Sunday, 29 May 2011

Footprints in the sand

Mintzberg is not a fan of Chief Executives being parachuted into run an organisation in an entirely different sector.

Jim Collins is disdainful of the cult of personality around leadership and had devoted his career to research into teamwork until his students talked him round.

I've been thinking about how organisations can make substantial improvements and ensure that they survive the daily inertia that drags people back to old habits and patterns.

Robust systems and effective teamwork are part of the process to embed improvements in the organisation, rather than relying on brilliant individuals. However, high quality change seems to rely on visionary leadership to ignite it and keep it burning.

What maintains the quality after the leader has gone?

Last night Manchester United faced Barcelona in the European cup final.

Both managers have good track records but Alex Ferguson has an astonishing record of success with his team. Much as Josep Guardiola deserves respect for his work, I think there is one man who has left his footprints firmly in the sand of Barcelona FC.

The Dutchman, Johan Cruyff, made a deep impression on Guardiola as a 13 year old player when Cruyff encouraged the youth team manager to move him into a midfield position to become the pivot for the whole team. It worked and this system was used in Barcelona to great effect thereafter.

Cruyff brought some of the extraordinary skills developed by Ajax, including team position flexibility (Total Football), developing equal ability with right and left foot and an exceptional youth development programme.

Cruyff left the job before Barcelona really made its mark internationally, but is still revered at the club.

He is still around and his son, Jordi, has made a name for himself in Spanish football, so the Cruyff family are not regarded as football 'tourists' just passing through to make a quick buck.

Steve Jobs is renowned for his storytelling and ability to weave the myths of Apple in a compelling way. That may be one reason that he has been able to inculcate values and lead large scale change at Apple so well.

Cruyff is famous for 'Cruyffisms' one line utterances that can seem obscure or confusing. He comments directly on leadership and taking responsibility for creating a vision:

'It's better to lose with your own vision than someone else's'

Thursday, 26 May 2011

Flat earth 3

I started this series with an example of a dominant paradigm and control exerted by the Church to maintain it.

In Scandinavia the nutritional Inquisition is alive and well in the form of a backlash from dietitians against those who challenge orthodoxy.

In Sweden Dr Annika Dahlqvist withstood 2 attempts by dietitians to have her struck off for putting patient safety in jeopardy by going against advice given by the National Food Administration and promoting a low carb/high fat diet. The Swedish National Board of Health and Welfare investigated and dismissed the claims in both cases after receiving expert research findings and witness statements. Elisabeth Johnsson brings us an English version of Dr Dahlqvist's blog.

LC/HF is popular in Sweden and supported by a group of practising doctors. Colleagues in Norway and Finland are also spreading the word.

Uffe Ravnskov was a Danish scientific researcher until he had an unpleasant encounter with orthodoxy:

'In 1977 I discovered that one of my co-workers had falsified part of his PhD thesis. Whistle blowers are not welcome in the academic world. So, instead of excluding the fraudulent researcher it was my research that was questioned. Finally I found the resistance from my superiors intolerable and decided to go into private practice.[4]'

He published 'The Cholesterol Myths' in Sweden in 1991. His research also demonstrated ways in which animal studies cannot be generalised to apply to humans because of the different ways we process nutrients (in this case the way proteins are dealt with by the kidneys.)

In discussing heart disease he said:

'Most researchers to-day in this field agree that inflammation of the arterial wall is the start. The crucial question is, what starts the inflammation? As cholesterol has been demonized for so many years we have not been able to clear the blackboard and rethink... all studies of dead people have failed to show an association between their intake of saturated fat, or their serum cholesterol, and the degree of atherosclerosis. People who avoid all saturated fat and who have low cholesterol become just as atherosclerotic as people who gorge in animal food and whose cholesterol is high.

Another misconception is that atherosclerosis is a disease. When arteries become inflamed the body immediately starts a repair process to strengthen the vascular wall. Smooth muscle cells proliferate, fibrosis follows, and later, if necessary for further strength, cholesterol and calcium are used for reinforcement. This is in particular important in the coronary arteries because due to the steady movements of the heart and the negative pressure at their outside they have to be stronger than for instance arteries running to the intestines or inside bony channels. Inflammatory processes go on now and then already from childhood; it is a natural defence mechanism and atherosclerosis should therefore be considered as scars, remnants from a long life's combat with noxious chemicals or microorganisms....I think that the final attack is caused by microorganisms, but this is not the only answer. Any factor that weakens our immune defense may facilitate the growth of microorganisms, also at the inside of our vessels. These factors may be environmental (toxic compounds) or nutritional. There is much evidence that microorganisms may play a role. I published a review about this issue a few years ago. This paper[29] has since long been one of the most-frequently read article in that journal.[4]'

Many years ago I had a conversation with a guy at a party about some of the therapeutic work I do. He was vehemently opposed to hypnotherapy and believed that living in an evangelical religious community was the only way to resolve problems and achieve good mental health. I tried to change the subject or suggest that we could agree to differ, but the man continued to harangue me in the hope of convincing me to accept his views.

Sometimes I'm reminded of his approach when reading or listening to some of the material on the internet produced by people who advocate a low carb high fat diet.

Vegetarians and vegans may be attacked and derided for their beliefs and choices, for example.

People who differ in their view of the acceptable quantity of animal protein and saturated animal fat to consume may also be criticised for not accepting the truth (according to LC/HF beliefs).

Tom Naughton strives to educate his readers and viewers in how to filter out poor science reporting. He distinguishes between observational and controlled randomised trials and clarifies the difference between correlation and cause and effect. He also comments on lies told by scientists.:

Dr Robert Lustig reminds us that people around the world have maintained a healthy weight on every type of diet (high fat/low carb and low fat/high carb). Not everyone is the same and genetics may play a major role in how we process food. Some individuals have a low tolerance for fats and cannot consume a high fat low carb diet without risking their health. He continues to research and challenge previous findings.

Chris Masterjohn is a phd student at the University of Conneticut. He strives to present research findings in relation to diet, fats and health in an honest and rigorous manner on his blog, the Daily Lipid. Here he tackles a sacred cow of the movement by challenging some of Dr Robert Lustig's statements about fructose.

Petro Dobromylskyj is a vet who also blogs about fat, health and diet on Hyperlipid. He eats a high fat diet and continues to scrutinise the science, rather than accepting current LC/HF orthodoxy without question.

These 4 people encourage us to think and continue to challenge accepted ideas.

The man I met at the party did not seem secure in his beliefs, hence his need to recruit me to the cause.

It would be a pity if low carb/high fat became a fanatical dogmatic religious cult rather than a group dedicated to promoting rigorous scientific debate.

If you visited this post from another site, you might like to read other posts in this category by clicking on diet.

Flat earth 2

Science journalist, Gary Taubes, has roundly challenged the lipid hypothesis. He is also critical of people in the field of medicine and was shocked to find how little rigorous debate of ideas seemed to take place compared to physics and chemistry.

Here he discusses the 'calories in calories out' view of weight loss and the central mechanism for regulating weight: insulin:

Gary Taubes, nicknamed 'Mr Meat' by his wife, recently revealed his lipid panel scores to demonstrate what a high fat, low carb diet has done for him. The results are excellent despite dire predictions by his critics.

One challenge to Taubes comes from Stephan Guyenet, a student of the neurobiology of fat regulation, who disagrees with the idea that carbohydrate causes obesity by elevating insulin, thereby causing increased fat storage in fat cells. His article is a clear analysis of the pros and cons of the idea, but recommends further research.

Former engineer, Dr Richard Bernstein, reversed the major symptoms caused by his diabetes through dietary changes designed to regulate insulin to normal levels. He wanted to publish his findings in medical journals but was dismissed. He retrained as a doctor so that he could treat other people whose symptoms worsened when they followed official guidelines.

Cardio thoracic surgeon Dr Steven Gundry subscribed to conventional wisdom about diet until he met a patient who had lost weight and reversed blockages in blood vessels of the heart using supplements.

He reflected on these results and developed his own diet. Here he talks about his education, career, research and how this contributed to his diet (clearly it worked for Dr Gundry):

Heart specialist, Dr William Davis, reduces coronary plaque in patients by making changes in diet and lifestyle. He recommends certain supplements and encourages people to eliminate wheat from their diet. Some of his patients have achieved spectacular results.

There are some key differences in all of these people's views about heart disease, health and diet, but they all agree on the need to reduce refined carbohydrates to normalise insulin.

What prevents health associations and governments from changing their guidance on heart health and diet?

In the United States elected representatives from each state come under pressure from special interest groups if their livelihood is threatened. Economies of some states are dependent on profits from agriculture based around wheat and maize, for example. A sudden change of opinion by government officials would jeopardize the fragile state of agriculture in a global economy.

The US government is also subject to pressure from lobbyists on behalf of corporations. One group that has benefited from government policy on health and diet is the pharmaceutical industry. Blood pressure medication, insulin injections and statins are enormous profit generators, so a move to reduce the need for medical intervention would damage their prospects.

If the government recommends reducing fat, then other macronutrients replace it, such as carbohydrates, including sugar. Sugar makes some foods more palatable and it also masks salt. None of this is beneficial to human health in the long term.

The food industry has also made substantial changes to fall in line with government regulation reducing saturated fat and substituting trans fats (now found to be much more damaging to human health). Sugar has been replaced by high fructose corn syrup, benefitting maize farmers and reducing the price of many goods. Carbonated soft drinks, crisps and other snack foods now occupy aisles of space in supermarkets but no substantial link has been made between empty sugars and carbs ('cafeteria diet') and the development of diabetes, obesity and heart disease by government officials. It would be a quick way to lose the next election in the US.

What keeps a dominant and erroneous paradigm in place? Money and power.

Ah but scientists wouldn't accept ideas without any evidence to substantiate them, would they?

How does medical science progress?

Research drives the field forward. Much of it is undertaken by or on behalf of pharmaceutical companies to develop products to solve particular medical problems and make a profit. Low cost solutions that are cheap for the consumer do not benefit drug companies. Other research requires public funding and that is often controlled by government and its policies.

In the UK, recent legislation bans the use of certain complementary medicines unless they are registered and have undergone rigorous and expensive testing. This is out of the reach of most practitioners and retailers, for whom the income generated from this area cannot cover the required outlay for registration. The precautionary principle is useful when applied to protect the safety of patients and clients. Unfortunately some of the products may be beneficial and not harmful, but they cannot now be used.

If government has opted for a particular paradigm, which research are they likely to fund, work that contradicts or supports it?

Dr Malcolm Kendrick and others describe medical opinion before and after Ancel Keys' 7 nations study and tell us that colleagues were sceptical or downright dismissive of the lipid hypothesis. However when funding and jobs depend on complying with government decisions, then most people tend to toe the line.

If the research isn't done or findings are not deemed sufficiently rigorous for publication, then ideas that may help the development of medical knowledge are not circulated or accepted. Dr Richard Bernstein was dismissed as merely touting anecdotal evidence and lacking the medical credentials to be taken seriously. The people who developed the idea of helicobacter pylori as a precursor to duodenal and gastic ulcers were caught in a similar bind and published in the popular press as a way to disseminate their hypothesis.

In the West we criticise Russia and China for their draconian response to dissidents. We would never send people to Siberia or imprison them for winning an award.

We overlook the simple, cost effective ways that we use to control people and keep them in line or 'on message'. Hit them in the pocket or keep them out of the loop. Cutting off money for research, sacking people from their jobs or banning them from a discussion group on the internet are some of the ways to maintain the status quo.

In the UK the NHS practises evidence based medicine. All evidence is equal, though it now seems that some evidence is more equal than others.

Here's an alternative proposal from a medical student who encourages people to use their own functioning brains.

Sometime it may be confirmation bias that determines what scientists see or toss in the waste bin, as explained here.

If you've visited this post from another site, you might like to read Part 3 here.

Flat earth 1

In the West we look back on some beliefs and attitudes of our ancestors with derision. The idea that the earth was flat and that a ship would drop over the edge of the world if it sailed too far was challenged by explorers such as Christopher Columbus in his mission to discover the Americas. Galileo defended the ideas of Copernicus that the earth revolves round the sun and not vice versa. He was subject to the Inquisition, banned from writing and placed under house arrest for the rest of his life. At the time the Church was the dominant authority governing acceptable views that affected the perceptions and mindsets of the world around us.

We now have a smug notion that defines our world view as one informed by scientific rationalism and evidence based medicine. We think that we'd never fall into the trap of being cowed into submission by a dominant authority telling us what to think, even if the facts don't support their view.

We've survived totalitarian regimes that banned subversive literature, art, music and ideas. The population of the UK have cast off Tony Blair's attempts to lie to us about weapons of mass destruction in Iraq, though Dr David Kelly was pilloried for his attempts to reveal the truth and lost his life in the process.

How is it then that most of us have accepted a doctrine on health peddled by successive governments that is based on damned lies and statistics?

Step forward Ancel Keys, poster boy of the US government at the time.

Tom Naughton gives an entertaining animated illustration of the process of fudging the stats in this segment of his excellent film 'Fat Head':

Ancel Keys 'proved' that heart disease was caused by saturated fat in the diet that raised cholestorol levels in the blood. This informed US health guidelines and the shift towards a high ratio of grains in the diet and lower levels of meat and fat. My memory of the food pyramid from childhood has sugar as a healthy substance near the bottom of the chart. A memorable advert for a chocolate bar was: 'a Mars a day helps you work, rest and play' emphasising the benefits of sugar.

This lipid hypothesis is now accepted as fact and has become the dominant paradigm. Ask anyone on the street and they'll tell you that high levels of dietary saturated fat will kill you by clogging your arteries and giving you a heart attack.

What's the evidence?

The Framinham Heart Study conducted over the long term on the residents of a small town in the USA is the biggest research project of its kind. It showed the following major findings (from Wikipedia):

Cigarette smoking increases risk of heart disease. Increased cholesterol and elevated blood pressure increase risk of heart disease. Exercise decreases risk of heart disease, and obesity increases it.

Elevated blood pressure increases risk of stroke. In women who are postmenopausal, risk of heart disease is increased, compared with women who are premenopausal. Psychosocial factors affect risk of heart disease.

High levels of HDL cholesterol reduce risk of heart disease.

Having an enlarged left ventricle of the heart (left ventricular hypertrophy) increases risk of stroke. Elevated blood pressure can progress to heart failure. Framingham Risk Score is published, and correctly predicts 10-year risk of future coronary heart disease (CHD) events. At 40 years of age, the lifetime risk for CHD is 50% for men and 33% for women.

So called «high normal blood pressure» increases risk of cardiovascular disease (high normal blood pressure is called prehypertension in medicine; it is defined as a systolic pressure of 120–139 mm Hg and/or a diastolic pressure of 80–89 mm Hg). Lifetime risk of developing elevated blood pressure is 90%. Obesity is a risk factor for heart failure. Serum aldosterone levels predict risk of elevated blood pressure. Lifetime risk for obesity is approximately 50%. The «SHARe» project is announced, a genome wide association study within the Framingham Heart Study. Social contacts of individuals are relevant to whether a person is obese, and whether cigarette smokers decide to quit smoking. Four risk factors for a precursor of heart failure are discovered. 30-year risk for serious cardiac events can be calculated. American Heart Association considers certain genomic findings of the Framingham Heart Study one of the top research achievements in cardiology. Some genes increase risk of atrial fibrillation. Risk of poor memory is increased in middle aged men and women if the parents had suffered from dementia.'

So high cholesterol (ie LDL) increases risk, but high HDL cholesterol reduces risk. The study begins the process of differentiating between types of cholesterol. Other studies have highlighted that particle size of LDL cholesterol is the crucial factor in risk for heart disease, ie small, dense particle LDL is dangerous and large fluffy particle LDL is helpful. A study by Christopher Gardner, PhD provided strong evidence that lipid values improve on a low carb/high fat diet.

Omega 3 fatty acids are protective against risk of stroke.

There is no evidence that high levels of dietary saturated fat cause high levels of small particle LDL or low levels of HDL cholesterol.

What is the evidence against the lipid hypothesis?

Dr Malcolm Kendrick explains it clearly in his excellent lecture series to a BMA meeting in Leeds:

Here he discusses genetic risk factors and the dangers of generalising from the patients who show up (as doctors don't see those who stay away).

Malcolm Kendrick gives a robust challenge to the efficacy of statins in protecting against death from heart disease:

Here he considers an underestimated factor in promoting heart disease - stress:

Malcolm Kendrick confirms that psychosocial factors have a great impact on heart disease. Here he discusses displaced populations:

The Framingham heart study shows that obesity is a risk factor for heart failure. No definitive evidence is given for its cause.

What causes obesity?

Dr Robert Lustig identifies some of the disastrous consequences of government health policies in the USA and the particular destruction caused by the introduction of high fructose corn syrup. Lustig challenges the 'calories in, calories out' view of weight gain, explaining that a global epidemic of obesity amongst 6 year olds makes no sense in those terms. He highlights the 'Coca Cola Conspiracy' where carbonated soft drinks are increased in size, contain caffeine and salt masked by sugar, which stimulate thirst and boost consumption of the drinks, leading to a massive increase in obesity and type 2 diabetes. This is a lecture given to adults interested in medical education without training to be doctors:

Jenny Ruhl studied the data on diabetes to take control of her own condition. She has some stark messages about the link between high blood sugar levels (1 hour after eating) and heart attacks.

Governments, diabetic and heart associations still claim that the earth is flat and the sun revolves round the earth in medical terms. All of the people quoted here continue to work in their fields, but seem to have marginal impact on orthodox thinking. Clearly the forces keeping the dominant paradigm in place are stronger than those pushing for change.

Sadly this has a major impact on people's health and well being as well as rising costs to our health and social care services.

If you've visited from another site, you might like to read part 2 here.

Thursday, 5 May 2011


Here's a song to encourage parents to vaccinate their children against polio.

This isn't a government health information campaign, but a song by a street band Staff Benda Bilili from around the zoo in Kinshasa, the capital of Congo. They all have polio, so know that of which they speak.

Before elections in 2006 they sang 'Allons voter' (Let's vote), which led to a 70% increase in turnout. They were allegedly ripped off by a UN agency that took credit for the song.

It's an interesting example of work for change by people often regarded as powerless. Mick Marchington would be proud.

Mark Kermode reviews a documentary about the band that won a prize at the Cannes Film Festival:

Monday, 2 May 2011

How to screw up Afghanistan

Aid for algriculture.

Give them machines they can't fix, crops that aren't local, make them dependent on fuel that they don't have.......

"Computer says NO"

In the last few years I've had dealings with Barclays bank in the UK. Their model of staff development and promotion depends on moving staff around constantly and upgrading them accordingly. The idea seems to be to familiarise everyone with different aspects of the business. If you happen to enjoy dealing with the public and don't want to become a back office manager, then your pay may be restricted and your work not so highly valued, because you choose to stay where you are. I imagine that head office regard the few who choose to stick to a particular frontline job as 'barnacle' managers and think that they slow the ship in its progress.

Instead of training staff in detail, information is made available through a centralised database. This is fine in theory yet seems to ignore how human beings actually function. I know that some people read the manual from cover to cover and learn everything there is to understand about a machine or system. Many people ignore the manual until they need something specific, at which time they drill down through the information as far as they need to make something work. That's OK if you're running a computer, but not so great if a client has come to ask you about a specific product or wants to make a change in their account. If it takes half an hour to access the information and apply it satisfactorily, then you're likely to lose all credibility with the customer and try their patience to the limit.

At Barclays, while waiting to see a particular 'barnacle' manager, I observed many times the same pattern. The young movers and shakers would approach the older 'barnacle' who could explain what they needed in 5 minutes, rather than leaving them to struggle (in front of their customer) for half an hour. What I could see and head office couldn't was that the 'barnacle' was the lynchpin of the branch, ensuring that the wheel didn't come off the bus.

Nonaka and Takeuchi have studied how organisations manage knowledge, in particular the tricky bits that come from experience known as tacit knowledge.

Much of what is really important exists informally in people's heads and they are typically not conscious of what they know. Nonaka and Takeuchi looked at how to make tacit local knowledge explicit and available to others using 4 processes:

1 Socialisation - encouraging teams to share tacit experiences and mental models through observations and imitation

2 Externalisation - expressing explicit knowledge by repeated exchanges so that its meaning is clarified

3 Combination - standardising knowledge and combining new ideas with existing knowledge

4 Internalisation - reframing implicit understanding to take account of new knowledge and enrich tacit knowledge

I'm not sure that Barclays head office is clear about tacit knowledge, but certainly tries to share information by externalising it in a computer database. The local lynchpin encourages socialisation and shares his tacit knowledge, to the benefit of young colleagues.

If the lynchpin is away, staff rely on the slower route to serving customers and there seems little encouragement to share and record or internalise what they've learnt, as they're likely to move on to another job before that happens.

I found the lynchpin manager via a trusted member of a business network. If I hadn't found this person who could help me solve a lot of problems quickly and easily, I'd probably have moved everything to a different bank.

Moving staff around, enabling them to learn every aspect of the business is worthwhile. It may help to prevent silos developing and encourage staff to think of the business as a whole. There's also value in recognising the achievement of lynchpins who hold the structure together, so that other colleagues can move around and progress.