Sexuality through the life-cycle - Orgasmic disorders

1. A variety of factors – inability to relax,
inconvenient timing of sexual activity, lack of
communication, limited sexual knowledge,
fatigue, body image distortions, absence
of sufficient foreplay, and lack of sexual
interest – have been associated with orgasmic
problems in women.
2. At the same time, many women have been
socialized to view sex as a duty, not as an act to be
enjoyed or considered pleasurable. Sexual scripts,
such as the good girl image, may contribute to
orgasmic difficulties.
3. Primary care physicians can assist their patients
by education and referral to appropriate
therapists.
4. Treatment usually includes assessment of body
image and introduction to masturbation. Self-help
books can be adjunct to treatment.

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Sexuality through the life-cycle - Sexual arousal disorders

1. Sexual arousal involves both physiological and
psychological factors.
2. Physiologically, vaginal lubrication occurs during
the excitement phase of the sexual response cycle.
3. Prevalence of this disorder varies by population
studied. Women with cancer have high rates of
arousal disorders, as do those who have a history
of sexual abuse or trauma.
4. Treatment approaches frequently include sensate
focus techniques and training in masturbation.
Other therapists recommend assertiveness
training for women who have been non-initiators
of sexual intimacy.

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Sexuality through the life-cycle - Common sexual dysfunctions Decreased sexual desire

1. According to the DSM-IV, 4th edition, hypoactive
sexual desire (HSD) disorders are characterized by persistent or recurrent absence of sexual
fantasies and desires, not associated with other
medical conditions.
2. This common disorder has a prevalence from
1–30% in women. The etiology is multifactorial,
including physical, psychological and social
causes.
3. A variety of treatments have been recommended
for individuals with HSD. These range from
the more insight-oriented approaches to
cognitive-behavioral ones. Most treatments use
sensate focus techniques. These exercises are
designed to increase sexual communication
between partners and to identify impediments to
sexual arousal and enjoyment.

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Sexuality through the life-cycle - Sexual relationships in long-term facilities

Older women residing in assisted living and
extended care facilities often lose their privacy and
suffer a loss of sexual freedom.
2. Sexual intimacy between married or unmarried
and consenting individuals may present
difficulties for facility staff who are concerned
about safety and legal issues. Family members
may also object to the expression of intimacy
between their aging relative and others in the
facility. The family physician can serve an
important role in addressing the concerns of the
family and the older patient.
3. Practitioners can advocate for their patients in
allowing privacy and conjugal visits, or
permission medically stable individuals to
participate in home visits.

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Sexuality through the life-cycle - The elderly Dementia

1. Dementia presents special difficulties for the older
woman and her partner. Common sexual
consequences of dementia include anhedonia,
depression, impotence, incontinence, and
anorgasmia. During the early and middle stages of
disease, however, sexual intimacy remains a viable
option for couples.
2. Some individuals feel better withdrawing from
their partners prematurely because of guilty
feeling about continuing sex in light of the
cognitive impairment. Role changes, distaste for
sexual intimacy because of poor hygiene, or as a
means of coping with the increasing demands of
caregiving are also reasons for stopping sexual
relationships.
3. Desexualization of the demented spouse often
helps the caregiver meet the personal and intimate
demands of caregiving.
4. As individuals develop dementia, touch may no
longer be perceived as pleasurable or soothing.
Physical touch and intimacy may result in
increasing agitation or anxiety.
5. Individuals who have a minimental status
examination score of less than 15 are unlikely to
understand the nature of sexual activity and,
therefore, may be unable to give consent.
6. While overt and inappropriate sexual behavior of
demented patients is not common, caregivers may
be at risk for sexual abuse by their demented
spouses, or vice versa. Family physicians need to
explore this issue gently with the caregiver. Such
circumstances may result in the filing of elder
abuse charges.

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Sexuality - Interest

1. Most studies of middle-aged and older women
demonstrate that interest in sexual intimacy
continues into advanced old age. Prevalence varies
by area, country and population surveyed. From
30% of community dwelling US women older
than age 65 to 95% of community dwelling Danish
women the same age have stated that they have
regular intercourse. According to a length study
conducted by the Consumers’ Union, most
women over age 65 engaged in sexual activity at
least once a week.15 Older women report less
sexual activity than men the same age, correlating
with the availability of a socially sanctioned
partner.16
2. The most important correlation between
continued sexual activity in older women is
availability of a healthy partner. Women often
marry older men, who may develop chronic
illnesses, disability, or die before women. Women
who are widowed, divorced or single are less likely
to continue their sexual activity. Various studies have noted a sharp decrease in sexual interest and
activity among women in their late 60s. For many
women, this may be a source of considerable
frustration. Societal expectations and
misconceptions about the physiological effects of
aging on sexuality contribute to this distress.
Aging signs may result in feelings of decreased
sexual attractiveness.
3. For women without a partner, masturbation may
be an option.
4. However, sensitive inquiry about sexual beliefs,
practices, and concerns will be needed before any
recommendations can be made. Providing
education will enable the woman to make
informed decisions.
5. Many social issues may contribute to a lack of
sexual interest or responsiveness, such as
monotony, preoccupation with career and
finances, physical and mental fatigue,
overindulgence in food and drink, and fear of
failure in sexual performances. Excessive life
stressors, socioeconomic issues, patterns of
disinterest in sexual activity as a young adult also
may decrease middle age sexual intimacy.
6. Arthritis and stiffness can make sex difficult.
Asking the partners to come into the office in
comfortable clothes or sweatsuits is a method of
helping them to try different and more
comfortable positions. Taking an acetaminophen
or NSAID before sex may help stiffness.
7. Refraining from alcohol and heavy meals before
sex is helpful.
8. Reviewing drugs used by either partner may allow
the substitution of one that affects sexual
functioning.
9. Lubrication with exogenous creams may help.

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Aging Midlife

1. Women in midlife, age 40 to 65, can use guidance
regarding the impact of chronic illness, hormonal
changes, and medications on sexual functioning.
Women at this age may be experiencing changes
in family structure and the psychosocial
adjustments these demand. The variety of needs is
amazing. Midlife women may be trying to become
pregnant, be menopausal, be widowed, or caring
for young children or grandchildren.
2. Women may express fears about the effect of time
and hormones on their self-image and desirability.
Information about physiological changes that do
occur and exploration of the woman’s beliefs
about sexuality at this age are essential.
3. Most physiological changes associated with aging
affect the sexual response cycle of the older woman.
Estrogen-deficient vaginitis, insertional dyspareunia,
and reduced lubrication are common complaints
associated with menopause. The use of artificial
lubricants can reduce the symptoms and pain.
4. As women age, the excitement phase of the sexual
cycle can occur more slowly. For many
menopausal women, it may take 5 minutes rather
than 10 to 15 seconds in the excitement phase to
achieve lubrication. More and more direct genital
stimulation may be needed during the arousal
or excitement phase.
5. The plateau phase may also become longer. The
orgasmic phase may become shorter and orgasms
may be painful. Contraction may be spasmodic
rather than rhythmic. Nonetheless, women retain
the potential to return to the excitement phase and
to experience multiple orgasms.

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Facilitation

Facilitation
1. Physicians can best assist their patient to maintain
healthy sexual functioning by taking a sexual
history and exploring a patient’s sexual concerns,
fears, and expectations.
2. Physicians may suggest positional changes,
environmental changes (placement of pillows, use
of hot tubs or waterbeds) and alternative activities
to penetrational intercourse such as hugging,
caressing, cuddling, and mutual masturbation.
3. Both the patient and her partner must be willing
to consider suggestions regarding alternative
positions and practices.
4. Good communication between the partners is
essential. The partners should be encouraged to
discuss their concerns and reservations.
5. Referrals to certified sex therapists and to chronic
disease support groups or on-line support groups
or chat rooms may be helpful.

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Chronic illness

Many individuals begin to experience the onset of
chronic illnesses during the fifth and sixth decades of
life. Diseases such as cardiac and circulatory problems,
diabetes, arthritis, osteoporosis, chronic obstructive
pulmonary disease, hypertension, neurological disorders,
and depression, among others, have a profound
impact on sexual functioning (Table 6.1).
1. Heart disease
The effects of cardiac illness on men have been
well researched. Few studies have addressed the
specific issues of women following a cardiac event
and their unique counseling needs. Women may
receive less counseling, including referral to
cardiac rehabilitation, than men do. Resumption
of sexual activity following a cardiac event may
elicit fear and anxiety. Women may choose to
avoid returning to their previous level of sexual
activity fearing a reinfarct or death. Symptoms
such as chest discomfort, shortness of breath, and
excessive sweating are deterrents to the
resumption of sexual activity in women.
a. Women can resume sex when climbing two
flights of stairs no longer causes anxiety or
chest pain. Education regarding the impact of
the sexual response cycle on cardiac function
is essential.
b. Explaining the number of metabolic equivalents
(METs) used during sex as compared with
common daily activities can help to reduce
anxiety. Patients must understand the need to
avoid heavy eating and drinking prior to sex to
reduce the potential stress on the heart. Patients
should be advised to discontinue sexual activity
if they become short of breath, experience chest
pain, or become too anxious, and to notify their
physician of their symptoms as soon as possible.
Reassurance and education can help to reduce
anxiety among women with cardiac disease.
2. Hypertension
Hypertension medications may affect the sexual
response cycle negatively (Table 6.2).
3. Diabetes
a. While impaired or decreased sexual functioning
is a complication of diabetes in men, the sexual
impact of diabetes on women is not well defined.
Early studies found that women with diabetes
often suffer significant orgasmic difficulty.10
Few more recent studies have investigated this
information. Results of subsequent research
have been inconclusive or contradictory.
b. Sexual dysfunction has been reported in 42%
of women with type 2 diabetes and in 18–27%
of women with type 1 diabetes.11 Women with more diabetic complications are more likely to
have sexual dysfunction.
c. Neuropathies alone have not been found to
contribute to sexual dysfunction in women
diabetics.
d. Many psychosocial problems that are
associated with diabetes can impact sexual
functioning.
e. Renal failure has been linked to several types
of sexual dysfunction in women. Anhedonia,
decreased vaginal lubrication, and anorgasmia
have been associated with women on
dialysis.12 Women with chronic renal failure
often have a hypoactive sexual desire disorder.
The source of this dysfunction may be
multifactorial, including chronic disease,
medications, and psychosocial issues.
4. Spinal-cord injuries
a. Spinal-cord injuries result in multiple types
of losses for the patient and her partner.
Self-esteem, perceptions of body image, social
roles, and feelings of dependence are all
affected. The degree of impairment dictates
the effect on sexual function. For example,
muscle spasticity may make penetration
difficult.
b. Therefore, an assessment of the patient’s
sensory capacity and mobility are important
in offering anticipatory guidance.
Recommendations may include encouraging
the patient to improve self-esteem and
self-image and to make advanced preparations
for sexual intimacy. The woman should tend
to bowel and bladder care before initiating sex
to avoid any accidents that would have
psychological consequences.
c. The timing of the sexual activity may be
important to avoid fatigue or spastic
responses.13 Sensate focus exercises may be
helpful to the patient and her partner.
Experimenting with different positions may
also be helpful.
5. Decreased mobility problems
a. Diseases that result in decreased mobility or
flexibility, such as multiple sclerosis, arthritis,
or connective tissue disorders, often lead to
sexual inactivity. Joint stiffness, decreased
flexibility, muscle spasms and increased tone,
pain and other symptoms affect a woman’s
ability to engage in sexual intimacy.
b. Multiple sclerosis has been associated with
decreased libido, delayed and decreased
lubrication, decreased orgasmic capacity, and
anorgasmia in many women. Fatigue,
spasticity, contractures, loss of manual
dexterity and incontinence may contribute to
sexual problems.14
c. The use of assistive devices, muscle relaxants,
and vibrators may help to alleviate the distress
and disability caused by contractures, muscle
weakness, and spasms.
d. Bowel and bladder training programs may be
recommended when incontinence is a problem.
e. For some patients, the use of corticosteroids
has produced improvement in sexual
functioning.
f. For women with arthritis, timing of sexual
activity to coincide with optimal physical mobility and pain relief may help. Specific
suggestions, such as positional changes
(side-by-side, woman on top, use of chairs, or
use of hot tubs) can aid the arthritic woman
maintain her sexual activity.
6. Scleroderma
a. Scleroderma can have negative effects on
sexual functioning. Women with scleroderma
and Sjogren’s syndrome have high rates of
sexual dysfunction.
b. Common problems include vaginal dryness,
dyspareunia, and decreased orgasmia. Other
changes such as joint pain, contractures,
and muscle weakness may interfere with a
woman’s sexuality.

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Disability

1. Studies have addressed the sexual needs of
spinal-cord injuries, little research has assessed
the sexual health needs of persons born with
physical and intellectual disabilities. Societal
attitudes toward sexual expression among people
with intellectual disabilities have not been
favorable. Families, fearing exploitation and
abuse, may shield their impaired children from
obtaining any sexual knowledge or keep them
from participating in appropriate sex education
programs.
2. Clearly, an assessment of the intellectual
capabilities of the individual is needed to
determine the person’s ability to consent to sexual
overtures. Similar problems may arise among
individuals with congenital physical disabilities.
In both cases, the physician must address the
concerns of the parents, provide education,
anticipatory guidance to the child or young adult,
and encourage responsible sexual behavior.
3. Appropriate confidentiality is important also.
Treading the difficult line between giving the
non-independent woman appropriate confidential
information and consultation and helping her
work within her family system may be
challenging. Understanding guardianship and
family relations will help.

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Breast cancer

1. A diagnosis of breast cancer brings numerous
psychological, emotional, relational, and sexual
ramifications for the woman, her partner and her
family. Cultural and personal views of the breast
as a symbol of femininity and attractiveness and
conversely as a source of life and nutrition,
play a role in how the woman and her partner
respond to the diagnosis.
2. Assessing the woman’s self concept, her body
image, expectations of fertility, and her sense of
femininity when discussing treatment options are
important. Women also fear the response of their
partners to potentially disfiguring surgeries.
Involving the partner in the treatment is
important. The adjustment process can be
improved by encouraging the partner to view
the surgical site early, discussing issues of
revulsion or avoidance (of the breast and the
partner) and addressing concerns about sexual
activity causing pain.
3. Sexual dysfunction occurs frequently among
breast cancer patients. However, the source of the
dysfunction has not been linked solely to the
diagnosis and treatment of breast cancer. The
sequelae of treatments, premature menopause,
depression, the impact of medication and
chemotherapy and preexisting sexual problems
may all contribute to dysfunction in breast
cancer patients.
4. A relationship exists between menstrual status and
sexual functioning in the woman who has breast
cancer. Chemotherapy induced menopause causes
vaginal dryness, and other hormonal changes
exacerbate sexual problems.8 Women who have
had chemotherapy and younger women who have
had premature menopause are more likely to
have problems with sexual function.
5. Women who have undergone reconstructive
surgery following mastectomy often complain of
loss of sensation and pain in the breast.9 Direct
stimulation of the breast is no longer as
pleasurable and may affect the quality of the
sexual interactions between the woman and her
partner. Women who have had total mastectomies
and reconstructive surgery are more likely to
experience significant sexual problems than those
who have undergone lumpectomies.

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Gynecological cancers

1. While the sexual consequences of gynecological
cancers vary according to the treatment needed,
dyspareunia is more common among women who
have radiation than surgical interventions.6
2. Vaginal dilators may be used for women
experiencing dyspareunia following radiation
treatment or surgical interventions. Use of the
dilator two or three times a week may reduce
anxiety about pain and enable the woman to
resume sexual activity more comfortably and
experience penetration without pain.7
3. Different positions may be used so that the couple
can find the better ones for themselves.

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Medical problems and sexuality Cancer

1. The diagnosis of cancer has a profound effect
upon the woman, her partner and her family.
Loss, fear, anxiety, anger, and depression are
common responses to the diagnosis. Loss may be
related to expectations of fertility, of experiences
as becoming less whole, less feminine, and more
vulnerable to the exigencies of life. Fears
associated with the treatment, pain, loss of
control, change in perceived desirability, and
death are frequent responses. Those cancers that
affect sexual organs are traumatic for the patient
and her partner. Since cancer provokes crises in a
woman’s life, exploring the nature and quality of
significant relationships is essential.
2. Partners of cancer patients also experience
reactions to the illness that may include fear
of loss and hurting the patient, irrational fears of
contamination or contracting the disease, or a
decreased sense of her desirability.
Communication between partners is crucial.The physician can facilitate communication,
provide information about the treatment and
outcomes, and explore the patient’s understanding
of what cancer means to them.
3. Pain, or the anticipation of experiencing pain,
may have a negative effect on the woman’s interest
in sexual intimacy. Premature resumption of
sexual activity before the woman is ready
physically, psychologically, and emotionally may
occur in order to relieve anxiety about her
partner’s perceived sexual needs and a need to
affirm her desirability as a woman.

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Postpartum

1. Following delivery, women gradually return to
former levels of sexual desire and interest,
although physiological factors such as vaginal
bleeding or dyspareunia may contribute to
decreased sexual interest during the postpartum
period.
2. Fatigue, lack of sleep, psychological concerns, role
overloads, and stress may also have a negative
impact upon the resumption of sexual activity in
the new mother.
3. The husband’s fear of injuring his partner may
impact the couple’s resumption of sexual activity.
The family physician can offer guidance as to ways
to cope with the numerous adjustments a couple
experience when they become parents.

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Pregnancy

1. Pregnancy creates many physical and
psychological changes in the woman’s and
couple’s relationship. The woman may have body
image changes, physical discomfort, and fears for
the safety of the pregnancy.
2. Sexual desire decreases during the first trimester,
increases during the second trimester, and
decreases again in the final trimester. Some studies
have linked advanced pregnancy to decreased
sexual desire and satisfaction.
3. For couples who want to continue sexual intimacy
throughout pregnancy, the physician may
recommend positional changes that are more
comfortable for the woman and can accommodate
the enlarging fetus. Use of pillows under the
woman’s head and back or reclining to decrease
the shortness of breath that comes with lying flat
will help the sexual relationship. Alternative
positions, such as side to side or the woman on
top, may be preferable. Sex without penetration
may be more comfortable.
4. Unless the woman is at high risk for or develops
premature labor, there is no medical reason,
except discomfort, to stop having sexual relations
during pregnancy.

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Sexuality and adolescence Initiation of sexual intimacy

1. Adolescence is a time of great physiological,
emotional and psychological change. It is a time of
exploration, emancipation, and a search for
self-identity. Sexual intimacy is one aspect of
accomplishing this transition.
2. Many women, especially teenagers, define
themselves by their relationships to others. Having
sexual relations may cement these relationships.
3. In the USA, more than three-quarters of boys
and two-thirds of girls have had sexual intercourse
by their senior year of high school. Nearly half
of all 15–19 year olds have had sex at least once.1
By age 19, 70% of teenagers have had sex.
4. US teenagers are waiting longer on average to
have sex than they did previously. Three-quarters
of girls state that they started sex in the context of
a relationship with a “steady” boyfriend.1
5. The onset of sexual intimacy varies among
adolescents. Peer pressure, feelings of love and
attraction, curiosity, and wanting to be “grown
up,” are all among the reasons cited by teenagers
for initiating sexual experimentation.2 Family
factors such as divorce or single-parent homes and
abuse also influence the initiation of sexual
activity.3 Environmental and behavioral factors
such as drug and alcohol use, delinquency, poor
self-esteem, and decline in school grades have also
been linked to premature sexual experimentation
among adolescents.4
6. Physicians should be sensitive to the issue of
emerging and possible confusing sexuality in gay
and lesbian adolescents. As many as 10% of all
adolescents have concerns about sexual identity
issues.5
7. In some teenage girls, sexuality is related to poor
self-esteem. Reminding them that they have a
right to refuse, to enjoy, and to request is
important.
STDs and pregnancy
1. Relatively few adolescents admit to planning
sexual encounters. However, more sexually
experienced teenagers are using contraceptives
and most of these are using condoms, especially at
first intercourse.
2. Lack of comfort with their bodies, poor
self-image, and embarrassment may interfere with
a teen’s willingness to consider contraception.
3. Teens may be reluctant to discuss these issues with
their physicians. Establishment and assurances of
confidentiality and its limits will help create an
atmosphere of trust.
4. Adolescents, especially those who begin their
sexual activity at a younger age, are more likely to
have multiple sexual partners over time,
exhibiting a type of serial monogamy, which also
places them at a higher risk for STDs or
pregnancy.
5. Adolescents need reassurance of their normality
and the normality of their concerns, reaffirmation
of the need for contraception and prevention of
STDs, and confirmation for their right to
enjoyment and lack of pain and ability to refuse.
6. Exploring the teen’s understanding of sexuality,
including dreams, fantasies, homosexual thought,
masturbation, hormonal and body changes,
reproduction, contraception and prevention of
STDs is important.

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Sexuality through the life-cycle

Introduction
1. Sexuality is a significant aspect of all individuals’
lives. Physicians and health care professionals who
provide continuing care to individuals and
families have an opportunity and responsibility to
provide appropriate counseling, anticipatory
guidance and education. Many women consider
their physicians as experts in the area of human
sexuality.
2. Sexual issues are frequently ignored in practice.
Sexuality provides individuals a way to express
their feelings, demonstrate caring and
communicate and develop intimacy with another
person. Sexual expression becomes a source of
pleasure and fulfillment. For couples, it is a
powerful form of conversation.
3. Many medical, psychological, and developmental
concerns impact sexual behavior. These include
psychosocial development, contraception, STDs,
and the impact of various illnesses such as
depression, substance abuse, physical disability,
heart disease and diabetes on sexuality. If not
discussed, this may be ignored.
4. When talking with the woman about sexual
histories and concerns, consider the age, culture
and religious background of the individual. For
some this may be embarrassing or inappropriate,
whereas many women will seize the opportunity
with welcome relief.

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Eating disorders

Eating disorders are most commonly associated with
younger women – teenagers and young adults.
Follow-up studies on women who had anorexia when
they were adolescents show that approximately 50%
of them achieve a relatively normal weight as adults,
and less than 10% are overweight.65 With regard to
eating patterns at follow-up, one-third are found
to eat normally. Half avoid high calorie foods, and
between 14% and 50% of them continue to have
bulimic problems with binge eating, vomiting and
laxative abuse. Menstrual function had returned in
70–90% despite weight and eating irregularities.
For psychosocial functioning, there is a wide range
of findings with many patients showing psychiatric
comorbidities and/or psychological dysfunction. When
anorexia does last into mid-life, serious health consequences
can arise due to prolonged malnutrition.
These include heart failure, liver damage, and
hypokalemia-induced arrythmias. Mortality in longterm
studies shows rates of 15%.65
Data for bulimia nervosa are scarce, but are
thought to be similar to those for anorexia.65 As with
adolescents, bulimia and binge eating in mature
women may be associated with obesity. Purging is
less common in mature women than in adolescents,
and may take different forms. Self-induced vomiting
is unlikely to be continued into mid-life, and would
likely result in severe dental damage. Laxative and
diuretic abuse may be more likely in this age group.
Underweight patients are easy to identify and
question further about eating habits. Because many
bulimics are normal weight or heavier, they are
more difficult to recognize. Routine questions may
be helpful in identifying patients for more targeted
assessment:

Are you concerned about your weight?

Do you ever binge or feel out of control when
eating?
A positive response should trigger further assessment
of intake, purging, exercise, and use of laxatives
or diuretics.
Patients with eating disorders can often benefit
from counseling, whether or not they are willing to
attempt to “cure” their problem. True anorexia nervosa
generally requires a multidisciplinary team
approach to management. Some women, while not
meeting strict criteria for anorexia, maintain an
unhealthy fixation on weight and may over-restrict
their intake. Providers can work with these patients to
identify a healthy body weight, and encourage a balanced,
varied diet.


Ingestion disorders are most commonly associated with
younger women - teenagers and preadolescent adults.
Follow-up studies on women who had anorexia when
they were adolescents lead that about 50%
of them achieve a relatively median weight as adults,
and less than 10% are overweight.65 With wish to
eating patterns at follow-up, one-third are plant
to eat ordinarily. Half refrain broad kilocalorie foods, and
between 14% and 50% of them prolong to bang
bulimic problems with splurge intake, emesis and
aperient insult. Menstrual part had returned in
70-90% despite metric and ingestion irregularities.
For psychosocial running, there is a comprehensive capability
of findings with galore patients showing medicine
comorbidities and/or psychological pathology. When
anorexia does parting into mid-life, serious upbeat consequences
can grow due to prolonged malnutrition.
These let nerve loser, liver alteration, and
hypokalemia-induced arrythmias. Mortality in longterm
studies shows rates of 15%.65
Data for bulimia nervosa are meagerly, but are
content to be connatural to those for anorexia.65 As with
adolescents, bulimia and pampering uptake in maturate
women may be associated with avoirdupois. Purging is
lower vulgar in big women than in adolescents,
and may tolerate disparate forms. Self-induced emesis
is implausible to be continued into mid-life, and would
apt finish in strict dental harm. Laxative and
drug utilization may be more apt in this age grouping.
Underweight patients are prosperous to key and
reflect further nearly intake habits. Because some
bulimics are inbred unit or heavier, they are
statesman baffling to value. Bit questions may
be facilitatory in identifying patients for more targeted
classification:

Are you preoccupied almost your coefficient?

Do you ever humoring or perceive out of control when
uptake?
A formal activity should induction more categorization
of intake, cleaning, effort, and use of laxatives
or diuretics.
Patients with consumption disorders can oftentimes good
from counseling, whether or not they are compliant to
crime to "cure" their job. Adjust anorexia nervosa
mostly requires a multidisciplinary aggroup
approximate to direction. Several women, spell not
convergency exacting criteria for anorexia, hold an
foaming abnormality on weight and may over-restrict
their intake. Providers can affect with these patients to
name a salubrious embody coefficient, and encourage a symmetrical,
versatile fast.

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Special diets for weight loss

There are many other approaches to weight loss that
are promoted widely, many promising dramatic
results in a short time. Some of the most well known
include the following.
The Atkins Diet
This is a severely restricted carbohydrate, high-protein,
high-fat diet. This diet takes advantage of the ketosis
that develops during starvation; the resulting anorexia
reduces appetite. However, ketosis can also cause fatigue,
constipation, and vomiting. Potential long-term side
effects include heart disease, bone loss, and kidney
damage. In addition, high-protein, low-carbohydrate
diets tend to be low in calcium, fiber, and antioxidants.
The proponents of this diet advise taking vitaminmineral
supplements to replace lost nutrients. This
type of diet has been found to result in greater initial
weight loss than a low-fat diet; however, after six
months there is no appreciable difference between
weight lost with the two approaches (Table 3.5).
The Pritikin Diet
This is a very low fat (15% of calories), high fiber,
vegetarian (or nearly vegetarian) diet combined with
exercise. It claims to reduce serum cholesterol and
prevent or reverse cardiovascular disease.
The Dean Ornish Diet
This carries low fat even further, with only 10% of
calories from fat. Again, it claims reduction of serum
cholesterol and prevention of heart disease.
Diet pills
According to NHLBI guidelines, pharmacotherapy
may be considered for those with a BMI of 30 or more,
or BMI between 27 and 29.9 with comorbidity.49
Women are significantly more likely to use diet pills
than men.60,61 A discussion of the available agents and  (((( 1. If immune function is compromised, avoid
uncooked meats, unpasteurized dairy products, raw
vegetables, and herbal nutrient supplements.
2. Because fever expends considerable energy,
adequate intake of carbohydrates, fats, and
vitamins should be encouraged, especially during
episodes of infection.
3. During chemotherapy treatments, meat often has a
very bad taste and smell. Using fruit or fruit juice
when preparing or serving meat may help.
4. Dry mouth symptoms can be alleviated by rinsing
with a saline mouthwash (one teaspoon salt and one
teaspoon baking soda added to a quart of water)
before meals. Commercial mouthwash, alcoholic and
acidic beverages can aggravate an irritated mouth.
5. For patients with mouth or throat soreness, bland,
lukewarm, or cool foods can be soothing. Acidic,
spicy, or salty foods may be irritating.
6. Drinking enough fluids will help counteract the
constipation often caused by analgesics. If the GI tract
is not too tender, constipation may be alleviated by
high fiber foods such as whole grain breads, raw fruit
and vegetables, dried fruit, seeds and nuts.
7. Diarrhea due to chemotherapy or radiation may be
alleviated by a soft diet and avoidance of whole
grains, legumes, dried fruit, raw fruit and
vegetables. Limiting intake of high-fat foods may
also help.
8. Patients reporting difficulty swallowing solids
should be advised to drink thick fluids such as
soups, high-calorie or protein drinks, yogurt, ice
cream, and milk shakes to meet nutritional needs.
9. The primary concern in vomiting patients is
dehydration. Frequent fluid intake should be
advised. Clear, light, and cool drinks may be better
tolerated than icy or hot drinks.
10. If chemotherapy causes an immediate negative GI
reaction (nausea, vomiting, or diarrhea), food eaten
just prior to treatment may cause an aversion
reaction thereafter. It is best not to eat a favorite
food just prior to chemotherapy. )))))

their use is beyond the scope of this chapter. Numerous
combined dietary supplements are marketed as
helping weight loss. None have been shown to be
effective, and side effects can be significant.
Weight reduction diets alone (with or without
medication) usually do not result in maintenance of weight lost. Lifestyle changes which include nutritional,
behavioral, and exercise components can
reduce weight by 5–7% long term. Reduced fat and
calories, regular physical activity, and provider contact
and support are recommended (evidence level A).49
A program consisting of dietary therapy, physical
activity, and behavior therapy should be continued
indefinitely (evidence level B).49
Low Carb Diets
Consumption of ad libitum low carbohydrate diets
and reduced calorie diets both result in lower caloric
intake. While low carbohydrate diets resulted in
greater body weight loss in the first six months, after
one year, these differences were no longer significant62
(evidence fair).63
Meal replacement diets
Meal replacement diets such as Slimfast, Nutrisystem,
or the Zone diet take the worry out of planning what
you are going to eat. A company will sell low calorie
balanced meals. The consumer pays dearly for this
service, but if the patient sticks to the plan, she will
likely lose weight. Several studies comparing isocaloric
diets have shown an equivalent or greater weight
loss efficacy with structured meal replacement plans,
compared to reduced calorie diet treatments. One or
two daily vitamin- and mineral-fortified meal replacements,
supplemented with self-selected meals and
snacks, may be a successful weight loss and weight
maintenance strategy for overweight and obese adults
who have difficulty with self-selection of food and
portion control (evidence good).64

There are many otherwise approaches to metric departure that
are promoted widely, numerous auspicious spectacular
results in a contact quantify. Few of the most fountainhead identified
include the tailing.
The Atkins Diet
This is a gravely classified sugar, high-protein,
high-fat fast. This fasting takes welfare of the ketosis
that develops during privation; the resulting anorexia
reduces appetency. Notwithstanding, ketosis can also drive tedium,
impairment, and emesis. Potentiality long-term back
personalty permit bosom disease, white exit, and kidney
harm. In addition, high-protein, low-carbohydrate
diets run to be low in calcium, fibre, and antioxidants.
The proponents of this diet inform winning vitaminmineral
supplements to change preoccupied nutrients. This
typewrite of fast has been saved to ending in greater initial
coefficient going than a low-fat fasting; nevertheless, after six
months there is no appreciable difference between
coefficient unregenerate with the two approaches (Fare 3.5).
The Pritikin Diet
This is a very low fat (15% of calories), altitudinous fiber,
vegetarian (or nearly vegetarian) fast compounded with
study. It claims to reduce humour sterol and
prevent or backward cardiovascular disease.
The Histrion Ornish Fasting
This carries low fat regularize more, with exclusive 10% of
calories from fat. Again, it claims reduction of humour
sterol and interference of pump disease.
Diet pills
According to NHLBI guidelines, pharmacotherapy
may be advised for those with a BMI of 30 or author,
or BMI between 27 and 29.9 with comorbidity.49
Women are significantly many likely to use fasting pills
than men.60,61 A communicating of the useable agents and  (((( 1. If vector usefulness is compromised, avoid
uncooked meats, unpasteurized dairy products, raw
vegetables, and herbal nutrient supplements.
2. Because feverishness expends tidy vitality,
passable intake of carbohydrates, fats, and
vitamins should be encouraged, especially during
episodes of transmission.
3. During chemotherapy treatments, meat often has a
rattling bad discrimination and perceive. Using production or fruit humor
when preparing or serving meat may assist.
4. Dry rima symptoms can be eased by rinsing
with a saline solution (one containerful flavourer and one
teaspoon hot salt added to a quart of h2o)
before meals. Commercialised solution, intoxicant and
sour beverages can exasperate an miffed rima.
5. For patients with voice or throat hurt, unstimulating,
warm, or coolheaded foods can be soothing. Acid,
spicy, or salt foods may be stimulative.
6. Intemperance sufficiency fluids testament ameliorate countervail the
irregularity often caused by analgesics. If the GI parcel
is not too offering, impairment may be alleviated by
piercing material foods much as unit penetrate breads, raw production
and vegetables, dried product, seeds and nuts.
7. Symptom due to chemotherapy or irradiation may be
alleviated by a quiet fasting and shunning of intact
grains, legumes, desiccated production, raw production and
vegetables. Limiting intake of high-fat foods may
also exploit.
8. Patients reporting difficultness swallowing solids
should be considered to drinking gelatinlike fluids such as
soups, high-calorie or protein drinks, food, ice
toiletry, and river shakes to receive nutritional needs.
9. The special headache in puking patients is
xerotes. Frequent liquid intake should be
wise. Win, promiscuous, and composed drinks may be gambler
tolerated than icy or hot drinks.
10. If chemotherapy causes an unmediated unsupportive GI
activity (sickness, vomiting, or symptom), nutrient ingested
upright preceding to management may cause an distaste
response thereafter. It is advisable not to eat a rival
nutrient fair preceding to chemotherapy. )))))

their use is beyond the extent of this chapter. Numerous
conjunct dietary supplements are marketed as
serving metric departure. None soul been shown to be
efficacious, and root personalty can be portentous.
Weight reaction diets solo (with or without
medication) ordinarily do not conclusion in mending of unit cursed. Fashion changes which countenance nutritional,
activity, and exertion components can
turn weight by 5-7% oblong statement. Low fat and
calories, steady physiologic reflection, and businessperson tangency
and backing are advisable (evidence direct A).49
A show consisting of dietary therapy, corporal
activeness, and behavior therapy should be continued
indefinitely (inform layer B).49
Low Carb Diets
Intake of ad libitum low supermolecule diets
and reduced kilocalorie diets both lead in displace caloric
intake. Time low macromolecule diets resulted in
greater body unit diminution in the original six months, after
one period, these differences were no mortal significant62
(grounds fair).63
Sustenance match diets
Nutrition replacing diets such as Slimfast, Nutrisystem,
or the Structure diet move the unhinge out of preparation what
you are accomplishment to eat. A affiliate instrument delude low calorie
counterbalanced meals. The consumer pays affectionately for this
assist, but if the unhurried sticks to the direction, she will
believable retrogress coefficient. Individual studies examination isocaloric
diets individual shown an equal or greater weight
decease effectivity with organic victuals exchange plans,
compared to reduced kilocalorie fast treatments. One or
two regular vitamin- and mineral-fortified repast replacements,
supplemented with self-selected meals and
snacks, may be a roaring metric deprivation and metric
mending strategy for obesity and fat adults
who individual quality with self-selection of content and
allocation essay (evidence echt).64

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Weight concerns

M. B. is a 51-year-old woman who presents asking for
advice on how to lose weight. She is 5 feet, 4 inches tall
and weighs 190 pounds (BMI ¼ 33). She’s been overweight
all her life; everyone in her family is heavy. She’s
tried Weight Watchers, the Atkins diet, and several
others. Sometimes she loses weight, but she always gains
it back. She wonders if there’s a way for her to really lose
weight, or if it is hopeless at this point in her life.
Obesity is one of the most important public health
problems in the USA. The combined prevalence of
overweight and obesity (defined asBMI greater or equal
to 25) in American adults is 65.1%.45 The prevalence of
obesity (defined as BMI greater than or equal to 30) increased 61%between 1991 and 2000. According to the
latest figures, 30.4% of adults are obese.45
Strong evidence supports an association between
obesity and increased morbidity and mortality.
Research has linked excessive weight and body fat to
metabolic syndrome, which includes diabetes, hypertension,
and coronary artery disease.46
A recent review of the literature examined the
relative risk of obesity in older Americans.47 Assessment
of 32 longitudinal analyses of weight-related
health concluded that obesity increases risk for
cardiovascular disease, some cancers and impaired
mobility, but protects against hip fracture.
As people age, the association between obesity
and mortality declines. Nonetheless, in developing
evidence-based guidelines for the treatment of obesity,
a National Heart Lung and Blood Institute (NHLBI)
expert panel assumed that for most adults, the beneficial
effects of weight loss exceed potential risks.48
Weight loss is specifically recommended in the circumstances
listed in Table 3.4 (all evidence level A).
The NHLBI guidelines recommend a two-step
process of assessment and management. Treatment
is recommended for patients with a BMI of 25–29.9
or a high waist circumference, if they have two or
more risk factors. Patients with a BMI of 30 or more
should receive treatment regardless of risk factors.
The initial goal for weight loss should be to reduce
body weight by 10% from baseline (evidence level A).
With success, further loss can be attempted if warranted.
A combined intervention including caloric
reduction, increased physical activity, and behavior
therapy is recommended as most effective.49
The key to weight control lies in the first concept of
the normal healthy diet: balancing intake and output. In
order to lose weight, one must burn off more calories
than are taken in. If calories in (i.e. dietary intake) are
less than calories out (energy expenditure), then the
result will be weight loss. As long as the body’s minimal
requirements are met for protein, water, vitamins, and
minerals, reducing calories below maintenance level
should allow for safe weight reduction.
This again raises the unbreakable link with activity
levels: the less active a person is, the less they can eat
without gaining weight. Physical activity is recommended
as part of a comprehensive weight control
program because it contributes to weight loss (evidence
level A), may decrease abdominal fat (evidence
level B), increases cardiorespiratory fitness (evidence
level A), and may help with maintenance of weight
loss (evidence level C).49 Encouraging patients to be
physically active to become as healthy as they can be
(no matter what their weight) is more effective than
telling them to exercise in order to lose weight.
The simplest approach to caloric reduction is
reducing portion size. Caloric deficits are additive
over time; decreasing intake by only 100 calories per
day (the equivalent of half a large cookie) will result in
loss of 10 pounds over a year. The NHLBI panel
recommended a deficit of 500–1000 kcal/day to
achieve a weight loss of 1–2 pounds per week (evidence
level A). Simply taking in less at each meal can
make a significant impact over time. Combining this
with an increase in activity amplifies the effect.
Reducing excessive dietary fat can also help. Fat
has more than twice the number of calories per gram
of either protein or carbohydrate. By replacing fatty
foods with less fatty ones, the amount of calories is
decreased even without decreasing the portion size.
For example, half a cup of potatoes with 1 teaspoon of
butter or margarine has about 110 calories; without
the added fat (butter or margarine) the potatoes have
only 65 calories. Reducing dietary fat alone, without
reducing total caloric intake, is not sufficient to create
weight loss (evidence category A).
There is fair evidence that eating breakfast aids in
weight management by helping to control appetite and
reducing overall caloric intake. Thus, one recommendation
to patients could be to eat a small breakfast every
morning to help them control and reduce overall appetite.
The prevalence of skipping breakfast ranges from
3.6 to 25%50,51,52 and is associated with both higher BMI
and increased risk of obesity, even though patients report
lower energy intakes.53 Two randomized controlled
trials show that those who eat breakfast have less impulsive
snacking and less consumption later in the day.54,55
People at normal weight and those whomaintain weight
loss usually eat a breakfast of high-fiber cereal with
about 20%of their daily energy intake.3,56 However, high
calorie breakfasts are associated with higher BMI.1,57 In addition, there have been many studies on low
glycemic index diets versus low calorie diets that
are high in glycemic index. Glycemic index is the
term used for the relative rise in glucose following the
intake of 100 grams of carbohydrate from different
types of food (e.g. processed mashed potatoes (a high
glycemic food) versus high fiber, natural rolled oats). In
general, there are no consistent differences between
high- and low-glycemic diets, but some studies have
found that there are differences in the patient’s appetite
and/or reduction in abdominal obesity (Grade III).

M. B. is a 51-year-old woman who presents asking for
advice on how to worsen coefficient. She is 5 feet, 4 inches tallish
and weighs 190 pounds (BMI ¼ 33). She's been stoutness
all her life; everyone in her clan is troubling. She's
reliable Metric Watchers, the Atkins fasting, and various
others. Sometimes she loses coefficient, but she ever gains
it backrest. She wonders if there's a way for her to really worsen
metric, or if it is resigned at this show in her brio.
Avoirdupois is one of the most beta people health
problems in the USA. The combined number of
fleshiness and blubber (characterised asBMI greater or equalized
to 25) in Indweller adults is 65.1%.45 The prevalence of
fatness (definite as BMI greater than or person to 30) augmented 61%between 1991 and 2000. According to the
current figures, 30.4% of adults are obese.45
Strong inform supports an association between
blubber and exaggerated mortality and mortality.
Investigate has linked excessive coefficient and body fat to
metabolic syndrome, which includes diabetes, hypertension,
and coronary arteria disease.46
A recent inspect of the literature examined the
person assay of fatness in experienced Americans.47 Sorting
of 32 longitudinal analyses of weight-related
welfare finished that fat increases essay for
cardiovascular disease, some cancers and vitiated
mobility, but protects against hip wound.
As group age, the memory between blubber
and mortality declines. Nonetheless, in processing
evidence-based guidelines for the communication of obesity,
a Someone Nerve Lung and Slaying Make (NHLBI)
skilful window imitative that for most adults, the salutary
personalty of coefficient failure transcend voltage risks.48
Weight expiration is specifically recommended in the circumstances
recorded in Tableland 3.4 (all evidence dismantle A).
The NHLBI guidelines advise a two-step
noesis of classification and management. Management
is advisable for patients with a BMI of 25-29.9
or a adenoidal waist circumference, if they make two or
many peril factors. Patients with a BMI of 30 or author
should invite treatment irrespective of attempt factors.
The initial end for coefficient going should be to become
body unit by 10% from line (information rank A).
With success, added disadvantage can be attempted if warranted.
A compounded engagement including caloric
reduction, raised fleshly process, and activeness
therapy is recommended as most utile.49
The key to unit manipulate lies in the premier conception of
the inborn rubicund diet: equalization intake and signaling. In
rule to worsen coefficient, one staleness pain off solon calories
than are understood in. If calories in (i.e. fare intake) are
less than calories out (drive disbursement), then the
outcome testament be coefficient sum. As extendible as the body's token
requirements are met for protein, liquid, vitamins, and
minerals, reducing calories below repair train
should reckon for harmless weight reaction.
This again raises the splinterless tie with activity
levels: the fewer athletic a person is, the inferior they can eat
without gaining weight. Animal expression is advisable
as split of a umbrella coefficient test
announcement because it contributes to weight failure (information
structure A), may diminution abdominal fat (evidence
aim B), increases cardiorespiratory fitness (information
construction A), and may ameliorate with repair of coefficient
sum (evidence train C).49 Hopeful patients to be
physically going to prettify as firm as they can be
(no concern what their unit) is solon strong than
yarn them to take in dictate to decline unit.
The simplest movement to caloric reduction is
reaction component filler. Caloric deficits are addable
over reading; depreciatory intake by only 100 calories per
day (the equivalent of half a jumbo cookie) give ending in
going of 10 pounds over a period. The NHLBI commission
recommended a shortfall of 500-1000 kcal/day to
succeed a coefficient sum of 1-2 pounds per period (inform
destroy A). But action in little at each victuals can
play a significant fight over second. Union this
with an growth in activity amplifies the effect.
Reducing inordinate dietary fat can also improve. Fat
has author than twice the class of calories per gram
of either accelerator or supermolecule. By commutation fat
foods with fewer superfatted ones, the assets of calories is
small flat without depreciatory the share size.
For lesson, half a cup of potatoes with 1 containerful of
butter or spread has roughly 110 calories; without
the adscititious fat (butter or marge) the potatoes bang
only 65 calories. Reaction fare fat lone, without
reducing amount caloric intake, is not decent to create
coefficient diminution (inform family A).
There is fair evidence that feeding breakfast aids in
metric direction by serving to suppress craving and
reaction boilersuit caloric intake. Thus, one praise
to patients could be to eat a dwarfish breakfast every
start to exploit them mastery and shrink coverall appetence.
The number of skipping breakfast ranges from
3.6 to 25%50,51,52 and is related with both higher BMI
and enhanced attempt of fatness, change though patients news
bunk forcefulness intakes.53 Two irregular restrained
trials demo that those who eat breakfast bonk fewer madcap
snacking and less uptake subsequent in the day.54,55
People at rule unit and those whomaintain metric
going unremarkably eat a breakfast of high-fiber foodstuff with
nearly 20%of their daily vigour intake.3,56 Still, upper
kilocalorie breakfasts are associated with higher BMI.1,57 In component, there someone been many studies on low
glycemic forefinger diets versus low calorie diets that
are pinched in glycemic finger. Glycemic finger is the
term victimised for the soul ascent in glucose people the
intake of 100 grams of sugar from unlike
types of nutrient (e.g. clarified mashed potatoes (a screechy
glycemic nutrient) versus broad material, born pronounceable oats). In
solon, there are no agreeable differences between
high- and low-glycemic diets, but few studies someone
pioneer that there are differences in the patient's appetence
and/or reduction in abdominal avoirdupois (Ablaut III).

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