Episode 173: This week's episode is an interview with PhD candidate, Alan Flanagan. This wide-ranging interview touches on the differences between biomedical science and nutrition, the problem with many so-called nutrition "experts", what happens when your beliefs become your identity, and the challenges of making nutrition recommendations at the population level.
Alan is currently pursuing his PhD in nutrition at the University of Surrey, having completed a Masters in nutrition science at the same institution.
Originally a lawyer by background in Dublin, Ireland, Alan combines an investigative and logical approach to nutrition together with advocacy skills to communicate the often-complicated world of nutrition science, and is dedicated to guiding healthcare professionals and the lay public in science-based nutrition.
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Chris Sandel: Welcome to Episode 173 of Real Health Radio. You can find the links talked about as part of this episode at the show notes, which is www.seven-health.com/173.
Welcome to Real Health Radio: Health advice that’s more than just about how you look. Here’s your host, Chris Sandel.
Hey, everyone. Welcome back to another episode of Real Health Radio. As I’m recording the intro to this podcast, I’ve just gone through all the applications for the new practitioner position, and I’m recording this a couple of weeks before this episode’s going to go out, so by the time you’re hearing this, the interview process should be over and we’ll have a new practitioner at Seven Health.
But I just want to mention how floored I’ve been with the responses, both in terms of the number of people who applied, but also the quality of applications. People with huge amounts of experience and really solid training. I didn’t really know what to expect when I first advertised the position. I knew that I wanted to find the right person and that if I didn’t get the right kind of applicants, I wasn’t going to just fill the role for the sake of doing it. But to say that I’m pleasantly surprised is a huge understatement.
So I’m hoping in a couple of weeks, I’ll have someone else who’s able to help share the workload with seeing clients. If you shared the job spec with anyone, I just want to say thank you so much for doing so. Many of the applicants who applied started their email by saying that they had been forwarded the job spec by a friend or a colleague. It’s wonderful to know the power of this podcast and asking for help from the masses. So thank you for all that.
This week on the podcast, I’m chatting with Alan Flanagan. Alan is currently pursuing his PhD in nutrition at the University of Surrey, having completed a Master’s in nutritional science at the same institution.
Originally a lawyer by background in Dublin, Ireland, Alan combines an investigative and logical approach to nutrition together with advocacy skills to communicate the often-complicated world of nutrition science, and is dedicated to guiding healthcare professionals and the lay public in science-based nutrition.
I’ve only fairly recently become aware of Alan. I’m not sure who recommended that I check out the Cut Through Nutrition podcast. It was launched in June of this year and is co-hosted by Alan and Dr. Joshua Wolrich. I think there’s six episodes in Season 1, and I must have listened to them in a matter of days when I found it.
This episode is probably a little different to the focus of most of my shows these days. Real Health Radio, when it first started out, was a lot more focused on nutritional science, but over the last couple of years, there’s been much more of a push or a focus on eating disorders and disordered eating and recovery. Except maybe for some of the more recent second edition episodes, nutrition science just doesn’t feature as heavily as it used to.
I know on some of the recent episodes as well – I think I mentioned with Marci Evans and with Tracy Brown, I actually spend a lot less time reading about this as a topic. While that is true, it definitely hasn’t lost an interest. It’s something I’m still very passionate about and interested in.
That’s what this episode is more about: looking at the state of nutrition science. We hit on understanding research, so topics like the hierarchy of scientific evidence, the difference between biomedical science and nutritional science, the problem of meta-analyses and systematic reviews in nutritional science, and the importance of observational studies in nutrition and what it means to be evidence-based. Then we chat about public health nutrition and the challenges that it faces.
Alan does a really fantastic job here talking about this, because he’s got a very good skill of being able to see multiple perspectives at once, and the strengths and weaknesses of different views. While I think we all have biases, at least Alan’s biases seem to have taken in many points of view, and he seems very objective and levelheaded in his assessment. I thoroughly enjoyed this episode. Even when we stopped recording, Alan and I continued chatting for quite a long time afterwards.
As I said, this is a little bit of a detour from what the podcast is often covering, but no less important, and it’s a great antidote for the hyperbole and the nonsense that is often circulating in the nutrition health world. Alan does enjoy an expletive, so there is some swearing in this one, just so you know. But let’s get on with the show. Here is my conversation with Alan Flanagan.
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Hey, Alan. Thanks for coming on the show today.
Alan Flanagan: Hey, Chris. Thanks for having me on.
Chris Sandel: I’m a big fan of your podcast, Cut Through Nutrition. That’s how I found you, the podcast that you do with Joshua Wolrich. You’ve done a really great job in the first season, so I’m looking forward to whatever comes up in Season 2.
Alan Flanagan: The second season, we’ve actually just brainstormed over some pizza and wine last week. Our goal with the first season was to very much have a broad introduction, but really talk through some of the more specific issues of why we have such a fractured discourse in nutrition right now. But we do want it to be a resource for practitioners in the healthcare space generally, to have something that they can be like, “I’m really confused about all the screaming about fat and heart disease or sugar and diabetes. Where can I go?”
What we’re doing with the subsequent seasons is focusing on a specific health condition. So Season 2 is going to be cardiovascular/coronary heart disease, and we’re going to go right the way back to the 1950s, the historical context, because there’s a lot of narratives around that in terms of “fat was demonized mistakenly.” Then you go back to the ’50s research and you’re like, “this is really persuasive evidence.”
Then we’re just basically going to go through all of the various parameters of nutritional determinants of heart disease, and also nutritional determinants of lowering heart disease risk. So we’re looking forward to it. We’ll get recording in the next couple of weeks, and we should have episodes out this side of Christmas.
Chris Sandel: Awesome. That’s really good to hear. I think a lot of today’s conversation is going to be probably ideas that you’ve touched on as part of that first season. Topics around nutrition research and understanding research and public health nutrition and socioeconomics and the intersection between those two.
I guess as a starting place, do you want to give listeners a bit of background on yourself? You’re a lawyer/nutritionist, which is an unusual combination.
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Alan Flanagan: Yeah, formal lawyer. I have a bit of a bizarre background. I wanted to be a lawyer coming out of school, but I wasn’t entirely sold on it. I majored in History & Classics and English. Then I did law, and then I started practice in 2009. I was at that for about 9 years.
But I had this real passion for nutrition in the background. I think maybe being a lawyer, I was drawn to “how can I find out facts?” I started delving into PubMed and becoming one of those annoying citizen scientists. [laughs] Eventually realized there’s a limit to self-learning in any discipline, and I started a Master’s program at the University of Surrey, where thankfully they unofficially keep a few spaces for people from non-biosciences undergrads.
So I got in, and it really was this accelerated curve that made me fall more in love with the science and the learning process, and wanted to get into research. Law is always kind of there. So I left law last year and committed full-time to a PhD, still at the same university. Very grateful to Surrey for giving a random lawyer from Dublin an opportunity to pursue what has now become my real passion.
Chris Sandel: Where are you with the PhD? How much longer have you got?
Alan Flanagan: I’m finishing my first year now. Two more years to go. We did a controlled trial this year. I’m looking at what’s known as chrono-nutrition. A bit of an overlap between chronobiology, so biological timing, and food intake, and how when we eat during the day or how we distribute energy influences health.
Chris Sandel: Is that connected with sleep as well, or is it more just timing the food?
Alan Flanagan: Sleep is a part of our overall 24-hour circadian rhythm. “Circadian,” the etymology of it, is “around the day.” So these are internal, biological rhythms that run around 24 hours. Humans, they’re slightly longer. We have external cues. Our exposure to light during the day or when we eat helps sync those rhythms to the actual 24-hour clock.
Sleep obviously is 8 hours, give or take, out of our 24. It’s a third of our day. It is an important part of it. I’m not looking at sleep specifically, but I am looking at things like social jetlag, which is the difference between how long someone sleeps during the week when an alarm forces them out of bed versus how long they would sleep on their free days, when they’re able to go to bed and wake on their own internal rhythms.
There’s some research suggesting that the more you have a disconnect between your internal – some people are later types, evening types. If you are an evening type, you’re more prone to this disconnect because school start times, work start times don’t tend to take into account that you’re an evening type, unfortunately. So we’re looking more at how people eat across the day and how that influences their health.
Chris Sandel: Yeah. I’ve seen recommendations around for school kids, especially as they’re teenagers, that actually the school day should start more at 10 a.m. or 11 a.m.
Alan Flanagan: One hundred percent.
Chris Sandel: Because that’s when they should be waking up later.
Alan Flanagan: Yeah. Teenagers from about 12 to 20-ish, give or take, will have what’s known as a phase delay. Their internal rhythms delay somewhat. How we know that is what’s called their midpoint of sleep. Your midpoint of sleep is the midpoint between when you would naturally go to sleep and when you would naturally wake.
So if we took a bunch of kids and didn’t force them awake – on weekends when people are like, “oh, lazy teenagers,” it’s like, no, they really just do sleep till 9-10 a.m. because they have this delay and their midpoint of sleep won’t be until maybe 6:00 in the morning, whereas we’re waking them up at 5:00-6:00. We’re literally dragging them out of bed. There’s been a couple of really cool pilot studies in schools that delayed the start time, and the difference in test scores was pretty night and day.
I think as a society, we’ve tended to have our structures dictated by virtue of the Industrial Revolution, and now that we’re in the Technological Revolution, I think we really need to start thinking about how we structure and organize our time so that we can better serve people’s health. Some companies now – you know, the cool, millennial-style companies like Facebook and Google or whatever – are letting people work to their own preferences, so to speak.
Chris Sandel: Although they’re normally working people into the ground.
Alan Flanagan: That’s it.
Chris Sandel: Winning in one way, losing in another.
Alan Flanagan: We’re still going to drag 70 hours out of you a week. [laughs]
Chris Sandel: Yeah. I’m reading Matthew Walker’s Why We Sleep book at the moment, which is really fascinating.
Alan Flanagan: It is. I think he did an amazing job of – a lot of scientists are poor communicators, I guess, to the lay public. For such an incredibly distinguished scientist, he did an amazing job with that book of making it really accessible, and his use of analogies was excellent.
The one criticism I would have about it – and this is probably where his purely academic side came through – is in terms of practical advice, it was about as useful as a shit-flavored lollipop. It was basically like “Sleep, do what I say or you’ll die. Cut out caffeine, cut out wine, never stay up.” [laughs] It was very didactic and it was very impractical, I think. No one’s giving up coffee, no one’s giving up wine. Stop telling us we’re going to die unless we do this stuff. [laughs]
Chris Sandel: I haven’t got that far into it to get to his real recommendations, so I’ll see what happens when I get there.
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You talked about initially being a lawyer and then transitioning out. What about you growing up – was food a really big part of an interest, or big in your household?
Alan Flanagan: In my household insofar as I’m Irish, and the famine was only 190 years ago. [laughs] Cultural legacies of food are quite interesting. I grew up in a very normal household food-wise, but it was very much like “starving kids in Africa, eat everything in front of you.” That’s the other legacy of what we call Irish mammy syndrome, where no matter how long you’ve been away for, they’re just convinced you haven’t eaten since the last time they saw you. [laughs] But it’s great. It makes Christmastime quite wonderful, actually.
But in terms of my interest, I think it sprouted more personally. I was always highly involved in sports growing up, rugby in particular. I got quite interested in my own training and nutrition as an adjuvant to that. Got quite interested in it at 15, 16. Thought it would help perform better, all that kind of stuff. That was I think where the interest started. It was very much more personal.
But around 2009-2010 – that was the blog revolution, where Gary Vaynerchuk was telling everyone they could be a millionaire just by starting a blog.
Chris Sandel: You’ve just got to hustle.
Alan Flanagan: Right, that’s it. Just hustle, even if Care Bears are your thing. It’s like, no. No one’s buying Care Bears. [laughs]
So there was this whole blogosphere revolution of nutrition. Mostly it was not academics, obviously; it was bros or it was – the paleo revolution was really happening at that time. So I suddenly had all of this access to “learning.” Probably the only website that I really found and relied on for “this person is really committed to science” was Martin Berkhan, who founded Leangains. I’m not sure if you’re familiar with that.
Chris Sandel: Yeah, I know him.
Alan Flanagan: Yeah. So Martin Berkhan was to me one of the first people who was really game-changing in terms of – no one was intermittent fasting then. No one was writing science-based information either. He would break down studies, and I was like, wow, this is really interesting.
I think in a big way, he got me more appreciative of the scientific approach, and that’s where I started self – because I was getting so much conflicting information, I think my inclination maybe as a lawyer was, how can I reconcile this? Where do I go? So I started going directly to scientific research myself.
But of course, I had no idea what I was doing. Nutrition science is something that is very underappreciated for being unique. It’s just conflated as a sub-branch of biomedical bioscience, and it’s absolutely not in many respects. There are really fundamental differences between investigating food as a subject of inquiry and investigating drugs and single compound interventions and surgeries.
A lot of the confusion in nutrition science actually arises because that whole model, the biomedical scientific model, is just superimposed onto nutrition, and everyone expects to get the same answers as you would if you were studying a drug. Of course, we don’t get those answers, and then everyone goes, “See? Nutrition science is bullshit and we can’t trust it.” It’s like, no, you were just asking the wrong questions in the first place, and in science, if you ask the wrong questions, you won’t get the right answers.
That was how I gravitated to it, and then I had amassed 5 years, really, of self-learning, but in a very abstract sense. I knew a lot of facts about nutrition. I could tell you that EPA was a 20 carbon polyunsaturated fatty acid. I had no idea what that meant biologically, and I certainly had no idea how to critically appraise a research paper that used EPA, for example.
I’ve always had a huge value – and one thing, I guess, that I did have an in-home culture of in my family was a huge value on education. There was never a limit to education and the value in it. Once I realized that was where my self-learning was at, I was like, “I need to do something formal with this and see where it goes.” That was the process that started me towards the Master’s, and now here I am. [laughs]
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Chris Sandel: You touched there on the difference between biomedical and nutritional sciences. Why don’t we just start here? I think this is a really good place. I think there’s so much of this mantra at the moment of “just do your research,” and my hunch with that is that’s good advice on the surface, but it’s not really great advice, because there’s a real art and skill to being able to understand research.
Alan Flanagan: 100%. This whole culture now of “woke,” and you get told by an anti-vaxxer in an online conversation to “educate yourself,” and you’re like, really? [laughs] This is the pot calling the kettle black. We have this culture right now where, one, we have an anti-intellectual culture currently. We have a culture of anti-expertise. I think Michael Gove made that culture quite famous in the Brexit run-up with his “I think this country’s had enough of experts.”
But the problem is, I think everyone’s had enough of experts, and people are more willing now – there’s a narrative that I’ve noticed in a lot of the people in nutrition or health that position themselves as experts. They’re often completely outside of the field. In one case of a guy in the States who wrote a book about nutrition and brain health, he went to film school. As far away from nutrition as you could get.
You get other people that are from medical backgrounds, so there’s this massive authority bias within the general public that they must know what they’re talking about, even though they’ve never studied nutrition for more than 5 hours over 5 years. And then you get people coming from other disciplines that try and offer their expertise.
What I’ve noticed is they tend to craft a narrative around their “expertise” that relates to their previous discipline. They’ll say, “The reason I’ve figured this out is because I’m an engineer, so when I started reading nutrition science, it all clicked” or “The reason I figured this out is because I went to film school, and actually figuring science out is about being creative.” It’s like, no.
I think part of why I’m sensitive to that narrative is because I could easily concoct it for myself. I could sit here and tell you that my 9 years as a practicing barrister unlocked nutrition science for me, and it would be an absolute fucking lie. [laughs] So I’m wary, and I see through that narrative when I see other people advancing it.
The bottom line is you can self-learn, but there’s a limit to how much you can self-learn unless you formally train in a discipline, and science is absolutely one of those – in the same way that I could give you the law of torts and you could read it to your heart’s content, but until you’re practicing, you don’t contextualize any of that information, right? It’s the same in any discipline.
Because nutrition is unique in the sense that everybody eats, there is this perception that we all have access to this knowledge just by virtue of needing nutrition on a daily basis as a species. Whereas you wouldn’t make this analogy for law, for example. It would just be assumed you need a lawyer. That’s expertise. You would never assume that a flight engineer knows how to fly the airplane, even though he probably knows where every little wire is and what every little button does.
So we make these assumptions about nutrition that we literally would never think of making with any other discipline, and the bottom line is, reading research or becoming aware of methodology is a skill. Interpreting it is not just a matter of the skill of understanding where research fits and where its applicability starts and ends and understanding principles of internal versus external validity and all this stuff, but it’s also a matter of your wider knowledge in that discipline to understand how you can contextualize those results. Like, where does this fit in the big picture?
And all of that is absolutely nothing unique to nutrition and science. It is simply what we expect of any industry or any field or discipline that has a specific subject matter, and that specific subject matter requires some expertise. But with nutrition, we’re willing to give a hall pass to anyone with abs on Instagram. We’re willing to give a hall pass to anyone with a cool story about having some illness and they healed themselves with this kind of diet. We’re willing to give a hall pass to literally anyone in a white coat. [laughs]
People in the public are very easily misled by a lot of these narratives. But on the same line of thinking, one thing that I also try and say is people in the public also have to be a bit more vigilant about cultivating where they receive information from. I think that people often say, “I don’t know, I’m so confused,” and then you find out they’re getting information from Netflix documentaries. They’re getting it from idiot influencers. Well, of course, you’re confused. You’re listening to people who you should, with any applicable common sense, know that they’re not credible.
But again, going back to everything we were just saying, with nutrition we give it a hall pass. But with other disciplines, we don’t. So I think that’s what makes nutrition unique. But science is its own field. Interpreting research is a skill. Like any skill, it takes practice, it takes refinement, it takes a lot of hours, and you don’t just lick it off the ground overnight. And you certainly don’t have anything that a previous life gives you towards those abilities. I am acutely aware of that fact because I come from a different background.
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Chris Sandel: I guess where it can be a little confusing for people is where it’s the doctor who then moves into more of the nutrition model, because it feels like on the surface, okay, they understand how to interpret medical research, and then it’s the same thing, so they’ll be able to pick that up pretty quickly.
Alan Flanagan: Yes, exactly. And it won’t. I gave a talk in a hospital the other day – and I always do this whenever I give talks to the medical profession – I outlined some of these differences. We don’t often think about them. It’s very much geeky methodology, but just I guess some simple examples for listeners when they’re like, “what is this difference?”
One is in the biomedical model, we have randomized controlled trials. Double-blind, placebo-controlled trials are considered the “gold standard.” That means as a design, they are the strongest design that can show that the intervention that you do causes the outcome. That design isn’t brought out of thin air; it’s very specifically created out of preconditions that will allow us to show that the intervention caused the outcome.
But those preconditions were based on the assumption that it would be applied to testing drugs. A drug will be a very specific compound, and it will act on a very specific part of our physiology for a very specific outcome. If we think about a statin, for example, which is a drug that lowers blood cholesterol, LDL cholesterol, we take a statin. The compound’s designed with really specific qualities, and in testing it, we know exactly how much will be absorbed, where it will be distributed, where it will act, how long it will take to be excreted, and how it will be excreted (via urine or via feces or whatever).
We know that it will act by inhibiting a really specific enzyme known as the HMG-CoA reductase enzyme. In inhibiting that enzyme, the processes that allow new cholesterol to synthesize, to be created, will be inhibited downstream from that, and we have a reduction in blood cholesterol levels. So that’s one specific compound designed to act on one specific enzyme for a very specific outcome.
But if we take blueberries, for example, and we’re looking at blueberries because we’re interested in their role in brain health and memory, we might be giving people a certain dose of blueberries every day for 12 weeks. But we can’t say whether the outcome is because of the vitamin C content or whether it’s because of the polyphenol content, which are these non-nutrients, but they have biological activity. And then within that polyphenol class, there are at least seven different subcategories, and then within each subcategory of that, there are subcategories again.
So you can’t have that conclusion that a specific isolated part of the food is responsible for the outcome. The problem is, because of the biomedical model, rather than just be comfortable with the fact that the food is the exposure of interest, we’ve been obsessed with distilling down further to try to find what specific compound in food is responsible for an outcome. But of course, that’s largely irrelevant to people’s eating habits because you don’t eat a polyphenol. You eat blueberries. You eat strawberries.
There are a lot of these differences that mean that – an example I use all the time, just to illustrate this for listeners, is in observational research – which also gets a bad rap in nutrition, but is actually really important and more reliable than people give it credit for – there’s been really strong associations and long-term studies between vitamin E intake and lower risk of cardiovascular and neurodegenerative disease, Alzheimer’s and dementia. That lower risk was from dietary intake, so nuts, oily fish, avocadoes, green leafy vegetables, that kind of stuff.
It’s really consistent. It’s observed in different populations, in different countries, in different cohorts. In the biomedical model, when an observation is observed, or they think something might be beneficial, they isolate it and then test it. So that’s what happened with vitamin E. They took supplemental synthetic forms of vitamin E and ran loads of really large randomized controlled trials that cost potloads of millions – and all of them came back negative.
The conclusion, then, is “Vitamin E does not reduce risk of heart disease.” That’s a completely incorrect conclusion, because vitamin E in diet is eight different forms. There’s eight different forms of vitamin E that all come together and are consumed as the one compound. But we only know a lot about one out of those eight. What they do in those supplement trials is take the synthetic version of one of those eight versions of the compound and give it.
So the hypothesis was never that vitamin E reduces heart disease in a controlled trial. It should have been that a synthetic, isolated version of one vitamin E compound lowers risk. Of course, they get to the end of the trial, they have no beneficial results, and they conclude that vitamin E doesn’t reduce risk of heart disease. Again, that’s wrong. The isolated supplemental version doesn’t. But of course, they did not test the effects of consuming vitamin E through diet.
Sometimes what we call reductionism, which is where we want to get to this exact, tiny, minute little causative agent in a diet or in a food, is actually not serving investigating nutrition and health outcomes very well.
Chris Sandel: Yeah, and I think that’s the case with a lot of the testing of so-called antioxidants. When you reduce them to just the one at a time, it doesn’t bode particularly well. But when you have them in food sources, it does work very well – and I think some of that is also because what is credited to being the antioxidants is actually more to do with polyphenols or hormesis or something else.
Alan Flanagan: Exactly. It’s interesting that most of the antioxidant trials, if not all, have largely failed. Absolutely. Hormesis, you mentioned – this idea that nutrients and biologically active constituents of food, they generally act at low doses. We don’t need them in huge doses. At low doses, they have biological activity, but if you take them in very high doses, they have the opposite effect. That principle might be really important for why they have biological activity in food, but not when we isolate them and double the concentration of them as a supplement.
It may be one reason why supplementing with vitamin A was actually observed to be associated with cancer. It was lung cancer specifically. The problem was that it was in a cohort of smokers. It’s very difficult not to just look at the obvious one there and be like, well, let’s maybe not blame the vitamin. But the people taking vitamin A supplements had higher incidence than even smokers. So it was the idea that there was an aggravating effect.
For all these reasons, we’re very much – and I think the field of nutrition has been live to this for certainly the last 5, 7, maybe 10 years and is very much looking to do food-based intervention. You have the famous PREDIMED trial in Spain where they didn’t give people supplemental vitamin E and oleic acid or polyphenols; the intervention was specifically to consume 4 tablespoons of olive oil a day in one group, and the other group ate an ounce of nuts every day.
So food-based interventions are, I think, the future. But we are still very much stuck in a bit of a nutrient-focused paradigm sometimes with research and when we ask questions about diet and health relationships.
00:34:25
Chris Sandel: You mentioned before about observational studies often being talked down about. Where do you think that they’re good, or why do you think people are misunderstanding how helpful they can actually be?
Alan Flanagan: Why? I think there’s three types of people who dismiss nutritional epidemiology, which is observational research. The first two are people who don’t understand nutritional epidemiology, and the third are people for whom the findings don’t agree with their particular worldview.
I think epidemiology is dismissed because, again, in the biomedical model there were a few scares on the disconnect between some results in population research and some results when they looked at it in RCTs. The most famous example of that is related to, in the late ’80s and early ’90s, hormone replacement therapy and cardiovascular disease risk.
This is just hammered into med students now in particular, but what, in effect, occurred was in observational research, there was a suggestion that hormone replacement therapy lowered risk of cardiovascular disease. Then they ran a large randomized controlled trial, and that found the exact opposite, that there was actually an increased risk of cardiovascular disease in the group taking HRT, and the trial was discontinued. It’s used as an example of “You see? We can’t trust the observation.”
But actually, when you scrutinize both those studies in more detail, what you realize is that the difference in the findings related to the timing of initiating hormone replacement therapy relative to the timing of the onset of menopause, when you factored in those two timing elements, the results actually were largely in accordance with each other.
The message for me here is never that we dismiss epidemiology; it’s that our duty as scientists is to reconcile discordant results by scrutinizing the literature in a bit more detail and doing our due diligence to make sure that we come up with the right answer as to why there was or was not a difference.
I think that part of the wider problem of why that doesn’t happen a lot, because although we’re training people to be healthcare professionals – you go to med school, yeah, you’re “learning” science, but you’re not really. You’re just learning information. You go to study dietetics or nutrition, it’s the same. You’re given research papers, but really, you’re approaching it the way you’d approach your A levels. It’s just like “learn the information, get through.” So a massive problem that we have now in healthcare is critical illiteracy. People assume that their degree correlates to the ability to critically appraise scientific research, and unfortunately, it absolutely doesn’t. I think we need to be a bit live to that.
But that’s almost a separate rabbit hole. Coming back to observational research, with nutrition, because most of the diseases that face us in society now, like cardiovascular disease and Type II diabetes and dementia and non-alcoholic fatty liver disease – these cardio, metabolic, and neurological conditions – they don’t develop early. They have what are known as long latency periods. You may get heart disease at 55, but you’re influencing getting that disease at 30, at 25, at 20, with nutritional practices – or other lifestyle variables; I don’t want to put everything on nutrition – earlier in life.
Point being that we can’t do an RCT randomizing people to a heart-healthy diet at the age of 20 and expect them to stay in an RCT for 50 years. It’s just never going to happen. So because we can’t do that, we use what are known as prospective cohort studies, and they’re prospective because we take people at a stage in their life before they have any disease. So they with be 30 or 35 or 40 when they’re recruited. They don’t have heart disease. We’re going to look at what happens over 20 years and who gets heart disease, and we’re going to use different collection methods to assess their diet over time.
That is the only way we can investigate long-term diet/disease relationships in nutrition, because we can’t lock people in a room for 50 years and investigate these things. [laughs] People assume that it’s entirely unreliable because there’s a margin of error in the questionnaire methods that are used to assess people’s diets, and food frequency questionnaires are often used. But people dismiss the food frequency questionnaire accuracy with rather, I find, an ignorance of understanding what they’re used for and what their purpose is.
The first thing to understand is that any food frequency questionnaire to be used in a population will be specific to the population. If we’re going to investigate the UK population, we’re going to develop a food frequency questionnaire, and at the start, what we’ll do is validate it by getting a subgroup of people – let’s say we have a big study. We have 40,000 people. We’ll take a group of maybe 4,000 out of that that are representative of the whole sample, and we’ll get them to weigh all their food and measure their beverage intake for a week. That’s as accurate a way as you can get of assessing someone’s diet.
Then what will happen is they’ll test the food frequency questionnaire in another small group of say 4,000, and then they’ll compare the results of the food frequency questionnaire to the weighted food diary and see how well they correlate. If we’re looking to look at saturated fat, for example, we’ll see how well using the food frequency questionnaires to distill down how much saturated fat was in the diet correlates with the weighted food diary.
The coefficient, the actual relationship between them, is dependent on the nutrient, but is often higher than people think. For saturated fat, for example, we know from validating food frequency questionnaires that the correlation coefficient is about 0.6 to 0.7. So that basically means 70% correlation.
Now, the thing we have to then understand is that we’re not looking to examine with 100% accuracy someone’s diet. If you think about this, every day, people do not get up and weigh and measure every morsel of food. Well, maybe 0.5% of the bro population. But normal people don’t do that, for the most part. But they might eat fairly similar foods.
Someone might have porridge every day for breakfast, and they might free-pour it, or they might get a measuring cup out and pour it in. Maybe let’s say they have 80 grams one day because they free-poured it in, and the other day they’re particularly hungry and they get out the measuring cup and fill a good, heaped cup and dump that in and that’s about 120 grams, and so on and so forth. Maybe it averages out over the lifetime as 90 grams a day. Because of those fluctuations, in free-living, normal populations that are going about their daily lives, you never eat 100% of the same thing every day.
What food frequency questionnaires are designed to capture is your average intake over time. So they’re not supposed to be, nor could they ever be, 100% accurate, but actually, that’s not what we’re interested in. We’re interested in the average intake over time.
And the important thing to remember then is when we get to these conclusions at the end of this study and we say a high saturated fat intake was associated with heart disease, or a high polyunsaturated fat intake was associated with lower risk, because we’re looking at average intake, and because the correlation is generally lower than the weighted diary, the effect of this is that the estimates are underestimated. I think that’s a really important point to make for people. When we have these associations, they’re often underestimated. Maybe the protective effect of a compound is more, but maybe the negative effect of another compound is more as well.
When we look at the track record of observational research in nutrition, it started in the 1920s when the major public health issues were not the conditions we have today, but they were actually deficiencies. Beriberi, vitamin B-1 deficiency, or iodine deficiency and goiter, or vitamin D deficiency and rickets or osteomalacia, or a condition known as pellagra, which is a vitamin B-3 deficiency. All of those relationships were identified through observational research, and all of those relationships were eradicated from the population by using interventions – so fortifying salt with iodine, fortifying milk with vitamin D, fortifying wheat and breads and cereals with B vitamins. All of these conditions were eradicated successfully by implementing the results of observational research.
We fast forward to now, we have eradicated trans fats from the food supply largely because of observational research. We have observational research that continues to show the same thing over and over again with regard to heart disease, which is that low intake of unsaturated fats and high intake of saturated fats puts people at risk for cardiovascular and heart disease. That’s supported by controlled studies then looking at the changes that happen in say cholesterol and stuff like that. We have really strong observations of the protective effect of a high dietary fiber intake from observations, and we have controlled trials that support that.
I think that people are too quick to dismiss nutritional epidemiology, when the track record so far warrants more confidence in the conclusions that it’s given us. And generally, the dismissal comes out of a place of ignorance, in my experience. People simply don’t understand the methodology used, and they simply don’t understand that particular discipline of scientific research.
00:45:25
Chris Sandel: I know there’s a lot of talk about the hierarchy of scientific evidence, like systematic reviews being at the top, and then randomized controlled studies. Do you think that actually holds true for nutrition science? Or there should be basically a separate hierarchy of scientific evidence for nutrition?
Alan Flanagan: I definitely think there should be, yeah. I have so many problems with the – you’ve just opened a can of worms. [laughs]
Chris Sandel: [laughs] Okay.
Alan Flanagan: I have a big problem with the hierarchy of evidence for two, or maybe three, reasons.
The first is, going back to that thing I said about healthcare professionals – and all disciplines; it’s nutrition and dietetics, it’s medicine – we have this real widespread critical illiteracy. People are not good at critically appraising scientific research. And often they don’t have to be to do their job well. It’s not a criticism. It’s just when people weigh in using the fact that “hey, I’m a doctor” or “hey, I’m a dietitian” as the basis for “listen to what I’m saying about this study” when what they say clearly shows they don’t understand what the study did or showed, then that’s a problem.
But the hierarchy of evidence is used as a crutch in many respects. People assume that if they’re reading a study and it was a systematic review, or in particular, if it was a meta-analysis, or if it was an RCT, then its results are automatically correct because of what the study was in terms of its design, nominally. That’s an entirely false premise, and I see it happening all the time in these conversations that are “evidence-based.” People say “this was an RCT” – and it’s generally the same people who dismiss observational research without understanding it. They’ll say “association isn’t causation.” Well, no, association is association, and when the association is consistent and it’s shown in different populations and keeps coming up again and again, then we use our brains and we infer causation using what’s known as the Bradford Hill criteria.
But the hierarchy of evidence becomes a problem for the conversations about the evidence-based because people assume that the hierarchy of evidence is a standard of proof. “If this is on top of the pyramid, it’s correct because it’s on top of the pyramid.” It leads to incorrect conclusions about the nature of causation when we’re talking about different issues.
For nutrition science, it’s particularly problematic because prospective cohort studies are third on the pyramid, and they’re behind randomized controlled trials and they’re behind systematic reviews and meta-analyses, and they’re way behind in terms of the weight that people give to them. There are different systems people use in research to grade evidence, and one is actually known as the grading system. But the grading system basically says if a study is observational, it’s not worth the paper it’s written on.
So you get these conclusions – and an example is the recent “keep eating as much meat as you want” conclusion from that Annals of Internal Medicine study. Most of the research we have supporting the recommendations we have to lower red and particularly processed meat consumption come from a combination of observational research and then mechanistic studies – so studies either very short-term in humans or in animal models, looking at why there could be a cause and effect relationship. Immediately, the whole weight of the evidence supporting that was written out of consideration because it was observational, allowing them to come to the conclusions they did.
In nutrition, we will always have more prospective cohort studies giving us information on a particular issue than we will randomized controlled trials. For me, the hierarchy of evidence merely indicates increasing potential confidence that a study, if it was done well, indicates a direct cause-effect relationship. That is all the hierarchy of evidence is. When we go beyond that and assume that the hierarchy means something beyond that, we’re in trouble.
True scientific thinking and true scientific inquiry and conclusions wouldn’t view the hierarchy at all. It would simply say, we have a total body of evidence; how do we assess it all, and how do we use our critical thinking and our scientific thinking to arrive at conclusions that probably – or in a probabilistic sense, because that’s all science gives us – is closer to an approximate truth than the other alternatives that could be presented from that same available body of information?
It’s a collective process of evaluation and of reconciling different forms of evidence with each other, and not being methodologically prejudiced against a source of fact or of evidence simply because it was a certain trial design or a certain study type. In nutrition, this is really problematic because particularly meta-analyses, in the biomedical model where they come from, they’re designed to give really confident conclusion on the question being asked.
If we’re going back to our statin example, if we do a meta-analysis of statin trials, we know that they’ve all been really tightly controlled. They’ve been controlled with a placebo. They might have been for similar durations. They’re all in the same population, because they’re people with high cholesterol and heart disease, and they’re all using similar drugs or similar doses. And if not, it’s so easy to stratify people based on the dose and the drug. So meta-analysis in that context gives you really confident conclusions on the efficacy of that intervention.
Whereas in nutrition, particularly if prospective cohort studies are included, they might have been done in different populations. They have different high or low levels of any given nutrient. They were studied over a different time period. Their baseline characteristics were different; one cohort started at 30, the other at 45. They have different stages of the disease advancing at that point. Even if they don’t have a diagnosis, the underlying processes are at play.
You just get this completely fudged, middle ground, muddy water conclusion, and then people go, “Ugh, we can’t trust nutrition science.” It’s like, no, we just can’t trust you and your methodology. [laughs]
Chris Sandel: You’re not comparing apples with apples.
Alan Flanagan: You are not. You are comparing apples and pigs. [laughs] It couldn’t be any different. In meta-analyses, you’re supposed to compare apples with apples, and that just doesn’t happen. So the hierarchy of evidence is more trouble than it’s worth, and I think we could really do with re-emphasizing what its actual purpose is.
All it is, is potentially increasing confidence – and I use the word “potential” very deliberately because whether that potential is realized or not depends on the methodology used, the rigorousness of the study, and all of that. In many respects – and people forget this all the time – a really well-conducted prospective cohort study that is observational has more power to infer causation than a badly controlled and executed randomized controlled trial.
00:53:20
Chris Sandel: One of the things about this is taking that evidence and then how do you use that in an evidence-based practice? I was reading an article – I think you linked to it recently on your Instagram from Sigma Nutrition, where they talked about the three components of an evidence-based practice being best current evidence, then the individual’s needs and ability, and personal experience, and how those three things need to come together. Do you want to speak a little bit about that?
Alan Flanagan: Yeah. I think we forget that evidence-based practice is a Venn diagram. One rung of that then is the evidence, what research is there, what it’s telling us. Another is the clinical experience of the practitioner. The third is the patient preference.
We’re being, I think at this moment, a bit too didactic with science. There’s a lot of weaponizing of science, and what I mean by that is using science just to further an agenda or assuming that if their science says X, then X holds in all circumstances. That’s absolutely not true, and it never has been.
I think part of the problem with this, certainly in medicine – there’s a really good critique by a very good proponent of, but also critic of, evidence-based medicine, Trish Greenhalgh, and her commentary was published about 10 years ago at this point in the BMJ. She spoke about how the problem with evidence-based medicine as a model was that it was only using the evidence to codify “if A happens, then B; if B happens, then C,” basically, and removing clinical experience and the input of the practitioner from the scenario. And that’s what’s come to pass. There’s no real scope for people in medicine to do anything other than what the chart is telling them to do. Is that really practicing healthcare? I would argue not.
We are at a similar point in many respects with nutrition. Particularly within dietetics, which is very resistant to change because of the fact that dietetics has been the only regulated and recognized nutrition title. There’s a lot of baggage, shall we say, that comes along with that and #TrustaDietitian, which is just such a toxic campaign, because why would I trust someone if the advice I’m getting is bad? [laughs] It’s appeal to authority bias and nothing else. We see it in other healthcare disciplines as well.
I think we are forgetting that clinical experience really does count for people that are clinicians. In experience and in gathering it, it’s where people are able to contextualize this body of evidence that they’re supposed to be applying. By contextualizing it, they’re able to see where the strengths and limitations of the applicability lie, and they’re able to have a consideration for “Okay, this is what this body of evidence is telling me, but is it all useful? Who is it true for? Is it true for all people in all circumstances? If this trial found that Intervention A was good for Outcome B, who’s in that trial, who’s in that study, and is this necessarily going to hold true in the case of the person sitting in front of me?”
We’ve become more obsessed with “this trial found A caused B,” so that’s what evidence-based practice is. You shove A = B down their throat, and it’s your job as a practitioner to get them to do Intervention A because it caused Outcome B.
You see that particularly in the health and fitness space, which is an area that I think is generally really problematic for a lot of the conversations around nutrition. It’s this assumption – one, the RCT is god; two, “if an intervention found high protein intake equals more fat mass reduction over 12 weeks, I will make sure that every one of my clients eats a high protein diet.” It’s completely forgetting that clinical experience is the experience of how you put this into practice. Not just I take what’s there and I force it on everyone because “that’s the evidence.”
Again, in this conversation, coming to the last but almost the most important point, is the patient preference. What if they don’t want to shovel Greek yogurt down their throat four times a day and eat every 3 hours and have X amount of food? This very broadly assumed compliance approach. I think one thing we’re lacking particularly in nutrition is we just don’t really have the human voice presence in science.
We don’t do a lot of qualitative research, which I think is an enormous limitation of nutrition science. We’ve run trial after trial after trial for 30 years looking at Diet A versus Diet B and Diet C versus Diet D. Weight loss as an outcome has been the primary concern of the field. Never once, really, has there been a broad influx of qualitative research to get the human voice in that. You read trial after trial where the attrition rate was 50%, 40%, 35% people dropping out, and all it is, is one sentence in a very vapid paper. It’s framed as a percentage. You’re like, okay, why did they drop out? Where is the qualitative element that investigated, why did they struggle with this? Was the intervention shit? Were they starving? All this kind of stuff.
We have missed a huge trick over the last 30 years by not incorporating the human voice into nutrition research. I think we would have a much more actionable evidence base right now if we had done so. But we’ve been so obsessed with the p value – and that’s science generally, to be perfectly honest, over the last 50 years. We’re more obsessed with the p value than we are with the biological relevance and real-world applicability of the results.
We certainly have done intervention after intervention in nutrition without actually trying to see what the barriers are, what was good, what was bad, why could people do it, why could people not? Why did 50% of the trial drop out after 6 weeks? We don’t have that data because we’ve never asked the question.
Chris Sandel: For me, because I do so much one-on-one work, now so much of what I read and focus on is how I can be better as a practitioner, and not necessarily how do I know more about nutrition, but how do I communicate better, how do I do behavior change? That’s where the focus is.
Alan Flanagan: 100%.
Chris Sandel: I also think the other thing with this evidence-based practice is for this to really work, there needs to be an open-mindedness. There’s an open-mindedness in terms of realizing that evidence will change, and I have to change my views on it, but also that sometimes personal experience is wrong.
I read The Undoing Project, which is about Amos Tversky and Danny Kahneman looking at how often our intuitions are wrong. So I’m constantly re-asking myself, why do I know this? Why do I think this? What would happen if I did something different here? Not just like I’ve seen this work so many times with other people, so it must be right, but thinking, could there be a different way that’s actually better than this? Or could there be some harms that are coming to this that I’m just not noticing because there’s some blind spot or whatever?
I think for evidence-based practice to genuinely work, people have to take the ego out of it and be just open to “I could be wrong, the evidence could be wrong, and how can I better serve the person who’s in front of me?”
Alan Flanagan: Right. I think that’s incredibly prescient right now, because I think when we were talking about experience there, the clinical experience is the experience of applying an evidence base. It’s not “I went with this because my gut feeling says so.”
I think that part of the problem with that is – yes, you’re right, research is always subject to change. At the end of the day, as much as we love to think we’re rational creatures that make decisions based on sound evidence and principles, the bottom line is we are fallible, irrational, emotional chimpanzees. The more that we can remind ourselves of that – I always refer to people on Instagram and social media as sapiens. [laughs]
People ask me, “Why do you call everyone sapiens?” I’m like, because I want a daily reminder, nearly, that we are just chimps, basically, and that the more we can – and it’s not a negative. It’s just a polite reminder to – like you said, how do I know what I know? Could what I know be wrong? Has what I know changed, and how do I keep asking questions of myself and my practice so that I’m constantly checking my innate, default, human capacity to fuck up? [laughs]
Chris Sandel: To all the biases and all the heuristics that we have.
Alan Flanagan: Yeah, because thinking – Daniel Kahneman, Thinking Fast and Slow – but thinking is a resource-consuming activity for human beings. We’re a default lazy species that will operate in default mode in terms of our cognitive capacities unless we have to force ourselves into a mode where we are thinking logically and trying to crunch on a problem or what that is.
Our brain likes to default to heuristics. It likes to default to the gut feeling. It likes to default to things we think we know or that we’ve convinced ourselves we do know and that are “true.” If we can acknowledge that this is just an innate part of being a fallible, emotional, irrational ape, then we’re better thinkers. [laughs] Because then we’re able to not fall into the hubris of the prefrontal cortex and assume that we’re great because we have the capacity to think.
I find that the danger is when people are not aware of these factors or where they’re insistent, “I’m aware of my biases,” but then they continue wearing them on their sleeve. I was in an interesting back-and-forth recently, earlier in the week, with one of the doctors that appeared on the Game Changers documentary.
It was just so insightful to me to see how this individual portrayed the documentary and how they saw it as this really benevolent and altruistic act of balancing, “There are all these awful myths about vegan diets and performance. All we were doing was setting out that you can have high-level performance on a vegan diet. That’s all it was saying.” It’s like, if you think that that’s all that it was saying, then you are so blind to what actually has become the product. The way that they continued to frame the information that was in it and what it actually meant for the wider public was just such this level of blinkers on, of cognitive dissonance, that I was so entertained by it.
On my suggestion that they were blind to all of these – the way it’s being received, the way it’s being talked about and everything like that – I got this soliloquy about how they’re a medical doctor and they used to think this, but now they’ve changed their mind and they’re rational and objective and unbiased. I was just like, wow. All I could picture was a chimpanzee basically gooing and gahing at me. I was like, aww, there’s the fallible human ape telling me how objective and unbiased they are, while they appear on a documentary telling you you’ll get better boners from black bean burritos.
So yeah, interesting dialogue. But I think it comes back to, like what you’re saying, the fallibility of being human. I think people are resistant to it because they see it as a negative. It’s not a negative. It’s simply the human condition. If we ask questions of ourselves, we can be better practitioners because we constantly question what we know and how we’re applying what we know, and we’re constantly able to update what we know and even improve on how we’re applying it because we’ve constantly questioned our practice and what we’re doing.
01:07:40
Chris Sandel: I think it’s also because – and this is happening more and more – people’s beliefs or just – I don’t even know how you characterize – things that people think are facts become part of their identity as opposed to “these are just facts that I know about a particular topic.” So it’s not like “I just need to change these ideas”; it’s like “but I was the paleo guy, and I now have to tell everyone that I’m no longer the paleo guy.” That’s a much bigger hurdle to get over than just “Oh yeah, when I wrote that one article about that one thing, I’ve now reviewed the evidence that’s just come out and I was wrong.”
Alan Flanagan: Yes, absolutely. Ciaran O’Regan, who is one of the Sigma Nutrition coaches and is writing this amazing series on “are you really science-based?” – it’s really epistemological and an excellent critique of what scientific thinking means and how we apply this – he makes the point in one of the Sigma articles that it’s the difference between you having an opinion or an idea about something and you being that opinion and idea. If you have an opinion at one given time, you can change it. But if you are the opinion, then all of your human instincts about your identity and your self-construct and all of this are now tied up in that belief. You’re not changing your opinion; you’re changing you, and no human is going to do that unless something really, really bad happens.
That’s where we get into so much of the problem with the discourse in nutrition now, because to me, I think it’s the only health science that I can think of that simultaneously doubles up as a belief system. People don’t say “I follow a vegan lifestyle.” They say “I am vegan.” They don’t say “I follow a low carb diet.” They say “I am low carb.” They are the belief. They are the diet. All of the baggage that comes wrapped up in that makes for a really fractious discourse that we have going on right now, and it’s really, really frustrating.
Chris Sandel: Definitely. You look at “Oh, I’m paleo, but when I looked at this research, I was really unbiased.” It’s like, how do you hold those two things at the same time?
Alan Flanagan: Right, exactly. Interestingly, that’s exactly part of the dialogue that I had with this person that was on the Game Changers documentary as one of the authorities. He was like, “It’s because I’ve looked at the science that I’ve now formed these views.” I’m like, so you’re saying you used the science to form a bias as opposed to just inform a position. I found it a funny self-contradiction in the point that the person was trying to make.
So there is a big difference, and it’s looking at evidence to come to a conclusion, knowing that that conclusion is subject to change. That’s the nature of science, and that’s what separates scientific thinking, whereas in the example I’m referring to, what was clearly at play was using science to come to a finite conclusion that “this is the best approach.” That’s the difference. It’s subtle, but it’s very important in distinguishing when someone’s saying, “I’ve arrived at this conclusion and it’s the best based on…” It’s like, if you’re arriving at that conclusion in a finite sense, then you’re not understanding what scientific thinking is.
Chris Sandel: Yeah. I think the classic example was when someone asked Gary Taubes, if all the evidence came back to prove that low carb was wrong, would he accept it? And he said no.
Alan Flanagan: No, because we know we’re right. It’s like, I hate you so much. Everything about your being. [laughs]
01:11:55
Chris Sandel: Let’s shift directions a little bit and talk about public health nutrition. I know this is an area that often gets a lot of bad rap, so why don’t you talk a little about public health nutrition, and maybe some of the difficulties that it has in making recommendations at a population level?
Alan Flanagan: Yeah. This is something myself and Josh tried to talk about a little bit, how it is that we come to conclusions with nutrition. We know a bit more than people give us credit for, and how do you communicate that?
If you think about the evolution of public health nutrition through the ’20s and ’30s, it was a much simpler process because the conditions that public health nutrition needed to address were conditions defined by isolated single nutrient deficiencies. By identifying that deficiency and the prevalence of it in the population, you were able to come up with simple interventions that eradicated that condition. I think we talked about this a bit earlier.
But the key distinction there is having that benefit and having that effect in the population didn’t require necessarily big education campaigns or big lobbying or anything like that. It simply required fortifying milk with vitamin D, or adding B vitamins to flour. The whole population consumes bread, so this is going to be a really effective vehicle to address this very specific issue and bolster nutrition status in the population.
Chris Sandel: Yeah. Individuals didn’t have to make a choice.
Alan Flanagan: Individuals didn’t have to make a choice, exactly. And it didn’t require any sort of policy-level change or interventions upstream other than deciding “we need to do this,” and then it was done. We’ve had this seismic shift in the dynamics of our relationship between industry and the food environment.
That shift, while we’re all very keen to look at nutritional determinants of that – “Oh, did we start eating more sugar in the 1970s? Did we start eating more fat, or did we start eating less of something?” – and while there are certain patterns there that we can say the shift, the reason why it’s a pattern shift and not an isolated nutrient shift, as it was in the ’20s or ’30s, is because it’s been an economic shift. The shift has reflected a second industrial revolution where the industrialization is not machinery, but the industrialization of the food supply. That has created a very unique dynamic that I think we’re only coming to have a body of evidence to understand now.
But the problem is, now is when we also have these enormous rates of Type II diabetes. Even though cardiovascular disease has been cut in half in terms of mortality rates since the ’60s, it’s still a leading cause of mortality in Western industrialized countries. So we’ve had this emergence and this trajectory upwards in these what we’ll call chronic lifestyle diseases at proportions that certainly Western industrialized societies are feeling the brunt of. But the problem is, when you step back and you try and look a little bit deeper at cause here, it becomes nothing to do with nutrition.
Really, what defines it, in particular, is the neoliberal economic model. Deregulation, no cap or barriers to industry, to market forces at play. The free market will decide. The problem with that mantra is the way the free market has decided – and I say “decided” in a pejorative sense, because most people in the free market have not had the freedom to make these decisions – is, for example, in the UK, there was a paper published 2 years ago that Public Health England even put a map on their website about. It was the density of fast food outlets relative to quintiles of social deprivation.
Across the UK, you have the greatest density of – there were four they modeled in the study – McDonald’s, KFC, Burger King, and one of those chicken shacks. The greatest density of all four establishments is in the areas of the lowest socioeconomic status across the UK.
Chris Sandel: Was this study done where they did it over every time the Census was taken? Because there was one I was looking at where every time the Census was taken, and then particular areas went up to be higher socioeconomics or came down, that actually those restaurants and stuff then shifted as well.
Alan Flanagan: No, this was just looking at current levels. But that is really, really interesting, and the shift. Yeah, one area gets a Waitrose as it goes up, and then the others get McDonald’s and KFC.
Chris Sandel: Correct.
Alan Flanagan: These are market forces at play. In order to address that, you have to really start to target industry, and you have to start to target having regulation and legislation and interventions that are what they call “upstream.” They’re not looking at the individual level; they’re not looking at behavior change at the individual level. They’re looking at modifying the environment to help individuals who are not in a position to change the environment for themselves.
The problem is, neoliberalism dictates you don’t mess with anything. You just deregulate every single element of society and you throw the pitchforks out there and let the place decay. That political and economic ideology is the biggest barrier to effecting change.
What happens in public health nutrition is they’ll use a vehicle like sugar – so even though sugar is not the cause of Type II diabetes, for example, even though sugar is not the cause of cardiovascular disease, and even though there is a whole diet pattern at play here and not simply one nutrient, sugar becomes a vehicle to get other issues on the table. That becomes the focus of trying to get some policy. It becomes the focus to try and get an initial tax. It becomes the focus to try and get people comfortable with mandatory regulation, which a tax obviously is. It’s not a voluntary tax; it’s mandatory. It’s essentially a policy vehicle to get these other elements on the table.
The problem, then, is people outside of public health nutrition look at that, particularly in the current environment we have where there’s very much a push back against diets, there’s a very big acceptance now of the effects of stigma, there’s a very big non-diet movement, and everyone from that paradigm then looks at this and goes “you’re demonizing sugar.” So there’s this total disconnect between the reason why sugar’s being used and the way it’s being perceived by other paradigms within nutrition.
Then, for example, you get beyond that and you get into even getting policy on the table in the first place. The rhetoric of that is still very much tied up in words like “obesity” and other weight-related terminology. Again, people from outside of public health nutrition will look at that and be like, “this is stigmatizing, this is a problem, you’re not paying attention to X, Y, and Z factors.”
But the reality is, you’re going to bat against people who have absolutely no idea about stigma. They’ve no idea about the health issues facing the population. They’re mostly Oxbridge type wealthy politicians. So unfortunately, the language that has to be used right now – it can obviously change, but the language that has to be used to even get the attention of people that you want to effect change is still tied up in that rhetoric.
Of course, that’s going to be a slow process to change, but it doesn’t mean that people in the public health space are ignorant of these issues. It just means, unfortunately, they’re in this really difficult place where they have to balance knowing, for example, the evidence for stigma exists, versus the pragmatism of how much they can take that into the discussions they have for an upcoming campaign, for example.
Knowing also – and I think this is really important – that industry are at the table every step of the way. The big barrier right now, one of the biggest barriers, is that usually what you should do is form a policy and then you bring industry in, and you say “This is the policy we’ve decided on based on the evidence. You’re industry, so you’re not in a position to assess or appraise. Now we’re talking with you about how we’re going to implement this policy and how you’re going to help us implement it.” What happens is the policy is shaped by industry from the get-go.
If you have the Cancer Research UK example – which was so, so appalling – they were getting input from professional psychologists, public health nutritionists basically saying “don’t do this again,” because they did it last year, using the evidence in favor of weight stigma and all of these other variables, and also, more importantly, the evidence that –
Chris Sandel: Socioeconomics matters more than anything else.
Alan Flanagan: Right, socioeconomics and the fact that we know smoking and other behavioral correlates are determinants of health. Negatively phrasing things does not affect behavior change. But this information was going to people who are not psychologists and are not public health nutritionists and are not any sort of other healthcare professional. They’re marketing and PR people within a charity who are going, “we think this will have high impact.” So then the campaign comes out, and then anyone’s that been working in the proximity of it gets slammed.
I think a big part of the problem now is it’s really, really difficult at the public health level to get anything that will be effective brought in, because everything that will be effective is mandatory, essentially, and it’s regulation. We have enough evidence for action; there is no action being taken by government or industry because government don’t want to take action and industry are happy for the status quo to continue.
And then on the sidelines, watching all of this, you have paradigms that are shouting at everything that’s going on for not considering X, not considering Y, being stigmatizing, demonizing food, and all of this stuff. So it’s a bit of a difficult conversation. I don’t think either side are doing particularly well at communicating with each other to understand their respective nuances. It’s impossible to communicate nuance to a whole population.
I think really, the big missing link here is both sides assume – what I notice in talking to people on both sides of the divide is both sides make a lot of assumptions that neither of them have biases against the other. Both sides make assumptions that they know entirely what the other side are talking about and that they’ve listened, in a reasoned and open-minded way, to all of their concerns and have ironically just decided they’re all bullshit. [laughs] Which if anything speaks of listening to something with your mind made up already and wearing your biases on your sleeve. It’s that conclusion.
So both sides act like they’ve given all the time in the world to the other to figure it all out and to listen, when neither of them obviously have. It’s a real error in communication. I have empathy for both. I think at the end of the day, it’s very, very difficult to – the stigma element of the conversation, which is only one part of it, obviously, there is a broader acceptance for that, I think in the last year to 18 months, with the WHO report in particular really adding to the weight of “Hey, this is a legitimate thing. We have an accumulated body of evidence supporting it.”
But some of the other stuff is a bit more difficult. For example, campaigns where they’ll remove junk food advertising on the tube, just as an example. A big criticism that comes up is “you’re demonizing foods and this is going to lead to negative” – no. Show me evidence that relates simply taking down the burger ad to someone then going and seeking out the burger because they noticed it wasn’t there. Really tenuous allegations of how this campaign or similar campaigns will play out at the population level.
I think that the “demonizing food” card, personally, is way overplayed. I think the stigma card is then downplayed to a degree on the other side of the house.
So it’s a very difficult conversation landscape right now. I think the biggest problem is neither side is truly listening to what the others are saying. I think if there was more appreciation of how difficult it is to get anything done at the public health level, there’d be less criticism of one side. And I think if there was more appreciation for how a lot of our approaches currently do have an impact in the population, there would be more appreciation on the other side. It’ll be interesting to see where that one goes.
01:26:30
Chris Sandel: Yeah. It’s just such a difficult thing to make a change at a population level. The things I would say look better are – and I don’t know if this is across the board, but there seems to be more of a shift away from just simply “we need to educate people more and people need to make better choices,” and that this is an individual thing, to like “how do we change the environment so that the right choice is the easy choice?” So people don’t even need to have to make that choice because things have been removed from the situation or things have been plopped in front of them so that it just naturally happens.
We were talking before we recorded about the problem with cognitive dietary restraint, and that when someone has to feel like they’re actively restricting, there’s a real problem with that. But if that choice just isn’t there to begin with – like people ate differently in the 1920s not because we had the exact same food environment and people were just different in their thinking then. It was because there was a different food environment in front of them.
Alan Flanagan: Right, exactly. Yes, absolutely, I think you’re right; there’s a massively broad acceptance now that the narratives about personal responsibility are nonsense. They’re unsupported by evidence entirely. The narratives about education are also nonsense, for the most part.
Chris Sandel: The people education works for is when you have influence and when you have money and when you have time and all of that. You’re helping the people who are also healthy.
Alan Flanagan: Exactly, so it comes back to the socioeconomic determinants. But if you line 10 people up against a wall, even from the most socially deprived background, and ask them if eating vegetables and fruit is good for them, 8 will say yes. So maybe education serves a purpose – just broadly speaking. Education is not the barrier.
Again, this isn’t an opinion. This is supported by research we have looking at these questions. There was a really nice qualitative paper published last year which looked at these issues and the food environment. It was just, again, the human voice. They published quotes, obviously, in the paper, and some of it was really insightful.
I’m paraphrasing them, but people saying “I know eating fruits and vegetables is good for me; they’re literally not available in my locality” or “It would be great to go to a supermarket, but there literally is not one in a surrounding three postcode area” and this kind of thing. We’re very much coming back to socioeconomic barriers, time, single parent working households, multiple jobs, low wages, all of these issues.
Those are political conversations, and part of the problem now is we politicize facts. The more we can just get a broad acceptance that they are the facts, the more then we can progress to the political conversations about what to do about those facts. But right now we’re still all arguing over the facts because, again, it suits the current political and economic ideology to keep everyone arguing over the facts, as if there’s some sort of debate.
But I think the move away from that individual narrative, the move to accept this is an environmental issue, I think the Foresight Group are really important in helping that.
Chris Sandal: Is it the Foresight Group that did the Marmot Report? Or is that someone separate?
Alan Flanagan: No, the Marmot Report was Sir Michael Marmot. That was separate. That’s excellent. The Foresight Group is a separate group, but a similar report, very much coming to similar conclusions.
Chris Sandal: Is that where they identified 100 or 120 different factors that lead to high weight?
Alan Flanagan: At least. They have this map. If listeners just google “Foresight Group map,” they will get presented with – there were seven different domains – psychological, biological, environmental, and all these others. I can’t remember the full seven. But within each one of them was a specific element or aspect or factor, and then they linked all of those factors to each other. It just looks like this giant, elaborate spider’s web.
For me, it’s the best visual representation for the complexity of the situation that we’re in with regard to public health and how complex it will be to disentangle it. But it very much then makes you realize that the individual is tied up in that spider’s web. Yes, human nature and behavior being what it is, some people will navigate that better than others. Not everyone born into socially disadvantaged circumstances is going to end up Type II diabetic or suffer coronary heart disease at 50. Not everyone born with a silver spoon is going to be free of those conditions.
So it’s not that it completely boils down to those variables, like your birthright, essentially. [laughs] What it’s about is simply that the risk in that given individual is so much stacked higher because of the social and economic circumstances that they’re born into. It’s about risk. It’s not that everyone will necessarily succumb to that risk.
But this focus now on the big picture stuff, on regulation, on tax, the focus on industry – there’s a big push in public health nutrition now happening. There was a committee the other day convened where multiple experts were basically berating the government. Again, paraphrasing the briefs of evidence given, but basically saying, “This isn’t about evidence. We have all the information we need. You’re simply not acting.”
The harsh reality is that there won’t be action until we make this a political issue and we put a party, however they are, in power that are happy to not just be complete slaves to neoliberal ideology and think that maybe society as a whole is greater than the sum of its parts. The unfortunate reality is that in certain countries, it’s very difficult to see that happening anytime soon, and the UK is one of those countries. [laughs]
01:33:15
Chris Sandal: As I said before we started recording, a lot of the work that I do is around people with eating disorders, people with messy relationships with food, people who have dieted, are chronic dieters – you kind of touched on this already, but so much of the messaging can then lead to people becoming obsessive and so fearful of food, or it can then lead to shame around food and then people doing the behaviors that we’re trying to get people to stop.
It’s a really difficult thing, as you alluded to earlier, but how do you think they could be doing better in the public policy around nutrition?
Alan Flanagan: I think that is maybe an intractable problem. The bottom line is we need to change the food environment. In order to change the food environment, we have to have hard conversations about the characteristics of the food being consumed on a population level that, over the long term, predispose people to an increased risk of cardiometabolic disease.
Denying that there is that relationship is more problematic than any rhetoric around removing advertising on the tube or zoning limits for fast-food restaurants around schools or any of these interventions where we expressly talk about food and the characteristics of the foods themselves.
I think what we really have to do is come back to – and this is maybe one hangover from my legal career – a proportionality test. We need to weigh, does the proportional weight of implementing interventions that expressly target food and the food environment outweigh the potential for a few excepted individuals within that environment to be negatively impacted by the rhetoric of that? I would argue that the proportionality is certainly in favor of action at the level of industry and at the level of food and at the level of the food environment.
But I think that we can certainly do far better with the rhetoric that comes out the backend about these campaigns. A recent example of that is the report from the Chief Medical Officer. The report in and of itself was overall really excellent, but there was one line in it, one line, where they said “We need to ban snacking for kids on public transport.”
And that one line scuppered the whole report, sank the whole thing, because – what nonsense. How it made it into the final draft, I don’t know. I certainly know from having a conversation with a couple of people that had more insight into the behind-the-scenes working that the people that were involved were just banging their head against the wall, because it meant that the Daily Mail and everything else grabs it and is like “Nanny State is going to stop you from snacking,” blah, blah, blah.
And then other reports that come out, or other measures that come out, still use this rhetoric of things like “childhood obesity.” The utility of the rhetoric when the campaign comes out, I question. If it has to be part of the behind-the-scenes negotiations to get people in politics or otherwise to listen, fine. But does it have to be part of the final rhetoric of a campaign that’s targeting a specific aspect of the food environment? I question the utility of that.
I think that absolutely, broadly speaking, we can do a way better job of cleaning up and improving the language and the semantics of how these questions are framed to the public and how these policy interventions come into the public realm. But fundamentally, those policies themselves are absolutely going to have to be focused on food, and we’re going to have to talk about food, and we’re going to have to talk about the food environment.
There’s no easy way around that. Like I said, the proportionality of doing those high-level, population-wide interventions outweighs the potential for that kind of campaign or rhetoric to be triggering in a small subset. I think that’s a reality of so much of what we do with public health. When it comes to nutrition, there’s just a lot more emotion loaded into that conversation.
But we do it with loads of other things. We do it with cigarette smoking, no one bats an eyelid. We do it with alcohol, no one bats an eyelid. There’s a lot of elements of public health generally where this balance is there, and it’s just not contentious. But there’s an extra emotional layer when it comes to food, and that obviously creates a very emotive discourse that can be a problem.
Chris Sandal: Yeah, definitely. I think part of that probably comes out of so much of the focus being on choices and the eradication of bringing in socioeconomics and all of those other factors that you talked about as being there, a lot of the time as if they’re not even a thing and they just don’t even get a look in. I think that can make it a lot more loaded in terms of how it feels for an individual than it would otherwise be if, as you say, the rhetoric around it was better.
Alan Flanagan: Yeah, exactly. The rhetoric can be improved, and I think there’s a broad acceptance now that the rhetoric can be improved. But these things are going to be slow to implement. The problem, certainly within the public health realm, is that they’re going to be slow to implement because there are so many different stakeholders at the table.
It’s easy for us as nutrition professionals to sit around and say “Oh my God, we have all this evidence for the effects of stigma,” or “We have evidence for the effects of behavior change,” and it’s very easy for us to view, as humans do, the problem merely through our own lens. The conversation takes on an entirely different complexion when there are multiple stakeholders at the table who aren’t an expert in your discipline, but have their experience from their own discipline, and that’s the lens through which they’re looking at it.
That is a very, very difficult place to be to try and bring in policy that reflects everything. Again, I think the recent Cancer Research UK example is probably quite a poignant example of that, because from their perspective, this was about raising awareness. They needed to make people aware, and awareness is good because people will change their behaviors once they’re aware. Totally divorced from the evidence about the effectiveness of positive versus negative messaging on behavior change. Totally ignorant of the evidence for – they weren’t ignorant of it; they were told about it. They just chose to ignore it. That’s the problem.
Chris Sandal: I also think the fact that it’s not just the public health messaging, it’s then all of the diet messaging and the blogs and the Instagram and all of that that’s giving this other message that’s encouraging people to be doing very problematic behaviors that’s happening alongside this, that then colors how someone thinks about public health messaging.
Alan Flanagan: Right, exactly. Social media is toxic for the most part. The influence that it has is enormously disproportionate to the level of expertise that is there. And because we are in the information age, there are no easy answers to the avenues through which people can receive misinformation now.
I don’t think social media does anything, really, that adds to this conversation in particular that we’re having. Social media, I think more than anything, is – and this is where we get more disconnected in the conversation, because on the one hand, you have the broader anti-diet and non-diet movement and the haze movement and otherwise, but on social media, that gets taken to this other ether where you have skinny nutritionists who’ve never had to diet screaming “diets don’t work!” at everyone.
So you get this massive disconnect between the rhetoric on social media, which is really artificially inflated in favor of one type of rhetoric, versus what we see at a public health level. It looks like there’s this massive discord, but in fact, the discord is really not about the nitty-gritty of what’s happening on the ground. The discord is about the perception that people get of the weight of these conversations because they’re exposed to it through things like social media.
01:43:00
Chris Sandal: The final thing I want to ask is, I see you’re joining Sigma Nutrition as their Research Communication Officer. What are you going to be doing there? What does that role entail?
Alan Flanagan: Nutrition being as fractured as it is, Danny has done such a great job over the years of cultivating a great brand in Sigma in being objective, in being committed to science-based discourse. Obviously the podcast as a vehicle to largely interview academics has been such a huge part of that.
I think what we really want to work on is trying to provide a resource to people in the public that, if there’s a position stand on a particular issue, it’s coming from a place of objectivity; it’s not coming from a belief system place. We’re putting out good information, we’re tackling some of the big questions in nutrition science and putting together very reasoned and objective critiques of the evidence that’s there to be able to try and start to come to some conclusions. I think the really important thing is Sigma’s independence in all of these conversations and the trust that people have in it.
So yeah, we have a couple of ideas for how we’ll start to communicate content. Nothing set in stone yet. We’re brainstorming. But very excited for how that content will translate, and very confident that we’re going to do a really great job of providing a resource that people can really trust, and trust that it’s objective, and trust that it’s not belief-system-driven, and trust that it’s truly science-based.
Chris Sandal: Nice. Is that what you would want to be doing as a career after the PhD? What’s your real passion area?
Alan Flanagan: It’s interesting. I came into the PhD with the Plan A very loosely being I’d love to get into research and continue and have a career in research and science – and nutrition, obviously. But I’m also realistic about how little funding there is in nutrition science. It’s scary/appalling that such a topic that we talk about every single day and is on everyone’s lips just has zero funding, really. Relative to other scientific disciplines.
Chris Sandal: And even within other scientific disciplines, there is the whole “publish or perish” problem.
Alan Flanagan: I’m live to those issues. I don’t want to end up just slogging through, trying to get funding, when I could be contributing to nutrition science in a different way. I love the communication aspect. I love the public-facing aspect and trying to help steer a more moderate conversation.
So to be honest, the Plan B that’s not really a B, but more of an A-2, could very well be that I simply finish the PhD and pursue more of that kind of private, more entrepreneurial avenue in, broadly speaking, science communication for nutrition.
Chris Sandal: Nice. You have a skill at being able to do that, so I wish you all the best.
Alan Flanagan: Thanks very much, Chris. Cheers.
Chris Sandal: Thank you for coming on the show. Where should people go if they want to find out more about you?
Alan Flanagan: @thenutritional_advocate on Instagram. This is going to be a few weeks before it comes out, right? So by the time this comes out, my own website will be live. I guess we can just link to it in the show notes, then.
Chris Sandal: Perfect. As I said at the beginning, Cut Through Nutrition, I highly recommend people check out that podcast as well.
Alan Flanagan: Great. Thanks very much, Chris.
Chris Sandal: Thanks for coming on.
Alan Flanagan: Cheers.
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