No tomorrows

A program to reverse childhood obesity in America, created by the Alliance for a Healthier Generation, a joint project of the William J. Clinton Foundation and American Heart Association, was just given the nation’s most prestigious health care quality award at a black tie gala in Washington, DC.

The National Committee for Quality Assurance* presented the award, which is given to those who’ve exemplified evidence-based medicine and helped health care achieve its fundamental purpose: to improve health, the NCQA president said in a press release.

The Let’s Just Play Go Healthy Challenge, a project of the Alliance for a Healthier Generation, working with Nickelodeon, was recognized. This collaboration seeks to teach kids “to eat better and play harder to combat the epidemic of obesity in America’s children.”

But, despite the NCQA’s focus on evidence-based medicine, there no evidence to support this childhood obesity program or the working assumptions behind it. In fact, it is interesting that the Alliance was launched two years ago, just as several major scientific reviews of the evidence surrounding childhood obesity initiatives had been released — all of which found that no program to date had been proven to work.

Mr. Clinton introduced his Alliance for a Healthier Generations at a media event held at a Manhattan school on May 3, 2005. There, he’d told the children that he’d been fat as a kid because he loved fatty, sugary foods and it had clogged his arteries and caused his heart attack. “The truth is, that children are consuming more sugar and fatty foods than ever before,” he said. “If young children ate 45 fewer calories a day, they would lose two pounds a year and be 20 pounds lighter when they graduated from high school.”

So, the mission of his Alliance centers on encouraging children to manage their weight by eating right and exercising, along with a variety of solutions targeting schools, the food industry and healthcare providers. Robert Wood Johnson Foundation granted $8 million last year to fund the Alliance’s Healthy Schools Program. The Alliance set as its goal to stop the increase in childhood obesity by 2010.

The priorities of Mr. Clinton’s Alliance are nearly identical to those of most childhood obesity initiatives, such as the U.S. Department of Agriculture’s “Eat Smart. Play Hard” or “Action for Healthy Kids” funded by the Robert Wood Johnson Foundation. To be nonpartisan in this discussion, it’s also similar to the childhood obesity initiatives introduced by President George Bush. Nickelodeon is even collaborating in his program, too.

While Mr. Clinton partnered with the American Heart Association, at the time of the Alliance's launch, even its scientists had just published in the journal Circulation the AHA Scientific Statement, “Overweight in Children and Adolescents: Pathophysiology, Consequences, Prevention, and Treatment.”

It called for the immediate development of large scale strategies to prevent childhood obesity, even though the actual evidence presented in its lengthy findings contradicted any notions that such initiatives would be effective. Noting the dismal success rates, the AHA scientists said:

Most efforts to prevent obesity among school-age children and adolescents have been implemented in school settings...that include classroom curricula, physical education curricula, changes in school meals, vending machines, and cafeterias, and after-school program....Many of these interventions have not successfully changed weight and body fat, however.

In reviewing all the evidence surrounding population-based or community-wide prevention efforts the AHA scientists could find no conclusive evidence for the effectiveness of any program. There was even weaker evidence for individual preventative measures, weight control or treatments.

The 2004 Institute of Medicine report, “Preventing Childhood Obesity: Health in the Balance,” commissioned and funded by the Robert Wood Johnson Foundation, also noted the lack of evidence for any of their far-reaching policy recommendations: “Presently, there is limited experimental evidence regarding the best ways to prevent childhood obesity and the extent to which various potential factors contribute to weight gain.”

And the U.S. Preventive Services Task Force, after reviewing 40 years of evidence, released in 2005 its Summary of Evidence on childhood obesity interventions, which was extensively reviewed here, along with the scathing commentary by the scientists, reviewed here, in which they strongly chastised professionals for charging ahead with interventions that risked harming children. If you missed these two pivotal posts, follow the links to catch the details.

Suffice it to say, as with the USPSTF, no scientific review has been able to find any quality evidence of any interventions to reduce or prevent childhood obesity — no matter how well-intentioned, comprehensive, restrictive, intensive, long in duration, and tackling diet and activity in every possible way — that have been effective, especially in any beneficial, sustained way; nor have they been able to demonstrate improved health outcomes or physiological measures, such as blood lipids (“cholesterol”), glucose tolerance, blood pressure or physical fitness.

Given the lack of credible evidence, not many parents or healthcare professionals are probably keen on the idea of experimenting on their growing children. But they may still be puzzled or incredulous as to why eating right and exercising doesn’t, and won’t ever, eliminate childhood obesity.

That’s because, as stunning as it may sound, childhood obesity can’t be blamed on what or how much kids eat or how much exercise they get. Regardless of their diets or “exercise,” children will still naturally grow up to be a wide range of heights and body weights. Normal human variation in size is determined by our genes. The DONALD (Dortmund Nutritional Anthropometric Longitudinally Designed) Study, for example, clinically followed children, actually weighing the individual children and recording their diets (the foods, amounts and eating occasions) at least ten times a year and followed them thusly for 17 years. They found that no matter what the children ate during childhood or adolescence, they naturally grew up to be a wide range of weights. While there were great differences in the children’s diets, these differences weren’t at all related to their weights.

This is just one study of a profusion of others, both clinical and epidemiological, over the past fifty years demonstrating that fat children (and adults) as a group normally eat exactly the same as thin people. Multiple researchers, using a variety of methodologies, have failed to find any meaningful or replicable differences in the caloric intake or eating patterns of the obese compared to the non-obese to explain obesity, concluded David Garner, Ph.D. and Susan Wooley, Ph.D., for example, in their review of some 500 studies on weight in Clinical Psychology Review.

Here is where it is easy to let our beliefs color our critical thinking skills. We all know that “association doesn’t mean causation” — when we see it on paper in a study. But not when we’re looking at it with our own eyeballs. We see a fat child eating a donut and say “Ah-ha! That is why the child is fat.” Meanwhile, we don’t turn around and see all of the thin kids eating a donut, too.

The lack of evidence for” bad” foods or diets as causing obesity is also seen on a population-wide basis. Another AHA Scientific Statement for healthcare professionals in 1996 called “Understanding Obesity in Youth,” reviewed all of the evidence and concluded: “Studies of diet composition in children do not identify the cause of obesity in youth. Current dietary fat and saturated-fat intakes of American children are lower than in the past.” This certainly isn’t what we hear in the news, but it is what the available evidence continues to show. For example, a recent study conducted by researchers at the National Center for Health Statistics, Centers for Disease Control and Prevention, and the National Cancer Institute, National Institutes of Health, examined dietary trends among youth ages 2 to 19 since the 1970s. While “childhood obesity” rates increased, they found the calories kids consumed had changed little and that total and saturated fat intakes had even decreased. Children continue to eat within the 25% to 35% recommended by the Dietary Guidelines.

Evidence is worldwide, too, that what most kids eat simply doesn’t have any relationship to what they weigh. [We are referring here, of course, to healthy children, not rare extreme cases or syndromes; or populations suffering from widespread poverty, war, food insecurity or starvation, and diseases which keep weight stats unhealthfully lower, as well as lifespans a fraction of those in developed areas.]

Despite fears of bad foods, numerous researchers have found that eating high-calorie, low-nutrient dense foods like sweets doesn’t correlate with children’s weights and that consumption is high among all kids. Canadian researchers looked at the diets of more than 130,000 kids in 34 countries and reported in a recent issue of Obesity Reviews that fat kids even eat the least sweets, and that kids’ body weights had nothing to do with how many fruits, vegetables or soft drinks they consumed.

There is no reason to suspect that 50 years of consistent, careful evidence and human physiology is suddenly going to change and negate the facts.

While generations of parents have wished their children ate better, concerns that today’s children are eating horribly and that the “bad” foods they are eating will lead to disease and premature death, are not based on credible evidence and fears have been greatly overblown, as we looked at here. We’ve come to believe that all-out efforts are imperative because of the crisis of childhood obesity. We certainly see nothing but the most extreme examples on the news to depict childhood obesity and convince us that it’s reached pandemic proportions. But how many have thought to question this claim?

I share the concerns of the USPSTF scientists, as probably do a lot of parents, that these interventions focusing on our children’s weight and diet are not only lacking in good science, but are not harmless. We’ve seen multiple examples of the harm already appearing as a result of the “healthy lifestyle” messages being taught to our children. They are exposed to relentless frightening news about the foods they love and about their bodies — the lessons they are taking away is that they must avoid bad foods, bad fats, bad carbohydrates, bad calories or they’ll become fat, diseased and die horrible deaths. We’ve come to believe and let our children believe that only those of “normal” weights are healthy, and that naturally fatter children are blights on our society and walking timebombs for disease and premature death.

It’s a mad world. I can only think of Gary Jule’s lyrics. Like Shinga, they leave me in a heap when I think of the despair so many children, surrounded by so much negative news, must be left feeling are the prospects for their future.

*Sidenote:

For nonmedical readers who may be unfamiliar with NCQA, it is a private organization founded in 1990 that offers a seal of quality for various managed health care programs (insurance plans). To win the NCQA seal, organizations must comply with the performance measures they adopt, such as Health Plan Employer Data and Information Set (HEDIS^®), the most widely used set of performance measures in the country. [These are things like how often screenings are to be done on plan members; how conditions such as diabetes, asthma and blood pressure are controlled with medications; length of hospital stays, etc.] NCQA says it creates its measures by building consensus among stakeholders and adopting strategies that they believe will improve care and reduce costs, such as paying providers based on performance, leveraging the internet and disease management. Upcoming posts will examine these in more detail.

This organization is funded almost entirely by the major pharmaceutical companies and a few pharmaceutical-sponsored trade groups, as well as foundations such as California Endowment and the Robert Wood Johnson Foundation. The significance of these two foundations playing such a major role in NCQA will become apparent in upcoming posts.

©2007 Sandy Szwarc. All rights reserved.