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

Bugs in New York

I admit that I haven’t followed the story of the blossoming bedbug population avidly.  Not that I’m cold to the heartache (and itch) that bedbug infestations can bring.  It’s just that an epidemiologist always gets more worked-up about bugs like mosquitoes and ticks that are vectors for microbial pathogens — and bedbugs aren’t.

But this AP article grabbed me.  According to New York City, over 6 percent of residents who responded to a community health survey claimed to have dealt with bedbugs in the past year.  In response, the city will withhold half-million dollars normally budgeted for the city’s health department  and redirect the funds to an anti-bedbug campaign.

Some might argue that the $500,000 would be better used for preventing deadly illnesses and accidents, not just bug bites.  Still, the campaign seems right.  According to the AP story, environmental health people will work with a “top entomologist.” (Professionals collaborating across sectors:  One City, One Health.  Good.)  A note by Javier Hernandez at the NY Times‘s City Room blog is guarded, but some (like Molly Fischer at the NY Observer) seem relieved that there will be a big anti-bedbug crusade at last.

Not a very big crusade, but at least a multifaceted one, as the Bed Bug Advisory Board’s Report suggests.

By Philip Alcabes | July 28th, 2010 | Categories: Health Professions, News, public health, Uncategorized | Tags: , , , | Comments Off

Early Onset of AIDS Therapy

Late last week, the NY Times reported that the city of San Francisco’s Department of Public Health is going to begin advising people with HIV to begin antiretroviral treatment (ART) immediately, rather than waiting for the CD4 count to decline.

The policy seems to be based primarily on a secondary analysis of longitudinal data from a multi-center study of HIV-infected people in the U.S. and Canada, the NA-ACCORD study.  The results were reported in the New England Journal of Medicine a year ago.  In that analysis, people with HIV whose CD4 counts were between 351 and 500 who began ART immediately were compared to those who deferred ART until CD4 count was 350 or less.  The deferred-ART group was found to have a 69% higher risk of mortality (from any cause) than were those who began ART before CD4 count fell to <350.  Similarly, among HIV-infected people with CD4 counts above 500, those who began ART after CD4 count was <500 had a 94% higher risk of mortality compared to those who began ART immediately.

But is this a good basis for across-the-board policy for a city the size of San Francisco?  Some physicians worry about the development of drug resistance among viral strains.  Others are concerned about toxicity, always a problem worth considering.  Paul E. Sax tracks the history of the idea and includes a few quotes in his blog post yesterday.

Some commentators wonder whether the new policy is meant to be a boon to pharmaceutical companies.  That’s not a crazy concern:  the Bay Area Reporter noted a couple of weeks ago that San Francisco plans to shift to a “status awareness” policy, increasing HIV testing by 70,000 people per year in an effort to halve the rate of new infections by 2015.  If successful, the increase in testing combined with an increase in recommendations for early ART would expand the market for antiviral medications substantially.

A few aspects of the April 2009 report on NA-ACCORD raise worries about whether it should be the basis for broad-based policy.  First, people who deferred therapy were observed very briefly (median 1.3 years, many of them for only 6 months), so any advantage to early therapy appears to refer to the period immediately post onset of therapy.  That’s important because toxicity and/or resistance might not be evident right away.  Second, looking only at people with an initial CD4 count above 500 and holding constant self-reported history of drug injection, there was only weak evidence for a slight effect of early treatment on mortality (the relative mortality hazard was 1.28 (95% confidence interval 0.85 to 1.83)).  Drug users had a higher mortality risk, and this finding—on which the authors of the New England Journal paper do not comment—suggests that early ART did not reduce the hazard of death for drug users.

Also, the authors of the NEJM paper could not possibly account for some of the hard-to-regiment aspects of HIV infection.  These would include variations in cause of death, treatment adherence, and monitoring of treatment effects — all of which would either not be evident in a cohort study or could not be controlled in a secondary analysis.

Finally, the authors are slightly cagey about the effect of drug-injection history in the above-500-CD4-count group, reporting a twofold increase in death hazard for those who delay ART after excluding people with a drug-injection history – but never reporting information on the effect of ART delay among drug injectors alone.

Most important, observations on people who transitioned to the next-lower CD4 compartment (i.e., from above 500 to <500, or from 351-500 to <350) were censored after 6 months if the individual had not yet initiated ART.  Therefore, the real comparison the NEJM authors are making is between immediate-onset ART while CD4 count remains in the same CD4 compartment vs. immediate-onset ART after CD4 count has dropped to the next lower compartment.  It’s not really a study of immediate versus delayed onset ART.

There’s plenty of reason (including the 2009 NEJM paper) to think that suppressing HIV early rather than late should be helpful, and some reason to think that the reduction in viral load produced by ART will lower infectivity in a way that makes transmission to uninfected sexual or drug-sharing partners less likely.  That in turn could be of public-health value.

Of course, nobody is being forced to start ART before he or she wants to, no matter the policy recommendation. Still, it’s worth wondering whether the expansion of testing and extension of early treatment will substantially improve the public’s health in a way that makes the cost, and self-evident advantages to pharmaceutical (and test-kit) manufacturers, worthwhile.

By Philip Alcabes | April 5th, 2010 | Categories: Disease, Health Professions, public health | Tags: , , , | 2 comments

Desperation Play on Flu Vaccine

DHHS Secretary Sibelius spoke at Hunter College in New York on Thursday, part of her barnstorming tour to exhort Americans to get immunized against swine flu — and thereby avoid embarrassment to herself and her agency on account of  the extremely poor uptake of swine flu vaccine in the U.S.   As Mike Stobbe of AP reported on Friday, the latest estimates by CDC put the proportion of Americans vaccinated at 20 percent.

Federal agencies are already scrambling to spin the disaster as a victory.  “From our point of view, this looks very successful,” CDC spokesman Richard Quartarone tells Stobbe.  Despite the fact (also noted in the AP story) that vaccine uptake was barely better among the flu-vulnerable groups who were the focus of the immunization effort:  22 percent of personnel at health care facilities, 38 percent of pregnant women.  Some success.

Apparently, New York State Health Commissioner Daines doesn’t want to be left off the victory train.  He announced on Friday that the law requiring immunization of staff of health care facilities would be enforced — even though a restraining order was issued by state Supreme Court Justice Thomas McNamara in October prohibiting enforcement.

(A federal district court judge in San Diego ruled this week in favor of the Rady Children’s Hospital’s union of nurses and technicians, according to San Diego CityBeat.  The union had requested arbitration of the hospital’s mandatory flu-immunization policy which, they claim, violates their collective-bargaining agreement.)

Health officials’ pandemic-flu-disaster story was flimsy from the get-go.  The evidence for a serious flu outbreak was slim, despite the attempts by officials and some reporters to make the situation look dire.  But through autumn 2009, at least there were some hospitalizations and deaths that served to maintain the sense of impending catastrophe that the disaster story sought to achieve.  Now, though, with flu activity in the U.S. less than usual for this time of year and no widespread occurrence of H1N1 flu reported, officials are playing with the numbers in their desperate attempt to peddle vaccine.

In her talk at Hunter College, for instance, Secretary Sibelius noted that “over a thousand” infants and children had died from H1N1 flu.  The CDC’s latest flu update counts 300 pediatric flu deaths from April 2009 through the beginning of the new year.  And it notes that about a third of the 236 pediatric flu deaths in the current season had bacteria cultured from sterile sites — suggesting the question of whether more timely medical care, rather than immunization, might have saved many of those kids.  Where the remaining 700 of Secretary Sibelius’s thousand pediatric flu deaths are to be found remains a mystery.

What’s happening here?  The federal government ordered 250 million doses of swine-flu vaccine last year.   Vaccine makers were looking at terrific earnings from this outbreak.  But they are now worried about losses in the anticipated $7.6 billion worth of global sales — because so much vaccine has gone unused.  Western European countries are stopping their orders and seeking to off-load existing stocks.  Americans don’t want the vaccine, at least not when swine flu seems to be less damaging than regular, seasonal flu and they aren’t feeling reassured about the safety of the rapidly produced vaccine.

Federal and state officials won’t let go, though.  It’s dispiriting.

The disaster in Haiti put the spotlight on suffering this past week.   Not just the tremendous death and damage from the event itself, but the penury and misery in which many Haitians lived even before they had to live with, or die in, the earthquake.  And the earthquake should have reminded anyone who was watching — which is to say, nearly everyone — to be appalled at the amount and degree of suffering in the world, even on days when there are no natural disasters making the news.

The disquieting thing, especially this week, is that people who are in a position to devote themselves to alleviating illness and dispelling misery — health officials, I mean — are preoccupied with covering up for their mistakes on flu and satisfying the needs of the pharmaceutical companies.  Instead of looking at the suffering in our midst.

By Philip Alcabes | January 17th, 2010 | Categories: Disease, epidemics, Health Professions, News, Physicians, public health, Uncategorized | Tags: , , , , , , , , | 1 comment

Revolving door? Official agencies and the private sector

In late December, Effect Measure reacted to former CDC director Dr. Julie Gerberding’s hiring as President of Merck Vaccines. With customary cogency and insight, Revere addresses the problem of the so-called Revolving Door.

At The Great Beyond, Daniel Cressey notes that Dr. Gerberding, while at CDC, was accused of promoting the Bush Administration’s agendas at the cost of scientific accuracy.  Naturally, now that she is heading for Merck, many are concerned about what looks like a cozy relationship between official agencies and pharmaceutical companies.

Merck says that its vaccine arm is worth $5 billion.  It “markets vaccines for 12 of the 17 diseases for which the U.S. Advisory Committee for Immunization Practices currently recommends vaccines,” according to the company’s press release.

Dr. Gerberding was close to the vaccine world as head of CDC. In fact, during her tenure there CDC’s   Advisory Committee on Immunization Practices (ACIP) called for the implementation of immunization against human papillomavirus and varicella zoster (chicken pox) virus and the agency pushed for expanded immunization against seasonal flu; within 10 months of her (January ’09) departure from CDC, the ACIP had issued recommendations for the use of anthrax vaccine and Cervarix and Gardasil vaccines against HPV.  Gardasil  is a Merck product.

But the problem is more than the “revolving door” metaphor implies.  To have a door there must be a wall — a clear demarcation between inside and out.   As if corporations (pharmaceutical companies among them) were outside of the official system, eager to get the ear of those inside.

Whereas it seems that there isn’t really much of a wall between official health agencies and big business at all.  To be an official today means taking a veritable oath of loyalty to corporate solutions.  The official has to deal in risk.  She has to be ready to sell risk as a kind of debt:  people should want to avoid risk, just as they avoid debt; but if their behaviors put them “at risk,” they can relieve it through “lifestyle” correction.  You can refinance if you know how.

The correction that allegedly relieves risk usually involves the use of better products. Cut out trans fats,  lower your cholesterol, elevate your mood, hop on a treadmill, lose weight, drink responsibly, get seasonal flu vaccine, get swine flu vaccine, wait patiently while the full-body scanners are used at the airport, eat more vegetables, wear sunblock, use hand sanitizer.  Health officials’ job is to get the means for personal risk reduction to the sorry at-risk population.  Have hand-sanitizer dispensers installed in public buildings.  Distribute condoms.  Publish recipes for healthy meals.

Notably, health officials are not supposed to argue for any of the things that would actually make a difference to the public’s overall health:  redress wealth disparities, provide excellent primary care for everyone (including immigrants), or build more decent and affordable housing.  When was the last time you heard a health official call for a campaign against poverty?

The official has to pitch personal risk reduction, in other words.  She has to be ready to support high-cost, individualized approaches to improving the public’s health — or well-being, which, Dr. Michael Fitzpatrick astutely notes at Spiked!, has replaced health as the main objective of modern Good Works .

Health officials keep faith with the dogma of risk avoidance.  Corporations preach risk reduction and peddle the wares by which people can restructure their lives — and avoid risk.  The wall separating government policy makers from corporate solutions gets more and more flimsy.

By Philip Alcabes | January 1st, 2010 | Categories: Ethics, Health Professions, public health, Risk | Tags: , , , , , , , , , , | 3 comments

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