Should the state intervene on behalf of morbidly obese children?

When we think of child abuse and neglect, we think of burns and bruises and children left unattended. We don’t think of obesity. But maybe, in some cases, we should.

In a recent commentary in the Journal of the American Medical Association (JAMA), David Ludwig, MD, PhD, director of the Optimal Weight for Life (OWL) Program at Children’s Hospital Boston, argues that life-threatening obesity—where a child’s body mass index (BMI) is beyond the 99 percentile and multiple attempts to help the child lose weight have failed—could call for state intervention, and in extreme cases foster care.

Children in this highest BMI category are at great risk for many serious health complications. We all know that childhood obesity can lead to life-long health complications, but in extreme cases it can be life-threatening in the short term. For example, type 2 diabetes, which is being seen in younger and younger patients as the childhood obesity epidemic continues, can cause very serious complications and even be fatal. Sleep apnea, which often occurs in obese children, can lead to very dangerous heart problems.

Because of these dangers Ludwig says the most severe instances of childhood obesity may justify a child’s removal from the home because of imminent health risks to the child and the parents’ continued failure to address those problems.

It’s a controversial stance, but not one without precedent. To date seven states have seen legal cases where the over-nourishment of a minor ended in sate intervention. According to Federal law, parental abuse or neglect takes place when:

 

“Any recent act or failure to act on the part of the parent or caretaker, which results in death, serious physical or emotional harm… or an act or failure to act presents an imminent risk of serious harm.”

David Ludwig, MD, PhD

By these definitions, it’s possible that parents of children whose obesity is life-threatening could be found negligent. But Ludwig says those parents are up against tough odds, and feels that any form of intervention has far more to do with acting on behalf of children than pointing fingers.

“The point isn’t to blame the parents, but rather to act in the child’s best interest and get them help that for whatever reason their parents can’t provide,” he says. “It’s ironic that we would blame parents for their child’s obesity when we tolerate as a society policies that directly promote obesity, like food ads aimed at young people, atrocious-quality school lunches, cutbacks in school budgets to support regular physical education. There’s plenty of blame to spread around.”

It’s also important to note that the term state intervention in most cases doesn’t mean foster care. Ludwig notes that often when protective services visit with a family they try many options before removing a child, and feels the same approach should apply to life threatening obesity. To accomplish this Ludwig advocates for in-home social support for parents. By providing nutritional education, family counseling, training on the importance of an active lifestyle, financial assistance and/or help accessing fresh fruit and vegetables and opportunities for physical activity, the state can treat the underlying problems that cause childhood obesity without disrupting homes.

In cases where interventions have been tried and failed, and the child’s obesity is presenting immediate health risks, bariatric surgery could be considered as well, but only in select cases. Ludwig says that because there hasn’t been much data collected on the long-term affects of pediatric bariatric surgery, its safety for young people is questionable and should only be considered on a case-to-case basis.

In the end Ludwig says he supports the consideration of state intervention for extreme cases of childhood obesity, but feels the government’s real goal should be creating preventive programs that treat the condition’s root causes. “Ultimately, government can reduce the need for such interventions through investments in the social infrastructure and polices to improve diet and promote physical activity among children,” he says in the JAMA piece.

To read the JAMA commentary in its entirety, click here.

  • Lindsey

    Anyone with any experience in the foster care system would only subject a child to it under extreme duress. Being too heavy should NOT warrant ripping a child away from their parents. If you think that CPS always does what is best for the child and always tries other measures first, then you haven’t paid much attention to CPS. 

    Using BMI as a measure of health has been criticized again and again because it doesn’t show the whole picture. What if a child is above the 99th percentile due to long-term use of steroids for asthma? What if a child is the type that packs on the pounds right before a growth spurt?

    I am all for encouraging healthy eating for kids, don’t get me wrong. I just don’t think that the State should be threatening to take a person’s kids away over it. 

    • Rebecca

      Good for you Lindsey.  I agree with you 100%. In addition, this website is public, isn’t it?  If I had a child suffering from obesity, I certainly would not bring he or she to CHB after reading this article.  Actually, I would be worried that this is the actual philosophy of this entire institution.  This is dangerous and thoughtless for countless families battling this disease.

    • Annoyed

      I completely agree with Lindsey.  While I cannot lie and say that I have raised a critical eyebrow when I see morbidly obese children and immediately react that this is bad parenting, I don’t have a clue what the reality of that situation really is. 

      Massachusetts is already turning into a huge “nanny state” following the federal trend of government over-reaching.  Enough! 

      Look at all the recent posts on the CHB website.  Clearly next on the agenda is limiting the drinks the adult employees(!) can enjoy while at work. That is ridiculous. I don’t need David Ludwig, Shari Nethersole or anyone else telling me what I should have with my lunch or where I should have it.

  • martin

    For the doctors who say the state  comes  in and assist with therapy, money,  or training   before ripping a child from the home.   What State are you talking about.  Children’s assist children from  a lot of states,  not just Massachusettes.   we don’t live in Mass.   we had problems with a child,  not  due to weight.  Even though we were getting assistance for her on our own, we were  brought to court for neglect.  (of course dropped because there was no cause for it, but what a way to tear a family apart)  If parents can’t have the finger pointed  at them, then should not take child  away.  Who will pay for foster care, housing.  We have to pay for our daughter.  Do you have all your facts as to what child welfare really does in every state???????

  • hyblosophy

    Really? Well then maybe we should take all minors out of homes who smoke, or those who participate in dangerous athletic sports. My sister had a daughter who she had in waterpolo practice daily ( because the daughter wanted to be there) was fed the same food as her other children who were not obese but even captain of their college number 1 collegiate waterpolo team. After years of trying everything Stanford Univ did perform bariatric surgery and since then she has been at a wonderful weight and found out she is not able to tolerate gluten. This is after years of spending thousands of dollars trying to find a solution , They loved her like no other child and put dones of time and resources that most people do NOT have at their disposal to spend on high medical costs. This is really off the top , lets pull all children who you feel are not caring and getting results from a medical team that is put before  them. I SAY STRONG NO TO THIs.

  • Loretta

    I think the child should remain in the home and the family should receive counseling and any help they need to improve the situation and help the child to eat and exercise it’s way to better health. Taking a child out of their home is a punishment and seldom leads to good mental health.

  • http://www.facebook.com/chantal.hutchinson Chantal Hutchinson

    I am certainly an advocate for doing what’s best for ANY child. I’m sure the state will do all necessary research and investigation before removing a child from their home just for being overweight. There are circumstances out of anyones control, and those are able to be identified.

    CPS doesn’t remove children from their homes for absolutely no reason- there are two sides to every story, and sometimes the truth lies somewhere in between, and the decision is never taken lightly.

  • Rebecca

    Seriously?  I was wondering if such a ludicrous proposition ought to be addressed; however I have found that zealots are precursors of all misery.  Physicians who worry about obesity ought to concentrate their efforts into reforming hospital and school cafeterias, as well as restaurant portions instead of involving states into a child’s life.  More precisely, how about diagnosing a child’s weight issue correctly?  That may just be what a family need.  Not the threat of foster care!  Then again, that request may be just too much work…….

  • Concerned for CHB

    What is it with the recent spate of political grandstanding with the likes of Claire McCarthy and David Ludwig pushing politics through Children’s Hospital? We seem to be going away from our core mission of treating patients to politics.  I love working here, but this trend is disturbing.

    • Thriving staff

      Dear Concerned,

      Thank you for your comment. The Thriving blog is a place for hospital staff to share their thoughts and opinions, some of which may touch on politics when those issues overlap with health care or pediatric health. Every post is the opinion of the author and may not necessarily reflect the official stance of the hospital. We do welcome different opinions on the blog and any staff member interested in submitting a blog topic or writing a guest post should get in touch with our editorial staff via email: thriving@childrens.harvard.edu.