What You Can Change . . . And What You Can't*: The Complete Guide to Successful Self-Improvement (52 page)

31
. R. Paffenbarger et al., “Physical Activity, All-Cause Mortality.” This paper is a classic, head and shoulders better in quality than the literature that precedes it.

32
. M. McCarthy, “The Thin Ideal, Depression, and Eating Disorders in Women,”
Behaviour Research and Therapy
28 (1990): 205–15. See Jeffrey et al., “Prevalence of Dieting Among Working Men and Women,” for dieting statistics. T. Wadden, A. Stunkard, and J. Smoller, “Dieting and Depression: A Methodological Study,”
Journal of Consulting and Clinical Psychology
54 (1986): 869–71, find that dieting, when measured from the beginning to the end, decreases depression among obese women who lost forty-five pounds on average. But when looked at from week to week, depression fluctuated wildly, with half the women getting noticeably more depressed occasionally.

33
. J. Girgus, S. Nolen-Hoeksema, M. Seligman, G. Paul, and H. Spears, “Why Do Girls Become More Depressed Than Boys in Early Adolescence?” Paper presented at the meeting of the American Psychological Association, San Francisco, August 1991.

34
. A. Fallon and P. Rozin, “Sex Differences in Perceptions of Desirable Body Shape,”
Journal of Abnormal Psychology
94 (1985): 102–5.

35
. The closest any study has ever come concerns lowering blood pressure. If you are obese and your blood pressure is high, even a small amount of weight loss (10 percent of your weight) will probably lower it. See G. Blackburn and B. Kanders, “Medical Evaluation and Treatment of the Obese Patient with Cardiovascular Disease,”
American Journal of Cardiology
60 (1987): 55g-58g. What is still unknown is: When the lost body weight returns, how much will blood pressure increase, and what will the health damage be then? In any case, blood pressure is quite a fallible predictor of health.

I find this study methodologically outdated. With what is known about the likelihood of weight regain after dieting, I believe that any claim about health benefit and weight loss can no longer be made on the basis of a “snapshot” study like Blackburn and Kanders’s. The question is not the momentary benefit after dieting, but the net health effect of dieting followed by regaining the weight.

36
. S. Blair et al., “Physical Fitness and All-Cause Mortality;” J. Holloway, A. Beuter, and J. Duda, “Self-Efficacy and Training for Strength in Adolescent Girls,”
Journal of Applied Social Psychology
18 (1988): 699–719; Paffenbarger et al., “Physical Activity, All-Cause Mortality.”

Again, this is probable but not certain, and I have used the qualifiers
seems
and
probably
to describe the beneficial effects on heart disease of taking up exercise. One study involving over eight thousand Swedish men found twice the risk for physically inactive men, which confirms the above studies. But when that study controlled for the factors correlated with exercise (occupation, diabetes, family history of coronary disease, and mental stress), the beneficial effect of exercise, in itself, disappeared. This finding is important because no one has yet done a large-scale random-assignment study of exercise and heart disease. So it is still unknown if exercising will prevent heart attack or if unchangeable factors that correlate with exercising prevent heart attack. See S. Johansson, A. Rosengren, A. Tsipogianni, et al., “Physical Inactivity as a Risk Factor for Primary and Secondary Coronary Events in Goteborg, Sweden,”
European Heart Journal
9 (supplement L) (1988): 8–19.

Dr. Ralph Paffenbarger of Stanford University recently reported that it is never too late to take up exercise. Based on a study of 10,000 Harvard alumni, he finds that men who start exercising between ages 45 and 54 live ten months longer, on average, than sedentary men; taking up exercise between ages 55 and 64 adds nine months, starting between 65 and 74 adds six months, and starting between 75 and 84 adds two months. See “Exercise to Live Longer, by 10 Months, That Is,”
The New York Times
, 25 February 1993, B7.

37
. The outstanding review of this large literature is G. Bray, “Exercise and Obesity,” in C. Bouchard, R. Shepard, T. Stephens, et al., eds.,
Exercise, Fitness, and Health. A Consensus of Current Knowledge
(Champaign, Ill.: Human Kinetics, 1990), 497–510. See also J. Foreyt and G. Goodrick, “Factors Common to Successful Therapy for the Obese Patient,”
Medicine and Science in Sports and Exercise
23 (1991): 292–97; and L. Ekelund, W. Haskell, J. Johnson, et al., “Physical Fitness as a Predictor of Cardiovascular Mortality in Asymptomatic North American Men,”
New England Journal of Medicine
319 (1988): 1379–84. S. Kayman, W. Bruvold, and J. Stern, “Maintenance and Relapse After Weight Loss in Women: Behavioral Aspects,”
American Journal of Clinical Nutrition
52 (1990): 800–807, found in a retrospective study that 90 percent of women who had dieted on their own and not regained weight exercised regularly, but that only 34 percent of relapsers did.

38
. National Academy of Sciences, National Research Council,
Diet and Health Risk: Implications for Reducing Chronic Disease Risk
, 159–258, 431–64. Martin Katahn’s popular
T-Factor Diet: Lose Weight Safely and Quickly Without Counting Calories or Even Cutting Them
(New York: Norton, 1989) is a useful guide to avoiding fatty foods. R. Stamler, J. Stamler, F. Gosch, et al., “Primary Prevention of Hypertension by Nutritional-Hygienic Means: Final Report of a Randomized, Controlled Trial,”
Journal of the American Medical Association
262 (1989): 1801–7.

39
. These steps come from the last chapter of Polivy and Herman,
Breaking the Diet Habit
, 190–211.

40
. C. Yale, “Gastric Surgery for the Morbidly Obese,”
Archives of Surgery
124 (1989): 941–46, followed 537 patients who underwent one of three kinds of surgery. In a five-year follow-up, gastric bypass was better than vertical-banded gastroplasty (VBG), which was much better than unbanded gastrogastrostomy. J. Hall, J. Watts, P. O’Brien, et al., “Gastric Surgery for Morbid Obesity: The Adelaide Study,”
Annals of Surgery
211 (1990): 419–27, followed 310 patients for three years, with similar outcomes. Cardiac function seems to improve after such surgery. See A. Alaud-din, S. Meterissian, R. Lisbona, et al., “Assessment of Cardiac Function in Patients Who Were Morbidly Obese,”
Surgery
108 (1990): 809–20.

CHAPTER 13
Alcohol

1
. 1. See my
Learned Optimism
(New York: Knopf, 1991),
chapter 6
, for a review of the evidence on this fascinating and robust illusion of control. The most recent piece showing realism as a risk factor for depression is L. Alloy and C. Clements, “Illusion of Control: Invulnerability to Negative Affect and Depressive Symptoms After Laboratory and Natural Stressors,”
Journal of Abnormal Psychology
101 (1992): 234–45.

2
. “Drunkenness a Vice, Not a Disease” is the title of an 1882 pamphlet by J. E. Todd (Hartford, Conn.: Case, Lockwood, and Brainard). The parallel to thieving and lynching comes from E. J. McGoldrick,
The Management of the Mind
(Boston: Houghton Mifflin, 1954).

3
. There have been at least ten heritability studies of alcoholism that converge on a substantial genetic risk. These are reviewed by D. Goodwin, “Alcoholism and Heredity,”
Archives of General Psychiatry
36 (1979): 57–61. The most complete review is in C. Cloninger and H. Begleiter, eds.,
Genetics and Biology of Alcoholism
(Banbury Report Number 33) (Cold Spring Harbor, N.Y.: Cold Spring Harbor Press: 1990).

4
. George Vaillant, in his landmark and courageous book
The Natural History of Alcoholism
(Cambridge, Mass.: Harvard University Press, 1983), uses this metaphor in his illuminating argument for retaining the medical model of alcoholism. It is, along with James Orford’s sober
Excessive Appetites: A Psychological View of Addictions
(New York: Wiley, 1985), one of the two must reads in the field of alcoholism.

5
. See G. A. Marlatt and J. Gordon,
Relapse Prevention
(New York: Guilford, 1985), for the argument that twelve-step programs and the disease concept are more pessimistic and imply greater chronicity than a “biopsychosocial model,” which defines the problem as a “habit disorder.” While these latter concepts are available and plausible to educated and sophisticated people, I cannot judge how plausible they are to the less sophisticated alcoholic.

6
. All major studies of the natural history of alcoholism are about men. There is not a single one about women. While considerably fewer women are alcoholic, given the large absolute numbers of female alcoholics, there is a serious need for knowledge about the course of recovery among women.

7
. See Vaillant,
The Natural History of Alcoholism
, 74–90; W. Beardslee, L. Son, and G. Vaillant, “Exposure to Parental Alcoholism During Childhood and Outcome in Adulthood: A Prospective Longitudinal Study,”
British Journal of Psychiatry
149 (1986): 584–91; and R. Drake and G. Vaillant, “Predicting Alcoholism and Personality Disorder in a 33-Year Longitudinal Study of the Children of Alcoholics,”
British Journal of Addiction
83 (1988): 799–807.

8
. The quote comes from M. Tyndel, “Psychiatric Study of One Thousand Alcoholic Patients,”
Canadian Psychiatric Association Journal
19 (1974): 21–24. See also C. Vaillant, E. Milofsky, R. Richards, and G. Vaillant, “A Social Casework Contribution to Understanding Alcoholism,”
Health and Social Work
12 (1987): 169–76.

9
. Someday the notion of “physical addiction” may come to have a specific physical, rather than just a behavioral, meaning. There is evidence that the brain may lose plasticity—the ability to make choices—as alcoholism gets worse. There is also evidence that when brain cells live in alcohol for a time, they change: They acclimate to an alcoholic medium and function better with alcohol than without it. See A. Urrutia and D. Gruol, “Acute Alcohol Alters the Excitability of Cerebellar Purkinje Neurons and Hippocampal Neurons in Culture,”
Brain Research
569 (1992): 26–37; D. Gruol, “Chronic Exposure to Alcohol During Development Alters the Membrane Properties of Cerebellar Purkinje Neurons in Culture,”
Brain Research
558 (1991): 1–12. Repeated doses of alcohol might even produce brain-cell “kindling” of the sort that Robert Post has hypothesized for cocaine, for stress, and for depression. See R. Post, “Transduction of Psychosocial Stress into the Neurobiology of Recurrent Affective Disorder,”
American Journal of Psychiatry
149 (1992): 999–1010. But at present, the “physical” part of addiction is mostly hypothetical.

10
. A. Pokorny, T. Kanas, and J. Overall, “Order of Appearance of Alcoholic Symptoms,”
Alcoholism: Clinical and Experimental Research
5 (1981): 216–20, lay out the steps of the progression, based on retrospective data.

11
. This latest data and theory are contained in a personal communication from George Vaillant, July 1992.

12
. See Vaillant,
The Natural History of Alcoholism
, 170–71, for a lucid discussion of the who and why of relapse.

13
. F. Baekland, L. Lundwall, and B. Kissim, “Methods for the Treatment of Chronic Alcoholism: A Critical Approach,” in R. Gibbons, Y. Israel, H. Kalant, et al., eds.,
Research Advances in Alcohol and Drug Problems
, vol. 2 (New York: Wiley, 1975), 247–327; D. Armor, J. Polich, J. Michael, and H. Stanbul,
Alcoholism and Treatment
(Santa Monica, Calif.: The Rand Corporation, 1976); R. Rychtarik, D. Foy, W. Scott, et al., “Five to Six Year Follow-up of Broad Spectrum Behavioral Treatment for Alcoholism: Effects of Controlled Drinking Skills,”
Journal of Consulting and Clinical Psychology
55 (1987): 106–8.

14
. George Vaillant, personal communication, July 1992.

15
. G. Vaillant, “What Can Long-term Follow-up Teach Us About Relapse and Prevention of Relapse in Addiction?”
British Journal of Addiction
83 (1988): 1147–57. G. Edwards, “As the Years Go Rolling By: Drinking Problems in the Time Dimension,”
British Journal of Psychiatry
154 (1989): 18–26, found that out of the ex-patients followed for a decade, 18 died (250 percent above expectation), 33 had good outcomes, 11 were equivocal, and 56 had bad outcomes.

16
. The single best study I can find of elaborate hospital-based treatment is G. Cross, C. Morgan, A. Mooney, et al, “Alcoholism Treatment: A Ten-Year Follow-up Study,”
Alcoholism: Clinical and Experimental Research
14 (1990): 169–73. Its results are good: 61 percent remission. Crucially, however, it lacks the matched control group. J. Wallace, “Controlled Drinking, Treatment Effectiveness, and the Disease Model of Addiction: A Commentary on the Ideological Wishes of Stanton Peele,”
Journal of Psychoactive Drugs
22 (1990): 261–84, argues articulately for the effectiveness of such units, but given only one study with a matched and randomly assigned control group that finds positive results (see note 19, below), I cannot in good conscience recommend such treatment as reliably more effective than natural healing.