Money changes everything

How do pediatricians address “obesity” in children who come into their offices? Dr. Sarah Barlow, M.D., M.P.H., and colleagues at Saint Louis University School of Public Health interviewed eight pediatricians in the St. Louis, Missouri, area and asked them to describe their experiences counseling children and their families about obesity. They wrote up the results of their interviews in the latest issue of Child: Care, Health and Development.

Not surprisingly, the pediatricians reported that their efforts to follow published guidelines and counsel about healthy eating and physical activity consistently failed to result in the children losing weight.

But that isn’t the value in this paper. Instead, it’s in the troubling private admissions these pediatricians made about how they saw the fat children and their families, and the disturbing inside look at how some doctors talk to fat children their parents. This paper also gives us a valuable take home lesson when we see an impressive list of studies.

There was no evidence that the pediatricians didn’t care or have the best interests of the children at heart. Most tried to find ways to provide counseling despite limited office time. But, as the study authors noted, none of the pediatricians questioned the benefits of the lifestyle recommendations they gave. Rather, they viewed the failure of the children to lose weight as proof of “patients and families not making those changes.” The doctors they interviewed said they saw parents as lacking motivation, being disinterested in changing their lifestyle behaviors, and failing to realize that weight was a serious problem.

“Paediatricians perceived that even when families were concerned, they seemed not to follow advice,” said the authors.

The doctors said the lifestyle recommendations they gave families included advice to cut out sodas and snack foods, and change the entire household to eating healthier and being more active. To try and motivate families to change their behaviors, most doctors emphasized the health dangers of being fat. The pediatricians admitted to frequently using any health problems of an older family member to warn that the child will develop it if they don’t lose weight, or the doctors said they’ll “do a lipid profile or a cholesterol and try to say,‘look, this is already a concern.’”

Universally, these doctors assumed that if a child was fat, he/she was eating too much and too much junk food, and was not active. And if the kids failed to lose weight, the doctors believed that the family hadn’t complied with their advice. As one said:

When [patients] try to give me the line that they don’t eat that much, I always respond, you know, ‘are you taking me for an idiot? You want me to come over there and write down what all you’re eating?’

These doctors admitted they assumed that the low-income parents were making especially unhealthy food shopping decisions and going to fast food places, rather then making healthy family meals. They presumed these parents had more time constraints and that their larger families were probably undermining the parents’ control over their children’s diets.

Still, the authors said, some doctors believed parents could be doing more. “I find the majority of them are not willing to make sacrifices to help their children,” one pediatrician was reported as saying.

According to Barlow’s team, pediatricians oftentimes perceived that parents were not concerned or only made a “pretense of concern, especially when the parents themselves were overweight.” One pediatrician was quoted as saying:

[They] only act like they’re listening. If it’s a fat mama... it’s just, ‘I’m fat, my mama has been fat, all my sisters are fat, well we’re just big people’... they can still eat their chips and watch television and their social life revolves around going to the doctor and waiting numerous hours at the Medicare.... Of course they all want to lose weight, but it doesn’t come in a box.

These illustrations of stereotypes of fat children and families as being irresponsible gluttons and sloths are disturbing in their own right, as is the presence of such glaring gaps in understanding of childhood obesity among these medical professionals. But it is impossible to know how accurately this depicts most pediatricians. Likely not, at least to the degree presented in this paper, as will become evident in a moment. While the authors presented these prejudicial views as if acceptable norms among medical professionals, that in itself could also be an effort to manipulate doctors and normalize the groupthink surrounding obesity. Clearly, conversations with eight doctors cannot be extrapolated to be representative of the entire medical profession. The authors also didn’t say if they randomly selected the doctors; they only said they chose those representing a variety of demographics and paid them for their participation.

The authors were far-reaching in their interpretations of the eight interviews, well beyond any evidence presented, yet also used them to suggest sweeping reforms. Where was the research? There were no attempts to verify the accuracy of any of the assumptions made by the doctors quoted in this paper — no clinical records were examined, no BMIs were recorded, and the actual “healthfulness” of the diets and home environments were not evaluated for any of the children. Nor did the authors examine the parenting skills or time spent with their children of any of the parents in question. There was no evidence of effectiveness for the dieting and lifestyle counseling being given by the doctors. And there was no attempt by the authors to analyze any harmful effects the doctor’s attitudes towards their fat patients, especially the poorer ones, might be having on the children and on the families, such as on avoidance or seeking of future medical care.

Barlow reported their interview findings unquestioningly as facts, saying in a St. Louis University press release:

Despite their best efforts to provide families with good advice, doctors find families lack the motivation or are so overwhelmed with the stresses of daily life that they don't attempt to attack weight problems by eating healthier and exercising more… In addition to poor home environments in many families, doctors described low family commitment.

Had the authors carefully fact-checked, very different problems from those they reported might have been identified — such as in the doctors’ and their own assumptions, and the anti-obesity interventions themselves.

A paper that’s little more than anecdotes and impressions of conversations may be a surprise to find being called “research” and published in a peer-reviewed medical journal. Most consumers, journalists and many healthcare professionals instinctively believe a citation in a medical journal refers to a study. This paper is just one example of why we cannot simply tally the number of published “studies” supporting one side or another to arrive at a conclusion, but have to closely look at their quality. When it’s poor, or a study’s conclusions don’t jive with the evidence, it’s often enlightening to look at why.

Spin or Science?

The first clue of the presence of something other than objective science came in the paper’s title: “Putting context in the statistics: paediatricians’ experiences discussing obesity during office visits.” The authors stated the context for their paper in its first sentence:

Paediatric providers are ideally positioned to address childhood obesity because the condition is common and because healthy eating and activity habits, the foundation for treatment, are part of paediatric care.

Context means interpreting information to determine its meaning. Spin means interpreting information in a biased way to sway public opinion. The second would appear to more accurately describe this paper, even down to the use of the word “statistics” in the title, when there were no statistics in this paper at all. [Counting to 8 doesn’t count. :-) When it comes to obesity research, as we’ve seen, it pays to be cautious of statistics as shaky math aptitude is common.]

While the pediatricians themselves, for instance, reported that they didn’t feel measuring BMI helped them identify the “overweight” children, Barlow stated that BMI charts should be a routine part of the office assessment in order to recognize overweight in more children before they reached more visually apparent excessive weights. Electronic medical records, she wrote, could automatically flag high BMIs for intervention. “Paediatricians need to continue to initiate the discussion and educate about health risks but identify at milder degrees of overweight.”

In a press release, Barlow said, without citing any evidence, that doctors are failing to diagnose children who may be starting to develop a weight problem. “It’s a missed opportunity for these doctors to help address weight problems early on,” she said. “If they’re going to have any effect at all, it’s going to be in encouraging small changes early.”

According to Barlow’s team, the pediatricians “described a profound sense of futility.” While the failure of counseling by pediatricians to impact childhood obesity concurs with the body of evidence, the paper’s authors attributed it to “societal forces that promoted overeating and inactivity.” Barlow and her colleagues asserted, again without providing evidence, that more success might be seen if broader social changes were made throughout society to influence behavior on a community level and if doctors used heightened media attention of obesity to step up their efforts:

Although physicians cannot control the media attention, they might stimulate a family’s contemplation of the problem…[for example] a letter sent prior to the visit that encourages families to consider the health of their child’s weight, activity and eating and to prepare questions for the paediatrician…. If clinicians can build on media attention and work to create motivation ahead of the visit and if they are prepared to provide answers to the families’ questions about healthy eating and activity practices, then clinicians may see more behaviour change without longer visits.

Most Junkfood Science readers are already seeing the similarities between the context being promoted in this paper and the government’s guidelines for addressing childhood obesity, calling for increased surveillance and BMI measuring of children, and widespread social changes to compel adherence to “healthy” eating and exercise. This connection is where we find the likely “why.”

Dr Barlow, an assistant professor of pediatrics at Saint Louis University School of Medicine with a joint appointment at the School of Public Health, disclosed that she is financially supported by the Agency for Healthcare Research and Quality and is a recipient of a K08 grant.

Let’s stop for a moment to grasp the significance of this information. The AHRQ is the health services arm of the U.S. Department of Health and Human Services and its role is to support government public health initiatives and “give information and technical assistance to State and local policymakers.” Its 2006 Congressional budget report noted, that they have been making “significant improvements in realigning the work we do with our strategic goals and those of the Department [of HHS].” A few examples:

In 2002, the AHRQ partnered with the Robert Wood Johnson Foundation in an initiative called, “Rewarding Results,” designed to facilitate the implementation by employers, health plans, and state Medicaid agencies of incentives for doctors and hospitals for compliance with specific performance measures. It was billed as the “largest and most diverse P4P project in U.S.”

The AHRQ and the HHS were funded by RWJF in 2003 for a five-year initiative called Prescription for Health. It is focused on transforming primary care practices and developing strategies to promote “healthy” lifestyle behaviors, targeting: physical activity, unhealthy diet, tobacco and alcohol usage. The first round of grants totalled $2.1 million.

AHRQ sponsored the Healthcare Cost and Utilization Project, which claimed last December that obese people were burdening hospitals — which we learned wasn’t actually the case at all.

For those unfamiliar with K08 Grants (“Mentored Clinical Scientist Development Awards”), briefly, they’re given by the National Institutes of Health for promotions that support the objectives of the HHS’s “Healthy People 2000” initiatives. The grant provides salary and fringe benefits for the recipient (in fiscal year 1999, the maximum salary was $125,900). There’s lots of jobs and funding for this kind of stuff, but not for this kind of stuff.

What Dr. Barlow didn’t reveal on her paper, however, is that she is also the director of the Cardinal Glennon Children’s Hospital Weight Management Program. She, and her co-author and research assistant, Melissa Richert, are also on staff at the St. Louis University Obesity Prevention Center, which is funded by RWJF, the NIH and NCI. It’s under the direction of Debra Haire-Joshu Ph.D., a RWJF Health Policy Fellow and an advisor on obesity and chronic disease for the Health, Education, Labor and Pensions Committee of Senator Edward Kennedy.

Dr. Barlow also wrote a series of papers with HHS Center for Disease Control and Prevention staff for the Treatment of Overweight Children and Adolescents: A Needs Assessment of Health Practitioners 2002 project funded by RWJF, which were published in the journal Pediatrics.

The third author of today’s study is Elizabeth Baker, Ph.D., M.P.H, who worked for years with Active Living Research, a national program of RWJF to promote environmental, community-based approaches to address obesity and obesity-related diseases.

This information shines a bright light on why this new study may have reached the conclusions it did and may help us put its findings into a better context for ourselves.

© 2007 Sandy Szwarc