2016 Edited to Add: When I first began writing here I generated a searchable database for references and I have since done away with that option. This entire series remains to be edited to include the full references within each piece. As time allows, this series will be edited to include complete references at the end of each part in the series.
Shifting the Goal Posts
As with many things impacted by the medical industrial complex, there has been increasing re-categorization of disease states that result in previously healthy people requiring medical intervention simply by moving the markers used to identify the condition.
Alecska Divisadero: Flickr.com
The indicators for diabetes, high-blood pressure, cholesterol levels, bone density, hypothyroidism and more have all had the screening cut-off points lowered in the past two decades [R. Moynihan, A. Cassels, Selling Sickness, 2005]. The process of lowering these identifiers for disease involves various committees of experts convened on behalf of the National Institutes of Health, the World Health Organization and the Centers for Disease Control and Prevention whose members predominantly have close ties to various pharmaceutical companies.
The underlying evidence-based medicine to support the changes in cut-off points for anything from cholesterol levels to hypothyroidism is slim to none.
And the cut-off points for “overweight” and “obese” also fly in the face of any clinical data. As the lowest mortality rates are experienced at almost BMI 27 for men and women, then being pre-obese, as classified by the NIH, WHO and CDC, is actually ideal.
How did it come to be that those who are in the range BMI 25-30, with excellent morbidity and mortality outcomes [KM Flegal, 2005], are now encouraged by the medical community to lose weight to ensure their health?
Medical Industrial Complex Explained
The term “industrial complex” is largely attributed to Eisenhower when he warned of the military industrial complex in his exit speech in 1961. When a society ramps up for war and wages war, then more of that society’s economic underpinnings are dependent upon the continuation of war. What ensues is a complex relationship between those who wage war (the country’s leaders and the military itself) and those who provide the products and services for war (the contractors, the weapons manufacturers, etc.).
In the aftermath of WWII, the Cold War became a useful construct for the continuation of an economic dependency that the U.S. had developed on its ability to wage war.
The same is true of medicine in most countries. As I mentioned in Part V of this series, between 1830 and 1940 there was a tremendous shift as medicine moved from predominantly palliative care of patients to active disease intervention and control. The Centers for Disease Control and Prevention was founded in 1942 as the Office of National Defense of Malaria Control Activities.
Malaria was endemic in the U.S. in the southern states at the time. The Office then became the Communicable Disease Center in 1946 and its mandate broadened to include sexually transmitted diseases in 1957. Tuberculosis control fell under its jurisdiction by 1960 and in 1963 its immunization program was established [CDC, 2010].
Phenomenal improvements in population health and life expectancy were achieved through these organized and centralized efforts to remove and/or control infectious disease across the United States and the world in the second half of the 20th century. The pinnacle was reached on May 8, 1980 at the thirty-third World Health Assembly when small pox was declared eradicated from the global human population [WHO, 2002].
Just as with the military industrial complex, the medical industrial complex that had been developed and organized to co-ordinate a systematic reduction and eradication of serious infectious diseases (that had plagued human populations for millennia), now needed new ‘wars’ to support the communities that now economically depended upon continued medical progress.
It seems that it is no coincidence that it is a "war" on obesity.
Blockbuster Drugs
Of course the linchpin of the medical industrial complex is the pharmaceutical industry. Corporations generate profit for shareholders and pharmaceutical companies are no exception.
There is no way for a pharmaceutical company to investigate chemicals for medical treatments and bring those drugs to market for consumers in such a way that it will not generate profit for shareholders. Enter the blockbuster drugs.
A blockbuster drug for a pharmaceutical company needs to generate approximately $2 billion in annual sales. A blockbuster drug also needs a large disease population able to pay for the drugs and the disease in question must be chronic to maximize the necessity of taking the drug over a normal life span [J. Robinson, Prescription Games, 2001].
And while the costs to bring a drug to market are disputed, given that the estimates are always provided by the industry itself, the 2003 estimate stood at $802 million [R. Collier, 2009]. The cycle is such that as more money is poured into maximizing shareholder returns on potential blockbusters, less money goes to developing any drug that may have a possibility of acting as a cure and/or supporting diseased populations unable to pay for the drug in question.
You are unlikely to become very ill and die early due to impotence (assuming it is not a symptom of some other distinct disease), and so Viagra is the blockbuster you would expect it to be. It is considered a lifestyle drug. The other preferred categories for blockbuster drugs are: cancer, hypertension, psychiatric disorders, osteoporosis, rheumatoid arthritis and, of course, weight loss.
Weight loss is unsustainable and therefore is ideal for lifelong pharmaceutical intervention. As long as the side effects are not life threatening, then it’s a solid blockbuster category.
1998 and the NIH Panel on Obesity
Shifting the goal posts to define 65% of the population in the U.S. as overweight and obese occurred in 1998. The National Institutes of Health assigned F. Xavier Pi-Sunyer to chair the panel and its subsequent report, Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults: the Evidence Report, was endorsed by the National Cholesterol Education Program, the National High Blood Pressure Education Program, National Task Force on the Prevention and Treatment of Obesity and the North American Association for the Study of Obesity.
Nowhere does the report acknowledge the financial support the panel members receive, or had received, from the weight loss industry and yet the ties were significant.
"Eight of the nine members of the National Institutes of Health task force on prevention and treatment of obesity have ties to the weight-loss industry, either as consultants to pharmaceutical companies, recipients of research money from them, or advisers to for-profit groups such as Weight Watchers." [K. MacPherson, E. Silverman, 1997]
Here is a list of contributor disclosures that F. Xavier Pi-Sunyer, the panel NIH Chair on obesity, did provide for the article he and his colleagues provided on Obesity and Weight Reduction in Hypertension to uptodate.com (an online service provider of medical information to clinicians):
“F Xavier Pi-Sunyer, MD, MPH
Grant/Research Support: Novo Nordisk (new weight loss drug); Merck (new weight loss drug). Consultant/Advisory Boards: Novo Nordisk (diabetes mellitus, obesity); AstraZeneca (obesity); McNeil Nutritionals (non-caloric sweeteners); Weight Watchers (obesity).” [Up to Date, 2010]
Do these industry ties and grant monies indicate that F. Xavier Pi-Sunyer and his fellow panelists (who were also supported by weight loss and drug industry organizations) selectively reviewed the evidence so that the end result might benefit their benefactors? There’s no way to tell one way or the other.
“The best mark is often a person to whom the possibility of a con never occurs, simply because he thinks he is too smart to be tricked…Many doctors know nothing about advertising, salesmanship, or public relations. They believe these are jobs for the people who could not get into medical school. This is probably why doctors are so easily fooled.” [C. Elliot, White Coat, Black Hat, 2010].
Any panelist who suggests that he is unequivocally not swayed by the monies and grants he receives from organizations that will directly benefit from decisions he must make, is untrustworthy precisely because he understands so little of how persuasion works on all human beings (medical school alumnus or not).
We Are Heavier and It’s A Big Fat Nothing
In 1985 the average life expectancy was 74. 6 years. In 2009 the average life expectancy had increased to 78.1 with most of the population having gained weight (averaging 8-17 lbs. heavier than in 1985).
What changed in those almost 25 years to allow us to get heavier and also live longer? The answer is most likely that we smoke a lot less and the rates of cardiovascular disease improved greatly. In 1985, 38% of the U.S. population smoked, in 2006 only 21% of the population smoked [Gallup, 2007]. The rate of heart disease and stroke in Canada has declined 50% in the past 20 years [Statistics Canada, 2008].
In that time frame we also became an older population. The baby boomers [b. 1945-1964] went from being in 30-40 years old to 55-65 years old – an age span during which people naturally increase in weight.
And just as the boomers top out in their heaviest weights, the statistics for the ‘obesity epidemic’ are magically leveling off and have been since 2004 [CDC, 2007]. Human beings naturally increase in weight through their adult lives up to about age 60-65 and then there is a natural decline from that point into advanced old age.
Let’s just recap the evidence:
Of the two foundational studies upon which the ‘fact’ that obesity is an epidemic and the ‘fact’ that it causes disease and early death, one never linked obesity to mortality and the other did not control for a host of other viable reasons for early death.
More ‘obese’ people are under eating rather than over eating. Calorie intake is not correlated to body mass index at all.
Humans actually generate fat stores more readily from carbohydrates than dietary fats meaning eating fat does not make you fat.
The majority of us have gained less than 1 lb. per year in the past 25 years. Only those already pre-disposed to heaviness have gained more than that. These very heavy individuals comprise under 5% of our population.
Shifting the goal posts that define disease is common in all areas of medicine and ‘obesity’ is no exception.
Weight loss is an ideal blockbuster drug category. Patients in fact do not die of being overweight and weight loss is almost always unsustainable, suggesting that the right pharmaceutical intervention would have to be administered for the expected life of the patient.
Defining 65% of the population as overweight and obese in 1998, and indicating that being overweight and obese actually raised both morbidity and mortality issues, was determined by a medical panel with eight of the nine members holding conflict-of-interest relationships with pharmaceutical companies involved in weight-loss drug development, and/or weight-loss companies such as Weight Watchers.
We have never lived longer and never been heavier than we are at this moment.
We are no longer getting any heavier (rates leveled off in 2004) which coincides with the Boomer generation now entering old age where weights naturally taper down.
Next: Health and weight, obesity and disease, thoughts on childhood ‘obesity’, the value of exercise…
Please note that systematic review data is now available on this site under Papers.