Archive for December 19, 2007

Growing Pains

A new report, Expert Committee Recommednations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report, issued by the American Academy of Pediatrics (AAP) this month, is designed to tackle the growing prevalence of childhood obesity in the United States.

Its recommendations should make any parent shudder – not only does the position of the AAP assume overweight and obesity in children is a problem of behavior, it assumes every child in the United States, with the exception of those classified as “underweight” by BMI, is in need of routine intervention and prevention to avoid overweight and obesity in adulthood.

I kid you not.

Every child in the United States, except those with a BMI classifed as “underweight,” will now be subject to a risk assessment and prevention measures at every doctor visit. The implication within the document is clear – parents simply cannot be trusted to know how to raise normal healthy weight children over the long-term, even when their child is a normal weight, thus routine, repeated messages must be delivered at each and every opportunity.

The new guidelines call for healthcare professionals to question and investigate all of your family behaviors and habits at home – everything from what you eat, when you eat, how often you watch television or use a computer, if you eat out, where and how often, and how much time is spent being sedentary versus being active is to be collected and noted in your childs medical chart.

Despite the fact your child is classified within a “healthy weight” you’ll be subject to your own scrutiny as a parent too – if you’re overweight or obese, your child will be flagged as “at risk” due to your weight, not their weight.

Should the clinician note any abberant behavior – heaven forbid you allow your child, for example, a level of television time deemed excessive – you’ll be scolded to limit television time. Heck, even if nothing is found and all is well, you’ll still get the lecture about diet, exercise, limiting fast food and avoid sugary drinks….just in case….overweight and obesity is, afterall, a problem of behavior and you need constant reminder of that if you are to comply.

Where the guidelines sink to Brave New World levels is what is recommended for those children who have a BMI classed at or above the 85th percentile. There is to be no more sugar-coating the problem. Children with a BMI between the 85th and 94th percentile are overweight and children at or above the 95th percentile are obese.

In addition to the above assessments of risk, they’ll now be subject to routine bloodwork and you’ll be expected to do something about the “problem behaviors” now.

The first stage will be “Prevention Plus” through your doctors office. You’ll now be expected to visit the doctors office for monitoring more frequently and ensure your child eats 5+ servings of fruits and vegetables daily, ideally eliminate sweetened beverages from your child’s diet or limit to 1 per day, limit television time to less than 2-hours per day, make your child do physicial activity for 1+ hours per day, prepare meals at home, eat at the family table 5-6 times per week, have a “healthy” breakfast daily, and get the whole family on-board with the changes. You’ll have 3-to-6 months for the doctor’s office to see results, with visits scheduled to follow-up and monitor each month, and if no progress is noted, you and your child will be bumped to stage 2.

Stage 2 assumes you didn’t do enough on your own, so now you and your family will be expected to follow a “structured” planned menu, reduce television time to less than 1 hour per day, engage in planned “supervised” physical activities and record what you are doing to prove you’re complying with the recommendations and “achieving targeted behaviors”! If progress is not noted within three to six months, yup, you’ll be bumped to stage 3.

In stage 3 you’ll enjoy an intervention team (note sarcasm) that includes a behavior counselor (social worker, physcologist or other mental health provider), registered dietitian, exercise specialist and primary care provider, as well as weekly office visits to monitor progress in the “structured program in behavior modification” which will include, “at minimum“, food monitoring, short-term diet and physical activity goal setting and “contingency management.”

This “Comprehensive Multidisciplinary Intervention” now intensifies the urgency and seeks to maximize “behavior changes.” That’s because, if all this fails to result in progress and a reduction of BMI to the “healthy weight” category, they’re going to pull out the big guns and take your child to stage 4 – the “Tertiary Care Intervention,” which can include admission to a tertiary care facility for children as young as two, very low-calorie diets for children as yound as two, medications for children as yound as six, and/or bariatric surgery for children older than twelve.

Within the link above is the second document, Assessment of Childhood and Adolescent Overweight and Obesity, which details how to determine if a child is overweight or obese and reinforces the need for intervention, even in healthy, normal weight children. Noteworthy in this document is the explicit determination that BMI is the end-all-be-all measure of risk. While they note the BMI has flaws, and that the use of calipers to determine fatness is useful – “skinfold thicknesses are predictive of body fat in children and adolescents” – they continue on to dismiss its use and state “the expert committee does not recommend the routine clinical use of skinfold thickness measurements in teh assessment of childhood obesity.”

What this means is that if you have an athletic, muscular child, who happens to have a high BMI due to muscle, you’re going to be expected to do something about his/her weight to bring BMI to a “normal healthy” range.

Throughout the document the expert committee goes to great lengths to detail how to ask questions of parents and children, what to look for as problematic behaviors, and how to convince parents to modify those problematic behaviors.

A third document within the PDF package, Recommendations for Prevention of Childhood Obesity, we learn the justicification of the new guidelines in the opening sentences, “The majority of US youth are of healthy weight, but hte majority of US adults are overweight or obese. Therefore, a major health cahllenge for most American chidlren and adolescents is obesity prevention – today, and as they age into adulthood.”

Let’s not address what caused adults in this country to grow heavier, let’s just continue to assume it’s gluttony and sloth, lack of willpower, eating too damn much food, being lazy and more – those bad, bad, bad behaviors – and not allow our children to fall into the same trap and repeat, repeat, repeat to children they must eat a healthy diet and exercise daily!

We must do this, even if they’re a healthy weight now, because – by golly – look at the adults around them! Bad examples, bad behaviors, bad, bad, bad.

Within the document we find lots of suggestions about how to monitor, control and modify behaviors – everything from positive reinforcement to cognitive restructuring to self-assessment to decision support.

Then there is the Recommendations for Treatment of Child and Adolescent Overweight and Obesity document. In it we’re treated to the dogma to eat a “healthful” diet before getting to the real meat of the purpose – sections on food behaviors and then dietary intervention that includes the “use of balanced macronutrient/low-energy diets” for our children as a means to an end.

This is followed with reminding readers about the importance of physical exercise and the role of structured and unstructured activity each day and more on limiting television viewing and media usage.

Of course it, like the other documents, would not be complete without a full presentation of behavior approaches and techniques to use when a child is overweight or obese by BMI along with the drugs of choice and the option for bariatic surgery.

It also justifies the use of a staged behavior modification approach starting with prevention and reaching tertiary care if needed. Unlike the previous documents, it provides more detail by age. Those details make it clear that a child as young as six, when after six-to-twelve months of increasing intensity without sufficient progress, it may then “be appropriate for patient to receive evaluation in tertiary care center,” followed by flow-charts to make the decision-making process as to when to step-up intensity a no-brainer.

I really have no problem with the idea of helping parents help their child eat a good diet, I have no problem with encouraging children to be active and play actively each day.

What I do have a problem with is the wholesale implication that children who are overweight and obese are so because they have behaviors which must be modified through intense, staged interventions that have no solid evidence to support their use across the population!

Worsening this is that now, even healthy normal weight children, are to be subject to repeated, routine messages to make it clear they must maintain a BMI within normal or else they too can look forward to intense behavior modification intervention.

You may wonder if anyone has ever investigated how such an approach may affect children long-term?

The last document includes an interesting sentence, “The purpose of this article is to offer practical guidance to providers by providing recommendations, including those that LACK THE BEST POSSIBLE EVIDENCE.” (emphasis mine)

It also includes a section titled “Potential Psycological Complications of Behavior-Based Treatment” and states, “Only one study, a 10-year follow-up study of children who completed behavior interventions for obesity, reported on potential complications of treatment. Epstein et al found increased rates of psychiatric disorders such as depression, substance abuse, and eating disorders…” noting it was unclear if these were a result of comorbid conditions associated with obesity.

Amazingly, after staing only one study followed-up on children after behavior intervention, they pooh-pooh this by pointing to another study as supporting behavior intervention comes with little to no risk to children in the future – “Other trials showed improvements in children’s psychological functioning and did not find higher rates of eating disorders among children treated with a family-based, behavior, weight management intervention.”

I wondered what that study was all about since the clear message here is not to worry about damaging children with this type of intervention. The reference is to a study conducted by Faith et al – Effects of contingent television on physical activity and television viewing in obese children – published in Pediatrics in 2001.

How this expert committee sleeps at night, I don’t know!

This is a bait-and-switch citation in what’s now being put forth as the standard of care to imply these interventions aren’t going to have any long-term consequences to our children’s mental health and well-being.

The study referenced, unlike the one that followed up TEN YEARS later, was short-term for twelve weeks, investigating whether making television viewing contingent on a physical activity (pedaling a stationary bike in front of the television) would reduce television viewing time. It did. But it DID NOT investigate any phsycological impacts, nor did it follow up years later to see if there were any psycological impacts.

Nice try though – and anyone reading the document who does not follow the reference trail will never know. Given this type citation madness is included, in what is probably the most important factor – long-term outcome and potential consequences – one must question what else in the document also has this type of reference?

Folks, we have here a plan to now subject every child to intense and routine messages about body weight, BMI, eating, activity and their “behavior” – with no hard evidence it will provide the desired long-term results and the potential to seriously cause harm as our children grow-up in such an environment of intense scrutiny, monitoring and implication that BMI must remain within “normal” or else.

This expert committee has apparently lost all belief in “First Do No Harm.”

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December 19, 2007 at 6:01 pm 15 comments


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