Severe childhood obesity and state intervention

I’ve been following David Ludwig’s commentaries in JAMA with interest lately; some of recent that I especially enjoyed:

So I was excited to see on Tuesday that another was published: State Intervention in Life-Threatening Childhood Obesity (with Lindsey Murtagh).  I uploaded the full text here.  It is short (so read it!), but the gist of it is that severely obese children (they define as the 99th percentile – that is it) may require more drastic steps to improve their health as their risk of disease is more immediate.  As the title of the paper suggests, they bring up placing the child under protective custody.  According to the authors (Murtagh is a research associate at Harvard, 1 of her degrees in law) this could be justified as it would be considered neglect, similar as to how undernourishment has been dealt with.  However only several states currently have legal precedent to do with with overnourishment.
In addition to the extreme of removing the child from the home for a period of time, support services such as “in-home social supports, parental training, counseling, and financial assistance” could be offered through state programs.
For the ~2 million children that this action would put under consideration, removal from the home into foster care of course does not guarantee improvement either.  Obviously, complete removal would be the last option and would have to be considered on an individual basis.
They emphasize:
“Ultimately, government can reduce the need for such interventions through investments in the social infrastructure and policies to improve diet and promote physical activity among children.”
That would be ideal, but given the slow (and not often evidence-based) nature of politics, it wouldn’t help the millions that need it now.
This isn’t a new argument, but given the high profile of the journal and Ludwig, it got lots of press.  Here is a sampling:
  • Harvard Researchers Want Fat Kids Taken from Their Homes – The Atlantic.  Terribly dramatic and doesn’t emphasize the severely obese.
  • Should Morbid Childhood Obesity Be Considered Child Abuse? – Scientific American.  Better title, good summary.  He writes: “Defining childhood obesity as abuse would place a tremendous burden on parents—and an unfair one. Considering the marketing and low cost of sweetened cereals, high-fat fast-food meals and other treats aimed squarely at kids, others also bear responsibility for our childhood obesity epidemic.”  Clearly these factors do have an influence, though parenting also must have some as well. As I said before, improvements in food infrastructure would be slow and incremental- this is an issue that needs some attention now.
  • Should parents lose custody of super obese kids? -Yahoo News (AP). Actually a decent article with some additional context. The opposing view by a ‘bioethicist’ Art Caplan is quoted as saying: “if you’re going to change a child’s weight, you’re going to have to change all of them [advertising, marketing, peer pressure, and bullying]”  That assumes though that they all equally contribute and similarly in each individual (which of course is not true- the root causes will be relatively different between cases) – placing a child in a monitored/controlled environment could certainly help them lose weight.  Regardless of who is to blame, the child is severely obese and something more drastic needs to be done as their lives are at risk.  This article has thousands of (mostly irrational) comments to it- to be expected on an emotional issue.
  • Fat children ‘should be taken into foster care': Obesity expert points the finger at parents – Daily mail never disappoints for a poor headline.
  • Can childhood obesity warrant child protective services? – WeightyMatters. Yoni provides a rational discussion.  His is probably the only perspective so far (besides Ludwig) from someone who actually treats obesity, and his wife’s previous job as a child protection worker helps.  If you read only 1 take, read his.
  • Should Obese Children Be Taken From Parents? – HuffPo (David Katz’ blog). David draws an analogy of smoking and drugs to second hand obesity- is it the same to think of second hand obesity as criminal like parents sharing cigarettes and drugs with their children? I’m not sure I like the analogy as you need food but not cigarettes or drugs to survive. David also only casually mentions this issue is about severely obese children (doesn’t emphasize the 99th percentile).  This is much more extreme than “giving a child a donut or fries or soda” as he writes.
  • Childhood Obesity: A Call for Parents to Lose Custody – ABC News.  Katz is quoted in this one as saying there is no evidence that the state would do a better job of feeding children than their parents.  David Orentlicher says protective service agencies might be too quick to put overweight children into foster care.  Ludwig responds that doing nothing is worse than what is currently done, and reemphasizes that removal is only the last resort, counseling and education would be the priority.
  • (Edit 7.19): Doc feels heat over foster care idea for obese kids – MSNBC. Ludwig responds to some of the media backlash emphasizing that foster care would be the last resort; first financial support, social services, safe recreation areas, and parenting courses could be offered.
  • (Edit 7.19): Should the State Remove Fat Kids from Their Homes? – Slate.  Other than the misleading title, a great article.
  • (Edit 7.19): An audio interview with Yoni on the issue- very clear and accurately reflects what the authors are saying.
  • (Edit 7.19): The War on Bad Parenting. – Forbes. Interesting in that it attempts to strawman Katz’ post in HuffPo- read the comments in which Katz responds.
  • (Edit 7.19): CEPEDA: Addressing childhood obesity. – Gwinnett Daily Post. A great article that quotes Ludwig some more.
  • And lots more.  (I will update with more articles if they add something new)
It seems like there are a lot of knee-jerk reactions to this have missed the point.  There is a difference between severe obesity and the average overweight child- the former places the child at much greater risk of immediate disease.

I wanted to hear some other thoughts on this- please leave a comment below.

Reference

Lindsey Murtagh, & David S. Ludwig (2011). State Intervention in Life-Threatening Childhood Obesity. Journal of the American Medical Association : 10.1001/jama.2011.903