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WHO fails to use quality evidence in recommendations

The World Health Organization (WHO) is concerned about the scientific basis of its health recommendations (a concern with WHO we've been vocal in expressing as well). In 2003, the WHO Cabinet recognized the need for process changes to improve the scientific evidence foundation for its policies. Its report appears in today's edition of The Lancet (free registration required).

Authors Andrew Oxman et al note:

WHO's regulations emphasise the role of expert opinion in the development of recommendations. In the 56 years since these regulations were initially developed, research has highlighted the limitations of expert opinion, which can differ both across subgroups and from the opinions of those who will have to live with the consequences. Experts have also been known to use non-systematic methods when they review research, which frequently results in recommendations that do not reflect systematic summaries of the best available evidence.

That's certainly the case in WHO's Report 916 , coincidentally generated in 2003, which selectively cited the literature and reached historically-extreme recommendations regarding dietary salt.

Oxman continues:

Evidence-informed dissemination and implementation strategies are increasingly recognised as a core part of the business of development recommendations.

Unfortunately, the authors found that WHO "almost always" employed the subjective expert committee approach in preference to the systematic review of published evidence. "The guidelines for developing WHO guidelines do not seem to be closely followed...," the report states, neutrally. In fact, they continue:

Although the WHO guideline recommendations are consistent with those developed by other organisations, the actual processes used to develop recommendations at WHO seem to be less rigorous than those of others. None of the directors [note: 23 WHO department directors were interviewed for the research] reported using the guidelines for WHO guidelines and only two reported plans to use them. Few directors reported using processes that were consistent with the guidelines.

Our experience with WHO in Geneva is that developing the nutrition guideline was virtually complete when the staff selected its expert panel; everything subsequent was a sham. With unfortunate results.

In the area of salt, evidence-based organizations like the Cochrane Collaboration and the US Preventive Services Task Force (HHS) have done systematic reviews of the health benefit potential of reducing dietary salt and both agree evidence is lacking to support such an intervention.

Everyone registering an opinion on dietary recommendations claims their advice is "evidence-based," but -- as this WHO study illustrates -- the truth is that governments and advocacy organizations routinely use the lowest form of evidence, expert committees, to formulate recommendations. It brings to mind a verse from the New Testament in the Bible (Matt. 15:8), "This people draweth nigh unto me with their mouth, and honoureth me with their lips; but their heart is far from me."

We need to do more to elevate the place of true evidence-based decision-making in public health nutrition policy through such means as ensuring effective enforcement of the U.S. federal Data Quality Act and opening the rich databases created for federally-funded studies to independent analysis by qualified experts. But, as the authors of this study lamented concerning WHO, achieving this broader objective "will require leadership."