My name is Martin Wiseman.

And I am a physician with a longstanding interest in nutrition, cancer and public

health.
And I have been a medical and scientific advisor
to the World Cancer Research Fund International for 20 years now.
The World Cancer Research Fund
wants to live in a world where no one develops a preventable cancer.
And its mission is to achieve this by
summarising the available scientific literature relating
diet and nutrition and physical activity
to the prevention and management of cancer.
And providing people with the information they need to make healthy choices,
as well as providing advice to policy makers
on how to create an environment that is conducive to those choices.
So to review the evidence,
which is part of our mission,
we have something called the Continuous Update Project,
which is a project that we conduct in collaboration with Imperial College London.
And this is a continuing review
of all the evidence relating diet, nutrition and physical activity to cancer.
And it provides an opportunity to extract all the relevant information
into a database that can then be interrogated at any particular time.
The way that these reviews are done by the Imperial College Team
is to conduct something called a systematic literature review,
which has peer-reviewed protocols, and transparent publication of the protocol
so that they can be open to challenge and discussion.
But then, the reviews are done, which include something called ‘meta-analyses’.
And the meta-analyses are a way of getting information
on the size of an effect of an exposure on an outcome,
by combining statistically the results of several studies together.
That is a very useful part of a systematic literature review.
But it’s not the whole of the systematic literature review,
because much of the evidence may not be able to be summarised
in that mathematical way.
So the systematic literature review is a broad review of all the evidence
that is produced in the literature over a period of time,
which contains meta-analyses.
We don’t exclude studies because of their quality.
We only exclude studies because they aren’t relevant to the question at hand.
If the quality is not good,
there are measurements that are made that allow us to
assess whether something is a high or a less good quality study.
If anybody has ever conducted a systematic literature review,
they’ll know that it’s really quite a painstaking process.
And for this particular purpose, where we have diet, nutrition, and physical
activity
in relation to cancer outcomes,
both of those are really quite complex.
And therefore, it can really take quite a long time from beginning to end.
The review itself might take anything from months to over a year,
and that doesn’t include the part
where these are presented to the Continuous Update Project Expert Panel
who interpret and assess the evidence and produce the recommendations.
So this is not something that’s done by just one or two people.
The Imperial College Team contains at least five people,
and sometimes more can be brought on for a particularly complex task.
But that’s only the beginning of the issue.
Because all the protocols, as well as the reports in draft form, are peer-reviewed.
So there are peer reviewers at every stage of the process,
not counting the people who are in the World Cancer Research Fund secretariat,
there may be half a dozen of us.
And there are maybe... there are also about a dozen people
who are on the Continuous Update Project Expert Panel.
So, together, there may be actually, including the peer reviewers,
some hundreds of people involved in producing the Third Expert Report,
which collated all the evidence from the last 10 years.
So the Continuous Update Project Expert Panel are there to take the reports,
that come from the Imperial College team, the systematic literature reviews,
and then assess and interpret them.
They assess the quality of the evidence, the amount of evidence,
what direction the evidence points to
in relation to a particular exposure and outcome,
or indeed a whole range of different exposures together.
And it’s that interpretation, on top of the basic facts,
which forms the basis for making recommendations.
The recommendations that the World Cancer Research Fund puts out,
are in fact the recommendations of the independent Expert Panel.
This Expert Panel is made up of people from many countries around the world
and covers a whole variety of different expertises:
from clinical oncology to epidemiology.
So, in order to produce recommendations based on the evidence,
it’s important not to come to them with too much of a prejudice about
what the answer might be, beforehand.
We make a lot of effort to try and avoid that kind of prejudice,
particularly by separating the fact that the reviews are conducted by a separate
team,
that are entirely separate from the Expert Panel.
But another way of ensuring that the recommendations are based
more on the evidence and less on prejudice,
is to produce criteria for how strong the evidence might be regarded
on criteria that are produced in advance.
These criteria are produced based on well-known criteria,
such as those produced by Austin Bradford Hill back in the 1960s
and have been well regarded.
So, the criteria that are used are based on those of Austin Bradford Hill,
who produced some ideas about how to interrogate
a framework of largely observational data.
So that you were more or less confident
about which associations that you find from the observational data
might truly be causal.
Because the recommendations should only be made
when there is a reasonable confidence that those associations are causal.
Otherwise intervening with them is not expected to have any useful effect.
The criteria that he put out, the framework,
drew upon a number of characteristics of the evidence.
There were 10 of them, I don’t want to go into them all now.
But critical amongst them
are the idea that there should be a reasonably large effect,
that there should be enough evidence to find a direction of effect,
that there should be biological plausibility,
that there should be a reasonably amount of evidence as well.
And there are several other ones.
These have all been codified in a predetermined way,
into categorizations of the evidence,
so that we can place the evidence into those categories,
without people judging it subjectively.
Anyone who is a practising clinician will know that they have to
take a body of evidence that is, by its very nature,
always imperfect and incomplete,
and make a clinical judgement
about what advice to give a patient in front of them,
or in terms of public health: what action might be taken.
We have exactly the same issue here,
where we have a body of evidence,
with variable amounts of evidence and variable quality of evidence.
But we have an important problem,
which is an increasing burden of cancer.
So, just like a clinician, with a patient in front of them,
it's incumbent upon us, as professionals,
to give the best advice possible.
The best advice possible comes from looking at all the evidence,
judging it as far as possible in an objective way,
and then drawing conclusions on which factors are truly causally related to
an increase or a decrease in risk of cancer.
When one has a degree of confidence in that evidence
then it’s possible to give guidance or recommendations.
And the amount of evidence is categorised as convincing,
which we judge unlikely to change in the near future,
probable, which is pretty strong but not quite so strong as convincing,
or limited, in which case there is not enough evidence to judge
whether there is any useful effect from intervening in that case.
While it’s impossible to remove subjectivity all together,
we try very hard to make the judgement of the evidence quite objective.
It’s never perfect.
But when making recommendations that’s a bit more of a subjective statement.
And so,
it’s clearly a matter of professional judgement
how the recommendations are phrased.
And in a situation with nutrition, where there is very rarely a particular
threshold,
to judge at what sort of levels to pitch the recommendations.
And so, the feasibility of the recommendations,
the likelihood that people will adopt them, is certainly part of the consideration.
But at the root of it is what the evidence tells us.
And so all the recommendations,
irrespective of whether they are more or less feasible,
are rooted in the strong evidence
that there is presented in a systematic literature reviews.
I don’t think it’s for WCRF to say people need to follow the recommendations.
Looking back at the evidence,
the evidence suggests, for a variety of reasons,
like interactions between the different components of healthy living,
that diet, physical activity, healthy body weight, and so on,
that the more that one sticks to the recommendations,
the more recommendations that one can adhere to,
the better your likelihood of achieving avoiding cancer and living longer.
So, it’s not that WCRF sees the need for people to do this,
rather it likes to present the evidence to people
that the more they can adhere to the recommendations,
and the more recommendations they can adhere to at any one time,
the more likely they are to gain benefits.
The evidence is very powerful for that.