Obesity: Inequalities in EBM, medical research and policy
Today’s main news story is that obesity is on the up and will continue to rise if coordinated action is not taken at local, national and international levels. A Lancet series of articles examines the evidence for the growing burden and cost of obesity globally and the policy steps needed to prevent 65 million more adults in the USA and 11 million more adults in the UK becoming obese by 2030. Successive governments have allowed the food industry to self-regulate and the evidence clearly suggests that this does not work, since the industry’s interest are profits.
What strikes me is that instructive lessons learned from a strikingly similar case-in-point over the last 60 years, namely the tobacco industry, are not being put into practice. There was good medical evidence for smoking and its detrimental effects of health since the work of Richard Doll and Austin Bradford Hill showed the link with lung cancer in the early 1950s, but it was not until 2005 that the World Health Organization adopted the Framework Convention for Tobacco Control, the world’s first and only public health treaty. Our policymakers smugly talk about tobacco as a tackled problem, but it was less than 10 years ago that UK policy started moving in the direction of smoke-free public places.
We have an obese body of evidence (pun intended) to show that the pathophysiology and epidemiology of obesity is bad for our health, and we have enough evidence to show that current methods of tackling industry problems are not working. Governments are quick to say that the food industry is different but what are the incentives for the food industry to behave differently? Is it going to be acceptable to wait 50-60 years before governments and global health policymakers put evidence into practice? Evidence-based medicine aims, at the end of the day, to institute changes which make the health of individuals better. It seems that there are inequalities in the way evidence is put into practice, based not just on societal interests, but on conflicts of interest, particularly multi-billion dollar industries. If we are serious about EBM and evidence-based policy, we should take lessons learned from other sectors and apply them accordingly.
The gaps between evidence, quality and policy
Microcredit is an idea that has won the brains behind it, Professor Muhammad Yunus, a Nobel Peace Prize, and has received billions of dollars in terms of global funding. The idea was simple: very small loans could make a disproportionate difference to a poor person, and so the Grameen Bank and many similar institutions like it have opened around the world. However, only one randomised control trial has ever been done for this intervention in Hyderabad and actually showed no benefit. So what we are saying is that billions of dollars have been spent with potentially no effect. Shouldn’t this study have been done earlier?
It got me thinking that regardless of the arena, whether policy, clinical practice, healthcare or economic, lack of the right kind of evidence can lead to the wrong intervention. As large-scale NHS reforms are upon us, this is particularly important.
Quality improvement is something which all adaptive organisations should be doing as part of their daily work, but it turns out that this fairly new discipline is gaining huge popularity because this vital component of clinical practice has been neglected.
In JAMA this week, the results of an RCT of a multi-centre, multi-component intervention to improve quality of intensive care were published. Like Atul Gawande’s surgical checklist, the authors took 6 quality measures that have been proven to improve patient outcomes(prevention of ventilator-associated pneumonia (VAP), prophylaxis for deep venous thrombosis (DVT), daily spontaneous breathing trials, prevention of catheter-related bloodstream infections, early enteral feeding, and prevention of decubitus ulcers) and looked at over 9000 ITU (intensive therapy unit) admissions across 15 Canadian hospitals.
ITUs were randomised to receive an intensive programme (including audit, video-conferencing and expert-led education) to increase adherence to these 6 measures or to continue normal practice. The authors found that the adoption of the 6 target measures was twice as likely in the intervention group, compared with the control group.
In an accompanying editorial, the urgent need for high quality science such as this complex trial, in quality improvement is highlighted. If it can be done in critical care medicine, then it can be done in any area of healthcare or policy. The fact that it was funded by a healthcare organisation as opposed to a central funding agency is also seen as a positive aspect, since all stakeholders have a part to play in improving quality and reducing costs. Those parties that argue that evidence is too difficult or takes too long might end up making costly mistakes.