It wasn't so long ago that the only body-fluid derangement of consequence in the curious milieu of marathon running was dehydration. Even people who knew better were at risk; in the psychologically intense environment of a long endurance event, it is all too easy to pass up water or other fluids in favor of saying "I feel fine" and forging on. The results can be nasty indeed, even fatal.
Nowadays, the marathon world is rife with participant-entrants who are in it for the health benefits and the camaraderie rather than to compete -- folks whose aim is not to run fast but to simply finish. As a result, threats that were once rare to nonexistent have become comparatively common, because more and more people are out on the course for five, six, even seven hours, exposing them to problems that used to be seen only in triathlons or other ultra-endurance endeavors. One of these is hyponatremia, a condition in which serum sodium levels become so dilute as a result of drinking massive amounts of electrolyte-free water that fluid is osmotically "sucked" into the brain (where sodium levels remain normal), leading to progressive disorientation, stupor, and coma, sometimes with lethal consequence. This has spawned more than a few articles on the matter, and the result has been a "hydration backlash" of sorts, with runners warning one another of the dangers taking in too much fluid during a marathon.
However, as dangerous as hyponatremia can be, the fact remains that far more people continue to suffer from dehydration than from low sodium levels. Each extreme carries its own set of pernicious effects, but to highlight one is no excuse to ignore the other. People simply have to learn what to do to forestall both.
This has no topical bearing on what I'm about to write, but you'll soon understand why I brought it up.
A woman named Laura Collins maintains a blog called "Are You Eating With Your Anorexic?" Evidently she has a daughter who suffers from the condition. Ms. Collins has written a thoughtful post about the drawbacks of certain aspects of efforts aimed at making kids better informed about the relationship between what they eat and how they feel. Specifically, she complains about an assignment given to her son in Cub Scouts -- to count calories. I agree that this is pointless, though perhaps not for precisely the same reasons Ms. Collins does. She writes:
"I do not hold to the idea that these influences cause eating disorders - I think the vulnerability is pre-existing and set in motion or triggered by dieting, overexercise, or illness. But these wrong-headed lessons can trigger those triggers, and are particularly counterproductive for children in recovery, and create a hostile environment for them when other kids are taught to parrot this stuff."
I agree. Some kids are more susceptible than others to the influences of peers, media imagery, etc., but these things do not cause eating disorders in the absence of pre-existing substrate, which often involves tumult in the home (e.g., abuse issues, parental drug or alcohol abuse) or factors that cannot easily be identified. (I am not making any assumptions here about Ms. Collins' family, by the way, I'm only paraphrasing from psychology textbooks.) But blaming runway models and Cosmo for the prevalence of EDs in America is simplistic and wrongheaded.
Ms. Collins goes on to say:
"Parents of kids with eating disorders often have their children pulled out of health classes, body fat testing, BMI checks, and other "triggering" experiences. I think this isn't enough. We ALL need to pull our kids from these anti-scientific lessons for the sake of all children.:
My sense is that she is not calling for a wholesale end to nutrition-related education, but imploring people to keep their kids isolated from its goofier facets. I think it's incumbent upon schools to teach sound science in a nonjudgmental way -- not only in the realm of nutrition and exercise, of course, but in all disciplines, because no society has ever suffered as a result of disseminating too much information. Monitoring BMI and body fat is assuredly not the job of schools; if some kids want to know their "stats," that's fine, but I would hope that schools would recognize the futility and counterproductive nature of requiring the tabulation of such data. So, regarding Ms. Collins' entry, all good.
However, pimping this post for her own misguided purposes is Sandy Szwarc, a shill for the food industry who defends and encourages overnourishment under the pretense of debunking alleged myths about the health effects of obesity on a blog called Junkfood Science. She has long been a patron saint of Big Fat Blog denizens and other close-minded, irrational, and angry persons of size, contributing enthusiastically to the morass of undiluted fiction at Tech Central Station before setting off on her own. Sadly, she's a registered nurse and is clearly very bright, but along the way seems to have found selling out a more fruitful prospect than selling facts.
In her post about Ms. Collins, she puts scare quotes around words such as "health" and "nutrition" (unfortunately, style considerations dictate that I use quotes as well) and claims that instruction in "healthy eating" puts kids at risk for disordered eating. Nowhere in her dolorous diatribe does she acknowledge that soda machines in schools and caloric excess puts kids at risk, although she's shown in the past that she's prepared to lie about the known relationships between higher adiposity and the increased risk of various diseases if necessary, typically by cherry-picking or coyly manipulating data. Mark Hoofnagle took the wrecking ball to her last fall, and her response only reinforced the points he made in his initial salvo. But she's not the sort to be discouraged by someone lighting her up because she has a fixed audience whose members have their minds made up in advance and will entertain only and exactly what people like Szwarc have to say.
Here, Szwarc writes:
"Overwhelming and consistent evidence continues to show these school nutrition policy initiatives and the CDC's 'Guidelines to promote lifelong healthy eating and physical activity' being enacted in schools cross the country do not improve children's diet's [sic], activity levels or health outcomes, or reduce obesity levels."
Note that this says nothing about the risks of overweight and obesity; it merely establishes that the way a lot of schools approach the problem is ineffective (viz. abstinence-only sex education).
Szwarc also writes (note the additional scare quotes):
"[T]here have been no significant increases in the numbers of children considered 'overweight' since 1999-2000 and children are healthier, their diets better, and the CDC expects today's children to live longer than at any other time in our history."
I'm not sure where she's getting her figures, but even if she's correct in claiming that the prevalence of overweight children has stabilized during the present decade, it's still extremely high -- about three times what it was in the mid-1970s. During this period there has been a concomitant rise in the incidence of Type II diabetes, a condition long known to be intimately connected with body habitus, yet quite a few people somehow manage to deny the obvious and attempt to dispel this association by yelling a lot and making angry blog posts. This accomplishes roughly as much as screaming at biologists for their godless and "evidence-free" claims about evolution, but presents more of a threat because it's a direct pubic-health issue.
Szwarc is a master at selective data presentation, but there's only so much deception and trickery someone can sling around before it becomes transparent.
Szwarc goes on to list numerous examples of how these well-meaning programs can backfire, building toward an emotion-heavy coda: "Children are also being made to fear getting fat and told it will give them all sorts of horrible health problems and that bad foods and slovenly behaviors will make them fat. Guilt among the naturally fat children is coupled with growing blame and prejudice directed towards them." Again, nothing here about the reality of excess weight. The entire post is a red herring -- akin to yowling ad nauseam about the dangers of hyponatremia and indicting race directors for providing too much Propel or Poland Spring while ignoring the reality of what happens to runners who take in too little water on a hot day.
My question is, if public-school nutrition courses can be considered damaging for their effect on ED-prone young women, what's the verdict on shameless enablers like Sandy Szwarc -- who, unlike a lot of grade-school teachers, damn well knows better? I'd bet anyone a million dollars that if you hit people like her with thiopental sodium and asked them what they really thought about fat and health, you'd hear them sing a tune 180 degrees out of phase with what they trumpet online (not that I would advocate such draconian measures).
The fact is, obesity and anorexia/bulimia are both serious problems, with the latter being more directly life-threatening but the former far more prevalent. The presence of anorexia is a recklessly poor excuse for ignoring the realities of being too fat. In an ideal universe we would not see damage being done at opposing ends of various spectra, because such situations inevitably invite all sorts of vicious dialogue between people with goals which, when you really think about it, are not in conflict at all. Unfortunately we do not inhabit such a universe, so we're forced to consider the fact that there are other possibilities besides dangerously fat and dangerously thin.
Although I can understand Ms. Collins's resistance to shaky forms of nutrition education and her rejection of the ways in which it is often conducted, ignoring the problem of overweight children and adolescents does no favors to either individuals or society. I like to think we are at a point in which the few extremists making noise about the total absence of obesity-driven health risks in adults and kids alike can be summarily ignored in favor of sane input, and I believe -- as do a lot of more moderate fat activists -- that the primary emphasis should be placed not on diet or "dieting" but on increasing activity levels. People who get regular exercise have markedly increased self-esteem no matter what they look like, and this in turn encourages them to make healthier decisions and become more invested in their own array of wellness outcomes. Focusing on things like calorie intake and BMI is absolutely counterproductive, but this is no more an excuse to toss the reality of obesity's health risks out the window than the side effects of Lipitor provide justification to ignore high cholesterol.
Medicine & Health
Comments
I love when you talk about these health issues, and I agree completely with your analogy about providing water for marathon runners. (Although in that case it would seem there's an easier solution--just provide drinks with electrolytes.)
I just recently started exercising consistently in the past nine months and have tried to improve my diet, which leads me to my question: Why do you think talk about BMI and calorie-counting is counterproductive?
Speaking from personal experience, I found both concepts very helpful. About nine months ago my BMI was about 24, and I was bordering on overweight. But everyone around me would say crap like, "You are sooo thin!" and I didn't realize it. Only after I started calculating my BMI did I realize there was a problem.
As for calorie-counting, that has been helpful if only because I didn't realize how many calories were in some of my main food staples. The chef boyardee meals I had were almost 700 calories a pop. A slice of pizza was 500. The huge iced coffee drinks I drank were like 900! If I hadn't paid any heed to calorie information, I might be eating and drinking all that crap, thinking it okay as long as I get some vegetables and fruits during the day, too.
So in that sense, I think calorie counting can be helpful. It gives you a realistic sense of how many calories things have (and I had no clue how calorie-packed a lot of the stuff was, like the coffee drinks).
What do you think would be a better way to educate people about these problems?
Posted by: Saint Gasoline | May 3, 2008 1:11 AM
Good questions.
"...it would seem there's an easier solution--just provide drinks with electrolytes."
They're out there, but a lot of people stick to water despite recommendations because they find that drinks with sugar or electrolytes don't agree with them when they're running. This can be overcome -- needs to be overcome, in fact -- by taking sugary and electrolyte-rich beverages during training runs. People who refuse to try stand as much chance of succeeding in marathons as do would-be ballplayers who cannot overcome their fear of a 95-MPH fastball.
"Why do you think talk about BMI and calorie-counting is counterproductive?"
I don't think talking about it is counterproductive; I just think stopping short of recording students' BMI and requiring them to submit calorie counts is a bad idea for certain people, i.e., those with body-image disturbances.
You are different in that you have an active investment in healthy weight reduction coupled with physical exercise. You are using the aforementioned tools in a productive, positive way. But just as there are those who ca relax with a single martini that would be a dire threat to a recovering alcoholic, there are people who can only do themselves harm by focusing exquisitely on their weight and food intake.
Those at the other end of the spectrum (overweight people) would do well to achieve the same realistic perspective you have with regard to energy content of foods; studies have routinely shown that people (overweight and otherwise) underestimate how much they actually eat. The raving fat activists who claim to be maintaining their weight on a given amount of food are not technically lying, but they're virtually always wrong -- a fact borne out by the weight loss that invariably occurs when people's ability to eat ad libitum is literally taken away from them, as with prisoners and unfortunates in Third World countries.
Some would respond to these "accusations" by pointing out that not everyone can be rail-thin and that losing weight is extraordinarily difficult. These things are true. I have yet to be convinced, however, that 300 pounds is a "natural" weight for anyone. Most of the people trumpeting on about losing weight only to regain it are merely reporting, without saying as much or even being aware of it, that their return to a previous high weight is always the result of slipping back into the habits that landed them in Fatville in the first place. This is common sense borne out by a wealth of observation, but the entire scene is so fraught with emotion that it is very difficult to get some people to see the reality, which boils down to understanding the difference between something that is simple in principle but anything but easy in practice.
Posted by: Kevin Beck | May 3, 2008 1:34 AM
Hi Kevin,
A lot of sense in the article. I admit that I've always been a slim man, then was diagnosed with chronic pancratitis whilst at college. Digestive problems linked to that seemed to support the theory that I have been undernourished for a VERY long time. Many of my colleagues consider this a 'lucky accident' of nature, I can consume 6000 calories a day and not gain weight. But the other side of the coin is; I HAVE to consume 6000 calories a day just to maintain a healthy weight.
So, of course, I did some research into nutrition and obesity, eating disorders etc. What I found was that most parent, when confronted with the evidence of their obese/bulimic/anorexic child simply make excuses. I won't bother listing all the excuses, we're all familiar with 'It's glandular' or 'She's a bit depressed' aren't we?
Although I agree that seeing runway models doesn't make a young girl anorexic or bulimic, I really don't think it helps them if they already suffer from low self-esteem problems. There are a number of factors involved, obviously. I actually see the factors that make young people overweight as the same factors that help make them anorexic/bulimic.
Despite a degree in Biomed Science, I'm not an expert on nutrition, but just a cursory glance at the evidence, and there is a lot of it, would suggest that, to lose weight, eat less AND exercise. It's a no-brainer, and it's not difficult to understand, but how many companies are there out there selling diets to desperate teens who want to fit in. Whoa, did I say teens? Er, people. Let's face it, it's not just a problem with the young.
We have a cultural problem here, it's not just the junk-food and models/media, it's also the instant gratification that we're used to now. Wanna be slim? Check! Try a diet? Check! Didn't work? Check! Never mind, there's always another diet to try.
My personal opinion is that diet books/plans/programs should only be allowed with approval from the FDA (in the US) and the other medico-legal bodies worldwide. Those people who peddle the diet garbage should be properly prosecuted to deter others from inventing other ways to fleece the public and destroy young lives.
ok, rant ends.
B
Posted by: Brent | May 3, 2008 3:45 PM
"I'm not sure where she's getting her figures, but even if she's correct in claiming that the prevalence of overweight children has stabilized during the present decade, it's still extremely high -- about three times what it was in the mid-1970s. During this period there has been a concomitant rise in the incidence of Type II diabetes, a condition long known to be intimately connected with body habitus, yet quite a few people somehow manage to deny the obvious and attempt to dispel this association by yelling a lot and making angry blog posts. "
She is getting her figures from the most recent publication in JAMA of the national survey data, a highly respectable source. Where are you getting your figures from about the "concomitant rise in type II diabetes?" The prevalence of type II diabetes in children is so low that there are almost no actual prevalence estimates and thus no good trend data. The total prevalence of any kind of diabetes in children is very very low, and I am not aware of any good trend data. A review of these data by Lee in the Archives of Pediatric and Adolescent Medicine says "Despite significant increases in prevalence rates of childhood obesity in the United States during the past 2 decades, rates of type 2 diabetes mellitus among children at the population level have not followed a similar trajectory as those in adults. "
Posted by: Kim | January 3, 2009 2:23 AM
Kim,
I would have slapped this up as a new entry, but you commented to an ancient post, so I'll just reply here and move on.
You're right in that there is, as yet, no simple, comprehensive data describing pediatric NIDDM for the country as a whole, at least not that I could find. Because it remains a relatively rare diagnosis (about 186,000 people under 20 years old, or 0.2% of Americans in this age group), vast numbers of people must be followed in order to properly elucidate true prevalence. As a result, researchers have been largely reliant on reports from individual centers rather than on an integrated whole.
Here's some data to get you started. The paper explains the difficulties inherent in collecting data as well as some trends, including this: "[I]n Cincinnati, Ohio, the incidence of type 2 diabetes in 10- to 19-year-old patients increased from 0.7 per 100,000 in 1982 to 7.2 per 100,000 in 1994." Some of this has to reflect clinicians detecting and diagnosing more cases, while some plainly hearkens toward a real increase. The paper also gives data specific to Pima Indians, but they form such a unique and comparatively isolated population that it would not make sense to extrapolate the results to other kids.
This Power Point presentation is also compelling, and notes some of the same things the abpove article does. This is useful as well as it makes a note of impaired glucose tolerance and cites other highly pertinent studies. And looking beyond the U.S., there's also this out of Western Australia.
Most of the data in these studies is at least seven years old, meaning that we don't yet know precisely how bad things are today, but can be confident that they are no better.
Note that 85% of kids diagnosed with NIDDM are obese, most health professionals agree that NIDDM often goes undiagnosed in kids, largely because a lot of doctors are still not on the lookout for it. Impaired glucose tolerance and metabolic syndrome are on the rise in children as well, and like adults, kids thus affected are at considerable risk for developing diabetes later on if they fail to make lifestyle changes. And NIDDM in younger people is a special problem because diabetes is a chronic illness, and so these patients will have to deal with its effects for unprecedented numbers of years.
I do find it interesting that many sources at least as respectable as JAMA, such as the NIH, mention that there has been an "alarming increase" in Type 2 diabetes and that it is a growing epidemic, just as they say the same about childhood overweight and obesity. While the latter can be and has been quantitated, the former cannot be teased out through simple anthropomorphic measurements, and requires bloodtesting. And often, these sources don't say why they claim that youth NIDDM is an epidemic, they just seem to stipulate it. So perhaps this is something of a meme in the medical community, but I think we're discovering that it is more than justified.
Personally I don't like seeing the term "epidemic" applied to non-infectious conditions, which means that I'm either a purist or I'm not accepting the breadth of the word's meaning; to me it smacks of the "War on [take your pick]" hysteria. But one thing that is plain and not debatable is that there are a lot more fat, inactive kids than there used to be, and that this is ultimately going to result not only in more diabetes in the adult population (young and otherwise) but in an increased prevalence of other morbidities. Fat activists/denialists like to harp on camparative non-issues like the precise number of deaths the CDC attribues to obesity and whether diabetes in kids is really that much of a problem, but this is like arguing the nitty-gritty details of Genesis 1 and 2 when the whole thing is obviously bullshit, and is nothing more than an excuse to avoid obvious danger signals. Fat kids are just as at risk as fat adults.
As something of an aside, I'm curious about one thing you wrote (or reported):
"review of these data by Lee in the Archives of Pediatric and Adolescent Medicine says 'Despite significant increases in prevalence rates of childhood obesity in the United States during the past 2 decades, rates of type 2 diabetes mellitus among children at the population level have not followed a similar trajectory as those in adults.'"
What does this mean? That because the prevalence of NIDDM continues to rise sharply in adults, an increase in childhood and adolescent prevalence in what was once considered a disease of adults is not significant? That sounds a little like "Despite the increased availability of cigarettes in underdeveloped countries, rates of bronchogenic carcinoma among African smokers has not followed a similar trajectory as those in the West."
Besides, if there are no trend data available for NIDDM in children, how can Lee or anyone draw any conclusions about a "trajectory"? The best he should be able to say is that he doesn't have sufficient numbers of cases to determine anything about prevalence or incidence, and if this were true, people would be equally justified in claiming a huge rise in NIDDM, a huge drop, or anything in between. But I strongly doubt that the manifest consensus among pediatricians and family-practice docs that diabetes and "pre-diabetes" are on the rise is rooted primarily in unfair bias. That a country full of more and more inert and bloated teenagers is home to more and more cases of diabetes and attendant problems is not only far from surprising, but predictable based on the known pathophysiology of glucose intolerance.
Posted by: Kevin Beck | January 3, 2009 2:34 PM
Hi Kevin, Thanks for the offer to "get me started" but I think I am okay. Take a look at the Lee article (Arch Pediatr Adolesc Med. 2008;162(7):682-687). It is not at all a "denialist" article about type 2 DM in kids. It has a useful table showing the existing prevalence estimates and their sources. The range for T2DM in adolescents ranges from 0.04% (from probably the best study actually) to 0.15%. For all children the estimate is 0.02% from the very large multicenter SEARCH for diabetes in youth study. Lee gets her trend info from comparison of two national surveys, both of which show very very low levels of diabetes among adolescents and show no apparent increase over time.
Sure, there are lots of speculative comments that can be made about future possibilities and some may well be correct. But the above is what the current data show. A very low prevalence of T2DM among children and no clear increases. You might think there "must be" increases or there "ought to be" increases or there are "predictable" increases, and that's fine, but it's simply an opinion, not data driven.
Posted by: Kim | January 7, 2009 2:18 PM