November 22, 2016 NAAFA’s COMMENT IN RESPONSE TO THE U.S. PREVENTIVE SERVICES TASK FORCE DRAFT RECOMMENDATION STATEMENT Obesity in Children and Adolescents: Screening Sirs: Thank you for the opportunity to share the thoughts and concerns of the public. NAAFA is a non‐profit, all volunteer, civil rights organization dedicated to protecting the rights and improving the quality of life for fat people. NAAFA works to eliminate discrimination based on body size and provide fat people with the tools for self‐empowerment through advocacy, public education, and support. NAAFA has grave concerns that a recommendation attempting to change a predominantly heritable trait such as body size/weight may set children on a path toward a lifetime of feelings of failure resulting in weight cycling, body hatred, food and body insecurity, with potential for development of eating disorders. We would offer suggestions for a weight‐neutral approach to assist healthcare professionals, educators, and parents in teaching children how to eat, live and flourish physically, mentally and emotionally. BACKGROUND: Heritability – Studies have shown that body size/weight has a strong hereditary component:  "Height, weight, and BMI were highly correlated across time, and a path analysis suggested that the major part of that covariation was genetic. These results are similar to those of other twin studies of these measures and suggest that human fatness is under substantial genetic control."i  "Genetic influences on BMI and abdominal adiposity are high in children born since the onset of the pediatric obesity epidemic."ii  "...the research by Wardle et al adds to our body of research on the genetics of BMI in children by confirming that prior findings of a high heritability remain valid, even in the face of the current obesity epidemic, and by extending that research to show that the same general conclusions apply to waist circumference."iii Weight Cycling – Weight cycling, aka yo‐yo dieting, is the push‐pull between an individual’s conscious and concerted efforts in food restriction for the expressed purpose of reduction of body weight and the body’s innate NAAFA’s COMMENT IN RESPONSE TO THE U.S. PREVENTIVE SERVICES TASK FORCE DRAFT RECOMMENDATION STATEMENT Obesity in Children and Adolescents: Screening November 19, 2016 Page 2 of 7 mechanism to protect the individual from starvation and death. The result can cause “dis‐ease” in our body’s functions and feelings of failure and discontent:  A 2013 evaluation of a nine‐month multicomponent, community‐based program for obese, inner‐city adolescents demonstrated modest clinical improvements and increased healthy lifestyle behaviors. However, the loss of clinical improvements nine months after the program was completed resulted in weight cycling.iv  A 2016 presentation at the American Heart Association's Scientific Sessions of a study of data from 158,000 women over age 50 found that weight cycling (aka yo‐yo dieting) behaviors had a 3.5 times greater risk for sudden cardiac death than those with stable weights. It was noted that it may also cause insulin resistance.v Body Hatred – An incredible amount of information about the body ideal and the ills of being “overweight” or “obese” is fed to our children every day and causing not only body dissatisfaction but body hatred and weight bias:  In a 1999 study of 62 third‐ through sixth‐grade boys and girls: "50% of all children wanted to weigh less and 16% reported attempting weight loss."vi  In 2001, a study of 969 third‐grade children found: "Overweight concerns and body dissatisfaction are highly prevalent among third‐grade girls and boys, across ethnicity and SES [socioeconomic status]."vii  In a 2006 study of third‐, fourth‐ and fifth‐grade girls and boys: "Overall results indicated that 50.6% of the children surveyed were dissatisfied with their current body shape, 41.8% wanted to be thinner, while 8.8% wanted to be larger. Fifty percent of the girls were dissatisfied with their current body shape, with 45.1% wishing to be thinner. Boys showed similar trends, with 48.9% dissatisfied and 38.9% wishing to be thinner. A greater percentage of boys wanted to be larger than their current body shape (12.3%) compared to girls (4.9%)."viii  A 5‐year longitudinal study in 2006 found: "...in general, lower body satisfaction does not serve as a motivator for engaging in healthy weight management behaviors, but rather predicts the use of behaviors that may place adolescents at risk for weight gain and poorer overall health."ix Food and Body Insecurity – Research has found that food restriction may in fact cause the desire for those restricted foods and feelings of guilt:  "Restricting girls’ access to foods may not only increase girls’ desire to obtain and consume those foods, but may set them up for negative self‐evaluation as they find their behavior at odds with parental expectations."x NAAFA, Inc. PO Box 4662, Foster City, CA 94404-0662
(916)558-6880 www.naafa.org
NAAFA’s COMMENT IN RESPONSE TO THE U.S. PREVENTIVE SERVICES TASK FORCE DRAFT RECOMMENDATION STATEMENT Obesity in Children and Adolescents: Screening November 19, 2016 Page 3 of 7 Eating Disorders – The potential of children developing eating disorders due to the stigma of weight is prevalent, especially in adolescents:  "Adolescent patients with obesity are at significant risk of developing an eating disorder (ED), yet due to their higher weight status their symptoms often go unrecognized and untreated. Although not widely known, individuals with a weight history in the overweight (BMI‐for‐age =85th percentile but <95th percentile, as defined by Centers for Disease Control and Prevention growth charts) or obese (BMI‐for‐age =95th percentile, as defined by the Centers for Disease Control and Prevention growth charts) range, represent a substantial portion of adolescents presenting for ED treatment. "xi  "Obesity and eating disorders (EDs) are both prevalent in adolescents. There are concerns that obesity prevention efforts may lead to the development of an ED. Most adolescents who develop an ED did not have obesity previously, but some teenagers, in an attempt to lose weight, may develop an ED...The focus should be on a healthy lifestyle rather than on weight."xii  "Whereas body dissatisfaction is common among overweight and obese girls, body satisfaction may protect against excessive weight gain and binge eating."xiii As an example of the implications of body dissatisfaction, ABC News online carried a story in 2011 about a 6‐year old girl named Taylor:xiv Taylor Call is a healthy, active 6‐year‐old pre‐kindergarten student who lives outside of Houston. By all outward appearances, she's a normal little girl who likes to play princess and has an outgoing, easy personality. But about a year ago, Taylor came home from school and said something that shocked her mother, Tanya Call. "We were at home and she just out of the blue said, 'Mommy, why is my tummy so fat? ... A girl in the bathroom at school asked me why I was fat,'" she said. Dr. Rachel Bray, Taylor's pediatrician, used the girl's height and weight to calculate her body mass index and said Taylor's weight is normal. Taylor told "Good Morning America" that she wanted to lose weight. "I don't like to be my weight and my teacher always tells me I have to run so I can be really, really not like this size," she said. NAAFA, Inc. PO Box 4662, Foster City, CA 94404-0662
(916)558-6880 www.naafa.org
NAAFA’s COMMENT IN RESPONSE TO THE U.S. PREVENTIVE SERVICES TASK FORCE DRAFT RECOMMENDATION STATEMENT Obesity in Children and Adolescents: Screening November 19, 2016 Page 4 of 7 ADDRESSING OTHER FINDINGS IN THE DRAFT RECOMMENDATION: USPSTF finding: "Obesity in children and adolescents is associated with morbidity such as mental health and psychological issues..." Fat stigma and stress result from children being asked to change a heritable trait; similar to asking them to change their eye color, length of their nose, or size of their ears:  A 2016 Australian study of 3,557 children found that contrary to popular belief, if a parent perceives their child as being "overweight" this is not a protective factor against weight gain and is instead associated with increased risk of future weight gain across childhood. Researchers suggest that the stigma of being viewed as "overweight' or "obese" may create stress that results in maladaptive coping responses that lead to weight gain.xv  A 2015 study from New Zealand's University of Otago found that younger infants, around 11 months of age, preferred to look at obese figures, whereas the older toddler group, around 32 months old, preferred to look at average‐sized figures and found that preference was strongly related to maternal anti‐fat prejudice. Study co‐author Associate Professor Kerry O'Brien from Monash University, says "weight‐based prejudice is causing significant social, psychological, and physical harms to those stigmatized. It's driving body dissatisfaction and eating disorders in underweight populations; and social isolation, avoidance of exercise settings, and depression in very overweight populations. We need to find ways to address this prejudice."xvi USPSTF finding: "Children and adolescents may also endure weight‐based victimization (e.g., teasing and bullying)." This is a true statement. However, again you are asking children to change a heritable trait instead of working to change the environment that perpetrates bullying. A 2013 study found that fat children are bullied even if they were to attempt to lose weight and succeed.xvii Weight is not always a matter of “over‐eating” but children do not recognize that it may be a symptom of a physical disorder. This was the case when the Huffington Post wrote about a little girl named LaNiyah Bailey in 2011:xviii For 6‐year‐old LaNiyah Bailey, being teased and called names because of her weight was a constant struggle. NAAFA, Inc. PO Box 4662, Foster City, CA 94404-0662
(916)558-6880 www.naafa.org
NAAFA’s COMMENT IN RESPONSE TO THE U.S. PREVENTIVE SERVICES TASK FORCE DRAFT RECOMMENDATION STATEMENT Obesity in Children and Adolescents: Screening November 19, 2016 Page 5 of 7 LaNiyah decided to pick up the pen to describe her struggles. Along with the help of her mother, LaToya White, she wrote a book entitled “Not Fat Because I Wanna Be” about being bullied because she was overweight, a condition which diet and exercise alone couldn’t solve. White opened up to NPR about her daughter’s health. LaNiyah has several health problems that contribute to her weight, including polydipsea. She was diagnosed with something called polydipsea before, which is also a term, like water diabetes type of thing that a lot of people may not know about. And that makes a person drink water or any kind of fluid, like, a lot. So they’re retaining a lot of fluid. NAAFA suggests that ALL children, parents, teachers and healthcare workers be educated on diversity (including size diversity) and inclusion; to embrace differences and eliminate bias and bullying based on physical appearance. USPSTF finding: "The USPSTF found adequate evidence to bound the harms of screening and comprehensive, intensive behavioral interventions for obesity in children and adolescents as small to none..." Adults that have been pressured to lose weight since childhood will often tell you of body hatred, food and body insecurity, and weight cycling resulting from so‐called interventions throughout their lives. Victims of childhood bullying show higher levels of depressive disorders, anxiety disorders, generalized anxiety, panic disorder, and agoraphobia into young adulthood. Dieting (forced famine) not only causes food insecurity: it causes adverse health results into adulthood. A 2012 famine study showed, "that a short period of moderate or severe undernutrition during postnatal development increases type 2 diabetes risk in adulthood."xix RECOMMENDATIONS: NAAFA strongly suggests that the final recommendation of the USPSTF be based on weight‐neutral principles, as in the Health At Every Size ® (HAES) tenets:xx HAES‐Based Role of Healthcare Workers and Educators‐ 1. Discourage dieting, skipping of meals, or the use of diet pills; instead, encourage and support the implementation of healthy eating and physical activity behaviors that can be maintained on NAAFA, Inc. PO Box 4662, Foster City, CA 94404-0662
(916)558-6880 www.naafa.org
NAAFA’s COMMENT IN RESPONSE TO THE U.S. PREVENTIVE SERVICES TASK FORCE DRAFT RECOMMENDATION STATEMENT Obesity in Children and Adolescents: Screening November 19, 2016 Page 6 of 7 2.
3.
4.
5.
6.
7.
an ongoing basis. The focus should be on maintaining full and happy lives rather than on body size or weight. Promote a positive body image among ALL children of all ages. Do not encourage body dissatisfaction or promote body shaming. Encourage more frequent family meals. Encourage families not to talk about weight or body size but rather about listening to your body's hunger and satiety cues, along with sharing how activity (such as family play time) help us be healthy and happy. Encourage family play time and enjoyable physical and mental activities. Inquire about mistreatment or bullying based on body size and address these issues with patients and their families. Carefully monitor weight loss to ensure the child has not developed an eating disorder and the medical complications of weight cycling or semi‐starvation. HAES‐Based Education in Schools: “Everybody in Schools HAES Tool Kit” available on the NAAFA website at http://www.naafaonline.com/dev2/education/haesschool.html HAES‐Based Education for Parents: “Healthy Bodies; Teaching Kids What They Need to Know” http://bodyimagehealth.org/healthy‐bodies‐curriculum/ Recommended Reading: “Am I Fat? Helping Young Children Accept Differences in Body Size” http://eric.ed.gov/?id=ED353534 ”Your Child's Weight: Helping Without Harming” http://www.ellynsatterinstitute.org/store/index.php?route=product/product&product_id=51 Body Diversity Educational Tool: Book: “Shapesville” by J.Andrew Smills and Rebecca Osbom http://www.gurzebooks.com/press/shvrelease.html Respectfully submitted, Darliene Howell NAAFA Board of Directors i
A twin study of human obesity., Stunkard AJ, Foch TT, Hrubec Z, 1986, JAMA. 1986 Jul 4;256(1):51‐4. NAAFA, Inc. PO Box 4662, Foster City, CA 94404-0662
(916)558-6880 www.naafa.org
NAAFA’s COMMENT IN RESPONSE TO THE U.S. PREVENTIVE SERVICES TASK FORCE DRAFT RECOMMENDATION STATEMENT Obesity in Children and Adolescents: Screening November 19, 2016 Page 7 of 7 ii
Evidence for a strong genetic influence on childhood adiposity despite the force of the obesogenic environment, Wardle J, et al., 2008, Am J Clin Nutr February 2008 vol. 87 no. 2 398‐404 iii
Obesity ‐ still highly heritable after all these years, Musani S, Erickson S, Allison D, 2008, Am J Clin Nutr February 2008 vol. 87 no. 2 275‐276 iv
Evaluation of a Community‐Based Weight Management Program for Predominantly Severely Obese, Difficult‐To‐Reach, Inner‐City Minority Adolescents, Rieder J, et al, 2013, doi:10.1089/chi.2012.0147 v
This Kind of Dieting Is Unhealthy for Women, Rasla S, et al., http://time.com/4571618/dieting‐weight‐loss‐heart‐health/ vi
Body dissatisfaction and dieting in young children, Schur E, Sanders M, Steiner H, 1999, DOI: 10.1002/(SICI)1098‐
108X(200001)27:1<74::AID‐EAT8>3.0.CO;2‐K vii
Overweight Concerns and Body Dissatisfaction Among Third‐Grade Children: The Impacts of Ethnicity and Socioeconomic Status, Robinson TN, Chang JY, Haydel KF, Killen JD, 2001, J Pediatr. 2001 Feb;138(2):181‐7. viii
Body Dissatisfaction Among Third, Fourth, and Fifth Grade Children, K. M. Skemp‐Arlt et al. / Californian Journal of Health Promotion 2006, Volume 4, Issue 3, 58‐67 ix
Does body satisfaction matter? Five‐year longitudinal associations between body satisfaction and health behaviors in adolescent females and males., Neumark‐Sztainer D, Paxton SJ, Hannan PJ, Haines J, Story M, 2006, J Adolesc Health. 2006 Aug;39(2):244‐51. x
Parents’ restrictive feeding practices are associated with young girls’ negative self‐evaluation of eating, Fisher JO, Birch LL, 2008, doi: 10.1016/S0002‐8223(00)00378‐3 xi
Eating Disorders in Adolescents With a History of Obesity, Sim L, Lebow J, Billings M, 2013, DOI: 10.1542/peds.2012‐3940 xii
Preventing Obesity and Eating Disorders in Adolescents, Golden N, Schneider M, Wood C, 2016, DOI: 10.1542/peds.2016‐
1649 xiii
Body satisfaction, weight gain and binge eating among overweight adolescent girls. Sonneville KR, Calzo JP, Horton NJ, Haines J, Austin SB, Field AE, 2012, Int J Obes (Lond). 2012 Jul;36(7):944‐9. doi: 10.1038/ijo.2012.68. xiv
Body Image Issues: 6‐Year‐Old Worries She is Fat, ABC News Online, June 20, 2011 xv
Parental Perception of Weight Status and Weight Gain Across Childhood, Robinson E, Sutin AR, 2016, Pediatrics May 2016, Volume 137 / Issue 5 xvi
Toddlers’ bias to look at average versus obese figures relates to maternal anti-fat prejudice, Ruffman T, et al., 2015,
http://dx.doi.org/10.1016/j.jecp.2015.10.008
xvii
Weight‐Based Victimization: Bullying Experiences of Weight Loss Treatment–Seeking Youth, Puhl R, Peterson J, Luedicke J, 2013, Pediatrics January 2013, Volume 131 / Issue 1 xviii
LaNiyah Bailey, 6‐Year‐Old, Writes Book About Bullying, The Huffington Post, March 25, 2011 xix
Famine Exposure in the Young and the Risk of Type 2 Diabetes in Adulthood, van Abeelen A, et al., 2012, http://dx.doi.org/10.2337/db11‐1559 xx
HAES ® Principles, Association for Size Diversity and Health, https://www.sizediversityandhealth.org/content.asp?id=152 NAAFA, Inc. PO Box 4662, Foster City, CA 94404-0662
(916)558-6880 www.naafa.org