TCS Daily

Dying to Be Thin

By Sandy Szwarc - July 22, 2003 12:00 AM

"At no time in history have women been so pressured to be thin," wrote Frances Berg, M.S., L.N., in Women Afraid to Eat -- Breaking Free in Today's Weight-Obsessed World (Healthy Weight Network, 2000).

Women and girls are bombarded with messages about thinness, ideals of beauty, and ways to lose weight. The average woman sees hundreds of commercials a week, and a Brigham and Women's Hospital study in 2000 found virtually all commercials aimed at girls and women focus on physical attractiveness. A series of studies of media in 1986 led by Brett Silverstein, Ph.D., found diet food advertisements targeting women outnumbered those to men by 63 to 1; and articles dealing with thin body images and diets appeared 96 times in women's magazines to every 8 times in men's.

A populace absorbed with desires to be slim and repulsed by fat is obviously advantageous for the diet industry, but generates a hoard of harmful repercussions for consumers.

Body Image Conscious

Multiple researchers have concluded that girls internalize these messages at young ages, resulting in negative perceptions of their weight and shape, and beliefs that being unnaturally thin is ideal. Attitudes towards thinness and ideal body size are formed as early as 3 years of age, according to Phebe Cramer, Ph.D., and Tiffany Steinwert, Ph.D., in a 1998 Journal of Applied Developmental Psychology. By elementary school age, girls fear looking fat more than losing their parents, getting cancer or a nuclear war. Eighty percent of women and 20 percent of men at the University of North Carolina reported actually being terrified of being overweight, according to Laura Hartung, M.A., R.D., in a 1997 Journal of the American Dietetic Association.

Meanwhile, the socially "ideal" weight continues to shrink, becoming increasingly distorted from reality. Today's celebrities wear sizes 0 or 2, as compared to a normal size 12 a few generations ago. That's a lot of pressure to be thin. Our obsession with thinness was highlighted in a March 22, 2000, Journal of the American Medical Association (JAMA) study that found that just in the last 30 years, the average BMI (Body Mass Index) of Miss America Pageant contestants has been reduced by one-third, down to 18 by 1990 -- well below the World Health Organization's (WHO) criteria for malnutrition. Besides starving themselves to achieve these gaunt figures, Miss America contestants work out an average of 14 and some as many as 35 hours a week.

But Miss America contestants look positively curvaceous compared to the bony waifs at this year's Oscars. A famous study by Peter Katzmarzyk, Ph.D., and Caroline Davis, Ph.D., in the International Journal of Obesity found 70 percent of the Playboy centerfolds the past 20 years were clinically underweight.

The level of underweight sanctioned by these cultural images and in life insurance tables is known to be dangerous, but never mentioned, Paul Ernsberger, Ph.D., associate professor of Medicine, Pharmacology and Neuroscience, Case Western Reserve School of Medicine, has said. "The health risk of even slightly underweight is real." Slender weights, especially as we age, is an indicator for poor survival, he noted.

Indeed, multiple studies published in the International Journal of Obesity-Related Metabolic Disorders have found that those who are thin or who've lost weight not only increase their risk of premature death, they have the highest risk. In short, those who seek culturally "ideal" bodies will die earlier than heavier people.

A long-term study by the National Heart, Lung and Blood Institute (NHLBI), published in a 1998 Journal of Public Health, for example, found that those with BMIs of 20 or less, or with even modest 10 percent weight losses after age 50, have higher premature death rates than those overweight, even when other variables such as smoking are taken into account. A clinical study at the University of Maryland published in the December 1999 Journal of American Geriatrics Society, found voluntary weight loss in mature women, no matter what they weigh, appears especially dangerous, quadrupling their likelihood of dying prematurely.

Lessons That Hurt

Just being exposed to idealized and unrealistic rail-thin images of beauty in the media and diet industry advertisements takes a toll on females, particularly impressionable girls, who feel they can never measure up and are already terrified of the normal weight gain that comes with maturation.

These thin stereotypes of beauty threaten their healthy psychological and physical development. Multiple studies, such as the one at Flinders University in South Australia and others published in the Archives of Pediatric and Adolescent Medicine, have found that girls exposed to such images have profoundly less confidence and self-esteem, have distorted body images, are more dissatisfied with their bodies, and feel more anger, stress and depression.

Not surprisingly, incessant harping on thinness results in unhealthy and frequently unnecessary desires to lose weight. Eighty percent of adolescent girls in the Center for Disease Control's (CDC) Youth Risk Behavioral Surveillance system last year wanted to lose weight, even though almost two-thirds of them were normal weights.

The obsession with thinness has not only affected how young people see themselves, but also how they view and treat others. Over the past 40 years a growing fear of fat has spawned an increasingly strong bias against those who don't conform to ideals. And, it's a lesson that carries on into adulthood.

Fat prejudice, formed by 8 years of age, is the strongest prejudice found among children, who then shun their overweight peers. A 1998 study published in the Journal of Adolescent Health found 96 percent of overweight adolescent girls reported negative experiences because of their weight -- hurtful comments, derogatory names, teasing, jokes -- that made them feel ashamed and humiliated and crushed their self-confidence.

"At the elementary level, children learn that it is acceptable to dislike and deride fatness," according the Report on Size Discrimination by the National Education Association. "From nursery school through college, fat students experience ostracism, discouragement, and sometimes violence. Often ridiculed by their peers and discouraged by even well-meaning education employees, fat students develop low self-esteem and have limited horizons. They are deprived of places on honor rolls, sports teams, and cheerleading squads, and are denied letters of recommendation." The promising futures of these young people are hindered immeasurably.

Tragically, children can't even escape the insensitivity brought on by our nation's fixation on thinness at school, among adults they trust and look up to. Yet, increasingly, school officials feel it their duty to measure youngsters' BMIs and send them home with denigrating notes if they don't measure up.

But BMI is little more than a nonsense measurement in children. "The available data do not show that the BMI adequately reflects body fat mass in children and adolescents," doctors wrote in the April 1999 issue of Journal of Pediatrics. Nor, does the data support childhood BMIs as correlating to adult outcomes, Katherine M. Flegal, Ph.D., of the Medical Statistics Branch of the CDC noted in a 1993 Critical Review of Food Science and Nutrition.

Numerous researchers have urged caution in interpreting BMIs in children at different ages or stages of development. Evaluating obesity in children requires arbitrary assumptions for factoring in age, maturity, gender, ethnicity and physical activity. Several studies, such as in the July 1997 issue of International Journal of Obesity, have shown even trained clinicians measuring the same children come up with different results with each measurement, making results unreliable and unreplicable. Little wonder, then, that a 2000 USDA study found a fourth of children were mislabeled as at risk or overweight who turned out to have normal body fat. But, the labels had already done their damage, as labels do, ostracizing bigger youngsters and escalating their frantic pressures to be thin.

In this kind of environment, it's no wonder our youngsters feel ready to do just about anything to be slim.

Three Ominous Trends

Feeling unaccepted and unacceptable if they don't meet ideals of thinness, young people often react without regard to their health:

Smoking: The trend of younger children taking up smoking, and the prevalence of smoking among students is worrisome. According to an October 1997 study in Pediatrics, 23 percent of 9- to 14-year-olds had smoked or were considering starting, and 36.4 percent of high school students were smoking as compared to 27.5 percent just six years earlier. The price tag? The University of Missouri has reported that 3,000 adolescents become habitual smokers and more than 6,000 try their first cigarettes every day in the United States -- and nearly 75 percent will become addicted. The National Institutes of Health (NIH) stated in a June 3, 2002, press release, "Current predictions are that, in the U.S., more than 5 million of today's young smokers will go on to die of tobacco-related illness." And a major contributor to this trend is that many young girls are driven to begin smoking by their desire to be thin. Last summer, the NIH released a study sponsored by the NHLBI finding worries about weight increased the risk of a girl becoming a daily smoker by the time she finished high school.

Birth weight: According to CDC data, there's been a frightening increase in low and very low birth weight babies the past couple decades -- with low birth weight births increasing 11.8 percent and very low birth weights by 24.3 percent from 1980 to 2000. Many obstetricians and neonatologists attribute this trend to the obsession with weight and dieting among females. One in four of these very low birth weight babies don't live to see their first birthdays, many more suffer impaired development and disabilities that extend far beyond infancy. A large body of research, such as that headed by Drs. Stephen Gardner, Gary C. Curhan, Bryndix Birgisdottir, Daniel Lackland and G.P. Ravelli, has found that undernutrition during fetal development and early infancy activates a host of permanent physiological changes that promote fat formation. The same starvation adaptation that appears with dieting can begin before birth. These researchers have concluded these immutable changes appear responsible for the rising childhood obesity and diabetes, as well as obesity and chronic diseases such as diabetes, high blood pressure, kidney disease and heart disease that manifest themselves later in life. Cara Ebbeling, Ph.D., and colleagues at the Division of Endocrinology at Children's Hospital Boston have noted that through these permanent physiological alterations during prenatal development, "diet-induced obesity could accelerate through successive generations."

Suicide: Teen suicides have tripled in the past 40 years and are now the third leading cause of teen deaths. Suicides are a problem with increasingly younger children. Just in the past 20 years, rates have doubled among 10- to 14-year olds, according to the U.S. Department of Health and Human Services (USDHHS). Suicide claims the lives of more than 5,000 teen-agers every year, according to the American Psychiatric Association (APA). For every teen who commits suicide, another 400 attempt it and 100 require medical care. And according to the CDC's Youth Risk Behavior Surveys, teens trying to lose weight or who believe they're overweight are more likely to attempt suicide.

In this war on obesity, the desperation innocent young victims feel to be thin increasingly becomes more than they can bear. They're not alone. Being obese in today's society takes a toll on adult women, too. In 2000, researchers at the Obesity Research Center at St. Luke's-Roosevelt Hospital in New York found obese women were 55 percent more likely to have attempted suicide than women of average weight.

Fear of Fat

The damage resulting from our nation's obsession with thinness and fear of fat carries into adulthood.

A comprehensive review of studies on discriminatory attitudes and behaviors against fat people done by researchers at Yale University's Department of Psychology in 2001 found "clear and consistent stigmatization, and in some cases discrimination, documented in three important areas of living: employment, education and health care."

On the education and job front, fat people as compared to their thinner counterparts are less likely to attend college or receive college funding, even though their academic and test scores are similar; are hired less often; earn 12 percent less on average; and pay higher insurance premiums. Among workers 50 percent over "ideal" weights, 26 percent are denied health insurance benefits and 17 percent reported being fired or pressured to resign...all because of their weight.

Weight discrimination has also been indicated with housing, adoptions, jury selection, and even found to be prevalent among healthcare providers.

A study of more than 400 physicians, another of 100 doctors and clinic workers, and another of 586 nurses found two-thirds believed fat people lacked self control and had emotional problems and a third thought them lazy. Overall, "obese patients were viewed as unintelligent, unsuccessful, inactive and weak-willed." Almost half of nurses agreed they felt uncomfortable caring for obese patients and a third preferred not to at all.

These beliefs may influence judgments and care given by health care professionals. A 1992 National Health Interview Survey found increased BMI was associated with decreased preventative health care services. On Jan. 1, 2002, the National Task Force on the Prevention and Treatment of Obesity reported obese patients are less likely to receive certain preventative care services, exacerbated by patient concerns of being disparaged by doctors or medical staff because of their weight. An American College of Physicians study of 220,000 adults, published in the Oct. 24, 2000, JAMA, examined unmet health needs and concluded that the "failure to monitor chronic conditions such as hypertension or diabetes substantially increase morbidity and may increase the nation's overall health costs."

No study has yet quantified those costs, but numerous organizations -- such as Council on Size and Weight Discrimination, National Association to Advance Fat Acceptance, Largely Positive and National Organization for Women Foundation -- have documented weight prejudice, especially towards women, in heartbreaking detail.

"A Place at the Table," an effort sponsored by SeaFATtle, memorializes those who've paid the ultimate price for size discrimination and fat phobias -- their lives. They write, "Fat people aren't allowed to take their place at the table and enjoy basic rights and privileges that others take for granted -- all because our culture has the idea that fat people are somehow less than human, and therefore shouldn't share the simple human right of fair and decent treatment. ...We want to raise public awareness of how ingrained these prejudices are in the fabric of our culture, how serious the consequences can be, and how essential it is to change them."

The war on obesity has been fought for almost forty years, yet our nation is now so fat, according to some, a crisis has been declared. Often brazenly overlooking or distorting the scientific evidence, diet admonitions -- from healthcare and diet industry promotions to government guidelines -- have succeeded in creating a nation preoccupied with thinness, but one suffering as a result. We must ask ourselves if all of those "trying to help" bear some responsibility for the tragic consequences that have resulted. Although their agenda is clearly off-course, it's shifting into high gear, and we shudder to think the greater harm that will befall more innocent people if it's allowed to continue.

Coming Thursday: Why diets should come with warning labels.

© 2003 Sandy Szwarc. All rights reserved.

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