The True Health State of the Union

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We are a stressed nation.  Every corner you turn, you are bombarded with negative headlines, social media rants, and sales pitches.  Work schedules often extend beyond the 40-hour workweek, and therefore meals of many families are purchased ready-made and eaten in the car or in front of a television screen.  When I was a child, me and my siblings and friends would play outside while our parents cooked dinner.  Now, I see children of elementary school age with their eyes glued to a phone or television screen while waiting at the bus stop.

Communication has gone from talking about your day at the dinner table, to texting, tweeting, or chatting online.  In turn, I have noticed that people are much more brazen online then they would be in person. In feeling more uninhibited behind their computer screen, more negativity then ever travels in real time from person to person, insults flung left and right, and to those children, tweens, and young adults that are in the midst of self-discovery, feelings are also battered and bruised.  The art of communication and having respect for others has seem to have gotten lost in the mix of many trying to get attention and gain approval from strangers online.

It is not surprising that this communication gap has caused concern for an increase in mental health issues, especially among youth.  One in four children aged 13 to 18 years old are diagnosed with an anxiety disorder according to the National Institutes of Mental Health (NIMH).  Eighteen-percent of adults 18 years of age and older have been diagnosed with an anxiety disorder, with nearly one-half of individuals reported to not seek treatment for such disorders.  Of those adults diagnosed with anxiety, women are 60-percent more likely to experience an anxiety disorder than men.

It is no surprise to me to find that obesity and mental health issues are closely related.  Several studies over the years have linked obesity with increased rates of depression and anxiety.  Mental health disorders can lead to disordered eating, hormone imbalances, and sedentary behavior which can cause a state of being overweight or obese. On the same note, obesity itself can lead to increased depression and anxiety. It is no coincidence that as obesity rates in adults rose in the United States from 10-15% in 1990 to 25-35%  in 2014, while statistics from the Supplemental Security Income (SSI) and Social Security Disability Insurance (SSRI) report the number of adults disabled by mental illness rose from 1 in 184 in 1987 to 1 in 76 in 2007.  Those states that have increased rates of depression have been statistically found to have increased rates of obesity, heart disease, stroke, sleep disorder, and less access to medical insurance.

What makes this situation even more dire is that when individuals do want to get nutritional counseling, most will not be covered for it.  Only about one-third of states have elected to provide coverage for nutritional counseling, with many setting provisions for coverage such as having diabetes, kidney disease or other chronic diseases; covering only weight loss drugs or home-health worker-provided nutrition therapy; or covering only bariatric surgery.

If someone wanted to prevent themselves from chronic obesity-related disease, if they have a family history of obesity or diabetes, or if they had a mental health issue that predisposed them to a higher risk of obesity-related conditions, they would not be able to get coverage for preventative nutritional counseling.  Most individuals who are at risk for obesity cannot afford to pay out-of-pocket costs to see a dietitian which I have seen range from $60-$300/hour.

If the health of the nation is going to improve, then nutritional counseling should be seen just like a preventative exam at the primary physician.  Anyone who has health insurance should be able to be covered for dietitian visits so they can get advice to prevent them from going down the road of obesity and its many related chronic conditions.  I have worked for various different weight loss programs, and motivated individuals who wanted to get healthy would quit before reaching their goals because they couldn't afford it or their insurance would stop covering the  costs because they were not making enough progress.  In these same programs, there would be repeat customers over and over again because deep down many of these individuals could benefit from therapy or counseling, but either would not seek it out, or did not have insurance coverage for such visits.

Therefore, weight loss programs should strive to include a mental health practitioner on staff to assist in providing patients with the most holistic care.  These mental health visits should be covered for anyone who participates in a weight loss program that meets the criteria for mental illness.

Which leads me to the screening for mental health.  Although some doctors may be apt in doing this, I know from personal experience that a lot of doctor's offices push patients in and out as quickly as possible to get as many people in as possible.  This leads to 10, maybe 15 minute meetings with the doctor if you are lucky.  This leaves barely enough time to go through a basic physical assessment, let alone a depression and anxiety screening.  I think the "depression screening" that I was given at my last appointment was a few questions about if I felt hopeless or had thought about taking my own life.  Now if I really felt that way, do you think most people would admit to those behaviors? Of course not.  It took me nearly a month or two of weekly support group meetings to get my patients to open up to me about their anxiety issues.  I think mental health screenings need to be revised and expanded to prevent mental health issues from remaining undiagnosed, otherwise many who struggle with mental health issues will be left untreated.

And if someone is not attending a weight loss program, physicians should take more time with patients to refer them to local weight loss programs or dietitians if they screen for overweight, obesity, or a family history of obesity-related conditions to help prevent chronic health issues.   If a patient opts for bariatric surgery, mandatory meetings with a therapist or dietitian should extend far beyond the pre-surgical mandated appointments.  Patients should be mandated for meetings with a therapist and dietitian at least one-year post-surgery since it is within this time that I see most gastric bypass patients relapse into old eating habits and gain weight back that they had lost.  The reason they may gain this weight back cannot be pinpointed. However, from the cases that I have seen it is because the mental health issues that led to the escalation of the patient's weight gain to begin with were not dealt with or resolved.

Although there have been many improvements in nutritional counseling and mental health coverage with insurance, there is still a long way to go if any serious impact is going to be made in mental health and obesity rates in the United States.  I hope that with support from other health care professionals and advocates, such policy improvements can continue to be made so that the country can reform itself into a better state of health in the coming years.