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 Researcher's Promise

I've had one of those days where I'm questioning whether researchers should even be allowed to present their findings to the general public.

It started with the report on the increase in autism rates. I don't want to minimize the devastating effects of autism on families. But it reaches a point that it defies credulity. A jump from 1 in 88 to 1 in 68? In two years? And with a nearly fourfold variation between the lowest and highest states? (Alabama and New Jersey. Can you think of some differences between Alabama and New Jersey to explain that?)

Another study reported that a third of school-age kids have borderline or high cholesterol. These were kids between 9-11, a time we know cholesterol increases naturally--and is probably a necessary increase. And we have no clue how or if this affects them as adults. (By the way, this was just a meeting abstract, not a peer-reviewed paper.)

And, of course, there's the study showing that toddler obesity plummeted, one with significant issues I've already written about. Another writer posted about it recently, raising a different set of (equally valid) problems. An interesting tidbit there was that the author of that piece was not giving media interviews. (And I'm trying to not be bitter that no one cared when I made my arguments a month ago!)

As a researcher, I've had to learn to understand the media, and learn to understand how to present my findings. I'm sure I've stumbled. But this is something we, as researchers, absolutely HAVE to learn--how to explain what we've found. And we have to be absolutely sure what we are presenting is accurate, not just statistically, but in how it gets presented.

Why is this so important? These three studies tell me 1) autism is increasing at a rate that will eventually make it the scourge of the US, 2) a third of kids need intensive cholesterol interventions, and 3) obesity is all better. None of these things are true. Autism prevalence is still a mystery tied up in diagnosis rates and societal norms for "disorder". The only kids who really have cholesterol problems are a small group with genetic hypercholesterolemia--the rest are probably just growing. Obesity, or whatever we want to call this increase in body size, is pretty much unchanged.

Our studies, when promoted in the media, are the foundation of public discourse. They determine the policies that get developed, the programs that get funded, how the public perceives health problems. Carefully putting information in the public domain is our responsibility. We work so hard to do good work and get it into the journals. But that is only the first step. Of course we don't have complete control over the media--but too many of us denigrate journalists as not understanding researchers. That's not true at all, in my experience. We, the researchers, seem to not understand the rest of the world.

I think we need a researcher's promise (with some inspiration from the Girl Scouts).

"On my honor, I promise to always try to ensure my work serves the people of this world, to take an active role in translating the message to non-researchers, and to generously offer my knowledge and time in making research have only a positive impact."

I'm willing to consider edits on that promise!

Be Wary of the Headlines: Has Toddler Obesity "Plummeted"?

Yesterday, a study was published showing the prevalence of obesity in children and adults over the last decade.

The headline that was commonly seen was "Toddler Obesity Plummets". This insinuates that the main story out of this study is that we are winning the "battle against obesity".

Let's look at two things: What the study says about toddler obesity and what it says overall.

First, the study did indeed find that toddler/preschool (ages 2-5) obesity in 2011-2012 is much lower than it was in 2003-2004. However, what it also showed is that the drop happened right after--in 2005-2006. In fact, if you look at the authors' previous work, you can see that it was much lower in 2001-2002. For some reason, 2003-2004 was anomaly in NHANES, or in obesity rates. The rates went from ~10% to ~14% to immediately back down to about ~10%.

To say that toddler obesity has plummeted in the last decade in disingenuous at best. It has only decreased when making the very specific comparison of one two-year cycle. The trend over the last decade is not significant. The authors do acknowledge the importance of the comparison, but do not discuss the very important difference in 2003-2004.

Second, although obesity in young children dominated the headlines, the paper actually examined children and adults at all ages. The real story of this paper, in my opinion? Nothing has changed. It hasn't changed for young children or teenagers, for young adults or older adults.

Don't let a shocking headline distract you.

The Stigma of Childhood Obesity

Some colleagues and I recently received a rejection of a letter to the editor of JAMA. When we saw this cover, we were immediately struck by the child in the middle, and decided a letter was needed. I guess I shouldn't be surprised by the rejection, given that JAMA recently rejected another piece of mine on how stigma pervades the medical and scientific communities that work on childhood obesity. (That piece, however, was accepted by another in the JAMA family, JAMA Pediatrics, and will be published July 1.)

The refusal to engage in the discussion is as informative as the original point we were trying to make. Below is the image on the cover, which should link you to Dr. Zylke's description--my apologies to those who can't access it freely. I think our letter was appropriate and true.
 



 

Dear Dr. Zylke,

It was with great excitement that child health researchers came across a special issue of JAMA focused on child health last week.  Unfortunately we found this issue’s cover alarming.  The illustration promotes the stigmatization of obesity that has not only pervaded popular culture, but, as so clearly demonstrated here, the research and medical communities, as well.
   
On the cover, we instantly saw a portrayal of an obese child with a large soda-an image that managed to meet all three criteria for defining pejorative images from the Yale Rudd Center for Food Policy and Obesity at Yale University media guidelines.¹  While you say this image tried to portray “problems stemming from social or environmental issues,” the use of a picture of an individual child with a large soda to reflect the high prevalence of obesity among children is stigmatizing in that it recognizes the individual behavior without also recognizing the larger environmental roots.  

Far more disturbing are the subtleties apparent in the image.  The fact that so many people in the scientific community must have looked at this obese girl—with an awkward facial expression, unflattering clothing, and avoiding the world—as an honest representation of childhood obesity is truly disheartening.  Social constructs of disease place responsibility on different individuals, assigning blame in ways that portray children as either victims or perpetrators.² On this cover, nearly all these children are either promoters of their own health or “victims” of their diseases, except this child, who is shown as a perpetrator of hers.  

In your description of the cover’s more idyllic images, you quote Norman Rockwell: “I paint life as I would like it to be.” We would like to offer up another of Mr. Rockwell’s quotes: “Right from the beginning, I always strived to capture everything I saw as completely as possible.” The narrow, incomplete and negative view of the obese child so painfully portrayed on the cover demonstrates the narrow, incomplete view that many people have of obese children and obesity itself. 

If we only focus on the doubt and difficulty of changing individual behaviors, we will not reduce the prevalence of obesity as significantly as if we address systemic factors.  Continual perpetuation of stigmatizing images of obese children reinforces beliefs that obesity is a problem driven only by individual behaviors. Such stigma serves to dehumanize obese people, and may even serve to perpetuate obesity itself.³





Asheley Cockrell Skinner, PhD

Stephanie E. Hasty, BA

Eliana M. Perrin, MD MPH 

References

1.         Yale Rudd Center for Food Policy and Obesity. Guidelines for the Portrayal of Obese Persons in the Media. 2012; http://www.yaleruddcenter.org/resources/upload/docs/what/bias/media/MediaGuidelines_PortrayalObese.pdf. Accessed May 9, 2013.

2.         Herek GM, Capitanio JP, Widaman KF. Stigma, social risk, and health policy: public attitudes toward HIV surveillance policies and the social construction of illness. Health Psychology. Sep 2003;22(5):533-540.

3.         Puhl RM, Latner JD. Stigma, obesity, and the health of the nation's children. Psychological Bulletin. Jul 2007;133(4):557-580.

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.