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ASDAH Letter to House
Association For Size Diversity and Health
February 9, 2010 Representative Nancy Pelosi Representative John Boehner Speaker of the House Republican Leader H-232, US Capitol H-204, US Capitol Washington, DC 20515 Washington,DC 20515
Dear Representatives Pelosi and Boehner,
We the leadership of the Association for Size Diversity and Health, an international organization composed of health professionals, scientists and activists committed to promoting all aspects of health and well-being for people of all sizes, are writing to express concern about weight-based language in the Senate Health Care Reform bill. We have serious concerns that weight loss will become institutionalized as a standard feature of prevention and wellness efforts. No doubt, weight loss is an easily measured and low-cost criterion; no training or special equipment is required to have someone step on a scale, in contrast to (for example) taking blood pressure, drawing blood to test for health markers, or performing a “stress test.” For this reason, as well as the widespread misconception that weight or Body Mass Index (BMI) is an appropriate measure of good health,it is reasonable to fear that many if not most programs adhering to proposed health care reform provisions will use BMI as a principal or sole criterion to provide incentives and rewards and/or to measure “adherence.” Secondly, weight-based prevention and wellness programs, the Safeway “Healthy Measures” program for example, run the risk of inequity. It is our concern, that the use of BMI as the primary criterion to measure the “success”of or perceived “compliance” with prevention and wellness strategies will have unfortunate consequences for several reasons:
Weight loss is at best a temporary fix, not a long-term solution, to health problems. Even if weight loss were a good measure of health (which is not supported by scientific evidence), there is no proven effective and safe method of permanent weight loss. Simply put, diets don’t work long-term.[1,2] When Medicare changed its rules to permit treatment for “obesity” in 2004, a comprehensive meta-study reviewed the results of every reliable, published study of the efficacy of diets and concluded that restrictive dieting “does not lead to sustained weight loss inthe majority of individuals:”
“In sum, the potential benefits of dieting on long-term weight outcomes are minimal, the potential benefits of dieting on long-term health outcomes are not clearly or consistently demonstrated, and the potential harms of weight cycling, although not definitively demonstrated, area clear source of concern. The benefits of dieting are simply too small and the potential harms of dieting are too large for it to be recommended as a safe and effective treatment for obesity.”[1]
Ninety-five to ninety-eight percent of dieters regain their weight[2], and any apparent health benefits of weight loss disappear as weight is regained. In a study comparing diet and non-diet approaches, though only dieters lost weight, both groups initially had similar improvements in metabolic fitness, activity levels, psychological measures, and eating behaviors. After two years, dieters had regained their weight and lost the health improvements, while the non-diet group sustained their health improvements.[3]
Weight cycling caused by repetitive restrictive dieting (“yo-yo dieting”) is deleterious to health. Weight cycling damages the immune system and may increase the risk of heart disease and Type 2 diabetes.[4]Evidence suggests that weight cycling is linked to increased overall mortality and mortality from cardiovascular disease, as well as higher risks for heart attack, stroke, diabetes, high HDL cholesterol, higher blood pressure, and suppressed immune function.[1] Thus, a high but stable weight is safer than repeated fluctuations in weight.[5]
Weight loss is a poor measure of health. While many studies report associations between “obesity” and health conditions such as diabetes, heart disease, and cancer, these studies donot show causation. It is possible to be fat and healthy, just as it is possible to be thin and unhealthy. Healthy people who lose weight do not live longer than those who do not lose weight.[6] In fact, the risk of death declines with increasing BMI among the elderly, up to levels considered severely obese.[7,8,9]
Weight-loss-based approaches misidentify those who need intervention. A recent government survey indicated that over half the “overweight” adults (51.3%) being targeted are metabolically healthy, and 1 in 4 “normal weight” (23.5%) metabolically unhealthy adults are overlooked.[10] Targeting only those that “look” like they need the intervention means significant wasteful expenditures.
Attainment-based incentive programs lead to inequity. Incentive schemes are defended on the grounds of personal responsibility. But the suggestion that one “ought” to have a specific outcome is often interpreted as“can” have a specific outcome. If people could lose weight, or reduce cholesterol and blood pressure simply by deciding to do so, few would have weight, cholesterol or blood pressure concerns in the first place. Moreover,for employees for whom specific targets are medically inappropriate, or who are disadvantaged because of multiple coexisting conditions, this presents anunfair distribution of benefits.
Prevention and wellness programs that target weight cause harm by stigmatizing fat children and adults, increasing the incidence of eating disorders, and failing to encourage healthy behaviors in people of all sizes. Stressand chronic discrimination have been identified as important health-related risk factors, especially for women.[11,12,13]
It would be unethical to include anything in the health care reform package that actually promotes activities that harm health or encourage inequity. In short, it would be irresponsible to institute programs - including incentives and rewards - that promote dietingand intentional weight loss efforts.
Rather programs should encourage participation in healthy behaviors such as improved nutrition, increased exercise, stress reduction, and other activities known to promote health. We ask that any language in the final Health Care Reform bill limit programs, incentives and rewards to health-promoting programs rather than adherence to outcome criteria such as weight loss or BMI.
Sincerely,
ASDAH Leadership Team and Public Policy Committee
President Deb Lemire, BFA Lily O’Hara, MPH, Ph.D. cand. Dana Schuster, M.S. Sandy Andresen, MA, Ph.D. abd Veronica Cook-Euell, MA Ellyn Herb, Ph.D. Barbara Altman Bruno, Ph.D. Peggy Elam, M.S., Ph.D. Amy Herskowitz, M.Sc. Paul Ernsberger, Ph.D. Deb Burgard, Ph.D. Fall Ferguson, JD, MA Nomi Dekel, MA, LMFT 1: Mann T, Tomiyama AJ, Westling E, Lew AM,Samuels B, & Chatman J. “Medicare’s search for effective obesitytreatments.” American Psychologist,2007; 62: 220-233. 2: Garner DM & Wooley S. “Confronting the failure of behavioral anddietary treatments for obesity.” Clinical Psychology Review, 1991; 11:729-780. 3: Bacon L, VanLoan M, Stern JS & Keim N. “Size acceptance andintuitive eating improves health for obese chronic female dieters.” Journalof the American Dietetic Association. 2005; 105: 929-936. 4: Nebeling L & Rigers CJ et al. “Weight cycling andimmunocompetence.” Journal of the American Dietetic Association. 2004;104:892-894. 5: Diaz, V, Manious III AG, Everett CJ (2005). “The association betweenweight fluctuation and mortality results from a population-based cohort study.”Journal of Community Health; 2005; 30(5); 153-165. 6: Gregg EW & Williamson DF. “Relationship of intentional weightloss to disease incidence and mortality,” in T. Wadden & A. Stunkard, eds. Handbookof Obesity Treatment (New York: Guilford Press, 2002). 7: Inoue K, Shono T, Toyakawa S & Kawakami M. “Body mass index as apredictor of mortality in community-dwelling seniors.” Aging Clin Exp Res. 2006;18: 205-210. 8: Alibhai SM, Greenwood C & Fayette H. “An approach to themanagement of unintentional weight loss in elderly people.” CMAJ. 2005;172: 773-780. 9: Janssen I, Katzmarzyk PT & Ross R. Body mass index is inverselyrelated to mortality in older people after adjustment for waist circumference. JAm Geriatric Soc. 2005; 105: 929-936. 10: Wildman RP, et al. (2008). “The obese without cardiometabolic riskfactor clustering and normal weight with cardiometabolic risk factorclustering: Prevalence and correlates of 2 phenotypes among the US population (NHANES1999-2004).” Archives of Internal Medicine, Aug 11, 168(15):1617-24. 11: Lewis TT et al. “Chronic exposure to everyday discrimination andcoronary artery calcification in African-American women: The SWAN heart study.”Psychosomatic Medicine. 2006; 262-368. 12: Muennig P. “The body politic: the relationship between stigma andobesity-associated disease.” BMC Public Health; 2008; 8:128.
13: Muennig P et al. “Gender and the burden of disease attributable toobesity.” American Journal of Public Health. 2006.
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