The recommendation in the Journal of the American Medical Association to consign extremely obese kids to foster care is eye-popping, but it's already transpired in a handful of U.S. cases in which a morbidly obese child was at risk of serious health problems.
That sort of radical intervention — intended as a temporary fix — might help prevent the development of severe health conditions like Type 2 diabetes, sleep apnea and liver problems in some of the 2 million or so very obese children in the U.S., Ludwig says. When children become that obese, with a BMI at or above the 99th percentile, it signals a "fundamentally different situation" than mere "poor parenting," write Ludwig and attorney Lindsey Murtagh, a Harvard public-health researcher, in JAMA. "State intervention may serve the best interests of many children with life-threatening obesity, comprising the only realistic way to control harmful behaviors."
Ludwig told the Associated Press that he starting thinking about the idea of state intervention nearly a decade ago, after a 3-year-old girl showed up at his obesity clinic weighing 90 lbs. By last year, at age 12, she had reached 400 lbs. and had developed diabetes, cholesterol problems, high blood pressure and sleep apnea.
The AP reported:
Her parents had physical disabilities, little money and difficulty controlling her weight. ... "Out of medical concern, the state placed this girl in foster care, where she simply received three balanced meals a day and a snack or two and moderate physical activity," [Ludwig] said. After a year, she lost 130 pounds. Though she is still obese, her diabetes and apnea disappeared; she remains in foster care, he said.
Ludwig would ideally want parent-child separations to be shorter — and used only as a last resort. States should remove children from their parents' homes only in the most severe situations and should simultaneously educate parents about the perils of obesity and how to help their child lose weight, he says.
"Child protective services typically provide intermediate options such as in-home social supports, parenting training, counseling, and financial assistance, that may address underlying problems without resorting to removal," he writes.
But in the most extreme cases, removal from the home may be a more ethical solution than having a child undergo weight-loss surgery, an option that is becoming increasingly popular in the U.S., but which carries physical risks and can be irreversible. At first glance, bariatric surgery might seem an easy fix, but Ludwig says the procedures don't have a lengthy safety record in teens, and they're not recommended for children.
Given that situations involving the undernourishment of children have frequently been defined as child abuse or neglect and warranted state intervention, it may be likely that overnourishment may be addressed similarly, Ludwig argues. States may already have statutes in place that would allow for extremely obese children to be removed from their parents' custody, he says.
But Art Caplan, director of the Center for Bioethics at the University of Pennsylvania, dismisses the idea. "Our laws give enormous authority to parents and rightly so," he writes in an op-ed for MSNBC. "The only basis for compelling medical treatment against a parent's wishes are if a child is at imminent risk of death — meaning days or hours — and a proven cure exists for what threatens to kill them. Obesity does not pass these requirements."
Like Ludwig, Caplan says blaming parents for child obesity is short-sighted. It is more prudent, he suggests, to focus on the food culture:
This means doing what we have done for smoking. Demonize the companies that sell and market food that is not nutritious. That means you, candy, soda, fried food and snack food outfits. Tax them too. And get Hollywood and television to make overeating and not exercising uncool just like they did with smoking. Put exercise back on the menu for all school kids.
Indeed, from any perspective, childhood obesity is a complex problem. About one in three kids are overweight or obese, according to the Alliance for a Healthier Generation, a partnership created by the William J. Clinton Foundation and the American Heart Association to halt the childhood obesity epidemic by 2015. The causes are myriad: 92% of American elementary-school children don't have daily physical education classes; meanwhile, they are surrounded in school by vending machines offering sugary, fat-laden treats. Back at home, busy parents may not have time to make healthy meals and kids settle in front of the television set for too long each day.
TV watching is a major contributor to weight gain, not only because it encourages kids to practice the art of being sedentary, but also because it bombards them with ads for unhealthy food. In June, the American Academy of Pediatrics advised parents to limit their kids' TV time in order to reduce their exposure to junk-food-hawking commercials. As Ludwig observed when I interviewed him in 2009 for a TIME article about child-focused advertising, "When is the last time you saw a commercial for broccoli, spinach or cauliflower on children's TV?"
I know how hard it can be to train a child to eat well. If a rising third-grader could be considered a foodie, then my son fits the bill. He likes traditional, calorie-rich kid foods such as mac-and-cheese and pizza as much as any child, but he also likes arugula and gravlax. The term "picky eater" doesn't resonate with him; the boy even eats Brussels sprouts.
So why am I concerned? Because he eats too many Brussels sprouts and too much of anything else that's around. He doesn't eat because he's hungry; he eats because he loves food. Obesity courses through his genetic pool, so I'm hypervigilant that he learn to recognize what it feels like to be full, that he stick to what I call "an 8-year-old portion," that he discern the difference between dipping — and drowning — pita in olive oil.
Thankfully, food is not his sole passion; soccer surpasses it. He has the ability to turn any semi-spherical object into a soccer ball, so he is hardly ever still. And he'll have to stay physically active, or I might start to fear that he'll balloon into a severely overweight kid and be taken away from me, as happened to Jerri Gray, a Greenville, S.C., mother whose 555-lb. 14-year-old son was removed from her custody two years ago.
According to the AP: