Friday, February 17, 2006

Obesity, medical studies, and gender politics

The other day, at the American Enterprise Institute conference called "Panick Attack" (focusing on modern culture's proneness to exaggerated fear), James Glassman talked about government- and media-promoted hysteria about obesity. Obesity is, by the way, an interesting issue politically: hostility to what some see as a campaign to exaggerate the dangers of fatness is found both on the libertarian right, which sees it as elitist do-gooder meddling with people's lifestyles, and on the cultural left, which sees it as an attempt to give medical validation to oppressive standards of beauty and body shape (you know -- fat liberation, fat-is-a-feminist-issue, etc.).

As an example of how misguided this campaign supposedly is, Glassman cited the recent study, publicized by Gina Kolata in the New York Times, claiming that reducing dietary fat does not reduce the risk of cancer and heart attack. This study, a part of the Women's Health Initiative, is the largest of its kind; it followed nearly 49,000 women ages 50 to 79 over the course of eight years, about 40% of whom were assigned to a low-fat diet. This led one researcher quoted by Kolata to call it "the Rolls-Royce of studies."

Well, it's certainly a Rolls-Royce cost-wise, at $415 million. But it may be a defective Rolls-Royce.

For instance, the Columbia Journalism Review daily points out, relying on a Wall Street Journal article:

The problem with the study, the Journal went on to point out, was that it did not distinguish between so-called "good" fats, like omega-3 fatty acids found in fish, and "bad" fats, such as the saturated and trans fats found in fried and processed foods. Also, the Journal noted, the women on the low-fat diet didn't do a great job of sticking with it. As a result, the overall difference between the two diets ended up being fairly minimal. That the resulting health differences were also fairly minimal, therefore, was not exactly big news.

Some of the same points are made in letters to the Times (no longer available online at the Times site).

For instance, Dr. David L. Katz of the Yale School of Medicine points out:

The diet component of the Women's Health Initiative compared some 20,000 women advised to cut dietary fat and increase their intake of produce to a comparable group given the federal dietary guidelines.

The difference in these interventions was modest; the advice to cut fat without attention to kinds of fat, questionable; and subject compliance, limited.

Thus, there were only rather trivial differences in the diets between groups, and despite that, a trend toward reduced rates of both breast cancer and cardiovascular risk factors in the intervention group.

That there were any discernible differences in outcomes at all is more surprising than how modest those differences were, particularly given that cancer and heart disease develop over decades and that this intervention occurred relatively late in life, in women well past menopause.

My convictions in the fundamentals of a healthful diet are unshaken.

Another writer notes:

In the mid-1990's, when my mother first became a subject of the Women's Health Initiative study, of which the low-fat study was a part, she complained after her first orientation session, ''They make no distinction between lard and olive oil!''

A slim, healthy senior citizen with no medical background, she was already aware, a decade ago, of mounting evidence that all fats are not equal.

But the study's designers paid no attention to this, and we went ahead and paid $415 million to carry it out.

It would be highly irresponsible of the American medical community if, as Dr. Michael Thun of the American Cancer Society suggests, this were to be the last word. The study was flawed and dated from the get-go.

Actually, it was. And some people even pointed it out at the time.

On November 2, 1993, The New York Times reported:

A committee of the Institute of Medicine said today that it was skeptical of the merits of a women's health study planned by the the National Institutes of Health at a cost of $625 million. The committee said much of the anticipated data could probably be obtained with smaller, better-focused and less costly projects.

The committee, which spent six months examining plans for the Women's Health Initiative at the request of the House Appropriations Committee, said it questioned the value of the nationwide study as designed and recommended changing it.

Much of the criticism, as it happens, focused on the low-fat diet/breast cancer study. (Among other things, according to a Washington Post report on the same date, committee members expressed doubt that the necessary diet modification could be carried out with such a large pool of subjects.) The panel also warned that the cost estimates for the study were far too low and that it would end up costing at least twice as much as projected. Considering that the low-fat diet study was only one of its many components and that it has already run up a $415 million tab, that seems likely.

All these recommendations were rejected. Why?

Well, let's recall how the WHI came into being in the first place. In the early 1990s, there was a big to-do about alleged neglect of women in medical research. For the most part, this neglect was a myth. For instance, while members of the Congressional Women's Caucus were outraged by a report showing that less than 14% of National Institutes of Health spending in 1987 was for research on female-specific illnesses, they apparently didn't noticed that fewer than 7% of the NIH budget was allocated to male-specific problems (the rest went to the far more numerous diseases that afflict both sexes). And, while there were a lot of claims that breast cancer research had been underfunded because it was "only" a women's disease, breast cancer was in fact one of the most extensively studied and most generously funded diseases long before the rise of women's health activism. In 1991, the National Cancer Institute allocated more research dollars to breast cancer than to any other single type of cancer -- indeed, more than to lung cancer and prostate cancer combined. From 1981 to 1991, the NCI spent $658 million on breast cancer research and $113 million on prostate cancer. Medline, the comprehensive database of medical journals, has nearly 18,000 entries for breast cancer in 1966-1991, compared to fewer than 1,800 for prostate cancer and about 8,600 for lung cancer.

Nonetheless, just about everyone picked up the "sexist bias in medicine" meme and ran with it. Then-NIH president Bernadine Healy, a major proponent of this myth, pushed for a major study to remedy this supposed bias. And so the WHI was born. Its champions' reaction to criticism of the study was telling.

According to The Washington Post:

Rep. Patricia Schroeder (D-Colo.), co-chair of the Congressional Caucus for Women's Issues, said that the IOM report is shortsighted. The Women's Health Initiative, she said, addresses a historical lack of interest in women's health issues; to make it shorter or less costly would repeat past inequities. "We just want to make sure," Schroeder said, "that nobody cuts the corners on us one more time."

The cry of sexism was echoed by Healy, in The New York Times:

"Billions of dollars have been spent to do research in men, and now a relatively modest study comes along to do studies in women, and it is subject to this kind of scrutiny," Dr. Healy said. "However, when this study is over, we will know a lot more about women's health than we do today."

(By the way, seven of the committee's 11 members were women.)

And so the study went forward as planned.

At this time, it is perhaps fitting to quote the words of Yale epidemiologist Dr. Kelly Brownell, one of the IOM panel members, who told The Washington Post, "the science has to be good or the money will be wasted."

Well, yeah. That's what happens when you get politics-driven science, whether the politics are based on religion, feminism, or any other type of ideology.


John A said...

Flawed, yes. And expensive. But a start, raising questions: now let's have a more focused study - or better, a series of such.

My own, non-medical, thinking is to call for moderation. Diet and exercise - but does the type of diet matter? Only that it be sustainable, if possible for life. The "Grapefruit Diet" will indeed take off pounds - but not for the long term.I think the controversy over low vs high carb diets is too driven by zealotry, that either works if it is the one you can live with.

Some of this feeling may be because of my own status. Those who say everyone should eat more veggies fail to take into account my allergies. And while more exercise would almost certainly be of benefit, even my doctor is at something of a loss as to how I can with my physical problems. Mind, I did not exercise when I could, and don't think I would want to eat stuff like lettuce if I could.

OTOH, I weigh fifty pounds less than I did when in High School...

Anonymous said...

It's a fair criticism that medical research is lop-sided with regard to gender. That is mostly due to two reasons. One is that a large male prison population has been the primary source of research rats. The second is that a high proportion of medical discoveries and advances have been made in wartime because the resources get allocated to a strategic necessity, and historically men have been the ones to go to war, because they were more expendable. Both these reasons have this in common - they are instances of a lower valuation of the lives and health of men. So yes, the lop-sidedness is the result of sexism.

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