Doctors — forced into becoming lifestyle police

If government agencies and the American Medical Association get their way, doctors and pediatricians will be compelled to police the behaviors of children and families to make sure they comply with the obesity initiatives of the world’s most influential interest groups.

This extraordinary development, which will forever change the face of pediatric medicine and private family life — eliminating the ability of doctors to practice quality medicine and of families to make their own choices on their foods and lifestyles, and even how parents may parent — was completely ignored by mainstream media.

This may sound melodramatic, but it won’t after you’ve read the new recommendations for the medical management of fat children and teens just released by the AMA, CDC and HHS from the “Expert Committee on the Assessment, Prevention and Treatment of Child and Adolescent Overweight and Obesity.” Before getting into just who is this Expert Committee and who is funding it, let’s get right to their harrowing clinical practice guidelines, which were posted on the AMA website.

As predicted here, they first recommend the definitions be changed so that children are labeled as “obese” and “overweight” using BMI percentiles, rather than the long-standing recognition that such classifications are inappropriate for growing children and teens. They also propose a new cut-off for children with BMIs in the 99th percentile, “to allow for improved accessibility of the data in the clinical setting and for additional study.” This is actually being heavily promoted by the bariatric industry for special targeting for bariatric surgery and pharmacological management, a topic for a future article.

Every well-child visit is now to include a qualitative assessment of eating behaviors, which must include identifying how often the family eats meals away from home, consumption of sweetened beverages, portion sizes, how often and what children and teens eat for breakfast, how much fruit juice is drunk, how many fruits and vegetables and foods high in fat or calories are eaten, and the frequency and types of snacks.

Each pediatric check-up should also include a determination of physical activity which is to include “at a minimum” if the young person is meeting recommendations for 1 hour of moderate to intense physical activity everyday and, if not, why and what social, environmental or familial situations are standing in the way; and how many hours they watch TV or videos, play video games and use the computer, to ensure screen time is less than 2 hours a day.

Every child deemed “overweight” or “obese” by these new standards should have not just blood pressure measurements, but a complete work-up for all “obesity-related risk factors” — one that appears more appropriate for an elderly, ill cardiac patient — as the referenced table shows:

Labwork for these heavier children, even those without risk factors, is to include lipid (“cholesterol”) profile, fasting glucose and a slew of other biomedical tests.

This Expert Committee goes on to recommend that all physicians and healthcare providers be made to counsel all patients, regardless of their weight, about weight management and lifestyle habits. All children and teens, of “normal” BMI ranges should be assured to be in compliance with the obesity prevention guidelines as it delineated.

Additionally, all children and teens with BMIs above the 85th percentile must receive special intervention by a primary care provider or healthcare professional trained in weight management and behavioral counseling. These interventions are staged, depending on the weight and compliance of the young person and family.

Stage 1

· Children and teens must eat 5 or more servings of fruits and vegetables each day, have 2 hours or less of screen time, not be allowed to have a television in their bedroom, engage in one or more hours a day of physical activity, and drink no sweetened beverages.

· The parents and family must be counseled to eat breakfast every day, against eating out, and to have family meals at least 5-6 times a week.

· The child or teen is to have monthly weigh-ins and their BMI must decrease as they grow.

If they fail to lose weight after 3-6 months, then they are moved to Stage 2.

Stage 2

· A strict low-calorie, low-fat diet plan; structured daily meals and snacks; supervised activity of at least one hour a day; screen time halved to 1 hour or less a day; and “increased monitoring by provider and/or family.”

They are given 3-6 months to comply, but if children 2-11 years of age do not lose 1 pound/month or older children and teens lose an average of 2 pounds/week, then they are advanced to Stage 3.

Stage 3

· Continuation of a strict diet.

· The child or teen is be placed in a structured behavioral modification program, which includes monitoring of their eating and activity, and the primary care provider and family is be involved in the behavioral modification.

Young people should remain in this weight loss program until their BMI comes below the 85th percentile. But children or teens with any risk factors and who are not successfully losing weight, or all children above the 99th percentile, are placed in the “Tertiary care protocol.”

Tertiary care protocol

· Referral to a weight management center to include a multi-disciplinary team to institute diet and exercise counseling, a very low calorie diet, medication and surgery.

This Expert Committee also recommended that all physicians and healthcare providers become community anti-obesity advocates for PE in schools and community redesigns for parks, walking and bike paths, and local physical activity programs; and they must make information available in their doctor’s offices. Healthcare professionals should also actively engage families where an adult is obese or diabetic.

Doctors and healthcare professionals are also directed to “encourage an authoritative parenting style in support of increased physical activity and reduced sedentary behavior, providing tangible and motivational support for children.” Parents should also be encouraged to model healthy eating, physical activity and limited television watching.

Not one single clinical practice recommendation is based on credible science on childhood obesity, has anything to do with healthy eating, or has any evidential support. In today’s “pay for performance” world, however, doctors who do not comply with clinical practice guidelines — based on their patients meeting requisite BMIs, behaviors and health risk factor numbers — will see their private and public insurance reimbursements cut.

What is this Expert Committee that’s recommending such far-reaching guidelines? According to the AMA media release, the members of the Committee include a host of industry and health professional trade and lobby organizations, convened by the AMA and funded with the Centers for Disease Control and Prevention, and the Department of Health and Human Services. The Committee members include representatives from:

American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Association of Family Physicians, American College of Preventive Medicine, American College of Sports Medicine, American Dietetic Association, American Pediatric Surgical Association, American Psychological Association, Association of American Indian Physicians, The Endocrine Society, National Association of Pediatric Nurse Practitioners, National Association of School Nurses, National Hispanic Medical Association, National Medical Association and the Obesity Society.

While technically true and these organizations all have vested interests in obesity, this doesn’t explain who is playing the key role and setting the agenda. The AMA says on its website that it is working to halt the spread of obesity that “the U.S. Surgeon General Richard Carmona, M.D., [has] called the greatest threat to public health today. It kills more Americans every year than AIDS, all cancers and all accidents combined. And it's causing problems in children that were unthinkable 20 years ago.”

But that still doesn’t explain the public-private partnership the AMA says it’s had in collaborating with the Dept. of HHS to produce its series of clinical obesity guidelines. The answer to that is in the adage: those who hold the purse strings name the rules of the game. The AMA has had a long-time backroom partnership with the foundation arm of the world’s largest pharmaceutical and healthcare products company, Johnson & Johnson, Inc. It has received countless millions of dollars for its cooperation.

Readers will remember that Robert Wood Johnson Foundation, with assets of $8.99 Billion, recently earmarked another $500 million towards childhood obesity programs, and in 2003 had given the AMA $50 million to create its adult guidelines, “Assessment and Management of Adult Obesity.” The blueprint for the children’s guide appeared in the 2005 Institute of Medicine’s report Preventing Childhood Obesity: Health in the Balance, which had been commissioned and financed by RWJF. According to IOM, it “offer[ed] a blueprint to guide concerted actions for many stakeholders including government, industry, media, communities, schools, and families. Many childhood obesity prevention policies and programs are currently underway to increase physical activity and promote healthful eating among children and youth.”

Following its release, RWJF directed the IOM “to assess progress ... across a variety of sectors and also to engage in a dissemination effort that would promote the implementation of the 2005 report's findings and recommendations.” The results of that were published in a RWJF-funded report, Progress in Preventing Childhood Obesity: How Do We Measure Up? It states it “presents a call to action for key stakeholders to lead and commit to childhood obesity prevention, evaluate policies and programs, monitor progress, and disseminate promising practices.” And RWJF continues to award grants focusing on healthy eating, food policies and the food environment in the name of preventing childhood obesity.

The unmistakable aspect of everything RWJF funds, unbeknownst to the public, is that the feel-good reforms are never for programs that actually care for sick people or children, but are always designed to coerce and move towards legislation that governs lifestyle issues, behaviors and societal values; and that increase the power and influence of governmental agencies and managed care, while undermining the choices of individuals and the judgment of doctors, parents and others directly involved in patient care. And with each one, computerized data collection is fundamental.

[Nor does RWJF hide that through its grants, “legislators [are] groomed to become strong-policy makers in critical health issues” and that it funds, for instance, a computerized tracking system to monitor health policy activities of legislators related to RWJF priorities and disseminate information to policymakers through its publications and informed RWJF staff; and for the identification and training of potentially favorable policy leaders.]

The grant funding used to influence for these agendas originates from the company which profits when the legislation and clinical guidelines are implemented, and the nonprofit groups it funds using millions of dollars become its marketing and lobbying arms. Yet, they’ve been so successful in convincing consumers that it’s all really about public health, that the problems being addressed are actual health crises, and that the lifestyle behaviors being restricted (such as eating “bad” fatty foods, watching television or drinking socially) are so deviant, that few question it. And few dare to defend those being targeted because they don’t want to be seen as condoning the “socially irresponsible” behavior.

It’s interesting that the war on obesity is often compared to that against smoking, because the two targets share surprising similarities, and not just because they’ve both become among the most socially condemned in our culture. Working in partnerships with government officials, NGOs and the AMA, RWJF has succeeded in buying considerable influence. The American Heart Association, American Cancer Society, American Lung Association and American Medical Association and numerous research entities, for instance, have recently received more than $200 million from RWJF to promote exaggerated dangers of second-hand smoke ("a single whif of someone's cigarette will hurt you") and enact smoking bans across the country. It appears the initiatives go beyond discouraging smoking due to health concerns, especially among children, to bans and legislating totally smoke-free states. The AMA, for example, has been given $88 million towards more pervasive anti-smoking efforts; and the ACS, AHA and ALA have received RWJF grants of $99 million. Meanwhile, how many consumers know that Johnson & Johnson is the largest manufacturer of pharmaceutical nicotine products (like Nicoderm, Nicoderm CQ, etc.) in the world, which alone are a $500 million annual business for the company? I didn't and was also (years ago) surprised to see how squishy the evidence on second-hand smoking being used was (and continues to be) and to learn recently that the second-hand smoke study done by the Environmental Health Department of St. Louis, MN, is said to be the only known independent one that wasn’t industry funded. Understanding toxicology (i.e. the dose makes the poison), you can probably guess what it showed.

Johnson & Johnson, Inc., with $53.324 billion in annual sales, is also an international giant in weight loss and healthy eating products, selling nutritional supplements (McNeil Nutritionals, LLC), artificial sweeteners (Splenda), diet pills, employer wellness programs (J&J Consumer Companies, Inc. Vida Nuestra), and bariatric surgical devices and lap bands (Ethicon Endo-Surgery, Inc.). And just this past week, the President and CEO of RWJF, Dr. Risa Lavizzo-Mourey, finally stepped down from the Board of Directors of Beckman Coulter, Inc., a company with $2.53 billion in annual sales of biomedical laboratory tests — a position she simultaneously held while at the helm of RWJF, ensuring preventive wellness guidelines calling for excessive screening tests.

Meanwhile, people paid by foundations such as RWJF often end up sitting on government agencies whose agendas they often played a key role in establishing, and on the very commissions and task forces that they helped to create.

[There are countless examples on state and national levels. Dr. J. Michael McGinnis, M.D., served as assistant Surgeon General and Deputy Assistant Secretary of Health from 1977 to 1995, during which time he led the development of the government’s national Healthy People agenda and the creation of the first U.S. Dietary Guidelines; administers the RWJF Health & Society Scholars Program and the RWJF Active Living programs; and serves on the FDA Food Advisory Committee; and is a senior scholar at the Institutes of Medicine — while he is also Senior Vice President and Director of the Health Group at RWJF.]

Yet foundations, such as RWJF, are exempt from taxes, they do not have to file reports or make disclosures as required of lobbying organizations; and private partners are not constrained by the same demands as a government entity would be under the U.S. Constitution. Still, the guidelines they create can have the same effect in coercing compliance among consumers and healthcare providers as a law might, and in diverting massive amounts of public funds to their programs. Grantmaking buys influence that neatly circumvents laws, testified Dr. Jane M. Orient, M.D., while Executive Director of the Association of American Physicians and Surgeons, Inc. They've followed corruption that runs deep and thick.

This isn’t the end of the story, but for this post, let’s get back to this week’s new pediatric guidelines. Politics make for such unpleasantness. And it's all so surreal and hard to believe, it could easily sound like conspiracy theory - if we didn't understand the science surrounding childhood obesity, normal and healthy growth and development, nutritional science, the harmful effects of dieting and eating disorders, and the societal effects of this degree of control and intrusion into private lives. For those who do, reading these new pediatric medical guidelines likely left them stunned in disbelief and outrage.

These new guidelines take the practice of medicine away from following credible “evidence-based” care. Medical professionals are to become lifestyle, morality and food police — grilling parents about the social correctness of their parenting styles, home life and time management, food choices, and whether they’ve made their children exercise — and then essentially scolding them if they misbehave. Worse, doctors will be compelled to report private information gathered about families and their compliance with anti-obesity guidelines on those electronic databases, from which doctors, too, will be judged and paid accordingly. What about professionals who don’t agree to advocate and “educate” about weight loss and lifestyle management, as defined in such guidelines? Will we even be able to keep our licenses if we dare speak out with the truth and do what is right by each child?

Most heartbreaking, are the effects these will have on innocent children, all of whom who will be subjected to constant scrutiny about their bodies, the foods they are (not) allowed to enjoy and their activities. Those whose genes put them in percentiles above 85% will be made out to be deviants, and subjected to the most harmful of interventions.

How much longer will the medical community continue to go along with the profits, power and prestige that these unsound initiatives can bring, or look the other way at the harm and costs to children, families and the fabric of our culture and not get involved? How far will all of this go before more of the public notices and gets mad enough to fight back and put a stop to it? It’s troubling how universally this story and others like it have been ignored by the media. Hopefully, the nonstop news of trivia like Nicole Ritchie and Ana Nicole Smith hasn’t succeeded in turning us all into nonthinking, mind-numbed robots. Then, this really would be 1984.

© 2007 Sandy Szwarc

Addendum: As I was posting this, I read this poignant, timely post from Carrie over at Eating Disorder Bites, speaking out with a personal perspective on this issue. Well worth a read!