Let’s start with the impetus for my morning study focus: requirements by the American Board of Pediatrics (ABP) for what they call “Maintenance of Certification”. Those of you reading this who are American physicians know what I mean: we are required to take Board Examinations every ten years, something I have just finished doing (again). Some of you reading this may be lawyers or therapists—imagine if you had to retake your professional exams every ten years. I am not talking about CME’s/CEUs or CLEs; this is in addition to those. I am talking about the full Board examination, just as you did when you were a newly minted graduate.
Ok, so that’s irritating, expensive and time consuming enough, but the real torture comes with the additional requirements for participation in courses and written “mini exams” required to fulfill “maintenance” in between the main exam every ten years.
I am a natural student. I like to study. I like to read. I don’t even really mind endless multiple-choice tests. But what I really, really hate is group think.
I just finished a course in genetics for fun, offered for free, through Coursera (in contrast to the terribly expensive Board exams -- a racket, in my humble opinion). It was wonderful and inspiring. I learned a great deal about things I had no concept of before I took the course. That’s my idea of intellectual heaven, and I strongly recommend it to anyone who wants such a thrill. But the course on “Obesity Management” I have had to endure for the ABP is the very opposite: a lengthy, pompous, confusing exhortation of pediatricians in the assessment of “fat” kids.
Published in the American Academy of Pediatrics (AAP) 2007 Journal as “Assessment of Child and Adolescent Overweight and Obesity” by highly educated and well-meaning colleagues of mine, this required reading seeks to make recommendations to pediatricians across the country and becomes immortalized in Board questions, which you have to get “right” (i.e. consistent with its conclusions). And the main article itself -- 32 pages long and listing 366 citations with a six page list of “articles citing this article” (the newest thing) -- is a poster child for everything that can be problematical with “evidence-based medicine”. Despite inadequate and frankly contradictory studies cited for their positions and recommendations throughout, the authors nonetheless make all the recommendations you would expect from those who do not dare to challenge conventional thinking on the subject.
The first six pages are arguments and justifications for using BMI to accurately assess “fatness” in children and adolescents. Then they move on to “implications” with, among other things, this statement: “Overweight and obesity in childhood and adolescence have been associated with adverse socioeconomic outcomes, increased health risks and morbidities and increased mortality rates in adulthood.”
Those of you who have become astute readers of scientific literature for kids with eating disorders may rightly home in on the words “associated with”. You know that to say A is associated with B does not prove that A causes B. They may both be caused by C, for example. But to expose the real problem (beyond the correlation/causation issue) try substituting the concept “being Black” for being overweight and obese and you get an equally true statement: “Being Black in America has been associated with adverse socioeconomic outcomes, increased health risks and morbidities and increased mortality rates in adulthood”. But what? Stop being black? Just because something is associated with with adverse outcomes does not mean it is possible --or desirable-- to change it. Group think glosses over these simple points of reflection in favor of simplistic popular conclusions.
As my car’s navigation system says: “recalculating….”
The contribution of genetics and environmental obesogens, other than food and exercise, are systematically ignored throughout this article. The recommendations were based on conclusions the authors had apparently come to before they examined the evidence. For example, they spend a great deal of time recommending that pediatricians assess the overweight child’s “readiness to change” (in a ten year old!?) as part of collaborative interventions, and yet they note that “several studies that applied these methods to nutrition and physical activity showed successful short-term results but less convincing long-term results.”
Could it be because we are not asking the right questions, and/or refusing to change our assumptions even when contradicted by evidence? Maybe it just plain doesn’t work and all the wishful thinking in the world -- not to mention the pressure placed on overweight children -- doesn’t change outcome in a meaningful way. Dressing the Emperor up in politically correct clothes such as “motivational interviewing” doesn’t change the fact of his nakedness.
In this field (obesity) I frequently see authors cite evidence that contradicts their personal, deeply held positions, and they basically deal with this by insisting that “larger studies” will no doubt justify what they think and assume to be true.
Obesity is a symptom, not a health outcome. Some obese people -- maybe even most -- also have symptoms/conditions thought to lead to bad health outcomes, such as high LDL, low HDL, high insulin levels, high blood sugar levels and high blood pressure, but many do not. Even where obesity can be shown to be associated with these things, it still does not mean that obesity causes them.
Another example: one of the recommendations made in this gigantic article is for a reduction in “meals eaten out of the home”. OK, I like the sound of that. But largely because it conforms with my own built-in social and generational prejudices and marginally because I think it may improve nutrient quality. But their own data report conflicting results, including one by French et al. which found that although it was associated with eating larger portions and more fat as well as fewer vegetables, “the frequency of fast food consumption by adolescents was not associated with overweight status”. Yet the article confidently recommends that pediatricians target changes in behaviors including “eating outside the home”. The evidence base is weak, but the recommendation is unabashedly strong.
This is what I call group think. The underlying, socially popular assumptions are not challenged, and the system is setup to perpetuate whatever “consensus” an official body has arrived at by inserting them into professional examinations and “standards of care” for “excellence” in practice.
Eighteen pages into the article the authors made three sweeping statements which for me epitomize preconceived notions carried into analysis (aka confirmation bias) and unaffected by conflicting evidence: “Diet and activity are inextricably linked” they say, (no citations). “Overweight and obesity result when daily energy intake is greater than daily expenditure over time”, completely ignoring the role of genetics on metabolism. And finally: “This concept of energy balance is crucial for successful assessment, prevention and management of overweight and obesity in childhood and adolescence” But then why do weight loss strategies utilizing dieting and exercise fail so spectacularly over time?
The many examples of weak evidence and unequivocal recommendations in this lengthy paper are too numerous to cite here, and would doubtless exceed the patience of most readers to hear about. It certainly exceeded mine.
I think I’ll go out in the garden.