Good Intentions, Unintended Consequences

Read carefully. And then read it again.

Read carefully. And then read it again.

How Scientific Research and Personal Health Journalism Bred a Weight-Loss Myth that Persists Despite Evidence to the Contrary

This is a story that begins in 1959.

It’s a true story about how scientific research and personal health journalism interact in unintentional ways that may discourage, rather than encourage, the public from pursuing better health.

In 1959, a physician in Pennsylvania and a researcher in New York co-authored a study published in the Archives of Internal Medicine entitled, “The Results of Treatment for Obesity.”

The authors of the study, Albert Stunkard and Mavis McLaren-Hume, set out to determine whether treating obesity—as part of the routine practice of the New York Hospital’s nutrition clinic—would result in measurable and permanent weight loss among obese patients referred to the clinic.

Exactly 100 obese patients were referred to the clinic for “treatment.” This treatment involved counseling patients during their initial clinic visit on “balanced weight-reduction diets” ranging from 800 to 1,500 calories. Thereafter, patients were seen in the nutrition clinic about every two to six weeks for follow up.

Why do I enclose the word “treatment” in quotation marks? Because by most standards today, the treatment (or, in more contemporary research jargon, the “intervention”) implemented in the clinic was far from comprehensive.

But that was the point. The researchers sought to determine whether a simplistic “treatment” that was easily incorporated into “routine clinic practice” could offer a feasible yet effective approach for helping patients lose weight—mostly on their own, outside of the clinic.

After two and a half years, the researchers pulled the patients’ charts and reviewed the data. The results were dismal. Only 12 patients lost at least 20 pounds at any time during the study, and only 2 patients maintained a loss of at least 20 pounds after two years. What’s more, two out of five patients failed to even return to the nutrition clinic after their initial visit.

What did the study’s authors conclude?

We can acknowledge that treatment for obesity is a terribly difficult business, one in which our experts achieve only modest success, and the rest of us, even less. It is a treatment which can be fraught with danger, a treatment not to be undertaken lightly by any obese person and by some perhaps not at all. Certainly weight reduction is not a matter to be left to unqualified practitioners. Lowering our level of aspiration may go far toward achieving our aims.

Yes, grave conclusions, indeed.

Fast forward to 1994.

In 1994, Rena Wing at Brown Medical School and James Hill at the University of Colorado established the National Weight Control Registry (NWCR), the largest prospective study of individuals successful at long-term weight loss. The NWCR tracks over 10,000 people (and counting since enrollment is ongoing) who lost a significant amount of weight and kept it off. Specifically, to be eligible for the registry, these “successful losers” must have maintained a 30-pound weight loss for at least one year at the time of enrollment.

On average, though, registry members have lost 66 pounds and maintained the loss for 5.5 years. Impressive, to say the least.

Data from this group of successful losers has been analyzed extensively in order to identify common characteristics among registry members. By way of example, we know that most NWCR participants eat breakfast almost every day, three out of four weigh themselves at least once a week to self-monitor their weight, most report participating in at least 60 minutes of moderate-intensity physical activity per day, and most limit their time in front of the television to less than 10 hours a week.

Not surprisingly, even a cursory skim of studies analyzing data from the NWCR paints a much more optimistic picture about individuals’ ability to lose weight (and keep it off) than the 1959 study would have you believe.

In an article published in the Annual Review of Nutrition, the co-founders of the NWCR state explicitly that one reason for developing the registry “was to counter the belief that ‘no one succeeds long-term at weight loss’.”

They conclude by emphasizing:

We believe the subjects of the NWCR show that you can achieve and maintain substantial amounts of weight loss. Furthermore, we have found that these subjects live ‘normal’ lives after weight loss and consistently report that life is better after weight loss. Our subjects tell us that their success requires substantial effort but that it is worth it. Finally, our data suggest that over time, it does get easier to maintain weight loss.

Fast forward, again, to 2011.

In December, 2011, the New York Times Magazine published a feature article entitled, “The Fat Trap,” in which Tara Parker-Pope cites research studies and describes her personal struggles with weight to support the following grim thesis:

For years, the advice to the overweight and obese has been that we simply need to eat less and exercise more. While there is truth to this guidance, it fails to take into account that the human body continues to fight against weight loss long after dieting has stopped. This translates into a sobering reality: once we become fat, most of us, despite our best efforts, will probably stay fat.

Sound familiar? Like something you read from 1959? Why, despite evidence to the contrary, does this myth persist to this day?

In many ways, the survival of this myth stems from the natural course of conducting and reporting on scientific research—whether in the biomedical or the social sciences—over many years and even decades. Research is a slow and iterative process. Figuratively speaking, tomorrow’s study will build on the results of today’s study, which built on yesterday’s study, which probably grew out of decades of prior research.

When researchers submit formal write-ups of studies to peer-reviewed journals for publication, they cite the related work of fellow researchers in the field, usually to provide background or to justify hypotheses about the relationships they’re investigating (e.g., Is fast food consumption associated with weight gain? Is running more effective than walking for losing weight? Does consuming red meat cause elevated blood cholesterol levels?).

Researchers must cite relevant prior studies in order to support the need for and expected contribution to knowledge of their own work. As a result, many novel or breakthrough research studies and related findings are cited repeatedly—some, for years and years—by many researchers publishing in the same or related fields. In short, certain studies and research findings have a way of becoming sticky, remaining in the literature over time.

According to Albert Stunkard himself—as quoted in a 1999 New York Times article entitled, “95% Regain Lost Weight, Or Do They?”: “The [1959] paper made a big impact because everybody thought obesity was pretty easy to treat. This showed that, for whatever reason, it wasn’t.” He adds that although it was state of the art for 1959, “the study has little relevance to the current understanding of how to control weight.”

Yet, the conclusion of the 1959 study remains frequently quoted in the obesity literature (and, I’ll add, in the popular press) to this day, despite evidence to the contrary and the fact that many experts realize the findings are “clinical lore.”

In a lengthy critique of “The Fat Trap” as symbolic of personal health journalism gone awry, journalist David Freedman explains that both journalists and researchers—as players within the broader scientific process—bear the responsibility for not misleading the public in ways that can lead to poor health decisions with potentially catastrophic consequences.

Writing for the Columbia Journalism Review in “Survival of the Wrongest,” Freedman argues:

 …even articles written by very good journalists, based on thorough reporting and highly credible sources, take stances that directly contradict those of other credible-seeming articles. There is more at stake in these dueling stories than there would be if the topic at hand were, say the true authorship of Shakespeare’s plays. Personal healthcare decisions affect our lifespan, the quality of our lives, and our productivity, and the result—our collective health—has an enormous impact on the economy.

As a result, Freedman emphasizes that the “potential damage of bad weight-loss-related journalism,” such as stories supporting the thesis that obesity largely is genetically determined and only minimally associated with the environment, may discourage people from trying at all.

Through the lens of health behavior theory, in other words, consumers may be convinced there’s little use in trying at all to lose weight if they’re bombarded with messages that erode their “locus of control” and sense of “self-efficacy.” An external locus of control (e.g., “Why bother trying to lose weight if it’s ultimately genetically determined?) combined with low self-efficacy (e.g., “I don’t have what it takes to watch what I eat as closely as I need to in order to lose weight.”) is a powerful combination likely to thwart many from simply trying.

Moreover, the potential consequences of perpetuating this myth extend well beyond discouraging individual efforts at weight loss. It is more important than ever that decision-makers—community leaders, policymakers, school administrators, etc.—understand the critical role that environmental interventions, regulations, and economic and agricultural policies play in supporting and promoting healthy behaviors.

The fact remains that the very process we rely on for learning about what works and what doesn’t when it comes to health—scientific research as the source of new knowledge and journalism as a means for disseminating it—is imperfect.

As Gary Taubes writes in the Columbia Journalism Review in response to David Freedman, “In a world in which virtually any argument can be made from the evidence at hand, our ultimate task, just as it is with science itself, is to communicate reliable knowledge.”

I have no doubt that the vast majority of researchers and journalists strive for this each and every day they head in to work.

Regardless, the next time you come across a newspaper or magazine article, television segment, podcast or radio broadcast—even a passing remark from friends, family, or colleagues—that perpetuates the weight-loss myth that just won’t go away, remember that it is only a myth. A myth that has managed to survive as a result of an imperfect, but necessary process.

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Image: Nick Hall

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