March 4, 2012
JOHN DITRAGLIA, MD
The February 1 issue of The Journal of the American Medical Association (JAMA) is full of obesity articles so here we go again.
Two of the articles appeared online first and have already been reviewed. Those are the reports that the prevalence of obesity in children and adolescents and adults has plateaued in the last 10 years. The other two are reviews of the literature about the treatment of obesity in children and adolescents. The first is titled “Programs to reduce childhood obesity seem to work, say Cochrane reviewers.” (1) That sounds like it’s going to say that programs to reduce childhood obesity seem to work. But that is contradicted in the first paragraph thusly, “Obesity prevention programs for children have produced mixed results that could lead one to wonder if they are effective. A recent review of the literature suggests such programs can work, but an optimal course of action remains elusive.” Cochrane reviews are a British endeavor that are really good for and synthesizing the evidence. They are a good barometer of what we really know about a subject.
For this review they analyzed 55 studies of efforts to reduce obesity in children. Jeepers, that’s a lot of studies. Haven’t we figured this out yet? Why are we doing so many studies? They are expensive. Anyway they summarized all the evidence and determined that all the interventions which include lots of educational, behavioral and health promotion things that are all over the place and so it’s hard to say what might actually work, but all together they can accomplish on average a 0.8% weight reduction.(2)
Then there’s a lot of punditry by experts in the field saying that even this small reduction in weight can have lots of benefit on the risk factors for diabetes and heart disease. No quarrel with that. That’s well established. So they go on to say that we should be doing all these things anyway. Sure. Yeah. But let’s stop saying that we can reduce obesity.
The last review entitled, “Weight loss strategies for adolescents” (3) is a case study of a particular 14 year old obese girl. These “Clinical Crossroads” are a regular feature in JAMA that provide guidance about treatment of common problems. The guest discussant is that royal-pain-in-my-butt Dr. David Ludwig from Harvard. So after a long winded discussion about how bad is our epidemic of obesity and how nothing works to treat it short of surgery, he proceeds to tell this poor girl and her mom that they “… may find some solace in the knowledge that they are not alone: several million adolescents and their families in the US struggle with obesity. Moreover, new and potentially more effective treatment options provide some grounds for optimism.” Then there are lots of recommendations but nowhere does he ever say anything to the effect -“look we can’t change your weight or shape but we can help prevent most of the complications of obesity, like diabetes and other risk factors for heart disease.” Which is to say the truth. He ends by saying that doctors “by virtue of their credibility and expertise” should be advocating for policies to “create a more healthful social environment for all children.” Well, as we’ve discussed in many articles the evidence for any of that is pretty poor too. Dr. Ludwig is a powerful advocate for such policy changes and he must be widely considered to be a credible expert.
A question for Dr. Ludwig is posed. “When should we recommend surgery?” Dr. Ludwig answers that we should first try everything else and finally, “Unfortunately, psychiatric illness, major behavioral issues, and parental neglect may contribute to the development of severe obesity, and the presence of these problems would tend to make affected individuals poor surgical candidates.” Whoa.
1. Mitka M. JAMA.2012;307(5):444-5.
2. Waters E eta l. Cochrane Database Syst. Rev. 2011:12:CD001871.
3. JAMA. 2012;307(5):498-508.
John DiTraglia, M.D., writes a weekly column devoted to “Fat Sciences,” one of the biggest preoccupations of America. He can be reached at 740-354-6605 or firstname.lastname@example.org or fat-science.org.