Friday, February 20, 2009

unprepared doctors front line on war on obesity...

Try setting a google alert for "childhood obesity" for a few days. My mailbox is full with dozens of stories about "new initiatives" and "promising programs" to fight childhood obesity which is really just the same old stuff we've been hearing for thirty years. Eat less and move more. Hasn't worked for thirty years, but what seems new in the news is that insurers are now covering doctor visits to address obesity. 
While this sound promising, the reality is that the majority of clinicians don't know what they're doing when it comes to treating 'obesity' in children. I should know, I was a doctor 'treating' kids and it wasn't working. I followed the guidelines provided by the CDC, and Pediatric and Family Practice groups. I watched as I counseled, cheered, problem-solved, referred to specialty weight loss clinics, referred to dieticians. I watched as the weight kept increasing, as the children looked more depressed and dejected with each visit. At some point they just stopped showing up. Not only was I not helping these families, my intuition told me I was doing more harm than good, and I was right. 
Now I know why it wasn't working. The dirty little secret is that the standard of care does not work for the vast majority of patients. Guidelines, such as those recently put out by the Endocrine Society are "evidence" based, but what you have to look for in the fine print is that there is no good evidence supporting the standard of care. The US preventive task force reviewed hundreds of studies over decades and found "no evidence that screening (and intervention) for overweight in children/adolescents improves age-appropriate behavioral or physiological measures, or health outcomes." Trust me, I wish this weren't the case. We know that 85-95% of diets in adults fail, why would we expect the outcome in children to be any different. 
The piece that is consistently missing is feeding dynamics (that's why I started FFD.) The research shows that the feeding relationship is critical to healthy growth rates. The best predictor of abnormal weight gain is restriction (diet...) Kids who are restricted and not trusted to eat with structure and limits will eat more when they aren't hungry, eat during times of stress and be heavier. The medical push to put small children on fat and portion restriction is fueling the epidemic. Parents, following medical advice, are helping to cause the very outcome they hope to prevent. There is a better way. Its called trust, and the Division of Responsibility and doctors, public health officials and the media need to stop promoting the conventional wisdom which isn't working and is causing harm. (For study summaries see Ellyn Satter's resource list under references, last PDF titled Why do children gain too much weight.) 

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