By Robert Verkerk PhD, scientific and executive director, ANH-Intl
The Journal of the American Medical Association (JAMA) - armed with an opinion piece scribed by eminent Stanford University professor, Dr John Ioannidis, has landed a devastating blow into the heart of the nutritional epidemiology community.
This community represents a group of highly influential nutritional epidemiologists, including Walter Willett and Dariush Mozzafarian, whose output forms the basis of government ‘healthy eating’ guidelines, especially in Western nations. These include MyPlate in the USA, the Eatwell Guide in the UK, PNNS in France, the Nutrition Circle in Germany and the Australian Dietary Guidelines. They all follow a similar tack that includes eating plenty of starchy carbs and limiting fats. Some like the German guide, mention the importance of avoiding burning foods to reduce the formation of carcinogenic byproducts.
Pincer movement closes in
These guidelines are coming under increasing pressure in what amounts to a pincer movement. You, dear reader, may well be a member of one or other of these groups, either side of the pincer.On one side, there’s a rapidly growing grassroots presence that is noted through burgeoning health blogs and social media posts. Many have seen fit to challenge the guidelines pushed on the public by governments because they found they were getting sick or obese when they ate in the manner suggested by their governments. When they made significant changes, such as going low carb, gluten-free, or anti-inflammatory, to name just three types of diet that are at odds of carb-loaded, low fat government guidelines, they got better. It was their personal experience that made up their mind. Nutritional epidemiologists of course argue that that it’s too early to tell if these diets are safe in the long-term. These attitudes then drive flawed studies such as the recent Lancet Public Health study we dismantled last week.
The other side of the pincer is comprised of experts, including doctors, other clinicians and scientists. Ioannidis is one of many, myself included. He is of course among the most influential and outspoken and it’s highly significant that he’s got his latest critical opinion piece published in JAMA.
In scientific circles, Ioannidis became something of a household (laboratory?) name after showing that most published research findings are false back in 2005. Since then, he’s become something of a gatekeeper of good science and he’s increasingly diverted his energies to the biomedical and nutritional sciences which he rightly feels needs a good shake up. Research, asserts Ioannidis, is amidst a credibility crisis.
What’s wrong with the studies governments rely on for their advice?
In his latest attack, Ioannidis goes after nutritional epidemiology that relies heavily on a category of observational evidence based on prospective cohort studies. He argues, in common with many of our own arguments, that:
The authors frequently misrepresent association for causation
They wrongly assume the things that people eat most (e.g. carbohydrates, fats) have the greatest influence on outcomes such as heart disease, cancer or death
Meta-analyses on which nutrition epidemiologists are heavily reliant, become nothing more than “weighted averages of [specific] expert opinions”
Relatively uncommon chemicals (e.g. contaminants, pesticides, carcinogenic byproducts from over-cooking red meat) may be influential but are generally ignored
All of the variation between one (healthy) cohort and another (diseased) may represent “almost exclusively the magnitude of the cumulative biases in this type of research, with extensive residual confounding and selective reporting”
Inherent variability between individuals resulting from genetic and environmental factors makes irrelevant the average perceived responses from average cohorts in large prospective studies
Findings are not only often misinterpreted by the authors, they are misrepresented further by the media. Since exposés by the likes of Drs Marcia Angell and Peter Gøtzsche, the cat is properly out of the bag in terms of pharma manipulation of the science on which its business model is reliant. A key driver is inevitably Pharma’s support of the mass media. Big Pharma currently provides around US$6 billion annually to the US media in advertising revenues alone.
Ioannidis concludes that full-scale reform is the only option as nutritional epidemiology just isn’t up to the task. He says, “Disentanging the potential influence on health outcomes of a single dietary component from these other variables is challenging, if not impossible.”
New types of clinical research needed
One solution proposed by Ioannidis is that researchers make their raw data publicly available so that other researchers can number crunch it and compare results. It’s a good way of trying to root out data manipulation, but only if the original data is reliable and has itself not been subject to tampering. Transparency at all levels is always good - especially when we’re talking about public health.But you can imagine some funders with vested interests may have a different view on disclosure.That won’t just be limited to private funders. It could also include government funders whose unspoken mission is often to maintain the corporatocracy in which just 147 corporations control 40% of global trade.
The words of retired Vice Chancellor BM Hedge written in the British Medical Journal back in 2005 are as true today as they were the day they were written: “The world runs on a curious logic of consumerism today. Any commodity that could be sold will make the world rich. Drugs and pharmaceuticals are no exception here. Doctors today have become sellers and the patients the buyers.”
But he says if clinical research can meet specific criteria that he describes in some detail, it may once again be valuable. This is at odds with the classic, establishment view, propagated by pharmaceutical interests, that suggests that randomised controlled trials (RCTs) and systematic reviews or meta-analyses of these, are the only proper gold standards. Ioannidis proposes the criteria be selected by asking some pertinent questions:
Problem base: Is there a health problem that is big/important enough to fix?
Context placement: Has prior evidence been systematically assessed to inform (the need for) new studies?
Information gain: Is the proposed study large and long enough to be sufficiently informative?
Pragmatism: Does the research reflect real life? If it deviates, does this matter?
Patient centeredness: Does the research reflect top patient priorities?
Value for money: Is the research worth the money?
Feasibility: Can this research be done?
Transparency: Are methods, data, and analyses verifiable and unbiased?
Ioannidis also shatters the notion that big money is the only way forward - a predicament that has played in the hands of the Big Pharma, Big Food and pro-pharma foundations such as the Bill and Belinda Gates Foundation (incidentally a funder of a considerable body of nutritional epidemiological research). He states: “Altering our approach could easily produce more clinical research that is useful, at the same or even at a massively reduced cost.”
There is no doubt that the combined assault on bad science has shaken the established, drug-dependent healthcare system to its core. You’d have to be blinkered, ignorant or an industry shill to suggest its credibility is not in tatters. Now, with a helping hand from Prof Ioannidis and others, the scientific foundations of nutrition - one of the most powerful non-drug based healthcare modalities - has been equally shaken.
The timing couldn’t be more serendipitous - just as the ‘corporatocratic beast’ has sustained such devastating blows. There’s also the spectre of an even more troubled UK National Health Service (NHS) given the increased likelihood of a Brexit ‘no deal’.These blows and challenges may not be fatal, but they should at least inspire fundamental reform and create new opportunities for research and clinical practice that are meaningful and of value to the people, rather than the corporations.