Letters from Maine

Bicycles have been woven into my life since I first straddled a hand-me-down with a fan belt drive when I was 3. At age 12 my friend Ricky and I took a 250 mile–plus 2-night adventure on our 3-speed “English” style bikes. We still marvel that our parents let us do it when neither cell phones nor GPS existed.

I have always bike commuted to work, including the years when that involved a perilous navigation into Boston from the suburbs. In our mid-50s my wife and I biked from Washington state back here to Maine with another couple unsupported. We continue to do at least one self-guided cycle tour out of the country each year.

Not surprisingly, I keep a close eye on what’s happening in the bicycle market. For decades the trends have shifted back and forth between sleek road models and beefier off-roaders. There have been boom years here and there for the dealers and manufacturers, but nothing like what the bike industry is experiencing now with the arrival of e-bikes on the market. Driven primarily by electrification, micromobility ridership (which includes conventional bikes and scooters) has grown more than 50-fold over the last 10 years. Projections suggest the market’s value will be $300 billion by 2030.

It doesn’t take an MBA with a major in marketing to understand the broad appeal of electrification. Most adults have ridden a bicycle as children, but several decades of gap years has left many of them with a level of fitness that makes pedaling against the wind or up any incline difficult and unappealing. An e-bike can put even the least fitness conscious back in the saddle and open the options for outdoor recreation they haven’t dreamed of since childhood.

In large part the people flocking to e-bikes are retiree’s who thought they were “over the hill.” They are having so much fun they don’t care if the Lycra-clad “serious” cyclists notice the battery bulge in the frame on their e-bikes. Another group of e-bike adopters are motivated by the “greenness” of a fossil-fuel–free electric powered transportation which, with minimal compromise, can be used as they would a car around town and for longer commutes than they would have considered on a purely pedal-powered bicycle.

Unfortunately, there is a growing group of younger e-bike riders who are motivated and uninhibited by the potential that the power boost of a small electric motor can provide. And here is where the ugliness begins to intrude on what was otherwise a beautiful and expanding landscape. With the increase in e-bike popularity, there has been an understandable increase in injuries in all age groups. However, it is the young who are, not surprisingly, drawn to the speed, and with any vehicle – motorized or conventional – as speed increases so does the frequency and seriousness of accidents.

The term e-bike covers a broad range of vehicles, from those designated class 1, which require pedaling and are limited to 20 miles per hour, to class 3, which may have a throttle and unmodified can hit 28 mph. Class 2 bikes have a throttle that will allow the rider to reach 20 mph without pedaling. Modifying any class of e-bike can substantially increase its speed, but this is more common in classes 2 and 3. As an example, some very fast micromobiles are considered unclassified e-bikes and avoid being labeled motorcycles simply because they have pedals.

One has to give some credit to the e-bike industry for eventually adopting this classification system. But, we must give the rest of us, including parents and public safety officials, a failing grade for doing a poor job of translating these scores into enforceable regulations to protect both riders and pedestrians from serious injury.

On the governmental side only a little more than half of US states have used the three category classification to craft their regulations. Many jurisdictions have failed to differentiate between streets, sidewalks, and trails. Regulations vary from state to state, and many states leave it up to local communities. From my experience chairing our town’s Bicycle and Pedestrian Advisory Committee, I can tell you that even “progressive” communities are struggling to decide who can ride what where. The result has been that people of all ages, but mostly adolescents, are traveling on busy streets and sidewalks at speeds that put themselves and pedestrians at risk.

On the parental side of the problem are families that have either allowed or enabled their children to ride class 2 and 3 e-bikes without proper safety equipment or consideration for the safety of the rest of the community. Currently, this is not much of a problem here in Maine thanks to the weather and the high price of e-bikes. However, I frequently visit an affluent community in the San Francisco Bay Area, where it is not uncommon to see middle school children speeding along well in excess of 20 mph.

Unfortunately this is another example, like television and cell phone, in which our society has been unable to keep up with technology by molding the behavior of our children and/or creating enforceable rules that allow us to reap the benefits of new discoveries while minimizing the collateral damage that can accompany them.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Bicycles have been woven into my life since I first straddled a hand-me-down with a fan belt drive when I was 3. At age 12 my friend Ricky and I took a 250 mile–plus 2-night adventure on our 3-speed “English” style bikes. We still marvel that our parents let us do it when neither cell phones nor GPS existed.

I have always bike commuted to work, including the years when that involved a perilous navigation into Boston from the suburbs. In our mid-50s my wife and I biked from Washington state back here to Maine with another couple unsupported. We continue to do at least one self-guided cycle tour out of the country each year.

Not surprisingly, I keep a close eye on what’s happening in the bicycle market. For decades the trends have shifted back and forth between sleek road models and beefier off-roaders. There have been boom years here and there for the dealers and manufacturers, but nothing like what the bike industry is experiencing now with the arrival of e-bikes on the market. Driven primarily by electrification, micromobility ridership (which includes conventional bikes and scooters) has grown more than 50-fold over the last 10 years. Projections suggest the market’s value will be $300 billion by 2030.

It doesn’t take an MBA with a major in marketing to understand the broad appeal of electrification. Most adults have ridden a bicycle as children, but several decades of gap years has left many of them with a level of fitness that makes pedaling against the wind or up any incline difficult and unappealing. An e-bike can put even the least fitness conscious back in the saddle and open the options for outdoor recreation they haven’t dreamed of since childhood.

In large part the people flocking to e-bikes are retiree’s who thought they were “over the hill.” They are having so much fun they don’t care if the Lycra-clad “serious” cyclists notice the battery bulge in the frame on their e-bikes. Another group of e-bike adopters are motivated by the “greenness” of a fossil-fuel–free electric powered transportation which, with minimal compromise, can be used as they would a car around town and for longer commutes than they would have considered on a purely pedal-powered bicycle.

Unfortunately, there is a growing group of younger e-bike riders who are motivated and uninhibited by the potential that the power boost of a small electric motor can provide. And here is where the ugliness begins to intrude on what was otherwise a beautiful and expanding landscape. With the increase in e-bike popularity, there has been an understandable increase in injuries in all age groups. However, it is the young who are, not surprisingly, drawn to the speed, and with any vehicle – motorized or conventional – as speed increases so does the frequency and seriousness of accidents.

The term e-bike covers a broad range of vehicles, from those designated class 1, which require pedaling and are limited to 20 miles per hour, to class 3, which may have a throttle and unmodified can hit 28 mph. Class 2 bikes have a throttle that will allow the rider to reach 20 mph without pedaling. Modifying any class of e-bike can substantially increase its speed, but this is more common in classes 2 and 3. As an example, some very fast micromobiles are considered unclassified e-bikes and avoid being labeled motorcycles simply because they have pedals.

One has to give some credit to the e-bike industry for eventually adopting this classification system. But, we must give the rest of us, including parents and public safety officials, a failing grade for doing a poor job of translating these scores into enforceable regulations to protect both riders and pedestrians from serious injury.

On the governmental side only a little more than half of US states have used the three category classification to craft their regulations. Many jurisdictions have failed to differentiate between streets, sidewalks, and trails. Regulations vary from state to state, and many states leave it up to local communities. From my experience chairing our town’s Bicycle and Pedestrian Advisory Committee, I can tell you that even “progressive” communities are struggling to decide who can ride what where. The result has been that people of all ages, but mostly adolescents, are traveling on busy streets and sidewalks at speeds that put themselves and pedestrians at risk.

On the parental side of the problem are families that have either allowed or enabled their children to ride class 2 and 3 e-bikes without proper safety equipment or consideration for the safety of the rest of the community. Currently, this is not much of a problem here in Maine thanks to the weather and the high price of e-bikes. However, I frequently visit an affluent community in the San Francisco Bay Area, where it is not uncommon to see middle school children speeding along well in excess of 20 mph.

Unfortunately this is another example, like television and cell phone, in which our society has been unable to keep up with technology by molding the behavior of our children and/or creating enforceable rules that allow us to reap the benefits of new discoveries while minimizing the collateral damage that can accompany them.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Bicycles have been woven into my life since I first straddled a hand-me-down with a fan belt drive when I was 3. At age 12 my friend Ricky and I took a 250 mile–plus 2-night adventure on our 3-speed “English” style bikes. We still marvel that our parents let us do it when neither cell phones nor GPS existed.

I have always bike commuted to work, including the years when that involved a perilous navigation into Boston from the suburbs. In our mid-50s my wife and I biked from Washington state back here to Maine with another couple unsupported. We continue to do at least one self-guided cycle tour out of the country each year.

Not surprisingly, I keep a close eye on what’s happening in the bicycle market. For decades the trends have shifted back and forth between sleek road models and beefier off-roaders. There have been boom years here and there for the dealers and manufacturers, but nothing like what the bike industry is experiencing now with the arrival of e-bikes on the market. Driven primarily by electrification, micromobility ridership (which includes conventional bikes and scooters) has grown more than 50-fold over the last 10 years. Projections suggest the market’s value will be $300 billion by 2030.

It doesn’t take an MBA with a major in marketing to understand the broad appeal of electrification. Most adults have ridden a bicycle as children, but several decades of gap years has left many of them with a level of fitness that makes pedaling against the wind or up any incline difficult and unappealing. An e-bike can put even the least fitness conscious back in the saddle and open the options for outdoor recreation they haven’t dreamed of since childhood.

In large part the people flocking to e-bikes are retiree’s who thought they were “over the hill.” They are having so much fun they don’t care if the Lycra-clad “serious” cyclists notice the battery bulge in the frame on their e-bikes. Another group of e-bike adopters are motivated by the “greenness” of a fossil-fuel–free electric powered transportation which, with minimal compromise, can be used as they would a car around town and for longer commutes than they would have considered on a purely pedal-powered bicycle.

Unfortunately, there is a growing group of younger e-bike riders who are motivated and uninhibited by the potential that the power boost of a small electric motor can provide. And here is where the ugliness begins to intrude on what was otherwise a beautiful and expanding landscape. With the increase in e-bike popularity, there has been an understandable increase in injuries in all age groups. However, it is the young who are, not surprisingly, drawn to the speed, and with any vehicle – motorized or conventional – as speed increases so does the frequency and seriousness of accidents.

The term e-bike covers a broad range of vehicles, from those designated class 1, which require pedaling and are limited to 20 miles per hour, to class 3, which may have a throttle and unmodified can hit 28 mph. Class 2 bikes have a throttle that will allow the rider to reach 20 mph without pedaling. Modifying any class of e-bike can substantially increase its speed, but this is more common in classes 2 and 3. As an example, some very fast micromobiles are considered unclassified e-bikes and avoid being labeled motorcycles simply because they have pedals.

One has to give some credit to the e-bike industry for eventually adopting this classification system. But, we must give the rest of us, including parents and public safety officials, a failing grade for doing a poor job of translating these scores into enforceable regulations to protect both riders and pedestrians from serious injury.

On the governmental side only a little more than half of US states have used the three category classification to craft their regulations. Many jurisdictions have failed to differentiate between streets, sidewalks, and trails. Regulations vary from state to state, and many states leave it up to local communities. From my experience chairing our town’s Bicycle and Pedestrian Advisory Committee, I can tell you that even “progressive” communities are struggling to decide who can ride what where. The result has been that people of all ages, but mostly adolescents, are traveling on busy streets and sidewalks at speeds that put themselves and pedestrians at risk.

On the parental side of the problem are families that have either allowed or enabled their children to ride class 2 and 3 e-bikes without proper safety equipment or consideration for the safety of the rest of the community. Currently, this is not much of a problem here in Maine thanks to the weather and the high price of e-bikes. However, I frequently visit an affluent community in the San Francisco Bay Area, where it is not uncommon to see middle school children speeding along well in excess of 20 mph.

Unfortunately this is another example, like television and cell phone, in which our society has been unable to keep up with technology by molding the behavior of our children and/or creating enforceable rules that allow us to reap the benefits of new discoveries while minimizing the collateral damage that can accompany them.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Many, many years ago there was a Thanksgiving when as I was just beginning to earn a reputation in my wife’s family. There were no place cards on the table and the usual hovering and jockeying seats was well underway. From behind me I heard one of my young nieces pipe up: “I want to sit next to Doctor I-don’t-know.”

After a few words of negotiation we were all settled in our places and ready to enjoy our meal. It took only a few seconds of introspection for me to grasp how I had received that moniker, which some physicians might consider disrespectful.

I was the only physician within several generations of that family and, as such, my in-laws thought it only appropriate to ask me medical questions. They courteously seemed to avoid personal questions about their own health and were particularly careful not to roll up their sleeves or unbutton their shirts to show me a lesion or a recently acquired surgical scar. No, my wife’s family members were curious. They wanted answers to deeper questions, the hard science so to speak. “How does aspirin work?” was a typical and painful example. Maybe pharmacologists today have better answers but 40 years ago I’m not so sure; I certainly didn’t know back then and would reply, “I don’t know.” Probably for the third or fourth time that day.

Usually I genuinely didn’t know the answer. However, sometimes my answer was going to be so different from the beliefs and biases of my inquisitor that, in the interest of expediency, “I don’t know” seemed the most appropriate response.

If you were reading Letters from Maine 25 years ago, that scenario might sound familiar. I have chosen to pull it out of the archives as a jumping-off point for a consideration of the unfortunate example some of us set when the COVID pandemic threw a tsunami of unknowns at us. Too many physician-“experts” were afraid to say, “I don’t know.” Instead, and maybe because, they themselves were afraid that the patients couldn’t handle the truth that none of us in the profession knew the correct answers. When so many initial pronouncements proved incorrect, it was too late to undo the damage that had been done to the community’s trust in the rest of us.

It turns out that my in-laws were not the only folks who thought of me as Doctor I-don’t-know. One of the perks of remaining in the same community after one retires is that encounters with former patients and their parents happen frequently. On more than one occasion a parent has thanked me for admitting my ignorance. Some have even claimed that my candid approach was what they remembered most fondly. And, that quality increased their trust when I finally provided an answer.

There is an art to delivering “I don’t know.” Thirty years ago I would excuse myself and tell the family I was going to my office to pull a book off the shelf or call a previous mentor. Now one only needs to ask Dr. Google. No need to leave the room. If appropriate, the provider can swing the computer screen so that the patient can share in the search for the answer.

That strategy only works when the provider merely needs to update or expand his/her knowledge. However, there are those difficult situations when no one could know the answer given the current parameters of the patient’s situation. More lab work might be needed. It may be too early in the trajectory of the patient’s illness for the illnesses signs and symptoms to declare themselves.

In these situations “I don’t know” must be followed by a “but.” It is what comes after that “but” and how it is delivered that can convert the provider’s admission of ignorance into a demonstration of his or her character. Is he/she a caring person trying to understand the patient’s concerns? Willing to enter into a cooperative relationship as together they search for the cause and hopefully for a cure for the patient’s currently mysterious illness?

I recently read about a physician who is encouraging medical educators to incorporate more discussions of “humility” and its role in patient care into the medical school and postgraduate training curricula. He feels, as do I, that if more physicians learned to say “I don’t know” early in their careers, the quality of care we are delivering as a profession will improve, as will the trust bestowed by our patients.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Many, many years ago there was a Thanksgiving when as I was just beginning to earn a reputation in my wife’s family. There were no place cards on the table and the usual hovering and jockeying seats was well underway. From behind me I heard one of my young nieces pipe up: “I want to sit next to Doctor I-don’t-know.”

After a few words of negotiation we were all settled in our places and ready to enjoy our meal. It took only a few seconds of introspection for me to grasp how I had received that moniker, which some physicians might consider disrespectful.

I was the only physician within several generations of that family and, as such, my in-laws thought it only appropriate to ask me medical questions. They courteously seemed to avoid personal questions about their own health and were particularly careful not to roll up their sleeves or unbutton their shirts to show me a lesion or a recently acquired surgical scar. No, my wife’s family members were curious. They wanted answers to deeper questions, the hard science so to speak. “How does aspirin work?” was a typical and painful example. Maybe pharmacologists today have better answers but 40 years ago I’m not so sure; I certainly didn’t know back then and would reply, “I don’t know.” Probably for the third or fourth time that day.

Usually I genuinely didn’t know the answer. However, sometimes my answer was going to be so different from the beliefs and biases of my inquisitor that, in the interest of expediency, “I don’t know” seemed the most appropriate response.

If you were reading Letters from Maine 25 years ago, that scenario might sound familiar. I have chosen to pull it out of the archives as a jumping-off point for a consideration of the unfortunate example some of us set when the COVID pandemic threw a tsunami of unknowns at us. Too many physician-“experts” were afraid to say, “I don’t know.” Instead, and maybe because, they themselves were afraid that the patients couldn’t handle the truth that none of us in the profession knew the correct answers. When so many initial pronouncements proved incorrect, it was too late to undo the damage that had been done to the community’s trust in the rest of us.

It turns out that my in-laws were not the only folks who thought of me as Doctor I-don’t-know. One of the perks of remaining in the same community after one retires is that encounters with former patients and their parents happen frequently. On more than one occasion a parent has thanked me for admitting my ignorance. Some have even claimed that my candid approach was what they remembered most fondly. And, that quality increased their trust when I finally provided an answer.

There is an art to delivering “I don’t know.” Thirty years ago I would excuse myself and tell the family I was going to my office to pull a book off the shelf or call a previous mentor. Now one only needs to ask Dr. Google. No need to leave the room. If appropriate, the provider can swing the computer screen so that the patient can share in the search for the answer.

That strategy only works when the provider merely needs to update or expand his/her knowledge. However, there are those difficult situations when no one could know the answer given the current parameters of the patient’s situation. More lab work might be needed. It may be too early in the trajectory of the patient’s illness for the illnesses signs and symptoms to declare themselves.

In these situations “I don’t know” must be followed by a “but.” It is what comes after that “but” and how it is delivered that can convert the provider’s admission of ignorance into a demonstration of his or her character. Is he/she a caring person trying to understand the patient’s concerns? Willing to enter into a cooperative relationship as together they search for the cause and hopefully for a cure for the patient’s currently mysterious illness?

I recently read about a physician who is encouraging medical educators to incorporate more discussions of “humility” and its role in patient care into the medical school and postgraduate training curricula. He feels, as do I, that if more physicians learned to say “I don’t know” early in their careers, the quality of care we are delivering as a profession will improve, as will the trust bestowed by our patients.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Many, many years ago there was a Thanksgiving when as I was just beginning to earn a reputation in my wife’s family. There were no place cards on the table and the usual hovering and jockeying seats was well underway. From behind me I heard one of my young nieces pipe up: “I want to sit next to Doctor I-don’t-know.”

After a few words of negotiation we were all settled in our places and ready to enjoy our meal. It took only a few seconds of introspection for me to grasp how I had received that moniker, which some physicians might consider disrespectful.

I was the only physician within several generations of that family and, as such, my in-laws thought it only appropriate to ask me medical questions. They courteously seemed to avoid personal questions about their own health and were particularly careful not to roll up their sleeves or unbutton their shirts to show me a lesion or a recently acquired surgical scar. No, my wife’s family members were curious. They wanted answers to deeper questions, the hard science so to speak. “How does aspirin work?” was a typical and painful example. Maybe pharmacologists today have better answers but 40 years ago I’m not so sure; I certainly didn’t know back then and would reply, “I don’t know.” Probably for the third or fourth time that day.

Usually I genuinely didn’t know the answer. However, sometimes my answer was going to be so different from the beliefs and biases of my inquisitor that, in the interest of expediency, “I don’t know” seemed the most appropriate response.

If you were reading Letters from Maine 25 years ago, that scenario might sound familiar. I have chosen to pull it out of the archives as a jumping-off point for a consideration of the unfortunate example some of us set when the COVID pandemic threw a tsunami of unknowns at us. Too many physician-“experts” were afraid to say, “I don’t know.” Instead, and maybe because, they themselves were afraid that the patients couldn’t handle the truth that none of us in the profession knew the correct answers. When so many initial pronouncements proved incorrect, it was too late to undo the damage that had been done to the community’s trust in the rest of us.

It turns out that my in-laws were not the only folks who thought of me as Doctor I-don’t-know. One of the perks of remaining in the same community after one retires is that encounters with former patients and their parents happen frequently. On more than one occasion a parent has thanked me for admitting my ignorance. Some have even claimed that my candid approach was what they remembered most fondly. And, that quality increased their trust when I finally provided an answer.

There is an art to delivering “I don’t know.” Thirty years ago I would excuse myself and tell the family I was going to my office to pull a book off the shelf or call a previous mentor. Now one only needs to ask Dr. Google. No need to leave the room. If appropriate, the provider can swing the computer screen so that the patient can share in the search for the answer.

That strategy only works when the provider merely needs to update or expand his/her knowledge. However, there are those difficult situations when no one could know the answer given the current parameters of the patient’s situation. More lab work might be needed. It may be too early in the trajectory of the patient’s illness for the illnesses signs and symptoms to declare themselves.

In these situations “I don’t know” must be followed by a “but.” It is what comes after that “but” and how it is delivered that can convert the provider’s admission of ignorance into a demonstration of his or her character. Is he/she a caring person trying to understand the patient’s concerns? Willing to enter into a cooperative relationship as together they search for the cause and hopefully for a cure for the patient’s currently mysterious illness?

I recently read about a physician who is encouraging medical educators to incorporate more discussions of “humility” and its role in patient care into the medical school and postgraduate training curricula. He feels, as do I, that if more physicians learned to say “I don’t know” early in their careers, the quality of care we are delivering as a profession will improve, as will the trust bestowed by our patients.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

While there may be some lactation consultants who disagree, in my experience counseling women attempting to breastfeed is more art than science. Well before the American Academy of Pediatrics (AAP) began to offer mini courses on breastfeeding for practitioners I was left to help new mothers based on watching my wife nurse our three children and what scraps of common sense I could sweep up off the floor.

Using my own benchmarks of success I would say I did a decent job with dyads who sought my help. I began by accepting that even under optimal conditions, not every woman and/or child can successfully breastfeed. None of the infants died or was hospitalized with dehydration. A few may have required some additional phototherapy, but they all completed infancy in good shape. On the maternal side I am sure there were a few mothers who had lingering feelings of inadequacy because they had “failed” at breastfeeding. But, for the most part, I think I succeeded in helping new mothers remain as mentally healthy as they could be given the rigors of motherhood. At least I gave it my best shot.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

While there may be some lactation consultants who disagree, in my experience counseling women attempting to breastfeed is more art than science. Well before the American Academy of Pediatrics (AAP) began to offer mini courses on breastfeeding for practitioners I was left to help new mothers based on watching my wife nurse our three children and what scraps of common sense I could sweep up off the floor.

Using my own benchmarks of success I would say I did a decent job with dyads who sought my help. I began by accepting that even under optimal conditions, not every woman and/or child can successfully breastfeed. None of the infants died or was hospitalized with dehydration. A few may have required some additional phototherapy, but they all completed infancy in good shape. On the maternal side I am sure there were a few mothers who had lingering feelings of inadequacy because they had “failed” at breastfeeding. But, for the most part, I think I succeeded in helping new mothers remain as mentally healthy as they could be given the rigors of motherhood. At least I gave it my best shot.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

While there may be some lactation consultants who disagree, in my experience counseling women attempting to breastfeed is more art than science. Well before the American Academy of Pediatrics (AAP) began to offer mini courses on breastfeeding for practitioners I was left to help new mothers based on watching my wife nurse our three children and what scraps of common sense I could sweep up off the floor.

Using my own benchmarks of success I would say I did a decent job with dyads who sought my help. I began by accepting that even under optimal conditions, not every woman and/or child can successfully breastfeed. None of the infants died or was hospitalized with dehydration. A few may have required some additional phototherapy, but they all completed infancy in good shape. On the maternal side I am sure there were a few mothers who had lingering feelings of inadequacy because they had “failed” at breastfeeding. But, for the most part, I think I succeeded in helping new mothers remain as mentally healthy as they could be given the rigors of motherhood. At least I gave it my best shot.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

A recent survey by the Pew Research Center has found that among adults younger than 50, the percentage who say they are unlikely to have children rose from 37% to 47%. With this trend freshly etched in my consciousness, I stumbled across an interview with Anastasia Berg, an assistant professor of philosophy at the University of California, Irvine. Professor Berg and Rachel Wiseman have just published What Are Children For? On Ambivalence and Choice. How could a pediatrician with time on his hands ignore a provocative title like that?

I was immediately drawn to Professor Berg’s observations about the “concerns, anxieties, and lines of reasoning people encounter when considering whether or not they should have children.” Prior to the 1960s, motherhood seemed to just be a natural progression from marriage. That’s the way my wife and I approached it when we had our first child while I was in my last year of medical school in 1971. There was no discussion of the pros and cons, except maybe that financially waiting until the eve of my first professional paycheck seemed to make sense.

However, as Professor Berg points out, from the 1960s up until well into the 1980s, as feminist thought gained a higher profile, there were anti-motherhood factions. There were others who wanted to see motherhood reformed and adapted so it “could once again be a legitimate source of meaning and value in life.” However, both camps agreed that the choice to have children was a decision that “women should make completely on their own.”

Now, well into the new millennium, we are looking at a completely different landscape. In the past, having children was woven into the fabric of human life in which we had a past, a present, and a role in creating the future. Professor Berg observes that currently, having children is often considered a project, not unlike our other projects such as “career choice or travel plans.” What are the pluses and minuses?

The Pew Survey found that 60% of adults younger than 50 who don’t have children said that not having children made it less difficult to be successful and have an active social life. Many felt that being a parent would improve the chances of having someone to care for you as you aged.

When my wife and I considered the financial costs of motherhood more than 50 years ago, our calculation was primarily about the timing. The decision to have a second child focused our concern around our ability to balance our attention between two siblings. A third child just sorta happened without any discussion.

Professor Berg echoes the Pew findings when she observes that currently woman are considering the cost in terms of their identities. Will motherhood transform me? Will there be a cost not only to my career but also to all the associations, interests, and activities I have accumulated? These costs are likely to be greater the longer the decision to have a child is put off. She adds that viewing motherhood as a transformation can make the decision to have children scarier than it needs to be. My wife and I, at age 26 and 27, were still in the early stages of building our identities. My wife had a 2-year college degree and no career plans on the horizon. Having a child was one of those things that was built into who we became.

But to compare our experiences in the 1970s to the realities of the first quarter of the 21st century ignores the concerns facing today’s adults who are facing the cloud of uncertainty hanging over all of us. Despite their claims to fix the situation, both sides of the political spectrum are leveraging fear to gain our support. Even climate change skeptics must have some concern in the spate of natural disasters we are experiencing. Not to mention the pandemic. Anxiety in this country is at an all time high. Optimism doesn’t seem to fit into today’s journalists’ lexicon, as they chose to focus on conflict instead of cooperation. It’s hard to question any adult who harbors serious doubts on taking on the challenge of parenthood and bringing a child into a world that feels unsettled.

However, based on her research and her own experience as a parent, Professor Berg offers some advice. She encourages people to think and discuss the decision to have children earlier in their life trajectory, before they have made decisions that may eventually limit their options. Second, she discourages making a list of pros and cons. Finally, she advises taking a long view and ask yourself whether you “choose to take a direct part in ushering in the next generation.”

Sounds like advice that will optimize the chances of making the good decision about having a child. I’m just thankful to have lived at time and in a situation when having child was just the thing most married couples did.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

A recent survey by the Pew Research Center has found that among adults younger than 50, the percentage who say they are unlikely to have children rose from 37% to 47%. With this trend freshly etched in my consciousness, I stumbled across an interview with Anastasia Berg, an assistant professor of philosophy at the University of California, Irvine. Professor Berg and Rachel Wiseman have just published What Are Children For? On Ambivalence and Choice. How could a pediatrician with time on his hands ignore a provocative title like that?

I was immediately drawn to Professor Berg’s observations about the “concerns, anxieties, and lines of reasoning people encounter when considering whether or not they should have children.” Prior to the 1960s, motherhood seemed to just be a natural progression from marriage. That’s the way my wife and I approached it when we had our first child while I was in my last year of medical school in 1971. There was no discussion of the pros and cons, except maybe that financially waiting until the eve of my first professional paycheck seemed to make sense.

However, as Professor Berg points out, from the 1960s up until well into the 1980s, as feminist thought gained a higher profile, there were anti-motherhood factions. There were others who wanted to see motherhood reformed and adapted so it “could once again be a legitimate source of meaning and value in life.” However, both camps agreed that the choice to have children was a decision that “women should make completely on their own.”

Now, well into the new millennium, we are looking at a completely different landscape. In the past, having children was woven into the fabric of human life in which we had a past, a present, and a role in creating the future. Professor Berg observes that currently, having children is often considered a project, not unlike our other projects such as “career choice or travel plans.” What are the pluses and minuses?

The Pew Survey found that 60% of adults younger than 50 who don’t have children said that not having children made it less difficult to be successful and have an active social life. Many felt that being a parent would improve the chances of having someone to care for you as you aged.

When my wife and I considered the financial costs of motherhood more than 50 years ago, our calculation was primarily about the timing. The decision to have a second child focused our concern around our ability to balance our attention between two siblings. A third child just sorta happened without any discussion.

Professor Berg echoes the Pew findings when she observes that currently woman are considering the cost in terms of their identities. Will motherhood transform me? Will there be a cost not only to my career but also to all the associations, interests, and activities I have accumulated? These costs are likely to be greater the longer the decision to have a child is put off. She adds that viewing motherhood as a transformation can make the decision to have children scarier than it needs to be. My wife and I, at age 26 and 27, were still in the early stages of building our identities. My wife had a 2-year college degree and no career plans on the horizon. Having a child was one of those things that was built into who we became.

But to compare our experiences in the 1970s to the realities of the first quarter of the 21st century ignores the concerns facing today’s adults who are facing the cloud of uncertainty hanging over all of us. Despite their claims to fix the situation, both sides of the political spectrum are leveraging fear to gain our support. Even climate change skeptics must have some concern in the spate of natural disasters we are experiencing. Not to mention the pandemic. Anxiety in this country is at an all time high. Optimism doesn’t seem to fit into today’s journalists’ lexicon, as they chose to focus on conflict instead of cooperation. It’s hard to question any adult who harbors serious doubts on taking on the challenge of parenthood and bringing a child into a world that feels unsettled.

However, based on her research and her own experience as a parent, Professor Berg offers some advice. She encourages people to think and discuss the decision to have children earlier in their life trajectory, before they have made decisions that may eventually limit their options. Second, she discourages making a list of pros and cons. Finally, she advises taking a long view and ask yourself whether you “choose to take a direct part in ushering in the next generation.”

Sounds like advice that will optimize the chances of making the good decision about having a child. I’m just thankful to have lived at time and in a situation when having child was just the thing most married couples did.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

A recent survey by the Pew Research Center has found that among adults younger than 50, the percentage who say they are unlikely to have children rose from 37% to 47%. With this trend freshly etched in my consciousness, I stumbled across an interview with Anastasia Berg, an assistant professor of philosophy at the University of California, Irvine. Professor Berg and Rachel Wiseman have just published What Are Children For? On Ambivalence and Choice. How could a pediatrician with time on his hands ignore a provocative title like that?

I was immediately drawn to Professor Berg’s observations about the “concerns, anxieties, and lines of reasoning people encounter when considering whether or not they should have children.” Prior to the 1960s, motherhood seemed to just be a natural progression from marriage. That’s the way my wife and I approached it when we had our first child while I was in my last year of medical school in 1971. There was no discussion of the pros and cons, except maybe that financially waiting until the eve of my first professional paycheck seemed to make sense.

However, as Professor Berg points out, from the 1960s up until well into the 1980s, as feminist thought gained a higher profile, there were anti-motherhood factions. There were others who wanted to see motherhood reformed and adapted so it “could once again be a legitimate source of meaning and value in life.” However, both camps agreed that the choice to have children was a decision that “women should make completely on their own.”

Now, well into the new millennium, we are looking at a completely different landscape. In the past, having children was woven into the fabric of human life in which we had a past, a present, and a role in creating the future. Professor Berg observes that currently, having children is often considered a project, not unlike our other projects such as “career choice or travel plans.” What are the pluses and minuses?

The Pew Survey found that 60% of adults younger than 50 who don’t have children said that not having children made it less difficult to be successful and have an active social life. Many felt that being a parent would improve the chances of having someone to care for you as you aged.

When my wife and I considered the financial costs of motherhood more than 50 years ago, our calculation was primarily about the timing. The decision to have a second child focused our concern around our ability to balance our attention between two siblings. A third child just sorta happened without any discussion.

Professor Berg echoes the Pew findings when she observes that currently woman are considering the cost in terms of their identities. Will motherhood transform me? Will there be a cost not only to my career but also to all the associations, interests, and activities I have accumulated? These costs are likely to be greater the longer the decision to have a child is put off. She adds that viewing motherhood as a transformation can make the decision to have children scarier than it needs to be. My wife and I, at age 26 and 27, were still in the early stages of building our identities. My wife had a 2-year college degree and no career plans on the horizon. Having a child was one of those things that was built into who we became.

But to compare our experiences in the 1970s to the realities of the first quarter of the 21st century ignores the concerns facing today’s adults who are facing the cloud of uncertainty hanging over all of us. Despite their claims to fix the situation, both sides of the political spectrum are leveraging fear to gain our support. Even climate change skeptics must have some concern in the spate of natural disasters we are experiencing. Not to mention the pandemic. Anxiety in this country is at an all time high. Optimism doesn’t seem to fit into today’s journalists’ lexicon, as they chose to focus on conflict instead of cooperation. It’s hard to question any adult who harbors serious doubts on taking on the challenge of parenthood and bringing a child into a world that feels unsettled.

However, based on her research and her own experience as a parent, Professor Berg offers some advice. She encourages people to think and discuss the decision to have children earlier in their life trajectory, before they have made decisions that may eventually limit their options. Second, she discourages making a list of pros and cons. Finally, she advises taking a long view and ask yourself whether you “choose to take a direct part in ushering in the next generation.”

Sounds like advice that will optimize the chances of making the good decision about having a child. I’m just thankful to have lived at time and in a situation when having child was just the thing most married couples did.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

As more and more of us begin to feel (or believe we are feeling) the symptoms of aging, our language has begun to incorporate new words and phrases such as “aging in place” or “healthy aging.” In fact, some scientists have created a diagnostic criteria to define “healthy aging.” If you have reached your 70th birthday without mental health issues, memory issues, physical impairments, or chronic disease, according to some researchers at T.H. Chan School of Public Health and Brigham and Women’s Hospital, you should receive a gold star for healthy aging.

I am now nearly a decade past that milestone and can’t remember where I’ve put my gold star, or even if I had ever received one. But, I get up each morning looking forward to another day of activity and feeling “pretty good.”

Healthy aging is not something you start doing when you turn 65. Aging is something that goes on from the moment you are born. For the first couple decades we call it “maturing.” If you have lived well, the odds are you will age well. And, for that reason we should take note of some recent work by Boston-based researchers.

Looking at recent data from 45,000 participants in the well-known Nurses Health Study, the investigators found that for every 2-hour increase in daily sedentary behavior, the participants cut their chances of healthy aging by 12%. On the other hand, for every 2 hours of light physical activity, they increased their odds of healthy aging by 6 %.

There are two important messages sitting just below the surface of these two observations. First, we continue to overemphasize the importance of “exercise” in our attempt to help our patients achieve wellness. The word “exercise” carries with it whole carousel full of baggage including “fitness programs,” gym memberships, pulse rate monitors, pain, sweat, and spandex, to name just a few. Exercise can conjure up bad memories of suiting up for phys ed class, group showers, and being picked last when teams were being chosen.

It turns out the we should simply be promoting activity, and light activity at that — vacuuming the living room, walking around the block, rearranging the books on your bedroom book shelf, making a pot of soup, doing the laundry. Just getting up off one’s behind and doing something instead of being a passive spectator.

This somewhat counterintuitive notion of the benefit of light activity is beginning to get more attention. Earlier this year, I reported on a study by Andre O. Abaje MD, MPH, in which he showed that light physical activity in children was superior to more vigorous activity in lowering lipids.

The more important message embedded in this paper based on the Nurses Health Study is that the researchers used television watching time as their proxy for sedentary behavior. The investigators chose TV viewing because it is ubiquitous and includes prolonged sitting. Being semi-reclined on the couch or in a lounger requires very little muscle activity, which is in turn linked to disruption of glucose metabolism, increased inflammation, and altered blood flow to the brain, to name just a few of its collateral damages. I would add that TV viewing often prompts viewers to stay up well beyond their healthy bedtime. And, we know sleep deprivation is not compatible with health aging.

A traditional warning issued to new retirees was once “Don’t let the old rocking chair get ya.” In fact, I wonder how many folks watching television even have or use wood rocking chairs anymore, which, if rocked, might qualify as a light exercise if the viewer made the effort to rock. Instead I suspect most television viewing is done cocooned in soft recliners or curled up on a couch.

I will admit that this recent paper merely supports a suspicion I have harbored for decades. Like many of you, I have wondered how our society got to the point where obesity is frequent enough to be labeled a disease, attention deficit diagnoses are becoming increasingly prevalent, and our life expectancy is shrinking. There are dozens of factors, but if I had to pick one, I would paraphrase James Carville’s advice to Bill Clinton: “It’s the television, stupid.”

Television viewing needs to be near the top of our list when we’re doing a wellness evaluation ... at any age. At least a couple of notches above “Are you wearing your seatbelt?” It can start with a nonjudgmental question such as “What are your favorite television shows?” And then deftly move toward compiling a tally of how many hours the patient watches each day.

How you manage the situation from there is up to you and can be based on the patient’s complaints and problem list. You might suggest he or she start by eliminating 2 hours of viewing a day. Then ask if he or she thinks that new schedule is achievable. If they ask for alternatives, be ready with a list of light activities that they might be surprised are healthier than their current behavior. Follow up with another visit or a call to see how they are doing. It’s that important, and your call will underscore your concern.

Sedentism is a serious health problem in this country and our emphasis on encouraging vigorous exercise isn’t working. Selling a television diet will be a tough sell, but it needs to be done.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

As more and more of us begin to feel (or believe we are feeling) the symptoms of aging, our language has begun to incorporate new words and phrases such as “aging in place” or “healthy aging.” In fact, some scientists have created a diagnostic criteria to define “healthy aging.” If you have reached your 70th birthday without mental health issues, memory issues, physical impairments, or chronic disease, according to some researchers at T.H. Chan School of Public Health and Brigham and Women’s Hospital, you should receive a gold star for healthy aging.

I am now nearly a decade past that milestone and can’t remember where I’ve put my gold star, or even if I had ever received one. But, I get up each morning looking forward to another day of activity and feeling “pretty good.”

Healthy aging is not something you start doing when you turn 65. Aging is something that goes on from the moment you are born. For the first couple decades we call it “maturing.” If you have lived well, the odds are you will age well. And, for that reason we should take note of some recent work by Boston-based researchers.

Looking at recent data from 45,000 participants in the well-known Nurses Health Study, the investigators found that for every 2-hour increase in daily sedentary behavior, the participants cut their chances of healthy aging by 12%. On the other hand, for every 2 hours of light physical activity, they increased their odds of healthy aging by 6 %.

There are two important messages sitting just below the surface of these two observations. First, we continue to overemphasize the importance of “exercise” in our attempt to help our patients achieve wellness. The word “exercise” carries with it whole carousel full of baggage including “fitness programs,” gym memberships, pulse rate monitors, pain, sweat, and spandex, to name just a few. Exercise can conjure up bad memories of suiting up for phys ed class, group showers, and being picked last when teams were being chosen.

It turns out the we should simply be promoting activity, and light activity at that — vacuuming the living room, walking around the block, rearranging the books on your bedroom book shelf, making a pot of soup, doing the laundry. Just getting up off one’s behind and doing something instead of being a passive spectator.

This somewhat counterintuitive notion of the benefit of light activity is beginning to get more attention. Earlier this year, I reported on a study by Andre O. Abaje MD, MPH, in which he showed that light physical activity in children was superior to more vigorous activity in lowering lipids.

The more important message embedded in this paper based on the Nurses Health Study is that the researchers used television watching time as their proxy for sedentary behavior. The investigators chose TV viewing because it is ubiquitous and includes prolonged sitting. Being semi-reclined on the couch or in a lounger requires very little muscle activity, which is in turn linked to disruption of glucose metabolism, increased inflammation, and altered blood flow to the brain, to name just a few of its collateral damages. I would add that TV viewing often prompts viewers to stay up well beyond their healthy bedtime. And, we know sleep deprivation is not compatible with health aging.

A traditional warning issued to new retirees was once “Don’t let the old rocking chair get ya.” In fact, I wonder how many folks watching television even have or use wood rocking chairs anymore, which, if rocked, might qualify as a light exercise if the viewer made the effort to rock. Instead I suspect most television viewing is done cocooned in soft recliners or curled up on a couch.

I will admit that this recent paper merely supports a suspicion I have harbored for decades. Like many of you, I have wondered how our society got to the point where obesity is frequent enough to be labeled a disease, attention deficit diagnoses are becoming increasingly prevalent, and our life expectancy is shrinking. There are dozens of factors, but if I had to pick one, I would paraphrase James Carville’s advice to Bill Clinton: “It’s the television, stupid.”

Television viewing needs to be near the top of our list when we’re doing a wellness evaluation ... at any age. At least a couple of notches above “Are you wearing your seatbelt?” It can start with a nonjudgmental question such as “What are your favorite television shows?” And then deftly move toward compiling a tally of how many hours the patient watches each day.

How you manage the situation from there is up to you and can be based on the patient’s complaints and problem list. You might suggest he or she start by eliminating 2 hours of viewing a day. Then ask if he or she thinks that new schedule is achievable. If they ask for alternatives, be ready with a list of light activities that they might be surprised are healthier than their current behavior. Follow up with another visit or a call to see how they are doing. It’s that important, and your call will underscore your concern.

Sedentism is a serious health problem in this country and our emphasis on encouraging vigorous exercise isn’t working. Selling a television diet will be a tough sell, but it needs to be done.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

As more and more of us begin to feel (or believe we are feeling) the symptoms of aging, our language has begun to incorporate new words and phrases such as “aging in place” or “healthy aging.” In fact, some scientists have created a diagnostic criteria to define “healthy aging.” If you have reached your 70th birthday without mental health issues, memory issues, physical impairments, or chronic disease, according to some researchers at T.H. Chan School of Public Health and Brigham and Women’s Hospital, you should receive a gold star for healthy aging.

I am now nearly a decade past that milestone and can’t remember where I’ve put my gold star, or even if I had ever received one. But, I get up each morning looking forward to another day of activity and feeling “pretty good.”

Healthy aging is not something you start doing when you turn 65. Aging is something that goes on from the moment you are born. For the first couple decades we call it “maturing.” If you have lived well, the odds are you will age well. And, for that reason we should take note of some recent work by Boston-based researchers.

Looking at recent data from 45,000 participants in the well-known Nurses Health Study, the investigators found that for every 2-hour increase in daily sedentary behavior, the participants cut their chances of healthy aging by 12%. On the other hand, for every 2 hours of light physical activity, they increased their odds of healthy aging by 6 %.

There are two important messages sitting just below the surface of these two observations. First, we continue to overemphasize the importance of “exercise” in our attempt to help our patients achieve wellness. The word “exercise” carries with it whole carousel full of baggage including “fitness programs,” gym memberships, pulse rate monitors, pain, sweat, and spandex, to name just a few. Exercise can conjure up bad memories of suiting up for phys ed class, group showers, and being picked last when teams were being chosen.

It turns out the we should simply be promoting activity, and light activity at that — vacuuming the living room, walking around the block, rearranging the books on your bedroom book shelf, making a pot of soup, doing the laundry. Just getting up off one’s behind and doing something instead of being a passive spectator.

This somewhat counterintuitive notion of the benefit of light activity is beginning to get more attention. Earlier this year, I reported on a study by Andre O. Abaje MD, MPH, in which he showed that light physical activity in children was superior to more vigorous activity in lowering lipids.

The more important message embedded in this paper based on the Nurses Health Study is that the researchers used television watching time as their proxy for sedentary behavior. The investigators chose TV viewing because it is ubiquitous and includes prolonged sitting. Being semi-reclined on the couch or in a lounger requires very little muscle activity, which is in turn linked to disruption of glucose metabolism, increased inflammation, and altered blood flow to the brain, to name just a few of its collateral damages. I would add that TV viewing often prompts viewers to stay up well beyond their healthy bedtime. And, we know sleep deprivation is not compatible with health aging.

A traditional warning issued to new retirees was once “Don’t let the old rocking chair get ya.” In fact, I wonder how many folks watching television even have or use wood rocking chairs anymore, which, if rocked, might qualify as a light exercise if the viewer made the effort to rock. Instead I suspect most television viewing is done cocooned in soft recliners or curled up on a couch.

I will admit that this recent paper merely supports a suspicion I have harbored for decades. Like many of you, I have wondered how our society got to the point where obesity is frequent enough to be labeled a disease, attention deficit diagnoses are becoming increasingly prevalent, and our life expectancy is shrinking. There are dozens of factors, but if I had to pick one, I would paraphrase James Carville’s advice to Bill Clinton: “It’s the television, stupid.”

Television viewing needs to be near the top of our list when we’re doing a wellness evaluation ... at any age. At least a couple of notches above “Are you wearing your seatbelt?” It can start with a nonjudgmental question such as “What are your favorite television shows?” And then deftly move toward compiling a tally of how many hours the patient watches each day.

How you manage the situation from there is up to you and can be based on the patient’s complaints and problem list. You might suggest he or she start by eliminating 2 hours of viewing a day. Then ask if he or she thinks that new schedule is achievable. If they ask for alternatives, be ready with a list of light activities that they might be surprised are healthier than their current behavior. Follow up with another visit or a call to see how they are doing. It’s that important, and your call will underscore your concern.

Sedentism is a serious health problem in this country and our emphasis on encouraging vigorous exercise isn’t working. Selling a television diet will be a tough sell, but it needs to be done.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Over the last couple of decades, I have become increasingly more uncomfortable watching American-style football on television. Lax refereeing coupled with over-juiced players who can generate g-forces previously attainable only on a NASA rocket sled has resulted in a spate of injuries I find unacceptable. The revolving door of transfers from college to college has made the term scholar-athlete a relic that can be applied to only a handful of players at the smallest uncompetitive schools.

Many of you who are regular readers of Letters from Maine have probably tired of my boasting that when I played football in high school we wore leather helmets. I enjoyed playing football and continued playing in college for a couple of years until it became obvious that “bench” was going to be my usual position. But, I would not want my grandson to play college football. Certainly, not at the elite college level. Were he to do so, he would be putting himself at risk for significant injury by participating in what I no longer view as an appealing activity. Let me add that I am not including chronic traumatic encephalopathy among my concerns, because I think its association with football injuries is far from settled. My concern is more about spinal cord injuries, which, although infrequent, are almost always devastating.

I should also make it perfectly clear that my lack of enthusiasm for college and professional football does not place me among the increasingly vocal throng calling for the elimination of youth football. For the 5- to 12-year-olds, putting on pads and a helmet and scrambling around on a grassy field bumping shoulders and heads with their peers is a wonderful way to burn off energy and satisfies a need for roughhousing that comes naturally to most young boys (and many girls). The chance of anyone of those kids playing youth football reaching the elite college or professional level is extremely unlikely. Other activities and the realization that football is not in their future weeds the field during adolescence.

Although there have been some studies suggesting that starting football at an early age is associated with increased injury risk, a recent and well-controlled study published in the journal Sports Medicine has found no such association in professional football players. This finding makes some sense when you consider that most of the children in this age group are not mustering g-forces anywhere close to those a college or professional athlete can generate.

Another recent study published in the Journal of Pediatrics offers more evidence to consider before one passes judgment on youth football. When reviewing the records of nearly 1500 patients in a specialty-care concussion setting at the Children’s Hospital of Philadelphia, investigators found that recreation-related concussions and non–sport- or recreation-related concussions were more prevalent than sports-related concussions. The authors propose that “less supervision at the time of injury and less access to established concussion healthcare following injury” may explain their observations.

Of course as a card-carrying AARP old fogey, I long for the good old days when youth sports were organized by the kids in backyards and playgrounds. There we learned to pick teams and deal with the disappointment of not being a first-round pick and the embarrassment of being a last rounder. We settled out-of-bounds calls and arguments about ball possession without adults’ assistance — or video replays for that matter. But those days are gone and likely never to return, with parental anxiety running at record highs. We must accept youth sports organized for kids by adults is the way it’s going to be for the foreseeable future.

The football that we see on TV, with all its hoopla, ugliness, and mind-numbing advertisements, shouldn’t discourage us from allowing kids who want to knock heads and bump shoulders to enjoy the sport at a young age. As long as the program is organized with the emphasis on fun nor structured as a fast track to elite play it will be healthier for the kids than sitting on the couch at home watching the carnage on TV.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Over the last couple of decades, I have become increasingly more uncomfortable watching American-style football on television. Lax refereeing coupled with over-juiced players who can generate g-forces previously attainable only on a NASA rocket sled has resulted in a spate of injuries I find unacceptable. The revolving door of transfers from college to college has made the term scholar-athlete a relic that can be applied to only a handful of players at the smallest uncompetitive schools.

Many of you who are regular readers of Letters from Maine have probably tired of my boasting that when I played football in high school we wore leather helmets. I enjoyed playing football and continued playing in college for a couple of years until it became obvious that “bench” was going to be my usual position. But, I would not want my grandson to play college football. Certainly, not at the elite college level. Were he to do so, he would be putting himself at risk for significant injury by participating in what I no longer view as an appealing activity. Let me add that I am not including chronic traumatic encephalopathy among my concerns, because I think its association with football injuries is far from settled. My concern is more about spinal cord injuries, which, although infrequent, are almost always devastating.

I should also make it perfectly clear that my lack of enthusiasm for college and professional football does not place me among the increasingly vocal throng calling for the elimination of youth football. For the 5- to 12-year-olds, putting on pads and a helmet and scrambling around on a grassy field bumping shoulders and heads with their peers is a wonderful way to burn off energy and satisfies a need for roughhousing that comes naturally to most young boys (and many girls). The chance of anyone of those kids playing youth football reaching the elite college or professional level is extremely unlikely. Other activities and the realization that football is not in their future weeds the field during adolescence.

Although there have been some studies suggesting that starting football at an early age is associated with increased injury risk, a recent and well-controlled study published in the journal Sports Medicine has found no such association in professional football players. This finding makes some sense when you consider that most of the children in this age group are not mustering g-forces anywhere close to those a college or professional athlete can generate.

Another recent study published in the Journal of Pediatrics offers more evidence to consider before one passes judgment on youth football. When reviewing the records of nearly 1500 patients in a specialty-care concussion setting at the Children’s Hospital of Philadelphia, investigators found that recreation-related concussions and non–sport- or recreation-related concussions were more prevalent than sports-related concussions. The authors propose that “less supervision at the time of injury and less access to established concussion healthcare following injury” may explain their observations.

Of course as a card-carrying AARP old fogey, I long for the good old days when youth sports were organized by the kids in backyards and playgrounds. There we learned to pick teams and deal with the disappointment of not being a first-round pick and the embarrassment of being a last rounder. We settled out-of-bounds calls and arguments about ball possession without adults’ assistance — or video replays for that matter. But those days are gone and likely never to return, with parental anxiety running at record highs. We must accept youth sports organized for kids by adults is the way it’s going to be for the foreseeable future.

The football that we see on TV, with all its hoopla, ugliness, and mind-numbing advertisements, shouldn’t discourage us from allowing kids who want to knock heads and bump shoulders to enjoy the sport at a young age. As long as the program is organized with the emphasis on fun nor structured as a fast track to elite play it will be healthier for the kids than sitting on the couch at home watching the carnage on TV.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Over the last couple of decades, I have become increasingly more uncomfortable watching American-style football on television. Lax refereeing coupled with over-juiced players who can generate g-forces previously attainable only on a NASA rocket sled has resulted in a spate of injuries I find unacceptable. The revolving door of transfers from college to college has made the term scholar-athlete a relic that can be applied to only a handful of players at the smallest uncompetitive schools.

Many of you who are regular readers of Letters from Maine have probably tired of my boasting that when I played football in high school we wore leather helmets. I enjoyed playing football and continued playing in college for a couple of years until it became obvious that “bench” was going to be my usual position. But, I would not want my grandson to play college football. Certainly, not at the elite college level. Were he to do so, he would be putting himself at risk for significant injury by participating in what I no longer view as an appealing activity. Let me add that I am not including chronic traumatic encephalopathy among my concerns, because I think its association with football injuries is far from settled. My concern is more about spinal cord injuries, which, although infrequent, are almost always devastating.

I should also make it perfectly clear that my lack of enthusiasm for college and professional football does not place me among the increasingly vocal throng calling for the elimination of youth football. For the 5- to 12-year-olds, putting on pads and a helmet and scrambling around on a grassy field bumping shoulders and heads with their peers is a wonderful way to burn off energy and satisfies a need for roughhousing that comes naturally to most young boys (and many girls). The chance of anyone of those kids playing youth football reaching the elite college or professional level is extremely unlikely. Other activities and the realization that football is not in their future weeds the field during adolescence.

Although there have been some studies suggesting that starting football at an early age is associated with increased injury risk, a recent and well-controlled study published in the journal Sports Medicine has found no such association in professional football players. This finding makes some sense when you consider that most of the children in this age group are not mustering g-forces anywhere close to those a college or professional athlete can generate.

Another recent study published in the Journal of Pediatrics offers more evidence to consider before one passes judgment on youth football. When reviewing the records of nearly 1500 patients in a specialty-care concussion setting at the Children’s Hospital of Philadelphia, investigators found that recreation-related concussions and non–sport- or recreation-related concussions were more prevalent than sports-related concussions. The authors propose that “less supervision at the time of injury and less access to established concussion healthcare following injury” may explain their observations.

Of course as a card-carrying AARP old fogey, I long for the good old days when youth sports were organized by the kids in backyards and playgrounds. There we learned to pick teams and deal with the disappointment of not being a first-round pick and the embarrassment of being a last rounder. We settled out-of-bounds calls and arguments about ball possession without adults’ assistance — or video replays for that matter. But those days are gone and likely never to return, with parental anxiety running at record highs. We must accept youth sports organized for kids by adults is the way it’s going to be for the foreseeable future.

The football that we see on TV, with all its hoopla, ugliness, and mind-numbing advertisements, shouldn’t discourage us from allowing kids who want to knock heads and bump shoulders to enjoy the sport at a young age. As long as the program is organized with the emphasis on fun nor structured as a fast track to elite play it will be healthier for the kids than sitting on the couch at home watching the carnage on TV.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

I recently encountered a study that reviewed return visits of pediatric patients after undergoing adenotonsillectomy. The investigators discovered that pain-related visits were higher for patients who had received prescriptions for opioids. After the Food and Drug Administration (FDA) issued a boxed warning about the use of codeine in postoperative pediatric tonsillectomy with adenoidectomy (T&A), patients pain-related return visits declined and steroid prescriptions increased.

On the surface, this inverse relationship between opioid prescriptions and pain-related visits seems counterintuitive. This is particularly true if you believe that opioids are effective pain medications. The relationship between pain-related visits, steroid use, and the boxed warning is a bit easier to understand and most likely points to the effectiveness of the steroids.

Keeping in mind this was a single-institution study that included more than 5000 patients and more than 700 return visits, we should be careful in reading too much into these results. However, I can’t resist the temptation to use it as a springboard from which to launch a short dissertation on pain management.

First, let’s consider whether there was something about the opioids that was causing more pain for the patients. I’m not aware of any studies that suggest pain as a side effect of codeine. Nausea and vomiting, yes. And, although the investigators were focusing on pain, it may have been that the general discomfort associated with the gastrointestinal effects of the drug were lowering the patients’ pain threshold. I certainly know of many adults who have said that they now avoid opioids postoperatively because of the general sense of unwellness they have experienced during previous surgical adventures.

However, my bias leads me to focus on this question: If the patients didn’t receive opioids postoperatively, were they receiving something else that was making them less likely to arrive at the hospital or clinic complaining of pain? I assume the researchers would have told us about some new alternative miracle painkiller that was being prescribed.

As a card-carrying nihilist in good standing, I am tempted to claim that this is another example of nothing is better than most well-intentioned somethings. However, I am going to posit that these patients were receiving something that lessened their need to seek help with their pain.

Most likely that something was a thoughtful preemptive dialogue postoperatively about what they (and in most cases their parents) might expect in the way of symptoms. And ... an easy-to-reach contact point preferably with a person with whom they were familiar. And ... were scheduled to receive follow up phone calls at intervals relevant to the details of their surgery.

I know many of you are going to say, “We are already doing those things.” And, if so, you are to be commended. And, I’m sure that every outpatient postoperative manual includes all of those common-sense ingredients of good follow-up care. However, you know as well as I do that not all postoperative instructions are delivered with same degree of thoroughness nor with sufficient pauses thoughtfully delivered to make it a real dialogue. Nor is the follow-up contact person as easy to reach as promised.

I’m not sure how much we can thank the FDA boxed warning about codeine for the decrease in postoperative pain-generated visits. However, it could be that when physicians were discouraged from prescribing postoperative opioids, they may have felt the need to lean more heavily on good old-fashioned postoperative follow-up care. Instructions presented more as a dialogue and preemptive follow-up calls made with an aura of caring are well known deterrents of middle-of-the-night calls for help.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

I recently encountered a study that reviewed return visits of pediatric patients after undergoing adenotonsillectomy. The investigators discovered that pain-related visits were higher for patients who had received prescriptions for opioids. After the Food and Drug Administration (FDA) issued a boxed warning about the use of codeine in postoperative pediatric tonsillectomy with adenoidectomy (T&A), patients pain-related return visits declined and steroid prescriptions increased.

On the surface, this inverse relationship between opioid prescriptions and pain-related visits seems counterintuitive. This is particularly true if you believe that opioids are effective pain medications. The relationship between pain-related visits, steroid use, and the boxed warning is a bit easier to understand and most likely points to the effectiveness of the steroids.

Keeping in mind this was a single-institution study that included more than 5000 patients and more than 700 return visits, we should be careful in reading too much into these results. However, I can’t resist the temptation to use it as a springboard from which to launch a short dissertation on pain management.

First, let’s consider whether there was something about the opioids that was causing more pain for the patients. I’m not aware of any studies that suggest pain as a side effect of codeine. Nausea and vomiting, yes. And, although the investigators were focusing on pain, it may have been that the general discomfort associated with the gastrointestinal effects of the drug were lowering the patients’ pain threshold. I certainly know of many adults who have said that they now avoid opioids postoperatively because of the general sense of unwellness they have experienced during previous surgical adventures.

However, my bias leads me to focus on this question: If the patients didn’t receive opioids postoperatively, were they receiving something else that was making them less likely to arrive at the hospital or clinic complaining of pain? I assume the researchers would have told us about some new alternative miracle painkiller that was being prescribed.

As a card-carrying nihilist in good standing, I am tempted to claim that this is another example of nothing is better than most well-intentioned somethings. However, I am going to posit that these patients were receiving something that lessened their need to seek help with their pain.

Most likely that something was a thoughtful preemptive dialogue postoperatively about what they (and in most cases their parents) might expect in the way of symptoms. And ... an easy-to-reach contact point preferably with a person with whom they were familiar. And ... were scheduled to receive follow up phone calls at intervals relevant to the details of their surgery.

I know many of you are going to say, “We are already doing those things.” And, if so, you are to be commended. And, I’m sure that every outpatient postoperative manual includes all of those common-sense ingredients of good follow-up care. However, you know as well as I do that not all postoperative instructions are delivered with same degree of thoroughness nor with sufficient pauses thoughtfully delivered to make it a real dialogue. Nor is the follow-up contact person as easy to reach as promised.

I’m not sure how much we can thank the FDA boxed warning about codeine for the decrease in postoperative pain-generated visits. However, it could be that when physicians were discouraged from prescribing postoperative opioids, they may have felt the need to lean more heavily on good old-fashioned postoperative follow-up care. Instructions presented more as a dialogue and preemptive follow-up calls made with an aura of caring are well known deterrents of middle-of-the-night calls for help.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

I recently encountered a study that reviewed return visits of pediatric patients after undergoing adenotonsillectomy. The investigators discovered that pain-related visits were higher for patients who had received prescriptions for opioids. After the Food and Drug Administration (FDA) issued a boxed warning about the use of codeine in postoperative pediatric tonsillectomy with adenoidectomy (T&A), patients pain-related return visits declined and steroid prescriptions increased.

On the surface, this inverse relationship between opioid prescriptions and pain-related visits seems counterintuitive. This is particularly true if you believe that opioids are effective pain medications. The relationship between pain-related visits, steroid use, and the boxed warning is a bit easier to understand and most likely points to the effectiveness of the steroids.

Keeping in mind this was a single-institution study that included more than 5000 patients and more than 700 return visits, we should be careful in reading too much into these results. However, I can’t resist the temptation to use it as a springboard from which to launch a short dissertation on pain management.

First, let’s consider whether there was something about the opioids that was causing more pain for the patients. I’m not aware of any studies that suggest pain as a side effect of codeine. Nausea and vomiting, yes. And, although the investigators were focusing on pain, it may have been that the general discomfort associated with the gastrointestinal effects of the drug were lowering the patients’ pain threshold. I certainly know of many adults who have said that they now avoid opioids postoperatively because of the general sense of unwellness they have experienced during previous surgical adventures.

However, my bias leads me to focus on this question: If the patients didn’t receive opioids postoperatively, were they receiving something else that was making them less likely to arrive at the hospital or clinic complaining of pain? I assume the researchers would have told us about some new alternative miracle painkiller that was being prescribed.

As a card-carrying nihilist in good standing, I am tempted to claim that this is another example of nothing is better than most well-intentioned somethings. However, I am going to posit that these patients were receiving something that lessened their need to seek help with their pain.

Most likely that something was a thoughtful preemptive dialogue postoperatively about what they (and in most cases their parents) might expect in the way of symptoms. And ... an easy-to-reach contact point preferably with a person with whom they were familiar. And ... were scheduled to receive follow up phone calls at intervals relevant to the details of their surgery.

I know many of you are going to say, “We are already doing those things.” And, if so, you are to be commended. And, I’m sure that every outpatient postoperative manual includes all of those common-sense ingredients of good follow-up care. However, you know as well as I do that not all postoperative instructions are delivered with same degree of thoroughness nor with sufficient pauses thoughtfully delivered to make it a real dialogue. Nor is the follow-up contact person as easy to reach as promised.

I’m not sure how much we can thank the FDA boxed warning about codeine for the decrease in postoperative pain-generated visits. However, it could be that when physicians were discouraged from prescribing postoperative opioids, they may have felt the need to lean more heavily on good old-fashioned postoperative follow-up care. Instructions presented more as a dialogue and preemptive follow-up calls made with an aura of caring are well known deterrents of middle-of-the-night calls for help.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

I am not planning on having a headstone on my grave, or even having a grave for that matter. However, if my heirs decide to ignore my wishes and opt for some pithy observation chiseled into a tastefully sized granite block, I suspect they might choose “He always knew which way the wind was blowing ... but wasn’t so sure about the tides.” Which aptly describes both my navigational deficiencies they have observed here over my six decades on the Maine coast as well as my general inability to predict the future. Nonetheless, I am going to throw caution to the wind and take this opportunity to ponder where obesity in this country will go over the next couple of decades.

In March of last year the London-based World Obesity Federation published its World Obesity Atlas. In the summary the authors predict that based on current trends “obesity will cost the global economy of US $4 trillion of potential income in 2035, nearly 3% of current global domestic product (GDP).” They envision the “rising prevalence of obesity to be steepest among children and adolescents rising from 10% to 20% of the world’s boys during the period 2029 to 2035, and rising fro 8% to 18% of the world’s girls.”

These dire predictions assume no significant measures to reverse this trajectory such as universal health coverage. Nor do the authors attempt to predict the effect of the growing use of GLP-1 agonists. This omission is surprising and somewhat refreshing given the fact that the project was funded by an unrestricted grant from Novo Nordisk, a major producer of one of these drugs.

Unfortunately, I think it is unlikely that over the next couple of decades any large countries who do not already have a functioning universal health care system will find the political will to develop one capable of reversing the trend toward obesity. Certainly, I don’t see it in the cards for this country.

On the other hand, I can foresee the availability and ease of administration for GLP-1 agonists and similar drugs improving over the near term. However, the cost and availability will continue to widen the separation between the haves and the have-nots, both globally and within each country. This will mean that the countries and population subgroups that already experience the bulk of the economic and health consequences of obesity will continue to shoulder an outsized burden of this “disease.”

It is unclear how much this widening of the fat-getting-fatter dynamic will add to the global and national political unrest that already seems to be tracking the effects of climate change. However, I can’t imaging it is going to be a calming or uniting force.

Narrowing our focus from an international to an individual resource-rich country such as the United States, let’s consider what the significant growth in availability and affordability of GLP-1 agonist drugs will mean. There will certainly be short-term improvements in the morbidity and mortality of some of the obesity related diseases. However, for other conditions it may take longer than two decades for us to notice an effect. While it is tempting to consider these declines as a financial boon for the country that already spends a high percentage of its GDP on healthcare. However, as the well-known Saturday Night Live pundit Roseanne Roseannadanna often observed, ”it’s always something ... if it’s not one thing it’s another.” There may be other non-obesity conditions that surge to fill the gap, leaving us still with a substantial financial burden for healthcare.

Patients taking GLP-1 agonists lose weight because they feel full and eat less food. While currently the number of patients taking these drugs is relatively small, the effect on this country’s food consumption is too small to calculate. However, let’s assume that 20 years from now half of the obese patients are taking appetite blunting medication. Using today’s statistics this means that 50 million adults will be eating significantly less food. Will the agriculturists have gradually adjusted to produce less food? Will this mean there is more food for the those experiencing “food insecurity”? I doubt it. Most food insecurity seems to be a problem of distribution and inequality, not supply.

Physicians now caution patients taking GLP-1 agonists to eat a healthy and balanced diet. When the drugs are more commonly available, will this caution be heeded by the majority? Will we see a population that may no longer be obese but nonetheless malnourished because of bad choices?

And, finally, in a similar vein, will previously obese individuals suddenly or gradually begin to be more physically active once the appetite blunting medicines have helped them lose weight? Here, I have my doubts. Of course, some leaner individuals begin to take advantage of their new body morphology. But, I fear that old sedentary habits will die very slowly for most, and not at all for many. We have built a vehicle-centric society in which being physically active requires making a conscious effort. Electronic devices and sedentary entertainment options are not going to disappear just because a significant percentage of the population is no longer obese.

So there you have it. I suspect that I am correct about which way some of the winds are blowing as the obesity becomes moves into its treatable “disease” phase. But, as always, I haven’t a clue which way the tide is running.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

I am not planning on having a headstone on my grave, or even having a grave for that matter. However, if my heirs decide to ignore my wishes and opt for some pithy observation chiseled into a tastefully sized granite block, I suspect they might choose “He always knew which way the wind was blowing ... but wasn’t so sure about the tides.” Which aptly describes both my navigational deficiencies they have observed here over my six decades on the Maine coast as well as my general inability to predict the future. Nonetheless, I am going to throw caution to the wind and take this opportunity to ponder where obesity in this country will go over the next couple of decades.

In March of last year the London-based World Obesity Federation published its World Obesity Atlas. In the summary the authors predict that based on current trends “obesity will cost the global economy of US $4 trillion of potential income in 2035, nearly 3% of current global domestic product (GDP).” They envision the “rising prevalence of obesity to be steepest among children and adolescents rising from 10% to 20% of the world’s boys during the period 2029 to 2035, and rising fro 8% to 18% of the world’s girls.”

These dire predictions assume no significant measures to reverse this trajectory such as universal health coverage. Nor do the authors attempt to predict the effect of the growing use of GLP-1 agonists. This omission is surprising and somewhat refreshing given the fact that the project was funded by an unrestricted grant from Novo Nordisk, a major producer of one of these drugs.

Unfortunately, I think it is unlikely that over the next couple of decades any large countries who do not already have a functioning universal health care system will find the political will to develop one capable of reversing the trend toward obesity. Certainly, I don’t see it in the cards for this country.

On the other hand, I can foresee the availability and ease of administration for GLP-1 agonists and similar drugs improving over the near term. However, the cost and availability will continue to widen the separation between the haves and the have-nots, both globally and within each country. This will mean that the countries and population subgroups that already experience the bulk of the economic and health consequences of obesity will continue to shoulder an outsized burden of this “disease.”

It is unclear how much this widening of the fat-getting-fatter dynamic will add to the global and national political unrest that already seems to be tracking the effects of climate change. However, I can’t imaging it is going to be a calming or uniting force.

Narrowing our focus from an international to an individual resource-rich country such as the United States, let’s consider what the significant growth in availability and affordability of GLP-1 agonist drugs will mean. There will certainly be short-term improvements in the morbidity and mortality of some of the obesity related diseases. However, for other conditions it may take longer than two decades for us to notice an effect. While it is tempting to consider these declines as a financial boon for the country that already spends a high percentage of its GDP on healthcare. However, as the well-known Saturday Night Live pundit Roseanne Roseannadanna often observed, ”it’s always something ... if it’s not one thing it’s another.” There may be other non-obesity conditions that surge to fill the gap, leaving us still with a substantial financial burden for healthcare.

Patients taking GLP-1 agonists lose weight because they feel full and eat less food. While currently the number of patients taking these drugs is relatively small, the effect on this country’s food consumption is too small to calculate. However, let’s assume that 20 years from now half of the obese patients are taking appetite blunting medication. Using today’s statistics this means that 50 million adults will be eating significantly less food. Will the agriculturists have gradually adjusted to produce less food? Will this mean there is more food for the those experiencing “food insecurity”? I doubt it. Most food insecurity seems to be a problem of distribution and inequality, not supply.

Physicians now caution patients taking GLP-1 agonists to eat a healthy and balanced diet. When the drugs are more commonly available, will this caution be heeded by the majority? Will we see a population that may no longer be obese but nonetheless malnourished because of bad choices?

And, finally, in a similar vein, will previously obese individuals suddenly or gradually begin to be more physically active once the appetite blunting medicines have helped them lose weight? Here, I have my doubts. Of course, some leaner individuals begin to take advantage of their new body morphology. But, I fear that old sedentary habits will die very slowly for most, and not at all for many. We have built a vehicle-centric society in which being physically active requires making a conscious effort. Electronic devices and sedentary entertainment options are not going to disappear just because a significant percentage of the population is no longer obese.

So there you have it. I suspect that I am correct about which way some of the winds are blowing as the obesity becomes moves into its treatable “disease” phase. But, as always, I haven’t a clue which way the tide is running.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

I am not planning on having a headstone on my grave, or even having a grave for that matter. However, if my heirs decide to ignore my wishes and opt for some pithy observation chiseled into a tastefully sized granite block, I suspect they might choose “He always knew which way the wind was blowing ... but wasn’t so sure about the tides.” Which aptly describes both my navigational deficiencies they have observed here over my six decades on the Maine coast as well as my general inability to predict the future. Nonetheless, I am going to throw caution to the wind and take this opportunity to ponder where obesity in this country will go over the next couple of decades.

In March of last year the London-based World Obesity Federation published its World Obesity Atlas. In the summary the authors predict that based on current trends “obesity will cost the global economy of US $4 trillion of potential income in 2035, nearly 3% of current global domestic product (GDP).” They envision the “rising prevalence of obesity to be steepest among children and adolescents rising from 10% to 20% of the world’s boys during the period 2029 to 2035, and rising fro 8% to 18% of the world’s girls.”

These dire predictions assume no significant measures to reverse this trajectory such as universal health coverage. Nor do the authors attempt to predict the effect of the growing use of GLP-1 agonists. This omission is surprising and somewhat refreshing given the fact that the project was funded by an unrestricted grant from Novo Nordisk, a major producer of one of these drugs.

Unfortunately, I think it is unlikely that over the next couple of decades any large countries who do not already have a functioning universal health care system will find the political will to develop one capable of reversing the trend toward obesity. Certainly, I don’t see it in the cards for this country.

On the other hand, I can foresee the availability and ease of administration for GLP-1 agonists and similar drugs improving over the near term. However, the cost and availability will continue to widen the separation between the haves and the have-nots, both globally and within each country. This will mean that the countries and population subgroups that already experience the bulk of the economic and health consequences of obesity will continue to shoulder an outsized burden of this “disease.”

It is unclear how much this widening of the fat-getting-fatter dynamic will add to the global and national political unrest that already seems to be tracking the effects of climate change. However, I can’t imaging it is going to be a calming or uniting force.

Narrowing our focus from an international to an individual resource-rich country such as the United States, let’s consider what the significant growth in availability and affordability of GLP-1 agonist drugs will mean. There will certainly be short-term improvements in the morbidity and mortality of some of the obesity related diseases. However, for other conditions it may take longer than two decades for us to notice an effect. While it is tempting to consider these declines as a financial boon for the country that already spends a high percentage of its GDP on healthcare. However, as the well-known Saturday Night Live pundit Roseanne Roseannadanna often observed, ”it’s always something ... if it’s not one thing it’s another.” There may be other non-obesity conditions that surge to fill the gap, leaving us still with a substantial financial burden for healthcare.

Patients taking GLP-1 agonists lose weight because they feel full and eat less food. While currently the number of patients taking these drugs is relatively small, the effect on this country’s food consumption is too small to calculate. However, let’s assume that 20 years from now half of the obese patients are taking appetite blunting medication. Using today’s statistics this means that 50 million adults will be eating significantly less food. Will the agriculturists have gradually adjusted to produce less food? Will this mean there is more food for the those experiencing “food insecurity”? I doubt it. Most food insecurity seems to be a problem of distribution and inequality, not supply.

Physicians now caution patients taking GLP-1 agonists to eat a healthy and balanced diet. When the drugs are more commonly available, will this caution be heeded by the majority? Will we see a population that may no longer be obese but nonetheless malnourished because of bad choices?

And, finally, in a similar vein, will previously obese individuals suddenly or gradually begin to be more physically active once the appetite blunting medicines have helped them lose weight? Here, I have my doubts. Of course, some leaner individuals begin to take advantage of their new body morphology. But, I fear that old sedentary habits will die very slowly for most, and not at all for many. We have built a vehicle-centric society in which being physically active requires making a conscious effort. Electronic devices and sedentary entertainment options are not going to disappear just because a significant percentage of the population is no longer obese.

So there you have it. I suspect that I am correct about which way some of the winds are blowing as the obesity becomes moves into its treatable “disease” phase. But, as always, I haven’t a clue which way the tide is running.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

A story in a recent edition of this newspaper reported on a disturbing, but not surprising, study by a third-year pediatric resident at the University of California, Davis, School of Medicine. Looking at just the Preparticipaton Physical Evaluations (PPEs) she could find at her institution, Tammy Ng, MD, found that only slightly more than a quarter “addressed all the criteria” on the American Academy of Pediatrics (AAP) standardized form. Although more than half included inquiries about respiratory symptoms, less than half contained questions about a cardiovascular history. The lack of consistency across all the forms reviewed was the most dramatic finding.

Having participated in more than my share of PPEs as a school physician, a primary care pediatrician, and a multi-sport high school and college athlete, I was not surprised by Dr. Ng’s findings. In high school my teammates and I considered our trip to see Old Doctor Hinds (not his real name) in the second week of August “a joke.” A few of us with “white coat” hypertension, like myself, had to be settled down and have our blood pressure retaken. But other than that wrinkle, we all passed. The football coach had his own eyeball screening tool and wouldn’t allow kids he thought were too small to play football.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

A story in a recent edition of this newspaper reported on a disturbing, but not surprising, study by a third-year pediatric resident at the University of California, Davis, School of Medicine. Looking at just the Preparticipaton Physical Evaluations (PPEs) she could find at her institution, Tammy Ng, MD, found that only slightly more than a quarter “addressed all the criteria” on the American Academy of Pediatrics (AAP) standardized form. Although more than half included inquiries about respiratory symptoms, less than half contained questions about a cardiovascular history. The lack of consistency across all the forms reviewed was the most dramatic finding.

Having participated in more than my share of PPEs as a school physician, a primary care pediatrician, and a multi-sport high school and college athlete, I was not surprised by Dr. Ng’s findings. In high school my teammates and I considered our trip to see Old Doctor Hinds (not his real name) in the second week of August “a joke.” A few of us with “white coat” hypertension, like myself, had to be settled down and have our blood pressure retaken. But other than that wrinkle, we all passed. The football coach had his own eyeball screening tool and wouldn’t allow kids he thought were too small to play football.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

A story in a recent edition of this newspaper reported on a disturbing, but not surprising, study by a third-year pediatric resident at the University of California, Davis, School of Medicine. Looking at just the Preparticipaton Physical Evaluations (PPEs) she could find at her institution, Tammy Ng, MD, found that only slightly more than a quarter “addressed all the criteria” on the American Academy of Pediatrics (AAP) standardized form. Although more than half included inquiries about respiratory symptoms, less than half contained questions about a cardiovascular history. The lack of consistency across all the forms reviewed was the most dramatic finding.

Having participated in more than my share of PPEs as a school physician, a primary care pediatrician, and a multi-sport high school and college athlete, I was not surprised by Dr. Ng’s findings. In high school my teammates and I considered our trip to see Old Doctor Hinds (not his real name) in the second week of August “a joke.” A few of us with “white coat” hypertension, like myself, had to be settled down and have our blood pressure retaken. But other than that wrinkle, we all passed. The football coach had his own eyeball screening tool and wouldn’t allow kids he thought were too small to play football.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Among the more unheralded examples of collateral damage of the COVID epidemic is chronic absenteeism. A recent NPR/Ipsos poll found that parents ranked chronic absenteeism last in a list of 12 school-related concerns. Only 5% listed it first.

This is surprising and concerning, given that prior to the pandemic the rate of chronic absenteeism nationwide was 15%, but during the 2021-22 school year this doubled to 30% and it has not declined. In fact, in some states the chronic absenteeism rate is 40%. In 2020 8 million students were chronically absent. This number is now over 14 million. Chronic absenteeism is a metric defined as a student absent for 15 days or more, which comes out to around 10% of the school year. Chronic absenteeism has been used as a predictor of the student dropout rate.

The initial contribution of the pandemic is easily explained, as parents were understandably concerned about sending their children into an environment that might cause disease, or at least bring the disease home to a more vulnerable family member. The reasons behind the trend’s persistence are a bit more complicated.

Family schedules initially disrupted by the pandemic have settled back into a pattern that may make it more difficult for a child to get to school. Day care and work schedules may have changed, but not yet readjusted to sync with the school schedule.

In the simplest terms, children and their families may have simply fallen out of the habit of going to school. For children (and maybe their parents) who had always struggled with an unresolved separation anxiety, the time at home — or at least not in school — came as a relief. Which, in turn, meant that any gains in dealing with the anxiety have been undone. The child who was already struggling academically or socially found being at home much less challenging. It’s not surprising that he/she might resist climbing back in the academic saddle.

It is very likely that a significant contributor to the persistent trend in chronic absenteeism is what social scientists call “norm erosion.” Not just children, but families may have developed an attitude that time spent in school just isn’t as valuable as they once believed, or were at least told that it was. There seems to be more parents questioning what their children are being taught in school. The home schooling movement existed before the pandemic. Its roots may be growing under the surface in the form of general skepticism about the importance of school in the bigger scheme of things. The home schooling movement was ready to blossom when the COVID pandemic triggered school closures. We hoped and dreamed that remote learning would be just as good as in-person school. We now realize that, in most cases, that was wishful thinking.

It feels as though a “Perfect Attendance Record” may have lost the cachet it once had. During the pandemic anyone claiming to have never missed a day at school lost that gold star. Did opening your computer every day to watch a remote learning session count for anything?

The threshold for allowing a child to stay home from school may be reaching a historic low. Families seem to regard the school schedule as a guideline that can easily be ignored when planning a vacation. Take little brother out of school to attend big brother’s lacrosse playoff game, not to worry if the youngster misses school days for a trip.

Who is responsible for reversing the trend? Teachers already know it is a serious problem. They view attendance as important. Maybe educators could make school more appealing. But to whom? Sounds like this message should be targeted at the parents. Would stiff penalties for parents whose children are chronically absent help? Would demanding a note from a physician after a certain number of absences help? It might. But, are pediatricians and educators ready to take on one more task in which parents have dropped the ball?

An unknown percentage of chronically absent children are missing school because of a previously unrecognized or inadequately treated mental health condition or learning disability. Involving physicians in a community’s response to chronic absenteeism may be the first step in getting a child back on track. If socioeconomic factors are contributing to a child’s truancy, the involvement of social service agencies may be the answer.

I have a friend who is often asked to address graduating classes at both the high school and college level. One of his standard pieces of advice, whether it be about school or a workplace you may not be in love with, is to at least “show up.” The family that treats school attendance as optional is likely to produce adults who take a similarly nonchalant attitude toward their employment opportunities — with unfortunate results.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Among the more unheralded examples of collateral damage of the COVID epidemic is chronic absenteeism. A recent NPR/Ipsos poll found that parents ranked chronic absenteeism last in a list of 12 school-related concerns. Only 5% listed it first.

This is surprising and concerning, given that prior to the pandemic the rate of chronic absenteeism nationwide was 15%, but during the 2021-22 school year this doubled to 30% and it has not declined. In fact, in some states the chronic absenteeism rate is 40%. In 2020 8 million students were chronically absent. This number is now over 14 million. Chronic absenteeism is a metric defined as a student absent for 15 days or more, which comes out to around 10% of the school year. Chronic absenteeism has been used as a predictor of the student dropout rate.

The initial contribution of the pandemic is easily explained, as parents were understandably concerned about sending their children into an environment that might cause disease, or at least bring the disease home to a more vulnerable family member. The reasons behind the trend’s persistence are a bit more complicated.

Family schedules initially disrupted by the pandemic have settled back into a pattern that may make it more difficult for a child to get to school. Day care and work schedules may have changed, but not yet readjusted to sync with the school schedule.

In the simplest terms, children and their families may have simply fallen out of the habit of going to school. For children (and maybe their parents) who had always struggled with an unresolved separation anxiety, the time at home — or at least not in school — came as a relief. Which, in turn, meant that any gains in dealing with the anxiety have been undone. The child who was already struggling academically or socially found being at home much less challenging. It’s not surprising that he/she might resist climbing back in the academic saddle.

It is very likely that a significant contributor to the persistent trend in chronic absenteeism is what social scientists call “norm erosion.” Not just children, but families may have developed an attitude that time spent in school just isn’t as valuable as they once believed, or were at least told that it was. There seems to be more parents questioning what their children are being taught in school. The home schooling movement existed before the pandemic. Its roots may be growing under the surface in the form of general skepticism about the importance of school in the bigger scheme of things. The home schooling movement was ready to blossom when the COVID pandemic triggered school closures. We hoped and dreamed that remote learning would be just as good as in-person school. We now realize that, in most cases, that was wishful thinking.

It feels as though a “Perfect Attendance Record” may have lost the cachet it once had. During the pandemic anyone claiming to have never missed a day at school lost that gold star. Did opening your computer every day to watch a remote learning session count for anything?

The threshold for allowing a child to stay home from school may be reaching a historic low. Families seem to regard the school schedule as a guideline that can easily be ignored when planning a vacation. Take little brother out of school to attend big brother’s lacrosse playoff game, not to worry if the youngster misses school days for a trip.

Who is responsible for reversing the trend? Teachers already know it is a serious problem. They view attendance as important. Maybe educators could make school more appealing. But to whom? Sounds like this message should be targeted at the parents. Would stiff penalties for parents whose children are chronically absent help? Would demanding a note from a physician after a certain number of absences help? It might. But, are pediatricians and educators ready to take on one more task in which parents have dropped the ball?

An unknown percentage of chronically absent children are missing school because of a previously unrecognized or inadequately treated mental health condition or learning disability. Involving physicians in a community’s response to chronic absenteeism may be the first step in getting a child back on track. If socioeconomic factors are contributing to a child’s truancy, the involvement of social service agencies may be the answer.

I have a friend who is often asked to address graduating classes at both the high school and college level. One of his standard pieces of advice, whether it be about school or a workplace you may not be in love with, is to at least “show up.” The family that treats school attendance as optional is likely to produce adults who take a similarly nonchalant attitude toward their employment opportunities — with unfortunate results.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Among the more unheralded examples of collateral damage of the COVID epidemic is chronic absenteeism. A recent NPR/Ipsos poll found that parents ranked chronic absenteeism last in a list of 12 school-related concerns. Only 5% listed it first.

This is surprising and concerning, given that prior to the pandemic the rate of chronic absenteeism nationwide was 15%, but during the 2021-22 school year this doubled to 30% and it has not declined. In fact, in some states the chronic absenteeism rate is 40%. In 2020 8 million students were chronically absent. This number is now over 14 million. Chronic absenteeism is a metric defined as a student absent for 15 days or more, which comes out to around 10% of the school year. Chronic absenteeism has been used as a predictor of the student dropout rate.

The initial contribution of the pandemic is easily explained, as parents were understandably concerned about sending their children into an environment that might cause disease, or at least bring the disease home to a more vulnerable family member. The reasons behind the trend’s persistence are a bit more complicated.

Family schedules initially disrupted by the pandemic have settled back into a pattern that may make it more difficult for a child to get to school. Day care and work schedules may have changed, but not yet readjusted to sync with the school schedule.

In the simplest terms, children and their families may have simply fallen out of the habit of going to school. For children (and maybe their parents) who had always struggled with an unresolved separation anxiety, the time at home — or at least not in school — came as a relief. Which, in turn, meant that any gains in dealing with the anxiety have been undone. The child who was already struggling academically or socially found being at home much less challenging. It’s not surprising that he/she might resist climbing back in the academic saddle.

It is very likely that a significant contributor to the persistent trend in chronic absenteeism is what social scientists call “norm erosion.” Not just children, but families may have developed an attitude that time spent in school just isn’t as valuable as they once believed, or were at least told that it was. There seems to be more parents questioning what their children are being taught in school. The home schooling movement existed before the pandemic. Its roots may be growing under the surface in the form of general skepticism about the importance of school in the bigger scheme of things. The home schooling movement was ready to blossom when the COVID pandemic triggered school closures. We hoped and dreamed that remote learning would be just as good as in-person school. We now realize that, in most cases, that was wishful thinking.

It feels as though a “Perfect Attendance Record” may have lost the cachet it once had. During the pandemic anyone claiming to have never missed a day at school lost that gold star. Did opening your computer every day to watch a remote learning session count for anything?

The threshold for allowing a child to stay home from school may be reaching a historic low. Families seem to regard the school schedule as a guideline that can easily be ignored when planning a vacation. Take little brother out of school to attend big brother’s lacrosse playoff game, not to worry if the youngster misses school days for a trip.

Who is responsible for reversing the trend? Teachers already know it is a serious problem. They view attendance as important. Maybe educators could make school more appealing. But to whom? Sounds like this message should be targeted at the parents. Would stiff penalties for parents whose children are chronically absent help? Would demanding a note from a physician after a certain number of absences help? It might. But, are pediatricians and educators ready to take on one more task in which parents have dropped the ball?

An unknown percentage of chronically absent children are missing school because of a previously unrecognized or inadequately treated mental health condition or learning disability. Involving physicians in a community’s response to chronic absenteeism may be the first step in getting a child back on track. If socioeconomic factors are contributing to a child’s truancy, the involvement of social service agencies may be the answer.

I have a friend who is often asked to address graduating classes at both the high school and college level. One of his standard pieces of advice, whether it be about school or a workplace you may not be in love with, is to at least “show up.” The family that treats school attendance as optional is likely to produce adults who take a similarly nonchalant attitude toward their employment opportunities — with unfortunate results.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.