Yet One More Junk Paper in JAMA Internal Medicine

Will they EVER learn statistics?

The paper Association of Animal and Plant Protein Intake With All-Cause and Cause-Specific Mortality, an “original investigation” (whatever that means, since they just crunched numbers), published on the 26th of August–this paper is behind a paywall. Interestingly, a nearly identical paper with a nearly identical title, published in the same journal in 2016: Association of Animal and Plant Protein Intake With All-Cause and Cause-Specific Mortality, with the same outcome. And what is that outcome?

Animal Protein Causes Earlier Death

Instead of writing about the article, I just provide the commentary I sent to JAMA Internal Medicine last night, and which published this morning. It explains everything. If you wish to read my commentary online, visit here and scroll down to comments–mine is the first one. Here it goes:

August 29, 2019
Concerns about Misleading Interpretation and Incorrect Conclusion
Angela Stanton, PhD | Stanton Migraine Protocol Inc.,

The article by Budhathoki et al.,(1) is akin to the article  in 2016 by Song et al (2). A study of association is used to support causation without appropriate statistical proof.

The article states in the abstract that “Intake of animal protein showed no clear association with total or cause-specific mortality” and then in the next sentence “In contrast, intake of plant protein was associated with lower total mortality.” If there is no clear association between meat protein and mortality, how can plant protein be associated with lower mortality? If there is no association, then there is no association.
In my view, the authors main findings are incorrect, confusing, and misleading.

This research is based on food frequency surveys for the previous year, completed once every five years. Food frequency questionnaires are questionable at best, particularly when a past year’s consumption has to be recalled.

A frequent  error in a food frequency analysis is the substitution of plant protein for animal protein “on paper” with “isocaloric substitution interpretation,” without the subjects actually changing their diet. Such substitution cannot be used to conclude what would have happened had they actually changed their diet. So we cannot infer if their mortality changed.

And finally, none of the hazard ratios shown meet the Bradford Criteria of 2 to suggest that the associations are significant enough to consider causation for even further analysis, let alone conclude any causal significance. This study shows no association of mortality with the type of protein consumed.

1 Budhathoki, S. et al. Association of Animal and Plant Protein Intake With All-Cause and Cause-Specific Mortality. JAMA Internal Medicine, doi:10.1001/jamainternmed.2019.2806 (2019).

2 Song, M., Fung, T. T., Hu, F. B. & et al. Association of animal and plant protein intake with all-cause and cause-specific mortality. JAMA Internal Medicine 176, 1453-1463, doi:10.1001/jamainternmed.2016.4182 (2016).

There. I think the trash quality of the article is clear.

Comments are welcomed, as always, and are monitored for appropriateness

Angela

About Angela A Stanton, Ph.D.

Angela A Stanton, PhD, is a Neuroeconomist focusing on chronic pain--migraine in particular--physiology, electrolyte homeostasis, nutrition, and genetics. She lives in Southern California. Her current research is focused on migraine cause, prevention, and treatment without the use of medicine. As a forever migraineur from childhood, her discovery was helped by experimenting on herself. She found the cause of migraine to be at the ionic level, associated with disruption of the electrolyte homeostasis, resulting from genetic variations of all voltage dependent channels, gates, and pumps (chanelopathy) that modulate electrolyte mineral density and voltage in the brain. In addition, insulin and glucose transporters, and several other variants, such as MTHFR variants of B vitamin methylation process and many others are different in the case of a migraineur from the general population. Migraineurs are glucose sensitive (carbohydrate intolerant) and should avoid eating carbs as much as possible. She is working on her hypothesis that migraine is a metabolic disease. As a result of the success of the first edition of her book and her helping over 5000 migraineurs successfully prevent their migraines world wide, all ages and both genders, and all types of migraines, she published the 2nd (extended) edition of her migraine book "Fighting The Migraine Epidemic: Complete Guide: How To Treat & Prevent Migraines Without Medications". The 2nd edition is the “holy grail” of migraine cause, development, and prevention, incorporating all there is to know. It includes a long section for medical and research professionals. The book is full of academic citations (over 800) to authenticate the statements she makes to make it easy to follow up by those interested and to spark further research interest. It is a "Complete Guide", published on September 29, 2017. Dr. Stanton received her BSc at UCLA in Mathematics, MBA at UCR, MS in Management Science and Engineering at Stanford University, PhD in Economics with dissertation in neuroscience (culminating in Neuroeconomics) at Claremont Graduate University, fMRI certification at Harvard University Medical School at the Martinos Center for Neuroimaging for experimenting with neurotransmitters on human volunteers, certification in LCHF/ketogenic diet from NN (Nutrition Network), certification in physiology (UPEN via Coursea), Nutrition (Harvard Shool of Public Health) and functional medicine studies. Dr. Stanton is an avid sports fan, currently power weight lifting and kickboxing. For relaxation (yeah.. about a half minute each day), she paints and photographs and loves to spend time with her family of husband of 45 years, 2 sons and their wives, and 2 granddaughters. Follow her on Twitter at: @MigraineBook, LinkedIn at https://www.linkedin.com/in/angelaastantonphd/ and facebook at https://www.facebook.com/DrAngelaAStanton/
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24 Responses to Yet One More Junk Paper in JAMA Internal Medicine

  1. chris c says:

    http://sci-hub.tw/10.1001/jamainternmed.2019.2806

    I’ll attempt to read it later, that or watch some paint dry. Looks like some more Seventh Day Adventist propaganda

    IMO the only way meat can do you harm is if you fry it in industrially produced Omega 6 seed oils and eat it with the bun and the fries and the Big Gulp.

    Liked by 1 person

    • Exactly. I am now experimenting with nearly raw beef–I already eat sashimi, which is raw fish, and loving it. I just sear my steak now for a few seconds on both sides and wow.. it melts in your mouth and I can eat a lot more of it without getting any uncomfortable fullness. I am still increasing my protein consumption–I am still eating less protein than I woudl like to eat for protein synthesis. Raw steak is getting me there.

      I now bought steak ground in front of my eyes instead of pre-ground stuff… so this time I will do the same with burgers as well. Just gonna pour melted cheese on top somehow.. gonna have to figure that one out: how to. lol.

      Like

      • chris c says:

        I eat mine as a farmer advised – grilled until it has nearly stopped mooing. That would probably be braised for you. I get some excellent Hereford rump steaks and eat them with seasonal greens, a couple of thickly buttered oatcakes and some Chilean Carmenere. I will also fry a slice of lamb’s liver and a giant mushroom in EVOO, grill some bacon and eat with the same seasonal greens,currently runner beans (pole beans?) earlier asparagus (buttered) and soon brussels sprouts or purple sprouting broccoli. Likewise takes next to no time to cook and transport costs are nearly nonexistent, it could walk here!

        I also do smoked gammon rashers and grate cheese to melt over the top, and with ground beef I usually chop up some bacon and add multicoloured peppers and chillies and assorted other things and put in lumps of Halloumi. That works!

        Now to re-read the other paper

        http://sci-hub.tw/10.1001/jamainternmed.2016.4182

        One big factor, look at the carb content of ALL the diets! Here’s the elephant in the room – animal protein comes with fat, some of which is saturated. Vegetable protein always comes with carbs. The FART-Lancet diet consists of 232g carbs which is about four times what I can handle and has been analysed as having a bunch of deficiencies. which I suspect our diets don’t.

        Liked by 1 person

        • I only eat meat and dairy now with some fruits. I stay away from veggies as much as I can. I woudl say I eat a salad maybe twice a month now but come fall I move back into carnivore with only a tiny mini pepper a day. I now started to eat some of my meat raw… so far beef, egg yolks, and fish raw (sashimi). This week I ate raw meat 4 days in a row. With beef, I keep it out on the kitchen counter under a bug-net half the day so it is very nice and soft. The other day I felt like melted cheese on top so I melted some cheese in a nonstick with nothing under, and then put the steak into it, flipped on my plate and yummy! Too bad I cannot insert an image into the comments without an http link.. duh..

          I don’t own any oil that is of plants at all. Plant oils replace cholesterol with plant sterols, and that is actually harmful. I ma not taking a chance on anything harmful prevent.

          So you gonna spend some time reading a bad article? 😉 It’s exactly as good as the one Jama published now… If I used printed paper, it would have some use as a fire starter or similar. It’s good for nothing else. Enjoy the laugh. 🙂

          Like

        • chris c says:

          I’m lucky most vegetation does me no harm, except wheat. Well I’m not good with fruit except berries or most root vegetables or other grains – too carby. Well there was that time my ex bought some Scotch Bonnet chillies and thinking they were cute little peppers I chopped up three and put them in the stir fry. Neither of us could finish it, and we both loved hot food. I shred a tiny piece of one, and other chillies, peppers, garlic etc. for flavour, also mushrooms and various greens, and nuts, along with my meat, poultry, game fish and dairy. I avoid Omega 6 seed oils but am fond of EVOO, again for the flavour, and also fresh ground black pepper with the salt, and sometimes other herbs and spices. Works for me though I guess not for you.

          I remembered that other paper, from the High Priests of the Seventh Day Adventist church. My verdict “you couldn’t even use it to wipe”.

          Our Leader Of The Opposition Jeremy Corbyn transitioned from vegetarian to vegan and now looks like a dead man walking with a severe case of Vegan Neck. I fear if he gets elected instead of the current moron he will be on board with banning meat.

          Liked by 1 person

        • Interestingly as I kept nearly a year break in vegetables, I can now tolerate a salad without getting sick from it. I suppose the body heals. I still avoid all other veggies. Eat the fruit-types like tomatoes, peppers, and similar, and some low carbs fruits. This summer I have been testing some high carbs fruits–cherries specifically that are all pure sugar–just to see how my migraines behave given that for migraineurs carbs are the worst thing. I did OK. Not a single migraine as long as I finished the fruit with salt. So cool! Theory has been proven extremely well.

          Yeah… none of those things you eat woudl work for me–cool though. Given an uninhibited island, we would not fight over food! 🙂 I am now experimenting with some raw meat–just beef and sashimi. Pretty darn good and so much easier to digest. I am quite hooked on them now.

          I had no idea Corbyn was vegan–he looks the part. I know nothing about politics, so not going there. I just feel sorry if he brings harm to UK. Hope that’s not going to happen.

          Like

        • chris c says:

          I was always meh on salads, I prefer my veggies cooked. I just had a succulent lamb chop which I grill (broil) for long enough that the glorious fat turns into crackling.

          An uninhibited island sounds good, even better than an uninhabited one!

          It seems a lot of people have problems with nightshades, fortunately I’m not one of them, except for potatoes – too carby.

          Politically we’re between a rock and a hard place, Boris will sell the NHS to the Yanks (no offence, I mean your insurance companies and HMOs) and Corbyn will make us vegan.

          Liked by 1 person

        • hahahahhahaha I am typo queen.. I have been holding this title all my life I suppose to never pass it on to others… I am fine with night shades. Love tomatoes and peppers. I cannot eat spinach or Brussels sprouts–or otehr cruciferous veggies much. I am a super taster for those nasty chemicals in spinach and will give you a sourpuss face from one leaf. it doesn’t matter if thy are cooked or raw. I don’t usually eat any veggies. I will stop salads in October and move back into the shoes of a hypercarnivore, eating only a tiny pepper as my only non-animal source food for the whole winter.

          I watched BBC today while on the treadmill… not sure he will be in power by the time I am back in carnivore mode.. he is an odd character I must say. Know nothing about Corbyn–only saw his white face hurry into a car. At least, for now, while Trump is in power, we have choices for medical insurance. I love my healthcare and medical insurance place (they are one and the same in my Kaiser, which is an HMO) and I get the best care on a moment’s notice. I need not even see my doctor–they now have 10-minute phone consults for non-emergencies I can set up with my doc. And for meds, I can send an email and request. It is awesome. I sure hope this won’t change…

          Like

        • chris c says:

          I’m the typo king! I catch most but not all of them. Best one was when I wrote elationship – which is exactly what it was!

          Vegetables defend themselves with toxins. We have evolved to detoxify some of them and even use them as drugs. Some people are better at this than others, mainly it is seeds I do not do well with. A dietician used to troll a diabetes forum warning of the “extreme dangers” of low carb diets, which mainly included scurvy and halitosis, which of course no-one ever suffered from while they got their A1c below 6 which doesn’t happen when you “base every meal on starchy carbohydrates”, advice which even the ADA has backed away from. They write the same stuff about the carnivores, who likewise do not seem to suffer from the “expected” dietary deficiencies.

          When we moved here fourteen years ago the health centre was excellent, you could see a doctor within a few days and they had no problem making simultaneous or adjacent appointments for my mother and me. Then they were turned into crap by The Management and the doctors complained they were being monitored by Big Brother. Now they have improved again but it can still take three or four weeks to see a doctor, probably because they spend most of their time testing well people for drug deficiencies. Since I’m hardly ever ill now, I have my sole prescription (for Amlodipine) on automatic renewal and just drop in to collect it every month. I believe Kaiser are one of the few who are NOT interested in buying the NHS, I’ve heard good things about them from others too.

          Liked by 1 person

        • Yes, there would be no interest by Kaiser in turning everything into NHS USA because that will destroy Kaiser. So I hope they stay for as long as my kids and I live… they are excellent.

          Stuff just happened to me in coming off of some meds I had been taking for asthma but eating carnivore and now back to keto cured my asthma. So I quit the inhaler but had this darned pill that is not possible to cut, so no chance to reduce. My pulmonary doc responded back to my email upon my asking for the child-dose, which is a chewable sweetened nonsense but can at least be cut, to just quit.

          So I quit but 3 day after I felt things tightening up so I took the pill again. I woke up in the morning with over a kilo of water retained and face so swollen I could hardly open my eyes! To cut to the chase, I wrote him again telling him that the abrupt quit was a bad idea and asked once more for the child chewable but he never responded–this was Friday afternoon and he may already have gone home.

          I sent an email off to my primary care doc, and my prescription was ready in one hour, picked it up right away.. ahead and forward now with a 90-day supply to reduce by little nips…

          All these would not have been possible under any medical plan other than Kaiser. So yes, I want to keep Kaiser. It’s 24/7 for everything, including pharmacy.

          Like

        • chris c says:

          I live near the coast, and something that has always amused me is that we have the wild versions of a lot of vegetables – and they are pretty much inedible. Sea kale and sea cabbage have leathery leaves, wild carrot and wild parsnip have roots like hawsers. Much breeding required to make edible versions. Sea beet (= spinach) is slightly better. Wild asparagus and samphire are edible as is with minor cooking, Asparagus is a local crop on the sands. Samphire grows on the marshes but strangely Fish Van Man gets it imported from Holland. Anyway I wonder how starving people must have been to eat some of this stuff, especially when they were surrounded by fish and shellfish.

          Shortly I shall stir-fry some bacon and pheasant breast with multicoloured peppers and chillies, garlic and olives, and a small portion of basmati rice to soak up the juices.

          Liked by 1 person

        • Basmati rice??? So you eat the SAD only replacing veg and seed oils with olive oil? That’s it?

          I agree on the impossibility of the carbs craze based on what they believe humans must have eaten for eons. In the meantime, read and watch this.

          Like

        • chris c says:

          Good Lord, no!!! I generally stick to around 50g carbs, I use EVOO largely for the flavour and also coconut oil and lashings of butter and cheese along with the meat, poultry, game and fish, and vegetables etc. for flavouring, I avoid most “processed” foods and Omega 6 seed oils as well as wheat, but I like my coffee, red wine and 85% chocolate.
          I’m generally in or near ketosis. I have next to nothing for breakfast and tend to alternate between one large and two smaller meals and seldom snack. I spend most of my time metabolising the food I ate earlier/the previous day. I spent most of my life dutifully eating low fat and failing to understand what caused my symptoms. The Horror – I even remember doing a taste test of every margarine on the market!

          Fungi are another thing I ponder. We have a few deadly ones, several that are otherwise toxic, and many that just taste bad. How did they work this out??? Watch people throw up or die and cross them off the list? There are not a few toxic wild plants too, some of which closely resemble edible ones.

          Georgia Ede is excellent.

          Liked by 1 person

        • Yes on the fungi… brave souls who experimented–and some still do and die or get major sick. I support fungi-eating in its safe forms since they are not plants and hopefully we avoid the toxic ones. I like to eat seaweed but not mushrooms. I never learned to like their taste.

          Like

        • chris c says:

          Oyster mushrooms are my favourite but not often available, I usually get “horse mushrooms” as we used to call them, which are huge. I like some “sea vegetables” but was warned off them when my thyroid blew up. I do eat samphire when it’s in season – imagine sea-flavoured asparagus.

          Thinking about it, how broken your metabolism determines how far back in time you have to find your diet. My specific problems are a lack of Phase 1 insulin, which means my glucose spikes with many carbs. and a tendency to insulin resistance without which I still have a decent Phase 2 insulin. All of my symptoms and damage are downstream of the insulin-glucose axis. I do well on a hunter-gatherer diet. You and others obviously do better on a hunter diet. Some people remain healthy on a low fat diet but there aren’t many of them. I suspect everyone would do better eating like their grandparents. Though in my case without the pastry and jam.

          Liked by 1 person

        • did you have an OGTT with insulin to test that?

          Like

        • chris c says:

          I wish – they don’t test insulin here and only do c-peptide on Type 1s, not even on misdiagnosed Type 2s who are actually LADA. I did have an OGTT which “only” indicated prediabetes, but as David Ludwig said, prediabetes isn’t really pre-anything.

          I had to work out what was occurring with my glucometer – I got significant glucose spikes at 1 hour postprandial with too many carbs but seldom to “genuine” diabetic levels. By 2 hours glucose was heading back down and at 3 – 4 hours it could be significantly below normal. The speed of the drop was what caused my “hypo” symptoms.

          Without the carbs my BG stays relatively level, and in ketosis even if my BG drops (extreme gardening or long walks) I no longer get symptoms.

          I had to guestimate what was happening with my insulin, with the help of other patients with the same syndrome, some of which had better doctors. Phase 1 is usually the first to go in many but not all forms of “Type 2” and for some of us it failed in early childhood but the Phase 2 is unaffected.

          It took about a decade but my doctor is now on board with low carbing. One of the others, not so much – he stated that “everyone’s BG spikes when you eat”. Another claimed that “you need carbs for energy” without noticing she was the size of a small building and had so much energy stored that she couldn’t access. She subsequently became diabetic but still wouldn’t low carb, she used the 5:2 diet. Not entirely their fault, they are clueless because they believe what they are told is “evidence-based medicine” when it is actually marketing-based marketing.

          I know a lot of diabetics who have tested friends and family and found the same as Richard Bernstein, who used to test meter salesmen – genuine nondiabetics have tightly controlled BG. But that’s just anecdotes . . .

          Liked by 1 person

        • You can probably get these tests though if you pay for it out of pocket. Many of my migraineurs cannot get the tests I require so they get them tested privately. In the US this is very easy now, with not even needing a doctor to prescribe the tests… It is fantastic. My doctor has so far been extremely supportive and gave me all the tests I wanted and is also supporting my diet–albeit him being of Indian heritage, he is likely a vegetarian though not sure.

          If your bg drops a lot in long walks, that would mean you use glucose for your walk and not ketones. Are you measuring your blood ketones?

          Getting significant spike 1 hour postprandial suggests your insulin weakened and then being taken below normal means your pancreas released more insulin as a result, but it then was too much and it took your bg below normal. I request my migraineurs run a 5-hour bg tests measuring every 30 minutes, and after having done several hundreds, I am pretty good at understanding them.

          I agree with David Ludwig: pre-diabetes and insulin resistance are just different stages of T2D–it is like a cold with sneeze versus cough versus both… you are still having a cold, only symptoms may vary. 🙂

          Like

        • chris c says:

          A pocket insulin meter would be a game changer! I suspect it would prove Joseph Kraft correct. I suspect I can still produce a lot of insulin, just at a low rate but I have to guess. Trigs/HDL is a good marker for insulin resistance, mine went from 15 to below 2 (US numbers). I reckon that if my pee smells of ketones first thing in the morning but not so much the rest of the day I am probably using them at the same rate I am generating them.

          A lot of people no longer get their trigs reported, which is ludicrous as they have to be measured to calculate LDL. The lab my doctor used to use actually measured LDL which was interesting as it came out roughly halfway between the Friedwald and Iranian calculation. Now they have changed labs and LDL is calculated again. The nurses can only get the cut down report – total cholesterol, HDL and a “ratio”, probably down to a cheapskate analyser.

          I had the idea of putting a load of lab equipment and a nurse/phlebotomist in a van and going door to door like the guys who service your car at home. Probably illegal without a doctor’s authorisation.

          Liked by 1 person

        • I think that using the measurements of blood glucose and blood ketones for 5 hours–taking measurements every 30 minutes–as I ask in my migraine groups, already proved Kraft correct hundreds of times over. One can use ketones as a surrogate or proxy for insulin. I have learned all the intricacies by now and totally understand what’s what in every blood test.

          I have heard about the trigs not being checked! How stupid is that??? Honestly? The drug industry is just going unethical with this. In the US you can now buy at-home cholesterol testing kit–it works similarly to a bg kit only more expensive and you need to replace the whole kit and not just the testing strips after so many tests. If you can get this in the UK, you can get the test on your own. Luckily in the US we also have private blood testing companies that will run any test for you without doctor authorization.

          Like

        • chris c says:

          I suspect the answer on trigs would be “we don’t have a drug for that” so why measure them? Even more ludicrous was a diabetic who was told she must stop low carbing “and we can tell if you are complying because your trigs will go up” NOT a good thing! It’s easy to drop them through the floor, and increase HDL by low carbing. I guess they are expected to be high since everyone is told to eat high carb low fat – though this is changing very slowly.

          I just had the season’s first Brussels sprouts with my rump steak. However you might approve of my other purchase – a giant slab of Vacherin Mont d’Or cheese. Imagine Brie with a turbocharger, and a faint tang of lemon. It’s seasonal and only available in winter

          Liked by 1 person

        • Well if this is not a “hint” of the real reason for wanting to keep you on the bad diet: “and we can tell if you are complying because your trigs will go up” means you remain unhealthy so good going! More meds for ya.. lol… the problems is that there still are people who believe their nutritionist or doctors that tell them to eat high carbs and grains.

          Like

        • chris c says:

          Yes as my doctor said “by now we would have expected you to be on two or three diabetes drugs” – instead I am on none.

          It’s like Tom “Fat Head” Naughton says – The Anointed vs. the Wisdom Of The Crowds. I did what millions of other people did and got what millions of people get. Pity it took over fifty years before I got there. Some of The Anointed have made minor changes but they are still decades behind the clueful patients.

          Liked by 1 person

        • But at least they are in the right direction now…

          Like

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