The “War” on Obesity: Call to Action for Clinicians Caught in the Crossfire

By Sandra Wartski, Psy.D., CEDS

Our culture and healthcare system present an array of confusing, misleading messages for Americans about “healthy eating” and weight. Clinicians working with individuals with Eating Disorders (EDs) are often caught in the crossfire, wanting to help their clients to think differently about food and their bodies but often representing a small minority in the flood of rampant, derogatory societal messages.

The current public health campaign of “The War on Obesity” ends up adding more detrimental layers to the already distorted crusade of attempting control of the body – not only for our clients but also for the general public.  The “War on Obesity” may sound like the “War on Drugs” and the “Just Say No to Drugs” advertising campaign which was prevalent during the 1980s and 1990s; however, addressing eating and weight is a drastically different issue.

ED clinicians have insider knowledge on how some of the conventional tactics for approaching with eating and bodies are not only ineffectual but downright damaging.  We also know that there are more effective, empowering, evidence-based strategies that can help individuals develop ​long-lasting ​habits of true healthful eating and positive body appreciation. So, when I saw that my professional organization, the American Psychological Association (APA), was seeking out comments on their draft guideline entitled “Clinical Practice Guideline for the Behavioral Treatment of Obesity and Overweight in Children and Adolescents,”  I knew this was my opportunity to provide some input.

APA is the national organization of psychologists which represents over 115,000 members.  Part of their mission is to “advance the creation, communication and application of psychological knowledge to benefit society and improve people’s lives” and to be involved in “encouraging the development and application of psychology in the broadest manner.” One of the ways in which APA furthers such goals is through creating task force reports, policy statements, press releases, tip sheets, reports and practice guidelines.  I have come to rely and trust many of these that are released as representing a high standard in the field of psychology, but the most recent Practice Guideline Draft needs considerable work and revision.

Orientation to the Guidelines Draft

The draft of the obesity treatment guidelines were developed by an APA guideline development panel “composed of scientists, clinicians, and client/community representatives.”  The focus is intended for delivering family-based multicomponent behavioral treatment of children and adolescents ages 2-18 years who are overweight or obese. The panel used Kaiser Permanente Research Affiliates Evidence-Based Practice Center (O’Connor, Burda, Eder, Walsh, & Evans, 2016) to help them to evaluate what is currently known about the treatment of obesity and how best to be delivering behavioral treatment with this population. The intended users of this document would “include psychologists, other health and mental health professionals, students/ training programs, consumers, families of consumers, policy makers, and the public.”  The actual draft is 104 pages long, but this includes introduction, disclaimers, disclosures and references.  Perusing through various sections provide one with a summary of the general conclusions.

Five key questions were asked and answered within the scope of the guidelines.  The way in which the questions are asked and the factors discussed provides a good overview of the orientation (and the bias) evidenced throughout the document:

“1. In children and adolescents with overweight or obesity, do family-based multicomponent behavioral interventions reduce and maintain change in age/sex- standardized BMI?

  1. What is the impact of selected characteristics of family-based multicomponent behavioral interventions (dosage of contact, setting, interventionist qualifications, mode of delivery, use of multidisciplinary team, involvement of psychologist, cultural tailoring) in the management of age/sex-standardized BMI?
  2. How do selected patient and family sociodemographic characteristics (child’s age, severity of adiposity, parental obesity, race, socioeconomic status) affect family-based multicomponent behavioral interventions?
  3. What is the impact of selected strategies of family-based behavioral interventions (goals and planning, comparison of outcomes, self-monitoring of behavior, self-monitoring of outcome, reward and threat, stimulus control, modeling of healthy lifestyle behaviors by parents, motivational interviewing, general parenting skills in the management of age/sex-standardized BMI?
  4. What is the effect of patient adherence (e.g., percentage of homework completed, percentage of sessions attended), engagement, and retention on BMI outcomes?”

Their website includes the draft guidelines and related materials: http://apacustomout.apa.org/commentPracGuidelines/Comment.aspx?siteCode=3

While I was initially a bit discouraged as I read over the guidelines, I was then pleased to read the comments already submitted by others.  My hope was buoyed as I saw many other clinicians from the ED field have commented astutely and passionately, though adding more of them will likely only support the serious consideration by the panel of some alternative ideas.   The comments portion of the current draft are available here (and remains open for comments through November 5th):   http://apacustomout.apa.org/commentPracGuidelines/viewcomments.aspx

Highlighting Some Areas of Concern

Within the Disclaimer section at the very beginning of the document, APA notes that “Guidelines differ from standards in that standards are mandatory and may be accompanied by an enforcement mechanism. Thus, guidelines are aspirational in intent. They are intended to facilitate the continued systematic development of the profession and to help assure a high level of professional practice by psychologists.“ Guidelines may indeed not be mandatory, but the existence of them certainly can provide the appearance of “best practice.”  In order for these guidelines to truly assure a high level of practice, attending to and including decades of ED research and treatment is mandatory.

From the very beginning in the Executive Summary, the draft notes that “Evidence-based clinical practice guidelines are intended to assist the healthcare system in providing appropriate care, improving quality and consistency of care, and reducing mortality and morbidity.”   While there is no argument in the mission of helping the healthcare system to prevent the onset of more serious health problems, the guidelines seem to be missing the way in which inappropriate work in this regard can actually lead to mental health problems and further health problems.  Most any experienced ED clinician has multiple stories of clients whose EDs started when a potentially well-being healthcare professional commented on their weight in perhaps a seemingly gentle or innocuous way but was absorbed in such a way that the cascade of other problematic thinking and behaviors followed.  It is recommended that the panel be urged to study the bigger issues at play and the way the lens of appropriate intervention needs to broadened.

Within the Introduction to the Topic section, there was the expected review of prevalence rates and the outlining of health risks of obesity.  The way in which weight can impact mental health and psychological development in children was also highlighted, though some of the findings appear somewhat circular.  The draft guidelines notes that “Children with overweight or obesity experience pervasive and often unrelenting weight stigmatization from an early age (Puhl & Latner, 2007; Harrist, Swindle, Hubbs-Tait, Topham, Shriver, & Page, 2016)” and also identifies how “Sources of  stigmatization include peers, parents, teachers, coaches and strangers (Puhl et al., 2013).”  The authors are applauded for recognizing the way in which weight is often  a source of teasing, bullying, and shame;  however, there does not seem to be the awareness that certain intervention programs can end up providing a platform from which various adults might end up being encouraged to provide a form weight stigmatization in a very harmful way.  The authors acknowledge that focusing on weight for children causes “higher rates of depression, social isolation, low self-esteem, and poorer quality of life (Small & Aplasca, 2016),” and so this needs to be taken in account for this particular program from the start.

In the Methods and Process section, various procedures utilized were outlined.  The method of concern which stood out most for me was the use of BMI.  The draft guideline suggests that:  “Obesity is defined as body mass index (BMI) ≥ 95th percentile while overweight is defined as BMI ≥ 85 % percentile based on the Centers for Disease Control (CDC) growth curves for age and gender.”  Most ED clinicians have come to know how weight and BMI as indicators of health are inaccurate and misleading.  There are many other factors that provide indicators of true holistic health. The panel is urged to look more closely at the HAES (Health at Every Size) literature as a starting point for a broader definition of health and well-being(www.haescommunity.com ).  The HAES approach is much more focused on interoceptive awareness and is much more ego-syntonic, and this leads to it being an approach that individuals can actually apply for the long term  Measuring behaviors and thinking is clearly much more difficult in researching than using a single number, but someone’s BMI – especially for a child – is so complex and multi-determined.  Even CDC themselves acknowledge some issues with BMI usage (https://www.cdc.gov/obesity/downloads/bmiforpactitioners.pdf).

There was some explanation made about the choice of BMI over weight: “The panel decided to focus on body mass index (BMI) and standardized BMI (zBMI), and not weight loss as some children may need to stop gaining weight while continuing to grow to return to a healthy weight range.” Rather than focus on weight or BMI, which is a complex, multi-determined marker, can we not focus on other, more true markers of physical and emotional health? Weight is not a behavior, and it is less controllable than is often assumed.  Much more empowering would be focus on behaviors that are controllable, like building strength, flexibility and appreciation.

Also of concern is the glaring fact that the panel does not seem to be taking into account that humans grow at different rates within a wide range of growth percentiles, not to mention that weight loss efforts during childhood can negatively impact a number of important systems in the body.  This is not a “one size fits all” model and can’t be reduced to a small margin of “acceptable” weight or BMI.  Children need to be compared to their own rates of growth rather than a statistical cut-off point, as this is what will allow a more accurate picture of whether there are concerns about significant weight changes for a child or not.

Within the Potential Harms and Burdens of Treatment section, there was a note to indicate that “The panel recognizes that family conflict could arise during treatment. Children could develop psychological issues related to the success or failure of the recommended intervention. Few studies assessed psychological well-being but did report on quality of life and only one study suggested a possible negative impact from the intervention.”  It is suspected that family conflict and negative quality of life factors might actually be quite problematic in a much higher number of cases, but the way in which this is measured needs to be considered in more detail.  Relying only on a parent’s report of conflict or a rating form of family stress will not capture the internal distress or confusing messages that children can and do adopt (which can then often lead to development of an ED).

These draft guidelines were compared to other  currently available treatments in several different sections. There seems to again be distinctive lack of attention to the ED field and “lessons learned” type of research that exists.  The authors did summarize that other plans included certain key components: “following a healthy diet, increasing physical activity and/or reducing sedentary time, incorporating behavioral practices in support of the required changes in behavior, and parental involvement.”  Children need not to be given more good/bad food labels (as our society does enough of this) or right/wrong exercise ideas; instead, they can be offered choices in a wide variety of foods, be urged to develop more of the intuitive eating abilities that are innate, and find activities they enjoy. The panel has an opportunity to potentially ­develop ground-breaking focus on very different ways to approach this situation, rather than do more of the same that hasn’t worked. The authors would be urged to seek out other methods of intervention, such as the highly-acclaimed Ellyn Satter’s Eating Competence Model and Division of Responsibility (www.ellynsatterinstitute.org).  Rather than shaming themselves, kids need to be helped to appreciate the strengths of their bodies and truly commit to taking care of themselves in a broad, non-weight-biased ways. I was also surprised that even the 2016 American Academy of Pediatrics (AAP) Guidelines on “Preventing Obesity and Eating Disorders” weren’t referenced, especially as their recommendations  include focus on “discouraging dieting, skipping of meals or the use of diet pills; promoting a positive body image; encouraging more frequent family meals; and suggesting that families avoid talking about weight.” ( www.aap.org/en-us/about-the-aap/aap-press-room/pages/AAP-Clinical-Report-Steps-to-Prevent-Teen-Obesity-and-Eating-Disorders.aspx )

There were various final recommendations made, including the following conclusion: “For child and adolescent patients with overweight or obesity, the panel strongly recommends the provision of family-based multicomponent behavioral interventions, with a minimum of 26 contact hours, initiated at the earliest age possible.”  There is concern about the blanket recommendations overall and the way in which the stigmatization potential seems strong, but this particular recommendation struck me in terms of the way that there was focus on addressing this with very young children.  This would seem to only increase stigmatization from an early age when they are growing, developing and actually still most in touch with intuitive eating.

The recommendations within this draft were focused on children and teens, but there really could be application to all humans.  The panel has an opportunity to zoom out for larger perspective of how our society could benefit from a shift to fewer labels, fewer weight-related assumptions, more focus on legitimate solutions and more inclusivity for well-being overall.

Within the concluding sections, there was a positive reference about how to approach these strategies: “The panel stressed the importance of treating children with overweight or obesity—as well as their parents or guardians—in a non-judgmental, non-stigmatizing manner. As noted, these children are already subjected to weight-based bullying and increased stigma. Adverse childhood experiences, such as abuse or exposure to violence, can also contribute to weight gain and should be considered. Furthermore, children may be singled out by their peers or other family members simply because they seek treatment or participate in a weight-management program.”  I would like to see more education and focus around this extremely important point.  It cannot be assumed that healthcare professionals have the knowledge base, sensitivity and skills to be able to approach this topic in the most effective way. It would be suggested that this notion be expanded and shifted to be of primary focus rather than more of an after-thought reference that could be easily missed.

In addition, there was another positive reference to the philosophy of how to make implementation more effective:  “The need for practitioners to develop knowledge, skills, and awareness related to weight bias and stigma (differential and negative treatment and attitudes experienced by people who have overweight or obesity). Health professionals and family members have been identified as the most frequent sources of weight stigma for individuals with obesity (Puhl & Brownell, 2006; Puhl & Latner, 2007; Puhl, et al., 2013). Weight stigma has a negative effect on weight management. An increased exposure to weight stigma is associated with higher BMI and controlled research has found increased cortisol and caloric consumption in adult women following stigmatization (Schvey, et al., 2011; Schvey, Puhl, & Brownell, 2014). Consequences of weight stigma reported in children include psychosocial concerns of lower self-esteem, depression, body dissatisfaction, and a negative impact on their interpersonal relationships (Puhl & Latner, 2007).”  These are excellent points and would be recommended to be included more prominently throughout any final guidelines that might be published, rather than tucked away more at the end of a guideline where they could be overlooked or lost.

More family intervention in effective ways is needed.  The panel does acknowledge that “Parents and guardians may also suffer from overweight or obesity and either be blamed or perceive being blamed for their child’s weight condition. Providers need to be sensitive to these issues and the impact they have on the child’s self-esteem and the willingness of the child and family to participate in treatment.”  It is suspected that a kinder, gentler, non-shaming approach would absolutely benefit children and their parents.  Parents don’t need training on how to be the “food police” or the “boot camp commander” but instead could be helped with skills such as developing intuitive eating, enjoying nature and appreciating individuals from the inside out.

There is much nuance in this work that can be missed but is critical.  If a child or teen is using emotional eating to soothe, suggesting more vegetables or less soda will not address the additional self-soothing tools that are needed.  It is also important, however, to not assume that all kids who are larger are engaging in emotional eating.  Some people have larger bodies, are supposed to have larger bodies and are not unhealthy.

Also within the Discussion section was a caveat to subjects who should not be included in this intervention: “Children and adolescents with eating disorders, for instance, may have problematic eating patterns or beliefs about food that will need to be addressed along with supportive changes to diet.” This area needs considerably more work. There may be some biases or assumptions that children or teens who are not underweight are less likely to have EDs, and we know this to absolutely not be the case. Just as we can’t assume that someone of larger body has an ED, we also can’t assume that they don’t.  The fact that Binge Eating Disorder now finally made it to its own distinct category in DSM-5 is a step towards more people potentially being helped with the most common type of Eating Disorder in the US.  Millions are suffering with this severe yet treatable illness, but food restriction and body shaming is not the recommended treatment.

In the Future Research Needs sections, there was frequent mention of “insufficient evidence” but one of the glaring areas of concerns to me was indication that “This review was also not able to report on potential harms of the interventions. As family-based, multicomponent behavioral interventions are considered to produce minimal harm, investigators rarely report on harms. However, to fully evaluate programs, potential physiological, as well as psychosocial (either to the child or the family), harms need to be routinely assessed and reported.”  This conclusion is absolutely critical.  Despite the fact that the well-meaning researchers might not be able to imagine the type of psychological impact that any type of weight-focused, family-based intervention might have on the child does not mean it does not exist.  They go on to acknowledge that they have “no additional outcome measures beyond BMI/zBMI” and that “information is needed on potential harms of interventions.” These are highly significant gaps in this line of intervention and should be resolved before any new guideline is finalized. With proper research exploration, the panel will uncover how weight loss interventions often trigger EDs.  There is strong evidence (not to mention ED clinician experience) to show that dieting leads to weight cycling, weight regain, resetting of metabolisms, and vulnerability to disordered eating patterns.  The authors may not call it dieting but changing terminology does not mean that others won’t interpret this intervention as finding ways for children to engage in restrictive eating. The rubber band effect then occurs, forcing one extreme leads to the eventual other extreme. Again, intentional weight loss can actually increase health problems.

Within one of the final sections of Author Disclosures, there were several red flags. Several of the authors seem to have been associated with weight loss centers and focused on weight loss as their primary area of research.  This would appear to be a very significant conflict of interest.  I was also saddened to see no ED professionals within the panel, and this seems to be a huge oversite that needs repair before the guideline editing can continue.  There are numerous highly skilled and knowledgeable professionals who would add depth, richness and clarity to the current panel.

Invitation to Speak Up

There are many issues with this draft guideline, and I hope other ED clinicians will choose to provide some input.  We have a responsibility to help educate the public and other clinicians about how weight loss interventions can and often do trigger ED behaviors and thinking. Let’s help APA not support fat phobia and socially acceptable prejudice.  Our country has made some progress in being more inclusive in diversity in other domains;  we are over-due in the need to increase body diversity acceptance as well.  The psychological community is well-positioned to help create a total paradigm shift in this domain.  That type of focus would be pioneering, and that type of work by APA is something that I could potentially get behind fully.

Comments on this draft are welcome from all interested individuals (including healthcare professionals, researchers, general public, clients/patients and their families,) through this link http://apacustomout.apa.org/commentPracGuidelines/Comment.aspx?siteCode=3.  The full draft guidelines, the Kaiser review of obesity treatment, and other comments made to date are available on that website.   The link will remain open for comments until midnight on November 5, 2017.

If you are an ED clinician who wishes not to be a soldier in the obesity war but instead be an activist using your knowledge for betterment of the larger society, please consider leaving a comment or feedback for APA to take into consideration as they move forward to produce the final version of the guideline. We owe it to our nation, our clients (present and future) and ourselves.

 

Sandra Wartski, Psy.D., CEDS is a licensed psychologist who has been working with Eating Disorders over the past 25 years. She works as an outpatient therapist at Silber Psychological Services in Raleigh, NC. She enjoys providing presentations and writing articles on a variety of mental health topics, particularly ED-related subject matter. Send comments to sandra@wartski.org

The opinions and views of our guest contributors are shared to provide a broad perspective of eating disorders and not intended as endorsement by iaedp Foundation or its Board of Directors.

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