Oblivobesity

A recent study and couple of conversations led me to this.

We fret over the idea that millions of people have diabetes or hypertension and are unaware. We don’t blame them for not knowing, we blame a health care system that does not provide adequate preventive care.

But we insult parents whose children fall into a BMI percentile that defines obesity, and do so using terms like “oblivobesity”. (That actually made me a little nauseated.) This is all based on the presumption that we can “see” this horrid affliction, and the blame for that affliction lies at the feet of the parents.

Let’s take a look at what David Katz had to say: (http://online.liebertpub.com/doi/full/10.1089/chi.2015.1131 )

[W]e are thus obligated to ensure that the ... enlightenment of families to trouble under their roof, does not invite such unintended consequences. If we are to eradicate oblivobesity, it will not be with objective measures alone, but also with compassion, guidance, and empowerment in the mix.

I hope everyone will still respect me after this, but you’ve got to be fucking kidding me. To use “oblivobesity” and “compassion” in the same sentence is the exact attitude that has given us this world of “appropriate stigma” and that confirms, for me, that Ivory Tower folk have no clue what they are talking about. “Trouble under their roof?” What about trouble from a world that doesn’t make it safe for children to play, or ensures them equal concern in the health care system if they are fat, or even makes it safe to exist with obesity?

There is a whole world of parenting beyond obesity. Parents of children with obesity aren’t oblivious. There are completely aware of the trouble under their roof—the one that leaks and the one that may not have electricity on if they don’t work a double shift. These families don’t need “enlightenment”. 

Does removing sodas from school work?

A new study, behind a lovely paywall, attempts to quantify the effect of California's school competitive beverage policy. The main point is that there was a decline in obesity prevalence, but only for schools in the wealthiest neighborhoods.

It’s not a bad study, I don’t guess. I think the point that policies affect different groups differently is probably spot-on, and something we should always look at.


1) The biggest problem is that there is no control group. I could go on a tirade about the sorry state of obesity research, but this is just critical. Their time point of change—2004/2005—is exactly when obesity trends declined nationwide. Let me say the lack of a control group again. It is simply not possible to attribute the change to the policy. Period. There was a change the same time as the policy, but there are plenty of other reasons I could argue also “caused” the effect.

2) What’s the plausibility of the effect? It’s a policy that said, essentially, you can only sell drinks that are half crap and half juice (so just a caloric as a soda). A second policy, which more clearly limited sugar content, went into place in 2007, and there is no effect of that on their outcomes.

3) They don’t look at harms. I don’t love the idea of Coke having a role in schools. But as long as we are unwilling to fund schools appropriately, the financial impact of these programs can’t be overlooked. What’s more is that these programs are most likely to help the poorest neighborhoods. Not only do poor kids not get the same positive effect, their schools also lack the resources to fill in the gaps of the lost income.

4) Finally, prevalence of overweight/obesity is not a great outcome. Change in z-score is hard because it’s not longitudinal, but if there is more severe obesity in minority or poor groups, then there will naturally be less transition into the healthy weight group.

I really want to find a policy that works. But I don’t think the obesity “epidemic” can be pinned on the devil of sugar sweetened beverages, much less cured with a SSB policy based only at schools. It is the nature of researchers to parse out interventions to their lowest part. But the complexity of obesity simply won’t yield to parsimony. Obesity won’t be cured with a cooking class, swapping out the coke for juice, or a school vegetable garden. (Oh, god, the zealotry of the school vegetable garden people.)

Ironically, one small thing like a beverage policy is unlikely to improve obesity, but it does have the power to be harmful. Just as it takes a lifetime to raise kids to be happy and well-adjusted, it takes only a single traumatic event to completely change trajectories. It’s easy to pass a policy banning beverages. It’s not easy to include in that policy coverage of the costs of that decision.

Conflict of Interest in Obesity Research

It started with a quote of mine, which alone sounds a little offensive:

"Obesity researchers and physicians, compared to the general population, are more likely to be thin. They're less likely to have experience with this. People who are thin, there's a tendency to think 'I'm thin. Why can't you act just like me?'"

Do I think this is true? Absolutely. Do I think all obesity researchers are like this? Absolutely not. And while I don't believe I've been misquoted, the written word obscures what was truly intended. I've certainly written before that the paradigm of "calories in + calories out = thin" is so pervasive that it may limit our ability to think creatively about obesity treatment. I particularly think that treating obesity by trying to have people with obesity mirror the behaviors of people without obesity is destined to fail. This does not mean I think all thin people believe this is a solution. (I'm a researcher. I sometimes forget that what I mean by "tendency" is not necessarily the same for the rest of the world. I take responsibility for that.)

If you ever attend an obesity research meeting, the lack of obesity may surprise you. If you were to attend a minority health meeting, you would see researchers who are members of minority groups. Not so in obesity research. Maybe this is because obesity is a disease and, indeed, there are researchers who have traveled their own journey through obesity. But in congregations of obesity researchers I've heard stories about weighing themselves each morning to ensure their weight is unchanged, heard people openly shamed for taking a second brownie, and listened to the word "just" more times than I can count (as in, "if people just did X").

This type of bias is prevalent and concerning in medicine and research. This is clear beyond my own personal experience. This does NOT mean that the state of obesity research is so terrible as to be entirely untrustworthy.

A different statement by Harriet Brown is far more worrisome, and not grounded in fact.

"It's rare to find an obesity researcher who hasn't taken money from industry..."

Where did this come from? I have no idea of the exact prevalence of industry ties in obesity research, or how this compares to other medical fields. But you won't have any trouble finding researchers without industry ties--look no further than right here. My lack of industry ties has nothing to do with  a fundamental belief that industry-based financial conflicts of interest always drive research outcomes, but more simply that I haven't had any.

Do I think research is overly branded and driven and industry? Probably. The influence of pharmaceutical companies, food companies, and medical device manufacturers is undeniable. Which begs the question--what ought we do? If, as Harriet Brown says, 70% of research is funded by industry, how would obesity research continue if not for those relationships? NIH funding is incredibly difficult to secure. One reason for that is that NIH reviewers are notoriously risk-averse. NIH wants to fund things that will show success, because without that success it's difficult to play the political game that can protect the NIH budget.

Let me say that more clearly. The political conflicts of interest that underlie NIH research are not inherently better or worse than the conflicts of interest associated with industry. Of course industry doesn't want to publish the results of negative studies for their products. But do you think the NIH wants negative results from a multimillion dollar trial? Do you think I would be able to get that published anyway?

The financial gain from industry may be significant for some. But do you think a small consulting fee engenders greater allegiance to Pepsi than the salary I need NIH to fund? My promotions are based on whether I get publications in high-impact journals. My job security is grounded in funding my salary. Most of that comes from NIH in some form. To pretend that NIH funding, and the need for future NIH funding, does not influence researchers is naive. The image of the scientist free to chase down the truth and perform research without regard to the result does not exist.

I have absolutely no doubt that bias influences obesity research. Our own biases affect everything we do. We should report them and consider them. Our biases are grounded in the interest of our funding sources, the paradigms in which we've been trained, and our own personal life experiences. It's easy to demonize one source, but let's don't assume any source is worse than another.

A Technicolor Rainbow of Gray

I've been reading Harriet Brown's new book, Body of Truth.  I don't want this to seem like a review of the book, because it's not. I've come to learn that I read books differently than most people, so I rarely recommend anything, as I have no idea if anyone else will see what I see. The tendency to read things as black or white is not something I understand--my mind is a technicolor rainbow of grays.

But the black-white dichotomy is one worth talking about. It is this dichotomy that keeps me from loving the book. On the one hand, I do like to see a critical look at the state of obesity research. On the other, deficits in our understanding of obesity does not equate to such hopelessness we should pretend obesity does not exist.

One premise that requires quite a bit of analysis is whether obesity is a disease. Is obesity a disease? I've written about this before, but I think I've come to the conclusion that the answer is "sometimes". Obesity has many characteristics of a disease, and when there are health effects, it's easy to conceptualize as a disease. In these cases, weight loss can be one important part of treatment plan to improve health. But sometimes fat is just a size. Sometimes there are no health effects. Even if we argue that there is potential for future risks, most of the time this sort of weight loss is focused exclusively on weight.

The problem is that there is not an either/or here. Obesity doesn't have to be either a disease requiring treatment or a simply a size. Those who argue that obesity is not a disease often want weight to be something that is not medicalized, that we allow bodies to all exist as they are. (Of course, there are those who think obesity is not a disease because it's subsequent to moral failure, but that's a whole different post.) Those who believe obesity is a disease in all cases, argue that treatment should be made accessible and we should work to remove the stigma of the thin ideal, focusing instead on health.

But this is all true. If you pick a value premise of "No One Knows the Truth About Obesity", or the opposite of "Obesity Will Definitely Kill You", then you miss everything in between. All that gray is where the truth really lies, and the truth may very well differ for everyone.

Well, I suppose we've got this obesity thing all figgered out

My good friend Ted Kyle passed along to me this morning a report from the Robert Wood Johnson Foundation, showing that childhood obesity is declining in many areas. With all due respect to RWJF, they have regularly used last year's report that obesity was declining in preschoolers as a demonstration that their policy efforts have been effective. They cite that again in this report, ignoring reports from the same data that contradict those findings. RWJF does incredibly important work, but these particular numbers do not show what we want to believe they do.

I see a bunch of numbers showing declines in obesity? Are you saying they are wrong?

No, I'm saying the numbers in the RWJF report do not say anything about childhood obesity. They say, for the most part, something about the population of underprivileged young children who are enrolled in WIC.

Well, isn't that good news?

Maybe. Maybe not. Children in WIC in 2008 may be different than those in 2011. In fact, we have every reason to believe they were. With the recession, more families became eligible for WIC, including those who were previously "better off" and thus had children at lower risk for obesity.

But we know these places were trying various policies? Even if it's only preschool children, aren't we showing they work?

No. When examining the effect of an intervention--like the policies referred to in the report--we must have a control group. Let me say that again. The decline in obesity rates means nothing without a control group. This report picks out the 19 states with reported declines in obesity in their WIC program. We can't determine if the effects are due to policy changes or regression to the mean. What about all the other states? Did they show an increase? Also, take a look at the magnitude of change. We are talking about changes typically under one percentage point.

Who cares if it's regression to the mean, obesity is still going down. Why are you so hung up on this control group?

Let's assume the data are all wonderful and we do indeed have a real decline in obesity, even if only a percentage point or so. That tells us absolutely nothing. We don't know which policies mattered. This is a critical point. We don't know where to spend our money in the future. We spend millions (billions?) trying to address childhood obesity, and we can't tell you what your money bought.

Maybe money isn't the biggest issue. Maybe we are just thrilled to see some improvement.

Or maybe we are causing harm and don't know it. The flipside of all interventions is that they can have unintended consequences. Maybe we are causing unhealthy eating behaviors. Maybe we're causing undue financial strain. Maybe we are generating psychological harm by stigmatizing obesity. We. Don't. Know.

Are you saying we should stop doing everything?

Of course not. There are many policies, particularly related to WIC that are objectively good, and should be studied for their effectiveness and cost-effectiveness. One example are those that provide WIC vouchers for fresh fruits and vegetables. These are unlikely to cause harm, and likely improve access to fresh fruits and vegetables. This is a great outcome on its own. It's a much bigger leap to assume they play a role in obesity rates.

But Asheley, you research childhood obesity. Aren't you a little biased towards keeping this a problem?

Indeed, I do a great deal of work in childhood obesity. However, I'm far more interested in the health consequences of obesity, measurement, and severe obesity. More importantly, if the childhood obesity problem just disappeared, I could do work in all the other areas that interest me, including child maltreatment and mental health and prescription drug abuse. Maybe I'd get funded in those areas!

So, what do we know for sure?

We know that childhood obesity has not significantly declined for the last 15 years or so.

We don't know that our policies related to childhood obesity have any effect, because we so rarely use control groups, or even adequate quasi-experimental designs in our study of them.

 Why do you even care?

I care because I don't want the country to assume childhood obesity is all better. I don't want the need for healthy foods and activity to drop from our radar. I want to be sure that we are not spending enormous amounts of money on programs that are ineffective at best, harmful and stigmatizing at worst. I want our children to be healthier, and reports about reductions in obesity--a measure that itself is hugely problematic--should not be interpreted as improvements in children's health. I want people to understand this problem, what it is and what it isn't, and to understand that numbers do not always tell a real story.

Tax Obesity?

Should we tax obesity? Although it's an older study, this article resurfaced on my twitter feed today. The focus is on how we can use taxes to modify behavior, including sin taxes on such things as cigarettes and alcohol. The author, Dr. Gruber, does point out that taxing obesity is trickier than these other specific items, and first makes a case for sugar-sweetened beverages.

In my opinion, there are good reasons to tax sugar-sweetened beverages. We should not tax sugar-sweetened beverages because of obesity. Sugar-sweetened beverages are not good for anyone, regardless of weight. Personally, I think these policies should be targeted to industry, not individual purchasers.

The next, idea, however, is "ultimately, what may be needed to address the obesity problem are direct taxes on body weight". As Dr. Gruber points out, it's hard to imagine this in federal tax policy, but we already do it through employer-sponsored insurance. Many others have made many arguments specific to employer-based health insurance, so let's think about this from a broader idea of "tax" of any form.

What is the motivation of a tax on obesity, be a tax on wages to the IRS or through health insurance premiums? In economics, the concept is that taxing something discourages consumption. This worked well for cigarettes--as taxes increased, consumption declined. (We'll set aside the much more complicated issues surrounding cigarette taxes.)

The problem is that most "sin taxes" target a behavior or an item. Taxing obesity would be taxing a characteristic. What would we need in order to actually implement an effective tax on obesity?

• We would need to be able to target the tax, so we would need to be able to measure obesity. This measure would need to be easy to obtain and have a clear tie to the health issues we are concerned about. BMI is easy to obtain, and I guess people could report it on their 1040, but it is not clearly tied to health issues. In fact, the only measures tied to health issues are the existence of health issues. 

• A tax would only be effective if it addresses something changeable. So, we would have to assume a perfect correlation between individual behaviors and weight. So, by changing a specific set of behaviors, you would lead to the exact desired weight. Of course, we know that doesn't happen.

• A tax would also only be effective if it doesn't induce other risky behaviors. What good is a tax on cigarettes if everyone began to smoke an equally dangerous alternative? By taxing a specific weight, wouldn't the motivation be to do anything to reach that weight?

We can't tax obesity, because there is nothing about it that is taxable. Yet, this idea is regularly raised, in the popular press and in science. Obesity is a characteristic. There are no other characteristics I can think of that we tax. We do tax behaviors, but not what people look like. We also don't tax diseases. We tax cigarettes, but we don't impose a tax  when someone is diagnosed with lung cancer.

There are plenty of ways to leverage policy in order to improve obesity. Taxes aren't one. Taxing health insurance is not one. Health insurance is actually an important tool to help people obesity improve their health--why would we restrict that?We can only address obesity be recognition of what it is and by using policy to support individual efforts to improve their health, not to punish them.

Treat the Obesity First?

So, I've been struggling with an internal debate about the new guidelines from the Endocrine Society about treating obesity and comorbidities.That's why I'm late to this party.

On the one hand, I think recognition of obesity as something that can and should be treated is great. On the other, I worry that putting obesity--defined here solely by BMI--above actual health problems is a risky, dangerous proposition.

The Good

It's refreshing to see guidelines for obesity treatment that view medications as positive and not as last-resort efforts. Of course, these are the guidelines for "Pharmacological Management of Obesity".

There is a clear recognition of the array of factors that cause obesity. 

The Bad

The labeling of individuals with obesity is clear from the start. Throughout the document, individuals are referred to as "obese patients" while diabetes is "patients with diabetes", not diabetics. The first and most important step in treating obesity appropriately is recognizing it as a disease, not a characteristic of the person.

One of the only recommendations they make based on the highest-quality evidence is that lifestyle modifications be included in all obesity treatment. I'm not pretending for moment that lifestyle modification is NOT useful, but it doesn't work long-term. A wide variety of reasons exist for this, from an unsupportive environment to metabolic changes occurring as a result of weight loss. The evidence is just not that good.

Successful treatment is defined only as weight loss. If someone stays at exactly the same weight, but show clear improvements in health, have we failed?  If weight loss occurs and there are no improvements in comorbidities, have we succeeded?

Health, not weight

I suppose my greatest concerns are with the media reporting of the guidelines, more than the guidelines themselves. Most articles report, and the lead author comments, that the "new paradigm" is the "treat the obesity first, then the comorbidities". I think the message should be "treat the obesity along with the comorbidities" and that's actually closer to what's in the actual guidelines.

Treating obesity is something that we absolutely, 100% need to do, and do more effectively. However, I can't overstate my opinion that we must view everything through the lens of health. Obesity is not simply size.

The Ever-Repeating New Year's Resolution

 A year ago I wrote:

"As a rule, I do not make New Year's Resolutions. I won't go into why, lest you think I'm some crunchy granola hippie, which I'm definitely not. But New Year's Resolutions are usually about doing something that's hard, something that you believe will make you a better person. A singular focus on weight loss is not about being a better person, it's about self-hatred of the person you are. You can't change the external you, no matter how much you hate it. You can change the internal things you feel and the choices you make. Perhaps external changes will follow, but if they don't have you truly failed?"

I guess not much has changed in the last year. The introduction to the New Year has come with all of the typical ads for diet and exercise products. Although I think I'm seeing more "get healthy" and less "lose weight", Slim-Fast is still front and center at my Walmart. I'm fighting crowds (crowds!) at my gym, and clearly everyone else has determined *my* elliptical is best. And, of course, all will return to normal by February, sadly.

Last year, we decided to try to eat sugar-free, which is actually turning into no added sugar and as little processed food as possible. It's working fine, though I must admit it wasn't a life-changing cure for all that ails us, as many other bloggers insisted it would be. Maybe we didn't eat enough processed food to begin with. But it has highlighted one of the problems we are facing in this world. A few months into really doing this with gusto, I'm STILL reading every. single. label. I can't trust that all tortilla chips are just corn, or that sour cream is just cream, or even that apples are just apples.

So, for the New Year, we have a bunch of people who are trying to get healthy (or lose weight, or whatever other positive or negative conception of that goal), and the deck is stacked against them. The part of my field that cares about nutrition still can't decide what's actually best, so we keep creating interventions without even knowing what to change. We try to help people individually, but no amount of education will ever overcome what we see in grocery stores. People try and try, and maybe they are healthier but the scale hasn't changed, or maybe they aren't feeling better, or maybe they just get tired of reading every single label, and they give up.

I don't blame them. Our knowledge base is a mess. The environment is designed to make them fail. The medical treatments, though better, are shameful. The only part of this obesity equation that isn't a disaster are all the individuals who live with it. They are trying--at the gym, at the grocery store, not just sitting around being lazy. People are doing what we tell them to do, but the message that gets told is from a mess of a dietary knowledge base, an environment that uses green boxes and "gluten free" to sell health, and doctors who don't know about or offer the few available medical treatments.

I'll come back to this in 2016, and everyone will be back again, trying, hoping, that this year will be different. Some year, maybe it will be.

**I promise my next post will not be so pessimistic! But that's not a New Year's resolution...