On the proposed South African sugar tax

As Africa Check reports in Daily Maverick, it’s not yet clear what the effects of the proposed sugar tax in South Africa will be. But it is clear that South Africa has a serious obesity problem – and that sugar is a clear causal factor for obesity.

A Mail&Guardian journalist recently approached me for comment on this (I’ll update this post with a link to the piece when it’s published), but because the M&G article will likely only quote snippets, here’s a fuller response to a few sugar tax issues. Continue reading “On the proposed South African sugar tax”

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.

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”

Big Food, Big Babies: moral panics and the business of eating

Earlier this year, Owen Frisby (the chairperson of SAAFoST) invited me to give a presentation at the 25th Congress of the Nutrition Society of South Africa. While the majority of speakers at the congress were dieticians and others working in medical science, my focus – as in previous posts and columns – was on poor critical reasoning and hyperbole in science writing, and the negative consequences this might have for public understanding of science. If you care to, you can read the text of my presentation below. Continue reading “Big Food, Big Babies: moral panics and the business of eating”

Pseudoscience Friday – Sweden abandons “diet dogma” (not), and sugar addiction

There are some pieces of information that one could call “zombie facts”, for two reasons – first, they are compromised in terms of their mere existence (zombies don’t exist, and these aren’t facts) and second because they are very difficult to kill.

In February 2012, we learnt that Keanu Reeves had died in a snowboarding accident, and it took myself and a few others most of the day before we managed to get South African Twitter to stop circulating this zombie fact.

When pointing out that the website in question has a footnote attesting to being 100% fake made no difference, I started tweeting that I – and many others – had died also. Go ahead and die for yourself, if you like, by editing this URL.

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Continue reading “Pseudoscience Friday – Sweden abandons “diet dogma” (not), and sugar addiction”

Problems with evidence-based medicine aren’t a license to make stuff up

In the paper that brought the idea of evidence-based medicine (EBM) to prominence, Professor David Sackett et. al. wrote that

Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. … By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centred clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens.

In short, EBM is about integrating the best available research knowledge with the expertise of clinicians, who might – and often do – spot something that a model or a manual might not recognise as significant. As much of a naturalist as you might be – and I’m a very committed one – raw data exists in a context, and the context might often be a significant clue in telling you what data are relevant, and how they should be interpreted.

downloadSo I share some of Dr. Malcolm Kendrick’s concerns, when he writes that “EBM is now almost completely broken as a tool to help treat patients” thanks to the “evidence” being susceptible to corruption by vested interests, and pharmaceutical companies in particular. If you fund enough research, and suppress results that you don’t like, it’s certainly possible to end up with all the “evidence” pointing in a favourable direction. Favourable for you, that is, but not for the patient.

But the fact that something is funded by a pharmaceutical company doesn’t guarantee bias. There’s a difference between being cognisant of potential biases, and writing something off in advance, just because of whence it came. That sort of pre-emptive dismissal is a logical error called “the genetic fallacy“, and you can tell when it’s being committed if someone stops paying attention to the evidence at all, or starts claiming that they don’t need to even bother doing so. Like this, perhaps (from Kendrick’s post):

Some years ago I stated that I no longer believe in many research papers that I read. All I tend to do is look at the authors, look at the conflicts of interest, look at the companies who sponsored the study, and I know exactly what the research is going to say – before I have even read the paper.

I have also virtually given up on references. What is the point, when you can find a reference to support any point of view that you want to promote? Frankly, I do not know where the truth resides any more. I wish to use evidence, and the results of clinical studies, but I always fear that I am standing on quicksand when I do so.

We are at a crisis point. Medical research today (in areas where there is money to be made) is almost beyond redemption. If I had my way I would close down pubmed, burn all the journals, and start again, building up a solid database of facts that we can actually rely on – free from commercial bias. But this is never, ever, going to happen.

It’s rather alarming to see the person responsible for writing The Great Cholesterol Con – and for encouraging most of us to stop taking statins to lower cholesterol – professing “I do not know where the truth resides any more”. (If he really means that, a career in anthropology rather than medicine might suit him better, I’d suggest, in that he’s already learnt a key mantra of the field.)

Another peculiar thing you’ll find on his website represents quite a cunning stratagem. You see, he’s talked himself into a bit of a bind with this “don’t trust The Man” stuff – if he ever wants to sell you something like a drug, how could he offer you “evidence” in support of it’s efficacy, assuming that he or someone else with a vested interest was involved in that research?

Easy – by redefining what conflict of interest means. For him only, mind you – not for others, where it means that you can’t trust them, and don’t even have to read them to know that you can’t trust them. In his “Disclosure of Interest” page, he notes “I have become the medical director for a company making a heart health supplement called ProKardia”, for whom he does paid consultancy work. And here’s the cunning bit:

If I do write about ProKardia or any of the ingredients in ProKardia, in a positive light, you need to know that I have a financial interest. I did not use the word conflict of interest in this statement, as I do not believe I have a conflict. I have become involved in developing, and using, a product that I entirely believe to be a good thing.

Got that? He has a financial interest alone, but no conflict. Authors of papers with connections to something he doesn’t trust, or research sponsored by pharmaceutical companies, always represent a conflict – and you don’t even have to read the paper in question to know this. (Which, amusingly, means that even if they were to try to insert the same Humpty Dumpty clause into their papers, Kendrick would never read that either.)

I say “Humpty Dumpty clause”, because the book Alice in Wonderland contains this fabulous line: “‘When I use a word,’ Humpty Dumpty said in rather a scornful tone, ‘it means just what I choose it to mean — neither more nor less.'”

It’s the same causal relationship to what words – and evidence – means that allows for claims that sugar is addictive (as addictive as cocaine, according to some), or that Harvard have endorsed low-carb high-fat diets. They haven’t – they’ve just said that carbs can sometimes be worse than fats, particularly the “bad”, saturated fats – yet the LCHF proponents cherry-pick this as support, even though the same group are explicit that the type of fat matters, and that animal fats remain something to be cautious about.

Or, it’s this casual relationship that allows for claims that Sweden has officially adopted the LCHF diet, even though the report – now finally available in English (the summary, at least), though that didn’t stop English speakers like Tim Noakes from relying on blog sources as authoritative on what it said – actually says (my emphasis):

in the short term (six months), advice on strict or moderate low carbohydrate diets is a more effective means of achieving weight loss than advice on low fat diets. In the long term, there are no differences in the effect on weight loss between advice on strict and moderate low carbohydrate diets, low fat diets, high protein diets.

I realise that this is just one element of the debate, which includes diabetes, heart disease and so forth. But these are two examples of scientists cherry-picking data that happens to support something they want to argue for – or that can be made to appear to support it, so long as you whip up enough hysteria, or persuade them that there’s some conspiracy afoot.

As Mark Wallace points out in piece for The Guardian on “addictive” sugar, “if the issue is people failing to act responsibly, then it won’t be rectified by treating them like children”. To that, we can add “treating them like fools”.

And when the same people doing the cherry-picking are giving themselves licence to simply ignore research they don’t like, and to dismiss conflict of interest issues (in their case, but not for you) with a regal wave, they stop being scientists, and start becoming shills.

“Addicted” to hyperbole

Some of you might have noticed that recent blog posts here have earned me some antagonism from defenders of the low-carb, high fat (LCHF) diet. In their defence, they of course think that I’m being needlessly antagonistic, especially towards someone (Prof. Tim Noakes) who they think of as doing pioneering – and very important – work in nutrition.

I’d like to try and approach the topic from a slightly different angle here, in the hopes of illustrating what I mean when I say that my criticisms are premised on a concern for exaggerating the quality and consequences of data, in a context of great uncertainty. In the same way as my language and arguments around religion have tempered significantly over the past 3 or so years, in science I’m equally concerned with the example we set as to how to think, where the claims we make should be proportional to the quality and amount of evidence we have.

A comment on one of my previous posts led me to this blog post by Prof. Grant Schofield, in which he responds to a press release from health professionals in New Zealand, decrying low-carb high-fat advocacy. Schofield’s post seems happy to embrace nuance and to acknowledge the limitations in what we can know right now about the long-term effects of LCHF diets, and is to me a great example of how to argue for an outlier position in a way that lures people into serious consideration of your case, rather than giving the impression that you’re being asked to join a religious cult.

As I wrote earlier in the week, the language of science should embrace uncertainty. We should not offer people dogma, both because it dumbs down the process of scientific reasoning, and second (an extension of the first, though) because it encourages people to think in terms of false dichotomies or other poorly defined and crude categories. What’s right is often about nuance, and doesn’t fit in a tweet or headline – and those of us who know better should not encourage a simplistic “X is right/wrong/healthy/good/bad”, especially when we know that’s what the market wants to hear.

The Doctor just tweeted a link to a great piece about “food fearmongering” that makes this point via examples of diet advice and promotions for books and movies about diet that are almost comical in their hyperbole. Food, basically, is trying to kill you – and unfortunately, you’re also addicted to it.

Until fairly recently, I was involved with a multi-disciplinary research team working in the field of pathological gambling, and as a result got to spend five years working with leading international addiction scholars, neuropsychologists, clinicians in the field of addiction, and so forth. In national prevalence studies and other research, I also got to spend a fair bit of time with people who describe themselves as addicts.

The simple takeaway, if I were to distill five years into one sentence, is that addiction is complex, and not a word to be used glibly. Today, anything we happen to like is often described as addictive, and people will talk about “brain scans show that area X lights up” when you eat a Snickers bar, while not thinking that perhaps area X happens to light up when you do stuff you enjoy. Or, that people who are inclined to addiction will find things to get addicted to, but that this doesn’t always mean that the thing in question is intrinsically addictive.

Today, people are variously addicted to sex, love, the Internet, cocaine, carbohydrates, sugar, crystal meth and so forth. But using the same word to describe all these things is profoundly misleading, and is also potentially insulting to people who suffer from the sort of unambiguous addiction that costs you your savings, your family, your health and so forth. To put a mild lack of self-control alongside heroin seems somewhat glib.

Cocaine, for example, often has no physical withdrawal effects. Psychotherapist Marty Klein says that, in 31 years of practice in the field, he’s never seen “sex addiction”, and describes it as a myth. Internet addiction was invented as a hoax in 1995, when Dr Ivan Goldberg took the diagnostic criteria for pathological gambling and adapted them to the Internet.

Internet addiction wasn’t included in the 2013 revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) – not even in the “Conditions for Further Study” chapter, that highlights things thought worthy of continued attention. “Internet gaming disorder” can be found in “Conditions for Further Study”, and “gambling disorder” does appear, in a new category for “behavioral addictions”. As I say, it’s complex.

Then, as I’ve written in the past, we might even want to be wary of treating the DSM as authoritative, perhaps especially with regard to the class of behavioural addictions, accused of making a “mental disorder of everything we like to do a lot”. My point is simply that this one word, “addiction”, is being made to do a lot of work – and a term that broad can sometimes appear rather meaningless in consequence.

It’s of course not meaningless for people who do suffer with an addiction of their own. The question I’m asking here: if we start speaking of anything that people struggle with as an “addiction”, what are the consequences of that? I fear that we’re not only encouraging shoddy thinking about addiction (and science, in general), but we’re also encouraging victimhood in that my lack of self-control can now simply be ascribed to the fact that I’ve been snared by the evil Internet, or the seductive candy bar.

And finally, there’s the danger of insensitivity – almost insult – to people who struggle with addictions that destroy lives. While being badgered by a LCHF devotee on Twitter, I was asked “do you have ANY experience with addiction that is not related to some scientific study? So much more to it than that.” In other words, I was being asked if I was an addict.

Now, this was Twitter, so you might say that this sort of thing comes with the territory. But what if I was an addict, really struggling with something, perhaps have just lost a job, or a spouse, or somesuch? Might one not think the question rude, crude, inappropriate – even indefensible? (Regardless, of course, of whether it was relevant or not, in that I was being asked “never mind the data, but do you have an anecdote?”)

I’d certainly think it inappropriate, perhaps even “triggering“, in the contemporary language of social justice. When it comes from someone who works at an addiction clinic, of all places, I’d be even more convinced.

And in this case, that’s exactly where it came from – a person offering treatment for “sugar and carbohydrate addiction”. The field of addiction – and addicts themselves – could do with us being a little more careful about the language we employ, and the categories we use to describe the things we enjoy.