Alvin N Eden, MD, FAAP

Emily was a beautiful 19-year-old honors student attending Barnard College in New York, New York, who contracted measles and developed post-measles encephalitis with resulting severe brain damage. I met Emily when visiting with a group of fellow pediatricians at Letchworth Village in Thiells, New York, a former residential institution for the physically and mentally disabled. We soon realized that, unfortunately, Emily was now barely able to function at the developmental level of a child aged 4 to 5 years.

That encounter made an indelible impression that has stayed with me to this day. The year was 1959, 60 years ago, and shortly before the measles vaccine was available. At that time, measles was one of the most common childhood illnesses.

Since the approval and licensing of the vaccine in 1963, we have seen a dramatic decrease in the prevalence of measles. The vaccine has been shown to be safe and effective. My office participated in the field trials in 1961. My son was an uncooperative, unwilling participant in the trial as I drew his blood, as were many of my other patients. In those days every practicing pediatrician was quite familiar with measles that was, along with chicken pox, seen very frequently.

The diagnosis of measles at times could be challenging. We learned about the 4 k’s: koplik spots, kough, koryza, and konjunctivitis. However, there were cases that did not present with all these features. Finding the koplik spots, which appeared before the rash, was not easy. Prying the mouth open of a sick and screaming toddler was hard enough. Locating these 1-mm to 3-mm blue white lesions with an erythematous base on the buccal mucosa opposite the first molar was even harder.

During the 1989-1991 outbreak, the mortality rate was 2.2 deaths per 1000 cases.

 Pneumonia was responsible for 60% of the deaths, mostly in children aged younger than 5 years.

 As illustrated by Emily, measles can also cause severe neurologic complications. Post-measles encephalitis is seen in 1 to 2 cases per 1000, usually developing several days after the rash. The hope at that time was for the vaccine to not only protect against measles, but more importantly to prevent the serious complications, which is exactly what has happened.

The vaccine had been an incredible success, so much so that in 2000 the Centers for Disease Control and Prevention (CDC) declared that measles was officially eliminated in the United States, as a result of so few reported cases in each of the previous few years.

However, now we are suddenly witnessing a major outbreak of measles, and so I am again reminded of Emily. I watch, with increasing frustration and anger, more and more antivaccine parents refusing to immunize their children with the measles/mumps/rubella (MMR) vaccine. As of September 19 this year, 1241 cases of measles have been reported by the CDC, the highest number since 1992. Why is there no public outcry to mandate universal measles vaccination without exception for all children?

I am certain that every parent wants only the best for his/her child, and this includes the antivaccine group. When I am faced with a parent who is hesitant or refuses to immunize his or her child, I explain to them how safe and effective the vaccine has been for over 50 years, but I also tell them about Emily and who she was before and after she caught measles.

Many practicing pediatricians have little or no experience with measles and its complications, unless, like me, they started practicing pediatrics before the routine use of the measles vaccine in 1963 or before the last major outbreak of measles that occurred 25 years ago. (The MMR vaccine was licensed in 1971 and recommended to be administered in 2 doses in 1989.)

For those community pediatricians who have little or no experience in diagnosing or treating measles, I implore you to emphasize to all your patients the absolute necessity to fully immunize every child on time and without delay, and explain to any reluctant parents that the group that questions the safety or effectiveness of the measles vaccine is not only wrong but is jeopardizing the health and well-being of their children. Tell them that the British physician who first reported that the MMR vaccine could cause autism was found to be a dangerous fraud and so lost his license to practice.

The antivaccine group must be made more aware of the terrible complications of measles. In my opinion, not vaccinating a child against measles is not only idiotic, it is immoral and dangerous.

Articles

Dr Eden remembers a patient who suffered extreme neurologic complications as a result of the disease.

Remember measles’ past when talking to parents

Pediatric obesity is a derangement of the energy regulatory system.

10 commandments of obesity prevention for children

, May 2018), while excellent for improving the health of children and their families, are not effective at prevention or treatment of the disease of obesity. They have been tried by pediatricians, parents, and children over the past 20 to 30 years and obesity prevalence statistics are quite clear. Lack of improvement in the prevalence of pediatric obesity makes sense if one looks at obesity as a disease and as a derangement of the energy regulatory system (ERS) resulting in the body defending an unhealthy set point. The evidence for the ERS is well outlined.

The ERS is a homeostatic mechanism that maintains our body’s composition and weight through various episodes of energy intake and energy expenditure, similar to blood pressure control, body temperature control, red cell mass maintenance, and liver mass maintenance.

A few children have simple, well-worked-out, genetically driven defects in the ERS; eg, leptin deficiency, leptin receptor deficiency, MC4R deficiency. For the vast majority of children with obesity, the problem in the ERS is not well worked out. The ERS is highly complex and, thus, many defects in the system are possible. The study of how genetics causes some children (many related and living in the same environment) to be susceptible or not to the disease of obesity is developing.

We need to take a physiologically based, evidence-based approach to prevention and treatment of the disease of obesity. We have tried an approach based on voluntary behaviors and personal responsibility. This approach has been based on correlations and cultural beliefs. Meanwhile, increases in the prevalence and severity of the disease of obesity have occurred. This approach is not correct.

As Lee Kaplan, MD. PHD, associate professor of Medicine at Harvard Medical School and director of the Obesity, Metabolism, and Nutrition Institute of Massachusetts General Hospital, Boston, stated recently at a National Academies of Sciences Roundtable on Obesity Solutions, “Overeating does not cause obesity, obesity causes overeating!”

It is not correct to blame the current obesity statistics on the parents, the children, or the primary care providers. This leads to shame, blame, stigma, and bias. We need education about the disease of obesity and aggressive research into what causes the malfunction of the ERS, leading to prevention strategies that work and treatment strategies that succeed.

1. Berthoud HR, MÃ¼nzberg H, Morrison CD. Blaming the brain for obesity: integration of hedonic and homeostatic mechanisms. 

2. Schwartz MW, Seeley RJ, Zeltser LM, et al. Obesity pathogenesis: an Endocrine Society scientific statement. 

3. Gadde KM, Martin CK, Berthoud HR, Heymsfield SB. Obesity: pathophysiology and management. 

4. Lee YS. Genetics of nonsyndromic obesity. 

5. Jou C. The biology and genetics of obesity-a century of inquiries. 

6. Kaplan LM. The physiology of weight regulation: Implications for effective clinical care. Presented at: Roundtable on Obesity Solutions; National Academies of Sciences; August 7, 2018; Washington, DC. Available at: 

https://conscienhealth.org/wp-content/uploads/2018/08/Physiology.pdf

The only answer to the problem of childhood obesity is early prevention.

I read with interest Dr. Browne’s response to my article “

, May 2018) and found myself agreeing with much of what he wrote, especially his statement right at the start that my program was “excellent for improving the health of children and their families.”

I also agree that genetics plays a large and poorly understood role in the development of obesity. Furthermore, I completely agree that the treatment of childhood obesity has been a dismal failure. Being a practicing pediatrician for more than 40 years, I have been trying thus far unsuccessfully to make inroads into the epidemic of childhood obesity. My first book, Growing Up Thin, which discussed the prevention and treatment of childhood obesity, was published in 1975.

Dr. Browne and I are on the same page as far as agreeing for the need for more education about obesity as well as for more research into its causes. He describes the problem as a derangement of the energy regulatory system (ERS) and again I agree, but in my latest book I call it “the X-factor.”

I also agree with Dr. Browne that instilling guilt onto the obese child at any age is not only unfair and wrong, but terribly cruel. Before discussing where Dr. Browne and I disagree, let me address his quotation from Lee Kaplan, MD, PHD: “Overeating does not cause obesity, obesity causes overeating!” It’s catchy and clever, and it reminds me of the old question, “Which came first, the chicken or the egg?” What difference does it make? The fact of the matter is that the high prevalence of childhood obesity is a reality and it continues to be a major public health problem.

So where do we disagree? I strongly disagree with his basic premise, namely, that my “10 commandments of obesity prevention” are not effective. The key concept in my article and the main theme of my latest book, 

Obesity Prevention for Children: Before It’s Too Late: A Program for Toddlers and Preschoolers

, is that the treatment of childhood obesity seldom is successful. Therefore, the only answer is prevention-the earlier the better-and before it’s too late. As I have emphasized, this approach is crucial, especially when dealing with high-risk families in which one or both parents are obese. I am certain that Dr. Browne would agree that treating an already obese school-aged child or adolescent from a high-risk family is almost always doomed to failure. In my opinion, obesity prevention programs, especially for high-risk children, must start very early in life in order to be successful.

A recent large-scale retrospective analysis from Germany, published in the 

, showed that among obese adolescents, their most rapid weight gain had occurred between ages 2 and 6 years.

 This study also showed that most of the children who were obese at ages 2 to 6 years were obese as teenagers. The majority who were obese at age 3 years also remained obese as adolescents. This further demonstrates that prevention must start early on.

Rather than waiting for the mystery of the genetic causes of obesity to be solved, the time to act is now. It makes intuitive good sense to follow my “10 commandments.” Further, the results of 3 large-scale studies of toddlers and preschoolers discussed in my recent book 

 suggest that my prevention program is effective. As the lady in the opera house balcony shouted down after all resuscitation methods failed and the tenor lying on the stage was pronounced dead, “Give him an enema!” “Why?” she was asked. Her reply? “It can’t hurt.”

Finally, if the “10 commandments of obesity prevention in children” are excellent for improving the health of children and their families, may well be effective, and can’t hurt, how can Dr Browne, or anybody else for that matter, object to their use?

1. Geserick M, Vogel M, Gausche R, et al. Acceleration of BMI in early childhood and risk of sustained obesity. 

https://www.nejm.org/doi/full/10.1056/NEJMoa1803527

Two pediatricians discuss the 10 commandments of obesity prevention for children and where the focus for treating obesity in childhood should be.

Two views of treating obesity in childhood

In 1975, I published my first childcare book 

, addressing the growing epidemic of childhood obesity. The obesity problem actually dates back to the 1950s, when there was a dramatic increase in the production of inexpensive, high-density, high-calorie foods. Sugar consumption rose by nearly 33%, due primarily to the use of high-fructose corn syrup.

The book was a huge success and received a great deal of publicity, but, sad to say, it failed to even make a dent into the prevalence of childhood obesity. In fact, there has been a significant increase in the prevalence of childhood obesity in the past few decades. A large-scale study recently published in the 

 showed that over 25% of children entering kindergarten were either overweight or obese, and 2 out of 3 of these children remained obese as teenagers and beyond.

 The American Academy of Pediatrics also has pointed out a sharp rise in severe obesity among 2- to 5-year-olds as 

 in the most recent 2-year cycle data from the National Health and Nutrition Examination Survey (NHANES), 2015-2016.

, “What happened during the past 40-plus years?”

1. More and more meals are eaten in “fast-food” establishments.

3. Besides TV, we now have computers, cellphones, and tablets for children, all of which increase sedentary time-what I call the SOB syndrome (Sitting On Butt syndrome).

4. Physical education time in schools has become more limited.

5. More safety issues are associated with outdoor play, such as increased automobile traffic and fear of abduction.

All these factors have resulted in the significant increase in the prevalence of childhood obesity.

Serious consequences of childhood obesity

The consequences of childhood obesity are well known. In addition to reducing overall life span, other major problems include the development of type 2 diabetes; elevated cholesterol and lipid levels; hypertension; sleep apnea; and psychologic/social difficulties attributed to a lack of self-esteem and self-worth. Further, obese children are more likely to be bullied and socially isolated.

This epidemic of childhood obesity continues unchecked despite massive attempts to stop it or at least to slow it down. What has become increasingly clear to me is that the treatment of both school-age and adolescent obesity is almost always doomed to failure. The longer a child is obese, the less likely any treatment will be effective.

I speak as a pediatrician with more than 40 years of frustration in treating overweight and obese children of all ages. Despite my best efforts, I rarely have been successful in treating an obese teenager.

The basic problem appears to be that neither the pediatric community nor the parents of young children are taking early onset obesity seriously enough. I find it difficult to convince the parents of toddlers and preschoolers who already are overweight or obese that there even is a problem. What is more upsetting is that even in high-risk families, in which 1 or both parents are obese, this lack of urgency holds true.

I firmly believe that most pediatricians do not spend enough time or effort in teaching the parents of very young children how to take the proper measures to lower the risk of obesity. Of interest is the fact that in the recommendations in the Bright Futures program of the American Academy of Pediatrics, none of the well-child visits from the 2-to 4-year list includes diet or nutrition as a priority.

The bottom line is that, in my opinion, the only way to make any significant inroads into the prevalence of childhood obesity is to 

 In other words, prevention rather than treatment is the key to success.

Parental motivation plays a strong role in predicting the effectiveness of childhood obesity intervention. Family-based intervention has been found to be most effective. The earlier this intervention is started, the greater the chance of success. This has been my experience as well as the experience of most healthcare professionals dealing with overweight and obese kids.

Pediatricians are in a position to be the strongest advocates for children. We must do more to shield and protect the next generation of infants, toddlers, and preschool children from facing the physical and emotional consequences of obesity as they grow up. We must teach the parents of young children how to prevent obesity before it’s too late.

In conclusion, follow these "10 commandments for winning the obesity battle" from the last page of 

1. Cunningham SA, Kramer MR, Narayan KM. Incidence of childhood obesity in the United States. 

2. Skinner AC, Ravanbakht SN, Skelton JA, Perrin EM, Armstrong SC. Prevalence of obesity and severe obesity in US children, 1999-2016. 

. 2018;141(3):e20173459. Epub ahead of print.

Pediatricians must do more to protect the next generation of children from the consequences of obesity before it’s too late.

Author | Alvin N Eden, MD, FAAP

Articles

Remember measles’ past when talking to parents

Two views of treating obesity in childhood

10 commandments of obesity prevention for children