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.
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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