Only the Finest Propaganda will Solve Childhood Obesity

Yes, life sometimes gets in the way of my blog posts; rather than keep you waiting for a fully referenced article I was hoping to post as follow up to the new recommendations to address childhood obesity, issued jointly from the AMA, CDC and HHRS, I'm going to keep this short and point first to a massive, 400+ page, document - Preventing Childhood Obesity: Health in the Balance - published in 2005 by the Food & Nutrition Board (FNB) of the Institute of Medicine (IOM) that painstakingly reviewed the evidence published regarding childhood obesity.

When you take some time to read it, you'll notice some critically important statements thoughout:

"Empirical data is lacking..."

"...problem exists, causes less clear..."

"...little clarity about the relative importance of possible causitive factors..."

"...a robust evidence base is not yet available."

"In reviewing the available evidence to inform this report, there was an abundance of scientific studies on the causes and correlates of obesity, but few studies testing potential solutions with diverse and complex social and environmental contexts, and no proven effective population-based solutions."

But that's okay, let's press forward without hard data; the latest AMA recommendations seem to have ignored the above lack of data and even ignored that the IOM document specifically states that within their publication there is "limited literature upon which to base these recommendations..." and chose instead to concentrate on "...parallel evidence from other public health issues..." to side-step empirical data and move forward to modify public opinion anyway.

"Now that the nation has begun to realize the significant health, psychological and societal costs of an unhealthy weight, it is time to re-examine its way of thinking and revise the social norms that are now accepted."

"In the absence of precise understanding of the eitology of the problem, it may be useful to look at the lessons learned from other public health campaigns and to try and determine if these lessons have any relevance for the prevention of childhood obesity."

Their playbook to resolve childhood obesity? Lessons learned from tobacco control, seat belt enforcement, underage drinking, childhood vaccination, and regulation of speed limits; with the most notable precedent examples throughout the section on Lessons Learned from Public Health Efforts and their Relevance to Preventing Childhood Obesity being the stunning success of tobacco control initiatives, that now leave smoking, in the minds of the majority of society, "nearly considered, if not deviant behavior, at least one in private;" and they note the magnitude of the change in public perception of smoking over the years of gradual change, from a time when smoking was viewed as a private matter, to now when smoking is viewed as a moral failing and deviant behavior.

They note, "Culture is not a static set of values and practices," and that programs to prevent and reverse obesity need to balance "the role of coersion versus the individual."

Coersion?

How they fail to see the under-current of shame and moralizing a behavior like smoking is scary. We're going to now do this with children, kids who happen to weigh too much for their age and height? Have we lost our minds?

Oh, it just gets better though.

The 'best practices' to be employed in a national campaign to address childhood obesity:

• Community-wide campaigns
• School-based initiatives
• Mass media strategies
• Laws and regulations
• Provider reminder systems
• Reduce costs to patients
• Home visits

The list includes elements of both formal planned interventions and recognized cultural and social factors. Detailed too are the necessary elements to convince the population at large there is a problem that requires drastic measures:

• A persuasive science base documenting a socially and scientifically credible threat
• A supportive partnership with the media
• Strategic leadership and a prominent champion
• A diverse constituency of highly effective advocates
• Enabling and reinforcing laws, regulations and policies

Notice above, the critically important factors are not solid evidence, but persuation, packaging the message for the media to propogate to the public, repeat the message through advocates and champions, and regulating laws and policies to conform to the pursuasive messages.

That's not science, that's carefully orchestrated propaganda.

"Propaganda is the deliberate, systematic attempt to shape perceptions, manipulate cognitions, and direct behavior to achieve a response that furthers the desired intent of the propagandist." Source: Garth S. Jowett and Victoria O'Donnell, Propaganda And Persuasion, 4th edition, 2006

This is what public health experts intend to do to our children.

In stunning clarity, the document provides insights into what we can expect in the coming years:

"Tough choices will have to be made at all levels of society. There will be trade-offs in convenience, in cost, in what's 'easy', in pushing oneself and one's organization, in choosing between priorities, in devising new laws and regulations, and in setting limits on individuals and industries."

The second document I'd like to direct your attention to is from the US Preventative Task Force, published in 2006, Screening and Interventions for Overweight in Children and Adolescents: Recommendation Statement.

It states, "There is insufficient evidence to ascertain the magnitude of the potential harms of screening or prevention and treatment interventions. The USPSTF was, therefore, unable to determine the balance between potential benefits and harms for the routine screening of children and adolescents for overweight."

Now, in 2007 - with no new science and still no compelling evidence, no empirical data, absolutely nothing more than "hope" this will work, the AMA, CDC, and HHRS is jumping in with both feet, and expects all of us to do the same; expects we'll all get on board, full steam ahead with little more than our fear that if we do nothing, our kids are going to die prematurely; anything is better than nothing.

Except that anything is may wind up destroying our children in the long-term.

But hey, they won't be fat, right?

The direction we're now heading in stubbornly and without evidence, reminds me of something Aldous Huxley said in a speech at the California Medical School in San Francisco, 1961:

"There will be in the next generation or so a pharmacological method of making people love their servitude and producing dictatorship without tears, so to speak, producing a kind of painless concentration camp for entire societies so that people will in fact have their liberties taken away from them but will rather enjoy it ... [through] brainwashing enhanced by pharmacological methods."

In the 1953 publication of The Impact of Science on Society, Bertrand Russel penned the following:

"Scientific societies are as yet in their infancy. . . . It is to be expected that advances in physiology and psychology will give governments much more control over individual mentality than they now have even in totalitarian countries. Fitche laid it down that education should aim at destroying free will, so that, after pupils have left school, they shall be incapable, throughout the rest of their lives, of thinking or acting otherwise than as their schoolmasters would have wished." "Diet, injections, and injunctions will combine, from a very early age, to produce the sort of character and the sort of beliefs that the authorities consider desirable, and any serious criticism of the powers that be will become psychologically impossible."

Impact of Community Based Diet Intervention, More than BMI

There's been a lot of fuss over the publication of the Shape Up Somerville: Eat Smart Play Hard.™, initiative results in the May issue of Obesity. (abstract)

As noted in the abstract, the objective "was to test the hypothesis that a community-based environmental change intervention could prevent weight gain in young children" as reflected in the change in BMI z-score.

In total, 1,178 children were enrolled - 385 in Somerville (the intervention group), and two control communities, one enrolling 561 children to be followed, the other 232 children to be followed. All the children were in grades 1 through 3 at the beginning of the study period, school year 2003-2004 (September to June).

The intervention was intensive, and expensive.

Overall, the researchers started with a $1.5-million dollar CDC grant. And, if that were not enough, the Tufts website notes the grant "received supplemental support from The US Potato Board, Dole Food Company, Blue Cross and Blue Shiled of MA. It is also supported through generaous donations by Whole Foods Market, WGBH, New Balance, Gaining Ground, Annie’s Homegrown, Stonyfield Farm, Organic Valley, White Wave, Earthbound Farms, Shaw’s Supermarkets, Cabot Creamery, Friendship Dairies, Newman’s Own, The Vermont Bread Company, and the Kashi Company."

The Wall Street Journal included some idea of this supplemental support in quantifiable terms...

"...the Tufts researchers helped the city win a grant from the Robert Wood Johnson Foundation for a bigger-ticket item, an extension of a bike path that will eventually go all the way to Boston. "

"...the City Council came up with its own ideas: reimbursements on gym membership for city employees and dozens of new bike racks for schools and streets."

"...Dr. Economos persuaded a Whole Foods store to donate about $35,000 in fresh produce."

"...a Department of Homeland Security grant is providing fitness equipment at fire stations and chefs to train the firefighters about nutrition and healthy meals."

"...a doctor sponsors the community fun run."

So, it's hard to add up all the additional monies and in-kind donations to know the true cost of the initative, but Somerville has secured an additional $1.5-million dollars to continue the efforts.

What exactly happened in Somerville that so much attention is focused on this small town?

Throughout the city of Somerville, the efforts to place the towns children on a diet and increase activity included:

• School lunches, classroom snacks and fundraisers revamped


• Teachers were trained to implement the new health curriculum, called The HEAT Club (Health Eating and Active Time)


• School Staff Role Modeling implemented


• After school program policies created for snacks


• After School policies for physical activity developed


• Increased time for recess, lunch, and physical education


• Annual height and weight data collected with reports for parents


• Monthly newsletter was sent to parents


• Monthly community newsletter to community members


• Parent education forums held for non-english speaking parents


• Area restaurants developed "Shape Up Approved" menu items


• Safe Routes to School maps were created


• Crosswalks were re-painted in thermoplastic material


• Bike racks installed at elementary schools


• School nurses and area Pediatricians were educated about taking weight and height of children

I don't think they missed an opportunity to intervene, do you? No Child Left Behind - heck, this was an "in your face" intervention, with no one left behind.

Throughout Somerville, it was impossible to escape the Shape Up Somerville messages.

So you'd think the results would be impressive given the media's attention the last few weeks.

The researchers trumpted "A community-based environmental change intervention decreased BMI z-score in children at high risk for obesity. These results are significant given the obesigenic environmental backdrop against which the intervention occurred. This model demonstrates promise for communities throughout the country confronted with escalating childhood obesity rates."

Based on their results that found over eight months, "At baseline, 44% (n = 385), 36% (n = 561), and 43% (n = 232) of children were above the 85th percentile for BMI z-score in the intervention and the two control communities, respectively. In the intervention community, BMI z-score decreased by –0.1005 (p = 0.001, 95% confidence interval, –0.1151 to –0.0859) compared with children in the control communities after controlling for baseline covariates."

Simply put, the kids in the intervention group gained about 1-pound less than the kids in the two control towns who received no intervention.

They didn't lose weight, they just gained less, which is expected - growing children gain weight each year (or are supposed to).

Within the full-text we find a curious table designed to highlight the effect of this intervention, Estimated intervention effect over 8 months on a child at the 75th percentile BMI z-score, which seems contrary to the objective of reducing the incidence of overweight and obesity, which is defined as a BMI that places a child in the 85th percentile or higher.

Nonetheless, the researchers included it to show how the intervention would effect children at the 75th percentile - children, it should be noted, already within the definition of a "healthy weight" for age.

It seems to have escaped many that with or without intervention such a child would remain within "normal, healthy" weight, as evidenced in the table data included.

Case in point - highlighted in the table - a boy, at baseline 8-years old has a BMI of 17 and is in the 75th percentile. Eight months later, without intervention (it's hypothesized) he might grow about an inch-and-a-half and gain 5.07 pounds; with intervention, just 4.25-pounds (a difference of 0.82-pounds, or about 12-ounces).

Without intervention the child's BMI is now 17.4; with intervention it is now 17.17 - in both instances the BMI increased, right?

But in both instances the child in this scenario fell on the charts, going from the 75th percentile to the 73.9 percentile without any intervention and the 71.1 with intervention, and at a cost of $1.5-million to keep this hypothetical child well within "normal" when he would have remained there anyway?

I wondered, what happened to the kids who were overweight or obese to start - the 170 of 385 children in the intervention.

As I combed through the data, another curiosity - no data was provided to show the intervention was effective for this particular subset of children within the intervention group.

Why was that data not provided?

I would think that would be the icing on the cake for the researchers to highlight the benefit of such an intense intervention, wouldn't you?

So, I got to thinking, what changes, based on the data provided, might happen for a child within this group?

The researchers neatly summed up the hypothetical child within normal, so how about we create the same table for a child who was at the 95th percentile at baseline to see what might happen.

Johnny is 8-years old, he stands 4' 2.25" and weighs 72-pounds - BMI 20.1, 95th percentile.

In eight months, like the scenario presented by researchers, he now stands 4' 3.75" (growing 1.5") and without intervention is likely to weigh 77-pounds (gained five pounds); with intervention he'd weigh about 76-pounds (gained four pounds).

Without intervention he's fallen to the 93.8 percentile; with it he's fallen to the 93rd percentile.

Yes - with or without intervention this hypothetical child went from "overweight" to "at risk for overweight" - which begins to explain the absence of data on the subject of where the children were on the charts at the end of the study period.

I'm not trying to say we shouldn't try to help children engage in more activity or eat a healthier diet, but quite frankly, these results are not as impressive as we're being led to believe.

We have no data to look to in our understanding of how this type of aggressive community-based intervention impacted children already underweight or at the bottom of "normal, healthy" weight; we have no clue as to how this type of intervention impacted those children who were well within "normal, healthy" weight; and without the hard data we don't know that any of this helped those children at risk for or already overweight!

I'd like to see the data and also see someone investigate impacts in other areas of life, like reading and math scores. Sandy Szwarc, over at Junkfood Science, pointed out that "While the school year was absorbed in diet and exercise, (after the Shape Up program was completed in 2005) the average reading test scores among Somerville kids are 15.4% below state average, and their math test scores are a whopping 26% below those of kids in the rest of the state."

I did some poking around and found the Somerville MCAS testing stats online; in the 2003/04 school year, third grade reading scores indicated that 44% needed improvement or were failing; in the 2004/05 school year - these same students, now 4th graders, tested in ELA (english language arts) showed 63% now needing improvement or failing, and 73% needed improvement or were failing math (not tested in 3rd grade).

Just some food for thought, and a hat tip to Sandy for the educational impacts that may be part of the intiatives overall impact not recorded in the results that are focused on BMI z-scores.