What “The Hardy Boys” taught me about childhood obesity

Frank, Joe and Chet (with big clue!) 1927

When my son John was in third grade he briefly glommed on to my collection of old Hardy Boys story books. We’d read them together at bedtime as I tried to instill in John a love for the Boys, their pals (“chums,” to be precise) and their ancient (to him) adventures. Alas, Harry Potter soon distracted him and the Hardy Boys went back to gathering dust.

For those of you too young to remember (or too Nancy Drew-ish in your literary tastes to care), The Hardy Boys was a 58-book series that ran from 1927 to 1979, coinciding with the sweet spot of my 1950s and ’60s childhood. (The success of the books also spawned a black-and-white Disney TV serial in the ’50s, a Saturday morning cartoon from 1969-71, and the truly awful Hardy Boys/Nancy Drew Mysteries, which ran from 1977-79.)* Long story short, The Hardy Boys books described the sleuthing adventures of Frank and Joe Hardy, sons of the famous private investigator Fenton Hardy, in sometimes excruciating prose.

Frank and Joe evolved over the books and years from cynical, in-it-for-the-money 1920s teenagers to paragons of 1950s authority-respecting American youth. A Hardy sidekick, Chet Morton, evolved in somewhat different fashion, which brings me to today’s topic: Parents of overweight and obese kids are getting really bad at telling that their kids have a weight problem. 

Chet was the clumsy, jalopy-driving foil to Frank and Joe’s buff manliness. In the very first book, “The Tower Treasure,” Chet is described thusly: “He was a plump boy who loved to eat and was rarely without an apple or a pocket of cookies.”** This puzzled John, who looked at the accompanying drawing and said, “Why do they call him plump? He looks pretty skinny to me.” He had a point. As you can see, Chet may have had a roundish face and a bit of fullness to his arms, but his waistline and legs are as skinny as Frank and Joe’s. “I guess that was considered fat back in those days,” I explained to John with a shrug. Then I looked it up and found that only about 2% of children were obese in the 1930s. By the time we were reading this in ~ 1999, about 15% of children were obese. By 2012, 21% of American teens were obese. It was true: back in the 1930s, an artistic bit of a double chin or a pinch of chub at the belt line was all it took to portray a kid who liked to keep his pockets lined with cookies.

Chet Morton, aka “Chubby,” 1971

Chet’s evolution over time says a lot about how we perceive child obesity. As time went on and obesity rates rose, his Jazz Era chubbiness wasn’t enough. Chet got fleshier. By the time the late ’60s cartoon appeared, Chet (renamed “Chubby,” in case kids zoned out on Sugar Smacks didn’t get the point) had taken on a doughy, full-figured form that signaled to contemporary viewers that Chet was, well, chubby. Today, when more than 1/3 of adults are considered to be obese, it’s getting harder to send that signal: portrayals of characters as truly “fat” have kind of gone over the top, and they’re usually pretty cruel.

A new study in the journal Child Obesity shows how society’s idea of “normal” weight has changed since the Depression. In a survey of parents of 2-5 year-olds, 94.9% of parents whose child was in the “overweight” category, and 78.4% of those who were frankly obese said that their child’s weight was “just about right.” As our kids get heavier, our “parent goggles” simply adjust. In a strange corollary, I talk to parents all the time who worry that their average-build kids are too skinny.

The sorta-good news? Parents’ mis-perception of their overweight children actually improved somewhat from a similar study done 20 years earlier.

Given all that, I wonder how Mr. and Mrs. Morton viewed their cookie-pocketed boy who got steadily heavier over the years but, strangely, never aged? Alas, in 58 books, they never said a word…

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* Shaun Cassidy as Joe Hardy?? Spare me…

Joe Hardy? Looks more like Justin Bieber…

** Chet was also described at various times as “big boy,” fat, plump, chubby, stout, heavy-set, chunky, “the chubby one,” portly and round. (“Portly” was my favorite.)

A good day to be in Washington!

Not much repenting going on…

We’re in Washington D.C. for my niece’s wedding on Saturday. When we heard the Supreme Court’s pro-gay marriage ruling this morning we headed over to the Court building from our hotel to check out the reaction. Lots of happy people, justifiably so–and a few not-so-happy hellfire and brimstone folks, too…

Between this and the ruling upholding the Affordable Care Act, it’s been a pretty Supreme week!

Anti-gay marriage demonstration or performance art? Couldn’t tell!

Mode of delivery and childhood illness: A randomized trial in 2004.

One of the biggest difficulties in proving a causal link between cesarean birth and chronic health problems in childhood is the type of research studies that can practically and ethically be done during pregnancy.

The gold standard in medical research is the randomized controlled trial (RCT). In an RCT researchers randomly place subjects into either “treatment” or “control” groups, then expose the treatment group to something—a new vaccine for Infection X, for example—and then compare outcomes in the two groups later on. (In this example, how many kids in the treatment [vaccinated] group came down with Infection X versus how many in the unvaccinated control group?) If there’s a significant difference in outcomes between the two groups, you’ve got a strong argument that the treatment made the difference.

How a randomized controlled trial works.**

As you can imagine, randomly assigning pregnant women to cesarean (treatment) or vaginal birth (control) groups is nigh onto impossible—ergo, you can’t do an RCT. This means that virtually all research studies on the issue of cesareans and chronic childhood have been observational in nature—looking backward in time at databases, for example, or trying to fish significant trends out of hospital registries, birth cohorts and the like. The best an observational study can tell you is that A and B are associated with one another, but that’s it—you can’t prove that A actually causes B. An observational study can’t prove that cesareans are a cause of asthma; it can only say that cesareans are associated with an increased risk of childhood asthma.*

So mode-of-delivery RCTs are out of the question…or are they? Actually, in 2004, a Canadian research team did one.

Well done, Northern Neighbors!

The multi-center, multi-nation Term Breech Trial wasn’t about whether cesareans might increase the risk of childhood asthma, diabetes and such. It was about trying to figure out whether elective cesarean section or vaginal birth was the safest way to deliver a breech baby at term. Since the existing research was somewhat murky at the time, it was considered ethical (with informed consent) to randomize women to have either a planned cesarean or attempt a vaginal birth.

The particulars of the breech birth debate are best left for another post, but tucked away in the study’s results section was this little nugget:

“…more parents in the planned cesarean birth group than the planned vaginal birth group reported that their children had had medical problems in the past several months…relative risk, 1.41; 95% CI, 1.05-1.89; P=0.2.”

Plain English version (mine): The toddlers who had been in the planned cesarean group were about 40% more likely to have been sick in the previous few months than those in the planned vaginal birth group. The types of medical problems—typical 2 year-old stuff like colds, ear infections and stomach flu—were no different between the groups. The only difference was in the numbers of children who’d gotten sick.

As is the case with all medical research, you can find things in the study to complain about: relatively small numbers, for example, the use of parental questionnaires and the fact that some mothers in planned vaginal birth group ended up having cesareans (and vice-versa), etc.

But here’s my bottom line:

In a randomized trial of pretty well-matched subjects, those babies whose mothers were in the planned cesarean group tended to get sick more often than those in the planned vaginal birth group.

This doesn’t address the issue of chronic illnesses like asthma, type 1 diabetes and the like, but it does support the theory that cesarean birth can mess with a baby’s developing immune system.

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*Here’s an exaggerated example of the trouble with mistaking association for causation: Virtually all adults who die suddenly of heart attacks drank water in the 24 hours before they died. So, drinking water is associated (time-wise) with heart attacks. But you would be wayyyy wrong to say that, based on that association, a glass of water can cause a heart attack.

**Credit: SUNY Downstate Medical Center

A great Father’s Day column…by my Mom.

Margaret “Peg” Sloan

My mother, Peg Sloan, was a writer and editor for our hometown Kankakee (Illinois) Daily Journal from the late 1970s to the mid-1990s. She published her first column in 1977, on the trials and tribulations of being a redhead. She went on to write nearly 700 more on subjects as varied as family, human nature, Irishness, the passage of time, and the memories of a big-city girl who married into an Illinois farm family. She won multiple awards for her writing and editing–from the Associated Press, United Press International and the National Press Women’s Association–and developed a large and loyal readership along the way.

Here’s one of my mother’s most popular columns, re-run this Father’s Day by the Daily Journal. It was written in 1979 about Mom’s father, my grandfather James Dalton, the year before he died. Grandpa was the quintessential Irishman: an accomplished musician, great dancer, master storyteller and a kind, gentle man. The column still gets to me, and with Mom now the same age Grandpa was back when she wrote it, I thought I’d share it with you.

P.S Peg Sloan is still alive and kicking. She lives in Wheaton, IL, with my father, Barney Sloan (and Happy Father’s Day, Pally Boy!). They’ve been married 68 years…

Things kids say: Disney-trashing edition

Bossy? Moi?

Overheard: A young girl talking to her mother at the V. Sattui winery picnic grounds in Napa, California (one valley over from where I live), last weekend…

“They call it the happiest place on earth, but it’s not. That princess-lady yelled at me for nothing.”

The girl’s mother reminded her that, in Disneyland at least, throwing a drink at her brother on a crowded sidewalk isn’t actually “nothing.” The girl paused, nibbled on a cookie, then huffed:

“Well, who made her the boss of that stuff anyway? She probably isn’t even a real princess.”

Once upon a time in cord clamping…

Modern science at work…

“Another thing very injurious to the child, is the tying and cutting of the navel string too soon; which should always be left till the child has not only repeatedly breathed but till all pulsation in the cord ceases. As otherwise the child is much weaker than it ought to be.”

Erasmus Darwin (Charles’s grandfather), 1801

That’s me on the radio…

Adriana Lozada

I just had the pleasure of discussing the advantages of delayed cord clamping with the wonderful Adriana Lozada over at birthful.com.

Here’s the link:

http://www.birthful.com/podcastdcc/.

Check out the rest of birthful.com, too–it’s a great resource–and read Adriana’s fascinating personal history. (Great photo here of Adriana with her 10-year old “mini-me,” Anika.) Adriana has a growing list of podcasts, including interviews with such well-known figures in the childbirth world as Gene Declercq, Rebecca Dekker and Sarah Buckley. I’m honored to be in their podcast presence. Thanks, Adriana!

Cesareans and chronic childhood disease: Time for a public discussion

From the Ishinhō, Japanese medical text, 1860

In an analysis published in the most recent edition of The BMJ, Drs. Jan Blustein and Jianming Liu examine the evidence that cesarean delivery is associated with an increased risk of chronic childhood diseases like asthma, type 1 diabetes, and obesity. Their conclusion: the bulk of the evidence suggests that the association is real.

The time has come, Blustein and Liu write, for maternity care providers to include the risk of chronic childhood disease in their discussions with women considering a “non-essential” cesarean, such as when the choice is between a VBAC or repeat cesarean, or in the case of a woman choosing a medically unneccessary cesarean in lieu of vaginal birth—the so-called “maternal request” cesarean.

This topic has intrigued me for some time now. As part of my recently completed MPH program at the University of Minnesota, I wrote a paper titled, “Do Cesarean Sections Increase the Risk of Child Asthma? A Systematic Literature Review.”

In writing the paper I read and analyzed every research study on the subject since 2001. Roughly two-thirds of those studies detected a small-to-moderate association between cesarean birth and childhood asthma. (In fact, 90% of the studies detected an association between the two, but not all were statistically significant.) Most of the studies that didn’t find the association were seriously flawed—too few subjects, for example, or ignoring possible confounders, like prematurity or a history of maternal asthma. Three meta-analyses (two in 2008, one in 2014) all reached similar conclusions: cesarean section is associated with about a 20% increase in the risk of child asthma.

My paper was limited to asthma, but as described in the BMJ analysis there’s evidence that cesareans increase the risk of other chronic childhood illnesses, too–type 1 diabetes and obesity. A 2015 study by Sevelsted et. al. analyzed a cohort of two million Danish children and found small-to-moderately increased risks of juvenile rheumatoid arthitis, connective tissue disorders, inflammatory bowel diseases, immune deficiencies, and even leukemia.

Given that body of evidence, you’d think that organizations like ACOG (the American Congress of Obstetricians and Gynecologists) and the U.K.’s National Institute for Health and Care Excellence would be pushing their members to share this information with their pregnant patients. But they’re not. According to Blustein and Liu,

“…knowledge about chronic disease risks could affect decision making in non-essential caesarean. The American College of Obstetrics and Gynecology and the UK’s National Institute for Health and Care Excellence recently issued consensus statements on caesarean delivery at maternal request. Based on evidence about maternal and perinatal outcomes, both groups concluded that a pregnant woman requesting caesarean should have that choice, if she still desires it after discussion of the risks and benefits of the procedure. Importantly, neither group acknowledged the long term risk of chronic disease. [Emphasis mine.]

Critics can (and do) point to the uneven quality and designs of the studies that support such links—it’s association versus causation all over again—but that’s not entirely fair. To prove beyond doubt that cesarean birth increases the risk of child asthma, you’d have to do trials where women are randomly assigned to cesarean or vaginal birth…which, as you can imagine, is a practical and ethical non-starter. That leaves us with observational studies, which can only point out that two things seem to be related, not that they definitely are.

Ah, but there has been a randomized study of the long-term effects of cesareans versus vaginal birth in term, breech deliveries, and at least one research team has made the case that randomized trials of mode of delivery aren’t really unethical. More on those topics soon.

Finally, just to re-re-reiterate: I’m not anti-cesarean. My wife and son are alive and well today thanks to a medically necessary cesarean. But the cesarean rate today is 6 times higher than it was when I was a junior in high school (1970, if you must know…). As Blustein and Liu point out in their analysis:

“We live in a world where caesarean rates cannot be explained by compelling medical indications.”

Perhaps increased awareness of the potentially negative impact of cesareans on child health will help reverse that decades-long trend.

Readers respond: Cord clamping around the U.S.

“Who even does early cord clamping anymore?”

This question was raised recently by a young doctor at the family medicine residency program where I teach. She and her residency colleagues had been taught in their OB rotation that delayed cord clamping is the childbirth standard of care. The benefits are proven, the resident said, and early clamping doesn’t do anything for anybody.

“So why would anyone do it?”

Good question. Yet judging from the emails I received after my last post, DCC is far from the standard of care around the country:

• An East Coast doula wrote that her clients can have DCC performed at birth “if they request it.” (If they request it?? That’s a bit like saying, “There’s this thing called oxygen, and if it looks like your baby’s at risk of brain damage from a lack of it, we can give him some. If you ask us to, that is.”)

• A California midwife wrote that the obstetricians at her hospital are adamant that DCC is “too risky” for newborns. Despite the evidence she presented to them, they’re sticking with ECC.

• A Midwestern family physician reported that the DCC/ECC debate has split the medical staff where she practices. Although there’s some overlap, the family docs are largely pro-DCC, while the OB staff is in favor of ECC.

Clinging to interventions that have been shown to be useless and even harmful is, unfortunately, nothing new in the history of medicine.

Poor Ignaz…

Perhaps the most infamous example in the maternity care world is that of Dr. Ignaz Semmelweis (1818-1865), a Hungarian-Austrian obstetrician who clearly demonstrated that simple handwashing could greatly reduce maternal deaths from puerperal fever—a virulent infection that plagued crowded maternity wards in the 19^th century. Everybody ignored him, his career crashed, and he died in an asylum…and a few decades later everyone was washing their hands. (A brief synopsis of his story is attached below, excerpted from my book, Birth Day: A Pediatrician Explores the Science, the History, and the Wonder of Childbirth.)*

I’m encouraged that the young doctors I work with see DCC as a no-brainer (or a pro-brainer, if you’ll pardon the pun.) But too many doctors don’t see the timing of cord clamping as the important issue it is. For them, it will probably take the Invisible Hand of the Market, in the form of pressure from pregnant clients, to change minds and practices, if not hearts.

So tell me, what’s the DCC/ECC environment where you live? Email me or (better still) add a comment on the blog!

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*(Shameless self-promotion: Birth Day—a ripping good yarn—is available in paperback or Kindle from Amazon, or you can order it from me directly at www.marksloanmd.com).

Excerpt from Birth Day: A Pediatrician Explores the Science, the History, and the Wonder of Childbirth (Copyright 2009, Mark Sloan M.D.)

“In 1844, Dr. Ignaz Semmelweis, an assistant lecturer in the First Obstetric Division of the Vienna Lying-in Hospital, began to make the same connection [as Dr. Oliver Wendell Holmes]. Semmelweis noticed that women who gave birth in his First Division, which was staffed by doctors and medical students, had eight times the risk of contracting puerperal fever than those who were delivered by midwives in a distant part of the hospital. Of the many differences in patient care between the two divisions, Semmelweis saw one that stood out. Doctors did autopsies on women who had died of puerperal fever. Midwives did not.

With no access to Holmes’s still obscure paper, it took three years and a number of failed hypotheses for Semmelweis to put it all together. The final piece of the puzzle fell into place when, like Holmes, he was struck by the similarities between puerperal fever and the death of a colleague from an infection incurred during an autopsy. “Suddenly a thought crossed my mind,” he wrote. “The fingers and hands of students and doctors, soiled by recent dissections, carry those death-dealing cadavers’ poisons into the genital organs of women in childbirth.”

Semmelweis immediately ordered all doctors and students in the First Division to wash their hands in a chlorinated lime solution before attending to patients. The results were startling: mortality rates from puerperal fever fell from 18 percent in the first half of 1847 to less than 3 percent by that November. But like Holmes’s in America, Semmelweis’s breakthrough was dismissed by his colleagues, including Friedrich Scanzoni, the most prominent obstetrician in Vienna.

Semmelweis’s discovery ultimately led to the ruin of his own career and health. He was dismissed from the Vienna Lying-in Hospital in 1849, in large part because of his increasingly strident arguments with colleagues. Despondent, he spent a few unproductive years at a hospital in his native Hungary before returning to Vienna. There he wrote articles and letters blasting his former colleagues. He even accused them of murder, calling them, among other things, “medical Neros” for ignoring his advice while women died. Disabled by severe depression, Semmelweis died in a mental hospital in 1865—ironically, from an infection that started in a cut on his finger.”

The benefits of delayed cord clamping: New evidence

Hold on a minute (or three)!

Something about the cord clamping debate has troubled me for quite some time now. Long after early cord clamping (ECC) was shown to be of no benefit to either mother or baby, and in fact may harm the baby through loss of iron during a critical period of brain development, some in the obstetrics community wanted to see more evidence before endorsing delayed cord clamping (DCC) for healthy term babies. The pro-DCC evidence was theoretical, they claimed; before they agreed to wait a couple of extra minutes to clamp the cord, they wanted hard proof that DCC actually helps babies.

The logic behind this foot-dragging—“We’re not abandoning a pointless practice without a darned good reason,” more or less—escapes me. After all, this isn’t like switching from one way of transplanting hearts to another. DCC doesn’t require new equipment or extensive training, and it’s not a budget-buster, either. You simply wait 2 or 3 minutes to clamp the cord, instead of doing it right at birth. It’s not brain surgery.

Well, there’s finally some solid evidence for the hard-to-convince, pro-ECC crowd. In a recently published randomized clinical trial, a Swedish research team led by Dr. Ola Andersson discovered that a group of healthy children who had been randomized to receive DCC (3 minutes after birth) had significantly better personal-social and fine-motor functioning at 4 years of age than did those who were randomized to receive ECC (< 10 seconds after birth). The effect was more marked in boys than in girls.

Andersson and colleagues checked the children’s iron stores at several points and found that, while DCC babies had more total body iron at 4 months of age, the ECC/DCC difference disappeared by 12 months of age. Looking at neurodevelopment, they found no differences between ECC and DCC babies at 12 months, but by 4 years the DCC children showed significant developmental advantages over the ECC group. It seems like an odd finding: how could a DCC-related “bump” in iron stores in early infancy cause developmental differences at 4 years but not at 12 months?

It likely comes down to an inadequate supply of iron at a critical time in neurodevelopment—those first few months, when many of the brain’s critical neural pathways are established. The resulting delays weren’t detectable with the kind of screening that can be done on a 12-month old, but by 4 years of age more extensive testing could pick it up.

The most important thing about this study is that it was a randomized clinical trial, a study design that can show that “a” is directly connected to “b”. The researchers in this case took two evenly matched groups of infants, randomly assigned them to different treatments (DCC or ECC), and then measured the relevant outcomes (iron stores + developmental differences). While there are some shortcomings to the study—the number of kids involved isn’t huge, for example—the findings fit with what’s currently known about the effects of iron deficiency in early childhood.

This study presents a solid argument in favor of DCC. And if that’s not enough to sway ECC advocates, what is?

More on iron metabolism (and why boys are affected more than girls) in upcoming posts…