What If We’ve Been Wrong? Implications of an Imperfect Science

Watch this. If you are pre-med, in medical school, in the health care field, or have ever felt a twinge of disdain for someone who was obese, watch this:

Back in April, as thousands of thinkers, innovators, and TED junkies descended upon DC for the 2013 TEDMED conference, I tweeted about my excitement to see the full talk by Dr. Peter Attia, a surgeon, researcher, and co-founder of the Nutrition Science Initiative (NuSI).

The full talk is finally out. And, man, is it powerful.

A Medical Establishment of Treating Bruises

Dr. Attia raises a provocative suggestion: What if we’ve been wrong about the causation behind obesity and diabetes? What if instead of obesity causing diabetes, obesity is actually a symptom of insulin resistance and other metabolic malfunctions?

Dr. Attia gives the somewhat comical yet strikingly apropos analogy of bruises and banging into coffee tables: Imagine a world in which we thought bruises were the problem. We would evolve “a giant medical establishment and a culture around treating bruises: masking creams, painkillers, you name it, all the while ignoring the fact that people are still banging their shins into coffee tables.” (emphasis mine)

It’s funny until you remember that less than two months ago, the AMA officially classified obesity as a disease. While the decision is unlikely to have much impact on currently research or public health efforts against obesity, I see one area where it could have a marked impact: spurring insurance payments for medical treatment of obesity, i.e. weight loss drugs and bariatric surgery.

  1. Weight loss drugs: Two new weight loss drugs, Qsymia and Belviq, entered the market last year. A day after the AMA decision, a group of lawmakers introduced bills in the Senate and House to require Medicare Part D to pay for weight loss drugs. Qsymia costs about $160/month, or $1920/year. Belviq costs about $200/month, or $2400/year. Our history with weight-loss drugs has not been that great, with many being ultimately pulled due to side effects or leading to rapid weight regain after discontinuation.
  2. Bariatric surgery: Currently, bariatric surgery coverage by Medicare or private payers is limited–something that may change given the new classification. However, the cost-effectiveness of bariatric surgery was called into question by a JAMA article published this February. The surgery and 30-day postoperative care cost $29,517. There was no significant reduction in health care costs for surgery patients compared to non-surgery patients in the 6 years following surgery.

Alarmingly, the vote went against the conclusions of the AMA’s Council on Science and Public Health, which studied the issue for a year and concluded that the main measure used to define obesity (BMI) is simplistic and flawed. More specifically: “Some people with a B.M.I. above the level that usually defines obesity are perfectly healthy while others below it can have dangerous levels of body fat and metabolic problems associated with obesity.” Which brings us back to Dr. Attia’s provocative suggestion: maybe we have cause and effect backwards.

“So what I’m suggesting is maybe we have the cause and effect wrong on obesity and insulin resistance. […] What if being obese is just a metabolic response to something much more threatening, an underlying epidemic, the one we ought to be worried about?” – Dr. Peter Attia

Revisiting an Imperfect Science

Intrigued, I went onto NuSI’s website to see what they’re actually doing. After overcoming my initial reaction that I had tripped upon another miracle weight-loss scam company, I dug deeper and realized that NuSI is actually gathering researchers to tackle significant shortcomings in the literature on the cause and effect of obesity.

Dr. Attia goes hard after the idea that carbohydrate restriction, independent of caloric restriction, is the way to reduce incidence of metabolic disorder, which then causes obesity. NuSI provides a great review of nearly 100 studies on diet and obesity and summarizes key points on why the existing research approach is insufficient. For those who want a summary of the summary, here are some key points:

  • The vast majority of dietary trials are “free-living studies“, in which researchers tell ordinary people to stick to a dietary regimen and then evaluate their adherence through questionnaires or food diaries. If people actually listened, we probably would have solved the obesity crisis by now.
  • The more stringent option is to isolate people in metabolic wards to monitor their intake. Any volunteers?
  • Even studies with sufficient sample size and decent adherence fail to parse out the effects of caloric restriction and carbohydrate restriction. This is a crucial nuance, as it precludes us from testing the hypothesis whether restricting a particular micronutrient (e.g. carbs) is more important for preventing obesity than reducing caloric intake overall.
  • A few studies have managed to make this distinction, but they relied on lean individuals. “Similar results might not have been obtained in a group of obese individuals or lean individuals susceptible to obesity.”

This last point is particularly provocative, as it suggests that obesity may be much less a result of “poor self-control” than we are inclined to assume. I had the opportunity to do a little research in the glorious field of gut bacteria research, and there’s rapidly growing evidence that of two perfectly identical people (at least from the outside) who consume the same foods, one may become strikingly more obese because of the gut bacteria in his/her gut. I recently began reading Dr. Eric Topol’s The Creative Destruction of Medicine, and I can easily foresee a world in which individuals have their gut bacteria characterized (which you can do for $80), and then have metabolic therapies tailored for them. But seeing as I’m already pushing 1000 words, that’s a story for another time.

What If We’ve Been Wrong?

Have you watched the video yet? If not, take two minutes and click to 13:30.

I think the power of Dr. Attia’s speech doesn’t come primarily from the provocative nature of his hypothesis, or from the facts he musters to support it. It comes from his tangible humility, and the painful implication that by staking our belief in an imperfect science, we may be letting our patients down.

“We can’t keep blaming our overweight and diabetic patients like I did. Most of them actually want to do the right thing, but they have to know what that is, and it’s got to work. […] If obesity is nothing more than a proxy for metabolic illness, what good does it do us to punish those with the proxy?” -Dr. Peter Attia

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