The Debate Surrounding Removal of Severely Obese Children from the Home: An Editorial Commentary

 

August 2011

 -by Martin Binks, PhD

 

Over the past several weeks there has been considerable public debate surrounding a controversial article published in The Journal of the American Medical Association(JAMA). The article proposes that the State should consider removing a specific subset of obese children (above the 99th percentile) from the home and placing them foster care temporarily as a remedy for their obesity1. It was suggested that this action could change the trajectory of the child’s obesity by providing a period of time where they were exposed to healthy nutrition and reasonable activity levels. It was noted that during the separation parents could be provided with education to assist them in managing their child’s weight. The central theme of the article is that this approach could be considered as opposed to more invasive surgical procedures. The article further states that under most existing child protective services laws, multiple less intrusive interventions such as in-home social supports, parenting training, counseling, and financial assistance, that may address underlying problems without resorting to removal of a child. In addition the authors note that broader preventative measures are needed to adequately impact childhood obesity and that government could “reduce the need for such interventions through investments in the social infrastructure and policies to improve diet and promote physical activity among children.”  The authors, Lindsey Murtagh, JD, MPH; and David S. Ludwig, MD, PhD,  are respected members of the academic and medical community (Department of Health Policy and Management, Harvard School of Public Health; and Optimal Weight for Life Program, Department of Medicine, Children's Hospital, Boston, Massachusetts; respectively) and have presented a thoughtful  analysis of this difficult topic. The purpose of this newsletter piece is not to summarize or even fully consider the entire debate. Nor is it to state any sort of official position of The Obesity Society. Rather we would simply like to add a few more thoughts for our readers’ consideration and invite your further input via email at This e-mail address is being protected from spambots. You need JavaScript enabled to view it

As scientists we know that out of controversy often times comes innovation and that in considering unpopular opinions we sometimes find truth (the image of boats sailing off the edge of the earth comes to mind). As scientists we are also bound by our belief in objective analysis and fact-based decision making in considering all potential solutions to a problem and that often it takes a bold and controversial stance to ignite the type of debate needed to stimulate critical thinking.  By its very nature the topic of obesity in children generates an emotional response. We as a society have agreed that protecting our children from harm is among our most primary responsibilities. Deciding what constitutes ‘neglect’ to a degree that justifies removal of a child from their home is among the hardest choices we have to make. So the fundamental question raised by Dr. Ludwig and Ms. Murtagh is this: Does obesity in its most severe form constitute neglect and if so, what is the best course of action? This is a fundamental question that is clearly in need of discussion as the prevalence of obesity and related diseases increases rapidly in our society’s most vulnerable population. It requires us to determine if as a society, in the case of our children’s weight, we are failing in our fundamental responsibility to protect our children from harm.  Childhood obesity rates have continued to climb and the medical consequences affecting our children have followed suit. Our efforts to tackle the issue on a large scale have been unsuccessful. The authors point out that the scientific community has identified a multitude of contributors ranging from the built environment and our continual proximity to calorically dense low nutrient foods to the influences of the human genome and our body’s physiological adaptation mechanisms. Within this broad spectrum is our social environment. This includes our children’s broader social environment (friends, school, and social gatherings) and their primary social environment (the family/home environment). Perhaps the most consistent argument heard against the notion of removing children who have severe obesity from the home is the fact that this approach singles out one among many contributors to the child’s obesity and focuses too narrowly on the influence of the primary caregivers. While clearly parental influence is important, especially in younger children, in the context of broader influences on eating and physical activity the argument to remove children from the home is seen by many as perhaps placing too great an emphasis upon the influence of the home environment (especially in older children and adolescents) in the context of the child’s broader food and physical activity environment. In fact studies have shown children are getting more of their food away from home in recent decades which may be limit the relative influence parents are able to exert2.

In making the point regarding the viability of removal of the severely obese child from the home, the article singles out adolescent bariatric surgery as a comparison/alternative intervention and suggests that surgical intervention is as yet unproven (although short-term results have been favorable, long-term outcomes are as yet unknown) and somehow potentially damaging to the family and individual due to the irreversible nature of the decision (vs. the ‘reversible’ situation created through temporary removal from the home). Both points are valid to consider given that the long-term physical and psychological impact of surgical weight loss for adolescents is relatively unknown. However, in considering this argument it is also essential to consider the fact that the impact of the proposed solution of removing the child from the home is completely unknown in terms of both efficacy in achieving physical outcomes (e.g. weight loss and health improvement) and the potential for permanent damage to the family unit and the child’s emotional well-being. The assumption that placement in foster care, for a limited time, can have any meaningful long-term impact on the child’s weight trajectory is unsubstantiated by the authors. However, even if we assume that a foster care placement will be able to effectively provide a healthy and structured food and activity environment (which is doubtful); the impact of this non-professional, limited scope ‘intervention’ on weight also remains unknown. By contrast, review of data show that surgical approaches (some of which are considered reversible such as Laprascopic Gastric Banding) have been effective in reducing weight and comorbidities in severely obese adolescents3,4,5.

The issue of stigma and our society’s long record of blaming victims for medical issues with behavioral components is also important to consider (i.e. alcohol, nicotine and other drug addiction). What role does blame play in our debate over placing obese children in foster care? While we are not technically blaming the obese child, could it still be seen as blaming a secondary victim, the obese child’s parent for being unable to combat on behalf of their child, the very same contributors to obesity we all agree are out of the direct control of any individual? Add to this the fact that we have a large proportion of parents of obese children who are themselves obese and we have what could be seen as blaming a primary victim on behalf of a secondary victim. Perhaps we need to step back a moment and consider what we each TRULY believe about who or what is to blame for obesity. Our professional consensus appears to be that environmental and psychosocial influences combine with our biological predispositions to impact adiposity in the context of our behavioral determinants. We often posit that those who are less biologically vulnerable are least likely to develop obesity or at minimum experience less severe forms of weight difficulty. Those individuals with the highest biological vulnerability are most likely to develop the disease in its most severe forms (including degree of obesity and comorbidities). Therefore, if we single out individuals with the most severe form of obesity for state sanctioned removal from otherwise loving homes, what type of society have we become? Is this an act of protection or one of discrimination based on biological vulnerability? The authors attempt to address issues such as unknown genetic disorders and biological influences in general; however they use as a basis of their initial argument for removing children from the home the following statement “Whereas typical children consume about 100 kilocalories per day more than requirements state, the energy imbalance for severely obese children may exceed 1000 kilocalories per day suggesting profoundly dysfunctional eating and activity habits”.  This statement clearly sets the tone that in order for a child to become super-obese they must be consuming huge quantities of food and furthermore in the context of the article, implies that those calories are being provided in the home. Given what we have learned in recent years about the influence of the broader environment on childhood obesity, coupled with the rapid increases in our understanding of biological influences on energy balance, using such a broad assumption about feeding to justify removing children from the home due to their obesity, in the absence of other signs of abuse and neglect may not be an ideal solution.

 It’s easy to engage in intellectual debate on the merits of this issue. In fact it’s easy to forget if we are not very careful, that the decisions we are discussing are not about some hypothetical family. We are talking about real people struggling with a complex multi-determined health condition. In fact it is very likely that this issue may impact the lives of our friends, colleagues, neighbors, and loved ones. These decisions carry with them a human toll. Think of your own colleagues, friends and family. Do they have an overweight or obese child? To what degree did the parent (your colleague, your friend, your family member) contribute to the issue through “neglect?” If their child happened to be unfortunate enough to progress towards severe obesity would you be willing to call protective services to remove their child from that home (with the same clear conscience you would have if you saw them beating their child) or is this issue somehow different?

 

References

1. Murtagh L, Ludwig, DS. State intervention in life-threatening childhood obesity. JAMA 2011; 306(2): 206-207. DOI: 10.1001/jama.2011.903

2. Lin BH, Guthrie J, Frazao E. Quality of children’s diets at and away from home: 1994-96. Food Review 1999b; 2-10.

3. Holterman AX, Browne A, Dillard BE 3rd, Tussing L, Gorodner V, Stahl C, Browne N, Labott S, Herdegen J, Guzman G, Rink A, Nwaffo I, Galvani C, Horgan S, Holterman M. Short-term outcome in the first 10 morbidly obese adolescent patients in the FDA-approved trial for laparoscopic adjustable gastric banding. J Pediatr Gastroenterol Nutr. 2007;45(4):465-73.PMID: 18030214

4. Al-Qahtani AR. Laparoscopic adjustable gastric banding in adolescent: safety and efficacy. J Pediatr Surg. 2007; 42(5):894-7.PMID: 17502207

5. Treadwell JR, Sun F, Schoelles K. Systematic review and meta-analysis of bariatric surgery for pediatric obesity. Annals of Surgery 2008; 248(5): 763-776 doi: 10.1097/SLA.0b013e31818702f4

 

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