Dr. Robert Atkins: The Art of the Footnote
How Do We Know that He Knows What He Says He Knows ?
Footnotes are supposed to document an author's claims and thereby give us confidence that the author knows what he is talking about. But, as this little case study shows, the confidence that footnotes convey may be false confidence.
Who doesn't have a weight problem ? We want to weigh less, we want to look thinner. Thinner is more attractive. We think that thinner is healthier, and perhaps it is. But in the pithy words of Lenin, what is to be done ?
Three obvious courses of action suggest themselves: a) eat less; b) exercise more; c) try to accept what you are.
As to c), it is true that the Mishnah suggests contentment with one's lot. But this advice is not popular in our Age of Entitlement. As for the rest: Eat less ? Hard to do, next to impossible in the long run. Exercise ? Alas, a great deal of exercise goes but a short way. Besides, exercise is not necessarily fun.
Enter the late but, in his lifetime and even beyond, phenomenally successful Dr. Robert C. Atkins. From the day he published his first "Diet Revolution" in 1972, to the day he died (a fat man, it must be said) in 2003 at the age of 72, Atkins taught what he and his many followers rightfully consider a revolutionary doctrine: Forget the abc's of conventional healthy living ! Do NOT be content with what you have ! Do NOT eat less ! Do NOT exercise if you don't feel like it ! Simply cut down on the carbohydrates in your diet. In other words, stay away from tomatoes but gobble up the steak. Don't eat the bread, just ladle in the butter. In short, eat to your heart's content, but not carbohydrates.
Does Dr. Atkins' diet work ? Well, the experts do not say absolutely no, although they generally don't think it's very healthy. (A "systematic" review by Bravata, et al. of the "efficacy and safety of low-carbohydrate diets" was published in the Journal of the American Medical Association on April 9, 2003; the American Heart Association, more forthrightly, warned against the Atkins diet in 2001 because of its high cholesterol content, among other problems). The experts also suspect that people who are free to eat all the steak and butter they want but no bread to go with it will soon tire of their diet. They suggest that the Atkins gluttons simply get turned off all that fatty meat and eat less, and therefore give Atkins the weight loss that he predicts. But be that as it may, I myself am no expert, and I certainly would not deny the reported weight losses, in the short run at least, that Atkins followers have claimed.
What I am seeking to explore here is not whether the Atkins diet works but rather whether the claims for it have been presented in a believable manner.
"Dr. Atkins' New Diet Revolution," first published by Dr. Robert C. Atkins, M.D. [sic] in 1992, is not, and certainly cannot be meant to be, a scholarly work. It is written in a breezy, popular style, full of folksy self-help advice.
Here is a sample of his prose:
I can't wait to get you started doing Atkins. But before I do, I want to increase your enthusiasm to a fever pitch. Are you ready to lose more weight and more fat -- and keep it off, permanently -- than you've succeeded in doing on any other weight loss and weight maintenance plan you've ever tried ? (p. 64)
I can't wait to hear the reader's answer to that one.
But despite its sensationalist style, the book is full of footnote references to the technical scientific literature, in the manner of journal articles written for medical research scientists. I counted a total of 315 such references, mostly to journals that rank very high in the hierarchy of medical research. The appearance is one of scrupulous, technical documentation of any and all claims made in the book.
That is the appearance. What is the reality ?
First, it must be noted that Dr. Atkins had training as a physician and cardiologist, not as a research scientist, not as a nutritionist. So it is not surprising -- but not confidence-inspiring either -- that none of the scientific research that he cites refers to his own research. The total body of research that he cites was done by others.
Second, while the heavy footnoting resembles that of scientific writing, the book lacks the major guarantee that is offered by scientific journals: it has obviously not been peer reviewed by specialists prior to its publication.
Now, as to the footnotes themselves, to what extent do they actually corroborate Atkins' claims for his famous diet ?
The Seventh Chapter
The seventh chapter of Atkins' book is entitled "Is There a Metabolic Advantage ? You Be the Judge." The "metabolic advantage" has to do with Atkins' contention that a radical reduction of carbohydrate intake will make you thin. Atkins here invites the reader to "judge" his claim that existing research corroborates his diet.
The research that is cited in this chapter was independently evaluated by Marjorie Freedman, et al., medical researchers at the U.S. Department of Agriculture and the University of California, in March of 2001. Their finding is as follows:
Studies cited by Atkins to support his contentions were of limited duration, conducted on a small number of people, lacked adequate controls, and used ill-defined diets. Some of these, as well as other studies, actually refute the contention that low-CHO [low carbohydrate] diets, in the absence of energy restriction, provide a metabolic advantage.
In brief, Dr. Freedman and her co-workers conclude, Dr. Atkins' footnotes do not tell the story that Dr. Atkins says they do.
The Second Chapter
Toward the beginning of Chapter 2, Atkins writes
As I've just said, [the Atkins Way] mobilizes more fat for use as energy than any diet you have ever encountreed. In a clinical setting and countless testimonials, Atkins has repeatedly been proven to take off more fat than other programs when an equal number of calories is consumed. This incredible advantage has been researched and validated. 7-14
The notation "7-14" refers to eight footnote references that are furnished at the end of the book. I have looked into each of these studies as much as I could. Some, but not all, are also part of the data investigated by Freedman, et al. (Most of these studies can now be accessed through Google's Scholar facility).
One of these references is to an unpublished talk and is not publicly available. Two other studies were so old that their authors could not be found on the Internet. I sent e-mail messages to the authors of the remaining five studies, asking whether their work could be interpreted as furnishing corroboration of Atkins' claims. Of these, three replied. All three emhatically stated that their work could in no way be so interpreted.
Here are the details:
7. A study by Young, et al., done in 1971. The three subjects who were on a low-carbohydrate diet lost a (non-significant) greater amount of weight than three others. The authors of the study recommend against the use of the Atkins diet because of undesirable side effects.
8. A study by Skov, et al., done in 1999. To a lay reader like me, this highly technical study appears to support some of Atkins' claims. However, one of the co-authors of this study, Dr. Arne Vernon Astrup, has written to me as follows: "This is clearly an abuse of my study (studies). The weight loss in the Skov, et al. study was clearly due to high-protein, not the low-carb, carb elimination claimed by Atkins." Dr. Astrup also referred me to an article he wrote in criticism of Atkins, "Atkins and other low-carbohydrate diets: hoax or an effective tool for weight loss ?," The Lancet, vol. 364, September 4, 2004.
9. An article by Willi, et al., dated 1998. The authors fed a low-carbohydrate, high-protein, very low-calorie diet to six adolescents for 8 weeks. They made no comparisons with a control or other group. Their subjects lost weight, as indeed one would expect from such drastic control on caloric intake. There is no relevance to Atkins that I could see.
10. An "abstract presentation" at a scientific meeting by Sharman, et al., 2001. Since there is no reference to a publication, this work cannot be checked.
11. A study by Garrow and Summerbell, 1995. This is a secondary analysis of twenty-eight studies that asked whether exercise, without dieting, would result in weight loss. The result, not very surprisingly, is yes, exercise will reduce weight. But these results are not relevant to the question of whether Atkins dieting helps. (I have only examined the abstract of this article, not the article itself.)
13. An article by Lean, et al., 1997. In a study of 110 women, the authors compared a high carbohydrate (CHO) with a lower CHO (Atkins) diet for both weight reduction and attendant risks. The results, the authors say, "provided some support for preferring a high CHO diet to a lower CHO [Atkins] approach in weight management, from the point of view of risk reduction, but do not indicate a consistently more rapid weight loss with either diet." In other words, this study also refutes Atkins. One of the authors of this study, M.E.J. Lean, is the co-author of a 2004 editorial that cricizes Atkins ("Is Atkins dead (again) ?").
14. A study by Benoit, et al., 1965. This study is now more than forty years old and does not show up in the data retrieving services, although of course it is still available in hard copy. It is difficult to see any relevance to the Atkins claims in this study. Seven sailors were put on a 1000 calorie diet for 10 days, and were compared to another group of sailors who were fasting. Moreover Freedman, p. 9S, quoting Grande, questions the scientific validity of this study.
I have examined only a small number of Atkins' 315 footnotes, but of those I have looked at, not one, once checked, says what Atkins says it does.
How do other readers of Atkins respond to his footnotes ? How many readers will take the trouble that I took to check on these claims to scientific respectability ? How many readers will be impressed simply by these footnotes being in the book, without checking them ? Finally, what does the Atkins art of footnoting say about the scientific probity of the man and his "diet revolution" ?
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