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JAMA proposes a medical mugging

by Deb Burgard, PhD

A recent JAMA editorial calls for government intervention – i.e., foster care – for “severely overweight children.”  The authors position state-sponsored kidnapping as a humane alternative to bariatric surgery, whose “long-term safety and effectiveness … remains unknown, and serious perioperative and long-term morbidity and mortality have been reported.” 

Interesting tactic.  Is a medical mugging (“your stomach or your home!”) really the best we can do?

When I read this sort of proposal I feel like the air gets sucked right out of the room.  I can’t decide if I get that reaction out of horror, terror, or being stunned by the arrogance of anyone thinking that they can read a parent’s actions from the size of a child’s body. 

For medical professionals and legal professionals and child welfare professionals to believe that parental neglect or abuse is the explanation for a child being very fat confounds me.  Where are the data?  As far as I can see, we don’t really know why some human bodies are phenomenally gifted at making fat from food.  And we don’t really know how to transform those bodies into thin bodies.  And though I can conceive of it, I am not aware of any documented psychopathological syndrome where a parent force-feeds a child to immobilize them.  And I am not aware of any medical intervention that transforms fat kids into thin kids that parents should be following to prove they are not neglecting their child.

I wonder if the JAMA authors could imagine a scenario where patients are removed from a clinician’s practice if they do not become thin from their weight loss intervention.  No provider who could not demonstrate lasting weight loss would be allowed to have patients.  Would they like to be held to the standard they are asking of parents?   

The only way I can make sense of this is to imagine that these professionals really believe that if people eat normally and exercise, we would all be average size.  Or they believe that because it would be unimaginably hard for them to reach a weight that high, it must be the case that this child is ingesting phenomenal amounts of food that “any reasonable parent” could modulate.  One would hope that any “expert” in the field would have abandoned these childlike notions long ago.

I can attest to the fact that there are certainly humans that ingest phenomenal amounts of food – but they come in all sizes.  Would we kidnap the average-sized 17-year-old adolescent whose family can’t stop her from binging and vomiting?  The emaciated 15-year-old who binges in the middle of the night and then goes out running unbeknownst to his parents? Families are begging for help for their children with eating disorders, which insurance companies routinely refuse to cover.  I don’t see JAMA editorials outlining this problem.  The medical problems and risks that these children face are far more immediate and deadly than someone who does not binge but is fat and runs a moderate risk of developing diabetes 30 years from now. 

Most of the very fat children discussed in the JAMA editorial have no current medical problems.  It is their weight that people are worried predicts future medical problems.  A few of the very fat children discussed in the JAMA editorial have current medical problems, as do a few of the children in any weight class.  There are no medical problems that fat people have than thin people don’t have – but when fat people have them, it tends to be blamed on their fat.

The good thing is that most medical problems have treatments.  For example, lots of children, fat and thin, have sleep apnea.  To kidnap a child and put them on a diet so they won’t develop sleep apnea is silly.  Why not just test for and treat the sleep apnea?

In my experience treating people with eating disorders, it is almost always the case that dieting precedes binging.  To fault a family for not putting a child on a diet is unfair and unscientific.  When families try to make their children lose weight by putting them on diets, it turns into a monumental power struggle that results in more binge eating and a more protracted struggle around food for that child that can last for the rest of their lives. 

Let us face the facts.  Being very fat is still a very rare situation, despite the images of the very fat people side-by-side with proclamations that “two-thirds of US adults are overweight!”  If the photos were commensurate with the statistics, the picture would show a person about 15 pounds heavier than they would have been a generation ago. But that doesn’t make for very dramatic news.  To become very fat requires a large number of factors that all point in the same direction, which is why so many people in our “obesogenic” environment are not fat. It is why not even all the children in a family with a very fat child are likely to be fat.  We don’t understand all of these factors and haven’t even identified some of them.  Ironically, one of them may be trying to become thinner.  Another may be being targeted for shaming about weight.  Above all, we won’t know until we have an intervention that makes fat people thin whether that is a good thing for them.  We are assuming that thin fat people would have the same risk profile as thin thin people, but no one knows. 

So until we have a very clear idea of what is going on and what, if anything, is problematic about what is going on, and what, if anything, is going to make a situation better, we should be very, very humble about yanking a child out of his or her home and subjecting him or her to something as barbaric and likely to fail as a diet. 

It really is chilling to imagine the trauma of being removed from your family, being placed with an unknown group of strangers with no necessary attachment to you, who will control all of your food access, with the demand that you be starved until your body is acceptable.  The authors seem to ignore all the potential psychological sequelae of such an “intervention.”  They also seem to ignore the implications for the civil rights of the child.

Healthcare-by-BMI is making us sick.  Of course we should care about the quality of life of our children and intervene when children are being neglected or abused.  But why we should think that a child’s body size is evidence of any particular parental behavior is as clueless and simple-minded as thinking that an adult patient’s body size is evidence of their eating or exercise practices.  This is weight stereotyping, not medicine.

There is a rational and humane way to support children and families in optimizing their health and well being.  It does not come from a short-term, dramatic “rescue” of a child from what outsiders, based solely on a child’s body size, conclude must be an unsafe environment.  It comes from long-term, broad policies that create a society that allows  parents to give their children nutritious food, loving attention, a safe place to live and play, and the skills to make friends, whatever their body size.  It is odd that so little thought or resources have been given to how to make movement opportunities more possible, pleasurable, and accessible for fatter people.  We also know that strong relationships support physical health, so whatever we can do make family attachments stronger and more loving is a lot more likely to benefit a child than demonstrating to him or her that nothing, not even having a home, is as important as losing weight.

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