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Are Childhood Obesity Screening Guidelines Misguided?

Yesterday the news wires were swamped with reports on a new recommendations by the U.S. Preventive Services Task Force to screen school kids for obesity:

The USPSTF recommends that clinicians screen children aged 6 years and older for obesity and offer them or refer them to intensive counseling and behavioral interventions to promoteĀ improvements in weight status.

The recommendation appears largely based on a paper by Evelyn Whitlock and colleagues who performed a systematic review on the effectiveness of weight management interventions in children just published in Pediatrics. The review concludes that despite important gaps, available research supports at least short-term benefits of comprehensive medium- to high-intensity behavioral interventions in obese children and adolescents.

In their recommendations, the USPSTF includes the previous American Medical Association Expert Committee recommendation on childhood obesity, namely to use

a stepwise approach that divides treatment into several stages including counseling, providing a structured weight management plan, and using a comprehensive multidisciplinary intervention/ tertiary care intervention delivered by multidisciplinary teams with expertise in childhood obesity.

So the recommended response to a “positive” screen is not 20 extra minutes of phys-ed per day or sitting through a class on healthy eating; no, the recommended response to a “positive” screen is comprehensive medical and behavioural intervention by a multidisciplinary team with expertise in childhood obesity…

…and herein lies the problem!

How many overweight and obese kids will actually have access to this kind of multidisciplinary weight management?

Indeed, it is only too easy to screen kids, label them as overweight or obese, and thereby destroy whatever is left of their self-esteem while amplifying their existing body-image concerns. Screening can probably also also point fingers and help heap blame on the parents, who may or may not be able to deal with these results in a constructive fashion.

Nowhere in the recommendations do I see any concern expressed about how these screening recommendations could possibly affect weight-bias and discrimination, have the potential to promote weight-based bullying and teasing, or result in potentially devastating outcomes including setting the poor kids off on unsustainable weight-loss attempts and weight cycling.

As I have blogged before, there is increasing evidence that weight bias and discrimination can increase depression and unhealthy eating behaviours – blame and ridicule has never been a good motivator for lifestyle change.

While I am as concerned as the next guy about the catastrophic increase in childhood obesity, I do not for a minute believe that screening and labeling 6 year-olds is the solution.

I can only imagine what some of my readers may have to say regarding this post.

Edmonton, Alberta


  1. Thanks for stealing my thunder!

    Had this tee’d up for Monday but frankly I couldn’t have (and didn’t ) said it any better myself.

    The world is out to lunch on obesity management, especially childhood obesity management.

    I can’t fathom how damaging it would be to a young child to be told he or she was so fat that they needed a special team of doctors to help them.


    While I’m all for treatment, treatment should be reserved for children who are already suffering from weight related co-morbidities such as type II diabetes, atherosclerosis, hyperlipidemia.

    For the rest? Treat/teach the parents but more importantly treat the environment. Healthy, calorie reduced, school foods made from real food, not reheated boxes; mandated calorie postings in restaurants; massive public health campaigns to anchor calories with real understanding energy balance especially in terms of energy in; energy balance taught throughout the school curriculum from early ages and not in health classes but rather through math problems, reading comphrension etc; mandatory cooking classes for kids in high school; free cooking classes for parents; tax ememptions for all whole foods, fitness equipment, gym memberships; changing the built environment to encourage stair use, more bike lanes etc.

    There, rant over.

    Guess I’ll have to think of something else for Monday.

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  2. …oops, sorry Yoni. But I somehow guessed we would see eye-to-eye on this one. Nevertheless, enjoy your weekend šŸ˜‰ Post a Reply
  3. Agree with all of the above. The pther concern about this type of approach is all the children you would be missing in this intervention. All the children that have (or are learning) poor eating habits and physical activity but are not yet obese. Another reason for a public health approcoach that would deal with the reasons for the problem in the first place.

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  4. Hi Arya: As usual, your comments are “spot on’. One of my 10 grandchildren is significantly overweight, and inspite of my 25+ years of involvement in adult Weight Management I have not spoken to her parents because I have had nothing constructive to offer and I did not want to create a situatiion such as you describe.
    Soooooo, what is available to parents & o/w children in Edmonton? I look forward to hearing from you. Doug Armstrong.

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  5. I hear you Doug – interestingly the two WW pediatric programs in Edmonton (the EGH and Covenant) provide exactly what is recommended: step-wise, mutidisciplinary, medically supervised, family oriented weight management. Surprisingly, despite the increase in childhood obesity, they are by no means oversubscribed.

    As I said, screening and labeling is not enough – politicians, administrators, health professionals and the public need to understand that childhood obesity is not about to go away and channelling patients into evidence-based treatments is probably the only chance for these kids.

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  6. The greatest risk to this style of assessment is that no one seems to know what to do with the information except feel bad. Kids are versatile and they change much faster than adults. Kids need to be educated to support the parents management of mediatime, calories and exercise. All of them, not just the overweight ones!

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  7. Here in NS my children were weighed and measured from birth on, and the doctor had charts of weight, height, & weight/height ratios for boys and girls at from birth to teenager, showing under- over- a normal range (percentiles). Kids see doctors and public health nurses for scheduled checkups and immunizations, including one at age 5 before the child goes to school. If kids are like mine they also see doctors for flus, ear infections, infected splinters, and assorted cuts and sprains.

    In Canada kids get general health care, in private, with a doctor or nurse. That seems to me to be a much better way to spend health care dollars than a one-issue screening program. The one-issue program is more of an American approach to take one problem and then declare a “War on __” – insert current issue.

    Here the problem is why do doctors not respond to overweight or obese children? Why would a doctor not treat overweight with the same urgency as a growing mole, an abnormally high blood sugar level, a dangerous persistent pain, or any other medical red flag?

    By “overweight” I mean above the normal range of healthy weight/height ratio for age & sex, not just being above the average weight but within a healthy range.

    Being significantly overweight is a symptom that something is making the child gain weight , and if that cause is not addressed, the child will continue to gain more and more and more weight. As I believe you have said, once someone is overweight or obese there is no cure, only lifelong management of a debilitating chronic problem. Prevention is crucial. Any doctor should be able to recognize overweight even if the child is there for another reason. To not treat an overweight child is cruel, like ignoring any medical red flag.

    In your circle of doctors, I dare say everyone is hypervigilant for overweight in children, but that’s not true everywhere.

    One of my children was overweight – measurably way above normal range for weight/height ratio on the doctor’s own charts.

    The doctor said:

    “She’ll grow out of it” (She didn’t.)

    “Provide healthy food but let her choose what and how much to eat, otherwise you’ll be causing eating disorders like anorexia which are worse than obesity”.
    (This advice worked perfectly for my children who had ordinary weights to start with. In retrospect, I should have been just as strict on her eating habits as I was strict with my Evil Keneivel kid keeping him from hanging onto moving cars while riding a skateboard. I should have realized that my overweight child was courting danger by eating whatever she felt like, and she needed to learn to be sensible and controlled about eating. Potential anorexia wasn’t the problem, any more than my skateboarder was in danger of becoming too timid if I set limits on his behavior.)

    “She’s a beautiful child”
    True, but irrelevant. This isn’t a cosmetic issue, and I didn’t like being dismissed as if I were a weight-obsessed beauty pagent stage mom.

    “She’ll be teased if she has to eat differently from other kids.”
    Would a doctor refuse to put a child on o diet for diabetes or kidney disease because the child would be teased? Is overweight not important enough to bother dealing with any teasing?
    Besides which, the teasing from being overweight is even worse than the teasing a child will get for eating right.

    As a teenager, my daughter asked her doctor for help and was referred to a hospital dietitian who taught her the Canada food guide, which she said she knew anyway. She said she was never told to count calories. As an adult, she’s managing her own weight, and she does count calories.

    I blew it with my daughter. She’s now overcoming a problem I should have avoided by teaching her from a very young age to strictly control her food intake. It’s ultimately my fault, but doctors didn’t help by dismissing my concerns, and the plan they finally offered my daughter didn’t stress calorie control which Dr Freedhoff says is key.

    Canada doesn’t need a screening program to find overweight kids.
    Canada does need family doctors who will actually recognize childhood overweight as a dangerous condition.

    And I hope the bad advice I got from doctor and nurses has long since been replaced with he approaches mentioned earlier in these posts and this blog.

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  8. Singling out these children through assessment does just not seem right. An overall education about healthy eating for ALL children needs to be implemented more thoroughly in schools. Sad to say but the less fortunate school disctricts need this the most. Families in these schools are more prone to having a diet full of carbohydrates, canned vegetables, and fried foods.

    …and don’t even get me started on the dwindling physical education programs at schools.

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  9. Why is it “not right” to single out a child who needs to watch calorie intake to avoid being overweight? Not to ridicule in front of peers, but to honestly recognize the situation with the child.

    There is no moral judgement in this, any more than teaching a child with a nut allergy to avoid nuts and to read labels to avoid hidden nuts.

    Some children have to avoid shellfish, some celiac children have to avoid wheat and glutin-containing foods, diabetic children have to learn to eat just the right amount not too much or too little, athletic children in heavy training learn to drink enough water and eat enough carbs at the proper time, kidney problems mean avoiding food that is good for most people like orange juice bannannas and tomatoes.

    And a child who has more fat tissue than is healthy needs to learn that this isn’t a moral failing or a character flaw, it’s a matter of balancing calories in food with calories used up.

    The popular Oprah approach is to regard a child with a weight problem as suffering intense psuchological trauma, and treating that, not the weight. In some cases that is so, but in most cases, the child just eats what’s around, and doesn’t realize how many calories they eat or burn, especially in a culture which has developed food with calorie content that packs a wallop like a caloric nuclear bomb.

    Children should learn that although there are general guidelines, there is no one healthy eating plan that covers ALL children.

    The kids on the soccer and track teams are going to need more calories than the kids who spend there extracirricular time in the art studio, and although everyone needs some physical activity, not everyone needs to spend hours a day doing athletics.

    Children vary in size and metabolic makeup, so even if they’re doing the same activities, they’ll need slightly different calories.

    Children need adults to be able to get the right food, but they also need to learn pick the right food for themselves, and that includes learning to recognize their own calorie needs, and pick the food that they need.

    Children need to learn that they can control their weight by balancing their calories (if adults make decent food available) and getting the right number of calories is just like learning to get enough vitamins.

    If adults tiptoe around the issue of weight, the kids get the impression that it’s their fault, there’s nothing they can do about it, they’re fat because they have big problems, it’s so bad it can’t even be talked about, so it has to be covered up. That’s the way to make kids neurotic about weight.

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  10. I am loving this discussion: I think some very good points are being made. Clearly, children with excess weight need to be identified and will likely have to make modifications (or rather their parents do) or, as nicely put by “anonymous”, the small problem will grow into a bigger problem (no pun intended).

    It is more about how this is best done: the paper in Pediatrics recognizes and advises that weight management requires substantial expertise and resources and clearly not all kids will have access to this.

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  11. A couple of generations ago the lowly housewife was able to keep her family fed and not fat. Maybe not 100%, but usually.

    How times have changed. It seems there was some expertise there that we’ve lost.

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  12. I vehemently disagree with many of the comments that “Anonymous” has made. Anonymous states that most kids are fat not because of psychological trauma, but because they’re eating whatever is lying around. NO. No, if they ARE eating whatever’s lying around, there’s a reason for it, and that reason lies in the mental and emotional factors that don’t seem to be explored or given the gravity they should in any of these posts.

    I don’t disagree that there are a lot of factors available in our modern society to make kids overweight. And sure, some kids probably have less-than-healthy eating habits. However, I think TRUE obesity is the result of much more than the tangibles of food, drink and exercise or sedentariness. You can try to change a child’s caloric intake and level of exercise all you want…you can keep nothing in the cabinets except rice cakes and post calorie counts of healthy food and unhealthy food on every flat surface until the icebergs turn to slush, but if that little person is being abused, or teased, or bullied, or ostracized, or hurt, or neglected, MEDICAL intervention isn’t going to make his or her obesity disappear. Changing the behaviors and conditioning that are teaching that child that he/she is BAD, WRONG, UGLY, UNLOVEABLE and WORTHLESS in this world…THAT might make the obesity disappear. (And even if it doesn’t, at least you’ve helped counteract the damage that that child has suffered and maybe built some self-esteem in its place.)

    I’m not a physician or medical expert, but as a fat adult who started out as a fat child growing up in a dysfunctional family and relentlessly bullying school environment (bullied by my teachers as well as peers), I feel quite certain that most kids get fat because they are responding to physical, emotional and social trauma. Kids don’t have the self-awareness and life experience to rationally analyze what problems are occurring in their lives and what action needs to be taken (hell, most adults don’t either!). They are vulnerable, and visceral, and powerless, and one of the only things they DO have power over is their bodies and how their bodies feel. When they feel hurt and empty, food fills that emptiness. When they have no stimulation making them feel alive and happy, food can be that stimulation. When the other kids are calling them “tubbo” and “lardass” and “whale” and “pig” and every minute of every day is SO lonely and unbearable, and there is NO COMFORT anywhere, and ALL there is is judgment and venom, they turn to something that doesn’t judge, that tastes sweet to counteract all that toxicity.

    it is really quite smart and self-preserving, when you think about it — and totally rational. And, honestly, a whole lot better than becoming a juvenile delinquent or a suicide statistic, right? Maybe we should give the fat kids a little credit for HAVING such innate self-preservation!

    The problem lies in the way that this turns into a vicious circle. Kids who are overweight get ostracized by their peers, and thus gain more weight to try to shut out the pain, which makes the peer-tormenting worse; kids in a dysfunctional household who are berated for not being what their parents had hoped for eat and become even more unacceptable to their parents, who then berate them for their bodies on top of everything else; kids who see images all around them, in every form of media, telling them that their bodies are a freak show of unforgiveable greed, sloth and gluttony eat to hide themselves from the world, which makes the world laugh at “those pathetic fatties” all the more…

    These circles have to be halted somewhere, and I don’t think mere medical intervention is going to do it (though it’s good that the tools exist). There has to be MORE than that — more than exercise, or calorie-counting, or meal-planning. There has to be a change that doesn’t blame the child, single out the child, make the child feel worse — more isolated, more hated, more of a total, worthless failure — and it has to take into account what’s going on with the child as a WHOLE, integrated person – not just as a BODY.

    That child has to be encouraged to feel totally different about him or herself, because a body can’t change or heal out of the energy of hate. He/she somehow has got to feel authentically loved, and beautiful, and worthy, and SAFE, regardless of his or her size. That means changing the toxic, hurtful environment that child is trapped in — his/her home (if that’s the case), and school (if that’s the case), and the WORLD. Our society. The people in that child’s world have to love him or her for REAL, through and through, outside and inside selves included. The teachers in that child’s school need to think that kid is FABULOUS, fat or thin or in between, and make it clear to all the other students that bullying and name calling will NOT be tolerated, ever. And the media that that kid takes in needs to affirm that bodies of all sizes, everywhere on the spectrum, are valid and deserving of love…because they’re what we live in.

    How do we figure out how to do that? How do we get that kind of internal, external and cultural healing to occur along with the medical model of healing? I don’t have any answers. If I did, I suspect I would have won some major awards by now…and I myself wouldn’t be fat.

    Finally, a note to Anonymous:

    Your daughter’s physician was absolutely right to tell you that your daughter was a beautiful little girl. It was important that he said that — NOT “irrelevant”, as you dismissed. It meant he saw more to her than her size. I hope he told HER that she was beautiful…especially if you weren’t telling her that.

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  13. Clarification: In my first paragraph, when I wrote “…and that reason lies in the mental and emotional factors that donā€™t seem to be explored or given the gravity they should in any of these posts”, by “posts” I meant “comments in response to the article”, not “in Dr. Sharma’s posts”. Sorry if that was confusing.

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