Severe Obesity in Children: A Call to Action

Letter from the President


Dear Colleagues,


As we lean into summer and prepare for ObesityWeekSM 2014 in Boston, Mass., Nov. 2-7, I’d like to take a few minutes to reflect on the public perception of the obesity problem in North America and our role as researchers and clinicians in the larger discussion, specifically as it relates to the recent discussion on pediatric obesity.

Last week, an intriguing paper hit the news on pediatric obesity (
JAMA Pediatrics, Skinner and Skelton), which is based on the NHANES longitudinal data set. Two key takeaways came to my attention. First, the overall, upward trend in pediatric obesity appears to be slowing. This positive news is consistent with the impact of the myriad public health efforts that began in earnest roughly a decade ago. The totality of our public health efforts - including awareness, education and intervention/prevention - must continue unabated if we are to move forward on this encouraging path. As a Society, we must be unwavering in our efforts to help create new solutions and quantify the effectiveness applying sound science. 

Disturbingly, Skinner and Skelton also report the continuing rise in severe obesity among children. Embedded in this fact are several interesting scientific questions that will need to wait for another forum for discussion. Regardless, the rise in severe obesity in children highlights several areas for improvement and a matching call to action. 

First, access to specialized pediatric care for severe obesity is limited. Improving referral networks to specialists can help ensure children affected by severe obesity can get in to see the nutritionists, weight-loss physicians and other specialists that can offer them the medical support they need. Further, the expansion of treatment options, particularly in pediatric obesity, can mean care that goes beyond the traditional. While there are no drug or surgical interventions approved for severe obesity in children, options like the pediatric medical home addressing obesity from a family level, represent novel and unique areas to treat the disease in children. The exploration of these types of approaches, as well as other community-based models, is severely needed.

Second, there is still a public and professional perception that the approaches that work so well for prevention, including lifestyle intervention via a healthy diet, behavior modification and physical activity, will be effective for treating severe obesity in children. 


Let me be clear: lifestyle intervention is the bedrock, but we also acknowledge that in many cases it may be insufficient. 


As is true for many diseases, prevention and treatment take various approaches. Think about infectious diseases, heart disease, and cancer - the tools of prevention are different than the tools of treatment. However, we have few treatment options for children with severe obesity that do not simply repeat prevention strategies.

In a CNN interview Skinner reinforced this concept when she said, "What we worry about is not that they're going to be unhealthy now, but if they have unhealthy behaviors that are going to follow them into adulthood." 

Implicit in this - and many other statements that appeared in the press - is that children with severe obesity developed the disease because of bad habits and unhealthy behaviors. The message continued… if only the environment was better they would not be in this state. Unfortunately, the measurement of BMI was not reported in the context of data on "unhealthy behaviors" so we await further analysis to precisely draw that specific conclusion.

Also implicit in the data is the fact that severe obesity was present before the upward trend began around 1980. Clearly, there is a greater problem today than in years past – evidence for alternate explanations and new areas of research.

One explanation may be reflected in the groundbreaking work of Sadaf Farooqi, Stephen O'Rahilly and other researchers, which suggests that, of children with severe obesity, many have identifiable genetic origins. O’Rahilly addressed this in his keynote at ObesityWeek 2013. However, this discussion of genes as a predisposing or causative factor in severe obesity was unfortunately not part of the dialogue in the media coverage of the Skinner article. Instead, we slipped again into the discussion of unhealthy behaviors and a public health model of prevention. Clearly, our environment has changed. We need to improve the environment to prevent disease, but the problem is certainly more complicated.

As part of this conversation shouldn’t we also be asking the hard questions: once severe obesity develops in children what are the best approaches to diagnosis and treatment? And while the research is still evolving in the area, what role does epigenetics and nutritional programming play in the increase in severe obesity? 

In other words, our ability to chart the problem greatly exceeds our ability to understand the problem and we should redouble our efforts to use the best tools of science, medicine and discovery to seek answers to help move all of our children toward a healthier future.




Steven R. Smith, MD

President, The Obesity Society

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