Health News Review

The following is a guest post by Kevin Lomangino, one of our story reviewers on HealthNewsReview.org. He is an independent medical journalist and editor who is currently Editor-in-Chief of Clinical Nutrition Insight, a monthly evidence-based newsletter which reviews the scientific literature on nutrition for physicians and dietitians. He tweets as @Klomangino.

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Last week, the New England Journal of Medicine published a review of the evidence on obesity that received a lot of attention. This was a “mythbusting” paper designed to separate fact from fiction and expose nonsense masquerading as truth. Journalists love these kinds of papers because they play to our skeptical worldview and make for excellent copy. And they’re useful to society too, as the authors point out, because clinging to unsupported beliefs can “yield poorly informed policy decisions, inaccurate clinical and public health recommendations, and an unproductive allocation of research resources and may divert attention away from useful, evidence-based information.”

But can we trust this particular team of mythbusters?

A number of observers (including Gary) raised this question after perusing the incredibly long list of potential financial conflicts that the authors disclosed at the end of the paper. This is truly an epic list of disclosures, and includes many different entities with considerable skin in the obesity game, ranging from giant food and beverage companies (Coca Cola, Pepsi, Kraft), to industrial agriculture interests (National Cattlemen’s Association, World Sugar Research Organisation) to drug companies with weight loss medications (Arena, Vivus), to companies selling weight loss programs or meal replacements designed to be used in such programs (Jenny Craig, Jason Pharmaceuticals).

Although the authors would surely disagree, I don’t think there is much doubt that these relationships influenced the content of the paper, and not for the better. How else to explain the choice of “facts” that the authors chose to highlight in the paper, and those they inexplicably left out?

Of the three interventions that the authors describe as “suited to clinical settings” in the “facts” section of the paper, two of them — meal replacements (e.g. low-cal shakes and bars) and weight loss drugs – figure prominently in the authors’ list of financial disclosures. But it’s curious that they didn’t think it worthwhile to discuss the benefits of intensive weight loss counseling using behavioral therapy.

This is an intervention whose value was recently demonstrated in a meta-analysis of 38 controlled trials by the U.S. Preventive Services Task Force. Medicare deemed the evidence strong enough to warrant reimbursing qualified counselors for providing this treatment. But the disclosure list doesn’t indicate any obvious financial stake in this approach for the authors. Could that have had anything to do with their decision not to mention it?

And what about soda and sugary drinks? At a time when New York City’s controversial legislation on cup size is fresh in the nation’s mind, it’s hard to imagine a topic that could benefit more from a hard-nosed look at the evidence. And yet nowhere in the paper do the authors address the role of soft drinks or sugar in obesity.

I really don’t know if that silence has anything to do with their ties to Coke, Pepsi, Red Bull, the World Sugar Research Organization, and similar organizations. And I’m not saying it’s an undisputed fact that cutting out soda reduces obesity (although the evidence from clinical trials seems to be close to erasing any doubts; see here and here). But considering the huge implications and obvious widespread confusion related to this issue, I think it’s strange that the authors didn’t include some kind of evidence-based discussion.

The authors did spend some time discussing the myth that sex burns a lot of energy. Personally, that’s not something I’ve heard very often, and I doubt that many people seriously think that sex plays any significant role in weight loss. I do, however, hear frequently that dietary supplements can help you lose weight, and I know that people spend billions on these products annually – most of it probably wasted. I also frequently hear that eating dairy products will help you lose weight, an idea that might well be a myth, and certainly isn’t a “fact” according to the authors’ criteria.

So again, I’m a little surprised that the article didn’t have more to say on these topics, and I can’t help but wonder if their decision-making had anything to do with ties to Basic Research, which according to WikiPedia makes the Zantrex-3 weight loss supplement, or multiple relationships with global dairy interests.

To be clear, I’m not suggesting that these relationships directly compromised the information that the authors presented in their article, or that the authors consciously tailored the content to benefit their funders. The article provides plenty of useful, evidence-based information, and I wholeheartedly agree with their call for better research in nutrition.

But do I think these relationships may have subtly influenced the choices these authors made with respect to what information to present, and how to present it. No question about it. And that influence could contribute to the “poorly informed policy decisions, inaccurate clinical and public health recommendations, and an unproductive allocation of research resources” that the authors say they are concerned about.

In his post, Gary concluded by asking whether these kinds of disclosures provide any meaningful information to readers. As someone who makes his living reporting on nutrition research for an audience of health care professionals, my answer is: absolutely.

Everyone looks at the world through their own individual lens of experiences and biases, and financial relationships have been shown to influence medical research and its reporting. It’s critically important to get these potential biases out in the open to the extent possible, so that readers have an opportunity to factor that information into their evaluation.

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Comments

Irene posted on February 5, 2013 at 8:24 pm

This post is nothing but innuendo and misdirection. I don’t see any evidence refuting the content of the paper, only slams against what it didn’t include. And where is the scorn for the NEJM reviewers, who surely should have caught some of the things that were “inexplicably left out”? If the author wants a thorough critical review of weight-loss supplements, soda/sugary drinks, etc., there’s nothing stopping him. That’s what a journalist or scientist would do–investigate, not insinuate.

    Kevin Lomangino posted on February 6, 2013 at 6:33 am

    Refuting the content of a paper isn’t the only way to say something useful about it. The authors presented a list of treatments for obesity that they said were supported by strong evidence (ie “facts”). They left out a treatment that fits that criteria and which it’s important for clinicians and patients to know about. They also presented myths and presumptions about obesity that didn’t address popular controversies and misconceptions. There was an apparent correlation between the topics the authors did/did not address and the financial interests they disclosed in the paper. For me, and I think for many clinicians as well, those are relevant and important observations — not innuendo and misdirection. And I shouldn’t have to write my own paper to find out what obesity treatments are supported by strong evidence — that’s what a review article in the New England Journal of Medicine is supposed to do for me.

Born Skeptic posted on February 7, 2013 at 1:14 pm

Irene wrote, “I don’t see any evidence refuting the content of the paper, only slams against what it didn’t include.”

Given the NEJM paper authors’ collective financial interests, isn’t the missing information alone enough to warrant criticism? Irene’s stone-throwing post makes me wonder which of the industries/companies most implicated in the country’s obesity epidemic are a part of her portfolio.

No, the mere disclosure of food industry financial interests by the authors alone is not reason enough to start flaming a published paper, especially if the paper itself is solid. But when those interests dovetail so neatly with the kinds of obesity treatment modalities that were / were not mentioned, you really do have to wonder why.

Or we could all just play dumb, eat more donuts, and, eventually, join Irene’s weight-loss clinic.

Jim Thornton posted on February 14, 2013 at 3:19 pm

I strongly agree with you that the potential for bias is quite real and compelling given the long list of potential financial conflicts of interest. I am also a big fan of the USPSTF and believe their recommendations are based on the best unbiased data that the Task Force members can find. On the other hand, the ongoing allegiance to diet and exercise as the best if not only hope for improving the nation’s (and most of the plantet’s, for that matter) obesity statistics seems to me to have its own drawbacks, as well, and the nutritional research community, I would imagine, has its own strongly vested interest in promoting the status quo. I would be interested in your take on several counterintuitive lines of research, too:

the Flegal et al paper in 2013 JAMA on All-Cause Mortality that showed that being overweight was associated with significantly lower all-cause mortality than normal and higher grade obesity; and that Grade 1 obesity (3.0-3<3.5) was not associated with any increase in all-cause mortality compared to normal weight.

a number of papers by Blair et al on the Obesity Paradox and the ability of fitness to cancel out the deleterious effects of obesity

and perhaps most intriguingly (to my mind), work by University of Virginia moral psychologist, Jonathan Haidt, whose moral foundations theory proposed five dimensions upon which most people base their moral judgments (for more, check here: http://www.moralfoundations.org/ ).

I interviewed Dr. Haidt for a piece on the different world views of liberals and conservatives, and here is a little of what he told me about the fifth of these dimensions:

The fifth foundation is purity-sanctity…It's about any kind of ideology that tells you that you can attain virtue by controlling what you do with your body, by controlling what you put into your body. And while the political right may moralize sex much more, the political left is really doing a lot of it with food. Food is becoming extremely moralized nowadays, and a lot of it is ideas about purity, about what you're willing to touch or put into your body."

Is it possible that your critique of the "Myths" paper might, in fact, have something to do with the possibility it is challenging a moral conviction that obesity, against all sorts of counter-evidence, is and/or should be something within a person's volitional control–that we can, or should be able, to choose what "good" foods we put into our mouths, and that we can, or should be able to, choose a righteous approach to combat sedentary impulses?

I read the Allison et al paper, and from what I managed to glean, the authors summarized the literature about the various "myths" they hoped to reveal while remaining equivocal on the various assumptions that are not yet convincingly proven or disproven (a la the effects of eating or skipping breakfast.)

Though the financial incentives of food marketers are very real, so too are those in the Diet Industry whose profitability depends on keeping alive the notion that obesity is largely treatable by volitional behavior, something that many obese patients, and the sustained wt loss rate of the LOOK AHEAD trial (<5 percent of BW sustained weight loss after 4 years; study's impact on coronary diseases halted early when no benefits were shown) might beg to differ with.

Let's face it: weight is very, very hard for most to modify significantly beyond a slight range; it's even harder to sustain such a change long term; and for some people, e.g., victims of single gene mutations in the leptin system, any change is impossible. Sniping about what does and doesn't work and the impact of financial interests on one side or the other won't change this. Nor will trying to inspire people with the idea that they have a lot of control over their body weight, either up or down, accomplish much good–especially for those who are most obese and likely most in the throes of biology beyond their control.

Jim Thornton posted on February 14, 2013 at 3:31 pm

One more note, and by no means do I mean to be obnoxious here. But I checked out Clinical Nutrition Insight, which has an incredibly prestigious list of editorial board members (including one from the USDA, which in some circles might raise a red flag.) But the company that owns and publishes this has a link for advertisers http://www.lww.com/webapp/wcs/stores/servlet/content_advertisingonline_advertisingprograms_11851_-1_12551 that makes me wonder if there exists anywhere in the modern world a single piece of totally unbuttered bread! I am not at all certain the human brain is capable of completely rational analysis of anything, and the odds of this happening with such a emotionally-charged, bamboozingly complex, and financially-riddled topic like obesity seems to me nigh on infinitesimal!

    Kevin Lomangino posted on February 15, 2013 at 9:38 am

    Jim, thanks much for sharing your thoughts. In my opinion, your comments about my motivations for writing the critique are neither here nor there. We all have our own biases and preconceived notions that we have to try to rise above. One way we do that is by acknowledging and considering evidence that might not fit with our beliefs and biases. In my opinion, these authors did not do that, which is why I have a problem with their paper. I am not arguing that counseling is more effective or better than other weight loss approaches, and I am not trying to “inspire people with the idea that they have a lot of control over their body weight.” I am merely pointing out that there is strong evidence that intensive counseling can have a clinically meaningful effect on body weight, and that it should have been mentioned in any evidence-based discussion of obesity facts.

    Ultimately, it is the specifics of each patient’s situation and their preferences that determine the best treatment approach. And as experts providing other clinicians with evidence-based treatment recommendations, these authors did their colleagues a disservice by omitting an approach that has proven value.

      Jim Thornton posted on February 15, 2013 at 2:14 pm

      Kevin, very sorry if my comments seemed at all condemning, and I really appreciate your blog and the points you raised in your critique of the NEJM paper. I’m actually working on a piece of the various biological factors that are involved in feeding behavior and energy expenditure and have interviewed a number of researchers including Dr. Jeffrey Friedman, who discovered the ob gene in mice and through this leptin, as well as Dr. Allison, who was one of the authors of the NEJM paper you reviewed. The gist of my article is on the relative potency of volitional behaviors vs. biological drivers in weight regulation. Though I have come to believe some people really have zero volitional control (for example, the extremely rare victims of an ob/ob genotype), I think many of us have some control, but how potent this really is outside a range of maybe 10 lb. up or down is likely less than most Americans believe and/or would like to believe. When you write that there is strong evidence that intensive counseling can have a clinically meaningful effect, I am curious about a) which evidence you mean, and over what kind of time period do changes in weight persist, b) if you believe that intensive counseling of the sort, for instance, used in the LOOK AHEAD trial can be cost-effectively applied to the real world where there remain huge constraints of the time of most practitioners, and c) what exactly you mean by clinically meaningful? Steven Blair, for his part, has found that improving cardiovascular fitness reduces a variety of health risks regardless of whether this leads to any meaningful weight loss. If we are speaking mainly about health outcomes, I am not aware of any research that has shown shedding weight by lifestyle intervention improves the health status of a formerly obese person (unless he or she becomes fitter in the process.) Bariatric surgery, on the other hand, though rife with problems, does seem to increase longevity.

      I guess what I am saying is that obesity, especially the morbid variety, is so profound a medical problem for those afflicted with it that the suggestion that lifestyle intervention can make much of an impact seems very unlikely. It couldn’t hurt, of course, and I suspect eating right and exercising would benefit most of us, regardless of our weight. But to hold this out as a meaningful treatment puts significant onus on the victims to take responsibility for a condition they are not, in so many ways, responsible for.

      I’m sure my view flies against the prevailing sentiment, but I think it’s time to consider lifestyle intervention as a kind of adjuvant treatment, at best, and turn much more of the research funding over to work on the biology of the disease.

Kevin Lomangino posted on February 15, 2013 at 7:12 pm

Jim, no offense take by your comments, and I appreciate the exchange. The evidence I’m talking about is in the linked USPSTF paper. I recall that they found an average of 6% weight loss after 12-18 months for programs that had more than 12 sessions. That’s not a huge amount of weight loss, but if you accept the threshold of 5% as clinically meaningful, it passes the bar. Plus, obviously, many people achieve more than that. This is a real world intervention that Medicare (and, I think, an increasing number of insurers) will actually pay for. I agree that it’s unclear if weight loss achieved through diet and exercise improves health outcomes, and the LOOK AHEAD results were a disappointment. But the paper was about weight loss, not health outcomes, and there is certainly some doubt as to whether weight loss achieved through medications and surgery also improves outcomes. The data showing that bariatric surgery increases longevity is based on a nonrandomized comparison, so there will remain some question as to whether this is a finding we can trust (though I agree it’s the best evidence available). Not to mention concerns about risks and adverse effects, cost, etc., that are not in question with lifestyle programs. Again, I am not arguing for or against any specific approach, but I think we need to have options because everybody is different. Lifestyle intervention clearly does have an impact for some people, and so to give up on it (or omit it from the discussion) is, in my view, misguided.

    Jim Thornton posted on February 18, 2013 at 9:55 am

    Kevin, I agree wholeheartedly. I am a masters swimmer and though even prodigious quantities of exercise doesn’t seem to help some of my fellow swimmers lose weight and sustain this loss, there are clearly people who benefit significantly. (One fellow, a former college swimmer who was 6′ 5″ his senior year, then ballooned up to 225 by his 30s, has lost 40 lb. since resuming swim training 1 1/2 years ago; on the other hand, another friend who is a great distance swimmer, who regularly trains 30,000 – 40,000 yards a week and watches what he eats more diligently than anyone I’ve ever met, can’t get his BMI below 30.) The twin studies by Dr. Bouchard seem to indicate that some people are diet responders; some are exercise responders; some respond to both; and some, alas, respond to neither. I think one of the more promising developments (hopefully within our lifetimes!) will be genetic analysis to get some sense of who is likely to respond best to what intervention. Did you happen to see the recent study in Diabetes regarding FTO Genotype and 2-Year Change in body composition in response to different styles of diets? It found that a high protein approach seems to work better for people with a specific risk allele, and not so well for those with other variations of this gene. This sort of thing, I suspect and hope, might one day silence some of the needless disputes between warring camps (i.e., Atkins vs. Ornish and the like.)

    All in all, I think weight control is one of the most fascinating topics in medical research today. It spans a range of inquiry from the most narrow minutiae (FTO variant rs1558902) to grandly philosophic (Free Will vs. Determinism), all of this laced with overtones of evolutionary biology, environmental changes (obesogens, microbiome alterations, increased atmospheric CO2, and host of other putative culprits), and money–that great goader and eroder of our nation’s greatness!

    Would you be able to send me your email address? Because I write frequently on topics related to health and fitness, it would be great to have you as a potential source for future stories (and perhaps even for the one I am working on now.) Thanks, Kevin

Jim Thornton posted on February 18, 2013 at 9:56 am

I left out the swimmer’s weight: he was 6′ 5″ and 160 lb. his senior year before ballooning up to 225.

Dr Martin Binks posted on February 23, 2013 at 10:52 am

These are good questions to raise – and should be raised in order to maintain research integrity. It appears, however, that many writers who level these criticisms do not post a similar list of disclosures of EVERY person, company and other financial supporter for themselves and all publications in which they have written where financial support has been provided (throughout your entire professional career). Transparency is key in research integrity and thus the authors of the NEJM provided such disclosure to allow us to make informed decisions re the content of the paper. Yet the media who criticize the scientists do not provide equivalent information re their own conflicts of interest and often have deep ties to relevant financial conflicts. It would therefore seem to be very appropriate to request that all individuals and organizations with opinions on scientific articles in the media to be held to the same standard the scientists are required to report.