April 16, 2010

The Committee: Problems with Obesity Researchers

A couple of years ago, I was on a committee of the American Academy of Pediatrics that focused on child nutrition and problems of overweight. We all agreed there was a problem. Maybe most adults, even those who don't work with children, have seen a generational change.

When I was a child, there was often one kid--if that--who was thought of as fat. I wasn't that child, and that child, at school at least, must have had a tough time. Honestly, I don't remember if there was such a child in the elementary schools I went to. There was a single classmate in grades 7-12, but at the school we shared, it would have been considered rude to make fun of anyone. (Though some were more competitive than others, I don't think anyone would have wanted to appear mean. I never got the impression he was anything but as happy as any of us were as teenagers.)

Things are clearly different now. Not just every school but every class has several overweight children, in every grade. Among these, some are dramatically overweight. Research confirms that though many kids get leaner when they grow into adolescents, many don't really recover from this early obesity. 

Given the lack of easy fixes for this problem, and the obviousness of the extent of the problem, it is a hot topic for research. I've been frustrated, however, by the work that's been done and the people who do it.

In general, I think people should go into fields they're interested in. This is not only important for their own happiness and job satisfaction, but also for their motivation and creativity. I was shocked, for example, to have met in my pediatric career more than a handful of people who don't particularly like children. That's OK, I suppose, but it implies a suboptimal career choice for both doctor and patient.

So, in this statistically-unsupported argumentum ad hominem, let me tell you about the people I've met in the obesity-science world. First, who do you think chooses to go into the field? The professor in medical school who lectured on the topic, and has published quite a bit on this topic since, had nothing in common with me. Rail thin, his lectures were, to my sensitive ears, fire-and-brimstone evangelical sermons on people being their own worst enemies, fast or prepared food of any kind being a narcotic-like poison that eats like a parasite at the very fiber of civilized society. He taught, at least this is what I recall, that eating is like smoking, and should be heavily regulated if not banned altogether. He could be seen in the cafeteria eating a salad without any dressing. I didn't sit at his cafeteria table. He actually said, and I remember this vividly, that doctors need to be models for their patients. I interpreted this to mean that doctors who struggle with their weight or smoking or personality flaws are pretty much equivalent to permitting an alcoholic counsel other alcoholics.

Uh, that actually works. In study after study, though by no means always successful, the Alcoholics Anonymous model--in which recovering addicts share their experience and hard-earned wisdom--has been about the most consistently worthwhile intervention. It has been copied for addictive behaviors of many kinds.

But the obesity research establishment hasn't gotten this message. They haven't even opened the mailbox to see that there might be a message waiting. It's because their aren't looking for this or some other message. They think, like that anorexic professor at Yale whose personal diet is uneconomic and unsustainable for even patients with the most driven eating disorders and who thinks that his obsessive neurosis is the only appropriate prescription for the millions of people with whom he has neither anything in common nor empathy, that they really know how to fix the problem.

So the research they do doesn't, ultimately, tell us much that's actually helpful. Studies that show that if you watch TV 6 hours a day you tend to be fatter than those whose varsity sports team practices 3 hours a day after school. The title is usually something like, 'Varsity sports participation is a protective factor for excessive body-mass-index in adolescents.' Or, 'Proportion of daily calories from fruit predicts lean body mass.'

Knowing the abysmal failure rate when doctors tell their patients they need to lose weight, and the worthless nature of this kind of research for any practical purpose except the resumé-building of the authors, I had assumed that the grind of inevitable progress would, by now, have brought us out of this dark cave. So I looked forward to joining this committee, in which I presumed to be kept at the very cutting edge of child obesity research. I wanted to find out what actually works, what has been tried, and what can I tell my patients and their families that will genuinely help them.

The committee met at a lovely upscale restaurant in San Francisco. I was one of 3 men. There were about 40 women on the committee, but not every member came to every meeting. Though their ages spanned from mid 20's to mid 40's, I feel comfortable, since this whole post is about judging books by covers, saying that they all could have been sisters. A pair of waiters came around to take our orders. You know the rest already, I suppose. Salad with no dressing--not even on the side. Fish grilled without butter or oil, no potatoes, no bread, no dessert. Even so, most didn't eat at the table, and just pushed the food around the plate. At the time, I felt humiliated and ashamed, as if they were all staring at me conspiratorially and silently agreeing that He's the reason we're here.

I thought the committee might address pediatric patients who have a nascent weight problem that needs to be addressed for their health. This group, as a subset of the obesity-research elite seeing to affirm their own dysfunctional relationship with food, was really just an excuse for these doctors to get together and affirm each other's neurosis. The consensus was that

More than one of the members of this committee proudly boasted that she had never, not once, eaten or even been inside a McDonald's.

I'm no apologist for McDonald's. But I think there's deep truth about patient care that these starvation-junkies have missed.

On a personal note, by the third meeting or so, I looked forward to the dinners. I would ask for extra butter on my mashed potatoes, ranch on the salad. At one point, about 25 people indicated that they didn't want dessert. I asked for an extra crème brûlée. It wasn't passive aggressive, it was just aggressive. The committee disbanded when the American Academy of Pediatrics realized, I suppose, that it would be cheaper to pay for these doctors to stand around outside of the restaurant rather than go inside and order food they didn't eat. And that it would not be possible for even less to get accomplished.

Next: what's missing from obesity research.
After that: some hope, or at least some reality, from recent research

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