Science by press release squared — Can children’s books really eradicate childhood obesity?
This story takes the prize for the most deceptive example of science by press release.
The media has been plastered over recent days with more than a hundred articles about a new study reportedly showing that simply reading a book helped fat pre-teen girls lose weight, make healthy eating and lifestyle changes, and improve their self-esteem. According to the news, this important study came from researchers at Duke University’s Healthy Lifestyle Program and had been presented at the Obesity Society’s annual meeting in Phoenix on Saturday.
Not one single reporter had accurately presented the research. Every single news story had been taken from statements made to the media. But that’s just the beginning.
We already know to regard studies presented at meetings with extreme skepticism because not only is study data and methodology unpublished and unavailable for peer review, it’s notable for being more marketing than sound research. While this study admittedly hadn’t been published in a peer-reviewed journal, you’ll never guess what media meant by it being “presented” at a meeting. Was this research presented at any of the lectures? No. Was it part of any of the break-out or corporate-sponsored symposiums? No. Was it presented at any of the exhibitor booths? No. Was it even among the oral abstract presentations? No.
None of the study’s authors even appear anywhere on the program. So, how exactly was this research presented?
It was a poster hung up at the meeting.
While a poster might provide all of the evidence national health reporters might believe makes credible presentation of medical research worthy of front page news, not many medical professionals would. More incredibly, had any writer gone to the original source and tracked down the poster, even it would have provided everything they needed to realize that this study was not credible research or a fair test of any clinical intervention:
Design: randomized, controlled
Participants: 64 obese females age 9-13 followed at the Duke Healthy Lifestyles program. Data was compared to 17 girls followed in the program who did not receive a book
Intervention: girls were randomized to read the intervention novel, which describes an overweight girl who discovers improved health and self-efficacy, or a control novel
Results: BMIs at beginning and after 6 months:
Group 1 (no book): 98.32 (1.15 SD) to 98.05 (1.37 SD)
Group 2 (control book): 98.22 (1.86 SD) to 97.92 (2.69 SD)
Group 3 (intervention book): 98.49 (1.52 SD) to 97.49 (2.72 SD)
Conclusions: Age-appropriate fiction, particularly if it addresses health-oriented behaviors, can augment weight loss in adolescent female participants in a weight management program.
Clinical implications: The novel provides a medium through which girls can learn about healthy lifestyle behaviors in a non-judgmental and self-paced format outside of the pediatrician’s office. Recommending such novels to girls is a straightforward, efficient, risk free intervention that could easily be performed during a routine office visit.
Did you catch the study’s greatest flaws? Or did the words “randomized, controlled” lead you to drop your guard and take this study seriously? Let’s start from the top, using the principles of fair test.
This study was conducted at Duke University’s Healthy Lifestyles Program and led by Alexandra Russell, a medical student at the Duke University School of Medicine in Durham, NC. The Duke program is an intensive weight loss treatment program for children with BMIs over the 85th percentile on growth curves. It says it follows the clinical guidelines recommended by the American Academy of Pediatrics [reviewed here] and begins with intense screening for cholesterol, blood sugar and other measures, mental health screening, and lifestyle surveys of the parents and child. Then begins an “intense lifestyle intervention phase” which includes five monthly visits where a Healthy Lifestyle Team member reviews progress and refines and sets goals. According to the program’s website, the children receive “fit kits” and written materials from Duke’s patented intervention called High Five for Fitness™ which is based on five behavioral strategies: choose “healthy” beverages, limit screen time to less than 2 hours a day, 1 hours of physical activity a day, sleep for health, and learning portion control and healthy eating. The children also keep daily food logs, recording everything they consume, which is reviewed at each visit.
The poster says that 64 girls already participating in the Duke program were randomized to receive a copy of either Lake Rescue (the intervention book) or Charlotte in Paris (the control book), both novels in the Beacon Street Girls series for tween girls. The publisher’s press release says its Beacon Street Girls brand “was specifically designed to entertain while providing healthy role models and positive messages" for girls. It adds that “Lake Rescue tells the story of an overweight girl whose adventures help her learn the importance of appropriate nutrition and exercise. The book was developed in consultation with five healthy lifestyle experts.”
According to the press release by Duke University, Lake Rescue was “carefully crafted with the help of pediatric experts to include specific healthy lifestyle and weight management guidance, as well as positive messages and strong role models.”
[All emphases added.]
Selection/allocation bias. The poster fails to reveal how long any of the girls had been involved in the Duke program when they received the book or if they controlled for that. [Yet, as we know, weight loss is most pronounced during the first 6 months of any weight loss intervention and then rebounds.] The poster fails to reveal the girls’ ages or if ages or maturity levels were controlled for. [Yet, ages 9 to 13 years is an especially sharp period of growth for girls, with extreme differences in heights and weights and changes in body composition.] In fact, no information about the girls is provided, such as socioeconomic status, other interventions, medications, or any confounding factor that might bias the results.
Attrition bias. The poster fails to reveal how many girls actually read the book or how many completed the 6 month program. We don’t know the attrition rate or reasons for those who might have dropped out and how they differed from the girls who completed the study.
Observation and intervention bias. This was not a blinded study, meaning there was no control to ensure the two groups underwent the same study experience. In other words, the girls who received the intervention book were known to the study authors and could have received more intensive weight loss reinforcement at each visit, and the girls knew they had received the book being studied. Blinding of participants is imperative in human research to avoid the powerful unconscious effects of our own beliefs and expectations.
Reporting bias. The study was not of adequate duration (6 months) to credibly evaluate the effectiveness of any weight loss intervention. As we know, the scientific panel for the FTC said, as have all obesity researchers, that no weight loss intervention lasting under 5 years can claim effectiveness, as weight regain is the rule for nearly all individuals, rather than the exception. This study was also not of sufficient size (32 girls in the intervention group) to be adequately powered to derive any meaningful differences between the groups.
The study reported no quantifiable information to make any credible clinical claims. The poster only reported the average percentiles that the girls fell on a BMI growth curve, making it impossible (especially without knowing their ages), how much their heights and weights had actually changed. The 95th percentile for BMI between ages 9 and 13 varies from BMIs of 22 to 27; weights of 94 to 150 pounds; and heights of 56.5 to 67 inches, for instance. A 6-month glimpse says nothing about any effect on their weight classification, as we know it is common for growing children to fluctuate in percentiles on the growth curve as they grow.
In fact, the poster reported that all of the girls remained in the >95th percentile category on the growth curve, with widening standard deviations, indicating no clinically meaningful changes in any of the girls. The group receiving the intervention book had reduced their predicted BMIs -0.71 unit compared to -0.33 unit for the placebo book — a clinically meaningless difference of 0.38 BMI unit after 6 months.
Most importantly, the authors failed to report any effects on the girls' diets and health risk behaviors, their health and wellbeing, or examine and balance the potential harms of their intervention. Sarah Armstrong, M.D., director of Duke's Healthy Lifestyles Program said in their press release: “This is the first prospective interventional study that found literature can have a positive impact on healthy lifestyle changes in young girls.” Addie Swartz, CEO of Btween Productions, Inc. which produces the Beacon Street Girls series, said in their press release: “We are extremely proud to be associated with this important study, as well as delighted that our dedication to quality media had a concrete impact on the health of a group of young girls.”
But neither marketing claim is supported by any evidence. As is so often the case, the intensity of the media reporting appears to be in inverse proportion to the strength of the science.
What were the young girls reading?
Among the uncritical, glowing news stories about this book — all verbatim from media statements — clearly not a single reporter had actually bothered to read it. Given the reported near magical abilities of this single children’s book to result in weight loss among young girls, it would be negligent not to read it before commenting. Thus, I began a difficult search for this book and finally found a single copy in the entire city. The manager of the national chain bookstore said this series doesn’t sell well, which could explain it’s obscurity.
I never expected to read a children’s book that was as disturbing as this one. It is with the strongest emphasis that I urge caution before any adult considers purchasing this book for any young girl.
Lake Rescue, is the latest book in the Beacon Street Girls series and released to the public last month. The book’s Acknowledgements say that it was created with Lilian Cheung, Catherine Steiner- Adair and Jill Zimmerman Rutledge. [Follow links for bios and disclosures.]
The main character is Chelsea Briggs, described in the book as “the big girl.”
Usually dressed in a baggy Patriots sweatshirt, and always sitting in the back of the room, Chelsea hardly ever spoke up in class. Some of the kids still called her Chelsea Bigg, a nickname from third grade… Mostly, kids just tended to ignore her. It was almost as if she were invisible which was odd, because Chelsea was so large.
Repeatedly, through Chelsea, girls read that other kids make fun of them and talk behind their backs if they’re fat. Talk about creating insecurities among already body-conscious pre-teens.
The boys used to tease her in elementary school a lot, but she had mastered the art of ignoring the junior high male. But the girls, they were harder to ignore. The girls weren’t outright mean, but Chelsea knew they always talked about her behind her back. She had seen the looks, the whispering and the pointing. And it had hurt… sometimes really bad.
Through Chelsea, fat girls are depicted as clumsy and out of shape, girls who don’t have friends, and are the source of embarrassing mishaps in gym class. Not liking gym, Chelsea skips class and gets called to the principal’s office. [The principal is cool.] That night she writes in her journal about her concerns of the upcoming school camping trip to Lake Rescue camp:
I don’t really ever have a friend. If it’s like those survivor programs, I’ll get picked to go home first— but what if I stick it out, exercise hard, eat only fish and coconut, and lose a hundred pounds. I can start over as the skinny girl with the tan.
Through the main character, the message reinforced is that fat girls stand out and are embarrassments because of their weight, and that fat kids are at risk for type 2 diabetes. Forced to go to gym, Chelsea is ashamed and says to the new gym teacher:
“I just hate gym. My doctor says I am supposed to lose thirty pounds. He said something about Type 2 diabetes. Whatever.”
Chelsea couldn’t believe she blurted that out to a total stranger. The gym teacher could see she needed to lose 30 pounds. Everyone could see Chelsea was “weight challenged.”
While shopping for a coat for camp, she can’t fit in the girls’ coats and, mortified, she has to go to the boy’s section. She is humiliated when fellow classmates see her at the store and know that she is too fat for the coats in the junior’s section:
When people are embarrassed that you are embarrassed, it just makes the whole thing ten times more embarrassing. I hate when people feel sorry for me. But that was only half the problem. The major thing was that none of the junior’s coats would fit me, so I am going to be wearing a boy’s coat at Lake Rescue… What’s with not making cute outdoor clothes for bigger girls?
The book depicts her classmates later talking about her behind her back, reinforcing this fear among any fat girl reading the book:
Maeve started brushing Isabel’s long black hair. “Can you believe that Chelsea Briggs couldn’t fit into any of the coats in the junior’s section of the sporting good store?”
“I felt kind of sorry for her, having us see her go to the boy’s department,” Charlotte added. “It must be hard to be that heavy.”
“Why doesn’t she lose some weight?” Avery suggested. “Maybe if she got more exercise, she could get in shape.”
“Or try eating less,” Maeve said.
“I wonder if she can handle the rope course at the camp,” Avery said. “If she’s out of shape, she probably won’t be able to life her own weight.”
At home, Chelsea’s mom proposes they spend summer vacation at a beauty spa where they can help Chelsea lose some weight. “We could come home 2 sizes, maybe 3 sizes smaller,” her mom says.
[Chelsea] wished her mom would lay off the weight thing. Her mom was obsessed that Chelsea would get diabetes like her grandfather. And maybe she was embarrassed that Chelsea was fat. No, that didn’t make sense, Chelsea reasoned. Her mom was kind of fat, too.
At Lake Rescue camp, Chelsea meets the head counselor, Jody. And the psychological manipulations begin, reinforcing every stereotype of naturally heavier children as disgusting and to blame for their size because of eating poor diets, psychological eating issues and being sedentary. Steadily, while at camp, Jody indoctrinates her into dieting, giving confusing mixed messages equating weight loss and smaller size with health; instilling the message that being thinner will help her feel better about herself and be more liked by others; co-opting nondiet language, such as throwing out the scale; and teaching dieting, restrained/disordered eating behaviors and avoidance of fattening “bad” foods as being “healthy eating,” and encouraging obsessive exercise to lose weight. When Chelsea is teased, Jody tells her:
“I think I know how you handle situations like that…you eat,” Jody said.
Here it comes, thought Chelsea. You would be such a pretty girl if you lost weight. Why don’t you try eating healthier and exercising more and then life would be perfect, blah, blah, blah.
“I did the same thing when I was your age,” said Jody. “I weight even more than you do.”
“You did?” Jody looked really fit…
“Yeah, I was a really overweight kid, and got bullied — people called me names all the time. But I went off to this outdoor camp… And it got me started in a new direction with my weight and with myself… Sometime, I’ll tell you how I went form being a heavy out-of-shape weakling to this wilderness goddess you see standing before you.”
Later, Jody pulls out a photo of herself as a young girl.
There was no other word to describe the kids who was obviously Jody at about twelve. Jody was fat. Really fat. Chelsea at her worst was never so big.
“What happened? You’re in great shape. I mean, you’re not skinny, but you look good. You know, healthy, fit. How did you.. and why do you carry that awful photo around all the time?”
“So I won’t forget,” Jody said... “I figured out I was never going to be a size 2, so I concentrated on being the absolute best, healthiest person I could be. My doctor told me that I was really at risk for diabetes. — So I figured that I would try and get healthy for awhile…eat healthy and exercise… And I really loved it. Next I gave up soda. Stopping watching TV all day on Saturday and Sunday. You know, that’s when eating gets out of control for me. I watch TV, I eat, I eat, I watch TV.”
Jody proceeds to give Chelsea diet and exercise advise, as they make lunch for the campers. “If you don’t get enough chewing, you don’t feel satisfied…I made a list of crunchy snacks that took maximum chewing — like carrots.” She tells Chelsea that to lose weight, she’d also joined a martial arts class, a dance class, and took yoga, on top of walking and biking everywhere.
“How long did it take you to lose as much weight as you wanted?” Chelsea asked.
“Two years, Chelsea…It wasn’t easy and some days I fell back into my old ways. But I didn’t stay there long and I knew that I wanted to feel better about myself... I’ll never go back. That’s why I look at that photo occasionally. Believe me, it sends chills down my spine to see that overweight, lonely kid — the kid that was me.”
Then she asked Chelsea: “Do you ever feel lonely?... You can feel terribly alone in a crowd…”
At lunch, Chelsea piles carrots, celery and an apple on her plate. She thinks:
In a couple of hours, she would probably be starving, but she might as well give this healthy eating thing a try.
Throughout camp, she learns other things, like chocolate is bad because of the sugar rush and to only eat little amounts and save the rest for later. In her journal one evening, she writes:
“I’m hungry, but I don’t feel like I have to eat chips all the time. I can’t explain it. It’s just different. That must be the whole emotional eating thing Jody was talking about.”
She makes resolutions when she gets home that she will eat healthier snacks, walk and bike as much as she can, ask her mom if she can join a health club where they have weights; and ask to go to outward bound camp next summer. She also vows: “Accept that I weigh about a thousand pounds and that someday I won’t. And maybe, I’ll even talk to my doctor about the whole ‘weight management’ thing.”
Her final journal entry said:
“I’m going to make a list of things I want to try once I’ve lost some weight. I’m not getting on a scale — noo! to scales. But I already feel lighter.”
These are little girls being taught that restrained eating and feeling hungry means healthy eating, thereby setting them up for lifetimes of troubled food and weight issues. Given these messages are said to be appropriate and healthy, is it any wonder so many young women are confused and fearful about food, health and weight, and don’t even know what normal eating means anymore? And is it any wonder why dieting is thought to be 'healthy eating' to so many young girls and why increasing numbers are suffering from disordered eating and troubled about their bodies?
The book concludes with a how-to of dieting. It’s not called dieting, of course. The young girls this book targets are told that these dieting behaviors are healthy. Among the highlighted tips for “How to Stay Healthy,” for example, girls are told to “go for water” to fill them up so they’ll eat less.
At the back of the book are “Ten tips for a healthier you,” written by Cheung and Mavis Jukes. The ten tips given young girls include watch “only a couple of tv shows each day, tops;” when dining out order from the healthy side of the menu and choose healthy salads and sandwiches; control portions and say no to supersize; join sports teams and exercise classes; drink fat-free milk because it’s healthier; increase fruits and vegetables, as juice isn’t as healthy; ask for nutritious snacks in vending machines at school; and limit unhealthy foods, which include fatty meats, sugar desserts, butter, sugary cereals, and white potatoes, rice and pasta.
Of course, as extensively covered, none of these food beliefs are based on sound nutritional science and every objective expert review of the evidence has concluded that none of these interventions has been shown to be effective in reducing childhood obesity or to have benefits that outweigh the risks and potential harm for young people. But you didn’t hear that from media.
© 2008 Sandy Szwarc
[All italicized indented sections are quotes from the book.]