A recent commentary in the Journal of the American Medical Association suggested placing children with severe obesity under protective custody as an alternative to bariatric surgery. What's striking about the article is the presumed attribution of familial or parental responsibility in the genesis of severe obesity – one of the most challenging medical conditions facing health-care providers today – and the failure to mention alternative therapeutic approaches. Are these really the only two options? Are they even suitable?
Child protection agencies are mandated to protect children from harm by intervening in cases of suspected abuse or neglect. Severe obesity is neither of these things. Its causes involve a mix of genetic, biologic, psychosocial, socio-economic, developmental and environmental factors. The barriers to weight loss and reasons for continued weight gain are equally complex. We must also recognize that many obese individuals, adults and children alike, experience significant discrimination, not to mention feelings of shame and fear of being judged. This all makes them reluctant to seek help.
Unfair comparisons are often made between obese and malnourished children. Our bodies have evolved to protect against starvation and are equipped with strong biologic drives that work to prevent excessive weight loss. In contrast, when weight is gained, the biologic drive to reverse it is muted. And while effective treatment for undernutrition exists, equally effective treatments for severe obesity do not.
For the expert obesity treatment programs that exist, the resource implications are significant. Current Canadian guidelines recommend that children with obesity receive care from interdisciplinary health-care teams, including a physician/nurse practitioner, psychologist, dietitian, exercise specialist, social worker and registered nurse, involving more than 25 hours of contact between the patient, family and health-care team for at least six months.
The program must include parental involvement, dietary and activity counselling, behaviour modification and mental-health support. There may also be a role for day-treatment programs and hospital admissions when needed. Bariatric surgery should be considered only in severe cases, and only after a child and the family has participated in an intensive six-month program.
Not surprisingly, access to such programs is often severely lacking. There are only two in Ontario that offer expert services specifically targeted to children with severe complex obesity (the Children's Hospital of Eastern Ontario in Ottawa and the Hospital for Sick Children in Toronto). In Eastern Ontario alone, there are more than 12,000 children with severe obesity; the Children's Hospital program can only serve 90 new patients a year.
Grounds for involving child protection services should be applied to all children, whether lean or obese. It's inappropriate to suggest these agencies have a role to play in the treatment of severe obesity when we, as a health-care system, are failing. This very notion suggests such treatment is as simple as placing children in a substitute home environment and lays blame solely at the feet of the family.
Until children and families dealing with severe obesity have access to an expert obesity treatment team and health-care providers have a better understanding of treatment options, there should be no discussion of involving child protection agencies in treating severe obesity.
Stasia Hadjiyannakis is a pediatric endocrinologist and Annick Buchholz a psychologist at the Children's Hospital of Eastern Ontario's Centre for Healthy Active Living.