Monday, March 30, 2015

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.

Sunday, March 29, 2015

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.