Like most things, obesity is a complex phenomenon about which it is dangerous to generalize. What is true for one person is not necessarily true for the next. Nevertheless, we shall try to make sense out of conflicting theories and give answers to people who struggle to maintain self-esteem in a world that seems to be obsessed with youth, thinness, and the perfect body -- whatever that may be.

• What is obesity?

  A person with anorexia nervosa may define obesity as a weight gain of five pounds, from 89 to 94. A grandmother past menopause may call herself obese because she carries 165 pounds on her large-boned, muscular body. A modeling agency may talk about obesity when one of the women on the payroll puts 135 pounds on her 5'10" body.

  None of these women is clinically obese. The anorexic and the model are underweight.

• Men are split in their personal definitions of obesity. Many are just as concerned about overweight as women are, while others, frankly rotund, believe they are just fine, perfectly healthy, and universally attractive to potential romantic partners.

  Physicians consider a person to obese if s/he weighs more than 20% above expected weight for age, height, and body build. Morbid or malignant obesity is weight in excess of 100 pounds above that expected for age, height, and build.

  In recent years, the definition of expected, or healthy, weight has expanded to include more pounds per height in view of research that links reduced mortality (longer lives) with more weight than is currently considered fashionable.

• How many Americans are obese?
  A 1999 study reported by the Centers for Disease Control and Prevention indicates that sixty-one percent of adults in the U.S. are overweight. A breakdown of that figure shows that thirty-five percent are slightly or moderately overweight, and that twenty-six percent are obese or grossly overweight. In addition, about thirteen percent of U.S. children are overweight or obese.

  Another government study published in October, 2002 indicates that thirty-one percent of the American public is obese. It further suggested that fifteen percent of young people between 6 and 19 are seriously overweight. Even ten percent of toddlers between 2 and 5 are seriously overweight. The study appeared in the Journal of the American Medical Association (10/9/02).

  A more recent study indicates that about 31 percent of American teenage girls and 28 percent of boys are somewhat overweight. An additional 15 percent of American teen girls and nearly 14 percent of teen boys are obese. (Archives of Pediatrics and Adolescent Medicine, January 2004) Causes include fast food, snacks with high sugar and fat content, use of automobiles, increased time spent in front of TV sets and computers, and a generally more sedentary lifestyles than slimmer peers.

  The prevalence of overweight and obesity is increasing in all major socioeconomic and ethnic groups, including children and younger adults between 25 and 44. (David Sacher, U.S. Surgeon General, December 2001)

• What are the causes of obesity?
  • Consumption of more calories than are burned through work, exercise, and other activities. In the late 1990s, Americans ate about 340 more calories per day than they did in the mid-1980s, and about 500 more calories per day than in the 1950s. The extra food was often some kind of refined carbohydrate (white flour or sugar) combined with fat, saturated fat in the unhealthiest cases. (University of California Wellness Letter, January 2002)
    Americans are eating out more often than ever before. Restaurants and fast food outlets offer much larger portions than they used to. The amount of home cooked food eaten with family around the dining room table has decreased, but portion size has increased. Food prepared at home offers the easiest way to make healthy choices about fat, sugar, salt, etc., but in today's world convenience often wins out over a home cooked meal.
  • Inexpensive, tasty, plentiful food and a combination of passive leisure pursuits, sedentary lifestyle, TV, time spent on the Internet, and other "activities" that require little or no physical effort.
  • Attempts to numb or escape emotional pain and distress. For various emotional reasons, including loneliness and depression, some people eat when their bodies do not need food. 
  • Diets and prolonged caloric restriction. When people try to make the body thinner than it is genetically programmed to be, it retaliates by becoming ravenous and vulnerable to binge eating. Ninety-eight percent of dieters regain all the weight they manage to lose, plus about 10 extra pounds, within five years. Yo-yo dieting repeats the cycle of weight loss followed by ever-increasing weight gain when hunger ultimately wins.
  • Some individuals are obese because of specific biological problems such as malfunctioning thyroid or pituitary glands. Others may have physical problems or disabilities that severely limit or prohibit exercise, strenuous work, and other physical activity.
  • Studies published in the New England Journal of Medicine (March 2003) indicate that certain genetic processes are an important and powerful underlying factor in the development of obesity and binge eating.
  • In addition, new research suggests that there is a biological link between stress and the drive to eat. Comfort foods -- high in sugar, fat, and calories -- seem to calm the body's response to chronic stress. In addition, hormones produced when one is under stress encourage the formation of fat cells. In Westernized countries life tends to be competitive, fast paced, demanding, and stressful. There may be a link between so-called modern life and increasing rates of overeating, overweight, and obesity. (Study to be published in Proceedings of the National Academy of Sciences. Author is Mary Dallman, professor of physiology, University of California at San Francisco [2003].)
  • Researchers believe that in most cases obesity represents a complex relationship between genetic, psychological, physiological, metabolic, socioeconomic, lifestyle, and cultural factors.
  • Miscellaneous factors.
    • The children of overweight parents are more likely to be overweight than the children of thin parents.
    • If friends and family members offer comfort in the form of food, people will learn to deal with painful feelings by eating instead of using more effective strategies.
    • Poor folks tend to be fatter than the affluent.
    • People living in groups that frequently celebrate and socialize at get-togethers featuring tempting food tend to be fatter than those who do not.
    • Even artificial sweeteners are implicated in weight gain and obesity. In a recent study at Purdue University, rats that were given artificial sweeteners ate three times the calories of rats given real sugar. Researchers hypothesize that the engineered sweeteners interfere with the body's natural ability to regulate food and caloric intake based on the sweetness of different foods. ("A Pavlovian Approach to the Problem of Obesity," International Journal of Obesity, July 2004)
    • Some individuals eat great quantities of food, exercise moderately or not at all, and never seem to gain weight. Others walk past a bakery and gain ten pounds. No two people are the same, and no two obesity profiles are identical.

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• Health risks associated with obesity
  • Hypertension. (High blood pressure, a contributor to stroke and heart disease). Overweight young people (20-45) have a six times higher incidence of hypertension than do peers who are normal weight. Older obese folks seem to be at even greater risk.
  • Diabetes. Even moderate obesity, especially when the extra fat is carried in the stomach and abdomen (instead of hips and thighs), increases the risk of non-insulin dependent diabetes mellitus (NIDDM) ten-fold.
  • Cardiovascular disease. Both the degree of obesity and the location of fat deposits contribute to the potential for heart and blood vessel disease. The fatter the person, the higher the risk. People who carry extra weight in the trunk area (stomach and abdomen) are at higher risk than folks who store fat in hips and thighs.
  • Cancer. Obese men are at elevated risk of developing cancer of the colon, rectum, and prostate. Obese women are at elevated risk of developing cancer of the breast, cervix, uterus, and ovaries.
  • Endocrine problems. Irregular menstrual cycles; other menstrual problems; and pregnancy complications, especially toxemia and hypertension. Hormone imbalances of various kinds may contribute to, or be the result of, obesity.
  • Gall bladder disease. Obese women 20-30 years old are at six times greater risk of gall bladder disease than their normal-weight peers. By age 60 almost one-third of obese women will have developed gall bladder disease.
  • Lung and breathing problems. Obesity can impede the muscles that inflate and ventilate the lungs. Obese individuals may have to work hard to get enough air and over time may not be able to take in the oxygen needed by all body cells.
  • Arthritis. Obese individuals are at increased risk of developing gouty arthritis, a distressingly painful disorder. In addition, excess weight stresses vulnerable joints, in particular the back and knee, which may develop osteoarthritis, a mechanical rather than metabolic problem.
  • Premature death. Research indicates that obese people die sooner than their normal weight peers.
• Other problems associated with obesity
  • Sleep disturbances, including sleep apnea (breathing stops for several seconds; then the person rouses, gasps, and struggles to catch breath. Episodes may continue through the night)
  • Inability to fully participate in recreational activities
  • Inability to compete effectively in sports and athletics; being picked last, or not at all, for team sports
  • Inability to perform some jobs; reduced job opportunities
  • Prejudice and discrimination in school and the workplace
  • Restricted social opportunities
  • Restricted opportunities for romantic relationships
  • Low self-esteem and body-image problems, related at least in part to prejudice and discrimination encountered in school, at work, and in social settings.
• One important piece of good news

  Obese people do not seem to have any more psychological problems, or more serious psychological problems, than folks of normal weight. The problems they do have are more likely a consequence of prejudice and discrimination than a cause of overweight. In fact, several studies have suggested that the obese are significantly less anxious and depressed than normal-weight peers.

• What can be done about obesity?
  • The simplistic answer: eat less and exercise more.
  • The realistic answer:
    • Work with a physician to identify and correct any underlying medical, biological, or metabolic problems contributing to excess weight.
    • Check with a counselor to see if you are using food for a purpose food cannot fulfill: love, comfort, escape, an antidote to boredom, and so forth. If you are self-medicating with food, work with the therapist to come up with better ways of managing stress, painful emotions, and problems.
    • Don't ever diet or restrict calories when you are legitimately hungry. If you do, you will set yourself up to binge later.
    • Eat normal, reasonable, moderate amounts of healthy foods. Emphasize fruits, vegetables, and whole grains. Don't cut out sweets and fats completely. If you do, you will crave and sneak them. Besides, your body needs the nutrients found in fats and carbohydrates. Just don't overdo it.
    • Most important: Exercise consistently. Get regular amounts of moderate, self-loving exercise. Start with a few minutes of walking and slowly extend the time until you can do 30-60 minutes a day, 3-5 days a week. If you haven't exercised in a while, be sure to check with your doctor first.
    • Find a support system. Friends are great; so are support groups. There are both online and in-person opportunities. Check our Links page for suggestions.
    • Be gentle and realistic with yourself. If everyone in your family is round and sturdy, chances are you will never be a super model -- but you can be happy and healthy. Also remember that healthy, realistic weight loss takes time. Losing one-half to one pound a week isn't very glamorous, but if you go any faster, you will make yourself hungry, and hunger will inevitably make you overeat.
• How about diet pills and other weight-loss products? Surgery?
  • Over-the-counter products. There are many items in drugstores and health food stores that claim to help people lose weight. None seem to be both safe and effective. The ones that are effective are only minimally so, and they have significant side effects and health risks. The ones that are safe don't seem to be very effective in helping folks lose weight and keep it off. Think about it: if there really were a safe and effective weight loss product available over the counter, everyone in the United States would be thin. Our best advice: save your money.
  • Prescription medications. In spite of a tremendous amount of research, there still is no magic pill that melts pounds away effortlessly. Obese people and their physicians had great hope for fen-phen, a combination stimulant and antidepressant, but those hopes were dashed when some of the people taking it developed potentially fatal heart problems. New medications are available, and more are in the pipeline. Talk to your doctor about their pros and cons. For the time being at least, the steps outlined above in the section titled "What Can Be Done About Obesity" seem to be the safest and most effective way of reducing excess weight.
  • Surgery. For some obese people, gastric bypass (and stomach stapling and related techniques) may be a lifesaving measure. The procedure is major surgery and is associated with risk of significant side effects and complications. For this reason it should be considered a treatment of last resort. Also, to be successful, the patient must cooperate with an entirely new way of eating and managing food. If nothing else has worked for you, and if your medical situation warrants such a drastic approach, talk to your physician to see if you might be a candidate for this procedure.

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Introduction to Identifying and Treating Eating Disorders

Increases in the incidence and prevalence of anorexia and bulimia nervosa in children and adolescents have made it increasingly important that pediatricians be familiar with the early detection and appropriate management of eating disorders. Epidemiologic studies document that the numbers of children and adolescents with eating disorders increased steadily from the 1950s onward. During the past decade, the prevalence of obesity in children and adolescents has increased significantly, accompanied by an unhealthy emphasis on dieting and weight loss among children and adolescents, especially in suburban settings; increasing concerns with weight-related issues in children at progressively younger ages; growing awareness of the presence of eating disorders in males; increases in the prevalence of eating disorders among minority populations in the United States; and the identification of eating disorders in countries that had not previously been experiencing those problems. It is estimated that 0.5% of adolescent females in the United States have anorexia nervosa, that 1% to 5% meet criteria for bulimia nervosa, and that up to 5% to 10% of all cases of eating disorders occur in males.There are also a large number of individuals with milder cases who do not meet all of the criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) for anorexia or bulimia nervosa but who nonetheless experience the physical and psychologic consequences of having an eating disorder. Long-term follow-up for these patients can help reduce sequelae of the diseases; Healthy People 2010 includes an objective seeking to reduce the relapse rates for persons with eating disorders including anorexia nervosa and bulimia nervosa.

The Role of the Pediatrician in the Identification and Evaluation of Eating Disorders

Primary care pediatricians are in a unique position to detect the onset of eating disorders and stop their progression at the earliest stages of the illness. Primary and secondary prevention is accomplished by screening for eating disorders as part of routine annual health care, providing ongoing monitoring of weight and height, and paying careful attention to the signs and symptoms of an incipient eating disorder. Early detection and management of an eating disorder may prevent the physical and psychologic consequences of malnutrition that allow for progression to a later stage.

Screening questions about eating patterns and satisfaction with body appearance should be asked of all preteens and adolescents as part of routine pediatric health care. Weight and height need to be determined regularly (preferably in a hospital gown, because objects may be hidden in clothing to falsely elevate weight). Ongoing measurements of weight and height should be plotted on pediatric growth charts to evaluate for decreases in both that can occur as a result of restricted nutritional intake. Body mass index (BMI), which compares weight with height, can be a helpful measurement in tracking concerns; BMI is calculated as:

weight in pounds x 700/(height in inches squared)
or
weight in kilograms/(height in meters squared).

Newly developed growth charts are available for plotting changes in weight, height, and BMI over time and for comparing individual measurements with age-appropriate population norms. Any evidence of inappropriate dieting, excessive concern with weight, or a weight loss pattern requires further attention, as does a failure to achieve appropriate increases in weight or height in growing children. In each of these situations, careful assessment for the possibility of an eating disorder and close monitoring at intervals as frequent as every 1 to 2 weeks may be needed until the situation becomes clear.

A number of studies have shown that most adolescent females express concerns about being overweight, and many may diet inappropriately. Most of these children and adolescents do not have an eating disorder. On the other hand, it is known that patients with eating disorders may try to hide their illness, and usually no specific signs or symptoms are detected, so a simple denial by the adolescent does not negate the possibility of an eating disorder. It is wise, therefore, for the pediatrician to be cautious by following weight and nutrition patterns very closely or referring to a specialist experienced in the treatment of eating disorders when suspected. In addition, taking a history from a parent may help identify abnormal eating attitudes or behaviors, although parents may at times be in denial as well. Failure to detect an eating disorder at this early stage can result in an increase in severity of the illness, either further weight loss in cases of anorexia nervosa or increases in bingeing and purging behaviors in cases of bulimia nervosa, which can then make the eating disorder much more difficult to treat. In situations in which an adolescent is referred to the pediatrician because of concerns by parents, friends, or school personnel that he or she is displaying evidence of an eating disorder, it is most likely that the adolescent does have an eating disorder, either incipient or fully established. Pediatricians must, therefore, take these situations very seriously and not be lulled into a false sense of security if the adolescent denies all symptoms. Table 1 outlines questions useful in eliciting a history of eating disorders, and Table 2 delineates possible physical findings in children and adolescents with eating disorders.

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Initial evaluation of the child or adolescent with a suspected eating disorder includes establishment of the diagnosis; determination of severity, including evaluation of medical and nutritional status; and performance of an initial psychosocial evaluation. Each of these initial steps can be performed in the pediatric primary care setting. The American Psychiatric Association has established DSM-IV criteria for the diagnosis of anorexia and bulimia nervosa (Table 3). These criteria focus on the weight loss, attitudes and behaviors, and amenorrhea displayed by patients with eating disorders. Of note, studies have shown that more than half of all children and adolescents with eating disorders may not fully meet all DSM-IV criteria for anorexia or bulimia nervosa while still experiencing the same medical and psychologic consequences of these disorders; these patients are included in another DSM-IV diagnosis, referred to as eating disorder-not otherwise specified. The pediatrician needs to be aware that patients with eating disorders not otherwise specified require the same careful attention as those who meet criteria for anorexia or bulimia nervosa. A patient who has lost weight rapidly but who does not meet full criteria because weight is not yet 15% below that which is expected for height may be more physically and psychologically compromised than may a patient of lower weight. Also, in growing children, it is failure to make appropriate gains in weight and height, not necessarily weight loss per se, that indicates the severity of the malnutrition. It is also common for adolescents to have significant purging behaviors without episodes of binge eating; although these patients do not meet the full DSM-IV criteria for bulimia nervosa, they may become severely medically compromised. These issues are addressed in the Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version, which provides diagnostic codes and criteria for purging and bingeing, dieting, and body image problems that do not meet DSM-IV criteria. In general, determination of total weight loss and weight status (calculated as percent below ideal body weight and/or as BMI), along with types and frequency of purging behaviors (including vomiting and use of laxatives, diuretics, ipecac, and over-the-counter or prescription diet pills as well as use of starvation and/or exercise) serve to establish an initial index of severity for the child or adolescent with an eating disorder.

The medical complications associated with eating disorders are listed in Table 4, and details of these complications have been described in several reviews. It is uncommon for the pediatrician to encounter most of these complications in a patient with a newly diagnosed eating disorder. However, it is recommended that an initial laboratory assessment be performed and that this include complete blood cell count, electrolyte measurement, liver function tests, urinalysis, and a thyroid-stimulating hormone test. Additional tests (urine pregnancy, luteinizing and follicle-stimulating hormone, prolactin, and estradiol tests) may need to be performed in patients who are amenorrheic to rule out other causes for amenorrhea, including pregnancy, ovarian failure, or prolactinoma. Other tests, including an erythrocyte sedimentation rate and radiographic studies (such as computed tomography or magnetic resonance imaging of the brain or upper or lower gastrointestinal system studies), should be performed if there are uncertainties about the diagnosis. An electrocardiogram should be performed on any patient with bradycardia or electrolyte abnormalities. Bone densitometry should be considered in those amenorrheic for more than 6 to 12 months. It should be noted, however, that most test results will be normal in most patients with eating disorders, and normal laboratory test results do not exclude serious illness or medical instability in these patients.

The initial psychosocial assessment should include an evaluation of the patient's degree of obsession with food and weight, understanding of the diagnosis, and willingness to receive help; an assessment of the patient's functioning at home, in school, and with friends; and a determination of other psychiatric diagnoses (such as depression, anxiety, and obsessive-compulsive disorder), which may be comorbid with or may be a cause or consequence of the eating disorder. Suicidal ideation and history of physical or sexual abuse or violence should also be assessed. The parents' reaction to the illness should be assessed, because denial of the problem or parental differences in how to approach treatment and recovery may exacerbate the patient's illness. The pediatrician who feels competent and comfortable in performing the full initial evaluation is encouraged to do so. Others should refer to appropriate medical subspecialists and mental health personnel to ensure that a complete evaluation is performed. A differential diagnosis for the adolescent with symptoms of an eating disorder can be found in Table 5.

Several treatment decisions follow the initial evaluation, including the questions of where and by whom the patient will be treated. Patients who have minimal nutritional, medical, and psychosocial issues and show a quick reversal of their condition may be treated in the pediatrician's office, usually in conjunction with a registered dietitian and a mental health practitioner. Pediatricians who do not feel comfortable with issues of medical and psychosocial management can refer these patients at this early stage. Pediatricians can choose to stay involved even after referral to the team of specialists, as the family often appreciates the comfort of the relationship with their long-term care provider. Pediatricians comfortable with the ongoing care and secondary prevention of medical complications in patients with eating disorders may choose to continue care themselves. More severe cases require the involvement of a multidisciplinary specialty team working in outpatient, inpatient, or day program settings.

The Pediatrician's Role in the Treatment of Eating Disorders in Outpatient Settings

Pediatricians have several important roles to play in the management of patients with diagnosed eating disorders. These aspects of care include medical and nutritional management and coordination with mental health personnel in provision of the psychosocial and psychiatric aspects of care. Most patients will have much of their ongoing treatment performed in outpatient settings. Although some pediatricians in primary care practice may perform these roles for some patients in outpatient settings on the basis of their levels of interest and expertise, many general pediatricians do not feel comfortable treating patients with eating disorders and prefer to refer patients with anorexia or bulimia nervosa for care by those with special expertise. A number of pediatricians specializing in adolescent medicine have developed this skill set, with an increasing number involved in the management of eating disorders as part of multidisciplinary teams. Other than the most severely affected patients, most children and adolescents with eating disorders will be managed in an outpatient setting by a multidisciplinary team coordinated by a pediatrician or subspecialist with appropriate expertise in the care of children and adolescents with eating disorders. Pediatricians generally work with nursing, nutrition, and mental health colleagues in the provision of medical, nutrition, and mental health care required by these patients.

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As listed in Table 4, medical complications of eating disorders can occur in all organ systems. Pediatricians need to be aware of several complications that can occur in the outpatient setting. Although most patients do not have electrolyte abnormalities, the pediatrician must be alert to the possibility of development of hypokalemic, hypochloremic alkalosis resulting from purging behaviors (including vomiting and laxative or diuretic use) and hyponatremia or hypernatremia resulting from drinking too much or too little fluid as part of weight manipulation. Endocrine abnormalities, including hypothyroidism, hypercortisolism, and hypogonadotropic hypogonadism, are common, with amenorrhea leading to the potentially long-term complication of osteopenia and, ultimately, osteoporosis. Gastrointestinal symptoms caused by abnormalities in intestinal motility resulting from malnutrition, laxative abuse, or refeeding are common but are rarely dangerous and may require symptomatic relief. Constipation during refeeding is common and should be treated with dietary manipulation and reassurance; the use of laxatives in this situation should be avoided.

The components of nutritional rehabilitation required in the outpatient management of patients with eating disorders are presented in several reviews. These reviews highlight the dietary stabilization that is required as part of the management of bulimia nervosa and the weight gain regimens that are required as the hallmark of treatment of anorexia nervosa. The reintroduction or improvement of meals and snacks in those with anorexia nervosa is generally done in a stepwise manner, leading in most cases to an eventual intake of 2000 to 3000 kcal per day and a weight gain of 0.5 to 2 lb per week. Changes in meals are made to ensure ingestion of 2 to 3 servings of protein per day (with 1 serving equal to 3 oz of cheese, chicken, meat, or other protein sources). Daily fat intake should be slowly shifted toward a goal of 30 to 50 g per day. Treatment goal weights should be individualized and based on age, height, stage of puberty, premorbid weight, and previous growth charts. In postmenarchal girls, resumption of menses provides an objective measure of return to biological health, and weight at resumption of menses can be used to determine treatment goal weight. A weight approximately 90% of standard body weight is the average weight at which menses resume and can be used as an initial treatment goal weight, because 86% of patients who achieve this weight resume menses within 6 months. For a growing child or adolescent, goal weight should be reevaluated at 3- to 6-month intervals on the basis of changing age and height. Behavioral interventions are often required to encourage otherwise reluctant (and often resistant) patients to accomplish necessary caloric intake and weight gain goals. Although some pediatric specialists, pediatric nurses, or dietitians may be able to handle this aspect of care alone, a combined medical and nutritional team is usually required, especially for more difficult patients.

Similarly, the pediatrician must work with mental health experts to provide the necessary psychologic, social, and psychiatric care. The model used by many interdisciplinary teams, especially those based in settings experienced in the care of adolescents, is to establish a division of labor such that the medical and nutritional clinicians work on the issues described in the preceding paragraph and the mental health clinicians provide such modalities as individual, family, and group therapy. It is generally accepted that medical stabilization and nutritional rehabilitation are the most crucial determinants of short-term and intermediate-term outcome. Individual and family therapy, the latter being especially important in working with younger children and adolescents, are crucial determinants of the long-term prognosis. It is also recognized that correction of malnutrition is required for the mental health aspects of care to be effective. Psychotropic medications have been shown to be helpful in the treatment of bulimia nervosa and prevention of relapse in anorexia nervosa in adults. These medications are also used for many adolescent patients and may be prescribed by the pediatrician or the psychiatrist, depending on the delegation of roles within the team.

The Role of the Pediatrician in Hospital and Day Program Settings

Criteria for the hospitalization in an eating disorder treatment facility of children and adolescents with eating disorders have been established by the Society for Adolescent Medicine (Table 6). These criteria, in keeping with those published by the American Psychiatric Association. acknowledge that hospitalization may be required because of medical or psychiatric needs or because of failure of outpatient treatment to accomplish needed medical, nutritional, or psychiatric progress. Unfortunately, many insurance companies do not use similar criteria, thus making it difficult for some children and adolescents with eating disorders to receive an appropriate level of care. Children and adolescents have the best prognosis if their disease is treated rapidly and aggressively (an approach that may not be as effective in adults with a more long-term, protracted course). Hospitalization, which allows for adequate weight gain in addition to medical stabilization and the establishment of safe and healthy eating habits, improves the prognosis in children and adolescents.

The pediatrician involved in the treatment of hospitalized patients must be prepared to provide nutrition via a nasogastric tube or occasionally intravenously when necessary. Some programs use this approach frequently, and others apply it more sparingly. Also, because these patients are generally more malnourished than those treated as outpatients, more severe complications may need to be treated. These include the possible metabolic, cardiac, and neurologic complications listed in Table 2. Of particular concern is the refeeding syndrome that can occur in severely malnourished patients who receive nutritional replenishment too rapidly. The refeeding syndrome consists of cardiovascular, neurologic, and hematologic complications that occur because of shifts in phosphate from extracellular to intracellular spaces in individuals who have total body phosphorus depletion as a result of malnutrition. Recent studies have shown that this syndrome can result from use of oral, parenteral, or enteral nutrition. Slow refeeding, with the possible addition of phosphorus supplementation, is required to prevent development of the refeeding syndrome in severely malnourished children and adolescents.

Day treatment (partial hospitalization) programs have been developed to provide an intermediate level of care for patients with eating disorders who require more than outpatient care but less than 24-hour hospitalization. In some cases, these programs have been used in an attempt to prevent the need for hospitalization; more often, they are used as a transition from inpatient to outpatient care. Day treatment programs generally provide care (including meals, therapy, groups, and other activities) 4 to 5 days per week from 8 or 9 AM until 5 or 6 PM. An additional level of care, referred to as an "intensive outpatient" program, has also been developed for these patients and generally provides care 2 to 4 afternoons or evenings per week. It is recommended that intensive outpatient and day programs that include children and adolescents should incorporate pediatric care into the management of the developmental and medical needs of their patients. Pediatricians can play an active role in the development of objective, evidence-based criteria for the transition from one level of care to the next. Additional research can also help clarify other questions, such as the use of enteral versus parenteral nutrition during refeeding, to serve as the foundation for evidence-based guidelines.

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The Role of the Pediatrician in Prevention and Advocacy

Prevention of eating disorders can take place in the practice and community setting. Primary care pediatricians can help families and children learn to apply the principles of proper nutrition and physical activity and to avoid an unhealthy emphasis on weight and dieting. In addition, pediatricians can implement screening strategies (as described earlier) to detect the early onset of an eating disorder and be careful to avoid seemingly innocuous statements (such as "you're just a little above the average weight") that can sometimes serve as the precipitant for the onset of an eating disorder. At the community level, there is general agreement that changes in the cultural approaches to weight and dieting issues will be required to decrease the growing numbers of children and adolescents with eating disorders. School curricula have been developed to try to accomplish these goals. Initial evaluations of these curricula show some success in changing attitudes and behaviors, but questions about their effectiveness remain, and single-episode programs (eg, 1 visit to a classroom) are clearly not effective and may do more harm than good. Additional curricula are being developed and additional evaluations are taking place in this field. Some work has also been done with the media, in an attempt to change the ways in which weight and dieting issues are portrayed in magazines, television shows, and movies. Pediatricians can work in their local communities, regionally, and nationally to support the efforts that are attempting to change the cultural norms being experienced by children and adolescents.

Pediatricians can also help support advocacy efforts that are attempting to ensure that children and adolescents with eating disorders are able to receive necessary care. Length of stay, adequacy of mental health services, and appropriate level of care have been a source of contention between those who treat eating disorders on a regular basis and the insurance industry.

Work is being done with insurance companies and on legislative and judicial levels to secure appropriate coverage for the treatment of mental health conditions, including eating disorders. Parent groups, along with some in the mental health professions, have been leading this battle. Support by pediatrics in general, and pediatricians in particular, is required to help this effort.

Recommendations

1. Pediatricians need to be knowledgeable about the early signs and symptoms of disordered eating and other related behaviors.
2. Pediatricians should be aware of the careful balance that needs to be in place to decrease the growing prevalence of eating disorders in children and adolescents. When counseling children on risk of obesity and healthy eating, care needs to be taken not to foster overaggressive dieting and to help children and adolescents build self-esteem while still addressing weight concerns.
3. Pediatricians should be familiar with the screening and counseling guidelines for disordered eating and other related behaviors.
4. Pediatricians should know when and how to monitor and/or refer patients with eating disorders to best address their medical and nutritional needs, serving as an integral part of the multidisciplinary team.
5. Pediatricians should be encouraged to calculate and plot weight, height, and BMI using age- and gender-appropriate graphs at routine annual pediatric visits.
6. Pediatricians can play a role in primary prevention through office visits and community- or school-based interventions with a focus on screening, education, and advocacy.
7. Pediatricians can work locally, nationally, and internationally to help change cultural norms conducive to eating disorders and proactively to change media messages.
8. Pediatricians need to be aware of the resources in their communities so they can coordinate care of various treating professionals, helping to create a seamless system between inpatient and outpatient management in their communities.
9. Pediatricians should help advocate for parity of mental health benefits to ensure continuity of care for the patients with eating disorders.
10. Pediatricians need to advocate for legislation and regulations that secure appropriate coverage for medical, nutritional, and mental health treatment in settings appropriate to the severity of the illness (inpatient, day hospital, intensive outpatient, and outpatient).
11. Pediatricians are encouraged to participate in the development of objective criteria for the optimal treatment of eating disorders, including the use of specific treatment modalities and the transition from one level of care to another.

COMMITTEE ON ADOLESCENCE, 2002-2003
David W. Kaplan, MD, MPH, Chairperson
Margaret Blythe, MD
Angela Diaz, MD
Ronald A. Feinstein, MD
Martin M. Fisher, MD
Jonathan D. Klein, MD, MPH
W. Samuel Yancy, MD

CONSULTANT
Ellen S. Rome, MD, MPH

LIAISONS
S. Paige Hertweck, MD
American College of Obstetricians and
Gynecologists
Miriam Kaufman, RN, MD
Canadian Paediatric Society
Glen Pearson, MD
American Academy of Child and Adolescent
Psychiatry

STAFF
Tammy Piazza Hurley

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TABLE 1. Specific Screening Questions to Identify the Child, Adolescent, or Young Adult With an Eating Disorder

What is the most you ever weighed? How tall were you then? When was that? What is the least you ever weighed in the past year? How tall were you then? When was that? What do you think you ought to weigh? Exercise: how much, how often, level of intensity? How stressed are you if you miss a workout? Current dietary practices: ask for specifics--amounts, food groups, fluids, restrictions? 24-h diet history? Calorie counting, fat gram counting? Taboo foods (foods you avoid)? Any binge eating? Frequency, amount, triggers? Purging history? Use of diuretics, laxatives, diet pills, ipecac? Ask about elimination pattern, constipation, diarrhea. Any vomiting? Frequency, how long after meals? Any previous therapy? What kind and how long? What was and was not helpful? Family history: obesity, eating disorders, depression, other mental illness, substance abuse by parents or other family members? Menstrual history: age at menarche? Regularity of cycles? Last menstrual period? Use of cigarettes, drugs, alcohol? Sexual history? History of physical or sexual abuse? Review of symptoms: Dizziness, syncope, weakness, fatigue? Pallor, easy bruising or bleeding? Cold intolerance? Hair loss, lanugo, dry skin? Vomiting, diarrhea, constipation? Fullness, bloating, abdominal pain, epigastric burning? Muscle cramps, joint paints, palpitations, chest pain? Menstrual irregularities? Symptoms of hyperthyroidism, diabetes, malignancy, infection, inflammatory bowel disease?

 

TABLE 2. Possible Findings on Physical Examination in Children and Adolescents With Eating Disorders
Anorexia Nervosa Bradycardia Orthostatic by pulse or blood pressure Hypothermia Cardiac murmur (one third with mitral valve prolapse) Dull, thinning scalp hair Sunken cheeks, sallow skin Lanugo Atrophic breasts (postpubertal) Atrophic vaginitis (postpubertal) Pitting edema of extremities Emaciated, may wear oversized clothes Flat affect Cold extremities, acrocyanosis	Bulimia Nervosa Sinus bradycardia Orthostatic by pulse or blood pressure Hypothermia Cardiac murmur (mitral valve prolapse) Hair without shine Dry skin Parotitis Russell's sign (callous on knuckles from self-induced emesis) Mouth sores Palatal scratches Dental enamel erosions May look entirely normal Other cardiac arrhythmias

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TABLE 3. Diagnosis of Anorexia Nervosa, Bulimia Nervosa, and Eating Disorders Not Otherwise Specified, From DSM-IV

Anorexia Nervosa Intense fear of becoming fat or gaining weight, even though underweight. Refusal to maintain body weight at or above a minimally normal weight for age and height (ie, weight loss leading to maintenance of body weight <85% of that expected, or failure to make expected weight gain during period of growth, leading to body weight <85% of that expected). Disturbed body image, undue influence of shape or weight on self-evaluation, or denial of the seriousness of the current low body weight. Amenorrhea or absence of at least 3 consecutive menstrual cycles (those with periods only inducible after estrogen therapy are considered amenorrheic). Types: Restricting--no regular bingeing or purging (self-induced vomiting or use of laxatives and diuretics). Binge eating/purging--regular bingeing and purging in a patient who also meets the above criteria for anorexia nervosa.

Bulimia Nervosa Recurrent episodes of binge eating, characterized by: a. Eating a substantially larger amount of food in a discrete period of time (ie, in 2 h) than would be eaten by most people in similar circumstances during that same time period. b. A sense of lack of control over eating during the binge. Recurrent inappropriate compensatory behavior to prevent weight gain; ie, self-induced vomiting, use of laxatives, diuretics, fasting, or hyperexercising. Binges or inappropriate compensatory behaviors occuring, on average, at least twice weekly for at least 3 mo. Self-evaluation unduly influenced by body shape or weight. The disturbance does not occur exclusively during episodes of anorexia nervosa Types: Purging--regularly engages in self-induced vomiting or use of laxatives or diuretics. Nonpurging--uses other inappropriate compensatory behaviors; ie, fasting or hyperexercising, without regular use of vomiting or medications to purge.

Eating Disorder Not Otherwise Specified (those who do not meet criteria for anorexia nervosa or bulimia nervosa, per DSM-IV All criteria for anorexia nervosa, except has regular menses. All criteria for anorexia nervosa, except weight still in normal range. All criteria for bulimia nervosa, except binges <3 times a mo. A patient with normal body weight who regularly engages in inappropriate compensatory behavior after eating small amounts of food (ie, self-induced vomiting after eating 2 cookies). A patient who repeatedly chews and spits out large amounts of food without swallowing. Binge eating disorder: recurrent binges but does not engage in the inappropriate compensatory behaviors of bulimia nervosa.

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TABLE 4. Medical Complications Resulting From Eating Disorders

Medical Complications Resulting From Purging Fluid and electrolyte imbalance; hypokalemia; hyponatremia; hypochloremic alkalosis. Use of ipecac: irreversible myocardial damage and a diffuse myositis. Chronic vomiting: esophagitis; dental erosions; Mallory-Weiss tears; rare esophageal or gastric rupture; rare aspiration pneumonia. Use of laxatives: depletion of potassium bicarbonate, causing metabolic acidosis; increased blood urea nitrogen concentration and predisposition to renal stones from dehydration; hyperuricemia; hypocalcemia; hypomagnesemia; chronic dehydration. With laxative withdrawal, may get fluid retention (may gain up to 10 lb in 24 h). Amenorrhea (can be seen in normal or overweight individuals with bulimia nervosa), menstrual irregularities, osteopenia.

Medical Complications From Caloric Restriction Cardiovascular Electrocardiographic abnormalities: low voltage; sinus bradycardia (from malnutrition); T wave inversions; ST segment depression (from electrolyte imbalances). Prolonged corrected QT interval is uncommon but may predispose patient to sudden death. Dysrhythmias include supraventricular beats and ventricular tachycardia, with or without exercise. Pericardial effusions can occur in those severely malnourished. All cardiac abnormalities except those secondary to emetine (ipecac) toxicity are completely reversible with weight gain. Gastrointestinal system: delayed gastric emptying; slowed gastrointestinal motility; constipation; bloating; fullness; hypercholesterolemia (from abnormal lipoprotein metabolism); abnormal liver function test results (probably from fatty infiltration of the liver). All reversible with weight gain. Renal: increased blood urea nitrogen concentration (from dehydration, decreased glomerular filtration rate) with increased risk of renal stones; polyuria (from abnormal vasopressin secretion, rare partial diabetes insipidus). Total body sodium and potassium depletion caused by starvation; with refeeding, 25% can get peripheral edema attributable to increased renal sensitivity to aldosterone and increased insulin secretion (affects renal tubules). Hematologic: leukopenia; anemia; iron deficiency; thrombocytopenia. Endocrine: euthyroid sick syndrome; amenorrhea; osteopenia. Neurologic: cortical atrophy; seizures.

 

TABLE 5. Differential Diagnosis of Eating Disorders

Malignancy, central nervous system tumor Gastrointestinal system: inflammatory bowel disease, malabsorption, celiac disease Endocrine: diabetes mellitus, hyperthyroidism, hypopituitarism, Addison disease Depression, obsessive-compulsive disorder, psychiatric diagnosis Other chronic disease or chronic infections Superior mesenteric artery syndrome (can also be a consequence of an eating disorder)

 

Addictions plague many people with ADHD. Here's a comprehensive look at self-medicating ADHD with alcohol and drugs plus treatment of ADHD and addictions.

It is common for people with ADHD to turn to addictive substances such as alcohol, marijuana, heroin, prescription tranquilizers, pain medication, nicotine, caffeine, sugar, cocaine and street amphetamines in attempts to soothe their restless brains and bodies. Using substances to improve our abilities, help us feel better, or decrease and numb our feelings is called self-medicating.

Putting Out Fires With Gasoline

The problem is that self-medicating works at first. It provides the person with ADHD relief from their restless bodies and brains. For some, drugs such as nicotine, caffeine, cocaine, diet pills and "speed" enable them to focus, think clearly, and follow through with ideas and tasks. Others chose to soothe their ADHD symptoms with alcohol and marijuana. People who abuse substances, or have a history of substance abuse are not "bad" people. They are people who desperately attempt to self-medicate their feelings, and ADHD symptoms. Self-medicating can feel comforting. The problem is, that self-medicating brings on a host of addiction-related problems which over time make people's lives much more difficult. What starts out as a "solution", can cause problems including addiction, impulsive crimes, domestic violence, increased high risk behaviors, lost jobs, relationships, families, and death. Too many people with untreated ADHD, learning, and perceptual disabilities are incarcerated, or dying from co-occurring addiction.

Self-medicating ADHD with alcohol and other drugs is like putting out fires with gasoline. You have pain and problems that are burning out of control, and what you use to put out the fires is gasoline. Your life may explode as you attempt to douse the flames of ADD.

A 1996 article in American Scientists states that "In the United States alone there are 18 million alcoholics, 28 million children of alcoholics, 6 million cocaine addicts, 14.9 million who abuse other substances, 25 million addicted to nicotine."¹

Who Will Become Addicted?

Everyone is vulnerable to abusing any mind altering substance to diminish the gut wrenching feelings that accompany ADHD. There are a variety of reasons why one person becomes addicted and another does not. No single cause for addictions exists; rather, a combination of factors is usually involved. Genetic predisposition, neurochemistry, family history, trauma, life stress, and other physical and emotional problems contribute. Part of what determines who becomes addicted and who does not is the combination and timing of these factors. People may have genetic predispositions for alcoholism, but if they choose not to drink they will not become alcoholic. The same is true for drug addictions. If an individual never smokes pot, snorts cocaine, shoots or smokes heroin, he or she will never become a pot, coke, or heroin addict.

The bottom line is that people with ADHD as a whole are more likely to medicate themselves with substances than those who do not have ADHD. Drs. Hallowell and Ratey estimate that 8 to 15 million Americans suffer from ADD, other researchers estimated that as many as 30-50% of them use drugs and alcohol to self-medicate their ADHD symptoms.² This does not include those who use food, and compulsive behaviors to self-medicate their ADD brains and the many painful feelings associated with ADHD. When we see ADD it is important to look for substance abuse and addictions. And when we see substance abuse and addictions, it is equally important to look for ADHD.

Prevention and Early Intervention

"Just Say No!" may sound simple, but if it was that simple we would not have millions of children, adolescents, and adults using drugs every day. For some their biological and emotional attraction to drugs is so powerful, that they cannot conceptualize the risks of self-medication. This is especially true for the person with ADHD who may have an affinity for risky, stimulating experiences. This also applies to the person with ADHD who is physically and emotionally suffering from untreated ADHD restlessness, impulsiveness, low energy, shame, attention and organization problems, and a wide range of social pain.3 It is very difficult to say no to drugs when you have difficulties controlling your impulses, concentrating, and are tormented by a restless brain or body.

The sooner we treat children, adolescents, and adults with ADHD the more likely we are to help them to minimize or eliminate self-medicating. Many well meaning parents, therapists and medical doctors are fearful that treating ADHD with medication will lead to addiction. Not all people with ADHD need to take medication. For those who do, however, prescribed medication that is closely monitored can actually prevent and minimize the need to self-medicate. When medication helps people to concentrate, control their impulses, and regulate their energy level, they are less likely to self-medicate.

Untreated ADHD and Addiction Relapse

Untreated ADHD contributes to addictive relapse, and at best can be a huge factor in recovering people feeling miserable, depressed, unfulfilled, and suicidal. Many individuals in recovery have spent countless hours in therapy working through childhood issues, getting to know their inner child, and analyzing why they abuse substances and engage in addictive behaviors. Much of this soul searching, insight, and release of feelings is absolutely necessary to maintain recovery. But what if after years of group and individual therapy, and continued involvement in addiction programs your client still impulsively quit jobs and relationships, can't follow through with their goals, and has a fast chaotic, or slow energy level. What if, along with addiction your client also has ADHD?

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Treating Both ADHD and Addictions

It is not enough to treat addictions and not treat ADHD, nor is it enough to treat ADHD and not treat co-occurring addiction. Both need to be diagnosed, and treated for the individual to have a chance at ongoing recovery. Now is the time to share information so that addiction specialists, and those treating ADHD can work together. It is critical that chemical dependency practitioners understand that ADHD is based in one's biology and responds well to a comprehensive treatment program that sometimes includes medications. It is also important for practitioners to support the recovering persons involvement in Twelve Step programs and help them to work with their fear about taking medication.

A Comprehensive Treatment Program Consists of:

• A professional evaluation for ADHD and co-occurring addiction.
• Continued involvement in addiction recovery groups or Twelve Step programs.
• Education on how ADHD impacts each individual's life, and the lives of those who love them.
• Building social, organization, communication, and work or school skills.
• ADHD coaching and support groups.
• Closely monitored medication when medication is indicated.
• Supporting individuals decisions to take medication or not ( in time they may realize on their own that medication is an essential part of their recovery).

Stages of Recovery

It is important to treat people with ADHD and addiction according to their stage of recovery. Recovery is a process that can be divided into four stages, pre-recovery, early recovery, middle recovery, and long term recovery.

PRE-RECOVERY: Is the period before a person enters treatment for their addictions. It can be difficult to sort out ADHD symptoms from addictive behavior and intoxication. The focus at this point is to get the person into treatment for their chemical and/or behavioral addiction. This is NOT the time to treat ADHD with psycho stimulant medication.

EARLY RECOVERY: During this period it is also difficult, but not impossible to sort out ADHD from the symptoms of abstinence which include, distractibility, restlessness, mood swings, confusions, and impulsivity. Much of what looks like ADHD can disappear with time in recovery. The key is in the life long history of ADHD symptoms dating back to childhood. In most cases early recovery is NOT the time to use psycho stimulant medication, unless the individual's ADHD is impacting his or her ability to attain sobriety.

MIDDLE RECOVERY: By now addicts, and alcoholics, are settling into recovery. This is usually the time when they seek therapy for problems that did not disappear with recovery. It is much easier to diagnose ADHD at this stage; and medication can be very effective when indicated.

LONG TERM RECOVERY: This is an excellent time to treat ADHD with medications when warranted. By now most people in recovery have lives that have expanded beyond intense focus on staying clean and sober. Their recovery is an important part of their life, and they also have the flexibility to deal with other problems such as ADHD.

Stimulant Medication and Addiction

Psychostimulant medication when properly prescribed and monitored is effective for approximately 75-80% of people with ADHD. These medications include Ritalin, Dexedrine, Adderall, and Desoxyn. It is important to note that when these medications are used to treat ADHD the dosage is much less that what addicts use to get high. When people are properly medicated they should not feel high or "speedy, instead they will report increases in their abilities to concentrate, control their impulses, and moderate their activity level. The route of delivery is also quite different. Medication to treat ADHD is taken orally, where street amphetamines are frequently injected and smoked.

Non stimulant medications such as Wellbutrin, Prozac, Nortriptyline, Effexor and Zoloft can also be effective in relieving ADHD symptoms for some people. These medications are frequently used in combination with a small dose of a psychostimulant. Recovering alcoholics and addicts are not flocking to doctors to get psychostimulant medication to treat their ADHD. The problem is that many are hesitant for good reasons to use medication, especially psycho stimulants. It has been my experience that once a recovering person becomes willing to try medication the chance of abuse is very rare. Again the key is a comprehensive treatment program that involves close monitoring of medication, behavioral interventions, ADHD coaching and support groups, and continued participation in addiction recovery programs.

There is Hope

For the last few years I have witnessed the transformation of lives that were once ravaged by untreated ADHD and addiction. I have worked with people who had relapsed in and out of treatment programs for ten to twenty years attain ongoing and fulfilling sobriety once their ADHD was treated. I have Witnessed people with ADHD achieve recovery once their addictions were treated.

"Each day I understand more about how pervasive ADHD is in my life. My clients, friends, family and colleagues are my teachers. I wouldn't wish ADHD and addictions on anyone, but if these are the genetic cards that you have been dealt, your life can still be fascinating and fulfilling."₃

ABOUT WENDY RICHARDSON, MA, L.M.F.C.C., CAS

Wendy Richardson, MA, LMFCC, author of The Link Between ADD & Addiction, Getting The Help You Deserve, Pi-on Press (1997) is a certified addiction specialist who began working in addiction treatment in 1974. Ms. Richardson is nationally recognized as an expert on ADHD and co-occurring addictions, eating disorders, and criminal behavior. She trains therapists, educators, addiction specialists, attorneys, judges, and correctional personnel in America, Canada and abroad. She has been in private practice in Soquel, CA, since 1986.

NOTES

¹Bum, Cull, Braver man, and Comings, 'Reward Deficiency Syndrome,' American Scientist, March-April (1996), p. 143
²Maureen Martin Dale, "A Double-Edged Sword," Student Assistant Journal (November-December 1995): 1
³Wendy Richardson, MA, LMFCC, The Link Between ADD & Addiction: Getting The Help You Deserve (Colorado Springs, Colorado: Pi-on Press, 1997)

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Comprehensive information on omega-6 fatty acids for treatment of anorexia, ADHD and alcoholism. Learn about the usage, dosage, side-effects of omega-6 fatty acids.

Also Known As:essential fatty acids (EFAs), polyunsaturated fatty acids (PUFAs)

• Overview
• Uses
• Dietary Sources
• Available Forms
• How to Take It
• Precautions
• Possible Interactions
• Supporting Research

Overview

Omega-6 fatty acids are considered essential fatty acids (EFAs), which means that they are essential to human health but cannot be made in the body. For this reason, they must be obtained from food. Omega-3 fatty acids are another important group of essential fatty acids. Together, omega-3 and omega-6 fatty acids play a crucial role in brain function as well as normal growth and development. EFAs belong to the class of fatty acids called polyunsaturated fatty acids (PUFAs). They are generally necessary for stimulating skin and hair growth, maintaining bone health, regulating metabolism, and maintaining reproductive capability.

Deficiencies in EFAs can lead to reduced growth, a scaly rash called dermatitis, infertility, and lack of ability to fight infection and heal wounds. Lack of omega-6 fatty acids, however, is extremely rare in diets of those living in certain Western countries, particularly the United States, as well as Israel. In fact, North American and Israeli diets tend to have too much omega-6, particularly in relation to omega-3 fatty acids. This imbalance contributes to long-term diseases such as heart disease, cancer, asthma, arthritis, and depression. For optimum health and disease prevention, the balance should consist of one to four times more omega-6 fatty acids than omega-3 fatty acids. A typical American diet, however, tends to contain 11 to 30 times more omega-6 than omega-3 fatty acids.

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In contrast, a Mediterranean diet is made up of a healthier and more appropriate balance between omega-3 and omega-6 fatty acids. The Mediterranean diet includes a generous amount of whole grains, fresh fruits and vegetables, fish, olive oil, and garlic; plus, there is little meat, which is high in omega-6 fatty acids.

There are several different types of omega-6 fatty acids. Most omega-6 fatty acids are consumed in the diet from vegetable oils as linoleic acid (LA; be careful not to confuse this with alpha-linolenic acid [ALA]gamma-linolenic acid (GLA) in th which is an omega-3 fatty acid). Linoleic acid is converted to e body and then further broken down to arachidonic acid (AA). AA can also be consumed directly from meat, and GLA can be ingested from several plant-based oils including evening primrose oil (EPO), borage oil, and black currant seed oil.

Excess amounts of LA and AA are unhealthy because they promote inflammation, thereby leading to several of the diseases described above. In contrast, GLA may actually reduce inflammation. Much of the GLA taken as a supplement is not converted to AA, but rather to a substance called dihomogamma-linolenic acid (DGLA). DGLA competes with AA and prevents the negative inflammatory effects that AA would otherwise cause in the body. In addition, DGLA becomes part of a particular series of substances, called prostaglandins, that can reduce inflammation. Having adequate amounts of certain nutrients in the body (including magnesium, zinc, and vitamins C, B3, and B6) helps promote the conversion of GLA to DGLA rather than AA.

It is important to know that many experts feel that the science supporting the use of omega-3 fatty acids to reduce inflammation and prevent diseases is much stronger than the information regarding use of GLA for these purposes.

 

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Omega-6 Uses

Some clinicians and preliminary research suggest that omega-6 fatty acids may be useful for the following purposes:

Omega-6 for Anorexia Nervosa
Studies suggest that women, and possibly men, with anorexia nervosa have lower than optimal levels of PUFAs and display abnormalities in the use of these fatty acids in the body. To prevent the metabolic complications associated with essential fatty acid deficiencies, some recommend that treatment programs for anorexia nervosa include PUFA-rich foods such as organ meats and fish.

Omega-6 for attention deficit/hyperactivity disorder (ADHD)
Studies suggest that children with attention deficit/hyperactivity disorder (ADHD) have lower levels of EFAs, both omega-6s and omega-3s. Given the relationship of EFAs to normal brain and behavioral function, this makes sense. Because of this logical connection and the low levels of EFAs measured in those with attention deficit/hyperactivity disorder (ADHD), scientists have speculated that replacement of EFAs through food or supplements may help lessen the behaviors and symptoms of this condition.

Research to date has suggested an improvement in symptoms and behaviors related to attention deficit/hyperactivity disorder (ADHD) from omega-3 fatty acids. Results of studies supplying omega-6 fatty acids in the form of GLA from EPO or other sources to children with attention deficit/hyperactivity disorder (ADHD), however, have been mixed and, therefore, not conclusive. More research on GLA for attention deficit/hyperactivity disorder (ADHD) is needed before conclusions can be drawn. In the meantime, ensuring a healthier balance of omega-3 to omega-6 fatty acids in the diet seems worthwhile for those with this behavioral condition.

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Diabetes
Omega-6 fatty acid supplementation, in the form of GLA from EPO or other sources, may assist nerve function and help prevent nerve disease experienced by those with diabetes (called peripheral neuropathy and felt as numbness, tingling, pain, burning, or lack of sensation in the feet and/or legs).

Eye Disease
GLA may be beneficial in dry-eye conditions such as Sjögren's syndrome (a condition with symptoms of dry eyes, dry mouth, and, often, arthritis).

Osteoporosis
A deficiency in essential fatty acids (including GLA and EPA, an omega-3 fatty acid) can lead to severe bone loss and osteoporosis. Studies have shown that supplements of GLA and EPA help maintain or increase bone mass. Essential fatty acids may also enhance calcium absorption, increase calcium deposits in bones, diminish calcium loss in urine, improve bone strength, and enhance bone growth, all of which may contribute to improved bone mass and, therefore, strength.

Menopausal Symptoms
Although EPO has gained some popularity for treating hot flashes, the research to date has not demonstrated a benefit of GLA or EPO over taking a placebo. With that said, there are individual women who report improvement; therefore, it may be worthwhile to talk to your doctor about whether it is safe for you to try EPO or another form of GLA supplements to alleviate hot flashes.

Premenstrual Syndrome (PMS)
Although results of studies have been mixed, some women find relief of their PMS symptoms when using GLA supplements from EPO or another source. The symptoms that seem to be helped the most are breast tenderness and feelings of depression as well as irritability and swelling and bloating from fluid retention. Breast tenderness from causes other than PMS may also improve with use of GLA.

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Acne and Psoriasis
Some speculate that dietary LA (from, for example, corn oil) may prove beneficial for these skin conditions by replenishing the low levels of LA in these lesions. Research in this area is needed to determine whether this theory has any basis.

Eczema
Several early studies suggested that EPO is more beneficial than placebo at relieving symptoms associated with this skin condition such as itching, redness, and scaling. However, more recent studies have not had the same positive results testing GLA derived from EPO. The bottom line is that whether EPO supplements work for someone with eczema may be very individual. Talk to your doctor about the possibility and safety of trying EPO for this condition.

Omega-6 for Alcoholism
EPO may help lessen cravings for alcohol and prevent liver damage. Some of this information comes from animal studies; more research in people is needed.

Allergies
People who are prone to allergies may require more EFAs and often have difficulty converting LA to GLA. In fact, women and infants who are prone to allergies appear to have lower levels of GLA in breast milk and blood.

To date, the use of EFAs to prevent allergic reactions or reduce their magnitude has had mixed results. There have been some reports of individuals lessening their allergic reaction by taking GLA from EPO. For example, one young boy who broke out in hives when around dogs, no longer had this response after taking EPO for one month. Well-conducted research studies are needed to determine whether EPO can be helpful for large numbers of people with allergies.

On the other hand, a study evaluating dietary intake of omega-6 fatty acids relative to the risk of having hay fever (called allergic rhinitis) found different results for this other type of allergic reaction. Nurses in Japan with higher amounts of omega-6 in their diet were more likely to have hay fever.

Omega-6 fatty acids from the diet or supplements, such as GLA from EPO or other sources, have a longstanding history of folk use for allergies. Whether this supplement improves your symptoms, therefore, may be very individual. Work with your healthcare provider to first determine if it is safe for you to try GLA and then follow your allergy symptoms closely for any signs of improvement or lack there of.

Rheumatoid Arthritis
Some preliminary information indicates that GLA, from EPO, borage oil, or black currant seed oil, may diminish joint pain, swelling, and morning stiffness. GLA may also allow for reduction in amount of pain medication used by those with rheumatoid arthritis. The studies to date, however, have been small in size. Additional research would be helpful, including testing a proposed theory that using GLA and EPA (an omega-3 fatty acid from fish oil) together would be helpful for rheumatoid arthritis.

In the meantime, talk to your doctor about whether using GLA is safe for you and then pay attention, over 1 to 3 months of use, to whether your symptoms get better or not. In terms of borage oil, some researchers theorize that it may not be safe to use with non-steroidal anti-inflammatory drugs (NSAIDs such as ibuprofen, which are commonly used for arthritis). This theory needs to be tested. See Possible Interactions.

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Cancer
Results of studies looking at the relationship of omega-6 fatty acids to cancer have been mixed. While LA and AA are cancer promoting in studies of colon, breast, and other cancers, GLA and EPO have shown some benefit for breast cancer in certain studies. The information is not conclusive and is somewhat controversial. The safest bet is to eat a diet with the proper balance of omega-3 to omega-6 fatty acids (see How To Take It), starting from a young age, to try to prevent the development of cancer.

Omega-6 for Weight Loss
Results of studies regarding use of EPO for weight loss have been mixed and, therefore, use of this type of supplement won't work for everyone. One study suggests that if the supplement is going to work, it does so mainly for overweight individuals for whom obesity runs in the family. In addition, a few other small studies suggest that the more overweight you are, the more likely that EPO will help. In fact, if your body weight is only 10% above normal (for example, 10 to 20 pounds above average), EPO is unlikely to help you lose weight.

High Blood Pressure and Heart Disease
Animal studies suggest that GLA, either alone or in combination with two important omega-3 fatty acids, EPA and DHA both found in fish and fish oil, may lower the blood pressure of hypertensive rats. Together with EPA and DHA, the GLA helped to prevent the development of heart disease in these animals as well. It is unclear whether these benefits would occur in people.

In one study evaluating people with peripheral artery disease (blockage in the blood vessels in the legs from atherosclerosis [plaque] causing cramping pain with walking), men and women with this condition did experience improvement in their blood pressure from the combination of EPA and GLA. Much more research is needed in people before conclusions can be drawn. Plus, it may not be the GLA conferring the benefit at all à ¢Ã¢â€š ¬Ã¢â‚¬Å“ the omega-3 fatty acids, which are better known for improving blood pressure and the risks for heart disease, may be solely responsible.

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Tuberculosis
Animal studies suggest that guinea pigs fed a diet rich in omega-6 fatty acids were better able to fight this infection than guinea pigs fed a diet rich in omega-3 fatty acids. Whether this would help people with tuberculosis is not known.

Ulcers Very preliminary evidence from test tube and animal studies suggest that GLA from EPO may have anti-ulcer properties. It is premature to know how this might apply to people with stomach or intestinal ulcers or gastritis (inflammation of the stomach).

 

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Dietary Sources for Omega-6 Fatty Acids

The American diet provides more than 10 times the needed amount of omega-6 oils in the form of linoleic acid (LA). This is because it comprises the primary oil ingredient added to most processed foods and is found in commonly used cooking oils, including sunflower, safflower, corn, cottonseed, and soybean oils.

Omega-6 fatty acids in the form of gamma linolenic acid (GLA) and LA are found in the plant seed oils of evening primrose, black currant, borage, and fungal oils.

Arachidonic acid (AA) of the omega-6 series is found in egg yolk, meats in general, particularly organ meats, and other animal-based foods.

 

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Available Forms of Omega-6

Omega-6 fatty acids are commercially available in supplemental oils that contain LA and GLA. Spirulina (often called blue-green algae) also contains GLA.

 

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How to Take Omega-6

For general health, there should be a balance between omega-6 and omega-3 fatty acids; the ratio should be in the range of 1:1 to 4:1; the typical North American diet, however, normally provides ratios from 11:1 to 30:1.

Pediatric

For nursing infants, adequate amounts of essential fatty acids are generally supplied in breast milk if the mother is adequately nourished.

For older children, essential fatty acids should be obtained through the diet. Because it is important to maintain a balance of fatty acids within the body, it may be appropriate to check fatty acid levels before considering supplements for children.

It is important to note that although dietary guidelines as described have been suggested, there are no established therapeutic doses for omega-6 fatty acid supplements in children. Some suggest that EPO 2,000 to 4,000 mg per day may be used safely in children for eczema; research is needed to confirm.

Adult

The recommended dosage for rheumatoid arthritis is 1,400 mg per day of GLA or 3,000 mg of EPO.

For diabetes it is 480 mg per day of GLA.

For breast tenderness or other symptoms of PMS, 3,000 to 4,000 mg of EPO per day is the dose suggested.

For other conditions discussed in Uses, a specific safe and appropriate dose for omega-6 supplements has not yet been established.

Studies have suggested that up to 2,800 mg of GLA per day is well tolerated.

 

 

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Precautions

Because of the potential for side effects and interactions with medications, dietary supplements should be taken only under the supervision of a knowledgeable healthcare provider.

Omega-6 should not be used if you have a seizure disorder because there have been reports of these supplements inducing seizures.

Borage seed oil, and possibly other sources of GLA, should not be used during pregnancy because they may be harmful to the fetus and induce early labor.

Doses of GLA greater than 3,000 mg per day should be avoided because, at that point, production of AA (rather than DGLA) may increase.

 

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Possible Interactions

If you are currently being treated with any of the following medications, you should not use omega-6 supplements without first talking to your healthcare provider.

Ceftazidime GLA may increase the effectiveness of ceftazidime, an antibiotic in a class known as cephalosporins, against a variety of bacterial infections.

Chemotherapy for cancer GLA may increase the effects of anti-cancer treatments, such as doxorubicin, cisplatin, carboplatin, idarubicin, mitoxantrone, tamoxifen, vincristine, and vinblastine.

Cyclosporine Taking omega-6 fatty acids during therapy with cyclosporine, a medication used to suppress the immune system after an organ transplant, for example, may increase the immunosuppressive effects of this medication and may protect against kidney damage (a potential side effect from this medication).

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Nonsteroidal Anti-inflammatory Drugs (NSAIDs) Theoretically, use of NSAIDs, such as ibuprofen, together with borage seed oil or other omega-6 fatty acids may counter-act the effects of the supplement. Research in this area is needed to know if this theory is accurate.

Phenothiazines for schizophreniaIndividuals taking a class of medications called phenothiazines (such as chlorpromazine, fluphenazine, perphenazine, promazine, and thioridazine) to treat schizophreniashould not take EPO because it may interact with these medications and increase the risk of seizures. The same may be true for other omega-6 containing supplements.

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Supporting Research

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Barham JB, Edens MB, Fonteh AN, Johnson MM, Easter L, Chilton FH. Addition of eicosapentaenoic acid to gamma-linolenic acid-supplemented diets prevents serum arachidonic acid accumulation in humans. J Nutr. 2000;130(8):1925-1931.

Barre DE. Potential of evening primrose, borage, black currant, and fungal oils in human health. Ann Nutr Metab. 2001;45(2):47-57

Baumgaertel A. Alternative and controversial treatments for attention-deficit/hyperactivity disorder. Pediatr Clin North Am. 1999;46(5):977-992.

Belch JJ, Hill A. Evening primrose oil and borage oil in rheumatologic conditions. Am J Clin Nutr. 2000;71(1 Suppl):352S-356S.

Bendich A. The potential for dietary supplements to reduce premenstrual syndrome (PMS) symptoms. J Am Coll Nutr. 2000;19(1):3-12.

Brown NA, Brown AJ, Harding JJ, Dewar HM. Nutrition supplements and the eye. Eye. 1998; 12(pt. 1):127-133.

Bruinsma KA, Taren DL. Dieting, essential fatty acid intake, and depression. Nutrition Rev. 2000;58(4):98-108.

Burgess J, Stevens L, Zhang W, Peck L. Long-chain polyunsaturated fatty acids in children with attention-deficit hyperactivity disorder. Am J Clin Nutr. 2000; 71(suppl):327S-330S.

Calder PC, Miles EA. Fatty acids and atopic disease. Pediatr Allergy Immunol. 2000;11 Suppl 13:29-36.

Calder PC, Zurier RB. Polyunsaturated fatty acids and rheumatoid arthritis. Curr Opin Clin Nutr Metab Care. 2001;4(2):115-121.

Chenoy R, Hussain S, Tayob Y, O'Brien PM, Moss MY, Morse PF. Effect of oral gamolenic acid from evening primrose oil on menopausal flushing. BMJ. 1994;19(308):501-503.

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Davies CL, Loizidou M, Cooper AJ, et al. Effect of gamma-linolenic acid on cellular uptake of structurally related anthracyclines in human drug sensitive and multidrug resistant bladder and breast cancer cell lines. Eur J Cancer. 1999;35:1534-1540.

Engler MM, Schambelan M, Engler MB, Ball DL, Goodfriend TL. Effects of dietary gamma-linolenic acid on blood pressure and adrenal angiotensin receptors in hypertensive rats. Proc Soc Exp Biol Med. 1998;218(3):234-237.

Fan YY, Chapkin RS. Importance of dietary gamma-linolenic acid in human health and nutrition. J Nutr. 1998; 128(9): 1411-1414.

Frenoux JMR, Prost ED, Belleville JL, Prost JL. A polyunsaturated fatty acid diet lowers blood pressure and improves antioxidant status in spontaneously hypertensive rats. J Nutr. 2001;131(1):39-45.

Furse RK, Rossetti RG, Zurier RB. Gammalinolenic acid, an unsaturated fatty acid with anti-inflammatory properties, blocks amplification of IL-1 beta production by human monocytes. J Immunol. 2001;1;167(1):490-496.

Garcia CM, et al. Gamma linolenic acid causes weight loss and lower blood pressure in overweight patients with family history of obesity. Swed J Biol Med. 1986;4:8-11.

Giamarellos-Bourboulis EJ, Grecka P, Dionyssiou-Asteriou A, et al. In vitro interactions of gamma-linolenic acid and arachidonic acid with ceftazidime on multiresistant Pseudomonas aeruginosa. Lipids. 1999;34:S151-152.

Graham-Brown R. Atopic dermatitis: unapproved treatments or indications. Clin Dermatol. 2000;18(2):153-158.

Grattan C, Burton JL, Manku M, Stewart C, Horrobin DF. Essential-fatty-acid metabolites in plasma phospholipids in patients with ichthyosis vulgaris, acne vulgaris and psoriasis. Clin Exp Dermatol. 1990;15(3):174-176.

Griffini P, Fehres O, Klieverik L, et al. Dietary W-3 polyunsaturated fatty acids promote colon carcinoma metastasis in rat liver. Cancer Res. 1998;58:3312-3319.

Head RJ, McLennan PL, Raederstorff D, Muggli R, Burnard SL, McMurchie EJ. Prevention of nerve conduction deficit in diabetic rats by polyunsaturated fatty acids. Am J Clin Nutr. 2000;71:386S-392S.

Hederos CA, Berg A. Epogam evening primrose oil treatment in atopic dermatitis and asthma. Arch Dis Child. 1996;75(6):494-497

Holman RT, Adams CE, Nelson RA, et al. Patients with anorexia nervosa demonstrate deficiencies of selected essential fatty acids, compensatory changes in nonessential fatty acids and decreased fluidity of plasma lipids. J Nutr. 1995;125:901-907.

Horrobin DF. The role of essential fatty acids and prostaglandins in the premenstrual syndrome. J Reprod Med. 1983;28(7):465-468.

Ikushima S, Fujiwara F, Todo S, Imashuku S. Gamma linolenic acid alters the cytotoxic activity of anticancer drugs on cultured human neuroblastoma cells. Anticancer Res. 1990;10:1055-1059.

Kankaanpaa P, Nurmela K, Erkkila A, et al. Polyunsaturated fatty acids in maternal diet, breast milk, and serum lipid fattty acids of infants in relation to atopy. Allergy. 2001;56(7):633-638.

Kast RE. Borage oil reduction of rheumatoid arthritis activity may be mediated by increased cAMP that suppresses tumor necrosis factor-alpha. Int Immunopharmacol. 2001;1(12):2197-2199.

Keen H, Payan J, AllawiJ, et al. Treatment of diabetic neuropathy with gamma-linolenic acid. The Gamma-Linolenic Acid Multicenter Trial Group. Diabetes Care. 1993;16(1):8-15.

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Kruger MC, Coetzer H, de Winter R, Gericke G, van Papendorp DH. Calcium, gamma-linolenic acid and eicosapentaenoic acid supplementation in senile osteoporosis. Aging Clin Exp Res. 1998;10:385-394.

Kruger MC, Horrobin DF. Calcium metabolism, osteoporosis and essential fatty acids: a review. Prog Lipid Res. 1997;36:131-151.

Leventhal LJ, Boyce EG, Zurier RB. Treatment of rheumatoid arthritis with black currant seed oil. Br J Rheumatol. 1994;33(9):847-852.

Leng GC, Lee AJ, Fowkes FG, et al. Randomized controlled trial of gamma-linolenic acid and eicosapentaenoic acid in peripheral arterial disease. Clin Nutr. 1998;17(6):265à ¢Ã¢â€š ¬Ã¢â‚¬ 271,

Little C, Parsons T. Herbal therapy for treating rheumatoic arthritis. Cochrane Database Syst Rev. 2001;(1):CD002948.

Madhavi N, Das UN. Effect of n-6 and n-3 fatty acids on the survival of vincristine sensitive and resistant human cervical carcinoma cells in vitro. Cancer Lett. 1994;84:31-41.

Manjari V, Das UN. Effect of polyunsaturated fatty acids on dexamethasone-induced gastric mucosal damage. Prostaglandins Leukot Essent Fatty Acids. 2000;62(2):85-96.

McCarty MF. Nutritional modulation of mineralocorticoid and prostaglandin production: potential role in prevention and treatment of gastic pathology. Med Hypotheses. 1983;11(4):381-389,

Menendez JA, del Mar Barbacid M, Montero S, et al. Effects of gamma-linolenic acid and oleic acid on paclitaxel cytotoxicity in human breast cancer cells. Eur J Cancer. 2001;37:402-413.

Miller LG. Herbal medicinals: selected clinical considerations focusing on known or potential drug-herb interactions. Arch Intern Med. 1998;158(20):2200 - Å“2211.

Mitchell EA, Aman MG, Turbott SH, Manku M. Clinical characteristics and serum essential fatty acid levels in hyperactive children. Clin Pediatr (Phila). 1987;26:406-411.

Morphake P, Bariety J, Darlametsos J, et al. Alteration of cyclosporine (CsA)-induced nephrotoxicity by gamma linolenic acid (GLA) and eicosapentaenoic acid (EPA) in Wistar rats. Prostaglandins Leukot Essent Fatty Acids. 1994;50:29-35.

Morse PF, Horrobin DF, Manku MS, et al. Meta-analysis of placebo-controlled studies of the efficacy of Epogram in the treatment of atopic eczema: relationship between plasma essential fatty changes and treatment response. Br J Dermatol. 1989;121(1):75-90.

Munoz SE, Lopez CB, Valentich MA, Eynard AR. Differential modulation by dietary n-6 or n-9 unsaturated fatty acids on the development of two murine mammary gland tumors having different metastatic capabilities. Cancer Lett. 1998;126:149-155.

Paul KP, Leichsenring M, Pfisterer M, et al. Influence of n-6 and n-3 polyunsaturated fatty acids on the resistance to experimental tuberculosis. Metabolism. 1997;46(6):619-624.

Plumb JA, Luo W, Kerr DJ. Effect of polyunsaturated fatty acids on the drug sensitivity of human tumour cell lines resistant to either cisplatin or doxorubicin. Br J Cancer. 1993;67:728-733.

Richardson AJ, Puri BK. The potential role of fatty acids in attention-deficit/hyperactivity disorder. Prostaglandins Leukot Essent Fatty Acids. 2000;63(1/2):79-87.

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Simopoulos AP. Essential fatty acids in health and chronic disease. Am J Clin Nutr. 1999;70(3 suppl):560S-569S.

Soyland E, Funk J, Rajka G, et al. Effect of dietary supplementation with very-long-chain n-3 fatty acids in patients with psoriasis. N Engl J Med. 1993;328(25):1845-1846.

Stevens LJ, Zentall SS, Abate ML, Kuczek T, Burgess JR. Omega-3 fatty acids in boys with behavior, learning and health problems. Physiol Behav. 1996;59(4/5):915-920.

Stevens LJ, Zentall SS, Deck JL, et al. Essential fatty acid metabolism in boys with attention-deficit hyperactivity disorder. Am J Clin Nutr. 1995;62:761-768.

Stoll BA. Breast cancer and the Western diet: role of fatty acids and antioxidant vitamins. Eur J Cancer. 1998;34(12):1852-1856.

Thompson L, Cockayne A, Spiller RC. Inhibitory effect of polyunsaturated fatty acids on the growth of Helicobacter pylori: a possible explanation of the effect of diet on peptic ulceration. Gut. 1994;35(11):1557-1561.

Tsai W-S, Nagawa H, Kaizaki S, Tsuruo T, Muto T. Inhibitory effects of n-3 polyunsaturated fatty acids on sigmoid colon cancer transformants. J Gastroenterol. 1998;33:206-212.

Wainwright PE. Do essential fatty acids play a role in brain and behavioral development? Neurosci Biobehav Rev. 1992;16(2):193-205.

Wakai K, Okamoto K, Tamakoshi A, Lin Y, Nakayama T, Ohno Y. Seasonal allergic rhinoconjunctivitis and fatty acid intake: a cross-sectional study in Japan. Ann Epidemiol. 2001;11(1):59-64.

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Wu D, Meydani M, Leka LS, et al. Effect of dietary supplementation with black currant seed oil in the immune response of healthy elderly subjects. Am J Clin Nutr. 1999;70:536-543.

Yam D, Eliraz A, Berry EM. Diet and disease - Å“ the Israeli paradox: possible dangers of high omega-6 polyunsaturated fatty acid diet. Isr J Med Sci. 1996;32(11):1134-1143.

 

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The publisher does not accept any responsibility for the accuracy of the information or the consequences arising from the application, use, or misuse of any of the information contained herein, including any injury and/or damage to any person or property as a matter of product liability, negligence, or otherwise. No warranty, expressed or implied, is made in regard to the contents of this material. No claims or endorsements are made for any drugs or compounds currently marketed or in investigative use. This material is not intended as a guide to self-medication. The reader is advised to discuss the information provided here with a doctor, pharmacist, nurse, or other authorized healthcare practitioner and to check product information (including package inserts) regarding dosage, precautions, warnings, interactions, and contraindications before administering any drug, herb, or supplement discussed herein.

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R. Reid Wilson, Ph.D. is a licensed psychologist who directs the Anxiety Disorders Treatment Program in Chapel Hill and Durham, North Carolina. He is also Clinical Associate Professor of Psychiatry at the University of North Carolina School of Medicine.

Dr. Wilson specializes in the treatment of anxiety disorders. He is author of Don't Panic: Taking Control of Anxiety Attacks (Harper Perennial), now in its Revised Edition, is co-author of Stop Obsessing! How to Overcome Your Obsessions and Compulsions (Bantam) and is co-author of "Achieving Comfortable Flight", a self-help kit for the fearful flier. He designed and served as lead psychologist for American Airlines' first national program for the fearful flier.

Dr. Wilson served on the Board of Directors of the Anxiety Disorders Association of America for 12 years. He served as Program Chair of the National Conferences on Anxiety Disorders from 1988-1991.

Educational Background:

• University of North Carolina at Chapel Hill, BA, Sociology, with highest honors, 1973
• Antioch Graduate School, Masters in Counseling, 1977
• Fielding Institute, Ph.D., Clinical Psychology, 1980

Television appearances:

• Oprah Winfrey Show
• Good Morning America
• America's Talking.

Areas of specialization: All anxiety disorders (panic disorder, phobias, social phobias, obsessions, compulsions), fear of flying.

next: Welcome ! Treating Anxiety Disorders: New Help Has Arrived!
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Quest for Freedom!

~ An insight into OCD ~ Obsessive Compulsive Disorder

Dear Diary,

Happy Halloween! It's been a year now since I started writing this OCD Diary! I can't believe that. It seems to have flown by and so much has changed and happened in that time. When I first began writing this, I never dreamt I would still be at my friend's house or that I wouldn't still be with Phil, or that I would have flown to America! Isn't it strange how life has a habit of just "happening" without you realising it?

My OCD is ok...ish! except that at certain times I seem to be attatched to the sink by elastic that keeps pulling me back to wash my hands just 'one more time'! It's so frustrating! It's at those moments that I wonder if the OCD meds are still working, I've been on the same ones for over a year now and I can't help but wonder if the effects are wearing off a bit. I get so many e.mails from people who have this problem and have to change them. I really don't want to have to get used to new side-effects though! :o(

I have been working on a new site ~ My Poetry Book. I'm not saying I'm a poet or anything, but when this illness had me virtually housebound, I found that writing my feelings down in the form of poetry helped, and seeing as I've got 90 or so of them I thought I'd something with some of them! Take a look if you like, you might find one you quite like! Inside :o)

I haven't heard anything from you know who! ~ Phil. It will soon be my birthday, but I don't suppose even that will make him get in touch! Just wish I didn't keep having dreams with him in them! If anyone reading this has gone through a separation /divorce and can offer some advise as to how best to get over it, I'd be grateful because I have a real hard job with it, and feel a sadness and pain that is difficult to shake off. :0)

The situation in America with the Anthrax is getting a bit scary and I wonder how fellow OCD'ers are handling it. This is a very "real" contamination threat as opposed to an "irrational" one.

Oh well, guess that's it for now.

I hope you reading this are as well as possible. Take care everyone.

Love and Hugs~Sani~

next: My Obsessively Clean Diary: November 2001
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Quest for Freedom!

~ An insight into OCD ~ Obsessive Compulsive Disorder

Dear Diary,

I apologise. I am very late with this entry and, as I write this, it is already April! I hope everyone had a good Easter! No, I haven't given up on my OCD Diary, and it's not because I've had better things to do and have neglected it.

The truth is that since Christmas, I haven't really known what to write! Until then, I had thought I could be strong enough. I had tried to be, even though inside I wasn't. I realise now I had just covered things up, hidden feelings and shyed away from them. I was so scared of feeling the pain and hurt too much; scared I wouldn't be able to handle those feelings and scared it would grind me to a halt.

My Dad has had nervous breakdowns in his life and I, too, broke down because of the OCD before. It is a very scary feeling to not be in control of things and to also feel alone.

I know I have a handful of people who care about me, which is more than some have, but you can be in a filled room and still feel alone and I do feel very alone sometimes.

Christmas was unbearably hard for me. I missed Phil sooo much and realised just how much I love him. It hit me like a ton of bricks, the void and space, the huge great hole he has left in my life.

Thank goodness I was with my Mum because she understood how I felt. The best way to describe it, I think, is to compare it to grief. I have lost someone I was closest to in the whole world, someone I married and believed I would be with forever, until we were old and grey. Suddenly that person was snatched away from me. I had no say in it. I was powerless to stop it from happening.

I tried to block the grief from this loss by constantly working on the computer, plodding on day after day, escaping into another world on the Web, and just hoping that I could be strong and get through it without cracking up! Christmas brought my loss to the fore though, and it hurt like no other pain I have ever felt. I hadn't handled things, I'd hid them!

The text messages I had over Christmas from Phil showed emotion at last and feeling for me too! A girlfriend told me she thought we really ought to meet up to talk and see what's there between us and I think she's right. The person I love and am married to hasn't died and it's not impossible that we could still have a future together. So maybe we need to explore that! Who knows?

Phil and I have spoken on the phone since Christmas and it was a really positive conversation. We even managed to laugh together a bit! He said awhile back that if any two people could get through all of this together we could and maybe that's right!

I'm sure his current arrangement isn't by any means perfect and I sense that a good part of him would like to give us a chance together. I wish he would. It's no more than we both deserve! He's aware that another person would get hurt in all of this so, of course, it would be difficult, but it's difficult for us as a pair too! We are married and have been for 10 years. We shouldn't throw that away if we don't need to and not even if it means someone else getting hurt along the way! Anyway I'm completely open to the idea and shall just wait and see how things go.

My OCD is the same really! Stable and pretty much in control. There are things that worry me and make me wash my hands an extra time, but that's it and so I can't really complain!

After years of being room-bound, I am now driving!! Tonight, I drove somewhere all by myself for the first time in years and it was really great! :0) I always knew that I COULD do it again but never really knew if I WOULD!

It's felt really spring-like here this weekend and it's nice to be able to get out in the fresh air and sunshine.

I will try to be more on schedule with my next Diary entry :0)

Love and hugs, Sani. xx

next: My Obsessively Clean Diary: April and May 2002
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Seeing ourselves in God's image

You are what you eat - or not

The old adage that connotes good eating as good health has been turned on its head by undue preoccupation with food and diet and an obsession with how we look.

Weight control has become a compulsion. Obesity has become a national scourge. And the late Dr. Robert Atkins, who formulated the now wildly popular diet of the same name, our hero.

Cantor Sharona Feller and therapist Cindy Weiser talk about community at the final session of this year's "Advanced Body and Soul" program at Temple Chai.
Photo by Vicki Cabot

"Being as thin as you can be is (often defined as) being the best you can be," notes local therapist Cindy Weiser. "(But) this whole thing about the perfect body, it's socially constructed," she says.

And insidious. Many of us don't realize how we conform to societal illusions of what is beautiful - or not.

Living in a culture where thinness is elevated to near-godliness, there is a movement to resist those glossy images. Delving into Jewish texts can help uncover the beauty within.

Weiser is one of four facilitators in the three-year-old Body and Soul program offered by the Deutsch Family Shalom Center at Temple Chai. The series of workshops for women and girls draws on Jewish values to promote self-esteem and positive identity.

"We are trying to put (body image) in proper perspective," says center director Sharona Silverman.

It was Silverman who first learned of the Atlanta-based Body and Soul National Institute a few years ago. She invited founder Donnie Winokur to Phoenix to help start a pilot program here. Winokur, in a telephone interview from her Georgia home, explained that Body and Soul grew from her own experience. A former actress and documentary filmmaker, she admits to being overly concerned with appearance. A conversation with a friend led to the resolve to do something about it.

"Here we were approaching middle age and still dealing with this stuff," says Winokur, now 48. "We were tired of it. We wanted to look inside ourselves spiritually and get rid of the baggage."

Winokur, whose husband Harvey is spiritual leader of Temple Kehillat Chaim in Roswell, Ga., began developing the program working with clergy, social workers and educational professionals. She drew on the Women of Valor Program from the Jewish Women's Archives in Boston and engaged a Union for Reform Judaism rabbinic intern from URJ's Department of Jewish Family Concerns to refine the Judaic content.

Winokur, who has a degree in psychology and produced documentaries on health and children's issues in Atlanta before marrying seven years ago, says she sought to help participants to look inside, beyond the mirror, drawing on intrinsic Jewish notions of specialness.

Every session includes Torah study to help guide the women to learn to value themselves as divine creations.

"We want to learn how to love ourselves in the image of God - not in the image of Madison Avenue," she says.

Playing on Winokur's model, Silverman developed three modules of body and soul, one for women and two others for girls of varying age groups. She, Weiser, professional counselor Sandy Lewis and Temple Chai Cantor Sharona Feller facilitate sessions.

The women's group just completed a third year of programming.

Judy Bernstein, a three-year participant, says she has battled weight issues since she was a teenager and her mother suggested joining Weight Watchers.

Now just turning 46, Bernstein says she has gained and lost the same 40 pounds for the past 30 years.

She credits the program with helping her maintain her weight by allowing her to become more accepting of herself.

She learned to appreciate her attributes and focus on her inner self. "I watch what I eat, I exercise, and I am comfortable with myself," she says.

High school junior Jackie Shapiro, who completed the teen course two years ago and then mentored younger girls in the program last year, says it helped her "get to know myself ... and make the right choices."

Shapiro notes that her girlfriends talk about weight incessantly. At least half are dieting - and most are in the normal weight range, she says.

The goal, says Winokur, is to "feel comfortable in your own skin."

A positive self-image is critical to developing healthy attitudes and behaviors toward eating, say therapists. In some cases, a poor self-image can lead to what Winokur terms "disordered eating," an over-preoccupation with food. In others, it can lead to more worrisome psychological and emotional problems and health-threatening behaviors.

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Eleanor Gross, a certified eating-disorder specialist in private practice here, differentiates between what she terms "the garden-variety obsessed" and those who engage in destructive behaviors that interfere with daily functioning.

Many women are preoccupied with appearance and acceptance, says Gross, who elected to specialize in eating disorders after recovering herself more than 30 years ago. But those who engage in excessive behaviors, whether bingeing or starving, are often dealing with issues of control and false images of perfection.

Eating what you want - or not eating what you want - is a fundamental means of exercising control. It feeds, too, into the perfectionist mentality that plagues many women.

"Especially in the Jewish community, "notes Winokur, "there is a propensity for perfection and achievement."

She notes that statistics show that 70 percent of normal weight women want to be thinner.

"It is the never-enough mentality," she says. "Not good enough, not smart enough, not pretty enough." Not thin enough.

Gross, who has facilitated support groups at the Valley of the Sun Jewish Community Center and Franciscan Renewal Center and currently is starting one at The New Shul, says that increased opportunities for women professionally have only added to the pressures.

"They must be successful in the workplace but still be women," she says. And being a woman is code for being attractive - and thin.

Support groups like the one at Temple Chai help women develop inner strength by reaffirming the positive aspects of their lives.

"We focus on who we are - what personal challenges we face and how Judaism addresses them," says Lewis.

Deep-seated problems may reflect unresolved family issues that need to be addressed in intensive therapy or underlying conditions such as depression, anxiety or obsessive/compulsive disorder that may respond to pharmacological intervention, say the mental health professionals.

"Bulimia, anorexia, those are tough ones," says Weiser, emphasizing that the conditions cut across all ages and walks of life. "It is an addiction, a hard road."

Caroline, a long time patient of Gross who asked that her last name not be used, has been battling an eating disorder for most of her life.

"The issues change as you get older," she says. "There are new things to work through so you are probably never finished."

Especially critical, say those in the field, is assuring that more young girls and women never start.

More, and better, health education is essential. Watching what our children eat and how, and increased awareness of danger signals, is crucial. Communicating healthy messages - and self-censoring those that overemphasize weight and appearance - is necessary. Acting as positive role models, moderating our own response to the societal pressures to be thin, young and attractive is also critical. Developing more programs in our schools and congregations to confront a growing problem is needed.

Seven million girls suffer from eating disorders in America (and more than one million men and boys), reports Winokur. Eight-year-old girls are denying themselves birthday cake for fear that they will get fat. And mothers are asking if they can put babies on the Atkins diet.

"We need to focus more on the essence of the person," says Gross. "A beautiful person is a beautiful human being. The beauty is from within."

next: Eating Disorders: How Bulimia Affects Fertility
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~ all articles on eating disorders

Self-Therapy For People Who ENJOY Learning About Themselves

Fantasy and Reality - Part 1

Part One is a bit theoretical. Part Two will be more practical.

NEVER THE TWAIN....

Popular culture says we are "crazy" if we can't tell fantasy from reality. If that's the definition, then we are all crazy. (No news there!)

The key to avoiding fantasy and reality problems is to always know which of the two you are dealing with!

DEFINITION OF FANTASY

Fantasy is ALL mental activity.

Most people know that dreams and daydreams are fantasies, but few realize that every single thought is a fantasy.

Example:
We can all agree that "2+2=4" is a true statement. But this true statement doesn't become real until we actually see two pairs of objects right in front of us.

Even if we'd all agree that some fantasy is TRUE, that does not mean that it is REAL.
It's a fantasy until it becomes real.

Reality is what comes to us through our senses. If we can see, hear, smell, taste or feel something it is real (except for a few rather insignificant things like optical illusions.)

We humans used to believe we were the only creatures able to fantasize. Then dolphins and other animals were studied and we found that we are not alone.

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The ability to fantasize opens up many avenues for fun and problem-solving, but it also opens up avenues for neurosis, psychosis and all types of "mental pain."

Poor dolphins..... Do you suppose they have therapists?

Use fantasy ONLY for entertainment and BRIEF problem solving.

Imagine yourself in any situation at all that is enjoyable to you. [Sometimes it can even be enjoyable to imagine violence! If you are that angry, you might need such fantasies just to relieve all the pressure.]

DON'T USE FANTASY TO CREATE FEELINGS THAT HURT YOU!

Creating bad feelings is never healthy entertainment! Don't imagine yourself in situations which frighten, sadden, or anger you unless you are trying to solve some problem (see below).

DON'T COMPARE ENTERTAINMENT FANTASIES WITH REALITY

Since fantasy can be perfect and reality can't, comparing our entertaining fantasies with reality will always lead to bad feelings!

USING FANTASIES FOR BRIEF PROBLEM-SOLVING

It is wise and necessary to use fantasy to solve problems.

If you are choosing between two apartments, for instance, you can imagine yourself living in each of them and compare the two feelings.

But this should only take a minute or two!

IT'S NOT PROBLEM-SOLVING WHEN IT TAKES TOO LONG.

Our brains work incredibly quickly, as fast as the fastest computers. After a few minutes of thinking, we already know intuitively whether a problem is unsolvable.

After that all we are doing is frustrating ourselves about how unsolvable the problem is!

When a problem can't be solved in a few minutes of thinking, we need to face that it's unsolvable
unless we get new information.

If the unsolvable problem causes you pain, call a friend, discuss it with your partner, look it up on the web, or contact an expert in the field. Do anything which might bring in new data.

If the unsolvable problem doesn't cause you much pain, let it go! (Just put it on that large "unsolved pile" that we all share!)

If the unsolvable problem causes emotional pain and you feel you just can't let it go, that's what therapists are for.

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Enjoy Your Changes!

Everything here is designed to help you do just that!

Fantasy and Reality - Part 2

Part One was mostly theoretical. Part Two is more practical.

SUMMARY OF PART ONE

1. Fantasy is all mental activity.
2. Reality is what we know through our senses.
3. Fantasy should only be used for entertainment and for brief problem solving.

Remember the great relief you felt when you realized that some nightmare was only a dream?
Remember that feeling of great joy when it seemed that some dream had come true?

As we improve at differentiating between fantasy and reality we get these wonderful feelings more and more!

One of the greatest problems we face is unnecessary and unnatural fear. It is destructive to believe our fears!

Fears are only fantasies about horrors. Spending time on them is painful, and a waste of energy.

Hope, like fear, is just a fantasy. But hope feels good!

So, never stop enjoying your hope!

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Each of us has a unique, completely different idea about how the world works. Some of us think "love makes the world go 'round," others think "everything is about power," or money, or trust, or being well-liked.... The list is endless.

But the truth is that nobody really knows how the world works.

It can be comforting to know we are all wrong, and yet somehow we all survive (and most of us do it quite well, thank you!).

Immerse yourself in your fantasies and in your reality separately.

Then, when you get good at never confusing the two, add a little of the fantasy to your reality just for the fun of it!

Improve your sex life by enjoying your fantasies completely, enjoying real sex intensely, and occasionally enhancing sexual reality with sexual fantasy.

Improve your career by enjoying your dreams of success completely, enjoying your daily work as much as you can, and enhancing daily work with your dreams occasionally.

Improve relationships with children by enjoying your hopes about them, enjoying their real growth, and "sprinkling" your hopes into your daily enjoyment of them.

Any aspect of your life can be improved by first immersing yourself in reality, then in fantasy
- keeping them separate most of the time, and occasionally "sprinkling" reality with fantasy just for the sheer fun of it.

When we need to make major decisions (relationships, career changes, etc.), fantasy can get in the way.

When faced with important life decisions, do your best to measure the REALITY of your situation against what you WANT.

Example #1:
When deciding about a career move, measure the guarantees offered to you against the kind of employment situation you want. While your hope may involve future promotions and other "possibilities," you are usually better off making your decision based on what you know for sure about the new situation.

Example #2:
When deciding about a partner, measure the reality of how they treat you against how you want to be treated. While your hope may be that they will change for the better, and you may fear that they will change for the worst, you are better off making your decision based on what you have actually observed about them.

Enjoy Your Changes!

Everything here is designed to help you do just that!

next: Feeling Safe

Learn about the benefits, side-effects and disadvantages of MAOIs (Nardil, Parnate) for treatment of anxiety and panic attacks.

Monoamine oxidase inhibitors, commonly called MAOIs, are the other major antidepressant family. Phenelzine (Nardil) has been the MAOI most researched for the treatment of panic. Another MAOI that may be effective against panic attacks is tranylcypromine (Parnate).

Possible Benefits. Helpful in reducing panic attacks, elevating depressed mood, and increasing confidence. Can also help social phobias. Well studied. Tolerance does not develop. Non-addicting.

Possible Disadvantages. Dietary and medication restrictions are important and bothersome to some people. These include avoiding certain foods like aged cheese or meat and certain medications like cold remedies. Some agitation during first days. Delayed onset requires weeks to months for full therapeutic effects. Not as helpful for anticipatory anxiety. Dangerous in overdose.

Dietary Restrictions. Certain foods contain a substance called tyramine, which when combined with an MAO inhibitor can cause a "hypertensive crisis" that can produce dangerously high blood pressure, a severe headache, stiff neck, nausea, stroke or even death.

The patient using an MAO inhibitor must be quite responsible, since this medication requires significant dietary restrictions. No cheese (except cottage, farmer or cream cheese), sour cream, homemade yogurt, red wine, vermouth, liquors, beer, ale, sherry, cognac, Bovril or Marmite yeast extracts (baked goods prepared with yeast are OK), aged meats and fish, meat prepared with tenderizer, liver or liverwurst, overripe bananas, avocados, fava beans, Italian green beans, Chinese or English pea pods, or lima beans are to be eaten while on this medication.

Foods to eat in moderation include avocados, chocolate, figs, raisins and dates, soy sauce, caffeinated drinks, white wine and distilled alcoholic beverages (e.g., whiskey, gin, vodka)

Medication Restrictions. MAOIs have major interactions with many other drugs including anesthetics, analgesics, other antidepressants, and anxiolytics. The patient using an MAO inhibitor should always consult the prescribing physician before taking any additional medications. This especially includes over-the-counter cold medicines (including nose drops or sprays), amphetamines, diet pills, tricyclic antidepressants, and certain antihistamines.

Possible Side Effects. Difficulty sleeping; increased appetite; sexual side effects, especially difficulty achieving orgasms for men and women; weight gain; dry mouth; sedation (sleepiness); and low blood pressure symptoms, particularly on standing up rapidly, which can lead to postural hypotension.

As with any antidepressant, some patients will experience "hypomania", which causes them to feel unusually "high" and full of energy, talkative and very self-confident, with little need for sleep and a high sex drive. Patients don't always recognize this as a problem, but it can certainly be irritating to those around them.

Phenelzine (Nardil)

Possible Benefits. Useful for panic disorder as well as depression. In one study, using between 45 mg to 90 mg per day, phenelzine produced significant panic symptom reduction in more than 75% of patients. complete control of the panic attacks usually takes 4 to 6 weeks of treatment. Current research also suggests it can be beneficial for social phobia.

Possible Disadvantages. See disadvantages-Monoamine Oxidase Inhibitors, above. Use during pregnancy only with the approval of your physician. Avoid breast-feeding while on this drug.

Possible Side Effects. See side effects-Monoamine Oxidase Inhibitors, above. Weight gain, sometimes up to 20 pounds, and postural hypotension are common. Swelling around the ankles from fluid retention, headache, tremors, fatigue, constipation, dry mouth, loss of appetite, arrhythmias, difficulty having orgasm, insomnia or sleepiness. Decreased libido, inhibited orgasm and difficulty maintaining erection.

Dosages Recommended By Investigators. Each tablet of phenelzine is 15 mg. The initial dose is usually 15 mg or less and then gradually increased to 30 mg daily, in divided doses. Dosage is then three to six tablets per day, usually based on body weight. Most patients need a minimum of 45 mg daily. Maximum dose is usually 90 mg. You can take the entire dose at bedtime after one or two weeks unless you find this interferes with your sleep.

Tranylcypromine (Parnate)

Possible Benefits. Useful for panic attacks and depression. Very little anticholinergic or sedative effect. Little problem with weight gain.

Possible Disadvantages. See disadvantages-Monoamine Oxidase Inhibitors, above. Insomnia and postural hypotension can be persistent problems.

Possible Side Effects. Insomnia, postural hypotension, swelling around the ankles, some trouble having orgasm.

Dosages Recommended By Investigators. Starting dose is one to two 10 mg tablets. Increase the dose one tablet every three to four days. Maintenance dose is 30 to 60 mg in one or two doses in the morning or early afternoon.

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