Philip Alcabes discusses myths of health, disease and risk.

Childhood Obesity: NYC’s Little Lies, Big Self-Congratulation

There is very little evidence that obesity is harmful to young children.  So I have to ask why NYC’s Department of Health and Mental Hygiene feels so strongly that fat schoolchildren should be forced to slim down.  And why it’s so eager to congratulate itself today on its policing of eating behavior — see reports by WSJ, Bloomberg, CBS (with photos of fat kids!), Huffington, and many other sources.  Why would the city’s health agency lie in order to claim that its jihad against a not-very-convincing evil has been successful?

The subject is a report published by CDC today claiming that obesity among NYC schoolkids in grades K through 8 has decreased 5.5%.

The city’s health commissioner, Thomas A. Farley has been true to the shades of history’s empty-headed warriors.  Farley announced that the drop in obesity prevalence is a “turning-point in the obesity epidemic” although it “does not by any means mark the end.”

A missed photo opp:  Dr. Farley standing on top of a fat child, holding up a sign reading, “Mission Accomplished.”

Farley is zealous about controlling people’s behavior and contemptuous of facts (nobody will ever accuse him of being an intellectual, either).  He blogs about his own work for the exclusive reading pleasure of Department of Health staffers.  This allows his staff to read the Farley-esque twist on truth.  One example for now:  in October of 2010, Farley’s blog exultantly told his staff that in 2009 the department had “immunized nearly 130,000 children [against flu] in more than 1,200 schools over a few months.”  Of course, health department employees are smart — many of them knew that the 2009 H1N1 vaccine Farley was talking about was a fiasco, far too late to make a difference, and aimed at an outbreak that was more of a whimper than a bang.

What about today’s “turning point” in the obesity war?  It’s worth noting that the supposed drop in obesity among NYC schoolkids is really just a very slight (1.2%) difference in the prevalence of obesity between 2006-7 and 2010-11.

A small difference between small numbers amounts to a large percentage difference.  So the 1.2%  actual difference magically turns into the advertised 5.5% — the proportionate change.

But the false advertising gets worse

1.  The prevalence of obesity in NYC was not measured multiple times on the same group of kids (to use epidemiology jargon:  this wasn’t a panel study).  Nobody observed fat children becoming less fat.  The city simply measured obesity prevalence each year on 5- to 14-year-olds who were in the school system.  So a high proportion of the 21.9% of kids who were labeled obese in 2006-7 would have been out of the age range for the 2010-11 assessment.

Plus, lots of kids leave the NYC school system after grade school (this has to do with Bloomberg administration’s bizarre system for preventing children from attending local schools).  So, even those children who haven’t aged out of the analysis by turning 15 would be absent from the data after a few years.  And, there’s also natural immigration and emigration.

Did the 2006 fat kids get slimmer?  Nobody knows.  The 2006-7 obesity prevalence among NYC schoolkids (21.9%) can’t be compared to the 2010-11 prevalence (20.7%).  If you were forced to compare these numbers, you’d say there had been a slight change — not a 5.5% decline.  There’s the first lie.

2.  The second lie is a little more complicated.   Since there is no widely accepted functional definition for childhood obesity, children are labeled obese if their body-mass index (BMI) falls into the upper 5% of the expected distribution of weight-for-height.  This expectation is based on an old-fashioned standard.  Fair enough.  But lots of distributions shift over time — SAT scores, human height, grades awarded at Ivy League colleges, and global average temperature, to name a few.

Sometimes the reason for an overall shift of this sort isn’t hard to specify (test prep, nutritional quality, relaxation of grading standards, generalized global warming, etc.).  But the main effect causing a shift in the distribution doesn’t explain why the few people who are in the upper reaches of the distribution are so far from the mean.  To say that fewer children are now above the high-BMI cutoff than in 2006-7 therefore the tendency of children to be fat is declining is a lot like claiming that because 2011 was cooler than 2009 and 2010, global temperatures are not really going up.

(Dr. Farley, I gather that statistics aren’t your strong suit, but surely when you witnessed that snowstorm we had this past October — an outlier if there ever was one — you didn’t conclude that the climate is actually getting colder, not hotter.  So what makes you think that a very tiny decrease in the proportion of kids with high BMIs means that the city’s kids are getting slimmer?)

3.  Claiming credit.   Attributing to the health agency’s own efforts a minuscule change in the proportion of kids who are in the upper tail of the broad BMI distribution requires self-congratulation so acrobatic as to stretch credulity.

Maybe there really has been some change in the city’s children since 2006.  Or in our food supply or buying habits.  Or exercising.  But to claim that such a change both caused the tiny decline in schoolkid obesity prevalence and that it was the result of the Health Department’s efforts — the exercising and the low-fat milk and the salad bars in the school cafeterias and so forth — is to commit the fallacy that Rene Dubos outlined (in his book Mirage of Health) nearly 50 years ago:

When the tide is receding from the beach it is easy to have the illusion that one can empty the ocean by removing water with a pail.

Is childhood obesity really a health problem?

It’s not crazy for health professionals to be concerned about body mass.  Obesity might be really bad for some people, and somewhat bad for many.

But those people are adults.  Why are health agencies like NYC’s so riled up about obesity in little children?

So far, there’s no strong evidence that obesity in younger children predicts any real harm later in life, other than being a fat adult.  With adults, several signs of impending debility are more commonly found in the obese than the non-obese, such as hardening of the arteries, fatty liver, sleep apnea, and diabetes.   And with adolescents, there’s some evidence that those who are obese develop similar warning signs.  But not younger kids.

A 2005 BMJ paper reported only social effects in adulthood (being unemployed and being without a romantic partner) of early obesity.  Similarly, one cohort study carried out in Newcastle upon Tyne found little evidence that fat children became fat adults, and no evidence for predictors of illness in adulthood among those who had been overweight as children — although other studies have shown correlations between adolescent obesity and adult problems.

For kids below age 15, the most visible problem with obesity is that it occurs most commonly among the poor and dark-skinned.  This bothers the obesity warriors.  In fact, not only is obesity more common in African- and Hispanic-American children in NYC, even the slipshod standards of today’s report on NYC schoolkids can’t be manipulated to show that obesity is declining among these children.

As with all holy wars, from the Children’s Crusade through the U.S. invasion of Iraq, the warriors aren’t really concerned about principle.  Something about somebody got under their skin.

Here’s how I answer my own question:  I guess the obesity crusaders don’t like it when the children of the wealthy look like the children of the poor.  They think that white kids on the Upper East Side aren’t supposed to look like kids who live in the Bronx.

It isn’t about health, in other words.  It isn’t even about obesity.  The “childhood obesity epidemic” is about making sure society looks the way that the health crusaders want it to look.

 

 

By Philip Alcabes | December 16th, 2011 | Categories: epidemics, obesity, public health, Uncategorized | Tags: , , , , , , | 1 comment

Life Expectancy Goes Up but Risk-reduction lectures Continue

Bravo! to Rob Lyons at Spiked. Since it’s now apparent that life expectancy has increased almost everywhere and is at historic high levels in much of the developed world, Lyons asks the logical question:  why is the public health system still scolding everyone about what people eat and how fat the average person is?

A paper by David Leon in this month’s International Journal of Epidemiology showed the dramatic increase in life expectancy — the median age at death, that is.  It has reached over 85 years for women in Japan, but it’s high even in countries where longevity was relatively low a generation ago.  Cheeringly, US life expectancy at birth is now 78 years; in the UK it’s 80.  And it’s even higher in some countries of western continental Europe.  Here are the graphs for different parts of the world from Leon’s paper, showing trends since 1970:

Life expectancy since 1970

Lyons has gone after the anti-obesity crusaders before (as well as related topics at his smart blog on contemporary food confusion, Panic On A Plate).  Now, he’s particularly disturbed by the sermonizing about eating. “You can’t even have a pie and a pint without someone telling you it will kill you, it seems,” Lyons writes at Spiked.

And, really, it’s even worse than that — because it’s not just eating that’s the subject of the lecturing.  It might be true that you will live longer if you give up smoking, cut your salt intake, drop your BMI down to 24.99, exercise four times per week for at least 20 minutes each time, get immunized against flu and human papillomavirus, drink in moderation, and take naps.  But unfortunately there’s not a bit of evidence that any of that — apart from the decline in smoking — has contributed to increasing longevity.

And of course, even with smoking cessation, there’s no telling whether it would make any difference to you — only on average.

So why are the public health messages so far away from what really matters — basically, prenatal care, postnatal care, and wealth (with its concomitant, standard of living)?  Well, there’s a puzzle.

What’s the point of having an industry whose main aim is to make sure that people are constantly in fear that they are doing something that will kill them — even as it becomes apparent that most of what people do is only making us live longer?   Lyons calls it Good News Omission Mentality Syndrome (GNOMES).

I ask you:  could it have something to do with control?  And the desire to sell products?

By Philip Alcabes | March 25th, 2011 | Categories: Behavior, Health Professions, obesity, public health, Risk | Tags: , , , , , , , , , | 8 comments

Media Culture: Beyond Fat and Salt?

Over at Media, Culture & Health, Steven Gorelick notes that a story on salt and the food industry, which appeared on page A1 of the print NY Times on Sunday, would not have made the front page in the past.

What has changed?  How does the story of wrangling over the sodium content of American food merit space in the main news sections of the most influential media — even the front pages of the NY Times or LA Times?

1.  One answer is that health occupies much of the American conversation today.  A visitor from another planet watching our TV news shows or reading the main newspapers would have to be forgiven for thinking that Americans are dying from a multitude of irrepressible disease threats.  We can’t seem to stop talking about how to improve our health.

(In fact, as Michael Haines notes at the Economic History Association website, U.S. life expectancy almost doubled between 1850 and 1960, from 39.5 years to 70.7 years; since then it has increased slowly, and is now estimated to be about 78.2 years.  In other words, health wasn’t a matter of news much during the time when longevity was improving dramatically, in the late 19th century and first half of the 20th.  By the time health became a cultural preoccupation, the majority of Americans were living well past middle age.)

2.  Another answer, perhaps more important is that when we talk about health today we mean personal responsibility.

When I began studying epidemiology, in the late 1970s, public health essentially meant disease control.  Yes, lip service was paid to so-called health promotion — much was made of the World Health Organization’s definition of health, promulgated in 1946:

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

But no metric for complete well-being was widely recognized.  And the usual epidemiologic measures of incidence and mortality rates, life expectancy, and so forth seemed to work just fine as ways of understanding why some groups of people lived longer and more capable lives, while others lived miserably and died young.

Sometime since then, the health sector, including public health, has turned to individual responsibility as the key to well-being.

If each of us is responsible for his or her own health, then it’s our own fault if we get sick.  Naturally, advice abounds:  buckle up, use a condom, eat less fat, know your cholesterol level, wash your hands, use mosquito repellent containing DEET, wear sunblock, eat fresh fruit and vegetables every day, lower your stress.

The advice adds up to this:  know your limits.  Federally sponsored research tells us that self-control is ontagious.

The personal-responsibility view of health says, “control your appetites.”

3.  But let’s think about another change:  more people are concerned about the American diet.  As noted last week, the food movement has given us ways to think about eating that go beyond the tiresome story of obesity and hypertension — Beyond Fat and Salt, you could say.

Of course, the main media outlets still tell the food story in Fat-and-Salt language, as the news articles in the NY Times, LA Times, and others show.  It’s the food industry vs. the foodies, or the food industry vs. public health, or the food industry and public health vs. appetites — anyway, somebody against somebody in the name of health.

The media aren’t quite past obesity and hypertension yet.  But as the culture moves beyond obsessive self-inspection in the name of health, no doubt media will, too.


By Philip Alcabes | June 3rd, 2010 | Categories: Behavior, Disease, Health Professions, Narratives, News, obesity, public health, Uncategorized | Tags: , , , , , , , | 2 comments

Putting Obesity in Perspective

Michael Pollan’s essay in this week’s NY Review of Books offers a framework for looking at modern food and eating.  If public health advocates took Pollan’s perspective, the vitriol of their anti-obesity crusade could turn into a force for real social reform.

Reviewing five books on what he calls the “food movements,” Pollan notes the widespread discontent with contemporary industrialized food production (I’ll call this “American eating,” although its dominance is increasing around the world).  And he suggests that its common theme is cultural discomfort. The food movement, Pollan argues, has “set out to foster new forms of civil society”:

It makes sense that food and farming should become a locus of attention for Americans disenchanted with consumer capitalism.  Food is the place in daily life where corporatization can be most vividly felt…  The corporatization of something as basic and intimate as eating is, for many of us today, a good place to draw the line.

This is a refreshing insight.  It’s thankfully broad, taking  the focus away from health, and therefore from the anti-obesity crusade and the “toxic food environment” view promoted by health advocates.

But Pollan’s perspective is especially refreshing because it renews the conversation about our private lives — particularly the extent to which we’ve ceded our innermost values to the demands of corporate profit and government policies.  And those demands, as Marion Nestle often points out (recently here), are generally linked.

Pollan reminds us that our innermost values are literally innermost:  they have to do with what goes into our stomachs.

I’ve already stated my argument that the anti-obesity crusade is really about control, not health (see here and here).   The crusaders do cite “public health” as a rationale for the war against obesity.  But when they describe what’s wrong, they do so in terms that are sometimes medical (diabetes, hypertension), sometimes technical (serving sizes, calorie counts, the infamous toxic food environment), and sometimes medieval (gluttony, laziness).  Their inability to articulate the source of the problem is a signal that they’re sure something is out of control but unsure exactly what.

The public health approach to obesity is a failure.  It doesn’t let us talk about what needs to be reformed.  And it’s often allied with efforts to make sure the poor stay poor — even though wealth inequality is surely part of the problem in the first place.  The public health industry’s demands for additional regressive taxation in the form of increased “fat” taxes on sugary beverages or high-calorie foods reveal its preference for the status quo.  Make the poor pay more for their soda and fast food; that will make them think twice about supporting industries that are making us fat.

Even well-meaning public health professionals who advocate government intervention against low-price-but-low-nutrition food  as a way of curtailing obesity ignore the central role of food and eating to liberty and happiness — they’re interested primarily in how many additional years of life (however unhappy) could be purchased by trading in the fries in favor of broccoli.  Or, worse, they’re interested only in the dollar costs to taxpayers — in terms of hypertension and heart disease — of tolerating obesity.

Pollan, today’s most thoughtful and insightful philosopher on the subject of food and eating, offers a more satisfying view.  Sure, you may want to change American eating because you think obesity is bad for people’s health.   But you might want to change eating simply because the food scene is distressing, because it crystallizes and exemplifies the many ways that we give over our private (innermost!) moral decisions to the influences of corporate/consumerist thinking.  You might want to change it because, as Pollan reminds us (in regard to a new book by Janet Flammang), the dominance of American statecraft by corporations allows the preparation of food to be relegated to the least valued, least powerful, and lowest paid workers.  You might want food to taste better — valuing pleasure over longevity.

With Pollan’s broad view, you  don’t have to join the anti-obesity crusade.  You don’t have to speak the technical language of risk.  The common language of freedom, desire, and pleasure will do.

By Philip Alcabes | May 26th, 2010 | Categories: Behavior, epidemics, Health Professions, Narratives, obesity, public health, Risk, Uncategorized | Tags: , , , , , , | 2 comments

AIDS Goes to Ground

This week, Donald McNeil, Jr. continues his praiseworthy efforts to highlight the sad reality of AIDS among the world’s poor.

In an article posted on the NY Times website Sunday (and published in the print edition Monday), McNeil reports on the inability of treatment programs in parts of Africa (this piece focuses on Uganda) to keep up with the need for AIDS medication as funding falls.   A very compelling video report accompanies the online version of the article.

An accompanying article explains the decline in funding, starting with the fall in the U.S. administration’s request on behalf of PEPFAR, as a Times graphic shows.

The number of new infections with the AIDS virus is estimated to be about 2 million per year now.  Some observers think annual incidence will rise as the population expands; even if not, the annual number of new AIDS virus infections is unlikely to fall in the near future, given present circumstances.

At the same time, the Times reports, anticipated PEPFAR funding is essentially flat to 2013, at $5 to $5.5 billion per year.  Financing for AIDS medications through the Global Fund to Fight AIDS, Tuberculosis and Malaria is in dire straits.

In terms of people, not dollars:  of the 33 million or so individuals who are infected with the AIDS virus worldwide, only about 4 million get regular antiretroviral therapy.

A few years ago, I wondered why,  after a quarter-century of AIDS and with the availability of effective treatment (at least in wealthy countries), Americans still didn’t see AIDS as an ordinary illness.

Now I have an answer:  we do see AIDS as ordinary… for poor countries.  To us, AIDS is no longer an epidemic problem worth our getting worked up over, or so it would seem judging by PEPFAR.  AIDS is like malaria, tuberculosis, or schistosomiasis.  It’s like diarrhea.  The Bill and Melinda Gates Foundation will put money into research or specific programs but we as a country will not need to care anymore.  We shift the funding away from the people in Africa, who are going to die young anyway, and put it into the hands of institutions (often, pharmaceutical companies) that can give us the promise of immunity from disaster.

The U.S. put less funding last year into PEPFAR than it did into preparations for H1N1 flu ($7.6 billion) or the school lunch program ($14.9 billion, according to the Robert Wood Johnson Foundation’s Center to Prevent Childhood Obesity), battleground in the war against childhood obesity.

Flu and obesity are epidemic.  They threaten American assumptions about ourselves.  “Epidemic” means:  crisis in our society.  Our epidemiologists say that malaria, diarrhea, and the other problems that collectively kill 20,000 or 25,000 people (mostly children) every day are endemic. 

“Endemic” means:  not our problem.

AIDS is endemic too, now.  It has gone to ground, gone the route of other once-dreaded infections that caused calamity in America and triggered heated debate (yellow fever, cholera, typhoid, TB) but have disappeared from our scene.  It’s their problem, now.

By Philip Alcabes | May 12th, 2010 | Categories: Disease, epidemics, Health Professions, obesity, public health, Uncategorized | Tags: , , , , , , , , | 2 comments

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