Fat checking … sorry, fact checking

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As I was living vicariously on Facebook again this afternoon, I came across a forwarded page from nutritionist Christine Cronau. She was previewing tonight’s (Australian) ABC episode of Catalyst, on the topic of the low fat diet.

It’s not that she or the ABC are necessarily wrong about low fat diets. Some scientists have been sceptical of the evidence for low fat diets every since they were proposed in the late 1970’s [1]. Often, low fat foods have been manufactured with extra sugar to make them palatable again [2]. So while western consumers have been thinking they’ve been doing the right thing, they’ve probably been making the problem worse.

We’re also a society of carnivores, and the meat consumed in modern society is much higher in saturated fat. Plant and seafood based diets contain a high number of poly-unsaturated fatty acids (omega-3 and omega-6) which has also been a recommendation for our heart health, however a study in JAMA in 2012 suggested that high levels of omega-3 PUFAs did not protect from cardiovascular disease or reduce all cause mortality [3]. On the other hand, it appears that reviews of scientific research have suggested that saturated fat doesn’t pose a significant risk for cardiovascular disease or all-cause mortality either [4].

So it’s true that we may have to review exactly why plant based diets are good for us. What I raised an eyebrow at was her suggestion that, “What in the world did we do before cholesterol-lowering meds? Oh, that’s right, before we started mass producing sugar and back when we enjoyed plenty of saturated fat, heart disease was pretty much non-existent.”

This is a classic case of “two wrongs don’t make a right”. Sure, low fat diets are probably not the all-glorious panacea that they were touted to be, but suggesting that heart disease didn’t exist before the rise of sugar and low fat foods is grossly inaccurate. A quick glance at the data of the Australian Bureau of Statistics shows that heart disease peaked in the late 1960’s, which was coincidentally before we started mass producing sugar and back when we enjoyed plenty of saturated fat, and has since dropped significantly.

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Is that because of dietary guidelines recommending a low fat diet? There are many contributors to heart disease, so low fat diets can’t be singled out as the sole cause, especially in light of the reviews I discussed above. The reduction of smoking may be part of it, as smoking has dropped in the same amount of time, although a significant proportion of our population still smoke.

Whatever the reason, it isn’t a good reflection when you try and support your argument against a fallacy with a fallacy of your own. I haven’t read any of her other material, so her books maybe quite cogent. However, Ms Cronau’s Facebook post today provides a good example of how cognitive biases can sometimes blind us to facts that don’t agree with our chosen position, and why we all need to be careful when evaluating the evidence of “experts” on line.

References

  1. La Berge, A.F., How the ideology of low fat conquered america. J Hist Med Allied Sci, 2008. 63(2): 139-77 doi: 10.1093/jhmas/jrn001
  2. Malnick, E., et al. Low fat foods stuffed with ‘harmful’ levels of sugar. The Telegraph, 2014. http://www.telegraph.co.uk/health/healthnews/10668189/Low-fat-foods-stuffed-with-harmful-levels-of-sugar.html
  3. Rizos, E.C., et al., Association between omega-3 fatty acid supplementation and risk of major cardiovascular disease events: a systematic review and meta-analysis. JAMA, 2012. 308(10): 1024-33 doi: 10.1001/2012.jama.11374
  4. Hoenselaar, R., Saturated fat and cardiovascular disease: the discrepancy between the scientific literature and dietary advice. Nutrition, 2012. 28(2): 118-23 doi: 10.1016/j.nut.2011.08.017
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Dr Caroline Leaf and the 98 Percent Myth

Dr Caroline Leaf believes that nearly all our diseases come from our thoughts.

Dr Caroline Leaf believes that nearly all our diseases come from our thoughts.

In the hustle and bustle of daily life, most people wouldn’t stop to consider what makes people sick.  In my profession, I get a front row seat.

In the average week, I get to see a number of different things.  Mostly “coughs, colds and sore holes” as the saying goes, although there are some rarer things too.  And sometimes, people present with problems that aren’t for the faint of heart (or stomach – beware of nail guns is all I can say).

Normally, the statistics of who comes in with what doesn’t make it beyond the desk of the academic or health bureaucrat.  The numbers aren’t as important as the people they represent.

But to Dr Caroline Leaf, Communication Pathologist and self-titled Cognitive Neuroscientist, the numbers are all important.  To support her theory of toxic thoughts, Dr Leaf has stated that “75 to 98% of mental and physical (and behavioural) illness comes from one’s thought life” [1: p37-38].  She has repeated that statement on her website, on Facebook, and at seminars.

As someone with a front row seat to the illnesses people have, I found such a statement perplexing.  In the average week, I don’t see anywhere near that number.  In general practices around Australia, the number of presentations for psychological illnesses is only about eight percent [2].

But Australian general practice is a small portion of medicine compared to the world’s total health burden.  Perhaps the global picture might be different?  The World Health Organization, the global authority on global health, published statistics in November 2013 on the global DALY statistics [3] (a DALY is a Disability Adjusted Life Year).  According to the WHO, all Mental and Behavioural Disorders accounted for only 7.2% of the global disease burden.

You don’t need a statistics degree to know that seven percent is a long way from seventy-five percent (and even further from 98%).

Perhaps a large portion of the other ninety-three percent of disease that was classified as physical disease was really caused by toxic thoughts?  Is that possible?  In short: No.

When considered in the global and historical context, the vast majority of illness is related to preventable diseases that are so rare in the modern western world because of generations of high quality public health and medical care.

In a recent peer-reviewed publication, Mara et al state, “At any given time close to half of the urban populations of Africa, Asia, and Latin America have a disease associated with poor sanitation, hygiene, and water.” [4] Bartram and Cairncross write that “While rarely discussed alongside the ‘big three’ attention-seekers of the international public health community—HIV/AIDS, tuberculosis, and malaria—one disease alone kills more young children each year than all three combined. It is diarrhoea, and the key to its control is hygiene, sanitation, and water.” [5] Hunter et al state that, “diarrhoeal disease is the second most common contributor to the disease burden in developing countries (as measured by disability-adjusted life years (DALYs)), and poor-quality drinking water is an important risk factor for diarrhoea.” [6]

Diarrhoeal disease in the developing world – the second most common contributor to disease in these countries, afflicting half of their population – has nothing to do with thought.  It’s related to the provision of toilets and clean running water.

We live in a society that prevents half of our illnesses because of internal plumbing.  Thoughts seem to significantly contribute to disease because most of our potential illness is prevented by our clean water and sewerage systems.  Remove those factors and thought would no longer appear to be so significant.

In the same manner, modern medicine has become so good at preventing diseases that thought may seem to be a major contributor, when in actual fact, most of the work in keeping us all alive has nothing to do with our own thought processes.  Like sanitation and clean water, the population wide practices of vaccination, and health screening such as pap smears, have also significantly reduced the impact of preventable disease.

Around the world, “Recent estimates of the global incidence of disease suggest that communicable diseases account for approximately 19% of global deaths” and that “2.5 million deaths of children annually (are) from vaccine-preventable diseases.” [7] Again, that’s a lot of deaths that are not related to thought life.

Since 1932, vaccinations in Australia have reduced the death rate from vaccine-preventable diseases by 99% [8].  Epidemiological evidence shows that when vaccine rates increase, sickness from communicable diseases decrease [9: Fig 2, p52 & Fig 8, p67].

Population based screening has also lead to a reduction in disease and death, especially in the case of population screening by pap smears for cervical cancer.  Canadian public health has some of the best historical figures on pap smear screening and cervical cancer. In Canada, as the population rate of pap smear screening increased, the death rate of women from cervical cancer decreased.  Overall, pap smear screening decreased the death rate from cervical cancer by 83%, from a peak of 13.5/100,000 in 1952 to only 2.2/100,000 in 2006, despite an increase in the population and at-risk behaviours for HPV infection (the major risk factor for cervical cancer) [10].

And around the world, the other major cause of preventable death is death in childbirth.  The risk of a woman dying in childbirth is a staggering one in six for countries like Afghanistan [11] which is the same as your odds playing Russian Roulette.  That’s compared to a maternal death rate of one in 30,000 in countries like Sweden.  The marked disparity is not related to the thought life of Afghani women in labour.  Countries that have a low maternal death rate all have professional midwifery care at birth.  Further improvements occur because of better access to hospital care, use of antibiotics, better surgical techniques, and universal access to the health system [11].  Again, unless one’s thought life directly changes the odds of a midwife appearing to help you deliver your baby, toxic thoughts are irrelevant as a cause of illness and death.

Unfortunately for Dr Leaf, her statement that “75 to 98 percent of mental, physical and behavioural illnesses come from toxic thoughts” is a myth, a gross exaggeration of the association of stress and illness.

In the global and historical context of human health, the majority of illness is caused by infectious disease, driven by a lack of infrastructure, public health programs and nursing and medical care.  To us in the wealthy, resource-rich western world, it may seem that our thought life has a significant effect on our health.  That’s only because we have midwives, hospitals, public health programs and internal plumbing, which stop the majority of death and disease before they have a chance to start.

Don’t worry about toxic thoughts.  Just be grateful for midwives and toilets.

References

1.         Leaf, C.M., Switch On Your Brain : The Key to Peak Happiness, Thinking, and Health. 2013, Baker Books, Grand Rapids, Michigan:

2.         FMRC. Public BEACH data. 2010  [cited 16JUL13]; Available from: <http://sydney.edu.au/medicine/fmrc/beach/data-reports/public%3E.

3.         World Health Organization, GLOBAL HEALTH ESTIMATES SUMMARY TABLES: DALYs by cause, age and sex, GHE_DALY_Global_2000_2011.xls, Editor 2013, World Health Organization,: Geneva, Switzerland.

4.         Mara, D., et al., Sanitation and health. PLoS Med, 2010. 7(11): e1000363 doi: 10.1371/journal.pmed.1000363

5.         Bartram, J. and Cairncross, S., Hygiene, sanitation, and water: forgotten foundations of health. PLoS Med, 2010. 7(11): e1000367 doi: 10.1371/journal.pmed.1000367

6.         Hunter, P.R., et al., Water supply and health. PLoS Med, 2010. 7(11): e1000361 doi: 10.1371/journal.pmed.1000361

7.         De Cock, K.M., et al., The new global health. Emerg Infect Dis, 2013. 19(8): 1192-7 doi: 10.3201/eid1908.130121

8.         Burgess, M., Immunisation: A public health success. NSW Public Health Bulletin, 2003. 14(1-2): 1-5

9.         Immunise Australia, Myths and Realities. Responding to arguments against vaccination, A guide for providers. 5th ed. 2013, Commonwealth of Australia, Department of Health and Ageing, Canberra:

10.       Dickinson, J.A., et al., Reduced cervical cancer incidence and mortality in Canada: national data from 1932 to 2006. BMC Public Health, 2012. 12: 992 doi: 10.1186/1471-2458-12-992

11.       Ronsmans, C., et al., Maternal mortality: who, when, where, and why. Lancet, 2006. 368(9542): 1189-200 doi: 10.1016/S0140-6736(06)69380-X

Autism Series 2013 – Part 3: The Autism “Epidemic”

Weintraub, K., Autism counts. Nature, 2011. 479(7371): 22-4.

Weintraub, K., Autism counts. Nature, 2011. 479(7371): 22-4.

It seems that autism is on the rise.  Once hidden away in institutions or just dismissed as odd, society is now faced with a condition that it is yet to come to grips with.  Some out in the community believe that it must be a toxin, or vaccines or mercury.  Others accuse doctors of simply giving in to the unreasonable demands of pushy parents to defraud the system of money – “Things have reached the point these days where any kid that’s not a charming little extrovert will be accused of being, ‘on the spectrum.’”[1]

So is there an epidemic of kids who are “not charming little extroverts”?  It depends on who you ask.

Take, for example, two articles written in the year 2000.  In the first, titled “The autism epidemic, vaccinations, and mercury”, Rimland said,

“While there are a few Flat-Earthers who insist that there is no real epidemic of autism, only an increased awareness, it is obvious to everyone else that the number of young children with autism spectrum disorders (ASD) has risen, and continues to rise, dramatically.”[2]

The other, written by Professor Tony Attwood, a world authority on Aspergers Syndrome, said,

“… is there an epidemic of people being diagnosed as having Asperger’s Syndrome? At present we cannot answer the question, as we are unsure of the diagnostic criteria, the upper and lower levels of expression and the borders with other conditions. Nevertheless, we are experiencing a huge increase in diagnosis but this may be the backlog of cases that have been waiting so long for an explanation.”[3]

I don’t think it’s very often Prof Attwood is lumped with ‘flat-earthers’.  But you can see the change in perspective from one side looking objectively to the other who need for there to be an “epidemic” of autism in order to strengthen their case.

So who’s right?  To see if this autism “epidemic” hypothesis has any real merit, we need to delve into some numbers.

First, some basic epidemiology – because part of the confusion in looking at the autism numbers is defining exactly what those numbers represent.  Here are some important epidemiology terms from the “Physicians Assistant Exam for Dummies”[4]:

Incidence: For any health-related condition or illness, incidence refers to the number of people who’ve newly acquired this condition.

Prevalence: Prevalence concerns the number of people who have this condition over a defined time interval.

Most autism figures are for prevalence, or often more specifically, point prevalence – “the number of people who have this condition at any given point in time.”

The other thing to remember from my last blog is that initially autism was only diagnosed on the strict rules of Kanner, and was considered to be a single disease caused mainly by bad parenting [5].  So through the 1960’s and 1970’s, only the most severe children were diagnosed as having autism because the high-functioning autism would not have met Kanners criteria, and even if they did, most parents didn’t want the label for fear of the social stigma.

So then, what are the numbers?  The early prevalence was estimated to be less than 5/10,000 or 1 in 2000[6], although in surveys done after 1987, the numbers began to rise past 7/10,000[7].  In the 1990’s, Autism prevalence climbed into the teens and the latest prevalence has been documented for autism is 20.6/10,000[7].

But that’s only about 1 in 485.  The CDC estimated a prevalence of 1 in 88 (113/10,000)[8].  Where did the other 400 people go?

This is where the importance of definitions is highlighted.  Autism is considered part of a spectrum, and at the time of the surveys reviewed by Fombonne, DSM III then DSM IV considered conditions like Pervasive Developmental Disorder and then Aspergers Disorder to be part of that spectrum.  Adding in the rate of PDD and you have a figure of 57.7/10,000 and adding in Aspergers gives you a combined rate of 63.7/10,000, or 1 in 157 people surveyed[7].

And yet even then, who you measure and how you measure makes much more of a difference, because a recent, rigorous study targeting all 7 to 12 year old children in a large South Korean populous found a prevalence of 2.64%, which is 264/10,000 or 1 child in every 38.  The authors noted that, “Two-thirds of ASD cases in the overall sample were in the mainstream school population, undiagnosed and untreated. These findings suggest that rigorous screening and comprehensive population coverage are necessary to produce more accurate ASD prevalence estimates and underscore the need for better detection, assessment, and services.”[9]

So if there has been a fifty-fold change in prevalence (from 5 to 264 cases per 10,000 people) in just thirty years, isn’t that an epidemic?

Well, no.  As much as some might ignorantly deny it, there is no real evidence for it.  Remember the definitions from the “Physicians Assistant Exam for Dummies”[4]:

Incidence: For any health-related condition or illness, incidence refers to the number of people who’ve newly acquired this condition.

Prevalence: Prevalence concerns the number of people who have this condition over a defined time interval.

It’s the rapid rise in the number of new cases diagnosed that defines an epidemic, which is the incidence and not the prevalence[10].  While the prevalence has changed a lot, the incidence has been fairly stable.  From Nature, “Christopher Gillberg, who studies child and adolescent psychiatry at the University of Gothenburg in Sweden, has been finding much the same thing since he first started counting cases of autism in the 1970s. He found a prevalence of autism of 0.7% among seven-year-old Swedish children in 1983 and 1% in 1999. ‘I’ve always felt that this hype about it being an epidemic is better explanation’, he said.”[11]

Fombonne agrees. “As it stands now, the recent upward trend in estimates of prevalence cannot be directly attributed to an increase in the incidence of the disorder.”[7]  He said later in the article that a true increase in the incidence could not be ruled out, but that the current epidemiological data which specifically studied the incidence of autism over time was not strong enough to draw conclusions.

While there’s no epidemic, there is the real issue of the genuinely increasing prevalence.  Why the rise in those numbers?  Fombonne went on to explain, “There is good evidence that changes in diagnostic criteria, diagnostic substitution, changes in the policies for special education, and the increasing availability of services are responsible for the higher prevalence figures.”[7]  Nature published a graph from the work of Professor Peter Bearman, showing that 54% of the rise in the prevalence of autism could be explained by the refining of the diagnosis, greater awareness, an increase in the parental age, and clustering of cases in certain geographic areas.

Weintraub, K., Autism counts. Nature, 2011. 479(7371): 22-4. (Adapted from King, M. and Bearman, P., Diagnostic change and the increased prevalence of autism. International Journal of Epidemiology, 2009. 38(5): 1224-34 AND King, M.D. and Bearman, P.S., Socioeconomic Status and the Increased Prevalence of Autism in California. Am Sociol Rev, 2011. 76(2): 320-46.)

Weintraub, K., Autism counts. Nature, 2011. 479(7371): 22-4. (Adapted from King, M. and Bearman, P., Diagnostic change and the increased prevalence of autism. International Journal of Epidemiology, 2009. 38(5): 1224-34 AND King, M.D. and Bearman, P.S., Socioeconomic Status and the Increased Prevalence of Autism in California. Am Sociol Rev, 2011. 76(2): 320-46.)

From Nature: “The fact that he still cannot explain 46% of the increase in autism doesn’t mean that this ‘extra’ must be caused by new environmental pollutants, Bearman says. He just hasn’t come up with a solid explanation yet. ‘There are lots of things that could be driving that in addition to the things we’ve identified,’ he says.”[11]

There is no autism epidemic, just medical science and our population realising just how common autism is as the definition becomes more refined, people become more aware, and some other biosocial factors come into play.

What can we take from the numbers?  That we’re being overtaken by Sheldon clones?  That soon there will be no more “charming little extroverts”?  If the CDC figure is accurate, then one person in every hundred is on the spectrum, so the world is hardly being overtaken by autism.  But the take home message is that Autism Spectrum Disorders are more common that we ever thought, and there are more people on the spectrum “hiding in plain sight”.  If the study from South Korea is accurate then one person in every thirty-eight is on the spectrum, but two thirds of them are undiagnosed.

Should there be more funding, more resources, or more political representation for people on the spectrum?  Perhaps, although the public and research funds are not unlimited, and other health concerns should also be treated fairly.  But since autism is life long and impacts on so many areas of mental health and education, understanding autism and managing it early could save governments billions of dollars into the future.

Rather, I think that the climbing prevalence of ASD is a clarion call for understanding and tolerance.  If we learn to tolerate differences and practice discretionary inclusion, then both the autistic and the neuro-typical can benefit from the other.  That’s a world which we’d all like to live.

REFERENCES

1. Bolt, A. If the autistic don’t get full cover, where’s the money going? 2013  2013 May 11]; Available from: http://blogs.news.com.au/heraldsun/andrewbolt/index.php/heraldsun/comments/if_the_autistic_dont_get_full_cover_wheres_the_money_going/.

2. Rimland, B., The autism epidemic, vaccinations, and mercury. Journal of Nutritional and Environmental Medicine, 2000. 10(4): 261-6.

3. Attwood, T., The Autism Epidemic: Real or Imagined, in Autism Aspergers Digest2000, Future Horizons Inc: Arlington, TX.

4. Schoenborn, B. and Snyder, R., Physician Assistant Exam For Dummies. 2012: John Wiley & Sons.

5. Pitt, C.E. Autism Series 2013 – Part 2: The History Of Autism. 2013  [cited 2013 2013 Aug 15]; Available from: https://cedwardpitt.com/2013/08/15/autism-series-2013-part-2-the-history-of-autism/.

6. Rice, C.E., et al., Evaluating Changes in the Prevalence of the Autism Spectrum Disorders (ASDs). Public Health Reviews. 34(2).

7. Fombonne, E., Epidemiology of pervasive developmental disorders. Pediatric research, 2009. 65(6): 591-8.

8. Baio, J., Prevalence of Autism Spectrum Disorders: Autism and Developmental Disabilities Monitoring Network, 14 Sites, United States, 2008. Morbidity and Mortality Weekly Report. Surveillance Summaries. Volume 61, Number 3. Centers for Disease Control and Prevention, 2012.

9. Kim, Y.S., et al., Prevalence of autism spectrum disorders in a total population sample. American Journal of Psychiatry, 2011. 168(9): 904-12.

10. “Epidemic vs Pandemic”. 2013  [cited 2013 Sept 03]; Available from: http://www.diffen.com/difference/Epidemic_vs_Pandemic.

11. Weintraub, K., Autism counts. Nature, 2011. 479(7371): 22-4.