Book Review

Child and Adolescent Obesity: Causes and Consequences, Prevention and Management

N Engl J Med 2003; 349:619August 7, 2003

Article

Child and Adolescent Obesity: Causes and Consequences, Prevention and Management
Edited by Walter Burniat, Tim J. Cole, Inge Lissau, and Elizabeth M.E. Poskitt. 416 pp., illustrated. Cambridge, United Kingdom, Cambridge University Press, 2002. $90. ISBN: 0-521-65237-5

On April 28, 1783, the following conversation took place between Dr. Samuel Johnson and his biographer James Boswell: “Speaking of a man who was grown very fat, so as to be incommoded with corpulency, he [Johnson] said `He eats too much, Sir.' BOSWELL, `I don't know, Sir; you will see one man fat, who eats moderately, and another lean, who eats a great deal.' JOHNSON, `Nay, Sir, whatever may be the quantity that a man eats, it is plain that if he is too fat, he has eaten more than he should have done. One man may have a digestion that consumes food better than common; but it is certain that solidity is encreased by putting something too it'” (Life of Samuel Johnson. New York: Heritage Press, 1965).

Are we any wiser today? Although we are indeed more knowledgeable, the argument still goes on. Boswell's point of view is reflected in much of today's literature on obesity, whereas others are convinced, and rightly so, that overweight people do eat too much.

Second only to dental caries, obesity is the most common nutritional disease in the developed world. We in the United States are in the midst of an epidemic, although the Europeans are doing their best to catch up. Indeed, most of the authors of Child and Adolescent Obesity are from Europe or the United Kingdom. They discuss all aspects of the obese state, from demographics to metabolic features, including the recently described leptin. Family therapy, bariatric surgery, appetite suppressants, the Prader–Willi syndrome, exercise therapy, and the relation between adolescent and adult obesity are included, and each chapter is heavily referenced.

Modern technology has largely done away with the classic nutritional ailments, and today's society has done its best to promote and ensure a superabundance of nutrients. One can hardly think of a set of circumstances better designed to promote obesity in our society: the ubiquitous automobile contributing to reduced physical activity; the abundance of food produced by modern farmers and sanitized by the Food and Drug Administration; and the fast-food “culture,” as described on January 9, 2000, by K.A. Marling in the New York Times Book Review: “In the saga of fast food, the burger is the real hero. . . . Visitors to the amusement park or the cattle show could stroll about as they ate, unencumbered by tableware and traditional good manners. . . . available for impulse purchase . . . it was associated with personal freedom, instant gratification of appetite, and a certain careless ease.”

Then there is the irrational exuberance of some nutritionists who, fearful of being criticized for recommending too little, want us to consume more nutrients than we need, so as to provide “a margin of safety.” There are compendiums of dietary consumption that call attention to the number of people who consume less of certain nutrients than they should but tend to gloss over all those who eat more than is necessary, schools that provide easy access to high-calorie drinks and snacks, and the multitude of television commercials devoted to food. The end result is an unparalleled surfeit of food, paired with a reduced need for exercise. Over many eons, humans have learned to deal with recurrent famine. We are now faced for the first time with a superabundance; we have yet to learn how to deal with it, and we are beginning to pay for it in terms of metabolic abnormalities and disease. Child and Adolescent Obesity makes clear the striking increase in the incidence of type 2 diabetes among adolescents. In our rush to find a metabolic cause for obesity, nutritionists and physicians have tended to downplay the role of excess energy, preferring to believe the results of dietary histories, but neglecting data that show that obese children often grow faster, have a larger fat-free weight and advanced skeletal maturation, and mature a bit earlier than their normal peers. Since these phenomena could not occur without an excess of food, obesity is truly a nutritional disease.

In their discussion of a wide range of issues related to the obese state, it is noteworthy that the authors portray the obese person as a human being, not merely as a metabolic machine. Although the results of treatment are disappointing, one can applaud the authors for pointing out that the goal of modern society should be to facilitate “lifestyles which discourage the development of obesity . . . else the present epidemic of obesity and overweight seems likely to continue until overweight is the norm.” One should not forget what was accomplished in the past to combat malnutrition; one hopes that we can rise to the present challenge.

Gilbert B. Forbes, M.D.
University of Rochester Medical Center, Rochester, NY 14642