Self-Esteem: A Barometer for the Shift in the Social Acceptance of the Gout Disease

Elevate - The Honor Society Magazine
Self-Esteem: A Barometer for the Shift in the Social Acceptance of the Gout Disease
May 25,2015

Earlier history

            Gout was first identified as a condition by the Egyptians in 2640 BC, and was later a point of interest to Hippocrates in the 5th century BC[1]. The disease – a form of arthritis, is caused by the buildup of uric acid in form of needlelike crystals that accumulate in various joints (but more commonly around big toes), creating severe pain and swelling. Traditionally, gout occurrence has been linked with the aristocracy and with an affluent lifestyle, which gained it the name “Disease of Kings”. This disease was particular to European culture and practically unknown to the Asian societies[2] up to the Industrial Revolution era. Gout was considered noble and socially desirable. Because the disease had prevalence among those who held political and social power (rarely showing among the common folk), exhibiting gout would typically result in an overnight boost of victim’s social worthiness. In popular consciousness, developing gout was also a sign of spiritual superiority. This popular belief was clearly mentioned by the 16th century physician, Geronimo Cardano: “What a man gout makes! Devout, morally pure, temperate, (and) circumspect. No one is so mindful of God as the man who is in the clutches of the pain of gout.”[3] Moreover, gout was seen as being prophylactic for other diseases and even having life-extending properties[4]. On a personal level, the disease would positively impact both one’s beliefs and emotions. Gout conferred its victim a boost in self-worthiness and sense of pride, hence raising one’s social self-esteem.

Modern history

            Moving into the Industrial Revolution, the relation between gout and social status had begun to weaken. Industrialization brought a larger amount of food at lower prices, making high-protein foods available to the masses. Protein was found to hold a high concentration of purine, a substance that was later established to be responsible for hyperuricemia (uric acid buildup); the latter was discovered by the English physician Sir Alfred Garrod to be the “cause […] of gouty inflammations” in the mid 1800’s[5]. With the increase in the wide consumption of red meats, shellfish, beer and alcohol, a direct connection between diet and gout incidence became easier to demonstrate. The hereditary component of the disease was demonstrated significant only in 1967 when it was linked to a purine enzyme deficiency[6].

Although corpulence used to have a predominant favorable view in the Industrial Era, soon after, it became stigmatized for aesthetic reasons. The negative view gained momentum as obesity was shown to increase mortality through diabetes, hypertension, heart or kidney disease[7]. Even further, science demonstrated a direct link between obesity and gout through sugar and fructose rich diets[8]. This has endorsed the popular assumption that a relationship exists between gluttony – a major Christian religion sin, and gout - as in the popular consciousness gout was already associated with “red-faced Dickensian gluttons […] port-quaffing Victorian gentlemen of excess and the obese Henry VIII”[9]. Reluctance among patients to admitting that they had gout often decreased their will to seek medical attention[10], creating inadequate care[11]. The historical positive relationship between gout and self-esteem morphed into its opposite.

A change in self esteem

It is evident that while the cause and expression of the disease have not changed over the time, opposite changes in the self-esteem of the afflicted occurred due in good part to the accumulation of a body of scientific knowledge regarding cause and association with other diseases.

Also interesting to observe is that in the case of gout, although the body image – an important component of one’s self esteem, goes through significant deterioration (major joint pain, redness, inflammation, swollen joints and limited range of motion), it becomes a booster to one’s self-image while there is a social context of acceptance or praise around the disease. It is the entire contrary in a modern society that holds gout as a self-inflicted issue[12] through its association with gluttony. In the modern era, the self-image in relation to gout becomes profoundly affected in a negative way, even though historically, gluttony could have been brought up as an argument against the favorably looked upon gout since the beginning of our era. It seems like just another example of how one’s fortune becomes another’s ruin, although they could be the same victim of the same disease.

What tips the balance between the two views seems to be a combination of both science and socio-economic development. For one part, science brings in a series of findings on gout, proving that there is not much one can do about it (i.e. heredity) or there is maybe not enough that one does (i.e. making significant changes in diet), and also that one could be associating him/herself with overeating/obesity (newer bad modern words already grown in common consciousness). Another part that tips the balance is that the old bi-directional relationship between gout and social superiority (only the smart, rich and powerful get the gout and therefore if you get the disease you must be somehow superior) was dismantled by the realization that the Industrial Revolution has made protein available for all, and cases of gout showed up without preference in all social strata.

Looking further into Psychology, we find self-esteem to have two components: is a measure of one’s self-image relative to the social environment (also called contingent self-esteem) and is also intrinsic, unconditional and internally stable (non-contingent). When it comes to contingent self-esteem (or social self-esteem), we find that science has already formulated theories in support of the fact that the social acceptance of a disease could be monitored through the afflicted person’s self-esteem.

Sociometer theory sustains that self-esteem is a measure of how well we are interacting socially and to what degree we are being accepted. Where the perceived quality of relations between individuals is low, self-esteem also tends to be low and vice versa. Being in sync with most acceptable views of a society, therefore, becomes a survival mechanism, a necessity to avoid social devaluation, rejection or death.  The notion is also sustained by the Terror Management theory by declaring that self-esteem is sought because it provides protection against the fear of death[13].  The tendency of “buying into” our own society’s common values in order to thrive or survive does not mean that societal change is no longer possible or desirable (it could be that it tends to be slow paced), but in the case of a disease that one cannot get rid of without social support, that person’s natural and immediate reaction is to follow the communal view of the disease.

From this angle, the notion follows that if I live with gout in a society where the disease is highly regarded, I will inevitably have a positive contingent self-esteem while trying to sync with the common view. Using similar logic, if gout becomes linked in the common consciousness to weakness and overindulgence (read gluttony) and I get the disease, then I should expect to experience a low self-esteem. Trouble is that I may find that I was genetically predisposed to the disease and that overindulgence may not necessarily be at fault, and that really seems to happen with gout cases[14]. Even so, my inability to connect to the society’s negative perception of the disease will devaluate my social relations, dragging me back into a lower form of self-esteem. A lower self-esteem for patients with chronic disease was also found to be connected to a tendency to reach out for even more social interaction[15], however since I have to live with a negative social context surrounding my disease, I will experience further (possibly spiraling) devaluation of my social interaction and hence even lower self-esteem.

Accommodating the Sociometer argument, one question still arises. If gluttony was always considered a sin or frowned upon, why wasn’t it also a social view changer on gout during Geronimo Cardano’s time, for example, only to be seen as a contributor to gout’s bad vibe in modern times? The answer could come from the fact that in the common public’s view, overindulgence is closely linked to obesity. Once one learns that overindulgence creates obesity, the reverse link tends to also be indiscriminately assumed as valid (if you are obese then somehow you must also be overeating, etc.), which by all means is a similar fallacy to that prevailing when those sick with gout were considered lucky or revered upon (gifted people have the gout, therefore if you get the gout you must be somehow gifted). In modern times, corpulence or obesity – otherwise enviable characteristics (in addition to gout) of the wealthy of the pre-industrial era, are no longer considered desirable or sign of wellbeing (except some parts of Africa[16],[17],[18]), but quite the opposite. In fact concepts like “the obesity of poverty”[19] have become more common. Once obesity started to be stigmatized the already existent lay association with gluttony resurfaced in the common memory.

Final Notes

By invoking Sociometer and (to a lesser degree) Terror Management theories, the social self-esteem level is linked to social interaction quality which in turn is determined by the common view upon the disease causation. The cause of the disease infiltrates the popular consciousness in forms that are significantly impacted by scientific findings while still retaining at times the influence of reminiscent traditional beliefs and fallacies.

Self-esteem drives many physiological attributes of daily life and is significant in both the short and long-term care of the patient. It interrelates with affect (cause of depression), predicts stress, degree of physical pain and psychological distress, is a coping mechanism, sets the level of social interaction and is a measure of symptom severity[20].

The set of beliefs that a community or society can project over a disease will shape the patient's self-esteem which through its multiple ramifications, will impact the recovery or the quality of life under chronic disease. Conversely, paying attention to and quantifying the social self-esteem of the afflicted may offer insight into a local or more spread pattern of view over the condition. The gained awareness of such patterns could be useful in formulating local community efforts of education where necessary.
-----------------------------------------------------------------------------------------------
[1] Nuki, George, and Peter Simkin. "A Concise History of Gout and Hyperuricemia and Their Treatment." Arthritis Research & Therapy. April 12, 2006. Accessed May 7, 2015. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3226106/.
[2] Schwartz, Stephan. "Disease of Distinction." November 1, 2006. Accessed May 7, 2015: 6, http://www.stephanaschwartz.com/PDF/disease_of_distinction.pdf.
[3] Ibid 7
[4] Nuki, George, and Peter Simkin. "A Concise History of Gout and Hyperuricemia and Their Treatment." Arthritis Research & Therapy. April 12, 2006. Accessed May 7, 2015. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3226106/.
[5] Copeman, W. S. C. "A Synopsis of the Gout." In A Short History of the Gout and the Rheumatic Diseases, 10. Berkeley, CA: Univ. of California Press, 1964.
[6] Nuki, George, and Peter Simkin. "A Concise History of Gout and Hyperuricemia and Their Treatment." Arthritis Research & Therapy. April 12, 2006. Accessed May 7, 2015. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3226106/.
[7] Eknoyan, G. "A History of Obesity, or How What Was Good Became Ugly and Then Bad." National Center for Biotechnology Information. October 13, 2006. Accessed May 7, 2015. http://www.ncbi.nlm.nih.gov/pubmed/17045228.
[8] Choi, Hyon, and Gary Curhan. "Soft Drinks, Fructose Consumption, and the Risk of Gout in Men: Prospective Cohort Study." BMJ : British Medical Journal. 2009. Accessed May 7, 2015. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2234536/.
[9] Warry, Richard. "Gout: Why I Don't Find It Funny at All - BBC News." BBC News. January 2, 2014. Accessed May 7, 2015. http://www.bbc.com/news/magazine-24348691.
[10] Pollack, Andrew. "Disease of Rich Extends Its Pain to Middle Class." The New York Times. June 12, 2009. Accessed May 7, 2015. http://www.nytimes.com/2009/06/13/health/13gout.html?_r=1&.
[11] Doherty, Michael, Karen Spencer, and Alison Carr. "Patient and Provider Barriers to Effective Management of Gout in General Practice: A Qualitative Study." Annals of the Rheumatic Diseases. March 22, 2012. Accessed May 7, 2015. http://ard.bmj.com/content/71/9/1490.abstract.
[12] Pollack, Andrew. "Disease of Rich Extends Its Pain to Middle Class." The New York Times. June 12, 2009. Accessed May 7, 2015. http://www.nytimes.com/2009/06/13/health/13gout.html?_r=1&.
[13] Pyszczynski, Tom, Sheldon Solomon, and Holly McGregor. "Terror Management Theory and Self-Esteem: Evidence That Increased Self-Esteem Reduces Mortality Salience Effects." Social Emotive Neuroscience. 1997. Accessed May 8, 2015. http://www.socialemotiveneuroscience.org/pubs/hj_etal97tm.pdf.
[14] Schwartz, Stephan. "Gout: Disease of Distinction." Gout: Disease of Distinction. November 1, 2006. Accessed May 7, 2015: 516, http://www.academia.edu/7785131/Gout_Disease_of_Distinction.
[15] Juth, Vanessa, Joshua Smyth, and Alecia Santuzzi. "How Do You Feel? Self-esteem Predicts Affect, Stress, Social Interaction, and Symptom Severity during Daily Life in Patients   with Chronic Illness." Europe PubMed Central. October 1, 2008. Accessed May 7, 2015. http://europepmc.org/articles/PMC2996275.
[16] Belahsen, R., and M. Rguibi. "Fattening Practices among Moroccan Saharawi Women." National Center for Biotechnology Information. September 1, 2006. Accessed May 7, 2015. http://www.ncbi.nlm.nih.gov/pubmed/17333802.
[17] Simmons, Ann. "Where Fat Is a Mark of Beauty." September 30, 1998. Accessed May 7, 2015. http://www.anthroprof.org/documents/Docs102/102articles/fat26.pdf.
[18] Harter, Pascale. "Mauritania's 'wife-fattening' Farm." BBC News. January 26, 2004. Accessed May 7, 2015. http://news.bbc.co.uk/2/hi/africa/3429903.stm.
[19] Haslam, David, and Fiona Haslam. "Fat, Gluttony and Sloth: Obesity in Literature, Art and Medicine." Fat, Gluttony and Sloth: Obesity in Literature, Art and Medicine. 2009. Accessed May 7, 2015. http://www.history.ac.uk/reviews/review/838.
[20] Juth, Vanessa, Joshua Smyth, and Alecia Santuzzi. "How Do You Feel? Self-esteem Predicts Affect, Stress, Social Interaction, and Symptom Severity during Daily Life in Patients  with Chronic Illness." Europe PubMed Central. October 1, 2008. Accessed May 7, 2015. http://europepmc.org/articles/PMC2996275.

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Self-Esteem: A Barometer for the Shift in the Social Acceptance of the Gout Disease

 Self-Esteem: A Barometer for the Shift in the Social Acceptance of the Gout Disease

Self-Esteem: A Barometer for the Shift in the Social Acceptance of the Gout Disease

Self-Esteem: A Barometer for the Shift in the Social Acceptance of the Gout Disease

Earlier history

            Gout was first identified as a condition by the Egyptians in 2640 BC, and was later a point of interest to Hippocrates in the 5th century BC[1]. The disease – a form of arthritis, is caused by the buildup of uric acid in form of needlelike crystals that accumulate in various joints (but more commonly around big toes), creating severe pain and swelling. Traditionally, gout occurrence has been linked with the aristocracy and with an affluent lifestyle, which gained it the name “Disease of Kings”. This disease was particular to European culture and practically unknown to the Asian societies[2] up to the Industrial Revolution era. Gout was considered noble and socially desirable. Because the disease had prevalence among those who held political and social power (rarely showing among the common folk), exhibiting gout would typically result in an overnight boost of victim’s social worthiness. In popular consciousness, developing gout was also a sign of spiritual superiority. This popular belief was clearly mentioned by the 16th century physician, Geronimo Cardano: “What a man gout makes! Devout, morally pure, temperate, (and) circumspect. No one is so mindful of God as the man who is in the clutches of the pain of gout.”[3] Moreover, gout was seen as being prophylactic for other diseases and even having life-extending properties[4]. On a personal level, the disease would positively impact both one’s beliefs and emotions. Gout conferred its victim a boost in self-worthiness and sense of pride, hence raising one’s social self-esteem.

Modern history

            Moving into the Industrial Revolution, the relation between gout and social status had begun to weaken. Industrialization brought a larger amount of food at lower prices, making high-protein foods available to the masses. Protein was found to hold a high concentration of purine, a substance that was later established to be responsible for hyperuricemia (uric acid buildup); the latter was discovered by the English physician Sir Alfred Garrod to be the “cause […] of gouty inflammations” in the mid 1800’s[5]. With the increase in the wide consumption of red meats, shellfish, beer and alcohol, a direct connection between diet and gout incidence became easier to demonstrate. The hereditary component of the disease was demonstrated significant only in 1967 when it was linked to a purine enzyme deficiency[6].

Although corpulence used to have a predominant favorable view in the Industrial Era, soon after, it became stigmatized for aesthetic reasons. The negative view gained momentum as obesity was shown to increase mortality through diabetes, hypertension, heart or kidney disease[7]. Even further, science demonstrated a direct link between obesity and gout through sugar and fructose rich diets[8]. This has endorsed the popular assumption that a relationship exists between gluttony – a major Christian religion sin, and gout - as in the popular consciousness gout was already associated with “red-faced Dickensian gluttons […] port-quaffing Victorian gentlemen of excess and the obese Henry VIII”[9]. Reluctance among patients to admitting that they had gout often decreased their will to seek medical attention[10], creating inadequate care[11]. The historical positive relationship between gout and self-esteem morphed into its opposite.

A change in self esteem

It is evident that while the cause and expression of the disease have not changed over the time, opposite changes in the self-esteem of the afflicted occurred due in good part to the accumulation of a body of scientific knowledge regarding cause and association with other diseases.

Also interesting to observe is that in the case of gout, although the body image – an important component of one’s self esteem, goes through significant deterioration (major joint pain, redness, inflammation, swollen joints and limited range of motion), it becomes a booster to one’s self-image while there is a social context of acceptance or praise around the disease. It is the entire contrary in a modern society that holds gout as a self-inflicted issue[12] through its association with gluttony. In the modern era, the self-image in relation to gout becomes profoundly affected in a negative way, even though historically, gluttony could have been brought up as an argument against the favorably looked upon gout since the beginning of our era. It seems like just another example of how one’s fortune becomes another’s ruin, although they could be the same victim of the same disease.

What tips the balance between the two views seems to be a combination of both science and socio-economic development. For one part, science brings in a series of findings on gout, proving that there is not much one can do about it (i.e. heredity) or there is maybe not enough that one does (i.e. making significant changes in diet), and also that one could be associating him/herself with overeating/obesity (newer bad modern words already grown in common consciousness). Another part that tips the balance is that the old bi-directional relationship between gout and social superiority (only the smart, rich and powerful get the gout and therefore if you get the disease you must be somehow superior) was dismantled by the realization that the Industrial Revolution has made protein available for all, and cases of gout showed up without preference in all social strata.

Looking further into Psychology, we find self-esteem to have two components: is a measure of one’s self-image relative to the social environment (also called contingent self-esteem) and is also intrinsic, unconditional and internally stable (non-contingent). When it comes to contingent self-esteem (or social self-esteem), we find that science has already formulated theories in support of the fact that the social acceptance of a disease could be monitored through the afflicted person’s self-esteem.

Sociometer theory sustains that self-esteem is a measure of how well we are interacting socially and to what degree we are being accepted. Where the perceived quality of relations between individuals is low, self-esteem also tends to be low and vice versa. Being in sync with most acceptable views of a society, therefore, becomes a survival mechanism, a necessity to avoid social devaluation, rejection or death.  The notion is also sustained by the Terror Management theory by declaring that self-esteem is sought because it provides protection against the fear of death[13].  The tendency of “buying into” our own society’s common values in order to thrive or survive does not mean that societal change is no longer possible or desirable (it could be that it tends to be slow paced), but in the case of a disease that one cannot get rid of without social support, that person’s natural and immediate reaction is to follow the communal view of the disease.

From this angle, the notion follows that if I live with gout in a society where the disease is highly regarded, I will inevitably have a positive contingent self-esteem while trying to sync with the common view. Using similar logic, if gout becomes linked in the common consciousness to weakness and overindulgence (read gluttony) and I get the disease, then I should expect to experience a low self-esteem. Trouble is that I may find that I was genetically predisposed to the disease and that overindulgence may not necessarily be at fault, and that really seems to happen with gout cases[14]. Even so, my inability to connect to the society’s negative perception of the disease will devaluate my social relations, dragging me back into a lower form of self-esteem. A lower self-esteem for patients with chronic disease was also found to be connected to a tendency to reach out for even more social interaction[15], however since I have to live with a negative social context surrounding my disease, I will experience further (possibly spiraling) devaluation of my social interaction and hence even lower self-esteem.

Accommodating the Sociometer argument, one question still arises. If gluttony was always considered a sin or frowned upon, why wasn’t it also a social view changer on gout during Geronimo Cardano’s time, for example, only to be seen as a contributor to gout’s bad vibe in modern times? The answer could come from the fact that in the common public’s view, overindulgence is closely linked to obesity. Once one learns that overindulgence creates obesity, the reverse link tends to also be indiscriminately assumed as valid (if you are obese then somehow you must also be overeating, etc.), which by all means is a similar fallacy to that prevailing when those sick with gout were considered lucky or revered upon (gifted people have the gout, therefore if you get the gout you must be somehow gifted). In modern times, corpulence or obesity – otherwise enviable characteristics (in addition to gout) of the wealthy of the pre-industrial era, are no longer considered desirable or sign of wellbeing (except some parts of Africa[16],[17],[18]), but quite the opposite. In fact concepts like “the obesity of poverty”[19] have become more common. Once obesity started to be stigmatized the already existent lay association with gluttony resurfaced in the common memory.

Final Notes

By invoking Sociometer and (to a lesser degree) Terror Management theories, the social self-esteem level is linked to social interaction quality which in turn is determined by the common view upon the disease causation. The cause of the disease infiltrates the popular consciousness in forms that are significantly impacted by scientific findings while still retaining at times the influence of reminiscent traditional beliefs and fallacies.

Self-esteem drives many physiological attributes of daily life and is significant in both the short and long-term care of the patient. It interrelates with affect (cause of depression), predicts stress, degree of physical pain and psychological distress, is a coping mechanism, sets the level of social interaction and is a measure of symptom severity[20].

The set of beliefs that a community or society can project over a disease will shape the patient's self-esteem which through its multiple ramifications, will impact the recovery or the quality of life under chronic disease. Conversely, paying attention to and quantifying the social self-esteem of the afflicted may offer insight into a local or more spread pattern of view over the condition. The gained awareness of such patterns could be useful in formulating local community efforts of education where necessary.
-----------------------------------------------------------------------------------------------
[1] Nuki, George, and Peter Simkin. "A Concise History of Gout and Hyperuricemia and Their Treatment." Arthritis Research & Therapy. April 12, 2006. Accessed May 7, 2015. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3226106/.
[2] Schwartz, Stephan. "Disease of Distinction." November 1, 2006. Accessed May 7, 2015: 6, http://www.stephanaschwartz.com/PDF/disease_of_distinction.pdf.
[3] Ibid 7
[4] Nuki, George, and Peter Simkin. "A Concise History of Gout and Hyperuricemia and Their Treatment." Arthritis Research & Therapy. April 12, 2006. Accessed May 7, 2015. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3226106/.
[5] Copeman, W. S. C. "A Synopsis of the Gout." In A Short History of the Gout and the Rheumatic Diseases, 10. Berkeley, CA: Univ. of California Press, 1964.
[6] Nuki, George, and Peter Simkin. "A Concise History of Gout and Hyperuricemia and Their Treatment." Arthritis Research & Therapy. April 12, 2006. Accessed May 7, 2015. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3226106/.
[7] Eknoyan, G. "A History of Obesity, or How What Was Good Became Ugly and Then Bad." National Center for Biotechnology Information. October 13, 2006. Accessed May 7, 2015. http://www.ncbi.nlm.nih.gov/pubmed/17045228.
[8] Choi, Hyon, and Gary Curhan. "Soft Drinks, Fructose Consumption, and the Risk of Gout in Men: Prospective Cohort Study." BMJ : British Medical Journal. 2009. Accessed May 7, 2015. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2234536/.
[9] Warry, Richard. "Gout: Why I Don't Find It Funny at All - BBC News." BBC News. January 2, 2014. Accessed May 7, 2015. http://www.bbc.com/news/magazine-24348691.
[10] Pollack, Andrew. "Disease of Rich Extends Its Pain to Middle Class." The New York Times. June 12, 2009. Accessed May 7, 2015. http://www.nytimes.com/2009/06/13/health/13gout.html?_r=1&.
[11] Doherty, Michael, Karen Spencer, and Alison Carr. "Patient and Provider Barriers to Effective Management of Gout in General Practice: A Qualitative Study." Annals of the Rheumatic Diseases. March 22, 2012. Accessed May 7, 2015. http://ard.bmj.com/content/71/9/1490.abstract.
[12] Pollack, Andrew. "Disease of Rich Extends Its Pain to Middle Class." The New York Times. June 12, 2009. Accessed May 7, 2015. http://www.nytimes.com/2009/06/13/health/13gout.html?_r=1&.
[13] Pyszczynski, Tom, Sheldon Solomon, and Holly McGregor. "Terror Management Theory and Self-Esteem: Evidence That Increased Self-Esteem Reduces Mortality Salience Effects." Social Emotive Neuroscience. 1997. Accessed May 8, 2015. http://www.socialemotiveneuroscience.org/pubs/hj_etal97tm.pdf.
[14] Schwartz, Stephan. "Gout: Disease of Distinction." Gout: Disease of Distinction. November 1, 2006. Accessed May 7, 2015: 516, http://www.academia.edu/7785131/Gout_Disease_of_Distinction.
[15] Juth, Vanessa, Joshua Smyth, and Alecia Santuzzi. "How Do You Feel? Self-esteem Predicts Affect, Stress, Social Interaction, and Symptom Severity during Daily Life in Patients   with Chronic Illness." Europe PubMed Central. October 1, 2008. Accessed May 7, 2015. http://europepmc.org/articles/PMC2996275.
[16] Belahsen, R., and M. Rguibi. "Fattening Practices among Moroccan Saharawi Women." National Center for Biotechnology Information. September 1, 2006. Accessed May 7, 2015. http://www.ncbi.nlm.nih.gov/pubmed/17333802.
[17] Simmons, Ann. "Where Fat Is a Mark of Beauty." September 30, 1998. Accessed May 7, 2015. http://www.anthroprof.org/documents/Docs102/102articles/fat26.pdf.
[18] Harter, Pascale. "Mauritania's 'wife-fattening' Farm." BBC News. January 26, 2004. Accessed May 7, 2015. http://news.bbc.co.uk/2/hi/africa/3429903.stm.
[19] Haslam, David, and Fiona Haslam. "Fat, Gluttony and Sloth: Obesity in Literature, Art and Medicine." Fat, Gluttony and Sloth: Obesity in Literature, Art and Medicine. 2009. Accessed May 7, 2015. http://www.history.ac.uk/reviews/review/838.
[20] Juth, Vanessa, Joshua Smyth, and Alecia Santuzzi. "How Do You Feel? Self-esteem Predicts Affect, Stress, Social Interaction, and Symptom Severity during Daily Life in Patients  with Chronic Illness." Europe PubMed Central. October 1, 2008. Accessed May 7, 2015. http://europepmc.org/articles/PMC2996275.