In the United States today, 33-40% of adult women and 20-24% of adult men are trying to lose weight, and another 28% of each group is trying to maintain weight (18,22). Frequently cited reasons for losing weight include concerns for future and current health, fitness, and appearance. Health concerns are most frequently cited by those with higher body mass index (BMI). Persons with lower BMI attempt weight loss for appearance and fitness concerns. Whereas women cite appearance as more important than fitness, the reverse is true for men (22). Biener and Heaton (4) confirmed this finding in that 33% of the women subjects in their study who were at an apparently healthy BMI (< 25) dieted strictly to improve appearance.
A substantial cost is made in the attempt to alter body weight and shape. Federal surveys indicate that among U.S. adults trying to lose weight, over a 2-yr period women make an average of 2.5 weight loss attempts, each lasting an average of 6.4 months, and men make an average of two attempts, each lasting an average of 5.8 months. As a result, in the United States over $30 billion are spent yearly on weight loss efforts (22). As with any goal, there are costs and consequences associated with the quest for the ideal body. If taken to an extreme, the ultimate cost may be life itself. This paper reviews the various costs incurred in weight control and the consequences experienced when these efforts are taken too far.
COST OF DIETING TO ACHIEVE THE IDEAL BODY
Dieting, the most commonly used weight loss strategy, has its costs. Of the $30+ billion spent yearly on weight loss efforts, most is spent on diet products (22). Typically, lower fat, low calorie, easy-to-prepare foods cost more than whole foods prepared sensibly and consumed in smaller portions. Consulting with dietitians or nutritionists, the costs of weight reduction programs, and the purchase of one or more of the many books promoted to the public further elevate expenses. Most of these diet books enjoy short-term but profitable success. Two popular books purporting high protein and restricted carbohydrate intake, for example, have significantly affected the public's attempts to lose weight. In 1996-97, Dr. Atkins' New Diet Revolution (paperback) was on The New York Times best seller list for over 71 wk and remains today as one of the top selling paperbacks. Barry Sears' The Zone and its companion Mastering the Zone (hardbacks) were bestsellers for 50 and 11 wk, respectively (16). Any diet is successful, at least in the short term, as long as energy expenditure exceeds intake, and adequate micro-nutrients are consumed. Many diet programs are short-lived, averaging 20-24 wk, often producing a 10% total body weight loss. However, maintenance of the reduced weight is often futile. As much as 67% of the weight lost is regained within a year, and almost all of it regained after 5 yr (22). This weight regain is often caused by relapse into former eating and lifestyle habits. As reviewed by Polivy (17), chronic dieting can produce significant psychological consequences. When deprived of food, both humans and animals show heightened emotional responsiveness, cognitive disruptions such as distraction, and a focus on food and eating. When the food restriction is lifted, there is often a tendency toward excessive eating or even bingeing.
In addition to restricting food intake, dieting can include risky behaviors, such as vomiting, fasting, and using diuretics, laxatives, or diet pills. Biener and Heaton (4), in their study of dieting behaviors of apparently healthy-weight (BMI <25) women, found that those with lower BMI (<21) were more likely to engage in such risky dieting behavior than women with higher BMI. The authors concluded that these thinner women may have unrealistic expectations of the amount of weight loss possible with conventional methods and thus engage in more risky behavior to achieve their desired results.
Several noteworthy financial costs are associated with exercise for fitness and weight control. In a large metropolitan city, fitness club memberships can range from $30-100+/month, magazine subscriptions at $15-25/magazine/yr, and the use of a personal trainer from $20-80/h. To exercise, special equipment and/or clothing may be required. Figure 1 provides the sales of fitness-related equipment and clothing in the United States from 1992 to 1996 (19,20). There is an increasing trend to buy more items and to spend more for them. According to the Sporting Goods Manufacturers' Association, the average consumer in the United States spent $193 for fitness clothing in 1993, but $286 in 1995. The average adult consumer shopped 10 times per year for fitness clothing. The average teenager, however, shopped 23 times.
Athletic shoes make up the biggest boost in sales. There are now more sport-specific shoes than ever before. Since 1992 there has been a 212% increase in the sales of hiking/outdoor shoes, a 79% increase in the sales of walking shoes, and a 32% increase in the sales of cross-training shoes. Associated with the increased sales of sport-specific shoes, there has been a decline in the popularity of running shoes (19).
From 1986 to 1996, exercise and fitness equipment rose from 8% to 14% of total sports equipment sales. Of the top 10 equipment related sales in 1996 (numbers indicate position in the top 10), seven were fitness-related: 1) stair climbing, 2) in-line skating, 3) treadmill, 6) nordic ski machines, 7) home gyms, 9) step aerobics, and 10) free weights. The Sporting Goods Manufacturers' Association recognizes that women make up a growing sector focusing on fitness and weight control. According to the Association, 6 of the 10 most popular activities for women were fitness oriented (numbers indicate position in the top 10): 1) fitness walking, 2) stationary bike, 3) exercise to music, 4) treadmill, 9) run/jog, and 10) free weights. The Association defines women as a target audience for continued growth in sales (19).
COST OF SURGERY TO ACHIEVE THE IDEAL BODY
In 1992 more than 1.5 million people in the United States underwent plastic surgery to alter appearance. In 1996, this figure rose to over 1.9 million. Women comprise 89% of clients who undergo plastic surgery (2). Table 1 provides the average surgeon fees for the more popular procedures associated with altering body contour and appearance.
Liposuction is the most popular of plastic surgery, accounting for 5.6% of all plastic surgeries. In 1996 more than 109,000 people elected to have liposuction alter their appearance (2). However, the satisfaction index for lipectomy is equivocal. In a survey of 1339 patients who underwent lipectomy, Dillerud and Háheim (7) reported a 76% satisfaction rate with the results. The authors observed that many of the patients assumed the procedure would permanently remove fat and prevent its regain. Thirty percent of patients complained that too little fat was removed. Half the patients reported weight gain after surgery, and 29% claimed that their fat returned to the site of the liposuction. Dissatisfaction and disillusion with the results of liposuction may lead to lawsuits. After 23 yr of battling weight with various energy-restricted diets, exercise regimens, and commercial weight loss programs, an Indianapolis, IN, radio news director in 1995 opted for an abdominal lipectomy. In 1997 she filed suit against the plastic surgeon claiming that, unbeknownst to her, the physician also removed fat from her buttocks, and the resulting body shape was not the shape she had requested. The patient argued that the removal of fat from her hips robbed of her ethnicity (African-American) and femininity (11). Her claim of a rounder woman's figure as more acceptable by African-American men than Euro-American men is supported by the data of Greenberg and LaPorte (9).
Willard et al. (24) suggest that patients diagnosed with bulimia nervosa may seek liposuction as an alternative purging behavior. Two cases were cited in which the patients' quest for lipectomy was accompanied with unrealistic expectations that the surgery would produce an emotional and physical panacea. Instead, these young women, who had 19% and 21% body fat at the time of surgery, ended up with loss of control, significant weight gain, and major clinical depression.
MEDIA'S CONTRIBUTION TO BODY DISSATISFACTION
Women may have unrealistic expectations of attainable weight and body shape, associated with the Western emphasis on thinness. In a study of female images presented in Playboy magazine and in the Miss America pageant, Garner et al. (8) demonstrated that, from 1959 to 1978, there was a significant shift toward a thinner ideal. Garner et al. (8) used the Metropolitan Life Insurance Company's 1959 height and weight tables (13) as the standard for each woman's expected weight. From 1959 to 1978 there was a steady decrease in average weight of the images portrayed in the media, with a concomitant rise in the body weight of American women. Figure 2 shows the trend in decreasing percent of expected weight among Playboy magazine's centerfolds and Miss America contestants. Over this same period of time, from 1959 to 1978, Garner et al. (8) also noted a continual increase in diet-for-weight-loss articles in leading magazines directed toward women.
In a similar study, Wiseman et al. (25) examined whether the trends observed by Garner et al. (8) changed during the 1980s (Fig. 2). They gathered data on percent expected weight and measurements of bust, waist, and hips of Playboy magazine centerfolds (1979-1988) and Miss America contestants (1979-1986.) Wiseman et al. (25) also critically examined the women's magazines Harpers Bazaar, Vogue, Ladies Home Journal, Good Housekeeping, Women's Day, and McCalls with regard to articles focusing on diet-for-weight-loss, exercise, and diet in combination with exercise, from the years 1959 to 1988. Figure 3 shows the percentage of total articles in these six women's magazines directed toward diet, exercise, and diet combined with exercise.
Wiseman et al. (25) found that the body size and measurements for Playboy centerfolds did not change from 1979 to 1988, but rather remained at a low body weight. On the other hand, the Miss America contestants became increasingly thinner (r = −0.77, P < 0.01) and smaller in hip size (r = −0.77, P = 0.01.) Over this 10-yr period 69% of Playboy centerfolds and 60% of Miss America contestants had weights 15% or more below the expected weight for their age and height. According to the Diagnostic and Statistical Manual of Mental Disorders-IV(1), a body weight this low is a major criterion for the diagnosis of anorexia nervosa. Of note, the authors found that the percent of expected weights of Playboy centerfolds of the year did not differ from other centerfolds, nor did the percent of expected weights of the Miss America winners differ from the non-winning contestants (24).
A 30-yr review of popular women's magazines by Wiseman et al. (25) indicated that there was a continued increase in the total magazine articles focusing on diet, exercise, and diet combined with exercise. As the number of articles on exercise with or without diet increased, the number of articles focusing on diet-only declined. Beginning in 1981, exercise articles surpassed those of diet. The authors concluded that the cultural ideal for women's body size remained thin and perhaps became even thinner. Their finding of the less curvaceous body, with a higher waist:hip ratio mirrored that of Morris et al. (15), who found the shape of English fashion models between 1967 to 1987 became more tubular, with bust and hips decreasing while height and waist increased. To attain this more androgenous shape, the popular women's magazines promote exercise or diet in combination with exercise.
To evaluate whether adolescent women receive similar messages, i.e., to use diet plus exercise to attain an androgynous shape, Guillen and Barr (10) collected data on the body shapes portrayed and the nutrition and fitness messages presented in Seventeen magazine from 1970 to 1990. Seventeen has positioned itself as "the best friend" of high school girls since its inception in 1944. The researchers assessed body shape by measuring bust:waist and hip:waist ratios of photographs of models wearing bathing suits or underwear. Written articles and advertisements for nutrition and exercise were analyzed for message and intent.
As was found with adult women models portrayed in magazines, the body shape presented to adolescent girls became more tubular over time. The hip:waist ratio decreased (F = 7.3, P < 0.01), especially in the later years. From 1970 to 1983, the hip:waist ratio was 1.32; after 1984 the ratio declined to 1.28. No significant change in bust:waist ratio occurred, but over time there was an upward trend (10).
Over the 20 yr studied by Guillen and Barr (10), there was no difference in the number of articles focusing on nutrition. Weight loss was a common theme, with half of the articles devoted to this subject. In all weight loss articles it was plainly stated that dieting would help improve appearance or increase attractiveness. Nutrition-related advertisements also focused on weight loss, with 25% of these ads promoting diet camps and 12% describing products to change weight. At the same time 9% of ads marketed sweets, candy, or snacks. Fitness articles were few in number until the mid-1970s. Since 1976, the number of fitness-related articles surpassed those of nutrition, as was also observed by Wiseman et al. (25). Almost 75% of the fitness articles encouraged the readers to exercise to be more attractive. Only 40% focused on exercise as a means to improve health and well-being. Fitness-related advertisements focused on appropriate clothes, shoes or equipment (10).
It is apparent that the message to be thin, have narrow hips, and use diet in combination with exercise to attain the ideal body shape is being delivered to both adult and adolescent women. Little girls' dolls mirror this trend. Barbie, Mattel Inc.'s, (El Segundo, CA) curvaceous, best-selling doll since 1960 became more tubular in 1998. The traditional rounded version is still offered in 18 versions of the doll, but six versions now have a smaller bust, thicker waist, and slimmer hips, i.e., the more tubular shape presented by models today (23).
To determine the appeal of the androgenous shape, Lenert et al. (12) tested an Athletic Image Scale on 65 college women who exercised regularly and 45 nonexercising cohorts. Both groups were presented with images of female physiques with and without muscular definition and were asked to choose their actual and ideal physiques. Regardless of exercise status, the majority (66% exercisers, 63% nonexercisers) of women chose a mesomorphic ideal physique with upper-body muscularity. The authors noted that the physique preferred can only be met by participating in regular physical activity and upper-body weight training.
CAN EXERCISING TO ATTAIN THE IDEAL BODY LEAD TO AN EATING DISORDER?
Data published by Davis et al. (5) suggest that there is a pathological significance of sport and exercise in the development of eating disorders. Forty-five women hospitalized with eating disorders were age matched to 51 randomly selected women without eating disorders. A content analysis of participant interviews with regard to their history and pattern of physical activity, produced the following themes:
Childhood physical activity. As children, 70% of those currently with eating disorders were more physically active than their peers. This difference started around age 12. The increased physical activity preceded any diet or weight loss.
Competitive athlete. Of those with eating disorders 60% were dancers or competitive athletes beyond that of the intramural level. The authors observed that a number of women developed the clinical disorder after terminating sport/dance participation. They noted that the termination, often because of an injury or conflicting academic pressures, was followed by an intense fear of weight gain and then significant food restriction.
Excessive exercise. Of those with eating disorders, 78% exercised beyond the degree and intensity of the normal range for that of age-matched controls.
Obsessive and ritualized activity. Of the women with eating disorders, 93% perceived their need to be active as "out of control." The exercise had become compulsive and ritualized.
Degree of weight loss related to degree of exercise. Of those with eating disorders, 75% reported that during acute weight loss their physical activity increased and became more ritualized, while their energy intake steadily dropped.
Chronology of dieting and exercise onset. In 60% of women with eating disorders, sport or physical activity preceded regular dieting. In only 13% did the exercise and diet occur concurrently.
Davis et al. (5,6) have proposed that sport and assiduous exercise can play a pathological role in the development and maintenance of eating disorders. They suggested that over-activity should not be viewed as a secondary symptom but rather as equivalent to other food-related behaviors displayed by those with eating disorders. Davis et al. (6) developed a theoretical model of the interaction between exercise, starvation, and obsessive compulsiveness. In a study comparing high-level exercisers, defined as those who exercise 5 h or more per week, and anorexics (bularexics), Davis et al. (6) found that both groups shared significant relationships between obsessive compulsiveness and activity level, and between weight preoccupation and the obligatory aspects of exercising (i.e., feeling guilty if exercise is missed.) Anorexics, however, also associated their weight preoccupation and pathological aspects toward exercise (i.e., continue to exercise in the face of illness or injury) with their level of activity. The proposed model, shown in Figure 4, illustrates how exercise, starvation, and obsessive compulsiveness may have a reciprocal and dynamic relationship. Davis et al. contended that these characteristics together can potentiate one another in a destructive loop that becomes self-perpetuating and resistant to change. High-level exercisers become at risk for eating disorders when they are highly weight preoccupied and characterized by perfectionism and an obsessive compulsive personality. If, however, high-level exercisers keep a healthy attitude toward weight, there is little risk of developing an eating disorder.
COST OF AN EATING DISORDER
In addition to the many physiological and psychological burdens resulting from an eating disorder, treatment bears a significant financial cost. For example, the Professional Relations Liaison of The Renfrew Center, a treatment facility dedicated exclusively to women's mental health, provided the following charges for treatment of eating disorders: intensive outpatient group counseling at a cost of $250 per week for 3-8 wk; individual outpatient sessions with mental health professionals at a cost of $75-180 per hour; and, intensive inpatient therapy at a cost of $900-1000 per day. Because of the growth of managed-care health plans, intensive outpatient group programs are the most popular. Even after intensive treatment, most clients need additional group or individual psychotherapy for an extended period of time. Drug treatment, such as antidepressants, may add significantly to the cost.
The ultimate cost, that of life itself, is associated with eating disorders. Crude mortality rates among anorexics have been reported from 0% to 20% (21). Møller-Madsen et al. (14) followed the records of 853 Danish anorexics (63 men, 790 women) hospitalized between 1970 and 1987. A 5.86% mortality rate (N = 50 deaths) was recorded during an average period of 7.8 yr post initial treatment. Five deaths were recorded for men, average age 24.5 yr at the time of death; for women (N = 45), average age at death was 36 yr. Almost half the deaths were unnatural, with suicide (N = 18) the most frequent cause. Natural causes accounted for 25 deaths, 13 of which were from anorexia itself. In all, anorexia nervosa and suicide together accounted for almost 60% of the entire mortality of formerly hospitalized anorexics. The mortality rate was particularly high during the first year following initial treatment, with 31% of women's deaths occurring during this period. Møller-Madsen et al. (14) suggested that treatment should remain intense and prolonged to prevent these high mortality rates, especially during the first year following initial treatment.
Regardless of the interventions employed in the quest for the ideal body, physiological, psychological, and financial costs may be incurred (22). Obsessive exercise and dieting may have severe adverse physical and psychological consequences. Those individuals who are highly motivated to alter body weight (and shape) are at risk and need to learn how to adopt more realistic expectations of an attainable physique, given an individual's own weight history, genetics, age, motivation, time, and resources available. If the pursuit of the ideal body is not kept in perspective, the cost can result in permanent damage to one's health.
The author expresses appreciation to Katherine Tuttle for her assistance with preparation of this manuscript.
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