What is the current best-practice for prevention of eating disorders among adolescent/young adults based on reduction of eating disorder risk factors (as determined by previously validated eating disorder behavior questionnaires)?
Elizabeth Parker, RD and Margery Lawrence, PhD, RD
December 6, 2017
Introduction: The purpose of this study was to determine the current best intervention program for reducing the risk of developing an eating disorder (ED), based on previously validated eating disorder behavior questionnaires. With over 10% of adolescent/young adult females developing eating disorders, prevention is increasingly important. Method: An evidence-based review was conducted looking at programs designed to reduce risk factors that have been shown to be associated with developing an eating disorder among high school and college students. The research found was limited to females, and primarily focused on those experiencing body dissatisfaction. Results: Twelve studies were reviewed, nine of which found cognitive-dissonance prevention programs to be significantly more effective than control groups. Conclusion: Cognitive dissonance-based programing (the Body Project) was found to be the most effective way to change negative beliefs and behaviors that lead to EDs among females. Further research should include studies that look at broader population bases, creating programming for males and those of the lesbian, gay, bisexual, transgender, and queer community (LGBTQ).
The prevalence of eating disorders (ED) has grown quite high, with approximately 10% (or more) of adolescent girls/young women meeting the diagnostic criteria for eating disorders based on the DSM-IV or DSM-5.1, 3, 4, 6, 7, 9, 10, 11 Additionally, roughly 50% of college-age women may have subclinical disordered eating behaviors.10 Behaviors and conditions commonly associated with disordered eating include: dietary restraint, purging (self-induced vomiting, over exercise, laxatives, diuretics, diet pills), binge-eating, self-deprecation, negative affect, difficulty regulating emotion, anxiety, depression, self-harm, thin-ideal internalization, and body dissatisfaction to name a few.
Many women who do receive treatment do not fully recover from their ED (e.g. 44% of those with bulimia nervosa do not, and that percentage is greater for those suffering from anorexia nervosa)10 which is why prevention of these disorders is so important. Early assessment and intervention is crucial for the best odds of recovery and restoration of health, especially in those under the age of 19.4 EDs generally develop in adolescence and prevention programs are more effective in early adolescence.6 On average, body dissatisfaction peaks in later adolescence but these older adolescents may be able to better comprehend the need for intervention of socially promoted “thin ideal.”6
It is concerning that only one-third of people with an ED have been asked about eating-related issues by their primary health care provider.4 Furthermore, less than one-third of people with EDs receive treatment!4, 6 Given that more people will see a primary medical provider than a specialist, primary care providers have an opportunity to assess patients for eating disorders and should be trained in how to screen for them.4 Many medical providers said they felt “ill-equipped” to screen for or treat eating disorders.4 Since schools have a unique opportunity to track and influence students over a longer period of time, many studies have looked at prevalence and prevention strategies among students.
Prevention programs are relatively new in the field of ED research, and are not widely practiced. In fact, most of the available studies performed to evaluate these programs were performed by the same pool of researchers. The purpose of this evidence-based review was to determine the current best intervention program for reducing the risk of developing an eating disorder, based on previously validated eating disorder behavior questionnaires.
Several programs were seen repeatedly among the various studies, suggesting that there was already some consensus on what programs might yield the most significant reductions in ED risk factors. The studies looked at reduction of ED risk factors, especially surrounding thin-ideal internalization, dieting practices, body dissatisfaction, depression/negative affect, and used similar self-reported scales.
Overall, the studies indicate that features of useful ED prevention programs include: cognitive-dissonance-based programing, multiple sessions (instead of a single session), interactive sessions (group, or other interaction), facilitation by professionals (as opposed to peers, teachers or other endogenous staff), use of validated assessments, and avoiding education about EDs and effects of EDs.
A Pubmed search was performed on August 21st, 2017 using the following search criteria: ((feeding and eating disorders/prevention & control*)) AND ((young adult OR adolescent) AND students) AND (risk factors AND eating disorders) AND ("last 10 years"[PDat] AND Humans[Mesh] AND English[lang])
The search yielded 35 articles, twenty of which were initially selected based on the abstract. This was further reduced to twelve by excluding any age groups that were not high school or college (undergraduate/graduate level). Since this is a relatively new topic (especially in areas of peer leaders; 2,9,12 internet-based program; 7 and female athletes 10), all study designs were initially included due to the small number of available studies. The significance was held at p= or <0.05 for all studies.
Of the resulting 35 articles, 23 were excluded due to: age of population, abstract not indicating ED prevention, or study types such as interview, reviews or meta-analyses. Twelve articles were selected for review as follows in table 1.
Of the 12 articles, 10 looked at cognitive dissonance-based (CD) prevention programs. Of those 10, 9 concluded that CD programs produced more significant reductions in ED risk factors than other prevention programs. The one exception was the study that focused specifically on athletes.10
Table 1. Study Comparison Table (click file to see PDF of table)
There are previously validated assessments for mental health and eating disorders as seen in the assessment methods used in the studies (see “key to abbreviations” at the end of this paper). These assessments were used to determine if there was a reduction in negative thoughts and disordered behaviors among participants.
The four most common interventions examined in studies were in-person cognitive dissonance-based programs (CD), internet-based cognitive-dissonance based programs, the NEDA brochure, and the documentary “Dying To Be Thin.” The most effective of these was in-person cognitive dissonance-based programs.
Cognitive Dissonance-Based (CD) ED programs (The “Body Project”):
Cognitive dissonance “is based on the presumption that creating an inconsistency between a belief and a behavior will elicit a feeling of discomfort in an individual”2 and that the individual will need to change the behavior to remove the discomfort. Programs focused on CD help to promote behavioral changes because consistency between beliefs and behaviors is human nature. By challenging disordered beliefs, behaviors are challenged; and to remain consistent behaviors must change along with the belief.7
The Body Project is an in-person CD group program, typically: 4 weekly 1-hour sessions, with 7-9 participants per group, led by a trained (for 9 hours) and scripted facilitator (counselor or peer).1 CD programs had the greatest effect on reducing ED symptoms in all the studies that included the “Body Project” as an intervention. 1, 2, 3, 4, 6, 9, 11, 12 CD challenges the thin ideal by creating cognitive dissonance with written, verbal, and behavioral exercises.1 With adequate training it worked for peers to “teach” the material, but not facilitate difficult discussions.10 Group programs, like the Body Project, further increase behavior change by the extra layer of public accountability.7
The Body Project has the greatest amount of research (relative to similar programs) and has a strong evidence-base.12 All researchers who used this intervention cited efficacy trials for dissonance-based programs that showed promise. The American Psychological Association (APA) supports dissonance-based prevention programs for interventions, for creating replicable results, and creating significant results against the control groups at 2 and 3 years, and to a 60% greater effect than assessment-only control groups.10 Many of the study authors commented that more sessions may have produced greater results.2, 4, 10
Internet-based Cognitive Dissonance Based Programming (The “eBody Project”):
The e-Body Project is CD-based like the Body Project, but delivered via the internet. The program was designed to remain interactive, and contains 6 modules to be completed over 3 weeks, at 30-40 minutes/session.1 The internet has become a constant source of thin-ideal, so to have the internet challenge that ideal through this program is very timely.1
Two studies reported that many schools and other settings found it difficult to recruit clinicians (school counselors/nurses/teachers) to learn the Body Project and lead the groups.7, 9 With over 95% of adolescents having internet access,1 a larger population can be reached via the internet.
The e-Body Project showed promising results where the in-person Body Project could not be performed. The ED risk reduction results were not as strong which may be due to the fact that participants could go through this program faster, meaning that there was less time submerged in the messaging. This had less impact on reduction of thin-ideal internalization.7
“Dying To Be Thin”:
This is a 55-minute documentary (McPhee, 2000). Widely-available at no-cost, this video covers body image, pressures to be thin, eating disorders, treatment, recovery, and consequences of eating disorders.1
This is a two-page brochure (National Eating Disorders Association, 2002) covering negative and positive body image and how negative body image may lead to eating disorders. The brochure lists ten steps to positive body image.1, 11
Quality of Studies:
The studies were inconsistent in quality. Though the majority (8 of 12) were randomized control trials (RCT), the criteria and methods left many of them lacking, with five of the twelve receiving a negative (-) grade. Four were well organized and received a positive (+) rating. Most of the studies had a strong conclusion, but due to lack of generalizability (homogeneity) or sample size, most (8 of 12) were categorized as a grade II, with only one study deserving of a grade I. Overall, the grade of research is: II, neutral.
All of the studies focused solely on females, with relatively homogeneous populations. Demographically, studies were representative of female students at American universities, but not the population at large.1, 3, 4, 5, 7, 11 Additionally, all of the studies had sample sizes of less than 1000 participants, the majority having less than 200.
There was a great likelihood of selection bias in all of the studies, as participants could voluntarily opt-in to the study or opt-out at any time. Several researchers noted that the participants who stayed in the studies may have had more interest in the topic of body image. Therefore, it is difficult to draw conclusions on how effective the interventions would be with a more universal population. Furthermore, as the study assessments were self-reported surveys, there was potential for error in interpretation of questions, or in answering questions how they think the researchers want to hear.
In conclusion, based on the studies reviewed, cognitive dissonance-based prevention programs in group settings (such as the Body Project) created the greatest reduction in ED risk factors, even at 3 years-post intervention, compared to control interventions. These CD-based programs have a greater likelihood of success in settings such as schools, especially Colleges/Universities. This is because of the unique setting schools offer in which it is often easier to deliver prevention programs. Although trained counseling clinicians were most effective, several studies noted that training peer leaders or other endogenous staff (such as teachers or school nurses) led to a statistically significant reduction of ED risk factors compared to control groups.
The one study that had participants go to a medical clinic, rather than having programming done at school, had high dropout rates.4 The authors explained that this was due to the greater time and effort needed to go to an off-campus clinic. This further shows how much more effective campus settings can be for prevention programs. With over 11.5 million female college students in 2017 in the U.S.13 (meaning approximately 1.15 million of which will develop a diagnosable eating disorder, given a 10% prevalence) this is utterly important.11
Universal programs (inclusive of all genders):
It was stated in one paper that there was research showing that programs targeting high-risk participants led to greater effects than programs that were “universal.”9 However, none of the studies evaluated for this review were universal, in that they were aimed at only females with body image concerns who did not have a diagnosed eating disorder. We believe that further studies could be done to assess whether or not cognitive dissonance-based prevention programs would be effective for males or those of the LGBTQ community. Due to body image differences among genders/gender identity, there would likely have to be different content for the CD programming to make it effective.
Programs for those with active EDs:
Potential participants with diagnosable EDs were excluded from all of the studies reviewed. This leads us to believe there is a gap in the research for programs that will reduce ED risk factors in those with clinical levels of EDs. This may be because at the point of having a diagnosable ED, it is not “prevention” anymore, but rather treatment. The disheartening piece is that according to background research in two studies (Linville, Cobb, Lenee-Bluhm, et. al; and Muller and Stice) over two-thirds of people who have EDs do not get diagnosed or receive treatment.4,6 Further research in programming that can help those with active EDs (who have not yet been identified as such) would help bridge the treatment gap.
Using this information in practice, we believe that all colleges should offer cognitive dissonance-based group programming (the Body Project). Ideally these groups would be led by trained counselors, but training peer leaders was also proven to reduce ED risk factors, and in remote areas (distance-learning / places where they cannot recruit leaders) internet versions of the Body Project can be offered. Challenging what people believe about body image and eating habits changes their behaviors to remain consistent with new beliefs. By inviting them to publically (in a group setting) denounce the thin-ideal (or other body image fads) they set themselves up for creating positive changes.
*Key to abbreviations:
AIM = Affect Intensity Measure (Larsen, 1984)
BDI = Beck Depression Inventory (Beck, Steer, & Garbin, 1988)
BMI = Body Mass Index
BSQ = Body Shape Questionnaire (Cooper, Taylor, Cooper, & Fairburn, 1987).
CDI-SF = Child Depression Inventory - Short Form (Kovacs, 1992)
CES-D = Center for Epidemiologic Studies - Depression Scale (Radloff, 1977)
DERS = Difficulties in Emotion Regulation Scale (Gratz & Roemer, 2004)
DRES = Dutch Restrained Eating Scale (van Strien, Frijters, Van Stavern, Defares, & Deurenberg, 1986)
DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. (American Psychiatric Association, 1994)
DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, Fifth edition. (American Psychiatric Association, 2013)
EAT-26 = Eating Attitudes Test (Garner, Olmstead, Bohr, & Garfinkel, 1982)
ED = Eating Disorder
EDDI = Eating Disorder Diagnostic Interview (Stice, Burton, & Shaw, 2004)
EDE = Eating Disorders Examination (Fairburn & cooper, 1993).
EDE-Q = Eating Disorder Examination-Questionnaire (Fairburn & Beglin, 1994).
EDDS = Eating Disorder Diagnostic Screen (Stice, Fisher, & Martinez, 2004)
EDI = Eating Disorder Inventory (Garner et al., 1983)
HWI = Healthy Weight Intervention (program) (Stice, Chase, Stormer, Appel, 2001; Stice, Shaw, Burton, & Wade 2006)
IBSS-R = Ideal Body Stereotype Scale-Revised (Stice, Ziemba, Margolis, & Flick, 1996).
PANAS-X = Positive Affect and Negative Affect Scale-Revised (Watson & Clark, 1992)
PSPS = Perceived Sociocultural Pressure Scale (Stice, Presnell & Spangler, 2002)
PSPS^ = Perceived Sociocultural Pressure Scale (Stice, Ziemba, Margolis, & Flick, 1996)
SATAQ-3 = (Sociocultural Attitudes Towards Appearance Questionnaire - 3 (Thompson et al., 2004)
SD-BPS = Satisfaction and Dissatisfaction with Body Parts Scale (Berscheid, Walster, & Bohrnstedt, 1973)
TOSCA-3 = Test of Self-Conscious Affect-3 Scale (Tangney, Dearing, Wagner, & Gramzow, 2000)
1. Stice E, Rohde P, Durant S, Shaw H. A Preliminary Trial of a Prototype Internet Dissonance-Based Eating Disorder Prevention Program for Young Women with Body Image Concerns. Journal of Consulting and Clinical Psychology. 2012;80(5):907-916. doi:10.1037/a0028016.
2. Black Becker, C, Bull, S, Smith, L, Ciao, A. (2008). Effects of Being a Peer-Leader in an Eating Disorder Prevention Program: Can We Further Reduce Eating Disorder Risk Factors? Eating Disorders.16(5), pp.444-459.
3. Stice E, Rohde P, Shaw H, Gau J. An Effectiveness Trial of a Selected Dissonance-Based Eating Disorder Prevention Program for Female High School Students: Long-Term Effects. Journal of Consulting and Clinical Psychology. 2011;79(4):500-508. doi:10.1037/a0024351.
4. Linville D, Cobb E, Lenee-Bluhm T, López-Zerón G, Gau JM, Stice E. Effectiveness of an Eating Disorder Preventative Intervention in Primary Care Medical Settings. Behaviour Research and Therapy. 2015;75:32-39. doi:10.1016/j.brat.2015.10.004.
5. Levitt DH. Participation in Athletic Activities and Eating Disordered Behavior. Eating Disorders. 2008;16(5):393-404. doi:10.1080/10640260802370556.
6. Müller S, Stice E. Moderators of the Intervention Effects for a Dissonance-Based Eating Disorder Prevention Program; Results from an Amalgam of Three Randomized Trials. Behavior Research Therapy. 2013;51(3):128-133. doi:10.1016/j.brat.2012.12.001.
7. Stice E, Durant, S, Rohde P, Shaw H. Effects of a Prototype Internet Dissonance-Based Eating Disorder Prevention Program at 1- and 2-year Follow-up. Health Psychology. 2012:77-86. doi:10.1093/med:psych/9780199859245.003.0007.
8. Gupta S, Rosenthal MZ, Mancini AD, Cheavens JS, Lynch TR. Emotion Regulation Skills Mediate the Effects of Shame on Eating Disorder Symptoms in Women. Eating Disorders. 2008;16(5):405-417. doi:10.1080/10640260802370572.
9. Stice E, Rohde P, Durant S, Shaw H, Wade E. Effectiveness of Peer-Led Dissonance-Based Eating Disorder Prevention Groups: Results from Two Randomized Pilot Trials. Behaviour Research and Therapy. 2013;51(4-5):197-206. doi:10.1016/j.brat.2013.01.004.
10. Becker CB, Mcdaniel L, Bull S, Powell M, Mcintyre K. Can We Reduce Eating Disorder Risk Factors in Female College Athletes? A Randomized Exploratory Investigation of Two Peer-Led Interventions. Body Image. 2012;9(1):31-42. doi:10.1016/j.bodyim.2011.09.005.
11. Stice E, Rohde P, Butryn ML, Shaw H, Marti CN. Effectiveness Trial of a Selective Dissonance-Based Eating Disorder Prevention Program with Female College Students: Effects at 2- and 3-year Follow-Up. Behaviour Research and Therapy. 2015;71:20-26. doi:10.1016/j.brat.2015.05.012.
12. Greif R, Becker CB, Hildebrandt T. Reducing Eating Disorder Risk Factors: A Pilot Effectiveness Trial of a Train-the-Trainer Approach to Dissemination and Implementation. International Journal of Eating Disorders. 2015;48(8):1122-1131. doi:10.1002/eat.v48.8.
13. Back To School Statistics. National Center for Education Statistics Website. https://nces.ed.gov/fastfacts/display.asp?id=372 Published 2017. Accessed November 11, 2017.
By: Lauren Goette
Lauren Goette received her B.S. in Psychology from Cal Poly, San Luis Obispo June 2017, and plans to become a licensed professional counselor in the future. Having personally struggled with anorexia, Lauren has become an advocate for mental health, working as a Peer Health Educator at Cal Poly and speaking out against the stigma surrounding mental illness. This was a paper she wrote her senior year (published with permission).
The deadliest mental disorder in existence, Anorexia Nervosa (AN) threatens the lives of millions of US citizens each year. According to Arcelus, Mitchell, Wales, and Nielsen (2011), anorexia has the highest mortality rate of any mental disorder. In fact, it has been estimated that anywhere from five to twenty percent of individuals with AN will die from the disorder (“Anorexia Nervosa,” n.d.). This exceptionally high mortality rate is largely the result of anorexics’ self-induced starvation, which can be achieved through methods such as calorie restriction and excessive exercise (“Feeding and Eating Disorders,” 2013). As a result of these behaviors, anorexia can lead to serious physical problems, such as slow heart rate, low blood pressure, reduced bone density, severe dehydration, fatigue, hair loss, and a plethora of other physiological issues (“Health Consequences of Eating Disorders,” n.d.). And while there are numerous physical complications that result from this disorder, a significant amount of damage is also inflicted on the cognitive level. A variety of studies conducted in the past two decades have shed light on the devastating cognitive impacts of anorexia, as well as the promising positive effects of refeeding. Current evidence shows, as a result of semi starvation, individuals struggling with anorexia can experience drastic structural brain changes, inhibited cognitive abilities, and memory impairments, which may be improved with weight restoration.
Structural Brain Changes
One of the most severe physical and psychological costs of anorexia is structural brain changes, which can cause significant harm to the cognitive functioning and overall mental health of anorexia sufferers. In the short term, a diet deficient in calories and nutrients, often coupled with excessive exercising, can lead to loss of both white and gray matter (Sidiropoulos, 2007). Prolonged caloric restriction promotes “abnormal reward responses to food and a deviation from a healthy feeling/perception of the body when eating.” These structural changes may, in part, explain why anorexics continually avoid food consumption, as the act itself appears to elicit a negative perception and/or sensation of the body. Additionally, this reduction of gray matter in may also contribute to the disturbance of the brain’s typical reward responses which encourage food consumption.
Often the direct result of structural brain changes, AN sufferers can experience a wide range of cognitive difficulties. Higgs (2009) explored the impact of interference from diet-related thoughts on anorexics’ cognitive abilities. On a cognitive task, restrained eaters’ reaction times when imagining eating cake were significantly slower compared to when they imagined drinking water. On the other hand, unrestrained eaters' reaction times did not significantly differ between the cake or the water conditions. Higgs maintained that the cognitive impairments displayed by restrained eaters were the direct result of a “reduction in processing capacity due to interference from diet-related thoughts.” With this reduction in processing capacity, dieters’ ability to perform basic cognitive tasks was drastically diminished, highlighting how impactful caloric restriction can be on AN individual's thoughts and on their execution of simple cognitive tasks.
In addition to these milder cognitive issues, AN sufferers can also develop chronic cognitive deficits. Specifically, Gillberg et al. (2010) found, eighteen years after AN onset, anorexics had more attention, executive function, and mentalizing problems. Anorexia was found to be associated with “a range of neuropsychological problems that are present long after the eating disorder… is no longer an important feature.” Even after starvation has ceased, weight-restored anorexia survivors can experience lingering cognitive issues. Gillberg et al. suggested that this is the result of severe structural damage which can leave important cognitive facilities critically damaged. Moreover, Fowler et al. (2006) found that even “relatively severe” neurocognitive impairments have the potential to adversely affect AN sufferers’ daily social and occupational functioning in the long term. These impairments can have a substantially negative effect on recovered individuals’ quality of life, making typically simple cognitive tasks exceptionally difficult to accomplish.
Along with cognitive difficulties, AN can also cause notable memory impairment. Kemps, Tiggeman, Wade, Ben-Tovim, and Breyer (2006) found that anorexic individuals’ frequent obsessive eating-disordered thoughts actively prevent their working memory from operating effectively, which can lead to various issues with basic memory functions such as recall. Chan et al. (2013) also found anorexic’s impairment in memory functions to be positively correlated with BMI. In other words, the lower an AN sufferer’s BMI, the worse their memory functions were, and vice versa. Kingston, Szmukler, Andrewes, Tress, and Desmond (1996) also discovered an association between anorexics’ lower weight and poorer performance on memory tasks. Kingston et al. maintained that this poor performance was directly related to anorexics’ degree of weight loss, concluding that anorexics’ memory performance declines with their decrease in weight. Chan et al. proposed that this correlation between BMI and memory impairment indicates that anorexics’ memory deficits may, in part, be associated with malnutrition, however current research remains inconclusive.
Having focused largely on the starvation-induced structural, cognitive, and memory impairments of AN, it is also imperative to recognize the simplest yet most effective treatment for such damage: weight restoration. Though not a “cure-all,” weight restoration, accomplished through the refeeding of the anorexic patient, has the potential to reverse much of the structural and cognitive damage caused by the disorder. In terms of brain matter recovery, Sidiropoulos (2007) demonstrated how weight restoration resulted in the return of white matter to premorbid levels. Simply by increasing caloric intake, anorexic patients were able to recover all of the white matter they had lost throughout the course of their disorder. Similarly, Wagner et al. (2006) found that weight restoration in long-term recovered anorexic individuals resulted in the reversal of structural brain abnormalities. These results imply that weight restoration has the power to reverse structural brain damage, and restore any and all white matter lost to anorexia.
Focusing on the psychological implications of structural brain recovery, Bernardoni et al. (2016) found a strong association between partial weight restoration and improvements in affect and eating disorder symptoms. With even minor increases in weight, recovering anorexics experienced significant improvements to their psychological wellbeing. On the cognitive side, Hatch et al. (2009) discovered that weight-restored individuals were notably faster on cognitive tasks, and exhibited superior verbal fluency and working memory. Hatch et al. concluded that, with refeeding and weight gain, cognitive impairments in weight-restored AN sufferers appeared to normalize.
Despite the existing support for weight restoration, it has noteworthy limitations. First and foremost, complete structural brain repair is not entirely possible through weight restoration While Sidiropoulos (2007) did find significant improvements in the quantity of white matter recovered in weight-restored individuals, in truth, some gray matter loss persisted. In spite of the recovery of white matter to premorbid levels, previously anorexic individuals sustained irreversible gray matter loss, which remained unaffected by their increased weight. Secondly, weight restoration fails to improve distorted cognitions about body image. Even after weight restoration, Bernardoni et al. (2016) revealed that patients remained dissatisfied with their bodies. Lastly, weight restoration fails to recover weight-restored individuals’ memory abilities. Nikendei et al. (2010), discovered that deficits in immediate and delayed story recall in currently ill AN patients persisted even after these patients were weight-restored. Nikendei et al. suggested that this was the result of a so-called “scar effect” on the brain caused by chronic starvation. They maintained that this scar effect may play an important role in the etiology and/or persistence of AN, and might also explain why memory impairments sustained during AN are seemingly irreparable.
The vast body of anorexia research available today highlights both the extensive damage AN can cause to anorexics’ brain structure, cognitive abilities, and memory, in addition to the reparative power of weight restoration. Tragically, for individuals struggling with AN, the damage sustained throughout the course of the disorder can inhibit their brains’ basic cognitive functions. The structural brain changes caused by AN can lead to an irreversible loss of brain matter, as well as serious complications with cognitive and memory functioning. Anorexia nervosa can make simple cognitive and memory tasks, such as attention and recall, exceedingly difficult to accomplish. These cognitive and memory impairments, which can be caused by both structural brain damage and cognitive interference, can make everyday functioning a challenge. Not to mention, the irreversible nature of some of this damage can cause long-term impairment, even in weight-restored individuals. Despite the seemingly endless list of structural, cognitive, and memory complications caused by AN, weight restoration may hold the key to the recovery of both brain matter and cognitive abilities. In spite of its shortcomings, weight restoration has the ability to effectively repair the structural brain damage and cognitive impairment caused by anorexia nervosa.
(originally posted 10/16/2016. libbysfitnutrition.com)
The Power of Habit: A Review
Author Charles Duhigg is a graduate of Harvard Business School (MBA) and Yale University (history major), and is a “Pulitzer-prize winning, investigative reporter for The New York Times” (1) since 2006 (2). Since writing The Power of Habit (New York Times Bestseller List for over 60 weeks!1), Duhigg has written another book, Smarter Faster Better, has appeared on NPR, as well as other well-known media platforms, and has spoken at colleges (including MIT), companies (like SC Johnson), and is available to speak at events by request (2).
The Power of Habit: Why We Do What We Do In Life And Business, is a book written for consumers to figure out how to change habits they do not like, such as smoking, or create new habits, like daily jogging after work. The book uses a simplified “habit loop” to teach readers how to break down their habit into three sections - the “cue” or trigger, the “routine” or habit, and the “reward” or reason for doing the routine. Duhigg uses examples of famous people and companies to illustrate why certain patterns develop, and how changing certain patterns can influence more than one area of work or life.
In Chapter 1, Duhigg describes “The Habit Loop”: where a “cue” triggers us into our “routine” which produces the “reward” (1).
The habit is built from doing something that gives us a “reward” (positive reinforcement). Once someone has experienced the “reward” in correlation to the “cue,” memory starts to connect the two in the basal ganglia of the brain (a primitive part of the brain near the spinal cord). The “routine” part of the equation (how we get from the cue to reward) is formed into habit that requires less and less thought every time we do it. This is how fast food chains get us. They keep everything the same so every time you visit the restaurant, whether in Minnesota or Tennessee, you have the same visual, auditory, and verbal “cues” prompting a sense of routine or habit to the reward of cheap/ easy/ tasty food.
Chapter 2, discusses how marketing moguls created new habits to sell mass quantities of products like toothpaste and Febreze. Creating new habits comes from creating a “craving” as the “cue” or trigger.
By creating a trigger to do something you can create a habit every time that trigger emerges. Duhigg uses the example of marketing toothpaste: the trigger is removing the “film” of plaque you notice as time elapses (usually over several hours, or a day), feeling this film (which naturally occurs) causes a cue to want to clean it off. The action? - Brushing your teeth. The reward - clean, film-free, teeth. This is the habit loop as explained in chapter 1. While people had always had this “film” on their teeth, the advertiser brought attention to it, and made a craving for “clean.”
The moral of this? Find a cue that comes up naturally to elicit a habit response. The author makes the example of: after work you put on your running shoes and go run, afterwards you reward yourself by watching tv. By choosing a specific cue (after work = run) and reward (run = tv), the habit is more likely to occur.
Chapter 2 also covers anticipation of rewards being a driving force to action. When one has experienced a reward for doing something enough times, the anticipation of reward makes the action automatic. The anticipation of the endorphin rush can make it easier for someone to continue exercising on a regular basis, but the first time it occurs will not be enough to develop the reward loop to create the habit. This must be repeated several times before the reward is worth the action. The expectation of the reward must be great enough to drive the action when the cue is presented.
Chapter 3 shows that to change a habit, the cue and the reward are kept the same, and the routine is changed. Routines are hard to change, so what makes it possible? Believing. Chapter 3 details how Alcoholics Anonymous (AA) works, not through scientific method, but through belief in a power greater than oneself to change the routine of an old cue. This is done by creating a list of triggers for the old routine (like triggers to drink, example: get off work), and the reward desired (example: socializing) and change the routine by addressing the desire for socializing by meeting up to talk to their sponsor. Belief that God (“as we understand him”/ a belief that things can get better/ belief there is something bigger than ourselves) will give strength to change the routine, when the triggers arise, is the premise of AA.
Groups are another major catalyst for maintaining change in routine. Whether it is seeing something as being for the greater good of the group, having accountability, or changing the status quo of life, groups give people a network of like-minded individuals to help them stay on course. As Duhigg put it,” Belief is easier when it occurs within a community”(1).
Chapter 4 looks at “keystone” habits that influence everything else. By finding the small habit that affects others, and changing it, you can make huge waves in the system. By creating a routine that builds on other routines, you can prepare yourself with small “wins” that make the bigger “victory” just the logical next step. This chapter uses Michael Phelps, Gay Pride, and safety in the workplace as examples of changing one, seemingly tiny, action to create big victories. Another example from this chapter is writing down what you eat to lose weight. As people make food journaling a habit, without being asked to do anything else, they start changing their diet to be healthier because they notice patterns emerging.
Chapter 5 tells us that self-discipline (willpower) is a learnable skill but, like a muscle, can be worn out over the course of a day and works best when rested. This means that we have less willpower to do hard things/ detailed work after a long day of using willpower and making decisions, than if we had a day where we did not have to think too hard. Strengthening willpower and discipline in one area of life makes that more automatic, and will spill over to other areas of life. A favorite quote from this chapter is, “That’s why signing kids up for piano lessons or sports is so important. It has nothing to do with creating a good musician or a five-year-old soccer star, when you learn to force yourself to practice...you start building self-regulatory strength”(1).
Planning ahead is another skill that foresees progress towards a goal. People who think through potential obstacles and how they will deal with them, in detail, are able to push through hard times and make the most progress toward their goal. Likewise when people are empowered to do something because they enjoy it or have it explained how it will help someone else, they use less willpower than if they were forced into doing something.
Chapter 6 shows how crises situations can change organizational habits. Vignettes of companies that had major crises showcase how big problems can lead to big changes.
Chapter 7 shares how companies like Target gather data on individual customers to drive marketing and sales. Retailers note that people tend to change brands of products when they are going through a life change such as marriage or divorce. The biggest life event for change in purchasing? A new baby. New parents will buy anything the need/want in one place because it is easy. If a company can get them to start buying diapers at their store, they know they can get them to buy other things because they are already in the store. Target looks at purchases made and, by looking at common trends, can determine fairly accurately when a woman is pregnant and due. What do they do with this information? Slip in subtle marketing cues next to the familiar. If a woman received coupons for just baby stuff she would get suspicious as to how the company knows, but mixed in among common items it does not see as personalized.
Chapter 8 explains how personal ties and social peer pressure can influence people to do things that they would find hard to choose on their own, at the risk of losing social benefits. “Weak social ties,(1)” as opposed to close friends, tend to have the strongest pull on obligation. An acquaintance could tell unfavorable comments about you to others for not fulfilling an obligation, where a close friend might understand why you would pull out of a commitment.
Chapter 9 looks at the neurobiology of habits and what is free will. Examples are sleep-terrors and gambling addiction. Do people have choice in these scenarios? It comes down to the primitive brain and ingrained habits. The parts of the brain (basal ganglia and brainstem) where habits form are the same parts where sleep terrors stem from. Duhigg believes that any habit that is cognizant can be changed with the decision to change it, and the knowledge of what your cue or trigger is.
The “Afterward” shares stories from people who contacted the author after the initial publication of the book on how it helped them. This chapter discusses lapses and relapses, and not looking at them as failure but as learning experiments.
The “Appendix: A Readers Guide To Using These Ideas” is a step-by-step guide to figuring out your own habit loop and how to make a plan to change the habit.
This book is aimed at readers who are looking to change a “bad” habit they have. It gives real-life case-studies of companies and people that readers have heard of, to explain how a habit change works. By breaking down how habits form, the author explains how habits can be broken and changed into more desirable habits that will get the reader to their goal. The design of the book is similar to a “business-help” book, which might draw in more readers that are in either a traditional corporate or entrepreneurial business sector.
Personally, I loved this book. It was engaging to read how prominent public figures from Michael Phelps to Rosa Parks made small habits work towards bigger goals, as well as how every-day habits, like eating an afternoon snack, are a summation of cues, routines, and rewards.
The strengths I identify in this book are: extensive research - mostly in personal interviews and scientific articles; easy-to-read format; a singular focus throughout the entire book; and the idea of “classical conditioning,” as Ivan Pavlov explained, to describe Duhigg’s “habit loop.” The ideas of “habit loop” and “classical conditioning” are very much the same in a stimulus or cue eliciting a routine that leads to a reward or positive reinforcement3. Another factor Duhigg lists is obligation towards an outside influencer (chapter 8), which authors Rowland and Splane liken to reasons of success in dietary restraint often stemming from religious “diets” such as Lent or Ramadan, or ethical reasons (Ex: vegetarian for animal rights)(3).
Duhigg is very effective at making his main point - the habit loop- clear, through writing that is both engaging, and easy to follow. His extensive background as an investigative journalist allows him to be an effective writer and good at finding necessary information. He shows how to take action on research already known, like the fact that overeating is typically due to cues in our environment triggering intake (4).
The weaknesses I see in this book are mainly from credentials and my perception of potential bias. As a journalist, Duhigg is trained to pick up a story and flush it out to make something people want to read. Science is not usually fascinating to the general public, so I wonder if he took any liberties to elaborate where there was not enough information. Additionally, Duhigg is not a science or health professional. Many of the topics he covers are in neurobiology and psychology, of which, I would assume he has not had formal training.
Overall, I highly recommend this book to anyone, professional or consumer, that wants to make a change in a habit they do, or help someone else figure out their habit loops. It brings insight into why we do what we do, and offers a way to pick and choose which habits we keep and change. It is not specific to any one type of change (such as weight loss), but rather encompasses the skills and case-studies to change any habit. I will be re-reading The Power of Habit soon.
(originally posted 7/21/2016. libbysfitnutrition.com)
People intrinsically want to believe and have hope in something. When “big-pharma” and doctors are not making patients feel significant and understood, people will go searching for healing elsewhere, this is where dietary supplements (DS) come in. Most DS work under the realm of “placebo effects,” unless they are being used to treat a nutritional deficiency.
The definition of “placebo effect” is, “improvement in the condition of a patient that occurs in response to treatment but cannot be considered due to the specific treatment used(1).” This phenomenon has been identified in several studies. One of which was a study of patients with irritable bowel syndrome (IBS) which “treated” patients with either “open-label placebo (non-deceptive and non-concealed administration)” or no treatment. Even knowing that the pill they were given was a placebo made of an inert substance, the sufferers found significant relief over those receiving no treatment. The conclusion was that “Placebos administered without deception may be an effective treatment for IBS (2).”
Doctors have long-known the benefits of placebo effects in patients and will utilize this in treatment. While the “placebo” thinking may help people heal, “no-cebo” thinking can render even an active drug useless. This phenomenon is summed up well in Henry Ford’s famous quote: “whether you think you can or cannot, you are correct.” It may be that doctors owe it to their patients to boost healing by any means possible, including treatment by placebos for more effectiveness (3). Nonetheless, the American Medical Association stated in 2006, that it is unethical for doctors to give patients undisclosed placebo treatment/medications (4). If doctors are ethically not allowed to give undisclosed placebos, then suggesting a DS labeled, “This product is not intended to diagnose, treat, cure, or prevent any disease” might be their way around this ethical dilemma.
Psychological effects of placebos
The placebo effect often is used, consciously or not, in the context of classical conditioning. Discovered by Ivan Pavlov, classical conditioning takes a neutral stimulus (which should cause no response - the “placebo”) and, through learned response, makes it a conditioned stimulus to elicit a conditioned response (5). An example of this in the medical setting would be giving a patient a pain medication that actually works to reduce pain every day for five days, then giving a sugar pill that looks the same on the sixth day and eliciting the same pain-reducing response.
The conscious expectations by a patient of a treatment to work may cause an inert substance to have a desired effect on the patient. These expectations can be elevated by how the health care professional (HCP) interacts with the patient. The study of medicine “generally does not pay adequate attention to psychological and social variables (6),” which are determined by the relationship of the HCP and patient. This may interfere with drug study controls. If the person in the placebo group of the study is getting attention and believes the treatment will work, then they may exhibit signs of the placebo working that may make the active treatment not have a significant desirable outcome over the placebo.
Yet, how can an inert substance elicit a similar response to an active treatment? A large part of this stems from the psychological variants at play. Much of the patient’s outcome may be determined by the HCP’s confidence in a treatment's ability to work, empathy, active listening, and care setting. “[it is] suggested that the success of the many forms of psychotherapy [are] due to a placebo effect rather than the distinctive features claimed by the different therapists (6).” Hope that it will work, and follow-through on actually seeking treatment, are other reasons that patients have better outcomes with either the active treatment or the placebo (7). DS are often prescribed either by licensed HCPs (like doctors) or “alternative healers” (like acupuncturists). The diplomas on the wall, or the attention given by the healer can contribute to the patient “feeling” the DS responding to treatment. Additionally, since chronic conditions often ebb and flow with severity, the patient is likely to look for treatment when symptoms are about to naturally decrease, leading to the belief that the DS “healed” them (8).
Physiological effects of placebos
Placebo effects are not “all in the head” as once thought. They can make actual physical changes in the body, under the right circumstances. A test group for an antidepressant medication versus a placebo showed interesting brain activity in the results. By viewing brain activity with fMRI studies, placebo responses increased activity in the prefrontal cortex of the brain, while the medication suppressed this activity. Both groups exhibited less perceived depression, though on different timelines (the drug working weeks faster than the placebo). To this finding, researchers said, “administration of an inert pill appears to be an active treatment rather than a no-treatment comparison as previously thought. [however, the] placebo response is not equivalent to an active drug response, since the two groups' brain physiology was altered differently (7).”
Even people with Parkinson’s disease can potentially have real physiological benefit from placebo “treatment.” The effect of the placebo increasing dopamine in the brain, modifying the neuron that is promoting the abnormal activity that causes the tremors (9). People in this study physically had reduced shaking while taking the placebo, showing that there is true physical effects in some placebo “treatments”.
Studies should have tighter placebo controls
The Food and Drug Administration requires new drugs to significantly outperform the placebo control before going to market (3). Placebo controlled, double blind trials have been the gold standard of research (8). However, most research studies for medical treatment (whether drug, DS, surgery, or other) could be better controlled for placebo response. This could be met with a few tweaks to methods of “treatment.”
Dr. John Farrar, a neurologist and epidemiologist, provides some insight into what can strengthen study design to control for placebo effects (3):
(originally posted 7/16/2016. libbysfitnutrition.com)
A paper I wrote for my Master's program class on dietary supplements. Bottom line- multi vitamin supplements may do more harm than good. If you cannot get all of your needed nutrients from food (which is totally do-able), then specific single nutrient supplements are a better choice than a multi. (HERE is a free handout on basic macronutrient composition we need to be eating.)
Here is the research:
Use of Multi Vitamin and Mineral Supplements for “Health Insurance” and Disease Prevention
Do “multi vitamin and mineral dietary supplements” have a place in health prevention and treatment? As will be discussed below, the answer appears to be a resounding no.
Background of Multi Vitamin and Mineral Supplements
Multi-Vitamin and Mineral Supplements (MVM) have been available to Americans since the 1940’s (1), and have only increased in use since that time. The general consensus is that a MVM contains three or more vitamins or minerals without other herbs or drugs (3); However, there is no one-definition for what a MVM is or contains (ingredient, number of ingredients, or level of potency). In fact, there are many dietary supplements (DS) on the market that are not labeled as MVMs that are essentially the same as other products labeled MVM (1). The 2011-12 NHANES data shows approximately 40% of Americans took at least one DS in the last 30 days (2). Many of the people surveyed listed to [maintain health, or prevent health problem(s)] as their reason for taking a DS (2). But what is the actual role of MVMs?
Usefulness, role, and dangers of MVMs
In the 1920s, the United States started fortifying major food sources starting with adding iodine to salt to counter widespread deficiency and prevent goiter. In the following years Vitamin D was added to commercially sold milk, and some B vitamins and iron were added to flour (3) minimizing deficiencies in the majority of Americans. Nowadays, many more foods for purchase are fortified with additional vitamins and minerals. With fortification meeting the needs of the general population, benefits of MVMs seem to be limited.
What is the reality of MVM use? MVMs may be beneficial if the blends of ingredients are tailored to the needs to the individual. According to the National Institute of Health (NIH), “several studies have found that MVM users tend to have higher micronutrient intakes from their diet than nonusers. Ironically, the populations at highest risk of nutritional inadequacy who might benefit the most from MVMs are the least likely to take them (1).”
Several large studies show this irony: In a large study of adult participants from Los Angeles and Hawaii, food frequency analysis showed that the majority of people (~75%) had adequate intakes from food alone (1). With MVM adequacy improved, especially for vitamins E, A, and zinc; but there was an increased risk of excessive intake, especially in vitamin A, iron, zinc, and niacin (1). A study of U.S. children under four, concluded that, “usual nutrient intakes were adequate for the majority of US infants, toddlers, and preschoolers, except for a small but important number of infants at risk for inadequate iron and zinc intakes (4).” They also noted that many children were at additional risk of excessive intake for folate, vitamin A, zinc, and sodium even without supplementation (4). Many children with autism are given MVMs, which are unnecessary, and contribute to excessive intake in many. Even with MVMs, there may be additional need for calcium and vitamin D in children, according to the Academy of Nutrition and dietetics (5).
There is an increased risk of nutrient toxicity when taking DS. The NIH states, “MVMs did not reduce the risk of any chronic disease (1).” and “There is potential for adverse effects in individuals consuming dietary supplements that are above the upper level. This can occur...in individuals who consume a healthy diet rich in fortified foods in combination with MVM supplements (3).” Typically MVMs have nutrient levels that are lower than the RDA for a particular nutrient, and without adequate food sources MVM users may need additional supplementation of nutrients (such as magnesium or calcium) not contained in high enough doses from the MVM; however, as discussed above, toxicity from supplementation is all too common (1), sometimes with irreversible health consequences.
Just a few examples of health issues caused by excess vitamin or mineral intake include: excess vitamin A or beta-carotene correlated to increased risk of lung cancer in smokers or former smokers (1); excess vitamin A (as preformed retinol) increasing risk of birth defects in fetuses of pregnant women taking supplements (1); and iron supplements have been noted as a “leading cause of poisoning in children until age 6 years (1),” due to children getting into supplement containers. Additionally, people taking blood thinning medications need to keep vitamin K levels steady, so any supplements should be checked and confirmed with their doctor before taking or changing doses (1).
Though many large-scale studies have been done separately with either male or female participants, there is not a significant difference in health risks between the genders. The Physician’s Health Study II was a large-scale, double-blind, placebo-controlled RCT of over 14,000 male doctors in the United States, the study showed that, “daily multivitamin supplementation modestly but significantly reduced the risk of total cancer (6).” In conflict, another study of the “295,344 men enrolled in the National Institutes of Health (NIH)-AARP Diet and Health Study (7) found that low-dose MVM use had no discernable increase in risk of prostate cancer, but those who took higher doses (more than 7 times/week) of MVMs had an “increased risk of advanced and fatal prostate cancers is of concern and merits further evaluation (7), than non MVM users (1). Another large study (n= 83,639) of male physicians found no association between cardiovascular disease and MVM use(1).
Women were no different in terms of conflicting research. A study of Swedish women (n= 35,329) found an increased risk of developing breast cancer with MVM use (1); while another study of U.S. women (n=37,920) “found no such association but did find indications that MVM use might reduce the risk of estrogen- and progesterone- receptor– negative breast cancer and breast cancer overall in women who consume alcohol (1).” Swedish women in a cohort study had a lower risk “of myocardial infarction when taking MVMs, especially when taken for at least 5 years (8).” A cohort study of Iowa women found a slight increased risk of mortality from long term MVM use compared with non-MVM-users (1). And finally, long-term MVM use appeared to have benefit for men but not women in total cancer and mortality risk in a NIH study, but no benefit to either group for CVD (3). Overall, the data is inconclusive of significant benefit to either gender taking MVMs long-term.
Is there still a use for MVM?
The NIH, Office of Dietary Supplements (ODS) states, “supplements cannot take the place of the variety of foods that are important to a healthy diet (1).” Eating a well-balanced nutritious diet is the goal for everyone, and can be done. That being said, there are populations that do benefit from taking specially-formulated MVMs or DS.
The American Academy of Pediatrics and the (formerly) American Dietetic Association, list potential populations that will benefit from use of MVMs: “[people with] nutritional risk....those who have anorexia or an inadequate appetite, follow fad diets, have chronic disease, come from deprived families or suffer parental neglect or abuse, participate in dietary programs for managing obesity, consume a vegetarian diet without adequate dairy products,..have failure to thrive...people with medical conditions and diseases that impair digestion, absorption, or use of nutrients [bariatric surgery]… some supplements might help people who do not eat a nutritious variety of foods to obtain adequate amounts of essential nutrients (1).”
However, not every MVM on the market is appropriate of any of these populations. In these scenarios, it would be far better to use specific formulations of needed vitamins and minerals to make up for lacking nutrients. The 2010 Dietary Guidelines for Americans, and the NIH–sponsored State-of-the-Science Conference, claims there is no supporting evidence for the general population to take a MVM to prevent chronic diseases (1, 7).
How should MVM be regulated?
Currently the Food and Drug Administration (FDA), or any government body, does not have the ability to test DS, legally (due to the Dietary Supplement Health Education Act, or “DSHEA”), or in resources (staff or funds) to do so. “Both the [FDA] and the Federal Trade Commission (“FTC”) regulate claims made by food and dietary supplement manufacturers (9).” The FDA regulates labeling, which prohibits false or misleading information on the supplement labels “under the Food, Drug and Cosmetic Act” (9). The FDA issues warning letters to manufacturers against law violations in labeling, but rarely uses other methods of enforcement (9) mainly due to inability to keep up with the booming DS industry. This means the regulating agencies are bound to fail when the staff is disproportionately small, and the enforcement of laws is poorly executed (9). If a DS was listed as a food additive, or drug, it would require pre-market approval (3), and there would not be the insurmountable task of keeping up with the production of DS.
While the FDA focuses on the direct product label, the FTC regulates the advertising of DS. This may include “evaluat[ing] dietary supplement labels if they are being used by an advertiser to promote the product...under the FTC Act, claims in advertising made about foods and dietary supplements may not be “unfair” or “deceptive” (9).” As presented in the American Journal of Law & Medicine, a “limited private right of action [private sector lawsuits] under the FTC act” would more easily bring “enforcement actions in federal court” to protect consumers regarding DS (9), and would greatly increase the amount of products being enforced.
The NIH has excellent recommendations regarding change in regulatory laws and action, for instance, “The FDA should have the authority to better inform consumers and health professionals regarding the existence of upper levels as well as the possible risks of exceeding those levels; [the FDA should] develop a formal, mandatory adverse event reporting system for dietary supplements; and mandate provision of a MedWatch toll-free telephone number or Web site on product labels to facilitate reporting of adverse events. Furthermore, we recommend that healthcare professionals, consumers, and manufacturers use the FDA MedWatch adverse event reporting system to report adverse events associated with the use of dietary supplements. Finally, we recommend that Congress revise and update the law to reflect current knowledge...design and conduct rigorous randomized control trials of the impact of individual supplements (or paired supplements, when biologically plausible) to test their efficacy and safety in prevention of chronic disease, using well-validated measures.(3).” Ultimately, DS should be regulated as drugs, due to the fact that they interact and “medicate” like drugs in the body.
Should this information change consumer behavior?
If approached properly, there may be a way to help consumers better understand the dangers and lack of regulation of DS. Two studies on consumer education about DS, showed that consumers taught about DSHEA and the regulation of DS “rated DS as less safe and less effective” than the control group (10). This gives us a starting place on what message needs to be making its way to consumers. “Consumers may be especially susceptible to health claims, because they usually lack the knowledge to assess claims referring to physiology or metabolic processes and may be especially impressed by purported scientific evidence bolstering the claims (9).”
MVMs, particularly due to the lack of content consistency, are not useful in human health and disease prevention or treatment. The Medical Letter, an unbiased publication for pharmacists, declares that long-term use of MVMs, or any substance, is not without risk; and taking vitamins A, C, E, or beta-carotene in high doses or long-term may be more harmful than helpful (12). They furthermore suggest the only beneficial supplements (in healthy people consuming a normal diet) are folic acid, vitamin D and B12, in specific populations (12). If supplemental nutrients are necessary for populations listed previously who cannot obtain enough from diet alone, they should be carefully chosen as individual (well-researched) DS, and not in MVMs which may (with or without accurate labeling) contain excessive levels of substances (vitamin/minerals, or drugs/herbs) that may be harmful. I strongly recommend against the use of MVMs given the research available to us today.
Libby is a Registered Dietitian focusing on eating disorder treatment and prevention. She is working on the central coast to create wellness in individuals and the community
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