In the Eye of the Beholder: Critical Evaluation of Nutrition Research will begin at the top of the hour

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1 NUTRI-BITES Webinar Series In the Eye of the Beholder: Critical Evaluation of Nutrition Research will begin at the top of the hour Audio for today s presentation is being broadcast over your computer speakers, so be sure they are turned on and the volume is up Today s presentation in handout form can be downloaded from: (type in your browser) NUTRI-BITES Webinar Series In the Eye of the Beholder: Critical Evaluation of Nutrition Research March 12, 2015 Presenter: Andrew W. Brown, PhD Nutrition & Obesity Research Center - Office of Energetics University of Alabama at Birmingham Moderator: James M. Rippe, MD Leading cardiologist, Founder and Director, Rippe Lifestyle Institute Approved for 1 CPE (Level 2) by the Commission on Dietetic Registration, credentialing agency for the Academy of Nutrition and Dietetics. Celebrate National Nutrition Month! Thank you Registered Dietitian Nutritionists and Dietetic Technicians, Registered for all you do! 1

2 ConAgra Foods Science Institute With a mission of: Promoting dietary and related choices affecting wellness by linking evidence-based understanding with practice Webinar logistics CEUs a link to obtain your Continuing Education Credit certificate will be ed and available on this webinar s page at within 2 days. A recording of today s webinar, slides, and summary PowerPoint will be available to download as a PDF within 2 days at: The presenter will answer questions at the end of this webinar. Please submit questions by using the Chat dialogue box on your computer screen. Today s Faculty Andrew W. Brown, PhD Nutrition & Obesity Research Center Office of Energetics University of Alabama at Birmingham Moderator: James M. Rippe, MD Leading cardiologist, Founder and Director, Rippe Lifestyle Institute 2

3 Learning Objectives NUTRI-BITES Webinar Series Critical Evaluation of Nutrition Research Review potential influences of biases in nutrition research Discuss the importance of critically evaluating new research (i.e. whether it confirms or refutes standard clinical practice or commonly held beliefs) Describe steps to minimize misinterpretation of research Identify strategies health professionals can use to objectively translate scientific knowledge to clinical practice In the Eye of the Beholder: Critical Evaluation of Nutrition Research Andrew W Brown, Ph.D. 2015, awbrown@uab.edu Acknowledgments and Disclosures I am involved with research funded by the National Institutes of Health and the non profit Coca Cola Foundation. UAB has received funding or gifts from numerous sources. Colleagues who may have helped with slides David B Allison Patrice Capers Ed Archer Kathryn A Kaiser Michelle M Bohan Brown Dwight Lewis The contents of this presentation represent my views and do not necessarily reflect the views of UAB or my colleagues. Full citations and slides are available upon request. 3

4 Outline How do we know about nutrition? Critically evaluating research to minimize misinterpretation What exactly was studied? How exactly was it studied? How does that compare to how it was communicated? Translating science to clinic or policy How do we know things in Nutrition Science? Wesleyan Quadrilateral Reason Scripture Tradition Experience How do we know things in Nutrition Science? Nutrition Quadrilateral Reason Research Tradition Experience The quadrilateral requires of a [nutrition scientist] no more than what he or she might reasonably be held accountable for: which is to say, a familiarity with [scientific literature] that is both critical and faithful; plus, an acquaintance with the wisdom of [nutrition science history]; plus, a taste for logical analysis as something more than a debater s weapon adapted from Outler. Wesleyan Theological Journal. 1985;20:1,p17 4

5 Are we using the same language? Word Definition 1 Definition 2 Nutritive Containing micronutrients Containing calories Significant Important P<0.05 Reduce Decrease Gaining electrons Toxicity Acutely hazardous Capacity to cause harm Uncertainty Anything is possible Constraining the known Diet Restrictions on eating Eating behaviors behaviors Bias Mathematical deviation from true results Human distortion Abstract concepts How Researchers Define Snacks and Meals By time: 8 10AM, 12 2PM, and 6 8PM =meals; Other times = snacks (Gregori et al, 2011; Gregori, & Maffeis, 2007) By food composition/type: Based on taxonomy of food, or calories in eating occasion Abstract concepts How Researchers Define Snacks and Meals By time: 8 10AM, 12 2PM, and 6 8PM =meals; Other times = snacks (Gregori et al, 2011; Gregori, & Maffeis, 2007) By food composition/type: Based on taxonomy of food, or calories in eating occasion How Individuals Define Snacks and Meals Meal 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, Appetite. 54(1), ) 5

6 Nebulous Descriptors of Food Euphemisms for Bad Foods Over Time Counts/Year Food The common fruits, because of their low nutritive value, are not, as a rule, estimated at their real worth as food. USDA Farmer s Bulletin, 1917 We encourage parents to stop serving cheese, meat, and other junk foods to children Physicians Committee for Responsible Medicine, 2012 Custom searches of How we each see nutrition 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. ACorn BAlfalfa sprouts CHot dogs D Spinach E Peaches F Bananas GMilk chocolate How we each see nutrition % of Respondents Students Physical plant workers National sample Faculty Students (+oranges) 0 Corn Alfalfa sprouts Hot dogs Spinach Peaches Bananas Milk chocolate 6

7 Outline How do we know about nutrition? Critically evaluating research to minimize misinterpretation What exactly was studied? How exactly was it studied? How does that compare to how it was communicated? Translating science to clinic or policy What exactly are we comparing? or The Tale of Two Cheese Sandwiches What exactly are we comparing? or The Tale of Two Cheese Sandwiches Whole Food Processed Food Bread Multi grain bread with whole sunflower seeds and wholegrain White bread kernels Cheese Cheddar cheese Processed cheese product Fat 17.5 g 14.5 g Protein 20 g 15 g Carbohydrates 40 g 49.5 g Sandwich 2 slices of bread 2 slices of cheese 3 slices of bread 2.28 slices of cheese 7

8 Modeling potential effects of reduced calories in kids' meals with toy giveaways Are assumptions adequate? Order of magnitude VS misestimation of weight effects of children s meal policy proposals Differential weight (lbs) from age 6 12 (6 years) kcal/meal Model 3500 kcal Hall et al kcal Hall et al kcal Hall et al. Fast food/wk Brown et al. Child Obes Dec;10(6):544 5 Original paper PMID: Modeling potential effects of reduced calories in kids' meals with toy giveaways Are assumptions adequate? Order of magnitude VS misestimation of weight effects of children s meal policy proposals Differential weight (lbs) from age 6 12 (6 years) kcal/meal Model 3500 kcal Hall et al kcal Hall et al kcal Hall et al. Fast food/wk The purpose of this collection is to make information on obesity prevention policies and the underlying evidence base easily searchable and accessible. Brown et al. Child Obes Dec;10(6):544 5 Original paper PMID: Are the methods good enough? DIET Usual American NCEP Step II Very Low Fat Energy Fat SFA MUFA PUFA Cholesterol Carbohydrate Protein Fiber Fat (% EI) SFA (% EI) MUFA (% EI) PUFA (% EI) Carbohydrate (% EI) Protein (% EI) Percent under (BLUE) or over (RED) estimation of dietary components with semiquantitative FFQ Bold/outlined cells significant at p<0.05 8

9 Are the methods good enough? TEE = Total Energy Expenditure, measured by doubly labeled water EI = Energy Intake estimated by FFQ Dietary patterns determined by cluster analysis of FFQ 1 Ratio of EI to TEE Mean (95% CI) 0 Difference Between EI and TEE Mean (95% CI) EI/TEE EI TEE (MJ/d) Sweet Starchy Healthy 0 8 Are the methods good enough? JADA, January 1953 kcal/d Self reported and Observerestimated Energy Intake 1 day food record Research dietary history It appears, therefore, that, unless special precautions are applied to the study of the fourth of the adult population which is overweight, any data collected on the caloric intake of populations by the record method is likely to be an underestimate. 0 Normalweight Overweight Are the methods good enough? JADA, January 1953 kcal/d Self reported and Observerestimated Energy Intake 1 day food record Research dietary history It appears, therefore, that, unless special precautions are applied to the study of the fourth of the adult population which is overweight, any data collected on the caloric intake of populations by the record method is likely to be an underestimate. 0 Normalweight Overweight We offer the contrary view that [self report measures of EI] are so poor as measures of actual EI that they no longer have a justifiable place in scientific research aimed at understanding actual EI... N.V. Dhurandhar et al., Int J Obes (Lond) Nov 13 9

10 What do we do with these problematic data? Dietary Guidelines for Americans 2015 Dietary Guidelines Advisory Committee Report Most of the DGAC data analyses used the National Health and Nutrition Examination (NHANES) data and its dietary component, What We Eat in America (WWEIA) (Appendix E 4) Many recommendations to expand questionnaires. Bias in Media Exposure Media II 3 3% III 5% I 17% II 1 7% II 3 1% III 8% I 40% High Impact Journals II 2 68% II 2 51% II 1 0% Hierarchy of research designs I Properly randomized controlled trial. II 1 Well designed controlled trials without randomization. II 2 Well designed cohort or case control analytic studies. II 3 Time series with or without the intervention. III Opinions. Media Cover Inferior Study Designs What s Being Published? Studies indexed in PubMed 40,000 30,000 20,000 Nutrition Related Studies: 886,658 In humans: 433,131 RCTs: 31,848 10,

11 Bias Presented to the Public Spin: specific reporting strategies, intentional or unintentional, emphasizing the beneficial effect of the experimental treatment Spin perpetuates throughout the reporting Biasing Interpretations of Own Results Selective Reporting Abstracts were categorized based on results and conclusions about breakfast and obesity Pro Breakfast Results Not Pro Breakfast Results 35% 65% Mentioned in Conclusions 78% 22% Not mentioned in conclusions Breakfast was more likely to be mentioned in conclusions if results were pro breakfast (p=0.0492) Brown A W et al. Am J Clin Nutr 2013;98: Meeting abstract presented at Experimental Biology: Stubborn Preconceptions 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. 11

12 Meeting abstract presented at Experimental Biology: Stubborn Preconceptions 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. Final published paper in the Journal of Nutrition 9 month change in 'Beverages with Sugar' kcal/d Intervention Control the [water] group increased water intake and decreased SSB intake significantly over time Title: 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: Conclusions not matching results RESULTS: Based on our observations, it appears that those who have higher BMIs are less likely to consume fast food as often. 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. PMID: Outline How do we know about nutrition? Critically evaluating research to minimize misinterpretation What exactly was studied? How exactly was it studied? How does that compare to how it was communicated? Translating science to clinic or policy 12

13 Simple terms for complex concepts Which of the following has the greatest number of empty calories? A B C D E F G H I 5 ounces of table wine 2x 1 ounce patties of pork sausage 3 ounces of roasted chicken thigh with skin (cooked weight) 1cup of frozen yogurt 3 ounces of regular, 80% lean ground beef (cooked weight) 1 medium, 2 ounce croissant 1 cup of fruit flavored, low fat yogurt 1 small, 2 ounce blueberry muffin 3x1 ounce slices of beef bologna Simple terms for complex concepts Food Total Empty Percent Calories Calories Empty A 5 ounces table wine B 2 x 1 oz. patties of pork sausage C 3 oz. roasted chicken thigh w/ skin D 1 c. frozen yogurt E 3 oz. regular, 80% lean ground beef F 1 medium, 2 oz. croissant G 1 c. fruit flavored, low fat yogurt H 1 small, 2 oz. blueberry muffin I 3 x 1 oz. slices of beef bologna management calories/calories/empty calories.html Simple terms for complex concepts Food Total Empty Percent Calories Calories Empty A 5 ounces table wine B 2 x 1 oz. patties of pork sausage C 3 oz. roasted chicken thigh w/ skin D 1 c. frozen yogurt E 3 oz. regular, 80% lean ground beef F 1 medium, 2 oz. croissant G 1 c. fruit flavored, low fat yogurt H 1 small, 2 oz. blueberry muffin I 3 x 1 oz. slices of beef bologna Age and gender Total Empty Percent Females yrs % Males yrs % management calories/calories/empty calories.html 13

14 Being cognizant of our own humanity Certainty (%) Strength of Belief Strength of Evidence Studies Food X is OKAY Discarded information Food X is Bad! Food X is BAD! Food X is Bad! Adapted from: Brown A W et al. Am J Clin Nutr 2013;98: Anecdote vs Data Often impossible to tell if something worked for an individual (e.g., responders vs non responders) Improvements could have been spontaneous Improvements may have been better with another option Impairments may have been mitigated Anecdote vs Data Often impossible to tell if something worked for an individual (e.g., responders vs non responders) Improvements could have been spontaneous Improvements may have been better with another option Impairments may have been mitigated Scientific investigation tells us whether, on average, a group does better under one condition than another RCTs in particular tell us whether a change in exposure causes a change in outcome The plural of anecdote is not data 14

15 Nutrition Quadrilateral Reason Clinic, Policy, or Science? Research Tradition Experience Resources In the Eye of the Beholder: Critical Evaluation of Nutrition Research Andrew W Brown, Ph.D. 2015, awbrown@uab.edu 15

16 Questions? NUTRI-BITES Webinar Series Critical Evaluation of Nutrition Research Based on this webinar the participant should be able to: State potential influences of biases in nutrition research Discuss the importance of critically evaluating new research (i.e. whether it confirms or refutes standard clinical practice or commonly held beliefs) Describe steps to minimize misinterpretation of research Identify strategies health professionals can use to objectively translate scientific knowledge to clinical practice ConAgra Foods Science Institute Nutri-Bites Webinar details A link to obtain your Continuing Education Credit certificate will be ed within 2 days Today s webinar, including certificate link, will be available to download within 2 days at: For CPE information: acontinelli@rippelifestyle.com Recent CEU webinars archived at the ConAgra Foods Science Institute website: Functional Foods: Phytochemicals Hidden Nutrition Gems Sodium: Too much, too little or just right? A Decade of Nutrigenomics: What Does it Mean for Dietetic Practice? Ethics for All: Applying Ethics Principles across the Dietetics Profession Sports Nutrition: The Power to Influence Exercise Performance Culinary Competency to Enhance Dietetic Practice 16

17 Next ConAgra Foods Science Institute Nutri-Bites Webinar Nutrition Support for the Bariatric Surgery Patient: When and Why Nutrition Support is Needed Kellene A. Isom, MS, RD, LDN Bariatric Program Manager and Senior Bariatric Dietitian AND Kris M. Mogensen, MS, RD, LDN, CNSC Team Leader Dietitian Brigham and Women's Hospital Boston, MA Date: May 6, pm EDT/1-2 pm CDT How are we doing? Stay on the line for a brief survey about today s ConAgra Foods Science Institute Nutri-Bites webinar: Critical Evaluation of Nutrition Research Thank you! 17