This study used Q methodology to explore culturally-available constructions of bulimia nervosa.In medical and psychological literature bulimia is commonly described as a mental illness. However, from a social constructionist perspective the meaning of bulimia will always be socially and historically situated and multiple. Thus, there is always the possibility for other understandings or Seventy-seven adults with varying experience of eating disorders took part in this Q methodological study. Online, they were asked to rank-order 42 statements about bulimia, and then answer a series of questions about the task and their knowledge of bulimia. A by-person factor analysis was then conducted, with factors extracted using the centroid technique and a varimax rotation.Six factors satisfied selection criteria and were subsequently interpreted. Factor A, “bulimia as uncontrolled behavior”, positions bulimia as a behavioral rather than psychological issue. Factor B, entitled “bulimia is a distressing mental illness”, reflects an understanding of bulimic behaviors as a dysfunctional coping mechanism, which is often found in psychological literature. Other perspectives position bulimia as about “self-medicating with food” (Factor C), “the pathological pursuit of thinness” (Factor D), “being the best at being thin” (Factor E), or as “extreme behavior vs. mentally ill” (Factor F). These constructions have distinct implications for the subjective experience and behavior of those engaged in bulimic behaviors, with some constructions possibly being more useful in terms of help-seeking (Factor B), while others position these individuals in ways that may be distressing, for instance as shallow (Factor D) or to blame (Factor E).This study has identified a range of distinct constructions of bulimia. These constructions are considered to have implications for the behaviors and experiences of those engaging in bulimic behaviors. As such, further research into constructions of bulimia may illuminate factors that influence help-seeking and the self-perceptions of such individuals. Clinically diagnosable bulimia nervosa can be identified in approximately one in every hundred young women in Western societies ,2. ThereA variety of factors have been implicated in the development and maintenance of bulimia, which can be broadly characterised as biological , psycholconstructions: these are coherent accounts, representations, or ways of thinking about a topic, that circulate widely in our culture [Proponents of social constructionist theory argue that meaning and knowledge are constructed in ongoing processes of social interaction . As such culture . This in culture –32.These different constructions have different real-world implications for the subjectivity of those individuals engaging in bulimic behaviors; social constructionism suggests that they frame feelings, experiences, sense of self and perceptions of one’s own behavior, making certain actions possible, while simultaneously closing down others ,29,33. FResearch driven by social constructionist theory has previously been used to explore some aspects of bulimia. For instance, social constructionism has highlighted the negative relationship between cultural constructions of bulimia and anorexia, with the former having connotations of being out-of-control and disgusting, whereas the latter is partially glamorised and admired –40. EvidIf constructions of eating disorders impact upon the experiences of those engaged in bulimia, with the potential to impact upon behaviours such as help-seeking, it is important to identify and explicate dominant constructions which operate in a particular historical and cultural context . In addiWhile research using social constructionist theory has been important in exploring some of the personal and social meanings of eating disorders, there are limitations. For instance, the focus is often on anorexia or eating disorders more generally, rather than bulimia and bulimic behaviors, specifically ,42. Furtconstruction of the issue can then be contrasted with that of other individuals, who share a different way of thinking about the topic [Q methodology combines both qualitative and quantitative techniques to study the “subjectivity involved in any situation” he topic . In Q mehe topic , p. 180)The strength of Q methodology is drawn from both qualitative and quantitative research traditions , and hasThis paper presents the results from a Q methodological study, which explored constructions of bulimia. While the starting point for this research is that a number of alternative constructions of bulimia exist, the principle of “finite diversity” suggests that the potential range of such constructions is limited by socio-historical forces ,51,55. AThe first step in a Q methodological study is to produce a set of items or statements about the topic that participants will sort. This Q set is derived through exhaustive sampling, so as to be as representative as possible of the opinion domain . ParticiThe participants rank items of the Q set according to their relative agreement or disagreement, such that each statement gains its full meaning only through how it is configured in relation to every other statement . It is tIn creating the Q set, statements should be representative of the different perspectives circulating in the public domain about that topic . A Q setA structured approach was employed to reduce the number of items , conductThe statement refining process resulted in a Q set of 54 items, which was piloted with volunteers using the web-based software Q-Assessor . In respMage = 22, SD = 6, a further three did not provide demographic details), who identified as having at least a general knowledge of bulimia; they were recruited through undergraduate psychology courses. It is standard practice in Q methodology to include individuals in the P set whose viewpoints are of particular significance to the research focus [Mage = 20, SD = 3). They were recruited through advertising on social media and through print material in public sites on university campuses across western Sydney.In Q methodology, recruitment of participants is a strategic, rather than random, process . Particich focus . The firch focus ,4; furthMage = 22, SD = 6). Three participants did not provide demographic details, something that may have been due to technical difficulties associated with online data collection, human error (e.g. missing a question or closing the window early), or to a resistance to providing any personal or potentially identifying information. While this sample size might be considered small for conventional factor analysis, the nature of the statistical technique in Q methodology, where the analysis is inverted, makes this sample perfectly adequate [The final P set of 77 participants ranged in age from 17 to 50  everybody might recognize and consider to be of importance” : a loading is significant if the amount of a Q sort’s variance explained by one factor exceeds 50% of the total variance explained rtance” , as cited in ). Given Interpretation of factors was facilitated by the creation of factor arrays; these are computed for each factor based on a composite of the Q sorts that load on it. By examining the meaning, ranking and overall configuration of statements in these arrays we begin to understand the construction of bulimia associated with that factor. The ranking of statements was compared across factors to determine similarities and points of divergence among the perspectives . Finallyc), with all exceeding the acceptable value of 0.7. In Table The centroid technique extracted seven factors that accounted for 60.5% of the total variance in this study. After varimax rotation all seven factors had eigenvalues in excess of one ≥4.12), however, only six had at least two significant Q sorts. Construct validity for each factor was indicated by the composite reliability coefficient  of being out of control of one’s behavior. Cultural standards of an ideal body shape are deemed to play a large role in bulimia’s development , with people with bulimia seen as being obsessed with being thin (22: +1). Defining participants agreed that while bulimia affects both women and men (40: +4), and may be underestimated in men (31: +2), the desire for a thin body is ranked as being more typically an issue for women (28: +3). As one 18 years old defining participant’s response to a question about the gender disparity associated with eating disorders suggests, “men also care about the way they present themselves, but they do not seem to go to the extremes that women do”. For the perspective associated with Factor A, bulimia is about extremes: while issues with weight and shape are prevalent in our culture, the concerns and behaviors that characterise bulimia are considered to be far more extreme, and distinct from regular dieting and exercise .Participants defining Factor A endorsed the view that the path to bulimia might begin with individuals experimenting with binging and purging behaviors (12: +2), perhaps falsely believing that it will help them achieve their desired body shape, with the notion that this behavior works as a method to eat what you want and stay thin rejected (11: −2). Instead bulimia becomes increasingly severe (3: +4), and individuals lose their self-control (25: +2), becoming unable to stop their behavior (13: −4) and, ultimately, sacrifice their health (37: +1). In this vein, a defining participant (20 years of age) described a friend with bulimia as “they wanted to be thin and weren’t happy with how they looked, ended up in hospital over it”.In the perspective associated Factor A, bulimia is characterised not only by a lack of control over one’s behavior, but also a lack of insight into it, with participants endorsing the view that people with this condition don’t understand why they binge and purge (4: +3). Bulimia is also positioned a distressing experience (1: +2), one from which recovery is desired (16: +3). However, as this requires a person to regain control over their behavior (25: +2), it is deemed to be difficult to achieve. This process, in which bulimia seems to begin with a choice but quickly becomes out-of-control, perhaps make the extent to which these individuals are victims difficult to judge (2: 0).Participants defining Factor A prioritised sociocultural influences, while psychological issues were viewed as secondary , or even rejected entirely, with food and eating not viewed as having any relationship to coping or mood improvement . Thus bulimia is not about gaining control (9: −1), but about being unable to control one’s behavior, to the point of being unable to stop (13: −4). As this perspective considers bulimia in terms of behavior, and the lack of control over ones behavior, the possibility that its underlying nature is biological or psychological is either uncertain or unimportant .Factor B accounted for 12.7% of the study variance. Seven participants had Q sorts that loaded significantly on this factor, with one being a negative relationship. These participants were all women, with an average age of 22.3 years and an age range of 18–37; three reported that they were engaged in bulimic behaviors currently, and another two had other personal experience (i.e. a close friend having bulimia). That one of the defining participants was negatively associated with this factor indicates that two coherent, but highly opposing perspectives on bulimia are subsumed under the one factor . The firThe first perspective that emerged from Factor B was a highly psychological account of bulimia. Defining participants endorsed the view that bulimia is a serious mental illness , distinct from normal practices of weight control and concerns about one’s body shape . While sociocultural pressure for a thin body is deemed to have a hand in its development , the desire for thinness is not positioned as the main issue in bulimia . Rather, participants defining this factor endorsed the idea that bulimic behaviors form as a means of dealing with upsetting issues in one’s life, such as past trauma (10: +1). This view is expressed in the open-response of one of the defining participants (18 years of age) “…for me at least, bulimic behavior isn’t solely due to concerns about my appearance – it’s a method of coping with overwhelming, negative feelings and self-loathing”. Further, as is suggested by this participant’s statement, individuals are considered to have some insight into their condition, and the reasons behind their bulimia, as defining participants disagreed with the idea that people in this state don’t know why they binge and purge (4: −1).In this perspective, bulimia is positioned as a “coping mechanism”; defining participants endorsed the view that individuals may find solace in food (5: +2), and gain a sense of control from bulimic behaviors (9: +3). However, this situation is ultimately deemed to be maladaptive, as the experience of bulimia is positioned as distressing (1: +2), and bulimic behaviors are ranked as being self-punishing (17: +4). As bulimic behaviors both alleviate and contribute to distress, it is difficult to say whether or not people with bulimia want to recover (16: 0).Participants defining the perspective of Factor B slightly endorsed the idea that the personality of the person dealing with bulimia has a role in their condition; they were, thus, likely to be high achievers (18: +1) or impulsive (23: +1). At the same time, and as with many biological illnesses, bulimia is positioned as something that anyone, man or woman, could develop (31: +3), as no predisposing characteristics are necessary (19: −2); an individual does not choose it , has little control over their condition (2: +3), and is unable to just stop it (13: −4).In the second perspective to emerge from Factor B, bulimic behaviors are positioned as a method an individual, most likely a woman (31: −3), uses to lose weight (11: +1). While there may be particular characteristics that make someone more likely to engage in bulimia (19: +2), these are unlikely to be psychological in nature . It is very much something that an individual has control over (13: +4); their choice to engage in binging and purging  is motivated by a desire to improve their appearance (37: +1). As the open-response by the woman (19 years of age), who defined this perspective, indicates, “they like to look skinny to impress men”. This behavior is deemed to be quite shameful (34: +2), perhaps because it is viewed as selfish (24: +3), or because these individuals have failed at restricting their food intake, like an anorexic (14: +3), and binging is therefore a sign of weakness (21: +1). On the other hand, bulimia is not positioned as a serious problem , and is more accepted socially than anorexia (35: +2).Factor C explained 6.9% of total variance with 4 participants significantly associated with this factor, three of whom were women. The average age of these participants was lower than the overall sample at 20.3 years, with a range of 17–25. Two defining participants indicated that they knew a friend who engaged in bulimic behaviors.The participants defining Factor C rejected the notion that bulimia is a mental illness (42: −3). Instead, individuals with bulimia are deemed to be the victims (2: +3) of a culture that basically encourages eating disordered behaviors (32: +2). Defining participants rankings suggest that this may be because of the way thin bodies are idealised (38: +2); therefore, while men experience bulimia (40: +3), from the viewpoint of participants defining Factor C, women are more commonly affected because they are usually under more pressure to be thin . The ubiquity of a culture that provides the preconditions for an eating disorder means, for participants exemplifying this perspective, that all individuals are affected to varying extents; thus while they rejected the idea that there is no standard for a normal relationship with food (30: −2), they did not deem bulimia to be so far removed from commonplace practices of dieting and weight control .While similar sociocultural issues are emphasised in other factors, the perspective in Factor C is distinguished by the important role of food. Defining participants endorsed the view that people with bulimia use food to improve their mood (6: +4), to get a high (20: +2), and to withdraw from problems in their lives (5: +3). Thus food is positioned as having a medicinal quality; one defining participant , in her open-response to a question about how she acquired her knowledge of bulimia, described a friend who “every time she gets angry, she eats a huge amount of junk food, then she regrets it and vomits everything she ate”.using food makes compensatory behaviors necessary in this viewpoint. Thus purging behavior is considered secondary to the disordered eating and seemingly less problematic, as unlike the perspectives for every other factor, participants defining Factor C did not out rightly reject the idea that purging after a large meal was “no big deal” (26: 0). The cycle of binging and purging is something the person with bulimia is ultimately positioned as responsible for (13: +2) and so in order to recover they must regain control of their disordered eating (25: +2). On the other hand, while the idea that bulimia is a serious problem is endorsed in this perspective (36: −4), defining participants indicated that the behaviors are not necessarily distressing (1: −1) and suggested that the reasons behind them are not unknown to the person with bulimia (4: −1). As such, individuals with bulimia may or may not wish to recover (16: 0).According to one of the defining participants  in Factor C, bulimia involves a “struggle between the desire to lose weight and binge eating”. This tension between longing for a particular body (22: +1) and Factor D accounted for 13.2% of the variance and was defined by seven participants. Four of these were women and two were men, with a further participant failing to provide socio-demographic data. The average age of these participants was again slightly lower than the overall average, at 20.5 years (range 18–25). Two of these participants, recruited as first year psychology students, indicated having engaged in some level of disordered, or what they considered to be distressing, eating behavior in the past, though they did not provide specific details. Another participant stated that they had a friend who had experienced both anorexia and bulimia.In the perspective associated with Factor D, the way a thin body is prized in our culture is deemed to be the biggest influence on the development of bulimia (33: +4). In particular, the role of the media in creating this ideal, and then pressuring individuals to attain it, is heavily endorsed in both defining participants ranking of statements (38: +4) and their open-responses: “I think people have it because of the pressure from the media to look a certain way” , “they (Women) want to look ‘skinny’ because according to most of society (mainly the (entertainment) media), only skinny girls are attractive and more feminine” . Thus for participants loading on Factor D, what separates people with bulimia from their normal and healthy peers is that they are overly influenced by these messages, to the point of obsession (22: +2). People with bulimia are also positioned as willing to go to more extreme and serious lengths to attain this physique , trading their health for looking good (37: +2). Therefore, bulimia is conceptualised outside the realm of normal eating (30: −2), dieting and weight management practices (29: +3), and cannot be explained by prevalent socio-historical conditions . This unequivocal stance can be contrasted with Factor C, where bulimic behaviors are not positioned as deviant or abnormal.While the cause of these behaviors might be societal, for the participants defining Factor D, binging and purging constitute a mental illness (42: +3); as one of these participants  suggested, it “affect(s) not just the body, but the mind of the individual as well”. Thus bulimia is deemed to be a distressing experience (1: +1), with individuals becoming the victim of their own extreme desire for thinness (2: +2). This situation of being a victim of one’s desire is perhaps why, for the participants defining Factor D, the extent to which a person with bulimia has chosen to be in that state , or has the ability to get out of it (13: 0), is difficult to judge.In Factor D, defining participants position bulimia as a problem that affects both women and men , and may even be underestimated in the latter group (31: +2). However, the ranking of statements also suggests that, as a thin body is much more a standard of beauty for women, bulimia is likely still more of an issue for them too . Indeed, defining participants’ comments indicate that being a woman puts an individual at risk for bulimia, because women are more “self-conscious” and “sensitive to other people’s thoughts about their weight/shape” , “paranoid about (their) appearance” , and tend “compare themselves to other women” . Therefore the pathological pursuit of thinness, which bulimia is positioned as in Factor D, is something more likely to be engaged in by women.Factor E accounted for 6.68% of total variance and was defined by two participants; both were women, aged 18 and 19 years, and neither indicated having any firsthand experience with eating disorders.susceptible to media and cultural messages; they are victims of these messages promoting a thin body, and the extreme behaviors they use to acquire it. On the other hand, the participants defining Factor E viewed people with bulimia not as victims (2: −1). Rather, these participants endorsed the idea that people with bulimia are seeking control (18: +4), particularly of their bodies because they are determined to be thin . They are methodical in their attainment of this goal, with the idea that people with bulimia are impulsive rejected (23: −3). Bulimia is therefore positioned by the participants defining Factor E as a method that allows individuals to eat what they want while still achieving a thin body (11: +3). Though attempts to be thin become increasingly destructive , the socially valued nature of this goal, and the measured way in which these individuals pursue it, perhaps makes it more difficult in this perspective than others to decide whether a person with bulimia is self-centred (24: 0).This perspective is in some ways similar to Factor D, with bulimia again considered a mental illness involving the extreme pursuit of thinness . However, there are subtle distinctions. For Factor D, those who develop bulimia are positioned as more For the participants defining Factor E, bulimia involves the rigid dedication to being thin, at any cost. While still conceptualised as a mental illness in this account, psychological issues are not viewed as important to either the development or maintenance of bulimia, with the notion that a person with bulimia experiences distress being treated neutrally or with mild disagreement , in contrast to Factor B. On the other hand, the rankings of defining participants suggest that as bulimia becomes worse as time goes on (3: +3), and results in the deterioration of health (37: +2), individuals with this condition generally want to recover (16: +1).Factor F explained 6.11% of the variance with two participants defining this factor; one of these participants was a woman of 20 years of age, while the other was a woman of 21 years who was recruited as part of the group that had engaged in bulimic behaviors. However, she did not label them as bulimia.The perspective of the participants defining Factor F is in some ways similar to that of Factor A, with both positioning bulimia as something one chooses to begin (15: +1), due to pressures within culture . However, while in Factor A bulimia is positioned as a behavioral problem, for those participants defining Factor F, it is conclusively positioned as a mental illness (42: +2). Indeed the ranking of a number of statements by the participants loading on Factor F suggests that it not so much bulimic behaviors that are the issue, but the underlying mental illness. For instance, defining participants suggested purging to be less problematic in this account than in most other factors, though it was still ranked negatively (26: −1). Further, the notion that bulimic behaviors are different from dieting and normal concerns about shape and weight is rejected (20: −2), with the whole notion of ‘normal’ being questioned (30: +3). Bulimic behaviors are also positioned as more socially acceptable than anorexia (35: +3). Thus, while bulimia forms around weight-management behaviors, for the participants defining Factor F, it may not be these behaviors that distinguish a person with bulimia, but other “predisposing characteristics” (19: +4). This idea is supported by one of the defining participants for Factor F, who reported engaging in binging, restricting, purging, and extensive amounts of exercise, but actively denied that they were bulimia or an eating disorder.The factors distinguishing extreme eating behaviors from the mental illness bulimia are deemed to be psychological; defining participants endorsed the view that bulimia provides an individual with a means of coping with difficulties in their life . As such, while for Factor F bulimia is likely underestimated in men (31: +4), an increased concern about physical appearance for men will not necessarily increase the number of men with bulimia (39: −2).While bulimia is positioned as a mental illness by the participants defining Factor F, the notion that it is also an ongoing lifestyle choice (15: +1) receives more agreement here than in any other factor. This may be because people with bulimia are deemed to not really want to recover (16: −2), as bulimia provides not only a method of dealing psychologically with any issues, but also a means of staying thin while being able to eat what you want (11: +1). At the same time, even if a person with bulimia wanted to get better, it wouldn’t be so easy to just stop (13: −3), as the psychological issues involved in this condition make the thought of recovery frightening (8: +2).Some of the statements were ranked in a similar way across factors. A number of items were included to examine individuals’ ideas about the gender disparity often found in statistics on the prevalence of eating disorders . Two staThis research study explored cultural constructions of bulimia using Q methodology. As is anticipated within social constructionist theory, this investigation found that understandings of bulimia were not confined to one singular account, but made possible through a number of alternate constructions. Further, and in line with the Q methodological principle of finite diversity , the numThese constructions differ in a variety of ways, including influencing factors, how bulimic behaviors are positioned, and the extent to which the individual engaging in such behavior is viewed as responsible. By examining the configuration of statements within and across factors, in conjunction with the comments and demographic details of defining participants, a richer and more contextualized account for each factor was produced.In the perspective of Factor A, entitled “bulimia as uncontrolled behavior”, individuals engaging in bulimia lack both control and insight into what they are doing. A potential implication of this construction is that they are unable to stop their behaviour alone, and, therefore, require the intervention of others to recover.On the other hand, for Factor B, bulimia is not just about behaviour, but is the manifestation of an underlying mental illness. This conceptualization is common in both popular and specialized texts  and has That almost half of the participants defining Factor B were women who reported engaging in bulimic behaviors suggests that these individuals may draw upon this construction to make sense of their own experiences. Perhaps, this is because this account offers a way of understanding bulimia that avoids blaming the individual, by positioning it as something separate from the self and outside normal behavior , and gives high priority to emotional/psychological issues and the experience of distress. Thus, an appropriate response to individuals experiencing bulimia is compassion and help. Further, similar to the perspective of Factor A, the potential for a person with bulimia to exert agency, or recover alone from their condition, is foreclosed upon, as it is positioned as something outside of their control.The other perspective associated with Factor B, defined by only one participant, has exactly the opposite implications. By positioning a person with bulimia as responsible for their condition, and able to recover if they wish, there is an explicit sense of blame not evident in other constructions, and also no implication that people with bulimia deserve sympathy.For the understanding of bulimia in Factor C, entitled “self-medicating with food”, the mood improving qualities of eating are prioritized; this echoes an area of research that explores pleasure and the negative affect regulating capacities of food in bulimia ,68. ThisThe perspectives of Factors C and D both strongly endorse the influence of culture on bulimia, and particularly the idealization of a thin body; however, they do so to remarkably different effect. For Factor C, bulimic behaviors, in particular purging, are not positioned as especially abnormal or problematic. This can be contrasted with the perspective of Factor D, “the pathological pursuit of thinness”, where bulimic behaviors are viewed as unequivocally deviant. This clear-cut difference between normal and abnormal ties into how bulimia is commonly conceptualized in practice, where the categorical nature of diagnosis suggests that eating disorders are “discrete entities, demarcated by firm boundaries between one another and normality” .The construction of bulimia in Factor E, entitled “being the best at being thin”, there is a more explicit sense of blame, as the person with bulimia is positioned as actively and methodically engaging in behaviors that allow them to stay thin. The endorsement that a certain type of person develops bulimia is also present in research into personality traits and eating disorders . The conFinally in the perspective of Factor F, “extreme behavior vs. mentally ill”, the issue of responsibility is determined by whether an individual is positioned as having the mental illness bulimia, or is simply engaging in behaviors that are culturally categorized as ‘bulimic’. There is a potentially dangerous implication of drawing upon this construction: if bulimic behaviours are not positioned as especially problematic, despite their associated health risk, then the likelihood of seeking help may be minimized.While there are some points of convergence across a number of these perspectives, they remain fairly distinct. Only two issues were perceived similarly across factors: first that bulimic behaviors are also an issue for men, and second that bulimia is serious. The unanimous positioning of men within a construction of bulimia is interesting, and works against the idea that eating disorders are predominately, or only, an issue for women ,73. ThusThis research study has demonstrated that there are a multitude of different ways of understanding bulimia and bulimic behaviors. Social constructionist theory suggests that these different constructions are not inert, but have the potential to impact on the practices of those engaged in bulimic behaviors, and on those around them. That is, by providing a lens through which people understand behavior and experience, different constructions may open up or limit the possibility for certain kinds of actions.range of culturally circulating constructions of bulimia, it would be beneficial for future research to use a more diverse sample, in terms of age, gender and cultural background, as well as knowledge and experience of eating disorders. It would also be useful for future researchers to directly examine the relationship between constructions of bulimia and help-seeking behavior, combining Q methodology with other qualitative and quantitative research methods.The strength of this research lies in its combining of qualitative sensitivity to meaning with robust quantitative statistical analysis, to explore constructions of bulimia. However, it is only a first step. In no way is the sample of participants used in this study representative of the wider population. This is not a major concern for Q methodology, which aims to study constructions in their available diversity, rather than attempting to generalize about the proportions to which these constructions are distributed in the population . HoweverConstructions of bulimia will frame not only the experiences of those engaged in bulimic behaviors but also the experiences and behaviors of those around them. As such, it is important for future research to incorporate other stakeholders, such as family members and health professionals who deal with eating disorders. While it is entirely possible that these groups make use of similar constructions to those identified in this study, this is unknown. Indeed individuals sharing a similar socio-historical location in relation to this issue may draw upon one particular construction, as was the case here for women reporting bulimic behaviors defining Factor B; other studies have found similarly, with particular stakeholder groups becoming associated with one factor perspective (e.g. ).In conclusion, this study has shown that bulimia is not understood uniformly in our culture, but is a concept made sense of through a number of alternate constructions. The six constructions of bulimia that have been identified here share some things in common but have important differences too, such as in how much control/responsibility/blame the person is considered to have for their behavior or illness. These constructions potentially have distinct implications for how individuals engaged in bulimic behaviors think and behave, as well as how those around them may respond to them. As such, further study of constructions of bulimia may be able to provide insights into how and why, or why not, individuals seek help for their bulimic behaviors, and also the success of any treatment. While the assumptions of Q methodology hold that no one construction of bulimia is more valid than any other , some wi


Dietary therapy represents an important tool in the management of chronic kidney disease (CKD), mainly through a balanced reduction of protein intake aimed at giving the remnant nephrons in damaged kidneys a “functional rest”. While dialysis, transplantation, and pharmacological therapies are usually seen as “high tech” medicine, non pharmacological interventions, including diets, are frequently considered lifestyle-complementary treatments. Diet is one of the oldest CKD treatments, and it is usually considered a part of “mainstream” management. In this narrative review we discuss how the lessons of complementary alternative medicines (CAMs) can be useful for the implementation and study of low-protein diets in CKD. While high tech medicine is mainly prescriptive, prescribing a “good” life-style change is usually not enough and comprehensive counselling is required; the empathic educational approach, on which CAMs are mainly, though not exclusively based, may support a successful personalized nutritional intervention.There is no gold-standard, low-protein diet for all CKD patients: from among a relatively vast choice, the best compliance is probably obtained by personalization. This approach interferes with the traditional RCT-based analyses which are grounded upon an assumption of equal preference of treatments . Whole system approaches and narrative medicine, that are widely used in the study of CAMs, may offer ways to integrate EBM and personalised medicine in the search for innovative solutions respecting individualization, but gaining sound data, such as with partially-randomised patient preference trials. Dialysis and transplantation are life-long, life-sustaining treatments requiring multiple drug therapies, and a high technological level of “mainstream medicine” –3. HowevIn this regard, CKD treatments merge technology , which belongs to/“mainstream medicine”, and lifestyle interventions  which are conversely often considered a part of the holistic approach attributed to “complementary and alternative medicine” (CAM).While several comprehensive reviews have addressed the issue of the efficacy of various therapeutic approaches, including diet, to date, no reviews have been dedicated to the relationship between a mainstream and a CAM approach to low protein diets in CKD patients.Indeed, nutritional treatments share these two facets: several recent papers aimed at a vast readership of family practitioners which assessed diverse diseases cite the addition of different foods or the use of specific diets as part of CAM approaches –7.For at least a century chronic uraemia has been considered an example of “protein intoxication”. Thus, in the history of “renal medicine”, diets have been attempted as a way to correct the metabolic alterations of kidney failure as much as possible , 9. IndeAt the beginning of the new millennium, “renal insufficiency” was redefined and CKD became an umbrella term encompassing several affections having variable evolution rates towards end-stage kidney disease (ESRD) –27. The Therapies aimed at slowing CKD progression have to deal with high baseline heterogeneity that hinders the demonstration of their long-term advantages and drawbacks –36. EvenSeveral studies have focused on different therapeutic goals which may partially overlap: these goals include removing the cause of CKD, treating the metabolic derangements, correcting lifestyle habits that are not necessarily consequent to CKD but that may potentially worsen the diseases, and reducing the work-load on the remnant nephrons , 37, 38.Dietary interventions in general, and low protein diets in particular may play a role at all these levels by, for example, treating obesity, correcting hypophosphataemia, avoiding processed foods, and most importantly, reducing the work-load on the remnant nephrons.Furthermore, the outcome measure is non-univocal: slowing the progression of CKD is not synonymous of delaying dialysis .Long-term follow-up of either homogeneous populations with similar baseline progression rates or of very large cohorts is ideally needed to demonstrate an effect of dietary interventions . TheConversely, delaying dialysis requires attaining stable metabolic balance that is, at least partly, independent of GFR. However, the analysis of this short term goal is only apparently easier since it is deeply entangled with the pharmacological “mainstream approach” and reflects various policies of dialysis start which are not merely based upon (relatively) simple measures, such as GFR. The new Canadian guidelines on dialysis start clearly underline that whenever an “intent to defer” policy is chosen, wise clinical judgement cannot be replaced by formulae .Heterogeneity of diseases, heterogeneity of progression, and heterogeneity of goals and measures add to the charm, but also to the complexity of the analysis of dietary approaches in CKD patients. Without a change in the approach, the issue will probably remain open forever.Many of the questions posed in the 1986 paper published in the Lancet entitled: “Dietary treatment for chronic renal failure, ten unanswered questions” are currently still unanswered. Among them, some highlight the complexity and heterogeneity of chronic kidney disease , while others underline the difficulties in standardization of low protein diets in clinical practice  . HoweverThe risk of malnutrition is frequently cited, but the data are at best as inconclusive as those cited by the diet “advocates” –68.Low protein diets are however still underutilized .Table The first reason why the treatment with the best cost-benefit ratio is underutilized in the expensive CKD scenario may be the difference between the amount of time it takes to prescribe a drug or define the parameters of a dialysis treatment , and to recommend lifestyle changes  which are deeply rooted in personal preferences and social habits. In this regard, the barriers for the implementation of LPDs may be the result of the difficulty in conciliating the prescription and follow-up of a diet with a classic “mainstream medicine” approach. Some comments regarding the MDRD study, the largest randomised controlled study on LPDs in CKD, are in line with this interpretation: some experts claimed that MDRD actually demonstrated that prescribing a diet is not enough, since patients tend to lean to the dietary habits of their choice –43. HencThe outstanding results obtained in some centres with a great deal of experience in selecting and following-up patients on low protein diets have rarely been replicated in other settings –59. The Wikipedia, the world’s largest source of on-line information, states “diet is the sum of food consumed by a person or other organism”; however, in clinical practice, the word “diet” is often interpreted with a restrictive (or even punitive) connotation, meaning the reduction of at least some foods , 78. LimThe concept of low-protein diets is presently undergoing a substantial change, mainly as a consequence of the changes in the definition of “adequate” protein intake which has shifted in recent years from 1–1.2 g/Kg/day to 0.8 g/Kg/day, according to the most recent FDA Reference Daily Intake or Recommended Daily Intake , 82. TheA low protein diet is not necessarily a healthy diet; however, the cultural trend towards reducing proteins and canned, preserved and processed foods plays in favour of our patients, for whom the older “moderate” protein restriction (0.8 g/Kg/day) is now synonymous of a “biologically normal/adequate” protein intake, and who may choose a vegan-vegetarian or traditional diet (for example “Mediterranean”) with a lower risk of being “discriminated” in a carnivorous world .Table In the general population, veganism and vegetarianism are not only diets, they are integrated into a philosophy of life. This is a setting in which a mainstream approach (need to reduce proteins) finds a fertile ground in the growing attention to a “healthy” lifestyle and in a philosophy of life which ranges from respect for animals to avoiding diseases –95. HencVegan-vegetarian diets are often discussed together since the distinction between them is relatively new. The term vegan was coined in 1944 by Donald Watson: “vegan” from the beginning and end of vegetarian “because veganism starts with vegetarianism and carries it through to its logical conclusion”. The two definitions were often used interchangeably in the past, however, these diets are different: vegan diets avoid any foods derived from an animal source, including eggs and dairy products –95. The It is thus clear that, beyond the CKD context, the differences are not related to “food” but also to the “concept of food” and, more extensively, to the concept of life –95.It is worth remembering a paper which signalled a new interest in LPDs in CKD patients which appeared about 30 years ago in the BMJ. It dealt with CKD in a group of Buddhist monks as compared with other subsets of Indian CKD patients. The very low protein content was indicated, together with the practice of meditation, as the putative cause of the very low progression rate in the monk population; at that time, the fact that Buddhist monks are vegetarians was not mentioned , 108. CoRegardless of the reason for making this choice, be it medical of personal, the preparation of vegan food is time consuming and attention must be paid to integrating different types of cereals, nuts and legumes into each meal to avoid nutritional deficits; however, provided deficits are avoided, these diets are safe in all phases of life, including pregnancy and lactation –114.Vegan-vegetarian diets are the basis for further integration into different schemes: very low protein (or “0.3”) diets are basically vegan and are supplemented by protein-free foods to supply energy, and by a mixture of aminoacids and ketoacids; a “0.6” simplified scheme has also been developed, with promising results also in elderly, diabetic or pregnant CKD patients –124. SupThe role of supplements is different in “very low” and “low” protein diets: in the former they are needed to avoid protein malnutrition while in the latter, the addition of supplements allows to simplify the dietary scheme in previously omnivorous patients who are “forced” into a vegan regimen, or in patients who do not like protein-rich plant foods, namely legumes.Hippocrates said that food is the first medicine.Humankind has quickly shifted in the last century from relatively low food availability to a higher protein and energy supply. In many traditional diets, including Mediterranean diets or the extensively studied Okinawa diet (from one of the islands with the greatest longevity in the world), animal-derived food is a sort of “nutritional complement” on the basis of an otherwise vegan diet –134. As Adaptation may be difficult in settings where the baseline diet is poor in vegetables, fruits, cereals and legumes; however it should be kept in mind that animal-derived protein content has only recently risen in the “rich” world and that most traditional or “poor” cuisines have a relatively low protein intake –137. TakProtein-free food is an idea that was “made in Italy” and conceived in an era of limited dialysis availability: “protein-free pasta” was invented in the sixties in a search for calorie-rich, protein-poor food .In fact, other natural protein-free, energy-rich foods  could be combined only in very monotonous diets which were extremely difficult to follow especially by patients who were already experiencing the deleterious effects of uraemia and acidosis on both their appetite and on gastrointestinal motility. The systematic use of protein-free food is limited to Italy where these products are available free of charge to CKD patients and where up to half of the protein intake derives from bread and pasta (12 g of protein per 100 g). Replacing these foods allows patients to reach the target protein intake without making any substantial changes in dietary habits –141. In On Google, the term “mainstream medicine” retrieves over 3 million results and there are several different definitions among the first hits. Some of them are tautological and some are centred on “who” practices the medicine: “Medicine as practised by holders of M.D. or D.O. degrees and by their allied health professionals” . Other dDiet or nutritional approaches are never cited within these definitions of mainstream medicine. Conversely, on Medline plus, along with a general definition of Complementary and alternative medicines, CAM is the term for medical products and practices that are not part of standard care. Standard care is what medical doctors, doctors of osteopathy, and allied health professionals, such as nurses and physical therapists, practice. Dietary supplements are cited, while natural products are in first place in the classification of CAMs in the National Institute of health website , 151.The concept of diet may however be different in mainstream and complementary medicine: in the first case, it is usually based upon specific, measurable prescriptions, while in the second case it is more commonly part of a lifestyle, often with emphasis on disease prevention . The limThe use of these terms is probably not only a semantic exercise: diet is often cited as an alternative to early dialysis or as a treatment that is complementary to ACE-inhibition or to other drug therapy  , 158–161In the era of personalised medicine, we might wonder whether a randomised controlled trial is the best way to demonstrate the effects of changes in dietary habits and, more than this, if it is ethically sound to randomise such an intrusive lifestyle change –169.In this regard, mainstream medicine should reflect on the lesson learned from CAMs and the focus might shift from proving the superiority of a single treatment  to an observational multidimensional “whole system” approach , 170–177A very interesting health technology assessment on the role of the preferences of professionals and patients in randomised controlled trials states that “All RCTs in which participants and/or professionals cannot be masked to treatment arms should attempt to estimate the participants’ preferences….” ). CurrenNo study is without pitfalls, and there are sound criticisms to virtually every study design . HoweverIf the focus on diets has to shift from issues regarding effectiveness to those of feasibility, then the implementation strategy should probably be personalized and should take into account the features of each patient . This “nTalking about diet, broadly defined on Wikipedia as “everything we eat”, is extremely complex and no review of a single issue, such as protein intake, can be exhaustive without touching upon other aspects, such as caloric intake, vitamins and oligo-elements, additives and contaminants. In particular, this is crucial in CKD where the presence of kidney disease impairs the activation of vitamin D, leading to a deficient absorption of calcium and to hyperphosphataemia; low-protein diets are usually deficient in vitamin B12, vitamin D, and iron. Conversely, hyper-vitaminosis may be a threat, in particular for vitamin D –194. TheThere is probably at present no best low-protein diet, but, in the absence of contraindications, the best approach is probably to offer the patients a choice of diets with different options and protein content, bearing in mind that the most important issue is not the optimal prescription, but the optimal compliance and target achievement Table .In this regard, the prescriptive approach that deals with low protein diets as it does with drug therapies may be combined with the educational approach that is typical of CAMs by integrating dietary habits into daily life –203.Patients should be aware that there is a high degree of uncertainty with regard to the choice of their dietary treatment and that its aim is to reduce the signs, symptoms and complications of renal failure and then to delay the need for dialysis. Furthermore, even if this is beyond the scope of this review, they should be warned that a low-protein diet is not necessarily a healthy diet, and that several other factors, such as type of renal disease, type of proteins, salt and phosphate intake, use of canned and processed food, and effective energy intake can modulate the risks and the clinical success –196.Long-term interventions that require a profound change in everyday life are difficult to assess, at least with the current study strategies. Clinical research needs long-term observations and long term follow-up, whenever possible even after the start of dialysis, to check for carry-over effects and for attrition biases. Since the report and publication biases suggest that only experienced centres with sound, positive data should publish their series and studies, efforts should be made to build large multi-centre series involving centres with different types of experience on low-protein diets. Multi-centre studies should take into account the important cultural differences in eating habits and cuisine which are often present even within the same country. Both “per protocol” and “intention to treat” analyses may be relevant in chronic interventions and both should probably be analysed , 204.Since it is somewhere between a mainstream prescription and a complementary therapy, the study of diet in chronic kidney disease should merge the suggestions of both approaches. Integration among various study designs that take into account patients’ preferences  is more promising than focussing on a single type of analysis, be it randomised or observational.There is no ideal low-protein diet for all CKD patients.However, on the basis of the present evidence which shows an advantage in terms of dialysis-free follow-up, and a lack of advantage (or even a disadvantage) in early dialysis start, all CKD patients should be offered a “good diet”, or better, an option among various “good diets” since the best one is the one that is truly followed by the patient. The methodological flaws and limitations of the present evidence are probably also linked to the fact that “traditional” RCTs are based upon an assumption of equal preferences that is not applicable to low-protein diets.A diet is not a drug.Diet integration into daily life is highly dependent upon preferences and personal choices, and in this regard, the experience of CAMs may be important for integrating this potentially precious tool into the life of our patients, shifting our efforts from standardization to adaptation, as per the lesson of narrative medicine.These approaches do not clash with classic, evidence-based medicine; on the contrary, they need solid EBM support, integrating the conventional, more rigid study designs, such as RCTs, with new ones, such as whole-systems approaches or partially randomised patient preference trials.


To explore the relationship between pathophysiological factors and premature lung aging in a cohort of community-dwelling subjects in a health-screening setting.16,107 pharmacy customers in Germany  participated in a lung function screening project by providing demographic data, including smoking status and known airway conditions and performing spirometry with a Vitalograph, a spirometry screening device. Lung age was calculated from the spirometric findings, and the difference between chronological age and calculated lung age was analyzed in its relationship to the demographic data in general linear models.1 to some degree, but this apparently had little impact on the detection of association of lung age with pathophysiological factors or the corresponding effect sizes. The most important factors associated with greater lung age based on strength of association were presence of dyspnea, being a smoker, and reporting a history of COPD or asthma. Corresponding effect sizes for the difference between age and lung age were 6.5, 5.7, 13.9, and 8.3 years over the chronological age.In the overall cohort, calculated lung age exceeded chronological age by 10.0 years. Based on the subset of non-smokers not reporting any airway conditions, Vitalograph data in this setting may underestimate FEVThese data confirm the usefulness of screening devices of lung function testing for epidemiological but potentially also for pharmaco-epidemiological studies. We all age, and that is not bad at all because there would be no life without aging. Lung function physiologically declines with aging, but only accelerated aging of the lung, due to inhalation of noxious substances, such as smoking, is bothersome and can lead to morbidity and incapability. Aging is inevitable, but healthy aging with maintenance of a good function can be expected. This requires understanding of the aging process and removal of factors associated with and perhaps even causing unhealthy aging, i.e., premature or accelerated functional decline.Similar to other organs, the lung also exhibits age-associated changes . These i1) and forced vital capacity (FVC); forced expiratory volume in 6 s (FEV6) is a suitable alternative to FVC in studies of lung function  , Nationa1 will be related to that for gender, ethnicity, chronological age, and height-matched predicted value (“% predicted”). By contrast, lung age relates the observed FEV1 to the age for which the measured value equals 100% predicted. A low observed FEV1 of a 48-year-old man  will be now matched to a corresponding higher age . It is assumed that premature lung aging has occurred due to pathophysiological factors. For instance, increased lung age is observed in patients with COPD  and received basic training in its use. During the study period, each pharmacy was requested to offer each customer participation in the study. Study participation was voluntary and anonymous and included both a lung function test on the Vitalograph and completing a case record form. This included subject gender, chronological age, height, population size of home town , presence of cough , presence of dyspnea , smoking habit , presence of allergies , and presence of current airway conditions . For information of the pharmacy and the participant, the case record form provided operational definitions related to cough and dyspnea , a variable also provided by the Vitalograph. These percentage values were converted into absolute values based on the following equations, which are used by the Vitalograph to calculate the percentage values:In most cases, FEV1 is expressed in liters, height in meters, and chronological age in years.In these equations, FEV–n = 395).Vitalograph reading of “!,” indicating a technically invalid measurement (–n = 26).Data missing for gender (–n = 137).Data missing for height (–1 in case record form (n = 869).Data missing for lung age and FEV–1 > reported FEV6 in case record form (n = 1642).Reported FEV–1 value implausible according to gender-specific 5σ-rule (n = 8).Reported FEV–n = 102).Subjects from four pharmacies with implausible values, identified by funnel plot , the following adjustments were made in the database prior to any analysis:–n = 124), smoking (n = 115), allergy (n = 418), common cold , COPD , asthma , dyspnea (n = 471), or other airway disease , this was considered as absence of the condition. For some subjects, this applied to more than one of these variables.If no response was given for presence of cough (–n = 5), or “no” was indicated for smoking but information on number of cigarettes or duration of smoking status was given (n = 5), or “no” was indicated for dyspnea but information on frequency of dyspnea was given (n = 7); in those cases, the “no” was reset to “yes” for plausibility reasons.In a small number of cases, “no” was indicated for presence of cough but positive statements on duration or expectoration were provided .All analyses were performed using 16,107 subjects. In line with the After application of the predefined exclusion criteria, data from 16,107 subjects  were available for analysis. Their demographic and airway-specific data are summarized in Table Cough was reported in 33.8% of the study population, and more than half of those reported chronic cough and/or cough with expectorations Table . Dyspnea1 and FEV6 was 2.33 and 2.91 L, respectively, with men, as expected, exhibiting larger values than women  to determine the linear relationship of FEV1 to height and chronological age in our dataset. This was done by the Global Linear Model procedure in SAS. The resulting coefficients in the equations are similar to those reported by Morris and Temple , subjects reporting it during usual daily activities by average had a 5.0 years older lung age than those with paroxysmal dyspnea. While smokers had a greater lung age than non-smokers (Table n = 4895) neither presence of expectoration nor chronic vs. acute cough had significant contributions.To further explore the impact of additional information on dyspnea, smoking, and cough, the same linear models were applied to the subsets of participants with the respective characteristic Table  and avai1. Accordingly, the difference between lung age and chronological age may be even larger than found here.The present study demonstrates a difference of 10 years between lung age and chronological age in a large cohort of community-dwelling subjects. This is even more remarkable as the calculation of lung age by the Vitalograph is based on the ECSC equations , which, The current study is based on community-dwelling subjects visiting a pharmacy for any reason. While the participating pharmacies were requested to offer study participation to each customer, it is possible that subjects concerned about their lung function may have been more likely to participate than those without. Thus, the pharmacy setting implies that our cohort despite being population based may be biased toward people having health complaints. This possible selection bias needs to be taken into consideration in the interpretation of both the demographic and the lung function data. However, we consider this unlikely to have limited our regression analysis to determine factors associated with lung age as it affects the distribution between healthy and diseased participants as compared to a population-based cohort but should have limited effect on the association between pathophysiology and lung age.1/high lung age does not establish a diagnosis but should rather be seen as stimulus to seek further clarification by a physician.Lung function is known to differ to some extent between ethnic groups with highest values for Caucasians . Our cas1 as compared to the ECSC reference equation , and time between inspiration and forced expiration (time dependence). While participating pharmacy staff had received some training in the correct use of the Vitalograph, it is possible that the overall technical quality of the measurements may have been lower than, for instance, measurements in a physician office . We consequation . While tA final technical consideration relates to the fact that physicians are primarily interested in effect sizes of associations. While we report such effect sizes, our regression models ranked parameters primarily by strength of association. Effect size and strength of association may not be tightly related, as a parameter with great variability in the population may exhibit a large effect size but nevertheless a rather weak association. This may explain why in our analysis, dyspnea had a considerable effect size but only a weaker association as compared to other parameters, as dyspnea is known to be a multifactorial symptom that exhibits great variability in the population. However, irrespective of the underlying cause of dyspnea, be it pulmonary, cardiac, or other, its presence has a negative impact on spirometry.The concept of lung age and its assessment by the Vitalograph have previously mainly been used in the screening for COPD , 17 and Dyspnea is a symptom that can be due to a range of pulmonary, cardiac, and other conditions. It was reported by almost a third of our study participants, of which about half reported it to occur during usual daily activities, such as climbing stairs. This prevalence is similar to that reported in a recent meta-analysis of dyspnea studies in people aged 65 and older . While oBeing a smoker had the second strongest association with greater lung age among candidate parameters in our study. The adverse effects of smoking on lung function are well known  see tex. While tSelf-reported COPD and asthma had somewhat weaker associations with lung aging, but with approximately 14 and 8.5 years had greater estimated effect sizes for the association with lung age than any other parameter see “”. These z-scores in the interpretation of spirometry and abandoning fixed ranges  also supports this view, particularly for older women (1 does not have lower limits to separate physiological from pathological values.Two parameters exhibiting moderately strong associations with greater lung age were chronological age and height. That height showed up as significant factor despite being part of the equation to calculate lung age may indicate that its association with lung age may not be as linear as the equations provided by Morris and Temple  would suer women . That cher women , and henBased on a systematic analysis of the available evidence, the U.S. Preventive Services Task Force has concluded in 2008 that a general screening for COPD based on spirometry was ineffective as it yields many false-positive cases . MeanwhiPK substantially contributed to the development of the data analysis strategy and interpretation of the data, led the search for relevant literature, has critically reviewed manuscript drafts for intellectual content, has approved the version to be published and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. TS contributed substantially to the design of the study, development of the data analysis strategy, and interpretation of the data, has critically reviewed manuscript drafts for intellectual content, has approved the version to be published, and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. TM contributed substantially to the design of the study, development of the data analysis strategy, and interpretation of the data, has critically reviewed manuscript drafts for intellectual content, has approved the version to be published, and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. HS contributed to development of the data analysis strategy and interpretation of the data, has performed the statistical analysis, has critically reviewed manuscript drafts for intellectual content, has approved the version to be published, and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. MM contributed to development of the data analysis strategy and interpretation of the data, has drafted the manuscript and critically reviewed it for intellectual content, has approved the version to be published, and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.In the last 5 years, Peter Kardos served on advisory boards for AstraZeneca, Chiesi, GlaxoSmithKline, Menarini, Novartis, Takeda, and Teva; received lecture fees from AstraZeneca, Boehringer Ingelheim, Cipla, Menarini, Novartis, and Teva; participated in sponsored clinical trials from AstraZeneca, Boehringer Ingelheim, and Novartis, and has been reimbursed for attending scientific symposia from AstraZeneca, Boehringer Ingelheim, Menarini, and Novartis. Tanja Schütt, Tobias Mück, and Martin C. Michel are employees of Boehringer Ingelheim; Helmut Schumacher is a former employee of Boehringer Ingelheim.


A Troublesome Inheritance: Genes, Race and Human History[Recently, I signed a letter to the New York Times. This is not something I do very often, but I felt strongly about the subject. And it wasn’t just me - so did the other 140 or so signatories, all of them population geneticists or human evolutionary biologists. What aroused the ire of this dusty community of academics? A pop science book by Nicholas Wade, A Troublesome Inheritance it does. A later study based on genome-wide SNPs[The objection to the book included its use of the population genetics literature to buttress claims for the existence of five major human races. The influential paper that exaide SNPs is also EPAS1 gene and adaptation to altitude in Tibetans[The book also makes much of the role of natural selection in humans, which is repeatedly described as ‘recent, copious and regional’. Examples are given of the Tibetans, lactaseHomo sapiens europeus, asiaticus and afer:It’s striking that, after its paean to the power of twenty-first century genomics, the book ends up essentially siding with Linnaeus and his 18th century sub-species classifications of Europeans: white, sanguine, muscular, inventive, governed by laws;• Asians: yellow, melancholy, severe, haughty, stingy, governed by opinions;• Africans: black, cunning, phlegmatic, ruled by impulse.• Wade castigates those who claim that race is just a social construct, stating that these deluded folks are leftists and Marxists, and that their views are politically motivated, and not scientific. And he is partly right. Some of the influential writers on this question have indeed been leftists and Marxists. It is difficult, if not impossible, for anyone to entirely divorce their background and political views from their professional life. If they are lucky enough to work on transcriptional control in yeast, for example, this is probably not much of an issue, but human genetics is a different game. By contrast, the heterodox crew who work on the biological reality of race are characterised as ‘courageous’ seekers after truth. But I’d hazard a guess they all have their own social and political baggage, too.A Troublesome Inheritance, we are told that racism and eugenics are Bad Things, that Hitler was a Bad Man, and that ‘opposition to racism is well entrenched’. Many people would beg to differ with that last statement. Racism is alive and kicking , and this book provides succour for racists by using speculation to support the idea that differences between population groups are in their genes. It also avers that linking the ‘success of the West’ to ‘Caucasian’ genetics is not racist, because ‘there is no assertion of superiority’. But from reading this book that is certainly not the message that comes across. Social psychologists have noted a significant increase in a belief in essential differences between whites and blacks as a result of genetic ancestry testing[A Troublesome Inheritance, whatever its author’s motives, will do the same in spades. Its enthusiastic proponents already include some high profile white supremacists and a former Grand Wizard of the Ku Klux Klan.At the beginning of  testing. A Troub


With much interest we read the recent paper by Teichtahl et al. , who gavLoss of water is a feature of disc degeneration. Therefore, disc height or volume is a simple parameter to monitor discal changes in large groups. The data shown in this research, however, suggest that this measure is probably not a clinically relevant parameter. Figure 2b of Teichtahl et al.  shows thTo improve the current golden standard, the relation to physiological parameters can be used as a benchmark. We would like to highlight that several continuous magnetic resonance imaging measures have already been developed, some of which have shown encouraging relations to biomechanical properties and biochemical content, in addition to significant associations with the Pfirrmann Score. Examples of these measures are T1ρ , T2* mapIn conclusion, there is a great need for relevant measures of disc degeneration. However, the results of this study indicate that disc height should not be used as a singular measure for disc degeneration.


Kuru, the first human transmissible spongiform encephalopathy was transmitted to chimpanzees by D. Carleton Gajdusek (1923–2008). In this review, I briefly summarize the history of this seminal discovery along its epidemiology, clinical picture, neuropathology and molecular genetics. The discovery of kuru opened new windows into the realms of human medicine and was instrumental in the later transmission of Creutzfeldt-Jakob disease and Gerstmann-Sträussler-Scheinker disease as well as the relevance that bovine spongiform encephalopathy had for transmission to humans. The transmission of kuru was one of the greatest contributions to biomedical sciences of the 20th century. Kuru is a disease that will forever be linked with the name of D. Carleton Gajdusek ,9,10,11.i.e., infectious is a microbiological term)  eating close relatives in mourning rites,[…] At one rather casual stage of hypothesizing, we wondered whether cannibalism without infection might be involved by a mechanism of hypersensitivity. […] Robert Glasse has quoted this as the only mention of cannibalism he found in our publishing writing. That this should have been the case, however, indicates not the prior absence of idea, but rather its complete its complete obviousness.” Some authors even denied the very existence of cannibalism  The lesions in the goat seem to be remarkably like those described for kuru. […] All this suggests to me that an experimental approach similar to that adopted for scrapie might prove to be extremely fruitful in the case of kuru. […] because I’ve been greatly impressed by the intriguing implication, I’ve submitted a letter to The Lancet.”“On July 21, 1959, while in New Guinea, Gajdusek received a letter from the American veterinarian, William Hadlow, at the Rocky Mountain Laboratory in Hamilton Montana ,71,72,73”, and took up Hadlow’s recommendation to hold small laboratory rodents and  apes and monkeys for longer periods of observation than had been thus far been carried out. He also renewed attempts to obtain optimal tissue for inoculation from rapidly autopsied kuru patients . although several of the inoculated primates died of acute infection during the period of observation, […] none has developed signs suggestive of chronic neurological disease until the recent onset in two chimpanzees . The fir.”In 1961, Gajdusek presented a lecture at the Xth Pacific Science Congress in Honolulu entitled “Kuru: an appraisal of five years of investigation. With a discussion of the still undiscardable possibility of infectious agent” in which he said: “In spite of all the genetic evidence, both the pathological picture and the epidemiological peculiarities of the disease persistently suggest that some yet-overlooked, chronic, slowly progressive, microbial infection may be involved in kuru pathogenesis. Similar suspicion prevails in our current etiological thinking about a number of less exotic and less rare chronic, progressive degenerative diseases of the central nervous system in man. Thus, […], amyotrophic lateral sclerosis, Schilder disease,leukoencephalitis, Koshevnikoff’s epilepsy syndrome in the Soviet Union, the Jakob-Creutzfeldt syndromes, acute and chronic cerebellitis, and even many forms of Parkinsonism, especially the Parkinsonism dementia encountered among the Chamorro population in Guam, continue to suggest the possibility that in man there may be infections analogous to the slow infections of the nervous system of animals which were intensively studied by Bjorn Sigurdsson, the Icelandic investigator who formulated the concept of “slow virus infections” ”. This contention preceded the discovery of kuru transmissibility by more than 4 years . ParenthKuru incidence increased in the 1940 and 1950s ,86,87,88The still baffling, unresolved problem of the etiology of kuru in the New Guinea Highlands has caused as to wonder whether or not any or many of the unusual features of its epidemiological pattern and its clinical course may not be changing with time, or even altering drastically under the impact of extensive rapid cultural change, the result of ever increasing inroads of civilization upon the culture of the Fore people”. This was indeed the case. The comparison of total number of deaths from kuru in the period 1961–1963 and 1957–1959 showed a 23% reduction, and among the children, 57% reduction and the kuru mortality rates dropped from 7.64 to 5.58 deaths per thousand. These alterations were not uniform, the North Fore reduction exceeded the South Fore reduction and it is worth recalling that the South Fore kuru deaths accounted for 60% of the total. This trend has tended to be observed until the disappearance of kuru epidemic  periods of sullen apathy were often interrupted by outbursts of furious screaming”,prodromal period characterized by earliest alterations in behavior; animals became inactive, sometimes “extremely dirty” and submissive. “b)like [..]in slow-motion cinema”.Period of minimal disabilities characterized by minor motor dysfunction; animals did not want to go outside cages, “to run or to climb”, they were slow and fell with forced movements; the movements were “2. Intermediate stage (II)quadrupedal – “knuckle walking” where animals placed hands on the ground not with palms but with knuckles and this pattern is preserved but the gait itself is grossly ataxic and dysmetric. Truncal titubation, so characteristic for human kuru, is present since stage II. Passive muscle tone is increased and flexion contractures may develop if an animal lives long enough. Severe coarse tremor is seen, choreiform movements are observed and the negligence develops. Difficulties in seeing, lateral nystagmus and intermittent left strabismus was seen. “Babinsky” sign was occasionally observed. The onset of this stage was characterized by difficulties exhibited when a chimp tried to rise from a supine position; gait became ataxic but animals still could sit. The gait of chimpanzees is 3. Late stage (III)Characterized by severe neurological deficits: they could not rise by themselves from a supine position, they could not sit but placed themselves in one position, and decubitus ulcers were common. They eat inedible objects. A severe startled response comprising flexion of all extremities accompanied by violent coarse trembling of all limbs was a characteristic finding.The transmission of kuru to chimpanzee  won a NoKuru neuropathology in chimpanzees was described by late Elisabeth Beck and Daniel ,110,111.I was still very young when I saw [kuru] and even after we treated it there was no help. Everyone was falling apart. [Kuru victims] were aware there was no cure and that they would die. It wasn’t just one person that this sickness came to – there were about three in a house line and then after they died there would be another three. It was…ongoing…there were many deaths. Once a [person]…was affected by kuru [their] family would think that the clan had poisoned [them] and they would start…shooting at each other and that made it worse. It was chaos ! (Taurubi) .“wokabaut yet; i.e., is still walking”, sindaun pinis; i.e., is able only to sit” and slip pinis; i.e., is unable to sit up”)  She barely moves and is weak and wasted. Her pressure sores may have spread widely to become huge rotting ulcers which attract a swarm of flies. She is unable to speak. The jaws are clenched and have to be forced open in order to put food or fluid in. […] Despite her mute and immobile state she can make clear signs of recognition with her eyes and may even attempt to smile”. It is worth mentioning incredibly strong support given by Fore to dying kinsmen. “The family members live with the dying patient, siblings sleep closely huddled to their brother or sister in decubitus, parents sleep with their Kuru-incapacitated child cuddled to them and a husband will patiently lie beside her terminal, uncommunicative, incontinent, foul smelling wife” .et al. in 1959 [The first systematic examination of kuru neuropathology (12 cases) was published by Klatzo  in 1959 ,126. Macet al. [small spongy spaces”, were noted in 7 of 13 cases studied by Beck and Daniel [Neurons were shrunken and hyperchromatic or, pale with dispersion of Nissl substance or contained intracytoplasmic vacuoles  similar et al. ,126, butd Daniel ,110,111.et al. [“A peculiar hereditary disease of the central nervous system in a family from lower Austria”  was mentioned by Neumann et al. [The most striking neuropathologic feature of kuru was the presence of numerous amyloid plaques found in 6 of 12 cases studied by Klatzo et al. ,126, andet al. ,111; theet al. ,132,133.et al.  as “A pen et al.  who was n et al. . et al. [Renewed interest in kuru pathology has been provoked by appearance of a novel form of CJD, variant CJD, characterized by numerous amyloid plaques, including “florid” or “daisy” plaques – a kuru plaque surrounded by a rim of spongiform vacuoles . To thiset al. ,140 examet al. [et al. [There are no ultrastructural observations on kuru in humans except those in a paper by Peat and Field  who descet al.  and Beck [et al.  found sed  was present not only as kuru plaques  and STMN2 (the gene encoding SCG10) [Even after 40 years, the summary of the genetics of kuru written by Michael P. Alpers  is still9Met Met . Furtherge group ,152,153.s et al. , McLean  [et al.  and us [ [et al.  were allg SCG10) .Met Met or 129Val Val) is overrepresented in kuru [et al. [Met Val) at codon 129, which is consistent with the interpretation that 129Met Val makes an individual resistant to TSE agents and that such a resistance was selected by cannibalistic rites. Another protective polymorphism G127V located in a highly conserved region of PrP was discovered by the Collinge’s group [Val was not found in any of kuru patients. Because of this 129Met Val heterozygote advantage, it has been suggested that the heterozygous genotype at codon 129 has been sustained by a widespread ancient practice of human cannibalism [et al. [PRNP 129Met Met heterozygotes provides a basis for a selection pressure not only in Fore but also in those human populations that practiced cannibalism. Of note this was preconceived by Alpers and Gajdusek in 1965 “In order to explain the combination of high incidence and high lethality, which at first glance might seem to entirely rule out a genetic cause unless there was an immense heterozygote advantage, we postulated that environmental change, of relatively recent origin, has given a lethal expression to a previously benign gene mutation established in the Fore population as a genetic polymorphism” [.The practice of endocannibalism underlying the kuru epidemic created a selective pressure on the prion protein genotype ,156. As  in kuru ,152,153. [et al. ,152 foun’s group ,158. Thinibalism . Furthernibalism ,161. Col [et al.  suggesteorphism” .d following digestion with proteinase K [d were found. The human PrPd type 1 and 4 occur only in individuals of the codon 129Met Met of the PRNP gene; type 3 is seen in individuals with at least one Val at this codon and type 2 occurs in all codon 129 variants. There is another classification based on only 2 PrPd types [Met Met) or 3  PrPd patterns and the glycoform ratio was similar to that of sporadic CJD but not typical for vCJD [i.e., coarser vacuoles situated in the subcortical structures and in deeper layers of the cerebral cortex was observed. PrPd consisted of doublet of 20 kDa and 21 kDa. The latter notion is supported by the fact of a similar transmission rate of kuru to transgenic mice lacking mouse PrP gene but expressing human Val ValPrP 129 gene [d in follicular dendrititic cells in the spleen suggests a possibility of the spreading of the kuru agent via the bloodstream. Collectively, those data suggest that kuru is unique and different from either sporadic CJD or variant CJD. The molecular strain typing of kuru cases was performed by the Collinge’s group ,163. Thieinase K . The fouPd types  and the for vCJD ,165,166.Val gene ,163. In Val gene  (Figure Kuru, an extinct exotic disease of a cannibalistic tribe in a remote Papua New Guinea, still impacts on many aspects of neurodegeneration research. First, it showed that a human neurodegenerative disease can result from an infection with an infectious agent, and then be called a “slow virus” . This di