Too Fat or Too Thin – Can The Law Help?

Newton State Rep. Kay Khan held a briefing earlier this month to introduce the idea of adding eating disorders to the list of required school health screenings.

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“Mommy, I’m fat,” says my daughter, all 40-something lbs. and 40-something inches of her.  I see a perfectly smooth belly, and a body that is all little-kid taut. She looks in the mirror and manages to stick out her tummy a bit farther by arching her back. “You’re not fat,” comes my truthful response. It's a conversation that goes on.

 As much as kids are their parents’ parrots, I hope my child is not copying my own body concerns – since I have my metabolism and city walking to thank and I’m not overweight. But to blame her behavior on any media is all too easy. Yet talk about fat we will – from Michelle Obama to Tom Menino, Disney World to City Hall, the conversation is hard to escape.

Half of the adults and a third of Boston’s children are either overweight or obese, according to the State of the City address Mayor Menino gave in January. New, city-wide anti-obesity efforts will be rolled out by the Public Health Commission this spring. But for all our emphasis on the persistent obesity epidemic, are we forgetting the health threats that can occur when the worrying about weight itself is out of control?

Eating disorders – such as anorexia, bulimia, and binge eating disorder – are serious physical and emotional problems that can be life-threatening.  Yet the complex relationship between obesity and these seemingly opposite conditions, whose hallmark is often underweight bodies, remains largely overlooked.

S. Bryn Austin, ScD, says eating disorders are in our “blind spot” in the push to prevent childhood obesity. Dr. Austin is the director of STRIPED (Strategic Training Initiative for the Prevention of Eating Disorders), based at the Harvard School of Public Health and Children’s Hospital Boston. Here’s an example of the link between the two: “Overweight youths are at higher risk than healthy-weight peers for disordered weight-control behaviors and binge eating,” Austin writes. For successful prevention, we need to understand that eating disorders and obesity are intertwined.

A University of Michigan study published in January considered the relationship between school anti-obesity programs and an increase in eating disorders, demonstrating the need for a range of related problems to be addressed together. Examples of obesity prevention efforts in schools included height and weight screenings, nutrition education, and limits on junk food in the classroom.

Thirty percent of parents polled reported “at least one worrisome behavior in their children [six to 14 years old] that could be associated with the development of eating disorders,” said the study. “Worrisome behaviors” included inappropriate dieting, preoccupation with food labels, and concern about too much physical activity. The study “raises concerns that some obesity prevention initiatives may inadvertently promote an unhealthy anxiety about eating or weight among certain children,” underscoring “how important it is for parents to be aware of and discuss nutrition messages presented to their children.”

The importance of positive parent involvement was also shown in a new study of low-income urban families by the New York University School of Medicine. Researchers looked at families who had participated in specific parenting support groups, which coached more responsiveness and nurturing and less harsh, more effective discipline methods to prevent kids’ behavioral problems from escalating. The workshops did not involve discussion of nutrition, weight, or physical activity. In follow-up studies, children from these urban minority families – at high risk for obesity – had lower rates of obesity compared with children whose similar families had not been through the intervention programs.

Massachusetts State Rep. Kay Khan, (D-Newton), who chairs the Joint Committee on Children, Families and Persons with Disabilities, raised the profile of eating disorders on March 6 at the State House in coordination with the National Eating Disorders Association (NEDA). “It’s an area I’ve been interested in for a long time,” she says.

While the screening tool of Body Mass Index (BMI) was phased in last year in all Massachusetts public schools as a check for obesity, Ms. Khan held a briefing to introduce the idea of adding eating disorders to the list of required school health screenings. NEDA estimates that 30 percent of high school girls and 16 percent of boys suffer from eating disorders. NEDA, STRIPED, and Khan emphasize the importance of early screening and intervention for the best potential outcomes.

But screening for eating disorders will not be as simple as the calculations for BMI, which uses a child’s height and weight measurements, obtained in a quick trip to the nurse’s office. BMI is age- and sex-specific, so that the same BMI values for boys and girls of different ages are interpreted differently. (Screenings at Mass. schools are done in grades 1,4,7, and 10.) For a child to be labeled “overweight,” he or she will fall in the 85th to 95th percentile. An “obese” child will be in the 95th percentile or above.  

 Not only nurses, but classroom teachers and P.E. instructors are some of the school professionals who might be trained to identify the warning signs of eating disorders. Khan says there is a mechanism in Massachusetts law which could provide the starting point for implementing a new eating disorder health screening. The 2010 law recommends establishing guidelines for the “training of all public school nurses in behavioral health and appropriate screening and resources for the treatment of childhood obesity and behavioral health disorders, including eating disorders.”

Khan’s briefing may be as close as we’ve gotten to action on this law in Massachusetts. But she and Dr. Austin of STRIPED, who also participated in the eating disorders briefing, were pleased by the attention garnered at their talk. This is the “first time it’s gotten this level of attention on Beacon Hill,” says Austin.  “It’s very encouraging.”


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