DebraSY

Thoughts on Science, Optimism and Bias

In Weight-Loss Maintenance on January 7, 2011 at 12:46 pm

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.

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  1. I love reading your blog because it’s like coming here and listening to myself think! (Only better written 😉

  2. Ah, thanks, NoCelery. Question: has the NWCR ever checked your contacts to make sure you aren’t lying?

  3. The “10% loss = success” reminds me of the “The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults” from the NIH (PDF) which recommends an initial weight loss goal of 10% of baseline weight. I’m wondering if they’re related.

    (If you read my blog and this sounds familiar, yes, I posted on the disconnect between the NIH guidelines and the popular notion that only dieting to “normal” weight is acceptable. For those who don’t read my blog, I’m not currently attempting or maintaining a loss, though my weight has been stable for over 5 years — aka since my last diet/regain cycle.)

  4. I’m sure the two have to be related. The copyright on the PDF is 2000, the NWCR’s publication is 2001.

    Change is slow. I think all the scientists with weight-loss bias (affiliated with a hospital or university weight-loss program) are having a prolonged (decade long) “Oh Sh*T” reaction. “We really can’t expect consistent long-term success with more than 10% loss, but our patients want to attain “normal” BMIs, and we continue to market that we can get them there, but we can’t seem to help them stay there.” The kind-hearted ones then say, “Hmmmmmm, we need to be rethinking this.” And a**holes say, “They’re just noncompliant. Look at these outliers here at the NWCR!” (That’s when I cringe!) Currently the a**holes outnumber the kind-hearted people. And the a**holes “win” the public debate in the marketplace of ideas, because people so desperately want to believe that weight-loss maintenance is just a simple matter of good character, a stiff upper lip and a commitment to a zippy lifestyle.

  5. I thought the idea of the 10% thing was that you would go for 10%, achieve that, stay there, and then try for another 10%, lather, rinse, repeat until you got to a “normal” weight. It looks like I misunderstood.

    • Teri, that’s how doctors first presented it to me in the 80s and 90s, and the NIH guidelines do include 10% as the initial goal to be reevaluated over time. But they also state that “[o]bese individuals typically want to lose 2 to 3 times the 8 to 15 percent often observed and are disappointed when they do not,” and discuss how to substitute other goals, like “improve blood pressure” or “be more active” when weight loss plateaus. So it appears the people at the NIH have an idea of what a typical weight loss IS, and are trying to set expectations around what’s typical.

  6. Oh, Teri, you understand all too well. The problem is that diet culture (and some in the scientific community) won’t acknowledge that those percentages add up, and the baseline remains at highest established weight. There’s a mythology that people can settle in at a new, lower set point and then may progress further. Statistics don’t seem to bear that out.

    • LOL. See, with my math brain, I was figuring 10% at each stage – so stage one would be 24 lbs, stage 2 would be 21.6 lbs, stage 3 19.4 . . . guess I have to get with the program. 😉

  7. So, out of curiosity, what would “a new, healthier and more realistic, approach to research” look like, were you crowned Queen of the NWCR (which, hey, great idea!)? Certainly an acknowledgment that both weight loss and maintenance are much more difficult, and thus much rarer, than “they” would have us believe. But do you think there is anything actionable the other 99% could learn from the long-term maintainers? Or are genes and luck (broadly defined, to include access to healthy food, time to cook it, money to buy it, time and ability to exercise, and etc.) as responsible as behaviors?

  8. Maybe I’m a bit off topic but here goes.

    There’s an old joke: “How do you get to Carnegie Hall?” Answer: “Practice. Practice. Practice.”

    To go along with that, there’s the saying: “Many are called. Few are chosen.”

    As someone who actually tried to become an opera singer in her twenties, I can attest to both the joke and the saying ringing very true.

    Furthermore, I think they also both apply to weight loss, and even more, to maintenance: Weight loss is the “practice, practice, practice” part. There are many, many aspiring world-class musicians and elite athletes doing just this as I type. And there are countless millions of people trying right now to lose weight.

    Of those many aspiring musicians (or athletes), only a handful will ever reach their goal (the few who are “chosen”). The same applies to the weight loss warriors and maintainers. They achieve their goal and maintain it through laser-like focus, constant practice and yes, luck (the time and money to buy and prepare the “right” foods, and exercise as much as necessary).

  9. Yes, NewMe, you are right, and meanwhile a cultural mythology develops that ANYONE, with persistence and talent, can achieve his or her goals. Untrue, but sooo compelling. Rags to riches. Luck will smile on you eventually (if you are deserving). There are daily news stories to support that myth, of the Susan Boyles, etc. For those of us who are would-be writers, we are told The Wizard of Oz was rejected 120 times before it was accepted. Cold comfort.

    And now, I’m “chosen” as a maintainer. And the fit is uncomfortable, because I’m simplified down to a few daily behaviors that some scientists think are key. And other people, would-be maintainers, are made to feel lesser, or guilty even, for not just doing the same, when I don’t even want that or necessarily believe that my simplest behaviors alone create this result.

  10. I’ve been a fairly serious musician as well, though I didn’t take it to the professional level (unless getting paid to play in a community orchestra counts). The thing is, music is beautiful. Practicing is a chore sometimes, but it’s never really unpleasant. Performing is intense and joyful, and people love to hear music. It’s full of patterns and complex interplay; it’s evocative and profound.

    But, maintaining a thin body? How is that comparable? Is it a way to perform the beauty standard? To give people the pleasure of seeing a body that more resembles a very problematic social ideal? Beauty and thinness aren’t the same thing, and being thin and beautiful is kind of boring, actually. It isn’t challenging in a aesthetic sense. It doesn’t make people question their assumptions. Or, is the resemblance purely in the practice, the listening, and the sensitivity it requires?

  11. I wasn’t trying to draw any deep, philosophical equivalence between being a great musician and a successful weight loser/maintainer, Dee Leigh.

    All I’m saying is that getting to the top as a musician or reaching one’s “goal” weight requires tons and tons of work. And even having put in the tons and tons of work required, many excellent musicians never reach their goal (of all the amazing singers I had the opportunity to meet while at the Conservatory, I know of only one who actually made it to anywhere near an international career, and if you know your opera singers, you probably wouldn’t recognize her name) just as the vast majority of people trying to lose weight, despite incredible effort, never “get there”.

    As to what’s more laudable, or satisfying, there’s no doubt in my mind that singing Vissi d’arte on the stage of the Metropolitan Opera in NYC or at Covent Garden beats a svelte figure hands down. Sadly, overweight sopranos (those fat ladies singing) are finding it harder and harder to get gigs because of their weight. It’s gotten to the point in the opera world where looks are known to beat out a beautiful voice.

  12. It’s gotten to the point in the opera world where looks are known to beat out a beautiful voice.

    I’ve heard that, and it makes me sick. One thing I loved about music was the blind auditions.

  13. Ahh, Debra, this essay is spectacular. What a beautiful piece of prose, as usual.

    When researchers finally get around to debunking the old calories in/calories out mythology, then we might advance our understanding. I don’t buy that reductionism for a minute, going by my own body as evidence. If I returned to sleeping for only 4 hours a night, most nights, I would gain weight without eating more. If I started taking SSRIs, I would gain without eating more. If I started eating more carbohydrate rich foods on a regular basis, without increasing actual calories, I would gain weight…quickly…and have accompanied nonstop hunger. It is so much more complex than the medical establishment, diet industry, and the NWCR can admit.

  14. The author of the original New Yorker article (Johah Leher) did a follow-up discussion here:
    http://www.newyorker.com/online/blogs/newsdesk/2011/01/jonah-lehrer-more-thoughts-on-the-decline-effect.html

    and Leher mentions that one way to reduce “the decline effect” involves mandating the public registration of every clinical trial in advance (I think that’s a quote). A biologist friend of mine says that protocol is followed in some European countries (Sweden?), and it keeps scientists honest, in addition to revealing the kinds of research being done that we usually never hear about. I’m particularly interested in endocrine supplements (such as sub-cutaneous injections of leptin) for helping people to enjoy weight loss maintenance as a lifestyle rather than an obsession or part-time job. Unfortunately, big pharma stands to make more more money by working on weight-loss drugs rather than maintenance meds (in addition, as Dr. Sharma has pointed out, there seems to be no mechanism for applying for clinical drug trials for a condition that is, apparently, “normal”. yeah, grrrr. ) Sometimes I think we are staring at a conspiracy, and other times I think *resembles conspiracy* happens to be a default appearance of badly regulated capitalism. Cheers!

  15. Thanks for the update, Hopeful. I look forward to reading the article! Venturing a thought prematurely: I suppose registration would make it impossible for big pharma to bury its null results. Verrrrry interesting! (But I can just hear the blow-back rhetoric: “socialism,” “nanny state,” “job killing.” etc.)

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