The impact of obesity treatment and dietary guidelines on eating disorders

To the Editor: We wish to highlight how the recently released National Health and Medical Research Council (NHMRC) Clinical practice guidelines for the management of overweight and obesity1 and the Australian dietary guidelines2 may affect clinical and public health practice. Children, adolescents and adults with obesity are at increased risk of eating disorders (EDs) compared with others in the community.3-5

The dietary guidelines provide sound nutritional advice to improve the health of the Australian population. Importantly, the document states, “When promoting healthy weight . . . it is essential to avoid inadvertently encouraging disturbed body image and disordered eating or exercise behaviour”.2 This is essential to changing the way government health campaigns on obesity are delivered, as previous campaigns may have increased obesity stigma and body image distress, both known contributors to EDs.

Restrictive eating in the community (but not participation in carefully designed health professional obesity treatments, which may include safe restriction in their approach) is known to increase the onset of EDs.6,7 We feel that a number of aspects in the dietary guidelines and accompanying consumer resources conflict with the recommendation on avoiding EDs. First, the foundation diets were based on modelling the nutritional needs of the smallest and least active people in each age group2 and are thus very restrictive. Second, taller and more active children and adults who are not overweight are told that to meet their energy requirement, extra serves or discretionary choices may be needed, which may stigmatise overweight children, by encouraging restriction of discretionary foods, which were previously considered a normal part of all children’s diets in small amounts. Third, the “healthy eating for children” brochure and the similar brochure for adults list the estimated kilojoule content of core food groups, and the website has calculators for the public to work out their energy requirements; this encourages dietary restriction. Despite the prevalence of obesity, it is our view that restrictive diets should not be encouraged at a general population level.

In contrast, the draft guidelines for obesity had a strong public consultation response, which highlighted omissions in the consideration of EDs. The final guidelines clearly articulate the need to consider body image, EDs and mood disorders in all aspects of obesity care. Practitioners are guided in how to discuss weight management in a way that recognises likely frustration, comorbid conditions and discrimination, which should reduce compounding obesity stigma or body image distress. Finally, EDs are not seen as a contraindication for any kind of obesity treatment, but as a comorbid condition that needs attention.1

In their recognition of disordered eating, both guidelines make important leaps forward in the integration of physical and mental health care.