Some want parents of fat children to be charged with child neglect — did they make their case?

Both Australian parents and doctors were targeted this past week with threatening-sounding proposals: to charge parents of fat children with child neglect and have their children taken from them, and to charge doctors with medical malpractice if they fail to report fat children to state child protective services. While Australian media reported that the State Department of Health Services was not entirely buying these proposals, this disturbing anti-child obesity movement is increasingly far-reaching, well-marketed and creeping into mainstream medicine and international health policies.

Parents from Australia have been writing JFS greatly concerned about hearing news accounts of these strategies, not knowing if they are being seriously considered or who was behind them. It turns out that the current issue of the Medical Journal of Australia, the journal of the Australian Medical Association, devoted an entire section to “lifestyle medicine,” which included calls for a range of “real government preventive action” to address obesity and “modern chronic diseases.” [Image above is from this issue.] This weekend, we’ll take a look at this issue, starting with the disturbing article behind these proposals.

For those outside of Australia who may have missed this week’s news, The Age, was typical, reporting:

Report obese children, doctor urges

LETTING your child grow too fat amounts to child abuse and doctors are duty bound to report such parents to child protection authorities, a Sydney obesity expert says… Dr Shirley Alexander of Westmead Children's Hospital in Sydney argued in yesterday's Medical Journal of Australia that if a child was severely obese, parents could be forced to sign "responsibility contracts" to manage their health. In extreme cases they should even be reported to the courts, she said. "Passive acquiescence by a doctor in the neglect of a severely obese child … could constitute a breach of a doctor's duty of care," the MJA article by Dr Alexander and three colleagues said. That neglect could include "failure by the child's parents to ensure a minimally adequate diet and exercise"…

The MJA medical journal article contained a surprising series of assertions, none of which were supported with clinical evidence, based on popularized beliefs about child obesity: First, that childhood obesity and its associated comorbidities are increasing in prevalence and “is a common problem.” Second, that child obesity is life-threatening, with “immediate and long-term medical and psychosocial health problems.” Third, that child obesity is largely caused by unhealthy lifestyles, eating bad foods and sedentary behaviors, and can be effectively treated in weight management programs. And finally, that “the food and beverage industries, government organisations and medical opinion concur [that] parental responsibility is also an essential element in the prevention and treatment of obesity in children.”

As such, they argued, parents of extremely obese children who “seem unable or unwilling to adhere to management programs aimed at weight loss for their affected child,” are noncompliant and their behavior a form of parental neglect. Doctors, in turn, they said, have an “ethical duty,” and it may also be a statutory requirement, to report the parents of these children to child protective services.

For parents, healthcare professionals and public policy officials who believe that there should be some clinical evidence to support massive and costly public health interventions before they’re enacted, especially ones that could destroy families and children’s lives, they found none in this article. In fact, the available evidence disproves the claims.

Defining the problem

In their discussion, the authors state that childhood obesity is common, with prevalence rates doubling or tripling over recent years, and has “significant adverse effects” on children’s health. “Public opinion recognizes the primary responsibility of parents,” they said. “However, to take ownership of this responsibility, it is first necessary to acknowledge that the child has a weight problem.” But most parents of fat children, they said, don’t see their child’s weight as a problem and aren’t bringing their children to a doctor to lose weight.

Missing balancing evidence. How many doctors followed the link to the original study that was cited as support of these claims of parental irresponsibility? It turned out to be a Melbourne survey that had found only 3% of 4-year old children fell at or above the 95^th percentile on growth curves. More worrisome, rather than parents not viewing their children as fat, it reported that 27% of parents thought their children were more overweight than they really were, and 30% of parents incorrectly perceived that their child ate more than their peers. MJA readers were not provided any of the evidence that’s failed to support accusations of parents as being in denial and unable to recognize their children’s weight problems, covered here.

Nor were readers given any of the government’s health statistics on the weight and health status of Australia’s youth. As examined just a few months ago, the latest government reports found no epidemic of childhood obesity and that Australia’s children and adolescents are healthier than ever. Australian Institute of Health and Welfare data showed that Australian children and teens are no fatter today than they were a decade ago, leading experts to call the exaggerated ‘obesity epidemic’ claims being put forth “by academic activists and others” as being irresponsible, increasing rates of eating disorders among young people, and having negative impacts on children’s self esteem. The larger Australian governmental report, Making progress: the health, development and wellbeing of Australia's children and young people, also examined the key indicators of youth health and found that children’s health and well-being today surpass all previous generations and children are living longer than ever, with child mortality fallen by a third just since 1997.

The authors then said that not all fat children may be being neglected, as their parents “may be very devoted to their child, however, there may be concerns about parenting skills, such as lack of parental limit-setting or parental supervision.” The only report they presented for this popular belief was a 1989 case report on 12 fat children in Chicago, associated with impaired parent-child interactions, including eating.

Evidence. The authors debunked this themselves, however, noting that more recent controlled studies have found no correlation between child obesity and parenting. In one of the studies they exampled, researchers at the University of Western Australia in Perth examined data on 329 children (6-13 years of age) from the Childhood Growth and Development Study, a prospective cohort study of children and mothers recruited from pediatric hospital endocrinology departments and primary schools in Perth, Western Australia. They found no association between children’s weight and adverse maternal or family characteristics, including maternal depression, negative life events, poor general family functioning, or ineffective parenting style. The most significant association was genetics and an association between a child’s weight status and their mother’s.

Most incredibly to find in a peer-reviewed medical journal, to make their case that severe child obesity should be considered a form of neglect, the MJA authors created a story of a fictitious 4-year old fat girl! They described her as victim of all of the popular stereotypes: continually munching on junk and laying around watching television 6 hours a day, and developing elevated blood pressure and obstructive sleep apnea. Then, child protection authorities were notified. As a result, she was hospitalized and with “simple weight management interventions of reduced dietary intake and a daily program of physical activity,” she lost nearly seven pounds in two weeks. The story ended by saying the 4-year old had reduced a dress size and the family “now feels much more confident in making healthy food and lifestyle choices.”

Missing balancing evidence. Despite the fact that story book tales and anecdotes are not medical evidence, obesity researchers have long recognized the primary genetics of obesity and the diversity of body shapes and sizes, height and other physical characteristics. As has been covered at length, decades of the most careful clinical studies using multiple different methodologies have found fat children eat no differently and are no less active than thin children to explain their size. It is physiologically implausible to force feed a normal child into a genetically different body type, let alone extreme obesity. Yet children at the upper end of the bell curve, like Anamarie in the United States and children in England, have been taken from parents by government workers under the assumption that extremely large children must be extremely overeating. Ignoring biological facts, these actions have devastated the lives of children and their families, while exploiting their stories to exaggerate a crisis of childhood obesity.

Nor are larger children inherently diseased. For example, researchers have found no support for claims that blood pressures have increased among pediatric patients because of a “childhood obesity epidemic,” or that real hypertension is even related to obesity. There is no evidence that hypertensive, asymptomatic children are at increased cardiovascular risk, numerous cardiologists have cautioned. [Blood pressures in adults are not rising, either, in the United States or among 38 world populations; nor is it related to adult obesity.]

Medical professionals also didn’t read in the MJA article that no weight loss intervention to date, regardless of how comprehensive, intense or long, has been shown to be effective, to produce lasting weight changes or, most importantly, to improve life expectancy. The U.S. Preventive Services Task Force had even examined 40 years of evidence (some 6,900 studies and abstracts) and concluded that there was no evidence for an effective intervention for childhood obesity in primary care settings; no evidence to support dietary counseling to promote a healthy diet; and no quality evidence showing that diet- or behavioral-weight loss interventions in young people improve health outcomes or physiological measures.

While the preventive health movement has promoted the benefits of variously-defined “healthy eating” and lifestyles, the results of every major randomized, controlled clinical trial to date has failed to demonstrate that food has significant benefit in preventing or causing chronic diseases, like the big three diabetes, heart disease or cancers, or helps people live longer. Nor has the sound evidence of such healthy eating interventions been shown to affect obesity rates, let alone give everyone a government-approved BMI. People around the world eat widely varied diets to prevent essential nutritional deficiencies and beyond that, food is fuel, not magic.

Not only do diets and restrained eating, and focus on weight, been shown ineffective, they are associated with significant risks for young people. Nor is the intense promotion of “healthy diets” and lifestyles and weight management harmless. But the MJA authors failed to consider the potential risks of harm for young people, not just fat children. Had doctors been given the balance of the evidence to date, they would likely have recognized that the risk-benefit analysis is unfavorable.

The MJA authors then skipped ahead to claim that treating obesity in children requires a family-based approach with a dedicated multidisciplinary team of health care professionals. “The weight-management program* aims to help the family and child adopt behavioral and lifestyle changes to enable the child to lose weight, but to be successful in the case of a pre-adolescent child, parents need to be involved,” they wrote. [*The weight management program referenced was their own.]

The doctors then compared parents of extremely fat children who fail to “adhere to weight loss programs” — in other words, the children are still fat — to “noncompliant parents who fail to follow medical advice” for other conditions, such as not giving asthma medications to children with asthma or rejecting medicines for an HIV-infected child.

How many readers thought the authors were saying that the weight management programs had been shown to help children lose weight or, more importantly, improve their health? Notice how the authors never actually said that, nor did they supply any evidence to support an effective behavioral and lifestyle weight loss program for children? In fact, the authors failed to even report the results of their own research of their own weight loss program… which we’ll look at in a moment.

Then, without providing any evidence that the health of fat children was at “severe risk” or that an effective treatment existed, they proceeded to claim that even if the health risks to children aren’t “immediate” or “urgent,” that doctors have a duty “to report severe cases of inadequately managed paediatric obesity to child protection agencies.” They said there “seems no reason why passive acquiescence by a doctor in the neglect of a severely obese child, through failure by the child’s parents to ensure a minimally adequate diet and exercise, could not constitute a breach of a doctor’s duty of care.” They then compared child obesity to HIV, citing case law of patients with sexually transmitted diseases and doctors’ medical liability should they fail to protect patients infected with HIV.

Continuing an illogical circular logic, they noted that statutory duties exist nearly everywhere that authorize or require health professionals to report to authorities any situation they have reasonable grounds to suspect that a child is being abused or neglected. Few health professionals would disagree. But, the authors went on to argue that these provisions should extend to parents who fail to get their children’s weight treated. They said doctors were obligated to turn parents in “even though there is risk that parents could lose custody of their child or be liable to criminal prosecution.”

They revealed a broader agenda when they admitted that reports to state child protection authorities could help to introduce financial funding for weight management services to mitigate the risks to the safety, welfare and wellbeing of fat children. They also suggested public officials could make “responsibility contracts” with parents to compel their participation in weight management programs and if parents refuse to consent, that the courts could override parents just like they do to parents who refuse “life-saving blood transfusions.”

In other words, the force of government and courts should be used to make parents put their children in weight management programs, again, without providing any evidence they are effective or beneficial, let alone “life-saving.”

But the most disturbing part of this paper came when it began discussing the ethics for these proposals and attempted to weigh the benefits and harms of leaving a fat child in the care of his/her parents. It was especially sad and disheartening from a compassionate ethicist who as spoken and written in medical and nursing journals against euthanasia and slippery slope eugenics policies and urged careful consideration of healthcare policies to protect the most vulnerable: the old, sick, feeble, disabled and unwanted. Co-author, Bernadette Tobin, is an associate professor in the Faculty of Medicine at the University of Sydney, director of the Plunkett Centre for Ethics at St. Vincent’s Hospital in Sydney, and serves on the Australian Health Ethics Committee.

No discussion of ethics, the rightness or wrongness of actions on behalf of children, or weighing of the risks and benefits of our actions on children and their families, can even begin unless we first work from facts — honestly evaluate the truth of health risks, the effectiveness of interventions we impose, and their potentials for harm. If it’s wrongly believed that death or danger is imminent, then considerable costs and risks may feel far more justified than they may truly be. If we wrongly believe weight loss interventions offer only benefits — and avert our eyes to the harmful consequences to children’s health and well-being — then we fail to act in the best interests of children and their families. We also fail others in our community who might need the medical resources we are diverting to unsound programs.

Similarly, it is impossible to truly advocate for any discriminated or disadvantaged group while working from, and promoting, the very preconceptions and stereotypes held about them — that a physical difference is a result of undesirable behaviors, a sign of a lesser quality person, a person less deserving of rights and choices, as diseased, a costlier burden to society, or a danger to themselves or society. Working against any form of discrimination must begin with the science to remove the underlying prejudices. History is filled with some of the most medically unethical and injurious actions, justified by bad science and prejudices, made in the name of “health.”

Disclosures

Anytime the science fails to support conclusions being made, we naturally look to the author disclosure statements in an effort to better understand what’s going on. Readers of MJA were not provided any information that could have helped them understand the career and financial interests.

For example, co-author Roger Magnusson is not only a professor of law at the University of Sydney, but the coordinator of the Health Law Program and heads the Australia Research Council-funded project, “Lifestyle Wars.” This program focuses on legal and regulatory population-wide approaches to address the “modern obesogenic environment” and influence behaviors, namely “healthy eating” and lifestyles, to eradicate “noncommunicable diseases caused by obesity and tobacco use.” [These approaches, he wrote, include fat taxes, preventive wellness, traffic light food labels, food Codex, ban fast food, obesity clinical guidelines, etc.] He also serves on the Board of the Australian and New Zealand Institute of Heath Law and Ethics (ANZHP), an independent organization of law teachers who consult on: euthanasia, natural death legislation (assisted suicide), abortion, reproductive technology, allocation of scarce resources, healthcare delivery to differing cultural backgrounds, and care of disabled [yes, what it sounds like]. He coordinated the ANZHP Symposium “Obesity — should there be a law against it?”

Another author, Dr. Shirley M Alexander, is the Staff Specialist in Weight Management Services at Children’s Hospital at Westmead, Sydney.

The key author, Dr. Louise A Baur, BSc, Ph.D., was disclosed to MJA readers as a professor in Pediatrics and Child Health at the University of Sydney. The journal didn’t share that she is also Chairman of the Board of Directors for the New South Wales Centre for Overweight and Obesity, and Director of Weight Management Services at The Children’s Hospital at Westmead. She is also Chair of the International Obesity Task Force and its Working Group on Childhood Obesity, co-editor of the IOTF’s report on childhood obesity to the World Health Organization, and on the IOTF Steering Committee of the Global Alliance. As a member of NSW Health's Population Health Priority Taskforce, she chairs the consultation group on food marketing to children. [Readers will remember Consumers International’s global campaign, authored by IOTF and IASO, to get the WHO to ban marketing of all food high in sugar, fat or salt to children, purporting them as the cause of a worldwide obesity pandemic.]

She lists multiple millions of dollars in grants and funding for the NSW Centre, obesity programs, and studies, including $200,000 for the Australasian Child and Adolescent Obesity Research Network (ACAORN), which she co-directs. ACAORN is a coalition of obesity research centers working to elicit funding for obesity research. For 2007-2009, she and two other ACAORN members also received funding for the Childhood Obesity Pooling Project, a database and network of obesity clinics.

Evidence for their weight management program*

The key clinical research published by Dr. Baur and colleagues at the NSW Centre is the PEACH (Parenting, Eating & Activity for Child Health) Study, a randomized controlled trial of the effectiveness of their community weight management program for pre-pubertal children. This is the weight management program and study referenced in the MJA article, yet the authors were oddly silent on its effectiveness.

Given the authors are proposing that parents of fat child be reported to child protective services and forced into just such a weight management program or risk losing their children, parents deserve to know what this study showed. Given that the authors are proposing that doctors report fat children to child protective services or risk being charged with medical malpractice, doctors deserve to know what this study showed.

The 12-month results were published in the March 2007 issue of the journal, Pediatrics. In the PEACH study, the authors began by acknowledging that effective interventions for child overweight “remain unclear,” with the assumed cornerstones of child weight management to be “energy intake moderation, increased physical activity, reduced sedentary activity, behavior modification, and family involvement.”

They found only one study of parent-led lifestyle management showing an effect** on child obesity, a small study from the Hebrew University of Jerusalem in Rehovot. But, Dr. Baur and colleagues noted that no other researchers have been able to replicate its findings.

Not mentioned. That Israeli study actually reported some troubling findings of its family, “health-centered approach.” Parents concerned about their children’s food intake, the authors wrote, are more apt to adopt controlling child feeding practices in an attempt to prevent overweight or negative health consequences. “Mothers reported using more restrictive feeding practices when they were invested in weight and eating issues, when they were concerned about daughters’ weight, and when daughters were heavier… Prospective studies of adolescent girls suggest that dietary restriction predates bulimic symptoms, with one study reporting that adolescent girls who were dieting had an 8-fold increased risk for being diagnosed with an eating disorder compared with nondieters.”

It turns out that Dr. Baur and associates’ weight management program is parent-based. The PEACH study evaluated the effects on 6-9 year old fat children, whose parents participated in their weight-management program, which consisted of 18 parenting-skills training and intensive lifestyle behavioral modification sessions. For this study, the authors screened 262 children during 2002-2003 to ensure their caregivers could read and understand English and attend the program sessions, the children were in Tanner Stage 1, and that the children were not on medications that could influence their weight or diagnosed with a chronic illness.

Finally, 111 children were randomized: 38 into the weight management program, 37 into an 11-session parental skills training alone, and 36 were put on the waiting list for the weight management program. All parental intervention sessions were conducted by the same dietitian. Over the following year, fewer than half of the parents in both intervention groups attended 3/4ths of the program sessions and 20% dropped out during the program (only 60 of the 75 in the intervention groups stuck with the program).

After one year, the BMIs among the respective intervention groups were only 0.02 to 0.11 units less than the control group — a clinically meaningless change that did not move the children into a different percentile on the growth curves.

But, only the boys had a statistically lower BMIz score compared to the beginning of the trial. The girls in the program’s intervention groups showed no change at all. The only statistical change in BMIz among girls occurred in the control group — in other words, the control group saw more weight loss than the weight management programs!

But the control group only changed by 0.13 BMI units, again, a clinically meaningless change that didn’t move them into a different percentile on the growth curves. The authors speculated that perhaps the current obesity epidemic hysteria in the media could explain that weight change seen in the control group.

The most important findings, if all of this is really about health and not just “dress size,” was that the interventions had no effect on any metabolic variable. The authors reported that there were statistically insignificant increases in LDL cholesterol, systolic blood pressure, glucose and insulin levels and reductions in HDL.

The authors failed to look at any actual clinical outcomes, or long-term effects. More troublingly, the authors didn’t evaluate or report adverse effects of their program on the family, parent-child relationships, or on the children.

Their conclusions? “A family-focused intervention using parenting-skills training and promoting a healthy family lifestyle may be an effective approach to weight management in prepubertal children but with a clear gender effect.”

“May” being the operative word, it would appear.

At the Centre’s website, Dr. Baur and colleagues report that results from their 2-year data of their parent-focused healthy lifestyle program on childhood obesity show that, while there had been a statistical difference between the groups seen at 6 months, the group differences were not maintained thereafter. No published data is available to evaluate.

How many doctors and parents would feel that this study provides sufficient support for the far-reaching proposals of these authors?

© 2009 Sandy Szwarc

** The Israeli authors said their weight findings were surprising and questioned the weight changes seen on their 7-year follow-up, noting a number of the participants were serving in the army by that time.