Childhood Casualties of the “War on Obesity:” A CALL TO ACTION for Health Care Providers

From a quick check of the mainstream medical literature, the “War on Obesity” appears to be in full swing. The alarm is audible everywhere, at our medical conferences, in our offices and hospitals, from government leaders, within our schools, and for many of us, within our own households. We as health care providers, are trained to believe that fat is the enemy, and that, beyond a certain BMI, we must help our patients lose weight (or at least maintain a stable weight during periods of growth) in order to make them healthier. Our training has been so focused on outcomes (e.g. weight and BMI) as indicators of health, that we actually feel progressive when we focus on “healthy lifestyle choices,” rather than on simply eradicating fat through weight loss. When we see the number on the BMI chart increase or witness rapid weight gain in a pre-pubescent child, we may feel pressure to make recommendations designed to promote weight loss in addition to a healthy lifestyle. We are encouraged to counsel patients and parents about increasing activity and favoring "healthy," "low energy-density" foods over higher-calorie food choices (in other words, to promote calorie restriction dieting). We have the best of intentions and the message out there is that danger is all around us, in the form of too much fat, and that we must act decisively and [strongly] to destroy our enemy through calorie restriction and vigorous exercise. We do this because we are the guardians of wellness, good health, and prevention, or so we think…

The problem with our “war on obesity” is that, as in all wars, there are unintended casualties for our children. When we tell children that the fat on their bodies will kill them, or that their bodies are unacceptable if they do not conform to the cultural thin ideal, or the bell-shaped curve of “acceptable” weight or BMI values, they internalize these judgments as shame, whether they recognize it in the moment or not. When we become alarmed about their weight or BMI, and start encouraging them to eat less and move more, without asking more questions, we risk eroding their self-confidence, body image, and attunement to their internal signals about when, why and how much to eat. The psychological consequences of our “war on obesity” are very real, and can set up a child for body hatred and a lifetime of yo-yo dieting (also known as weight cycling, which has been proven more harmful (physically and psychologically) than maintaining a high but stable weight). Encouraging a child to exercise vigorously in order to make their body more acceptable sets them up for potential injury, and worse, for hating exercise, which is an important part of enjoying (and thus sustaining) a wellness-promoting lifestyle.

Consider that perhaps the enemy is not the fat, but rather the stigma surrounding it, which our patients are quick to internalize and which drives them to be dissatisfied with their bodies and restrict calories, or diet, or engage in excessive exercise “in order to become healthier.” The real problem is that the prevailing recommendation for those with a BMI or weight above a certain number is calorie restriction, which does not usually lead to sustainable weight loss and does not ultimately improve health. Medical professionals who recommend calorie restriction dieting would do well to remember that the psychological consequences of dieting and weight-cycling include negative body image, poor self-esteem and self-efficacy, and weight-obsessed misery. The potential physical consequences of dieting include weight re-gain, becoming overweight, weight cycling, body dissatisfaction, binge eating, and an increased risk for developing an eating disorder. Add to these consequences the fact that our alarm, rhetoric, and admonitions to eat less and exercise more have not proven effective in making our children lighter or healthier, and we might conclude that we need better strategies to promote real wellness in our children.

From a mental health standpoint, trying to change outcomes (weight, BMI, lab values) without focusing on the psychological underpinnings of true wellness and sustainable behavior change is like building a mansion on a beach without a foundation. Unacknowledged beliefs and thought patterns, like the rising and receding tides, will undermine the very best intentions and efforts, if the strategies and skills that promote long-term success are not built in to the construction plans. On the other hand, deliberately teaching a youngster to accept and care for his or her body and mind with love, respect, attunement, and the self-care strategies and life skills to cope with the inevitable obstacles and challenges of real life, is more akin to building the same mansion on a well-designed, carefully planned, solid and flexible foundation that will weather the daily tides as well as the occasional storm.

We as medical practitioners have spent the past 50+ years giving nutritional advice based upon faulty science, in large part because the "eat less and move more" mantra was hardwired in to our education. There is no question that eating nutritiously and engaging in daily physical activity promotes health. It's just that restricting calories is not the answer it was purported to be. We are learning that the content of the diet matters, just not in the way we were taught to believe. Not all calories are created equal, and the highly-processed, sugar-laden foods that are provided to our children in schools and promoted in the media to overworked, underpaid parents, are far more dangerous to their metabolic health than a few pounds of fat. Encouraging a family to restrict calories when the calories are coming from foods that are 1.) highly processed and 2.) laced with countless chemicals, amounts to metabolic disaster and a recipe for reactive eating and binging. The sad fact is that for our poorest youth, many of whom live in food deserts without access to grocery stores selling fresh, unadulterated produce and protein sources, nutritious food that promotes their health is not even available. The psychological strength and will that these youth, as well as the rest of us, will have to muster to feed themselves healthfully on a consistent basis, given the realities of our current food environment, is incredible. In order to make choices that serve them, they will need to be taught to think critically about what is really in their best interests, as opposed to what serves the advertisers, the food industry, or the weight-loss industry. We can train our patients and families to practice the self-compassion and good self-care that support and help sustain wellness-promoting behaviors. That training starts with promoting body appreciation, acceptance of diversity in body types, attunement to internal signals, and rejection of weight stigma, and and it starts with health care providers leading by example.

 Tracy L. Tylka, Rachel A. Annunziato, Deb Burgard, Sigrún Daníelsdóttir, Ellen Shuman, Chad Davis, and Rachel M. Calogero, “The Weight-Inclusive Versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being Over Weight Loss, Journal of Obesity (2014): 3-4. http://dx.doi.org/10.1155/2014/983495

 Evelyn Tribole. “Warning: Dieting Increases Your Risk of Gaining More Weight (an update),” https://www.intuitiveeating.com/content/warning-dieting-increases-your-risk-gaining-more-weight-update.

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Paige O'Mahoney