Ellyn Satter

Articles & Commentaries

Anamarie Martinez-Regino

Commentary on the case of Anamarie Martinez-Regino, Albuquerque, New Mexico, a 3-year old removed from her home on the grounds of her parents' failure to intervene with her obesity.

Mark Twain said, "If your only tool is a hammer, everything starts to look like a nail." The case of Anamarie Martinez-Regino illustrates the point. The nail: The courts have assumed that Anamarie's parents have neglected her by overfeeding and under-exercising her. The hammer: parents were to keep her on a weight-reduction diet. When they failed at that, she was taken away, presumably to be put with people who are better at wielding the hammer. As this case progressed, the hammers got bigger and bigger: the physician, social services, the courts. Eventually, the biggest hammer of all came down–the state. The tragedy of it all is that the courts didn't really know Anamarie's situation in any detail. They were going by the most imprecise of indicators–her fatness. I routinely evaluate children of size in my clinic, and I do not make any judgments without knowing a great deal more about the child and parents than the courts appeared to know in this case.
The issue of childhood obesity is complex, and the ability of clinicians, let alone the legal profession, to sort out the complexity is rare. Was Anamarie too fat? She looks fat, but you can't tell by just looking, or even by comparing her weight with cutoff points on a weight-for-height or body mass index chart. You can only tell by examining weight records from birth. Has Anamarie been consistently fat from the time she was a baby? If so, her fatness is natural or normal for her. Contrary to the popular assumption that we should all come from the same size-and-shape cookie cutter, some children are normally fat.
If, on the other hand, Anamarie's weight has diverged upward on the growth charts as she has gotten older, we have to ask ourselves why. It is normal for children to eat normally, grow consistently and achieve their constitutional endowment for size and shape. If they don't, something is seriously wrong. It takes a lot to make a child gain too much weight. To locate the source of the disruptions requires a careful and detailed evaluation of past and present medical, social, developmental and environmental issues.
Children don't just automatically get fatter than nature intended them to be–there are reasons. A child may have been temperamentally difficult, hard to reach and hard to discipline so parents have used food to comfort, connect or subdue. Parents may have been frightened by a child's early health problems and have overfed because of anxiety about the child's survival. But overfeeding is not common. To overfeed, parents have to consistently feed beyond the child's signs of fulness, meal after meal, day after day. Children compensate–they make up for parents errors in feeding by not getting hungry as quickly or by eating less the next time.
Children can overeat–or under-exercise–because they are stressed. Children are stressed when parents are too busy and don't take much interest in them; children are stressed when parents are so overburdened by life circumstances that they can't keep them safe. The alarming statistics about the increase in child obesity are heavily weighted by children who are living in poverty, in geographical areas where children are not safe. Finally, children often overeat because they are afraid they aren't going to get enough to eat. Children who live day after day with food insecurity eat as much as they can get, when they can get it. Children whose parents limit their food intake for fear they will get fat do the same. Children whose food intake is restricted tend to get fatter, not thinner, as they get older. Unnecessarily removing a child from her parents will enormously exacerbate her stress.
In my clinical practice, I have found that once the source of the problem is identified, most parents can follow a reasonable course of action. A weight-reduction diet is not reasonable. Not feeding a child enough is policing, not parenting. Instead, parents can optimize: provide regular meals and snacks, limit the child's in-between grazing for food, give opportunities to be active, and parent in such a way that the child feels safe. Given optimum parenting, children can be allowed to grow up to get the body that is right for them. If they are fat, so be it.
Some parents need ongoing support or psychotherapy to get to the point where they can act in the best interest of the child. Others demonstrate that they are incapable, even with help. Only when the family is truly incapable of providing for the child can removal from the home be legitimately considered.

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