(tw) Trigger warnings

As Libby Nelson recently observed, “There are probably more articles on the internet arguing about trigger warnings on college syllabuses than there are actual trigger warnings on college syllabuses”.

Even if their prevalence at universities is often overstated, they are frequently encountered on blogs, Facebook and other social media as a device for warning people that the ensuing discussion might contain distressing content.

fears-and-phobiasAs I’ve argued previously, trigger warnings can serve as a way to infantilise an audience, especially at universities where part of the point is to be exposed to challenging ideas. But they can equally serve a similar role to advisories on films, where an audience is forewarned that they might be exposed to violence, profanity, and so forth.

We’ve become accustomed to these warnings for films, and I’ve never heard of anyone finding them problematic. In fact, I suspect many more of us would be bemused – whether or not offended – to unwittingly purchase tickets for a movie featuring extreme violence without having been forewarned of this.

So one response to the issue of trigger warnings might be to say, why not include a simple (tw: violence) or somesuch before a discussion or link to an article describing the potentially “triggering” thing?

First, because there’s no consensus among psychologists* that this is the best way to handle the issue, even for people who might potentially be “triggered”. In fact, because “trigger warnings emphasize a victim rather than survivor role for the potential reader”, they “potentially increasing distress in the long-term via reinforcement of avoidance behaviors.”

And second, which is my focus here, they can treat us all as unable or unwilling to deal with stumbling upon content that might be distressing, and I worry that over-sensitivity of this sort might dampen expression of and debate on controversial topics.

Anything is potentially distressing for someone, so it’s difficult to see a logical (as in, necessary) end-point for trigger warnings, where there is some content that would never need a warning. And if everything gets a warning, that’s one less thing we need to think about – we don’t need to try and make certain judgments about who the speaker is and the context of the discussion, because that work has been done for us in advance.

The problems are at least two: what if that work has been done poorly, and we’re warned against things we don’t need protecting from? And second, making those judgements might well be a skill worth exercising and preserving.

Of course I’m aware that it’s easier for me to question the value of trigger warnings (to restate, given that I do think they have value: for me to question whether they are sometimes or often overused). And I’m well aware that much questioning of the value of trigger warnings comes from folk who have a profound insensitivity to the distress suffered by the people who often argue for trigger warnings.

But speaking from a position of relative sympathy for selective and thoughtful use of trigger warnings doesn’t mean I’m not concerned at what appears to be thoughtless use of them. To return to threat of over-sensitivity, mentioned above, we have to be able to tolerate occasional, accidental and/or marginal threats to our comfort, because any other world is practically impossible to arrange.

It would be impossible to arrange for even one person, never mind all of us. So the trigger warning conversation, and sensitivity to it, is a bi-directional negotiation: people who are speaking might need to try and avoid certain surprises (what? when? etc. are questions I’ll leave aside), but people who are listening also need to be as fair as possible in not placing undue responsibility or blame on a speaker.

As I say, I don’t know what we need to be sensitive of, or when. Well, that’s not quite true – I know as well as you do that we socially negotiate rules of conduct with the people we encounter, in a dynamic way. And the trigger warning debate does highlight that the game in question isn’t equitable, in that it privileges those of us who find little, if anything, sufficiently distressing to want to be forewarned of it.

But an equal and opposite overreaction isn’t desirable either. Here’s an example of what I mean, to finish this off. Last night, a friend Tweeted a link to an article in the guardian, headlined “Sudan’s security forces killed, raped and burned civilians alive, says rights group”.

He was criticised for not including a trigger warning, and his protestation that this was a headline that served as its own trigger warning for the article that followed didn’t satisfy the critic.

This is an overreaction first because, if the word rape appearing in a headline is triggering to you, it’s difficult to understand how you can survive on the Internet at all – there seems no way to arrange for an Internet that isn’t triggering in this way, and the requirement that we do so seems unduly onerous.

Second, and on another practical note, a Tweet is limited to 140 characters and at that sort of length, most of us would take in the Tweet at once, rather than parsing each word. In other words, there’s little or no time for a (tw) to do any substantive work in a headline like that – I don’t think it’s reasonable to think that anyone can see (tw) and then the word “rape” a few characters later, where that (tw) has had a chance to cause you to stop reading, or prepare yourself for that word in any way.

At this point, the trigger warning becomes less a thoughtful application of sensitivity to the interests of others, and more a thoughtless application of a disputed protocol. If we want our social justice concerns and interventions to be meaningful, I don’t think it sensible for us to turn them into clichés.

*Disclosure of potential bias, and a little shameless promo: the author of that post is a friend and my co-author of the forthcoming book Critical Thinking, Science, and Pseudoscience: Why We Can’t Trust Our Brains.

Charlie Charlie, wherefore art thou?

Ferlon Christians, the Western Cape Leader of the African Christian Democratic Party, would have you believe that the problem with the occult – especially in schools – is that we don’t take it seriously enough. In fact, the problem is the opposite one – we take the occult far too seriously.

“We” take it seriously enough, in fact, that our Department of Basic Education, which sometimes can’t even provide textbooks or toilets to schools, are dispatching “officials to investigate‚ together with school authorities‚ the ‘Charlie Charlie Challenge’”.

For those of you who aren’t Error Naidoo or Harry Potter, you can catch up on what the ‘Charlie Charlie’ challenge is by watching eNCA’s “full investigation”. Alternatively, you can take my word for the fact that it’s a parlour game involving creating a yes/no grid, stacking two pencils on top of each other, and then freaking out when gravity causes the pencils to move.

The freaking out is as a result of the “successful” summoning of a Mexican spirit who is mysteriously called Charlie, in honour of the many thousands of Mexicans who are called Charlie. You ask Charlie a question, and then the pencils move to provide a yes or no answer.

And, the freaking out on the part of Mr Christians, the Department of Basic Education and Bored from Bonteheuwel, that frequent caller to talk-radio, is due to simple superstition and ignorance.

You’d think that schools and national Departments of Education would use this as an opportunity to teach basic physics, as well as truths about human psychology such as confirmation bias. Instead, we read of school principals saying that “any pupil caught playing it will be expelled”, and of school pupils reporting suicides and school walls collapsing as a result of this game.

Well, this is what happens when you take a perfectly explicable phenomenon and add wacko metaphysics involving demons and curses to your explanation of it, just as we used to do with something like the Ouija board.

Seriously, parents, Mr Christians and the Department of Basic Education – if kids kill themselves as a result of playing Charlie Charlie, it’s not a Mexican demon’s fault. It’s the fault of a worldview detached from reality, and an education system that tolerates and even encourages that worldview.

In other words, and to some extent, it’s your fault, and blaming imaginary Mexican demons makes as much sense as blaming Harry Potter would.

Here’s a Whatsapp message a friend forwarded to me, which is apparently being circulated in one school:

Parents, guardians and learners.
This is extremely important.
I have received a letter from a school today encouraging parents to speak to there children about the Demonic Game Charlie Charlie they are playing on the schools nowadays.

A grade 4 boy fainted while playing this game and his pencil started spinning. When he woke up the pencil was still spinning.

Then I received a Whatsapp message of an incident that took place in Tafelsig Mitchells Plain today regarding this Demonic Game Charlie Charlie. Some boys placed two pens across each other and called out Charlie Charlie. The pens started to spin by itself and stopped by pointing at one boy.

This boy just started to bleed from his head profusely. The condition of the boy is still unknown.

According to our Ulama and experts in Jinn, its a demon (very dangerous jinn) from Mexico moving around schools inciting youngsters to play this game in order to harm them. This could even result in their death. Plz inform as many as you can.

And, for more hyperbole, consider this official press statement from the aforementioned ACDP Provincial Leader, Mr Christians:

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You can science too – it’s easy!

mouse-801843_1280If you’ve always wanted a career in science, but never got around to studying biology, physics or whatever it is that you’re interested in, don’t fear – being (treated as) an authority is easier than you might think.

First, find a conclusion you like. Let’s say, for example, the claim that sugar is addictive. Then, find a study that supports that conclusion, and publicise it:

In this study, conducted on rats, we are told that sugar is addictive – a line that Prof. Tim Noakes repeats with some regularity. It’s of course more complicated than that, but let’s not be negative – this is a post about how easy science is, after all.

Next, what you need is a way to discredit studies that say things that don’t support your conclusions. Don’t worry about being consistent at this point – it’s fine if you apply one standard to research that supports your conclusion, and another standard to research that doesn’t.

A mouse model shows that eating high-fat diets during pregnancy might ‘program’ your baby to be fat? Rubbish – mice are not women!

There’s a mouse study that shows high-carb diets lead to as long and healthy a life as any other diet? Rubbish – mice are not men!

(Some of you might, upon reading confounding studies, be tempted to think that science is complicated, and rarely – if ever – suitable for justifying dogmatism. Eliminate that negativity – there’s no place for it in sciencing!)

Now, what do you do when someone praises you as a lifesaver, but in doing so, also endorses avoiding conventional doctors, seeking out naturopaths, regarding “almost all” drugs as “toxic” and vaccines as “highly dangerous”?


Well, you retweet them, of course (while perhaps reciting your mantra that science is not religion). And if someone calls you out for endorsing vaccine quackery, do not fear – dismiss their question with an insult and an appeal to authority:

Like Ms. Child, I’m also not an expert on immunology. And no, I haven’t read the book, which apparently “needs to be read by everyone with an opinion on vaccination debate”.

But why would one read this book when a cursory Google search results in extensive, well-referenced accounts of (at least) 11 flat-out misrepresentations of data in that book?

Or, when you discover that the only places the author is taken seriously is sites like quack-central Mercola? If you’re still not convinced that you’d be wasting your time reading it, what if you learned that the author is sympathetic to homeopathy?

You’d think of her as a quack herself, I’d wager, and you’d certainly not endorse her as an authority. Unless, of course, you have a conspiracy story to tell about big pharma and the medical establishment colluding to sell you drugs, while hiding “the truth” from you.

But let’s imagine you ignore all that instead. Now, you know that the public are rather upset to hear anti-vaccine messages – after all, didn’t around 170 people get measles just this year (so far) in the USA, mostly thanks to being unvaccinated?

Also, you’ve been in trouble for appearing to endorse anti-vaxx messages before, when tweeting a link to a video featuring Andrew Wakefield on how the CDC arranged a cover-up of evidence relating to vaccines and autism.

(Maybe, you also think of that pesky HPCSA hearing coming up later this year, and how it might complicate things for you to appear to be supporting a viewpoint that is widely believed to indirectly kill people, especially babies.)

So, let’s just deny that the book is anti-vaccination, instead calling it something more grand, like a “unique historical analysis”.

Except, how do you square that with the publisher’s own description of the book, which tells us that the book argues that vaccines are not “responsible for the increase in lifespan and the decline in mortality from infectious diseases”, or accounts of her work like this one, from Dr. David Gorski?

I suppose you just hope that people take your word for it. While, perhaps, reciting your mantra that science is not religion, and calling anyone who disagrees with you a “troll”.

If you are happier and healthier on LCHF, great, I’m happy for you. But you can, and should, expect more from those who you take as your authorities on diet and more importantly, the scientific method.

As I’ve said before, I think the jury is out on the diet questions. It’s not out on vaccinations, and hasn’t been for quite some time now.

It’s shamefully irresponsible to suggest otherwise, and disingenuous to pretend that this isn’t what you’re doing in recommending books like those of Humphries.


Noakes is asking “have you read the book?” to anyone challenging him on this on Twitter. You don’t need to read the book – there are many interviews with this author available online, including an outline of the arguments in the book on sites like Mercola’s.

Asking if you’ve read the book is mostly serving Noakes as a way to refuse to contemplate the dereliction of common-sense that is anti-vaccination endorsement on this scale. But even if he refuses to contemplate that, you nevertheless can.

Here’s something else that might interest you, on the author in question, linking to various other strange views she holds.

#NoakesHearing, day 1: Reflections on futility

hpcsaAs anyone who clicked through to this piece probably knows, yesterday saw the start of a Health Professionals Council of South Africa (HPCSA) hearing to assess whether Prof. Tim Noakes is guilty of unprofessional conduct. The charge against Prof. Noakes states:

That you are guilty of unprofessional conduct or conduct which, when regard is had to your profession, in that during the period between January 2014 and February 2014 you acted in a manner that is not in accordance with the norms and standards of your profession in that you provided unconventional advice on breastfeeding babies on social networks (tweet/s).

I attended all of yesterday’s session, and offer some thoughts on what transpired, below. I have not attempted to catalogue everything that happened – if you want a more detailed account, the News24 live-blog offers an accurate summary.

On futility – once more with the distinctions

It continues to exasperate that I can think of only one person a handful of people who understand that there are (at least) two distinct issues at play in the general discussion around Noakes, LCHF and Banting. The first is the set of questions related to diet, and which is healthier for you.

In this set of questions, I’m bundling in long-term vs. short-term, treatment for obesity and diabetes, what proportion of population X are insulin-resistant and so forth. I do not, in general, comment on those issues. They are not a field of expertise for me. As I’ve repeatedly said, Noakes might well end up being a frontrunner in what eventually becomes scientific consensus.

The second set of questions relates to logic and philosophy of science, and to our responsibilities as educators, or journalists, or health professionals to discourage sloppy thinking on matters of significance (well, on all matters, but the stakes are sometimes higher than others).

So, I’ve consistently (with a few lapses, I’m sure) focused on the quality of argument that emerges from the Banting camp, rather than on the superiority of any particular conclusion. If you don’t care about those issues (you of course should), then you shouldn’t be reading my comments on them.

You certainly shouldn’t be asking me to present evidence that low-carb is bad, because that’s not what I’m claiming. You also shouldn’t be telling me that “there’s so much more bad science for the consensus” or somesuch, because maybe there is, and maybe there isn’t, but that’s not what I’m talking about. The fact that someone else (proponents of the consensus view) also does things wrong doesn’t give anyone else a free pass to be sloppy in their reasoning.

On futility II – the hearing that never happened

We spend the entire day hearing arguments about the constitution of the panel that was set to hear the case, and proceedings were eventually terminated at around 15:30 when it was agreed that the panel was improperly constituted. Proceedings will resume on November 23, assuming nothing else interferes with the process.

Should this hearing be happening at all?

I have mixed feelings about this. As with so many of our policies (and even heuristics related to social interaction), there’s a vast difference between what made sense in a pre-digital era and what makes sense now. Noakes is often to be found on Twitter – he’s written an ode to it, in fact, and his fans love him for how much he engages there.

The point of highlighting the pre/post-digital era is of course it would be irresponsible for a physician to encounter you in the street and tell you what your baby should eat, unless your advice is something rather generic and consensus-based. Even if the consensus is wrong, as Noakes thinks it is, it does sit with an advantage here – his job is to create a new consensus, after which he’ll get the same advantages.

But perhaps Twitter is different, in that it’s a broad discussion or sounding board for ideas, in which we shouldn’t expect people to view what Noakes tweets as prescriptions in the medical sense. That’s presumably what he thinks. I think he’s wrong in practice, because people do view them as prescriptions, and he should know that and act accordingly.

However, it’s possible that holding him to account for all possible consequences of his tweets does overstate the importance and role of Twitter, and also paternalise his Twitter following. For example, a non-prejudicial look at the tweet that started all the trouble is consistent with slowly weaning a child onto LCHF, perhaps in a manner that doesn’t run the risk of causing the complications the complainants in this case claim it would.

So, this case is raising very important background issues related to the appropriateness (or not) of how people with positions of influence engage on social media.It’s not going to be a waste of time, but is rather going to force everyone to resolve what I think are important issues.

It’s a great shame that many of Noakes’ supporters are struggling to see anything beyond a vendetta or bad faith here, and also that Noakes himself misses the point that it’s not about freedom of speech, but rather about the responsibilities of healthcare professionals to avoid causing harm.

He’d retort that it’s the Association for Dietetics in South Africa’s (ADSA) advice that causes the harm, but even if true (and even if he’s even representing what their advice is accurately), that’s something you demonstrate in journals, not with other people’s babies.

Is Noakes speaking “outside his field of expertise”?

One of the things that caused a fuss during the hearing was a statement made by the HPCSA’s lawyer that Noakes was operating or speaking as if he were a dietician, and that this is not his field of expertise. To briefly return to my futility theme, this was immediately leapt on by the Noakes-supporters as an attempt to suppress Noakes’ freedom to research and write on nutrition, while it was in fact nothing of the sort.

The argument was simply that because he’s operating outside of the “normal” General Practitioner (GP) set of ideas but rather as a dietician, it makes sense to include a dietician on the panel. Nevertheless, the motivated reasoning in response to this was quite something to behold, as it was immediately taken up as further evidence of the conspiracy against Noakes, who was now “not allowed” to talk about diet.

The clue as to what GPs do is in the name – they consult on a general set of health-related concerns, one of which is diet. But the claim made by the HPCSA lawyer was that Noakes was presenting himself as more than a generalist, but rather as a specialist in this area, and he should thus be assessed by a specialist also.

What was the problem with the panel composition?

The technical problem that (rightly) led to the cessation of the hearing was that the panel was lacking one particular member as per the regulations, where that member needed to be in Noakes’ profession, i.e. a GP. There was one GP on the panel, who was also a pediatrician, as well as a dietician (who I’ll return to in a moment), but there needed to be another Medical and Dental Board-registered GP present for a properly constituted panel.

What was interesting about the debate on the panel composition?

Both sides seemed intent on creating as favourable a panel as they could, which should of course be no surprise. The complainants argued strongly for the presence of a dietician, and Noakes’ lawyers argued strongly against. Noakes, of course, thinks that the dieticians exemplify bad science in this area, and he’d probably argue that they aren’t competent to assess the evidence he’ll present.

However, the problem with ruling them out is two-fold: one, it presents a circular argument, in that it assumes they are incompetent (or rather, cedes the argument regarding their competence) as reason to rule them out as assessors of the evidence; and two, if they are as incompetent as he thinks, surely it would be a simply matter to demonstrate this in the course of the hearing?

There’s the risk of a strategic blunder from the Noakes team here – the more intent they appear on trying to rule a dietician out as a panelist, the more people might wonder what they are so concerned about. If they are as scientifically backward as Noakes would have us believe, why not publicly expose that via the hearings?

And then….

The strange case of Prof. Blaauw

The dietician panelist, Prof. Blaauw, was initially considered a perfectly acceptable member of the panel, until we discovered two things about her (and the second, only rather late in the day). Over lunch, she informed the (superb) Chair of proceedings, Joan Adams, that she had once co-supervised an ethics thesis on the “media implications of Tim Noakes”. This was claimed to not impair her objectivity, and the Noakes legal team seemed happy with her, despite this knowledge.

Later on, though, we discovered that she was also a member of ADSA, whose President in fact laid the complaint against Prof. Noakes. This caused significant dissent around her suitability, as you’d expect it to given the conflict of interest.

Debate then ensued as to whether she was in fact legally part of the panel at all, as given that it had already been ruled that the panel was improperly constituted, she could not officially or automatically be considered part of a future, properly constituted panel either. Noakes’ lawyers went as far as to say that they might consider taking this issue to the High Court, if Prof. Blaauw ended up remaining on that future panel.

Bad faith and Tex bars

In an amusing turn of events, we reconvened after lunch to find that some prankster had placed Tex bars (a chocolate) on the desks in front of each panelist. Some of the Noakes supporters on Twitter immediately assumed that this was ADSA’s doing, which seemed to fit the generally uncharitable attitude on the #NoakesHearing hashtag, which also included some fat-shaming of various members of the complainant’s party.

Yes, these are emotive issues, and I can understand why people feel that someone they respect and admire for standing up to orthodoxy is being unfairly singled-out, but you don’t make an effective case for his virtue by demonstrating a lack of virtue yourselves. Even if “the other side” sometimes do the same, that does not make your doing so more appropriate either.

One of the Noakes supporters seems to have cottoned on to the reality that people like me don’t have a vendetta, but is rather simply interested in the arguments and ethics of how we debate them. But there’s still far too much ad hominem, and accusations of trolling put in terms that are themselves distinctly trollish. This is the problem of the filter bubble, as I’ve argued before, and I’ll again simply suggest that there is a conversation to be had here, and some of us are having it in good faith – whatever you might believe.

In conclusion

The Noakes legal team seem better prepared, and certainly appeared more effective in their rhetoric and argumentation. Now that the hearings have been extended to run for 7 days, I suspect that the complainants are going to have a difficult time competing. And, at the end of the day, Noakes will “win” on any permutation.

If he is (in the extreme scenario) struck off the roll and disallowed from practicing medicine, that’s of little consequence to his main interest, which is research and (mostly public) dissemination of findings related to diet. And, he and his supporters will have further “evidence” of his persecution.

And if he wins, that will of course serve as his – and the Banting diet’s – most significant tipping point towards public acceptance yet…

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P.S.: The screenshot above is from Noakes’ Real Meal Revolution website, and you might find the last bullet-point of interest.

Sugar given Carte Blanche to cause panic

When you (by which I mean, the average person) thinks about something as being “addictive”, I think we mean that the substance or activity in question is particularly likely to cause you to develop some combination of dependence, tolerance, cravings and withdrawal symptoms.

You’d also, if addicted, go to significant lengths to obtain the thing that you are addicted to. On a trivial end of this spectrum, people who smoke cigarettes might walk out into a cold and rainy evening to go and purchase cigarettes, instead of staying under the duvet like any sensible (i.e., non-addicted) person would.

When you think of addiction, in other words, I’d guess that you typically don’t mean that you know this fellow, George, who has become so obsessed with playing Minecraft that you describe Minecraft as addictive, as opposed to acknowledging that people can become “addicted” to Minecraft.

sugarThe distinction is important, and points to one of the significant problems in discourse around sugar “addiction”, as recently portrayed on the South African current affairs show, Carte Blanche. It’s important because the things we like are rewarding at the level of the brain, in that they result in dopamine release – but this does not necessarily mean that they are addictive in the stronger sense that we tend to reserve for things that you can’t help but find rewarding.

In other words, there’s almost zero chance of my becoming addicted to running, because I don’t like doing it, and tend not to do it. But there’s a significant chance – and a similar chance to your chance – of my becoming addicted to heroin, if either of us were to try it.

We’re using the word “addictive” in a very broad sense when we describe the Internet, exercise, and sugar as addictive. In fact, the sense in which it’s being used is broad enough as to mostly lose its meaning, by contrast to the strong sense in which certain substances are very likely to result in the sorts of reactions mentioned above, for many people.

Most of us exercise, use sugar or the Internet, and have sex quite unproblematically (in terms of addiction, Beavis). More of us use things like heroin or cocaine unproblematically than the standard sorts of addiction panics claim also, but that’s a story for another day. The point I’m making here is quite simply that any claim that sugar is “addictive” is using the word “addictive” in a misleading and hyperbolic way.

Long-term addiction is the exception, not the rule – we suffer from a confirmation bias here in the sense that we don’t get to hear about the people who live with addictions that are largely under control and remitting (in other words, most of them). We hear about the horror-stories, of people struggling with a demon, and (sometimes) heroically fighting it off.

And, as the cases and science detailed in Johann Hari’s Chasing the Scream persuasively suggest, the primary vehicle we have for escaping addiction is to give ourselves a sense of purpose and above all, agency – and agency is last thing that panics around things like sugar addiction have time for. Instead, the narrative is all about you being a victim of conspiracy.

You can watch the Carte Blanche insert yourself, in which you’ll be told that “sugar may be as addictive as nicotine and hard drugs”, that sugar can “hijack the brain” and so forth. But what you’ll mostly see is three self-described (and apparently self-diagnosed) sugar addicts telling you how addictive it is.

Their primary scientific resource, Prof. Nicole Avena, doesn’t even herself support the strong addiction claim, saying “a little bit of sugar won’t hurt you. It’s not a bad thing in general, it’s just the way we are consuming it is a bad thing”. The “we” is perhaps too broad there, in the sense that many of us who aren’t on LCHF-type diets have been restricting added sugars for our entire lives already, given that warnings about refined sugars have been a staple of dietary advice for quite some time now.

Nevertheless, I’d agree that people are eating too much sugar. And, people who are prone to compulsive behaviour might well find themselves becoming “addicted” to sugar – and you wouldn’t be surprised to find (as you do in one of the three cases presented in the show) that these people can become “addicted” or even addicted to a range of things over the course of their lives.

The problem, in short, might be with their lives and their circumstances – at least in large part – rather than in the substances or activities. We should not be surprised that our brains find food rewarding, and that we seek it out. We’d be surprised if it was any other way. But if we can (typically, as with most consumers of sugar) control the impulse to eat too much of it, then addicts need to shoulder a large portion of the responsibility themselves, and not hand it over to sugar.

But, say some (and as presented at 2m21s in the video, with an unfortunate reference to quack-central Natural News), studies prove that sugar is more addictive than cocaine. Unfortunately, studies prove what you want them to, depending on which studies you read, and which you ignore.

Plus, of course, how attentively you read them can be an issue – as I’ve noted before, Avena and others are far more circumspect and tentative than they are presented to be by the media and vested interests. Her own oft-cited paper is full of scare-quotes for the word “addiction”, and stresses that “whether or not it is a good idea to call this a “food addiction” in people is both a scientific and societal question that has yet to be answered.”

The hyperbole in blogs and online news sources, never mind repositories of the worst sorts of pseudoscience like Natural News, don’t help resolve these issues. Neither do personal anecdotes, regardless of our compassion for people who struggle with compulsive behaviour of various sorts. Movies like Fed Up are of little use also, in that they simply populate the scaremongering filter-bubble with cherry-picked and misrepresented data.

If you want to read about why the Lenoir et. al. study quoted in Natural News doesn’t resolve my doubts about sugar addiction, not to mention comparing rat data to human experience – especially given the fact that psychological rather than physiological factors seem most relevant to addiction – I’d recommend reading this Scicurious post closely.

That post points out that there’s perhaps a vast difference between the self-administration of drugs in humans compared with rats, who can’t reason about their choices like we can. It also notes that the study doesn’t measure a progressive ratio – in other words, it doesn’t tell us what the rat prefers when it really has to work to get its reward. When things get tough, will it prefer sugar, or will it quit trying?

We don’t yet have good human data for sugar addiction. What we do seem to have is limited evidence for “eating addiction“, but as I’ve stressed above, an addictive behaviour is not the same thing as an addictive substance. People who are addicted to eating might well find foods – including sugar – deeply rewarding, but it’s premature to blame the sugar itself.

To conclude: there’s no problem with saying we find sugar rewarding. Of course we do, as we would exercise and so forth. To say it’s addictive makes a far stronger claim, and that claim is the suggestion that it’s a sinister substance that’s out to get you, rather than something you’re free to enjoy in moderation, just as you can alcohol or any other drug, depending on the legislation where you live, and your own personal risk-tolerance.

One thing I’m quite concerned about, though, and have noted before, is that it seems quite likely to me that your risk-tolerance can only be compromised through being treated like a perpetual victim – and that believing your food is out to kill you seems a wholehearted embracing of that victimhood.

Saturated fat not exonerated in 2015 US dietary guidelines

I’m traveling back from giving a talk to a room full of dieticians about their social responsibilities, in which I emphasised that one of their important tasks is to try to beat back the surge of hyperbole and exaggeration coming out of the Banting and LCHF camps.

There are plenty of posts here on Synapses on the topic, many dealing with Professor Tim Noakes and how his confirmation bias has led him to re-tweeting false and potentially dangerous claims. You’d recall him “just asking questions” on vaccines and autism, or spreading the (false) idea that Sweden had become the first nation to “officially” adopt LCHF as their diet.

imagesAs I’ve said many a time, and repeated at the talk last night, some of the ways in which we can aid the spread of scientific literacy is through simply reminding people of the virtues of not overstating the evidence we have for our claims, and also through encouraging people to be consistent in their judgements – if something is wrong in one case, it’s usually wrong in similar cases also.

A recent example of salesmanship trumping science arrived in time to include in my remarks, and I also want to note it here for folks who have been following the topic. Yesterday morning, Prof. Noakes tweeted

The text of the tweet is a quote from the linked post, so not Noakes’ words, but I am fairly confident that he endorses the sentiment seeing as he’s frequently said similar things. Many times, they have in fact been described as “tipping points”, which makes one wonder how many tipping points are necessary before whatever it is actually gets around to tipping.

Anyway – if you go read the post that is linked to in the Tweet, you’ll find that it’s a smug “I told you so” by Dr Malcolm Kendrick, author of “The Cholesterol Con”. What he wants to gloat about is that he was right all along, and that in short, “cholesterol is healthy, saturated fat is healthy, salt is healthy and sugar is unhealthy”. Speaking of the 2015 Dietary Guidelines Advisory Committee’s (DAG) report, he says:

The entire report, I believe, stretches to about a bazillion pages. However, here are four of the highlights.

Cholesterol is to be dropped from the ‘nutrients of concern’ list. [I love that phrase ‘nutrient of concern’].

Saturated fat will be… ‘de-emphasized’ from nutrients of concern, given the lack of evidence connecting it with cardiovascular disease.’ [Whatever de-emphasizing may be. Pretending you never said it in the first place, I suppose].

There is concern over blanket sodium restriction given the… ‘growing body of research suggesting that the low sodium intake levels recommended by the DGAC (Dietary Guidelines Advisory Committee) are actually associated with increased mortality for healthy individuals.’

And… ‘The identification and recognition of the specific health risks posed by added sugars represents an important step forward for public health.’

The entire report does indeed stretch to a bazillion pages, or close enough at 571 pages. I presume that’s why Kendrick hasn’t read it, and therefore goes on to substantially misrepresent what it says.

To say that “cholesterol is healthy” is misleading because while dietary cholesterol has been de-emphasised, the DAG has not concluded that cholesterol in the blood is unproblematic – contrary to what Noakes’ journalist has reported.

To say that saturated fat will be “de-emphasised” is literally false, as that line comes from the Academy of Nutrition and Dietetics, who (this press release is even pasted in Kendrick’s post) say that they support “the DGAC in its decision to drop dietary cholesterol from the nutrients of concern list and recommends it deemphasize saturated fat from nutrients of concern” (my emphasis).

So, the Academy of Nutrition and Dietetics say to DGAC “good work, but you could do better” (on their model, of course). But the report does not say what Kendrick says it does, and the US Guidelines will continue to warn against overconsumption of saturated fat. If you read it, or even do a simply word-search for “saturated”, you’d know that, because you’d read that they recommend “less than 10 percent of total calories from saturated fat per day”.

I didn’t read up on the sodium commentary, and agree that added sugars are problematic (while not being addictive), so will say nothing about those last two bullet points, except to quote the report in saying “the DGAC also found that two nutrients—sodium and saturated fat—are overconsumed by the U.S. population relative to the Tolerable Upper Intake Level set by the IOM or other maximal standard and that the overconsumption poses health risks.” Go figure.

But before wrapping up by giving you a few quotes from the DGAC report’s conclusions, I’d like to note the double-standards at play in endorsing the Academy of Nutrition and Dietetics’ comment to the report, as Kendrick does and Noakes would likely do also, seeing as he’s explicitly told us that saturated fat is not a concern.

When the Association for Dietetics in South Africa (ADSA) decided to report Noakes to the Health Professions Council for “unprofessional conduct”, he and his supporters had a field day on Twitter looking at ADSA’s list of sponsors, and then dismissing ADSA’s case on the grounds that they had had financial dealings with Kelloggs and other (allegedly) evil corporations.

Why is the same standard not applied to the Academy of Nutrition and Dietetics, who have been the subject of a Senate enquiry thanks to their pharmaceutical connections, and who have a list of sponsors and funders a mile long, including Sarah Lee (makers of evil carb products!), Coca Cola (so very evil!) and evil Monsanto (the Great Satan!).

It can’t simply be because they say the right things, can it? Because that’s not how science works, as the Doctor and Professor surely know.

Lastly, seeing as the Noakes’ echo chamber on Twitter is in full swing with “see, he’s vindicated!” types of comments following the release of the DAG report, I’ll leave you with this quote from it. Make up your own minds as to whether it supports Banting, or whether it’s largely the same advice as ever.

The dietary patterns associated with beneficial outcomes for cardiovascular disease:

Dietary patterns characterized by higher consumption of vegetables, fruits, whole grains, low-fat dairy, and seafood, and lower consumption of red and processed meat, and lower intakes of refined grains, and sugar-sweetened foods and beverages relative to less healthy patterns; regular consumption of nuts and legumes; moderate consumption of alcohol; lower in saturated fat, cholesterol, and sodium and richer in fiber, potassium, and unsaturated fats.

The dietary patterns associated with beneficial outcomes for obesity:

Dietary patterns that are higher in vegetables, fruits, and whole grains; include seafood and legumes; are moderate in dairy products (particularly low and non-fat dairy) and alcohol; lower in meats (including red and processed meats), and low in sugar-sweetened foods and beverages, and refined grains; higher intakes of unsaturated fats and lower intakes of saturated fats, cholesterol, and sodium.

Dietary patterns in childhood or adolescence that are higher in energy-dense and low-fiber foods, such as sweets, refined grains, and processed meats, as well as sugar-sweetened beverages, whole milk, fried potatoes, certain fats and oils, and fast foods are associated with an increased risk.

(But the diet’s not for everyone, only for the insulin resistant!) The dietary patterns associated with beneficial outcomes for Type 2 diabetes:

Dietary patterns higher in vegetables, fruits, and whole grains and lower in red and processed meats, high-fat dairy products, refined grains, and sweets/sugar-sweetened beverages.


Flu vaccines might be ineffective, so try… water (otherwise known as Oscillococcinum)?

A friend forwarded a press release issued by “LeBron Health” to me, and the quackery it contains is too delightful to keep to myself. But because the press release also trades on fear-mongering of a rather pathetic sort, it’s also an reminder of how uninformed or unethical some medical “professionals” are, and of how quackery can harm in scaring people away from effective treatment.

The press release discusses the upcoming flu season in South Africa, and in particular, how to cope with the H3N2 strain of influenza. The H3N2 strain of influenza is indeed deadly, having reportedly killed dozens of children during the most recent US winter. That’s not good, of course – we’d like the number of deaths to either be 0, or much closer to 0 than that.

However, the number of deaths and hospitalisations this winter have not been significantly out of the normal range – the flu is not killing more people than it typically does. Furthermore, it’s also quite routine for the CDC to “issue a health warning to doctors”, as they are reported by the press release to have done. A “health warning” is not an advisory broadcast regarding an impending apocalypse, but (typically) simply information that the CDC thinks practitioners might find useful.

The health warning itself also reports something quite mundane on an aggregate level (though of course not mundane at all if you’re someone who has had flu-related illness or death in the family). It simply says that the current vaccine can’t compete effectively against H3N2, and that everyone should be prepared for a bad flu season.

This is also routine – vaccine developers select flu strains in January to May (for the US), based on which strains they predict will be most prevalent, and vaccination then begins in October. Things can change between those two phases – they are 5 months or more apart, after all – and one of the things that can change is the seriousness with which you could have (with perfect hindsight) regarded the threat of a particular influenza strain.

But you can’t know, 6 months in advance, and so you make the most informed predictions you can. Some years, the vaccine works very well, because you picked the right strains, and other years it works far less well.

And here’s the frustrating thing: in December last year (when the flu season hit the USA), the same scaremongering was prevalent. We read that the CDC had “admitted” that the vaccine doesn’t work, just as in this local press release’s headline, which claims that “flu vaccines may not work”.

Well, the CDC admitted nothing of the sort, and the flu vaccine “works” just fine, within the parameters of how it normally works, where the reasonable standard is never “perfectly”.

Even though this might be a particularly bad year for the vaccine’s efficacy, it’s still going to be better at helping you to avoid influenza than certain other “remedies” would be. It will help more than prayer, it will help more than avoiding cellphone towers, and it will certainly help more than homeopathy (with the caveat that hydration is good, so homeopathy in extreme quantities might help a little bit, because water).

Homeopaths disagree, as you might expect them to. One of those homeopaths is Dr Erika Coertzen, who suggests that we take a “reputable medicine such as Oscillococcinum, the most popular homeopathic product for flu symptoms in France”.

This box contains as much medicine as a microscopic box of Oscillococcinum does.

That quote tells us that Dr Coertzen and my understanding of what the word “reputable” means is as orthogonal as our understanding of the word “medicine”. We can also note that a “medicine’s” popularity is only relevant to sales, profit, and analysis of marketing and gullibility – it tells us nothing about efficacy.

As with all homeopathic “remedies”, there is no good clinical data to support the claims made in favour of Oscillococcinum as treatment for influenza. It’s not going to help you to “rebalance and heal”, and even if it is true (no citation is given for this claim) that a “majority of patients who take Oscillococcinum at the onset of flu-like symptoms show improvement or resolution of symptoms after reduced time”, if this is in comparison to patients who take nothing, then the placebo effect is a perfectly good explanation for this observation.

But I suspect that the data is more… what’s the technical term?… made up than that, or that it at the least involves some fairly extravagant inferences being made from a poor data set. Dr Coertzen says that patients “symptoms show improvement or resolution of symptoms after reduced time” – if this is true, the data should support this claim. Unfortunately, they don’t.

As assessed by the Cochrane Collaboration, where trials do show favourable results for Oscillococcinum, “the overall standard of research reporting was poor, and thus many aspects of the trials’ methods and results were at unclear risk of bias. We therefore judged the evidence overall as low quality, preventing clear conclusions from being made about Oscillococcinum® in the prevention or treatment of flu and flu‐like illness.”

Amusingly, the Oscillo.com website – of course not a neutral scientific arbiter – claims that “unlike other flu medicines, Oscillococcinum does not cause drowsiness or interact with other medications”. Given that Oscillococcinum is a homeopathic “remedy”, therefore containing nothing that might cause drowsiness or negative interactions, this claim only gains traction if you’re able to persuade people that homeopathy is at all respectable or efficacious – surely nothing that any “reputable” healthcare practitioner would do?

In her defence, Dr Coertzen isn’t ever quoted as directly suggesting that you not take real medicine also, which might be the only thing that prevents the Health Professions Council (HPCSA) Medicines Control Council (MCC) from chastising her for this batshittery.

However, if she is the “medical expert” quoted in the headline, telling the public that vaccines might not work and that they should consider alternatives does seem to be a direct encouragement to forsake medicine in favour of homeopathy, and I do hope that a complaint is laid so that the MCC HPCSA can then rule against this idiocy.

Briefly, on Oscillococcinum itself, you’d be amused to read up on it, as the story of its origins and composition is quite the catalogue of pseudoscience in action. While there might be nothing that trumps Scientology for batshittery, Oscillococcinum gives it a damn good try…



Flu vaccines may not work, consider alternatives — medical expert

Global health authorities have cautioned that current flu vaccines may not prevent a severe new strain of influenza, highlighting the need to seek alternative ways to protect against falling ill this winter.

The US Centers for Disease Control and Prevention (CDC) issued a health warning to doctors during the northern hemisphere winter about the severity of the 2015 flu season. It said the current flu vaccination protects against three or four strains but is not a match for the dangerous H3N2 strain which has mutated and has contributed to more deaths and hospitalisations of children and the elderly. (See: http://www.health24.com/Medical/Flu/Preventing-flu/Flu-vaccine-missing-its-mark-20150112)

Nearly 30 children died in one of the worst flu outbreaks in the US over their winter. In SA, a new modified vaccine is now available to match two of three new strains, including H3N2. However flu can still be contracted if other strains are not covered by the vaccine (See: http://www.health24.com/Lifestyle/Winter-Wellness/South-Africans-warned-of-severe-flu-strains-20150420).

SA doctor and homeopath, Dr Erika Coertzen, suggests boosting the immune system naturally by following a healthy, nutritious and balanced diet, getting enough sleep, regular exercise and taking preventative natural or homeopathic medicines to counter the onset of flu symptoms.

“A reputable medicine such as Oscillococcinum, the most popular homeopathic product for flu symptoms in France, has shown to help alleviate flu symptoms such as body aches, pains, chills and fever without drowsiness or the worry of negative interaction with other medication. Oscillococcinum works with the body to help rebalance and heal, and is suitable for all ages. Oscillococcinum’s efficacy in reducing the severity and duration of flu-like symptoms is well-known. A majority of patients who take Oscillococcinum at the onset of flu-like symptoms show improvement or resolution of symptoms after reduced time” she said.

For product info visit http://www.lebron.co.za/, www.oscillo.com or call 021-403-6390.

Roundup – 2015 LCHF Summit #OMHealth #LCHF2015

In news that came as a surprise to some us who are here, myself included (thanks to the generosity of the organiser, Karen Thomson), critics of Noakes and the low carbohydrate, high fat diet are apparently “boycotting” the Old Mutual Health Convention, that wraps up today.

The convention took place over 4 days – the first 3 operating as a professional event, with healthcare practitioners earning continuing professional development (CPD) points for attending, and the last day defined as a public event. Continue reading “Roundup – 2015 LCHF Summit #OMHealth #LCHF2015”

Professor Noakes and the Echo Chamber Made of Lard

The 2014 “Collector’s Edition” of The Big Issue contains a number of interesting pieces, but there’s one specific piece that I’ve been looking forward to being able to share with you.

The day for doing so has finally arrived, so here is the first instalment of some thoughts on “The Digital Doctor”, contributed by Prof. Tim Noakes, and freshly uploaded to the Interwebs (thanks to @BigIssueSA on Twitter).

As a framing concept for this post, consider the “echo chamber“, which you can understand as roughly analogous to, or intersecting with, confirmation bias and the “filter bubble“.

Participants in online communities may find their own opinions constantly echoed back to them, which reinforces their individual belief systems. This can create significant barriers to critical discourse within an online medium.

Another emerging term for this echoing and homogenizing effect on the Internet within social communities is cultural tribalism.

What the extract highlights is the problem of “groupthink”: if you surround yourself with people who say the sorts of things that agree with the sorts of things you’d like to believe are true, you all end up reinforcing each others’ beliefs, and opposing views have a difficult time getting heard.

So, it seems fairly obvious – given we know that we’re prone to weighting confirmatory evidence more favourably than disconfirmatory evidence – that someone who cares about keeping their mental furniture nearly arranged would actively seek out ways in which they might be wrong.

Supporters of Prof. Tim Noakes believes that he does exactly that, and that this is why he could famously change his mind on something so fundamental as the value of an entire category of organic compounds (carbohydrates, in case you aren’t aware).

But – and yes, I have said this before – one change of mind, no matter how fundamental or (in)famous, does not indicate anything about a general disposition, and it’s perfectly possible that Noakes (again, regardless of whether his conclusions are correct or not) has adopted (and is encouraging) sloppy thinking in this regard.

Which brings me back to The Big Issue, where it wouldn’t be unfair to describe Noakes’ contribution as a love-letter to confirmation bias, or an attempt to attract companions to occupy an echo chamber made entirely out of lard.

The piece begins with a rejection of expertise, where it turns out (according to Noakes) that an “exclusive clan who have climbed the academic ladder of success” “carefully programmed” Noakes and his fellow students to believe that what the clan professed is the “absolute truth, for now and forever”.

Alien_probeTo help this conspiracy narrative along, these evil people with their degrees and academic credentials are given the sneery nickname of “The Anointed”, which helps to set up the us vs. them dichotomy, where the everyday folk are victims of an intellectual aristocracy, preserving their privilege at our expense.

At this point, some of us are perhaps thinking about how odd it seems that one of the people who has climbed the academic ladder about as high as one can in South Africa thinks he should be trusted, despite his own membership of this shadowy clan.

But by definition, Noakes cannot be part of The Anointed, for he has seen the light, and rejects their gospel. Perhaps he might be part of the New Reformed Anointed or somesuch, because he makes it quite explicit that the outdated dogma he was taught is false, and should be replaced by something else.

The something else, though, is never expressed with qualifications, or room for being wrong – it’s presented as absolute truth. And this is the problem – replacing one dogma with more (albeit different) dogma doesn’t help the argument for being critical of received wisdom. It simply asks you to replace received wisdom with an alternative version of the same.

There’s a problem in this simplistic account of dogma also, in that it’s only unthinking consensus that’s a problem (what we normally call dogma) – consensus isn’t a problem of necessity. So, if “The Anointed” happen to be wrong in this instance, we shouldn’t use that as an excuse for discarding the idea of expertise in general.

Experts do exist, and “common wisdom” is frequently very far from wise. Yes, “experts” can also be wrong – but as ever, we can assess arguments on their merits, rather than throw the epistemic baby of expertise out with the bathwater of a few bad arguments.

Then – crucially – we’re dealing with a complete misrepresentation of what “The Anointed” say. On the Noakes narrative, dieticians and these sneaky academic folk are pushing the line that fats are bad, and carbs at least not as bad as Noakes would have you believe (some might even say that some carbs can be good).

However, the truth doesn’t support these caricatures. It’s (now) common cause that we used to over-emphasise the dangers of fats in general. It’s (now) common cause that refined carbs are bad.

The point is that “The Anointed” have modified their position over the years, in light of the evidence. Noakes might say that they haven’t modified their position enough, or that they are ignoring some evidence or over-valuing other evidence.

But either way, they are not dogmatically pushing one line. Their arguments have evolved (whether rightly or wrong, time will tell), and it’s untrue and uncharitable to present them as inflexible purveyors of eternal “truths”.

There’s only one dogmatic voice in this conversation, and as far as I can tell, it’s not that of The Anointed.

P.S. Noakes’ solution to the problem of The Anointed is to rely on The Wisdom of the Crowds, and especially Twitter, which is “unquestionably the best way to acquire the most up-to-date information on my particular areas of scientific interest” (this is no joke. Well, I mean it’s an accurate quote.) But more on that another day.

Consensus guidelines are anti-science, says Noakes

Here’s an elegant lesson in salesmanship at the expense of principled communication about science. It’s from Professor Noakes™, as so many of my recent examples have been – the popularity of his lifestyle/diet message means that here in South Africa, source material is unlikely to run dry anytime soon.

Earlier this year, Noakes™ addressed a conference in Australia on the “Medical aspects of the low carbohydrate lifestyle”. Those interested in his arguments around health should watch the video below – it’s one of the better ones of his that I’ve watched, in that it’s clear, succinct, and mostly free of conspiracy and ad hominem argument.

The bit I want to focus on starts at 10:17, where he says:

And you must never trust consensus guidelines, because they are anti-science. Science is not about consensus, it’s about disproof, disbelief and skepticism. It’s not about consensus. When you’ve got consensus, you’ve got trouble.

This conflates two very different stories into one, to serve the rhetorical purpose of granting credence to the underdog-story. The two stories are first, that yes, dogma is antithetical to science. The second is that if a preponderance of evidence points in a consistent direction, consensus guidelines could be well-justified, and it would only be irrational or inattentive people who would not believe in that consensus.

In the second story, you’d have been rational to believe in the consensus account even if it later turns out to be false. I spend a lot of time talking about this at TAM2014 as well as in the paper I gave at a recent nutrition conference, so won’t repeat all that here, but the point is that denying a well-justified consensus doesn’t make you a better scientist – it makes you a conspiracy theorist (or simply wrong).

In other words, consensus guidelines that emerge out of honest engagement with the evidence, and that are open to correction, are not anti-science at all. They are the product of good science, and their later overturning (if that happens) in favour of a new consensus is also the product of good science.

You don’t measure or identify good science from its conclusions – because we don’t know that those will survive future data – but by method, and by openness to correction in light of evidence. The first kind of story mentioned above, involving dogma, is of course an example of bad science. That doesn’t mean that consensus is by definition bad.

Science is indeed about “disproof, disbelief and skepticism” – but all of these serve to challenge any existing view and replace it with a better one. They are tools, or methods, for reaching a better consensus, not for rejecting consensus in general.

The simplest way of putting the point is this: Noakes™ would like it to be the case that medical practitioners and educational programmes see the light, and teach the same message he professes. In other words, he’d like his own views to be the basis of a new consensus, because he believes that the existing consensus is wrong.

When you’ve got dogma, you’ve got trouble. And when you’ve got consensus, you might have dogma. But you might also have a bunch of responsible people agreeing that yes, that’s what the data imply, and until we learn something to overturn our view, the evidence leads us – as rational, responsible scientists – to a certain consensus.

In short, while the quote above can play as a sexy soundbite for undercutting received wisdom, it’s another instance of Noakes™ playing scorched earth with understanding of the scientific method.