Three Things That Should Be Required For Weight Loss Research

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I have written plenty about the sorry state of weight science – an area of science wherein research that would get a freshman flunked out of their intro to research methods class gets published in peer-reviewed academic journals (some of which are actually owned and operated by the weight loss industry!)

Today I’m offering three things that, if they were required of all weight loss studies, would instantly create massive improvement in the information that could be gleaned from these studies by healthcare practitioners, the media, and the public at large.

Five-Year Follow-Up with Required Publication

We have a century of data showing that the vast majority of people lose weight in the short term (about a year) and regain weight in the long-term (about 2-5 years). The weight loss industry has known this for decades and has taken advantage of that knowledge by creating studies with timeframes designed to capture the period of short-term weight loss, and not capture (or obfuscate) the weight regain (including by their famous two-year studies in which they claim something like “all subjects regained some weight but remained below their baseline weight” forgetting, somehow, to mention that the trajectory of their weight gain was going straight up when the study conveniently stopped looking.

Let’s talk about a couple of arguments against this:

The first thing I hear is that it’s difficult to get funding for studies that have five years of follow-up and I don’t doubt that’s true. It’s also true that a ton of this research is funded by the diet industry itself so they are refusing the fund long-term studies and then using their refusal as a reason not to do long-term studies – nice work if you can get it. Regardless, if the FDA required five years of follow-up in order to approve an intervention, then those funding challenges would have to be solved. Better no research than research that promotes interventions which are not only almost certain to fail long-term, but can actually create significant harm through weight cycling.

We’ve already had a hundred years of short-term research followed by long-term (often not captured or appropriately reported) intervention failure, let’s not sign up for a hundred more.

Another argument is that shorter studies should be funded to see if it is worth longer-term follow-up. This would be reasonable if the weight loss industry could be trusted to be clear in its published research and with the media that the results of these studies are not appropriate to draw conclusions from or to put into practice, and if the media could be trusted to be clear about that as well. Unfortunately, we’ve seen that the weight loss industry cannot be trusted in this regard and the media has been more than happy to act as co-conspirators (either on purpose or out of ignorance.)  So, I propose that in order to start the research five years of funding be secured. The funding can always be canceled at any time and the remaining funding repurposed.

Which brings us to the second part of this section. Something that isn’t necessarily well known is that research isn’t required to be published. This has long been a tool used by the pharmaceutical industry to artificially inflate positive results – they simply don’t publish the negative results. (If you’re interested in digging deeper into this, I highly recommend the book Bad Pharma: How Drug Companies Mislead Doctors and Harm Patients by Ben Goldacre. It was published ten years ago and, tragically, is still incredibly relevant today.)

The people who currently get to make the decision of whether or not to publish the studies are often the funders (which often includes the weight loss industry) or the researchers (who are often direct employees of the weight loss industry/funders, taking payments from the weight loss industry/funders, and/or have their careers and finances pinned to the weight loss industry.) This allows them to serve us dinner on their best china while hiding a kitchen full of shattered dishes and ripped paper plates.

By requiring that research results be published (including if the study was ended early, why, and what the results were at termination) doctors, patients, and the media would have access to much clearer, complete, and accurate information.

As a caveat, I would suggest that more dangerous interventions, like procedures that take a healthy digestive system and surgically create an irreversible disease state or drugs that are meant to be taken for the duration of a patient's life should require at least ten years of follow up with a plan for continuous follow-up throughout the lives of the patients.

Information in bold print at the beginning

For too long, the diet industry has been able to write conclusions/abstracts that make unsupported or inflated claims about their research, hiding the truth behind a paywall and/or burying it in the discussion section, often with the help of some…let’s call it creative… use of terminology and statistics.

To avoid this, there is some information that I think should be required to be printed in bold type at the beginning/in front of the pay wall of weight loss studies if anything else from the study is available in front of the paywall (I actually would like to see a lot more information than this, but I’ll start here as a bare minimum)

Dropout rate – presented as a number and percentage

I have seen weight loss studies with incredibly high dropout rates (including more than 60%) that were not mentioned in the conclusions (which touted intervention success.) We deserve to know how many people actually made it through the study.

For those who completed the full study - average weight of the participants and average weight lost presented in pounds and as a percentage of body weight as well as minimum and maximum weight loss

This is basic information that should be easy to find.

A simple line graph showing the average weights of those who didn’t drop out of the study throughout the entire study

We should be able to easily visibly see (and access alt text) that tells us the trajectory of participants’ weight - was it sustained? Did it drop and then start rising steadily? Show us.

Study demographics

At bare minimum:

• Percentages of each race, ethnicity, and gender (including trans and non-binary folks)

• Range and average age of the participants

• Range and average weight of the participants

• Inclusion and exclusion criteria

First of all, this could create some accountability for inclusion or lack thereof in a research world where both inclusion and accountability for it are often sorely lacking. It also gives us an idea of the extrapolatability of the study findings.

Weight/Health Disclosure

The uncritical use of weight as a proxy for health and weight loss as a proxy for increasing health has allowed the weight loss industry to consistently claim that their interventions increase health with no actual proof. So, if weight was the only outcome measured, a disclosure should be prominently included saying something to the effect of “this study only measured changes in weight and thus can draw no conclusions about positive or negative impacts of the intervention on participant health.”

And if they do measure health outcomes…

Weight-neutral comparator group

Given that

• weight and health are two separate things

• weight loss interventions have inherent risks

• research has found that positive health impacts that happen during diets are likely due to the behavior changes and not the weight loss

• research shows that weight loss without behavior change (as through liposuction) does not create health benefits

• there is a significant body of research showing the health benefits of weight-neutral interventions (where the focus is on supporting health directly rather than trying to manipulate body size as a path to health,)

weight loss studies that try to claim positive health impacts of weight loss should be required to determine if any health changes are actually due to body size changes or if they are due to behavior changes.

One possible way to do this is with a weight-neutral comparator group. This group would focus on health-supporting behavior changes (one option might be the Matheson four habits, but could also include things like sleep, stress management, fat-positive social connection etc.) We know that weight loss interventions carry risks including weight cycling and disordered eating/eating disorders so a weight-neutral comparator group would let us know if, as research suggests, the same or greater health benefits could be achieved without the risks of attempted weight loss.

If they aren’t required to/fail to have a weight-neutral comparator group then, at the very least, they should either have to explain the methodology they used to separate the impacts of the weight loss from the impacts of any behavior changes that participants undertook, or they should have to disclose something like “We are unable to discern if these health improvements were due to weight changes or the behavior changes that preceded them” with a citation to Mann, Ahlstrom and Tomiyama.

If the research includes a “placebo” or “no intervention” comparator group, then a weight-neutral comparator group should also be included.

Since its inception, the weight loss industry has been allowed to ride roughshod over any reasonable concept of research methods ethics and best practices. This has led to staggering profit for them, deep and abiding weight stigma and misinformation in the healthcare system, and massive harm to higher-weight people.

It has to stop and, obviously, it never will if we continue to leave it up to the weight loss industry (and those conducting their research) to do the right thing. (I also want to point out that there are researchers who aren’t weight loss industry shills who have simply been so indoctrinated to the current paradigm that they aren’t able to see the issues with the research they are producing.)

Regardless, if we want ethical weight science research that produces useful information we are going to have to force that to happen and I think that these three demands are a good place to start.

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More research and resources:
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*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.