Remove Obese Children from their Parents’ Custody?

state intervention obesityAn editorial published this week in the Journal of the American Medical Association suggests that severely obese children (defined as Body Mass Index at or greater than the 99th percentile) are at such a great risk for life threatening complications, that treatment such as surgical weight loss or state-intervention should be considered. The editorial argues that for children who are morbidly obese, inadequate or unskilled parenting can leave them vulnerable to external factors such as poor food options and insufficient physical activity, fueling weight gain and even being considered neglectful. The authors suggest that state intervention – perhaps through removing the child from the home – may be the best option for these children, as it would separate them from the harmful lifestyle behaviors of the family.

We asked several national experts for their opinions about the editorial. Dr. Jaime Ponce, bariatric surgeon at the Gastric Band Institute in Tennessee, told us:

This is a bigger problem that requires more than just thinking of the home environment as responsible for a child’s obesity. First, obesity is a multifaceted entity that not only is associated with consumption of high caloric foods and lack of exercise, but also can be related to genetic influence, endogenous hormonal or metabolic factors, and psychosocial issues. And because this is a complex issue, taking a child out of the home will not solve many of the different contributing factors. Second, our country’s cultural environment includes multimedia marketing for fast foods and candy to both children and adults; extra-large food portions offerings dependent on competitive consumer strategies; easy access to fast foods related to our fast pace way of living; and lack of daily activity. All of these problems are part of being a wealthy country with more resources, and people having access to the comfort and richness of our general lifestyle.
It is true that if a home environment offers positive influences on the kids, that the outcome may change, but what is really needed is better education at all levels, better control in marketing strategies, and better stimulus for positive lifestyle. State custody, with all the organizational problems that this might have, is not the solution and could create significant problems in the needed interpersonal relationship between the child and family.

Dr. Christine Ren Fielding, bariatric surgeon at NYU Langone Weight Management Center addressed the author’s attitude toward other weight loss options:

What Dr. Ludwig neglects to recognize, is the choice of bariatric surgery. It is appalling that an ‘expert’ would rather a child be taken away from the family which provides emotional and physical support, and placed with strangers who have no qualifications as better ‘weight-loss’ parents, rather than offer them bariatric surgery which would undeniably target a main etiology of overeating, which is hunger and satiety. Surgery decreases appetite and improves the level of satisfaction with smaller portions of food. In addition, the child can be supported by their family to make the appropriate behavioral changes necessary to optimize outcomes.
Placing these children in foster care does absolutely nothing to address the cause of obesity and is simply conjecture.

Dr. Vafa Shayani, bariatric surgeon at the Bariatric Institute of Greater Chicago, also spoke with us. He said:

Undoubtedly, there are instances where taking children away from their home environment may prove helpful to their healthy growth and development. However, basing this decision solely on the child’s struggles with obesity might be too aggressive of an approach. The complexities of “primary parent-child” relationship may never be adequately replicated in a foster-home environment and accordingly, one must be careful with recommending a transition from the parental home to foster home, based on the eating habits of the parents and/or the child. Having said that, JAMA‘s editorial on this topic raises many valid concerns which will hopefully lead to better societal approaches to the epidemic of childhood obesity (such as availability of healthier foods at schools and more appropriate use of funds provided by the state and the local governments to the families in need).

Dr. Sunil Bhoyrul, bariatric surgeon at Olde Del Mar Surgical in San Diego, told us that he thinks the idea of state intervention for childhood obesity is wrong morally, scientifically, and ethically. He explained:

It is the thin end of the wedge for “doctors playing god” – our moral and ethical role as physicians needs much debate before supporting a stance like this. In my opinion, we are not even close to starting, let alone completing that debate. Scientifically, the study of epigenetics is revolutionizing our understanding of the clinical illness of obesity – to simplify a complex disease by blaming parents is the scientific equivalent of blaming a parent if their child develops cancer. To treat obesity as a social condition, rather than a clinical illness, is a huge step backwards.

Dr. Mark Fusco, bariatric surgeon at Lifeshape Advanced Bariatrics Center of Florida addressed specific issues with the editorial, saying:

My first concern is that the authors take it as a given that obesity is preventable and treatable by a change in the child’s environment. Twenty-five years ago, Stunkards published a classic study which evaluated weight similarity between adopted children and both their biologic and adopted parents. This study demonstrated the importance of genetics and biologic factors in obesity. (Stunkard AJ, Sorenson TIA, Hanis C et al. An adoption study of human obesity. N Eng J Med 1986; 314:193-198.) In addition, the authors state “it may be unethical to subject such children to an invasive and irreversible procedure without first considering foster care.” Yet they present no data that removal of a child from an otherwise non-dysfunctional home is innocuous in the long term. They also provide no data for the efficacy of foster care for weight reduction. A study by Hadfield showed that children placed in foster care were more likely to be overweight and obese than the general population and 35% had an increase in weight while in foster care. (Hadfield SC, Preece PM. Child Care Health Dev. 2008 Nov;34(6):710-2. Obesity in looked after children: is foster care protective from the dangers of obesity?)
In spite of ongoing strides we have made in removing the stigma associated with the disease of Obesity, this commentary is worrisome that we not only have a long way to go, but unfortunately the stigma of obesity may be spreading to the parents of our patients.

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