• What to do about really obese kids

    Some of my libertarian friends are losing their minds over this:

    Despite a well-established constitutional right of parents to raise their children as they choose, the state may intervene to protect the child’s interests. Federal law, which establishes a minimum standard for states, defines child abuse and neglect as “any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm . . . or an act or failure to act which presents an imminent risk of serious harm.” The seriousness of neglect is judged according to the magnitude or risk of harm and by its chronicity. Improper feeding practices, causing undernourishment and failure to thrive, have long been addressed through the child abuse and neglect framework. However, only a handful of states, including California, Indiana, Iowa, New Mexico, New York, Pennsylvania, and Texas, have legal precedent for applying this framework to overnourishment and severe obesity. Nevertheless, mandated reporter laws may obligate physicians to contact child protective services in the cases of children for whom chronic parental neglect has resulted in severe weight-related health complications.

    State intervention may serve the best interests of many children with life-threatening obesity, comprising the only realistic way to control harmful behaviors. 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. These less burdensome forms of legal intervention may be sufficient and therefore preferable in many cases. In some instances, support services may be insufficient to prevent severe harm, leaving foster care or bariatric surgery as the only alternatives. Although removal of the child from the home can cause families great emotional pain, this option lacks the physical risks of bariatric surgery. Moreover, family reunification can occur when conditions warrant, whereas the most common bariatric procedure (Roux-en-Y anastomosis [gastric bypass]) is generally irreversible.

    I have to agree with them. Although I loathe slippery slope arguments, parents do tons and tons and tons of things that are inherently unhealthy for their kids. I’m guilty, too. Some of my friends are horrified that I let my kids drink soda. I’d argue that I’m happier with them drinking diet decaffeinated soda than sugar-laden juice. Others may think I’m a terrible parent for letting them play video games. Or watch TV. Or, you might question what I let them watch on TV. I also let them eat popcorn before the AAP recommended age. And hot dogs. And steak, for that matter.

    On the other hand, I’m horrified by parents who smoke around their kids. I probably should stop my kids when they yell at other kids who don’t wear bike helmets, but I don’t. And many people I know let their kids out of booster seats far too early.

    But I’m not advocating for protective services for those kids. The foster care system is WAY overtaxed already.

    Moreover, I’m uncomfortable with too much state interference into private matters, and this feels like it crosses the line.

    That said, this is a big issue with real health consequences, and I think we need solutions. Austin sent me this yesterday, and it burned my eyes. (via Tyler Cowen who shares the blame)

    I’m pleased JAMA is allowing the debate.

    UPDATE: Many of you are putting me in the same camp as those who are “angry” about the editorial or who equate this with “jack-booted thugs” invading homes.  Please. That’s not what I’m saying.  Look at the sentence at the end of the post.

    I’m a pediatrician. I have personally been involved in many cases where my gut reaction is to get the kid out of the home. I feel that way more than I’d like. But I can tell you that we need to be very careful in removing a child from his or her family. It’s possible to do more harm than good, emotionally as well as physically. I’m not saying it should never happen. I’m saying it should happen only when absolutely necessary.

    I’m not convinced this is one of those areas. I’m not convinced that this is where we should be aiming the state. Personally, I’m much more comfortable with financially penalizing groups and other solutions before breaking up families.

    And for those of you who think there is no slippery slope here, what’s the line? Is it a certain weight? Is it a certain BMI? What’s the point when you take a child out of their family?

    • Aaron,

      Respectfully, I think you missed the point of the JAMA commentary (as did the majority of news outlets that picked up the story). The examples you gave (on the slippery slope which you loathe) just don’t seem relevant here — the government has no interest in interfering with mainstream differences in parenting styles. State intervention to address anything that harms the welfare of a child — be it undernourishment, overnourishment, or abuse — is only justified when the child is in imminent danger. Morbid obesity threatening extreme complications is such a case. If you agree we should take children away from their parents when irreversible abuse is likely, then a similar justification should apply to obesity.

    • Well, the specifics are important here. We’re not talking about people giving their kids too many cookies after dinner one time.


      That piece [in the journal Pediatrics] discussed a 440-pound 16-year-old girl who developed breathing problems from excess weight and nearly died at a University of Wisconsin hospital. Doctors discussed whether to report her family for neglect. But they didn’t need to, because her medical crisis “was a wake-up call” for her family, and the girl ended up losing about 100 pounds, said co-author Dr. Norman Fost, a medical ethicist at the university’s Madison campus…. Another case involved a mother who lost custody of her 555 lb. 14-year-old son, a boy who’s now living with his aunt and has lost 200 lbs.

      I share your knee-jerk reaction, but this is only about the most egregious cases imaginable.

    • Hasn’t bariatric surgery been shown to more detrimental to health than the weight?

    • I think you might be overly concerned about the slippery slope risks here. There are plenty of examples where parental behavior affects kids’ health, and generally (not always, but the vast majority of the time) docs and others manage to muddle along with some basic common sense.

      For example: say you see a kid in the clinic who has asthma, and the parent tells you they smoke in the home. Do you call child protective services? Of course not. Now say you’re intubating that same kid for status asthmaticus for the third time this year, and the parent is still proudly proclaiming their God-given right to smoke wherever they damn well please. I would involve CPS, and I suspect most of my peers would do the same. What if it wasn’t DM related to obesity but instead type I DM, and you were admitting the kid to their nth ICU stay for severe DKA because their parents refused to offer insulin or modify their diet?

      I don’t think the authors of the JAMA piece are saying that jackbooted thugs should audit your grocery bill looking for sugary cereals, but rather that in the rare (although not as rare as they used to be) cases where a kid’s weight leads to truly life-threatening complications, and when despite maximal efforts at education and support parents are still behaving in ways that put the child’s life at risk, CPS should be considered an option. When you think about it, that’s not too wildly different from how we approach most health problems.

    • Do kids that are obese who are moved in to foster homes for other reasons begin losing their excess weight? This would be an interesting statistic to look in to.

    • “And for those of you who think there is no slippery slope here, what’s the line? Is it a certain weight? Is it a certain BMI? What’s the point when you take a child out of their family?”

      When there is evidence of end organ damage. CHF, uncontrolled diabetes with renal damage, severe sleep apnea with pulmonary consequences. I cant see taking away a kid just because they are fat. However, if they are super massively obese, demonstrating damage as a result and family is negligent, I can see taking them away. I think we would do the same for Munchausens by proxy or a parent who was slowly poisoning a child.


    • A “slippery slope” argument is by definition a logical fallacy. If intellectual honesty is important to you, you should always disagree with such arguments.

      Although you do not spell it out, the implied argument is as follows:
      (1) It would be overly intrusive for government officials to remove children from parents who do things that are inherently unhealthy, such as smoke around their kids or allow them to drink soda.
      (2) Allowing the government to remove morbidly obese children from their parents would lead to government being able to remove children from parents who do inherently unhealthy things.
      (3) Therefore, allowing the government to remove morbidly obese children from their parents would be a bad idea.
      This argument is fallacious because you have failed to establish (2). Why should we believe (2) is true?

      There may be legitimate arguments for and against removal of morbidly obese children, but you have failed to address them here.

    • Aaron,

      I’d like to know more about a peripheral issue you raise in your post, namely that you allow your children to drink diet decaffeinated soda. Are you not worried about the effects of artificial sweeteners on children? Do you believe one artificial sweetener is safer than another for children?

      My question is not an implied criticism. I am trying to decide whether to allow my grandchildren to drink diet decaffeinated soda when I take them out to eat, and I would value your opinion.

    • You are being fundamentally dishonest in equating government involvement with removing children from the home. Please do not do this. The vast majority of CPS involvement does nothing of the kind and has no desire to do so.

      If you have no issue with child neglect laws, what is the problem? It’s not like there is some hard and fast rules on the low BMI end of the spectrum either. But I don’t know too many people that have a problem with intervening when children are malnourished or appear to be starving.

      Ultimately, children are not the property of the parents. They are people with rights that don’t always correspond with that of their parents. Too many people forget this.