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Day After Day —

January 16, 2012

On Friday, I had intended to write about an entirely different subject all together, and because it took 2,800 words just to cover all the reasons why targeting fat kids‘ parents is a real crap idea, I never returned never arrived at my intended destination.

I knew I shoulda taken that left turn at Albuquerque.

But then at 2:55 p.m. on Friday , I finally received the first response to any of my many emails to Children’s Healthcare of Atlanta. Kevin McClelland, Director of External Communications for CHOA, wrote to tell me, among other things, that “we are having members of our medical team review your post so we can appropriately respond to you.”

Holy shit.

Do you know what that means?

It’s a medical euphemism for dioxin poisoning. Viktor Yushchenko received a similar email the week before his assassination attempt.

Fortunately, we’ve got Ron Paul’s ten-year emergency food supply in the basement.

I kid.

But, seriously, we’ve already covered why it’s a terrible idea for public health campaigns to target childhood obesity alone, and suggested that, instead, we get the attention of all parents that metabolic disorders can affect all children who eat an energy-dense diet and lead a sedentary lifestyle. Obesity is, at best, a modest indicator of metabolic abnormalities, according to Gerald Reaven (aka the guy who in 1988 reintroduced the concept of syndrome X (aka metabolic syndrome, aka Reaven’s syndrome)).

And according to Reaven,

[A]lthough being overweight/obese increases the chances of an individual being significantly insulin resistant, by no means are all overweight/obese individuals insulin resistant, and, of greater clinical relevance, weight loss in overweight/obese individuals who are not insulin resistant does not lead to substantial clinical benefit. [emphasis mine]

Now, while we’re waiting for the lovingly-crafted response from the medical team at CHOA, I’d like to explain how metabolic disorders, including obesity, are directly related to our environment. For many of us, we are born into circumstances beyond our control and raised in an environment largely influenced by socio-economic and political forces that can limit the freedom of millions of Americans, the poorest of whom are often the heaviest on average.

According to a November 2011 article in American Diabetes Association’s Diabetes journal, a study of 3,139 counties in the U.S. found that socio-economic status and weight were strongly correlated:

“In contrast to international trends, people in America who live in the most poverty-dense counties are those most prone to obesity. Counties with poverty rates of >35% have obesity rates 145% greater than wealthy counties.”

Data from 3,139 counties in the U.S. Quintiles are cohorts of counties ranked by the percentage of people living with poverty. Quintile 1, the wealthiest quintile, includes 630 U.S. counties with a mean county poverty rate of 8.2% (median household income, $56,259). Quintile 5, the poorest quintile, includes 629 counties with a mean poverty rate of 25% (median household income, $32,679). A: County age-adjusted obesity rates by poverty quintile. B: County obesity rates vs. county leisure-time sedentary rates (sedentary adults are those who report no physical activity or exercise other than at their regular job). C: County sedentary rates. D: Age-adjusted diabetes rate by poverty quintile.

While the wealthy are not immune to diabetes or cardiovascular disease, having less than a high school education or having a family income below poverty level both double your risk of dying from type 2 diabetes, according to the June 2010 public health report from the CDC (PDF). And in the May 1996 issue of the ADA’s Diabetes Care, a study of 2,400 Europeans found that those with a primary education (less than 14 years) had slightly worse health than their college educated peers (I’ve removed p-values, but they are available in the abstract):

People with a primary education were older and had diabetes for longer than those with a college education. The mean percentage of HbA1c [an indicator of how well blood glucose levels are controled]  was worst in the primary-educated men (6.6 vs. 6.1%) and women (6.5 vs. 6.0%). Total cholesterol level was higher in primary-educated than in college-educated men (5.6 vs 5.3 mmol/l), as was triglyceride level (1.23 vs. 1.02 mmol/l). College-educated people were the least likely to be current smokers, and were most likely to partake in vigorous exercise. Surprisingly, there was little difference in the prevalence of heart disease by educational status in men, while it was highest in the least educated women… glycemic control could not fully account for these differences.

And in the October 2011 Medical News, even one of the most laughable ledes I’ve ever read states, “Helping people move out of poor neighborhoods into those that are better off may help reduce levels of obesity and diabetes, researchers found.” The health outcomes are promising for a study of nearly 4,500 women with children.

In a large social experiment, people who used vouchers to move to an area with better socioeconomic conditions were significantly less likely to have a high body mass index (BMI) and elevated glycated hemoglobin (HbA1c) levels than those who remained in poor neighborhoods, Jens Ludwig, PhD, of the University of Chicago, and colleagues reported in the Oct. 20 issue of the New England Journal of Medicine.

The results, described as “modest but potentially important reductions in the prevalence of extreme obesity and diabetes,” include a 13% relative reduction in those a BMI of 35 and over, a 19% relative reduction in those with a BMI of 40 and over (morbid obesity), and a 21% relative reduction of HbA1c of 6.5% or higher.

And, finally, in a report from Harvard’s Division of Public Health Practice published in the October 1998 British Medical Journal, the authors found that regardless of income level, individuals living in states with the greatest income inequalities were 30% more likely to report their health as fair or poor. In this report, Georgia earned a Category 4 rating for having the greatest inequalities in income.

To say that poverty and obesity are strongly related is not a controversial statement. To say that wealth and privilege improve long-term control of diabetes is not a controversial statement. According to an article in the 2004 issue of Oxford’s Epidemiologic Reviews, the disparity is due in part to better access to adequate health care, functional health literacy, language barriers, culture and acculturation, mental health, social supports, social integration, competing demands and, above all, stress.

CHOA responded to Bronwen through Facebook that the 75% study, which they are still “collecting,” was based on surveys in Atlanta and Macon, Georgia. According to the Metro Atlanta Task Force for the Homeless, “Atlanta is the poorest city in the U.S. for children — more children in Atlanta live in poverty than in any other city.” Also, “48% of all the children in Atlanta in poverty live in families with annual incomes of less than $15,000 a year.”

While the October 2009 Forbes magazine named Macon one of the 10 most impoverished cities in the United States with a per capita income of nearly $22,000. Plus, 19% of Georgians are completely uninsured, and incomes are declining from the top on down.

Meanwhile, the middle class has been getting squeezed on all sides for decades. Remember when 9-5 literally meant an eight hour day including an hour for lunch? No? Me, neither, and I’ve been working my way up from the service industry into a professional office for half of my 32 years.

As Elizabeth Warren describes so wonderfully in The Two Income Trap, middle class families began moving to the suburbs in search for better schools and safer neighborhoods, which created a bidding war that ran them deep into debt. With suburban sprawl came the long-distance commute with an hour, or longer, spent in the car both to and from work.

In two generations’ time, families went from modest 8-10 hour work days for one of the household’s adults to a 10.5-12.5 hour work days for both of the household’s adults, if there are two. If there’s only one adult, then the time crunch is even more severe.

To put it in perspective, I wake up at 7:30 a.m. every morning to catch the 8:06 train, and get to the office by 9 a.m. I get an unpaid half hour of a lunch and leave at 5:30 a.m., only to get home by 6:30 p.m. That is 11 hours each day spent preparing for, traveling to, and participating in my job.

We are fortunate because Veronica is a stay-at-home mom, but if we were both working, her schedule would be roughly similar due to where we live and where the best-paying professional jobs are located.

Now, add in the minimum recommended 7-9 hours of sleep that the Mayo Clinic recommends for optimum health (and considering that sleep experts say that not getting enough sleep contributes to obesity, it would seem that getting those minimum recommend hours would be important), and that leaves between 4-6 hours each night that we would have to spend with our family and to spend destressing after a long day of work (and considering the correlation between chronic stress and obesity, it would seem that having time to destress would be important).

That 4-6 hours has to include the cooking, the cleaning, bath time, and all of the family time we spend with the people we love. And that’s not even taking into consideration that physical activity is also necessary for health.

And I can tell you from experience, that incorporating physical activity into your life must, by necessity, take up a good chunk of that free time.

In September 2010, our family got a membership to the YMCA, where I began using the elliptical twice weekly, while Veronica goes to a water aerobics class. We do this on Tuesday and Thursday evening, which means that on those nights when I get home, the girls are just finishing supper so that we can get to V’s class on time. After packing up the girls, we head to the gym and do our thing.

After we exercise, sometimes we take the girls for a swim in the pool as well. The nights we do swim, we get back home about 9 p.m., just in time for bed, but if we forgo swimming (and break their little hearts) we get home at 8:30 p.m.

Again, I cannot imagine being able to do this if Veronica were not a stay-at-home mom. And even though she is, and can prepare dinner in early, there is still the fact that while I’m on the elliptical, I don’t get to spend time with my girls. It’s a trade off. Yeah, I’m being a good fatty and getting my exercise, but as a parent, I’m losing time that I could spend with my family.

And that’s just getting aerobic exercise. The American College of Sports Medicine not only recommends 150 minutes of moderate aerobic exercise (or 75 minutes of vigorous) per week, but strength training as well. We don’t have time to do strength training on Tuesdays and Wednesdays, so we have taken up weight lifting on Mondays and Wednesdays, which is also bath night, so our evenings are completely packed with fitness regimens.

And yet, I’m still fat.

Were I to believe the public health outcry against people with bodies like mine, I might feel like spending all of this time at the gym just isn’t worth it because I’m busting my butt and not getting the results that I’m told to expect.

And I’m fortunate enough to be in a situation where my wife can stay home and take care of the cooking and the cleaning because, otherwise, I don’t know what we’d do.

But this is the reality for millions of middle class Americans: time is precious and valuable, and how you spend that time has become part of the public domain, where complete strangers will judge you for choosing to optimize your time by incorporating convenience foods into their food preparation.

Yet, I know plenty of wealthy people who use convenience foods as well. The only difference is that they buy their convenience foods from the deli at Whole Foods, where delicious, whole foods are served up to save them time.

For the poor and middle class, convenience foods are affordable, fast and tasty, but are often times loaded with preservatives and high energy density (more calories per bite). Popular thinking is that energy dense foods plus a more sedentary workforce are largely responsible for the rise in obesity rates (that leveled off in 1999 for women and children and in 2004 for men).

So, self-righteous critics of convenience foods will inevitably point out that rice and beans are cheap and filling, and that it’s about choices, and that people simply aren’t willing to make the choice of eating healthy foods.

But rice and beans still takes time to cook. I could buy a frozen box of rice and beans and microwave it in two minutes in its own dish, while I clean up the house a bit. Or I can boil the rice and beans myself for 15 minutes (and every minute matters, mind you) and remain relatively tethered to the kitchen.

But most importantly, rice and beans just don’t taste as good as a cheeseburger from McDonalds. This galls food critics the most because health should be more important than taste.

Yet wealthy people who buy convenience foods are able to afford freshly prepared, nutritious foods that are also delicious. But poor and middle class people should be content to a life of rice and beans because it’s cheap and healthy, and delicious just isn’t that important.

Bullshit.

Unless you’re a chronic dieter on the perpetual quest for thinness, nobody enjoys eating bland health food night after night. We are conditioned to enjoy food, and this idea that people should sacrifice flavor for health is condescending bullshit.

But something has to give. We either need more free time in our evening and money (not to mention the cooking equipment, utensils and knowledge) to prepare fresh, whole, delicious meals ourselves, or else somebody needs to start developing a line of affordable, healthy, and delicious convenience foods for the poor and middle class.

This is why I completely and totally support the federal attempts to increase the amount of children who can participate in the National School Lunch Program, as well as the attempts to improve the nutritional quality of school lunches. Parents are already stretched thin in terms of time and money, and the NSLP can ensure that their children do not suffer as a consequnce.

However, improving school lunches, teaching nutrition to students, and adding more physical exercise to schools will not result in thinner students. Consider the experience of three large school-based trials that did just that: Pathways (a three-year randomized, controlled trial of 1,700 3rd through 5th grade Native American students); CATCH (the largest ever school-based trial by the National Institutes of Health, which included  four states over three years); and Shape Up Somerville (a three-year trial of 1st through 3rd graders in Somerville, Massachusetts). All three found that they had positive outcomes regarding health and nutrition knowledge and general health improvements, yet none experienced a significant reduction in weight (although Shape Up Somerville averaged a one pound loss).

Again, this aligns well with the Health at Every Size®, in which health outcomes, not weight, is the metric by which you judge success. So, although these three programs failed to make their kids thinner, they did improve their health and their understanding health, both net positives. Yet by public health measures, all three programs would be considered failures since they failed to reduce the childhood obesity rates.

This is why I have said repeatedly that I will support Strong4Life’s efforts to make nutritious foods more available, as well as provide safe places for kids to exercise. These things are important and necessary.

But providing those resources will not produce the desired results that Strong4Life seems to be pushing. And what do we make of a family who increases the amount of fresh fruits and vegetables in their diet, as well as the amount of exercise they get, but remain fat? Do we consider them failures?

I will not support Strong4Life’s simplistic approach to childhood health, which revolves around lecturing fat kids about eating too much, when the world in which they are raised can make it difficult, if not impossible, to make the choices they are “supposed” to make. And when those choices are limited by the circumstances of their family’s socio-economic status, the social determinants of health can play a significant role in what those choices are.

Wikipedia has an excellent summation of the differences between traditional public health care approaches and ones that take the social determinants of health into consideration. In the traditional public health care approach, such as the one Strong4Life promotes, the following ten items are common recommendations for getting and staying healthy:

  1. Don’t smoke. If you can, stop. If you can’t, cut down.
  2. Follow a balanced diet with plenty of fruit and vegetables.
  3. Keep physically active.
  4. Manage stress by, for example, talking things through and making time to relax.
  5. If you drink alcohol, do so in moderation.
  6. Cover up in the sun, and protect children from sunburn.
  7. Practice safer sex.
  8. Take up cancer-screening opportunities.
  9. Be safe on the roads: follow the Highway Code.
  10. Learn the First Aid ABCs: airways, breathing, circulation.

But when you consider the role that the social determinants of health plays in public health, the following ten items might be more appropriate:

  1. Don’t be poor. If you can, stop. If you can’t, try not to be poor for long.
  2. Don’t have poor parents.
  3. Own a car.
  4. Don’t work in a stressful, low paid manual job.
  5. Don’t live in damp, low quality housing.
  6. Be able to afford to go on a foreign holiday and sunbathe.
  7. Practice not losing your job and don’t become unemployed.
  8. Take up all benefits you are entitled to, if you are unemployed, retired or sick or disabled.
  9. Don’t live next to a busy major road or near a polluting factory.
  10. Learn how to fill in the complex housing benefit/ asylum application forms before you become homeless and destitute.

Life is complicated and most parents are doing the best they can to maintain their own health and their child’s health, but the influence of our culture, our family, our education, our genetic endowment, can all work against us.

Rather than trying to shame people for the unhealthy choices they make, maybe it’s time we try to understand better why they are making them. Rather than portraying the parents of fat children as apathetic assholes who don’t care what they feed their kids, maybe it’s time we ask them how we can better support their needs.

Because badgering parents because they aren’t able to provide the time, money or energy necessary to give their children the very best health and nutrition options all the time will only compound the stress they feel in their lives. The guilt and self-loathing that comes from being made to feel like a bad parent will only lead to worse mental and physical health.

Stop treating parents like idiots in need of a benevolent dictator, and start treating them for what they are: doing their best in a difficult environment that rewards economic achievement (whether earned or inherited) and punishes subsistence living with shame and derision.

I will be posting a second, smaller post shortly that will explain how are strategy this week will be shifting away from shaming CHOA (as you cannot shame an organization that delights in controversy) and toward getting more professional organizations to join our cause.

Thank you for everything you’ve done last week and for all that you will continue to do until the billboards come down.

5 Comments leave one →
  1. vesta44 permalink
    January 16, 2012 12:37 pm

    An amazing summation, Shannon. But I’m afraid it would go way over the heads of the people at CHOA. They have it in their minds that they are right and nothing we say, no research we cite is going to change their minds. For them, it’s set in stone, and I’m afraid we don’t have a big enough jackhammer to break them out of their misguided jackassery.

  2. Mulberry permalink
    January 16, 2012 4:45 pm

    Beautiful post, Shannon. Absolutely beautiful.

    This note underneath the charts caught my eye: (sedentary adults are those who report no physical activity or exercise other than at their regular job)

    Aren’t a lot of jobs that poor people might have physically demanding ones?

    • vesta44 permalink
      January 16, 2012 11:41 pm

      Yeah, most of the jobs that poor people have aren’t ones where they’re sitting on their butts all day long. Those are usually jobs where you’re standing/walking/carrying all day long, cleaning/packing/cooking/washing/waiting tables, etc. Those jobs aren’t the sedentary jobs that don’t give you any exercise but walking to and from your car – those are the jobs that have you working so hard you’re exhausted when you come home from work and don’t have the energy to cook a meal or clean your house, let alone get on a treadmill or an exercise bike. It’s not the lack of exercise that keeps poor people fat, it’s all the other factors that Shannon listed in his post – most poor people are too busy working their asses off to put a roof over their heads, clothes on their backs, and food on the table to have time to exercise outside of work.

    • February 13, 2012 1:27 pm

      Mulberry, this is going to blow your mind. There was a study on this very topic, and it found that hotel chambermaids who PERCEIVED THEMSELVES as active were healthier than those in similar jobs who didn’t. Check it out: http://www.npr.org/templates/story/story.php?storyId=17792517.

      Theresa
      The Fat Personal Trainer
      http://www.biggirlsworkout.com / http://www.bigguysworkout.com

  3. Fab@54 permalink
    January 16, 2012 4:57 pm

    Damn, Shannon…. that was gooooooood. :-)

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