Health News Review

A paper in the New England Journal of Medicine, “Myths, Presumptions, and Facts about Obesity,” drew lots of news attention.

The authors reported:

We identified seven obesity-related myths concerning the effects of small sustained increases in energy intake or expenditure, establishment of realistic goals for weight loss, rapid weight loss, weight-loss readiness, physical-education classes, breast-feeding, and energy expended during sexual activity. We also identified six presumptions about the purported effects of regularly eating breakfast, early childhood experiences, eating fruits and vegetables, weight cycling, snacking, and the built (i.e., human-made) environment. Finally, we identified nine evidence-supported facts that are relevant for the formulation of sound public health, policy, or clinical recommendations.

Conclusions

False and scientifically unsupported beliefs about obesity are pervasive in both scientific literature and the popular press.

The Associated Press reported:

“Independent researchers say the authors have some valid points. But many of the report’s authors also have deep financial ties to food, beverage and weight-loss product makers – the disclosures take up half a page of fine print in the journal.

“It raises questions about what the purpose of this paper is” and whether it’s aimed at promoting drugs, meal replacement products and bariatric surgery as solutions, said Marion Nestle, a New York University professor of nutrition and food studies.

“The big issues in weight loss are how you change the food environment in order for people to make healthy choices,” such as limits on soda sizes and marketing junk food to children, she said. Some of the myths they cite are “straw men” issues, she said.”

In an NBC story, Nestle said, “I can’t understand the point of the paper unless it’s to say that the only things that work are drugs, bariatric surgery, and meal replacements, all of which are made by companies with financial ties to the authors. ”

And here is the list of disclosures in the NEJM paper:

The views expressed in this article are those of the authors and do not necessarily represent the official views of the National Institutes of Health.

Supported in part by a grant (P30DK056336) from the National Institutes of Health.

Dr. Astrup reports receiving payment for board membership from the Global Dairy Platform, Kraft Foods, Knowledge Institute for Beer, McDonald’s Global Advisory Council, Arena Pharmaceuticals, Basic Research, Novo Nordisk, Pathway Genomics, Jenny Craig, and Vivus; receiving lecture fees from the Global Dairy Platform, Novo Nordisk, Danish Brewers Association, GlaxoSmithKline, Danish Dairy Association, International Dairy Foundation, European Dairy Foundation, and AstraZeneca; owning stock in Mobile Fitness; holding patents regarding the use of flaxseed mucilage or its active component for suppression of hunger and reduction of prospective consumption (patents EP1744772, WO2009033483-A1, EP2190303-A1, US2010261661-A1, and priority applications DK001319, DK001320, S971798P, and US971827P); holding patents regarding the use of an alginate for the preparation of an aqueous dietary product for the treatment or prevention of overweight and obesity (patent WO2011063809-A1 and priority application DK070227); and holding a patent regarding a method for regulating energy balance for body-weight management (patent WO2007062663-A1 and priority application DK001710). Drs. Brown and Bohan Brown report receiving grant support from the Coca-Cola Foundation through their institution. Dr. Mehta reports receiving grant support from Kraft Foods. Dr. Newby reports receiving grant support from General Mills Bell Institute of Health and Nutrition. Dr. Pate reports receiving consulting fees from Kraft Foods. Dr. Rolls reports having a licensing agreement for the Volumetrics trademark with Jenny Craig. Dr. Thomas reports receiving consulting fees from Jenny Craig. Dr. Allison reports serving as an unpaid board member for the International Life Sciences Institute of North America; receiving payment for board membership from Kraft Foods; receiving consulting fees from Vivus, Ulmer and Berne, Paul, Weiss, Rifkind, Wharton, Garrison, Chandler Chicco, Arena Pharmaceuticals, Pfizer, National Cattlemen’s Association, Mead Johnson Nutrition, Frontiers Foundation, Orexigen Therapeutics, and Jason Pharmaceuticals; receiving lecture fees from Porter Novelli and the Almond Board of California; receiving payment for manuscript preparation from Vivus; receiving travel reimbursement from International Life Sciences Institute of North America; receiving other support from the United Soybean Board and the Northarvest Bean Growers Association; receiving grant support through his institution from Wrigley, Kraft Foods, Coca-Cola, Vivus, Jason Pharmaceuticals, Aetna Foundation, and McNeil Nutritionals; and receiving other funding through his institution from the Coca-Cola Foundation, Coca-Cola, PepsiCo, Red Bull, World Sugar Research Organisation, Archer Daniels Midland, Mars, Eli Lilly and Company, and Merck. No other potential conflict of interest relevant to this article was reported.

What does this disclosure tell us?  Is this meaningful to those who read the NEJM article?  Is it meaningful to readers of stories like the AP story to learn that so many authors had so many potential conflicts to disclose?

We welcome your thoughts.

 

ADDENDUM ON FEB. 5:  See Kevin Lomangino’s followup analysis, “Should we trust the New England Journal of Medicine obesity mythbusters?

 

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Comments

Tom posted on January 31, 2013 at 10:24 am

I never know what to do with disclosures like this. Should I disbelieve the entire article? That doesn’t make any sense. What should I believe or disbelieve? Or should I somehow “discount” my belief? How much? 10%? 50%? And what does that mean?

I think such disclosures are just a feel-good policy that don’t really add to the quality of our discourse.

Ken Leebow posted on January 31, 2013 at 10:36 am

As someone who does a tremendous amount of research into diet, health, and lifestyle issues, I already know that much of the information is not backed by solid and sound research. I think one of the biggest myths is: Eat Less, Exercise More. However, that’s my belief, not backed by rigorous research.

With that said, when I read the article and saw the volume of conflicts of interest, I discounted it completely.

Of course. this paper will be wildly reported in the news and will not advance the issue of weight-loss one iota.

Cathy posted on January 31, 2013 at 11:40 am

I’m with Tom, I don’t see how the long list of disclosures really adds to the discourse, except to give those who don’t want to hear the message a reason to dismiss it. Are we only to listen to scientists who have never taken private funds, who are pure as the driven snow? Isn’t everyone influenced somewhat by economic considerations? Surely Marion Nestle would like people to buy her books; should we therefore discount anything she has to say on the issue as self-serving? The fact is, most of us know that the majority of “studies” on weight loss are crap, and better research needs to be done. Focusing on the disclosures, or insisting that only scientists that have never taken money from commercial interests are acceptable voices in the debate (and good luck finding them) seems like a distraction that keeps us from addressing the real issue—how to fund and conduct better research.

Brad F posted on January 31, 2013 at 12:16 pm

In addition to vetting COI’s (welcome), please post evidence-based dissections of the paper countering their findings? Do they strike you as biased? They did not for me.

Perhaps because of a biased literature base, we have a biased review? I cannot say.

Regardless, the authors wisely claim:
“Our proposal that myths and presumptions be seen for what they are should not be mistaken as a call for nihilism.”

Brad

Les posted on February 1, 2013 at 12:34 pm

Thanks for mentioning this. The thrust of the paper is misleading. One, if I get it correctly, it basically says that we do not have randomized controlled studies supporting these statements that he calls “myths”. That may be true, but that does not mean that the statements in question are false, or that we don’t have any evidence linking these factors to weight loss. It just means that we haven’t done RCTs (which are not as easy to do as folks think). Second, funny enough, one of the statements that they claim is a “myth” is that snacking is linked with obesity. This “myth” doesn’t seem to be getting reported as much as the sex one! But that statement would be in line with prior statements by the lead author.

The author, David Allison, according to Wikipedia, has already faced controversy when he tried to make a similar claim years ago: that there was “no supported evidence” that drinking sodas was associated with obesity. He also tried to argue that posting calorie counts in restaurants would cause people to eat more! (This was in an affidavit for the New York Restaurant Association.) He ended up resigning his position as incoming president of the Obesity Society after that one.

The author is a biostatistician. He did not himself do any research; he merely reviewed research and pronounced which studies met his criteria and which didn’t. Funny enough, he ignored good statistics showing, for instance, the not insignificant mortality and morbidity from bariatric surgery (let alone weight loss pharmaceuticals). He did not mention that many of these “myths” may not have RCTs supporting them. That’s because RCTs are fairly difficult to do in an ethical, practical way for some of the questions. Seriously, your’e going to randomly assign kids to breastfeeding or bottle with no input from moms? You’re going to randomly assign kids to PE or not, regardless of school district policy? This is why we have population studies, and scientists can and do slice and dice the data to correct for various factors and see where the correlations are. And many, if not all, of these “myths” are based in those populations studies.

If you look at the reports of the paper (I haven’t yet paid JAMA for the full copy, but plan to), it appears to be a classic example of mixing possible/probable truth with other, more questionable statements that the author would like people to accept. It’s likely, for instance, that the average person isn’t burning too many calories during sex – depends. The author may be correct about the mixed results with regards to rapid vs slow weight loss, or setting “realistic” goals vs setting the bar high. But much of the rest of it appears designed to say: it’s really not your fault! You can keep on snacking, and exercise? well that will help once you’ve lost it. Here, take this pill, have this surgery.

It’s perhaps not surprising that this paper got released just as Coca Cola is making a pitch for “being part of the solution”.

JP Sand posted on February 1, 2013 at 3:56 pm

It is heartening to see that this paper (“Myths, presumptions, and facts about obesity”, New England Journal of Medicine, January 30, 2013) has raised some eyebrows in the mainstream press regarding the authors’ favored weight loss solutions and their epic conflicts of interest — particularly financial ties to makers of food, beverage and weight-loss products. Unfortunately, medical news sources are presenting it without any critical framework, or counter-argument, whatsoever.

One of the more grotesque positions in this paper is the dismissal of “realistic weight-loss goals” in favor of extreme weight-loss goals. The unexpected capper in support of this position comes when lead author, Dr Krista Casazza, works up to a decidedly non-scientific endorsement of TV’s spectacularly exploitative, and wildly popular, program: The Biggest Loser.

Elsewhere in the press today, Dr. Casazza is quoted as saying: “There are facts about obesity of which we may be reasonably certain — facts that are useful today”. Well, yes, that much is true. But too many of Cassazza’s “facts” are overly-ripe for commercial exploitation. Out of the whole sorry mess, here’s the only cited fact that is both entirely TRUE and FREE:

~ “Physical activity does help in promoting weight loss and has health benefits even in the absence of weight loss.”

The rest of it is for sale and it is sad to see that the blowout was supported in part by a grant from the National Institutes of Health. As noted here by Health News Review, the authors’ conflict of interest disclosures take up a perhaps unprecedented half-page in the NEJM. That too is quite an unsavory feast for the eyes.

The final word is best left to Harvard Medical School’s Dr. Marcia Angell — who is, incidentally, former Editor-in-Chief of the New England Journal of Medicine. She wrote the following in a 2009 article for the New York Review of Books and, although it doesn’t refer to this particular study from Casazza et al, it couldn’t be more apt:

~ “It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine.” (From a review titled Drug Companies & Doctors: A Story of Corruption; http://www.nybooks.com/articles/archives/2009/jan/15/drug-companies-doctorsa-story-of-corruption/?page=1).

Deborah Collyar posted on February 1, 2013 at 5:08 pm

Thanks for bringing up COIs (another recurrent issue).

As a patient advocate, COIs are an important step toward transparency. We want results that will actually help people, not just promote business interests. Sometimes it’s a win/win for both, but we can only deduce that if we know who’s on the various playing fields involved.

If COIs aren’t listed (like omissions in the past), then readers won’t know what biases might exist.
Sure, it may complicate the answer of whether the authors are voicing opinions, making assertions or providing facts, but it also shows the complex world that we live in today.

I agree that very few researchers, institutions, doctors, or non-profit leaders are free from conflicts. The very people who have studied the problems and can offer important input usually have ties to companies. That doesn’t mean we shouldn’t hear from them, but we also shouldn’t assume that everything they say is ‘golden’.

I would rather know about potential COIs and urge authors to think about their comments in a reasoned way before publishing. Scrutiny doesn’t ensure ‘truth’, but it may help better balance the arguments that hope to persuade us.

Donna M posted on February 2, 2013 at 11:15 am

Should we expect anything more? The medical profession revolves around identifying and managing sets of symptoms. Causation is too risky to discuss. It is profitable to address symptoms with medication and surgery. The industry was resistant to curing ulcers with antibiotics that addressed the responsible bacteria, identified through correlation. What we label as diseases are really just fancy words for buckets of symptoms. Diabetes? Autoimmune diseases? IBS? PCOS? CPOD? These are symptoms, the result of largely unidentified catalysts. Why is the body developing insulin & leptin resistance? Why is the body’s immune system attacking itself? Our bodies have systems designed to keep functioning – as anyone who has ever had food poisoning knows. The challenge is to figure out what triggers these responses and eliminate the triggers.

Doug Mathias posted on February 4, 2013 at 10:44 am

All of the discussion about disclaimers and comments begs the question . . . is the analysis presented in the paper well done and based on verifiable facts that outweigh conflicting evidence in some real way that is not based on correlation, nor ecological study evidence, and does the paper provide directions for legitimate future research? Should we not be presenting the findings first, and then discussing the inherent quality of he research, THEN pursuing conflict of interest statements where these may provide an explanation for portions of the article that could be defined as “bad science”, either deliberately or through poor research methodology??

Doug Mathias posted on February 4, 2013 at 10:46 am

PS Mr. Dunning over at Skeptoid.com woud caution us all against “ad hominem” arguments, i.e., arguing against a position based on who is promoting it, rather than by examining the evidence they use to support that position.

Public Health Advocate posted on February 4, 2013 at 2:27 pm

What is disturbing with the article is that after reading it, you don’t know what to do if you want to loose weight in a sustainable manner. It only gives negatives, no solutions. Is that because they could not promote medicinal products or surgery?

Mary posted on February 11, 2013 at 2:00 pm

On the subject of disclosure of Conflict of Interests (COI) only, I can add that since August 2012 the requirements for reporting COIs changed for any researcher who receives research (grant) funding from the agencies under the Public Health Service. These authors received funding from NIH, therefore they have been subject to these new more-stringent requirements.

At my institution, I have seen the committee that reviews these conflicts require that the authors disclose ALL their financial conflicts in publications, talks, etc.

Therefore, we will be seeing more disclosures such as this listed with publications.