www.medscape.com/viewarticle/470344
From Medscape Pediatrics
Pediatrics Perspective
Soft Drinks, Schools, and Obesity
Posted 03/08/2004
Howard Markel, MD, PhD
The American Academy of Pediatrics issued a major policy statement in January urging the restriction of soft drinks in the nation's schools.[1] That sounds like wise medical advice, given that the number of obese children has more than doubled since 1980 and that studies consistently show that overweight children tend to stay that way into adulthood. As many as 85% of American school-aged children consume at least 1 soft drink daily, and the average 12-ounce soda contains about 10 teaspoons of sugar and 150 calories.[1]
Although soft-drink consumption is certainly not the only cause of childhood obesity, limiting easy access to these drinks in schools seems like a welcome -- and common-sense -- contribution to public health. So why did the nation's leading group of pediatricians take so long to take a stand?
Since the 1990s, schools have opened their doors to soft-drink and fast-food companies in exchange for hefty fees to bolster their operating budgets. According to the Centers for Disease Control and Prevention, 98% of American high-school students can buy fast food, soda pop, candy bars, potato chips, and other high-fat snacks without stepping off the school premises.[2]
Dr. Barbara Frankowski, a pediatrician at the University of Vermont and one of the authors of the American Academy of Pediatrics's policy statement on soft drinks, acknowledges that pediatricians have been slow to respond to the obesity epidemic. "Many pediatricians don't always look at the community aspect of things until it hits them in the face," she said.
Paradoxically, the pediatric profession has a long tradition of aggressive advocacy for child welfare and the prevention of disease. After all, children often cannot speak up for themselves, so it has been essential for pediatricians to protect their patients' interests. When the field of public health first appeared in the late 19th and early 20th centuries, pediatricians were vociferous activists for providing clean milk for infants, controlling the spread of deadly infections, developing vaccination programs, and lobbying against child labor and for safer schools. During the 1960s, Dr. Benjamin Spock extended this clinical philosophy to protest the Vietnam War and the rise of nuclear weapons because he deemed them a threat to his patients.
The achievements of these doctors were phenomenal. A little more than a century ago, 20% of American babies died before their first birthday -- usually of maladies such as smallpox, whooping cough, or diphtheria. In 2003, the infant mortality rate was lower than 1%.[3]
Instead of focusing on the frequently fatal illnesses routinely seen at the turn of the century, most pediatric practices today center on far less life-threatening conditions, such as learning disabilities, behavioral disorders, and attention-deficit/hyperactivity disorder. In the process, the profession's activist roots have withered, especially with regard to health problems that don't have quick solutions or conditions that are poorly reimbursed by third-party insurers, such as obesity.
"A century ago, pediatricians were often at the forefront in many of the struggles around food safety, child protection, environmental health, and disease prevention," said Dr. David Rosner, Director of the Center for the History and Ethics of Public Health at Columbia University in New York City. "Today, there is a much greater ambivalence among physicians about their responsibility to advocate on behalf of their patients, much less on behalf of consumers -- whether they are children or adults."
On the issue of obesity, "the medical profession has been AWOL," said Dr. David Kessler, Vice-chancellor of the University of California at San Francisco Medical School and a former commissioner of the Food and Drug Administration. "It has missed the most important epidemic facing the vast majority of Americans."
Greg Critser, author of Fat Land: How Americans Became the Fattest People in the World (Mariner Books, 2004), said that recent efforts to get fast food out of schools have mostly been a result of grass-roots campaigns rather than a movement among medical professionals, and that doctors need to become far more active in their communities. "They need to pick up the ball in educating their patients about healthy eating, working with the schools to make sure high-fat, high-sugar foods are not so widely available to kids and get the insurance companies to cover treatments and counseling for obesity," he said.
Yet Dr. Jerold Lucey, the Editor of Pediatrics, the journal of the American Academy of Pediatrics in which the soft-drink policy statement appeared,[1] maintains that "pediatricians have been involved in obesity for a long time, and we have published many studies documenting obesity among children." He added, "But you have to understand that it is very difficult to treat and in many cases it seems hopeless. Many doctors who like to succeed in their treatments find this very discouraging."
Even so, said Dr. Rosner of Columbia University, "Doctors need to remember that being clinically objective doesn't mean being silent or giving up one's responsibility to protect a patient from harm. As we struggle with medical dilemmas in the 21st century, living up to the Hippocratic tenet to "do no harm" may increasingly entail ruffling, indeed pulling out, corporate feathers."
Perhaps, said Dr. Robert Murray, a pediatrician at Ohio State University and a coauthor of the American Academy of Pediatrics statement, doctors are again preparing to take on thorny health problems that exist in wider society. "There are many ways one can make use of his or her MD," he said. "We want this era's pediatricians to essentially act as health advocates for American children just as their predecessors did."
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Howard Markel, MD, PhD, George E. Wantz Professor of the History of Medicine, Professor of Pediatrics and Communicable Diseases; Director of the Center for the History of Medicine at the University of Michigan; and author of When Germs Travel, forthcoming from Pantheon Books.
Disclosure: Dr. Markel has no significant financial interests to disclose. He has reported that he does not discuss any investigative or unlabeled uses of commercial products in this activity.
Medscape Pediatrics 6(1), 2004. © 2004 Medscape
Pediatrics Perspective - Soft Drinks, Schools, and Obesity
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