BMJ Response: 19/10/18

Dear Dr Lahart, Guess, Mellor, and Nunan,

I am now in a position to respond more fully to your open letter. I appreciate your robust engagement with the BJSM. The BMJ encourages comment and criticism, and your questioning of the BJSM’s policy on freeing up content is an example of the scrutiny that all journals should welcome.

You raise a number of concerns: that governance of the journal’s decision making policies is not robust or transparent, leaving too much scope for individual editorial bias; that your rebuttal was not made freely available, which you maintain has allowed the BJSM editorial on low carb diets to be given an uncritical reception on social media; that these articles are “irrelevant,” by which I think you mean they are out of scope for the journal; and that the journal is publishing what you consider to be “imbalanced narratives.” You also question how the BJSM makes its decisions about which papers to free up. Finally, you ask about possible conflict of interests.

In order to respond to these concerns, I asked our publisher of BJSM (Ms Janet O’Flaherty) to update me on your complaints leading up to this open letter, I reviewed the articles you highlight, I discussed your concerns with senior members of BMJ staff, and I had a teleconference with Professor Khan (on Tuesday 16th October) as well as further email exchanges.

Governance of decision making policies: The BJSM shares the same overall governance processes, decision making policies, and commitment to transparency as all BMJ journals. In addition to the twice-yearly management meeting with co-owners BASEM and BMJ, the BJSM editors hold an annual two-day retreat at BMA House in London, which engages a wide group of staff from BMJ. The BJSM editor attends BMJ’s annual editors retreat and is in regular email contact with our publisher, associate publisher and myself. Professor Khan schedules working meetings in London about twice a year in conjunction with professional meetings. In short, there is a great deal of oversight of the BJSM and I am confident in the journal’s governance.

We are also committed to editorial independence. This is essential for the reputation any academic journal. It means, of course, that it is not unusual for readers and indeed owners to disagree with editors’ decisions. In relation to the specific issues raised in your letter, editors have the right to lead social media strategy and promote papers as they see fit. Professor Khan is an international leader in sport and exercise medicine, and I believe that he and his journal colleagues have done an exceptional job of promoting science and debate in the specialty worldwide.

Which papers does an editor choose to make freely available? Editors of BMJ journals are encouraged to make some of the articles they publish freely available, to promote engagement and debate beyond the immediate community of regular readers. These decisions are at their discretion and will therefore inevitably reflect their biases to some extent. Editing a journal is in many ways a subjective activity and we select our editors in chief with great care for that reason.

I agree that some balance should be attempted in what is freed up. BJSM has allocated 192 Editor’s Choice (free) papers between 2015 and 2018 of which five (2.6%) and not 10 as you say in your letter, went to articles that make the case that ‘low carb’ may be something to consider for health.[1][2][3][4][5] I don’t consider these five articles to be disproportionate among the body of work published or freed up by BJSM. I also note that the BMJ press officer, Caroline White, who makes her own decisions about what articles will interest the general public, chose articles by Dr Malhotra for press release in 2015 and 2017.[2][5]

The five freed up ‘low carb’ articles have four different sets of authors (Dr Malhotra the only common link) and include Dr Rita Redberg and Professor Timothy Noakes, both of whom are scientists with strong national peer-review funding records. Dr Zoe Harcombe’s work was part of a PhD thesis and she has also published in Open Heart, which is a sign that other peer-reviewers acknowledge the importance of her work. Dr Harcombe’s article criticising the ‘Eatwell Guide’ is consistent with the BJSM’s mission to challenge to the status quo in some settings. I note that this paper of hers was not freed up as an Editor’s Choice article. Professor Noakes’ narrative review on the possible risks of the standard western diet makes compelling reading. I believe one can make a case for these papers being important at a time when the adult lifetime risk of Type 2 diabetes mellitus is 50%. Who can be sure the status quo is correct?

Which leads me to the question of the journal’s openness to rebuttal of these views, and whether these rebuttals should themselves be made freely available when the article has been freed up. I think you make a good point. The BMJ and BMJ journals are exceptionally open to post-publication critique from readers, with easy to post and free to read rapid responses/e-letters. I understand that you did not avail yourself of the opportunity to submit a letter to the editor in the year or so after Dr Aseem Malhotra’s 2017 editorial on coronary artery inflammation was published, and that Professor Khan subsequently offered you an editorial in order to give prominence to your concerns. I interpret that as evidence against ‘editorial bias’ or ‘personal bias’ in relation to that article. Unlike electronic letters, editorials are not routinely made freely available. However, given the exceptional interest in the Malhotra article, Professor Khan and I acknowledge your concern. Your editorial has now been freed up on the website. http://ow.ly/A4mF30mioIv

Journal scope: Your letter suggests that you consider nutrition to be out of scope for the journal, since you call these articles “irrelevant.” This is an interesting question worthy of debate. Sports Medicine may traditionally have focussed on joints and tendons and muscles, but as with medicine more widely, and as reflected in recent articles commissioned for The BMJ, nutrition is now being properly recognised as an essential aspect of health. I therefore consider such topics to be well within the remit of BJSM. Professor Khan tells me that the agenda for the January 2019 retreat includes an item on revision of the scope of the journal to explicitly include research and debate on healthy eating, healthy weight, and dietary approaches to improving performance. Prompted by your letter, I have suggested that he might bring this item for discussion at an earlier meeting of the editorial board.

Conflicts of interest : You ask for “declaration of any and all relevant conflicts of interest relevant to the nature of this request, the related topics and/or any individuals it concerns.” This is a rather broadly framed request.

Reviewing your email exchanges with the associate publisher, Claire Langford, I gather that a key concern is about the handling of articles by members of the editorial board. Across all of our journals we strive to ensure that decisions about such papers are made in as independent a fashion as possible. This is not always easy to achieve, but the publisher has confirmed Professor Khan’s assurance to me that individual editors disqualify themselves from papers of authors with whom they have worked closely. BJSM has three editors and Dr Babette Pluim has served as the final decision-making editor for some of the ‘low carb’ papers you have cited.

Your open letter suggests a broader concern about conflicts of interest. Our conflict of interest policy is available here http://ow.ly/LDNB30milQL and Professor Khan’s conflict of interest statement can be found here https://bjsm.bmj.com/pages/wp-content/uploads/sites/17/2018/10/COI.pdf. If you are aware of any specific interests that have not been declared, whether by editors or authors, I hope you will let me know. BJSM does not accept sponsorship from the food industry.

In summary, I hope this resolves some of the concerns you have raised. Academic criticism such as yours is welcome and can be submitted in the form of articles through the usual journal channels or as rapid responses/e-letters, which as I have said above are freely available to readers. BJSM is of course just one channel among many for debate and discussion. Readers and authors can also post their own blogs, as you have done, can use all forms of social media, and can publish in many relevant journals. Nutrition is clearly a fertile area for research and healthy debate, which is why we have recently launched a new open access journal, BMJ Nutrition (nutrition.bmj.com), to which you are welcome to submit your work.

This reply will also be posted on the BJSM website.

All best wishes, Fiona Godlee

Hallberg S. ‘Reversing type 2 diabetes starts with ignoring the guidelines’: education from Dr Sarah Hallberg’s TEDx talk. Br J Sports Med 2018; 52: 869-871. Malhotra A, Redberg RF, Meier P. 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. Br J Sports Med 2017; 51: 1111-1112. Noakes TD, Windt J. Evidence that supports the prescription of low-carbohydrate high-fat diets: a narrative review. Br J Sports Med 2017; 51: 133-139. Harcombe Z. Dietary fat guidelines have no evidence base: where next for public health nutritional advice? Br J Sports Med 2017; 51: 769-774. Malhotra A, Noakes T, Phinney S. It is time to bust the myth of physical inactivity and obesity: you cannot outrun a bad diet. Br J Sports Med 2015; 49: 967-968.

Original Letter

Dear Ms Phipps, Dr Nagpaul, Dr Godlee, and Mr Holloway,

As academics (scientists, lecturers, researchers), practitioners and students in the fields of sport and exercise science and medicine, evidence-based medicine/health care, nutrition and dietetics, public health, general practice/family medicine, as well as patients and members of the public, we wish to express our concern about the editorial governance of the British Journal of Sports Medicine (BJSM).

We are specifically concerned about actions and consequences that are in direct opposition to the collective mission, values, and vision of not just the BJSM, but also each of your organisations.

We wish to highlight editorial bias at the BJSM evidenced by a lack of robust and transparent governance of the decision-making processes of the Editor in Chief (EIC). There appears to be an absence of systems to prevent personal views held or supported by the EIC from generating irrelevant and/or imbalanced narratives. If there are such systems, they are not being sufficiently enacted.

Evidence of editorial bias is provided in the form of the following:

A post on Pubpeer from signatories of this letter providing complete details of actions by the EIC and ensuing discussions with the EIC that indicate a lack of appropriate governing systems (or at least unwillingness by the EIC to share information on such systems should they exist) and illustrates the impact of personal bias leading to imbalanced dissemination and promotion of a particular narrative by the BJSM: https://pubpeer.com/publications/0C1B5A45793038A959D0ADAA168ADA A blog that briefly outlines the details of the Pubpeer post here: http://www.weightymatters.ca/2018/10/guest-post-does-bmj-publishing-group.html

We provide a summary of the evidence in an Appendix at the bottom of this letter.

WHY WE ARE WRITING THIS LETTER:

It is important in the spirit of this debate that we too are transparent; the purpose of this letter is not to query the narratives being promoted per se (this is done anyway in the paywall rebuttals), but to highlight the lack of editorial processes and policies that should be in place (or their misapplication if they are) to prevent bias in outputs and their dissemination by the BJSM.

Furthermore, we believe that the publication of these irrelevant and/or imbalanced narratives is in direct opposition and/or falls short of the aims and objectives of the journal (https://bjsm.bmj.com/pages/about/):

** British Journal of Sports Medicine (BJSM) is a multi-media portal that provides original research, reviews and debate relating to clinically-relevant aspects of sport and exercise medicine, including physiotherapy, physical therapy and rehabilitation. We contribute to innovation (research), education (teaching and learning) and knowledge translation (implementing research into practice and policy). Our web, print, video and audio material, combined with active social media, serves the international community of clinicians who treat active people.**

The BMA (https://www.bma.org.uk/about-us/mission-vision-and-values):

** We are an indispensable source of credible information, guidance and support throughout doctors’ professional lives.

– The BMA welcomes open debate and free exchange of ideas.**

The BMJ Publishing group (https://www.bmj.com/company/who-we-are/values/):

** Our mission is to advance healthcare worldwide by sharing knowledge and expertise to improve experiences and outcomes. [values include]:

– Improving health care requires independent and unbiased information, even if this means challenging perceived wisdom.

– The best decisions depend on the best evidence.

– We create trust by being transparent and open.**

And BASEM (https://www.basem.co.uk/about-us/):

** The British Association of Sport and Exercise Medicine (BASEM) was founded in 1952 and is the largest multidisciplinary sports medicine organisation in the UK, offering full membership to medical practitioners and associate membership to allied professionals such as physiotherapists and sports scientists.

BASEM has its own internationally recognised journal, The British Journal of Sports Medicine and is dedicated to the promotion of good health through physical activity and the provision of sports medicine expertise to optimise athletic performance at all levels.

The Association aims to provide support and education to all healthcare professionals involved in the care of athletes and individuals undertaking, or aspiring to undertake, regular physical activity at all levels.

– 3.6 To promote the adoption of evidenced-based practice in all areas of Sport and Exercise Medicine;**

WHAT WE WOULD LIKE TO HAPPEN:

Our aim is to improve the systems in place at the BJSM to prevent editorial bias resulting in imbalanced outputs and their dissemination.

We also want better systems to ensure appropriate inclusion of topics and discussions which are relevant to the journal’s aims and readership.

Given the above, we welcome your individual responses to the following:

Do you intend to investigate these charges? If so, we should be grateful if you would detail, step-by-step, how you will go about this and the anticipated timelines. If you do not intend to investigate, please could you outline your reasons? If your investigation confirms that editorial governance at the BJSM is currently lacking systems that prevent avoidable biases as we have described, we should be grateful if you would detail in a transparent manner the procedures you will undertake to develop such robust systems and how these will be adopted, monitored, and enacted (where necessary). If your investigation confirms that editorial governance at the BJSM already includes sufficient systems in place to prevent avoidable biases as described, please detail in a transparent manner why these appear not to have been enacted in the examples highlighted in this letter and why the EIC is unwilling to share details of these systems. Will you provide a written, public statement outlining the reasons and nature of any investigations you will undertake and the resultant outcomes of any such investigations? Equally, if you do not intend to conduct an investigation, will you provide a written public statement outlining the nature of the call for an investigation and your reasons for not conducting one? We would welcome declaration of any and all relevant conflicts of interest relevant to the nature of this request, the related topics and/or any individuals it concerns. The lead signatories of this letter have provided their DOIs at the bottom of the page.

Yours faithfully,

***************************

NOTES FOR SIGNATORIES

This letter is coordinated by the authors of the most recent relevant rebuttal in the BJSM. Please direct any queries to Ian Lahart (i.lahart@wlv.ac.uk) or David Nunan (david.nunan@phc.ox.ac.uk) The BJSM’s Editorial Board remit:

(1) The BJSM and IPHP Editorial Boards work hand in hand to deliver quality clinically relevant material for the sports medicine community. We use the Blog, Podcasts, Web and Print resources to share cutting-edge material. The IPHP group focuses particularly, but not exclusively, on the four issues of BJSM that are supported by the International Olympic Committee.

(2) The Senior Associate Editors are responsible for journal direction. They provide diverse input representing the various disciplines in our field, geographic perspectives and areas of specialisation.

(3) Associate Editors support the Senior Associate Editors in relation to journal strategy and play a major role in reviewing and in suggesting appropriate reviewers.

(4) The Editorial Board serves in various roles including connecting BJSM with various end-user groups, suggesting emerging themes and providing peer review more frequently than do “occasional” reviewers.

A list of signatories will be pasted beneath these notes and updated at regular intervals. Some people who would like to sign the letter have expressed concern at potential ramifications for their current/future career prospects if they did so. Whilst this is a sad, but nonetheless telling, reflection of the current status quo, we respect this decision. With their permission, we have compiled a google sheet of such emails with individuals’ details redacted: https://docs.google.com/spreadsheets/d/10uAj48ne7rR3YYYTi3727jsqqJtlDjGpXO0Ehh_kX0o/edit?usp=sharing We are collecting email addresses to verify responses. You will only receive one email confirming receipt and one follow-up email notifying all signatories when the letter is sent to the BMA, the BMJ, and BASEM. We are posting responses from the BMA, BMJ and BASEM if and when we receive them here:

https://docs.google.com/spreadsheets/d/1mNUotdIlSqtqz7hnRnnI_0BsOTLWBkVIMswExbtYetk/edit?usp=sharing

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