PEN eNews 7(5) April 2018

The greatest enemy of knowledge is not ignorance, it is the illusion of knowledge

Last month the world lost a science legend with the passing of Stephen Hawking.  An extraordinarily curious man, he sought answers to some of the really big questions of our time.  He was obviously a brilliant thinker and reflecting on his life and accomplishments reminded me of an interesting blog I read a couple of years ago about how we, as humans, think and process or make sense of information and some of the flaws in the process.  

I became aware of the Cognitive Bias Codex in a blogpost by Buster Benson.  Using the 175 biases listed on Wikipedia, he organized them by what problem the bias or flaw in our thinking processes were attempting to address.  (Full disclosure – I liked his approach to organizing cognitive biases so much I purchased the poster and have in hanging in my office!)

1. Too much information – to deal with the information overload our brain filters most information out and retains other bits that might be useful. However, this means we may be more apt to notice things that have been repeated often or are funny or bizarre, we recall and build on information we just read, and we are drawn to results or stories that confirm our existing beliefs.
   
2. Not enough meaning – we take this filtered information and see patterns and fill in gaps with what we think we know to “update our mental models of the world” (1). Some ways we tend to deal with this is that we tend to see patterns where none exist, we rely on stereotypes and generalities, and we simplify mathematical probabilities to predict if something will happen. 
3. We need to act fast – it is likely a survival instinct that requires that we take new information and make quick decisions and use the new information to anticipate the future. As a result, we may choose the simple or less risky option rather than the best option.
4. What should we remember? – There is too much information coming at us and so we must constantly make decisions about what to remember and what to let go. In the process we reinforce some memories and edit them incorrectly over time; we drop specifics and formulate generalities and whether we remember something may not be based on how important it is but rather what was going on or how we were feeling at the time. 

Benson goes on to suggest that our cognitive solutions create the following issues:

• We sometimes filter out important information
• Our assumptions can create context or imagined details that lead to faulty conclusions
• Some of our quick decisions can be unfair and self-serving
• Our memory can be faulty and self-serving and can reinforce the errors in our thinking. 
  

Do read the full blog as it is full of great examples and links to descriptions of the various cognitive biases. 

Researchers are also subject to bias.  David Sackett, another brilliant thinker and a giant in the field of evidence-based practice published a “catalog of biases which may distort the design, execution, analysis and interpretation of research” (2).  As a tribute to David Sackett, the Catalog of Biases Collaboration (supported by the Centre for Evidence-based Medicine at the University of Oxford) has created an online resource that describes the particular biases encountered in research, provides examples, discusses the impact of the bias and suggests research methods or steps that can be taken to prevent or reduce the impact of the bias.  https://catalogofbias.org/

To give you a taste, here are two biases from the Catalog of Bias that caught my eye.  

Hot stuff bias: “When a topic is fashionable (“hot”) investigators may be less critical in their approach to their research, and investigators and editors may not be able to resist the temptation to publish the results.”  They go on to cite examples such as use of statins or HRT – I wonder if vitamin D or ketogenic diets might fit the hot stuff bias definition in the nutrition world these days.  

One-sided reference bias: “When authors restrict their references to only those works that support their position.” Also known as “cherry-picking” it can lead to a false sense of the body of knowledge on a particular topic and is why transparency regarding search strategies is so important. See How do I...Find Search Strategies in PEN?

The issues of too much information, not enough information, our need to act fast and rely on our faulty memory will always be with us.  Being aware of how we deal with these issues and finding tools and strategies to address them, can help us be better thinkers, problem-solvers and decision makers.  

In this issue of PEN eNews 7(5), we:

• Visit Mexico
• Debate nutrition labelling
• Learn about the new PEN feature: search strategies
• And most importantly, thank our many PEN volunteer authors and reviewers!  

Enjoy PEN eNews 7(5)!

References:

1. Cognitive Bias Cheat Sheet – Because thinking is hard. Better Humans Blog by Buster Benson. Sept 1, 2016. Available at: https://betterhumans.coach.me/cognitive-bias-cheat-sheet-55a472476b18
2. Sackett DL. Bias in analytical research. Chron Dis 1979;32:51-63. Available at: http://www.jameslindlibrary.org/sackett-dl-1979/ (scroll down below the first page preview to access the entire article.
3. Catalogue of Bias Collaboration, Aronson JK, Bankhead C, Nunan D. Hot stuff bias. In: Catalogue of Bias 2017. Available at: https://catalogofbias.org/biases/hot-stuff-bias/
4. Catalogue of Bias Collaboration, Spencer EA, Brassey J, Heneghan C. One-sided reference bias. In: Catalogue of Bias 2017. Available at: https://www.catalogofbias.org/biases/one-sided-reference-bias 

Written by:
Jayne Thirsk RD PhD FDC
Director PEN: Practice-based Evidence in Nutrition^®
eNews@pennutrition.com

What's New in PEN^®

PEN Goes to Mexico!  

 While the purpose of the meeting was to conduct strategic planning for the international PEN System for the year ahead, it was also an opportunity to meet with colleagues from Mexico who share a passion for evidence-based dietetic practice.

Our hosts were Dr. Manuel Lopez Cabanillas Lomeli, Director of the Facultad de Salud Publica y Nutricion (FaSPyN) of the Univesidad Autonoma de Nuevo Leon (UANL), Dra. Elizabeth Solis Perez Director, Centro de Incubacion de Empresas y Transferencia de Tecnologia of UANL, Maria Guadalupe Solís, Presidenta de la Junta de Honor del Colegio Mexicano de Nutriólogos and Dra. Edna Judith Nava González, Profesor-Investigator in the FaSPyN at UANL and President and Council Director of the Colegio Mexicano de Nutriólogos 2017-2019. Upon arrival, the PEN Global Governance group was treated to a tour of Monterrey and a fabulous dinner featuring regional cuisine. 

The next day, we were welcomed to the UANL by Dr. Daniel González Spencer, Vice President of International Relations at UANL, following which, we met with about 100 faculty, staff and students from area universities and through a panel of presentations shared an international perspective of Building the Nutrition and Dietetics Profession for the Future.

• Future Dietitian 2025 – designing and leading the future Sue Kellie, British Dietetic Association 
• Advancing Practice: Learning and Connecting Claire Hewat, Dietitians Association of Australia 
• Dietitians CAN! Who are dietitians, what do they do and why do they matter Dr. Jayne Thirsk, Dietitians of Canada 
• Dietitians as Knowledge Translation Leaders Dr. Judy Bauer, Dietitians Association of Australia 

This was followed by an afternoon workshop demonstrating the Power of the PEN System delivered by Dr. Jayne Thirsk, Director of PEN: Practice-based Evidence in Nutrition.

There was tremendous interest in the PEN System by those in attendance and we look forward to welcoming Colegio Mexicano de Nutriólogos and Mexican universities training dietitian/nutritionists into the PEN Community. Our hosts prepared a lovely movie of the highlights of our time together and we invite you to view it here. 

Written by:
Jayne Thirsk RD PhD FDC
Director PEN: Practice-based Evidence in Nutrition^®
enews@pennutrition.com 

How do I… find Search Strategies in PEN? 

Behind the Scenes (and the Evidence) – The PEN Search Strategy

Do you ever read a Practice Question in PEN and wonder: What was the time period of the literature search? or Where did the author find the evidence? or Why wasn’t a specific article included?

One of the most critical parts of providing an evidence-based answer is conducting a literature review. To do a rigorous literature review, a search strategy is needed. Every PEN Practice Question begins with a search strategy. This search strategy tells reviewers and the PEN Team:

• what search terms were used
• what databases and grey literature sources (e.g. international guidelines) were searched
• what reviews or studies were excluded and why
• what is the time frame for the search.

This information has always been a valuable part of our internal files. Going forward, the PEN Team is adding Search Strategies to the PEN website for new and updated Practice Questions so that PEN users can review them. You can see the link to the Search Strategy underneath some Practice Question titles now, as in the example below. 

When Search Strategy is clicked on, you will see the information used to conduct the search:

We hope you find this new resource helpful in your evidence-based work. 

Submitted by:
Heather Alaverdy MA, RD
PEN^® Editor
heather.alaverdy@dietitians.ca

Has the role of the nutrition label shifted? 

In March, I was attending the British Dietetic Association’s annual conference in London, UK. With my research interest in nutrition labelling in mind, I listened to a representative of SpoonGuru address the audience of dietitians about their new app: technology which provides the consumer with a personalised list of available products based on their nutrition and health preferences.

That’s it, I thought. Consumers do not need to read nutrition label information again.

Nutrition information is now a familiar part of the food label. A printed collection of numbers on food packaging, there to help consumers make informed choices about the foods they buy and eat. But has this actually had an effect on health? Obesity levels are not yet significantly lower. Recent data from the UK National Diet and Nutrition Survey shows the population are still eating more sugar and saturated fat than they should (1). Yet nutrition labels have become more sophisticated, and now include additional voluntary ‘front of pack’ nutrition signposting on an increasing number of products. Legislation on mandatory nutrition labelling has evolved further still. Nutrition information is now required for products in Europe and the UK, where it was already prevalent, and modifications to the US Nutrition Facts Panel will now promote sugar and calorie content (2,3). 

Legislation still seems to believe in the nutrition label as a public health approach providing consumers with the means to choose a healthy diet. Yet research has shown that nutrition labels may not be equitable, with the motivated and knowledgeable ‘nutritional elite’ more likely to use them than other socio-demographics (4). It has also been shown that many types of consumers have difficulties using and interpreting complex numerical nutrition labelling (5). Consequently, nutrition labels may not be realistically useable by all consumers and therefore fail to impact on population health. Accordingly, research has struggled to find evidence of the effect of nutrition labels on consumers’ real-life food behaviours and purchases. That said, the expectation of enhanced labelling with legislation is great: with theoretical estimates on obesity reduction in Europe modelled between 2- 6.5% (6).

Independent of consumer use, nutrition labels are essential in many ways to support better dietary health. For example, nutrition information is needed by manufacturers who want to optimise specific nutrients or make health or nutrition claims about their products. Nutrition information also enables food industry recipe reformulation to change levels of key nutrients, which could result in positive changes to population nutrient intakes over time (7). Without nutrition labels, dietitians and nutritionists would not be able to compile food composition databases to undertake dietary intake assessment.

Perhaps we need to change our approach to nutrition labels and how they can improve dietary health. Advances in technology, including personalised ‘nutrition’ apps, can now be considered together with the research findings concerning how consumers really use nutrition label information in real-life. See PEN Food and Nutrition Labelling Knowledge Pathway for more on the growing research evidence base. Beyond the emphasis on legislation to drive the use of the nutrition information on the food label, it might just be time to rethink exactly how we, as dietitians, promote use of the nutrition information when aiming to improve our population’s dietary health.

References

1. National Diet and Nutrition Survey. Results from Year 7 and 8 of the rolling programme. 2018. Accessed March 16, 2018. Available from: https://www.gov.uk/government/uploads
2. Butriss J L. The role of nutritional labelling and signposting from a European perspective. Proceedings of the Nutrition Society. Conference on ‘Improving nutrition in metropolitan areas’ Symposium 5: The role of regulation to improve nutrition. 2018. P1.
3. Food and Drug Administration (FDA): Change to the Nutrition Facts Label. Accessed March 24 2018. Available from: https://www.fda.gov/Food/GuidanceRegulation/GuidanceDocuments
4. Nabec L. Improving dietary behaviour with nutrition labelling: Towards a research agenda that serves consumer wellbeing. Recherche et Application en Marketing. 2017. 1-27. Abstract available from: http://journals.sagepub.com/doi/abs/10.1177/2051570716685522 
5. Campos S, Doxey J, Hammond D. Nutrition Labels on pre-packaged foods: a systematic review. Public Health Nutr. 2011;14(8):1496-506. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/21241532 
6. Storckdieck Gennannt Bonsman S, Willis JM. Nutrition Labelling to Prevent Obesity: Reviewing the Evidence from Europe. Curr Obes Rep. 2012;1(3):134-140. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/22924157
7. National Diet and Nutrition survey. New PHE Data on salt intake levels, 2016. Available from: https://www.gov.uk/government/news/new-phe-data-on-salt-consumption-levels

Submitted by:
Sally Moore BSc. (Hons.), MMedSci, RD, FHEA
Registered Dietitian and Researcher
England, UK

The PEN Team Bids a Fond Farewell to EatRight Ontario  

Since it first opened its “doors” ten years ago, the EatRight Ontario (ERO) Dietitian Contact Centre has provided outstanding direct service to the public living in the province of Ontario, Canada, as well as support to health intermediaries providing nutrition services. The contact centre was established to provide expanded access to the trusted advice from dietitians. Using a special version of the PEN database (contact centre PEN or ccPEN) they provided evidence-based nutrition advice to literally millions of consumers and health intermediaries via phone, email or on their award-winning website. The ERO team produced hundreds of practical tools to help translate the science of nutrition into actionable steps to promote healthier eating. The PEN database is proud to host many of these outstanding resources and to make them available to PEN users. We congratulate all our colleagues at EatRight Ontario for a job well done.

Sadly, the government funding to support ERO has been directed elsewhere. We’ll miss you!

Take a moment to review their achievements in this EatRight Ontario Legacy Report.

Dietitians of Canada has heard from dietitians, health care professionals and the public that they value the consumer friendly, evidence-based content on the award-winning EatRightOntario website. Dietitians of Canada is pleased to be expanding this website under the new name of UnlockFood.ca. UnlockFood.ca will continue to be based on PEN evidence and help our audiences understand who dietitians are, what they do and why they matter. In addition to maintaining the nutrition and healthy eating content, the site will help the public to find a dietitian and understand how dietitians make a difference. 

Written by:
Jayne Thirsk RD PhD FDC
Director PEN: Practice-based Evidence in Nutrition^®
enews@pennutrition.com 

 

 

 

 

 

As always, we welcome your feedback.

PEN^® Resource Managers:
Jane Bellman MEd, RD
Kerri Staden BSc, RD
jane.bellman@dietitians.ca
kerri.staden@dietitians.ca

"Being a PEN^® reviewier contributes to my professional portfolio" 

PEN^® Insider

Spotlight on How the PEN^® System incorporates peer review 

Dietitians around the world have similar practice-based questions and face similar challenges in trying to stay on top of emerging evidence and nutrition research. Peer review is an integral part of the PEN^® content development processes. Peer review ensures that we are asking the right practice questions, and that the research is effectively translated into actionable and practical guidance. 

Peer review occurs throughout the PEN^® content development process: 

• During question identification for new content and during the question verification stage of updating existing content peer reviewers from the three PEN partners – BDA, DAA and DC are invited to comment.
• During the review stage of PEN^® content development including our practice questions, backgrounds and Trending Topics. 

When practice questions are developed, we try to involve both academic experts and practitioners who will be using the information. PEN aims to address real issues faced in actual dietetic practice. 

PEN supports its peer reviewers PEN has a PEN^® Authors and Reviewers Guide, which includes tools and checklists to assist and standardize the peer review process (1). Included in the PEN^® Authors and Reviewers Guide are guidelines to ensure peer reviewers are familiar with the criteria that authors have used to create their content. Similarly, authors are familiar with the criteria that their peers will use to review the PEN^® content. Peer reviewers are asked to consider: 

• Accuracy, clarity and conciseness of the content.
• Is the content comprehensive? Are any key issues missing in the response to the question?
• Is the content valid, will it make an important difference to practice? Will this information be applicable in practice settings?
• Are there any key references missing? Are the references included objective, current and inclusive?

Reviewers who have agreed to be listed as a reviewer in the PEN^® System are recognized as peer reviewers in each practice question under the link: Pathway Contributors section of each knowledge pathway.  

PEN also recognizes peer reviewers in PEN eNews when we thank our international volunteers for their peer review contributions to the PEN^® content development process. In the PEN Content Management System (PCMS) reviewers receive a thank you letter for their contribution and they can obtain a letter of contribution to PEN over a period of time that they define. This letter can then be used to add to your professional, continuing education portfolio as most regulatory bodies recognize reviewer’s contributors to PEN. In addition to contributing to the PEN^® System, peer review helps to expand our current knowledge, writing skills and encourages self-reflection of our own biases and assumptions. 

References:

1. Dietitians of Canada. Practice-based Evidence in Nutrition® PEN® Authors and Reviewers Guide. [accessed 2018 Apr. 2.] Available from: https://www.pennutrition.com/resources/PEN%20Writers%20Guide%20New%20March%2028%202015.pdf 

This ia an updated article originally compiled by:
Kristyn Hall MSc, RD

Updated by:
Beth Armour M.Ed, RD
PEN^®Content Manager
beth.armour@dietitians.ca

thank you to our PEN^® volunteers

Canada 

Contact Us

Do you have comments, questions or feedback? Connect with us!

 

To access current and archived copies of PEN^® eNews, go to: http://www.pennutrition.com/enews