Pediatric obesity is a derangement of the energy regulatory system.
Allen F Browne, MD, FACS, FAAP
Dr. Alvin Eden’s “10 commandments of obesity prevention for children” (Contemporary Pediatrics, 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.1-3
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.4,5
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!”6
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, Münzberg H, Morrison CD. Blaming the brain for obesity: integration of hedonic and homeostatic mechanisms. Gastroenterology. 2017;152(7):1728-1738.
2. Schwartz MW, Seeley RJ, Zeltser LM, et al. Obesity pathogenesis: an Endocrine Society scientific statement. Endocr Rev. 2017;38(4):267-296.
3. Gadde KM, Martin CK, Berthoud HR, Heymsfield SB. Obesity: pathophysiology and management. J Am Coll Cardiol. 2018;71(1):69-84.
4. Lee YS. Genetics of nonsyndromic obesity. Curr Opin Pediatr. 2013;25(6):666-673.
5. Jou C. The biology and genetics of obesity—a century of inquiries. N Engl J Med. 2014;370(20):1874-1877.
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. Accessed October 15, 2018.