Episode 59 - Red meat for the public health crowd
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Welcome once again to Free Associations for the Boston University School of Public Health, the public health and medical journal club podcast for anyone who is as confused by the latest health study as my dog is by the cone that we just had to put around his head. So my dog had to have surgery, minor surgery, no big deal, but they had to

You know, like he bites at the wound, so he had to put the cone on him today. And it didn't take him too long to get used to it. However, I mean, when I say get used to it, it didn't take him too long to accept that it was there. However, he cannot get around the house without bumping into every single wall, every single

or anything that there is. So poor guy is on his own. With the cone of shame. With the cone of shame. And I feel terrible about it. So I am hopeful that if he's listening right now, he knows that I understand. So as you can guess, I am Matt Fox from the Department of Global Health here at the Boston University School of Public Health, Department of Global Health and Epidemiology. And I am here...

For the first time ever with only one other guest host. So we can only get one, not guest host, one other host. And that is Jennifer Ryder.

Now, a bit of news for those who are listening to the podcast. So Chris is just away this week, so we just missed him and couldn't schedule a time to get him into the studio, so he'll be back next week. However, we do have an official change in hosting duties. Don has stepped away from the podcast for a bit. He is, well, probably more than a bit. And Jen has agreed to take over and step in. So how do you feel about being the official host?

I don't know whether you're the second or the third host of Free Associations. I am thrilled. This is my lifelong dream. So thank you. I didn't, I mean, I've always assumed that for most people, it's their lifelong dream to host a public health themed podcast, but you know, you never know. So I just wanted to make sure before we went too far. Some kids want to be firefighters or vets, but. Do they, do you know, do they make little kids dolls, you know,

themed in public health podcast hosts yet? It's like it was the hottest Halloween costume this year. I kind of thought it would be. Anyway, a quick reminder, as always, to go to the Population Health Exchange website. That is BU's hub for lifelong learning. And also don't forget to go and give us a rating on iTunes, Stitcher,

Whatever the kids use for their podcast these days, I don't really know. But give us a rating that really helps other people find us and helps us feel good about ourselves. So now on to the show. So we have a one that we are particularly excited about that Jen and I are going to discuss. So in our first segment, which is the Journal Club, we are going to talk about...

A study, and I put study in quotes, study of whether red meat is in fact bad for us. Now, this is one that people will probably have heard about in the news a bit ago because this didn't just come out immediately. It was several weeks ago that this was big in the news, but I'm actually glad we waited a little bit because more information kind of came out on this one.

Then in the second part of the podcast, which is our deep dive, we're going to talk about creating a kinder research culture. Although I will say there's a chance we don't actually get to that depending on how much we have to say, because this is a really juicy one for the first one. So we'll see how much we have to say on the second one. Meaty. Meaty. I would say this is a bit of red meat for the public health crowd. Would you say that? Yeah.

And then in our amazing and amusing, Jen will tell us some late breaking news on avocado pricing, I assume. Not again. You don't have any updates on the price of avocados? Okay.

All right, so let's get into segment one. So the article that we're going to talk about is on the health effects of eating red meat. It was published in the Annals of Internal Medicine, and the study was entitled Unprocessed Red Meat and Processed Meat Consumption. Dietary Guideline Recommendations from the Nutri-Rex Consortium. The first author on this was Bradley Johnston of the Department of Community Health and Epidemiology at Dalwes University.

Sounds about right. Dalhousie? No, Dalhousie. D-A-L-H-O-U-S-I-E University in Halifax, Nova Scotia, up in the great 51st state of Canada.

Sorry to our Canadian listeners who probably hate me saying that. Okay, so this article got a lot of attention. You probably heard about this. Your parents probably heard about this and are asking you whether or not they can now eat red meat again. So I looked it up. This article, if you go to the altmetric scoring, which I know you're a... I love the altmetric. For reasons that you're going to tell us.

Perhaps. I think I've already talked about that. You may have, but that was a very long time ago and our listeners will have forgotten. But anyway, I looked up the altmetric score and this was, at the time that I looked at it, and I know they can continue to grow over time, but at the time I looked at it, which is probably a week ago, it was 3,577. Now to put that in context, President Obama's JAMA article...

which was on United States healthcare reform progress to date and next steps, got a score of 8,063. So we're not in that ballpark yet. Okay. But your article? You know, I haven't looked recently, but it's definitely under 2,000. Okay. So this is a little bit above that. Yeah. All right. But I will note that the number six article in 2016 said,

got a score of 3,753 and that was an article about Zeke so we're roughly in the top six articles at least of 2016 so we'll see where this pans out but this was a this was a big one and I know Jen and I both have a ton to say about this one so I do want to make the warning now that the second segment might get cut short might get cut out completely depending on how long we want to

We want to go on about this. But let me give you some headlines on this one. And I kept a bunch in here. And there is a reason for that because I thought they kind of spoke to different things. So BBC News says, is meat really that bad for you? Question mark. Yahoo News says, should you keep eating red meat? Controversial study says well-known health risks are just bad science. Whole lot in that title. Is eating beef healthy?

The new fight raging in nutrition science explains, says Fox.com. Forbes says the new guidelines to continue eating red and processed meat are dangerous and irresponsible. And so the reason why I'm highlighting these is that even in the headlines, there was actually differing opinions on how to cover this particular story. USA Today says red meat study, known health risks unfounded. Doctors decry guidelines. Yeah.

So I'm not sure what that even means because which guidelines are we talking about? Which doctors? Yeah. Which, yeah. Then I'm going to give a highlight from the CBC, the Canadian Broadcasting Corporation, I assume. Hamilton professor calls criticism of his red meat study, quote, hysterical and, quote, extreme.

And last one from the New York Times, scientists who discredited meat guidelines didn't report fast food industry ties, which I think gets into a little bit of what we're going to talk about here. But so...

Jen, you are our resident expert on getting us up to speed on these studies. So tell us what this study was all about and what they did and what they found. Sure. So I just wanted to start by providing some context in what the current meat guidelines are. Oh, good, because I'm not sure I know this. Okay. So, you know, of course, there are several different agencies that offer guidelines. So the U.S. Department of Health and Human Services has

2015 to 2020 dietary guidelines for Americans suggest limiting red meat, including processed meat, to one weekly serving. How are you doing? What now? One weekly serving of red or processed meat. Or, not and. Or. So I'm supposed to have one serving of bacon a week? That's correct.

Yeah. Okay. I got some homework to do. Public Health England, they suggest limiting intake of red or processed meat to 70 grams per day. I can't do grams. What's that? A pound? I actually... No, it's not. Not even close. You wish. You wish. I do. But I thought the English kind of think of bacon as a condiment. Yeah.

Again, remember, these are recommendations. The World Cancer Research Fund, American Institute for Cancer Research, suggests moderate amounts of red meat and very little processed meat, so a little less quantitative. Yep.

IARC, there was a working group on red and processed meat intake. Can you just say what IARC is? Because I think some people know that, but not everyone. Sure. So it's the International Agency for Research on Cancer, and it's part of the WHO. And they make most of the recommendations around what is considered to be carcinogenic? They do, but one just important caveat is that they convene independent working groups for each of those issues. So it's not IARC-ish.

itself, but panelists who are invited to participate. Fair enough. Got it. So they determined based on their evaluation that red meat is probably carcinogenic, which is, that is a specific classification that they have, probably. And red meat specifically, not just processed meat, but red meat. So they looked at processed meat separately and they found that processed meat was carcinogenic. Oh, got it. So a stronger recommendation.

Do you know what the categories are for IARC? So there's possibly, probably, and carcinogenic, and then there's no evidence. Got it. So...

So that's sort of where we stand right now in terms of the recommendations. But the authors felt that the recommendations have primarily been based on observational studies, and therefore there was a lot of potential for confounding. They also noted that many of the studies that have been published in this area have not reported absolute confounding.

magnitude of the effects. So they all reported relative risk estimates, but you don't get a sense of the absolute risk. A problem, I agree. They also thought that the recommending agencies had not conducted or accessed rigorous systematic reviews of the evidence. They felt that the prior publications have been limited in addressing conflicts of interest, which is interesting given some of what we'll discuss later. And another

Another very interesting aspect of this paper is the emphasis on values and preferences regarding meat consumption. And they say that prior work has not addressed that. And values and preferences meaning that we should care about whether or not people really like red meat and therefore that should influence our consumption.

That the recommendations. Yes. I mean, that's what these authors are claiming, that recommendation should not only be based on the association between your exposure and your outcome, but also how willing people are to change. But people really like smoking and smoking is addictive. I mean, there there's a lot to talk about. OK, OK.

So in response to all of those shortcomings that the authors viewed in prior studies, they formed the Nutritional Recommendations International Consortium, which they abbreviate to Nutri-Rex.

And the recommendations in this particular paper are based on five different systematic reviews that are published in the same issue of Annals of Internal Medicine. So four of those systematic reviews focused on randomized control trials and observational studies of unprocessed red meat and processed meat consumption on cardiometabolic and cancer outcomes. Mm-hmm.

The final systematic review focused on personal health-related values and preferences regarding meat consumption. Okay. Okay. So in putting together these recommendations, Nutri-Rex formed three different teams. They had a leadership team, a guideline panel, and then a literature review team.

The guideline panel included a number of health experts. So they had experts in health research methods, nutritional epi, dietetics, basic and translational research, family medicine, and also general internal medicine. It also included three members from outside the medical and health community. So one of the things I mentioned was that they were very concerned about potential conflicts of interest. So their process...

I'm really trying to be objective here, Matt. Of course. Okay. Their process included inviting potential members who did not appear to have any perceived conflicts of interest to, within the last three years at least, to participate in the panel. People who responded and were interested in

then had to report much more detailed information on any potential conflicts, and only individuals without conflicts were invited to be on the panel. They decided to focus exclusively on health outcomes that were thought to be associated with red or processed meat consumption, and not on animal welfare or environmental issues.

and maybe we can discuss that a little bit more later. But they had some outcomes that they considered critically important for the development of their recommendations. So those were things like all-cause mortality, the major cardiometabolic outcomes such as CVD mortality, stroke,

myocardial infarction and diabetes, as well as cancer incidence and mortality for GI cancers, prostate cancers, and gynecologic cancers. So there were a number of individual cancers that they looked at. Also in that critical category were issues of quality of life and willingness to change red or processed meat consumption.

Then they had a separate category of outcomes that they considered not critically important, but just important for recommendation development. Those were things like surrogate outcomes of weight, BMI, blood lipids, anemia, and also the reasons that people chose to eat red meat. So that was considered. They had separate recommendations for red and processed meat, and they were explicit in stating that their recommendations were really targeted at

at individuals who consume red or processed meat. So the quote from the article is that the focus was on individual decision-making rather than a public health perspective. Okay. Makes sense. I mean, I don't know that it makes sense as a decision, but it makes sense what they did. You're clear on what they did. I'm clear on what they did. Yes.

Okay, so they, to develop the guidelines, they used a methodology that some of the authors on this paper had previously developed and published. It's called the GRADE methodology, stands for Grading of Recommendations, Assessment, Development, and Evaluation.

And I'm just going to read the quote because I don't know how else to summarize this. So the goal is that the strength of a recommendation reflects the extent to which we can be confident that the composite desirable effects of a management strategy outweigh the composite undesirable effects. So that is the goal.

They followed a systematic review protocol that was developed and also previously published by the authors. For these systematic reviews, the databases were primarily searched through July 2018, except for Medline that went through April 2019. So we are incorporating a lot of the most recent evidence. Mm-hmm.

For the analyses of harms and benefits, they included randomized controlled trials and cohort studies that included at least 1,000 adults that assessed diets of varying quantities of red or processed meat for at least six months. It didn't include studies where more than 20% of the participants were pregnant, had a prior cancer or chronic health condition other than cardiometabolic disease.

The guideline panel determined that three servings a week was a realistic reduction in meat consumption. So all of their evidence is framed according to that contrast.

And they had to have some source of information on current risks associated with, sorry, risks associated with current levels of red and processed meat consumption. So they used the Emerging Risk Factors Collaboration Study for cardiometabolic incidence and mortality and Globocan for cancer outcomes. Makes sense, I think. For the health-related values and preferences, they used Prozac.

previously published qualitative studies and also quantitative cross-sectional studies that were conducted in adults.

All right. So I think we're ready to move into the results. Let's give us, give us what they found or what they did or what they concluded. Cause they didn't do, I mean, they sort of did. They did do some systematic reviews. They did. Yes. That they did do. Okay. So they summarized all of those systematic reviews into just a couple of recommendations, one for unprocessed red meat and the other for processed meat. So for unprocessed red meat,

They suggest that adults continue their current levels of consumption. Just keep going. Just keep going. Don't change. So 11, and that is a weak recommendation based on low certainty at evidence. So that's part of this grade methodology is you are explicit about your –

the strength of your recommendation. So 11 of 14 panel members actually voted for that, for this weak recommendation to continue consumption. Three actually voted for a weak recommendation to reduce consumption. Yep. Okay.

So the results of the randomized controlled trials, that evidence was based on 54,000 participants. They found that there was little or no effect on risk for major cardiometabolic outcomes, cancer incidence, or mortality. And then there were

The evidence was also based on cohort studies for cardiometabolic outcomes. The dose response meta-analysis included 23 trials of 1.4 million participants, and they found that there was low to very low certainty evidence

that decreasing unprocessed red meat intake may result in a small reduction in risk of major cardiovascular outcomes or type 2 diabetes with no significant associations with all-cause mortality or cardiovascular mortality.

And for cancer, which was based on dose response meta-analyses from 17 cohorts with 2.2 million participants, they again found low certainty evidence that decreasing intake may result in a very small reduction of overall lifetime cancer mortality. And as I mentioned in the beginning, one...

aim of this study was to provide absolute risks, which had not been included in many of the prior studies. So just for instance, for cancer, overall lifetime cancer mortality, they found an absolute risk reduction of seven per 1000 persons for a decrease of three servings per week. So when you say decrease, so if you dropped

three servings per week, your estimated reduction in risk is? Seven out of 1,000. Seven cases. Cases of cancer per 1,000 people over a lifetime? Yes, and this is mortality. So seven cancer deaths. Oh, sorry, cancer deaths. Yes, correct. Over a lifetime? Correct. Yeah. The other cancer outcomes that they looked at, so prostate cancer mortality, incidence of overall cancer, breast cancer, et cetera, they found no significant differences there.

And then for processed meat consumption, which they also suggested that adults just continue their current consumption, 11 out of 14 panelists also voted for that weak recommendation to continue, while, again, three voted for a weak recommendation to reduce consumption.

There weren't any randomized control trials for them to evaluate with respect to this exposure. For cardiometabolic outcomes, the dose response meta-analysis from 10 cohort studies with 778,000 participants showed low to very low certainty evidence that decreased intake was associated with a small reduction in risk for the major cardiometabolic outcomes.

So there, the absolute risk reduction was somewhere between 1 to 12 fewer events per 1,000 people, again, for three servings a week reduction, depending on what the specific outcome was. For cancer outcomes, the

dose response meta-analysis included 31 cohorts with 3.5 million participants. There they found low to very low certainty evidence that decreased intake was associated with a very small absolute reduction in overall lifetime cancer mortality, prostate cancer mortality, and incidence of esophageal, colorectal cancer, and breast cancer, with an absolute reduction of one to eight fewer events per 1,000 persons, with a reduction of three servings per week.

but there was no significant difference in incidence or mortality for the other 12 cancer outcomes that they looked at. And then finally, the last thing they looked at were health-related values and preferences.

That assessment was based on 54 different articles. 41 of those were quantitative cross-sectional studies and 13 were qualitative studies. And the bottom line is that meat eaters like meat. Shocker. They think it is an essential component of a healthy diet. And finally, that they have limited skills to prepare meals that don't include meat. Limited skills.

to prepare meals that don't include red meat specifically? Red or processed meat. Correct. So they don't know how to, you wouldn't know how to substitute chicken or fish or an impossible burger. Got it. Got it. That was the feedback. So the certainty of evidence was low for the reasons for meat consumption. And the certainty of evidence was also low for willingness to reduce meat consumption. Okay. Okay.

So it seems to me the take-home message here from the article, not necessarily the take-home message that I want to take, but the take-home message from this article is just keep doing what you're doing. If you're eating red meat, go for it. If you're not eating red meat, no reason to start, but probably they... But they didn't really look at that. They don't really... Yeah. They don't really have much of a recommendation there. Okay. Okay.

There has been a lot of controversy about this, as you can imagine. And part of that seems to me stems from the fact that there are a lot of entrenched interests here. There is obviously the beef industry who is going to have an opinion on this. There are people who write nutrition guidelines who have an interest in this. There is people who have staked their careers on researching diet, nutrition, who have staked positions on this. So you've got a whole...

lot of interests here and those are competing. So no, there was no doubt to me that there was, this was going to be controversial once you read the headline. Then we'll talk about in a minute, there were some conflict of interest issues. Before we get to that, I am going to give you the first ever Free Associations quiz. You're giving me the quiz? I'm giving you the quiz. Oh dear. Yes. Now you are, you are...

You are able to say you don't know to any of these questions. Okay. But here are my questions. Okay. When you read this, were you more influenced by the observational data or the trial data?

I think, well, it's, I don't think I would make a distinction based on reading the paper. Okay. So no, no distinction. No distinction. Yeah. Do you think the authors were more influenced by the trial data or the observational data? Absolutely. The trial data. The trial data. Okay. And I would agree with you on that one. I think that the authors were more interested, more, more influenced by the trial data and the difference between the two being that the trial data was essentially null and

No difference, you know, eating three servings versus not eating three servings per week or a reduction of three servings, depending on how you want to look at it, had really no benefit. Whereas the observational study suggested that there was some benefit, just not a huge benefit. Correct. Okay. How many trials for the majority of these findings, how many trials were those studies, were the results based on?

So there were only 12 trials based on 54,000 participants evaluated. Okay. All right. Is that the right answer? No, it is not. Oh. Are we going to come back to that one? Shit.

Were those trials, trials of a diet of red meat and or processed meat? No, they were on dietary. Well, there were two, there's another aspect of the study that I didn't cover and that was the dietary pattern part of it. Go ahead. So as a kind of sensitivity analysis, they also looked at studies where people

or processed meat wasn't the primary exposure of interest, but they looked at dietary patterns that contain different levels of meat. So in other words, the differences between those different diets wasn't just the meat. There were also other differences in the dietary pattern. And the authors hypothesized that the result, if there really was a,

an adverse effect of red or processed meat, that the studies that looked at those exposures specifically would show stronger associations than the studies of dietary patterns, since it was a less direct assessment. Where in fact, that is not what they found. Yeah, yeah. Did you look at any of the meta-analyses that these were based off of? I did. So there were a bunch of them. Five. Five meta-analyses. And they were all published together with this article. Yeah.

I am going to submit to you exhibit A. Okay. This is a randomized trial.

From the Women's Health Initiative published in what year was it? 2006, I think? 2006, correct. Can you read the title? Low Fat Dietary Pattern and Risk of Cardiovascular Disease. And can you read for me the sample size, which I have circled for you there? It's a randomized controlled trial of 48,835 postmenopausal women. Almost the entirety of the data. Yeah.

Fascinating. Yes. Or these meta-analyses come from one randomized trial, trialed in the Women's Health Study, which is not a trial of red meat. Yeah. It's a trial of reducing fat. Right. Which I find mind-boggling. I don't mean to imply that there were no other trials, but most of the other trials that even were, there were very few trials, and of the trials that were available...

Most of them were excluded because they didn't meet the conditions. So there was... I mean, this is essentially...

An entire set of guidelines, because I agree with you that I think that they were much more influenced by the trial data than the observational data. But the trial data is largely based on this one trial. Yeah, that is very misleading. You do not get that sense at all in reading the recommendations paper. No. And so, I mean, right there, it immediately...

raises red flags to me. And again, that's a big sample size. So that's, it's nice to see it was a big sample size, but it was given that, that it's only one study and I'm always skeptical of, of recommendations from one study and given that it is to me. And again, I'm, I'm reading into things here because, you know, they don't exclude the observational data, but you know, they, they, they're not primarily focused on the observational data's effects, I think, in drawing their conclusions. Okay. Okay.

A couple more questions. Do you think that the authors went into this with a prior? I'm not sure. Yeah, I'm not sure either. I was trying to think about this. And the question becomes, should you have a prior if you're on a guideline committee? Because I regularly write down my prior before I read every study. So I always have a prior.

But I think, but it might be different with a guideline panel because the, I mean, you have to, there's no point in going through the exercise if you already know where you're going to come out at the end. Yeah, I think that's right. Yeah. I think that's right. On the other hand, it's impossible not to have some kind of prior, right? I mean, you have to have...

But I don't know what their prior was. I know by reputation some of these authors who did this work and, you know, sterling reputation. So, you know, I'd like to think that they, you know, were this all kind of by the book. But at the same time, I don't know how you go into this without an opinion, right?

You know, in the same way, like, how do you find a jury that's going to, you know, be completely never heard of the, you know, the Whitey Bulger story and get a, you know, I just, I don't know that you can do it. Right. But it seems like you need to be willing to move. Like, yes, you may have a prior, but you need to be willing to move. And I think, I mean, the interesting, when you read about this grade methodology, right?

I think, you know, the point of that is to make the process of going from evidence to guidelines more systematic and rigorous. I think that was, that's the goal. And I don't really, you know, I didn't do further reading on the grade methodology, but they do, they...

they have these grade evidence to decision frameworks. So this is supposed to help panelists use the evidence summaries to develop recommendations. So that's part of their methodology. And that seems like a good idea to have, you know, a structured process for this. Yeah, no, I agree with that. I agree with that. So I've been involved in two processes that use grade. Okay. And it is my experience that

Grade is never... You are always going to have weak evidence for anything that is nutritional. So anything... First of all, I mean, once you're in the world of observational studies, the evidence immediately becomes weak, right? So by... I mean, you start off at weak. You might be able to get to stronger if this was a particularly good set of studies, but you're generally going to be in the weak evidence area, which, you know, I mean...

we're never going to have randomized trials of certain things. So the evidence by the grade standard is always going to be weak. And that was one of the issues that came up was should the, you know, should the standards that were developed for decisions around drug trials be applied to things that are not drugs? And, you know, I don't know that the standard of evidence necessarily changes. On the other hand, the decisions that we need to make

don't go away just because we'll never have really good randomized trials. Now, even in the case of dietary randomized trials, they don't often get put into the category of strong evidence for a number of reasons. Number one is you can't blind them. The adherence is often low. All kinds of reasons that the evidence ends up getting

knocked down a bit. And I don't know what the right thing to do there is, but it does strike me as problematic to be using guidelines that were designed for, at least my understanding, were designed for summarizing and evidence and making decisions around drugs for things that are never going to meet the standard. So in this paper, these evidence summaries were used for health effects, so the results of these prior studies, but also for values, preferences,

cost, acceptability, and feasibility of a recommendation. Are those typically included in GRADE? I can't say. I mean, they were not involved in the process that I was involved in, but no, those were not. I didn't have any interaction with those. Okay. Next question. Should Annals have published this paper? No. Why not?

So, well, I think there are a number of things about the recommendations paper. So the systematic reviews may be, but there are a number of things about this summary in the recommendations paper that I just, I think could be misleading. And I think that's apparent from the headlines that resulted after its publication. Yeah. I mean, I think, you know, when you're talking about recommendations, I suppose you're

In the realm of science, but you know that those are going to be picked up in a way that is... That's the purpose. I mean, these are recommendations aimed at individuals. That's the point. Yep. Okay. All right. So that is as far as I'm going to go for my quiz. Are you going to answer your own quiz questions? Did I have any that I didn't answer? Do you think Annals should have published this? Oh, sorry. I didn't answer that one. Yeah, I was conflicted over this because...

So in my working through this one, I went from, yeah, you know, finally they're, you know, saying this stuff is all bogus and we knew this all along. And if Chris were here, he would, he would of course be saying that he, you know, puts no stock into any nutritional study whatsoever. But I mean, look, we have to make decisions and we have to make recommendations and the recommendations are always going to be based off of

you know, not amazing evidence for nutritional studies. I mean, we have one and only one randomized trial here that this is based off of. I mean, there are others, but the majority of the evidence. And what do we do? I mean, when is it appropriate to make recommendations when we know the evidence is not great?

Because that's the thing. I mean, I don't think the evidence is great. Right. I mean, they admit their own recommendation is weak and based on low certainty evidence. But I completely agree with you. If that's all you have, should you be making the recommendation? Yeah.

I mean, so what would the alternative be? I mean, the alternative would be to say, we don't know. And I think there are other situations, you know, in cancer screening guidelines where that is one of the categories. There's just there's not enough evidence to make a recommendation.

I think that's better than making a recommendation based on very weak evidence, particularly when the recommendation is just to continue doing what you're doing. But in particular, when that recommendation goes against the current guidelines. Guidelines. Like all of the guidelines. All of them. Yes. Yeah.

And so it's not clear to me. On the other hand, I mean, I don't... So I think the evidence is overstated here. On the other hand, I don't think it's completely wrong. I mean, I do think that it is fair to say that the observational evidence, at least as presented, and I don't want to say that I have gone through all the meta-analyses and said, oh, you missed this study and you should have... But let's just... If we go with what's in the meta-analyses that they have published...

We're not talking about huge effects from these reductions. Now, maybe that's because we're talking about small reductions and we should be thinking about bigger interventions. But, you know, is it like enough that I would say it's really important that we get everybody to stop eating red meat? I don't know.

Yeah, I'm with you. I see what you're saying. But I do. I think that, you know, the idea... I guess for me, it's hard for me to evaluate these knowing that the authors are so focused on the individual who already consumes meat. Because...

They're trying to take from population-based studies something that then gets whittled down into something very personal that's based on values among only the people who are already consuming. There's something about that that just feels problematic to me. Yeah, I know what you're saying. I do know what you're saying. And as I said to you before, I mean...

We don't, we wouldn't, we wouldn't make the same argument around smoking. We wouldn't say, well, people like smoking. People like it. You know, smokers like to smoke. And it's hard to change. And it's very hard to change. It's an addictive substance. So, you know, I mean, we should just let people smoke. We wouldn't, we wouldn't, we wouldn't say that. So why we do that with something like this, I'm not really clear. Okay. So did we need then another recommendation? Yeah.

I mean, did we need this contradiction? Do we come away with anything but confusion? No, I do not think we needed another recommendation. I think the point about...

the quality of the prior studies could have been made through the systematic reviews potentially. I mean, I think what you pointed out with how strongly the recommendations were influenced by one single study, you know, also is another reason why there's a problem in the leap from the actual systematic review to the guidelines.

But no, I don't think we needed another recommendation. Yeah, and I agree with you there. I think that what this, I mean, right or wrong, and I can't say I'm, you know, at the point where I could say these people are wrong. I don't necessarily think that. But what I take away from what they're saying is there is actually probably some benefit to reducing red meat. It's just not a massive benefit.

And given that's the case, what's the advantage to coming away with a new recommendation that says, just keep doing what you're doing, which, you know, again, I can understand the lie if this was the first recommendation to ever come out on the issue of red meat.

Then saying, look, we don't have a lot of evidence to say you really should cut back, maybe think about it, but you're not going to have major benefits. Although I will say on a population level, if we could get everyone to stop eating red meat, there would be population benefits. But this was aimed at individuals, Matt. They took an individual perspective. They absolutely did, which maybe was designed to do that. But given that there is research consensus, given that everybody already thinks we don't know what we're talking about,

What's the benefit to adding a new recommendation based on weak evidence that doesn't really say much? Yeah, I completely agree. I also, you know, part of the rationale for their recommendation is that they anticipated that the small reduction in risk would be insufficient to motivate people to stop eating red meat. It's like the tail wagging the dog, right? It's like, since that won't be enough for people to change, we're not going to ask them to change. Rather than just...

making the recommendation based on the evidence and letting people decide for themselves whether that's big enough. And, you know, we haven't gotten yet to this issue of not considering environmental issues, which I feel like we have to do. So bring that one up because that was an interesting take. So in the limitations section of the paper,

Mm-hmm.

And I think that the studies that were included in these meta-analysis also didn't consider issues of animal welfare, but they also weren't telling people just to continue consuming the way they are currently consuming. Yeah, and they were not guidelines, right? They were individual studies. Right.

And so I'm not sure, actually, the extent to which the other guidelines considered those types of environmental or sustainability issues in their recommendations, if that was a consideration at all. But again, it didn't really have to be because they were telling people to limit their consumption to some particular amount. Yeah, I find this one really, really difficult to make a decision on because this...

Where do you draw the line? I mean, do we get into ethical issues, animal welfare issues? Do we get into what's in and what's out when we make the calculations? But I'm not saying it's just health. I don't necessarily believe that those issues belong in these papers, but I think that if you're considering an individual's values and preferences,

You know, then you start thinking maybe maybe now we are in that domain where we should consider these these larger issues. I agree. And if you did, you wouldn't consider the individuals only the individuals who consume meats perspectives. You would consider the societal perspective. That's a good point. You know, because we as a society have to deal with the effects of of.

all the issues with climate of which farming is one of them. And, you know, we have to deal with it whether or not we choose to consume or not to consume meat. You would want to have a societal perspective on that. That was something that they chose not to. And I, again, I can't say that that is completely wrong, but I know there are lots of people who do feel that way, who feel that was a disadvantage.

A decision that was, you know, set up to confirm a belief that you should just keep continuing doing what you're doing. I don't know what to say about that one. Okay, so last issue, I think the last issue. Let's get into the conflict of interest issue. Okay, so they seem like from what you described, they went through a very lengthy process of

To determine whether or not the people who were on these committees had conflicts of interest. Yes. And in fact, in the introduction, they talk about how the prior research raised, and I'm quoting, raised questions regarding adherence to guideline standards for trustworthiness. And so when they published this paper, they declared their conflicts of interest. That's right. Which included how much meat they ate.

It is one of the funniest tables I've seen in a paper in a long time. It's really interesting because they don't really... There's very little to this table other than...

how much meat they consume. Right. So the first, just as an example, the first voting panel member who is a methodologist, no financial conflicts, no intellectual conflicts, other relevant disclosures, consumes three to four servings of both red or processed meat per week. And they go through that for every person on the panel. Yep. So then it emerges that the first author of this study had previously done one of these studies

Guideline recommendation type panels relating to the health effects of sugar. Okay. And had... Okay, I don't want to get this wrong because I don't want to misstate it, but had ties to the sugar industry. No, I don't know whether those ties are specifically receiving funding. Okay, so let me read to you the New York Times article on this. It says...

Dr. Johnson also indicated on a disclosure form that he did not have any conflict of interest to report during the past three years. But as recently as 2016, he was the senior author on a similar study that tried to discredit, this is the New York Times opinion trying to discredit, but fine, international health guidelines advising people to eat less sugar. That study, which appeared in the annals as well, was paid for by the International Life Sciences Institute.

Now,

That was not disclosed in this particular study. That's right. And when that came out, that became a source of attack, both of the author, but also of the journal. Because the author technically did nothing wrong, because the journal's conflict of interest guidelines say only ask about the past three years. And so this person appropriately said, I did not receive...

It's not totally clear whether there was actually support from this group that's funded by the beef industry or not. I'm not totally clear on that. But the point is, that's the kind of thing that you disclose, even if it's not within the three-year window, just to be transparent. Because it's so related to the topic that they're looking at. Yes. And when you go to all the trouble to list how much beef you consume...

But you don't mention that in the past, again, I don't know that it was this study, but in the past you've been funded by this industry and you've done studies like this before that have been industry-funded guideline reviews. That seems kind of relevant. Well, and the paper, just the whole premise of this study being based on more transparency and in the introduction they don't go so far to point out

point out anyone who, or any prior authors who did not disclose potential conflicts, but they definitely insinuate that that could have happened. Yeah. Yeah. And so, I mean, I, I hear that and I, I, my mind then goes to, okay, do I completely discard everything that's been said?

Or do I say, okay, you can be funded by industry groups and still... You can beef funded? Did I say that? Did I say beef funded? It is capable. One is capable of receiving funding. Is that better? Yes. From industry groups in the way that drug trials are done at universities often, but funded by...

by the drug companies themselves and to still, you know, give a reasonable review of the evidence. But you have to give people the information they need. But it wasn't disclosed. That's the unfortunate part. Because I do think if that was disclosed, like would that, I mean, I'm not a huge fan anyway, I guess, but, you know, I don't know that that would have completely changed my opinion of how

Would it for you? I think it would. If it would have been disclosed? I think it would. And I say that. Well, but they do say no panelists. But those were, was this particular author a panelist or an author? Yeah.

Because they go through... Oh, good question. Oh, so there's a difference is what you're saying. There is a difference. Okay. Because there were 13 panelists and they say that those panelists were not invited if they had any conflicts. But they don't say the same about the authors. So the meat consumption disclosures in the appendix table are just for the panelists, not necessarily for all the authors. This was a panelist. A panelist. Okay. So that's worse. Panelists.

Panelist and lead author. So I assume they would have been, I would have assumed they were panelists. I don't know. So I have grown increasingly skeptical of industry funding, the inability to remove the influences of industry funding. And I say that because

Based on some bad experiences, bad experiences, I'm putting in quotes there because it didn't happen to me, but things we've reviewed on this podcast around drugs for depression and nondisclosure of information that led us as a group to look at some of the systematic reviews that divide up

into whether or not they were industry-funded and non-industry-funded, and the industry-funded ones seem to find effects that the non-industry-funded ones don't. And so I have grown increasingly skeptical of – not that it makes it, you know, that there is – like, you've got to throw it all out, but that I take it all with a grain of salt. As soon as I find out there's industry funding –

the bar you're going to have to get over to convince me is higher. Yeah. And I think that's appropriate. And that's why we disclose so that people can, can evaluate the study accordingly. Yeah.

All right. Well, I think we're going to leave it there. We skipped segment two because we had so much to say about that one. And I think that is totally fine. Maybe we'll come back to a kinder researcher culture another time. Let's get on to our amazing and amusing. You want to lead? Sure. I'd be happy to. Actually, no, no, wait. I take it back. I want to go first because mine actually follows on. Oh, it does? Okay. Mine is completely unrelated. No, no. Mine is totally related. Okay. Which is mine...

For this time, it's the onion headline. I love the onion. You know that I am a University of Wisconsin grad where the onion started. I know that it came from the University of Wisconsin, but I did not know that you were a University of Wisconsin. You're a badger. I'm a badger. I didn't know that. Okay. Okay. So this was the onion headline that came out about this study. And the headline was, Nutritionists report they wouldn't have to figure out which foods were bad for you if Americans would just eat normal for once. I love it.

Which I thought, you know, has some relevance to so many things in public health, but in particular nutrition, I thought Chris would have co-signed on that one as well. What do you got? Okay.

So this is a study that I just came across. It was actually published as a news report in the newspaper, The Guardian. But the original study was published in a journal called Australian Mammal Mammalogy. Oh, it's very. Yeah, I usually read that one on the beach. Yeah. So it started out. Do you know that Nick was reading the same study? Wait, before I even mentioned that you didn't see this sitting here and you just were reading The Guardian and you came across this study? Yeah.

Wow. And you found this? And we converged on the same topic. You and Nick have like the mind meld. That's crazy. Wow. Okay. Well, it is pretty interesting. So I'm going to present this as a bit of a mystery. Okay. Okay. I like mysteries. Over a 15-day period, researchers in the Kimberley region of Western Australia started observing a large number of toadstools.

toad carcasses. So over 15 days, they found 38 toad carcasses. And all of these toad carcasses are cane toads. I knew you were going to say cane toads. You did? I will come back to why. Yep. I knew you were going to say cane toads.

So the really shocking thing, other than that just seeing that many dead cane toads is unusual, is that all of the carcasses had this incision in the chest that was of about the same size. So again, we're going to have to do millimeters. I'm sorry, because it's the Guardian. But about 10.8 millimeters vertically and 12.2 millimeters horizontally. This is very precise. Okay.

So a little background on cane toads. They were first introduced into Australia and Queensland way back in the 1930s, but they've been moving. You know why? I do. Okay. Cause they actually don't say this in the article, why they were first introduced. Oh, so it's, this is, so the story of the cane toads is one of these. So we're,

Fantastic stories of unintended consequences. Yeah. Well, so they do mention that it's been devastating the native species and moving westward ever since they were introduced. And that's been a huge problem. And a number of native species are now close to extinction because of the cane toad. They brought them in to eat the cane grubs, which turned out they didn't eat the cane grubs, but they ate everything else. What a mess. Yeah.

Well, these researchers think that they may have found a solution to this problem. A solution to the holes? The cane toad problem. Oh, the cane toad problem, period. So the little surgeons making incisions in these cane toads, it turns out, are, it's the native water rat species.

Also known as the Rakali. R-A-K-A-L-I. Am I saying that right? Wait a minute. The incisions are being made by an animal? Yep. A rat. A native water rat. So this animal is apparently highly intelligent. It has very sharp claws and teeth. And it can grow up to a kilogram. So it's pretty big.

Awesome. So in all of these cane toads that had washed up on the riverbank, there was no evidence that they had bite marks anywhere else on their body or on their heads. But it seems like the rats are holding the toads on their backs and then incising them in the chest and

to remove some of their organs. And it's even more specific than that. They remove the gallbladder because that's highly poisonous. So they excise the gallbladder and then they eat the heart because that isn't poisonous and is apparently super tasty. I did know they were poisonous, but I didn't know it was the gallbladder. Yeah. So...

The other crazy thing is that the biologists notice that all of the dead toads seem to be on the large end of the toad spectrum. And so they have since died.

hypothesize that it's easier for them to do, for the rats to do their surgery on the larger ones. Or maybe it's just, you know, if you're going to take the risk of tearing apart a poisonous toad, you're going to go for the big heart. And in some cases they, so the skin of the toads is also poisonous. So there are also examples where the skin of the

thigh has been torn off and then the rats have eaten the thigh muscle, which is apparently, you know, it's a good, it's a meaty muscle. Yeah. It's a good payoff. Absolutely. Um,

So they don't really know how the rats have figured out how to do this. It's possible that they have learned from other poisonous toads in the area. But one interesting thing about these rats is that they spend a whole lot of time with their young. So this particular biologist that they interviewed for this article thinks that maybe, you know, they're passing down this knowledge to the younger generation of rats. Time to teach you how to...

Bite into a cane toad. I remember when my parents taught me. Yeah. So now this particular biologist, whose name is Dr. Parrott, she is now really focused on water rat conservation. To get rid of the cane toads. To get rid of the cane toads. This could be the solution that they're looking for. But she notes that the rats are at risk of...

of pollution from waterways. They're often caught in fishing lines and they're also hunted by other animals like cats, foxes, and dogs. Which are also not native to Australia. Probably not. Probably not. But I love her last quote. A story like this has really raised the Rakhalis profile and made people not only realize that they are very clever, but they are a very beautiful animal we should be protecting. Oh, it's got a happy ending. Yeah, exactly.

That is so cool because, first of all, it's just so cool. But second of all, so when I graduated from my undergraduate days, one of my good friends bought me, gave me as a gift, the documentary. I don't remember the name of it, but there's a documentary that was probably made in the 80s, maybe 2000.

maybe early 90s, but I think it was the 80s, about the story of the cane toads that is absolutely hilarious. And it's the story of how they brought the cane toads. They then took over. People hate them. They try to drive over them. They are poisonous. Some people smoke the, or I don't know how they ingest the poison and they have like trippy,

you know, whatever's visions. Yeah. And yeah, I guess you gain the intelligence of the toad. I don't know how it works and it is so worthwhile. So go, go, you have to go look that up. All right. And you can, Oh, you can find on YouTube, Nick says. And so everyone go and watch the cane toad movie. It is a delight. Well, thank you for that. So that is the end of our program. If you've got any feedback on this or any other episode,

Or you want to suggest a topic for us to take on, you can tweet us at at pophealthyex, or you can tweet me at at profmadfox, or you could tweet Jen at Jennifer R. R. R. Ryder. Can we call you Jennifer R. R. R. Ryder?

Sure. Jennifer, that is a no. That is a definite no. I know how to read those signs. Jennifer R. Ryder. Or you can find us at the Population Health Exchange website at www.popheltex.org. We want to thank Leslie Talali and Director of Lifelong Learning at the BU School of Public Health for supporting the podcast.

And Nick Guler for sound editing. And this week for also finding the exact same story about cane toads and pointing us to the cane toad movie online. So thanks for joining us. We hope you enjoyed it. We hope you will download our next episode.