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Frequently Asinine Questions —

January 17, 2012

On Day Six of Errr… We’ll Get Back to You Watch, I thought it might be fun to see what Strong4Life has to teach us about childhood obesity. Ever eager to oblige, the Strong4Life website includes a “Learn” page that makes for some interesting reading.

The first question, “What is obesity?” seems pretty basic, yet their answer (“Obesity is defined as excess body fatness and is generally assessed by BMI (Body Mass Index)”) is factually incorrect. According to the 2005 Overweight and Obesity in Georgia report (PDF) from Georgia’s Department of Health, as well as the Centers for Disease Control and Prevention, a child’s status as obese, overweight, normal or underweight are determined by the child’s growth percentile, not BMI. While the two are related, they are not the same.*

By the third question, I began to realize something: either the person who provided the content for Strong4Life doesn’t know what they’re talking about, or else they are intentionally misleading people.

Because in response to the question “What is BMI and why is it important?” the first answer honestly says, “BMI is a measure of a person’s body fat.”

No. No it is not, you simpletons.As the name indicates, Body Mass Index is a measurement of how much mass your body has. BMI does not distinguish between fat and muscle and bone. BMI is a simple equation used to quantify the amount of people with similar amounts of mass.

The reason why BMI is bullshit is because a fat person who begins to exercise and eat a balanced, nutritious diet will most likely exchange fat for muscle, where fat is denser than muscle, thus possessing greater mass. So, although internally your percentage of body fat and muscle may be making incredible changes, your BMI may change very little because your weight does not reflect these internal changes.

Later in the answer, they say, “It is used because it correlates well with body fatness,” but attempting to clarify a flat-out falsehood with mentions of correlates only obfuscates reality.

By the fourth question, I’m leaning toward “intentionally obfuscating reality” because in response to the question, “Is childhood obesity a crisis?” the author replies “Childhood obesity is a crisis because nearly 40% of children in the state are overweight or obese.”

The question didn’t ask if overweight was a problem, so why don’t they just give the obesity rate? I have been unable to find a single statistic, but according to a 2007 Georgia Data Summary from the Department of Human Resources (PDF), between 12% and 24% of children are obese, depending upon age.

Were these statistics not startling enough? Why conflate obesity and overweight in a question about obesity? So many questions.

Then, of course, is the unsubstantiated claim that pops up again in the fifth question, “What makes Georgia different?” Among the responses, “75% of parents in Georgia who have overweight or obese children do not recognize the problem.”

But it’s the last question that I really want to tackle, where obfuscation and statistical shenanigans reign supreme.

In response to the question “Why should I care?” the answer reflects the national discussion on why obesity matters: “Childhood obesity threatens the health of our kids, strains family relationships and costs our state a lot of money. Georgia’s obesity costs are estimated to be $2.4 billion per year due to the rise in this epidemic.” [emphasis mine]

We’ve covered this issue before, where one study on how obesity costs us billions of healthcare dollars each year, at least a quarter of that expense was attributed to affective disorder, a psychological disorder.

We’ve also covered how data from the Medical Expenditure Panel Survey (MEPS) relies on questionable methods and results to issue a stunning estimate that obesity costs the workplace $73 billion. That study was underwritten by our friends at Allergan, and written by Eric Finkelstein, whose fingerprints turn up all over this estimate that Strong4Life relies upon.

But first, some interesting background on the $2.4 billion estimate and its use to defend draconian measures to combat childhood obesity.

Strong4Life launched its program on May 6, 2011 (which, ironically, is International No Diet Day) with the now-infamous ad campaign. On May 10, Georgia Governor Nathan Deal gave a speech regarding the state’s SHAPE initiative, which also addresses childhood obesity.

In his speech, Gov. Deal claimed, ““he health care price tag for childhood obesity in Georgia is $2.4 billion annually and rising.”

Turns out, Gov. Deal dabbled in a bit of confusion and/or obfuscation himself. According to PolitiFact, that $2.4 billion figure refers to the cost of adult obesity, not childhood obesity. After crunching the numbers, PolitiFact estimates the costs of childhood obesity to be around $110 million, or 4.6% of obesity costs.

These estimates include “obesity-attributable medical expenditures” which require a secondary diagnosis of “obesity” to be included. Therefore, it’s more of a measure of how much money in healthcare obesity people use each year, rather than an indication of how much obesity costs.

So, missing from this discussion is how much “overweight” or “normal” people spend on healthcare so that we can see just how out-of-control the costs for obesity have become.

Before we dig into that, however, I highly recommend reading this Health Beat blog post in which Maggie Mahar thoroughly explains how the rising costs of healthcare in this country have absolutely nothing to do with obesity.

In a nutshell, this graph says it all:

But let’s play their game and say that the costs of disease treatment justify Strong4Life’s Shame Campaign. Does this line of reasoning still stand?

First off, the $2.4 billion estimate is based on research from the 2004 issue of Obesity Research, which was written by — wait for it — Eric Finkelstein, and based on data culled from — wait for it — MEPS.

The good people at MEPS are kind enough to provide a statistical brief of cost trends in healthcare related to BMI, which make it easy to compare costs.

First, population data is important, and according to MEPS, in 2001 the BMI categories included 48.2 million obese, 72.3 million overweight, 79.6 million normal weight, and 4.0 million underweight. In 2006, there were 58.9 million obese, 75.7 million overweight, 78.3 million normal weight, and 3.9 million underweight. While the nation’s population grew by 12.8 million, the obese population grew by 10.7 million, accounting for 84% of the state’s population growth.

Oddly enough, today, Dr. Katherine Flegal released NHANES data confirming, yet again, that obesity rates have been level since 1999 for women and children and since 2004 for men.

So, it’s strange that MEPS, which relies on telephone surveys for BMI data, would have an increase primarily in obesity rates during a time when actual, measured weights have plateaued.

There are a few other puzzling anomalies in the MEPS data. For instance, in 2001, obesity cost an estimated $167 billion, while overweight and normal weight cost over $200 billion each. Yet after the 2006 report, obesity costs $303 billion, while overweight and normal cost $275 billion and $260 billion, respectively.

What changed in those five years? Why was it cheaper to be fat in 2001? What explains the meteoric rise in costs?

Was it because of the sudden influx of 11 million fatties into the country in 2006? Or is something else afoot in this data? Dig deeper, people, and you’ll find more interesting data.

For instance, while the cost of caring for obese people in 2006 is estimated at $5,148, the cost of caring for underweight people is $5,075. Meanwhile the costs of overweight and normal remain neck and neck at between $3,300 and $3,600.

The underweight population comprises just 4%, so the overall costs are lower. But this study suggests that the costs of underweight are just as shocking as the costs of obesity, no? But why, pray tell, did obesity experience a 33% jump in costs, while underweight jumped merely 14%? What is driving the discrepancy?

These quirks appear when you examine the percentage of total expenditures in each BMI category:

In 2001, by all objective measures, obesity cost less than either the overweight or normal categories. Yet in 2006, the demographics shift and suddenly obesity costs more.

What happened between 2001 and 2006 that could account for these differences?

In a word: war.

Four months after Richard Carmona and the CDC fanned the flames of obesity panic in March 2004, Medicare shifted its long-standing position and began accepting obesity as a diagnosis. The results, according to the study, could benefit patients and doctors alike:

How many patients fall into the Medicare gap in coverage — those who are obese but do not suffer comorbidities that would qualify them for interventions — and would gain coverage with the policy change?

Diagnosing one’s patient as obese suddenly improved the likelihood that Medicare would cover the expense. Is it any surprise, then, that the number of patients diagnosed with obesity, regardless of its contributions to metabolic disorders, have skyrocketed?

This muddies the water a bit in terms of obesity and its healthcare costs. And what muddies the water even further is the fact that the costs associated with obesity pale in comparison to the group which contributes most to the costs of disease treatment.

In fact, according to a 2006 Health and Human Services report, just 5% of the population accounts for 49% of our healthcare spending, while half the population spends almost nothing at all on healthcare. And the population that costs the most?

The elderly (age 65 and over) made up around 13 percent of the U.S. population in 2002, but they consumed 36 percent of total U.S. personal health care expenses. The average health care expense in 2002 was $11,089 per year for elderly people but only $3,352 per year for working-age people (ages 19-64).


So, the elderly account for 36% of personal health care expenses, obesity accounts for 9%. And in Georgia, childhood obesity accounts for just 4.6% of the costs associated with obesity.

Regardless of all of these cost estimates, one thing we know for sure is that helping people of ALL sizes have access to healthy foods and safe places to exercise is vital for improving one’s health, as well as cutting down on the costs of healthcare.

*Interesting side note: In 2007, an Expert Committee recommended, and the CDC adopted, new guidelines for defining the terms obese and overweight. Georgia’s report defines overweight as having a BMI in the 95th percentile and uses the term “at risk for overweight” for those in the 85th to 95th percentiles. After the 2007 report, the CDC redefined these terms, making the 85th to 95th percentile “overweight” and those over the 95th percentile “obese.”

8 Comments leave one →
  1. vesta44 permalink
    January 17, 2012 3:21 pm

    Kinda makes you wonder who’s responsible for their website and its accuracy. Also could explain why they’re ignoring everyone who’s telling them that their ad campaign is bullying kids. If inaccuracies on their website don’t bother them, why should anything else that’s wrong with the campaign bother them?
    Personally, I think it’s all about money. Get parents alarmed about their kids being unhealthy, bring them into CHOA, CHOA treats them and is paid (either by insurance or Medicaid), and nothing changes for the kids – they’re still fat, still bullied, still blamed, probably not any healthier – but CHOA has made money off the fear they’ve created, all the while collecting money from the very corporations they’re blaming for this supposed “childhood obesity epidemic”. Talk about hypocrisy. It’s a win-win situation for CHOA and life goes on as usual for fat kids and their parents – the same old shame/blame game that never ends.

    • January 19, 2012 1:43 pm

      Yeah. Talk about a messaging fail… if you’re running a public health campaign, you best get your public health facts straight. I don’t want to be so cynical as to say it’s all about money, but, yeah, it’s all about the money. Controversy drives attention drives donations drives sustainability. They just don’t seem to care about the consequences.


  2. January 18, 2012 1:07 am

    I will admit that I’m a damn dummy when it comes to math and it makes my head spin. But from personal observation as someone who has cared for the elderly since 1988, I can tell you this. The so called “diseases of obesity” are actually diseases of aging and affect people of all sizes equally–and yes (shocker) there are obese elderly people. The two differences that I have observed is that very slender people tend to be more prone to osteoporosis whereas very heavy people tend to develop osteoarthritis in the lower extremities (knees and ankles) at an earlier age. This tends to even out, and I can’t say offhand if perhaps these individuals had jobs that required a lot of standing/walking. Also, I place no value judgment, it’s simply an observation.
    My (normal weight) son is doing his clinical rotation to become a pharmacy technician and will thereafter begin his pre-med studies. He has said that he thinks that BMI as a measurement of health is a load of crap and that it was never intended at the time of its creation to be used as a health diagnosis. He has sworn never to use BMI as a determinant of a person’s health but instead to utilize other criteria such as blood pressure, cholesterol measurements, blood sugar, and such and to help people develop a plan of care that works for their particular situation rather than simply saying “you’re fat–eat less and exercise more.”
    I wonder what health care would be like if all health care professionals would develop such a common sense approach. Imagine not being afraid to seek medical care for fear of being shamed. What a revolution that would be!
    I only point out that my son is normal weight to illustrate that some folks who aren’t obese think that the body mass index and body shaming is a load of crap too.

    • January 19, 2012 1:42 pm

      You’re exactly right on the diseases of aging. It’s something people completely ignore: our population is aging at a rapid rate and any increase in disease prevalence (including obesity) needs to take this into account. They don’t, of course, but they should.

      BMI is completely useless. Lifestyle is what matters. I’m glad your son is already versed in this. That’s just one more good doctor on the way.


  3. January 18, 2012 11:14 pm

    You seriously need to get on that book. I’m in awe of your blog post creating power. It’s like reading mini-essays (that aren’t that mini!) that someone wrote for university.

    • January 19, 2012 1:39 pm

      It’s mentally exhausting to write so much, and then I worry that it’s too much for anyone to possibly slog through, so I’m glad that’s not the case. 🙂


  4. Ruth permalink
    January 19, 2012 10:22 am

    Just a technical word choice deal:

    I believe you meant to say muscle is denser than fat, not the other way around. I’m still reading the rest of this post–glad you’re back!

    • January 19, 2012 1:38 pm

      Did I really get that backward? Ugh, what a maroon! Thanks Ruth. 🙂


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