The ‘war on obesity’ has backfired, and scientists know why | 5 Questions
Research has shown that our current focus on obesity -- and Body Mass Index measures in particular -- can lead to eating disorders, body dissatisfaction, worse health -- and add pounds.
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That anti-fat messaging, a staple of public health initiatives for decades, hasn’t helped, according to Janell L. Mensinger, associate professor at Villanova’s M. Louise Fitzpatrick College of Nursing.
Indeed, her research has shown that our current focus on obesity — and body mass index measures, in particular — can cause harm, instead, in the form of eating disorders, body dissatisfaction, and even an increase in the BMI.
Mensinger, also a fellow of the Academy of Eating Disorders, is the lead author on a paper recently published in the journal Psychosomatic Medicine that provides new data about the unintended harm of our “war on obesity.”
We spoke to her recently about it.
When you talk about anti-obesity messaging, what do you mean?
It’s a broad umbrella term that encompasses health care weight monitoring, nutrition education that teaches people to keep food diaries and count calories, and, most important, anything that uses the BMI as a marker for someone’s health and well-being. There is this notion of fatness being bad.
Moralizing food choices is also an anti-obesity message. So when a person chooses to eat, say, a doughnut for breakfast as opposed to a piece of fruit, that’s known as a “bad choice.” It’s an anti-obesity message. A person who is in a larger body is going to be more chastised for that choice than a person in a smaller body.
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The thing to explain here is that obesity is a medical term. It implies disease. It implies that there is something physically wrong with the body. For a lot of people who fall into that classification, there is no disease. We have data showing that one-third of the people in the “obese” BMI category have nothing wrong with them. No high blood pressure. No high cholesterol levels.
Furthermore, we miss people by using the BMI classification because 25% of the people who are classified as “normal” by the BMI actually do have problems that are being overlooked. So more than half of people are being misclassified by this BMI formula.
We’ve been in the midst of this obesity epidemic for 30-plus years, since the ’80s. Yet we still have not figured out a way to help people have a lower BMI in any kind of long-term way. To tell a person they have a BMI that’s over the healthy range and not have a way to solve it is a really bad anti-obesity message.
What are the unintended harms of this messaging?
It doesn’t work. It is showing in the data to be contributing to more weight gain.
Some schools have something called the BMI report card. This is one of the worst anti-obesity messages. It labels kids as obese, overweight, normal, or underweight. This labeling was meant to try to help curb the obesity epidemic. But our research shows that kids who were labeled obese through this report card system had significantly more weight gains than the control kids who were not labeled.
Other research has shown similar results. In a large study funded by the National Institutes of Health, those who reported being identified as “too fat” in their medical appointments had significantly higher odds of having an “obese” BMI level 10 years later.
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At the same time, I hesitate to say it’s bad that the kids gained weight. Why? I don’t want to imply that this weight gain is so horrific that that is the only reason the report cards are bad.
The worst thing is that the report cards can stigmatize kids to the point where they are developing eating disorders, and even trauma symptoms. For children and adolescents, weight bullying is the No. 1 form of bullying.
Tell us more about eating disorders and how they’re related to anti-fat messaging.
Eating disorders are serious, life-threatening illnesses that have doubled in global prevalence over the last two decades. They now impact 1 in every 13 people. Eating disorders are especially more prevalent among people who are higher on the weight spectrum. Until the opioid epidemic, eating disorders were the deadliest mental health disorder.
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For the study we wrote about in our recent paper, we sampled nearly 3,000 individuals in higher levels of specialty care for eating disorders — residential treatment centers and intensive outpatient clinics. Some 37% did not know what caused their eating disorder. But among those who identified a specific cause, 28.5% identified anti-fat messaging. Also, those who attributed their eating disorder to anti-fat messaging had more severe symptoms.
We can’t necessarily prove that’s the cause of their disorder. Eating disorders have multiple causes. But it’s still important for eating disorder professionals to know that the messages these kids are getting is a factor in the development of eating disorders.
How should we be approaching obesity instead?
Health care professionals need to recognize the normalcy of body diversity. The research shows that people who are all shapes and sizes can achieve good health. My goal for the future is to develop a really good curriculum for physicians, nurses and other health care professionals that helps them understand that being outside the so-called normal is normal.
The BMI was never developed to be a health parameter. It was developed by a Belgian statistician as an algorithm to understand population height and weight statistics. It wasn’t intended for health, and it shouldn’t be used for health.
Instead, talk to patients about health behaviors and well-being. How are you feeling? What kinds of self-care do you engage in? It doesn’t sound so prescriptive, with morally good and bad behavior.
The other important point is that people will avoid health care if they’re feeling judged. They don’t do preventative appointments, or even sick appointments, for fear that they will be judged.
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What else should we be doing?
My conclusions have consistently been that we need to decouple weight loss from health. These two just should not be associated. Everyone thinks that if they lose weight, they are going to have long-term health gains. They might have short-term health gains. But long term? We just don’t have the data.
School health curriculums first and foremost need to simply stop the weight and diet monitoring for the sake of improving children’s health. If we stepped back and did nothing, we would be better off.
Babies are born with the innate knowledge of knowing when to start and stop eating. So maybe the answer to the obesity epidemic is to listen to our own internal signals — our signals of hunger and satiety. We need to trust our bodies to know when to eat and when not to eat.
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One caveat is that not everyone has access to food security. We have found that people with food insecurity are likely to have more eating disorders because they may be restricting their own intake for the sake of their children.
Otherwise, with intuitive eating, once people start paying attention, they start to crave the things that are good for them. We have been brainwashed into not paying attention to our bodies.
The whole idea of trusting in our bodies, physiologically, is hard for people. But once you get there, it’s freedom.