Fat Kids = Child Abuse?

As a child-health advocate, I am absolutely convinced that it is abusive to be complicit in a child’s obesity. As a future physician, however, I can’t consider this sufficient justification to remove an obese child from an otherwise loving home— childhood obesity is far more complex than parental complicity alone.

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I spent 2013 investigating the cultural factors of obesity in El Salvador(1), and one thing I learned is that it is counterproductive to moralize BMI. On a personal level, I will admit that my own bias leads me to pass judgment on the parents, but as a profession and a society we need to be better than that.

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In order to make a healthy choice, consumers need three things: information, opportunity, and motivation. To intervene with Child Protection Services would be to decide that the parents lack the motivation to care for their child. Despite the parents’ “dismissive” attitude, however, it is fundamentally opportunity that is lacking. I make this claim on the basis that adolescent obesity has more than quadrupled in the past 30 years(2-3), and it seems unlikely that a whole generation of parents is suddenly less motivated to care for their children.

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Parents have a fundamental obligation to promote their child’s wellbeing, just as government has a fundamental obligation to promote public health. Thus, the decision to remove this child from the home is not a question of ethics per se, but of practicality (i.e. when it comes to matters of state policy, consequentialism should take precedence over idealism). There is a cost to individuals and to society for raising unhealthy kids who grow into unhealthy adults. There is also a steep cost to forcefully disrupting families, and no evidence that this would be an effective intervention.

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As expressed in a report from the Symposium on Ethical Issues in Interventions for Childhood Obesity(4), it is “essential to target family-level behavior” to combat childhood obesity. A recent Cochrane review(5) gives credence to the idea that individual, family-based interventions can lower a child’s weight, but emphasizes that these interventions might not be effective long-term societal remedies. In fact, reviews of randomized controlled studies(6) have shown that these interventions produce marginal results. Adverse environmental factors undermine interventions that seek to reduce caloric intake and increase activity. We now live in a “food carnival” in which even educated and motivated consumers fail to eat healthfully. As a society, if we are really serious about protecting children’s health, we will focus more on environmental stewardship and the ethics of food manufacturing and marketing than on parenting.

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The medical community has unique power to change the focus from weight-loss to health-promotion. If as physicians our best response to the obesity epidemic is to blame parents(7), then we are not being intellectually honest, nor are we being helpful. We already know that diet and behavior vastly outweigh genetics in determining bodyweight, and these environmental factors are widespread. In our zeal for passing moral judgment, it is easy to overlook that obesity has become a common problem, not an individual one. As physicians, we should be leading the conversation on a societal level, not just bemoaning the non-compliance of our overweight patients.

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Recognizing that the only truly effective intervention will be widespread changes in the social environment(8), this child should not be removed from her home. Rather, physicians need to acknowledge the toxic environment and the socioeconomic factors that drive this family to need two full-time incomes just to scrape by. We need to acknowledge that the current childhood obesity epidemic did not originate with biological malfunction, but with societal change. Physicians will have to broaden our scope to promote a healthier environment. If we want to improve our patients’ diets, physicians can advocate for taxes on fast food and sugary drinks, subsidies for healthy foods, and regulating political contributions from the food industry. To improve pediatric physical activity, let’s conserve open spaces and fund physical education in schools. Increased funding for research and healthcare is what we are accustomed to, but it has not slowed the problem since a Lancet editorial first called for pediatric obesity prevention more than 40 years ago(9).

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Childhood obesity is a practical problem of social, not individual, negligence. Children today are losing their right to a healthy environment in droves. Bad parenting is a convenient scapegoat, but misses the larger societal shifts that lead to less healthy childhoods. Yes, the parents are being negligent of the child’s health, even cavalier about her downward spiral. But aren’t we all?

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References
1. Owen A, Suazo C. Sociodemographic and cultural factors of adult obesity in El Salvador. J of Global Health. 2015. In Press.
2. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. Journal of the American Medical Association 2014;311(8):806-814.
3. National Center for Health Statistics. Health, United States, 2011: With Special Features on Socioeconomic Status and Health. Hyattsville, MD; U.S. Department of Health and Human Services; 2012.
4. Perryman ML. Ethical family interventions for childhood obesity. Prev Chronic Dis 2011;8(5):A99.
5. Oude Luttikhuis H, Baur L, Jansen H, Shrewsbury VA, O’Malley C, Stolk RP, Summerbell CD: Interventions for treating obesity in children. Cochrane Database Syst Rev 2009:CD001872.
6. LH Epstein LH, Myers MD, Raynor HA, Saelens BE. Treatment of pediatric obesity. Pediatrics. 1998;101:554-570.
7. Murtagh L, Ludwig DS. State intervention in life-threatening childhood obesity. JAMA 2011; 306(2):206-207.
8. Ebbeling CB, Pawlak DB, Ludwig DS. Childhood obesity: public-health crisis, common sense cure. Lancet. 2002 Aug 10;360(9331):473-82.
9. Infant and adult obesity. Lancet. 1974. 1:17-18

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