MD, PhD, MAE, FMedSci, FRSB, FRCP, FRCPEd.

case-control study

Although bullshit is common in everyday life and has attracted attention from philosophers, its reception (critical or ingenuous) has not, to our knowledge, been subject to empirical investigation. Pseudo-profound bullshit consists of seemingly impressive assertions that are presented as true and meaningful but are actually vacuous.

In this study, researchers presented participants with bullshit statements consisting of buzzwords randomly organized into statements with syntactic structure but no discernible meaning (e.g., “Wholeness quiets infinite phenomena”). Across multiple studies, the propensity to judge bullshit statements as profound was associated with a variety of conceptually relevant variables (e.g., intuitive cognitive style, supernatural belief). Parallel associations were less evident among profundity judgments for more conventionally profound (e.g., “A wet person does not fear the rain”) or mundane (e.g., “Newborn babies require constant attention”) statements.

The authors concluded that these results support the idea that some people are more receptive to this type of bullshit and that detecting it is not merely a matter of indiscriminate skepticism but rather a discernment of deceptive vagueness in otherwise impressive sounding claims. Our results also suggest that a bias toward accepting statements as true may be an important component of pseudo-profound bullshit receptivity.

Harry G Frankfurt published his delightful booklet ‘ON BULLSHIT‘ in 2005. Since then, the term ‘bullshit’ has become accepted terminology in philosophy and science. But what exactly is bullshit? Frankfurt explains that is something between a lie and a bluff, perhaps more like the latter than the former.

In another recent article, Fugelsang explains that the growing prevalence of misleading information (i.e., bullshit) in society carries with it an increased need to understand the processes underlying many people’s susceptibility to falling for it. He also reports two studies (N = 412) examining the associations between one’s ability to detect pseudo-profound bullshit, confidence in one’s bullshit detection abilities, and the metacognitive experience of evaluating potentially misleading information.

The results suggest that people with the lowest (highest) bullshit detection performance overestimate (underestimate) their detection abilities and overplace (underplace) those abilities when compared to others. Additionally, people reported using both intuitive and reflective thinking processes when evaluating misleading information. Taken together, these results show that both highly bullshit-receptive and highly bullshit-resistant people are largely unaware of the extent to which they can detect bullshit and that traditional miserly processing explanations of receptivity to misleading information may be insufficient to fully account for these effects.

I am sure that some of the discussions on this blog are excellent examples for people with low bullshit detection performance overestimating their detection abilities and overplacing those abilities.

Many community pharmacies in Switzerland provide so-called alternative medicine (SCAM) approaches in addition to providing biomedical services, and a few pharmacies specialise in SCAM. A common perception is that SCAM providers are sceptical towards, or opposed to, vaccination.

The key  objectives of this study were to examine the potential roles of biomedically oriented and SCAM-specialised pharmacists regarding vaccine counselling and to better understand the association between vaccine hesitancy and SCAM. The researchers thus conducted semistructured, qualitative interviews. Transcripts were coded and analysed using thematic analysis. Interview questions were related to:

  • type of pharmaceutical care practised,
  • views on SCAM and biomedicine,
  • perspectives on vaccination,
  • descriptions of vaccination consultations in community pharmacies,
  • and views on vaccination rates.

Qualitative interviews in three language regions of Switzerland (German, French and Italian). A total of 18 pharmacists (N=11 biomedically oriented, N=7  SCAM specialised) were invited.

Pharmacist participants expressed generally positive attitudes towards vaccination. Biomedically oriented pharmacists mainly advised customers to follow official vaccination recommendations but rarely counselled vaccine-hesitant customers. SCAM-specialised pharmacists were not as enthusiastic advocates of the Swiss vaccination recommendations as the biomedically oriented pharmacists. Rather, they considered that each customer should receive individualised, nuanced vaccination advice so that customers can reach their own decisions. SCAM-specialised pharmacists described how mothers in particular preferred getting a second opinion when they felt insufficiently advised by biomedically oriented paediatricians.

The authors concluded that vaccination counselling in community pharmacies represents an additional option to customers who have unmet vaccination consultation needs and who seek reassurance from healthcare professionals (HCPs) other than physicians. By providing individualised vaccination counselling to vaccine-hesitant customers, SCAM-specialised pharmacists are likely meeting specific needs of vaccine-hesitant customers. As such, research and implementation efforts should more systematically involve pharmacists as important actors in vaccination provision. SCAM-specialised pharmacists particularly should not be neglected as they are important HCPs who counsel vaccine-hesitant customers.

I must say that I find these conclusions odd, perhaps even wrong. Here are my reasons:

  • Pharmacists are well-trained healthcare professionals.
  • As such, they have ethical obligations towards their customers.
  • These obligations include behaving in a way that is optimal for the health of their customers and follows the rules of evidence-based practice.
  • This includes explaining to vaccine-hesitant customers why the recommended vaccinations make sense and advising them to follow the official vaccination guidelines.
  • SCAM-specialised pharmacist should ask themselves whether offering SCAM is in line with their ethical obligation to provide optimal care and advice to their customers.

I fear that this paper suggests that SCAM-specialised pharmacists might be a danger to the health of their customers. If that is confirmed, they should consider re-training, in my view.

Swedish researchers examined the relationship between cognitive ability and prompt COVID-19 vaccination using individual-level data on more than 700,000 individuals in Sweden.

The analyses were based on individual-level data from several administrative registers in Sweden. The study population consisted of all men and women who enlisted for military service in Sweden between 1979 and 1997. During this period, enlistment was mandatory for men the year they turned 18 or 19. Women could not enlist for military service before 1980 but were then allowed to do so on a voluntary basis.

The study population thus covered almost the entire population of Swedish men born between 1962 and 1979, in total 750,381, as well as the sample of women who enlisted during the period of 1980–1997, in total 2703. In addressing the role of confounders, the researchers analyzed the sub-sample of 6750 twin brothers (3375 twin-pairs) in the enlistment records (identified by shared biological mother and year and month of birth).

The results show a strong positive association between cognitive ability and swift vaccination, which remained even after controlling for confounding variables with a twin-design. Consistent with this, the researchers showed that simplifying the vaccination decision through pre-booked vaccination appointments alleviates almost all of the inequality in vaccination behavior.

The authors concluded that the complexity of the vaccination decision may make it difficult for individuals with lower cognitive abilities to understand the benefits of vaccination.

On this blog, we have repeatedly discussed similar or related findings, e.g.:

I know, it would be politically incorrect, unkind, unhelpful, etc. but is anyone not tempted to simplify the issue by assuming that people who are against (COVID) vaccinations are intellectually challenged?

The KFF provides reliable, accurate, and non-partisan information to help inform health policy in the US. The KFF has just released its ‘Health Misinformation Tracking Poll Pilot‘ examining the public’s media use and trust in sources of health information and measuring the reach of specific false and inaccurate claims surrounding three health-related topics: COVID-19 and vaccines, reproductive health, and gun violence. It makes grimm reading indeed. Here are but a few excerpts pertaining to health/vaccination:

Health misinformation is widespread in the US with 96% of adults saying they have heard at least one of the ten items of health-related misinformation asked about in the survey. The most widespread misinformation items included in the survey were related to COVID-19 and vaccines, including that the COVID-19 vaccines have caused thousands of deaths in otherwise healthy people (65% say they have heard or read this) and that the MMR vaccines have been proven to cause autism in children (65%).

Regardless of whether they have heard or read specific items of misinformation, the survey also asked people whether they think each claim is definitely true, probably true, probably false, or definitely false. For most of the misinformation items included in the survey, between one-fifth and one-third of the public say they are “definitely” or “probably true.” The most frequently heard claims are related to COVID-19 and vaccines.

Uncertainty is high when it comes to health misinformation. While fewer than one in five adults say each of the misinformation claims examined in the survey are “definitely true,” larger shares are open to believing them, saying they are “probably true.” Many lean towards the correct answer but also express uncertainty, saying each claim is “probably false.” Fewer tend to be certain that each claim is false, with the exception of the claim that more people have died from the COVID-19 vaccines than from the virus itself, which nearly half the public (47%) recognizes as definitely false.

Across the five COVID-19 and vaccine related misinformation items, adults without a college degree are more likely than college graduates to say these claims are definitely or probably true. Notably, Black adults are at least ten percentage points more likely than White adults to believe some items of vaccine misinformation, including that the COVID-19 vaccines have caused thousands of sudden deaths in otherwise healthy people, and that the MMR vaccines have been proven to cause autism in children. Black (29%) and Hispanic (24%) adults are both more likely than White adults (17%) to say that the false claim that “more people have died from the COVID-19 vaccine than have died from the COVID-19 virus” is definitely or probably true. Those who identify as Republicans or lean towards the Republican Party and pure independents stand out as being more likely than Democratic leaning adults to say each of these items is probably or definitely true. Across community types, rural residents are more likely than their urban and suburban counterparts to say that some false claims related to COVID vaccines are probably or definitely true, including that the vaccines have been proven to cause infertility and that more people have died from the vaccine than from the virus.

Educational attainment appears to play a particularly important role when it comes to susceptibility to COVID-19 and vaccine misinformation. Six in ten adults with college degrees say none of the five false COVID-19 and vaccine claims are probably or definitely true, compared to less than four in ten adults without a degree. Concerningly, about one in five rural residents (19%), adults with a high school education or less (18%), Black adults (18%), Republicans (20%), and independents (18%) say four or five of the false COVID-19 and vaccine misinformation items included in the survey are probably or definitely true.

________________________________

If you have followed some of the comments on this blog, you might find it hard to be surprised!

I do encourage you to read the full article.

This study aimed to clarify the psychological mechanism by which individuals accept health misinformation from social media and how health misperceptions affect subsequent unhealthy behavior in the context of dewormer use.

An online survey was conducted with 307 South Korean adults exposed to dewormer use information on social media. The positive association between the respondents’ uncertainty about their health and factual misbeliefs about dewormer use was moderated by their pre-existing attitude toward so-called alternative medicine (SCAM) vs. standard treatments, suggesting that individuals who are uncertain but more favorable toward SCAM tend to accept factual misbeliefs more easily. Individuals’ uncertainty about their health and treatment for the health management was positively associated with conspiracy beliefs. Factual misbeliefs were the key mediator in the association between the interaction of uncertainty and pre-existing attitude toward SCAM vs. standard treatments and dewormer-taking intention.

 

Image result for misinformation, cartoon

This is a subject that we have discussed many times before. See, for instance, here:

In my view, it is hugely important. Consumers who are uncertain, easily misled, convinced that ‘the establishment’ is against them, or prone to other conspiracy theories tend to be the ones that also fall easily for the lies of SCAM promoters. Indeed, I have previously suggested that SCAM itself is a conspiracy theory in disguise. Anyone who has been following the comment sections on this blog will find more evidence for this theory than he had ever needed, I fear.

It is clear to me that misinformation undermines not just evidence-based medicine but – much more dangerous -rationality in general. It would be thus urgent to do something about it.

But what?

In my view, the answer is to promote critical thinking. This, of course, is what I am aiming at with my blog. But my effort is merely a drop in the ocean. What we need is a systematic promotion of critial thinking on a much larger scale. It has to start at school and should be followed through to post-graduate education and beyond.

Such a strategy would require a very broad backing, not least on the political levels. And this is where the concept runs into insurmountable difficulties: politcians might not want us to be critical thinkers! This could enable the public to realize what often dismally poor jobs they might be up to.

Vaccine hesitancy has become a threat to public health, especially as it is a phenomenon that has also been observed among healthcare professionals. In this study, an international team of researchers analyzed the relationship between endorsement of so-called alternative medicine (SCAM) and vaccination attitudes and behaviors among healthcare professionals, using a cross-sectional sample of physicians with vaccination responsibilities from four European countries: Germany, Finland, Portugal, and France (total N = 2,787).

The results suggest that, in all the participating countries, SCAM endorsement is associated with lower frequency of vaccine recommendation, lower self-vaccination rates, and being more open to patients delaying vaccination, with these relationships being mediated by distrust in vaccines. A latent profile analysis revealed that a profile characterized by higher-than-average SCAM endorsement and lower-than-average confidence and recommendation of vaccines occurs, to some degree, among 19% of the total sample, although these percentages varied from one country to another: 23.72% in Germany, 17.83% in France, 9.77% in Finland, and 5.86% in Portugal.

The authors concluded that these results constitute a call to consider health care professionals’ attitudes toward SCAM as a factor that could hinder the implementation of immunization campaigns.

In my view, this is a very important paper. It shows what we on this blog have discussed often before: there is an association between SCAM and vaccination hesitancy. The big question is: what is the nature of this association. There are several possibilities:

  1. It could be coincidental. I think this is most unlikely; too many entirely different investigations have shown a link.
  2. It could mean that people start endorsing SCAM because they are critical about vaccination.
  3. It could be that people are critical about vaccination because they are proponents of SCAM.
  4. Finally, it could be that some people have a mind-set that renders them simultaneously hesitant about vaccination and fans of SCAM.

This study, like most of the other investigationson this subject, was not desighned to find out which possibility is most likely. I suspect that the latter two explanations apply both to some extend. The authors of this study argue that that, “from a theoretical point of view, this situation may be explicable by reasons that are both implicit (i.e., CAM would fit better with certain worldviews and ideological standpoints that conflict with the epistemology and values that underlies scientific knowledge) and explicit (i.e., some CAM techniques are doctrinally opposed to the use of vaccines). Although we have outlined these potential explanations for the observed relationships, more research is needed to better understand the underlying mechanisms”.

 

Online misinformation is disproportionality created and spread by people with extreme political attitudes, especially among the far-right. There is a debate in the literature about why people spread misinformation and what should be done about it. According to the purely cognitive account, people largely spread misinformation because they are lazy, not biased. According to a motivational account, people are also motivated to believe and spread misinformation for ideological and partisan reasons. To better understand the psychological and neurocognitive processes that underlie misinformation sharing among the far-right, an international team of researchers conducted a cross-cultural experiment with conservatives and far-right partisans in the Unites States and Spain (N = 1,609) and a neuroimaging study with far-right partisans in Spain (N = 36).

Far-right partisans in Spain and U.S. Republicans who highly identify with Trump were more likely to share misinformation than center-right voters and other Republicans, especially when the misinformation was related to sacred values (e.g., immigration). Sacred values predicted misinformation sharing above and beyond familiarity, attitude strength, and salience of the issue. Moreover, far-right partisans were unresponsive to fact-checking and accuracy nudges. At a neural level, this group showed increased activity in brain regions implicated in mentalizing and norm compliance in response to posts with sacred values.

The authors concluded that these results suggest that the two components of political devotion – identity fusion and sacred values – play a key role in misinformation sharing, highlighting the identity-affirming dimension of misinformation sharing. We discuss the need for motivational and identity-based interventions to help curb misinformation for high-risk partisan groups.

People who have followed the discussions on this blog closely could be forgiven in assuming that right-wing political devotion also plays an important role in spreading misinformation about healthcare (e.g. vaccination) and so-called alternative medicine (SCAM). It would be good, if someone could test this hypothesis more directly.

PS

Just as I had finished writing this post, I came across a quote given yesterday by Ben Habib on GBN:

“I’m very reluctant to put my destiny in the hands of scientists. You know, unbridled authority given to faux knowledge.”

QED

In an aging society, it is crucial to understand why some people live long and others do not. There has been a proliferation of studies in recent years that highlight the importance of psycho-behavioral factors in the ways of aging, one of those psychological components is intelligence. In this meta-analysis, the association between intelligence and life expectancy in late adulthood is analysed through the Hazard Ratio (HR). The objectives are:

  • (i) to update a previous meta-analysis, especially the estimate of the association between survival and intelligence;
  • (ii) to evaluate the role of some moderators, especially the age of the participants, to explore intelligence–mortality throughout adulthood and old age.

The results show a positive relationship between intelligence and survival (HR: 0.79; 95% CI: 0.81–0.76). This association is significantly moderated by the years of follow-up, the effect size being smaller the more years elapse between the intelligence assessment and the recording of the outcome.

Fig. 2

The authors concluded that intelligence is a protective factor to reach middle-high age, but from then on survival depends less and less on intelligence and more on other factors.

The consistency of the primary studies is remarkable. This suggests that the association is real. Yet, the question remains: what causes the relationship between intelligence and longevity? Factors such as childhood environment, family income, schooling, and healthy/unhealthy lifestyle habits (diet, exercise, tobacco use, alcohol, illnesses), have been studied. There seems to be a reciprocal dynamic association between intelligence and health throughout life, and although there are several constructs associated with health/ illness and death (e.g., parental social class, intelligence in youth, more education, higher health literacy, healthy behaviors, and more affluent social class) shared genetic differences are likely to account for only a small proportion of these associations.

Arden and colleagues analyzed three twin studies (from the U.S., Denmark, and Sweden) and found a small positive phenotypic correlation between intelligence and lifespan, furthermore, in the combined sample, the genetic contribution to covariance was 95%; in the US study, 84%; in the Swedish study, 86%, and in the Danish study, 85%. These authors pointed out that any genetic factors contributing to intelligence and mortality may operate indirectly via good health choices.

Following this line of argument, I might (with my tongue placed firmly in my cheek) postulate that intelligence leads people to opt for medical treatments that are effective and thus prolong life, while avoiding so-called alternative medicines (SCAMs).

There is evidence that, in the US, Republican-leaning counties have had higher COVID-19 death rates than Democratic-leaning counties and similar evidence of an association between political party affiliation and attitudes regarding COVID-19 vaccination. This investigation assessed political party affiliation and mortality rates for individuals during the initial 22 months of the COVID-19 pandemic.

A cross-sectional comparison of excess mortality between registered Republican and Democratic voters between March 2020 and December 2021 adjusted for age and state of voter registration was conducted. Voter and mortality data from Florida and Ohio in 2017 linked to mortality records for January 1, 2018, to December 31, 2021, were used in data analysis. The main outcome measure was the excess weekly death rates during the COVID-19 pandemic adjusted for age, county, party affiliation, and seasonality.

Between January 1, 2018, and December 31, 2021, there were 538 159 individuals in Ohio and Florida who died at the age of 25 years or older in the study sample. The median age at death was 78 years (IQR, 71-89 years). Overall, the excess death rate for Republican voters was 2.8 percentage points, or 15%, higher than the excess death rate for Democratic voters (95% prediction interval [PI], 1.6-3.7 percentage points). After May 1, 2021, when vaccines were available to all adults, the excess death rate gap between Republican and Democratic voters widened from −0.9 percentage points (95% PI, −2.5 to 0.3 percentage points) to 7.7 percentage points (95% PI, 6.0-9.3 percentage points) in the adjusted analysis; the excess death rate among Republican voters was 43% higher than the excess death rate among Democratic voters. The gap in excess death rates between Republican and Democratic voters was larger in counties with lower vaccination rates and was primarily noted in voters residing in Ohio.

Image

The authors concluded that, in this cross-sectional study, an association was observed between political party affiliation and excess deaths in Ohio and Florida after COVID-19 vaccines were available to all adults. These findings suggest that differences in vaccination attitudes and reported uptake between Republican and Democratic voters may have been factors in the severity and trajectory of the pandemic in the US.

In light of what has been discussed repeatedly, these findings are in my view most impressive and seem to speak for themselves. The authors are nevertheless prudent and stress that their study has several limitations which mean that we ought to interpret their results with caution.

  • First, there are plausible alternative explanations for the difference in excess death rates by political party affiliation beyond the explanatory role of vaccines discussed herein.
  • Second, the mortality data, although detailed and recent, only included approximately 83.5% of deaths in the US and did not include the cause of death. Although overall excess death patterns in our data are similar to those in other reliable sources, such as the Centers for Disease Control and Prevention National Center for Health Statistics data, it is possible that the deaths that our study data did not include may disproportionately occur among individuals registered with a particular political party, potentially biasing our results. In addition, the completeness of the mortality data may vary across states or time, potentially biasing our estimates of excess death rates.
  • Third, all excess death models rely on fundamentally untestable assumptions to construct the baseline number of deaths one would expect in the absence of the COVID-19 pandemic.
  • Fourth, because no information on individual vaccination status was available, analyses of the association between vaccination rates and excess deaths relied on county-level vaccination rates.
  • Fifth, the study was based on data from 2 states with readily obtainable historical voter registration information (Florida and Ohio); hence, the results may not generalize to other states.

As we have recently discussed diet and its effects on health, it seems reasonable to ask whether there is a diet that is demonstrably healthy. A recent investigation attempted to answer this question.

This study was aimed at developing a healthy diet score that is associated with health outcomes and is globally applicable. It used data from the Prospective Urban Rural Epidemiology (PURE) study and tried to replicate it in five independent studies on a total of 245 000 people from 80 countries.

A healthy diet score was developed on the basis of the data from 147 642 people from the general population, from 21 countries in the PURE study. The consistency of the associations of the score with events was examined in five large independent studies from 70 countries.

The healthy diet score was developed based on six foods each of which has been associated with a significantly lower risk of mortality [i.e. fruit, vegetables, nuts, legumes, fish, and dairy (mainly whole-fat); range of scores, 0–6]. The main outcome measures were all-cause mortality and major cardiovascular events [cardiovascular disease (CVD)].

During a median follow-up of 9.3 years in PURE, compared with a diet score of ≤1 point, a diet score of ≥5 points was associated with a lower risk of:

  • mortality [hazard ratio (HR) 0.70; 95% confidence interval (CI) 0.63–0.77)],
  • CVD (HR 0.82; 0.75–0.91),
  • myocardial infarction (HR 0.86; 0.75–0.99),
  • stroke (HR 0.81; 0.71–0.93).

In three independent studies with vascular patients, similar results were found, with a higher diet score being associated with lower mortality (HR 0.73; 0.66–0.81), CVD (HR 0.79; 0.72–0.87), myocardial infarction (HR 0.85; 0.71–0.99), and a non-statistically significant lower risk of stroke (HR 0.87; 0.73–1.03). Additionally, in two case-control studies, a higher diet score was associated with lower first myocardial infarction [odds ratio (OR) 0.72; 0.65–0.80] and stroke (OR 0.57; 0.50–0.65). A higher diet score was associated with a significantly lower risk of death or CVD in regions with lower than with higher gross national incomes (P for heterogeneity <0.0001). The PURE score showed slightly stronger associations with death or CVD than several other common diet scores (P < 0.001 for each comparison).

Association of Prospective Urban Rural Epidemiology healthy diet score vs. Events in those with and without prior cardiovascular disease in the four independent prospective studies (n = 191 476). Hazard ratios (95%) are per 20 percentile increment in the diet score. Hazard ratios (95% CI) are multivariable adjusted.

The authors concluded that consumption of a diet comprised of higher amounts of fruits, vegetables, nuts, legumes, and a moderate amount of fish and whole-fat dairy is associated with a lower risk of CVD and mortality in all world regions, but especially in countries with lower income where consumption of these natural foods is low. Similar associations were found with the inclusion of meat or whole grain consumption in the diet score (in the ranges common in the six studies that we included). Our findings indicate that the risks of deaths and vascular events in adults globally are higher with inadequate intake of protective foods.

The authors rightly stress that their analyses have a number of limitations:

First, diet (as in most large epidemiologic studies) was self-reported and variations in reporting might lead to random errors that could dilute real associations between diet scores and clinical outcomes. Therefore, the beneficial effects of a healthier diet may be larger than estimated.

Second, the researchers did not examine the role of individual types of fruits and vegetables as components in the diet score, since the power to detect associations of the different types of fruits and vegetables vs. CVD or mortality is low (i.e. given that the number of events per type of fruit and vegetable was relatively low). Recent evidence suggests that bioactive compounds and, in particular, polyphenols which are found in certain fruit or vegetables (e.g. berries, spinach, and beans) may be especially protective against CVD.

Third, in observational studies, the possibility of residual confounding from unquantified or imprecise measurement of covariates cannot be ruled out—especially given that the differences in risk of clinical events are modest (∼10%–20% relative differences). Ideally, large randomized trials would be needed to clarify the clinical impact on events of a policy of proposing a dietary pattern in populations.

Fourth, the use of the median intake of each food component as a cut-off in the scoring scheme for each diet may not reflect the full range of consumption or provide a meaningful indicator of consumption associated with the disease. However, the use of quintiles instead of medians within each study or within each region yielded the same results indicating the robustness of our findings.

Fifth, the level of intake to meet the cut-off threshold for each food group in the diet score may differ between countries. However, in sensitivity analyses where region-specific median cut-offs were used to classify participants on each component of the diet score, the results were similar to using the overall cohort median of each food component. Further, with unprocessed red meat and whole grains included or excluded from the diet score in these sensitivity analyses, the results were again similar.

Sixth, misclassification of exposures cannot be ruled out as repeat measures of diet were not available in all studies. However, the ORIGIN study, in which repeat diet assessments at 2 years were conducted, showed similar results based on the first vs. second diet assessments. This indicates that misclassification of dietary intake during follow-up was not undermining the findings.

Seventh, one unique aspect of the study is the focus on only protective foods, i.e. a dietary pattern score that highlights what is missing from the food supply, especially in poorer world regions, but this does not negate the importance of limiting the consumption of harmful foods such as highly processed foods. While the PURE diet score had significantly stronger associations with events than other diet scores, the HRs were only slightly larger for PURE than for most other diet scores. However, the Planetary score was the least predictive of events. The analyses provide empirical evidence that all diet scores (other than the Planetary diet score) are of value to predicting death or CVD globally and in all regions of the world.

So, what should we, according to these findings, be looking for and how much of it should we consume? Here is the table that should answer these questions:

Fruits and vegetables 4 to 5 servings daily 1 medium apple, banana, pear; 1 cup leafy vegs; 1/2 cup other vegs
Legumes 3 to 4 servings weekly 1/2 cup beans or lentils
Nuts 7 servings weekly 1 oz., tree nuts or peanuts
Fish 2 to 3 servings weekly 3 oz. cooked (pack of cards size)
Dairy 14 servings weekly 1 cup milk or yogurt; 1 ½ oz cheese
Whole grainsc Moderate amounts (e.g. 1 serving daily) can be part of a healthy diet 1 slice (40 g) bread; ½ medium (40 g) flatbread; ½ cup (75–120 g) cooked rice, barley, buckwheat, semolina, polenta, bulgur, or quinoa
Unprocessed meatsc Moderate amounts (e.g. 1 serving daily) can be part of a healthy diet 3 oz. cooked red meat or poultry
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