Thursday, May 21, 2015


A recent study and couple of conversations led me to this.

We fret over the idea that millions of people have diabetes or hypertension and are unaware. We don’t blame them for not knowing, we blame a health care system that does not provide adequate preventive care.

But we insult parents whose children fall into a BMI percentile that defines obesity, and do so using terms like “oblivobesity”. (That actually made me a little nauseated.) This is all based on the presumption that we can “see” this horrid affliction, and the blame for that affliction lies at the feet of the parents.

Let’s take a look at what David Katz had to say: ( )

[W]e are thus obligated to ensure that the ... enlightenment of families to trouble under their roof, does not invite such unintended consequences. If we are to eradicate oblivobesity, it will not be with objective measures alone, but also with compassion, guidance, and empowerment in the mix.

I hope everyone will still respect me after this, but you’ve got to be fucking kidding me. To use “oblivobesity” and “compassion” in the same sentence is the exact attitude that has given us this world of “appropriate stigma” and that confirms, for me, that Ivory Tower folk have no clue what they are talking about. “Trouble under their roof?” What about trouble from a world that doesn’t make it safe for children to play, or ensures them equal concern in the health care system if they are fat, or even makes it safe to exist with obesity?

There is a whole world of parenting beyond obesity. Parents of children with obesity aren’t oblivious. There are completely aware of the trouble under their roof—the one that leaks and the one that may not have electricity on if they don’t work a double shift. These families don’t need “enlightenment”. 

Tuesday, May 5, 2015

Does removing sodas from school work?

A new study, behind a lovely paywall, attempts to quantify the effect of California's school competitive beverage policy. The main point is that there was a decline in obesity prevalence, but only for schools in the wealthiest neighborhoods.

It’s not a bad study, I don’t guess. I think the point that policies affect different groups differently is probably spot-on, and something we should always look at.

1) The biggest problem is that there is no control group. I could go on a tirade about the sorry state of obesity research, but this is just critical. Their time point of change—2004/2005—is exactly when obesity trends declined nationwide. Let me say the lack of a control group again. It is simply not possible to attribute the change to the policy. Period. There was a change the same time as the policy, but there are plenty of other reasons I could argue also “caused” the effect.

2) What’s the plausibility of the effect? It’s a policy that said, essentially, you can only sell drinks that are half crap and half juice (so just a caloric as a soda). A second policy, which more clearly limited sugar content, went into place in 2007, and there is no effect of that on their outcomes.

3) They don’t look at harms. I don’t love the idea of Coke having a role in schools. But as long as we are unwilling to fund schools appropriately, the financial impact of these programs can’t be overlooked. What’s more is that these programs are most likely to help the poorest neighborhoods. Not only do poor kids not get the same positive effect, their schools also lack the resources to fill in the gaps of the lost income.

4) Finally, prevalence of overweight/obesity is not a great outcome. Change in z-score is hard because it’s not longitudinal, but if there is more severe obesity in minority or poor groups, then there will naturally be less transition into the healthy weight group.

I really want to find a policy that works. But I don’t think the obesity “epidemic” can be pinned on the devil of sugar sweetened beverages, much less cured with a SSB policy based only at schools. It is the nature of researchers to parse out interventions to their lowest part. But the complexity of obesity simply won’t yield to parsimony. Obesity won’t be cured with a cooking class, swapping out the coke for juice, or a school vegetable garden. (Oh, god, the zealotry of the school vegetable garden people.)

Ironically, one small thing like a beverage policy is unlikely to improve obesity, but it does have the power to be harmful. Just as it takes a lifetime to raise kids to be happy and well-adjusted, it takes only a single traumatic event to completely change trajectories. It’s easy to pass a policy banning beverages. It’s not easy to include in that policy coverage of the costs of that decision.