Archive for June, 2008
In the last month, two major media sources (Washington Post and Time magazine) have devoted page upon page to the epidemic of childhood obesity.
There is no doubt in my mind that there are, indeed, more children who are much heavier today than there were when I was growing up, and that parents of obese children should have access to resources to help them help their child.
What I find disturbing is that the current level of alarm, hysteria and obsession with children’s growing waistlines hasn’t caused any to pause, step back, and examine the facts. Instead, it seems, the drum beats on to reduce calories, reduce fat, add mroe fruits and vegetables, lots of whole grains and increase activity.
The message is part of a perpetual campaign to convince our population that we must do it “for the children,” with an indictment against parents who are said to not see nor do anything about their fat children; that the community, doctors, schools, health organizations, the food industry and the government must lead these wayward parents to understand how to improve both diet and activity levels for their children.
We see and read about extreme cases of childhood obesity, extreme examples of poor eating habits, and extreme lifestyle habits; we’re reminded that is how it happens – too much food and not enough activity, the recipe for growing fat children in America today.
But excess accumulation of fat isn’t the only problem – we’re also hit with the sobering reality that, in addition to heavier children, our children are also growing sick sooner; we’re told of children with type II diabetes (once called “adult onset” diabetes since it was virtually unheard of in children or teens), dyslipidemia, PCOS, metabolic syndrome, precocious puberty, high blood pressure, heart disease and more. The statistics are frightening and we’re constantly reminded that today’s children will likely die earlier than their parents if we don’t do something!
The mind-numbing statistics, experts expressing grave concerns, fine examples of poor eating habits, and images of the most extreme cases of obesity in children all work to create a strong sense that we all must do something, that all of our children are at risk, that the future is at stake if we don’t do the right thing and do it now!
Is the hype really helping?
Are the solutions on the table going to work not only to prevent childhood obesity, but reverse it in those children whom are already obese?
Considering the solutions presented today is identical to the solutions offered throughout the past three decades, I can only conclude things will get worse not better; the longer it goes on, the stronger the pressure on parents will grow to ‘get with the program’ and follow the direction of the expert recommendations.
As parents, we have an obligation to protect our children, keep them safe, nurture them and do the best we can as we raise them.
My previous post provided an example of how the current guidelines to use BMI as the gold standard measure of overweight and obesity in children is problematic. The fact that a child can be a normal healthy weight in one month and then overweight or obese in another without any change in weight or height tells us the charts are inaccurate. The fact that the hypothetical child would have dropped from 59th to 52nd percentile for weight on the traditional chart, but went from normal to overweight on the BMI chart, speaks volumes about its deep flaws.
What’s telling is that almost all the comments left in the hypothetical ‘set-up’ of the situation post were the belief the child gained weight. That is understandable, given the repeated message we all hear that overeating and inactivity make you gain weight. If the child now had a BMI indicating she was overweight, she must have gained weight if her BMI just two months ago said she was normal-healthy weight. Too bad it wasn’t true.
If we, as parents and a nation, truly wish to resolve the issue of childhood obesity, we must begin to re-examine our assumptions and how we’ve arrived where we are today. Our children are not only growing fatter, they’re growing sicker, and doing the same thing with only the volume turned up on the message isn’t going to change this. Throwing medication at the problem isn’t going to make it go away. Surgical intervention isn’t going to reverse it, and certainly can’t prevent it before the fact.
We have the answer, yet we ignore it.
We’ll explore that in another post coming soon!
In the meantime, feel free to leave your comments about the issue of childhood obesity, its causes and its solution.
I charted the hypothetical little girl at 3-years 8-months as standing 38″ tall and weighing 34.5-pounds – placing her in the 84th percentile for BMI for age, the top of the “normal healthy weight” classification. With no upward growth and no weight gain in two months, this same child would now be in the 85th percentile for BMI for age, making her “at risk for overweight” in some circles, or simply “overweight” in others.
Interestingly, if we calculate her traditional fall on the height and weight charts, her weight at 3-years 8-months places her in the 59th percentile for weight for age; at 3-years 10-months it’s dropped to the 52nd percentile for weight for age. Yet this child is now labeled as being among the statistics of overweight and/or obese children.
The dirty little secret about children’s BMI charts is they slope downward starting at age 2 until about age 6! Take a look:
How often do we read or hear how parents are totally blind to their child’s weight problems?
How many out there realize the difference between “normal healthy weight” of a three year old girl and ‘at risk for overweight” (or overweight) is just 0.5-pounds, to be classified “overweight” (or obese) it’s just one more pound if you use the BMI for age chart?
How many realize that within as short a period of time as a month, with no gain or loss and no upward growth a child can move from one category, normal healthy weight, up to overweight?
Yet this is the “gold standard” we parents are told is best to determine if our child is overweight or obese, in need of intervetion to prevent them from becoming an obese adult!
What do you think?
You can go play with the calculators available online:
Imagine for a moment, you’re a parent – of an adorable 3-year old girl. Since birth she’s thrived and is quite the little social butterfly now that she’s getting older. She eats well, plays hard and is just a delight. Your last visit to the pediatrician, when she was 3-years 8-months old, went great – with all the alarms about childhood obesity, you were pleased the doctor was so proactive to weigh and measure her, even more happy when he declared she was a healthy weight and doing great!
Fast forward a couple of months, today your little girl has what seems to be a cold that’s progressing, so you make an appointment and the doctor’s office squeezes you in.
When you arrive, the nurse takes you into the exam room, weighs and measures your daughter (just like last time) and takes her temperature. She asks you to wait a few minutes, the doctor will be in soon.
A short time passes and the doctor comes in, examines your daughter and doesn’t think it’s something that needs antibiotics and explains how to monitor her fever and keep her hydrated. He then says, we need to talk about her weight, her BMI places her in the 85th percentile, which puts her at risk for overweight.
How could this have happened in just two months?
How is it possible you’ve not seen this coming?
A recent survey found that being obese invites social discrimination, but the obese do not wish to be labeled as “sick” or diseased. As noted in the press release about the survey findings:
“Obese people frequently feel overwhelmed and disheartened by the publicity about their condition,” he said. “They often feel disrespected and not understood by medical practitioners. Our participants express the view very forcefully that they feel victimized by current social attitudes about obesity. To be told that, in addition to the problems that they recognize only too well, they are now regarded as ‘sick’ is unlikely to assist them to find a solution.”
Study participants said they find it difficult to act on the health messages about obesity, he said. Most participants reported that they had tried weight loss remedies that their physician recommended and were generally dissatisfied with the help doctors provide.
Health care providers’ efforts to convince overweight patients to lose weight are largely unsuccessful, Komesaroff believes, possibly because they do not understand the key issues that obese people face.
Readers may recall that last year, in March 2007, a study was published from a dietary trial comparing four dietary approaches for weight loss: Atkins, Ornish, LEARN and Zone – the A to Z Weight Loss Study.
Many reading through the findings cried foul – those in the Ornish group hadn’t reduced their fat sufficiently, those in the Atkins group consumed more carbohydrate than recommended, and so on.
In my blog post I noted “…this study failed to achieve compliance out of the gate!”
I also noted that “We have before us is a study that really does indicate carbohydrate restriction can work well over a period of one year. Without sub-group analysis to evaluate results tied to compliance (hey, some of the participants had to be doing the various diet right, dontcha think?) we can’t know just how effective doing Atkins or any of the diets is with good compliance though since the researchers didn’t take their data to that level of analysis in this paper.”
Ask and ye shall have an answer!
A follow-up paper was published in the International Journal of Obesity – Dietary Adherance and Weight Loss Success Among Overweight Women: Results from A to Z Weight Loss Study.
As the researchers note in the background of their abstract: “Dietary adherence has been implicated as an important factor in the success of dieting strategies; however, studies assessing and investigating its association with weight loss success are scarce.”
“We aimed to document the level of dietary adherence using measured diet data and to examine its association with weight loss success.”
And so they performed a secondary analysis on the data from the trial and lo’ and behold, those who closely adhered to the dietary recommendations of their assigned diets were found to have greater weight loss when compared with those less compliant with their dietary recommendations.
The researchers found that “within each diet group, adherence to score was significantly correlated with 12-month weight change.”
Atkins rs= 0.42 p=0.0003
Zone rs= 0.34 p=0.009
Ornish rs= 0.38 p=0.004
When comparing the highest level of compliance with the lowest the researchers noted significant differences in weight loss in the Atkins group!
Highest compliance = 8.3kg
Lowest compliance = 1.9kg
p = 0.0006
Highest compliance = 3.7kg
Lowest compliance = 0.4kg
p = 0.12
Highest compliance = 6.5kg
Lowest compliance = 1.7kg
p = 0.06
The researchers concluded, “Regardless of assigned diet groups, 12-month weight change was greater in the most adherent compared to the least adherent tertiles. These results suggest that strategies to increase adherence may deserve more emphasis than the specific macronutrient composition of the weight loss diet itself in supporting successful weight loss.”
Obviously the debate about classifying obesity a disease is not a new idea, for years various researchers, special interest groups and organizations have debated the merits of defining obesity as a disease, with each round of reasoning and review of the evidence leading to the determination that obesity is not a disease unto itself, leaving it to remain categorically a health issue – a risk marker and a condition one is better to address than to ignore, but not a disease in need of specific medical intervention per se, but a condition with treatment options at the discretion of those within the medical community treating obese patients.
This distinction is important – while medical interventions are available, they are not the sole option for those who are obese; nor are all individuals with a BMI of 30 or greater automatically deemed to have a chronic disease in need of treatment by licensed healthcare professionals. If someone is obese, they are clearly able to seek medical treatment if they desire that option, just as they can opt instead to join Weight Watchers, read and follow the South Beach Diet on their own, or, gasp!, do nothing if their obesity is not causing them other health problems.
In order to fully understand the implications of the current position foisted in the Obesity Society white paper, it’s important to look at the arguments as they’ve developed over the years. One exceptionally well written paper was published in October 2001 in the International Journal of Obesity – Is Obesity a Disease?
In that paper, the authors take time to review and discuss the “characteristics of obesity to determine if they fit the common and recurring elements of definitions of disease.” They utilize a sample of definitions of disease taken from “authoritative English language dictionaries” to determine a common understanding of what defines “disease” and from there, examine if obesity fits the definition.
They tell us, “we identified the following common and recurring components:
(a) a condition of the body, its parts, organs, or systems, or an alteration thereof;
(b) resulting from infection, parasites, nutritional, dietary, environmental, genetic, or other causes;
(c) having a characteristic, identifiable, marked, group of symptoms or signs;
(d) deviation from normal structure or function (variously described as abnormal structure or function; incorrect function; impairment of normal state; interruption, disturbance, cessation, disorder, derangement of bodily or organ functions)
Then ask, “[h]ow well does obesity fit the definition of disease?”
Using the above criteria for disease, they evaluate whether defining obesity as a disease can be accomplished within the definition of disease.
There should be little disagreement that obesity satisfies conditions (a) and (b) above. That is, (a) an excess accumulation of fat can certainly be thought of as a condition of the body, and as for (b), the list of potential causes is so extensive that the causes of obesity must surely be found there.
Condition (c) poses a problem. Indeed, obesity can be diagnosed visually from physical proportions, or with the help of height and weight measurements. In cases of doubt, body composition methodologies offer numerous methods to measure body fat to the required degree of precision. However, there are no signs that inevitably characterize the condition other than the excess adiposity, which is the definition of obesity. The causes of obesity are numerous and diverse, ranging from and including combinations of environmental, behavioral and genetic aspects of energy intake, partitioning and expenditure. Its common accompaniments¾impaired glucose tolerance, dyslipidemia, hypertension¾are not inevitably present. Thus, condition (c) is met, but only in a circular or tautological sense: the only characteristic (pathonomic), identifiable sign of obesity is also the characteristic which defines obesity, ie fatness.
Condition (d) is even more problematic. The deviations specified range from simple deviation from normality, to impairment, interruption or cessation of vital functions. Moreover, what is meant by deviation from normality is not clear¾it can imply undesirable variation or simple statistical rarity.
Evidence for impaired physical and social functioning in severe obesity (eg BMI>40) clearly exists. In these cases, excess fat is usually accompanied by various signs of impairment and it can be argued that severe or extreme obesity would usually meet condition (d) for most definitions of disease, including those which specify impairment of function.
However, impairment is not inevitable or even usual in most persons who meet the present BMI or percentage fat criteria for obesity. In contrast to severe obesity, mild obesity only ‘threatens’ eventual impairment inasmuch as a risk factor, by definition, confers a greater probability of some future adverse event. Yet its association with these events is, at our present state of understanding, probabilistic. We cannot foretell who will develop an obesity-related health problem. In fact, some persons who meet the criteria for obesity will live long lives free of any of the morbidities known to be influenced by obesity. We are therefore placed in the conceptually awkward position of declaring a disease which, for some of its victims, entails no affliction.
Many obese persons are competent, functioning members of society. Nor do these persons necessarily subjectively consider themselves impaired, except perhaps insofar as they feel themselves victims of social discrimination. They might fail to meet some arbitrary standard of physical fitness (eg climbing stairs, running) but such a standard would also exceed the capability of many non-obese but sedentary individuals. While physical fitness is desirable, its absence has not generally been considered an impairment. It would be possible to set an arbitrary standard of fitness which many obese and non-obese people would fail to meet, and to consider this as evidence of impairment; however the present criteria for obesity do not do so.
A further conceptual problem arises when obesity occurs in a disease such as Cushing’s Syndrome. Obesity is one of the components or signs of that syndrome. Is the obesity which is a sign of Cushing’s disease, itself a separate disease?
In sum, to call obesity defined solely on the basis of a BMI or percentage body fat in excess of some threshold a disease leads immediately to the following problems:
- the only sign or symptom may be the excess fat which is also the only defining feature of the condition¾there are no other inevitable clinical or subclinical signs;
- many obese persons suffer no impairment as a consequence of their obesity;
- it ignores the probabilistic nature of the relation between obesity and consequent adverse events which is accurately conveyed by the term risk factor;
- it poses conceptual problems, eg is the obesity which is a sign of a disease, itself a disease?
They continue on, at great length about the various ethical issues involved – from the creation and fostering of a victim ‘mentality’ of the obese, to the issue of responsibilities that range from patient behaviors to obligation to provide medical treatment, from the problems of vested interests leading the cause to declare obesity a disease to determining who pays for treatments.
They come full circle and conclude, “None of the foregoing is meant to argue that obesity is not a public health problem of the first magnitude. However, it would be a mistake to attempt to label it a disease in the traditional sense in order to emphasize its importance if it does not meet reasonable criteria for such diseases. Conceptual clarity is a cardinal virtue in science and philosophy and it should not be sacrificed to expediency.
Finally, it seems neither logically necessary nor tactically essential to have obesity labeled a disease in order for it to be taken seriously. Public health measures and preventive medicine often receive generous funding (eg annual physical examinations, immunization programs, smoking cessation campaigns, promotion of exercise and active lifestyles). Whether and how our institutions and organizations pay for obesity treatment should ultimately depend on what health outcomes we value, how much we value them, and the cost of achieving them, not on whether obesity is labeled a disease.”
I left readers with photos of three incredibly fit men on Friday – each is an elite athlete in the octagon, practicing mixed martial arts, at the top of their game.
I asked one question, aside from the UFC, what do they share in common?
Many answered they all share the common BMI classification “obese” – although that is correct, the answer I was going for was they’re all “diseased” and in need of medical treatment for their obesity according to the authors of a new white paper published by the Obesity Society.
That’s right, if the opinions expressed in this white paper are adopted, the men pictured would all be considered suffering a chronic, debilitating disease which needs treatment by healthcare professionals.
The committee that drafted the position paper took the unusual step to discard the evidence-based (forensic) model and opted for a philosophical argument from a utilitarian perspective.
While they credit themselves for taking this approach because “there can be no higher authority than reason,” they ignore the important qualification for something to be declared a disease – is it a disease?
This abandonment of evidence, data and scientific inquiry undermines their approach by simply skirting the true purpose to determine if something is rightly, indeed, a disease state. To get around this wee inconvenience, instead they argue “…the utilitarian argument can address the question “should obesity be declared a disease?” as opposed to “is obesity a disease?”
The ramifications of this mind-bending mental-gymnastics are far-reaching, the authors ignore the moral and ethical can of worms opened if their position is adopted, with their beliefs trumping evidence as they remain steadfast in the belief that it doesn’t matter *if* obesity is a disease, it should be declared one anyway because,
“Many obese people are desperate for treatment – the number of people who self-treat and those treated by commercial programs is larger than the number currently treated by the medical establishment. If obesity were considered a disease and entitled to the same considerations given to other diseases, treatment paradigms would change fundamentally…If treatment were covered, more physicians would be likely to engage patients in treatment protocols. The FDA would come under pressure to approve obesity drugs, and physicians would be more likely to use obesity drugs in treatment…With this increased attention, medical treatment options, especially drug treatment, likely would become more aggressive. Medical treatment and obesity surgery would be given more attention by physicians, health administrators, insurance companies, and employers, resulting in greater access by patients to higher quality care.”
For those unaware of the various philosophical approaches, Utilitarianism is the idea that the moral worth of an action is solely determined by its contribution to overall utility, that is, its contribution to happiness, satisfaction, preferences or pleasure as summed among all persons affected. This is a form of consequentialism – the moral worth of an action is determined by its outcome – the ends justifies the means.
Because it is an ‘ends justifies the means’ line of thinking, it can be characterized as a quantitative and reductionist approach to ethics. And to be sure, this issue has far reaching ethical and moral implications – in the stroke of a pen, this perspective potentially takes 1/3 of our population and defines them as diseased, in need of medical intervention and treatment, by way of the crudest measure of obesity – the BMI.
As the three men in Friday’s post highlight, obesity as defined by BMI is unreliable, thus flawed as a measure to determine if one is obese. This flaw isn’t news, it’s well established in the medical and research community as problematic, which is a reason why many continue to suggest the utilization of more refined measures, like waist-hip ratio and/or an actual measure of body fat percentage.
But even this well known flaw does not stop the authors from even suggesting the BMI standard be LOWERED to classify obesity! That’s right, not only do these folks think we should abandon medical standards and wax lyrical about how obesity should be declared a disease, they also feel the BMI needs to be lower too!
Sandy Szwarc at Junkfood Science has a well written article about the paper already, so I’ll skip the points she already made. I’ll note here that one sentence bears repeating about why the philosophical approach in this paper is wrong, “By this logic, or course, poverty could be a disease… Black or ethnic minority a disease… Old age a disease… Homosexuality a disease… Ugliness a disease… Low intellect or literacy a disease.”
In addition to the points made by Sandy, a big issue remains – what about the legal issues and medical ethics involved if obesity were declared a disease?
First and foremost is that should obesity be declared a disease, therefore a chronic medical condition, it would then follow that only licensed healthcare professionals would be qualified to treat obesity. The treatments would, of course, include a handful of diet pills, lifestyle interventions and/or bariatric surgery. Fully medicalized as a disease, obesity would no longer be ‘treated’ outside the licensed medical community because anyone offering services to the obese would be practicing medicine without a license since all disease treatments are the protected domain of licensed healthcare professionals.
More importantly however, is the problematic position “declaring obesity a disease” becomes for the healthcare professional. We’ll explore these issues throughout the coming week.
What do you think? Should obesity be declared a disease? Why or why not?