C-sections increase the risk of obesity by 15%? Big deal: 15% is essentially nothing.

Baby being born via Caesarean Section coming out

The mainstream media is buzzing with the news that C-sections purportedly increase the risk of obesity in offspring by 15%.

Here’s the LA Times:

There’s just one problem. An increase of 15% is essentially nothing.

Your very first moments of life can influence your risk of obesity for years, a new study shows.

Babies delivered via cesarean section were 15% more likely to be obese as kids, teens and young adults than were babies who made the trip through the birth canal, according to the report in JAMA Pediatrics…

Nutritional epidemiologist Changzheng Yuan of the Harvard T.H. Chan School of Public Health and her study coauthors had good reason to suspect that a C-section put a baby on the path to obesity. Two recent reports that pooled data from other studies found that cesarean birth was associated with a 22% increased risk of obesity.

There’s just one problem. An increase of 15% is essentially nothing.

The study is Association Between Cesarean Birth and Risk of Obesity in Offspring in Childhood, Adolescence, and Early Adulthood, and appears to be methodologically excellent, correcting appropriately for confounding variables like maternal weight.

The problem is the importance they place on a very tiny difference that may be no difference at all.

Consider a different relationship, smoking and lung cancer. Smoking increases the risk of lung cancer by more than 2000%.

How about homebirths? Homebirth advocates are fond of claiming that the increased risk of neonatal death at homebirth is trivial, but CDC statistics indicate that it is in the range of 200% and the most definitive statistics, from Oregon, show that homebirth increases the risk of perinatal death by 800%.

Several years ago Gary Taubes wrote a piece for the New York Times Magazine explaining how lay people can judge the results of epidemiological studies, Do We Really Know What Makes Us Healthy? He was writing in the wake of new revelations about estrogen replacement therapy that showed that the benefits of estrogen had been vastly overstated. He pointed out that the estrogen fiasco was a foreseeable result of using weak epidemiological data to make sweeping pronouncements. It was a cautionary tale similar to many cautionary tales in epidemiology, particularly those concerning lifestyle behaviors.

…[T]he perception of what epidemiologic research can legitimately accomplish — by the public, the press and perhaps by many epidemiologists themselves — may have run far ahead of the reality. The case of hormone-replacement therapy for post-menopausal women is just one of the cautionary tales in the annals of epidemiology. It’s a particularly glaring example of the difficulties of trying to establish reliable knowledge in any scientific field with research tools that themselves may be unreliable.

Taubes offered lay people rules of thumb for evaluating claims based on epidemiological data.

…[H]ow should we respond the next time we’re asked to believe that an association implies a cause and effect, that some medication or some facet of our diet or lifestyle is either killing us or making us healthier? We can fall back on several guiding principles, these skeptical epidemiologists say. One is to assume that the first report of an association is incorrect or meaningless, no matter how big that association might be… Only after that report is made public will the authors have the opportunity to be informed by their peers of all the many ways that they might have simply misinterpreted what they saw…

If the association appears consistently in study after study, population after population, but is small — in the range of tens of percent — then doubt it. For the individual, such small associations, even if real, will have only minor effects or no effect on overall health or risk of disease. They can have enormous public-health implications, but they’re also small enough to be treated with suspicion until a clinical trial demonstrates their validity (my emphasis).

The authors of the C-section paper acknowledge that similar studies have found no difference in obesity rates, or small differences, and many studies that claimed to find differences in obesity rates did not correct for confounding variables:

Despite inconsistent findings from individual studies, two recent meta-analyses reported a 22% increased odds of adult obesity associated with cesarean delivery. However, many of the studies included in these meta-analyses—particularly in the meta-analyses for adult obesity—failed to account for important potential confounders, most importantly for maternal prepregnancy BMI.

Let’s apply Taubes’ principles to the claim that C-section increases the risk of obesity in offspring by 15%.

1. Assume that the first report of an association is incorrect or meaningless: This is not the first report of an association.

2. If the association appears consistently in study after study, population after population: This finding does not appear consistently. A number of studies have found no association between C-section and obesity

3. If the association appears … small — in the range of tens of percent — then doubt it: An increase of only 15% is very small, essentially no difference at all.

C-sections increase the risk of obesity in offspring by 15%?

May so, maybe no, but either way the difference is so small that it doesn’t tell us whether C-sections have any impact on obesity at all.

 

Addendum: Here’s the relevant chart from the paper.

image

  • MrG

    The speculative future risk of obesity in the offspring should never be a good enough reason to not do a cesarean, especially when it’s done to save the baby’s or mother’s life,”
    http://www.reuters.com/article/us-health-cesareans-child-obesity-idUSKCN11D2O2

  • Abby

    Argh!!!! Surely obese women are more likely to have cesearean sections and babies of obese women are more likely to be obese!!!!! Argh!!! Why is no one saying this on the news!!!! I just can’t take the stupidity of the human race any more!! Sorry for the exclamations just feeling so cross…

    • RMY

      I really hoped they controlled for obesity in parents in this study. I kind of think it’d be higher if they hadn’t… but I’m not any kind of doctor.

  • Fleur

    OT, but when did it become the ideal to have a baby that doesn’t cry when it’s born? I was just reading a magazine article where one of the mothers interviewed was boasting that her baby had such a lovely, relaxing birth experience thanks to hypnobirthing that it came out completely silent and just lay there and stared when it was born. I’m just a layperson, but I find it hard to believe that a baby’s first cry amounts to a one-star review of its birth experience.

    • Gene

      In the hundreds of births I’ve attended, I once saw a baby who never cried (who was otherwise healthy). Apgars were 8-9/10. One off for color at 1min, 1 off for no cry at 1&5 min. Not stunned, no reap distress, just did not cry. Once.

      Oh, and he was a c-section. Go figure.

      • Megan

        My first daughter did not cry for a bit (though she did by 1 minute), just kind of looked around in awe. APGARs 9 & 9. Second daughter screamed the OR down (and still screams our house down whenever she is mad!). APGARs 9 & 9. Both CS. When I used to deliver babies, I saw both “types” of baby and I don’t think it’s a reflection of the birth “experience.” My older daughter continues to be very cautious and pensive, a little shy. My second daughter so far seems to be very expressive, both when happy and upset. Perhaps it’s just temperament?

        • Gene

          No idea. I RARELY ever gave a 10 at 5 min because most newborns still have pale or blue hands/feet then. And that’s why I think most homebirth 10/10s are bullshit. This kid though, pink and vigorous and looked amazing. And never cried for the first 30min. Ever with vigorous toweling and his VitK shot (he grimaced a little). This was over a decade ago and I still remember him and how the nurses with me (who been attending deliveries for decades) were amazed.

          • Wren

            My little sister was like that, to the point they started to worry she couldn’t cry. As she grew up a little we just realised it was temperament.

    • moto_librarian

      We knew our second was in distress when he was close to being born. The NICU team was already on hand because of mec in the waters, and I still remember hearing the nurse ask if she needed to page the OB Emergency Team. The midwife said “we need to get him out now,” and told me to push in the absence of a contraction. I did, and he had to be unrolled out of his umbilical cord. I was very worried that he wasn’t crying, and I remember watching the team work on him. He was breathing, but not vigorously, and needed O2 via CPAP, deep suction, and vigorous stimulation. I remember the attending neonatologist saying that he was just a bit stunned, and sure enough, he was stable and in my arms within 20 minutes. It’s not a good thing for a baby not to cry at birth.

      • Fleur

        I’m glad everything worked out ok for you and your second!

        Yes, I think it’s the unthinking privilege that bugged me. For anyone who has ever suffered a loss or been close to someone who lost their baby or experienced health concerns during pregnancy, those first few seconds are incredibly tense. I can imagine that (as other commenters have mentioned below) there might be the occasional healthy baby who is just naturally quiet, but anyone who can casually dismiss complete silence after birth with “oh, that’s the baby validating my birth choices!” has clearly never had to think about how badly wrong things can go.

  • nomofear

    Has anyone seen this? My local peds group posted it and I suspect it’s flawed, but don’t have access to the actual study – and, who am I kidding, probably wouldn’t have the skills to properly analyze it, anyway. My first question is whether income was controlled for, since income is a huge indicator of asthma risk, right? http://www.techtimes.com/articles/176353/20160905/infants-predisposed-to-asthma-may-find-protection-from-respiratory-symptoms-in-breastfeeding.htm

    • Roadstergal

      It’s a poster at a conference, not a paper. Just a tease of something that might or might not be there. If there’s enough for a paper at some point, we can judge then. Definitely not worth a news article .

      Ah, Switzerland. They care so much for their babies, they don’t vaccinate them…

      • nomofear

        Oh. Well, I asked some pointed questions on the post. I like this office for their firm stance on vaccines, but one of their docs and their lac consultant made this trip to The Farm together a while back and were so proud of themselves for advocating for birth choice. Then, they’ll post stuff like this. What is this, even? “Tech Times”?

      • Charybdis

        Just ask Barzini…

  • Roadstergal

    So, as the local Ebul Big Biotech rep – suppose we came up with a drug that decreased the risk of obesity by 15%. Suppose the side effects were serious infections, broken bones, hypoxic brain injury, all of the risks to the baby of vaginal birth…

    Would we be sued quickly, or instantly?

    • The Computer Ate My Nym

      I would not approve the drug, certainly not without a black box warning.

  • MaeveClifford

    What’s more likely? That un-accounted for confounding variables lead to both higher c-section rates AND later obesity (fetal weight variations within “normal” range, maternal age, paternal weight, ethnic factors, metabolic factors, SES factors, etc. etc.)
    OR
    That somehow, a trip through the birth canal confers a LIFELONG protective effect against obestiy. The proposed mechanism of which is????

    Oh, don’t tell me. The *~microbiome~* .

    • Roadstergal

      QUANTUM EPIGENETIC MICROBIOME

    • Nick Sanders

      Don’t be silly. It just squeezes the excess juices out of the baby so it doesn’t get soggy and swollen.

  • 3boyz

    Interesting. Did they also control for things like GD, which also increases the risk of obesity for the child? Happens to be, I was born by c section and I do struggle with my weight, but so does everyone on my dad’s side. And having 3 kids in fairly quick succession probably didn’t help matters. All my kids are skinny, they take after my husband. Ironically, my third, who was my only c section, was my smallest baby. He was born at 36 weeks, so not quite full term.

    • fiftyfifty1

      “Did they also control for things like GD”

      Yes, they did control for gestational diabetes. Although how gestational diabetes is tested for has changed significantly from when most of the births occurred. For example, back in the 1980s many doctors used a risk approach. If a woman was deemed to be “low risk”, then she was not tested. And even in women who were tested, mildly abnormal values were often accepted as normal. In contrast, the current protocol is that every pregnant woman is screened. And abnormal and borderline values automatically prompt a more rigorous follow up test. With today’s protocol, GDM is no longer missed with the frequency it used to be.

      • Mattie

        just out of interest, are you in the US? If so, do all pregnant women have a GTT? Regardless of risk factors/symptoms

        • fiftyfifty1

          I’m in the US. All women get the 1 hour glucose screening test. If that is abnormal then they get the formal 3 hour Glucose tolerance test.

          • Mattie

            interesting 🙂 AFAIK here (UK) women with risk factors get the GTT at 25 weeks, and also if they show glucose in urine on 3 visits they also get the GTT, but not everyone.

          • Azuran

            In the part of Canada where I live, everyone gets a 1h and 2h glucose tests between 24-28 week. Those with any kind of risk factors also do it somewhere between 8-12 weeks.

      • netrolller3d

        I’m not sure if she meant gestational diabetes or genetic disposition. From her next sentence, it sounds like the latter.

        Also, did they control the fact that countries with more doctors capable of performing a C-section generally have fewer famines and a lower risk of malnutrition (which would bias obesity statistics downwards)?

  • Amy Tuteur, MD

    OT: Another horrifying case of medical neglect at unassisted homebirth

    https://business.facebook.com/skepticalob/posts/438659736304731

    • Heidi

      “I’m getting really worried.” If you say those words, call 911, drive to the ER, or drive to the pediatrician. Anything that you are “really worried” should not be addressed by a lactation consultants or other random homebirthers!

      • Madtowngirl

        Or anyone on the Internet, really. Get that baby to a doctor!

        • Heidi

          Let’s hope someone she trusts gives her this advice and she takes it! Maybe an LC will pipe up and tell her it could be a very serious condition that can’t be fixes by lactation support.

          • momofone

            It astounds me that anyone could look at that baby and have to ask what to do next. Get to the hospital ASAP!

          • Heidi

            It is astounding, but I guess if you’ve already bought the whole idea that women’s bodies are meant to birth babies and if you just trust your body, your body will birth a perfectly healthy baby, you have a hard time seeing that maybe your body didn’t do that. I’m sure she’s forgone GD testing, ultrasounds, blood pressure checks, urine testing, GBS swab, all the stuff that helps more babies and mothers survive pregnancy because she believed nothing could go wrong. But, yeah, still you’d think something would click the moment you saw that baby and you’d rush out the door to the hospital because you have nothing too important to lose by going to the hospital but YOUR BABY to lose if something is seriously wrong.

      • Amy

        OMG this!

        I DO NOT GET people whose first reaction to a medical emergency is to ask Facebook what to do.

        • Azuran

          I know right. Where I live, aside from 911, we also have a free 24/7 health care line. You can also call the ER or any private of public health clinic.
          When I went for my first appointment for my pregnancy they gave me another phone number and told me to call at any time to speak with a nurse specialized in pregnancy and neonatal care at any time if I ever felt there was anything wrong.
          You can easily get an answer in less than 5 minutes. Why wait 10 hours on facebook?

        • demodocus

          really. When my kid’s leg got broken last summer I didn’t even think to call a soul until we needed a ride home with our newly casted and doped up toddler. Don’t think I posted on FB for a week.

          • Heidi

            I’m sure you tried Thieve’s oil first, though, right?

          • demodocus

            Nah, breastmilk.

          • Heidi

            You know, I said that thinking it was totally absurd, that surely no one could legitimately think EOs could cure a broken bone, but I googled it and THEY DO THINK THAT. Of course, they do. What was I thinking?

          • demodocus

            there a lot of people i’d love to sell some swamp land to

    • MB

      I really hope that woman takes her baby to the hospital. That baby looks on the large side too. I wonder if the baby is hypoglycemic? My baby was born hypoglycemic. It is generally asymptomatic, except that the baby (who looks healthy) is lethargic. He wouldn’t rouse to nurse. Hypoglycemia in newborns can cause profound brain damage. It is one of those “standard” things that hospitals usually check for in the first hours of birth because it is so preventable. My baby had to go on glucose drip and be bottle fed by the nurses in the special care unit on a rigorous schedule. The colostrum would not have provided him with enough stable sugars to support him. Just hope that baby is ok and her mother comes to her senses.

      • 3boyz

        2 of my 3 were hypoglycemic. My second was only slightly so, so he didn’t need the NICU, but they did give him a few ounces of formula after each nursing session. We were discharged on time. Although I hadn’t been diagnosed with GD, I now think I may have had it and they didn’t catch it, because he was also 9 lbs and I did have GD with my third. That baby was born slightly prematurely, but I had been having placental issues throughout the third trimester (partial abruption, then at the end, a full abruption) and he was admitted to the NICU was a sugar level of 26. He needed a central line with the highest concentration of dextrose solution they had. He was there for 9 days before his sugar stabilized enough that he could come home. I was told that while it certainly didn’t help, the GD wasn’t the problem. It was the crappy placenta that didn’t nourish him properly that caused it. Low blood sugar is nothing to mess around with. My baby is fine now, no lasting effects, because he was got top notch medical care in a timely manner.

      • Charybdis

        Was this the baby with the rash?

        • MB

          Yes, the baby with the rash. Just an observation that she looked kind of large. …Though admittedly it was hard to tell from the pics without some point of reference.

    • Platos_Redhaired_Stepchild

      I clicked the link and it said the page had been deleted. Looks like a cover up to me.

      • Amy Tuteur, MD

        I deleted it because I didn’t want to be banned from Facebook. The mothers friends were complaining.

        • momofone

          How fucked up (and typical) is that?! They complain about that, but apparently not about the fact that this baby needs medical attention.

          • corblimeybot

            Well, it’s only the mother who matters with these people. Her feelings are more important than her child’s life, every single time. They TRULY believe this.

  • Anonymous

    I don’t know if I trust a study with that number of participants b/c it doesn’t look as though they’re taking confounding factors into account, in this case, stress eating, less exercise, change in diet due to budgetary requirements, etc. Show me where these women are in 20 years and I’ll be interested in that.

  • Laura J

    Here is a similar study two years ago, large number of participants…

    http://abcnews.go.com/Health/cesarean-delivery-linked-childhood-obesity/story?id=16413001

  • Megan

    I could discuss the uncontrolled variables here that matter to this issue, but since others (fiftyfifty1, in particular by mentioning no control for fetal weight) already mentioned them, I’m just going to comment that I’m just so sick of this incessant demonizing of CS and the innuendo of the “inappropriate” MRCS. Just enough already.

    • Azuran

      Yea, all for something that really has no real consequences. Someone on the reddit linked bellow put it in actual number, something like 1.2 pounds. My weight varies by that much on a daily basis… This whole thing is basically nothing to even bother thinking about.

      • Megan

        Seriously, that’s the equivalent of a good poo! Or that lovely day where I finally diurese after my period!

        • Azuran

          Do you think they had anyone poo and pee before they weighted them? XD

          • Glia

            They didn’t weigh them. They asked them “hey, what was your prepregnancy weight 10-15 years ago?”

          • Azuran

            Wait, really? Here we are, actually talking about this study in a serious matter, trying to explain their results, and they just ASKED people how much they weighted?
            Wow…

          • Glia

            Yes, they just asked. I think I misread, though, looks like they did ask them at a relevant time as part of a previous study, then looked them up for this one.

            Edit: Yes, they were sent questionnaires every 2 years, it looks like. Then for this study, I think the authors looked up their answers from before their pregnancies. That information is in a whole different paper that they cited, though.

  • Azuran

    They say they adjusted for a lot of things, and kinda make it sounds like since they adjusted, it cannot possibly, in any way, have affected their results.
    But then again, I doubts it’s possible to have a 100% accurate adjustment of all those parameters at the same time. So it’s entirely possible that their tiny 15% increase could just be that they didn’t completely removed the influence of some of those parameters.

    • AS

      They don’t attempt to adjust for socioeconomic status – while it can be ignored in twin studies, not so much for siblings.

      • Azuran

        Indeed. My mom got me and my older brother when she was still at school. We were poor AF and living in cheap moldy apartments in poor neighbourhoods until I was like 5. By the time the 2 youngest were born, we were much better off, with both parents having well paid full time jobs and living in a house.

  • Dr Kitty

    Since the study compared siblings, did they control for paternal BMI and consider misattributed paternity?

  • Laura J

    My family is thin. Some of our cousins were C-sections and they are on target, or actually underweight by three pounds. Sepsis came out of nowhere with no symptoms for baby #1. The second, not enough fluid for my 7lb baby. In my case, and I had GD on the last one, pre baby weight 120, baby is fine with weight. The Dr. said it was the placenta sending off hormones that interfered with my own glucose although my diet was strictly based on controlling mild case of GD. Vegetables, greens and chicken & fish, with one apple a day with almond butter. Since then my weight is 120 after baby. While it seems like the study seems valid, and it is new, there is margin for error with so many variables that affect obesity. Maybe it’s preservatives. Maybe it’s synthetic sugars such as sucralose. Perhaps there will be another study on the same merit and see if it holds up in 5 years. My 2 cents for the day. Have a lovely day folks.

  • The Bofa on the Sofa

    Let me grant for a second that it is true, there is a 15% increase in obesity with a c-section.

    OK, which c-section that has been done should not have been based on this?

    Oh, I know – all those MRCS…right? Because there are so many of them. And who cares about the mother’s wishes, they need to be educated as to what’s really good for them. Or their baby, that is. Maybe. Well, it’s a 15% chance of what might be better for their baby.

    Can’t we just work with them on how to maintain a good, healthy diet with exercise?

    • Sarah

      There were a particularly high number in the 80s, it would seem! Here was me thinking they were quite rare back then.

  • Dr Kitty

    One analysis I read said that on average it meant that a sibling born by CS would have a BMI 0.3 more than their vaginally born sibling.
    For two 5’7” siblings a difference between a BMI of 29 (overweight) and a BMI of 30 (obese) is 7lbs.
    So we’re talking about fewer than 5lbs difference.

    5lbs is the difference between a couple of big meals,a few days of PMS-related bloating and constipation and a period related diuresis, diarrhoea and a few light dinners for many of us.

    Most of us will have a weight that fluctuates by a few lbs up or down from week to week.

    • Amy

      And for those of us on the shorter side, it takes even less of a weight difference to tip the BMI. I’m four foot ten. My BMI goes up and down depending on when I last ate or used the bathroom.

    • AS

      That being said, most of the factors that are discovered to affect obesity risk, are of about that magnitude individually. 5..10 pounds.

  • Sarah

    I may be barking right up the wrong tree here, but I’m always surprised when people suggest things like VB, breastfeeding etc have a protective effect against obesity. I mean maybe they do, although the literature doesn’t support it, but it seems counter intuitive. Most humans throughout history haven’t had access to the resourced needed to become obese, have they? Starvation has been an ever present risk, whereas obesity has only recently and only in some parts of the world become a pressing concern. Prior to that, the ability and desire to eat a lot of fat and sugar when it was available and to keep fat on was an advantage in resource marginal environments. Which is part of the reason many struggle with obesity now, because traits that were evolutionarily advantageous have suddenly become less desirable.

    With that in mind, wouldn’t it make more sense for VB to be associated with obesity, if any form of birth were to be, because the traits that make people obese have more usually been useful?

  • Platos_Redhaired_Stepchild

    “Nutritional epidemiologist Changzheng Yuan of the Harvard T.H. Chan School of Public Health and her study co-authors had good reason to suspect that a C-section put a baby on the path to obesity.”

    How? No, really how? I really want to hear why surgically removing a child from a uterus somehow causes that child to be prone to obesity….or, really, anything.

    • It also sounds to me that the authors had a preconceived theory — that is, that obesity happens more often to children born by C/S, and then went looking for evidence.

      • J.B.

        Just as with breastfeeding research I wonder about confounders. What is the impact of genetics and poverty?

    • Jackie

      I have the same question. From what I understand as a layperson, body weight is determined by genetics, diet, physical activity, and other biological factors like hormones. How could method of delivery possibly affect any of these things. I dont get it. Doctors/scientists, could you weigh in? (I can’t read the paper myself because I can’t access it on my phone and my computer is broken).

    • TheArtistFormerlyKnownAsYoya

      Yeah, I have the same question about all the alleged dangers of c-section…like how is c-section allegedly “causing” things like diabetes. If these claims are to be made someone needs to explain the mechanisms at work. Correlation causation.

  • CSN0116

    I’m confused. How are they defining the “risk” in order to call it increased? Not every baby is born possessing the same amount of risk for becoming obese (and the number of variables to control for to sort that out would be insane and go well beyond maternal pre-pregnancy BMI). So… they’re not stating that C-section babies are straight-up 15% fatter than their vaginal counterparts, rather that every single baby has the same “X” risk of being fat and cesareans increase that “X” risk by 15%? But how is “X” named?!

    What if my general risk of getting eaten by a polar bear is 0.0001%. But if I go to the North Pole that risk is increases by 15%, cuz duh… I’m physically closer to the thing that can kill me. So my new risk is 0.0015%. (A) My risk is still very small, meaningless, (B) So long as I exercise some common sense and don’t poke a damn polar bear, I could probably mitigate much of that 0.0015%, (C) My silly example here gives a logical mechanism by which closer physical proximity will increase my risk of being murdered by a polar bear. Even if this C-section-obesity finding was causational… by what logical mechanism? What about a brief surgical procedure could cause obesity?! What what what?! It’s not plausible and if I were the researcher I would credit my findings to unknown confounding variables, period.

    • MB

      Does anyone know of an actual study done that truly weighs the risk (mortality/profound injury to mother or baby) of c-section vs. vaginal birth? (No slipping those emergency c-sections in with the other scheduled c-sections – or even better maybe it compares the risk of emergency c-section w/ scheduled c-section and also includes the “fail” rate of vaginal birth – i.e. x% of planned vaginal births end in emergency c-section).

      • AS

        Number of maternal request c-sections without previous c-section is probably too low and has inherent hard to filter choice bias present.

        What is being studied instead is subsequent pregnancies after first c-section, as trial-of-labor-after-c-section and emergency-repeat-c-section.

        TOLAC has slightly increased risk of perinatal death and brain damage when comparing with ERCS. The more recent study you’ll look at, the more results will emphasize that ‘absolute risks are small’, but they are there. (And then there are studies that happily proclaim ‘uncomplicated VBAC is safest’. Sure it is, no one is arguing that, but it’s not like we can pick and choose uncomplicated VBACs now can we?

        TOLAC only comes ahead once you consider lifetime risks during future pregnancies (well that, and the fact that some would consider the open abdominal incision a ‘profound injury’ to begin with). Each subsequent abdominal surgery increases risks during future pregnancies, labor or repeat surgeries, quite significantly.

        • MB

          Thanks for the info!

    • Amy

      To be a bit of an arithmetic nerd here, if your risk is .0001% and then increases by 15%, it only goes up to .000115%. .00015% is a 50% increase.

      • CSN0116

        My bad!

  • Amy

    And just from a cursory, late-evening, post-long-day-at-work glance, I see the word “associated.” As in, no control for confounding factors. How many of those babies were delivered by c-section BECAUSE of macrosomia? How many of the mothers were already clinically obese? It’s like the studies that say that babies who are breastfed have higher IQs, as if IQ tests are even meaningful to begin with, and as if there’s no correlation between educational and socioeconomic levels of families and the likelihood of breastfeeding.

    Meanwhile, I know this is just anecdata, but my older child has consistently been borderline underweight regardless of diet and activity levels, and my younger child is dead average and competes regionally (and practices five days a week) in her chosen sport.

    • MI Dawn

      That was JUST my thought. How many of the babies were macrosomic? Or children of diabetic or GD mothers? They claim to have accounted for cofounders like pre-pregnant BMI in the mother. (Can’t read the study at work)

    • guest

      My daughter was delivered via c-section because she wasn’t tolerating labor well. It turned out that she had a small placenta, that *that* may put her at risk of obesity later in life (via epigenetics: if she was starved for nutrients in the womb, that environment may have activated genes to seek out and retain calories). But if you don’t exclude her from a study like this, it would look like the c-section is associated with it.

  • Obesity (or, rather, thinness) is a class marker, just like extended breastfeeding, an all-organic diet, the ability to go years without a paycheck in the service of perfect AP mothering, the unconscionable noxious privilege of the antivax stance, and all the rest of the woo and woo-adjacent stuff that tends to go along with NCB. The moral panic about obesity has always seemed to me to be at least as much about the fear of a highly-visible low-status marker as it is about “health.”

    Connecting it to C-sections is just like the vaginal seeding bullshit that was in the news a few months ago: another reminder that there is one “right way to live,” and most of us are doing it wrong. I mean, there are no news articles about shoulder dystocia or the risks of breech birth, but C-sections are always good fodder for a two-minute hate, what with the lazy “too posh to push” good-for-nothing so-called mothers using up valuable resources and going through a terrible recovery after taking the easy way out and depriving our babies of our microbiomes and something something breastfeeding and now we find out we’re probably making our kids FAT?

    Fair trade pearls are being clutched, people.

    • Stephanie Rotherham

      I love you.

    • Megan

      Brilliant.

  • Gatita

    Good write-up. Thanks for breaking it down.

  • fiftyfifty1

    I don’t have access to the whole study, so can anyone answer this for me?: They control for maternal weight, and that’s hugely important. But do they control for fetal weight (equally important)? I won’t even ask if they control for paternal weight, because I’m sure they didn’t.

    • AA

      Fulltext of the publication (this will lead you to a PDF)

      http://docdro.id/DoaOdmJ

      • fiftyfifty1

        Thanks for the link AA.

        So it looks like they controlled for maternal weight, but not fetal weight except at the extremes. So term babies that weighed anywhere from 5 lb 1 oz to 9 lb 14 oz were all lumped in the same “no known risk” category. But we know that a nearly 10 lb baby is far more liekly to get stuck in a pelvis and need a CS than a ~5 lb baby. And we know that large babies are more likely to grow into large adults. They were able to treat maternal pre-pregnancy weight as a continuous variable, so why not fetal weight?

        Am I missing something here?

        • AA
        • indigosky

          That was my first thought too – big baby equals more likely for a C-Section, thus more likely to be obese.

          Sort of like the stupidity that autism is caused by C-Sections. No…C-Sections are caused by autism. Autistic kids are more likely to have larger heads and this harder to go through the birth canal.

          But it’s more fun to switch things and make inflammatory headlines and scare the crap out of moms. Jerks.

          • Vast

            Also, babies with neurological issues are more likely to be breech regardless of head size (due to some lack of instinct to orient their head down or something)… read about that and freaked out when my son was beech. (He appears to be doing great as a toddler, although maybe with some slight Aspergerish tendencies like his father.)

  • LadyKatie16

    There seems to me to be no logical reason to assume that any relationship would be causal. I’m sure obese women are more likely to have c-sections and there babies are more likely to be obese later in life. How is that news?

    • Juana

      That’s what I’m thinking, too. I haven’t read the paper, but does it offer any explanation for a causal relation?
      I can imagine a c-section as a cause for, say, intermittent respiratory problems in the neonate (don’t now the exact term, but I think you get what I mean) – lung being squished in the birth canal vs. not being squished.
      But obesity? How should the mode of exit from the mother’s womb cause that?

      • Monkey Professor for a Head

        I’m assuming people will attribute it to differences in the microbiome.

    • TheArtistFormerlyKnownAsYoya

      “There seems to me to be no logical reason to assume that any relationship would be causal”

      Just like pretty much any study demonizing formula feeding and c section. They claim to have controlled for mother’s BMI but not father’s or baby’s weight.

  • Prey on something people dreadfully fear: getting fat. That’s at the heart of this – those who wish to reduce the caesarean rate know that women have a fear of fat and that many women would rather reduce their child’s risk of getting fat than having an unnecessary caesarean. Because while getting fat is something to be feared, being brain damaged is something people fear more – so this research is really only targeting those who would choose a caesarean.

    • Wait – now it is clear, they actually did separate this out, and this research is specifically aimed at “caesareans of convenience”….

      • Madtowngirl

        Which are somehow medically different than those that are not of convenience.

      • Amy Tuteur, MD

        Here’s the chart from the paper:

      • Monkey Professor for a Head

        I can’t access the full paper, so this might be explained in there. The abstract mentions c sections done without medical indication, whereas the chart that Dr Tuteur just posted has women with no known risk factors as a subgroup. Does the paper conflate these? Does it only look at elective c sections or does it look at c sections done following an unsuccessful trial of labour?

        • Monkey Professor for a Head

          Thanks AA for posting the link to the full text. A quick look tells me that elective and emergency c sections are both included, and there is no information available on the indications for intrapartum c sections. It seems that there are still quite a few potential confounding factors here. The phrase “women without known indications for cesarean delivery” from the abstract seems like a poor choice of wording to me, when it seems like they mean “women without known risk factors for cesarean delivery”.

          • fiftyfifty1

            “The phrase “women without known indications for cesarean delivery” from the abstract seems like a poor choice of wording to me”

            Yes, I don’t understand this either. They got these data from a study of nurses. Unfortunately, the nurses were not asked the indication for their CS. Being nurses, they probably could have told the reason without any difficulty (e.g. fetal distress, baby wouldn’t fit etc). And the “baby too big to fit” seems relevant, especially for the discordant sib portion. “Little Suzy weighed 7 lbs and I had her no problem, but Billy weighed 9 lb 14 oz and wouldn’t fit” seems important to know.

          • swbarnes2

            This any be a dumb question, but is there really a robust association between a baby’s weight at term and obesity later in life? Does being a big baby really lead all the way to being a bigger adult?

          • It isn’t inevitable. As with so many things, there are so many factors involved. Take two kids, each in the 99th percentile for height and weight at birth. One has a fat mother who’s constantly pushing food on her kid, who hates exercise and has his nose buried in a book 20 hours a day, or sits in front of the boob tube endlessly, and the other is a picky eater without much appetite but burns 5000 calories a day on the sports field, practicing endlessly to be the next Lebron James. Betcha they don’t remain in the same percentile consistently throughout childhood — and I haven’t even mentioned the method of birth and infant feeding.

          • fiftyfifty1

            “One has a fat mother who’s constantly pushing food on her kid, who hates exercise and has his nose buried in a book 20 hours a day, or sits in front of the boob tube endlessly, ”

            Wow, you’ve managed to hit all the most offensive stereotypes about people with obesity in less than a single sentence…

          • Maud Pie

            I’m outraged that reading is portrayed as an undesirable activity.

          • MaineJen

            “You should read to your kids so they learn to love books/learning.”
            “Don’t let them sit with their nose in a book or they’ll get fat.”
            “Breastfeed on demand or else.”
            “Don’t feed your kid junk whenever he wants it.”
            “Put your kid in sports, it’s good for him.”
            “Don’t push your kid, it’s not good for him.”

            Sometimes parenthood sucks.

          • Azuran

            Basically, whatever you are doing, it’s wrong.

          • The Bofa on the Sofa

            “Everything you are doing is bad, I want you to know this.”

            https://www.youtube.com/watch?v=ncGHiVKJh0Y

          • Charybdis

            Sometimes? You can’t win for losing anymore.

          • fiftyfifty1

            ” Does being a big baby really lead all the way to being a bigger adult?”

            Of course it’s no guarantee, but it’s enough to explain something piddly like a 15% increase rate.

          • swbarnes2

            I guess I’m thinking just about the sibling comparison, because that’s doing a decent job of correcting for genetics and environment, and they still saw a small effect. The one thing about that is, they didn’t do a lot of VBACs in the 80’s right? So those sibling comparisons are going to be very skewed towards the first child being vaginal, and later ones being C-section. Is sibling order a significant factor for obesity?

          • Azuran

            Even genetics can vary a lot between children. My SIL daughter is over 95percentile since birth and her son is about 30 percentile.
            Same parents, both vaginal birth, both breastfeed up to 6 months. The daughter was a hard labour, (since she was a very big baby, duh), almost ended up in a c-section. If she did, it would definitely makes it look like c-section made her fat.

          • AS

            They claim ‘regardless of birth order’.

          • Azuran

            Probably a good enough one to explain the 15% increase.
            It’s not that being a big baby by itself will make you fat. More like, if people in your family have a tendency to be tall/large people, then you are most likely to have the same genetic profile. Which would make you a bigger than average baby as well.

            As a totally unscientific example. From my maternal grandfather’s side, everyone is build like a goddamn fridge. They are all super tall, with super large shoulders and chest and a very obvious tendency for obesity. Despite my grandmother’s very small frame, she had 2 over 9 pounds baby. Both my mom and her brother ended up having their fathers physique.
            The two of them together ended up with 6 kids. All over 9 pounds, very big babies. We are all over average heights, with large shoulders, big bones and a tendency to gain weight very easily if we are not constantly careful.
            Basically, we were big baby because we are ‘big’ people, not the other way around.

      • fiftyfifty1

        “this research is specifically aimed at “caesareans of convenience”….”

        Which is interesting because it is very likely that none of these births was an actual “caesarean of convenience” i.e. Maternal Request CS. These were births from the ~1980s, when that was virtually never done. There was a medical indication for each of these CS, it’s just that the researchers don’t have the data for what those reasons were. So it’s unclear to me how they can be confident that these unknown medical reasons are not causing residual confounding. In particular I worry about fetal size. They label babies up to 9 lb 14 oz as having “no known risk factors for CS”. But we know that babies this size are more likely to end up with CS, and we know that macrosomic babies are more likely to become macrosomic adults.

    • CanDoc

      Yes, the perfect incisive comment.

    • Charybdis

      But only if the baby is fat because you had a CS and are formula feeding. Because *everyone* knows that if a baby is born vaginally and breastfed on demand within an inch of it’s life, then it can’t possibly be fat/overfed.

      EFF baby getting 3 oz of formula = ZOMG!! You are force feeding that baby like a Thanksgiving turkey! S/he’ll grow up obese! What?!?! Already in the 97th percentile on the weight/growth charts AND a CS delivery? YOU ARE DIRECTLY CONTRIBUTING TO THE OBESITY EPIDEMIC!!!

      EBF baby staying on the breast 22 hours a day, suckling all the while = GREAT job Mama! Look at those fat rolls on the baby! You must make CREAM instead of milk! Baby getting constant trickle of milk because of all the time spend on the boob? NO PROBLEM!! You are mothering through breastfeeding and besides, breastmilk doesn’t make babies fat, you can’t overfeed a breastfed baby! Vaginal delivery as well? GREAT job again, Mama! Healthy gut microbiome as well as breastmilk tailored to EVERY. SINGLE. NUANCE. of your baby and fed on demand? YOU ARE THE SAVIOR OF MANKIND.

      I can’t roll my eyes any harder.

      • Azuran

        Well…..a starving baby is indeed unlikely to be overweight. At least as long as you don’t feed it properly.

        • Charybdis

          This is true. A dead baby is also unlikely to be overweight.

      • demodocus

        its actually easier for me not to overfeed my ff kid than my bf’d kid, thanks to #1’s tendency to fall asleep still drinking and my oversupply. Kid 2 spits up far less than kid 1 did.

      • Maud Pie

        I can’t remember which book this was in, but it said that if a baby consumes all the formula in the bottle, the mother should interpret that as a “reproach” because the baby probably wants more. This was presented as another example of the superiority of breastfeeding–the BF’d babies always get as much as they want, while FF’d babies get only what stingy mothers begrudgingly dole out.

        If these people could just get their stories straight and stick to them…

        • Azuran

          Schrodinger baby! It is both overfed, and starving, at the same time.

          • Charybdis

            Do Schrodinger’s babies emerge from Schrodinger’s cervixes? You know, the ones that were fully dilated and effaced with a CPM home birth, but suddenly “slammed shut”?

          • Heidi

            Of course! The mom failed at breastfeeding and had to resort to formula because she ended up having a toxic hospital birth/c-section, but this is all her fault because didn’t trust birth and her cervix just took her lead. You know, the hospital probably pushed formula on her – that is they didn’t tell her how formula was going to make her baby’s stomach bleed, make her baby sick all the time, make her hate her baby, cause her to have PPD, cause obesity and so forth. I mean, just because she had undiagnosed gestational diabetes (it’s soooo not a big deal and is natcheral) and her macrosomic baby emerged with a super low blood sugar doesn’t mean we should resort to a bottle of formula! Hypoglycemia is natcheral too! By giving that baby a bottle of formula, we caused mom to lose confidence in her ability to breastfeed, and like her cervix, her breasts followed her lead and now she has her overfed starving baby.

        • Maud Pie

          For weeks after reading this I called my DD Oliver Twist baby every time she finished the bottle. And then I mixed another two ounces for her.

  • Mel

    As an obese person I am probably biased, but I do think that being fat is better than being dead or an orphan.

    • Linden

      As a thinner person, I think that too. Go figure.

    • Maud Pie

      I’m also overweight, and I would rather die in my 60s of a weight-related cause than die young of malnutrition.

      • mabelcruet

        I’m the same, and at the other end of life I’d rather die quickly and a littler earlier as a podge than hang around as a slowly dementing beanpole.

        I’m sure I read something that suggested being overweight (as opposed to severely obese) was protective against fractured hips. I have a very distinct memory of reading a paper where they put Danish? Norwegian? some sort of Scandinavian women into padded knickers to mimic big fat hips, and they had a reduced incidence of fractured neck of femur. Presumably my big bum is padding, or maybe I have a lower centre of gravity and so I wobble like a weeble but don’t fall down.

        • Azuran

          I do remember a study that came out a little while ago that said that our evaluation of ‘healthy weight’ is biased by our aesthetic standard. And those with the longest life expectancy where those that were 10-15 pounds over what we consider ‘perfect weight’

        • TheArtistFormerlyKnownAsYoya

          “Slowly dementing beanpole” seems to run in my family.

    • Montserrat Blanco

      I would take obesity over neurological problems as well.

      I am waiting to see Modern alternative mama saying she prefers a brain damaged baby than an obese one.

      • Mel

        I have some mild neurological problems from being a preemie and my twin is profoundly deaf – which is listed as a severe neurological problem much to my surprise.

        I’m ok with both of those rather than being dead, having my twin be dead or having my mom be dead.

        Having spent most of my life around deaf adults and kids, having deafness as a “really bad” outcome feels more manageable to me than a lot of other neurological problems. In fact, my response to finding out that our kidlet is deaf would be two-fold. First, I need to have my ASL skills checked by an educator and start taking classes to get more fluent if I’m using this daily and second, I need to get moving on teaching my husband more ASL.

        • Montserrat Blanco

          I actually didn’t know deafness was considered severe. You are right it is probably much more manageable than other problems.

          And yes, I would prefer a deaf son over a dead one as well. Actually I would prefer anything over a dead son.

    • T.

      Same.
      Actually, this is really insulting. They are saying “hey better take the chance of death than being like you”.

      F*ck them. I am obese, and I live a great life. If I die at 60, then I had 60 years to live.

  • Sue

    Why do these papers never calculate some sort of risk-benefit ratio?

    • Monkey Professor for a Head

      I suppose the risk:benefit ratio of c sections will vary on a person by person basis. For example, in the case of complete placenta previa, the risk:benefit ratio is clearly in favour of c section, whereas for an uncomplicated pregnancy with no risk factors, the risk:benefit ratio is much closer. It’s also complicated by the fact that there are (at least) two people involved in each birth. What benefits one party may place risk upon the other party. The risk:benefit ratio will vary on a population by population basis also. In a population of women who have poor access to contraception, a high number of pregnancies and who may have difficulty accessing medical care in future pregnancies, the risks of c sections are higher. In populations with higher maternal age and more obesity, the benefits of c sections are higher. This is why the concept of an ideal global c section rate is ridiculous.

      • Sue

        Exactly, MPFAH, well-said.. I guess my question was rhetorical. It makes no sense to quote only a risk of doing, without outlining the risks of not doing.

  • Madtowngirl

    Or, or, or, here’s a thought-perhaps this supposed increase in obesity has to do with increasingly sedentary lifestyles, a salad costing $7 whereas fries are $1.50, or maybe genetics?

    Nah, it’s the c-section rate.

    • indigosky

      I think it has a lot to do with being busy. Most families both parents work. When I worked a 10 hour day with a one hour commute plus one direction and a military husband gone a lot, the microwave was my friend. Oven only got used weekends and holidays. Or I’d get a pizza or run through one of the many drive-thrus right by our house.

      Now that I work from home, with less hours and my husband is at a duty station that has banker’s hours, we make very healthy and balanced meals because I have time and sanity to do so.

      • Mattie

        I don’t always have a ton of time, so I started buying frozen veggies, and I make a lot of pasta with them, they cook fast and are still pretty healthy, but yeh, microwave is tempting often

        • J.B.

          The good news is that there are some healthy microwave options-steam in bag veggies, or the frozen veggies mixed into pasta are fine. It’s the energy for the meal planning and the getting everything together that’s the big deal. Once you get past that hurdle it’s usually faster than takeout.

        • The Bofa on the Sofa

          What’s wrong with cooking in the microwave? The reason I cook in the microwave is because I CAN. If I can make something in the microwave, I’d much rather do that than having to use the stove or oven.

          There are a lot of things that don’t come out right in the microwave, and there I won’t bother, but if I can? Sure.

          • Mattie

            aside from veggies (microwaving vegetables is the healthiest way of cooking them) I just prefer the taste of things cooked in an oven/not microwaved, so for me if I have the time I cook as much as possible

          • Sean Jungian

            Vegetables are great steamed in the microwave. I find it useful for steaming rice as well, but it’s really about the same as on the stovetop. Eggs turn our well in the microwave. Things don’t carmelize or brown in the microwave as well as they do in the oven or on the stovetop so I do prefer that.

            I use my slow-cooker much more often for cooking but I use my microwave to heat things up or steam food.

          • Heidi

            I’ve found I can cook things like onions and peppers in the microwave for a few minutes and then transfer them to a skillet where they will brown/caramelize in no time. Waiting for them to brown on their own can take an hour or longer!

          • Sean Jungian

            An hour! Goodness, are you cooking over the flame of a Bic lighter? 😉 I kid, I kid

      • Madtowngirl

        This is incredibly true as well. The world is so different than it was 30 years ago, when my mom could spend an hour making a nice, healthy meal for the whole family – because she didn’t work.

        • Maud Pie

          30 years ago my mother mother didn’t work and spent about 20 minutes fixing convenience foods.

    • Sean Jungian

      I am obese, and a lot of my weight was gained while I was an unemployed single mom and unable to afford high-quality food for BOTH of us, so the kid won out. It doesn’t help that we also live in a food desert, and without reliable transportation it was difficult for me to even get groceries.

      When I started working full-time again, the time factor for cooking went waaaay down. I have since learned how to juggle chores, housework, and meal planning but it takes time and education to learn how to plan, shop for, prepare and preserve healthy meals even for just 2 people. So many times you’re so exhausted you think, “Oh man, I don’t care about cooking healthy or good-tasting, I just want to not be hungry anymore and go to bed!”

      I now make use of a deep freeze, and I do almost all of my major cooking on Sundays for the following week. This way I am only maybe 20 minutes from a full meal on any given weekday. But when you’re poor and unemployed, and have a hard time even getting to where there is a variety of food available to purchase, you can’t really afford to fill up a freezer with sale items like meat and roasts. You’re left with a lot of baked and processed things because they are cheap and reasonably filling.

      Just throwing in my perspective. BTW I was born vaginally, as was my son (he is not obese but does tend to be on the thicker side).

      • Madtowngirl

        I used to work in a school where 95% of the kids were on the free meal plan (meaning their parents didn’t pay for school lunches because they were too poor). Some of these kids would come to school with chips for breakfast because they cost a whopping 99 cents at the corner store. You see, there were no grocery stores in this area, and they were not easy to get to via the bus system. My coworkers would sneer at this – “why are they bringing crap to school?” Dude, it’s cheap, and they don’t want to be hungry.

        We’re pretty well off, but I just went grocery shopping this morning, and I got really fed up with how few non-organic options there were for produce. I don’t want to pay the ridiculous mark-up for unscientific nonsense, but I don’t have a choice, because that’s all that the grocery store has.

        It sounds a little extreme when I type it, but maybe it’s true – healthy eating seems to be increasingly a privilege only for the rich.

        • Sean Jungian

          It certainly seems like it sometimes.

          I live in a very small, very rural town. We are incredibly lucky in that we do have a local grocery store, but it is very overpriced. Still, I do my best to support it since not having a grocery store would be a catastrophe for our area.

          It’s very limited in selection and of course caters to our more-well-off population. I couldn’t even find brown rice there (I had to have them order it for me) let alone a 5 or 10-lb bag of it, same with dried beans, whole grain flours, all the things you seek out when you’re on a strict budget. Plenty of pre-made and deli items, lots of bakery goods. Very limited produce since the cost of transporting it here is so high.

          The population here, though, is relatively wealthy, and think nothing of driving the 1 hour (each way) to get to a larger store with more selection and cheaper prices. They often don’t realize that this isn’t an option for poor people or people who can’t drive or don’t have transportation. There are no buses.

          I’m no longer in the dire straits I was in several years ago (and I didn’t mention it but should have: depression played a huge role in my weight gain, as well as untreated PCOS [due to not having health insurance]). I still try to support the local businesses as much as I can for the sake of other people who are in that situation.

          Being poor is just a cascade of falling dominoes stacked against you in the worst ways. I’m still not wealthy by any means but we have what we need and a lot of the things we want, which to me is a decent metric for my quality of life. But I am left in a far more debilitating physical state than I would have been had I been able to retain health insurance and continued my treatment for depression and PCOS, and I daresay I might have found employment sooner if these issues hadn’t hung over my head for so long.

          • Old Lady

            When I didn’t have much money and could only buy/have in the pantry what I needed for the week it was much harder to eat well. Psychologically I would enter this sort of food preoccupation mode where I felt the urge to eat high calorie foods all the time. Now that we are comfortable enough it’s so much easier to say no to a bag of chips. The fuller my pantry (and bank account) the easier it is to not eat and focus on other things. I migh not eat that bag of chips but having it sitting in the pantry means I could if I wanted.

          • Sean Jungian

            Agreed. Food security has a big impact on what I eat as well. Having money in the bank and plenty of food in the pantry and freezer make me feel secure; not having those things feels very insecure and I might eat to assuage that anxiety.

        • Heidi

          I also find eating frugally is a privilege too. Some people always think they know how poor people can eat on a tiny amount of money. I mean, I know you know this, but I just get so frustrated when people think poor people aren’t buying the right thing at the grocery store. I save so much money on food because I have access to reliable transportation anytime. I can buy in bulk and buy in bulk during sales because our bank account is decently padded.

          • Sean Jungian

            This is what I was trying to say, too. Getting to a place that actually has bulk rice, beans, potatoes, etc. etc. plus a decent price for proteins, IS a privilege. I mean I have been where those kids with the 99-cent-potato-chip-breakfasts are – something is better than nothing, being hungry is awful.

        • The Bofa on the Sofa

          I don’t want to pay the ridiculous mark-up for unscientific nonsense, but I don’t have a choice, because that’s all that the grocery store has.

          It sounds a little extreme when I type it, but maybe it’s true – healthy eating seems to be increasingly a privilege only for the rich.

          No.

          You choose not to have the non-organic food, because it wasn’t good enough for you. Not because it wasn’t healthy.

          The problem with the American diet is not that it doesn’t have enough organic fruits and vegetables, or locally grown, it’s that it has too many french fries and potato chips.

          We’d be perfectly fine with canned or frozen non-organic fruits and vegetables. No, they might not taste as good to you, but then again, others like them (my kids love canned green beans, won’t touch fresh or frozen). And most people can afford that.

          If that’s what everyone ate, we’d be fine. But instead we eat Twinkies and potato chips.

          • Sean Jungian

            I think maybe you misread what @Madtowngirl is saying.

          • The Bofa on the Sofa

            maybe. the last sentence, though, I read.

        • demodocus

          it doesn’t seem the least bit extreme to me, but then i’ve lived carless in a city and worked in an urban school..