PEN eNews 4(1) June 2014

Transparency best informs decisions

Did you know – results from only half of the clinical trials conducted ever get published?  Positive trial results are twice as likely to be published as those that are negative.  Information on what was done and what was found could be lost forever when results from clinical trials are not published. This means that the contributions of hundreds of thousands of people who took part in these trials remains unused and unusable.  Listen to Dr Ben Goldacre in this compelling three minute video outlining why publishing all trial results is critical for the healthcare system including patients, doctors and policy makers. http://www.alltrials.net/2014/new-alltrials-video-make-clinical-trials-count/ 

Publication bias is an issue that all health care professionals need to be aware of as they consume evidence to inform their practice. We think this reflection on transparency from one of our PEN LinkedIn Group Members summed up the issue well:  “Research illustrating a negative result is just as important as studies illustrating a positive result especially when we apply our skills that enable us to critically evaluate the published article. It is not to highlight flaws of a study, but to allow us to determine how to interpret the results. We cannot make the best informed decisions if we are not truly informed.” Natasha Barber MEd, RD, RCC. 

What's New in PEN^®

How do I…access PEN if I forgot my username or password?     

Written by Lisa Koo, RD PEN Quality Assistant

#1. I forgot my PEN password

If you forget your PEN password, there is a link underneath the password field box on the PEN Login page that says “Forgot it?” 

 

 

 

If you click on that link you will be taken to a screen where you can enter your PEN username.  

 

 

 

An automated email will be sent to you at the email address you have registered with PEN, with instructions on how to reset your password.

 

#2. I forgot my PEN username

 

There is a link at the bottom of the Forgot your Password screen that says “Forgot your username as well? Click here.” To get to this screen from the PEN login page, click on the link underneath the password field box that says “Forgot it?”. 

 

 

 

You will then be taken to the screen that has a link at the bottom that says “Forgot your username as well? Click here.” 

 

 

You will then be asked to provide the email address that you used to create your PEN account. Enter your email and a message will be sent to you providing you with your PEN username.

 

 

#3. I forgot both my PEN password and username

On the PEN Login page, click on the a link underneath the password field box that says “Forgot it?”  

 

 

 

Closing the Evidence-to-Practice Gap

Translating research into practice is an international issue challenging all health professions. This evidence to practice gap has been recognized for over 20 years and timeframes of 15-17 years for research to be implemented are not uncommon (1).  Although there have been advances in technology which have closed some of this gap in recent years such as electronic submission of manuscripts to journals, decreased review times and early online view of accepted articles, the uptake of new evidence by practitioners.  Glasziou & Haynes (2) coined the phrase ‘practice famine amid the evidence glut’ to describe this ongoing issue.  

 References:

1) Contopoulos-Ioannidis, D.G.,Alexiou, G.A., Gouvias, T. C., Ioannidis, J. P. A. (2008). Life Cycle of Translational Research for Medical Interventions Science, 321 (5894), 1298-1299. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18772421 

2) Glasziou, P., & Haynes, B. (2005). The paths from research to improved health outcomes. Evidence Based Nursing, 8(2), 36-38. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15830412 

3) 2012 Journal Citation Reports® Science Edition (Thomson Reuters, 2012).

Two Problems 

with Nutrition 

science

But I still love it!

A smart woman said to me once: "I don’t really know what to eat since every food has something bad about it”.

Nutrition science has two problems that can create headaches for dietitians as we help guide the population through the nutrition jungle. Those problems are the iterative nature of science and the popularity of observational studies in nutrition research.

1) Science is an iterative process.
This means that lots of research needs to be done to figure out the underlying facts. The media and public are very interested in the science of nutrition. During this iterative process, Journalists need to report news, and they are usually unaware that they are often reporting on one of the many iterations that help to shape our thinking about a topic. Unfortunately, the public ends up thinking we are frequently changing our minds.

A recent study reported that contradictions in the media lead to confusion about what foods are best to eat, and the public begins doubting even the basic nutrition recommendations (1). Of most concern, this confusion plus a lack of confidence in nutrition recommendations was found to result in negative effects on health behaviours (1).

2) Observational studies
Another problem we have as dietitians is that nutrition research is hard to do for several reasons. The difficulties include: a) participants may find it hard to make dietary changes for the long duration of some trials, b) food changes are difficult to blind the subjects to, c) the best control of dietary intake require the research team to purchase and prepare all of the participants food and beverages, and d) eating is a social activity and participants in such trials may have to forgo social eating events. Since randomized trials of dietary intake are difficult and expensive to implement, the process of our science usually begins with analyses from observational studies. Compared to designing and running a randomized trial, insight into many interesting nutrition questions can be obtained by analyzing data from observational studies. However, the quality of the answers from observational studies are not equal to those from randomized trials.

Observational studies report associations between variables. If a significant association is found, e.g. between a specific food and an outcome such as heart disease or cancer, the research is likely to be accepted for publication. The media may then report that food “x” causes/prevents the disease. Studies that find no associations are not likely to be published and the media rarely report on studies that found no association unless it conflicts with commonly held nutrition guidelines in which case it is “news”. This effect of a higher likelihood of studies with significant findings being more likely to be published is called “publication bias”.

The problem is the observational studies findings about food “x” might be wrong. It is possible that food “x” does not cause or prevent any problems at all. The findings could be due to people who eat more food “x” also smoke more or less, they may eat fewer or more vegetables, and they may exercise more or less. The actual cause or preventative factor is actually the smoking, the vegetable consumption, or the exercise, but we cannot tell from the information from the observational study. We call this incorrect identification of the important cause of the disease “confounding”.

Observational research is at risk for something called “spurious correlations”. As shown in the Tyler Vigen website. The per capita consumption of cheese in the USA correlates with the number of people who died by becoming tangled in their bedsheets. Other examples of ludicrous correlations are noted. Tyler Vigen spoke in this video, highlighting that while two events can be related because there really is a relationship, many other statistical correlations can be observed that are not related at all, but look like they are simply due to coincidence. Further research is needed to determine whether there is a causal mechanism that can explain the relationships.

If we are lucky, randomized controlled trials (RCTs) are conducted, and we get a better understanding of the true effect of the exposure. If the RCTs are well-designed and conducted, then the confounding variables (we may not ever know exactly what they are) are controlled for by the randomization step. Randomization controls for, and eliminates confounding, by evenly distributing the confounding variables (such as lifestyle choices) into the study arms. Blinding is another important tool used in RCTs. When subjects are blinded to which intervention they receive blinding helps prevent those randomized to the food or nutrient to report feeling better simply because of the placebo effect. Blinding of the investigators prevents the investigators from being influenced by this knowledge when judging the outcomes, or from letting the participants know whether they are in the intervention or control group, and thus influence the participants’ perception of their condition.

We have been through this process of testing observational findings with RCTs for some nutrients. At first numerous observational studies reported that vitamin E, beta-carotene and antioxidants could prevent cardiovascular disease and cancer, and that lowering blood levels of homocysteine with folic acid could prevent cardiovascular disease. However, these claims were found to be incorrect when the randomized trials were conducted.

Sometimes studies reported in the media are RCTs, but are conducted among animals or cells in a test-tube (in vitro) instead of among humans. Although animal and cell studies can be useful to gain some understanding of what may be happening at the biochemical level, animals and isolated cells differ from humans in terms of physiology, lifestyles, as well as the social aspects of eating. Therefore, animal and in vitro studies need to be considered lower level evidence for most nutrition questions and the results of these studies should be reported as perhaps interesting, but not totally applicable to humans.

The above problems highlight the art of how dietitians bridge evidence to practice. In PEN^® we describe the level of certainty of the evidence supporting the key practice points answering our nutrition questions with our evidence grading system. This helps you to be well informed about where the science’s iterations are at for your questions of interest.

Conducting critical appraisals, considering the bias of the research, considering the health literacy of a client and translating the evidence in a client-centered way – just some of the challenges in reporting research, but also why I love science as it helps dietitians navigate through the jungly world of nutrition research.

Reference:
Nagler RH. Adverse outcomes associated with media exposure to contradictory nutrition messages. J Health Commun. 2014[cited 2014 May 21];19(1):24-40. Abstract available from http://www.ncbi.nlm.nih.gov/pubmed/24117281.

Written by
Tanis Fenton RD, PhD
PEN^® Evidence Analyst

National Nutrition Month 2014 Takes the Cake!

Canada’s 2014 Nutrition Month theme focused on cooking skills. It was the ultimate in translating nutritional science and evidence into the daily lives of Canadians and onto their plates.  The slogan Simply Cook and Enjoy! was embraced by many dietitians, food loving fans and tweeters alike. This was the third consecutive campaign I was commissioned to run for Dietitians of Canada (DC). What stood out for me, like no other campaign before, was early interest, enthusiasm and engagement by volunteer nutrition month spokespeople, DC regional representative teams and DC members, all whom are dietitians. I suppose I shouldn’t be surprised given those of us who love the topic of nutrition are food-lovers too!

Savvy Tweeting Promotes Healthy Eating

In addition to participating in Dietitians of Canada's (DC) official 2014 Nutrition Month campaign "Simply Cook and Enjoy" with the provision of healthy recipes and messaging in newspaper articles, TV and radio interviews, we tweeted up a storm.

Throughout March, a group of Nutrition Month spokespeople steadily tweeted gorgeous, appetizing photos of what they were eating for meals and snacks. This was not an 'official' part of the campaign per se but became a new twist that added an extra dimension of fun and health-promoting ideas for consumers while building camaraderie amongst the spokesperson team, having fun and raising the dietitian's profiles (a nice form of "payment" in a voluntary campaign effort). A picture being worth a thousand words, these shared photos were retweeted and demonstrated to consumers that healthy eating should look and taste great too. This was a beautiful support to the popular Cookspiration App introduced by DC during the campaign.

Social Media Trends and the Dietitian

Social media is an umbrella term for technology that “enables people with no specialized technical knowledge to create their own websites to self-publish, create and upload audio and video files, share photos and information, and complete other tasks ex: marketing” (1).  It is a communications channel providing practitioners with more ways to communicate with and engage peers and the public (2).  Social media is reportedly the number one reason people all over the world use the internet (3). This popularity is likely fuelled by the availability of mobile technology (3).

Canadians gained confidence in the kitchen!

Every March, Dietitians of Canada celebrates Nutrition Month with dietitians from coast to coast celebrating healthy eating. The 2014 Nutrition Month campaign “Simply Cook & Enjoy!” allowed dietitians to communicate with Canadians about healthy eating through cooking. Dietitians helped Canadians get back into the kitchen to prepare nutritious meals for themselves and their families.

I had the opportunity to work with a producer of a local community television show and a local community kitchen to do an episode of Simply Zen. We had a family join us and they shared some of their tips that help to bring their family together to prepare and share meals. This family agreed that mealtime needs to be a priority and they look forward to sharing meals together with good conversation daily.

Announcements from PEN

The PEN^® Global Team Just Got Bigger!

Dr. Judy Lawrence 

Gail Scarlett 

Click YES to continue to receive PEN^® eNews! 

In the past month, you should have received an email from the PEN^® team asking you to click YES to continue to receive PEN^® eNews.  This email was sent because of new Canadian anti-spam legislation, which specifies that we must formally obtain your consent to contact you.  While many of our subscribers do not live in Canada, because the PEN^® system is administered from Canada, we must comply with this new legislation.

5 Reasons why students, dietetic interns and dietitians should read PEN^® eNews:

1. Critical appraisal is an essential skill. PEN^® eNews will enhance your skills in critically appraising the literature.
2. In these times of information overload, we can all use help identifying what is the best possible care for our clients and patients. PEN^® eNews will enhance your knowledge of and participation in transferring the most valid and important research findings into practice. 
3. PEN^® is created by and for dietitians. PEN^® eNews will help you to position yourself as a leader in evidence-based nutrition practice.  
4. PEN^® is a dynamic resource. PEN^® eNews will help you keep up to date on new content, features and technology available in PEN^®.    
5. PEN^® is a powerful database with 184 knowledge pathways, 1095 practice questions, 60 toolkits and 1437 consumer and 1513 professional tools/resources and more content is added every day! PEN^® eNews will help you get the most out of the PEN^® system.

 PEN^® eNews can be accessed at www.PENnutrition.com/enews

Contact Us