Skepticism about science and medicine

In search of disinterested science

The anti-obesity fuss: II — Worse than useless Official Reports

Posted by Henry Bauer on 2014/09/03

Clinical Guidelines on the Identification , Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report [1] from the National Institutes of Health has the typical flaws of official Reports that I’ve illustrated elsewhere [2]: Excessive verbiage hiding rather than revealing essential issues; incompetent drawing of conclusions; innumerable eminent names — “panel members” or “committee members” — shown as the purported authors, while the actual research and writing was done by non-eminent staff.

This particular Report has 262 pages, but what is worth saying would take no more than a few pages.

Typically, all the right things are said — and then ignored. For example, that BMI (body mass index) alone is not a decisive determinant of risks supposedly associated with obesity — followed by defining obesity precisely by BMI slightly modified by waist size:

BMI-waist-risks

The Report’s unnecessary verbiage includes many such banalities as:

“Standard obesity treatment approaches should be tailored to the needs of various patients or patient groups. The possibility that a standard approach to weight loss will work differently in diverse patient populations must be considered when setting expectations about treatment outcomes. Evidence Category B” [italics in original].
[“Category B pertains when few randomized trials exist, they are small in size, and the trial results are somewhat inconsistent, or the trials were undertaken in a population that differs from the target population of the recommendation” (p. xiii)]
Does it really need to be said that individual patients should be treated as individuals? Is an Evidence Category necessary to support that recommendation?
Further: The description of Evidence Category B amounts to saying that it isn’t really evidence at all, just inadequate trials and no replication, no better than anecdotes. But this is far from the weakest “evidence” on which this Report bases its pretentious conclusions and recommendations. Some of them are “supported” only at level C or D:

EvidenceCategoriesCD

C describes anecdotes, which mainstream sources typically pooh-pooh when they contradict official dogma. As for D, “Panel Consensual Judgment” sounds so much more impressive than the equally correct description, “Mere opinion in absence of evidence upon which an informed opinion could be based”.
Other things that don’t need to be said include
“A diet that is individually planned . . . to help create a deficit of 500 to 1,000 kcal/day should be an integral part of any weight loss program” (p. xix).
“An integral part”? How about the whole thing? As I pointed out in an earlier post, an effective diet is easily constructed.

And then there’s this:
“An increase in physical activity is an important component of weight loss therapy, although it will not lead to substantially greater weight loss over 6 months” (p. xix). “An important component” that doesn’t do anything?

And also this:
“Family involvement” helps against progression of obesity (p. 11).
What a surprise!

Not only is over-eating medicalized as “obesity”, more research is needed (p. 21) to confirm or disconfirm that obesity may be related to psychological disorders. In the meantime, such future research is preempted by already defining “binge eating disorder (BED)” “characterized by eating larger amounts of food than most people would eat in a discrete time period (e.g., 2 hours) with a sense of lack of control during these episodes”.
Hardly a precise definition; and presumably one would exclude fraternity rites of passage or eating contests as only sociologically but not individually psychopathological.

There is also a “Treatment Algorithm” that adds nothing to common sense but serves presumably to add to the illusion that there is something scientific and worthwhile here:

TreatmentAlgorithm

The Report’s goals bear little relation to the asserted risk: “The initial goal of weight loss therapy is to reduce body weight by approximately 10 percent from baseline. If this goal is achieved, further weight loss can be attempted, if indicated through further evaluation” (p. xix).

But how often would that be a meaningful reduction of risk? With extreme obesity, 10% lower would get at most from “extremely high risk” to “very high risk”. With “very high” risk, not everyone in that class would get to merely “high”. How meaningful would those apparent reductions in estimated risk be?

That remains inscrutable because there is not even claimed to be definitive evidence of any real benefit:
“Although there have been no prospective trials to show changes in mortality with weight loss in obese patients, reductions in risk factors would suggest that development of type 2 diabetes and CVD would be reduced with weight loss” (pp. xiii-xiv).
”Would suggest?” Once again this is guesswork, speculation, not an evidence-based conclusion.
Moreover, ”risk factors” are mere correlations, symptoms, and reduction in risk factors is not the same as reduction of actual risk; treating symptoms is not the same as treating the underlying condition.

The Report has not only unnecessary verbiage and banalities, it can also be misguided and misleading, for instance that “Prevention of overweight and obesity is as important as treatment” (p. 11).
Utter nonsense. Prevention is the only truly effective treatment, because it prevents any possible harm; subsequent treatment cannot negate harm already done. Furthermore, it is much better and much more feasible not to get into bad habits in the first place than it is to change bad habits after they are entrenched.

All this illustrates how common sense takes leave when human behavior is treated as a medical condition — and when bureaucracies try to justify their existence by promulgating lengthy Reports. It is perfectly sensible to say that prevention of infection (cholera, malaria, syphilis, etc. etc.) should be given as much attention as treatment of cases that could not be prevented; it makes little sense to say that learning not to over-eat in the first place is as important as learning not to over-eat after the habit has been formed; the former is clearly much more desirable, i.e. important.

These sad aspects of the Report are far from the worst, however.
Most reprehensible is the medicalization of over-eating as “obesity”, a condition calling for medical treatment. The pharmaceutical industry for several decades has looked to re-defining normal conditions into diseases to be treated [3], and officialdom has gone along with this health-damaging and expensive sleight of words. In the present Report, this is done by using BMI numbers as a basis for several types of conditions, even though there is no evidentiary warrant for dividing a continuum into discrete categories nor for the assignment of risk levels.
This façade of “scientific” appearance lends tacit approval to the use of drugs (and also surgery) to “treat obesity”.

Of course the right things are again said, namely, that drugs should be used only in addition to diet control when the latter alone does not suffice. But this is totally unrealistic. The only individuals who might need assistance from drugs or surgery are those suffering endogenous obesity, pathologically high weight owing to hereditary factors. In practice, doctors prescribe drugs without being able to monitor whether patients actually control their diets; and we are all prone to take our pills in the hope that they will make us lose weight no matter how we continue to over-eat.
And those pills can kill.

—————————————————————
[1] Publication 98-4083, September 1998, National Institutes of Health: National Heart, Lung, and Blood Institute in cooperation with The National Institute of Diabetes and Digestive and Kidney Disease
[2] Henry H. Bauer, Dogmatism in Science and Medicine: How Dominant Theories Monopolize Research and Stifle the Search for Truth, McFarland (2012), Chapter 8
[3] Moynihan & Cassels, Selling Sickness: How the World’s Biggest Pharmaceutical Companies Are Turning Us All Into Patients, Nation Books (2005). The point is also made in quite a few of the other works listed in What’s Wrong with Medicine [link loads slowly, sorry]

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