A few months ago I wrote a column in which I reluctantly supported designating obesity as a disease. My rationale was that in the more than 50 years that I have been watching the ebb and flow of medicine in this country I have seen very little, if any, evidence of success in our attempts to prevent obesity. Given this abysmal track record, the pragmatic side of my brain says why not label it a disease and begin to focus on treatment. However, I closed the column urging that we not lose sight of our core values and completely abandon any attempts at prevention.
As the months have rolled by, I have become increasingly concerned that preventing obesity is slipping further down the slippery slope to oblivion, greased by the success of semaglutide and the prospect of similar drugs in the pipeline. Before turning in our credentials as card-carrying preventionists, we need to step back and take another look at how we approach obesity from the pediatric side.
Dr. William G. Wilkoff
The majority of Americans believe that obesity occurs when an individual consumes more calories than he or she burns by being active. Some nutritionists criticize this “energy balance” model view as too simplistic and prefer a carbohydrate insulin model, which considers obesity as a metabolic disorder that is better managed by adjusting what the individual eats with less focus on amounts and the role of exercise. However, while the public may acknowledge that there are some individuals to whom genetics has dealt a more difficult hand, it continues to put a high priority on the dual roles of willpower and exercise.
But, what about children? At what point, if ever, does willpower enter the obesity discussion? A child may be able to exert some control over his or her diet by eating selectively. But, until the child acquires a certain level of resources and maturity it is parents who should be dictating the volume and variety of available food from which the child can choose. And, on the other side of the energy equation, parents should be playing a significant role in how much or how little physical activity their children engage in.
Of course there are many children whose genes predispose them to obesity when food is cheap and abundant. And, there are numerous families for whom socioeconomic factors limit their ability to control their children’s diet and activity options. However, we mustn’t lose sight of the fact that the majority of families may be making choices for their children that are contributing to the obesity problem in this country.
For example, a recent study published in Pediatrics has found that mean television viewing time during childhood and adolescence was associated with metabolic syndrome at age 45. Is this a failure on our part to anticipate this finding when for decades we as physicians have already seen anecdotal evidence to support it? Or is this another example of a willpower deficit by parents who likewise must have had an inkling that sitting on the couch watching television wasn’t healthy for their children?
Or is this just more evidence that as a nation we lack the political will to enact laws and develop programs aimed at heading off obesity in early childhood before it reaches the point that we have learned, from sad experience, is beyond the reach of dietary change, increased physical activity, and the fragility of normal human willpower. Here I’m talking about the disappearance of meaningful physical education in the schools, the failure to effectively prevent the marketing of poor nutritional foods and beverages to children, and the failure to aggressively promote universal breastfeeding-friendly workplaces and schedules, to name just a few.
As individuals we know all too well the limits of our own willpower. But, collectively as a nation we should be able to pool those fragmentary resources into a force for positive change. We may have thrown in the towel when we have opted to treat obesity as a disease in adults. Let’s find the will to work on prevention in early childhood when the window for change is still open.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.