Saturday Stories: Britain's Antisemites, Polish Polarization, Civility's Death

Tanya Gold, in Harper's Magazine, with what she learned hobnobbing with Britain's antisemites.

Anne Applebaum, in The Atlantic, on Polish polarization as a harbringer for North America.

Mark Oppenheimer, in The New Republic, on the death of civility in the #SoMe era.

Guest Post: Does the BMJ publishing group turn a blind eye to anti-statin, anti-dietary guideline & low-carb promoting editorial bias?

Truth be told, I'm fond of the British Journal of Sports Medicine, but as anyone who reads it knows, it has this strange habit of publishing articles about non-sports related dietary guidelines, the dangers of cholesterol lowering medications, and on the alleged superiority of low-carb diets. That's an odd thing, or maybe it's not, for as today's 4 guest posters (Drs Nicola Guess, Ian Lahart, Duane Mellor, and David Nunan) lay out, it may simply reflect the editor in chief's personal bias. So have a peek at their story, and if while you're reading you're on the fence, ask yourself if it would be odd for the American Journal of Clinical Nutrition to publish ankle sprain treatment guidelines, or if the Journal of the American College of Cardiology published a review of the efficacy of orthotics for plantar fasciitis? And note, at the end of their guest post is a link to an open letter to the BMJ that they've penned, which by following the link, you can also sign.

Scientific journals have the potential to allow researchers to keep up to date with developments in their field, to publish their own research, and to comment on the research and ideas of their peers. Journal editors play a vital role as impartial gatekeepers of this process, and importantly they should ensure their own personal beliefs and prejudices do not impact decisions related to content that is published in their journal.

Here we provide a synopsis of an example of poor gatekeeping we are currently experiencing and how this can skew the scientific discourse in favour of a personal agenda. A full account of this story is available here.

In April 2017, an opinion piece editorial entitled ‘Saturated fat does not clog the arteries: coronary heart disease is a chronic inflammatory condition, the risk of which can be effectively reduced from healthy lifestyle interventions’ was published in the British Journal of Sports Medicine (BJSM), and then repeatedly promoted by the journals Twitter account, which is jointly run by the journal’s Editor in Chief (EIC).* Promotion of an editorial is completely normal—often an EIC will highlight an article or opinion piece that they believe to be of interest. However, it is also normal and expected that the editor acknowledges and welcomes debate and rebuttals from others who disagree with points made in the published article. Two of us (David Nunan and Ian Lahart) emailed the EIC immediately following publication of the original article offering a rebuttal, but received no response. After three months without reply, we published an open rebuttal in PubCommons (latterly Pubpeer) highlighting what we thought were important deficiencies in the original article.

We were surprised to see the EIC tweeting the saturated fat article a year later and stating that ‘importantly’ the editorial had not had any rebuttals. We immediately contacted the EIC again, and after a series of emails received acceptance that our rebuttal would be published in the BJSM.

An important point--one that we believe highlights the bias in gatekeeping at the BJSM—is that the original article was published “open access”, meaning it is was made freely available to academics, public and the media. This is important for openness and access to science, and also allows interested members of public to read articles which frequently are hidden behind a paywall. This of course is good practice. Key here though is that decisions to make articles such as these open access is made entirely by the EIC of the BJSM.

Naturally in the spirit of open debate, we would only consider it reasonable that our rebuttal would be published open access, along with some social media promotion. This way, readers could read both the original article and the rebuttal and consider all the arguments presented. However, we were told by the EIC that our article would not be made available as open access, but that we could instead pay for it (£1,950) to be made free of charge to read.

We were further concerned and surprised when we examined other articles on similar subjects also unrelated to the remit/readership (e.g., dietary guidelines, statins) published in the BJSM. Of 10 such articles, all were open access, they all had narratives that denigrated current dietary guidelines and/or statins and promoted an exclusively low-carb dietary approach. All of the articles were authored by supporters of these narratives, with some writing two or more articles. The EIC, via the BJSM twitter account, has regularly promoted these narratives on social media. Four rebuttals/counter arguments to these articles have been published (including our most recent) – none of these were made available as open access by the EIC. There has also been next to no promotion of these rebuttals via social media from the BJSM twitter account.

Furthermore, during the two-month period we were communicating with the editorial team to have our article published open access, or at the very least a footnote added to state we had been denied free open access (both requests were turned down), the BJSM produced two podcasts from authors of 2 of the 10 free articles, including the one in question here.

To be clear, our rebuttal was not in complete disagreement with all the points made in the original editorial. Our rebuttal was more about using robust methods to emphasize the strength of the evidence and highlighting knowns and unknowns that were overlooked in original editorial. Furthermore, we have healthy disagreements amongst ourselves about the evidence in this field (e.g., dietary guidelines). These disagreements, however, should be debated openly in the scientific literature. The EIC’s role is to facilitate this in an unbiased manner and ensure systems are in place to prevent biases skewing the scientific discourse to the journal’s audience. Imagine if a journal only published and promoted open access articles on the effectiveness of aspirin to prevent heart attacks, yet hid every rebuttal (highlighting potential harms) quietly behind a paywall?

We are concerned about the editorial conduct and procedures of the BJSM. Given the journal is part of the BMJ publishing group (governed by the British Medical Association (BMA)), this also raises questions over governance across over 50 of its journals The BJSM is also co-owned by the British Association of Sports and Exercise Medicine (BASEM). We think this is worth pursuing further and have written an open letter to each of these organizations requesting the issues raised here are looked into.

Our open letter is available for signing (and reading) by clicking here.

[*it would be reasonable to question the fit of such an editorial to the journal’s scope and readership: “…provides original research, reviews and debate relating to clinically-relevant aspects of sport and exercise medicine, including physiotherapy, physical therapy and rehabilitation.”]

Dr Nicola Guess is a lecturer in the Department of Nutritional Sciences at King’s College London in the UK and a Registered Dietitian. Her research interests are on the effect of diet on the pathophysiology of type 2 diabetes. 

Dr. Ian Lahart is a senior lecturer in exercise physiology and researcher at Institute of Human Sciences, University of Wolverhampton. He completed his PhD in the role of exercise in breast cancer. Through his PhD work, he conducted an exercise randomised controlled trial in women with breast cancer. Ian is also the lead author of a recent Cochrane collaboration review on the effects of exercise in women with breast cancer post-adjuvant therapy. Through his role as a research fellow at Russells Hall hospital, Dudley, UK, he helped set up and manage a MacMillan funded exercise-based cancer rehabilitation service. Although his research focus is on the role of exercise in breast cancer rehabilitation and survivorship, he has additionally worked with patients with other cancers, arthritis, cardiovascular disease, and diabetes and related metabolic conditions. He is also interested in the communication of science and meta-research—a field of research that investigates research practices and quality.

Dr. Duane Mellor has worked clinically as a dietitian, mainly in diabetes management and education and then as a researcher in clinical trials. However, reflecting back on the first 2 decades of his career he has begun to question a number of aspects of nutrition and dietetic practice. He is now interested in looking at evidence in nutrition, both in terms of causality and quality along with how this is communicated to the public by the media. Looking to challenge thinking in this area, to consider aspects of benefit and the risks of harm, ultimately looking at how the public can be best supported to eat food they enjoy that also supports good health.

Dr. David Nunan's career in academic research started over 15 years, with a focus on clinical care and evidence-based medicine over the past 8 years. Upon completion of his PhD, he joined the Centre for Evidence-Based Medicine and his role is now divided between research, teaching and outreach activities.

Meta-Analysis Of Low-Carb Meta-Analyses Finds The Ones Most Excited About Low-Carb Diets Are Of "Critically Low Quality"

Meta-analyses, studies that combine a slew of relevant studies to come to one larger conclusion, are undoubtedly valuable, but that doesn't mean there isn't plenty of room for debate about their findings.

Why?

Because their findings depend on the criteria they used in order to determine which studies should be included. So when considering a meta-analysis on the impact of low-carb diets (LCD), variables that would affect outcome might include the definition of LCD (ie how many grams per day of carbohydrates constitutes a low carb diet), the duration of the diet, the number of databases searched, how risk of bias was assessed and applied, and investigation of the causes of heterogeneity to name just a few of those found in the more complete (AMSTAR) list seen here:

And in fact, a study analyzing the quality of meta-analyses of low-carb diets was recently published in Obesity Reviews, and its findings fall in line with my very admitted confirmation bias which sees low-carb diets being as good or as bad as any other diet, and that at the end of the day, what matters more than the diet prescribed is diet adherence.

The authors found that,

"critically low quality (low-carb diet/LCD) meta-analyses showed superiority of LCD for weight loss while moderate quality showed inconsistent results, and high quality showed little or no difference"

Of course all of the studies included looked at overall losses between different prescribed diets, but in my opinion, that may not be the best way to evaluate them.

Because as the DIETFITs study so elegantly illustrated, there are people who do incredibly well with low-carb or low-fat diets, while other people do incredibly poorly, and all within the same study population.

I would argue further that this is true for any diet.

All this to say, be wary both of any study or meta-analysis that crowns one diet better than another, and of anyone suggesting that a particular diet isn't worth trying. One person's best diet is another person's worst.

(Photo by Jenna Hamra from Pexels)

Saturday Stories: Remembering, Revenge, And Not Debating

Anita Hill, February 2018

Jessica Shortall, in Medium, with a rage and sorrow inducing piece about everything she can remember.

Jennifer Weiner, in the New York Times, on wanting to burn the frat house of America to the ground.

Laurie Penny, in Longreads, on not debating.

And here's a recent live podcast I did with Darya Rose at this year's Fireside conference where we cover the basics of successful weight management and why I think chocolate's more important to success than hunger.

[Photo By Gage Skidmore, CC BY-SA 3.0, Link]

An Incredibly Innovative Solution For Parents And Politicians Concerned About The Potential End of School Organized Chocolate Milk Sales

Chocolate Milk And Health Canada's Inaction On Canada's Food Guide Just Cost The New Brunswick Liberals The Election

Yesterday there was an election in New Brunswick.

The Conservatives won by a single seat.

So what was the main issue New Brunswickers were voting for or against in this election?

Believe it or not, it was chocolate milk in schools, which was described by the Toronto Star as the issue at, "the centre of the New Brunswick election campaign".

Seriously.

The centre of the New Brunswick campaign was whether or not the sale of chocolate milk would be banned in New Brunswick schools, with Blaine Higg's Conservatives saying "No", and the Liberals Brian Gallant saying, "Yes".

PC Leader Blaine Higgs with Blair and Ashton having Chocolate milk on The Big Blue Bus. pic.twitter.com/MIuRn56AIy

— Paul D'Astous (@d_astous) August 31, 2018

But here's the thing.

If Canada's Food Guide stated that sugar-sweetened milks were not nutritionally equivalent to white milk, and that in fact sugar-sweetened milk consumption should be limited to half a cup daily in children, school chocolate milk sales wouldn't have been an election issue in the first place, as with that admonition, schools almost certainly would have put an end to the daily sale of an item Canada's Food Guide recommends kids explicitly limit.

And there's very little doubt that the next Food Guide, if it's ever released, won't be kind to chocolate milk. And that's not just me reading the tea leaves, it's also me remembering when Dr. Hasan Hutchinson, the Director General of the Health Canada unit responsible for the Food Guide stated, over 4 years ago (honestly, what could we possibly still be waiting for) during a public debate that we held,

"One thing we're doing right now (Note: Right now means February 2014) is doing a reassessment of all of those things and certainly me personally, I agree with Yoni that it (chocolate milk) should not be there either"

So the next time someone tells you that Canada's Food Guide doesn't matter you remind them that Health Canada's inexplicable foot dragging on its much needed revision just cost the New Brunswick Liberals the election.

(Stay tuned, because on Thursday, I'm going to post an incredibly innovative solution to the issue of chocolate milk in schools)

Saturday Stories: Obesity, Mortality, and Belief

Michael Hobbes, in Huffington Post's Highline, explains why everything you know about obesity may be wrong.

Bari Weiss, in The New York Times, on the occasion of Yom Kippur, with her thoughts on facing our own mortality.

Caitlin Flanagan, in The Atlantic, with a powerful piece on why she believes Dr. Christine Blasey Ford.

There's No Realistically Prescribable Amount Of Exercise That Will By Itself Lead To Useful Weight Loss, But That Doesn't Mean You Shouldn't Exercise!

This isn't the first time I've noted that there is no realistically prescribable amount of exercise that by itself will lead to clinically meaningful weight loss, and it probably won't be the last. And that said, it doesn't mean it's impossible, but reality really is a useful place to live, and is probably a worthwhile frame of reference.

Today's reiteration stems from a recent-ish study that looked at "energy compensation in response to aerobic exercise training in overweight adults" which when translated refers to whether or not people eat back the calories they burn exercising and if that's why the results of exercise for weight loss studies so often disappoint.

The authors followed 36 men and women with varying degrees of excess weight (BMIs ranged from 25-35) and randomly assigned them to exercise either 30 minutes daily or 60 minutes daily, 5 days a week, for 12 weeks.

3 months on analyzed data later and the authors summarized conclusions include this statement,

"Results of the current study suggest the recommendation should be closer to 300 minutes per week to achieve appreciable fat loss"

because in their study it was only the participants who averaged 335 minutes of weekly exercise who were seen to lose a statistically significant amount of weight (and though significant statistically, it was only an average of 5.7lbs).

Though it's not noted in the study, it should go without saying that whatever intervention you employ to lose weight, if you stop that intervention, the weight you lost by way of its impact will likely return. And so while perhaps 335 minutes of weekly exercise for another bunch of months would lead to further loss, if you stop or decrease exercising that much, the weight you lost with it is likely to return.

Back to the headline of this blog post. If you think the average person, living a real life, replete with its many stressors, challenges, and responsibilities, can sustainably and consistently find upwards of 300 minutes of weekly exercise, I'd invite you first to get that much yourself even for just 3 weeks, as for the majority of people out there, it's not even a remotely realistically prescribable amount.

Instead of continuing to tie exercise to weight, and in so doing motivate people to start exercising in the name of weight loss, which in turn risks disappointment and the cessation of exercise if while successfully increasing exercise to a more realistically obtainable amount no weight is lost, the focus needs to shift to the fact that exercise is arguably the single healthiest modifiable behaviour anyone can undertake, that any amount is terrific, and that it's incredibly beneficial regardless of whether or not weight is lost in the process.

Photo by David Whittaker from Pexels

Saturday Stories: Museum Fires, Non-Sexual Harassment, and Lucy Wills

Ed Yong, in the Atlantic, with his coverage of the devastating Brazilian museum fire.

Linda Bloodworth Thomason, in The Hollywood Reporter, on Les Moonves and how not all harassment is sexual 

Hilda Bastian, in The James Lind Library, with the life and times of the remarkable Lucy Wills

Every Physician Ought To Know Which Common Medications Cause The Most Weight Gain

While it would be wonderful if all primary care physicians were interested enough in understanding how to treat their practices' most prevalent chronic condition to actually go out of their way and take the time to learn how to do so, there's a bare minimum that I think they do need to know, and that's which medications contribute to weight gain and their weight friendly alternatives.

Last week, my friend and colleague Sean Wharton, along with his collaborators, published an open access article summarizing drugs and weight gain, and I think it's a must read for all prescribers.

And for those who struggle with clicking, here's a summary of their summary by way of the article's various tables, because while it may be too much to ask for all MDs to truly take the time to learn about obesity, understanding which drugs are more likely than others to cause weight gain is something there's no excuse for them not to know.

[Cautionary note: If you're currently on one or more of the medications that are shown below to lead to greater weight gain, please don't stop it without first consulting with your prescriber, but do feel free to bring these lists along with you to discuss whether or not there are possible alternatives]

Saturday Stories: Tucker Carlson, Medical Error, and Physicans' Moral Injuries

By Gage Skidmore, CC BY-SA 2.0, Link

Lyz Lenz in Columbia Journalism Review, with a masterful profile of Tucker Carlson.

Deborah Cohen in BBC news details the heart breaking case of the medical error of Dr. Bawa-Garba.

Simon G. Talbot and Wendy Dean in STAT, on physicians' moral injuries.

Small, Short, Crossover Breakfast Study Says Maybe You Shouldn't Skip It

This was a very small study, but unlike many other "breakfast" studies, it prescribed specific breakfasts, and more to the point, they're not bowls of ultra-processed carbs, but rather high protein options with a breakdown of 340 calories made up of 30g of protein, 36g of carbohydrates, and 9g fat.

What the authors were interested in were the differences, in the same individuals, of having a high protein breakfast vs. skipping breakfast (first meal at noon), on hunger, fullness, desire to eat, prospective food consumption (PFC) and related hormones, food cue–stimulated functional magnetic resonance imaging (fMRI) brain scans, ad libitum evening food intake, sleep quantity and sleep quality.

The participants were healthy young men and women without obesity and each arm of the experiment lasted for 7 days with a 3 day washout period in between.

The results saw breakfast eaters see their hunger, desire to eat, PFC, and ghrelin levels decrease on breakfast days versus skipping days, while their fullness and related hormones increased.

What didn't differ however was total energy consumed, this despite the fact that when they ate breakfast, participants on average consumed 30% fewer carb based evening snacks. There was also no real impact on sleep or sleep markers.

What was great about this study was that it didn't just look at next meal consumption, but rather the impact of breakfast on whole days, something my clinical experience has been screaming for years was necessary. That said, at least in this short study, it didn't seem to matter, at least not to total daily energy intake.

So does this mean you shouldn't skip breakfast? Not exactly, but it does suggest that eating a high protein breakfast, though it won't make you eat fewer calories, it may leave you feeling fuller and decrease evening processed food snacking.

And so once again, the answer is personal and not particularly complicated. If breakfast helps you to eat less, eat better, or feel better, then yes, you should eat it, and if it doesn't, don't.

Saturday Stories: Rape Culture, Alcohol, And Food Need Hierarchies

Molly Galbraith, on her Facebook page, in light of recent events, discusses rape culture in the fitness industry.

Julia Belluz, in Vox, takes on nutritional epidemiology and what amount of alcohol is safe to drink.

Jason Lusk, on his blog, with his take on how the hierarchies of food needs fuel dietary fads and nutritionism.

Taking Medication For Obesity (Or Anything Else For That Matter) Is Not A Failure

The other day a GP tweeted at me that there was "no role for pharmacology" in the treatment of obesity along with an #LCHF hashtag. I can only presume she believes low-carb high-fat diets are the global panacea that everyone needs, and that those not adopting and succeeding with them are personal failures.

And hers isn't an isolated viewpoint, nor is it one that's relegated only to the #LCHF crowd as I've heard from other non-LCHF hashtagged physicians that forks and feet are what's required, not medications or surgery.

But those viewpoints tend only to be extended to obesity, not to any of the literally dozens of other chronic, non-communicable diseases, that lifestyle may prevent or treat, and so yes, while useless truisms like eating less and exercising more would help people to lose weight, and while #LCHF would help some too, it's bias that has obesity as the sole medical condition that people feel comfortable proclaiming that medication (or surgery) has no role in treatment.

Clinically useless truisms aside, obesity is complicated, and moreover we have yet to discover a non-surgical, reproducible, sustainable, and uniformly effective plan for the management of obesity. And while there's no argument about the fact that in a ideal world everyone would take it upon themselves to live the healthiest lives possible, there are two problems with that argument. Firstly, not everyone is interested or able to change their lifestyles, and secondly, statistically speaking, the majority of even those who are interested and successful with lifestyle change will ultimately regress.

Is it lazy to want to improve your quality and/or quantity of life? Because for many that's what the treatment of obesity would do, and that's true for pharmacologically assisted weight loss and surgical weight loss too. And yes, sure, it'd be lovely if everyone had the very real luxuries of possessing the health, time, money, and inclination to regularly and genuinely exercise, cook, and life broadly healthful lives everyday, forevermore, but except in the minds of those filled with dripping I can do it and so should you lifestyle sanctimony, that's simply not the case for a large percentage of our real life population.

So yes, medications for those who want and need them. Same with surgery. And also varied dietary approaches and behavioural strategies. Because my job as a physician is to provide people with enough information about their options for them to make their own informed decisions, it's not to be a myopic, biased, patient-blaming, blowhard, dietligious, zealot

Please Stop Judging Other People's Shopping Carts And Fast Food Orders

Ever wonder if you're biased against people with obesity?

Have you ever stood in line behind someone with obesity at the supermarket and judged them on the basis of the items they were pulling out of their cart? Or behind someone with obesity at a fast food place and judged them on the basis of their order?

Now ask yourself if you have, or would have, similarly judged a thin person pulling out those same items or making that same order.

And it's worth noting, there's no good answer here.

If you answered, no, you wouldn't have judged a thin person similarly, well that reflects weight bias.

And if you answered, yes, you'd be judging them the same way, well that reflects you judging people on the basis of things that are none of your business.

Everyone's life is complicated, and moreover, food plays roles far beyond fuel and serves as comfort, as celebration, is one of life's most seminal pleasures, and it's not for anyone to judge anyone else on the basis of their choices therein.

Saturday Stories: A Single Read Week (It's A Really Worthy Read)

John Ioannidis, in JAMA, on the incredibly flawed foundations of nutritional research and dietary recommendations. Given subscribers here are likely interested in nutrition, I believe this to be an important enough read that I don't want to recommend you read anything else.

If A Woman With Obesity Is Denied Fertility Treatment, Does She Have Grounds To Sue?

It is a fairly common practice for fertility clinics to deny treatments to women with obesity. The rationale presented usually references the increased risks posed to both mom and fetus consequent to mom's obesity.

And indeed, there are increased risks in pregnancy in women with obesity including of gestational diabetes, preeclampsia, prolonged first stage of labour, increased instrumental deliveries, shoulder dystocia, macrosomia (big babies), congenital anomalies, and C-Sections.

But here's the thing, there are plenty of pre-existing conditions that women seeking fertility treatments have that confer comparably increased risks, and yet those women are not denied access to treatment, instead they are counselled about those risks, informed consent is obtained, and treatment is provided.

Couple the above with the fact that there simply are no gold standard non-surgical means by which women with obesity can ensure they'll lose weight, and that denying fertility treatment to women has been shown to negatively affect self-esteem, social isolation, anxiety, and depression, and I can't help but wonder whether there are grounds for a lawsuit? Grounds that have been made that much stronger by the recent publication of the Canadian Fertility and Andrology Society's recommendations on obesity and reproduction which spell out all of the above (minus the legal question), and which are well worth a read by women with obesity seeking fertility treatments.

Two New Studies Pour Cold Water On Water's Role In Weight Management

Two new studies are bound to disappoint those who still want to believe water makes a difference in weight management.

The first of these studies, Increasing water intake influences hunger and food preference, but does not reliably suppress energy intake in adults, asked participants to drink 500, 1000, 1500, or 2000ml of water in the morning before an all you can eat lunch buffet to see if doing so reduced how much people ate. The researchers found that even drinking 2L of water before lunch didn't reduce how many calories were consumed at the buffet.

The second, Complementary and compensatory dietary changes associated with consumption or omission of plain water by US adults, compared the self-reported dietary intake patterns (which you should know aren't generally thought to be be reliable) of individuals who had days recorded with and without water intake to see if there were a difference in calories reportedly consumed. There wasn't.

As to how pervasive the belief that water is a key player in weight management, you might be surprised by how many people I meet in my office who believe water drinking makes or breaks an effort, though when you consider the fact that 63.4% of adults in a recent US survey of weight loss practices cited water drinking as one of theirs, maybe it shouldn't be all that shocking.

In my mind the only thing that's surprising is that I would have thought it to be fairly self-evident, that water drinking was an incredibly minor player at best, because if drinking 8 or more glasses of water a day contributed even moderately to successful weight management, we'd see a great many more success stories walking around.

[That said, if you replace all your regularly consumed caloric beverages with water, well that might lend a hand.]

Saturday Stories: Glyphosphate, Glyphosphate, And Katie Stubblefield

Robert O'Conner, in Medium, with his expert thoughts on glyphosphate (RoundUp) and cancer.

Andrew Kniss, in his blog, with his expert thoughts on glyphosphate and cancer.

Lynn Johnson, in National Geographic, with an incredible story about Katie Stubblefield's face and life.

Study Finds Giving Prebiotics To Kids Doesn't Change Their Energy Intake And Ups A Major Hunger Hormone Yet Still Concludes Prebiotics Have Potential To Help With Childhood Obesity?

Today will be discussing a study that had kids randomly assigned to taking either 8g oligofructose enriched inulin (prebiotic) per day or placebo (maltodextrin) for 16 weeks.

The study's pre-registered primary outcome measure, as recorded in ClinicalTrials.gov, was change in baseline fat mass at 16 weeks.

Secondary outcome measures (as recorded) were changes in baseline appetite at 16 weeks (assessed with visual analog scales and an eating behavior questionnaire), and objective appetite measures including a weighed breakfast buffet, weighted 3-day food records, and serum satiety hormone levels.

(Not preregistered as an outcome of interest? Body weight change or BMIz score.)

Outcome wise, here's a snapshot of the study's abstract:

Reading through the study, here's what I found as outcomes:

• According to their 3 day food diaries (but be aware, food diaries are notoriously inaccurate), there was no difference in 3 day energy intake between the prebiotic and placebo arms.
• When all ages were included in the analysis, there was no difference in all-you-can-eat breakfast buffet energy intake between the probiotic and placebo arms, BUT, by dividing the kids into those between the ages of 7-10 and 11-12, suddenly, but only in the older group, kids ate less breakfast in the prebiotic arm, while in the younger group, they ate more.
• The hunger hormone ghrelin was found to be significantly elevated in those taking the prebiotic (an increase of 28%) from baseline, whereas placebo was not demonstrably different from baseline (an increase of 8%).
• There was no difference reported in subjective post-breakfast buffet hunger in either group
• There was no difference reported in subjective eating behavior questionnaires between groups, but parents reported improvements in fullness, but equally in both prebiotic and placebo groups.
• The primary outcome of change in baseline fat mass was not mentioned anywhere in the study.

The authors' conclusions about a prebiotic supplement that was shown to markedly increase hunger hormone levels, that didn't decrease 3 day food diary energy intake, that didn't change all-you-can-eat breakfast buffet energy intake (unless you arbitrarily after the fact divided up the kids into those aged 7-10 and 11-12), and where the study's registered primary outcome wasn't mentioned in the study itself sure look differently than what you might expect, with their concluding sentence being,

"This simple dietary change has the potential to help with appetite regulation in children with obesity"

I also found it surprising that the study was free to read, and given the incredibly unexciting findings, it's more difficult to imagine the authors paying for its open access. Easier to imagine the company that makes the prebiotic that a randomized controlled trial published in an impactful journal explicitly concluded, "has the potential to help with appetite regulation in children with obesity" (even though it didn't), paying the extra fees as open access articles generally gather more citations.

As to what Beneo, the manufacturer of the prebiotic used in this study had to say, I found these quotes in an article published on the trade-zine Nutraingredients at the time of the study's publication,

"Beneo regards this research of highest importance",

and despite the study not even remotely coming to this conclusion also added,

"The intake of 8g of prebiotic inulin (Orafti Synergy 1) in a glass of water prior to dinner is a simple dietary intervention that supports children in their weight management efforts. The results show that they were naturally eating less (YF: no they didn't) than the control group having maltodextrin"

Beneo also put out an excited press release to publicize the study.

And you can bet your bottom dollar, it's studies and conclusions like this one that supplement companies use to suggest great benefits to their products, and it's also studies like this one where I wish the journal employed open peer review as I can't fathom how this one got through as is.

Lastly, while the authors didn't report any conflicts of interest with this particular study, the supplements and placebos were provided by Beneo, and it was noted that one of the authors had previously enjoyed funding from Beneo. Unfortunately there is no mention as to who paid for this study's open access.