Use of Diet Pills and Other Dieting Aids in a CollegePopulat.docx

Use of Diet Pills and Other Dieting Aids in a College
Population with High Weight and Shape Concerns
Christine I. Celio, MA1
Kristine H. Luce, PhD1
Susan W. Bryson, MS1
Andrew J. Winzelberg, PhD1
Darby Cunning, MA1
Roxanne Rockwell, BA2
Angela A. Celio Doyle, PhD3
Denise E. Wilfley, PhD2,4
C. Barr Taylor, MD1*
ABSTRACT
Objective: The current study examines
diet aid use among college women at
risk for eating disorders and explores
characteristics associated with diet aid
use.

Method: Participants were 484 college
women <30 years from 6 universities in
the San Francisco Bay Area (SF) and San
Diego who were at risk for developing
eating disorders. A checklist assessed
diet pill, fat blocker, diuretic, laxative,
and other diet aid use over the past
12 months.
Results: Thirty-two percent of the col-
lege women reported using a diet aid.
Diet aid use was double the rate in San
Diego (44%) compared with SF (22%) ( p ¼
.000). Weight and shape concerns were
higher among diet aid users than among
nonusers across sites.
Conclusion: A significant number of
college women at risk for eating disor-
ders are using diet aids. We recommend

that clinicians inquire about diet aid use
among college-aged patients. VVC 2006 by
Wiley Periodicals, Inc.
Keywords: diet aids; diet pills; college
women; high risk
(Int J Eat Disord 2006; 39:492–497)
Introduction
College women report high levels of body dissatis-
faction and weight concerns.1,2 Concerns about
one’s weight, dieting, and related behaviors are so
prevalent among college-aged women that they
often are considered to be a normative part of the
female college experience.2,3 For instance, in a
study of female college freshmen living in resi-
dence halls, >40% of women who were surveyed
were classified as casual dieters.4 Among a sample
of incoming female freshmen college students at-
tending a summer orientation, approximately 27%
reported dieting for weight control and 22% char-
acterized their dieting as always or often.5 In a pop-
ulation of high school and college women, Tylka
and Subich6 found that many young women re-
ported skipping meals (59%), eating <1,200 calories
a day (37%), eliminating fats (30%) and carbohy-
drates (26.5%) from their diets, and fasting for
>24 hr (26%).
Not only do college women diet by restricting

their caloric intake or avoiding certain categories of
food, but many women also report using over-the-
counter pills, herbal remedies, supplements, laxa-
tives, and diuretics to aid dieting efforts. Many types
of diet aids exist, including traditional diet pills or
appetite suppressants, home remedies such as
apple cider vinegar, and actively dangerous herbal
supplements such as ephedra.7 Diet aid use is con-
sidered to be risky because the safety and efficacy
of diet aids are unknown and are not evaluated by
the U.S. Food and Drug Administration.8 Accurate
information about diet aids is limited and Internet
sites make dubious claims of effectiveness and
safety. In 1998, approximately 2% of adult men and
3% of adult women reported using diet pills and 1%
of men and 2% of women reported using diuretics
to assist them with weight loss.9 In a more recent
study, 7.9% of normal weight adult women reported
using nonprescription weight loss products, includ-
ing dangerous products such as phenylpropanol-
amine (PPA) and ephedra,10 indicating a possible
increase of diet aids in the U.S. adult population
and the introduction of more harmful products.
Several studies have been conducted to deter-
mine the prevalence of diet aid use among college
Portions of the current article were presented at the annual
meeting of the Academy of Eating Disorders, Orlando, Florida,
April
29–May 2, 2004.
Published online 5 May 2006 in Wiley InterScience

(www.interscience.wiley.com). DOI: 10.1002/eat.20254
VVC 2006 Wiley Periodicals, Inc.
1 Department of Psychiatry and Behavioral Sciences, Stanford
University, Stanford, California
2 Center for Eating and Weight Disorders, San Diego,
California
3 Department of Psychiatry, The University of Chicago
Hospitals,
Chicago, Illinois
4 Department of Psychiatry, Washington University School of
Medicine, St. Louis, Missouri
Accepted 31 May 2005
*Correspondence to: C. Barr Taylor, MD, Department of
Psychia-
try and Behavioral Sciences, Stanford University, 401 Quarry
Road,
Stanford, CA 94305-5722. E-mail: [email protected]
492 International Journal of Eating Disorders 39:6 492–497
2006—DOI 10.1002/eat
REGULAR ARTICLE
women. Tylka and Subich6 found rates of laxative
(7.2%) and diuretic use (6.6%) for the purposes of
weight control within a combined college and high

school sample. Another study of college women
found that approximately 28% of women indicated
that they have combined the use of diet pills, diet
powders, and dieting (using methods to restrict
caloric intake) at any 1 time and 3% reported laxa-
tive use for weight control.11
From these studies, there is ample evidence that
general samples of college women engage in diet
restriction and use extreme weight control methods
at high rates. However, the use of diet aids among
women with high weight and shape concerns has
not been directly assessed and knowledge of these
behaviors could help inform prevention and treat-
ment efforts.
The first aim of the current study was to examine
diet aid use in a large sample of college women
with high weight and shape concerns. The second
aim was to explore demographic and psychosocial
characteristics associated with higher diet aid use
in this group.
Method
Recruitment
Study participants were recruited via flyers, college
newspaper advertisements, and e-mail solicitations sent
out by student health centers. Potential participants who
expressed interest in participating in a body image
enhancement program completed an on-line Weight and

Shape Concerns (WCS12) screening questionnaire. Poten-
tial participants with a WCS score of 50, participants who
answered ‘‘moderately’’ or ‘‘very’’ on Question 2 (i.e.,
‘‘How afraid are you of gaining 3 pounds?’’), or partici-
pants who answered ‘‘more important than most, but not
all, things in my life’’ or ‘‘most important’’ on Question 4
(i.e., ‘‘Compared to other things in your life, how impor-
tant is your weight to you?’’) were invited to participate
in a randomized study designed to determine if an inter-
active Internet-delivered intervention would prevent eat-
ing disorders. Informed consent was obtained from inter-
ested and eligible students after the screening question-
naire. The study was approved by the human subjects
committees at each of the participant institutions and by
the human subjects committees at Stanford University
and San Diego State University.
Participants
Participants were 484 undergraduate women from 3

private and 4 public universities in San Diego (n ¼ 228)
and the San Francisco Bay Area (n ¼ 256) in California.
Eligible participants were women 18–30 years of age,
women at risk for developing eating disorders based on
high scores on the WCS,12 and women who had a body
mass index (BMI; kg/m2) >18 and a BMI <32. Students
were excluded from participation if they met clinical cri-
teria for an eating disorder as defined in the 4th ed. of the
Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV; Washington, DC: American Psychiatric Associa-
tion; 1994),
13
were actively suicidal, had a level of psy-
chopathology that would interfere with their participa-
tion, were >18–30 years, and were obese (�95% for their
height/weight). Other exclusion criteria included not
being in the area, being unavailable for follow-up, being
at low risk for an eating disorder, having a high frequency
of vomiting, binging, or fasting, or abusing laxatives, diu-

retics, alcohol, or drugs. Laxative and diuretic abuse con-
sisted of >3 times per month on average for the last
3 months or >4 times in any month. Eligible participants
were randomized to the intervention or control groups.
Students who met clinical criteria for a DSM-IV eating
disorder14 were referred to appropriate clinical programs.
Women who reported current prescription medication
use for mood or anxiety disorders were included if their
medication had been stable for �2 months and were not
disqualified using other exclusion criteria. Women with
major depression were included on a case-by-case basis
by the principal investigators.
Initially, 4,993 people responded, with near equal
numbers at both sites, and 4,375 were excluded. Of those
excluded, 1,249 received no further contact and 1,324
were ineligible based on exclusion criteria, 1552 declined
to be part of the study, and 250 were unable to partici-
pate. Of those invited for the assessment (n ¼ 641), 161
were excluded, 28 for aforementioned exclusion criteria,

91 because the baseline assessment was not completed,
26 for other reasons, and 16 dropped out before random-
ization. Each site had similar numbers of ineligible
women based on exclusion criteria. Assessments were
completed before randomization into the larger study.
Screening Criteria
The WCS12 was used to screen for at-risk students. The
WCS consists of 5 questions that assess worry about
weight and shape, fear of gaining 3 lb, last time the
respondent went on a diet, the importance of weight,
and feelings of fatness. The items were derived from
principal components analysis (PCA) of a set of self-
report questions used to assess eating disorder symp-
toms.12 It is significantly correlated with the Eating Dis-
order Inventory (EDI14) overall and Body Dissatisfaction
subscales.15 The WCS has a test-retest reliability of
approximately .85, a 1-year stability of approximately r ¼
.75, and good predictive validity.
15,16

Two prospective
studies demonstrated that adolescents with high scores
USE OF DIET PILLS AND OTHER DIETING AIDS
International Journal of Eating Disorders 39:6 492–497 2006—
DOI 10.1002/eat 493
in the upper 25th percentile of the WCS were much more
likely to develop a subclinical or clinical-level eating dis-
order than were students in lower percentiles.
15,16
A WCS
score �57 represents approximately the upper quartile of
scores. An ROC analysis of a subset15 of 1 sample found
that a WCS score �47 had a sensitivity of 79%, a specific-
ity of 67%, and positive predictive value (PPV) value of
13% for identifying adolescents who developed partial or
full-syndrome eating disorders.17 All participants were
interviewed with the Eating Disorder Examination.
17
Measures
Diet Aids Checklist (DACL). The DACL was created for

the purposes of the current study and included a com-
prehensive list of over-the-counter diet aids. Google
searches were conducted in the fall of 2000 using the
terms diet aid, fat blocker, and diet pills to identify prod-
ucts. The DACL obtained a 12-month history of diet aid
use listed by brand names and separated in categories as
defined by the manufacturer (e.g., laxatives, diuretics,
diet pills, fat blockers). Diet aids that did not fit into a
clear category were grouped as other. Participants were
allowed to write in the name of any diet aid they had
used that was not listed in the DACL.
WCS. The WCS is a five-item questionnaire that assesses
concern about weight and shape, fear of gaining weight,
dieting frequency, importance of weight, and feelings of
fatness.
12
Scores range from 0 to 100, with higher scores
representing greater weight and shape concerns. A WCS

score >47 suggests high risk for the development of an
eating disorder.16 Good stability has been reported for
this measure at 7-month and 1-year intervals (test-retest
reliability r ¼ .71 and .75, respectively),12,15 and predictive
validity has been established.12
Center for Epidemiologic Studies Depression Scale
(CESD). The CESD18 is a 20-item self-report questionnaire
that was developed to assess depression in the general
population. The CESD has high internal consistency (a ¼
.89 with patients with cancer19) and adequate test-retest
reliability.
Brief COPE. The brief COPE20 is a 14-item self-report
questionnaire adapted from the original 60-item version
that assesses how people cope with stressful life events.
Two items assessing substance use coping were used in
the current study (i.e., ‘‘I use alcohol or other drugs to
make myself feel better’’ and ‘‘I use alcohol or other
drugs to help me get through it’’). Reliability and validity
data have reported Cronbach alpha coefficients s ranging
from .50 to .90.20

Anthropometric Data. Weight was determined using a
digital stand-on scale or a calibrated, balance-beam
scale. Participants wore light indoor clothing without
shoes or coats. Height was measured using a stadiometer
using standard procedures.
Analytic Plan
Rates of diet aids use by geographic location were
examined using chi-square analysis. Analyses of variance
(ANOVAs) were used to compare mean scores on contin-
uous measures (i.e., BMI, age, weight and shape con-
cerns, and the use of drugs/alcohol to cope) between
those who used diet aids and those who did not. Finally,
an ROC analysis was performed to identify combinations
of characteristics that distinguished those two groups.
Results
The mean age of the participants was 21 years (SD
¼ 2.6) and their mean BMI was 23.8 (SD ¼ 3.1).
Sixty percent identified themselves as White, 17.0%
as Asian/Pacific Islander, 10.0% as Hispanic, 7.0%
as multiethnic, 2.0% as African American, 0.4% as

Native American, and 3.6% as other. Across sites,
32.4% (n ¼ 157) of women reported using �1 diet
aid in the past 12 months. The percentage of
women in San Diego who reported using diet aids
(44%) was twice the percentage of women in the
San Francisco Bay Area (22%) (p ¼ .01). In both
sites, the majority of women who reported using
diet aids used diet pills (65.4%). Nearly one fourth
of the women (24.8%) used diet aids that were not
identified on the DACL, 17.2% used laxatives, and
4.5% used fat blockers. Although the San Diego par-
ticipants used diet pills more than the participants
in the San Francisco Bay Area, laxative use and fat
blocker use were similar (Figure 1). Of the 157
women who reported using diet aids, 75% reported
using only 1 type of diet aid, 21% used 2, and
4% used �3 types of diet aids within the past
12 months.
WCS scores were higher at both sites among
women using diet aids. In San Diego, on average,
women using diet aids had WCS scores of 67.5 (SD ¼
11.9), which was 7.2 points higher than the average
WCS scores of women not using diet aids (p < .01).
In the San Francisco Bay Area, women using diet
aids, on average, scored 65.4 (SD ¼ 13.1), 6.1 points
higher than their nonusing counterpoints (p < .01)
(Table 1). Also, women who used diet aids reported
significantly higher rates (p < .01) of drug and alco-
hol use to cope with difficulties or problems in their
CELIO ET AL.
2006—DOI 10.1002/eat

lives. Diet aid users in both sites had significantly
higher BMIs than non-diet pill users (p � .05).
Participants were further grouped by overweight
(BMI � 25) and normal weight (BMI � 24). Stu-
dents classified as overweight in San Diego reported
higher rates of diet aid use compared with over-
weight students in the Bay Area or with normal
weight students in either location.
To determine the characteristics of women who
used diet aids compared with nonusers, baseline
variables (i.e., geographic location, BMI, use of
alcohol and drugs for coping, and weight and
shape concerns) were entered into an ROC analy-
sis. As expected, the first factor was region. Within
the San Diego region, 79% (27 of 34) of women
with a very high WCS score (WCS > 68) and a BMI �
25 used diet aids compared with 50% (22 of 44) of
women with equally high WCS scores and a BMI �
24. For women with WCS < 68 and who were sopho-
mores or above in school, diet pill use was 46% (44
of 95). However, for freshmen, the rate was 14% (8
of 55).
FIGURE 1 [Color figure can be viewed in the online issue,
which is available at www.interscience.wiley.com.]
TABLE 1. Characteristics of women with high weight and shape
concerns who use diet aids by region

San Francisco Bay Area San Diego Area
No Diet Aids
(n ¼ 200)
Diet Aids
(n ¼ 56)
No Diet Aids
(n ¼ 127)
Diet Aids
(n ¼ 101)
M M M M
BMI (kg/m2)* 23.6 (2.7) 24.1 (3.6) 23.4 (3.2) 24.4 (3.0)
WCS** 60.3 (13.1) 67.5 (11.9) 59.3 (12.1) 65.4 (13.1)
EDE-Q Eating Concerns* 1.5 (1.1) 1.6 (1.1) 1.3 (0.9) 1.6 (1.1)
EDE-Q Shape Concerns* 3.4 (1.1) 3.4 (1.2) 3.3 (1.1) 3.8 (1.1)
EDE-Q Weight Concerns* 2.9 (1.1) 3.2 (1.2) 2.8 (1.1) 3.1 (1.1)
EDI Drive for Thinness** 27.2 (6.5) 29.4 (6.2) 27.5 (6.8) 29.7
(6.6)
COPE-Substance Use** 1.3 (0.5) 1.6 (0.7) 1.3 (0.6) 1.3 (0.6)
CESD* 18.4 (6.0) 21.0 (7.3) 19.5 (6.4) 19.2 (7.3)
Note: M ¼ mean; BMI ¼ body mass index; WCS ¼ Weight
Concerns scale; EDE-Q ¼ Eating Disorder Examination-
Questionnaire; EDI ¼ Eating Disorder
Inventory; CESD ¼ Center for Epidemiologic Studies
Depression Scale.
* p � .05. ** p < .01, for overall analysis of variance.

DOI 10.1002/eat 495
The ROC analysis also found different factors de-
fining higher diet aid use groups in the two regions.
In the San Diego region, higher use occurred among
students with very high WCS scores. A BMI > 25 fur-
ther increased the prevalence of diet aid use. For
those with moderately high WCS scores, higher rates
of diet aid use were found in women �20 years
compared with 18-year-olds and 19-year-olds.
Conclusion
A significant number of young women at risk for
eating disorders use nonprescription, over-the-
counter diet aids, and of the different aids, diet pills
are most commonly used. Diet aid use varied by
region, with students in the San Diego area using
diet aids at twice the rate of those in the San Fran-
cisco Bay Area.
In the San Francisco Bay Area region, the use of
drugs and alcohol as a coping strategy was associ-
ated with much higher rates of diet aid use. It is
possible that those who seek out substances to
cope with problems are more comfortable trying
diet aids or vice versa.
The reasons for these regional differences are not
certain. A number of reasons may explain the
higher rates of diet aid use in the San Diego area.
For example, there may be greater peer pressure to
use diet aids or there may be a more normative

attitude towards diet aids, diet aids could be more
available, and/or more advertising space could be
dedicated to diet aids in the San Diego area. Racial
representation was similar at both sites, with
slightly more Asians (18.6% vs. 15.0%) and multi-
ethnic/other/unknown women (12.3% vs. 17.9%) at
the San Francisco Bay Area site and more Hispanic
women at the San Diego site (13.7% vs. 7.5%).
The San Francisco Bay Area and San Diego had
different school compositions that could be poten-
tially confounding. Of the schools form which par-
ticipants were recruited, the public school popula-
tion in the San Diego area had a combined total of
56,000 students and the private school in San Diego
only had 7,000 students. In the Bay Area schools,
the public schools had a combined total of 62,000
students and the private schools had a combined
student population of approximately 22,000. Partic-
ipants from the San Francisco Bay Area comprised
166 women from private schools and 87 women
from public schools. The San Diego site had
213 women participating from a public school and
only 14 from a private school.
The private schools at each site were more likely
to have freshmen and upperclassmen live on cam-
pus and had smaller student bodies. From these
data it is possible to infer that at private schools, of
which the Bay Area drew a larger population, a
larger proportion of women are using diet aids.
Smaller schools attract more homogenous popula-
tions and more normative behavior, especially when
more students live together in campus housing. If it
were normative to not use diet aids, perhaps it could
explain the lower rate at the San Francisco Bay Area

site. Although family income data were not ob-
tained, tuition at the private schools was much
higher than tuition at the public schools, indicating
a possible difference in socioeconomic status that
could produce a confounding difference.
Overall, the rates of diet aid use in this high-risk
group are alarming. The advent of the Internet may
increase the exposure of college women to adver-
tisements related to diet aids and these products are
advertised in city, town, and college newspapers.
Advertisements for diet aids are often misleading
and, at best, overstate the intended effects of the
product, and at worst, do not inform the consumer
of the potential risks. A recent review by the Rand
Corporation found that ephedra plus caffeine, one
of the most popular combinations of ingredients in
diet aids, had little effect on short-term weight loss,
was without evidence for long-term weight loss, and
was associated with serious adverse events.21
Because college women are likely to be con-
cerned with their weight and their shape, we rec-
ommend that health care providers directly ask stu-
dents about their use of diet aids. Eisenberg et al.22
reported that 60% of U.S. adults did not disclose
the use of ‘‘complimentary medicine’’ to their
physicians. A study by Trigazis et al.
23
found that
adolescents with eating disorders frequently use
herbal remedies (e.g., metabolean, ma-huang, gin-
seng, Echinacea) for weight control and non-

weight control purposes and they did not regularly
inform their physicians about their use.
Because of the varied and increasing amounts of
diet aids available on the market, one limitation of
the current study is the likely incomplete list of diet
aids. An increasing number of diet aids are put on
the market each year and because the DACL was
created in 2000, it may have not included some of
the more popular, newer diet aids. Even though
there was a write-in area of the DACL, name recog-
nition might have changed the results. Another lim-
itation could be that because women with high
rates of laxative and diuretic use as found in the
Eating Disorder Examination (EDE) were excluded
from the study, we do not have information on that
CELIO ET AL.
2006—DOI 10.1002/eat
group of women. The exclusion of women with high
rates of use makes the rates in this comparatively
lower risk sample all the more alarming. Also, it was
not until the follow-up stage of the study that we
inquired about the frequency of use of these diet
aids as opposed to overall use, meaning a woman
who used diet pills 1 day during 1 month were put
in a category with women who used them every day
for 1 month. Future studies should evaluate the fre-
quency of use of diet aids, function of use (e.g., for
regular weight management or to compensate for a
binge), and how they are obtained (e.g., Internet,

drug stores, friends, physicians).
The women involved in the current study might
represent a biased sample because although all were
at high risk for developing eating disorders, they
were all motivated enough to seek treatment through
an on-line program billed to improve body image. It
is unknown to what degree non–help-seeking, high-
risk women are using diet aids. Using this motivated,
high-risk group as a guide, however, points to the
importance of health care providers, especially at
college health centers, asking about use and educat-
ing campuses about healthy weight management.
These data demonstrate that college women with
a high risk of developing eating disorders report
high rates of diet aid use. Further research within
the population of the high-risk college women
should be conducted to determine the long-term
effects of these diet aids on the development of
subclinical and clinical eating disorders. In addi-
tion, frequency of use should be examined to see to
what extent these women are using these products.
Also unknown is whether these aids are used for
weight management or whether they are used to
cope with binges or as a purging surrogate. With
much media attention being focused on e-mail
SPAM, it would also be of interest to investigate the
source of information for these products, whether
via the Internet, through SPAM, pop-ups, or through
magazines, drugstores, or friends. Because much of
the information on the health and safety of these
products is unknown, it is important that health care
professionals inquire more often about the use of
diet aids in this population and advise individuals of
the risks of such products.

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