5 16
Editorial correspondence
This same problem may occur with other similarly named preparations such as Slo-Phyllin (80, GG, and 150) or Tedral (elixir and suspension). We also would like to remind practitioners that the use of a household teaspoon must be avoided with the concentrated preparations. As the teaspoon varies from 2.5 to 9.0 ml, the dose of theophyltine with Elixophyllin pediatric suspension may vary from 50 to 180 mg per household teaspoon. We strongly encourage the dispensing of an accurate measuring device with this product. In summary, we feel that Chipps, Talamo, and Teets were too mild in their summary. Products o f similar name must be avoided, and that the search for an "equivalent" less expensive preparation is extremely difficult with these preparations. Physicians must avoid the use of generic prescriptions with liquid xanthine preparations. We also feel that should a generic preparation be used, the pharmacist must be sure that more than chemical equivalence is assured. Use of generic preparations should be known by both physician and pharmacist. John F. Tourville, Pharm.D. Assistant Professor of Clinical Pharmacy West Virginia University Medical Center Charleston Division Charleston, W V Michael A. Finer, M.D. Children's Hospital of Buffalo Buffalo, N Y
REFERENCES 1.
Chipps BE, Talamo RC, and Teets KC: TheophyUine and the danger of differing absorption capabilities, J PBDrATR 91:346, 1977. 2. American Academic Pediatric Committee on Drugs: Adverse reactions to iodide therapy of asthma and other pulmonary diseases, Pediatrics 57:272, 1976. 3. Weinberger MM, Bronsky EA, et al: Interaction of ephedrine and theophylline, Clin Pharmacol Ther 17:585, 1975. 4. Weinberger MM, and Bronsky EA: Evaluation of oral bronchodilator therapy in asthmatic children, J PEDtATR 84:421, 1974. 5. Smith LJ, and Slavin RG: Drugs containing tartrazine dye, J Allergy Clin Immunol 58:456, 1976. 6. Mattar ME, Markello J, a n d Yaffe SJ: Inadequacies in the pharmacologic management of ambulatory children, J PEDIATR 87:137, 1975.
Controversies in childhood obesity To the Editor: Certain remarks by Dr. William Well, 1 in his otherwise excellent review on current controversies in childhood obesity, are difficult for me to understand. The first is his conclusion, "the forces derivative from social status, attitudes, and customs are probably the dominan~ones in the establishment of adiposity." Without underestimating the
The Journal of Pediatrics March 1978
importance o f both personal and social customs, attitudes, etc., I remain impressed by the fact that the bodies of fat children seem different through much of their growing up period in that the bone structure is heavier, the chests are thicker, the entire bodily structure looks different from that of slender people. I recognize Dr. Well is an expert and has reviewed the literature and I am a practicing physician and have not. Nonetheless I find it difficult to accept his statement as the dominant explanation of what I see with my eyes. All the experience that I know of with fat people indicates that they must watch their diet for life, whereas medium or slenderly built people do not. How does one account for this difference? The other comments which I do not understand are the twin statements that the typical male physician is moderately obese, and women physicians are likely to be thin and less tolerant of obesity than others. I wonder what is the basis for this statement?
Avrum L. Katcher, M.D. Director, Pediatric Services Hunterdon Medical Center Flemington, NJ 08822 REFERENCE 1. Well WB: Current controversies in childhood obesity, J PEDIATR 91:175, 1977.
Reply To the Editor: Dr. Katcher is correct in his impression that fat children tend to be different physically from the nonfat. Both the recent publication of Forbes I and the work by Cram and Clark ~ would support Dr. Katcher's view that obese children tend to be taller, have more bone mass, and, in addition, have higher hemoglobins and mature more rapidly at adolescence. As Forbes points out, if one is ingesting more calories than are necessary for maintenance, growth, and activity, there will be increased growth of not only body fati but if the diet is a reasonable one, of muscle mass, organ mass, and bone mass as well. This appears to be an expected phenomenon but does not detract from the proposition that "the forces derivative from social status, attitudes, and customs are probably the dominant ones in theestablishment of adiposity." Those forces that begin to determine what we are, what we do, how we behave, etc. act from the time we are born until we die. It is not surprising, therefore, that if for a given individual those forces combined with that individual's genetic constitution result in the ingestion of calories in excess of needs, that individual will become larger and obese and will tend to remain so as long as the external forces operating in the individual's own sphere are essentially unchanged. This may well explain why behavior modification techniques are at the moment the most effective therapeutic measure we have in the treatment of obesity. The next question that Dr. Katcher asks relates to why heavy people seem to have more difficulty controlling their weight on the basis of variation of food intake than do medium weight or slender people. There is no totally acceptable answer to this
Editorial correspondence
This same problem may occur with other similarly named preparations such as Slo-Phyllin (80, GG, and 150) or Tedral (elixir and suspension). We also would like to remind practitioners that the use of a household teaspoon must be avoided with the concentrated preparations. As the teaspoon varies from 2.5 to 9.0 ml, the dose of theophyltine with Elixophyllin pediatric suspension may vary from 50 to 180 mg per household teaspoon. We strongly encourage the dispensing of an accurate measuring device with this product. In summary, we feel that Chipps, Talamo, and Teets were too mild in their summary. Products o f similar name must be avoided, and that the search for an "equivalent" less expensive preparation is extremely difficult with these preparations. Physicians must avoid the use of generic prescriptions with liquid xanthine preparations. We also feel that should a generic preparation be used, the pharmacist must be sure that more than chemical equivalence is assured. Use of generic preparations should be known by both physician and pharmacist. John F. Tourville, Pharm.D. Assistant Professor of Clinical Pharmacy West Virginia University Medical Center Charleston Division Charleston, W V Michael A. Finer, M.D. Children's Hospital of Buffalo Buffalo, N Y
REFERENCES 1.
Chipps BE, Talamo RC, and Teets KC: TheophyUine and the danger of differing absorption capabilities, J PBDrATR 91:346, 1977. 2. American Academic Pediatric Committee on Drugs: Adverse reactions to iodide therapy of asthma and other pulmonary diseases, Pediatrics 57:272, 1976. 3. Weinberger MM, Bronsky EA, et al: Interaction of ephedrine and theophylline, Clin Pharmacol Ther 17:585, 1975. 4. Weinberger MM, and Bronsky EA: Evaluation of oral bronchodilator therapy in asthmatic children, J PEDtATR 84:421, 1974. 5. Smith LJ, and Slavin RG: Drugs containing tartrazine dye, J Allergy Clin Immunol 58:456, 1976. 6. Mattar ME, Markello J, a n d Yaffe SJ: Inadequacies in the pharmacologic management of ambulatory children, J PEDIATR 87:137, 1975.
Controversies in childhood obesity To the Editor: Certain remarks by Dr. William Well, 1 in his otherwise excellent review on current controversies in childhood obesity, are difficult for me to understand. The first is his conclusion, "the forces derivative from social status, attitudes, and customs are probably the dominan~ones in the establishment of adiposity." Without underestimating the
The Journal of Pediatrics March 1978
importance o f both personal and social customs, attitudes, etc., I remain impressed by the fact that the bodies of fat children seem different through much of their growing up period in that the bone structure is heavier, the chests are thicker, the entire bodily structure looks different from that of slender people. I recognize Dr. Well is an expert and has reviewed the literature and I am a practicing physician and have not. Nonetheless I find it difficult to accept his statement as the dominant explanation of what I see with my eyes. All the experience that I know of with fat people indicates that they must watch their diet for life, whereas medium or slenderly built people do not. How does one account for this difference? The other comments which I do not understand are the twin statements that the typical male physician is moderately obese, and women physicians are likely to be thin and less tolerant of obesity than others. I wonder what is the basis for this statement?
Avrum L. Katcher, M.D. Director, Pediatric Services Hunterdon Medical Center Flemington, NJ 08822 REFERENCE 1. Well WB: Current controversies in childhood obesity, J PEDIATR 91:175, 1977.
Reply To the Editor: Dr. Katcher is correct in his impression that fat children tend to be different physically from the nonfat. Both the recent publication of Forbes I and the work by Cram and Clark ~ would support Dr. Katcher's view that obese children tend to be taller, have more bone mass, and, in addition, have higher hemoglobins and mature more rapidly at adolescence. As Forbes points out, if one is ingesting more calories than are necessary for maintenance, growth, and activity, there will be increased growth of not only body fati but if the diet is a reasonable one, of muscle mass, organ mass, and bone mass as well. This appears to be an expected phenomenon but does not detract from the proposition that "the forces derivative from social status, attitudes, and customs are probably the dominant ones in theestablishment of adiposity." Those forces that begin to determine what we are, what we do, how we behave, etc. act from the time we are born until we die. It is not surprising, therefore, that if for a given individual those forces combined with that individual's genetic constitution result in the ingestion of calories in excess of needs, that individual will become larger and obese and will tend to remain so as long as the external forces operating in the individual's own sphere are essentially unchanged. This may well explain why behavior modification techniques are at the moment the most effective therapeutic measure we have in the treatment of obesity. The next question that Dr. Katcher asks relates to why heavy people seem to have more difficulty controlling their weight on the basis of variation of food intake than do medium weight or slender people. There is no totally acceptable answer to this
