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The Medical Issue

The fat fighter

Research pediatrician Dr. David Ludwig sees reversing the rise in childhood obesity as more than just a job. For him, it’s an act of political will.

Illustration by Emiliano Ponzi

SIPPING GREEN TEA in his corner office at Children’s Hospital, his back to a sweeping view of Boston’s Muddy River, Dr. David Ludwig looks every bit the mild-mannered research pediatrician he is and not a whit the political activist he claims to be. He is soft-spoken and deliberate, and his comments seem almost choreographed – perhaps for good reason. The good doctor is all too familiar with the sting of public disapprobation.   

Ludwig, who holds a chair in pediatric endocrinology at Harvard and directs the Optimal Weight for Life (OWL) program at Children’s Hospital, is arguably the nation’s leading crusader in the battle against childhood obesity. With nearly a third of US children and teens overweight, and fully 17 percent obese, Ludwig believes this battle is one we cannot afford to lose. So this summer he took off the gloves. In a carefully worded commentary in the Journal of the American Medical Association, Ludwig and a coauthor proposed that in a small percentage of “severe instances,” morbidly obese children not helped by counseling and other interventions might for their own safety be removed from their homes and placed, at least temporarily, in foster care. Framing this as a possible alternative to the treatment of last resort – bariatric surgery – the authors wrote that “placement of the severely obese child under protective custody warrants discussion.” The furor that ensued, ranging from insults to threats, shocked Ludwig. “I expected this to be a spirited scholarly debate,” he told a Boston Globe reporter at the time. “I did not expect this to be a commentary heard around the world.”

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Perhaps as a result of the raging response, Ludwig today makes every effort to qualify his views. Still, he cannot conceal his contempt for the American way of eating. “Most people would be outraged if the state did not intervene to save a starving child,” he says. “But today we have historically unprecedented rates of overfeeding, and children are sick, even dying. It’s not merely a matter of blaming parents – the schools, the insurance industry that refuses to pay for obesity treatment, city governments that don’t invest in safe biking and walking paths, a federal government that dumps tens of billions of taxpayer dollars into high-calorie commodities like corn. Parents have some responsibility, of course, but there’s plenty of blame to go around.” 

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LUDWIG RESERVES his harshest criticism for the food industry. Thanks to a barrage of advertising and marketing, he says, Americans in general and children in particular are persuaded to consume low-quality, high-calorie processed foods and to prefer these over what he calls “real” foods: fruits, vegetables, whole grains, nuts, and lean protein. Chain restaurants like Olive Garden, responding to pressure from groups such as Michelle Obama’s Let’s Move! campaign, have publicly pledged to improve the healthfulness of their offerings. Ludwig remains skeptical. “I’d rather commend industry for actions taken, not for promises that all too often are motivated by public relations,” he says. Ludwig’s enemy number one is the 100-calorie snack pack. “Small portions of junk food at an even higher unit cost than large packages,  the lowest quality products around,” he calls them. “And after eating one, you feel very little satiety, so you eat two, three, four. It’s brilliant marketing with unfortunate consequences.”

Those consequences show up as the patients Ludwig treats: teenagers with advanced fatty liver disease, grade schoolers with life-altering heart and lung problems, and a growing legion of 12-year-olds with what was once called adult onset diabetes. It’s not any particular major nutrient – fat, carbohydrate, protein – that’s given rise to such tragedies, he says, nor is it a lack of data or a scientific misunderstanding of the problem. It’s a public health failure. “The obesity epidemic is a symptom of a political problem,” he says. “The answer doesn’t rely on new drugs or fancy surgical procedures. What’s required is a comprehensive national strategy that puts public health ahead of private profit.”

Ludwig has worked hard to contribute to that strategy, proposing public interventions ranging from more transparent nutritional labeling on menus and packages to better and safer playgrounds. One of his most active campaigns has been against beverages sweetened with sugar or high-fructose corn syrup. In 2009, Ludwig joined a cadre of public health advocates calling for a tax on beverages with added sugar. Given that obesity is a particular scourge of the poor, he reasoned, the funds could be used to help repay the growing public cost of caring for patients unable to foot the bill themselves. Not surprisingly, the proposal ignited a firestorm of opposition from the food industry and the public interest groups it sponsors. But the proposal also was attacked by some economists, who argued that so-called fat taxes are not always effective in changing human behavior and that a tax on soda in particular would tend to punish the poor. Ludwig, whose own research has found a link between soda consumption and obesity in children, remains unconvinced. He was an active supporter of Boston’s recent ban on selling sugar-sweetened drinks on public property.

Dina Rudick/Globe Staff

Dina Rudick/Globe Staff

RX FOR CHANG “The obesity epidemic is a symptom of a political failure,” says Dr. David Ludwig. “The answer doesn’t rely on new drugs or fancy surgical procedures. What’s required is a comprehensive national strategy that puts public health ahead of private profit.”

“There is strong evidence that sugary beverages promote diabetes and weight gain,” he says. “Yet in Massachusetts, we exempt sugary beverages [like all food]  from sales taxes. Based on the evidence we have now, taxing beverages will decrease consumption, improve public health, save money, and raise revenues.” Ludwig is aware that levying such a tax may increase use of low- and no-calorie sweeteners, which some fear pose their own problems. To grapple with that question, he is recruiting adults for a study that he hopes will determine conclusively what impact, if any, diet beverages have on body weight. “Shockingly, as of now, we don’t have the data to answer that question.”

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LUDWIG, 53, WAS RAISED in Los Angeles, attended college at Berkeley and medical school at Stanford, came to Boston for a residency at Children’s, and never left. Born into a family of activists – his father, a real estate manager, participated in the civil rights movement and protested the Vietnam War, his mother was a union organizer – Ludwig shares his parents’ ideals, but has found a different way to rally for change. “I got into science and medicine with an eye toward social justice,” he says.  “What’s unprecedented today is that so many children are obese at such an early age.  That’s the problem we should be focused on, as a nation and as individuals.”

Ludwig advocates parents take forceful steps to protect their children: Learn to cook a handful of simple healthy recipes, insist children eat a good breakfast at home, encourage activities like after-dinner walks, and steer clear of fast food, soft drinks, and other highly processed foods. Ludwig himself has no trouble following this advice, in part because his wife, Dawn, is a chef. (They met around the veggie table at a 2005 whole-foods conference in Vermont.) Selling his Volvo and walking to work every morning from his home in Brookline doesn’t hurt either.

But Ludwig insists that feeding a family real food is not as daunting as some exhausted parents fear. Guiding our kids to a healthy lifestyle, he says, is a matter of taking back the power to dictate food choices now wielded by the food industry and its television advertising. Kids, he says, are naturally inclined to make good food choices; it’s all about ridding ourselves of preconceived ideas of what they will or won’t eat. To illustrate, he pulls out his cellphone and clicks on photos of his 3-year-old son, Benji. In the first shot, Benji eyes a forkful of spinach suspiciously. In the second, he grins broadly, and in the third, he’s a mini-Popeye. “His favorite food is blueberries,” Ludwig says proudly. Whether Benji will eventually succumb to the siren song of Happy Meals remains to be seen, but for now, Ludwig is focused on helping him – and all kids – avoid that trap. His next project is an obesity prevention center funded by the New Balance Foundation that will integrate research, clinical care, and, perhaps most important, community action. “My earliest childhood recollections are marching in demonstrations and antiwar protests,” Ludwig says. “Obesity is just as political an issue. The only way to win this fight is with collective action.”

Ellen Ruppel Shell is a professor and science journalist who teaches at Boston University. Send comments to magazine@globe.com.
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