Controversy in obesity field

Special interest groups wield unprecedented power

Controversy abounds in the obesity field. Much of the difficulty stems from the way early research was conducted, without the quality standards demanded for other health conditions and diseases, and heavily influenced by special interest groups in the diet industry. Perhaps pseudoscience was allowed because weight was then considered more of a cosmetic issue than a medical concern.

Any risks associated with obesity were assumed to be caused by it, because that assumption was promoted. Treatment was assumed to be safe and effective, because it seemed to be initially. Short-term treatment, often lasting only two to six weeks, was considered lasting; no questions asked. Vested interests took root.

Research in the field was and continues to be bound up with special interest groups at a number of universities and even at the federal policy-making level. The fact that today major international pharmaceutical firms are involved in financing a vast network of research and program funding at all levels, along with promoting weight loss medications, serves only to increase the difficulty of getting accurate and straight-forward information.(1,2,3,4,5)

Consequently, many highly-publicized studies not only claim that obesity is associated with a long list of severe health risks, but that it causes them. Although this is not supported by research (association does not prove cause), it has been repeated so often that it is generally believed by both health professionals and the public. Typically, such studies reinforce the notion that obesity treatment is effective and safe and that, above all, leanness is critical for health and longevity, although science fails to support this, as well.

References

1. Berg FM. Women Afraid to Eat: Breaking Free in today’s Weight-Obsessed World, 2001, p193-211. Healthy Weight Network: Hettinger, ND.
2. Berg FM. Children and Teens Afraid to Eat: Helping Youth in Today’s Weight-Obsessed World, 2001, p29-36, 92-96. Healthy Weight Network: Hettinger, ND.
3. Berg FM. Underage and Overweight: Our Childhood Obesity Crisis – What Every Family Needs to Know, 2005, p139-155. Hatherleigh Press: NY.
4. Ernsberger P, Haskew P. Re-thinking obesity: An alterna­tive view of its health implications. Journal of Obesity and Weight Regulation, 1987;6(2), 1-81.
5. Fraser L.. America’s obsession with weight and the industry that feeds on it, 1997. New York: Dutton.
6. Gaesser GA. Big fat lies: The truth about your weight and your health, 2002. Carlsbad, CA: Gurze Books.

Health professionals and consumers are asking these questions:

• Why do federal agencies pursue 'war on obesity'?
  In 2003, as the Iraq war began, U.S. Surgeon General Richard Carmona told reporters the most serious threat to health was not weapons of mass destruction, but obesity.(1)

This obsession with obesity at federal levels and the extreme pressures on Americans to be thin is being called the "war on obesity." Fought on the battlegrounds of medical journals, newspapers and popular magazines with weak science and fearmongering, it reaches into clinics and classrooms and social gatherings to pursue and harass thousands of vulnerable children and adults. Federal health agencies, the medical community and the media are actively involved in fighting this war, seemingly against America's own citizens.(2)

“A witch-hunt masquerading as a public health initiative that encourages people to hate their bodies if they fail to conform to an absurdly restrictive ideal,” Paul Campos, author of The Obesity Myth calls this war.(3)

If this effort had been put into improving physical activity in the past decade, how much stronger, healthier and longer-lived would Americans be today? How much harm would have been avoided?(4)

Instead battle tactics have focused on food restriction, obsessions with thinness, weight loss at all costs, and even unnecessary but risky surgery. We are overwhelmed by confusion on eating and nutrition advice and underwhelmed by any comprehensive efforts to increase physical activity.

If this effort had been put into improving physical activity, how much stronger, healthier and longer-lived would Americans be today?

This approach has harmed people of all sizes, genders and ethnicity, with no end in sight, and our federal health agencies surely bear some of the responsibility for the harm done.(5)

What is being gained by the war on obesity? Does it solve health problems? Does it reduce obesity? Apparently not. Considerable research suggests that weight loss efforts tend to backfire and instead can lead to increased weight gain.

Far from doing no harm, the increasing pressures to lose weight over the past decade and a half appear to have led to further weight gain, smoking for weight control, and rising rates of eating disorders, nutrient deficiencies, harmful weight loss efforts, body hatred and size harassment.(6)

Apparently, it has done little to increase physical activity – long considered a key factor in curbing the rise in obesity and associated health issues.

How can we bring about a peaceful settlement?

“Nothing could be easier than to win this war. All we need to do is stop fighting it.” says Campos.

Scientists at the Cooper Institute Aerobics Center in Dallas, who have researched this issue for over 30 years, agree:

“We strongly suggest that clinicians and other health professionals spend at least as much time encouraging sedentary women to become more physically active as encouraging overweight and obese women to lose weight.”(7)

Adds Steven N. Blair of the Institute, “Fitness, not fatness, is the issue.”

References

1. Campos Paul. The Obesity Myth. 2004, p3. Penguin Books: New York.
2. Koop urges docs to treat obesity as a disease. Boston Herald. October 30, 1996:2.
3. Campos, Paul. The Obesity Myth, xvii
4. Berg FM. Underage and Overweight: Our Childhood Obesity Crisis – What Every Family Needs to Know, 2005, p135-155. Hatherleigh Press: NY.
5. Berg FM. Women Afraid to Eat: Breaking Free in today’s Weight-Obsessed World, 2001, p31-50. Healthy Weight Network: Hettinger, ND.
6. Berg FM. Children and Teens Afraid to Eat: Helping Youth in Today’s Weight-Obsessed World, 2001, p18-23. Healthy Weight Network: Hettinger, ND.
7. Farrell SW, Braun L, Barlow CE, Cheng YJ, Blair SN. Relation of body mass index, cardiorespiratory fitness, and all-cause mortality in women. Obes Res 2002 Jun;10(6):417-23.
   
   

If 'overweight' is benign, why not acknowledge it?
The category of overweight is shown by Flegal's CDC research and numerous other studies to be the category associated with the lowest mortality risk. While no one denies there are risks associated with severe obesity, this comprehensive analysis shows relatively little risk with mild and moderate obesity.(1)

In fact, together the two heavier categories had lower relative risk than the normal and underweight categories. Underweight is associated with the highest death rates.

If overwieght is “healthier” than normal or healthy weight, isn’t that a contradiction in terms? Why do federal agencies refuse to acknowledge it?

References

1. Flegal KM; Graubard BI; Williamson DF; et al. Overweight, and Obesity Excess Deaths Associated With Underweight. JAMA. 2005;293(15):1861-1867.
2. Berg FM. Underage and Overweight: Our Childhood Obesity Crisis – What Every Family Needs to Know, 2005, p219-233. Hatherleigh Press: NY.
   

Why are eating disorders ignored by health agencies?
Why are there no federal statistics on eating disorders? Why are there almost no federal efforts to prevent or deal with this severe and too-often-fatal illness?

America has been called an eating-disordered culture, and with good reason. An estimated 10 million people (90 to 95 percent female) have clinical eating disorders. By comparison, this is double the number of Americans with Alzheimer’s disease, yet Federal funding for Alzheimer’s is $647 million compared with only $12 million for eating disorders.

Eating disorders have the highest fatality rate of any mental illness, with an estimated mortality as high as 15 to 20 percent for anorexia nervosa and bulimia. They are among the top four leading causes of burden of disease in terms of life lost through disability or death. An estimated 50 percent of teen girls have a significant eating disturbance at some point in their adolescence.(1,2)

Recovery can be long and difficult. Fewer than half the patients with severe disorders recover completely, and even then severe health consequences such as osteoporosis, gastrointestinal complications and dental problems may be significant health and financial burdens throughout life.(3)

Eating disorder organizations have long urged federal and state governments to undertake educational programs to help prevent eating disorders, to compile national statistics. But, inexplicably, the National Center for Health Statistics keeps no statistics on eating disorders, despite the fact that agency provides a minutiae of statistics and information on obesity and virtually every other health condition and disease.(4,5,6)

So why are eating disorders being left out of national health programs? Why are they barely mentioned in Healthy People 2010, the nation's 10-year health agenda?

As in the obesity field we have to ask: what special interest groups benefit from this silence and inaction? Must we again follow the money to special interests that benefit most when restrictive dieting and body hatred are supported by federal health agencies?

What special interest groups benefit most from silence and inaction? Which benefit most from federal health agencies' support of dieting and body hatred?

What might happen, instead, if the public were fully informed of the risks of eating disorders and obsessive thinness among young girls and women? What might happen if the public – and health providers – knew the extent and consequences of dysfunctional eating, nutrient deficiencies and dangerous weight loss interventions?(7)

References

1. http://www.nationaleatingdisorders.org/
2. Berg FM. Children and Teens Afraid to Eat: Helping Youth in Today’s Weight-Obsessed World, 2001, p17-29, 117-137. Healthy Weight Network: Hettinger, ND.
3. Berg FM. Women Afraid to Eat: Breaking Free in today’s Weight-Obsessed World, 2001, p71-110, 129-167. Healthy Weight Network: Hettinger, ND.
4. Fallon P, M Katzman, S Wooley, edits. Feminist perspectives on eating disorders. 1994. Guilford Press, NY.
5. Grange D, J Tibbs, J Selibowitz. Eating attitudes, body shape, and self-disclosure in adolescent girls and boys. EatingDis 1995:3:3:253-264.
6. Smolak L, M Levine. Toward an empirical basis for primary prevention of eating problems with elementary school children. Eat Disorders 1994;2:4:293-307.
7. Berg FM. Underage and Overweight: Our Childhood Obesity Crisis – What Every Family Needs to Know, 2005, p76-94. Hatherleigh Press: NY.
   
   
   

Weight categories set too low?

"Such a serious public health issue deserves a far more balanced discussion."

In 1998 a set of guidelines supposedly aimed at helping health providers deal with weight issues was developed by a 24-member panel of obesity specialists convened by the National Health Lung and Blood Institute (NHLBI). The report, Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report, nearly doubled, in one stroke, the number of Americans defined as overweight and obese.(1)

They did this by lowering the category of normal weight or healthy weight so it was below a BMI of 25 (previously about 27.5). This category supposedly encompassed the weight where mortality risks were at their lowest level. Anyone over this weight was declared overweight or obese and considered at health risk.

However, oddly, this defines health risks as beginning at a BMI of 25, which was much lower than suggested by research at the time.

The panel members themselves could hardly have avoided knowing this. In setting the levels they first analyzed 236 randomized controlled trials. Results suggested the lowest mortality was about at the level of a BMI of 24.8 for white men, 24.3 for white women, 27.1 for African-American men, 26.8 for African-American women, and 25 to 30 for adults age 55 and older. As seen in the above chart, this encompasses about the level they chose to set as the overweight category.(2)

Apparently, the research results they found with this analysis did not satisfy panel members. So instead, they began to cite Harvard’s Nurses Health Study as their rationale for lowering the weight categories.(3)

The ongoing Nurses Health Study presented a number of publishing biases. Being neither randomized nor controlled, it surveyed mostly-white female nurses in 11 states. Weight was self-reported by mailed-in questionnaires. Even more unfortunate, the data in its 1995 report applied to only a small subgroup of the nurses studied. Deaths in this subgroup, which was used to rationalize the NHLBI guidelines, totaled only 11 percent of total deaths and only 4 percent of the sample in follow-up. Even so, the adjusted relative risk of 1.2 for mortality for BMIs of 25 to 26 was not statistically significant. Racial and gender comparisons could not be fairly made since 98 percent of the nurses were white and nearly all were women.(4)

However, unlike most other studies, which found lowest risk at a BMI of around 24 to 30, the Nurses Study reported higher risks at a BMI as low as 23. This was apparently the desired result.

Incredibly, despite its many shortcomings and biases, the Nurses Health Study was cited as the panel’s support for lowering weight categories – for both men and women of all ethnicities and ages throughout the U.S. Overweight, thus, was defined at the very level that correlated with the lowest death rate. Suddenly 55 percent of American adults were overweight or obese, nearly double the number identified by previous NHANES II standards.

Lowering the categories was clearly unjustified. It greatly exaggerated the increase in overweight and exaggerated any related health risks.

Special interest groups have insisted that overweight and obesity are increasing so rapidly and include such severe risks that it should be called a “disease” and its spread an “epidemic.” Much pressure was excerted to make this happen. However, since obesity has some clear health benefits, including osteoporosis prevention and lower death rates under certain conditions, it cannot properly be called a disease or epidemic.(7)
 
Critics scoffed, but the media – caught up in the storm and continually pressured by special interest groups – were not in a mood to listen.

Vested interests
How could all this happen in what is supposedly the science-based, medical field of obesity?

Unfortunately, it’s simple. Research distortions in the obesity guidelines benefit the special interest groups. So it is legitimate to ask: How many people on that 24-member NHLBI panel that designed the Guidelines have financial affiliations with the weight loss industry?

In this case, as often happens with federal advisory groups in this field, the panel members working on the NHLBI guidelines were not required to disclose their conflicts of interest. Nevertheless, the vested interests of the panel chairman provide some illumination. The chair was F. Xavier Pi-Sunyer, MD, head of the Obesity Research Center at St. Luke's/Roosevelt Hospital, N.Y., who had previously acknowledged his financial support from seven companies involved in the weight loss industry. They are Weight Watchers and Lilly, Genentech, Hoffman-LaRoche, Neutrogen, Wyeth-Ayerst and Knoll Pharmaceuticals. He did not disclose funding sources for the Obesity Research Center or for research conducted there.

Naturally, special interests groups and the individuals who are financially associated with them will promote their own agenda and market their own products, even perhaps with some manipulation of the facts. This is to be expected, and let the buyer beware.

But what is unacceptable, and probably illegal, is that special interests in the obesity field have gained such hidden power within the U.S. Health and Human Services Department and its various branches that they are able to control the message and issue misinformation as fact. The NHLBI guidelines are just one example.

Challenges from other federal sources
Challenges were ignored, even when they came from federal sources.

“The new NHLBI Clinical guidelines: Will they promote health?” asked researchers at the Human Population Laboratory, Public Health Institute in Berkeley, CA, led by William Strawbridge, PhD, in the March 2000 issue of the American Journal of Public Health.(10)

Scientists there conduct epidemiologic research and act as a resource for other programs within the U.S. Department of Health and Human Services. To make their point, they analyzed risk of death in the landmark Alameda County Study, now in its 31st year and considered similar in age, sex and ethnic mix to the U.S. as a whole.

They found precisely what most credible studies before and since have found, that people in what is now called the overweight category tend to live longer than people in any other category.

“Our results are consistent with other studies and fail to justify lowering the overweight threshold on the basis of mortality,” they concluded. But they were tactful of their colleagues in NHLBI, and noted that they were not questioning serious health consequences associated with a high BMI.

”What we are questioning is the rush to ignore the many caveats in the NHLBI report. … Such a serious public health issue deserves a far more balanced discussion that it has received to date.”

Since then other research has amassed further evidence to question those official weight categories. Most notable is the analysis of actual deaths in the U.S. over a 30-year period by Centers for Disease Control and Prevention’s own scientists, led by Katherine Flegal, PhD, senior research scientist with CDC’s National Center for Health Statistics.(11)

CDC is showing some ambivalence in partially accepting the Flegal findings. It has discontinued the linking of “overweight and obesity,” by dropping the reference to overweight in most of its website materials. Further, it has replaced with a new figure of 111,909, the previous claims of 300,000 and 400,000 annual deaths “caused by” obesity.

Unfortunately, however, CDC has kept its weight categories unchanged: the misnamed category of normal or healthy weight still remains below what research shows is the level of lowest mortality.

References

1. Clinical Guidelines on the Identification, Evaluation,and Treatment of Overweight and Obesityin Adults. Bethesda, Md: National Heart, Lung, and Blood Institute; 1998.
2. Berg FM. NIH-NHLBI Guidelines: An Evaluation. Healthy Weight Journal 1999;13:2:26-29.
3. Manson JE, Willett WC, Stampfer MJ, et al. Body weight and mortality among women. JAMA. 1995;257:353–358.
4. Strawbridge WJ, Wallhagen MI, Shema SJ. New NHLBI clinical guidelines for obesity and overweight: will they promote health? Am J Public Health. 2000;90:340-343.
5. Mokdad AH, et al. Actual causes of death in the US. JAMA 2004;291:1238-1245.
6. Berg FM. Underage and Overweight: Our Childhood Obesity Crisis – What Every Family Needs to Know, 2005, p26-27. Hatherleigh Press: NY.
7. Koop urges docs to treat obesity as a disease. Boston Herald. October 30, 1996:2.
8. Berg FM. Underage and Overweight, p142.
9. National Task Force on the Prevention and Treatment of Obesity. Long-term pharmacotherapy in the management of obesity. JAMA 276 (1996):1907-1915.
10. Strawbridge WJ. New NHLBI clinical guidelines for obesity and overweight: will they promote health?
11. Flegal KM, Graubard BI, Williamson DF, Gail MH. Excess Deaths Associated With Underweight, Overweight, and Obesity. JAMA. 2005;293:1861-1867 (April 20, 2005). jama.ama-assn.org/cgi/reprint/293/15/1861.pdf
12. http://www.healthypeople.gov/data/midcourse/html/focusareas/FA19Objectives.htm  Accessed 2/20/09.    

Flegal research confronts
health risk claims

Health risks of obesity are greatly exaggerated; severe risks of underweight are ignored

On April 20, 2005, a comprehensive analysis published by Centers of Disease Control (CDC) researchers in the Journal of the American Medical Association (p1861-1867) shook the foundations of two popularly-held assumptions: first, whether there is a correlation between higher death rates and overweight and mild or moderate obesity and, second, whether obesity causes the diseases commonly associated with it.(1)

The study, led by Katherine Flegal, PhD, senior research scientist with CDC’s National Center for Health Statistics, looked at the actual deaths in the U.S. over a 30-year period. It was far more rigorous than previous highly-publicized CDC studies, which were based on abstract mathematical models rather than actual deaths.

Using normal weight as the reference group, this new and more inclusive research finds annual excess death estimates as follows.

ADULTS
WEIGHT CATEGORY   EXCESS DEATHS Underweight   33,746 Normal weight   0 Overweight   --86,094 Obesity   111,909

The negative 86,094 figure means that the overweight group had that many fewer deaths per year than the normal weight group, and about 120,000 less than the underweight group – the number of “saved lives."

Looked at another way, comparing the two leaner groups below a BMI of 25, with the two heavier groups, shows there were 7,931 more deaths in the two leaner groups, as below:

The conclusions showed these mortality risks with the four weight groups:

Overweight (BMI 25 to 29.9) was the group with the lowest death rate of any of the four categories.

There were relatively more deaths in the two leanest categories (underweight and normal weight) than in the two heaviest categories (overweight and obese).

There were fewer deaths in the two heaviest categories, BMIs of 25 and over, compared with BMIs under 25. Even in the obese group most had a lower mortality risk than in the normal group. It was only in the heaviest subgroup of these that mortalitly risk exceeded that of the normal group.

Backlash and rebuttal
No sooner had the news hit the media than a backlash began and the Flegal paper was attacked.(2) The Harvard group of obesity specialists called a news conference to criticize its findings. As quoted in the New York Times, Dr. Frank Hu, an associate professor of nutrition and epidemiology at Harvard, home of the Nurses Health Study, insisted that as body mass index increases “the death rate increases dramatically.”(3)

Hu and Dr. JoAnn Manson, also of Harvard, charged that the new federal analysis had failed to exclude smokers and people who were already ill. (This was untrue. The federal researchers analyzed the data both ways, with essentially no differences found.)

“That can lead to serious underestimates of mortality linked to overweight and obesity,” Manson insisted.

Dr. Walter Willett, chair of nutrition at the Harvard public health school, called the new analysis “deeply flawed.”

Dr. Katherine Flegal replied that she and her colleagues had analyzed their data in a variety of ways, both with and without current or former smokers and people who had chronic diseases. She said the results always came out the same; there was no mortality risk from being overweight and little from being obese, except at the extreme end.

Flegal’s co-author Dr. David F. Williamson added that one reason for the discrepancy between their results and other findings could be the populations under study. While the Harvard group polled mostly-white nurses in a few states with mailed-in self-reported questionnaires, and cancer researchers questioned volunteers, Williamson said, “We have data sets that are truly nationally representative of the U.S. population.”

Another reason for the differing conclusions, Flegal said, could be that the Harvard and cancer researchers excluded large numbers of subjects from their analysis for one reason or another. One analysis of the Nurses Study excluded nearly 90 percent of deaths, she pointed out.(4) (Although Flegal didn’t say it, critics call this “cherry picking” – sorting out a subset that gives desired results, then reporting it as if including all subjects.)

She and her colleagues used actual measured weights and heights, not self reported ones, she added, so her team may have had more accurate numbers to work with.

“I don’t know what to say” about the attack on the paper, Flegal said. “I don’t have a problem with people at a conference talking about their data, but I do have a problem with their talking about our data and saying we should have found the same things that they found.”

Flegal and co-authors, Williamson and Elsie Pamuk, concluded, “Hu et al. speculate that the number of deaths attributable to obesity in the United States may be underestimated when relative risks are calculated on the basis of current body mass index (BMI).

“They cite no data to support their speculations, but instead invoke the notion of ‘reverse causality.’ They hypothesize that relative risks are lowered by obese people who become ill, lose weight because of this illness to become normal weight, and die shortly thereafter of the underlying illness, surviving just long enough to be included in the study.

“However, this reverse-causation hypothesis is unlikely to be the correct explanation for the lower relative risks in the elderly for two reasons: first, because data show that exclusion of preexisting illness has little effect on relative risk estimates, and second, because weight loss from obesity to normal weight is relatively uncommon.”

Controversy has likely simmered within government agencies, as well.(5,6) CDC Director Julie Gerberding, MD, seemed to repudiate the Flegal findings and said the agency will continue its fight against obesity.(7)

However, the agency did publish Katherine Flegal’s rebuttal through an analysis of the data online. It may be reviewed at the following site: http://www.cdc.gov/nchs/products/pubs/pubd/hestats/excess_deaths/excess_deaths.htm

References

1. Flegal KM, Graubard BI, Williamson DF, Gail MH. Excess Deaths Associated With Underweight, Overweight, and Obesity. JAMA. 2005;293:1861-1867 (April 20, 2005). jama.ama-assn.org/cgi/reprint/293/15/1861.pdf
2. Kolata Gina. Study Tying Longer Life to Extra Pounds Draws Fire. New York Times, May 27, 2005.
3. Harvard Panel: CDC Study Wrong on Obesity Risk; Harvard Experts Say Obesity Death Risk Getting Higher, Not Lower. WebMD, May 26, 2005.
4. Manson JE, Willett WC, Stampfer MJ, et al. Body weight and mortality among women. JAMA. 1995;257:353–358.
5. Internal CDC Documents: Researchers Apparently Knew 400,000-Obesity-Death Study Used 'Wrong Formula.' Consumer Freedom News, May 27, 2005.
6. Berg FM. Underage and Overweight: Our Childhood Obesity Crisis – What Every Family Needs to Know, 2005, p27. Hatherleigh Press: NY.
7. Milloy  Steven. Obesity Hysteria Survives Despite Official Debunking. Fox News, May 06, 2005.

Weight loss interventions
Are weight loss programs effective long-term? If so, how safe are they?

This may be the greatest controversy of all. On the other hand, perhaps there’s little argument, because so much is known, so much has been promised, so much has failed; we’ve all been through far too much..

Suffice it to say that despite nearly four decades of intensive research on dieting and other weight loss interventions, obesity specialists are unable to show lasting success for any weight loss method, whether diet, drugs or surgery. All must be considered experimental. None are proven safe and effective.(1,2,3,4,5,6)

See Weight Loss section on this website.

References

1. NIH Technology assessment conference: Methods for voluntary weight loss and control. Mar30-Apr1, 1992.
2. Berg FM. Underage and Overweight: Our Childhood Obesity Crisis – What Every Family Needs to Know, 2005, p135-194. Hatherleigh Press: NY.
3. Kassirer JP, Angell M. Losing weight: An illfated New Year’s resolution. N Engl J Med 1998;338:5254.
4. Garner DM, Wooley SC. Confronting the failure of behavioral and dietary treatments for obesity. Clin Psych Rev 1991;11:729-780.
5. Berg FM. Women Afraid to Eat: Breaking Free in today’s Weight-Obsessed World, 2001, p129-167. Healthy Weight Network: Hettinger, ND.
6. Berg FM. Children and Teens Afraid to Eat: Helping Youth in Today’s Weight-Obsessed World, 2001, p75-116. Healthy Weight Network: Hettinger, ND.

Publishing Bias: What is it?
Bias in publishing has been employed widely in obesity research for nearly three decades.(1) Today there is increasing concern over ethical research in this and many other fields, as well.

Publishing bias is more likely, suggests John P.A. Ioannidis, Adjunct Professor, Tufts University School of Medicine, when there is a prevailing bias in the field and greater financial interests at stake.(2)

Both these factors apply in the obesity field. First, an undeniable bias exists in American culture in regard to large children and adults.(3,4) And, second, the money is there, with an estimated $50 billion or more spent annually on weight loss efforts and large sums available from the industry for financing academic research, grants and stipends for scientists, medical conferences, research journals and educational campaigns.(5,6,7)

Ioannidis defines publishing bias as the combination of various design, data, analysis, and presentation factors that tend to produce research findings when they should not be produced, and can entail manipulation in the analysis, and selective or distorted reporting of the findings.

Much publishing bias in the obesity field involves one or more of the following:

Assuming that association proves cause. Obesity is being blamed for much illness and disease for which there is little or no evidence it is causal. Making the leap from association to cause is a violation of science not permitted for other health conditions. Yet for obesity it is widely assumed, reported and believed.(8,9)

Conclusion and abstract differs from body of study. Determining at the outset how a study will turn out is not responsible science, but happens often in this field. In its least subtle form, a negating paragraph may simply be tacked on, for example, to a federal report that shows the ineffectiveness or harmful effects of dieting. It’s been called the “P.S. paragraph,” the non sequitur that does not follow, but says, in effect, “In spite of all this, keep dieting.”

“Cherry picking.” In a practice known as cherry picking, a subset is found that gives the desired results. The research report is based on this subset, rather than the larger study population.

Short-term intervention. By its nature, weight is lost easily at first, but not sustained. Typically, weight regain follows until all lost weight, and perhaps more, is regained. Therefore, a short-term study is irrelevant because it fails to show true results. A one-year study does not represent lasting change.(10,11)

Undisclosed side effects. A full reporting of trial results is needed, including detrimental effects, but these are often unavailable. Not publishing the whole story can lead to inappropriate clinical interventions.

High dropout rate. High dropout rates indicate high failure rates, so are important in understanding a weight loss intervention. It is irresponsible to report on the final, smaller number of “successes” remaining in the study as if they represent the total group enrolled.

Non-representative sample of subjects. The sample needs to accurately represent the group being studied, and the results not extrapolated beyond that population. This is often violated in the obesity field when results from small, specialized groups are reported as if they apply to the general population, or only half the findings are reported.  

Self-reported data; mailed-in questionnaires.  Self-reported answers are not always reliable, especially in regard to weight, height and weight loss or maintenance. Further, a low reply rate weakens the study, as respondents may be self-selected in a way that skews results.

Transparency goals
In response to the growing concern for ethical publishing today, several institutions and governing bodies are working to create registries to increase transparency and full reporting of trial results. They recommend voluntary registration of all clinical trials.(12)

Dennis Dixon, PhD, president of the Society for Clinical Trials, says this doesn’t go far enough. His organization is advocating for federal legislation requiring the registration of all clinical trials. The stated goal is transparency for all who want to know the truth about scientific research – physicians, re­sear­ch­ers, patients, the general public – and to enable health providers to prescribe medications with complete knowledge of trial results.

Can registration spell the end of publishing bias in the obesity field? (It seems too good to be true – and of all the lessons learned, the most enduring has been that what has seemed too good to be true in this field, invariably was.)

It seems doubtful the field of obesity can change without a revamping of murky past research.

However, research and reporting on weight and weight loss certainly can be improved, and that’s a goal worth striving for.

References

1. Berg FM. Women Afraid to Eat: Breaking Free in today’s Weight-Obsessed World, 2001, p193-211. Healthy Weight Network: Hettinger, ND.
2. Ioannidis JP. Why most published research findings are false. PloS Medicine 2005(Aug):2:8:696 – 701.
3. Teachman BA, Brownell KD. Implicit anti-fat bias among health professionals: Is anyone immune? International Journal of Obesity 2001;25, 1525-1531.
4. Goodman WC. The invisible women: Confronting weight prej­udice in America, 1995. Carlsbad, CA: Gurze Books.
5. Ernsberger P, Haskew P. Re-thinking obesity: An alterna­tive view of its health implications. Journal of Obesity and Weight Regulation, 1987;6(2), 1-81.
6. Fraser L.. America’s obsession with weight and the industry that feeds on it, 1997. New York: Dutton.
7. Gaesser GA. Big fat lies: The truth about your weight and your health, 2002. Carlsbad, CA: Gurze Books.
8. American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective, 2007. The Second Expert Report. Washington, DC.
9. Flegal KM, et al. Cause-Specific Excess Deaths Associated with Underweight, Overweight, and Obesity. JAMA 2007;298.17: 2028-37.
10. National Institutes of Health.. Technology Assessment Confer­ence: Methods for voluntary weight loss and control. Annals of In­ternal Medicine, 1992;116(11), 942-949.
11. Garner DM, Wooley S. Confronting the failure of behav­ioral and dietary treatments for obesity. Clinical Psychology Review, 1991;11, 729-780.
12. Ioannidis JP. Why most published research findings are false. See 2, above.

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