The scientific report guiding the US dietary guidelines: is it scientific?
BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4962 (Published 23 September 2015) Cite this as: BMJ 2015;351:h4962
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In response to concerns raised about this article[1] by the Center for Science in the Public Interest (CSPI),[2] [3] we asked Cochrane to recommend experts in systematic reviews of evidence for guidelines who might undertake a formal post-publication review. Two people were recommended to us, and through initial correspondence with them we identified two others. Two of these four agreed to review the article: Professor Lisa Bero, Chair of Medicines Use and Health Outcomes at the University of Sydney, and Professor Mark Helfand, Professor of Medical Informatics and Clinical Epidemiology at the Oregon Health & Science University. We asked each of them to pay special attention to the points raised in the CSPI’s letter, to give us their views on whether we should retract Teicholz’s article, and to allow their signed reviews to be published. Our letter to them and their reviews are available on thebmj.com [see attachments below].
Both reviewers agreed with the authors of the CSPI letter in finding that the report of the Dietary Guidelines Advisory Committee (DGAC) described methods (such as a search strategy and predefined inclusion criteria) for the selection of evidence for its report. But they also noted problems with the committee’s methods and rejected the letter’s contention that Teicholz’s article should be retracted. The problems noted by the reviewers included the committee’s methods being out of date and lacking sufficient detail, which could have introduced bias.
Bero describes how some of the reviews by the DGAC “circumvent the systematic search process,” and how, “regarding the search strategies, inclusion of studies and quality assessment,” there are aspects of the methods of the DGAC report that “sometimes lack sufficient detail and may introduce bias.” She concludes, “Teicholz’s criticisms of the methods used by DGAC are within the realm of scientific debate.” Helfand says: “I found nothing to contradict Teicholz’ central concern that the DGAC’ processes to protect against bias are inadequate. It is clear that further investigation of the composition of the committee, as well as its conflict of interest policies and work group structure, are warranted. The NEL and DGAC do not appear to have incorporated key developments in methodology and governance of evidence-based guideline development since 2010. The DGAC’s role in grading the evidence and the lack of an evidence to decision framework are examples of practices that may fall below the current international standard for conducting systematic reviews.”
On the basis of these reviews and our own internal assessment of the issues raised, we find no grounds for retraction of the article. We did find that some of the points raised by the CSPI merited either correction or clarification, and we have published a notice to that effect: http://www.bmj.com/content/355/bmj.i6061. Nina Teicholz has provided a response to the post publication review of her article, which can be found here, http://www.bmj.com/content/351/bmj.h4962/rr-49.
We stand by Teicholz’s article and its critique of this highly influential advisory committee’s processes for reviewing the evidence, and we echo her conclusion: “Given the ever increasing toll of obesity, diabetes, and heart disease, and the failure of existing strategies to make inroads in fighting these diseases, there is an urgent need to provide nutritional advice based on sound science.”
Neither Teicholz nor The BMJ are new to criticism. Healthcare is rife with controversy, and the field of nutrition more so than many, characterised as it is by much weak science, polarised opinion, and powerful commercial interests.[4] But nutrition is perhaps one of the most important and neglected of all health disciplines, traditionally relegated to non-medical nutritionists rather than being, as we believe it deserves to be, a central part of medical training and practice. The current state of nutrition research should be a matter of grave concern to those attempting to develop evidence based health and economic policies that truly serves the public interests. The BMJ plans to continue to provide a forum for debate on the science and politics of food; and is collaborating with researchers at the University of Cambridge and Tufts University in Massachusetts on a series of articles examining the science and politics of food, which is due to be published next year.
References
1. http://www.bmj.com/content/351/bmj.h4962
2. http://cspinet.org/bmj-retraction-letter.html
3. http://www.bmj.com/content/351/bmj.h4962/rr-36
4. http://www.bmj.com/content/347/bmj.f6698
Competing interests: I am the editor of The BMJ and responsible for all it contains
The external and internal review of this matter has taken longer than any of us would have liked. However, we are close to being able to share the outcome. As has already been reported in the press, our review has found no grounds for retraction of Nina Teicholz's article in The BMJ.
Competing interests: I am editor in chief of The BMJ and responsible for all that it contains.
November 4, 2016
Fiona Godlee, MB, BChir, BSc
Editor-in-Chief
The BMJ
Dear Dr. Godlee:
It has now been more than a year since the BMJ published Nina Teicholz’s article, “The scientific report guiding the US dietary guidelines: is it scientific?” on September 23, 2015. [1] It has been a year since more than 180 scientists wrote to the BMJ on November 5, 2015, citing 11 factual errors in the article and requesting that it be retracted. [2] (The letter omitted incorrect or biased interpretations of research.)
On November 19, 2015—shortly after receiving the scientists’ letter requesting the retraction—BMJ Executive Editor Theodora Bloom posted a response saying that an external expert review of the letter was being undertaken and “details of the review process will be available shortly.” [3]
We are still waiting for those details.
Since then, we have repeatedly requested information about the status of the review. On May 25, 2016, you emailed: “This process has taken longer than I had hoped, but we are nearly in a position to release the outcome of the post-publication review of Nina Teicholz's article. All being well, we should be able to do this in the next three weeks and certainly before the end of June.”
On September 23, 2016, Politico reported that, according to Ms. Teicholz, the BMJ will not retract the piece. [4] Ms. Teicholz then told the website Retraction Watch that she learned of this decision from the BMJ in April 2016: “The journal’s reason was that the outside reviewers found that the criticism of the methods used by [the Dietary Guidelines advisory] committee ‘are within the realm of scientific discussion, and are therefore not grounds for retraction.’” [5]
Our first concern is with the BMJ’s lack of transparency. Promised details of the review process were never made public. Apparently, a decision was reached and communicated to the author, but never communicated either to the 180-plus scientists who raised the issue or to BMJ readers. In fact, if Ms. Teicholz is correct, more than a month after the apparent decision, you affirmatively failed to communicate that decision while leaving the impression that deliberations continued (see quote above).
Our larger concern is that the BMJ has never released the report of the independent review panel or the journal’s response to the report. Did the review panel find errors? If so, will the journal explain how the errors came to be published, despite its peer review and editorial process? Who were the members of the independent review panel, who were the initial peer reviewers, and how were each selected? If the BMJ concludes that the Teicholz article had additional errors, how will the journal act to prevent similar errors in the future? Will the journal release all correspondence between the author and the BMJ staff members to ensure that the pre- and post-publication review process is transparent?
The BMJ’s failure to respond to the retraction letter is particularly disturbing in view of the journal’s response to the independent statins review panel [6] and audit [7] convened after the BMJ published two articles containing errors on the adverse effects of statins in October, 2013. In an editorial announcing your decision to convene the statins panel, you wrote, “I have committed to implementing the panel’s recommendations in full.” [8] Yet the steps that the BMJ promised to take in 2014 were not in evidence in 2015. For example:
• Respond in timely fashion. In August, 2014, the independent statins review panel recommended that the BMJ conduct an audit [7] to “identify what would need to have been in place to ensure that the correction was made in a more timely fashion.” That untimely response took seven months. But it has been one year (to date) and the BMJ has still not responded to the scientists’ letter.
• Give extra attention to controversial issues. The independent review panel on statins recommended that “extra attention should be given to manuscripts that have been noted by reviewers and editors to be controversial and potentially slanted or one-sided.” In response, the BMJ editors wrote that “additional flags and warnings are now put in place for particularly controversial articles, both on the manuscript tracking system and via discussion at team meetings.” [9] Furthermore, the review panel recommended that editors give extra attention to “possible selective citing of material, failure to critically appraise evidence that is used to support authors’ arguments, and over criticism of evidence that does not support authors’ arguments.” The BMJ stated that “editors are now alerted to consider these issues in particular in controversial articles, and to ask reviewers to do so.” Surely, Teicholz’s article, which charged that the Scientific Report of the 2015 Dietary Guidelines Advisory Committee “used weak scientific standards,” would warrant this additional scrutiny. Yet, judging by the errors cited in our letter and the correction [10] and two clarifications [11] posted in 2015 (not to mention the numerous spelling errors in the supplements [12]), the “flags and warnings” for controversial articles were either not in place or were ignored.
• Resist pressure to meet outside news agendas. The BMJ’s audit [7] of its handling of the statins papers concluded that the “BMJ editors should resist pressure to publish at a time suited to the general media, authors and their institutions, or other external parties. Extra care should be taken whenever there is a ‘news agenda’ that is not dictated by the journal, or when news cycles drive publication timing.” In fact, the Teicholz article, which was published on September 23, 2015, noted that “these issues will likely come to a head at a Congressional hearing on the guidelines in October, when two cabinet secretaries are scheduled to testify.” Again, given the errors, posted corrections, and misspellings, it appears that the journal did not take “extra care” to resist pressure to meet an outside news agenda.
Finally, let’s be clear that the scientists’ letter requested a retraction because of 11 straightforward errors. Surely, it should take less than a year for a journal to publish the results of its external expert review of those errors. Surely, the journal should have acted promptly to correct any errors and diminish any damage they or the Teicholz article have done to the Dietary Guidelines Advisory Committee, the integrity of the government’s Dietary Guidelines for Americans 2015–2020, and the public’s confidence in diet advice from scientific experts and the U.S. government.
Surely, it is high time for the BMJ to respond.
Sincerely,
Bonnie F. Liebman, M.S.
Director of Nutrition
Center for Science in the Public Interest
Michael F. Jacobson, Ph.D.
President
Center for Science in the Public Interest
References
1 http://www.bmj.com/content/351/bmj.h4962
2 https://cspinet.org/new/201511051.html
3 http://www.bmj.com/content/351/bmj.h4962/rr-37
4 http://www.politico.com/tipsheets/morning-agriculture/2016/09/dietary-gu...
5 http://retractionwatch.com/2016/09/23/bmj-wont-retract-controversial-die...
6 http://journals.bmj.com/site/bmj/statins/Final%20report%20of%20the%20ind...
7 http://www.bmj.com/BMJ-critical-event-audit-outcomes
8 http://www.bmj.com/content/348/bmj.g3306.long
9 http://www.bmj.com/bmj-response-report-independent-panel
10 http://www.bmj.com/content/351/bmj.h5686
11 http://www.bmj.com/content/351/bmj.h4962/rr-12
12 http://www.bmj.com/content/351/bmj.h4962/related
Competing interests: No competing interests
From the beginning of Nina Teicholz's article: "... why does the expert advice underpinning US government dietary guidelines not take account of all the relevant scientific evidence?" Good question, but my question is better: Why are fully ignored the fundamentals and principles of biology, biochemistry, nutrition and health sciences? Nina Teicholz has right, but her criticism isn't strong enough. The reality is darker. Without true science of salt, all the nutrition science is a big heap of junk – including DGA 2015. The real scientific evidences (fundamentals) are totally ignored.
We eat, because we need energy. We adopted only the natural mineral content of foods, but no the added sodium salts. The salt is the greatest blunder of the Homo sapiens. Sodium content of extracellular fluids (blood and lymph) is about 140 mmol/l, but in our cells is only around 10 mmol/l (and must be within a narrow range). The continuous diffusion of sodium ions into the cells = the necessary and ordered circumstance decline. This means - the entropy (the disorder) is growing. Our cells needs continuous energy expenditure against spontaneous diffusion by continuous work of the sodium/potassium pumps (needs and expends energy of ATP molecules). "The activity of Na-K pump has been estimated to account for 20-40 % of the resting energy expenditure in a typical adult." [1] This is a significant part of our total energy expenditure (even in a breast-feed infant), and the expended (squandered!) energy depends on unnecessary sodium intakes. This is the most dangerous wasting of the humanity. The sodium intake above the optimum generates a cascade of unhealthy consequences. We cannot adopt the salted foods. The growing entropy is our fiercest enemy, and the salt is his perfect food. We squander the energy against excess diffusion and excess entropy, in our cells. The real science of salt is a taboo, but this is a fatal error because craziness or villainy to increase the water level deliberately - on an area hit with flood. The essence of the true science of salt is so simple - a kindergartener may understand it. But at least in the past 50 years the "health science" - worked on it - let nobody understand it. This work is very successful, the global ignorance is frightening. For example:
http://chriskresser.com/shaking-up-the-salt-myth-healthy-salt-recommenda...
and in 226 comments, and:
https://theconversation.com/blame-sugar-weve-been-doing-that-for-over-10...
and in 22 comments.
"Men are born ignorant, not stupid. They are made stupid by education." Bertrand Russell
But in the near future, men will be born stupid. Men are born humans, but they are converted into experimental animals by health sciences, and in the near future, men will be born animals.
This is an astonishing irresponsibility of health scientists. The "science" of salt, nutrition and health = hear no truth, see no truth, speak no truth! Unfortunately, this is a global epidemic among "health scientists" - this is the Three Monkeys Syndrome.
"Only two things are infinite, the universe and human stupidity and I'm not sure about the former." Albert Einstein
Third is the human irresponsibility. I'm not sure about the first also - but, unfortunately all three expand.
From a 36 years old article in the New England Journal of Medicine [2]:
"Much of the metabolic energy produced by the body is used to establish high intracellular concentrations of potassium (K+) and low concentrations of sodium (Na+), the reverse of the relative concentrations of these ions in the extracellular fluids. The extrusion of sodium requires its movement against a gradient of concentration (higher outside than inside) and electrical potential (inside about 70 mV more negative than outside); work is therefore needed to overcome this electrochemical gradient. The transmembrane pumping of sodium and potassium that establishes these gradients has been studied intensively and is among the best understood membrane transport processes."
But unfortunately it is effectively ignored by health and nutrition scientists, this is a Non-Communicable Knowledge (NCK).
A very fresh and very valuable article in Current Biology; Pontzer et al. [3], Constrained Total Energy Expenditure and Metabolic Adaptation to Physical Activity in Adult Humans
The figure 1 is the key to understand the essence (and the consequences of the unnecessary sodium intakes).
From the Summary: "Here we tested a Constrained total energy expenditure model (CTEE model), in which total energy expenditure increases with physical activity at low activity levels but plateaus at higher activity levels as the body adapts to maintain total energy expenditure within a narrow range. We compared total energy expenditure, measured using doubly labeled water, against physical activity, measured using accelerometry, for a large (n = 332) sample of adults living in five populations /9/. After adjusting for body size and composition, total energy expenditure was positively correlated with physical activity, but the relationship was markedly stronger over the lower range of physical activity. For subjects in the upper range of physical activity, total energy expenditure plateaued, supporting a Constrained total energy expenditure model. Body fat percentage and activity intensity appear to modulate the metabolic response to physical activity. Models of energy balance employed in public health /1–3/ should be revised to better reflect the constrained nature of total energy expenditure and the complex effects of physical activity on metabolic physiology."
The 84 years old Kleiber’s law [4, 5] strongly supports and predicts the Constrained Total Energy Expenditure (model).
But what will happen, when instead of physical activity, one other kind of energy expenditure increases significantly? Namely the (aerobic and anaerobic) energy expenditure of the sodium/potassium pumps significantly increases - induced by high sodium intakes (NaCl and other Na-salts) from foods of modern societies. What is the logic consequence if an obese person - eating foods highly salted - regularly makes intense exercises? Naturally, every other vital processes (functional processes of the cells and organs) receive less energy = everything work worse in the body (heart, brain, other organs, immune system, regulating systems, regeneration processes etc.) - even in healthy range of BMI.
We haven't enough energy, and we haven't enough time for the regeneration, because we enhance the entropy (by high sodium intakes) and we squander the energy in our every cell. Day by day, again and again, the excess entropy "devours" our energy. All this (including consequences) is the Sodium-Induced Disorder Syndrome (SIDS). SIDS is the real global epidemic, not the obesity or high BP etc. - obesity and high BP (etc.) is only ones among the dangerous consequences.
Note: By our technical civilisation and medical sciences we stopped natural selection = we’ve stopped evolving = we have started our devolution, which will accelerate as in a nuclear bomb the chain reaction. And nobody will be able to stop it. The entropy (the disharmony) is growing in human genome even we nourish the entropy in our every cell - in fundamentals of our existence. By unnecessary sodium salts we speed our devolution. This is really a fatal error. NCK is too much in salt science, it's time to change that.
The following articles also support the CTEE (mainly, as a consequence of high sodium intakes) [6 - 8]. From the ref. 8:
"Overall FMD (flow-mediated dilatation) was reduced 2 h postprandially. FMD was significantly more impaired after the HSM (high-salt meal) than after the LSM (low-salt meal) at 30 min ... An HSM (65 mmol Na = 3.8 g NaCl), which reflects the typical amount of salt consumed in a commonly eaten meal, can significantly suppress brachial artery FMD within 30 min. These results suggest that high salt intakes have acute adverse effects on vascular dilatation in the postprandial state. ... We speculate that one of these possible mechanisms by which salt impairs endothelial function is via an alteration in plasma sodium. Two studies have reported responses to oral salt loading over a postprandial time period, which showed a rise in plasma sodium in response to 100 mmol Na (5.8 g salt) loading in healthy persons of 3 mmol/L, which occurred within 2-3 h of consuming the test meal /16, 17/. It has been postulated that a high salt intake may acutely impair vascular function by raising plasma sodium by as much as 3 mmol/L. ... It appears that higher salt intakes have acute adverse effects on vascular dilatation in the postprandial phase."
Indisputable: Impaired vascular function = impaired oxygen supply. And less oxygen = less energy.
On 14 Aug 2012 in a comment on PLoS One [7] I wrote:
"Some consequences of high sodium intake (The specialists talk about these rarely or never):
1. bigger and longer hunger stimulus - we overeat
2. we drink many sugary soft drinks - we get fat
3. we get tired soon, we move little
4. higher energy requirements for Na-K pump, and kidney
5. all the rest of our vital processes receive less energy (because the metabolic rate - speed and capacity of enzyme reactions - is limited)
6. all of our vital processes work worse.
7. we get sick often, and we will die soon. = Extra profit in food and pharmaceutical industry and health services, and savings in the pension funds."
The salted humanity's energy expenditure presumably is in the CTEE range (independently from physical activity, that can be predicted from [4, 5 and 7]), and everything works worse in our body. Undebatable that this has many acute and chronic adverse consequences (not only the illnesses, but for example: less energy to the brain = more accidents). But the true science of salt is an ignored and censored taboo, and pseudosciences bloom.
A new article about Salt Wars (without real science of salt): Why do we think we know what we know? A metaknowledge analysis of the salt controversy. In International Journal of Epidemiology [9 and 3 commentary].
Abstract: "Background: Although several public health organizations have recommended population-wide reduction in salt intake, the evidence on the population benefits remains unclear. We conducted a metaknowledge analysis of the literature on salt intake and health outcomes.
Methods: We identified reports - primary studies, systematic reviews, guidelines and comments, letters or reviews - addressing the effect of sodium intake on cerebro- cardiovascular disease or mortality. We classified reports as supportive or contradictory of the hypothesis that salt reduction leads to population benefits, and constructed a network of citations connecting these reports. We tested for citation bias using an exponential random graph model. We also assessed the inclusion of primary studies in systematic reviews on the topic.
Results: We identified 269 reports (25% primary studies, 5% systematic reviews, 4% guidelines and 66% comments, letters, or reviews) from between 1978 and 2014. Of these, 54% were supportive of the hypothesis, 33% were contradictory and 13% were inconclusive. ... In all, 48 primary studies were selected for inclusion across 10 systematic reviews. If any given primary study was selected by a review, the probability that a further review would also have selected it was 27.0% (95% CI 20.3% to 33.7%).
Conclusions: We documented a strong polarization of scientific reports on the link between sodium intake and health outcomes, and a pattern of uncertainty in systematic reviews about what should count as evidence."
From the article "The World Health Organization (WHO) recommends reducing sodium intake to < 2 g/day in adults. /3/ Opponents of population-based salt reduction argue that the relationship between sodium intake and clinical outcomes is U- or J-shaped and that the harms associated with low sodium intakes may mitigate any potential benefits of blood pressure reductions arising from decreased salt intakes. /4,5/ In a recent report, the United States Institute of Medicine of the National Academies of Science concluded that there is a lack of evidence for benefits of reducing sodium intake to the very low levels recommended by the WHO./6/"
It seems - the authors don’t know that before industrial revolution the salt was (very) expensive. For example the bread was made without added salt. The natural sodium content of wheat flour approximately 20 mg/kg. In Hungary - the upper limit of salt in bread is 25 g/kg (in dried matter, Codex Alimentarius Hungaricus 1-3/81-1 Certain bread and bakery products http://www.omgk.hu/Mekv/1/13811_2012.pdf ). This is 490 times higher sodium content as our predecessors ate it about 2 centuries before. And nothing about the Na/K pump in this article and in 3 commentary.
Luck at the U- or J-shaped clinical outcomes [10 – 12, 12/c]. In the figures are no points (no curves) below ~ 1 g sodium per day. Why? In 10th ed. of RDA (1989) was 500 mg Na per day [13]. Australian recommendation now is 460-920 mg/day [14]. 460-500 mg Na/day is (approximately) calculable from the sodium and energy content of human milk, which is the evolutionary perfect food for babies, and is the perfect guide for adult nutrition. And where are the sodium intakes of healthy, isolated (hunter-gatherer) tribes - no-salt cultures, for example Yanomamos? [15] In these clinical trials - where are the really healthy control groups? Nowhere, all the modern societies are affected by sodium-induced disorder.
Comparing the x- and y-axes in the figures (U- or J-shaped), something is very strange, but not a surprise for me. Does nobody see it? Y-axes were made (especially) gummy! And why? Presumably: How to lie, cheat, manipulate, and mislead using statistics and graphical displays [16]. Naivety, if the scientists and researchers believe really, that the newer trials and meta-analyses are better than the older ones. In summary: clinical trials, meta-analyses and the salt war = lack of real science = pseudoscience.
Some of the old touchstones of the salt debate (in political science of salt by Gary Taubes, 1998)
-Midgley et al., 1996. Meta-analysis of 56 clinical trials concludes that benefit from salt reduction is small and DOES NOT SUPPORT current dietary recommendations
http://jama.jamanetwork.com/article.aspx?articleid=402918#Abstract
https://www.researchgate.net/publication/14578810
-Cutler et al., 1997. Meta-analysis of 32 clinical trials concludes that benefit of salt reduction is larger and DOES SUPPORT current dietary recommendations
http://jama.jamanetwork.com/article.aspx?articleid=416446#Abstract
https://www.researchgate.net/publication/14051013
It was 33 clinical trials. And the title of the article: "Effects of oral POTASSIUM on blood pressure. Meta-analysis of randomized controlled clinical trials." The first author was Paul K. Whelton, Cutler was the third.
-Graudal et al., 1998. Meta-analysis of 114 clinical trials DOES NOT SUPPORT a general recommendation to reduce salt intake.
http://jama.jamanetwork.com/article.aspx?articleid=187486#Abstract
https://www.researchgate.net/publication/13702128
Exactly: it was 58 trials.
On the scientific media in 2015: Why Everything We 'Know' About Diet and Nutrition Is Wrong
http://www.realclearscience.com/blog/2015/06/why_everything_we_know_abou...
From the original article (in Mayo Clinic Proceedings) "The Inadmissibility of What We Eat in America and NHANES Dietary Data in Nutrition and Obesity Research and the Scientific Formulation of National Dietary Guidelines" [17]:
"Five decades of controversy surrounding basic dietary guidelines and nutrition recommendations is a public acknowledgement of a failed research paradigm."
And is a consequence of the astonishingly wrong education. A new paradigm is necessary – a new deal – back to the real science.
From the end of an article of Niels Graudal, 2005 [18]: "It is tempting to end this commentary with another provocative citation from Chapman and Gibbons: /1/ ‘Many (articles) possess historical interest only. Others, while defective in some respects, contain suggestions that have led to later and more valuable work. Still others have had influence out of all proportion to their intrinsic work and are RESPONSIBLE for VAST AMOUNTS of WASTED RESEARCH ENDEAVOUR on the part of later investigators’. In that connection, considering that the salt controversy now is dealing with an effect size of about 1 mm Hg, one may ask, has it been worth 100 years of effort?"
Unfortunately, Gradual is on the bad side in the salt war, but really the good side is not better.
From an article in J Cardiovasc Dis Res. - R. K. Mathur, 2010 [19]:
"To determine the mechanism of thermogenesis, Osaka et al. /7-9/ infused hypertonic solution of glucose, NaCl, fructose, and amino acids in the intestine of urethane-anesthetized rats. A higher core body temperature was observed with increasing amounts of the above-mentioned nutrients. Furthermore, an intravenous injection (IV) of these nutrients also caused thermogenesis accompanied by an increase in plasma osmolality. However, thermogenesis caused by IV was lesser than that caused by the intestinal infusion of NaCl and the solutions of the other above-mentioned nutrients, suggesting an involvement of intestinal osmoreceptors. This further suggests that it is unlikely that IV and intestinal osmotic stimulation induces identical mechanisms of thermogenesis. However, it does show that an increase in the plasma osmolality, within the physiological range, elicits thermogenesis. The mechanism of thermogenesis is not clear. However, it may involve intestinal osmoreceptors. The authors also found that food intake stimulated the metabolic rate of the whole body and increased the core body temperature. The core body temperature is measured by inserting a thermister in the anus. The skin or cutaneous body temperature is measured by a thermister taped to the lateral surface of a rat's tail. The mechanism of core and skin temperatures are regulated differently /10, 11/. It is this thermogenesis that is responsible for the generation of atherosclerotic plaque."
From the end of the article: "Patients are advised to stay away from fatty foods, which obviously does not help because fatty meal is not the cause for atherosclerosis. Therefore, the researchers should first examine the cause of the disease before trying to cure it; otherwise, we will be treating symptoms rather than curing the disease itself. ... Finally, this field requires some broad theories and hypotheses explaining the involvement of foods, diabetes, hypertension, cigarette smoking, and others in the formation of atherosclerotic plaque. We have a mission but are lacking the vision. That is why WE HAVE NOT MADE ANY PROGRESS even though we have worked on it FOR MORE THAN 50 YEARS."
9 years after Osaka et al., (yes, this is the censored work, cited in my first response here: http://www.bmj.com/content/351/bmj.h4962/rr-5 ) and 45 years after Klahr & Bricker (also cited in my first response) - and why not clear? Floor gas Na/K pumps and kidneys use more energy. Our cells must "burn" anaerobically, even from the glycogen reserve for the excess ATP (re)productions. And see Henningsen 1985 (also in my first response), our cells (red blood cells, leukocytes, macrophages, endothelial cells and others - everywhere in our body) are dying. This is the ignored cause in the formation of atherosclerotic plaque. And we haven't enough time and we haven't enough energy for the regeneration. Was the mechanism not clear really? Or the scientific elite did not allow it to enlighten? Instead of theories and hypotheses would be better to use the already existing knowledges.
American Heart Association - now, Apr 13, 2016 [20]:
"Atherosclerosis. How does atherosclerosis start and progress?
It's a complex process. Exactly how atherosclerosis begins or what causes it isn't known, but some theories have been proposed. Many scientists believe plaque begins to form because the inner lining of the artery, called the endothelium, becomes damaged. Three possible causes of damage to the arterial wall are:
Elevated levels of cholesterol and triglycerides in the blood
High blood pressure
Cigarette smoking"
Where is the progress of the health sciences in the past 60 years? In the shadow of the multinational big food and big pharma industry - the science is blowing in the wind. How much is the worthless article in the indexed medical literature? These may be some millions. While noncommunicable diseases prematurely take 16 million lives annually and WHO urges more action [21].
Well, look at the WHO.
Diet, nutrition and the prevention of chronic disease. Report of a Joint WHO/FAO Expert Consultation. 2003 [22]
From this report (TRS-916), on page 90 (100 of 160): "Potassium Adequate dietary intake of potassium lowers blood pressure and is protective against stroke and cardiac arrythmias. Potassium intake should be at a level which will keep the sodium to potassium ratio close to 1.0, i.e. a daily potassium intake level of 70-80 mmol per day. This may be achieved through adequate daily consumption of fruits and vegetables."
But are no explanation, no evidence and no references for this (molar) ratio. Is this science - or what?
Again the WHO (2006) - Reducing salt intake in populations [23]
On page 26: "Several national and international agencies recommend individual dietary sodium intakes of no more than 100 mmol/day (6 g salt/day) and in some cases no more than 65 mmol/day (4 g salt/day). Two WHO expert consultations recommended that the population average for salt consumption should be < 5 g/day (WHO, 1983; WHO/FAO, 2003).
While well below the average salt consumption in most countries, this recommendation reflects a pragmatic COMPROMISE since well-conducted trials clearly indicate that even greater sodium reductions (to 50–60 mmol/day) would achieve greater health benefits. (Denton, 1982; WHO – International Society of Hypertension, 1999; Sacks et al, 2001; He & MacGregor, 2004)
Additionally, numerous countries worldwide have set adequate intake levels for sodium. In Australia and New Zealand the adequate intake for adults for sodium was set at 460–920 mg/day (20–40 mmol/day) to ensure that basic nutritional requirements are met and to allow for adequate intakes of other nutrients (Nutrient Reference Values for Australia and New Zealand, 2005)."
This compromise is a pact with the enemy. The unnecessary sodium intakes = we deliver weapons and ammunition for our fiercest enemy, "who" uses it without hesitation - against us. This fiercest enemy = the LAW of ENTROPY (the second law of thermodynamics). The life on Earth, our history and our entire individual life is a continuous war against entropy. Even we nourish the entropy in our every cell, but the health scientists do not speak about this. And this is a fatal error. With our life quality, with illnesses, with our shorter life - we pay for this expensively.
Nutrient Reference Values for Australia and New Zealand, Sodium [24]
From this:
"The Intersalt Cooperative Research Group (1988) found that the rate of sodium excretion ranges from less than 0.2 mmol of sodium/day in the Yanomamo Indians of Brazil to 242 mmol/day in Tianjin in China (Intersalt Cooperative Research Group 1988). Estimated intakes in Australia are about 150 mmol/day (Beard et al 1997, Notowidjojo & Truswell 1993). An almost identical figure has been found in New Zealand (Thomson & Colls 1998).
There many healthy populations with estimated intakes of less than 40 mmol/day (Intersalt Cooperative Research Group et al 1988). Survival at extremely low levels such as that of the Yanomamo reflects the ability to conserve sodium by reducing urine and sweat losses. With maximal adaptation, the smallest amount of sodium needed to replace losses is estimated to be no more than 0.18 g/day (8 mmol/day). However, a diet providing this level of sodium intake is unlikely to meet other dietary requirements in countries such as Australia and New Zealand."
The optimum is in human milk. Less and more are not good. But we can adapt only to the less. This is the evolutionary heritage of many million years.
Back to WHO (2012, published online in January 2013): WHO issues new guidance on dietary salt and potassium [25, 26]
Sodium intake for adults and children - from this - on page 2 (10 of 56):
"WHO recommends a reduction in sodium intake to control blood pressure in children (strong recommendation). The recommended maximum level of intake of 2 g/day sodium in adults should be adjusted downward based on the energy requirements of children relative to those of adults."
Why downward? Why not from mature human milk?
On page 3 (11 of 56):
"Addressing the optimal ratio of sodium to potassium was outside the scope of this guideline; however, if an individual consumes the amount of sodium recommended in this guideline and the amount of potassium recommended in the WHO guideline on potassium intake, the ratio of sodium to potassium would be approximately one to one, which is considered beneficial for health /12/."
And on page 19 (27 of 56):
"These recommendations do not address the optimal sodium to potassium ratio; however, if this guideline and the WHO guideline on potassium intake are achieved, the molar ratio of sodium to potassium would be approximately one to one."
Potassium intake for adults and children - from this - on page 3 (11 of 52):
"... however, if an individual consumes sodium at the levels recommended in the WHO guideline on sodium intake, and potassium as recommended in the current guideline, the ratio of sodium to potassium would be approximately one to one, which is considered beneficial for health /8/."
And on page 16 (24 of 52):
"These recommendations do not address the optimal ratio of sodium to potassium; however, if this guideline and the WHO guideline on sodium consumption are achieved, the molar ratio of sodium to potassium would be approximately one to one."
But Ref. /12/ = Ref. /8/ = WHO Diet, nutrition and the prevention of chronic disease. Report of a Joint WHO/FAO Expert Consultation. Geneva, World Health Organization (WHO), 2003. This is the TRS-916 [22]. This is just a pseudoscientific self-reference, and this is a perfect example – how to make (and spread) pseudoscience. No evidence for beneficial effect of 1 to 1 sodium/potassium molar ratio. And WHO urges more action?
The CSPI, Bonnie Liebman, and the 173 scientists (and thousands of health scientists worldwide) simply tolerate the pseudoscience? Does nobody want to retract it? Shameful irresponsibility! Attacking Nina Teicholz's article - they believe that they do defend the science and the public interest? The new DGA is only a selected collection from the big heap of worthless junk. That is lack of scientific fundamentals. In reality, they do defend the pseudoscience and the public ignorance. By this they damage public health severely worldwide (not only in US).
From the ref. 18 of Nina Teicholz's article [27]: "Furthermore, many trials of advice to modify dietary intake of fat have included 1 or more other elements of dietary and non-dietary advice; examples include advice to increase fibre intake, reduce meat consumption, reduce body weight, stop smoking, reduce salt intake, increase fruit and vegetable consumption, increase physical activity, or reduce alcohol consumption."
That's all about the salt. But high fat diet = high sodium content, and high fruits and vegetables = less sodium. But this is an ignored difference. Randomised controlled trials and meta-analyses don't make health science, especially when the fundamentals are ignored and the results (and trials) are manipulated.
From an article appearing promising - A multidisciplinary reconstruction of Palaeolithic nutrition that holds promise for the prevention and treatment of diseases of civilisation. In Nutrition Research Reviews, 2012 [28]:
"While iodide is added to table salt in many countries, margarines and milk have become popular food products for fortification with vitamins A and D."
This is a review article, more than 30 pages and with 450 references. But that's all about the salt. Is this true science and a real promise? Not, this is lack of real science = pseudoscience, and this article is a goldmine for nutrition charlatans - both amateur and professional (universities educated) "doctors". Why the medical doctors and nutritionists cannot understand that the diffused amount of sodium (into the cells) is proportional with the surface? They don't understand the entropy law?
For example Christopher B Scott in Nutrition & Metabolism (2005): Review - Contribution of anaerobic energy expenditure to whole body thermogenesis [29].
Some important keywords in this article: entropy, energy, sodium pump, anaerobic pathway, lactate. From the article: "The second law describes how energy is transferred from one form to another. For example heat, as an expression of energy, always flows in one direction – from hot to cold. Other ways of stating this are that energy flows "downhill" or, from a state of lower entropy to one of higher entropy. Entropy represents energy that is not available to perform work so that simply put, energy transfer is inefficient. Inefficiency also appears in the form of heat production that is usually discarded into the environment. ... Brisk activity of the sodium pump necessitates a rapid rate of ATP re-synthesis. If this is true then it is important to recognize that in some cells lactate with presumed heat production is better correlated with sodium and potassium pumping than is oxygen uptake"
This is not too much. Would this be the progress of the health science over 40 years (between Klahr & Bricker 1965 and 2005)? And even now in 2016 the progress and the pure science are practically in deep freeze.
The surface (billions) of our cells is extreme large. Consequently, little increase in extracellular Na concentration induces significant excess diffusion and significant excess work for Na/K pumps = significant excess energy expenditure against excess entropy. But our capacity is limited. Our ancestors and for example Yanomamos and Hadza hunter-gatherers do not eat salt. We cannot adopt the salted foods. The entropy is nourished in us with sodium salts, but the health scientists do not talk and do not write about this. Even Graham A. MacGregor - a popular chairman of the salt reducing movements - doesn't use the real science of salt [30]. The bad side does not have a real weapon in the salt war. The good side has very strong weapons, but these are not used. Both side in the salt war - use only the pseudoscience, so this is a never ending war. Good education and really responsible scientists are needed, and will end of the pseudoscientific lies and meaningless salt wars – forever.
Really, the growing entropy is our number one public enemy on every level of our existence. But – if nobody knows this enemy (because it is kept in secret), nobody can fight against it. The race is on. We will be champions, or the growing entropy destroys us? I don't know the answer, but we have little chance to win, if we nourish the entropy longer in our own body. Scientists and researchers, wake up - before it's not too late!
References
1. Oregon State University, Linus Pauling Institute, Micronutrient Information Center
Sodium (Chloride) http://lpi.oregonstate.edu/infocenter/minerals/sodium/
2. Kathleen J. Sweadner and Stanley M. Goldin:
Active Transport of Sodium and Potassium Ions - Mechanism, Function, and Regulation
N Engl J Med; 302:777-783 April 3, 1980 DOI: 10.1056/NEJM198004033021404
http://www.nejm.org/doi/full/10.1056/NEJM198004033021404
3. Herman Pontzer, Ramon Durazo-Arvizu, Lara R. Dugas, Jacob Plange-Rhule, Pascal Bovet, Terrence E. Forrester, Estelle V. Lambert, Richard S. Cooper, Dale A. Schoeller, Amy Luke: Constrained Total Energy Expenditure and Metabolic Adaptation to Physical Activity in Adult Humans
Current Biology Jan 2016 Volume 26, Issue 3, p410–417, 8 February 2016
http://dx.doi.org/10.1016/j.cub.2015.12.046
http://www.cell.com/current-biology/fulltext/S0960-9822(15)01577-8
https://www.researchgate.net/publication/292208779
4. Kleiber, M.: Body size and metabolism.
Hilgardia 6(11), 315-353 (1932) DOI:10.3733/hilg.v06n11p315
http://hilgardia.ucanr.edu/Abstract/?a=hilg.v06n11p315
Pdf of full article:
http://ucanr.edu/repository/fileaccess.cfm?article=152052&p=VOWQRB
5. Fernando J. Ballesteros, Vicent J. Martínez, Andrés Moya and Bartolo Luque:
Energy balance and the origin of Kleiber’s law (2014)
http://arxiv.org/vc/arxiv/papers/1407/1407.3659v1.pdf
https://www.researchgate.net/publication/263930177
6. Pete C. Trimmer, James A.R. Marshall, Lutz Fromhage, John M. McNamara, Alasdair I. Houston: Understanding the placebo effect from an evolutionary perspective
Evolution & Human Behavior Volume 34, Issue 1 , Pages 8-15, January 2013.
(Received 13 September 2011; accepted 24 July 2012. published online 30 August 2012.)
http://www.ehbonline.org/article/S1090-5138(12)00070-0
7. Herman Pontzer, David A. Raichlen, Brian M. Wood, Audax Z. P. Mabulla, Susan B. Racette, Frank W. Marlowe: Hunter-Gatherer Energetics and Human Obesity
(2012), PLoS ONE 7(7): e40503. doi:10.1371/journal.pone.0040503
http://dx.plos.org/10.1371/journal.pone.0040503
8. Kacie M Dickinson, Peter M Clifton, and Jennifer B Keogh:
Endothelial function is impaired after a high-salt meal in healthy subjects.
Am J Clin Nutr March 2011 vol. 93 no. 3 500-505
http://ajcn.nutrition.org/content/93/3/500.full
9. Ludovic Trinquart, David Merritt Johns, Sandro Galea:
Why do we think we know what we know? A metaknowledge analysis of the salt controversy
Int. J. Epidemiol. (2016) doi: 10.1093/ije/dyv184 First published online: February 17, 2016
http://ije.oxfordjournals.org/content/early/2016/02/17/ije.dyv184.full
https://www.researchgate.net/publication/295077608
9/c1. Bruce Neal: Commentary: The salt wars described but not explained - an invited commentary on ‘Why do we think we know what we know? A metaknowledge analysis of the salt controversy’
Int. J. Epidemiol. (2016) doi: 10.1093/ije/dyw005 First published online: February 17, 2016
http://ije.oxfordjournals.org/content/early/2016/02/17/ije.dyw005.full
https://www.researchgate.net/publication/295077829
9/c2. Martin O'Donnell, Andrew Mente, Salim Yusuf:
Commentary: Accepting what we don’t know will lead to progress
Int. J. Epidemiol. (2016) doi: 10.1093/ije/dyw014 First published online: February 17, 2016
http://ije.oxfordjournals.org/content/early/2016/02/17/ije.dyw014.full
https://www.researchgate.net/publication/295077607
9/c3. John P.A. Ioannidis: Commentary: Salt and the assault of opinion on evidence
Int. J. Epidemiol. (2016) doi: 10.1093/ije/dyw015 First published online: February 17, 2016
http://ije.oxfordjournals.org/content/early/2016/02/17/ije.dyw015.full
https://www.researchgate.net/publication/295077828
10. M.J. O’Donnell, A. Mente, A. Smyth, and S. Yusuf:
Salt intake and cardiovascular disease: why are the data inconsistent?
European Heart Journal (2013) 34, 1034–1040 doi:10.1093/eurheartj/ehs409
http://eurheartj.oxfordjournals.org/content/ehj/34/14/1034.full.pdf
https://www.researchgate.net/publication/233964143
11. Andrew Smyth, Martin O’Donnell, Andrew Mente, Salim Yusuf:
Dietary Sodium and Cardiovascular Disease
Current Hypertension Reports June 2015, 17:47 First online: 17 May 2015
http://link.springer.com/article/10.1007%2Fs11906-015-0559-8
http://link.springer.com/article/10.1007/s11906-015-0559-8/fulltext.html
https://www.researchgate.net/publication/277074137
12. Heaney, Robert P.: Making Sense of the Science of Sodium
Nutrition Today: March/April 2015 - Volume 50 - Issue 2 - p 63–66 doi: 10.1097/NT.0000000000000084
http://journals.lww.com/nutritiontodayonline/Fulltext/2015/03000/Making_...
https://www.researchgate.net/publication/276359897
12/c. Cheryl A. M. Anderson, Rachel K. Johnson, Penny M. Kris-Etherton, Emily Ann Miller: Commentary on Making Sense of the Science of Sodium
Nutrition Today: March/April 2015 - Volume 50 - Issue 2 - p 66–71 doi: 10.1097/NT.0000000000000086
http://journals.lww.com/nutritiontodayonline/Fulltext/2015/03000/Comment...
https://www.researchgate.net/publication/276906306
13. RDA 10th ed. 1989
http://www.nap.edu/catalog/1349/recommended-dietary-allowances-10th-edition
http://www.nap.edu/read/1349/chapter/12#253
14. Nutrient Reference Values for Australia and New Zealand - Sodium
http://www.nrv.gov.au/nutrients/sodium
http://www.nrv.gov.au/sites/default/files/page_pdf/n35-sodium_0.pdf
15. W J Oliver, E L Cohen, J V Neel: Blood pressure, sodium intake, and sodium related hormones in the Yanomamo Indians, a "no-salt" culture.
Circulation 1975; 52: 146-151
http://circ.ahajournals.org/content/52/1/146
http://circ.ahajournals.org/content/52/1/146.full.pdf+html
https://www.researchgate.net/publication/22023760
16. How to lie, cheat, manipulate, and mislead using statistics and graphical displays
http://cseweb.ucsd.edu/~ricko/CSE3/Lie_with_Statistics.pdf
17. Edward Archer, Gregory Pavela, Carl J. Lavie:
The Inadmissibility of What We Eat in America and NHANES Dietary Data in Nutrition and Obesity Research and the Scientific Formulation of National Dietary Guidelines
Mayo Clinic Proceedings July 2015 Volume 90, Issue 7, Pages 911–926
http://dx.doi.org/10.1016/j.mayocp.2015.04.009
http://www.mayoclinicproceedings.org/article/S0025-6196%2815%2900319-5/f...
18. Niels Graudal: Commentary: Possible role of salt intake in the development of essential hypertension Int. J. Epidemiol. (October 2005) 34 (5): 972-974. doi: 10.1093/ije/dyi016
http://ije.oxfordjournals.org/content/34/5/972.full
https://www.researchgate.net/publication/30965300_Commentary_Possible_ro...
19. Ram K. Mathur: Role of diabetes, hypertension, and cigarette smoking on atherosclerosis
J Cardiovasc Dis Res. 2010 Apr-Jun; 1(2): 64–68.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2945206/
https://www.researchgate.net/publication/46579781_Role_of_diabetes_hyper...
20. American Heart Association – Atherosclerosis (Apr 2016)
http://www.heart.org/HEARTORG/Conditions/Cholesterol/WhyCholesterolMatte...
21. Noncommunicable diseases prematurely take 16 million lives annually, WHO urges more action, WHO 19 January 2015
http://www.who.int/mediacentre/news/releases/2015/noncommunicable-diseas...
22. Diet, nutrition and the prevention of chronic disease. Report of a Joint WHO/FAO Expert Consultation. Geneva, World Health Organization (WHO), 2003
http://whqlibdoc.who.int/trs/WHO_TRS_916.pdf
23. REDUCING SALT INTAKE IN POPULATIONS Report of a WHO Forum and Technical meeting 5-7 October 2006, Paris, France
http://www.who.int/dietphysicalactivity/reducingsaltintake_EN.pdf
24 Nutrient Reference Values for Australia and New Zealand, Sodium
http://www.nrv.gov.au/nutrients/sodium
25. Sodium intake for adults and children (WHO 2012)
http://www.who.int/nutrition/publications/guidelines/sodium_intake/en/
26. Potassium intake for adults and children (WHO 2012)
http://www.who.int/nutrition/publications/guidelines/potassium_intake/en/
27. Skeaff C.M., Miller J.: Dietary fat and coronary heart disease: summary of evidence from prospective cohort and randomised controlled trials.
Ann Nutr Metab 2009; 55: 173-201. (DOI:10.1159/000229002)
http://www.karger.com/Article/Pdf/229002
https://www.researchgate.net/publication/26810530
28. Remko S. Kuipers, Josephine C. A. Joordens and Frits A. J. Muskiet: A multidisciplinary reconstruction of Palaeolithic nutrition that holds promise for the prevention and treatment of diseases of civilisation
Nutrition Research Reviews (2012) 25, 96–129 doi:10.1017/S0954422412000017
http://dx.doi.org/10.1017/S0954422412000017
https://www.researchgate.net/publication/230677843
29. Christopher B Scott: Review - Contribution of anaerobic energy expenditure to whole body thermogenesis
Nutrition & Metabolism 2005, 2:14 doi: 10.1186/1743-7075-2-14
http://www.nutritionandmetabolism.com/content/2/1/14
30. Feng J. He, Graham A. MacGregor: Reducing Population Salt Intake - Time for Global Action
The Journal of Clinical Hypertension Volume 17, Issue 1, pages 10–13, January 2015
DOI: 10.1111/jch.12404
http://onlinelibrary.wiley.com/doi/10.1111/jch.12404/abstract
http://onlinelibrary.wiley.com/doi/10.1111/jch.12404/full
Competing interests: No competing interests
We have initiated post-publication review of the issues raised by Liebman and colleagues. As soon as we have received the reports from our external reviewers, we will post them along with a response from the journal.
Competing interests: I am employed by The BMJ
This commentary, written nearly 20 years ago, outlines my continuing concerns regarding the dietary guidelines issued by the US government:
Competing interests: No competing interests
I am appalled that The BMJ would even consider yielding to the pressure from "competing interests" by withdrawing Nina Teicholz's article. American doctors (of whom I have seen many in my lifetime and professional career) claim that they base their practice and prescribing on "evidence-based medicine;" all Teicholz asks is that the evidence for these dietary recommendations be presented.
We have seen many recommendations in medicine change since 1980, including those for immunization schedules, cancer screenings, use of antibiotics, prescribing opiates, delivering babies by Caesarean section surgery, as a few examples. All these changes were based on empirical evidence of the efficacy and outcomes of these practices, both detrimental and beneficial to the well-being of the patients subjected to them. Teicholz is the voice demanding that the empirical evidence that certain dietary regimens are beneficial and efficacious be presented, and be subjected to the same criteria for validity as any other substance for daily use. When policy-makers and budget allocators make their decisions based upon these recommendations, the public deserves to see the supporting evidence for making significant alterations in their daily lives. Instead of castigating Nina Teicholz, The BMJ and its audience should be thanking her for so objectively and rationally questioning the evidence used to make these decisions.
Competing interests: No competing interests
We read with interest the paper by Teicholz on the scientific report guiding US dietary guidelines and the ensuing online discussion regarding the relative risks and benefits of dietary fat and carbohydrates.1 Ultimately, however, dietary decisions are made by consumers, not scientists. Consumers’ perceptions of the nutritional value of various food types are probably not only shaped by scientific discussions in the BMJ, but also by numerous other influences. These perceptions are difficult to measure, but the number of views received by a recent YouTube video2 and a newspaper article3 about the perils of sugar and the broad public support for the introduction of a “sugar tax”, proposed by a well-known British naked chef4 suggest that views of the nutritional value of sugar are indeed changing.
To quantify public attitudes towards dietary fat and sugar, we used a public web facility, "Google Trends" (http://www.google.com/trends), to compare how often the phrases "low fat" and "low sugar" were entered in the world’s most popular internet search engine in preceding years (Figure 1). The term "low fat" shows a distinctive saw-tooth pattern: interest in this phrase is markedly attenuated during the holiday season, followed by a sharp rise in the number of searches at the beginning of each year. The search phrases "diet", “weight loss”, "healthy food" and "quit smoking" show a similar pattern (data not shown), suggesting that these searches are indeed a reflection of a common desire to modify unhealthy behavior at the start of the new year. Interestingly, the popularity of the search phrase "low fat" has declined gradually since at least 2004, the earliest year for which data are available. In contrast, searches for "low sugar" have become increasingly common and the phrase will probably overtake "low fat" in popularity this year (Figure 1).
A potential pitfall of this analysis is that a search phrase may have multiple meanings. For instance, the words "low sugar" may also have been entered by people worried about low blood glucose levels. However, Figure 1 shows that in recent years, the curve for "low sugar" has started to show a typical saw-tooth pattern similar to “low fat”, suggesting that the phrase is increasingly entered by people seeking to change their dietary habits as part of their new year’s resolutions rather than those with concerns about hypoglycemia.
These data suggest that the public perception of the relative health risks of dietary sugar and fat is indeed changing and that increasing numbers of people are seeking ways to limit their sugar intake at the start of the year. This is cause for modest optimism with regard to future obesity rates, as recent data indicate that a diet low in carbohydrates is probably more effective in reducing obesity and its associated cardiovascular risks than a low-fat diet.5 However, the benefits should not be overestimated: only a small minority of all new year's resolutions are actually kept.6
References
1. Teicholz N. The scientific report guiding the US dietary guidelines: is it scientific? BMJ [Internet] 2015 [cited 2015 Sep 27];351(sep23_1):h4962. Available from: http://www.bmj.com/content/351/bmj.h4962
2. Sugar: The Bitter Truth - YouTube [Internet]. [cited 2015 Dec 27];Available from: https://www.youtube.com/watch?v=dBnniua6-oM
3. Is Sugar Toxic? - The New York Times [Internet]. [cited 2015 Dec 23];Available from: http://www.nytimes.com/2011/04/17/magazine/mag-17Sugar-t.html?_r=0
4. Cameron under pressure as public backs sugar tax | Society | The Guardian [Internet]. [cited 2015 Dec 29];Available from: http://www.theguardian.com/society/2015/oct/24/sugar-tax-poll-obesity-ca...
5. Sackner-Bernstein J, Kanter D, Kaul S. Dietary Intervention for Overweight and Obese Adults: Comparison of Low-Carbohydrate and Low-Fat Diets. A Meta-Analysis. PLoS One [Internet] [cited 2015 Oct 21];10(10):e0139817. Available from: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0139817
6. The Science Behind Failed Resolutions - WSJ [Internet]. [cited 2015 Dec 27];Available from: http://www.wsj.com/articles/SB10001424052748703478704574612052322122442
Figure legends
Figure 1: Comparison of the number of searches for “low fat” and “low sugar” on Google, the world’s most popular search engine. Data are publicly available on www.google.com/trends. Google Trends allows the comparison of different search terms but does not provide absolute numbers. A typical saw-tooth pattern is visible in the curve of “low fat”: interest is low during the holiday season and increases sharply at the beginning of each year. A similar pattern has emerged recently in the use of the phrase “low sugar”. The popularity of “low fat” shows a gradual decline, while “low sugar” has become more common. As a result, low sugar will probably overtake “low fat” in 2016 as a new year’s resolution
Competing interests: No competing interests
Dear Editor:
A recent article by journalist Nina Teicholz (http://bit.ly/1KCD7HR, which was published as a “BMJ Investigation” of the Scientific Report of the 2015 Dietary Guidelines Advisory Committee (DGAC) (http://1.usa.gov/1K2jJqQ), included numerous errors and misrepresentations. Below we have summarized only factual errors, excluding incorrect or biased interpretations of research. The mistakes are bolded. (For the formatted version, please refer to http://cspinet.org/bmj-retraction-letter.html)
Because the “investigation” as a whole is so riddled with errors, we urge the BMJ to retract it, not only to inform your readers, but also to protect the BMJ’s credibility.
________________________________________
1.) Teicholz states that “in its 2015 report the committee stated that it did not use NEL reviews for more than 70% of the topics, including some of the most controversial issues in nutrition. Instead, it relied on systematic reviews by external professional associations, almost exclusively the American Heart Association (AHA) and the American College of Cardiology (ACC), or conducted an [sic] hoc examination of the scientific literature without well defined systematic criteria for how studies or outside review papers were identified, selected, or evaluated.”
Correction: In Appendix E-2 (http://1.usa.gov/1TSINT8), the Evidence Portfolios for the key topics addressed by Teicholz specify the search strategy, inclusion criteria, search results, and AMSTAR ratings for methodological quality for the existing systematic reviews (SR) and meta-analyses (MA).
________________________________________
2.) Teicholz states that “instead of requesting a new NEL review for the recent literature on this crucial topic, however, the 2015 committee recommended extending the current cap on saturated fats, at 10% of calories, based on a review by the AHA and ACC, a 2010 NEL review, and the committee’s ad hoc selection of seven review papers (see table A on thebmj.com).” Table A states that “no methodology for this section of the report: no reason given for why certain studies were selected for review and others were not, nor how they were evaluated relative to each other."
Correction: Appendix E-2.43 (http://1.usa.gov/1T4xQhf) gives the search strategy, inclusion criteria, search results, and AMSTAR ratings for methodological quality for the seven review papers, along with a list of excluded articles and the reasons for exclusion. (Note: In Table A (http://bit.ly/1IbW34R), Teicholz states that “the overall conclusion [of the 2012 Cochrane review by Hooper, et al.] is therefore that while saturated-fat restriction appears to reduce heart attack risk, it does not reduce overall or cardiovascular mortality (death), which is arguably the more important endpoint.” This statement contradicts Teicholz’s article, which said that Hooper, et al. “failed to confirm an association between saturated fats and heart disease.” The BMJ corrected this error a month after it was published.)
________________________________________
3.) Teicholz states that “use of external reviews by professional associations is problematic because these groups conduct literature reviews according to different standards and are supported by food and drug companies.”
Correction: The “problematic” external review cited by Teicholz was not conducted solely by professional associations. The review was actually a “clinical practice guideline” developed by the American Heart Association and the American College of Cardiology in partnership with the National Heart, Lung, and Blood Institute (http://1.usa.gov/1QsmJkx). The NHLBI’s website clearly describes its rigorous standards for assessing the quality of studies and its policy for managing potential conflicts of interest and relationships with industry.
________________________________________
4.) Teicholz states that “in the NEL systematic review on saturated fats from 2010…fewer than 12 small trials are cited, and none supports the hypothesis that saturated fats cause heart disease (see table B (http://bit.ly/1NAhzgp) on thebmj.com).”
Correction: It is incorrect to state that none of the trials cited in the 2010 NEL review supports the hypothesis that saturated fats cause heart disease. The 2010 NEL review found “strong evidence” that saturated fat intake increases the risk of cardiovascular disease. In Table B, Teicholz over-rules the 2010 NEL review by assigning each trial to one of four categories (a) “trials that should not have been included because they did not meet inclusion criteria,” (b) “trials that should not have been included because they did not test normally occuring [sic] saturated fats or saturated fats at all,” (c) “trials concluding that saturated fats had a neutrial [sic] or beneficial effect on health,” and (d) “trials with mixed results on blood lipid measures.” (Note: Table B has additional errors too numerous to list here.) Thus, Teicholz concludes that the 2010 NEL review is substandard, but she also argues that the 2015 “committee’s report used weak scientific standards,” because it did not rely sufficiently on NEL reviews.
________________________________________
5.) Teicholz states that “perhaps more important are the studies that have never been systematically reviewed by any of the dietary guideline committees. These include the large, government funded randomized controlled trials on saturated fats and heart disease from the 1960s and ’70s. Taken together, these trials followed more than 25 000 people, some for up to 12 years. They are some of the most ambitious, well controlled nutrition studies ever undertaken.”
Correction: It is incorrect to state that these trials were not reviewed by the DGAC. The DGAC considered a 2012 Cochrane review (http://1.usa.gov/1QsmUMV) that included 4 of the 6 trials cited by Teicholz and a 2010 meta-analysis (http://1.usa.gov/1ObAOT5) that included 5 of the 6 trials cited by Teicholz. (The review and meta-analysis both concluded that replacing saturated fats with unsaturated fats reduce the risk of heart disease.) One trial (http://1.usa.gov/1P9xgxO) cited by Teicholz is excluded from most meta-analyses because it tested a multifactorial intervention including drug treatment for hypertension, counseling for cigarette smoking, and dietary advice for lowering blood cholesterol levels.
________________________________________
6.) Teicholz states that “there have been at a minimum, three National Institutes of Health funded trials on some 50 000 people showing that a diet low in fat and saturated fat is ineffective for fighting heart disease, obesity, diabetes, or cancer. Two of these trials are omitted from the NEL review... When the omitted findings from these three clinical trials are factored into the review, the overwhelming preponderance of rigorous evidence does not support any of the dietary committee’s health claims for its recommended diets.”
Correction: The two trials (http://1.usa.gov/1Yllrfr; http://1.usa.gov/1ObAV0R) that were “omitted from the NEL review” did not assess the impact of diet “for fighting heart disease, obesity, diabetes, or cancer.” They assessed the impact of diet on serum cholesterol levels. Furthermore, all three trials were included in the Cochrane review that was considered by the DGAC.
________________________________________
7.) Teicholz states that “The report also gave a strong rating to the evidence that its recommended diets can fight heart disease.…The committee reviewed other, more recent studies but not using any systematic or predefined methods.”
Correction: Appendix E-2.26 (http://1.usa.gov/1QPWPFG) gives the search strategy, inclusion criteria, search results, and AMSTAR ratings for methodological quality for the six “more recent studies,” along with a list of excluded articles and the reasons for exclusion.
________________________________________
8.) In Table D, Teicholz includes sections (under “dietary patterns and heart disease” and “dietary patterns and obesity”) entitled “DGAC ad hoc review of the scientific literature” where she states that “no systematic methodology is given for the selection of these studies. It is therefore impossible to know if they fairly represent the literature.”
Correction: These were not ad hoc reviews. The DGAC details the systematic methodology for selecting these studies in Appendices E-2.26 (http://1.usa.gov/1QPWPFG) and E2.27 (http://1.usa.gov/1ObB18L). Note: Teicholz’s Table D (http://bit.ly/1MjPmbI) consists largely of Teicholz’s criticism of the NEL’s Systematic Reviews on the Relationship between Dietary Patterns and Health Outcomes (http://bit.ly/1O9YO2E), published in 2014. Note that Teicholz argues that NEL reviews are substandard, but she also argues that the 2015 “committee’s report used weak scientific standards,” because it did not rely sufficiently on NEL reviews.
________________________________________
9.) Teicholz states that “Consulting the NEL for a review on this topic turns up a surprising fact: a systematic review on health and red meat has not been done. Although several analyses look at ‘animal protein products,’ these reviews include eggs, fish, and dairy and therefore do not isolate the health effects of red meat, or meat of any kind.
Correction: The NEL reviews cited by Teicholz (http://bit.ly/1PbDr6r; http://bit.ly/1QvQwZj; http://bit.ly/1P9xzsh; http://bit.ly/1lUl6zy) do examine the results (http://bit.ly/1OzmYUM; http://bit.ly/1IX5DIR; http://bit.ly/1QvQH7d) on red meat and processed meats separately from the results on other animal proteins.
________________________________________
10.) Teicholz states that “The committee’s approach to the evidence on saturated fats and low carbohydrate diets reflects an apparent failure to address any evidence that contradicts what has been official nutritional advice for the past 35 years. The foundation of that advice has been to recommend eating less fat and fewer animal products (meat, dairy, eggs)while shifting calorie intake towards more plant foods (fruits, vegetables, grains, and vegetable oils) for good health. And in the past decades, this advice has remained virtually unchanged.”
Correction: The 2015 DGAC did not recommend “eating less fat” or reducing the consumption of eggs or dairy products. (In fact, Teicholz wrote in a February New York Times op-ed (http://nyti.ms/1IbWUCF) that “experts on the committee that develops the country’s dietary guidelines acknowledged that they had ditched the low-fat diet.”) The Dietary Guidelines for Americans has never recommended eating less meat or dairy products. (In some editions, the DGA has included advice such as “moderate your use of eggs” or “use egg yolks and whole eggs in moderation. Use egg whites and egg substitutes freely…”).
________________________________________
11.) Teicholz states that “studies showed mixed health outcomes for saturated fats, but early critical reviews, including one by the National Academy of Sciences, which cautioned against the inconclusive state of the evidence on saturated fats and heart disease, were dismissed by the USDA when it launched the first dietary guidelines in 1980.”
Correction: The USDA (and DHHS) published the 1980 Dietary Guidelines for Americans in February 1980. Toward Healthful Diets, the National Academy of Sciences report cited by Teicholz, was published in May 1980. USDA could not have dismissed Toward Healthful Diets, because the report was published after the Dietary Guidelines were released.
________________________________________
In summary, the Teicholz/BMJ “investigation” is based on non-facts. Such a paper has no place in the pages of a prominent scientific journal and should be retracted.
Sincerely,
Affiliations are listed for identification purposes only.
*Steven Abrams, MD
Chair of Pediatrics
Director, Dell Pediatric Research Institute
Dell Medical School
University of Texas at Austin
Austin, Texas, USA
*Lucile L. Adams-Campbell, PhD
Professor of Oncology
Associate Dean
Associate Director, Minority Health & Health Disparities Research
Georgetown University Medical Center
Washington, D.C., USA
*Cheryl Anderson, PhD, MPH
Associate Professor of Preventive Medicine
Department of Family and Preventive Medicine
School of Medicine
University of California, San Diego
La Jolla, California, USA
Lawrence J. Appel, MD, MPH
C. David Molina, MD, MPH Professor of Medicine Epidemiology and International Health
Director, Welch Center for Prevention, Epidemiology, and Clinical Research
Johns Hopkins Medical Institutions
Baltimore, Maryland, USA
Fernando Arós Borau, MD, PhD
Department of Cardiology
University Hospital of Araba
Vitoria, Spain
Alberto Ascherio, MD, DrPH
Professor of Epidemiology and Nutrition
Department of Nutrition
Harvard T.H. Chan School of Public Health
Professor of Medicine
Harvard Medical School
Boston, Massachusetts, USA
Guy De Backer, MD, PhD
Emeritus Professor in Public Health
Ghent University
Ghent, Belgium
Adam B. Becker, PhD, MPH
Executive Director
Consortium to Lower Obesity in Chicago Children
Chicago, Illinois, USA
Maira Bes-Rastrollo, PharmD, PhD
Associate Professor
Department of Preventive Medicine and Public Health
Faculty of Medicine
University of Navarra
Navarra, Spain
Henry Blackburn, MD
Professor Emeritus, Epidemiology & Community Health
Division of Epidemiology & Community Health
University of Minnesota
Minneapolis, Minnesota, USA
Marie-Christine Boutron-Ruault, MD, PhD
Medical Practitioner, Internist, and Gastroenterologist
Practitioner at Antoine Béclère University Hospital
Inserm Research Director
Head of INSERM UMR 1018
Clamart, France
*J. Thomas Brenna, PhD
Professor of Human Nutrition and of Chemistry
Cornell University
Ithaca, New York, USA
Ingeborg Brouwer, PhD
Professor of Nutrition for Healthy Living
Health Sciences
VU University Amsterdam
Amsterdam, The Netherlands
Kelly D. Brownell, PhD
Dean, Sanford School of Public Policy
Robert L. Flowers Professor of Public Policy
Professor of Psychology and Neuroscience
Duke University
Durham, North Carolina, USA
Aurora Bueno Cavanillas, MD, PhD
Professor of Preventive Medicine and Public Health
University of Granada
Granada, Spain
Pilar Buil-Cosiales, PhD, MD
Primary Health Care Practitioner
Servicio Navarro de Salud-Osasunbidea
National Health System
Navarra, Spain
Joanne Burke, PhD, RD, LD
Director of the University of New Hampshire Dietetic Internship
Thomas W. Haas Professor in Sustainable Food Systems
University of New Hampshire
Durham, New Hampshire, USA
Carlos A. Camargo, Jr., MD, DrPH
Professor of Medicine, Harvard Medical School
Professor of Epidemiology, Harvard School of Public Health
Boston, Massachusetts, USA
*Wayne Campbell, PhD
Professor, Department of Nutrition Science
Purdue University
West Lafayette, Indiana, USA
Raffaele De Caterina, MD, PhD
Professor and Chair of Cardiology
G. d’Annunzio University - Chieti-Pescara
Chieti, Italy
Alan Chait, MD
Edwin L. Bierman Professor of Medicine
Head, Division of Metabolism, Endocrinology & Nutrition
University of Washington
Seattle, Washington, USA
Jorge E. Chavarro, MD, ScD
Associate Professor of Nutrition and Epidemiology
Harvard T.H. Chan School of Public Health
Assistant Professor of Medicine
Harvard Medical School
Boston, Massachusetts, USA
*Steven K. Clinton, MD, PhD
John B. and Jane T. McCoy Chair of Cancer Research
The Ohio State University Comprehensive Cancer Center
Professor
Division of Medical Oncology
Department of Internal Medicine
The Ohio State University School of Medicine
Columbus, Ohio, USA
Isobel R. Contento, PhD
Mary Swartz Rose Professor of Nutrition and Education
Coordinator, Program in Nutrition
Faculty Director, Laurie M. Tisch Center for Food, Education & Policy
Department of Health and Behavior Studies
Teachers College Columbia University
New York, New York, USA
Dolores Corella, PhD
Professor, Preventive Medicine and Public Health
Genetic and Molecular Epidemiology Unit
School of Medicine
University of Valencia
Valencia, Spain
Patricia Crawford, DrPH
Senior Director of Research, Nutrition Policy Institute
Cooperative Extension Specialist
University of California Agriculture and Natural Resources
Berkeley, California, USA
Lidia A. Daimiel-Ruiz, PhD
Principal Investigator
Pabellón Central del Antiguo Hospital de Cantoblanco
University de Cantoblanco
Madrid, Spain
Richard J. Deckelbaum, MD, CM, FRCPC
Robert R. Williams Professor of Nutrition
Professor of Pediatrics
Professor of Epidemiology
Director, Institute of Human Nutrition
College of Physicians and Surgeons
Columbia University Medical Center
New York, New York, USA
Jean-Pierre Després, PhD, FAHA, FIAS
Scientific Director
International Chair on Cardiometabolic Risk
Professor, Department of Kinesiology
Faculty of Medicine, Université Laval
Director of Research, Cardiology
Québec Heart and Lung Institute
Québec, Canada
William Dietz, MD, PhD
Director, Sumner M. Redstone Global Center for Prevention and Wellness
Milken Institute School of Public Health
George Washington University
Washington, D.C., USA
Deirdre A. Dingman, DrPH, MPH, CHES
Postdoctoral Fellow
Public Health Law Research
Temple University
Philadelphia, Pennsylvania, USA
Ligia J. Dominguez, MD
Geriatric Unit
University of Palermo
Palermo, Italy
Ana Clara Duran, MS, PhD
Postdoctoral Research Fellow
University of Illinois, Chicago
Chicago, Illinois, USA
Ibrahim Elmadfa, PhD
Emeritus Professor of Nutrition
University of Vienna
Vienna, Austria
Javier Díez Espino, MD, PhD
Primary Care Manager
Servicio Navarro de Salud-Osasubidea
Navarra, Spain
Ramon Estruch, MD, PhD
Department of Internal Medicine
Hospital Clinic, University of Barcelona
Barcelona, Spain
Alejandro Fernández-Montero, MD, PhD
Project Director, “Healthy Diet, It’s up to you”
Department of Prevention of Occupational Hazards
University of Navarra-IDISNA
Navarra, Spain
Oscar H. Franco, MD, PhD, FESC, FFPH
Professor of Preventive Medicine
PI Cardiovascular Epidemiology group
Director ErasmusAGE
CEO Erasmus Epidemiology Resources
Deputy Science Director NIHES
Department of Epidemiology
Erasmus MC, University Medical Center Rotterdam
Rotterdam, The Netherlands
Gary E. Fraser, MD, PhD
Professor of Epidemiology
Loma Linda University
Loma Linda, California, USA
Itziar Zazpe Garcia, PhD, RD
Professor
Department of Clinical Science and Physiology
Universidad de Navarra
Navarra, Spain
Christopher Gardner, PhD
Professor of Medicine
Director of Nutrition Studies
Director of NIH/NHLBI Postdoctoral Training Program
Stanford Prevention Research Center
Palo Alto, California, USA
Alfredo Gea, PhD
Assistant Professor
Department of Preventive Medicine & Public Health
University of Navarra, Spain
Navarra, Spain
Angel Gil, PhD
President of the Iberoamerican Nutrition Foundation (FINUT)
Full Professor Department of Biochemistry and Molecular Biology II
Institute of Nutrition and Food Technology
Centre of Biomedical Research
University of Granada
Granada, Spain
David C. Goff, Jr., MD, PhD
Dean
Colorado School of Public Health
Aurora, Colorado, USA
Carlos A. González, MD, PhD
Unit of Nutrition and Cancer (Emeritus)
Cancer Epidemiology Research Programme
Catalan Institute of Oncology (ICO)
Barcelona, Spain
Teresita González de Cosío, PhD, MSc
Directora de Departamento de Salud
Universidad Iberoamericana
Mexico City, Mexico
Michael I. Goran, PhD
Director, Childhood Obesity Research Center
Co-Director, USC Diabetes and Obesity Research Institute
Professor of Preventive Medicine; Physiology & Biophysics; and Pediatrics
The Dr. Robert C. & Veronica Atkins Chair in Childhood Obesity & Diabetes
USC Keck School of Medicine
Los Angeles, California, USA
Antonio M. Gotto Jr., MD, DPhil
Professor of Medicine
Provost for Medical Affairs and Dean Emeritus Weill Cornell Medical College
New York, New York, USA
Philip Greenland, MD
Harry W. Dingman Professor
Department of Preventive Medicine
Northwestern University Feinberg School of Medicine
Chicago, Illinois, USA
Joan Gussow, EdD
Mary Swartz Rose Professor Emerita of Nutrition Education
Teachers College
Columbia University
New York, New York, USA
Michael W. Hamm, PhD
C.S. Mott Professor of Sustainable Agriculture
Director, Center for Regional Food Systems
Departments of CSUS, PSM, FSHN
Michigan State University
East Lansing, Michigan, USA
Carole V. Harris, PhD
Vice President, Public Health and Survey Research Division
ICF International
Atlanta, Georgia, USA
Serge Hercberg, MD, PhD
Chef d'équipe - Equipe de Recherche en Epidémiologie Nutritionnelle (EREN)
Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité
Université Paris
Bobigny, France
*Frank B. Hu, MD, PhD
Professor of Nutrition and Epidemiology
Harvard T.H. Chan School of Public Health
Professor of Medicine
Harvard Medical School
Boston, Massachusetts, USA
Rod Jackson, MBChB, PhD
Professor of Epidemiology
Faculty of Medical and Health Sciences
University of Auckland
Auckland, New Zealand
David Jacobs, PhD
Professor, Division of Epidemiology & Community Health
School of Public Health
University of Minnesota
Minneapolis, Minnesota, USA
Michael F. Jacobson, PhD
President
Center for Science in the Public Interest
Washington, D.C., USA
Philip T. James, CBE, MD, DSc
Honorary Professor of Nutrition
London School of Hygiene
London, United Kingdom
David Jenkins, MD, PhD, DSc
Professor, Canada Research Chair in Nutrition and Metabolism
Department of Nutritional Sciences
Director, Risk Factor Modification Centre, St. Michael’s Hospital
University of Toronto
Toronto, Canada
Laura Johnson, PhD
Lecturer in Public Health Nutrition
Centre for Exercise, Nutrition and Health Sciences
School for Policy Studies
University of Bristol
Bristol, United Kingdom
Martijn B. Katan, PhD
Emeritus Professor of Nutrition
VU University Amsterdam
Department of Health Sciences
Amsterdam, The Netherlands
David Katz, MD, MPH, FACPM, FACP
Director, Yale University Prevention Research Center
President, American College of Lifestyle Medicine
Founder, True Health Initiative
New Haven, Connecticut, USA
George A. Kelley, DA, FACSM
Professor & Director, Meta-Analytic Research Group
School of Public Health
Department of Biostatistics
Co-Director, WVCTSI Clinical Research Design, Epidemiology, and Biostatistics Program
West Virginia University
Morgantown, West Virginia, USA
Thomas Kelly, PhD, MA
Chief Sustainability Officer/Director
Sustainability Institute
University of New Hampshire
Durham, New Hampshire, USA
Emmanuelle Kesse-Guyot, PhD
Research Director
COMUE Sorbonne-Paris-Cité
Equipe de Recherche en Epidémiologie Nutritionnelle (EREN)
Centre d’Epidémiologie et Biostatistiques Paris Nord
Institute for Health and Medical Research (Inserm, U1153)
Institut National de la Recherche Agronomique (INRA, U1125)
Conservatoire National des Arts et Métiers (CNAM)
Paris 13 University
Paris, France
Kay-Tee Khaw, MD, MSc, PhD
University of Cambridge School of Clinical Medicine
Clinical Gerontology Unit
Addenbrooke’s Hospital
Cambridge, United Kingdom
Vivica I. Kraak, PhD, RD
Assistant Professor of Food and Nutrition Policy
Department of Human Nutrition, Foods & Exercise
Virginia Tech
Blacksburg, Virginia, USA
Fernanda Kroker, MSc, PhD
Scientific Researcher
Population Nutrition
Institute of Nutrition of Central America and Panama -INCAP-
Guatemala City, Guatemala
Daan Kromhout, PhD, MPH
Emeritus Professor
Division of Human Nutrition
Wageningen University
Wageningen, The Netherlands
Lewis H. Kuller, MD, DrPH
Department of Epidemiology
Graduate School of Public Health
University of Pittsburgh
Pittsburgh, Pennsylvania, USA
Larry Kushi, ScD
Director of Scientific Policy
Kaiser Permanente
Oakland, California, USA
Darwin R. Labarthe, MD, MPH, PhD
Professor of Preventive Medicine
Northwestern University Feinberg School of Medicine
Chicago, Illinois, USA
Rosa M. Lamuela-Raventos, PhD
Associate Professor
Department of Nutrition and Food Science
School of Pharmacy, University of Barcelona
Barcelona, Spain
Robert S. Lawrence, MD
Director, Center for a Livable Future
Professor of Environmental Health Sciences and International Health
Johns Hopkins Bloomberg School of Public Health
Baltimore, Maryland, USA
Sally Ann Lederman, PhD
Special Lecturer
Institute of Human Nutrition
Columbia University
New York, New York, USA
Allen S. Levine, PhD
Professor, Food Science and Nutrition
University of Minnesota
Minneapolis, Minnesota, USA
Elyse Levine, PhD, RD
Associate
Booz Allen Hamilton
Rockville, Maryland, USA
David A. Levitsky, PhD, MPhil, MS
Stephen H. Weiss Presidential Fellow
Professor of Nutrition and Psychology
Cornell University
Ithaca, New York, USA
Barry Lewis, MD, PhD, FRCP, FRCPath
Emeritus Professor
University of London
London, United Kingdom
*Alice Lichtenstein, DSc
Senior Scientist and Director
Cardiovascular Nutrition Laboratory
Jean Mayer USDA Human Nutrition Research Center on Aging
Professor of Medicine
Tufts University School of Medicine
Boston, Massachusetts, USA
Bonnie F. Liebman, MS
Director of Nutrition
Center for Science in the Public Interest
Washington, D.C., USA
Esther Lopez-Garcia, PhD, MPH
Associate Professor
Department of Preventive Medicine and Public Health
School of Medicine
Universidad Autónoma de Madrid
Madrid, Spain
José López Miranda, MD, PhD
Catedrático de Medicina Interna
Vicedecano de Asuntos Hospitalarios
Director UGC Medicina Interna
Hospital Universitario Reina Sofia
Facultad de Medicina
Universidad de Cordoba
Cordoba, Spain
Vasanti Malik, ScD
Research Scientist
Harvard T.H. Chan School of Public Health
Boston, Massachusetts, USA
Mario Mancini, MD
Emeritus Professor
University of Naples
Naples, Italy
James Mann, MD
Professor, Human Nutrition and Medicine
Dunedin School of Medicine
University of Otago
Otago, New Zealand
JoAnn E. Manson, MD, DrPH
Professor of Medicine
Michael and Lee Bell Professor of Women's Health
Harvard Medical School
Professor, Department of Epidemiology
Harvard T.H. Chan School of Public Health
Chief, Division of Preventive Medicine
Brigham and Women's Hospital
Boston, Massachusetts, USA
Barrie Margetts, PhD, FFPH, MSc
Professor Emeritus of Medicine
University of Southampton
Southampton, United Kingdom
Miguel A. Martinez-Gonzalez, MD, PhD, MPH
Chair, Department of Public Health
University of Navarra-CIBEROBN
Navarra, Spain
J. Alfredo Martinez Hernandez, D.Pharm, MD, PhD
Professor
Department of Nutrition, Food Science, Physiology and Toxicology
School of Pharmacy
University of Navarra
Navarra, Spain
William McCarthy, PhD
Adjunct Professor
UCLA Fielding School of Public Health
Department of Health Policy and Management
Los Angeles, California, USA
*Barbara Millen, DrPH, RD
Founder and President
Millennium Prevention, Inc.
Westwood, Massachusetts, USA
Nana Gletsu Miller, PhD
Assistant Professor
Department of Nutrition Science
College of Health and Human Sciences
Purdue University
West Lafayette, Indiana, USA
Marc Molendijk, PhD
Assistant Professor Clinical Psychology
Leiden University and Leiden University Medical Center
Leiden, The Netherlands
Carlos A. Monteiro, MD, PhD
Professor of Nutrition and Public Health
Department of Nutrition, School of Public Health
University of Sáo Paulo
Sáo Paulo, Brazil
Roni Neff, PhD, MS
Assistant Professor, Environmental Health Sciences
Bloomberg School of Public Health
Program Director, Food System Sustainability
Center for a Livable Future
Johns Hopkins University
Baltimore, Maryland, USA
*Miriam Nelson, PhD
Associate Dean, Tisch College of Citizenship and Public Service
Professor, Friedman School of Nutrition Science and Policy
Tufts University
Boston, Massachusetts, USA
*Marian L. Neuhouser, PhD, RD
Full Member, Cancer Prevention Program
Division of Public Health Sciences
Fred Hutchinson Cancer Research Center
Seattle, Washington, USA
Kaare R. Norum, MD, PhD
Professor Emeritus
Department of Nutrition
Faculty of Medicine
University of Oslo
Oslo, Norway
Angeliki Papadaki, PhD, MSc, FHEA
Lecturer in Public Health Nutrition
Programme Director, MSc Nutrition, Physical Activity and Public Health
Centre for Exercise, Nutrition and Health Sciences
School for Policy Studies
University of Bristol
Bristol, United Kingdom
Diana C. Parra, PhD, PT, MPH
Assistant Professor
Program in Physical Therapy and Department of Surgery (Prevention)
Scholar, Institute for Public Health
Washington University School of Medicine
St. Louis, Missouri, USA
Jan I. Pedersen, MD, PhD
Emeritus Professor
Department of Nutrition
Institute of Basic Medical Sciences
University of Oslo
Oslo, Norway
*Rafael Perez-Escamilla, PhD
Professor of Epidemiology and Public Health
Director, Office of Public Health Practice
Director, Global Health Concentration
Yale School of Public Health
New Haven, Connecticut, USA
Francisco Perez-Jimenez, MD, PhD
Full Professor of Internal Medicine
Reina Sofia University Hospital
University of Cordoba
Cordoba, Spain
F. Xavier Pi-Sunyer, MD
Professor of Medicine
Institute of Human Nutrition
Columbia University
New York, New York, USA
María Puy Portillo, DPharm
Professor of Nutrition
Director, Nutrición y Obesidad
Department of Pharmacy and Food Science
University of the Basque Country
Bilbao, Spain
John D. Potter, MD, PhD
Senior Advisor, Public Health Sciences Division
Fred Hutchinson Cancer Research Center
Seattle, Washington, USA
Neil Poulter, MD
Professor of Preventive Cardiovascular Medicine
Imperial College
London, United Kingdom
Pekka Puska, MD, PhD, MPolSc
Professor, National Institute for Health and Welfare (THL), Finland
Past President, World Heart Federation (WHF)
Past President, International Association of National Public Health Institutes
Helsinki, Finland
Kalevi Pyörälä, MD
Emeritus Professor of Medicine
University of Eastern Finland
Kuopio, Finland
Tim Radak, DrPH, MPH, RD
Academic Coordinator for DrPH and PhD Public Health Programs
College of Health Sciences
Walden University
Minneapolis, Minnesota, USA
Sujatha Rajaram, PhD
Chair, SPH Doctoral Committee
Program Director, DrPH in Nutrition
School of Public Health
Loma Linda University
Loma Linda, California, USA
Mike Rayner, DPhil
Professor of Population Health
Director, British Heart Foundation Centre on Population Approaches for Non-Communicable Disease Prevention
Nuffield Department of Population Health
University of Oxford
Oxford, United Kingdom
Cristina Razquin Burillo, PhD
Colaborador de investigación
Department of Preventive Medicine and Public Health
School of Medicine
University of Navarra
Navarra, Spain
Bill Reger-Nash, EdD
Professor Emeritus
West Virginia University School of Public Health
Associate Chair, Morgantown Pedestrian Safety Board
Morgantown, West Virginia, USA
Shaun Riebl, PhD, RDN, LDN
Clinical Assistant Professor
The University of North Carolina at Chapel Hill
Gillings School of Global Public Health and UNC School of Medicine
Department of Nutrition
Department of Medicine - Division of Nephrology and Hypertension
UNC Hospitals Kidney and Hypertension Specialty Clinic
Chapel Hill, North Carolina, USA
Eric Rimm, ScD
Professor of Medicine
Harvard Medical School
Channing Division of Network Medicine, Brigham and Women's Hospital
Professor of Epidemiology and Nutrition
Director, Program in Cardiovascular Epidemiology
Harvard T.H. Chan School of Public Health
Boston, Massachusetts, USA
Ulf Risérus, MMED, PhD
Associate Professor in Clinical Nutrition
Department of Public Health and Caring Sciences
Clinical Nutrition and Metabolism
Faculty of Medicine, Uppsala University
Uppsala, Sweden
Lorrene Ritchie, PhD, RD
Director, Nutrition Policy Institute
Cooperative Extension Specialist
University of California Agriculture and Natural Resources
Berkeley, California, USA
Juan Rivera Dommarco, PhD, MS
Director
Center for Research in Nutrition and Health
Instituto Nacional de Salud Publica
Cuernavaca, Mexico
Kim Robien, PhD, RD, CSO, FAND
Associate Professor
Department of Exercise and Nutrition Sciences
Department of Epidemiology and Biostatistics
Milken Institute School of Public Health
George Washington University
Washington, D.C., USA
Fernando Rodríguez-Artalejo, MD, PhD
Professor of Preventive Medicine and Public Health
School of Medicine
Universidad Autónoma de Madrid
Madrid, Spain
Dora Romaguera, MSc, PhD
Institut d’Investigació Sanitària de Palma (IdISPa) and CIBER-OBN
Hospital Universitari Son Espases, Unitat de Recerca
Palma de Mallorca, Spain
Emilio Ros, MD, PhD
Former Director, Lipid Clinic
Endocrinology & Nutrition Service
Hospital Clínic
CIBERobn, ISCIII, Spain
Barcelona, Spain
Donald (Diego) Rose, PhD, MPH
Professor and Head of Nutrition Section
School of Public Health and Tropical Medicine
Tulane University
New Orleans, Louisiana, USA
Miguel Ruiz-Canela, PhD, MPH
Associate Professor
Department of Preventive Medicine and Public Health
University of Navarra
Navarra, Spain
Joan Sabaté, MD, DrPH
Professor of Nutrition
School of Public Health
Loma Linda University
Loma Linda, California, USA
Frank Sacks, MD, ScB
Professor of Cardiovascular Disease Prevention
Department of Nutrition
Harvard T.H. Chan School of Public Health
Boston, Massachusetts, USA
Guillermo Saez Tormo, MD, PhD
Department of Biochemistry and Molecular Biology
Coordinator for International Relations and Mobility Programs
Faculty of Medicine and Odontology
Service of Clinical Analysis
University Hospital Doctor Peset Aleixandre
University of Valencia
Valencia, Spain
Jordi Salas-Salvadó, MD, PhD
Professor of Nutrition
Director, Human Nutrition Unit
Department of Biochemistry & Biotechnology, IISPV
School of Medicine
Rovira i Virgili University
CIBERobn, Instituto Carlos III
Director, Centre Català de la Nutrició - Institut d'Estudis Catalans
Past President, Federation of Spanish Food, Nutrition and Dietetic Scientific Societies
Director, Red Iberoamericana RIBESMET
Chairman, INC - World Forum for Nutrition Research and Dissemination
Reus, Spain
Almudena Sánchez-Villegas, PhD
Associate Professor of Preventive Medicine and Public Health
Department of Clinical Sciences
Universidad de las Palmas de Gran Canaria
Las Palmas, Spain
Wim H.M. Saris, MD, PhD
Professor of Human Nutrition
Department of Human Biology
NUTRIM: School of Nutrition and Translational Research
Maastricht University Medical Centre
Maastricht, The Netherlands
Dennis Savaiano, PhD, MS
Virginia C. Meredith Professor
Director, North Central Nutrition Education Center
Department of Nutrition Science
Purdue University
West Lafayette, Indiana, USA
Matthias B. Schulze, DrPH
German Institute of Human Nutrition
Department of Molecular Epidemiology
Nuthetal, Germany
Ursula Schwab, PhD
Associate Professor, Nutrition Therapy
Department of Public Health and Clinical Nutrition
School of Medicine
University of Eastern Finland, Kuopio Campus
Kuopio, Finland
Marlene B. Schwartz, PhD
Director
Rudd Center for Food Policy and Obesity
University of Connecticut
Storrs, Connecticut, USA
Jacob C. Seidell, PhD
Professor of Nutrition and Health/University Professor
VU University Amsterdam
Amsterdam, The Netherlands
Lluis Serra-Majem, MD, MSc, PhD
Professor of Public Health
Director, Public Health Nutrition Research Center, University of Barcelona
President, Nutrition Without Borders
University of Gran Canaria
Gran Canaria, Spain
A. G. Shaper, FRCP, FRCPath, FFPHM
Ex-director, British Regional Heart Study
University College of London
London, United Kingdom
*Anna Maria Siega-Riz, PhD
Professor of Epidemiology and Nutrition
Associate Dean for Academic Affairs
Gillings School of Global Public Health
Chapel Hill, North Carolina, USA
Jeremiah Stamler, MD
Professor Emeritus, Preventive Medicine and Epidemiology
Northwestern University Feinberg School of Medicine
Chicago, Illinois, USA
Meir Stampfer, MD, DrPH
Professor of Medicine, Harvard Medical School
Professor of Epidemiology and Nutrition, Harvard T.H. Chan School of Public Health
Associate Director, Channing Division of Network Medicine
Department of Medicine, Brigham and Women's Hospital
Boston, Massachusetts, USA
Rosemary Stanton, PhD, OAM
Visiting Fellow
School of Medical Sciences
University of New South Wales
Sydney, Australia
Marie-Pierre St.-Onge, PhD, FAHA
Assistant Professor, Department of Medicine
New York Obesity Research Center
Institute of Human Nutrition
College of Physicians & Surgeons
Columbia University
New York, New York, USA
*Mary Story, PhD, RD
Professor of Global Health and Community and Family Medicine
Duke University
Durham, North Carolina, USA
Boyd Swinburn, MBChB, MD, FRACP, FNZCPHM
Professor of Population Nutrition and Global Health
University of Auckland
Alfred Deakin Professor
Deakin University, Melbourne
Melbourne, Australia
Daniel R. Taber, PhD, MPH
Assistant Professor
Department of Health Promotion & Behavioral Sciences
University of Texas School of Public Health
Austin, Texas, USA
Lindsey Smith Taillie, PhD, MPH
Research Assistant Professor, Department of Nutrition
Fellow, Carolina Population Center
University of North Carolina at Chapel Hill
Chapel Hill, North Carolina, USA
Linda Tapsell, PhD, FDAA, AM
Discipline Leader, Nutrition and Dietetics
Graduate School of Medicine
Faculty of Science, Medicine and Health
University of Wollongong
Wollongong, Australia
Cynthia Thomson, PhD, RD
Professor, Health Promotion Sciences
Director, University of Arizona Canyon Ranch Center for Prevention & Health Promotion
Mel & Enid Zuckerman College of Public Health
University of Arizona
Tucson, Arizona, USA
Estefania Toledo, MD, PhD, MPH
Associate Professor
University of Navarra
Navarra, Spain
Mathilde Touvier, PhD, HDR
Centre de Recherche en Epidémiologie et Statistiques Sorbonne Paris Cité
Equipe de Recherche en Epidémiologie Nutritionnelle
Universités Paris 5, 7 et 13
Bobigny Cedex, France
Alison Tovar, PhD, MPH
Assistant Professor
Department of Nutrition and Food Sciences
University of Rhode Island
Kingston, Rhode Island, USA
Antonia Trichopoulou, MD
Emeritus Professor, Nutritional Epidemiology
University of Athens Medical School
Athens, Greece
Josep A. Tur, PhD
Professor of Physiology
Research Group on Community Nutrition & Oxidative Stress
University of the Balearic Islands & CIBERobn CB12/03/30038
Palma de Mallorca, Spain
Matti Uusitupa, MD, PhD
Professor Emeritus
Institute of Public Health and Clinical Nutrition
University of Eastern Finland
Kuopio, Finland
Linda Van Horn, PhD, RD
Professor, Preventive Medicine
Associate Dean for Faculty Development
Feinberg School of Medicine
Northwestern University
Chicago, Illinois, USA
Carlo La Vecchia, MD
Professor of Medical Statistics and Epidemiology
Department of Clinical Sciences and Community Health
Università degli Studi di Milano
Milan, Italy
Jesus Vioque, MD, PhD, MPH
Unidad de Epidemiología de la Nutrición
Campus San Juan. Facultad de Medicina
Universidad Miguel Hernandez
Alicante, Spain
David Wallinga, MD
Senior Health Officer
Natural Resources Defense Council
San Francisco, California, USA
May Wang, DrPH
Professor, Community Health Sciences
Fielding School of Public Health
University of California, Los Angeles
Los Angeles, California, USA
Connie M. Weaver, PhD
Distinguished Professor and Department Head
Department of Nutrition Science
Director, Women's Global Health Institute
Purdue University
West Lafayette, Indiana, USA
Howell Wechsler, EdD, MPH
Chief Executive Officer
Alliance for a Healthier Generation
Washington, D.C., USA
Elisabete Weiderpass, MD, PhD, MSc
Professor of Cancer Epidemiology, Department of Community Medicine, Faculty of Health Sciences, University of Tromsø, The Arctic University of Norway
Tromsø, Norway
Senior Cancer Epidemiologist, Department of Etiological Cancer Research, Cancer Registry of Norway
Oslo, Norway
Professor of Medical Epidemiology, Department of Medical Epidemiology and Biostatistics, Karolinska Institutet
Stockholm, Sweden
Group Leader, Genetic Epidemiology Group, Folkhälsan Research Center
Helsinki, Finland
Shelley Weinstock, PhD, CNS, FACN
Career Services
Institute of Human Nutrition
Columbia University
New York, New York, USA
Emily Welker, MPH, RD
Program Coordinator
Healthy Eating Research
Duke Global Health Institute
Duke University
Durham, North Carolina, USA
Paul Whelton, MD, MSc
Show Chwan Professor of Global Public Health
Tulane University School of Public Health and Tropical Medicine
New Orleans, Louisiana, USA
Walter Willett, MD, DrPH, MPH
Frederick John Stare Professor of Epidemiology and Nutrition
Chair, Department of Nutrition
Harvard T.H. Chan School of Public Health
Professor, Department of Medicine
Harvard Medical School
Boston, Massachusetts, USA
Alicja Wolk, DMSc
Professor of Nutritional Epidemiology
Vice-chairman, Institute of Environmental Medicine
Head, Division of Nutritional Epidemiology
Karolinska Institutet
Stockholm, Sweden
Jayne Woodside, PhD
Nutrition and Metabolism Group
Centre for Public Health
Belfast, United Kingdom
Kana Wu, MD, PhD
Senior Research Scientist
Department of Nutrition
Harvard T.H. Chan School of Public Health
Boston, Massachusetts, USA
Lisa R. Young, PhD, RD
Adjunct Professor of Nutrition
New York University
New York, New York, USA
*2015 Dietary Guidelines Advisory Committee member
Graduate Students
Christina Chauvenet, MSc
Doctoral Student
Maternal and Child Health
Royster Fellow
University of North Carolina Gillings School of Public Health
Chapel Hill, North Carolina, USA
Cesar Octavio Ramos Garcia, MHN, CN
Doctoral Student in Public Health Sciences
Director of Nutrition
Tonala University Center
University of Guadalajara
Guadalajara, Mexico
Alexandra B. Morshed
Doctoral Student
Brown School
Washington University
St. Louis, Missouri, USA
Taulant Muka, MD, MSc, DSc
PhD Candidate, Erasmus MC, The Netherlands
Visiting Researcher at Harvard School of Public Health
Boston, Massachusetts, USA
Luis A. Rodríguez, MPH, RD, CNSC
Doctoral Student, Epidemiology & Translational Sciences
UCSF School of Medicine
Pediatric Clinical Dietitian, UCSF Benioff Children's Hospital
San Francisco, California, USA
Christian Wright, MS
Doctoral Candidate
Department of Nutrition Science
Laboratory of Nutrition, Fitness, and Aging
NSGSO President
Purdue University
West Lafayette, Indiana, USA
Competing interests: Please see attachment.
Response by Nina Teicholz
I’m delighted that The BMJ has stood by this article and decided against retraction. Two outside reviewers judged that the criticisms of the piece did not merit its retraction, and in the end, the corrections made by The BMJ do not, in my view, materially undermine any of the article’s key claims. This article therefore stands as one of the most serious ever, peer-reviewed critiques of the expert report for the US Dietary Guidelines for Americans (DGAs).
The importance of the DGAs, and therefore of this article, should not be understated (and indeed was recognized by many in the mainstream media when the article was published). The DGAs have long been considered the “gold standard,” informing the US food supply, military rations, US government feeding assistance programs such as the National School Lunch Program which are, altogether, consumed by 1 in 4 Americans each month, as well as the guidelines of professional societies and governments around the world, and eating habits generally.
Yet rates of obesity began to shoot upwards in the very year, 1980, that the DGAs were introduced, and the diabetes epidemic began soon thereafter. A critically important yet little understood issue is why the DGAs have failed, so spectacularly, to safeguard health from the very nutrition-related diseases that they were supposed to prevent.
In documenting fundamental failures in the science behind the DGAs, this article offers new insights; It establishes that a vast amount of nutrition science funded by the National Institutes of Health and other governments worldwide has, for decades, been systematically ignored or dismissed, and that therefore, that the DGAs are not based on a comprehensive reviews of the most rigorous science. Incorporating this long-ignored relevant science would likely lead to fundamentally different DGAs and could very well be an important step in infusing them with the power to better fight the nutrition-related diseases.
A fundamental question is why 170+ researchers (including all the 2015 DGA committee members, or “DGAC”), organized by the advocacy group, the Center for Science in the Public Interest (CSPI), would sign a letter asking for retraction. After all, in the weeks following publication, any person had the opportunity to submit a “Rapid Response” to the article, and both CSPI and the DGAC did so, alleging many errors. I responded to them all in my Rapid Response. This is the normal post-publication process.
Yet after all this, CSPI returned for a second round of criticisms, recycling two of the issues (CSPI points #3 and #10) that I had already addressed in my Rapid Response (and which had required no correction), adding another 9 (one of which, #4, contained no challenge of fact), and demanding that based on these alleged errors, the article be retracted. CSPI then circulated this letter widely to colleagues and asked them to sign on.
This lack of substance in the retraction effort seems to point to the reality that it was first and foremost an act of advocacy—a heavy handed attempt to silence arguments with which CSPI, a longtime supporter of the Dietary Guidelines and its allies disagree.[ footnote 1] And this applies not just to the retraction letter but to other CSPI efforts to stifle alternative viewpoints. Earlier this year, for example, I was dis-invited from the National Food Policy Conference after CSPI, together with the USDA official in charge of the Dietary Guidelines, threatened to withdraw if I were included, details of which are reported here and which a Spiked columnist called an act of “censorship.”
It’s important to note that I am not the only person disturbed by the lack of rigorous science underpinning our dietary guidelines. Numerous scientists around the world have expressed concern about the science. And indeed, this consternation is shared by no less than the US Congress, which held a hearing on Oct 7, 2015 to address its serious doubts about the DGAs. Such was this concern that last year that Congress mandated the first-ever major peer-review of the DGAs, by the National Academy of Medicine. Congress appropriated $1 million for this review, and it additionally stipulated that all members of the 2015 DGA committee recuse themselves from the process.
What is the dangerous information challenging the DGAs that cannot be heard on a conference panel nor published in a peer-reviewed journal?
The major findings of this article are that:
1. The DGAC’s finding that the evidence of a “strong” link between saturated fats and heart disease was not clearly supported by the evidence cited. (Note that as of last year, the Heart and Stroke Foundation of Canada no longer limits saturated fats. Note, also, that Frank Hu, the Harvard epidemiologist in charge of the DGAC review on saturated fats, was an energetic promoter of the retraction letter against my article that critiqued his review, according to emails obtained through FOIA requests);
2. Successive DGA committees have for decades ignored or dismissed a large body of rigorous (randomized controlled trial) literature on the low-fat diet, on more than 50K subjects, collectively finding that this diet is ineffective for fighting obesity, diabetes, heart disease or any kind of cancer;
3. Although the DGAs have for decades recommended avoiding saturated fats and cholesterol to prevent heart disease, no DGA committee has ever directly reviewed the enormous body of rigorous (government-funded, randomized controlled trials) evidence, testing more than 25,000 people, on this hypothesis. Many reviews of this data have concluded that saturated fats have no effect on cardiovascular mortality;
4. The DGAC ignored a large body of scientific literature on low-carbohydrate diets (including several “long term” trials, of 2-years duration) demonstrating that these diets are safe and highly effective for combatting obesity, diabetes, and heart disease;
5. The Nutrition Evidence Library (NEL) set up by USDA to do systematic reviews of the science did not meet its own standards for its review of saturated fats in 2010;
6. Although the DGAC is supposed to consult the NEL to conduct systematic reviews of the science, the 2015 DGAC did so for only 67% of the questions that required systematic reviews;
7. For a number of key reviews, the 2015 DGAC relied on work done in part by the American Heart Association and the American College of Cardiology, which are private associations supported by industry and therefore have a potential conflict of interest;
8. The DGAs, for the first time, introduce the “vegetarian diet” as one of its three, recommended “Dietary Patterns,” yet a NEL review of this diet concluded that the evidence for this its disease-fighting powers is only “limited,” which is the lowest rank of evidence assigned for available data;
9. The DGA’s three recommended “Dietary Patterns” are supported by only limited evidence. The NEL review found only “limited” or “insufficient” evidence that the diets could combat diabetes and only “moderate” evidence that the diets can help people lose weight. The report also gave a strong rating to the evidence that its recommended diets can fight heart disease, yet here, several studies are presented, but none unambiguously supports this claim. In conclusion, the recommended diets are supported by only a small quantity of rigorous evidence that only marginally supports claims that these diets can promote better health than alternatives;
10. The DGA process does not require committee members to disclose conflicts of interest and also that, for the first time, the committee chair came not from a university but from industry;
11. The 2015 DGAC conducted a number of reviews in ways that were not systematic. This allowed for the potential introduction of bias (e.g., cherry picking of the evidence).
This last claim, on the systematic nature of the DGAC reviews, is the subject of the corrections published in The BMJ this week, and refer to CSPI points #1, #2, #7, and #8 (two of which are statements in the text and two of which are in the supporting tables). I am grateful to have had the opportunity to work with The BMJ on developing this notice.
The BMJ has placed a word limit on my response. For the rest of this comment, please see: http://thebigfatsurprise.com/comment-bmj-correction-notice/
Footnote 1
CSPI has fought for decades to eliminate saturated fats from the American food supply (so much so, that throughout the late 1980s, CSPI advocated for replacing saturated fats with trans fats and succeeded in driving up consumption of trans fats to historic levels, as described in The Big Fat Surprise, pp.227-228). CSPI has also long advocated for shifting away from animal foods containing saturated fats, towards a plant-based diet based on grains and industrial vegetable oils. The researchers who joined CSPI in signing the letter are largely adherents to this view; many have participated in generating the science that has been used to support the hypothesis that fat and cholesterol cause heart disease, and it is upon this hypothesis that the Guidelines have been based.
Competing interests: I have read and understood BMJ policy on declaration of interests and declare that I am the author of The Big Fat Surprise (Simon & Schuster, 2014), on the history, science, and politics of dietary fat recommendations. I have received modest honorariums for presenting my research findings presented in the book to a variety of groups related to the medical, restaurant, financial, meat, and dairy industries. I am also a board member of a non-profit organization, the Nutrition Coalition, dedicated to ensuring that nutrition policy is based on rigorous science.