In their recent JAMA commentary on the problem of malignant childhood obesity, Murtagh and Ludwig advocate the referral of morbidly obese children to state protective service agencies in cases where their families fail to implement and follow plans for effective weight reduction. They justify their recommendations in part because morbid obesity in childhood frequently results in the development of irreversible type 2 diabetes, a condition that has been shown to diminish both quality and span of life. In short, in the opinion of these authors, morbid childhood obesity should be considered a form of parental neglect.
Having worked in primary care pediatrics for over 30 years, I have witnessed first-hand the development of our national obesity epidemic in children and adolescents. Despite our well-intentioned clinical interventions, the problem of childhood obesity—particularly morbid obesity—has only escalated over the past two decades. I have spent much of my professional career counseling parents and children on proper dietary intake and the need for regular physical activity. Overall, my advice has been largely ineffective. I am not alone in this lamentable fact. From anecdotal conversations with other clinicians coupled with the exponential increase in pediatric BMIs greater than the 99th percentile, it appears that such clinical interventions are lacking in efficacy. It is the rare individual or family that can make the commitment to implementing those lifestyle changes needed to insure adequate weight loss and maintenance of healthy body weight.
I have come to regard childhood obesity as a public health problem, driven by new cultural norms. Many of today's children remain largely sedentary, glued to the screens of their televisions, computers, video games, and smart phones; constantly pummeled by advertisements touting the latest fast-food fads, sugary drinks, and calorie-dense snacks. Because of budgetary constraints, physical education has been phased out in many of our secondary schools over the past decade. Many morbidly obese children (though certainly not all) come from lower socioeconomic households, where limited family income does not support the selection of healthier diets rich in fresh fruits and vegetables. (Aside: I recently learned from one of my patients that ten TV dinners can be had at a local supermarket for the cut-rate price of $10; accordingly, her children eat TV dinners daily for lunch and supper.) Without the support of the community at large—and in this case I would even include the national community—the likelihood of us making some sort of meaningful intervention in the lives of these children remains slim.
The authors of the JAMA article raise the question of bariatric surgery for those morbidly obese children who have failed to shed meaningful amounts of weight, correctly noting that the surgery itself is not without risks and complications. Indeed, a recent review of pediatric bariatric surgical interventions concludes that in view of postoperative complications, compliance issues, and problematic follow-up, a cautious approach to child and adolescent bariatric surgery is warranted. Finally, the authors broach the subject of referring morbidly obese children to protective services, their rationale being that, if parents cannot enact effective interventions to curb obesity in the home, perhaps the controlled environment of a safe home in foster care might be the ticket to improved health.
I suspect that such well-meaning recommendations would prove to be marginally effective at best and more than likely result in further treatment failures as well. In my dealings with state supported foster care, I have not been overly impressed with the quality of surrogate households. In the region where I practice, there are few good foster homes capable of providing the level of consistency and intervention necessary for success. In my experience, many foster homes provide only marginal care at best.
Referring these families for state intervention raises ethical questions as well. Having dealt with a good number of child abuse cases over the span of my professional career, I have learned that if proving abuse is difficult, substantiating neglect is even more so. The burden of proof lies with the clinician. I for one would not look forward to appearing in the dock charged with supporting the recommendation that a morbidly obese child be removed from the home because the parents were unable to control his weight.
Tackling the problem of our epidemic of childhood and adolescent obesity requires a public health approach, with widespread, meaningful education and intervention on community levels, if we are to make any sort of progress toward curbing this problem. Casting the parents of these children in the role of neglectful perpetrators will only serve to fragment the family structure and place additional stress on obese children and adolescents, actions guaranteed to negatively impact the outcome of those already compromised by their excessive weight.
Brian Maurer practices pediatrics at Enfield Pediatric Associates, Enfield, Connecticut. He is the author of Patients Are a Virtue and blogs at http://briantmaurer.wordpress.com/.