El problema probatorio de la comida

el sardinero
El Sardinero

En el contexto de la nutrición, la aplicabilidad del principio de precaución – en caso de duda, no hacer nada – solo puede extenderse hasta cierto punto, debido a la necesidad humana de alimentos.
Con la naturaleza de la ciencia de la nutrición, que inherentemente se basa en múltiples líneas de evidencia, la investigación observacional, quizás solo unos pocos ECA en un área en particular, incluso un resultado ‘estadísticamente significativo’ o un pequeño número de resultados conduce a una conclusión inevitable: “necesitamos más pruebas ”. El principio de precaución a menudo gana el día, y con la posibilidad de que la evidencia permanezca suspendida en la animación.
Lo que esto refuerza, como David Rex destacó en su excelente artículo, «Un enfoque de» sentido común «basado en la evidencia para la evaluación de las intervenciones dietéticas en el TEA y el TDAH» (1), es una jerarquía particular para las intervenciones de salud:

  1. Drogas
  2. Suplementos
  3. Alimentos

Seamos muy claros: no hay nada de malo en esta jerarquía en principio, y no hay nada de malo en las intervenciones por drogas. De hecho, la creciente narrativa de “la comida es medicina” se está convirtiendo cada vez más en un motivo de preocupación, dado el potencial de que tanto los profesionales sanitarios como el público descarten la farmacoterapia y sobrestimen el papel de la nutrición en un contexto dado.

Donde puede surgir el problema con esa jerarquía en particular es con respecto al posible malentendido de cuándo es apropiado o, a la inversa, cuándo puede ser necesario reevaluarlo. Parece haber un pensamiento cada vez más binario de que las intervenciones de salud o la elección entre medicamentos versus «estilo de vida» [en el lenguaje popular], que puede ser problemático de dos maneras. El primero es el contexto de aplicación; malinterpretar el papel de la nutrición, a través de la falta de conocimiento de la evidencia, o el deseo de exagerar o subestimar la evidencia relativa a creencias preconcebidas sobre la dieta y la salud [ver la veneración continua de las comunidades basadas en plantas de Dean Ornish y Caldwell Esselstyn a este respecto, o la disonancia cognitiva de las comunidades bajas en carbohidratos para la investigación de Kevin Hall]. El segundo es el contexto de la evaluación de la evidencia; En lugar de llenar los vacíos en la evidencia con afirmaciones débiles, es importante evaluar la evidencia para las intervenciones nutricionales mediante la aplicación de un marco práctico específico de nutrición para evaluar la evidencia que existe, de manera objetiva.

Estos dos acertijos en competencia están vinculados en un incómodo ciclo de retroalimentación. Primero, la jerarquía crea una suposición de que la dieta está tan abajo en la escalera de las prioridades de evidencia, que se pueden hacer recomendaciones sin una comprensión adecuada de la evidencia, mientras que simultáneamente eleva la dieta al número 1 en orden de prioridad: una combinación peligrosa de competencia y exceso de confianza, también conocido como el efecto Dunning-Kruger. La principal justificación para esta elevación de la dieta a la máxima prioridad, en ausencia de conocimiento, suele ser una suposición problemática, «¿dónde está el daño?»

La jerarquía antes mencionada puede ser responsable de sustentar tal convicción, derivada del hecho de que los profesionales médicos están capacitados en el contexto de la evaluación de riesgos para considerar el riesgo relativo a los medicamentos o intervenciones quirúrgicas, las cuales conllevan un potencial de riesgo mucho mayor y por lo tanto onerosas consideración para su uso. El problema traslacional es cuando esto se convierte en un calificativo para evidencia bastante falsa o débil para el asesoramiento relacionado con la nutrición. Este es el quid de este problema: no es que pueda haber daño a una determinada intervención nutricional. Se trata de comprender los límites de la nutrición para el tratamiento de afecciones médicas y comprender dónde comienza y dónde termina la evidencia.

El segundo tema, que retroalimenta al primero, es la posibilidad de combinar estándares probatorios que pueden aplicarse a la decisión de recomendar medicamentos o dietas. No es una buena práctica basada en la evidencia simplemente asumir que debido a que las cualidades de la evidencia pueden no ser equívocas, eso justifica el abandono de los estándares basados ​​en la evidencia. Es igualmente importante comprender cómo evaluar adecuadamente la evidencia para la nutrición en ausencia de niveles de evidencia de grado farmacéutico.

Este problema se ve agravado por el hecho de que, con «base de evidencia» o no, las personas consumirán alimentos. Esta es la razón por la que es importante poder extraer consejos y recomendaciones de la investigación, pero aún más por qué existe el deber de garantizar que los consejos y recomendaciones sean apropiados y se comuniquen de manera responsable.

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