Obesity Screening Often Overlooks Eating Issues

With the “obesity epidemic” in the United States seeing no real end in sight, the government is starting to look at potential health solutions that will put the issue of weight and size even more in the spotlight.

Obesity has been linked to many health issues, and it is now the recommendation of the U.S. Preventive Services Task Force to screen for obesity and provide weight loss programs for people with a body mass index (BMI) over 30. An article in the Los Angeles Times suggests that health insurance plans would be required to fully cover the screening and resulting weight loss programs.

While screening for obesity and potential referrals to weight loss programs could be a wake-up call for many Americans, it is uncertain how this focus on obesity could affect other aspects of health, such as mental health and the growing stigma against overweight people.

The recommendation statement from the task force even considers that as a result of obesity detection and intervention, there is potentially “an increased risk for eating disorders.” However, trials for weight loss interventions found no evidence associating the interventions with increased risk for eating disorders and depression. Other experts have additional concerns in regard to obesity screening and resulting weight loss programs.

Judith Matz, a licensed clinical social worker, director of the Chicago Center for Overcoming Overeating, and co-author of the book The Diet Survivor’s Handbook: 60 Lessons in Eating, Acceptance and Self-Care, said in an email that obesity screening and resulting weight loss programs can lead to further stigma and discrimination against overweight and obese people.

“This type of program … will increase weight stigmatization by promoting the myths that all fat people are unhealthy and that anyone can lose weight,” Matz said. “The scientific literature says otherwise, but beliefs about thin and fat run so deep that they are often ignored. Unfortunately, weight discrimination negatively affects both physical and mental health.”

She suggested that there should be less of a focus on weight and more of a focus on a healthy lifestyle. “The Health At Every Size paradigm offers an excellent alternative by focusing on wellness rather than weight so that people can achieve optimal health,” Matz said. In addition, the task force recommends screening based on the BMI, which she states is generally ineffective. “These obesity programs potentially hurt the very people they are trying to help,” Matz said. “Research shows that when using body mass index as a proxy for health, there will be a significant percentage of people who fall in the obese category but are actually healthy, and there will be a significant percentage of people who fall in the normal weight category but are actually unhealthy.”

“Therefore, the solution is to make any referrals to counseling based on an individual’s health status rather than using BMI and then to focus on sustainable behaviors that support health, such as physical activity, attuned eating (eating according to physical hunger and choosing from a wide variety of foods), lowering stress, good sleep patterns, etc. rather than focusing on weight,” she added.

Even the weight loss intervention programs suggested by the task force for people with a BMI over 30 are mostly ineffective in the long run and could increase an already unhealthy relationship with food. “Counseling for weight loss is ineffective; while most weight loss plans and programs result in short-term weight loss, research shows that approximately 95 percent of people will gain back the weight and two-thirds [will end] up heavier than their pre-diet weight,” Matz said. “People who diet are at greater risk for eating disorders, depression, [and] poorer health as the result of yo-yo dieting and are likely to experience shame when their diet inevitably fails.”

Jessica Setnick, a registered dietician and the author of the American Dietetic Association Pocket Guide to Eating Disorders, said in an email that the recommendation by the task force could possibly benefit obese Americans more than their current options. “It is better than what is happening now – doctors tell their patients that they are overweight but then give them textbook advice to diet and exercise that is useless in the majority of cases and occasionally causes serious mental health issues like depression and eating disorders,” Setnick said.

“As someone who has treated overlarge individuals, it is a much more detailed process, slower and longer and harder than anyone gives them credit for,” she added. “The only way for most people to get the help they need from dietitians and counselors is if it is covered by insurance. Appropriate insurance coverage would ensure that the mental health causes of overweight and consequences of being overweight in a weight-phobic society could be addressed.”

She said that weight can be linked to mental health in many ways, and although weight loss can be beneficial in some cases, it’s not the final solution. “It is very depressing to be overweight in a weight-obsessed culture,” Setnick said. “However, weight loss is not the only answer to mental health issues. Often mental health issues predate weight gain and then also prevent weight loss. It is a vicious cycle that can only be broken with both kinds of care—nutritional and psychological.”

She has one major suggestion for the type of intervention that would be most useful for Americans who are struggling with weight and health issues. “Stop wasting time screening people based on the almost useless criteria of weight and instead offer every man, woman, and child in America three visits with a counselor and a dietitian to evaluate their current eating behaviors and their current and future problems,” Setnick said. “This is going to require individual and personalized intervention.”

She added that doctors will have to give more attention to potential eating disorders while they do the obesity screening. “Many individuals who seek medical care for weight loss have an eating disorder,” Setnick said. “They will receive many options for temporary weight loss that will not last, and most will not receive treatment for their eating disorder. Other individuals who are normal weight but have severe eating disorders are not seen as having a problem.”

“Our medical community and our insurance community need to get on board with better eating disorder education (for themselves) so that they know what to look for and how to refer those in need onward to eating disorder experts,” she added. “I can’t even begin to summarize the damage that well-meaning doctors have done to my patients with eating disorders, both over and underweight, in making it seem like nutrition and eating is a simple task.”

Related articles:
Binge Eating Disorder and Health at Every Size
We Are Greater Than The Sum Of Our Parts: Internal Family Systems Therapy for Eating Disorders
Do I Have a Healthy Relationship With Food and My Body?

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  • Bridget

    Bridget

    July 13th, 2012 at 11:11 AM

    This is one of those issues that we continue to treat the symptoms of something but not the real cause. Most people don’t get this way because they simply like to eat too much. For most obese people there is an underlying cause for this type of behavior that never gets acknowledged and cured. For some it may be that they have fears that they are trying to control or other emotions that they are trying to stuff away with the food. Whatever the root cause we are ignoring that and only looking to get people to slim down. I want people to look good and feel good physically, but none of that can happen and be maintained without changing how they look and feel emotionally and mentally too.

  • york

    york

    July 13th, 2012 at 3:19 PM

    Last time I checked people get fat cause they eat too much.

    When are we going to stop the blame game and just admit the facts? They have no willpower or otherwise they would be able to stop when they’ve had enough.

    For most of them there is never enough cause they have lost sight of the important things. For them it’s all about food and satisfaction that they get from the food.

    Push awau from the table a little early every now and then and you wouldn’t have those problems.

  • Emmett

    Emmett

    July 14th, 2012 at 4:20 AM

    Very educated, york. Note the intended sarcasm.

    I have been heavy for most of my life and it all started with hiding food as a child and then progressing from there. My weight was always a way for me to hide. I didn’t want anyone to see me, so I ate and hid behind the fat. I knew that once you get big, people really do stop seeing you. They don’t wish to have to deal with those issues so they ignore you. And of course then it gets out of control and you don’t know how to make it stop even once you have started to believ that you could be ready to change.

  • grant

    grant

    July 14th, 2012 at 6:37 AM

    What’s wrong with insurance companies charging higher premiums to people who are overweight and obese?
    If they want to pay the higher premiums then go ahead and keep the weight on.
    If they choose to have their premiums reduced then find a way to eat right and exercise and the weight will come off..I don’t think that it is wrong at all for those who have something going on that they could prevent to have to pay a higher price for insurance. That includes smokers too.

  • russell bernard

    russell bernard

    July 14th, 2012 at 1:15 PM

    as much as I agree with Judith Matz,i still think people with a high BMI need to be made a target of these drives because although anybody can be unhealthy in their eating habits, it is usually people with these high BMI that are most at-risk for health issues related to eating and obesity.

  • Shaun B

    Shaun B

    July 14th, 2012 at 3:47 PM

    I may have a BMI much greater than you but if you are eating all the wrong kinds of food and my BMI is higher not due to bad eating habits but genetic or something then you are in the red, not me!

  • nathan

    nathan

    July 15th, 2012 at 8:07 AM

    grant, its not necessary that those who are overweight are unhealthy.different people have different body types and a lot of factors go into deciding a person’s weight,frame,etc.one could be of the ideal weight and still have poor eating habits.

    and let us not even get started on anorexia.it is as harmful,if not more than,obesity.you wouldn’t expect an insurance company to charge someone a higher premium because they are excessively lean,now,would you?

  • grant

    grant

    July 15th, 2012 at 4:21 PM

    So let’s look at it this way- most of the time you see higher rates of heart disease and such among the overweight population. I am not saying that we all have to be model thin, that would not be the way that we are built. Some are bound to be a little heavier and some a little thinner. But all I am saying is that we should have to at least keep up our end of the bargain. We should at least have to maintain some ideal of health for the insurance companies to take a chance on us. Don’t I have to pay higher homeowner insurance rates if I live in a flood or hurricane zone? Don’t I have to pay higher auto insurance rates if I have a horrid driving record? With that in mind? then why shouldn’t I have to pay higher premiums for health insurance if I am less than the ideal candidate?

  • Ellie

    Ellie

    July 16th, 2012 at 4:35 AM

    The more my own doctors harped on me about how important it is to eat right and lose weight, the worse it makes me feel about myself. They always seem so critical and rather than helping me it makes me feel like they are really working against me and any effort that I have ever nade trying to lose weight. Why don’t they see that this is hard, harder for some of us than it is for the rest? Hard to kick those bad habits that we have been entrenched in since early in life? And harder still to see that under most of this we feel like a failure already?

  • Lisa

    Lisa

    July 17th, 2012 at 2:07 PM

    I really appreciate the comments from Judith Matz, she’s right on target, unlike some of the commenters who are woefully out of date in their assumptions about other people’s health.

    First off: pestering people about their weight – which creates body dissatisfaction – leads to MORE weight gain, not weight loss (see “Body satisfaction, Weight Gain and Binge Eating Among Overweight Adolescent
    Girls” Sonneville, Calzol, Horton, Haines, Austin & Field). This is something any eating disorders clinician could tell you, but it’s nice to have some new well done studies showing this. So if you don’t want people gaining more weight, stop making them feel bad about their body size. Be more size accepting.

    Second: the mortality risk for overweight and obese people is no greater than for ‘normal’ people when hypertension and diabetes are controlled for (see: (Jerant & Franks’ “Body Mass Index, Diabetes, Hypertension, and Short-Term Mortality: A Population-Based Observational Study, 2000–2006″ J Am Board Fam Med July-August 2012 vol. 25 no. 4 422-431). What we know is that there are plenty of fat people who are just as healthy (and non-eating-disordered) as their thin compatriots, and plenty of thin people with diabetes and/or hypertension and/or disordered eating who are being undertreated because hey, they’re BMI says their “healthy”. Is this fair to them?

    We all really need to stop making assumptions about people’s health, behaviors and lifestyles based on their body sizes. We’re harassing people who don’t need the harassment and ignoring people who might need some help. When are we going to finally “get it”: The data just does not support the very tired, very old fat=unhealthy paradigm. Let’s get over it!!

  • Jennifer Frank, Ph.

    Jennifer Frank, Ph.

    July 17th, 2012 at 2:21 PM

    People like York and Grant are espousing outdated and short-sighted information, respectively. York: there is a large, ever-growing body of evidence that becoming fat is not as simple as calories in equals calories out. You suggest we stop the blame game, but you are, in fact, blaming people for what you personally fail to understand. Grant: health premiums are already supposed to be based on health, and fat people are already paying more than others, based purely on their weight. If your argument is that people in dangerous situations should pay more insurance, that is even more reason not to base insurance rates on BMI, which doesn’t distinguish health from weight, but on factors indisputably correlated with health problems, like blood pressure, heart disease, blood sugar, etc. If you look at the data you will find many thin people who have these problems and many fat people who don’t. It makes better economic sense for all of us for the health and insurance industries to determine who really needs intervention, rather than creating unnecessary expenses for the healthy and automatically overlooking the unhealthy whose problems aren’t visible to the naked eye.

  • Shivaun Nestor

    Shivaun Nestor

    July 17th, 2012 at 2:52 PM

    I so appreciate this article. As someone who for over 2 decades has worked with adolescents regarding sexuality and body I so support Ms. Weaver’s recommendations. The focus on BMI in a fat-phobic culture can only increase eating disorders throughout the population, and as the author points out, will miss out on nutrition and exercise counseling for “normal weight” people, many of whom will have eating disorders, who might benefit. The emphasis on weight and the resulting stigmatization of heavier people (as illustrated by a number of commentators here), has resulted in an epidemic of very unhealthy yo-yo dieting which has itself greatly contributed to the obesity epidemic. If weight management were a simple matter of calories in / calories out, as York and others seem to imply, no one would be obese in such an environment, where fat folk experience discrimination on a daily basis. More to the point, it is a myth that being overweight in and of itself is a health risk. A number of studies over the years have found that people with BMIs higher than the normal range actually have better mortality (death) and morbidity (disease) outcomes than their “normal” counterparts, and that the health outcomes of those in the underweight BMI range – which would include the majority of actresses and supermodels now widely perceived as the “ideal” – actually have far worse health outcomes.

  • Susan Koppelman

    Susan Koppelman

    July 28th, 2012 at 11:56 AM

    The calories in/calories out idea has been for so long rendered laughable by scientifically testing it as if it were a description of reality, it is so thoroughly disproved, that I wonder if the idiots who promolgate the idea, as have some in the list of commentors here, just for the sake of argument. Surely those people aren’t serious — nor do I believe they are that stupid, so what is their reason for saying stupid things?

  • Susan Koppelman

    Susan Koppelman

    July 28th, 2012 at 2:01 PM

    I detect, as I read these comments, a lot of ideas that seem predicated on the desire to make money, to find a market for a particular set of skills and credentials. “Hmmm, how can I use the oppressive and pointless war against obesity to make a buck?” The real trouble with HAES is that no one is going to get rich off of it. Some will make some money being in the setting the rest of the world straight and helping people loosen their addiction to the worship of unnatural ideas about body size, weight, health, ad beautfy. But there won’t be a lot of return customers. Once you kick the addiction to internalized bigotry, you don’t need to pay for anything more. You just live your life and feel good about yourself, proud that you have survived the soul murder and eager to go forward with your life. Whereas those folks selling diets — which, if you remember, fail 95% of the time — get a lot of return business. Keep selling an unreachable goal to a marketplace trained to want desperately the product you’re selling and it’s a dance all the way to the bank, to the Cayman Islands, to buying gold to hold onto during the depression. Then your only problems are how to hold on to your clientele and how to invest and spend your bounty.

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