Counting Chickens —

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.