Obesity in children: What is the responsibility of doctors?

Lying in a hospital bed, my seriously obese patient could barely see her swollen and odorous right foot over her abdominal fat. The foot was soon to be amputated, the result of an untreatable infection exacerbated by diabetes and kidney failure, which developed in part because of obesity.Her two children, ages 6 and 12, hovered from the hospital bed to the couch. In between, the bedside table was strewn with empty fast-food bags, pastry crumbs and large soda cups.

Like their mother, the children were exceedingly overweight.The mother was in her 30s; I had all but given up hope for her long-term survival. And as I watched her children, I feared for their health.

Childhood obesity is a recent disease. During medical school in the late 1980s, I do not recall a single lecture or patient case presentation on the subject. But much has changed; in just the past two decades, obesity among children has more than doubled, from 7 percent to 18 percent, and among adolescents it has more than tripled, from 5 percent to 18 percent. These children are more likely to have pre-diabetes, bone and joint problems, sleep apnea, and risk factors for cardiovascular disease.

Certainly parents have responsibility here. But I often wonder: What is the responsibility of the medical establishment?

Three months ago, the American Medical Association recognized obesity as a disease. We doctors are now struggling to figure out our role in treating this newly declared illness — and how to approach children and their parents about healthy eating and exercise habits that will last a lifetime.

When I spoke about this with a pediatrician in my community near Memphis, she sounded discouraged. In a typical case of an overweight teenager, she said, “I show the mother the growth curve and point out that the child is way off the charts. Then I ask, ‘Have you thought about controlling the weight?’

“First there is denial,” she said. “And often there is the blame game — it’s the grandma or the dad” who overindulges the child. This isn’t a problem that is easily solved in a doctor’s office, she said.

One tool in her limited kit is something called “5210 Every Day.” Adapted from a program that originated in Maine and is spreading nationwide, 5210 promotes four “numbers to live by”: Kids should eat 5 or more servings of fruit and vegetables a day; spend 2 hours or less on recreational screen time; get 1 hour or more of physical activity; and consume 0 sugary drinks.

She explains the program to her patients and sends them home with a 5210 brochure.

brochure? “How much can I do in 15 minutes?” the pediatrician said. That’s how long she has to tend to the problem that prompted the visit, plus provide other counseling: vaccinations, drinking, drugs, sexually transmitted diseases, bicycle helmets, and yes, diet and exercise. And it may be another year before she sees the youngster again.

I understand the pediatrician’s quandary. For one thing, how do you tell a mother to send her children outside to play if their street has boarded-up windows and drug dealers on the corner? How hard is it for her to buy and prepare fresh foods? In other situations, where families are fortunate enough to live in a safe neighborhood and have plenty of fruit and vegetables in the refrigerator, we see some parents who are too worried about their children’s self-esteem to talk to them about their weight.

The medical community is taking some concrete steps: For example, childhood-obesity clinics are popping up at academic centers nationwide. The head of pediatrics at one such center tells me a team approach is used to help young patients manage diabetes and hypertension — a nutritionist, a physical therapist, a social worker, a psychologist and pediatric specialists. But he acknowledges that few private pediatrics offices have all these resources. A broader problem is getting Medicaid and private insurers to reimburse doctors for obesity counseling.I fear that we will not come close to solving this problem anytime soon.

Here in Memphis — named the fattest big city in the United States in a 2011 Gallup study – I see a root cause of childhood obesity every time I make the drive to one of my hospitals: Take a left turn at the Krispy Kreme Doughnuts and the Burger King, just after the McDonald’s and before the Wendy’s, Taco Bell and Pizza Hut — which are all on the same road as a famous local fried chicken place with a billboard advertising a $5 meal. Our children are growing up among land mines disguised as play areas.

These are some ironies of our society and health system: We allow our children to be poisoned by excessive high-sugar, high-fat foods and then we treat them for the diseases that are caused in part by such foods. We spare no expense to save a baby’s life, yet we’re not willing to reimburse doctors for nutritional and social counseling if that baby grows into an obese child.The U.S. health-care system is designed to function best when doctors are treating acute illnesses, such as a heart attack or pneumonia. Slowly it is being pushed to provide better treatment for chronic illnesses such as diabetes. But it still misses the mark on prioritizing and promoting preventive and lifestyle changes.

For a moment I imagine a health-care system in which reimbursement is not based entirely on the sickness of the patient but is partly based on what experts call “population health.” Doctors, hospitals, insurance companies, pharmaceutical firms and home health agencies would be paid not only for treating individuals’ illnesses but for demonstrating that they had advanced and maintained the health and wellness of the community.

It would be a gigantic shift. Still, I am hopeful: Much is happening to turn the tide. First lady Michelle Obama is leading the “Let’s Move” campaign, which is placing awareness of childhood obesity on the public agenda. New York Mayor Michael R. Bloomberg (I) is trying to limit the size of sugary drinks. And the 5210 campaign and similar programs are spreading to more and more cities.

Here in Tennessee, a community campaign supported by Healthy Memphis Common Table – a regional health collaborative that I helped found a decade ago — appears to have had some encouraging results. The campaign works with local farmers markets, schools and beverage companies; one of its efforts led to junk food being banned from the vending machines in elementary schools, and another turns vacant lots into thriving gardens. The preliminary results of a study by Vanderbilt University School of Medicine indicate that the rate of obesity among adults here has dropped below the state average, whereas more thank a decade ago the rate was 5 percent above the state average.

We doctors must look upstream to the causes of obesity and get creative about our role.

As I stood in my patient’s room, where the odor of rotting flesh mixed with the aroma of leftover French fries, I considered her life-threatening infection, preceded by kidney failure and diabetes, which were preceded in turn by a massive weight gain that did not have to happen. I realized she would not live as long as her mother had, and I recalled studies that have predicted that for the first time in U.S. history, children have a shorter life expectancy than their parents, largely because of obesity-related conditions.

The woman I cared for in that hospital died a year later from complications of diabetes, renal failure, hypertension and obesity. It’s her children who need help now.

Manoj Jain is an infectious disease physician and contributor to the Washington Post, where this article originally appeared, and The Commercial Appeal.  He can be reached at his self-titled site, Dr. Manoj Jain.

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  • Ron Smith

    Can you share more about the life of this woman. Certainly the obesity is terrible. But surely we need more information about how she made her living? What were her other lifestyle choices? What was her education level? How compliant had she been with recommendations you or others made?

    I would even be interested in what her religious preferences were if you know them?

    Surely obesity is not something we can consider in medical vacuum?

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

    • Guest

      If I might hazard a guess at some of her characteristics, I bet she was low socioeconomic status, poor diet (evidenced by the food on the table), lack of physical activities that she enjoyed, noncompliance with medications, low education level. Likely unemployed, if not working a minimum wage job. Probably Christian of some denomination.

      Many of these things we as doctors can’t do a lot about. Ultimately the responsibility for the choices she makes must fall on her shoulders. But surely we can come up with a better way to help these people than to simply say “o well ur problem!” The healthcare system is being crushed under the weight of complications (pun absolutely intended) from preventable disease. Just as rampant disease led to the invention of vaccines, the growing (hohoho) problem of obesity must lead to a new battle plan.

      At this point it’s either find a way to fix it or accept defeat, and the consequences that come with it.

      • sandraleesucks

        How does Christian faith cause obesity?

        • Guest

          It doesn’t. I just meant that the majority of Americans identify as Christian, so it’s likely she is as well. Also, those of a lower socioeconomic status also tend to be Christian. No offense was implied

          • Guest

            I notice that you felt free to link religion to obesity, but you steered clear of race, even though it’s also a known fact that some races tend more towards obesity than others. Bigotry against Christians is one of the last remaining acceptable bigotries I guess.

      • dontdoitagain

        I was with you until we got to the Christian part! Are there studies which show that Christians have an obesity problem to the exclusion of other religions? I mean, Buddha was/is a little on the heavy side…wouldn’t his practitioners want to emulate him, thereby making Buddhists fat?
        As far as saying “oh well, your problem”, what DO we do? Lock up fat people in fat people internment camps until we get them to where medical workers are happy? There isn’t much solution to the problem of obesity.
        I don’t buy the current busybody type ideation that anybody who (name the vice) is responsible for rising medical costs. Medical costs are rising for other reasons. To say that everybody who (name the activity) is bad and driving up prices for the pure and innocent is disingenuous.

  • Eric Thompson

    A major portion of any solution has to rest on those who are afflicted by obesity. In areas where fresh fruit and vegetables are available in low income neighborhood stores, it rots on the shelves. The residents prefer the fast food and high calorie snacks. No health care provider can force patients to eat right.

    • GT

      You are correct. If low-income areas were actually crying out for more fresh fruit & veg outlets, if local residents really would have preferred places to get healthy low-fat low-calorie meals rather than fast food joints on every corner, the market would have gone there.

      The problem is that there’s no money to be made in opening up a healthy food joint in areas where no-one wants to eat healthy food!

      McDonalds tries every now and then to put something healthier on their menus: yogurt and muesli breakfasts, the ill-fated “McLean” hamburger, all sorts of “heart-healthy” alternatives … and they’re always dead losses, almost no-one buys them.

      I guarantee that if I were to open up a low-cal low-fat vegetarian take-out restaurant right next to a Popeye’s in a low income area, I’d go broke within a week.

      • http://www.dpsinfo.com LaurieMann

        I normally don’t go to fast food places but was traveling last weekend, stopped at a Burger King and tried their new “lower fat” fries. They had an odd after-taste.

        There were fat kids back in the ’60s and ’70s as I was one of them. I don’t remember a doctor talking much about my weight to me, other than sometimes giving me diets. I’ve had a doctor for nearly 20 years who does not nag about weight, but who does monitor my bloodwork and blood pressure and the like.

    • http://www.transcriptionoutsourcing.net/ Elizabeth

      I think the response there then is more education. Host free cooking classes teaching people how to cook easy and healthy dishes, how to pick out the best fruit, what to do with kale or squash or radishes to make them taste delicious. More often than not I feel people are intimidated by fruits and veggies, and if their parent didn’t cook them they don’t know what to do with them.

      • Jess

        With all due respect, kale and squash and radishes will never taste as delicious as burgers, fried chicken and french fries. Unless you can convince these people to forgo that which they enjoy, and make do with something that’s harder to prepare and doesn’t taste as nice, in exchange for some future health benefit that they won’t see immediately, it’s not going to work. It’s as much a psychological issue as anything.

        Some people simply can’t see the point in forgoing immediate gratification in exchange for some nebulous gain far into the future. We see the same thing in those young people who can’t understand why they should make the sacrifice to finish high school and go to college rather than just do whatever they feel like doing. Maybe there’s a spiritual (not religious, just spiritual) component as well: if in your heart you don’t think anything you do is going to change your life, if you don’t have hope for a better future for yourself, it actually makes sense to grab all the satisfaction you can now. Before you can learn the skill of delayed gratification, you have to have faith that there’s going to be a pay-off in the future for the things you’re sacrificing today.

        People such as this don’t need little Martha Stewarts marching in and teaching them what to do with kale, squash or radishes, they need an infusion of hope. They need to be given something to look forward to.

  • SarahJ89

    I am on an online forum. One of the members is an RN who posts pictures of her three-year old son. The child is so obese he has rolls of belly fat cascading down his body. When he stands his arms stick out like ours used to as children when we were in our 1950′s snowsuits–only in his case he can’t bend his arms because they are encased in fat.

    These pictures horrify me. I simply cannot understand how someone can be a nurse and NOT see the massive obesity. I really don’t understand it.

    I finally asked a friend on the forum, who is a mother herself, what sense she could make of this situation. She replied “It’s because she can’t say no to her son. He asks for food and she always gives it to him because she simply cannot say no.”

    If you start with that premise (and it makes the most sense to me) then the parent kind of has to muster up a high level of denial in order to keep saying yes.

    It’s really, really sad to see a small child so hemmed in by his body. Really sad.

  • bill10526

    In my youth everybody knew that acne was exacerbated by eating chocolate. EVERYBODY. Then somebody did an experiment that showed chocolate had no effect on pimples and eventually references to chocoltte causing acne died out.

    ” We allow our children to be poisoned by excessive high-sugar, high-fat foods” is like chocolate causing acne. The relationship has been studied without confirmation. Sandy Szwarc has done wonderful work about weight.

  • T H

    In real life, no one likes to be the bad guy. We all (at least a little) like to be liked. When we point out a child is obese, mom feels like a failure and she retaliates or withdraws. Overcoming that is EXCEEDINGLY difficult.

    But….

    We MUST make the effort. As physicians, our duty is to do the right thing, not the nice thing. If we always want to do the nice thing, we need to find different a profession.