The Psychology of Eating: From Healthy to Disordered Behavior

Table of Contents

Cover

Table of Contents

Title

Copyright

List of Figures

Foreword

Acknowledgments

1: Introduction

The Aim of This Book

The Focus of This Book

The Structure of This Book

Further Reading

2: Healthy Eating

What Is Healthy Eating?

The Role of Diet in Contributing to Illness

The Role of Diet in Treating Illness

Who Has a Healthy Diet?

The Impact of Health Concerns

A Note on Measuring Food Intake

Conclusion

3: Food Choice

Developmental Models of Food Choice

Cognitive Models of Food Choice

Psychophysiological Models of Food Choice

Conclusion

4: The Meaning of Food

Food Classification Systems

Food as a Statement of the Self

Food as Social Interaction

Food as Cultural Identity

Measuring Beliefs About the Meaning of Food

Conclusion

5: The Meaning of Size

Media Representations

The Meaning of Sex

The Meaning of Size

Conclusion

6: Body Dissatisfaction

What Is Body Dissatisfaction?

Who Is Dissatisfied With Their Body?

Causes of Body Dissatisfaction

Consequences of Body Dissatisfaction

Conclusion

7: Dieting

Putting Dieting in Context

The Dieting Industry

What Is Dieting?

Dieting and Overeating

The Consequences of Dieting

Problems With Restraint Theory

Conclusion

8: Obesity

What Is Obesity?

How Common Is Obesity?

What Are the Consequences of Obesity?

What Are the Causes of Obesity?

Physiological Theories

The Obesogenic Environment

Problems With Obesity Research

Conclusion

9: Obesity Treatment

Doctors’ Beliefs About Obesity

Dietary Interventions

Should Obesity Be Treated at All?

The Treatment Alternatives

The Success Stories

Preventing Obesity

Conclusion

10: Eating Disorders

Anorexia Nervosa

What Are the Consequences of Anorexia Nervosa?

Bulimia Nervosa

What Are the Consequences of Bulimia Nervosa?

Causes of Eating Disorders

Conclusion

11: Treating Eating Disorders

Psychoanalytic Psychotherapy

Cognitive Behavioral Therapy (CBT)

Family Therapy

Inpatient Treatment

An Integrated Approach to Treatment

12: An Integrated Model of Diet

A Summary of the Literature on Diet

Common Themes Across the Literature on Eating Behavior

An Integrated Model of Diet

Conclusion

References

Author Index

Subject Index

End User License Agreement

List of Illustrations

1: Introduction

Figure 1.1 From healthy to disordered eating: A spectrum of diet.

2: Healthy Eating

Figure 2.1 Healthy eating.

Figure 2.2 Healthy eating in young adults.

3: Food Choice

Figure 3.1 Food choice.

Figure 3.2 Social eating.

Figure 3.3 The basics of the theory of reasoned action.

Figure 3.4 The basics of the theory of planned behavior.

Figure 3.5 Neurochemicals and food choice.

4: The Meaning of Food

Figure 4.1 The meaning of food.

Figure 4.2 Food and sex.

Figure 4.3 Food: Guilt versus pleasure.

Figure 4.4 Food as self-control.

Figure 4.5 Food and the family.

Figure 4.6 Food: Health versus pleasure.

Figure 4.7 Food and religion.

5: The Meaning of Size

Figure 5.1 Contemporary ideals of beauty.

Figure 5.2 The meaning of size.

Figure 5.3 The meaning of size: Control.

Figure 5.4 The meaning of size: Success.

6: Body Dissatisfaction

Figure 6.1 Body dissatisfaction.

Figure 6.2 Body silhouettes for adults.

Figure 6.3 Smoking as a response to body dissatisfaction.

7: Dieting

Figure 7.1 Diets work.

Figure 7.2 The central role for control.

Figure 7.3 Dieting and overeating.

Figure 7.4 The boundary model of overeating.

Figure 7.5 A comparison of the boundaries for different types of eating.

Figure 7.6 Overeating as relapse.

Figure 7.7 From dieting to overeating.

8: Obesity

Figure 8.1 Grades of obesity by height and weight.

Figure 8.2 The relationship between BMI and mortality.

Figure 8.3 Weight and depression.

Figure 8.4 Changes in physical activity and obesity.

Figure 8.5 Changes in food intake over 40 years.

Figure 8.6 Changes in calorie consumption and obesity.

Figure 8.7 Changes in the carbohydrate–fat ratio and obesity.

9: Obesity Treatment

Figure 9.1 Multidimensional packages for obesity.

Figure 9.2 Mortality and fitness level in individuals with a BMI > 25.4.Annals of Internal Medicine, 199 (1993), pp. 702–6.)

Figure 9.3 Searching for the magic bullet for obesity.

Figure 9.4 Gastric bypass.

Figure 9.5 Vertical stapled gastroplasty.

Figure 9.6 Life events and sustained behavior change.

10: Eating Disorders

Fig. 10.1 A common portrayal of an anorexic patient.

Fig. 10.2 Possible consequences of anorexia nervosa.

Fig. 10.3 The changing incidence of bulimia nervosa since its description.

Figure 10.4 Possible consequences of bulimia nervosa.

Figure 10.5 The causes of eating disorders.

Figure 10.6 A sociocultural model of eating disorders.

11: Treating Eating Disorders

Figure 11.1 Focal psychoanalytic psychotherapy.

Figure 11.2 The stages of change model.

12: An Integrated Model of Diet

Figure 12.1 From healthy to disordered eating: A spectrum of diet.

Figure 12.2 An integrated model of diet.

The Psychology of Eating

From Healthy to Disordered Behavior

2nd edition

Jane Ogden

This edition first published 2010

© 2010 Jane Ogden

Edition history: Blackwell Publishing. (1e, 2003)

Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing program has been merged with Wiley’s global Scientific, Technical, and Medical business to form Wiley-Blackwell.

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Library of Congress Cataloging-in-Publication Data

Ogden, Jane, 1966–

The psychology of eating : from healthy to disordered behavior / Jane Ogden.

p. cm.

Includes bibliographical references and index.

ISBN 978-1-4051-9121-0 (hardcover : alk. paper) — ISBN 978-1-4051-9120-3 (pbk. : alk. paper) 1. Eating disorders. 2. Appetite disorders. 3. Food habits. I. Title.

RC552.E18O47 2010

616.85′26–dc22

2009035840

A catalogue record for this book is available from the British Library.

List of Figures

1.1 From healthy to disordered eating: A spectrum of diet

2.1 Healthy eating

2.2 Healthy eating in young adults

3.1 Food choice

3.2 Social eating

3.3 The basics of the theory of reasoned action

3.4 The basics of the theory of planned behavior

3.5 Neurochemicals and food choice

4.1 The meaning of food

4.2 Food and sex

4.3 Food: Guilt versus pleasure

4.4 Food as self-control

4.5 Food and the family

4.6 Food: Health versus pleasure

4.7 Food and religion

5.1 Contemporary ideals of beauty

5.2 The meaning of size

5.3 The meaning of size: Control

5.4 The meaning of size: Success

6.1 Body dissatisfaction

6.2 Body silhouettes for adults

6.3 Smoking as a response to body dissatisfaction

7.1 Diets work

7.2 The central role for control

7.3 Dieting and overeating

7.4 The boundary model of overeating

7.5 A comparison of the boundaries for different types of eating

7.6 Overeating as relapse

7.7 From dieting to overeating

8.1 Grades of obesity by height and weight

8.2 The relationship between BMI and mortality

8.3 Weight and depression

8.4 Changes in physical activity and obesity

8.5 Changes in food intake over 40 years

8.6 Changes in calorie consumption and obesity

8.7 Changes in the carbohydrate–fat ratio and obesity

9.1 Multidimensional packages for obesity

9.2 Mortality and fitness level in individuals with a BMI > 25.4

9.3 Searching for the magic bullet for obesity

9.4 Gastric bypass

9.5 Vertical stapled gastroplasty

9.6 Life events and sustained behavior change

10.1 A common portrayal of an anorexic patient

10.2 Possible consequences of anorexia nervosa

10.3 The changing incidence of bulimia nervosa since its description

10.4 Possible consequences of bulimia nervosa

10.5 The causes of eating disorders

10.6 A sociocultural model of eating disorders

11.1 Focal psychoanalytic psychotherapy

11.2 The stages of change model

12.1 From healthy to disordered eating: A spectrum of diet

12.2 An integrated model of diet

Foreword

The study of eating covers a range of areas from food choice to weight concern and eating-related problems such as obesity and eating disorders, and a range of fields from social sciences including sociology, psychology, and nutrition to physical and medical sciences such as physiology, psychiatry, and medicine. My own work has concentrated on factors influencing eating behavior, especially dieting and its place in the etiology and treatment of eating disorders and obesity. Obesity has long been decried as a serious medical disorder. For example, a government-sponsored conference in the United States in the early 1980s concluded that anyone who was as little as 5 lbs. heavier than ideal weight should be considered to be obese. It was recommended that anyone suffering from such obesity should be aggressively treated with calorie-restricted diets. Many in the medical profession have long seen obesity as the primary health threat facing Western societies (and their definition of obesity, as the US National Institutes of Health conference indicates, includes more than half of the adult population). Obesity has been accused of causing heart disease, diabetes, elevated blood pressure, and a whole host of other medical maladies that may contribute to elevated mortality. More ominously, the incidence of obesity has been rising steadily since the 1960s. Dieting, then, seems on the face of it to be a solution to a widespread health threat.

What those condemning the harmful effects of obesity often fail to notice is the strong association between overweight and repeated, often chronic, attempts at weight loss through caloric restriction, or dieting. Approximately 30 years ago, I attended a scientific conference focused on eating behavior and obesity. I presented my newly published research on what appeared to be paradoxical overeating in restrained eaters (or chronic dieters), and suggested that weight loss dieting not only might fail to be helpful to obese patients, but also could actually be harmful. A doctor in the audience jumped up and angrily accused me of killing people by encouraging them not to diet. He insisted that dieting was the only cure for the disease of obesity, a disease that would surely kill anyone so afflicted.

In fact, several researchers, including Ruben Andres and Paul Ernsberger among others, have demonstrated that for many disorders attributed to obesity, dieting and weight fluctuations are more likely to be the culprits than is merely being overweight. A more sinister association that also gets little attention from the obesity field is that between the increase in the incidence of dieting over the past 4 decades and the corresponding increase in the incidence of obesity. The growth in obesity is usually cited as a reason for imposing more diets on the overweight; the fact that it is just as likely that the proliferation of diets and weight loss programs is causing increased obesity is rarely acknowledged. In fact, the multibillion-dollar diet industry relies on the failure of its products to produce weight loss to maintain its profitability. The fact that diets may promote obesity may simply be a fortuitous side effect, from their point of view.

Since the 1970s, a new eating-related problem has attracted increasing attention from the media, the public, and the medical and health establishment. Eating disorders, some related to obesity (e.g., binge-eating disorder) and some not necessarily directly related to overweight (e.g., anorexia and bulimia nervosa), have been identified and recognized as serious health threats, especially for younger women. Body dissatisfaction and an unhealthy desire to be thin seem to be at least partial contributors to eating disorders. Naturally, an immediate solution to the problem of needing to be thinner that springs to most people’s minds is, once again, dieting.

Before the mid-1970s, research on dieting focused exclusively on how to make people eat less and lose weight. Occasionally the issue of how to maintain weight loss was addressed, but in general, the only query was how much weight the person could lose. The question of whether someone who was overweight (by whatever definition) should try to lose weight never arose, nor did the question of whether the dieting individual might already be too thin. Since that time, there has been steadily increasing attention to the impact of repeated weight loss attempts on the person and on society. Research on dieting has shifted to an examination of what restrictive dieting does to various aspects of behavior, emotion, and self-image, as well as to its personal and societal costs. Psychologists, sociologists, nutritionists, physiologists, and medical specialists have all contributed to the growing literature examining the various effects of restricting one’s caloric intake in order to lose weight. Societal, family, and individual factors influencing the decision to diet are being investigated to broaden our understanding of who diets and why. The contribution of these same factors, as well as dieting and body dissatisfaction, to eating disorders such as anorexia nervosa, bulimia nervosa, and obesity is also coming under closer scrutiny. Instead of a general recommendation that everyone should diet and lose weight, prescriptions for self-improvement now emphasize healthy eating and exercise; lifestyle changes have replaced self-starvation.

The growth of the dieting research establishment may not be as prodigious as that of the diet industry itself, but the sheer variety of disciplines wherein dieting is now an accepted topic of investigation militates against anyone being able to be conversant with all aspects of the literature. In The Psychology of Eating, however, Jane Ogden brings together research on dieting from these diverse domains. She examines the full spectrum of healthy eating and food choice, through the body dissatisfaction pervasive among women in Western culture and contributing to the epidemic of weight loss attempts, and on to obesity and clinically disordered eating and their treatments. In this updated edition, Ogden reviews both the classic literature and the latest findings, cogently discusses the prevailing theoretical approaches to the understanding of weight loss dieting and its associated maladies, and carefully examines the contributions and shortcomings of each theory. Although it is probably no longer possible to be exhaustive in reviewing this line of work, Jane Ogden, a longtime, well-regarded contributor to this field herself, has managed successfully to bring together the principal issues and domains concerning the interrelated areas of dieting, obesity, body image, and eating disorders. In addition, she presents an integrated scrutiny of the major themes and motifs running through the field. This sort of overview of such a wide-ranging area is difficult to perform, but this volume does an excellent job, providing a much-needed synthesis for those who study and treat individuals with disordered eating and body image. This is also an outstanding introduction for anyone entering the field. For researchers, practitioners, and those simply interested in understanding the complexities of eating and related issues, this book provides a valuable resource.

Janet Polivy

Toronto, Canada

Acknowledgments

The first edition of this book was the product of many years of research, supervision, teaching, and conferences. It is now 6 years later, and even more students have passed through my room and even more lectures and talks have been given. Over the past few years, I have also increasingly taught a nonpsychology audience including medics, counselors, dieticians, and nutritionists and have written papers for a more lay readership. I believe this has helped me to distill the wood from the trees and to see exactly what it is about psychological theory and research that is relevant to understanding eating behavior. I am therefore grateful to all my students who have enthusiastically engaged with my lectures on eating behavior and have wanted to carry out studies in this area. I am also grateful to my colleagues who have supported my research interests and have been prepared to discuss ideas and projects. I hope that I have now got the balance between wood and trees right!

1

Introduction

Obesity and overweight are on the increase, eating disorders are becoming more common, and many people diet to lose weight. In parallel, diet-related subjects are in vogue and over the past few years there has been an explosion of interest in any aspect of diet, from healthy eating through to eating disorders. The popular press offers features on diet, bookstores sell books on healthy eating, and television producers broadcast documentaries on people who are overweight, are underweight, have a solution to weight, or need a solution to their weight. The academic and research literature has also proliferated. Diet provides the focus for dieticians, nutritionists, endocrinologists, geneticists, psychiatrists, sociologists, and a range of psychologists from social, biological, health, and clinical psychology perspectives. There are journals dedicated to the subject of diet, specialist books produced, and conferences held to provide a forum for discussion. This book aims to provide a detailed map of this expanding area.

This chapter covers the following:

The aim of this book

The focus of this book

The structure of this book

Further reading

The Aim of This Book

The literature on diet is vast and is contributed to by individuals with a range of different interests. Some are interested in healthy eating, others are concerned with eating-related problems, and most produce work which is focused on their one area. Work is specialized to enable detailed research and theoretical development. As a result the relationships between different aspects of diet-related work become unclear. For example, healthy eating provides a context for understanding obesity, but these two literatures are often kept separate. Food choice offers a context for understanding eating disorders, but the paths of these areas rarely cross. Dieting and body dissatisfaction are relevant to understanding eating disorders, obesity, and food choice but are only sometimes studied by the same people and written about in the same papers and same books.

This book aims to provide a detailed map of the diet literature and to cover the spectrum of eating behavior, from healthy eating through body dissatisfaction and dieting to obesity and eating disorders. In doing so, it aims to show how these different areas are related to each other and to draw out some common themes which run through this immense body of work.

The Focus of This Book

Diet is studied from a range of different disciplinary and theoretical perspectives, and a comprehensive understanding of diet cannot be achieved without these different literatures. This book therefore includes literature from a range of approaches such as nutrition, physiology, psychiatry, and sociology. But the primary focus of the book is psychology. In particular, this book draws on mainstream psychology in the form of developmental, cognitive, clinical, social, and health psychology. It integrates this approach with that from the psychotherapeutic literature which is often based on clinical experience and informed by feminist or psychoanalytic perspectives. This book therefore offers the psychology of eating in the broadest sense and illustrates how a wealth of perspectives have been used to analyze this complex area of work.

The Structure of This Book

The structure of the book is illustrated in figure 1.1. Chapter 2 focuses on healthy eating and describes what is currently considered to be a healthy diet, how diet influences health as a cause of both morbidity and mortality, and how diet is used as a treatment once a diagnosis has been made. It then explores who has a healthy diet and describes large-scale surveys which have assessed children’s diets, the diets of young adults, and the diets of the elderly. This chapter draws on both the medical and nutrition literatures.

Figure 1.1 From healthy to disordered eating: A spectrum of diet.

Next, chapter 3 explores the research on food choice. This chapter focuses on three main theoretical approaches from psychology, and assesses the contribution of developmental theories, with their emphasis on exposure, social learning, and associative learning, and cognitive theories, with their focus on social cognition models. It also describes psychophysiological approaches in terms of the role of metabolism, the role of the hypothalamus, the impact of neurochemicals on hunger and satiety, and the role of stress in determining either under- or overeating. It is argued that, although useful as a means to explain healthy eating, these approaches to food choice only implicitly include the complex meanings associated with both food and body size.

In line with this, chapters 4 and 5 address the meanings of food and the meanings of size, respectively. Chapter 4 draws on the sociological and anthropological literatures which have examined the meaning of food and integrates these with writings of psychotherapists. Chapter 5 examines the meaning of size in terms of the impact of the media and the associations with thinness and obesity, and examines both the social psychology and feminist approaches. As a result of these meanings, food choice is complex, and many individuals develop weight concerns.

One form of weight concern is body dissatisfaction; chapter 6 examines what body dissatisfaction is, how it is measured, and what causes it. Body dissatisfaction often leads to dieting, which is the focus of chapter 7. This chapter describes why body dissatisfaction leads to dieting. It explores the consequences of attempted food restriction and specifically examines the relationship between dieting and overeating and the role of boundaries, mood, cognitions, self-awareness, and denial. These two chapters on weight concern mainly focus on psychological research, with an emphasis on experimental and cross-sectional work. Weight concern illustrates the point at which healthy eating starts to become problematic. It is a common phenomenon and one which has unpleasant consequences for the majority of those who show both body dissatisfaction and dieting.

Obesity is another eating-related problem, and this is addressed in the next two chapters. Chapter 8 describes the prevalence, consequences, and causes of obesity, and argues that, although diet plays an important part in its etiology, eating behavior needs to be placed within a multidimensional causal model. Chapter 9 addresses the treatment of obesity and explores the effectiveness of dietary treatments, addresses the question of whether obesity should be treated at all, and explores alternative treatments including exercise, drugs, and surgery.

Anorexia and bulimia nervosa are also diet-related problems, and these form the focus of chapters 10 and 11. Chapter 10 explores the prevalence and causes of these eating disorders; chapter 11 examines the treatment approaches which have been developed and tested. The chapters on obesity and eating disorders describe the psychological, epidemiological, nutritional, and psychiatric perspectives on these problems. Throughout the book many themes recur across disparate aspects of diet and from different literatures.

The final chapter (chapter 12) first provides a summary of the book. It then highlights these common themes and offers an integrated model of diet.

The second edition

It is now 5 years since I wrote the first edition of this book. During this time the literature on eating behavior, obesity, and eating disorders has proliferated, and concerns of unhealthy diets and eating problems are in the public eye more than they have ever been. This second edition aims to cover some of the newest research and address the latest thinking about the psychology of eating in the broadest sense. Each chapter has been updated with recent data derived from recent debates, reviews, and research studies. I am aware that this book can never be an exhaustive overview of all the literature relevant to eating behavior. But I hope that this second edition will satisfy most researchers’ need for information or, if not, will at least be able to provide them with a map and enable them to know where to find out more.

Further Reading

This book provides a comprehensive overview of the literature on diet from healthy to disordered eating. Below is a guide to journals, books, and websites for further reading on the subject.

Journals

There are many journals which publish work in the area of diet. The following are some of the major specialist journals:

International Journal of Eating Disorders

International Journal of Obesity

Appetite

European Eating Disorders Review

Obesity Research

European Journal of Clinical Nutrition

American Journal of Clinical Nutrition

Journal of the American College of Nutrition

British Journal of Nutrition

Nutrition Review

These journals can be accessed online through databases such as Pubmed, Medline, and Psychinfo.

Books

There are numerous popular and academic books on aspects of diet. The following are some key books which are useful sources of information.

Healthy eating

Truswell, A.S. 1999: ABC of Nutrition, 3rd ed. London: BMJ Books.

Food choice

Capaldi, E. (ed.) 1996: Why We Eat What We Eat: The Psychology of Eating. Washington, DC: APA Press.

Connor, M. and Armitage, C. 2002: The Social Psychology of Food. Maidenhead, UK: Open University Press.

Gilbert, S. 1986: Pathology of Eating. London: Routledge.

Mela, D.J. and Rogers, P.J. 1997: Food, Eating and Obesity: The Psychobiological Basis of Appetite and Weight Control. London: Chapman and Hall.

Rappoport, L. 2003: How We Eat. London: Independent Publishing Group.

Shepherd, R. (ed.) 1989: Handbook of the Psychophysiology of Human Eating. London: Wiley.

Weight concern

Grogan, S. 2008: Body Image: Understanding Body Dissatisfaction in Men, Women and Children. London: Routledge.

Ogden, J. 1992: Fat Chance! The Myth of Dieting Explained. London: Routledge.

Polivy, J. and Herman, C.P. 1983: Breaking the Diet Habit. New York: Basic Books.

Thompson, J.K. and Smolak, L. (eds.) 2009: Body Image, Eating Disorders, and Obesity in Youth: Assessment, Prevention, and Treatment, 2nd ed. New York: APA Press.

Obesity

Allison, D.B. (ed.) 1995: Handbook of Assessment Methods for Eating Behaviors and Weight Related Problems: Measures, Theory, and Research. Newbury Park, CA: Sage.

British Nutrition Foundation Task Force. 1999: Obesity: The Report of the British Nutrition Foundation Task Force. Oxford: Blackwell Science.

Brownell, K.D. and Foreyt, J.P. (eds.) 1986: Handbook of Eating Disorders: Physiology, Psychology and Treatment of Obesity, Anorexia and Bulimia. New York: Basic Books.

NHS Centre for Reviews and Dissemination, University of York. 1997: Systematic Review of Interventions in the Treatment and Prevention of Obesity. York, UK: Author.

Eating disorders

Allison, D.B. (ed.) 1995: Handbook of Assessment Methods for Eating Behaviors and Weight Related Problems: Measures, Theory, and Research. Newbury Park, CA: Sage.

Brownell, K.D. and Fairburn, C.G. (eds.) 2005: Eating Disorders and Obesity. New York: Guilford Press.

Buckroyd, J. and Rother, S. (eds.) 2008: Psychological Responses to Eating Disorders and Obesity: Recent and Innovative Work. Oxford: WileyBlackwell.

Duker, M. and Slade, R. 2007: Anorexia and Bulimia: How to Help, 2nd ed. Maidenhead, UK: Open University Press.

Fallon, P., Katzman, M.A. and Wooley, S.C. (eds.) 1994: Feminist Perspectives on Eating Disorders. New York: Guilford Press.

Gordon, R.A. 2000: Eating Disorders: Anatomy of a Social Epidemic, 2nd ed. Oxford: Blackwell.

Stunkard, A.J. and Stellar, E. (eds.) 1984: Eating and Its Disorders. Research Publications, Association for Research in Nervous and Mental Disease, Vol. 62. New York: Raven Press.

Szmukler, G., Dare C. and Treasure, J. (eds.) 1995: Handbook of Eating Disorders: Theory, Treatment and Research. London: Wiley.

Classic texts

Bruch, H. 1974: Eating Disorders: Obesity, Anorexia and the Person Within. New York: Basic Books.

Keys, A., Brozek, J., Henscel, A., Mickelson, O. and Taylor, H.L. 1950: The Biology of Human Starvation. Minneapolis: University of Minnesota Press.

Orbach, S. 1978: Fat Is a Feminist Issue . . . How to Lose Weight Permanently – Without Dieting. London: Arrow Books.

Orbach, S. 1993: Hunger Strike: The Anorectic’s Struggle as a Metaphor for Our Age, 2nd ed. London: Faber and Faber. (Original work published in 1986)

Websites

www.b-eat.co.uk/Home

This is the website for the Eating Disorders Association and provides information and contacts about eating disorders.

www.aso.org.uk

This is the website for the Association for the Study of Obesity which provides information about obesity, further reading, and events.

2

Healthy Eating

This chapter explores what constitutes a healthy diet, with a focus on the five main food groups. It then describes the role of diet in health in terms of contributing towards illnesses such as coronary heart disease (CHD), cancer, and diabetes; protecting the body against such illnesses; and being part of interventions to improve health once a diagnosis has been made. Finally it examines the results of large-scale surveys which have described the diets of children, young adults, and the elderly.

This chapter covers the following:

What is healthy eating?

The role of diet in contributing to illness

The role of diet in treating illness

Who has a healthy diet?

What Is Healthy Eating?

The nature of a good diet has changed dramatically over the years. In 1824 The Family Oracle of Good Health published in the UK recommended that young ladies should eat the following at breakfast: plain biscuit (not bread), broiled beef steaks or mutton chops, under done without any fat and half a pint of bottled ale, the genuine Scots ale is the best, or if this was too strong it suggested one small breakfast cup . . . of good strong tea or of coffee – weak tea or coffee is always bad for the nerves as well as the complexion. Dinner is later described as similar to breakfast, with no vegetables, boiled meat, no made dishes being permitted much less fruit, sweet things or pastry . . . the steaks and chops must always be the chief part of your food. Similarly in the 1840s Dr Kitchener recommended in his diet book a lunch of a bit of roasted poultry, a basin of good beef tea, eggs poached . . . a sandwich – stale bread – and half a pint of good home brewed beer (cited in Burnett, 1989). In the US at this time, diets were based around the staples of corn, rye, oats, and barley for making bread; the use of molasses as a cheap sweetener; and a quantity of salt pork which could survive the warmer weather in the absence of refrigeration. Blood pudding was also a source of meat; it was made from hog or occasionally beef blood and chopped pork, seasoned, and stuffed into a casing which was eaten with butter crackers to provide a meal for the workers (McIntosh, 1995). What constituted a healthy diet in the nineteenth century was very different from current recommendations.

Concerns about the nation’s diet in the UK came to a head following recruitment attempts during the Boer War at the beginning of the twentieth century, when 38 percent of volunteers were rejected due to malnutrition and poor health. This resulted in the establishment of the Inter Departmental Committee on Physical Deterioration, and the passing of the Education Act in 1906 and the Medical Inspection Act in 1907, introducing free school meals and free medical and dental checks for children. The government also introduced parent education classes to inform mothers about the nature of a healthy diet. In the US, the Great Depression of the 1930s resulted in President Franklin D. Roosevelt’s New Deal programs, the establishment of food subsidies, and the distribution of surplus agricultural products to families and schools. Refrigeration and canned foods also became more available at this time. Greater improvements in the diets of many Western countries, however, mainly came about as a result of the rations imposed during both the world wars. These rations resulted in a reduction in the consumption of sweet foods and an increase in the place of carbohydrates in the diet. In addition, the need to provide the armed forces with safe and healthy food stimulated research into food technology and established dietary standards.

Since this time there has been a proliferation of the literature on healthy eating. A visit to any bookstore will reveal shelves of books proclaiming diets to improve health through weight management, or salt reduction, or a Mediterranean approach to eating, or the consumption of fiber. There is, however, a consensus among nutritionists nowadays as to what constitutes a healthy diet (Department of Health, 1991). Food can be considered in terms of its basic constituents: carbohydrate, protein, alcohol, and fat. Descriptions of healthy eating tend to describe food in terms of broader food groups and make recommendations as to the relative consumption of each of these groups. Current recommendations are illustrated in figure 2.1; these are as follows:

Figure 2.1 Healthy eating. (Source: The balance of good health, reprinted by permission of the Health Education Authority 1994.)

Fruit and vegetables : A wide variety of fruit and vegetables should be eaten, and preferably five or more servings should be eaten per day (National Heart Forum, 1997).

Bread, pasta, other cereals, and potatoes : Plenty of complex carbohydrate foods should be eaten, preferably those high in fiber.

Meat, fish, and alternatives : Moderate amounts of meat, fish, and alternatives should be eaten, and it is recommended that the low-fat varieties are chosen.

Milk and dairy products : These should be eaten in moderation, and the low-fat alternatives should be chosen where possible.

Fatty and sugary foods : Food such as potato chips, candy, and sugary drinks should be consumed infrequently and in small amounts.

Other recommendations for a healthy diet include a moderate intake of alcohol (a maximum of 3–4 units per day for men and 2–3 units per day for women), the consumption of fluoridated water where possible, a limited salt intake of 6 g per day, eating unsaturated fats from olive oil and oily fish rather than saturated fats from butter and margarine, and consuming complex carbohydrates (e.g., bread and pasta) rather than simple carbohydrates (e.g., sugar). It is also recommended that men aged between 19 and 59 consume about 2,550 calories per day and that similarly aged women consume about 1,920 calories per day, although this depends on body size and degree of physical activity (Department of Health, 1995).

Recommendations for children are less restrictive for fatty foods and dairy products, and it is suggested that parents should not restrict the fat intake of children aged under 2. By 5 years old, however, children should be consuming a diet similar to that recommended for adults, indicating that a child’s fat intake should be gradually reduced between the ages of 2 and 5. Prentice and Paul (2000) argued that the fat requirements for children can be judged in terms of sufficient fat in the diet to provide fuel for energy, to give an adequate supply of essential fatty acids, and to allow the adequate absorption of fat-soluble minerals. Children therefore need more fat than adults, and for younger children breast milk is an essential source of fat, particularly in developing countries where weaning foods tend to be low in fat. Children also require more dairy products than adults to meet their greater need for calcium.

Current recommendations for healthy eating in adults therefore describe a balanced and varied diet which is high in fruit and vegetables and complex carbohydrates and low in fat. Children’s diets should approximate this, but can be higher in fat and dairy products. Healthy eating is considered important as it impacts on health in two main ways. First, a healthy diet can be protective against the development of illness, while an unhealthy diet may contribute towards disease. Second, a healthy diet can help manage or treat an illness once a diagnosis has been made. Over recent years there has been a proliferation of research into the association between diet and health. Much of this remains controversial, and even the most generally accepted facts have not been left uncontested. What is presented here reflects the state of research at this time.

The Role of Diet in Contributing to Illness

An individual’s health is influenced by a multitude of factors including their genetic makeup, their behavior, and their environment. Diet plays a central role and can contribute directly towards health. It can also impact on health through an interaction with a genetic predisposition. The effect of both over- and underweight on health and diseases such as coronary heart disease, hypertension, and cancer is discussed in chapters 8 and 10. The impact of the actual composition of a person’s diet is described here.

Diet and coronary heart disease

Before the beginning of the twentieth century, coronary heart disease was a rare condition. Its incidence increased steadily in Western countries from 1925 to 1977 except for a dip during World War II. Since this time its incidence has fallen dramatically in the US and Australia and has fallen by about 25 percent in the UK (World Health Organization, 1994). In contrast, Eastern European countries including Russia, Hungary, and the Czech Republic have experienced an increase in coronary mortalities in recent years. At this time, coronary heart disease remains the single largest cause of death in the US and the UK. Although biological factors play a part in coronary heart disease, diet is probably the fundamental factor. This is clearly shown by incidence of the disease in immigrant groups. For example, coronary mortalities are very rare in Japan, but Japanese groups who move to the West quickly show the pattern of mortality of their new environment (Syme et al., 1975). Coronary heart disease usually involves three stages: 1) the development of atherosclerosis (narrowing of the arteries); 2) a thrombosis superimposed on the atherosclerotic plaque (a blood clot), and the impact of this, which can be sudden death, heart attack, angina, or no symptoms; this depends on 3) the state of the myocardium. Each of these three stages is influenced by different components of the diet.

Atherosclerosis

The material that accumulates in the arteries causing atherosclerosis is cholesterol ester. Cholesterol ester exists in the plasma of the blood and is higher in individuals with a genetic condition called familial hypercholes-terolemia. Half of the cholesterol in the blood is biosynthesized by the liver, and half comes from the diet. Diet influences blood levels of cholesterol in two ways. First, blood cholesterol can be raised by saturated fat found in animal fat and in boiled, plunged, or espresso coffee (not instant or filtered). Secondly, blood cholesterol levels can be reduced by polyunsat-urated fats found in plant oils; by soluble types of fiber such as pectin found in fruit and vegetables and by oat fiber found in vegetables, oatmeal, and oat bran; and by soya protein (Truswell, 1999).

Thrombosis

A blood clot is caused by an increase in the coagulation factors in the blood including Factor VIII, fibrinogen, and platelets. Under normal healthy conditions a blood clot is essential to stop unwanted bleeding. If there is