THE MANAGEMENT OF EATING DISORDERS AND OBESITY

NUTRITION 0 AND 0 HEALTH Adrianne Bendich, Series Editor

The Management of Eating Disorders and Obesity, edited by David 1. Goldstein

Vitamin D: Physiology, Molecular Biology, and Clinical Applications, edited by Michael F. Holick

Preventive Nutrition: The Comprehensive Guide for Health Professionals, edited by Adrianne Bendich and Richard 1. Deckelbaum

THE MANAGEMENT

OF EA:IING DISORDERS

AND OBESITY

Edited by

DAVID J. GOLDSTEIN, MD, PHD

Lilly Research Laboratories; Indiana University School of Medicine, Indianapolis, IN

Foreword by

ALBERT J. STUNKARD, MD

University of Pennsylvania Medical Center, Philadelphia, PA

~ SPRINGER SCIENCE+BUSINESS ~MEDIA,LLC

© 1999 Springer Science+Business Media New York Originally published by Humana Press Inc. in 1999

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1098765432

Library of Congress Cataloging-in-Publication Data

The management of eating disorders and obesity/edited by David J. Goldstein; foreword by Albert J. Stunkard. p. cm.--(Nutrition and health)

Includes index. ISBN 978-1-4757-6761-2 ISBN 978-1-59259-694-2 (eBook) DOI 10.1007/978-1-59259-694-2 I. Eating disorders--Prevention. 2. Obesity-Prevention. 3. Anorexia nervosa. 4. Bulimia. I. Goldstein, David

J. (David Joel), 1947- Series: Nutrition and health (Totowa, NJ) [DNLM: I. Eating Disorders-therapy. 2. Obesity-therapy. WM 175 M266 1999]

RC552,E 17N364 1999 6 16.85'2606--dc2 I DNLM/DLC for Library of Congress 98-53443

CIP

SERIES INTRODUCTION

The mission of the Nutrition and Health Series of books is to provide health profes­sionals with texts that are considered essential, because each book includes (I) a synthesis of the state of the science, (2) timely, in-depth reviews by the leading researchers in their respective fields, (3) extensive, up-to-date-fully annotated reference list, (4) a detailed index, (5) relevant tables and figures, (6) identification of paradigm shifts and their consequences, (7) virtually no overlap of information between chapters, but targeted interchapter referrals, (8) suggestions of areas for future research, and (9) balanced, data­driven answers to patients' questions, which are based on the totality of evidence rather than the findings of any single study.

The series volumes are not the outcome of a symposium. Instead, each editor has the potential to examine a chosen area with a broad perspective, both in subject matter as well as choice of chapter authors. The international perspective, especially with regard to public health initiatives, is emphasized where appropriate. The editors, whose training are both research and practice oriented, have the opportunity to develop a primary objec­tive for their books, definite the scope and focus, and invite leading international authori­ties to be part of their initiative. The authors are encouraged to provide an overview of the field, discuss their own research, and relate their research findings to potential human health consequences. Because each book is developed de novo, the chapters can be coordinated so that the resulting volume imparts greater knowledge than the sum of the information contained in the individual chapters.

The Management a/Eating Disorders and Obesity, edited by David J. Goldstein, MD, PhD, represents a significant contribution to the Nutrition and Health Series. Dr. Goldstein is to be congratulated for his forward-looking vision and sensitivity toward the treatment of individuals with eating disorders. As Dr. Goldstein indicates, obesity is not technically considered to be an eating disorder; however, the health professionals who care for overweight individuals also often see those with eating disorders. Thus, for many health-care providers, this book targets several related treatment areas. Dr. Goldstein has carefully ensured that this book is up to date and provides chapters by the most respected members of the medical as well as the research community. The Foreword by Dr. Alfred J. Stunkard reminds us of the past difficulties of developing safe drugs for the treatment of obesity, and the authors of chapters related to bulimia and anorexia candidly discuss new options for patients.

Yet, the overriding, consistent message from the editor and chapter authors is that prevention is the most effective course. Moreover, preventing further deterioration by the patient's health is given in-depth analysis in several key chapters. Dr. Goldstein includes chapters related to the opportunities that are presented to many health care providers (1) to raise the warning flag and enhance early diagnosis, (2) to provide varied options including psychological counseling, and (3) to encourage exercise programs and long-term commitments to healthy eating patterns. Equally important, The Management a/Eating Disorders and Obesity includes informative chapters on the role of heredity in obesity development as well as insights into the mechanism of action ofbioactive mol­ecules identified recently as being critical for weight management. Finally, the book

v

VI Series Introduction

contains authoritative analyses of the latest data concerning new therapeutic options and related case studies to enhance patient care. Thus, The Management of Eating Disorders and Obesity provides the reader with authoritative options for managing some of the fastest growing problems in U.S. health care today. Thus, the book represents a compre­hensive, essential resource for health-care providers interested in improving the manage­ment of patients with eating disorders and obesity.

Adrianne Bendich, PhD SmithKline Beecham Consumer Health Care

Parsippany, NJ

FOREWORD

As I sit down to write the foreword for The Management of Eating Disorders and Obesity, the world of weight control is still stunned by the accumulated bad news of the recent past. The August 1996 report by Abenhaim (1) alerted us to the devastating complication of primary pulmonary hypertension among persons who had been receiv­ing fenfluramine (1). The blow was somewhat softened by the realization that the disorder was extremely rare. It took 200 cardiology and pulmonary medicine centers two years to find Abenheim's 95 cases; the risk was 28 cases per million person-years of exposure, about that of penicillin-induced anaphylaxis.

Then came the new blow-valvular heart disease---and this time the problem was not rare (2). Still, fragmentary reports suggest that nearly one-third of persons receiving fenfluramine suffered from this complication, usually in combination with another appetite suppressant, phentermine.

Dexfenfluramine and its racemic mixture of DL-fenfluramine were promptly with­drawn from the market amid predictions ofthe end ofthe drug treatment of obesity, and it is still unclear what to expect. Two entirely different scenarios are possible.

One scenario is that drug therapy of obesity will come to a screeching halt. A report in the Wall Street Journal of October 24, 1997 described a meeting of 100 product liability lawyers who discussed what could be the largest class action suit in American legal history. Even smaller legal actions will make physicians think twice about prescrib­ing drugs and pharmaceutical companies about developing drugs for them to prescribe.

There is a precedent for such an unfavorable scenario. In the 1970s, congressional hearings on the abuse of amphetamines for weight reduction led, quite appropriately, to their removal from the market. Quite inappropriate was the radical reduction in the prescription of all other appetite-suppressant medication that followed. It was only the landmark report of the effectiveness of the fenlphen in 1992 that emboldened the medical profession to once again prescribe medication for obesity (3). It is entirely possible that the late 1990s has seen a replay of the 1970s and the abandonment of drug therapy for obesity.

An entirely different scenario, however, may well unfold. Driven by the remarkable effectiveness of the fen/phen combination, pharmaceutical companies may decide to embark on a reinvigorated program of drug discovery. Two agents, sibutramine and orlistat, have been approved, and a larger number of agents are in various stages of devel­opment. Furthermore, the recent discoveries of fundamental mechanisms of metabolism and of the control of food intake mean that new and far better targeted drugs can be designed. The fenfluramine experience will certainly mean that far greater vigilance and safety will be required. However, the fenlphen successes may be only the prelude to a far more extensive use of pharmacotherapy of obesity.

A major problem that will affect most pharmacotherapy for obesity is the need to assess safety over long periods of time. It has become clear that any weight lost with the aid of medication is promptly reversed when the medication is withdrawn. The consis­tency of this finding has evoked the theory that appetite-suppressant medication acts primarily to lower a body-weight set point and only secondarily to suppress appetite. The

Vll

viii Foreword

implication is clear: medication to treat obesity must be used indefinitely or not at all. Long-term use means long-term monitoring for safety, a requirement that we have not appreciated and to which we will have to become accustomed.

The bad news about drug therapy has had one salutary consequence for the treatment of obesity. It means that physicians and patients must carefully weigh the risks and benefits of the treatments that they consider and they must share the decision as to how to proceed. For behavior therapy, the risks are small and they may be acceptable to most people, even those who simply want to lose a few pounds for a wedding. For medications, however, we must assume that there will be risks and that the extent of the risks will be uncertain. However, the benefits to an obese person with severe comorbidity may well be worth taking. Here is an area in which the wisdom of the physician will be tested as never before.

This foreword has dealt with the treatment of obesity, as that is the area that presents the greatest current problems. However, the same issues apply to treatment of eating disorders. For both obesity and eating disorders, The Management of Eating Disorders and Obesity should achieve its goal of providing guidance to the general practitioner to improve success and end the cycle of recurrent attempts and failures. I commend it to you.

References

Albert J. Stunkard, MD Department of Psychiatry

University of Pennsylvania School of Medicine, Philadelphia, PA

1. Abenheim L, Monde Y, Brenot F, et al. Appetite suppressant drugs and the risk of primary pulmonary hypertension. N Engl J Med 1996; 335:609--616.

2. Connolly HM, Crary JL, McGoon MD, et al. Valvular heart disease associated with fenfluramine-fentermine. N Engl J Med 1997; 337:581-588.

3. Weintraub M, Sundaresen PR, Schuster B. Long-term weight control study. Clin Pharm Therapeut 1992; 51:586-607.

PREFACE

Eating disorders-bulimia nervosa, anorexia nervosa, and binge eating-are com­monly seen in office practice. Symptoms associated with bulimia nervosa are seen in at least 5% of college-age women. Obesity, not generally considered an eating disorder, is prevalent in a third of the US adult population. Binge-eating disorder, which is present in as many as a quarter of obese patients, has been proposed as a separate entity with an obese phenotype. All of these conditions are becoming more prevalent and it can be expected that they will continue to have a substantial impact on the health of those affected and on direct and indirect costs to society.

All health practitioners encounter patients with eating disorders and obesity. Popular­press articles on eating disorders are alerting many to the risks of the eating disorders, yet patients often conceal their condition from family, friends, and health professionals as long as they can. Although treatment of bulimia nervosa and anorexia nervosa is often considered the realm ofthe specialist, there is much that the general practitioner can do. It is important to recognize the signs of these conditions since early intervention may be more successful than intervention when the patient has later developed additional psy­chiatric comorbidities and physical disabilities. Patients need to be evaluated both medi­cally and psychologically because of the high comorbidity associated with these eating disorders. Uncomplicated cases can be managed by generalists; because the treatment of eating disorders and obesity is often multimodal, occasional input from specialists may still be necessary.

Obesity is much more amenable to treatment by the generalist, in part because signifi­cant psychiatric comorbidity is less common than for the eating disorders, although input may be required on selected patients with particularly difficult comorbid conditions. Further, the health care practitioner needs a foundation of basic information to guide patients toward effective, long-term solutions. This is particularly important since obese patients are bombarded with lay information on the latest diet, medication, or other magical way to reduce weight and keep it off, and health care professionals need to be able to offer sound, knowledgeable advice. Thus, a major objective of The Management of Eating Disorders and Obesity is to provide information regarding those treatments that are more amenable to general health care. It is hoped that the health care practitioner will be more comfortable intervening earlier, before comorbidities make medical interven­tion more urgent.

Often, health care professionals fail to diagnose these conditions until late in their course. When a diagnosis is made, treatment is frustrating for both the health care prac­titioner and the patient, because both eating disorders and obesity tend to be chronic and relapsing conditions, requiring lifelong therapy. There is a need for improvement in the treatment of eating disorders and obesity; without more effective treatments, these con­ditions will continue to impact health care adversely, as well as to incur high individual and societal costs. Thus, the main objective of The Management of Eating Disorders and Obesity is to provide clinical health care practitioners with practical information on the management of eating disorders and obesity.

For all eating disorders and obesity, the first step toward effective therapy is a thorough medical and dietary assessment. Based on this information, the initial program is devel-

ix

x Preface

oped. Such programs should combine cognitive behavioral therapy with other psycho­therapy specifically tailored to the patients' needs. Often this will include dietary coun­seling and may include exercise counseling. When comorbidities exist, they need specific treatment. Pharmacologic therapy is also considered on a case-by-case basis.

In 1992, after reports about the use of combined therapy for obesity were carried by the popular press, sales ofphentermine and fenfluramine increased exponentially. The US Food and Drug Administration (FDA) approved dexfenfluramine, the first agent for use in obesity since the 1960s. In 1997 the FDA approved fluoxetine as the first drug for treatment of bulimia nervosa. Sibutramine was approved in 1998 for obesity treatment, and orlistat was approved for the same indication in 1999. Because of the recent impact of pharmacologic agents in treating bulimia nervosa and obesity, each section of The Management of Eating Disorders and Obesity contains a significant proportion ofinfor­mation on treatment with these agents.

The Management of Eating Disorders and Obesity consists of three major sections, one each for bulimia nervosa, anorexia nervosa, and obesity. Each section contains brief, practical, and timely reviews of the eating disorders and their management provided by foremost experts in the field. Many share their personal experience in providing treat­ment. These reviews provide assistance to those practitioners who want to realize a maximal impact on patient health. Recommendations are given for potential early inter­vention, in an effort to reduce the severity of these conditions and improve outcomes. Insights are given into possible future therapies.

Dr. Steven Romano (Chapter 1) reviews the history, diagnosis, prevalence, psychiatric comorbidity, and medical complications of bulimia nervosa. With this background estab­lished, Dr. James Mitchell (Chapter 2) reviews the assessment of the patients, monitoring of potential medical complications, and specific counseling strategies, including the use of self­help manuals and when to refer the patient. Dr. James Hudson (Chapter 3) reviews the scientific evidence for, and the use of, pharmacologic therapy for bulimia nervosa. The approval of the first pharmacologic agent for treatment ofbulimia nervosa is likely to encour­age the development of other treatments for bulimia. Dr. Cheryl Rock (Chapter 4) describes the role of dietary patterns and nutrition on the development of eating disorders and provides evidence of predictors of bulimia nervosa and anorexia nervosa.

As he did for bulimia nervosa, Dr. Steven Romano (Chapter 5) provides an overview of anorexia nervosa. Dr. George Hsu (Chapter 6) provides an overview of the treatment for anorexia nervosa that contains suggestions based on his own experience. Dr. Walter Kaye (Chapter 7) summarizes the experience with pharmacologic therapy for treatment of anorexia nervosa and offers a suggested guideline for clinical treatment.

The section on obesity is much more detailed. Here, I reveal that my personal interest has been focused more intensively on obesity, and my observations that obesity is more commonly observed and more amenable to treatment by generalists than either anorexia or bulimia nervosa. Dr. Richard Atkinson (Chapter 8) discusses the genetic, environmen­tal, and metabolic etiologies of obesity. Dr. Xavier Pi-Sunyer (Chapter 9) describes the epidemiological data on obesity and its many associated complications. The medical consequences of obesity are a primary driver for treatment since weight loss reduces the risks associated with obesity, particularly non-insulin-dependent diabetes mellitus, hy­pertension, and hyperlipidemia. These benefits of weight reduction are discussed by Dr. George Blackburn (Chapter 10).

Preface xi

Relatively recently, binge-eating disorder has been proposed as a separate entity. It differs from other eating disorders in several characteristics and some have proposed different treatment approaches for the obese binge eater and the non-obese binge eater. Dr. Marsha Marcus (Chapter 11) describes binge-eating disorder, including its treatment both in general and in detail.

The treatments for obesity are summarized by Dr. John Foreyt (Chapter 12). Repre­sentatives from the National Institute for Fitness led by Dr. Michael Busk (Chapter 13) review the role of activity and exercise in the treatment of obesity. Clearly exercise is one of the best ways to maintain reduced weight-but is inadequately used by patients. They provide some concrete examples of the issues that prevent patients from initiating and maintaining an exercise program and offer specific suggestions to help motivate the patient. Dr. Thomas Wadden (Chapter 14) discusses the role of behavior treatment. Behavior treatment includes exercise and nutrition behaviors. When large amounts of weight need to be lost rapidly, but nonsurgically, very-low-calorie diets are often used. Dr. Edward Mascioli (Chapter 15) discusses the role of very-low-calorie diets in the treatment of obesity. He describes the diets, as well as the selection and management of patients using those diets.

Because behavioral obesity treatments have proven to be unsuccessful in the long term, other strategies have been used. Dr. George Bray (Chapter 16) summarizes the types of and experience with pharmacologic agents for weight reduction. Dr. Richard Atkinson (Chapter 17) discusses combination therapy. Dr. Jose Caro (Chapter 18) sum­marizes the genetic evidence for obesity and the recent molecular findings that are now contributing to the development of new research strategies and expanding our under­standing of the molecular mechanisms involved in eating. His emphasis is on leptin and the leptin receptor. Finally, Dr. Peter Benotti (Chapter 19) describes the surgical manage­ment of obesity. Although considered the treatment of last resort for obesity, this tech­nique has been very effective and has improved considerably over the original surgical techniques used.

Chapters 20 and 21 describe the practicalities of treating obesity in the private office and in the multidisciplinary team setting. Both of these chapters use case histories to demonstrate specific issues related to treatment. First, in the description about treatment in the office setting, Dr. Ronald S. Rogers summarizes the treatment issues as expressed by patients. He used the Internet to discuss these issues with patients. These have prac­tical implications for a practitioner who wants to establish an effective and patient­comfortable setting. Next, Dr. Richard Lutes describes his experience. He focuses on ascertaining the time when the patient is ready to lose weight, the "teachable moment." Dr. Roy Blank describes his use of the phentermine--fenfluramine protocol in his office practice. Although fenfluramine is no longer marketed in the United States, this still provides an approach for the use of medications for obesity treatment. Both Dr. Lutes and Dr. Blank agree that it is important to thoroughly evaluate the patient's history and physical condition before initiating a program. Finally, I discuss a process for maximiz­ing the use of pharmacologic therapy in obesity treatment.

To further understand obesity therapy one also needs to understand the barriers to treatment including those of patients, providers, and society. Dr. Arthur Frank (Chapter 22) reviews these.

Xll Preface

The best cure is prevention, and in concluding this volume Dr. Barbara C. Hansen (Chapter 23) reviews research on this issue to provide this perspective.

David J. Goldstein, MD, PHD

CONTENTS

Series Introduction ......................................................................................................... v

Foreword by Albert J. Stunkard .................................................................................. vii

Preface ........................................................................................................................... ix

Contributors .................................................................................................................. xv

PART I BULIMIA NERVOSA

A GENERAL INFORMATION

1 Bulimia Nervosa ............................................................................... 3 Steven J. Romano

B TREATMENT

2 Counseling Patients with Bulimia Nervosa .................................... 11 James E. Mitchell and Sara Engbloom

3 Pharmacologic Therapy of Bulimia Nervosa ................................. 19 James L Hudson, Harrison G. Pope, Jr., and

William P. Carter

C PRECEDENTS

4 Prevention of Anorexia Nervosa and Bulimia Nervosa: A Nutritional Perspective ........................................................... 33

Cheryl L. Rock

PART 1/ ANOREXIA NERVOSA

A GENERAL INFORMATION

5 Anorexia Nervosa ........................................................................... 49 Steven J. Romano

B TREATMENT

6 Treatment of Anorexia Nervosa ..................................................... 59 L. K. George Hsu

7 Pharmacologic Therapy for Anorexia Nervosa .............................. 71 Walter H. Kaye

PART II/ OBESITY

A GENERAL INFORMATION

8 Etiologies of Obesity ...................................................................... 83 Richard L. Atkinson

9 Medical Consequences of Obesity ................................................. 93 F. Xavier Pi-Sunyer

XlII

xiv Contents

10 Syndrome X and the Benefits of Weight Loss ............................. 113 Margaret C. Flynn, Samuel Chan, and

George L. Blackburn

11 Obese Patients with Binge-Eating Disorder ................................. 125 Marsha D. Marcus

B TREATMENT

12 Overview and the Future of Obesity Treatment ........................... 139 John P. Foreyt and Walker S. C. Poston II

13 The Role of Physical Activity, Exercise, and Nutrition in the Treatment of Obesity .......................................................... 155

Edward T. Mannix, Jill M. Dempsey, Reed J. Engel, Becky Schneider, and Michael F. Busk

14 Behavioral Treatment of Obesity: New Approaches to an Old Disorder ....................................................................... 173

Thomas A. Wadden and David B. Samer

15 Very-Low-Calorie Diets ............................................................... 201 Edward A. Mascioli

16 Pharmacologic Therapy of Obesity .............................................. 213 George A. Bray

17 Practical Aspects of Obesity Treatments: Combination Therapies ............................................................ 249

Richard L. Atkinson

18 Genetics and Potential Treatments for Obesity ............................ 261 David J. Goldstein and Jose F. Caro

19 Surgery in the Management of Severe Obesity ........................... 273 Peter N. Benotti

20 Treating Obesity in the Physician's Office .................................. 285 David J. Goldstein, Ronald S. Rogers, Richard A. Lutes,

and Roy C. Blank

21 Obesity Treatment: A Team Approach ......................................... 313 Judy Loper, Richard A. Lutes, and Patrick Mahlen O'Neil

22 Barriers to Treatment .................................................................... 331 Arthur Frank

23 Prevention of Obesity ................................................................... 347 Barbara C. Hansen

Index .............................................................................................. 359

CONTRIBUTORS

RICHARD L. ATKINSON, MD • Department of Medicine, University of Wisconsin Medical School, Madison, WI

PETER N. BENOTTI, MD • Department of Surgery, Englewood Hospital and Medical Center, Englewood, NJ

GEORGE L. BLACKBURN • Nutritional Support Services, New England Deaconess Hospital, Boston, MA

Roy C. BLANK • Presbyterian Health Care Center, Monroe, NC GEORGE A. BRAY, MD • Pennington Biomedical Research Center, Louisiana State

University, Baton Rouge, LA MICHAEL F. BUSK, MD • Indiana University School of Medicine, Indianapolis, IN;

The National Institute for Fitness and Sport, Indianapolis, IN JOSE F. CARO, MD • Vice President of Endocrine Research, Lilly Research

Laboratories, Indianapolis, IN WILLIAM P. CARTER· Department of Psychiatry, Harvard Medical School, Boston,

MA; Biological Psychiatry Laboratory, McLean Hospital, Belmont, MA SAMUEL CHAN, MD • Department of Anesthesia, University of Pennsylvania,

Philadelphia, P A JILL M. DEMPSEY • National Institute for Fitness and Sport, Indianapolis, IN SARA ENGBLOOM • Department of Psychiatry, University of Minnesota,

Minneapolis, MN REED 1. ENGEL • National Institute for Fitness and Sport, Indianapolis, IN MARGARET C. FLYNN • Nutritional Support Services, New England Deaconess

Hospital, Boston, MA JOHN FOREYT, PHD • Department of Behavioral Medicine Research, Baylor College

of Medicine, Houston, TX ARTHUR FRANK, MD • Obesity Management Program, George Washington University,

Washington, DC DAVID J. GOLDSTEIN, MD, PHD • Neuroscience Division, Lilly Research Laboratories,

Eli Lilly & Co., Indianapolis, IN BARBARA C. HANSEN • Obesity and Diabetes Research Center, Department of

Physiology, University of Maryland School of Medicine, Baltimore, MD L. K. GEORGE Hsu • Department of Psychiatry, New England Medical Center,

Boston, MA JAMES I. HUDSON, MD • Clinical Neurophysiology Laboratory, McLean Hospital,

Belmont, MA WALTER H. KAYE • Eating Disorders Clinic, Western Psychiatric Institute,

University of Pittsburgh, Pittsburgh, PA JUDY LOPER, PHD • Central Ohio Nutritional Center, Columbus, OH SHAN Lu, MD • Department of Medicine, University of Massachusetts Medical Center,

Worcester, MA RICHARD A. LUTES • Central Ohio Nutritional Center, Columbus, OH EDWARD T. MANNIX, PHD • Indiana University School of Medicine, The National

Institute for Fitness and Sport, Indianapolis, IN

xv

xvi Contributors

MARSHA D. MARCUS, PHD • Western Psychiatric Institute and Clinic, University of Pittsburgh, Pittsburgh, P A

EDWARD N. MASCIOLI· Boston Center of Nutrition, Chestnut Hill, MA JAMES E. MITCHELL, MD • Department of Neuroscience, University of North Dakota

School of Medicine, Fargo, ND PATRICK MAHLEN Q'N ElL • Department of Psychiatry and Behavior Sciences,

Medical University of South Carolina, Charleston, SC F. XAVIER PI-SUNYER, MD • Department of Medicine, St. Lukes-Roosevelt Hospital

Center, New York, NY HARRISON G. POPE, JR. • Department of Psychiatry, Harvard Medical School,

Boston, MA; Biological Psychiatry Laboratory, McLean Hospital, Belmont, MA WALKER S. C. POSTON II, PHD • Department of Behavioral Medical Research, Baylor

College of Medicine, Houston, TX CHERYL L. ROCK, PHD, RD • Department of Family and Preventive Medicine, Cancer

Prevention and Control, University of California, San Diego, CA RONALD S. ROGERS • Eli Lilly & Co., Indianapolis, IN STEVEN J. ROMANO, MD· Department of Clinical Research, Lilly Research

Laboratories, Indianapolis, IN DAVID B. SARWER • Department of Psychiatry, University of Pennsylvania,

Philadelphia, PA BECKY SCHNEIDER • National Institute for Fitness and Sport, Indianapolis, IN THOMAS A. WADDEN, PHD • Department of Psychiatry, University of Pennsylvania

Medical Center, Philadelphia, PA