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AD JUSTMENT TO DIETARY CHANGES IN MARION S SOMATIC DISORDERS * HILDE BRUCE and MARJORIE JANIS Department of Psychiatry, Johns Hopkins University Medical School This report deals with the influence of psychological factors upon the ad- justment to a prescribed diet. The observations were made on children in whom a change of previous eating habits became necessary for medical reasons. Investigation of the family background permitted insight into the factors influencing the child's personality development in general and his success or failure in adjusting to the new diet in particular. It was hoped that the endings might prove of help in evaluating the psy- chological factors involved in general nutritional changes due to wartime con- ditions. Although the reasons for the need of dietary changes are greatly different in a nation-wide rationing program and in an individualized pre- scription ire a medical office, the come-on factor is the circumstance that in both instances individuals, family groups or the whole nation, find themselves confronted with the problem of suddenly giving up customary eating habits, not because they have spontaneously changed their taste and appetite, but because they are being told to do so by some outside authority. Different individuals will react differently. It is essential that cooperation is obtained on as wide a scale as possible in order to insure survival in an emergency. The patients on whom the observations were made were recruited from the Protein Clinic of the Medical Department, and the Diabetes and Epilepsy Clinics of the Pediatric Department. We are greatly indebted to the physi- cians, dieticians and social workers of these clinics for their assistance and cooperation. The observations in allergic, diabetic, and epileptic patients were intended to sense as a control to previous observations in a large group of obese children. The obesity study has extended over more than five years and comprises more than coo children, both boys and girls, who were patients at the Pediatric Department of the Columbia Presbyterian Medical Center in New York. It was found that in all instances food was of central impor- tance for the children and their families. Originally the study had been planned for the purpose of recognizing with greater accuracy the endocrine factors which, according to prevailing concepts, were responsible for the progressive accumulation of fat tissue. Contrary to expectation it was fourth that instead of the assumed, but unconfirmed, endocrine dysfunction, ex- cessive eating, coupled with muscular inactivity, was the outstanding causal factor. Viewed as a problem of energy balance it should have been possible to achieve weight reduction simply by reducing food and increasing activity. * This study was made possible by a grant from the Josiah Macy, Tr. Foundation to the Committee on Food Habits. 66

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~ dj~`st~7~e~t to Dietary Changes 67 In clinical experience, however, this proves to be exceedingly difficult. There is marked objection to any change in the established habits, which pointed the way to a study of the psychological factors involved in the food habits of these children It was found that the need for excessive food intake and the fear of activity and social contacts are intricately interwoven with the human relationships within the family circle, the child's personality develop- ment, and life experiences. The family frame is such that it does not offer sufficient emotional security to the obese child so that eating serves not only the appeasement of bodily hunger but is also charged with high emotional significance for maintaining a precarious balance in the relationship between the obese child and his mother. Overeating helps the child to combat anxiety and to achieve a sense of satisfaction and comfort, and food is overvalued as the main, sometimes only, expression of love and affection. The exag- gerated bodily size in itself becomes of emotional importance. It gives a sense of strength and power to the timid, fundamentally insecure fat child. Inter- ference with the established eating habits, even when asked for by the patient who suffers from his ungainly bulk, is likely to bring into the open the con- flicts and anxiety which have been hidden under the cover of the excess fat. A changed eating program can be carried through successfully only after the underlying emotional factors have found consideration. These observa- tions have been published in a series of articles, a list of which follows this report. There have been a number of corroborating publications from other clinics in the United States, Canada, and South America. For this year's study it had been planned to observe how these fat people, for whom large quantities of food are of such extraordinary importance, would adjust to shortages and rationing. Thus far food restrictions have not been stringent enough to make an appreciable difference in the eating habits of the obese. Eight obese families in Baltimore were contacted and repeated home visits were made to obtain information on their adjustment to the various stages of the rationing program. It is surprising how little interference there has been thus far with their eating habits. None of them had diminished the quantity of food, and the need for replacement of one foodstuff by another (such as rice, noodles and spaghetti for potatoes) was accepted with equanimity. This seems to be due to the fact that obese people generally overeat on carbohydrates which have been plentiful and inex- pensive. One might even expect increase in obesity in some cases. There has been an increasing shortage of chocolate and candy and similar products. One may expect changes in the younger group of fat children who generally are overstuffed with sweets, candy and ice cream. The mothers of these children will have to find new ways of expressing or withholding affection. It is planned to continue the observations on the reaction of the obese to rationing and shortages in the previously studied families in New York. Unwillingness and inability to change faulty eating habits and to accept therapeutic restrictions are present in the obese with such regularity that it seemed profitable to study other groups of patients in whom special and re- stricted diets are prescribed. The following observations were made in fifteen diabetic, six epileptic, and seven allergic children and their families. This is

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~8 The Problem of Changing Food Habits a small number as compared with the large group of obese children previ- ously studied. The differences in the reaction between the obese and other children with dietary problems are so striking that the observations are suf- ficient to demonstrate them. The obese children, and even more their mothers, raise objections against dietary restriction with such vehemence and regu- larity that one might be led to believe that eating habits during childhood are such an intimate aspect of the family life that any interference and necessary changes would prove impossible or exceedingly difficult. In contrast to the one-sided type of reaction of the obese, the patients in other groups showed various reaction patterns. Many showed themselves quite capable of integrating the new eating habits without upsetting their previous pattern of living. In others, some problems of adjustment arose, but only rarely of such central importance as in the obese. The problems with which the patients in the different groups are con- fronted, show some differences. The reducing diet for an obese child is usually not different from that of the average child. It is '`reduced" only by comparison with the previous enormous intake. Really low caloric diets are indicated only in exceptional cases. All the objections against the hardship of dieting are made against a diet which is normally satisfying. The diabetic diet is similar except that greater exactness is required. The different items are weighed at each meal, carbohydrates are kept low, and exact spacing of the different meals is necessary. There is little variety and eating for special occasions like parties and picnics has to be carefully planned. The allergic diet is restricted only insofar as one or the other specific item is being eliminated, whereas the quantity is left unaltered. The most difficult diet is the ketogenic diet prescribed for epileptics. Carbohydrates are cut out as far as possible with the use of natural foodstuffs, and are replaced by large amounts of fat which are difficult to eat without bread or crackers as a carrier. Wartime changes added one more difficulty. Heavy cream, which could be offered in the rather pleasant form of whipped cream, is no longer available. The amount of butter had therefore to be increased. The diet is very small in bulk and allows for little variation. The epileptic is also in a more difficult psychologic situation as to the relation of the dietary change to his illness. These patients come to the clinic because they have convulsions not a feeding difficulty. IJnexpectedly, and for reasons which are difficult to understand, they receive instruc- tions for a ketogenic diet, which is quite unlike what any ordinary child would choose as his food. The relationship to clinical improvement is nor always convincing. Sometimes there is no influence at all, or the attacks be- come only less frequent. In an exaggerated way, these epileptic patients il- lustrate the difficulties which a previously not-food-conscious group faces when suddenly confronted with the task of adjusting to a strange and un- attractive diet without a clearly recognizable goal. In spite of all the diffi- culties, the experience of the Epileptic Clinic shows that quite a number of families are capable of carrying out the prescription. For external reasons, there are only two "cooperative?' cases among the six families whom we could study. Analysis of the material shows that the frequent inability to accept

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Adjustment to Dietary Changes 69 the diet has as much to do with psychological factors within the total setting as with the difficulties inherent in the diet. The relationship of the diet to the complaint problem appears more ob- vious in the other conditions. In allergy, the elimination of the specific pre- cipitating substance may bring about freedom from distressing symptoms, a relationship which can be experimentally verified by the patient by eating this food. In the diabetic, the dietary restrictions seem to stand in a direct relation- ship to the sugar excretion, and digression from the calculated diet may be followed by recurrence of serious symptoms. Even if preoccupation with food was not present before the disease, careful attention to eating may be expected in these families since serious complications, even death, may follow non-adherence. Although severe degrees of obesity may be just as disastrous for a child's development as the dangers which beset the way of the diabetic, the need for treatment is generally accepted with less seriousness by the obese family. The close relationship of faulty food habits to the development of the condition is quite obvious to the outside observer, but often vehemently denied by the fat child and his parents. It is this group which of Eers the greatest diff;- culties in changing eating habits which in themselves are an expression of their emotional dissatisfaction. As was stated before, Congolese patients with dietary problems are capable of accepting a new diet as part of their total living. In contrast to the central food problem in the obese, these other patients show that dietary changes may serve different psychological functions and are integrated accordingly. Com- mon to all patients is the expectation of complete cure after some time. Working under the concept of a time limitation for the restrictions seems to be one mechanism which helps in making it possible to tolerate a strictly supervised regime. It was previously observed in the obese group that re- sults of treatment were better when the patients were seen at weekly inter- vals with a definite goal of what was expected of them for the coming week. The material at hand allows a division into three groups who handle the task in different ways. Since most observations were made on diabetic chil- dren, the following discussion is based mainly on the reactions of this group. In addition to the restriction of the diet, the diabetic children have to contend with repeated daily insulin injections, urine tests, frequent trips to the clinic, and other burdensome tasks. There seems to exist a fairly accurate parallel- ism between the way the diet and the other problems are handled. The first way may be described as one of intellectual acceptance of the new situation with good, though not rigid cooperation. There may be, in the beginning, confusion and anxiety until all the details are understood and can be handled with ease. Tl~e second group is even more cooperative. Adherence to the diet is more than fulfillment of a task for a definite physiological reason. It becomes endowed with a magic power of its own. The concept of reward and punish- ment plays a great role. There is strictest adherence to the new diet and obsessive features are quite marked. One might call this a neurotic integration, most often with an obsessive pattern. The third group is "uncooperative;" that means these patients experience marked difficulties in following the dietary prescription. In many ways the problems of these patients resemble

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7o The P'oblem of Changing Food Habits those of the obese. The changes in the eating habits seem to upset their whole pattern of living. As in the obese, the whole issue centers around art unre- solved dependent relationship to the mother, in which offering and receiving of food plays a paramount role. It is not astonishing that some of these patients had been frankly obese or showed tendencies in that direction. The number of observations is too small to allow for figures of frequency and distribution. An intellectual acceptance without serious interference in the total personality development is certainly not rare. All the various tasks can be handled quite well, without a feeling of undue hardship arid depriva- tion, if the fundamental emotional relationships are sound. In some families the manifold tasks make for greater closeness between the mother and child and a spirit of teamwork develops. Sometimes the family as a whole adjusts its eating habits to the prescribed diet, to make it easier for the patient-and this is done without resentment against him. Although these families are aware of the gravity of the condition, the new diet is not enforced with a threat of death if broken in some detail. There is appeal to "it is good for you," particularly with younger children. Generally food had not been mis- used for discipline before the onset of the illness. A representative case is that of a seven year old girl, the youngest child in a farmer's family. She had become sick, following a short febrile disease, about a year and a half ago. The mother tells how they were disturbed when the nature of the little girl's illness was first discovered. "It struck us like a thundercloud." Now she speaks quite objectively about her way of handling the situation. When the child came home from the hospital after the initial standardization, the two older brothers of high school age helped her with weighing the diet and calculating food exchanges. Now- the girl herself takes active part. To the mother, the numerous small tasks were nothing new, since she had nursed her own mother during several years of sickness. That was part of her position as the youngest daughter who had stayed ore the farm and whose husband had become the new owner. She speaks with warpath of the good relation of the patient to her older siblings, how they all like tl~e little girl and helped out when she became sick and hospitalization was neces- sary. The girl is not self-conscious about having diabetes; she is as active socially as before and feels in no way slighted because she has to eat accord- ing to a prescription. The mother tells with amusement how the girl runs to the drugstore to get her an ice cream cone to prevent the mother's giving it up in her behalf. In a number of these families there are more initial difficulties or in others the relationships are not as smooth. Sometimes the loyalty to the clinic which has helped in the present and past emergencies is the incentive that makes some patients adhere to a diet which would be too difficult a task otherwise. So we may find children with behavior difficulties in this first group, without food becoming a focus for their problems. In the second group there is very strict adherence to the diet with much anxiety about the slightest deviation. The concept of "cure" plays a great role, riot in the way it was observed in all cases that there should be a time limit to this strict supervision, but in the definite feeling that a cure will come

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d ji~st3?te77t to Dietary Changes 7I as a reward for goodness. The task is not seen in relation to the disorder but as magic that will bring about cure if all rituals are carefully attended to. The slightest deviation arouses anxiety because it means that the magic has been spoiled. Changes in the regime are diflScult to accept for these patients. One boy of ~5 is characteristic of this type of adjustment. He is most painstaking in weighing his diet and refuses any other food like poison. He follows his diet with greatest accuracy, but if there is a trace of sugar in Lois urine, "he worries and worries about how it could have happened." To him it is not a question of practical adjustment but one of justice, and he feels depressed and insulted because he does not get the just reward that is coming to him. The boy has shown obsessive features in many other ways since early childhood. He was always neat as a pin and he is so fond of cleaning and scrubbing that his mother says of him, he should have been a girl. In this boy the diabetes became manifest at the age of ~3 when the father suddenly left the family and married another woman. This boy had been particularly close to his father, an attachment that went back to the time when his younger brother was born. He was so jealous that he did not want to speak to his mother. "I am Daddy's boy. Mother has another baby !" In other cases of this group it is the mother's obsessiveness that endows the diet with a magic function. Other children compensate for their rigid goodness by bad behavior in other respects, like petty stealing or showing off in school. There is generally much embarrassment about the disease with an attempt to hide all emotional reactions to it. Both these groups are comparatively simple from a medical point of view. Once they are standardized, minor changes and adjustment will keep the metabolic condition under control. They may be sent to the psychiatrist for behavior disturbances w loch stand only in an indirect relationship to the diabetic condition. The third group has difficulties in accepting the diet from the start and makes an adequate control of the diabetic disturbance Tactically impossible. , . - .. ~., ~. ~ , ~ In addition, these Wren are in a constant emotional turmoil which in turn has an effect on the sugar excretion. They are constantly in and out of the hospital. After careful adjustment, the sugar excretion becomes unbalanced again as soon as they go home. Fortunately cases with such serious emotional disturbances are not frequent. There are only two among the fifteen diabetic patients. Both boys were unable to adhere to the dietary restriction not be- cause the prescription was more severe but because the total life situation lacked security and emotional support. One of these boys has since developed a schizophrenic reaction. Even in the hospital situation he would deliberately break his diet, generally in a petty way, apparently to demonstrate that he was not being controlled by anyone. That adequate dietary control is possible in spite of severe conflicts in the family background, was demonstrated in one case of epilepsy where the mother received psychotherapy during the period when the child was being treated by the ketogenic diet. In spite of all the inherent difficulties, she became capable of handling her very unruly and aggressive child with

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~2 The Problems of Changing Food Habits calm and kindness so that lie accepted the diet from her without objec- tion. As the relationship improved he became less aggressive and wanted to show his affection to her which generally assumed the form of his taking the best looking fruits and other food from his grandmother's pantry (the grandmother had been a most disturbing factor), with the intention of bringing it to his mother. If one tries to correlate these observations with the problems which face the population at large, one might draw the conclusion that people who are reasonably secure and constructive in their outlook on life will be able to accept a wide range of changes and limitation in their eating habits. One might expect that which we call intellectual acceptance as the normal pattern, whereby slightly panicky and confused reaction will occur in the beginning until the principles and aims are mastered and understood. In some instances there may be a neurotic, obsessive acceptance, with fear and panic and ex- pectation of magical help. This type might become upset about minor changes and variations. These might be the people who become anxious about the point rationing system with its fluctuating values from one month to another. People who react in the way the third group of our patients do, have to find the same type of consideration as other sick people in a program of this sort. People who really cannot adjust to prescribed changes in their eating habits will need special consideration and treatment just as people with organic disease. This report has been written with the full awareness that the work raised new questions instead of answering them. It needs continuation in different directions, partly in an attempt to evaluate the direct reaction to food ra- tioning, and also in the more strictly psychosomatic aspects. The study of non-obese patients with food problems was carried out for the purpose of gaining an understanding of the underlying personality structure in different organic diseases. By focusing on their adjustment to the dietary changes a very slanted picture was obtained, yet sufficient of a picture to show, e.g., that the diabetic patients are a different and less uniform group than the obese. Further work for the delineation of the various features is indicated. Another plan for future work will deal with the effect of food deprivation in infancy and its relation to affective security and to later personality de- velopment. The observations of this year's study suggest that the emotional security of the home may go a long way to counteract harmful effects of deprivation and restrictions. BIBLIOGRAPHY PUBLICATIONS ON OBESITY IN CHILDHOOD BY HILDE BRUCH I. Physical growth and development of obese children. Am. J. Dis. Child., 58: 457-484, ~939. a. Basal metabolism and serum cholesterol of obese children. Am. J. Dis. Child., 58: 1001-1002, 1939. 3. The-Froehlich syndrome. Am. T. Dis. Child., 58:~28~-~289, :939.

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Adjustment to Dietary Changes 73 4. Physiologic and psychologic aspects of the food intake of obese children. Am. J. Dis. Child., 5g: 73g-78~. ~940. 5. Energy expenditure of obese children. Am. J. Dis. Child., 60:~o8~-~og, Age. 6 The family frame of obese children. (Together with G. Touraine.) Psychosom. Med., 2: ~4~-206, Ago. 7. Obesity in childhood and endocrine treatment. J. Pediatrics, ~8 :35-56, ~94~. 8. Obesity in childhood and personality development. Am. J. Orthopsychiat., At: 467- 474, i94~. 9. Obesity in relation to puberty. T. Pediatrics, ~9: 365-375, ~94~. lo. Benzedrine sulphate in the treatment of obese children and adolescents. (Together with I. Waters.) J. Pediatrics, 20:54-64, i94~. At. Children who grow too fat. Child Study, ~8: 82-84, ~94~. 12. The management of obesity in childhood. Our Children's Health, Dept. Health N. Y. C., 3: 8-~2, ~94~. . Psychiatric aspects of obesity ir1 childhood. Am. J. Psychiat., 99:752-757, Age.