Fat children burdens?

Another costs of “obesity” claim appeared in the news this week, this one pointing to children. Reuters reported: “Obesity raises children’s health costs.”

Fatter children were blamed for using the health care system more and “incurring significantly higher health care expenditures than their ‘healthy-weight peers.’” The headline and soundbytes implied, of course, that the children’s fatness is at fault for rising costs.

The actual findings of the study being reported, however, demonstrate that the concept was as contrived as the “costs of obesity” being attributed to adults.

Doctors at Children's Mercy Hospitals and Clinics and the University of Missouri–Kansas City School of Medicine analyzed the billing records and charts for 8,404 children who were seen for checkups during 2002-2003. The children who had been labeled “obese” or “overweight” had medical charges that were on average $172 higher.

Was it because the children were sicker?

No.

The higher medical costs were laboratory tests ordered by healthcare providers. The “obese” children were 5.5 times more likely to have had laboratory screening tests ordered, indicating that the doctors had complied with “expert committee recommendations for laboratory evaluation of obese children and adolescents,” said the authors. [In fact, the researchers found no relationship between the young people's BMI and emergency room usage or visits to the doctor.]

The belief that fat children are at risk for adult diseases has led fatter children to be more closely scrutinized. Finding blood pressures or lab values for cholesterol or blood sugars higher among larger children — which have never been routinely checked in healthy kids before — does not mean the numbers are a problem, but the prevailing belief is that any difference found in a fat child must be bad. Never mind that a large 50-year prospective study of Scottish-born children, published in Circulation, found no association between children’s BMI (body mass index) and heart disease later in life. Obesity researchers, such as Paul Ernsberger at Case Western Reserve School of Medicine, Cleveland, Ohio, have found that larger children are more developed than their thinner counterparts, which is reflected in slightly higher health indices such as blood pressures, comparable to slightly older children. But there is no evidence that they’re harmful and the numbers rise with age throughout childhood and adolescence, all within normal limits. And a study by researchers at the University of Southern California in a recent Diabetes Care, found weight was unrelated to children’s risks for insulin resistance (a stepping stone to type 2 diabetes).

Looking at cholesterol screening, for example, neither the American College of Physicians nor the U.S. Preventive Services Task Force under the Agency for Healthcare Research and Quality, recommends testing cholesterol in children or teens. Not to mention, decades of research and analysis done by Dr. Malcomb Kendrick and others with the International Network of Cholesterol Skeptics, has found no credible scientific evidence to support cholesterol as causing heart disease in the first place! In fact, they’ve documented that the evidence shows it to be protective in the elderly, associated with lower rates of cancer, and to have neurological and cognitive benefits for all ages.

But the American Heart Association, American Academy of Pediatrics and National Cholesterol Education Program (even while recognizing that for most children “obesity” is unrelated to elevated cholesterol levels) issued guidelines recommending testing all “obese” children (in the upper 5th percentile of BMI) for hyperlipidemia (high serum “cholesterol”). Along with the American Diabetes Association, the American Heart Association says all fat children should be screened for type 2 diabetes, as well as blood pressure, sleep apnea and orthopedic abnormalities.

Many consumers may be unaware just how controversial these guidelines are in the medical community. Besides lacking evidence, there have been multiple exposures of conflicts of interest among those establishing the guidelines. For example, Dr. Jerome Kassirer, editor in chief emeritus of the New England Journal of Medicine, wrote that of the nine-member NCEP panel only one had no financial ties, and “six had each received research grants, speaking honoraria or consulting fees from at least 3 and in some cases all five of the manufacturers of statins” (“cholesterol” lowering drugs).

In Family Practice News, Dr. Richard M. Schieken, professor and chairman of pediatric cardiology at the Medical College of Virginia, Richmond, wrote against screening and treating serum lipid levels in children saying “we really don’t know [if there is any benefit because] it hasn’t been studied.” Children’s serum lipid levels are normally extremely variable, he said, and it’s difficult to predict which children will go on to develop “high cholesterol” as adults, as most don’t. The risks of putting children on a lifetime of statins has never been studied, said Dr. Thomas B. Newman, a pediatrician and professor in the department of epidemiology and biostatistics at the University of California, San Francisco. “It would be all risk and no benefit for children,” he told the New York Times. “In the first ten or twenty years, you’re going to prevent zero heart attacks because there is no heart disease to prevent at that age.”

But healthcare providers are being increasingly compelled by third-party payers to follow these screening guidelines. In this cost study, the children insured by Medicaid were 60% more likely to have been labelled “obese” and have labwork drawn, as required by Medicaid guidelines for children with a family history of obesity.

While this study didn’t delineate higher rates of health problems among the fat children, any coincidental correlations between health problems and body weights would likely have misplaced the true contributing causations, as other studies have erroneously done. Most of the children in this study were African-American and on Medicaid, with significant genetic and socioeconomic factors to be considered. Minorities are twice as likely to be “overweight” than whites, but according to the U.S. Census Bureau, minority families with children are three times more likely to be living in poverty, which is actually the most significant factor in health disparities.

In this study, the researchers said that additional efforts were needed so that more healthcare providers followed screening guidelines and diagnosed “obesity” in children. According to the researchers’ own calculations of the children’s body mass index (using height and weight measurements), less than half of the “obese” children had been labelled as such by their doctors.

There was another notable difference, besides insurance coverage, between the children labelled “obese” and targeted for heightened testing and those who weren’t. Boys in the upper 5th percentile of BMIs were about half as likely as girls to be labelled as “obese.” This confirms other studies which have found that parents and healthcare providers show greater concern for fatness in adolescent girls than in teen boys, despite the fact that as girls approach puberty, it’s normal and healthy to gain up to 20-30% of body weight in fat as their bodies ready for menstruation and the ability to bear children.

A related study in the journal Pediatrics by Chicago pediatricians, also released this week, surveyed a diverse population of children from 13 pediatric practices. Among the fat children, those labelled on their charts as being “overweight” (in the upper 5th percentile of BMI) were 54% more likely than the other fat children to receive screening evaluations for “obesity-related” comorbidities.

So, we have fatter children being labelled and subjected to more laboratory tests, despite no evidence for the efficacy of such screenings. Then, the costs of those tests are used to blame fat children for raising health costs!

P.S. You may have noticed that the words “obese” and “overweight” are being used differently in the two studies this week. That’s because an insidious change of definition is afoot to double the numbers of children labelled as “too fat” and in need of intervention. More about that later!

© Sandy Szwarc 2007