August 25, 2019 2

John Schoonbee: Panel discussion on “What evidence can we trust?”

John Schoonbee: Panel discussion on “What evidence can we trust?”


Hi everybody, we’re running a little late. If you could please sit down for me. I’m very pleased that that got the blood pumping
a little bit and as Fiona said, I think the steam was rising a little bit and there are
disagreements and what’s astonishing is that the recommendations we’ve seen from different
people, are different. And all of this is based on evidence. That’s really why we’re having the conference. I spoke to a good friend of mine David Unwin yesterday, and he’s very conciliatory and collaborative and he said to me, “Agreement
is really good.” I’m gonna start off with a little bit of agreement. I’m gonna ask you, who thinks sugar sweetened
beverages are not good for you? Hands up please. Isn’t that lovely? Green vegetables, who thinks green vegetables
is a good thing? Fantastic. And oily fish? Apologies to vegetarians. Oily fish? Yes. So there is a little glimmer of overlap that
we have, right? And it’s really good. My hope for this conference is that, that
overlap with all the different diets that Matthias showed us, that that overlap grows
slightly overtime. And we agree on certain foods that are good
for us. I was in China last week and I’ve been thinking
about this conference for many months, and I won’t say that I see my boss in the back. I’ve been doing a lot of things too, but I
have been thinking a lot about the conference. I was in a city called Changsha in Hunan Province
in China, at a Swiss Re conference and I went to the most amazing place one afternoon. This is Hunan University and what you can
see on the right of over here, is this is one of the parks and this university was founded
in 976 A.D., so it’s been going for over 1000 years. It has never stopped. Not for dynasty changes, for world wars, for
nothing. It’s been going for over 1000 years. Beautiful place. We went to kind of almost like a temple of
knowledge, where they have a whole lot of Chinese symbols and beautiful calligraphy. I saw this and I asked a colleague next to
me, a Chinese colleague, “What does that mean?” My Chinese is a little rusty so I had to get
this verified. I don’t know if any of you can read Chinese,
but it struck incredibly related to this conference and particularly related to this panel discussion. It says, “Seeking truth from facts.” It’s just wonderful. When you look at what this panel is about,
and what evidence can we trust, that’s really it, right? ‘Cause we want the truth, that’s what we want. And it’s not always easy to find the truth. I’m going to begin, Fiona mentioned early
on that we should mention our conflicts. I work for Swiss Re, but one of the other things,
and John Ioannidis of course talks about this, is that our bias is also personal. I will talk to you about my dietary preference,
I reduce carbohydrates significantly, I’ve been doing it for quite a while and I feel
good on it. But that’s my choice. In terms of what evidence do I believe we
can trust, I don’t know. I really liked Darrius’ commentary in the
beginning, that there are pros and cons to all of them and we need to take kind of what
we can. It would be wonderful, we could do RCTs forever
on people but we can’t. There are downsides to that, it’s very costly,
you don’t have a longterm studies, whereas of course the observational studies are prone
to potential confounders. And it’s association, not causation. There are pros and cons to everything but
we need the answers. And I hope this panel can help us get there. I’m going to sit down now, so that the panelists
can start speaking. I have a list of questions, I hope I don’t
need to ask any of them, ’cause we really do want to include the audience. We want the audience to ask as many questions
as possible. Zoe asked me last night what order am I gonna
go in, and I wasn’t sure. Then I saw this morning, in very good Swiss
and Swiss Re fashion, it’s in alphabetical order. That’s not accidental. I’m going to start on that side, the surnames
are in alphabetical order. I’ve asked the panelists to briefly introduce
themselves, mention their dietary preferences, their conflict of interests and then very
briefly answer the question, “What evidence can we trust?” Zoe, over to you. Thank you very much. Until about 2009, I had what my mother would
describe as a proper job. I was an HR Director for global organizations,
blue chip organizations. And I had the opportunity in 2009 to make
my passion my vocation. I’d written a book in 2004 called, Why Do
You Overeat, When All You Want Is To Be Slim? That had been a fascination of mine since
being at Cambridge University. People don’t want to be obese, and yet we
have more than a third of the developed world’s population, who are suffering from that affliction. It doesn’t make sense. So I now read, write and talk about obesity,
diet and nutrition as a vocation. I have no third party organization conflicts
of interest, I work for no other organization, I publish and write content online and in
print. If individuals enjoy what I write, I get to
put steak on the table and if they don’t, it’s white pasta. In 2012 having started on this new venture,
I undertook a PhD and I used systematic review and meta analysis to examine the evidence
base, both RCT and epidemiological for the dietary fact guidelines that were introduced
in 1977 in the US and 1983 in the UK. The particular unique aspect of the PhD was
it went back to look at the evidence that was available at the time and concluded that
the evidence simply was not there to introduce the total fat guideline of 30% and the saturated
fat guideline of 10%. So, that’s what I do now. When John asked the question, “What evidence
can we trust?” I find it easy to say what can’t we trust. I don’t trust epidemiology, I find there are
too many reports coming out on an every other week basis, one minute eggs are good for us,
next minute eggs are bad for us. Apparently if you eat red meat, it will increase
your risk of googling cat videos on YouTube. It’s getting absurd. I don’t trust epidemiology, it’s not getting
anywhere close to the Bradford Hill criteria of the strength of the association before
you then get near double which would take you into the other eight Bradford Hill criteria. Interestingly in this field, I don’t trust
RCTs. Because it’s impossible to change just one
thing. If we swapped out meat and put in cereals,
we would change all macronutrients and all micronutrients. The simplest RCT we can do is to swap out
one oil for another, we change all three fats and we lightly change plant sterols which
will directly impact cholesterol and confound the results. So I don’t trust RCTs. What do I trust? I trust non-findings. We don’t take non-findings seriously enough. In the Hoopa study of dietary fats and the
RCTs, there are 11 out of 12 non-findings. Which we don’t often enough talk about. We continually talk about the one finding
of cardiovascular events which when put under scrutiny itself folds away. At the end of the day, what I do trust is
not so common sense. I kind of think, if we could only just eat
what we’ve been eating for the last three and a half million years, we’ve obviously
done a lot better on plants and animals and anything we could gather or catch, than we
have on Twinkies or anything that’s in the supermarket today. That drives my own eating habits. My eating habits can be summed as, I eat real
food. To the keto community, I’m probably quite
high carb and low fat. To the government community I’m definitely
low carb and high fat. That’s what I eat, real food. Thank you for this opportunity. Thank you Zoe. Aseem My name is Aseem Malhotra, I am a Consultant
Cardiologist, I’ve been a qualified doctor for almost 17 years. I wrote a book recently called The Pioppi
Diet, that’s my declaration of interest. However, although I may have an intellectual
conflict, I don’t think I have a financial one. I hope I don’t, as I’m giving all the proceeds
and royalties for the book to the Academy Of Medical Royal Colleges Choosing Wisely
campaign. It is also is in conjunction with The BMJ,
because I think that’s extremely important. Now, what evidence can we trust? Well, the first thing I can say, and Zoe’s
already alluded to it, is the fact that we have more than 60% of our adult UK population
and many western countries are overweight or obese. And the huge burden of chronic disease for
me is a clear indication that we have failed, we are failing our patients and we failing
in our healthcare system. The question is, why? Well, the father of evidence based medicine
movement, David Sackett, I always come back to my patients because ultimately as a front
line doctor, my responsibility is to do what’s best for my patients. And to practice evidence based medicine, you
need to use your individual clinical expertise, which we all do as doctors. The best available evidence that we have. And most importantly patient preferences and
values. I’m gonna come onto that a little bit later. Why and how important that is in all of this. The sad reality is, that the best available
clinical evidence sadly has been hijacked by commercial influence. Now, we’ll hear from John Ioannidis later
on and I defer to him in terms of how we can improve the data quality. But, the fact that from his analysis, that
even for medical therapy interventions, only 7% are estimated to actually fill full criteria
for being both high quality and relevant to patients, is really a big wake up call. When I started my journey, along the way I
wrote a quite a controversial paper in 2013 in The BMJ called, Saturated Fat’s Not The
Major Issue. From my own observations, I had concluded
that a root cause behind this epidemic of obesity and Type 2 Diabetes was fatally flawed
science. When I say fatally flawed science, I think
of a huge campaign that had been going on for quite some time, to reduce cholesterol
and saturated fat has failed to curb the epidemic of heart disease. And it’s increased our consumption of ultra
processed foods, predominately refined carbohydrates and sugar. For me, when you look at the data now, the
elephant in the room is that we’re ignoring the most important risk factor of heart disease,
which is insulin resistance. I wrote an editorial with Rita Edberg and
Pascal Meyer last year in the British Journal of Sports Medicine, saying we need to shift
the paradigm because actually if we concentrate on insulin resistance, 66% of people
meet with heart attacks now have the insulin resistance syndrome. Through lifestyle changes, that’s gonna be
the most important way to tackle obesity and chronic disease. I know we’re running out of time, I know a
lot of the discussion in the next few days is gonna be a little bit about placing low
carb versus low fat. There’s been some great results from the direct
study from Rod Taylor and Mike Lean to show that, Type 2 Diabetes can be put into remission. However, is there another way or is there
perhaps a better way. Well, data from Verta and diabetes.co.uk show
that 25-50% of people involved in a low carb real food program, which is without restricting
calories, actually put patients into remission as well. The question then is, where do we stand? Well, I think one thing that’s gonna emerge
soon, and I hope everyone will pay attention to this, is the two Cochran researches and
Professor Hannopell is here in the audience today. Are about to publish a systematic review looking
at low carb versus low fat for Type 2 Diabetes. Looking at quality of life, cardiovascular
risk factors and glucose control. I don’t know the results but if the results,
but if the results show at least equivalence or even that the low carb approach is better,
I believe that we should be using that as first line approach for our patients. I’m just gonna finish with one very quick. I received a … Talking about patient values
and preferences, I just wanna read this from someone who posted on my Facebook today. it’s just
to give the example of patient preferences and values about the best approach to tackle
this. Okay, so watched tonight’s episode of the
Fast Fix, four weeks in the lab with powdered shakes, they all still had low mood, motivation,
energy. Sending them home for another four weeks of
powdered shakes, no nutritional information whatsoever, setting up to fail by using fear
tactics, not a sensible way to develop a good relationship with healthy eating/living. Feeling very annoyed and frustrated at the
moment, by the way I reversed my Type 2 Diabetes by eating meat, fat, leafy greens, cruciferous
vegetables, nuts, berries, dairy and a glass of good red wine on the weekend. They can keep their shakes, thank you very
much. Thanks Aseem. Rita. Hi, I’m Rita Redberg, I’m a Cardiologist at
University of California San Francisco and I’m also Editor of JAMA Internal Medicine. My own eating, I would say is mediterranean
diet, largely vegetarian actually because 10-15 years ago when my older daughter who’s
here today, was vegetarian. It was simplest for us all to eat that way
and then I also, thanks partly to her learned it’s not just better for you as we’ve talked
about, but also better for the environment in the world because of the incredible energy
inefficiency from eating meat and cows and the methane contribution and all the issues
of climate change which Darius referred to also, in your introductory remarks. And also living in Northern California, I’m
basically mostly fruits and vegetables that we either grow at this time of year or that
I can get from the local farmer’s market. Barbara Kingsolver’s book actually, I thought
if she can eat locally from Northern Virgina, I could certainly eat mostly locally from
living where I do, which is … That’s all my diet. Conflicts of interest, nothing except what
I already listed with the journal. In terms of sources of evidence that we can
trust, I think for the food industry just as for the medical profession, I look a lot
at funding and where were studies funded. This point was really driven home to me in
terms of the food industry when we at JAMA Internal Medicine published a paper two years
ago, actually from some of my colleagues at UCSF, Kristin Kernes and Stan Glance on the
sugar industry and the history of how the sugar industry had a major role in the papers
that suggested that the real culprit in terms of heart disease was fat. They were actually funding research, funding
some researchers from Harvard and in particular without disclosures, which weren’t routine
at that time. Because they had actually gotten documents at the request that looked at correspondence
from the 50s and 60s between the sugar research foundation and these researchers. To basically, try to suppress the evidence
that was clear about the role of sugar in diet and heart disease and to shift the focus
onto fat. And clearly, then the whole low fat movement
and its unsuccessful popularity, but its lack of success in reducing heart disease, I think
stemmed a lot from that kind of work. Part of their conclusion was that you have
to be careful of sources of funding and sources of funding should be transparent as well as
data should be transparent. I think that’s as true or more true for food
research as it is for medical research. I will say, Aseem has alluded to I think currently
in medicine we spend a lot more time focusing on medicines and not enough on diet and lifestyle. As a Cardiologist, I’m more often talking
to people that what they are eating and the kind of exercise they can do, not smoking
than I am about in particular statins which maybe we’ll talk more about later. Even when I talk about food, I talk about
real food and not all the vitamins and pills. People have still a very mistaken idea that
you can replace or supplement healthy eating by taking pills and that’s why we have this
multi billion dollar supplement industry and I don’t think that there’s data to support
that. I think that to stay healthy and get the benefits
it has to come from actual eating of real foods as Zoe said. I’ll look forward to more discussion on all
those points. Thanks very much. Gary. My name is Gary Taubes, I am a Journalist,
I’ve written books which are on diet and health, which are conflicts of interest, I co-founded
a not for profit that I am now President of, called The Nutrition Science Initiative, which
was found to fund and facilitate clinical trials that we thought could resolve many
of the issues in the field. I actually personally funded Kristin Kernes
to get the documents Rita was talking about, the sugar industry. Briefly about my background, I was an investigative
science reporter, my specialty was bad science. What physicists would call pathological science,
which is the science of things that aren’t so. If you think about the first principle of
science, which the Nobel Laureate Richard Feynman described as, you must not fool yourself
and you’re the easiest person to fool. Pathological science by that definition is
science that’s been done by people who don’t think they’re fooling themselves and don’t
think they’re easy to fool. As such, in the early 90s I got into public
health and my first major article in the field was on chronic disease epidemiology, it was
relatively infamous and it was the paper you cited before John Ioannidis came along. In effect to take over for me. I had issues with nutritional epidemiology
in general because much of the rigor and critical science that I had been taught had to be done
by my mentors in the physics and chemistry industry, was considered a luxury in, or at
least in my perception, was considered a luxury in the world of nutritional epidemiology ’cause
it’s simply too hard to do. I’ve always been a critic of that, so when
it comes to the question of what science we should believe or what evidence we should
believe. To me, nutritional epidemiology, epidemiology
in general gives us associations between our correlations, between diet and health, it
doesn’t give us causation. When I first wrote my piece, Epidemiology
Reached Its Limit for the Journal of Science back in ’93. These associations were considered defacto
logically hypothesis generating. And to me, they’re still logically defacto
hypothesis generating, and yet even at a meeting like this, I see people using the risk factor
epidemiology, the chronic diseases correlations and implying causality sort of in passing. I find that deeply troublesome. I find in fact, from my journalistic perspective
of the field, deeply troublesome. It’s true that randomized clinical trials
are also flawed. But I don’t believe that two flawed sources
of evidence can used to equal one truth in any they’re interpreted. Along the way- Along the way my evolution in this field,
I also did another infamous article for the New York Times magazine, a cover story called,
“What if it’s been a Big, Fat Lie?” That started out as an investigation of what
might have caused the obesity epidemic. In the course of that research I came upon
what, to me, is the most important data in this field, which are the clinical trials
of low carbohydrate, high fat diets. Based on, in large part, nutritional epidemiology,
you have these hypotheses that say that plant based diets are better than animal product
based diets for your health. Clearly not for the animals, but for your
health. And low fat diets or polyunsaturated fat rich
diets are better than saturated fat rich diets. And calorie restricted diets are better than
ad libitum diets because we get fat, clearly, because we eat too much. And you do a randomized control trial where
you compare a- Back then in 2002 these were all known as Atkins diets. So you compare a diet that’s rich in saturated
fat, rich in animal products, in theory rich in calories, but carbohydrate restricted to
what were then just low fat, American Heart Association control diets, which are calorie
restricted and low in fat. And you would expect based on your hypothesis
that these Atkins-like diets would kill people and would lead to more weight gain because
they’re ad libitum. And in all these cases where these studies
are done you see, not only do they improve lipid profiles with the unfortunate exception
of LDL cholesterol. But people lose weight compared to the calorie
restricted, low fat diet. So from my take on this, this was the anomalous
observation- this was the observation that today we’re still wrestling with. When I see a presentation in which, based
on nutritional epidemiology, we should be telling everyone, including the 30-40% of
the population that’s obese and the 60% that’s overweight and the 10% that’s diabetic, they
should be eating whole grains and fruit and they’re healthier if they do that than if
they don’t, I wanna ask myself, “How do they know? What’s the evidence?” If I have a child that’s overweight or obese,
I wanna know. Are they really gonna be healthier if I feed
them a Mediterranean diet or a Swiss diet? If I feed them a diet rich in whole grains
and fruits and vegetables, I believe one of the speakers said we should “flood”- What’s
the word that was used there? Should we flood an excess of fruits, vegetables,
whole grains. Is that really healthier? And then the question comes, “How do we know?” And the only way I know the answer to the
“How do we know” questions was the clinical trial. And it’s true that all the clinical trials
to date have been flawed. But the question is, “Can they be done better?” And can we find the societal will to do them
better? And along the way I gave up starches and grains
because I find that they make me fatter. Thanks, Gary. Thank you very much. Walter? Sure. I guess in terms of conflict of interest,
I’ve basically descended five generations of Michigan dairy farmers. And I grew up in that context of drinking
many glasses of milk a day and eating mashed potatoes, roast beef, and gravy. But as the evidence came in, my diet has shifted
pretty far away from that. And I can say it’s much more enjoyable. I’m an omnivore but more Mediterranean type
diet, largely plant based. And I think Zoe’s wrong, although I agree
she was right when she started looking at the data early 1990’s, this recommendation
to consume low fat, higher carbohydrate diets was not supported by any of it at all. In fact what I realized that time was that
there was pretty much almost no evidence on the long term consequences of diet which is
why we set up our long term cohort studies beginning in 1980 to actually track people’s
diets and what happens to them. That has clearly shown that low fat diets
are, in general, are not beneficial. But that the type of fat and the type of carbohydrate
is very important. Both Jennie Brand-Miller and Nita showed that
evidence in a very clear way. And also the point that in some ways we shouldn’t
trust without questioning any study, any length, any type of study. We should look at every study critically. And they are all going to be imperfect. We have to live with this. You can wait for Gary to do the perfect study
but I can tell you it’ll be dead first. And probably your grandchildren will be as
well. And we really will have to rely on the combination
of all of the evidence, weighing its strengths and weaknesses. I think Zoe’s wrong that epidemiology studies
are all over the place, inconsistent. If you read a lot of newspapers and radio
you will maybe get that impression because they’re always hyping the latest study that’s
different from anything else and rarely published informatory study. And these are often the weakest evidence,
the weakest studies that are being cited. And I totally sympathize with the public in
terms of being confused. I would be confused if I didn’t know much
deeper the evidence. But like Dr. Schulze showed that if you look
at the Mediterranean diet observational studies, there were about 15. And not a single one showed a positive association
and they consistently showed inverse associations and also consistent with a randomized trial,
part of that study for cardiovascular disease and diabetes. So the reality is that the newer generation
of large cohort studies produces findings that are very consistent. I started and have been part of the Diet and
Cancer Pooling Project that combines the data from all the large cohort studies from around
the world to look at various aspects of diet and cancer. And it really is impressive how consistent
the data are when you line up all those studies. You’re using the primary data that are often
not published, as well as the published results. Very consistent findings. Now, there’s still potential for confounding. We should also look at that critically. But when you do combine that, as again others
have made the point already, control trials of intermediate risk factors, and combine
that with the longitudinal epidemiologic studies. We reach a high level of certainty. And certainty is really a continuum. Where they may start from a neutral position,
but as the evidence piles up we can get closer and closer to a high level of certainty. We probably will never get to 100%. You can have the world’s perfect randomized
trial but they’ll never be perfect for all the reasons that have been mentioned. But even that, you can still have chance findings
and we cannot be 100% sure of truth. But in many of these areas we can get to a
high degree of certainty. Another example in addition to a couple of
those that have been made already is on trans fats, which we started working on in the 1970’s. And Darie actually has summarized
that evidence nicely in the New England Journal paper that we have the data from multiple
cohort studies showing consistently in the overall meta-analysis, robust association
through coronary heart disease. And we have randomized control trials, feeding
studies over a period of a few weeks showing adverse affects on blood lipid and inflammatory
factors and LDL particle size. All consistent with showing adverse associations. And you put those control feeding studies
together with large cohort studies and you can reach a higher level of certainty. You can always make an objection that not
one of those studies is perfect. But the weight of the evidence is clearly
that trans fats have harmful effects. And on that basis we’ve removed them from
food supply in the US. Pretty much it will be illegal in the United
States next Monday to produce trans fats. And there are many other examples. In some ways the fact that we can’t do randomized
trials is not unique. In courts of law we make decisions without
randomized trails. Thousands of decisions every day on the weight
of evidence. How many people here believe that climate
change is happening and affected by human activity? Most people do. Can you imagine doing a randomized trial on
climate change? The bigger the question often it’s more difficult
to do randomized trails. That is a paradigm that we should use every
time we can. But much of the time we just simply can’t. Even worse than that, we can often get the
wrong answer. And that’s the worst consequence. The most powerful risk factor we have is smoking
and the randomized trials of smoking cessation and mortality show no benefit. Do you really believe that? Of course not. Nobody believes that. But if you really stuck with randomized trials
they reproducibly show no benefit. Which is, again, why every study has to be
looked at critically. So I’ll stop there. Thank you very much. Sorry, sir. Can we respond? Yeah. So I’ll let the panel just respond to each
other a little bit and then we’ll open it up. So you would all make terrible Swiss because
your time keeping to three minutes is appalling. But absolutely, go ahead and go. John, I’d like to make just one quick point
because I was the main focus of attack, I think, from my learned colleague at the end
of the row here. The particular point that I’m making with
epidemiology is that we do have to back of a tail criteria from 1965. And epidemiology is not getting into that
strength of association of 100% or factor of two. It’s not even getting close. The studies that we’ve seen are 10% difference. She quoted predimed which will
quote the relative risk of 30%, which is actually three in 1000 person years. So we’re playing with the numbers. They’re tiny. I don’t think we have that power of evidence. So that’s my defense back on that one. Yeah, well that’s silly if you believe a 30%
increase or decrease in heart disease risk is not important. So be it. We make lots of decisions on that and that
translates if you look at heart disease risk into many tens of thousands of cases per year. It is important. So Walter and I were co-authors with Nida
Forouhi and Ron Krauss, who’s not here, on the Dietary Fat article. This dynamic has played out over the course
of the year, I think. We had documents in edit mode that Nida must
have taken- Yeah. if there are long term consequences to aspirin
use to deal particularly with my comment. I find Walter’s argument, and he knows this
and we’ve fought about this publicly and privately, sophistic on many levels. So, this isn’t climate change. So when we’re talking about climate change,
whether you believe it or not, yes it’s true we have one earth. And it’s always a reasonable thing to say,
it’s because we don’t know what’s gonna happen that we should act to prevent it. It’s a completely resonable assumption. In this case, when we’re talking about diet
and health and even cigarettes, it’s a separate issue. So whether or not cigarettes cause lung cancer,
removing cigarettes from your lifestyle seems to be a reasonable thing to do that is not
going to cause harm. And back in 1981 in the British Medical Journal
there was a seminal article written on public health epidemiology. The argument made was that, and this is in
our Dietary Fat argument, that if you’re argument to remove an unnatural aspect of the environment
or the diet or the lifestyle because you’ll be healthier, that’s a reason
you can make on a public health benefit. So you can argue to remove trans fats. That’s one reason why I don’t disagree. Because trans fats are certainly an unnatural
aspect of our diet. You can argue to remove cigarettes because
cigarettes are not something we’ve been consuming for two-and-a-half million years. As Zoe put it, you can argue back. When we did argue to remove saturated fats,
part of the basis of that argument was that the high levels of saturated fat or high levels
of fat in the diet were unnatural. It was based on debatable assessments of paleolithic
diets. But that was the argument. When you’re arguing something based on epidemiology
that we should all eat, for instance, plant oils instead of animal fats, now you’re arguing
that we should eat something that’s relatively new to human diets. If you’re arguing that we should remove animal
fats which have been in human diets depending on form for, again, millions of years, that’s
a fundamentally different argument. And the way I think about it is I think, in
effect, what I’m being told on a base level is I’m feeding my children right now- I’m
one of these people that thinks butter’s a health food and I hope I’m right. And I can act like that in my own family,
I don’t think I’m doing my children harm. But I’m being told that if I switch them to
butter to corn oil or soy oil or rapeseed oil they will live longer. And I have no way to know. I will never know, in fact, whether they’re
right. If my kids live to be 90 I won’t know if they’d
lived to be 100 if they had stayed on butter. It’s a hypothesis that I’m being asked to
act on. And before I act on that hypothesis I want
to know. I want to have harder evidence than when we
look at healthy people in populations and we compare them to unhealthy people. Jennie made this point discussing carbohydrates. I forget what it was that people eat white
bread are very different than people who don’t. And people who eat vegetarian diets or plant
based diets are very different than people who eat meat rich diets. And people who eat sugar based diets are very
different than people who avoid sugar. And we may be comparing incomparable people. People who have a whole, and I hope John Ioannidis
will talk about this, a whole universe of factors that go with these things. And I want to have better evidence before
I switch my kids diet. Gary, Gary. Walter do you want to have a quick word? And then we have to keep the answers short,
please. Right. I’m not gonna report you for child abuse,
feeding your daughter butter but- Son, son. Son, either. But you do have quite a bit of evidence that
the control feeding studies, your son would have clearly better lipids, and I’m expanding- He would have better LDL. He will have just as good other lipid fractions. If you wanted a long term, tested thousands
of years you could use olive oil. That’s readily available. These plant oils, these are not like trans
fats. These have been part of our diet, maybe not
in quite the amounts, but they have been part of our human diet. They’re not artificial chemicals like trans
fats were. And we have long term studies showing that
substitution of animal fats, including butter, with plant oils is related to lower risk of
cardiovascular disease. So there’s a lot of weight of evidence, whether
it’s controlled feeding studies, metabolic studies, long term epidemiologic studies,
and randomized trials that Nita talked about that all are pointing in the direction, maybe
not 100% causality, but all the evidence of different kinds points that replacing animal
fats with plant oils will be better. Now you can say it’s imperfect and then not
one of these studies is perfect. But there’s nothing pointing the other way,
except you argue for ecological or historical precedence. But in fact what you’re describing is that
the Finnish diet of the 1960’s, which was very high in animal fat and if you want to
go to ecological studies, it’s the weakest kind of evidence but the- Did we talk about the Finnish diet? I’m gonna stop it there. Can I stop it there? Because this is going into a rabbit hold of
dietary fat. And we’re going to open it to the audience. So let’s have two or three questions. If you can take the mics to a couple of people
with their hands up and- over there. Go ahead. Okay. Is that helpful? Sure. Just introduce yourself very briefly and ask
the question very briefly, please. And to who you might be wanting an answer. Okay, not sure who it’s attached to yet. My name is Amanda Atkins. I am former reinsurance] director,
actually, so I have an interest. But, also a diabetic. I was diagnosed with 10.3 HbA1c 18 months
ago. It’s now 5.3 based on a low carb, high fat
diet. I chose to do that based on a randomized control
study that I saw. I found out about this industry after that. My question is there are thousands of people
like me who have changed their diet to low carb, high fat, because you’re eating less
carbs. All of them have got lipid profiles that show
improving lipid profiles, improving heart profiles, improving liver, lung, kidney function,
you name it. The role of n=1 people who are actually doing
these diets and who are actually changing their health. They have got real data, they have got information
that they can give to the medical community, to the scientific community that can help
them choose what to study next. Why are you guys not making the best use of
all of that actual data from individuals via what is now available on the internet? Okay. Thank you. The question over there. Sorry. Yes, Martin Like Amanda, I have reversed my diabetes in
a low carb diet. So I’ll declare that interest. But my questions away from that. I have a background in business and we’re
seeking truths from facts. I just want to put a fact up and then ask
a question. Very quickly Yeah very quickly. The fact is that no corporation can spend
money unless it’s in the interest of the corporation. It’s against corporate law. It’s bad to spend it on yourself and it’s
also bad not to spend it for the benefit of the corporation. That means increasing sales. My question is, if we’re trying to improve
research, has it been considered to set up a journal that set’s
up a rule that says there will be no corporate influenced research in this journal? That’s a good question. We just have one third one and then we’ll- Yes, Naveed Sattar from Glasgow University. I’m a professor of metabolic medicine. So I really enjoyed this and I thought, Walter,
you did a really nice job of giving balanced comments to the others. There was some evidence of observational associations
that others were presenting. And I think we’re getting slightly mixed up. One, there’s cardiovascular outcomes. And two, there’s obesity. And there’s conversations
that happen. And Walter, you know this well. And I think the key other aspect, I think
Garry, you made, ad lib it to them, low fat diets, or sorry, low carb diets. Yes they can have ad lib it to them, but actually
what the evidence is they end up eating less calories because it ends up giving you more
satiety. And the key thing is it’s not necessarily
sustainable over the long term. And I think, our colleague from Sydney said
that as well. So I completely accept that low fat, low carb
diets will make you lose weight just as well as low fat diet, we know that, these are analyzed
meta-analyses in a journal that shows that. It’s a question of what is the question you’re
after? And what’s the long term sustainability of
that answer as well? And I think, those things we need to be mindful
of. Thanks very much. So, I’m going to jump, Rita, to you, regarding
the question about a journal and not allowing funding from outside vested interests. Your comment on that. Right. So, certainly all, or most journals, there
are a lot newer and some predatory journals, but most of the journals that follow ICMJ,
The International Committee Medical Journal Editor have conflict of interest policies,
but that’s different from what you’re saying is not taking funding. You know, that’s, I think we’re all variable
and people have looked at it. The policies only mandate disclosure of conflicts
of interest. So if the study was funded, I can say, speaking
from my own journal, we always look at the source of funding for a study because you
want to know that there wasn’t undue influence and bias. And that doesn’t mean we would never publish
an industry, and it’s usually pharmaceutical industry funded study. But we want particular assurance that it was
independently analyzed, it was independent and that the findings are free of bias and
that’s certainly a big concern. But I would say in general, that is a big
concern, particularly, as for pharmaceutical and some for food industry, as well because,
you’re right, everyone is responsible to their shareholders. And even the way we search questions or forms
have a lot to do with the kind of answer you’re giving and your funding source. So it’s really important to look at. There’s not a lot of independent sources of
funding. So, a journal that didn’t publish any studies
that are industry funded has a very limited, you know, way of government source of funding,
and that’s about it. And even government, even NIH, is often partnering
with industry. And so, its great to have this conference
and talk about it. I mean, part of the reason that in medicine
we’re talking so little about lifestyle, which is so important in health, and so much about
drugs and pills as the solution, is because that’s where the money is in medicine. The money is in pharmaceuticals. Rita, quick, quick question. Should the reviews of what is published, not
be more not be more unbiased and objective? So, I know, Zoe is very good at doing investigations
and ripping apart systematic reviews and going through them very carefully in quite an unbiased
way, because she looks at all studies from all sides. Should journals not make the review process
more onerous and unbiased, is that possibility? You mean the peer-review process to be more
unbiased? Yeah. And more rigorous. It that unreasonable? It’s not unreasonable. No. So, Fiona, for the people on the live stream, Fiona Godly just said not unreasonable at all. No, I’m sure BMJ and a lot of other journals
we, avoid reviews that have conflicts of interest, we ask people to disclose. But again, we’re not the FBI, we don’t investigate,
we relay on people to be honest. And sometimes people will say oh they didn’t
disclose and then, and then maybe we’ll get into it. But there’s a lot of discussion over intellectual
conflicts of interest and financial conflicts of interest and we certainly try to avoid
it. I think journals could certainly, try to be
better and be more open. I think, maybe feel, VMJs
is an open reviewer where you can see who review. We offer reviewers the opportunity to be open,
but they don’t have to say if they’re open. The data I’ve seen don’t suggest that there’s
a difference in the quality of the review. But you’re trusting a lot to the editors and
the reviewers. So, I’m just going to, the either two questions
were both related to low carb. There’s a low carb panel discussion this afternoon. So, I’m going to take those. Because this is mean to be about what evidence
can we trust, so I’m going to try keep the focus a little bit. Go ahead, over there. I’m Tim Key from Oxford University in Britain. Two comments and a question. I just want to challenge a couple of the statements
from the panel. Dr. Malhotra said that the changes in diet
have had, you know, have failed to reduce the risk of ischemic heart disease. I think that the facts just show the opposite
the rates of heart disease had gone down in all western countries some of that is diet
some of it is drug, smoking etc. Zoe Beachcomber accused the SACON committee
in the UK of being completely biased due to one committee member who works for industry,
which is a requirement of the committee to have a member from industry. As a member of that committee I find it totally
outrageous to claim that the whole committee’s conclusion has been swayed by one person who
works for industry. If that were the only conflicts on the panel
from industry I would accept that accusation, but it’s not. A few people speaking this afternoon have
shown adverse associations of high meat intakes, not only processed meat also red meat with
diabetes and ischemic heart disease. And a point that’s really been glossed over
in the arguments for reducing carbohydrate intake is there’s a large body of research
in vegetarian cohorts showing very consistently, in the western populations in the US, in Europe
that vegetarians have a relatively high intake a carbohydrate higher, than any of the other
groups the meat-eaters, fish eaters. In these studies they have a high intake of
carbohydrate they have a much significantly, lower body mass index, lower blood pressure
and lower risk of ischemic heart disease. Maybe they’re choosing particularly good carbohydrates. Sorry, do you have a question? I’m just being mindful of time. Just when you suggest that, you know that,
low carbohydrate is always better because these people are eating more and they’re doing
better than the people who are eating less. Sorry was there a question? The question was do the people who argue for
creating less carbohydrate how do they explain these observations in vegetarians who have
a particularly high intake of carbohydrates? Okay, thank you. The healthy persons syndrome. Wait, hang on, we’re just going to have the
other question. Dr. David McCarran I’m an adjunct professor
at UC Davis. A nephrologist by training, which I think,
helped me as I wandered into nutrition. I radicalized Gary Tarbes in 1998 so, Walton
you can blame me. the question to the panel actually addresses
the topic up therewith Dash Diet was described by our program in 1984 in the science paper
it was not low-fat it was not low sodium and go look at the paper clearly the diet got
described by the National Heart Lung and Blood Institute arbitrarily as low-fat and then
got described by the National Heart Lung and Blood Institute as a low-sodium time and while
we have these concerns about corporations which, I agree there are many I think most
of you might be concerned that our governments have caused some of the problems through which
we are addressing here, and we have to get back to that and I just wonder how the panel’s
feels about that. Great, thank you very much. So, we’ll have one more question. So, wait for the mic please. It’s a methodological comment as opposed to
any particular nutrient. As many of you know, sorry, okay I’m Salim
Yusuf from McMaster University representing the low and middle-income countries, Canada. As many of you know my first two thirds of
my career and still I was doing large randomized trials in the last 25 years we’ve been doing
epidemiology and, with Walters help we got into nutrition epidemiology because of our
interest in ethnicity, and then the pure study, the Inter-heart study and the inter-stroke
study. I’ve randomized over half a million people
into trials and, I’ve included nearly half a million people into epidemiological study
so I sit between these two gentlemen here. I’d like to say the real evidence is when
there’s a coherence of information from different methodologies. Every methodology has its limitations. And I think we can criticize them til the
cows come home. I think though there is something useful to
think there are two principles to think about anything physiological will follow a U-shape
curve, it’s there in your textbook Walter if you reduce something that people normally
eat for millions of years down into their boots you’re going to get into trouble if
you give them too much of it they’re going to get into trouble so our starting point,
in nutritional epidemiology not for the external toxins but for the internal things we eat
has to be the U-shaped curve. Unfortunately our epidemiological studies
haven’t had the diversity or the size to generally affect this. External toxins, remember Bradford Hill’s
work and Rose’s work based on occupational and air toxins there you can start to believe
to see harm and it wasn’t to see benefit. Rose said if you get an odds ratio more than
two you can believe it less than that you can’t. The problem is if the collectivity of diet
reduces risk by 30% each component has to be some fraction of it. It’s very hard to have, to control biases
to such an extent that your confounding, is a fraction of 15% so you do need both trials
and epidemiology but epidemiology has to evolve to a whole different plane of using, what
we call instrumental variable analysis, like Mendelian randomization so my, I would urge
people, yes, thank you John I would shut up and sit down in a minute. I would urge people, this debate epidemiology
versus our cities will never go away but try to find where can each complement each other. So, we have a few minutes, and it’s a pity
we do because that would have been a really beautiful conclusion thank you, thank you
very much I’m just gonna give 30 seconds. Please, if you can very quickly to respond
to the gentleman over there about cardiovascular disease, mortality reduction because of diet. Certainly trans fat seems to be consistent
we know, that smoking reduction 50% at least of cardiovascular death rates were reduced
because of smoking. People talked about cholesterol and statins. How many people here think that statins have
reduced cardiovascular mortality in secondary prevention in the population? Okay, quite a few hands raised here. Well, they haven’t. They haven’t, it was a stunning study published
in the BMJ 2016 observational across 12 European countries, 12 years no reduction of cardiovascular
death rates. Is that because of scientific fraud? No. The science explains that if you look at the
actual median increase in life expectancy in industry sponsored trials, highly selected
patients media increases only 4.2 days. More than 50% of patients stop their statins
in secondary prevention after two years. As a cardiologist that’s prescribed these
like Smarties there’s a big problem there so you can explain the science so it hasn’t
done, certainly in my view, cholesterol lowering the population through diet drugs has failed
to reduce cardiovascular mortality in the population, that’s my interpretation. Over there, at the back, Amanda, is that your
hand? So, I’m not in the medical profession but
in the mathematical profession. So, maybe to get back to the topic of seeking
the truth from facts. What I’d like to sorry
yes I’m sorry, Swiss Re I’m the hub head for a mayor so the actuaries and the underwriters
in my team getting back and also I have a background actuarial science and statistics
so, the point of my question is, statistics can be manipulated intentionally or unintentionally. And going back to what someone presented earlier
in terms of the being able to reproduce the information. How do you we, and this is the question, how
do we in terms of answering this provide the level of transparency and disclosure to those
people who are interested so, that we can draw our own conclusions from the data and
the evidence understanding both the limitations, and the outcomes so that we are not necessarily
being told but can draw our own conclusions from the analysis and the disclosures. Great, thank you Amanda. I just wanted to comment that, those who doubt
the value of changing doubt for cardiovascular disease shouldn’t really forget the very massive
reduction that was produced in Korea and Finland when they went for the Mediterranean diet. Thank you very much. So, would Walter or Gary would one of you
like to respond to the question about making the findings available in a way that is transparent
for other people to see the truth? Let’s see, I’m not sure exactly what’s requested
there, that different people want to see the findings in different forms. Some people want just a very simple bottom
line, other people would like to know the methods deeper, more deeply and I hope that
that’s what we do in the journals that the findings should be judged on the basis of
the methods oftentimes you’ll have to go back like, saying that one of our studies looking
at diet we’ve often published data separate papers before and the validity of the dietary
measurements and the documentation to the endpoint so, it often will need to be necessary
to go back to other publications. We’re only usually allowed three thousand
words or something like that in the journal sometimes supplementary documents more and
more since we’re allowed do that online. In terms of disclosure conflict of interest
if those are there now. I think all journals require that so, if there’s
something more specific that’s being asked for I would be happy. Garry, do you think there’s transparency in
terms of what is published and that somebody like Amanda who’s very mathematical and statistical
can actually get to, is there truth? There’s different types of transparency. One of the issues always in the public health
sphere and, this was set forth pretty clearly again in the 1980s. The kinds of changes we’re talking about actually,
have even though, Walter will talk about 30 percent the reductions in cardiovascular deaths
if this is correct and there’s no unintended consequences these, actually translate to
tiny effects and individuals and, it’s not really well understood how it translates to
tiny effects in individual. So, for instance in the late 1980s there were
three studies done at Harvard, McGill and UC San Francisco looking at, just taking cholesterol
levels, lowering them by as much as what and in fact a statin would do and looking at how
that would increase longevity in humans using the Framingham data as the baseline and, the
answer was that on average we would all live, if we all cut our cholesterol, LDL cholesterol
by 30 points, we would all live from one week to two months longer and, in fact the US Surgeon
General tried to get to convince JAMA not to publish the study that they funded, because
they didn’t like the reply. So, the way we deal with this as a public
health organization is we, don’t talk about the individual benefits because we don’t know
what they are, and we play up the benefits to get everyone to embrace these lifestyle
or diet changes such, that we can get benefits over the population. And the same thing happens even when you tell
people to view seat belts for instance. Only 1 in 600 or so, on average will benefit
from wearing seat belts over the course of our lifetime, but you tell everyone to do
it so that 1 in 600 will actually be wearing a seat belt or her seat belt when she needs
it. So, there’s some interesting philosophical
approaches that lead us to not being open about actually, the benefits if they’re even
real and we discussed this when we wanted to write our paper we suggested that maybe
we could quantify and, Garry, I think you even asked this at one point wouldn’t it be
good if we could quantify how much people would benefit if they replace say five percent
of the saturated fats they consumed with polyunsaturated fats how much I or my sons how much longer
can we expect to live and I’m pretty confident the numbers infinitesimal I’m just going to give Zoe a chance and then,
Walter, I’ll get back to you. I just wanted only 10 seconds on the North
Karelia thing. The North Karelia situation is very interesting
in the Second World War 400,000 people were displaced from that region we also know from
Glasgow that displacement is a significant factor in cardiovascular disease so the death
rates observed in the seven countries study in that part that particular cohort were extraordinarily
high they were the highest in the whole of the seven countries study cohorts and of course
then they’d have to fall post, that because you can’t die twice. Also in the U.S. rates of coronary heart disease
mortality dropped by 75% it’s not just … I’m just going to give Rita a chance. I’m going to get shouted at. I can carry on, I can carry on? Oh no, I can’t. Just briefly, on the issue of data sharing
because I think, that is an important topic and I think the goal of most journals I would
say, is that the methods should be clear as someone said so, that you could reproduce
the study and that also means the data has to be available. There’s a lot of discussion again in ICMJE
I think BMJ has really been a leader in sort of promoting a more broad interpretation of
data sharing but I don’t think there’s not even consensus in ICMJE at this time on data
sharing. So, I think we’re moving in that direction
and, I think that is a very reasonable expectation is that you should be able to, you know, read
the paper and then be able to look at the methods and we try to reproduce those results
on your own. So, I would really like to thank the panel,
as Fiona mentioned earlier we’re not going to this is not it, we’re not going to get
the final answer today or tomorrow. It’s a beginning of a discussion so I’d really
like to thank the panelists, please join me.

2 Replies to “John Schoonbee: Panel discussion on “What evidence can we trust?””

  • Thales Nemo says:

    At around 14:00 when the woman vegan gives her reasoning as to why she supports it.

    At 37:00–38:00 the gentleman replying to Mr Taubes is stressing plant oils! With the exception of olive oil the rest of those PUFAS are just evil concoctions which have no place in the human diet.

    Debunking of :Dr Michael Greger is a strident vegan. The first article claims “Yes, this really is food to help you LIVE LONGER!” book is called “The How Not to Die Cookbook.”
    http://www.zoeharcombe.com/2018/01/food-to-help-you-live-longer/

    Fact checked Dr Gregor
    https://www.humanewatch.org/hsus_doc_exposed_as_schlock/

    Ten ways vegans are ruining the world.
    https://youtu.be/RyNmgSefNA4

    Why a vegan diet is bad !

    https://sciencebasedmedicine.org/death-as-a-foodborne-illness-curable-by-veganism/

    Historically & religious origin of veganism and vegetarianism from the 19th century
    https://youtu.be/ol8g9LcuDnc

    Vegan and vegetarian can not be sustained long term -five generations
    https://youtu.be/1_E3iMrq-UA

    Nutrition and dementia.
    Review article
    Gray GE. J Am Diet Assoc. 1989.

    https://www.ncbi.nlm.nih.gov/m/pubmed/2687349/?i=1&from=/2687349/related

    World Alzheimer’s Day – Is Alzheimers Type 3 Diabetes?

    https://thenoakesfoundation.org/news/blog/world-alzheimers-day-is-alzheimers-type-3-diabetes

    April 2016
    Metabolic Syndrome and the Risk of Mild Cognitive Impairment and Progression to Dementia
    Follow-up of the Singapore Longitudinal Ageing Study Cohort
    Tze Pin Ng, MD1; Liang Feng, PhD1; Ma Shwe Zin Nyunt, PhD1; et al
    JAMA Neurol. 2016;73(4):456-463. doi:10.1001/jamaneurol.2015.4899

    http://linkis.com/jamanetwork.com/5Uu7b

    The differences between plant and animal proteins
    https://youtu.be/T6D6FKANp8E

    A brief history of why we get fat, why we hate it
    https://youtu.be/Vinqph-g5QI

    Dr Gary Fettke :The role of nutrition in everything
    https://youtu.be/ctkvriSwX8I

    WHO statement on meat.

    http://www.iarc.fr/en/media-centre/iarcnews/pdf/Monographs-Q%26A_Vol114.pdf

    Carnivorous diet
    Amber O’Hearn

    https://youtu.be/0WJBHEhmXqc

    Two men all meat diet for one year 1930 by Walter S McLean and Eugene F Du Bois
    http://www.jbc.org/content/87/3/651.full.pdf

    Nina Teicholz: Red meat and health

    https://youtu.be/1rz-8H_i1wA

    Sweden Becomes First Western Nation to Reject Low-fat Diet Dogma in Favor of Low-carb High-fat Nutrition
    https://healthimpactnews.com/2013/sweden-becomes-first-western-nation-to-reject-low-fat-diet-dogma-in-favor-of-low-carb-high-fat-nutrition/

    Effect of the amount and type of dietary fat on cardiometabolic risk factors and risk of developing type 2 diabetes, cardiovascular diseases, and cancer: a systematic review
    Ursula Schwab, Lotte Lauritzen, Tine Tholstrup, Thorhallur I Haldorsson, Ulf Riserus, Matti Uusitupa, Wulf Becker

    Food & nutrition research 58 (1), 25145, 2014

    https://scholar.google.com/scholar?q=sweden+16,000+rct+studies+review&hl=en&as_sdt=0&as_vis=1&oi=scholart#d=gs_qabs&p=&u=%23p%3DUcPx_ecoBHoJ

    Why vegans dislike Jordan Peterson ( Awesome argument— its a BELIEF DUH)

    https://youtu.be/Kh5uz13MsmA

    Did America Get Fat by Listening to Government Experts?
    https://fee.org/articles/did-america-get-fat-by-listening-to-government-experts/

    Evolution of modern humans’ diet
    https://youtu.be/XQKMKa_ZJ2g

    *Bad science Big business created the obesity epidemic!

    https://youtu.be/3vr-c8GeT34

    * The oiling of America

    https://youtu.be/fvKdYUCUca8

    Non alcoholic fatty liver disease Part 21-NAFLD ( Why carbohydrates are bad )
    https://youtu.be/_8v1iDvZP1M

    Dr. Tim Noakes testimony before the South African Parliament
    82 /3-25 minute videos
    https://www.youtube.com/playlist?list=PLJ4V1OUNHZVhrT5AmBmqWnPJtAU1kLM2j

    What is the optimal human diet
    https://deniseminger.com/2010/03/18/what-is-the-optimal-diet-for-humans-part-2/

  • Niko F. says:

    anomalous observations is what keeps science going forward.. and the low carb high fat diet is certainly a huge black swan.. it merits to have an RCT but no one wants to fund that study.

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