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We eat to live and eating is an important focus for our family and social lives. In a country like the United States, food is readily available. But large amounts of food put us at risk for the three major eating disorders: obesity, bulimia, and anorexia nervosa. This fact sheet will discuss the role of behavior therapy in the treatment of these disorders.
A recent report from the National Institutes of Health suggests that people who are more than 20% over their ideal weight should seek treatment. Over one quarter of all women, and nearly as many men, in the United States fall into this category. Obesity is related to health risks, including high blood pressure, diabetes, and gall bladder disease. At very high levels of obesity, life expectancy is shortened. People should lose weight for health reasons and not for beauty reasons.
We do not understand all the causes of obesity. Recent research suggests that both family genetics and the environment are involved. Environmental factors include easy access to large amounts of food, eating high-caloric and high-fat foods, and having lower activity levels, including little or no excercise.
For people who have up to about 50 pounds to lose, behavior therapy has been a successful approach to treatment. It is better than medicines that curb the appetite and dietary treatments. Treatment is usually done in groups of 8 to 12 people. It consists of learning to look at and change key behaviors. Keeping records of eating activity forms the basis of treatment. The records are used to help change the way one eats, for example, eating in fewer places and eating more slowly; to change to a heart-healthy diet by decreasing the amount of fat one eats and increasing dietary fiber; and to increase activity levels.
Losing weight and keeping it off is hard work. People who manage to change these key behaviors and continue to practice them over the years are the ones who lose the most weight at first and who keep it off the longest. Weight loss of about a pound a week can be expected with this treatment. In addition, the lost weight is usually kept off for at least a year.
People who have more weight to lose should try a combination of behavior therapy and a very-low-calorie diet (less than 800 calories). The diet should be done under medical supervision. The combination has been shown to be more successful than using the very-low-calorie diet alone. These treatment programs are usually available in specialized centers, such as eating disorders clinics. These clinics are usually found at major medical centers.
Should overweight children be treated?
Overweight children at any age have a greater risk of becoming obese adults than normal-weight children. These children tend to have higher blood pressure and cholesterol levels than normal weight children do. High blood pressure and cholesterol are risk factors for heart disease in later life. This is why overweight children should be treated. Behavior therapy programs tailored to the child’s age have both short-term and long-term success in helping children lose weight. These programs usually involve parents.
Social standards for body shape change over time. This is especially true for women. In the United States, a thin body is expected for women. Most women diet from time to time. However, a few restrict their diet in a major way. These women tend lose control of their eating and begin to binge-eat. Binge eating leads to the possibility of weight gain. As a result, individuals begin to purge. Some ways people purge include vomiting or using laxatives or diuretics. Less often, people purge by not eating for several days.
Over time, an extreme concern about body shape develops. This fosters more severe dieting and increases the frequency of purging when diet rules are broken. These behaviors are known as bulimia. Bulimia carries health risks, including increased dental problems and a loss of potassium, which may lead to problems such as abnormal heart rhythms. Psychological problems, including irritability and depression, can also occur. The vast majority of bulimics are women, although a few men do develop this problem.
Cognitive behavior therapy has been shown to be helpful in overcoming bulimia. Treatment consists of careful record keeping. This can be used to help the patient form new behaviors, including:
- eating three or more balanced meals each day;
- delaying and then stopping purging;
- looking at and changing false beliefs about food, dieting, and body shape; and
- learning that things other than body shape are important to developing a good self-image.
The length of treatment depends on the severity of the bulimia. The average number of treatment sessions is between 15 and 20. Cognitive behavior therapy has some benefits for people who are bulimic. Most people have increased self-control of binge eating and purging. Also, about two-thirds of patients are able to return to normal eating patterns. Weight gain after treatment is the exception rather than the rule. When people do gain weight, these gains are usually small. Behavior therapy for bulimia nervosa is available at a number of eating disorders centers. When choosing a treatment program, it is important to ask about the therapist’s experience in treating patients with bulimia. Antidepressant medications have also been shown to be useful. Such medication may be especially helpful for patients who do not get better with behavior therapy.
Should bulimics be hospitalized?
Unless there are major medical problems, or a related severe mental health problem, hospitalization is not usually necessary for the treatment of bulimia. Hospitalization takes people out of the environment in which the problem occurs. This may make recovery from the disorder harder because bulimics must learn to eat normally in their own environment.
Anorexia is the rarest of the three eating disorders. Anorexia is characterized by a large loss of body weight. People often fall 20% to 30% below their ideal weight. Anorexia nervosa may become a chronic illness. It usually begins in early adolescence. It can require frequent hospitalization for the medical problems of starvation. About 5% of anorexic patients die because of the disorder. About half of those die from the complications of the disorder and about half from suicide. Most patients with this disorder need to be hospitalized, preferably in a unit designed for the treatment of eating disorders. Early cases, in which weight loss has not fallen to low levels, can be treated on an outpatient basis.
Behavior therapy forms the basis of modern treatment of anorexia nervosa. Most patients with this disorder are worried about gaining weight. They know they need to gain weight to be healthy and to have normal social functioning. However, weight gain and changes in body shape can be frightening for the anorexic. These people feel “fat” even though they are often very thin.
A rewarding environment that helps the anorexic want to gain weight is set up to help them overcome their problems. Within such an environment, weight gain leads to access to pleasant activities. This rewards weight gain. As the patient gains weight, the family is usually involved in helping the patient return to a normal social life. In addition, the anorexic is helped to build up behaviors that will aid in the process.
Research has shown that about three quarters of anorexics treated with behavior therapy will gain a reasonable amount of weight. In addition, they will return to reasonably normal activities. Some anorexics will relapse and will need to be rehospitalized. A few patients will not get better with this treatment.
Much progress has been made in understanding and treating the eating disorders over the past 20 years. Because of strong research efforts, behavior therapy has become either the treatment of choice or a major part of treatment for these problems. If support for research continues, we should expect to keep improving our ability to treat these disorders.