The Truth About Nutrition: How You Can Take a Science-Based Approach | Bradley Johnston PhD

Dr. Gabrielle Lyon: 00:00

The loaded term and phenomenon of misinformation has left many Americans asking, What if everything I know about nutrition is wrong? How often have we trusted headlines only defined years later, the advice was misleading or incomplete. From demonizing red meat to hyping plant based diets, nutrition science has become a battleground for conflicting advice and misconceptions. Hi, I'm Dr Gabrielle Lyon, and today we're cutting through the noise to uncover the truth about what we really know about nutrition. Joining me is Dr Bradley Johnston, a world renowned expert and researcher who's reshaping the way we think about food and health with almost 200 peer reviewed papers, Dr Johnston has been at the forefront of nutrition science, who has tackled some of the most intense topics. His groundbreaking studies have sparked global debates and even challenged the advice from organizations like the World Health Organization. In this episode, we'll tackle how much influence we have over the dietary advice we're told to trust. We're also going behind the scenes to explore how public health policies are shape uncover hidden biases in nutrition science and give you actionable tips for making smarter food choices backed by evidence, not hype. So my friends, if you've ever felt overwhelmed by conflicting advice about what to eat, or you've questioned whether you're getting the full story. This episode is for you join me as we separate fact from fiction when it comes to nutrition. Dr Bradley, Johnston, welcome to the show. I am so thrilled to have you here. I've been a huge fan of your work. I think that you've done a tremendous job at helping us think about evidence based practices, how we can sift through information. And you have your PhD. You also, I believe that you're also a professor. Now, are you still, are you

Dr. Bradley Johnston: 02:19

teaching? Yes, I'm a professor Texas A and M University.

Dr. Gabrielle Lyon: 02:23

Amazing, amazing. Tell us a little bit about your background, what your PhD is in, how you became interested in the work that you're doing now?

: 02:31

Yeah, sure. So thanks for asking. Thanks for having me. My undergraduate degree is in kinesiology, and then I did doctoral training in experimental medicine at the University of Alberta. And then from there, did post doctoral training in evidence based healthcare at Oxford University or University of Oxford, and McMaster University in clinical epidemiology and biostatistics. And it was really at McMaster, where my understanding and passion for evidence based practice and health research methodology, I should say human health research methodology really kind of was inspired. I would say

Dr. Gabrielle Lyon: 03:15

it is all coming into focus for me now, because one of our mutual colleagues, Stu Phillips, says, McMasters is the home of evidence based practices. Have you heard him say that?

: 03:27

I haven't. But this is true, and my mentor when I was at McMaster, Dr Gordon Guyatt, is kind of the guy who coined the term evidence based medicine, and he's a wonderful mentor to this day, and a great friend, so I've been very fortunate to work with him. The

Dr. Gabrielle Lyon: 03:46

term is thrown around a lot. What is involved in studying evidence based and do you say evidence based medicine, or do you say evidence based practice? What would be the correct term?

: 03:57

Yeah, good question. I think evidence based practices is a better term because it's applicable to medicine, nutrition, pharmacology, etc, etc, surgery, and it's really three central tenets of evidence based practice. Number one is, well, first, you actually have to start with what is your clinical question, or your public health question. So the your target population, intervention, comparator outcome. You're a clinician, so you're faced with clinical questions on a regular basis. Once you you have clarity on that and what you're trying to resolve clinically, or from a public health perspective, the first central tenant is using the best available evidence to answer that question, and it's usually not always in the form of systematic reviews, high quality, up to date systematic reviews with meta analysis, or high quality, up to date practice guidelines, whether it's a clinical practice guideline or a public health. Practice Guideline. Second tenant is expertise. Dr, lying, you've got lots of clinical expertise that really matters. It's a part of evidence based practice. And the third tenant is it's not the the evidence that drives the decision clinically. It should be the values and preferences of your client or your patient or your target population, if they're informed, if your patient or client or the population has an understanding as an is informed about the best available evidence,

Dr. Gabrielle Lyon: 05:33

that's quite fascinating. I don't think I've ever really thought about the tenants and how they would then apply, right as a clinician, you think, here's a problem, here's the outcome. For example, we want to help you lose body fat or lower your blood pressure. We then go to, you know, for physicians in the US or elsewhere, there's up to date. It would be a database that pulls together and utilizes all the information out there and then provides processes algorithms to then treat Yeah, I have two questions, I suppose. The first one is, how did you become interested in that? Because you were interested in it before. I think it was a thing, you know, I don't exactly know how to put that in terms, before it was something to be thought of.

: 06:32

Well, so my mentor, Dr, guy at he's like, I say the one of the prime movers in that space, and his mentor was a guy by the name of Dave Sackett who founded the McMaster Department of Clinical Epidemiology and Biostatistics. So it's evidence based medicine and practice has been around. I think the term was coined in around 1990

Dr. Gabrielle Lyon: 06:58

and just so it's not, I mean, it's not that old,

: 07:01

yeah, for me, it's kind of old. But like, yeah, relatively speaking, it's Yeah.

Dr. Gabrielle Lyon: 07:08

Also that's after the dietary guidelines. They didn't even put they implemented dietary guidelines in 1980 Yeah, evidence based practices. Then, I suppose, became something in 1990

: 07:23

that's wild, yeah. So, so my interest when I did my PhD at the University of Alberta, my summer job was working at the Evidence Based Practice Center, which is was sponsored by AHRQ, which is a US organization. They have evidence based practice centers around the US, and they used to have them and sponsor them in Canada. I don't think they're any longer in Canada. So I became somewhat inspired there. I got involved with the Cochrane Collaboration. Started doing Cochrane Systematic reviews of the literature, particularly, particularly on probiotics for gastrointestinal infections. And then luckily, I arrived at McMaster eventually, and kind of learned firsthand from some of the prime movers.

Dr. Gabrielle Lyon: 08:09

Was it the exploration of the information that was so fascinating, or was it potentially trying to come to a conclusion? What was the driver in the process of thinking in that very unique way.

: 08:28

Good question, I would say, when you're in the space of people that are doing research, that emphasize or have been trained in evidence based practice. At least at McMaster, there's a real emphasis on health research methods and understand and doing systematic reviews and getting an understanding of the methodology of randomized trials, cohort studies, case control studies. And eventually you as a trainee, you do more and more systematic reviews of the literature, meta analysis, and you start to appreciate health research methods and how studies are done, the anatomy of studies and what's great and what's not so great so and then eventually, I guess I found myself in a situation where I'd done a lot of different systematic reviews on quite disparate topics, and then I got into the space of doing some guideline work, and realized that methods should be at the center of it, and people that have really strong understanding of the of the of the methodology of human research should be kind of chairs or co chairs of guideline committees, at least from the McMaster perspective, which is kind of the the foundational school that that did a lot of the work, the foundational work in the space of evidence based part. Practice,

Dr. Gabrielle Lyon: 10:00

which would be a bit unusual in the way that when we think about guidelines, from my understanding, they, for example, the AUA, the American Urological Association, they will have urologists that study sexual medicine or Andrology that will then inform the guidelines. I had never quite thought about the individual's ability to think about the foundation, right? This is kind of the, I think maybe you called it the architecture of the study, which seems as if those are two very separate qualifications. Is that fair to say,

: 10:42

yeah, really important is expertise in a, for example, a clinical area, but fundamentally important in guidelines is expertise in health research methods and and being agnostic, ideally to what the data says you know, so that that's that's really important too. We spend a lot of time when we're doing guidelines, making sure that we're managing any potential conflicts of interest or disclosures up front that

Dr. Gabrielle Lyon: 11:15

that's must be challenging slightly, you know, I had Dr Kevin Mackey on and Kevin Mackey, who is a epidemiologist by training. Do you know dr Mackey? I definitely know the name. I've not met him. He's a representative. I in fact, believe you guys would get along quite well, just wonderful human and he said when he was in his training, he is a former president of the American lipid Association, okay, okay. And he said, I believed that cholesterol was going to be terrible. So he had come in with this preconceived notion that cholesterol was going to be very bad for an individual to eat. And when he did these rigorous evidence based practices, I'm assuming, and if you're listening Dr Mackey, I'm holding your feet to the fire, but he said was absolutely not what he thought. And he had to really begin to manage his bias and understanding that while he believed something, the evidence completely showed something else, which caused him to actually learn a level of neutrality going in to thinking about things,

: 12:23

yeah, well, I think maybe I don't know exactly what his his research questions were that he was working on within this context. But another important component of evidence based practice is when we're working either from a systematic review level and and definitely, if you're doing a guideline, is we, we spend time trying to understand and prioritize the outcomes that matter most to the target population, and it's usually not cholesterol, unless the guideline is specific To You know best interventions to manage cholesterol or hypercholesterolemia. It's usually, if you ask patients or members of the public, it's things like mortality, stroke, myocardial infarction, health related quality of life. And so we spend a lot of time talking about this. The concept is often referred to as patient important outcomes, and it's, it's so you know, studies, whether it's clinical trials or observational studies, they measure lots of things. And for example, I'm the co chair of the Canadian pediatric obesity management guidelines that will be published sometime, hopefully early in 2025 we started that process by interviewing parents of children with obesity and as well as experts in the field, but mostly parents of children, to find out what outcomes matter most to them as as a family and to their children or adolescents. And then, once we understood that, we did systematic reviews of the literature, and turns out that they said that the most important outcomes to them, and based on their observations of their children, were things like anxiety, depression, quality of life, and secondary to that was things like BMI, said weight, right? So we kind of, we still did systematic reviews of BMI, BMI Z weight and different lipids, but the outcomes that we really focused on were quality of life.

Dr. Gabrielle Lyon: 14:35

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: 16:50

Yeah, and of course, we would, we would get all that we got. We've collected all the data on lipids and blood pressure and anthropometrics. But also, in addition, I think we're the first to to do systematic reviews and use them to inform guidelines on essentially quality of life items for elements. Yeah,

Dr. Gabrielle Lyon: 17:12

why would someone for those who don't know quite what evidence based practices are? Why is it important to have them and to understand them?

: 17:27

Well, yeah, really good question. Well, I would say that when I talked about the three central tenets, you know, if we kind of agree that we should focus on outcomes that matter most to our clients or to the public, and if we agree that we should use the best available evidence, human evidence, to drive our clinical or public health decisions, and if we agree that we should kind of this, like You've talked about the art of medicine or or, let's say, clinical practice, we should engagement with the values and preferences of of the client, the philosophy of evidence based practice. And it is a philosophy. I'm not saying that there's this is the only way, but I think it's a very good way. It's been around for 40 years now, and I think there's a lot of confusion. If we believe these things, if these things make sense, then ideally the client family should understand, what does the evidence say, and then they should be should drive the decision. So we've referred to it is value and preference sensitive decision making. It's often referred to as evidence based decision making, but maybe a more specific, maybe to be a bit more specific, it's value and preference sensitive decision making based on the best available evidence.

Dr. Gabrielle Lyon: 18:56

What do you think confuses people the most, both clinicians, physicians or people. There's a lot of discussion around evidence based practices, and we throw those terms around quite frequently. Myself, my colleagues will say, this is evidence based practices. This is evidence informed what do you think from both perspectives, both the lay, public and the expert finds most where would they be most misled, or where would it be most confusing for them? Do you think,

: 19:40

uh, good question. It's it's a little tough to answer. We'd probably have to survey them to find out. But I would say my my observation is there's a lot of confusion about what evidence based practice is and isn't I would say that, let's take a let's take an example. So I. We've done a systematic review and what we call a network meta analysis, which is a way to do comparative effectiveness research on all of the available randomized control trials that look at different dietary programs. And when I say programs, I mean diet plus lifestyle and as well as medication. So in in people like cardiovascular risk, with considerable cardiovascular risk, so let's say they have obesity and their blood lipids are off, or they have obesity and they have high hypertension. What is the best available dietary program? So we, we did this systematic review, published it in British Medical Journal in 2023 we found 40 randomized control trials that look at hard outcomes like all cause mortality, myocardial infarction, stroke. We found 40 trials of seven different dietary programs, so things like the Mediterranean style diet, low fat diets, various versions of low fat, like low fat, very low fat. The best available evidence for the question, what is the best dietary program to prevent major, hard cardiovascular outcomes and mortality is Mediterranean style diet. So there's actually for the outcome, all cause mortality. There's seven randomized control trials, most of them are done in Europe, particularly in Spain, and the risk reduction, the absolute risk reduction over five years, is 1.8% so perhaps said in a more intuitive way, 18 fewer events per 1000 people followed over five years. And this certainty of evidence, if you if we bring in the grade approach for that risk reduction is moderate, we concluded that there is moderate certainty evidence the next best diet was a low fat diet. Now, of course, low fat is kind of code for higher fruits and vegetables, higher whole grains, clean meats, fish, that type of thing. For all cause mortality. Over five years, low fat diets were a point 9% risk reduction, so not even 1% point nine. So nine fewer cases per 1000 and both estimates were statistically significant. So if a if you're working with a family or a patient, you can tell them the best, the best dietary programs are Mediterranean style and low fat. And here's what the the absolute risk reductions are. Here's the certainty of the evidence. By the way, there was moderate certainty evidence for low fat as well, and they can make their own value and preference sensitive decisions. So that would be evidence based practice, perhaps done optimally. And I know as a physician, you have limited time to do this stuff.

Dr. Gabrielle Lyon: 22:58

Time. Actually, my first visit with a patient will be an hour and a half to two hours, ah, and our second visit will be hour and a half an hour.

23:10

Okay, so you're an abnormal physician,

Dr. Gabrielle Lyon: 23:11

yes, and all the providers in our practice, we spend a tremendous amount of time getting to know our patient's favorite color and what their dog's name is. Everything is awesome, and they find their socks. Whatever it is, when you are taking us through that process, it is, it seems as if it's, I don't want to say tedious, because there's a couple questions that I have. You know, as I think about this, the first thing that comes up is, how do we ask the question, if we are looking at dietary programs, and someone is thinking, does the question, are we asking the right question to get the answer that we're looking for? Does this make sense? So I'll give you an example. Sure, and this might not be the greatest example, but when I was doing my fellowship in geriatrics and Nutritional Sciences, the question was always, why are these individuals obese, right? And there was this constant focus on obesity and body composition, in that way focus on fat. But when we switched the conversation and we began to examine why there were challenges with healthy skeletal muscle, we seemed to get at least I did in my practice. I seemed to get better outcomes.

: 24:42

Yeah, it makes sense right away. I think, well, people can probably control their their their skeletal muscle more than they can control their body fat Exactly.

Dr. Gabrielle Lyon: 24:52

And my question to you is, as we think about evidence based practices, because ultimately, what we all want is we're all. While wanting to make people's lives better, you are doing that through examining evidence, making the evidence and the guidelines accessible in a way to provide a framework and an architecture for us to think about it. And then my job as a clinician is to go out and implement that. And when someone asks, for argument's sake, what is the best dietary program to reduce all cause mortality, the first step in my mind would be, when you're thinking about evidence based practices, is we have to get the question right, what is am I thinking about this in an appropriate manner?

: 25:41

Yeah, well, so ideally, our questions should be informed by our patients or members of the public. And so when I talked about the example of how we come up with the outcomes that are a part of our question that, in our case for the obesity management guidelines, was informed by parents and caregivers of those with children and adolescents with obesity. I'm not sure if I'm answering your question optimally, but Yeah, the question is, is really, really important? Clear, clean, structured questions is, it's actually a skill in evidence. It's one of the competencies of evidence based practice. What are

Dr. Gabrielle Lyon: 26:23

the I don't want to get ahead of myself, but I'm curious as to what the process is to get to the right question, because if we're not asking the right question, and you know, we can interview our patients, and they might not be able to verbalize appropriately what they want. But you know, as we begin to think about course correcting for the public and obviously evidence based practices, could be exercise, it could be nutrition, it could be medication, right? It could be all these various domains of health, asking the right question. Seems like that. That is probably a challenge. You said that that's a skill. So what are the core competencies for understanding evidence based

: 27:13

practices? Yeah, or for or for being evidence based? Yeah, right. Good question. So Open Network paper from 2018 I forget the first author's name, but my mentor, Dr Guyot and other leads in evidence based medicine practice were a part of basically a Delphi study where they tried to figure out for the health professions, what are the core competencies that they need to have. And they they came up with 68 core competencies, so that's a lot, and it's competencies you

Dr. Gabrielle Lyon: 27:44

get that online. Is that a can I get that certificate online? Yeah,

: 27:48

it'll only take you two years. There's competencies in treatment, prevention, prognosis and diagnosis. But if we, if we narrow the scope and think about nutrition, I think nutrition, like registered dietitians, they usually are working with treatment and prevention, and one of my graduate students, Ruth Ghosh, has led recently a systematic review of the competencies of nutrition professionals and students like at least what the literature says. We don't actually know what their competencies are, but we have insights from the literature, and we come up with her paper we can we boiled it down to what we think are six core core competencies, and they are, one, asking a clear, clean question, a structured question, two skills in finding the literature to answer that question, so you talked about up to date, but also skills in searching PubMed, which is a free version of Medline for your listeners, if you want to search the literature, there's other databases, like Dynamed that kind of brings the best available evidence together for giving clinical questions or public health questions. The third competency is skills in essentially assessing risk of bias and determining the methodological quality of a study, whether it be a randomized trial, a cohort study or a systematic review of those studies. Fourth competency, and this one is really important, and it's often left out, is competencies and understanding treatment or exposure effects, right? So we everybody knows about p values and statistical significance, but what we really need to know to make informed decisions is, is the is the average effect? Is it trivial, small, moderate or large, or perhaps very large. And so there we look at the point estimate, like we start with, looking at the relative effects, relative risk odds ratio, hazard ratio. But. Ideally, the data needs to be presented also as an absolute estimate of effects, so a risk difference or an absolute risk reduction or increase, which are much more intuitive for decision makers. So that's the fourth competency. And number five is the certainty of evidence, right? So you have a risk reduction. So let's go back to that. The example, if I could on dietary programs for reducing hard cardiovascular outcomes and mortality, Mediterranean style dietary program had the best available evidence, a 1.8% risk reduction. Again, the certainty of evidence was moderate, but it could have been possibly high or low, or perhaps very low, if it's informed by the great approach. So an estimate of effect and a p value without some indication of how certain we are in that estimate of effect, to me, is kind of meaningless if you really want to have make informed decisions.

Dr. Gabrielle Lyon: 31:05

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: 32:57

And then the which competency Am I on the the LA, the next competency is essentially values and preferences, right? So

Dr. Gabrielle Lyon: 33:10

this is probably the easiest one, right? It's, what does the the individual want?

: 33:14

Yeah, but like you say, it's an art. So if your patient or the public understand what the absolute risk reduction is or increase what how certain we are in those estimates of effect for outcomes that really matter to your patient or to the public, then the art of working with them around their values and preferences to find out what works for them is, is really important, and That depends on their kind of unique clinical situation, maybe their their income, all kinds of things, right? If you ask if the best evidence is a Mediterranean style diet, and it's quite expensive to do that, or people live in a food desert, it's probably very unlikely that they're going to be able to follow a Mediterranean style diet to reduce their risk of all cause mortality over the next five years, when

Dr. Gabrielle Lyon: 34:03

you had said based on the best available evidence, if someone is wanting to have an evidence based practice or for themselves, How much evidence is required to say, okay, because I think that when you look at the Mediterranean diet you had mentioned, was there, was it 40, or was it seven? There was somewhere, how many studies were evaluated? Oh,

: 34:33

seven, seven trials on seven on the Mediterranean style diet, for the outcome, all cause mortality, okay? And in fact, I think there's now a

Dr. Gabrielle Lyon: 34:42

amazing in my mind, I'm thinking, Okay, well, that's only seven, but perhaps, you know, two would be enough. How? When can we say there's enough data to have an evidence based Press. Practice Interesting?

: 35:00

Well, it actually more important than the number of studies. Is the size of the of the studies, how many participants were enrolled and followed and completed. If it's an experimental study, it's different. We have lots of very large cohort studies. It doesn't necessarily mean that we have a lot of certainty in there in those estimates of effect. But I would, you know, you look at the number of studies, you look at the sample size, and then ideally, there's at least a few studies that have replicated the finding in different geographic regions.

Dr. Gabrielle Lyon: 35:41

Is there? Do you think that there is, and this is just a personal question, in the way that, do you think that there's risk if we are not doing evidence based practices, meaning, you know, I don't know. Do you because you had spent your life studying this, really bringing this process forward? Well,

: 36:07

there's a risk in that we can have walk backs if we got it wrong in terms of the recommendations that we that we've made, so and that that that's a risk, and you risk the trust of the public, for example, or the trust of your patient or your patient base, if you if it turns out that you're making recommendations either at a clinical level or a public health level, where the evidence eventually shows you something quite different, right? So a good example in nutrition that's often used is, for years, we thought that antioxidants would reduce cardiovascular events, but it was largely based on observational studies. Then they did a large randomized control trial of antioxidants, but this time in kind of supplemental form.

Dr. Gabrielle Lyon: 36:55

This is Vitamin e1, of those. It doesn't matter whether it was vitamin

: 36:59

C and also antioxidant combinations. And there's a caulker review that basically shows there's no difference in hard patient important outcomes, and in fact, there's a small possibility of risk. So we don't generally, I think most people know now that there's not really good evidence for multivitamins minerals or for antioxidants. Now it's not to say that there's not certain antioxidants and that multivitamins minerals are not important if you've got nutritional deficiency totally, which is a big issue in lots of areas of the world, they can be extremely important and save lives, but in our affluent society, probably no difference for health outcomes that matter. It's

Dr. Gabrielle Lyon: 37:50

it. And that makes me think of two things. Number one, the health outcomes that matter, nutrition, medicine is so dynamic, so complex. For example, the outcome of mortality is important to some people. And for me, I might not want to lose my hair so well. I might need, right? So I might need, you know my mind. Okay. Well, how do I make sure that my vitamin mineral status is optimized to make sure I have enough copper and biotin or any of these various nutrients,

: 38:23

fair enough. But then, if you actually did experimental studies of biotin, what do they actually show? I don't know if there are any, but Biotin is, we know it's, I think, I guess rich in skin and nails and hair, I might be getting something wrong here, and so we make an assumption based on our understanding of physiology, but it doesn't actually mean that if you take biotin, that you're gonna not lose your hair. You're gonna lose less hair. We'd need to know that from a well done experimental study, ideally a randomized control trial. I don't know if there's any that have been done, but there's all kinds of examples where we think we have all kinds of ideas based on what we understand about physiology and but then experimental studies come along and it shows something different. That's

Dr. Gabrielle Lyon: 39:13

a very good point. Is that, do you think that that is a challenge for providers, and I don't want to say just clinicians, because it's not, it's really everybody. Not, it's really everybody. This is, it's our health. Are nutritional type studies challenging to do?

: 39:31

I would say yes, very challenging. But first of all, you have to say what type of nutritional studies? So if you're doing a if you get funding to do a study on supplementation versus no supplementation versus placebo, it's basically like doing drug trials. It's not near as complicated. But if you are doing a study, let's say in a clinical trial on dietary programs, well, it's not a supplement. You can use a placebo, and the the the antioxidant supplement looks the very same as the placebo, and you can blind the study on multiple levels. If you're doing dietary programs, people know what they're getting, so right away, you there's going to be some limitations in terms of the inferences that you can potentially make.

Dr. Gabrielle Lyon: 40:23

Do you think that if you could wave a magic wand? I'm sure that we have some up in my kids' rooms. We have all sorts of magic wands and things of that nature, for an understanding perspective for the listener. What do you think would be critical for them to I would say, understand about this landscape of evidence based practices and thinking about it where you could say, Okay, I'm gonna correct your way of thinking and interpreting this. There you go. I've just now anointed you

: 40:58

like so some some tips for

Dr. Gabrielle Lyon: 41:01

the biggest misconception, the biggest challenge of you know, again, we throw these terms around all the time, evidence based practices, evidence in form. But is it really evidence based? Is there, you know, you have highlighted with your work, which has been absolutely tremendous, you've published almost, I don't know, 200 peer reviewed papers really, at the forefront of nutritional sciences in various aspects, tackling all kinds of questions, because I think your passion has been asking a question and then examining the evidence of The things that we think that we know, right?

: 41:43

Yeah. Well, so I would say, Gabrielle, what would I say? Well, so you talked about evidence informed, and, of course, evidence based, I would say, we're all trying to help people. We're all using evidence to inform. I think our practice, if you're a clinician or a public health person or a researcher. But to me, I kind of make a distinction, Evidence Informed is using evidence, but it's probably it may not necessarily, necessarily be systematic, up to date evidence or systematic, up to date and high quality. So we're all evidence informed. But lots of times people say, Oh, it's evidence based. It's evidence based. I think lots of times it might be better to say, well, that person's evidence informed. But the if you want to be more geeky and nerdy, evidence based practice or philosophy is these three central tenets, and then understanding the competencies. And then I think, if you're in the space of doing applied human research, for example, it's having a strong understanding of research methodology and doing the, you know, doing high level study methods to try and answer the questions that we we have uncertainty about and

Dr. Gabrielle Lyon: 43:01

you had mentioned the quality of evidence those high moderate is, how many categories is high, moderate and low? Is there a gray in between?

: 43:11

Yeah. So I think, well, maybe I'll talk a little bit about grade, exactly where a grade approach or grade methods. So grade is a part of evidence based practice. It's really a, you know, the sophisticated part of evidence based practice in some ways. So grade does two things. First, it's a method that we use when we're producing systematic reviews with meta analysis. And so, by the way, a lot of people just use the term meta analysis. And I always say, I don't care about meta analysis. I want to know if it's first based on all of the all of the evidence. So is it a systematic review with a meta analysis? And what are those things? What are those things? So it's if not, wants to know if you have a clinical question, yeah, or a public health question, and you go out and you do a systematic literature search to find all of the evidence, whether it be randomized trials or non randomized studies, like cohort studies, and you bring together all of the evidence on your given question, and you essentially have a team of people screen the articles independently. They do data extraction, they do risk a bias assessment, they and then they assess the certainty of evidence using the grade approach. So the with going back to grade, if I, if I could. So grade is a method to when you're doing systematic review with meta analysis, you basically assign a certainty of evidence for each outcome on an outcome by outcome basis. So and the it can be high, moderate, low or very low. So there's four categories to answer your question, and there's a whole bunch of questions that go into determining what the. Certainty of evidence is and there is some subjectivity to grade. People have criticized grade because some claim that it's subjective. I would say that there's over 40 studies that have been published on the grade methodology. It's been around for 20 years. It's based on a group of methodological people from around the world. And so there's a ton of merit to grade is a perfect No, but one of the goals of grade is to be transparent about how did you arrive at moderate certainty? Evidence you may

Dr. Gabrielle Lyon: 45:35

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: 47:16

like when you looked at the risk of bias, When you looked at issues of potential, imprecision, etc. So making copious, transparent notes within your research reports about how you arrived at the certainty of evidence and another group, somebody else, that wants to use your systematic review, they might say, Oh, I don't think the certainty of evidence is moderate. I think it's high, or I think it's low, that's fine. They can disagree, but doesn't. It should create conversation and transparency, rather than black box kind of science. The

Dr. Gabrielle Lyon: 47:48

way that I'm hearing it is, it's actually should be somewhat unifying, ideally. Yes, you know, I'm looking at this article right now, and we can link it. I want to make sure this is open access. This is great evidence to decision frameworks, and it's a systematic and transparent approach to making well informed healthcare choices. Yes,

: 48:08

yeah, so the evidence, the great evidence decision framework, is what we use and follow in order to make our recommendations. So it looks at the totality of evidence on benefit, on harm, the certainty of evidence values and preferences, has questions on cost, on acceptability and feasibility of potential interventions that you're looking at. So it's a way to move from the body of evidence like a systematic review with meta analysis to a recommendation for patients or the public. May I

Dr. Gabrielle Lyon: 48:44

ask your opinion on something Sure? Why do we care about this? Why

: 48:49

do we care about grade or evidence decision frameworks? Is that,

Dr. Gabrielle Lyon: 48:53

yeah, both, because I think that there's one. And this is a personal question, and I can go first if you want me to. But why do we care about using a grade methodology first and then secondly? Why do we care about evidence based practices? Yeah,

: 49:12

well, I think that's a really good question. So grade has been adopted by, I think now, over 120 organizations worldwide. So who? CDC? Cochrane, Joanna Briggs, Institute in nutrition, the American Academy of Nutrition and Dietetics uses it to inform its evidence analysis library, which they do, systematic reviews and guidelines. So it's good to have a common standard across totally great health sciences, right? So whether it's surgery or medication or nutrition, we're at we're comparing apples with apples. I

Dr. Gabrielle Lyon: 49:49

totally agree with you, and actually, you were the first person that I when I started reading some of your work, really, because. Yes, I'm a clinician. Yes, I'm a physician, but I'm very interested in the impact of our choices from a nutritional aspect. I mean, that was my first love, and it was very fascinating to read some of your papers using grade analysis. And again, this grade system, which has been used by hundreds, if not 1000s, of people, but it was, it was quite helpful, and it laid out a framework to help me personally evaluate evidence. And so I, I think that there's a ton of benefit from it. I don't know if you have something you want to add there, yeah, well, and

: 50:39

so the and the main benefit is, if you as a clinician, are looking at systematic review evidence to inform your practice, you can say, okay, there's moderate certainty or there's low certainty, and that can help inform your and then the second component of grade, or grade approaches is the methodology, like You've we've talked about a bit to move from systematic reviews to recommendations or making strength of recommendations. So exactly as you pointed out, evidence that decision framework so great is is you can kind of think of it in two different categories

Dr. Gabrielle Lyon: 51:15

when you are thinking about the decision making process. And, you know, we talked about meta analysis systematic reviews. Are there ways that people could pick out what a good systematic review is?

: 51:33

Yeah, there's definitely. There's tons out there. Yeah, there's tools available to us to determine the quality of systematic reviews. So the one that's used most is called am star two. I forget what the acronym stands for, but it's out of the University of Ottawa, Beverly, Shea, you Canadians. And there's also something called robust, which was developed by The Cochrane Collaboration. So there are two instruments that can be used to determine the methodological quality of systematic reviews. Amstar has 16 questions that you have to go through. And there's also things like Jama users guides to the medical literature and what we've produced, the nutrition users guides to the to the nutrition literature, essentially. And there's we have guidance available to help people make sense of systematic reviews. Do

Dr. Gabrielle Lyon: 52:28

you think that this, and again, this is more of a personal question in terms of your personal opinion. Do you think with the influx of information, I mean, you're very well trained, do you think that there is benefits and challenges with all the information that has been coming out if we don't have a structured way of examining it? And I can ask that in a different way?

: 52:56

Well, I think I know what you're driving at. You definitely need a common structure, otherwise people's biases get in the way. There's a whole field of cognitive biases, and even scientists are very good sometimes at having biases that they may be unaware of, right? There's, there's thing. There's something called the sophistication effect. It's a cognitive biases where smart people can explain away their answers, right? So, yes, we need common structures to answer clinical and public health questions and make guideline recommendations otherwise and in a transparent structure otherwise, it's hard to have conversations and reach consensus.

Dr. Gabrielle Lyon: 53:43

Is there a way that someone could Well, I guess even to back it up, why does it matter so much to you?

: 53:55

Why does it matter to you? Well, I was kind of trained in in evidence based practice and health research methods and and I it's, it's a passion because that it's a hard question. Why does it matter so much to me? Well, it matters because we're trying to help people, okay? And we want to help people make informed decisions. We want them to understand, if they're so inclined, there's lots of people. I'm sure you have lots of patients. They just say, you know, you tell me, Doc. But there's lots of patients and families that would love to know what is the best available evidence, and can you help me understand it? If I take this drug versus I do a behavioral intervention versus surgery, right? So I think about the Canadian pediatric obesity management guidelines. We've done systematic reviews on all of those topics, and the goal is, when it's published, is people can make more informed decisions about the all of the outcomes that we've some. They can choose the outcomes that matter most to them and get a sense of what the risk reductions are and the certainty of the risk reductions and the potential harms, rather than, for example, the expert or the clinician driving that decision always. I don't think that that's necessary. It's obviously a great idea if you're in acute care medicine, but it's not a great idea for managing chronic disease. I

Dr. Gabrielle Lyon: 55:24

think it's extraordinary. I think that it again. We often have scientists come on and discuss their randomized control trials and their mechanistic data. But what I think that you offer, which is absolutely extraordinary, is a way of thinking about something, to get a particular answer, whether you one likes that answer or not. It allows us to to our best capacity. Number one, I am hoping, which I think you and I both agree. It is unifying. It is not divisive. It is a way of saying, okay, here are my biases. I think this nutrition plan is the best because I grew up on a farm or X, Y and Z, versus someone else grows up. I don't know in New York City that by creating a framework, in an architecture, we can actually begin to have unified, rather than divisive, conversations again, to set the framework for conversations to ultimately make good choices

56:36

that would be ideal, optimal. Yeah.

Dr. Gabrielle Lyon: 56:41

Is there, and would you say that, as people are going through grade and again, this is a framework for thinking about maybe thinking is not the right word, a grade work, a framework for evaluation. Is there places where it is really excellent, for example, pharmacology or the questions that we are asking. So grade is exceptional at, and I'm just throwing this out there, evaluating if a statin is going to reduce all cause mortality, or grade is exceptional at determining, for example, I've had many patients ask me about rapamycin, and as I'm thinking about this, I'm thinking, Okay, well, I can use and I understand that this is somewhat of a technical episode, so we'll probably follow it up with maybe taking someone through the process, because I should go through this process myself, as I'm looking at, for example, rapamycin, and determining what is the best available evidence, yeah, or nutrition is grade. You know, where can we think about where grade is excellent versus maybe it's excellent across the board? Yeah? Well,

: 57:55

there's so there's been debate about, is grade applicable? Is it, is it optimal for the in the space of nutrition, and I believe we believe that it is and nutrition is complex sometimes, as we've talked about, when you're doing grade or using grade, it's very important to be working with nutrition experts to make sure that you and that that you understand, or the group has an understanding of the nutritional intervention, and maybe the biochemistry under it and so forth, so that when we're we're doing the certainty of evidence on an outcome by outcome basis, that we're not missing something, right? So great has a there's a domain called, I won't go into nitty gritty, but there's a domain called indirectness, which essentially means, if there's issues of indirectness. So if you have animal model data and you're trying to make a recommendation for a patient, you have an indirectness

Dr. Gabrielle Lyon: 58:53

issue, which is a challenge all the time, right? So using grade,

: 58:57

you would probably rate the certainty of evidence down, so you might have a body of randomized control trials, but they're all rodent model studies, but it's the only data that that's available for for the clinical question you're trying to resolve randomized trials using grades started high, but can be rated down for different issues, including indirectness. So you would rate, you would definitely rate down at least one level, or probably two or three levels, because you only have animal model data. So it would quickly go from high certainty, even though it's based on a systematic review of randomized trials, probably to low or very low because of this indirectness issue. Hmm.

Dr. Gabrielle Lyon: 59:40

And when you're reading the certainty of evidence from a translatable perspective, obviously you want it to be high or moderate. But is there a way that it balances out? And I don't know, maybe you have an exact example, you know, have a handful of papers. Here. But if, for example, you ask a question, and you've got the results based on grade are, you have high certainty of evidence, and you're trying to go to an answer, does statins improve all cause mortality? And then by what number, if someone, if you are looking at the totality of evidence, yeah, because, again, there's so much information out there for both clinicians, patients, armchair researchers, it's bananas. Yes, right? It's only followed in the bananas level of the amount of cartoons that are coming out. It is crazy. Well,

: 1:00:36

that's the other thing is evidence based practice is kind of hard work. You have to, you know, to keep up with the literature. When in a kind of banana type atmosphere, it's smoothly Well, yeah,

Dr. Gabrielle Lyon: 1:00:49

how would we is there a formula for collectively understanding what that outcome is? So you've got some things that show the certainty of evidence is high, and then you have a handful of things that show the certainty of evidence is moderate to low. Is there a unifying formula to say overall, based on all of the data, there is a moderate level of certainty that statin use decreases all cause mortality by 18% as I'm making it up, yeah,

: 1:01:28

so I'm not exactly sure how to answer your question. What's the specific question? Well, I as

Dr. Gabrielle Lyon: 1:01:37

I'm thinking about guidelines, right? As these guidelines are coming out. You know, it's challenging from my perspective, and I can just speak for myself. So I am thinking about the upcoming 2025, dietary guidelines. Me personally, I issued a statement about my position on it, and I know that Dr Donald Layman and a handful of other people of my colleagues have issued these statements, and these guidelines will come out, and there obviously will be various components to these guidelines, whether it's protein, whether it's hetero fat. How can we think about the certainty of evidence when something goes in to a guideline, and it doesn't have to be the dietary guidelines, but basically, because there is the you said, the values and preferences, right? So we have values and preferences. Am I good student? Gives you a very good surmal, yeah. So we have values and preferences, and then collaboratively, we get together, or individuals get together to say, okay, these are the values and preferences based on this, the certainty of evidence for this recommendation, I'll say for me, point eight grams of point eight grams per kg of dietary protein is, I don't know the minimum amount to support healthy aging. That certainty of evidence could be, I don't know moderate to or

: 1:03:13

maybe it's low, maybe, maybe there's evidence and it's low and and people are willing to embrace the uncertainty that we don't really know and and that's okay, like I think sometimes there's people are fearful of low or very low certainty evidence. So when I talked about grade to make, to do, strength of recommendation, so our recommendations, when we follow grade, are either strong recommendations or they're conditional. I'm

Dr. Gabrielle Lyon: 1:03:42

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: 1:05:30

and the strong recommendation can either be for or against, an intervention as well as the conditional recommendation can be for or against. A strong recommendation basically means just do it. There's very compelling evidence, and most patients are members of the public. They value the intervention. The trade off between benefits and harms is, is it's much in favor of benefit, and we can make a strong recommendation. Could

Dr. Gabrielle Lyon: 1:05:58

you give me an example that would that be? Like you should get a colonoscopy at age 50 or 45 would that be, you know, I mean, I'm just making this up. Yeah,

: 1:06:08

no, well, why do I'm thinking. I don't know what the evidence is for that, but I know there's been controversy, probably at least in things like prostate and breast screening and so forth,

Dr. Gabrielle Lyon: 1:06:18

yeah, or something that you can think about that maybe is just and so the reason I'm asking this question is because, as we frequently have these very scientific conversations with various experts, this now provides, because you have agreed to be a guest, this now provides just a way of Thinking about the framework differently. Meaning, are there certain things that we can evaluate that we definitely know that we should all be doing? Yeah?

: 1:06:47

Well, so I can use an example from managing obesity, whether it's adults or children. I think generally, we tend to make a strong recommendation for multi component behavioral intervention. So if you meet criteria for obesity, and especially if you've got your lipids are off, and we know it's a an important risk factor for early mortality or early chronic disease, we can make a strong recommendation. We'd have to look at a specific situation, but strong recommendation for multi component interventions, so diet, physical activity, maybe kind of psychological support, or group support, behavioral support, that is, that would be perhaps an example of a strong recommendation. I don't know what the recommendations are on statins, but I'm sure that there's strong recommendations for certain patient populations in like up to date would probably give guidance on that, I suspect.

Dr. Gabrielle Lyon: 1:07:51

And is there a unifying agreement, for example, is there a qualification that something that is required for a strong recommendation.

: 1:08:03

Yeah, so generally, we using the great approach, we make a strong recommendation if the certainty of evidence is high and all, or almost all, patients or members of the public value that trade off between benefits and harms.

Dr. Gabrielle Lyon: 1:08:23

It is, it's really fascinating when someone is going through the process of understanding the evidence, are there things that potentially are, I don't want to say, simple to understand, but this idea of randomized control trials could a people will say the quality of evidence from a randomized control trial is the gold standard, right? And again, this is

: 1:08:54

maybe it depends. This is what I was asking people did that trial with rigor and reproducibility.

Dr. Gabrielle Lyon: 1:09:02

That was my question.

:: 09:06

So what's the specific question

Dr. Gabrielle Lyon: 1:09:10

as we examine the quality of evidence? Yeah, and we discuss it by saying, you know, here is a randomized control trial, here's a whatever uh, cohort study or case control study, there is a variation. How about this? Is there a variation as to the quality, even if something is a randomized control trial, as we're examining the evidence, as we are trying to create a framework for men, women and children that are listening to this, physicians that are listening to this. Is there a variation the quality of what we consider, quote, high quality data, like a randomized control trial?

: 1:09:50

Yeah, there's definitely variation in terms of how well people do studies. And I think it's important to remember that when we're talking about grade and certainty of evidence. It's, it's, this is applicable only for systematic reviews with meta analysis, right if you're just looking at a single study? Well, we know, like from the hierarchy of evidence, that randomized trials tend to give more reliable answers and observational studies, but we can assume that because there's one randomized trial that we have high that shows a favorable outcome for outcomes that matter to patients. You can't assume that that's high certainty evidence. There could be other studies that have been published that you've missed. So I'm talking really from the application of grade is at obviously an evidence synthesis level. And the other thing that I thought might be worth talking about is most recommendations that are made using the grade approach are conditional, meaning we don't have great evidence. And there's nothing wrong with conditional recommendations. It was grade. Previously used the word weak recommendation, and people grade eventually learned that people don't like the idea of a weak record. Wait,

Dr. Gabrielle Lyon: 1:11:06

what do you mean? Great. What do you mean, weak recommendation? Can you say that again? I just Yeah. So

: 1:11:12

when grade up until just a few years ago, the language that grade was using was mostly strong versus weak recommendation, but they've decided as a group to use conditional rather than weak because a lot of people were uncomfortable with making a weak recommendation for maybe an intervention that they've been using for years. And you know, it puts people in a somewhat uncomfortable position. But I think what's important to understand is okay, conditional recommendation basically means the evidence isn't great. Values and preferences differ, like some patients will take it, or some members of the public will be interested in in following it, and others won't. And it should be ideally, they should be informed. It should be shared decision making. There's nothing wrong with with that, and if we did that more often, maybe in the space of nutrition, maybe there's less room for walk backs. If we, if we like the example of antioxidants, eventually we realize that there's no good evidence for taking antioxidants to reduce cardiovascular risk.

Dr. Gabrielle Lyon: 1:12:14

It. And I will say that I'm just looking at the history of the meta analysis. It the word meta analysis was coined in 1976

: 1:12:25

Yes, not that long ago. I forget his first thing, glass, yeah, Gene glass

Dr. Gabrielle Lyon: 1:12:31

and who stated meta analyzes refers to the analysis of analyzes.

: 1:12:39

Yes, the analysis. Yeah. So analyzing multiple studies, yeah,

Dr. Gabrielle Lyon: 1:12:44

which, I think the statement that, that you brought up about, it's, it's okay, it's, there is, again, there's a lot of emotion involved with people's health, and maybe it's within all spaces, I'm just not I mean, I don't know. Do people in physics argue about this kind of thing? I'm not entirely sure. Or maybe in electricity, I don't know, but whether something is weak or strong, if there's a way to remove some of the emotion behind it, then it's okay if it's a weak recommendation and you choose to follow it.

: 1:13:25

Yeah, I think, I think another important component is, I think some people that maybe have a perception that if you only have observational studies for a public health question or a clinical question, then automatically it's going to be a weak or conditional recommendation automatically, the certainty of evidence is low. That's not necessarily always the case using the grade method. So some people might be familiar with the old school static hierarchy of evidence, where at the top were systematic reviews and meta analysis of RCTs, and after that with systematic reviews of observational studies, and below that was RCT, a single RCT, single cohorts. Grade is a sophisticated approach to its kind of starts to some degree with that hierarchy, but the evidence can move up or down depending on a whole bunch of questions we ask of the body of evidence. So there are examples of observational data only that move up from low to possibly even high certainty evidence. So the example that most people would be familiar with is smoking and lung cancer, right? We don't have randomized trials of smoking and the risk of lung cancer, but we have a lot of observational data, and we have observational data that shows large exposure effects and a very clear and reproducible dose response curve. So with that observational data, which has its limitations, we do have a. High certainty that smoking is a problem when it comes to risk of lung cancer. You

Dr. Gabrielle Lyon: 1:15:06

created a website. It's evidence based nutrition.org Can you tell me a little bit about it and why you created it's actually phenomenal. We'll put a link to it. But why did you create this? And how can someone utilize this?

: 1:15:25

Yeah, sure. So we created it, a group of us who kind of work together regularly, a lot of people that have kind of come through McMaster University, the

Dr. Gabrielle Lyon: 1:15:35

home of evidence based

: 1:15:37

practices, home of evidence based practice. Well, I mean, a lot of people, I guess, have websites now. It's a resource where we kind of park materials to help people interpret the literature, like our nutrition users guides that we're starting to publish. I saw that we talk about some of our guideline work on the website. And, yeah, it's just a home to really promote evidence based practice in the field of nutrition, because my sense is it needs some uplifting

Dr. Gabrielle Lyon: 1:16:15

Yeah, I think that you're absolutely right, and it's the one thing that everybody does. We all eat? And just being able to understand and and sift through the things that could potentially have high quality evidence, like probably eating fruits and vegetables? Maybe I'm curious.

: 1:16:35

I've never looked at that question, but it's we probably have mostly observational studies, and it's what fruits and vegetables at what dose.

Dr. Gabrielle Lyon: 1:16:46

I mean. This is just highlights the complexity of the question of, how do you think that it is more challenging to do nutritional research than maybe other domains of research? For example, you studied Kinesiology.

: 1:17:02

Well, if you're doing like dietary programs, it's very hard, because people know what they're getting. You can't blind it. People can. They're kind of typically done in free living environments, although, of course, there are feeding trials that are you've done feeding trials or pass Yeah, or as a day challenging, oh my

Dr. Gabrielle Lyon: 1:17:22

gosh. So there was, again, you can only keep people in a metabolic ward for so long. We've done at the University of Illinois. I did where we fed them all their meals. We would pack everything, and they would show up. And expensive, too expensive, yes,

: 1:17:39

yeah, yeah. And unfortunately, as I understand it, a lot of those metabolic boards are kind of drying up, and there's not a lot of funding to keep them going, which is really sad, because there's still a lot of work to do in this space. And I'm a huge believer that we need more randomized trials in the space of nutrition, because there's a lot of controversy. There's a lot of areas that we really have uncertainty about. And the only way to answer some of these questions, not all, because there's limitations with randomized trials, of course, is to do, to do the trials. And I can talk about examples. Yeah,

Dr. Gabrielle Lyon: 1:18:17

I would. I would love you to please. So the systematic

: 1:18:21

review that I mentioned earlier, that we published in the British Medical Journal, led by Giorgio cram, who's currently a medical student at the University of Manitoba.

Dr. Gabrielle Lyon: 1:18:30

Was this the evidence based practice competencies? No,

: 1:18:34

this is BMJ systematic review, network meta analysis of popular diets for cardiovascular or for reducing mortality in cardiovascular outcomes. Okay, so I talked about seven randomized trials that measure all cause mortality. Only one of them. All of them are mostly most of them are in Europe, I should say, and the biggest ones that people might be familiar with are PREDIMED almost 7500 people randomized. So that's that single trial is probably driving the effect size to a considerable degree. There's only one randomized trial of a Mediterranean style diet in patients that have cardiovascular risk in United States, one.

Dr. Gabrielle Lyon: 1:19:26

I want to just repeat that there is one randomized control trial, only

: 1:19:30

one, and it shows basically no important effect when it comes to reducing all cause mortality, like trivial to no effect. So we should be doing, there's a Food Is Medicine Research Initiative now by the American Heart Association and others. We should be doing Mediterranean style dietary interventions for these patients, and comparing it to the, you know, the the either. Low fat type intervention or whatever the typical standard of care is. A second example is you might be familiar with salt substitutes, low sodium salt substitutes. There's some really compelling randomized control trial data, mostly out of China, that shows important risk reductions in stroke and mortality

Dr. Gabrielle Lyon: 1:20:21

is this with potassium chloride type. Yeah,

: 1:20:24

so normal table salt is like 100% 100% sodium chloride. But you replace some of that sodium chloride with potassium chloride, exactly like 25% of it, based on the the some of the Chinese studies, and you're we're showing important risk reductions, absolute risk reductions, with, I think, a probably a moderate certainty evidence level. But there's only one randomized trial, again, that's been done in the United States or in Canada, and they only measured like surrogate outcomes, like blood pressure, they didn't measure mortality, if I'm not mistaken, and the study is quite old. I think it might be 20 years old now or more. So we need to do the trials here in North America to see if we can reproduce these studies and to help determine the certainty of evidence after we do experimental studies or more experimental studies.

Dr. Gabrielle Lyon: 1:21:26

And are the are some of the challenges getting, for example, students, you run a program at Texas A and M is is part of the challenge, getting students, people interested in do you run a PhD program, master's program? Can you tell me a little bit about the the about the program that you're running?

: 1:21:44

Sure, yeah, yeah. So I don't run it. I just, I'm a,

Dr. Gabrielle Lyon: 1:21:48

maybe you're going to be up for Dean. Who knows I'm a

: 1:21:51

Professor and Associate professor there, and I've got grad students, a number of PhD students, and we, we don't do randomized trials. We do a lot of work in evidence, synthesis, systematic reviews, primary studies on values and preferences. I think we need a group of trialists that are in the space of nutrition, that come together and can work together to ask some of these important questions and do rigorous, high quality randomized trials there, you know, but there needs to be funding, not necessarily within nutrition. I think you can get funding from different NIH groups. You just need people that have that nutrition expertise and clinical trial expertise, methodological expertise, to come together as a team and to write those research proposals and try to get them funded.

Dr. Gabrielle Lyon: 1:22:52

Are there less of those individuals? I think so.

: 1:22:56

I mean, I don't know systematically, but that's what I kind of hear or see on social media. But I think we need more experimental studies, and we need to train people more the next generation. Yeah, ideally,

Dr. Gabrielle Lyon: 1:23:09

it the the landscape seems to be changing in the way. And again, this is just from my perspective, that more people are moving towards various other avenues of exploration that maybe are moving a bit away from science and actually doing higher education. Again, I only hear this from my colleagues, that it is more difficult to recruit students. It's more difficult the interest in science, while I think we're in a very privileged space where we are very interested in it, the listeners. And by the way, I love you guys. I do this because I I believe so wholeheartedly that collectively, we can make a difference. That, you know, people are going to various careers, being a Instagram star, or just it's the landscape is changing. I think that the importance of very specific cognitive processes and rigor has changed. The importance of it seems to have changed. And, you know, you talk a little bit about, I've heard you refer to quote this kind of scientific mindset.

: 1:24:24

Yeah, the scientific mindset. Well, all of us as scientists, we endeavor to have that. And I think we probably all have different definitions. But when I think of that, I think of curiosity, intellectual curiosity, about questions, about staying open to the data. I think about being agnostic to the data, especially if you're doing guideline work or doing systematic review work. It takes also, I think, a bit of bravery. I. Them to be agnostic and to be open minded and stay curious. It's like we all are human beings, and we've got our cognitive biases. So I can tell you maybe a story of my own cognitive biases that I probably remember for many years is not that many years ago, we were doing a systematic review meta analysis on, again, dietary programs, but not for mortality, but for cardiovascular risk factors like blood pressures, cholesterols and weight, and we found 14 different dietary programs across 100 and I think 20 some randomized control trials. This is also, I think in it was published in the in the British Medical Journal, and low fat diets did quite well. They were in like the top five or something. And this is probably going back five or six years ago. I said to my mentor, Dr guy, and I said, I'm kind of surprised about low fat, you know, maybe, like, Should we call it something else or and he I, he said to me, the data is the data, and that's that was the end of the conversation. So it's hard to stay curious, I think, and I now do not take any funding from industry. I don't. It's not because I believe it's bad. I think you can do very rigorous, important work with industry funding. And usually industry is involved in supporting randomized trials, for example, to some degree, paying for the intervention, paying for refrigeration, but because I'm in the space of doing evidence based practice and guidelines, it's best to just avoid any misperceptions. Yeah,

Dr. Gabrielle Lyon: 1:26:53

you know, I've never spoken about this before, but one of my goals this year is to create a non for profit that a portion of what the podcast generates, a portion of you know, eventually I would love to create a supplement. And these are things that I feel very passionate about, that we take a portion of that revenue and we put it back into evidence based practices for research. So that is on the docket for

: 1:27:26

that would be wonderful. I'll be sending you emails. So that is,

Dr. Gabrielle Lyon: 1:27:31

you know, just, I think, as we do better and we build it, we educate the public that should go back funds should go back into research so that again, I've never talked about it, right? It's something that I feel very passionate about, because we do have to evolve it. Where do you think, if at all? Do you think AI is going to be helpful in this landscape?

: 1:27:56

Definitely, yes, it's. It's a part of the landscape already. I tell my students that AI can either be your competition or your research assistant. Better to make it your research assistant. So we need to keep up with our developed skills and how to use it when it comes to evidence synthesis, there are tools now that we can use to screen studies. There's still a lot of room for improvement, but it's definitely I know of colleagues in Australia who do a lot in the space of evidence based medicine practice, and they've been, I forget the name of their kind of group, robot reviews. I think in Australia, if you look up Paul Glasgow, they work with AI tools. They've been doing it for over five years to create systematic reviews. But one of the main lessons they've learned is you actually have to have a methodologist at the center of the review all the time to make decisions, and if you do, it's very helpful. And I think they've done reviews in something like two weeks where we're working with AI and working with methodologists to make decisions along that pathway. So there's, yeah, there's, I don't know a whole lot about this, the space of AI and systematic reviews, admittedly, but I do, I do believe that it's an important part of the future, and it's already here, and I probably have to work on my AI skills and

Dr. Gabrielle Lyon: 1:29:31

fit same but it, it sounds also that we still need cognitive manpower that computers are or AI, and some of this technology, we still require scholars, scholarly activity, critical thinking, and just ways to further advance the sciences is,

: 1:29:54

yeah, and I think hopefully we need, we need humans at the at the center of science. Science like once AI is being done only by computers, or, sorry, science is being done by computers in certain domains, that's kind of scary. There needs to be a lot of transparency and reproducibility to everything that's done. And you know where you have your data open for investigation if it's created in part or enlarged by by different AI tools. Well, Dr

Dr. Gabrielle Lyon: 1:30:28

Bradley, Johnston, I'm so grateful for you sharing your time and your wisdom. The work that you do is tremendous, and it has been extraordinarily helpful for me, and I know many of my colleagues and many others. So thank you so much for joining me.

:: 30:45

Thanks for having me. Dr Lyon, it's been wonderful. You.