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June 02, 2005

CDC investigates obesity "outbreak"

It's all very well for the CDC to be doing epidemiological research in areas with rapidly increasing obesity rates, but why call these increases "outbreaks"? Is the terminology a publicity ploy by the CDC? Could they only get the funding if they called it "an outbreak" instead of "a trend"?

C.D.C. Team Investigates an Outbreak of Obesity [NYT]

For the first time, the Centers for Disease Control and Prevention has sent a team of specialists into a state, West Virginia, to study an outbreak of obesity in the same way it studies an outbreak of an infectious disease.

Kerri Kennedy, the program manager at the West Virginia Physical Activity and Nutrition Program, said the state had requested the agency's investigation.

"We were looking at our data," Ms. Kennedy said, and saw that "we are facing a severe health crisis."

The state ranked third in the nation for obesity - 27.6 percent of its adults were obese, compared with 20.4 percent in the country as a whole. And, Ms. Kennedy said, "our rate of obesity appears to be increasing faster than the rest of the nation."

Going along with the obesity was a high prevalence of diabetes and high blood pressure, which are associated with extra pounds. West Virginia ranks fourth in the nation for diabetes, with 10.2 percent of the population affected, compared with 6.4 percent nationwide. And it is No. 1 in its prevalence of high blood pressure, with 33.1 percent having the condition, compared with 25.8 percent of people nationwide.

So the state asked the agency's disease detectives to tackle its obesity problem, and a three-week investigation began on April 25. It focused, Ms. Kennedy said, on two places that represented towns and cities in the state - Gilmer County, with 7,160 residents, and Clarksburg, a city with 16,743 residents.

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Lindsay: You are 100% correct. This is epidemiological nonsense. CDC is trying to recoup the serious PR hit it took when it mishandled the obesity problem and is making the same mistakes as previously. Overweight is a serious risk factor for many conditions and needs to be addressed. But addressing it in this way is another signal that CDC has lost its way. Third raters sliding down even further. Very sad.

They should make a movie with Dustin Hoffman hunting a monkey that's handing out Krispy Kremes.

Whether CDC's action is nonsense or not depends on whether they have hypotheses which further field data will either support or contradict. What might some of these look like?

Specific aspects of technological change are thought to be a major contributor. See USDA's May 2004 workshop on "The Economics of Obesity", which reviewed the then current state of knowledge and surmises on the obesity problem. The workshop proceedings are at http://www.ers.usda.gov/publications/efan04004/

The Cutler/Glaeser/Shapiro paper that was discussed is at http://post.economics.harvard.edu/faculty/dcutler/papers/Why_Have_Americans_Become_More_Obese.pdf

Revere of course may have a better idea as to how to investigate the problem. Regrettably he seems to have run into a similar problem to that of Fermat - the margin of this blog is too narrow to contain his description.

Thanks, Mike, I'll check that paper out.

Here's a shorter version of the URL:

The Cutler/Glaeser/Shapiro paper that was discussed is at: http://tinyurl.com/9ygr3

You can make a compact version of any URL by using this free site:
http://tinyurl.com/create.php

Like I said, I have no quarrel with the CDC investigating a sharp local increase in obesity. I'm just wondering what's behind the unusual description of the project.

It's linguistic framing at work. Like the term "obesity epidemic" itself, the term "outbreak" invokes models of disease, spread, and infection. It encourages people to think in terms of social and medical interventions to stop the "outbreak."

Just calling it "the obesity problem" or talking about "too many obese people" wouldn't have the same effect. Usually people think of obesity as a matter of individual preference and personal weakness, not as something that needs to be addressed through public health measures.

So the sarcasm of the moment; are that people
are like puffer fish. They baloon up when they
are scared. Or as Canadian Saturday Night Live
would say , (one the late John Candy), they
blow up real good! Sense and Sensibility rtg.

Did the CDC or the NYT call it an "outbreak"? Because it doesn't make sense even if obesity was a contagious disease, obesity would be an epidemic techinically, as the word "outbreak" inmplies that virginia is suffering an isolated or special case of obesity within the national population, when it's actually ranked third for levels of obesity which means there are two states which more accuratly would class as an "outbreak", if obesity could "outbreak", which it can't.

I reckon it's more likely that who ever wrote the NYT piece thought: "The New York Times needs to be more sensationalist! The CDC are investigatin causes of obesity in Virginia? 'CDC to investigate obesity outbreak...'"

Are we sure there isn't something strange going on in West Virginia? For all I know, people are waking up in the morning, astonished to find they've accrued 150 pounds of blubber overnight. (And not at a singles bar - ba-dump-bump.)

Y'know what would be sweet? A 24-hour obesity bug. "Can't come in to work today, my ass is too huge. Maybe tomorrow."

Can you catch it from a toilet seat?

I was told that Indiana is numero uno in the percentage of obese adults in the population, but maybe the rate has risen fastest, or at least faster, in WV? It does seem like an inappropriate way to frame the problem.

Following up on R. Mildred's ruminations, perusal of yesterday's CDC telebriefing transcript (where New York Times reporter Gina Kolata got the story) yields some insight. During this telebriefing, the word "outbreak" is mentioned just once, in CDC Director Julie Gerberding's opening statement:

"Another component of the new CDC is that we're learning to adopt some of the methods that we have used for outbreak investigations and apply them to obesity. For example, one of our states has requested CDC's assistance in investigating the growing problem of obesity in the states. That's something that we do, for example, with meningitis or West Nile fever. Now, we're applying exactly the same strategy to understanding the determinants of obesity at the state level" (italics added).

In other words, the CDC sees skyrocketing obesity prevalence as a national epidemic, and it is "adopt[ing] some of the methods" of "outbreak investigations" to understand this phenomenon scientifically and focus public health interventions more efficiently. Gina Kolata was the one who labeled the West Virginia situation "an outbreak of obesity." CDC used the term to describe an established protocol for addressing public health dangers. The question of whether it is appropriate to classify the West Virginia case as an "outbreak" (Kolata's claim) is separable from the question of whether adaptation of the outbreak investigation protocol is a wise public health strategy for dealing with skyrocketing excess weight prevalence in that state (the CDC position).

In light of this, Lindsay and Revere's knee-jerk CDC bashing, based on a headline and lede to one article, seems to jump the gun and charge the discussion with an unfortunate overlay of invective. There are several more nuanced aspects of this topic that deserve more careful treatment, such as:

• The curious ambiguity in Gerberding's statement above. On the one hand, she says CDC is "learning to adopt some of the methods" of the outbreak investigation protocol to the public health challenge of addressing non-infectious, chronic diseases such as obesity. Yet in the next breath, she says "we're applying exactly the same strategy" in West Virginia as the one used to combat West Nile virus and meningitis outbreaks. "Adopting some of the methods" and "applying exactly the same strategy" are not quite the same things. So what precisely does this West Virginia obesity strategy look like, and how similar is it to a traditional infectious disease outbreak investigation?

• West Virginia asked CDC to conduct an outbreak investigation. Again, check the telebriefing transcript: "CDC doesn't send people into the states. We get invited, and we are just delighted that the health officials in West Virginia appropriately recognized that they had a serious problem with obesity in their state, and they really wanted to do more than just describe it." Lindsay, is your criticism of CDC based on evidence that CDC pressured Kerri Kennedy or others at the West Virginia Physical Activity and Nutrition Program to make this request? Or are you saying that CDC should have refused West Virginia's request? If so, on what grounds would you have CDC turn down the request?

These would seem to be salient lines of inquiry to pursue, given that the last statement in Gerberding's telebriefing appears to give the green light to other states and localities to follow the West Virginia example: "So we do that at the invitation of health officials and we have a large cadre of disease detectives, and we look forward to doing everything we can to help state and local governments solve this problem."

I'm outbreaking my waistline as we speak. Translate: My pants are getting tight. I need to cut back on my sugars and my carbs.

Actually, calling it an epidemic is also alarmist hyperbol on the CDC's part, as at this point, obesity is still a social trend that more resembles a kind of atmospheric poisoning than an infectious disease, which is what most people think of when they hear "epidemic".

Obesity is a metaphorical epidemic, and their PR people should know better than to start messing around with metaphors in front of today's press.

I believe it is actually a false belief that an epidemic implies contagion.

Gordon, I don't know whether the CDC should have accepted Virginia's request. That depends on the rules for getting federal help for epidemiological investigations. If it's normal for the CDC to dispatch a team to investigate trends in chronic disease at the state level, then I'm all for it. If it's unusual, I'd like to know how they justified this particular intervention. Are they expanding the definition of "outbreak"? And if so, why?

My impression is that the CDC sets aside resources for SWAT teams to investigate acute outbreaks of infectious diseases in the States. If a state health department needs help finding the salmonella or the Legionnaire's disease, the feds will step in.

There must be some rules about how a state qualifies for CDC intervention. It sounds to me like someone is bending the rules for federal assistance, but I could be wrong. Maybe expanding the rules is a good thing. I'd just like to hear more background on this story.

Some clarifications. Technically an epidemic is an increase in disease incidence ("risk") beyond what is expected. I think obesity, if it is a disease, qualifies as an endemic disease, not an epidemic one, but that depends on what you "expect." Anyway, as Lindsay says, contagion is not needed.

CDC sends Epidemic Intelligence Service (EIS) officers to investigate "outbreaks" when requested and subject to resources and its own judgment. This is a highly unusual request and response. It seems designed to make a PR impact, not a public health impact. As several public health folks quoted in Kolata's article note, it can be expected to find the obvious and learn nothing. In a word, it is stupid.

Moreover it seems bizarre to send a SWAT team to WV which has one of the most polluted environments in the country in the Kanawha Valley (chemical plants) to inquire about PE programs and fatty foods.

As for CDC bashing, I have worked for decades with colleagues from CDC. It has had a dedicated and knowledgeable workforce and many true heroes with a passion for public health are still hanging on -- for dear life. Director Gerberding's Disorganization Plan has been a disaster of a different kind and in any other administration a management consultant flying squad would have been sent there long ago to stem the hemorrhage of qualified senior scientists who are trampling each other at the exit doors.

The whole obesity problem--a real problem as I note--has been so thoroughly bungled that it defies the imagination. Incompetent suck ups who surround themselves with toadies deserve to be bashed.

Given the potential for some serious outbreaks of bugs like avian flu, it's very much in the CDC's interest to preserve as much cred as possible. This "obesity outbreak" BS doesn't exactly fill the bill.

It appears that on one point, Revere is correct - the "disease detectives" referenced by Gelberding in the June 3 CDC telebriefing are scientists working with the CDC's Epidemic Intelligence Service (EIS). According to the CDC website, "[t]he EIS was established in 1951 following the start of the Korean War as an early warning system against biological warfare and man-made epidemics. The program, composed of medical doctors, researchers, and scientists who serve in 2-year assignments, today has expanded into a surveillance and response unit for all types of epidemics, including chronic disease and injuries" (italics added).

Regarding Lindsay's question about the appropriateness of CDC's response to the West Virginia request, take a look at the description of EIS Officer Activities:

• Conduct epidemiologic investigations, research, and public health surveillance • Serve the epidemiologic needs of state health departments (italics added) • Present epidemiologic papers at scientific and medical conferences; publish their work in the scientific literature • Disseminate vital public health information to the media and the public.

The second bullet indicates that it is a formal part of the EIS mission to respond to requests for help from state governments - something that is very important, given that many state public health departments are strapped for cash and have limited expertise in dealing with public health epidemics.

Further, it is important to note that not all EIS "disease detective" work deals with infectious disease outbreaks. For example, the top three examples of EIS casework referenced elsewhere on the CDC website concern investigations of non-infectious diseases (thyrotoxicosis from eating beef containing cows thyroid tissue; lung cancer from smoking, and ovarian cancer from contraceptive pills).

Regarding Revere's opinion that rising excess weight prevalence is an endemic, not epidemic trend, check out the CDC's Behavioral Risk Factor Surveillance System map of national obesity trends from 1995-2003 [Warning: 7.1MB Powerpoint file] and decide for yourself.

Finally, Revere, did the CDC break up one of your picnics a few years back or are you always this ornery?

Gordon: I guess I'm always this ornery. I've had a very good working relationship with CDC over the years and have a lot of respect for many people there. In fact I personnaly have never had a problem working with them. But over the last 30 years the agency has gone down considerably. They can't retain people and the Gerberding Disorganization has been an unmitigated disaster, further crippling a once proud agency. Public health has no standing in this administration and Gerberding has willingly played patty cake with the Bush administration (which is why she is still around). Her main virtue is that she is genuinely a skilled communicator. But a terrible manager who has not fought for public health nor become a leader. She is not even a decent functionary.

Isn't obesity the sign of a prosperous society?

What I'm finding puzzling is the need to conduct an epidemiological investigation of obesity on a location-specific basis. You would think we already have sufficient understanding of the causes to start to work on interventions. Are the factors underlying occurrence of obesity in WV going to be different than elsewhere in the US?

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