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child abuse

On Wednesday, July 13, I was interviewed by Lindsey Ward of WSLS TV channel 10 in Roanoke about an article that had appeared in the Journal of the American Medical Association (JAMA) on Tuesday.

You can see an excerpt from that interview, and read the JAMA article. Lindsey and I spoke for about 20  minutes, and what you see on the video is about 20 SECONDS of my very long-winded answer to the question: "should extremely obese children be removed from their families and placed into foster care?" Since I have the luxury of no limits to my blog posts (other than the interest and attention of my dear readers), and I am not writing "sound bites" for a TV show, I thought I would elucidate a bit more on my comments here.

I have seen many severely obese children in my work as a pediatric intensivist. I have observed children so overweight for so many years that they have developed life-threatening problems.

Although most attention in the media (and the JAMA article) is placed on the development of type 2 diabetes, many children and adolescents end up admitted to an intensive care or stepdown unit because obesity causes severe breathing problems associated with obstructive sleep apnea (OSA). When OSA becomes severe enough it can lead to irreversible heart failure because of high blood pressure in the blood vessels in the lungs, a condition known as pulmonary hypertension. The right side of the heart becomes so dilated that eventually it cannot pump and death occurs from a severe lack of oxygen. Old people can develop such a problem with chronic lung disease, most often caused by smoking; in young people this can happen occasionally from certain forms of congenital heart disease (abnormalities of the heart and circulation that you are born with) or severe OSA. When OSA is caused by obesity, it is possible to TREAT the symptoms and perhaps stop the progression of heart disease by using adjuncts to breathing during sleep (generally a machine that provides positive pressure and prevents the person from stopping breathing during the night), but the only way to get at the basic problem is to lose weight. I have treated many teens with obesity and OSA; some of them successfully able to lose weight over time and be able to resume natural breathing during sleep, but its terribly hard for them. I have had to beg insurance companies to allow payment for inpatient weight loss programs, and have NEVER been successful until I could prove secondary problems from the obesity such as heart failure from the OSA, or uncontrollable type 2 diabetes from their obesity.  Most insurance plans won't even cover the cost of nutritional counseling. The worst case I have ever seen was a 4 year old child who came into our PICU (not in Roanoke) weighing over 100 pounds. His mother and her entire extended family were all morbidly obese, weighing in the 300-400 pound range. While they understood how bad it was for the boy to weigh so much, and they could see the effects of his OSA (his oxygen level during sleep would drop so low as to be immediately life-threatening) they didn't see what they could do or how they could do it.

Everyone in the family was "large" and they accepted that was how it was meant for them to be.

I am not sure whether or not there was a genetic component but testing for commonly associated genetic and endocrine disorders in the child did not reveal any identifiable abnormality. Nonetheless, nutritional counseling on a daily basis was futile. The family members would come to the bedside with huge trays of food from the cafeteria filled mostly with french fries and deli sandwiches. They didn't know how to say no to the child when he begged for food. Going without adequate oxygen in your bloodstream causes more than just effects on the heart and lungs. There are often severe behavioral and cognitive problems seen in people of all ages who suffer from severe dips in their oxygen levels on a repetitive basis. So this child developed increasingly severe behavioral problems. At the age of four he was big enough and strong enough to generally get his own way, and the family had no idea how to help him. He would not keep the potentially life-saving mask on his nose and mouth when asleep that would keep him breathing, so eventually we had to get permission to perform a tracheotomy (putting a tube into the trachea [breathing tube] ) through which pressure or actual mechanical breaths could be applied to keep his lungs open and prevent the apnea during sleep. A few weeks after the procedure, he was behaving much better, and through significant dietary restrictions we had been able to induce some weight loss. We referred the entire family to their family doctors and to an adult sleep lab for testing. They all had sleep apnea, hypertension and type 2 diabetes. I DID call child protective services for this child; not to take him away from the family, but to emphasize to the family how severe this problem was, and to get them some services they sorely needed. This was a family from a severely disadvantaged neighborhood. One of our home care workers went with a couple of family members to the local grocery store to help them learn how to shop for healthy foods. She returned with a report that shocked us, but shouldn't have; there was NO edible fresh produce in the store. The bananas were black, the apples were soft, the green beans were rotten. Prominently displayed were bags and cans of preserved, high fat, high carb and high sodium foods. It was unlikely that this family would be successful in changing their lifestyle (oh did I mention the drug dealers on nearly every street corner near their apartment, making it difficult to walk or do any activity outside in safety?) unless and until their socioeconomic situation was improved. And our team worked on that, with the help of CPS. We were able to move them to a better neighborhood, based on physician attestations of how essential that was for the child's eventual well-being. the entire family went on a weight loss plan, and the YMCA provided complimentary memberships and programs.

Would it have been better to remove this child because his family couldn't provide the care he needed?

Perhaps, but where would he have gone? Most foster care in this country is provided by relatives, whenever possible. There were no relatives in better situations than his family. Should he have gone into foster care with strangers? Well that is impossible to evaluate, isn't it? Kids in foster care NOT with family members tend to bounce around, have little continuity, almost never keep the same physician, may develop long-term problems with attachment and behavior, and the list goes on and on.

So my answer to the question about removing obese children is that if it occurs it should clearly be the LAST resort.

We need to attend to all the other issues surrounding the obesity issue. Families need to be educated on healthy eating habits. People need to learn how to cook. Fresh fruits and vegetables need to be available and accessible in the neighborhoods where obesity thrives (poor urban as well as rural areas; although clearly wealthy folks can be obese as well). Our schools need to be more involved and empowered. PE programs need to come back to the schools and be supported by parents, teachers, local governments.  TV and computer time needs to be curtailed. Calorie dense food ads should be monitored or eliminated. Health plans need to cover treatment (and prevention)  for overweight and obesity, including nutritional counseling, gym memberships, cooking classes (?), safe neighborhood areas in which kids can play outside. There are innovative programs everywhere encouraging kids to walk a few blocks to school (school bus drops them off a few blocks away, not right outside the door), limiting calorie-dense foods in school meal programs, neighborhood walking and playing programs, etc, but they all need to be better funded, and may not stand a chance given the dire realities of the budget cuts our nation is  facing.

Obesity is a societal problem, and until we approach it as such, it will stand NO CHANCE of improving.

So what can you do? GET INVOLVED. Most local YMCAs have programs to help kids (and parents) get fit, many neighborhoods are initiating programs--if yours isn't, then start one. Lets give our kids a chance to grow up with healthy habits, feeling better, learning better, breathing better, living longer, and using fewer heatlth care dollars in the long run. There is my rant for the week. Take it or leave it. Well, really what I want is to start a conversation. Please leave a comment, tell us about a program you know of, or relate a story about the issues related to obesity. Oh, yeah, and let me know what you think about the initial premise--should severely obese kids be removed from their families?

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