Chewing the Fat: Starting a Discussion of Ethical Issues in the Life-long Drug Treatments of Obese Children

The medical significance of obesity in children is found in the extract below from the Perspective section of the September 25, 2008 issue of the New England Journal of Medicine and available as a free full article titled
“Storm over Statins — The Controversy Surrounding Pharmacologic Treatment of Children” by Sarah de Ferranti, M.D., M.P.H., and David S. Ludwig, M.D., Ph.D.

During the past 25 years, the prevalence of pediatric obesity has tripled; in some minority-group populations, the majority of adolescents are overweight or obese. Recent research suggests that increasing body weight in childhood, even within the range considered normal, is strongly associated with the risk of cardiovascular disease in adulthood. Case reports have identified renal failure requiring dialysis, limb amputation, and death before 30 years of age among persons who developed type 2 diabetes during adolescence. Because of such effects, some experts have predicted that life expectancy will decrease in the United States for the first time in more than a century unless something is done about childhood obesity.

As you will read in the article, the American Academy of Pediatrics has released a revised recommendation for the management of elevated cholesterol in children based on evidence that hardening of the arteries begins in childhood and the treatment with statin drugs which lower the cholesterol in adults may reduce the chances that the child will later develop coronary artery disease or other diseases of the arteries. It is suggested by the recommendations that screening for fats in the blood begin at age 2 and drug therapy for elevated LDL (“bad cholesterol”) may begin in 8 year old children. This would be in addition to attempt to prevent or reduce childhood obesity through control of diet and exercise. The “storm” and the ethics regarding the recommendation is related first to the unknown harm on normal physiologic development in children when cholesterol levels are reduced. Is starting a medication in a child with its physiologic consequences unknown ethical? Also a "slippery slope" may begin so that other cardiovascular and metabolic medications given to adults will be started in children as preventatives for heart disease, hypertension and diabetes. Slippery slopes raise ethical concerns about laxity regarding further unknown harms with these medications. Remember, controlled research studies are far less common in children than in adults. Another ethical concern relates to whether pharmaceutical companies can rid themselves of their conflict of interest when they are evaluating the role of these drugs for use in prevention of the adult disease. After all, starting a life-long medication in childhood has a better financial outcome for the company than starting the drugs only when the child becomes an adult.

In addition, open to discussion is who is responsible for obesity in children? Simply genetics, the parents, the schools, society in general? Should the professional guidelines for treatment of obese children with drugs trump the need for the parents and others to attend to the proper nutritional and activity factors to prevent childhood obesity and its consequences? ..Maurice.