Does obesity prevention cause eating disorders

The problem of childhood obesity has captured the nation’s attention. Health professionals, school administrators, child advocates, and state and federal policymakers have mobilized to stem the tide of this health crisis. Because the diagnosis of childhood obesity does not have one easily identifiable etiology, myriad prevention and intervention strategies have been considered to influence children’s eating and physical activity. Unlike other public health problems like smoking, where the goal is to get people to stop a behavior entirely, healthy eating and physical activity exist on a behavioral continuum that may be unhealthy at either extreme. This has led to a tug-of-war among health professionals. On one side, some are promoting dramatic environmental and policy changes to decrease overeating and inactivity, such as banning junk food from schools, mandating menu calorie labeling, sending home body mass index (BMI) reports to parents, requiring daily physical education, and taxing soft drinks. On the other side, other professionals are concerned that such changes may lead to an increase in our societal preoccupation with dietary restraint and worsening body image, thereby increasing the incidence of eating disorders. Some argue that even labeling obesity as ‘‘a public health problem’’ promotes the idea that overweight bodies are undesirable, unacceptable, and even diseased. These concerns raise important empirical and ethical questions for proponents of obesity prevention. The aim of this article is to examine this tension and outline the need to move the field toward unity through research on clear and specific health-promoting messages. To understand the concern that obesity prevention may be iatrogenic, it is necessary to appreciate the complex etiology of eating disorders. Dozens of risk factors have been identified; among these are biological characteristics (e.g., carrying specific genes), temperamental traits (e.g., perfectionism, negative affect), family and peer values (e.g., appearance orientation, appearance-related teasing), and social factors (e.g., activities like ballet, gymnastics). Furthermore, ‘‘eating disorders’’ represents a heterogeneous diagnostic category that includes anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified (which includes binge eating disorder). Research on whether obesity prevention causes eating disorders should assess the range of clinical disorders as well as subclinical behaviors (e.g., vomiting, laxative use, skipping meals). There are data to suggest that our recent societal focus on obesity prevention has not led to a discernable increase in eating disordered behavior. Overall trends measured by the Centers for Disease Control and Prevention’s National Youth Risk Behavior Survey indicate that there has been no significant change over time from 1995 to 2005 in the percentage of high school students who took laxatives, diet pills, powders, and liquids or vomited to lose weight or prevent weight gain. Although the prevalence rates are concerning (i.e., 4.5%Y6% for vomiting and laxative use, 6.3%Y9.2% for diet supplements), there is no evidence that increased media and professional discussions about childhood obesity have been associated with a concomitant increase in pathological findings. Further data comes from the evaluation of Arkansas’ statewide multicomponent effort to reduce childhood obesity, which included BMI reports. Three-year follow-up data indicate that BMI has leveled off, and there has been no increase in youth reports of taking diet pills, exercising excessively, starting diets, or weight-based teasing. This suggests that large-scale policies can be implemented responsibly and successfully prevent a BMI increase without unintended consequences. A handful of controlled trials have also addressed this issue. Schwartz and colleagues evaluated a school intervention implementing nutrition guidelines for snack sales in middle schools. Students were assessed for eating behaviors, desire to lose weight, and dieting behavior before and after intervention. Accepted April 28, 2009. This article was reviewed under and accepted by Associate Editor James J. Hudziak, M.D. Schuyler W. Henderson, M.D., served as assistant editor for this editorial. Drs. Schwartz and Kathryn Henderson are with Yale University and the Rudd Center for Food Policy and Obesity. Correspondence to Marlene Schwartz, Ph.D., Rudd Center for Food Policy and Obesity, Yale University, 309 Edwards Street, Box 208369, New Haven, CT 06520-8369; e-mail: Marlene.schwartz@yale.edu. 0890-8567/09/4808-0784 2009 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/CHI.0b013e3181acfb88 E D I T O R I A L