Public health dogmatism versus the lived experience

5 minute read

Clinical Evidence Based

By

Dr Joe Kosterich

While remaining the official gold standard for evidence, we must acknowledge RCTs have their limitations, writes Dr Joe Kosterich

Sometimes a person with cancer goes into remission and we do not know why. This does not mean it has not occurred. We don’t criticise them or suggest it better they went out of remission.

A 2003 BMJ paper systematically reviewed trials of whether parachutes were effective in preventing trauma related to gravitational challenge. It found this had not been subjected to rigorous evaluation using randomised control trials.

Oh dear!

A conflict can arise when the lived experience of the individual (or the obvious), has not been demonstrated in randomised control trials. While remaining the official gold standard, they have limitations and there are other, as valid ways, of assessing clinical outcomes.

Yet the public health establishment increasingly rejects them and seeks to shut down any dissent. Sometimes using lawfare.

Editor, Richard Horton wrote in The Lancet: “Public health science needed to pay more attention to the lived experiences of people in societies.”   

A famous paper by John Ioannidis of Harvard looked at 49 of most highly regarded and influential studies of the previous 13 years. On retesting, 41% were wrong or significantly exaggerated. A paper published in March this year showed trials were subject to bias and this was generally hidden or ignored.

Most public health recommendations are based on epidemiological studies, also subject to bias and being wrong.

Remember, too, that most patients in general practice bear no resemblance to trial populations.

The Medical Republic, on January 18, reported only 5% of those with asthma would be accepted into trials of asthma medications. A different approach was the pragmatic evaluation trial (PET) where real world assessment of 4223 patients was done without exclusions. The results are far more applicable in the real world.

All this debate is fine – except when we reject the lived experience of the individual who has improved their health without a trial to back them. We can rightly say there is no trial evidence, but there is no excuse for the vitriol directed at these patients (and their healthcare supporters) who have found a way that works for them, especially when our current views are as likely to be wrong as to be right.

The most egregious example of this is the diet wars between supporters of low fat dietary guidelines (introduced without any actual evidence) in the early 1980s, and those advocating a low carb diet. Food sales show that the public has followed the guidelines. Obesity and type 2 diabetes rates have increased over the same time. Yet public health blames the public for not being compliant. 

There actually is significant evidence for a low carb approach in weight management and type 2 diabetes. Recent work confirmed that a lower carb diet improves control in type 1 diabetes. Yet many on a low carb diet who improved their diabetes markers report being told to increase their carb intake and “balance” with insulin. This is a bit like having a fire and being told to pour petrol on it and “balance” with water.

AMSL Diabetes Ambassador Neil McLagan, who has type 1 diabetes, rode a push bike from Perth to Sydney on a low carb diet, showing what can be done. 

Similarly, what of the person on a ketogenic or (shock horror) a paleo diet, who reports improved energy levels or reduced aches and pains?  Do we ignore this? Do we tell them to eat more carbs? Do we abuse them for being whacko? Sadly, the mainstream approach is all of the above, because the lived experience does not matter. 

Radiologist and blogger Dr Saurabh Jha wrote: “Science is at its weakest when scientists are most certain and the science is settled.”  

A plenary speaker at the Dietitians Australia Conference in May tweeted she found the best track change EVER (sic) when seeing members of the LCHF (low-carb, high-fat) community described as “7 letters … begins with a w…” rather than non-conformists. Charming! She deleted it and apologised – but the attitude was evident. Defiance is to be condemned. New ideas are not welcome.

This typifies the public health establishment approach to those findings that ignoring official dietary advice improves their health. How dare you ignore us and improve your health?

Surely, we can be more open minded to the lived experience?

The last word goes to Richard Horton: “Public health today is crudely reductionist, often ignoring or denying the lives of those it purports to defend. Public health has evolved into an elitist endeavour, more concerned with its own power, reputation and survival.”

Dr Joe Kosterich is a Perth-based general practitioner. You can read more at drjoetoday.com

References:

1. https://www.kevinmd.com/blog/2017/06/science-hijacked-puritans-needs-rescuing-heretics.html 

2. https://www.theatlantic.com/magazine/archive/2010/11/lies-damned-lies-and-medical-science/308269/ 

3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1182327/ 

4. https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(18)30304-0.pdf 

5. http://medicalrepublic.com.au/randomised-controlled-trials-case-false-idols/12561 

6. https://www.tandfonline.com/doi/full/10.1080/07853890.2018.1453233 

7. http://bjsm.bmj.com/content/51/10/769 

8. https://www.bmj.com/content/327/7429/1459 

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Rosemary Stanton
Rosemary Stanton
6 years ago

Could you please explain your statement that “food sales show that the public has followed the guidelines”. The ABS reports that “Most Australians do not meet the minimum recommended serves for the five major food groups” (1). Only 4% of Australians follow the guideline about vegetables. Almost one in three consume the minimum recommended number of serves for fruit (2 pieces/day) and grains (varies with age and activity level), but one-third of the fruit serves was from juice and dried fruit (recommended only occasionally and juice at just 125 mL/serve) and two-thirds of the grains and cereals were from refined grains rather than the whole grain varieties recommended in the guidelines (1).

Note too that nutrient-poor, energy dense foods (specifically listed as foods for which many Australians have no room) now contribute 35% of adults’ and over 40% of children’s energy intake (1).

Data from the Australian Health Survey found of the 58 per cent of the average household food budget was spent on ‘unhealthy’ foods not recommended in the guidelines. (2)

The dietary guidelines are based on foods, not fats or carbs. Such delineation is way too gross. The guidelines recommend healthy foods that contain fats, including fish, nuts, seeds, avocado, olive and other liquid oils and modest amounts of meats, chicken, milk, cheese and yoghurt. They also recommend wholegrains, fruits, legumes, vegetables, milk and yoghurt as healthy sources of carbohydrate. Foods that are high in fat and/or carbohydrate are not recommended. These include soft drinks and cordials, energy drinks, vitamin waters, cakes, biscuits, confectionery, pies and pastries, many sugary desserts, chips, crisps and savoury snack foods and most take-away foods.

(1) http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4364.0.55.012~2011-12~Media%20Release~Australians%20failing%20to%20meet%20dietary%20guidelines%20(Media%20Release)~18
(2) https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-2996-y

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Joe Kosterich
Joe Kosterich
Reply to  Rosemary Stanton
6 years ago

Food sales figures from USA https://ninateicholz.com/new-us-food-availability-data/
Australian figures comprable. People have followed the low fat dietary guidelines of big public health – to their detriment. I am not hearing any apology – just a blaming of the public for doing what they were, wrongly, told.

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Malcolm Mackay
Malcolm Mackay
6 years ago

The claim that public health advice to reduce fat intake contributed to an increase in obesity and diabetes is mischevious. US data shows that dietary fat intake increased every decade from 1950 through to 2010.

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Malcolm Mackay
Malcolm Mackay
6 years ago

Several studies have found that low carbohydrate diets are associated with increased mortality. Patients should be informed of this side effect.

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Dr John Barr
Dr John Barr
6 years ago

41% is nearly a half. Factor in the fact that trials funded by industry are suspiciously likely to find in favour of the drug, and we don’t know who to believe.
We will need to listen to the “experts”.
Oh, they only have access to the same probably skewed/biased/possibly non-reproducible/possibly frankly fraudulent information that I have. Since I see thousands of patients per year, and therefore am really my own PET, that probably makes me more of an “expert” than the “experts”.

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