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Counting Chickens —

January 26, 2012

Last week, I sliced and diced the FAQ on Strong4Life’s website, explaining how the cost estimates associated with obesity are being conflated, and obfuscated, by Strong4Life’s willful manipulation of the facts.

Setting aside the factual issues with their claims that fat kids are costing Georgians “a lot of money,” I find the financial argument that justifies the shaming of fat children to be extremely distasteful and misguided. We have seen this kind of “do anything to save a buck” mentality at work before in even graver situations.

Translated, this Nazi-era poster says*, “This person suffering from hereditary defects costs the community 60,000 Reichsmark during his lifetime. Fellow Germans, that is your money, too.”

Just to be clear, I am not comparing Strong4Life to the Nazis. Although I find the shaming of fat children to be reprehensible and indefensible, the actions of Children’s Healthcare of Atlanta (CHOA) pale in comparison to the atrocities committed by the Nazi party.

That being said, this kind of fiscal rationalization for medical policy can be used to justify any number of injustices, and when organizations spend more time appealing to your pocketbook than your sense of humanity and decency, your red flags ought to immediately be raised.

Economic justification aside, the more humane appeal lies in the claim that CHOA has been overrun by fat kids presenting a range of “obesity-related” illnesses. And on their FAQ, Strong4Life claims that childhood obesity is a crisis because “obese children are at risk for developing heart disease, hypertension, liver and kidney disease and type 2 diabetes.”

But is obesity, or the presence of “excess” fat, responsible for these diseases? And, if so, how prevalent are they?

According to the Texas Heart Institute, the cause of heart disease in children is primarily due to cigarette smoking, not weight:

Among young people who would otherwise have a very low risk of heart disease, cigarette smoking may cause as many as 75 percent of the cases of heart disease.

So only 25% of pediatric heart disease is caused by something other than smoking. It’s simple to conclude that the other 25% would be caused by obesity, but what about the role of genetic heart defects, stress and weight cycling, all of which may also contribute to childhood heart disease.

One of the major risk factors for heart disease is chronic hypertension, but according to Dr. Gerald Reaven, father of our modern understanding of metabolic syndrome, it is the combination of chronic hypertension and high cholesterol that gives us the greatest predictive power. So how prevalent is hypertension among children?

According to the Texas Heart Institute, fewer than 3% of children in the United States have high blood pressure and less than 15% of children have high cholesterol levels.

Considering the fact that Strong4Life repeatedly asserts that 40% of Georgia’s children are overweight or obese, so one would expect these numbers to be much higher.

Although obesity and hypertension are correlated, obese children aren’t the only kids with high blood pressure. According to a 2002 review in the American Heart Association’s Hypertension journal, obese children (those in the 95th percentile for weight) comprised 34% of children with hypertension, while kids with in the 90th percentile and above make up 57% of kids with high blood pressure.

This suggests that 43% of hypertension cases are found in kids in less than the 90th percentile (aka, the kids Strong4Life isn’t targeting), although the percentiles don’t quite add up to 100% in this chart.

But is the child’s weight the determining factor here? If so, you would expect these, and other metabolic indicators, to be consistent across weight classes, regardless of racial and socio-economic barriers. Of course, that just isn’t the case.

In a 1999 study in the Journal of Pediatrics, researchers found that while 11% of overweight white girls presented three cardiovascular risk factors, while 65% of overweight black girls had three risk factors. The same results were found for boys.

So, what accounts for this discrepancy?

In hypertension, the risk factors include obesity, but also sodium intake, hormone regulation, insulin resistance, sympathetic nervous system activation, vascular smooth muscle function, and genetics, which accounts for an estimated 30-60% of variation in blood pressure.

And, in this month’s issue of the Journal of Hypertension, researchers found that “insulin resistance plays a role on hypertension independently from obesity, fat distribution and puberty across weight classes.”

Once again, insulin resistance appears to play a greater role in the development of hypertension, and other metabolic disorders, than obesity. Obesity, hypertension, high cholesterol and type 2 diabetes can all be symptoms of insulin resistance, yet public health organizations like Strong4Life remain committed to combating the symptoms rather than the cause.

Another perfect example of this is when they cite kidney disease as a consequence of obesity. Again, not true.

A December 2011 study in the Clinical Journal of the American Society of Nephrology looked at children with chronic kidney disease and found that “[46%] percent had hypertension, 44% had dyslipidemia, 15% were obese, and 21% had abnormal glucose metabolism.”

Once again, Strong4Life takes a minor correlation and inflates obesity into a major contributing factor. Nearly 85% of children with chronic kidney disease are not obese, yet Strong4Life lists it as one of the reasons why childhood obesity is a crisis.

But the King of Crisis for childhood obesity has to be type 2 diabetes.

You can’t swing a bag of cupcakes without hitting the childhood obesity/diabetes trope. But just how prevalent is type 2 diabetes in children? A simple search in WebMD reveals the facts:

According to a 2006 study in the Archives of Pediatrics and Adolescent Medicine, 39,000 kids have type 2 diabetes ages 12-19.

That’s a lot of kids. But there are approximately 25 million kids between the ages of 12 and 17. Even allowing that there are even more aged 18 and 19, and you get a conservative estimate that less than 0.15% of kids have type 2 diabetes.

And since there are 2.5 million Georgians under age 18 (PDF), this suggests that in the entire state of Georgia there are 3,750 kids who have type 2 diabetes.

According to estimates of diabetes,  15% of adolescents with impaired fasting glucose are in what is now the obese weight category, while 9.5% of adolescents were in the normal weight. Focusing on weight, rather than the more reliable metrics for detecting diabetes, will result in a free pass given “normal weight” adolescents who may be at risk for diabetes.

So do we point at these children and shame them for costing taxpayers money too? Do we shame their families for failing to rein in metabolic disorders and costing us money? Or do we look at the underlying influences on health, the ones that explain the differences between fat white children and fat black children.

For example, a powerful influence on metabolic health, is early life determinants, including poverty, pregnancy-induced hypertension, smoking during pregnancy, low birthweight, no breast feeding and high sodium diets in infancy.

All of these contributing factors are influenced by socioeconomic status and all of them are part of the social determinants of health, which I explained in greater detail in this post. Are black people more genetically prone to hypertension than white people or are black people more likely to suffer the consequences of an economic system that limits upward mobility and, therefore, their access to greater health and self-care options? And how does living in poverty contribute to stress, yet another powerful influence on our metabolic health?

According to a December 2011 study in the journal Metabolism, stress is tied to many of these issues.

[T]he experience of acute intense physical or emotional stress, as well as of chronic stress, may lead to the development of or may exacerbate several psychologic and somatic conditions, including anxiety disorders, depression, obesity, and the metabolic syndrome… Fetal life, childhood, and adolescence are particularly vulnerable periods of life to the effects of intense acute or chronic stress. Similarly, these life stages are crucial for the later development of behavioral, metabolic, and immune abnormalities.

And guess what contributes to chronic stress… you guessed it, stigma.

So although childhood obesity is correlated with some of the health issues Strong4Life raises, it is by no means the most important risk factor for those diseases, and it is the diseases themselves, not the size or shape of the child’s body, that costs money in the end.

Healthcare organizations should be in the business of treating disease, not shaming kids for having diseases. Promote healthy eating and exercise for all children, and maybe we can reduce the incidents of metabolic disorders in all children, not just those who physically repulse Strong4Life.

*Hat tip to Amber Bante for the poster and translation.

12 Comments leave one →
  1. January 26, 2012 3:56 pm

    Wow, Shannon, great minds think alike, but you’re so much better at writing about it, and of course your use of statistics and data is second to none. I shared this post on a little itty bitty teeny weeny page that I made on Facebook. I know one friend has already shared it as well.
    This is the URL to our Facebook page, in case anyone is interested in such things.

    • January 26, 2012 3:57 pm

      I have long said that if the fat haters could get away with it they would march us off to the “showers” same as the Nazis did to all their perceived enemies of the state.

    • January 26, 2012 4:44 pm

      Thanks Faycin. I think fat haters (those who are outright disgusted by fat people and have no compunction about telling us so) would be more likely to propose something as drastic as euthanizing fat people (or at the very least, detaining them against their will until they lose weight), but I don’t think CHOA or Strong4Life are on that level. Yet.


  2. vesta44 permalink
    January 26, 2012 4:37 pm

    I said something like that when I first found FA and boy, oh boy, did a lot of people come down on me for that. I was told that I was over-reacting, that it would never come to that, that I was comparing the discrimination fat people face to the discrimination the Jews faced (I wasn’t, I just said that if the government had its way, all fat people would be rounded up and put in camps so we could be “re-educated” about how to eat and exercise, and forced to do so until we became whatever size they determined was “normal”). And these were people who had been in FA for quite a while, were influential in FA. Welcoming to newcomers? Open to debate and new ideas? Yeah, not so much, I found out. But it’s an idea that’s been in the back of my mind ever since, and everything I’ve seen since then hasn’t done anything to convince me I was wrong then, or that I’m wrong now in thinking it could still happen (rendition, anyone?).

    • January 26, 2012 4:42 pm

      I wouldn’t equate Strong4Life with Nazis, but I do find the comparison of making money the most important consideration in this debate to be eerily reminiscent of the actual eugenics policies espoused by the Nazis. I don’t think we’re in danger of being rounded up or euthanized, but this emphasis on how much the undesirables are costing the rest of us is disturbing.


  3. January 26, 2012 6:26 pm

    Not crazy about the Nazi rhetoric – I’m Jewish – but the very vague theory is totally on point. Eliminating the “undesirables” has been a theme in group discourse for ages – it’s all about getting your group (nation/religion/ethnicity/whatever) to be “the best”. Americans have been looking at the fat as undesirables for decades, if not centuries. The major difference being that right now we’re being shamed instead of shot.

    • January 26, 2012 7:44 pm

      Hi CC,
      I hope I didn’t offend. I don’t want to draw Nazi comparisons, but the dehumanization strategy common to both was to bracing not to mention.


      • January 27, 2012 1:24 pm

        No, I understand why you did it. It’s just hard when you’re Jewish not to jump to a knee-jerk reaction, when there are actually real sociological comments that can be made. Just, if the comparisons can be made to other things, so much the better. Occasionally, they can’t.

        • January 27, 2012 9:56 pm

          Okay, I’m throwing my 2 cents in on this dialog. Historically, certainly the last 150 years or so in this country, various groups of people have been made the scapegoats of society, typically at the point at society seems ready to rip apart at the seams (which is pretty much whenever the economy goes through a bust cycle).

          Traditionally the scapegoats are anyone who can be pretty much anyone who can be quickly identified for their differences from “normal” society, by color, features, language, etc.. Now it’s the fatties who’ve been scapegoated.

          I think people tend to go to the Nazis the fasted because they took their hatred to an incredible extreme. I also like to think that we’re better off as a society that people haven’t forgotten about the atrocities committed by the Nazis, but I can certainly sympathize and relate to your point of view, CC. I also think that comparing people to Nazis won’t help one’s argument, rather you’re more likely to be dismissed as being hysterical and closed off to discussion.

          So we can use the Klan or another hate group other than the Nazis. Or we could use the US government like when they rounded up Japanese and Japanese Americans and put them in internment camps.

  4. January 27, 2012 11:04 am

    When we analyze rhetoric (that hides and denies harmful consequences), and we find clear parallels between the fascist propaganda which was used to dehumanized gay people (or people who had been labelled “disabled”, or people given various diagnoses of “unhealthiness” that devalued them in consensus reality)–and when we see that the contemporary rhetoric is strategically identical to that which predated violent reactions (posters or billboards proclaiming, for instance, that “those people” will have shorter life spans, anyway), well, even though they might not come out directly and advocate the of use physical violence against them, the RESULTS are predictable. There will be violence, hate, and shame. This is not a war against “unhealthy” behaviors. People who are wealthy and powerful, for instance, do not feel ashamed for partaking everyday in conspicuous mass consumption of earth’s dwindling and costly *resources*–they stroll leisurely along miles of pristine golf courses and private beaches, cut down forests for vacation resort homes to escape the rabble of cities, guzzle/burn fossil fuels as if there are no consequences to anyone else, endlessly manufacture crap to distract the masses as if we are small children in playpens–but fat children are labelled “unhealthy” and accused of being a drain on society, accused of contributing to a “dangerous epidemic” that must be fought like a war, with enemies, good guys vs. bad guys. The *good guys*, of course, wear white coats (gee, like the nazi in the photo), and they are called “professionals” who use science to “help” our nation win this terrible fight against…who? The people who “eat too much?” The people who are “costing the rest of us?” It’s not a fight about “health” but about maintaining status and power at the expense of human lives.

    • Emerald permalink
      January 27, 2012 2:33 pm

      I think Paul Campos (someone correct me if I’m wrong) made the suggestion that fat people are used as scapegoats for a society which is, on some level, well aware that it’s over-consuming the world’s resources – point the finger at a group who aren’t actually consuming that much (but who can be made out to look as if they are), and it salves their guilty conscience. It’s a theory that makes a lot of sense. As others have pointed out, the way many political cartoonists and some members of the occupy movement depict the bankers et al as literal ‘fat cats’ – when most of the world’s richest people are actually fairly thin – is a good example. And in tough financial times, people unfortunately look for scapegoats.

      • January 27, 2012 7:00 pm

        Paul Campos’ theory sounds interesting and provocative because the displacement of shame has become ritualized throughout social media, some might say fetishized, in the name of controlling physical health–and the constant focus on fat (headless) bodies suggests a gaze of self-deception that aims to hide the evidence of social mindlessness (soulless interaction) in contemporary cultural relations between humans-as-objects–as signified by that which is omitted. Not to go all Derrida on you. Still. 🙂

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