Thursday, February 04, 2010

Should we be treating children for obesity?

Long term readers of my blog may know that generally I'm leery of childhood obesity treatment programs (if you've got to this page from the CBC website on bariatric surgery and teens, please be aware that this blog post has solely to do with medical weight management programs and that surgery may in many cases be an extremely appropriate teenage option).

My issues with them are pretty straightforward. I worry about what it will do to the self-esteem and body image of a child to be put through an inter-disciplinary weight management program (kid, you're so fat you need a team of doctors and dietitians to help you); I worry that kids are not emotionally or cognitively mature enough to have insight into treatment (especially younger kids); and I worry that by treating the kid we're avoiding the cause - the parents who've enabled whatever behaviours that have led their kids to need help in the first place and the environment in which we all now live.

Really the only time I think it's suitable to treat children is when there are already established co-morbidities - hypertension, hyperlipidemia, diabetes, non-alcoholic steatohepatitis, etc. Otherwise I think we should be treating their parents and encouraging them to live the lives they want their children to live and to teach their children through role modeling rather than lecturing.

Well here's a worry I didn't have before but I do now. I worry that maybe you can't even give childhood obesity treatment programs away.

What do I mean?

Have a peek at this news article. The article's about a young girl named Paris living in Chicago. Paris is overweight and Paris' pediatrician urged her to participate in a year long program of weekly sessions with a dietitian, a personal trainer and a physician held at Chicago's Rush University. The program was offered free of charge. They'd have workouts with the trainer when they were there, and the docs and RDs would help them work on lifestyle changes.

At the outset, things went great for Paris but then life intervened. She and her family started missing appointments, Paris started eating out more often and despite an initial loss, by the end of the year Paris had gained 12lbs.

The not for profit cost estimate for the year of intensive therapy was in the neighbourhood of $4,000.

So at the end of the day here's a motivated family (they had to have been to commit to weekly visits for a year), a desperate teen with a $4,000 scholarship to an intensive treatment program - a program that provided an exemplary level of care consistent with the recent recommendations of the US Preventive Task Force, that fairly quickly the family and the teen blew off.

I know, one isn't exactly a sample size but given the challenge I see in compliance with adults, when I couple that with the inherent lack of organization of a child/teen along with the realities of life and the pressures of youth I worry that these interventions might in fact do more harm than good (harm to self-esteem and body image with a lack of demonstrable lifelong success despite the best of intentions).

Now I don't have any basis for my worries other than my gut. Hopefully there's someone out there following children through these programs into their adulthood to track their mental well being, their body image, their self-esteem and their weight, and until I see those studies saying I've got nothing to worry about, I'm going to stick to my adults only approach.

In my mind prevention is the key to dealing with childhood obesity, not treatment and while maybe I'm a broken record, here are some suggestions:

  • Expanded and enhanced nutritional education in schools encompassing energy balance with an emphasis on energy in and spread throughout the curriculum (reading comprehension, math, geography etc.); mandatory posting of calories on menus in schools; ridding schools of energy dense highly processed garbage; mandatory cooking courses (where parents are encouraged to attend); snack time built into the curriculum and the establishment of a national nutrition policy and food program for schools.

  • A federal ban on advertising targeting children.

  • Mandatory calorie posting in chain restaurants.

  • New zoning laws to ensure variety stores and fast food restaurants be further than walking distance from schools.

  • Massive public education campaigns on the importance of eating frequently, having breakfast, having minimums of calories per meal and snack, the importance of protein and fibre in satiety, calories needed per person per day and basic label reading.

  • New labeling laws to ensure more uniformity in suggested serving size and the inclusion of calories per package as well as a ban on misleading front-of-package health claims and programs.

  • The establishment of a nominal junk food and/or soft drink tax (a penny an ounce sounds good to me) with proceeds to subsidize the costs of fresh whole foods.
  • Changes to the existing tax laws so as to remove tax from healthful, whole foods.

  • Tax deduction status for all sports equipment, gym memberships, organized sports for kids and adults alike.

  • Those are just off the top of my head. Put together a think-tank and we can come up with dozens more. If we want to tackle childhood obesity we have to tackle the cause - the environment and the parents. Tackling the kids just puts them at risk for injury.

    Whitlock, E., O'Connor, E., Williams, S., Beil, T., & Lutz, K. (2010). Effectiveness of Weight Management Interventions in Children: A Targeted Systematic Review for the USPSTF PEDIATRICS, 125 (2) DOI: 10.1542/peds.2009-1955

    [Hat tip to BMI's Director of Operations Lorne for pointing me to the article]