Happy New Year! Hope you all had lovely holidays. It’s good to be back at the blog, and back on the internet, for that matter. (Long story involving words like #!%^&$!#!!, and a whole lotta bad Karma directed at AT&T.)
Between holiday adventures and internet mayhem, I managed to slip in a post about one of my weight maintenance peccadilloes – my ability to measure fluid in ounces using my gulp mechanism. I must admit that when I get that personal, I do feel a bit self-conscious and self-indulgent, but I think it’s instructive – for me, mostly, but also for others who participate in the fray. We broke into a lovely discussion about the admirable pursuit of goals, and when that pursuit crosses an invisible line and becomes something less noble. I don’t think we reached any conclusions, but I came away recommitted to the idea that I should NEVER suggest, “if I can do this anyone can.” Even if it’s true that anyone CAN do what I do, maybe not everyone should. One person’s pursuit of a goal may be, in all likelihood, another person’s gateway to disorder.
Somehow, in the comments, RNegade was possessed to share a couple of science-related links. (Whew!) My favorite was this New Yorker article by Jonah Lehrer on the “Decline Effect” that happens to our sense of scientific certainty. This “Decline Effect” is part of a larger problem with bias in science that misshapes our understanding of a variety of social and medical issues. I put the phrase in quotes, because, as Lehrer notes, “This phenomenon doesn’t yet have an official name, but it’s occurring across a wide range of fields, from psychology to ecology. In the field of medicine, the phenomenon seems extremely widespread . . .”
As I understand it, the “Decline Effect” happens when the scientific method, and all its noble precepts, leads a scientist (or team) to discover a statistically significant anomaly, which may promise to improve the health and well being of many people. Hypotheses are formed (and tested) by lovely people possessed of optimism and the best of intentions. Sadly, optimism can be biasing, and the anomaly may be only a statistical fluke. Replicating the first set of promising results may not happen again. Over time, as repeated tests fail to confirm the initial findings, there is a “decline” in the integrity of the thesis, hence the parlance “Decline Effect.” (I would submit that there is a corresponding decline in our communal optimism, which is disappointing but probably healthy.)
The decline effect is abetted by the unavoidably slow process of scientific discovery. The initial study (before attempts to replicate its results can begin) appears in a peer-reviewed journal and starts acquiring interest, enthusiasm and fanfare. The study may even be dubbed a “breakthrough” (sometimes by a headline-happy media machine or a pharmaceutical company marketing department, but other times with help from the zealous scientist who is okay with some self-promotion, in the noble pursuit of more grants and future research). As an example of the problem, Lehrer sites the initial rock-star popularity of second-generation anti-psychotic drugs, which no longer hold the promise of their initial experiments. I think it would be useful for us to consider examples from our pet area of study – weight loss and maintenance.
Weight loss is especially vulnerable to early “breakthrough” hopes and exaggerations (which ultimately prove disappointing or dangerous). This likely happens because we root our optimism in the assumption (mythology) that fat is a pernicious evil, and weight loss is noble, healthy and comes at little or no cost. Pseudo-science, therefore, perpetuates a never-ending string of “discoveries” of berries, herbs and other (potentially harmful) supplements (think Metabolife) that promise earnestly to create weight loss. In addition to the pseudo-practitioners, legit scientists and medical doctors also fall prey to weight-loss optimism and hype. I can remember begging my gynecologist for a Fen-Phen or Redux prescription when those drugs were popular. Thank GOD she wasn’t (and isn’t) a pill-pusher and acted with more caution than many of her colleagues.
On the assumption that any weight loss is healthy and after seeing some initial promising weight-loss results, doctors started prescribing the Fenfluramine-Phentermine combination (off label) in the early 1990s (maybe sooner), and in 1996, the FDA approved the chemically similar Redux for medically assisted weight-loss, before the human costs were clearly understood or acknowledged. (But, BOY, was there an optimistic marketing campaign!) In 1996, doctors handed out an estimated 18 million prescriptions for these harmful drugs, which were pulled from the US market in September of 1997. Many people, therefore, in exchange for some luke-warm weight-loss results, had to suffer or die from heart valve damage. By the grace of God and my OB/Gyn, I was not one of them.
The Fen-Phen/Redux debacle wasn’t so much a gentle “Decline Effect” as it was a dramatic crash and burn. Now we see the FDA pushing forward with approval of bariatric surgery for increasingly thinner “overweight” people, and all on the basis of one study conducted by the company poised to recognize the most profit from this policy change, and based on the optimistic assumption that any weight-loss is good, and worth the costs. And, BOY, is there a marketing campaign happening for lap-band surgery! Anyone care to deny that?
Related, but in a different vein, I predict that the “Decline Effect,” or something akin to it, with regard to weight-loss maintenance will soon be acknowledged with regard to my pet scientific think tank, the National Weight Control Registry. Thankfully, it won’t be a “crash and burn” situation with injuries and fatalities, since they have only prescribed behavior-based strategies for maintenance. They may not acknowledge a “decline” yet in the optimistic results they once-upon-a-time described and predicted to flourish, but surely others see it and will acknowledge it soon.
The group was founded in 1993 on the idea that weight-loss maintainers exist (indeed, we do), and that their (our) behaviors can be described (agreed), then commonly replicated (oh, yeah? Not so fast). As a result, we’ll all be healthier and trimmer for it. What optimism! What a boon to humanity.
Well, the NWCR first presented those behaviors in 1997, and the results have been publicized widely in the popular media. It’s hard to find a person today who doesn’t acknowledge that to maintain weight loss you have to exercise more than most people, eat breakfast, weigh yourself regularly, continually and consistently watch what you eat throughout the week and even on holidays, and eat a nutritionally balanced reduced-calorie diet. Whether or not the public knows who to credit for this information, it was a gift from the NWCR.
But despite the widespread acceptance of this information – which I have no reason to contradict, I am a model NWCR registrant and do all of that stuff – there is no evidence that maintainers are becoming a more common lot. This is because sustaining all of that behavior is much more difficult than simply committing to it – probably because of the tenacity of the endocrine that we maintainers battle and the redundant biological systems that try to return all people to their highest established weights.
The NWCR often boasts of having 6,000 registrants, but I would challenge that their number is hardly boast-worthy in the grand scheme of our diet culture where millions of people lose tens of millions of pounds (and regain them) every year. Moreover, registrants are not kicked off the registry for regaining weight. Depending on the NWCR study, participants who have lost an average of 66 lbs, or 72 pounds, are maintaining “a minimum” of 30 pounds lost after five years. It’s a little misleading – an average weight loss maintained would be more informative – but, still, those people at “minimum” have regained more than half their lost weight.
I know that when I fill out my annual survey each year, they assure me that I am of interest to them even if I have regained weight that year. They do not tell us how much we must regain before we will be booted from the registry, but I suspect (and probably my fellow registrants suspect) it is the minimum that we were required to get on it – 30 pounds. And their research reports would support this. But it’s still mysterious. I don’t know for sure.
I would be curious to know just how many people are floating right at or above that minimum. I know I place value on my participation in the registry. I don’t want to be booted (though this blog will probably accomplish that). I suspect other maintainers feel as I do, and wear it as a private badge of honor, of sorts, not to mention a useful measure of annual accountability. If there is a significant number floating at minimum, could it be that people stretch the truth (lie) in order to stay on the registry? We’re supposed to supply our doctor’s name and a back-up contact, so that the NWCR may check up on us, but we’re never asked to update that information. Moreover, the NWCR has never checked mine. I have asked my contact people several times. I ask my doctor at every annual physical whether he’s heard from the NWCR. The NWCR didn’t even check with my contacts in the first year when I signed on. (Maybe my surveys smell so honest that I don’t require checking, but it shakes my faith in the group that they don’t check up.)
I don’t know whether it was an act of cynicism or resignation (or a nod to ugly reality), but rather than admit that the percentage of people who maintain radical weight loss is dismal and likely won’t budge, in 2001 the NWCR proposed a watered-down definition of success and in 2005 it solidified that definition, a definition so weak that self-respecting maintainers won’t acknowledge it as success, and, heck, the NWCR doesn’t even count it. While the group formally defines “success” as a ten percent loss maintained for one year, and assures us that 20% of people may attain this lovely benchmark, that success, alone, won’t earn you a spot on their venerated registry unless you started out at more than 300 pounds before losing weight, which many of us did not.
By watering down ”success,” the NWCR may have postponed the day when someone (other than me) declares the “Decline Effect” to have worked its wiles on their initial optimism for behavior-driven weight-loss maintenance. I don’t expect them to have the courage to declare it themselves. They remain affiliated with a hospital weight-loss program, and acknowledging this truth – that weight-loss maintenance is much more rare and difficult than their optimism (and the narrative spin in their research) would suggest – would pretty much sabotage the goals of that program. Nevertheless, what a lovely thought: that one of the most venerated obesity think tanks, and the only one devoted exclusively to maintenance, might step up and submit to the public that it’s early optimism may have been biasing and may merit reconsideration, and that a new, healthier and more realistic, approach to research may emerge! Ah, Debra. Methinks you live in Fantasyland.