In an opinion piece in the Journal of the American Medical Association, a couple of doctors suggested that kids who were extremely obese with health problems should in some cases be subject to intermediate interventions by child protective services and, in extreme cases put in temporary protective custody. This is one of those things that causes a knee jerk reaction from both sides so I want to try to cover this as calmly and rationally as possible.
I first saw this article about it on Yahoo (thanks to readers Karen, Barbara, Jennifer and anyone else I’m forgetting for bringing it to my attention!) I was concerned that I wasn’t getting the full story from Yahoo so I went to the horse’s mouth at JAMA and paid $30 to read the piece (the things I do for you guys!). In this case I’m really glad that I read it.
It’s not nearly as bad as I expected. The author’s main focus seems to be suggesting intervention by the state as a better solution than the dangerous bariatric surgeries that are currently being recommended. They are also in favor of trying everything possible prior to removal from the home:
Child protective services typically provide intermediate options such as in-home social supports, parenting training, counseling, and financial assistance, that may address underlying problems without resorting to removal. These less burdensome forms of legal intervention may be sufficient and therefore preferable in many cases. In some instances, support services may be insufficient to prevent severe harm, leaving foster care or bariatric surgery as the only alternatives. Although removal of the child from the home can cause families great emotional pain, this option lacks the physical risks of bariatric surgery. Moreover, family reunification can occur when conditions warrant, whereas the most common bariatric procedure (Roux-en-Y anastomosis [gastric bypass]) is generally irreversible.
That actually sounds reasonably logical and I am happy to see a doctor speak out against weight loss surgery, but that’s not to say that I don’t have concerns. I absolutely do:
It’s tricky to use body size as a diagnosis:
- What about families where there are more than one child who eat the same diet but only one meets the definition of “extreme obesity”? Do they do interventions with all the children?
- What about parents who raise kids who eat lots of fast food and are sedentary but don’t become fat? Do those kids not get attention for their health issues?
We don’t actually know that much about childhood obesity:
Despite the fact that everyone and their overbearing mother thinks that they know exactly why we have a childhood obesity crisis, the truth is that nobody is sure. There is even some argument as to whether a crisis even exists. We don’t know if there are things in the environment that trigger some kids to gain a lot of weight, we don’t know if it’s that we have a fast food culture etc. Nothing is proven here so no matter how vehemently someone says that they know, they don’t. That makes it hard to find fault and place blame.
We don’t have a proven solution:
- Every weight loss method tested shows a less than 5% success rate over a five year period. This is particularly bothersome in situations where children are placed in foster care, lose the weight and then return to their family with a 95% chance that they’ll regain the weight and their parents will be labeled as repeat offenders.
- If they go to foster care and do not lose weight or gain weight, are the foster parents then at risk for being accused of neglect? What happens next?
Determining Fault
- The system already deals with “failure to thrive” cases in which parents are suspected of starving their children. Even those cases are problematic because sometimes there is a health issue with the child (celiac’s disease for example or food allergies) that are causing the issue.
- Unless the parents are force-feeding these kids, there are issues determining causality and fault.
Slippery Slope:
- Where are we going with this? Who is next?
- What about smokers who raise kids? Secondhand smoke contains more than 250 chemicals known to be toxic or carcinogenic (cancer-causing), including formaldehyde, benzene, vinyl chloride, arsenic, ammonia, and hydrogen cyanide. Children who are exposed to secondhand smoke are inhaling many of the same cancer-causing substances and poisons as smokers. Do we remove the ones who develop asthma? The ones with elevated blood pressure? Those born pre-term or with low birthweight?
- What about parents who choose not to vaccinate. If the kids get diseases after the parents refuse to vaccinate them, should they be removed?
This is a tricky and knotty issue. It deals with everything from parental rights to kid’s autonomy. Children who are under-nourished have long been subject to the type of interventions that are mentioned above despite many similar issues. I honestly don’t know the solution for these individual cases and it’s possible that, just like in under-nourishment situations, in some cases intervention probably is warranted but I certainly don’t want to have to decide which ones.
More importantly, CPS intervention and Gastric Bypass are not the only two options. What I think we really need to get out of this is how important it is for people to have information and access to the building blocks of health. Information about healthy eating and movement in combination with access to affordable foods and safe, affordable movement options that kids enjoy, affordable accessible preventative health care (not just reactive sick care). PE in every school and options that encourage a lifetime love of movement, rather than a lifetime of bitterness about PE. Dodgeball should go the way of the dinosaur. What if schools could offer more than just sports: dance, walking/hiking, Kinect style video games that incorporate movement etc? And not just during a PE hour but before and after school and during lunch and free periods, even on weekends? What if they offered busses and share-a-ride systems to the local YMCA or to the schools after-hours PE program? Wondering where you’ll get the money?
We’ve talked about this before but every year we give the diet industry $58 Billion dollars. Can you imagine what we could do if we could take that money out of their back pocket and use it to create access to food and movement for people in under-served areas? If we could get Michelle Obama to be for healthy kids instead of against obese ones? If we stopped body shaming and bullying fat kids allowing them to have the mental health that can only exist when they don’t live in a constant state of stigmatization would they be more likely to make healthy choices? I think so.
As usual I think our focus on weight is wasting time, money and effort and pushing us in the exact wrong direction. I would wager my life savings that if we would focus on health, spend our time thinking of ways to create access to health, invest our money creating access to health, we would actually have more health.
Dances With Fat 
This nanny state idea is completely appalling. Something that I have always thought would be helpful for everybody is the removal of certain substances from the food supply, particularly high fructose corn syrup and monosodium glutamate. Dr. Joseph Mercola discusses in this article how high fructose corn syrup is processed differently by the body than regular sugar is. So yes, your body can tell the difference!
http://articles.mercola.com/sites/articles/archive/2009/03/24/Why-HighFructose-Corn-Syrup-Causes-Insulin-Resistance.aspx
“Additionally, there’s hard empirical evidence showing that refined man-made fructose like HFCS metabolizes to triglycerides and adipose tissue, not blood glucose. And one of the most thorough scientific analyses published to date on this topic found that fructose consumption leads to decreased signaling to your central nervous system from the hormones leptin and insulin.”
Monosodium glutamate actually causes increased hunger as well as digestive problems and sometimes respiratory reactions. It is actually a neurotoxin and provides no flavor on its own.
Other than this, insuring that children get recess time at school (something many schools have cut back or eliminated) and encouraging active play (while dissuading children from scapegoating their larger classmates) would be helpful in making kids of all sizes more healthy.
The doctor who came up with the insane idea of removing heavy kids from their families needs his head examined. He appears to be missing a brain.
cuddos…right on
how many recesses did we get a day as children? i remember a am and a pm recess myself. now the kids only get one recess, after lunch for 20 mi. and that often gets cut at the teachers discretion for behavior problems or to make up work. this wonderful no child left behind act has turned schools into little test machines. pe is 2 days a week, and they get exactly 1/2 hour of movement a day (if they are good kids, and not in trouble) and we wonder why kids are more sedentary these days.
In my kids elementary, they get 3 recesses. One around 10 am, 20 minutes or so after lunch, and one at 2 pm. Although it might must be the 1-3 graders who get all three, I think by 6th grade my child only got 2.
When I was in grade school, we got three recesses – a 15 minute one at the two hour mark, a 30 minute lunch/recess two hours later, another 15 minute one two hours after that.
It’s the same break schedule that almost every hourly job I’ve ever worked provided — only real difference is that in the adult world, the two 15 minute ones were unpaid while the 30 minute one has usually been paid. Although to be fair, that might have changed — last time I worked was probably 10 years ago. I have issues being around strange men, or in a situation where anyone may come up behind me and touch me without me expecting it. Heck I freak out at home when a cat sneaks up on me and touches me lol.
We got 15 minutes at AM and PM, and an hour for lunch. My son was a very energetic child and when he was in 5th grade, the teacher was always punishing him by keeping him in from lunch for “fidgeting.” By the time she let him go to lunch, there was sometimes nothing left. The lad is hypoglycemic, to make this matter even worse! When he finally told me about this treatment, I was livid. The teacher’s response was to insult me by saying that “we don’t want him to grow up to be a waitress like his mother” and to say that he was hyperactive and should be on Ritalin. When I went to the principal, he backed her. I ended up taking my son out of that school.
WOW, that is appalling on so many levels. I wish we could take every child out of that school.
Excellent article. Thank you for reading the paper. I think I first read about this report in the Toronto Star’s parentcentral.ca (http://www.parentcentral.ca/parent/familyhealth/children'shealth/article/1023926–should-parents-lose-custody-of-super-obese-kids), where the reporting was reasonably balanced. At least I thought the article made it clear that the guiding principle was supposed to be (as it is supposed to be in all custody questions) the best interest of the child, rather than shaming parents, and that temporarily removing a child from its parent’s custody was seen as a last-ditch kind of thing.
That said, the article, apparently like the paper on which it reported, presented extreme obesity as a matter of individual choice and circumstance. In particular, this case stood out to me:
So the aunt has the resources to provide a special diet and exercise. The mom, presumably, is still working long hours and scratching by. Who’s to say that with better financial assistance, or with better support from community health and welfare, better access to exercise, better support in the home and the community, this family couldn’t be reunited? But better support costs money, so it’s cheaper for the state to look to another family member for suppor than it is to help Ms Gray and her son maintain the special diet and levels of exercise he needs while keeping them together.
The whole idea of this really bothers me. Why in the world would we lay more burdens at the feet of an already overburdened CPS?? And for something that may not even be preventable.
Actually, my first statement is a bit of an understatement. DH and I are going to be filing to adopt next year. We are already limited to what countries we can adopt from because of my size and past issues with depression. (For example, China and South Korea have BMI requirements for adoptive parents and you can’t adopt from Russia if you’ve EVER been diagnosed with depression.) So now what happens if we adopt a child who’s genetically prone to weight issues? That won’t stop the way he and I love him or her, of course, but if this were to go into effect, the government could take that child away from us? From two loving parents that sacrificed over and over just to bring that child into the family??
It legitimately frightens me.
“For example, China and South Korea have BMI requirements for adoptive parents and you can’t adopt from Russia if you’ve EVER been diagnosed with depression.”
What the heck is the logic behind that??
I’ve always wanted to adopt, but I have always been “overweight” and I have bipolar disorder. Wow… sad to see that the stigma on weight and mental health (another hot button issue of mine, along with sexism) extends beyond the US.
sadly, if anything, i think the stigma tends to be worse in asian countries. any sort of excess tissue at all is generally frowned upon, and they have stricter ideas than we do about what constitutes ‘excess’.
I was expecting you to blog about the JAMA article. I’m glad it’s an opinion piece and not a study that got through the rigors of peer review! Thank you SO MUCH for shelling out the $30 to read the full article. I only saw the CNN and Yahoo articles, and they were terrible. The authors probably didn’t even read the study, just picked apart a summary or an AP piece. I may or may not have left a few ranty comments on the CNN article (OK, I did).
I have a couple issues I want to comment on. First, the state of science/health reporting in the US. I recently read The Panic Virus by Seth Mnookin (yes I spelled that right), which discusses the idea that vaccines cause autism. Mr. Mnookin looks at the original study by Andrew Wakefield, and how a study that didn’t even pass the first stage of peer review and was ridiculed by doctors in the US and UK managed to take hold of the public. One major reason is that when a news outlet needs to make cuts, which so many do now, the first thing to go is typically science/health reporters. Now we have reporters who don’t know anything about science or health reporting on the topic. These reporters typically take the most interesting nuggets from studies and include those in the article. They’re more interested in a good story than, well, the truth. I see a lot of parallels between the spread of the belief that vaccines cause autism** and the belief that obesity is an epidemic and we have to “fight” it tooth and nail.
I too am worried about a slippery slope. I was a chubby kid but very healthy (still am). My friend, on the other hand, was very skinny, but ate nothing but junk. Her parents were fat, and still are fat (well, her mother is… her father died from hospital acquired sepsis, but the doctors blamed it on his fat… but I digress). Should she and her thin brothers have been taken away because their parents were fat? And where do we draw the line? Who determines who is too unhealthy to live with their parents? Would it be standardized? How would this affect the already overtaxed CPS system?
I also love your point that there are options to encourage health. I volunteered for a while at an after school tutoring program for high school kids in the bad section of Providence. There were three goals to the program: 1) Get kids off the street after school; 2) Get them the homework help that they need; and 3) Keep them out of their homes after school. The last point was the most important, and at orientation the volunteer leader explained this more in-depth. Most of the kids’ parents were from other, mainly Spanish or Portuguese speaking countries. The children, until they were school age, only spoke Spanish. It’s hard to do well in school when you don’t speak the language (then again, it was just reported that many Providence public school teachers don’t even pass the basic English literacy tests, and the school administration is making them take classes and learn better English, but I again digress). All of the tutors were English speakers, and keeping the kids around English speaking people for 10 more hours a week would greatly benefit their language skills. Additionally, they were mostly poor, and their parents worked several jobs just to keep food on the table and clothing on their backs. The parents didn’t have time to focus on helping their kids do their homework or encouraging them to read before bed. Most of the parents weren’t even home after school as they were working a second or third job. Education starts at home, and by keeping the kids away from home for a couple more hours each day, and keeping them in an environment where they could learn and focus on their homework was greatly beneficial. These kids were excited to come to tutoring after school, and their faces would light up when they saw their favorite tutor sitting and waiting to guide them through homework.
I think we could do the same for physical health. Have volunteer-run after school play programs where kids can play kick ball, swing on the swings, play tag, or just enjoy the sunshine, instead of sitting at home alone in front of the TV waiting for mom and dad to get home from work. Have healthy snacks on-hand, like fruit and vegetables. This type of program doesn’t have to be expensive. Create the initiative and market it, and then have volunteers from the community run it. It would also be a great way to get citizens invested in education and children’s health.
**I am not mentioning this to spart a debate about vaccines and autism. I’m just using it for the sake of an example, as I see the parallels. The Panic Virus is a great book, but if you do believe that vaccines cause autism, it’s triggering.
It just irks me (and so much more) to think that children could be removed from nurturing, loving and wonderful homes/parent/s because of weight. I actually had someone flat out tell me that everyone knows that obesity is unhealthy, period, and that parents of children who are obese are abusing them, period. What to the who in the f*&k are you to tell me that it’s abuse?! I’ll be perfectly honest, my head voice became my vocal voice when I heard that. Ok, technically I read it, and my vocal voice was me typing something along the lines of “GAH!!! Say it with me boys and girls: Correlation does NOT equal causation!” and then informing the offending parties that there is no hard evidence that excess adipose causes health issues, but only evidence that there is a correlation. I also reminded them that you can’t tell a persons health simply by looking at their weight. Nothing more has been said, and I’m not entirely surprised by that.
I had more I wanted to say on the subject, but this morning has been hell.
Thanks for mentioning the improvement of PE… as a person who has been skinny but unhealthy for most of my life (until a few years ago when I decided to take care of myself better even though the scale said I “didn’t have to,” boy was I wrong) I remember avoiding doing anything in PE because it was all about sports, which I was terrible at. I didn’t start enjoying PE until halfway through high school, where they gave us a choice between norlam, sports-centric PE, strength training, and aerobics. I did aerobics and loved it, and finally looked forward to going to PE every day.
And yeah… it seems like most of these articles tend to confuse correlation with causation. I’m pretty sure that Statistics 101 should be a required course for everyone, especially journalists…
norlam=normal 🙂
This sounds like me! What am I learning about health by chilling in the outfield while the rest of the class plays baseball around me? In high school there was a “body conditioning” option that included walking or running around the campus and neighboring parks, flexibility and strength training. We got one-on-one visits with the teacher to discuss our fitness goals. It was waaayyy better.
Yup. I didn’t hate regular PE, but the only PE class I well and truly liked was called Muscle Development. We learned some anatomy and physiology, how to safely use weights and other equipment, *set our own fitness goals,* and worked to achieve them. While we did have to periodically re-evaluate (setting new goals if we achieved the old ones and refining strategies if we weren’t making progress), goals like, “I want to get comfortable using every piece of equipment in the weight room,” and, “I want to master good form with my bicep curls,” were seen as just as valid as, “I want to be able to bench press XXX pounds.”
I hated PE. I had some coordination problems and the other kids were absolutely vicious to me. I think that if the adults had nipped this sort of crap in the bud, I may not have become exercise-phobic or been quite so self-conscious about my body.
I’m afraid I might feel more strongly about this issue than most because I spent some time in foster care. I was around seven years old and my younger siblings were around 3 and 4 years old. The foster “parents” took us to their split level home and we spent the evening in a dark basement huddled on a large bean bag chair. Some older kid I don’t remember ever seeing was playing loud heavy metal music in the room next door. My younger siblings were crying and wanting to know why we were there and where were our parents? I think part of me thought we had been kidnapped because no one else would take little kids from their parents. The next day they took us for a car ride. They showed me where my new school was. Can we say this was all terrifying? We went to the foster care center and I was relieved to see my aunt and uncle there. They told me that we couldn’t go home to our parents, but would we be okay living with them? Naturally after one terrifying sleepless night I said we’d be happy to stay with them. Those years with my aunt and uncle and at the time four cousins were some of the most stable times in our lives…still no kid wants to be in foster care– even with relatives.
Obesity alone is no reason for taking kids out of a stable home environment, especially since the foster care system in the US is horribly overburdened and there aren’t nearly enough altruistic foster parents in it for the right reasons. You’ve already stated some of the other issues like what if the family is doing everything “right” and the child is still overweight or if there are medical issues (still I’m glad to see they’re thinking this would be an extreme cases). If a child isn’t being abused or neglected and their parents aren’t abusing illegal substances or alcohol then there’s no reason to take them out of their homes. The trauma isn’t worth it. Is it better than having a dangerous surgery like bariatric surgery? Maybe physically, but I’m not convinced emotionally it’s any better (or worse).
I was in foster care for two weeks when I was about 6 or 7. My mom had to go to the hospital for surgery and there was no one to care for me. It was not a case of parental mistreatment or neglect. I just needed a home for two weeks.
These were certainly the worst two weeks of my life. Over forty years later, I still remember how lonely and frightened I was and how meanly I was treated.
We must tread very carefully when removing kids from their parents. Even children who are genuinely mistreated by their parents are often just further traumatized by being taken out of their home. It’s a complicated and terrible decision, even when it’s made with the best interests of the child in mind.
How right you are! I was raised by an alcoholic mom, but it was still better than being taken away.
This article is a bit spooky to me. I’ve always been overweight and I grew into a very overweight teenager. My mother had be dieting at 9 years old–my grandmother, who liked reminding me that “boys don’t like fat girls”, sent me to school with Slim Fast shakes. None of this worked very well; I was a picky eater and a fussy child. That wasn’t my parents fault.
At 16, my mother brought me in for bariatric surgery. At the time, I was the youngest person in my area to have it (this was back in 2001). Everyone ranted and raved about how this was the best idea ever and, being a child still, figured it was a quick fix and I’d feel “pretty and less depressed”. I never lost much weight. In fact now, at 27, I’m almost as heavy as I was at 16.
I know now that I should have never had surgery at a young age. But my mother thought she was helping me. I also don’t think children should be taken from their family because of their weight because we don’t really know what’s going on. I try to imagine being my little fat self again at 9 or 12 and what it would be like to have Child Services come in and say “Your family is letting you get fat, we’re taking you out of here to help.” I think to a child, that may be one of the most frightening and scarring events ever.
I really do agree with your ideas of improving PE and the reiteration of putting an emphasis on being healthy rather than thin. I know PE is a horror to a lot of kids, heavy or not–we get embarrassed, laughed at, and shut down when we can’t compete with kids who are healthier. But when PE, recess, and outdoor activities are made to be more fun and accessible to everyone, even the lifetime haters of Gym class start to enjoy it.
I just hope this idea of “fat kids go to foster care” don’t go through and backfire, which tends to be the case in situations like these. I’ve worked with kids and teenagers who spent *any* amount of time in the foster system, for a variety of reasons, and always seems to have a rough impact on them.
Thank you Ragen for pointing out the systematic problems when it comes to good health. This sort of proposition assumes that it is all on the individual rather than as you pointed out access to healthcare, nutritious food, and places to exercise, which you usually do, but in this case in particular I find it important and significant that you point out the complexity of holding people responsible in some ways, but also pointing out how access is a huge factor in this. I love your ideas for how to integrate movement into secondary education! As usual, you are awesome. =)
You should run over to Lesley Kinzel’s blog where today she discusses a new Robert Wood Johnson study that seems to suggest we’re not getting fatter by much after all. “Recent studies have shown that the number of obese children and adolescents may have leveled off since 1999, except among the very heaviest boys ages 6-19, but the rates remain startlingly high.” 12 years with no increase except for very fat boys? And they think there’s a crisis? It also shows, with the margin of error, that the rest of the country hasn’t gotten much fatter since 2007. http://blog.twowholecakes.com/2011/07/margins-of-error/
PE in schools also needs to be adjusted to encourage healthy living, rather than giving bully coaches a venue to harass and humilate the “out of shape.” Trying to motivate someone to run by telling them loudly that they are “fat and disgusting” doesn’t motivate. It destroys. I was a scrawny runt in my childhood, and received harassment for being at the other end of the scale. The words are different, but the net effect is the same. I didn’t want to go to PE and get in better shape. I wanted to stay away from the meathead jocks that thought they were better than everyone else because their genes gave them a better aptitude for sports. I wanted to stay away from the embarrassment of being picked last for teams, to play sports that I hated playing anyway, and I wanted to stay away from coaches that thought all I had to do was “try harder” and I would become just as good as the jocks.
The funny thing is, my wife’s fat grandmother would have probably kicked all their asses. I would love to have seen what would have happened if someone had tried to take away her kids or grandkids, claiming that she was abusing them by being fat, or by the fat that many of them had inherited the body composition. She’d have shown them some abuse all right…
What if schools could offer more than just sports: dance, walking/hiking, Kinect style video games that incorporate movement etc? And not just during a PE hour but before and after school and during lunch and free periods, even on weekends?
The high school where I teach is actually lucky enough to be able to do this, thanks to a special grant. I teach yoga twice a week after school, and several other teachers facilitate and teach activities like basketball, biking, Wii Fit programs, etc. We get a lot of participation from kids who otherwise might not be active — they might not do varsity sports, don’t have PE, are afraid to dress out in PE because of negative attitudes from other students or teachers, etc. It’s a pretty neat thing to have.
Wow… why is childhood obesity being targeted to have children removed from homes?? What about children of people who smoke?? That has consistent, proven negative consequences but no one is entertaining the idea of removing smokers’ children.
Same could be said for removing children from the homes of those who own guns. There are a great many more adult behaviors/activities that are dangerous to children than a child being obese. If a social worker is concerned maybe they should talk to the parent about the child’s habits and encourage regular physical activity/ healthy diet or a trip to the doctor to make sure there isn’t anything wrong.
Let me rephrase that… Rather than assume there is no physical activity and poor eating habits, the social worker should check for that. If none are present THEN encourage it. If they are, then either 1) Suggest the family physician for a check or 2) Accept that the child/teen is at their natural or “set point” weight.
Particularly if weight is the only problem and the child has no markers of ill health (high blood sugar, high BP, high cholesterol, etc…)
The one thing I keep wanting to scream from the rooftops, as a victim of child abuse myself, is that all of this wastes an awful lot of time and resources that the kids who ARE being abused by their parents desperately need.
Not to mention that I was abused BECAUSE I was fat (“punished” for being so disobediently fat) while my younger, thin brother escaped abuse. How many more kids need to suffer before we as a society get it that punishing them for how their bodies naturally are is abuse in itself?
I am concerned that *even if* some intervention is warranted and there are feeding problems (and this can happen with skinny children as well) most of our medical health professionals do not know enough about proper childhood feeding to actually help. Many parents have gotten bad advice to put their large (but growing consistently) children on diets and this has only shown to exacerbate the problem of extreme weight gain in childhood. Ellyn Satter is the guru on childhood feeding (and HAES oriented) and she writes about her clients constantly receiving bad advice from health professionals. And the other infuriating thing is how childhood obesity is defined – often in very young children it is just being above the 85th percentile or so, even though the child might be growing consistently at this pace (which is the ultimate goal – stable growth). This is just really infuriating to me and really scary too.
I just wanted to say I was a “fat kid” until I was 12 and hit the all important change in life lol. I grew 5 inches, had boobs, and gained 10 lbs and went from a size 14 to a size 8. What would they do with me? My body was just storing fat so I could grow…it knew what it was doing, even if everyone around me was devestated that I was the fat kid.