APA DOCUMENTATION

from Publication Manual of the American Psychological Association 2010 (6th ed.)

The Purpose of Referencing/Documentation

A. to identify (cite) other people’s ideas and information used within your essay or term paper, and
B. to indicate the sources of these citations in the References list at the end of your paper.

Avoiding Plagiarism - Citation Principles for Essays and Term Papers

Within essays, term papers, and any other written assignments (as in all academic work), you must
identify (i.e., reference, document, cite) all quotations, paraphrases, ideas, and images from someone else’s work.
You must name the original author or source and surround quoted material with quotation marks or set it in a
block format as described in this handout. Copying any material and submitting it as your own (plagiarism) is an
academic offence. Plagiarism may result in failure on the assignment and, in some cases, expulsion from a
course.

Referencing/Citing Sources Within Your Paper

Whenever you use a quotation from an author or summarize or paraphrase a person’s ideas or research,
you must identify (reference/cite) the source. This in-text citation is formatted with parentheses and shows

 the last name of the author(s) of the work, unless already stated [APA p. 174]
or the first few words of the References list entry (usually the title) if the author
is not known [APA p. 176]

 the year of publication or n.d. (no date) if the year is not known [APA p. 174]
 page number(s) if available

Citing Short Quotations (fewer than 40 words) [APA pp. 92, 170-172]

When you incorporate a direct quotation into a sentence, you must cite its source.

Author’s name in your text Lee (2007) stated, “The ability to think critically is
needed in this revolutionary age of
OR technological change” (p. 82).

Author’s name in parentheses ( ) One researcher emphasized that “the ability to think
critically is needed in this revolutionary age of
technological change” (Lee, 2007, p. 82).

Note: You must blend quotations into your own sentences. Begin with your own words or start with the
author/date and follow with the quoted material (see examples above). When using the author said/stated format,
start the quotation with a capital letter.

Citing Long Quotations (40 or more words) [APA pp. 92, 170-172]

 Use a block format in which all lines of the quotation are indented approximately ½ inch from the left
margin.
 Do not use quotation marks.
 Introduce the quotation with a complete sentence and a colon.
Wang, Johnston, Juarez, and Marks (2010) described effective time management as an ongoing process:
Time management is not a skill that can be achieved at once; it takes self-awareness, planning,
execution, and reflection. The perception about time management is that the work is done once a
schedule is created. In reality, that is only the first step. Successful students are adaptable and
flexible; they are able to make changes to a schedule because they can purposefully and proactively
move tasks around to adjust to new situations. (p. 27) *period before the parentheses for long
quotations

Citing Summaries or Paraphrases [APA pp. 171, 174]

When you put information in your own words by summarizing or paraphrasing, you must cite the original author.
APA (2010) also recommends you include a page or paragraph number to “help an interested reader locate the
relevant passage” (p. 171).

One researcher emphasized the necessity of flexibly applied thinking to cope with rapidly changing
technology (Lee, 2007, p. 82).

OR

Lee (2007) emphasized that flexibly applied thinking is vital to cope with rapidly changing technology (p.
82).

Citing Information If No Page Numbers Are Available [APA pp. 171-172; FAQ]

Electronic sources such as websites commonly have no page numbers, so you cannot put a page number for the
in-text citation. PDFs, however, normally show original page numbers.

 If the source has no page numbers but explicitly numbers the paragraphs, you can include paragraph
number(s), preceded by the abbreviation “para.” in the citation parentheses.
 If the document has no page or paragraph numbers but does have headings, use the heading (with capitals
and no quotation marks) of the section you are taking information from and then give the number of the
paragraph under it that contains the information you are incorporating in your essay. The example below
includes the complete heading: Fostering health security. Note that the heading has capital letters when in the
parentheses.

According to the World Health Organization (2010), “one of the greatest threats to international health
security arises from outbreaks of emerging and epidemic-prone diseases” (Fostering Health Security, para.
1).

 If the heading is long, shorten it, keep capital letters, and put quotation marks around it. The heading What
is the Burden of Alzheimer’s Disease in the United States? has been shortened to “What is the Burden?” in
the example below.

Centers for Disease Control and Prevention (2010) have pointed out that “Alzheimer’s disease is one of the
top ten leading causes of death in the United States” (“What is the Burden?,” para. 1).
 If the source has no headings, count the paragraphs and include the paragraph number in parentheses, e.g.,
(para. 7). [FAQ]

Citing a Source Found/Cited in Another Source [APA p. 178]

Often an author writes about research that someone else has done, but you are unable to track down the
original research report. For example, in your paper you might include research described in your course
textbook. In the sample below, research done by Pithers is discussed in a journal article written by Lee. Include
only Lee’s article in the References list.

A 2000 review by Pithers found little empirical research on students’ critical thinking (as cited in Lee, 2007,
p. 83).

Citing References Within Your Paper

The following examples demonstrate APA formatting for either quotations or paraphrased information taken
from a reference.

Subsequent Subsequent
First time citing a
First time citing a citations of the citations of a
reference, using
reference when reference in another reference, using
Type of citation authors are named in paragraph with
parentheses format at
parentheses format at
the end of your
your sentence authors named in the end of your
sentence
your sentence sentence

One author Lee (2007) stated, Lee (2007) also ----------- (Lee, 2007, --------------- (Lee,
“---------------” (p. stated, “-------------” p. 82). 2007, p. 112).
82). (p. 112).

Smith and Jones Smith and Jones

------- (Smith & --------- (Smith &
(2004) found that (2004) also said,
Two authors Jones, 2004, p. 93). Jones, 2004, p. 98).
“-----” (p. 93). “-------” (p. 98).
(use & between (use & between
(use and between (use and between
names) names)
names) names)
Simpson, Stahl, and
Three to five As well, Simpson et ---- (Simpson, Stahl,
Francis (2004) ----------- (Simpson
authors al. (2004) found & Francis, 2004, p.
argued that ----------- et al., 2004, p. 18).
(All subsequent ------- (p. 18). 10).
(p. 10). (uses et al. format)
citations use et al.) (uses et al. format)
Kallai et al. (2011) Kallai et al. (2011)
------------- (Kallai et ------------- (Kallai et
said that “----------” also stated that
Six or more authors al., 2011, p. 121). al., 2011, p. 125).
(p. 121). -------- (p. 125).

TransCanada (2006)
TransCanada (2006) --------- -------------
Organizations, reported that
further explained that (TransCanada, 2006, (TransCanada, 2006,
institutions, etc. ----------------- (p.
“---------------” (p. p. 11). p. 13).
as group author 11).
13).
Group author, no World Health WHO (2010) ------------------ ---------------- (WHO,
page numbers (use Organization (WHO, reported on the (World Health 2010, Fostering
web page headings 2010) found that problem, saying that Organization Health Security, para.
and paragraph --------- (Fostering --------- (Fostering [WHO], 2010, 8).
numbers) Health Security, Health Security, Fostering Health (World Health
para. 1). para. 8). Security, para. 1). Organization is
(World Health written as an
Organization is acronym in
written as an subsequent citations)
acronym in
 subsequent citations)

No author - article The article “Ancient As well, “Ancient

(use shortened title Tool Makers Tool Makers
--------- (“Ancient --------- (“Ancient
of article in quotation Discovered Fire Discovered Fire
Tool,” 2009, p. 6). * Tool,” 2009, p. 8). *
marks in place of Treatment” (2009) Treatment” (2009)
author’s last name) stated the ----- (p. 6). found the ----- (p. 8).

*Note: If the author’s name is unavailable, use the shortened title first in the citation. Include the appropriate capitalization,
and use quotation marks for articles, chapters, or web page titles and italics for books, reports, or brochures.

Buzan (n.d.) Buzan (n.d.) also

No date available ----------------- --------------- (Buzan,
explained that argued that
(use n.d.) (Buzan, n.d., p. 23). n.d., p. 28).
-------------- (p. 23). -------------- (p. 28).

Sample Research Paper Paragraph with Citations

1st use of a reference
– paraphrase
Followed by 2nd use of reference,
same page – quotation
1st source cited again – uses et al.
4th and 5th use of
same reference – quotation from
different page*
Using a source cited in another
source
Personal communication
cited here, but do NOT put in
References
Long quotation block format –
period comes before the
parentheses
When students learn more about the process of learning and begin to
incorporate the use of specific strategies, self-monitoring, and self-reflection into
their academic endeavours, they are more successful in reaching their goals. In
their examination of students’ acquisition of learning strategies, Simpson, Stahl,
and Francis (2004) stressed that students will use a strategy if they understand
how, why, and when to use it (p. 3). The researchers explained that learning this
“procedural knowledge would help them understand the steps . . . and how to
modify those steps” (p. 3). Simpson et al. argued that using the specific strategy
taught in a course is often not as important as using the process the students learn
of “selecting, summarizing,
organizing, elaborating, monitoring, self-testing, reflecting and evaluating” when
working on course content (p. 4). The researchers recommended that faculty
teach students “how to decipher their own academic tasks” (p. 6).
In addition, Lee (2007) argued that once students have acquired a repertoire of
study strategies, they should be taught critical thinking skills to evaluate and
modify their use of specific strategies (pp. 82-83). Acquisition of strategic
learning is, as Hadwin et al. in 2001 explained, “enacted over time through a
series of events” (as cited in Simpson et al., 2004, p. 3). P. Foley, a professor
at North London University, observed that motivation is strongly linked to
student use of learning strategies (personal communication, May 16, 2007).
Motivation, in turn, can be influenced by students’ beliefs about learning.
Simpson et al. (2004) commented on such beliefs:
[Many] college freshmen . . . believe that learning should be easy,
completed quickly (i.e., the night before in a cramming session) and
should happen to them because of what others do for them (i.e., the
professor did not teach me to solve that problem). (p. 4)

Flexible use of strategies, self-reflection, and motivation can enhance academic

success. If there are.....

*NOTE: When authors are named in your sentence and you use the reference again in the same
paragraph, list authors, date, and page number the first time. List only the page number for the
subsequent citations if it is clear, from context, that the authors are the same. If you write the authors’
names again to assure clarity, omit the date. However, when you use that reference in a later paragraph,
include again the authors (with et al. if applicable), date, and page number.
Integrating Research into Your Writing

The professor’s study explained that “students who use active listening
Citing a quotation and
techniques to stay engaged in a class lecture demonstrated better marks on
then continuing with a
paraphrase from the exams” (Velasquez, 2011, p. 72); her report described the various strategies
same source later in the
that successful students use to mentally participate in the learning process (p.
sentence
81).
OR
Velasquez (2011) explained that “students who use active listening techniques
to stay engaged in a class lecture demonstrated better marks on exams” (p.
72); her report described the various strategies that successful students use to
mentally participate in the learning process (p. 81).
He found that the “results demonstrated that the first variable (persistence)
had the most effect on the outcome of an exam” (Twoyoungmen, 2010, p. 96),
Citing a quotation used at
the start of a sentence, and but the study lacked sufficient detail.
then continuing with your
own words/ideas/ OR
comments Twoyoungmen (2010) found that the “results demonstrated that the first
variable (persistence) had the most effect on the outcome of an exam” (p. 96),
but the study lacked sufficient detail.

Creating Your References List

Start the References list on a separate page at the end of your paper. [APA p. 37]

 Include only those sources you have cited within your paper. [APA p. 180] Exceptions are personal
communications, classical religious works such as the Bible and the Qur’an, and classical works. These do
not appear in the References list. [APA pp. 174, 178-179]

 Double-space the entire References list. Do not add an extra blank line after the title. [APA p. 180]

 Position the first line of each reference flush-left, with subsequent lines wrapping with a ½-inch (hanging)
indent. [APA p. 180]

 Organize the list in alphabetical order according to the first letter beginning each entry. Normally, the
author’s last name, unless unknown, is the first piece of information in each entry. Use initials for the
author’s first/middle names. [APA pp. 181-183]
The Parts of a Reference

author year published book edition

Book,
McWhorter, K. (2010). Academic reading (7th ed.). Boston, MA: Longman.
edition is book title place published publisher
stated

Journal author year published article title journal name

article Smith, G. (2012). Barthes on Jamie: Myth and the TV revolutionary. Journal of Media Practice,
13, 3-17. http://dx.doi .org/10.1386/jmpr.13.1.3_1
volume, page range DOI

Chapter in chapter authors year published chapter title book editor book title
an edited Smith, F. M., & Jones, W. (2004). The college student. In C. Wood (Ed.), Cross-cultural education
book (pp. 75-105). London, Canada: MacMillan.
chapter page range place published publisher

Web page on
website, no author (no publication date –use n.d.) website URL
publication Buzan, T. (n.d.) Mind maps. Retrieved September 3, 2009, from http://www.buzanworld.com
date web page title date retrieved
/Mind_Maps.htm
 References
Start your
reference list on a Alberta Social Services and Community Health. (2005). Breaking the
new page
(no extra space pattern: Understanding wife abuse. Edmonton, Canada: Author.
after title)
[APA p. 37] Ancient tool makers discovered fire treatment. (2009, August 13). The Globe and

Double-space Mail. Retrieved from http://www .theglobeandmail.com/

between lines Arnold, A. (1985). Afghanistan: The Soviet invasion in perspective (Rev. ed.).
[APA p. 180]
Retrieved from http://books.google.com/
Put references in
alphabetical order, Bennett, J. D., & Briggs, W. L. (n.d.). Statistical reasoning. In Scientific and
according to the
first letter of the mathematical literacy for the modern world (2nd Custom ed., pp. 69132).
reference Toronto, Canada: Pearson Custom.
[APA pp. 181183]
Brandt, F. (Producer), & Messina, P. F. (Director). (1995). Too smart for strangers
Use a ½ inch [Motion picture]. Burbank, CA: Walt Disney Home Video.
hanging indent for
subsequent lines of Buzan, T. (n.d.). Mind maps. Retrieved September 3, 2009, from
a  http://www.buzanworld.com/Mind_Maps.htm
reference
Include only the Cell division. (2008). In E. Martin & R. Hine (Eds.), Dictionary of biology.
sources cited in
Retrieved from http://www.oxfordreference .com
your paper
[APA pp. 178180] Downing, L., Carter, J. C., & McManus, T. (2007). Students in our midst. Toronto,
Canada: Doubleday.
Use publisher name
Fung, M. (2006, December 12). Asthma rates increasing. Winnipeg Free Press,
only: Doubleday
(Publishers Ltd). pp. C4, C7C8.
[APA p.187]
Lee, K. (2007). Online collaborative case study learning. Journal of College
Reading and Learning, 37, 82100.
McWhorter, K. (2010). Academic reading (7th ed.). Boston, MA: Longman.
Simpson, M. L., Stahl, N. A., & Francis, M. A. (2004). Reading and learning s
trategies: Recommendations for the 21st century. Journal of
Developmental Education, 28(2), 2-15, 32.
Smith, F. M., & Jones, W. (2004). The college student. In C. Wood & M. Meyer

Break website URL (Eds.), Cross-cultural education (pp. 75-105). London, Canada: MacMillan.
before TransCanada. (2006). Annual report. Retrieved from http://www.transcanada.com/
punctuation
such as / or –[APA p. investor/annual_reports/2006 /media/pdf/TransCanada_2006_
192]
Annual_Report.pdf
Webber, S. (2007, July 11). Survey of plagiarism penalties [Blog post].
Retrieved from http://information-literacy .blogspot.com/2007/07.html

References Examples
A. Books

NOTE: only the first word, the first word after a colon, and all proper nouns of book titles are capitalized

A1 Book, 1 author /
Johnston, M. (2009). Perspective, persistence, and learning. Thousand Oaks, CA:
no edition [APA p.
Sage.
202]

A2 Book, 1 author /
edition McWhorter, K. (2010). Academic reading (7th ed.). Boston, MA: Longman.
stated [APA pp. 203,
205]
A3 Book with 2 to 7 Downing, L., Carter, J. C., & McManus, T. (2007). Students in our midst. Toronto,
authors,
not from U.S. [APA p. Canada: Doubleday.
184] NOTE: Country name replaces state abbreviation for non-U.S. publications.

A4 E-book of print
book retrieved from O’Brien-Pallas, L., Hiroz, J., Cook, A., & Mildon, B. (2005). Nurse-physician
library subscription
relationships: Solutions and recommendations for change. Retrieved from
database [APA p. 203]
[Electronic Guide p. http://www.ebrary.com
17]

A5 E-book retrieved
Arnold, A. (1985). Afghanistan: The Soviet invasion in perspective (Rev. ed.).
from web [APA p.
203] Retrieved from http://books.google.com/

B. Entries and Chapters in Edited Books (includes encyclopedia and dictionary entries)

NOTE: Both book editor(s) and chapter/story/poem author(s) need to be credited

B1 Chapter with Smith, F. M., & Jones, W. (2004). The college student. In C. Wood & M. Meyer
known author in an
(Eds.), Cross-cultural education (pp. 75105). London, Canada:
edited book
[APA p. 204] MacMillan.

Jefferson, T. (2008). Masculinities and crimes. In D. E. King & J. A. Winterdyk

(Eds.), Diversity issues and the criminal justice system: Course readings
B2 Chapter with
known author for Applied Justice Studies (AJUS) 2231 (pp. 325347). Calgary,
from an edited book, Canada: Mount Royal University. (Reprinted from The Oxford handbook
included in a course
pack of criminology (2nd ed.), pp. 535557, by M. Maguire, R. Morgan, & R.
with pagination Reiner, Eds., 1997, Oxford, England: Oxford University Press).
[APA p. 204]
NOTE: In-text citations should include both dates and use the course pack page numbering if
available. If the course pack does not have its own page numbers, use the original page numbers of
the chapter, i.e., (Jefferson, 1997/2008, p. 326).
Davidson, T. (2002). Common cold. In J. L. Longe (Ed.), The Gale encyclopedia
B3 Entry/definition
of medicine (2nd ed., Vol. 2, pp. 869872), Detroit, MI: Gale Group.
in print
encyclopedia, author
known [APA p. 205]
B4 Entry or Cell division. (2008). In E. Martin & R. Hine (Eds.), Dictionary of biology.
definition in a web
encyclopedia, author Retrieved from http://www.oxfordreference.com
unknown [APA p. NOTE: The title comes first when the author is unknown and is used for the in-text citation, i.e.,
205] (“Cell Division, 2008, para. 1.)
Bennett, J. D., & Briggs, W. L. (n.d.). Statistical reasoning. In Scientific and
B5 Chapter in
customized mathematical literacy for the modern world (2nd Custom ed., pp.
textbook [APA pp. 69132). Toronto, Canada: Pearson Custom.
202-203]

C. Articles: Journals and Periodicals (newspapers, magazines)

NOTE: only the first word, the first word after a colon, and all proper nouns of article titles are capitalized, but
journal names are capitalized

C1 Scholarly journal Smith, G. (2012). Barthes on Jamie: Myth and the TV revolutionary.
article
with 1 author, from a Journal of Media Practice, 13, 317.
library database, with http://dx.doi.org/10.1386/jmpr.13.1.3_1
DOI
[APA p. 198; NOTE: A digital object identifier (DOI) should be included at the end of the reference
(http://dx.doi.org/###).
Electronic Guide p.12]
C2 Scholarly journal
article, Kallai, J., Makany, T., Csatho, A., Karadi, K., Horvath, D., Kovacs-Labadi,
more than 7 authors,
B., . . . Jacobs, J. W. (2007). Cognitive and affective aspects of
with
DOI: list first 6, then thigmotaxis strategy in humans. Behavioral Neuroscience, 121,
use
2130. http://dx.doi.org/10.1037/0735-7044.121.1.21
. . . , and list last
author [APA p. 198;
Electronic Guide p.12]
C3 Scholarly journal Simpson, M. L., Stahl, N. A., & Francis, M. A. (2004). Reading and learning
article, up
to 7 authors, from a strategies: Recommendations for the 21st century. Journal of
library Developmental Education, 28(2), 2-15.
database, no DOI
[APA p. 199] NOTE: Italicize the journal name and volume number but not the issue number.
C4 Scholarly article
with 2 Brown, C., & Austin, D. (2009). Fatty acids, breastfeeding and autism spectrum
authors, found through disorder. E-journal of Applied Psychology, 5(1), 4952. Retrieved from
web
search, not a library http://ojs/lib.swin.edu.au/
database [APA pp. 191192, NOTE: Give the URL of the journal home page.
199]
C5 Scholarly journal
article Lee, K. (2007). Online collaborative case study learning. Journal of College
with 1 author, paper-
Reading and Learning, 37, 82-100.
bound,
no DOI available
[APA p. 199]
C6 Newspaper Fung, M. (2006, December 12). Asthma rates increasing. Winnipeg Free Press,
article, with
pp. C4, C7-C8.
author, on multiple,
discontinuous pages, NOTE: Include the year, month, and date for periodicals.
print [APA p. 200]
C7 Newspaper
article, with
Harris, M. (2011, August 16). Grades improve if classes start later, studies find.
author, on the web,
not from The Calgary Herald. Retrieved from http://www.calgaryherald.com/
a library database
[APA pp. 200-201;
Electronic Guide p. 9]
C8 Newspaper
article, author Ancient tool makers discovered fire treatment. (2009, August 13). The Globe
unknown, on the
and Mail. Retrieved from http://www.theglobeandmail.com/
web, not
from a library
database [APA p. 200]
C9 Magazine article, Singer, P. (2011, August). Visible man: Ethics in a world without secrets.
with
Harper’s Magazine, 323(1935), 31-36.
author, print copy
[APA p. 200]
C10 Magazine article Wells, P. (2009, July 28). Our universities can be smarter. Maclean’s,
with
122(29/30). Retrieved from http://www2.macleans.ca
author, web version
[APA p. 200]
C11 Review of book, Klein, N. (2002, December 16). The new apartheid [Review of the book We are
in a magazine, from a the poor: Community struggles in post-apartheid South Africa, by A.
library
database, no DOI Desai]. Nation, 275(21), 25-28.
[APA p. 209]

D. Websites

NOTE: There is a formatting difference (italics or regular font) for the title of a website, a web page, or a web
document. Use regular font for titles of web pages but use italics for titles of websites and web documents

D1 Web page on
Buzan, T. (n.d.). Mind maps. Retrieved September 3, 2009, from
website,
with author, no date http://www.buzanworld.com /Mind_Maps.htm
[APA pp. 192, 205-
206, FAQ]
D2 Web page on How to study effectively – 8 concentration strategies. (2007). Retrieved
website, September 10, 2009, from http://studenthacks.org/2007/10/12/study-
author unknown
[APA pp. 192, 205- effectively/
206, FAQ]
D3 Web page on
World Health Organization. (2010). The WHO agenda. Retrieved July 17, 2010,
website,
group or corporate from http://www .who.int/about/agenda/en/index.html
author [APA pp. 192,
205-206, FAQ]
D4 Document on a TransCanada. (2006). Annual report. Retrieved from
website, http://www.transcanada.com /investor/annual_reports/
group or corporate
author [APA pp. 206, 2006/media/pdf/TransCanada_2006_Annual_Report.pdf
FAQ]
D5 Report by U.S. Department of Health and Human Services, National Institutes of Health,
organization that National Cancer Institute. (2011). Annual report to the nation on the
is part of a larger
organization, found on status of cancer, 19752007, featuring trends in brain cancer:
website (larger entity Questions and answers. Retrieved from http://www.cancer.gov
listed 1st) [APA p. 205
#31, 206 #32] /newscenter/qa/2011/ReportNation2011QandA

Lundquist, C. (2012, February). Recapping ICCB: New Zealand hosts historic

D6 Newsletter article, congress for conservation biology. Society for Conservation Biology
with
author, found online Newsletter, 20(1). Retrieved from
[APA p. 200] http://www.conservationbiology.org/Publications
[Electronic Guide p.
14] /Newsletter/Archives/2012-2-February /news2.cfm

D7 Blog post Webber, S. (2007, July 11). Survey of plagiarism penalties [Blog post].
[Electronic Guide p. 2]
Brackets [ ] used to Retrieved from http://information-literacy.blogspot.com/2007/07/this-
describe was-published-last-month-tennant -p.html
form of reference
[APA p. 186]
Angelou, M. [DrMayaAngelou]. (2013, June 9). You can only become truly
D8 Twitter update or accomplished at something you love [Tweet]. Retrieved from
tweet [Electronic
Guide p. 33] https://twitter.com/DrMayaAngelou/status /343844424767389696/
[APA p. 215] NOTE: Include both the author’s real name and [screen name]. Use the screen name without
[ ] if no real name is available.

D9 Video blog post SevereAvoidance. The official Grumpy Cat [Video file]. (2012, September 25).
(YouTube),
author unknown Retrieved from http://www.youtube.com/watch?v=INscMGmhmX4
[APA p. 215] NOTE: Include both the real name and [screen name] of the person who posted the video as
the author. Use the screen name without [ ] if no real name is available.

E. Other Kinds of Information Sources

E1 Government Alberta Social Services and Community Health. (2005). Breaking the pattern:
report,
Understanding wife abuse. Edmonton, Canada: Author.
publisher is same as
author,
paper-bound [APA p.
205]
E2 Government Sosiak, A. (1999). Evaluation of recent trends in water quality in the Elbow
report on a
River upstream from Glenmore Reservoir. Retrieved from Alberta
website, with author
[APA p. 205] Environment and Sustainable Resource Development website:
http://environment.gov.ab.ca/info/library/5695.pdf
E3 Statistics Canada Statistics Canada. (2009). Workers who use an official language most often or
data
report (graph, table, regularly at work, by province and territory, (2006 Census). Retrieved
chart) from http://www40.statcan.gc.ca/l01 /cst01/demo44a-eng.htm
on a website [APA p.
211]
E4 ERIC document
with Beswick, D. M., Chuprina, L., & Canipe, J. B. (2002). Investigating self-
Document directed learning in culture, learning styles and creativity. Retrieved
Reproduction
Service number from ERIC database. (ED473804)
identified [Electronic
Guide p. 31]
E5 Motion picture
Brandt, F. (Producer), & Messina, P. F. (Director). (1995). Too smart for
with
producer and director strangers [Motion picture]. Burbank, CA: Walt Disney Home Video.
identified [APA p.
209]
E6 Brochure, Family Counselling Centre. (2003). Dealing with a delinquent student
corporate author,
[Brochure]. Calgary, Canada: Author.
publisher is same as
author [APA p. 186]
Samuels, M. (2010). Midterm review points. Retrieved from Mount Royal
E7 Class handouts or
University PSYC1105 Blackboard website:
slides (ppt) on course
http://courseware.mymrc.ca/courses/1/PSYC-2200-081_Psychology
Blackboard
_200301/content/midterm_Review_Points.doc
site [APA pp. 205-206]

Department of Chemistry. (2012, Fall). CHEM 0130 Basic Chemistry II

E8 Lab manual [APA
p. 211] laboratory manual. Calgary, Canada: Mount Royal University.

E9 Legislation on a
Criminal Code, R.S.C. 1985, c. C-46, s. 318(1). (CANLII).
website [APA p. 220]
 (Arial/ Times New Roman – 11/12)
Obesity in
Children 1
(short title and page number)

Can Medication Cure Obesity in Children?

A Review of the Literature

(full title)

Luisa Mirano
Psychology 108, Section B
Professor Kang
October 31, 2013

(writer’s name, course/subject, section, instructor’s name and date – all centered)
 Obesity in Children 2

(Abstract appears on separate page)

Abstract
-1 inch- -1 inch-
In recent years, policymakers and medical experts have expressed alarm about the
growing problem of childhood obesity in the United States. While most agree that the
issue deserves attention, consensus dissolves around how to respond to the problem.
This literature review examines one approach to treating childhood obesity:
medication. The paper compares the effectiveness for adolescents of the only two
drugs approved by the Food and Drug Administration (FDA) for long-term treatment
of obesity, sibutramine and orlistat. This examination of pharmacological treatments
for obesity points out the limitations of medication and suggests the need for a
comprehensive solution that combines medical, social, behavioral, and political
approaches to this complex problem.
 Obesity in Children 3

Can Medication Cure Obesity in Children?

A Review of the Literature full title

In March 2004, U.S. Surgeon General Richard Carmona called attention to a

health problem in the United States that, until recently, has been overlooked:
childhood obesity. Carmona said that the “astounding” 15% child obesity rate
constitutes an “epidemic.” Since the early 1980s, that rate has “doubled in children
and tripled in adolescents.” Now more than 9 million children are classified as
obese.1 While the traditional response to a medical epidemic is to hunt for a vaccine
or a cure-all pill, childhood obesity is more elusive. The lack of success of recent
initiatives suggests that medication might not be the answer for the escalating
problem. This literature review considers whether the use of medication is a
promising approach for solving the childhood obesity problem by responding to the
following questions:
1. What are the implications of childhood obesity?
2. Is medication effective at treating childhood obesity?
3. Is medication safe for children?
4. Is medication the best solution?
Understanding the limitations of medical treatments for children highlights the
complexity of the childhood obesity problem inthe United States and underscores the thesis
statemen
need for physicians, t

1Obesity is measured in terms of body-mass index (BMI): weight in

kilograms divided by square of height in meters. A child or an adolescent with a BMI
in the 95th percentile for his or her age and gender is considered obese.
footnote

(footnote is used to define an essential term that would be cumbersome to define within the text)
 Obesity in Children 4

advocacy groups, and policymakers to search for other solutions.

What Are the Implications of Childhood Obesity?

Obesity can be a devastating problem from both an individual and a societal

perspective. Obesity puts children at risk for a number of medical complications,

including Type 2 diabetes, hypertension, sleep apnea, and orthopedic problems

(Henry J. Kaiser Family Foundation, 2004, p. 1). Researchers Hoppin and Taveras

(2004) have noted that obesity is often associated with psychological issues such as

depression, anxiety, and binge eating (Table 4).

Obesity also poses serious problems for a society struggling to cope with rising

health care costs. The cost of treating obesity currently totals $117 billion per year—a

price, according to the surgeon general, “second only to the cost of [treating] tobacco

use” (Carmona, 2004). And as the number of children who suffer from obesity grows,

long-term costs will only increase.

Is Medication Effective at Treating Childhood Obesity?

The widening scope of the obesity problem has prompted medical professionals to

rethink old conceptions of the disorder and its causes. As researchers Yanovski and

Yanovski (2002) have explained, obesity was once considered “either a moral failing

or evidence of underlying psychopathology” (p. 592). But this view has shifted: Many

medical professionals now consider obesity a biomedical rather than a moral

condition, influenced by both genetic and environmental factors.

Yanovski and Yanovski have further noted that the

 Obesity in Children 5

development of weight-loss medications in the early 1990s showed that “obesity

should be treated in the same manner as any other chronic disease . . . through the

long-term use of medication” (p. 592).

The search for the right long-term medication has been complicated. Many of

the drugs authorized by the Food and Drug Administration (FDA) in the early 1990s

proved to be a disappointment. Two of the medications—fenfluramine and

dexfenfluramine—were withdrawn from the market because of severe side effects

(Yanovski & Yanovski, 2002, p. 592), and several others were classified by the Drug

Enforcement Administration as having the “potential for abuse” (Hoppin & Taveras,

2004, Weight-Loss Drugs section, para. 6). Currently only two medications have been

approved by the FDA for long-term treatment of obesity: sibutramine (marketed as

Meridia) and orlistat (marketed as Xenical). This section compares studies on the

effectiveness of each.

Sibutramine suppresses appetite by blocking the reuptake of the neurotransmitters

serotonin and norepinephrine in the brain (Yanovski & Yanovski, 2002, p. 594).

Though the drug won FDA approval in 1998, experiments to test its effectiveness for

younger patients came considerably later. In 2003, University of Pennsylvania

researchers Berkowitz, Wadden, Tershakovec, and Cronquist released the first double-

blind placebo study testing the effect of sibutramine on adolescents, aged 13-17, over

a 12-month period. Their findings are summarized in Table 1.

Obesity in Children 6
Table 1

Effectiveness of Sibutramine and Orlistat in Adolescents

__________________________________________________________________________
Average weight
Medication Subjects Treatmenta Side effects loss/gain
Sibutramine Control 0-6 mos.: Mos. 6-12: After 6 mos.:
placebo increased loss of 3.2 kg
blood (7 lb)
6-12 mos.: pressure;
sibutramine increased
After 12 mos.:
pulse rate
loss of 4.5 kg
(9.9 lb)
___________________________________________________________________________
Medicated 0-12 mos.: Increased After 6 mos.:
sibutramine blood loss of 7.8 kg
pressure; (17.2 lb)
increased
pulse rate After 12 mos.:
loss of 7.0 kg
(15.4 lb)
____________________________________________________________________________
Orlistat Control 0-12 mos.: None Gain of 0.67 kg
placebo (1.5 lb)
Medicated 0-12 mos.: Oily spotting; Loss of 1.3 kg
orlistat flatulence; (2.9 lb)
abdominal
discomfort

Note. The data on sibutramine are adapted from “Behavior Therapy and Sibutramine
for the Treatment of Adolescent Obesity,” by R. I. Berkowitz, T. A. Wadden, A. M.
Tershakovec, & J. L. Cronquist, 2003, Journal of the American Medical Association,
289, pp. 1807-1809. The data on orlistat are adapted from Xenical (Orlistat)
Capsules: Complete Product Information, by Roche Laboratories, December 2003,
retrieved from http://www.rocheusa.com/products/xenical/pi.pdf
a
The medication and/or placebo were combined with behavioral therapy in all groups
over all time periods.

(A NOTE gives the source of the data. A content note explains data common to all subjects.)

Obesity in Children 7
 After 6 months, the group receiving medication had lost 4.6 kg (about 10

pounds) more than the control group. But during the second half of the study, when

both groups received sibutramine, the results were more ambiguous. In months 6-12,

the group that continued to take sibutramine gained an average of 0.8 kg, or roughly 2

pounds; the control group, which switched from placebo to sibutramine, lost 1.3 kg,

or roughly 3 pounds (p. 1808). Both groups received behavioral therapy covering diet,

exercise, and mental health.

These results paint a murky picture of the effectiveness of the medication: While

initial data seemed promising, the results after one year raised questions about

whether medication-induced weight loss could be sustained over time. As Berkowitz

et al. (2003) advised, “Until more extensive safety and efficacy data are available, . . .

weight-loss medications should be used only on an experimental basis for

adolescents” (p. 1811).

A study testing the effectiveness of orlistat in adolescents showed similarly

ambiguous results. The FDA approved orlistat in 1999 but did not authorize it for

adolescents until December 2003. Roche Laboratories (2003), maker of orlistat,

released results of a one-year study testing the drug on 539 obese adolescents, aged

12-16. The drug, which promotes weight loss by blocking fat absorption in the large

intestine, showed some effectiveness in adolescents: an average loss of 1.3 kg, or

roughly 3 pounds, for subjects taking orlistat for one year, as opposed to an average

gain of 0.67 kg, or 1.5 pounds, for the control group (pp. 8-9). See Table 1.

Obesity in Children 8

Short-term studies of orlistat have shown slightly more dramatic results.

Researchers at the National Institute of Child Health and Human Development tested

20 adolescents, aged 12-16, over a three-month period and found that orlistat,

combined with behavioral therapy, produced an average weight loss of 4.4 kg, or 9.7

pounds (McDuffie et al., 2002, p. 646). The study was not controlled against a

placebo group; therefore, the relative effectiveness of orlistat in this case remains

unclear.

Is Medication Safe for Children?

While modest weight loss has been documented for both medications, each

carries risks of certain side effects. Sibutramine has been observed to increase blood

pressure and pulse rate. In 2002, a consumer group claimed that the medication was

related to the deaths of 19 people and filed a petition with the Department of Health

and Human Services to ban the medication (Hilts, 2002). The sibutramine study by

Berkowitz et al. (2003) noted elevated blood pressure as a side effect, and dosages

had to be reduced or the medication discontinued in 19 of the 43 subjects in the first

six months (p. 1809).

The main side effects associated with orlistat were abdominal discomfort, oily

spotting, fecal incontinence, and nausea (Roche Laboratories, 2003, p. 13). More

serious for long-term health is the concern that orlistat, being a fat-blocker, would

affect absorption of fat-soluble vitamins, such as vitamin D. However, the study

found that this side effect can be minimized or eliminated if patients take vitamin

supplements two hours before or after administration of orlistat (p. 10). With close

(For a source with six or more authors, the first author’s name followed by “et al.” is used for the first
and subsequent references.)

Obesity in Children 9

monitoring of patients taking the medication, many of the risks can be reduced.
 Is Medication the Best Solution?

The data on the safety and efficacy of pharmacological treatments of childhood

obesity raise the question of whether medication is the best solution for the problem.

The treatments have clear costs for individual patients, including unpleasant side

effects, little information about long-term use, and uncertainty that they will yield

significant weight loss.

In purely financial terms, the drugs cost more than $3 a day on average

(Duenwald, 2004). In each of the clinical trials, use of medication was accompanied

by an expensive regime of behavioral therapies, including counseling, nutritional

education, fitness advising, and monitoring. As journalist Greg Critser (2003) noted in

his book Fat Land, use of weight-loss drugs is unlikely to have an effect without the

proper “support system”—one that includes doctors, facilities, time, and money (p.

3). For some, this level of care is prohibitively expensive.

A third complication is that the studies focused on adolescents aged 12-16, but

obesity can begin at a much younger age. Little data exist to establish the safety or

efficacy of medication for treating very young children.

While the scientific data on the concrete effects of these medications in children

remain somewhat unclear, medication is not the only avenue for addressing the crisis.

Both medical experts and policymakers recognize that solutions might come not only

from a laboratory but also from policy, education, and advocacy.

Obesity in Children 10

A handbook designed to educate doctors on obesity called for “major changes in some

aspects of western culture” (Hoppin & Taveras, 2004, Conclusion section, para. 1).
 Cultural change may not be the typical realm of medical professionals, but the

handbook urged doctors to be proactive and “focus [their] energy on public policies

and interventions” (Conclusion section, para. 1).

The solutions proposed by a number of advocacy groups underscore this interest

in political and cultural change. A report by the Henry J. Kaiser Family Foundation

(2004) outlined trends that may have contributed to the childhood obesity crisis,
Brackets
indicate a including food advertising for children as well as
word not
in the
original a reduction in physical education classes and after-school athletic programs, an
source.
increase in the availability of sodas and snacks in public schools, the growth in

the number of fast-food outlets . . . , and the increasing number of highly

processed high-calorie and high-fat grocery products. (p. 1)

Addressing each of these areas requires more than a doctor armed with a prescription

pad; it requires a broad mobilization not just of doctors and concerned parents but of
A
quotation
educators, food industry executives, advertisers, and media representatives.
longer
than 40 The barrage of possible approaches to combating childhood obesity—from
words is
indented scientific research to political lobbying—indicates both the severity and the
without
quotation
marks. complexity of the problem. While none of the medications currently available is a

miracle drug for curing the nation’s 9 million obese children, research has illuminated

The tone
of the
conclusio
n is
objective.
Obesity in Children 11

some of the underlying factors that affect obesity and has shown the need for a

comprehensive approach to the problem that includes behavioral, medical, social, and
political change.

Obesity in Children 12

References

Berkowitz, R. I., Wadden, T. A., Tershakovec, A. M., & Cronquist, J. L. (2003).

Behavior therapy and sibutramine for the treatment of adolescent obesity. Journal
 of the American Medical Association, 289, 1805-1812.

Carmona, R. H. (2004, March 2). The growing epidemic of childhood obesity.

Testimony before the Subcommittee on Competition, Foreign Commerce, and

Infrastructure of the U.S. Senate Committee on Commerce, Science, and

Transportation. Retrieved from http://www.hhs.gov/asl/testify/t040302.html

Critser, G. (2003). Fat land. Boston, MA: Houghton Mifflin.

Duenwald, M. (2004, January 6). Slim pickings: Looking beyond ephedra. The New

York Times, p. F1. Retrieved from http://nytimes.com/

Henry J. Kaiser Family Foundation. (2004, February). The role of media in childhood

obesity. Retrieved from http://www.kff.org/entmedia/7030.cfm

Hilts, P. J. (2002, March 20). Petition asks for removal of diet drug from market. The

New York Times, p. A26. Retrieved from http://nytimes.com/

Hoppin, A. G., & Taveras, E. M. (2004, June 25). Assessment and management of

childhood and adolescent obesity. Clinical Update. Retrieved from

http://www.medscape.com/viewarticle/481633

McDuffie, J. R., Calis, K. A., Uwaifo, G. I., Sebring, N. G., Fallon, E. M., Hubbard,

V. S., & Yanovski, J. A. (2002). Three-month tolerability of orlistat in

adolescents with obesity-related comorbid conditions. Obesity Research, 10,

642-650.