There's no debate that childhood obesity is a tremendous concern. I went to medical school in the early 1990s, and even just 20-odd years ago, what we know now as "Type 2 Diabetes" was still called "Adult Onset Diabetes." Not anymore. Nowadays kids with single-digit ages are coming down with what was once a disease of adulthood, and kids younger than 20 are being found to have the once-only-middle-age conditions of hardening of the arteries and fatty liver disease.
And of course it's not just medical problems these kids face. Studies on bullying behavior demonstrate kids with obesity are 2 to 3 times more likely to be bullied than their skinnier peers (Kukaswadia, 2011). Add that to the incredibly pervasive societal stigma against those with obesity, and it's hard to imagine that obesity isn't having a terrible impact on these kids' self esteem.
So if childhood obesity is so problematic, why wouldn't I suggest we treat it?
It's not the primary problem.
I'll repeat that. Childhood obesity is not the primary problem -- or, to put it slightly differently, kids are not the problem. There's not an epidemic loss of willpower among 5 year olds, yet already by first grade, 1 in 3 children in America will be overweight or obese. The kids these days are no different than when we were kids. What's different is the world our kids are growing up in. Today's world is a Willy Wonkian dietary dystopia. It's an environment filled with nutritional misinformation, predatory advertising, misguided crop subsidies and aisles and aisles of ultra-processed boxes masquerading as food. It's a world where kids can't step on a blade of grass without being rewarded with a treat, where school fundraisers occur in Chick-Fil-A, and where Olympic gold medalists like Shawn Johnson, Chris Bosh, Apolo Ohno and Elana Meyers are busy helping to peddle chocolate milk to children as a "recovery" drink. (I've got to ask. What could these kids possibly be doing where for "recovery" they need a beverage can contain 20% more calories and double the sugar of a full-sized Snickers bar?) Our world is the disease, and childhood obesity is just the symptom, and as a physician I know that while it's nice to treat symptoms, it's always more important to cure diseases.
But I guess, given that we're not about to cure the world, it's fair to ask, "Shouldn't we treat the symptom?" Again, I draw on my training to answer. I was also taught that we shouldn't offer treatments without evidence to back up both the treatment's efficacy and its safety.
So is there a safe and effective diet for children? One that reproducibly, in a substantial and significant percentage of cases and in a sustainable manner, causes weight loss or prevents excessive gain? Unfortunately, the answer is plainly "no." And don't be lulled into thinking, "Yes, but we'll just have those kids eat less and exercise more." If it were that simple, do you think we'd still have a problem? Do you think these kids and society as a whole want to be bullied and victimized because of their weights? That they're choosing to purposely go out of their ways to "eat more and exercise less"? If you do, then I suppose you must also think playing the stock market is easy, because all you have to do is "buy low and sell high." But even if you're of the school that believes such an intervention or diet exists, is there data out there that tells me that administering that diet isn't going to irreparably damage a child's lifelong relationship with food, with their body image, or with their self-esteem?
I don't treat children in my practice, nor do I put my adult patients on prescriptive "diets." My oath as a physician to "do no harm" is one I take seriously, and given that I'm not aware of any diet plan for children that's actually proven to be safe, effective, and sustainable, picking up in my office where the schoolyard bullies left off, or suggesting that a parent do so, isn't something I'm comfortable recommending. And believe you me, as is evidenced by the story in Vogue, a physician's expectation of parental action isn't necessarily what's actually going to happen once that parent gets his or her kid home. Moreover, I've got to ask, if full-grown, insightful, incredibly motivated, intelligent, mature adults with clearly weight responsive medical conditions struggle with long-term weight management and "dieting," how can anyone imagine that a young, innocent, immature, not-fully-developed-frontal-lobed child is going to be able to pull it off?
There is good news, though. There have been a number of studies now that demonstrate treating the parents can help the child (Golan, 2004, Boutelle, 2012). That's why I'll regularly recommend that, to treat individual cases of childhood obesity, we should be treating their parents and not the children. What I teach the parents in my practice is to live the lives they want their children to live, and to never, ever, put an emphasis on doing so for weight-related reasons (their own or their children's). It's about cultivating and nurturing healthy living behaviors -- as regardless of a child's weight, every family, including those with skinny little rails, can benefit from more family-based cooking with whole, healthful ingredients, from active parents who carve out fitness time for themselves and their families, from less screen time and from more warmth. Those healthy living behaviors apply to every weight.
I've seen too many patients in my adult office who trace their struggle with food and weight back to a well-intentioned doctor and his or her straight talk about their "not so little anymore bellies" -- or to a well-intentioned Mom or Dad who took them at an incredibly young age to Weight Watchers. Coupling that with the clear-cut fact that studies on parental feeding behaviors in kids demonstrate that being more restrictive backfires and leads to further dietary disinhibition and weight struggles (Scaglioni, 2011), I can't in any good conscience recommend that children be placed on diets.
Until we have that reproducible, sustainable, effective and safe diet that we can prescribe with confidence, where we're assured we'll be doing no harm, I think we should stick to the parents, and also to rage against the world. The kids have it tough enough already.
Atif Kukaswadia, Wendy Craig, Ian Janssen, William Pickett (2011) Obesity as a Determinant of Two Forms of Bullying in Ontario Youth: A Short Report. Obes Facts 2011;4:469-472
Moria Golan and Scott Crow (2004) Targeting Parents Exclusively in the Treatment of Childhood Obesity: Long-Term Results Obesity Research 12, 357-361
Boutelle KN, Cafri G, & Crow SJ (2012). Parent Predictors of Child Weight Change in Family Based Behavioral Obesity Treatment. Obesity doi:10.1038/oby.2012.48
Silvia Scaglioni, Chiara Arrizza, Fiammetta Vecchi, and Sabrina Tedeschi (2011) Determinants of children's eating behavior Am J Clin Nutr December 2011 vol. 94 no. 6 Suppl2006S-2011S
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However there is a risk that targeting parents is again shifting the blame to yet another individual, and yet another single factor. To most people 'parent' equals 'mum' and a focus on parents = blame. But parents have difficulties making decisions too, and their parenting decisions are also constrained and influenced by their families, lives and environments. It's clear that a range of measures at various levels are necessary to promote healthy behaviours (from environmental change to regulation of advertising to changing working hours etc etc) - it would have been good if your article mentioned that too.
There's no surprise that (in the UK at least, i don't know about US) there are strong relationships between socio-economic status and child weight. 'Good parenting' (including feeding and exercising kids) needs huge amounts of energy and emotional (and sometimes financial) resources that many poor parents simply don't have due to the nature of their lives. Let's address this as well as focusing on individual parents' beliefs and attitudes.
There's also a strong risk that exclusively blaming parents will turn them away from engaging in issues of health that can be beneficial to them and their families. Whenever we mention child obesity we should mention parents, but whenever we mention parents we should also mention environment, markets, advertising and poverty.