The HAES (health at any size) movement is now demanding that doctors “do not prescribe weight loss as a medical intervention” and “provide me shame free medical care”. See the hand out card at the bottom of this page:
So, we don’t let anorexic people kill themselves through their diet, even going as far as forced interventions and we treat it first as a mental health issue, then only after that try and get them to make diet and lifestyle change. Should we do the same for obese people? Rather than a doctor just saying ‘you need to lose weight, change your diet and get some exercise’ , first perhaps refer them to counselling to treat the mental health issue, THEN make the diet and lifestyle changes.
We all pay higher costs for medical care and insurance because of the huge incidence of problems caused by obesity, should we let the HAES people demand “shame free medical care” ? I would hope the health problems caused by obesity are obvious enough, but in case they are not, here is a cite:
I think it should be an “all of the above” approach. I think the mental health care should take place along with the diet/exercise and physical health recommendations. But I agree, the food-related mental obstacles that are in place for many obese people (and non-obese people as well) preventing them from reaching optimal health are under-addressed.
Sure ideally, it should be all of the above, but currently there isn’t a recognised disorder in the DSM V (diagnostic and statistical manual), which I as I understand it means that any such mental health counselling couldn’t be covered by insurance costs. The only relevant one is “Binge Eating Disorder” which is a specific issue that most obese people do not have.
Well, you mention anorexia. That has an acute effect; a person can be said to be facing immanent death. Obesity is rarely if ever like that. It is supposed to be unhealthy and may shorten one’s lifespan, but we can’t say for certain in most particular cases.
And what about mothers? Having kids makes a lot of people fat. Are they crazy?
There are plenty of chronic illnesses that don’t kill you but instead cause long term health complications. Obesity is one of those.
“obese” has a specific medical meaning, a BMI of 30 or greater. I am not aware that being a mother “causes” you to reach that BMI. Also I have never used the word “crazy” and no mental health professional ever does. Have a mental health disorder of any kind does not make you “crazy”.
The problem with that approach is that it can take years to treat mental illness with no guarantee of success. I have been under nearly continuous treatment for Major Depressive Disorder for 20 years, with little success. Also, I’m fatter now, about 400lbs.
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We all pay higher costs for medical care and insurance because of the huge incidence of problems caused by obesity,
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My mental heath has cost you, the taxpayer, more than my obesity has so far. (I just spent a week in the psych ward at SFGH.)
My food & depression issues go way back to kindergarten. I don’t know what I did wrong to end up like this.
Diet & lifestyle changes can be very difficult. As I have mention before, I live in a hotel room with no kitchen, just a mini-fridge & microwave.
I am sorry to hear you have had no success Foggy. It’s unfortunate that many anti-depressants also cause issues with water retention or make it harder to lose weight.
However, being obese also makes it harder to treat depression, because of self esteem issues and because of complications in obtaining the correct dosage of many medications. In such cases it’s suggested that the mental health professional needs to take an active role in managing both depression and obesity:
After you’ve suffer a total failure of your Thyroid gland, then undergo a Total Hysterectomy at age 52, then undergo a Lumbar Laminectomy with residual neuropathy on your left side plus decide to quit smoking 2 1/2 packs a day for 25 years… you come back here and tell me my weight gain of 100 pounds is a mental or eating disorder.
None of those serious medical issues can cause obesity. Only behaviour… specifically eating significantly more than your average daily caloric requirement over an extended period of time can cause obesity. And yes, this behaviour may be the result of a mental health disorder. That’s the debate here.
I have zero interest in any particular individuals weight. I am talking about the costs to society and trying to debate if there are more effective treatment options or should be . Here is a paper showing the costs to Australia’s economy as 37 billion a year in 2008. Extrapolate to your local country as needed: http://www.medibank.com.au/client/documents/pdfs/obesity_report_2010.pdf
This subject is near and dear to my heart, as I’m both a psychologist, have had therapy for -unrelated- mild depression, and have lost about 80 pounds with a Mini Gastic Bypass Surgery.
So let’s just stick to the facts. Currenty, there is NO effective form of psychotherapy that can treat obesity.
There are a lot of therapies that claim to treat it, as obesity is a goldmine. Lots of desperate clients and if you don’t deliver, just blame your clients’ weak willpower. But they make the clients lose at most 10 pounds and they always try to cover up the bad results by claiming that the clients now have “a healthier relationship with food that will surely allow them to lose weight in the future”. Yeah right. A very typical example of this is the first study I ran into on Pubmed. Two-year follow-up of an interdisciplinary cognitive-behavioral intervention program for obese adults - PubMed
On the other hand, there is the instrument of bariatric surgery. After a rocky start with a few procedures that caused about 50 % complications (the stomach band, particularly) there have now been developed procedures that are spectacularly effective as well as safe. Like the gastric bypass. Continued excellent results with the mini-gastric bypass: six-year study in 2,410 patients - PubMed . Average weight loss at one year was 59 kg (80% of excess body weight). The most frequent long-term complications were dyspepsia and ulcers (5.6%) and iron deficiency anemia (4.9%.) Weight loss was well maintained over 5 years, with <5% patients regaining more than 10 kg.
So, while there may be a place for psychotherapy in some form of supportive role, anyone who would recommend psychotherapy over bariatric surgery to lose weight substantially is, sorry I have to say this, a quack.
As for the larger scale societal prevention and reduction of obesity, it is more promising to see it as an environmental disorder. That yields more results then making it an individual problem and debating whethether fat people are bad, sad or mad. The fact that the obesity rate strongly differs per country supports that it is a cultural and environmental issue.
Thank you Maastricht, you raise some excellent points.
If you’re saying that only surgery has been shown to work for obesity, in other words that obese people cannot rationally control a behaviour that is clearly self destructive, that seems an argument in my favour. An in-ability to control a self destructive behaviour is usually categorised as a mental health (or at least an addiction) issue. It just happens to be a mental health issue that we do not have successful treatments for yet. However, the success rate of psychotherapy ALONE for mental illnesses (depression for example) is also very low. The highest rate of success is achieved by a combination of medication, cognitive behavioural therapy and lifestyle and diet changes. Likewise a combination of fat absorption blockers (Xenical), appetite suppressants, cognitive behavioural therapy and then diet and lifestyle changes could turn out to be the most effective with surgery as a last resort. Bariatric surgery costs an average of $20,000 USD in the US and is only recommended when diet and exercise have failed. Cost alone means it’s not an option for many people.
I entirely agree with you about obesity being an environmental issue, but what possible solutions are there? Banning all advertising for fast food and forcing plain labels and calorie warning stickers on all meals over a certain size? Reversing automation and creating millions of jobs involving manual labour? Shipping all obese people to live in asian countries with the lowest obesity rates? One of the papers you cited claims that wealth differences between neighbourhoods is a huge factor, so now we have to solve the problem of wealth distribution to combat obesity… seems an ever more impossible problem.
However none of this applies if an obese person presents at a doctor for treatment and refuses to discuss weight loss options, as in my example of the HAES doctor presentation card in my first post. In such a case the only possible option would seem to be to refer them for mental health treatment.
There are worrying investigations that suggest that it is generally unproven that weight is linearly related to health or death rates. It is certainly true that severe obesity leads to deterioration in other health issues and early death, but less evidence that this cuts in before a BMI OF 40.
In fact people with a BMI between 25 and 35 have been shown to have LOWER mortality and morbidity than people with ‘healthy’ BMIs.
I have heart failure and there is a clear indication that survival rates are higher for people with moderately high BMIs than for the ‘healthy’ weights.
If it is a mental health issue, it is not a mental illness issue.
It is more akin to people who put their health at risk through other risky habitual behaviour- smoking, drinking, mountaineering, middle aged man on motorbikes, and so on.
The so called “obesity paradox” applies to only certain specific diseases and is controversial.
If you have evidence that people with BMI over 30 (which is the definition of clinically obese) are OVERALL healthier than people in the normal range (18-25), then please provide cites.
And the trees moving have been shown to cause the wind to blow. All that higher BMI=lower mortality is because there are a lot of sick people who lose a lot of weight before death.
A study by the Centers for Disease Control and Prevention in 2010 found that almost two per cent of U.S. adults age 20 years and older are underweight or have a body mass index of 18.5. Factors linked to being underweight were revealed as malnourishment, drug or alcohol use, smoking, poverty and mental health issues.
You’re comparing healthy people to sick people and are somehow astonished when the sick people die sooner. I’ll alert the media.
My claim is that there is no linear relation ship between obesity measured by BMI and health or early death.
If you believe there is, please provide evidence of that.
I certainly accept that over certain levels mortality and morbidity do increase linearly and exponentially. But no one has shown a clear linear relationship between BMI and mild to moderate obesity.
The mechanism of lower mortality in heart failure is known as eventually heart failure debilitates the body and starts to endanger vital organs. People who start with higher reserves of expendable energy (fat) survive longer.
I am pointing out that there is not a proven linear relationship between BMI and morbidity and mortality. It is considerably more complex than that.
If you believe that there is such a linear relationship and that it is not a complex disease related variable, then produce the evidence that shows a universal relationship between BMI and health outcomes.
Morbidity rates are irrelevant. Obesity doesn’t need to kill you to be bad, it’s enough that it causes chronic medical issues and has increased social costs to society. See here:
Average medical costs over a nine year period are double for people with BMI over 30. Those costs are passed along and effect all of us, especially in countries with socialised healthcare (e.g. all of the developed world apart from the US).