Pediatric Medicine Weighs In

By Michael Applebaum, MD, JD, FCLM

In the August 2003 issue of Pediatrics, the American Academy of Pediatrics (AAP) published its first policy statement dealing solely with identifying and preventing the problems of “obesity” and “obesity”-related disorders in children.

The policy asks doctors to keep “obesity” prevention in mind and to specifically measure body-mass index (BMI).  A co-author indicated that this will help them spot unusually rapid growth that might signal an increased risk of “obesity”.  Until now, most pediatricians only tracked children's height and weight.  The BMI is a height-to-weight ratio.  Vive la difference.

Calling this a “new policy,” as the media have, is interesting.  In 1998, an article in Pediatrics recommended “that children with a body mass index (BMI) greater than or equal to the 85th percentile with complications of "obesity" or with a BMI greater than or equal to the 95th percentile, with or without complications, undergo evaluation and possible treatment.”  Where have the BMI calculations been for the last five years? 

We now know that for at least the last half decade, vigilant oversight and determined efforts by the pediatric medical community have not been effective in dealing with the weight problems of children.  Otherwise why is “obesity” among children still a problem?

Somewhere along the line, the real influences on and determinants of childhood behavior must be enlisted in the effort.  This is what the pediatric societies should make as their policy priority: enrolling those who can really make the difference -- the four “Fs:” family, fashion, fame, and franchises.

Family – meaning parents.  They do have an influence.  Really.  Not only can they teach children proper eating behaviors, they can feed them healthy meals.  The AAP recognizes this.  However, if through nutritional child abuse parents do not provide healthful foods, behold another “F” -- felony.  Let the medical societies advocate responsible parenting and consequences for irresponsibility.  Parents also affect an additional “F” – funds.  But for parents, most children do not have a good source of income.  Money frivolled away on food should not be replaced.  A choice has been made by the child.  Buy food and you cannot afford to buy anything else.  Medical societies should encourage parental control of “underage spending.”

Fashion – clothing.  I find it interesting that some manufacturer’s of women’s clothing have re-sized their lines.  What used to be a size 10 was renamed size 6.  Thus the corpulent are misled into believing they are the thinulent.  Clever.  When it comes to kid’s clothing not only should the medical societies come out against a similar kind of re-sizing, they should advocate a change in sizing nomenclature.  A rough “BMI” can be determined from waist and inseam measurements.  Those sizes that suggest larger than healthy kids can be renamed, for example, “Garaniphants” or “Garanipotami” “Tummy Stillbigger” and “FABA” (fat ass, big ass).  Stores can place the clothing of super-sized boys adjacent to reasonable-sized girls and clothing for Star Jones-sized girls adjacent to reasonable-sized boys.  Maybe a little peer pressure will go a long way.

The AAP takes great pains to be a kinder, gentler medical society and avoids hurting the feelings of overfat kids.  It suggests that “the psychologic stress of social stigmatization imposed on obese children may be just as damaging as the medical morbidities.  The negative images of obesity are so strong that growth failure and pubertal delay have been reported in children practicing self-imposed caloric restriction because of fears of becoming obese.”  Yeah, well if the “negative images of obesity are so strong” then why is there an “obesity” epidemic?  If the AAP believes that this is a real problem, then advocate adult control, not coddling and negotiation.  By the way, I hope that the AAP would not be so understanding of nutritional child abuse at the other end of the spectrum – starvation.

Fame – famous people influencing kids.  These people need to be engaged in the effort.  For example, at each concert:

Britney could lip-sync that “obesity” is bad

Christina could explain how if she were “obese” she would be too embarrassed to dress as cheaply as she does

Justin could tell all the girls to keep their underpants off the stage if they are bigger than Cameron (“Would I date someone as large as you?”)

Ricky could tell his fans to avoid living la vida gorda

Eminem could tell kids to buy his recordings not his eponymous candy

The people who speak best to the listening of children just might not be pediatricians.  Medical societies should aggressively seek to influence entertainers (including athletes) for endorsements aimed at kid’s health.  The societies should foment and direct public pressure at convincing recording labels, clothing manufacturers and sports clubs to assume the responsibility of requiring healthful lifestyle PSAs as part of an entertainer’s/spokesperson’s contract.  In-office petitions signed at the time of a patient visit and sent by physician organizations en masse to relevant recipients would be a nice start.

Franchises – fast food, food stores, etc.  Gram Shop Acts (as in grams of fat) are needed.  These laws, akin to Dram Shop Acts for bars and alcohol, would empower restaurants and food emporiums to refuse service to children who appear at risk.

I have left out one “F,” friends, on purpose.  The reason being that, at least with kids, like appears to attract like.  The “cool” kids hang out with each other, as do the “geeks,” “jocks” and gang members.  Unless a group of overfat kids is really determined, the probability is that they would just support themselves in eating and not in changing lifestyle.  This “F” is one more place where Family can help.  Parents should discourage their kids from friendships with children who display poor nutritional behavior.

The “new policy” of the AAP is a small step.  Actively creating partnerships with those specific segments of society that have greater influence over children will go a lot farther towards solving childhood “obesity” than will the well-meaning proclamations of organized medicine and BMI measurements.