Scientific Writing, HRP 214 Weekly Quiz

1
Scientific Writing, HRP 214Weekly Quiz
2
Scientific Writing, HRP 214Weekly Quiz

• A. It was a secret among friends.
• B. It was a secret between friends.

3
Scientific Writing, HRP 214Weekly Quiz

• A. It was a secret among friends.
• B. It was a secret between friends.

4
Scientific Writing, HRP 214Weekly Quiz

• A. The close friendship that existed between
  them was quickly dissolved.
• B. The close friendship that existed among them
  was quickly dissolved.

5
Scientific Writing, HRP 214Weekly Quiz

• A. The close friendship that existed between
  them was quickly dissolved.
• B. The close friendship that existed among them
  was quickly dissolved.

6
Scientific Writing, HRP 214 Weekly Quiz

• A. She eluded to the fight that occurred earlier.
• B. She alluded to the the fight that occurred
  earlier.

7
Scientific Writing, HRP 214 Weekly Quiz

• A. She eluded to the fight that occurred earlier.
• B. She alluded to the the fight that occurred
  earlier.

8
Scientific Writing, HRP 214 Weekly Quiz

• A. She eluded the fight.
• B. She alluded the fight.

9
Scientific Writing, HRP 214 Weekly Quiz

• A. She eluded the fight.
• B. She alluded the fight.

10
Scientific Writing, HRP 214Weekly Quiz

• A. She lies out in the sun.
• B. She lays out in the sun.

11
Scientific Writing, HRP 214Weekly Quiz

• A. She lies out in the sun.
• B. She lays out in the sun.

12
Scientific Writing, HRP 214Weekly Quiz

• A. She is lying out in the sun.
• B. She is laying out in the sun.

13
Scientific Writing, HRP 214Weekly Quiz

• A. She is lying out in the sun.
• B. She is laying out in the sun.

14
Scientific Writing, HRP 214Weekly Quiz

• A. She laid out in the sun yesterday.
• B. She lay out in the sun yesterday.

15
Scientific Writing, HRP 214Weekly Quiz

• A. She laid out in the sun yesterday.
• B. She lay out in the sun yesterday.

16
Scientific Writing, HRP 214Weekly Quiz

• A. She had laid out in the sun too much as a kid.
• B. She had lain out in the sun too much as a kid.

17
Scientific Writing, HRP 214Weekly Quiz

• A. She had laid out in the sun too much as a kid.
• B. She had lain out in the sun too much as a kid.

18
Scientific Writing, HRP 214Weekly Quiz

• A. She lies the book on the table.
• B. She lays the book on the table.

19
Scientific Writing, HRP 214Weekly Quiz

• A. She lies the book on the table.
• B. She lays the book on the table.

20
Scientific Writing, HRP 214Weekly Quiz

• A. She is lying the book on the table.
• B. She is laying the book on the table.

21
Scientific Writing, HRP 214Weekly Quiz

• A. She is lying the book on the table.
• B. She is laying the book on the table.

22
Scientific Writing, HRP 214Weekly Quiz

• A. She laid the book on the table this morning.
• B. She lay the book on the table this morning.

23
Scientific Writing, HRP 214Weekly Quiz

• A. She laid the book on the table this morning.
• B. She lay the book on the table this morning.

24
Scientific Writing, HRP 214Weekly Quiz

• A. She had lain the book on the table.
• B. She had laid the book on the table.

25
Scientific Writing, HRP 214Weekly Quiz

• A. She had lain the book on the table.
• B. She had laid the book on the table.

26
Scientific Writing, HRP 214Weekly Quiz

• A. Now I lay down to sleep.
• B. Now I lie down to sleep.

27
Scientific Writing, HRP 214Weekly Quiz

• A. Now I lay down to sleep.
• B. Now I lie down to sleep.

28
Scientific Writing, HRP 214Weekly Quiz

• A. Now I lay me down to sleep.
• B. Now I lie me down to sleep.

29
Scientific Writing, HRP 214Weekly Quiz

• A. Now I lay me down to sleep.
• B. Now I lie me down to sleep.

30
Scientific Writing, HRP 214Weekly Quiz

• A. She commented on the clearly defined mutant
  traits.
• B. She commented on the clearly-defined mutant
  traits.

31
Scientific Writing, HRP 214Weekly Quiz

• A. She commented on the clearly defined mutant
  traits.
• B. She commented on the clearly-defined mutant
  traits.

32
Scientific Writing, HRP 214Weekly Quiz

• A. I am disinterested in your results.
• B. I am uninterested in your results.

33
Scientific Writing, HRP 214Weekly Quiz

• A. I am disinterested in your results.
• B. I am uninterested in your results.

34
Scientific Writing, HRP 214 Weekly Quiz

• A. We think you should look into an alternative
  career path, i.e. get a new job.
• B. We think you should look into an alternative
  career path, e.g. get a new job.

35
Scientific Writing, HRP 214 Weekly Quiz

• A. We think you should look into an alternative
  career path, i.e. get a new job.
• B. We think you should look into an alternative
  career path, e.g. get a new job.

36
Scientific Writing, HRP 214 Weekly Quiz

• A. They prefer mixed drinks, e.g. gin and tonic
  or martinis.
• B. They prefer mixed drinks, i.e. gin and tonic
  or martinis.

37
Scientific Writing, HRP 214 Weekly Quiz

• A. They prefer mixed drinks, e.g. gin and tonic
  or martinis.
• B. They prefer mixed drinks, i.e. gin and tonic
  or martinis.

38
Scientific Writing, HRP 214 Weekly Quiz

• She served as a disinterested party in the
  dispute.
• She served as an uninterested party in the
  dispute.

39
Scientific Writing, HRP 214 Weekly Quiz

• She served as a disinterested party in the
  dispute.
• She served as an uninterested party in the
  dispute.

40
Scientific Writing, HRP 214 Weekly Quiz

• A. You should eat more sweets, e.g. chocolate.
• B. You should eat more sweets, i.e. chocolate.

41
Scientific Writing, HRP 214 Weekly Quiz

• A. You should eat more sweets, e.g. chocolate.
• B. You should eat more sweets, i.e. chocolate.

42
Scientific Writing, HRP 214 Weekly Quiz

• A. Runners who develop overuse running-related
  injuries have lower intakes of several key
  nutrients compared to non-injured runners.
• B. Runners who develop overuse running-related
  injuries have lower intakes of several key
  nutrients compared with non-injured runners.

43
Scientific Writing, HRP 214 Weekly Quiz

• A. Runners who develop overuse running-related
  injuries have lower intakes of several key
  nutrients compared to non-injured runners.
• B. Runners who develop overuse running-related
  injuries have lower intakes of several key
  nutrients compared with non-injured runners.

44
Scientific Writing, HRP 214 Weekly Quiz

• A. Over half the runners sustained an injury
  during the year.
• B. More than half the runners sustained an injury
  during the year.

45
Scientific Writing, HRP 214 Weekly Quiz

• A. Over half the runners sustained an injury
  during the year.
• B. More than half the runners sustained an injury
  during the year.

46
Scientific Writing, HRP 214

• Lecture 7
• The Abstract, Introduction, and Discussion

47
Scientific Writing, HRP 214Abstracts

• Abstracts (about, traherepull to pull out)
• Overview of the main story
• Gives highlights from each section of the paper
• Limited length (100-300 words, typically)
• Stands on its own
• Used, with title, for electronic search engines
• Most often, the only part people read

48
Scientific Writing, HRP 214Abstracts

• Gives
• Background
• Question asked
• We asked whether, We hypothesized that,etc.
• Experiment(s) done
• Material studied (molecule, cell line, tissue,
  organ) or the animal or human population studied
• The experimental approach or study design and the
  independent and dependent variables
• Results found
• Key results found
• Minimal raw data (prefer summaries)
• The answer to the question asked
• Implication, speculation, or recommendation

49
Scientific Writing, HRP 214Abstracts

• Abstracts may be structured (with subheadings) or
  free-form.

50
Scientific Writing, HRP 214Abstracts

• Structured example (The Lancet, 2006 Feb
  11367(9509)475-81.)
• Development of adenoviral-vector-based pandemic
  influenza vaccine against antigenically distinct
  human H5N1 strains in mice.
• Hoelscher MA, Garg S, Bangari DS, Belser JA, Lu
  X, Stephenson I, Bright RA, Katz JM, Mittal SK,
  Sambhara S.

51
Scientific Writing, HRP 214Abstracts

• INTRODUCTION Avian H5N1 influenza viruses
  currently circulating in southeast Asia could
  potentially cause the next pandemic. However,
  currently licensed human vaccines are
  subtype-specific and do not protect against these
  H5N1 viruses. We aimed to develop an influenza
  vaccine and assessed its immunogenicity and
  efficacy to confer protection in BALB/c mice.
• METHODS We developed an egg-independent strategy
  to combat the avian influenza virus, because the
  virus is highly lethal to chickens and the
  maintenance of a constant supply of embryonated
  eggs would be difficult in a pandemic. We used a
  replication-incompetent, human adenoviral-vector-b
  ased, haemagglutinin subtype 5 influenza vaccine
  (HAd-H5HA), which induces both humoral and
  cell-mediated immune responses against avian H5N1
  influenza viruses isolated from people.

52
Scientific Writing, HRP 214Abstracts

• FINDINGS Immunisation of mice with HAd-H5HA
  provided effective protection from H5N1 disease,
  death, and primary viral replication (plt0.0001)
  against antigenically distinct strains of H5N1
  influenza viruses. Unlike the recombinant H5HA
  vaccine, which is based on a traditional subunit
  vaccine approach, HAd-H5HA vaccine induced a
  three-fold to eight-fold increase in
  HA-518-epitope-specific interferon-gamma-secreting
  CD8 T cells (p0.01).
• INTERPRETATION Our findings highlight the
  potential of an Ad-vector-based delivery system,
  which is both egg-independent and
  adjuvant-independent and offers stockpiling
  options for the development of a pandemic
  influenza vaccine.

53
Scientific Writing, HRP 214Abstracts

• Structured example 2
• N Engl J Med. 2006 Feb 16354(7)684-96.
• Calcium plus vitamin D supplementation and the
  risk of colorectal cancer.
• Wactawski-Wende J, Kotchen JM, Anderson GL,
  Assaf AR, Brunner RL, O'Sullivan MJ, Margolis KL,
  Ockene JK, Phillips L, Pottern L, Prentice RL,
  Robbins J, Rohan TE, Sarto GE, Sharma S,
  Stefanick ML, Van Horn L, Wallace RB, Whitlock E,
  Bassford T, Beresford SA, Black HR, Bonds DE,
  Brzyski RG, Caan B, Chlebowski RT, Cochrane B,
  Garland C, Gass M, Hays J, Heiss G, Hendrix SL,
  Howard BV, Hsia J, Hubbell FA, Jackson RD,
  Johnson KC, Judd H, Kooperberg CL, Kuller LH,
  LaCroix AZ, Lane DS, Langer RD, Lasser NL, Lewis
  CE, Limacher MC, Manson JE Women's Health
  Initiative Investigators.

54
Scientific Writing, HRP 214Abstracts

• ABSTRACT
• BACKGROUND Higher intake of calcium and vitamin
  D has been associated with a reduced risk of
  colorectal cancer in epidemiologic studies and
  polyp recurrence in polyp-prevention trials.
  However, randomized-trial evidence that calcium
  with vitamin D supplementation is beneficial in
  the primary prevention of colorectal cancer is
  lacking.
• METHODS We conducted a randomized, double-blind,
  placebo-controlled trial involving 36,282
  postmenopausal women from 40 Women's Health
  Initiative centers 18,176 women received 500 mg
  of elemental calcium as calcium carbonate with
  200 IU of vitamin D3 twice daily (1000 mg of
  elemental calcium and 400 IU of vitamin D3) and
  18,106 received a matching placebo for an average
  of 7.0 years. The incidence of pathologically
  confirmed colorectal cancer was the designated
  secondary outcome. Baseline levels of serum
  25-hydroxyvitamin D were assessed in a nested
  case-control study.

55
Scientific Writing, HRP 214Abstracts

• RESULTS The incidence of invasive colorectal
  cancer did not differ significantly between women
  assigned to calcium plus vitamin D
  supplementation and those assigned to placebo
  (168 and 154 cases hazard ratio, 1.08 95
  percent confidence interval, 0.86 to 1.34
  P0.51), and the tumor characteristics were
  similar in the two groups. The frequency of
  colorectal-cancer screening and abdominal
  symptoms was similar in the two groups. There
  were no significant treatment interactions with
  baseline characteristics.
• CONCLUSIONS Daily supplementation of calcium
  with vitamin D for seven years had no effect on
  the incidence of colorectal cancer among
  postmenopausal women. The long latency associated
  with the development of colorectal cancer, along
  with the seven-year duration of the trial, may
  have contributed to this null finding. Ongoing
  follow-up will assess the longer-term effect of
  this intervention.

56
Scientific Writing, HRP 214Abstracts

• Even more subheadings
• Effect of Rimonabant, a Cannabinoid-1 Receptor
  Blocker, on Weight and Cardiometabolic Risk
  Factors in Overweight or Obese Patients RIO-North
  America A Randomized Controlled Trial
• F. Xavier Pi-Sunyer, MD Louis J. Aronne, MD
  Hassan M. Heshmati, MD Jeanne Devin, MS Julio
  Rosenstock, MD for the RIO-North America Study
  Group
• JAMA. 2006295761-775.

57
Scientific Writing, HRP 214Abstracts

• Context  Rimonabant, a selective cannabinoid-1
  receptor blocker, may reduce body weight and
  improve cardiometabolic risk factors in patients
  who are overweight or obese.
• Objective To compare the efficacy and safety of
  rimonabant with placebo each in conjunction with
  diet and exercise for sustained changes in weight
  and cardiometabolic risk factors over 2 years.
• Design, Setting, and Participants  Randomized,
  double-blind, placebo-controlled trial of 3045
  obese (body mass index 30) or overweight (body
  mass index gt27 and treated or untreated
  hypertension or dyslipidemia) adult patients at
  64 US and 8 Canadian clinical research centers
  from August 2001 to April 2004.
• Intervention  After a 4-week single-blind
  placebo plus diet (600 kcal/d deficit) run-in
  period, patients were randomized to receive
  placebo, 5 mg/d of rimonabant, or 20 mg/d of
  rimonabant for 1 year. Rimonabant-treated
  patients were rerandomized to receive placebo or
  continued to receive the same rimonabant dose
  while the placebo group continued to receive
  placebo during year 2.

58
Scientific Writing, HRP 214Abstracts

• Results  At year 1, the completion rate was 309
  (51) patients in the placebo group, 620 (51)
  patients in the 5 mg of rimonabant group, and 673
  (55) patients in the 20 mg of rimonabant group.
  Compared with the placebo group, the 20 mg of
  rimonabant group produced greater mean (SEM)
  reductions in weight (6.3 0.2 kg vs 1.6 0.2
  kg Plt.001), waist circumference (6.1 0.2 cm
  vs 2.5 0.3 cm Plt.001), and level of
  triglycerides (percentage change, 5.3 1.2 vs
  7.9 2.0 Plt.001) and a greater increase in
  level of high-density lipoprotein cholesterol
  (percentage change, 12.6 0.5 vs 5.4 0.7
  Plt.001). Patients who were switched from the 20
  mg of rimonabant group to the placebo group
  during year 2 experienced weight regain while
  those who continued to receive 20 mg of
  rimonabant maintained their weight loss and
  favorable changes in cardiometabolic risk
  factors. Use of different imputation methods to
  account for the high rate of dropouts in all 3
  groups yielded similar results. Rimonabant was
  generally well tolerated the most common
  drug-related adverse event was nausea (11.2 for
  the 20 mg of rimonabant group vs 5.8 for the
  placebo group).

59
Scientific Writing, HRP 214Abstracts

• Conclusions  In this multicenter trial,
  treatment with 20 mg/d of rimonabant plus diet
  for 2 years promoted modest but sustained
  reductions in weight and waist circumference and
  favorable changes in cardiometabolic risk
  factors. However, the trial was limited by a high
  drop-out rate and longer-term effects of the drug
  require further study.

60
Scientific Writing, HRP 214Abstracts

• Science. 2006 Feb 17311(5763)1020-2. Causal
  reasoning in rats. Blaisdell AP, Sawa K, Leising
  KJ, Waldmann MR.
• Empirical research with nonhuman primates
  appears to support the view that causal reasoning
  is a key cognitive faculty that divides humans
  from animals. The claim is that animals
  approximate causal learning using associative
  processes. The present results cast doubt on that
  conclusion. Rats made causal inferences in a
  basic task that taps into core features of causal
  reasoning without requiring complex physical
  knowledge. They derived predictions of the
  outcomes of interventions after passive
  observational learning of different kinds of
  causal models. These competencies cannot be
  explained by current associative theories but are
  consistent with causal Bayes net theories.

61
Scientific Writing, HRP 214Introduction and
Background

• Introduction and Background Section

62
Scientific Writing, HRP 214Introduction and
Background

• The Literature Search
• Utilize online databases, such as MEDLINE,
  PubMed, and Ovid.
• Have a search strategy.
• Have an organizational system!

63
Scientific Writing, HRP 214Introduction and
Background

• The Literature Review
• Summarize the current state of knowledge in the
  area of investigation.
• You may have to return to the literature once
  your results are in hand.
• Assume your reader is knowledgeable about the
  field.
• Do not provide an exhaustive historical review.
• Avoid nonessential details.
• Summarize previous results and conclusions, but
  do not give the methods that generated these
  findings unless they are relevant to your
  research question (i.e., your experiment
  addresses a specific methodologic limitation of
  previous experiments)
• Refer the reader to general surveys or reviews of
  the topic if available.
• Cite references that reflect the key work that
  led to your research question.
• Limit the number of references.

64
Scientific Writing, HRP 214

• In writing the literature review, summarize
  rather than listing every possible reference and
  example.

65
Scientific Writing, HRP 214Introduction and
Background

• Introduction and Background
• 1. Whats known
• 2. Whats unknown
• limitations and gaps in previous studies
• 3. Your burning question
• 4. Your experimental approach
• 5. Why your experimental approach is new and
  different and important

• From Essentials of Writing Biomedical Research
  Papers by Mimi Zeiger

66
Scientific Writing, HRP 214Introduction

• Tell a story
• Write it in plain English, not tech-speak.
• Take the reader step by step from what is known
  to what is unknown. End with your specific
  question.
• (Known?Unknown?Question)
• Emphasize what is new and important about your
  work.
• Do not state the answer to the research question.
• Do not include results or implications.

67
Introduction

• Overweight, Obesity, and Mortality from Cancer in
  a Prospectively Studied Cohort of U.S.
  AdultsEugenia E. Calle, Ph.D., Carmen Rodriguez,
  M.D., M.P.H., Kimberly Walker-Thurmond, B.A., and
  Michael J. Thun, M.D.  

68

• The relations between excess body weight and
  mortality, not only from all causes but also from
  cardiovascular disease, are well
  established.1,2,3,4,5,6 Although we have known
  for some time that excess weight is also an
  important factor in death from cancer,7 our
  knowledge of the magnitude of the relation, both
  for all cancers and for cancers at individual
  sites, and the public health effect of excess
  weight in terms of total mortality from cancer is
  limited. Previous studies have consistently shown
  associations between adiposity and increased risk
  of cancers of the endometrium, kidney,
  gallbladder (in women), breast (in postmenopausal
  women), and colon (particularly in
  men).8,9,10,11,12 Adenocarcinoma of the esophagus
  has been linked to obesity.11,13,14 Data on
  cancers of the pancreas, prostate, liver, cervix,
  and ovary and on hematopoietic cancers are scarce
  or inconsistent.7,8,9,10,11,15,16,17 The lack of
  consistency may be attributable to the limited
  number of studies (especially those with
  prospective cohorts), the limited range and
  variable categorization of overweight and obesity
  among studies, bias introduced by reverse
  causality with respect to smoking-related
  cancers, and possibly real differences between
  the effects of overweight and obesity on the
  incidence of cancer and on the rates of death
  from some cancers.18,19
• We conducted a prospective investigation in a
  large cohort of U.S. men and women to determine
  the relations between body-mass index (the weight
  in kilograms divided by the square of the height
  in meters) and the risk of death from cancer at
  specific sites. This cohort has been used
  previously to examine the association of
  body-mass index and death from any cause.5

69
Scientific Writing, HRP 214

• Introduction
• Exogenous estrogens prevent or substantially
  retard the decrease in bone mineral density (BMD)
  that accompanies menopause 1. However, it is
  unclear whether exogenous estrogens, administered
  as oral contraceptives (OCs), can modify
  premenopausal BMD. Several studies suggest that
  exposure to OCs during the premenopausal years
  has a favorable effect on BMD 2-10, whereas
  other studies show no effect 11-18.
• Past studies of the relationship between OC use
  and BMD have several limitations. Studies have
  focused primarily on crude measures of OC use,
  such as current, past and never. These
  categories combine diverse types of OC use and
  may reduce the power to detect an effect. Many
  studies also failed to take into account
  lifestyle characteristics of study participants.
  Finally, few studies have considered an effect of
  OCs on BMD in women of races other than white.
• The aim of this study was to evaluate the
  associations of OCs with spine, hip and whole
  body BMD in black and white premenopausal women.
  Our primary hypothesis was that there would be an
  association between cumulative exposure to
  estrogen from OCs and BMD.

70
Scientific Writing, HRP 214

• Neurohumoral Features of Myocardial Stunning Due
  to Sudden Emotional StressIlan S. Wittstein,
  M.D., David R. Thiemann, M.D., Joao A.C. Lima,
  M.D., Kenneth L. Baughman, M.D., Steven P.
  Schulman, M.D., Gary Gerstenblith, M.D.,
  Katherine C. Wu, M.D., Jeffrey J. Rade, M.D.,
  Trinity J. Bivalacqua, M.D., Ph.D., and Hunter C.
  Champion, M.D., Ph.D. T
• New Engl J Med Volume 352539-548 Feb 10, 2005.

71
Scientific Writing, HRP 214

• The potentially lethal consequences of emotional
  stress are deeply rooted in folk wisdom, as
  reflected by phrases such as "scared to death"
  and "a broken heart." In the past decade, cardiac
  contractile abnormalities and heart failure have
  been reported after acute emotional
  stress,1,2,3,4,5,6 but the mechanism remains
  unknown. We evaluated 19 patients with "stress
  cardiomyopathy," a syndrome of profound
  myocardial stunning precipitated by acute
  emotional stress, in an effort to identify the
  clinical features that distinguish this syndrome
  from acute myocardial infarction and the cause of
  transient stress-induced myocardial dysfunction.

72
Introduction systematic review

• Effectiveness of speed cameras in preventing
  road traffic collisions and related casualties
  systematic review
• Paul Pilkington, lecturer in public health1,
  Sanjay Kinra, lecturer in epidemiology and public
  health medicine2 1 University of the West of
  England, Faculty of Health and Social Care,
  Bristol BS16 1DD, 2 Department of Social
  Medicine, University of Bristol, Bristol .
• BMJ Feb. 10, 2005

73

• Road traffic collisions are an important cause
  of death and disability worldwide. Every year
  around the world 1.2 million people are killed
  and up to 50 million are injured or disabled as a
  result of road traffic collisions.1 Morbidity
  from road traffic collisions is expected to
  increase in future years, and it is estimated
  that road traffic collisions will move from ninth
  to third place in the global burden of disease
  ranking, as measured in disability adjusted life
  years.2 3
• Measures to reduce traffic speed are considered
  essential to reducing casualties on the road.1 4
  5 Speed cameras are increasingly used to help to
  reduce traffic speeds in the belief that this
  will reduce road traffic collisions and
  casualties, and an expansion in the use of speed
  cameras is under way in many countries, most
  notably the United Kingdom.6 The use of speed
  cameras is controversial, however. Vociferous
  opponents, including some motoring associated
  organisations, oppose their use, and cameras are
  often criticised in the media.7-9 The lack of
  readily available evidence of the effectiveness
  of cameras has made it difficult for road safety
  and health professionals to engage in an informed
  debate about the effectiveness of speed cameras.
• A previous small non-systematic review of six
  studies found a 17 reduction in collisions after
  introduction of speed cameras.10 Non-systematic
  reviews can, however, be limited by bias. We
  aimed, therefore, to systematically assess the
  evidence for the effectiveness of speed cameras
  in reducing road traffic collisions and related
  casualties.

74
Introduction cohort study

• Adherence to Mediterranean diet and risk of
  developing diabetes prospective cohort study
• M Á Martínez-González, professor of epidemiology
  and chair,1 C de la Fuente-Arrillaga, research
  assistant,1 J M Nunez-Cordoba, research
  fellow,1,2 F J Basterra-Gortari, research
  fellow,1,3 J J Beunza, assistant professor,1 Z
  Vazquez, research assistant,1 S Benito, research
  assistant,1 A Tortosa, research fellow,1 and M
  Bes-Rastrollo, assistant professor1
• BMJ June 14, 2008

75

• Diabetes mellitus is an increasingly important
  global public health problem that threatens to
  reach pandemic levels by 2030.1 2 As some
  randomised trials have consistently shown,
  increased physical activity and weight loss are
  efficient approaches for the control and
  prevention of type 2 diabetes.3 4 Diet has also
  long been believed to be an important risk factor
  for diabetes. Many studies have shown that the
  Mediterranean food pattern has a role in
  prevention of cardiovascular disease.5 6 7 8 9
  The similarity of some risk factors and some
  empirical and mechanistic evidence suggest that
  the Mediterranean diet can also protect against
  diabetes. The major protective characteristics
  include a high intake of fibre, a high intake of
  vegetable fat, a low intake of trans fatty acids,
  and a moderate intake of alcohol.4 10 11
  Moreover, a particular feature of the diet is the
  abundant use of virgin olive oil for cooking,
  frying, spreading on bread, or dressing salads.12
  This leads to a high ratio of monounsaturated
  fatty acids to saturated fatty acids. This ratio
  can be used to score adherence to a Mediterranean
  diet8 as the traditional diet. Despite having a
  relatively high total fat content, this food
  pattern is rich in monounsaturated fatty acids
  (from olive oil) and poor in saturated fatty
  acids. Diets rich in monounsaturated fatty acids
  improve lipid profiles and glycaemic control in
  people with diabetes, suggesting that a high
  intake improves insulin sensitivity.13 14 15 16
  Together these associations suggest the
  hypothesis that following an overall pattern of
  Mediterranean diet can protect against diabetes.
  In addition to having a long tradition of use
  without evidence of harm, a Mediterranean diet is
  highly palatable, and people are likely to comply
  with it.17

76

• Few prospective studies have evaluated the
  specific role of the Mediterranean diet on the
  risk of developing diabetes in initially healthy
  Mediterranean populations. A prospective
  follow-up study recently reported an inverse
  association between adherence to the diet and the
  incidence of diabetes.18 All members of that
  study, however, had survived a previous
  myocardial infarction and the tool to assess
  dietary habits had inherent limitations because
  it included only a short list of items, and the
  authors did not attempt to measure the entire
  diet.
• We evaluated the association between adherence to
  a Mediterranean diet and the incidence of
  diabetes using a full validated food frequency
  questionnaire to measure the entire diet.

77
Scientific Writing, HRP 214Introduction and
Background

• Introduction and Background
• 1. Whats known
• 2. Whats unknown
• limitations and gaps in previous studies
• 3. Your burning question
• 4. Your experimental approach
• 5. Why your experimental approach is new and
  different and important

• From Essentials of Writing Biomedical Research
  Papers by Mimi Zeiger

78
Scientific Writing, HRP 214Introduction

• Tell a story
• Write it in plain English, not tech-speak.
• Take the reader step by step from what is known
  to what is unknown. End with your specific
  question.
• (Known?Unknown?Question)
• Emphasize what is new and important about your
  work.
• Do not state the answer to the research question.
• Do not include results or implications.

79
Scientific Writing, HRP 214THE DISCUSSION

• The Discussion is the section that
• Gives you the most freedom
• Gives you the most chance to put good writing on
  display
• Is the most challenging to write

80
Scientific Writing, HRP 214The Discussion

• Follow your rules for good writing!

81
Scientific Writing, HRP 214The Discussion

• The purpose of the discussion
• Answer the question posed in the Introduction
• Support your conclusion with details (yours,
  others)
• Defend your conclusion (acknowledge limits)
• Highlight the broader implications of the work
• i.e., What do my results mean and why should
  anyone care?

82
Framework of the Discussion
Table 2, Adapted From Welch HG. Preparing
Manuscripts for Submission to Medical Journals
The Paper Trail. Effective Clinical Practice.
1999 2 131-137.
83
Scientific Writing, HRP 214The Discussion

• The introduction moves from general to specific.
  
• The discussion moves from specific to general.

84
Scientific Writing, HRP 214The Discussion

• Elements of the typical discussion section

85

• Key finding (answer to the question(s) asked in
  Intro.)
• Supporting explanation, details (lines of
  evidence)
• Possible mechanisms or pathways
• Is this finding novel?
• Key secondary findings
• Context
• Compare your results with other peoples results
• Compare your results with existing paradigms
• Explain unexpected or surprising findings
• Strengths and limitations
• Whats next
• Recommended confirmatory studies (needs to be
  confirmed)
• Unanswered questions
• Future directions
• The so what? implicate, speculate, recommend
• Clinical implications of basic science findings
• Strong conclusion (kicker!)

86
EXAMPLE Samaha FF, Iqbal N, Seshadri P, et al.
A low-carbohydrate as compared with a low-fat
diet in severe obesity. N Engl J Med
20033482074-2081.

• INTRODUCTION
• The differences in health benefits between a
  carbohydrate-restricted diet and a calorie- and
  fat-restricted diet are of considerable public
  interest. However, there is concern that a
  carbohydrate-restricted diet will adversely
  affect serum lipid concentrations.1 Previous
  studies demonstrating that healthy volunteers
  following a low-carbohydrate diet can lose weight
  have involved few subjects, and few used a
  comparison group that followed consensus
  guidelines for weight loss.2,3 The reported
  effects of a carbohydrate-restricted diet on risk
  factors for atherosclerosis have varied.2,3,4 We
  performed a study designed to test the hypothesis
  that severely obese subjects with a high
  prevalence of diabetes or the metabolic syndrome
  a would have a greater weight loss, b without
  detrimental effects on risk factors for
  atherosclerosis, while on a carbohydrate-restricte
  d (low-carbohydrate) diet than on a calorie- and
  fat-restricted (low-fat) diet.

87
Scientific Writing, HRP 214The Discussion

• 1. We found that severely obese subjects with a
  high prevalence of diabetes and the metabolic
  syndrome lost more weight in a six-month period
  on a carbohydrate-restricted diet than on a fat-
  and calorie-restricted diet. answer to a The
  greater weight loss in the low-carbohydrate group
  suggests a greater reduction in overall caloric
  intake, rather than a direct effect of
  macronutrient composition. mechanisms However,
  the explanation for this difference is not clear.
  Subjects in this group may have experienced
  greater satiety on a diet with liberal
  proportions of protein and fat. However, other
  potential explanations include the simplicity of
  the diet and improved compliance related to the
  novelty of the diet. possible mechanisms/unanswer
  ed questions

88
Scientific Writing, HRP 214The Discussion

• 2. Subjects in the low-carbohydrate group had
  greater decreases in triglyceride levels than did
  subjects in the low-fat group nondiabetic
  subjects on the low-carbohydrate diet had greater
  increases in insulin sensitivity, and subjects
  with diabetes on this diet had a greater
  improvement in glycemic control. No adverse
  effects on other serum lipid levels were
  observed. answer to b Most studies suggest that
  lowering triglyceride levels has an overall
  cardiovascular benefit.14,15,16 Insulin
  resistance promotes such atherosclerotic
  processes as inflammation,17 decreased size of
  low-density lipoprotein particles,18 and
  endothelial dysfunction.19 Impaired glycemic
  control in subjects with other features of the
  metabolic syndrome markedly increases the risk of
  coronary artery disease.20 As expected, we found
  that the amount of weight lost had a significant
  effect on the degree of improvement in these
  metabolic factors. comparison to previous
  studies and paradigms However, even after
  adjustment for the differences in weight loss
  between the groups, assignment to the
  low-carbohydrate diet predicted greater
  improvements in triglyceride levels and insulin
  sensitivity. unexpected Subjects who lost more
  than 5 percent of their base-line weight on a
  carbohydrate-restricted diet had greater
  decreases in triglyceride levels than those who
  lost a similar amount of weight while following a
  calorie- and fat-restricted diet. supporting
  details

89
Scientific Writing, HRP 214The Discussion

• 3. There was a consistent trend across
  weight-loss strata toward a greater increase in
  insulin sensitivity in the low-carbohydrate
  group, although these changes were small and were
  not significant within each stratum. supporting
  details dose/response Although greater weight
  loss could not entirely account for the greater
  decrease in triglyceride levels and increase in
  insulin sensitivity in the low-carbohydrate
  group, we cannot definitively conclude that
  carbohydrate restriction alone accounted for this
  independent effect. mechanisms Other
  uncontrolled variables, such as the types of
  carbohydrates selected (e.g., the proportion of
  complex carbohydrates or the ratio of
  carbohydrate to fiber), or other unknown
  variables may have contributed to this effect. In
  addition, more precise measurements of insulin
  sensitivity than we used would be needed to
  confirm this effect of a carbohydrate-restricted
  diet. limitations/future studies

90
Scientific Writing, HRP 214The Discussion

• 4. Many of our subjects were taking
  lipid-lowering medications and hypoglycemic
  agents. Although enrolling these subjects
  introduced confounding variables, it allowed the
  inclusion of subjects with the obesity-related
  medical disorders typically encountered in
  clinical practice. Analyses from which these
  subjects were excluded still revealed greater
  improvements in insulin sensitivity and
  triglyceride levels on a carbohydrate-restricted
  diet than on a fat- and calorie-restricted diet.
  limitations and how they were addressed

91
Scientific Writing, HRP 214The Discussion

• 5. Our study included a high proportion of black
  subjects, a group previously underrepresented in
  lifestyle-modification studies. strength As
  compared with the white subjects, the black
  subjects had a smaller overall weight loss.
  Future studies should explore whether greater
  weight loss in this population can be achieved by
  more effective incorporation of culturally
  sensitive dietary counseling. future directions
• 6. The high dropout rate in our study occurred
  very early and affected our findings. The very
  early dropout of these subjects may indicate that
  attrition most closely reflected base-line
  motivation to lose weight, rather than a response
  to the dietary intervention itself. limitation

92
Scientific Writing, HRP 214The Discussion

• 7. Taken together, our findings demonstrate that
  severely obese subjects with a high prevalence of
  diabetes and the metabolic syndrome lost more
  weight during six months on a carbohydrate-restric
  ted diet than on a calorie- and fat-restricted
  diet. The carbohydrate-restricted diet led to
  greater improvements in insulin sensitivity that
  were independent of weight loss and a greater
  reduction in triglyceride levels in subjects who
  lost more than 5 percent of their base-line
  weight. conclusion restate answers to a and b
  These findings must be interpreted with caution,
  however, since the magnitude of the overall
  weight loss relative to our subjects' severe
  obesity was small, and it is unclear whether
  these benefits of a carbohydrate-restricted diet
  extend beyond six months. Furthermore, the high
  dropout rate and the small overall weight loss
  demonstrate that dietary adherence was relatively
  low in both diet groups. big picture This study
  proves a principle and does not provide clinical
  guidance given the known benefits of fat
  restriction, future studies evaluating long-term
  cardiovascular outcomes are needed before a
  carbohydrate-restricted diet can be endorsed.
  take-home message

93
Scientific Writing, HRP 214The Discussion

• Things to avoid in the discussion
• Do not simply repeat what is in the Results
• Do not try to explain every minor flaw
• Do not attempt to explain away every unexpected
  result
• Do not exaggerate or make extravagant claims
• Dont hedge

94
What NOT to do!

• Dont start your discussion like this!!
• Discussion
• This meta-analysis is subject to a number of
  limitations. The estimates of risk for melanoma
  subsequent to using sunlamps/sunbeds are based on
  published data in a series of 10 articles over a
  period of 20 years. A pooled analysis of original
  observations taken in the 10 studies would have
  provided a more powerful approach

95
Scientific Writing, HRP 214The Discussion verb
tense

• Verb Tenses (active!)
• Past, when referring to study details, results,
  analyses, and background research
• We found that
• They lost more weight than
• Subjects may have experienced
• Miller et al. found
• Present, when talking about what the data suggest
  
• The greater weight loss suggests
• The explanation for this difference is not
  clear.
• Potential explanations include

96
EXAMPLE 2 Low-Fat Dietary Pattern and Risk of
Colorectal Cancer The Women's Health Initiative
Randomized Controlled Dietary Modification Trial.
JAMA. 2006295643-654.

• INTRODUCTION
• The Women's Health Initiative (WHI) Dietary
  Modification Trial is a randomized controlled
  trial designed in 1991-1992 to test whether a
  low-fat eating pattern with increased fruits,
  vegetables, and grains reduces the risk of breast
  cancer, colorectal cancer, or, secondarily,
  coronary heart disease in postmenopausal women.
  At that time, international comparisons suggested
  that countries with 50 lower fat intake than the
  US population had approximately one third the
  risk of colorectal cancer.1-2 Migration studies
  supported this hypothesis. Women migrating from
  countries with low fat consumption to countries
  with high fat consumption experienced the higher
  colorectal cancer rates of their new country.3-4
  Fairly consistent evidence existed for an effect
  of dietary fat, vegetables and fruits, and grains
  on colorectal cancer risk from within-country
  observational studies,2, 5-8 although the
  protective effect of lower fat intake was no
  longer clear after adjusting for energy intake.2,
  9 The WHI Dietary Modification Trial is the first
  randomized trial to directly address the health
  effects of a low-fat eating pattern in
  predominantly healthy postmenopausal women from
  diverse racial/ethnic, geographic, and
  socioeconomic backgrounds. This article reports
  the principal results for colorectal cancer. the
  question

97
Scientific Writing, HRP 214The Discussion

• 1. An intervention aimed toward a low-fat eating
  pattern did not reduce colorectal cancer risk in
  postmenopausal women. answer to the question
  asked Despite a significant change in fat intake
  and increases in vegetable, fruit, and grain
  consumption, the intervention hazard ratio is in
  the direction of an increased risk. supporting
  evidence from this trial There were no
  substantial differences in tumor characteristics
  or in rates of bowel screening between groups.
  supporting evidence Although self-reported
  incidence of colorectal polyps or adenomas was
  lower in the intervention group, no evidence of a
  trend toward lower colorectal cancer risk with
  time in the intervention group was observed over
  the mean 8.1-year study period.

98
Scientific Writing, HRP 214The Discussion

• 2. These findings are consistent with the
  findings from the Polyp Prevention Trial,31 a
  secondary prevention trial of polyp recurrence,
  which had a similar goal for fat, fruit, and
  vegetable intake but also included a goal of 18
  g/1000 kcal of dietary fiber.32 The Polyp
  Prevention Trial observed no effect on polyp
  recurrence in the 2079 participants followed up
  for 4 years.32 A small trial in Toronto, Ontario,
  of high fiber and low fat showed no effect on
  recurrence of neoplastic polyps, but, within an
  intensive counseling subgroup, concentrations of
  fecal bile acids appeared to be reduced.33 A
  small factorial trial in Australia of a low-fat
  intervention, -carotene supplementation, or
  wheat bran supplementation found no reduction in
  recurrence rates of adenomas but suggested that
  the combination of low fat and wheat bran reduced
  the transition from smaller to larger adenomas.34
  supporting evidence other TRIALS

99
Scientific Writing, HRP 214The Discussion

• 3. Since the WHI Dietary Modification Trial was
  designed, the hypothesized relationship between
  dietary fat and risk of colorectal cancer has
  been questioned.35 More recently, higher red meat
  consumption has been associated with increased
  colorectal cancer risk,23, 36-39 particularly in
  the distal colon.23 The putative mechanism may be
  related to heme, the iron carrier of red meat,
  rather than to its fat content.23 In the WHI, the
  dietary intervention reduced red meat consumption
  (Table 2), with no apparent overall benefit on
  colorectal cancer risk but, perhaps, some shift
  in risk in distal vs proximal colon cancers.
• consistency with the latest paradigm
• mechanisms is red meat more important than
  fat?

100
Scientific Writing, HRP 214The Discussion

• 4. Mixed support exists for an influence of
  vegetables and fruits on colorectal cancer
  risk.37, 40-42 Some of the antioxidants they
  contain have not proved efficacious in reducing
  colorectal adenomas or preventing incident
  colorectal cancer in randomized trials.43-45
  Regular consumption of alcohol has been
  associated with elevated risk of colorectal
  cancer in some prospective studies, particularly
  among persons with low folate status.46 This
  pattern was not found in the comparison group of
  this study. Observations in East Africa by
  Burkitt47 led to the hypothesis that very high
  fiber reduces colorectal cancer risk. This has
  mixed support from observational studies48-50 and
  polyp and adenoma recurrence trials.31,
  33-34,51-52 A European trial found an adverse
  effect of soluble fiber on colorectal adenoma
  recurrence,51 while an Arizona trial found no
  effect of wheat bran supplement on colorectal
  adenoma recurrence.52 Our study is consistent
  with lack of association in that women in the
  intervention group modestly increased their fiber
  (Table 2) with no apparent benefit over 8.1 years
  of follow-up.
• existing paradigms does fiber matter?

101
Scientific Writing, HRP 214The Discussion

• 5. The observed interactions between the
  intervention and baseline aspirin use, and
  between intervention and use of combined hormone
  therapy, are consistent with synergistic effects
  of a low-fat dietary pattern and these
  potentially protective agents. However, given the
  large number of interactions tested, these
  findings could also have occurred by chance.
• Could the null finding be wrong? Maybe low-fat
  diet matters for some groups

102
Scientific Writing, HRP 214The Discussion

• 6. From National Health and Nutrition
  Examination Survey (NHANES) data, in 1977, women
  reported consuming 40.5 of their energy from
  fat, while in 1987, the average was only 35.9,54
  and in 2000, the average was 33 (NHANES
  1999-2000). Organizations including the National
  Cancer Institute, American Cancer Society, and
  Institute for Cancer Prevention have recommended
  both lower fat intake and increased vegetable and
  fruit use.55-56
• 7. One explanation for a lack of intervention
  effect on colorectal cancer could be that the
  intervention did not achieve a large enough
  difference between the intervention and
  comparison groups. Although the changes achieved
  were substantial, and likely as large as could be
  achieved in a trial of free-living individuals,
  they fell short of the original design
  assumptions based on the Women's Health Trial
  studies.27 Using food frequency data, the WHI
  intervention on average achieved only about 70
  of the designed reduction in fat. If design
  assumptions are revised to take into account this
  departure from goal, the predicted HR would have
  been 0.86, an effect size excluded by these
  results. The power to detect this effect size
  under the observed comparison group incidence
  rate and the achieved adherence is approximately
  40. Could the null finding be wrong?
  Alternative explanations to no association

103
Scientific Writing, HRP 214The Discussion

• 8. Whether greater adherence, intervention of
  longer duration, or initiation of change at an
  earlier age would influence colorectal cancer
  risk remain unanswered questions. The
  self-reported first occurrence of polyps or
  adenomas was lower in dietary intervention women,
  suggesting that longer follow-up (currently
  planned) may reveal delayed benefit in favor of
  the intervention. Yet no time trends regarding
  colorectal cancer risk over 8 years of follow-up
  have been seen. To the extent that the WHI
  Dietary Modification Trial intervention addressed
  the recommendations from national organizations,
  the current results suggest that changing dietary
  patterns to meet these recommendations in mid to
  late life will have limited or no benefit in
  preventing colorectal cancers in postmenopausal
  women. Defending their results

104
Scientific Writing, HRP 214The Discussion

• 9. The strengths of this study are its
  randomized design, long-term follow-up, large
  numbers of participants, diversity of
  race/ethnicity and socioeconomic status, and high
  retention rate. The limitations of this study
  include not attaining intervention goals as
  designed for reducing fat intake or achieving
  large separation from the comparison group in
  increased fruit, vegetable, or grain intake. Thus
  the potential intervention effect of the WHI
  low-fat dietary pattern may be underestimated.
  Furthermore, there was no study-specified
  colonoscopy, nor was there systematic screening
  for adenomatous polyps hence, the incidence of
  both colorectal cancer and polyps or adenomas
  would be underestimated. Strengths and
  limitations

105
Scientific Writing, HRP 214The Discussion

• 10. In conclusion, there is no evidence that
  a low-fat dietary pattern intervention reduces
  colorectal cancer risk over an average of 8.1
  years of follow-up. Restatement of findings
  Evidence from this study, along with that from
  polyp prevention trials, strongly suggests that
  lowering dietary fat intake and increasing fruit,
  vegetable, and fiber intake in mid to late life
  cannot be expected to reduce the risk of
  colorectal cancer in this length of time.
  Take-home message

106
EXAMPLE Adherence to Mediterranean diet and
risk of developing diabetes prospective cohort
studyBMJ June 2008

• END OF INTRODUCTION
• We evaluated the association between adherence
  to a Mediterranean diet and the incidence of
  diabetes using a full validated food frequency
  questionnaire to measure the entire diet.

107
Scientific Writing, HRP 214The Discussion

• 1. This large prospective study shows that a
  traditional Mediterranean food pattern is
  associated with a significant reduction in the
  risk of developing type 2 diabetes. answer to
  question asked

108
Scientific Writing, HRP 214The Discussion

• 2. Interestingly, among participants with the
  highest adherence to the diet, there was a high
  prevalence of important risk factors for
  diabetes, such as older age, higher BMI, family
  history of diabetes, and personal history of
  hypertension and a higher proportion of
  ex-smokers. Therefore, we would have expected a
  higher incidence of diabetes among these
  participants. These higher risk participants with
  better adherence to the diet, however, had a
  lower risk of diabetes, suggesting that the diet
  might have a substantial potential for
  prevention. bonus finding/additional
  evidence This finding is consistent with our
  previous report of an inverse association between
  a Mediterranean diet and the metabolic
  syndrome.24 fits with previous research The
  metabolic syndrome is closely associated with a
  generalised metabolic disorder of insulin
  resistance, which is one of the underlying causes
  of type 2 diabetes. Therefore a high biological
  plausibility exists to support the causality of
  our findings. biological mechanisms In
  addition, a previous cohort study of survivors of
  myocardial infarction also reported that a higher
  adherence to a Mediterranean diet was associated
  with a reduction in the risk of type 2
  diabetes,18 fits previous research despite use
  of a relatively inaccurate tool for the dietary
  assessment. The inverse graded dose-response
  pattern and the significant inverse trend that we
  observed also support a causal relation.
  dose-response evidence

109
Scientific Writing, HRP 214The Discussion

• 3. Diet and disease
• Experimental evidence suggesting that a diet
  similar to the Mediterranean diet and rich in
  plant based foods might protect against diabetes
  can also be found in the Indian diabetes
  prevention programme. That trial promoted a plant
  based diet (together with increases in physical
  activity) and found a significant reduction in
  the incidence of diabetes,28 although there are
  clear differences between the Mediterranean and
  Indian food patterns. There is an analogy between
  coronary heart disease and diabetes because
  patients with type 2 diabetes and no coronary
  heart disease have a risk of coronary heart
  disease similar to patients without diabetes but
  with prior coronary heart disease.29 There is
  evidence that a Mediterranean diet protects
  against coronary heart disease, and the analogy
  between coronary heart disease and diabetes
  suggests that this diet might also prevent
  diabetes. It has been shown to provide protection
  against coronary mortality8 9 30 31 and the
  incidence of non-fatal myocardial infarction.32
  In addition, both cohort studies33 34 35 and
  randomised trials36 have found that adherence to
  a Mediterranean diet protects against mortality
  in patients who already have established coronary
  heart disease. more supporting background
  evidence

110
Scientific Writing, HRP 214The Discussion

• 4.The potential mechanisms explaining the
  protective effect of a Mediterranean diet on
  diabetes have been reviewed elsewhere.37 38 39 40
  Two trials have shown that virgin olive oil
  protects against insulin resistance and the
  metabolic syndrome.6 7 Indexes of insulin
  resistance were significantly improved among
  participants allocated to a Mediterranean diet
  rich in virgin olive oil. Olive oil is rich in
  monounsaturated fatty acids, and a diet rich in
  monounsaturated fatty acids is beneficial among
  those with diabetes and might lead to improved
  insulin sensitivity and better lipid profiles
  than diets rich in carbohydrate.13 15 39 People
  allocated to a Mediterranean diet secrete more
  glucagon-like peptide-1,16 a finding also seen in
  animals.14 The non-fat minor components of virgin
  olive oil also exert a beneficial effect on
  pro-inflammatory cytokines.40 41 42
• Apart from olive oil, adherence to an overall
  Mediterranean-type food pattern is related to
  lower plasma concentrations of inflammatory
  markers and markers of endothelial dysfunction.43
  44 These biomarkers are predictive of the future
  occurrence of type 2 diabetes.45 46 In addition,
  a large cross sectional study nested in the
  nurses health study found that increased
  adherence to a Mediterranean diet was associated
  with higher levels of adiponectin,47 and higher
  levels of adiponectin are associated with a
  reduced risk of diabetes.

supporting evidence in the literature/biological
mechanisms
111
Scientific Writing, HRP 214The Discussion

• Limitations
• The number of new cases of diabetes was small,
  despite the follow-up of several thousand people
  for over four years. This small number of
  incident cases is a major drawback and can
  compromise the statistical power of our study.
  Nevertheless, our participants had high absolute
  levels of consumption of the typical food items
  of the Mediterranean diet, even among those
  participants classified as poorly compliant
  (score lt3). For example, among those in the
  lowest category of adherence to the diet, the
  estimated mean daily absolute consumption (g/day)
  of olive oil (12), vegetables (308), fruits
  (176), cereals (77), and legumes (17) can be
  considered as healthy for the standards of
  nutritional epidemiological studies. This high
  consumption of plant based foods in our cohort
  could be because our participants were from a
  Mediterranean country and were highly educated
  and health conscious. The small number of new
  cases observed in this study should therefore not
  be surprising. If the Mediterranean diet is
  actually protecting against diabetes, we would
  expecta low incidence in a young cohort (mean age
  is 37.8 years) with these characteristics. The
  low number of observed cases precluded assessment
  of the specific role of single dietary factors
  because we would have needed
• ..
• A potential limitation, inherent to every
  observational design, is the possibility of
  residual confounding by unmeasured or unrecorded
  factors. Our major confounders, however, were sex
  and age. Additional adjustment for other factors
  made only negligible changes in the estimates,
  suggesting that residual confounding is
  unlikely.in the nurses health study found that
  increased adherence to a Mediterranean diet was
  associated with higher levels of adiponectin,47
  and higher levels of adiponectin are associated
  with a reduced risk of diabetes.

Limitations5 paragraphs!!
112
Scientific Writing, HRP 214The Discussion

• Conclusion
• Our prospective cohort study suggests that
  substantial protection against diabetes can be
  obtained with the traditional Mediterranean diet,
  rich in olive oil, vegetables, fruits, nuts,
  cereals, legumes, and fish but relatively low in
  meat and dairy products. The limited number of
  cases of diabetes and the possibility of
  under-reporting, however, requires that further
  larger cohorts and trials are needed to confirm
  our findings.

Restatement of the