Re: Challenge for Peter Banks

["Peter Banks" <pbanks@diabetes.org>]

Dr. Feinman:

You sate that health agencies are not directing patients to the relevant
literature and giving them access to data that may conflict with their own
position.

Untrue, in ADA's case. We strive to make patients aware of the latest in
nutritional research, whatever the conclusions of the research.

See, for example, the patient INFORM section on diabetes.org, which gives
patients access to the primary literature. 

See http://www.diabetes.org/diabetes-research/summaries/nutrition.jsp for
the section on nutrition.

Included here are summaries of papers which either support a higher
protein/lower carbohydrate approach to dietiing, among them this paper,
which showed the efficacy of low-carbohydrate diets for weight loss: Aude
YW, Agatston AS, Lopez-Jimenez F, et al.: The national cholesterol
education program diet vs a diet lower in carbohydrates and higher in
protein and monounsaturated fat: A randomized trial. Arch Intern Med
164:2141-2146, 2004. [I do regret that this summary does not link to the
full-text paper; the American Medical Association is one of the few
publishers who have declined to make the text of articles available.]

Please also look at our open-access newsmagazine, DOC News, which recently
had this story, Research Shows Benefit of Low*Glycemic-Load Diet Over
Low-Fat Diet
[http://docnews.diabetesjournals.org/cgi/content/full/2/6/10?maxtoshow=&HITS=20&hits=20&RESULTFORMAT=&searchid=1122388192018_28&stored_search=&FIRSTINDEX=0&tocsectionid=CONSUMING*AORBDIET*&displaysectionid=Diet+and+Nutrition&journalcode=docnews]

It is true that Assocaition's patient education materials do not recommend
low-carbohydrate diets such as Atkins, but the scientific data supporting
them is far less convincing than you suggest. The assocaition really does
not advocate one diet, but rather individualized diets based on a
patient's medical status and nutritional needs. These could include diets
moderate in carbohydrate and higher in monounsaturated fats.

Also, our journal Diabetes Care is perhaps the leading journal publishing
nutrition research on diabetes. It is free access starting 3 months after
publication, and patients can read recent research for and against
low-carbohydrate dietary approaches.

So, do I deny the charge that we are directing patients only to one set of
nutritional information? Yes. You may wish to spend more time exploring
sites such as ours, or those of the American Cancer Society and American
Heart Association, before you accuse us of providing patients only one
brand of advice.

Peter Banks
Publisher
American Diabetes Association
Email: pbanks@diabetes.org

>>> RFeinman@downstate.edu 07/25/05 8:05 PM >>>

I am afraid Peter Banks is right.  It is not access to the literature that
is preventing patients from getting real information. It is that they
trust government agencies and medical organizations who, rather than
pointing them to published information, provide interpretations and
recommendations. Patients are not inclined to access the literature and
assume that official interpretation of the literature must be correct. For
example, although it takes some surfing one can find, on the internet, the
National Health and Nutrition Examination Survey (NHANES) showing that,
during the obesity and diabetes epidemic of the past thirty years,
consumption of carbohydrates has drastically increased.  Consumption of
total and saturated fat has decreased - for men, the absolute amount of
both total and saturated, for women (whose caloric intake has increased
more than men) the per cent has decreased.  Also, although many of the
original articles are not easily obtainable, there are numerous papers
showing that replacing fat with carbohydrates is deleterious to control of
insulin, blood sugar and other features of diabetes and metabolic syndrome
(the combination of high blood triglycerides (fat), HDL ("good
cholesterol"), blood pressure and body mass).  This information is
summarized in a recent article by Arora & McFarlane in our open access
journal, Nutrition & Metabolism
(http://www.nutritionandmetabolism.com/content/2/1/16). Nonetheless, the
American Diabetes Association continues to recommend still lower fat and
still higher carbohydrate. Their website is very well constructed and
convincing.  It does not seem like there is any conflicting data.  Who
needs access to the literature.

So here's the challenge for Peter Banks (or anybody else).  Actually, two
challenges.  In the first year course at Downstate Medical Center, we give
students a questionnaire on nutrition.  We then use the answers to discuss
certain topics in nutrition and metabolism. We recently published a
discussion of the use of this questionnaire in an open access journal,
Nutrition Journal (http://www.nutritionj.com/content/4/1/2). The article
first gives the reader a chance to take the quiz as we give it to medical
students.

My first challenge is to take the quiz without looking at the answers.  I
am sure Mr. Banks will do well although the discussion in the article
points out that not all physicians do.

The second challenge: the discussion of the answers, emphasizes the real
inconsistencies between the recommendations of government and health
agencies and the data in the literature.  The article is directed at
medical education but the point for this group is: shouldn't health
agencies be directing patients to the relevant literature and giving them
access to data that may conflict with their own position.  Under these
circumstances we would find out if the public needs more information
through open access.  My final challenge is for Peter Banks: How say you,
Sir. Can you deny all this?

Richard Feinman
Professor of Bichemistry
Co-editor-in-chief, Nutrition & Metabolism
Department of Biochemistry
SUNY Downstate Medical Center
Brooklyn, NY 11203