Anorexia, Bulimia...and Obesity

ou see their photos everywhere: gaunt models strutting the latest in fashion, skinny socialites dining in trendy restaurants, svelte young actresses partying till dawn at the newest club. No wonder American women seem obsessed with their weight.

But when is thin too thin? And when does dieting turn into a life­threatening eating disorder?

Over the past few years, the media have been filled with the tragic stories of famous women whose abnormal eating behavior led to serious health problems and even death. For the most part, these women suffered from anorexia nervosa or bulimia nervosa. Together these eating disorders affect approximately 8 million Americans—mostly young women and teenaged girls. At the opposite extreme, excessive overweight (obesity), while rarely deadly in itself, increases your risk of life­threatening medical conditions ranging from breast cancer to heart disease.

All three of these problems represent normal diet gone awry. Anorectic women relentlessly pursue thinness by literally starving themselves for varying periods of time. Victims of bulimia suffer repeated binges of eating followed by purging through self­induced vomiting, laxatives, and similar measures. Seriously overweight women—defined medically as those who are more than 20 percent over their ideal weight—are often plagued by compulsions to eat.

It's important to remember that these disorders are not merely the normal variations in eating we all go through. Dieting is not automatically a sign of anorexia any more than an occasional eating binge such as consuming an entire package of cookies in one sitting means you are suffering from bulimia. If you're 5 or 10 pounds overweight, you may feel “fat,” but that doesn't make you medically obese.

Anorexia Nervosa

The word anorexia means “loss of appetite,” but this name is misleading. Anorectics—95 percent of whom are women—often have a normal appetite but because of an abnormal fear of being fat and a distorted body image, they're convinced that they're obese and refuse to eat. In most cases their weight is within—or below—acceptable limits. Anorexia is considered a psychological disorder because there is no known physical cause for the extreme weight loss associated with the condition.

Tipoffs of Anorexia

You may be anorectic if you:

• Lose at least 25 percent of your original weight.
• Have not had a physical or mental illness that could have caused the weight loss.
• Think of yourself as fat even if you're not.
• Fear being overweight and losing control over your eating behavior.
• Refuse to eat enough to maintain or return to a normal weight.
• Fail to menstruate for at least three consecutive months.
• Feel that all of your energy is going into controlling your weight.
• Feel that staying hungry is the only way you can avoid becoming fat.

Other signs that you may have anorexia include growth of a fine covering of hair all over your body, sensitivity to cold, and constipation. You may also feel depressed or anxious.

Weight loss is the most visible symptom of anorexia. Most anorectics drastically reduce the amount of food they eat. Some cut back mainly on certain types of “fattening” foods such as bread and sweets, while others eat less of everything. Sometimes anorectics lose control and go on an eating binge. Like bulimics, they usually follow this binge with laxatives or self­induced vomiting, to prevent food from being absorbed into the body.

Many anorectics are compulsive exercisers, and their typical program is far more strenuous than normal. Women with anorexia often devote a major portion of their waking hours to aerobics, weight training, calisthenics, or running.

While most women worry about their weight and diet at some point in their lives, the anorectic organizes her life around food. If a social occasion involves eating, she'll decline the invitation. The dieter, on the other hand, will generally put in an appearance and try not to eat too much.

Who's at Risk?

Anorexia is most likely to begin sometime between adolescence and the early 20s, but it can appear in children under the age of 10 or in women as old as 70. Although the disorder receives a great deal of publicity, it's relatively rare. For example, among teenage girls—the group at highest risk—the rate of anorexia is under 1 percent. While the disorder is most common among the middle and upper classes, it occurs in all social classes and ethnic groups.

Certain personality traits increase the risk of developing anorexia. Anorectic girls are often described as “model children” or perfectionists. Many have overcontrolling parents who are themselves fascinated by fitness and appearance. Faced with the impossible task of always being perfect, these girls discover that they can take charge of at least one aspect of their lives by exerting control over their eating and their weight.

Family background may also predispose a woman to anorexia. If you have a mother or sister with anorexia, you are more likely to have the problem than if there were no history of the disorder in your family. However, in a number of cases, there is no familial link.

Why It Happens

Anorexia and eating disorders are unhealthy responses to stress, painful feelings, and other problems. While the specific cause is unknown, the condition seems to stem from a combination of psychological, biological, familial, and cultural factors.

The teens and early twenties are tumultuous years for a woman. Moods and emotions can swing wildly from one day to the next. The dutiful daughter turns into the rebel, eager to assert her independence—sometimes in self-destructive ways.

Some researchers see anorexia as a power struggle between a strong­willed girl and her dominating parents. Starving herself, she unconsciously shows that she is in control of her own body and affirms that her parents are powerless to stop her.

Since anorexia usually causes menstrual periods to stop and breasts to flatten, other experts theorize that girls who refuse to eat may be expressing a desire to remain children, free of adult bodies, adult sexual relationships, and adult responsibilities.

Stress can play a major role in anorexia. Taking an exam, moving to a new home, starting college or a new job, becoming pregnant, and beginning or ending a relationship may sometimes push a woman into beginning the heavy dieting that ends with anorexia.

Our equation of thinness with beauty, social success, and even desirability is also at fault. In America, the pressure to be thin is intense. Most young women can handle it successfully, but a few respond in extreme ways, such as anorexia.

For some adolescents, ordinary biology poses a problem. As their bodies mature, many girls discover that they can no longer eat as they used to without gaining weight. Most can cut back as needed; a few lose control. Sensible dieting is fine, but when low calories become no calories, it's time to admit there's a problem.

Consequences of Anorexia

Ironically, most anorectics develop an intense interest in food and a fascination with recipes and cookbooks. They spend many hours planning menus, buying groceries, and preparing meals for others, yet eat next to nothing themselves. This preoccupation may grow stronger as the pounds continue to drop off.

Stringent dieting leads to muscle and fat loss. The body begins to look like a skeleton, bones protrude, legs resemble matchsticks, and breasts disappear. Facial muscles tighten because there is no layer of fat beneath the skin to cushion them.

Anorexia can last for many years and cause severe health problems. Besides weight loss and absence of menstrual periods, the physical consequences of anorexia may include:

• Anemia
• Constipation, digestive discomfort, and abdominal bloating
• Dehydration, muscle cramps, and tremors
• Dental problems
• Downy body hair on the face, back or arms
• Dry skin
• Dull and brittle hair
• Excessively low blood pressure
• Icy hands and feet
• Irregular heartbeat

If anorexia remains untreated, it can be fatal. Some victims literally starve themselves to death or die of conditions related to their malnourished state. Others commit suicide.

How Doctors Decide It's Anorexia

Doctors look for such common signs of anorexia as a patient's conviction that she needs to lose weight, a weight loss of at least 25 percent, and absence of at least 3 consecutive menstrual periods. The physician must also rule out other medical problems that could be responsible for the weight loss.

There is no laboratory test for anorexia, although your doctor may draw blood to check for physical problems such as anemia. Since several other physical diseases and mental disorders cause many of the same physical problems, your physician will rely mainly on your attitude toward eating and information about your behavior in making a diagnosis.

Getting Treatment

Self­help doesn't work for anorexia because the victims do not consider themselves sick. Most believe they are doing the right thing and are convinced that their attitude toward food and weight is reasonable. They are quite happy to go on starving themselves and rarely seek medical care on their own—at least not for the anorexia itself. They may see a doctor because they are concerned about missing their periods or are worried about other physical symptoms. Sometimes concerned parents take their daughter to a physician because her extreme weight loss makes them suspect she is anorectic.

If you think you have anorexia or are worried about a family member, ask your physician for an evaluation and a referral to someone who can help. If the situation seems life­threatening, go immediately to a hospital emergency room or call a crisis hotline (listed in the Yellow Pages under Crisis Intervention Service).

Anorectics need more than orders to “eat more.” The first step is to restore a normal or near­normal body weight. In extreme cases, when the anorectic has lost so much weight that her life is in danger, the priority is to save her from starvation. After stabilizing her weight, the anorectic must relearn normal eating behavior and abandon drastic weight loss strategies, such as excessive exercise and vomiting or purging. This can't be achieved without coming to grips with the personality or family problems that have helped cause the illness.

The best way to conquer anorexia is to catch and treat it early. If you have this dangerous eating disorder, your doctor may hospitalize you until you have gained weight. If you decide to stay home, you'll need regular medical checkups and counseling.

Some anorectics undergoing hospital in-patient treatment programs try to continue controlling their weight by flushing food down the toilet, making themselves vomit, or taking laxatives. They also find ways to make their weight seem higher during examina- tions. Experienced doctors and nurses know how to handle such deceptions.

Because they understand the anorectic's fear of being fat, physicians, nurses, or others treating her usually encourage her to gain only the minimum weight necessary for her height to maintain normal, healthy body functions, such as menstruation and temperature control.

Stopping such dangerous weight­loss tactics as self­induced vomiting and the frequent use of laxatives can produce some side effects. You may temporarily gain weight as your body becomes rehydrated. Cramps, abdominal fullness, and constipation may continue for some time during this readjustment period. If you experience any of these symptoms, don't panic and revert to the habits that made you sick. Your body must go through these changes on its way back to health.

If you've suffered extreme weight loss, treatment may include forced nutrition through intravenous infusions and tube feeding. However, many anorectics resent these measures which they regard as an attempt to control their behavior and weight, and this, in turn, makes recovery even more difficult.

Counseling and therapy are essential to recovery from anorexia. Individual psychotherapy will help the anorectic face her problem, while family therapy helps those close to her change patterns of behavior that may have contributed to the disorder. Many patients also benefit from group therapy or support groups where they can share their feelings and gain strength from others who have the same problems. Nutritional counseling can be a practical help.

Occasionally, physicians prescribe medications such as tranquilizers, antidepressants, and lithium carbonate. Unfortunately, no drug now on the market has proven successful in treating anorexia, though some of the new antidepressants have been helpful. A combination of individual and family therapy is usually the best route to recovery.

Is Recovery Possible?

An estimated 50 to 70 percent of anorectics in treatment return to their normal or near­normal weight. Reaching this goal takes at least 6 months. About 15 to 20 percent will have an occasional relapse. Women who force themselves to vomit, and purge with laxatives are at highest risk for failure. They may binge intermittently during or after treatment. If you fit this description, you need to continue seeing your doctor or therapist for help and encouragement. Fifteen to 20 percent of anorectics need treatment for many years.

For those who don't try to beat the disease, the prognosis is guarded. An estimated 10 to 20 percent of anorectics die from related problems. The cause of death ranges from starvation and suicide to heart problems brought on by imbalances in the body due to excessive vomiting. Some women succumb to infections and diseases that overcome their weakened immune systems.

Treatment substantially improves the odds of survival. Among those who seek therapy, the mortality rate is only 5 percent. Recovery rates may grow even higher in coming years as researchers find better ways of fighting this very dangerous disorder.

Bulimia Nervosa

The hallmark of bulimia is a repeated uncontrollable urge to eat large amounts of food in a short time. After this binge, the bulimic often induces vomiting or uses laxatives, enemas, or diuretics to prevent weight gain. Some bulimics never purge themselves, but most go on strict diets between binges.

Until 15 or 20 years ago, doctors considered bulimia and anorexia two aspects of the same disorder. The conditions do have some characteristics in common. Both mainly affect women—particularly teens and young adults—and both are marked by binges of eating. However, while women with anorexia are obsessed by the urge to become ever thinner, those with bulimia usually maintain a normal weight and start a binge/purge cycle to avoid getting fat.

Profile of a Bulimic

All victims of bulimia are plagued by irresistible urges to binge on food. During a binge, bulimics often choose foods—such as ice cream, candy bars, puddings and cookies—that are high­fat, high­sugar, easy­to­swallow, and easy­to­vomit afterward. Bulimics usually gorge in secret. A binge typically lasts about 2 hours—although some are shorter or longer—and only stops when the bulimic gets a stomachache, feels sleepy, or is interrupted.

After a binge, self­induced purging is the norm. Bulimics usually make themselves vomit or use laxatives, diuretics, or diet pills to get rid of all the excess food. Some then follow a strict diet or exercise compulsively to undo the damage until the cycle begins all over again.

Women with this eating disorder often feel depressed, ashamed, and guilty after a binge. They realize that their behavior is abnormal, and that they are out of control.

The pattern of binge eating varies. Some bulimics binge several times a day for a few days, then not at all for a long time. Others follow a predictable pattern, such as binging and purging 3 times a week. Some binge only in response to certain stressful situations. The behavior may go on for years, although many bulimics often eat normally between phases of binging and purging. A few bulimics are totally given over to the binge and purge pattern and never maintain a normal diet. The amount of food consumed during a binge also varies considerably, but is always much more than the bulimic would ordinarily eat in a day.

Who's at Risk?

While young and middle or upper class women are particularly susceptible to bulimia, the disorder strikes people of all economic backgrounds and is found among all ethnic groups. The illness usually begins between the ages of 15 and 24, but it can occur in younger or older women and in men. If you are a young woman, your odds of developing bulimia are estimated to be between 1 in 10 and 1 in 20.

Studies have shown that bulimics frequently have obese parents or siblings, which may explain their exceptional fear of becoming fat themselves. Studies have also found that close family members of bulimics suffer from depression more often than would be expected.

Some bulimics adopt this abnormal eating pattern for professional reasons. Dancers, actors, models, and athletes whose careers depend on low body weight often stay thin by purging themselves with laxatives or inducing vomiting. They do not, however, always indulge in binge eating.

Why It Happens

To date there is no conclusive evidence linking bulimia to such biological factors as chemical imbalance in the brain. According to one theory, after you have eaten a usual amount of food, your brain sends a message to turn off the desire to eat more. But if you have starved yourself or followed a strict diet between binges, you are in a food­deprived state. When you resume eating during a binge, the turnoff message may fail to work. You then continue eating well beyond the point where you ordinarily would stop.

A few researchers have suggested that physical, psychological, or especially sexual abuse in childhood may cause bulimia later in life. These findings are controversial, and the role child abuse plays in causing bulimia is unclear.

Social pressures could also play a part. Society's emphasis on thinness as the ideal form of feminine beauty may be what causes some young women to become so afraid of the idea of becoming fat that they fall into the binge/purge pattern of bulimia. One thing is certain: If you are susceptible to bulimia, your first episode may be triggered by a stressful situation such as school problems, death in the family, career changes, divorce, or pregnancy.

Consequences of Bulimia

Unlike anorectics, most bulimics know that their behavior is abnormal and that their eating binges are not merely ordinary overeating. They also know that anxiety and depression sometimes trigger their episodes. However, they are usually unable to break the binge and purge cycle without professional help.

If you have bulimia, you're probably fascinated with food. You enjoy reading articles about food, buying cookbooks, and talking about food and cooking. Food and eating become ways to escape from life's many stresses.

You probably plan well for your binges, hoarding food, buying special treats, and preparing elaborate dishes. The foods you choose may be those you do not let yourself have at other times because you think they are “bad” and will make you gain weight. Sweets fit into this category.

You are also careful to conceal your illness. You may go to a number of different stores so that your purchases do not cause attention. Perhaps you tell the checkout clerks that you have a large family or are planning a party as a way to explain your overflowing shopping cart.

During the binge, you may abandon normal table manners and stuff yourself, gulping food as fast as you can. If you are sure you will not be discovered, you may eat at a more normal pace. By the time you're finished, you may have consumed 3 to 30 times more than you would normally eat in a day.

You probably have a secret place to binge—perhaps a closet. You have also found ways to vomit without being discovered; locked bathrooms are a popular choice. Because of your secrecy, you may have been able to hide your binge and purge episodes from your parents, husband, siblings, or roommates for years.

This destructive behavior eventually takes a toll on your body. Physical consequences of bulimia include:

• Broken blood vessels in the face and bags under the eyes
• Dehydration, fainting spells, tremors, and blurred vision
• Indigestion, cramps, abdominal discomfort, bloating, gas and constipation
• Internal bleeding and infections
• Laxative dependency and damage to the bowels
• Liver and kidney damage
• Loss of tooth enamel from repeated vomiting
• Suicidal depression
• Swollen glands in the neck under the jaw.
• Upset of the body's fluid/mineral balance, possibly causing rapid or irregular heartbeats or even a heart attack
• Weight fluctuations from alternating diets and binges
• Rupture of the esophagus (upper gastric tract)

Though bulimia is not as deadly as anorexia, fatalities do occur.

How Doctors Decide It's Bulimia

A physician who suspects bulimia looks for signs and symptoms established by the American Psychiatric Association:

• Recurrent episodes of binge eating
• A feeling of a lack of control over eating behavior during the binges
• Regular self­induced vomiting, use of laxatives or diuretics, strict dieting or fasting, or vigorous exercise in order to prevent weight gain
• A minimum average of two binge eating episodes a week for at least three months
• Persistent excessive concern with body shape and weight

Getting Treatment

Bulimics may not develop the life­threatening medical problems that anorectics are prey to. Bulimics are generally treated with psychotherapy rather than the hospitalization and constant supervision required for some anorectics. There are exceptions to this guideline. If you feel suicidal or severely depressed, you may have to be hospitalized briefly for examination and preparation of a treatment plan. You may also need a short stay in the hospital if your bulimia has caused physical problems that require medical attention.

Unlike anorectics, who deny their illness and resist treatment, some bulimics want help and are willing to try to change their behavior. If you do begin treatment, you should realize, however, that you may experience some initial side effects. Temporary weight gain may occur as your body begins to retain fluid again; and symptoms such as constipation, abdominal fullness, and cramps may continue for some time.

The goal of treatment is to change your eating patterns while maintaining your normal weight. Your therapist will help you to uncover and deal with unconscious motives for your compulsion to binge and work with you to change your attitude toward food and weight. You will also be taught ways to overcome bad habits that keep you focused on food, such as maintaining records of how much food you eat, counting calories, weighing yourself frequently, and constantly reading recipes and cookbooks. You will have to stop labeling foods as “good” and “bad” and accept the fact that it is all right to eat high­calorie or sweet foods in moderation.

While antidepressants and other medications are sometimes tried during treatment of anorexia, they do not seem to break the binge/purge cycle of the typical bulimic. Research also shows that after initial improvement, many bulimics receiving drug therapy regress to their former behavior. Because these powerful medications may produce undesirable side effects, doctors usually reserve them for cases in which severe depression accompanies the bulimia.

Neither medication or individual therapy are always the answer to bulimia. If you're having trouble the doctor may recommend family therapy and group sessions with other bulimics. Other options include daytime care in a clinic or hospital and supervised use of a self­help manual.

Is Recovery Possible?

Although bulimia is not as dangerous as anorexia, doctors have found that it's more difficult to treat, and the recovery rate is lower. By one estimate, about 40 percent of bulimics respond well to treatment, 40 percent have moderate success, and 20 percent show no improvement. Relapses are common and can be triggered by any stressful event such as school exams, career change, illness, marriage, or divorce.

Your chances of returning to a normal life may be better if you can establish a good relationship with your therapist or physician. If you feel comfortable during treatment, you may return for more help if you have a relapse. It is also important to avoid taking a job associated with food preparation or serving. Bulimics who become cooks or waitresses often resume their former dangerous eating patterns.

Obesity

Although simply being overweight is not a disorder of the same caliber as anorexia and bulimia, it's still a major health problem and a cause of concern and frustration for millions of Americans. If you have trouble keeping your weight down, you're far from alone. About a quarter of the population is technically classified as “obese.”

The Official Definition

Medically speaking, obesity is not just another word for “fat.” To be considered obese, you must weigh at least 20 percent more than the norm for a woman of your height and bone structure. What's more, there are four grades of obesity. If you are 20 percent heavier than your ideal weight, you are slightly obese. At 40 percent above normal you are moderately obese; at 50 percent, morbidly obese; and at 100 pounds or more over the weight you should be, you are hyperobese.

Doctors worry about obesity because it is a contributing factor in a variety of dangerous medical conditions including diabetes, high blood pressure, and heart disease.

Who's at Risk?

Obesity often runs in families, although the exact nature of this apparent genetic influence on body weight is still unknown. Since you can't pick your parents, you can't control your predisposition to developing this disorder.

Obesity is also related to your economic background. Being overweight is more common in working­class groups than in the wealthy, possibly because less affluent people cannot afford the expensive diet and exercise programs favored by the rich. In addition, among the well­off, it is unacceptable to be obese or even moderately heavy, while working­class people are more tolerant of weight problems.

Gender and age also influence your weight. About twice as many women as men qualify as obese; and in both women and men, weight often increases with age.

Your ethnic background also makes a difference. Eskimos, for instance, tend to have slower metabolisms, burning energy more slowly than others and generally tending to be heavier. In this country, obesity is a greater problem for blacks than for whites.

Why It Happens

If you think the answer is “too much food,” you're not entirely wrong. However, there are a couple of factors that determine what's too much. Inactivity reduces your calorie requirement, making more of what you eat unnecessary. A slow metabolism that burns fewer calories does the same. Psychological factors can also contribute to the problem. If you turn to food for comfort in times of stress, chances are greater that you'll wind up overeating.

Consequences of Obesity

Medical consequences aside, severe overweight can lead to numerous other problems, including real psychological difficulties. Subtle put­downs, outright criticism, and even insults all take their toll. Years of discrimination can batter self­esteem to the point that psychotherapy is needed along with an attack on the excess weight.

How Doctors Gauge Obesity

A doctor generally decides that you are obese simply by looking at you. Most doctors form mental images of the various categories of obesity, from moderate to hyperobese. After judging your appearance, the doctor will then confirm his or her impression by more objective means.

The most common method is by comparing your weight to the figures on standard height and weight charts. These charts are based on life insurance company statistics. They list a range of ideal weights for various heights and body frames. At each height, the ideal weight-range for people with a particular type of frame can vary more than 20 pounds; and for a given height, the range from the lowest weight in the small­frame category to the heaviest in the large­frame category can be as high as 40 pounds.

Some experts argue that these height and weight charts are inaccurate for one reason or another. They are widely used, however, and provide a standard baseline for making decisions about weight.

Another common way of measuring obesity is called the skinfold “pinch test.” To test you in this way, a doctor measures folds of skin at various parts of your body.

When you see a doctor for treatment of obesity, your examination is likely to include questions about obesity in your family. You will also be asked about your eating and exercise habits, use of cigarettes and alcohol, your occupation, and your experiences with gaining and losing weight in the past. During your physical examination, the doctor will check for signs of other medical conditions that might be responsible for your excess weight. Lower than normal activity of the thyroid or adrenal glands are two possibilities. However, these and other medical conditions are to blame in only about 1 percent of obesity cases.

Attacking the Problem

There's no way around it: to rid yourself of obesity you need to diet rigorously, though regular exercise is also helpful in shedding pounds and keeping them off. Although both over­the­counter and prescription medications help take off pounds temporarily, there is little evidence that they are effective in helping you maintain weight loss over the years.

The best diet includes nutritious foods served in smaller portions than you're in the habit of eating. Be sure to check with your doctor before undertaking low carbohydrate diets, liquid protein fasts, and other “fad diets.” Some can be dangerous. Liquid diets of the past, for example, caused several deaths and hospitalizations; the dieters apparently starved to death because the liquids provided only a few hundred calories per day.

Losing weight can be a struggle, particularly if your problem is severe enough to classify you as obese. You may find help and support from local chapters of such organizations as Weight Watchers and Overeaters Anonymous. These groups can offer both advice on weight loss and a chance to ease your feelings of isolation by talking with people who understand what you're going through. (For more information, see the directory of support groups at the end of the book.)

Medical treatment ranges from dieting under a doctor's supervision to outpatient or residential programs. These treatment programs are usually run by private doctors; some are associated with hospitals.

In an outpatient program, you will have regular consultations with the physician or other professionals. You will probably eat prepackaged diet foods for several months before gradually reverting to other foods. To prevent you from reverting to your old eating habits, the treatment may include behavior modification counseling.

Residential programs are more comprehensive; many include various forms of psychotherapy designed to treat obesity as an addiction. A residential program may charge thousands of dollars; outpatient therapy can cost you several hundred dollars or more per month.

Surgery is reserved only for people who are massively obese or whose health is at risk. The two most common surgical techniques are liposuction and intestinal bypass. In liposuction, a tool is inserted under the skin to suck fat from the body. In bypass surgery, the digestive flow is routed past the large and small intestines to reduce the amount of food absorbed. Both surgical techniques can be dangerous and should only be used as a last resort.

How To Increase the Odds of Success

Unfortunately, success rates for long­term weight loss are low. It is estimated that only 20 percent of patients lose 20 pounds and keep them off for more than 2 years. An even smaller percentage maintain higher rates of weight loss.

Your best chance for success is a multi­pronged attack, employing a variety of strategies and emphasizing maintenance of weight loss more than the initial loss of excess fat. A well­rounded treatment program that includes a low calorie diet, counseling to help change eating behavior, regular exercise, and social support is the approach most likely to work. It also helps to have a close, supportive relationship with your therapist or physician. Above all, you must be motivated to attain your goal and keep the pounds off. More Women's Health...