The language of causes

The obesity-weight loss industry is increasingly co-opting the language of other movements. Last week, it was usurping the lingo of the fat acceptance movement, as the largest diet company in the world tried to convince the public that their diet wasn’t really a diet because “diets don’t work.” This week’s British Medical Journal exhibited two more.

First a bit of background. A November editorial had reviewed over-the-counter Alli, which GlaxoSmithKline is trying to gain approval from the European Agency for the Evaluation of Medicinal Products to sell throughout Europe. Dr. Gareth Williams, professor of medicine and dean at the University of Bristol, had written:

Firstly, it is unlikely that many users will see significant health benefits. Clinical trials inevitably show antiobesity drugs at their best, because the participants are relatively motivated and are supported by dedicated staff who reinforce lifestyle advice... Moreover, the benefit of orlistat over placebo in clinical trials is small—typically 2-5 kg after one year, and declining to 2.7 kg after four years.... Under real world conditions Alli might not fare so well...

The “oops” factor, he noted, will not encourage adherence, either. But also, “we have no strong evidence that the benefits of short term weight loss are carried forward if weight is regained — which always happens when drug treatment stops.” He went on to write:

The only real beneficiary will be GSK. We will never know whether Alli is useful, as there will be no proper follow-up. Viewed commercially, proof of efficacy is irrelevant—money will roll in for as long as the obesity pandemic continues to yield enough people prepared to pay for a quick fix... ConsumerPrice-Watch.net, whose top ten diet pills include several products that are known to be dangerous or are devoid of evidence that they actually work (or both). Nevertheless, Alli will probably generate income for GSK.

His points on lack of efficacy based on the evidence were supported with 8 papers. Conversely, he believed “eating less and exercising more must remain the cornerstones of managing obesity,” but failed to support this assertion with any evidence. Still, the evidence in his editorial went undisputed.

In fact, Dr. Timothy Connery, a general practitioner in Nottingham, wrote to share an audit their office had conducted on the 52 patients who had been prescribed orlistat (the prescription-strength Alli) over the previous 3 1/2 years and found each had lost an average of 3.3kg but some actually gained weight while on orlistat. And, of course the losses were short-lived and at least a dozen gained substantial amounts of weight the moment they came off the medication. “Totalling up the cost of their prescriptions, this worked out at a price of $147.25 (U.S. Dollars) per kilogram lost.” Calling it an “ineffective medication for people to lose weight,” he said medication is not the answer to obesity.

Nonetheless, Dr. William’s overview of the evidence was met with an argument co-opted from alternative modalities. Caroline Mozley, head of the R&D Alliance, of the British NHS (National Health Service) trusts, wrote in support of Alli, saying:

People should be free to spend their money as they wish...That is their choice and their problem. The medical profession doesn’t have a monopoly of knowledge about the input-output logic of weight control... The medical profession doesn’t have a great record of success in this matter and should not be restricting access to a safe drug that may help people to help themselves.

This stance will be very familiar to professionals who’ve worked to protect consumers from health fraud. It’s precisely the argument used by those selling quackery. As skeptics have written concerning those not following careful use of scientific evidence and logic: “There are numerous and powerful influences in society that strongly appose [sic] the scientific basis of medicine. Driven by some combination of ideology or the desire for profit they wish to eliminate standards of science in health care, or (often under the guise of “health care freedom”) create a double standard in which unscientific methods and products can thrive unchecked.”

While medical professionals can apply these sound principles when debunking alternatives, it can sometimes be harder to apply that same critical thinking when it comes to an industry that supports one’s livelihood. There has never been a diet drug or weight loss intervention that’s proven safe or effective for long-term weight loss for virtually all patients and to improve health and longevity. Critical thinking is especially obligatory after a century of ineffective weight loss solutions, but the race for blockbuster profits continues. As CNN Money reported this week, the diet industry is a multibillion-dollar enterprise and there is an especially lot of money to be made on diet pills:

In the U.S., Europe and Japan, the market for weight-loss drugs totaled about $600 million in 2005, and is expected to surge globally to roughly $2 billion in 2010, according to a recent report from drug industry market information provider Espicom Healthcare Intelligence.

The second example of co-opting the language of other causes came in another letter in this issue, also in response to Dr. Williams. The familiar refrain goes something like this: The debate is over and the scientific consensus has been reached. Everyone knows this to be true. So, no more discussion, we must act now. Where have we heard that before? :)

Nicole Lavery, a “community adviser,” called for all further research on obesity to stop and action now. She wrote:

I believe we have now reached saturation point as to how many studies and articles it takes to convince us that we are too fat as a nation...Given all the suggested health assessments, dietitians’ advice, government guidelines, and supermarket labels, there is something missing: action to force planners, developers, councils, and local authorities to end totally unsustainable, fat making practices....

I suggest that all research stops now, all advice stops now, and all infuriatingly patronising labelling stops now. The money must now be spent on buying land from private owners, farmers, developers—and on building cycle paths. The only way we will be able to tie our laces in the future and not need cardiopulmonary resuscitation at the age of 35 is to demand and build a functioning, cyclist and pedestrian centred, integrated, reliable public transport network....

She presented no evidence in support that mandating more physical activity — through transportation means, no less — will have any effect on obesity. Of course, there is none. The myth of sloth as a cause or cure for the natural diversities of our sizes is just that.

This exemplifies what Prometheus called “Science by decree.” As he wrote, it “appeals those who are absolutely convinced that there is no possibility that they might be wrong,” but the popular belief that scientific reality can be legislated is a myth and has a dismal history. Such advocates are, as the old saying goes, “Often in error but never in doubt."