Obesity and Eating Disorders (ie Which came first? The chicken or the egg?)

ss_245472493_doctor_girl_teenAs I was preparing for a talk about effective obesity screening with the US Department of Health and Human Services (see below for link), I found myself getting really frustrated with the over-simplification of obesity.

Childhood and adolescent obesity is definitely a problem. It has increased a lot over the past 4 decades (like three- to six-fold). Over 1 in 5 youth are currently obese.And there are serious health risks associated with obesity, including type 2 diabetes, heart disease, certain cancers, etc.  Over a lifetime, childhood obesity costs $19,000 per obese child as compared to a normal weight child. Due to this, the US Preventative Services Task Force (USPSTF) has recommended that clinicians screen for obesity by checking Body Mass Index (BMI, ratio of weight to height that’s standardized for age and gender), and determine treatment based on that BMI.

I get it. Obesity is a major public health issue. But it’s also a really complex problem, much more complex than a simple mathematical calculation. There are many factors that figure into weight: genetic factors, social factors, psychological, and environment. There can be health related problems across the spectrum of weight. Let’s talk about the flip side (or same side of different coin?  I’m not sure of the proper metaphor): eating disorders, and how they are related to obesity. Believe it or not, they are not mutually exclusive.

As the prevalence of obesity has increased, so has the prevalence of eating disorders. The incidence of eating disorders has doubled since 1960. We have seen hospitalization rates for eating disorders rise, increasing 18 percent between 1999 and 2006 (up 119% in kids under 12 years).

There are many common risk factors for eating disorders and obesity:

  • genetic factors: both obesity and eating disorders tend to run in families
  • psychological factors: low self-esteem, poor coping mechanisms
  • sociocultural factors: body dissatisfaction, mixed media messages

Eating disorders can be the cause of obesity. More than one-third of obese individuals in weight-loss treatment programs report difficulties with binge eating. Night eating syndrome (one of the lesser known eating disorders where patients consume most of their food after dinner and get up in the middle of the night to eat) also has a link to obesity.

However, eating disorders can also be the effect of inappropriate counseling for obesity. I’m sure it’s not surprising that I have had a lot of patients who were bullied at school for being overweight and resorted to extreme measures to lose weight, like starving themselves, making themselves throw up after eating, taking diet pills, etc. I have also had a lot of patients who were told by a health care provider that they were obese and need to lose weight to be healthy, and these patients also resorted to extreme measures to lose weight. The patients felt bullied by their health care provider and traded one health issue for another.

I may sound like I’m against measuring height/weight and calculating BMI, but I’m definitely not. BMI is an important data point in a patient’s health, but it is just that: a data point. It says nothing about the individual situation of the person (Are they on a medication that increases appetite? Are both parents working to pay the rent and it’s easier to have prepackaged meals for the kids to make themselves?), and only gives a small piece of the picture in regards to health. Weight discussions can be very emotional and personal.  In the wrong hands, the weight/BMI discussions can cause a lot of harm. We should treat obesity as a medical diagnosis just like we consider eating disorders medical diagnoses. Weight/BMI should not be something that we use to create guilt or blame (which is why I struggle with teens getting their BMI tested in health class. The well-meaning health educator should not be making a medical diagnosis and it definitely should not be done in public with the watchful eyes of their peers. Every year after that unit, I get a handful of patients that have adopted some risky weight loss behaviors).

What are we to do?

The focus should be on healthy habits, not weight or BMI.  Even people in a healthy BMI category may have unhealthy habits which need to be improved.  Healthy habits include eating a balanced diet, getting enough physical activity, limiting sedentary behaviors (screen time, texting, etc), and limiting intake of sugary beverages.  UW Health has summed up healthy habits in a nifty little 5-2-1-0 campaign (as in 5 daily servings of fruits/vegetables, less than 2 hours of screen time daily, 1 hour physical activity daily, and 0 sweetened beverages). I would also add in the number 3, as in eating 3 meals a day.  Skipping meals is not an effective strategy for weight loss.  Eating together as a family is another healthy habit that can be protective for both obesity and development of eating disorders.

We should all aspire to the same goal – a healthy, disease-free population who eat well, are physically active, and are satisfied with their bodies.

Here’s a link if you’re interested in the webinar for Tuesday 11/10/15 at 10am. http://adolescenthealthseries.net/event/effective-screening-and-counseling-for-obesity-in-adolescents/#eventtop