As a health professional, I am expected to undertake evidence based practice.
Now this makes sense in many fields. The Cochrane Collaboration Logo showing the benefit of corticosteroid treatment of women threatening premature labour and its huge benefit towards preventing complications in their unborn babies because it stimulates the development of their lungs is a fine example of why evidence can make a huge difference to lives.
However, it raises the question – who thought about giving these women steroid treatment in the first place. Where there was no evidence, someone thinking about practice and the principles of biochemistry and physiology came up with the idea.
This is where practice based evidence comes in, and it is a hard to deny the benefit that can be derived by a practitioner observing a particular disease state and asking how it be best treated using first principles.
Unfortunately, training in health sciences does not encourage this kind of work at this time. The training for health professionals focuses on the idea that there as an algorithm for the diagnosis of disease, and in many cases this is an efficient and effective process by which health care can be decided and managed.
Where it falls down, is that those people who do not fit the algorithm are either labelled as being non-compliant in treatment or will spend all their lives under the suspicion that the disease they suffer from is psychological in origin.
Obesity (my specialist area) is amongst the areas which suffer from this algorithm approach in the worst way.
For the vast majority of obese individuals, their obesity is a simple mismatch of energy intake versus energy expenditure. In a country where over one-quarter of the population is obese this probably accounts for 70% of the cases of obesity. Approximately another 12% can have their obesity explained by this energy imbalance exacerbated by either comorbid health problems associated with the original obesity (insulin resistance, reduced mobility due to osteoarthritis) or their obesity has been worsened by the medical treatment of conditions such as mental illness or diabetes. This leaves approximately 8%of the population. In these cases there are a multitude of possible causes, which broadly fall into complex psychological or social factors (overreaching in response to childhood trauma), or genetic factors.
Recent work has demonstrated that approximately 1% of the adult population has MC4 receptor defects, which is contributing to their severe obesity. However if you spoke to 100 doctors, you might find one who was aware of this research, and was prepared to consider this as a possible cause of someone’s problematic weight gain.
My own interest in severe and complex obesity is where it interfaces with HLA mediated autoimmune conditions. I have seen in my own practice individuals who are both malnourished and obese, and to respond to the removal of gluten (the protein associated with wheat, rye, barley)p with a dramatic improvement in their health, and with a calorie deficit achieve substantial weight loss.
Getting acceptance, and/or funding for this kind of research to be shifted from practice-based evidence to evidence-based practice has proved to be something of a nightmare.
If anyone knows someone who might be willing to spend a spare hundred thousand pounds or so on this, please send them in my direction!