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CHAPTER 7 Eating for a Healthy Life 7 Eating for a Healthy Life M any women spend significant portions of their lives thinking about food. From the moment that a preadolescent gets the first inkling of the changes happening to her body to the day an octogenarian gives away the pots and dishes she will not be needing at the retirement home, a substantial portion of nearly every day goes into considering what should or should not be on her own and other peopleâs plates. So central is this concern that, according to survivorsâ accounts, women (and men) starving in World War II concentration camps passed the time by discussing menus and recipes for the feasts they planned to prepare after their liberation. But in a lifetime spent concentrating on cooking and eating; in decade upon decade of perusing articles and clipping recipes from maga- zines and newspapers, of seeking nutritional counsel from obstetricians and pediatricians, of studying labels and assessing produce in supermarkets, of fretting about unwanted pounds, of helping a mate cut back on fat or salt or caffeine, of sharing kitchen tips with friends, and, often, of putting three squares (or at least one or two) on the table nearly every day of the year, many an American woman neglects to find out how best to eat for her own health. Despite the most stable and abundant larder in human history, despite grocery prices far cheaper as a proportion of income than in many 119
I N H E R O W N R I G H T other countries, despite food choices from abalone to zucchini, American girls and women typically eat diets that put them at risk for certain health problems. And these nutrition-related conditions differ somewhat from those most common in men. So striking a pattern of behavior is not, of course, an accident. First, and most obviously, womenâs bodies face nutritional chal- lenges that menâs never do. The monthly menstrual flow taxes their stores of iron. Pregnancy and lactation place immense burdens on both womenâs bodies and their ability to consume the nutrients they need to create and nourish a new life without depleting the nutritional stores they need to maintain their own health. Then, after menopause, due to the drop in estrogens and the protection they impart, a variety of chronic diseases apparently related at least in part to diet choices made during earlier de- cades arise: osteoporosis, cardiovascular disorders, and reproductive can- cers. Despite growing evidence for a diet-disease connection, how- ever, such ties have been difficult to nail down definitively. Specific mechanisms of action often remain elusive. International comparisons, for example, clearly show a relationship between a nationâs breast cancer rate and the level of fat in its peopleâs diet, but science has yet to isolate the precise biological elements of this connection. In nutritional epidemiology, the science that studies the inter- play of food and illness, ânew hypotheses are easily generated because so many diet variables allow many comparisons to be made,â warns Elizabeth Barrett-Connor, M.D., professor of epidemiology at the University of California, San Diego, School of Medicine. Conflicting studies have sug- gested, for example, that eating yogurt both does and does not raise the risk of ovarian cancer. Further investigations have shown an even more complicated apparent connection between cancer risk, use of birth control pillsâwhich seem to provide some protection against malignancy of the ovariesâand consumption of dairy products. Such a ârather convoluted association is biologically plausible,â Barrett-Connor notes. A diet high in the milk sugar lactose results in a high intake of the sugar galactose, which in turn stimulates production of gonadotrophins, hormones lowered by the Pill. This theory serves to âhighlight another characteristic of epidemiological studies of diet and 120
CHAPTER 7 Eating for a Healthy Life disease: it is possible to find and explain almost anything,â she goes on. âThe metabolic pathways of humans are sufficiently complicated, as are our other behaviors (e.g., taking oral contraceptives), that we can explain almost any nutrition-disease association we find.â The lesson Barrett- Connor draws: researchers must guard against becoming âprematurely enamored with causality.â Thatâs why, she says, a large, well-controlled trial like the Womenâs Health Initiative (WHI) will play an important role in distinguishing âwhich associations are causal and which are coinciden- tal.â1 Other methodological problems lie in wait for the researcher stalking connections between diet and disease. âSocial mores may conceal the truth about diet,â Barrett-Connor goes on. âHampering scientistsâ efforts to track fat, for example, is the fact that âit is no longer socially acceptable in California to admit to anyone that you eat three eggs for breakfast, consume red meat twice a day, never cut the fat off anything.â When âthe lay media constantly remind us of how we should eat and drink,â people may give interviewers fashionable rather than truthful an- swers. And, âif women are more educated about good food habits than men, and I expect they are, then their reported diet could more readily obscure diet-disease associationsâ simply because they keep up on current thinking about whatâs sensible and whatâs not.2 As yet, therefore, only a few specific ills have been traced to particular eating habits. In large part because of these difficulties, experts emphasize that good nutrition does not depend on certain specific edibles that act as âmagic bulletsâ against particular problems, like oat bran or fish oil, to name two that became national fads. Nor does it lie in specific vitamins or minerals gulped down in supplements. Rather, it entails a judicious selec- tion of ordinary foods, which should be the ânormal vehicle for delivering nutrients,â according to Janet King, Ph.D., professor of nutritional sci- ences at the University of California, Berkeley.3 Only in special circum- stances should a healthy woman require dietary supplements, and those should be carefully tailored to her particular needs. Otherwise, the neigh- borhood grocery can provide virtually all the nourishment necessary for health. To face the special challenges of female life, and to reduce their risk of chronic disease, experts advise American women to follow the 121
I N H E R O W N R I G H T same general guidelines that ought to mold everyoneâs menu. IOMâs Committee on Diet and Health has formulated nine simple instructions that make it easy, in the committeeâs words, to âeat for lifeâ (see Table 7- 1). A book by that name, published by the National Academy Press in 1992, gives complete details. The committee believes that a varied diet low in fat; high in grains, vegetables, and fruits; and moderate in protein, salt, and sweets will provide the building blocks of health for every age beyond infancy and very early childhood. To cut the excessive fat typical of American meals, the ancient concept of âour daily breadâ ought once again to form the foundation of our food choices, with complex carbohydrates like pastas, cereals, and whole grain breads accounting for our largest single food category. We should also âstrive for fiveâ servings of vegetables and fruits daily, as the supermarket slogan goes, emphasizing the citrus family, yel- lows, oranges and greens. Low-fat meat, fish, poultry, or legume dishes should appear in small portions two or three times each day to provide protein. Women in particular also need two or three servings of high- calcium, and preferably low-fat, milk products daily. Sweets, sugars, and oils ought to show up sparingly at best. These high-calorie foods provide few nutrients and can crowd out other, more nourishing possibilities. The same goes for alcohol. Given these choices, American women who are not pregnant or nursing or who do not have other specific health prob- lems ought to attain adequate nourishment without resorting to supple- ments. A LOSING PROPOSITION Good food habits should start early in life, because, as we have seen, they quite literally build the framework for future health. But a nefarious combination of physiological demands and social influences con- spires to rob many American girls of, among other things, their best shot at what Barrett-Connor calls âthe optimal bone mass to which they are genetically entitled,â adding to their risk of osteoporosis and fracture in their later years.4 During the very years that they need to be laying down the calcium supply in bone that must last a lifetime, as well as other 122
CHAPTER 7 Eating for a Healthy Life TABLE 7-1 The Nine Dietary Guidelines 1. Reduce total fat intake to 30 percent or less of your total calorie consumption. Reduce saturated fatty acid intake to less than 10 percent of calories. Reduce cholesterol intake to less than 300 milligrams daily. 2. Eat five or more servings of a combination of vegetables and fruits daily, especially green and yellow vegetables and citrus fruits. Also, increase your intake of starches and other complex carbohydrates by eating six or more daily servings of a combination of breads, cereals, and legumes. 3. Eat a reasonable amount of protein, maintaining your protein consumption at moderate levels. 4. Balance the amount of food you eat with the amount of exercise you get to maintain appropriate body weight. 5. It is not recommended that you drink alcohol. If you do drink alcoholic beverages, limit the amount you drink in a single day to no more than two cans of beer, two small glasses of wine, or two average cocktails. Pregnant women should avoid alcoholic beverages. 6. Limit the amount of salt (sodium chloride) that you eat to 6 grams (slightly more than 1 teaspoon of salt) per day or less. Limit the use of salt in cooking and avoid adding it to food at the table. Salty foods, including highly processed salty foods, salt-preserved foods, and salt-pickled foods, should be eaten sparingly, if at all. 7. Maintain adequate calcium intake. 8. Avoid taking dietary supplements in excess of the U.S. Recommended Daily Allowances in any one day. 9. Maintain an optimal level of fluoride in your diet and particularly in the diets of your children when their baby and adult teeth are forming. SOURCE: Institute of Medicine, Eat for Life: The Food and Nutrition Boardâs Guide to Reducing Your Risk of Chronic Disease, 1992, page 6. nutritional stores to see them through the challenges ahead, they decrease their intake of dairy products as they face an intense and growing cultural pressure that competes with their need for a nutritious, well-balanced diet. Women around the world, of course, face social challenges to 123
I N H E R O W N R I G H T eating properly. In many developing countries, Scrimshaw notes, food is scarce for everyone, but social practices make the situation even worse for women. They frequently eat only after the men and boys have finished, for example, getting only what is left over, rarely the most desirable foods. The best, most nutritious delicacies may in fact be specifically earmarked for males. âBoth in absolute terms and in relation to recommended daily allowance[s], women and girls eat less than men and boys,â Scrimshaw says. âDeficiency, of course, is greatest among the lowest socioeconomic class. And women get less food because theyâre seen as both less needy and also less deserving. The physical size and strength of men is equated with greater needs, to a degree where women [in developing countries] donât get enough.â5 Even nutritional experts may reinforce this misconception, she notes. A health program in Guatemala, for example, proposed giving male plantation workers an iron supplement. But an anthropologist familiar with the areaââand I guess I can say now it was my mother,â Scrimshaw confidesâdisagreed. âWomen got up before the men to prepare meals and look after children, went to the fields and did the same work as men, returned home to tend children, kitchen gardens and small animals raised for food and income, and were also responsible for purchasing food and keeping the house clean,â she goes on. âOften, all of this was done while pregnant and lactating. The men rose later in the morning, had fewer family-related chores and rested in the evening after work.â6 âIf anyone needed that iron supplementation, it was the women,â she goes on. âWhatâs more, the men and women had different spending patterns for income. Women were more likely to put extra money into food or books or clothes for children; men were more likely to spend money on alcohol or something like a radio. The assumption that additional income produced by men would automatically go into childrenâs mouths was incorrect.â7 Studies in other countries find similar results. Many cultures prescribe special eating patterns during such nu- tritionally sensitiveâyet spiritually or socially powerfulâperiods as men- struation, pregnancy, and nursing, whether to protect the community at large from the spiritual danger of menstrual blood or to ensure a healthy 124
CHAPTER 7 Eating for a Healthy Life child. In some places, menstruating or expectant women are forbidden to cook or to eat certain foods. In others, they get special helpings of highly nourishing treats. And following birth, Scrimshaw notes, âin many cul- tures, female infants and children receive less food, less health care and less attention.â8 Such early deprivation, of course, often results in the prob- lems of bone structure, pelvic development, anemia and the like, that take such a toll during childbirth and in later life. American girls, of course, generally need not worry about an actual physical scarcity of food, or about disease and poverty leaving them too weak and depleted to grow and function at their best. But poverty is not the only social force that can deprive people of the nourishment they need. From the time an American female begins putting on the fat that heralds her coming reproductive powers, from the time she begins to think about herself in relation to the opposite sex, the culture around her insists that an attractive female must be thin. For many women, this de- mand lasts at least through the end of their reproductive years. And all too often, it translates into a mandate to scant on sensible nutrition. Two or three generations ago, this pressure was less intense. Curves were the fashion; men hankered after a shapely âbroadâ who met that description in various strategic locations. But the prepubescent con- tours of todayâs top fashion models and film stars contrast startlingly with the amplitude of erstwhile sex goddesses like Marilyn Monroe and Sofia Loren, not to mention the âsweater girlsâ and pinups who tantalized GIs during the 1940s. Over recent decades, though everyday Americansâ aver- age weight has in fact risen, the celluloid and video ideal of feminine beauty has shrunk to a standard of slimness utterly unattainable by the great majority of ordinary people. But genetic and nutritional impossibility cannot dissuade large numbers of girls and women, especially in the teens and twenties, from striving for the approved degree of stylish emaciation. Such unrealistic images produce a situation that would be ridiculous were it not so danger- ous. Not only are about one-fourth of all adult Americans trying to lose weight, but so are about 11% of those who consider their weight âabout rightâ and even 4% of those who think themselves underweight. This last, and most troubling, group of dietersâa likely source of future eating disorder victimsâincreased fivefold just between 1985 125
I N H E R O W N R I G H T and 1990.9 A substantial number of women at or slightly above their ideal weight are âobsessed with dieting and weight loss,â says IOMâs Commit- tee to Develop Criteria for Evaluating the Outcomes of Approaches to Prevent and Treat Obesity. Cultural dictates, the committee believes, fuel âthe current emphasis on thinness in this and many other [affluent] coun- tries,â mainly among women, and help to shape the attitudes of both genders.10 These pressures convince many, especially adolescent girls, to put their figure ahead of their future needs. Eating habits may well be worst during lifeâs second decade, but some important nutritional de- mands, most particularly for calcium, are especially high. Though Ameri- can men generally get enough of this bone-building mineral, most women get less than the recommended dietary allowance, especially during the prime bone-building years between puberty and 30. âUnfortunately, many female teenagers are more concerned about having thin thighs than ad- equate calcium and prefer to drink a diet colaâ rather than a glass of milk, Barrett-Connor laments.11 Indeed, getting adequate nutrition while keeping weight low can take careful planning of a kind not encouraged by media advertising that simultaneously pushes both high-fat fast foods and snacks and low- calorie, artificially sweetened diet foods. Studies of military women, for example, mostly young and, if anything, more physically fit than their civilian counterparts, highlight the difficulty. For those who have chosen a career in the armed services, âbody weight and thinness mean more than just aesthetics and health,â write Colonel Karen Fridlund of the Office of the Surgeon General and colleagues.12 Meeting specified weight limits for oneâs gender is a prerequisite for continuing a career. As only about half of Army women studied exercise three or more times a week, diet appears their main method of weight control. Many soldiers get most or all of their food through Army ra- tions, which, in their various freshly cooked, âpre-plated,â and freeze- dried versions, are designed to provide the Military Recommended Daily Allowances. The prescribed quantities of certain nutrients exceed the ci- vilian standard to allow for soldiersâ greater physical activity. Military males generally appear able to meet these goals within a calorie supply that maintains their weight. 126
CHAPTER 7 Eating for a Healthy Life Whether in uniform or out, though, women generally eat less than men, even of their own height or weight. Studies have therefore found Army women falling short in needed energy, protein, and, like their civilian sisters generally, calcium and iron. Indeed, Fridlund and colleagues speculate that, as the rations now stand, women would have to eat almost 30% more calories than necessary to maintain their weight in order to get their full recommended supply of those two minerals exclu- sively from food.13 Considering that soldiers eat meals professionally de- signed to provide adequate nutrition, and probably much better balanced than young Americans would pick on their own, the chances that a young woman who chooses her own food could do any better are small indeed. So while women in many foreign countries struggle daily just to get enough to eat, and while dietary deficiencies account for many deaths from childbirth and disease in developing countries around the world, Americans worry not about under- but overconsuming calories, not about malnutrition but about overweight. And though some of this worry, especially among the young, involves frivolous concerns about appearance, much of it, especially as women age, involves far more serious considerations of health. Obesity has in fact been described as âthe single most prevalent nutrition problem in the United States.â14 A WEIGHTY PROBLEM âLife in the United States is conducive to obesity,â is a truth obvious not only to the obesity committee, but also to anyone who examines the statistics showing that Americans are fatter and heavier than ever before.15 According to some counts, fully 35% of women and 31% of men older than 20 fall into the category of obese.16 But while all authori- ties agree that excessive heft carries significant health hazards, not every- one agrees on how to define it. âOverweightâ and âobeseâ both describe people who tip the scales at higher than the recommended poundage for their height and build. In common parlance, the former denotes the person a bit above the mark and the latter a person extremely so. Strictly speaking, however, the terms do not occupy a single continuum. In technical language, someone is overweight if he weighs too much and obese if his body contains too 127
I N H E R O W N R I G H T much fat. Usually, of course, these conditions go hand in hand, but one can and sometimes does exist without the other. A zealous body builder, for example, might carry a good number of extra pounds as solid muscle. An inactive âcouch potatoâ or an elderly person, on the other hand, may be simultaneously thin and flabby. âFor practical purposes, however,â concludes the committee, âmost overweight people are also obese.â17 But, as if to exemplify the general interchangeability of the terms, the committee itself chooses to use the term âobesityâ âconsistently in refer- ring to the condition of excess body weight.â18 If defining the word requires precision, deciding exactly whom it applies to involves even finer distinctions and sometimes complicated methodology. The several available methods for gauging body fat, which include underwater weighing, measuring the thickness of skin folds, using dual-energy X-ray absorptiometry, and sending a tiny electric current through a personâs body for bioelectric impedance analysis often require skilled examiners using sophisticated equipment. When these anthropo- metric tests are used, men and women are usually considered obese at 25 and 30% body fat, respectively.19 But the two most popular methods of determining overweight use mathematical comparisons of weight and height. Weight-for-height tables have been compiled from information on millions of individuals by both insurance companies like Metropolitan Life, whose 1959 and 1983 efforts remain in wide use, and the federal government, which issued its own in 1990. Various versions of such tables have come under attack for specifying weight categories too wide or too narrow, too heavy or too light, or permitting or not permitting weight to creep up toward middle age. Another widely used indicator, the body mass index (BMI), is popu- lar in research and health care. It divides a personâs weight in kilograms by the square of his height in meters. Thus, BMI = kg/m2. The values are ordinarily presented in tables that can also be translated into inches and pounds. (See Table 7-2.) Ascertaining an individualâs proportion of fat is complicated, whatever method is used. But figuring out when that number becomes a potential health problem is more complicated still. In 1993 the NIH Na- tional Task Force on Prevention and Treatment of Obesity pegged that threshold at a BMI of 25 or more through age 34 and at 27 for ages 128
TABLE 7-2 Body Weight (in pounds) According to Height (in inches) and Body Mass Index Body Mass Index 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 Height Body Weight 58 91 95 100 105 110 114 119 124 129 133 138 143 148 152 157 162 59 94 99 104 109 114 119 124 129 134 139 144 149 154 159 164 169 60 97 102 107 112 117 122 127 132 138 143 148 153 158 163 168 173 61 101 106 111 117 122 127 132 138 143 148 154 159 164 169 175 180 CHAPTER 7 62 103 109 114 120 125 130 136 141 147 152 158 163 168 174 179 185 63 107 113 119 124 130 135 141 147 152 158 164 169 175 181 186 192 64 111 117 123 129 135 141 146 152 158 164 170 176 182 187 193 199 129 65 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 66 118 124 131 137 143 149 156 162 168 174 180 187 193 199 205 212 67 121 127 134 140 147 153 159 166 172 178 185 191 198 204 210 217 68 125 132 139 145 152 158 165 172 178 185 191 198 205 211 218 224 69 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 70 133 140 147 154 161 168 175 182 189 196 203 210 217 224 231 237 Eating for a Healthy Life 71 136 143 150 157 164 171 179 186 193 200 207 214 221 229 236 243 72 140 148 155 162 170 177 185 192 199 207 214 221 229 236 244 251 73 143 151 158 166 174 181 189 196 204 211 219 226 234 241 249 257 74 148 156 164 171 179 187 195 203 210 218 226 234 242 249 257 265 75 151 159 167 175 183 191 199 207 215 223 231 239 247 255 263 271 76 156 164 172 181 189 197 205 214 222 230 238 246 255 263 271 279 continued on next page
TABLE 7-2 Continued Body Mass Index 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Height Body Weight 58 167 172 176 181 186 191 195 200 205 210 214 219 224 229 233 238 59 174 179 184 188 193 198 203 208 213 218 223 228 233 238 243 248 60 178 183 188 194 199 204 209 214 219 224 229 234 239 244 250 255 I N 61 185 191 196 201 207 212 217 222 228 233 238 244 249 254 260 265 62 190 196 201 206 212 217 223 228 234 239 245 250 255 261 266 272 H 63 198 203 209 214 220 226 231 237 243 248 254 260 265 271 277 282 E R 64 205 211 217 223 228 234 240 246 252 258 264 269 275 281 287 293 O 65 210 216 222 228 234 240 246 252 258 264 270 276 282 288 294 300 130 W N 66 218 224 230 236 243 249 255 261 268 274 280 286 292 299 305 311 R 67 223 229 236 242 248 255 261 268 274 280 287 293 299 306 312 319 68 231 238 244 251 257 264 271 277 284 290 297 304 310 317 323 330 I G H T 69 236 243 250 257 263 270 277 284 290 297 304 311 317 324 331 338 70 244 251 258 265 272 279 286 293 300 307 314 321 328 335 342 349 71 250 257 264 271 279 286 293 300 307 314 321 329 336 343 350 357 72 258 266 273 281 288 295 303 313 317 325 332 340 347 354 362 369 73 264 272 279 287 294 302 309 317 324 332 340 347 355 362 370 377 74 273 281 288 296 304 312 319 327 335 343 351 358 366 374 382 390 75 279 287 294 302 310 318 326 334 342 350 358 366 374 382 390 398 76 287 296 304 312 320 328 337 345 353 361 370 378 386 394 402 411 SOURCE: Institute of Medicine, Weighing the Options: Criteria for Evaluating Weight-Management Programs, 1995, Table 2-1, pp. 41â42.
CHAPTER 7 Eating for a Healthy Life beyond that, basing its decision on studies correlating weight and health in various populations. Other authorities disagree, however, arguing that weight gain with age is not necessarily either acceptable or desirable.20 The National Center for Health Statistics, on the other hand, takes a somewhat different approach, eschewing the term âobesityâ alto- gether. It distinguishes âoverweightâ and âextreme overweight,â using the 85th and 95th percentiles, respectively, of 20- to 29-year-olds mea- sured in the 1976-1980 Second National Health and Nutrition Examina- tion Survey (NHANES II). These cutpoints correspond to BMIs of 27.8 and 31.1 for men and 27.3 and 32.3 for women and are based on popula- tion distributions and not health experience.21 NHANES III, completed in 1994, provides the most up-to- date figures available on the American physique. Information collected between 1988 and 1991 is now available and finds, by NCHS standards for BMI, a whopping 33% of men and women over 20 overweight and 14% severely so.22 Both of these figures represent increases over previous surveys, and a 36% increase in just under 30 years.23 People in nearly all age categories are getting heavier.24 (See Table 7-3.) We Americans generally gain weight as we age; among women, overweight is commonest between 50 and 59. More women than men of every race register as overweight, although the gender differential among whites is only about half of a percentage point, between 31.6% of men and 32.1% of women. Just under half of African American and Mexican- American women fall into the category of overweight, however, exceed- ing their men by about 17 and 8 percentage points, respectively. In certain age groups, as many as 80% of African Americans, Native Americans, Pacific Islanders, and Hispanics are overweight or obese.25 These apparent racial differences, however, may really repre- sent sociology and culture rather than genes. In general, the poorer and less educated weigh more, a correlation especially strong among women. Only 29% of Americans who have been to college are overweight, as opposed to 36% of the high school graduates and 39% of those with less than a high school diploma.26 Indeed, some studies suggest that African American and white women hold somewhat different views about weight, with African American women less concerned about being thin. The added stress of lower-class life could also make weight loss more difficult, 131
I N H E R O W N R I G H T TABLE 7-3 Suggested Weights for Adults Weight (pounds)b Heighta 19â34 Years Old 35 Years Old and Over 5â0â 97â128 108â138 5â1â 101â132 111â143 5â2â 104â137 115â148 5â3â 107â141 119â152 5â4â 111â146 122â157 5â5â 114â150 126â162 5â6â 118â155 130â167 5â7â 121â160 134â172 5â8â 125â164 138â178 5â9â 129â169 142â183 5â10â 132â174 146â188 5â11â 136â179 151â194 6â0â 140â184 155â199 6â1â 144â189 159â205 6â2â 148â195 164â210 6â3â 152â200 168â216 6â4â 156â205 173â222 6â5â 160â211 177â228 6â6â 164â216 182â234 NOTE: The higher weights in the ranges generally apply to men, who tend to have more muscle and bone; the lower weights more often apply to women, who have less muscle and bone. aWithout shoes. bWithout clothes. SOURCE: Institute of Medicine, Weighing the Options: Criteria for Evaluat- ing Weight-Management Programs, 1995, Table 2-2, page 45. some observers believe.27 Of course, as yet unknown metabolic differ- ences among racial groups may also contribute. If culture and values play such an important role, obesity is clearly a medical disorder unlike most others. âOne remarkable feature of obesity is that its management requires a great deal of effort from the individual. Health-care providers or counselors can offer only advice and technical support at this time,â the obesity committee notes.28 132
CHAPTER 7 Eating for a Healthy Life Neither the public nor the health profession expects people, through their own efforts and the exercise of will, to cure themselves of chronic diseases like diabetes or arthritis, nor would we blame them if they tried and failed. Only a small number of the extremely obese, how- ever, are appropriate candidates for an effective medical intervention like gastric surgery. Available drugs, for example, are not generally considered safe for use over the long term. Stopping medication, moreover, often leads to gaining back the weight lost. For such an immensely common long-term condition, however, medical science provides not much more than counsel, chastisement, and encouragement. âThere are few diseases in which health-care providers can offer so little for those who struggle so much,â the obesity committee believes.29 Obesity is also unusual among medical conditions because âits victims suffer discrimination,â the committee continues. âPerhaps most laypersons, health-care providers, and even obese individuals themselves do not perceive the metabolic nature of the disease and thus view obesity as a problem of willful misconductâeating too much and exercising too little.â Two out of three family doctors surveyed, for example, thought that obese people âlack self-control,â and more than a third believed them âlazy.â Third-year medical students expressed similar views, finding them âunpleasant, worthless, and bad.â30 Clearly, though, it is our lack of knowledge about the conditionâs roots rather than the individuals struggling to overcome it that should be criticized. An obese person trying to control her weight faces âa continuous, lifelong struggle with no expectation that the struggle re- quired will diminish with time,â the committee believes. Even a tempo- rary lapse brings immediate consequences. Why should losing weight be such a struggle? For most of human history, and for many people even today, the abilityânot to men- tion the opportunityâto put on extra pounds, far from posing a threat to health, was a priceless advantage in the fight for survival. We Americans generally live in a world of plentiful food and scant exercise. For most of humankind, life has always been the reverse: endless toil and unpredict- able provisions. Women, in particular, seem programmed to gain weight. In- deed, because bringing a healthy child to term takes 55,000 calories, and 133
I N H E R O W N R I G H T months or years of nursing takes scores of thousands more, the speciesâ very survival has depended in large measure on womenâs ability to sock away energy in the form of adipose tissue.31 Among less affluent peoples, ample feminine dimensions connote health, prosperity, and fertility, in short, the presumed ability to sustain a pregnancy regardless of the vagaries of harvest or hunt. Indeed, no girl can menstruate unless and until her body attains a sufficient ratio of fat to lean. When women become too thin, whether because of famine, athletic training, or anorexia, their peri- ods simply stop. Over the past 100 or more years, improving diets and, possibly, reduced exerciseâeither or both of which could produce larger, heavier girlsâappear to account for the 3-year drop in the average age of menarche (to the middle of the thirteenth year) between the early decades of the last century and the middle of this.32 MOTHERS OF RETENTION This close and specifically female tie between fat and fertility lies at the root of what many women consider their basic weight problem, the time they spent bearing and nursing their children. Nutrition and weight become literally vital issues during pregnancy. Too little weight gain can, as both medical and lay people have long understood, make the difference between safety and danger, between health and sickness, and, sometimes, between life and death, for both mother and child. It has been obvious since ancient times that a womanâs ability to nourish her baby both in the womb and at the breast essentially deter- mines his chances of survival. What has been much less clear is what childbearing and nursing mean to the motherâs own long-term well-be- ing. Until very recently, in fact, both clinicians and researchers have con- sidered nutrition during and after pregnancy essentially as it affects the infant and the birth. Preparing its 1991 report, for example, IOMâs Sub- committee on Nutrition During Lactation could locate âno studies that evaluated the effects of maternal nutrition on long-term outcomes related to lactation.â It did, however, find the reason for this astounding omis- sion, as well as for the âlack of interest in maternal outcomesâ in general, to be âunclear.â33 It is clear, however, that extremely obvious, even el- ementary, questions about the consequences of childbearing for the mother 134
CHAPTER 7 Eating for a Healthy Life have remained unanswered and, until the past decade or so, essentially unasked. The mother nourishes the fetus exclusively from her own body. What she eats, doctors have long known, therefore figures importantly in fetal growth. But the babyâs size figures just as crucially in both motherâs and babyâs chances of not dying in childbirth. In an age when maternal death is a rarity and safe cesareans commonplace, we need an effort of imagination to recall that, for the overwhelming bulk of the human expe- rience, and in some places to this day, pregnancy and delivery took a woman through a passage fraught with mortal peril. Shakespeare por- trayed an adult who had survived being âfrom his motherâs womb un- timely rippâdââas had Macbethâs nemesis, Macduffâas so surpassingly uncommon that his identity became the hinge on which the great tragedyâs plot turned. Only in recent generations has such an operation ceased to be a desperate last resort that generally ended in catastrophe for mother, child, or both. And one of the commonest situations requiring this drastic inter- vention was a baby too large to pass through his motherâs birth canal. Until the early twentieth century, therefore, doctors seeking easier and safer deliveries restricted the motherâs diet to keep the fetal weight down. The first published study on the subject, appearing in 1901, in fact noted that limiting a pregnant womanâs intake could drop her babyâs birth weight by 400 to 500 grams.34 By the 1920s, however, with medical care and maternal sur- vival improving, doctors began to consider that the motherâs weight gain also related to the babyâs growth, indeed, that her weight gain could serve to indicate herâand, presumably, the babyâsâstate of nutrition. Studies definitely proved a connection between the amount of weight she gained and the babyâs size at birth. Doctors now began to routinely track moth- ersâ weight, paying more attention to excess rather than inadequate pound- age. The former, they believed, indicated a risk of toxemia and its poten- tially fatal consequences. Avoiding salt became a common tactic for controlling gain, which doctors advised should amount to no more than 15 pounds altogether. On average, according to studies published in the late 1930s and early 1940s, women put on only about 20 pounds.35 By the early 1970s, however, researchers were convinced that 135
I N H E R O W N R I G H T a larger gain, 27.5 pounds, represented the âphysiological normalityâ for a healthy young woman carrying her first pregnancy. They also believed that the motherâs weight both before and during pregnancy exerted sepa- rate, but cumulative, influences on the babyâs weight at birth. Heavier women who also put on considerable weight during pregnancy bore big- ger babies than did thin women who put on a similar number of pounds.36 During the mid-1970s, constituent bodies of the Food and Nutrition Board, the American College of Obstetricians and Gynecolo- gists, and the American Dietetic Association all recommended 20 to 25 pounds as the desirable range, to go on pretty steadily from the thirteenth week onward, ideally between 2.2 pounds (1 kilogram) and 6.6 pounds for each of the last 6 months.37 By the late 1970s, textbooks were suggest- ing an end to weight limits and, within reason, permission for women to eat what they wanted. It also became clear that gestational weight gain should bear some relationship to a motherâs weight before conception, with thinner women being advised to gain more. Over the past half century, in short, the recommended gain has essentially doubled, from 15 to about 30 pounds.38 That figure of 30 pounds is merely an average, however. Study- ing a group of women who gave birth to healthy babies, âyou see that the range of weight gains was quite broad,â King says; âa few women didnât gain any weight at all and as many as 5 percent gained over 51 pounds.â The largest single group put on between 26 and 30 pounds, but they made up only 20% of participants.39 In the heterogeneous American popu- lation, no one recommendation can serve for everyone. Many factors, including age and ethnic background, determine the weight gain appro- priate for a given individual. For example, African Americans need to gain more than whites on average to bear babies of the same weight, and girls who become pregnant within a year or two of menarche need to gain more than girls who are older. Obese women, on the other hand, might do well to gain less because they have higher rates of complicated births and infant mortality than women of normal weight or below.40 Weight gain depends largely on how much a woman eats. Equally crucial to her own and her babyâs health, however, is exactly what constitutes that intake. Studies have consistently shown that pregnant Americans average less than the Recommended Daily Allowances of eight 136
CHAPTER 7 Eating for a Healthy Life important nutrients: vitamins B6, D, E, and folate; calcium, iron, magne- sium, and zinc.41 Adequate iron is particularly crucial to safe delivery, and, as we have seen, anemia is a major cause of maternal death worldwide. Discouragingly, though, research in Europe shows that, in the pregnancy committeeâs words, âwomen in industrialized countries often cannot meet their iron needs from diet alone.â42 Expectant mothers and their doctors thus face an important question: should they make up these nutritional deficiencies with supple- ments? Though supplementation can solve one problem, it can cause another: in large quantities, minerals such as iron, selenium, and zinc, and vitamins including A, B6, C, and D can prove toxic to the fetus. As science cannot predict how much of a given substance consumed by the mother will cross the placenta to the fetus, experts advise that a carefully planned diet be the main source of nutrition. All pregnant Americans, however, need to receive iron in supplementary form, and appropriate amounts of B6 have recently been shown to guard against the neural tube defects responsible for spina bifida and hydrocephalus. Given the centrality of an adequate diet to a healthy mother and child, the fate of poorly nourished women and those lacking the means to buy proper food becomes all the more crucial. In 1974, the U.S. Department of Agricultureâs Special Supplemental Food Program for Women, Infants and Children (WIC) began to provide low-income moth- ers and their children food packages and vouchers as well as nutrition education and counseling. Studies show that WIC participants get sub- stantially more of the nourishment they need than comparable women who do not participate.43 The WIC program strives to give women who face special nutritional problems the knowledge and wherewithal to eat properly. And that, experts believe, should be the care providerâs goal for every expect- ant mother. Early and adequate prenatal care becomes an absolute neces- sity if, as King recommends, all expectant mothers are to âreceive an assessment of their dietary practicesâ and requirements in time to make a difference. Particular attention should go to âscreening for women who may have problems relating to their lifestyle.â44 These include smoking, drug abuse, previous extreme dieting for weight loss, multiple pregnan- cies, and pica, the practice of eating nonfood substances such as laundry 137
I N H E R O W N R I G H T starch. Such an assessment can determine both the amount of weight an individual might sensibly gain and whether she needs any special dietary supplements. NURSING MOTHERS Only a minority of American mothers breastfeed for any sub- stantial amount of time. Although experts now recommend motherâs milk as the optimal food for all infants, just over half of new mothers undertake to nurse their newborns. After five or six months, fewer than half of those who started, and under one-fifth of all mothers, are still feeding their babies at the breast. Nor do the mothers who nurse represent a cross section of the nation. Twice as many married mothers as unmarried breastfeed, nearly twice as many whites as African Americans, and nearly twice as many residents of the mountain and West Coast states as of the Southeast. (See Figures 7-1 and 7-2.) The more educated a woman and the higher her family income, the more likely she is not only to begin breastfeeding but also to persevere.45 Breastfeeding has not always been the choice of the nationâs best informed and most affluent, however. Early in the twentieth century, as is still true today, sophisticated people who kept up with scientific developments overwhelmingly chose the latest in nutritional methods. These individuals of course included independent-minded women who sought broader career horizons than their old-fashioned mothers. For many of our mothers and grandmothers, the most up-to-date choice was feed- ing their babies formula from bottles. At a time when the promise of better infant survival rates was becoming real, making sure that a baby got the proper amount of milk seemed rational and prudent. At a time when only those wealthy enough to afford wet nurses could avoid nursing their children at their own breasts, breastfeeding symbolized not the most for- ward-looking nutritional and ecological awareness but an apparently out- moded domesticity. Thus, as the newer, more âscientificâ bottlefeeding method spread from the opinion-making elite to the broader public, the percentage of American women breastfeeding fell through most of this century. About three-quarters of babies born in the late 1930s were nursed. By the early 1970s the number was under one-quarter.46 138
CHAPTER 7 139 Eating for a Healthy Life FIGURE 7-1 Breastfeeding initiation rates, by census region and ethnic background (W: white, B: black, and H: Hispanic). SOURCE: Nutrition During Lactation, Institute of Medicine, 1991, Figure 3-2, page 34.
I N H E R O 140 W N R I G H T FIGURE 7-2 Breastfeeding rates at 5â6 months postpartum, by census region and ethnic background (W: white, B: black, and H: Hispanic). SOURCE: Nutrition During Lactation, Institute of Medicine, 1991, Figure 3-3, page 35.
CHAPTER 7 Eating for a Healthy Life By the middle of the 1970s, however, a new understanding of breast milkâs unique benefits began changing mothersâ opinions and feed- ing habits, again with the best-off and best educated leading the way toward apparently new and apparently more natural methods, such as breastfeeding. During this same period, natural childbirthâa return to delivery with a minimum of anestheticâalso returned to favor, ousting the more aggressive anesthetic and surgical methods that had earlier seemed to be the ultimate in medical progress. The advantages of breastfeeding derive, of course, from the fact that, because the food comes from the motherâs own body, it matchlessly suits the infant who receives it. But that advantage also means that the milkâs constituents can come only from either the motherâs food supply or her own bodyâs stores of nutrients. Because research has concentrated overwhelmingly on the supply and composition of the milkâin other words, on the babyâs needs rather than the motherâs experienceââthe nutritional status of lactating women has not been thoroughly or exten- sively studied,â the lactation subcommittee notes.47 It does appear that well-nourished American women generally have no difficulty providing their babies ample nutrition. Nursing de- mands about 640 calories per day, more than twice the 300 needed each day to support the last six months of pregnancy.48 A daily 2,700 calories rich in sources of calcium, protein, vitamins, and minerals appears to supply essentially all the nutrients a woman needs both to nourish her baby and to sustain or replenish her own bodyâs stores of nutrients, with the possible exception of calcium and zinc. If her diet falls much below that calorie level, however, or if it is substantially less nutritious than the average American intake, she will most likely lack other vitamins and minerals as well.49 The nursing mothers most at risk for eating poorly belong, not surprisingly, to those groups who generally eat poorly in any case: young adolescents, especially those of poor families; African Ameri- can women; and the poor. Here, again, the WIC program can make a major difference. THE LONG RUN Of all that science does not yet know about maternal nutrition 141
I N H E R O W N R I G H T during pregnancy and lactation, perhaps the least known and least studied aspect is what they ultimately do to the motherâs body. The large supplies of nutrients as well as the drastic adjustments needed to nourish an em- bryo from a single cell to a 7- or 8-pound newborn and then to feed that baby while he doubles his weight in the first 4 to 6 months âinvolve nearly every maternal organ system,â according to the lactation subcom- mittee.50 And increasing evidence suggests that, in case a motherâs supply proves inadequate to satisfy them both, the babyâs needs often take prece- dence over her own, stripping her own stores to supply him. A poorly nourished woman thus grows her baby in part at her own bodyâs expense. But we do not know what specifically this drain of calories, minerals, and other substances does to even a healthy, well-nourished mother over the long term. A woman bestows about 30 grams of calcium on her baby during pregnancy, for example, and another 8 to 10 grams during each month she nurses. A woman weighing in the range of 120 pounds thus provides 3% of her own bodyâs total calcium before her baby is even born and another 5% by the time she has nursed for 6 months. Some evidence existsâfrom animal rather than human studies, howeverâ that her ability to absorb calcium from food may rise during lactation. But even so, replacing what she loses means consuming hundreds of milli- grams each day on top of the 1,000 daily milligrams recommended to all women.51,52 Does this massive calcium transfer contribute to later osteoporo- sis? âData suggest that acute bone loss is likely to occur during lactation,â the subcommittee notes, but studies also indicate that the metabolism of bone changes to accommodate these tremendous demands without devas- tating the motherâs skeleton. Some researchers even deem it likely that breastfeeding may hasten the deposition of calcium in at least some of the motherâs bones. And studies have found higher bone mass among post- menopausal white women who had nursed than among those who had not. But the evidence about a possible relationship between the vital female function of nourishing oneâs children and one of the most preva- lent feminine diseases of later life remains, in the subcommitteeâs words, âinconclusive.â53 The other big reproductive question weighing, as it were, on womenâs minds is the connection between pregnancy, lactation, and obe- 142
CHAPTER 7 Eating for a Healthy Life sity. Here there is a body of research, and, alas, it does confirm âwomenâs sense that overweight in mid-life is related to reproductive events,â says Kathleen Maher Rasmussen, Sc.D., R.D., professor of nutritional sciences at Cornell. Women âweigh more and are fatter after delivery than they were at conception.â The more pounds a pregnant mother puts on before birth, the more she will take off afterward, but the more she will also weigh when next she conceives.54 Lactation, however, takes off pounds and fat. Mother rats, at least, are leaner when they finish nursing than they were when they conceived. Whether the same goes for women is not yet clear. Those studied, generally college-educated whites, lose, on average, a pound or two a month for the first half year or so they nurse.55 The loss continues in later months, but its rate slows. But women who nurse differ systemati- cally from the general population, and the nature of that differentness has changed over recent decades, facts that considerably complicate the statis- tics of recent research. And since rats all nurse for essentially the same amount of time, and never supplement their babiesâ diets with bottles or foods, their experience makes them far more uniform research subjects than human mothers, who nurse as long and as often as they wish and feed their children whatever else they please on the side. This and just about every other aspect of human reproduction is now discretionary, in this country at least. Women thus have âchoices about how much they will weigh at mid-life,â Rasmussen believes, and several of the most important have to do with reproduction. The 2 pounds or so that two or three children will add, on average, to their motherâs figure probably will not weigh heavily in her decision making. But more children than that may add a considerably larger amount of cumulative poundage. Thus, staying at the low end of the recommended weight gain range in each pregnancy might save her five or more retained pounds. Deciding to breastfeed will also help her get back to where she started, especially if she watches her calories during the time she nurses.56 THE LATER YEARS What she ate and did in earlier decades has obviously already said a good deal about a womanâs health before she passes into the last 143
I N H E R O W N R I G H T third of her life. Her peak bone density, determined by the calcium she ate or did not eat while young, is already a decade or two in the past. Her chances of breast and other reproductive cancers may well depend in part on the fat content of long-ago meals. But that is not to say that what she eats day to day does not still play a crucial role in maintaining her well-being. The question now be- comes not so much âhow we can achieve a longer life, although that would be nice,â says Irwin Rosenberg, M.D., director of the U.S. De- partment of Agricultureâs Human Nutrition Research Center on Aging at Tufts University, âbut the quality of life and the maintenance of a high degree of activity and the prevention of disabilityââfactors that, as we have seen, determine a womanâs ability to remain independent and in- volved in old age. âAnd there is where I think the nutrition and health nexus is particularly important.â57 Though an older woman can no longer affect the maximum mineral density of her bones, she can do a good deal to preserve the bone mass she has. In addition to calcium, vitamin D appears crucial to the state of the older skeleton, although blood levels of the vitamin tend to drop with age. Between the twenties and the eighties, a personâs skin loses as much as 60% of its ability to synthesize this vitamin in sunlight. The intestines also lose some of their ability to absorb it from food. With less of the vitamin available from former sources, studies show that supple- mentation can help preserve womenâs mineral density, making vitamin D a âcompellingâ issue in the question of how to retain bone mass, Rosenberg believes.58 Adequate levels of other vitamins may also help preserve other crucial capacities. As the bodyâs ability to absorb vitamin B12 drops, espe- cially in the presence of certain stomach conditions, so may cognitive function. Supplementation, however, may counteract this trend. Adequate supplies of zinc and B6 may slow the decline in immune function. And vitamin C may be useful in preventing cataracts, half again as common in women as in men.59 These problems with vitamins are only some of the bodily changes that make the later years nutritionally challenging. Indeed, at a time when a woman needs more of certain nutrients in her diet than ever before, her body conspires to make her need less food over all. Not only 144
CHAPTER 7 Eating for a Healthy Life are the bones thinning and the fat layer thickening, but an individualâs lean body mass declines with age and the muscle mass declines even more dramatically. With the drop in lean tissue, and especially in muscles, the personâs daily caloric requirement also falls at the rate of about 100 calories a decade. By the time it reaches 1,400 or 1,500 during the Social Security years, planning an adequately nutritious diet that does not put on weight becomes rather difficult. Exercise, which has been shown to build muscle even in a womanâs tenth decade, thus becomes crucial to maintaining the muscle mass needed for both mobility and nutrition. It also enables a woman to consume more food without gaining weight, thereby improv- ing her nutritional status if the choices are appropriate ones. THE DIETERâS DILEMMA Still, with culture and probably endocrinology and genetics against them, more Americans of all ages are dieting than ever before, spending billions of dollars each year on books, drugstore diet aids, special foods, and commercial weight loss programs, and the like, to shed un- wanted pounds. Regardless of how they go about it, though, whether they join a support group or enroll in a commercial plan, whether they buy special foods or count their calories or fat grams, most Americans experience results that are, in the words of Judith Stern, Sc.D., professor of Nutrition at the University of California at Davis, âquite dismal.â Even among those enrolling in obesity treatment programs, most âreally donât lose significant weight permanently.â According to one classic study, âabout a third wonât lose any weight, a third will lose significant amounts of weight, and a third will drop out.â And over a period of years, even the big losers regain much or all of their hard-lost flab.60 Thatâs because, even more dishearteningly, âbased on scientific evidence, it appears that some obese people, when they reduce their weight, are not made normal by weight reduction.â61 They may, for example, have started out with more fat cells than thinner individuals. For them, losing weight merely reduces the size but not the number of âthese cells waiting to be filled upâ again, Stern notes. Whatâs more, she adds, the enzyme lipoprotein lipase, present in fatty tissue, acts âas a gatekeeper enzyme to allow fat to enter the fat cell.â62 Obese individualsâand obese 145
I N H E R O W N R I G H T animals, tooâhave high levels of this enzymatic activity. It drops with their weight, but not to the levels typical of people of normal dimensions. Scientists speculate that the enzyme may thus ease the almost inevitable return of the unwanted pounds. Given these discouraging realities, Stern believes, âitâs no won- der that we rarely . . . design diets that effectively keep weight off forever. In addition, we donât really understand the fundamental causes of obesity, and obesity isnât a single disease.â63 Thatâs why those dissatisfied with their figures face such a plethora of options: diets of every description, self-help organizations, commercial groups, over-the-counter drugs, medi- cally supervised very-low-calorie diets and near-fasts, and, for the truly morbidly obese, surgery. These various methods combine limiting intake, usually by counting calories (800 to 1,200 daily in many low-calorie diets, below 800 daily in the very-low-calorie versions) or grams of fat; increas- ing physical activity, though this is often âan afterthought, rather than an integral partâ of the program, according to the obesity committee64; be- havior modification, such as trying to learn new habits through systems of rewards and self-monitoring; and medications that either dampen appetite or raise metabolism. Gastric surgery, appropriate only for certain very overweight individuals proven unable to control their obesity by conven- tional means, reshapes the stomach to limit intake. âIn this country, where successful weight management has proven an elusive goal for most obese individuals, the marketplace has provided many legitimate, as well as unfounded, products and services,â the obesity committee warns. The latter operators âplay legal tag with government regulatory agencies while taking financial advantage of a pub- lic desperate for answers. Improving the rate of success at weight manage- ment requires that would-be dieters understand that methods from thigh creams to esoteric diets must be substantiated by validated evidence of efficacy. They may represent no more than small countermeasures to an incompletely understood disorder of energy balance.â65 Indeed, those people who do manage to lose weight and keep it off seem to use methods neither exotic nor extreme. A fundamental part of most successful programs is exercise, which not only burns calories but alters metabolism. It must remain a continuing part of the dieterâs life, 146
CHAPTER 7 Eating for a Healthy Life however, because ceasing to exercise regularly also changes metabolism, but in the wrong direction. People who lose weight and maintain their loss are twice as likely as those who lose and then regain it to have designed their own programs. The details of each individualâs private systemâcounting calo- ries, cutting out certain categories of foods, keeping track of fats, adopting bits and pieces of various commercial methodsâseem less important, Stern believes, than the fact that âit was the individual who took responsibility for the weight loss program, not the health care worker.â66 Personal motivation and values are clearly central to successful diet control. In the Womenâs Health Trial, a precursor to WHI, women inspired by the possibility of reducing their known high risk for breast cancer succeeded in dropping their fat intake to a mere 20% of total caloriesâabout half of the average American levelâfor an impressive 24 months. And they did it by revising their total eating habits. Their success, Henderson speculates, could highlight âan area in which there could be a distinct gender difference linked with the responsibility for providing food. Itâs so much easier to change food planning, purchasing and preparation, than exercising restraint at the table.â67 And, indeed, men do generally choose a different approach to weight loss than do women, preferring exercise over dieting, the main female strategy. Also indicating the relationship of values and weight, white women appear to value weight loss somewhat more than African American women do. And lots of women, but many fewer men, who are not even overweight nonetheless actively diet. The effect of repeated cycles of loss and gainâso-called yo-yo dietingâon an individualâs health and future ability to maintain a reasonable weight remains controversial. Some believe that severe dieting results in a lower basal metabolism at the end than at the beginning, as the body goes into a crisis mode to avoid starvation. Others disagree. But one type of dieter at least, the nonobese teenage girl, âshould be actively discouraged,â Stern notes, because âshe may under some circumstances be setting herself up for obesity later on by depressing her basal metabolism.â68 Clearly, of course, the best solution would be for all women to avoid becoming overweight in the first place. Studies of both women who never gained excessively and those who lost weight and kept it off 147
I N H E R O W N R I G H T revealed an activist attitude, both toward keeping track of their weight and keeping physically active. Such women also took a more direct ap- proach to daily problems and stress than women who lost weight but relapsed into obesity.69 While government goals for the turn of the century call for no more than 20% of adults and 15% of adolescents to be obese, our nationâs efforts to shape up have not met with conspicuous success. And our national experience with smoking ought to encourage skepticism that deeply ingrained behaviors are anything but extremely difficult to change. Still, âthe most optimistic featureâ of this situation lies in the promise of current and future research, the obesity committee believes. âLearning more about how health-related behaviors develop and can be modified, together with the rapid growth of knowledge and better tools in areas such as molecular genetics and metabolic regulation, gives promise that at some point we will understand the underlying causes of obesity. This should ultimately lead to the development of programs that treat the underlying causes of obesity and not just the symptoms.â70 But we need not wait for these important discoveries to be realized before we adopt a far healthier attitude toward weight and nutri- tion. âMany people are obsessed with their weight in a culture that en- courages one both subtly and overtly to equate thinness with beauty and obesity with sloth,â the committee continues. Rather, the goal for every- one, regardless of their weight, age, or gender, should be to adopt a diet that maximizes health. For those whom overweight threatens to harm, the obesity committee advises the goal of weight management, which, in contrast to mere weight loss, judges eating and other habits âmore by their effects on the overall health of participants than by their effects on weight alone.â71 If every woman in America adopted this attitude, and the eat- ing pattern it implies, if we could break the tyranny of thinness and refocus on physical and mental well-being, then young girls would not starve themselves in the cause of fashion, mothers and babies would re- ceive the nutrition they need, and the rates of chronic diseases in the later years would fall. By âeating for lifeâ rather than for appearanceâs sake, women can not only lengthen their lives but enrich them. 148
CHAPTER 7 Eating for a Healthy Life NOTES 1. Barrett-Connor (1991), 4. 2. Ibid., 7. 3. King (1991), 7. 4. Barrett-Connor (1991), 9. 5. Ibid., 27. 6. Scrimshaw (1991), 3. 7. Ibid., 4. 8. Ibid., 11. 9. Weighing the Options: Criteria for Evaluating Weight-Management Programs, 54. 10. Ibid. 11. Barrett-Connor (1991), 9. 12. Fridlund et al. (1991), 8. 13. Ibid., 22. 14. Healthy People 2000: Citizens Chart the Course, 112. 15. Weighing the Options, 134. 16. Ibid., 27. 17. Ibid., 40. 18. Ibid. 19. Ibid., 40. 20. Ibid., 44-5. 21. Ibid., 43. 22. Ibid., 47. 23. Ibid. 24. Ibid., 47-8. 25. Ibid., 128. 26. Ibid., 126. 27. Ibid., 129. 28. Ibid., 38. 29. Ibid., 39. 30. Ibid. 31. Nutrition During Pregnancy, 169. 32. Ibid., 43. 33. Nutrition During Lactation, 196. 34. Ibid., 38. 35. Ibid. 36. Ibid. 37. Ibid., 39. 38. Ibid., 40. 39. King (1991), 4. 40. Ibid., 6. 41. Nutrition During Pregnancy, 269. 42. Ibid., 278. 43. Ibid., 269. 44. King (1991), 11. 45. Nutrition During Lactation, 33. 46. Ibid., 29, 30. 47. Ibid., 74. 48. Ibid., 213. 149
I N H E R O W N R I G H T 49. Ibid., 229. 50. Ibid., 197. 51. Ibid., 104. 52. Eat for Life: The Food and Nutrition Boardâs Guide for Reducing Your Risk of Chronic Disease, 21. 53. Nutrition During Lactation, 208. 54. Rasmussen (1991), 12. 55. Nutrition During Lactation, 74. 56. Rasmussen (1991), 14. 57. Rosenberg (1991), 3. 58. Ibid., 9. 59. Ibid., 12 , 13, 18. 60. Stern (1991), 2. 61. Ibid. 62. Ibid., 3. 63. Ibid., 2. 64. Weighing the Options, 83. 65. Ibid., 36. 66. Stern (1991), 8. 67. IOM 1992 Annual Meeting, 20. 68. Stern (1991), 20. 69. Ibid., 9. 70. Weighing the Options, 30. 71. Ibid., 131. 150