Isolationist Science and the Failure of Obesity Research

I'm an "obesity researcher". I have to admit that I'm not 100% sure what that means. I'm interested in the health issues that affect people who are overweight or obese, but I'm also interested in those health problems when they affect "healthy weight" people. I'm interested in how weight has changed across the population over time, and I'm interested in understanding the huge, complex system that led to those changes.

Even though I'm an "obesity researcher", I'm becoming more and more disillusioned with obesity research with each passing day. In some ways, I can see how "curing" the obesity epidemic seems to us now much like early efforts to "cure" infectious diseases. Except that with obesity, it's not that there aren't any easy answers--rather, there appear to be virtually no answers at all.

One of the reasons I think obesity research has struggled to find a "cure" is that most of the work aims to determine how much some variable affects obesity. Oh, everyone acknowledges that obesity is a complex problem, with many influential factors. But when it comes time to actually do research, we fall back on the traditional "randomized trial as gold standard" method of research (and I am most assuredly guilty of this myself). For a problem like obesity, it really doesn't matter how much any particular variable affects the outcome. It matters how all the variables work together. It matters how all the variables feed back on each other. It's "the system". (Click the picture for a blog post and link to an interactive version.)


 

There is certainly a (relatively) small group of people trying to think about obesity from this perspective. And almost any obesity researcher would agree that the above chart is "true". But doing this well requires funding, and funders make their decisions based on the wisdom of seasoned researchers, and most of these researchers find it particularly difficult to break out of the clinical paradigm of isolating a single variable.

At the moment, though, I'm struggling to decide if I should continue to fight the paradigm, or perhaps just go work at Waffle House. (See how complex obesity is? My decision on whether or not to study the complexities of obesity will affect my obesity!)

Do we really know the best nutrition policy?

If it's possible to reblog from wordpress to here, I don't know how. But here's the link to an amazing blog post from Laura Schoenfeld, about nutrition policy in the US.

I'm not even going to try to write much more about it, because she does such a great job. All I can say is that we really take for granted that our nutrition recommendations are based on science and evidence.

A New Approach to Data?

We all know that new technologies are changing how we do research. One of the most interesting was first introduced to me several years ago by a student of mine, who was particularly interested in how social media spread information about health-related issues. The first goal was to see how accurate the information was, but I think it's becoming more and more obvious that social media can be used to identify things more quickly than traditional research methods.

A post by kottke shows a fascinating result of using Google to identify disease breakouts. This picture is the interesting point:

The Orange is US data, Blue is Google-based data.

The tracking of certain Google search terms is very, very close to CDC data. What appears to be happening, though, is that Google identifies the trends a couple of weeks before CDC data.

Potentially more interesting, though, is what this could mean for other types of disease outbreaks. The US has a good system for tracking certain infectious diseases, particularly flu. But what about for diseases or problems that are newly emerging? Can we use Google, or other social media, to identify problems before we even know there is a problem we should be looking for?

We haven't even begun to understand how we can make use of all of the data that are being generated by millions of individuals across the world. This is the true "new frontier" of research.

Inertia

A Forbes article from earlier this month tries to dispel the myth that doctors will only increase their (uncompensated) work burden if they are willing to communicate with patients via email. Personally, I communicate with my physicians via email--I actually go so far as to nearly use that as a criteria when choosing a physician. But I think this form of communication is important for a far greater reason.

The power differential in the doctor-patient relationship is a key factor in how a particular patient's care will proceed, as I've written about before. Email has the benefit of being a low-pressure method of communication, one that doesn't require confident, direct interaction. Many individuals, no matter their background, find it difficult to speak openly with their physician, to ask questions, to be sure they are sharing all of the information and history they should. But email provides an opportunity for the patient to carefully consider what they want to say, and to do outside the pressure of the exam room. Patients may share information--some which might be critical to providing the best care--that might otherwise be left out or simply overlooked.

As technology becomes more and more integrated into all aspects of life, including medicine, health care will have to embrace these changes. People are embracing them. We can't let inertia prevent improvements in care.

Dangerously Stubborn

I stumbled across this article in Slate today, where a leading environmental activist professes he was wrong about opposing genetically modified crops. In and of itself, it's an outstanding, and seemingly courageous thing to do.

I say "seemingly" because, in truth, this is how science should always be. The steadfast adherence to a particularly belief is one of the most dangerous things in science, and one that far too many scientists are guilty of. I understand, I really do. It's difficult to write something and then go back later and say that maybe you were wrong. But the point is, barring truly poor or fraudulent science, studies aren't ever wrong--they just all provide different results. The entire point of the scientific method is to replicate until the preponderance of the evidence suggests a particular hypothesis to be true.

Unfortunately, we live in a scientific world where novelty is valued over replication, regardless of what it means for a particular hypothesis. I do believe we are making some strides, particularly with the advent of journals whose purpose is publish either negative findings, or to publish other things that might not get much interest but are still scientifically sound.

As I have begun to pay more attention to this phenomenon, I've become more determined to not allow myself to fall prey to this pressure. I hope, throughout my career, that I will be able to recognize and admit when I am wrong, and that I will always work towards doing the right things, as a scientist. I probably won't have a very storied career, but at least I'll know I've done well.

No child left behind in recess?

Earlier this week, the American Academy of Pediatrics issued a new policy statement on the importance of recess during school for kids. Recess is NOT the same as physical education, the statement makes is clear that both are needed.

This certainly isn't the first time that we've been told that kids need more recess. As childhood obesity has become a mainstream issue, many parents and policymakers have argued that recess is critical for kids to ensure they are active during the day. However, many schools continued to focus on classroom instruction time, particularly with regard to the standardized testing required as part of No Child Left Behind. My personal experience has been one of frustration with the seemingly endless amount of class time and homework for my children, but I'm also sympathetic to the administrators and teachers who are so dependent on successful testing scores.

One thing the policy statement makes clear (and this is not new information, but it's always nice to see it in an actual policy statement) is that recess is not good just for children's bodies, but their social, emotional, and cognitive development. In short--if you replace class time with recess, you get kids who are more successful in class.

Will this make a difference? I just don't know. I think the culture of testing has become the axle around which all of public school instruction turns. A policy statement is a start, but schools have rarely heeded the advice from non-educational professionals. I don't think it's because they don't want to, but because the risk of poor test scores is too great. We've created a monster that, in its effort to hold teachers and schools accountable to children's educational success, is not held accountable for the damage it does to children's overall health and success.

Is obesity really a health issue?

I've long had concerns about how we measure and define overweight and obesity, and what it means for health. The entire reason to wage a "war" on the "epidemic" of obesity is because we want to improve the health of individuals and the population. Many studies have demonstrated previously that being overweight and (in some cases) obese is NOT a risk factor for mortality. Obesity only becomes an issue at levels of "Grade 2 Obesity". However, I've always found it difficult to reconcile the data with the message. These studies--and I've been involved in a few related to child obesity--are difficult to publish, precisely because they go against the paradigm, and when they are, they receive little attention.

Yesterday, a study was published that should have helped bring the matter to a close. In a meta-analysis of 97 studies, representing nearly 3 million people and 270,000 deaths, Flegal and her colleagues demonstrated that being in the overweight category (so, a BMI of 25-30, the lowest of the overweight groups) was associated with lower mortality than being "healthy weight". Grade 1 obesity (BMI 30-35) was associated with no difference in mortality.

This is not an inconsequential finding. Meta-analyses have their own set of critiques, but, at least in my opinion, this one addresses to the extent possible most of them. They appear to have a rigorous a clear protocol for selecting the included studies, and perform the analyses in several different ways (presenting all of the findings). Indeed, Dr. Flegal herself is a well-known obesity researcher at the National Center for Health Statistics and has played an important role in development of obesity-related research. If she has any subconscious bias, I would expect it to be in the direction of demonstrating overweight obesity are bigger problems.

The authors make very little comment on the meaning of these findings. They do, however, note that possible explanations include earlier presentation to health care for heavier patients (meaning more screening for risks), and higher metabolic reserves (a fancy way of saying that when you get cancer or other severe illness and lose a bunch of weight, heavier people can tolerate that better). An accompanying editorial (which, unfortunately, can not be accessed for free) extends the discussion a bit, but discuss whether BMI is a good measure of obesity (in terms of fat tissue) and that, of course, weight alone should not be the only factor a physician considers when estimating a patient's risk.

What no one is willing to come out and say is this: Maybe overweight and (moderate) obesity are just not a big deal? Maybe we defined these "diseases" all wrong, and maybe we're creating problems that don't really exist. Maybe we let social perceptions of what someone "should" look like effect these definitions? Maybe we have been unwilling to consider the possibility that overweight is not a health risk because we are so invested in the paradigm of obesity = really, really bad that we are unwilling, as a field, to step outside that paradigm.