Fat kids picked on again

Last week, we were engulfed by news reports headlining: “High Rate of Overweight and Obesity Found in Children Having Surgery.” They were all taken from the same University of Michigan Health System press release.

The study was published in this months’ Journal of the National Medical Association, which says it's a publication that promotes the interests of osteopathic physicians and patients of African descent. The study and the news devoted most of their copy discussing the “epidemic of overweight and obesity” in children and the magnitude of the problems they create for doctors and surgeons, and even parents with their supposed “behavior problems.” There were also multiple references to bariatric surgeries for children, which is puzzling as none of the children in this study had the surgery, the FDA has not approved lap bands for use in children, and only about 1% even had adult-calculated BMIs (body mass index) high enough to be considered under adult guidelines. The researchers looked retrospectively through the records of 6,017 pediatric surgeries performed at their hospital from 2000 to 2004 and found 31.5% of the children were “overweight” or “obese.” [Remember that number.]

“The high rates of overweight and obesity that we found among children are striking because overweight children have a higher risk of problems before, during and after surgery,” said lead author Bukky Nafiu, M.D., FRCA, an anesthesiology resident.

How many of you glanced at the news and thought that fat children have higher rates of surgery than normal weight children?

They got you. The word “high” does not mean “higher.”

This is another example of using carefully worded headlines and statements to heighten the perception of a crisis of childhood obesity. You will remember the story just two weeks ago, as written about here, blaming fat children for raising healthcare costs which turned out to be not the children’s fault at all.

After calculating the childrens’ BMIs, the University of Michigan researchers used U.S. Centers for Disease Control and Prevention growth charts and labeled those with BMIs in the 85th-95th percentile as “overweight” and those at the 95th percentile or higher as “obese.” While their cut-offs corresponded to the CDC’s latest BMI-based growth charts, the labels they applied to the children didn’t. The CDC states children at or above the 95th percentile are “overweight” and those in the 85th-95th percentiles are “at risk.” But these researchers went a step further and used adult BMI categories to label some of the children as “morbidly obese,” which isn’t even recognized in pediatrics.

There has been a recent movement among weight loss interests to use the term “obese” in children, even though it disregards established pediatric practice and evidence that the term is inappropriate in children. [Upcoming: “New Age Numerology: Why kids are little Tyrannosaurs rexes.”] But words are powerful things and you can’t have an epidemic of childhood obesity without obese children. It also serves to effectively double the numbers of children that can now be considered “overweight and obese.”

The CDC states, as of the latest NHANES 1999-2002, that 32% of children in the U.S. population are “at risk for overweight” and “overweight.”

So this study actually found slightly fewer children in the upper percentiles among those having surgery. Fat children are not having more surgeries than other children.

Well, that wouldn’t do. They then looked for a way to support their claim that fat children have a “higher risk of problems before, during and after the surgeries.” Did they examine any clinical data to measure health problems or complication rates among the children, as we might be tempted to assume?

No.

They applied an unusual classification system created in 1941 by the American Society of Anesthetists (which later became the Anesthesiologists) to note the acuity — the level of “sickness” — of patients prior to selecting the anesthetic or performing surgery. Cleveland Clinic said this about the ASA classification: “Describing patients’ preoperative physical status is used for recordkeeping, for communicating between colleagues, and to create a uniform system for statistical analysis. The grading system is not intended for use as a measure to predict operative risk.”

ASA Classification

· Class 1 - Generally healthy, localized pathologic process

· Class 2 - Stable mild to moderate systemic condition (controlled hypertension or diabetes, smoker, obesity, COPD, pregnant, asthma, over 70 years of age)

· Class 3 - Moderately severe systemic disorder (poorly controlled diseases of more than one body system, history of heart disease and angina, morbid obesity, congestive heart failure, chronic renal failure)

· Class 4 - Severe and clearly life-threatening disorder (recent heart attack, unstable angina, severe congestive heart failure or COPD, liver or kidney failure)

· Class 5 - Little chance of survival; procedure performed in desperation

Their simple move to categorize children using adult definitions for “obese,” let alone “morbidly obese,” was expected to tend to place the fat children in higher categories and label them as more unhealthy. But it didn’t work that way. “We were quite surprised to find a nonlinear relationship between BMI and ASA status...since adult data suggest that overweight and obese patients are usually given higher ASA scores,” they wrote in their conclusions. The ASA scores, independently performed by doctors and registered nurse anesthetists, showed the mean BMIs were the same among Class 1 as Class 4. In fact, those in Class 3 had the lowest BMIs. The researchers were equally surprised by how many “obese” and “morbidly obese” children were in Class 1 and healthy!

Interestingly, in this study, most of the operations performed on the pediatric patients were ear, nose and throat (otolaryngologic) surgeries. According to Dr. Amelia Drake, M.D., chief of pediatric otolaryngology at the University of North Carolina School of Medicine, tonsillectomies are still the most common surgical procedure performed in children in the United States and the primary reasons are chronic infections, followed by enlarged tonsils. Not a child’s weight.

I hope the fat kids were at least allowed some ice cream after having their tonsils out.

© 2007 Sandy Szwarc