and S.P. Roose 1992. Personality disorder diagnoses in patients with bulimia nervosa: Clinical correlates and changes with treatment. J. Clin. Psychol. 53:90–96. Bemis, K.M. 1978. Current approaches to the etiology and treatment of anorexia nervosa. Psychol. Bull. 85:593–617. Blundell, J.E., and A.J. Hill 1990. Serotonin, eating disorders and the satiety cascade. Pp.125–129 in Serotonin-System-Related Syndromes (SRS)—Psychopathological and Therapeutic Links, G.B. Cassano and H.S. Akisal, eds. International Congress and Symposium Series No. 165. London: Royal Society of Medicine Services. Brewerton, T., E. Muller, H. Brandt, M. Lesem, A. Hegg, D. Murphy, and D. Jimerson 1989. Dysregulation of 5-HT function in bulimia nervosa. Pp. 500–502 in The Psychobiology of Human Eating Disorders, L.H. Schneider, S.J. Cooper, and K.A. Halmi, eds. Ann. N.Y. Acad. Sci., vol. 575. Brownell, K.B. 1991. Dieting and the search for the perfect body: Where physiology and culture collide. Behav. Ther. 22:1–12. Bruch, H. 1973. Eating Disorders. New York: Basic Books. 1977. Psychological antecedents of anorexia nervosa. Pp. 1–10 in Anorexia Nervosa, R.A. Vigersky, ed. New York: Raven Press. 1978. The Golden Cage. Cambridge, Mass.: Harvard University Press.

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations DISCUSSION JOHN DE CASTRO: John, a lot of the eating disorders, they are what I think of as the tip of the iceberg phenomena, those individuals come in seeking help or are referred to help. The vast majority of people who are eating disordered are not showing up in those kinds of situations. We studied with the food intake diaries for bulimics who said that they would work with us as long as we didn't make them go to therapy, they didn't want to have anything to do about that. And what we found was that a lot of binge eating did, indeed, occur with other people. And a lot of bulimic behavior occurred socially. It turned out that, the more people that were present at a binge, the more they would eat. JOHN FOREYT: I saw your data and found it interesting. That is why I made that comment. JOHN DE CASTRO: But if you are saying getting people together to control binging, with a lot of bulimics, it works the opposite way. The more people you bring in, the greater the binge is going to be. JOHN FOREYT: Those are the people, again, who don't seek out help. We have seen it in college sororities, but that was because, you know, people study college sororities. But you get a population that we don't get, which are people seeking out help. That is very interesting. But yours may be more typical of military, people who do not seek out help in terms of eating patterns. JOHN DE CASTRO: What we find in the university undergraduate female population, is that there is an incidence of about 10 to 12 percent. It is very high. JOHN FOREYT: You are right, this would be the tip of the iceberg. JOHANNA DWYER: Are there any studies that the military might know about, of the prevalence of these disorders in the military? ALLISON YATES: I think there may be one at the military academy. I know that they monitor that kind of thing much more closely. Whether that has been anything other than a record keeping, I think they are doing some of that at West Point.

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations BARBARA ROLLS: Are the cognitive treatments any different in the male population we see, the small percentage? JOHN FOREYT: The male population has been essentially untreated. There are very few. Arthur Andersen has published some work on the treatment of male bulimic and male anorexics. Most of them have gender disturbance that come to treatment. So, you would focus on whether they are unhappy with their feelings about themselves. But otherwise, the treatment is similar, but with that added. PARTICIPANT: (Question off microphone re: perfection.) JOHN FOREYT: Oh, the need to be perfect is definitely there. Sure. The ones I treat now, one is a model, an athlete—their life styles are in a life style that needs a very low body weight, in the first place, or a heavy emphasis on appearance. So, you need to deal cognitively with that. And they are tough, I mean, obviously, because that is how they make their living, or a big part of their life. BARBARA ROLLS: And something you didn't really mention, but obviously I have worked with eating disorder patients a lot, but what may be a problem in the military is the excess exercise and activity. And that might be something that you don't see so much in the eating but people in the military are— JOHN FOREYT: Good point, Barbara. There are many ways to compensate for calories. And I just mentioned one of them. But you are right, there are lots of ways including strong, heavy, emphasis on exercise. And I think you are right, and very well taken. That is very strong one. DAVID SCHNAKENBERG: A question for Dr. Halberg. A few years ago the army undertook a couple of studies to cope with the problem of translocation of troops, say from the U.S. over to Europe, and jet lag, what could you do collectively. And some studies looked at a package of things—sleep priority, lighting control, perhaps some timing of eating. Subsequently, there were some minor effects shown at the outcome, but we couldn't tease out how much was diet, how much was light control or whatever. Is there anything in the emerging literature that deals with that problem, in terms of rapid relocation of troops, both directions, east and west? I wonder if there is something fruitful that we could consider putting on our research agenda to try to adjust something with at least the diet side of coping with the circadian or other rhythms.

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations FRANZ HALBERG: The question is, if you have chronome, with the new recognition, we rapidly adjust our circadian. Society simply synchronizes it. That is why I showed the 15¹C continuous darkness firing of neurons. Certainly, society synchronizes it, but it is there in vitro. So, attention to circumvent things would be quite important because it could reverse the effect of circadians. And today we have the monetary capabilities. We could do one not only on temperature and activity monitors, very refined ones. So, we would know whether that in terms of performance—as you suggest, it is a reasonable thing to do, and we could do it. And of course, these trips occur with some delays. We can optimize it, and we should optimize the chronome. People have unhooked the circadian, so, again, that is in the 1950s. Today, we have also components that play a critical role. Most of these are soldiers going to combat, going to Bosnia, perhaps, or wherever. For those it would be very important to take the chronome into account and see what you can do to, first exercise concomitantly, and if you need to do it, then remember, that eating has been according to what is recommended. But we should do pharmacodynamics and pharmacokinetics, before we recommend drugs. So, yes, there is a problem. Yes, there is a chronome. We have ways to optimize things. The work remains to be done. JOHANNA DWYER: I thought I heard you say it again. Now you said melatonin. Before you said carotene and aspirin, I thought you said, as well. Could you suggest—I could see if, in fact, these agents were to modify these rhythms, how that would work. What I don't understand is how it would be possible, given the quixotic sorts of demands on soldiers, how you could do very much with circadian rhythms. I mean, if they have to fight, they have to fight. Could you explain that a little bit more? FRANZ HALBERG. I would love to. I would like to kill two birds with one stone. One stone is for actually what Dr. Schnakenberg of a major concern about this would be concern about the commanders before you come to the soldiers. So, when he came to the soldiers he could use the soldiers as models for the population as a whole, if cardiovascular changes, as we found in Korea, are suddenly there at 19 and 20 years of age. At least we can measure the differences in blood pressure or in stroke, or in the acceleration of the velocity in the blood, if circadian attributes at birth in newborn, then the timing beyond is probably the best catch-all to have a prophylactic pill. So, they are two separate problems but they mesh and we have a concern about the circadian circuits.

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations If I could speak for just one more second. I want to make this point very strongly, that one of my fellows just finished a study where he gives an answer to a meta analysis of 70,000 people who all received aspirin, and the story is still controversial. What he showed was that the effect on blood pressure at one time was in one direction, but the rest of the time it was in the opposite direction. And when he took everything together, there was no effect. So, we can continue with this potential of 40 percent diagnosis. But in fact, what it does, it keeps on doing. So, the army would be a wonderful place to do this. HOWARD SCHUTZ: This is for John. I am cheating because I talked to him at the break, but I want to share it. In addition to increasing the length of time because of number of people you interact with, I entertained the hypothesis, which he then agreed with and he will explain, that it could be also due, in part, to disinhibition. The more people that are there, the more likely they will behave in a way that you don't typically behave, and give you a model. And then it breaks the conflict. I think that alcohol data supports that, because I think it contributes to further disinhibition. JOHN VANDERVEEN: I agree. JOËL GRINKER: John, when I talked to you, you said that you have some evidence of compensation in subjects that you had data on over only one or two days. I wondered if you could speak to that. Did that only go on in specific meals or what? JOHN DE CASTRO: When I was talking to you about that, I was referring to the manipulative study, where we told the students to eat by themselves. The evidence for the compensation was simply the fact that the alone meals were much larger than what you see in spontaneously ingested alone meals. There are a number of interpretations but one of those is the compensatory interpretation of that. ROBERT NESHEIM: Thank you for the last four speakers and the issues they are dealing with. Now we want to start taking a look at some of the strategies that might be employed to combat undernutrition, and see about the resolution of the problem. In order to kick this off, we have asked a panel of discussants to come together and to share some of their thoughts and to interact with themselves

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations if they desire, and eventually let the whole group here comment on what they have heard over the last essentially day-and-a-half. The members of the panel are Robert E. Smith, who is a senior vice president of Nabisco Research Foods Group in New Jersey; Howard Moskowitz of Moskowitz Jacobs, Inc. of Valhalla, New York; Cheryl Achterberg, Department of Nutrition at Penn State University, University Park; and Robin Kanarek, Department of Psychology at Tufts. I don't know who is going to start. Bob, do you want to?

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