When faced with lots of options and conflicting opinion –
ask yourself if your living like HUE.
Why Health/Nutrition Science is Contradictory.
As a nutrition first medical doctor whose mission is to keep people on the right path (or get them back on the right path) toward longevity and healthspan, I am regularly asked about things that are recently publicized in the media, social media or in a documentary. I am asked about them because they are so often 180 degrees contradictory to something else another post/blog/news story/physician’s advice that they have also received. Should I take Vitamin D or is it worthless? Should I be “plant based” or “carnivore”? If fruit is loaded with antioxidants why would it be bad on a ketogenic diet? Are saturated fats lowering my insulin or raising my cholesterol? Does MCT in my coffee break my fast? All of the contrary evidence seems to be backed (at least in headline) by Medical/Scientific studies. How can both be right or wrong?
Antioxidant Cornucopia or Fat inducing Fructose load?
The problem is twofold – one is in the inherent difficulty in producing health/wellness/nutrition science and second is media/social media quoting of inherently flawed science as medical or scientific FACT. The latter is a source printing headlines without actually reading the results, conclusions or looking at the design of the study. Often times the headline news article or post is just inherently wrong based on what is actually resulted in the study and we should all be careful not to over-react.
In medicine and traditional science, we are empiricists. In an ideal setting we use a scientific method to prove or disprove a hypothesis. This time-tested system works pretty well when the question/hypothesis is black and white with a defined endpoint: Does X drug lower serum cholesterol levels. To test the hypothesis, you first determine the number of subjects you need to study to see the result (known as adequate POWER of the study), and the amount of TIME you need to run the study to see the desired effect. Then you need to match similar individuals (known as MATCHED CONTROLS) for things like age, sex, race, disease and randomly put them in two groups – one that receives the intervention and one that receives a placebo (known as RANDOMIZATION). Neither the participant nor the scientist observer knows which category a participant is in (known as DOUBLE BLINDING) and then the results are presented, and the hypothesis is proved (Drug X does affect cholesterol) or disproven (Drug X does not affect cholesterol). Lastly the study is analyzed for things that could have affected the results – these important factors are known as BIASES.
As you can see a LOT goes into adequately proving or disproving a theory/hypothesis. Indeed, it is why it is so expensive to do this type of study that has the appropriate DURATION, is adequately POWERED, CONTROLLED, DOUBLE BLINDED studies that is PROSPECTIVE (make an intervention and see the change). These studies although hard to do, are common (and in fact necessary to pass FDA) in the pharmaceutical world, they are rare to non-existent in the health/nutrition/supplement world.
How can this be when social media experts are constantly quoting “studies.” The studies quoted nearly universally fall short of the high standard set above. Rarely are they PROSPECTIVE (they are usually survey based RETROSPECTIVE), never are they BLINDED (You know if you are eating plant based food or steak), and often poorly POWERED (100 people rarely powers anything), insufficiently TIMED (atherosclerosis and vascular disease takes 30 years to develop, neurodegenerative usually longer), and lastly always inherently BIASED.
Compare the process above to the standard study on a particular diet and its influence on health. Since it takes 30 plus years to see changes like heart disease, cancer and other disease of aging, instead of being PROSPECTIVE and doing a 30-year study as above they are RETROSPECTIVE or EPIDEMIOLOGIC (studying groups). Nutrition studies usually ask groups of individuals (“Vegans” or “Standard Dieters”) what they ate over the past 10 years and look for their current health. Do you see the huge contrast in the scientific method above versus an inherently flawed study design of asking people to remember everything they ate over a decade? Unlike Chrissy Rudman, very few of us have logged food daily for a decade.
More importantly these are inherently biased. The two most common biases seen are Observer bias and something called the Healthy user bias. If you are paleo writing a blog post or creating a documentary, you are going to consciously or unconsciously select for the best outcome that fit your lifestyle/thought – the observer bias. Even for someone like me who is trained in medical dogma to be an empiricist, I often have to fight the urge to cheer or over focus on studies that supports my lifestyle or downplay studies that may refute it. As strong as this inherent bias is, I would argue more important and often more difficult to see is the healthy user bias.
The Healthy User Bias and The Healthy User Effect (HUE)
If we can pick the worst diet, nutrition and lifestyle in the world, it would be that of the “average” American. Too much sedentary time watching TV or on computer/phone. Reliance on a health care system built for fixing problems after they are broken rather than prevention. Most importantly, consuming a Standard American Diet (SAD) that is too high in total calories, processed foods, and sugars all consumed with no mindfulness and lots of distraction.
Enter the retrospective or epidemiological nutrition study. When you compare virtually ANY diet to that of the standard American diet, it will show benefit. Comparing the slowest human in the world to a turtle running a 100 meter race – the human will win, every time. Thus, if you compare Plant Based/Carnivore/Keto/Paleo to the SAD the controlled diet will show a benefit, every time. Enter media and selection bias and you get a reporting of science “facts” that are less facts and more of a RELATIVE BENEFIT.
This observer bias is complicated by the Healthy User Effect. Do you know someone who has been a Vegan/Pescatarian/Paleo person for years? Tell me, compared to the average American, someone who follows a nutrition plan, are they more or less likely to smoke? Are they more or less likely to exercise regularly? Are they more or less likely to do a check in with their doctor? My guess is its yes to just about all. Thus, users who engage in one “healthy” effect are more likely to engage in more than one.
Lots of gyms have smoothie bars located near their exits. I used to wonder that even though the nutritional content of some of the smooths is similar to that of what you would get at a donut shop, on average the people who visit the donut shop daily look different in body composition then that (on average) then those coming out of the gym with a smoothie. It is the magical power of the antioxidants? The increased leucine in the protein powder they add? I assure you those would be negated by the 50 grams of sugar. I think it is those that are drinking the smoothie are engaging in other more healthful behaviors throughout their day – they are the healthy users.
This is the bias. Is there less vascular disease in patients (pick your diet) because of the diet or because they also don’t smoke, exercise regularly, see their doctor who intervenes earlier, practice mindfulness or fill in whatever healthful behavior. These studies when comparing diets are phenomenally conflicted with healthy user bias.
The best researchers / practitioners and media often note this but then sometimes use healthy user bias as a hammer to strengthen their own observer bias – “the opposing study is inflicted with healthy user bias and thus should be dismissed”. Since we know that certain behaviors effect these studies to make them less reliable, instead of calling them biases, I call them HEALTHY USER EFFECTS.
I believe the key to longevity and healthspan is to maximize as many and for as long as possible the Healthy user effects (HUE). So when in doubt – always act like HUE.
Hi, I’m HUE
A good example of this was represented by a study on flu vaccines in the elderly. I am not diving into the topic of should you or should you not VAX but more on what they found on outcomes. The purpose of the vaccine push, especially in the elderly is less about preventing flu spread but more about preventing hospitalizations, ICU stays and death in the elderly or immunocompromised from influenza. Interestingly the study showed not a great effect on preventing hospitalizations HOWEVER, when they looked at the data a different way – hospitilazations and major health events in NON-FLU SEASON months in those elderly vaccinated versus not vaccinated they found statistically significant less hospitilazations and cardio-vascular events in the vaccinated elderly. Why is this? Is it some immune benefit to a flu shot we don’t know about? Maybe. More likely it is a healthy user effect. If you are choosing to seek medical care to prevent hospitalization with this treatment you are probably more likely to be doing other things (medication compliance, exercise, nutrition) then those that are not going to get this shot. The are simply being like HUE.
On Becoming Your own version of HUE.
Do you want to be plant based because you feel better on that and its better for our global eco-system? Awesome, but maximize your other HUEs and exercise, see your doctor and check your B12 level, and consider B12 and carnitine/carnosine supplementation. Want to be carnivore as your GI system has never felt better? OK, make sure you are eating nose-to-tail by adding organ meat and consider supplementing Vitamin C and Folate as well as checking your Cholesterol levels (YES BTW cholesterol (namely high LDL-P over time) DOES matter in creation of vascular disease).
Likewise, do you like traditional yoga and Pilates and hate traditional cardio/HIIT and Strength training? Fabulous but realize that all exercises have a purpose and know that in our 80’s we need flexibility, strength and the ability to walk a flight of stairs without shortness of breath to Improve lifespan and healthspan. Or do you just lift weights and not focus on flexibility? The largest predictor of death within one year the only risk factor was inability to pick yourself up off the floor with only one hand on ground. That takes strength AND flexibility.
Becoming HUE isn’t simple. It is compounded by those that want to tear down other lifestyles because they have a bias or financial interest in promoting their own choice. Find the things that help you find your own HUE and do as many as possible. This blog going forward is going to talk about proven HUE choices. Customize them. Change them as often as you like (I assess every 90 days my nutrition, exercise and supplement regimen) – its ok to be plant based for years and then add in meat/fish if you feel better, its ok (and probably better) to completely switch up your exercise routine and try something new. Get educated to where you are on your path, be mindful of the choices you are make and don’t just blindly follow and know what you are lacking. If you follow this path you will live a healthy, active long life…like HUE.
P.S. Speaking of being mindful, my next post is on the Importance of Mindfulness/Meditation in not just health but in happiness. If you want to pre-read on the best book I have read in a while click on the title of the link below for Mo Gawdat’s book “Solve for Happy“.
Guarantee it will be one of the best books you read in 2020. https://amzn.to/37h8qKj