TCS Daily


The Emperor's New Crisis

By Sandy Szwarc - April 8, 2004 12:00 AM

On Sept 12, 2002, Health and Human Services Secretary Tommy Thompson released the health statistics report from the Centers for Disease Control which revealed the average American's health "has changed dramatically for the better over the past 50 years." He announced: "In 2000, Americans enjoyed the longest life expectancy in U.S. history -- almost 77 years."1

The report documents that gains haven't been merely in lowered infant mortalities; death rates among adults have dropped 50%, too. Despite aging significantly, the population is healthier than ever. The four leading causes of death continue to see noteworthy improvements: Actual death rates due to heart disease are down 70%, strokes down 80%, cancer and unintentional injury deaths have been dropping for decades. Even children and young adults have enjoyed sharp declines in deaths from heart disease and cancer.2

In the HHS press release, Sec. Thompson said: "As we take better care of ourselves and medical treatments continue to improve, the illnesses and behaviors that once cost us the lives of our grandparents will become even less threatening to the lives of our grandchildren." CDC Director, Julie L. Gerberding, MD added: "Effective public health efforts, greater knowledge among Americans about healthier lifestyles and improved health care all have contributed to these steady gains in the nation's health."1

The CDC's records of actual causes of deaths brought good news indeed. But two years later, those very same figures were given a completely different spin....

On March 9, 2004, Sec. Thompson cited "a dangerous increase in deaths" as he launched his new aggressive national advertising campaign and National Institutes of Health plan to combat what he called "an epidemic of obesity and overweight."

"Americans need to understand that overweight and obesity are literally killing us," he said. Between 1990 and 2000, "deaths due to poor diet and inactivity rose by 33%...and may soon overtake tobacco as the leading preventable cause of death." The situation "is both tragic and unacceptable," added Gerberding.3

The creation of a new health crisis entailed brazen manipulations of numbers and revisions of the truth by the Department of HHS. Their basis for this new crisis was a Special Communication by Gerberding and CDC colleagues published the following day in the Journal of the American Medical Association. It claimed that in 2000 "400,000 deaths were attributable to poor diet and physical inactivity, an increase of one-third from 300,000 deaths estimated [in 1990]."4

While the strategy used by the CDC authors to arrive at this conclusion is ambiguous and complicated, several statistical antics are evident.

It's worth noting that the population of the country increased by over 33 million during that decade, with a corresponding increase in the number of people to die.5 Even using their embellished figure of 400,000 deaths attributable to overweight, the death rate, as a percentage of deaths, increased only 2.6% over 10 years -- not 33%.

The CDC authors chose 9 behavioral and environmental factors they decided were unhealthy (such as drinking, smoking, sexual behavior, illicit drug use, and obesity). They then did a Medline search of published articles looking for those key words. No attempt was made to evaluate the soundness of the studies or the statistical significance of their results. They simply mined the articles for relative risk factors -- those are fractions that indicate the probability that one risk factor (such as obesity) influences a particular outcome (like death).

But they excluded from their search many factors known to increase death risks such as aging, low socioeconomic status and medical treatment errors.6 They did this despite the fact that aging is the single greatest risk factor for death. Katherine Flegal, PhD, with the CDC National Center for Health Statistics, cautioned researchers in an article in 2000 that "the prevalence of [health risk factors such as heart disease] is related to age, rather than to weight itself." Failing to consider age "may exaggerate the excess risk associated with BMI."7 That went unheeded by these CDC authors.

Once the CDC authors had their dubious compilation of relative risks, they simply guestimated how many of the actual deaths from health statistics in 2000 were caused by their chosen bad behaviors. Incredibly, they labeled their estimates "Actual Causes of Death."4

The CDC authors claimed to have used "a method similar to that used by McGinnis and Foege." Those were the JAMA authors who had first attributed 300,000 deaths in 1990 to lifestyle factors: sedentary activity levels and poor diets.8 But the CDC authors' statistical exploits went far beyond the earlier study's methods --- so much so that McGinnis and Foege themselves wrote an editorial in the same issue of JAMA critiquing the CDC study and remarking on its "especially notable increase in those deaths attributable to poor diets and physical inactivity." In contrast to their 1990 study, they pointed out that the CDC authors set out to blame deaths on "the specific issue of overweight and obesity rather than the full range of conditions related to diet and activity patterns" they had considered.

Thus, the CDC authors introduced their own bias about the causes of overweight and obesity -- poor diet and inactivity -- which they lumped together into a single risk behavior.9 However, there are thin people who eat poorly and don't exercise, too, and not everyone who dies from heart disease or cancer is fat, so the CDC authors added a meager 15,000 death correction, but admitted that "may be conservative." McGinnis and Foege stressed how low this estimate seemed, "given the substantial number of cardiovascular and cancer deaths that may be attributable to the dietary and inactivity patterns of those who are not overweight or obese."

In predicting mortality, the CDC authors justified their use of obesity and overweight as equal to poor diet and physical inactivity by citing Steven Blair, PED and Milton Nichaman, MC, ScD of the Cooper Institute in Dallas which they claimed found "overweight would account for the major impact of poor diet and physical activity on mortality."

But that's not what Blair and Nichaman found. In fact, Blair and colleagues are renowned for decades of research showing weight is not a significant predictor of mortality, it's fitness, and both fat and lean people are active and fit.10-12 In that attributed study, the Cooper researchers actually concluded: "We think that...obesity is unlikely due to increases in daily [dietary] energy intake....We do not know what has happened to energy expenditure trends over the past few decades. However....We find that a fit and active way of live reduces mortality risk in virtually all subgroups -- the middle-aged and the elderly, women and men, the fat and the thin."13 Interestingly, the CDC authors also ignored their own findings that physical activity and consumption of fruits and vegetables had increased during the decade, despite rising obesity.

How did the CDC authors estimate how many deaths to attribute to their derived relative risk number to arrive at their 400,000 deaths figure?

They said: "We used the same procedure reported by Allison et al to estimate annual overweight-attributable deaths." But those were the authors who took McGinnis and Foege's findings and turned the two lifestyle factors -- diet and activity -- into obesity and turned an association into causation, making 300,000 deaths in 1990 caused by obesity. [See "The Birth of the 'Fat Kills 300,000' Myth." ]

Allison explained their technique: "Our calculations assume that all excess mortality in obese people is due to their obesity."14 In other words, any death of a fat person - even if they're hit by a bus it seems -- is due to their fatness.

Piling On

The HHS had additional help exaggerating their dangerous increase in overweight and obesity from 1990 to 2000 because, as you'll remember, in 1998 the NIH changed the definition of overweight from BMIs over 27 to over 25, instantly making some 29 million more Americans overweight. The change wasn't made because being overweight increases mortality, though. In fact, recent data from Allison and colleagues themselves showed the lowest mortality among men at BMIs of 27.3 (fat by the government's definition).15

So, if you're a 6-foot man weighing 185 pounds or more, or an average 5-4 woman weighing 145 pounds -- the government says you're fat. Should you be hit by lightning while jogging, your death will become part of its "fat-kills" stats. And if you're fat you can never die of old age -- the government won't allow it.

Endnotes

1. HHS Issues Report Showing Dramatic Improvements In Americans' Health Over Past 50 Years. HHS CDC/NCHS Press Release, Sept 12, 2002.

2. Thompson TG, Geberding JLL, Sondik EJ. Health United States 2002. HHS, CDC, National Center for Health Statistics, Aug 2002.

3. Citing "Dangerous Increase" in Deaths, HHS Launches New Strategies Against Overweight Epidemic. HHS Press Release, March 9, 2004.

4. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, 2000. JAMA, 2004; 291 (10): 1238-1245.

5. U.S. Population: The Basics. AmeriStat, Aug 2001.

6. Starfield B. Is US Health Really the Best in the World? JAMA, 2000; 284 (4): 483-485.

7. Flegal KM. Obesity, Overweight, Hypertension, and High Blood Cholesterol: The Importance of Age. Obesity Research, 2000; 8: 676-677.

8. McGinnis JM, Foege WH. Actual Causes of Death in the United States, 1990. JAMA, 1993; 270: 2207-2212.

9. McGinnis JM, Foege WH. The Immediate vs the Important. JAMA, 2004; 291 (10): 1263-1264.

10. Farrel SW, etal. The Relation of Body Mass Index, Cardiorespiratory Fitness, and All-Cause Mortality in Women. Obesity Research, 2002; 10: 417-423.

11. Blair SN, etal. Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women. JAMA., 1996; 276: 205-10.

12. Blair S. Cooper Watch --Fitness, not Fatness, is the Issue. Well, Fall 1999; 1 (2).

13. Blair SN, Nichaman MZ. The Public Health Problem of Increasing Prevalence Rates of Obesity and What Should Be Done About It. Mayo Clinic Proceedings, Editorial, February 2002; 77 (2): 109-113.

14. Allison DB, Fontaine KR, Manson JE, Stevens J, VanItallie TB. Annual Deaths Attributable to Obesity in the United States. JAMA, 1999; 282 (16): 1530-1538.

15. Allison DB, Zhu SK, Plankey M, Faith MS, Heo M., Differential associations of body mass index and adiposity with all-cause mortality among men in the first and second National Health and Nutrition Examination Surveys (NHANES I and NHANES II) follow-up studies, Journal: Int J Obes Relat Metab Disord, 2002; 26 (3): 410-6.


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