Widely covered editorial extolling importance of diet over exercise “temporarily removed”

Source: NIH
Source: NIH

The British Journal of Sports Medicine has “temporarily removed” an editorial arguing that physical activity alone will not cure the obesity epidemic, following an expression of concern.

In its place stands the following message:

This paper has been temporarily removed following an expression of concern.

First author Assem Malhotra, based at the Department of Cardiology, Frimley Park Hospital and Consultant Clinical Associate to the Academy of Medical Royal Colleges, told us the paper was pulled due to a “technical issue,” and an “official explanation” would be forthcoming.

Indeed, just this morning, we received a statement from Fiona Godlee, editor of the British Medical Journal, which publishes the British Journal of Sports Medicine:

The article was taken down temporarily, mainly to address concerns about some undeclared conflicts of interest. It will be reposted shortly.

Second author Timothy Noakes believes he has the explanation. He told us the article may have been pulled because he didn’t declare a potential conflict of interest related to his popular books about health:

It seems that it was largely my fault as I failed to declare a conflict of interest from the books that I write relating to exercise or nutrition or both. Since all the royalties from all those books are donated to two Trusts that I run to support research (as now fully declared in my COI statement) I did not consider it a conflict of interest. In 40 years of research I have never declared my books as a COI and I am not aware of many other authors who routinely declare books as COI.

Noakes, based at the University of Cape Town and Sports Science Institute of South Africa, even passed along a COI form he recently completed for the journal, declaring this potential conflict.

What’s puzzling, however, is that the journal appeared to pull the editorial from its website (although you can read in full here), and has not released the “expression of concern” referenced in the note (at least, not any EoC we can find). Does a missing potential COI warrant removing the article entirely before it can be added?

The strongly worded editorial received a good deal of press coverage when it was published last month. The authors argue that many people are being given the false message that exercise alone will help them lose weight, when bad diet is the main culprit:

…members of the public are drowned by an unhelpful message about maintaining a ‘healthy weight’ through calorie counting, and many still wrongly believe that obesity is entirely due to lack of exercise. This false perception is rooted in the Food Industry’s Public Relations machinery, which uses tactics chillingly similar to those of big tobacco… It is time to wind back the harms caused by the junk food industry’s Public Relations machinery. Let us bust the myth of physical inactivity and obesity. You cannot outrun a bad diet.

At the bottom of “It is time to bust the myth of physical inactivity and obesity: you cannot outrun a bad diet,” the authors note:

Competing interests None declared.

Update, 5 p.m. Eastern, 5/7/15: The journal has replaced the paper and issued a statement on the removal:

This article was first published online on 29 April 2015. It was temporarily removed on May 1 to include competing interests that had not been divulged by Stephen Phinney and Tim Noakes at the time of submission.Stephen Phinney is a paid member of the Atkins Scientific Advisory Board and has authored books on low carb/high fat diets.Tim Noakes has also written and co-authored books, the proceeds of which are donated to charitable trusts for the purposes of research.
BMJ, the publisher of the British Journal of Sports Medicine (BJSM), stands by the content of the editorial.
Professor Karim Khan, the journal’s editor, comments: “The editorial team subscribes to BMJ’s motto of ‘Asking questions, questioning answers’. It is clear from the international media uptake of Dr Malhotra’s editorial, and related content by him and others, that current dietary guidelines need questioning.“BJSM does not claim to have the answer to the question ‘What is the ideal diet for health?’ But we are ideally placed to contribute to the debate as BJSM does not receive funding from any of the key players who have declared interests. Healthy food choices are as central to sport and exercise medicine as knee ligament injuries.”He adds: “The BJSM editorial team has a responsibility to address readers’ concerns seriously and to take down material while undertaking due diligence. At no point did the BJSM editorial team question the legitimacy or the veracity of Dr Malhotra’s editorial.”We look forward to the amended version contributing to the important debate in the field, and to the improved health of those looking to make evidence-based choices.”

The “Footnotes” section of the paper now reads:

Correction notice This article has been amended from the original published on 29th April 2015. The body of the text was slightly edited and a reference removed. Competing interests have been added.

Competing interests SP is a paid member of the Atkins Scientific Advisory Board and has authored books on low carb/high fat diets: New Atkins and You and The Art and Science of Low Carbohydrate Living; TN is the author of the books Lore of Running and Waterlogged and co-author of The Real Meal Revolution and Challenging Beliefs. All royalties from the sale of Real Meal Revolution are donated to the The Noakes Foundation of which he is the Chairman and which funds research of insulin resistance, diabetes and nutrition as directed by its Board of Directors. Money from the sale of other books is donated to the Tim and Marilyn Noakes Sports Science Research Trust which funds the salary of a senior researcher at the University of Cape Town, South Africa (research focuses on the study of skeletal muscle in African mammals with some overlap to the study of type 2 diabetes in carnivorous mammals and of the effects of (scavenged) sugar consumption on free-living (wild) baboons).

Provenance and peer review Not commissioned; internally peer reviewed.

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23 thoughts on “Widely covered editorial extolling importance of diet over exercise “temporarily removed””

  1. It makes sense to me that books on the same or similar subject should be included in declared competing interests, because the author could derive additional income from book sales by publishing the paper. This does not strike me as dissimilar from when an author publishes on a drug that a company that he works for sells. So people should declare books in competing interests.

    On the other hand, there always almost is a conflict of interest. One could always say that the authors derive some independent benefit from publishing papers (whether it be simply resume building or getting a postdoc position). And given that papers are generally only published if the results are “positive”, one could argue that authors have an interest in describing reality in the most favourable light to themselves.

    So where does one draw the line?

    1. That’s what I find confusing in this particular wording – in what sense does Noakes’ book publishing COMPETE (not shouting just emphasising) with the message of the editorial. as far as I can say it SUPPORTS it all respects.

      Is this perhaps a piece of legal jargon that has crept into common use ?

      1. Peter Apps
        That’s what I find confusing in this particular wording – in what sense does Noakes’ book publishing COMPETE (not shouting just emphasising) with the message of the editorial. as far as I can say it SUPPORTS it all respects.
        Is this perhaps a piece of legal jargon that has crept into common use ?

        Yes, although I think ‘competing interests’ is just a euphemism for ‘conflict of interest’, not necessarily a legal term. Well, journals are no strangers to euphemisms, given what they can achieve in the way of avoiding the word ‘plagiarism’…

        1. “Conflict” has the same problem as “Competing” – a connotation in normal English that the article and the author’s other activities somehow contradict one another. If there is a conflict, what is it against ?

          Should we not be looking for a clear statement that an authors objectivity might be compromised by ……… (being in league with the devil, getting paid by big anything etc etc).

          There’s the heading of the future: “Compromisers of objectivity:…”

  2. I note that the website asks for “Competing interests”, not “Conflicts of Interest” – pedantry compels me to suggest that “Supporting interests” might be a more informative question in this (and other) cases.

  3. The article enormously exaggerated risk of diabetes by misquoting the paper it referenced. “A large econometric analysis of worldwide sugar availability, revealed that for every excess 150 calories of sugar (say,one can of cola), there was an 11-fold increase in the prevalence of type 2 diabetes, in comparison to an identical 150 calories obtained from fat or protein.the risk of diabetes was increased 11 fold by consuming an additional 150 kcal from sugar.” Whereas in fact the paper referenced reported a 1.1% increase in the prevalence – orders of magnitude lower. The more robust meta-analysis published in the Lancet (Ley et al. Lancet 2014; 383:1999-2007) indicates a small 1.2 increase in relative risk for high vs low consumed of SSB which is trivial compared to changes in weight. The suggestion in the editorial that high protein and fat, and low carbohydrate diets should be promoted is nutritionally unsound and unsustainable in terms of global nutrition. Furthermore, vegetarians tend to get most of their food energy from carbohydrates but tend to be leaner than meat-eaters, and have a lower incidence of diabetes. Indeed in the Oxford EPIC study, it was the intake of animal protein that was most strongly linked to increased BMI. If you have not read Chris Snowden’s blog in the Spectator it is well worth the read (http://blogs.spectator.co.uk/christophersnowden/2015/04/ignore-the-quackery-and-get-active/). There is also a blog with the emails from Malhotra and the BMJ (http://velvetgloveironfist.blogspot.co.uk/2014/08/peer-review-in-action.html).

    1. I think the simple arguments of one versus another source of calories as being “good” or “bad” is far too simplistic and has not helped anyone other than authors. It allows this endless argument without resolution. I fully accept I may not be on the right tack, but my view is that fatty liver can only occur when excess calories derived from carbohydrates are consumed, while simply excess calories results in overall fatness.
      Unless you are an extreme exercise practitioner, ordinary folk are unlikely to make much dent on their overweight state unless they also address bad diet – bad diet not being simply excess calories although you can’t get fat without an excess.

  4. Conflict has rightly focused on financial issues, but desperately needs to be widened to other conflicts of interests, including ideological ones. Regardless of whether he sells a single book, this becomes a problem in articles of this nature.

  5. Tom, Thanks for your fascinating comment! It gives much depth to the issue above. An 11-fold versus a 1.1% difference is certainly of note, particularly when this error is in an editorial. My sense is that editorials are much more likely to create stories in the press as opposed to scientific articles.

  6. Alison

    I wasn’t going to comment on this until my complaint about this editorial had been dealt with, but as Fiona Godlee see’s fit to comment upon the outcome, prematurely I think, I see no reason not to discuss it.

    Firstly, Professor Noakes claims that “Since all the royalties from all those books are donated to two Trusts that I run to support research (as now fully declared in my COI statement) I did not consider it a conflict of interest.”

    What Professor Noakes considers a ‘conflict of interest’ is entirely irrelevant. The BMJ competing interest form makes it clear to authors under Section 2.2 that ‘Organisational financial interests’ must be declared and this includes money paid to organisations rather than the individual.

    It’s pretty obvious why such declarations are needed: the Noakes Foundation is an NPO which can pay those who “carry out its objectives” of “promoting low carb diets”, and it appears to have no competing interest policy which would preclude Prof Noakes from awarding himself a research grant (indeed he is listed as a ‘researcher’ on the website).

    Perhaps more troubling however, and the main reason for my complaint was the co-authorship of Dr Stephen Phinney. As noted above, he is a scientific advisor to Atkins which I would expect has some direct personal financial interests which need to be declared (another member of the board – Jay Wortman – recently declared the following in a paper “JW is on the Scientific Advisory Board of Atkins Nutritionals Inc. with paid retainer, honoraria, and travel costs”.

    In addition the BMJ recently changed their policy on education articles (which includes editorials) such that they claim to have zero tolerance on authors with industry links http://www.bmj.com/content/349/bmj.g7197. If, and that’s yet to be established, Dr Phinney does have undeclared competing interests from Atkins it seems untenable to me that as Dr Godlee claims “It will be reposted shortly.”, or indeed that it should be.


  7. Whatever you call it, whether “competing interest” or “conflict of interest”, I would certainly like to know that the author has written several books on the same subject. The fact that profits from the books go to a foundation is also significant. The co-author, Dr Phinney, as a “scientific advisor” to Atkins, is even more conflicted. The point is that these associations and books are part of the authors’ web of interests that affect the point of view that they display in the editorial.
    Thus, both issues should be reported, and “conflict of interest” is the best place to put it. The mistake of “11 fold” instead of 1.1 percent suggests a bias.
    The idea that fatty liver is caused by excess carbohydrates specifically is an interesting one, and should be addressed experimentally.

    1. The notion that “carbs” can cause a fatty liver is sketchily supported by animal studies. Primarily it seems to be a case for fructose and rats or mice. But extrapolating these experimental settings to human populations are in my opinion – as stated initially – sketchy at best… I am not aware of supporting data from human studies.

    2. I wonder whether publication of books is specially significant. Some book authors get paid royalties, and sales might be boosted through publication of journal articles, but, as lar points out, publication of journal articles can advance a scientist’s career in all sorts of financially rewarding ways.

      If books have to be declared, how about chapters in multiauthor books ? Does peer review of the books or chapters make a difference ? Is it only authors that make money from books that should declare ? If the payment for the book was an up front lump sum then boosting sales makes no difference to the author’s income, should those books be declared ?

      I ask for a practical reason, as well as publishing peer reviewed articles I also write books whose subject matter overlaps with the articles. Sadly they do not generate anything like the income of Tim Noake’s cookery books. Mentioning that as a conflict of interest never occurred to me, and I must say that declaring myself as a book author would feel uncomfortably like self promotion.

  8. @Tom Sanders, @DTX, @Conrad Seitz MD

    I am not going to defend either side of the argument, but there is a flaw in the criticism drawn by Tom Sanders to the calculations used by the authors. If you read the abstract of the quote econometric paper (Basu et al 2013, Plos One), you will read “we found that every 150 kcal/person/day increase in sugar availability (about one can of soda/day) was associated with increased diabetes prevalence by 1.1% (p ,0.001)”. From this, it seems that the authors of the editorial got it all wrong, and Tom is right.

    However, read into the manuscript: “Each 150 kilocalorie/person/day increase in total calorie availability related to a 0.1% rise in diabetes prevalence (not significant), whereas a 150 kilocalories/person/day rise in sugar availability (one 12 oz. can of soft drink) was associated with a 1.1% rise in diabetes prevalence (95% CI: 0.48–1.7%; p<0.001) after all control variables were incorporated into the model."

    Now read again the quote from the editorial: “A large econometric analysis of worldwide sugar availability, revealed that for every excess 150 calories of sugar (say,one can of cola), there was an 11-fold increase in the prevalence of type 2 diabetes, in comparison to an identical 150 calories obtained from fat or protein.the risk of diabetes was increased 11 fold by consuming an additional 150 kcal from sugar.”

    What the editorial says is that the 150 cals of sugar have an eleven-fold increase in risk compared total calories availability. The increase in type II diabetes prevalence from 150 cals total calories (including fat and proteins) was 0.1%; from sugar only it was 1.1%. That is where the 11-fold comes from.

    What I do think the authors got wrong in quoting said paper, at least in first impression, is that the 0.1% increase did not come from fat/protein only, but rather from total calories.


    1. I see how you could derive an 11-fold increase in diabetes risk RELATIVELY: an increase in total calories only increased risk 0.1% (NS) but if the increase was all sugar, the risk increased 1.1%(p<0.001). There's no 95% confidence range given for the increased risk posed by 150 kcal total increased calories– presumably it overlaps with zero. If you look at the confidence intervals, though, you can see that an 11 fold increase in risk assumes that the 0.1 and 1.1 are exact numbers, which they are not by any means. For example, if the increased risk from increasing total calories was actually zero (quite possible given the confidence interval), then the increased risk from increasing sugar calories as compared to increasing total calories would be "infinite-fold" or just meaningless if you want to be mathematically pure…
      So I don't think saying "11-fold increased risk" is really a helpful number at all. Better to just give the original numbers, insignificant increase versus 1.1% increase.
      The numbers suggest that consumption of sugar and carbohydrates are significant risk factors for diabetes and may have a negative effect on one's blood sugar if one is a diabetic. The first of these two statements is particularly important when counselling healthy patients about how to avoid diabetes. 150 calories is about 37.5 grams of sugar, or a little over an ounce. Not much when you're scarfing down a couple of "Swiss Rolls" or "Twinkies."

      1. Dear Conrad,

        I agree with you. Treating the data as “exact” values as you say of little help – though quite often done – and using the 11-fold comparison creates a wrong impression. My point though was simply to bring up how the 11-fold arrived from that 1.1%, not to judge whether that was the best way to read the results. From the first comment on this topic readers were left with the impression (at least I was, which is why I went after the original paper) that the authors of the editorial either deliberately changed the values or “forgot” a comma going from 1.1 to 11, which I believe was not the case.

    2. Conrad,
      1)If the increased prevalence was 1.1% greater for sugar and 0.1 for the same amount of calories provided by fat or protein. The increase in prevalence 1.1 – 0.1=1 not an 11 fold increase.
      2) The data are based on food availability and prevalence rates between countries – not intakes in individuals who go on to develop diabetes compared with those who do not. The data are not relative risks or odds ratio.

      1. There needs to be a better policy for stating percentages.

        Political polls often give candidates a percentage then give a margin of error as a percentage. Maybe 10% with a 5% error. I have to presume that means between 5% and 15%

        Contrast that with a reading on a scale of 10 with a 5% error, which would mean between 9.5 and 10.5.

        Or a mortgage rate going up by 0.5%. If you were paying 4% that is actually an increase of 1/8 or 12.5% in what you pay.

        A confounding factor In terms of studying the sugar in drinks is the effect on appetites of artificial sweeteners.

  9. This is a November 2014 talk given by Phinney. “Jeff” is Jeff Volek his co-author on Art & Science books, and let’s not forget authoring The New Atkins for a New You in 2010!

    These two links are to the same talk and cue to the important parts about a company that Phinney and Volek have started

    This second mention is the most concerning:

    What does “technically a for profit company” mean?

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