Obesity secondary to mental health conditions
I am of course happy to address obesity secondary to mental health conditions as an intermediate step. It will be interesting to see how recent legal developments may or may not lead to changes at the VA in relation to obesity being rated itself and what those ratings may look like, but for now it is a wait and see game on that of course.
Some common conditions that obesity at least as likely as not due to mental health conditions may be involved in include, but are not limited to: obstructive sleep apnea, hypertension, GERD, diabetes, etc.
Here is some sample language I might use for cases where obesity from a mental health conditions like depression, anxiety, PTSD, etc. is a factor. I used he here in this example but of course the same research applies for women as well. For example, the excerpt below related to sleep apnea secondary to PTSD (including obesity at least as likely as not due to PTSD). Of course there is research for other mental health conditions as well:
PTSD negatively impacts motivation (ex: reducing activity) and can lead to overeating. His PTSD increases the risk for weight gain and obesity, which in turn further increases the risk for obstructive sleep apnea. The Veteran’s weight gain occurred in the context of PTSD. Subthreshold and threshold post-traumatic stress disorder (PTSD) are associated with binge eating symptoms in both men and women [see Braun J, El-Gabalawy R, Sommer JL, Pietrzak RH, Mitchell K, Mota N. Trauma exposure, DSM-5 posttraumatic stress, and binge eating symptoms: results from a nationally representative sample. The Journal of Clinical Psychiatry. 2019;80(6):19m12813]. Hoerster, et. al. (2015) noted in “PTSD and depression symptoms are associated with binge eating among US Iraq and Afghanistan veterans” [see Eating Behaviors; Volume 17, April 2015, Pages 115-118] that “PTSD and depression are common conditions among Iraq/Afghanistan Veterans. In the present study, PTSD and depression symptoms were associated with meeting binge eating screening criteria, identifying a possible pathway by which psychiatric conditions lead to disproportionate burden of overweight and obesity in this Veteran cohort.” Dorflinger & Masheb (2018), in the research article “PTSD is associated with emotional eating among veterans seeking treatment for overweight/obesity” [see Eating Behaviors, Volume 31, December 2018, Pages 8-11] presented findings that “suggest that emotional eating is common among veterans reporting PTSD symptoms, and that any degree of PTSD symptom severity is associated with more frequent emotional eating.” Mental health difficulties can have a significant impact on activity levels and eating behaviors, influencing weight gain. For example, it is notable that major depressive disorder in the DSM-5-TR (pg. 183) lists diagnostic criteria such as “markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day…” and “significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day…” and “psychomotor agitation or retardation,” and “fatigue or loss of energy nearly every day” and others. PTSD (pg. 302) includes criteria like “markedly diminished interest or participation in significant activities). Overeating and inactivity are symptoms of mental health difficulties which lead to weight gain and obesity. It is at least as likely as not that his mental health concerns caused his weight gain. Weight gain is not simply a comorbidity; weight gain is a direct, physical, anatomical effect of PTSD. His mental health difficulties at least as likely as not impacted his eating behaviors and activity levels. As a result, his mental health difficulties at least as likely as not caused the direct effect on his anatomy of weight gain and obesity. Obesity is a significant risk factor and it along with PTSD itself are the most likely explanation for the presence of his sleep apnea. There is no support for the idea that he would have had sleep apnea in the absence of his PTSD and obesity. Sleep apnea does not cause itself. It is at least as likely as not that his PTSD caused his obesity which caused his sleep apnea. He likely would not have otherwise developed sleep apnea.
Common flawed reasoning from C&P examiners on obesity in mental health secondary claims:
C&P examiners will sometimes provide opinions related to obesity that are not VA policy compliant. They will often not actually address anything specific in a Veteran’s own medical records which may have caused the obesity. For example, the examiner may say something like “the most common causes of obesity are overeating and physical inactivity.” They may also go on to describe these as the result of a choice (sometimes they even put the word choice in all capital letters). This, of course, represents the CE examiner attempting to singlehandedly re-adjudicate court cases related to obesity being allowed as a condition that can be an intermediate step. The examiner completely disregards VA policy and the VA’s legal obligations. The examiners using this type of logic also clearly lack relevant expertise in mental health conditions, or they would recognize that mental health difficulties can at least as likely as not cause overeating and reduced physical activity (these are the sort of behaviors they should be exploring when talking with the Veteran- assuming they even spoke with the Veteran). Simply blaming the Veteran for their “lifestyle choices” is a stigma-driven bias that risks blaming the Veteran for their mental health symptoms. It is like saying someone who is so depressed they can’t get out of bed isn’t limited because that symptom of not getting out of bed is a CHOICE. The examiner’s stigma-driven, biased approach to mental health and obesity results in the examiner discounting the impact of mental health symptoms as the impact of willful problems with the Veteran’s character. This is unacceptable. This of course is a problem that can be created when the VA relies on people with no expertise in mental health conditions.
Examiners will sometimes give laundry lists of risk factors like “body weight is the result of genetics, metabolism, environment, behavior, and culture.” These types of nebulous statements are not grounded in the Veteran’s medical records and they are next to useless. They do not contradict mental health conditions as a cause of obesity. In terms of genetics- the examiner of course does not identify any specific gene or gene combination that was actually shown to cause obesity nor do they demonstrate anywhere in the medical records where the Veteran was actually demonstrated to possess a gene or gene combination that has been shown to cause obesity. There is actual scientific evidence supporting changes in behavior from mental health conditions that can cause obesity. In terms of metabolism- the examiner does not demonstrate any metabolic abnormality demonstrated in the medical records that the Veteran is actually shown to possess that causes obesity. In terms of environment- this is such a vague statement as to be worthless, but again, the examiner does not demonstrate anything about the “environment” which causes the Veteran’s obesity. In terms of “behavior-” this is ironic given that his behavior is heavily impacted by the behavioral disorder of mental health conditions (something the examiner clearly lacks sufficient expertise in). Psychology is also often referred to as the study of human behavior, so tying the cause to behavior but then trying to say psychology isn’t involved is absurd. In terms of culture, the examiner did not identify any specific aspect of his “culture” which directly caused his obesity. Again, this is a vague and useless statement that is not specific to the Veteran’s own medical evidence.
These types of opinions, often from poorly trained contract examiners, should be disregarded as not sufficient for rating purposes.
Feel free to reach out and see if Dr. Finnerty can help: Free Consultation – Nexus Letters from a Psychologist