Wednesday, December 19, 2007

Growing Pains

A new report, Expert Committee Recommednations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report, issued by the American Academy of Pediatrics (AAP) this month, is designed to tackle the growing prevalence of childhood obesity in the United States.

Its recommendations should make any parent shudder - not only does the position of the AAP assume overweight and obesity in children is a problem of behavior, it assumes every child in the United States, with the exception of those classified as "underweight" by BMI, is in need of routine intervention and prevention to avoid overweight and obesity in adulthood.

I kid you not.

Every child in the United States, except those with a BMI classifed as "underweight," will now be subject to a risk assessment and prevention measures at every doctor visit. The implication within the document is clear - parents simply cannot be trusted to know how to raise normal healthy weight children over the long-term, even when their child is a normal weight, thus routine, repeated messages must be delivered at each and every opportunity.

The new guidelines call for healthcare professionals to question and investigate all of your family behaviors and habits at home - everything from what you eat, when you eat, how often you watch television or use a computer, if you eat out, where and how often, and how much time is spent being sedentary versus being active is to be collected and noted in your childs medical chart.

Despite the fact your child is classified within a "healthy weight" you'll be subject to your own scrutiny as a parent too - if you're overweight or obese, your child will be flagged as "at risk" due to your weight, not their weight.

Should the clinician note any abberant behavior - heaven forbid you allow your child, for example, a level of television time deemed excessive - you'll be scolded to limit television time. Heck, even if nothing is found and all is well, you'll still get the lecture about diet, exercise, limiting fast food and avoid sugary drinks....just in case....overweight and obesity is, afterall, a problem of behavior and you need constant reminder of that if you are to comply.

Where the guidelines sink to Brave New World levels is what is recommended for those children who have a BMI classed at or above the 85th percentile. There is to be no more sugar-coating the problem. Children with a BMI between the 85th and 94th percentile are overweight and children at or above the 95th percentile are obese.

In addition to the above assessments of risk, they'll now be subject to routine bloodwork and you'll be expected to do something about the "problem behaviors" now.

The first stage will be "Prevention Plus" through your doctors office. You'll now be expected to visit the doctors office for monitoring more frequently and ensure your child eats 5+ servings of fruits and vegetables daily, ideally eliminate sweetened beverages from your child's diet or limit to 1 per day, limit television time to less than 2-hours per day, make your child do physicial activity for 1+ hours per day, prepare meals at home, eat at the family table 5-6 times per week, have a "healthy" breakfast daily, and get the whole family on-board with the changes. You'll have 3-to-6 months for the doctor's office to see results, with visits scheduled to follow-up and monitor each month, and if no progress is noted, you and your child will be bumped to stage 2.

Stage 2 assumes you didn't do enough on your own, so now you and your family will be expected to follow a "structured" planned menu, reduce television time to less than 1 hour per day, engage in planned "supervised" physical activities and record what you are doing to prove you're complying with the recommendations and "achieving targeted behaviors"! If progress is not noted within three to six months, yup, you'll be bumped to stage 3.

In stage 3 you'll enjoy an intervention team (note sarcasm) that includes a behavior counselor (social worker, physcologist or other mental health provider), registered dietitian, exercise specialist and primary care provider, as well as weekly office visits to monitor progress in the "structured program in behavior modification" which will include, "at minimum", food monitoring, short-term diet and physical activity goal setting and "contingency management."

This "Comprehensive Multidisciplinary Intervention" now intensifies the urgency and seeks to maximize "behavior changes." That's because, if all this fails to result in progress and a reduction of BMI to the "healthy weight" category, they're going to pull out the big guns and take your child to stage 4 - the "Tertiary Care Intervention," which can include admission to a tertiary care facility for children as young as two, very low-calorie diets for children as yound as two, medications for children as yound as six, and/or bariatric surgery for children older than twelve.

Within the link above is the second document, Assessment of Childhood and Adolescent Overweight and Obesity, which details how to determine if a child is overweight or obese and reinforces the need for intervention, even in healthy, normal weight children. Noteworthy in this document is the explicit determination that BMI is the end-all-be-all measure of risk. While they note the BMI has flaws, and that the use of calipers to determine fatness is useful - "skinfold thicknesses are predictive of body fat in children and adolescents" - they continue on to dismiss its use and state "the expert committee does not recommend the routine clinical use of skinfold thickness measurements in teh assessment of childhood obesity."

What this means is that if you have an athletic, muscular child, who happens to have a high BMI due to muscle, you're going to be expected to do something about his/her weight to bring BMI to a "normal healthy" range.

Throughout the document the expert committee goes to great lengths to detail how to ask questions of parents and children, what to look for as problematic behaviors, and how to convince parents to modify those problematic behaviors.

A third document within the PDF package, Recommendations for Prevention of Childhood Obesity, we learn the justicification of the new guidelines in the opening sentences, "The majority of US youth are of healthy weight, but hte majority of US adults are overweight or obese. Therefore, a major health cahllenge for most American chidlren and adolescents is obesity prevention - today, and as they age into adulthood."

Let's not address what caused adults in this country to grow heavier, let's just continue to assume it's gluttony and sloth, lack of willpower, eating too damn much food, being lazy and more - those bad, bad, bad behaviors - and not allow our children to fall into the same trap and repeat, repeat, repeat to children they must eat a healthy diet and exercise daily!

We must do this, even if they're a healthy weight now, because - by golly - look at the adults around them! Bad examples, bad behaviors, bad, bad, bad.

Within the document we find lots of suggestions about how to monitor, control and modify behaviors - everything from positive reinforcement to cognitive restructuring to self-assessment to decision support.

Then there is the Recommendations for Treatment of Child and Adolescent Overweight and Obesity document. In it we're treated to the dogma to eat a "healthful" diet before getting to the real meat of the purpose - sections on food behaviors and then dietary intervention that includes the "use of balanced macronutrient/low-energy diets" for our children as a means to an end.

This is followed with reminding readers about the importance of physical exercise and the role of structured and unstructured activity each day and more on limiting television viewing and media usage.

Of course it, like the other documents, would not be complete without a full presentation of behavior approaches and techniques to use when a child is overweight or obese by BMI along with the drugs of choice and the option for bariatic surgery.

It also justifies the use of a staged behavior modification approach starting with prevention and reaching tertiary care if needed. Unlike the previous documents, it provides more detail by age. Those details make it clear that a child as young as six, when after six-to-twelve months of increasing intensity without sufficient progress, it may then "be appropriate for patient to receive evaluation in tertiary care center," followed by flow-charts to make the decision-making process as to when to step-up intensity a no-brainer.

I really have no problem with the idea of helping parents help their child eat a good diet, I have no problem with encouraging children to be active and play actively each day.

What I do have a problem with is the wholesale implication that children who are overweight and obese are so because they have behaviors which must be modified through intense, staged interventions that have no solid evidence to support their use across the population!

Worsening this is that now, even healthy normal weight children, are to be subject to repeated, routine messages to make it clear they must maintain a BMI within normal or else they too can look forward to intense behavior modification intervention.

You may wonder if anyone has ever investigated how such an approach may affect children long-term?

The last document includes an interesting sentence, "The purpose of this article is to offer practical guidance to providers by providing recommendations, including those that LACK THE BEST POSSIBLE EVIDENCE." (emphasis mine)

It also includes a section titled "Potential Psycological Complications of Behavior-Based Treatment" and states, "Only one study, a 10-year follow-up study of children who completed behavior interventions for obesity, reported on potential complications of treatment. Epstein et al found increased rates of psychiatric disorders such as depression, substance abuse, and eating disorders..." noting it was unclear if these were a result of comorbid conditions associated with obesity.

Amazingly, after staing only one study followed-up on children after behavior intervention, they pooh-pooh this by pointing to another study as supporting behavior intervention comes with little to no risk to children in the future - "Other trials showed improvements in children's psychological functioning and did not find higher rates of eating disorders among children treated with a family-based, behavior, weight management intervention."

I wondered what that study was all about since the clear message here is not to worry about damaging children with this type of intervention. The reference is to a study conducted by Faith et al - Effects of contingent television on physical activity and television viewing in obese children - published in Pediatrics in 2001.

How this expert committee sleeps at night, I don't know!

This is a bait-and-switch citation in what's now being put forth as the standard of care to imply these interventions aren't going to have any long-term consequences to our children's mental health and well-being.

The study referenced, unlike the one that followed up TEN YEARS later, was short-term for twelve weeks, investigating whether making television viewing contingent on a physical activity (pedaling a stationary bike in front of the television) would reduce television viewing time. It did. But it DID NOT investigate any phsycological impacts, nor did it follow up years later to see if there were any psycological impacts.

Nice try though - and anyone reading the document who does not follow the reference trail will never know. Given this type citation madness is included, in what is probably the most important factor - long-term outcome and potential consequences - one must question what else in the document also has this type of reference?

Folks, we have here a plan to now subject every child to intense and routine messages about body weight, BMI, eating, activity and their "behavior" - with no hard evidence it will provide the desired long-term results and the potential to seriously cause harm as our children grow-up in such an environment of intense scrutiny, monitoring and implication that BMI must remain within "normal" or else.

This expert committee has apparently lost all belief in "First Do No Harm."


  1. Anonymous1:09 PM

    And of course, no-one being interviewed will answer with anything but the truth!!!
    What a waste of money

  2. Anonymous1:42 PM

    The motto of "experts" everywhere: Parents are morons.

    *sigh* I've never been more thankful that the medical system as it stands is overloaded. The committee members who favor "a doctor in every home approach" have apparently never attempted to make an exam appointment for healthy children at a busy practice. I can't imagine my family doctor wasting that kind of time to cross examine the parents of obviously healthy children. I also can't imagine case workers adding "obese" children to their endless list of abuse cases, but stranger things have happened.

    Of course, another real issue is that if actually implemented, such a measure would prevent the parents who might need such intervention from going at all. Heck, after the vaccines were given, I'd think twice about bringing my kid into the system that would attempt create such an intrusion into my family life. Emergencies only after vaccines if I was cross-examined and scolded about an otherwise healthy kid.

  3. And just think, even with all this Big Brother oversight, the malnourished, underweight kids will slip through. Cause you can never start being too rich or too thin!

    Sounds like a plan to move copious amounts of money into the hands of diet doctors. If this goes into practice, how much you want to bet that a special government allowance will go to pay for all of this BS screening? Can't pay when little Johny has a cold, but can for this BS!

  4. This means absolutely nothing. As others have noted, pediatricians are overloaded as it stands, and since most of the "outside the office" actions would be against the wishes of the parents, they would have to be passed as law. Which simply isn't going to happen.

    Build a rapport with your pediatrician. Communicate freely. Make it clear that you respect them and their knowledge. If you don't get respect in return, find another doctor. Ultimately, the parents and not the doctors are the final decision makers and no "expert group" is going to change that any time soon.

  5. How on earth would we even begin to pay for this? Social services are so strained they can't even take care of kids who really need intervention because of mistreatment.

  6. Anonymous5:06 PM

    It won't happen - because no one will pay for it! The insurance companies will not and the government will not either. If no one pays, the doctors won't bother with it. So don't worry.

  7. This sort of thing is already happening in the UK. And their NHS is already overburdened and underfunded. Obese children have bene taken from their homes, because the parents were deemed negligent for allowing the kids to become obese.

    Truly outrageous. We can look forward to even more teenagers and young adults with eating disorders in the future.

  8. Anonymous9:16 AM

    There is a trouble maker also named Wilshire (some relation to Regina) who once suggested a moratorium on ALL dietary recommendations not supported by Level I evidence.

    Looks like the powers-that-be don't want to give up the powers-that-they-have.....

    A shame.

  9. Gary Taubes explores this paradox in his book, Good Calories, Bad Calories. Chapter 4 of the book titled ‘The Greater Good’ Geoffery Rose, an epidemiologist, is quoted as saying “ 49 out of 50 would eat differently every day (i.e. avoiding saturated fat) every day for 40 years and perhaps get nothing from it.” He suggested that you needed to create social pressure to change. This is the whole basis of public heatlh heart disease prevention model. This would be fine if the intervention offered a large degree of benefit compare to a small degree of risk, e.g. Typhoid vaccination to those who have been exposed to a carrier. The problem is that we’ve gotten into a situation where the (public health) intervention is worse than the cure. One example is the mass prescription of statins, a treatment, at best, only marginally effective in the prevention of heart disease or, more precisely, in the prevention of the recurrence of heart disease with many minor and serious side effects and a significant cost.
    The dilemma is that the public health bureaucrat, who is typically a doctor, must treat the entire population to prevent the illness of a few, even if there are negative consequences to some in that population. This violates Hippocratic oath of First Do No Harm. A more cynical person than I would say this is a case of attempting to justify one’s existence (i.e. salary) when there was no need. More likely it’s a case of group think, that we experts (technocrats) are here to solve your problems (whether you want us to or not.) Oops there’s that cynicism again.

    Taubes goes on to explain the problems with this approach. The most imporant being that once the public health campaign is adopted, it is effectively impossible to backtrack and say “Oops we were wrong. In fact, the science now shows that saturated fat is not a risk factor and that it’s the excess carbs that are harmful.”

  10. I sometimes wonder if in the early days of nazi germany everything seemed pretty normal except a few offbeat things of this same nature.

  11. Wow!! When mine were little all they cared about were the underweight kids. My daughter was always tall and thin (90+ percentile for height, 10th for weight). My doc wasn't a problem, but every other health care worker I was in touch with were!

    My DD is now 25, tall and thin. Every trip to WIC was a nightmare! Her health was fine, she wasn't anemic, had plenty of energy, was obviously happy, intelligent, etc...but at every visit I had to listen to lectures about how thin she was and how she could get sick at such a low weight! She was the healthiest in the family!

    I was "counseled" and questioned at every visit. I was told to give her milk shakes, ice cream, and pudding to put fat on her....even if she didn't eat her meal! It got to a point, just before she turned 5 (the cut off for WIC) that I was threatened with a social service referral! At that point my doc intervened and told them to back off....I was lucky.

    This is what moms and dads will go thru if they have to use any of these services. Of course it will be the poorer families that will get the most intense "counseling", which I guess is good since we all KNOW that poor are fatter because they're lazier and eat more, right? (note sarcasm).

    Don't you just love the stupidity?!

    This whole "at risk" garbage drives me nuts! I am SO glad my kids are grown!

  12. Anonymous4:18 AM

    Gee, I suppose that childhood obesity has nothing to do with taking away recess, PE and school lunches with poor nutritional values...

    Makes me think twice about taking my kids in for their check-ups...

  13. Anonymous10:12 AM

    Some times you just have to believe your own eyes. As I pass by the loccal school yard and look at the kids at recess I see very few obese children. If you were to ask Americans if they thought most kids were obese the majority would answer yes but their eyes tell them a different story, such is the power of the media.

  14. I agree with anonymous....I watch people, it's one of my favorite past times in stores, airports, etc. While the fat kids do seem to be fatter, there are a LOT of skinny kids out there! Many of them (well dressed, clean, etc) look like they're being starved!!

    I was harrassed when mine were little because my DD was very thin. I know it just made me mad. If I didn't have a supportive pediatrician and mom, I don't know what I would have done! It VERY scary to be told you may loose your kids when you didn't do anything wrong!

  15. Don't worry, no one who belongs to the AAP and provides primary care will ever have the time to implement any of this. Furthermore, insurance companies will never pay for it.