Experience from medical reviews. Interview with Kjell Asplund

For years, what overweight people should eat was a matter of heated medical debate. But in 2012 the experts reached a consensus, after reviewing and synthesising the best available research. Kjell Asplund, doyen of systematic review in medicine and a member of EviEM’s Executive Committee, has been a driving force in putting environmental management on a similar scientific basis.

Too much reliance on opinion in environmental management

Put simply, it is a matter of separating the wheat from the chaff. The most effective methods need to be identified, and the ones that do more harm than good rejected.
‘There’s been too much reliance on opinion in environmental management,’ says Kjell Asplund, an emeritus professor of medicine.

Researchers, like the rest of us, often ignore facts that do not fit their own world view. But, Asplund points out, there are a number of safeguards to ensure that the experts carrying out a systematic review, i.e. putting together an overall picture of the best evidence, do not fall into the same trap as individual scientists. One such safeguard is the requirement to track down all the best available research.
‘In the literature search, you make sure you dig out everything of relevance. Everything must be laid out on the table. Not just findings that support your own view.’

Kjell Asplund. Photo: Magnus Aronson.

Kjell Asplund. Photo: Magnus Aronson.

We meet outside the offices of SBU, the Swedish Council on Health Technology Assessment. Professor Asplund parks his bike and takes a few long strides through the revolving door of the central Stockholm building. For the last 27 years, SBU has been collecting, reviewing, synthesising and communicating the best research findings and methods in the field of medicine. Asplund, its former board chairman and one-time director-general of Sweden’s National Board of Health and Welfare, has long experience of this work, and has seen how it can help dislodge entrenched positions.He cites diet in obesity as a good example. In 2012, after reviewing the scientific evidence, researchers reached a consensus. Before that, the issue had been fiercely debated. One side advocated a low-carbohydrate diet, with huge amounts of fat and just a little bread and potatoes; the other believed that all animal fats, such as cream, were dangerous and that such a diet would send cholesterol levels sky-high.
‘The conclusion was that, short-term, a low-carb diet posed less risk than its opponents claimed, but that there were no long-term data. On a longer view, in other words, such a diet is experimental.’

Safeguards avoid a one-sided view of the world

Professor Asplund has now retired, but keeps busy as chair of SBU’s Scientific Advisory Committee. And as a much-consulted expert on evidence-based health care – care based on the best available research. At present, he is on a commission investigating possible systemic failings in the treatment of Sture Bergwall, convicted of eight murders under the name Thomas Quick, but recently acquitted following a much-publicised series of retrials.

Asplund’s expertise on the appraisal and synthesis of research findings is one reason he is a member of EviEM’s Executive Committee. He was a driving force behind the creation of EviEM in 2012, believing that environmental management, too, has much to gain from being evidence-based. He has other examples of safeguards to help EviEM’s review teams avoid a one-sided view of the world.
‘Statistical methods are used to spot publication bias – a tendency for results going against a hypothesis not to be published, or to end up in less well-known journals. Also, the review team represent different types of knowledge, professions and angles. If a question is controversial, both sides are involved. What’s more, outside experts scrutinise the review.’

The initial selection of the team also requires careful thought. Who should it include? Preferably leaders in the field, of course, but also people who are open to different approaches and who will inspire confidence in users of the results. Not least, individuals who are able to think analytically.
‘Successful researchers often have a welldeveloped analytical mind, but to say that all researchers do would be a gross exaggeration.’

Today’s research community rewards excellence. Excellent researchers often have a strong ego, but, Asplund stresses, a systematic review requires teamwork and people who are able to work together. Above all, they must be prepared to work hard.
‘Almost everyone involved in a project of this kind is surprised at how much literature there is, how much they have to sift through.’

SBU’s reviews are mostly carried out by key figures in Swedish medical care, who are well placed to communicate the findings to others. Many of EviEM’s experts are international researchers. On the other hand, EviEM engages from the outset in a close dialogue with stakeholders in Sweden.
‘That’s something SBU could learn from. It creates goodwill and curiosity about the results.’

Interactive methods are most effective in getting your message across

Communicating new findings is notoriously difficult. SBU, as a government agency, has a fast track to people in positions of influence. Its reviews become official reports and are sent to the Board of Health and Welfare, which writes national guidelines based on them. EviEM is an independent council, but could, according to Asplund, deliver reports in the same way to the Swedish Environmental Protection Agency, as a basis for its guidelines.

Fact sheets are another way to be seen. The ones SBU produces are sometimes placed in pharmacies. However, written material and one-off lectures have proved to have a limited impact.
‘Seminars and other interactive methods are more effective than one-way information in getting your message across.’