"Fat Children Eat Less Than Their Thinner Peers". That's the tweet Linda Bacon from HAES fame sent out to her followers at 9:55am yesterday morning.
It certainly fits the HAES narrative that the world's completely backwards in regard to anything and everything weight related.
Sadly it also continues Linda's confusing practice of tweeting bad data.
Linda's HAES platform, whether you agree or disagree with it, rests on the shoulders of her critical analysis of the medical literature on obesity, and her take is that many of the studies with which researchers and clinicians have vilified obesity, were either poorly designed or poorly analyzed.
But yet here's Linda promoting a Medscape news piece on a non-peer reviewed, poster presentation from a pediatric conference, where the findings are readily debatable.
The poster whose findings she was authoritatively retweeting, tracked the dietary recall of 12,316 children between the ages of 1 and 17 years of age.
Tweet and actual data accuracy aside, what the researchers truly reported wasn't that all fat children eat less than their thinner peers, but rather that the caloric intake of overweight and obese kids aged 1-7 exceeded that of their thinner peers but that the pattern "flipped" at age 7.
So what does "flipped" mean?
According to the poster, 9-11 year old kids with overweight and obesity reported consuming 1,988 calories daily, while their thinner peers reported consuming 2,069 (a difference of 4% which I'd venture isn't likely to be a statistically significant one). The study's 15-17 year olds with overweight and obesity reported consuming 2,271 calories daily, while their thinner counterparts reported 2,537 (a difference of 12%).
But can we really trust the dietary recall of children with overweight and obesity?
I'm not trying to be harsh. This world is not kind to overweight and obese children (or adults), and Linda would certainly know better than most of the stigma, bias and bullying those kids likely face on a daily basis - potentially even from their parents, their schools and their physicians. I don't think it would be an even remotely surprising finding that when participating in dietary recall surveys, children with overweight and obesity, especially older children who've had more time to experience hateful weight bias, might be more likely to under report.
So is there data to suggest that's a real possibility? Could these kids be under-reporting by more than the 12% seen in the oldest age group?
Absolutely.
In fact just this past February there was a review paper published in the International Journal of Pediatric Obesity titled, Assessing dietary intake in children and adolescents: Considerations and recommendations for obesity research. Regarding under-estimation, here's what the review paper's authors had to say,
"One of the most robust findings in dietary studies of children and adolescents is the positive association between under reporting and increased body fatness, particularly in adolescents (4,14,15). This is consistent with studies in overweight and obese adults (16). The extent of mis-reporting irrespective of weight status increases with age and has been reported as 14% of energy intake in 6-year-olds (17), 25% in 10-year-olds (18) and 40% (4,19) to 50% (14) in obese adolescents.."The authors further report that the type of study most likely to suffer from under-reporting is the very type performed for the poster in question,
"Studies characterising under-reporting have focused on total diet assessment methods and in particular, energy intake"To be clear, I think Linda Bacon's contribution to the field of overweight and obesity research, as well as public policy and attitude, is tremendously important. I just can't rationalize the scientifically critical Linda Bacon with her Twitter persona that seems to just retweet anything that satisfies the HAES narrative, no matter how weak or poorly designed the study (or in this case, the poster) may be.
Sigh.
There's got to be a better way to fight misinformation and statistically indefensible conclusions than the promulgation of misinformation and statistically indefensible conclusions.
Magarey, A., Watson, J., Golley, R., Burrows, T., Sutherland, R., McNaughton, S., Denney-Wilson, E., Campbell, K., & Collins, C. (2011). Assessing dietary intake in children and adolescents: Considerations and recommendations for obesity research International Journal of Pediatric Obesity, 6 (1), 2-11 DOI: 10.3109/17477161003728469
Posts
Off the top of my head, I can think of a couple of ways to "flip" the self reporting. I would use photographs of foods inan online food diary format for children reporting in pre-K through third grade with softwear programmed to analyze the foods for macro and micro nutritive content (eg photos of hamburgers with buns, individual serving sizes of whole foods). Children choose the foods and how many of those foods they eat.
ReplyDeleteFor everyone else, incentivize the reporting by asking them to report foods eaten with the goal of attaining 100% RDI micronutrients adjusted for age, gender and reproductive needs and a >75% daily intake of whole/minimally processed foods. Suddenly, diarists are scratching their heads and trying to list every morsel in order to meet goals.
Use software which analyzes caloric content and macro nutrients along with the micronutrients, and the picture should change a bit. Whether this will induce over-reporting would be of interest.
This would accomplish a couple of things which the HAES folks should appreciate:
gets at the underlying nutrient value of food
relates calories within a nutritive value system (Is what you are eating healthful?)
relegates weight to a secondary position in nutrition
Lastly, I wondered if you ever give patients prescriptions to shop only in the perimeter aisles of the grocery or to change their diets to >xx% whole/minimally processed foods?
Given the atrocious health literacy levels, I wonder if this would be easier and simpler to follow? You could "sell" it based on the faster time to shop (no need to read food labels and worry about fortification/macronutrient/caloric content). Essentially, shop like great-grandmother.
Good points AEK. Although the kids studied are maybe too young, most older kids will have a camera on their mobile phones. I do suggest to patients to take a photo of their food before they eat, to create a photo food diary for the week. I'm not too interested in the food types/calories that are photographed, but in trying to create a space to attend to eating, to address mindless eating.
ReplyDeleteI like the supermarket suggestion, not sure how Canadian supermarkets differ to the UK (more maple syrup, elk burgers and moose I suppose) but in every supermarket in the UK you have to walk through the veg and fruit before you enter the rest of the store. It could be interesting to help people to spend time paying attention to the food in this section, the smell, texture and shape of the food. Bring an unusual fruit to clinic to eat!
These are solid suggestions. One other helpful thing parents could do, is shop with their kids now and again at the local farmers' market, especially during the high season when they're operating at full blast. Give them a treat: buy some fresh produce and eat it. They'll see an eye-popping world of difference, compared even with the produce section of their supermarket.
ReplyDeleteYou know what happens at age 7 to thin, athletic kids is they start participating in sports year around. My kids started age group club swimming at the ages of 5 and 7 and swimmers eat a lot. Plus they were still doing baseball, soccer, basketball, golf and tennis. By the time they reached high school, they were both three sport athletes so there's a good chance they were eating more calories than overweight and obese children. I would order 16 dozen breadsticks when I would have the high school swim team (~24 boys) over for pasta night.
ReplyDeleteHow was the data collected? Self reporting? The heavy's will under report more, leaving out the junk food at night, evenings snacks. Typical value of under reporting... 30%. But the heavy's will move less, no sugar rush movement, no spontaneous movements, little enthusiasm for physical games. Another study sold, more research paid for, and the world turns on the transfer of money.
ReplyDeleteAs someone who deals with obesity from a scientific/medical perspective, I realize that I may be somewhat out of touch with the cultural, psychological, and sociological implications of obesity (and hence also incomplete in my understanding of causal pathways). In order to enlighten my perspective, I have spent time reading numerous books on obesity politics, food politics, body image, as well as many books and blogs on first hand accounts of living with (and fighting against or managing, depending on the person's perspective) obesity. When first reading the HAES literature I thought 'great! a new perspective! a rational approach to health and weight!' However, in delving deeper into the field I have become increasingly frustrated. The same HAES promoters who tear down what are, in fact, reasonably designed and conducted studies on the risks (and sometimes lack of risk) associated with excess weight seem to be the same people who champion even the most minor, poorly conducted, non peer reviewed study that shows benefits associated with obesity. NB - I am not saying all studies demonstrating benefits of obesity are poorly conducted; rather, HAES advocates seem to wear rose coloured glasses in reviewing the literature that supports their 'cause.' There really needs to be a rational middle. Surely the HAES advocates realize that there are some pitfalls to extreme BMIs?
ReplyDeleteDr. Freedhoff, please be harsher. Those of us who work with these kids everyday are intimatly aware that they ingest many more calories than they need. Comparative analysis is a waste of time and sends us down the wrong path. Each obese child has a unique set of circumstances and physiology. Obese children do not have a sensible rationale with food under any circumstances, let alone recall.
ReplyDeleteThere are rafts of diet surveys going back to the 1950's that show that obese children and adults do not eat more than thin people. Is it because all fat people are liars? That's one hypothesis. But calorie intake tracks very well with self reported physical activity. Joggers eat many more calories than obese individuals. Michael Phelps the Olympic simmer famously eats more than 10,000 calories a day, and scientists stationed in Antarctica consume that much and more.
ReplyDeleteSo, if low calorie counts by fat people reflect mere lying, then we must also assume that exercising makes you more truthful.
The more likely hypothesis is that physical activity is the main determinant of calorie intake, and obese people are less physicially active.
Another misconception is that it takes a massive calorie consumption to maintain a high body weight. This is not true. Stored triglycerides do not increase caloric expenditure. A positive energy balance will lead to fat storage, but a positive energy balance is not required to maintain it.
The entire obesity epidemic can be explained by 10 extra calories a day, which causes an extra pound a year of weight gain. 10 calories is too small to be measured in a dietary survey.
Hm, 10 extra Calories per day? That's exactly what Taubes said when I saw him promoting his book. Does not sound plausible to me. References please? I want to examine this myself.
DeleteI covered the 10 calories a day business in my review of Taubes' book (though there he talks of 20 calories a day).
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