Primum Non Nocere*

November 28th, 2011 by MorganDowney Leave a reply »

Many media outlets are reporting on the removal of a 200 lb. 8 year old from his family in Cleveland. Cleveland is, of course, the home of Toby Cosgrove, MD, head of the Cleveland Clinic, who proclaimed his desire to not hire workers who were obese. This came a year or so after the American Medical Association took the official position that persons who are obese are not entitled to compensation for being disabled for being unable to work. 

The intellectual justification for the forced removal of the child from his family is that provided by Dr. David Ludwig of Harvard Medical School.  State Intervention in Life-Threatening Childhood Obesity, July 13, 2011, Murtagh and Ludwig 306 (2): 206 — JAMA In the Commentary in July in the Dr. Ludwig had indicated that the forced removal by the state of children who were obese was justified. 

On what basis, you might ask? Well, there were several and they were all, in my opinion, intellectually bankrupt.

First, Dr. Ludwig and his co-author Lindsey Murtagh, J.D., assume “even mild parenting deficiencies such as having excessive junk food in the home or failing to model a physically active lifestyle, may contribute to a child’s weight problem.”

Excuse me? Before you go calling these “parental deficiencies,” how about defining: “excessive”, “junk food” or “failing to model a physically active lifestyle? Well, forget about it. They don’t define their terms.

What do they mean by “may contribute” to a child’s weight problem? If you are arguing that these “mild parental deficiencies” cause life-threatening conditions, is “may” good enough? What is the degree of evidence? If you are arguing that these conditions merit breaking up a family should not the evidence be like, beyond a reasonable doubt or a preponderance of the evidence? Is “may” good enough?

Second, they posit that severe obesity (a BMI at or beyond the 99th percentile) represents a fundamentally different situation than most overweight and obese children who have “the opportunity to ameliorate these risks through behavior change and weight loss as adults.” So, they say that severe obesity is fundamentally different “suggesting profoundly dysfunctional eating and activity habits”. Obesity of this magnitude can cause immediate and potentially irreversible consequences, most notably type 2 diabetes”.

Excuse me? Where is it written that persons with severe obesity as a child have a much smaller likelihood of reversing it as an adult than those with a lower level of obesity?

And what makes the BMI, which we know is a limited measure of body adiposity, at the 99th percentile different from the 97th percentile or the 95th percentile or the 92nd  percentile for that matter?

They argue that  severe obesity ‘suggests’ profoundly dysfuncitional eating and physical activity habits? ‘Suggests?’ They aren’t sure? If they are proposing breaking up a family maybe something more than ‘suggests’ is warranted. More importantly, could it not be that we are confusing cause and effect.  If there is anything to the increases in height and weight over the past 350 years, if there is anything to the contribution of genetic inheritance to obesity, if there is anything to the contribution of epigenetic factors to obesity, then, we must at least allow the suggestion that some children are born programmed to be overweight or obese. Upon achieving that status, one would assume they would overeat and underexercise compared to their normal weight peers. Would these be acquired ‘habits’ or the adaptions to their body habitus?

When they say that obesity of this magnitude can cause immediate and potentially irreversible consequences, most notably type 2 diabetes, what do they mean? Only a subset will develop type 2 diabetes immediately and for many, it will be manageable by lifestyle, drugs or surgery. Others, at a BMI lower than the 99th percentile and some who are merely overweight or normal weight will develop diabetes as well.

Third, (here’s the rub) the authors point with alarm that these patients may have to have bariatric surgery, whose long-term safety and effectiveness is not established. Therefore, they propose an alternative “therapeutic approach” i.e., placement of the severely obese child under state protective custody. The authors state, “Indeed, it may be unethical to subject such children to an invasive and irreversible procedure without first considering foster care.”

Doh? Did I get this right? Because at some point in the future, a child has continued to suffer with obesity and decides to have bariatric surgery, Ludwig and Murtagh propose the state comes in when the child is a juvenile and break up the only family the child has ever known?

Friends, I have worked for years with the professional jealousy of surgeons and internists and non-physician health care professionals. For the most part, they keep these often bitter inter-professional competitions to themselves. But this approach of Ludwig and Murtagh is nothing more than saying that breaking up a family, taking an obese child away from their mother and father and siblings, making them a ward of the state, having them raised by strangers who are paid for their care is better than even the potential that someday that person may want/be eligible for/can pay for bariatric surgery. 

The bias is demonstrated by the additional point raised by the authors that, “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.” Well, this is factually wrong. Roux-en-Y is not the most common bariatric procedure. The reversible laproscopic gastric banding is. Metabolic/bariatric surgery Worldwide 2008. [Obes Surg. 2009] – PubMed – NCBI  And  emotional pain may play a  particularly important role on the development of obesity. See this recent post.

And what does family reunion “when conditions warrant” mean? There are several options here which are starkly different and completely unaddressed by the authors. One option is that the obese child has returned to normal weight. The second option is that the obese child is still obese or has lost some weight but has improved eating or physical activity behaviors. The third option is that one parent or both have improved their ‘deficiencies’ by (a) removing only ‘excessive’ junk food in the home and/or (b) modeling a physically active lifestyle, independent of any change in the child. (Did I mention that the NIH guidelines for pediatricians on weight management did not find much support for physical activity?)

The fourth option is that that the foster care parents are both removing excessive junk food and modeling a physically active lifestyle and the child is continuing to gain weight. In some cases, there may be no “family reunification” but a succession of foster homes, all equally unable to affect the child’s excess adiposity. 

At the very end of their Commentary, Ludwig and Murtagh do a bit of a CYA, stating, “Nevertheless, state intervention would clearly not be desirable or practical, and probably not be legally justifiable, for most of the approximately 2 million children in the United States with a BMI at or beyond the 99th percentile. Moreover, the quality of foster care varies greatly; removal from the home does not guarantee improved physical health, and substantial psychosocial morbidity may ensure. Thus, the decision to pursue this option must be guided by carefully defined criteria such as those proposed by Varness et al with less intrusive methods used whenever possible.”

Now, dear reader, when one comes upon a statement like this, one assumes that Varness, et al, is in at least broad agreement with Ludwig and Murtagh. So it came as some surprise to actually read the cited Varness articles. See Childhood obesity and medical neglect. [Pediatrics. 2009] – PubMed – NCBI 

What Varness says is that, for a child to be removed from their home, all 3 of the following criteria have to be met: (1) a high likelihood that serious imminent harm will occur; (2) a reasonable likelihood that coercive state intervention will result in effective treatment and (3) the absence of alternative options for addressing the problem.

Regarding #1, a high likelihood that serious imminent harm will occur, Varness states, “The mere presence of childhood obesity does not predict serious imminent harm…Although childhood obesity is a risk factor for the development of multiple diseases as an adult, increased risk for adult diseases does not constitute serious imminent harm.” At the other end of the spectrum are current risks, such as severe obstructive sleep apena with cardiorespiratory compromise, uncontrolled type 2 diabetes and advanced fatty liver disease with chirrhosis. In some cases, like advanced hepatic fibrosis, the harm cannot be reversed in adulthood. Varness et al state, contrary to Ludwig and Murtagh, “There is no clear threshold level of childhood obesity (overweight, obese, or severely obese) that automatically predicts serious imminent harm….Although it is true that childhood obesity can lead to adult obesity, childhood obesity itself does not seem to lead to irreversible changes that are significant enough to mandate coercive state intervention.”

Regarding #2, a reasonable likelihood that coercive state intervention will result in effective treatment, Varness states, “In other words, is it truly reasonable to demand that families be able to achieve effective weight loss for their children? In addition, if it has been impossible for a family to reduce weight, what evidence is there to suggest that removal from the home would be more successful?” 

Regarding #3, the absence of alternative options for addressing the problem, Varness clearly does not share Ludwig and Murtagh’s antipathy for bariatric surgery. He states, “In summary, medications and surgery hold some promise but still have a questionable risk/benefit ratio, in both the short term and the long term. Although these may seem to be attractive options for some motivated adolescents with severe obesity, they are not options that are likely to be mandated for a child over the family’s objections. In contrast to the Ludwig-Murtagh paradigm of “mild parenting deficiencies,” Varness observes, “ In most cases of obesity, families make a good-faith effort to address the problem when they are made aware of the condition and the potential adverse health consequences. The development of a serious comorbidity can serve as a “wake-up call” for families, prompting full cooperation with intensified medical services.”

In sum, Varness makes the case that state intervention for obese children with no comorbidity is not justified; for those with a serious imminent harm, e.g. obstructive sleep apnea with cardiorespiratory compromise, intervention is probably justified. In between, only those risks known to be irreversible as an adult, such as hepatic fibrosis resulting from nonalcoholic fatty liver disease as opposed to cardiovascular disease, seems to be justified.

Finally, contrary to the misinformation about bariatric surgery, Varness notes that, “If a medical or surgical intervention that has a very high probability of decreasing weight with minimal adverse events is developed, then the availability of this effective treatment might result in a stronger intervention on behalf of children. For instance, gastric banding is a reversible procedure that involves the laparoscopic placement of an adjustable band around the proximal stomach. This procedure is not approved by the Food and Drug Administration for adolescents, and long-term data on its efficacy and complications are lacking. However, this procedure may hold some promise for extremely obese children, particularly as it is reversible.” In other words, coercive state action may be justified for bariatric surgery, rather than as an alternative to bariatric surgery, as desired by Ludwig and Murtagh. Not to belabor the point, but it seems Varness contradicts every major point Ludwig and Murtagh make. Curious, no?

My problem with the Ludwig-Murtagh commentary is not just on its intellectually bankruptcy and the harm it is bringing on persons who have enough pain it their lives. It is the question of what is Organized Medicine doing? So the position of Organized Medicine is this: Persons with obesity should be denied jobs (and, presumably, employer-provided health care), denied disability compensation when they cannot work, empathetic treatment by their physician and now the support of their own families in favor of unknown, paid-to-be-parents in foster care? Shouldn’t medicine be looking for better treatments? Maybe diagnosing their own patients? Maybe making appropriate referrals? Why don’t Dr. Ludwig and Attorney Murtagh call on pediatricians to develop better treatment protocols for children and adolescents with obesity? Why don’t they call on the American Academy of Pediatrics to lobby for dedicated funding for research on new treatments? Why don’ they criticize their fellow pediatricians who neglect to advise their patients on weight loss, in my opinion, unethically so. Pediatricians, in particular, have spent decades telling parents their children will ‘grow out of’ their weight problems. Now that obesity has become epidemic, they have done next to nothing to actually treat the disease, instead pointing to food companies’ marketing, television viewing, computers, vending machines, and parents as the culprits. Is it too much to ask them to develop treatments for their patients and quit blaming everyone else?

This blaming is only driving parents away from consulting with primary care providers, as discussed in Dr. Arya Sharma’s blog today. www.drsharma.ca.



If medicine, and especially, pediatrics, cannot help, at least stop making matters worse. 

See County places obese Cleveland Heights child in foster care | cleveland.com

Associated Press, MSNBC News: U.S. News – Ohio puts 200-pound third-grader in foster care

ABC News: Health » Obese Third Grader Taken From Mom, Placed in Foster Care Comments Feed

Background: Should parents lose custody of super obese kids? – Washington Times 

* Latin for “First, Do No Harm”