With change comes disruption

Today, I decided to integrate this blog a little more with Facebook. Unfortunately, it means that pre-existing comments weren't compatible. I apologize to those of you who have taken the time to leave comments here, and welcome new and re-posted comments! The comments aren't lost; they're just hidden. If there's a way to nicely integrate them, I'm all ears!

Burn the boats: Why you're going to fail. Or not.

I've been studying and reading health research for decades, and this post is just a bit of my biased gestalt on the state of affairs on obesity, obesity research and the new hope that arises within a TON of people every January.

The preponderance of obesity research indicates that most of you will fail at achieving your goal of weight loss this year; and that of those of you who succeed at achieving the goal within this particular year will ultimately fail because the data generally shows that the weight comes back, resulting in a net effect of zero. What we don't fully understand still, is why this failure happens; and I'm not sure that we're going to truly unearth it anytime soon enough to make a difference in your resolution this year.

The evidence, in short, is incredibly depressing.

However, this is one of those situations in which I think anecdotal evidence has a powerful and important role to play because it provides a very vivid counterpoint to the darkness of sample-based research evidence on predicting your future. What's even more interesting about these anecdotes is finding the common themes within these narratives that highlight the elements of success, many of which cannot be replicated in a study or even reliably sampled because they cannot be truly measured.

Success in weight loss or any self-improvement goal depends mainly on the ability of a person to adhere to a new behaviour. Quitting smoking is a good, simple example (albeit of a very difficult task): You succeed at quitting smoking by engaging in behaviours that do not involve smoking. Do or do not, there is no try. Taking a drag on a cigarette means you've relapsed and are no longer an ex-smoker.

Weight loss is not as simple of a goal. It can involve multiple behaviours, many of which involve changing substantial portions of one's day from both a time and a performance perspective. For instance, beginning to exercise is a behaviour that requires time investment. That means exercise has to DISPLACE another activity that you've grown accustomed to doing. Eating less or eliminating certain foods means the performance of eating changes. And then on top of it all, there's the social dimension of weight loss, which can mean displacing perfectly enjoyable activities that not only provide nutrition/caloric value but also contribute substantially to our sense of well-being and belonging (e.g. a weekly pub night, or after-work drinks and appetizers, or Sunday dinner with parents.)

The most common theme I've discovered (and this is, in and of itself, just opinion and anecdote) from watching patients attempt to enact lifestyle changes and reading stories of people who have had overwhelming success, however, comes down to something perhaps equally as unpleasant as making a lifestyle change that you've failed at in the past: pain, and sometimes, fear. Unfortunately, this is, thus far, a fairly immeasurable quality, so making causal associations between pain/fear and dietary success is fairly difficult, though, with the right research team, not impossible.

When it comes to adherence to new behaviours, (and I'm not sure this has even been studied at all yet, in the way that I'm going to state it), is the introduction of a situation in which the pain of staying in the same place (or moving backwards) becomes so great that success is the only option. I have personally witnessed (though with limited verifiability) patients who, after suffering a serious hand injury that would affect their ability to earn a living, stopped smoking the day of the injury. These were people who had tried to quit in the past unsuccessfully and years later, are still smoke-free, even though the danger of affecting their hand function by smoking is pretty much gone.

In medical school, we're taught to try to find reasons for patients to change their lifestyle. Sometimes, it's an injury or a new diagnosis. Sometimes, it's being around for their loved ones. In most circumstances, it's the pain of the situation, or the pain of the fear that ultimately moves people to action.

Personally, I think that the reason why most people fail at their goals is because it's really not that painful to fail. If you fail, you'll get over it. Your waist size doesn't change, or it might even get a little bigger, but on the whole, your life is pretty good. There is a famous story of Alexander the Great, who upon landing on the shores of Persia, ordered his men to burn the boats, thereby removing all realistic hope of retreat. If your income was contingent on your ability to stay at a certain BMI, regardless of your beliefs about the BMI and whether you are an "outlier" or not, you'd get there and stay there. You would find a way to stay there. You might bitch and complain about it, but given the option of unemployment or BMI, my guess is most people would pick BMI. In a way, it's no different than doing your job. If you don't do your job, you get fired. Come hell or high water, when crunch time comes, you'll find a way to get that job done because you know the personal stakes are high.

Finding that intolerable state is what motivates successful change. Eventually, you may come to enjoy the new life you've created. I can't think of a single ex-smoker who regrets quitting smoking. I can't think of a single person who, after successfully losing weight and keeping it off, regrets making sweeping changes to the way they live. They tell me that the process of quitting/changing really sucked, but that they would never trade their old life for their new one. One patient of one of my mentors, after quitting smoking, kept putting the money he spent on cigarettes in a large jar. A few years later he bought a massively expensive sports car (I can't remember the make/model), which he enjoys far more than any cigarette he ever smoked (or so he tells me.) It doesn't mean you have to live a painful life forever. But enacting change without consequence of failure, I think, is embarking on a journey to which there is always a convenient exit.

So, as unpleasant as it is to contemplate, my challenge to those of you serious enough to take it, is to find that pain. If that means making your life intolerable to failure, then perhaps that's not a bad approach. Find ways to put yourself in situations where getting out is more painful than staying in.

It's 2012. Find your pain. Burn the boats.

For slightly more positive tips on lifestyle changes, here are some my previous posts, or you can click the "lifestyle change" tag in the cloud on the right:

Death by sand: When do the fine details really matter?
Defending yourself against decision overload
The Information Diet
Fitness, nutrition and a Peruvian fruit stall

Twenty three and a half hours

I love this video. Most of my readers do more than 30 minutes, but let's say you can't get to the gym, or you're injured. Or you're just not in your workout groove. There's making gains, which is what we're always trying to achieve, but sometimes, you have to take victory during times of stress to just not go backwards. So if you do nothing else, know that 30 minutes a day is positively associated with many benefits.

Toe-ing the line: What I think about this whole shoe thing

Oldest discovered leather shoe: 5500 years old

I've had a few emails asking me to review some of the literature on the new shoe trend. Every company is jumping on the bandwagon to create their version of the Vibram five TOE shoes (sorry, I'm going to be a hand and wrist sub-specialist. Toes are NOT fingers). It's a little reminiscent of the "body-toning" shoe thing, without all of the wildly outrageous claims, and a trend that I think will live long enough to warrant weighing in on. Most studies to date have really focused on how the shoes alter foot and gait biomechanics. I would argue that most of the claims on the Vibram website are still largely unsubstantiated or just what I call "motherhood statements", like: "Eating your greens is good for you," and "Puting on your jacket when it's cold outside is good for you." (basically, statements that don't really have any clout one way or another, but just make you feel better.)

The claims (according to their website) are that they:

1) Strengthen your foot and lower leg muscles
2) Improve range of motion in your ankles, feet and toes
3) Stimulate neural function for improved balance and agility
4) Improve posture by removing heel lift, which aligns the spine
5) Allow the foot and body to move naturally

Oddly, the Vibram website also recommends that you consult your physician or a medical professional to see if natural running in their shoes is right for you. I'm pretty sure most physicians have about as much knowledge on running and gait biomechanics as I know about dark matter (that is, to say, I'm sure someone knows a lot about it, but I don't know who and I sure as hell wouldn't know if I saw it.)

In terms of possible running benefits, we know that barefoot running does tend to produce a gait that strikes more in the mid foot than the heel. Interestingly, this is the same gait change that Masai Barefoot Technology shoes (which then evolved into the rocker toning shoes) sought to achieve with a distinctly different approach to shoe design.

In a culture of increasing complexity and options in almost all dimensions of life, there is a counter-culture of minimalism, and also "naturalism" that has also sprung up. The Paleo diet is an excellent example of going back to "evolutionary roots", and using retrospective vision to justify evolutionary arguments.

There are two main points I want to make about the new shoe issue:

1) "Everything works. Nothing works forever."

I don't know if Alwyn Cosgrove came up with this on his own, but he's the one I remember saying it, so I'm going to credit him for it. It is only in the past year that the five-toed barefoot shoe trend has really caught on. Epidemiologically speaking, we're going to experience "lag-time bias" when it comes to evaluating the effectiveness and "safety" of these shoes. The number of early adopters was small compared to the number of projected users to come before the trend hits a peak. Therefore, the number of injured individuals is going to be tiny until the denominator hits a critical mass for a pattern of injury to become apparent. It's also going to take time for the "barefoot injury" to appear since it's going to emerge only after prolonged chronic use. "Nintendo thumb" didn't become apparent until well after the first generation Nintendo console had been produced. It took millions of kids hundreds of hours to develop a cohort big enough for medical professionals to make the association, and then the _causal_ association.

Barefoot shoes change your gait. There's no dispute on that. If you have a chronic injury that is somehow linked to your gait or your posture in your non-barefoot shoes, then changing your gait or posture is going to make your injury feel different. It's great that the general trend is that these chronic issues tend to feel better in barefoot shoes, but I like to think of it as being similar to putting a knee in a brace. Sure, your knee feels better in the brace, but that doesn't mean your knee is any better off for it.

Do I think barefoot five-toed shoes are harmful? Not in the immediate term. Do I think that in the next few years, there will be at least a few epidemiological studies on injury patterns associated with barefoot five-toed shoes? You betcha.

2) Evolution doesn't necessarily proceed in a beneficial direction.

One of first things a biology undergrad has to learn is to let go of the idea that evolution is always making things better. It's easy to look backwards in time at a giraffe and say, "Well, of course the longer neck is a survival advantage because it allows giraffes to exploit a food source," when in fact, there could have been a whole genetic start-up of longer necked pigs that never made it to the present day, or into the fossil record because there weren't many trees in their habitat. To say that the human foot has evolved to run bare has similar pitfalls, and to state that the human foot is _meant_ to run barefoot is a La Brea tar pits full of pitfalls.

Evolving to run barefoot assumes that running provided a survival benefit; and while we all have been fed romanticized notions of hunters stalking and chasing prey and escaping vicious wild predators, I would posit that in fact, the evolutionary pressure on ancestral man was not to run, but rather to survive. Running towards or away from something is merely a single factor in successful survival. Successful _hiding_ could arguably be just as important as running; and you don't need special shoes for that.

Lastly, there is no question that human behaviour is influenced by technology. The idea that behaving "au naturel" is the best way probably has more to do with our own romanticized ideas of battling increasing technology and further "evolution" than it does with figuring out what's "better". Even if feet were meant to run bare, there's nothing that says that it's the best way to run any more than there is anything behind the statement, "The best way to see is without glasses," or that, "Cold weather is best experienced without clothes."

When it comes to lifting, I think similar arguments apply, with the additional caveat that minimal-sole shoes with no toes are probably just as good. I'm not entirely convinced that the stiff sole allows for much independent toe movement, or that independent toe movement is actually that pivotal to performance or injury prevention. I'm not trying to paint all toed-shoe-users with the same brush (because some of them are my very good friends) but there's something disconcerting about seeing a guy squat in Vibrams with 10-pound plates under his heels.

So in the end, I don't think barefoot five-toed shoes are better than conventional shoes. I think they're just different. If they're a good motivational tool or a psychological support for you, then it's probably worth your investment in them. Likewise, it's probably not a bad thing if they're relieving chronic symptoms--even if there's probably a different host of aches and pains that we're going to read about in the future. But I think their contribution to your success as an athlete, a weekend-warrior, a marathon runner, or just a joe at the gym trying to lift heavier things without getting too injured is tiny compared to the other factors that are probably in play. Wear' em if you like, but don't feel like you're missing out if you're not.

P.S. This Thursday, November 24th is Evolution Day, the anniversary of the publication of "The Origin of Species" Happy Evolution Day!

What will your legacy be?

There are a lots of things we take for granted. In medicine, this is highlighted every day. It's not just walking or the ability to do things, but also even basic life functions like eating, talking, and breathing; and some cases, just appearing "normal". There are days when I'm just happy my patient has a regular heart beat--I'm not even shooting for independent breathing or even independent blood pressure. 

The reality is that if you're reading this, and any part of this blog, you're fairly healthy, mobile, and possessed of your mental faculties enough to read. You have the ability to enact change in your life. If you're sitting on the fence, you're choosing to sit there.

Fitness,working out, dieting--these are all luxuries. They are all choices you are allowed to make because you have food abundance, the economic means to choose, even the mysterious privilege to have been born in an environment that has afforded you technology, education and health care. Each day that you don't take full advantage of these opportunities is a day that is squandered potential--even if the opportunity you're supposed to take advantage of is rest (which is, in and of itself, a luxury.)

I have come to view the opinion that you should live your life as though each day is your last with mixed opinions. I like the underlying message of seizing the day like it's your last one, but it's really hard to live each day that way. There are certain realities and responsibilities that we have already chosen to commit to, and while it's a great idea to plan your escape strategy if you're not doing what you really want to do, the dirty laundry isn't going away in the event you don't die before tomorrow morning.

For another, I think most of us would live our last day in a fairly self-centered fashion. My last day would presumably be filled with all of the things _I_ would want to experience as the last earthly sensations of my existence. I probably wouldn't go to work. And the day would very much be about me. Maybe I'm selfish that way. I confess to having days where I get caught up in the day-to-day, and that it takes moments of reflection for the extraordinary-that-has-become-ordinary to become extraordinary again. But I was lucky enough to have a life-changing experience 2 weeks ago on my first mission with Operation Smile that was so phenomenally powerful that the way I look at the world and my role in it will never be the same again.

Today is the launch day of Brian Grasso's short film, "Life By Numbers". It's a powerful piece asking you to challenge your life. I usually keep my blog endorsement-free to avoid bias, but I think everyone should see this film at least once. I also want to take things one step further, because I think it's not enough to take the courage to pursue the dream you've always want to chase. I think that while you're contemplating what it is you REALLY want to do with your life, it's worth also considering what difference you can make for others who dont't enjoy your position of privilege, and the creation of YOUR legacy. A great body is something we are all lucky enough to have the chance to shoot for and is, in my opinion, a noble pursuit, but what do you want to be remembered for?

What price would you pay for muscles?

Not everyone works out for performance. I would count myself amongst the folks who work out basically for looks. There was a time when I lifted to get better at my sport, but the reality is that my career and most of my current hobbies don't require me to perform at a much higher skill level than sewing two hollow tubes about 1mm in diameter together, which clearly doesn't require heavy squats to improve.

This entry's article came to my attention from Ryan Zielonka, who wrote,

"Quick question for you. I work out to look good, period. I'm also blessed with a full and thick head of hair. I recently started taking creatine (again, I've never been particularly consistent) and came across some anecdotal evidence as well as one study that shows the potential for hair loss while using creatine.

What are your thoughts on this? I'd hate to sacrifice my full head of hair for just a slight uptick in swoleness."

This is a perfect example of trade-off decision making, which, for the most part, is the central issue in most medical decision making. There's no question that every intervention, fitness or medical (which I think are one and the same, personally) carries risk and benefit. We choose to pursue an intervention based on whether we think the benefits outweigh the risks. Is it worth exposing your wrist to pain, a scar, the possibility of infection and the possibility of no improvement for the chance at getting rid of your carpal tunnel syndrome? Is the risk of injury, and the cost of time, discomfort and (to some extent) denial of "junk food" worth it to perform better or to look better?

Creatine has been shown to have many benefits, not the least of which are performance-related as well as aesthetic. We still don't understand how creatine makes these benefits possible and there are several theories, none of which are truly dominant as to why it works. But what if one of these theories was true and what if the trade-off for using creatine for its benefits meant some form of hair loss? Would this change your decision to use it or not?

van der Merwe J, Brooks NE, Myburgh KH. Three weeks of creatine monohydrate supplementation affects dihydrotestosterone to testosterone ratio in college-aged rugby players. Clinical Journal of Sport Medicine, 19:399-404, 2009.

Introduction:

As much as I agree with the statement that the long-term safety of creatine supplementation has not yet been established, I don't think that the question is going to be answered in my lifetime, but that doesn't mean that we should stop studying it.

There are a few theories as to how creatine improves performance, but none have really emerged as dominant so far. One of these theories is that creatine somehow affects the production of testosterone. Testosterone can be converted to dihydrotestosterone (DHT) which is a more bioactive androgen (i.e. it takes less to have the same effect). It isn't known whether creatine has an effect on DHT production and whether THIS might be one of the mechanisms by which creatine produces the observed effects that it has.

Although DHT is a more potent androgen, it is also linked to other conditions such as baldness (alopecia), male-pattern baldness as well as prostate hypertrophy. Understanding whether creatine alters DHT levels, therefore, has relevance not only in figuring out how creatine works, but also in determining whether long-term use may have other, possibly unwanted consequences.

Methods:

The design of this study was a randomized controlled cross-over design. So, each of the subjects was randomly assigned to receive either a placebo or creatine first, and then after a 6-week washout period of taking neither placebo nor creatine, were given whatever they didn't have in the first phase.

The method by which the subjects were randomized is not one that most trialists would condone: Subjects were given a number based on the order in which they arrived for initial testing. Odd numbers were assigned to one group, and even numbers to the other. Twenty subjects were recruited in total, but the study was only done on 16, due to 4 drop-outs.

The subjects were all 18-19 years old, male rugby players in their competitive season.

The total supplementation period was 21 days. A 7-day loading phase (25g per day) followed by the maintenance phase (5g per day) was used. Creatine was taken with glucose (25g). The placebo group got the glucose with no creatine. It's not mentioned who was blinded in this experiment, only that it was "double blind". The creatine and placebo were given in capsules.

In terms of training and diet, these athletes were all part of an institute and therefore trained together (for their positions) and ate together.

Body mass, and skin folds were measured for Day 0, 7 and 21 for both phases of the study. Blood samples were drawn on day 0, 7 and 21 for serum testosterone and DHT.

Comparisons were made using ANOVA's for repeated measures with post hoc Tukey tests for significant ANOVAs. They did do baseline statistical comparisons, but I've bitched enough about how this is inappropriate, particularly for a cross-over trial.

Results:

None of the body-mass or skin-fold measurements changed substantially at the 7-day or 21-day points. This included percent body fat as well as fat-free mass.

Testosterone levels did not change substantially for either the placebo or the creatine phase at any time point. However, what did change was DHT levels. These levels were higher in the creatine phase at both day 7 and day 21, with the day 7 level being higher.

The baseline DHT level for the creatine phase was 0.98 (SD 0.37). At day 7, this rose to 1.53 (SD 0.50) and then fell at day 21 to 1.38 (SD 0.45). These increased levels were statistically significant. As a result, the DHT:T ratios were also higher and statistically significant.

What's interesting is that the baseline DHT level for the placebo phase was 1.26 (SD 0.52). More on this in the discussion area.

Discussion:

Most of the discussion of this article centred around the potential health effects of increased serum DHT.

I think my only major grief with this study is that they reported that DHT levels were 56% higher after 7 days, and then 40% higher than baseline after 21 days on creatine. But the baseline level of DHT in the placebo phase (i.e. the mean level of DHT in the SAME subjects on day 0 of the placebo phase) was 1.26 (SD 0.52). When compared statistically, the DHT level at day 7 was only 21% higher than this baseline, and not statistically significant; which then begs the question as to whether the variability of DHT (either as normal variance in the assay itself, or as normal physiological variance in 18-19 year old rugby players) is high enough that the increased level of 1.53 is meaningful.

However, this issue is not only a good example of trade-off decision making, but it's also a great example of how a single study isn't always enough to put a particular issue into an appropriate context. Yes, the study shows an increase in DHT. Yes, increases in DHT are linked to male-pattern baldness, but I think it's important to note that the study cited in this paper whose purpose it was to investigate DHT and baldness show that even at the highest levels of DHT measured in these rugby players, the association with male-pattern baldness is not very strong.

In the cited paper (Bang et al, Comparative studies on levels of androgens in hair and plasma with premature male-pattern baldness, Journal of Dermatological Science, 34:11-16, 2004), the median level of DHT in males (aged 26-43)with premature baldness was 2.8 with a range of 1.99-4.88. The range of DHT in males without premature baldness was from non-detectable to 2.74 with a median of 1.20 (aged 25-27). Mind you, these are DHT levels in the HAIR itself, not serum concentration levels (which were published in ng/ml, not nmol/L--the units used in the creatine study) so comparison is tricky.

It's impossible to know whether taking creatine will make YOU go bald prematurely if your baseline DHT levels are hanging out in the grey zone of "just short of going bald" unless you know what your baseline DHT levels actually are. It's also impossible to know whether these rugby players' DHT levels at age 18-19 are compatible with the levels that would have been observed had the baldness researchers measured their prematurely bald subjects at age 18-19 (i.e. we don't know which of these 16 rugby players is going to become prematurely bald).

However, it would appear that despite elevated levels of DHT in the serum of rugby players aged 18-19 after 7 and 21 days of creatine supplementation, that the elevation is not likely to correlate with those levels that one could deem necessary to produce male-pattern baldness. There's also a fair amount of overlap in DHT levels between males who did have male-pattern baldness and those who didn't in at least two studies examining the issue; so elevated DHT is probably not the ONLY causative factor in the case of whether you'll go bald or not.

Bottom line: If you're going to go bald, it's probably inevitable. It seems unlikely that taking creatine is going to be the thing that tips you over the edge into Cueball-world (if you're even hanging out at the edge that is). I, for one, will continue to take creatine for what that's worth.

Why isn't overeating an eating disorder?

My very first peer-reviewed manuscript was back in the early 2000's, and wasn't a study. It was a discussion paper comparing anorexia nervosa to a new proposed psychiatric disorder which was to be named, "Muscle Dysmorphia". This proposed disorder was popularized by the book, "The Adonis Complex" in which the authors suggested that an emergent pattern of disordered thinking was becoming more prevalent amongst men. This disordered thinking was defined as the preoccupation that one was not muscular enough, and manifested itself in obsessive-compulsive-like behaviour (e.g. compulsion to go to the gym, or significant distress when one was not able to go to the gym) as well as possible self-harming behaviours, such as not participating in social activities because of one's workout or diet routine, or use of anabolic or other performance-enhancing drugs for the purposes of getting more muscular (I'm not going to debate whether taking anabolic steroids is considered "self-harm" behaviour; it is, however, an example of such in the proposed criteria.)

My position on the proposed "Muscle Dysmorphia" remains unchanged. I do not feel it belongs in the DSM in its current state, largely due to the subjective criteria for its proposed diagnostic criteria, which depends entirely on whether the diagnostician feels the patient is already "muscular enough".

However, recent events got me thinking back to my original manuscript. I had originally written the first incarnation of the paper in my undergrad when I took a life-changing course in my final year entitled, "Critical Issues in Medical Epistemology" in which we examined the social construction of disease from a historical point of view. At the time, the first papers on "muscle dysmorphia" had not yet been written, so I had written about what I also thought was an emerging phenomenon which had casually been referred to as "biggerexia", or "reverse anorexia" in some of the popular and sparse academic literature.

Epistemology is the study of how we gain knowledge. By social construction, I'm referring to how a disease entity evolves to become "known"; not just from its biological origins and cluster of symptoms and signs, but inevitably its assigned "source".  Broadly speaking, sources come from "within" and "without". For a few years before HIV was isolated, AIDS was thought to be a disease that came from "within". Now, we largely think of AIDS as being caused by an external agent, though there is still a small group of scientists that believes otherwise.

In January of this year, I decided to commit to a physical transformation. During my transforming time (arguably, I am still transforming), what struck me as remarkable was the kinds of comments people around me gave me. Many were complimentary, which was flattering, but some alluded to the idea that I wasn't behaving in a healthy manner. "You're wasting away," was a common one. And because I work in an environment where I am quite close to my colleagues, people noticed when I was fasting, and commented that it wasn't healthy. This experience has been reported by many of my fitness colleagues and their clients as well (though, this is all anecdotal.)

While we recognize obesity as a health problem today, what strikes me as odd is the fact that there has been virtually no "pathologicalization" of the behaviour of overeating (other than "food addiction" which is a whole other topic--Can you, in fact, be addicted to a substance you need to survive?) We are, in fact, more likely to label undereating as disordered than we are overeating. Overeating is, in fact, culturally sanctioned in North American culture, particularly around social events and holidays. It is even celebrated (admittedly, "Man vs Fasting" just doesn't have a sensational pitch behind it.) Undereating is part of some religions, but is largely sporadic, with some exception of some religions advocating weekly or annual, or seasonal fasting. It is otherwise, not that socially acceptable to eat less, or to simple occasionally not eat at all.

However, if we examine overeating as a potential pathological behaviour, it exhibits criteria for a disorder:

1) A substantial amount of time is spent on eating, such that a pre-specified time of day is scheduled and mandated by many labour laws to accommodate this behaviour due to its overwhelming prevalence.

2) A substantial amount of money is spent acquiring excessive calories, despite understanding the consequences of chronic overeating.

3) Eating behaviour continues despite sufficient caloric intake, and/or feelings of satiety, independent of energy requirements to perform daily activities, or even periodic heavy activity.

4) Unchecked by subsequent caloric deficit, it inevitably leads to harm: Heart disease, vascular disease and liver disease being the most direct, with linkages to other diseases such as some forms of cancer.

5) Ongoing overeating behaviour can cause marked anxiety and significant stress on self-image and self-perception.

6) People continue to engage in the behaviour despite knowing the consequences for its continuation.

In the right context, almost anything can be explained in a disease model, including love. This is not to make light of an anorexia or bulimia diagnosis, or true body dysmorphic disorder or obsessive-compulsive disorder.  I'm not advocating that overeating be classified in the DSM as a psychiatric disorder, but with some of the negative attention that one receives while trying to make, or demonstrate a positive change, it does make me think a bit more on why it is that pursuing a leaner, even a more muscular body might make it onto the official list of psychiatric disorders before eating more than you need to does.