Cover for No Agenda Show 1520: Hambone
January 12th • 3h 3m

1520: Hambone

Shownotes

Every new episode of No Agenda is accompanied by a comprehensive list of shownotes curated by Adam while preparing for the show. Clips played by the hosts during the show can also be found here.

Great Reset
NOTAM was fat finger mistake
Mayor pete may be a dunce, but he knows how to get money
FAA Administrator and many other open positions - MONEY GRAB!!!!
Fighter jets and air refuellers were all over the USA during the shutdown
The ground stop and Federal Aviation Administration systems failures Wednesday morning that impacted thousands of flights across the U.S. appear to have been the result of a mistake that occurred during routine scheduled systems maintenance, according to a senior official briefed on the internal review.
The ground stop and Federal Aviation Administration systems failures Wednesday morning that impacted thousands of flights across the U.S. appear to have been the result of a mistake that occurred during routine scheduled systems maintenance, according to a senior official briefed on the internal review.
An engineer “replaced one file with another,” the official said, not realizing the mistake was being made. As the systems began showing problems and ultimately failed, FAA staff feverishly tried to figure out what had gone wrong. The engineer who made the error did not realize what had happened.
“It was an honest mistake that cost the country millions,” the official said.
Earlier Wednesday, the FAA said normal operations were "resuming gradually" after ordering a nationwide pause on all domestic departures until 9 a.m. on Wednesday morning following a computer failure that has delayed and canceled flights around the country.
"The ground stop has been lifted," officials said at about 8:50 a.m. ET. "We continue to look into the cause of the initial problem[.]"
Departures were resuming at about 8:15 a.m. ET at two of the nation's busiest hubs -- Newark, New Jersey, and Atlanta -- FAA officials said on Twitter, adding, "We expect departures to resume at other airports at 9 a.m. ET."
An engineer “replaced one file with another,” the official said, not realizing the mistake was being made. As the systems began showing problems and ultimately failed, FAA staff feverishly tried to figure out what had gone wrong. The engineer who made the error did not realize what had happened.
“It was an honest mistake that cost the country millions,” the official said.
Earlier Wednesday, the FAA said normal operations were "resuming gradually" after ordering a nationwide pause on all domestic departures until 9 a.m. on Wednesday morning following a computer failure that has delayed and canceled flights around the country.
"The ground stop has been lifted," officials said at about 8:50 a.m. ET. "We continue to look into the cause of the initial problem[.]"
Departures were resuming at about 8:15 a.m. ET at two of the nation's busiest hubs -- Newark, New Jersey, and Atlanta -- FAA officials said on Twitter, adding, "We expect departures to resume at other airports at 9 a.m. ET."
Mandates & Boosters
VAERS
BLM LGBBTQQIAAPK+ Noodle Boy
Prime Time Takedown
Smartmatic voting machines not used in Brazil’s 2022 election | AP News
In 2020, Brazil’s Superior Electoral Court (TSE) released a statement saying that Smartmatic has had contracts with the electoral authority for data provision and voice connection services, but not for developing or operating voting machines.
“We have never provided voting machines to Brazil,” Samira Saba, a spokesperson for Smartmatic, confirmed to the AP in an email. Saba also noted that Smartmatic did not provide any additional services for the 2022 election.
Digital ID
Ukraine & Russia
Artificial Intelligence
Ministry of Truthiness
Climate Change
Big Pharma
Big Tech
BTC CBDC FTX
STORIES
NEW: Matt Gaetz Announces Republicans Will Release 14,000 Hours of J6 Tapes that were Hidden by Democrats
Thu, 12 Jan 2023 18:25
During an interview with Charlie Kirk on his radio show on Tuesday, Florida Republican congressman Matt Gaetz announced that Republicans would be releasing 14,000 hours of January 6 tapes that have been hidden from the public.
Gaetz said that releasing the tapes ''would give more full context to that day rather than the cherry-picked moments of the January 6th committee.''
The Republican congressman revealed that this was one of the deals he made with House Speaker Kevin McCarthy to give the American people more context about the events on January 6th instead of the narrative pushed by the Democrat party.
''One of my favorite members of Congress is Thomas Massie and the fact that he is going to be on this new committee (the Church Committee) really gives me hope,'' Kirk said during the interview.
''Matt, do you anticipate allowing the dogs to be released if you will against this fourth branch of government?'' he asked.
Gaetz replied, ''Kevin McCarthy told us he is going to get the evidence out in front of the American people and that means releasing the 14,000 hours of tapes that have been hidden that I think would give more full context to that day (January 6th) rather than the cherry-picked moments the January 6th committee tried to use to inflame and further divide out country.''
''So yes, I do believe that part of this deal is a concession that we are going to get the truth out in front of the American people,'' he asserted.
WATCH:
Gaetz: Republicans will release ''14,000 hours of [J6] tapes that have been hidden''
BAM!
Looks like truth about Pelosi's Fed-Op is going to be exposed even further! pic.twitter.com/ybf3RSgoow
'-- DC_Draino (@DC_Draino) January 10, 2023
NEW: Matt Gaetz says Republicans will release 14,000 Hours of J6 Tapes that were hidden by Democrats.
Gaetz for the win, once again.
'-- Collin Rugg (@CollinRugg) January 10, 2023
Also on Tuesday, Gaetz revealed a new amendment to the House rules which would require the House speaker to broadcast floor proceedings on C-SPAN.
''I've received a lot of feedback from constituents about how interesting it was and that you were able to see in real time how our government is functioning, what alliances are being created, what discussions are being had, what animated moments drive the action,'' Gaetz said Fox News during an interview. ''And the pool view of the Congress is antiquated and a little boomer-fied.''
''I have talked to a handful of colleagues and I have yet to encounter one who didn't view the broader transparency as a net positive,'' Gaetz said.
''It's interesting to see how our leaders communicate with one another, and it's humanizing,'' he added. ''I had constituents reach out to me about a friendly chat that the country observed me having with [Democratic Rep.] Sheila Jackson Lee. And while Sheila and I certainly have had very high-octane moments in the House Judiciary Committee, and while neither one of us like to give an inch when it comes to effective argumentation, I've also found her to be a warm person interpersonally.''
''And you know of people observed me having conversations with [Democratic Rep.] Debbie Wasserman Schultz, former head of the Democratic Party,'' he continued. ''So, there are moments of bipartisanship and collegiality that occur every day. And the country doesn't get to see those.''
Follow me on Twitter @CollinRugg!
John Bolton confirms he will run for president in 2024 | Just The News
Thu, 12 Jan 2023 18:20
Former Trump National Security Advisor John Bolton this week confirmed that he will be mounting a 2024 presidential bid, one meant in part to prevent former President Donald Trump himself from once again claiming the White House.
Bolton told Good Morning Britain that he was planning on entering the race as a legitimate candidate and not merely a spoiler for Trump. ''I wouldn't run as a vanity candidate,'' he told the show. ''If I didn't think I could run seriously, then I wouldn't get in the race.''
The onetime U.S. ambassador to the United Nations has emerged as a fierce and vocal critic of Trump following his 2019 firing by Trump via Twitter.
Bolton in 2020 published a memoir of his time in the White House, The Room Where it Happened; the Trump White House at the time sought to block publication of it but ultimately failed.
Mike Pence's PAC Spent $91,000 On His Book. It Became A Bestseller.
Thu, 12 Jan 2023 18:19
Former Vice President Mike Pence signs copies of his book "So Help Me God" at the Republican Jewish Coalition Annual Leadership Meeting on Nov. 18 in Las Vegas. (Photo by Scott Olson/Getty Images)
Getty ImagesMike Pence's political action committee bought $91,000 of the former vice president's memoir.
On Nov. 9, the Great America Committee paid Books on Call NYC $91,000 for what the PAC described as ''collateral materials,'' according to a report the PAC filed in December with the Federal Election Commission. Pence's ''So Help Me God'' came out six days later. A spokesperson for Pence confirmed that the money went towards buying the memoir.
''So Help Me God'' debuted at No. 2 on the New York Times' best-seller list for hardcover nonfiction and remained on the rankings for six weeks. Although the list typically notes when retailers report bulk orders of a book, no such marking accompanied Pence's memoir.
Since Pence is not a current candidate for federal office, he could legally use his PAC to funnel donor funds into his personal pocket, according to Brett Kappel, an attorney specializing in campaign finance at Harmon, Curran, Spielberg & Eisenberg. But a spokesperson for Pence, Devin O'Malley, said that the former vice president took steps to avoid that from happening, following guidance from the FEC on how to ensure he could use PAC money without personally receiving compensation from it.
Even if officials don't profit directly when their political committees buy their book, it can benefit them. Purchases from retailers can help a book reach the best-seller list, which helps to further market the book. And politicians' ability to tap into donor funds for purchases might make publishers more likely to strike deals with them in the first place.
After leaving office, Pence signed a two-book agreement with Simon & Schuster worth $3 million to $4 million, CNN reported in 2021. Spokespeople for the publisher did not immediately respond to requests for comment.
A spokesperson for the New York Times confirmed that purchases of a book before its publication date are counted toward its week-one sales on the best-seller list.
News of the Great America Committee's purchase was first published by Raw Story.
A PAC associated with Mike Pence spent $91,000 at a bookseller just days before the former vice president's book was published
Federal Election Commission/Great America Committee
How the populist left has become vulnerable to the populist right
Thu, 12 Jan 2023 18:19
UPDATE (Jan. 12, 2023 12:00 p.m. E.T.): This piece has been updated to reflect Glenn Greenwald's response to a question about funding for his show on Rumble.
Since the mid-2010s, the rise of the populist left and the populist right has shaken up the American political spectrum. Both movements have maneuvered to pressure and persuade the political establishment to adopt their objectives. But in recent years something unusual has been happening. We're seeing the formation of a pipeline that circumvents the center altogether '-- and directly connects left-wing to right-wing populism.
A group of journalists and media personalities who once were at home on the far left has formed a niche but influential political subculture that encourages leftists to abandon leftism for the populist right. Its most recognizable faces are former icons of leftist discourse who have millions of diehard fans: Glenn Greenwald, a co-founder of The Intercept, known as one of the most powerful critics of the ''war on terror'' in the Bush era. Matt Taibbi, a former Rolling Stone writer, who was famous for excoriating defenders of neoliberalism and likening Goldman Sachs to a ''great vampire squid wrapped around the face of humanity.'' Tulsi Gabbard, formerly a Democratic House member and 2020 presidential candidate, was aligned with the Bernie Sanders wing of the party.
But in recent years their focus has changed. These commentators had never hesitated to criticize Democrats alongside Republicans. But now they've pivoted to targeting liberals nearly exclusively, while forming ties with the authoritarian right.
Anti-lib populism might not necessarily convert leftists into MAGA activists. But it could still do damage by generating cynicism.
On issues such as free speech, the war in Ukraine, and social inclusivity, this group's commentary has garnered tremendous attention and plaudits from right-wingers, and some of them have grown fond of using conservative media platforms to spread their message. In 2022 this trend appeared to reach new heights. Gabbard served as a guest host for Fox News' white nationalist-in-chief, Tucker Carlson. Taibbi became right-wing Twitter CEO Elon Musk's go-to stenographer for a series of leaks from Twitter's internal documents meant to make Musk's takeover of the social media platform look necessary. Greenwald attended the premier of a documentary about right-wing disinformation mogul Alex Jones and conducted a shockingly sympathetic interview with him.
Collectively, these and other lesser-known pundits push a political position that could be called ''anti-lib populism.'' (''Lib'' as in the pejorative slang term for a liberal, in currency among leftists and the right.) Like all populisms, it purports to oppose elitism and speak on behalf of the people. But as a practice, it funnels people toward the snake-oil populism of the right.
Anti-lib populism may not necessarily convert leftists into MAGA activists en masse. But it could still do damage by generating cynicism that could divide the left. That's why the left must be vigilant about its rise.
The free speech fallacyOne of the most prominent strategies of anti-lib populists is casting liberal media as the biggest threat to free speech in America. Taibbi and Greenwald spend a lot of energy warning about cancel culture and opposing deplatforming and speech regulation on internet platforms OKed by a liberal worldview. Some of it is legitimate '-- I, too, worry about opaque internet censorship and certain aspects of cancel culture like self-sabotaging groupthink and targeting people's jobs for misbehavior. But what's odd about the anti-lib outlook is its singular focus on liberals.
The right is at least as worrisome on the issue of restricting speech, and in some respects far more. The GOP has become an overt advocate for government censorship on college campuses and in schools and libraries. When he was president, Trump ramped up legal attacks on the media and harassed journalists. The MAGA right endeavors to dampen the very meaning of free speech by embracing disinformation as a political strategy. Billionaires who are hostile to the left own social media platforms and make decisions about speech based on profit motives.
Yet somehow Taibbi has said he finds Republicans ''irrelevant'' on matters of speech, has downplayed Fox's enormous influence on the right, and has preposterously argued that all elites are on the left side of the spectrum. Greenwald focuses the lion's share of his criticisms of censorship as a phenomenon tied to Democrats and liberal media.
Taibbi's blinkered attitude about speech likely explains why Musk, who has revealed himself to be a QAnon-friendly fan of MAGA politics, appears to have entrusted Taibbi with a cache of Twitter documents to report on Twitter's history of controlling speech on its platform. To be clear, the leaks have helped shine a light on some deeply troubling issues, like the FBI's apparent input into Twitter's speech regulation. But it's notable that Taibbi has exaggerated and misframed the import of his expos(C), and that by agreeing to conditions set by Musk (or Musk-connected sources) regarding his access to the information and where he could publish it, he has tainted his findings with the aura of a comms operation. (Taibbi once noted in the past, ''Once you start getting handed things, then you've lost.'') He has also conveniently lost his sharp tongue when it comes to Musk's arbitrary suppression of users on Twitter.
If you are a free speech warrior, you should be concerned about threats to robust speech that manifest across the political spectrum, and you should take steps to demonstrate your independence from plutocrats who are whimsically buying public squares. Instead, anti-lib populists finds common cause with the right and designate Democrats as the implacable enemy.
The populist right is not antiwarAnother example of how anti-lib populism tries to nudge the left to come to mistaken conclusions about the nature of the right is the war in Ukraine. Now, Gabbard and other anti-lib populists have correctly pointed out that the Democratic Party has been overly blas(C) about nuclear escalation with Russia, and has stigmatized even minor dissent over the issue of how the U.S. should approach vital diplomacy with Moscow. That concern overlaps with the leftist antiwar posture of groups like the Democratic Socialists of America.
But the anti-lib populists focus almost all their energy on the Democrats, despite the fact that most Republican lawmakers share the Democrats' position. Gabbard cited Ukraine policy as the primary reason she left the Democratic Party and slams it as controlled by "warmongers"; Greenwald trumpets MAGA dissent on Ukraine aid as a sign of the GOP's politico-intellectual health.
More worryingly, they implicitly imply the MAGA right is antiwar when it's anything but. While it's true that the MAGA wing's increasing hesitation to involve itself in Ukraine has the effect of calling for a less hawkish position than many Democrats, the actual ideology underlying the position isn't fundamentally antiwar.
Trump and MAGA Republicans are nationalists interested in militarizing domestic American life. They're in favor of aggressively securing the borders, supporting armed vigilante formations and emboldening militarized police. And while Trump isn't interested in the kind of nation-building that both parties supported during the war on terrorism, he exhibited no lack of appetite for war when he torpedoed the Iran nuclear deal, played chicken with North Korean leader Kim Jong Un, requested colossal defense budgets, continued drone warfare but with less transparency, called for military parades in the streets and employed strategists such as Steve Bannon who enjoy saber-rattling about the prospect of war with China.
The reality is that Democrats and Republicans today are hawkish in different ways, and anybody who cares about making America less bellicose '-- both at home and abroad '-- should be angling to pressure both parties. But the anti-lib populists focus all their energy on disparaging the Democrats.
There are also other players who aren't as big as Gabbard, Greenwald or Taibbi are also involved in this game of pushing the left to consider right-wing populism across a number of different issues. YouTuber Jimmy Dore deemed the self-described leftist lawmakers in "the squad" frauds for declining to try to block Nancy Pelosi's speakership to "force the vote" on Medicare-for-all, a strategic question that split the left at the beginning of the Biden presidency. Regardless of one's position on that issue '-- I had mixed feelings '-- it's illuminating to contrast Dore's eagerness to dismiss the squad as sellouts with his charitable attitude to the right. Just a few months later he conducted a remarkably credulous interview with a Boogaloo Boi, a member of a violent accelerationist movement with roots in right-wing, anti-government and white nationalist belief systems.
The hosts of ''Red Scare,'' a popular podcast once considered part of "the dirtbag left," also probably also fits into the anti-lib populist scene. The cohosts of Red Scare issue critiques of capitalism and reserve plenty of venom for liberals. But they also pal around with the authoritarian right; they've conducted friendly interviews with Jones of Infowars and Curtis Yarvin, a neo-monarchist blogger.
How anti-lib populism inverts left-wing populismIt is not unusual for leftists activists and thinkers to focus a significant amount of energy on criticizing Democrats, since Democrats are, theoretically, more likely to be receptive to or susceptible to left-wing ideas, and are more realistic bargaining partners on a number of policy issues like expanding the welfare state. Meanwhile, the right is often seen as a lost cause. (Or sometimes the right is seen as indistinguishable from Democrats, depending on the issue.) But in anti-lib populism, liberal politics is portrayed as irreversibly corrupt, and the populist right is hinted at as an idyllic alternative.
Anti-lib populists can do something doctrinaire right-wing populists can't '-- use their cred in leftist circles to issue critiques that act as a crowbar to crack open fissures on the left.
A skeptic of my schematic might say that I'm simply describing right-wing populists. Well, not exactly. First of all, these commentators don't fit neatly into any conventional ideological box (and, complicating things further, never really did very neatly fit on the left). Greenwald's stated normative views are decidedly not conventionally right-wing; Gabbard identifies as an independent and has declined to join the Republicans (at least for now); Taibbi calls himself a ''run-of-the-mill, old-school ACLU liberal'' who likes Sen. Bernie Sanders, I-Vt.
Moreover, as discusser earlier, they still hold some views that overlap with a leftist sensibility, and it's reasonable to assume they still have many left-wing followers. And that's why their interventions matter. Anti-lib populists can do something doctrinaire right-wing populists can't '-- use their cred in leftist circles to issue critiques that act as a crowbar to crack open fissures on the left. And they can distort the nature of the right to make it appear innocuous. Witness Greenwald's (tortured) attempt to portray Tucker Carlson, Steve Bannon and 2015-era Donald Trump as socialists.
I can't say I understand the origins of this phenomenon, or that there's a single explanation for it. Part of it could be a reactionary response to the the rise of "woke politics," a preoccupation of almost all anti-lib populists. Part of it could be growing fed up with the Democratic establishment, particularly after it fended off the Sanders insurgency in two presidential primaries, and resolving to go to war against it. Part of it could be the economics of provocation and contrarianism '-- anti-lib populists are almost always in independent media, and might find it financially rewarding to relentlessly own the libs. Part of it could be based on their commonly articulated (and misguided) belief that media '-- and mostly liberal media '-- is the single greatest source of power in society. Part of it could be naivete about what the populist right really stands for. Whatever it is, the result is an orientation that's adept at generating cynicism.
The authoritarian right loves the chaos The authoritarian right has delighted in the emergence of anti-lib populism. It knows that even if disillusioned leftists don't join the right, it's worth destroying their faith in the possibility of building a mass movement including Democrats. Yarvin, one of the most influential intellectuals of the ''new right,'' has said a key strategy for his movement is to ''sow acorns of dark doubt'' in the minds of the left and pounce when its ''conviction and energy flag.'' Put more simply: divide and conquer. This is why Yarvin and a number of influencers on the right mingle with anti-lib populists, help them with exposure and seek to work with them on media platforms.
Political axes are being scrambled. Strange bedfellows roam the streets and the halls of power.
Greenwald has recently launched a show with what he describes as a ''cable news budget'' on Rumble, an independent alternative to YouTube. Greenwald told me in a direct message over Twitter that Rumble is providing the funding and paying him for the show. Rumble is backed by Peter Thiel, a Silicon Valley tycoon who has funded ultranationalist political candidates for the Senate, such as the recently elected Republican J.D. Vance of Ohio, and has said he doesn't ''believe that freedom and democracy are compatible.'' Greenwald and Taibbi have hosted podcasts on Callin, a podcast platform backed by David Sacks, a right-wing venture capitalist and pal of Musk. Gabbard is a paid contributor to Fox News. Blake Masters, who ran a failed ultra-MAGA campaign for the Senate in Arizona in November, said he and Thiel have met with one of the hosts of ''Red Scare'' and would consider financially backing the podcast.
None of this is to suggest that anti-lib populists have been bought off or are taking direct editorial cues from owners of platforms. The point is authoritarian elements of the capitalist class are cultivating relationships with anti-lib populists and backing platforms that can facilitate the left-to-right-wing populism pipeline. Networks and infrastructure are being crafted.
It's too early to identify how this scene could be reshaping political identity and behavior. But it should be taken seriously. This scene has lots of followers and citizens take ideological cues from leaders.
We live in an era of ongoing ideological rupture. Political axes are being scrambled. Strange bedfellows roam the streets and the halls of power. For leftists, this is a time for discipline and clear-eyed appraisals of possibility and peril. If we are to have a civilized, democratic society, the populism pipeline must flow the other way.
Disney Prepares for a Board Fight by Nelson Peltz - The New York Times
Thu, 12 Jan 2023 16:32
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After months of talks, the activist investor Nelson Peltz is jockeying for a director position at the entertainment giant as he pushes for a series of changes.
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Jan. 12, 2023, 7:57 a.m. ET
Image The activist investor Nelson Peltz wants a Disney board seat. Credit... Tamir Kalifa for The New York Times How Nelson Peltz picked his fight with Disney Disney already faces enormous challenges, including ballooning costs at its streaming service and unclear C.E.O. succession plans. Now it faces a proxy fight from Nelson Peltz's Trian, the activist investment firm known for taking on blue-chip companies like Procter & Gamble.
But while their fight became public on Wednesday '-- after Disney rejected Mr. Peltz's bid for a board seat '-- tensions between the two sides have been growing for months. A Disney regulatory filing released this morning reveals how the House of Mouse came to clash with one of Wall Street's top activist investors.
Last July, Peltz met with Disney's then-C.E.O., Bob Chapek, at Disneyland Paris. At the time, Trian hadn't yet invested in the company, but Mr. Chapek was under pressure: He had gotten Disney entangled in a political fight in Florida; its Disney+ streaming service was losing money; and he had alienated important Hollywood partners. Still, Disney had just renewed Mr. Chapek's contract for three more years. Soon after, Mr. Peltz met with two Disney directors about potentially joining the board.
In August, another activist, Dan Loeb's Third Point, disclosed a stake in Disney and proposed spinning off ESPN, buying Comcast's stake in the streaming platform Hulu and adding more board members. Mr. Loeb reached a truce with Disney a month later, with the company naming the former Meta executive Carolyn Everson as a director.
In early November, Disney delivered a disastrous quarterly earnings report. Within days, Mr. Peltz called Mr. Chapek to start formal discussions between the two companies; they met on Nov 12. On Nov. 20, Disney fired Mr. Chapek and brought back his predecessor, Bob Iger. By then, Trian had about $800 million worth of Disney shares. Executives from Trian and Disney met for 30 minutes later that month, and Mr. Peltz made his pitch to join the board.
In early December, Mr. Peltz informed Disney of his intention to nominate himself for its board and pushed for a meeting. By the end of the month, the board finally agreed to a meeting with Mr. Peltz, but Mr. Iger told him it would have to wait until after he returned from yachting off the coast of New Zealand.
Earlier this week, Disney and Trian met for 45 minutes. Mr. Peltz noted that the company's shares were at a near-eight-year low, and urged Disney to revamp its streaming business, refocus on growing profits, reinstate its dividend and identify a successor to Mr. Iger. Afterward, the company offered to make Mr. Peltz a ''board observer'' '-- but not a full director '-- and asked him to stop fighting publicly; the activist declined. Within days, Disney announced Mr. Peltz's intentions, and Trian went public with its campaign.
Disney is hoping it can ward off Mr. Peltz. The newly revealed background of Trian's challenge suggests that Disney has been shaking itself up '-- including by firing Mr. Chapek and reinstalling Mr. Iger '-- perhaps in part to deny Mr. Peltz grounds to describe himself as an agent of change. Mr. Iger remains popular among many investors and analysts for leading Disney to record financial results during his previous 15-year run as C.E.O.
It's unclear whether that will be enough to convince investors. Though Mr. Peltz isn't pushing for Mr. Iger to step down, he has repeatedly criticized the Disney chief for overpaying in his $71.3 billion takeover of 21st Century Fox. And Trian can point to its successful shake-ups of companies like P.&G. and General Electric, though revamping an entertainment giant is a new challenge.
In any case, investors should bring some popcorn and watch the fireworks.
HERE'S WHAT'S HAPPENING Flight delays persist as the F.A.A. recovers from a system outage. Hundreds of flights within, into and out of the United States were delayed or canceled this morning, after a pilot notification service went down on Wednesday. The problems underscore the F.A.A.'s challenge to modernize systems that critics say need to be updated urgently.
Subway weighs a sale. The privately held sandwich chain has hired advisers and hopes to fetch more than $10 billion, The Wall Street Journal reports. Subway had an estimated $9.4 billion in sales in 2021, but revenue has declined in recent years amid growing competition.
FTX says it has found more than $5 billion in liquid assets. The discovery of billions in cash and easily sellable cryptocurrency will be welcomed by customers and creditors, but another major hurdle remains: The amount of its customer shortfall still isn't known.
Amazon loses its bid to overturn unionization at a Staten Island warehouse. A federal labor official rejected the e-commerce giant's claim that a union vote at its JFK8 site last April was marred by improprieties. Amazon plans to appeal.
Twitter weighs new avenues to raise money. Elon Musk's social network has considered selling off at least some dormant user names, The Times reports. But it isn't clear how much that would raise for the company, which is suffering from a sharp drop in advertising revenue as brands remain wary of spending on the platform.
What to watch for in today's C.P.I. data Economists are forecasting that the latest Consumer Price Index report for the United States, due out at 8:30 a.m. Eastern, will show a decline in inflation for a third straight month. Investors are now speculating that the data could make the Fed pivot on interest rates, and that the central bank may yet pull off its ''soft landing'' objective of lower prices without a recession. You can follow the Times's coverage here.
A growing number of Wall Street analysts are feeling bullish about on Thursday's reading. The consensus forecast on C.P.I. is that prices rose 6.5 percent on an annualized basis last month. That's still well above the Fed's target, but would represent a substantial improvement from June, when the so-called headline C.P.I. figure hit 9.1 percent, a 40-year high.
Assuming that the worst of inflation is over, investors have started moving back into both risky and stable assets: The Nasdaq has gained 7 percent in the past two weeks, while the yield on 10-year Treasury notes has fallen by more than 35 basis points in the same period.
Falling energy prices '-- gasoline prices fell 10 percent last month, according to RBC Capital Markets '-- and slumping car sales will likely have played roles in depressing the headline number, economists say. But the big question is whether wage gains in recent months have fueled so-called ''service inflation,'' or rising prices for things like travel, restaurants and entertainment.
''While we expect this deflation to continue as we head into 2023, the factors driving inflation have now switched to services inflation,'' said Andrew Patterson, senior economist at Vanguard, in a note on Wednesday, adding that factor could keep core inflation above the Fed's 2 percent target for much of the year.
Markets are still betting on smaller interest rate increases, and some Fed officials seem to be on the same page. Susan Collins, the president of the Boston Fed, told The Times's Jeanna Smialek that she's leaning toward a quarter-point rate increase at the central bank's next rates-setting meeting '-- but only if data shows inflation is under control.
Corporate America's get-to-work message for Washington The traditionally tight bond between the U.S. Chamber of Commerce and Republicans has frayed in recent years. It weakened further after Representative Kevin McCarthy, Republican of California, reportedly suggested that the business lobbying group replace Suzanne Clark as C.E.O., as he sought conservative support for his pursuit of the House speakership.
Ms. Clark remains in place, however, and hasn't backed off from challenging lawmakers. DealBook has gotten a preview of her annual State of American Business address, scheduled to be delivered at 11 a.m. Eastern; in it, she plans to call out both political parties.
''When it comes to Washington, the state of American business is fed up,'' Ms. Clark plans to say. ''Businesses don't have the clarity or the certainty to plan past the next political cycle. It means our country won't be able to advance an agenda that extends beyond two to four years, or pass the policies needed to position us for our future.''
But Ms. Clark won't just chide lawmakers. She will also introduce an ''agenda for American strength,'' essentially a policy wish list. It includes:
Continuing a bipartisan approach that led to Congress approving $1 trillion in infrastructure spending. The Chamber hopes Republicans and Democrats can team up to overhaul permitting of energy infrastructure projects and approve offshore leasing for oil and gas projects.
Expanding access to employment-based visas, and fixing ''the broken immigration system by securing the border'' and protecting the undocumented immigrants known as Dreamers.
Continuing to be tough on China's human rights abuses and unfair trade practices '-- but also recognizing the country's ''value as a commercial partner.''
''We must hold social-media companies accountable for the experiment they are running on our children for profit.'' '-- President Biden, in a Wall Street Journal opinion essay, urging Congress to pass bipartisan legislation that would protect consumer privacy and limit ad targeting by Big Tech firms.
The latest on layoffs More companies announced job cuts on Wednesday as corporate America moves to shrink its work force in the face of challenging economic conditions. Here's an update:
Goldman Sachs laid off more employees on Wednesday as part of a cost-cutting drive that involves reducing head count by 3,200. (Some workers were reportedly given as little as 30 minutes to pack up their desks, according to The Financial Times.) More are expected to leave after receiving bonuses that will be sharply lower than last year's.
BlackRock will cut up to 500 jobs, in the asset-management giant's first set of layoffs since 2019. The firm's belief that an economic downturn is coming may be driving the move: ''A recession is a matter of when, not if,'' Gary Shedlin, BlackRock's C.F.O., told analysts last month.
Verily, a health care division of Alphabet, plans to cut 200 jobs, or 15 percent of its work force. It's the first in what is expected to be a round of layoffs at Google's parent company.
Flexport, a start-up that produces supply-chain software, will lay off 640 workers, or 20 percent of its staff. Executives said a slowdown in shipping, tied to lower consumer demand, required cost-cutting measures.
THE SPEED READ
Deals
Microsoft considered bidding for Figma, the design software maker, before it was sold to Adobe for $20 billion. (CNBC)
JPMorgan said it was duped by fake user data in its $175 million acquisition of a financial planning site focused on college-age consumers. (Forbes)
T-Mobile US is reportedly weighing a deal to buy Mint Mobile, a budget wireless network backed by the actor Ryan Reynolds. (Bloomberg)
Policy
The U.S. may finally breach the debt ceiling. (NYT)
Apple will reportedly reveal more about why apps get pulled from its app store following pressure by activist investors. (FT)
President Biden's aides found another batch of classified documents, the second such discovery this week. (NYT)
China is close to naming a vice foreign minister and U.S. specialist as its next ambassador to Washington. (WSJ)
Best of the rest
News Corp's Dow Jones, the publisher of The Wall Street Journal, is laying off employees. (Reuters)
For Kanye West, the risk of losing lawsuits by default is growing as the rapper doesn't appear to have legal representation. (Insider)
Rebecca Blumenstein, a deputy managing editor at The Times, has been named president of editorial at NBC News. (NYT)
We'd like your feedback! Please email thoughts and suggestions to dealbook@nytimes.com.
Microsoft's creepy new VALL-E AI can imitate anyone's voice in just 3 seconds | Tom's Guide
Thu, 12 Jan 2023 15:45
HomeNewsComputers(Image credit: Shutterstock)Microsoft has unveiled a new text-to-speech AI model called VALL-E which can accurately simulate anyone's voice with just a three-second audio clip of them speaking.
As reported by Ars Technica (opens in new tab) , the software giant's researchers have demonstrated VALL-E in action in a new research paper (opens in new tab) and GitHub demo. Although it's still in its infancy, VALL-E is already impressing the scientific community '-- and creeping out the rest of us '-- with its ability to synthesize audio of a person saying anything while preserving their emotional tone.
VALL-E's creators believe that their new AI model could one day be used in text-to-speech software, to edit pre-existing recordings and even to create new audio when used alongside other AI models like GPT-3.
According to Microsoft, VALL-E is a ''neural codec language model'' that builds off a technology from Meta called EnCodec announced back in October of last year. It sets itself apart from other text-to-speech methods by generating discrete audio codec codes from text and acoustic prompts as opposed to manipulating waveforms to generate speech.
Synthesizing personalized speechIn order to synthesize personalized speech, VALL-E generates acoustic tokens after listening to a three-second clip of a person speaking and then uses them to ''synthesize the final waveform with the corresponding neural codec decoder'' according to Microsoft's researchers.
To train its new AI model, the company's researchers used an audio library from Meta called LibriLight. The library itself is made up of 60,000 hours of English speech from over 7,000 speakers though most of this recorded speech was pulled from public domain audiobooks.
If you're interested in seeing just how realistic VALL-E's personalized speech is, you should check out the demo on GitHub as it has dozens of audio samples of the AI in action (shown in the video above). In these samples, the ''Speaker Prompt'' is the original three-second audio clip while the ''Ground Truth'' is a recording of this same speaker saying a particular phrase. Meanwhile, the ''Baseline'' is an example of another text-to-speech synthesis model and the ''VALL-E'' sample is the one generated by Microsoft's new AI model.
Another interesting thing about VALL-E is that it can imitate the ''acoustic environment'' of the three-second clips used to impersonate people's voices. This means that if the original speaker was in their car or on a phone call, the AI model will produce speech with those same acoustic characteristics.
VALL-E won't be used in deepfakes anytime soon
(Image credit: NurPhoto/Getty)Deepfakes have the potential to turn our world on its head as we'll no longer be able to know for sure whether the video or audio clips we see are genuine. This is why, unlike with ChatGPT, Microsoft hasn't nor does it have any plans to make VALL-E generally available.
The software giant has also ensured that a detection model can be built to tell whether or not an audio clip was created by its new AI model. At the same time, Microsoft has promised to put its AI principles ''into practice when further developing the models''.
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Anthony Spadafora is the security and networking editor at Tom's Guide where he covers everything from data breaches and ransomware gangs to password managers and the best way to cover your whole home or business with Wi-Fi. Before joining the team, he wrote for ITProPortal while living in Korea and later for TechRadar Pro after moving back to the US. Based in Houston, Texas, when he's not writing Anthony can be found tinkering with PCs and game consoles, managing cables and upgrading his smart home.
XBB 1.5. Omicron sub variant nicknamed Kraken: Who proposed the moniker?
Thu, 12 Jan 2023 15:35
A nurse administers a COVID-19 test outside the Salt Lake County Health Department. AP
A new Covid variant, the subvariant of Omicron XBB.1.5, that has now become the dominant strain in US, has picked up a new moniker, ''Kraken.''
World Health Organisation (WHO) said that the ''Kraken'' variant has now been identified in over 28 countries.
XBB.1.5, the descendant of the Omicron XBB variant, was named by an expert group convened by WHO. The group has been responsible for naming all the Covid variants of global concern and normally uses Greek alphabets to identify a variant.
Previous strains like Alpha, Beta and Delta fell under this convention, according to a report by Bloomberg.
However, following the emergence of Omicron, the last Greek-named subvariant of Covid, it was thought the world wouldn't witness the origin of another variant or strains. Omicron itself has a string of sub-lineages, including XBB.1.5 and their names are based on a mix of alphabets and numbers called ''Pango.''
This method of naming variants and their sub-lineages led to the rise in informal online nicknames, which includes ''Kraken.'' The XBB.1.5 was named by an evolutionary professor on Twitter to equate its strength with a mythical sea monster.
WHO says XBB most transmissible subvariant
The WHO's Covid-19 technical lead Maria Van Kerkhove said the global health officials are worried about how quickly the subvariant is spreading in the northeastern US.
The WHO said that XBB.1.5, however, does not appear to make people sicker.
''It is the most transmissible subvariant that has been detected yet,'' Kerkhove said, adding, ''The reason for this are the mutations that are within this subvariant of omicron allowing this virus to adhere to the cell and replicate easily.''
She further said the WHO does not have any specific data yet on the severity of XBB.1.5, ''but there's no indication at the moment that it makes people sicker than previous versions of omicron.''
Kerkhove further said the WHO's advisory group that tracks Covid variants is conducting a risk assessment on XBB.1.5 and is expected to publish it in the coming days.
''The more this virus circulates the more opportunities it will have to change. We do expect further waves of infection around the world but that doesn't have to translate into further waves of death because our countermeasures continue to work,'' she added.
Read all the Latest News, Trending News, Cricket News, Bollywood News,India News and Entertainment News here. Follow us on Facebook, Twitter and Instagram.
Louisiana Law Now Requires Age Verification At Any Site Containing More Than One-Third Porn | Techdirt
Thu, 12 Jan 2023 15:07
from the [whips-out-dipstick-to-check-site's-porn-level] deptVery few issues have generated as much ridiculous legislation as preventing minors from accessing pornography. Almost everyone agrees something must be done. And most seem to agree that doing anything '-- no matter how stupid '-- is better than doing nothing.
Extremely stupid versions of ''something'' have cropped up around the nation, most of them propelled by a self-proclaimed anti-porn activist who once tried to marry his own computer in protest of gay marriage and has engaged in a number of performative lawsuits, including one against Apple for failing to prevent him from accessing porn on his devices.
Many of these bills have gone nowhere. However, a few have actually become law, providing the legislation's supporters with some cheap wins that look good on the anti-porn resume, if it they don't really do much to actually prevent children from accessing explicit content.
A law passed last year in Louisiana has just gone into effect, requiring age verification at sites that meet the state's watershed for porn content.
The porn industry has been around for a while and in today's digital age business is booming. When Laurie Schlegel isn't seeing her patients who struggle with sex addiction, she's at the Louisiana State Capitol.
The Republican state representative from Metairie passed HB 142 earlier this year requiring age verification for any website that contains 33.3% or more pornographic material.
''Pornography is destroying our children and they're getting unlimited access to it on the internet and so if the pornography companies aren't going to be responsible, I thought we need to go ahead and hold them accountable,'' said Schlegel.
There's some weird stuff going on here, likely due to the law [PDF] being about 90% performative nonsense and 10% legalese.
First off, there's the strangely arbitrary cutoff point of one-third porn content. Unmentioned anywhere is how porn percentage will be determined. Also unmentioned is whether or not the law still applies when the total percentage of porn content dips below 33%.
This language appears to borrowed from the UK's disastrous porn filter legislation, which proposed the same cutoff line while similarly being vague about how the porn percentage of sites would be determined.
That sets the baseline for enforcement, suggesting a government entity might have to access all available content on a site to determine whether or not it can be held liable (via civil suits brought by residents or the state attorney general) for failing to properly conduct age verification.
But to get to all of this, one first has to wade through a paragraph presumably written by Rep. Schlegel, which supposedly justifies everything that comes after it.
Pornography contributes to the hyper-sexualization of teens and prepubescent children and may lead to low self-esteem, body image disorders, an increase in problematic sexual activity at younger ages, and increased desire among adolescents to engage in risky sexual behavior. Pornography may also impact brain development and functioning, contribute to emotional and medical illnesses, shape deviant sexual arousal, and lead to difficulty in forming or maintaining positive, intimate relationships, as well as promoting problematic or harmful sexual behaviors and addiction.
This sounds a lot like the stuff said by others pushing anti-porn legislation, a lot of it composed by a man who sued Apple for allowing him to access porn. It's a smokescreen that allows prudish legislators to hide their desire to control what content even adults can consume (by raising state-sponsored barriers) behind statements about concerns for the health and well-being of constituents.
This may be Schlegel's own writing, however. Her statements to WAFB contain plenty of other absurd assertions.
She said problems like depression, erectile dysfunction, lack of motivation, and fatigue can be directly linked to porn. She also said to prevent these issues from occurring at younger ages, this law is imperative.
''It's tied to some of the biggest societal ills of human trafficking and sexual assault. And in my own practice, the youngest we've ever seen is an 8-year-old,'' noted Schlegel.
There's little if anything linking porn to sexual assault. And I don't know which of these problems the state rep observed in an 8-year-old, but I sincerely hope it wasn't erectile dysfunction.
The law may prevent sites required to verify the ages of visitors from collecting or storing credentials/personal info used for verification, but the author of the bill thinks the easiest way to verify age is to run it through a verification app created by a private company in partnership with the Louisiana government.
According to Schlegel, websites would verify someone's age in collaboration with LA Wallet. So, if you plan on using these sites in the future, you may want to download the app.
''I would say so,'' said Sara Kelley, project manager with Envoc. ''I mean, I think it's a must-have for anyone who has a Louisiana state ID or driver's license.''
LA Wallet is a digital drivers license. At the time of its creation, it was the first of its kind in the country. Nudging porn viewers towards state-sponsored apps is all part of the plan. If people believe (correctly or incorrectly) the government may have some way of knowing they're visiting sites containing at least 33.3% porn, they're less likely to visit these sites. So, this law may claim it's for the children, but it's all about steering people away from content certain legislators don't like.
It also will nudge sites to more directly police user-generated content for porn to help ensure they don't inadvertently pass the one-third mark and open themselves up to litigation. The law controls content on both ends of the equation: the distributor and the consumer.
Not that the law is going to actually prevent kids from accessing porn. Plenty of porn can be found on sites not subject to the law. And plenty of porn can be easily accessed even with a state mandate in place. Since most sites affected by this aren't actually located in Louisiana, they're under no obligation to verify the ages of users, even if the users are located in this state. And the law creates no demand (nor could it without creating even greater privacy concerns) that sites police incoming internet traffic for users' locations at the time of access.
It's all a bunch of performative stupidity that, at best, will encourage stupid, performative people to file stupid, performative lawsuits. And maybe that's really the end goal: the pointless hassling of tech companies for not being better parents to the children of Louisiana.
Filed Under: adult content, age verification, laurie schlegel, louisiana, porn, porn license
COMPETITION | Miss Universe
Thu, 12 Jan 2023 15:06
COMPETITION DETAILS
The 71st MISS UNIVERSE® competition will be held in New Orleans, Louisiana on Saturday, January 14, 2023. The international event will be hosted at the New Orleans Ernest N. Morial Convention Center.
The highly anticipated event will feature almost 90 women from around the globe vying for the job of Miss Universe, through the process of personal statements, in depth interviews and various categories including evening gown & swimwear. The evening will culminate with the 70th Miss Universe, Harnaaz Sandhu, who brought the title back to India for the first time in twenty-one years, crowning her successor.
''The City of New Orleans and the Miss Universe Organization share common values of celebrating inclusion, culture and the empowerment of women,'' said New Orleans Mayor LaToya Cantrell , the first female Mayor in the city's 300-year history. ''Former Miss Universe delegates and winners have gone on to become surgeons, diplomats, politicians and business leaders, and they all champion social causes that are important to them. Hosting this event demonstrates the significant global impact an international city like New Orleans has on the world's tourism and cultural stages. We are honored to host the 71st annual Miss Universe pageant and show people around the globe why New Orleans is the best in the world at executing major events, festivals, conferences and conventions with a culture that is absolutely unmatched.'' STAY TUNED FOR MORE UPDATES
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MISS UNIVERSE APP
Michigan animal sacrifice
Thu, 12 Jan 2023 14:11
In a photo from Sunday, May 10, 2015, in Hamtramck, Mich., the Beth Olem Cemetery is shown on the grounds of the General Motors Co.'s Detroit Hamtramck'...In a photo from Sunday, May 10, 2015, in Hamtramck, Mich., the Beth Olem Cemetery is shown on the grounds of the General Motors Co.'s Detroit Hamtramck Plant. Public access to the green oasis is limited to a couple days a year, including this past Sunday. The Jewish cemetery survives through historical quirks _ particularly a pact reached about 35 years ago to preserve the cemetery as GM sought to demolish a neighborhood and build a plant. (AP Photo/Carlos Osorio)by: Associated Press
Posted: Jan 11, 2023 / 03:02 PM EST
Updated: Jan 11, 2023 / 03:02 PM EST
HAMTRAMCK, Mich. (AP) '-- Residents of a Detroit-area community with a large Muslim population can sacrifice animals at home for religious reasons.
The Hamtramck City Council explicitly approved the practice, 3-2, Tuesday, another step in recognizing a cultural shift in a city whose 20th century history was shaped by Polish immigrants.
The council in December had voted to continue a ban on animal slaughter but reversed course, at least for religious reasons, after legal advice and objections from people who follow the Islamic faith, the Detroit Free Press reported.
''If somebody wants to do it, they have a right to do their practice,'' Council member Mohammed Hassan said.
Muslims often slaughter animals, especially goats or sheep, during the holiday of Eid al-Adha or pay someone to do it for them. Meat is shared with family, friends and the poor.
''It's not something new or novel,'' explained Dawud Walid, director of the Michigan branch of the Council on American-Islamic Relations.
''This is when Muslims recognize Abraham sacrificing a sheep instead of having to sacrifice his son,'' Walid said, referring to the Old Testament passage.
Hamtramck residents will be required to notify the city, pay a fee and make their property available for inspection.
Hamtramck has a population 28,000. More than half of the residents are of Yemeni or Bangladeshi descent, the Free Press said.
Top StoriesMore StoriesLatest Video HeadlinesFox 8 Cleveland WJW VideoMore from Fox 8 Cleveland WJW
HUGE: Matt Gaetz Reveals Republicans Will Release the 14,000 Hours of J6 Tapes That Have Been Hidden (VIDEO)
Thu, 12 Jan 2023 14:05
Looks like we will finally get the full story on what really happened on January 6th. Congressman Matt Gaetz (R-FL) told Charlie Kirk today on Kirk's radio show that the new Republican Congress will unveil the hidden J6 tapes.
Gaetz told Charlie Kirk that releasing the tapes ''would give more full context to that day rather than the cherry-picked moments of the January 6th committee.'' He further explained this is one example of the deal made with Kevin McCarthy to provide the American people the truth rather than the lies propagated by the Biden Regime.
VIDEO:
Gaetz: Republicans will release ''14,000 hours of [J6] tapes that have been hidden''
BAM!
Looks like truth about Pelosi's Fed-Op is going to be exposed even further! pic.twitter.com/ybf3RSgoow
'-- DC_Draino (@DC_Draino) January 10, 2023
TRENDING: HISTORY IN THE MAKING: The State of New California Holds Its 10th Constitutional Convention
Here is the relevant part of their conversation:
Kirk: One of my favorite members of Congress is Thomas Massie and the fact that he is going to be on this new committee (the Church Committee) really gives me hope.
Matt, do you anticipate allowing the dogs to be released if you will against this fourth branch of government (the Deep State).
Gaetz: Kevin McCarthy told us he is going to get the evidence out in front of the American people and that means releasing the 14,000 hours of tapes that have been hidden that I think would give more full context to that day (January 6th) rather than the cherry-picked moments the January 6th committee tried to use to inflame and further divide out country.
So yes, I do believe that part of this deal is a concession that we are going to get the truth out in front of the American people.
Should Congress actually follow through and release the tapes, this will serve as the first step toward getting justice for the January 6th prisoners. The Gateway Pundit has provided numerous accounts of the horrifying conditions the Regime has placed them in.
TGP owner Jim Hoft has been particularly outspoken over the treatment of the Regime's political prisoners and has attended protests speaking on their behalf. TGP writer Cara Castronuova has also broken numerous critical stories on the prisoners' suffering.
The deal made between McCarthy and the conservative rebels continues to look better as the days go by. We have patriots like Matt Gaetz to thank for this.
Woke leaders at USC ban the word 'field' because it's racist | Daily Mail Online
Thu, 12 Jan 2023 14:01
Woke leaders at USC ban the word 'field' because it's racist: They will use the term 'practicum' when discussing their workThe University said the term may have connotations for descendants of slavery and immigrant workersThe move is meant to reflect 'anti-racist' values but it has come under fire One person asked if it is just 'empty virtue signaling'By James Callery For Mailonline
Published: 04:39 EST, 11 January 2023 | Updated: 03:02 EST, 12 January 2023
The University of Southern California's School of Social Work has published a letter saying it will remove the word 'field' from its curriculum and practice and replace it with the word 'practicum' instead.
The move is meant to reflect 'anti-racist' values, but some have argued that it insults the intelligence of the people who it is addressing.
'This change supports anti-racist social work practice by replacing language that could be considered anti-Black or anti-immigrant in favor of inclusive language,' the letter read.
'Language can be powerful, and phrases such as "going into the field" or "field work" may have connotations for descendants of slavery and immigrant workers that are not benign.'
The University of Southern California's School of Social Work published a letter noting it would stop using the word 'field' when referring to a person's area of expertise, instead, replacing it with the word 'practicum'
A tweet included a copy of the letter from the University of Southern California
Houman David Hemmati, a board-certified MD Ophthalmologist and PhD research scientist, tweeted: 'Today, @uscsocialwork sent out this letter announcing that they will no longer use the word "field" (as in "conducting field work") because it's perceived as racist. Is this with merit or empty virtue signaling?'.
Interim dean of the USC Suzanne Dworak-Peck School of Social Work, Vassilios Papadopoulos, sought to clarify the situation. He told Fox News Digital that he understands the decision was made by the Office of Practicum Education 'out of a desire to more accurately describe its work'.
He added: 'Because the Office is not an academic department, its name change was not subject to a formal review process. The university does not maintain a list of "banned" or discouraged words. As an institution of higher education, we will continue to use words - including the word "field" '' that accurately encompass and describe our work and research, while also continuing our efforts to create a more inclusive and welcoming environment for all.'
Pictured: The University of Southern California. The change in the curriculum at the School of Social Work was said to stem from an adherence to the radical orthodoxy of 'anti-racist' methodology, but some have argued that it insults the intelligence of the people who it is addressing
Responding to the announcement that the word 'field' will be removed by that department, one Twitter user wrote: 'For someone who spent more than 7 years at USC with 2 graduate degrees from this institution, I am so embarrassed at what's happening there. I wonder how much of my money they spent on coming up with this amazingly useful change.'
Another commented: 'Wow, I went to USC and never thought it was particularly woke. Of course that was 10 years ago now'... and I didn't study social work.'
A third tweeted: 'Are they still going to have baseball and football fields?'
Pictured: The University of Southern California's School of Social Work
Last year, the University of Washington issued an IT inclusive language guide that aimed to cut out 'words that reflect racial or other discriminatory bias,' covering the full woke spectrum.
'Mantra' was among the problematic words highlighted, as many people in the Buddhist and Hindu communities hold this term as highly spiritual and religious.
The phrase 'no can do' was also listed, as it is apparently an imitation of Chinese Pidgin English, dating from the mid-nineteenth to early-twentieth centuries - an era when Western attitudes towards the Chinese were markedly racist.
Stanford University published a similar index of 'harmful language' last year. One of the words considered damaging was 'guru' as the term is a sign of respect in Buddhist and Hindu traditions. 'Brave' also appeared on the list because the University considered it to perpetuate the stereotype of the 'noble courageous savage'.
Stanford University also said it wanted to swap the word 'American' with 'US citizen', as the former 'often refers to people from the United States only, thereby insinuating that the US is the most important country in the Americas (which is actually made up of 42 countries)'.
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Computer "Outage" Hits Canadian Flight System Hours After US System Went Down | ZeroHedge
Thu, 12 Jan 2023 14:00
Update (1426ET):
Nav Canada, the not-for-profit corporation that operates Canada's civil air navigation system, reports the Candian real-time safety alerts system for pilots, otherwise known as NOTAM -- short for Notice to Air Mission -- has been hit with an outage.
So far, no delays have been attributed to the outage.
"We are assessing impacts to our operations and will provide updates as soon as they are available," Nav Canada said.
pic.twitter.com/xLCZ0CVwvz
'-- NAV CANADA (@navcanada) January 11, 2023This is the second NOTAM system in North America over the last 12 hours that has been hit with outages. As we explained below, the US grounded all planes earlier this morning due to NOTAM outages but restored departures around 0900 ET.
The disruption was enough to spark a travel nightmare for US travelers today and is worsening by the hour. The latest figures from flight tracking website FlightAware show 8,000 flights have been delayed and another 1,200 canceled.
So how do authorities explain the US and Canada's NOTAM systems experiencing outages on the same day?
'‹* * *
Update (1210ET):
This is one travel mess the airlines can deflect and blame the federal government.
Three hours after the FAA reopened the skies after a nationwide grounding of all commercial jets following a computer outage, there are 7,000 flights delayed and another 1,000 canceled, according to flight tracking website FlightAware.
People are not happy with Secretary of Transportation Pete Buttigieg:
MAYOR Pete an expert? Where in the hell was the backup system dude? When system updates occur usually a backup or parallel system is running to make sure the update installed correctly.Delayed flights will happen and backup airports.
'-- Susan Kienle (@profskienle) January 11, 2023Remember FAA is too busy going 'woke' to care about other important things.
If you're surprised that the FAA's systems went down this morning grounding all domestic flights, you shouldn't be.Below are DOT and FAA's approps focus in the 2023 budget:
''Racial equity,'' ''inclusion,'' ''income inequality,'' ''environmental justice, and ''climate change.'' pic.twitter.com/83N70Qs0aj
'-- John Cardillo (@johncardillo) January 11, 2023Look what's trending on Twitter.
People aren't happy with Buttigieg.
Pete Buttigieg couldn't organize a one-car funeral.He was never remotely qualified for this role.
'-- Tom Cotton (@TomCottonAR) January 11, 2023How many more transportation screwups are we going to tolerate from @PeteButtigieg. pic.twitter.com/u34XbsKGYl
'-- Stealthwave (she/it) ðŸ--´ (@Stealth1014) January 11, 2023.@PeteButtigieg is running a master class on how to f-up a political career. Somehow he was in better shape when he was just a former Mayor of a small town in Indiana.
'-- Michael Biundo (@MichaelBiundo) January 11, 2023@PeteButtigieg you suck ass at your job. No pun intended
'-- ZMT (@RDZT44) January 11, 2023Pete Buttigieg must have been busy "chest" feeding and dropped the ball.
'-- Intellectual Self Defense (@BenoJosi) January 11, 2023* * *
Update (0900ET):
"Normal air traffic operations are resuming gradually across the US following an overnight outage to the Notice to Air Missions system that provides safety info to flight crews. The ground stop has been lifted," FAA tweeted.
But, grounding all domestic flights for hours has sparked travel chaos this morning. There are currently 4,000 delays within, into, or out of the US, flight tracking website FlightAware showed. Another 700 were canceled.
And then there's this...
If you're surprised that the FAA's systems went down this morning grounding all domestic flights, you shouldn't be.Below are DOT and FAA's approps focus in the 2023 budget:
''Racial equity,'' ''inclusion,'' ''income inequality,'' ''environmental justice, and ''climate change.'' pic.twitter.com/83N70Qs0aj
'-- John Cardillo (@johncardillo) January 11, 2023'‹'‹'‹What a mess. At least airlines, this time around, can blame the government for flight disruptions.
* * *
Update (0742ET):
President Biden has been briefed about the FAA's system failure.
*PRESIDENT HAS BEEN BRIEFED ON FAA SYSTEM OUTAGE, PRESS SEC SAYS*JEAN-PIERRE: NO EVIDENCE OF CYBERATTACK AT THIS POINT
'-- zerohedge (@zerohedge) January 11, 2023And now domestic departures halts will extend 30 minutes until 0930 ET.
*US FAA DOMESTIC DEPARTURES PAUSE EXTENDED TO 9:30 AM ET: CBS
'-- zerohedge (@zerohedge) January 11, 2023Hmmm.
*BIDEN: FAA EXPECTS IN A FEW HOURS TO HAVE A SENSE OF CAUSE
'-- zerohedge (@zerohedge) January 11, 2023* * *
Update (0730ET):
FAA ordered all airlines to halt domestic departures until 0900 ET.
Update 3: The FAA is still working to fully restore the Notice to Air Missions system following an outage.'°'°The FAA has ordered airlines to pause all domestic departures until 9 a.m. Eastern Time to allow the agency to validate the integrity of flight and safety information.
'-- The FAA ''¸ (@FAANews) January 11, 2023So far, 1,366 flights have been delayed within, into, or out of the US, flight tracking website FlightAware showed. Another 108 were canceled.
* * *
Update (0719ET):
"The FAA is still working to fully restore the Notice to Air Missions system following an outage ... some functions are beginning to come back online, National Airspace System operations remain limited," FAA tweeted.
Cleared Update No. 2 for all stakeholders: '°'°The FAA is still working to fully restore the Notice to Air Missions system following an outage. '°'°While some functions are beginning to come back on line, National Airspace System operations remain limited.
'-- The FAA ''¸ (@FAANews) January 11, 2023* * *
Early Wednesday morning, the US Federal Aviation Administration's (FAA) system that notifies pilots about hazards or any changes to airport facility services suffered an outage that might result in a nationwide grounding.
The FAA wrote in an advisory update that its NOTAM (Notice to Air Missions) system had "failed." The aviation agency provided no immediate estimate for when it would return online.
"THE FAA is experiencing an outage that is impacting the update of NOTAMS. All flights are unable to be released at this time," the FAA said in a statement.
In a statement to NBC News, the FAA said, "Operations across the National Airspace System are affected."
So far, 1,162 flights have been delayed within, into, or out of the US, flight tracking website FlightAware showed. Another 94 were canceled.
Flights are being grounded nationwide.
Just an FYI if you are planning to fly today (as I sit on a plane I boarded at 5am), FAA's NOTAM system is down and basically all planes within and coming in and out of the U.S. are grounded. Our pilot says they have no idea when it will be functioning again. So. pic.twitter.com/4iW11Ns2vr
'-- Asha Rangappa (@AshaRangappa_) January 11, 2023BREAKING NEWS: 🚨🚨Dozens of flights have been delayed at Charleston International airport due to a FAA computer malfunction.We haven't seen any flights leave Charleston in the past 40-45 minutes.Tune into @ABCNews4 for the latest updates #Working4You pic.twitter.com/kcZugsJaqo
'-- Sean Mahoney (@SeanMahoneyTV) January 11, 2023It's probably not a good time to fly this morning.
BREAKING: Widespread U.S. flight delays expected after critical FAA system goes down; agency currently working on getting it back online pic.twitter.com/DVQAw4nsTE
'-- CNBC Now (@CNBCnow) January 11, 2023Passengers are beginning to complain on social media about delayed flights.
FAA computer outage has grounded flights nationwide this morning. Boarded at 5:30AM as the first flight of the day. Currently delayed indefinitely. Idk if I'll be making this cruise out of Florida'... ðŸðŸŒ´ðŸš pic.twitter.com/SBy8q2sD2N
'-- Stephanie Grindley (@StephanieGTV) January 11, 2023FAA outage also affecting flights abroad. Our flight from FCO - PHL is halted on the runway.
'-- Allie Evans (@whattheklutz) January 11, 2023The FAA has grounded all flights due to a computer outage. Sitting on a plane @EWRairport on @UnitedAirlines pic.twitter.com/Rlq5OBmiJd
'-- Alan Smith (@alan_f_smith) January 11, 2023Currently sitting on the runway and am seeing that the FAA is grounding all flights in the US for a system outage'...if yal gone cancel, do it now so I can go get back in my bed ðŸ(C)ðŸðŸ½
'-- Jay Dub (@TheSweetest_Jay) January 11, 2023Sitting in DCA, they just told us there is a nation-wide FAA outage. No flights are moving anywhere. Anyone have any clue what's going on?
'-- GChris (@GChris65) January 11, 2023@AmericanAir I've been sitting on a full plane at the gate at LAX for 2+ hours for a system issue with the FAA. When will this be resolved? #flightdelay
'-- Lynn (@birdsonglynn1) January 11, 2023Loading...
Biden White House Extends COVID Public Health Emergency Through April | The Daily Wire
Thu, 12 Jan 2023 13:53
The Biden White House announced Wednesday that it is extending the COVID public health emergency for another 90 days following increased cases of the latest subvariant.
The announcement extends the public health emergency into April, marking the twelfth extension since it was first set in place by then-President Donald Trump in 2020, allowing millions of Americans to remain eligible for Medicaid benefits.
Health and Human Services Secretary Xavier Becerra has committed to giving state leaders and healthcare executives a 60-day notice before allowing the action to expire.
Millions of Americans could lose health insurance under Medicaid when the extension expires. Enrollment has increased by an additional 24 million Americans since the start of the policy. The Daily Wire previously reported that Medicaid enrollment is expected to hit the 100 million mark soon, according to a recent report.
The renewal occurs as subvariant XBB.1.5 comprises more than 70% of COVID cases in the Northeast and 28% nationwide, according to the Centers for Disease Control and Prevention (CDC). As of January 4, an average of 67,000 daily positive cases were recorded, with 390 COVID-related daily deaths.
The CDC's COVID-19 Integrated County View for reporting shows that nearly 75% of the nation's counties are considered at high risk for community transmission.
The increased coronavirus, flu, and RSV cases have led to a growing number of schools and other locations returning to masking. The Ann Arbor Public School system in Michigan reintroduced a two-week mask mandate from January 9-20 following increased illnesses in December.
''During this time of return from travel and social activities, the requirement of masks while indoors at school is a measure to reduce the spread of respiratory illnesses and related absenteeism and to prioritize health and in school learning, particularly at this transition time following winter break,'' Superintendent Jeanice Swift wrote.
Some schools in Massachusetts, New Jersey, and Pennsylvania have also returned to required indoor mask-wearing.
Other school systems, such as Chicago Public Schools, asked students and staff to test themselves for COVID before returning to school.
''If you test positive, please report the positive test using the COVID-19 Self-Reporting Form, and follow the guidance outlined on our safety page,'' the notice read.
White House COVID-19 Response Director Dr. Ashish Jha addressed the spread of the XBB.1.5 subvariant last week, expressing concern over the increased cases while encouraging the updated vaccine and other measures to minimize risk.
Study finds Athlete Deaths are 1700% higher than expected since Covid-19 Vaccination began '' [your]NEWS
Thu, 12 Jan 2023 13:37
Research links COVID-19 vaccines to increase in athlete deaths
An investigation of official statistics has found that the number of athletes who have died since the beginning of 2021 has risen exponentially compared to the yearly number of deaths of athletes officially recorded between 1966 and 2004.
So much so that the monthly average number of deaths between January 2021 and April 2022 is 1,700% higher than the monthly average between 1966 and 2004, and the current trend for 2022 so far shows this could increase to 4,120% if the increased number of deaths continues, with the number of deaths in March 2022 alone 3 times higher than the previous annual average.
According to a scientific study conducted by the 'Division of Pediatric Cardiology, University Hospital of Lausanne, Lausanne, Switzerland which was published in 2006, between the years 1966 and 2004 there were 1,101 sudden deaths among athletes under the age of 35.
The GoodSciencing.com team has comprehensive list of athletes who have collapsed and/or died since January 2021, a month after the first Covid-19 injection was administered to the general public.
The full list can be accessed in full here.
The following chart shows the number of recorded athlete collapses and deaths between January 2021 and April 2022, courtesy of the linked list above ''
There has been a rise from January 2021 onwards.
In all between Jan 21 and April 22 a total number of 673 athletes are known to have died. This number could however, be much higher. So that's 428 less than the number to have died between 1966 and 2004. The difference here though is that the 1,101 deaths occurred over 39 years, whereas 673 recent deaths have occurred over 16 months.
The following chart shows the number of recorded athlete deaths in different time periods ''
The yearly average number of deaths between 1966 and 2004 equates to 28. January 2022 saw 3 times as many athlete deaths than this previous annual average, as did March 2022. So this is obviously highly indicative of a problem.
The 2021 total equates to 394 deaths, 14x higher than the 1966 to 2004 annual average. The Jan to April 2022 total, a period of 4 months, equates to 279 deaths, 9.96x higher than the annual average between 1966 and 2004.
However, if we divide the 66 to 04 annual average by 3 to make it equivalent to the 4 months worth of deaths so far in 2022, we get 9.3 deaths. So in effect, 2022 so far has seen deaths 10x higher than the expected rate.
The following chart shows the monthly average number of recorded athlete deaths ''
Between 1966 and 2004. the monthly average number of deaths equates to 2.35. But between January 2021 and April 2022, the monthly average equates to 42. This is an increase of 1,696%.
A study of 566 patients who received either the Pfizer or Moderna vaccines shows that signs of cardiovascular damage soared following the 2nd shot. The risk of heart attacks or other severe coronary problems more than doubled months after the vaccines were administered, based on changes in markers of inflammation and cell damage.
Patients had a 1 in 4 risk for severe problems after the vaccines, compared to 1 in 9 before. Their 5-year heart attack risk went from 11% to 25% thanks to the vaccines (that is a 227% increase).
Dr. Steven Gundry, a Nebraska physician and retired cardiac surgeon, presented the findings at the Scientific Sessions of the American Heart Association's annual conference in Boston On November 12-14. An abstract of his paper was published on November 8 in Circulation, the AHA's scientific journal.
https://www.opindia.com/2021/11/mrna-covid-19-vaccines-increase-possibility-of-coronary-diseases-study/amp/https://www.ahajournals.org/doi/abs/10.1161/circ.144.suppl_1.10712?s=09
Myocarditis is a condition that causes inflammation of the heart muscle and reduces the heart's ability to pump blood, and can cause rapid or abnormal heart rhythms.
Eventually, myocarditis weakens the heart so that the rest of the body doesn't get enough blood. Clots can then form in the heart, leading to a stroke or heart attack. Other complications of the condition include sudden cardiac death. There is no mild version of myocarditis, it is extremely serious due to the fact that the heart muscle is incapable of regenerating.
The following chart shows reports of myocarditis to the U.S. Centers for Disease Control's Vaccine Adverse Event Reporting System by year ''
Heart damage is ubiquitous throughout the vaccinated population, and the damage is being diagnosed in multiple ways. Acute cardiac failure rates are now 475 times the normal baseline rate in VAERS. Tachycardia rates are 7,973 times the baseline rate. Acute myocardial infarction is 412 times the baseline rate. The rates of internal haemorrhage, peripheral artery thrombosis, coronary artery occlusion are all over 300 times the baseline rate.
yourNEWS is a hyper-local social news and advertising platform. Our monetization model empowers Citizen Journalists to report the news in local and national markets. The views expressed in this article are those of the author and do not reflect the official position of yourNEWS. (Note: Articles may not be original content. Referenced byline for original source.)
What is NOTAM? FAA system outage caused ground stop, flight delays
Thu, 12 Jan 2023 13:34
An overnight computer outage at the Federal Aviation Administration lead to widespread flight delays and disruptions Wednesday morning. The FAA said it was working to restore operations in the hours following.
The FAA said the outage was in the Notice to Air Missions system, which provides pilots and flight crews with essential safety information.
The FAA ordered all U.S. airlines to pause domestic departures shortly before 7:20 a.m. ET, Wednesday.As of 8:50 a.m. ET, the "ground stop" had been lifted and normal air traffic was "resuming gradually across the United States," according to an agency update.More than 7,800 flights within, into, or out of the United States were delayed, according to the tracking website FlightAware, and over 1,100 flights were canceled as of 1:30 p.m. ET."This is rare... The fact that they had to initiate a ground stop across the United States, that hasn't happened since September 11th, 2001. So you get an idea of the magnitude of this," Mike McCormick, assistant professor in applied aviation sciences at Embry-Riddle Aeronautical University, told reporters in a press call Wednesday morning.
While the exact cause of the outage remains unknown, White House Press Secretary Karine Jean-Pierre said there was "no evidence of a cyberattack" as of Wednesday morning. President Joe Biden directed the Department of Transportation to investigate.
Here's what you need to know about NOTAMs.
Live updates:Thousands of flights delayed across US following FAA computer outage
What is a NOTAM?A Notice to Air Missions is a notice that provides pilots and other flight personnel with real-time, safety information concerning flight operations, conditions and airports.
NOTAMs alert of potential hazards and conditions that can impact flights '' from runway construction or possible icing to a change in an aeronautical facility or flight service. Pilots are required to consult NOTAMs before starting every flight.
The FAA notes that a NOTAM ''states the abnormal status of a component of the National Airspace System (NAS) '' not the normal status.'' The federal agency adds that NOTAMs are ''not known far enough in advance to be publicized by other means.''
The NOTAM system was telephone-based in the past, with pilots calling flight service stations for the information, but it has now moved online.
McCormick told reporters that the NOTAM system has been "incrementally upgraded over the past several years" to transition from a manual system to an internet-based system. "There are redundancies built into it," he said.
When did the NOTAM system outage occur?The NOTAM system failed at 8:28 p.m. ET on Tuesday, according to FAA advisories.
In efforts to keep departures flying overnight, the FAA used a telephone hotline. But the telephone system was overwhelmed as daytime traffic increased.
The stop order on Wednesday morning impacted nearly all commercial and shipping flights. Some medical flights were able to get clearance.
The outage did not impact military flights. Ann Stefanek, Air Force spokesperson, confirmed to the Associated Press that the military has its own NOTAMs system that is separate from the FAA's system.
USA TODAY analysis:Here are the 10 airports with the most flight cancellations around the holidays
Are NOTAM system outages common?An outage of its kind appears to be very rare.
McCormick told reporters on Wednesday that the there hasn't been a nationwide ground stop since 9/11. Other experts underlined the significance of the event.
''Periodically there have been local issues here or there, but this is pretty significant historically,'' Tim Campbell, a consultant in Minneapolis and former senior vice president of air operations at American Airlines, told The Associated Press.
Campbell added that there has been concern about the FAA's technology for a long time, and not just the NOTAM system.
''So much of their systems are old mainframe systems that are generally reliable but they are out of date,'' he said.
What's everyone talking about? Sign up for our trending newsletter to get the latest news of the day
Contributing: Zach Wichter, USA TODAY. The Associated Press.
COVID-Narrative Dissenters File Antitrust Action Against Legacy Media Over Coordinated Censorship '' [your]NEWS
Thu, 12 Jan 2023 13:25
A coalition of outspoken critics and skeptics of the mainstream narratives on COVID-19 has brought an antitrust lawsuit against some of the world's largest news organizations, accusing them of working in collaboration to suppress dissenting voices surrounding the pandemic.
The lawsuit (pdf), filed on Tuesday in a federal court in Texas, targets The Washington Post, the British Broadcasting Corp (BBC), The Associated Press (AP), and Reuters'--all of which are members of the ''Trusted News Initiative (TNI),'' a self-described ''industry partnership'' formed in 2020 among legacy media giants and big tech companies.
''By their own admission, members of the TNI have agreed to work together, and have in fact worked together, to exclude from the world's dominant internet platforms rival news publishers who engage in reporting that challenges and competes with TNI members' reporting on certain issues relating to COVID-19 and U.S. politics,'' the complaint reads.
Robert F. Kennedy Jr., a critic of the Biden administration's COVID-19 vaccination policies, led the lawsuit. He is joined by Creative Destruction Media, Trial Site News, Truth About Vaccines founders Ty and Charlene Bollinger, independent journalist Ben Swann, Health Nut News publisher Erin Elizabeth Finn, Gateway Pundit founder Jim Hoft, Dr. Joseph Mercola, and Ben Tapper, a chiropractor.
The plaintiffs, the lawsuit alleges, are among the many victims of the TNI's ''group boycott'' tactic, defined as a coordinated effort to facilitate monopoly by cutting off the competitors' access to supplies and necessities.
In this case, the TNI members are accused of engaging in group boycott'--in concert with their big tech partners'--against small, independent news publishers by denying them access to internet platforms they need to compete and even survive in the online news market.
''As a result of the TNI's group boycott, [the plaintiffs] have been censored, de-monetized, demoted, throttled, shadow-banned, and/or excluded entirely from platforms like Facebook, YouTube, Twitter, Instagram, and Linked-In,'' the lawsuit states.
Read More at The Epoch Times
yourNEWS is a hyper-local social news and advertising platform. Our monetization model empowers Citizen Journalists to report the news in local and national markets. The views expressed in this article are those of the author and do not reflect the official position of yourNEWS. (Note: Articles may not be original content. Referenced byline for original source.)
With Green Politics Looming, US Farmers Score Major Win, Avoiding a Dystopian Future a Little Longer
Wed, 11 Jan 2023 23:20
Commentary By Mike Landry January 9, 2023 at 2:17pm Farmers won a victory Sunday when John Deere agreed to let the growers fix their own tractors.
A memorandum of understanding between the venerable agricultural implement maker and the American Farm Bureau Federation allows farmers access to John Deere software, specialty tools and repair training.
The company previously claimed a proprietary interest in these items, allowing only John Deere technicians to service newer equipment and in effect creating a monopoly.
The issue has been festering for several years, and the resolution Sunday represents a substantial victory for farmers, increasingly pressed from all sides.
There have been efforts toward right-to-repair legislation in the United States and Canada, and nine Illinois farmers filed a class action lawsuit against John Deere, the publication Farm Equipment reported Monday.
''Every time we take a truck or tractor in, it's $175-200 an hour to get something serviced,'' Jim Leverich, who has a thousand Wisconsin acres growing soybeans and corn, said prior to the MOU.
''Many of us could do that ourselves, or we could hire a technician on our own farms to do it, but we can't get the software,'' Leverich said.
Self-repair of farm equipment has a been long and necessary tradition.
''In agriculture, we run things until they're dead and then we run 'em a little bit more after that,'' Nebraska farmer Tom Schwartz said in a Freethink video posted on YouTube a year ago.
''There's a tractor sitting in the shop here that's built in 1943,'' he continued. ''We don't dispose of things on the farm. We keep 'em running forever.
''And it's important to us as farmers, in order to keep our costs down, when we buy something, we need to run it a long time to make it pay out.''
Climbing into a giant new cab-enclosed John Deere tractor, Schwartz is heard saying, ''From this model on, you know, everything's basically run by the computer in the tractor.''
''Companies feel that all the programming and the technology that's in the tractor, they can continue to own after they sell me the tractor,'' he said.
''So, you're saying I have to pay for this, but you own it,'' Schwartz continued. ''I mean, there's some really fuzzy things that happen there '' at this point in time, if I want diagnostics, then I have one option and that's to call my [John Deere] dealer.
''If a farmer out here through his own ingenuity is able to fix something, I think he ought to be able to do so.
''And bluntly, I think that's the way it should be whether we're talking about tractors or cellphones or computers.''
Schwartz and other farmers now have what they wanted: the ability to access certain John Deere proprietary materials, according to the MOU.
Do you think you deserve the right to repair your own stuff?
Yes: 100% (202 Votes)
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The document represents itself as ''a voluntary private sector commitment to outcomes rather than legislative or regulatory measures.''
It not only allows farmers but also independent technicians access to John Deere materials. And they are free to replicate the tools and software, provided they do not resell them.
While the John Deere MOU is a victory for farmers, it's against an ominous backdrop affecting American agriculture.
China is gobbling up farmland in the U.S., a big national security concern.
Microsoft co-founder Bill Gates is doing the same thing: With nearly 270,000 acres, he is the largest private owner of farmland in the country, The Associated Press reported last year.
Meanwhile, the hysteria over climate change is putting the onus on small farmers to direct attention away from their crops to making labor-intensive calculations of emissions data. Those data regarding fertilizer, chemicals and fuel are to go to corporations regulated by the Securities and Exchange Commission.
Also, the drought-riddled American Southwest is seeing scarce water supplies taken by farms owned by Middle Eastern countries.
In addition, growers themselves may be in danger. John Deere has visions of automated tractors doing row farming (the technology is already available).
Can you imagine giant corporations launching acres and acres of tractor-robots tended by just a few people? Something like that has already happened here in northwest Arkansas, where many family chicken farms have given way to caretaker-managed giant corporate spreads.
But, for today, let's enjoy the victory farmers have won to repair their equipment and hold back a corporate monopoly.
And, for the moment, try to forget that phrase that keeps making the rounds: You will own nothing and be happy.
SummaryMore Biographical Information Recent Posts ContactMike Landry, PhD, is a retired business professor. He has been a journalist, broadcaster and church pastor. He writes from Northwest Arkansas on current events and business history.
Mike Landry, PhD, is a retired business professor. He has been a journalist, broadcaster and church pastor. He writes from Northwest Arkansas on current events and business history.
Los Angeles Declaration on Migration and Protection | The White House
Wed, 11 Jan 2023 23:17
We, the Heads of State and Government of the Argentine Republic, Barbados, Belize, the Federative Republic of Brazil, Canada, the Republic of Chile, the Republic of Colombia, the Republic of Costa Rica, the Republic of Ecuador, the Republic of El Salvador, the Republic of Guatemala, Co'‘operative Republic of Guyana, the Republic of Haiti, the Republic of Honduras, Jamaica, the United Mexican States, the Republic of Panama, the Republic of Paraguay, the Republic of Peru, the United States of America, and the Oriental Republic of Uruguay, gathered in Los Angeles on the margins of the Ninth Summit of the Americas, reiterate our will to strengthen national, regional, and hemispheric efforts to create the conditions for safe, orderly, humane, and regular migration and to strengthen frameworks for international protection and cooperation.
We embrace the need to promote the political, economic, security, social, and environmental conditions for people to lead peaceful, productive, and dignified lives in their countries of origin. Migration should be a voluntary, informed choice and not a necessity.
We are committed to protecting the safety and dignity of all migrants, refugees, asylum seekers, and stateless persons, regardless of their migratory status, and respecting their human rights and fundamental freedoms. We intend to cooperate closely to facilitate safe, orderly, humane, and regular migration and, as appropriate, promote safe and dignified returns, consistent with national legislation, the principle of non-refoulement, and our respective obligations under international law.
We acknowledge that addressing irregular international migration requires a regional approach, and that ongoing health, social, and economic challenges of the pandemic exacerbate the root causes driving irregular migration, including the vulnerabilities of many migrants and their communities.
We value the tradition of our region in welcoming refugees and migrants and showing solidarity with our neighbors. We recognize the positive contributions of refugees and migrants to the socio-economic development of their host communities. We recognize the sustained efforts of States in our hemisphere in hosting refugees, providing regular migration pathways, promoting local economic and social integration, facilitating safe, dignified, and voluntary return, and supporting the sustainable reintegration of returnees.
We remain committed to collectively leveraging the benefits of migration while addressing its challenges in countries and communities of origin, transit, destination, and return. We do so in a spirit of collaboration, solidarity, and shared responsibility among States and in partnership with civil society and international organizations. We reaffirm our shared commitment to supporting host communities; strengthening and expanding regular pathways and access to international protection; fostering opportunities for decent work; facilitating regularization and access to basic services; and promoting principles of safe, orderly, humane, and regular migration.
We also intend to strengthen the institutions that are responsible for migration management in our countries and exchange best practices in order to provide efficient and adequate care to migrants and access to protection for refugees.
Promoting Stability and Assistance for Communities of Destination, Origin, Transit, and Return
We affirm that countries of origin and countries and communities hosting large numbers of migrants and refugees may need international financing and assistance related to development, basic humanitarian needs, protection, security, public health, education, financial inclusion, and employment, among others. We support efforts that allow all migrants, refugees, asylum seekers, and persons in situations of vulnerability to integrate into host countries and access legal identity, regular status, dignified employment, public services, and international protection, when appropriate and in accordance with national legislation, to rebuild their lives and contribute to those communities. We plan to continue efforts to prevent and reduce statelessness. We intend to expand efforts to address the root causes of irregular migration throughout our hemisphere, improving conditions and opportunities in countries of origin and promoting respect for human rights. We reaffirm the importance of safe, dignified, and sustainable return, readmission, and reintegration of migrants to help them reestablish themselves in their communities of origin. We further reaffirm the importance of ensuring all foreign nationals receive prompt consular assistance when needed or requested, and returnees are treated humanely and in a dignified manner, regardless of their immigration status, including in the process of their repatriation and return.
Promoting Regular Pathways for Migration and International Protection
We affirm that regular pathways, including circular and seasonal labor migration opportunities, family reunification, temporary migration mechanisms, and regularization programs promote safer and more orderly migration. We intend to strengthen fair labor migration opportunities in the region, integrating robust safeguards to ensure ethical recruitment and employment free of exploitation, violence, and discrimination, consistent with respect for human rights and with a gender perspective. We intend to promote, in accordance with national legislation, the recognition of qualifications and the portability of social benefits. We intend to pursue accountability for those who commit human rights violations and abuses. We plan to promote access to protection and complementary pathways for asylum seekers, refugees, and stateless persons in accordance with national legislation and with respect for the principle of non-refoulement. We seek to promote border security and management processes that respect human rights and encourage and facilitate lawful, safe, and secure travel within the region. We commit to guarantee human rights to individuals in vulnerable situations and to provide access to international protection, as appropriate. We further intend to provide specialized and gender-responsive attention to individuals in situations of vulnerability.
Promoting Humane Migration Management
Renewing our commitment to respect and ensure the human rights of all migrants and persons in need of international protection, we recognize each country's responsibility to manage mixed movements across international borders in a secure, humane, orderly, and regular manner. We intend to expand collaborative efforts to save lives, address violence and discrimination, counter xenophobia, and combat smuggling of migrants and trafficking in persons. This includes expanded collaboration to prosecute migrant smuggling and human trafficking criminal organizations as well as their facilitators and money laundering networks. We commit to provide appropriate protection and assistance to victimized individuals. We intend, in accordance with national legislation, to improve and facilitate regional law enforcement information sharing, with the purpose of supporting the investigation and prosecution of crimes. We intend to explore new mechanisms, while preserving and leveraging existing regional, subregional, hemispheric, and global fora, to strengthen cooperation on border management and apply current mechanisms on visa regimes and regularization processes to combat exploitation by criminal groups. In the instance of foreign nationals without a need for international protection and without a legal basis to remain in their country of presence, we commit to conduct any returns in a manner consistent with our respective obligations under international human rights law and international refugee law, and that respects the dignity of the individual, integrates safeguards to prevent refoulement, and promotes the return of children to safe conditions.
Promoting a Coordinated Emergency Response
Recognizing the imperative of promoting safe, orderly, and regular migration, and the safety of migrants, refugees, and asylum seekers in the region, we intend to work to cooperate in emergency response and humanitarian assistance in situations of mass migration and refugee movements. We plan to strengthen existing regional coordination mechanisms and, as appropriate, the participation of civil society and international organizations to advance those aims. This includes strengthening information sharing, as appropriate and in accordance with national legislation, enhancing early warning systems, leveraging existing relevant fora and processes, and defining a common set of triggers that activate a coordinated response.
A Shared Approach to Reduce and Manage Irregular Migration
To advance the common goals laid out in this Declaration and create the conditions for safe, orderly, humane, and regular migration through robust responsibility sharing, we intend to work together across the hemisphere to:
Convene multilateral development banks, international financial institutions, and traditional and non-traditional donors to review financial support instruments for countries hosting migrant populations and facing other migration challenges, without prejudice to existing financing priorities and programs. Improve regional cooperation mechanisms for law enforcement cooperation, information sharing, protection-sensitive border management, visa regimes, and regularization processes, as appropriate and in accordance with national legislation.Strengthen and expand temporary labor migration pathways, as feasible, that benefit countries across the region, including through new programs promoting connections between employers and migrant workers, robust safeguards for ethical recruitment, and legal protections for workers' rights. Improve access to public and private services for all migrants, refugees, and stateless persons to promote their full social and economic inclusion in host communities.Expand access to regular pathways for migrants and refugees to include family reunification options where appropriate and feasible, in accordance with national legislation.This Declaration builds upon existing efforts and international commitments and advances the vision set forth in the Global Compact on Refugees and the Global Compact for Safe, Orderly and Regular Migration (GCM) anchored in the 2030 Agenda for Sustainable Development. We acknowledge the progress noted in the International Migration Review Forum Progress Declaration for the GCM. We affirm the fundamental work that continues under the Comprehensive Regional Protection and Solutions Framework (MIRPS), the Regional Conference on Migration (RCM), and the South American Conference on Migration (SACM), as key regional bodies to facilitate the implementation of this Declaration, as well as the Quito Process and the Regional Inter-agency Coordination Platform for refugees and migrants from Venezuela. The United Nations 1951 Refugee Convention; its 1967 Protocol; the Convention against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment; the Geneva Conventions of 1949 and International Humanitarian Law; the United Nations Convention against Transnational Organized Crime; its Protocol to Prevent, Suppress and Punish Trafficking in Persons, especially Women and Children; its Protocol against the Smuggling of Migrants by Land, Sea and Air; the United Nations Convention on the Rights of the Child; the International Convention on the Protection of the Rights of all Migrant Workers and Members of their Families; as well as other international conventions, remain binding on Parties to those conventions that endorse this Declaration. This Declaration aligns with States' commitments in the International Labour Organization's Declaration on Fundamental Principles and Rights at Work and its General Principles and Operational Guidelines for Fair Recruitment. We reiterate the importance and meaning of the principle of non-refoulement as a cornerstone of the international protection of refugees. We applaud efforts throughout the region to provide a coordinated and comprehensive response to all migrants, returnees, refugees, asylum seekers, and stateless persons. We make this Declaration of non-legally binding commitments to enhance cooperation and shared responsibilities on managing migration and protection in ways grounded in human rights, transparency, nondiscrimination, and State sovereignty.
###
Declaration of North America (DNA) | The White House
Wed, 11 Jan 2023 23:13
Today, President Andr(C)s Manuel L"pez Obrador, President Joseph R. Biden, and Prime Minister Justin Trudeau met in Mexico City for the 10th North American Leaders' Summit (NALS). The leaders are determined to fortify our region's security, prosperity, sustainability and inclusiveness through commitments across six pillars: 1) diversity, equity, and inclusion; 2) climate change and the environment; 3) competitiveness; 4) migration and development; 5) health; and 6) regional security.
North America shares a unique history and culture that emphasizes innovation, equitable development, and mutually beneficial trade to create inclusive economic opportunities for the benefit of our people. We are not just neighbors and partners. Our people share bonds of family and friendship and value '' above all else '' freedom, justice, human rights, equality, and democracy. This is the North American DNA.
Diversity, Equity, and Inclusion
Diversity, equity, and inclusion is foundational to the strength, vibrancy, and resilience of our countries. We focus on providing marginalized communities opportunities for their full, equal, and meaningful participation in our democracies and economies. To advance these objectives, President L"pez Obrador, President Biden, and Prime Minister Trudeau reiterated their joint commitment to protect civil rights, promote racial justice, expand protections for LGBTQI+ individuals and deliver more equitable outcomes to all.
In partnership with Indigenous Peoples, we will promote innovative and sustainable solutions that honor traditional knowledge, foster Indigenous-led growth and drive job creation. We will continue our cooperation to build societies where Indigenous women and girls can live, learn, and lead without fear through the Trilateral Working Group on Violence Against Indigenous Women and Girls. Indigenous women from all three countries will convene in the coming weeks to facilitate discussions about priorities and best practices including in areas of political, economic, and social development. The three countries also reaffirm our commitment to gender equality and empowerment of women and girls, in all their diversity by aiming to improve financial and political support for women's and girl's rights.
Climate Change and Environment
Mexico, the United States, and Canada recognize the critical nature of taking rapid and coordinated measures to tackle the climate crisis and respond to its consequences. This includes achieving our respective 2030 nationally determined contributions under the Paris Agreement, and working together and with other countries to keep a 1.5-degree C temperature limit within reach. To promote buy-in for ambitious cuts to emissions, we will come together to align approaches on estimating the social cost of greenhouse gas emissions.
We will continue to implement and build on commitments from the 2021 North American Leaders' Summit on climate mitigation, adaptation, and resilience, while renewing our focus on reducing methane emissions from all sources, with a new focus on waste methane. We will explore standards to develop hydrogen as a regional source of clean energy. We will move swiftly to accelerate the energy transition by deploying clean energy solutions, increasing the production and adoption of zero-emission vehicles in North America and transitioning to cleaner fuels. In partnership with Indigenous Peoples, we reiterate our pledge to protect biodiversity, to work toward ending deforestation, and doing our part to conserve 30 percent of the world's land and waters by 2030.
Competitiveness
We seek to deepen our regional capacity to attract high quality investment, spur innovation, and strengthen the resilience of our economies, recognizing the benefits brought by the United States-Mexico-Canada Agreement. To boost regional competitiveness, the three countries will seek to forge stronger regional supply chains, as well as promote targeted investment, in key industries of the future such as semiconductors and electric vehicle batteries, which will be critical to advance electric vehicle development and infrastructure. We will convene public-private dialogues and map out supply chains to address common challenges and opportunities.
Critical minerals are an essential component to accelerating North America's clean energy transition. Each country will review and map out existing and potential reserves of critical mineral resources in the region, while taking care of the environment, respecting local communities, and adhering to high ethical standards.
To support innovation, job creation, and workforce development, the three governments commit to working with the private sector, civil society, labor and academia across North America to foster high-tech entrepreneurship, promote small and medium-sized enterprises, and strengthen technical education. We will also consider trilateral approaches to promote sustainable, inclusive jobs and develop the workforce to meet our climate commitments.
Migration and Development
Today marks the six-month anniversary of the Los Angeles Declaration on Migration and Protection, a bold new framework for regional responsibility-sharing that 21 leaders endorsed on the margins of the Ninth Summit of the Americas. The three countries of North America each made ambitious commitments under the Los Angeles Declaration, including working together to advance labor mobility in North America, particularly regarding regular pathways, and have been delivering on these commitments.
Since June, Mexico, the United States and Canada have collectively welcomed record numbers of migrants and refugees from the Western Hemisphere under new and expanded labor and humanitarian programs. Today, we affirm our joint commitment to safe, orderly, and humane migration under the Los Angeles Declaration and other relevant multilateral frameworks. This includes assisting host communities and promoting migrant and refugee integration; providing protection to refugees, asylum seekers, and vulnerable migrants; strengthening asylum capacity in the region; expanding and promoting regular pathways for migration and protection; addressing the root causes and impacts of irregular migration and forced displacement; and collaborating to counter xenophobia and discrimination against migrants and refugees.
Now more than ever, we need to identify and address the root causes of irregular migration and forced displacement. Mexico, the United States, and Canada commit to supporting countries across the Western Hemisphere to create the conditions to improve quality of life, especially in marginalized communities that are vulnerable to both forced internal and regional migration and displacement. To that end, we will continue to work together and with our respective private sectors to promote responsible business practices, implement obligations under the USMCA and international labor conventions, and cooperate to eradicate the use of forced and child labor in our supply chains.
Health
Trilateral health cooperation will focus on launching an updated North American Plan for Animal and Pandemic Influenza (NAPAPI) to improve prevention, preparedness, agility, and to provide rapid response to health emergencies in North America. The North American Health Security Working Group will develop and launch a new, revised NAPAPI as a flexible, scalable, and cross-sectoral platform to strengthen regional prevention, preparedness and response to a broader range of health security threats that include influenza and beyond. As we emerge from the acute phase of the COVID-19 pandemic, we also recognize that resilient health systems, including a strong health workforce, are the foundation upon which effective pandemic preparedness and response will be built. We will continue efforts to build stronger and more resilient health systems that meet the broad range of health needs in our countries.
Regional Security
Mexico, the United States, and Canada will focus on strategies to bolster our shared continental security against domestic, regional, and global threats, including cyber threats. Security cooperation will continue to abide by our common understanding that respect for human rights and the rule of law contribute to a more secure North America. Our security cooperation includes actions to disrupt criminal actors and associated crimes across our shared borders, including money laundering, child sexual exploitation, firearms and human trafficking. We also are taking a consistent approach to the collection, use, processing, retention, and protection of Passenger Name Record (PNR) data to strengthen our shared security perimeter and the safety of our citizens, including advocating for the global adoption of standards and recommended practices of the International Civil Aviation Organization on PNR data.
We will continue our North American Drug Dialogue and further advance our cooperative international efforts to address the growing global synthetic drug threat as the United States takes the chair in 2023. We will enhance trilateral work to address the use of precursor chemicals in the production of illegal substances in North America and to disrupt drug trafficking, as well as strengthen public health approaches to prevention, harm reduction, treatment, and recovery.
As both natural and human-induced hazards and disasters increase risks to vulnerable populations, we will continue to work together to share training and best practices to keep our people safe and address emergencies including natural and other disasters. Recognizing the differentiated impact disasters have on women and girls, we aim to integrate a gender perspective in these efforts.
Looking forward
The commitments made during this summit are rooted in a shared vision for a more equitable, just, inclusive, resilient, secure, and prosperous North America and a shared responsibility to achieve more equitable outcomes responsive to the needs and aspirations of our citizens. As we work to implement these commitments in the upcoming year, we seek to model a democratic and sustainable path based on trust to promote inclusive prosperity and security. Mexico, the United States, and Canada look forward to building on this progress at the eleventh NALS (NALS XI), to be hosted by Canada.
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Leo Frank - Wikipedia
Wed, 11 Jan 2023 20:52
American factory superintendent and lynching victim
Leo Frank
BornLeo Max Frank
( 1884-04-17 ) April 17, 1884DiedAugust 17, 1915 (1915-08-17) (aged 31)Cause of deathLynchingResting placeNew Mount Carmel Cemetery, Glendale, New York 40°41'²34'"N 73°52'²52'"W >> / >> 40.69269°N 73.88115°W >> / 40.69269; -73.88115 >> ( Leo Frank's resting place ) EducationBachelor's degree in mechanical engineering (1906), pencil manufacturing apprenticeship (1908)Alma materCornell UniversityEmployer(s)National Pencil Company, Atlanta (1908''1915)Criminal chargeConvicted on August 25, 1913 for the murder of Mary PhaganCriminal penaltyDeath by hanging (1913); commuted to life imprisonment (1915)SpouseLucille Selig
(
m. 1910)
Leo Max Frank (April 17, 1884 '' August 17, 1915) was an American factory superintendent who was convicted in 1913 of the murder of a 13-year-old employee, Mary Phagan, in Atlanta, Georgia. His trial, conviction, and appeals attracted national attention. His lynching two years later, in response to the commutation of his death sentence, became the focus of social, regional, political, and racial concerns, particularly regarding antisemitism. Today, the consensus of researchers is that Frank was wrongly convicted and Jim Conley was likely the actual murderer.
Born to a Jewish-American family in Texas, Frank was raised in New York and earned a degree in mechanical engineering from Cornell University before moving to Atlanta in 1908. Marrying in 1910, he involved himself with the city's Jewish community and was elected president of the Atlanta chapter of the B'nai B'rith, a Jewish fraternal organization, in 1912. At that time, there were growing concerns regarding child labor at factories. One of these children was Mary Phagan, who worked at the National Pencil Company where Frank was director. The girl was strangled on April 26, 1913, and found dead in the factory's cellar the next morning. Two notes, made to look as if she had written them, were found beside her body. Based on the mention of a "night witch", they implicated the night watchman, Newt Lee. Over the course of their investigations, the police arrested several men, including Lee, Frank, and Jim Conley, a janitor at the factory.
On May 24, 1913, Frank was indicted on a charge of murder and the case opened at Fulton County Superior Court, July 28, 1913. The prosecution relied heavily on the testimony of Conley, who described himself as an accomplice in the aftermath of the murder, and who the defense at the trial argued was, in fact, the perpetrator of the murder. A guilty verdict was announced on August 25. Frank and his lawyers made a series of unsuccessful appeals; their final appeal to the Supreme Court of the United States failed in April 1915. Considering arguments from both sides as well as evidence not available at trial, Governor John M. Slaton commuted Frank's sentence from capital punishment to life imprisonment.
The case attracted national press attention and many reporters deemed the conviction a travesty. Within Georgia, this outside criticism fueled antisemitism and hatred toward Frank. On August 16, 1915, he was kidnapped from prison by a group of armed men, and lynched at Marietta, Mary Phagan's hometown, the next morning. The new governor vowed to punish the lynchers, who included prominent Marietta citizens, but nobody was charged. In 1986, Frank was posthumously pardoned by the Georgia State Board of Pardons and Paroles, although not officially absolved of the crime. The case has inspired books, movies, plays, and a TV miniseries.
His case spurred the creation of the Anti-Defamation League and the resurgence of the Ku Klux Klan.[1]
Background Social and economic conditions In the early 20th century, Atlanta, Georgia's capital city, underwent significant economic and social change. To serve a growing economy based on manufacturing and commerce, many people left the countryside to relocate in Atlanta.[2][3] Men from the traditional and paternalistic rural society felt it degrading that women were moving to the city to work in factories.[4]
During this era, Atlanta's rabbis and Jewish community leaders helped to resolve animosity toward Jews. In the half-century from 1895, David Marx was a prominent figure in the city. In order to aid assimilation, Marx's Reform temple adopted Americanized appearances. Friction developed between the city's German Jews, who were integrated, and Russian Jews who had recently immigrated. Marx said the new residents were "barbaric and ignorant" and believed their presence would create new antisemitic attitudes and a situation which made possible Frank's guilty verdict.[5] Despite their success, many Jews recognized themselves as different from the Gentile majority and were uncomfortable with their image.[n 1] Despite his own acceptance by Gentiles, Marx believed that "in isolated instances there is no prejudice entertained for the individual Jew, but there exists wide-spread and deep seated prejudice against Jews as an entire people."[7][n 2][n 3]
An example of the type of tension that Marx feared occurred in April 1913: at a conference on child labor, some participants blamed the problem, in part, on the fact that many factories were Jewish-owned.[9] Historian Leonard Dinnerstein summarized Atlanta's situation in 1913 as follows:
The pathological conditions in the city menaced the home, the state, the schools, the churches, and, in the words of a contemporary Southern sociologist, the 'wholesome industrial life.' The institutions of the city were obviously unfit to handle urban problems. Against this background, the murder of a young girl in 1913 triggered a violent reaction of mass aggression, hysteria, and prejudice.[10]
Early life Leo Max Frank was born in Cuero, Texas[11] on April 17, 1884 to Rudolph Frank and Rachel "Rae" Jacobs.[12] The family moved to Brooklyn in 1884 when Leo was three months old.[13] He attended New York City public schools and graduated from Pratt Institute in 1902. He then attended Cornell University, where he studied mechanical engineering. After graduating in 1906, he worked briefly as a draftsman and as a testing engineer.[14]
At the invitation of his uncle Moses Frank, Leo traveled to Atlanta for two weeks in late October 1907 to meet a delegation of investors for a position with the National Pencil Company, a manufacturing plant in which Moses was a major shareholder.[12] Frank accepted the position, and traveled to Germany to study pencil manufacturing at the Eberhard Faber pencil factory. After a nine-month apprenticeship, Frank returned to the United States and began working at the National Pencil Company in August 1908.[14] Frank became superintendent of the factory the following month, earning $180 per month plus a portion of the factory's profits.[15]
Frank was introduced to Lucille Selig shortly after he arrived in Atlanta.[16] She came from a prominent, upper-middle class Jewish family of industrialists who, two generations earlier, had founded the first synagogue in Atlanta.[n 4] They married in November 1910.[18] Frank described his married life as happy.[19]
In 1912, Frank was elected president of the Atlanta chapter of the B'nai B'rith, a Jewish fraternal organization.[20] The Jewish community in Atlanta was the largest in the Southern United States, and the Franks belonged to a cultured and philanthropic community whose leisure pursuits included opera and bridge.[21][22] Although the Southern United States was not specifically known for its antisemitism, Frank's northern culture and Jewish faith added to the sense that he was different.[23]
Murder of Mary Phagan Phagan's early life Mary Phagan was born on June 1, 1899, into an established Georgia family of tenant farmers.[24][25] Her father died before she was born. Shortly after Mary's birth, her mother, Frances Phagan, moved the family back to their hometown of Marietta, Georgia.[26] During or after 1907, they again relocated to East Point, Georgia, in southwest Atlanta, where Frances opened a boarding house.[27] Mary Phagan left school at age 10 to work part-time in a textile mill.[28] In 1912, after her mother married John William Coleman, the family moved into the city of Atlanta.[26] That spring, Phagan took a job with the National Pencil Company, where she earned ten cents an hour operating a knurling machine that inserted rubber erasers into the metal tips of pencils, and worked 55 hours per week.[28][n 5] She worked across the hallway from Leo Frank's office.[28][30]
Discovery of Phagan's body On April 21, 1913, Phagan was laid off due to a materials shortage.[29] Around noon on April 26, she went to the factory to claim her pay. The next day, shortly before 3:00 a.m., the factory's night watchman, Newt Lee, went to the factory basement to use the toilet.[31] After leaving the toilet, Lee discovered Phagan's body in the rear of the basement near an incinerator and called the police.
Her dress was up around her waist and a strip from her petticoat had been torn off and wrapped around her neck. Her face was blackened and scratched, and her head was bruised and battered. A 7-foot (2.1 m) strip of 1 ' 4 -inch (6.4 mm) wrapping cord was tied into a loop around her neck, buried 1 ' 4 in (6.4 mm) deep, showing that she had been strangled. Her underwear was still around her hips, but stained with blood and torn open. Her skin was covered with ashes and dirt from the floor, initially making it appear to first responding officers that she and her assailant had struggled in the basement.[32]
A service ramp at the rear of the basement led to a sliding door that opened into an alley; the police found the door had been tampered with so it could be opened without unlocking it. Later examination found bloody fingerprints on the door, as well as a metal pipe that had been used as a crowbar.[33] Some evidence at the crime scene was improperly handled by the police investigators: a trail in the dirt (from the elevator shaft) along which police believed Phagan had been dragged was trampled; the footprints were never identified.[34]
Two notes were found in a pile of rubbish by Phagan's head, and became known as the "murder notes". One said: "he said he wood love me land down play like the night witch did it but that long tall black negro did boy his slef." The other said, "mam that negro hire down here did this i went to make water and he push me down that hole a long tall negro black that hoo it wase long sleam tall negro i write while play with me." The phrase "night witch" was thought to mean "night watch[man]"; when the notes were initially read aloud, Lee, who was black, said: "Boss, it looks like they are trying to lay it on me."[n 6] Lee was arrested that morning based on these notes and his apparent familiarity with the body '' he stated that the girl was white, when the police, because of the filth and darkness in the basement, initially thought she was black. A trail leading back to the elevator suggested to police that the body had been moved by Lee.[36][37]
Police investigation One of the two murder notes found near the body
In addition to Lee, the police arrested a friend of Phagan's for the crime.[38] Gradually, the police became convinced that these were not the culprits. By Monday, the police had theorized that the murder occurred on the second floor (the same as Frank's office) based on hair found on a lathe and what appeared to be blood on the ground of the second floor.[39]
Both Newt Lee, after the discovery of Phagan's body, and the police, just after 4 a.m., had unsuccessfully tried to telephone Frank early on Sunday, April 27.[40] The police contacted him later that morning and he agreed to accompany them to the factory.[41] When the police arrived after 7 a.m. without telling the specifics of what happened at the factory, Frank seemed extremely nervous, trembling, and pale; his voice was hoarse, and he was rubbing his hands and asking questions before the police could answer. Frank said he was not familiar with the name Mary Phagan and would need to check his payroll book. The detectives took Frank to the morgue to see Phagan's body and then to the factory, where Frank viewed the crime scene and walked the police through the entire building. Frank returned home about 10:45 a.m. At this point, Frank was not considered a suspect.[42]
On Monday, April 28, Frank, accompanied by his attorney, Luther Rosser, gave a written deposition to the police that provided a brief timeline of his activities on Saturday. He said Phagan was in his office between 12:05 and 12:10 p.m., that Lee had arrived at 4 p.m. but was asked to return later, and that Frank had a confrontation with ex-employee James Gantt at 6 p.m. as Frank was leaving and Lee arriving. Frank explained that Lee's time card for Sunday morning had several gaps (Lee was supposed to punch in every half-hour) that Frank had missed when he discussed the time card with police on Sunday. At Rosser's insistence, Frank exposed his body to demonstrate that he had no cuts or injuries and the police found no blood on the suit that Frank said he had worn on Saturday. The police found no blood stains on the laundry at Frank's house.[43]
Frank then met with his assistant, N. V. Darley, and Harry Scott of the Pinkerton National Detective Agency, whom Frank hired to investigate the case and prove his innocence.[44] The Pinkerton detectives would investigate many leads, ranging from crime scene evidence to allegations of sexual misconduct on the part of Frank. The Pinkertons were required to submit duplicates of all evidence to the police, including any that hurt Frank's case. Unbeknownst to Frank, however, was Scott's close ties with the police, particularly his best friend, detective John Black who believed in Frank's guilt from the outset.[n 7]
On Tuesday, April 29, Black went to Lee's residence at 11 a.m. looking for evidence, and found a blood-smeared shirt at the bottom of a burn barrel.[46] The blood was smeared high up on the armpits and the shirt smelled unused, suggesting to the police that it was a plant. The detectives, suspicious of Frank due to his nervous behavior throughout his interviews, believed that Frank had arranged the plant.[47]
Frank was subsequently arrested around 11:30 a.m. at the factory. Steve Oney states that "no single development had persuaded ... [the police] that Leo Frank had murdered Mary Phagan. Instead, to the cumulative weight of Sunday's suspicions and Monday's misgivings had been added several last factors that tipped the scale against the superintendent."[48] These factors were the dropped charges against two suspects; the rejection of rumors that Phagan had been seen on the streets, making Frank the last person to admit seeing Phagan; Frank's meeting with the Pinkertons; and a "shifting view of Newt Lee's role in the affair."[49] The police were convinced Lee was involved as Frank's accomplice and that Frank was trying to implicate him. To bolster their case, the police staged a confrontation between Lee and Frank while both were still in custody; there were conflicting accounts of this meeting, but the police interpreted it as further implicating Frank.[50]
On Wednesday, April 30, a coroner's inquest was held. Frank testified about his activities on Saturday and other witnesses produced corroboration. A young man said that Phagan had complained to him about Frank. Several former employees spoke of Frank flirting with other women; one said she was actually propositioned. The detectives admitted that "they so far had obtained no conclusive evidence or clues in the baffling mystery ...". Lee and Frank were both ordered to be detained.[51]
In May, the detective William J. Burns traveled to Atlanta to offer further assistance in the case.[52] However, his Burns Agency withdrew from the case later that month. C. W. Tobie, a detective from the Chicago affiliate who was assigned to the case, said that the agency "came down here to investigate a murder case, not to engage in petty politic[s]."[53] The agency quickly became disillusioned with the many societal implications of the case, most notably the notion that Frank was able to evade prosecution due to his being a rich Jew, buying off the police and paying for private detectives.[54]
James "Jim" Conley The prosecution based much of its case on the testimony of Jim Conley, the factory's janitor, who is believed by many historians to be the actual murderer.[n 8] The police had arrested Conley on May 1 after he had been seen washing red stains out of a blue work shirt; detectives examined it for blood, but determined that it was rust as Conley had claimed, and returned it.[57] Conley was still in police custody two weeks later when he gave his first formal statement. He said that, on the day of the murder, he had been visiting saloons, shooting dice, and drinking. His story was called into question when a witness told detectives that "a black negro ... dressed in dark blue clothing and hat" had been seen in the lobby of the factory on the day of the murder. Further investigation determined that Conley could read and write,[58] and there were similarities in his spelling with that found on the murder notes. On May 24, he admitted he had written the notes, swearing that Frank had called him to his office the day before the murder and told him to write them.[59] After testing Conley again on his spelling '' he spelled "night watchman" as "night witch" '' the police were convinced he had written the notes. They were skeptical about the rest of his story, not only because it implied premeditation by Frank, but also because it suggested that Frank had confessed to Conley and involved him.[60]
In a new affidavit (his second affidavit and third statement), Conley admitted he had lied about his Friday meeting with Frank. He said he had met Frank on the street on Saturday, and was told to follow him to the factory. Frank told him to hide in a wardrobe to avoid being seen by two women who were visiting Frank in his office. He said Frank dictated the murder notes for him to write, gave him cigarettes, then told him to leave the factory. Afterward, Conley said he went out drinking and saw a movie. He said he did not learn of the murder until he went to work on Monday.[61]
The police were satisfied with the new story, and both The Atlanta Journal and The Atlanta Georgian gave the story front-page coverage. Three officials of the pencil company were not convinced and said so to the Journal. They contended that Conley had followed another employee into the building, intending to rob her, but found Phagan was an easier target.[61] The police placed little credence in the officials' theory, but had no explanation for the failure to locate Phagan's purse that other witnesses had testified she carried that day.[62] They were also concerned that Conley did not mention that he was aware a crime had been committed when he wrote the notes, suggesting Frank had simply dictated the notes to Conley arbitrarily. To resolve their doubts, the police attempted on May 28 to arrange a confrontation between Frank and Conley. Frank exercised his right not to meet without his attorney, who was out of town. The police were quoted in The Atlanta Constitution saying that this refusal was an indication of Frank's guilt, and the meeting never took place.[63]
On May 29, Conley was interviewed for four hours.[64][65] His new affidavit said that Frank told him, "he had picked up a girl back there and let her fall and that her head hit against something." Conley said he and Frank took the body to the basement via the elevator, then returned to Frank's office where the murder notes were dictated. Conley then hid in the wardrobe after the two had returned to the office. He said Frank gave him $200, but took it back, saying, "Let me have that and I will make it all right with you Monday if I live and nothing happens." Conley's affidavit concluded, "The reason I have not told this before is I thought Mr. Frank would get out and help me out and I decided to tell the whole truth about this matter."[66] At trial, Conley changed his story concerning the $200. He said Frank decided to withhold the money until Conley had burned Phagan's body in the basement furnace.[67]
The Georgian hired William Manning Smith to represent Conley for $40. Smith was known for specializing in representing black clients, and had successfully defended a black man against an accusation of rape by a white woman. He had also taken an elderly black woman's civil case as far as the Georgia Supreme Court. Although Smith believed Conley had told the truth in his final affidavit, he became concerned that Conley was giving long jailhouse interviews with crowds of reporters. Smith was also anxious about reporters from the Hearst papers, who had taken Frank's side. He arranged for Conley to be moved to a different jail, and severed his own relationship with the Georgian.[68]
On February 24, 1914, Conley was sentenced to a year in jail for being an accomplice after the fact to the murder of Mary Phagan.[69]
Media coverage The Atlanta Georgian headline on April 29, 1913, showing that the police suspected Frank and Newt Lee.
The Atlanta Constitution broke the story of the murder and was soon in competition with The Atlanta Journal and The Atlanta Georgian. Forty extra editions came out the day Phagan's murder was reported. The Atlanta Georgian published a doctored morgue photo of Phagan, in which her head was shown spliced onto the body of another girl, and ran headlines "Says Women Overheard Conley Confess" and "Says Women Heard Conley Confess" on July 12.[70] The papers offered a total of $1,800 in reward money for information leading to the apprehension of the murderer.[71] Soon after the murder, Atlanta's mayor criticized the police for their steady release of information to the public. The governor, noting the reaction of the public to press sensationalism soon after Lee's and Frank's arrests, organized ten militia companies in case they were needed to repulse mob action against the prisoners.[72] Coverage of the case in the local press continued nearly unabated throughout the investigation, trial, and subsequent appeal process.
Newspaper reports throughout the period combined real evidence, unsubstantiated rumors, and journalistic speculation. Dinnerstein wrote, "Characterized by innuendo, misrepresentation, and distortion, the yellow journalism account of Mary Phagan's death aroused an anxious city, and within a few days, a shocked state."[73] Different segments of the population focused on different aspects. Atlanta's working class saw Frank as "a defiler of young girls", while the German-Jewish community saw him as "an exemplary man and loyal husband."[74] Albert Lindemann, author of The Jew Accused, opined that "ordinary people" may have had difficulty evaluating the often unreliable information and in "suspend[ing] judgment over a long period of time" while the case developed.[75] As the press shaped public opinion, much of the public's attention was directed at the police and the prosecution, whom they expected to bring Phagan's killer to justice. The prosecutor, Hugh Dorsey, had recently lost two high-profile murder cases; one state newspaper wrote that "another defeat, and in a case where the feeling was so intense, would have been, in all likelihood, the end of Mr. Dorsey, as solicitor."[76]
Trial The courtroom on July 28, 1913. Dorsey is examining witness Newt Lee. Frank is in the center.
On May 23, 1913, a grand jury convened to hear evidence for an indictment against Leo Frank for the murder of Mary Phagan. The prosecutor, Hugh Dorsey, presented only enough information to obtain the indictment, assuring the jury that additional information would be provided during the trial. The next day, May 24, the jury voted for an indictment.[77] Meanwhile, Frank's legal team suggested to the media that Jim Conley was the actual killer, and put pressure on another grand jury to indict him. The jury foreman, on his own authority, convened the jury on July 21; on Dorsey's advice, they decided not to indict Conley.[78]
On July 28, the trial began at the Fulton County Superior Court (old city hall building). The judge, Leonard S. Roan, had been serving as a judge in Georgia since 1900.[79] The prosecution team was led by Dorsey and included William Smith (Conley's attorney and Dorsey's jury consultant). Frank was represented by a team of eight lawyers '' including jury selection specialists '' led by Luther Rosser, Reuben Arnold, and Herbert Haas.[80] In addition to the hundreds of spectators inside, a large crowd gathered outside to watch the trial through the windows. The defense, in their legal appeals, would later cite the crowds as factors in intimidation of the witnesses and jury.[81]
Both legal teams, in planning their trial strategy, considered the implications of trying a white man based on the testimony of a black man in front of an early 1900s Georgia jury. Jeffrey Melnick, author of Black-Jewish Relations on Trial: Leo Frank and Jim Conley in the New South, writes that the defense tried to picture Conley as "a new kind of African American '' anarchic, degraded, and dangerous."[82] Dorsey, however, pictured Conley as "a familiar type" of "old negro", like a minstrel or plantation worker.[82] Dorsey's strategy played on prejudices of the white 1900s Georgia observers, i.e., that a black man could not have been intelligent enough to make up a complicated story.[83] The prosecution argued that Conley's statement explaining the immediate aftermath of the murder was true, that Frank was the murderer, and that Frank had dictated the murder notes to Conley in an effort to pin the crime on Newt Lee, the night watchman.[84]
The prosecution presented witnesses who testified to bloodstains and strands of hair found on the lathe, to support their theory that the murder occurred on the factory's second floor in the machine room near Frank's office.[84][85] The defense denied that the murder occurred on the second floor. Both sides contested the significance of physical evidence that suggested the place of the murder. Material found around Phagan's neck was shown to be present throughout the factory. The prosecution interpreted the scene in the basement to support Conley's story '' that the body was carried there by elevator '' while the defense suggested that the drag marks on the floor indicated that Conley carried the body down a ladder and then dragged it across the floor.[86] The defense argued that Conley was the murderer and that Newt Lee helped Conley write the two murder notes. The defense brought many witnesses to support Frank's account of his movements, which indicated he did not have enough time to commit the crime.[87][88][89]
The defense, to support their theory that Conley murdered Phagan in a robbery, focused on Phagan's missing purse. Conley claimed in court that he saw Frank place the purse in his office safe, although he denied having seen the purse before the trial. Another witness testified that, on the Monday after the murder, the safe was open and there was no purse in it.[90] The significance of Phagan's torn pay envelope was disputed by both sides.[91]
Frank's alleged sexual behavior The prosecution focused on Frank's alleged sexual behavior.[n 9] They alleged that Frank, with Conley's assistance, regularly met with women in his office for sexual relations. On the day of the murder, Conley said he saw Phagan go upstairs, from where he heard a scream coming shortly after. He then said he dozed off; when he woke up, Frank called him upstairs and showed him Phagan's body, admitting that he had hurt her. Conley repeated statements from his affidavits that he and Frank took Phagan's body to the basement via the elevator, before returning in the elevator to the office where Frank dictated the murder notes.[93][94]
Conley was cross-examined by the defense for 16 hours over three days, but the defense failed to break his story. The defense then moved to have Conley's entire testimony concerning the alleged rendezvous stricken from the record. Judge Roan noted that an early objection might have been upheld, but since the jury could not forget what it had heard, he allowed the evidence to stand.[95][96] The prosecution, to support Frank's alleged expectation of a visit from Phagan, produced Helen Ferguson, a factory worker who first informed Phagan's parents of her death.[97] Ferguson testified that she had tried to get Phagan's pay on Friday from Frank, but was told that Phagan would have to come in person. Both the person behind the pay window and the woman behind Ferguson in the pay line disputed this version of events, testifying that in accordance with his normal practice, Frank did not disburse pay that day.[98]
The defense called a number of factory girls, who testified that they had never seen Frank flirting with or touching the girls, and that they considered him to be of good character.[99] In the prosecution's rebuttal, Dorsey called "a steady parade of former factory workers" to ask them the question, "Do you know Mr. Frank's character for lasciviousness?" The answers were usually "bad".[100]
Timeline The Atlanta Journal 's diagram of Jim Conley's account of the events after Phagan's murder
The prosecution realized early on that issues relating to time would be an essential part of its case.[101] At trial, each side presented witnesses to support their version of the timeline for the hours before and after the murder. The starting point was the time of death; the prosecution, relying on the analysis of stomach contents by their expert witness, argued that Phagan died between 12:00 and 12:15 p.m.
A prosecution witness, Monteen Stover, said she had gone into the office to get her paycheck, waiting there from 12:05 to 12:10, and did not see Frank in his office. The prosecution's theory was that Stover did not see Frank because he was at that time murdering Phagan in the metal room. Stover's account did not match Frank's initial account that he had not left the office between noon and 12:30.[102][103] Other testimony indicated that Phagan exited the trolley (or tram) between 12:07 and 12:10. From the stop it was a two- to four-minute walk, suggesting that Stover arrived first, making her testimony and its implications irrelevant: Frank could not be killing Phagan because at the time she had not yet arrived.[n 10][n 11]
Lemmie Quinn, foreman of the metal room, testified that he spoke briefly with Frank in his office at 12:20.[106] Frank had not mentioned Quinn when the police first interviewed him about his whereabouts at noontime on April 26. Frank had said at the coroner's inquest that Quinn arrived less than ten minutes after Phagan had left his office,[107] and during the murder trial said Quinn arrived hardly five minutes after Phagan left.[108] According to Conley and several experts called by the defense, it would have taken at least thirty minutes to murder Phagan, take the body to the basement, return to the office, and write the murder notes. By the defense's calculations, Frank's time was fully accounted for from 11:30 a.m. to 1:30 p.m., except for eighteen minutes between 12:02 and 12:20.[109][110] Hattie Hall, a stenographer, said at trial that Frank had specifically requested that she come in that Saturday and that Frank had been working in his office from 11:00 to nearly noon. The prosecution labeled Quinn's testimony as "a fraud" and reminded the jury that early in the police investigation Frank had not mentioned Quinn.[111]
Newt Lee, the night watchman, arrived at work shortly before 4:00 and Frank, who was normally calm, came bustling out of his office.[112] Frank told Lee that he had not yet finished his own work and asked Lee to return at 6:00.[113] Newt Lee noticed that Frank was very agitated and asked if he could sleep in the packing room, but Frank was insistent that Lee leave the building and told Lee to go out and have a good time in town before coming back.[114]
When Lee returned at 6:00, James Gantt had also arrived. Lee told police that Gantt, a former employee who had been fired by Frank after $2 was found missing from the cash box, wanted to look for two pairs of shoes he had left at the factory. Frank allowed Gantt in, although Lee said that Frank appeared to be upset by Gantt's appearance.[115] Frank arrived home at 6:25; at 7:00, he called Lee to determine if everything had gone all right with Gantt.[116]
Conviction and sentencing During the trial, the prosecution alleged bribery and witness tampering attempts by the Frank legal team.[117] Meanwhile, the defense requested a mistrial because it believed the jurors had been intimidated by the people inside and outside the courtroom, but the motion was denied.[n 12] Fearing for the safety of Frank and his lawyers in case of an acquittal, Roan and the defense agreed that neither Frank nor his defense attorneys would be present when the verdict was read.[n 13] On August 25, 1913, after less than four hours of deliberation, the jury reached a unanimous guilty verdict convicting Frank of murder.[n 14]
The Constitution described the scene as Dorsey emerged from the steps of city hall: "...three muscular men swung Mr. Dorsey, (the prosecuting attorney,) on their shoulders and passed him over the heads of the crowd across the street to his office. With hat raised and tears coursing down his cheeks, the victor in Georgia's most noted criminal battle was tumbled over a shrieking throng that wildly proclaimed its admiration."[122]
On August 26, the day after the guilty verdict was reached by the jury, Judge Roan brought counsel into private chambers and sentenced Leo Frank to death by hanging with the date set to October 10. The defense team issued a public protest, alleging that public opinion unconsciously influenced the jury to the prejudice of Frank.[123] This argument was carried forward throughout the appeal process.[124]
Appeals Under Georgia law at the time, appeals of death penalty cases had to be based on errors of law, not a re-evaluation of the evidence presented at trial.[125] The appeals process began with a reconsideration by the original trial judge. The defense presented a written appeal alleging 115 procedural problems. These included claims of jury prejudice, intimidation of the jury by the crowds outside the courthouse, the admission of Conley's testimony concerning Frank's alleged sexual perversions and activities, and the return of a verdict based on an improper weighing of the evidence. Both sides called forth witnesses involving the charges of prejudice and intimidation; while the defense relied on non-involved witness testimony, the prosecution found support from the testimony of the jurors themselves.[126] On October 31, 1913, Judge Roan denied the motion, adding, "I have thought about this case more than any other I have ever tried. With all the thought I have put on this case, I am not thoroughly convinced that Frank is guilty or innocent. But I do not have to be convinced. The jury was convinced. There is no room to doubt that."[127][128][129][130]
State appeals The next step, a hearing before the Georgia Supreme Court, was held on December 15. In addition to presenting the existing written record, each side was granted two hours for oral arguments. In addition to the old arguments, the defense focused on the reservations expressed by Judge Roan at the reconsideration hearing, citing six cases where new trials had been granted after the trial judge expressed misgivings about the jury verdict. The prosecution countered with arguments that the evidence convicting Frank was substantial and that listing Judge Roan's doubts in the defense's bill of exceptions was not the proper vehicle for "carry[ing] the views of the judge."[131][132] On February 17, 1914, in a 142-page decision, the court denied Frank a new trial by a 4''2 vote. The majority dismissed the allegations of bias by the jurors, saying the power of determining this rested strictly with the trial judge except when an "abuse of discretion" was proved. It also ruled that spectator influence could only be the basis of a new trial if ruled so by the trial judge. Conley's testimony on Frank's alleged sexual conduct was found to be admissible because, even though it suggested Frank had committed other crimes for which he was not charged, it made Conley's statements more credible and helped to explain Frank's motivation for committing the crime according to the majority. On Judge Roan's stated reservations, the court ruled that these did not trump his legal decision to deny a motion for a new trial.[132][133] The dissenting justices restricted their opinion to Conley's testimony, which they declared should not have been allowed to stand: "It is perfectly clear to us that evidence of prior bad acts of lasciviousness committed by the defendant ... did not tend to prove a preexisting design, system, plan, or scheme, directed toward making an assault upon the deceased or killing her to prevent its disclosure." They concluded that the evidence prejudiced Frank in the jurors' eyes and denied him a fair trial.[133][134]
The last hearing exhausted Frank's ordinary state appeal rights. On March 7, 1914, Frank's execution was set for April 17 of that year.[135] The defense continued to investigate the case and filed an extraordinary motion[n 15] before the Georgia Supreme Court. This appeal, which would be held before a single justice, Ben Hill, was restricted to raising facts not available at the original trial. The application for appeal resulted in a stay of execution and the hearing opened on April 23, 1914.[137] The defense successfully obtained a number of affidavits from witnesses repudiating their testimony. A state biologist said in a newspaper interview that his microscopic examination of the hair on the lathe shortly after the murder did not match Phagan's. At the same time that the various repudiations were leaked to the newspapers, the state was busy seeking repudiations of the new affidavits. An analysis of the murder notes, which had only been addressed in any detail in the closing arguments, suggested Conley composed them in the basement rather than writing what Frank told him to write in his office. Prison letters written by Conley to Annie Maude Carter were discovered; the defense then argued that these, along with Carter's testimony, implicated Conley was the actual murderer.[138][139]
The defense also raised a federal constitutional issue on whether Frank's absence from the court when the verdict was announced "constituted deprivation of the due process of law". Different attorneys were brought in to argue this point since Rosser and Arnold had acquiesced in Frank's absence. There was a debate between Rosser and Arnold on whether it should be raised at this time since its significance might be lost with all of the other evidence being presented. Louis Marshall, President of the American Jewish Committee and constitutional lawyer, urged them to raise the point, and the decision was made that it should be made clear that if the extraordinary motion was rejected they intended to appeal through the federal court system and there would be an impression of injustice in the trial.[140] For almost every issue presented by the defense, the state had a response: most of the repudiations were either retracted or disavowed by the witnesses; the question of whether outdated order pads used to write the murder notes had been in the basement before the murder was disputed; the integrity of the defense's investigators were questioned and intimidation and bribery were charged; and the significance of Conley's letters to Annie Carter was disputed.[141] The defense, in its rebuttal, tried to bolster the testimony relating to the murder notes and the Carter letters. (These issues were reexamined later when the governor considered commuting Frank's sentence.)[142] During the defense's closing argument, the issue of the repudiations was put to rest by Judge Hill's ruling that the court could only consider the revocation of testimony if the subject were tried and found guilty of perjury.[143] The judge denied Frank a new trial and the full court upheld the decision on November 14, 1914. The full court also said that the due process issue should have been raised earlier, characterizing what it considered a belated effort as "trifling with the court".[144][145]
Federal appeals The next step for the Frank team was to appeal the issue through the federal system. The original request for a writ of error on the absence of Frank from the jury's announcement of the verdict was first denied by Justice Joseph Rucker Lamar and then Justice Oliver Wendell Holmes Jr. Both denied the request because they agreed with the Georgia court that the issue was raised too late. The full Supreme Court then heard arguments, but denied the motion without issuing a written decision. However, Holmes said, "I very seriously doubt if the petitioner ... has had due process of law ... because of the trial taking place in the presence of a hostile demonstration and seemingly dangerous crowd, thought by the presiding Judge to be ready for violence unless a verdict of guilty was rendered."[146][147] Holmes's statement, as well as public indignation over this latest rejection by the courts, encouraged Frank's team to attempt a habeas corpus motion, arguing that the threat of crowd violence had forced Frank to be absent from the verdict hearing and constituted a violation of due process. Justice Lamar heard the motion and agreed that the full Supreme Court should hear the appeal.
On April 19, 1915, the Supreme Court denied the appeal by a 7''2 vote in the case Frank v. Mangum. Part of the decision repeated the message of the last decision: that Frank failed "to raise the objection in due season when fully cognizant of the fact."[148] Holmes and Charles Evans Hughes dissented, with Holmes writing, "It is our duty to declare lynch law as little valid when practiced by a regularly drawn jury as when administered by one elected by a mob intent on death."[149]
Commutation of sentence Hearing Governor John Slaton and wife
On April 22, 1915, an application for a commutation of Frank's death sentence was submitted to a three-person Prison Commission in Georgia; it was rejected on June 9 by a vote of 2''1. The dissenter indicated that he felt it was wrong to execute a man "on the testimony of an accomplice, when the circumstances of the crime tend to fix the guilt upon the accomplice."[150] The application then passed to Governor John Slaton. Slaton had been elected in 1912 and his term would end four days after Frank's scheduled execution. In 1913, before Phagan's murder, Slaton agreed to merge his law firm with that of Luther Rosser, who became Frank's lead attorney (Slaton was not directly involved in the original trial). After the commutation, popular Georgia politician Tom Watson attacked Slaton, often focusing on his partnership with Rosser as a conflict of interest.[151][152]
Slaton opened hearings on June 12. In addition to receiving presentations from both sides with new arguments and evidence, Slaton visited the crime scene and reviewed over 10,000 pages of documents. This included various letters, including one written by Judge Roan shortly before he died asking Slaton to correct his mistake.[153] Slaton also received more than 1,000 death threats. During the hearing, former Governor Joseph Brown warned Slaton, "In all frankness, if Your Excellency wishes to invoke lynch law in Georgia and destroy trial by jury, the way to do it is by retrying this case and reversing all the courts."[154][155][n 16][n 17] According to Tom Watson's biographer, C. Vann Woodward, "While the hearings of the petition to commute were in progress Watson sent a friend to the governor with the promise that if Slaton allowed Frank to hang, Watson would be his 'friend', which would result in his 'becoming United States senator and the master of Georgia politics for twenty years to come.'"[158]
Slaton produced a 29-page report. In the first part, he criticized outsiders who were unfamiliar with the evidence, especially the press in the North. He defended the trial court's decision, which he felt was sufficient for a guilty verdict. He summarized points of the state's case against Frank that "any reasonable person" would accept and said of Conley that "It is hard to conceive that any man's power of fabrication of minute details could reach that which Conley showed, unless it be the truth." After having made these points, Slaton's narrative changed course and asked the rhetorical question, "Did Conley speak the truth?"[159] Leonard Dinnerstein wrote, "Slaton based his opinions primarily upon the inconsistencies he had discovered in the narrative of Jim Conley."[160] Two factors stood out to Slaton: the transporting of the body to the basement and the murder notes.[161]
Transport of the body During the initial investigation, police had noted undisturbed human excrement in the elevator shaft, which Conley said he had left there before the murder. Use of the elevator on the Monday after the murder crushed the excrement, which Slaton concluded was an indication that the elevator could not have been used as described by Conley, casting doubt on his testimony.[n 18][n 19][n 20]
During the commutation hearing, Slaton asked Dorsey to address this issue. Dorsey said that the elevator did not always go all the way to the bottom and could be stopped anywhere. Frank's attorney rebutted this by quoting Conley, who said that the elevator stops when it hits the bottom. Slaton interviewed others and conducted his own tests on his visit to the factory, concluding that every time the elevator made the trip to the basement it touched the bottom. Slaton said, "If the elevator was not used by Conley and Frank in taking the body to the basement, then the explanation of Conley cannot be accepted."[164][n 21]
Murder notes The murder notes had been analyzed before at the extraordinary motion hearing. Handwriting expert Albert S. Osborn reviewed the previous evidence at the commutation hearing and commented, for the first time, that the notes were written in the third person rather than the first person. He said that the first person would have been more logical since they were intended to be the final statements of a dying Phagan. He argued this was the type of error that Conley would have made, rather than Frank, as Conley was a sweeper and not a Cornell-educated manager like Frank.[166]
Conley's former attorney, William Smith, had become convinced that his client had committed the murder. Smith produced a 100-page analysis of the notes for the defense. He analyzed "speech and writing patterns" and "spelling, grammar, repetition of adjectives, [and] favorite verb forms". He concluded, "In this article I show clearly that Conley did not tell the truth about those notes."[167] Slaton compared the murder notes, Conley's letters to Annie Maude Carter, and his trial testimony. Throughout these documents, he found similar use of the words "like", "play", "lay", "love", and "hisself". He also found double adjectives such as "long tall negro", "tall, slim build heavy man", and "good long wide piece of cord in his hands".[168]
Slaton was also convinced that the murder notes were written in the basement, not in Frank's office. Slaton accepted the defense's argument that the notes were written on dated order pads signed by a former employee that were only kept in the basement.[169] Slaton wrote that the employee signed an affidavit stating that, when he left the company in 1912, "he personally packed up all of the duplicate orders ... and sent them down to the basement to be burned. This evidence was never passed upon by the jury and developed since the trial."[170]
Timing and physical evidence Slaton's narrative touched on other aspects of the evidence and testimony that suggested reasonable doubt. For example, he accepted the defense's argument that charges by Conley of perversion were based on someone coaching him that Jews were circumcised. He accepted the defense's interpretation of the timeline;[171] citing the evidence produced at trial '' including the possibility that Stover did not see Frank because she did not proceed further than the outer office '' he wrote: "Therefore, Monteen Stover must have arrived before Mary Phagan, and while Monteen Stover was in the room it hardly seems possible under the evidence, that Mary Phagan was at that time being murdered."[172] Slaton also said that Phagan's head wound must have bled profusely, yet there was no blood found on the lathe, the ground nearby, in the elevator, or the steps leading downstairs. He also said that Phagan's nostrils and mouth were filled with dirt and sawdust which could only have come from the basement.[173]
Slaton also commented on Conley's story (that Conley was watching out for the arrival of a lady for Frank on the day of the murder):
His story necessarily bears the construction that Frank had an engagement with Mary Phagan which no evidence in the case would justify. If Frank had engaged Conley to watch for him, it could only have been for Mary Phagan, since he made no improper suggestion to any other female on that day, and it was undisputed that many did come up prior to 12.00 o'clock, and whom could Frank have been expecting except Mary Phagan under Conley's story. This view cannot be entertained, as an unjustifiable reflection on the young girl.[174]
Conclusion On Monday, June 21, 1915, Slaton released the order to commute Frank's murder conviction to life imprisonment. Slaton's legal rationale was that there was sufficient new evidence not available at the original trial to justify Frank's actions.[175] He wrote:
In the Frank case three matters have developed since the trial which did not come before the jury, to-wit: The Carter notes, the testimony of Becker, indicating the death notes were written in the basement, and the testimony of Dr. Harris, that he was under the impression that the hair on the lathe was not that of Mary Phagan, and thus tending to show that the crime was not committed on the floor of Frank's office. While defense made the subject an extraordinary for a new trial, it is well known that it is almost a practical impossibility to have a verdict set aside by this procedure.[176]
The commutation was headline news. Atlanta Mayor Jimmy Woodward remarked that "The larger part of the population believes Frank guilty and that the commutation was a mistake."[177] In response, Slaton invited the press to his home that afternoon, telling them:
All I ask is that the people of Georgia read my statement and consider calmly the reasons I have given for commuting Leo M. Frank's sentence. Feeling as I do about this case, I would be a murderer if I allowed that man to hang. I would rather be ploughing in a field than to feel for the rest of my life that I had that man's blood on my hands.[177]
He also told reporters that he was certain that Conley was the actual murderer.[177] Slaton privately told friends that he would have issued a full pardon, if not for his belief that Frank would soon be able to prove his own innocence.[n 22]
The public was outraged. A mob threatened to attack the governor at his home. A detachment of the Georgia National Guard, along with county policemen and a group of Slaton's friends who were sworn in as deputies, dispersed the mob.[179] Slaton had been a popular governor, but he and his wife left Georgia immediately thereafter.[180]
For Frank's protection, he was taken to the Milledgeville State Penitentiary in the middle of the night before the commutation was announced. The penitentiary was "strongly garrisoned and newly bristling with arms" and separated from Marietta by 150 miles (240 km) of mostly unpaved road.[181] However, on July 17, The New York Times reported that fellow inmate William Creen tried to kill Frank by slashing his throat with a 7-inch (18 cm) butcher knife, severing his jugular vein. The attacker told the authorities he "wanted to keep the other inmates safe from mob violence, Frank's presence was a disgrace to the prison, and he was sure he would be pardoned if he killed Frank."[182]
Antisemitism and media coverage Tom Watson, publisher of
Watson's Magazine and
The Jeffersonian, incited public opinion against Frank.
The sensationalism in the press started before the trial and continued throughout the trial, the appeals process, the commutation decision, and beyond.[n 23] At the time, local papers were the dominant source of information, but they were not entirely anti-Frank. The Constitution alone assumed Frank's guilt, while both the Georgian and the Journal would later comment about the public hysteria in Atlanta during the trial, each suggesting the need to reexamine the evidence against the defendant.[184] On March 14, 1914, while the extraordinary motion hearing was pending, the Journal called for a new trial, saying that to execute Frank based on the atmosphere both within and outside the courtroom would "amount to judicial murder." Other newspapers in the state followed suit and many ministers spoke from the pulpit supporting a new trial. L. O. Bricker, the pastor of the church attended by Phagan's family, said that based on "the awful tension of public feeling, it was next to impossible for a jury of our fellow human beings to have granted him a fair, fearless and impartial trial."[185][n 24]
On October 12, 1913, the New York Sun became the first major Northern paper to give a detailed account of the Frank trial. In discussing the charges of antisemitism in the trial, it described Atlanta as more liberal on the subject than any other Southern cities. It went on to say that antisemitism did arise during the trial as Atlantans reacted to statements attributed to Frank's Jewish supporters, who dismissed Phagan as "nothing but a factory girl". The paper said, "The anti-Semitic feeling was the natural result of the belief that the Jews had banded to free Frank, innocent or guilty. The supposed solidarity of the Jews for Frank, even if he was guilty, caused a Gentile solidarity against him."[187] On November 8, 1913, the executive committee of the American Jewish Committee, headed by Louis Marshall, addressed the Frank case. They did so following Judge Roan's reconsideration motion and motivated by the issues raised in the Sun. They chose not to take a public stance as a committee, instead deciding to raise funds individually to influence public opinion in favor of Frank.[187]
Albert Lasker, a wealthy advertising magnate, responded to these calls to help Frank. Lasker contributed personal funds and arranged a public relations effort in support of Frank. In Atlanta, during the time of the extraordinary motion, Lasker coordinated Frank's meetings with the press and coined the slogan "The Truth Is on the March" to characterize the efforts of Frank's defense team. He persuaded prominent figures such as Thomas Edison, Henry Ford, and Jane Addams to make statements supporting Frank.[188] During the commutation hearing, Vice President Thomas R. Marshall weighed in, as did many leading magazine and newspaper editors, including Herbert Croly, editor of the New Republic; C.P.J. Mooney, editor of the Chicago Tribune; Mark Sullivan, editor of Collier's; R. E. Stafford, editor of the Daily Oklahoman; and D. D. Moore, editor of the New Orleans Times-Picayune.[189] Adolph Ochs, publisher of The New York Times, became involved about the same time as Lasker, organizing a prolonged campaign advocating for a new trial for Frank.[n 25] Lindemann argues that the publicity campaign had a wide national reach:
Outside of Georgia, as the case gained national visibility, widespread sympathy for Frank was expressed. He received at final count close to a hundred thousand letters of sympathy in jail, and prominent figures throughout the country, including governors of other states, U.S. senators, clergymen, university presidents, and labor leaders, spoke up in his defense. Thousands of petitions in his favor, containing over a million signatures, flowed in.[191]
Both Ochs and Lasker attempted to heed Louis Marshall's warnings about antagonizing the "sensitiveness of the southern people and engender the feeling that the north is criticizing the courts and the people of Georgia." Dinnerstein writes that these attempts failed, "because many Georgians interpreted every item favorable to Frank as a hostile act."[192]
Tom Watson, editor of the Jeffersonian, had remained publicly silent during Frank's trial. Among Watson's political enemies was Senator Hoke Smith, former owner of The Atlanta Journal, which was still considered to be Smith's political instrument. When the Journal called for a reevaluation of the evidence against Frank, Watson, in the March 19, 1914 edition of his magazine, attacked Smith for trying "to bring the courts into disrepute, drag down the judges to the level of criminals, and destroy the confidence of the people in the orderly process of the law."[193] Watson also questioned whether Frank expected "extraordinary favors and immunities because of his race"[193] and questioned the wisdom of Jews to "risk the good name ... of the whole race" to save "the decadent offshoot of a great people."[194] Subsequent articles concentrated on the Frank case and became more and more impassioned in their attacks. C. Vann Woodward writes that Watson "pulled all the stops: Southern chivalry, sectional animus, race prejudice, class consciousness, agrarian resentment, state pride."[n 26]
When describing the public reaction to Frank, historians mention the class and ethnic tensions in play while acknowledging the complexity of the case and the difficulty in gauging the importance of his Jewishness, class, and northern background. Historian John Higham writes that "economic resentment, frustrated progressivism, and race consciousness combined to produce a classic case of lynch law. ... Hatred of organized wealth reaching into Georgia from outside became a hatred of Jewish wealth."[n 27] Historian Nancy MacLean writes that some historians have argued that this was an American Dreyfus affair, which she said "[could] be explained only in light of the social tensions unleashed by the growth of industry and cities in the turn-of-the-century South. These circumstances made a Jewish employer a more fitting scapegoat for disgruntled whites than the other leading suspect in the case, a black worker."[197] Albert Lindemann said that Frank on trial found himself "in a position of much latent tension and symbolism." Stating that it is impossible to determine the extent to which antisemitism affected his image, he concluded that "[Frank was seen as] a representative of Yankee capitalism in a southern city, with row upon row of southern women, often the daughters and wives of ruined farmers, 'at his mercy' '' a rich, punctilious, northern Jew lording it over vulnerable and impoverished working women."[n 28]
Abduction and lynching of Frank The June 21, 1915 commutation provoked Tom Watson into advocating Frank's lynching.[199] He wrote in The Jeffersonian and Watson's Magazine: "This country has nothing to fear from its rural communities. Lynch law is a good sign; it shows that a sense of justice lives among the people."[200][n 29] A group of prominent men organized themselves into the "Vigilance Committee" and openly planned to kidnap Frank from prison. They consisted of 28 men with various skills: an electrician was to cut the prison wires, car mechanics were to keep the cars running, and there was a locksmith, a telephone man, a medic, a hangman, and a lay preacher.[201] The ringleaders were well known locally but were not named publicly until June 2000, when a local librarian posted a list on the Web based on information compiled by Mary Phagan's great-niece, Mary Phagan Kean (b. 1953).[202] The list included Joseph Mackey Brown, former governor of Georgia; Eugene Herbert Clay, former mayor of Marietta and later president of the Georgia Senate; E. P. Dobbs, mayor of Marietta at the time; Moultrie McKinney Sessions, lawyer and banker; part of the Marietta delegation at Governor Slaton's clemency hearing;[203][n 30] several current and former Cobb County sheriffs; and other individuals of various professions.[204]
On the afternoon of August 16, the eight cars of the lynch mob left Marietta separately for Milledgeville. They arrived at the prison at around 10:00 p.m., and the electrician cut the telephone wires, members of the group drained the gas from the prison's automobiles, handcuffed the warden, seized Frank, and drove away. The 175-mile (282 km) trip took about seven hours at a top speed of 18 miles per hour (29 km/h) through small towns on back roads. Lookouts in the towns telephoned ahead to the next town as soon as they saw the line of cars pass by. A site at Frey's Gin, two miles (3 km) east of Marietta, had been prepared, complete with a rope and table supplied by former Sheriff William Frey.[205] The New York Times reported Frank was handcuffed, his legs tied at the ankles, and that he was hanged from a branch of a tree at around 7:00 a.m., facing the direction of the house where Phagan had lived.[206]
The Atlanta Journal wrote that a crowd of men, women, and children arrived on foot, in cars, and on horses, and that souvenir hunters cut away parts of his shirt sleeves.[207] According to The New York Times, one of the onlookers, Robert E. Lee Howell '' related to Clark Howell, editor of The Atlanta Constitution '' wanted to have the body cut into pieces and burned, and began to run around, screaming, whipping up the mob. Judge Newt Morris tried to restore order, and asked for a vote on whether the body should be returned to the parents intact; only Howell disagreed. When the body was cut down, Howell started stamping on Frank's face and chest; Morris quickly placed the body in a basket, and he and his driver John Stephens Wood drove it out of Marietta.[206][208]
Leo Frank's lynching on the morning of August 17, 1915. Judge Morris, who organized the crowd after the lynching, is on the far right in a straw hat.
[209][n 31]In Atlanta, thousands besieged the undertaker's parlor, demanding to see the body; after they began throwing bricks, they were allowed to file past the corpse.[206] Frank's body was then transported by rail on Southern Railway's train No. 36 from Atlanta to New York and buried in the Mount Carmel Cemetery in Glendale, Queens, New York on August 20, 1915.[210] (When Lucille Frank died, she was not buried with Leo; she was cremated, and eventually buried next to her parents' graves.)[211] The New York Times wrote that the vast majority of Cobb County believed he had received his "just deserts", and that the lynch mob had simply stepped in to uphold the law after Governor Slaton arbitrarily set it aside.[206] A Cobb County grand jury was convened to indict the lynchers; although they were well known locally, none were identified, and some of the lynchers may have served on the very same grand jury that was investigating them.[211][212] Nat Harris, the newly elected governor who succeeded Slaton, promised to punish the mob, issuing a $1,500 state reward for information. Despite this, Charles Willis Thompson of The New York Times said that the citizens of Marietta "would die rather than reveal their knowledge or even their suspicion [of the identities of the lynchers]", and the local Macon Telegraph said, "Doubtless they can be apprehended '' doubtful they will."[213]
Several photographs were taken of the lynching, which were published and sold as postcards in local stores for 25 cents each; also sold were pieces of the rope, Frank's nightshirt, and branches from the tree. According to Elaine Marie Alphin, author of An Unspeakable Crime: The Prosecution and Persecution of Leo Frank, they were selling so fast that the police announced that sellers would require a city license.[214] In the postcards, members of the lynch mob or crowd can be seen posing in front of the body, one of them holding a portable camera. Historian Amy Louise Wood writes that local newspapers did not publish the photographs because it would have been too controversial, given that the lynch mob can be clearly seen and that the lynching was being condemned around the country. The Columbia State, which opposed the lynching, wrote: "The heroic Marietta lynchers are too modest to give their photographs to the newspapers." Wood also writes that a news film of the lynching that included the photographs was released, although it focused on the crowds without showing Frank's body; its showing was prevented by censorship boards around the U.S., though Wood says there is no evidence that it was stopped in Atlanta.[215][n 32]
After the trial The lynching of Frank and its publicity temporarily halted lynchings.[216]
Leo Frank's case was mentioned by Adolf Kraus when he announced the creation of the Anti-Defamation League in October 1913.[217][218] After Frank's lynching, around half of Georgia's 3,000 Jews left the state.[219] According to author Steve Oney, "What it did to Southern Jews can't be discounted ... It drove them into a state of denial about their Judaism. They became even more assimilated, anti-Israel, Episcopalian. The Temple did away with chupahs at weddings '' anything that would draw attention."[220] Many American Jews saw Frank as an American Alfred Dreyfus, like Frank, a victim of antisemitic persecution.[221]
Two weeks after the lynching, in the September 2, 1915 issue of The Jeffersonian, Watson wrote, "the voice of the people is the voice of God",[222] capitalizing on his sensational coverage of the controversial trial. In 1914, when Watson began reporting his anti-Frank message, The Jeffersonian's circulation had been 25,000; by September 2, 1915, its circulation was 87,000.[223]
The consensus of researchers on the subject is that Frank was wrongly convicted.[n 33][n 34] The Atlanta Constitution stated it was investigating the case again in the 1940s. A reporter who visited Frank's widow (she never remarried), Lucille, stated that she started crying when he discussed the case with her.[211]
Jeffrey Melnick wrote, "There is near unanimity around the idea that Frank was most certainly innocent of the crime of murdering Mary Phagan."[226] Other historians and journalists have written that the trial was "a miscarriage of justice" and "a gross injustice",[n 35] "a mockery of justice",[n 36] that "there can be no doubt, of course, that ... [Frank was] innocent",[n 37] that "Leo Frank ... was unjustly and wrongly convicted of murder",[229] that he "was falsely convicted",[n 38] and that "the evidence against Frank was shaky, to say the least".[231] C. Vann Woodward, like many other authors,[n 39] believed that Conley was the actual murderer and was "implicated by evidence overwhelmingly more incriminating than any produced against Frank."[56]
Critics cite a number of problems with the conviction. Local newspaper coverage, even before Frank was officially charged, was deemed to be inaccurate and prejudicial.[n 40] Some claimed that the prosecutor Hugh Dorsey was under pressure for a quick conviction because of recent unsolved murders and made a premature decision that Frank was guilty, a decision that his personal ambition would not allow him to reconsider.[n 41] Later analysis of evidence, primarily by Governor Slaton and Conley's attorney William Smith, seemed to exculpate Frank while implicating Conley.[n 42]
Websites supporting the view that Frank was guilty of murdering Phagan emerged around the centennial of the Phagan murder in 2013.[244][245] The Anti-Defamation League issued a press release condemning what it called "misleading websites" from "anti-Semites ... to promote anti-Jewish views".[246]
Applications for posthumous pardon Historical marker where Frank was hanged. The marker mentions Frank's posthumous pardon in 1986.
First attempt In 1982, Alonzo Mann, who had been Frank's office boy at the time of Phagan's murder, told The Tennessean that he had seen Jim Conley alone shortly after noon carrying Phagan's body through the lobby toward the ladder descending into the basement.[247] Though Mann's testimony was not sufficient to settle the issue, it was the basis of an attempt by Charles Wittenstein, Southern counsel for the Anti-Defamation League, and Dale Schwartz, an Atlanta lawyer, to obtain a posthumous pardon for Frank from the Georgia State Board of Pardons and Paroles. The board also reviewed the files from Slaton's commutation decision.[248] It denied the pardon in 1983, hindered in its investigation by the lack of available records. It concluded that, "After exhaustive review and many hours of deliberation, it is impossible to decide conclusively the guilt or innocence of Leo M. Frank. For the board to grant a pardon, the innocence of the subject must be shown conclusively."[249] At the time, the lead editorial in The Atlanta Constitution began, "Leo Frank has been lynched a second time."[250]
Second attempt Frank supporters submitted a second application for pardon, asking the state only to recognize its culpability over his death. The board granted the pardon in 1986.[249] It said:
Without attempting to address the question of guilt or innocence, and in recognition of the State's failure to protect the person of Leo M. Frank and thereby preserve his opportunity for continued legal appeal of his conviction, and in recognition of the State's failure to bring his killers to justice, and as an effort to heal old wounds, the State Board of Pardons and Paroles, in compliance with its Constitutional and statutory authority, hereby grants to Leo M. Frank a Pardon.[251]
In response to the pardon, an editorial by Fred Grimm in the Miami Herald said, "A salve for one of the South's most hateful, festering memories, was finally applied."[252]
Historical marker In 2008, a state historical marker was erected by the Georgia Historical Society, the Jewish American Society for Historic Preservation, and Temple Kol Emeth, near the building at 1200 Roswell Road, Marietta where Frank was lynched.[253] In 2015, the Georgia Historical Society, the Atlanta History Center, and the Jewish American Society for Historic Preservation dedicated a Georgia Historical Society marker honoring Governor John M. Slaton at the Atlanta History Center.[254]
Anti-lynching memorial National Anti-Lynching Memorial sited at the Leo Frank Memorial, Marietta, Ga.
In 2018, The Jewish American Society for Historic Preservation, with support from the ADL, and Rabbi Steve Lebow of Temple Kol Emeth, placed the first national anti-lynching memorial at the Georgia Department of Transportation designated Leo Frank memorial site. The anti-lynching memorial was facilitated by a strong letter of support to the Georgia Department of Transportation by the late Congressman John Lewis when the Department turned down siting permission.[255] The text of the anti-lynching memorial text reads, "In Respectful Memory of the Thousands Across America, Denied Justice by Lynching; Victims of Hatred, Prejudice and Ignorance. Between 1880-1946, ~570 Georgians Were Lynched."[256][257]
Conviction Integrity Unit In 2019, Fulton County District Attorney Paul Howard founded an eight-member panel called the Conviction Integrity Unit to investigate the cases of Wayne Williams and Frank.[258] The board will re-examine the cases and make recommendations to Howard on whether they should be re-adjudicated.
In popular culture During the trial, the Atlanta musician and millworker Fiddlin' John Carson wrote and performed a murder ballad entitled "Little Mary Phagan". During the mill strikes of 1914, Carson sang "Little Mary Phagan" to crowds from the Fulton County courthouse steps. His daughter, Moonshine Kate, later recorded the song.[259] An unrecorded Carson song, "Dear Old Oak in Georgia", sentimentalizes the tree from which Leo Frank was hanged.[260]
The Frank case has been the subject of several media adaptations. In 1921, African-American director Oscar Micheaux directed a silent race film entitled The Gunsaulus Mystery, followed by Murder in Harlem in 1935.[261] In 1937, Mervyn LeRoy directed They Won't Forget, based on the Ward Greene novel Death in The Deep South, which was in turn inspired by the Frank case.[262] An episode of the 1964 TV series Profiles in Courage dramatized Governor John M. Slaton's decision to commute Frank's sentence. The episode starred Walter Matthau as Governor Slaton and Michael Constantine as Tom Watson.[263] The 1988 TV miniseries The Murder of Mary Phagan was broadcast on NBC, starring Jack Lemmon as Gov. John Slaton and also featuring Kevin Spacey.[264] The 1998 Broadway musical Parade, based on the case, won two Tony Awards.[265] In 2009, Ben Loeterman directed the documentary film The People v. Leo Frank.[266]
See also Blood libelBeilis affairAntisemitism in the United StatesLynching of Samuel BierfieldAbraham SuraskyReferences Informational notes
^ A 1900 Jewish newspaper in Atlanta wrote that "no one knows better than publishers of Jewish papers how widespread is this prejudice; but these publishers do not and will not tell what they know of the smooth talking Jew-haters, because it would widen the breech [sic] already existent."[6] ^ Dinnerstein wrote, "Men wore neither skullcaps nor prayer shawls, traditional Jewish holidays that the Orthodox celebrated on two days were observed by Marx and his followers for only one, and religious services were conducted on Sundays rather than on Saturdays."[7] ^ Lindemann writes, "As in the rest of the nation at this time, there were new sources of friction between Jews and Gentiles, and in truth the worries of the German-Jewish elite about the negative impact of the newly arriving eastern European Jews in the city were not without foundation."[8] ^ Levi Cohen, from her maternal lineage, had participated in founding the first synagogue in Atlanta.[17] ^ Oney writes, "Ordinarily, she was scheduled to work fifty-five hours. During the past six days, however, she'd been needed only for two abbreviated shifts. The sealed envelope awaiting her in her employer's office safe contained just $1.20."[29] ^ Lee said that these were his words in his evidence later at the trial.[35] ^ Oney writes: "Yet where Frank may have harbored a hidden agenda, Scott brought with him an undeniable conflict of interests...he was closely tied to the police. Private investigators operating in the city were required to submit duplicate copies of their reports to the department, even if the documents implicated a client. This much Scott would reveal to Frank. What he would not reveal, however, was that his allegiance to the force went deeper than the statutes required, that indeed, one of his best friends, someone with whom he often worked in tandem, was the individual who from the outset had believed Frank guilty: Detective John Black.[45] ^ For example: "The best evidence now available indicates that the real murderer of Mary Phagan was Jim Conley, perhaps because she, encountering him after she left Frank's office, refused to give him her pay envelope, and he, in a drunken stupor, killed her to get it."[55] "The city police, publicly committed to the theory of Frank's guilt, and hounded by the demand for a conviction, resorted to the basest methods in collecting evidence. A Negro suspect [Conley], later implicated by evidence overwhelmingly more incriminating than any produced against Frank, was thrust aside by the cry for the blood of the 'Jew Pervert.'"[56] ^ Lindemann indicates there was a developing stereotype of "wanton, young Jewish males who hungered for fair-haired Gentile women." A familiar stereotype in Europe, it reached Atlanta in the 1890s "with the arrival of eastern European Jews." "Fear of Jewish sexuality may have had a special explosiveness in Atlanta at this time because it could easily connect to a central myth, or cultural theme, in the South '' that of the pure, virtuous, yet vulnerable White woman."[92] ^ Both the motorman, W. M. Matthews, and the conductor, W. T. Hollis, testified that Phagan got off the trolley at 12:10. In addition, they both testified that Epps was not on the trolley. Epps said at trial that Phagan got off the trolley at 12:07. From the stop where Phagan exited the trolley, according to Atlanta police officer John N. Starnes, "It takes not over three minutes to walk from Marietta Street, at the corner of Forsyth, across the viaduct, and through Forsyth Street, down to the factory."[104] ^ Frank stated in his initial police deposition that Phagan "came in between 12:05 and 12:10, to get her pay envelope".[105] ^ In its motion for a mistrial, the defense presented examples of the crowd's behavior to the court.[118] ^ This was challenged as a violation of Frank's due process rights in Frank's appeal to the Georgia Supreme Court in November 1914,[119] and in his U.S. Supreme Court appeal, Frank v. Mangum (1915).[120] ^ The Atlanta Journal reported the next day that deliberation took less than two hours; at the first ballot one juror was undecided, but within two hours, the second vote was unanimous.[121] ^ Dinnerstein defines an "extraordinary motion" as a motion based on new information not available at the time of the trial. It was needed to continue through the appeals process because the ordinary procedures had been exhausted.[136] ^ The Roan letter was addressed to the pardons board but received by Rosser. It said, "I recommend executive clemency in the case of Leo. M. Frank. I wish today to recommend to you and the Governor to commute Frank's sentence to life imprisonment."[156] ^ Roan further wrote, "After many months of continued deliberation, I am still uncertain of Frank's guilt. The state of uncertainty is largely due to the character of the negro Conley's testimony, by which the verdict was evidently reached ... The execution of any person whose guilt has not been satisfactorily proved to the constituted authorities is too horrible to contemplate." Roan indicated a willingness to meet with the governor and the parole board, but died before he could do so.[157] ^ "Thus, Conley's elaborate testimony, which included using the elevator with Frank to take the body to the basement, was put into question."[162] ^ "Where in the past, Frank's lawyers had caught Conley in little lies, ones he blithely admitted, here, for the first time in an official forum, they had apparently caught him in a big lie, one that cast doubt on his entire testimony."[163] ^ "If one accepted the fact that the girl's body did not reach the basement via the elevator, then Conley's whole narrative fell apart, the Governor concluded."[160] ^ Quoting from Slaton's statement, "In addition, there was found in the elevator shaft at 3 o'clock Sunday morning, the parasol, which was unhurt, and a ball of cord which had not been mashed."[165] ^ "Privately, Slaton confided to friends that he believed Frank innocent and would have granted a full pardon if he were not convinced that in a short while the truth would come out and then 'the very men who were clamoring for Frank's life would be demanding a pardon for him.' The Governor knew certain 'facts' about the case, which he did not reveal at the time, corroborating the defense's theory of the way Conley had murdered Mary Phagan."[178] ^ The Georgian offered a $500 reward for information on the case, and produced several extras during the trial. Speaking on the impact of the reward money, Oney wrote, "In effect, the bounty served to deputize the entire city, and by late Monday, the officers working the case would be spending more time following dubious tips than developing legitimate leads."[183] ^ Bricker wrote in 1943, "My feelings, upon the arrest of the old negro nightwatchman, were to the effect that this one old negro would be poor atonement for the life of this innocent girl. But, when on the next day, the police arrested a Jew, and a Yankee Jew at that, all of the inborn prejudice against Jews rose up in a feeling of satisfaction, that here would be a victim worthy to pay for the crime."[186] ^ Oney writes, "December 1914 found the New York Times in the midst of an all-out drive of the sort it had never undertaken before. Only three days during the month did the paper not publish a major article on the Frank case. Some of its stories, particularly if there was a new development, strove for balance, but by and large, Ochs's sheet was more interested in disseminating propaganda than in practicing journalism."[190] ^ Among Watson's comments: "Here we have the typical young libertine Jew who is dreaded and detested by the city authorities of the North for the very reason that Jews of this type have an utter contempt for law, and a ravenous appetite for the forbidden fruit '' a lustful eagerness enhanced by the racial novelty of the girl of the uncircumcized."[195] ^ Higham places the incidents in Atlanta within the context of a wider national trend. The failure of progressives to solve national and international problems led to nativist displays "of hysteria and violence that had been rare or nonexistent since the 1890s."[196] ^ Lindemann wrote, "Even many Jews in Atlanta long remained doubtful about the importance of Frank's Jewishness in his arrest and conviction. They could hardly ignore the much-heightened tensions between Jew and non-Jew in the city as a result of the trial, as a result particularly of the widespread belief, after Frank's conviction, that the Jews were trying, through devious means, to arrange that a convicted murderer be freed."[198] ^ About two dozen people were lynched each year in Georgia; in 1915 the number was 22; see Oney p. 122. ^ For the list of alleged lynchers, see Donald E. Wilkes Jr. (May 5, 2004). "Steve Oney's List of the Leo Frank Lynchers". ^ The New York Times wrote at the time that, after the lynching, it was Morris who got the crowd under control; see "Grim Tragedy in Woods", The New York Times, August 19, 1915. Years later, he was identified as one of the ringleaders; see Alphin p. 117. ^ Wood writes that Kenneth Rogers, the head of photography at The Atlanta Constitution and The Atlanta Journal-Constitution between 1924 and 1972, had access to at least one of the photographs, leaving it in the Kenneth Rogers Papers at the Atlanta History Center. She assumes he got it from the newspapers' archives, though the newspapers did not publish it; they accompanied their stories instead with images of the woods near the hanging, and of the crowds who viewed Frank's body later in the funeral parlor; see Wood, pp. 106, 288, footnote 59. See Alphin p. 122 for details of the souvenir sales. ^ "The modern historical consensus, as exemplified in the Dinnerstein book, is that ... Leo Frank was an innocent man convicted at an unfair trial."[224] ^ "The consensus of historians is that the Frank case was a miscarriage of justice."[225] ^ Woodward wrote, "Outside the state the conviction was general that Frank was the victim of a gross injustice, if not completely innocent. He presented his own case so eloquently and so ingenuously, and the circumstance of the trial were such a glaring indication of a miscarriage of justice, that thousands of people enlisted in his cause."[227] ^ He wrote: "Ignoring all other evidence, especially that associated with a black janitor named Jim Conley, and focusing exclusively on Frank, prosecutors brought Leo Frank to trial in what can only be termed a mockery of justice."[228] ^ Watson '' In reviewing Lindemann's book he wrote, "Turning to his main theme, Lindemann provides a succinct and very scholarly account of the three cases he compares, Dreyfus, Beilis (in which a Jew was tried in Kiev in 1913), and Frank (in which a Jew was convicted of rape and murder in Atlanta, Georgia, in 1915). There can be no doubt, of course, that all three were innocent." ^ "That case, in which a Jewish manufacturer in Atlanta was falsely convicted of murdering a thirteen-year-old girl who worked for him, then lynched in 1915, reeked of anti-Semitism and was devastating to southern Jewry."[230] ^ Dan Carter, in a review of Oney's work, places his work within the context of previous works. "On the central issue he agrees with earlier researchers: Leo Frank did not murder Mary Phagan, and the evidence strongly suggests that Jim Conley did so." Other quotes include: "The best evidence now available indicates that the real murderer of Mary Phagan was Jim Conley, perhaps because she, encountering him after she left Frank's office, refused to give him her pay envelope, and he, in a drunken stupor, killed her to get it.";[232] "It seems certain, however, that the actual killer was James Conley ...";[233] "Conley was the likely solo killer";[234] "Many people, then and later, were of the opinion that Conley not only lied at the trial but that he himself was probably the murderer.";[235] "The much more concrete evidence against Conley was thrust aside as the public cried for the blood of the 'Jew pervert'."[236] ^ Early newspaper charges included a charge by a madam, Nina Formby, that Frank wanted her assistance in keeping a young girl on the night of the murder.[237] A private detective claimed to have seen Frank rendezvousing with a young girl in a wooded area in 1912.[238] Early reports of blood and hair samples in the office next to Frank's turned out to be suspect.[239] ^ It is alleged that Dorsey "suppressed evidence" favorable to Frank, intimidated and bribed witnesses, "drilled Conley in false testimony", "may have lacked the moral strength to back down" as contradictory evidence was uncovered, and feared that if he reversed himself he would have "ruined his career" and be accused of "having sold out to the Jews."[240] Dinnerstein writes on p. 19, "He had recently prosecuted two important accused murderers and had failed each time to convict them." A local newspaper said another failure would be "the end of Mr. Dorsey as solicitor."[241]"Among reporters, the consensus was that the Phagan prosecution represented nothing less than a last chance for him."[242] ^ Physical evidence suggested the murder occurred in the basement rather than upstairs (as claimed by Conley). Smith's analysis of the murder notes convinced him Conley composed them independently and were planted by Phagan's body as if she wrote them. Oney writes, "Slaton offered a legal rationale for commuting Frank's sentence to life imprisonment, asserting that contrary to the claims of those who opposed the action, there was sufficient new evidence not introduced at the trial ...".[243] Citations
^ "100 Years Since the Death of Leo Frank | Britannica". www.britannica.com. ^ Dinnerstein 1987, pp. 7''8. ^ MacLean p. 921. ^ Dinnerstein 1987, p. 10. ^ Lindemann p. 231. ^ Dinnerstein 1994, pp. 177''180. ^ a b Dinnerstein 1994, p. 181. ^ Lindemann p. 231. ^ Oney p. 7. ^ Dinnerstein 1987, p. 9. ^ Frey p. 19. ^ a b Oney p. 10. ^ Dinnerstein 1987, p. 5. ^ a b Frey p. 20. ^ Lindemann p. 251. ^ Oney p. 80. ^ The Selig Company Building '' Pioneer Neon Company. Marietta Street ARTery Association. ^ Oney p. 84. ^ Oney pp. 85, 483. ^ Oney p. 11. ^ Lawson pp. 211, 250. ^ Phagan Kean p. 111. ^ Alphin p. 26. ^ R. Barri Flowers (October 6, 2013). Murder at the Pencil Factory: The Killing of Mary Phagan 100 Years Later. True Crime. p. 8. ^ Phagan Kean p. 11. ^ a b Phagan Kean p. 14. ^ Phagan Kean pp. 12, 14. ^ a b c Oney p. 5. ^ a b Oney pp. 8''9. ^ Frey p. 5. ^ Oney p. 21. ^ Oney pp. 18''19. ^ Oney pp. 20''22. ^ Oney pp. 30''31. ^ Golden p. 162 ^ Golden pp. 19, 102. ^ Oney pp. 20''21, 379. ^ Oney pp. 61''62. ^ Oney pp. 46''47. ^ Oney p. 31. ^ Phagan Kean p. 76. ^ Oney pp. 27''32. ^ Oney pp. 48''51. ^ Oney p. 62. ^ Oney p. 62''63. ^ Oney p. 65. ^ Oney pp. 65''66. ^ Oney p. 61. ^ Oney pp. 63''64. ^ Oney pp. 69''70. ^ Dinnerstein 1987, pp. 16''17. ^ Oney p. 102. ^ Oney p. 112. ^ Oney p. 111. ^ Lindemann p. 254. ^ a b Woodward p. 435. ^ Oney p. 118. ^ Oney pp. 128''129. ^ Oney pp. 129''132. ^ Oney pp. 133''134. ^ a b Oney pp. 134''136. ^ Oney p. 3. ^ Oney pp. 137''138. ^ Oney p. 138. ^ Dinnerstein 1987, p. 24. ^ Oney pp. 139''140. ^ Oney p. 242. ^ Oney pp. 147''148. ^ Frey p. 132. ^ Saturday, July 12, 1913: "Final and Home Editions, respectively" "Says Women Heard Conley Confession". ^ Oney pp. 36, 60. ^ Dinnerstein 1987, p. 15. ^ Dinnerstein 1987, p. 14. ^ Oney pp. 74, 87''90. ^ Lindemann p. 249. ^ Dinnerstein 1987, p. 19. ^ Oney pp. 115''116, 236. ^ Oney pp. 178''188. ^ Leonard S. Roan, 1913''1914. Archived October 17, 2017, at the Wayback Machine Court of Appeals of the State of Georgia. ^ Oney p. 191. ^ Knight p. 189. ^ a b Melnick p. 41. ^ Gerald Ziedenberg (2012). Epic Trials in Jewish History. AuthorHouse. p. 59. ISBN 978-1-4772-7060-8. ^ a b Dinnerstein 1987, pp. 37, 58. ^ Oney p. 233. ^ Oney pp. 208''209, 231''232. ^ Golden pp. 118''139. ^ Phagan Kean p. 105. ^ Oney p. 205. ^ Oney pp. 197, 256, 264, 273. ^ Oney pp. 179, 225, 228. ^ Lindemann p. 239. ^ Oney pp. 241''243. ^ Dinnerstein 1987, pp. 40''41. ^ Dinnerstein 1987, pp. 45''47, 57. ^ Oney pp. 245''247, 252''253, 258''259, 265''266, 279. ^ Oney pp. 75''76. ^ Oney pp. 273, 280. ^ Oney pp. 295''296. ^ Oney pp. 309''311. ^ Oney p. 115. ^ Dinnerstein 1987, pp. 37''40. ^ Oney pp. 50, 100. ^ Dinnerstein 1987, p. 48; Oney pp. 50, 197, 266. ^ Lawson p. 242. ^ Oney pp. 278, 285. ^ Oney pp. 87, 285. ^ Lawson p. 226. ^ Dinnerstein 1987, p. 49. ^ Oney p. 359. ^ Oney p. 329. ^ Lawson pp. 182''183. ^ Dinnerstein 1987, p. 2. ^ Phagan Kean p. 70. ^ Oney pp. 47''48. ^ Oney pp. 50''51. ^ Phagan Kean p. 160. ^ Lawson pp. 398''399. ^ Lawson p. 410, fn. 2. ^ "Appellate Decisions in the Leo Frank Case". University of Missouri''Kansas City School of Law. Archived from the original on January 14, 2017 . Retrieved October 1, 2016 . ^ Lawson p. 407. ^ "Finds Mob Frenzy Convicted Frank." The New York Times, December 14, 1914. ^ Lawson p. 409. ^ Oney pp. 352''353. ^ Dinnerstein 1987, p. 77. ^ Dinnerstein 1987, pp. 77''78. ^ Oney p. 364. ^ Linder, Douglas. "New Evidence and Appeals," in The Trial of Leo Frank: An Account. ^ Dinnerstein 1987, p. 79. ^ Friedman pp. 1477''80 with footnotes 39''52. ^ Dinnerstein 1987, pp. 81, 163''165. ^ a b Oney pp. 369''370. ^ a b Dinnerstein 1987, pp. 81''82. ^ Oney p. 370. ^ Oney p. 377. ^ Dinnerstein 1987, p. 201 (fn 12). ^ Oney p. 395. ^ Dinnerstein 1987, pp. 84''90, 102''105. ^ Oney pp. 371''373, 378''380, 385''387, 389''390. ^ Dinnerstein 1987, pp. 90''91. ^ Oney pp. 403''416. ^ Oney pp. 416''417. ^ Oney p. 418. ^ Dinnerstein 1987, pp. 107''108. ^ Oney p. 446. ^ Freedman p. 56. ^ Dinnerstein 1987, p. 109. ^ Dinnerstein 1987, p. 110. ^ Oney p. 468. ^ Oney pp. 470, 473, 480''488. ^ Dinnerstein 1987, pp. 123''124. ^ Lindemann p. 270. ^ Oney pp. 489''499. ^ "Begin Last Frank Plea to Governor", The New York Times, June 13, 1915. ^ Dinnerstein 1987, p. 125. ^ Golden p. 262. ^ Oney pp. 469''479. ^ Woodward p. 440. ^ Oney pp. 499''500. ^ a b Dinnerstein 1987, p. 127. ^ Oney pp. 500''501. ^ Lindemann p. 269. ^ Oney p. 489. ^ Oney pp. 495''496, 501. ^ Golden pp. 266''267. ^ Oney p. 482. ^ Oney p. 483. ^ Oney p. 433. ^ Dinnerstein 1987, p. 128. ^ Golden pp. 267''269. ^ Oney p. 501. ^ Golden pp. 268''269. ^ Dinnerstein 1987, pp. 127''128. ^ Golden p. 348. ^ Oney p. 502. ^ Golden p. 352. ^ a b c Oney p. 503. ^ Dinnerstein 1987, pp. 129, 169''171. ^ John M. Slaton (1866''1955) Archived October 7, 2012, at the Wayback Machine, The New Georgia Encyclopedia. ^ "Slaton Here; Glad He Saved Frank", The New York Times, June 30, 1915. ^ Oney 2003, pp. 513''514. ^ For stories about the attack, see:"Leo Frank's Throat Cut by Convict; Famous Prisoner Near Death", The New York Times, July 18, 1915."Frank Survives Assassin's Knife", The New York Times, July 19, 1915."Frank's Assailant Before Governor", The New York Times, July 25, 1915."Frank's Head in Braces; Excessive Heat Delaying Recovery from Wound in Throat", The New York Times, August 2, 1915. ^ Oney p. 37. ^ Dinnerstein 1987, p. 31. ^ Oney pp. 381''382. ^ Dinnerstein 1987, p. 33. ^ a b Oney p. 366. ^ Oney pp. 367, 377''378, 388. ^ Oney p. 491. ^ Oney p. 457. ^ Albert S. Lindemann, Esau's tears : modern anti-semitism and the rise of the Jews, 1870-1933 (Cambridge University Press, 1997) p. 382. ^ Dinnerstein 1987, pp. 91''92. ^ a b Dinnerstein 1987, p. 97. ^ Oney p. 383. ^ Woodward pp. 437''439. ^ Higham p. 185. ^ MacLean p. 918. ^ Lindemann pp. 238''239. ^ Woodward p. 439. ^ Woodward p. 432. ^ Phagan Kean p. 223. ^ Emory University, Leo Frank Collection, Mary Phagan Kean's list of vigilance committee's members, Box 1, Folder 14. ^ Sawyer, Kathy (June 20, 2000). "A Lynching, a List and Reopened Wounds; Jewish Businessman's Murder Still Haunts Georgia Town". Washington Post. Archived from the original on December 15, 2017 . Retrieved August 13, 2016 . ^ Oney p. 527. ^ "Parties Unknown.", Boston Evening Transcript, August 24, 1915. ^ a b c d "Grim Tragedy in Woods". The New York Times, August 19, 1915. ^ "Leo Frank Forcibly Taken From Prison; He Is Hanged To A Tree Near Marietta; His Body Has Been Brought To Atlanta". The Atlanta Journal, August 17, 1915. In Beller, Miles; Cray, Ed; Kotler, Jonathan (eds.). American Datelines, p. 153. ^ For Slaton's role, see Dinnerstein 1987, pp. 123''134. Also see "GEORGIA: A Political Suicide". Time, January 24, 1955. (subscription required) For details of the lynching, see Coleman p. 292.Also see "Body Of Frank Is Found Dangling From A Tree Near The Phagan Home". Associated Press, August 17, 1915.For the souvenirs and violence, see Alphin p. 122. ^ "The lynching of Leo Frank". leofranklynchers.com. Archived from the original on August 15, 2000 . Retrieved August 22, 2010 . ^ Oney pp. 573''576. ^ a b c "Leo may have been killed, but she served a life sentence..." History Atlanta. February 8, 2020 . Retrieved June 25, 2020 . ^ Alphin p. 123. ^ Oney pp. 582''583. ^ Alphin p. 122. ^ Wood pp. 77, 106, 148. ^ "The Crime in Florida". The Gazette Times. Pittsburgh. August 21, 1916. p. 4. ^ Moore p. 108. ^ Chanes p. 105. ^ Theoharis and Cox p. 45. ^ Yarrow, Allison (May 13, 2009). "The People Revisit Leo Frank". Forward. ^ Oney p. 578. ^ Woodward p. 446. ^ Woodward p. 442. ^ Wilkes, Donald E Jr., Flagpole Magazine, "POLITICS, PREJUDICE, AND PERJURY", p. 9 (March 1, 2000). ^ Ravitz, Jessica (November 2, 2009). "Murder case, Leo Frank lynching". Cable News Network. Turner Broadcasting System, Inc. ^ Melnick p. 7. ^ Woodward p. 346. ^ Eakin p. 96. ^ Sorin, Gerald. AJS Review, Vol. 20, No. 2 (1995), pp. 441''447. ^ Scholnick, Myron L., The Journal of Southern History, Vol. 61, No. 4 (November 1995), pp. 860''861. ^ Friedman p. 1254. ^ Lindemann p. 254. ^ Dershowitz, Alan M. "America on Trial: Inside the Legal Battles That Transformed Our Nation" p. vii. ^ Arneson, Eric. "A Deadly Case of Southern Injustice". ^ Henig p. 167. ^ Moseley p. 44. ^ Moseley pp. 43''44. ^ Oney pp. 114''115. ^ Lindemann pp. 242''243. ^ Lindemann pp. 250, 252. ^ Dinnerstein 1987, pp. 19, 151, 154''155. ^ Oney pp. 94''95. ^ Oney pp. 427''455, 498''502. ^ "The Leo Frank Case Research Library". Leofrank.org. ^ "History". The American Mercury. Online version of a magazine founded by H. L. Mencken in 1924. Most articles in the History category are on the topic of Leo Frank. ^ "ADL: Anti-Semitism Around Leo Frank Case Flourishes on 100th Anniversary". Anti-Defamation League . Retrieved August 31, 2015 . ^ The Tennessean special news section, p. 15, in Dinnerstein 1987. ^ Oney p. 684. ^ a b Oney pp. 647''648. ^ Dinnerstein, Leonard (October 1996). "The Fate Of Leo Frank", American Heritage, Vol. 47, Issue 6. Retrieved May 15, 2011. ^ Dinnerstein, Leonard (May 14, 2003). "Leo Frank Case". New Georgia Encyclopedia. ^ Grimm, Fred (March 12, 1986). "Lynch-Mob Victim is Pardoned; Case Was Symbol of Anti-Semitism". The Miami Herald . Retrieved July 13, 2016 . ^ Leo Frank Lynching: Georgia Historical Society, The Georgia Historical Society. Retrieved October 28, 2014. ^ "Historical Marker Dedication: Gov. John M. Slaton (1866''1955)". Georgia Historical Society. June 17, 2015 . Retrieved July 27, 2015 . ^ "John Lewis, Leo Frank, and the National Anti-Lynching Memorial". ^ "The Story of Leo Frank Lives On". August 26, 2020. ^ Brasch, Ben. "Cobb's Leo Frank memorial site is getting a national lynching marker". The Atlanta Journal-Constitution. ^ Boone, Christian (May 7, 2019). "Fulton DA review board to re-examine Wayne Williams, Leo Frank cases". Atlanta Journal-Constitution . Retrieved May 18, 2019 . ^ "Little Mary Phagan". University of North Carolina . Retrieved July 26, 2015 . ^ Melnick p. 18. ^ " Matthew Bernstein. "Oscar Micheaux and Leo Frank: Cinematic Justice Across the Color Line". Film Quarterly. Summer 2004. Archived from the original on April 13, 2010. ^ Frank S. Nugent (July 15, 1937). "They Won't Forget (1937)". The New York Times. ^ "Profiles in Courage: Governor John M. Slaton (TV)". The Paley Center for Media . Retrieved December 11, 2016 . ^ "The Murder of Mary Phagan". Rotten Tomatoes . Retrieved December 11, 2016 . ^ "Winners: The American Theatre Wing's Tony Awards". Tony Award Productions . Retrieved May 18, 2019 . ^ "Leo Frank Film". Ben Loeterman Productions, Inc . Retrieved January 4, 2015 . Bibliography
Alphin, Elaine Marie. An Unspeakable Crime: The Prosecution and Persecution of Leo Frank. Carolrhoda Books, 2010. Google Books abridged version. Retrieved June 10, 2011. ISBN 978-0-8225-8944-0.Carter, Dan. "And the Dead Shall Rise: The Murder of Mary Phagan and the Lynching of Leo Frank". Journal of Southern History, Vol. 71, Issue 2 (May 2005), p. 491. DOI: 10.2307/27648797.Chanes, Jerome. "Who Does What?". In Maisel, Louis; Forman, Ira; Altschiller, Donald; Bassett, Charles. Jews in American Politics: Essays. Rowman & Littlefield, 2001. p. 105. ISBN 978-0-7425-0181-2.Coleman, Kenneth. A History of Georgia. University of Georgia Press, 1991. ISBN 978-0-8203-1269-9.Dinnerstein, Leonard. Antisemitism in America. Oxford University Press, 1994. Google Books abridged version. Retrieved June 5, 2016. ISBN 978-0-19-503780-7.Dinnerstein, Leonard. The Leo Frank Case. University of Georgia Press, 1987. ISBN 978-0-8203-3179-9.Eakin, Frank. What Price Prejudice?: Christian Antisemitism in America. Paulist Press, 1998. ISBN 978-0-8091-3822-7.Freedman, Eric. Habeas Corpus: Rethinking the Great Writ of Liberty. New York University Press, 2003. Retrieved August 23, 2014. ISBN 978-0-8147-2718-8.Frey, Robert Seitz; Thompson-Frey, Nancy. The Silent and the Damned: The Murder of Mary Phagan and the Lynching of Leo Frank. New York, New York: Cooper Square Press (of Rowman & Littlefield), 2002. Google Books abridged version. Retrieved June 17, 2015. ISBN 978-0-8154-1188-8.Friedman, Lawrence M. "Front Page: Notes on the Nature and Significance of Headline Trials". St. Louis University Law Journal, Vol. 55, Issue 4 (Summer 2011), pp. 1243''1284.Golden, Harry. A Little Girl is Dead. World Publishing Company, 1965. Retrieved June 25, 2011. (published in Great Britain as The Lynching of Leo Frank)Henig, Gerald. "'He Did Not Have a Fair Trial': California Progressives React to the Leo Frank Case". California History, Vol. 58, No. 2 (Summer 1979), pp. 166''178. DOI: 10.2307/25157909.Higham, John. Strangers in the Land: Patterns of American Nativism, 1860''1925. Rutgers University Press, 1988. ISBN 978-0-8135-1308-9.Knight, Alfred H. The Life of the Law. Oxford University Press, 1996. Google Books abridged version. ISBN 978-0-19-512239-8.Kranson, Rachel. "Rethinking the Historiography of American Antisemitism in the Wake of the Pittsburgh Shooting." American Jewish History 105.1 (2021): 247-253. summaryLawson, John Davison (ed.). American State Trials Volume X (1918), contains the abridged trial testimony and closing arguments starting on p. 182. Retrieved August 23, 2010.Lindemann, Albert S. The Jew Accused: Three Anti-Semitic Affairs (Dreyfus, Beilis, Frank), 1894''1915. Cambridge University Press, 1991. Google Books abridged version. Retrieved June 11, 2011. ISBN 978-0-521-40302-3.MacLean, Nancy. "The Leo Frank Case Reconsidered: Gender and Sexual Politics in the Making of Reactionary Populism". The Journal of American History, Vol. 78, No. 3 (December 1991), pp. 917''948. DOI: 10.2307/2078796.Melnick, Jeffrey Paul. Black-Jewish Relations on Trial: Leo Frank and Jim Conley in the New South. University Press of Mississippi, 2000. Google Books abridged version. ISBN 978-1-60473-595-6.Moore, Deborah. B'nai B'rith and the Challenge of Ethnic Leadership. State University of New York Press, 1981. ISBN 978-0-87395-480-8.Moseley, Clement Charlton. "The Case of Leo M. Frank, 1913''1915". The Georgia Historical Quarterly, Vol. 51, No. 1 (March 1967), pp. 42''62. (subscription required) Oney, Steve. And the Dead Shall Rise: The Murder of Mary Phagan and the Lynching of Leo Frank. Pantheon Books, 2003. ISBN 978-0-679-76423-6.Phagan Kean, Mary. The Murder of Little Mary Phagan. Horizon Press, 1987. ISBN 978-0-88282-039-2.Samuels, Charles; Samuels, Louise Night Fell on Georgia, Dell, 1956Theoharis, Athan; Cox, John Stuart. The Boss: J. Edgar Hoover and the Great American Inquisition. Temple University Press, 1988. ISBN 978-0-7881-5839-1.Watson, D. R. "Reviewed Works: Dreyfus: A Family Affair, 1789''1945 by Michael Burns; The Jew Accused: Three Anti-Semitic Affairs (Dreyfus, Beilis, Frank), 1894''1915 by Albert S. Lindemann". The Journal of Modern History, Vol. 66, No. 2 (June 1994), pp. 393''395. DOI: 10.1086/244854.Wood, Amy Louise. Lynching and Spectacle. The University of North Carolina Press, 2009. ISBN 978-0-8078-3254-7.Woodward, Comer Vann. Tom Watson: Agrarian Rebel. New York: Oxford University Press, 1963. Google Books abridged version.External links Wikimedia Commons has media related to
Leo Frank
.
Historical marker at the Old Marietta City Cemetery, Marietta, GeorgiaLeo Frank Clemency File Archived May 17, 2016, at the Wayback Machine from the Georgia ArchivesLeo Frank Exhibit from the Digital Library of GeorgiaLeo Frank Papers from the Digital Library of GeorgiaLeo M. Frank v. C. Wheeler Mangum, Sheriff of Fulton County, Georgia Writ of habeas corpus filed by FrankMultiple victims
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Evans, Eli | Encyclopedia.com
Wed, 11 Jan 2023 20:48
EVANS, ELI (1936'' ), U.S. administrator and Jewish historian. Evans was born in Durham, North Carolina, where his father served six terms as mayor from 1950 to 1962. His grandmother founded the first southern chapter of the Hadassah organization in the pre-World War i period.
After graduating from the University of North Carolina in 1958, he took a law degree at Yale University in 1963. He worked in various branches of government, state and national, as a speechwriter for President Lyndon Johnson, and as a White House assistant.
In 1973, he published The Provincials: A Personal History of Jews in the South. The book provided an insight into the Jewry of the southern United States, which had never been studied in depth previously. One of Evans' most revealing statistics was that more than 45 Jews held mayorships and other leading government positions in southern communities. The book generated a new field of study of southern Jewry.
Turning his focus to philanthropy, in 1977 Evans became the first president of the Revson Foundation, the charitable organization started by Charles Revson, the founder of Revlon. He guided the foundation in four specific areas: urban affairs, with special emphasis on New York City; education; bio-medical research policy; and Jewish philanthropy and education.
In the Jewish field, the foundation made a number of significant gifts. The first major grant helped to underwrite the ten-part television series Civilization and the Jews, narrated by Abba Eban. A second gift made possible the production of Sesame Street in Hebrew by Israel Education Television. A further large gift was allocated to the Jewish Museum, New York, for its remodeling and expansion to provide an electronics education center on all aspects of Judaism.
In 1988 Evans published a biography of the Civil War secretary of state Judah P. Benjamin: The Jewish Confederate. Evans mined previously untapped sources and demonstrated aspects of Benjamin's personality that reflected the continuing strain of his Judaism even though the well-known southerner did not practice his faith. In 1993 he published a collection of essays entitled The Lonely Days Were Sundays: Reflections of a Jewish Southerner.
Evans retired from the Revson Foundation in 2003. In 2004 the foundation honored its president emeritus with a substantial financial gift to the Carolina Center for Jewish Studies at the University of North Carolina at Chapel Hill to establish a program in Evans' name to support outreach activities on campus and in communities across North Carolina. The center, which was established at unc's College of Arts and Sciences in 2003, engages in teaching and research to explore Jewish history, culture, and religion in the United States and abroad. Involved with the center for Jewish studies since its inception, Evans serves as chairman of the advisory board.
Often referred to as "the poet laureate of southern Jews," Evans has served as the voice, as well as the heart and soul, of both his fellow southerners and fellow Americans.
[David Geffen /
Ruth Beloff (2nd ed.)]
We Shall Overcome - Wikipedia
Wed, 11 Jan 2023 20:35
Protest song of the civil rights movement
Joan Baez performs "We Shall Overcome" at the White House in front of President
Barack Obama, at a celebration of music from the period of the civil rights movement.
"We Shall Overcome" is a gospel song which became a protest song and a key anthem of the American civil rights movement. The song is most commonly attributed as being lyrically descended from "I'll Overcome Some Day", a hymn by Charles Albert Tindley that was first published in 1901.[1][2]
The modern version of the song was first said to have been sung by tobacco workers led by Lucille Simmons during the 1945''1946 Charleston Cigar Factory strike in Charleston, South Carolina. In 1947, the song was published under the title "We Will Overcome" in an edition of the People's Songs Bulletin (a publication of People's Songs, an organization of which Pete Seeger was the director), as a contribution of and with an introduction by Zilphia Horton, then-music director of the Highlander Folk School of Monteagle, Tennessee (an adult education school that trained union organizers). Horton said she had learned the song from Simmons, and she considered it to be her favorite song. According to Horton, "one of the stanzas of the original hymn was 'we will overcome'. ... It sort of stops them cold silent.'" [3]
She taught it to many others, including Pete Seeger,[4] who included it in his repertoire, as did many other activist singers, such as Frank Hamilton and Joe Glazer, who recorded it in 1950.
The song became associated with the civil rights movement from 1959, when Guy Carawan stepped in with his and Seeger's version as song leader at Highlander, which was then focused on nonviolent civil rights activism. It quickly became the movement's unofficial anthem. Seeger and other famous folksingers in the early 1960s, such as Joan Baez, sang the song at rallies, folk festivals, and concerts in the North and helped make it widely known. Since its rise to prominence, the song, and songs based on it, have been used in a variety of protests worldwide.
The U.S. copyright of the People's Songs Bulletin issue which contained "We Will Overcome" expired in 1976, but The Richmond Organization asserted a copyright on the "We Shall Overcome" lyrics, registered in 1960. In 2017, in response to a lawsuit against TRO over allegations of false copyright claims, a U.S. judge issued an opinion that the registered work was insufficiently different from the "We Will Overcome" lyrics that had fallen into the public domain because of non-renewal. In January 2018, the company agreed to a settlement under which it would no longer assert any copyright claims over the song.
Origins as gospel, folk, and labor song [ edit ] "I'll Overcome Some Day" was a hymn or gospel music composition by the Reverend Charles Albert Tindley of Philadelphia that was first published in 1901.[5] A noted minister of the Methodist Episcopal Church, Tindley was the author of approximately 50 gospel hymns, of which "We'll Understand It By and By" and "Stand By Me" are among the best known. The published text bore the epigraph, "Ye shall overcome if ye faint not", derived from Galatians 6:9: "And let us not be weary in doing good, for in due season we shall reap, if we faint not." The first stanza began:
The world is one great battlefield,With forces all arrayed;If in my heart I do not yield,I'll overcome some day.
Tindley's songs were written in an idiom rooted in African American folk traditions, using pentatonic intervals, with ample space allowed for improvised interpolation, the addition of "blue" thirds and sevenths, and frequently featuring short refrains in which the congregation could join.[6] Tindley's importance, however, was primarily as a lyricist and poet whose words spoke directly to the feelings of his audiences, many of whom had been freed from slavery only 36 years before he first published his songs, and were often impoverished, illiterate, and newly arrived in the North.[7] "Even today," wrote musicologist Horace Boyer in 1983, "ministers quote his texts in the midst of their sermons as if they were poems, as indeed they are."[8]
A letter printed on the front page of February 1909, United Mine Workers Journal states: "Last year at a strike, we opened every meeting with a prayer, and singing that good old song, 'We Will Overcome'." This statement implied that the song was well-known, and it was also the first acknowledgment of such a song having been sung in both a secular context and a mixed-race setting.[9][10][11]
Tindley's "I'll Overcome Some Day" was believed to have influenced the structure for "We Shall Overcome",[9] with both the text and the melody having undergone a process of alteration. The tune has been changed so that it now echoes the opening and closing melody of "No More Auction Block For Me",[12] also known from its refrain as "Many Thousands Gone".[13] This was number 35 in Thomas Wentworth Higginson's collection of Negro Spirituals that appeared in the Atlantic Monthly of June 1867, with a comment by Higginson reflecting on how such songs were composed (i.e., whether the work of a single author or through what used to be called "communal composition"):
Even of this last composition, however, we have only the approximate date and know nothing of the mode of composition. Allan Ramsay says of the Scots Songs, that, no matter who made them, they were soon attributed to the minister of the parish whence they sprang. And I always wondered, about these, whether they had always a conscious and definite origin in some leading mind, or whether they grew by gradual accretion, in an almost unconscious way. On this point, I could get no information, though I asked many questions, until at last, one day when I was being rowed across from Beaufort to Ladies' Island, I found myself, with delight, on the actual trail of a song. One of the oarsmen, a brisk young fellow, not a soldier, on being asked for his theory of the matter, dropped out a coy confession. "Some good spirituals," he said, "are start jess out o' curiosity. I been a-raise a sing, myself, once."
My dream was fulfilled, and I had traced out, not the poem alone, but the poet. I implored him to proceed.
"Once we boys," he said, "went for to tote some rice, and de nigger-driver, he keep a-calling on us; and I say, 'O, de ole nigger-driver!' Den another said, 'First thing my mammy told me was, notin' so bad as a nigger-driver.' Den I made a sing, just puttin' a word, and den another word."
Then he began singing, and the men, after listening a moment, joined in the chorus as if it were an old acquaintance, though they evidently had never heard it before. I saw how easily a new "sing" took root among them.[14]
Coincidentally, Bob Dylan claims that he used the very same melodic motif from "No More Auction Block" for his composition, "Blowin' in the Wind".[15] Thus similarities of melodic and rhythmic patterns imparted cultural and emotional resonance ("the same feeling") towards three different, and historically very significant songs.
Music scholars have also pointed out that the first half of "We Shall Overcome" bears a notable resemblance to the famous lay Catholic hymn "O Sanctissima", also known as "The Sicilian Mariners Hymn", first published by a London magazine in 1792 and then by an American magazine in 1794 and widely circulated in American hymnals.[16][17][18][19][20] The second half of "We Shall Overcome" is essentially the same music as the 19th-century hymn "I'll Be All Right".[21] As Victor Bobetsky summarized in his 2015 book on the subject: "'We Shall Overcome' owes its existence to many ancestors and to the constant change and adaptation that is typical of the folk music process."[16]
Role of the Highlander Folk School [ edit ] In October 1945 in Charleston, South Carolina, members of the Food, Tobacco, Agricultural, and Allied Workers union (FTA-CIO), who were mostly female and African American, began a five-month strike against the American Tobacco Company. To keep up their spirits during the cold, wet winter of 1945''1946, one of the strikers, a woman named Lucille Simmons, led a slow "long meter style" version of the gospel hymn, "We'll Overcome (I'll Be All Right)" to end each day's picketing. Union organizer Zilphia Horton, who was the wife of the co-founder of the Highlander Folk School (later Highlander Research and Education Center), said she learned it from Simmons. Horton was Highlander's music director during 1935''1956, and it became her custom to end group meetings each evening by leading this, her favorite song. During the presidential campaign of Henry A. Wallace, "We Will Overcome" was printed in Bulletin No. 3 (September 1948), 8, of People's Songs, with an introduction by Horton saying that she had learned it from the interracial FTA-CIO workers and had found it to be extremely powerful. Pete Seeger, a founding member of People's Songs and its director for three years, learned it from Horton's version in 1947.[22] Seeger writes: "I changed it to 'We shall'... I think I liked a more open sound; 'We will' has alliteration to it, but 'We shall' opens the mouth wider; the 'i' in 'will' is not an easy vowel to sing well ...."[4] Seeger also added some verses ("We'll walk hand in hand" and "The whole wide world around").
In 1950, the CIO's Department of Education and Research released the album, Eight New Songs for Labor, sung by Joe Glazer ("Labor's Troubador"), and the Elm City Four. (Songs on the album were: "I Ain't No Stranger Now", "Too Old to Work", "That's All", "Humblin' Back", "Shine on Me", "Great Day", "The Mill Was Made of Marble", and "We Will Overcome".) During a Southern CIO drive, Glazer taught the song to country singer Texas Bill Strength, who cut a version that was later picked up by 4-Star Records.[23]
The song made its first recorded appearance as "We Shall Overcome" (rather than "We Will Overcome") in 1952 on a disc recorded by Laura Duncan (soloist) and The Jewish Young Singers (chorus), conducted by Robert De Cormier, co-produced by Ernie Lieberman and Irwin Silber on Hootenany Records (Hoot 104-A) (Folkways, FN 2513, BCD15720), where it is identified as a Negro Spiritual.
Frank Hamilton, a folk singer from California who was a member of People's Songs and later The Weavers, picked up Seeger's version. Hamilton's friend and traveling companion, fellow-Californian Guy Carawan, learned the song from Hamilton. Carawan and Hamilton, accompanied by Ramblin Jack Elliot, visited Highlander in the early 1950s where they also would have heard Zilphia Horton sing the song. In 1957, Seeger sang for a Highlander audience that included Dr. Martin Luther King Jr., who remarked on the way to his next stop, in Kentucky, about how much the song had stuck with him. When, in 1959, Guy Carawan succeeded Horton as music director at Highlander, he reintroduced it at the school. It was the young (many of them teenagers) student-activists at Highlander, however, who gave the song the words and rhythms for which it is currently known, when they sang it to keep their spirits up during the frightening police raids on Highlander and their subsequent stays in jail in 1959''1960. Because of this, Carawan has been reluctant to claim credit for the song's widespread popularity. In the PBS video We Shall Overcome, Julian Bond credits Carawan with teaching and singing the song at the founding meeting of the Student Nonviolent Coordinating Committee in Raleigh, North Carolina, in 1960. From there, it spread orally and became an anthem of Southern African American labor union and civil rights activism.[24] Seeger has also publicly, in concert, credited Carawan with the primary role of teaching and popularizing the song within the civil rights movement.
Use in the 1960s civil rights and other protest movements [ edit ] In August 1963, 22-year old folksinger Joan Baez, led a crowd of 300,000 in singing "We Shall Overcome" at the Lincoln Memorial during A. Philip Randolph's March on Washington. President Lyndon Johnson, himself a Southerner, used the phrase "we shall overcome" in addressing Congress on March 15, 1965,[25] in a speech delivered after the violent "Bloody Sunday" attacks on civil rights demonstrators during the Selma to Montgomery marches, thus legitimizing the protest movement.
Four days before the April 4, 1968 assassination of Martin Luther King Jr., King recited the words from "We Shall Overcome" in his final sermon, delivered in Memphis on Sunday, March 31.[26] He had done so in a similar sermon delivered in 1965 before an interfaith congregation at Temple Israel in Hollywood, California:[27]
We shall overcome. We shall overcome. Deep in my heart I do believe we shall overcome. And I believe it because somehow the arc of the moral universe is long, but it bends towards justice. We shall overcome because Carlyle is right; "no lie can live forever". We shall overcome because William Cullen Bryant is right; "truth crushed to earth will rise again". We shall overcome because James Russell Lowell is right:
Truth forever on the scaffold, Wrong forever on the throne. Yet that scaffold sways the future, And behind the then unknown Standeth God within the shadow, Keeping watch above his own.
With this faith, we will be able to hew out of the mountain of despair a stone of hope. With this faith, we will be able to transform the jangling discords of our nation into a beautiful symphony of brotherhood. With this faith, we will be able to speed up the day. And in the words of prophecy, every valley shall be exalted. And every mountain and hill shall be made low. The rough places will be made plain and the crooked places straight. And the glory of the Lord shall be revealed and all flesh shall see it together. This will be a great day. This will be a marvelous hour. And at that moment'--figuratively speaking in biblical words'--the morning stars will sing together and the sons of God will shout for joy[28]
"We Shall Overcome" was sung days later by over fifty thousand attendees at the funeral of Martin Luther King Jr.[29]
Farmworkers in the United States later sang the song in Spanish during the strikes and grape boycotts of the late 1960s.[30] The song was notably sung by the U.S. Senator for New York Robert F. Kennedy, when he led anti-Apartheid crowds in choruses from the rooftop of his car while touring South Africa in 1966.[31] It was also the song which Abie Nathan chose to broadcast as the anthem of the Voice of Peace radio station on October 1, 1993, and as a result it found its way back to South Africa in the later years of the Anti-Apartheid Movement.[32]
The Northern Ireland Civil Rights Association adopted "we shall overcome" as a slogan and used it in the title of its retrospective publication, We Shall Overcome '' The History of the Struggle for Civil Rights in Northern Ireland 1968''1978.[33][34] The film Bloody Sunday depicts march leader and Member of Parliament (MP) Ivan Cooper leading the song shortly before 1972's Bloody Sunday shootings. In 1997, the Christian men's ministry, Promise Keepers featured the song on its worship CD for that year: The Making of a Godly Man, featuring worship leader Donn Thomas and the Maranatha! Promise Band. Bruce Springsteen's re-interpretation of the song was included on the 1998 tribute album Where Have All the Flowers Gone: The Songs of Pete Seeger as well as on Springsteen's 2006 album We Shall Overcome: The Seeger Sessions.
Widespread adaptation [ edit ] "We Shall Overcome" was adopted by various labor, nationalist, and political movements both during and after the Cold War. In his memoir about his years teaching English in Czechoslovakia after the Velvet Revolution, Mark Allen wrote:
In Prague in 1989, during the intense weeks of the Velvet Revolution, hundreds of thousands of people sang this haunting music in unison in Wenceslas Square, both in English and in Czech, with special emphasis on the phrase 'I do believe.' This song's message of hope gave protesters strength to carry on until the powers-that-be themselves finally gave up hope themselves.In the Prague of 1964, Seeger was stunned to find himself being whistled and booed by crowds of Czechs when he spoke out against the Vietnam War. But those same crowds had loved and adopted his rendition of 'We Shall Overcome.' History is full of such ironies '' if only you are willing to see them.
'--'‰
'Prague Symphony', Praha Publishing, 2008[35]The words "We shall overcome" are sung emphatically at the end of each verse in a song of Northern Ireland's civil rights movement, Free the People, which protested against the internment policy of the British Army. The movement in Northern Ireland was keen to emulate the movement in the US and often sang "We shall overcome".[36]
The melody was also used (crediting it to Tindley) in a symphony by American composer William Rowland.[citation needed ] In 1999, National Public Radio included "We Shall Overcome" on the "NPR 100" list of most important American songs of the 20th century.[37] As a reference to the line, on January 20, 2009, after the inauguration of Barack Obama as the 44th President of the United States, a man holding the banner, "WE HAVE OVERCOME" was seen near the Capitol, a day after hundreds of people posed with the sign on Martin Luther King Jr. Day.[38]
As the attempted serial killer "Lasermannen" shot several immigrants around Stockholm in 1992, Prime Minister Carl Bildt and Immigration Minister Birgit Friggebo attended a meeting in Rinkeby. As the audience became upset, Friggebo tried to calm them down by proposing that everyone sing "We Shall Overcome". This statement is widely regarded as one of the most embarrassing moments in Swedish politics. In 2008, the newspaper Svenska Dagbladet listed the Sveriges Television recording of the event as the best political clip available on YouTube.[39]
On June 7, 2010, Roger Waters of Pink Floyd fame released a new version of the song as a protest against the Israeli blockade of Gaza.[40]
On July 22, 2012, Bruce Springsteen performed the song during the memorial-concert in Oslo after the terrorist attacks in Norway on July 22, 2011.
In India, the renowned poet Girija Kumar Mathur composed its literal translation in Hindi "Hum Honge Kaamyab (हम होंगे कामयाब)" which became a popular patriotic/spiritual song during the 1970s and 80s, particularly in schools.[41] This song also came to be used by the Blue Pilgrims for motivating the India national football team during international matches.
In Bengali-speaking India and Bangladesh, there are two versions, both of which are popular among school-children and political activists. "Amra Korbo Joy" (à...†à...®à...°à...¾ à...•à...°à...¬à§‹ à...'à...¯à...¼, a literal translation) was translated by the Bengali folk singer Hemanga Biswas and re-recorded by Bhupen Hazarika. Hazarika, who had heard the song during his days in the US, also translated the song to the Assamese language as "Ami hom xophol" (à...†à...®à... à...¹'à...® à...¸à...à...²).[42] Another version, translated by Shibdas Bandyopadhyay, "Ek Din Shurjer Bhor" (à...à...• à......à...à...¨ à...¸à§‚à...°à§à...¯à§‡à...° à...­à§‹à...°, literally translated as "One Day The Sun Will Rise") was recorded by the Calcutta Youth Choir and arranged by Ruma Guha Thakurta during the 1971 Bangladesh War of Independence and it became one of the largest selling Bengali records. It was a favorite of Bangladeshi Prime Minister Sheikh Mujibur Rahman and it was regularly sung at public events after Bangladesh gained its independence in the early 1970s.[citation needed ]
In the Indian State of Kerala, the traditional Communist stronghold, the song became popular on college campuses during the late 1970s. It was the struggle song of the Students Federation of India SFI, the largest student organisation in the country. The song translated to the regional language Malayalam by N. P. Chandrasekharan, an activist for SFI. The translation followed the same tune of the original song, as "Nammal Vijayikkum". Later it was also published in Student, the monthly of SFI in Malayalam as well as in Sarvadesheeya Ganangal (Mythri Books, Thiruvananthapuram), a translation of international struggle songs.
"We Shall Overcome" was a prominent song in the 2010 Bollywood film My Name is Khan, which compared the struggle of Muslims in modern America with the struggles of African Americans in the past. The song was sung in both English and Hindi in the film, which starred Kajol and Shahrukh Khan.
In 2014, a recording of We Shall Overcome arranged by composer Nolan Williams Jr. and featuring mezzo-soprano Denyce Graves was among several works of art, including the poem A Brave and Startling Truth by Maya Angelou, were sent to space on the first test flight of the spacecraft Orion.[43]
The Argentine writer and singer Mar­a Elena Walsh wrote a Spanish version called "Venceremos".[44]
Copyright status [ edit ] The copyright status of "We Shall Overcome" was disputed in the late 2010s. A copyright registration was made for the song in 1960, which is credited as an arrangement by Zilphia Horton, Guy Carawan, Frank Hamilton, and Pete Seeger, of a work entitled "I'll Overcome", with no known original author.[9] Horton's heirs, Carawan, Hamilton, and Seeger share the artists' half of the rights, and The Richmond Organization (TRO), which includes Ludlow Music, Essex, Folkways Music, and Hollis Music, holds the publishers' rights, to 50% of the royalty earnings. Seeger explained that he registered the copyright under the advice of TRO, who showed concern that someone else could register it. "At that time we didn't know Lucille Simmons' name", Seeger said.[45] Their royalties go to the "We Shall Overcome" Fund, administered by Highlander under the trusteeship of the "writers". Such funds are purportedly used to give small grants for cultural expression involving African Americans organizing in the U.S. South.[46]
In April 2016, the We Shall Overcome Foundation (WSOF), led by music producer Isaias Gamboa, sued TRO and Ludlow, seeking to have the copyright status of the song clarified and the return of all royalties collected by the companies from its usage. The WSOF, which was working on a documentary about the song and its history, were denied permission to use the song by TRO-Ludlow. The filing argued that TRO-Ludlow's copyright claims were invalid because the registered copyright had not been renewed as required by United States copyright law at the time; because of this, the copyright of the 1948 People's Songs publication containing "We Will Overcome" had expired in 1976. Additionally, it was argued that the registered copyrights only covered specific arrangements of the tune and "obscure alternate verses", that the registered works "did not contain original works of authorship, except to the extent of the arrangements themselves", and that no record of a work entitled "I'll Overcome" existed in the database of the United States Copyright Office.[9]
The suit acknowledged that Seeger himself had not claimed to be an author of the song, stating of the song in his autobiography, "No one is certain who changed 'will' to 'shall.' It could have been me with my Harvard education. But Septima Clarke, a Charleston schoolteacher (who was director of education at Highlander and after the civil rights movement was elected year after year to the Charleston, S.C. Board of Education) always preferred 'shall.' It sings better." He also reaffirmed that the decision to copyright the song was a defensive measure, with his publisher apparently warning him that "if you don't copyright this now, some Hollywood types will have a version out next year like 'Come on Baby, We shall overcome tonight ' ". Furthermore, the liner notes of Seeger's compilation album If I Had a Hammer: Songs of Hope & Struggle contained a summary on the purported history of the song, stating that "We Shall Overcome" was "probably adapted from the 19th-century hymn, 'I'll Be All Right ' ", and that "I'll Overcome Some Day" was a "possible source" and may have originally been adapted from "I'll Be All Right".[47]
Gamboa has historically shown interest in investigating the origins of "We Shall Overcome";[9] in a book entitled We Shall Overcome: Sacred Song On The Devil's Tongue, he notably disputed the song's claimed origins and copyright registration with an alternate theory, suggesting that "We Shall Overcome" was actually derived from "If My Jesus Wills", a hymn by Louise Shropshire that had been composed in the 1930s and had its copyright registered in 1954.[48][49] The WSOF lawsuit did not invoke this alternate history, focusing instead on the original belief that the song stemmed from "We Will Overcome".[9][47] The lawyer backing Gamboa's suit, Mark C. Rifkin, was previously involved in a case that invalidated copyright claims over the song "Happy Birthday to You".[50]
On September 8, 2017, Judge Denise Cote of the Southern District of New York issued an opinion that there were insufficient differences between the first verse of the "We Shall Overcome" lyrics registered by TRO-Ludlow, and the "We Will Overcome" lyrics from People's Songs (specifically, the aforementioned replacement of "will" with "shall", and changing "down in my heart" to "deep in my heart") for it to qualify as a distinct derivative work eligible for its own copyright.[51][52]
On January 26, 2018, TRO-Ludlow agreed to a final settlement, under which it would no longer claim copyright over the melody or lyrics to "We Shall Overcome".[53] In addition, TRO-Ludlow agreed that the melody and lyrics were thereafter dedicated to the public domain.[54][55][56]
See also [ edit ] Civil rights movement in popular cultureTimeline of the civil rights movementChristian child's prayer § SpiritualsNotes [ edit ] ^ Bobetsky, Victor (2014). "The complex ancestry of "We Shall Overcome" ". Choral Journal. 57: 26''36. ^ Lynskey, Dorian (2011). 33 revolutions per minute. London, UK: Faber & Faber. pp. 33. ISBN 978-0061670152. ^ "We Will Overcome," by FTA-CIO Workers, Highlander Students; People's Songs, Sept. 1948 ^ a b Seeger, Pete (1997). Where Have All The Flowers Gone '' A Musical Autobiography. Bethlehem, PA: Sing Out. ISBN 1881322106. ^ Tindley, C. Albert (1900). "I'll Overcome Some Day". New Songs of the Gospel. Philadelphia: Hall-Mack Co. ^ Horace Clarence Boyer, "Charles Albert Tindley: Progenitor of Black-American Gospel Music", The Black Perspective in Music 11: No. 2 (Autumn, 1983), pp. 103''132. ^ Boyer, [1983], p. 113. "Tindley was a composer for whom the lyrics constituted its major element; while the melody and were handled with care, these elements were regarded as subservient to the text." ^ Boyer (1983), p. 113. ^ a b c d e f Graham, David A. (14 April 2016). "Who Owns 'We Shall Overcome'?". The Atlantic . Retrieved 13 July 2016 . ^ "Lawyers who won Happy Birthday copyright case sue over "We Shall Overcome" ". Ars Technica. 13 April 2016 . Retrieved 13 July 2016 . ^ The United Mine Workers was racially integrated from its founding and was notable for having a large black presence, particularly in Alabama and West Virginia. The Alabama branch, whose membership was three-quarters black, in particular, met with fierce, racially-based resistance during a strike in 1908 and was crushed. See Daniel Letwin, "Interracial Unionism, Gender, and Social Equality in the Alabama Coalfields, 1878''1908", The Journal of Southern History LXI: 3 (August 1955): 519''554. ^ James Fuld tentatively attributes the change to the version by Atron Twigg and Kenneth Morris. See James J. Fuld, The Book of World-Famous Music: Classical, Popular, and Folk (noted by Wallace and Wallechinsky)1966; New York: Dover, 1995). According to Alan Lomax's The Folk Songs of North America, "No More Auction Block For Me" originated in Canada and it was sung by former slaves who fled there after Britain abolished slavery in 1833. ^ Eileen Southern, The Music of Black Americans: A History, Second Edition (Norton, 1971): 546''47, 159''60. ^ Higginson, Thomas Wentworth (June 1867). "Negro Spirituals". The Atlantic Monthly. 19 (116): 685''694. ^ From the sleeve notes to Bob Dylan's "Bootleg Series Volumes 1''3" '' "...it was Pete Seeger who first identified Dylan's adaptation of the melody of this song ["No More Auction Block"] for the composition of "Blowin' in the Wind". Indeed, Dylan himself was to admit the debt in 1978, when he told journalist Marc Rowland: "Blowin' in the Wind" has always been spiritual. I took it off a song called "No More Auction Block" '' that's a spiritual, and "Blowin' in the Wind sorta follows the same feeling..." ^ a b Bobetsky, Victor V. (2015). We Shall Overcome: Essays on a Great American Song. pp. 1''13. ISBN 9781442236035 . Retrieved October 18, 2016 . ^ Seward, William (November 1792). "Drossiana. Number XXXVIII. The Sicilian Mariner's Hymn to the Virgin". European Magazine. 22 (5): 342, 385''386 . Retrieved October 26, 2016 . ^ Shaw, Robert, ed. (May 1794). "Prayer of the Sicilian Mariners". The Gentleman's Amusement: 25 . Retrieved October 26, 2016 . ^ Brink, Emily; Polman, Bert, eds. (1988). The Psalter Hymnal Handbook . Retrieved October 18, 2016 . ^ Wallechinsky, David; Wallace, Irving, eds. (1978). The People's Almanac #2. pp. 806''809. Archived from the original on February 25, 2015 . Retrieved October 18, 2016 . ^ Kytle, Ethan J.; Roberts, Blain (March 15, 2015). "Birth of a Freedom Anthem". The New York Times. ^ Dunaway, 1990, 222''223; Seeger, 1993, 32; see also, Robbie Lieberman, My Song Is My Weapon: People's Songs, American Communism, and the Politics of Culture, 1930''50 (Urbana: University of Illinois Press, [1989] 1995) p. 46, p. 185 ^ Ronald Cohen and Dave Samuelson, Songs for Political Action: Folkmusic, Topical Songs And the American Left 1926''1953, book published as part of Bear Family Records 10-CD box set issued in Germany in 1996. ^ Dunaway, 1990, 222''223; Seeger, 1993, 32. ^ Lyndon Johnson, speech of March 15, 1965, accessed March 28, 2007 on HistoryPlace.com ^ "A new normal". Archived from the original on 2011-10-12 . Retrieved 2008-10-01 . ^ "Hearing Voices - Radio Transcript #". Hearingvoices.com . Retrieved 14 March 2022 . ^ From the first King had liked to cite these same inspiration passages. "The arc of the moral universe is long, but it bends toward justice" is from the writings of Theodore Parker the Unitarian abolitionist minister who was King's favorite theologian. Compare the transcript of this 1957 speech given in Washington, D.C."Give Us the Ballot". Address Delivered at the Prayer Pilgrimage for Freedom, Washington D.C. 1957-05-17. . ^ Kotz, Nick (2005). "14. Another Martyr". Judgment days: Lyndon Baines Johnson, Martin Luther King Jr., and the laws that changed America. Boston: Houghton Mifflin. p. 419. ISBN 0-618-08825-3. ^ Alan J. Watt (2010). Farm Workers and the Churches: The Movement in California and Texas, Volume 8. Texas A&M University Press. p. 80. ISBN 9781603441933 . Retrieved 15 July 2016 . ^ Thomas, Evan (2002-09-10). Robert Kennedy: His Life. New York: Simon & Schuster. pp. 322. ISBN 0-7432-0329-1. ^ Dunaway ([1981, 1990] 2008) p. 243. ^ "CAIN: Events: Civil Rights: Bob Purdie (1990) The Northern Ireland Civil Rights Association". Cain.ulster.ac.uk . Retrieved 14 March 2022 . ^ "CAIN: Events: Civil Rights - "We Shall Overcome" .... published by the Northern Ireland Civil Rights Association (NICRA; 1978)". Cain.ulster.ac.uk . Retrieved 14 March 2022 . ^ Allen, Mark (2008). Prague Symphony (PDF) . Praha Publishing. p. 192 . Retrieved 16 October 2016 . ^ McClements, Freya (4 March 2017). "Derry and 'We Shall Overcome': 'We plagiarised an entire movement' ". The Irish Times . Retrieved 27 October 2019 . ^ "The NPR 100 The most important American musical works of the 20th century". Npr.org . Retrieved 14 March 2022 . ^ "We Have Overcome", Media General. January 20, 2009. ^ Ledarbloggens Youtubiana '' hela listan! Svenska Dagbladet, 2 October 2008 (in Swedish) ^ Roger Waters releases "We Shall Overcome" video, Floydian Slip, June 7, 2010 ^ "Lyrics of Hum Honge Kaamyab (Hindi)". Prayogshala.com . Retrieved 9 February 2017 . ^ Dutta, Pranjal. "The African American Bhupen Hazarika". The Sentinel. ^ Siceloff, Steven (25 Nov 2014). "Orion Flight Test to Carry Mementos and Inspirational Items". NASA . Retrieved 22 October 2021 . ^ "Maria Elena Walsh, Argentine writer and singer, dies at 80". Washington Post. Associated Press. 11 January 2011 . Retrieved 7 August 2022 . ^ Seeger, 1993, p. 33 ^ Highlander Reports, 2004, p. 3. ^ a b "We Shall Overcome Foundation, C.A. No. on behalf of itself and all others similarly situated v. The Richmond Organization, Inc. (TRO Inc.) and Ludlow Music, Inc" (PDF) . S.D.N.Y. Retrieved 13 July 2016 . ^ " 'We Shall Overcome' belongs to Cincinnati". Cincinnati Enquirer. Gannett Company . Retrieved 13 July 2016 . ^ Gamboa, Isaias; Henry, JoAnne F.; Owen, Audrey (2012). We Shall Overcome: Sacred Song On The Devil's Tongue. Beverly Hills, California: Amapola. ISBN 978-0615475288. ^ " 'Happy Birthday' Legal Team Turns Attention to 'We Shall Overcome' ". Billboard. 12 April 2016 . Retrieved April 15, 2016 . ^ "Judge throws out 57-year-old copyright on 'We Shall Overcome' ". Ars Technica. September 11, 2017 . Retrieved September 11, 2017 . ^ Karr, Rick (September 11, 2017). "Federal Judge Rules First Verse Of 'We Shall Overcome' Public Domain". Npr.org . Retrieved September 11, 2017 . ^ As published in copyright registration numbers EU 645288 (27 October 1960) and EP 179877 (7 October 1963). ^ Gardner, Eriq. "Song Publisher Agrees 'We Shall Overcome' Is in Public Domain in Legal Settlement". Hollywood Reporter . Retrieved 26 January 2018 . ^ "Wolf Haldenstein Frees the Copyright to we Shall Overcome, the US's Most Powerful Song". Whafh.com . Retrieved 3 February 2018 . ^ "Stipulation and Order of Dismissal With Prejudice" (PDF) . Whafh.com . Retrieved March 14, 2022 . References [ edit ] Dunaway, David, How Can I Keep from Singing: Pete Seeger, (orig. pub. 1981, reissued 1990). Da Capo, New York, ISBN 0-306-80399-2.___, "The We Shall Overcome Fund". Highlander Reports, newsletter of the Highlander Research and Education Center, August''November 2004, p. 3.We Shall Overcome, PBS Home Video 174, 1990, 58 minutes.Further reading [ edit ] Sing for Freedom: The Story of the Civil Rights Movement Through Its Songs: Compiled and edited by Guy and Candie Carawan; foreword by Julian Bond (New South Books, 2007), comprising two classic collections of freedom songs: We Shall Overcome (1963) and Freedom Is A Constant Struggle (1968), reprinted in a single edition. The book includes a major new introduction by Guy and Candie Carawan, words and music to the songs, important documentary photographs, and firsthand accounts by participants in the civil rights movement. Available from Highlander Center.We Shall Overcome! Songs of the Southern Freedom Movement: Julius Lester, editorial assistant. Ethel Raim, music editor: Additional musical transcriptions: Joseph Byrd [and] Guy Carawan. New York: Oak Publications, 1963.Freedom is a Constant Struggle, compiled and edited by Guy and Candie Carawan. Oak Publications, 1968.Alexander Tsesis, We Shall Overcome: A History of Civil Rights and the Law. Yale University Press, 2008.We Shall Overcome: A Song that Changed the World, by Stuart Stotts, illustrated by Terrance Cummings, foreword by Pete Seeger. New York: Clarion Books, 2010.Sing for Freedom, Folkways Records, produced by Guy and Candie Carawan, and the Highlander Center. Field recordings from 1960 to 1988, with the Freedom Singers, Birmingham Movement Choir, Georgia Sea Island Singers, Doc Reese, Phil Ochs, Pete Seeger, Len Chandler, and many others. Smithsonian-Folkways CD version 1990.We Shall Overcome: The Complete Carnegie Hall Concert, June 8, 1963, Historic Live recording June 8, 1963. 2-disc set, includes the full concert, starring Pete Seeger, with the Freedom Singers, Columbia # 45312, 1989. Re-released 1997 by Sony as a box CD set.Voices Of The Civil Rights Movement: Black American Freedom Songs 1960''1966. Box CD set, with the Freedom Singers, Fanny Lou Hammer, and Bernice Johnson Reagon. Smithsonian-Folkways CD ASIN: B000001DJT (1997).Durman, C 2015, 'We Shall Overcome: Essays on a Great American Song edited by Victor V. Bobetsky', Music Reference Services Quarterly, vol. 8, iss. 3, pp. 185''187Graham, D 2016, "Who Owns 'We Shall Overcome'?", The Atlantic, 14 April, accessed 28 April 2017, Who Owns 'We Shall Overcome'?Clark, B. & Borchert, S 2015, "Pete Seeger, Musical Revolutionary", Monthly Review, vol. 66, no. 8, pp. 20''29External links [ edit ] Wikisource has original text related to this article:
We Shall Overcome Lyrics download in PDF.We Shall Overcome on National Public RadioLyricsAuthorized Profile of Guy Carawan with history of the song, "We Shall Overcome" from the Association of Cultural EquityFreedom in the Air: Albany Georgia. 1961''62. SNCC #101. Recorded by Guy Carawan, produced for the Student Non-Violent Coordinating Committee by Guy Carawan and Alan Lomax. "Freedom In the Air ... is a record of the 1961 protest in Albany, Georgia, when, two weeks before Christmas, 737 people brought the town nearly to a halt to force its integration. The record's never been reissued and that's a shame, as it's a moving document of a community through its protest songs, church services, and experiences in the thick of the civil rights struggle."'--Nathan Salsburg, host, Root Hog or Die, East Village Radio, January 2007.Susanne's Folksong-Notizen, excerpts from various articles, liner notes, etc. about "We Shall Overcome".Musical Transcription of "We Shall Overcome," based on a recording of Pete Seeger's version, sung with the SNCC Freedom Singers on the 1963 live Carnegie Hall recording, and the 1988 version by Pete Seeger sung at a reunion concert with Pete and the Freedom Singers on the anthology, Sing for Freedom, recorded in the field 1960''88 and edited and annotated by Guy and Candie Carawan, released in 1990 as Smithsonian-Folkways CD SF 40032.NPR news article including full streaming versions of Pete Seeger's classic 1963 live Carnegie Hall recording and Bruce Springsteen's tribute version."Pete Seeger & the story of 'We Shall Overcome'" from 1968 interview on The Pop Chronicles."Something About That Song Haunts You", essay on the history of "We Shall Overcome," Complicated Fun, June 9, 2006."Howie Richmond Views Craft Of Song: Publishing Giant Celebrates 50 Years As TRO Founder", by Irv Lichtman, Billboard, 8, 28, 1999. Excerpt: "Key folk songs in the [TRO] catalog, as arranged by a number of folklorists, are 'We Shall Overcome,' 'Kisses Sweeter Than Wine' 'On Top Of Old Smokey,' 'So Long, It's Been Good To Know You,' 'Goodnight Irene,' 'If I Had A Hammer,' 'Tom Dooley,' and 'Rock Island Line.'"
Talented tenth - Wikipedia
Wed, 11 Jan 2023 20:31
Essay by W. E. B. Du Bois
This article is about the African-American leadership class and W. E. B. Du Bois essay. For the hip-hop album, see
Talented 10th.
The talented tenth is a term that designated a leadership class of African Americans in the early 20th century. Although the term was created by white Northern philanthropists, it is primarily associated with W. E. B. Du Bois, who used it as title of an influential essay, published in 1903. It appeared in The Negro Problem, a collection of essays written by leading African Americans and assembled by Booker T. Washington.[1]
Historical context [ edit ] John D. Rockefeller funded the
ABHMS, which promoted "Talented Tenth" ideology
The phrase "talented tenth" originated in 1896 among White Northern liberals, specifically the American Baptist Home Mission Society, a Christian missionary society strongly supported by John D. Rockefeller. They had the goal of establishing Black colleges in the South to train Black teachers and elites. In 1903, W.E.B. Du Bois wrote The Talented Tenth; Theodore Roosevelt was president of the United States and industrialization was skyrocketing. Du Bois thought it a good time for African Americans to advance their positions in society.[2]
The "Talented Tenth" refers to the one in ten Black men that have cultivated the ability to become leaders of the Black community by acquiring a college education, writing books, and becoming directly involved in social change. In The Talented Tenth, Du Bois argues that these college educated African American men should sacrifice their personal interests and use their education to lead and better the Black community.[3]
He strongly believed that the Black community needed a classical education to reach their full potential, rather than the industrial education promoted by the Atlanta Compromise, endorsed by Booker T. Washington and some White philanthropists. He saw classical education as the pathway to bettering the Black community and as a basis for what, in the 20th century, would be known as public intellectuals:
Men we shall have only as we make manhood the object of the work of the schools '-- intelligence, broad sympathy, knowledge of the world that was and is, and of the relation of men to it '-- this is the curriculum of that Higher Education which must underlie true life. On this foundation we may build bread winning, the skill of hand and quickness of brain, with never a fear lest the child and man mistake the means of living for the object of life.[4]
In his later life, Du Bois came to believe that leadership could arise on many levels, and grassroots efforts were also important to social change. His stepson David Du Bois tried to publicize those views, writing in 1972: "Dr. Du Bois' conviction that it's those who suffered most and have the least to lose that we should look to for our steadfast, dependable and uncompromising leadership."[5]
Du Bois writes in his Talented Tenth essay that
The Negro race, like all races, is going to be saved by its exceptional men. The problem of education, then, among Negroes must first of all deal with the Talented Tenth; it is the problem of developing the Best of this race that they may guide the Mass away from the contamination and death of the Worst.
Later in Dusk of Dawn, a collection of his writings, Du Bois redefines this notion, acknowledging contributions by other men. He writes that "my own panacea of an earlier day was a flight of class from mass through the development of the Talented Tenth; but the power of this aristocracy of talent was to lie in its knowledge and character, not in its wealth."
Du Bois and betterment [ edit ] W.E.B. Du Bois believed that college educated African Americans should set their personal interests aside and use their education to better their communities. Using education to better the African American community meant many things for Du Bois. For one, he believed that the "Talented Tenth" should seek to acquire elite roles in politics. By doing so, Black communities could have representation in government. Representation in government would allow these college educated African Americans to take "racial action."[6]
That is, Du Bois believed that segregation was a problem that needed to be dealt with, and having African Americans in politics would start the process of dealing with that problem. Moving on, he also believed that an education would allow one to pursue business endeavors that would better the economic welfare of Black communities. According to Du Bois, success in business would not only better the economic welfare of Black communities, it would also encourage White people to see Black people as more equal to them, and thus encourage integration and allow African Americans to enter the mainstream business world.[6]
Conceptual revision [ edit ] In 1948, W.E.B. Du Bois revised his "Talented Tenth" thesis into the "Guiding Hundredth."[7] This revision was an attempt to democratize the thesis by forming alliances and friendships with other minority groups that also sought to better their conditions in society. Whereas the "Talented Tenth" only pointed out problems African Americans were facing in their communities, the "Guiding Hundredth" would be open to mending the problems other minority groups were encountering as well.[7] Moreover, Du Bois revised this theory to stress the importance of morality. He wanted the people leading these communities to have values synonymous with altruism and selflessness. Thus, when it came to who would be leading these communities, Du Bois placed morality above education.[7]
The "Guiding Hundredth" challenged the proposition that the salvation of African Americans should be left to a select few. It reimagined the concept of black leadership from "The Talented Tenth" by combining racial, cultural, political, and economic ideologies.[8] Without much success, Du Bois tried to keep the idea of education around. Taking on a new approach of education being a gateway to new opportunities for all people. However, it was viewed as a step in the wrong direction, a threat of reverting to the old ways of thinking, and continued to promote elitism.[8] This revision while also being an attempt at democratization of the original thesis, was also Du Bois' attempt at creating a program for African Americans to follow after the war. A way to strengthen their "ideological conscience."[8]
Du Bois emphasized forming alliances with other minority groups because it helped promote equality among all blacks.[8] Both "The Talented Tenth" and "The Guiding Hundredth" exhibit the idea that a plan to for political action would need to be evident in order to continue to speak to large populations of black people. Because to Du Bois, black people's ability to express themselves in politics was the epitome of black cultural expression.[8] To gain emancipation was to separate black and White. The cultures could not combine as a way to avoid and protect the spirit of "the universal black."[8]
Contemporary interpretations [ edit ] The concept of the "Talented Tenth" and the responsibilities assigned to it by Du Bois have been received both positively and negatively by contemporary critics. Positively, some argue that current generations of college-educated African Americans abide by Du Bois' prescriptions by sacrificing their personal interests to lead and better their communities.[7] This, in turn, leads to an "uplift" of those in the Black community. On the other hand, some argue that current generations of college educated African Americans should not abide by Du Bois' prescriptions, and should indeed pursue their own private interest. That is, they believe that college-educated African Americans are not responsible for bettering their communities, whereas Du Bois thinks that they are.[2]
Advocates of Du Bois' prescriptions explain that key characteristics of the "Talented Tenth" have changed since Du Bois was alive. One author writes, "The potential Talented Tenth of today is a 'me generation,' not the 'we generation' of the past."[2] That is, the Talented Tenth of today focuses more on its own interests as opposed to the general interests of its racial community. Advocates of Du Bois' ideals believe that African Americans have lost sight of the importance of uplifting their communities. Rather, they have pursued their own interests and now dwell in the fruits of their "financial gain and strivings."[2] Although the percentage of college-educated African Americans has gone up, it is still far less than the percentage of college-educated White Americans.[2] Therefore, these advocates believe that modern-day members of the "Talented Tenth" should still bear responsibility to use their education to help the African American community, which continues to suffer the effects of racial discrimination.
In contrast, those not in favor of Du Bois' prescriptions believe that African Americans have the right to pursue their own interests. Feminist critics specifically, and critics of Du Bois in general, tend to believe that marginalized groups are often "put in boxes" and are expected to either remain within those constructs or abide by their stereotypes. These critics believe that what an African American decides to do with their college education should not become a stereotype either. Furthermore, many of Du Bois' original texts, including The Talented Tenth, receive feminist criticism for exclusively using the word "man", as if only African American men could seek out a college education. According to these feminists, this acts to perpetuate the persistence of a culture that only encourages or allows men to pursue higher education.[2]
Attainability [ edit ] To be a part of this "Talented Tenth," an African American must be college educated. This is a qualification that many view as unattainable for many members of the African American community because the percentage of African Americans in college is much lower than the percentage of White people in college. There are multiple explanations for this fact.
Some argue that this disparity is the result of government policies. For instance, financial aid for college students in low income families decreased in the 1980s because problems regarding monetary inequality began to be perceived as problems of the past.[9] A lack of financial aid can deter or disable one from pursuing higher education. Thus, since Black and African American families make up about 2.9 million of the low income families in the U.S., members of the Black community surely encounter this problem.[10]
Moreover, because African Americans make up such a large number of the low income families in the U.S., many African Americans face the problem of their children being placed in poorly funded public schools. Because poor funding often leads to poor education, getting into college will be more difficult for students. Along with a poor education, these schools often lack resources that can prepare students for college. For instance, schools with poor funding do not have college guidance counselors: a resource that many private and well funded public schools have.[11]
Therefore, some argue that Du Bois' prescription or plan for this "Talented Tenth" is unattainable.
See also [ edit ] African-American upper class '' Contemporary successors of the Talented Tenth.Negro Academy '' Scholarly institute that published many works of the Talented Tenth.References [ edit ] ^ Du Bois, W. E. B. (1903). "The Talented Tenth". In Washington, Booker T. (ed.). The Negro Problem: a series of articles by representative American Negroes of today. New York: James Pott and Company. pp. 31''75. ^ a b c d e f King, L'Monique (2013). "The Relevance and Redefining of Du Bois's Talented Tenth: Two Centuries Later". Papers & Publications: Interdisciplinary Journal of Undergraduate Research. 2: 7 '' via JSTOR. ^ Battle, Juan; Wright, Earl (2002). "W.E.B. Du Bois's Talented Tenth: A Quantitative Assessment". Journal of Black Studies. 32 (6): 654''672. doi:10.1177/00234702032006002. ISSN 0021-9347. JSTOR 3180968. S2CID 143962872. ^ W.E.B. Du Bois, "The Talented Tenth" (text), Sep 1903, TeachingAmericanHistory.org, Ashland University, accessed 3 Sep 2008 ^ Joy James, Transcending the Talented Tenth: Black Leaders and American Intellectuals, New York: Routledge, 1997 ^ a b Gooding-Williams, Robert (2020), "W.E.B. Du Bois", in Zalta, Edward N. (ed.), The Stanford Encyclopedia of Philosophy (Spring 2020 ed.), Metaphysics Research Lab, Stanford University , retrieved 2020-11-24 ^ a b c d Rabaka, Reiland (2003). "W. E. B. Du Bois's Evolving Africana Philosophy of Education". Journal of Black Studies. 33 (4): 399''449. doi:10.1177/0021934702250021. ISSN 0021-9347. JSTOR 3180873. S2CID 144101148. ^ a b c d e f Jucan, Marius (2012-12-01). " "The Tenth Talented" v. "The Hundredth Talented": W. E .B. Du Bois's Two Versions on the Leadership of the African American Community in the 20th Century". American, British and Canadian Studies. 19 (2012): 27''44. doi:10.2478/abcsj-2013-0002 . ^ Carnoy, Martin (1994). "Why Aren't more African Americans Going to College?". The Journal of Blacks in Higher Education (6): 66''69. doi:10.2307/2962468. ISSN 1077-3711. JSTOR 2962468. ^ Du Bois, W.E.B. (1903). The Talented Tenth. Project Gutenberg. ^ Brownstein, Janie Boschma, Ronald (2016-02-29). "Students of Color Are Much More Likely to Attend Schools Where Most of Their Peers Are Poor". The Atlantic . Retrieved 2020-11-24 . Further reading [ edit ] The Negro Problem, New York: James Pott and Company, 1903W. E. B. Du Bois, Dusk of Dawn, "Writings," (Library of America, 1986), p 842External links [ edit ]
Rosenwald School - Wikipedia
Wed, 11 Jan 2023 20:29
Schools in the United States
The Rosenwald School project built more than 5,000 schools, shops, and teacher homes in the United States primarily for the education of African-American children in the South during the early 20th century. The project was the product of the partnership of Julius Rosenwald, a Jewish-American clothier who became part-owner and president of Sears, Roebuck and Company and the African-American leader, educator, and philanthropist Booker T. Washington, who was president of the Tuskegee Institute.[1]
The need arose from the chronic underfunding of public education for African-American children in the South, as black people had been discriminated against at the turn of the century and excluded from the political system in that region. Children were required to attend segregated schools, and even those did not exist in many places.
Rosenwald was the founder of the Rosenwald Fund. He contributed seed money for many schools and other philanthropic causes. To encourage local commitment to these projects, he conditioned the Fund's support on the local communities' raising of matching funds. To promote collaboration between black and white people, Rosenwald required communities to also commit public funds and/or labor to the schools, as well as to contribute additional cash donations after construction. With the program, millions of dollars were raised by African-American rural communities across the South to fund better education for their children, and white school boards had to agree to operate and maintain the schools. Despite this program, by the mid-1930s, white schools in the South were worth more than five times per student, what black schools were worth per student (in majority-black Mississippi, this ratio was more than 13 to one).[2]
Rosenwald-Washington collaboration [ edit ] In the segregated schools of the South, African American children were sent to woefully underfunded schools. The collaboration of Rosenwald and Washington led to the construction of almost 5,000 schools for black children in the eleven states of the former Confederacy as well as Oklahoma, Missouri, Kentucky, and Maryland. As a result of their collaboration, approximately one-third of African American children were educated in these schools.[3]
The Rosenwald-Washington model required the buy-in of African American communities as well as the support of white governing bodies. Black communities raised more than $4.7 million to aid in construction, plus often donating land and labor. Research has found that the Rosenwald program accounts for a sizable portion of the educational gains of rural Southern black persons during this period. This research also found significant effects on school attendance, literacy, years of schooling, cognitive test scores, and Northern migration, with gains highest in the most disadvantaged counties.[4]
Role of Julius Rosenwald [ edit ] Julius Rosenwald (1862''1932) was born to a Jewish-German immigrant family. He became a clothier by trade after learning the business from relatives in New York City. His first business went bankrupt, but another he began in Chicago, Illinois, became a leading supplier to the growing business of Richard Warren Sears, Sears, Roebuck, and Company, a mail-order business that served many rural Americans. Anticipating demand by using the variations of sizes in American men and their clothing, determined during the American Civil War, Rosenwald helped plan the growth in what many years later marketers would call "the softer side of Sears": clothing. In 1895, he became one of its investors, eventually serving as the president of Sears from 1908 to 1922. He was its chairman until his death in 1932.
After the 1906 reorganization of the Sears company as a public stock corporation by the financial services firm of Goldman Sachs, one of the senior partners, Paul Sachs, often stayed with the Rosenwald family at their home during his many trips to Chicago. Julius Rosenwald and Sachs often would discuss America's social situation, agreeing that the plight of African Americans was the most serious problem in the United States.[citation needed ] The millions in the South had been disenfranchised at the turn of the century and suffered second-class status in a system of Jim Crow segregation. Black public schools and other facilities were chronically underfunded.[citation needed ]
Role of Booker T. Washington [ edit ] Sachs introduced Rosenwald to Booker T. Washington (1856''1915), the famed educator who in 1881 started as the first principal of the normal school that he developed as Tuskegee University in Alabama. Washington, who had gained the respect of many American leaders including U.S. President Theodore Roosevelt, also had obtained financial support from wealthy philanthropists such as Andrew Carnegie, George Eastman, and Henry Huttleston Rogers. He encouraged Rosenwald, as he had others, to address the poor state of African-American education in the U.S.
In 1912, Rosenwald was asked to serve on the board of directors of Tuskegee, a position he held until his death in 1932. Rosenwald endowed Tuskegee so that Washington could spend less time traveling to seek funding and be able to devote more time toward management of the school. As urged by Washington, Rosenwald provided funds for the construction of six small schools in rural Alabama, which were constructed and opened in 1913 and 1914 and overseen by Tuskegee.
Rosenwald Fund [ edit ] Because many schools were located in areas lacking electricity, the fund designed architectural plans that took advantage of natural light
Julius Rosenwald and his family established the Rosenwald Fund in 1917 for "the well-being of mankind".[5] Unlike other endowed foundations, which were designed to fund themselves in perpetuity, the Rosenwald Fund was intended to use all of its funds for philanthropic purposes. It donated more than $70 million (equivalent to $789,488,000 in 2021) to public schools, colleges, universities, museums, Jewish charities, and black institutions before the funds were depleted in 1948.[citation needed ]
The school building program was one of the largest programs administered by the Rosenwald Fund. Using state-of-the-art architectural plans designed by professors at Tuskegee Institute,[6] the fund spent more than $4 million to build 5,388 schools, 217 teacher homes, and 163 shop buildings in 883 counties in 15 states, from Maryland to Texas. The Rosenwald Fund was based on a system of matching grants, requiring white school boards to commit to maintenance and black communities to aid in construction. Fulfilling the goals of the match grant program, African American communities contributed $4.8 million to the building of 5,338 schools throughout the South.[7]
Preservation [ edit ] Interior of a Rosenwald School
In some communities, surviving structures have been preserved because of the deep meaning they had for African Americans as symbols of the dedication of their leaders and communities to education. Others were threatened by lack of funds in rural areas, urbanization, changes in demographics, changing styles of education to consolidated and integrated schools, and other social changes.
Former Rosenwald students have led some efforts to preserve Rosenwald Schools. For example, in Georgia, three former Rosenwald Schools were preserved by the efforts of former students and Georgia's Historic Preservation Division, leading to their being listed on the National Register of Historic Places by 2001.[8]
In 2001, the National Trust for Historic Preservation named Rosenwald Schools near the top of the country's most endangered places and created a campaign to raise awareness and money for preservation. At least 60 former Rosenwald Schools are listed on the National Register of Historic Places.[9] In 2015, the National Trust classified the Rosenwald Schools as National Treasures.
A Rosenwald School in East Columbia, Texas, was donated to the Columbia Historical Museum in West Columbia, Texas, in 2002. The City of West Columbia gave permission to move the building onto a city park behind the museum and restoration work began. In 2009, the museum received a $50,000 grant from Lowe's and the National Trust and restoration was completed. The Columbia Rosenwald School opened to the public on Oct. 24, 2009, as the only interpretive center in the nation. More than 80 percent of the building is original, including the teacher's chair, the slate boards and a student desk.
Historical marker dedication for Barney Colored Elementary School in Brooks County, Georgia
In Georgia, several Rosenwald School sites have been commemorated through the Georgia Historical Marker Program, currently administered by the Georgia Historical Society. In partnership with community organizations, markers have been erected for the Hiram Rosenwald School (2006, Paulding County), Macon County Training School (2016, Macon County), Barney Colored Elementary School (2013, Brooks County), and Noble Hill Rosenwald School (1995 by the Georgia Department of Natural Resources, Bartow County).
Some schools have been adapted for new uses. Walnut Cove Colored School in Stokes County, North Carolina, won a National Preservation Honor Award for its rehabilitation for use as a senior citizen community center. The Hope Rosenwald School in Pomaria, South Carolina, also will be used as a community center. The Highland Park School in Prince George's County, Maryland, had been in continuous use by the school system. It was recently renovated for use as a Headstart Center. The Canetuck Rosenwald School in Currie, North Carolina, has been renovated by the local Black community and is used as a busy community center. The Beauregard Parish Training School in DeRidder, Louisiana, was renovated with a federal grant in 2007 and opened in 2009 as BeauCare Head Start.[10]
In 2012, the National Trust for Historic Preservation, a privately-funded nonprofit organization, published a guide to restoring Rosenwald Schools.[11]
In 2022 Congress passed a bill directing the National Park Service to study feasilibility of a national historical park preserving and explaining Rosenwald Schools.[12]
Effects [ edit ] Researchers measured the effects of Rosenwald Schools on rural southern blacks based on US Census and World War II records, and found that the effect on literacy levels and cognitive scores was large.[13] A 2021 study also found that attending the Rosenwald schools increased the life expectancy of the students, as well as increased their propensity to migrate to the Northern United States.[14]
See also [ edit ] List of Rosenwald SchoolsJane AddamsGrace AbbottEmil HirschJulian MackClaudia StackRosenwald (film)Rosenwald Junior CollegeRagged schools, in BritainReferences [ edit ] ^ Deutsch, Stephanie (2015). You Need a Schoolhouse: Booker T. Washington, Julius Rosenwald, and the Building of Schools for the Segregated South. Evanston, Illinois: Northwestern University Press. ISBN 978-0-8101-3127-9. ^ McMillen, Neil R. (1990). Dark Journey: Black Mississippians in the Age of Jim Crow. University of Illinois Press. p. 84. ISBN 0-252-06156-X. ^ Brooker, Russell; Kaplan, Fran. "The Rosenwald Schools: An Impressive Legacy of Black-Jewish Collaboration for Negro Education". America's Black Holocaust Museum. Archived from the original on June 15, 2013. ^ Federal Reserve Bank of Chicago, "The Impact of Rosenwald Schools on Black Achievement", September 2011 ^ Meier, Allison C. (August 4, 2020). "How Black Communities Built Their Own Schools". JSTOR Daily . Retrieved August 9, 2020 . ^ "History of the Rosenwald School Program". National Trust for Historic Preservation. Archived from the original on December 14, 2013 . Retrieved December 14, 2013 . ^ Anderson, James D. The education of Blacks in the South, 1860-1935. Univ of North Carolina Press, 2010. ^ "Saving Georgia's Rosenwald Schools" (PDF) . Reflections. Historic Preservation Division, Georgia Department of Natural Resources. 1 (4): 3''5. August 2001. Archived from the original on August 9, 2014. {{cite journal}}: CS1 maint: unfit URL (link) ^ At least 60 in List of Rosenwald Schools are documented to be NRHP-listed. ^ KPLCTV: Historic DeRidder school starts new chapter- Retrieved 2016-07-27 ^ Williams, Joseph (February 1, 2022). "In Maryland, a segregated school is one of many in the country to be preserved". Washington Post. ^ "Congressional act celebrating Julius Rosenwald's 'tzedakah' would enshrine his memory in a national park". Jewish Telegraphic Agency . Retrieved December 29, 2022 . ^ Daniel Aaronson and Bhashkar Mazumder. The Impact of Rosenwald Schools on Black Achievement. Journal of Political Economy, 119:5 (October 2011), pp. 821-888. doi:10.1086/662962 ^ Aaronson, Daniel; Mazumder, Bhashkar; Sanders, Seth G.; Taylor, Evan J. (May 4, 2020). "Estimating the Effect of School Quality on Mortality in the Presence of Migration: Evidence from the Jim Crow South". Journal of Labor Economics. 39 (2): 527''558. doi:10.1086/709783. ISSN 0734-306X. S2CID 233244980. External links [ edit ] Reporting for Arkansas: New Schools for Arkansas, a 2006 documentary produced by Jack HillRosenwald Schools of South Carolina, An Oral History Exhibit, University of South CarolinaSaving the Rosenwald Schools: Preserving African American HistoryRosenwald Schools Initiative, National Trust for Historic PreservationRosenwald School Archives at Fisk University, searchable database of many Rosenwald Schools, with historic data and photographs from when they were builtHistory South: "Rosenwald Schools"Rosenwald Harlanites, Inc., nonprofit organization to preserve the legacy of the Rosenwald School in Harlan, KentuckyShiloh Community Restoration Project, a nonprofit organization to restore the Shiloh-Rosenwald School, Notasulga, AlabamaNoble Hill Wheeler Memorial Center; restored 1923 Rosenwald School in northwestern GeorgiaPhotographs of some Rosenwald Schools by Sarah Hoskins (the schools in the pictures are not identified)Under the Kudzu, a film by Claudia Stack about two North Carolina Rosenwald SchoolsCarrie Mae: An American Life, a film by Claudia Stack about a teacher who was educated in Rosenwald Schools and then taught in themMultiple-Property Documentation Form, National Register of Historic Places, Virginia Department of Historic Resources; full details about Rosenwald Schools throughout Virginia
Sally Hemings | Hamilton Wiki | Fandom
Wed, 11 Jan 2023 20:03
Sarah Hemings Sarah "Sally" Hemings was an enslaved woman of mixed race held by President Thomas Jefferson. According to The New York Times, there is a "growing historical consensus" among scholars that, as a widower, Jefferson had a long-term relationship with Hemings, and that he was the father of her six children, born after the death of his wife Martha Jefferson, who was the half-sister of Sally Hemings. Four of Hemings' children survived to adulthood. Hemings died in Charlottesville, Virginia, in 1835.
Musical Sally Hemings is personified on stage but has no lines in Hamilton. She is seen in the first song in Act II, What'd I Miss? Thomas Jefferson asks her to open the letter on his desk, calling her "darlin'", betraying their close relationship to the audience.
In The Hamilton Mixtape, Sally Hemmings is referenced again by Alexander Hamilton during Cabinet Battle #3, first indirectly by accusing Thomas Jefferson of being against the government freeing slaves because he would be unable to find another mistress, then calls her out by name, saying that Jefferson wastes times and avoids the issue while he remains in a relationship with an enslaved woman.
Song References "Sally, be a lamb, darlin'. won'tcha open it"
'-- Thomas Jefferson. "What'd I Miss" "All your hemming and hawing, while you're hee-hawing with Sally Hemings"
'-- Alexander Hamilton, "Cabinet Battle #3"
Benjamin Rush - Wikipedia
Wed, 11 Jan 2023 19:55
American Founding Father physician, educator, and author (1746''1813)
Benjamin Rush
Born ( 1746-01-04 ) January 4, 1746DiedApril 19, 1813 (1813-04-19) (aged 67)Resting placeChrist Church Burial Ground, PhiladelphiaAlma materPrinceton UniversityUniversity of EdinburghOccupation(s)Physician, writer, educator, medical doctorKnown forSigner of the United States Declaration of IndependenceChildren13, including Richard and JamesBenjamin Rush (January 4, 1746 [O.S. December 24, 1745] '' April 19, 1813) was a Founding Father of the United States who signed the United States Declaration of Independence, and a civic leader in Philadelphia, where he was a physician, politician, social reformer, humanitarian, educator, and the founder of Dickinson College. Rush was a Pennsylvania delegate to the Continental Congress.[1] His later self-description there was: "He aimed right."[2][3] He served as surgeon general of the Continental Army and became a professor of chemistry, medical theory, and clinical practice at the University of Pennsylvania.[4]
Rush was a leader of the American Enlightenment and an enthusiastic supporter of the American Revolution. He was a leader in Pennsylvania's ratification of the U.S. Constitution in 1788. He was prominent in many reforms, especially in the areas of medicine and education. He opposed slavery, advocated free public schools, and sought improved, but patriarchal,[5] education for women, and a more enlightened penal system. As a leading physician, Rush had a major impact on the emerging medical profession. As an Enlightenment intellectual, he was committed to organizing all medical knowledge around explanatory theories, rather than rely on empirical methods. Rush argued that illness was the result of imbalances in the body's physical system and was caused by malfunctions in the brain. His approach prepared the way for later medical research, but Rush undertook none of it. He promoted public health by advocating clean environment and stressing the importance of personal and military hygiene. His study of mental disorder made him one of the founders of American psychiatry.[6] In 1965, the American Psychiatric Association recognized Rush as the "father of American psychiatry".[7]
Early life and career [ edit ] Coat of Arms of Benjamin Rush
The birthplace of Benjamin Rush, photographed in 1959.
Rush was born to John Rush and Susanna Hall on January 4, 1746 (December 24, 1745 O.S.). The family, of English descent,[8] lived on a farm in the Township of Byberry in Philadelphia County, about 14 miles outside of Philadelphia (the township was incorporated into Philadelphia in 1854). Rush was the fourth of seven children. His father died in July 1751 at age 39, leaving his mother, who ran a country store, to care for the family. At age eight, Benjamin was sent to live with an aunt and uncle to receive an education.[9] He and his older brother Jacob[10] attended a school run by Reverend Samuel Finley, which later became West Nottingham Academy.
In 1760, after further studies at the College of New Jersey (which in 1895 changed its name to its present name, Princeton University), Rush graduated with a Bachelor of Arts degree at age fourteen. From 1761 to 1766, Rush apprenticed under Dr. John Redman in Philadelphia. Redman encouraged him to further his studies at the University of Edinburgh in Scotland, where Rush studied from 1766 to 1768 and earned an M. D. degree.[11][12][13]:'Š60'Š [14]:'Š40'Š Rush became fluent in French, Italian, and Spanish as a result of his studies and European tour. While at Edinburgh, he became a friend of the Earl of Leven and his family, including William Leslie.[13]:'Š51''52'Š
Returning to the Colonies in 1769, Rush opened a medical practice in Philadelphia and became professor of chemistry at the College of Philadelphia (which in 1791 changed its name to its present name, University of Pennsylvania).[15] After his election to the revived American Philosophical Society in 1768, Rush served as the society's curator from 1770 to 1773, as secretary from 1773 to 1773, and vice president from 1797 to 1801.[16] Rush ultimately published the first American textbook on chemistry and several volumes on medical student education and wrote influential patriotic essays.[14]
Revolutionary period [ edit ] Rush was active in the Sons of Liberty and was elected to attend the provincial conference to send delegates to the Continental Congress. Thomas Paine consulted Rush when writing the profoundly influential pro-independence pamphlet Common Sense. Starting in 1776, Rush represented Pennsylvania and signed the Declaration of Independence.[1] He also represented Philadelphia at Pennsylvania's own Constitutional Convention.[1]
In an 1811 letter to John Adams, Rush recounted in stark fashion the signing of the Declaration of Independence. He described it as a scene of "pensive and awful silence". Rush said the delegates were called up, one after another, and then filed forward somberly to subscribe what each thought was their ensuing death warrant.[17] He related that the "gloom of the morning" was briefly interrupted when the rotund Benjamin Harrison of Virginia said to a diminutive Elbridge Gerry of Massachusetts, at the signing table, "I shall have a great advantage over you, Mr. Gerry, when we are all hung for what we are now doing. From the size and weight of my body I shall die in a few minutes and be with the Angels, but from the lightness of your body you will dance in the air an hour or two before you are dead."[17] According to Rush, Harrison's remark "procured a transient smile, but it was soon succeeded by the Solemnity with which the whole business was conducted."[17]
While Rush was representing Pennsylvania in the Continental Congress (and serving on its medical committee), he also used his medical skills in the field. Rush accompanied the Philadelphia militia during the battles after which the British occupied Philadelphia and most of New Jersey. He was depicted serving in the Battle of Princeton in the painting The Death of General Mercer at the Battle of Princeton, January 3, 1777 by the American artist John Trumbull.[18]
The Army Medical Service was in disarray, between the military casualties, extremely high losses from typhoid, yellow fever and other camp illnesses, political conflicts between Dr. John Morgan and Dr. William Shippen, Jr., and inadequate supplies and guidance from the medical committee.[19]:'Š29''43,'Š65''92'Š Nonetheless, Rush accepted an appointment as surgeon-general of the middle department of the Continental Army. Rush's order "Directions for preserving the health of soldiers" became one of the foundations of preventive military medicine and was repeatedly republished, including as late as 1908.[20][21]:'Š36''41'Š However, Rush's reporting of Dr. Shippen's misappropriation of food and wine supplies intended to comfort hospitalized soldiers, under-reporting of patient deaths, and failure to visit the hospitals under his command, ultimately led to Rush's resignation in 1778.
Controversy [ edit ] Rush criticized General George Washington in two handwritten but unsigned letters while still serving under the surgeon general. One, to Virginia Governor Patrick Henry dated October 12, 1778, quotes General Thomas Conway saying that if not for God's grace the ongoing war would have been lost by Washington and his weak counselors. Henry forwarded the letter to Washington, despite Rush's request that the criticism be conveyed orally, and Washington recognized the handwriting. At the time, the supposed Conway Cabal was reportedly trying to replace Washington with Horatio Gates as commander-in-chief.[14]:'Š133''34'Š Rush's letter relayed General John Sullivan's criticism that forces directly under Washington were undisciplined and mob-like, and contrasted Gates' army as "a well-regulated family".[22]:'Š212''215'Š Ten days later, Rush wrote to John Adams relaying complaints inside Washington's army, including about "bad bread, no order, universal disgust" and praising Conway, who had been appointed to inspector general.[14]:'Š136''37'Š
Dr. Shippen sought Rush's resignation and received it by the end of the month after Continental Congress delegate John Witherspoon, chairman of a committee to investigate Morgan's and Rush's charges of misappropriation and mismanagement against Shippen, told Rush his complaints would not produce reform.[13]:'Š219''20'Š Rush later expressed regret for his gossip against Washington. In a letter to John Adams in 1812, Rush wrote, "He [Washington] was the highly favored instrument whose patriotism and name contributed greatly to the establishment of the independence of the United States." Rush also successfully pleaded with Washington's biographers Justice Bushrod Washington and Chief Justice John Marshall to delete his association with those stinging words.[14]:'Š137'Š
In his 2005 book 1776, David McCullough quotes Rush, referring to George Washington:
The Philadelphia physician and patriot Benjamin Rush, a staunch admirer, observed that Washington "has so much martial dignity in his deportment that you would distinguish him to be a general and a soldier from among 10,000 people. There is not a king in Europe that would not look like a valet de chambre by his side."[23]
Post-Revolution [ edit ] In 1783, he was appointed to the staff of Pennsylvania Hospital, and he remained a member until his death. He was elected to the Pennsylvania convention which adopted the Federal constitution and was appointed treasurer of the United States Mint, serving from 1797 to 1813.[1] He was elected a fellow of the American Academy of Arts and Sciences in 1788.[24]
He became a professor of medical theory and clinical practice at the University of Pennsylvania in 1791, though the quality of his medicine was quite primitive even for the time: he advocated bloodletting for almost any illness, long after its practice had declined. While teaching at the University of Pennsylvania, one of his students was future president William Henry Harrison, who took a chemistry class from Rush.[25] He became a social activist and an abolitionist and was the most well-known physician in America at the time of his death.
He was also founder of Dickinson College in Carlisle, Pennsylvania. In 1794, he was elected a foreign member of the Royal Swedish Academy of Sciences. In the 1793 Philadelphia yellow fever epidemic, Rush treated patients with bleeding, calomel, and other early medicinal techniques that often were ineffective and actually brought many patients closer to their deathbeds. Rush's ideas on yellow fever treatments differed from those of many experienced French doctors, who came from the West Indies where they had yellow fever outbreaks every year.
Rush was a founding member of the Philadelphia Society for Alleviating the Miseries of Public Prisons (known today as the Pennsylvania Prison Society[26]), which greatly influenced the construction of Eastern State Penitentiary in Philadelphia.[27] He supported Thomas Jefferson for president in 1796 over the eventual winner, John Adams.[28]
Corps of Discovery [ edit ] In 1803, Jefferson sent Meriwether Lewis to Philadelphia to prepare for the Lewis and Clark Expedition under the tutelage of Rush, who taught Lewis about frontier illnesses and the performance of bloodletting. Rush provided the corps with a medical kit that included:
Turkish opium for nervousnessemetics to induce vomitingmedicinal winefifty dozen of Dr. Rush's Bilious Pills, laxatives containing more than 50% mercury, which have since colloquially been referred to as "thunderclappers." Their meat-rich diet and lack of clean water during the expedition gave the men cause to use them frequently. Although their efficacy is questionable, their high mercury content provided an excellent tracer by which archaeologists have been able to track the corps' actual route to the Pacific.[29][30][31]Reforms [ edit ] Anti-slavery [ edit ] In 1766, when Rush set out for his studies in Edinburgh, he was outraged by the sight of 100 slave ships in Liverpool harbor. As a prominent Presbyterian doctor and professor of chemistry in Philadelphia, he provided a bold and respected voice against the slave trade.[32] He warmly praised the ministry of "Black Harry" Hosier, the freedman circuit rider who accompanied Bishop Francis Asbury during the establishment of the Methodist Church in America,[33] but the highlight of his involvement was the pamphlet he wrote in 1773 entitled "An Address to the Inhabitants of the British Settlements in America, upon Slave-Keeping." In this first of his many attacks on the social evils of his day, he assailed the slave trade as well as the entire institution of slavery. Rush argued scientifically that Negroes were not by nature intellectually or morally inferior. Any apparent evidence to the contrary was only the perverted expression of slavery, which "is so foreign to the human mind, that the moral faculties, as well as those of the understanding are debased, and rendered torpid by it."[34]
Anti-capital punishment [ edit ] Rush deemed public punishments such as putting a person on display in stocks, common at the time, to be counterproductive. Instead, he proposed private confinement, labor, solitude, and religious instruction for criminals, and he opposed the death penalty.[35] His outspoken opposition to capital punishment pushed the Pennsylvania legislature to abolish the death penalty for all crimes other than first-degree murder.[4] He authored a 1792 treatise on punishing murder by death in which he made three principal arguments:[36]
I. Every man possesses an absolute power over his own liberty and property, but not over his own life...II. The punishment of murder by death, is contrary to reason, and to the order and happiness of society...III. The punishment of murder by death, is contrary to divine revelation.Rush led the state of Pennsylvania to establish the first state penitentiary, the Walnut Street Prison, in 1790. Rush campaigned for long-term imprisonment, the denial of liberty, as both the most humane but severe punishment.[37] This 1792 treatise was preceded by comments on the efficacy of the death penalty that he self-references and which, evidently, appeared in the second volume of the American Museum.[36]
Status of women [ edit ] After the Revolution, Rush proposed a new model of education for elite women that included English language, vocal music, dancing, sciences, bookkeeping, history, and moral philosophy. He was instrumental to the founding of the Young Ladies' Academy of Philadelphia, the first chartered women's institution of higher education in Philadelphia.[38] Rush saw little need for training women in metaphysics, logic, mathematics, or advanced science; rather he wanted the emphasis on guiding women toward moral essays, poetry, history, and religious writings. This type of education for elite women grew dramatically during the post-revolutionary period, as women claimed a role in creating the Republic. And so, the ideal of Republican motherhood emerged, lauding women's responsibility of instructing the young in the obligations of patriotism, the blessings of liberty and the true meaning of Republicanism. He opposed coeducational classrooms and insisted on the need to instruct all youth in the Christian religion.[39]
Medical contributions [ edit ] Physical medicine [ edit ] Rush was a leading proponent of heroic medicine. He firmly believed in such practices as bloodletting patients[40] (a practice now known to be generally harmful,[41] but at the time common practice), as well as purges using calomel and other toxic substances. In his report on the Philadelphia yellow fever epidemic of 1793, Rush wrote: "I have found bleeding to be useful, not only in cases where the pulse was full and quick but where it was slow and tense. I have bled twice in many and in one acute case four times, with the happiest effect. I consider intrepidity in the use of the lancet, at present, to be necessary, as it is in the use of mercury and jalap, in this insidious and ferocious disease." During that epidemic, Rush gained acclaim for remaining in town and treating sometimes 100 patients per day (some through freed black volunteers coordinated by Richard Allen), but many died. Even Rush acknowledged the failure of two treatments, sweats in vinegar-wrapped blankets accompanied by mercury rubs, and cold baths.[22]:'Š329'Š
William Cobbett vociferously objected to Rush's extreme use of bloodletting, and even in Rush's day and location, many physicians had abandoned on scientific grounds this favorite remedy of Rush's former teachers Thomas Sydenham and Hermann Boerhaave.[14]:'Š223''31'Š Cobbett accused Rush of killing more patients than he had saved. Rush ultimately sued Cobbett for libel, winning a judgment of $5,000 and $3,000 in court costs, which was only partially paid before Cobbett returned to England.[14]:'Š239''47'Š Nonetheless, Rush's practice waned as he continued to advocate bloodletting and purges, much to the chagrin of his friend Thomas Jefferson.[42][43][14]:'Š296'Š Some even blamed Rush's bleeding for hastening the death of Benjamin Franklin, as well as George Washington (although the only one of Washington's medics who opposed the bleeding was Rush's former student), and Rush insisted upon being bled himself shortly before his death (as he had during the yellow fever epidemic two decades earlier).[22]:'Š331,'Š363'Š [14]:'Š220,'Š295'Š
Rush also wrote the first case report on dengue fever (published in 1789 on a case from 1780).[44] Perhaps his greatest contributions to physical medicine were his establishment of a public dispensary for low income patients, and public works associated with draining and rerouting Dock Creek (eliminating mosquito breeding grounds, which greatly decreased typhus, typhoid and cholera outbreaks).
Another of Rush's medical views that now draws criticism is his analysis of race. In reviewing the case of Henry Moss, a slave who lost his dark skin color (probably through vitiligo), Rush characterized being black as a hereditary and curable skin disease. Rush wrote that the "disease, instead of inviting us [whites] to tyrannise over them [blacks], it should entitle them to a double portion of our humanity." He added that this "should teach white people the necessity of keeping up that prejudice against [miscegenation], as it would tend to infect posterity with '... their disorder" and called for an "endeavour to discover a remedy for it."[45]
Rush was interested in Native American health. He wanted to find out why Native Americans were susceptible to certain illnesses and whether they had higher mortality rates as compared to other people. Other questions that he raised were whether they dreamed more and if their hair turned gray as they got older. His fascination with these people came from his interest in the theory that social scientists can better study the history of their own civilization by studying cultures in earlier stages of development, "primitive men". In his autobiography, he writes "From a review of the three different species of settlers, it appears that there are certain regular stages which mark the progress from the savage to civilized life. The first settler is nearly related to an Indian in his manners. In the second, the Indian manners are more diluted. It is in the third species only that we behold civilization completed. It is to the third species of settlers only that it is proper to apply the term of farmers. While we record the voices of the first and second settlers, it is but just to mention their virtues likewise. Their mutual wants to produce mutual dependence; hence they are kind and friendly to each other. Their solitary situation makes visitors agreeable to them; hence they are hospitable to a stranger."[46]
Mental health [ edit ] "The Moral Thermometer." from Benjamin Rush's
An Inquiry into the Effects of Spirituous Liquors on the Human Body and the Mind. Boston: Thomas and Andrews, 1790 (Library Company of Philadelphia)
Rush published one of the first descriptions and treatments for psychiatric disorders in American medicine, Medical Inquiries and Observations, Upon the Diseases of the Mind (1812).[47][48] He undertook to classify different forms of mental illness and to theorize as to their causes and possible cures. Rush believed (incorrectly) that many mental illnesses were caused by disruptions of blood circulation or by sensory overload and treated them with devices meant to improve circulation to the brain such as a centrifugal spinning board, and inactivity/sensory deprivation via a restraining chair with a sensory-deprivation head enclosure ("tranquilizer chair").[49] After seeing mental patients in appalling conditions in Pennsylvania Hospital, Rush led a successful campaign in 1792 for the state to build a separate mental ward where the patients could be kept in more humane conditions.[50]
Rush believed, as did so many physicians of the time, that bleeding and active purging with mercury(I) chloride (calomel) were the preferable medical treatments for insanity, a fact evidenced by his statement that, "It is sometimes difficult to prevail upon patients in this state of madness, or even to compel them, to take mercury in any of the ways in which it is usually administered. In these cases I have succeeded, by sprinkling a few grains of calomel daily upon a piece of bread, and afterwards spreading over it, a thin covering of butter."[51] Rush followed the standard procedures of bleeding and treatment with mercury, he did believe that "coercion" and "restraint", the physical punishment, chains and dungeons, which were the practice of the time, were the answer as proven by his invention of the restraint chair and other devices. For this reason, some aspects of his approach could be seen as similar to Moral Therapy, which would soon rise to prominence in at least the wealthier institutions of Europe and the United States.[52]
Rush is sometimes considered a pioneer of occupational therapy particularly as it pertains to the institutionalized.[22] In Diseases of the Mind (1812), Rush wrote:
It has been remarked that the maniacs of the male sex in all hospitals, who assist in cutting wood, making fires, and digging in a garden, and the females who are employed in washing, ironing, and scrubbing floors, often recover, while persons, whose rank exempts them from performing such services, languish away their lives within the walls of the hospital.
Furthermore, Rush was one of the first people to describe Savant Syndrome. In 1789, he described the abilities of Thomas Fuller, an enslaved African who was a lightning calculator. His observation would later be described in other individuals by notable scientists like John Langdon Down.[53]
Rush pioneered the therapeutic approach to addiction.[54][55] Prior to his work, drunkenness was viewed as being sinful and a matter of choice. Rush believed that the alcoholic loses control over himself and identified the properties of alcohol, rather than the alcoholic's choice, as the causal agent. He developed the conception of alcoholism as a form of medical disease and proposed that alcoholics should be weaned from their addiction via less potent substances.[56]
Rush advocated for more humane mental institutions and perpetuated the idea that people with mental illness are people who have an illness, rather than inhuman animals. He is quoted to have said, "Terror acts powerfully upon the body, through the medium of the mind, and should be employed in the cure of madness."[57] He also championed the idea of "partial madness," or that people could have varying degrees of mental illness.[58]
The American Psychiatric Association's seal bears an image of Rush's purported profile at its center.[59][60][61] The outer ring of the seal contains the words "American Psychiatric Association 1844".[61] The Association's history of the seal states:
The choice of Rush (1746''1813) for the seal reflects his place in history. .... Rush's practice of psychiatry was based on bleeding, purging, and the use of the tranquilizer chair and gyrator. By 1844 these practices were considered erroneous and abandoned. Rush, however, was the first American to study mental disorder in a systematic manner, and he is considered the father of American Psychiatry.[61]
Educational legacy [ edit ] During his career, he educated over 3,000 medical students, and several of these established Rush Medical College in Chicago in his honor after his death. His students included Valentine Seaman, who mapped yellow fever mortality patterns in New York and introduced the smallpox vaccine to the United States in 1799.[62] One of his last apprentices was Samuel A. Cartwright, later a Confederate States of America surgeon charged with improving sanitary conditions in the camps around Vicksburg, Mississippi, and Port Hudson, Louisiana. Rush University Medical Center in Chicago, formerly Rush-Presbyterian-St. Luke's Medical Center, was named in his honor.[63]
Religious views and vision [ edit ] Rush advocated Christianity in public life and in education and sometimes compared himself to the prophet Jeremiah.[64] Rush regularly attended Christ Church in Philadelphia and counted William White among his closest friends (and neighbors). Ever the controversialist, Rush became involved in internal disputes over the revised Book of Common Prayer and the splitting of the Episcopal Church from the Church of England. He dabbled with Presbyterianism, Methodism (which split from Anglicanism in those years), and Unitarianism.[13]:'Š312'Š [22]:'Š11''12,'Š16''17,'Š269''70,'Š322,'Š346'Š In a letter to John Adams, Rush describes his religious views as "a compound of the orthodoxy and heterodoxy of most of our Christian churches."[65] Christian Universalists consider him one of their founders, although Rush stopped attending that church after the death of his friend, former Baptist pastor Elhanan Winchester, in 1797.[66]
Rush fought for temperance[13]:'Š379''380'Š and both public and Sunday schools. He helped found the Bible Society at Philadelphia (now known as the Pennsylvania Bible Society)[67][68] and promoted the American Sunday School Union.[69] When many public schools stopped using the Bible as a textbook, Rush proposed that the U.S. government require such use, as well as furnish an American Bible to every family at public expense. In 1806, Rush proposed inscribing "The Son of Man Came into the World, Not To Destroy Men's Lives, But To Save Them."[70] above the doors of courthouses and other public buildings. Earlier, on July 16, 1776, Rush had complained to Patrick Henry about a provision in Virginia's constitution of 1776 which forbade clergymen from serving in the legislature.[71]
Rush felt that the United States was the work of God: "I do not believe that the Constitution was the offspring of inspiration, but I am as perfectly satisfied that the Union of the United States in its form and adoption is as much the work of a Divine Providence as any of the miracles recorded in the Old and New Testament".[72] In 1798, after the Constitution's adoption, Rush declared: "The only foundation for a useful education in a republic is to be laid in Religion. Without this there can be no virtue, and without virtue there can be no liberty, and liberty is the object and life of all republican governments."[69] One quote popularly assigned to Rush, however, which portrays him as a medical libertarian: "Unless we put medical freedoms into the Constitution, the time will come when medicine will organize into an undercover dictatorship [. . .] To restrict the art of healing to one class of men and deny equal privileges to others will constitute the Bastille of medical science. All such laws are un-American and despotic and have no place in a republic [. . .] The Constitution of this republic should make special privilege for medical freedom as well as religious freedom," is likely a misattribution. No primary source for it has been found, and the words "un-American" and "undercover" are anachronisms, as their usage as such did not appear until after Rush's death.[73]
Before 1779, Rush's religious views were influenced by what he described as "Fletcher's controversy with the Calvinists in favor of the Universality of the atonement." After hearing Elhanan Winchester preach, Rush indicated that this theology "embraced and reconciled my ancient calvinistical, and my newly adopted (Arminian) principles. From that time on I have never doubted upon the subject of the salvation of all men." To simplify, both believed in punishment after death for the wicked. His wife, Julia Rush, thought her husband like Martin Luther for his ardent passions, fearless attacks on old prejudices, and quick tongue against perceived enemies.[14]:'Š297''298'Š
Rush helped Richard Allen found the African Methodist Episcopal Church. In his autobiography, Allen wrote:
...By this time we had waited on Dr. Rush and Mr. Robert Ralston, and told them of our distressing situation. We considered it a blessing that the Lord had put it into our hearts to wait upon... those gentle-men. They pitied our situation, and subscribed largely towards the church, and were very friendly towards us and advised us how to go on.We appointed Mr. Ralston our treasurer. Dr. Rush did much for us in public by his influence. I hope the name of Dr. Benjamin Rush and Mr. Robert Ralston will never be forgotten among us. They were the two first gentlemen who espoused the cause of the oppressed and aided us in building the house of the Lord for the poor Africans to worship in. Here was the beginning and rise of the first African church in America."[74]
Personal life [ edit ] Julia Stockton Rush, painted by Charles Willson Peale
On January 11, 1776, Rush married Julia Stockton (1759''1848), daughter of Richard Stockton, another signer of the Declaration of Independence, and his wife Annis Boudinot Stockton. They had 13 children, 9 of whom survived their first year: John, Ann Emily, Richard, Susannah (died as an infant), Elizabeth Graeme (died as an infant), Mary B, James, William (died as an infant), Benjamin (died as an infant), Richard, Julia, Samuel, and William. Richard later became a member of the cabinets of James Madison, James Monroe, John Quincy Adams, Andrew Jackson, James K. Polk, and Zachary Taylor (at one point during each of their presidencies).[75][76]
In 1812, Rush helped reconcile the friendship of Jefferson and Adams by encouraging the two former presidents to resume writing to each other.[77]
Statue of Benjamin Rush on "
Navy Hill" which is, due to security, in a section of Washington, DC inaccessible to tourists and foot traffic
Death [ edit ] After dying of typhus fever, he was buried (in Section N67) along with his wife Julia in the Christ Church Burial Ground in Philadelphia, not far from where Benjamin Franklin is buried.[78] At the site, a small plaque honoring Benjamin Rush has been placed. However, the box marker is next to the plaque on the right, with inscriptions on the top. The inscription reads,[79]
In memory ofBenjamin Rush MDhe died on the 19th of Aprilin the year of our Lord 1813Aged 68 yearsWell done good and faithful servantenter thou into the joy of the LordMrs Julia Rushconsort ofBenjamin Rush MDBorn March 2, 1759Died July 7, 1848For as in Adam, all die, even so in ChristShall all be made alive
Legacy [ edit ] Benjamin Rush Elementary School in Redmond, Washington was named by its students for him.[80] The Arts Academy at Benjamin Rush magnet high school in Philadelphia was established in 2008. Rush County, Indiana, is named for him as is its county seat, Rushville.[81] Rush University Medical Center in Chicago is named after Rush. Benjamin Rush State Park in Philadelphia is named after Rush. The eponymous conservative Benjamin Rush Institute is an associate member of the State Policy Network.[82]
Controversy regarding quotations [ edit ] George Seldes includes in his widely recognized 1960 book The Great Quotations a quote by Rush:
"The Constitution of this Republic should make special provision for medical freedom. To restrict the art of healing to one class will constitute the Bastille of medical science."[83]
The book includes a detailed depiction of sources and methodologies used by Seldes to gather the quotes. However Thomas Szasz in recent years has claimed to believe this is a false attribution, while avoiding to mention Seldes' book: "...Not a single author supplies a verifiable source for it. Hence, I believe this false attribution, depicting Rush as a medical libertarian, needs to be exposed as bogus."[84]
Writings [ edit ] Rush, Benjamin (1773). "An Address to the Inhabitants of the British Settlements in America, Upon Slave-keeping". Philadelphia: J. Dunlap . Retrieved January 1, 2017 . Rush, Benjamin (1819) [1791]. An inquiry into the effects of ardent spirits upon the human body and mind : with an account of the means of preventing, and of the remedies for curing them. Josiah Richardson. Rush, Benjamin (1794). An account of the bilious remitting yellow fever, as it appeared in the city of Philadelphia, in the year 1793. Philadelphia: Thomas Dobson. Rush, Benjamin (1798). Essays: Literary, Moral, and Philosophical. Philadelphia: Thomas & Samuel F. Bradford. 1989 reprint: Syracuse University Press, ISBN 0-912756-22-5Rush, Benjamin (1799). "Observations Intended to Favour a Supposition That the Black Color (As It Is Called) of the Negroes Is Derived from the Leprosy". Transactions of the American Philosophical Society. 4: 289''297. doi:10.2307/1005108. JSTOR 1005108. Rush, Benjamin, M.D. (1806). A plan of a Peace-Office for the United States. Essays, Literary, Moral and Philosophical. (2nd ed.). Philadelphia: Thomas and William Bradford. pp. 183''88 . Retrieved June 3, 2010 '' via Internet Archive. Rush, Benjamin (1808) [1778]. Directions for preserving the health of soldiers : addressed to the officers of the Army of the United States. Philadelphia: Thomas Dobson. Rush, Benjamin (1812) Medical Inquiries And Observations Upon The Diseases Of The Mind, 2006 reprint: Kessinger Publishing, ISBN 1-4286-2669-7. Free digital copies of original published in 1812 at http://deila.dickinson.edu/theirownwords/title/0034 [permanent dead link ] . or https://web.archive.org/web/20121024024628/http://collections.nlm.nih.gov/muradora/objectView.action?pid=nlm%3Anlmuid-2569036R-bkRush, Benjamin (2003). "Medical Inquiries and Observations, Upon the Diseases of the Mind: Philadelphia: Published by Kimber & Richardson, no. 237, Market Street; Merritt, printer, no. 9, Watkins Alley, 1812". Their Own Words. Carlisle, Pennsylvania: Dickinson College. OCLC 53177922. Archived from the original on January 7, 2004 . Retrieved October 20, 2017 . Rush, Benjamin (1815). "A Defence of Blood-letting, as a Remedy for Certain Diseases". Medical Inquiries and Observations. 4 . Retrieved October 24, 2012 . Rush, Benjamin (1830). Medical Inquiries and Observations upon Diseases of the Mind (4 ed.). Philadelphia: John Grigg. pp. 98, 197. Rush, Benjamin (1835). Medical Inquiries and Observations Upon the Diseases of the Mind (Fifth ed.). Philadelphia: Grigg and Elliott, No. 9 North Fourth Street. OCLC 2812179 . Retrieved October 20, 2017 '' via Internet Archive. Rush, Benjamin (1947). The selected writings of Benjamin Rush. New York: Philosophical Library. p. 448. ISBN 978-0-8065-2955-4. Butterfield, Lyman H., ed. (1951). Letters of Benjamin Rush. Memoirs of the American Philosophical Society. Princeton University Press. OCLC 877738348. The Spur of Fame: Dialogues of John Adams and Benjamin Rush, 1805''1813 (2001), Liberty Fund, ISBN 0-86597-287-7Rush, Benjamin (1970) [1948]. George Washington Corner (ed.). The autobiography of Benjamin Rush; his Travels through life together with his Commonplace book for 1789''1813. Westport, CT: Greenwood Press. Fox, Claire G.; Miller, Gordon L.; Miller, Jacquelyn C. (1996). Benjamin Rush, M.D: A Bibliographic Guide. Greenwood Press. ISBN 978-0-313-29823-3. Archival collections [ edit ] The Presbyterian Historical Society in Philadelphia, Pennsylvania, has a collection of Benjamin Rush's original manuscripts.
See also [ edit ] Biography portal List of abolitionist forerunnersMemorial to the 56 Signers of the Declaration of IndependenceNotes [ edit ] ^ a b c d "Benjamin Rush: 1745''1813: Representing Pennsylvania at the Continental Congress". Signers of the Decl of Independence. ushistory.org. Archived from the original on February 7, 2018 . Retrieved February 7, 2018 . ^ Renker, Elizabeth M. (1989). " 'Declaration-Men' and the Rhetoric of Self-Presentation". Early American Literature. 24 (2): 123 and n. 10 there. JSTOR 25056766. ^ Rush, Benjamin (1970) [1948]. George Washington Corner (ed.). The autobiography of Benjamin Rush; his Travels through life together with his Commonplace book for 1789''1813. Westport, CT: Greenwood Press. ^ a b "Benjamin Rush (1746''1813)". University of Pennsylvania. Archived from the original on June 10, 2011 . Retrieved August 20, 2011 . ^ Fraser, James (2019). The school in the United States : a documentary history (Fourth ed.). New York, NY: Routledge. p. 25. ISBN 978-1-138-47887-9. ^ Muccigrosso, Robert, ed. (1988). Research Guide to American Historical Biography. Vol. 3. pp. 1139''42. ^ Shorter, Edward (1997). A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. Wiley. ^ Irvine, James (1893). "Descendants of John Rush". The Pennsylvania Magazine of History and Biography. 17 (3): 334. JSTOR 20083549. ^ "About the Author: Benjamin Rush (1745''1813)". Their Own Words. deila.dickinson.edu. July 9, 2004. Archived from the original on January 26, 2004 . Retrieved October 20, 2017 . ^ The identity of Rush's siblings is confused: there are web pages saying Rush and one brother were responsible for the entire family, and also giving Rush's brothers names as William (a lawyer) and Samuel "Descendants of Thomas Rush". Archived from the original on October 9, 2012 . Retrieved 2012-12-30 . lists Rush's siblings as Jacob, James, John, Rebecca, Rachel, and Stephenson. Most likely, though William and Samuel were relatives and close friends, for Benjamin was a 5th generation removed from the Cromwell era Rush and Benjamin's father's family lived in the Byberry area for generations. ^ "Benjamin Rush". Signers of the Declaration of Independence. Archived from the original on June 29, 2015 . Retrieved December 7, 2014 . ^ Goodrich, Rev. Charles A. (1856). "Benjamin Rush, 1745''1813". Archived from the original on January 8, 2010 . Retrieved December 16, 2017 . ^ a b c d e Hawke, David Freeman (1971). Benjamin Rush: Revolutionary Gadfly . Indianapolis: Bobbs-Merrill. ^ a b c d e f g h i j Binger, Carl (1966). Revolutionary Doctor / Benjamin Rush (1746''1813). New York: Norton & Co. ^ North RL (2000). "Benjamin Rush, MD: assassin or beloved healer?". Proc Bayl Univ Med Cent. 13 (1): 45''9. doi:10.1080/08998280.2000.11927641. PMC 1312212 . PMID 16389324. ^ Bell, Whitfield J., and Charles Greifenstein, Jr. Patriot-Improvers: Biographical Sketches of Members of the American Philosophical Society. 3 vols. Philadelphia: American Philosophical Society, 1997, I:26, 33, 61''62, 184, 193, 250, 452''64, 453,466, 504, II: 136,257, 369, 386, 393, III:49, 54, 135, 204, 254, 272, 408, 524, 573. ^ a b c "Benjamin Rush to John Adams, July 20, 1811". National Park Service . Retrieved November 22, 2019 . ^ "The Death of General Mercer at the Battle of Princeton, January 3, 1777". Yale University Art Gallery. ^ Gillette, Mary (1981). The Army Medical Department 1775''1818. Army Medical Department Office of Medical History . Retrieved October 24, 2012 . ^ Rush, Benjamin (1808). Directions for preserving the health of soldiers : addressed to the officers of the Army of the United States. Philadelphia: Thomas Dobson. ^ Bayne-Jones, Stanhope (1968). Evolution of Preventative Medicine in the United States Army 1607''1939 (PDF) . Office of the Surgeon General, Department of the Army. Archived from the original on August 1, 2013 . Retrieved October 24, 2012 . ^ a b c d e Brodsky, Alyn (2004). Benjamin Rush: Patriot and Physician. New York: Truman Talley Books/St. Martin's Press. ^ McCullough, David G (2006). 1776: America and Britain at war. London: Penguin. ^ "Book of Members, 1780''2010: Chapter R" (PDF) . American Academy of Arts and Sciences . Retrieved July 28, 2014 . ^ Rabin, Alex (January 25, 2017). "With a Penn graduate in the Oval Office for the first time, here's a look at former President William Henry Harrison's time at the University". The Daily Pennsylvanian . Retrieved April 3, 2019 . ^ "The Prison Society '' About Us". The Pennsylvania Prison Society. Archived from the original on November 5, 2008 . Retrieved November 16, 2008 . ^ "The Philadelphia Society for Alleviating the Miseries of Public Prisons". The Library Company of Philadelphia. World Digital Library . Retrieved January 1, 2014 . ^ McCullough, David (2008) [2001]. John Adams . New York: Simon and Schuster. p. 470. ISBN 9781416575887. ^ Woodger, Elin; Toropov, Brandon (2009). Encyclopedia of the Lewis and Clark Expedition. Infobase Publishing. pp. 304''06. ISBN 9781438110233. ^ Duncan, Dayton; Burns, Ken (1997). Lewis & Clark: The Journey of the Corps of Discovery. New York: Alfred A. Knopf, Inc. pp. 9''10. ISBN 9780679454502. ^ Ambrose, Stephen (1996). Undaunted Courage: Meriwether Lewis, Thomas Jefferson, and the Opening of the American West. New York: Simon & Schuster. pp. 81, 87''91. ISBN 9780684826974. ^ D'Elia, Donald J (1969). "Dr. Benjamin Rush and the Negro". Journal of the History of Ideas. 30 (3): 413''22. doi:10.2307/2708566. JSTOR 2708566. ^ Webb, Stephen H. (March 2002). "Introducing Black Harry Hoosier: The History Behind Indiana's Namesake". Indiana Magazine of History. Trustees of Indiana University. 98 (1): 30''42. Archived from the original on September 5, 2014 . Retrieved February 20, 2017 . ^ Dolbeare, Kenneth M.; Cummings, Michael S. (2010). American political thought (6 ed.). p. 44. ^ "Amendment VIII: Benjamin Rush, On Punishing Murder by Death". press-pubs.uchicago.edu . Retrieved September 4, 2018 . ^ a b "The Founders' Constitution, Volume 5, Amendment VIII, Document 16". The University of Chicago Press. ^ Manion, Jen (2015). Liberty's Prisoners: Carceral Culture in Early America. University of Pennsylvania Press. ^ Savin, Marion B.; Abrahams, Harold J. (1957). "The Young Ladies' Academy of Philadelphia". History of Education Journal. 8 (2): 58''67. ^ Straub, Jean S (1987). "Benjamin Rush's View on Women's Education". Pennsylvania History. 34 (2): 147''57. ^ Rush, Benjamin (1815). "A Defence of Blood-letting, as a Remedy for Certain Diseases". Medical Inquiries and Observations. 4 . Retrieved October 24, 2012 . ^ "Why fair tests are needed". jameslindlibrary.org. 2009. Archived from the original on January 2, 2007 . Retrieved January 8, 2017 . ^ "Introduction: Thomas Jefferson to Meriwether Lewis: "bring back your party safe" ". University of Virginia: Historical Collections at the Claude Moore Health Sciences Library:Medicine and Health on the Lewis and Clark Expedition. Rector and Visitors of the University of Virginia. 2007. Archived from the original on October 20, 2017 . Retrieved October 20, 2017 . ^ "Benjamin Rush and the State of Medicine in 1803". Jefferson National Expansion Memorial. National Park Service: United States Department of the Interior. April 10, 2015. Archived from the original on October 17, 2015 . Retrieved October 20, 2017 . ^ Rush, Benjamin, M.D. (1794). An account of the bilious remitting fever, as it appeared in Philadelphia in the year 1793. Philadelphia, Pa.: Thomas Dobson. ^ Rush, Benjamin (1799). "Observations Intended to Favour a Supposition That the Black Color (As It Is Called) of the Negroes Is Derived from the Leprosy". Transactions of the American Philosophical Society. 4: 289''297. doi:10.2307/1005108. JSTOR 1005108. ^ J. Kunitz; Benjamin Rush (1970). "Benjamin Rush on Savagism and Progress Stephen". Ethnohistory. Duke University Press. 17 (1/2): 31''42. JSTOR 481523. ^ "Rush, Benjamin. Medical Inquiries and Observations, Upon the Diseases of the Mind: Philadelphia: Published by Kimber & Richardson, no. 237, Market Street; Merritt, printer, no. 9, Watkins Alley, 1812". Their Own Words. Carlisle, Pennsylvania: Dickinson College. July 17, 2003. OCLC 53177922. Archived from the original on January 7, 2004 . Retrieved October 20, 2017 . ^ Rush, Benjamin (1835). Medical Inquiries and Observations Upon the Diseases of the Mind (Fifth ed.). Philadelphia: Grigg and Elliott, No. 9 North Fourth Street. OCLC 2812179 . Retrieved October 20, 2017 '' via Internet Archive. ^ Beam, Alex (2001). Gracefully Insane: Life and Death Inside America's Premier Mental Hospital. ^ Deutsch, Albert (2007). The Mentally Ill in America: A History of Their Care and Treatment From Colonial Times. ^ Rush, Benjamin (1830). Medical Inquiries and Observations upon Diseases of the Mind (4 ed.). Philadelphia: John Grigg. pp. 98, 197. ^ Gamwell, Lynn; Tomes, Nancy (1995). Madness in America: Cultural and Medical Perceptions of Mental Illness before 1914. State University of New York at Binghamton. ^ Treffert, Darold A. (2009). "Savant Syndrome: An Extraordinary Condition: A Synopsis: Past, Present, Future". Philosophical Transactions of the Royal Society B: Biological Sciences. The Royal Society Publishing. 364 (1522): 1351''1357. doi:10.1098/rstb.2008.0326. PMC 2677584 . PMID 19528017. ^ Elster, Jon (1999). Strong Feelings: Emotion, Addiction, and Human Behavior. MIT Press. p. 131. ISBN 978-0-262-55036-9. ^ Durrant, Russil; Thakker, Jo (2003). Substance Use & Abuse: Cultural and Historical Perspectives. Thousand Oaks, CA: Sage Publications. ^ Rush, Benjamin (1805). Inquiry into the Effects of Ardent Spirits upon the Human Body and Mind. Philadelphia: Bartam. ^ "Medical Inquiries and Observations Upon the Diseases of the Mind" Author Benjamin Rush. Published 1835. Page 209. ^ Madden, Etta (2006). "PhD". Early American Literature. 41 (2): 241''272, 396. doi:10.1353/eal.2006.0022. S2CID 161899076. ProQuest 215394022. ^ "American Psychiatric Association Logo". University of California, San Francisco. Archived from the original (JPEG) on October 20, 2017 . Retrieved October 20, 2017 . ^ Moran, Mike (May 28, 2015). "New APA Logo Unifies Image of Psychiatry". Psychiatric News. American Psychiatric Association. 50 (11): 1. doi:10.1176/appi.pn.2015.6a14. The seal features the profile of Benjamin Rush, M.D., who is considered the father of American psychiatry and was a signer of the Declaration of Independence. The seal will continue to be used for ceremonial purposes and some internal documents. ^ a b c Ozarin, Lucy D. (April 17, 1998). Ramchandam, Dilip (ed.). "History Notes: The Official Seal of the APA". Psychiatric News. American Psychiatric Association. Archived from the original on August 29, 2008 . Retrieved October 20, 2017 . ^ Wilson, James Grant (1893). The Memorial History of the City of New-York: From Its First Settlement to the Year 1892. New York History Company. ^ "History". Rush University . Retrieved September 30, 2015 . ^ Hawke, p.5, citing Jeremiah's lament, "Woe is me, my mother, that thou has borne me, a man of strife, and a man of contention to the whole earth. I have neither lent on usury, nor have men lent to me on usury, yet every one of them doth curse me," in Letter to John Adams, December 26, 1811. ^ Letter to John Adams, April 5, 1808 in Butterfield, Letters of Benjamin Rush, pp. 2:962''963 ^ "Benjamin Rush". Unitarian Universalist Association. July 8, 2010. Archived from the original on July 27, 2010 . Retrieved July 8, 2010 . ^ "Dr. Benjamin Rush Diary" . Retrieved July 23, 2013 . ^ "Benjamin Rush, Signer of Declaration of Independence". adherents.com. November 28, 2005. Archived from the original on February 15, 2006. {{cite web}}: CS1 maint: unfit URL (link) ^ a b America's God and Country Encyclopedia of Quotations, by William Federer, 1999, ISBN 1-880563-09-6, p. 543 ^ (1) Rush, Benjamin (1806). "A plan of a Peace-Office for the United States". Essays, Literary, Moral and Philosophical (2 ed.). Philadelphia: Thomas and William Bradford. pp. 183''88 . Retrieved June 3, 2010 . (2) Runes, Dagobert D., ed. (1947). "A Plan of a Peace-Office for the United States". The Selected Writings of Benjamin Rush. New York: Philosophical Library. pp. 19''24 . Retrieved December 15, 2011 . ^ Rush, Benjamin (July 16, 1776). "To: Patrick Henry". Delegates to Congress: Letters of Delegates to Congress, 1774''1789, Volume 4, May 16, 1776 '' August 15, 1776. Electronic Text Center, University of Virginia Library. Archived from the original on December 15, 2012 . Retrieved October 20, 2017 . ^ To Elias Boudinot on July 9, 1788. Letters of Benjamin Rush L. H. Butterfield, ed., (American Philosophical; Society, 1951), Vol. I, p. 475. ^ Szasz, Thomas (March 1, 2005). "A bogus Benjamin Rush quote: contribution to the history of pharmacracy". History of Psychiatry. 16 (1): 89''98. doi:10.1177/0957154X05044554. ISSN 0957-154X. PMID 15981368. S2CID 20261840. ^ "The Life, Experience, and Gospel Labours of the Rt. Rev. Richard Allen. ^ Hawke (1971), pp. 170''171 ^ Brodsky (2004), p. 385. ^ Brodksy (2004), pp. 422''426. ^ Brodsky (2004), pp. 363''365 ^ Clark, Edward L. (June 2012). A Record of the Inscriptions on the Tablets and Grave-stones in the Burial-grounds of Christ Church. Applewood Books. p. 464. ISBN 9781429093095. ^ "Rush History". Retrieved October 25, 2018. ^ Goodrich, Dewitt Clinton; Tuttle, Charles Richard (1875). An Illustrated History of the State of Indiana. Indiana: R. S. Peale & co. pp. 572. ^ "Benjamin Rush Institute". State Policy Network . Retrieved June 23, 2021 . ^ Seldes, George (1960). The Great Quotations. p. 652. ^ Szasz, Thomas (March 2005). "A Bogus Benjamin Rush Quote: Contribution to the History of Pharmacracy". History of Psychiatry. London, Thousand Oaks, California, and New Delhi: SAGE Publications. 16 (1): 89''98. CiteSeerX 10.1.1.999.4430 . doi:10.1177/0957154X05044554. PMID 15981368. S2CID 20261840. Further reading [ edit ] Goodman, Nathan G. (1934). Benjamin Rush, Physician and Citizen, (1746''1813). Philadelphia: University of Pennsylvania Press. Binger, Carl (1966). Revolutionary Doctor: Benjamin Rush (1746''1813). New York: Norton & Co. Hawke, David Freeman (1971). Benjamin Rush: Revolutionary Gadfly. Indianapolis: Bobbs-Merrill. Levine, Harry G. (1978). "The Discovery of Addiction: Changing Conceptions of Habitual Drunkenness in America" (PDF) . Journal of Studies on Alcohol. 15 (1): 493''506. doi:10.15288/jsa.1978.39.143. PMID 344994. Archived from the original (PDF) on August 10, 2017. Renker, Elizabeth M. (1989). " 'Declaration-Men' and the Rhetoric of Self-Presentation". Early American Literature. 24 (2): 120''134. JSTOR 25056766. McCullough, David (2001). John Adams . Simon & Schuster. ISBN 978-1-4165-7588-7. Brodsky, Alyn (2004). Benjamin Rush: Patriot and Physician. New York: Truman Talley Books/St. Martin's Press. Myrsiades, Linda S. (2012). Law and medicine in revolutionary America : dissecting the Rush v. Cobbett trial, 1799. Bethlehem, PA: Lehigh University Press. Spencer, Mark G. (2013). Encyclopedia of the American Enlightenment. London: Bloomsbury Academic. Fried, Stephen (2018). Rush: Revolution, Madness, & the Visionary Doctor Who Became a Founding Father. New York: Crown. Unger, Harlow Giles. Dr. Benjamin Rush: The Founding Father Who Healed a Wounded Nation (Da Capo Press, 2018). 320 pp. online reviewRush, Benjamin (1800). A report of an action for a libel : brought by Dr. Benjamin Rush, against William Cobbett, in the Supreme Court of Pennsylvania. Philadelphia : Printed by W.W. Woodward. A report of an action for a libel : brought by Dr. Benjamin Rush, against William Cobbett, in the Supreme Court of Pennsylvania, December term, 1799, for certain defamatory publications in a news-paper, entitled Porcupine's gazette, of which the said William Cobbett was editor External links [ edit ] "Benjamin Rush (1746''1813)". University of Pennsylvania. "Rush, Benjamin" . Appletons' Cyclop...dia of American Biography. 1900. Article and portrait at "Discovering Lewis & Clark" Archived December 3, 2007, at the Wayback Machine"Benjamin Rush: The Revolution's Doctor of Medicine and Universal Humanitarian" '' excerpts from his writings"An oration, delivered before the American Philosophical Society, held in Philadelphia on the 27th of February, 1786; containing an enquiry into the influence of physical causes upon the moral faculty."Works by Benjamin Rush at LibriVox (public domain audiobooks) Papers from the Historic Psychiatry Collection, Menninger Archives, Kansas Historical Society"Benjamin Rush: Patriot and Physician". C-SPAN. July 4, 2004 . Retrieved March 25, 2017 . Guide to the Benjamin Rush Lectures circa 1775''1825 at the University of Chicago Special Collections Research CenterGuide to Benjamin Rush, On the Influence of Physical Causes on the Moral Faculty 1786 at the University of Chicago Special Collections Research Center
Covenant of salt - Wikipedia
Wed, 11 Jan 2023 19:03
The phrase covenant of salt appears twice in the Hebrew Bible:
In the Book of Numbers, God's covenant with the Aaronic priesthood is said to be a covenant of salt.[1] In the second book of Chronicles, God's covenant with the Davidic kings of Israel is also described as a covenant of salt.[2] According to the New Oxford Annotated Bible, "of salt" most likely means that the covenant is "a perpetual covenant, because of the use of salt as a preservative".[3]
The commandments regarding grain offerings in the Book of Leviticus state "every offering of your grain offering you shall season with salt; you shall not allow the salt of the covenant of your God to be lacking from your grain offering. With all your offerings you shall offer salt."[4]
See also [ edit ] Bread and saltReferences [ edit ] ^ Numbers 18:19 ^ 2 Chronicles 13:5 ^ Marc Brettler; Carol Newsom; Pheme Perkins, eds. (1 March 2018). The New Oxford Annotated Bible: New Revised Standard Version. Oxford University Press. p. 370. ISBN 978-0-19-027606-5. ^ Leviticus 2:13
Covenant Of Salt Definition and Meaning - Bible Dictionary
Wed, 11 Jan 2023 19:03
COVENANT OF SALT
solt (berith melach; halas, classical Greek hals):
As salt was regarded as a necessary ingredient of the daily food, and so of all sacrifices offered to Yahweh (Leviticus 2:13), it became an easy step to the very close connection between salt and covenant-making. When men ate together they became friends. Compare the Arabic expression, "There is salt between us"; "He has eaten of my salt," which means partaking of hospitality which cemented friendship; compare "eat the salt of the palace" (Ezra 4:14). Covenants were generally confirmed by sacrificial meals and salt was always present. Since, too, salt is a preservative, it would easily become symbolic of an enduring covenant. So offerings to Yahweh were to be by a statute forever, "a covenant of salt for ever before Yahweh" (Numbers 18:19). David received his kingdom forever from Yahweh by a "covenant of salt" (2 Chronicles 13:5). In the light of these conceptions the remark of our Lord becomes the more significant: "Have salt in yourselves, and be at peace one with another" (Mark 9:50).
Edward Bagby Pollard
Jordan Maxwell | Esoteric Scholar
Wed, 11 Jan 2023 18:32
Jordan Maxwell continues as a preeminent researcher and independent scholar in the field of occult / religious philosophy. His interest in these subjects began as far back as 1959. He served for three and a half years as the Religion Editor of Truth Seeker Magazine, America's oldest Freethought Journal (since 1873). His work exploring the hidden foundations of Western religions and secret societies creates enthusiastic responses from audiences around the world.
He has conducted dozens of intensive seminars, hosted his own radio talk shows, guested on more than 600 radio shows, and written, produced and appeared in numerous television shows and documentaries (including three 2-hour specials for the CBS TV network, as well as the internationally acclaimed 5-part Ancient Mystery Series - all devoted to understanding ancient religions and their pervasive influence on world affairs today.
His work on the subject of secret societies, both ancient and modern, and their symbols, has fascinated audiences around the world for decades.
Considering the rapidly moving events of today, and the very real part that hidden religious agendas play in our modern war-torn world, he feels these controversial subjects are not only interesting to explore, but too important to ignore! His extraordinary presentations includes documents and photographs seldom seen elsewhere. Jordans areas of interest include: * Astro-Theology * Sexual Symbolism in World Religions * Foundations for Modern-Day Religion * Secret Societies and Toxic Religion * World Mysteries: Ancient and Modern * Ancient Symbols and Occult Emblems * Ancient Sciences and Technology * Hidden Bible Teachings and Mysteries * The Sun in the History of Politics and Religion * The Story Your Church Doesn't Want You to Know * Secret Societies and their Influence on World Events
Affiliations: A & S Research Inc. Vice President 2006 to Present
Greater Los Angeles Press Club 1994 to Present Society of Professional Journalists 1993 to Present Borderlands Network Research Consultant and VP of Acquisitions 2003 to Present Truth Seeker Company, Inc. Religion Editor / Editorial Board Member 1991 to February 1998 United Sensitives of America Board of Directors 1989 to Present Ohana Council of the Native Hawaii Brotherhood Ambassador of the Sovereign Kingdom of Hawaii to America 1993 to Present Kronia Communications Group - Astro Physics Society Board of Advisors and Media Rep. 1995 to Present
Seminars & Conferences
Stargate of the Gods Solar Eclipse Egypt Tour 2006 Cairo, Egypt - Giza Plateau - Nile Tour March 25 - April 6, 2006 Featured Speaker (6 Hours)
PQI Events 2006 Q3 International Conference Malta - Radisson SAS Golden Sands February 25 - March 5, 2006 Keynote & Featured Speaker (6 Hours)
The Bay Area UFO Expo, August 2004 Santa Clara Convention Center Keynote Speaker Conspiracy Con 2004 Santa Clara Convention Center, May 2004 Featured Speaker (1 hour) Egypt Ancient Wisdom Tour 2004 Cairo - Giza Plateau - Nile Tour Featured Speaker (6 hours) Signs of Destiny II I Tempe, Arizona, Nov 21-23, 2003 Featured Speaker (2 hours) Conspiracy Con 2003 Santa Clara Convention Center, May 24-25, 2003 Featured Speaker (Saturday, 2 hours) Egypt in the New Millennium Giza Plateau, Egypt, May 9-18, 1999 Host and Speaker, International Millennial conference at the Great Pyramid of Giza Lapis Conferences Manchester, Blackpool, and York, England, October 1998 Keynote Speaker and Lecturer, "The Gods of Ancient Theologies" (2 hours) Kronia Astro-Physics World Conference Portland, Oregon, January 3-5, 1997 Co-host, MC and Panel Moderator, "Planetary Violence in Human History" The Third Annual Bay Area UFO Expo Santa Clara Convention Center, Sept. 14-16, 2001 Featured Speaker Conspiracy Con 2001 Santa Clara Convention Center, May 26-27, 2001 Keynote Speaker (Saturday 2-hours - Sunday 2-hours) CIRAEP Need-To-Know Seminar Philadelphia, PA, May 6-7 & July 15-16, 2000 Appeared with Preston Nichols and Al Bielek The Bay Area UFO Expo Santa Clara Convention Center, California, Aug. 1999 Keynote Speaker International UFO Congress Mosquite, Nevada, Oct. 1999 Conference opening Keynote Speaker Area 51 Rachel, NV, August 1996 "Occult Symbols in the Church Today" (2 hours) Whole Life Expo Los Angeles, California, October 1995 with Comedian/Musician Steve Allen and KABC newsman Bill Jenkins "Church, State, and Toxic Religion" (2 hours) Whole Life Expo Los Angeles, California, May 1995 with Comedian/Musician Steve Allen and KABC newsman Bill Jenkins "Secret Societies and Ancient Religion" (2 hours) International UFO Congress Mosquite, Nevada, Dec. 1994 Speaker (2 hours) Global Sciences, 13th Annual Congress Denver, Colorado, August 1995 "The Future Belongs to Those Who Are Prepared for It" One 1-hour lecture, and two 2-hour workshops Area 51 Rachel, Nevada, December 1994 "Occult Religion and Hidden Symbols" (3 hours) Sui Juris Coalition Ward Center, Hawaii, September 1994 "Ancient Influences on Modern Religions" (6 hours) Italian American Friendship Club Las Vegas, Nevada, July 1994 "The Hidden History of Religion" (2 hours) Zulu Nations/Abbey Entertainment Hollywood, California, July 1994 "Egypt, Light of the World" (3 hours) The Breakfast Club (sponsor) Las Vegas, Nevada, October 1993 "Hidden Influences in Our Government" (3 hours) Sui Juris Coalition Paki-Hale, Oahu, Hawaii, October 1993 "Secret Societies and their Influence on World Governments" (4 hours) Sui Juris Coalition Kona, Hawaii, September 1993 "The Truth About the Separation of Church and State" (4 hours) Black and Latino Multicultural Center Pasadena, California, 1993 - 1996 "Ancient Origins of Religions" Nine 3-hour presentations Global Deception Seminar Wembley Arena, London, England, January 1993 sponsored by Nightlink Communications Company (invited speaker) Privately Produced Seminar Los Angeles, California, Nov. and Dec. of 1992 "The Greatest Story Never Told", co-hosted with Zears Miles (6 hours) Self-produced Seminar Palmdale, California, December 1992 "More Than Meets the Eye" (4 hours) Private Seminar Los Angeles, California, July 1992 "What Your Church Didn't Tell You", with KABC News Reporter Bill Jenkins (4 hours) International Research and Education Society (sponsor) Los Angeles, California, 1991 "Secret Societies in Religion and Politics",with KABC newsman Bill Jenkins (5 hours) Privately sponsored, invitation-only seminar company San Francisco, California, June 1991 "The Greatest Story Never Told" (8 hours) Influence of Secret Societies on the Church Private Seminar Los Angeles, CA, Feb. 1989
Lectures
University of Hawaii Honolulu, Hawaii, May 1996 for Hawaiian Humanist Association "The Religion of Church and State" (3 Hours) University of Georgia Atlanta, Georgia, April 1995 "Church, State, and the Occult" (3-hour Lecture) University of Southern California Los Angeles, California, March 1995 "Politics and Religion, the Two Hands" (3-hour Lecture) University of California at Los Angeles Los Angeles, California, March 1995 "Occult Theology - Modern Religion" (2-hour Lecture) University of California at Santa Barbara Santa Barbara, California, March 1994 "What the Church Did Not Tell You" (2-hour Lecture) Ventura College Ventura, California, March 1995 "The Story the Church Didn't Tell You!" (3-hour Lecture) Century City Rotary Club Century Plaza Hotel, Beverly Hills, Ca, Aug 1994 "The Law of God" (1-hour Lecture) Brain Mind Symposium Los Angeles, California, June 1993 and July 1994 "Ancient Mysteries of the Bible" (Lecture and 2-hour Workshop) Humanist Association of Los Angeles University of California at Los Angeles, March 1994 "The Truth Behind State-Church Separation" (3-hour Lecture) International UFO Congress Laughlin, Nevada, December 1994 and August 1998 "Secrets of the Bible" (1-hour Lecture) Whole Life Expo Los Angeles, California, November 1994"The Story Your Church Didn't Tell You "(Lecture and 2-hour Workshop) Whole Life Expo Las Vegas, Nevada, October 1994 "The Story Your Church Didn't Tell You" (Lecture and 2-hour Workshop) Whole Life Expo San Diego, California, September 1994 "Hidden Secrets of Western Religion" (Lecture and 2-hour Workshop) Extraordinary Research Expo Los Angeles, California, September 1994 "Secret Societies and World Mysteries" (Lecture and 2-hour Workshop) National New Age Conference Phoenix-Mesa, Arizona, September 1994 "The Occult and Secret Societies" (Lecture and 2-hour Workshop) Republican Candidates for Nevada Fund Raiser Las Vegas, Nevada, July 1994 "Something's Wrong with the System" (1 hour) Psynetics Foundation Anaheim, California, March 1994 and June 1994 "The Story Your Church Doesn't Want You to Know" (2-hour lecture) Antiquarian Book Fair Burbank, California, May 1994 "Astral Theology and Religious Cults" (Lecture and 2-hour Workshop) UFO Expo West Los Angeles, California, June 1993 and May 1994 "Religion, Politics, and the Occult Connection" (Lecture and 2-hour Workshop) Whole Life Expo Los Angeles, California, April 1994 "Hidden Secrets of Western Religion" (Lecture and 2-hour Workshop) National Health Federation Annual Conference Pasadena, California, February 1994 "Ancient Influences on Modern Government" (1-hour Lecture) Whole Life Expo Los Angeles, California, June 1993 "Ancient Origins of Religion" (Lecture and 2-hour Workshop) Whole Life Expo Pasadena, California, March 1993 "Ancient Foundations of Religion" (Lecture and 2-hour Workshop) National New Age Conference San Diego, California, March 1993 "Religion, Politics, and the Occult Connection" (Lecture and 2-hour Workshop) Atheists United Marina del Rey, California, February 1993 "Messianic Cults" (2-hour Lecture) Look Within Books Arcadia, California, all in 1993 * "Basic Slide Presentation" (3-hour Lecture) * "The Story Your Church Didn't Tell You" (3-hour Lecture) * "Occult Influences on Religion" (3-hour Lecture) * "Religion, Politics, and the Occult Connection" (3-hour Lecture) National Health Federation Annual Conference Pasadena, California,January 1993 "Secret Societies and World Government" (1-hour Lecture) Whole Life Expo San Diego, California, June 1993 "Ancient Foundations of Modern-Day Religion" (Lecture and 2-hour Workshop) Need to Know Seminar Civilian Intelligence Network, Arcadia, California, June 1992 "Occult Symbols of Government" (2-hour Lecture) Need to Know Seminar Civilian Intelligence Network, Garden Grove, California, April 1992 "Hidden Influences of Religion and Government" (1-hour Lecture) Whole Life Expo Los Angeles, California, 1992 "Hidden Sciences and Technologies" (lecture and 2-hour Workshop) Whole Life Expo Pasadena, California, February 1991 "Signs and Symbols of Ancient Man" (Lecture and 2-hour Workshop) Masonic Lodge of La Crescenta La Crescenta, California, February 1991 "Understanding the New Age" (2-hour Lecture)
Motion Pictures
Man of Faith 7 Spirits Entertainment with Faye Dunaway Robert Wagner William McNamara Brad Dourif and introducing Jordan Maxwell
Earth's Original Sin (2010) Un-Named Productions
Publications
Articles Written by Jordan Maxwell
Esoteric Christianity Astro-Theology, the Hidden Church New Dawn Magazine Melbourne, Australia February 2002 Astro-Theology Retelling an Ancient Story Exposure Magazine Queensland, Australia February 1999 God the Son Worship of the Heavens Whole Life Times Los Angeles, California April 1994 Seeking the Truth Rancho Bernardo Sun San Diego, CA June 1996 Symbols Part One Truthseeker Magazine San Diego, CA May 1996
Articles Written About Jordan Maxwell
Cross(Reference)ing Jordan: Scholars at Conspiracy Con React to a UFO Magazine Article and the Work of Jordan Maxwell UFO Magazine Marina Del Rey, California May 2007 Volume 22 No 5
Hollywood Stars: Their Magical Powers Leyed Bare UFO Magazine Marina del Ray, California May 2006 Volume 21 Basic Slide Presentation Atlantis Rising Livingston, Montana March/April 2004 Matrix of Power Namaste Shrewsbury, England Vol. 6 Issue 3 March 2004 Doing His Own Homework Atlantis Rising Livingston, Montana December 2003 FBI - Paranoid Pleasures Fortean Times London, England September 2001 Trend Territory Bay Area UFO Expo UFO Magazine Los Angeles, California November 1999 The Secret World of Freemasons Fate Magazine St. Paul, Minnesota September 1997
Radio Interviews
The following is a just small sampling of over 600 radio interviews Coast to Coast AM With George Noory Premiere Radio Network 2 hours, April 2005
Coast to Coast AM With George Noory Premiere Radio Network 3 hours, March 2004 The Bob Grant Show WABC Radio, New York 2 hours, December 1991 The Tom Leykis Show KFI Radio Los Angeles, California 2 hours, 1991 The Art Bell Show "Dreamland", Pahrump, Nevada Premiere Radio Network 3 hours, 1995 NPR - Morning Edition National Public Radio Washington, DC May 1995 The Doug Stephen Show KABC Radio, Los Angeles, California 2-hour show, 1996 The Ray Bream Show KABC AM, with co-guest KABC newsman Bill Jenkins Los Angeles, California 3-hour show, 1994 The Peter Weisback Show KOGO Radio, with host Peter Weisback, San Diego, California 1-hour show, April 1996 The Jeff Rense Show Sightings Radio Network Seven 90 minute shows from 1997 to 2001 The Roy of Hollywood Show with co-guest Astronaut Edgar Mitchell and KABC newsman Bill Jenkins KPFK, LA, California 2-hour show, 1993 Marian Bistriceanu Show Societatea Romana de Radiodifuziune (National Romanian Network Radio) Bucuresti, Romania 30 minute interview Sci-Zone hosted by Bill Boshears, WLW Radio, Cincinnati, Ohio Two 1-hour shows The Lou Epton Show KLAV Radio Las Vegas, Nevada Eight 2-hour shows, 1996 - 1999 Main Street America hosted by KABC news anchor Bill Jenkins Los Angeles, California Two 2 hour shows, 1995 The Bruce Fisher Show KGU AM, Honolulu, Hawaii 1 hour show, 1994 The Don Smith Show K108 AM, Honolulu, Hawaii Two 1-hour shows, 1994 Timeless Voyager Radio Toronto, Canada Syndicated Six 1-hour shows, 1993-1994 Voices on the Wind hosted by Ivy West, K108 AM Honolulu, Hawaii Eight 2-hour shows, 1993 The Stan Johnson Show Syndicated shows Topeka, Kansas Two 1-hour shows, 1993 The Other Side of Religion hosted by Bruce Steven Holmes, KUSB FM University of California at Santa Barbara 1 hour show, 1993 Vortex Network hosted by Michael El Legion, KIEV Radio, Los Angeles, California Three 2 hour shows, 1992-1993 The Hour of the Time hosted by William Cooper, satellite network and short-wave Two 1-hour shows, 1993 Family Tree Show hosted by Marcus Lewis, KPFK, Los Angeles, California Three 90-minute shows and one 2-hour show, 1992 The Bottom Line hosted by Dr. Roy Muddey, nationally syndicated radio, Beverly Hills, California Two 1-hour shows, 1992 Ebony "92" hosted by Ms. Gerta Steel Pasadena City College Radio, KPCC FM, Pasadena, California 1-hour show, 1992 Radio Free America Network with Anthony J. Hilder Three 2-hour shows, 1991
Television Tamasha International Network Persian Television , Iran 1 hour interview, 2004 Holy Conflict Seven Spirits Entertainmenthosted by Robert Wagner with Jordan Maxwell90 minute television show, 2002 Encounters with the Unexplained PAX TV NetworkOn-screen Expert Witness1-hour show - July 2001 Atlantis The Learning Channel / Of Like Mind ProductionsHollywood, CaliforniaOn-screen Expert Witness1-hour show - March 2001 Area 51 Revisited Discovery Channel / Termite Art Productions Studio City, CaliforniaOn-screen Expert Witness1-hour show - Feb 2001 In Search Of Fox TV Network with ISO ProductionUniversal Studios, Orlando FLOn-screen Expert and Research Consultant1-hour show - Dec 2000 Year 2000 Apropos Film, ZDF (Germany) and ORF (Austria)Featured Guest and On-screen Expert 1-hour television special, December 1999 The New Apocalypse: Mankind's Last Exodus Madacy Entertainment GroupSt. Laurent, Quebec, CanadaOn-screen Expert and Research Consultant 1-hour show, December 1999 Strange Universe UPN Network / Rysher ProductionsOn-screen Expert and Research Consultant, 1999 Ancient Secrets of the Bible, Part 1 CBS Television NetworkOn-screen Expert and Research Consultant 2-hour special, May 1992 Ancient Secrets of the Bible, Part 2 CBS Television NetworkOn-screen Expert and Research Consultant 2-hour special, May 1993 Ancient Mysteries of The World, Part 3 CBS Television NetworkOn-screen Expert and Research Consultant2-hour special, May 1994 Another Point of View interview with Jordan Maxwell and comedian/musician Steve AllenSanta Monica, California1-hour show, January 1998 Past, Present, and Future hosted by Elvira Bohle,Santa Barbara Cable (California) Š(8 1-hour shows, 1992-1995) Mars Hill Show Channel 33, Long Beach, California* "Is America a Christian Nation?" (1-hour show, 1993)* "Ancient Mysteries" (1-hour show, 1993)* "Lucifer 2000"Jordan Maxwell interview (two 1-hour shows, 1993) Book Beat hosted by Rita Dyson, Channel 56, KDOC, Orange County* "Secret Societies, Past and Present" (30-minute show, March 1994)* "Storm of the Century" (30-minute show, March 1994)* "The Church and State Affair" (30-minute show, 1993)* "Ancient Influences on Modern Religion" (30-minute show, 1993) Superstitions hosted by Loren Peck, Channel 33, Long Beach, California1-hour show, 1993 OLELO-TV hosted by Ivy West, Honolulu, Hawaii Four 2-hour shows and four 30-minute shows, Fall 1993 Age of Reason hosted by Jonathan Bogg, Paragon Cable TelevisionOrange County, CA1991, two 1-hour shows Videos produced by Jordan Maxwell
Symbols, Sex and the Stars - Parts I, II and III written and narrated by Jordan Maxwell 1998, 90 minute, 60 minute, 90 minute videos Jordan Maxwell on Religion and Politics 1998, 90 minute video Astrological Prophecy and World Events produced for Arizona Television Dr. Louis Turi and Jordan Maxwell 1995, 1 hour show
Religion, Reality and Cosmic Awareness Lecture and Slide Presentation Written and narrated by Jordan Maxwell 90 Minutes. 1992 The Naked Truth - Part 1 aka The Hidden Truth * written by Jordan Maxwell hosted by British TV journalist, Derek Partridge broadcast on KCLA-TV (Channel 9) in Los Angeles, and New York City produced for the International Research and Educational Society 1991, 1 hour show The Naked Truth - Part 2 * Written by Jordan Maxwell With British TV journalist, Derek Partridge and KABC newsman, Bill Jenkins produced for the International Research and Education Society 2 hour show, 1991 Egypt - Light of the World * Written and narrated by Jordan Maxwell produced for the International Research and Education Society 1 hour show, 1992
Ancient Belief Systems * Written and narrated by Jordan Maxwell produced for the International Research and Education Society 1 hour show, 1992 Matrix of Power * Written and narrated by Jordan Maxwell produced for the International Research and Education Society 1 hour show, 1992 * Jordan Maxwell is no longer affiliated in any way with IRES Co., producers of the Naked Truth series.
The following videos were produced by Jordan Maxwell between the years of 1992 and 2005. Click on each title for more information.
Ancient Religious History
The Dark Side
Basic Slide Presentation
Chief Cornerstone
Egypt in the New Millenium
Magic Dominates the World
Private Interview With Zecharia Sitchin
Signs of Destiny
Sons of God
Toxic Religion
Secret Societies & Word Meanings
The Bible, End Times & Prehistory
Other videos featuring Jordan Maxwell Zeitgeist: The Movie (Viewed by over 100,000,000 people)
UFOs: Past Present & Future
The Book Your Church Doesn't Want You to Read: The Video
Ancient Secrets of the Bible, Part 1 CBS Television Network On-screen Expert and Research Consultant 2-hour special, May 1992 Ancient Secrets of the Bible, Part 2 CBS Television Network On-screen Expert and Research Consultant 2-hour special, May 1993 Ancient Mysteries of The World, Part 3 CBS Television Network On-screen Expert and Research Consultant 2-hour special, May 1994
The New Apocalypse: Mankind's Last Exodus
Millenium 2000
Violence Definition & Meaning - Merriam-Webster
Wed, 11 Jan 2023 18:27
1
a : the use of physical force so as to injure, abuse, damage, or destroy
b : an instance of violent treatment or procedure 2
: injury by or as if by distortion, infringement, or profanation : outrage 3
a : intense, turbulent, or furious and often destructive action or force the violence of the storm b : vehement feeling or expression : fervor also : an instance of such action or feeling
4
: undue alteration (as of wording or sense in editing a text)
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(16) diamond dead - Twitter Search / Twitter
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Privilege Definition & Meaning - Merriam-Webster
Wed, 11 Jan 2023 18:07
: a right or immunity granted as a peculiar benefit, advantage, or favor : prerogative especially : such a right or immunity attached specifically to a position or an office
transitive verb
2
: to accord a higher value or superior position to privilege one mode of discourse over another Synonyms Example Sentences Noun It is evolving into an elite institution, open chiefly to the well-educated few. In short, marriage is becoming yet another form of privilege . '-- Barbara Dafoe Whitehead , Commonweal , 2 Dec. 2005 The oldest of the students, she had become a confidante of Fern's and she alone was allowed to call her by her first name. It was not a privilege the others coveted. '-- Edward P. Jones , The Known World , 2003 But the two were grown in the same petri dish of power, prep school and privilege . '-- Howard Fineman , Newsweek , 16 Oct. 2000 Good health care should be a right and not a privilege. We had the privilege of being invited to the party. I had the privilege of knowing your grandfather. He lived a life of wealth and privilege. Verb The new tax laws unfairly privilege the rich. only professionals who meet the education and experience requirements set by law are privileged to use the title ''interior designer'' in Oklahoma See More Recent Examples on the WebNoun
The privilege '-- written into the U.S. and California constitutions as well as the San Diego City Charter '-- often means that politicians must listen at public meetings while they are challenged over decisions like new taxes or development projects. '-- San Diego Union-Tribune, 24 Dec. 2022 Still, the right to vote remained a white, male privilege for decades. '-- Brittny Mejiastaff Writer, Los Angeles Times, 22 Dec. 2022 And the privilege of advising seven Presidents of the United States over almost 40 years. '-- Alice Park, Time, 20 Dec. 2022 During the one-hour conversation moderated by writer Pamela Cohn, Jain discussed her body of work, which looks at cultural constructs such as privilege, caste, class and gender, revealing their ubiquity in contemporary Indian society. '-- Addie Morfoot, Variety, 15 Nov. 2022 On July 14th, the Romanovs had unexpectedly been allowed the special privilege of a service, conducted for them at the Ipatiev House by a local priest, Father Ivan Storozhev. '-- Caroline Hallemann, Town & Country, 14 Nov. 2022 Until the pandemic struck, this shrine to privilege, paranoia, and American ingenuity sat mostly empty, providing abstract peace of mind to faraway owners. '-- Jenna Russell, BostonGlobe.com, 27 Oct. 2022 Glose's book is a privilege to read, a tribute to his comrades in war and peace, a divulgence of truth that gives necessary attention to veterans and their families. '-- Stefanie Milligan, The Christian Science Monitor, 19 Oct. 2022 But the prospect of being in the minority can suddenly make white identity '-- and all the historical privilege that comes with it '-- salient. '-- Rayna Reid Rayford, Essence, 11 Oct. 2022 Verb
Later on in his piece, Cronon writes: Without our quite realizing it, wilderness tends to privilege some parts of nature at the expense of others. '-- Keith Kloor, Discover Magazine, 29 July 2011 Such provocative claims fly in the face of long-standing paradigms, many of which continue to privilege Anglophone actors. '-- Ned Blackhawk, Washington Post, 4 Oct. 2022 And their rules often privilege those already in power. '-- T.c. Sottek, The Verge, 7 Jan. 2021 Once again false narratives of Indian history are at play, narratives that privilege the majority and oppress minorities, and these narratives, let it be said, are popular, just as the Russian tyrant's lies are believed. '-- Lauren Markham, Harper's Magazine , 20 July 2022 In refusing to privilege human drama over natural processes, Hildyard captures the ecosystem's delicate interconnectedness and suggests a new way of writing about our toll on the environment. '-- The New Yorker, 15 Aug. 2022 Although there's no real reason to situate north at the top of maps, this eventually became the norm '-- explained in part by European mapmakers wanting to privilege their own positions in the world. '-- Nancy Lord, Anchorage Daily News, 23 July 2022 And the commitment went beyond a single show '-- part of Nicola's belief that directors are equal partners with playwrights in an American theater system that tends to privilege the latter. '-- New York Times, 13 July 2022 Continuing to privilege bigger firms and more established technology could hit extra hard as the Federal Reserve continues to raise interest rates in the name of combating inflation. '-- Kate Aronoff, The New Republic, 22 June 2022 See More These example sentences are selected automatically from various online news sources to reflect current usage of the word 'privilege.' Views expressed in the examples do not represent the opinion of Merriam-Webster or its editors. Send us feedback.
Word HistoryEtymology
Noun and Verb
Middle English, from Anglo-French, from Latin privilegium law for or against a private person, from privus private + leg-, lex law
First Known Use
Noun
12th century, in the meaning defined above
Verb
14th century, in the meaning defined at sense 1
Time Traveler
The first known use of privilege was in the 12th century Dictionary Entries Near privilege Cite this Entry ''Privilege.'' Merriam-Webster.com Dictionary, Merriam-Webster, https://www.merriam-webster.com/dictionary/privilege. Accessed 11 Jan. 2023.
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Produce Justice ® | Neely Fuller Jr's "Counter-Racist Code"
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New York (CNN) '-- The Federal Aviation Administration lifted its order to halt all domestic flight departures across the United States Wednesday after it restored the system providing pilots with pre-flight safety notices. The overnight outage caused extensive disruption, and thousands of flights remain delayed across the country.
The agency put a ground stop order in place after its NOTAM -- or Notice to Air Missions -- system failed. The FAA lifted the order shortly before 9 a.m. ET, and the agency said normal air traffic operations were resuming across the country. It said it was still trying to determine the cause of the problem.
But airlines continued to delay or cancel flights because of ongoing congestion. An airline source familiar with the situation said airlines may implement ground delay programs, which could potentially lead to further timetable issues.
The FAA's website was still showing a ground delay at New York's LaGuardia Airport as of 10:50 a.m. ET. The site also showed a ground delay at Charlotte Douglas International Airport in North Carolina, one of American Airlines' largest hubs.
The Chicago Department of Aviation said ground stops at O'Hare and Midway had been lifted but "residual delays or cancellations" are likely.
Major US carriers including United Airlines, Delta and American Airlines all said they had grounded flights in response to the situation. United Airlines has issued a North America travel waiver in response to the outage. FlightAware, which tracks delays and cancellations, showed more than 6,100 flights to, from and within the United States as being delayed as of 10:50 a.m. ET, and more than 1,000 flights canceled so far.
Southwest, which canceled tens of thousands of flights after Christmas following a systemwide meltdown, has more cancellations and delays than the other airlines. About 9% of Southwest flights are canceled and 45% of flights are delayed.
The airline said mid-morning Wednesday that operations have resumed.
"As a result of the FAA's outage, we anticipate some schedule adjustments will be made throughout the day," Southwest said in a statement, encouraging travelers to check their flight status online or via the airline's app. Southwest has also issued a waiver allowing travelers to change their flights. Cause of outage still unclear
The affected system, Notice to Air Missions (NOTAM), sends alerts to pilots to let them know of conditions that could affect the safety of their flights. It is separate from the air traffic control system that keeps planes a safe distance from each other, but it's another critical tool for air safety. US President Joe Biden said there was no immediate information on what had caused the outage -- the second US aviation crisis in a matter of weeks. He said he had been briefed on the situation and was in touch with Transportation Secretary Pete Buttigieg.
"I just spoke with Buttigieg," he told reporters as he departed the White House. "They don't know what the cause is. But I was on the phone with him the last 10 minutes. I told them to report directly to me when they find out. Aircraft can still land safely, just not take off right now."
He continued, "They don't know what the cause of it is. They expect in a couple of hours they'll have a good sense of what caused it and will respond at that time."
Asked whether it was a cyberattack, Biden said: "They don't know. They will find out."
There is "no evidence of foul play based on our discussions with DOT/FAA," a senior US official familiar with matter told CNN.
Earlier, White House Press Secretary Karine Jean-Pierre said in a statement that there was "no evidence of a cyberattack at this point," but that Biden had ordered a Department of Transportation investigation.
Buttigieg said via Twitter Wednesday morning that he had ordered an "after-action process to determine root causes and recommend next steps."
Calls came swiftly for aviation system upgrades.
"Today's FAA catastrophic system failure is a clear sign that America's transportation network desperately needs significant upgrades," said Geoff Freeman, president and CEO of the U.S. Travel Association.
"Americans deserve an end-to-end travel experience that is seamless and secure. And our nation's economy depends on a best-in-class air travel system."
International flights affected
International flights bound for the United States were continuing to take off from Amsterdam and Paris despite the situation. A Schiphol Airport spokesperson told CNN that "a workaround had been issued" and flights were still departing from Amsterdam.
No flights have been canceled from Paris' Charles de Gaulle airport, but delays were expected, according to the airport's press office. Frankfurt Airport also told CNN it had not been impacted.
A London Heathrow Airport spokesperson told CNN that they were "not aware of canceled flights and that flights to the US had left recently," however there were passenger reports of significant delays.
Shabnam Amini told CNN that she and other travelers had been sitting on board Americans Airlines flight 51 to Dallas for almost three hours at Heathrow because of the FAA outage.
She said they had been informed that there were delays but were still boarded onto the aircraft.
Commercial airline pilots use NOTAMS for real-time information on flight hazards and restrictions. The FAA stipulates NOTAMS are not to be relied on as a sole source of information, and so some flights may be able to satisfy safety requirements by using other data.
Wednesday's incident comes on the heels of another aviation crisis. A huge winter storm over the end-of-year holidays caused extensive disruption and helped trigger the Southwest Airlines meltdown that affected thousands of passengers.
CNN's Barry Neild, Paul P. Murphy, Betsy Kline, Livvy Doherty, Chris Isidore, Sean Lyngaas, Betsy Klein, Marnie Hunter and Stephanie Halasz contributed to this story.
All US domestic flights grounded after software glitch '-- RT World News
Wed, 11 Jan 2023 15:49
The Federal Aviation Administration (FAA) has reported a failure of the crucial Notice to Air Missions System
A software glitch in the US Federal Aviation Administration's (FAA) system used to send essential information to aircraft has prompted the regulator to halt all further domestic departures in the US.
The issue affected the Notice to Air Missions System (NOTAM) on Wednesday morning, the FAA said in a statement. This is used to communicate crucial data to air traffic control.
The regulator said the mishap was affecting all flights across the US and that its technical staff were performing validation checks and trying to reboot the system, but offered no indication of how long it would take.
Cleared Update No. 2 for all stakeholders: '°'°The FAA is still working to fully restore the Notice to Air Missions system following an outage. '°'°While some functions are beginning to come back on line, National Airspace System operations remain limited.
'-- The FAA ''¸ (@FAANews) January 11, 2023Later in the day, the agency said it had ordered the suspension of domestic departures for several hours, as the system was gradually restoring functionality. The FAA stated that planes already in the sky were not at risk as a result of the NOTAM outage.
Serious issues with flights were previously reported by US media. FlightAware, a service tracking such events, reported more than 2,500 delays and over 300 cancellations of flights traveling to or from US airports.
Two hours after the initial report, the regulator announced that the ground stop had been lifted.
US Secretary of Transportation Pete Buttigieg briefed President Joe Biden about the outage, according to White House Press Secretary Karine Jean-Pierre. There is ''no evidence of a cyberattack at this point,'' she added.
Phantom Candidates and Ghost Newspapers - The Bulwark
Wed, 11 Jan 2023 15:48
After the New York Times and other publications reported that newly elected Rep. George Santos probably didn't descend from Holocaust survivors or run an animal-protection charity, or [gestures broadly] any of it, many suggested that it would have been more helpful for the press to dig into this before the election.
''This would all have been exposed before the election if local newspapers were not running on fumes,'' tweeted former Senator Claire McCaskill.
A few news cycles later it emerged that actually the local press had reported on the Santos story. A local paper, the North Shore Leader, had declared that the Republican nominee was ''most likely just a fabulist'--a fake.''
So which is it: The triumph of the local press or a sign of its demise? More the latter, though for some surprising reasons.
L et's start with the scoop. In September, the North Shore Leader reported that Santos' financial disclosure form in 2020 claimed no assets over $5,000:
And his income was only just over $50,000 for the prior year, derived from a venture fund called ''Harbor Hill Capital,'' that was closed and seized in 2020 by US federal prosecutors as a ''Ponzi Scheme.'' Santos was the New York Director of that ''fund.''
Now, in a filing dated September 6th, 2022, Santos claims his assets are now as much as $11 million, including personal bank accounts of between $1 million and $5 million; a Condo in Rio de Janeiro, Brazil, of between $500,000 and $1 million; and business interests of between $1 million and $5 million.
The paper, whose staff had been hearing rumors of various Santos concoctions for a while, followed up with that stinging editorial calling him a fraud.
Then . . . nothing happened. No other media outlets pursued the story. Not the six local TV stations or WNYC, or Politico, New York, the Times, the Daily News. Not even Newsday, the formerly-august news source for Long Island. Grant Lally, the publisher and owner of the North Shore Leader, told me he didn't get a single call from another publication inquiring about it. ''If this had run 25 years ago, it would have been gobbled up,'' he said. ''There'd have been 20 follow ups from Newsday and other publications and the weeklies.''
His reference to the weeklies is important. A couple of decades ago, many individual towns on Long Island had robust weekly papers that both did original reporting and amplified stories from other outlets. They've mostly merged into larger chains, and many don't even have editorial offices in the covered towns anymore. For instance, a few days after the Times piece, the website of the Mineola American, which covers the county seat of Nassau County, still hadn't mentioned the story. But maybe that's not a surprise: The site hadn't been updated since May.
A nother part of this case, though, is the attention economy. Succeeding in media today requires doing good journalism and then building your own audience for it, and the North Shore Leader didn't successfully disseminate their scoop. They didn't mention their story on their Facebook or Instagram accounts (not updated since 2021), nor did they tweet about it, though that stems more from them not having a Twitter account. Which isn't really surprising since the paper doesn't have anyone working social media hard'--in part because they've shrunk. ''We lost half our advertising during COVID and most of it really hasn't come back,'' Lally explained.
In other words: The whole local media ecosystem is compromised. Even when someone manages to get a good story, the rest of the system can't amplify it or pursue it. In the past, the food chain worked pretty reliably. If a small paper broke a story, it would be picked up by a bigger paper, or the Associated Press, which would prompt the TV stations and radio stations to dive in. Now the hyperlocal small newsrooms rarely do investigative work, and when they do, the bigger players don't pay attention.
And in smaller communities, the weekly papers are the entire foodchain, so their demise is even more consequential.
A ll of which takes us to the big picture: The collapse of local news is both a colossal and catastrophic development in America. More than 3,400 weekly papers have closed since 2004. Newspaper advertising revenue has dropped 82 percent since 2000. More than 1,800 communities have no local news source. Of the counties with no newspapers, 93 percent have populations under 50,000.
As a result, the number of reporters has plummeted by 57 percent since 2004'--and this decline has come as both population and local government spending have risen. (The decline in the ratio of reporters-per-$100-million-in-state-and-local-government-spending is 67 percent.)
This is why media scholars invented a new term to go alongside ''news deserts'''--''ghost newspapers.'' There are thousands of these slim papers full of wire copy, press releases and ads. One study showed that only 17 percent of stories in local papers were on local civic affairs.
One consequence of this hollowing out is that voters have little to no information on which to base their choices in local elections. This would seem to be a fairly significant problem for, you know, democracy. And ironically, the more local the election, the worse the coverage is likely to be.
But the harm goes much deeper. Other studies show that areas with less local news have more corruption, fewer competitive elections, less resident involvement in PTAs, and even lower bond ratings. Lally, who ran for Congress as a Republican, says Republican voters should care more about the decline of local news. ''It's about quality control,'' he said. ''People on both sides shouldn't be accepting fraudsters.''
There's now evidence that the decline of local news exacerbates polarization, too. Studies show, for instance, that in areas with less coverage, voters are less likely to split their tickets. That's because the vacuums created by the contraction of local news are filled largely by national cable TV, radio, and social media. The contraction of local news accelerates the nationalization of politics while at the same time, we have less of the kinds of information that binds together communities'--everything from obituaries to high school sports.
B ut wait'--there's more. Many communities have moved from good information, to no information, to deceptive information. A new wave of ''pink slime'' sites'--often set up by political activists'--to impersonate traditional news sites while actively promoting particular candidates or businesses.
Two scholars recently concluded that most discussions about democracy's woes ''don't account for the most dramatic change in the civic life U.S. communities have experienced in the last 20 years: the decimation of the local news media.''
Philanthropic organizations ought to view hiring local reporters as one of the most important elements of strengthening democracy. And we need to advance public policies that could help local news without endangering editorial independence.
This isn't a new idea, by the way. The Founding Fathers instituted a postal subsidy to subsidize the running of newspapers. The spiritual cousin to that approach is the Local Journalism Sustainability Act, which provides tax credits to newsrooms to hire and retain local journalists, to small businesses that advertise in local press and to consumers who purchase local news.
Perhaps Rep. Santos could co-sponsor the bill.
Correction, January 9, 2023, 8:28 p.m.: Due to an editing error, he piece originally said, ''Of the counties with populations under 50,000, 93 percent don't have a newspaper.'' This is incorrect. Of the counties with no newspapers, 93 percent have populations under 50,000. The text has been changed accordingly.
Why 'herd immunity' is as an outdated concept when it comes to COVID
Wed, 11 Jan 2023 15:47
There is no such thing as ''Herd Immunity'' for COVID-19. In this context it is a concept as antiquated as the ''Earth is Flat''. The theory was based upon the work of William Farr in 1840 who proposed a bell-shaped curve which illustrated the body's ability to mount a lasting response to an unchanging pathogen.
As stated by one ''herd immunity'' supporter in the comments section, ''The disease dies out because enough people have been exposed and developed relative immunity or died that the disease has no means of propagating itself on a large scale.''
More:There is no such thing as 'herd immunity.' Why the ongoing dangers of COVID-19 are real
This concept was formulated before science knew what viruses and mutations were. In actuality, many biological systems are highly dynamic and constantly adapting. This is eloquently described in Steffanie Strathdee and Thomas Patterson's book the Perfect Predator. This work describes the biological dance between viral phages and their bacterial prey, each one adapting and reengaging in a duel, the outcome of which is uncertain. With the exception of smallpox, no pathogen has ever been eradicated from the earth and with smallpox, eradication was achieved with a highly effective long-lasting vaccine.
But with mutating RNA viruses, ''herd immunity'' is an extinct construct. Even surges of the common cold and the seasonal flu finally subside because of changing seasons. And unlike the relatively stable DNA virus of smallpox, RNA viruses have a much higher mutation rate.
If one looks at the SARS-CoV-2's (the virus which causes COVID-19) epidemiological curve for our nation, it is a colliding roller coaster and nowhere near a bell curve. We have been hit with variant after variant, Delta infections transitioned to Omicron and now we are struck by a soup of variants, composed of pathogens harboring a plethora of different immune-avoiding mutations, making the concept of ''Herd Immunity'' next to useless.
Unfortunately, SARS-CoV-2 appears to be the most adaptive and dynamic foe we have ever faced and hoping that the antiquated concept of ''Herd Immunity'' will save the day, causing SARS-CoV-2 to ''miraculously (go) away'', is just pure fantasy.
More:$58.8 million: 8 ways Louisville could spend its remaining COVID money
SARS-CoV-2's high mutation rate is amplified by its extremely high infectivity. The CDC estimated that the Delta Variant was as infectious as chickenpox, which has an R0 of 10 to 12. Newer variants have evolved into some of the most infectious pathogens known to man. As the virus spreads it mutates. And as it mutates it increases its ability to infect, evade our immunity and even attack our immune system.
Evidence is mounting regarding the immune dysfunction caused by SARS-CoV-2. We are seeing a dramatic rise in hospitalizations for the seasonal flu, respiratory syncytial virus (RSV) and even scarlet fever. The increase in RSV hospitalizations has been blamed on immunological weakening due to the enactment of measures such as masking. (Of course to argue this point, one also has to admit masks work.) However, through the end of November 2022, the United States had correspondingly less RSV infections than in the previous year, when an RSV surge was also seen. Germany also had a surge in RSV hospitalizations last winter, and now is seeing overwhelming RSV hospitalizations.
Not only does SARS-CoV-2 evade and attack our immunity, but what immunity is produced is fleeting. The virus also resides in a variety of animal hosts where it can mutate and then reinvade the human population. Transmission of a mutated virus from white tail deer to humans has been documented and there is evidence that Omicron originated in rodents then jumped to humans in South Africa.
The dangers of Long COVID, persistent cardiovascular disease, blood clots and a plethora of mental problems caused by COVID-19 were all documented in 2020, well before vaccines. These dangers are real and are adversely affecting the health of our workforce and our communities.
Our goal must be to decrease pathogen spread so society can function, with infections decreasing to a level that we can live with the virus. In this regard, it appears the virus is currently winning.
We need to embrace vaccinations, the use of N95 masks in crowded venues, along with home delivery, curbside pickup and outside dining. Indoor air quality must be improved to the point where it is safer indoors than it is outdoors.
If we continue to be a society focused on individualism rather than community or public health I am afraid we will lose this fight. We need a paradigm shift in the way we strategize to control COVID-19, away from ''herd immunity'' and towards adapting our lives to live with this highly dynamic and constantly adapting foe.
Kevin Kavanagh is a retired physician from Somerset, Kentucky, and chairman of Health Watch USA.
FAA lifts airline ground stop as flight delays, cancellations pile up across the country | Fox Business
Wed, 11 Jan 2023 15:02
The U.S. Federal Aviation Administration lifted its ground stop order Wednesday morning after suffering a nationwide technical outage causing mass cancellations and delays.
The travel chaos was caused by the failure of the FAA's Notice to Air Missions (NOTAM) system, which alerts pilots and other personnel about airborne issues and other delays at airports across the country. More than 740 flights were canceled in the U.S., and more than 4,300 more flights in the U.S. were delayed, as of 9:20 a.m. ET.
FAA investigators are continuing to search for the cause of the outage.
BIDEN SAYS FAA OUTAGE CAUSE MAY NOT BE KNOWN FOR 'A COUPLE HOURS'
"Normal air traffic operations are resuming gradually across the United States following an overnight outage to the FAA's Notice to Air Missions (NOTAM) system that provides safety information to flight crews," the FAA wrote in its fifth update of the morning.
Passengers wait to depart Chicago's Midway Airport as flight delays stemming from a computer outage at the Federal Aviation Administration has brought flights to a standstill across the U.S. Wednesday, Jan. 11, 2023, in Chicago. (AP Photo/Charles Rex Arbogast / AP Newsroom)
"The ground stop has been lifted. The agency continues to look into the cause of the initial problem," the statement continued.
Ticker Security Last Change Change % DAL DELTA AIR LINES INC. 38.56 +0.47 +1.25%AAL AMERICAN AIRLINES GROUP INC. 15.36 +0.17 +1.12%UAL UNITED AIRLINES HOLDINGS INC. 46.51 +0.76 +1.66%LUV SOUTHWEST AIRLINES CO. 36.30 +0.09 +0.23% PETE BUTTIGIEG OFTEN FLIES ON TAXPAYER-FUNDED PRIVATE JETS, FLIGHT DATA SHOW
Most airlines had already chosen to ground their own craft due to the system's failure early Wednesday.
Steve Gasser of Chicago looks at flight information screen at Chicago's Midway Airport that reflects the flight delays stemming from a computer outage at the Federal Aviation Administration that brought flights to a standstill across the U.S. Wednesd (AP Photo/Charles Rex Arbogast / AP Newsroom)
United Airlines announced its decision to ground all of its aircraft until 10 a.m. ET due to the outage.
The incident comes roughly a week after an air traffic issue prompted the FAA to slow all flight traffic in Florida earlier in January. That failure involved the En Route Automation Modernization at airports across the state.
PILOTS SAY FAA COMPUTER OUTAGE THAT GROUNDED US FLIGHTS NATIONWIDE UNPRECEDENTED
Four Southwest Airlines passenger jets sit at their gates at Chicago's Midway Airport as flight delays stemming from a computer outage at the Federal Aviation Administration has brought departures to a standstill across the U.S. Wednesday, Jan. 11, 2 (AP Photo/Charles Rex Arbogast / AP Newsroom)
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The earlier January incident affected Southwest Airlines in particular, leaving many travelers stranded without their bags.
Ray Epps's Jan 6th Interview Gets Even Weirder Than His 'I Orchestrated It' Text.
Wed, 11 Jan 2023 14:45
Ray Epps's January 6th interview is bizarro-world.
The entire thing reads like an exculpatory public relations effort, replete with assistance from committee members more concerned with helping Epps clear his name than getting to the bottom of his actions that day. But Epps's interview is even stranger than these '' CYA '' attempts.
Reps Schiff, Murphy, Aguilar, and Kinzinger were present during the interview finally conducted on January 21st 2022, after months of work by Darren Beattie's Revolver.news , among others, which brought Epps's activities on January 5th and 6th to light.
Here are the top 12 strange, stand-out moments:
Epps says, early on, that he was a member of the Oath Keepers, but that he left because national leader Stewart Rhodes was trying to ''direct'' Antifa. It is amazing how within just a few questions, Epps is already attempting to prove his credentials in the arena of not being an entryist, or a Fed, by laying out how organizations he was a part of engaged in Fed-style entryist tactics. How convenient. He recalls:
''I think it was Portland. It was Portland. I think that's when antifa had first come out, and we were seeing a lot of things. They were burning things and doing different things on the news, and he thought it would be wise if we were to go there and try to direct the, get in with them and direct them to do other things '-- other ways. I didn't agree with that so we kind of split ways.''
The person questioning Epps, whose name is redacted, hurries along from the matter remarkably quickly: ''Got it'... so now, I want to fast forward from the couple of years you were in the Oath Keepers to the 2020 general election.''
Hold on a minute. This is a self-professed member of the Oath Keepers, who was on the front lines on January 6th, telling you about their organization's infiltration attempts, and you want to ''fast forward''? Hm.
A few moments later, Rep. Kinzinger revisits the topic: '''...when you talked about the antifa side of things, were you saying his goal was to kind of infiltrate and influence, like, partner, or was it kind of influence and sabotage or stray differently?''
Epps: ''I believe he was going to try to turn them to our way of thinking.''
This is the first of many attempts to establish a fact pattern that suggests Epps himself would never think of infiltrating and sabotaging. In fact, you'll never see Kinzinger be so nice to a supposed Trump supporter as he is throughout this interview.
This one is a recurring red flag, because Epps claims he originally refused to go to D.C. on Jan 6th, before his wife convinced him there might be trouble, and that his son might need help. What assistance an elderly man might offer his adult son traveling with his friends is not made clear. By page 13, however, we learn that Epps's wife had booked his travel, but had not booked him anywhere to stay. As a result, Epps ended up sleeping on his son's bed at the Washington Marriott, while his son Jim's friend slept on the floor.
''It was going to be a great vacation and get to see the sights and '-- and show him what I had done with my father earlier [in life],'' Ray told the committee.
If any of you take tourniquets on vacation with you, please let me know in the comments. Because tourniquets don't sound like my idea of a ''great vacation,'' and yet, by page 15, we learn that Epps was texting someone called Nathen Jones for tourniquets, combat gauze, and breathing tubes.
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Seriously:
''So it's supposed to be a fun kind of family vacation, but we also see you packing first aid,'' Epps is then asked.
''Like I said before, prepare for the worst, hope for the best,'' he replied.
At this point, Adam Kinzinger chimes in with yet another highly implausible comparison, in an attempt to get Epps off the hook for this bizarre behavior:
KINZINGER : ''Just '-- Mr. Epps, again just '-- would the mindset be comparable to '-- for instance, I pretty much wherever I go, I conceal carry. I certainly hope I never have to use it, but I have it just in case.''
Huh? Carrying tourniquets, gauze, and breathing tubes to the nation's capital during a family vacation is the same as concealed carrying? Pull the other one.
Speeding on past this strange behavior as the committee did, we find ourselves hearing about one Mr. Paul Carver, on page 22:
Q: ''And when you returned back to D.C., what did you all do? What was your next steps that day?''
Epps: ''It was kind of difficult, because there wasn't a lot of restaurants open, so I'm trying to - oh, yeah, yeah, yeah. I do remember. We had a gentleman that kept trying to call me while we were gone, and he is from Arizona, and I don't '-- just a second. I can't find it here. I believe his last name is Carver. He had called several times and tried to reach us, so I called him back. He wanted to meet us for dinner. And I had met him one other time at a VFW, and I didn't really remember him, but that's okay. So we met at a small restaurant and had dinner.''
Q: ''So we saw in your call records an individual named Mr. Paul Carver on January 5th. Is that the individual that was calling you?
Epps: ''It was Paul Carver, yes, sir.''
Q: ''Take us through what happened. What did you all do after did with Mr. Carver?''
Whoa, whoa, whoa, whoa, whoa. What do you mean after dinner with Mr. Carver? There's some random dude who Epps says he doesn't know, who is calling him and trying to meet up all day, and then they meet up and have dinner, and there are no immediate questions about who this person was? The only other reference to this comes way down on page 74, where Epps is asked: ''And Mr. Carver, does he work for the FBI or CIA or NSA, to your knowledge?'' Epps replies: ''Not that I'm aware of, sir.''
Ooookay.
The questioning quickly turns to the infamous scenes of Epps at Black Lives Matter Plaza, before briefly looping back to Carver:
Epps: ''I hadn't talked to him before '-- before that. I mean, I '-- I don't know how he would know [that we were in DC], but he kept trying to call me, so '-- When he talked to me, he found out I was in D.C'... He may have known. I '-- I don't know how he would have found out because I '-- I had not talked to him before that, since I met him the first time. In fact, I didn't know who he was, but he was from Arizona, he was calling me, and we met up.''
Q: Okay. Thank you.
WHAT DO YOU MEAN 'OKAY THANK YOU'?!
This random dude from Arizona is calling Epps all day. Epps claims he has no idea who the guy is, decides to have dinner with this stranger anyway (despite claiming to be such a cautious person that he travels with first aid supplies), and the trail of questions on that matter ends there? Um'...
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At this point it's worth revisiting some of Ray Epps's ''best of'' moments from January 5th and 6th, as his explanation in his testimony stretches credulity, and indeed, as some on social media have noted, he appears to have actually further implicated himself in subsequent text messages to his family.
So here, we see Epps on the night of the 5th, after his dinner with stranger ''Paul Carver,'' and after ostensibly both meeting up with his son and his friend at Black Lives Matter Plaza, and then becoming separated again (this happens very often for someone traveling specifically to protect his son).
Epps is asked by the Jan 6 committee: '''...you said that you may get arrested for saying this, that the group needs to go into the Capitol the next day. Why did you think you could be arrested for saying what you were saying?''
''I didn't,'' Epps replies. ''I was trying to '-- to get some common ground.''
So, in other words, gaining the trust of the crowd to try to influence them? The same tactic he claims he left the Oath Keepers over?
''I '-- I got caught up in the moment,'' he further explains, before going on to state that a) he secretly believed the U.S. Capitol would be open to visitors the next day (no one believed that); and b) that he did not hear them chanting ''FED! FED! FED!'' in response to his suggestion. As you can see from the video, they were chanting it about 10 centimeters from his face. Another ridiculous stretch of credulity. And so, like clockwork, on page 28, in steps Rep. Adam Kinzinger:
Kinzinger: '''...it seemed to me that [the crowd around you] '-- their focus at that moment was basically trying to incite violence that night. You were trying to stop violence that night. Is that an accurate assessment on my end?''
Epps : ''Yes, sir.''
Kinzinger: ''Ok, that's all I have for the moment. Thank you, sir.''
Huh??? He's on camera inciting an invasion of the Capitol and Kinzinger's takeaway is that he was trying to stop violence? Even if the next day's events hadn't transpired the way they did, that is an impossible conclusion to reach, given the evidence. The new Republican-controlled Congress should immediately subpoena Kinzinger himself, and force him to publicly account for this ridiculous conclusion/cover up.
See also, page 31: ''Some people in the crowd started chanting 'Fed' towards you. Do you remember that?''
Epps: ''I don't. I even asked my son. I '-- I had a hard time believing it at first. I thought it might have been dubbed in or something. I '-- I didn't hear it. My son said he didn't hear it.''
Utter. Fucking. Rubbish.
At this point, instead of pressing Epps on the ludicrous claims over the night of the 5th, the conversation turns into yet another attempt to clear him of any collusion with authorities.
Q: ''At any point on January 5th '-- so we've asked you this question about December 27th through January 4th, but now let's just focus in on January 5th. did you co-ordinate or speak with any law enforcement officials from the FBI?''
Epps : ''No, sir.''
Q: ''The Metropolitan Police Department?
Epps : ''No, sir.''
Q : ''The CIA or NSA?''
Epps : ''No, sir.''
It goes on like this. Except remember, Epps has dinners with strangers who call his cell phone. And he also can't hear when someone is shouting ''Fed!'' in his face from a tourniquet's length away.
On page 33, we learn that Epps's son Jim had text his dad, asking if he was still out at BLM Plaza.
Q : ''It looks like you had a lengthy '-- or 140 seconds, so what's that? That's not even 3 minutes '-- conversation with your son just after midnight. Is that possible that you guys were separated still at that point, or were you back to the hotel room?''
Epps : ''Yes, it is possible. I had to walk back.''
Okay, he had to walk back. Does that account for the near TWO HOUR difference between when Epps's son text him, and when he appears to reach the hotel? Not really. Something else strange happens at this point in the conversation: the questioner asks for a break, and when they return, Epps has additional counsel:
We know that Epps says he stayed at the ''Washington Marriott''. Well, there are indeed a few Marriotts in D.C., but not a lot of ''Washington Marriotts''. There are Courtyards by Marriott, AC Hotels by Marriott, etc. But in so far as hotels named ''Marriott'' '' there are three biggies: the Washington Marriott, the Washington Marriott Georgetown, and the JW Marriott, as indicated below. There's also the new Marriott Marquis attached to the D.C. Convention Center, where you see the 'Unconventional Diner' on the map:
The walk from BLM Plaza to the Washington Marriott takes 10 minutes. The walk from BLM Plaza to the JW Marriott takes 12 minutes. The walk between the JW Marriott and the Washington Marriott is 8 minutes. So unless Epps really got turned around and walked 10 blocks in the wrong direction to the Georgetown Marriott, or 20 minutes to the Marriott Marquis '' several times over '' the idea that the two hours is accounted for by trying to find his hotel 10 minutes away makes little sense. He might've ambled around, but remember, this is an old dude in a strange city, who was just in a fracas with randos at BLM Plaza, at midnight.
His son even text him at 10:30pm, asking his whereabouts but on page 38 we learn that Epps was still making calls at 12:17am and 12:19am, to his son and his brother ''Scott or Darrell'' (he oddly can't remember) respectively. This time period, broadly unaccounted for, is never further explored by the committee. But within 6 hours or so, the trio '' Epps, his son, and his son's friend Zack '' were outside the White House ready for the rally at the Ellipse.
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On page 42, Epps says the three of them stayed ''All the way up to President Trump,'' which is an odd thing to do for someone who traveled across the country, from Arizona, ostensibly in part to hear President Trump speak. Why even wait at the Ellipse at 6am, if you were just going to leave when the keynote speaker started? To their mild credit, this question was asked by the committee, though the answer raises more questions:
Q : Why did you leave when President Trump started speaking?''
Epps : ''There was a group that started running towards the Capitol. I mean, they were moving quite fast, and so I just thought, you know what, I want to be in the front; I'll get up there. And on the way there, I noticed that it was some of the same people that were there on the night before. They had blow horns. They were trying to incite people and stir things up. I thought it important that I get up there, and I did.''
Right. Because the guy who couldn't find the Washington Marriott for two hours was going to single-handedly stop a running group (coincidentally the same people from last night?) from breaching the Capitol? But wait, it gets more ridiculous:
Epps : ''I wasn't walking with anybody. I called a few people out on the way there that had megahorns '-- you know, megaphones that were trying to incite things and , you know, tried to get them to stop, and then we were at the Capitol.''
This is some grade-A horse shit for several reasons:
Revisit the video above. Epps is the one directing people to the Capitol;
He claims to have reached there in 20 minutes. No, that's about a 35 minute walk without crowds;
He admits that despite flying to Washington to protect his son, he was once again separated from his son at this point '' ''I don't know where they were.'' [Page 45]
And again, do remember, this is the guy who took two hours to find the Washington Marriott, suddenly managing to sprint through a heaving crowd, to the Capitol, take a wicked whizz (see screenshot), and call ''a few people out on the way,'' all within 20 minutes.
Impressive .
SuperEpps!But wait, there's more!
On page 46 we are treated to some real Ray Epps gold.
He's asked: ''You said you wanted to get out in front'... but what were you trying to get out in front of as you started walking to the Capitol?''
Epps : ''Well, there's a few different reasons. One, we were freezing our butts off. It was cold out. If we were going to get in the Capitol, I wanted it to be inside. My son since has referenced the same thing. We weren't dressed properly for it.''
Remember '' this is MR. ALWAYS PREPARED we're talking about. The guy with the tourniquets, whose wife sent him to protect their precious boy. He says he wanted to get inside the Capitol BECAUSE HE WAS COLD.
The next part, I promise you, despite how it sounds, is not even a joke. Epps continues: ''Two, I didn't want any fighting to break out or any '-- you know, it going in the wrong direction. Marines are always in the front, not in the back.''
Yeah, ok Ray. Marines are always in the front. BUT NOT BECAUSE THEY ARE COLD.
Of course just when you think you cannot suspend any more disbelief on this, Rep. Kinzinger pipes in. [Writer's note: I feel as if I have started to write satire or fiction now, but this is all real].
Kinzinger : ''Mr. Epps, would you say that was a pretty high adrenaline moment, kind of, you know, a lot going on, you're trying to take in a lot of details and act? And also was there still maybe a concern at this point in the back of your mind that there could be - and I know I keep going back to this, but there could maybe be antifa seeded throughout trying to provoke something bigger? Was that a concern?
Kinzinger, in other words, is both accidentally right about Antifa presences on Jan 6, but also attempting to allow Epps an escape from his own behavior, in his own words, being out front and inside the Capitol. Has Kinzinger metaphorically blown any other Jan 6 interviewee in such a fulsome and borderline pornographic fashion?
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This is the part so many have already zoned in on. Epps is asked: ''So it looks like, around 9am, your nephew texts you'... and then, at 2:12pm'... you text back: 'I was in the front with a few others. I also orchestrated it.'''
Boom. Surely? Case closed! Ray Epps admits, in writing, in his own words, in his own texts, to his own family, to ''orchestrating'' actions on January 6th, after dinner with a stranger, hours missing the night before, and of course the plethora of video evidence showing him personally inciting riots and criminal actions. Charge him? Surely?
But, no. For reasons we are never told, Ray Epps is both a free man and getting fellated by Adam Kinzinger.
Q : ''What did you mean by ''orchestrate''? What did you orchestrate?''
Epps : ''I just meant that I got - you have to understand our relationship, uncle-nephew. We hunt together. We fun with each other. We do that kind of stuff. What I meant by ''orchestrate,'' I helped get people there.''
Wait '' what? Was that Joe Biden responding? What the heck does his relationship with his nephew have to do with it? And what does ''we fun with each other'' mean? Or perhaps bigger, still, how does ''orchestrate,'' mean ''help get people there,'' without also meaning incitement?
Those questions will obviously be asked next by the enterprising representatives of the January 6th committee, right? WRONG.
The most Epps got back was: ''I'm just trying to understand why that word 'orchestrated' was used because it sounds like you're sort of adopting the whole thing, including the stuff that you were walking away from.''
Actually, it's ''the stuff'' he incited, but who cares about verbiage, eh? It's not like we're attempting to investigate the so-called greatest attack on American soil since 9/11 or whatever else they're calling it nowadays. This is like having Mohammad Atta on the stand and asking him if traffic to the airport was bad.
Epps equally bizarrely responds: ''You would have to understand the relationship between me and my nephew. It's just '-- yeah, I took credit for it, but I didn't know what I was taking credit for.''
Right. There it is. Again. An admission. ''Book him!'' But again, no. Nothing. Not one attempt by the January 6th committee to actually hold someone accountable WHO ADMITTED TO BEING INVOLVED MULTIPLE TIMES.
''I shouldn't have used that word,'' Epps says on page 65.
''What's a better word now?'' he's asked in response.
''I helped get people there.''
The reply, is, of course, incredible.
''I see. Fair enough. I appreciate that. Thank you.''
Oh that's fair enough, is it? What about the hundreds of detainees held without charge or release and who have been treated like dogs for doing far less than Ray Epps did that day? Is it fair enough for them? Is it fair enough to the people whose lives have been irretrievably ruined by that day? Is it fair enough to history and the public record that this kabuki theatre is allowed to sail by, unridiculed, unfisked, and unabated?
You're 3500 words and 69 pages in, with just 500 words to read. So you might as well stick this out. Believe me this is the brief version. The full document is 25,000 words. You're welcome!
Does the below seem odd, from a guy worried about infiltrators and trouble?
Oh, yeah: someone told me they were shooting Trump supporters so I got in a car with a random Trump supporter but also people were infiltrating and pretending to be Trump supporters and this Trump supporter didn't know I was a Trump supporter because I had taken off my hat on account of the shooting of Trump supporters but he still agreed to drive me to my hotel which we couldn't find. Vastly plausible.
By now you understand the importance of going through all this. The next few pages concern the text messages Epps received on the days in question. See if this line of questioning feels appropriate to you:
Q: ''Mr Carver, does he work for the FBI or CIA or NSA, to your knowledge?''
Epps : ''Not that I'm aware of.''
'...
Q : ''Do you recognize a Mr. Christopher Hupke?''
Epps : ''This is something to do with Twitter and something to do with Twitter. I don't know what it is. I didn't open it and I haven't responded.''
Q : ''Thank you.''
'...
Q : ''There were two incoming text messages at around 3:52 '' they actually might be the same text messages because they're both at the exact same time '' from an [REDACTED NUMBER]. You did not respond back, but do you know what this number is?''
Epps : ''I do not.''
Q: ''Okay.''
'...
Q : ''And then the last number where we saw outgoing and incoming texts was a [REDACTED] number. We have done our own research on this, and there has been public reporting that this sometimes shows up on people's phone records, and it's not a specific number for anyone. It just sometimes shows up on phone records, so '--''
Epps : ''I have never heard of it. I couldn't find it on my phone either. I'm not sure how you got that.''
Do any of these seem like normal interactions over phone records, incoming calls or texts, or am I off my chump ? For instance '' what do you mean a number just shows up on call records? And how are these interviewers not following up on records for which Epps claims to have no further information? Not even '' ''Hey, well, would you mind looking into that for us and figuring out who you talked to, please?''
No, instead it's just ''K cool, no worries.''
On page 96, the conversation comes to a close. But not without one more acutely awkward moment between Epps's counsel and his interviewer. Enjoy:
Perhaps I've lost my mind. But none of Epps's testimony rings normal to me. None of it carries the same tone as other interviews given to the January 6th committee. There's no probing. Epps is hurried along between timelines and subjects. He offers bizarro explanations and is never pulled up on them. And more than anything: more questions are raised as a result of this interview, than those that were answered. Were any answered? Is Ray Epps still searching for the Marriott Hotel? Has he found his son yet? Is he at a local ball game in Arizona with a fanny pack loaded with gauze and breathing tubes?
Maybe we'll find out when they admit Lee Harvey Oswald was a patsy. In the meantime, there is something far more pernicious about this interview than I had even imagined when it was first quietly released. Read the whole thing for yourself, if you wish. Don't forget to share this article, and comment below.
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FTX Former Engineering Chief Nishad Singh Looking for Deal From Feds: Report
Wed, 11 Jan 2023 14:29
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Another one of Sam Bankman-Fried's former confidants and roommates is said to be engaging with the U.S. Attorney's Office in the Southern District of New York with the hope of getting a plea agreement, according to a report from Bloomberg.
Nishad Singh, FTX's former director of engineering and a housemate of Bankman-Fried, is said to have met with prosecutors in a "proffer session." Such meetings often include an offer of "limited immunity" to encourage the interviewee to speak freely. Singh has not been accused of wrongdoing.
Former Alameda Research CEO Caroline Ellison and former FTX CTO Gary Wang have both pleaded guilty to fraud charges.
Central to Singh's deal is information on FTX's and Bankman-Fried's large donations to various political campaigns, according to Bloomberg, citing people familiar with the matter.
Singh personally has donated more than $9.3 million to Democratic Party-aligned initiatives since 2020. In April 2021, the political action committee Mind The Gap, founded by Bankman-Fried's mother, received a $1 million donation from Singh.
According to court documents from November, Singh received $543 million in loans from Alameda Research. The former FTX affiliate is recorded as granting $4.1 billion in loans to related parties.
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Wall Street Silver on Twitter: "The real reason for the egg shortage is NOT avian flu. According to this farmer '... the producers can't cover their costs, so there are now millions of fewer hens, and many millions of fewer eggs produced PER DAY. 🧐 ðŸ
Wed, 11 Jan 2023 04:27
Wall Street Silver : The real reason for the egg shortage is NOT avian flu.According to this farmer '... the producers can't cover their'... https://t.co/K3MfcN4B6y
Tue Jan 10 22:28:57 +0000 2023
Saartjie : @WallStreetSilv We have the same problem in south africa. With supermarkets not paying farmers a fair price for their produce.
Wed Jan 11 04:25:41 +0000 2023
David Svendsen : @WallStreetSilv @akheriaty Millennials brought us craft brewing. Time for GenZ to bring us craft poultry.
Wed Jan 11 04:25:01 +0000 2023
Keis Shdh : @WallStreetSilv Boycott eggs.
Wed Jan 11 04:24:49 +0000 2023
TenaciousBill : @WallStreetSilv Its a chain reaction. More costs for producer, more costs for consumers, more costs for consumers l'... https://t.co/hkTRTF4Uhe
Wed Jan 11 04:23:50 +0000 2023
Ataxerex2020 : @WallStreetSilv No
Wed Jan 11 04:23:14 +0000 2023
NEW: Matt Gaetz Announces Republicans Will Release 14,000 Hours of J6 Tapes that were Hidden by Democrats
Wed, 11 Jan 2023 00:06
During an interview with Charlie Kirk on his radio show on Tuesday, Florida Republican congressman Matt Gaetz announced that Republicans would be releasing 14,000 hours of January 6 tapes that have been hidden from the public.
Gaetz said that releasing the tapes ''would give more full context to that day rather than the cherry-picked moments of the January 6th committee.''
The Republican congressman revealed that this was one of the deals he made with House Speaker Kevin McCarthy to give the American people more context about the events on January 6th instead of the narrative pushed by the Democrat party.
''One of my favorite members of Congress is Thomas Massie and the fact that he is going to be on this new committee (the Church Committee) really gives me hope,'' Kirk said during the interview.
''Matt, do you anticipate allowing the dogs to be released if you will against this fourth branch of government?'' he asked.
Gaetz replied, ''Kevin McCarthy told us he is going to get the evidence out in front of the American people and that means releasing the 14,000 hours of tapes that have been hidden that I think would give more full context to that day (January 6th) rather than the cherry-picked moments the January 6th committee tried to use to inflame and further divide out country.''
''So yes, I do believe that part of this deal is a concession that we are going to get the truth out in front of the American people,'' he asserted.
WATCH:
Gaetz: Republicans will release ''14,000 hours of [J6] tapes that have been hidden''
BAM!
Looks like truth about Pelosi's Fed-Op is going to be exposed even further! pic.twitter.com/ybf3RSgoow
'-- DC_Draino (@DC_Draino) January 10, 2023
NEW: Matt Gaetz says Republicans will release 14,000 Hours of J6 Tapes that were hidden by Democrats.
Gaetz for the win, once again.
'-- Collin Rugg (@CollinRugg) January 10, 2023
Also on Tuesday, Gaetz revealed a new amendment to the House rules which would require the House speaker to broadcast floor proceedings on C-SPAN.
''I've received a lot of feedback from constituents about how interesting it was and that you were able to see in real time how our government is functioning, what alliances are being created, what discussions are being had, what animated moments drive the action,'' Gaetz said Fox News during an interview. ''And the pool view of the Congress is antiquated and a little boomer-fied.''
''I have talked to a handful of colleagues and I have yet to encounter one who didn't view the broader transparency as a net positive,'' Gaetz said.
''It's interesting to see how our leaders communicate with one another, and it's humanizing,'' he added. ''I had constituents reach out to me about a friendly chat that the country observed me having with [Democratic Rep.] Sheila Jackson Lee. And while Sheila and I certainly have had very high-octane moments in the House Judiciary Committee, and while neither one of us like to give an inch when it comes to effective argumentation, I've also found her to be a warm person interpersonally.''
''And you know of people observed me having conversations with [Democratic Rep.] Debbie Wasserman Schultz, former head of the Democratic Party,'' he continued. ''So, there are moments of bipartisanship and collegiality that occur every day. And the country doesn't get to see those.''
Follow me on Twitter @CollinRugg!
Hill Country Cattle Women | Serving the Texas Hill Country since 1979
Tue, 10 Jan 2023 17:41
Hill Country CattleWomen (HCCW)
We are teachers, real estate agents, lawyers, business owners, policewomen, accountants, flight attendants, principals, judges, ranchers'...we are CattleWomen. Our members join a community of women committed to preserving the Texas ranching heritage. The goal of Hill Country Cattlewomen is to promote and support the production of beef and the beef industry through cooperation with the National Cattlemen's Beef Association (NCBA), Texas and Southwestern Cattle Raiser Association (TSWCRA), American National CattleWomen (ANCWA), Texas CattleWomen (TCWA), and local beef supporters. HCCW supports private property rights and encourages federal and state legislation that will maintain and protect property rights.
Margaret Borland was the first woman to lead a cattle drive. After the death of her husband in 1867, Borland became the sole owner and manager of their large Victoria ranch and 8,000 longhorns.
Our membership covers 14 counties in the beautiful Texas Hill Country including Bandera, Bexar, Blanco, Edwards, Gillespie, Kendall, Kerr, Kimble, Llano, Mason, McCulloch, Menard, Real and San Saba.
Women's Ranch SeminarThe Spring Roundup fundraiserAg Days booths serving 1200 students in 5 countiesFredericksburg Food & Wine Fest BoothBEEF Gift certificates to local Food BanksBEEF GIFT CERTIFICATES to Kerr County Veterans ProgramBEEF Gift Certificate to Veterans Recipe Contest winnerDonations to Hill Country Youth RanchHamburger Feed to Hill Country Youth RanchFredericksburg Light the Night Christmas Parade FloatLegislative Action CallsDistribution of BEEF Education Materials
Vaccine crisis communication manual: step-by-step guidance for national immunization programmes
Tue, 10 Jan 2023 17:39
21 February 2022
| Technical document
Overview This manual was developed to support countries in effectively respondingto events which may erode the public's trust in vaccines and theauthorities that deliver them. In addition, a small section of thismanual focuses on how to best prepare for a potential crisis andprovides some insights into conducting post-crisis assessments. For theresponse phase, step-by-step guidance is provided on how to manage thecommunication aspects of a vaccine crisis.
Reference numbers
WHO Reference Number: WHO/EURO:2022-3471-43230-60590
Thailand Flip Flops On Proof Of Vaccination Rule Effective Immediately - LoyaltyLobby
Tue, 10 Jan 2023 17:23
Thailand's Public Health Minister, Mr. Anutin, has flipped-flopped on the covid-19 vaccination requirement that he announced late last week (read more here) and which was communicated to the airlines yesterday (read more here) and further amended today (read more here).
The Thai government has decided that they won't require incoming passengers to prove that they have had a complete set of covid-19 vaccines or medical reasons not to. However, the mandate to have travel insurance for passengers whose next destination requires a negative covid test will remain in place.
Here's what happened over the past few days:
The health minister on Thursday announced that Thailand would only welcome fully vaccinated visitors from Sunday.
Thailand Reinstates Covid-19 Vaccination Requirement For All VisitorsThere was no communication from Thailand about what the requirements are and exactly when they will be in place.
Up In The Air: New Entry Requirements For Thailand From Monday, January 9, 2023 !?Then Thailand issued a notice to airlines that they need to deny boarding people who were not fully vaccinated.
Thai Airways & Other Thailand-bound Carriers Issue Passenger Notice Of Entry Regulations Effective January 9, 2023And issued another notice on Monday morning that airlines could transport passengers that Thailand doesn't consider fully vaccinated, but there would be covid-test at the airport.
Thailand Amends Entry Requirements Again '' Effective January 9, 2023Excerpt from the Bangkok Post:In an abrupt U-turn on Monday, Mr Anutin said requiring visitors to show evidence of two vaccine doses was ''inconvenient'' and a panel of experts had resolved that it was unnecessary as enough vaccinations had been administered globally.
Mr Anutin said visitors not vaccinated at all would also be granted entry without restriction.
''Showing proof of vaccination would be cumbersome and inconvenient, and so the group's decision is that it is unnecessary,'' Mr Anutin told reporters.Authorities will still require foreigners whose next destination is a country requiring a negative pre-entry Covid-19 test to show they have health insurance covering treatment for the disease, Mr Anutin said.
Airlines are unaware of these drastic changes over the past few hours, and even Thai Airways still requires passengers on the evening flight from Singapore to Bangkok to have the vaccination record available or avail themselves of rapid antigen tests at the airport.
Conclusion
Perhaps the Public Health Minister was unaware that they couldn't have administered all these sudden tests and documentation overview at international arrivals airports in Thailand with the current passenger numbers.
The airlines transporting passengers to the country could have verified vaccination or Covid-19 test results, but to do this at Thai airports would have been impractical, if not completely impossible.
This is a good reminder that international travel still has obstacles, and the rules can change with practically no notice.
Let's hope that not many passengers were denied boarding due to these changes over the past 24 to 48 hours.
Smartmatic voting machines not used in Brazil's 2022 election | AP News
Tue, 10 Jan 2023 17:18
CLAIM: Brazil used Smartmatic voting machines to ''steal'' theOctober 2022 presidential election, similar to how the 2020 election wasmanipulated in the U.S.
AP'S ASSESSMENT: False. Smartmatic, avoting technology firm, does not provide voting machines in Brazil and did notsupply any services for the 2022 presidential election, a spokesperson for thecompany stated. Claims that Smartmatic helped flip the 2020 election in theU.S. to Joe Biden are baseless , The Associated Press reported.
THE FACTS: After leftist President Luiz Incio Lulada Silva defeated far-right incumbent Jair Bolsonaro in Brazil's election,Bolsonaro's supporters protested his loss across the country.
Social media users shared false posts to claim Brazil's electionwas marred by fraud, including claims that Smartmatic voting machines were usedto tamper with the vote.
''Millions are showing up in Brazil to protest their Presidentsstolen election with smartmatic voting machines!'' one tweet falsely claimed.
Similar claims have circulated online since 2018, asserting thatSmartmatic provided voting equipment for Brazil's elections. However,Smartmatic has never provided voting machines or software for elections in thecountry, according to the company and election officials in Brazil.
In 2020, Brazil's Superior Electoral Court(TSE) released a statement saying thatSmartmatic has had contracts with the electoral authority for data provisionand voice connection services, but not for developing or operating votingmachines.
''We have never provided voting machines to Brazil,'' Samira Saba,a spokesperson for Smartmatic, confirmed to the AP in an email. Saba also notedthat Smartmatic did not provide any additional services for the 2022election.
In the 2020 U.S. election, Smartmatic technology wasused in a single district , Los Angeles County, California, the AP reported.
Former President Donald Trump and his allies have fueled acampaign of attacks against voting equipment since he lost the presidency.There's no evidence that voting machines were manipulated to steal the election, northat widespread fraud occurred.
___
This is part of AP's effort toaddress widely shared misinformation, including work with outside companies andorganizations to add factual context to misleading content that is circulatingonline. Learn more aboutfact-checking at AP.
The 'Kraken' COVID subvariant: What to know about quickly rising omicron descendant | Live Science
Tue, 10 Jan 2023 17:13
HomeNews A new version of the omicron variant has become more common in the U.S. in recent weeks. (Image credit: Matt Anderson Photography)Editor's note: This page will be updated as new data about XBB.1.5 emerges.
A new flavor of the omicron variant of SARS-CoV-2, the virus that causes COVID-19, was identified in October 2022. In the past several weeks, it has steadily gained prominence in the United States. The subvariant is known as XBB.1.5 but has also been given the unofficial nickname "Kraken," after the mythical sea monster.
Here's what we know so far about XBB.1.5 so far.
Related: Most widely used COVID-19 vaccines and how they work
How did XBB.1.5 emerge and where is it spreading? Scientists first identified XBB.1.5 in New York state in October 2022, The New York Times reported (opens in new tab) .
The subvariant stems from a broader branch of the omicron family tree known as "XBB," which emerged as a result of two earlier versions of omicron '-- BA.2.10.1 and BA.2.75 '-- swapping genes, according to the World Health Organization (opens in new tab) (WHO). These closely related omicron subvariants had the opportunity to swap genes when they infected the same person at the same time.
From their two parents, XBB viruses gained mutations that helped them evade protective antibodies gained through prior COVID-19 infections and through vaccinations. But there was a tradeoff: XBB viruses simultaneously lost some of their ability to bind tightly to cells, a key step in infection, the New York Times reported. This may explain why other versions of omicron initially outcompeted XBB viruses.
However, as XBB viruses spread, they picked up new mutations and XBB.1.5, a.k.a. the "Kraken," was born. The Kraken harbors a mutation called F486P, which appears to restore the virus's ability to tightly latch onto cells, researchers reported Jan. 5 in research posted to the preprint database bioRxiv (opens in new tab) . (This research has not yet been peer-reviewed or published in a scientific journal.)
In a Jan. 4 news conference (opens in new tab) , WHO Director-General Dr. Tedros Adhanom Ghebreyesus (opens in new tab) reported that XBB.1.5 is "on the increase in the U.S. and Europe and has now been identified in more than 25 countries." Genomic data submitted to the open access database GISAID (opens in new tab) shows that U.S., U.K., Austria, Denmark, Canada, Israel and Germany have detected the most XBB.1.5 sequences so far, and that the subvariant remains relatively rare elsewhere.
How easily does it spread? Available evidence suggests that XBB.1.5 is the "most transmissible" omicron descendent yet detected, Maria Van Kerkhove (opens in new tab) , the WHO's COVID-19 technical lead, said at a news conference on Jan. 4, according to The New York Times. In the U.S., XBB.1.5 is beginning to gain dominance over other circulating omicron subvariants.
In early December, the Kraken made up an estimated 2% of all COVID-19 cases in the U.S., The Washington Post reported (opens in new tab) . That figure jumped to 40% in the last week of December, STAT reported (opens in new tab) .
The Centers for Disease Control and Prevention (opens in new tab) (CDC) have not yet analyzed all the data from early January 2023, but their current projections suggest that XBB.1.5 accounted for more than 27% of U.S. cases in the first week of the year. In the northeastern U.S., where XBB.1.5 was first detected and remains most common, the subvariant accounts for more than 70% of new cases, according to The Washington Post.
That said, nationwide, other flavors of omicron '-- namely BQ.1 and BQ.1.1 '-- were still circulating at comparable levels to XBB.1.5 during the first week of January, the CDC's projections suggest.
Is XBB.1.5 more likely to cause severe disease? Scientists will need to see many weeks of hospitalization and death data before determining whether XBB.1.5 is more likely to trigger severe disease compared with earlier versions of SARS-CoV-2, the virus that causes COVID-19.
As the U.S. experiences a nationwide surge in COVID-19 infections, "we're seeing hospitalizations have been notching up overall across the country," Dr. Barbara Mahon (opens in new tab) , director of CDC's Coronavirus and Other Respiratory Viruses Division, told NBC News (opens in new tab) . "They don't appear to be notching up more in the areas that have more XBB.1.5," which hints that the subvariant isn't necessarily more likely to cause severe disease than its predecessors.
How well do boosters and treatments work against XBB.1.5? Early data suggests that the so-called bivalent boosters '-- the two recently updated boosters made by Moderna and Pfizer '-- offer decent protection against XBB viruses, despite the lineage's ability to evade antibodies, according to a Dec. 21 report in the New England Journal of Medicine (opens in new tab) .
"Lab studies suggest that the bivalent vaccine is still effective in protecting against severe disease, though perhaps not as much against infection," Andy Pekosz (opens in new tab) , a professor of Molecular Microbiology and Immunology at the Johns Hopkins Bloomberg School of Public Health, said in a statement (opens in new tab) . "XBB.1.5 is derived from the omicron variant BA.2, and while the current bivalent vaccine was developed for the BA.5 variant, it has been shown to generate antibodies that recognize BA.2," he said.
"Things like boosters are always beneficial," Kristian Andersen (opens in new tab) , a professor in the department of immunology and microbiology who tracks coronavirus variants at the Scripps Research Institute, told The Washington Post. "Even if you get infected, you are expected to have less viral load, and you are expected to be able to transmit the virus less."
(Notably, as of Jan. 4, less than 16% of eligible U.S. residents had received a bivalent booster, the CDC reported (opens in new tab) .)
Palxovid, an oral antiviral pill used to treat COVID-19, will be effective at treating infections with XBB.1.5, The New York Times reported. The pill may not be prescribed to all COVID-19 patients, as it's not compatible with certain medications, Pakosz noted, "but overall, for the vast majority of people, Paxlovid is still a good drug to be prescribed if you get COVID-19."
Nicoletta Lanese is a staff writer for Live Science covering health and medicine, along with an assortment of biology, animal, environment and climate stories. She holds degrees in neuroscience and dance from the University of Florida and a graduate certificate in science communication from the University of California, Santa Cruz. Her work has appeared in The Scientist Magazine, Science News, The San Jose Mercury News and Mongabay, among other outlets.
Microsoft's new AI can simulate anyone's voice with 3 seconds of audio | Ars Technica
Tue, 10 Jan 2023 17:02
My Voice is no longer my password '-- Text-to-speech model can preserve speaker's emotional tone and acoustic environment. Benj Edwards - Jan 9, 2023 10:15 pm UTC
Enlarge / An AI-generated image of a person's silhouette.
Ars Technica
On Thursday, Microsoft researchers announced a new text-to-speech AI model called VALL-E that can closely simulate a person's voice when given a three-second audio sample. Once it learns a specific voice, VALL-E can synthesize audio of that person saying anything'--and do it in a way that attempts to preserve the speaker's emotional tone.
Its creators speculate that VALL-E could be used for high-quality text-to-speech applications, speech editing where a recording of a person could be edited and changed from a text transcript (making them say something they originally didn't), and audio content creation when combined with other generative AI models like GPT-3.
Microsoft calls VALL-E a "neural codec language model," and it builds off of a technology called EnCodec, which Meta announced in October 2022. Unlike other text-to-speech methods that typically synthesize speech by manipulating waveforms, VALL-E generates discrete audio codec codes from text and acoustic prompts. It basically analyzes how a person sounds, breaks that information into discrete components (called "tokens") thanks to EnCodec, and uses training data to match what it "knows" about how that voice would sound if it spoke other phrases outside of the three-second sample. Or, as Microsoft puts it in the VALL-E paper:
To synthesize personalized speech (e.g., zero-shot TTS), VALL-E generates the corresponding acoustic tokens conditioned on the acoustic tokens of the 3-second enrolled recording and the phoneme prompt, which constrain the speaker and content information respectively. Finally, the generated acoustic tokens are used to synthesize the final waveform with the corresponding neural codec decoder.
Microsoft trained VALL-E's speech-synthesis capabilities on an audio library, assembled by Meta, called LibriLight. It contains 60,000 hours of English language speech from more than 7,000 speakers, mostly pulled from LibriVox public domain audiobooks. For VALL-E to generate a good result, the voice in the three-second sample must closely match a voice in the training data.
Advertisement On the VALL-E example website, Microsoft provides dozens of audio examples of the AI model in action. Among the samples, the "Speaker Prompt" is the three-second audio provided to VALL-E that it must imitate. The "Ground Truth" is a pre-existing recording of that same speaker saying a particular phrase for comparison purposes (sort of like the "control" in the experiment). The "Baseline" is an example of synthesis provided by a conventional text-to-speech synthesis method, and the "VALL-E" sample is the output from the VALL-E model.
Enlarge / A block diagram of VALL-E provided by Microsoft researchers.
Microsoft
While using VALL-E to generate those results, the researchers only fed the three-second "Speaker Prompt" sample and a text string (what they wanted the voice to say) into VALL-E. So compare the "Ground Truth" sample to the "VALL-E" sample. In some cases, the two samples are very close. Some VALL-E results seem computer-generated, but others could potentially be mistaken for a human's speech, which is the goal of the model.
In addition to preserving a speaker's vocal timbre and emotional tone, VALL-E can also imitate the "acoustic environment" of the sample audio. For example, if the sample came from a telephone call, the audio output will simulate the acoustic and frequency properties of a telephone call in its synthesized output (that's a fancy way of saying it will sound like a telephone call, too). And Microsoft's samples (in the "Synthesis of Diversity" section) demonstrate that VALL-E can generate variations in voice tone by changing the random seed used in the generation process.
Perhaps owing to VALL-E's ability to potentially fuel mischief and deception, Microsoft has not provided VALL-E code for others to experiment with, so we could not test VALL-E's capabilities. The researchers seem aware of the potential social harm that this technology could bring. For the paper's conclusion, they write:
"Since VALL-E could synthesize speech that maintains speaker identity, it may carry potential risks in misuse of the model, such as spoofing voice identification or impersonating a specific speaker. To mitigate such risks, it is possible to build a detection model to discriminate whether an audio clip was synthesized by VALL-E. We will also put Microsoft AI Principles into practice when further developing the models."
Amazon launching Ring car camera for vehicles
Tue, 10 Jan 2023 16:53
(CNN) '' Ring parent company Amazon is introducing a ring camera for your car.
It's a small dual-facing camera that sits on the dashboard and captures the vehicle's exterior as well as its interior.
The camera is able to detect activity, such as a break-in, and begin recording while also sending an alert and live video to the owner.
The ''traffic stop'' feature lets drivers start recording when they get pulled over or have an accident.
The device supports a cellular connection, but requires a subscription to Ring's ''protect-go'' service for $6 a month or $60 a year.
An LED light indicates when the camera is recording and there's an interior privacy shutter, so the video or audio can be cut off at any time. You can pre-order the Ring car cam for $200 now before the formal launch next month.
The price will go up to $250 in February.
Copyright 2023 CNN Newsource. All rights reserved.
Pfizer Vaccine is Using STERILIZATION Delivery Techniques Developed by SpayVac. The DPX Delivery System was Designed for Sterilizing Animal Populations. '' BREAKING-NEWS.CA
Tue, 10 Jan 2023 16:40
Posted byu/AscensionBeam
Buckle up. This is long but important. The other thread on SpayVac missed a massive point regarding the Pfizer vaccine. This is a potential nail in the coffin for Pfizer '' SpayVac's DPX lipid nanoparticle delivery system.
SpayVac produces the PZP infertility vaccine. They licensed their DPX lipid nanoparticle delivery technology to Pfizer for them to make the COVID vaccine.
https://spayvac.com/f/covid-19-on-everyones-mind
The PZP vaccine doesn't cause immediate sterility '' it takes over a year to appear. (Funny, Pfizer only studied a few months.) But PZP causes short term menstrual cycle changes as the immune system attacks the ovary cells. The SAME menstrual changes are being seen in women WORLDWIDE.
https://www.businessinsider.com/covid-19-vaccine-impact-on-menstrual-cycle-30000-report-changes-2021-9
PZP requires storage temperatures down to -40C, unusual for most vaccines. Also, it requires two first shots given 2-6 weeks apart then a booster from 6-12 months, depending on species.
They created the DPX liposome technology to make sure the vaccine reaches its target destination and patented it under IMV Inc. IMV partnered with Pfizer in 2020 to produce the COVID vaccine, using the same liposome technology, now called the lipid nanoparticle delivery system.
This DPX lipid nanoparticle system is designed as a ''NO-RELEASE'' system. It will NOT release anything at the injection site. Rather only at the ''target destination'', which for the PZP vaccine was the ovaries and, also, the spleen which had similar receptors.
https://www.imv-inc.com/the-dpx-platform
The Pfizer injection also concentrates at the spleen and ovaries. Makes sense as they use the identical delivery system. Look at the below source in Table 2. Look at the concentration, NOT the % dose of injection. The small intestines have a huge % of dose but they are way larger than the ovaries. The ovaries have a massive concentration in regards to their size.
https://healthfeedback.org/claimreview/covid-19-vaccines-dont-affect-ovaries-or-fertility-in-general-the-vaccines-are-highly-effective-at-preventing-illness-and-death/
THEY ARE LYING TO YOU
IT IS DESIGNED TO NEVER RELEASE ANYTHING AT THE INJECTION SITE.
It stays at the injection site, but the lipid nanoparticle will ONLY open at the target site. So effectively anything at the injection site is inactive and waiting to be released. This works like a long-acting drug. It will never open and release the treatment/mRNA at the site of injection '' only as the lipid nanoparticle shella migrate from the injection site to a target destination will they open up and release the treatment.
The way the PZP vaccine works is it triggers an immune response against the invasive pig ovary eggs. The immune system then creates antibodies for the pig egg, but it goes overboard and targets parts that are also on the normal non-invasive eggs. Over time after reexposure, or in the case of the DPX delivery system a long term release, the normal non-invasive eggs will be viewed as hostile and attacked.
The Pfizer vaccine works in a SIMILAR WAY. The DPX delivery system brings the mRNA vaccine to the ovaries (and other areas). The lipid nanoparticle opens and releases mRNA which will convert ovary cells into a virus/ovary hybrid that the immune system will attack. Once it kills the mutated ovary cell, it will mark various parts of the ''pathogen'' with antibodies. This has a HIGH CHANCE over repeat exposure it will view the ovary cells and eggs themselves as hostile, potentially causing the immune system to attack ovary cells.
Please share this. They are using a delivery system developed by a company that was designed to sterilize animal populations. The fact that infertility as an outcome is disregarded and wasn't even tested despite this knowledge should be criminal.
Sources:
https://spayvac.com/f/history-of-spayvac-pzp-single-dose-efficacy
https://spayvac.com/about-spayvac
PLEASE SUPPORT A FREE AND INDEPENDENT PRESS!PLEASE SUPPORT A FREE AND INDEPENDENT PRESS!
Edit: Also, the mRNA vaccine has a chance that it will target other cells too via the same mechanism. The circulatory system being the carrier of the lipid shells means when the shell breaks down, it will target the nearest heart/vein cells. Then, our immune system attacks the converted cell and gets antibodies for the spike.. but also creates antibodies for the innocent cell parts. Then, upon each re-exposure to the vaccine, the immune system has a stronger reaction and produces antibodies to attack the virus but also the unaffected heart/veins which it previously identified as being part of the virus.
The mRNA vaccine is the same method to the SpayVac PZP vaccine technique '' make the body target innocent cells. However, the heart and vein cells may be unitended consequences of the true delivery mechanism to the ovaries (and presumably, testes).
Edit 2:ANALOGY TIME! This is how turning healthy ovarian cells into spike protein mutants is a bad idea.
It's like a normal Yellow Toyota Corolla car. Totally normal and safe, right? But then a theif breaks in and steals it for a joyride. The police stop the car, kill the thief and put out a wanted posted for any of his friends. But then they see the car and also put out wanted posters for cars that are 1) Yellow and 2) Toyota Corollas. (Then the body gets a booster vaccine) Suddenly, the cops see MORE Yellow Toyota Corollas driven by thieves and they say ''OK, this isn't a coincidence. It keeps happening over and over, these Corollas are bad news. Destroy ALL the Yellow Toyota Corollas.'' Via: https://www.reddit.com/r/conspiracy/comments/qw69yx/pfizer_vaccine_is_using_sterilization_delivery/
This is accurate and stemmed from decades of research on canines, felines, equines, does & fawns, elephants, kangaroos, primates, mice and feral pigs. A piece from 2009 references this; it's called immunosterilization
https://educate-yourself.org/cn/ottimmunosterilization25sep09.shtml
PZP is used to sterilise wild horses in America. The first 2 doses must be taken within 2 to 6 weeks apart with a 8 month to yearly booster follow up. This reduces pregnancy rate 80%-90%.
Something about the schedule sounds familiar but I just can't put my finger on it'...
Pfizer CEO is also a veterinarian'... how convenient
Your Guide to the 2023 Farm Bill | Farming and Agricultural News | lancasterfarming.com
Tue, 10 Jan 2023 16:31
Saying the Farm Bill is for farmers is like saying Ronald Reagan was a famous actor. It's true, but it's far from the whole story.
The Farm Bill helps farmers weather downswings in commodity prices, yes. But it also protects waterways and forests, provides groceries for needy people and supports the development of markets for local food. It even helps rural communities purchase police cars.
Congress is preparing to craft its 19th Farm Bill this year, the 90th anniversary of the original passed in 1933 to get farmers through the Great Depression.
From a controversial package of subsidies and production controls, the Farm Bill has grown, through renewals roughly every five years, to encompass a cornucopia of programs for both rural and urban America.
The 2023 Farm Bill will likely cost more than $600 billion over five years, according to numbers from the Congressional Research Service.
This year's negotiations start with a Jan. 7 listening session at the Pennsylvania Farm Show and will ideally be done before Sept. 30, the expiration date of the 2018 version.
One sign of how much the Farm Bill has changed is that crop insurance and commodity supports now combine for less than 20% of the Farm Bill's mandatory outlays. More than three-quarters of the bill goes to food aid such as the Supplemental Nutrition Assistance Program, formerly known as food stamps.
Conservation, with 7% of the money, is the other category of funding that's big enough to see on a pie chart.
Since the Farm Bill's inception, support for its programs has been driven by commodity groups representing corn, wheat, cotton and the like. But the emphasis placed on each commodity in a given Farm Bill can vary based on what's produced where the members of the House and Senate agriculture committees live, according to the University of Illinois.
That could be good news for the Northeast this year, with U.S. Rep. Glenn Thompson of Pennsylvania taking over as chairman of the House Agriculture Committee. The Senate committee's leaders are from the Midwest and South.
Farm Programs As long as the Farm Bill is called the Farm Bill, it will probably be known best for providing a safety net to help farmers through natural disasters and market downturns.
These programs have evolved over the years, but today they include Price Loss Coverage and Agriculture Risk Coverage for field crops, the Tree Assistance Program for orchards, the Livestock Indemnity Program and Dairy Margin Coverage.
Federal support for crop insurance is permanently authorized, so its existence doesn't depend on the Farm Bill. But Congress can use the Farm Bill to modify crop insurance rules.
The 2014 Farm Bill created Whole-Farm Revenue Protection, designed to cover all of a farm's crops and livestock under a single insurance policy.
Beyond payments to farmers, the Farm Bill funds research that could improve American farmers' resilience to climate change and their competitiveness in the world economy.
U.S. public funding for agricultural research and development fell by a third from 2002 to 2019, while ag powerhouses like China, the European Union and Brazil boosted their spending, according to USDA's Economic Research Service.
The Farm Bill also provides Specialty Crop Block Grants that states use to support their local horticulture industries. Projects funded in 2022 include studying control of phorid flies in Pennsylvania mushroom houses, training Maryland growers on food safety rules, and promoting New York-grown produce.
Another offering, the Local Agriculture Market Program, funds farmer projects in direct marketing, local food enterprises and value-added production.
In the conservation title of the bill, t he Environmental Quality Incentives Program and Conservation Stewardship Program are popular options for funding water-quality projects such as stream buffers.
Created in the 2014 Farm Bill, the Regional Conservation Partnership Program has provided millions of dollars to public-private partnerships in the Chesapeake Bay watershed and other areas across the nation. It is also helping to reforest former mine lands in the Alleghenies and improve coastal habitat for New Jersey aquaculture.
The conservation section of the Farm Bill even funds farmland preservation through the Agricultural Conservation Easement Program.
Lawmakers also spice up the Farm Bill with policy changes outside of the law's mainstay programs.
The 2018 law adjusted the formula for milk pricing to help food businesses stabilize their input costs. Some dairy farmers soured on the provision when it contributed to negative producer price differentials in 2020 and 2021.
The current Farm Bill also legalized commercial production of hemp, opening farming and manufacturing possibilities across the country.
Food Assistance Nutrition programs, now the lion's share of the Farm Bill, were added to the mix in 1973 and became part of the law's fundamental bargain: Rural and urban lawmakers both get programs important to their constituents, and the urban members provide votes the farm programs might need to get passed.
While the omnibus nature of the Farm Bill can bolster bipartisanship, it risks battles for funding among crop, livestock, nutrition and environmental interests, and between regions of the country.
In one case, debates were so contentious and protracted that what was supposed to be the 2012 Farm Bill became the 2014 Farm Bill.
Part of the conflict, in that and the following Farm Bill, came from House Republicans seeking '-- ultimately without success '-- to tighten SNAP eligibility requirements.
Over the past decade there have even been rumblings about splitting the farm and nutrition programs into separate legislation. Daren Bakst, senior research fellow at the conservative Heritage Foundation, argued in 2015 that the current arrangement discourages critical assessment of the programs' merits in favor of political convenience.
Meanwhile, some SNAP supporters have mused that the program could pass on its own without ag lawmakers' votes, according to Parke Wilde, a food policy professor at Tufts University.
No matter the tenor of negotiations, lawmakers have a major incentive to pass something and not let the Farm Bill simply lapse.
Without reauthorization, some programs would cease to operate, and farm commodity programs would revert to musty, expensive supply-control regimes that were given up decades ago.
Mired in the 2012-2014 negotiations, lawmakers extended the existing Farm Bill for a time rather than let it sunset.
Exceptions While the Farm Bill includes SNAP and The Emergency Food Assistance Program, it does not authorize the Women, Infants and Children program or the National School Lunch Program.
Those are handled by a separate bill called the child nutrition reauthorization. The 2010 edition is familiar to farmers as the law that caused whole milk to be removed from schools.
In addition to the Farm Bill, Congress has been working on a new version of the child nutrition bill. Both bills run through the Agriculture Committee in the Senate, but in the House, the children's bill falls to the Education and Labor Committee.
Though not the primary legislation for the topic, the Farm Bill still influences school meals. It can modify the USDA Foods program, which provides 15 to 20% of the food served in school lunches, as well as the Farm to School and healthy snack programs.
Any changes to SNAP eligibility will indirectly affect schools and needy children too.
''Children from families enrolled in SNAP are directly certified for free school meals, meaning their families don't have to fill out applications. Schools are having a hard time collecting applications right now,'' said Diane Pratt-Heavner, spokeswoman for the School Nutrition Association.
Money Along with the farm and nutrition programs, the Farm Bill authorizes a host of small but important efforts '-- on trade promotion, food relief to developing countries, forest management, rural broadband, biofuel development and the national animal vaccine bank.
The bulk of Farm Bill funding is mandatory, meaning the programs actually receive the funding in the legislation. Some programs, though, are only authorized in the Farm Bill and rely on annual appropriations bills for funding '-- which may be less than the amount suggested in the Farm Bill.
When the 2018 Farm Bill was enacted, the Congressional Budget Office estimated that the cost of the mandatory programs over the law's five-year life span would be $428 billion, or $2 billion more than if the 2014 Farm Bill had been extended.
On a 10-year basis, the agency estimated the cost at $867 billion '-- budget neutral compared to extending the 2014 version.
Later this spring, the budget office is expected to release an updated Farm Bill baseline. That is the amount of spending on mandatory programs assuming current law continues.
The most recent projection, from last May, put the baseline at $648 billion over five years and $1.3 trillion over 10 years, according to the Congressional Research Service.
Those numbers will help lawmakers determine which programs should see level, decreased or increased funding. Those will be complex questions, and the answers will affect farmers '-- and Americans of all kinds '-- in every part of the country.
How to Quit Your Job to Fight Climate Change - Bloomberg
Tue, 10 Jan 2023 16:17
Tackling climate change will transform the labor market. With the right policies in place, more than 24 million green jobs could be created globally by 2030, according to the International Labor Organization. But finding people to fill those roles quickly won't be easy. One 2022 LinkedIn survey found that listings for green jobs have grown at an annual pace of 8% since 2015, while green talent grew only 6% each year over the same period.
One bright spot: Many job seekers are now looking to work in companies aligned with climate goals. A 2021 Yale School of Management survey of 2,000 students across 29 business schools globally found that 51% would accept lower salaries to work for an environmentally responsible company. That's a good sign, because filling the labor gap will require both new skills and people leaving their existing jobs for new and rapidly evolving industries. A reckoning is needed across the workforce, and there are some signs it's already underway.
UK's most popular baby names for 2022 revealed, as Sophia and Muhammad top the list - LBC
Tue, 10 Jan 2023 16:13
22 November 2022, 14:11 | Updated: 22 November 2022, 14:25
The Baby name list for 2022 saw Muhammad and Sophie top the list. Picture: LBC / Alamy By Danielle DeWolfe
The annual list of the nation's most popular baby names has been released, with the top 100 girls' names undergoing something of a shake-up for 2022.
When it came to girls' names, Olivia traditionally proved the most popular, topping the Office of National Statistics' list for the past six years. Meanwhile, Noah topped last year's list for the boys.
However, both the boys and girls rankings have seen their top names change over the course of 2022, with Muhammad now topping the boys list and Sophia the girls'.
Compiled by the BabyCentre, the research collates names registered on the site by tens of thousands of new parents.
Sarah Redshaw, UK Managing Editor for BabyCentre, told The Mirror that the organisation has seen a notable increase in celebrity and reality TV-inspired names.
It comes as the boy's name Luca shot into the top 10 '' an uplift of over 20 places from the previous year, thought to be connected to reality show Love Island and one half of its winning couple, Luca Bish.
Love Island winners Luca Bish and Gemma Owen are thought to have contributed to the spike in popularity. Picture: Contributor: Doug Peters / Alamy Stock Photo Read more: The Wanted singer Tom Parker's widow Kelsey finds new love with man who was jailed for killing stranger with one punch
Read more: Triple murder probe after mother and her two children killed in flat fire that was 'started deliberately'
Meanwhile, the names Liam, Luca, Rosie, Alex, Zara, Millie and Teddy '' all names of Love Island contestants, made it onto the 2022 list.
Redshaw said: "Love Islander names are definitely parents' type on paper. And BabyCentre parents haven't been putting all their eggs in the 2022 Love Island basket either.
''It's possible that the islanders' continued fame on social media and more reality TV is causing this surge. We now want to keep a watch on the names of 2022 winners Ekin-Su and Davide to see if they become more popular as they go on to bigger things."
The names of two other past Love Island contestants from 2019 '' Maura and Ovie '' also featured in BabyCentre's Top 100 for the very first time.
There's also been a notable revival in names linked to the 90s. A trend that not only is sweeping the fashion world, the sense of nostalgia also appears to extend to newborn babies.
Top boys' names include Muhammad and Thomas. Picture: Contributor: famveld / Alamy Stock Photo Speaking of the 90s revival, Redshaw added: "We wonder if parents are just excited to be dusting off their bucket hats or if 90s babies are now starting to have their own and giving into nostalgia when it comes to naming their little ones!"
The research also found that mothers over the age of 35 were more likely to have babies with more traditional names, while younger mothers tended to choose shortened versions of the traditional favourites.
Top 10 boys names1. Muhammad
2. Noah
3. Theo
4. Leo
5. Oliver
6. Jack
7. George
8. Luca
9. Ethan
10. Freddie
11. Arthur
12. Ryan
13. Harry
14. Oscar
15. Henry
16. Charlie
17. Archie
18. Teddy
19. Thomas
20. Adam
21. Aiden
22. Alfie
23. Louie
24. Finley
25. Liam
26. Jacob
27. Lucas
28. Daniel
29. Caleb
30. Joshua
31. Jaxon
32. Max
33. Isaac
34. Elijah
35. Zayn
36. Theodore
37. Reuben
38. Arlo
39. Jayden
40. James
41. William
42. Jude
43. Tommy
44. Mason
45. Ali
46. Albie
47. Ezra
48. Alexander
49. Nathan
50. Dylan
51. Yusuf
52. Kai
53. Rory
54. Logan
55. Toby
56. Roman
57. Samuel
58. Michael
59. Elliot
60. Myles
61. Ayaan
62. Sebastian
63. Finn
64. Kian
65. Harrison
66. Alex
67. Jesse
68. Jason
69. David
70. Grayson
71. Levi
72. Benjamin
73. Hunter
74. Hudson
75. Gabriel
76. Ollie
77. Rowan
78. Zachary
79. Asher
80. Ibrahim
81. Riley
82. Brodie
83. Eli
84. Oakley
85. Abdul
86. Luke
87. Matthew
88. Joseph
89. Milo
90. Hugo
91. Reggie
92. Edward
93. Ronnie
94. Aaron
95. Jasper
96. Omar
97. Zion
98. Bobby
99. Abdullah
100. Syed
Top girls' names include Sophia and Olivia. Picture: Contributor: Tetyana Vychegzhanina / Alamy Stock Photo Top 10 girls names1. Sophia
2. Lily
3. Olivia
4. Isla
5. Ava
6. Amelia
7. Freya
8. Aria
9. Maya
10. Ivy
11. Emily
12. Isabella
13. Mia
14. Grace
15. Evie
16. Zara
17. Millie
18. Ella
19. Hannah
20. Daisy
21. Rosie
22. Elsie
23. Willow
24. Luna
25. Poppy
26. Zoe
27. Isabelle
28. Sophie
29. Sienna
30. Ada
31. Nur
32. Florence
33. Charlotte
34. Evelyn
35. Emilia
36. Maryam
37. Fatima
38. Harper
39. Phoebe
40. Ayla
41. Mila
42. Maisie
43. Chloe
44. Hallie
45. Eliana
46. Layla
47. Lyla
48. Emma
49. Erin
50. Eva
51. Alice
52. Aurora
53. Aaliyah
54. Ruby
55. Matilda
56. Leah
57. Bella
58. Thea
59. Nora
60. Molly
61. Anna
62. Darcie
63. Lottie
64. Eleanor
65. Robyn
66. Violet
67. Maeve
68. Anaya
69. Maddison
70. Arabella
71. Maria
72. Holly
73. Ellie
74. Penelope
75. Imogen
76. Lucy
77. Talia
78. Rose
79. Mirha
80. Bonnie
81. Eliza
82. Iris
83. Abigail
84. Nova
85. Aisha
86. Nancy
87. Orla
88. Gabriella
89. Gracie
90. Esme
91. Jessica
92. Scarlett
93. Amira
94. Elizabeth
95. Jasmine
96. Olive
97. Lara
98. Lola
99. Mabel
100. Harriet
Muhammad: The 2nd-most-popular name in Netherlands in 2022
Tue, 10 Jan 2023 16:13
Fast News
The name is given to 671 baby boys in Netherlands last year, according to data released by Dutch Social Insurance Bank.
Top names for newborns were Noah and Emma, says Dutch Social Insurance Bank. (AP Archive)The second-most-popular name for newborn boys in the Netherlands in 2022 was Muhammad, according to new figures.
According to data released by the Dutch Social Insurance Bank (SVB) on Thursday, the top name for newborn boys in the country last year was also based in faith '' Noah, with 871 '' while Emma was the top girl's name with 677.
Combining the various spellings of the name, Muhammad took second place among the names given to baby boys with 671.
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NIH-Funded "Food Pyramid" Rates Lucky Charms Healthier Than Steak
Tue, 10 Jan 2023 16:09
A couple months back, at a small gathering of ops and tech leads hosted by Founders Fund, I met Justin Mares, the founder of True Medicine and Kettle & Fire. Over dinner, our conversation turned to diet, and to my delighted horror I learned the tale of Tufts' insane new food recommendations. Immediately, I knew I had to share it with the Pirate Nation.
Justin has made a career of nutrition, and built a national brand from his passion for health. Today, he guests with a story that cuts across many important cultural faults '-- the American obesity epidemic, the academic obsession with reducing meat consumption, the intersection of corporate interests and the government. This story is weird as hell, and yet perfectly unsurprising in the clown world. Bon app(C)tit.
-Solana
A few weeks ago the White House hosted a conference on hunger, nutrition and health. One of the key organizers of the conference '-- Dariush Mozaffarian, Dean of the Tufts School of Nutrition '-- had just finished spending 3 years and millions of dollars designing a new food pyramid. His findings? Lucky Charms are healthier than steak.
Americans have a massive obesity and disease problem. Are we really not understanding why?
According to the Tufts Food Compass '-- which they tout as ''the most comprehensive and science-based nutrient profiling system to date'' '-- Lucky Charms are healthier than whole milk, more than twice as healthy as beef, and better for you than a baked potato or cooked green peas.
See how your favorite foods rank (100 is the top score, 1 the worst) below.
Yes, you're reading this right. A major university really did spend three years and millions of dollars of NIH funding to tell us Frosted Mini Wheats and Honey Nut Cheerios are health foods. As the excellent Nina Teicholz says on her Substack :
The Food Compass, which gives top ratings to Cheerios, Lucky Charms and Cocoa Puffs, is absurd on the face of it. In all, nearly 70 brand-named cereals from General Mills, Kellogg's, and Post are ranked twice as high as eggs cooked in butter or a piece of plain, whole-wheat toast. Egg whites cooked in vegetable oils are also apparently more healthy than a whole, boiled egg, and nearly all foods are healthier than ground beef.
There are absurdities galore in the Food Compass' scoring of various foods. How about chocolate covered almonds (78 score) handily beating ground beef (26)? Lucky Charms (60) over a whole egg fried in butter (29)? Or poor pita bread receiving a 1, while wheat-based branded cereals like Cheerios (95), Frosted Mini Wheats (87), and Raisin Bran (72) receive scores that put them firmly in the ''to be encouraged'' camp? Our friend Dariush must have gotten a real bad case of pita poisoning to bring down the hammer so hard on poor pita.
Why does this matter? After all, anyone can just ignore Tufts' findings, because they're obviously crazy. But in the field of public health this is precisely the kind of work that matters. Studies like this are what lead to the last half century's famously misguided dietary guidelines , which have coincided with the sickest Americans our nation has ever seen.
On the ground floor, school boards across the country look to research of this kind to inform what's allowed in school lunches. The same school lunches empirically linked to higher rates of obesity for kids . An incredible shock, I'm sure, to anyone paying attention to the happenings of Congress, where pizza was declared a vegetable . It's the tomato sauce that does it, apparently (a fruit, of course, but at this point who even cares?).
And while most Americans have long since given up on the idea that our nation's chronically incapable school boards might achieve results that actually help children, we still expect a little more from our doctors. These people went to medical school, after all. But in a country where 80% of medical schools have zero required nutrition training or teaching, the Lucky Charms health guidelines cooked up at places like Tufts become the source material overworked, nutritionally uninformed doctors and nurses fall back on when they make recommendations to their sick patients.
And boy are there are a lot of patients. Americans today are sicker, fatter, and less fertile than any generation of Americans before us. 40% of Americans are obese, 71.6% of adults over 20 are overweight , and 88% of Americans are metabolically unhealthy . And for the first time in decades, life expectancy is falling due to chronic illness .
This explosion in chronic illness has also led to an explosion in healthcare costs. At present, healthcare spend approaches $2.2 trillion (almost 20% of total GDP). Chronic diseases drive almost 75% of this cost : diseases that are almost entirely mediated by a poor food environment, poor food policy, and misguided health and nutrition guidelines.
Or, ''misguided.'' Because you may be wondering '-- and you'd be right to find this bit confusing '-- how a top tier university comes to the shocking conclusion that sugary cereals are more nutritious than red meat, one of the most nutritionally-dense foods on the planet. Why, it's almost as if these studies are funded by people selling sugary cereal!
Let's talk about Big Food and Agriculture.
In 1963, the Sugar Research Foundation (SRF) paid Harvard researchers the equivalent of $50k to refute sugar's role in heart disease, and researchers happily produced the results they were hired to produce. Instead of blaming sugar, Harvard and the SRF blamed cholesterol and saturated fat. Today, after 60 years of fat-is-bad food policy, Americans have never been in worse health, with no shortage of studies vindicating fat '-- including saturated fat .
Big Food continues their funding tricks to this to this day. One classic trick is to deflect blame: surely, Big Food says, we aren't seeing historic rates of illness and obesity due to our highly processed food-like products! The nation just doesn't exercise!
It's a phenomenal piece of propaganda, because it's only partially untrue; exercise is important. Unfortunately, there's no such thing as a healthy diet consisting of daily sugar-water consumption, no matter how many walks around the block you take. It should therefore come as no surprise Coca-Cola has spent millions creating and funding the Global Energy Balance Network (GEBN), which invented and promoted the idea of ''energy balance.'' Eat whatever you want '-- just hop on that bike after and you're fine !
In addition to starting questionable marketing organizations, Coca-Cola started funding ''research'' several decades ago. According to Food Fix , from 2008 to 2016 the company funded 389 articles in 169 journals concluding physical activity was more important than diet, and soft drinks and sugar are essentially harmless. In total, Coke provided more than $120 million to US universities, health organizations, and research institutions between 2010 and 2015. The company is not alone.
Big Food played similar tricks to muddy the waters on trans fats for decades, likely killing a million-plus Americans in the process ( as I wrote about here ). ''Research'' is essential to the strategy. The food industry spends more than $11 billion a year funding nutrition studies '-- dwarfing the NIH, which spends only $1 billion '-- polluting and diluting independent research, and confusing policy makers, the public, and even most doctors and nutritionists.
You heard that right: for every dollar the NIH spends on nutrition research, trying to understand why and how we are getting sicker and fatter every year, the food industry spends $11. On ''research.'' From respected universities. Which appears in respected journals.
One might reasonably ask, why does Big Food do this? Why spend so much money funding biased nutrition research and sway policy away from whole foods towards Lucky Charms and the like?
The answer is pretty simple: money. A 2016 USDA report showed that 5% of SNAP (a nutrition-assistance program for low-income people) funds '-- or $3.5b in 2016 '-- are spent on soft drinks ( here's an easy-to-read summary by NYT ). Which means it's conceivable that revenue from taxpayer-funded SNAP made up close to 20% Coke's annual US revenue that year .
Yes: in a government program specifically engineered to help lower-income people improve their nutrition , sugary drinks are one of the largest line-items in SNAP, accounting for almost 10% of the ''food'' purchased by the program. Legally, you can't purchase a hot meal or rotisserie chicken using SNAP benefits because they're not healthy enough. But sprinkle in a bit of lobbying and voila! $7b a year goes to soda.
Similarly, 87% of schools serve brand-name Big Food items (McDonald's, Snickers, etc) in their cafeterias. 80% of schools have contracts with soda companies . The reason monstrosities like the Food Compass get funded, the reason Big Food funds bad research, is all the same. The government funded piggy bank '-- across SNAP, school lunches, prison lunches, hospitals, etc. '-- is just too big to ignore. And if they can shift even small amount of federal spending away from lower-margin whole foods and towards higher-margin, highly-processed Frankenfoods like Lucky Charms, all the better for their bottom lines, and all the worse for the American public.
Ultimately, initiatives like the Food Compass would be laughable if they didn't make their way into food policy. Recently, we've seen NYC announce the switch to ''plant-based'' foods in hospitals as a default (along with meatless Monday and vegan Fridays in NYC schools). When talking plant-based, they make sure to focus heavily on fruits, vegetables, grains, and nuts, as they say on their site:
Plant-based nutrition is a style of cooking and eating that emphasizes, but is not necessarily limited to, fruits and vegetables, whole grains, legumes, nuts and seeds, plant oils, and herbs and spices, and reflects evidence-based principles of health and sustainability.
Lovely. Here is a picture of the ''fruits and vegetables, whole grains, legumes, and nuts'' in question:
Let's play a fun game of ''count the publicly traded food companies with products on this tray.'' Image: @jamescophotoThat's what you can look forward to in NYC hospitals when you get the now-default vegan option (we wish you a speedy recovery!). And if you're a child unfortunate enough to be stuck in a NYC public school for lunch, you too get a helping of processed food, with almost no protein. I'm sure that won't negatively impact your growth, development, and focus at all.
Frauds like the Food Compass and the plant-based push in hospitals and schools are just thinly disguised ploys by Big Food to push more of their high-margin, processed products on the American consumer. Health consequences be damned.
Sorry, American consumer. You are well and truly fucked. But at least it will taste good.
Editor's note: the original version of this article said that in 2016, taxpayer-funded SNAP made up nearly 20% of Coke's annual US revenue, which, while conceivable, is not a certainty. Reports published in 2016 indicate these facts: SNAP 2016 expenditures were $70.8b , and 5% of SNAP funds '-- or just under $3.5b '-- are spent on soft drinks . Coke's US revenue in 2016 was $19.9b . If even half of SNAP's soft drink spending went to Coke that year, 8.7% of the company's revenue would have come from SNAP funds. If 100% of the soft drink spend went to Coke in 2016, its SNAP revenue would have been north of 17% of total U.S. revenue. We've updated the piece to reflect this.
Justin Mares is the founder of True Medicine and writes a monthly newsletter on health and entrepreneurship at The Next . You can find him on Twitter @jwmares . For more reading on the insanity that is the Tufts Food Compass, see full rankings here .
Justin has made a career of nutrition, and built a national brand from his passion for health. Today, he guests with a story that cuts across many important cultural faults '-- the American obesity epidemic, the academic obsession with reducing meat consumption, the intersection of corporate interests and the government. This story is weird as hell, and yet perfectly unsurprising in the clown world. Bon app(C)tit.
-Solana
A few weeks ago the White House hosted a conference on hunger, nutrition and health. One of the key organizers of the conference '-- Dariush Mozaffarian, Dean of the Tufts School of Nutrition '-- had just finished spending 3 years and millions of dollars designing a new food pyramid. His findings? Lucky Charms are healthier than steak.
Americans have a massive obesity and disease problem. Are we really not understanding why?
According to the Tufts Food Compass '-- which they tout as ''the most comprehensive and science-based nutrient profiling system to date'' '-- Lucky Charms are healthier than whole milk, more than twice as healthy as beef, and better for you than a baked potato or cooked green peas.
See how your favorite foods rank (100 is the top score, 1 the worst) below.
Yes, you're reading this right. A major university really did spend three years and millions of dollars of NIH funding to tell us Frosted Mini Wheats and Honey Nut Cheerios are health foods. As the excellent Nina Teicholz says on her Substack :
The Food Compass, which gives top ratings to Cheerios, Lucky Charms and Cocoa Puffs, is absurd on the face of it. In all, nearly 70 brand-named cereals from General Mills, Kellogg's, and Post are ranked twice as high as eggs cooked in butter or a piece of plain, whole-wheat toast. Egg whites cooked in vegetable oils are also apparently more healthy than a whole, boiled egg, and nearly all foods are healthier than ground beef.
There are absurdities galore in the Food Compass' scoring of various foods. How about chocolate covered almonds (78 score) handily beating ground beef (26)? Lucky Charms (60) over a whole egg fried in butter (29)? Or poor pita bread receiving a 1, while wheat-based branded cereals like Cheerios (95), Frosted Mini Wheats (87), and Raisin Bran (72) receive scores that put them firmly in the ''to be encouraged'' camp? Our friend Dariush must have gotten a real bad case of pita poisoning to bring down the hammer so hard on poor pita.
Why does this matter? After all, anyone can just ignore Tufts' findings, because they're obviously crazy. But in the field of public health this is precisely the kind of work that matters. Studies like this are what lead to the last half century's famously misguided dietary guidelines , which have coincided with the sickest Americans our nation has ever seen.
On the ground floor, school boards across the country look to research of this kind to inform what's allowed in school lunches. The same school lunches empirically linked to higher rates of obesity for kids . An incredible shock, I'm sure, to anyone paying attention to the happenings of Congress, where pizza was declared a vegetable . It's the tomato sauce that does it, apparently (a fruit, of course, but at this point who even cares?).
And while most Americans have long since given up on the idea that our nation's chronically incapable school boards might achieve results that actually help children, we still expect a little more from our doctors. These people went to medical school, after all. But in a country where 80% of medical schools have zero required nutrition training or teaching, the Lucky Charms health guidelines cooked up at places like Tufts become the source material overworked, nutritionally uninformed doctors and nurses fall back on when they make recommendations to their sick patients.
And boy are there are a lot of patients. Americans today are sicker, fatter, and less fertile than any generation of Americans before us. 40% of Americans are obese, 71.6% of adults over 20 are overweight , and 88% of Americans are metabolically unhealthy . And for the first time in decades, life expectancy is falling due to chronic illness .
This explosion in chronic illness has also led to an explosion in healthcare costs. At present, healthcare spend approaches $2.2 trillion (almost 20% of total GDP). Chronic diseases drive almost 75% of this cost : diseases that are almost entirely mediated by a poor food environment, poor food policy, and misguided health and nutrition guidelines.
Or, ''misguided.'' Because you may be wondering '-- and you'd be right to find this bit confusing '-- how a top tier university comes to the shocking conclusion that sugary cereals are more nutritious than red meat, one of the most nutritionally-dense foods on the planet. Why, it's almost as if these studies are funded by people selling sugary cereal!
Let's talk about Big Food and Agriculture.
In 1963, the Sugar Research Foundation (SRF) paid Harvard researchers the equivalent of $50k to refute sugar's role in heart disease, and researchers happily produced the results they were hired to produce. Instead of blaming sugar, Harvard and the SRF blamed cholesterol and saturated fat. Today, after 60 years of fat-is-bad food policy, Americans have never been in worse health, with no shortage of studies vindicating fat '-- including saturated fat .
Big Food continues their funding tricks to this to this day. One classic trick is to deflect blame: surely, Big Food says, we aren't seeing historic rates of illness and obesity due to our highly processed food-like products! The nation just doesn't exercise!
It's a phenomenal piece of propaganda, because it's only partially untrue; exercise is important. Unfortunately, there's no such thing as a healthy diet consisting of daily sugar-water consumption, no matter how many walks around the block you take. It should therefore come as no surprise Coca-Cola has spent millions creating and funding the Global Energy Balance Network (GEBN), which invented and promoted the idea of ''energy balance.'' Eat whatever you want '-- just hop on that bike after and you're fine !
In addition to starting questionable marketing organizations, Coca-Cola started funding ''research'' several decades ago. According to Food Fix , from 2008 to 2016 the company funded 389 articles in 169 journals concluding physical activity was more important than diet, and soft drinks and sugar are essentially harmless. In total, Coke provided more than $120 million to US universities, health organizations, and research institutions between 2010 and 2015. The company is not alone.
Big Food played similar tricks to muddy the waters on trans fats for decades, likely killing a million-plus Americans in the process ( as I wrote about here ). ''Research'' is essential to the strategy. The food industry spends more than $11 billion a year funding nutrition studies '-- dwarfing the NIH, which spends only $1 billion '-- polluting and diluting independent research, and confusing policy makers, the public, and even most doctors and nutritionists.
You heard that right: for every dollar the NIH spends on nutrition research, trying to understand why and how we are getting sicker and fatter every year, the food industry spends $11. On ''research.'' From respected universities. Which appears in respected journals.
One might reasonably ask, why does Big Food do this? Why spend so much money funding biased nutrition research and sway policy away from whole foods towards Lucky Charms and the like?
The answer is pretty simple: money. A 2016 USDA report showed that 5% of SNAP (a nutrition-assistance program for low-income people) funds '-- or $3.5b in 2016 '-- are spent on soft drinks ( here's an easy-to-read summary by NYT ). Which means it's conceivable that revenue from taxpayer-funded SNAP made up close to 20% Coke's annual US revenue that year .
Yes: in a government program specifically engineered to help lower-income people improve their nutrition , sugary drinks are one of the largest line-items in SNAP, accounting for almost 10% of the ''food'' purchased by the program. Legally, you can't purchase a hot meal or rotisserie chicken using SNAP benefits because they're not healthy enough. But sprinkle in a bit of lobbying and voila! $7b a year goes to soda.
Similarly, 87% of schools serve brand-name Big Food items (McDonald's, Snickers, etc) in their cafeterias. 80% of schools have contracts with soda companies . The reason monstrosities like the Food Compass get funded, the reason Big Food funds bad research, is all the same. The government funded piggy bank '-- across SNAP, school lunches, prison lunches, hospitals, etc. '-- is just too big to ignore. And if they can shift even small amount of federal spending away from lower-margin whole foods and towards higher-margin, highly-processed Frankenfoods like Lucky Charms, all the better for their bottom lines, and all the worse for the American public.
Ultimately, initiatives like the Food Compass would be laughable if they didn't make their way into food policy. Recently, we've seen NYC announce the switch to ''plant-based'' foods in hospitals as a default (along with meatless Monday and vegan Fridays in NYC schools). When talking plant-based, they make sure to focus heavily on fruits, vegetables, grains, and nuts, as they say on their site:
Plant-based nutrition is a style of cooking and eating that emphasizes, but is not necessarily limited to, fruits and vegetables, whole grains, legumes, nuts and seeds, plant oils, and herbs and spices, and reflects evidence-based principles of health and sustainability.
Lovely. Here is a picture of the ''fruits and vegetables, whole grains, legumes, and nuts'' in question:
Let's play a fun game of ''count the publicly traded food companies with products on this tray.'' Image: @jamescophotoThat's what you can look forward to in NYC hospitals when you get the now-default vegan option (we wish you a speedy recovery!). And if you're a child unfortunate enough to be stuck in a NYC public school for lunch, you too get a helping of processed food, with almost no protein. I'm sure that won't negatively impact your growth, development, and focus at all.
Frauds like the Food Compass and the plant-based push in hospitals and schools are just thinly disguised ploys by Big Food to push more of their high-margin, processed products on the American consumer. Health consequences be damned.
Sorry, American consumer. You are well and truly fucked. But at least it will taste good.
Editor's note: the original version of this article said that in 2016, taxpayer-funded SNAP made up nearly 20% of Coke's annual US revenue, which, while conceivable, is not a certainty. Reports published in 2016 indicate these facts: SNAP 2016 expenditures were $70.8b , and 5% of SNAP funds '-- or just under $3.5b '-- are spent on soft drinks . Coke's US revenue in 2016 was $19.9b . If even half of SNAP's soft drink spending went to Coke that year, 8.7% of the company's revenue would have come from SNAP funds. If 100% of the soft drink spend went to Coke in 2016, its SNAP revenue would have been north of 17% of total U.S. revenue. We've updated the piece to reflect this.
Justin Mares is the founder of True Medicine and writes a monthly newsletter on health and entrepreneurship at The Next . You can find him on Twitter @jwmares . For more reading on the insanity that is the Tufts Food Compass, see full rankings here .
9,000 NYC Nurses Preparing To Strike If No Tentative Agreements Reached With Hospitals Tonight - Activist Post
Tue, 10 Jan 2023 15:58
By Tyler Durden
Thousands of nurses from New York City hospitals could strike as early as Monday morning if unions and hospitals cannot agree on tentative contract agreements by midnight.
York State Nurses Association (NYSNA) President Nancy Hagans said at a press conference Saturday that 8,700 nurses will strike at 0600 ET Monday if no agreement is reached with hospitals by 2359 ET Sunday.
BronxCare and The Brooklyn Hospital Center have already reached tentative agreements with the union to increase wages, better health benefits, and improve safe staffing levels. Still, Mount Sinai, Mount Sinai Morningside, Mount Sinai West, and Montefiore are hospitals that have yet to reach deals with the union.
ABC7 New York said Mount Sinai is preparing for a strike. The hospital began moving newborns under intensive care and vulnerable patients to other hospitals this weekend amid the looming labor action. The hospital could also cancel non-emergency procedures.
Hospitals are canceling elective surgeries & moving NICU babies as 10,000 NYC nurses prepare to go on strike next week. @CBSNewYork https://t.co/uCNw5hVscA pic.twitter.com/V4LijcjGpv
'-- Ali Bauman (@AliBaumanTV) January 7, 2023
Mount Sinai's chief nursing officer, Dr. Frances Cartwright, railed against the strike threat:
''Talk about vulnerable patients, defenseless little babies.
''We can't wait until Monday, we have to plan. I sure am hoping for the best, but you have to plan for the worst.''
An internal memo from Mount Sinai informed staff of ''aggressive planning in response'' to a possible strike tomorrow, which would include ''diverting a majority of ambulances,'' beginning ''to cancel some elective surgeries '... will perform emergency surgery only,'' ''starting to transfer patients'' to other hospitals and ''working to discharge as many patients as appropriate safely.''
New York Gov. Kathy Hochul said days ago her ''full expectation is that this will be resolved because there is no alternative.''
Source: ZeroHedge
Image: CBS/Ali BaumanTV/Twitter
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Kumail Nanjiani: Studios Refuse to Cast Non-White Actors as Bad Guys '' The Hollywood Reporter
Tue, 10 Jan 2023 15:29
Kumail Nanjiani says Hollywood is still limiting the kinds of roles that actors of color can play.
The Eternals, Big Sick and Silicon Valley actor, who is promoting his recent Hulu limited series Welcome to Chippendales, said in a new interview that decision-makers are reluctant to cast nonwhite actors in villain roles.
''I think that Hollywood now '-- even though they're trying to be more diverse '-- is still weird,'' the actor told Esquire UK. The article notes Nanjiani believes that the problem is ''good intentions can sometimes lead to misguided solutions: If the bad guy is a brown guy, what message is that sending?''
''And that's just as limiting as anything else,'' Nanjiani said. ''I want to play more bad guys.'' He pointed to actor Sebastian Stan, who plays Marvel superhero the Winter Solider as well as a cannibal in the 2022 movie Fresh. ''He does these big Marvel movies, and then he'll play a psychopath,'' he says. ''I was told that's going to be hard because people don't want to cast nonwhite people as bad guys.''
In Welcome to Chippendales, Nanjiani plays the iconic strip club's Indian founder, Somen ''Steve'' Banerjee, as he goes from an up-and-coming businessman in the 1980s to a vilified accessory to murder in the early '90s. Nanjiani added that he suspects such a role would have gone to a white actor if the project wasn't based on a true story.
Previously, Nanjiani told THR about the role: ''I've never gotten the opportunity to play a character like this, who has such a big arc and a descent into darkness. I've always [wanted to play] the bad guy '-- I don't mean just guys who were kind of shitty; I mean a bad bad guy. The story itself was so exciting and unexpected. There are, like, 20 unbelievable things that happen in the course of our show, and that all happened in real life. And it had interesting stuff to say about the American dream and how accessible it is to different kinds of people, and to see that through the lens of an immigrant. I'm an immigrant, and I had a certain idea of the American dream before coming here. And now, obviously, that's evolved. To be able to explore that through the eyes of someone who, in some ways, had a similar experience to me is rare.''
Welcome to Chippendales is available to stream now on Hulu.
We Live In The Age of The Bullshitter ''§ Current Affairs
Tue, 10 Jan 2023 15:10
''A little hyperbole never hurts. '... People want to believe that something is the biggest and the greatest and the most spectacular. I call it truthful hyperbole. It's an innocent form of exaggeration'--and a very effective form of promotion.'' '--Donald J. Trump, The Art of the Deal
Give them the old Trump bullshit,'' Donald Trump reportedly once told his architect. ''Tell them it is going to be a million square feet, sixty-eight stories.'' (''I don't lie, Donald,'' replied the architect.) From his earliest days, Trump has rarely cared much about whether what he was saying at any given moment was true. Frequently it isn't.
Elon Musk is the richest man on planet Earth. He is also a complete bullshitter. He makes false claims about the cars he makes. He constantly promises that he is going to accomplish things that he never, in fact, accomplishes. In March 2020, he made the confident COVID-19 prediction that ''based on current trends, probably close to zero new cases in US too by end of April.'' After convincing cities around the country that his ''Boring Company'' was going to build tunnels that would alleviate traffic congestion for low, low prices, Musk's company simply went silent after municipal governments asked it to follow through on its commitments.
Sam Bankman-Fried was cryptocurrency's most respectable figure, a wunderkind billionaire who was sympathetically profiled across the press. Bankman-Fried was supposedly a deeply moral person who lived like an ascetic and had committed himself to the ''Effective Altruism'' movement, which aims to achieve maximal moral goodness through benevolent acts and philanthropy. But it turned out that Bankman-Fried had essentially gambled away customers' deposits at his company, leaving the customers in the lurch and destroying Bankman-Fried's fortune virtually overnight. He is now being prosecuted for fraud. Bankman-Fried admitted to Vox that when he had talked about ethical commitments he had been basically uttering ''shibboleths'' that he didn't really believe in. ''Man all the dumb shit I said,'' he told the reporter, referring to his high-minded talk about the importance of integrity in business. Many of our era's ''most beloved people,'' he said, ''are basically shams.'' Bankman-Fried's selflessness was certainly a sham; it turned out that the supposedly self-denying ascetic lived in a $40 million Bahamian penthouse.
George Santos has been elected as a member of the United States House of Representatives. He has also falsely claimed that his mother was killed in the 9/11 attacks, that his employees died in the Pulse nightclub shooting, that he is Jewish, that he is half Black, that he once had a brain tumor, that he graduated from college, that he worked for Goldman Sachs, and that he owned various properties.1 The Republican Party hasn't said much about any of this, perhaps because a party that recently gave us a Donald Trump presidency is in no position to take a firm stance against fabulists.
I am consistently aghast at the number of people who manage to be very successful in our society despite extreme levels of ignorance and/or dishonesty. Those who have read this magazine for a few years will know that I have ended up becoming a specialist in ''debunking'' bad arguments and exposing the mendaciousness of prominent public intellectuals, pundits, and politicians. This has proven a wearying task, because there is a seemingly inexhaustible supply of individuals who have both large platforms and ill-informed opinions.
Joe Rogan, the world's most popular podcaster, who has accumulated a vast fortune and has a major deal with Spotify, limits his research to casual Googling, even though he speaks to millions of people on some of the most important topics facing humanity. As a result, listeners can come away with the impression that Atlantis was real, ivermectin can cure COVID-19, and aliens live among us. Ben Shapiro, who speaks confidently and quickly on subjects he has clearly never read a book on, was nevertheless dubbed ''the cool kid's philosopher'' by the New York Times in 2018. Jordan Peterson, who writes impenetrable prose concealing fallacious arguments, sells millions of books and publishes in major newspapers.
It's not just conservatives. In 2019, I was depressed to see Pete Buttigieg and Beto O'Rourke becoming the subject of affection among liberal Democrats, given that both men were plainly self-promoting strivers who had little real commitment to improving the lives of their fellow human beings. One only had to read Buttigieg's memoir or the sympathetic media profile of O'Rourke in Vanity Fair to see that both were ''empty suit'' politicians who took political positions out of expedience rather than commitment.
Everywhere I look, I see bullshitters. Dr. Oz, a television doctor who recommends dubious treatments in flagrant violation of basic medical ethics, is one of the country's most recognized health authorities, and 46 percent of Pennsylvania voters thought he should be their U.S. senator. Yuval Noah Harari, a bestselling historian and favorite author of Barack Obama, predicted an end to pandemics in 2017 and makes unsupported claims about scientific fields he doesn't understand. Heck, Obama himself is a bullshitter, a man who manipulated people's emotions with stirring messianic rhetoric about how his election would mean the oceans would stop rising and change would come to the land, then delivered eight years of milquetoast centrism. Obama not only continued the Bush administration's foreign policy, but even his signature legislative accomplishment, the ''Affordable Care Act,'' was a giant lie that forced Americans to buy crappy financial products that shouldn't exist in the first place (a.k.a. health insurance). Is healthcare affordable now? It sure isn't.2
Even self-described ''rationalists'' who pride themselves on being able to cut through bad arguments and think logically, such as Sam Harris and Steven Pinker, are themselves just as bad as those they critique. Pinker, for instance, denounces mainstream environmentalists with the kind of hysterical hyperbole that he would condemn as emotional rhetoric if used by others, and Harris has boosted the racist pseudoscience of Charles Murray. Often those who critique left-wing ''wokeness'' do so in the name of reason and science, but are just as unfair and sloppy in their thinking as the ''social justice warriors'' supposedly are.
You can't even trust that the ''gold standard'' of education will give you information of reliable accuracy. The online conservative video platform ''PragerU'' is not a real university, but Harvard is theoretically supposed to be one. Yet Harvard PhDs can be just as confident in ignorant opinions as any other blowhard. The New York Times and Wall Street Journal op-ed pages are regularly filled with poorly-reasoned rubbish, and I seem to spend half my time trying to expose the faulty logic of some of our most highly-credentialed and trusted sources.
When I say that ''bullshitters'' abound, what do I mean exactly? What quality unites Steven Pinker, Jordan Peterson, Sam Bankman-Fried, Elon Musk, Donald Trump, Dr. Oz, and Barack Obama? What does it mean to be a bullshitter?
The clearest philosophical exposition of a Theory of Bullshit was put forth by Harry Frankfurt in his short classic On Bullshit. Frankfurt argued that bullshit was different than lying, and in some ways worse. A liar knows what they are saying is false. A bullshitter doesn't care whether it is true or false. The liar has not abandoned all understanding of truth, but they are deliberately trying to manipulate people into thinking things are otherwise than they actually are, whereas the bullshitter has simply stopped checking whether the statements they are making have any resemblance to reality:
''When an honest man speaks, he says only what he believes to be true; and for the liar, it is correspondingly indispensable that he considers his statements to be false. For the bullshitter, however, all these bets are off: he is neither on the side of the true nor on the side of the false. His eye is not on the facts at all, as the eyes of the honest man and of the liar are, except insofar as they may be pertinent to his interest in getting away with what he says. He does not care whether the things he says describe reality correctly. He just picks them out, or makes them up, to suit his purpose.''
One reason we have so much bullshit, Frankfurt said, is that in public life, people find themselves in circumstances where they are called to express opinions on topics they don't understand, and feel the need to muddle along by just coming up with some bullshit:
''Bullshit is unavoidable whenever circumstances require someone to talk without knowing what he is talking about. Thus the production of bullshit is stimulated whenever a person's obligations or opportunities to speak about some topic exceed his knowledge of the facts that are relevant to that topic. This discrepancy is common in public life, where people are frequently impelled'--whether by their own propensities or by the demands of others'--to speak extensively about matters of which they are to some degree ignorant. Closely related instances arise from the widespread conviction that it is the responsibility of a citizen in a democracy to have opinions about everything, or at least everything that pertains to the conduct of his country's affairs.''
Frankfurt's work is amusing and useful, but I think it gets a few things wrong. For one, having now read the collected works of many hundreds of bullshitters, I don't actually think Frankfurt's distinction between the ''honest man'' and the ''bullshitter'' quite holds up. One thing I've concluded is that, on the whole, people truly believe their own bullshit. That is, they do care about ''reality''; they just think their personal beliefs are an accurate description of it. (Steven Pinker, for example, has the utmost concern with rationality'--his latest book is Rationality: What It Is, Why It Seems Scarce, Why It Matters.) Professing reasonableness and actually being reasonable are totally different things, but many people I would place in the category of ''bullshitters'' are convinced that their every word is God's own truth. They just haven't checked whether that's the case.
Trump is an interesting case. Many people call Donald Trump a serial liar, and it's beyond dispute that much of what he says is factually false. (Trump himself admitted to the intentional use of ''truthful hyperbole,'' an oxymoron.) Frankfurt's theory would tell us that it's better to call Trump a bullshitter, since he simply doesn't seem to care about truth or falsity one way or the other. He's not a liar because he's not even aware of the facts; he just says whatever he expects will get the desired response from his audience.
I think it's absolutely the case that Trump doesn't check whether what he's saying is true, and thus is a classic case of the Frankfurtian bullshitter. But after many years of Trump-watching (and having written an entire book on Trump), I've become convinced that at any given moment, Trump completely believes the words that are coming out of his mouth to be true. He might contradict himself in five minutes. But at any given moment, Trump is certain he's right. Nothing would get him to admit the slightest mistake. John Kelly, Trump's former chief of staff, has said that Trump ''does not ever, ever, ever want to appear weak '... or that he might have been wrong,'' and won't admit mistakes because ''his manhood is at issue.''
The bullshitter is not just marked by a failure to test their opinions against the facts of the world. They are also characterized by having extreme confidence that they are right. The figures I have classified as bullshitters present themselves as authorities, and sometimes as sages or prophets. They issue predictions and consider themselves the embodiment of right-thinking reasonableness. The bullshitter's arrogance is just as important as their relationship with the truth.
some prominent bullshittersHere we can start to see hints of an explanation for why there is so much bullshit circulating around us. I think many of us are far too easily swayed by confident people who pose as experts, especially on subjects where we don't have the knowledge ourselves to evaluate the claims being made. I suspect that the careers of Shapiro and Peterson have been made possible in large part by these men's astonishing levels of confidence in themselves. Peterson's word salad magnum opus Maps of Meaning declares at the outset that it will speak truths that have never been previously discovered by humankind. It offers mostly mumbo jumbo instead (along with some comically convoluted diagrams), but Peterson speaks with such authority that confused readers may find themselves thinking that, given they can't understand a word, they must simply be incapable of grasping the deep thoughts of the great Genius.
We must add to this the fact that many of these men (and it is usually men, although Elizabeth Holmes certainly belongs on the list) are extremely rich, and it's easy to assume that a rich person must be a smart person, if we are not ourselves rich. After all, they knew at least one thing we don't know, i.e., how to make a large sum of money. And if intelligence is some single quality (IQ) then their wealth is proof of their ability to reason.
Intelligence is not actually, of course, a single quality, and plenty of people who know how to do one thing well (such as trade cryptocurrencies or develop real estate) know precious little else. In fact, if someone has devoted their entire life to the pathological pursuit of riches, they are likely to be very ignorant of a lot of the world's knowledge, because much of it simply won't have been relevant to their area of interest. When I read the memoirs of various billionaires, I was struck by how little they seemed to know about anything outside of the world of business'--though they also seemed confident that there was nothing else they ought to know.
Another problem is that we do not have media and educational institutions that successfully expose bullshit. Peterson's Maps of Meaning was praised by the chair of the Harvard psychology department, Sam Bankman-Fried made the covers of Forbes and Fortune, and Elizabeth Holmes was given a long sympathetic profile in the New Yorker. (The writer did not comment on the fact that when she was asked how her magic blood testing technology worked, she gave the worryingly imprecise answer ''a chemistry is performed so that a chemical reaction occurs.'' Her board members, among them multiple former U.S. cabinet officials, did not seem to notice this either, or were unconcerned.) We do not have, in this country, a mainstream press that is devoted to exposing bullshit. Even Matt Levine of Bloomberg, probably the country's best financial journalist, said after the collapse of Bankman-Fried's FTX empire that he thought Bankman-Fried was ''likable, smart, thoughtful, well-intentioned, and candid.'' In fact, Bankman-Fried was a sociopath who lied to everyone he knew. (Astonishingly, Bankman-Fried had previously admitted to Levine's face that he was ''in the Ponzi business'' but Levine apparently saw no red flags.) Men like this never fool Current Affairs (we described Bankman-Fried as having a fraud-based business model before his company's collapse), but it would be nice if the mainstream financial press would be a little more cynical toward obvious bullshitters. There are actual serious harms done by bullshitters, who swindle and exploit the people who trust them.
One of the problems is that for-profit media has a very bad set of incentives. For instance, every time Elon Musk makes some confident prediction about how he is going to implant chips in human brains or build a Mars colony or tunnel under Miami or whatever, tech websites are faced with a choice. They can print a story with the headline ''MUSK SAYS BRAIN CHIPS COMING IN SIX MONTHS'' or they can ignore Musk's bluster until he offers proof that he has actually invented one of the things he keeps promising to invent. To ignore Musk is to sacrifice the precious clicks that a new Musk prediction will inevitably garner. Thus a for-profit tech journalism website faces a conflict between its financial self-interest and its integrity. In a time when it's tough for media outlets to survive, it's hard to turn down the clicks.
We simply don't have enough public bullshit-catchers. Twitter, a colossal pit of bullshit, is now run by the king bullshitter himself. (Shortly after acquiring Twitter, Musk promoted a deranged conspiracy theory that Nancy Pelosi's husband had been attacked by a gay lover.) We have got to have more people who help others see through the confident wrong assertions of the noisy and successful. Bullshit is often dangerous'--over the course of the pandemic, plenty of people have listened to the terrible medical advice of people who don't know what they're talking about, and some who avoided vaccination or thought ivermectin was better than a mask have ended up dead.
The amount of ''fake news'' on social media has been endlessly commented on. But the problem is far deeper than the algorithms of Twitter and Facebook feeds. We also have a culture in which arrogance is rewarded rather than kept in check, and people can see that with enough shameless bluster you might become the richest person in the world or the president of the United States. There is no quick fix for the problem'--if I offered one, I would be the very kind of bullshitter I strive to avoid being'--but we at the very least need to recognize what it is we are trying to change. We are trying to create a culture of thoughtfulness and insight, where people check carefully to see whether what they're saying is true, and excessively egotistical people are looked upon with deep suspicion. With time and patient effort, perhaps we can create a world in which the people who rise to the highest offices and reap the greatest rewards are not also the ones who are most full of shit.
Please subscribe to Current Affairs, so we can keep exposing bullshit and protecting the public from propaganda and manipulation.
Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity | Pediatrics | American Academy of Pediatrics
Tue, 10 Jan 2023 14:48
Skip Nav Destination From the American Academy of Pediatrics | Clinical Practice Guideline | January 09 2023
Sarah E. Hampl, MD, FAAP ; a Children's Mercy Kansas City Center for Children's Healthy Lifestyles & Nutrition, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
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Sandra G. Hassink, MD, FAAP ; Sandra G. Hassink, MD, FAAP
b Medical Director, American Academy of Pediatrics, Institute for Healthy Childhood Weight, Wilmington, Delaware
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Asheley C. Skinner, PhD ; c Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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Sarah C. Armstrong, MD, FAAP ; Sarah C. Armstrong, MD, FAAP
d Departments of Pediatrics and Population Health Sciences, Duke Clinical Research Institute, Duke University, Durham, North Carolina
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Sarah E. Barlow, MD, MPH, FAAP ; Sarah E. Barlow, MD, MPH, FAAP
e Department of Pediatrics, University of Texas Southwestern Medical Center, Children's Medical Center of Dallas, Dallas, Texas
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Christopher F. Bolling, MD, FAAP ; Christopher F. Bolling, MD, FAAP
f Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Kimberly C. Avila Edwards, MD, FAAP ; Kimberly C. Avila Edwards, MD, FAAP
g Children's Health Policy & Advocacy, Ascension; Department of Pediatrics, Dell Medical School at The University of Texas at Austin, Austin, Texas
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Ihuoma Eneli, MD, MS, FAAP ; Ihuoma Eneli, MD, MS, FAAP
h Department of Pediatrics, The Ohio State University, Center for Healthy Weight and Nutrition, Nationwide Children's Hospital, Columbus, Ohio
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Robin Hamre, MPH ; i Centers for Disease Control and Prevention; Atlanta, Georgia
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Madeline M. Joseph, MD, FAAP ; Madeline M. Joseph, MD, FAAP
j Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of Florida College of Medicine''Jacksonville, University of Florida Health Sciences Center''Jacksonville, Jacksonville, Florida
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Eneida Mendonca, MD, PhD, FAAP ; Eneida Mendonca, MD, PhD, FAAP
l Departments of Pediatrics and Biostatistics & Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana
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Marc P. Michalsky, MD, MBA, FAAP ; Marc P. Michalsky, MD, MBA, FAAP
m Department of Pediatric Surgery, The Ohio State University, College of Medicine, Nationwide Children's Hospital, Columbus, Ohio
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Nazrat Mirza, MD, ScD, FAAP ; Nazrat Mirza, MD, ScD, FAAP
n Children's National Hospital, George Washington University, Washington, DC
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Eduardo R. Ochoa, Jr, MD, FAAP ; Eduardo R. Ochoa, Jr, MD, FAAP
o Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
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Mona Sharifi, MD, MPH, FAAP ; Mona Sharifi, MD, MPH, FAAP
p Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
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Amanda E. Staiano, PhD, MPP ; Amanda E. Staiano, PhD, MPP
q Louisiana State University Pennington Biomedical Research Center, Baton Rouge, Louisiana
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Ashley E. Weedn, MD, MPH, FAAP ; Ashley E. Weedn, MD, MPH, FAAP
r Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Susan K. Flinn, MA ; s Medical Writer/Consultant, Washington, DC
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Jeanne Lindros, MPH ; t American Academy of Pediatrics, Itasca, Illinois
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Kymika Okechukwu, MPA u American Academy of Pediatrics, Itasca, Illinois
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FUNDING: No external funding.
FINANCIAL/CONFLICT OF INTEREST DISCLOSURES: An Independent review for bias was completed by the American Academy of Pediatrics. Dr Barlow has disclosed a financial relationship with the Eunice Kennedy Shriver National Institute of Child Health and Human Development as a co-investigator.
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Sarah E. Hampl, Sandra G. Hassink, Asheley C. Skinner, Sarah C. Armstrong, Sarah E. Barlow, Christopher F. Bolling, Kimberly C. Avila Edwards, Ihuoma Eneli, Robin Hamre, Madeline M. Joseph, Doug Lunsford, Eneida Mendonca, Marc P. Michalsky, Nazrat Mirza, Eduardo R. Ochoa, Mona Sharifi, Amanda E. Staiano, Ashley E. Weedn, Susan K. Flinn, Jeanne Lindros, Kymika Okechukwu; Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. Pediatrics 2023; e2022060640. 10.1542/peds.2022-060640
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You have in your hands, or at your fingertips, the first edition of the American Academy of Pediatrics clinical practice guideline for evaluation and management of children and adolescents with overweight and obesity. Putting together this guideline was no small task, and the Academy is grateful to the efforts of all the professionals who contributed to the production of this document. This work is a true testament to their passion and dedication to combatting childhood and adolescent overweight and obesity.
The Subcommittee responsible for developing this guideline comprises a diverse group of professionals from a variety of disciplines representing both governmental entities and private institutions. Experts all, they are united by a common desire to provide the finest, most effective care and treatment to children and adolescents with overweight and obesity. Over the course of several months, the members of the Subcommittee reviewed the technical reports produced from the study review, then worked in concert to develop the Key Action Statements and Expert Consensus Recommendations contained within this guideline. These were crafted with meticulous care by the Subcommittee members, to align with current literature and to place appropriate emphasis on each statement.
While representing such a broad spectrum of perspectives, the members of this committee are all keenly aware of the multitude of barriers to treatment that patients and their families face. These barriers impact not only their access to treatment, but their ability to follow prescribed treatment plans. Whereas some patients are able to adopt the lifestyle changes and habitualize elements of their prescribed treatment plans, so many others struggle to do so for a wide variety of reasons. The members of the Subcommittee understand all of this. To assist with optimizing health equity and overcoming these barriers, guidance on a number of multilevel factors related to barriers to treatment have been included in this guideline. During the course of their work, members of the Subcommittee acknowledged that, although so much has been learned to advance the treatment of children and adolescents with overweight and obesity, there is still so much we have yet to discover. The Subcommittee recognizes the importance that future studies will play in advancing our knowledge and understanding of this chronic disease, knowledge and understanding that will lead to the development of new and more effective treatments. Specific discussion about the needs for future research are included in the guideline.
It is the fervent hope of every member of the Subcommittee that this guideline and the resources that accompany it will provide you with a more complete understanding of the issues, factors, and needs of patients combating overweight and obesity, as well as successful treatment options to assist them in their battle. This guideline and the resources that accompany it are not only for you, they are because of you, and all that you do to care for each and every patient as if they were the most important one. Because, as we all know, they are.
Be well,
Doug Lunsford, Family Representative
I. IntroductionThe current and long-term health of 14.4 million children and adolescents is affected by obesity,1,2 making it one of the most common pediatric chronic diseases.3''5 Long stigmatized as a reversible consequence of personal choices, obesity has complex genetic, physiologic, socioeconomic, and environmental contributors. As the environment has become increasingly obesogenic, access to evidence-based treatment has become even more crucial.
A significant milestone in the fight to counter misperceptions about obesity and its causes occurred in 1998, when the National Institutes of Health (NIH) designated obesity as a chronic disease. The NIH made a further commitment to necessary research in the ''Strategic Plan for NIH Obesity Research,'' released by the NIH Obesity Task Force in 2011.6 In 2013, on the basis of accumulating evidence, the American Medical Association recognized obesity as a complex, chronic disease that requires medical attention.7
The scientific and medical community's understanding of obesity is constantly evolving. Increased understanding of the impact of social determinants of health (SDoHs, see Definition of Terms section) on the chronic disease of obesity'--along with heightened appreciation of the impact of the chronicity and severity of obesity comorbidities'--has enabled broader and deeper understanding of the complexity of both obesity risk and treatment.8,9 Multiple randomized controlled trials and comparative effectiveness studies have yielded effective treatment strategies, demonstrating that, despite the complex nature of this disease, obesity treatment can be successful.10,11
The knowledge and skills to treat childhood obesity have become necessities for clinical teams in pediatric primary and subspecialty care. For more than 2 decades, the American Academy of Pediatrics (AAP) and its members have had the opportunity to collaborate with multiple scientific and professional organizations to improve the clinical care of children with overweight and obesity. Notable milestones include the 1998 ''Expert Committee Recommendations,''12 the 2007 ''Expert Committee Recommendations,''13''15 the creation of the AAP Section on Obesity and founding of the Institute for Healthy Childhood Weight, both in 2013; and the Institute's ''Algorithm for the Assessment and Management of Childhood Obesity'' in 2016.16
This is the AAP's first clinical practice guideline (CPG) outlining evidence-based evaluation and treatment of children and adolescents with overweight and obesity.
This guideline does not cover the prevention of obesity, which will be addressed in a forthcoming AAP policy statement.
The CPG also does not include guidance for overweight and obesity evaluation and treatment of children younger than 2 years. Children under the age of 2 were not part of the inclusion criteria for the evidence review, because it is difficult to practically define and measure excess adiposity in this age group. The CPG also does not discuss primary obesity prevention, as no studies reporting results of obesity prevention interventions met the inclusion criteria for the evidence review.
Nonetheless, the topics of obesity prevention and evaluation and treatment of children younger than 2 years are very important to reduce this threat to children's current and future health. Future CPGs may include these topics; in the meantime, information that may assist pediatricians and other pediatric health care providers (PHCPs) is included on the AAP Institution for Healthy Childhood Weight's Web site (aap.org/obesitycpg). Further information on the CPG's methodology and the writing committee's approach is covered in subsequent sections.
The CPG contains Key Action Statements (KASs), recommendations based on evidence from randomized controlled and comparative effectiveness trials as well as high-quality longitudinal and epidemiologic studies. The CPG writing Subcommittee uses the term ''pediatricians and other pediatric health care providers'' to include both pediatric primary and specialty care physicians and other medical providers as well as allied health care professionals, since all will encounter and can intervene with children with overweight, obesity, and obesity-related comorbidities. An algorithm with these KASs is provided in Appendix 1.
The KASs are supplemented by Consensus Recommendations that are based on expert opinion and address issues that were not part of the supporting technical reports (TRs). These consensus recommendations are supported by AAP-endorsed guidelines, clinical guidelines, and/or position statements from professional societies in the field and an extensive literature review.
This CPG stands on the shoulders of the pediatricians, other PHCPs, clinical researchers, and other stakeholders who collaborated to create the previous Expert Recommendations, which have been valued sources of guidance for health care professionals, clinical systems, parents, and other key stakeholders. It is our hope that this CPG will further advance the equitable care of children and adolescents with this chronic disease.
II. ApproachChildhood obesity results from a multifactorial set of socioecological, environmental, and genetic influences that act on children and families. Individuals exposed to adversity can have alterations in immunologic, metabolic, and epigenetic processes that increase risk for obesity by altering energy regulation.17''19 These influences tend to be more prevalent among children who have experienced negative environmental and SDoHs, such as racism.20 Overweight and obesity are more common in children who live in poverty,21,22 children who live in underresourced communities,23 in families that have immigrated,24 or in children who experience discrimination or stigma.25''32 As such, obesity does not affect all population groups equally.33 This fact highlights the importance of understanding the role of SDoHs34 as well as the social context of children and their families in the etiology and treatment of overweight and obesity.
Children with overweight and obesity benefit from health behavior and lifestyle treatment, which is a child-focused, family-centered, coordinated approach to care, coordinated by a patient-centered medical home, and may involve pediatricians, other pediatric health care providers (such as registered dietitian nutritionists [RDNs], psychologists, nurses, exercise specialists, and social workers), families, schools, communities, and health policy.35 Obesity is long-lasting and has persistent and negative health effects, attributable morbidity and mortality, and social and economic consequences that can impact a child's quality of life.36''39 Because obesity is a chronic disease with escalating effects over time, a life course approach to identification and treatment should begin as early as possible and continue longitudinally through childhood, adolescence, and young adulthood, with transition into adult care.36,39''41
A. Health Equity ConsiderationsIt is not uncommon for the differences in disease prevalence and outcomes among population groups to be described in terms of ethnicity, race, gender, and/or age and for these differences to be referred to as ''disparities.''42 Disparity, however, only defines differences between groups without referring to inequities that cause these differences among populations (ie, ''economic, civil-political, cultural, or environmental conditions that are required to generate parity and equality''42 ). Precisely because of the intertwining of inequities throughout the life course, health disparities can be found from maternal pregnancy outcomes through adolescence and, as such, can have an inevitable impact on childhood obesity.
This distinction between health disparities and inequities is particularly important when considering chronic disease, because: (1) obesity risk factors are embedded in the socioecological and environmental fabric of children's lives; and (2) there is a danger of stigmatizing children with obesity and their families on the basis of race and ethnicity, age, and gender based on the disparities of outcome'--with failure to recognize the systemic challenges that cause and maintain inequities.43,44
Inequities are often associated with each other45 and result in disparities in obesity risk and outcomes across the socioecological spectrum. Importantly, they represent neighborhood-, community-, and population-level factors that can be changed.46 Inequities that promote obesity in childhood can have a longitudinal effect leading to disparities in adult health and contributing to adult obesity and chronic disease.47
The AAP is dedicated to reducing health disparities and increasing health equity for all children and adolescents.28 Attainment of these goals requires addressing inequities in available resources and systemic barriers to quality health care services for children with obesity.48 To that end, ''practice standards must evolve to support an equity-based practice paradigm'' and payment strategies must promote this approach to care.28
It is our hope that individual clinical encounters with patients and families will provide opportunities to ''screen and address the social, economic, educational, environmental, and personal-capital needs of the children with obesity and their families.''49 In addition, understanding the wider determinants of the chronic disease of obesity will enable pediatricians and other PHCPs to ''raise awareness of the relevance of these social and environmental determinants of childhood obesity in their communities.''49
B. RacismRacism as an SDoH has been defined as a ''system of structuring opportunity and assigning value based on the social interpretation of how one looks (race) that unfairly disadvantages some individuals and communities (and) unfairly advantages other individuals and communities'...''50,51 that ''impacts the health status of children, adolescents, emerging adults and their families.''52
Inequalities in poverty, unemployment, and homeownership attributable to structural racism have been linked to increased obesity rates.53 Racism experienced in everyday life has also been associated with increased obesity prevalence.54 Youth with overweight and obesity have been found to be at increased risk not only for weight-based harassment but also for sexual harassment and harassment based on race and ethnicity, socioeconomic status (SES), and gender.55 In adults, studies have found positive associations between self-reported discrimination and waist circumference,56,57 visceral adiposity,58 and BMI57 in both non-Latino and Latino populations.59
C. Weight Bias and Stigma ConsiderationsIndividuals with overweight and obesity experience weight stigma, victimization, teasing, and bullying, which contribute to binge eating, social isolation, avoidance of health care services, and decreased physical activity.28,43 Importantly, internalized weight bias has been associated with a negative impact on mental health.60 Collectively, these factors may adversely affect quality of care, prevent patients with overweight and obesity from seeking medical care, and contribute to worsened morbidity and mortality, independent of excess adiposity.28,43,44
Pediatricians and other PHCPs have been'--and remain'--a source of weight bias. They first need to uncover and address their own attitudes regarding children with obesity. Understanding weight stigma and bias, and learning how to reduce it in the clinical setting, sets the stage for productive discussions and improved relationships between families and pediatricians or other PHCPs. Acknowledging the multitude of genetic and environmental factors that contribute to the complexity of obesity is an important mitigator in reducing weight stigma.61 Additional actions that reduce weight stigma include having appropriately sized office furniture, using appropriate capacity medical equipment, ensuring that aesthetic and/or instructional images posted in the office are inclusive, and avoiding stigmatizing language.28 Accordingly, the CPG utilizes person-first language (ie, using the term ''child with obesity, rather than ''obese child'') to avoid labeling the child.28 This practice is consistent with recommendations from the AAP and other national organizations, including the Academy of Nutrition and Dietetics, the Obesity Society, and the Obesity Action Coalition.62
D. Adverse Childhood ExperiencesAdverse childhood experiences (ACEs) are negative experiences caused by situations or events in the lives of children and adolescents that can pose threats to their current and future physical and mental health.63,64 These experiences range from family turmoil and violence to financial hardship, loss of a parent, divorce, abuse, and parental mental illness'--to name a few.65 ACEs have been associated with obesity, both in adulthood and in childhood.66''68 Children and adolescents who live in poverty have a higher likelihood of experiencing ACEs, but risk for ACEs occurs at every income level.65,69 The greater the number of ACEs a child or adolescent experiences, the greater the risk for obesity.70 The most commonly cited mechanisms linking ACEs to obesity are social disruption, negative health behaviors, and chronic stress response.71
Approach SummaryThe recommendations in the CPG are child-centric and not specific to a particular health care setting and are written to inform pediatricians and other PHCPs about the standard of care for evaluating and treating children with overweight and obesity and related comorbidities. To reflect the pediatrician's and PHCP's individual relationship with the child and family, the Subcommittee refers to ''evaluation'' (eg, for comorbidities) rather than ''screening.'' It is anticipated that a pediatrician's or other PHCP's setting, training, and expertise may moderate how elements of the CPG are implemented. Helpful resources can be found in accompanying implementation materials.
Understanding the underlying genetic, biological, environmental, and social determinants that pose risk for obesity is the bedrock of all evaluation and intervention. Allowing the family to have a safe space to understand and process the complexity of obesity and its chronicity requires tact, empathy, and humility. Achieving this goal enables the patient and family to gain the knowledge and understanding needed to recognize risk factors in their environment and behaviors, to honor cultural preferences, and to institute changes independently as well as under the guidance of a trusted and well-trained advocate'--such as pediatricians and other PHCPs.
Finally, to emphasize important goals of treatment'--both improved weight status and reduction or elimination of comorbidities'--the Subcommittee uses the term intensive health behavior and lifestyle treatment (IHBLT) rather than ''intensive lifestyle or behavioral modification'' or ''weight management.'' Additional definitions are listed in the next section.
III. Definition of TermsBMI: BMI is a measure used to screen for excess body adiposity; it is calculated by dividing a person's weight in kilograms by the square of height in meters. For children and teens, BMI interpretation is age- and sex-specific. A child's BMI category (eg, healthy weight, overweight) is determined using an age- and sex-specific percentile for BMI rather than the BMI cut-points used for adult categories.72
Capacity-building: ''Building individual competencies and technical expertise, strengthening organizational capacities, and enabling supportive structural environments'' to maintain or improve health services delivery.73
Children with special health care needs: Children with special health care needs are those who have, or who are at increased risk for, a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.74
Chronic care model: The chronic care model identifies essential elements of a health care system that encourage high-quality chronic disease care: the community; the health system; self-management support; delivery system design; decision support, and clinical information systems.75
Chronic disease: The Centers for Disease Control and Prevention (CDC) defines chronic diseases broadly as ''conditions that last 1 year or more and require ongoing medical attention or limit activities of daily living or both.''76 Obesity is a chronic disease that results in altered anatomy, physiology, and metabolism'--all of which adversely affect the physical and mental health trajectory of children and adolescents.77 The Obesity Medicine Association defines obesity as a ''chronic, relapsing, multifactorial, neurobehavioral disease, wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces, resulting in adverse metabolic, biomechanical, and psychosocial health consequences.''78
Comprehensive obesity treatment: Comprehensive obesity treatment (COT) (Fig 1) includes79,80 :
Providing intensive, longitudinal treatment in the medical home
Evaluating and monitoring child or adolescent for obesity-related medical and psychological comorbidities
Identifying and addressing social drivers of health
Using nonstigmatizing approaches to clinical treatment that honor unique individual qualities of each child and family
Using motivational interviewing that addresses nutrition, physical activity, and health behavior change using evidence-based targets for weight reduction and health promotion
Setting collaborative treatment goals not limited to BMI stabilization or reduction; including goals which reflect improvement or resolution of comorbidities, quality of life, self-image, and other goals related to holistic care
Integrating weight management components and strategies across appropriate disciplines, which can include intensive health behavior and lifestyle treatment, with pharmacotherapy and metabolic and bariatric surgery if indicated
Tailoring treatment to the ongoing and changing needs of the individual child or adolescent, and the family and community context
FIGURE 1
Treatment experience of obesity as a chronic disease (this figure illustrates how longitudinal care is important to help address this chronicity and to address and buffer the social and contextual factors that influence a person's health).
FIGURE 1
Treatment experience of obesity as a chronic disease (this figure illustrates how longitudinal care is important to help address this chronicity and to address and buffer the social and contextual factors that influence a person's health).
Close modal Comprehensive patient history: A comprehensive patient history includes a review of systems; family history; history of present illness; and appropriate nutritional, physical activity, and psychosocial history.
Family-based treatment: Family-based treatment centers on the role of family at each stage of child development, includes consideration of the family's critical role in supporting child health, and understands the unique contextual elements that affect the patient and family and influence treatment.
Intensive health behavior and lifestyle treatment: IHBLT educates and supports families in nutrition and physical activity changes that improve weight status and comorbidities and promote long-term health. IHBLT is most often effective when it occurs face-to-face, engages the whole family, and delivers at least 26 hours of nutrition, physical activity, and behavior change lessons over 3 to 12 months. IHBLT is foundational to COT and should continue longitudinally. It should be provided in conjunction with pharmacotherapy and metabolic and bariatric surgery if these treatments are indicated. IHBLT may be available in the form of a defined program and may be offered in pediatrician and other PHCP offices, medical centers or health systems, or in partnership with community organizations.
Longitudinal care: Care provided by a group of health care professionals who monitor a patient's weight and other health indicators over a length of time sufficient to be associated with health improvements. Longitudinal care is continuous and coordinated and should include a plan for transition into adulthood.
Overweight and obesity: Overweight is defined as a BMI at or above the 85th percentile and below the 95th percentile for children and teens of the same age and sex. Obesity is defined as a BMI at or above the 95th percentile for children and teens of the same age and sex.
Pediatricians and other pediatric health care providers: For the purpose of this CPG, pediatricians and other pediatric health care providers refers to a qualified primary or tertiary care medical provider operating within their scope of practice and providing clinical care to children and adolescents. Examples include physicians, nurse practitioners, and physician assistants. (This document also refers to dietitians, licensed psychologists, exercise specialists, and other health care professionals who are not practicing medicine in the same manner.)
Pediatric medical home: The ''pediatric medical home'' delivers accessible, continuous, comprehensive, patient- and family-centered, coordinated, compassionate, and culturally effective health care. In this venue, well-trained pediatric physicians known to the child and family deliver or direct primary medical care.81
Pediatric obesity specialist or clinician with expertise: Pediatric obesity specialists and clinicians with expertise are health care professionals with additional training in pediatric obesity medicine. Training may take the form of certification programs specific to obesity, fellowship, or a focus during specialty training, such as within endocrinology or gastroenterology specialty training. It may also take the form of an informal apprenticeship combined with professional workshops. For the purposes of this document, such training occurs within the context of recognized health care professional organizations.
Person-first language: According to the CDC, person-first language emphasizes the individual, not their disabilities.82 Hence, this CPG describes ''children with obesity'' or ''adolescents with overweight,'' not ''obese children'' and/or ''overweight adolescents.''
Severe obesity: The expanded definition of ''severe obesity'' includes Class 2 and Class 3 obesity.83
Class 2 obesity ('‰¥120% to <140% of the 95th percentile) or a BMI '‰¥ 35 kg/m2 to <39 kg/m2, whichever is lower based on age and sex
Class 3 obesity ('‰¥140% of the 95th percentile) or BMI '‰¥ 40 kg/m2, whichever is lower based on age and sex
Social determinants of health (SDoHs): SDoHs are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. SDoHs can be grouped into 5 domains: economic stability, education access and quality, neighborhood and built environment, and social and community context.8,84,85
Treatment intensification: Treatment intensification occurs through increased frequency of contact, increased length of treatment, or other means of increasing the dose of treatment. Treatment intensification could include additional health care professionals and/or additional methods, such as physical therapy, psychotherapy, medical nutrition therapy, pharmacotherapy, or metabolic and bariatric surgery.
IV. Methodology A. Subcommittee Process and SupportIn 2017, the CDC supported the AAP's Institute for Healthy Child Weight (the Institute) to conduct an evidence review of obesity treatment and obesity-related comorbidities. The Institute identified a methodologist and convened an evidence review committee consisting of pediatricians and researchers with expertise in pediatric obesity etiologies, diagnosis, and management. This committee, which met regularly in 2018 to 2019, followed established methods (elaborated on below) to create 2 TRs, which capture the evidence review committee's findings and detail the search criteria, systematic review process, and research history. One TR is on overweight and obesity treatment (https://doi.org/10.1542/peds.2022-060643) and the second is on overweight and obesity comorbidities (https://doi.org/10.1542/peds.2022-060643).
Staff from the Institute and the AAP's Council on Quality Improvement and Patient Safety formed a CPG writing Subcommittee, comprising the methodologist and several evidence review committee members; a range of pediatric primary and tertiary care providers; behavioral health, nutrition, and public health researchers; a pediatric surgeon; medical epidemiologists from the CDC Division of Nutrition, Physical Activity and Obesity; an implementation scientist; a parent representative; and a representative from the AAP Partnership for Policy Implementation. Most Subcommittee members also have other national organization affiliations relevant to pediatric overweight and obesity.
The Subcommittee members were identified by the AAP and met regularly in 2019 and 2020 and virtually thereafter. Members were assigned sections and met virtually to complete their sections. Sections were reviewed by the chair or cochair and outstanding issues were resolved by group consensus. The parent member was an at-large member of all the writing groups and reviewed each section. Members' potential conflicts of interest were identified and considered; no conflicts prevented Subcommittee members from participating in the CPG development process.
B. Scope of the ReviewThis review was designed to answer 2 overarching key questions (KQs). KQ1 was: ''What are effective clinically based treatments for pediatric obesity?'' KQ2 was: ''What is the risk of comorbidities among children with obesity?''
The Subcommittee developed this focus based on the needs of pediatricians and other PHCPs and the evidence required to inform the future development of clinical practice guidelines. The review did not attempt to address treatment strategies for comorbidities (eg, hypertension [HTN], sleep apnea, type 2 diabetes mellitus [T2DM]), as other guidelines and reviews are available to guide such treatment.86''90
B.1. Rationale for KQ1: Intervention StudiesPediatricians and other PHCPs are a trusted source of health information for parents, including on issues related to nutrition and physical activity, which are key components of obesity prevention and treatment. To meet this need, pediatricians and other PHCPs need to know the strategies that have high-quality evidence for effectiveness in preventing and treating obesity. Additionally, pediatricians and other PHCPs need guidance on which treatments are effective for their population and how to leverage available resources for obesity treatment efforts.
B.2. Rationale for KQ2: Comorbidity StudiesPrevious recommendations have included assessments of comorbidities, including HTN, dyslipidemia, glucose, fatty liver disease, and others. It is not clear whether these assessments lead to improved treatment strategies or outcomes. Additionally, it is not clear whether conducting these assessments would result in an adverse outcome. We examined specific conditions that were previously recommended or that would reasonably require screening: dyslipidemia, HTN, diabetes, fatty liver disease, depression, sleep apnea, and asthma. This is not intended to be a comprehensive list of all conditions comorbid with obesity but represents those most common and for which screening is potentially helpful.
C. Search StrategyThe Evidence Review Subcommittee searched PubMed and CENTRAL (for trials). The initial search was on April 6, 2018, and an additional search was conducted to update the review, covering the time period April 7, 2018 through February 15, 2020. Both searches followed the same procedures, which are described below.
The Subcommittee combined the searches for both KQ1 and KQ2 because of their significant overlap to more efficiently review studies. Because the focus was on interventions that are relevant to primary care, the Subcommittee did not search other discipline-specific databases, such as ERIC or PsycInfo.
The Subcommittee searched for studies of children or adolescents, with a focus on overweight, obesity, or weight status; involving pediatricians, other pediatric health care providers, health care, or other treatment or screening (KQ1); and examining common comorbidities (KQ2). For both questions, the Subcommittee limited only using key words, not filters, to ensure the inclusion of the newest studies that had not yet been fully indexed. No date limits were placed on searches. In practice, this meant the Subcommittee reviewed studies from 1950 to 2020, although fewer than 2% of the studies were from before 1980.
The complete search strategies are included in Appendix 2 of the accompanying TRs (https://doi.org/10.1542/peds.2022-060642 and https://doi.org/10.1542/peds.2022-060643).
D. Inclusion Criteria D.1. Inclusion Criteria Common to All StudiesAll studies were required to include children ages 2 to 18 years. Studies could also include young adults up to age 25, if this population was stratified from older adult participants, as long as children younger than 18 years were also included in the study. Children could have other conditions (eg, asthma), as long as these conditions were not known to cause obesity, or be taking medications (eg, steroids) other than those known to be significantly obesogenic. Conditions known to cause obesity, such as Prader-Willi syndrome, obesogenic medication (eg, antipsychotics), or known genetic mutations associated with obesity (eg, melanocortin 4 receptor [MC4R]) were excluded.
All studies had to originate from Organization for Economic Cooperation and Development member countries and be available in English.
The race distribution of the samples is reported in the accompanying technical report evidence overview (Appendix 5 in TRs [https://doi.org/10.1542/peds.2022-060642 and https://doi.org/10.1542/peds.2022-060643]) to assist in interpretation of evidence within a health equity framework. The technical report authors notated in the ''special populations'' section of Appendix 5 when each study specifically focused on a lower-resourced population, as well as race and ethnicity distributions for all studies.
D.2. Inclusion Criteria for KQ1 (Intervention Studies)The primary aim of the intervention studies had to be examination of an obesity prevention (intended for children of any weight status) or treatment (intended for children with overweight or obesity) intervention. The primary intended outcome had to be obesity, broadly defined, and not an obesity comorbidity. Studies of obesity interventions that reported other outcomes were included.
Interventions could involve any approach, including screening, counseling, medically managed weight loss, pharmaceutical treatment, or surgery. Regardless of the intervention components, there had to be some level of outpatient clinical involvement in the treatment (ie, not just referral to an outside program), such as screening or a clinic follow-up appointment. Interventions that occurred completely outside the scope of health care were excluded. For example, school-based obesity prevention programs or community-based activity programs with no pediatrician or other pediatric health care provider involvement were excluded.
The Subcommittee did not limit the search by study design but did report experimental and nonexperimental studies separately. Although nonexperimental designs were included, all studies had to have a relevant comparison group to be included in the TR on interventions (https://doi.org/10.1542/peds.2022-060642).
D.3. Inclusion Criteria for KQ2 (Comorbidity Studies)The Subcommittee included studies that had a primary aim of comparing comorbidities among those with and without obesity or by severity of obesity. Obesity and the comorbidity had to be measured contemporaneously to reflect the practice of clinical screening. Obesity had to be categorized using a BMI-based measure into accepted categories (ie, healthy weight, overweight, class 1 obesity, class 2 obesity, class 3 obesity). These categories could be based on percentiles or z-scores and could use the distributions relevant to the studied population (eg, World Health Organization [WHO] or the CDC).91,92
All studies had to include 1 or more of the following comorbidities: lipids, blood pressure (BP), HTN, liver function, glucose metabolism, obstructive sleep apnea (OSA), asthma, or depression. These were chosen based on known associations with weight and potential for screening in the primary care setting.
The complete inclusion criteria are included in Appendix 3 of the accompanying TR on comorbidities (https://doi.org/10.1542/peds. 2022-060643).
E. Review ProcessThe Subcommittee used Covidence to manage the review process (https://www.covidence.org/). Covidence is a program for online collaboration and management of systematic reviews. All abstracts were reviewed by 2 independent reviewers on the Subcommittee, who assessed the study's inclusion in the full-text review process. All conflicts were discussed and resolved. Articles excluded at this stage were assigned an exclusion reason, with a hierarchy, which is shown in Appendix 4 of the accompanying TRs (https://doi.org/10.1542/peds.2022-060642 and https://doi.org/10.1542/peds.2022- 060643).
F. Data Extraction and Quality AssessmentAll articles deemed to meet criteria for full text inclusion were categorized into different data extraction strategies. Randomized trials were given a quality assessment using the Cochrane Risk of Bias tool. The Subcommittee decided not to limit studies based on the study quality, because many of them did not reach ''high-quality'' status (ie, at low risk of bias for most or all domains in the Cochrane Risk of Bias Assessment) using any of the tools. This occurred largely because studies consisted primarily of behavioral interventions without the possibility of blinding.
All studies, regardless of group, were fully extracted by 2 reviewers, and conflicts were discussed and resolved. Intervention studies were categorized into 5 groups for data extraction.
F.1. Group 1 ExtractionGroup 1 articles included randomized trials of diet or ''lifestyle'' interventions. Extraction of these articles included: sponsorship or funder, design, population information, provider type, detailed intervention strategies and intensity, and BMI-based outcomes. The Subcommittee also identified outcomes other than BMI, including lipids, glucose metabolism, BP, other laboratory values, other obesity measures, psychosocial outcomes, mental health, behaviors, and other outcomes (primarily parent BMI and child cardiovascular fitness).
The Subcommittee categorized the intensity of interventions in a manner consistent with the US Preventive Services Task Force (USPSTF) to allow for comparisons with its findings, into interventions with a dose (number of hours) of <5 hours; 5 to 25 hours; 26 to 51 hours; and 52 or more hours. All interventions occurred over less than 1 year. The Subcommittee conducted quality assessment for group 1 articles.
F.2. Group 2 ExtractionGroup 2 articles included randomized controlled trials of pharmaceutical treatments. Similar information as above was extracted, using a brief description of the treatment and no categorization of intensity. These articles also received a quality assessment.
F.3. Groups 3 Through 5 Extractioni) Groups 3 Through 5 Articles Group 3 articles included nonrandomized comparative studies of diet and ''lifestyle'' treatments, group 4 articles included nonrandomized comparative studies of pharmaceutical treatment, and group 5 articles included any surgical studies.
Because of small numbers, the Subcommittee combined randomized and nonrandomized surgical studies. Brief treatment descriptions and BMI-related outcome data were extracted from these, but the Cochrane Risk of Bias tool was not used because these were observational designs.
F4. KQ2 Extraction (Comorbidity Studies)All studies were extracted by 2 reviewers who reported prevalence of comorbidities or mean values of laboratory parameters by weight classification. The Subcommittee included healthy weight, overweight, class 1 obesity, class 2 obesity, and class 3 obesity.
Because all classes of obesity severity were not always reported in the studies, these classes may include higher groups. For example, reporting of '‰¥95th percentile would only be considered class 1 obesity, although children at higher levels may be included. (See the TR for a detailed description of the KQ1 extraction procedures.)
G. Data Synthesis and AnalysisThe Subcommittee's primary method of data synthesis was narrative. To allow broad inclusion, the Subcommittee did not limit to specific designs or measures that would facilitate meta-analysis. The Subcommittee has reported on studies in each group based on their type and design and has reported findings for outcomes other than BMI.
The AAP policy statement, ''Classifying Recommendations for Clinical Practice Guidelines,'' was followed in designating aggregate evidence quality levels for the available evidence (Fig 2).93 The AAP policy statement is consistent with the grading recommendations advanced by the University of Oxford Centre for Evidence-Based Medicine.
FIGURE 2
Grading matrix.
Evidence grades were determined based on the grading matrix in Fig 2. Although we included both trials and observational studies in the technical reports, they are reviewed separately. Study design was considered in the aggregate evidence quality grades, as indicated by the matrix. We did not explicitly use risk of bias scores, but this information was available and used in the Subcommittee's final assessment.
The Subcommittee reached consensus on the evidence, which was then used to develop the clinical practice guideline's KASs. When the scientific evidence was at least ''good'' in quality and demonstrated a preponderance of benefits over harms, the KAS provides a ''strong recommendation'' or ''recommendation.'' Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present; clinicians are prudent to follow a recommendation but are advised to remain alert to new information and be sensitive to patient preferences (Fig 2).
Integrating evidence quality appraisal with an assessment of the anticipated balance between benefits and harms leads to a designation of a strong recommendation, recommendation, option, or no recommendation. Once the evidence level was determined, an evidence grade was assigned. AAP policy stipulates that the evidence supporting each KAS be prospectively identified, appraised, and summarized, and an explicit link between quality levels and the grade of recommendation must be defined.
Possible grades of recommendations range from ''A'' to ''D,'' with ''A'' being the highest:
Grade A: consistent level A studies;
Grade B: consistent level B or extrapolations from level A studies;
Grade C: level C studies or extrapolations from level B or level C studies;
Grade D: level D evidence or troublingly inconsistent or inconclusive studies of any level; and
Level X: not an explicit level of evidence as outlined by the Centre for Evidence-Based Medicine. This level is reserved for interventions that are unethical or impossible to test in a controlled or scientific fashion and for which the preponderance of benefit or harm is overwhelming, precluding rigorous investigation.
When it was not possible to identify sufficient evidence, recommendations are based on the consensus opinion of the Subcommittee members.
VI. Epidemiology of Childhood and Adolescent Obesity A. Prevalence of Childhood ObesityObesity is a common, complex, and often persistent chronic disease associated with serious health and social consequences.94 Childhood obesity is typically defined as having a BMI of '‰¥95th percentile for age and sex.95 Severe obesity is defined as BMI '‰¥ 120% of the 95th percentile for age and sex. The percentage of US children and adolescents affected by obesity has more than tripled from 5% in 1963 to 1965 to 19% in 2017 to 2018.2 In 2017 to 2018, the rise in obesity prevalence slowed in children younger than 6 years of age, but increases continued among certain populations, including adolescents and non-Hispanic Black and Mexican American youth.4 A predictive epidemiologic model estimates that if 2017 obesity trends hold, 57% of children aged 2 to 19 years will have obesity by the time they are 35 years of age, in 2050.36
Obesity prevalence increases with increasing age.3 For example, in 2015 to 2016, the prevalence of obesity in children aged 2 to 5 years, 6 to 11 years, and 12 to 19 years was 13.9%, 18.4%, and 20.6%, respectively.3 Among children younger than 6 years, there were no significant trends in obesity from 1999 to 2018 for those 2 through 5 years of age.4 For children 6 through 11 years of age, significant trends in obesity show an increased prevalence from 15.8% in 1999 to 2002 to 19.3% in 2015 to 2018.4 Similarly, among adolescents 12 through 19 years, trends show increased obesity in the same time period from 16.0% to 20.9%.4 The proportion of children and youth 2 to 19 years of age with severe obesity increased from 4.9% in 1999 to 2000 to 7.9% in 2015 to 2016.4,96 The prevalence of severe obesity in youth 12 to 19 years of age in 2015 to 2018 was 7.6%.4
The COVID-19 pandemic has significantly affected the lives and routines of children and adolescents. In 1 analysis, the pandemic period was associated with a doubling in the rate of BMI increase compared with the prepandemic period.97 Obesity prevention and management efforts should routinely include health care provider screening for BMI, food security, and social determinants of health and increased access to evidence-based pediatric weight management programs and food assistance resources to mitigate such effects in the future.97
Disparities exist among children and youth with obesity, including, but not limited to, lower level of parental education, lower income, less access to healthier food options and safe and affordable physical activity opportunities, and higher incidence of ACEs.70,98,99 For example, among 5345 children 6 to 9 years of age, those whose parents had lower levels of education had a greater odds of having obesity compared with children whose parents had higher levels of education (odds ratio: 1.78; 95% confidence interval [CI]: 1.36 to 2.32).100 A cross-sectional analysis of 111'‰799 children in Massachusetts at the school district level showed that for every 1 percentage point increase in the proportion of children with low SES, there was a 1.17 percentage point increase in the prevalence of obesity.101 Furthermore, children with disabilities, including those with intellectual disabilities, are at higher risk for developing obesity than their peers without disabilities.102
Finally, among 43'‰864 children and adolescents aged 10 to 17 years old, the presence of 2 or more early ACEs was associated with an increased odds of obesity later in childhood and adolescence (odds ratio: 1.21; 95% CI: 1.02 to 1.44).103 Together, these disparities highlight the burden of obesity in children from families of lower SES and the need to provide strategies to minimize these inequities.
Disparities also exist in obesity prevalence across ethnic and racial groups. In 2015 to 2018, non-Hispanic Black children and Mexican American youth 6 to 11 years of age had a higher prevalence of obesity compared with non-Hispanic white children (22.7% and 28.2% vs 15.5%, respectively).4 An analysis of the Indian Health Services National Data Warehouse showed that in 2015, the prevalence of overweight and obesity in American Indian and Alaska Native (AI/AN) children and adolescents was 18.5% and 29.7%, respectively.104
Among children 2 to 5 years of age from lower-income families enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children program, recent analyses indicate a modest but significant decline in obesity prevalence from 2010 (15.9%) to 2018 (14.4%).106 Among these children, obesity prevalence ranged across states from 8.5% to 20.2%; disparities persisted by race and ethnicity despite changes in prevalence over time.105
In addition, children and youth with special health care needs (CYSHCN) have a higher prevalence of obesity and lower levels of physical activity compared with children having typical growth and development.106''108 Among CYSHCN, a metanalysis of studies of adolescents with intellectual disabilities found a pooled odds ratio of obesity of 1.80 compared with adolescents with typical development.102
B. Impact of Obesity in ChildhoodChildren with obesity commonly become adolescents and adults with obesity; severe obesity during adolescence increases the risk for severe obesity during young adulthood.109,110 BMI levels strongly track throughout childhood and adolescence and are predictive of high adult BMI.110
Obesity puts children and adolescents at risk for serious short- and long-term adverse health outcomes later in life, including cardiovascular disease, including HTN; dyslipidemia; insulin resistance; T2DM; and nonalcoholic fatty liver disease (NAFLD).38,96,111''113 Additionally, prediabetes in youth with obesity, compared with youth with normal weight, has been associated with elevated systolic blood pressure and low-density lipoprotein, and lower insulin sensitivity.114
In addition to physical and metabolic consequences, obesity in childhood and adolescence is associated with poor psychological and emotional health, increased stress, depressive symptoms, and low self-esteem.115 Several studies have determined that children of some racial and ethnic groups have a greater prevalence of comorbidities associated with childhood obesity, including HTN, T2DM, hypercholesterolemia, and depression, compared with non-Hispanic white children.116''120
Obesity in childhood and adolescence is associated with health care utilization and costs. For example, the most common primary conditions that cooccur with a secondary diagnosis of obesity and may increase costs and utilization include pregnancy, mood disorders, asthma, and diabetes.121 A modeling study has estimated that the total lifetime medical costs for 10-year-olds with lifelong obesity to be in the range of $9.4 to $14 billion for that cohort alone.122
Tracking obesity across the lifespan underscores the importance of primary and secondary prevention and treatment efforts early in life. These efforts include evaluating for obesity using BMI; identifying children at high risk and adolescents; providing or referring to evidence-based obesity treatments for children, youth, and their families; and addressing SDoHs.
VII. Diagnosis and MeasurementAlthough KAS 1 was not explicitly studied and referenced by the TR, most of the TR studies implicitly included measurement of height and weight and calculation and plotting of BMI as part of the study procedures. Thus, the concept of appropriate measurement, calculation, charting, and tracking is implicit in research-based evidence included in the TR (eg, references123,124,126,130 ).
A. Use of BMI as a Screening and Diagnosis ToolThe gold standard measurement of body composition'--dual-energy x-ray absorptiometry'--to identify, locate, and quantify body fat, and can be expensive and difficult to implement. In clinical practice, BMI is frequently used as both a screening and diagnostic tool for detecting excess body fat because it is easy to use and inexpensive. BMI is a validated proxy measure of underlying adiposity that is replicable and can track weight status in children and adolescents.38,131,132 Because of its ease of use, BMI is also frequently used to follow a child or adolescent's weight trajectory over time. The CDC BMI growth curves are frequently used to visualize BMI trajectory over time. Furthermore, BMI is often used to evaluate the success or impact of interventions to improve weight status.
For most individuals, BMI is generally well-correlated with direct measures of body fat, including skinfold thickness measurements, bioelectrical impedance, densitometry, and dual-energy x-ray absorptiometry.131,133''139
BMI has limitations, however, including high specificity and low sensitivity for detecting excess adiposity.132 BMI does not directly measure body composition and fat content and may under- or overdetect excess adiposity in certain racial and ethnic groups.140,141 Finally, children and adolescents who have high fat-free mass may have a high BMI and, as a result, be incorrectly classified as having overweight or obesity.142
The CDC's 2000 Growth Charts are based on NHANES data from the 1960s through the early 1990s and include age- and sex-specific BMI-for-age charts.143 The CDC Growth Charts provide a historical comparison of children's weight status relative to a time before the current obesity epidemic during that healthier growth patterns predominated; thus, percentiles on the Growth Charts do not equate to the current population distribution of BMI. The CDC Growth Charts are recommended for clinically tracking BMI patterns among US children and adolescents aged 2 to 18 years; although the CDC Growth Charts can be used for adolescents aged 19 to 21 years, in practice, most pediatricians and other PHCPs transition to adult BMI calculation and categorization for patients older than 18 years.143
''Overweight'' is defined as a BMI at or above the 85th percentile and below the 95th percentile for age and sex; ''obesity'' is defined as a BMI at or above the 95th percentile for age and sex. ''Severe obesity'' is defined as a BMI equal to or more than 120% above the 95th percentile, which approximates the 99th percentile. The CDC Growth Charts were not intended to track growth of children with extremely high BMI values. Because of limited data on children and adolescents above the 97th percentile in the reference population, higher percentile curves could not be generated. Caution was recommended in extrapolation of percentiles beyond the 97th percentile, as this may generate unusual or unexpected results.144 In older adolescents, the adult cut-off of a BMI equal to or greater than 30 kg/m2 can be used to define obesity if this value is less than the 95th percentile BMI for age and sex.
Conversion of BMI percentiles to z-scores (a statistical measure that describes a value's relationship to a population mean) derived from the CDC Growth Charts have historically been used for assessing longitudinalchange in adiposity over time among children and adolescents with obesity.127 The change in z-score, however, may not accurately detect meaningful changes in weight status or comorbidity risk over time, particularly for children and adolescents with severe obesity caused by compression of z-scores corresponding to extremely high BMI values into a very narrow range.145 Consequently, investigators have proposed and described various alternative options, including using the degree to which, expressed in percentage, a particular BMI percentile was above the 95th percentile, or the median, for age and sex (referred to as percentage above the 95th percentile, or percentage above the median, respectively).
The ''extended'' method for calculating BMI z-scores and percentiles at extremely high BMI values was developed to address these limitations. This method incorporates data on children and adolescents with obesity from more recent NHANES surveys to better characterize the BMI distribution above the 95th percentile while retaining the 2000 CDC Growth Chart BMI distribution below the 95th percentile.
The CDC and the AAP recommend that weight status in children up to 2 years of age be tracked using the WHO's weight-for-length, age-, and sex-specific charts.146,147 Specialized growth charts for children and adolescents with certain conditions, such as trisomy 21, can provide useful growth reference information for special populations. These charts may, however, be limited, for example, by the small sample sizes used in developing them, which may not be representative of all children and youth with trisomy 21.148
B. The Clinical Utility of BMIBMI is a useful evaluation measure to clinically identify children with overweight and obesity for appropriate treatment'--such as family-based behavioral therapy'--which can lead to improvements in BMI and related comorbidities.123,124,127''130,149''152
Following comprehensive systematic reviews, the USPSTF issued a Grade B recommendation that pediatricians and other PHCPs screen children and adolescents aged 6 years or older annually for obesity'--defined by BMI percentile'--and offer, or refer children and adolescents to, a comprehensive, intensive, family-based behavioral treatment to improve weight status.79 (A ''comprehensive, intensive behavioral treatment'' was defined as a treatment of 26 hours or more over a period of 2 to 12 months.) (See Evaluation and Treatment sections.)
Furthermore, the AAP's Bright Futures recommendations, which are based on systematic reviews and expert panels, offer prevention guidelines including annual assessment of BMI alongside dietary nutrition and physical activity counseling for children and adolescents starting at 2 years old127,153 (Appendix 2).
Appendix 2 describes the USPSTF recommendations, Bright Futures recommendations, and the recommendations reflected in this CPG's KAS 1. All 3 sources recommend annual screening for excess weight using BMI, with the USPSTF beginning at 6 years old and both Bright Futures and this CPG beginning at age 2 years. For children or adolescents with a BMI '‰¥ 95th percentile for age and sex, the USPSTF provides recommendations for primary care providers to offer, or refer them to, a comprehensive, family-based weight management intervention. Bright Futures recommends that primary care providers screen for excess weight and provide dietary nutrition and physical activity counseling for all children and adolescents with either overweight or obesity (BMI '‰¥ 85th and <95th percentile for age and sex). Bright Futures also provides implementation tips and guidance for pediatricians and other PHCPs including, for example, providing counseling using motivational interviewing. Bright Futures offers guidance to states by offering a framework for meeting national performance standards under Title V. Finally, Bright Futures suggests how communities and families can support healthier lifestyles and prevention. This CPG recommends referral to evidence-based weight management interventions for all children 2 years and older who have a BMI '‰¥ 95th percentile for age and sex (see KAS 1, above).
The practice of annual BMI measurement at well-child visits is recommended and central to the management and tracking of overweight and obesity in children.127,153,154 Limitations to this approach include missed opportunities to track and manage weight changes that occur in less than a 12-month period.127,153 However, other visit opportunities can be used to assess BMI outside the well-child visit.153 This CPG's KAS on evaluation, based on the evidence described above, and in concordance with USPSTF and the Bright Futures recommendations, continues to highlight the critical importance of annual evaluation for excess weight and the provision of, or referral to, evidence-based interventions, as indicated, to promote the health and well-being of all children and adolescents.
C. Communication of BMI and Weight Status to Children and ParentsDespite its limitations, BMI is currently the most appropriate clinical tool to screen for excess adiposity and make the clinical diagnosis of overweight or obesity. Thus, the BMI must be communicated to the patient and family, as it guides next steps for comprehensive evaluation and treatment of obesity and related comorbidities. Weight-related discussions can be uncomfortable for clinicians who want to avoid stigmatizing children because of their shape or size. Avoiding this discussion may, however, cause delays or barriers to patients receiving evidence-based care. In addition, obesity stigma can result in patient avoidance of health care and disruption of clinician-patient relationships. There is evidence that having conversations about obesity can facilitate effective treatment.155''157
Three key factors can facilitate a nonstigmatizing conversation about weight with patients and families:
Ask permission to discuss the patient's BMI and/or weight.
Avoid labeling by using person-first language (''Child with obesity''; not ''obese child'' or ''my patient is affected by obesity; not ''my patient is obese'').158
Use words that are perceived as neutral by parents, adolescents, and children. In several studies inclusive of diverse racial, ethnic, and rural and urban populations, preferred words include: ''unhealthy weight, gaining too much weight for age, height, or health, demasiado peso para su salud (too much weight for his or her health).'' Words perceived as most offensive include: ''obese, morbidly obese, large, fat, overweight, chubby, or sobrepeso (overweight).''156
Recognize that discussing BMI with children, adolescents, and families, even when using nonstigmatizing language and preferred terms, can elicit strong emotional responses including sadness or anger. Acknowledging and validating those responses, while keeping the focus on the child's health, can help to strengthen the relationship between the pediatrician or other PHCP and patient and family to support ongoing care.159
VIII. Risk Factors for Child and Adolescent Overweight and ObesityObesity is a chronic disease that has a multifactorial etiology. Risk factors for overweight and obesity'--many of which are SDoHs'--include broader policies and systems factors; institutional or organizational (ie, school); neighborhood and community; and family, socioeconomic, environmental, ecological, genetic, and biological factors (Table 1).21,160 These individual, social, and contextual risk factors often overlap and/or influence one another and can operate longitudinally throughout childhood and adolescence, initiating weight gain and escalating existing obesity. Children and their families interact with their environment at all of these levels and have a unique and ''insider's'' point of view that needs to be understood in delivering culturally sensitive care.161
Pediatricians and other PHCPs need to be aware of the risk factors for pediatric obesity to provide early anticipatory guidance for obesity prevention, monitor their patients closely, and intervene early when weight trajectory increases.
Consensus RecommendationThe CPG authors recommend pediatricians and other pediatric health care providers:
perform initial and longitudinal assessment of individual, structural, and contextual risk factors to provide individualized and tailored treatment of the child or adolescent with overweight or obesity.
A. Policy FactorsThe larger macroenvironment'--including societal attitudes and beliefs, government policies, food industry practices, and the educational and health care systems'--can influence obesity risk.162 It is difficult to make or sustain healthy behavior changes in an obesogenic environment that promotes high-energy intake, unhealthy dietary choices, and sedentary behavior.
A.1. Marketing of Unhealthy FoodsMarketing of unhealthy food and beverages directed at children tends to negatively impact their dietary choices and behaviors.163''166 Foods and beverages embedded in entertainment media have been shown to influence eating behavior choices of children and also increase consumption of foods during or after exposure to the embedded foods.167
A systematic review and meta-analysis showed that even short exposure to unhealthy food and beverage marketing targeted to children resulted in in increased dietary intake and behavior during and after the exposure.168 Both younger children and male children (sex assigned at birth) tend to be more susceptible to the food and beverage marketing,168 and because of their stage of cognitive development, younger children are more likely to be susceptible to advertising and interpret it as factual.169,170
Currently, marketing to children targets highly palatable relatively inexpensive energy-dense foods and beverages.166 This marketing occurs via television, websites, online games, at supermarkets, and outside schools.166 Children are, unfortunately, frequently exposed to foods of low nutritional values from advertisements; therefore, it is not surprising that they have preferential increase in consumption of foods of low nutritional value.167
A.2. Underresourced CommunitiesUnderresourced communities are settings in which obesity risk factors can predominate over health-promoting factors. Children and families in these settings may be unable to access fresh fruits and vegetables and safe physical activity spaces and may suffer from food insecurity.170''172 Limitations in transportation, cost, affordability, and availability may reduce access to health care and obesity treatment. Families may be struggling with poverty, access to healthy foods, lack of social supports, racism, and/or immigration status. Understanding these contextual factors that impact each child and family is crucial in being able to provide compassionate and effective obesity treatment.
A.2.a. Socioeconomic StatusObesity has been shown to disproportionately affect children and adolescents who have low SES.173''175 Even though the prevalence of obesity has been stabilizing among US children overall, the rates continue to increase among children with low SES.173,176 According to the Children's Defense Fund, the poverty rate among US children is alarmingly high.177
A longitudinal analysis of predominantly non-Hispanic white children in the United States found that low SES before 2 years of age was associated with higher obesity risk by adolescence in both boys and girls; this analysis also indicated that the effect of early poverty endures later in life.178 Similarly, another study found that low SES in early childhood had a long-term impact on overweight and obesity.179 This study found that the risk of experiencing overweight or obesity in adulthood was not altered by either upward or downward mobility of poverty after early childhood,179 indicating the long-term effect of poverty-related stress in early childhood.
Low SES may also be associated with higher risk for obesity by increasing the child's experience with toxic stress. In addition, poverty may limit access to healthy foods and opportunities for physical activity.180''182 Another study of a large dataset of children followed longitudinally from 9 months of age to kindergarten entry showed that SES played a major role in BMI z-score gaps in Hispanic children, whereas rapidity of weight gain in the first 9 months ''accounted for much of the disparity between white children and children'' of other races and ethnicities (other than Hispanic children).180
A.2.b. Children in Families That Have ImmigratedFor decades, researchers have believed that despite poverty and other negative SES factors, recently arrived immigrants are healthier than their US-born counterparts. Recent studies, however, have examined large datasets in novel ways and now call this idea into question when it comes to children in families that have immigrated.183
As families who have immigrated try to adjust to a new culture, they may adopt Americanized foodways, which are high in fat, sugar, and salt. This tendency could be heightened by children's exposure to media advertising these foods and high-energy snacks and by reduced physical activity.184,185
Patterns of childhood overweight and obesity among families that have immigrated vary substantially by both ethnicity and generational status. Immigrants to the United States generally originate from countries that have a lower prevalence of obesity, but as families acculturate to US eating and activity patterns, rates of obesity may increase. One study found that second-generation Hispanic immigrants were 55% more likely to have obesity than nonimmigrant white children, whereas first-generation Asian immigrants had a 63% lower risk of having obesity.180
Several studies have indicated different patterns of developing obesity in Mexican-origin populations among adults and children. Obesity among adults of Mexican origin in the United States has been associated with longer stays in the United States and with being born in the United States versus Mexico, which are 2 proxies for acculturation. This pattern differs in children, in whom ''significantly higher obesity prevalence has been observed for first-generation young adult males (ages 18''24) and adolescent females (ages 12''17).''186
In addition, in some cultures, larger body sizes may be preferred as an indication of health and wealth.187 This cultural factor may make it more difficult for parents to understand the gravity of their children's overweight or obesity. For this and many other reasons, it is vital to ensure that children and families who have immigrated and who are native-born have access to culturally competent health care.188
A.3. Food InsecurityThe literature positing an association between food insecurity and overweight and obesity in children has been inconsistent when looking at general child populations. Children living in households with food insecurity have been found, however, to have higher BMI z-scores and waist circumference measurement and a greater likelihood of having overweight or obesity.189 The correlation between food insecurity and obesity has been found to be higher in adolescents, who may have had more exposure to food insecurity over their life-course.190 Female children appear to more at risk for obesity in food-insecure environments, compared with male children.191
Food insecurity is highly associated with poverty, and the cost of fruits and vegetables192 and fast food have been found to influence consumption in low-income families193,194 and to be positively related to overweight in children.195 Associations between consuming more sugar from sugar-sweetened beverages, and less frequency of eating breakfast and eating dinner with family have also been noted in families with food insecurity.190,196 Family dynamics around feeding may change in situations of food insecurity and include pressure to eat as well as monitoring and restrictive eating practices.191,197 Experiences of food insecurity are stressful for children and families and may add to the burden of chronic stress, which can result in altered eating patterns in the direction of either restricting intake or increasing consumption of energy-dense foods.190,196
The AAP and Food Research and Action Center's toolkit, Screen and Intervene: A Toolkit for Pediatricians to Address Food Insecurity, is designed to help pediatricians identify and address childhood food insecurity (available at https://frac.org/aaptoolkit). The Toolkit assists pediatricians and other PHCPs to: (1) better identify children living in households struggling with food insecurity; (2) sensitively address the topic; (3) connect patients and their families to federal nutrition programs and community resources; and (4) advocate for greater food security and improved overall health of children and their families. The toolkit also includes the ''Hunger Vital Sign,'' a simple, validated 2-question tool that can be used in the clinical setting to evaluate for food insecurity (see link to toolkit above).
B. Neighborhood and Community Environment Influences or Contributors to ObesityEnvironmental factors play an important role in obesity prevalence. Families' dietary and physical activity opportunities and practices (mentioned above) are influenced by their neighborhoods (Table 1).
TABLE 1Selected Examples of Multilevel Influencers and Contributors to Obesity
Example . Description . A. Policy factors ' Marketing of unhealthy foods ' Underresourced communities ' Food insecurity B. Neighborhood and community factors 1. School environment 2. Lack of fresh food access 3. Fast food proximity 4. Access to safe physical activity 5. Environmental health C. Family and home environment factors 1. Parenting feeding style 2. Sugar-sweetened beverages 3. Portion sizes 4. Snacking behavior 5. Dining out and family meals 6. Screen time 7. Sedentary behavior 8. Sleep duration 9. Environmental smoke exposure 10. Psychosocial stress 11. Adverse childhood experiences D. Individual factors D.1. Genetic factors 'ƒa. Monogenetic syndromes and polygenetic effects 'ƒb. Epigenetic effects D.2. Prenatal risk 'ƒa. Parental obesity 'ƒb. Maternal weight gain 'ƒc. Gestational diabetes 'ƒd. Maternal smoking D.3. Postnatal risk 'ƒa. Birth weight 'ƒb. Early breastfeeding cessation and formula feeding 'ƒc. Rapid weight gain during infancy and early childhood 'ƒd. Early use of antibiotics D.4. Childhood risk 'ƒa. Endocrine disorders 'ƒb. Children and youth with special health care needs 'ƒ1. Children with autism spectrum disorder 'ƒ2. Children with developmental and physical disabilities 'ƒ3. Children with myelomeningocele 'ƒc. Attention-deficit/hyperactivity disorder 'ƒd. Weight-promoting appetitive traits 'ƒe. Medication use (weight-promoting medications) 'ƒf. Depression Example . Description . A. Policy factors ' Marketing of unhealthy foods ' Underresourced communities ' Food insecurity B. Neighborhood and community factors 1. School environment 2. Lack of fresh food access 3. Fast food proximity 4. Access to safe physical activity 5. Environmental health C. Family and home environment factors 1. Parenting feeding style 2. Sugar-sweetened beverages 3. Portion sizes 4. Snacking behavior 5. Dining out and family meals 6. Screen time 7. Sedentary behavior 8. Sleep duration 9. Environmental smoke exposure 10. Psychosocial stress 11. Adverse childhood experiences D. Individual factors D.1. Genetic factors 'ƒa. Monogenetic syndromes and polygenetic effects 'ƒb. Epigenetic effects D.2. Prenatal risk 'ƒa. Parental obesity 'ƒb. Maternal weight gain 'ƒc. Gestational diabetes 'ƒd. Maternal smoking D.3. Postnatal risk 'ƒa. Birth weight 'ƒb. Early breastfeeding cessation and formula feeding 'ƒc. Rapid weight gain during infancy and early childhood 'ƒd. Early use of antibiotics D.4. Childhood risk 'ƒa. Endocrine disorders 'ƒb. Children and youth with special health care needs 'ƒ1. Children with autism spectrum disorder 'ƒ2. Children with developmental and physical disabilities 'ƒ3. Children with myelomeningocele 'ƒc. Attention-deficit/hyperactivity disorder 'ƒd. Weight-promoting appetitive traits 'ƒe. Medication use (weight-promoting medications) 'ƒf. Depression B.1. School EnvironmentChildren spend most of their time in school. Therefore, schools play an important role in influencing children's food choices and physical activity level and, ultimately, their body weight. For example, the presence of fast foods, vending machines, and/or sweetened beverages in schools may negatively influence children's food choices.198
Systematic reviews have shown an association between fast food outlets and convenience stores located near schools and obesity in children.199,200 When analyzed by subgroups, a positive association has been seen between fast-food outlets and proximity to schools among Hispanic, Black, and white children. Although the association was seen for all grade levels, the effect was larger in younger grades.199 This review also reported a stronger association between fast-food outlets and grocery stores located near schools and obesity in socioeconomically underresourced neighborhoods.
B.2 Lack of Fresh Food AccessA neighborhood's food environment has been shown to have mixed association with children's BMI. Although some studies have shown that a 1.6-km distance or shorter from a home to a supermarket is associated with a lower BMI,201 other studies have found that the greater the number of supermarkets located near a child's home, the higher the child's BMI.202 Similarly, a systematic review reported mixed association, with some studies showing a negative association between supermarket accessibility and childhood and adolescent obesity, and other studies either showing a positive effect or no association.203
Some of the differences were attributed to variations in assessment measures and lack of adjustment for confounding variables. Hence, it is not only the presence of supermarkets that is important, but also other factors that may impact dietary choices'--such as the type of foods stocked, pricing, etc. Some, but not all, studies have reported a positive association between neighborhood poverty and childhood and adolescent obesity.204
It has been suggested that lack of access to fresh fruits and vegetables may be a risk factor for childhood and adolescent obesity, as it may lead to an increased reliance on, and consumption of, unhealthy foods. The data for this association have been inconsistent, however. A recent systematic review showed that, although there was a negative association between access to fresh fruits and vegetables and healthy eating behavior, the association between access to fresh fruits and vegetables and overweight and obesity was inconclusive.205
B.3. Presence of Fast-food RestaurantsFast-food restaurants generally serve relatively low-priced and calorie-rich fast foods with high levels of saturated fat, simple carbohydrates, sugar, and sodium. Because of their easy availability, taste, and marketing strategies, fast foods tend to be popular with children and adolescents.206
Fast-food consumption has been associated with weight gain.207 Some, but not all, studies have shown an association between access to fast-food restaurants and pediatric obesity.208 A meta-analysis and recent systematic review showed a mixed association between access to fast-food restaurants and weight-related behaviors and weight status in children and adolescents.209 This association was shown to be stronger in populations with lower SES.209
B.4. Access to Safe Physical ActivityA child's environment may influence the amount of physical activity they get. For example, living in an urban environment that lacks safe walkable and/or green spaces in which children can play may result in decreased physical activity levels. Greater exposure to green space has been shown to be associated with higher levels of physical activity and lower risk of obesity.210
A recent systematic review of the literature on the influence of the built environment and childhood obesity found significant association between childhood obesity and traffic air pollution and indicators of walkability (which included intersection density and presence and amount of park area in the neighborhood).211
In addition to green spaces, other aspects of the environment'--including safety'--are important in these spaces' use. A study of low-income preschool children in New York City reported an association of lower obesity risk in neighborhoods with trees alongside the streets and a positive association between obesity and higher homicide rates in the neighborhood.212
B.5. Environmental HealthExposure to environmental hazards during the prenatal period, infancy, and childhood can have impacts on the health and well-being of children. Endocrine-disrupting chemicals (EDC) can cross the placental barrier and affect the fetus.213 There are some data that show an association between prenatal exposure to bisphenol A and polyfluoroalkyl and childhood obesity.214,215
In the postnatal and infancy period exposure may occur through breastfeeding, inhalation, ingestion, or absorption through the skin. Children get exposed to chemicals that are used in household products including cleaning agents, food packaging, pesticides, fabrics, upholstery, etc. Leaching of chemical products (eg, bisphenols, phthalates, parabens, and other EDCs) has been reported in baby feeding bottles, clothing, diaper creams, etc. Exposure to EDCs during early childhood can affect programming of several systems, including endocrine and metabolic systems, which may affect BMI, cardiovascular, and metabolic outcomes later in life.213
C. Family and Home Environment FactorsThe family's dietary preferences and lifestyle habits have a crucial role in influencing the child's weight.216 Parenting feeding practices and modeling of eating behavior and the type and quantities of foods and beverages in the home have been reported to be important influences in children's appetitive behaviors and food preferences.217
C.1. Parenting Feeding StylesParenting styles differ and may have an impact on a child's risk for obesity. Four types of parent feeding styles have been described: authoritative (responsive and warm with high expectations); authoritarian (not responsive but with high expectations); permissive or indulgent (responsive and warm but lenient with few rules); and negligent (not responsive with few rules). The 4 parenting styles discussed were initially defined by Baumrind (1966) and later expanded by Maccoby and Martin (1983).218,219 (Restrictive feeding was not included as 1 of the parenting styles.)
Authoritative feeding, where parents respond to the child's cues of hunger and satiety, is considered to be protective against excessive weight gain. Children from authoritative parenting homes have been shown to eat more healthy foods, be more physically active, and have healthier BMI, compared with children raised in homes with authoritarian, permissive or indulgent, or negligent parenting styles.220,221
One possible mechanism of parenting style's influence on a child's weight status is thought to be from interference in the child's ability to self-regulate their dietary intake. An authoritarian parent, for example, may not respond to a child's cues for energy intake, resulting in poor ability on the part of the child to self-regulate their own energy intake, and a higher likelihood of overindulging when presented with an opportunity to eat.222,223
A large cross-sectional study showed that, among preschool- and school-aged children, authoritarian or negligent parenting is associated with a higher risk of obesity,224 whereas authoritative parenting was associated with healthy BMI.221 Among preschoolers, the effect of the parenting feeding style was found to be modulated by poverty, with the effect only being seen among children who were not living in poverty.224
C.2. Family Home Environment OrganizationA systematic review of associations between the organization of the family home environment and childhood obesity found that greater organization of the home environment, which included practices such as having family routines and setting limits, was inversely associated with obesity.225 This relationship was present for younger and older children. Most but not all of the 32 studies included in the review controlled for sociodemographic factors.
C.3. Sugar-Sweetened BeveragesA systematic review of 20 prospective cohort studies and randomized controlled trials from 2013 to 2015 found that sugar-sweetened beverages (SSBs) were positively associated with obesity in children in all but 1 study (96%).226 Based on this review and others demonstrating a link between SSB and multiple other medical and dental diseases, the AAP published a policy statement on SSBs in 2019, calling for broad implementation of policies restricting SSB consumption in children and adolescents.227
C.4. Portion SizesMuch of the research on the influence of portion size on children's intake has been performed in laboratory settings providing a single meal to preschool-aged children. A comprehensive review of this research reported that children who serve or are served larger portions of commonly liked energy-dense foods typically consume larger amounts but cautioned that long-term studies of the effects of larger portions over time on a number of variables, including body weight, are lacking.228
C.5. Snacking BehaviorA recent systematic review of body fat and consumption of ultra-processed foods (defined as snacks, fast foods, junk foods, and convenience foods) in children and adolescents found a positive association but noted that longer-term studies examining the association of these foods and obesity are needed.229
C.6. Dining Out and Family MealsEating outside of the home has been shown to be associated with higher energy intake in both children and adults.230,231 In the United States, food eaten outside the home is characterized by higher fat content, larger portions, and greater energy intake.230
In a systematic review of pediatric and adult studies, eating at fast-food establishments was associated with much higher weight gain, compared with eating at other types of restaurants.231
Take-away food has also been associated with high BMI.231 Hence, eating outside of the home'--irrespective of the type of restaurant establishment visited'--is associated with higher risk of weight or BMI gain. Conversely, 2 meta-analyses found that increased frequency of eating family meals was associated with lower risk of childhood obesity.232,233
C.7. Screen TimeSome, but not all, studies report an association between screen time duration, childhood adiposity,234''236 and adult BMI.237 Some studies have shown a dose-response effect of screen time and childhood adiposity,235 with screen time greater than 2 hours per day being positively associated with higher risk of overweight or obesity.236 A recent meta-analysis reported 42% greater risk of overweight or obesity with more than 2 hours per day of television (TV) compared with 2 or fewer hours.238
There is evidence to support the association between screen time and consumption of unhealthy diet and high energy intake.235 The appearance or depiction of food items while engaging in screen time may affect a child's dietary behavior. A systematic review examining food choice and intake showed that food included in entertainment media affects eating behaviors of children.167 Children and adolescents are more exposed to food and beverage advertisements when watching TV.239 Additionally, increase in screen time may displace physical activity and interfere with sleep.235,240
Although ''screen time'' includes TV, computer, video or videogames, mobile phones, and other digital devices, the majority of the studies published examined the effect of TV viewing.235 Male children and adolescents tend to spend more time on media screen devices and other Internet technology than female children and adolescents do.236
C.8. Sedentary BehaviorThe association between sedentary behavior and adiposity has been shown to range from small to inconsistent.241 Studies examining the effect of sedentary behavior alone on weight using accelerometer measures have shown no association between sedentary behavior and obesity. Teasing out the effects of sedentary behavior alone in treatment studies may be challenging, as this is often confounded with other behaviors such as physical activity, screen time, or increased intake of unhealthy foods.241
C.9. Sleep DurationShort sleep duration is associated with higher risk of obesity in children.242''244 A meta-analysis of prospective cohort studies demonstrated a dose-response inverse association between sleep duration and risk of childhood overweight and obesity.244 Children 13 years and younger with short sleep duration ('¼10 hours) had a 76% increased risk of overweight or obesity compared with their counterparts with longer sleep duration (12.2 hours).
Sleep restriction may be associated with increased calorie consumption.245,246 Additionally, fatigue and decreased physical activity has also been associated with short sleep duration. It is unclear whether the inverse association between sleep and adiposity is causal or a consequence of hormonal or metabolic disturbance.247 Although the exact mechanism for this association is unknown, some of the consequences of short sleep duration include hormonal and metabolic alterations'--such as increased ghrelin and decreased leptin'--which may lead to increased hunger.242
C.10. Environmental Smoke ExposureChildren exposed to environmental tobacco smoke (ETS) have been found to have higher BMI compared with their nonexposed counterparts, according to a systematic review of ETS exposure and growth outcomes in children up to 8 years of age.248
C.11. Psychosocial StressPsychosocial stress in the prenatal period may have an effect on endocrine function (hypothalamic-pituitary-adrenal axis and glucose''insulin metabolism) in the child's life course. A meta-analysis showed that prenatal psychological stress was associated with higher risk of childhood and adolescent obesity.249
Psychosocial and emotional issues may lead to weight gain through maladaptive coping mechanisms, including eating in the absence of hunger to suppress negative emotions, appetite up-regulation, low-grade inflammation, decrease in physical activity, increase in sedentary behavior, and sleep disturbance.154,250,251 Depression has been shown to be a risk factor in both pediatric and adult obesity.251 The association between depression and obesity could be reciprocal, as obesity may increase depression risk.
C.12. Adverse Childhood ExperiencesA number of studies have documented an association between ACEs and the development of overweight and obesity. ACEs impact occurs via toxic stress, which occurs ''when a child experiences strong, frequent, and/or prolonged adversity'--such as physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship'--without adequate adult support.''252,253
ACEs include a history of physical, emotional, or sexual abuse; exposure to domestic violence; household dysfunction from parental divorce or substance abuse; economic insecurity; mental illness; and/or loss of a parent because of death or incarceration.69,254''257
A US study found that cumulative ACEs doubled the risk of children having overweight or obesity, compared with their counterparts with no history of ACEs.258 Unresolved stress and emotional issues may result in maladaptive coping strategies'--such as binge eating, eating in the absence of hunger, impulsive eating, and poor sleep hygiene'--which may result in further weight gain.
Poverty and associated toxic stresses in utero and early childhood have been suggested to initiate neuroendocrine and/or metabolic adaptations that produce biological phenotypes and obesogenic behaviors that lead to obesity.259,260 These effects may persist throughout the lifetime.260
D. Individual-Level Influences or Contributors to Obesity D.1. Genetic FactorsHeritability studies suggest that there is a 40% to 70% genetic contribution to an individual's obesity risk.261''263 Genome-wide association studies have identified 32 loci of significance to obesity predisposition.264 Genetic causes of obesity include both common and rare genetic variants that involve impairment of gene expression or function.264
D.1.a and D.1.b. Monogenetic Syndromes and Polygenetic EffectsPolygenetic causes of obesity are by far the most common, and single gene defects are rarer causes of obesity. For example, MC4R, a heterozygous mutation, is the most common form of monogenic obesity and accounts for only 2% to 5% of severe obesity in children.265,266 Polygenic inheritance refers to a single inherited phenotypic trait that is controlled by 2 or more different genes. Polygenic variants, on their own, have little effect on an individual's phenotype. The phenotypic effect manifests only in the presence of, or in combination with, other predisposing factors.
Children with genetic causes of obesity may present with characteristic clinical features that have historically included findings such as short stature, dysmorphic features, developmental delay, skeletal defects, deafness, retinal changes, or intellectual disability. It is important to note that more recently discovered genetic disorders associated with obesity are not necessarily characterized by these findings in childhood; for instance, short stature is not a hallmark of leptin deficiency in children. Table 2 lists selected monogenetic causes and syndromes associated with obesity.
TABLE 2Genetic Syndromes Associated With Obesity
Genetic Syndrome . Monogenetic disorders 'ƒMC4R deficiency Increased lean body mass, accelerated linear growth. Hyperinsulinemia. May have lower blood pressure. 'ƒLeptin deficiency Normal linear growth with reduced adult height. Rapid-onset obesity with hypothalamic dysfunction (hypogonadotropic hypogonadism, hypothyroidism). Alterations in immune function. Responsive to leptin treatment. 'ƒLeptin receptor deficiency Normal linear growth with reduced adult height. Rapid-onset obesity with Hypothalamic dysfunction (hypogonadotropic hypogonadism, hypothyroidism). Alterations in immune function. Not responsive to leptin therapy. 'ƒPOMC deficiency Accelerated childhood growth. Adrenocorticotropic hormone deficiency, mild hypothyroidism. Red hair, light skin (in non-Hispanic white individuals). 'ƒProprotein subtilisin or kexin type 1 deficiency Failure to thrive in early infancy. Hypoglycemia, adrenocorticotropic hormone deficiency. Intestinal malabsorption, diarrhea. 'ƒSRC1 deficiency Impaired leptin-induced POMC expression. Syndromic forms of obesity 'ƒPrader-Willi syndrome In neonatal period poor feeding, failure to thrive, and hypotonia. By 4''8 y, hyperphagia with food impulsiveness. Short stature. Growth hormone deficiency, hypogonadism. Dysmorphia, intellectual disability, behavioral difficulties. 'ƒAlstrom syndrome Short stature. Insulin resistance, T2DM, hypogonadism, hyperandrogenism in females, hypothyroidism. Visual impairment, hearing loss, cardiomyopathy, hepatic dysfunction, renal failure. 'ƒBardet-Biedl syndrome Normal stature. Hypogonadism, polydactyly, retinal dystrophy, renal malformation, cognitive disabilities, polyuria, and polydipsia. 'ƒSmith-Magenis syndrome Short stature. Disrupted melatonin signaling. Craniofacial anomalies, intellectual disability, self-injurious behaviors, sleep disturbance. 'ƒSH2B1 deficiency Hyperinsulinemia, delayed speech and language development, aggressive behavior. 'ƒSim1 deficiency Short stature. Hypopituitarism. Neonatal hypotonia, facial dysmorphism, developmental delay. 'ƒ16p11.2 microdeletion syndrome Developmental delay, intellectual disability, autism spectrum disorder, impaired communication, and socialization skills. 'ƒBrain derived neurotrophic factor deficiency Hyperphagia, impaired short-term memory, hyperactivity, learning disability. Patients with Wilms tumor-aniridia (WAGR syndrome) have subset of deletions on chromosome 11p.12 including brain derived neurotrophic factor locus. 'ƒAlbright's hereditary osteodystrophy Short stature, round face, brachydactyly, subcutaneous ossifications. Some patients may have mild developmental delay. If inherited from the mother, may be associated with pseudohypoparathyroidism type 1a. 'ƒCohen syndrome Hypotonia, intellectual disability, distinctive facial features with prominent upper central teeth, broad nasal tip, smooth or shortened philtrum, thick hair and eyebrows, long eyelashes, retinal dystrophy, acquired microcephaly, joint hyperextensibility. 'ƒBeckwith-Wiedemann syndrome Macrosomia, macroglossia, hemihyperplasia, anterior abdominal wall defects, visceromegaly, neonatal hypoglycemia, embryonal tumors, renal anomalies. Genetic alteration in chromosome 11p15.5. Genetic Syndrome . Monogenetic disorders 'ƒMC4R deficiency Increased lean body mass, accelerated linear growth. Hyperinsulinemia. May have lower blood pressure. 'ƒLeptin deficiency Normal linear growth with reduced adult height. Rapid-onset obesity with hypothalamic dysfunction (hypogonadotropic hypogonadism, hypothyroidism). Alterations in immune function. Responsive to leptin treatment. 'ƒLeptin receptor deficiency Normal linear growth with reduced adult height. Rapid-onset obesity with Hypothalamic dysfunction (hypogonadotropic hypogonadism, hypothyroidism). Alterations in immune function. Not responsive to leptin therapy. 'ƒPOMC deficiency Accelerated childhood growth. Adrenocorticotropic hormone deficiency, mild hypothyroidism. Red hair, light skin (in non-Hispanic white individuals). 'ƒProprotein subtilisin or kexin type 1 deficiency Failure to thrive in early infancy. Hypoglycemia, adrenocorticotropic hormone deficiency. Intestinal malabsorption, diarrhea. 'ƒSRC1 deficiency Impaired leptin-induced POMC expression. Syndromic forms of obesity 'ƒPrader-Willi syndrome In neonatal period poor feeding, failure to thrive, and hypotonia. By 4''8 y, hyperphagia with food impulsiveness. Short stature. Growth hormone deficiency, hypogonadism. Dysmorphia, intellectual disability, behavioral difficulties. 'ƒAlstrom syndrome Short stature. Insulin resistance, T2DM, hypogonadism, hyperandrogenism in females, hypothyroidism. Visual impairment, hearing loss, cardiomyopathy, hepatic dysfunction, renal failure. 'ƒBardet-Biedl syndrome Normal stature. Hypogonadism, polydactyly, retinal dystrophy, renal malformation, cognitive disabilities, polyuria, and polydipsia. 'ƒSmith-Magenis syndrome Short stature. Disrupted melatonin signaling. Craniofacial anomalies, intellectual disability, self-injurious behaviors, sleep disturbance. 'ƒSH2B1 deficiency Hyperinsulinemia, delayed speech and language development, aggressive behavior. 'ƒSim1 deficiency Short stature. Hypopituitarism. Neonatal hypotonia, facial dysmorphism, developmental delay. 'ƒ16p11.2 microdeletion syndrome Developmental delay, intellectual disability, autism spectrum disorder, impaired communication, and socialization skills. 'ƒBrain derived neurotrophic factor deficiency Hyperphagia, impaired short-term memory, hyperactivity, learning disability. Patients with Wilms tumor-aniridia (WAGR syndrome) have subset of deletions on chromosome 11p.12 including brain derived neurotrophic factor locus. 'ƒAlbright's hereditary osteodystrophy Short stature, round face, brachydactyly, subcutaneous ossifications. Some patients may have mild developmental delay. If inherited from the mother, may be associated with pseudohypoparathyroidism type 1a. 'ƒCohen syndrome Hypotonia, intellectual disability, distinctive facial features with prominent upper central teeth, broad nasal tip, smooth or shortened philtrum, thick hair and eyebrows, long eyelashes, retinal dystrophy, acquired microcephaly, joint hyperextensibility. 'ƒBeckwith-Wiedemann syndrome Macrosomia, macroglossia, hemihyperplasia, anterior abdominal wall defects, visceromegaly, neonatal hypoglycemia, embryonal tumors, renal anomalies. Genetic alteration in chromosome 11p15.5. Adapted from Pediatric Obesity-Assessment, Treatment, and Prevention: An Endocrine Society Clinical Practice Guideline.268
Early onset of severe obesity and the presence of hyperphagia are the 2 clinical characteristics that distinguish genetic disorders of obesity. ''Early onset'' refers to the presence of obesity before age 5. As noted previously, ''severe obesity'' is defined as BMI '‰¥ 120% of the 95th percentile for age and sex. ''Hyperphagia'' is the presence of insatiable hunger in which the individual's time to satiation is long, the individual's duration of satiation is shorter, the individual's feelings of hunger are prolonged, and the individual has a severe preoccupation with food and experiences distress if denied food.267
D.1.c. Epigenetic FactorsEpigenetic factors can result in alterations in gene expression without alteration in genetic code. These epigenetic factors may modify the interaction of environmental and individual factors in promoting weight gain.269 One of the critical periods in the establishment of the epigenome is considered to be during embryonic development.270 Prepregnancy maternal or paternal obesity, for example, may influence epigenetic changes during subsequent pregnancy, increasing the risk of overweight or obesity in the offspring.269 Other risk factors during pregnancy'--such as gestational diabetes or maternal excessive weight gain'--may result in epigenetic changes and increase the risk of obesity in the offspring.
D.2. Prenatal Risk FactorsThe perinatal environment plays an important role in a child's later development of overweight or obesity. The mechanisms by which the fetal environment predisposes to the development of obesity are complex and poorly understood. They probably include gene-environment interactions or epigenetic changes attributable to several environmental factors, including maternal diet, physical activity, and/or other environmental contaminants.271,272
Preterm infants have a greater likelihood of developing childhood obesity.273''275 Although the exact mechanisms for this association are uncertain, several risk factors have been postulated, including feeding patterns leading to accelerated weight gain in preterm infants.273
D.2.a. Parental ObesityParental weight is a strong predictor of pediatric obesity. Children are at greatest risk of developing obesity as an adult if at least 1 of their parents has obesity.276 A meta-analysis reported an increased risk of adolescent excess adiposity if either parent had overweight or obesity; the risk increased if both parents had obesity.277 Contributors to this association include genetic, environmental, and behavioral factors or the interaction of these factors, resulting in intergenerational transmission of adiposity.
Maternal BMI is a stronger predictor of childhood and adolescent obesity, compared with paternal obesity.247 Maternal obesity more than doubles the risk of adult obesity (see below). Paternal obesity has been associated with childhood and adolescent obesity and has an additive effect to maternal obesity.278
D.2.b. Maternal Weight GainPrepregnancy adiposity and weight gain during pregnancy are associated with neonatal, infancy, and childhood adiposity.247 The known effect of maternal weight on the offspring led the Institute of Medicine (IOM) to recommend different ranges for weight gain during pregnancy, varying from 12.5 to 18 kg for underweight women to 5 to 9 kg for women with obesity (BMI > 30 kg/m2).279 Yet, between 1997 and 2007, almost half of pregnant US individuals gained more than the weight recommended by the IOM.280
Excess maternal adiposity has been suggested to affect fetal metabolic programing and make the offspring more vulnerable to the obesogenic environment and increase the risk of obesity. This effect was illustrated in metabolic and bariatric surgery studies, in which children born to mothers with obesity after gastric bypass surgery had lower prevalence of macrosomia and severe obesity at adolescence, compared with their siblings born before the mothers' surgery.247 Fetal or infant macrosomia and gestational diabetes are some of the complications associated with maternal obesity and serve as risk factors for later onset of obesity and T2DM in the offspring.281
The exact mechanism by which maternal obesity predisposes to adverse outcomes in the offspring is unclear. It has been suggested that the pathways that are affected control the central regulation of appetite and insulin sensitivity and cardiovascular regulation.281 Alteration of the fetal hypothalamic-pituitary-adrenal axis function has been implicated in programming the metabolic syndrome of the offspring of mothers with obesity.282
D.2.c. Gestational DiabetesInfants and children of mothers with gestational diabetes mellitus (GDM) have higher fat mass and BMI than their counterparts whose mothers did not have GDM.283 Adjusting for maternal BMI and other potential confounders, GDM was shown to be associated with childhood obesity with odds ratio of 1.6 to 2.8.284,285 The odds of developing higher waist circumference ('‰¥95th and percentile) in children of mothers with GDM was also found to be higher after controlling for potential confounders (OR, 1.55; 95% CI, 1.03''2.35).285 Sibling studies controlling for shared genetics and environment have shown higher BMIs in offspring exposed to diabetes in utero compared with their unexposed siblings.286
Although the exact mechanisms of the effect of GDM are not fully understood, it has been postulated that the effect may be mediated through insulin. Pregnant women with GDM have higher insulin resistance compared with pregnant women without GDM.287,288 It has been suggested that maternal insulin resistance and hyperglycemia causes fetal hyperinsulinemia, resulting in excessive fetal growth with associated macrosomia and increased adiposity.287 Maternal hypertriglyceridemia from insulin resistance has also been thought to lead to increased adiposity and birth size even when glucose levels are well-controlled.289 Additionally, maternal diabetes is associated with increased leptin synthesis in the offspring.290 Epigenetic changes in infants of mothers with GDM is another suggested mechanism, affecting gene expression regulation body fat accumulation or other related metabolic pathways.291
D.2.d. Maternal SmokingExposure to ETS has been shown to increase the prevalence of childhood and adolescent obesity.292''294 A systematic review and meta-analysis reported an association between prenatal ETS and childhood and adolescent obesity; children exposed to ETS in utero had about 1.9 times greater risk of developing obesity, compared with their nonexposed counterparts.295 Prenatal exposure to the risk from tobacco smoke can occur both directly from smoking mothers and indirectly through ETS, although maternal smoking was found to more strongly predict obesity.
Children exposed to smoking in utero have a dose-dependent increased risk of developing overweight and obesity.296
D.3. Postnatal Risk FactorsAs with the prenatal environment, the postnatal environment is important to the later development of overweight and obesity. In addition to epigenetic mechanisms, behavioral habits begin to get set at an early age. Acceptance of foods, availability of high calorie foods, establishment of the microbiome, and early eating habits are only a few of the proposed mechanisms for postnatal factors to influence later weight status.297
D.3.a. Birth WeightSeveral studies have shown a U-shaped or J-shaped distribution between birth weight and adult BMI.247 Infants with both low (<2500 g) and high (>4000 g) birth weight have been shown to have higher risk of obesity, compared with infants with birth weight between 2500 and 4000 g.298 A high BMI and central adiposity are more prevalent among low-birth weight infants.299 Maternal prepregnancy weight and nutritional status are strong predictors of neonatal outcomes, with underweight prepregnancy increasing the risk of preterm birth and small-for-gestational-age neonates.300 Maternal pregnancy overweight and obesity are significantly associated with large-for-gestational-age babies.300
D.3.b. Early Breastfeeding Cessation and Formula FeedingSome, but not all, studies have reported decreased risk of childhood and adolescent obesity in breastfed infants.247 The majority of evidence is derived from observational studies and may include confounding effects.247 Some studies have reported that, compared with bottle-fed infants, breastfed infants are better able to regulate their energy intake and have lower risk of childhood excess weight gain.301 Other studies have also shown that body weight gain is slower in breastfed infants.247
Breastfeeding has been found to be inversely associated with overweight risk in the first year of life, independent of maternal BMI and SES. Breastfeeding cessation before 6 months was associated with an increased risk of rapid weight gain and overweight by 12 months of age, compared with exclusive breastfeeding.302
A systematic review of feeding practices associated with rapid infant weight gain found that certain practices (such as overfeeding, inappropriately concentrating formula, placing infants in bed with a bottle, or adding cereal to a bottle) may lead to rapid infant weight gain.303 In addition, infants fed high-protein formulas are at greater risk of elevated BMI later in childhood.247,304
D.3.c. Rapid Weight Gain During Infancy and Early ChildhoodIn resource-abundant countries, rapid weight gain in infancy and during the first 2 years of life is associated with higher risk of obesity both in later childhood and in adulthood.247,305 A systematic review and meta-analysis found that children who experienced rapid weight gain from birth to age 2 were up to 3.6 times more likely to have overweight or obesity in childhood or adulthood, with the relationship being stronger between rapid infant weight gain and childhood overweight or obesity.306
Therefore, rapid weight gain in infancy and early childhood can be viewed both as a risk factor for later excess weight gain and also as a signal, as mentioned previously, for pediatricians and other PHCPs to look for other underlying risk factors and causes for excess weight gain. For instance, early introduction (at younger than 4 months of age) of complementary foods has been found to increase the risk of childhood obesity in several systematic reviews.307,308
D.3.d. Early Use of AntibioticsLiterature on antibiotic exposure in early life (<2 years) is mixed, with some suggestion that it may slightly increase the risk of childhood and adolescent obesity.309''312 The association is stronger with repeated antibiotic exposure,313,314 exposure within the first 6 months of infancy,314 and broad-spectrum antibiotic use.310 With similar antibiotic exposure, boys appear to be more susceptible to weight gain than girls.295 Gut microbiota is usually established during the first years of life; it is hypothesized that the effect of antibiotics is mediated through the alteration of the gut microbiome, which plays a role in energy balance.
D.4. Childhood Risk FactorsVarious medical conditions that present in childhood and adolescence are associated with the development and progression of overweight and obesity. Similarly, certain behaviors established in childhood and adolescence can increase the risk of later development of overweight and obesity.
D.4.a. Endocrine DisordersEndocrine disorders account for less than 1% of all the causes of pediatric obesity. These disorders can be associated with endogenous or exogenous glucocorticoid excess (eg, Cushing syndrome, use of corticosteroid medications). Short stature or growth failure and abnormally high BMI may result from pseudohypoparathyroidism type 1a, growth hormone deficiency, or hypothyroidism.268,315
D.4.b. Children and Youth With Special Health Care Needs Impacting Nutrition and Physical Activity D.4.b.1 Children With Developmental and Physical DisabilitiesA survey of data from NHANES, the National Health Interview Survey, and the National Survey of Children's Health found that children with disabilities were from 27% to 59% more at risk for obesity than children without disabilities.316
In addition to factors experienced by children without disabilities, factors that affect children with disabilities that have been implicated in their greater obesity risk are: more difficulty breastfeeding,317 disrupted appetite regulation,318 weight-gain promoting medications,319,320 food selectivity and sensitivity issues,321 behavioral disorders,322 physical activity limitations,323 and use of food rewards.316 A lack of adaptive physical education or sports,324 and specialized supervision and instruction324 also play a role in increasing obesity risk.
Furthermore, it is important to consider that children with disabilities are at a disadvantage when it comes to obesity treatment strategies that are tailored to their needs. For example, most community or school weight management, nutrition or physical activity interventions are not readily adapted for children with disabilities. Therefore, many children with disabilities do not have the support or strategies that they need to address excess weight. Finally, children may face bullying or stigmatization and bias in school. They may also receive unhealthy incentives as rewards from caregivers increasing their risk for obesity. These systemic trends and biases make providing adequate care for children with disabilities extremely difficult.
D.4.b.2 Children With Autism Spectrum DisorderChildren and youth with autism spectrum disorder (ASD) have a higher risk of developing overweight or obesity. In the United States, children and adolescents 2 to 18 years of age with ASD have a 43.7% greater risk of obesity compared with their counterparts without ASD.325 Although the exact mechanisms through which ASD increases the risk for excess weight gain is unknown, a recent meta-analysis of international studies showed that positive moderators to this association include children of certain races and ethnicities, female biological sex, increased age, and living in the United States.325 This meta-analysis did not control for other risk factors for obesity, however, such as use of antipsychotic medications, food intake challenges, or limited physical activity. Hence, the variable of race could be reflective of a negative SDoH.
Several etiological factors have been postulated to contribute to the association between ASD and obesity, including: genetic variants (eg, 16p11.2 deletion and microdeletion 11p14.1),326,327 prenatal exposure to certain infections or medications,328,329 pre and postnatal exposure to toxins,330,331 maternal diabetes,332 maternal obesity,333 intrauterine growth restriction and preterm birth,334,335 food selectivity,336,337 and physical limitations.338,339
D.4.b.3 Children With MyelomeningoceleSeveral studies report increased rates of obesity of children with myelomeningocele,340''342 with children having more severe disease tending to have higher BMIs.340 Children and adolescents with myelomeningocele have increased total body fat343 and lower energy expenditure,342 compared with children without myelomeningocele. Risk factors for obesity in this population include limited ambulation, sedentary lifestyle, decreased lean body mass, and reduced resting energy expenditure.344 In addition, children with myelomeningocele may be less likely to have routine weight and height, and primary care providers' discussions may be lacking with respect to addressing healthy lifestyles.
D.4.c. Attention-Deficit/Hyperactivity DisorderA systematic review and meta-analysis showed significant association between attention-deficit/hyperactivity disorder (ADHD) and obesity among unmedicated individuals with ADHD'--but not among medicated individuals.345 The prevalence of obesity was found to be 40% higher among children and adolescents with ADHD, compared with those without ADHD. This association is not affected by gender or by study setting, country, or quality. Causality between ADHD and obesity could not be inferred from this meta-analysis, because the studies were cross-sectional; however, some prospective studies have shown that ADHD precedes the diagnosis of obesity.346,347
Some of the known symptoms of ADHD may contribute to weight gain. For example, binge eating, which is a manifestation of impulsivity in individuals with ADHD, may result in increased energy intake. Inattentiveness, another symptom of ADHD, may lead to lack of planning, or of following through on a plan, resulting in missed meals or the consumption of unhealthy meals and snacks.348 Other psychiatric comorbidities that are often associated with ADHD'--such as depression, anxiety, and circadian rhythm disturbances'--may also be risk factors for obesity.348
Dopamine plays an important role in some of the addictive behaviors of ADHD and obesity. Functional MRI studies have identified shared neuropsychiatric circuits that are associated with reward, response inhibition, and emotional regulation in obesity, ADHD, and abnormal eating behavior.348
D.4.d. Weight-Promoting Appetitive TraitsDifferences in children's appetitive traits manifest as early as infancy (for example, suckling behavior) and may become more pronounced when children get exposed to an obesogenic food environment.217 Although the exact reasons why some children have better control of their energy intake is unknown, interaction between genetic predisposition and children's early environment may explain some of the individual differences in appetitive traits. Parent feeding style, as discussed, has been shown to be of importance.217
Systematic review and meta-analysis of adult data showed a positive association between eating quickly and higher BMI,349 and in longitudinal studies, faster eating rate was associated with excess weight gain.349 Similarly, 2 cross-sectional pediatric studies have reported a positive association between eating fast and childhood and adolescent obesity.350,351 Eating quickly has been suggested to result in greater energy intake.
A recent American Heart Association policy statement on caregiver influences on young children's eating behaviors synthesized appetitive traits consistently associated with child adiposity. In addition to more rapid eating pace, these traits include eating in the absence of hunger, high enjoyment of food, low responsiveness to satiety, and low level of restrained eating.352
D.4.e. Medication UseMedications within many categories have been associated with weight gain. The magnitude of risk associated with medication use is not fully known; therefore, there is an urgent need for more research in this area as well as mediating strategies. Medications implicated include glucocorticoids, sulfonylureas, insulin, thiazolidinediones, antipsychotics, tricyclic antidepressants, and antiepileptic drugs.353''356 In particular, second-generation antipsychotics (ie, risperidone, clozapine, quetiapine, and aripiprazole) can lead to rapid weight gain and comorbidities such as prediabetes, diabetes, and dyslipidemia.357,358
A recent review discusses the more commonly prescribed medications in children and adolescents with obesity and comorbidities, and offers suggestions on alternative therapeutic agents (Table 3).359
TABLE 3Selected Examples of Commonly Prescribed Medications and Weight Gain in Pediatric Practice359
Medication . Obesogenic Medications . Nonobesogenic Medications . Allergies and asthma management ' antihistamines' steroids (systemic) ' inhaled nasal steroids' montelukast Antidepressants ' amitriptyline' nortriptyline' paroxetine' sertraline ' bupropion' imipramine HCL' buspirone' trimipramine maleate' citalopram' protriptyline HCL' desipramine HCL' trazadone' venlafaxine' doxepin' escitalopram' fluoxetine' fluvoxamine Antiepileptics ' carbamazepine' gabapentin' pregabalin ' valproate' vigabatrin ' felbamate' lamotrigine' levetiracetam' phenytoin' topiramate' zonisamide Antipsychotics ' aripiprazole ' clozapine' haloperidol' mirtazapine' olanzapine' perphenazine' quetiapine' risperidone' sertindole' thioridazine' ziprasidone ' molindone' pimozide Anxiolytics not applicable ' alprazolam' lorazepam Migraine management ' amitriptyline' atenolol' divalproex sodium' flunarizine' gabapentin' imipramin' nortriptyline' pizotifen' propranolol ' lamotrigine ' levetiracetam' protriptyline' timolol' topiramate' zonisamide Mood stabilizers and antimania ' carbamazepine' gabapentin' lithium' valproate ' lamotrigine' topiramate' zonisamide Psychostimulants not applicable ' amphetamine' methylphenidate' dextroamphetamine sulfate Medication . Obesogenic Medications . Nonobesogenic Medications . Allergies and asthma management ' antihistamines' steroids (systemic) ' inhaled nasal steroids' montelukast Antidepressants ' amitriptyline' nortriptyline' paroxetine' sertraline ' bupropion' imipramine HCL' buspirone' trimipramine maleate' citalopram' protriptyline HCL' desipramine HCL' trazadone' venlafaxine' doxepin' escitalopram' fluoxetine' fluvoxamine Antiepileptics ' carbamazepine' gabapentin' pregabalin ' valproate' vigabatrin ' felbamate' lamotrigine' levetiracetam' phenytoin' topiramate' zonisamide Antipsychotics ' aripiprazole ' clozapine' haloperidol' mirtazapine' olanzapine' perphenazine' quetiapine' risperidone' sertindole' thioridazine' ziprasidone ' molindone' pimozide Anxiolytics not applicable ' alprazolam' lorazepam Migraine management ' amitriptyline' atenolol' divalproex sodium' flunarizine' gabapentin' imipramin' nortriptyline' pizotifen' propranolol ' lamotrigine ' levetiracetam' protriptyline' timolol' topiramate' zonisamide Mood stabilizers and antimania ' carbamazepine' gabapentin' lithium' valproate ' lamotrigine' topiramate' zonisamide Psychostimulants not applicable ' amphetamine' methylphenidate' dextroamphetamine sulfate This is not an exhaustive list; it is included as an example of medications that may result in weight gain and possible alternatives.
D.4.f. DepressionChildren with obesity are more likely to have anxiety and depressive symptoms compared with their peers of healthy weight. It is not clear whether obesity is a risk factor for these symptoms.360,361 Some earlier research reported bidirectional associations between obesity and depression and anxiety. Limitations of some of the studies included small samples; self-reported data on anthropometry; assessment of symptoms based on self-administered questionnaires; and not controlling for potential confounders, such as family history, neuropsychiatric disorders, and SES. A more recent study showed that obesity was a risk factor for anxiety and depression among children and adolescent after adjusting for SES, neuropsychiatric disorders, and family history of anxiety or depression.362
The association between obesity and depression and anxiety may be attributable to interactions and shared pathophysiological mechanisms between these conditions.363,364 Some of the shared risk factors include genetic, physiologic, and environmental factors. Obesity is associated with subclinical inflammation and oxidative stress, which have been shown to be important etiological factors for depression, and this has been suggested as possible common link between obesity and depression.363 Other factors that can potentially impact the association between obesity and anxiety and depression include sleep disturbance, unhealthy diet, physical activity, antior bullying of children/or bullying of children.
IX. Evaluation of the Pediatric Patient With Overweight or Obesity A. Evaluation of Patients With Overweight or ObesityThis evaluation is an important part of COT (see COT section in the Treatment section). As with all chronic diseases, a complete history, review of systems (RoS), and physical examination are important for treatment. Specific elements of both history and physical relating to obesity are of special importance. Evaluation of the patient and family's readiness to change behavior is critical to effectively help with obesity treatment (see algorithm in Appendix 1).
The early and accurate classification of overweight and obesity and identification of obesity-related comorbidities is fundamental to the provision of timely and appropriate treatment (see the Comorbidities section, below). The routine classification of weight status allows for early recognition of abnormal weight gain. This is particularly important because patients'--including children and adolescents'--often do not perceive overweight and obesity as a health problem.366 Caregivers, families, pediatricians, other pediatric health care providers, and other health care providers367 can also be slow to recognize abnormal weight status, even in the presence of severe obesity.368,369
Patients and caregivers identify pediatricians and other PHCPs as trusted and preferred sources of information about weight status,370 starting with discussions of feeding practice in infancy and continuing with evaluation of healthy nutrition and activity into adulthood. Pediatricians and other PHCPs are also uniquely qualified to evaluate patients for overweight, obesity, and related comorbidities.
Routine well-child checks (WCCs) in the medical home are an opportune time for the evaluation of a child or adolescent with overweight and obesity, but this can occur during problem-focused visits as well. When the discussion of weight status is normalized and nonstigmatizing, the family and provider can exit a WCC or other visit with a clear and practical plan to improve health and quality of life. Successfully and sensitively treating overweight and obesity can be highly rewarding for both the family and the pediatrician (or other pediatric health care provider), because families suffering from overweight and obesity often have experienced previous shaming or negative experiences with treatment.28,371
Shaming of children with regard to their weight may happen at school and even at home in misguided efforts to ''motivate'' the child to adopt healthier behavior. Overt or subtle and unintended bias in health care leads to adverse health, behavioral, and psychological outcomes.61 In addition, when feeding practices are identified as unhealthy, parents may feel blame. It is important, although challenging, for pediatricians and other PHCPs to communicate support and alliance with children, adolescents, and parents as they diagnose and guide obesity treatment.62
In the AAP statement on obesity bias, steps to provide supportive and nonbiased behavior include recognition of the complex genetic and environmental influences on obesity. Recommendations include use of neutral words like ''BMI'' or ''excess weight'' rather than ''fat'' or ''chubby,'' use of people-first language (ie, ''a child with high weight'' or ''a child with obesity'' rather than ''an overweight child'' or ''an obese child''), an office set-up that accommodates different body sizes, and a private weighing station.28 Ongoing successful communication of support and empathy during obesity treatment is essential to reduce the effect of weight bias, because families will not continue to seek help if they experience stigma.372,373
B. Medical HistoryBoth a complete medical history and physical examination are necessary to evaluate any patient with a chronic disease. Obesity is no exception and, like other chronic diseases, requires comprehensive evaluation in certain areas of both the history and physical examination, which may require additional time to that which is allocated in a routine visit. The medical history includes the chief complaint, history of the present illness, and family history.
The chief complaint is notable for determining whether overweight and obesity is a concern for the patient and family. An open-ended question such as ''What concerns, if any, do you have about your child's growth and health?'' can provide a wealth of insight on this issue.
The history of the present illness provides a more comprehensive picture of the trajectory of overweight and obesity. Starting with an inquiry about maternal weight gain during pregnancy and prenatal factors that predispose to obesity, and then moving on to childhood and later adolescent factors that predispose to obesity, the pediatrician or other pediatric health care provider can glean valuable information on causes and therefore management for a particular patient's obesity. These prenatal and postnatal causes are described in detail in the Risk Factors section. Information about the onset of excess weight gain and consistency of weight status over time (including a review of the growth curve and previous weight control attempts) can provide an understanding of what weight status represents for the patient. It can also offer clues as to root causes, necessary diagnostic evaluation, and potential therapeutic targets.
The family history focuses on obesity-related comorbidities and potential genetic causes of obesity in addition to other family health problems. A family history of obesity and obesity- related comorbidities may influence both evaluation and treatment. Although shared environment, SDoHs, and stress can contribute to obesity within the same family, a family history of obesity can also provide a clue to genetic susceptibility to obesity'--especially if the family history includes severe obesity resulting in metabolic and bariatric surgery or severe obesity present in multiple family members and generations.
The medication history should be complete and should include medications associated with weight gain, such as antipsychotics, especially atypical antipsychotics; antidepressants including selective serotonin reuptake inhibitors; steroids; anticonvulsants; antihypertensives; birth control agents, including injected forms; and medications used in diabetes mellitus.
Table 4 summarizes the RoS and provides a valuable framework for investigating a variety of obesity-related conditions.
TABLE 4Special Considerations in the Review of Systems for the Patient With Overweight or Obesity
System . Symptom . Possible Obesity-Related Causes . General Poor or slowed linear growth velocity Endocrinologic contributor (eg, hypothyroidism, Cushing syndrome) Hyperphagia from early childhood, developmental delay, obesity onset under age 5 y, or syndromic features Various genetic etiologies (see Table 2, genetic syndromes associated with obesity) Respiratory Shortness of breath Obesity-related asthma phenotype, deconditioning Snoring, apnea, disordered sleep Obstructive sleep apnea (OSA) Gastrointestinal Asymptomatic vague abdominal pain NAFLD, NASH Heartburn, dysphagia, chest pain, regurgitation Gastroesophageal reflux disease Abdominal pain, enuresis, encopresis, anorexia Constipation Right upper quadrant pain Gall bladder disease Hyperphagia Prader-Willi, other genetic causes Endocrine Polyuria, polydipsia Diabetes mellitus (DM) type 1 or 2 GYN Oligomenorrhea, dysfunctional uterine bleeding Polycystic ovarian syndrome Orthopedic Hip, thigh, or groin pain, painful or uneven gait Slipped capital femoral epiphysis (SCFE) Knee pain SCFE, Blount disease Foot pain Increased weight bearing Back pain Increased weight Proximal muscle wasting Cushing syndrome Mental health Sadness, depression, anhedonia, body dissatisfaction, school avoidance, poor self-image Depression or anxiety, bullying, sexual, physical, or emotional abuse Impulsive eating, distractibility, hyperactivity ADHD Purging, restricting intake, binge-eating, night eating Disordered eating or eating disorders Flat affect Depression or anxiety Urinary Nocturia, enuresis DM, OSA Dermatologic Rash Intertrigo Darkened skin on flexural surfaces Acanthosis nigricans Pustules, abscesses Hidradenitis suppurativa Hirsutism in females PCOS Flesh-colored striae Rapid weight gain Purplish striae Cushing syndrome Skin fold irritation Candida Neurologic Morning headaches OSA Daytime sleepiness OSA Persistent headache Idiopathic intracranial hypertension (IIH) System . Symptom . Possible Obesity-Related Causes . General Poor or slowed linear growth velocity Endocrinologic contributor (eg, hypothyroidism, Cushing syndrome) Hyperphagia from early childhood, developmental delay, obesity onset under age 5 y, or syndromic features Various genetic etiologies (see Table 2, genetic syndromes associated with obesity) Respiratory Shortness of breath Obesity-related asthma phenotype, deconditioning Snoring, apnea, disordered sleep Obstructive sleep apnea (OSA) Gastrointestinal Asymptomatic vague abdominal pain NAFLD, NASH Heartburn, dysphagia, chest pain, regurgitation Gastroesophageal reflux disease Abdominal pain, enuresis, encopresis, anorexia Constipation Right upper quadrant pain Gall bladder disease Hyperphagia Prader-Willi, other genetic causes Endocrine Polyuria, polydipsia Diabetes mellitus (DM) type 1 or 2 GYN Oligomenorrhea, dysfunctional uterine bleeding Polycystic ovarian syndrome Orthopedic Hip, thigh, or groin pain, painful or uneven gait Slipped capital femoral epiphysis (SCFE) Knee pain SCFE, Blount disease Foot pain Increased weight bearing Back pain Increased weight Proximal muscle wasting Cushing syndrome Mental health Sadness, depression, anhedonia, body dissatisfaction, school avoidance, poor self-image Depression or anxiety, bullying, sexual, physical, or emotional abuse Impulsive eating, distractibility, hyperactivity ADHD Purging, restricting intake, binge-eating, night eating Disordered eating or eating disorders Flat affect Depression or anxiety Urinary Nocturia, enuresis DM, OSA Dermatologic Rash Intertrigo Darkened skin on flexural surfaces Acanthosis nigricans Pustules, abscesses Hidradenitis suppurativa Hirsutism in females PCOS Flesh-colored striae Rapid weight gain Purplish striae Cushing syndrome Skin fold irritation Candida Neurologic Morning headaches OSA Daytime sleepiness OSA Persistent headache Idiopathic intracranial hypertension (IIH) Adapted from Krebs et al.14
B.1. Social HistoryA thorough social history is helpful in the evaluation of the child or adolescent with overweight and obesity. An understanding of family living arrangement will identify resources and barriers that are unique to the patient and their family. Factors such as eating routines and schedules; eating at multiple households; and eating environments, such as family meals, eating at a table, eating with or without screens, are all important elements in assessing contributors to and potential treatment targets for excess weight gain. Determining a family's relationship with food is also important (eg, Is food a common reward? How is food used in celebrations? Is there pressure for the child to eat?).
Because overweight and obesity tends to cluster in social groups as well as families,374 discussions of neighborhood, school, and friend groups can guide pediatricians, other PHCPs, and families to productive areas for treatment. Social history can heighten an awareness of, and provide insight into, patients who are most exposed to negative SDoHs. Given that inequities exist in obesity risk factors, an SDoH evaluation is important to increase awareness and provide insight in identifying patients who are more vulnerable to obesity. Assessment of SDoHs is also important to contextualize the patient's and family's treatment challenges. Standardized tools for use in primary care exist and include the Safe Environment for Every Kid model375 and the Accountable Health Communities Health-Related Social Needs Screening Tool.376
Being alert to and recognizing SDoHs are the initial steps in trauma-informed care (TIC). ACEs can have a profound impact on health over a lifetime and, as noted, include stressors as diverse as harsh parenting, food insecurity, and parental incarceration. These factors can trigger physiologic abnormalities that increase a patient's risk for obesity, cancer, and numerous other diseases. TIC is characterized by screening and recognition of these ACEs, responding to them, and working to prevent reexposure to trauma. Initial recognition of the importance of ACEs on health occurred in the field of adult obesity treatment. The importance of TIC and addressing ACEs in pediatric obesity management is ongoing.68,377,378
B.2. Nutrition and Physical Activity HistoryGathering a nutrition history and physical activity history often takes the form of a patient and/or caregiver completing a healthy habits survey before seeing the pediatrician or other pediatric health care provider (Table 5). Electronic health records, waiting room kiosks, and emailed previsit surveys can all be used to help gather this information.
TABLE 5Assessment Components
Dietary Intake Can Be Addressed by Assessing the Following: . Physical Activity Can Be Addressed by Assessing Physical Literacy379 : . Eating outside the home Physical literacy: The motivation, confidence, physical competence, knowledge, and understanding to engage in age-appropriate physical activity for a lifetime. Routine ambient activity is built into daily living. Consumption of sweet drinks Sedentary time, especially recreational screen time. Portion size Moderate activity levels, characterized by a mild increase in pulse and respiratory rate but still able to talk. Meal habits, including skipping meals Vigorous activity levels, characterized by increased breathing, elevated heart rate, or sweating. Snack habits Fruit and vegetable consumption Dietary Intake Can Be Addressed by Assessing the Following: . Physical Activity Can Be Addressed by Assessing Physical Literacy379 : . Eating outside the home Physical literacy: The motivation, confidence, physical competence, knowledge, and understanding to engage in age-appropriate physical activity for a lifetime. Routine ambient activity is built into daily living. Consumption of sweet drinks Sedentary time, especially recreational screen time. Portion size Moderate activity levels, characterized by a mild increase in pulse and respiratory rate but still able to talk. Meal habits, including skipping meals Vigorous activity levels, characterized by increased breathing, elevated heart rate, or sweating. Snack habits Fruit and vegetable consumption There are many additional tools to assess nutrition and physical activity. These include: 24-hour recalls, electronic and written food diaries, telephone- and text-prompted diaries, and various smartphone applications that track food intake. Pedometers and other wearable activity monitors can assist with physical activity assessment. Pediatricians and other PHCPs may find some of these applications and tools at their disposal.
Cultural dietary habits, limited English proficiency, and limited literacy levels may influence the accuracy of the tool used. In comparison with adults, physical activity assessment is challenging, because children and adolescents are less reliable in performing recall of performed activity.379 And, because of the greater burden of overweight and obesity on people of certain race and ethnicities, these differences should be acknowledged and any limitations should be mitigated. An example of a healthy habit survey can be found at https://mainehealth.org/-/media/lets-go/files/childrens-program/pediatric-family-practices/full-healthcare-toolkit.pdf. Sensitivity to cultural, economic, and literacy barriers is necessary with the nutrition history and physical activity history, as with other assessments. Furthermore, the presence of eating disorders, obsessive-compulsive disorder, and other mental health conditions may preclude the use of certain tools that require intensive tracking.
B.3. Assessments for Behavioral Health and Disordered Eating ConcernsBecause rates of behavioral health illnesses are greater in patients with obesity than other patients, it is important for pediatricians and other PHCPs to evaluate the emotional health of children with overweight and obesity.380 A common comorbidity of obesity in children is weight-based bullying and teasing.28,43 If a patient responds affirmatively when asked if they have ever been teased or bullied about their weight, pediatricians and other PHCPs can consider provision of resources (such as those found at stopbullying.gov ) to the child and parent as well as local counseling referral.
Various in-office tools can be used to address behavioral health disorders seen in greater prevalence in patients with obesity. Overall behavioral functioning can be assessed through the Pediatric Symptom Checklist's parent or teen versions.381 Evaluation for depression can be conducted through the teen version of the Patient Health Questionnaire 2- or 9- question version.382 Assessment of anxiety by tests such as the General Anxiety Disorder assessment or the Screen for Child Anxiety Related Disorders assessment.383,384 In addition, ADHD can be assessed by the Vanderbilt ADHD Rating Scales.385,386
As discussed in the AAP clinical reports, ''Preventing Obesity and Eating Disorders in Adolescents''387 and ''Identification and Management of Eating Disorders in Children and Adolescents,''388 adolescents with obesity may engage in unhealthy practices to lose weight. These practices include skipping meals, using diet pills or laxatives, and inducing vomiting. Therefore, it is important for pediatricians and other PHCPs to evaluate the adolescent with overweight or obesity for these and other related behaviors, and to examine the growth chart for evidence of more rapid than expected decline in BMI.
As noted in the clinical reports above, pediatricians ''should be knowledgeable about the variety of risk factors and early signs and symptoms of eating disorders in both male and female children and adolescents. Pediatricians should evaluate patients for disordered eating and unhealthy weight-control behaviors at annual health supervision visits. Pediatricians should evaluate weight, height, and BMI by using age- and sex-appropriate charts, assess menstrual status in girls, and recognize the changes in vital signs that may signal the presence of an eating disorder.''388 For more information on this evaluation, please see the AAP clinical report.388
B.3.a. Physical EvaluationA complete physical examination is necessary in the patient with overweight and obesity because of the disease's complex and multisystem effects. The 2015 article ''Physical Examination Findings Among Children and Adolescents with Obesity: An Evidence-Based Review,'' by Armstrong et al provides a thorough explanation of special considerations for patients with or at-risk for weight-related illness.365 Pediatricians and other PHCPs are encouraged to reference this AAP-published review. The physical exam also requires focused attention to certain obesity-related findings related to physical evaluation (Table 6). These include:
Vital signs such as heart rate, pulse, and blood pressure should be taken; blood pressure should be measured accurately with an appropriately sized cuff.87
Other important signs: short stature may be a sign of a genetic or endocrinologic cause for overweight and obesity. Flat affect may indicate depression, and anxious mood may indicate anxiety. Attention-seeking may be a signal for underlying distress over overweight and obesity. Syndromic features may also offer indications of the presence of an underlying genetic cause for obesity.
Skin examination should be performed to look for intertrigo and hidradenitis suppurativa associated with excess skin folds as well as acanthosis nigricans associated with insulin resistance. Flesh-colored striae may be seen on the abdominal wall and/or thighs as an indication of rapid weight gain. The combination of purplish abdominal striae, slowed linear growth, cervicodorsal fat accumulation, proximal muscle wasting, full facies, and hypertension should prompt evaluation for Cushing syndrome.
Examination of the head, ears, eyes, nose, and throat should occur to look for papilledema associated with pseudotumor cerebri, tonsillar hypertrophy associated with sleep apnea and goiter associated with thyroid disease.
A cardiopulmonary examination should be performed to look for a spectrum of impairment that can be associated with overweight and obesity. Simple deconditioning may present with tachypnea, dyspnea, or tachycardia. Wheezing may be suggestive of intrinsic or exercise-induced asthma. Tonsillar hypertrophy may be a sign that increases the likelihood of sleep apnea. In more severe obesity, congestive heart failure may present with basilar rales or other signs of more significant cardiac disease.
Liver size should be assessed by palpation and auscultation. If present, right upper quadrant tenderness should be noted.
Genito-urinary examination should be performed to assess pubertal status and genital appearance looking for signs of endocrine or genetic abnormality. Hypogonadism may be present in certain syndromes associated with obesity or be a result of obesity.389,390 More commonly, biological males with abdominal obesity may have a suprapubic fat pad obscuring the penis, a so-called ''vanishing penis,'' and need instruction on proper voiding and genital hygiene to avoid development of skin breakdown.
Neurologic evaluation may reveal papilledema, as described above, as well as paresthesia.
Orthopedic findings associated with obesity include abnormal gait, knee tenderness, pes planus, genu valgum (''knock knees''), genu varum (leg bowing), foot pain, back tenderness, and hip pain. Obesity may also make detection of scoliosis more difficult.
Neuromuscular evaluation of obesity, as with the orthopedic evaluation of obesity, includes assessment of bone structure, gait and pain, but also includes assessment for balance, coordination, lower limb muscle strength, flexibility and motor skill proficiency. Patients with obesity frequently experience impairment in these areas. Such limitations can result in further reduction of ability to engage in physical activity.391
TABLE 6Physical Examination Findings in Children and Adolescents With Obesity
. Physical Examination Finding . Definition . Other Causes and Differential . Vital signs Hypertension SBP or DBP '‰¥ 95th percentile on at least 3 readings Numerous, including essential, stress-induced, renal parenchymal or vascular disease, cardiovascular disorders, obstructive sleep apnea syndrome, substance abuse or medication side effect, pheochromocytoma, anemia, hyperthyroidism, Cushing syndrome, Williams syndrome, Turner syndrome Increased HR Heart rate above upper limit of normal for age Numerous, including fever, anemia, drugs, anxiety, pain, arrhythmia, myocarditis, substrate deficiency, hypovolemic shock, sepsis, anaphylaxis, toxic exposure, hyperthyroidism, Kawasaki disease, acute rheumatic fever, pheochromocytoma Anthropometric Changes in height velocity Early height velocity increase True pattern characteristic of obesity, but early height increases can also be: familial tall stature, precocious puberty, gigantism, pituitary gland tumor Changes in weight gain Early weight gain before age 5 y Genetic causes, overfeeding Earlier onset of peak height velocity Slowing of height can be attributable to medications, inflammatory bowel disease, hypothyroidism, hypercortisolism, dysplastic or genetic syndrome, constitutional delay, growth hormone deficiency Slowing of height age 8''18 y HEENT Papilledema Edema of the optic disc secondary to increased intracranial pressure (Frisen scale) Intracranial mass lesion, hydrocephalus, cerebral venous thrombosis, medications, autoimmune disorders, anemia, and cranial venous outflow abnormalities Dental caries White, brown, or black spots (noncavitary) or eroded areas of enamel or dentin (cavitary) Developmental disease of the tooth and gum, trauma, infection Tonsillar hypertrophy Tonsils occupy at least 50% of the oropharynx (Brodsky classification 3+ and 4+). Infectious causes Chest Gynecomastia >2 cm of breast tissue in biological males Hyperaromatase syndrome; hypogonadism, hyperprolactinemia, chronic liver disease, and medications, particularly H2 antagonists Cervicodorsal hump Fibrous fatty tissue over the upper back and lower neck Endogenous (Cushing syndrome) or exogenous corticosteroid exposure, adrenal carcinoma, adrenal adenoma; HIV with secondary hyperinsulinemia Gastrointestinal Liver enlargement (hepatomegaly) Liver span >5 cm in 5-y-olds and 15 cm in adults or liver edge palpable below the right costal margin by >3.5 cm in adults or >2 cm in children Multiple, including hepatitis, storage disorders, infiltrative, impaired outflow, and biliary tract disorders Genitourinary Buried penis Suprapubic fat accumulation leading to the appearance of a shortened penile shaft Trapped penis, webbed penis, and micropenis Musculoskeletal Gait Collapse into hip (''waddle''), Trendelenburg or antalgic gait (external rotation or out-toeing on affected side) Arthritis, SCFE Lordosis Trunk sway associated with postural adaptations Spondylolisthesis, achondroplasia, muscular dystrophy, other genetic conditions Hip pain and/or limp Knee or hip pain, subacute onset, pain with external rotation of hip Multiple problems present with chronic hip, knee, or thigh pain including slipped capital femoral epiphysis (SCFE), growing pains, femoral neck fracture, groin injury, Perthes disease, osteonecrosis associated with systemic disease, juvenile idiopathic arthritis, reactive arthritis, overuse injuries, chondrolysis, tumors, osteitis pubis Genu varum or valgum Genu varum (bow legs) Tibia vara (Blount disease), rickets, skeletal dysplasia, celiac sprue, collagen disorder and hypermobility syndromes (eg, Marfan syndrome), Loeys-Dietz, classic Ehler Danlos syndrome)15 Genu valgum (knock-kneed) Physiologic in children under 6 y; in older children and adolescents, consider postaxial limb deficiency, neoplasms, genetic and metabolic disorders, neurofibromatosis, and vitamin D''resistant rickets Pes planus Rigid versus flexible, sometimes with pain Posterior tibial tendon insufficiency, tarsal coalition, congenital vertical talus, rheumatoid arthritides, trauma, neuropathy Skin Acanthosis AN is thickened and darker skin, occasionally pruritic at the nape of the neck (99%), axillae (73%) and, less commonly, groin, eyelids, dorsal hands, and other areas exposed to friction Medication side effect, and uncommonly, visceral malignancy. Hirsutism or acne Hirsutism: familial, Cushing syndrome, thyroid disorders Acne: physiologic, folliculitis, rosacea Striae Linear, usually symmetrical smooth bands of atrophic skin that initially appear erythematous, progressing to purple then white; perpendicular to the direction of greatest tension in areas with adipose tissue Pregnancy, Cushing syndrome, and topical corticosteroid use Intertrigo Macerated, erythematous plaques in skin folds Inflammatory diseases, metabolic disorders, malignancies (rare in pediatrics), and various infections by site Pannus Excess skin and subcutaneous fat below the umbilicus Pregnancy, malignancy . Physical Examination Finding . Definition . Other Causes and Differential . Vital signs Hypertension SBP or DBP '‰¥ 95th percentile on at least 3 readings Numerous, including essential, stress-induced, renal parenchymal or vascular disease, cardiovascular disorders, obstructive sleep apnea syndrome, substance abuse or medication side effect, pheochromocytoma, anemia, hyperthyroidism, Cushing syndrome, Williams syndrome, Turner syndrome Increased HR Heart rate above upper limit of normal for age Numerous, including fever, anemia, drugs, anxiety, pain, arrhythmia, myocarditis, substrate deficiency, hypovolemic shock, sepsis, anaphylaxis, toxic exposure, hyperthyroidism, Kawasaki disease, acute rheumatic fever, pheochromocytoma Anthropometric Changes in height velocity Early height velocity increase True pattern characteristic of obesity, but early height increases can also be: familial tall stature, precocious puberty, gigantism, pituitary gland tumor Changes in weight gain Early weight gain before age 5 y Genetic causes, overfeeding Earlier onset of peak height velocity Slowing of height can be attributable to medications, inflammatory bowel disease, hypothyroidism, hypercortisolism, dysplastic or genetic syndrome, constitutional delay, growth hormone deficiency Slowing of height age 8''18 y HEENT Papilledema Edema of the optic disc secondary to increased intracranial pressure (Frisen scale) Intracranial mass lesion, hydrocephalus, cerebral venous thrombosis, medications, autoimmune disorders, anemia, and cranial venous outflow abnormalities Dental caries White, brown, or black spots (noncavitary) or eroded areas of enamel or dentin (cavitary) Developmental disease of the tooth and gum, trauma, infection Tonsillar hypertrophy Tonsils occupy at least 50% of the oropharynx (Brodsky classification 3+ and 4+). Infectious causes Chest Gynecomastia >2 cm of breast tissue in biological males Hyperaromatase syndrome; hypogonadism, hyperprolactinemia, chronic liver disease, and medications, particularly H2 antagonists Cervicodorsal hump Fibrous fatty tissue over the upper back and lower neck Endogenous (Cushing syndrome) or exogenous corticosteroid exposure, adrenal carcinoma, adrenal adenoma; HIV with secondary hyperinsulinemia Gastrointestinal Liver enlargement (hepatomegaly) Liver span >5 cm in 5-y-olds and 15 cm in adults or liver edge palpable below the right costal margin by >3.5 cm in adults or >2 cm in children Multiple, including hepatitis, storage disorders, infiltrative, impaired outflow, and biliary tract disorders Genitourinary Buried penis Suprapubic fat accumulation leading to the appearance of a shortened penile shaft Trapped penis, webbed penis, and micropenis Musculoskeletal Gait Collapse into hip (''waddle''), Trendelenburg or antalgic gait (external rotation or out-toeing on affected side) Arthritis, SCFE Lordosis Trunk sway associated with postural adaptations Spondylolisthesis, achondroplasia, muscular dystrophy, other genetic conditions Hip pain and/or limp Knee or hip pain, subacute onset, pain with external rotation of hip Multiple problems present with chronic hip, knee, or thigh pain including slipped capital femoral epiphysis (SCFE), growing pains, femoral neck fracture, groin injury, Perthes disease, osteonecrosis associated with systemic disease, juvenile idiopathic arthritis, reactive arthritis, overuse injuries, chondrolysis, tumors, osteitis pubis Genu varum or valgum Genu varum (bow legs) Tibia vara (Blount disease), rickets, skeletal dysplasia, celiac sprue, collagen disorder and hypermobility syndromes (eg, Marfan syndrome), Loeys-Dietz, classic Ehler Danlos syndrome)15 Genu valgum (knock-kneed) Physiologic in children under 6 y; in older children and adolescents, consider postaxial limb deficiency, neoplasms, genetic and metabolic disorders, neurofibromatosis, and vitamin D''resistant rickets Pes planus Rigid versus flexible, sometimes with pain Posterior tibial tendon insufficiency, tarsal coalition, congenital vertical talus, rheumatoid arthritides, trauma, neuropathy Skin Acanthosis AN is thickened and darker skin, occasionally pruritic at the nape of the neck (99%), axillae (73%) and, less commonly, groin, eyelids, dorsal hands, and other areas exposed to friction Medication side effect, and uncommonly, visceral malignancy. Hirsutism or acne Hirsutism: familial, Cushing syndrome, thyroid disorders Acne: physiologic, folliculitis, rosacea Striae Linear, usually symmetrical smooth bands of atrophic skin that initially appear erythematous, progressing to purple then white; perpendicular to the direction of greatest tension in areas with adipose tissue Pregnancy, Cushing syndrome, and topical corticosteroid use Intertrigo Macerated, erythematous plaques in skin folds Inflammatory diseases, metabolic disorders, malignancies (rare in pediatrics), and various infections by site Pannus Excess skin and subcutaneous fat below the umbilicus Pregnancy, malignancy Adapted from Table 4 and used with permission by Armstrong et al. et al.365 HEENT, head, eye, ear, nose, and throat examination.
C. Assessment of Patient Readiness to Change''Readiness to change'' refers to a patient's interest in changing a behavior (Importance) and their belief that they can bring about this change (Confidence). This evaluation is important when discussing healthy nutrition and activity with patients who have BMI in the healthy range; it assumes even greater importance with a patient and family who are struggling with overweight, obesity, or severe obesity where health concerns are elevated. This evaluation of readiness to change is central to deciding how and when to embark on obesity treatment. Motivational interviewing (MI), discussed in the Treatment section, provides a useful framework for evaluating and discussing a patient's readiness to change.392
Readiness to change, perceptions of weight status, health challenges, nutrition habits, and access to physical activity are influenced by familial, cultural, and socioeconomic factors. For this reason, understanding these factors is beneficial in forging a productive relationship with children and their families. It is also important to remember that patients and families care about their health and their child's health regardless of race, ethnicity, and/or SES. Caregivers should be reminded that the presence of overweight or obesity is NOT an indication of poor parenting.
D. Laboratory EvaluationBased on BMI classification'--and augmented by findings in the history, physical examination, and patient readiness to change assessments'--laboratory evaluation of the patient represents the next important step in evaluation. This laboratory evaluation and its connection to the delineation of more common comorbid illnesses is described in the Comorbidities section. Other laboratory evaluations can be performed as clinically indicated.
X. Comorbidities of Pediatric Overweight and Obesity Introduction to ComorbiditiesChildren and adolescents with obesity have increased prevalence of comorbidities, and a greater risk for obesity in adulthood, morbidity, and premature death.36,393''395 The risk for obesity-related comorbidities increases with age and severity of obesity and prevalence varies by ethnicity and race.396 For example, there is a higher prevalence of NAFLD in Hispanic children and a lower prevalence in Black children.397,398 AI/AN, Black, and Hispanic youth have higher prevalence of prediabetes and diabetes, compared with white youth.399,400 Pediatricians and other PHCPs need to recognize that the association between ethnicity and race and obesity and related comorbidities in both children and adults likely reflects the impact of epigenetic, social, and environmental factors, such as SDoHs, low SES, exposure to structural racism, neighborhood deprivation, and inadequate built environment in these subpopulations.399,401''408
Obesity and related comorbidities should be evaluated concurrently with an obesity-specific history and review of systems, family and social history, physical examination, and laboratory testing. This evaluation provides pediatricians and other PHCPs with an opportunity to assess for both the etiology and complications of obesity (see the Evaluation section). Pediatricians and other PHCPs need to take into consideration patient-specific factors that may increase the risk for comorbidities. For example, prediabetes and diabetes occur more frequently among children who are 10 years and older, are in early pubertal stages, or have a family history of T2DM.399,400,409
There is compelling evidence that obesity increases the risk for comorbidities and that weight loss interventions can improve comorbidities.80,396,410 Thus, the recommendations for comorbidity evaluation uses input from the technical report on comorbidities for the prevalence, age, and weight category396 associated with comorbidities, and the technical report on treatment of obesity intervention outcomes on dyslipidemia, prediabetes and diabetes, HTN, and NAFLD.80 Studies on optimal age, frequency, benefits, and harms of evaluating for comorbidities for children with obesity remain limited. To address when to begin evaluation, what tests to obtain, and frequency of testing, input from other clinical practice guidelines was also considered.87,88,90,411,412
The KASs in this section are limited to comorbidities addressed in the technical reports and/or guidelines from professional organizations or societies. Consensus recommendations are included to cover the breadth of relevant comorbidities associated with pediatric overweight and obesity and to provide context for implementation. Each KAS or consensus recommendation is drawn from the technical reports, an extensive review of the literature, and clinical guidelines or position statements from premier organizations or professional societies in the field. The inclusion criteria for the guidelines and position statements are in Table 7. When there was more than 1 guideline from the same organization or professional society, the most recent guideline was given precedence. Other considerations for inclusion were guidelines supported by a technical report or endorsed by the AAP.
TABLE 7Inclusion Criteria for Guidelines or Position Statements Reviewed for Comorbidities
Inclusion Criteria . ' Clinical guideline or position statement was published in the last 15 y. ' The organization or professional society is recognized as the leading scientific expert in the field. ' The clinical guideline or position statement uses an established grading matrix to assess the evidence. Inclusion Criteria . ' Clinical guideline or position statement was published in the last 15 y. ' The organization or professional society is recognized as the leading scientific expert in the field. ' The clinical guideline or position statement uses an established grading matrix to assess the evidence. The following section is divided into 3 sections:
Overall KASs for Laboratory Evaluation of Obesity-Related Comorbidities for children with overweight and obesity (KASs 3''3.1);
Concurrent Treatment of Obesity and Obesity-Related Comorbidities (KAS 4); and
Specific Recommendations for Evaluation for Common Comorbidities (KASs 5''8) and Guidelines for Other Comorbidities.
Recommendations for reevaluation and initial management of common comorbidities are in Appendix 3.
A. Laboratory Evaluation of Obesity-Related Comorbidities for Children With Overweight and ObesityThe 2007 AAP Expert Committee on Child Obesity recommended laboratory evaluation for children with obesity for dyslipidemia, prediabetes, and NAFLD starting at 10 years by obtaining a fasting lipid panel, fasting glucose, alanine transaminase, and aspartate transaminase levels every 2 years.92 For children with overweight, the recommendation was only for a fasting lipid panel unless additional risk factors were present (such as family history of obesity-related diseases, elevated BP, elevated lipid levels, or tobacco use).14 KASs 3 and 3.1 build on the 2007 recommendations'--taking into account recent studies, guidelines, and pediatrician and other PHCP behaviors'--while balancing the harm versus benefit of evaluation at the individual and population levels.
Children '‰¥10 YearsTo encourage a pragmatic and efficient evaluation strategy, KAS 3 and 3.1 recommend that, for children with obesity, evaluation for lipid abnormalities, abnormal glucose metabolism, and liver dysfunction be obtained at the same time and begin at age 10 years. The expectation is that pediatricians and other PHCPs will find it easier to adhere to recommendations when all tests are obtained at the same time. They may order fasting laboratory tests for the evaluation, because a fasting lipid panel is still the recommended test to evaluate for dyslipidemia for children and adolescents with overweight and obesity (see the dyslipidemia section, below, for additional information).
Children 2''9 YearsFor children 2 to 9 years of age with obesity, evaluation for lipid abnormalities may be considered (KAS 3.1). This recommendation aligns with the 2011 National Heart Lung Blood Institute (NHLBI) Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents.86 In population-based studies, lipid abnormalities occur in children younger than 10 years, with higher rates among children with obesity.80,395,417 High triglycerides (TG) and low high-density lipoprotein (HDL) levels (the typical pattern of dyslipidemia that occurs with obesity) have been reported in children with obesity as young as 3 years.395
As the risk profile for NAFLD and diabetes mellitus in children younger than 10 years is lower (especially in the absence of severe obesity), obtaining tests for abnormal glucose metabolism or liver function is not universally recommended for this population.88,90,415,418
Detailed and specific recommendations are provided in the following sections on dyslipidemia, prediabetes and diabetes mellitus, and NAFLD.
Children With OverweightFor children 10 years and older with overweight, evaluating for lipid abnormalities is recommended in the absence of additional risk factors (KAS 3).86,412 For evaluation of type 2 diabetes mellitus (T2DM), additional risk factors need to be considered, which include: family history, history of gestational diabetes, signs of insulin resistance (such as acanthosis nigricans), and use of obesogenic psychotropic medication.90,358,419 For NAFLD, additional risk factors include family history of NAFLD, central adiposity, signs of insulin resistance, prediabetes or diabetes mellitus, dyslipidemia, and sleep apnea.88
Considerations for TestingAmong children with obesity, there is clustering of comorbidities, a higher risk profile for more severe disease and/or progression than may be commonly or previously recognized.396,421''423 For example, regardless of the definition used for metabolic syndrome, the prevalence is 0% to 4.7% among children with healthy weight and increases to 14.5% to 35% among children and adolescents with obesity.396 In a cohort of 675 children with NAFLD from 12 clinical centers across the United States, one-third had T2DM or prediabetes,422 2 conditions that have significant morbidity in childhood. Adolescents with severe obesity'--who have comparable BMI and metabolic profiles as adults'--are more likely to present with advanced liver damage and severe systemic inflammation, suggesting that pediatric NAFLD may be more aggressive.424 Similarly, in T2DM, children have a more rapid rate of progression of islet β cell failure and dysglycemia compared with adults.425''427
Concerns about overtesting and cost are warranted but are balanced by the significant impact of obesity and comorbidities on morbidity and mortality. Almost half (43%) of children and adolescents with obesity have at least 1 abnormal lipid level,417 and 1 in 5 US adolescents have prediabetes,423 which are both precursors for future cardiometabolic disease. Although the prevalence of T2DM in children is low, at approximately 1%, the incidence has increased from 9 in 100 000 in 2002 to 13.8 in 100 000 in 2015, a worrisome annual percentage change of 4.8%.399 NAFLD is considered one of the most common chronic liver diseases in children88,397,398,428 and occurs more frequently in male children, older children, and Hispanic children.397,429
Finally, although obesity prevalence rates continue to rise, the rate of evaluating for obesity or comorbidities in practice is low'--suggesting that any concerns about overtesting are likely to be more theoretical than real.3,394,430''432
See Appendix 3 for information on frequency of testing for comorbidities.
B. Concurrent Treatment of Obesity and Obesity-Related ComorbiditiesThere is substantial evidence to support concurrent treatment of obesity and comorbidities to achieve weight loss, avoid further weight gain, and improve obesity-related comorbidities. The majority of studies reviewed in the technical report on comorbidities396 demonstrate an association between overweight and/or obesity, severity of obesity, and higher prevalence of comorbidities. Studies also report improvement in comorbidities with intensive lifestyle treatment, weight loss medication, and/or bariatric surgery.80,126,438 Specifically, cardiometabolic markers improved significantly in children with obesity who underwent intensive pediatric obesity treatment of 3 to 6 months, which provides an opportunity for clinicians to emphasize health outcomes of lifestyle management.80,410,439 Interventions that meet the intensity or ''dose'' threshold of 26 hours or more over 2 to 12 months can lead to clinically significant improvements in BMI,79 and decreases in BMI can lead to clinically meaningful improvements in comorbidities.440''444
Guidelines for dyslipidemia, T2DM, NAFLD, and HTN all recommend lifestyle treatment of the primary management of the comorbidity.86''88,90,414,415,419,420 Although the specific dietary recommendation may differ slightly (eg, CHILD-1 and 2 for dyslipidemia, low-glycemic diet for prediabetes, limiting sugary beverages for NAFLD, and a Dietary Approaches to Stop Hypertension [DASH] Diet for elevated BP), there is overlap between the dietary recommendations and all comorbidities improve with weight stabilization and reduction.80,410,436
Children are often seen at least once a year for WCCs, at which the pediatrician or other pediatric health care provider reviews the growth chart, provides anticipatory guidance on growth, feeding, nutrition, sedentary screen time, and participation in physical activity. At a minimum, the WCC can include evaluation for comorbidities for children with overweight and obesity, and anticipatory guidance on risk for comorbidities with increasing BMI or obesity. It may be helpful for pediatricians and other PHCPs to include the diagnosis of obesity to the problem list to heighten awareness and remind providers to address weight concerns at subsequent clinic encounters.445,446 In a large adult study, documentation of an obesity diagnosis on a problem list was independently predictive of at least 5% weight loss.445 To avoid any harmful effects related to potential weight bias and stigma, however, pediatricians and other PHCPs need to be mindful of how this diagnosis is conveyed to the child and/or caregiver.28
There may also be a potential benefit for improved weight outcomes with comorbidity evaluation. In adult studies, identifying obesity-related comorbidities has been shown to be a motivating factor to address weight concerns.447''449 The evidence in pediatrics is, however, sparse and inconsistent.434,450 Adolescents identify a desire for improved health as a primary motivation for change.451 Another study analyzed clinic records of 4000 youth aged 10 to 18 years with overweight or obesity in an academic primary care network and found that youth who were evaluated (n = 2815) with a glycosylated hemoglobin (HbA1c) had a decrease in BMI-z slope per year after the HbA1c test compared with similar peers (n = 2087) who had not been evaluated. Among those who had an HbA1c test, the decline in BMI-z slope per year was greater for youth with HbA1c in the prediabetes-range.434 An earlier study with a similar pediatric clinic population but a smaller sample size (n = 128) did not find a positive effect on BMI change following cholesterol evaluation.450 There is a need for more studies before definitive conclusions can be reached about whether evaluating families for comorbidities increases engagement, adoption of healthy choices, and weight loss or has unintended negative effects.
C. Specific Guidelines for Initial Evaluation for ComorbiditiesThe following sections provide specific recommendations on initial comorbidity evaluation. Guidance on repeat evaluation and initial comorbidity management may be found in Appendix 3.
C1. DyslipidemiaChildren and adolescents with overweight and obesity have increased prevalence of abnormal lipid levels.396 The combination of hypertriglyceridemia and low high-density lipoprotein (HDL) levels, driven largely by underlying insulin resistance, is the most common type of dyslipidemia seen with overweight and obesity. Children and adolescents with overweight and obesity can also have elevated total cholesterol and low-density lipoprotein (LDL) levels.86 NHANES data from 2011 to 2014 showed that prevalence of abnormal lipid level was 3 times higher among children and adolescents with obesity, compared with those with a healthy BMI (43% vs 14%).417
Studies indicate that cardiovascular risk factors track from childhood into adult life and that lifestyle treatments can improve outcomes with respect to these risk factors.393,413,452 Being aware of the association of these ''silent'' cardiovascular comorbidities with overweight and obesity'--as well as their persistence into adulthood with potential serious health consequences'--obliges pediatricians and other PHCPs to perform laboratory testing, educate patients and families about the long-term risks of cardiovascular disease and provide nutrition and activity counseling.
This KAS is supported by both the 2011 NHLBI Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents and 2018 American Heart Association and American College of Cardiology Guidelines, which recommend evaluation for early risk of atherosclerotic cardiovascular disease and counseling on risk-reduction behaviors in children and adolescents.86,411 Evaluation for dyslipidemia with obesity is recommended for younger children, as well as for children 10 years and older. Although data are limited in young children, 1 population-based study showed that 10% of children with obesity aged 3 to 5 years have elevated TG and low HDL levels.395
In addition to obesity, other risk factors for dyslipidemia include cigarette use, HTN, diabetes, and a family history of cardiovascular disease in a first- or second-degree relative ('‰¤55 years for males and '‰¤65 years for females) with a history of myocardial infarction, sudden death, or HTN.86,437 All of these conditions warrant laboratory evaluation and may help guide clinical decisions for assessment of dyslipidemia in younger children. Additionally, awareness of an association of social factors, specifically ACEs, with cardiovascular risk factors is important.455
C.1.a. Laboratory Tests for Diagnosis of DyslipidemiaThe NHLBI expert panel recommends a fasting lipid panel for evaluation of dyslipidemia for children with overweight and obesity.86 Because dietary fats and carbohydrates (particularly simple sugars) increase serum TG concentrations, 8 to 12 hours of fasting before testing is recommended.456 Given that a combination of high TG and low HDL cholesterol is the most common pattern of dyslipidemia observed in children with overweight and obesity, the recommendation to obtain a fasting lipid panel is important, because nonfasting TG levels will not be accurate.86
For practical purposes, a nonfasting lipid panel using the non-HDL level may be easier to obtain for routine evaluation in the primary care setting. The non-HDL level is the total cholesterol minus the HDL cholesterol level. If the non-HDL cholesterol level is abnormal (non-HDL '‰¥145 mg/dL) and/or the HDL level is <40 mg/dL, a fasting lipid panel needs to be obtained for diagnosis.412 The nonfasting lipid panel is recommended for all children 9 to 11 years of age to evaluate for familial hypercholesterolemia.86 Estimates are that approximately 25% of children would be referred for a fasting lipid panel because of elevated non-HDL lipid evaluation.457 Because of the elevated risk of lipid abnormality among youth with overweight and obesity, a fasting lipid panel is recommended. See the implementation guide for additional information.
The cut-off criteria for lipids in the 2011 NHLBI guidelines are the same across different age groups, except for triglycerides, as indicated in Table 8.
TABLE 8NHLBI Criteria for Lipid Testing Results
Lipid Category . Low (mg/dL) . Acceptable (mg/dL) . Borderline High (mg/dL) . High (mg/dL) . Total cholesterol '-- <170 170''199 '‰¥200 LDL cholesterol '-- <110 110''129 '‰¥130 HDL cholesterol <40 >45 '-- Triglycerides 'ƒ0''9 y '-- <75 75''99 '‰¥100 'ƒ10''19 y '-- <90 90''129 '‰¥130 Non-HDL cholesterol '-- <120 120''144 '‰¥145 Lipid Category . Low (mg/dL) . Acceptable (mg/dL) . Borderline High (mg/dL) . High (mg/dL) . Total cholesterol '-- <170 170''199 '‰¥200 LDL cholesterol '-- <110 110''129 '‰¥130 HDL cholesterol <40 >45 '-- Triglycerides 'ƒ0''9 y '-- <75 75''99 '‰¥100 'ƒ10''19 y '-- <90 90''129 '‰¥130 Non-HDL cholesterol '-- <120 120''144 '‰¥145 Adapted from the Expert Panel on Integrated Guidelines for Cardiovascular Health.86 '--, not applicable.
See Appendix 3 for information on frequency of laboratory testing and information about initial management of dyslipidemia.
C.2. Prediabetes and Type 2 Diabetes MellitusT2DM is now increasingly diagnosed in the pediatric population. Between 2002 and 2015, the incidence of T2DM among 10- to 19-year-olds in the United States increased from 9.0 to 13.8 per 100 000.290,399,458 Based on the 2005 to 2016 NHANES, 1 in 5 adolescents (12''18 years) have prediabetes.423 Although uncommon, T2DM has been diagnosed in children younger than 10 years, some as young as 4 years of age.459,460 For this reason, pediatricians and other PHCPs should consider risk factors and symptoms of altered glucose metabolism in all ages (eg, polydipsia, polyphagia, polyuria, blurred vision, unexplained weight loss).
Because obesity is a strong predictor for developing prediabetes and T2DM,423,461,462 pediatricians and other PHCPs need to have an increased index of suspicion when caring for children with obesity, especially in the presence of other risk factors (Table 9).90,408,414,415,463 Both genetics and SDoHs account for some of the racial and ethnic disparities observed in the incidence of T2DM.401,408
KAS 2. Pediatricians and other PHCPs should evaluate children 2 to 18 y of age with overweight (BMI '‰¥ 85th percentile to <95th percentile) and obesity (BMI '‰¥ 95th percentile) for obesity-related comorbidities by using a comprehensive patient history, mental and behavioral health screening, SDoH evaluation, physical examination, and diagnostic studies.
Aggregate Evidence Quality . Grade B . Benefits Early detection and treatment can reduce future serious sequelae, detection of comorbidity may motivate treatment engagement. Risks, harm, costs Increased anxiety, overtesting, time needed for counseling, potential false-negative or false-positive tests, costs of tests. Benefit-harm assessment Potential to identify and manage comorbidities that have short and long term serious sequelae exceeds potential harm especially for high-risk patients. Intentional vagueness Frequency of evaluation, patient level of risk. Role of patient preferences Family history, families' concern about the test, ease and accessibility for testing must be considered. Exclusions '‰¤24 mo old. Strengths Strong recommendation. Key references 80, 365 Aggregate Evidence Quality . Grade B . Benefits Early detection and treatment can reduce future serious sequelae, detection of comorbidity may motivate treatment engagement. Risks, harm, costs Increased anxiety, overtesting, time needed for counseling, potential false-negative or false-positive tests, costs of tests. Benefit-harm assessment Potential to identify and manage comorbidities that have short and long term serious sequelae exceeds potential harm especially for high-risk patients. Intentional vagueness Frequency of evaluation, patient level of risk. Role of patient preferences Family history, families' concern about the test, ease and accessibility for testing must be considered. Exclusions '‰¤24 mo old. Strengths Strong recommendation. Key references 80, 365 TABLE 9Other Risk Factors for Prediabetes and T2DM90,358,415,419
Risk Factors . ' Maternal history of diabetes or gestational diabetes ' Family history of diabetes in first- or second-degree relative ' Signs of insulin resistance or conditions associated with insulin resistance (acanthosis puberty nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, or small-for-gestational-age birth weight) ' Use of obesogenic psychotropic medications Risk Factors . ' Maternal history of diabetes or gestational diabetes ' Family history of diabetes in first- or second-degree relative ' Signs of insulin resistance or conditions associated with insulin resistance (acanthosis puberty nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, or small-for-gestational-age birth weight) ' Use of obesogenic psychotropic medications The pathogenesis of prediabetes and T2DM is a peripheral and hepatic resistance to insulin accompanied by progressive loss of islet cell function. Insulin resistance, when assessed by the homeostatic model assessment of insulin resistance test, varies across weight categories, with highest levels observed among children with severe obesity.396 Some children with T2DM have rapidly progressive disease, which underscores the need for early identification and intensive treatment in collaboration with a pediatric endocrinologist.425
C.2.a. Laboratory Tests for the Diagnosis of Prediabetes and T2DMTesting for T2DM should always be performed if there is suspicion of hyperglycemia in a patient with symptoms and signs of hyperglycemia, such as new onset thirst (polydipsia), frequent urination (polyuria) or new onset bedwetting, excessive hunger and eating (polyphagia), blurred vision, unexplained or unexpected weight loss, or fatigue.
Diagnostic tests for prediabetes and T2DM are fasting plasma glucose (FPG), 2-hour plasma glucose after oral glucose tolerance test (OGTT), and HbA1c.90 There are several clinical guidelines that do not recommend one test over the other for evaluation.90,268,415,416,419,420,465 Pediatricians and other PHCPs need to be aware of the strengths and shortfalls of each test and take patient preferences and test accessibility into consideration. In addition, the concordance between all 3 tests is imperfect.416 For instance, the FPG is highly reproducible; the OGTT, which does not fare as well on reproducibility, is effective in identifying dysglycemia. This is a good reason to use the OGTT as a confirmation test if the initial test result is equivocal.466''470 The OGTT, however, may not be readily available at some medical settings, requires fasting before the test, lasts at least 2 hours, and includes an unpalatable glucose drink'--all of which are factors that can limit its use in pediatric outpatient settings as an evaluation test.
The HbA1c test is easy to obtain as fasting is not required. It provides a measure of chronic hyperglycemia, and use of the test has been shown to increase evaluation for T2DM in primary care settings.471 It is also the recommended test for monitoring prediabetes.90,414''416,418,464,472 The sensitivity of HbA1c for diagnosing diabetes is lower in children473 when compared with adults.473,474 Pediatricians and other PHCPs also need to be aware that HbA1c levels can be 0.1% to 0.2% higher in individuals with iron deficiency anemia.475,476
Fasting insulin is not recommended for diagnosis of prediabetes or T2DM because the levels are highly variable and do not reliably correlate with the level of insulin resistance.268,477
The cut-off values are similar for pediatric and adult populations, as illustrated in Table 10, above. If the results are unequivocally high and indicative of T2DM, obtaining a second or repeat confirmatory test is not recommended; instead, treatment should be initiated.90,415 Guideline recommendations for tracking glycemic control over time use the HbA1c test; however, the FPG can be substituted using the cut-off criteria in Table 10. See the implementation guide for further discussion on use of OGTT or FBG tests.90,414,415,419,464
TABLE 10Criteria for Diagnosing Prediabetes and T2DM90
. Prediabetes or Impaired Glucose Tolerance . Diabetes Mellitusa . Fasting plasma glucose (FBG)b 100''125 mg/dL '‰¥126 mg/dL 2-h plasma glucose (OGTT)c 140''199 mg/dL '‰¥200 mg/dL Random plasma glucose (RBG)d Not applicable '‰¥200 mg/dL HbA1ce 5.7% to 6.4% '‰¥6.5% . Prediabetes or Impaired Glucose Tolerance . Diabetes Mellitusa . Fasting plasma glucose (FBG)b 100''125 mg/dL '‰¥126 mg/dL 2-h plasma glucose (OGTT)c 140''199 mg/dL '‰¥200 mg/dL Random plasma glucose (RBG)d Not applicable '‰¥200 mg/dL HbA1ce 5.7% to 6.4% '‰¥6.5% a In the absence of unequivocal hyperglycemia, diagnosis is confirmed if 2 different tests are above threshold or a single test is above threshold on 2 separate occasions.
b Fasting for at least 8 h with no calorie intake.
c Oral glucose tolerance test (OGTT) using a load 1.75 g/kg of body weight of glucose with a maximum of 75 g.
d In patients with hyperglycemic crises or classic symptoms of hyperglycemia (eg, polyuria, polydipsia).
e Glycosylated hemoglobin (HbA1c) is the preferred test for monitoring prediabetes.478
See Appendix 3 for more information on frequency of evaluation and on initial management of prediabetes and T2DM.
C.3. Nonalcoholic Fatty Liver DiseaseNAFLD is a chronic liver disease marked by steatosis (fat accumulation), inflammation, and fibrosis. The underlying pathogenesis is insulin resistance, which alters the process of fat oxidation in the liver, increasing oxidative stress and inflammation'--with resultant liver damage. Among children with obesity, rates as high as 34% have been reported.429
Three diagnostic terms are used to describe the histology of the disease progression: NAFLD, nonalcoholic fatty liver (NAFL), and nonalcoholic steatohepatitis (NASH). NAFLD refers to the whole spectrum of the disorder, from mild steatosis to cirrhosis of the liver. NAFLD is divided into steatosis (NAFL) and steatohepatitis (NASH). In NAFL, the milder form of the condition, there is fatty infiltration in '‰¥5% of the liver, with or without fibrosis. In NASH, there is inflammation, steatosis, and fibrosis with ballooning injury to the hepatocytes.433
The risk profile and natural history of the disorder in the pediatric population are still evolving, given that there are limited long-term studies in children. Pediatric NAFLD may reflect the early onset of a chronic disease with a more aggressive course, particularly once NASH has occurred.424,479 Preadolescent children with NAFLD have higher rates of mortality over 20 years, compared with their peers without NAFLD.479 Children with increasing weight gain; higher levels of alanine transaminase (ALT), Î" glutamyl transferase (GGT), and cholesterol at baseline; worsening levels of HbA1c; and an incident diagnosis of T2DM are more likely to have severe disease or progression (Table 11).433,479 However, in a recent study of children 8 to 17 years of age with biopsy-confirmed NAFLD who received standardized nutrition and exercise counseling consistent with the 2007 AAP Expert Recommendations at 12-week intervals over 1 to 2 years, about half demonstrated any improvement in resolution of NASH or regression of fibrosis. Among children with borderline or definite NASH, resolution occurred in about one-third. Adolescents were more likely to develop worsening steatosis and less likely to experience any resolution of NASH or regression in fibrosis than younger children.433
TABLE 11Risk Factors for Diagnosis and Progression of NAFLD88,397,433
NAFLD . Risk Factorsa . Diagnosis Male sex, '‰¥10 y, obesity, sibling with NAFLD, prediabetes or diabetes mellitus, obstructive sleep apnea, dyslipidemia Progression Adolescent '‰¥14 y; higher or increasing alanine transaminase; elevated baseline aspartate transaminase, Î" glutamyl transferase (GGT), and LDL cholesterol; prediabetes or diabetes mellitus; obstructive sleep apnea; increasing wt or waist circumference NAFLD . Risk Factorsa . Diagnosis Male sex, '‰¥10 y, obesity, sibling with NAFLD, prediabetes or diabetes mellitus, obstructive sleep apnea, dyslipidemia Progression Adolescent '‰¥14 y; higher or increasing alanine transaminase; elevated baseline aspartate transaminase, Î" glutamyl transferase (GGT), and LDL cholesterol; prediabetes or diabetes mellitus; obstructive sleep apnea; increasing wt or waist circumference a Consideration should be given to groups of certain races/ethnicities with higher rates of NAFLD (eg, Hispanic, Asian), for which higher prevalence can be attributed to genetic, socioeconomic, and environmental factors.480
C.3.a. Laboratory Tests for Diagnosis of NAFLDThe 2017 North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) clinical practice guidelines recommend ALT as the preferred test for NAFLD.88 ALT is more specific for liver disease than aspartate transaminase (AST), easily accessible at laboratory centers, minimally invasive relative to other testing modalities for NAFLD, and has been used most often in pediatric NAFLD studies. Higher levels of ALT correlate with more advanced liver disease with steatosis and fibrosis; however, a normal ALT does not definitively exclude NAFLD.429 In a population of children older than 10 years with overweight and obesity who were referred from a primary care clinic, an ALT level '‰¥80 IU/L had a sensitivity of 57% and a specificity of 71% for NASH.481 Elevations in AST and GGT, especially at baseline, can be indicative of severe disease or rapid progression.433,481
NAFLD is less common in children younger than 10 years. In an autopsy study of 742 children, 3.3% of 5- to 9-year-old children had fatty liver, compared with 11.3% in 10- to 14-year-olds and 17.3% in 15- to 17-year-olds.397 There is a higher risk for NAFLD in young children 2 to 9 years of age who have severe obesity, however.88 Thus, pediatricians and other PHCPs may consider evaluating NAFLD by obtaining an ALT level every 2 years in these children.
See Appendix 3 for more information on the frequency of evaluation for NAFLD and on managing NAFLD.
C.4. HypertensionThe prevalence of HTN among children and adolescents with overweight and obesity ranges from 5% to 30%, with higher prevalence with increasing BMI percentile.396 Children with excess weight also have abnormal diurnal variation in BP. One-third of children with obesity have a decreased nocturnal BP dip, increasing the potential risk for end-organ damage.482 Among children with obesity, additional cardiometabolic risk factors'--such as insulin resistance or dyslipidemia'--may affect BP, independent of obesity.
Studies indicate that HTN during childhood and adolescence increases the risk for adult HTN and cardiovascular disease.483''485 More concerning, studies have shown that, among children with obesity, HTN is associated with vascular changes, increased left ventricular mass, and carotid intima media thickness during childhood.486,487 These findings support the importance of evaluating for HTN early and consistently throughout childhood and adolescence among individuals with overweight and obesity.413,488
C.4.a. Evaluation for HTNObesity is the strongest risk factor for HTN in childhood.87,488 Elevated BP is observed in early childhood and prevalence increases with age and BMI category.396 A large study conducted in primary care settings found that 8% of children 3 to 5 years of age with obesity had elevated BP levels; the percentage increased to 20% among children 11 to 15 years of age.489 HTN prevalence varies by race and ethnicity, with highest prevalence occurring among non-Hispanic Black and Hispanic youth.490 SES is also a risk factor for HTN,491 as are adverse childhood experiences, both prenatally and during childhood.87 These factors may contribute to the higher prevalence of hypertension observed among non-Hispanic Black and Hispanic youth.490
Pediatricians and other PHCPs should obtain a history of salt intake (eg, addition of salt while cooking and/or at meals) and sources of sodium from processed, frozen, and fast foods, because high sodium intake is associated with childhood HTN. Obtaining a history of physical activity and inactivity levels is also recommended, because decreased activity levels are associated with childhood HTN.87 Finally, evaluation of sleep duration and disordered breathing are recommended because of the association between abnormal sleep duration and OSA and elevated BP.492,493
This KAS aligns with the 2017 AAP's ''Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents,'' which recommends evaluation of elevated BP and HTN for children with obesity at every clinic visit beginning at 3 years of age.87 Frequent monitoring of BP among children with overweight and obesity fosters earlier detection of elevated BP.
C.4.b. Diagnosis of HTNIn 2017, the AAP published a CPG on HTN that included recommendations for evaluation for elevated BP and updated HTN definitions of ''elevation,'' ''stage 1 BP,'' and ''stage 2 BP'' (see Table 12). This CPG recommended that an elevated initial BP measurement ('‰¥90th percentile), taken either by oscillometry or auscultation, should be repeated twice with auscultation and averaged, at the same visit, to determine accurate BP measurement and category. For diagnosis, BP by auscultation should be repeated with confirmed elevated BP measurements on 3 separate clinic visits for elevated BP and stage 1 HTN, and on 2 separate visits for stage 2 HTN.87
TABLE 12BP Categories by Age and Number of Visits Needed for Diagnosis
BP Category . Children 1''13 Years of Age . Children '‰¥13 Years of Age . Number of Visits to Diagnosis . Normal BP < 90th percentile BP <120/80 mm Hg NA Elevated BP '‰¥ 90th percentile to <95th percentile 120/<80 to 129/<80 mm Hg 3 Stage 1 BP '‰¥ 95th percentile to <95th percentile + 12 mmHg 130/80 to 139/89 mm Hg 3 Stage 2 BP '‰¥ 95th percentile + 12 mm Hg '‰¥140/90 mm Hg 2 BP Category . Children 1''13 Years of Age . Children '‰¥13 Years of Age . Number of Visits to Diagnosis . Normal BP < 90th percentile BP <120/80 mm Hg NA Elevated BP '‰¥ 90th percentile to <95th percentile 120/<80 to 129/<80 mm Hg 3 Stage 1 BP '‰¥ 95th percentile to <95th percentile + 12 mmHg 130/80 to 139/89 mm Hg 3 Stage 2 BP '‰¥ 95th percentile + 12 mm Hg '‰¥140/90 mm Hg 2 Used with permission and adapted from the AAP HTN CPG,87 Fig 2, and AAP Pediatric Obesity Clinical Decision Support Chart.494 NA, not applicable.
TABLE 13Summary of KASs for Evaluation of Comorbidities Among Children and Adolescents With Overweight and Obesity
KAS # . Key Action Statement (KAS) . Evidence Quality, Recommendation Strength . A. laboratory evaluation of obesity-related comorbidities 3 In children 10 y and older, pediatricians and other PHCPs should evaluate for lipid abnormalities, abnormal glucose metabolism, and abnormal liver function in children and adolescents with obesity (BMI '‰¥ 95th percentile) and for lipid abnormalities in children and adolescents with overweight (BMI '‰¥ 85th percentile to < 95th percentile) B, Strong 3.1 In children 10 y and older with overweight (BMI '‰¥ 85th percentile to < 95th percentile), pediatricians and other PHCPs may evaluate for abnormal glucose metabolism and liver function in the presence of risk factors for T2DM or NAFLD. In children 2 to 9 y of age with obesity (BMI '‰¥ 95th percentile), pediatricians and other PHCPs may evaluate for lipid abnormalities. C, Moderate B. Concurrent treatment of obesity and obesity-related comorbidities 4 Pediatricians and other PHCPs should treat children and adolescents for overweight (BMI '‰¥ 85th percentile to < 95th percentile) or obesity (BMI '‰¥ 95th percentile) and comorbidities concurrently. A, Strong C. Evaluation for diagnosis of dyslipidemia, prediabetes, T2DM, NAFLD, and hypertension 5 Pediatricians and other PHCPs should evaluate for dyslipidemia by obtaining a fasting lipid panel in children 10 y and older with overweight (BMI '‰¥ 85th percentile to < 95th percentile) and obesity (BMI '‰¥ 95th percentile) and may evaluate for dyslipidemia in children 2 through 9 y of age with obesity. B, Strong (10 y and older); C, moderate (2''9 y of age) 6 KAS 6. Pediatricians and other PHCPs should evaluate for prediabetes and/or diabetes mellitus with fasting plasma glucose, 2-h plasma glucose after 75-g oral glucose tolerance test (OGTT), or glycosylated hemoglobin (HbA1c).a B, Moderate 7 KAS 7. Pediatricians and other PHCPs should evaluate for NAFLD by obtaining an alanine transaminase (ALT) test.b A, Strong 8 Pediatricians and other PHCPs should evaluate for hypertension by measuring blood pressure at every visit starting at 3 y of age in children and adolescents with overweight (BMI '‰¥ 85 percentile to < 95th percentile) and obesity (BMI '‰¥ 95th percentile). C, Moderate KAS # . Key Action Statement (KAS) . Evidence Quality, Recommendation Strength . A. laboratory evaluation of obesity-related comorbidities 3 In children 10 y and older, pediatricians and other PHCPs should evaluate for lipid abnormalities, abnormal glucose metabolism, and abnormal liver function in children and adolescents with obesity (BMI '‰¥ 95th percentile) and for lipid abnormalities in children and adolescents with overweight (BMI '‰¥ 85th percentile to < 95th percentile) B, Strong 3.1 In children 10 y and older with overweight (BMI '‰¥ 85th percentile to < 95th percentile), pediatricians and other PHCPs may evaluate for abnormal glucose metabolism and liver function in the presence of risk factors for T2DM or NAFLD. In children 2 to 9 y of age with obesity (BMI '‰¥ 95th percentile), pediatricians and other PHCPs may evaluate for lipid abnormalities. C, Moderate B. Concurrent treatment of obesity and obesity-related comorbidities 4 Pediatricians and other PHCPs should treat children and adolescents for overweight (BMI '‰¥ 85th percentile to < 95th percentile) or obesity (BMI '‰¥ 95th percentile) and comorbidities concurrently. A, Strong C. Evaluation for diagnosis of dyslipidemia, prediabetes, T2DM, NAFLD, and hypertension 5 Pediatricians and other PHCPs should evaluate for dyslipidemia by obtaining a fasting lipid panel in children 10 y and older with overweight (BMI '‰¥ 85th percentile to < 95th percentile) and obesity (BMI '‰¥ 95th percentile) and may evaluate for dyslipidemia in children 2 through 9 y of age with obesity. B, Strong (10 y and older); C, moderate (2''9 y of age) 6 KAS 6. Pediatricians and other PHCPs should evaluate for prediabetes and/or diabetes mellitus with fasting plasma glucose, 2-h plasma glucose after 75-g oral glucose tolerance test (OGTT), or glycosylated hemoglobin (HbA1c).a B, Moderate 7 KAS 7. Pediatricians and other PHCPs should evaluate for NAFLD by obtaining an alanine transaminase (ALT) test.b A, Strong 8 Pediatricians and other PHCPs should evaluate for hypertension by measuring blood pressure at every visit starting at 3 y of age in children and adolescents with overweight (BMI '‰¥ 85 percentile to < 95th percentile) and obesity (BMI '‰¥ 95th percentile). C, Moderate a Per KAS 3 and 3.1: pediatricians and other PHCPs should evaluate children 10 y and older with obesity (BMI '‰¥ 95th percentile) for abnormal glucose metabolism and may evaluate children 10 y and older with overweight (BMI '‰¥ 85th percentile to <95th percentile) with risk factors for T2DM or NAFLD for abnormal glucose metabolism. (Refer to evidence tables for KAS 3 and 3.1.)
b Per KAS 3 and 3.1: pediatricians and other PHCPs should evaluate children 10 y and older with obesity (BMI '‰¥ 95th percentile) for abnormal liver function and may evaluate children 10 y and older with overweight (BMI '‰¥ 85th percentile to <95th percentile) with risk factors for TD2M or NAFLD for abnormal liver function. (Refer to evidence tables for KAS 3 and 3.1.)
BP measurements should be taken with an appropriately sized cuff; the bladder length should be 80% to 100% of the circumference of the arm, and the width should be at least 40% of the arm circumference.87 (See https://www.cdc.gov/nchs/data/nhanes/nhanes_07_08/manual_an.pdf.)
For children and adolescents with excess weight, a larger cuff size may be required to obtain accurate measurements. For children and adolescents with severe obesity, a thigh cuff may be needed. Additionally, for children and adolescents with obesity, ambulatory blood pressure monitoring (ABPM) is recommended to assess HTN severity and identify possible abnormal circadian BP patterns, which increases risk for end-organ damage. ABPM also helps to identify masked HTN and/or ''white coat'' HTN.87
Elevated BP in the office setting is unrecognized in approximately 25% of cases.495 The AAP's CPG on HTN provides pediatricians and other PHCPs with practical tools to assist with identification of elevated BP and HTN. Improved identification of children at high risk and youth allows for a thorough evaluation, treatment, and follow-up, with the goal of decreasing long-term cardiovascular morbidity and mortality.
See Appendix 3 for more information on repeat evaluation for HTN and on management of HTN. Table 13 lists the KASs for the comorbidities covered in the TR.
D. Other Comorbidities D.1. Obstructive Sleep ApneaOSA is a sleep disorder ''characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction that disrupts normal ventilation during sleep.''89 The condition is associated with cardiovascular complications, neurocognitive impairment, and decreased quality of life. Children with obesity have a higher prevalence of OSA: 45% among children obesity compared with 9% among children with healthy weight. One study indicated that a 1-unit increase in the BMI SD score increased the odds of having OSA by a factor of 1.9 independent of age, sex, tonsillar hypertrophy, and asthma.441
Evaluation for OSA is based on history of symptoms and examination. Children with obesity, tonsillar hypertrophy, craniofacial anomalies, trisomy 21, and neuromuscular disorders are at higher risk for OSA. Common symptoms include frequent snoring, gasps or labored breathing during sleep, disturbed sleep, daytime sleepiness, inattention and/or learning problems, nocturnal enuresis, and headaches. Examination findings may include tonsillar hypertrophy, adenoidal facies, micro- or retrognathia, high-arched palate, and elevated BP. Diagnosis is made by obtaining a polysomnography, the gold standard test, with an apnea-hypopnea index of 1 or more episodes per hour in children.496 Because of limited availability of sleep centers with pediatric expertise, referral to a pediatric otolaryngologist for further evaluation, diagnosis, and management may be needed.
Consensus RecommendationsThe CPG authors recommend pediatricians and other PHCPs obtain:
A sleep history, including symptoms of snoring, daytime somnolence, nocturnal enuresis, morning headaches, and inattention, among children and adolescents with obesity to evaluate for OSA.
A polysomnogram for children and adolescents with obesity and at least 1 symptom of disordered breathing.
See Appendix 3 for more information on the initial management of OSA.
D3. Polycystic Ovarian SyndromePolycystic ovarian syndrome (PCOS) is a heterogeneous disorder characterized by hyperandrogenism and disordered ovulatory function and is often associated with obesity and insulin resistance. The condition increases risk for infertility, T2DM, cardiovascular disease, and cancer.497
Four different sets of criteria have been published for diagnosis of PCOS in adults as outlined by differing professional organizations (Table 14).498 Establishment of diagnostic criteria for PCOS in adolescence has been difficult, because characteristic features of PCOS can be normal physiologic events during early adolescence.499 International pediatric and adolescent specialty societies have made recommendations for diagnosis specific to adolescents, which include the following: (1) evidence of clinical or biochemical hyperandrogenism, and (2) persistent irregular menstrual cycles (<20 days or >45 days) 2 years after menarche.500 Limited data are available on prevalence of PCOS in adolescents. Estimates range from 3% to 11%, depending on the criteria for diagnosis.501
TABLE 14Definitions and Criteria for PCOS
Definition . Diagnostic Criteria . National Institutes of Health Requires the presence of: 'ƒ1. Hyperandrogenism (clinical and/or biochemical) 'ƒ2. Ovarian dysfunction American Society of Reproductive Medicine (Rotterdam) Requires the presence of at least 2 criteria: 'ƒ1. Hyperandrogenism (clinical and/or biochemical) 'ƒ2. Ovulatory dysfunction 'ƒ3. Polycystic ovarian morphology American Endocrine Society Requires the presence of hyperandrogenism (clinical and/or biochemical) and either: 'ƒ1. Ovulatory dysfunction 'ƒ2. Polycystic ovarian morphology Androgen Excess and Polycystic Ovary Syndrome Society Requires the simultaneous presence of: 'ƒ1. Hyperandrogenism (clinical and/or biochemical) 'ƒ2. Ovarian dysfunction (ovulatory dysfunction and/or polycystic ovarian morphology) Definition . Diagnostic Criteria . National Institutes of Health Requires the presence of: 'ƒ1. Hyperandrogenism (clinical and/or biochemical) 'ƒ2. Ovarian dysfunction American Society of Reproductive Medicine (Rotterdam) Requires the presence of at least 2 criteria: 'ƒ1. Hyperandrogenism (clinical and/or biochemical) 'ƒ2. Ovulatory dysfunction 'ƒ3. Polycystic ovarian morphology American Endocrine Society Requires the presence of hyperandrogenism (clinical and/or biochemical) and either: 'ƒ1. Ovulatory dysfunction 'ƒ2. Polycystic ovarian morphology Androgen Excess and Polycystic Ovary Syndrome Society Requires the simultaneous presence of: 'ƒ1. Hyperandrogenism (clinical and/or biochemical) 'ƒ2. Ovarian dysfunction (ovulatory dysfunction and/or polycystic ovarian morphology) All of the diagnostic criteria for PCOS require the exclusion of other disorders of adrenal excess, such as nonclassic or late-onset congenital adrenal hyperplasia, Cushing syndrome, hyperprolactinemia, hypothyroidism, acromegaly, premature ovarian failure, a virilizing adrenal or ovarian neoplasm, or a drug-related condition.
Evaluation for PCOS in an adolescent requires first excluding other medical conditions that may cause menstrual dysfunction (oligomenorrhea or amenorrhea) and/or signs of androgen excess (acne, hirsutism, or alopecia). Additionally, for adolescents, evaluation should occur 2 years after menarche, because irregular menstrual cycles are not uncommon during this timeframe. Laboratory testing may include: 17-hydroxyprogesterone, total testosterone, free testosterone, sex hormone-binding globulin, dehydroepiandrosterone sulfate, androstenedione, luteinizing hormone, follicle-stimulating hormone, estradiol, prolactin, free thyroxine, thyroid stimulating hormone, and insulin. Interpretation of laboratory results should be made in the context of age-appropriate reference ranges; therefore, referral to a laboratory that can perform ultrasensitive pediatric assays is recommended. Routine ovarian imaging is not indicated for the diagnosis of PCOS in adolescents.498,502 An algorithm for evaluation is provided in the implementation materials from previously published consensus recommendations.503
See Appendix 3 for more information on the initial management of PCOS.
Consensus RecommendationThe CPG authors recommend pediatricians and other PHCPs:
Evaluate for menstrual irregularities and signs of hyperandrogenism (ie, hirsutism, acne) among female adolescents with obesity to assess risk for PCOS.
D4. DepressionThe relationship between pediatric obesity and depression is less well understood than the physical comorbidities; however, identification of depression is an important component of the assessment and management of pediatric obesity, given its potential impact on treatment outcomes. A systematic review and meta-analyses conducted in 2019 showed that children 18 years and younger with obesity have a 32% increased odds of having or developing depression compared with children of healthy weight, with the highest odds (44%) among females with obesity.504
Studies are limited on the effect of treatment of pediatric obesity on depression. A recent meta-analysis of 36 studies found a small but significant reduction in depressive symptoms following structured pediatric obesity treatment. Notably, no adverse mental health outcomes were reported.505 Additionally, the interventions technical report indicates that obesity treatment may improve psychosocial outcomes for youth with obesity, including quality of life.80 Further research in this area is needed; however, pediatricians and other PHCPs should be aware that obesity treatment interventions have not been associated with increased symptoms of depression.80
Evaluation for depression includes awareness of symptoms and risk factors. Symptoms include irritability, fatigue, insomnia, excessive sleeping, decline in academic performance, family conflict, and weight changes. Risk factors include personal or family history of depression, substance use, trauma, frequent psychosomatic complaints, psychosocial stressors, and other mental health conditions. The AAP CPG for depression recommends evaluating adolescents 12 years and older for depression annually using a formal self-report tool, such as the Patient Health Questionnaire-9.506 Additionally, routine monitoring of psychosocial function and using an evaluation tool when a patient presents with symptoms of depression is recommended.
If initial evaluation for depression is positive, evaluation with a standardized depression tool should be conducted. Assessment for depression should also include direct, separate interviews with the patient and family members to include functional impairment at home, school, and peer settings and safety and/or suicide risk.506 The implementation materials include additional information and resources, including tools for pediatricians and other PHCPs, in addition to an assessment and management algorithm.506
See Appendix 3 for more information on the initial management of depression.
Consensus RecommendationThe CPG authors recommend pediatricians and other PHCPs:
Monitor for symptoms of depression in children and adolescents with obesity and conduct annual evaluation for depression for adolescents 12 years and older with a formal self-report tool.
D5. Orthopedic Comorbidities D.5.a. Slipped Capital Femoral EpiphysisSlipped capital femoral epiphysis (SCFE) is the most common hip disorder in the adolescent period. It occurs between 9 and 16 years of age, spanning periods of rapid linear growth. There is a 1.5:1 male-to-female ratio, and SCFE occurs more often in Black, Hispanic, and AI/AN children.507,508 SCFE is bilateral in 25% to 80% of cases.507 Weakening of the proximal femoral physis (growth plate) causes a slip in the physis, with a corresponding displacement of the epiphysis (femoral head). Risks such as obesity exert mechanical stress on the physis, whereas metabolic conditions (eg, hypothyroidism, hypopituitarism) weaken the physis, creating the ideal setup for a slip.
The common presentation is hip pain, although many children may present with knee pain alone or in addition to hip pain. The pain can happen only with weight bearing or be constant. On physical examination, there is external rotation with passive hip flexion, limitation of internal rotation and antalgic gait. Pain can also be elicited passively with internal rotation of the hip. SCFE is characterized as stable if the child can bear weight with or without crutches and as unstable when weight-bearing is not possible.509 Because SCFE can be bilateral, the pediatrician or other pediatric health care provider needs to remember to obtain a history and exam for the contralateral leg. The history and examination should also exclude differential diagnoses for hip pain (eg, infections, inflammation or autoimmune conditions, neoplasms, and trauma).
As the pathophysiologic process continues, the child is at greater risk for increased morbidity, including avascular necrosis. Thus, the importance of early diagnosis cannot be overemphasized. Once SCFE is suspected, pediatricians and other PHCPs should confirm the diagnosis and place an emergent referral to the orthopedic surgeon. The mainstay for diagnosis is plain radiographs of the hip and pelvis (Table 15). Ultrasonography and computerized tomography are not useful. In cases with equivocal radiography results and a high index of suspicion, MRI, which is more sensitive at assessing the physis, can be obtained.
TABLE 15Recommended Imaging for Slipped Capital Femoral Epiphysis and Blount Disease
Condition . First-Line Imaging . Additional Tests . SCFE Bilateral hip (anteroposterior and lateral), frog-leg radiographs If SCFE is unstable, cross-table lateral radiograph. MRI for equivocal imaging results, or assess blood supply to femoral head. Blount Long leg (anteroposterior and lateral), knee (anteroposterior and lateral) radiographs MRI of the knee to delineate level and extent of deformity, assess blood supply to physis.a Condition . First-Line Imaging . Additional Tests . SCFE Bilateral hip (anteroposterior and lateral), frog-leg radiographs If SCFE is unstable, cross-table lateral radiograph. MRI for equivocal imaging results, or assess blood supply to femoral head. Blount Long leg (anteroposterior and lateral), knee (anteroposterior and lateral) radiographs MRI of the knee to delineate level and extent of deformity, assess blood supply to physis.a aAdditional tests are determined by orthopedic surgeon.
See Appendix 3 for more information on the initial management of SCFE.
D.5.b. Blount DiseaseBlount disease is a growth disorder that primarily affects the proximal medial tibial physis and epiphysis.510,511 It often presents as a triad of asymmetric tibia vara, tibial torsion, and precurvatum. As with SCFE, excess weight is a risk factor, because it increases mechanical stress on the physis. Blount disease disproportionately affects non-Hispanic Black or Hispanic children.510,511 The reason for this predilection is unclear, but it may reflect epigenetic, social, or cultural factors that affect early ambulation, growth, or obesity. Other risk factors include a family history of Blount disease and ambulation before 12 months of age.510,511 Symptoms and signs include leg pain, abnormal gait with bowing of the lower legs, and leg-length discrepancy.
Blount disease is classified into 2 categories: (1) infantile or early-onset, and (2) late-onset or adolescent Blount disease, based whether the onset occurred before or after age 10 years, respectively. Infantile Blount disease is bilateral but asymmetric, occurs more often in males, and often includes a preceding history of early ambulation. For young children, pediatricians and other PHCPs should exclude physiologic bowing typically seen during toddlerhood, which is bilateral but symmetrical and resolves by age 3 or 4 years. In the adolescent subtype, the tibia vara deformity is milder, unilateral, and predominantly associated with severe obesity.510''513
Plain radiographs are the initial imaging of choice (Table 15). When used, MRI provides a more sensitive investigation of the deformity.
See Appendix 3 for more information on the initial management of Blount disease.
Consensus Recommendations The CPG authors recommend pediatricians and other PHCPs: Perform a musculoskeletal review of systems and physical examination (eg, internal hip rotation in growing child, gait) as part of their evaluation for obesity.
Recommend immediate and complete activity restriction, nonweight-bearing with use of crutches, and refer to an orthopedic surgeon for emergent evaluation, if SCFE is suspected. PHCPs may consider sending the child to an emergency department if an orthopedic surgeon is not available.
D.5.c. Idiopathic Intracranial HypertensionIdiopathic intracranial hypertension (IIH) (previously known as pseudotumor cerebri) is a neurologic condition with serious long-term morbidity.514,515 It occurs most often in females of child-bearing age, and obesity is a well-established risk factor.516''518 In a population-based study in Olmstead County, Minnesota, the incidence of IIH among adult females aged 15 to 44 years with obesity was 3.5-fold higher than that of all females in that age group.517
The pathogenesis is unclear, hence the name; however, 3 hypothesized mechanisms are increased venous pressure, decreased cerebrospinal fluid (CSF) drainage, and increased CSF production. Other factors associated with for IIH include medications (eg, doxycycline, tetracyclines, retinoic acid, sulfonamides), autoimmune disorders (eg, systemic lupus erythematosus), and hormonal disorders (eg, Cushing disease, Addison disease). A higher prevalence of IIH has also been reported in females with PCOS.519
Typical symptoms are persistent headaches, pulsatile synchronous tinnitus, and visual changes or loss, although the history can be variable. Physical examination includes a fundoscopy for papilledema and a thorough neurologic evaluation for cranial nerve deficits such as sixth nerve palsy. The presence of altered consciousness or neurologic deficit with localized peripheral findings should prompt pediatricians and other PHCPs to consider another etiology. The serious sequelae for IIH is vision loss. Thus, a review of system should be obtained to evaluate any child with obesity who has significant or progressive headaches. There should also be a high index of suspicion for IIH with new-onset headaches and significant weight gain (5% to 15% of body weight), particularly when it occurs in the prior 12 to 18 months.518,520
Initial evaluation for IIH involves conducting comprehensive evaluation by the neurologist and ophthalmologist or at an integrated IIH clinic.
See Appendix 3 for more information on the initial management of IIH.
Consensus RecommendationThe CPG authors recommend pediatricians and other PHCPs:
Maintain a high index of suspicion for IIH with new- onset or progressive headaches in the context of significant weight gain, especially for females.
D.6. SummaryIn summary, a thorough history and physical examination is invaluable in guiding pediatricians' and other PHCPs' assessment for comorbidities. This section of the CPG, the algorithm in Appendix 1, Appendix 3, and the accompanying implementation resources provide a framework for evaluation, reevaluation, and initial management. Obesity is a linchpin disorder with attendant comorbidities, some of which are not covered in this section or in the technical report (eg, pes planus). For these comorbidities, pediatricians and other PHCPs are encouraged to seek resources available through the AAP and other professional societies.
XI. Treatment of Child and Adolescent Overweight and Obesity A. Obesity is a Chronic DiseaseObesity is a chronic disease and should be treated with intensive and long-term care strategies, provision of ongoing medical monitoring and treatment of associated comorbidities and ongoing access to obesity treatment. As noted previously, obesity is associated with increased prevalence of comorbidities, including abnormal lipids, glucose dysregulation and other endocrinopathies, abnormal liver enzymes, and elevated BP. A key component of treating obesity is to concurrently monitor and treat the comorbidities (see Comorbidities section).
The chronic care model requires care to be delivered within the context of individual patient factors, taking into consideration the child's household and familial influences, access to healthy food and activity spaces, and other SDoHs.522 Recommendations for obesity treatment should be integrated within existing community and social systems.521 The medical home model is the preferred standard of care for children who have chronic conditions,522 and the child's medical home should serve as a care coordinator in the treatment of children with obesity, coordinating with subspecialists, including obesity treatment specialists, and community resources.
Treatment of obesity varies based on individual-level factors. No specific studies were found that compare different treatments by a patient's underlying condition, special needs, or developmental status. Nonetheless, it is important to recognize that the following recommendations will require adaptation based on the patient's unique medical, family, developmental, social, and environmental factors. No evidence exists, however, to exclude children with special health care needs, complex disease, or developmental limitations from the treatment options outlined below, except where specifically noted.
The evidence for pediatric obesity treatment that is presented in this CPG shows that several treatments are effective in treating both obesity and related comorbidities. It is important to note, however, that in all of these studies, if the treatment is discontinued, children tend to regain weight and lose the attendant health benefits. There is limited longitudinal evidence about durability of weight change after treatment. The natural course of obesity across the lifespan is characterized by responses to treatment and relapse when treatment ends.77 Therefore, continuous coordinated care is required to support ongoing obesity treatment throughout childhood and adolescence into young adulthood.503
B. Evidence-based Pediatric Obesity Treatment Reduces Risks for Disordered EatingIn the field of pediatric nutrition, in the treatment of both obesity and eating disorders, concerns have been raised as to whether diagnosis and treatment of obesity may inadvertently place excess attention on eating habits, body shape, and body size and lead to disordered eating patterns as children grow into adulthood. The literature refutes this relationship, however. Cardel et al refer to multiple studies that have demonstrated that, although obesity and self-guided dieting consistently place children at high risk for weight fluctuation and disordered eating patterns, participation in structured, supervised weight management programs decreases current and future eating disorder symptoms (including bulimic symptoms, emotional eating, binge eating, and drive for thinness) up to 6 years after treatment.378,505,523 The structure and underlying principles of the primary care-based and intensive health behavior and lifestyle programs described here share multiple similarities with eating disorder programs. These include a focus on increasing healthful food consumption, participating in physical activity for enjoyment and self-care reasons, and improving overall self-esteem and self-concept. Structured and professionally run pediatric obesity treatment is associated with reduced eating disorder prevalence, risk, and symptoms.505,523
C. Motivational InterviewingMI (also discussed in the Evaluation section) is a patient-centered counseling style that identifies and reinforces a patient's own motivation for change'--in contrast to the more traditional approach in which a provider prescribes behavior change. MI guides families to identify a behavior to change, based on what the parent(s) or child feels is important and can be accomplished.524
MI does not impose a particular goal but is successful when the family changes the selected behavior'--which could be nutritional, such as reducing sugar-sweetened beverages; increasing physical activity; or engaging in other behaviors, such as eating meals together or improving sleep hygiene. The target of MI is the person who is responsible for the behavior change. Pediatricians and other PHCPs focus on parent motivation when patients are preadolescent or younger, and transition to patient motivation, usually combined with parent motivation, when patients reach adolescence.
MI consists of 4 processes: engaging, focusing, evoking, and planning. These processes, described below, are particularly salient when discussing weight status and devising a change plan.524
The MI process of engaging is facilitated by the existing medical pediatrician-patient relationship. Through engaging, MI can help answer the question of whether to attempt behavior change. Attempts at obesity treatment often fail because of a disconnect between pediatricians and other PHCPs who see impending health problems with regard to weight status and a caregiver who sees a thriving, growing child. The presence of other challenges'--such as financial constraints and other SDOHs, mental illness, or competing health considerations'--may make obesity treatment a low priority.
An evaluation of these factors is necessary before any action. The longitudinal nature of many pediatrician-family relationships can enable ongoing monitoring of weight, health status, and family challenges. More focused obesity treatment efforts can ensue when families are ready. And regardless of their readiness to engage in more ''active'' obesity treatment, all patients need follow-up, encouragement, and monitoring of health status.
The MI process of focusing furthers respect for the autonomy of the patient and family. Behavior change is the patient's and family's decision, not the pediatrician's or other PHCP's. Identifying behaviors to change is a collaborative process. Caregivers and pediatricians (or other pediatric health care providers) tend to feel that the locus of control for pediatric behavior change resides with the caregiver longer than it actually does, however. Between 6 and 12 years of age, a steady shift of control occurs from caregiver to patient. By the early teen years, the vast majority of behavioral decisions reside in the patient'--not the caregiver. Therefore, the patient should increasingly be the target of the readiness to change assessment and focusing as they age.
The MI principle of evocation advances the autonomy of the patient and family. Pediatricians and other PHCPs can evaluate values that are important to the patient and family. Speaking to an adolescent patient who is more concerned about athletic performance than health, pediatricians and other PHCPs may have better traction discussing what the patient hopes to accomplish physically than attempting to incite concern about potential future disease. Likewise, encouraging a very self-conscious patient to exercise in a public setting may come across poorly. Taking time to evaluate individuals' values, goals, and barriers is a critical piece of assessing readiness to change.
With regard to the MI process of planning, pediatricians and other PHCPs can evaluate a patient's knowledge of what is necessary for a particular strategy and what resources and support are available to them. As a consultant, pediatricians and other PHCPs play a crucial role providing support and guidance for the patient's collaboratively chosen course of action. Because obesity treatment is characterized by frequent setbacks and relapses, pediatricians and other PHCPs can also serve as valuable experts who can assess why behaviors may have reverted and what strategies might be appropriate for patients who seek to ''get back on track.''
Table 16 summarizes MI processes as a way of evaluating and responding to patient readiness to change. Note that the MI tools are suggestions; in practice, each tool may find utility in every phase of evaluation.
TABLE 16Possible Use of MI to Evaluate and Respond to Readiness to Change392
MI Process . Phase of Evaluation . Goal . Possible MI Tool . Engaging Early, getting to know patient Establishing collaborative role, understanding patient issues Open-ended questions, affirmations, nonjudgmental graphics, empathic reflections Focusing Early and when desire to change weight status is expressed Identifying appropriate and productive strategies to change weight status Readiness ruler, elicit-provide-elicit, healthy habits survey, identifying and responding to change talk and sustain talk Evoking When behavior change is desired Triggering internal motivation, empowering change Values statement, double-sided and amplified reflections Planning When embarking on change Carrying out effective change plan, dealing with relapse Readiness ruler, action reflections, summarization, teach back, SMART goals (specific, measurable, achievable, realistic, and timely) MI Process . Phase of Evaluation . Goal . Possible MI Tool . Engaging Early, getting to know patient Establishing collaborative role, understanding patient issues Open-ended questions, affirmations, nonjudgmental graphics, empathic reflections Focusing Early and when desire to change weight status is expressed Identifying appropriate and productive strategies to change weight status Readiness ruler, elicit-provide-elicit, healthy habits survey, identifying and responding to change talk and sustain talk Evoking When behavior change is desired Triggering internal motivation, empowering change Values statement, double-sided and amplified reflections Planning When embarking on change Carrying out effective change plan, dealing with relapse Readiness ruler, action reflections, summarization, teach back, SMART goals (specific, measurable, achievable, realistic, and timely) TABLE 17Treatment Intensity and BMI Reduction in Randomized Controlled Trials
Authors . Study Population . BMI Outcomes . Duration . Wilfley (2017)615 US; ages 7''11; OW/OB; n = 172 Not reported; ''''6.71 percent overweight'' at 8 mo 26''51 h per 8 mo Butte (2017)642 US; ages 2''12; OW/OB; n = 549 ''0.42 at 12 mo; only effective in ages 6''8 >52 h per 12 mo Nemet (2005)621 Israel; ages 6''16; OB; n = 46 ''2.2 at 12 mo 26''51 h per 3 mo Savoye (2007)439 US; ages 8''16; OB, n = 174 ''3.3 at 12 mo, ''2.8 at 24 mo >52 h per 12 mo Vos (2011)617 Germany; ages 7''15; OB; n = 73 ''0.2 (BMIz) at 12 mo 26''51 h per 3 mo Weigel (2008)612 Germany; ages 7''15; OB; n = 73 ''4.3 at 12 mo >52 h per 12 mo Reinehr (2010)643 Germany; ages 7''15; OW/OB; n = 66 ''1.5 at 6 mo >52 h per 6 mo Authors . Study Population . BMI Outcomes . Duration . Wilfley (2017)615 US; ages 7''11; OW/OB; n = 172 Not reported; ''''6.71 percent overweight'' at 8 mo 26''51 h per 8 mo Butte (2017)642 US; ages 2''12; OW/OB; n = 549 ''0.42 at 12 mo; only effective in ages 6''8 >52 h per 12 mo Nemet (2005)621 Israel; ages 6''16; OB; n = 46 ''2.2 at 12 mo 26''51 h per 3 mo Savoye (2007)439 US; ages 8''16; OB, n = 174 ''3.3 at 12 mo, ''2.8 at 24 mo >52 h per 12 mo Vos (2011)617 Germany; ages 7''15; OB; n = 73 ''0.2 (BMIz) at 12 mo 26''51 h per 3 mo Weigel (2008)612 Germany; ages 7''15; OB; n = 73 ''4.3 at 12 mo >52 h per 12 mo Reinehr (2010)643 Germany; ages 7''15; OW/OB; n = 66 ''1.5 at 6 mo >52 h per 6 mo OW, overweight; OB, obese.
C.1. Motivational Interviewing and Weight StatusProspective studies specifically examining MI have demonstrated that the approach has positive effect on weight status, compared with controls.525''528 The outcomes included greater decline in BMI percentile or BMI SD score (also known as z-score), and less of an increase in BMI. These studies were all low-intensity treatments (ie, less than 5 hours) that were delivered in pediatric primary care practices by medical providers and dietitians who successfully learned and used MI.
MI is a tool used with many different strategies aimed at encouraging nutrition and physical activity change, and so the use of MI does not guarantee effect. Tables 2 and 3 in the technical report on interventions (https://doi.org/10.1542/peds.2022-060642) provide an overview of all the programs, including impact and use of MI. Of the 2 additional effective low-intensity studies (not aimed at MI evaluation), 1 included MI in both arms529 and 1 did not use MI.530
Approximately 23 low-intensity studies were ineffective, of which 14 included MI.531''551 These programs varied in participant age, sample size, duration, and other components.
Among moderate-intensity interventions (5''25 hours), about one-third of the approximately 20 effective interventions used MI.552''574
Conversely, approximately one-quarter of the ineffective programs used MI.123,125,150,151,567,575''611
Use of MI in high-intensity programs is more difficult to interpret, because many of these studies resulted in several publications at different outcomes points, with discrepant effects. Some used MI in both study arms.439,610,612''614 An estimated one-quarter of the effective high-intensity programs used MI, however.439,612,613,615''622
Although much more work is needed to examine the optimal characteristics that might moderate MI's impact, like training, fidelity to the MI process, potential patient characteristics, as well as target behaviors, the success of the studies in which MI was the core treatment supports this KAS.
D. Intensive Health Behavior and Lifestyle TreatmentIHBLT is the foundational approach to achieve body mass reduction or the attenuation of excessive weight gain in children. It involves visits of sufficient frequency and intensity to facilitate sustained healthier eating and physical activity habits.79 IHBLT typically involves engagement with, and participation of, families in discussions of necessary treatment based on the severity of disease. It also involves interaction with pediatricians and other PHCPs who are trained in lifestyle-related fields and requires significantly more time and resources than are typically allocated to routine well-child care.623
There are known limitations for families to access and participate in IHBLT. These limitations include the relative scarcity and distribution of such treatment programs and pediatricians or other pediatric health care providers with experience and/or training in pediatric obesity treatment, family transportation challenges, loss of school or work time to attend multiple recurring appointments during what are typically working hours, SDoHs, competing health issues for children or family members, and mismatched expectations between the family (who may expect significant weight loss) and pediatricians or other pediatric health care providers.624 IHBLT is appropriate for typically developing children and adolescents as well as CYSHCN, although will require modification based on the patient's unique health conditions and developmental factors.
The most consistently effective IHBLT programs deliver 26 or more hours of face-to-face, family-based counseling on nutrition and physical activity over at least a 3- to 12-month period, for children aged for children 6 years and older with overweight and obesity, with more limited evidence for children 2 to 5 years of age.625 Although not universally available, treatment programs that provide engaging, group-based physical activity and nutrition programming are currently available in various forms across the United States.222,626 Some IHBLT are housed in academic medical centers or community hospitals, some are in primary care offices or obesity treatment specialty clinics (ie, weight management clinics), and others are delivered through partnerships with local community entities such as the YMCA627 or parks and recreation departments.628 Clinic-community partnerships in particular have demonstrated implementation feasibility and are engaging to low-income and racially diverse populations.629 Pediatricians and other PHCPs should investigate local programs in the area and become familiar with the referral requirements and processes to connect patients with this treatment option (Fig 3).
FIGURE 3
Intensive health behavior and lifestyle treatment.
FIGURE 3
Intensive health behavior and lifestyle treatment.
Close modal Each of the components of the KAS below are supported by evidence that is detailed in the technical report on interventions and summarized here:
26 or more hours: The major factor driving the effectiveness of IHBLT is the intensity (or dose) of the intervention, measured in hours of face-to-face patient contact. The number of hours, or ''dose,'' delivered is directly proportional to the likelihood a child will experience a reduction in BMI (Table 17). Although a threshold effect was observed at 26 or more hours over a 3- to 12-month period, interventions that delivered '‰¥52 hours of contact over the same duration demonstrated the most consistent and significant reduction in BMI and cardiometabolic comorbidity improvement.625 As described in the technical report, 28% of treatments <5 hours,525''527,529, 531''535,537''540,546''549,630 38% of treatments 5 to 25 hours,527,537,554, 555,557,559,560,563,567,568,570,572,573, 575''583,602 and 75% of treatments '‰¥26 hours290,554,555,557,559, 560,563,567,568,570,572,573,575''583,602, 604''606,612,617,618,621,631 led to significant improvements in BMI among pediatric participants.80 Hence, pediatricians and other PHCPs should look for programs that engage families often and frequently. No studies directly compare the same intervention over a shorter versus longer period of time, however.
Face-to-face: Most of the studies included interventions where IHBLT occurred in group settings where families gathered together in a health care or community location, or in a family's home as part of a home visit. Sessions were led by a variety of individuals or combinations of individuals, including community health workers, nutritionists, exercise physiologists, physical therapists, and social workers. Fewer studies evaluated the effectiveness of treatment that did not take place in a face-to-face setting, including mobile health tools for parents or adolescents,530,632 telemedicine- delivered counseling sessions,557 or guided self-help for families.578 Although there is promising evidence that these strategies may be successful, more research is needed to understand the target population, effectiveness on health outcomes, and implementation potential.
Family-based: In all effective studies, the parent or the family unit was included in the treatment. Prior evidence has demonstrated that parent involvement is associated with early success in child obesity treatment632 and that family-based interventions are more effective in achieving and sustaining child BMI reduction than interventions that target the child without including the family (ie, school-based, summer camp, after school).633 For adolescent populations, the evidence and best practices for including parents in obesity treatment is less clear.634 Several studies measure parental BMI as a treatment outcome, along with adolescent BMI, although none included in the technical report have demonstrated significant reduction in parent BMI.549,566, 568,569,578,563,606,628 Obesity tends to affect families; thus, family-based treatment has the potential to improve the health and weight status of other household members, including siblings, although no data are available to support this outcome.
Multicomponent: Nearly all of the evidence for effective treatment of childhood obesity includes components that focus on healthy eating and physical activity. The specific nutritional and exercise content varies widely among studies, and is delivered in different combinations, so no one unified approach has demonstrated superiority over another.
The physical activity component is more effective when children are engaged in a combination of aerobic and nonaerobic physical activity,635 compared with physical activity counseling. Noncompetitive, cooperative, fun activities that build motor skills as well as self-confidence are more engaging for children. Several studies have noted adaptations for children with obesity, including a preference for water-based activities and nonweight-bearing activities (ie, cycling) and considerations for physical therapy or conditioning or training if a child has a low level of fitness.
Nutrition skill-building sessions that involve direct meal preparation or tasting are more effective in increasing children's acceptance of new foods and increasing parent confidence to prepare meals at home, compared with nutrition education.636 Specific nutritional content included in treatment varies as well. Several studies relied on published guidelines (ie, NHLBI-supported CHILD-1diet), whereas others used specific dietary approaches, such as the reduced-glycemic load diet553,564,574 or using meal replacements.591
Several of the more-intensive programs that demonstrate effectiveness also included a focus on mental health and parenting skills; thus, evidence exists to support the addition of these components to increase effectiveness.613,618,619,622,637''639
Programs often address other components of health as well, including getting enough sleep, reducing sedentary screen time, and addressing stigma and weight bias. Although these additional elements are generally recognized as positive and are consistent with anticipatory guidance, they do not have evidence for additional benefit in the context of IHBLT.
Over a 3- to 12-month period: The criteria for the evidence review required a weight-specific outcome at least 3 months after the intervention started. The rationale for excluding shorter-term lifestyle treatments was to ensure that pediatricians and other PHCPs focus on treatments that have a more-sustained treatment effect and that reinforce with parents that obesity does not have a ''quick fix,'' but requires long-term and ongoing attention. Treatments with duration longer than 12 months are likely to have additional and sustained treatment benefit. There is limited evidence, however, to evaluate the durability of effectiveness and the ability of long-term treatments to retain family engagement.
For children 2 to 18 years of age with overweight and obesity: The USPSTF identified evidence for intensive ''lifestyle'' treatments starting at age 6 years.79 This KAS includes children down to age 2, recognizing that several recent studies show treatment effectiveness in preschoolers 2 to 5 years of age.565,566,569,570,618, 631,638,640 Treatment studies delivered care differently depending on the child's age. For example, studies targeting preschoolers more often involved home visits and focused on parental skills training. Studies targeting adolescents more often focused on the teen's autonomy, preferences, and self-image. Intensive behavioral interventions should be tailored to the child's developmental abilities and learning skills.
D.1. Evidence for EffectivenessThe 2017 USPSTF recommendation for pediatric obesity treatment is based on high-quality randomized and nonrandomized studies that demonstrate a significant BMI reduction and were published through January 2016 (n = 42).79,625 The evidence review to inform this CPG additionally included a systematic evidence review of randomized and nonrandomized interventions leading to BMI reduction (March 2020; 214 total intervention studies of all types; of these, 126 were randomized lifestyle studies).
The evidence review is additive to the USPSTF review, as it includes new studies since January 2016 as well as studies with a comparative effectiveness design. Dose is clearly the factor most strongly correlated with treatment outcomes, as evidenced by a selection of trials that deliver ''high intensity'' and ''comprehensive'' contact over a 2- to 12-month625 or 3- to 12-month time period.80
In research settings simulating clinical practice, intensive behavioral intervention has evidence for effectiveness in lowering child BMI, reducing comorbidities, and improving quality of life. Interventions that provide more '‰¥26 hours of treatment are associated with a reduction in BMI z-score between ''0.10 and ''0.50530,565,569,570,612,618,622,641 or a range of ''1.6 to ''8.1 kg (3.5 to 18 lb) weight loss over 1 year. Interventions that meet the intensity or ''dose'' threshold of 26 hours or more over 3 to 12 months can lead to clinically significant improvements in BMI, systolic and diastolic BP, insulin, and glucose levels and to clinically meaningful improvements in comorbidities such as asthma, obstructive sleep apnea, and NAFLD.440''444 Interventions lasting less than 3 months did not demonstrate effectiveness.
High-intensity: Greater contact hours lead to greater treatment effect. In all of the studies, intervention dose is most strongly associated with weight outcomes. Although weight management interventions above a threshold of 26 contact hours are generally effective in reducing excess weight (mean BMI z-score reduction 0.2), higher-dose interventions with contact time '‰¥52 hours demonstrate a stronger and more consistent BMI reduction effect.625 The mean difference in change of BMI z-score between controls and interventions with '‰¥52 hours of contact is ''0.31 (95% CI, ''0.16 to ''0.46), and absolute BMI z-score reductions in the pooled intervention groups is 0.05 to 0.34.625 This treatment effect is observed in children 2 to 16 years of age but most consistently in children 6 to 12 years of age.642 Savoye showed effective treatment in those 8 to 16 years of age but less effectiveness among those 13 to 16 years of age,439 and BMI reduction is driven by the younger age groups in the Weigel612 and Reinehr643 studies. A high dropout rate in obesity treatment is a known threat to delivering actual treatment hours. In research settings, attrition rates of 40% are common439 ; in real-world settings working with low-income families, attrition rates can be as high as 60%.644
Comprehensive: Interventions that include behavior, physical activity, and nutrition components are associated with child BMI reduction. In randomized studies, effective behavior change uses a family-focused approach.615 Parents are taught self-management for their own behaviors (eg, role modeling), as well as positive parenting strategies and contingency management. Children learn goal-setting, body acceptance, and strategies to manage bullying. Effective interventions, for example, deliver moderate-to-vigorous physical activity for at least 50 minutes twice a week for 6 months and 40 minutes of nutrition counseling weekly for 6 months.439,645 Nutrition content includes a nondiet, lifestyle modification approach that teaches families to set goals for meal preparation, grocery shopping, and learning skills including portion size and label reading.439,612,643
There is no evidence that obesity treatments harm patients' quality of life. Among the studies that included quality of life measures, none showed worsening; about one-third showed improvement to quality of life.535,555,615,642 More study on treatments' impact on mental health is needed, however. Few studies examined mental health impact; although none showed worsening mental health, all of the studies excluded subjects who had established mental health disorders at baseline.553,579,646
The prevalence of eating disorders is not well-characterized in patients participating in obesity treatment,647 but disordered eating patterns may be more common among youth with obesity compared with youth at a healthy weight.387 Therefore, pediatricians and other PHCPs should evaluate patients before, during, and after intensive behavioral intervention for the presence of disordered eating (as discussed in the evaluation section) as well as for greater-than-expected weight change.
D.2. Referral StrategiesLimiting factors to IHBLT effectiveness include lack of engagement or participation by families and high attrition rates. Thus, when referring to more intensive treatment, pediatricians and other PHCPs should inform patients and their family members about the reason for the referral, encourage families to actively participate in the treatment, and schedule follow-up visits to monitor progress in the treatment.
One factor in early attrition may be mismatched expectations for weight loss.648 Families can best make decisions about IHBLT participation after providers inform them of commitment and likely outcomes. Pediatricians and other PHCPs are encouraged to help to set reasonable expectations for these outcomes among families, as there is a significant heterogeneity to treatment response and there is currently no evidence to predict how individual children will respond. Many children will not experience BMI improvement, particularly if their participation falls below the treatment threshold. As described in the Health Behavior and Lifestyle Treatment section, those who do experience BMI improvement will likely note a modest improvement of 1% to 3% BMI percentile decline.396
D.3. Prompt IHBLTA key distinction from prior recommendations is for pediatricians and other PHCPs to refer as soon as possible to IHBLT. Current practice patterns involve counseling in primary care practices, often for months to years, before referring to more intensive programs. Although providing patient-centered and nonstigmatizing nutrition and activity counseling is important for children of all weight classifications, there is no evidence to support either watchful waiting or unnecessary delay of appropriate treatment of children who have already developed obesity. Many children are only referred to treatment programs when their obesity has become more severe.529,626 A delay in care ultimately reduces the likelihood of treatment success for the child.649
Similarly, no evidence supports selectively referring patients to obesity treatment programs based on those who meet certain criteria, such as obesity severity, presence of comorbidities, and/or readiness or motivation to change. Although there is currently limited evidence for obesity treatment in children 2 through 5 years of age, excess weight gain in early life predicts future obesity650 ; therefore, future studies should examine treatment in this age group. Pediatricians and other PHCPs are advised to prioritize the most effective treatment available for patients with obesity and encourage patients and families to use these programs at the time of obesity diagnosis.555,615,642
It is necessary to provide IHBLT within various sites of health care delivery. Face-to-face time with pediatricians and other PHCPs cannot realistically achieve the intensity that is most effective. Thus, RDNs, health behavior specialists, and exercise professionals should be part of the health care team and have critical skills for IHBLT. They can work within a multidisciplinary obesity treatment clinic, be embedded within a medical home organization so that they coordinate with pediatricians and other PHCPs, and participate in care through referrals. Given the number of children who meet criteria for treatment, and the current limitations on number of pediatricians and other PHCPs who deliver IHBLT, a significant effort toward medical home capacity-building will be needed to achieve equitable access for all children. Current programs are generally located in cities, and often in academic centers.651 An individual center may or may not offer the entire range of intensive treatment, including intensive lifestyle, pharmacotherapy, and surgery. Providers should be familiar with the treatment programs at local centers; their knowledge of the child and family, along with awareness of available options, can guide treatment direction. Rural communities need resources and programs, especially ones that accommodate the distinct challenges of rural living, including transportation and economic and cultural factors.652
On the strength of the literature, the USPSTF gives the evidence for intensive ''lifestyle'' treatment of childhood obesity a ''B'' rating, which means that health plans should cover this care.79,625 The USPSTF is authorized by Congress to assign grades to the state of the evidence regarding treatment options for diseases. Under the Affordable Care Act, grades of ''A'' or ''B'' are mandated to be covered with no deductibles, copayments, or cost-sharing.653 A large gap currently exists, however, between this expectation and the actual policies in state Medicaid and commercial health plans. Health care systems should build the capacity necessary to deliver this evidence-based level of care (see the Implementation Barriers section for more discussion).
E. When Intensive Programs Are Not AvailablePediatricians and other PHCPs are on the frontline of identifying overweight and obesity. Consistent success in behavior-based obesity treatment is highly related to treatment intensity. Both individual and systemic barriers may, however, keep many families from receiving the recommended moderate- to high-intensity multicomponent obesity treatment. In addition, pediatricians and other PHCPs should be aware that pediatric patients who seek bariatric surgical treatment may encounter significant disparities in access to care based on demographics, SES, and insurance type.654
Availability of IHBLT or other treatments is generally poor, as described in a Children's Hospital Association report in 2013.655 Differences in access based on demographics and similar factors have not been well studied. A consortium of academic centers with pediatric weight management programs reported a high proportion of publicly insured patients and racial and ethnic diversity626 ; however, these sites are safety-net medical centers in larger cities and, as such, are a small sample of the children in the United States with obesity. Pediatricians and other PHCPs are encouraged to pay attention to difference in care access and seek mechanisms to mitigate these challenges.654
Although the health care and payment systems often limit the time and resources available within the primary care office, families can benefit from guidance outside of intensive programs, including pre and postprogram participation. Several successful studies have been conducted in the primary care setting, with less than 5 hours of treatment and using individual visits rather than group visits. These treatments varied in their approach and included clinical decision support built into electronic health records (EHRs), MI, and a self-guided curriculum for teens and parents.525,529,591 Strategies that may help pediatricians and other PHCPs include use of EHRs to remind and streamline care during office visits, MI training to effectively encourage families to take action, and resources for families to use outside of office visits.
When an IHBLT is not available, pediatricians and other PHCPs can increase the intensity of weight management support through collaboration and by connecting families with community resources to support nutrition and address food insecurity (eg, food provision programs), physical activity (eg, local parks, recreation programs), and other SDoHs. Pediatricians and other PHCPs should familiarize themselves with resources and actively collaborate with other specialists and community programs.
For example, pediatricians and other PHCPs should assess the availability and pediatric expertise of local dietitians and offer referrals to patients where possible. RDNs can assess a child's nutritional needs, including appropriate food groups and portion sizes, and provide guidance for specific diet needs and preferences, including cultural patterns. Some RDNs have received special certification in pediatric and adolescent obesity, and the Academy of Nutrition and Dietetics offers RDNs additional learning opportunities in pediatric and adolescent obesity and encourages training in patient-centered counseling techniques. RDNs can complement the care of medical providers and may be the most widely available specialist with whom pediatricians and other PHCPs can work to provide more intensive behavioral intervention. Behavioral health specialists, ideally integrated into primary care, can focus on the process of behavior change, including parenting skills, role modeling, and consistent reinforcement techniques.
Implementation tools can help address actions in low-resourced settings. Exercise specialists can provide counseling and training to engage children and families in noncompetitive, cooperative, fun, aerobic and nonaerobic activities. Behavior goals related to physical activity include aiming for the physical activity guidelines of 60 minutes perday of moderate to vigorous physical activity635,642 and reducing time spent in sedentary behavior.656 Physical activity limitations, such as joint pain related to musculoskeletal comorbidities or increased work of breathing related to severe obesity, should be considered, and a stepped care plan for a gradual increase in physical activity can be made. Medicaid and other insurance plans may restrict coverage to specific medical conditions which do not include obesity or risk factor reduction. Providers can search for community programs that follow a philosophy of noncompetitive, fun activities, ideally engaging the whole family. See Figure 4 for facilitators of successful health behavior lifestyle treatment.
FIGURE 4
Facilitators for successful health behavior lifestyle treatment (this figure highlights some of the factors that are associated with successful health behavior and lifestyle treatment).
FIGURE 4
Facilitators for successful health behavior lifestyle treatment (this figure highlights some of the factors that are associated with successful health behavior and lifestyle treatment).
Close modal Consensus RecommendationsThe CPG authors recommend that pediatricians and other PHCPs:
Deliver the best available intensive treatment to all children with overweight and obesity.
Build collaborations with other specialists and programs in their communities.
F. Specific Health Behavior RecommendationsMany pediatricians and other PHCPs, especially those in primary care, have an important role in recommending specific health behaviors to improve energy balance. The following specific health behavior recommendations do not form a KAS, because randomized controlled trial (RCTs) that test each in isolation do not exist and are unlikely to be performed.
Effective programs described in the technical report incorporated many nutrition, physical activity, and behavior change strategies simultaneously, an approach that is responsive to the multiple behaviors that contribute to energy imbalance. Single-component interventions, such as physical activity alone, were generally not successful, and the multicomponent studies were not designed to isolate the impact of one component over another. If the study target were too narrow (for example, consumption of 5 fruits and vegetables a day), any impact on weight or BMI would likely be too small to detect.
Most of the successful interventions described in the technical report described nutrition counseling without a structured diet. (Exceptions were a small study that found both low and modified carbohydrate diets were better than control,572 and a study that found a focus on only beverages and a focus on multiple nutrition changes were both superior to control but not different from each other.571 ) Two effective studies of adolescents implemented caloric restriction of 1300 to 1550 calories per day, but the interventions also included additional components, such as physical activity promotion and behavior change strategies.563,591 Two small studies found benefit from interventions that reduced glycemic load.564,574
Despite the lack of evidence for specific strategies on weight outcomes, many of these strategies have clear health benefits and were components in RCTs of intensive behavioral intervention. Many strategies are endorsed by major professional or public health organizations. Therefore, pediatricians and other PHCPs can appropriately encourage families to adopt these strategies.
Pediatricians and other PHCPs should present these specific strategies in the context of MI, helping families to identify their own goals and to determine steps to overcome barriers in making change. The AAP's Next Steps: A Practitioner's Guide of Themed Follow-up Visits to Help Patients Achieve a Healthy Weight provides step-by-step strategies for the pediatrician or other PHCP on content and delivery of each theme, including portion sizes, screen time and sleep, meal patterns and snacks, and bullying and teasing.657,658
Table 18 lists specific behavior strategies endorsed by major professional and public health organizations. Some systematic reviews are cited, which include many association studies, but a comprehensive search for studies and reviews was not performed.
TABLE 18Behavior Strategies
Strategy . Description . References . Reduction of sugar-sweetened beverages (SSBs) Higher intake of sugar-sweetened beverages (carbonated beverages, sweetened beverages, soda, sports drinks, and fruit drinks) is associated with greater wt gain in adults and children. The American Heart Association (AHA) recommends not more than 25 g (6 tsp) each day of added sugar and not more than 1, 8-oz serving of SSB per week. The AAP discourages the consumption of sports drinks and energy drinks for children and adolescents. The AAP statement on fruit juice notes that it is a poor substitute for whole fruit because of its high sugar and calorie content and pediatricians should advocate for elimination of fruit juice in children with excessive wt gain. Systematic review659 ; AHA SSB660 ; AAP sports and energy drinks661 ; AAP fruit juice662 Choose My Plate MyPlate is the US Department of Agriculture's (USDA) broad set of recommendations for healthy eating for Americans. These recommendations include multiple healthy diet goals: low in added sugar, low in concentrated fat, nutrient dense but not calorie dense, within an appropriate calorie range without defined calorie restriction, and with balanced protein and carbohydrate. The principles can be adapted to different food cultures. There is a surprising dearth of literature on the impact of these guidelines on health and BMI outcomes and on the most effective education practices. USDA choosemyplate.gov 60 min daily of moderate to vigorous physical activity Aerobic exercise, especially for 60 min at a time, is associated with improved body weight in youth although its effect may be small and variable. It is also associated with better glucose metabolism profiles. High-intensity interval training in youth with obesity may improve body fat, weight, and cardiometabolic risk factors, although the effect is variable.663 The Physical Activity Guidelines for Americans recommends 60 min per day for children and adolescents. Systematic reviews664''667 ; AAP physical activity; Guidelines for Americans379,635 Reduction in sedentary behavior Reduction in sedentary behavior, generally defined as reduced screen time, has consistently shown improvement in BMI measures, although impact is small. Early studies focused on reduced television, a discrete activity that is simpler than current multifunctional electronic devices. The AAP recommends no media use under age 18 mo, a 1-h limit for ages 2''5 y, and a parent-monitored plan for media use in older children, with a goal of appropriate, not-excessive use but without a defined upper limit. AAP media and young minds170 ; systematic review656 Strategy . Description . References . Reduction of sugar-sweetened beverages (SSBs) Higher intake of sugar-sweetened beverages (carbonated beverages, sweetened beverages, soda, sports drinks, and fruit drinks) is associated with greater wt gain in adults and children. The American Heart Association (AHA) recommends not more than 25 g (6 tsp) each day of added sugar and not more than 1, 8-oz serving of SSB per week. The AAP discourages the consumption of sports drinks and energy drinks for children and adolescents. The AAP statement on fruit juice notes that it is a poor substitute for whole fruit because of its high sugar and calorie content and pediatricians should advocate for elimination of fruit juice in children with excessive wt gain. Systematic review659 ; AHA SSB660 ; AAP sports and energy drinks661 ; AAP fruit juice662 Choose My Plate MyPlate is the US Department of Agriculture's (USDA) broad set of recommendations for healthy eating for Americans. These recommendations include multiple healthy diet goals: low in added sugar, low in concentrated fat, nutrient dense but not calorie dense, within an appropriate calorie range without defined calorie restriction, and with balanced protein and carbohydrate. The principles can be adapted to different food cultures. There is a surprising dearth of literature on the impact of these guidelines on health and BMI outcomes and on the most effective education practices. USDA choosemyplate.gov 60 min daily of moderate to vigorous physical activity Aerobic exercise, especially for 60 min at a time, is associated with improved body weight in youth although its effect may be small and variable. It is also associated with better glucose metabolism profiles. High-intensity interval training in youth with obesity may improve body fat, weight, and cardiometabolic risk factors, although the effect is variable.663 The Physical Activity Guidelines for Americans recommends 60 min per day for children and adolescents. Systematic reviews664''667 ; AAP physical activity; Guidelines for Americans379,635 Reduction in sedentary behavior Reduction in sedentary behavior, generally defined as reduced screen time, has consistently shown improvement in BMI measures, although impact is small. Early studies focused on reduced television, a discrete activity that is simpler than current multifunctional electronic devices. The AAP recommends no media use under age 18 mo, a 1-h limit for ages 2''5 y, and a parent-monitored plan for media use in older children, with a goal of appropriate, not-excessive use but without a defined upper limit. AAP media and young minds170 ; systematic review656 Table 19 presents strategies that are common but have not at this time been addressed by the AAP or other major health organizations. For some, rigorous systematic reviews provide information about potential benefit as well as harm or lack of harm. Brief mention of existing literature is included, but extensive searches for publications were not performed.
TABLE 19Common Strategies
Strategy . Description . References . Avoidance of breakfast skipping Breakfast skipping among children is associated with overweight and obesity and with lower quality of dietary intake throughout the day. Systematic review668 Traffic Light Diet This approach to teaching healthy eating has shown consistent success within the context of moderate- to high-intensive multicomponent programs, in which experienced providers help families learn and use the diet. Evidence summary can be found on the Academy of Nutrition and Dietetics Web site: https://www.andeal.org/topic.cfm?cat=1429&evidence_summary_id=250033&highlight=traffice%20light%20diet&home=1. 5 2 1 0 This messaging emerged from a consortium of primary care pediatricians as simple, memorable, and feasible (www.mainehealth.org/Lets-Go/Childrens-Program). Each component of 5-2-1-0 messaging aligns with a major recommendation or guideline: 5 fruits and vegetables a day is consistent with the USDA ChooseMyPlate recommendations, 2 h or less of screen time is consistent with earlier versions of AAP policy; 1 h or more of moderate to vigorous physical activity is consistent with Physical Activity Recommendations for Americans, and 0 (or nearly no) sugar-sweetened beverages aligns with USDA, AHA, and AAP. Scant literature on weight or BMI impact.669,670 Attainment of 5-2-1-0 behaviors is low.671 Use of screen-based physical activity (exergames) Video games that require physical activity can reduce children's body wt. Players can reach levels of light-to-moderate intensity physical activity during exergame play, especially games that involve whole-body movement. Systematic reviews have shown that children can lose body weight or attenuate weight gain when playing exergames over a sustained period of time. Specific setting in which exergaming resulted in weight, adiposity, or BMI z-score improvement included home, part of a structured physical activity program, and part of a multicomponent obesity treatment. Children experienced modest reductions in weight, adiposity, or BMI z-score when exergames were provided in the home, within a structured physical activity program, and within an obesity treatment program. There is less evidence to date for newer technologies like smartphone apps and wearables, but these are promising tools to engage and sustain youths' interest in healthy behaviors. 645,672''683 Appropriate amount of sleep for age Obesity is associated with shorter sleep duration, and the association appears to be driven by increased calorie consumption, decreased physical activity from fatigue, and potential hormonal and metabolic alterations such as increased ghrelin and decreased leptin leading to hunger. Systematic review243''247 Strategy . Description . References . Avoidance of breakfast skipping Breakfast skipping among children is associated with overweight and obesity and with lower quality of dietary intake throughout the day. Systematic review668 Traffic Light Diet This approach to teaching healthy eating has shown consistent success within the context of moderate- to high-intensive multicomponent programs, in which experienced providers help families learn and use the diet. Evidence summary can be found on the Academy of Nutrition and Dietetics Web site: https://www.andeal.org/topic.cfm?cat=1429&evidence_summary_id=250033&highlight=traffice%20light%20diet&home=1. 5 2 1 0 This messaging emerged from a consortium of primary care pediatricians as simple, memorable, and feasible (www.mainehealth.org/Lets-Go/Childrens-Program). Each component of 5-2-1-0 messaging aligns with a major recommendation or guideline: 5 fruits and vegetables a day is consistent with the USDA ChooseMyPlate recommendations, 2 h or less of screen time is consistent with earlier versions of AAP policy; 1 h or more of moderate to vigorous physical activity is consistent with Physical Activity Recommendations for Americans, and 0 (or nearly no) sugar-sweetened beverages aligns with USDA, AHA, and AAP. Scant literature on weight or BMI impact.669,670 Attainment of 5-2-1-0 behaviors is low.671 Use of screen-based physical activity (exergames) Video games that require physical activity can reduce children's body wt. Players can reach levels of light-to-moderate intensity physical activity during exergame play, especially games that involve whole-body movement. Systematic reviews have shown that children can lose body weight or attenuate weight gain when playing exergames over a sustained period of time. Specific setting in which exergaming resulted in weight, adiposity, or BMI z-score improvement included home, part of a structured physical activity program, and part of a multicomponent obesity treatment. Children experienced modest reductions in weight, adiposity, or BMI z-score when exergames were provided in the home, within a structured physical activity program, and within an obesity treatment program. There is less evidence to date for newer technologies like smartphone apps and wearables, but these are promising tools to engage and sustain youths' interest in healthy behaviors. 645,672''683 Appropriate amount of sleep for age Obesity is associated with shorter sleep duration, and the association appears to be driven by increased calorie consumption, decreased physical activity from fatigue, and potential hormonal and metabolic alterations such as increased ghrelin and decreased leptin leading to hunger. Systematic review243''247 When actively intervening to treat overweight and obesity in the primary care setting, pediatricians and other PHCPs should also evaluate and address the modifiable risk factors for obesity that are described in the Risk Factors section. These include parenting feeding styles, frequency of dining out and eating fast food, and ACEs, among other household risk factors. Awareness of supports and barriers in the patient's community will also help guide the family to resources outside the home, such as parks and recreation programs, community gardens, and school wellness policies.
Parents and caregivers have a crucial role to play in obesity treatment through strategies such as parental monitoring, limit setting, reducing barriers, managing family conflict, and modifying the home environment.15,684,685 A systematic review of parental involvement in childhood obesity treatment studies found that medium- to high-intensity parental involvement was associated with weight-related measures of treatment effectiveness.686 Parents can serve as role models and provide support in obesity treatment. In addition, an enhanced parent-child relationship functions as a mediator in development of healthier behaviors and further weight control.687 Parents themselves and family relationships may also benefit from children's obesity treatment.
A recent systematic review found that certain common features involving parents in obesity treatment interventions with their preadolescent children were successful in producing nutrition and physical activity behavior change. These features include promotion of intrinsic motivation and self-efficacy through empowerment of parents and children and fostering shared value and whole-family ownership. The activities most commonly associated with positive behavior change included parental leadership in goal setting, problem solving, social support, demonstrating desired behaviors, and restructuring the home environment. It is encouraging that the majority of studies that included low-income populations in this review found favorable results.688
Adolescence can present substantial challenges to family-based care, because this period is marked by a developmentally normative period of increased desire for independence and autonomy, despite continued reliance on parents for many needs. Given these challenges, the research investigating specific clinical paradigms for parent involvement in adolescent obesity treatment demonstrates mixed findings regarding the ideal level of involvement and the specific parenting strategies that can optimize treatment. Further research and detailed reporting are needed to inform clinical guidelines for optimizing the role of parents in adolescent obesity treatment.634
G. Self-ManagementObesity is a complex chronic disease with biologic, environmental, and other causative factors that are systemic and operate at the local, regional, and global level. As with all chronic disease, the patient and family have to manage the demands of the disease and evidence-based treatment in the context of these factors. This means that individual patients and their families will have unique challenges to overcome based on the severity of their disease and the adversity of their environments. Effective obesity treatment helps patients and families develop self-management strategies that are critical for chronic disease management in this context.
Self-management has been defined as ''the development of a range of attitudes, health behaviours and skills to help minimize the impact of their condition on all aspects of life for themselves and their families and caregivers.''689 Self-management has also been described ''as a dynamic, interactive, and daily process in which individuals engage to manage a chronic illness,''690 and ''the ability of the individual, in conjunction with family, community, and health care professionals, to manage symptoms; treatments; lifestyle changes; and psychosocial, cultural, and spiritual consequences of health conditions.''691 For example, dietary change is an important treatment strategy in the self-management of many chronic diseases692,693 and is about ''tailoring support to improve knowledge, skills and confidence''694 by promoting facilitators such as ''location, language, incentive and tailored resources''695 while mitigating barriers, such as inadequate knowledge or skills or lack of time.696 For young children and children with disabilities, ''self-management'' may apply to caregivers on behalf of or in conjunction with the patient.
The complex environment in which children and adolescents with obesity and their families live needs to be acknowledged in the way providers individualize and tailor self-management supports.
H. Treatment Considerations for Children and Youth With Special Health Care NeedsCYSHCN are those who have, or who are at increased risk for, a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.74
It is important that management of obesity for CYSHCN includes similar protocols and processes as those for children with typical development. This includes assessing health behaviors, identifying community resources and policies, sharing appropriate resources, and promoting healthy behaviors.697,698 Pediatricians and other PHCPs are encouraged to assess risks contributing to obesity in collaboration with families and interdisciplinary teams (specialists, psychologists, primary care providers, mental health professionals, social workers, physical therapists, and dietitians), providing their patients (CYSHCN) and their families with essential skills and resources to manage obesity.
In addition, it is critical to recognize that CYSHCN may have physical, emotional, and/or cognitive condition(s) preventing them from engaging in community or clinical activities that are available for their peers with typical development.699 Therefore, creative solutions for promoting physical activity and healthy nutrition and behavior change are vital for this special population. Solutions come from guidance and supervision from families, health care providers, and community recreation staff for appropriate physical activities and consumption of healthier food options.700''702
It is essential to emphasize the numerous benefits of recreational activities for CYSHCN to include improve socialization, fitness level, and motor and movement skills.703,704 Additional nutrition, physical activity, and sedentary time recommendations can be found in a recent report from the Healthy Weight Research Network, an interdisciplinary group of clinical investigators and experts providing obesity treatment of children with autism and other intellectual and/or developmental disabilities.697
The International Classification of Functioning (ICF), Disability, and Health model and AAP recommendations are appropriate frameworks related to assessing pertinent health conditions and contextual factors affecting CYSHCN to aid in planning to treat obesity, as seen in Fig 5. The ICF framework can be used to organize approaches in the management of childhood obesity.
FIGURE 5
The ICF framework and the F-words.705 Used with permission.
FIGURE 5
The ICF framework and the F-words.705 Used with permission.
Close modal Children with obesity-related genetic syndromes, behavioral difficulties, developmental disabilities, and hypothalamic disorders (Table 2) have added obesity risk and may need additional supports in obesity treatment.316
Hyperphagia can be particularly challenging to manage in CYSHCN. A combination of specific behavioral techniques within the context of family-based behavioral treatment and the use of pharmacotherapy may be necessary.700
Prader Willi syndrome is a complex genetic disorder affecting 1 in 15 000 to 1 in 30 000 people and is associated with obesity and hyperphagia.706,707 Specific recommendations for health supervision and multicomponent care can help pediatricians and other PHCPs institute a longitudinal treatment approach to care.
Hypothalamic obesity is a neuroendocrine disorder resulting from damage to the hypothalamus, disrupting the body's energy regulatory system, which requires intensive multicomponent treatment.708
ADHD is associated with obesity, and symptoms such as deficits in alertness and attention that are caused by sleep-disordered breathing attributable to obesity can overlap with those of ADHD. Impulsivity in ADHD may contribute to dysregulated eating and weight gain. Effective treatment of ADHD in children with obesity can be associated with attainment of healthier weight status.709
I. Use of Pharmacotherapy Consensus RecommendationThe CPG authors recommend pediatricians and other PHCPs:
May offer children ages 8 through 11 years of age with obesity weight loss pharmacotherapy, according to medication indications, risks, and benefits, as an adjunct to health behavior and lifestyle treatment.
Although IHBLT has the largest body of evidence meeting the evidence review's high-quality evidence for effectiveness criteria, it is important to consider the use of pharmacotherapy for children and adolescents who require an additional treatment option to manage their obesity. In particular, children with more immediate and life-threatening comorbidities, those who are older, and those affected by more severe obesity may require additional therapeutic options. For children younger than 12 years, there is insufficient evidence to provide a KAS for use of pharmacotherapy for the sole indication of obesity. There are, however, specific conditions outlined below for which use of medication may be indicated. Additionally, although the evidence is insufficient at the time of this evidence review, the use of pharmacotherapy to aid BMI reduction in children is a rapidly evolving field; new evidence may lead to additional options for children younger than 12 years in the future.
Studies IncludedAt the time of the evidence review for this CPG, 27 randomized studies met the inclusion criteria for review, and an additional 8 observational studies were also considered. The majority of the studies evaluated the efficacy of metformin either alone (n = 16 randomized, 7 observational) or in combination with other medications (n = 7 randomized). Other studies evaluated orlistat (n = 2 randomized), exenatide (n = 2 randomized), or other medications with only 1 study cited (phentermine, mixed carotenoids, topiramate, ephedrine, and recombinant human growth hormone). Since the evidence review, additional high-quality evidence has been published to define the safety and efficacy of novel agents (setmelanotide, liraglutide, and the combination phentermine or topiramate) and are included in this discussion.
Medication Use and Mechanisms of ActionMetformin is an antidiabetic agent used in T2DM among patients 10 years and older. Metformin also has several indications not approved by the US Food and Drug Administration (FDA), including prediabetes, PCOS, and prevention of weight gain when used with atypical antipsychotic medications. Metformin is a biguanide drug that reduces blood glucose levels by decreasing blood glucose production in the liver, decreasing intestinal absorption, and increasing insulin sensitivity. It comes in immediate- and extended-release formulations; the recommended starting dose is 500 mg, once or twice daily, with gradual increases up to a maximum total daily dose of 2500 mg. Adverse effects are dose-dependent, and include bloating, nausea, flatulence, and diarrhea. Lactic acidosis is a serious but very rare complication in pediatric populations.711
Metformin has not been approved as a weight-loss drug. A 2020 meta-analysis of metformin studies in adults with obesity showed modest (<5%, or 1 BMI unit) weight reduction with metformin when used as an adjunct to lifestyle; however, the effectiveness is inconsistent across different populations.712 The evidence for effectiveness of metformin for weight loss in pediatric populations is similarly conflicting. One small study randomized 39 teens 13 to 18 years of age with obesity participating in a lifestyle modification program to either metformin hydrocholoride XR 2000 mg, or placebo once daily for 48 weeks.713 Adolescents taking metformin reduced BMI by approximately 1 kg/m2 as compared with a slight increase in BMI among teens in the lifestyle-only program.
Another well-designed randomized study of 100 children 6 to 12 years of age with severe obesity (mean BMI 34.6 kg/m2) showed a BMI reduction of approximately 1 kg/m2 at a dose of 1000 mg twice daily for 6 months, also as an adjunct to lifestyle treatment.714 Gastrointestinal symptoms limited the tolerated maximum dose in nearly 20% of patients, however, and no additional BMI reduction was noted with treatment beyond 6 months. Of the 16 studies of metformin that met quality inclusion criteria for the evidence review, about two-thirds showed modest BMI reduction.713''724 One-third showed no benefit.725''728
The effective studies typically included higher metformin doses, more intensive lifestyle adjunct treatment, and use in children or adolescents with more severe obesity and/or a secondary diagnosis, such as prediabetes or PCOS. Given the modest and inconsistent effectiveness, metformin may be considered as an adjunct to intensive health behavior and lifestyle treatment and when other indications for use of metformin are present.
Orlistat is an intestinal lipase inhibitor that blocks fat absorption through inhibition of pancreatic and gastric lipase. It is currently approved for children 12 years and older at a dose of 120 mg, 3 times per day. Adverse effects include steatorrhea, fecal urgency, and flatulence; these adverse effects greatly limit tolerability, and thus, orlistat is uncommonly used in pediatric obesity treatment. Orlistat is FDA approved for long-term treatment of obesity in children 12 years and older.729,730
Glucagon-like peptide-1 receptor agonists, such as liraglutide, exenatide, dulaglutide, and semaglutide, decrease hunger by slowing gastric emptying and by acting on targets in the central nervous system. Depending on the medication, the formulation is either oral or a daily or weekly subcutaneous injection. Two small studies of exenatide (weekly injection) among children as young as 8 years showed BMI reduction ranging from 0.9 to 1.18 U but with significant adverse effects. Exenatide is currently approved in children 10 to 17 years of age with T2DM. A recent randomized controlled trial found liraglutide (daily injection) more effective than placebo in weight loss at 1 year among patients 12 years and older with obesity who did not respond to lifestyle treatment.710 The magnitude of the difference was approximately 4.5 kg body weight lost, or 5% BMI reduction. The starting dose is 0.6 mg per day up to a maximum dose of 3.0 mg per day, by subcutaneous injection. Adverse effects include nausea and vomiting, and among patients with a family history of multiple endocrine neoplasia, a slightly increased risk of medullary thyroid cancer.710 Liraglutide is FDA approved for long-term treatment of obesity (with or without T2DM) in children 12 years and older.
Melanocortin 4 receptor (MC4R) agonists, such as setmelanotide, act on the MC4R pathway to restore normal function for appetite regulation that has been disrupted because of genetic deficits upstream of the MC4 receptor. MC4 receptors in the brain regulate hunger, satiety, and energy expenditure. The daily dose is 1 to 3 mg daily, given subcutaneously, and results in weight loss of 12% to 25% over 1 year in a small, uncontrolled study of patients with these rare deficits. Common adverse effects include injection site reaction and nausea. Setmelanotide is FDA approved for patients 6 years and older with proopiomelanocortin (POMC) deficiency, proprotein subtilisin or kexin type 1 deficiency, and leptin receptor deficiency confirmed by genetic testing.
Phentermine is a central norepinephrine uptake inhibitor but also nonselectively inhibits serotonin and dopamine reuptake and reduces appetite. Recommended doses include 7.5 mg, 15 mg, 30 mg, or 37.5 mg, and adverse effects include elevated BP, dizziness, headache, tremor, dry mouth, and stomachache. Adverse effects are dose-dependent; however, effectiveness does not always increase with increasing dose. Phentermine is FDA approved for short-course therapy (3 months) for adolescents 16 years or older.
Topiramate is a carbonic anhydrase inhibitor and suppresses appetite centrally through largely unknown mechanisms. The major adverse effect is cognitive slowing, which can interfere with academic concentration or other activities of daily living. In addition, topiramate is a potential teratogen and requires counseling and reliable birth control for patients able to become pregnant. Typical dosing for headache prevention ranges from 25 mg a day to 100 mg a day in twice daily doses. Although topiramate has an indication for treatment of binge eating disorder in adults (age '‰¥ 18), only 1 study has evaluated the use of topiramate in children, and it did not differ from placebo. Topiramate is currently FDA approved for children 2 years and older with epilepsy and for headache prevention in children 12 years and older.
Phentermine and topiramate as a combination medication is approved for weight loss in adults. Recent data show that among adolescents 12 to 17 years of age with documented history of failure to lose sufficient weight or failure to maintain weight loss in a lifestyle modification program (mean age, 14 years; mean BMI, 37.8 kg/m2), BMI percent change at 56 weeks was -10.44 (high dose; 15 mg/ 92 mg) and ''8.11 (mid dose; 7.5 mg/46 mg) as compared with placebo.731 Treatment also improved HDL and TG cholesterol profiles. Adverse events reported were not more common than placebo in the high- or mid-dose range.
Lisdexamfetamine is similar in mechanism to phentermine and is a stimulant-class medication approved for children 6 years and older with ADHD. It has an indication for treatment of binge eating disorder in patients 18 years and older; thus, it is used off-label for children with obesity. However, no evidence is available at the time of this review to demonstrate safety or efficacy for the indication of obesity in children.
Prescriber QualificationsWeight loss medications require the same oversight and expertise in management as other medications used in pediatric care. To adequately inform patients and parents about the risks and benefits of off-label or experimental use of new therapies, pediatricians and other PHCPs who prescribe weight loss medications should have knowledge of the patient selection criteria, medication efficacy, adverse effects, and follow-up monitoring guidelines. In addition, injectable medications may require additional teaching for families that is not available in all primary care offices. Pediatricians and other PHCPs may choose to refer to pediatric obesity experts or treatment centers for prescribing weight loss medication.
No current evidence supports weight loss medication use as a monotherapy; thus, pediatricians and other PHCPs who prescribe weight loss medication to children should provide or refer to intensive behavioral interventions for patients and families as an adjunct to medication therapy.
J. Pediatric Metabolic and Bariatric SurgeryIt is widely accepted that the most severe forms of pediatric obesity (ie, '‰¥class 2 obesity; BMI '‰¥ 35 kg/m2, or 120% of the 95th percentile for age and sex, whichever is lower) represent an ''epidemic within an epidemic.'' Moreover, severe obesity is a harbinger of the establishment and cumulative progression of numerous related comorbidities, diminished long-term health status, and shortened life expectancy.654,739
For adults, the evidence supporting the clinical indications and associated recommendations on the use of metabolic and bariatric surgery is founded on a body of literature that has been expanding since the early 1960s.740 Corresponding analyses related to the use of various surgical weight loss procedures in pediatric populations have been primarily established in the last 20 to 30 years. Large contemporary and well-designed prospective observational studies have compared adolescent cohorts undergoing bariatric surgical treatment versus intensive obesity treatment or nonsurgical controls.
These studies suggest that weight loss surgery is safe and effective for pediatric patients in comprehensive metabolic and bariatric surgery settings that have experience working with youth and their families. Laparoscopic Roux-en-Y gastric bypass and vertical sleeve gastrectomy are both commonly performed in the pediatric age group and result in significant and sustained weight loss, accompanied by improvements and/or resolution of numerous related comorbid conditions.732 Laparoscopic adjustable gastric band procedures, approved by the FDA only for patients 18 years and older, have declined in use in both adults and youth because of worse long-term effects as well as higher-than-expected complication rates.647,652,654,655,706,732''736,739''744
Similar to the adult experience, an expanding body of data shows that pediatric bariatric patients also experience durable reduction in BMI,152,744''748 as well as significant improvement and/or complete amelioration of several obesity-related comorbid conditions. These include HTN, T2DM, dyslipidemia, cardiovascular disease risk factors, and weight-related quality of life.152,654,734
Furthermore, recent evidence showing that adolescents had a higher probability of remission of certain cardiometabolic risk factors (T2DM and HTN) compared with adults highlights the argument that earlier surgical intervention may impart specific advantages related to the cumulative impact of chronic obesity-related diseases.736 The significantly lower magnitude of efficacy of intensive behavioral interventions'--compared with larger and more durable improvements in BMI and comorbidity resolution after metabolic and bariatric surgery'--has led to a significant increase in pediatric bariatric surgical case volume since the early 2000s.126
The majority of complications following metabolic and bariatric surgery in the pediatric population are minor (15%), occur mostly in the early postoperative timeframe, and consist of a combination of postoperative nausea and/or dehydration, although major perioperative (30-day) complications have been reported in 8% of individuals.654,733 Subsequent related procedures may be required in 13% to 25% of patients up to 5 years following metabolic and bariatric surgery.744,746,747 In addition, recent data showing multiple micronutrient deficiencies following metabolic and bariatric surgery serve to highlight the need for routine and long-term monitoring.
Although the determination of eligibility for metabolic and bariatric surgery relies heavily on a multicomponent and individualized approach between members of the metabolic and bariatric surgery team, the patient, and the patient's parents or guardians, initial steps toward consideration should be provided, when appropriate, within the medical home. Specifically, pediatricians and other PHCPs should be familiar with recent and clearly defined clinical and anthropometric benchmarks, which serve as a prompt for the initiation of these discussions with the patient and family and ongoing bilateral communication between the medical home and surgical center654,733 (Table 20). In addition to knowledge of indications for metabolic and bariatric surgery, pediatricians and other PHCPs should build and maintain skills in discussing this topic with families in a nonbiased and sensitive manner. Pediatricians and other PHCPs should also seek to establish a local and/or regional referral mechanism to qualified facilities that offer pediatric-focused metabolic and bariatric surgical services.
KAS 3. In children 10 y and older, pediatricians and other PHCPs should evaluate for lipid abnormalities, abnormal glucose metabolism, and abnormal liver function in children and adolescents with obesity (BMI '‰¥ 95th percentile) and for lipid abnormalities in children and adolescents with overweight (BMI '‰¥ 85th percentile to <95th percentile).
Aggregate Evidence Quality . Grade B. . Benefits Allows for early detection and management to reduce risk factors for future cardiometabolic disease. Result will guide treatment. May motivate treatment engagement. Risks, harm, costs Cost, access, patient anxiety, labeling with chronic medical condition, stress, and time of undergoing treatment. Benefit-harm assessment Identification and management of cardiometabolic comorbidities in childhood and adolescence exceeds potential harm, especially for high-risk patients. Intentional vagueness Age. Role of patient preferences Parent and patient knowledge, family history, families' concern about the test, ease and accessibility of testing should be considered. Exclusions <24 mo old. Strengths Strong. Key references 80, 86, 88, 90, 396, 397, 413''416 Aggregate Evidence Quality . Grade B. . Benefits Allows for early detection and management to reduce risk factors for future cardiometabolic disease. Result will guide treatment. May motivate treatment engagement. Risks, harm, costs Cost, access, patient anxiety, labeling with chronic medical condition, stress, and time of undergoing treatment. Benefit-harm assessment Identification and management of cardiometabolic comorbidities in childhood and adolescence exceeds potential harm, especially for high-risk patients. Intentional vagueness Age. Role of patient preferences Parent and patient knowledge, family history, families' concern about the test, ease and accessibility of testing should be considered. Exclusions <24 mo old. Strengths Strong. Key references 80, 86, 88, 90, 396, 397, 413''416 TABLE 20Criteria for Pediatric Metabolic and Bariatric Surgery733
Weight Criteria . Criteria for Comorbid Conditions . Class 2 obesity, BMI '‰¥ 35 kg/m2 or 120% of the 95th percentile for age and sex, whichever is lower Clinically significant disease; examples include but are not limited to T2DM, IIH, NASH, Blount disease, SCFE, GERD, obstructive sleep apnea (AHI >5), cardiovascular disease risks (HTN, hyperlipidemia, insulin resistance), depressed health-related quality of life. Class 3 obesity, BMI '‰¥ 40 kg/m2 or 140% of the 95th percentile for age and sex, whichever is lower Not required but commonly present. Weight Criteria . Criteria for Comorbid Conditions . Class 2 obesity, BMI '‰¥ 35 kg/m2 or 120% of the 95th percentile for age and sex, whichever is lower Clinically significant disease; examples include but are not limited to T2DM, IIH, NASH, Blount disease, SCFE, GERD, obstructive sleep apnea (AHI >5), cardiovascular disease risks (HTN, hyperlipidemia, insulin resistance), depressed health-related quality of life. Class 3 obesity, BMI '‰¥ 40 kg/m2 or 140% of the 95th percentile for age and sex, whichever is lower Not required but commonly present. AHI, apnea-hypopnea index.
Individual determination of eligibility status at the time of referral to a center that offers metabolic and bariatric surgical intervention for the pediatric population involves a comprehensive and multidisciplinary assessment of longitudinal BMI and comorbidity status as well as physiologic and psychosocial assessment, including the determination of potential contraindications such as correctable causes of obesity, ongoing substance use disorder, and pregnancy. Important elements include the ability to determine the patient's and family's capacity to understand the risks and benefits of metabolic and bariatric surgery and adhere to required lifestyle modifications leading up to and following such intervention. The evaluative process is rooted in a framework of thoughtful, shared decision making between the patient, parents(s) and/or guardian(s), and medical and surgical providers and ideally includes coordinated and ongoing communication with the patient's medical home.654,733
A referral to a comprehensive metabolic and bariatric surgery center with experience and expertise in treatment of patients younger than 18 years does not necessarily mean the child will ultimately have surgery. This referral provides the family with important information and additional evaluation of risks and benefits for use in making an informed decision. In the case of younger children, recommendations for referral to a comprehensive multidisciplinary obesity treatment center with surgical capability should be considered on a case-by-case basis.
Although data addressing surgical intervention in the younger age group are limited, recent comparative analysis show sustained efficacy and similar safety profiles when compared with adolescents.737,738 Additional research is needed before broad recommendations can be made for children 12 years and younger.
Age is not the sole determinant of eligibility for metabolic and bariatric surgery. The pediatrician or other PHCP should take into account the patient's physical and psychosocial needs. Evaluation for metabolic and bariatric surgery should include a holistic view of the patient and family, including individual and social risk factors. Families should be fully informed of the benefits and risks of metabolic and bariatric surgery, and their preferences are paramount. As highlighted in a recent AAP policy statement, the decision to continue care with a pediatrician or pediatric medical or surgical subspecialist should be made solely by the patient (and the family, as appropriate).749
Insurance authorization is a key consideration for individuals considering metabolic and bariatric surgical intervention regardless of age; however, data highlight a significant disparity regarding benefit coverage when comparing pediatric versus adult populations.126 Efforts to determine coverage availability, including potential mitigation strategies designed to address coverage gaps, should be the focus of early discussions between the family, medical home, and metabolic and bariatric surgical specialty providers. Children and adolescents who are referred for evaluation for metabolic and bariatric surgery should have this referral visit covered, and those who are deemed eligible for metabolic and bariatric surgery should have their preparation visits, the surgery itself, hospitalization, postoperative visits, and ongoing care covered.
K. Comprehensive Obesity Treatment (COT) for Children and AdolescentsThe essential components of COT of children and adolescents include treatment of the obesity as a chronic disease and evaluation and management of comorbidities. This treatment is delivered by primary care providers and their teams, in collaboration with pediatric obesity specialists, allied health providers, community partners, and metabolic and bariatric surgery teams.
COT: COT includes79,80 :
Providing intensive, longitudinal treatment in the medical home
Evaluating and monitoring child or adolescent for obesity-related medical and psychological comorbidities
Identifying and addressing social drivers of health
Using nonstigmatizing approaches to clinical treatment that honor unique individual qualities of each child and family
Using MI that addresses nutrition, physical activity, and health behavior change using evidence-based targets for weight reduction and health promotion
Setting collaborative treatment goals not limited to BMI stabilization or reduction, including goals that reflect improvement or resolution of comorbidities, quality of life, self-image, and other goals related to holistic care
Integrating weight management components and strategies across appropriate disciplines, which can include intensive health behavior and lifestyle treatment, with pharmacotherapy and metabolic and bariatric surgery if indicated
Tailoring treatment to the ongoing and changing needs of the individual child or adolescent and the family and community context
Who delivers COT? Ideally, primary care teams and pediatric weight management specialty teams will partner to provide COT for children and adolescents with obesity. Primary care providers evaluate for obesity, evaluate for comorbidities, and provide patient-centered and evidence-based nutrition and physical activity guidance, using MI. Some primary care practices may also be able to provide IHBLT and pharmacotherapeutic options. IHBLT, regardless of where it is delivered, requires the allocation of significantly more time and resources than are typical in the provision of routine well childcare. Coordination in the medical home with additional professionals, such as dietitians, exercise specialists and behavioral health practitioners, will depend on the child's COT plan and available resources. Pediatric health care providers can augment COT with referral to community resources and programs (see algorithm in Appendix 1).
XII. Systems of Care for Children With Overweight and ObesityObesity is a chronic disease'--similar to asthma and diabetes. Children and adolescents with obesity have the potential to benefit from the foundational standards for systems of care designed for children and youth with special health care needs.153,750 CYSHCN are defined as ''those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.''74 The principles of the chronic care model and the medical home that can also benefit children with obesity include the following:
A. Provision of Evidence-based CareAll care provided to children and youth with obesity and their families should be evidence based where possible; where evidence-based approaches do not exist, care should be evidence informed and/or based on promising practices.
As pediatric obesity becomes an increasing public health issue and recognizable chronic disease, it becomes critical to rely on evidence-based medicine and or expert recommendations to establish prevention, assessment, and treatment of obesity. To date, several guidelines have been developed and updated to address obesity in children. Examples include ''Pediatric Obesity'--Assessment, Treatment, and Prevention: An Endocrine Society Clinical Practice Guideline,'' and ''Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity.'' These guidelines have been critical in moving forward with the prevention, assessment, and treatment of obesity in children as new research is conducted and more new evidence becomes available. This CPG adds to this body of knowledge.15,268,685
B. Partnership With Children and FamiliesChildren and families of children and youth with obesity should be active and core partners in decision making in all levels of care.
Patient-centered care involves not only an understanding of the family's social and cultural context but also an appreciation for their desires as decisions are made about obesity treatment. Family desire for treatment should not be assumed despite attendance at primary care or specialty weight management visits. Pediatricians' and other PHCPs' use of MI techniques can, however, reinforce the importance of family-driven treatment decisions and foster families' internal motivation that can sustain treatment. As a relationship is built with the family, MI can form the foundation for shared decision making between pediatricians (and other PHCPs) and families about treatment continuation and intensification.751
The advent of parent and patient EHR portals has enabled bidirectional communication between families and health care teams and can facilitate shared decision making in obesity treatment. Additional facilitators may include tools featuring direct input from families, such as care plans and care coordination agreements.752 A patient decision aid to promote shared decision-making about options for adolescent severe obesity treatment was found to be feasible and acceptable by pediatricians (and other pediatric health care providers) and families.753
C. Provision of Health Care That Recognizes Cultural ValuesAll services and supports for children and youth with obesity and their families should be implemented and delivered in a linguistically appropriate and accessible manner that recognizes cultural values.
All written materials provided to children and youth with obesity and their families should be culturally appropriate and in a manner and format appropriate for children and their parents or caregivers who have limited English proficiency, lower levels of literacy, or sensory impairments. With families with limited English proficiency, vigilance is needed to also provide a trained interpreter and use growth charts in educating about obesity.754
D. Medical Home Children With Obesity Should be Cared for in a Medical HomeThe benefits of a medical home for children and youth with obesity include streamlined care, efficient use of resources (home-, school-, and community-based services), expanded expertise and competence for the involved providers, establishment of a forum for problem solving, and improved satisfaction for the patient, family, and provider. Primary care providers can help identify children early as obesity is developing and base intervention efforts on family dynamics and reduction in high-risk dietary and activity behaviors.755 Linkages should also be established between primary care practices and obesity treatment clinics to coordinate care with obesity specialists when necessary (eg, psychologist, dietitian, physician). The medical home also provides an effective model for implementing successful transitions to adult-oriented systems to treat obesity.
E. Transition to Adult Primary Care Providers Children and adolescents with obesity should have a plan for a transition of care to adult primary care providers.Transition of care for children with obesity to adult primary care providers is an important field for which evidence and recommendations have been developing. Generally, the concept of transition of care highlights the importance of the collaboration of the primary and/or subspecialty pediatric, adolescent, or family medicine care team, with the adult provider who is preparing to assume the role of primary care provider for a young adult. The importance of a formal transition plan has been shown in children with diabetes mellitus, sickle cell disease, and congenital heart disease.468,756''762 Specifically, transition of care plans have been shown to improve knowledge and self-efficacy and help to integrate the young adult into a new medical home or neighborhood.757,761,763,764
The transition of care literature for childhood obesity is limited but growing.752,765,766 In general, transition of care for obesity involves the development of specific goals and a timeline for the transition.759 This also includes the development of a registry type system to track and alert pediatricians and other PHCPs when a child reaches the age of 12 years so that outreach to the family to start the transition process can occur.468,762,763 It is generally understood that timing of these discussions and the actual transition of care to an adult primary care provider(s) or team depends on the individual needs of the patient and family as well as developmental and neurocognitive abilities. It is also understood that these discussions should be ongoing, at least annually. It is highly recommended that the providers and teams should be in direct communication with each other. Peer support groups are also highly recommended to assist the patient and family and to provide a peer network as part of the medical home.752,767
The complex nature of obesity management and care, including the structured changes involved in behavioral strategies, the connection with community-based programs, and the need for medication therapy and surgery for a number of children and adolescents with obesity highlights the importance of a coordinated transition plan, frequent communication with the patient and family, and between providers and teams early on.752,765,766,768,770
XIII. Barriers and Recommendations for CPG ImplementationPediatricians and other PHCPs and families face numerous barriers to promoting healthy, active lifestyles and to supporting obesity treatment among children. The successful implementation of this CPG into routine practice requires careful consideration of barriers and facilitators at the policy, community, practice, and provider level that can modify implementation, effectiveness, and sustainability.
A. Policy LevelAt the forefront of the policy-level barriers to the implementation of these guidelines are both direct and indirect costs that are associated with recommended evaluation and effective treatment of obesity. In 2010 and again in 2017, the USPSTF designated a grade B classification for evidence of effectiveness of childhood obesity screening and high-intensity, family-based behavioral treatment.79 Although a grade B designation should secure reliable insurance payment under the statutes of the Affordable Care Act , the lack of payment by insurers remains a major barrier to childhood obesity treatment.769,770 There is currently no consistent coverage of other evidence-based treatment strategies not explicitly included in the USPSTF recommendation.
Direct costs to families include payment for obesity evaluation and treatment that insurers do not pay for, as well as insurance plans with high deductibles or copays. These cost barriers make it difficult for families to access care, obtain laboratory testing, attend follow-up visits, and initiate and/or complete treatment programs. Differences in payment policies between public and private insurers and restrictive provider networks can make it challenging for pediatricians and other PHCPs to achieve consistent management practices. The overall lack of financial support from either insurance companies or families' inability to pay for treatment programs disincentivizes the expansion of their availability, and there have not been robust studies on best practices for scaling up and sustaining effective treatment programs.
For patients and families, efforts to implement the recommendations for behavior change are also associated with indirect costs (such as time and costs associated with healthier foods and exercise) and are heavily impacted by policies at the federal, state, and local level. These policies include agricultural subsidies, school nutrition, and physical activity standards and curricula, zoning and public spaces to promote safe physical activity, tax deductions for direct advertising of unhealthy foods to minors, and nutrition labeling.771''773 As the recent AAP policy statement on the role of racism in child health and well-being notes, the long-standing structural racism that has plagued these policies manifests in the form of limited access to high-quality education, safe neighborhoods for active play, healthy food, and health care for people of certain races and ethnicities.52,774
One simulation-based cost effectiveness analysis of multiple interventions for childhood obesity found that 3 policies were estimated to be cost-saving; in other words, they would save more in health care costs through reduction in obesity prevalence than it would cost to implement.771 The policies are: (1) implementing an excise tax on SSBs; (2) elimination of the tax deduction for companies advertising unhealthy foods to children; and (3) improving nutrition standards for food and beverages sold in schools outside of meals. Another simulation study projected that an excise tax on SSBs, banning child-directed advertising of fast food, and providing after-school physical activity programs would all reduce obesity prevalence while also reducing disparities.773
Implementation Consensus Recommendation 1 : The subcommittee recommends that the AAP and its membership strongly promote supportive payment and public health policies that cover comprehensive obesity prevention, evaluation, and treatment. The medical costs of untreated childhood obesity are well-documented and add urgency to provide payment for treatment.122 There is a role for AAP policy and advocacy, in partnership with other organizations, to demand more of our government to accelerate progress in prevention and treatment of obesity for all children through policy change within and beyond the health care sector to improve the health and well-being of children. Furthermore, targeted policies are needed to purposefully address the structural racism in our society that drives the alarming and persistent disparities in childhood obesity and obesity-related comorbidities.
B. Community and Population LevelAt the community and population level, SDoHs can limit the implementation and prioritization of health behavior recommendations (including counseling on nutrition, physical activity, sleep, and screen time) for both pediatricians (or other PHCPs) and families. These SDoHs include food security, safe neighborhoods and housing, health literacy, weight-related parenting skills, household chaos, and access to transportation.
Many communities lack access to evidence-based, high-intensity weight management programs for treatment, either in clinical or community-based settings.775,776 Telehealth and mobile technologies are emerging as a potential means to close this access gap, but little is known about the effectiveness of pediatric weight management treatments via these modalities.777 The well-described digital divide may also limit their utility among populations disproportionately impacted by obesity.778,779 A failure to consider these factors could lead to worsening disparities.
The recent iteration of the Obesity Chronic Care Model proposes an integrated framework for the prevention and treatment of obesity.521,780 The framework discusses the importance of coordinating and integrating approaches to address obesity across clinical and community systems as well as stakeholders. In doing so, an integrated approach strives to identify and address barriers to equitable implementation, access to healthier options, and data sharing. An important part of integration includes the identification of an integrator or convener that brings stakeholders together in a collaborative effort to address population health. Integrators are essential to addressing social determinants of health and complex problems that no single stakeholder can address.
Implementation Consensus Recommendation 2 : The subcommittee recommends that public health agencies, community organizations, health care systems, health care providers, and community members partner with each other to expand access to evidence-based pediatric obesity treatment programs and to increase community resources that address social determinants of health in promoting healthy, active lifestyles.521
C. Practice and Provider LevelAt the practice and provider level, classic barriers to implementation of guidelines include the lack of time, resources, knowledge, awareness, self-efficacy (confidence in one's ability to perform a behavior), and outcome expectancy (the belief that a recommended behavior will lead to a specific effect).781 Evidence indicates that clinical decision support (CDS) can be delivered through EHR systems to help overcome some of these practice- and provider-level barriers and improve evaluation and effective management. Evidence-based CDS tools include assessment components (ie, flagging abnormal heights, weights, and BMIs) and provision of suggestions for obesity treatment, such as order sets for recommended laboratory tests or other follow-up actions.529,782''784 Most pediatric providers currently use EHRs that calculate and plot BMI; however, limitations of EHR systems hinder rapid dissemination and implementation of innovations to support practice.785''787
Implementation Consensus Recommendation 3 : The subcommittee recommends that EHR vendors, health systems, and practices implement CDS systems broadly in EHRs to provide prompts and facilitate best practices for managing children and adolescents with obesity.
At the same time, EHRs can only do so much and are ineffective in the absence of a clinical workforce that is knowledgeable about evidence-based obesity treatment and skilled in delivering high-quality, patient-centered care that will yield improved health outcomes for children with obesity. The recent AAP policy statement on weight stigma highlights the detrimental effects of weight bias and ineffective approaches to the diagnosis and management of obesity.28
Implementation Consensus Recommendation 4: The subcommittee recommends that medical and other health professions schools, training programs, boards, and professional societies improve education and training opportunities related to obesity for both practicing providers and in preprofessional schools and residency and fellowship programs. Such training includes the underlying physiologic basis for weight dysregulation, MI, weight bias, the social and emotional impact of obesity on patients, the need to tailor management to SDoHs that impact weight, and weight-related outcomes and other emerging science.
XIV. Evidence Gaps and Future Research DirectionsResearch in the field of pediatric overweight and obesity has rapidly increased over the past decade and supports the evidence-based recommendations and guidelines contained in this CPG on the assessment and management of pediatric overweight and obesity. Although research has progressed in these areas, significant gaps remain and are described in detail in the accompanying technical reports. The gaps and limitations that are most relevant to pediatricians and other PHCPs treating children with obesity include duration and heterogeneity of treatment effects and limits in our understanding of how specific treatment components interact.
Duration of treatment effects. Limited research with long-term follow-up exists to determine: (1) whether treatment leads to sustained weight improvements, and (2) how comorbidities develop throughout childhood. Longer-term data are needed to establish sufficient weight loss or cardiovascular improvements influencing health into adulthood.
Heterogeneity of treatment effects and special populations. Current research does not provide sufficient information about the heterogeneity of treatment effects for obesity interventions, limiting our ability to identify which treatment is most likely to be effective for a specific child. Many factors may increase obesity risk and impact treatment course but are poorly isolated in studies to date. These factors may include geographical region, food insecurity, poverty, ACEs, and other social drivers. Perhaps most importantly, severity of obesity has not been clearly considered in most interventions, and treatment is likely to have different effectiveness in children with greater severity of disease. Similar to obesity research, most research on treatment and comorbidities use relatively restrictive inclusion criteria, excluding children with comorbidities (including mental health conditions), children with physical activity limitations, children with disabilities, or those using medications. In clinical practice, these children often have the greatest need for support in addressing obesity.
Limited understanding of specific components, dose, and duration. Published intervention studies often provided limited information about the dose, duration, and specifics of the intervention components.80 This limitation makes it difficult to provide detailed information about specific intervention content, behavior change techniques, and approaches to improve retention and family motivation. Further, the limited research on potential synergies among lifestyle intervention components as well as pharmaceutical and surgical interventions prevents the development of individualized treatment plans tailored to a child's weight and health status, motivation, and readiness.
Despite these limitations, half of the lifestyle randomized-control trials reviewed were effective in reducing adiposity. Reports of future studies detailing specific treatment components, implementation of behavioral approaches, provider involvement in clinical practice, and the socioeconomic and cultural context of the family and community are needed to better understand which interventions work, for whom, and in what situations.
In addition to these critical areas for future research, there are other limitations that should be considered in the context of the guidelines.
For comorbidity assessment, studies were mostly cross-sectional, limiting the ability to assess within-individual changes in comorbidity prevalence across age and obesity class and, therefore, guidance on the appropriate age to begin laboratory evaluation for cardiometabolic comorbidities. Epidemiologic studies intended for specific age ranges and that examine comorbidity prevalence across different levels of overweight and obesity would help identify specific ages and BMI classes with increased prevalence of cardiometabolic comorbidities to focus further research. Longitudinal studies would also help identify the optimal age and BMI ranges to begin evaluation and are needed to monitor progression of comorbidity related to age and BMI level and provide guidance on the recommended frequency of comorbidity reevaluation. Consistent thresholds of laboratory values across studies are also needed.
Although many treatment studies examined change in biomedical outcomes as markers of secondary prevention of comorbidities, few studies in primary care evaluated outcomes other than BMI. Additionally, studies that assess if comorbidity assessment and/or diagnosis influences patient and family engagement in weight management treatment are lacking. The role of SDoHs and culture in the treatment of obesity comorbidities is also limited. Studies examining motivation for behavior change related to health outcomes and inclusion of SDOH factors in treatment outcomes are needed. Finally, most studies provided no or very limited assessment of harms or unintended consequences. In general, behavioral interventions carry low-risk of harms; this is not well-documented in the existing literature, however, as few studies report adverse events.
The scope of the evidence review for this CPG did not include primary prevention of obesity or assessment and treatment of children 0 to 2 years of age. Early prevention of obesity is important, as 1 in 7 preschool-aged children already have obesity, and disparities in obesity are evident in the first years of life.3 Identification and guidance on treatment strategies in this population are needed. Resources for primary prevention in children of all ages and treatment of children younger than 2 years can be found on the AAP Institute for Healthy Childhood Weight's Web site (www.ihcw.aap.org) and are also provided in the implementation materials. Future CPGs should incorporate the voices of caregivers, children or adolescents, and organizations that represent families to lend important context.
In addition to the above, a list of other gaps and considerations for further research are provided in Table 21.
Type of Gap . Example of Gap . Epidemiology ' Key drivers of reducing obesity prevalence' Predictors of severe obesity' Factors associated with obesity among racial and ethnic groups, including impact of SDoHs on disparities' Identification of medical costs associated with obesity and comorbidities Definition or measurement ' Alternative, accurate measurements of adiposity in primary care; ' BMI trajectories in clinical practice and response to treatment over time; ' BMI trajectories and development of comorbid conditions; ' BMI status and trajectories among race/ethnic groups and the impact of social drivers on BMI status and trajectories Risk factors ' Mechanism by which maternal obesity predisposes to adverse outcomes in the offspring' Impact of sedentary behavior alone on BMI and comorbidities' Improved understanding of associations between obesity and food insecurity Comorbidities ' Age to begin evaluation for cardiometabolic comorbidities' Frequency of evaluation to monitor progression of comorbidity' Comorbidity identification as motivation for behavior change' Role of social determinants of health in obesity comorbidities, especially among minority populations' Role of social determinants of health in obesity comorbidities Treatment ' Tailored age-based treatment approaches' Evidence-based treatment options for 0''5 = year-olds' Optimal level of parent involvement among adolescents in weight management' Optimizing MI use with respect to training, fidelity to the MI process, and potential patient characteristics' Evidence for specific components of intensive lifestyle intervention on BMI trajectory in clinical practice' Approaches to intensive lifestyle intervention that are most effective, including clustering of behavioral recommendations, messaging, delivery, and implementation, especially in primary care' Optimal duration of treatment, including strategies to address attrition and sustainability' Adverse events of treatment' Treatment outcomes by age, degree of obesity, and social determinants of health' Studies reporting long term outcomes are limited' Paucity of published studies reporting negative outcomes' Evaluation of intervention on quality of life and mental health' Studies of EHR tools, including clinical decision support, to improve attention to weight, counseling, and referral' Telemedicine and electronic and mobile health approaches' Robust community programs with clinical linkages' Cultural considerations in wt management Systems of care ' Feasibility of application and benefits of recommended systems of care for CYSHCN in obesity, including care transition strategies on the adolescents' and young adult's improvements in the treatment of obesity and health outcomes Barriers to and facilitators of CPG implementation ' Evidence informing best practices for rapid, cost-effective, and sustainable scale up of effective treatment program for childhood obesity that balance fidelity with adaptability to unique contexts' Research addressing the inconclusive evidence around technology-based interventions for obesity prevention777 Type of Gap . Example of Gap . Epidemiology ' Key drivers of reducing obesity prevalence' Predictors of severe obesity' Factors associated with obesity among racial and ethnic groups, including impact of SDoHs on disparities' Identification of medical costs associated with obesity and comorbidities Definition or measurement ' Alternative, accurate measurements of adiposity in primary care; ' BMI trajectories in clinical practice and response to treatment over time; ' BMI trajectories and development of comorbid conditions; ' BMI status and trajectories among race/ethnic groups and the impact of social drivers on BMI status and trajectories Risk factors ' Mechanism by which maternal obesity predisposes to adverse outcomes in the offspring' Impact of sedentary behavior alone on BMI and comorbidities' Improved understanding of associations between obesity and food insecurity Comorbidities ' Age to begin evaluation for cardiometabolic comorbidities' Frequency of evaluation to monitor progression of comorbidity' Comorbidity identification as motivation for behavior change' Role of social determinants of health in obesity comorbidities, especially among minority populations' Role of social determinants of health in obesity comorbidities Treatment ' Tailored age-based treatment approaches' Evidence-based treatment options for 0''5 = year-olds' Optimal level of parent involvement among adolescents in weight management' Optimizing MI use with respect to training, fidelity to the MI process, and potential patient characteristics' Evidence for specific components of intensive lifestyle intervention on BMI trajectory in clinical practice' Approaches to intensive lifestyle intervention that are most effective, including clustering of behavioral recommendations, messaging, delivery, and implementation, especially in primary care' Optimal duration of treatment, including strategies to address attrition and sustainability' Adverse events of treatment' Treatment outcomes by age, degree of obesity, and social determinants of health' Studies reporting long term outcomes are limited' Paucity of published studies reporting negative outcomes' Evaluation of intervention on quality of life and mental health' Studies of EHR tools, including clinical decision support, to improve attention to weight, counseling, and referral' Telemedicine and electronic and mobile health approaches' Robust community programs with clinical linkages' Cultural considerations in wt management Systems of care ' Feasibility of application and benefits of recommended systems of care for CYSHCN in obesity, including care transition strategies on the adolescents' and young adult's improvements in the treatment of obesity and health outcomes Barriers to and facilitators of CPG implementation ' Evidence informing best practices for rapid, cost-effective, and sustainable scale up of effective treatment program for childhood obesity that balance fidelity with adaptability to unique contexts' Research addressing the inconclusive evidence around technology-based interventions for obesity prevention777 CPG, clinical practice guideline; CYSHCN, children and youth with special health care needs; EHR, electronic health record; MI, motivational interviewing.
XV. Conclusion'--Putting it All TogetherPediatricians and other PHCPs now have more evidence-based tools than ever before that support obesity treatment that is effective, provides ongoing health benefits, supports children and families longitudinally, and reduces potential harms for disordered eating. In contrast to previous recommendations, these clinical guidelines highlight the urgency of providing immediate, intensive obesity treatment to each patient as soon as they receive the diagnosis of obesity.
As highlighted in the previous sections, there are Key Action Statements (KASs) that, collectively, comprise a holistic patient-centered approach to COT that should be coordinated within the context of the medical home. These strategies form the basis for applying evidence-based approaches that take the child's health status, family system, community context, and resources for treatment into consideration to create the best evidence-based treatment plan for each individual child. Obesity is a complex chronic disease but societal stigma around obesity results in pervasive weight bias. This makes compassionate and sensitive communication with patients and families even more imperative (see the Communication of BMI and Weight Status to Children and Parents section).
It is important to recognize that treatment of obesity is integral to the treatment of its comorbidities and overweight or obesity and comorbidities should be treated concurrently (KAS 4). It is also important to consider that a child with overweight and obesity and their family require longitudinal and coordinated care in a medical home (KAS 9) (see algorithm in Appendix 1).
Measuring BMI and assessing weight classification (KAS 1) is a screening step that is applied to a practice population of children, which allows the pediatrician and other PHCP's to initiate obesity evaluation. This evaluation is guided by a comprehensive history, physical examination, and diagnostic studies, including those for SDoHs, disordered eating, and mental and behavioral health (KAS 2). Overall guidance for evaluation of comorbidities is that in children 10 years and older, pediatricians and other PHCPs should evaluate for lipid abnormalities, abnormal glucose metabolism, and abnormal liver function in children and adolescents with obesity (BMI '‰¥ 95th percentile) and for lipid abnormalities in children and adolescents with overweight (BMI 85th to <95th percentile).
For younger children or children who are overweight, the recommendations are more conservative. In KAS 3.1, for children 10 years and older with overweight (BMI 85th to <95th percentile), pediatricians and other PHCPs may evaluate for abnormal glucose metabolism and liver function in the presence of risk factors for T2DM or NAFLD. In c