Two views of treating obesity in childhood

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.

REFERENCES

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.

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

Alvin N Eden, MD, FAAP

I read with interest Dr. Browne’s response to my article “10 commandments of obesity prevention for children” (Contemporary Pediatrics, 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 New England Journal of Medicine, showed that among obese adolescents, their most rapid weight gain had occurred between ages 2 and 6 years.¹ 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 Obesity Prevention for Children 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?

REFERENCE

1. Geserick M, Vogel M, Gausche R, et al. Acceleration of BMI in early childhood and risk of sustained obesity. N Engl J Med. 2018;379(14):1303-1312. Available at: https://www.nejm.org/doi/full/10.1056/NEJMoa1803527. Accessed October 15, 2018.