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Conflicting, conflicted, and incomplete narratives in nutrition and obesity research

Andrew W Brown, PhD

awbrown@uab.edu

@andrewbrownphd

Acknowledgments and Disclosures

• Some slides were inspired by, made through collaboration with, or borrowed from others, and I try to give appropriate credit throughout.

• When critiquing others’ work, I try to omit names as a professional courtesy.• References and slides are available upon request.

• However, the content reflects my thoughts, and not necessarily these individuals, anyone else, or any organization.

Acknowledgments

DisclosuresDr. Brown has received travel expenses from Academy of Nutrition and Dietetics, Alberta Milk, American Heart Association, DC Metro Academy of Nutrition and Dietetics, Federation of American Societies for Experimental Biology, and International Life Sciences Institute; speaking fees from Academy of Nutrition and Dietetics, Alberta Milk, American Society for Nutrition, Birmingham District Dietetic Association, International Food Information Council, and Rippe Lifestyle Institute, Inc.; monetary awards from Alabama Public Health Association, American Society for Nutrition, and Science Unbound Foundation; and grants from NIH/NIGMS-NIA-NINDS, and UAB NORC. He has been involved in research for which his institution or colleagues have received: unrestricted gifts from National Restaurant Association; and grants from Coca-Cola Foundation, NIH/NIDDK, and PepsiCo.

Smith 2009 J R Soc Med 102 44-45

Conflicts of interest

Genetic Fallacy Guilt by Association

Ad hominem Appeal to Irrelevant Authority

Discounting a result because of from whom or where it came

Discounting a study because of with

who or what the study is associated

Attacking the originator of a study instead of the study itself

Supporting a result with comments from

a respected but unrelated expert

Ali Almossawi https://bookofbadarguments.com/

Conflicts of interest

Given the disclosure below, do you believe the results more or less?

Would you believe the results more or less if they were in the opposite direction?

Funding disclosures impair objectivity

Hypothetical drug studies of varying rigor and disclosed funding.

Disclosure of industry funding vs no disclosure decreased:• ratings of rigor of trials (OR: 0.63 [0.46,0.87])• confidence in the results (OR: 0.71 [0.51,0.98])• willingness to prescribe the hypothetical drugs (OR: 0.68 [0.49,0.94])

Outline

• Introduction

• Messy advice: internally and externally inconsistent narratives

• Beliefs, calls-to-action, and scientific conclusions

• Moving forward

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Definitions

Conflicted narratives occur when a narrative or source is internally inconsistent

Conflicting narratives occur when different compelling narratives disagree, and are therefore externally inconsistent

Incomplete narratives occur when there is a large, conceptual void in the logic or analysis used to make a conclusion

CONCLUSIONS: “These schoolchildren are exposed to an obesogenic environment, and it is not surprising that in this situation, many of these children are already overweight and will likely become obese as adults.”

RESULTS: “Based on our observations, it appears that those who have higher BMIs are less likely to consume fast food as often.”

Conflicted Reports of Research

“Although there is evidence that certain saturated fatty acids (i.e.,

stearic acid) have fewer cholesterol-raising effects than others,

there is no simple means of incorporating this information into

dietary guidelines.”

American Heart Association (2000)

Circulation 102: 2296-2311

“The addition of added sugars to

the Nutrition Facts Panel is a giant

step forward,” said … chair of the

AHA’s nutrition committee

February 27th, 2014

Conflicted standards from trusted sources A little conflicted comic relief

Conflicting recommendations, side-by-side

"Swap that coffee for tea, replace the granola with eggs and wake up 10 minutes earlier. Boom: You just lost 10 pounds this week alone."

• Prepare breakfast the night before• Melt fat with delicious tea• Catch the worm• Give your alarm a label• Let the sunshine in• Drink a glass of water• Use the scale• Meditate• Do a fast workout• Get dressed for breakfast• Eat something• But sit down first• Change things up• Chuck out your sugary cereals• Include protein• But pick the right protein

• Balance that protein with good carbs and fiber

• Head to YouTube• Sprinkle on the pepper• Have protein bars nearby• And keep plenty of apples around• Toss out bagels• Dust on the cinnamon• Consider vegetables• Don’t forgo the yolk• Chase it with a glass of whole milk• Drink coffee• But don’t drink too much• And then get a good night’s sleep• Get it on before you get up

Conflicted and Conflicting Recommendations

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Conflicting teaching and research

Supports Healthy Weight Promotes Obesity

Eating breakfast regularly Sweetened beverage intake

Fruit juice Snacking frequencies on junk food

Eating frequency Time spent watching TV

Dietary variety Dietary fat intake

Dietary fiber Sugar intake

Parental restriction on food Carbohydrates intake

Regular physical activity Frequency of eating away from home

Protein intake Fast food consumption

Reduced fat food products Total caloric intake

Increased fruits and vegetables Portion sizes consumed

Energy density of the diet

“To assess knowledge scores, correct and incorrect answers were tallied for beneficial and detrimental choices on both pre- and post-tests.”

Incomplete by Confounding

• Vegan• Vegetarian• Pesco-vegetarian• Semi-vegetarian• Omnivorous

Diet Plants Eggs/Milk Fish Meat

Vegan

Vegetarian

Pesco-vegetarian

Semi-vegetarian Limited

Omnivorous

Pla

nt-

Bas

ed

Re

stri

ctio

n

Incomplete Recommendations in the Same Magazine

Contributes to heavy metal

poisoning

Binds to the same receptors

as marijuana

Can cause irregular

heartbeat, low blood pressure,

coma, and death

Causes hepatic necrosis in rats

Incomplete in Context

A CornB Alfalfa sproutsC Hot dogsD SpinachE PeachesF BananasG Milk chocolate

Assume you are alone on a desert island for one year and you can have water and one other food. Pick the food that you think would be best for your health (never mind what food you would like). Check the food you would pick.

Which foods should you eat?

Incomplete in Context

0

10

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30

40

50

Corn Alfalfasprouts

Hot dogs Spinach Peaches Bananas Milkchocolate

% o

f R

esp

on

de

nts

StudentsPhysical plant workersNational sampleFacultyStudents (+oranges)

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Incomplete because of irrelevance

Fruit Veg F & V

Weight Change S NS NS

Waist Circumference S NS NS

Risk of weight gain or abdominal obesity

S S S

Mean weight change (high v low)

NS NS NS

• Higher intake of fruits was

associated with decreased weight

• -13.68 g BW/y per 100-g/d in fruit

intake.

100 𝑔 𝐹𝑟𝑢𝑖𝑡𝑑

×365 𝑑𝑦𝑟

−13.68 𝑔 𝐵𝑊𝑑

×1 𝑘𝑔1000 𝑔

=

“Nevertheless, when combined with evolutionary nutrition and epidemiological modeling studies, these findings have public health relevance and support all initiatives to increase fruit and vegetable intake.” (emphasis added)

2.67 tonnes of fruit per 1 kg weight loss per year

Outline

• Introduction

• Messy advice: internally and externally inconsistent narratives

• Beliefs, calls-to-action, and scientific conclusions

• Moving forward

Beliefs, Calls-to-action, and Science

Science: “knowledge about or study of the natural world based on facts learned through experiments and observation”

Belief: “a feeling of being sure that someone or something exists or that something is true” www.merriam-webster.com

www.merriam-webster.com

Call to action: “an instruction to the audience to provoke an immediate response”

en.wikipedia.org

A call to action involves using a belief and value structureto tell others what to do.

Science isn’t required.For science, only three things matter:1. The data2. The methods used to generate the data3. The logic connecting the data to conclusions

Biases in scientific articles may reflect beliefs

“Our findings do not lead to conclude that SSB replacement with water does not support reduction of metabolic syndrome risk factors but rather that intervention provided was ineffective in reducing other sugary beverage intake.”

“… the [water] group increased water intake and decreased SSB intake significantly over time…”

-252 -115

Intervention Control

kcal

/d

9 month change in 'Beverages with Sugar'

Substituting water for sugar-sweetened beverages reduces circulating

triglycerides and the prevalence of metabolic syndrome in obese but not

in overweight Mexican women in a randomized controlled trial.

PMID: 25332472

Meeting abstract presented at Experimental Biology:

Final published paper in the Journal of Nutrition

Title:

Misleadingly citing research

6.2

8.9

7.7

6.0

0

2

4

6

8

10

Bkfst No Bkfst Bkfst No Bkfst

Breakfast No Breakfast

We

igh

t L

oss (kg

)

Breakfast-by-strata interaction: p<0.06.No main effects.

• Schlundt et al. AJCN 1992

• 52 obese adult women assigned to eat or skip breakfast, stratified according to their baseline breakfast-eating habits in a 12 week weight loss study

• Cited by 91 papers in English; 42 ratable

Brown A W et al. Am J Clin Nutr 2013;98:1298-1308

Biases in scientific articles may reflect beliefs Biases in scientific articles may reflect beliefs

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Labeling calories and

removing value pricing on

menu items.

Awareness of calories and

eliminating value pricing will

decrease energy

consumption

Men ate more calories.

Describe certain

restaurants and foods as

more “healthful” and

“low-calorie.”

Decrease caloric consumption

and shift consumption

toward “healthful” foods.

Consumers consumed more calories in side

dishes and beverages, and underestimated

total meal calories when choosing “healthy”

restaurants or main dishes.

Action Good intention Documented unintended consequence

Label “unhealthful” foods

with messages that

encourage consuming

fruits and vegetables.

Increase “healthful”

behaviors and decrease

“unhealthful” behaviors.

Increased selection of an “unhealthful”

snack.

Tax sugar sweetened

beverages (SSBs).

Decrease energy intake to

decrease weight.

Increased consumption of beer beyond the

decrease in sugar sweetened beverages.

Discourage chocolate

consumption.

Decrease caloric

consumption.

Chocolate consumption increased for some

women in some circumstances.

Calls to Action: good intentions with consequences

“Active” Supplement

Perceived Progress

Nougat ConsumptionX

“These thought-provoking findings can serve as a basis for educating the public about the myth that they are free to feel liberated from the need to regulate their eating when using

weight-loss supplements.”

1234567

"Active" Control

Perceived Weight Reduction Progress

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"Active" Control

Nougat Consumed (g)

0

1

2

3

4

"Active" Control

Amount of Sugar Chosen

MediationAnalysis:

p<0.001

p<0.001

p<0.001

Group 1 – Given placebo pillGroup 2 – Given same pill and told it is a weight-loss supplement

Potential consequences of health halos

Simple recommendations for complex concepts

Which has the greatest empty calories?

A 5 ounces of table wineB 2 x 1 ounce patties of pork sausage

C 3 ounces of roasted chicken thigh with skin (cooked weight)

D 1 cup of frozen yogurt

E 3 ounces of regular, 80% lean ground beef (cooked weight)

F 1 medium, 2 ounce croissant

G 1 cup of fruit flavored, low-fat yogurt

H 1 small, 2 ounce blueberry muffin

I 3 x 1 ounce slices of beef bologna

“It is important to limit empty calories to the amount that fits your calorie and nutrient needs. You can lower your intake by eating and drinking foods and beverages containing empty calories less often or by decreasing the amount you eat or drink.”

http://www.choosemyplate.gov/weight-management-calories/calories/empty-calories.html

Age and gender Total Empty Percent

Females 31-50 yrs 1800 160 9%

Males 31-50 yrs 2200 265 12%

FoodTotal

CaloriesEmpty

CaloriesPercent

Empty

A 5 ounces table wine 121 121 100

B 2 x 1 oz. patties of pork sausage 204 96 47

C 3 oz. roasted chicken thigh w/ skin 209 47 22

D 1 c. frozen yogurt 224 119 53

E 3 oz. regular, 80% lean ground beef 229 64 28

F 1 medium, 2 oz. croissant 231 111 48

G 1 c. fruit flavored, low-fat yogurt 250 152 61

H 1 small, 2 oz. blueberry muffin 259 69 27

I 3 x 1 oz. slices of beef bologna 261 150 57

Simple recommendations for complex concepts

Recommendations

Study Cross-over Length (days) Body weight BMI BF WC Other

Bertéus Forslund 2008 365 NS

Poston 2005 168 NS

Tey 2011 84 NS NS NS NS NS

Zaveri 2009 84 NS NS NS NS NS

Vander Wal 2006 56 NS NS NS

Viskaal van Dongen 2010 56 NS NS

Waller 2004 28 NS

Whybrow 2007 x 14 NS

Johnstone 2000 x 9 NS

Obesity outcome

0

1

2

3

4

5

6

7

8

9

Cross Sectional Longitudinal Cross Sectional Longitudinal

Children Adults

Nu

mb

er

of

Stu

die

s

Positive

Null

Negative

Adapted from Mesas et al Obesity reviews 2012

Associations between snacking and weight.

Effects of snacking on weight.

Slide adapted from Allison, Lewis, and Brown presentation (2014)

Snacking: simple or complex concept?How Researchers Define Snacks and Meals• By time: 8-10AM, 12-2PM, and 6- 8PM = meals; Other times = snacks

• By food composition/type: Based on ‘taxonomy’ of food, or calories in

eating occasion

(Gergori et al, 2011; Gregori, & Maffeis, 2007)

How Individuals Define Snacks and MealsMeal Related-Perceptions Snack Related-Perceptions

Eating with family vs. Eating alone

Cloth napkin vs. Paper napkin

Sitting while eating vs. Standing while eating

Expensive vs. Inexpensive

Prepared food vs. Packaged food

‘Healthy’ food vs. ‘Unhealthy’ food(Adapted from Wansink et al, 2010. Appetite. 54(1), 214-16)

Implications for advice about snacks and meals?

Slide adapted from Allison, Lewis, and Brown presentation (2014)

Definitions are Important

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Fruits and Vegetables: Language is Important Language is Important: Headlines vs Study

May disagree with recommendations… and each other

Effect of the Healthy Schools Program on Prevalence of

Overweight and Obesity in California Schools, 2006–2012

Study

• “Analyses showed no difference between Healthy School Program schools and control schools in overweight and obesity prevalence”

• “Healthy School Program appears to be an important means of supporting schools in reducing obesity…”

“Now, as the Alliance celebrates its 10-year anniversary, a new peer-

reviewed study confirms we are delivering on our mission of reducing

the prevalence of childhood obesity.” http://www.wassermanfoundation.org/news/new-study-shows-that-

combating-childhood-obesity-in-schools-works/

http://www.cdc.gov/pcd/issues/2015/15_0020.htm

Conclusion spinning to inspire action

Headline

Outline

• Introduction

• Messy advice: internally and externally inconsistent narratives

• Beliefs, calls-to-action, and scientific conclusions

• Moving forward

A lemon market will be produced by the following:• Asymmetry of information, in which no [reader] can accurately assess the value

of [research] and [communicator] can more accurately assess the value

• An incentive exists for the [communicator] to pass off a low-quality product as a higher-quality one

• [Communicators] have no way to disclose credibility to [readers]

• [Readers] are sufficiently pessimistic about [research] quality

• Deficiency of effective public quality assurances

Bolstering Science and Science Communication

Adapted from Cottrell 10.1177/1747016113494651,Akerlof 1970, and Wikipedia

An Economics Analogy: Lemon Markets

“The valuable capacity of the human mind to simplify a complex situation becomes dangerous when not controlled in terms of definitely stated criteria.”

– Simon Kuznets, 1934

Adapted from: Brown A W et al. Am J Clin Nutr 2013;98:1298-1308

Thinking about food

Food X is Bad!

Food X is Bad!

Food Xis

BAD!

Food X is OKAY

0

20

40

60

80

100

0 50 100

Ce

rtai

nty

(%

)

Studies

Strength of Belief

Strength of Evidence

Discarded information

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Resources

www.senseaboutscience.org

https://bookofbadarguments.com/

www.nhs.uk/News/Pages/NewsIndex.aspx

www.healthnewsreview.org

Latest obesity and energetics researchwww.obesityandenergetics.comhttp://nationalpress.org/

Conflicting, conflicted, and incomplete narratives in nutrition and obesity research

Andrew W Brown, PhD

awbrown@uab.edu

@andrewbrownphd