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  • Summer Essays: A Moment of Betrayal

Summer Essays: A Moment of Betrayal

Her heart hammered against her rib cage as she slid to the ground.

By Naneen Karraker

Published:

Katarzyna Bialasiewicz

Editor’s Note: Summer essayists contemplate personal moments of disloyalty, sharing their stories that range from a failing body and objection to war to peer pressure and loss of faith.

An act of betrayal can cause hopelessness and despair. But people show amazing resilience and often overcome the temporary setbacks disloyalty leaves in its disastrous wake.

The East Bay Monthly asked East Bay writers to consider a moment of betrayal in the summer essay contest. The theme seemed to resonate well with the wordsmiths, and essayists responded by turning in moving prose about infidelity, loss, abusive relationships, inside jokes, bullying, and other topics.

The essays chosen to present in print address betrayal in wide-ranging ways, touching on the strains of a weakening body, standing up to the U.S. Marines, and making a gut decision that puts a group of friends at odds. They explore a loss of faith in a trusted adult and a careless act in wartime. They are poignant, dramatic, exciting, heartwarming, and humorous tales, and they are well-written.

Congratulations to the winning essayists, Naneen Karraker, Robert Menzimer, Stacy Appel, Patricia Young, Anna Rabkin, Flossie Lewis, and Bobbie Stein. Thanks to all the many Bay Area writers for submitting such wonderful prose—it was truly great reading. Look for our next essay contest in the winter.

This is the first of the seven winning essays:

 

My heart is pounding, a thundering fills my head, and I can’t catch my breath as I reach the top of the Philadelphia subway station stairs. This isn’t me. I’m healthy. At 66, I am strong and brave enough to do handstands several times a week. I travel a lot, too. These days I fly east several times a year for meetings. Today, I’m on my way to a two-day advisory board meeting at the Quaker Center.

Through the pouring rain, I see a smudge of lights. If I squint and concentrate really hard, they look enough like the drugstore I’m trying to find. I need an umbrella. It’s six long blocks to my meeting. As blurry as they are, the lights become a beacon, a goal, helping me move ahead instead of lying down right where I am.

"I’ve got to get an umbrella." I say it again and again as I fight against the growing weakness in my legs. I can barely put one foot ahead of the other, inching toward the half-dozen people waiting for the light to change.

The light changes. I step off the curb, dragging my new rolling carry-on with one hand and clutching in the other a bag of crisp red apples I’d picked yesterday at my cousin’s Hudson Valley farm. The drugstore lights are just ahead. But when I reach them, I can’t find a door. Just the cold, hard side of a city building interrupted by a ribbon of faintly lit windows. Above them, a Walgreens sign shines a bright red into the dark, autumn evening. I’m imagining a friendly space where I can sit and finally catch my breath. But now what?

I know I need to get out of the rain. I spot an opening in the side of the building, another subway exit, to my left. I push myself to take the dozen or so steps to reach it. Just inside, there’s a narrow landing, maybe 4 feet wide, before stairs leading down to the tracks. I park my suitcase against the wall just inside the opening and lean against it, fighting to suck in one long breath after another. A young man is perched on a ledge about 6 feet across the opening from me. He’s dressed casually, wearing earphones, swaying slightly to his music, eyes closed, waiting for the rain to let up. People rush in and out of the subway and along the sidewalk. My heart hammers against my ribs. My legs give way. I slide slowly down the wall, hoping my new suitcase can hold me. I remember something about how women can experience a heart attack without chest pains or shooting pains down the left arm. Fear spurs me to reach for my cellphone. I dial 911.

A woman finally answers. Somehow I find the words to tell her I think I’m having a heart attack. "Where are you?" she asks. "Near the Walgreens on Broad and Chestnut," I mumble, praying I’ve accurately named my location. Philadelphia is a new city for me.

"We’ll send an ambulance right away."

I can barely focus through the fog that is now settling across my eyes. The steady flow of people becomes a blur. No one stops to help as my legs give way and I curl slowly to the damp sidewalk, knees bent, my back against the suitcase. Still grasping for air, I begin to tremble, afraid that the ambulance will come too late to find me. Then desperate, I lean toward the young man perched on the ledge across from me, struggling to make my voice heard.

"Help me, I think I’m dying."

He looks up, hops off the ledge, and kneels beside me.

"Ma’am, I’m here. What’s going on?"

"I called 911, but I don’t hear any sirens."

"Don’t worry," he assures me. "I hear them. They’re coming."

I strain to hear and struggle against the weight that’s making me feel like stretching out on the wet pavement. To hell with the pedestrians! So what if they have to step around me!

He puts his arm around my shoulders, holding me close. Finally I can hear the sirens through the rain and traffic and pedestrian noise. Closer and closer. He then pulls away, gently propping me against my suitcase.

"They’re across the street," he announces. He jumps up, racing toward the blur of flashing lights. I crumble sideways, stretching out on the wet sidewalk.

Moments later he is beside me, carefully lifting me so I’m sitting again. "They’re here," he assures me. I can vaguely make out two EMTs, dragging their gurney, heading toward us. One of them guides me onto the gurney. He attaches an oxygen mask over my nose and mouth. As I focus on sucking in one breath after another, I can feel the young man moving around, making sure the EMTs have not only me, but also my suitcase and the bag of apples. Then he is gone.

I’m still here, still here and beginning to breathe more easily, even though my body is not the body I’ve trusted for so many years.

Over the past 46 years, Naneen Karraker honed her writing skills by passionately arguing for reducing overreliance on incarcerating people in the United States through letters to the editor, op-ed pieces, pamphlets, grant applications, and speeches. She and her late husband, a criminal defense attorney, raised two sons in Berkeley.

Editor’s Note: This story appears in the July edition of our sister publication, The East Bay Monthly.

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  • Summer Essays: A Moment of Betrayal

Summer Essays: A Moment of Betrayal

Her heart hammered against her rib cage as she slid to the ground.

By Naneen Karraker

Published:

Katarzyna Bialasiewicz

Editor’s Note: Summer essayists contemplate personal moments of disloyalty, sharing their stories that range from a failing body and objection to war to peer pressure and loss of faith.

An act of betrayal can cause hopelessness and despair. But people show amazing resilience and often overcome the temporary setbacks disloyalty leaves in its disastrous wake.

The East Bay Monthly asked East Bay writers to consider a moment of betrayal in the summer essay contest. The theme seemed to resonate well with the wordsmiths, and essayists responded by turning in moving prose about infidelity, loss, abusive relationships, inside jokes, bullying, and other topics.

The essays chosen to present in print address betrayal in wide-ranging ways, touching on the strains of a weakening body, standing up to the U.S. Marines, and making a gut decision that puts a group of friends at odds. They explore a loss of faith in a trusted adult and a careless act in wartime. They are poignant, dramatic, exciting, heartwarming, and humorous tales, and they are well-written.

Congratulations to the winning essayists, Naneen Karraker, Robert Menzimer, Stacy Appel, Patricia Young, Anna Rabkin, Flossie Lewis, and Bobbie Stein. Thanks to all the many Bay Area writers for submitting such wonderful prose—it was truly great reading. Look for our next essay contest in the winter.

This is the first of the seven winning essays:

 

My heart is pounding, a thundering fills my head, and I can’t catch my breath as I reach the top of the Philadelphia subway station stairs. This isn’t me. I’m healthy. At 66, I am strong and brave enough to do handstands several times a week. I travel a lot, too. These days I fly east several times a year for meetings. Today, I’m on my way to a two-day advisory board meeting at the Quaker Center.

Through the pouring rain, I see a smudge of lights. If I squint and concentrate really hard, they look enough like the drugstore I’m trying to find. I need an umbrella. It’s six long blocks to my meeting. As blurry as they are, the lights become a beacon, a goal, helping me move ahead instead of lying down right where I am.

"I’ve got to get an umbrella." I say it again and again as I fight against the growing weakness in my legs. I can barely put one foot ahead of the other, inching toward the half-dozen people waiting for the light to change.

The light changes. I step off the curb, dragging my new rolling carry-on with one hand and clutching in the other a bag of crisp red apples I’d picked yesterday at my cousin’s Hudson Valley farm. The drugstore lights are just ahead. But when I reach them, I can’t find a door. Just the cold, hard side of a city building interrupted by a ribbon of faintly lit windows. Above them, a Walgreens sign shines a bright red into the dark, autumn evening. I’m imagining a friendly space where I can sit and finally catch my breath. But now what?

I know I need to get out of the rain. I spot an opening in the side of the building, another subway exit, to my left. I push myself to take the dozen or so steps to reach it. Just inside, there’s a narrow landing, maybe 4 feet wide, before stairs leading down to the tracks. I park my suitcase against the wall just inside the opening and lean against it, fighting to suck in one long breath after another. A young man is perched on a ledge about 6 feet across the opening from me. He’s dressed casually, wearing earphones, swaying slightly to his music, eyes closed, waiting for the rain to let up. People rush in and out of the subway and along the sidewalk. My heart hammers against my ribs. My legs give way. I slide slowly down the wall, hoping my new suitcase can hold me. I remember something about how women can experience a heart attack without chest pains or shooting pains down the left arm. Fear spurs me to reach for my cellphone. I dial 911.

A woman finally answers. Somehow I find the words to tell her I think I’m having a heart attack. "Where are you?" she asks. "Near the Walgreens on Broad and Chestnut," I mumble, praying I’ve accurately named my location. Philadelphia is a new city for me.

"We’ll send an ambulance right away."

I can barely focus through the fog that is now settling across my eyes. The steady flow of people becomes a blur. No one stops to help as my legs give way and I curl slowly to the damp sidewalk, knees bent, my back against the suitcase. Still grasping for air, I begin to tremble, afraid that the ambulance will come too late to find me. Then desperate, I lean toward the young man perched on the ledge across from me, struggling to make my voice heard.

"Help me, I think I’m dying."

He looks up, hops off the ledge, and kneels beside me.

"Ma’am, I’m here. What’s going on?"

"I called 911, but I don’t hear any sirens."

"Don’t worry," he assures me. "I hear them. They’re coming."

I strain to hear and struggle against the weight that’s making me feel like stretching out on the wet pavement. To hell with the pedestrians! So what if they have to step around me!

He puts his arm around my shoulders, holding me close. Finally I can hear the sirens through the rain and traffic and pedestrian noise. Closer and closer. He then pulls away, gently propping me against my suitcase.

"They’re across the street," he announces. He jumps up, racing toward the blur of flashing lights. I crumble sideways, stretching out on the wet sidewalk.

Moments later he is beside me, carefully lifting me so I’m sitting again. "They’re here," he assures me. I can vaguely make out two EMTs, dragging their gurney, heading toward us. One of them guides me onto the gurney. He attaches an oxygen mask over my nose and mouth. As I focus on sucking in one breath after another, I can feel the young man moving around, making sure the EMTs have not only me, but also my suitcase and the bag of apples. Then he is gone.

I’m still here, still here and beginning to breathe more easily, even though my body is not the body I’ve trusted for so many years.

Over the past 46 years, Naneen Karraker honed her writing skills by passionately arguing for reducing overreliance on incarcerating people in the United States through letters to the editor, op-ed pieces, pamphlets, grant applications, and speeches. She and her late husband, a criminal defense attorney, raised two sons in Berkeley.

Editor’s Note: This story appears in the July edition of our sister publication, The East Bay Monthly.

This page requires javascript. It seems that your browser does not have Javascript enabled. Please enable Javascript and press the Reload/Refresh button on your browser.

Add your comment:

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Thursday’s Briefing: Hurricane Michael Lashes Florida; El Niño Grows in Pacific

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Edit Module Show Tags

40 Percent Off at Kouzina

Edit Module Show Tags

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Hoedown at the O’ Club

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Webster Street Finds

Artist Elizabeth Sher Plays With Perception

Eyeing the Black Risk Takers of Paulson Fontaine Press

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Building the Future

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In the Mayor’s Race, Will Oakland Become the Next Boston?

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People

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Diferencia entre un curriculum vitae documentado y no documentado

La diferencia entre los por lo que tiene unas potentes opciones para elegir al editar su curriculum vitae. Echemos un vistazo Documentado el procedimiento de.

diferencia entre un curriculum vitae documentado y no documentado

Key Points Goal setting is an important method of: Deciding what you want to achieve in your life. Diferencia entre curriculum vitae documentado y no … This set of resources for teachers offers interactive environments to support work on graphical interpretation at Key Stage 4. But, it is important to remember that you might not necessarily know if your situation is going to be complicated until you discuss your estate with a professional.

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Saving Private Ryan Essay the battle in shock, even thought he has probably gone into war battles many times before he still is shocked at the sights of it. Games are fun, but a true addict cannot moderate.

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Healthy minds need healthy bodies, and this camp is unique in that much physical activity is built into each day. Some say you should be as specific as possible to avoid misleading your readers and manage their expectationswhile others recommend taking a more abstract approach.

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Key Points Goal setting is an important method of: Deciding what you want to achieve in your life. Diferencia entre curriculum vitae documentado y no … This set of resources for teachers offers interactive environments to support work on graphical interpretation at Key Stage 4. But, it is important to remember that you might not necessarily know if your situation is going to be complicated until you discuss your estate with a professional.

Saving Private Ryan Essay the battle in shock, even thought he has probably gone into war battles many times before he still is shocked at the sights of it.

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    In Warhammer Online: Age of Reckoning, war is the name of the game. To succeed (or at the very least survive), you’ll need to be on your toes and know the ins and outs of your chosen class, but information can be scarce in the world. Fortunately for you, the Ten Ton Hammer crew is cranking away in their slave pits bringing you everything you need. This week, Dalmarus brings you the full set of Dwarf abilities!

    Do you like gadgetry of all sorts? Don’t want to continue your days of endless sword swinging? Then the Engineer may be the class for you. They’re the masters of tinkering and technology. With a wide arsenal of grenades, mines, turrets, and a massive spanner for those moments you want an up close and personal touch, this is one class to be careful of. Want to learn even more? Study the Engineer ability lists to bring out the best of this beast of a class!

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    Items Data ¶

    Values GameData.ItemTypes found in sub 0x005B07A2().

    TYPEVALUE
    NONE0
    SWORD1
    AXE2
    HAMMER3
    SHIELD5
    ROBE6
    BOW7
    GUN9
    STAFF11
    DAGGER12
    SPEAR14
    PISTOL15
    LIGHTARMOR18
    MEDIUMARMOR19
    HEAVYARMOR20
    QUEST21
    MEDIUMROBE22
    ENHANCEMENT23
    TROPHY24
    CHARM25
    DYE27
    BASICMOUNT29
    ADVANCEDMOUNT30
    POTION31
    SALVAGING32
    MARKETING33
    CRAFTING34
    ACCESSORY35
    CURRENCY36
    TELEPORT37
    TELEPORT_GROUP38
    SIEGE39
    TREASURE_CHEST40
    TREASURE_KEY41
    REFINER_TOOL45

    Values GameData.Item found in sub 0x005B07A2().

    EITEMFLAGVALUE
    NO_CHARGE_DELETE0
    CAN_USE_IN_TRIAL1
    BIND_ON_PICKUP2
    BIND_ON_EQUIP3
    TEMPORARY4
    NO_MOVE5
    BROKEN6
    DECAYED7
    DYE_ABLE8
    MUNDANE_SALVAGABLE10
    MAGICAL_SALVAGABLE9
    NO_SELL13
    HIDE_ITEM_LEVEL19

    Character Slot ID ¶

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    _images/character_slot_id.png

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    Icons images are stored in interface.myp in DirectDraw_Surface format.

    Association between ID and image file name are stored in interface/default/eatemplate_icons/source/icons.xml
    (0xBC8564953C316BF6) in interface.myp.

    TYPEID ICON
    Misc Icons0-99
    Skill Icons100-199
    Item Icons200-799
    Greenskin Shield Textures1000-1199
    Greenskin Weapon Icons1200-1499
    Greenskin Armor Icons1500-2099
    Greenskin Ability Icons2100-2999
    Dwarf Shield Icons3000-3199
    Dwarf Weapon Icons3200-3499
    Dwarf Armor Icons3500-4099
    Dwarf Ability Icons4100-4999
    Generic Ability Icons5000-5099
    Chaos Ability Icons5100-5999
    Chaos Armor Icons6000-7599
    Chaos Weapon Icons7600-7899
    Empire Ability Icons7900-8799
    Empire Armor Icons8800-10399
    Empire Weapon Icons10400-10699
    Empire Shield Icons10700-10899
    Dark Elf Ability Icons10900-11199
    Dark Elf Weapons Icons11200-11499
    Dark Elf Shields Icons11500-11699
    Dark Elf Armor Icons11700-13299
    High Elf Ability Textures13300-13699
    High Elf Weapons Icons13700-13999
    High Elf Shields Icons14000-14199
    High Elf Armor Icons14200-15799
    NPC Weapon Icons14500-14600
    Illuminated Letters Icons20065-20179
    Career Icons20180-20214
    Mount Icons20215-20249
    Crafting Icons20250-22249
    Renown Icons22250-22649
    Tactic Icons22650-22999
    Pregame Race Icons23000-23049
    ME Icons23050-23099
    Siege Icons23100-23149
    Archetype Icons23150-23399
    Siege Abilities Icons23400-23499
    Event Icons23500-23799
    Sigil Icons23800-24999
    RVR Icons25000-25099
    TK Weapons25100-26999
    TK Inventory27000-28199
    TK Glyphs28200-28299
    TK MISC28300-28399
    TK Armor28400-30099
    TK CLOAKS30100-30199
    TK TROPHIES30200-30299
    TK TALISMANS30300-30399
    WILD HUNT PAW PRINTS30400-30449
    GENERIC ACCESSORY ICONS30550-40000
    MTX ICONS30437-50000
    Extra Mount ICONS and Trophies50001-500100
    T5 BH and 7 armor ICONS50101-50500

    References ¶

    [1] http://en.wikipedia.org/wiki/DirectDraw_Surface

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    Freakonomics: What Went Right? Responding to Wrong-Headed Attacks

    by Stephen J. Dubner

    Warning: what follows is a horribly long, inside-baseball post that most people will likely have little interest in reading, and which I had little interest in writing. But it did need to be written. Apologies for the length and the indulgence; we will soon return to our regular programming.

    *     *     * 

    I. Going on the attack is generally more fun, profitable, and attention-getting than playing defense. Politicians know this; athletes know it; even academics know it. Or perhaps I should say that especially academics know it?

    Given the nature of the Freakonomics work that Steve Levitt and I do, we get our fair share of critiques. Some are ideological or political; others are emotional.

    We generally look over such critiques to see if they contain worthwhile feedback, or point to an error in need of correction. But for the most part, we tend to not reply to critiques. It seems only fair to let critics have their say (as writers, we’ve already had ours). Furthermore, spending one’s time responding to wayward attacks is the kind of chore you’d rather skip in order to get on with your work.

    But occasionally an attack is so spectacularly ridiculous, so riddled with errors and mangled logic, that it’s worth addressing.

    The following essay responds to two such attacks. The first one was relatively minor, a recent blog post written by a Yale professor. The second was more substantial, an essay by a pair of statisticians in American Scientist. Feel free to skip ahead to that one (at section III below), or buckle up for the whole bumpy ride.

    *     *     *

    II. On Jan. 27, an assistant professor of political science and economics at Yale named Chris Blattman published on his blog a post called “ Do the big newspaper blogs plagiarize ?” It began:

    I regularly read at least two big blogs run by newspapers — Freakonomics at the NY Times and Ideas Market at WSJ. They find a wonderful sampling of things across the web.

    What’s interesting: they seldom say where they find their material. The bloggy custom of hat tipping is nearly absent. Once in a while Freakonomics gives a blog hat tip, but (oddly) they never actually hyperlink. …

    Impolite? Yes. Nefarious. Possibly. Plagiarizing? I’d ding my students if they did this so regularly and egregiously.

    At first, I thought the post was a joke. In fact, I only knew Blattman’s name via numerous posts and links on our blog . So I looked up Blattman’s e-mail address and sent him a note with the subject line “was that a joke?”:

    the thing you wrote about the freakonomics blog, I mean. fwiw, we haven’t been on NYT for a year (and even when we were, we were hardly “run by” the paper)

    but I’d argue we are borderline zealous about attribution, linking, and hat-tipping. I’d invite you to actually read our last 100 posts, or last 1,000, and tell me if you really believe in what you just wrote. especially compared to the general esthetic of many blogs which routinely reprint entire articles and hijack photos with neither attribution nor payment.

    Blattman promptly replied:

    Hi Stephen

    Well, I could be mistaken, but to use myself as an example (and this is not a self-interested search for blog traffic–especially since my post might up ending traffic from the blogs I discussed), I can say that a quick search done right now shows a h/t to me once in each of December and November of 2011, but not a hyperlink. My point was simply that this practice is uncommon and, to some, impolite. 

    Actually, what drew my attention was a switch, perhaps a year or two back. One of the  first times I was linked from Freakonomics, there was a hyperlink, which I noticed only because of the surge in traffic. But I seem to recall that hyperlink was actually removed later that day, and then later mentions didn’t have the hyperlink, just the name. This is what made me think it was more of a deliberate policy.

    Now it was my turn to reply:

    Chris, 

    I’m sorry but I think you are wrong on just about every front here. 

    Here’s what you wrote in your post:

    + Your headline is “Do the big newspaper blogs plagiarize?” First of all, as I wrote in my first e-mail, we are not “a big newspaper blog.” Second of all: do you know what plagiarizing is? Is that what you’re charging us with? Even I don’t think so but for some reason, that’s the word you chose in your headline, so … what say you?

    + You then wrote: “What’s interesting: they seldom say where they find their material. The bloggy custom of hat tipping is nearly absent. Once in a while Freakonomics gives a blog hat tip, but (oddly) they never actually hyperlink.” Hard to believe, but it appears that just about everything in this paragraph is wrong. We “seldom say where” we “find our material”? Please, go look at any selection of Freakonomics posts and tell me that this is even remotely true. Or just search for “ blattman ” and look at the most recent posts. There are links; there are explanations; there are excerpts; and there are hat tips. In fact, I’d argue that our blog adheres more to the rules of journalistic attribution than a) the vast majority of blogs; and b) a lot of mainstream news sources. Furthermore, you write that “the bloggy custom of hat tipping is nearly absent.” “Nearly absent”? Are you serious? You do know that “HT” stands for “Hat tip,” right? Again, please look at our posts and tell me we don’t hat tip — including to you! Maybe you are unhappy that our hat tips sometimes aren’t linked to the blog of the tipper? I agree it’s probably better to do so than not do so, and I’m sure we are very inconsistent, but the tone and content of your post imply a far more serious set of charges that I would argue are at least 99% wrong.

    Furthermore, to charge someone in a headline with plagiarizing, and then to defend that post in a followup e-mail with “Well, I could be mistaken, but to use myself as an example …” and “I seem to recall that hyperlink was actually removed” strikes me as an astronomically weak argument. We don’t routinely remove links, or even edit posts unless an error is found, because we believe in the established rules of journalism and publishing, and those rules generally forbid messing with things once they’ve been published unless explaining to the reader why it’s been done. So as for a “deliberate policy” — well, our deliberate policy is to conduct ourselves with a considered appreciation for where ideas come from, to describe them well and accurately, and to expect others to do the same. Why you decided to single us out for behavior that we don’t practice is beyond me but suffice it to say I’ll be happy to not hat tip you in the future, or link to you, or ever mention your name. 

    Sincerely,

    SJD

    Blattman’s response:

    Hi Stephen

    The continued association to the Times was my mistake, which I’ll correct. The plagiarization charge was a cheap shot in your instance, and I will fix this as well. I think it applies more to the ideas market blog than Freakonomics, because you are right in that you hat tip. N
    onetheless, as I mentioned in the post and my last email, what seemed unusual to me about the Freakonomics blog in particular is that it seldom hyperlinks its HTs. This doesn’t mean you deserve to get lumped with those that are more egregious, but the practice might be something to reconsider. In any case, I’m sorry this escalated. It’s my fault, for taking the charge too far, and a product of hasty and sometimes thoughtless blogging.

    Chris

    Blattman had graciously apologized and promised to amend his post but I was still worked up, I must admit, at how wrong and facile and flip-floppy this argument was, especially coming from a professor at Yale. Perhaps I am naïve about modern standards in the academic community? Is it okay to toss off a false and inflammatory charge and, if you happen to get caught, mumble an apology and chalk it up to haste?

    So I wrote back:

    explanation and apology accepted and we will try to do better at creating *linked hat tips*. am still a bit astonished, however, that the issue of *linked hat tips* could provoke such a broadly erroneous charge, especially from an academic. oh well. thnx, sjd

    Soon after, Blattman published another post on his blog, headlined “ More on yesterday’s cheap shot @freakonomics and @WSJIdeasMarket .” He writes:

    First, lest anyone mistake this blog for a quality news and analysis outlet, let me remind everyone I blog hurriedly in my nearly non-existent spare time, and do not think much before I write. For if I did, there would not be a blog post every day.

    My first thought was this: it is of zero interest to me whether a man named Chris Blattman is able to produce a blog post every day – unless or until his daily quota results in a false accusation against me.

    I was also surprised to see a Yale professor admit that he doesn’t “think much before I write,” especially when he’s writing about the writing habits of people who do.

    Here’s more:

    Nonetheless, there is thoughtless and then there is reckless. Sometimes I am the latter. …

    Why spend more blog space on such frivolous things? No good reason. On this occasion, I started it and I should fess up when I overstate myself, or falsely accuse.

    Also, I have an overdeveloped sense of justice, which often pushes me in the right direction, but sometimes leads me along silly and fruitless paths, such as accosting strangers on New York City sidewalks for littering, or (more successfully) trying to bring order to Dubai airport lines when hundreds of people are jumping queues during a 4am rush.

    I will admit: I still get a great sense of satisfaction from the memory of hundreds of people from as many nations meekly looking ashamed and falling back into line.

    The arc of Blattman’s two posts strikes me as remarkable. He begins by wrongly accusing us of plagiarism and lesser sins, and writes that “I’d ding my students if they did this.” Then, when confronted with some facts, he freely admits his errors. But then, in his follow-up apology post, he explains that while he indeed may be guilty of having filed false charges, the fault can be traced to his acute moral sense. This is a man who travels the world cleaning up other people’s messes — at 4 a.m., no less!

    My advice to people like Chris Blattman is simple: if you want to leave the world neater, try starting fewer messes yourself! Rather than shouting “plagiarism” in a crowded blogosphere, you could send an e-mail saying, “Hey Dubner, it sure would be nice if you linked to my blog every time you hat-tip me.”

    But that would have deprived Blattman content for a blog post. As I wrote above, the incentives to attack in public are strong, no matter how wrong-headed the attack may be. This is similar to the strong incentives that lead people to predict the future . Wrong predictions are usually forgotten and barely ever punished — but on the off chance that you do successfully predict a rare event, the bragging rights last forever.

    *     *     *

    III. The Jan.-Feb. 2012 issue of American Scientist includes an article headlined “ Freakonomics: What Went Wrong ?” It was written by a pair of statisticians named Andrew Gelman and Kaiser Fung . They damn us with a bit of faint praise, including this:

    The word “freakonomics” has come to stand for a light-hearted and contrarian, yet rigorous and quantitative, way of looking at the world.

    But make no mistake: Gelman-Fung come to bury, not to praise. Their central charge: 

    In our analysis of the Freakonomics approach, we encountered a range of avoidable mistakes, from back-of-the-envelope analyses gone wrong to unexamined assumptions to an uncritical reliance on the work of Levitt’s friends and colleagues. 

    I’ll give Gelman-Fung credit: they certainly spent more time on their attack than did Blattman. But it doesn’t seem to have helped much. Let’s look at the evidence. 

    1. Their first example of a “mistake” concerns a May, 2005, Slate column we wrote about the economist Emily Oster ’s research on the “missing women” phenomenon in Asia. Her paper, “Hepatitis B and the Case of the Missing Women,” was about to be published in the Aug. 2005 issue of the Journal of Political Economy . At the time, Levitt was the editor of JPE, and Oster’s paper had been favorably peer-reviewed.

    Oster argued that women with Hepatitis B tend to give birth to many more boys than girls; therefore, a significant number of the approximately 100 million missing females might have been lost due to this virus rather than the previously argued explanations that included female infanticide and sex-selective mistreatment.

    Other scholars, however, countered that Oster’s conclusion was faulty. Indeed, it turned out they were right, and she was wrong. Oster did what an academic (or anyone) should do when presented with a possible error: she investigated, considered the new evidence, and corrected her earlier argument. Her follow-up paper was called “ Hepatitis B Does Not Explain Male-Biased Sex Ratios in China .”

    Levitt subsequently wrote a Freakonomics blog post about the Oster affair, headlined “ An Academic Does the Right Thing .” He detailed the error, the new data, etc.; he wrote:

    I have great admiration for her doing this. I know a lot of people who wouldn’t have done the same thing. They wouldn’t have undertaken a study that could show their biggest result was wrong, and if they found a negative result, the
    y would try to bury it.

    Also, hats off to Justin Lahart at the Wall Street Journal who wrote this article on the topic. Here are the key papers .

    What do Gelman-Fung make of this exchange? 

    Monica Das Gupta is a World Bank researcher who, along with others in her field, has attributed the abnormally high ratio of boy-to-girl births in Asian countries to a preference for sons, which manifests in selective abortion and, possibly, infanticide. … In a follow-up blog post, Levitt applauded Oster for bravery in admitting her mistake, but he never credited Das Gupta for her superior work. Our point is not that Das Gupta had to be right and Oster wrong, but that Levitt and Dubner, in their celebration of economics and economists, suspended their critical thinking.

    In other words, Gelman-Fung are distressed that, in a blog post that Steve Levitt wrote about Emily Oster’s admission of error, he did not specifically name one of Oster’s critics — even though, in that post, Levitt linked both to the relevant Journal article and a secondary Journal article listing the “key papers” on the topic, both of which spelled out Das Gupta’s involvement.

    Seriously? This amounts to a “suspension of critical thinking”? I’m sorry, but I can’t give Gelman-Fung any points for this one.

     

    2. Gelman-Fung take issue with a column we wrote in the New York Times in 2006 called “ A Star Is Made .” It concerned the research of K. Anders Ericsson, a psychologist at Florida State University whom we’ve written about several times . The column argued that “the trait we commonly call talent is highly overrated.” Here are Gelman-Fung:

    It begins with the startling observation that elite soccer players in Europe are much more likely to be born in the first three months of the year. The theory: Since youth soccer leagues are organized into age groups with a cutoff birth date of December 31, coaches naturally favor the older kids within each age group, who have had more playing time. So far, so good. But this leads to an eye-catching piece of wisdom: The fact that so many World Cup players have early birthdays, [Dubner and Levitt] write,

    may be bad news if you are a rabid soccer mom or dad whose child was born in the wrong month. But keep practicing: a child conceived on this Sunday in early May would probably be born by next February, giving you a considerably better chance of watching the 2030 World Cup from the family section.

    Perhaps readers are not meant to take these statements seriously. But when we do, we find that they violate some basic statistical concepts. Despite its implied statistical significance, the size of the birthday effect is very small.

    The authors acknowledge as much three years later when they revisit the subject in SuperFreakonomics. They consider the chances that a boy in the United States will make baseball’s major leagues, noting that July 31 is the cutoff birth date for most U.S. youth leagues and that a boy born in the United States in August has better chances than one born in July. But, they go on to mention, being born male is “infinitely more important than timing an August delivery date.” What’s more, having a major-league player as a father makes a boy “eight hundred times more likely to play in the majors than a random boy,” they write.

    So here’s what we seem to have done:

    • We wrote a 2006 Times column that explored a surprising birthdate bulge among high-level sports rosters and the bulge’s relevance to professional accomplishment (a topic expanded upon in Malcolm Gladwell’s 2008 book Outliers , and elsewhere); and then:
    • We ourselves expanded on this idea in our 2009 book SuperFreakonomics , again describing the birthdate-bulge effect and noting that, as significant as this timing effect may be, in the realm of sport at least it seems to be overwhelmed by hereditary and/or environmental factors.

    I fail to see an error here other than our inability to write in a 2006 magazine column what we were able to write in a 2009 book. Do you?

     

    3. Gelman-Fung take issue with what we’ve written about the perils of drunk walking:

    In SuperFreakonomics, Levitt and Dubner use a back-of-the-envelope calculation to make the contrarian claim that driving drunk is safer than walking drunk, an oversimplified argument that was picked apart by bloggers. The problem with this argument, and others like it, lies in the assumption that the driver and the walker are the same type of person, making the same kinds of choices, except for their choice of transportation. Such all-else-equal thinking is a common statistical fallacy. In fact, driver and walker are likely to differ in many ways other than their mode of travel. What seem like natural calculations are stymied by the impracticality, in real life, of changing one variable while leaving all other variables constant.

    There is some validity to this criticism. We tried to make clear in the book, and in a subsequent Freakonomics Radio segment , that we had to make certain assumptions in this analysis. While there is a lot of good data on drunk driving (and driving in general), there is much less on walking, and especially drunk walking.

    So, as Gelman-Fung rightly note, there is no way to know if, for instance, “the driver and walker are the same type of person.”

    There’s also the fact that a drunk walker is likely to travel a much shorter distance than a drunk driver. (That’s why we offered a per-mile analysis rather than a time-based analysis.) Most important, we made clear that a drunk driver poses a danger to other people while that is much less true of a drunk walker (although wandering into a roadway while drunk can certainly pose a danger to others). 

    Gelman-Fung write that our argument was “picked apart by bloggers.” Their American Scientist article includes only a cursory bibliography and no footnotes or endnotes, nor do Gelman-Fung cite any specific sources in this case, so it’s unclear who those bloggers were and what they picked apart.

    That said, I agree we should have done a better job spelling out these assumptions and caveats. But to me the big picture is clear. Even though we don’t know much about the overlap between drunk drivers and drunk walkers, and even though it’s obvious that drunk walkers travel shorter distances than drunk drivers, the raw numbers a
    re compelling:

    • In 2009, there were 33,808 traffic fatalities in the U.S.;
    • Of these, 17,640 were driving a vehicle;
    • Of these 17,640 drivers, 7,281 (41.3%) were drunk (BAC = .08+);
    • Of the 33,808 total fatalities, 4,092 (12.1%) were pedestrians (including children).
    • Of these pedestrians, 1,408 were drunk (BAC = .08+), representing 34.4% of all pedestrians. If you factor out pedestrian fatalities for victims 13 and younger, the drunk walkers constitute 36.5% of pedestrian fatalities. Also worth noting, however: in the case of 237 of those pedestrian fatalities, the driver was also drunk.

    So, while our methodology is hardly foolproof, I’d hope that most people would appreciate the baseline argument here: drunk walking is a dangerous activity that has been largely overlooked and, therefore, was worth writing about.

    For what it’s worth, those are two of the key criteria that go into determining what Levitt and I write: overlooked and worth writing about.

    Furthermore, it should be said: just because we have identified drunk walking as a real danger, we have repeatedly made clear that we do not in any way encourage drunk driving. Still, some people feel that talking about drunk walking misses a larger problem. For instance, our recent radio piece on drunk walking provoked some interesting pushback from pro-bicycle and anti-car quarters, who feel that pedestrians, drunk or otherwise, are the innocent bystanders of a car-mad society.

      

    4. Gelman-Fung write about a section in SuperFreakonomics describing an effort to identify potential terrorists via U.K. banking data. Levitt did this analysis in collaboration with a U.K. bank-fraud expert whom we call Ian Horsley (his real identity had to be protected).

    This portion of Gelman-Fung’s essay is so error-ridden and deprived of logic that it’s hard to decipher. So let me back up and explain what they’re actually writing about.

    The SuperFreakonomics section in question begins with a discussion of how forensic analysis of this sort is particularly challenging when you’re dealing with a relatively small amount of wrongdoing within a large population. As we write:

    When data have been used in the past to identify wrongdoing — like the cheating schoolteachers and collusive sumo wrestlers we wrote about in Freakonomics — there was a relatively high prevalence of fraud among a targeted population. But in this case, the population was gigantic (Horsley’s bank alone had many millions of customers) while the number of potential terrorists was very small.

    We then discuss the sad fact that even if you could create an algorithm that identified potential terrorists at a 99 percent accuracy rate, this still wouldn’t be acceptable: 

    We’ll assume the United Kingdom has 500 terrorists. The algorithm would correctly identify 495 of them, or 99 percent. But there are roughly 50 million adults in the United Kingdom who have nothing to do with terrorism, and the algorithm would also wrongly identify 1 percent of them, or 500,000 people. At the end of the day, this wonderful, 99-percent-accurate algorithm spits out too many false positives — half a million people who would be rightly indignant when they were hauled in by the authorities on suspicion of terrorism.

    Nor, of course, could the authorities handle the workload. 

    This is a common problem in health care. A review of a recent cancer-screening trial showed that 50 percent of the 68,000 participants got at least 1 false-positive result after undergoing 14 tests. …

    We then describe how Horsley and Levitt created a smaller, tighter algorithm, built on a variety of metrics concerning the banking habits of customers of Horsley’s own bank, which wound up having significant predictive power:

    Starting with a database of millions of bank customers, Horsley was able to generate a list of about 30 highly suspicious individuals. According to his rather conservative estimate, at least 5 of those 30 are almost certainly involved in terrorist activities. Five out of 30 isn’t perfect — the algorithm misses many terrorists and still falsely identifies some innocents — but it sure beats 495 out of 500,495.

    Maybe you think that identifying only five terrorists out of a potential 500 isn’t worthwhile. But keep in mind these data were drawn solely from Horsely’s own bank. The idea was to create an algorithmic model that could be shared with other banks and institutions to ultimately cast a wider net.

    Here, then, is how Gelman-Fung, critique this section of the book:

    The straw man [Levitt and Dubner] employ—a hypothetical algorithm boasting 99-percent accuracy—would indeed, if it exists, wrongfully accuse half a million people out of the 50 million adults in the United Kingdom. …

    But in the course of this absorbing narrative, readers may well miss the spot where Horsley’s algorithm also strikes out. The casual computation keeps under wraps the rate at which it fails at catching terrorists: With 500 terrorists at large (the authors’ supposition), the “great” algorithm finds only five of them. Levitt and Dubner acknowledge that “five out of 30 isn’t perfect,” but had they noticed the magnitude of false negatives generated by Horsley’s secret recipe, and the grave consequences of such errors, they might have stopped short of hailing his story. The maligned straw-man algorithm, by contrast, would have correctly identified 495 of 500 terrorists.

    I don’t understand how Gelman-Fung conclude that we “[kept] under wraps the rate at which [the algorithm] fails.” I literally don’t understand it. Are they reading the same thing that we wrote – the same thing that you just read above?

    But more bizarrely, they seem to extol the “maligned straw-man algorithm” which “would have correctly identified 495 of 500 terrorists.”

    Yes, it would have correctly identified 495 of 500 terrorists – at a cost of rounding up an additional 500,000 law-abiding citizens!

    In accusing us of failing to understand the tradeoff of false positives versus false negatives, it seems as if Gelman-Fung simply don’t care about the tradeoff of false positives versus false negatives. Are they advocating the British authorities round up entire neighborhoods throughout the country in order to extract 500 potential bad guys? If so, then their comprehension of democratic society is perhaps even worse than their comprehension of what we have written.

    In the end, Levitt and Horsley turned over their results to MI5. Given the nature of this project, we can’t say any more than that. But imagine if, instead of producing a list with 30 names on it, 5 of whom were quite possibly terrorists, Gelman-Fung would apparently prefer that Levitt and Horsley had strolled into MI5 with a list of half a million names. Here, there are probably 500 bad guys on this list. Good luck. That meeting wouldn’t have likely lasted long.

      

    5. Strangely enough, Gelman-Fung don’t write about a mistake we once made that I’d consider more substantial that those they include.

    In Freakonomics, we wrote about th
    e author and civil-rights activist Stetson Kennedy – who had infiltrated the Ku Klux Klan in the 1940’s in an attempt to break it up. We based our account on interviews with Kennedy in his home, his own published and unpublished works, and several other Klan histories. After our book’s publication, we were presented with unpublished evidence arguing that Kennedy had significantly embellished his role in infiltrating the Klan, and that his portrayal of said role was inaccurate. We then sought out further historical evidence and presented it to Kennedy, again in person, in order that he might rebut it. No satisfying rebuttal was forthcoming. Then, with a heavy heart, we wrote a 2006 New York Times column presenting evidence of Kennedy’s embellishments. I say “with a heavy heart” because it is of course no fun to admit you’ve been had (our column was headlined “Hoodwinked?”); but also because Kennedy was a national treasure (he died last year ), a man on the right side of many good fights, and exposing him was therefore an unsavory task. 

    But: because our original writing had perpetuated an error that occurred in many books and other historical portrayals, we felt compelled to correct it, and we did, as publicly as we knew how.

    Why did Gelman-Fung omit this story?

    Perhaps they reasoned that readers of their essay might conclude that we do approach our work with the utmost appreciation for accuracy and legitimacy, and are willing to explain in the New York Times when we’ve been had. Which, of course, might lead that same reader to conclude that the “mistakes” Gelman-Fung point out are in fact not mistakes at all.

    Nor do Gelman-Fung mention our Freakonomics Radio, produced in collaboration with American Public Media and WNYC . I don’t know whether this means they found it faultless, were unaware of its existence, or neither. In any case, the radio project represents the majority of our new content over the past two years, with more than 60 podcasts and 10 hour-long radio shows to date.  If you believe Gelman-Fung’s claims and doubt that our work is intellectually honest and rigorous, I’d invite you to take a look at our radio archives , which include complete transcripts and links to supporting material.

     

    *     *     *

     

    6. Gelman-Fung conclude their essay by offering some advice “for the would-be pop-statistics writer,” using what Levitt and I have done “wrong” as a cautionary tale.

    In this section, Gelman-Fung offer plenty of practical advice about writing in general. My only objection is that whenever they write specifically about us and our work, it becomes clear that they don’t know what they’re talking about. Which leads them to use exceedingly weasely language to promote their argument. For instance:

    Although there’s no way we can be sure, perhaps, in some of the cases described above, there was a breakdown in the division of labor when it came to investigating technical points. 

    Although there’s no way we can be sure, perhaps, in some of the cases described above …”?! 

    It is hard to imagine writing a sentence that hedges more. Years ago, I taught a freshman comp class at Columbia, called “Logic and Rhetoric.” It encouraged young writers to concentrate on those two essential elements of worthwhile writing: the logic (and accompanying ideas, facts, examples, etc.) and the rhetoric (clear, crisp, transparently honest communication). I think I learned as much about writing that year as I taught about writing. That said, I would occasionally come across a student’s sentence like the one above that Gelman-Fung wrote. I’d explain to its author why it was so bad: with rhetoric as contorted and sketchy as that, a reader has every right to distrust whatever “logic” you’re about to unload. Language and rhetoric are inextricably bound up with each other; the failure of one contributes to a failure in the other. When I read that Gelman-Fung sentence, it seems to me that what they are really saying is: We don’t actually know what we’re talking about when we talk about how Levitt and Dubner work, and we’re certainly not going to go to the trouble to do any original reporting or even fact-checking, but in the interest of attacking a ripe target like Freakonomics, let’s make some assumptions and worry later about the facts …

    When they turn their attention specifically to SuperFreakonomics, Gelman-Fung write:

    Success comes at a cost: The constraints of producing continuous content for a blog or website and meeting publisher’s deadlines may have adverse effects on accuracy.

    That might seem a sensible argument — unless the exact opposite is true. No one holds a gun to our head to write anything. Most of what we write on our blog is a natural continuation of what we’ve already written or a casual version of what we’re working on next. Furthermore: we, not our publisher, set the deadline for our second book. Nor did we rush it. Indeed, we address the timing at the very beginning of SuperFreakonomics

    As profitable as it might have been to pump out a quick follow-up – think “Freakonomics for Dummies” or “Chicken Soup for the Freakonomics Soul” – we wanted to wait until we had done enough research that we couldn’t help but write it all down. So here we finally are, more than four years later …

    Did Gelman-Fung simply fail to read the book they decided to trash? I wouldn’t have thought so, but they also write this:

    The strongest parts of the original Freakonomics book revolved around Levitt’s own peer-reviewed research. In contrast … SuperFreakonomics relies heavily on anecdotes, gee-whiz technology reporting and work by Levitt’s friends and colleagues.

    This is grotesquely wrong. Here’s how:

    1. “Relies heavily on anecdotes?” Simply not true. I’d love Gelman-Fung to provide a list so that I could refute it. Do we tell stories? Yes. Are the stories generally a) backed by data; and b) illustrative of a larger point we’re making? Also yes.
    2. “Gee-whiz technology reporting”? By this Gelman-Fung may be referring to our controversial chapter about global warming, which indeed discussed a variety of technological solutions. But how do we rely on “gee-whiz” reporting? Having read their essay, I am not sure that Gelman-Fung actually understand what reporting is, and they certainly don’t seem to have done much for the essay. Rather, they interpret (quite sloppily) what they have read in our books, look around to see what some bloggers have to say, and make a bunch of claims that you couldn’t get away with in an op-ed for a second-rate newspaper.

    Our books, meanwhile, feature a good deal of original reporting in addition to the writing based on empirical analysis. SuperFreakonomics alone reflects hundr
    eds of interviews and reporting trips to, among other places: London and elsewhere in the U.K. (for the terrorism project described in Chapter 2); Washington, D.C. (for the medical-informatics system known as Azyxxi in Chapter 2); Bellevue, Wash. (the anti-hurricane measures and anti-global warming measures in Chapters 4 and 5); Grand Rapids, Mich. (the inefficiency of chemotherapy, Chapter 2); New Haven (the monkey experiments in the Epilogue); an undisclosed location in the northeast (for the car-seat crash tests we commissioned, as described in Chapter 4); and Queens, N.Y. (for the Kitty Genovese story, as described in Chapter 3.) Granted, that last trip was only a subway ride for me — but reporting is reporting, and Gelman-Fung’s inability to recognize and acknowledge it strikes me as a great deficit.

    Finally, Gelman-Fung argue that SuperFreakonomics, unlike Freakonomics, featured the research of Levitt’s “friends and colleagues” rather than Levitt himself. This is one of their largest assumptions, and perhaps their faultiest as well. I cannot say for certain how they came to this conclusion but I do have a guess.

    Our books feature stories that include a combination of reporting, data analysis, and character-based narrative. The characters we’ve written about — the sociologist Sudhir Venkatesh, the economist John List, the U.K. fraud officer Ian Horsley, etc. – are often co-authors with Levitt on academic papers. While writing about the analysis and/or investigations that Levitt and/or I have done, we tend to focus on these co-authors rather than insert ourselves as protagonists in the narrative.

    Why? It is a way to both share credit and to not be constantly thumping one’s own chest. (The irony is that Chris Blattman accuses us of spreading too little credit, while Gelman-Fung interpret our credit-spreading as having failed to do original work.) In both Freakonomics and SuperFreakonomics, we devote a lot of space (and effort) to writing an endnotes section that fully explains our sources and methodologies. In SuperFreakonomics, the endnotes section ran about 12,700 words, about the length of a book chapter. 

    Here, drawn from those SuperFreakonomics endnotes, are some of the original Levitt research around which the book was built:

    Steven D. Levitt and Jack Porter, “ How Dangerous Are Drinking Drivers? ” Journal of Political Economy 109, no. 6 (2001).

    Steven D. Levitt and Sudhir Alladi Venkatesh, “ An Empirical Analysis of Street-Level Prostitution ,” working paper.

    Ilyana Kuziemko and Steven D. Levitt, “ An Empirical Analysis of Imprisoning Drug Offenders ,” Journal of Public Economics 88 (2004). 

    Steven D. Levitt and Chad Syverson, “ Antitrust Implications of Outcomes When Home Sellers Use Flat-Fee Real Estate Agents ,” Brookings-Wharton Papers on Urban Affairs, 2008.

    Roland G. Fryer, Steven D. Levitt, and John A. List, “ Exploring the Impact of Financial Incentives on Stereotype Threat: Evidence from a Pilot Study ,” AEA Papers and Proceedings 98, no. 2 (2008).

    Mark Duggan and Steven D. Levitt, “Assessing Differences in Skill Across Emergency Room Physicians,” working paper.

    “Identifying Terrorists Using Banking Data,” Steven D. Levitt and A. Danger Powers, working paper.

    Steven D. Levitt and Matthew Gentzkow, “Measuring the Impact of TV’s Introduction on Crime,” working paper.

    Steven D. Levitt, “ The Effect of Prison Population Size on Crime Rates: Evidence from Prison Overcrowding Litigation ,” The Quarterly Journal of Economics 11, no. 2 (May 1996).

    Steven D. Levitt and John A. List, “ What Do Laboratory Experiments Measuring Social Preferences Tell Us About the Real World ,” Journal of Economic Perspectives 21, no. 2 (2007).

    Levitt and List, “Viewpoint: On the Generalizability of Lab Behaviour to the Field ,” Canadian Journal of Economics 40, no. 2 (May 2007).

    Levitt and List, “ Homo Economicus Evolves ,” Science, February 15, 2008.

    Levitt, List, and David Reiley, “ What Happens in the Field Stays in the Field: Professionals Do Not Play Minimax in Laboratory Experiments ,” Econometrica (forthcoming, 2009)

    Levitt and List, “ Field Experiments in Economics: The Past, the Present, and the Future, ” European Economic Review (forthcoming, 2009).

    Steven D. Levitt and Jack Porter, “ Sample Selection in the Estimation of Air Bag and Seat Belt Effectiveness ,” The Review of Economics and Statistics 83, no. 4 (November 2001).

    Steven D. Levitt, “ Evidence That Seat Belts Are as Effective as Child Safety Seats in Preventing Death for Children ,” The Review of Economics and Statistics 90, no. 1 (February 2008).

    Levitt and Joseph J. Doyle, “ Evaluating the Effectiveness of Child Safety Seats and Seat Belts in Protecting Children from Injury ,” Economic Inquiry, forthcoming.

    Ian Ayres and Steven D. Levitt, “ Measuring Positive Externalities from Unobservable Victim Precaution: An Empirical Analysis of LoJack ,” Quarterly Journal of Economics 113, no. 8 (February 1998).

    Given these citations, how can one justify what Gelman-Fung wrote about SuperFreakonomics? If I had to guess I’d say that either a) they were wed to the anti-Freakonomics argument they’d embarked on and were unwilling to let facts stand in the way; or b) they simply failed to read the endnotes. They would hardly be the first people to fail to read a book’s endnotes – but, given the fact that they are launching a scholarly attack published in a journal like American Scientist, one might have expected otherwise.

    *     *     *

    7. Finally: it is true, as Gelman-Fung write, that we sometimes feature the work of researchers we’ve come to know. (We also write about lots and lots of people we don’t know at all. Furthermore, Andrew Gelman himself has turned up on our blog several few times – and as he has made clear, he is plainly not our friend.)

    Gelman-Fung present this “friend and colleague” idea as an argument that we favor or feature the work of certain scholars because we happen to know them. There is indeed an arrow to be drawn between what we write and whom we know – but Gelman-Fung have the arrow traveling in the wrong direction.

    < p>It isn’t that we necessarily write about friends’ and colleagues’ work simply because we know them; it’s that we sometimes become friends and colleagues with people who do interesting work.

    And I’d be surprised if Gelman and Fung didn’t do exactly the same thing. Isn’t that the point of living a life of the mind – to seek out the most fascinating, energetic, right-minded thinkers you can find and spend your time learning from them and with them? 

    Indeed, if you take a look at Gelman’s blog , you’ll find he consistently references and praises the work of certain scholars whom he seems to admire. One of them, as it happens, is Chris Blattman . And Blattman, on his blog, seems to admire Gelman as well .

    So Gelman and Blattman seem to like each other’s work, and I’m happy for that. If they are real friends in real life, so much the better. That’s how things work. But having one set of rules for yourself and another set for the people you choose to attack is neither good logic nor good rhetoric.

    Another scholar who often appears on Gelman’s blog is Dan Kahan , a professor of law and psychology at Yale. Kahan is a leader of the Cultural Cognition Project , a scholarly group that explores how people’s underlying beliefs and biases color their rational assessment of important topics like climate change and nuclear power. 

    I interviewed Kahan for a recent Freakonomics Radio podcast called “ The Truth Is Out There … Isn’t It ?” It’s about how even smart people – in fact, especially smart people – tend to seek out information that confirms their ideological or moral views rather than honestly assessing the evidence.

    In the podcast, I describe some interesting research Kahan and others had done on the perceived risks of climate change.

    DUBNER: [Ellen] Peters and Kahan found that high scientific literacy and numeracy were not correlated with a greater fear of climate change. Instead, the more you knew, the more likely you were to hold an extreme view in one direction or the other — that is, to be either very, very worried about the risks of climate change or to be almost not worried at all. In this case, more knowledge led to … more extremism! Why on earth would that be? Dan Kahan has a theory. He thinks that our individual beliefs on hot-button issues like this have less to do with what we know than with who we know.

    We then hear from Kahan:

    KAHAN: My activities as a consumer, my activities as a voter, they’re just not consequential enough to count. But my views on climate change will have an impact on me in my life. If I go out of the studio here over to campus at Yale, and I start telling people that climate change is a hoax – these are colleagues of mine, the people in my community—that’s going to have an impact on me; they’re going to form a certain kind of view of me because of the significance of climate change in our society, probably a negative one. Now, if I live, I don’t know, in Sarah Palin’s Alaska, or something, and I take the position that climate change is real, and I start saying that, I could have the same problem. My life won’t go as well. People who are science literate are even better at figuring that out, even better at finding information that’s going to help them form, maintain a view that’s consistent with the one that’s dominant within their cultural group.  

    I found this observation fascinating. It’s a striking example of what Danny Kahneman calls being “ blind to our blindness ” — that is, how our biases lead us to form conclusions that we think are rational but in fact are merely extensions of our preexisting beliefs.

    Were Gelman-Fung blind to their blindness? Did they come to believe, for whatever personal or professional reasons, that Levitt’s and my work was in need of attack, and did they then set out to gather evidence that seemed to support their bias?

    Or, put more colloquially: once they’d picked up a hammer, did everything look like a nail?

    I can certainly understand why Freakonomics is an appealing target for someone like Gelman-Fung. As I noted earlier, there are strong incentives to attack, particularly in the public sphere, where one can get a ton of attention in a blink by assailing the reputation of someone who’s been plugging away for years. Whether in the academy, the media, the political arena, or elsewhere, public discourse these days often seems little more than a tit-for-tat game in which you wait for someone or something to achieve a certain momentum and then shout as loudly as you can that it’s “wrong!” Or, in written form: Epic fail.

    That is generally not what Levitt and I try to do in our Freakonomics work. There are a lot of different ways to explore and explain how the world works, and to resort so easily to attack mode seems to strike me as both counterproductive and exhausting.

    To be fair, I’m guessing that even Andrew Gelman and Kaiser Fung and Chris Blattman would agree with me on this point. A shouting match can be fun to watch once in a while, but the world is more interesting than that, or at least it should be. 


    Elias


    I think Blattman is right. A proper h/t is not just a name, but a link to the blog in which you found out about the story.

    Michael


    Agreed!

    Just listing the blog or author’s name without a link to the specific article is like only listing the publication name in a citation in a research paper. The reader shouldn’t have to use a card catalog or google to discover the real source.

    And link to the specific article, not to the blog’s front page.

    With the narrow exception of when you’re discussing spam, sites that promote hate or other such nonsense.

    frankenduf


    it appears, then, that the correct critique is ur too sensitive!?

    164


    Many of the commenters seem to be coming from the other blogs along with their thumbs up or down attacks. Keep up the good work Freakonomics and don’t let the negative comments get you down.

    Brett


    Blattman makes a good point overall, and later apologized for his overstep, and you respond with this? Seriously, please lose the ego.

    Also, the Gelman and friends critique can be read as a narrow one — the specific cases they cite and that you respond to — or as a broad one: your egos and insularity prevent you from seeing the bigger picture, while you dismiss all criticism as being emotional, political, or ideological. This post kind of confirms all of that.

    Myles


    No, Blattman makes a poor point overall. He accuses the Freakonomics blog of plagiarism, a serious charge to level at a professional journalist. His point in the original post, failing to give due credit, is verifiably wrong. Then, instead of fully and publicly admitting his error in attacking the integrity of the blog he attempts to turn it into an example of his moral acumen.

    Gelman & Co. make a similar attack to the integrity of the work of Levitt and Dubner. The accusations amount to sacrificing quality work in favor of profit, the use of sloppy calculations and arguments in lieu of substantive evidence and a general disregard for proper citation. And let’s not forget the charge of cronyism. All of these amount to an attack on the character of the authors, an assault on their integrity masquerading as a criticism of the actual work done. The Gelman critique can be read as a narrow one; it can also be read as the broadest of salvos, cherry picking examples to make a violent point.

    Integrity is not something to be taken lightly. It is significantly more fragile and more valuable than all the ego in the world, especially when one’s profession (and this is true of all professions) is based on the professionals underlying integrity.

    Read more…

    Elias


    If you look at, for example, the Yale policies on plagiarism, Blattman’s accusation stands (http://yalecollege.yale.edu/content/cheating-plagiarism-and-documentation). It is not , perhaps, the same as Dubner’s understanding of what constitutes plagiarism; this is a fair point. It’s certainly different than the idea of plagiarism as simple “copy/paste.”

    “Plagiarism is the use of someone else’s work, words, or ideas as if they were your own. Thus most forms of cheating on examinations are plagiarism; but we usually apply the word to papers rather than to examinations.

    If you use a source for a paper, you must acknowledge it[…] What counts as a source varies greatly depending on the assignment, but the list certainly includes readings, lectures, Web sites, conversations, interviews, and other students’ papers. Every academic discipline has its own conventions for acknowledging sources.”

    I think that simply citing a Website without a link does not actually fulfill internet standards for acknowledging sources.

    Read more…

    Nick Davis


    Thought I’d check Twitter (how do I hyperlink to that?) before falling asleep…fifteen minutes later here I am responding to this exhaustive/exhausting blog post. It was like a detective novel written by a neurotic brain surgeon. I really quite enjoyed it.

    The overarching analysis that making attacks is simpler, more invigorating and more attention-grabbing than making defences is nice, although on this occasion an impassioned defence definitely won the day. Is there such thing as an impassioned attack? I’m not so sure. Aggressive, zealous…yes, but maybe the beauty of making a defence is that passion is mostly reserved for, and most evident when, your integrity or whatever is in question. Oh, I think I may have rambled a little. Goodnight from Melbourne.

    Shayna


    Dubner – just want to commend you on your strong rebuttal. I agree that it is bothersome and time consuming to respond to criticism. However, in this case, I am glad you did.

    Tristan


    I remember when I first read the Gelman-Fung article, it seemed to be one of the longer and better researched pieces critiquing the unique perspective that Freakonomics (both the books and blog) take. But it soon became obvious that it was filled with both factual and logical errors. I actually came away from that article with more respect for the work Dubner and Levitt – if that’s the strongest criticism that can be brought, and it’s so weak, that must mean that the authors of freakonomics have really done a good job.

    Erik


    Heh, I like it. But what first pulled me in was the odd conclusion you make here:

    “But occasionally an attack is so spectacularly ridiculous, so riddled with errors and mangled logic, that it’s worth addressing.”

    So…the poorer the attack, the more it needs rebuttal? I’d think it would be the other way around.

    RJ Roy


    The problem is that in terms of more “technical” fields like science or politics, poorer attacks are often easier for the typical person to understand (not to mention quicker to put out). This means that it’s easier for the false idea to grab root.

    And it’s often much easier to respond to poor attacks, especially if you can point right back to the work they are attacking. Responding to the well written attacks on Emily Oster’s paper, for example, required a more through review of the research material, whereas Stephen Dubner needed only to quote things he and his colleagues already said.

    Søren


    Take away #1: Don’t let your inner tabloid edit and title your blog posts.

    Take away #2: Don’t let your inner apologetic answer when confronted with your own writing.

    Mitch


    While it seems like your critics have overstepped their bounds and made things too personal, I think you do a disservice to yourself and your work with parts of this post. Was it really necessary to make a silly attack on Ezra Klein like that, with the gross generalization that “he too seems to be in the business of attacking at any cost?” Your work with Levitt has been wonderful, but it’s important to acknowledge and accept some of the critiques about the importance and validity of the major assumptions behind it, especially since you and the media tend to paraphrase it with these “wild” one sentence questions and headlines. Is it possible that you are blind to some of your own blindness?

    Jonathan


    Well Gelman has responded to Dubner’s criticism. Enjoy!

    http://andrewgelman.com/2012/03/a-kaleidoscope-of-responses-to-dubners-criticisms-of-our-criticisms-of-freaknomics/

    Joe J


    “I was also surprised to see a Yale professor admit that he doesn’t “think much before I write,””
    Which surprises you, that he doesn’t think before he writes, or that he admitted it.?

    My own bias (yes, we all have one) is that I’d be surprised he admitted it, not that he doesn’t think.

    People swept up in their own ” overdeveloped sense of justice”, often don’t let minor things like truth or reality get in the way of their crusade. I have found that charistic, does go along with some professors, again my own bias.

    Tonya Riney


    Horribly long. Not horribly boring, and incites critical thinking. Excellent!

    Miss Steak


    This was one Freakonomics piece that was FULL of flaws:

    Nightclubs as Research Labs

    Jared


    While you make some reasonable points, you do your cause significant disservice with your tone and the personal attacks. Gelman and Fung (claim to have) found some problems with the science and tried to explain how they might have happened and suggested some possible remedies. OK, you disagree with some/all of the claims and the explanation. Fine. But there’s no need to paint Gelman & Fung as out to get you, resorting first to attack mode, or blind to their own motives. Gelman goes out of his way at every turn to say that he is a fan and that he appreciates much of the Freakonomics work. He’s also willing to allow for the possibility that he’s wrong and that he could learn from you. You might learn to do the same. Isn’t it at least possible that you yourself are blind to your blindness? I think there would be tremendous value to all parties in having an actual discussion with them, privately, instead of one-off journal articles or a blog fight where the tendency is to talk past one another.

    Read more…

    CM


    I like this: “Gelman-Fang may be referring to our controversial chapter about global warming…”

    They may be and they are! Having read their criticism, they are not circumspect about this. It’s interesting that you don’t respond to that criticism at all and then weasel around with rhetoric like this. What would you think if one of your students was so indirect?

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    Freakonomics : A Rogue Economist Explores the Hidden Side of Everything
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    Author Info:

    Stephen J. Dubner


    Ever had the sensation of staring at a print by M. C. Escher and
    thinking that if you could just look at it from the right angle you’d be
    able to see behind the surface to the trick? Well, the same is certainly
    true for economics, where the most powerful economist in the world, Fed
    Chairman Alan Greenspan, is notorious for speaking impenetrable
    gobbledygook and Harry Truman famously asked for a one-handed economist
    because: All my economists say, “on the one hand…on the other hand’.
    Economics presents us with vast arrays of numbers, often contradictory,
    even self-contradictory and always confusing. What the renowned young
    economist Steven D. Leavitt offers us is unique angles for seeing inside
    some of those numbers and, perhaps, making some sense of them. This is necessarily a hit-or-miss business–for instance, his attempted correlation of Roe v. Wade to the decline in crime seems a big miss –but the hits are more frequent and even the misses force us to think them through.

    Most will be familiar with Mr, Leavitt’s work through the series of essays he’s co-written–or inspired? or whatever–with Stephen Dubner. Having run in the NY Times Magazine they’ve generated big, and worthy, buzz and this book followed. As interesting as the topics they cover are, there’s something disconcerting about the manner in which their material is presented. Are the two men actually co-authors, or is Mr. Dubner writing pieces in Mr. Leavitt’s voice because he can make them more accessible to a general readership or has the time to do so or both? If you’ve not read their work this may seem a minor point, but it’s actually quite distracting and detracts from the book significantly, though not fatally. indeed, the book remains enjoyable and the essay on how the cheating in sumo wrestling relates to cheating by teachers to improve their students’ standardized test scores is worth the price of admission all by itself.

    (Reviewed:)

    Grade: (A-)


    Tweet
      

    Websites:

    See also:

    Economics

    Stephen Dubner Links:

        -BLOG: Freakonomics

        -AUTHOR SITE: Stephen Dubner

        -Steven D. Leavitt (Professor Department of Economics University of Chicago )

        -EXCERPT: What Do Schoolteachers and Sumo Wrestlers Have in Common? from Freakonomics

        -ESSAY: Abortion, and how it cut crime (Steven Levitt, 6/26/05, Times of London)

        -ESSAY: Monkey Business (STEPHEN J. DUBNER and STEVEN D. LEVITT, 6/05/05, NY Times Magazine)

        -ESSAY: The Search for 100 Million Missing Women : An economics detective story. (Stephen J. Dubner and Steven D. Levitt, May 24, 2005, Slate)

        -ESSAY: Trading Up : Where do baby names come from? (Steven D. Levitt and Stephen J. Dubner, April 12, 2005, Slate)

        -ESSAY: A Roshanda by Any Other Name : How do babies with super-black names fare? (Steven D. Levitt and Stephen J. Dubner, April 11, 2005, Slate)

        -PROFILE: Toward a Unified Theory of Black America (STEPHEN J. DUBNER , 3/20/05, NY Times Magazine)

        -ESSAY: What the Bagel Man Saw (STEPHEN J. DUBNER and STEVEN D. LEVITT, June 6, 2004, NY Times Magazine)

        -ESSAY: Why Drug Dealers Live With Their Moms : If you had a job paying $3.30 an hour, you’d be bunking at home too. (Steven D. Levitt and Stephen J. Dubner, April 24, 2005, LA Times)

        -TRIBUTE: Stephen Dubner recalls the cardinal as a peacemaker — between him and his mom. (STEPHEN J. DUBNER, May 5, 2000, New York)

        -AUDIO REPORT: Conversion: In the first of a two-part series, our reporter, Stephen Dubner, himself a convert and author of the book TURBULENT SOULS, looks at the experience of John Curry, principal of a school for at-risk students in New York. (Stephen J. Dubner, 11/20/00, Religion & Ethics)

        -EXCERPT: Chapter One of Confessions of a Hero-Worshiper: Finding Franco Harris by Stephen J. Dubner

        -REVIEW: of The Exes By Pagan Kennedy (Stephen J. Dubner, NY Times Book Review)

        -REVIEW: of THERE ONCE WAS A WORLD: A Nine-Hundred-Year Chronicle of the Shtetl of Eishyshok By Yaffa Eliach (Stephen J. Dubner, NY Times Book Review)

        -REVIEW: of HEART OF A SOLDIER: A Story of Love, Heroism, and September 11th By James B. Stewart (Stephen J. Dubner, NY Times Book Review)

        -AUDIO INTERVIEW: ‘Freakonomics’: Musings of a ‘Rogue Economist’ (Scott Simon, April 9, 2005, Weekend Edition)

        -CHAT: ‘Freakonomics’ — A New York Times Writer and a Rogue Economist Explore the Hidden Side of Everything (Stephen Dubner, June 8, 2005, Washington Post)

        -AUDIO INTERVIEW: Notes on “Confessions of a Hero Worshipper” (Bill Littlefield, 1/25/2003, Only a Game)

        -INTERVIEW: Q & A with Stephen Dubner : Author of Turbulent Souls: A Catholic Son’s Return to his Jewish Family (HalfJew.com)

        -PROFILE: ‘It’s not like I go looking for trouble’ : The offbeat take of ‘Freakonomics’ author Steven Levitt (May 11, 2005, AP)

        -PROFILE: Odd numbers (Tim Harford, April 22 2005, Financial Times)

        -ESSAY: When Numbers
    Solve a Mystery : Meet the economist who figured out that legal abortion was behind dropping crime rates. (STEVEN E. LANDSBURG, April 13, 2005, Opinion Journal)

        -ESSAY: The Miracle That Wasn’t (JOHN TIERNEY, 4/16/05, NY Times)

        -ESSAY: Pre-emptive Executions? : The notion that legalizing abortion drives down crime rates is logically flawed and morally repugnant. (Steve Sailer, 5/09/05, American Conservative)

        -ESSAY: A good book errs on link between abortion, crime rate (THOMAS ROESER, 5/14/05, Chicago Sun-Times)

        -ARCHIVES: “Stephen J. Dubner (New York Magazine)

        -REVIEW ARCHIVE: Freakonomics: A Rogue Economist Explores the Hidden Side of Everything By Steven D. Levitt and Stephen J. Dubner (MetaCritic)

        -REVIEW ARCHIVE: freakonomics (Reviews of Books)

        -REVIEW: of FREAKONOMICS: A Rogue Economist Explores the Hidden Side of Everything By Steven D. Levitt and Stephen J. Dubner (Jim Holt, NY Times)

        -REVIEW: of Freakonomics (Gregg Easterbrook, Washington Post)

        -REVIEW: of Freakonomics (The Economist)

        -REVIEW ESSAY: The Freakonomics of Race and IQ (Steve Sailer, April 25, 2005, V-Dare)

        -REVIEW: of Freakonomics (Dean Barnett, Weekly Standard)

        -REVIEW: of Freakonomics (Justin Fox, Fortune)

        -REVIEW: of Freakonomics (Andrew Leanord, Salon)

        -REVIEW: of Freakonomics (John Coleman, Townhall)

        -REVIEW: of Confessions of a Hero-Worshiper: Finding Franco Harris By Stephen J. Dubner (FRED WAITZKIN, NY Times Book Review)

        -REVIEW: of Confessions of a Hero-Worshiper (Todd Leopold, CNN)
    -REVIEW: of TURBULENT SOULS: A Catholic Son’s Return
    to His Jewish Family By Stephen J. Dubner (JONATHAN WILSON, NY Times Book Review)

        -REVIEW: of TURBULENT SOULS: A Catholic Son’s Return
    to His Jewish Family By Stephen J. Dubner (JULIE SALAMON, NY Times)

        -REVIEW: of Turbulent Souls (LORE DICKSTEIN, Forward)

    Book-related and General Links:

        -ESSAY: Hoodwinked? (STEPHEN J. DUBNER and STEVEN D. LEVITT, 1/08/06, NY Times)

        -INTERVIEW:
    Why bagels could hold the key to human behaviour : Sumo wrestlers, Chicago school teachers, drug dealers who live with their mothers and even the humble bagel – rogue economist Steven Levitt says it’s the little things in life that help explain the way the world works. (Gary Younge, June 21, 2005, The Guardian)

        ‘Freakonomics’ Abortion Research Is Faulted by a Pair of Economists (JON E. HILSENRATH, November 28, 2005, THE WALL STREET JOURNAL)

        -ESSAY: The Original Freakonomics (Max Borders, 6/03/05, Tech Central Station)

        -ESSAY:
    Life after birth : Everyone blames the parents – but some scientists say parenting has zero impact on how kids turn out (Emily Wilson, April 13, 2005, The Guardian)

    Copyright 1998-2015 Orrin Judd

    ★How to write a book review: writing introductions

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    Writing a Critical
    Book Review in History, by John Jones

     

    Introduction

     

    On being required
    to write my first critical book review for an upper level history course I was
    filled with questions as were many of my peers. I was aware that the discourse
    is different between disciplines and that each discipline has its own unique
    requirements. I also suspected that there was a difference in the objectives
    between English and History critical book reviews. My suspicions were confirmed
    as soon as I read some critical history book reviews. The objectives in book
    reviews between the disciplines are different animals. The most difficult part
    of any assignment is understanding what needs to be done, and how.

    Like many of my
    peers, I was a third-year student in a fourth-year class expected to write at
    the fourth-year level. The transition to upper level writing across the
    disciplines can be traumatic for the unprepared. Many of us had never written a
    critical book review for history, and not all of us were history majors. A
    number of students dropped out of the course after writing their first critical
    book review in history simply because they did not know what was required and
    did not conduct the research to find out. The critical book review in history
    is unique to the discipline and a skill that is expected to be mastered by
    history students after their first year. Understanding whata critical book review in history is
    supposed to consist of is the first step in writing one.

     

    Purpose

    The purpose of the
    critical book review for history is to share information about an historical
    topic – it is not a book report that summarizes the content. Historiography is
    the history of writing on a particular topic. The historical source under
    review is usually secondary, that is, it is about an event in history that the
    author has contributed some new information. The review is critical in that it
    discusses and evaluates the significance of this new information. Book reviews
    also provide the historian with a thumbnail sketch of the contents – that may
    be very useful in research work. Writing a book review requires that you assess
    the books strengths and weaknesses as they pertain to historiography – it is
    not a literary review. You should also tell the reader why you liked or
    disliked the book.


    Reviewing books is
    an essential part of the historian�s profession. History students are expected
    to learn the discipline: to become historians. In order to review a book on
    history it is essential to have some information on the subject, the region,
    and the period. The bibliography in the book should supply you with references
    to sources with related information. Journals are also a good place to find
    this information and to look for scholarly book reviews that will also help you
    understand the form, and give you an idea of what your review should look like.

     

    What
    is a critical book review
    ?

    The book review is
    simply an essay with three parts: an introduction, a body, and a conclusion.
    The three parts of the critical book review for the historian are: who wrote
    it, why did they write it, and what do they have to offer. Good historical
    writing is also an argument. Arguments are intended to extend our knowledge,
    and also can be described as having three parts: a premise, supporting
    evidence, and a conclusion.


    1 Who wrote it?

    Biographical
    information about the credibility, and expertise of the author must be taken
    into consideration. Who is the author, what is his or her background, how does
    the author�s background affect his or her writing? Education, class, ethnicity,
    nationality, gender, and political or religious affiliations may affect the
    authors expertise, bias, or interpretation. Is the author an authority or
    qualified to write on the subject.

    2 Why did the author write it?

    What is the author
    attempting to do? What is the theme: the argument? What assumptions has the
    author made? Is the argument well supported, with good documentation or does it
    have contradictions? Is the author�s conclusion convincing?

     

    3 What does the author
    contribute?

    What is new or
    different about this book, or does it offer anything new? Does the author
    present new information or evidence? Does the author raise new issues or leave
    unanswered questions for other scholars? How does this book differ from the
    general understanding of the topic or time?

     

    History
    and Rhetoric
    .

     

    Rhetoric is the
    art of argument, and good historical writing is always argumentative. Good
    historical writing is also about creating something new. Combine these two and
    you have, an argument about a new historical perception.

    Getting started

    1 Summarize

    ����������� Attempt to summarize the author�s
    thesis in a single sentence. This may be difficult if the author has merely
    implied rather than explicitly explained his or her thesis. You might have to
    read the whole book in some cases to determine what the author�s thesis is.
    Watch out for transitions or verbs that imply proof. Careful, critical reading
    is essential. An historical book, paper or essay, such as a critical book
    review is an argument. Arguments are very important to historians. Books such
    as Anthony Weston�s, A Rulebook for Arguments, or Trudy Govier�s, A
    Practical Study of Argument
    , are very helpful if you are unsure of what an
    argument is.

     

    2 Take a
    position

    ����������� You need a thesis statement of your
    own to produce an authoritative review. You should take a position pro or con
    and support it with evidence.

     

    3 Make a
    statement

    Make
    a relevant statement that clearly states your position and reveals your
    impression of the book. Your argument should be based on your interpretation of
    the author�s thesis.

     

    The Introduction

    Book reviews are
    short and concise, they may vary from half a page to several pages depending on
    the assignment. The introduction is extremely important, it must be short,
    effective, and it must contain your thesis.

    The thesis

    Developing a good thesis is often the most difficult
    part of writing. What happened, why is it interesting, why or how did it
    happen? The answers to these questions should set up the body of your thesis.
    Develop a hypothesis and then look for weak or vague words that detract from a
    strong, concise statement.Summarize
    the author�s thesis in a single powerful sentence if possible. Your thesis
    should appear in the last sentence of the first paragraph. Note – In a book
    review the conclusion should appear in the introduction unless you are posing a
    question, because your conclusion or question, is the argument that you are
    discussing. Often you cannot write a good thesis until you completed the first
    rough draft of your paper. Rewriting and refining are the keys to producing a
    good thesis.


    I have included a
    book review for illustration purposes. In my first attempt to do a critical
    book review I examined a number of critical book reviews in history in search
    ofthe common elements. Examining the
    work of others can provide invaluable information. I would recommend that you
    read a number of book reviews if you are uncomfortable about writing. I think
    the following book review is a good example of a critical book review in
    history. The entire review is less than two pages, approximately 650 words,
    that also fits the criteria for most upper level assignments.

     

    The Forgotten Cause of the Civil War

    A New Look at the
    Slavery Issue

    Lawrence R. Tenzer

    Scholars’ Publishing House
    1997

     

    A book review by Danny Yee ( [email protected] ),  Copyright � 1998
    http://www.anatomy.usyd.edu.au/danny/book-reviews/

     

    One of the things
    that has always puzzled me about the history of the United States is how a
    civil war could be fought and won to end slavery, but full civil rights not be
    granted to blacks until a century later. Tenzer’s
    The
    Forgotten Cause of the Civil War
    suggests that one of the major contributions to tension between North
    and South – and hence one of the causes of the civil war – was
    white slavery, or the perception of slavery by
    Northerners as a personal threat.

    Tenzer begins with the legal
    definition of slavery and of terms such as White, Black, and mulatto (which
    often differed from the social definitions). The
    partus
    sequitur ventrem
    rule made
    the offspring of a slave mother slaves, regardless of their colour. (No slave
    could be White, of course, so white slaves were classified as mulattos.)
    Chapter two looks at the consequence of this rule, the presence of white slaves
    in the South. Tenzer makes no attempt to provide quantitative figures here,
    stressing instead the accessibility of accounts of white slaves in the North
    (notably advertisements for runaway slaves who could "pass" as
    white). However many of them there actually were, the
    idea of slaves indistinguishable from free whites
    was widespread in the North.

    Chapter three looks at Southern
    racial theory, in particular the fabrication of figures for insanity in the
    1840 census and Dr Nott’s idea that mulattos were unhealthier and shorter lived
    than black slaves. This leads to a chapter on the illicit slave trade, which
    Tenzer argues is the explanation for census results showing an apparently
    higher "fecundity" for black slaves than for free blacks and
    mulattos. His argument for an extensive illicit slave trade (continued in an
    appendix) is indirect but persuasive.

    The 1850 Fugitive Slave law allowed
    runaway slaves to be reclaimed without due process, creating the possibility
    that free whites could be seized accidentally, or even kidnapped. This was
    perceived as an attack on freedoms inside the North and many states passed
    personal liberty laws in response. The political power of the South and events
    such as the destruction of the Missouri Compromise and the
    Dred
    Scott
    decision also raised
    fears of slavery being extended into the territories and Northern states. Mixed
    with ideas that "capital should own labor" and that slavery was
    right, regardless of colour, this produced an explosive atmosphere. However
    seriously leaders in the South may have contemplated the nationalization of
    slavery or the possibility of enslaving free white laborers in the North, there
    was enough evidence for this to make it a major theme in anti-slavery campaigns
    and Republican political propaganda.

    Detailed references and some of the
    argument are left to the endnotes, and
    The Forgotten Cause of the Civil
    War
    is accessible to the
    non-specialist – despite having only a slender background knowledge of the
    period I had no trouble following it. I found Tenzer’s thesis convincing: it
    resolved my perplexity about a war being fought to end slavery without blacks
    being granted civil rights. In any event,
    The Forgotten Cause of the Civil
    War
    , with its extensive
    quotations from newspapers and other texts of the period, both Southern and
    Northern, paints a vivid picture of attitudes to slavery in the decades before
    the Civil War.

     

    Disclaimer: I received a review copy of The Forgotten Cause of the Civil
    War
    from the Scholars’ Publishing House, but I have no stake,
    financial or otherwise, in its success.

     

    %T
    The Forgotten Cause of the Civil War

    %S A New Look at the Slavery Issue
    %A Lawrence R. Tenzer
    %I Scholars' Publishing House
    %C Manahawkin
    %D 1997
    %O paperback, bibliography, index
    %G ISBN 0-9628348-0-7
    %P xxvi,273pp
    %K history , United States


    The Introduction

    �One of the things that has always puzzled me
    about the history of the United States is how a civil war could be fought and
    won to end slavery, but full civil rights not be granted to blacks until a
    century later. Tenzer’s
    The Forgotten Cause of the Civil War suggests that one of the major contributions
    to tension between North and South – and hence one of the causes of the civil
    war – was
    white
    slavery, or the perception of slavery by Northerners as a personal threat.�

    This introduction in two sentences is short.
    The first sentence injects the writer into the work with a question that
    catches the reader�s interest,

    �One of the things that has always puzzled me
    about the history of the United States is how a civil war could be fought and
    won to end slavery, but full civil rights not be granted to blacks until a
    century later.�

    The second sentence identifies the author, the book, and the authors
    thesis; the issue of white slavery.

    �Tenzer’s The Forgotten Cause of the Civil
    War
    suggests that one of
    the major contributions to tension between North and South – and hence one of
    the causes of the civil war – was
    white slavery, or the perception of slavery by
    Northerners as a personal threat.�

    The writer has clearly identified both the
    authors thesis and his own. In this example the writer�s thesis is presented as
    a question that is being covered by the writer and the reader can expect the
    conclusion at the end.

    The body of the essay explains the theme of the book in three
    paragraphs that elaborate on points made in the introduction. The first
    paragraph explains the colour and physical characteristics ofWhite, Black, and Mulatto slaves. The second
    paragraph compares Mulatto to Black slaves, and the illicit slave trade. The
    third paragraph discusses slave laws and the possibility that free whites could
    be seized accidentally, or even kidnapped. The author�s thesis, the case for
    Northern concerns being sufficiently aroused to provoke the civil war, is
    wrapped up in the last two sentences of the third paragraph.

    �Mixed with ideas that "capital should own labor" and that
    slavery was right, regardless of colour, this produced an explosive atmosphere.
    However seriously leaders in the South may have contemplated the
    nationalization of slavery or the possibility of enslaving free white laborers
    in the North, there was enough evidence for this to make it a major theme in
    anti-slavery campaigns and Republican political propaganda.�

    The concluding paragraph states the writers thesis and answers the
    question asked in the first line. The conclusion also provides the writer�s
    opinion of the author�s work and recommends the book to readers with little
    knowledge of the period. This book review provides enough insight into the
    contents of the book for the reader to get a snap shot of the entire book.

    A
    book review for history then is
    simply an essay with three parts, an introduction, a
    body, and a conclusion. The three parts of the critical book review for the
    historian are: who wrote it, why, and what does the author have to offer. In �The
    Forgotten Cause of the Civil War
    : A New Look at the Slavery Issue�
    these three questions are readily answered. In addition, the answer to the last
    question, what does the author have to offer, perhaps also poses an interesting
    question for further research ��ideas that �capital should own labour� and that
    slavery was right regardless of colour�.

    Genre

    It is important to identify the historical genre of
    the book. The genre may be��
    characterized by style, form, or content as: biography, cultural,
    demographic, economic, environmental, ethno-history, feminist, intellectual,
    labour, legal, military, diplomatic, political, psychohistory, religious,
    social, or urban.

     

    Evidence and Credibility of Sources

     

    A clear
    distinction must be made between primary and secondary evidence.
    Evaluating a book for history requires detective work and critical evaluation.
    Books are usually secondary evidence, but good books are supported by adequate
    primary evidence. The credibility of the author also must be considered.


    Primary evidence is
    contemporary to the problem being studied.

    Examples:

    Journals, diaries, letters,
    autobiographies, personal papers, government publications, maps, census
    reports, newspaper articles, pamphlets, treatises, sermons, oral histories, and
    artifacts.

    Secondary evidence is a
    synthesis of primary sources written by a historian for the purpose of
    argumentation or explanation. The quality of the synthesis is very important.

    Examples:

    Scholarly books, journal articles,
    and theses.

     

    Authors

    Academic
    Historians
    are ranked by their degree, B.A., M.A., or Ph.D..

     

    Amateur Historians may have
    been journalists who write history and maintain high standards. Lawyers,
    politicians, civil servants, and fiction writers may also turn to writing
    history.

    Non-Historians may be
    propagandists, holocaust- deniers, and those who deliberately falsify history
    for many different reasons.

     

    Documentation

    Documentation is
    extremely important to Historians. Proper documentation is easy if you have a
    guide. If you do not want your professor to have a hairy fit, and use a lot of
    red ink, pick up A Handbook For UCC History Students and use it. This
    guide was written by the History Faculty at UCC for history students. Another
    useful guide for documentation, and recommended by a member of the history
    faculty at UCC is A Pocket Guide To Writing In History, by Mary Lynn
    Rampolla.



    Back to Essays Page

     


     
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    How to Write a Book Review

    How to Write a Book Review


    Your opinion is important—dont be afraid to voice it in a book review

    Writing a book review is not the same as writing a book report or a summary. A book review is a critical analysis of a published work that assesses the work’s strengths and weaknesses. A prominent reviewer can have a major impact on a book’s reception. Many authors strive to have their books reviewed by a professional because a published review (even a negative one) can be a great source of publicity.

    One need look no further than Oprah Winfrey’s famed Book Club to see the effect that this type of publicity can have on a book’s sales. There are countless book review examples , but first, let’s discuss how to write a book review.

    You aren’t in high school anymore

    A book review is not a book report. Resist the temptation to summarize the character, plot , theme, and setting, which was probably the formula you used in your high school English classes. Your readers are not interested in having the book re-told to them, and are certainly not interested in having the ending spoiled.

    To become a legitimate book reviewer, you need to be able to tell your readers whether the book you are reviewing is interesting, thorough, original, and worth spending money on (or at least borrowing from the library).

    Preparing to write a review

    Before writing a book review, you must, of course, read the book. Reading the first page, last page, and dust jacket won’t cut it—you must read the book in its entirety, making quick notes about your impressions as you read.

    We also recommend that you ask yourself questions as you read. If the book is non-fiction, ask yourself, “Does the author have a clear argument that he or she is trying to prove? Is it original? Does he or she prove the argument successfully? Are the arguments sound? Is it well-researched and well-written? Does the author omit any information that would have been relevant?”

    For a work of fiction, ask yourself, “Is this work original? Are the characters well-rounded and believable? Does the plot twist, turn, and thicken, or does it plod along? Does the book address universal themes? Is the dialogue realistic?”

    Make notes about the author’s writing style: Is it irreverent or dry? Fast-paced or excruciatingly detailed? These are all things that potential readers will want to know. As a reviewer, you must tell them.

    Get to the point

    When you begin writing the review, think about what your thesis is. Will your review be favorable, or do you plan to advise your readers to spend their money elsewhere? Just like in a college paper, remember to make your thesis known in the first few lines of your review. This will help your reader focus and will provide you with an argument for your review.

    Don’t forget the details

    Briefly include some biographical information about the author at the beginning of your review. Is this his or her first book? If not, what types of books has he or she written before? How has his or her background qualified him or her to write about this particular subject? Also, be sure to include the book’s complete title, the number of pages it has, its publisher, and its price.

    Before launching into your nuanced and cerebral analysis, briefly tell the reader what the book is about, its genre, and who its intended audience is. Is the book designed for mass commercial appeal or for a select group of academic specialists? Providing this information at the beginning will let readers know if they’re interested in reading the entire review.

    Support your argument with direct quotes

    Just as you would in academic writing , carefully select passages from the book you are reviewing to support your argument. These passages will help readers understand what you mean when you write that the book is a tender love story, a violent murder mystery, or a dull yawner. Since a book review is generally quite short (less than 1,000 words), we suggest selecting brief passages.

    Try to use a natural, informal tone. A book review is not rocket science; you are simply communicating your impressions and opinions of an author’s work. What’s more, always remember to edit and proofread your review multiple times before publishing it. If you’re going to rip a novel apart for being overly verbose and hard to follow, you’d better triple check to make sure your review is grammatically sound and succinct!

    Image source: Amador Loureiro/Unsplash.com

    Academic Editing

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    Five Habits to Avoid in Your Academic Writing

    After editing thousands of pieces of academic writing, our editors have compiled five of the most common mistakes that academics make and offer suggestions on how to avoid them.

    How to Write a Book Report

    How to Write a Book Report

    Writing a book report can be a difficult task that requires you to deal with a large amount of information in a relatively small space. But don’t be discouraged—in this article we outline how to prepare for your book report and in our later article we discuss how to write a book report.

    How to Write a Report on a Book

    How to Write a Report on a Book

    We have already provided students with useful tips on the importance of taking notes when reading a novel for a book report. Now it’s time to put those notes into action and start writing a book report.


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    ★Electrical Safety

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    Electricity and its dangers cause many people to die yearly. We must do something to stop this. One way is by telling people how to prevent and protect. The first thing to know is electrical fire.Electrical fires are different than other fires. Because water conducts electricity, throwing water on an electrical fire can cause the fire to get larger. In that case, it is very important to NEVER use water on an electrical fire. The next step is to tell an adult to turn off the main power to the house. If the fire can be put out safely, tell an adult to use a proper chemical fire extinguisher. If the fire cannot be put out safely, leave the house and take everyone with you. Call 911 or your emergency number and tell them it is an electrical fire.The next topic is electric shock. You can never tell when contact with electricity will be fatal, but you can be sure it will always hurt. Electric shock can cause muscle spasms, weakness, shallow breathing, rapid pulse, severe burns, unconsciousness, or death. In a shock incident, the path that electric current takes through the body gets very hot. Burns occur all along that path, including the places on the skin where the current enters and leaves the body. It’s not only giant that can kill or injure you if you contact them. You can also be killed by a shock from an appliance or power cord in your home. It is good to put toothpaste or cream to cool down the burns of electric shock.That’s why it’s important to avoid electrical hazards and always have an extinguisher to prevent electrical fire.
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    Healthy Mind, Healthy Body

    Healthy Mind, Healthy Body

    Healthy mind, healthy body

    Healthy mind, healthy body

    Most of us have heard or read about this and some people also keep saying this to others as friendly advice. It has a simple but deep meaning. For a healthy mind, healthy body, we obviously know we should be both physically and mentally healthy and fit. But most of us seem to be ignoring this simple mantra in today’s times—including me.

    A healthy mind lives in a healthy body. Mental health is imperative for physical health.  If the mind is unsullied and pure, it will greatly help in maintaining physical well-being and health.

    Case Study

    When I started my career as a Psychologist and a Life Skills Trainer, I was extremely excited about this new phase of my life. I wanted to do everything in a perfect manner and be successful. In order to achieve my goal, I only focused on work. As a result, my health was ignored. I did not eat on time. I did not exercise and also was not sleeping adequately.

    As a result, I put on weight, developed a back ache and also started getting irritated easily. My father, who was observing all these changes, advised me to change my lifestyle for the better.

    I did, I followed a proper routine, slept properly, and did some physical exercise and things changed for the better. Today, I feel physically and mentally fit.

    In today’s fast life, we are mostly stressed and racing against time to finish our to-do list each day. We are so busy that we do not get time to eat properly, do some physical exercise and even sleep adequately. Most of us remain constantly stressed. We are always under pressure to meet deadlines or complete our targets. We want to achieve and accomplish a lot in no time. Lets not forget,

    Only noble thoughts lead to a noble life. ( Tweet this )

    But, we are forgetting that in order to achieve all this, we need to remain healthy, physically and mentally. We are searching for mental peace all the time to counter stress in our daily lives but, we do not realize that if we are neglecting our bodies, how can we nourish our mind.

    All of us can follow some simple tips of healthy habits for a healthy mind, healthy body and a healthier lifestyle.

    • Timely Meals– Take your meals on time, have a proper three meals a day, avoid junk and fried food. Eat on regular intervals and do not skip your breakfast. Always remember,

    Eat, not for the sake of it but to nourish your body. ( Tweet this )

    • Fruits and Vegetables For a healthy mind, healthy body, adding fresh fruits and veggies to your diet is imperative as they are the main source of nutrition for your body and they help in keeping your appetite in check.
    • Exercise– Take some time out from your busy schedule to exercise. Walk, jog, skip, do yoga for 30 minutes for at least 5 days a week which is an extensive booster of not only a healthy body but also for a healthy mind.
    • Stay Hydrated– Drink plenty of water and liquid to keep yourself hydrated and to remove toxins from of your system.
    • Sleep Tight– Get yourself a minimum of seven hours sleep every night, so that you feel fresh and energized throughout the day. Sleep tight, all night because that is your time to be with you.

    Sleeping is nice. You forget about everything around you for a while. ( Tweet this )

    • Take a Chill Pill– Take some time out from your busy schedule for yourself. Once in a while take a break from your daily routine. Go for dinner, watch movies, and spend time with family and friends. You will feel physically and mentally relaxed and refreshed.
    • Say No To Stress– Do not carry emotional baggage from the past. Focus on your present and future. Do not stress yourself for what you cannot change. Learn from your mistakes and move on. This is one quote I’ve always loved,

    Let your Mess be your Message. ( Tweet this )

    • Balanced Life– Try to have a balance between your personal and professional life and treat them as two different worlds. If your personal issues affect your professional life or vice-versa, it is bound to increase stress, anger and frustration.
    • Do What You Love– Try to take time out for your hobbies like gardening, music, reading, cooking. Our hobbies have the power of therapy and they give us a lot of mental peace and act as a stress-buster.

    Conclusion – Healthy Mind, Healthy Body

    Healthy mind, healthy body—we often hear this, but don’t do much to incorporate it in our lifestyle. Our fast lives have not left us with much choice, except to multitask. We all are trying to do so many things in a limited time period and our lives have become hectic which leads to irregularity in following a healthy routine with lots of healthy habits . As a result, our physical and mental health suffer and we do not feel fit enough to chase our dreams and complete our to-do lists.

    According to an English proverb, “A healthy mind lives in  a healthy body.” Even if the body is not healthy the effects of this condition will not be permanent provided the mind is not allowed to get affected. Feelings of depression and weakness grow into a disease only when they prolong and rooted in thoughts and feelings for a long time.

    We must not forget that “Health is Wealth.” If we do not take care of our physical health, our mental health will automatically suffer. So, eat on time; sleep on time; do some exercise; take some small breaks; pursue your hobby to balance yourself; and move towards a healthy lifestyle and a healthier “YOU.”

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    • emotional health
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    About the Author

    Varsha Tyagi

    Varsha Tyagi is a Master’s in Psychology with 5 years of Experience as
    a Life Skills Coach and a Counseling Psychologist. She has worked with
    many schools, colleges and corporates as a Counselor and a Life Skills
    Trainer and dealt with both children and adults. She is currently
    working as a Life Skills Facilitator with an organization.

    Leave a Reply

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    ★Introduction: Language Analysis Essay


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    VCE Language Analysis sample essay

    May 25th, 2015  | 

    Published in
    e-news

    Pitched at VCE students and one of the essay types in the year 12 exam.
    Introduction
    Sentence one: Definition of the issue in broad terms.
    Recent controversy has arisen over a government report which suggests that women be allowed to fight in the front line.

    Sentence two: Outline the opposing points of view.
    Those who support the proposal argue that women are just as capable soldiers as men and those who oppose it argue that women are not suited to frontline combat.

    Body paragraphs must look at the arguments, beginning with the writer’s main argument.

    Paragraph one
    The writer claims that it is male prejudice that is preventing women to fight in the frontline. By referring to events from 30 years ago the writer is suggesting that those who believe that women should not be in the frontline are old fashioned. This argument is an appeal to the desire to be up-to-date and modern. The writer also suggests that those who believe that is worse for women to be killed in combat are prejudiced or irrational. This technique suggests that those who oppose women being on the frontline have not thought about the issue but only make judgments based on prejudice.

    Paragraph two
    The writer explains that other countries allow women to fight in the frontline this shows the writer to be knowledgeable about the topic. This argument also suggest that Australia is old fashioned compared to these countries. In this paragraph the writer also uses evidence from recent army tests to support the argument drawing on expert opinion. This makes the writer seem knowledgeable and authoritative on the subject and thus likely to convince the reader.

    Paragraph three
    In paragraph three the writer rebuts the argument that women should not be exposed to the dangers of frontline combat. The writer’s use of the phrase “old soldiers” implies that this is an old fashioned view and the writer suggests that this is also based on an outdated view of soldier’s work.

    Paragraph four
    The writer states that the army requires more recruits suggesting that placing women in roles of direct combat is a practical measure to resolve the army’s recruiting problems. In addition, the writer suggests that women have been disadvantaged by the current policy and this technique is designed to show sympathy for women in this situation and to portray the writer as supporting women’s rights. The writer builds on this point by suggesting that “modern women” do not want to be protected by men because this is a form of prejudice and women want to be treated as equal.

    Conclusion
    Sum up the issue without making judgment.

    Comments are closed.

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    VCE Language Analysis sample essay

    May 25th, 2015  | 

    Published in
    e-news

    Pitched at VCE students and one of the essay types in the year 12 exam.
    Introduction
    Sentence one: Definition of the issue in broad terms.
    Recent controversy has arisen over a government report which suggests that women be allowed to fight in the front line.

    Sentence two: Outline the opposing points of view.
    Those who support the proposal argue that women are just as capable soldiers as men and those who oppose it argue that women are not suited to frontline combat.

    Body paragraphs must look at the arguments, beginning with the writer’s main argument.

    Paragraph one
    The writer claims that it is male prejudice that is preventing women to fight in the frontline. By referring to events from 30 years ago the writer is suggesting that those who believe that women should not be in the frontline are old fashioned. This argument is an appeal to the desire to be up-to-date and modern. The writer also suggests that those who believe that is worse for women to be killed in combat are prejudiced or irrational. This technique suggests that those who oppose women being on the frontline have not thought about the issue but only make judgments based on prejudice.

    Paragraph two
    The writer explains that other countries allow women to fight in the frontline this shows the writer to be knowledgeable about the topic. This argument also suggest that Australia is old fashioned compared to these countries. In this paragraph the writer also uses evidence from recent army tests to support the argument drawing on expert opinion. This makes the writer seem knowledgeable and authoritative on the subject and thus likely to convince the reader.

    Paragraph three
    In paragraph three the writer rebuts the argument that women should not be exposed to the dangers of frontline combat. The writer’s use of the phrase “old soldiers” implies that this is an old fashioned view and the writer suggests that this is also based on an outdated view of soldier’s work.

    Paragraph four
    The writer states that the army requires more recruits suggesting that placing women in roles of direct combat is a practical measure to resolve the army’s recruiting problems. In addition, the writer suggests that women have been disadvantaged by the current policy and this technique is designed to show sympathy for women in this situation and to portray the writer as supporting women’s rights. The writer builds on this point by suggesting that “modern women” do not want to be protected by men because this is a form of prejudice and women want to be treated as equal.

    Conclusion
    Sum up the issue without making judgment.

    Comments are closed.

      • facebook
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      • Pinterest
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    • Recent Posts

      • Forthcoming – Collection of Novellas
      • VCE English and Literature Information Session
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    GI Partners Sells Plum Healthcare to Bay Bridge Capital

    • Dec 10, 2012
    • Private Equity

    GI Partners (“GI”), a leading mid-market private equity firm, announced today the sale of its portfolio company, Plum Healthcare Group, LLC (“Plum”), one of the fastest growing companies in healthcare services, to Bay Bridge Capital Partners (“Bay Bridge”).

    Plum’s current portfolio consists of 50 skilled nursing facilities and five home health and hospice agencies located in strategic geographic clusters throughout California, Utah, and Arizona. Known for its pre-eminent clinical care, Plum serves over 5,000 medically-complex patients every day. The company was acquired by GI Partners in 2006 and, during the firm’s six-years of ownership, has successfully acquired and turned around 39 skilled nursing facilities. By improving clinical quality and increasing staff across its facilities, Plum has achieved industry-leading patient outcomes and occupancy rates as well as significantly increased the mix of medically-complex residents it serves. Under GI’s stewardship, Plum has strengthened facility-level resources, clinical and administrative consulting services, and invested heavily in clinical quality and IT infrastructure. Plum has also diversified geographically by moving in to two additional states, and has developed new post-acute service lines by entering into the home health and hospice markets. As a result of these and other initiatives, Plum has grown revenue and EBITDA at a 32% and 30% compounded annual growth rate (“CAGR”), respectively, over the last five years.

    Howard Park, a Managing Director of GI Partners, said, “We are extremely pleased with everything we were able to accomplish working closely with Plum management over the past few years, despite the challenging healthcare reimbursement environment. The unique human touch Plum brings to a healthcare services business has made it a rewarding investment. Our initial investments in clinical quality, staffing, infrastructure, IT, and key personnel have really positioned Plum to generate success over the next phase of growth that they are about to embark on with Bay Bridge. We look forward to closely following their future achievements.”

    Since founding Plum in 1999, co-CEOs Mark Ballif and Paul Hubbard have been at the helm of Plum and will continue in this capacity under Bay Bridge’s ownership. Mark said, “Our partnership with GI demonstrates how investors and providers can come together to provide better patient care. We have been able to achieve outstanding performance by investing in great people and superior clinical systems. These make a huge difference in our patients’ lives.” Paul added, “GI helped us use our deep commitment to people and clinical excellence as a springboard to professionalize our unique approach and grow. It has been a pleasure to work with such fine people and thought-partners.”

    Jefferies & Company, Inc. served as lead financial advisor to GI Partners and Plum on the transaction. Edgeview Partners also served as co-advisor to Plum. Paul Hastings LLP served as legal advisor to GI Partners and Plum.

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    Reviews/Commentaries/ADA Statements

    Nutrition Recommendations and Interventions for Diabetes

    A position statement of the American Diabetes Association

    1. American Diabetes Association

      Diabetes Care 2007 Jan; 30(suppl 1): S48S65. https://doi.org/10.2337/dc07-S048

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      A position statement of the American Diabetes Association

      • CHD, coronary heart disease
      • CKD, chronic kidney disease
      • CVD, cardiovascular disease
      • DPP, Diabetes Prevention Program
      • FDA, Food and Drug Administration
      • GDM, gestational diabetes mellitus
      • MNT, medical nutrition therapy
      • RDA, recommended dietary allowance
      • USDA, U.S. Department of Agriculture

      Medical nutrition therapy (MNT) is important in preventing diabetes, managing existing diabetes, and preventing, or at least slowing, the rate of development of diabetes complications. It is, therefore, important at all levels of diabetes prevention (see Table 1 ). MNT is also an integral component of diabetes self-management education (or training). This position statement provides evidence-based recommendations and interventions for diabetes MNT. The previous position statement with accompanying technical review was published in 2002 ( 1 ) and modified slightly in 2004 ( 2 ). This statement updates previous position statements, focuses on key references published since the year 2000, and uses grading according to the level of evidence available based on the American Diabetes Association evidence-grading system. Since overweight and obesity are closely linked to diabetes, particular attention is paid to this area of MNT.

      The goal of these recommendations is to make people with diabetes and health care providers aware of beneficial nutrition interventions. This requires the use of the best available scientific evidence while taking into account treatment goals, strategies to attain such goals, and changes individuals with diabetes are willing and able to make. Achieving nutrition-related goals requires a coordinated team effort that includes the person with diabetes and involves him or her in the decision-making process. It is recommended that a registered dietitian, knowledgeable and skilled in MNT, be the team member who plays the leading role in providing nutrition care. However, it is important that all team members, including physicians and nurses, be knowledgeable about MNT and support its implementation.

      MNT, as illustrated in Table 1 , plays a role in all three levels of diabetes-related prevention targeted by the U.S. Department of Health and Human Services. Primary prevention interventions seek to delay or halt the development of diabetes. This involves public health measures to reduce the prevalence of obesity and includes MNT for individuals with pre-diabetes. Secondary and tertiary prevention interventions include MNT for individuals with diabetes and seek to prevent (secondary) or control (tertiary) complications of diabetes.

      GOALS OF MNT FOR PREVENTION AND TREATMENT OF DIABETES

      Goals of MNT that apply to individuals at risk for diabetes or with pre-diabetes

      To decrease the risk of diabetes and cardiovascular disease (CVD) by promoting healthy food choices and physical activity leading to moderate weight loss that is maintained.

      Goals of MNT that apply to individuals with diabetes

      1. ) Achieve and maintain

        • Blood glucose levels in the normal range or as close to normal as is safely possible

        • A lipid and lipoprotein profile that reduces the risk for vascular disease

        • Blood pressure levels in the normal range or as close to normal as is safely possible

      2. ) To prevent, or at least slow, the rate of development of the chronic complications of diabetes by modifying nutrient intake and lifestyle

      3. ) To address individual nutrition needs, taking into account personal and cultural preferences and willingness to change

      4. ) To maintain the pleasure of eating by only limiting food choices when indicated by scientific evidence

      Goals of MNT that apply to specific situations

      1. ) For youth with type 1 diabetes, youth with type 2 diabetes, pregnant and lactating women, and older adults with diabetes, to meet the nutritional needs of these unique times in the life cycle.

      2. ) For individuals treated with insulin or insulin secretagogues, to provide self-management training for safe conduct of exercise, including the prevention and treatment of hypoglycemia and diabetes treatment during acute illness.

      EFFECTIVENESS OF MNT

      Recommendations

      • Individuals who have pre-diabetes or diabetes should receive individualized MNT; such therapy is best provided by a registered dietitian familiar with the components of diabetes MNT. (B)

      • Nutrition counseling should be sensitive to the personal needs, willingness to change, and ability to make changes of the individual with pre-diabetes or diabetes. (E)

      Clinical trials/outcome studies of MNT have reported decreases in HbA1c (A1C) of ∼1% in type 1 diabetes and 1–2% in type 2 diabetes, depending on the duration of diabetes ( 3 , 4 ). Meta-analysis of studies in nondiabetic, free-living subjects and expert committees report that MNT reduces LDL cholesterol by 15–25 mg/dl ( 5 , 6 ). After initiation of MNT, improvements were apparent in 3–6 months. Meta-analysis and expert committees also support a role for lifestyle modification in treating hypertension ( 7 , 8 ).

      ENERGY BALANCE, OVERWEIGHT, AND OBESITY

      Recommendations

      • In overweight and obese insulin-resistant individuals, modest weight loss has been shown to improve insulin resistance. Thus, weight loss is recommended for all such individuals who have or are at risk for diabetes. (A)

      • Structured programs that emphasize lifestyle changes, including education, reduced energy and fat (∼30% of total energy) intake, regular physical activity, and regular participant contact, can produce long-term weight loss on the order of 5–7% of starting weight. Thus, lifestyle change should be the primary approach to weight loss. (A) (also see primary prevention section)

      • Low-carbohydrate diets (restricting total carbohydrate to <130 g/day) are not recommended in the treatment of overweight/obesity. The long-term effects of these diets are unknown and although such diets produce short-term weight loss, maintenance of weight loss is similar to that from low-fat diets and impact on CVD risk profile is uncertain. (B)

      • Physical activity and behavior modification are important components of weight loss programs and are most helpful in maintenance of weight loss. (B)

      • Weight loss medications may be considered in the treatment of overweight and obese individuals with type 2 diabetes and can help achieve a 5–10% weight loss when combined with lifestyle modification. (B)

      • Bariatric surgery may be considered for some individuals with type 2 diabetes and BMI ≥35 kg/m2 and can result in marked improvements in glycemia. The long-term benefits and risks of bariatric surgery in individuals with pre-diabetes or diabetes continue to be studied. (B)

      The importance of controlling body weight in reducing risks related to diabetes is of great importance. Therefore, these nutrition recommendations start by considering energy balance and weight loss strategies. The National Heart, Lung, and Blood Institute guidelines define overweight as BMI ≥25 kg/m2 and obesity as BMI ≥30 kg/m2 ( 9 ). The risk of comorbidity associated with excess adipose tissue increases with BMIs in this range and above. However, clinicians should be aware that in some Asian populations, the proportion of people at high risk of type 2 diabetes and CVD is significant at BMIs of >23 kg/m2 ( 10 ). Visceral body fat, as measured by waist circumference ≥35 inches in women and ≥40 inches in men, is used in conjunction with BMI to assess risk of type 2 diabetes and CVD ( Table 2 ) ( 9 ). Lower waist circumference cut points (≥31 inches in women, ≥35 inches in men) may be appropriate for Asian populations ( 11 ).

      Because of the effects of obesity on insulin resistance, weight loss is an important therapeutic objective for individuals with pre-diabetes or diabetes ( 12 ). However, long-term weight loss is difficult for most people to accomplish. This is probably because the central nervous system plays an important role in regulating energy intake and expenditure. Short-term studies have demonstrated that moderate weight loss (5% of body weight) in subjects with type 2 diabetes is associated with decreased insulin resistance, improved measures of glycemia and lipemia, and reduced blood pressure ( 13 ). Longer-term studies (≥52 weeks) using pharmacotherapy for weight loss in adults with type 2 diabetes produced modest reductions in weight and A1C ( 14 ), although improvement in A1C was not seen in all studies ( 15 , 16 ). Look AHEAD (Action for Health in Diabetes) is a large National Institutes of Health–sponsored clinical trial designed to determine if long-term weight loss will improve glycemia and prevent cardiovascular events ( 17 ). When completed, this study should provide insight into the effects of long-term weight loss on important clinical outcomes.

      Evidence demonstrates that structured, intensive lifestyle programs involving participant education, individualized counseling, reduced dietary energy and fat (∼30% of total energy) intake, regular physical activity, and frequent participant contact are necessary to produce long-term weight loss of 5–7% of starting weight ( 1 ). The role of lifestyle modification in the management of weight and type 2 diabetes was recently reviewed ( 13 ). Although structured lifestyle programs have been effective when delivered in well-funded clinical trials, it is not clear how the results should be translated into clinical practice. Organization, delivery, and funding of lifestyle interventions are all issues that must be addressed. Third-party payers may not provide adequate benefits for sufficient MNT frequency and time to achieve weight loss goals ( 18 ).

      Exercise and physical activity, by themselves, have only a modest weight loss effect. However, exercise and physical activity are to be encouraged because they improve insulin sensitivity independent of weight loss, acutely lower blood glucose, and are important in long-term maintenance of weight loss ( 1 ). Weight loss with behavioral therapy alone also has been modest, and behavioral approaches may be most useful as an adjunct to other weight loss strategies.

      Standard weight loss diets provide 500–1,000 fewer calories than estimated to be necessary for weight maintenance and initially result in a loss of ∼1–2 lb/week. Although many people can lose some weight (as much as 10% of initial weight in ∼6 months) with such diets, without continued support and follow-up, people usually regain the weight they have lost.

      The optimal macronutrient distribution of weight loss diets has not been established. Although low-fat diets have traditionally been promoted for weight loss, two randomized controlled trials found that subjects on low-carbohydrate diets (<130 g/day of carbohydrate) lost more weight at 6 months than subjects on low-fat diets ( 19 , 20 ). However, at 1 year, the difference in weight loss between the low-carbohydrate and low-fat diets was not significant and weight loss was modest with both diets. Changes in serum triglyceride and HDL cholesterol were more favorable with the low-carbohydrate diets. In one study, those subjects with type 2 diabetes demonstrated a greater decrease in A1C with a low-carbohydrate diet than with a low-fat diet ( 20 ). A recent meta-analysis showed that at 6 months, low-carbohydrate diets were associated with greater improvements in triglyceride and HDL cholesterol concentrations than low-fat diets; however, LDL cholesterol was significantly higher on the low-carbohydrate diets ( 21 ). Further research is needed to determine the long-term efficacy and safety of low-carbohydrate diets ( 13 ). The recommended dietary allowance (RDA) for carbohydrate (130 g/day) is an average minimum requirement and is lower than most individuals consume ( 22 ). Therefore, low-carbohydrate diets (restricting total carbohydrate to <130 g/day) are not recommended. An important reason for not recommending low-carbohydrate diets is that they eliminate many foods that are important sources of energy, fiber, vitamins, and minerals and are important in dietary palatability.

      Meal replacements (liquid or solid prepackaged) provide a defined amount of energy, often as a formula product. Use of meal replacements once or twice daily to replace a usual meal can result in significant weight loss. Meal replacements are an important part of the Look AHEAD weight loss intervention ( 17 ). However, meal replacement therapy must be continued indefinitely if weight loss is to be maintained.

      Very-low-calorie diets provide ≤800 calories daily and produce substantial weight loss and rapid improvements in glycemia and lipemia in individuals with type 2 diabetes. When very-low-calorie diets are stopped and self-selected meals are reintroduced, weight regain is common. Thus, very-low-calorie diets appear to have limited utility in the treatment of type 2 diabetes and should only be considered in conjunction with a structured weight loss program.

      The available data suggest that weight loss medications may be useful in the treatment of overweight individuals with and at risk for type 2 diabetes and can help achieve a 5–10% weight loss when combined with lifestyle change ( 14 ). According to their labels, these medications should only be used in people with diabetes who have BMI >27.0 kg/m2.

      Gastric reduction surgery can be an effective weight loss treatment for obesity and may be considered in people with diabetes who have BMI ≥35 kg/m2. A meta-analysis of studies of bariatric surgery reported that 77% of individuals with type 2 diabetes had complete resolution of diabetes (normalization of blood glucose levels in the absence of medications), and diabetes was resolved or improved in 86% ( 23 ). In the Swedish Obese Subjects study, a 10-year follow-up of individuals undergoing bariatric surgery, 36% of subjects with diabetes had resolution of diabetes compared with 13% of matched control subjects ( 24 ). All cardiovascular risk factors except hypercholesterolemia improved in the surgical patients.

      NUTRITION RECOMMENDATIONS AND INTERVENTIONS FOR THE PREVENTION OF DIABETES (PRIMARY PREVENTION)

      Recommendations

      • Among individuals at high risk for developing type 2 diabetes, structured programs that emphasize lifestyle changes that include moderate weight loss (7% body weight) and regular physical activity (150 min/week), with dietary strategies (such as reduced intake of fat) to reduce calories, can reduce the risk for developing diabetes and are therefore recommended. (A)

      • Individuals at high risk for type 2 diabetes should be encouraged to achieve the U.S. Department of Agriculture (USDA) recommendation for dietary fiber (14 g fiber/1,000 kcal) and foods containing whole grains (one-half of grain intake). (B)

      • There is not sufficient, consistent information to conclude that low–glycemic load diets reduce the risk for diabetes. Nevertheless, low–glycemic index foods that are rich in fiber and other important nutrients are to be encouraged. (E)

      • Observational studies report that moderate alcohol intake may reduce the risk for diabetes, but the data do not support recommending alcohol consumption to individuals at risk of diabetes. (B)

      • No nutrition recommendation can be made for preventing type 1 diabetes. (E)

      • Although there are insufficient data at present to warrant any specific recommendations for prevention of type 2 diabetes in youth, it is reasonable to apply approaches demonstrated to be effective in adults, as long as nutritional needs for normal growth and development are maintained. (E)

      The importance of preventing type 2 diabetes is highlighted by the substantial worldwide increase in the prevalence of diabetes in recent years. Genetic susceptibility appears to play a powerful role in the occurrence of type 2 diabetes. However, given that population gene pools shift very slowly over time, the current epidemic of diabetes likely reflects changes in lifestyle leading to diabetes. Lifestyle changes characterized by increased energy intake and decreased physical activity appear to have together promoted overweight and obesity, which are strong risk factors for diabetes.

      Several studies have demonstrated the potential for moderate, sustained weight loss to substantially reduce the risk for type 2 diabetes, regardless of whether weight loss was achieved by lifestyle changes alone or with adjunctive therapies such as medication or bariatric surgery (see energy balance section) ( 1 ). Moreover, both moderate-intensity and vigorous exercise can improve insulin sensitivity, independent of weight loss, and reduce risk for type 2 diabetes ( 1 ).

      Clinical trial data from both the Finnish Diabetes Prevention study ( 25 ) and the Diabetes Prevention Program (DPP) in the U.S ( 26 ) strongly support the potential for moderate weight loss to reduce the risk for type 2 diabetes. The lifestyle intervention in both trials emphasized lifestyle changes that included moderate weight loss (7% of body weight) and regular physical activity (150 min/week), with dietary strategies to reduce intake of fat and calories. In the DPP, subjects in the lifestyle intervention group reported dietary fat intakes of ∼34% of energy at baseline and 28% of energy after 1 year of intervention ( 27 ). A majority of subjects in the lifestyle intervention group met the physical activity goal of 150 min/week of moderate physical activity ( 26 , 28 ). In addition to preventing diabetes, the DPP lifestyle intervention improved several CVD risk factors, including dsylipidemia, hypertension, and inflammatory markers ( 29 , 30 ). The DPP analysis indicated that lifestyle intervention was cost-effective ( 31 ), but other analyses suggest that the expected costs needed to be reduced ( 32 ).

      Both the Finnish Diabetes Prevention study and the DPP focused on reduced intake of calories (using reduced dietary fat as a dietary intervention). Of note, reduced intake of fat, particularly saturated fat, may reduce risk for diabetes by producing an energy-independent improvement in insulin resistance ( 1 , 33 , 34 ), as well as by promoting weight loss. However, it is possible that reduction in other macronutrients would also be effective.

      Several studies have provided evidence for reduced risk of diabetes with increased intake of whole grains and dietary fiber ( 1 , 35 – 37 ). Whole grain–containing foods have been associated with improved insulin sensitivity, independent of body weight, and dietary fiber has been associated with improved insulin sensitivity and improved ability to secrete insulin adequately to overcome insulin resistance ( 38 ). There is debate as to the potential role of low–glycemic index and –glycemic load diets in prevention of type 2 diabetes. Although some studies have demonstrated an association between glycemic load and risk for diabetes, other studies have been unable to confirm this relationship, and a recent report showed no association of glycemic index/glycemic load with insulin sensitivity ( 39 ).

      Thus, there is not sufficient, consistent information to conclude that low–glycemic load diets reduce risk for diabetes. Prospective randomized clinical trials will be necessary to resolve this issue. Nevertheless, low–glycemic index foods that are rich in fiber and other important nutrients are to be encouraged. A 2004 American Diabetes Association statement reviewed this issue in depth ( 40 ), and issues related to the role of glycemic index and glycemic load in diabetes management are addressed in more detail in the carbohydrate section of this document.

      Observational studies suggest a U- or J-shaped association between moderate consumption of alcohol (one to three drinks [15–45 g alcohol] per day) and decreased risk of type 2 diabetes ( 41 , 42 ), coronary heart disease (CHD) ( 42 , 43 ), and stroke ( 44 ). However, heavy consumption of alcohol (greater than three drinks per day), may be associated with increased incidence of diabetes ( 42 ). If alcohol is consumed, recommendations from the 2005 USDA Dietary Guidelines for Americans suggest no more than one drink per day for women and two drinks per day for men ( 45 ).

      Although selected micronutrients may affect glucose and insulin metabolism, to date, there are no convincing data that document their role in the development of diabetes.

      Diabetes in youth

      No nutrition recommendations can be made for the prevention of type 1 diabetes at this time ( 1 ). Increasing overweight and obesity in youth appears to be related to the increased prevalence of type 2 diabetes, particularly in minority adolescents. Although there are insufficient data at present to warrant any specific recommendations for the prevention of type 2 diabetes in youth, interventions similar to those shown to be effective for prevention of type 2 diabetes in adults (lifestyle changes including reduced energy intake and regular physical activity) are likely to be beneficial. Clinical trials of such interventions are ongoing in children.

      NUTRITION RECOMMENDATIONS FOR THE MANAGEMENT OF DIABETES (SECONDARY PREVENTION)

      Carbohydrate in diabetes management

      Recommendations

      • A dietary pattern that includes carbohydrate from fruits, vegetables, whole grains, legumes, and low-fat milk is encouraged for good health. (B)

      • Low-carbohydrate diets, restricting total carbohydrate to <130 g/day, are not recommended in the management of diabetes. (E)

      • Monitoring carbohydrate, whether by carbohydrate counting, exchanges, or experienced-based estimation remains a key strategy in achieving glycemic control. (A)

      • The use of glycemic index and load may provide a modest additional benefit over that observed when total carbohydrate is considered alone. (B)

      • Sucrose-containing foods can be substituted for other carbohydrates in the meal plan or, if added to the meal plan, covered with insulin or other glucose-lowering medications. Care should be taken to avoid excess energy intake. (A)

      • As for the general population, people with diabetes are encouraged to consume a variety of fiber-containing foods. However, evidence is lacking to recommend a higher fiber intake for people with diabetes than for the population as a whole. (B)

      • Sugar alcohols and nonnutritive sweeteners are safe when consumed within the daily intake levels established by the Food and Drug Administration (FDA). (A)

      Control of blood glucose in an effort to achieve normal or near-normal levels is a primary goal of diabetes management. Food and nutrition interventions that reduce postprandial blood glucose excursions are important in this regard, since dietary carbohydrate is the major determinant of postprandial glucose levels. Low-carbohydrate diets might seem to be a logical approach to lowering postprandial glucose. However, foods that contain carbohydrate are important sources of energy, fiber, vitamins, and minerals and are important in dietary palatability. Therefore, these foods are important components of the diet for individuals with diabetes. Issues related to carbohydrate and glycemia have previously been extensively reviewed in American Diabetes Association reports and nutrition recommendations for the general public ( 1 , 2 , 22 , 40 , 45 ).

      Blood glucose concentration following a meal is primarily determined by the rate of appearance of glucose in the blood stream (digestion and absorption) and its clearance from the circulation ( 40 ). Insulin secretory response normally maintains blood glucose in a narrow range, but in individuals with diabetes, defects in insulin action, insulin secretion, or both impair regulation of postprandial glucose in response to dietary carbohydrate. Both the quantity and the type or source of carbohydrates found in foods influence postprandial glucose levels.

      Amount and type of carbohydrate.

      A 2004 ADA statement addressed the effects of the amount and type of carbohydrate in diabetes management ( 40 ). As noted previously, the RDA for carbohydrate (130 g/day) is an average minimum requirement ( 22 ). Although there are no trials specifically in patients with diabetes, diets restricting total carbohydrate to <130 g/day are not recommended in the management of diabetes. However, 1-year follow-up data from a small weight-loss trial ( 20 ) indicate, among the subset with diabetes, that the reduction in fasting glucose was 21 mg/dl (1.17 mmol/l) and 28 mg/dl (1.55 mmol/l) for the low-carbohydrate and low-fat diets, respectively, with no significant difference for change in A1C levels. The 1-year follow-up data also indicate that the macronutrient composition of the treatment groups only differed with respect to carbohydrate intake (mean intake of 230 vs. 120 g). Thus, questions about the long-term effects on intake and metabolism, as well as safety, need further research.

      The amount of carbohydrate ingested is usually the primary determinant of postprandial response, but the type of carbohydrate also affects this response. Intrinsic variables that influence the effect of carbohydrate-containing foods on blood glucose response include the specific type of food ingested, type of starch (amylose versus amylopectin), style of preparation (cooking method and time, amount of heat or moisture used), ripeness, and degree of processing. Extrinsic variables that may influence glucose response include fasting or preprandial blood glucose level, macronutrient distribution of the meal in which the food is consumed, available insulin, and degree of insulin resistance.

      The glycemic index of foods was developed to compare the postprandial responses to constant amounts of different carbohydrate-containing foods ( 46 ). The glycemic index of a food is the increase above fasting in the blood glucose area over 2 h after ingestion of a constant amount of that food (usually a 50-g carbohydrate portion) divided by the response to a reference food (usually glucose or white bread). The glycemic loads of foods, meals, and diets are calculated by multiplying the glycemic index of the constituent foods by the amounts of carbohydrate in each food and then totaling the values for all foods. Foods with low glycemic indexes include oats, barley, bulgur, beans, lentils, legumes, pasta, pumpernickel (coarse rye) bread, apples, oranges, milk, yogurt, and ice cream. Fiber, fructose, lactose, and fat are dietary constituents that tend to lower glycemic response. Potential methodological problems with the glycemic index have been noted ( 47 ).

      Several randomized clinical trials have reported that low–glycemic index diets reduce glycemia in diabetic subjects, but other clinical trials have not confirmed this effect ( 40 ). Moreover, the variability in responses to specific carbohydrate-containing food is a concern ( 48 ). Nevertheless, a recent meta-analysis of low–glycemic index diet trials in diabetic subjects showed that such diets produced a 0.4% decrement in A1C when compared with high–glycemic index diets ( 49 ). However, it appears that most individuals already consume a moderate–glycemic index diet ( 39 , 50 ). Thus, it appears that in individuals consuming a high–glycemic index diet, low–glycemic index diets can produce a modest benefit in controlling postprandial hyperglycemia.

      In diabetes management, it is important to match doses of insulin and insulin secretagogues to the carbohydrate content of meals. A variety of methods can be used to estimate the nutrient content of meals, including carbohydrate counting, the exchange system, and experience-based estimation. By testing pre- and postprandial glucose, many individuals use experience to evaluate and achieve postprandial glucose goals with a variety of foods. To date, research has not demonstrated that one method of assessing the relationship between carbohydrate intake and blood glucose response is better than other methods.

      Fiber.

      As for the general population, people with diabetes are encouraged to choose a variety of fiber-containing foods such as legumes, fiber-rich cereals (≥5 g fiber/serving), fruits, vegetables, and whole grain products because they provide vitamins, minerals, and other substances important for good health. Moreover, there are data suggesting that consuming a high-fiber diet (∼50 g fiber/day) reduces glycemia in subjects with type 1 diabetes and glycemia, hyperinsulinemia, and lipemia in subjects with type 2 diabetes ( 1 ). Palatability, limited food choices, and gastrointestinal side effects are potential barriers to achieving such high-fiber intakes. However, increased fiber intake appears to be desirable for people with diabetes, and a first priority might be to encourage them to achieve the fiber intake goals set for the general population of 14 g/1,000 kcal ( 22 ).

      Sweeteners.

      Substantial evidence from clinical studies demonstrates that dietary sucrose does not increase glycemia more than isocaloric amounts of starch ( 1 ). Thus, intake of sucrose and sucrose-containing foods by people with diabetes does not need to be restricted because of concern about aggravating hyperglycemia. Sucrose can be substituted for other carbohydrate sources in the meal plan or, if added to the meal plan, adequately covered with insulin or another glucose-lowering medication. Additionally, intake of other nutrients ingested with sucrose, such as fat, need to be taken into account, and care should be taken to avoid excess energy intake.

      In individuals with diabetes, fructose produces a lower postprandial glucose response when it replaces sucrose or starch in the diet; however, this benefit is tempered by concern that fructose may adversely affect plasma lipids ( 1 ). Therefore, the use of added fructose as a sweetening agent in the diabetic diet is not recommended. There is, however, no reason to recommend that people with diabetes avoid naturally occurring fructose in fruits, vegetables, and other foods. Fructose from these sources usually accounts for only 3–4% of energy intake.

      Reduced calorie sweeteners approved by the FDA include sugar alcohols (polyols) such as erythritol, isomalt, lactitol, maltitol, mannitol, sorbitol, xylitol, tagatose, and hydrogenated starch hydrolysates. Studies of subjects with and without diabetes have shown that sugar alcohols produce a lower postprandial glucose response than sucrose or glucose and have lower available energy ( 1 ). Sugar alcohols contain, on average, about 2 calories/g (one-half the calories of other sweeteners such as sucrose). When calculating carbohydrate content of foods containing sugar alcohols, subtraction of half the sugar alcohol grams from total carbohydrate grams is appropriate. Use of sugar alcohols as sweeteners reduces the risk of dental caries. However, there is no evidence that the amounts of sugar alcohols likely to be consumed will reduce glycemia, energy intake, or weight. The use of sugar alcohols appears to be safe; however, they may cause diarrhea, especially in children.

      The FDA has approved five nonnutritive sweeteners for use in the U.S. These are acesulfame potassium, aspartame, neotame, saccharin, and sucralose. Before being allowed on the market, all underwent rigorous scrutiny and were shown to be safe when consumed by the public, including people with diabetes and women during pregnancy. Clinical studies involving subjects without diabetes provide no indication that nonnutritive sweeteners in foods will cause weight loss or weight gain ( 51 ).

      Resistant-starch/high-amylose foods.

      It has been proposed that foods containing resistant starch (starch physically enclosed within intact cell structures as in some legumes, starch granules as in raw potato, and retrograde amylose from plants modified by plant breeding to increase amylose content) or high-amylose foods, such as specially formulated cornstarch, may modify postprandial glycemic response, prevent hypoglycemia, and reduce hyperglycemia. However, there are no published long-term studies in subjects with diabetes to prove benefit from the use of resistant starch.

      Dietary fat and cholesterol in diabetes management

      Recommendations

      • Limit saturated fat to <7% of total calories. (A)

      • Intake of trans fat should be minimized. (E)

      • In individuals with diabetes, limit dietary cholesterol to <200 mg/day. (E)

      • Two or more servings of fish per week (with the exception of commercially fried fish filets) provide n-3 polyunsaturated fatty acids and are recommended. (B)

      The primary goal with respect to dietary fat in individuals with diabetes is to limit saturated fatty acids, trans fatty acids, and cholesterol intakes so as to reduce risk for CVD. Saturated and trans fatty acids are the principal dietary determinants of plasma LDL cholesterol. In nondiabetic individuals, reducing saturated and trans fatty acids and cholesterol intakes decreases plasma total and LDL cholesterol. Reducing saturated fatty acids may also reduce HDL cholesterol. Importantly, the ratio of LDL cholesterol to HDL cholesterol is not adversely affected. Studies in individuals with diabetes demonstrating the effects of specific percentages of dietary saturated and trans fatty acids and specific amounts of dietary cholesterol on plasma lipids are not available. Therefore, because of a lack of specific information, it is recommended that the dietary goals for individuals with diabetes be the same as for individuals with preexisting CVD, since the two groups appear to have equivalent cardiovascular risk. Thus, saturated fatty acids <7% of total energy, minimal intake of trans fatty acids, and cholesterol intake <200 mg daily are recommended.

      In metabolic studies in which energy intake and weight are held constant, diets low in saturated fatty acids and high in either carbohydrate or cis-monounsaturated fatty acids lowered plasma LDL cholesterol equivalently ( 1 , 52 ). The high-carbohydrate diets (∼55% of total energy from carbohydrate) increased postprandial plasma glucose, insulin, and triglycerides when compared with high–monounsaturated fat diets. However, high–monounsaturated fat diets have not been shown to improve fasting plasma glucose or A1C values. In other studies, when energy intake was reduced, the adverse effects of high-carbohydrate diets were not observed ( 53 , 54 ). Individual variability in response to high-carbohydrate diets suggests that the plasma triglyceride response to dietary modification should be monitored carefully, particularly in the absence of weight loss.

      Diets high in polyunsaturated fatty acids appear to have effects similar to monounsaturated fatty acids on plasma lipid concentrations ( 55 – 58 ). A modified Mediterranean diet, in which polyunsaturated fatty acids were substituted for monounsaturated fatty acids, reduced overall mortality in elderly Europeans by 7% ( 59 ). Very-long-chain n-3 polyunsaturated fatty acid supplements have been shown to lower plasma triglyceride levels in individuals with type 2 diabetes who are hypertriglyceridemic. Although the accompanying small rise in plasma LDL cholesterol is of concern, an increase in HDL cholesterol may offset this concern ( 60 ). Glucose metabolism is not likely to be adversely affected. Very-long-chain n-3 polyunsaturated fatty acid studies in individuals with diabetes have primarily used fish oil supplements. Consumption of ω-3 fatty acids from fish or from supplements has been shown to reduce adverse CVD outcomes, but the evidence for α-linolenic acid is sparse and inconclusive ( 61 ). In addition to providing n-3 fatty acids, fish frequently displace high–saturated fat–containing foods from the diet ( 62 ). Two or more servings of fish per week (with the exception of commercially fried fish filets) ( 63 , 64 ) can be recommended.

      Plant sterol and stanol esters block the intestinal absorption of dietary and biliary cholesterol. In the general public and in individuals with type 2 diabetes ( 65 ), intake of ∼2 g/day plant sterols and stanols has been shown to lower plasma total and LDL cholesterol. A wide range of foods and beverages are now available that contain plant sterols. If these products are used, they should displace, rather than be added to, the diet to avoid weight gain. Soft gel capsules containing plant sterols are also available.

      Protein in diabetes management

      Recommendations

      • For individuals with diabetes and normal renal function, there is insufficient evidence to suggest that usual protein intake (15–20% of energy) should be modified. (E)

      • In individuals with type 2 diabetes, ingested protein can increase insulin response without increasing plasma glucose concentrations. Therefore, protein should not be used to treat acute or prevent nighttime hypoglycemia. (A)

      • High-protein diets are not recommended as a method for weight loss at this time. The long-term effects of protein intake >20% of calories on diabetes management and its complications are unknown. Although such diets may produce short-term weight loss and improved glycemia, it has not been established that these benefits are maintained long term. (E)

      The Dietary Reference Intakes’ acceptable macronutrient distribution range for protein is 10–35% of energy intake, with 15% being the average adult intake in the U.S. and Canada ( 22 ). The RDA is 0.8 g good-quality protein · kg body wt−1 · day−1 (on average, ∼10% of calories) ( 22 ). Good-quality protein sources are defined as having high PDCAAS (protein digestibility–corrected amino acid scoring pattern) scores and provide all nine indispensable amino acids. Examples are meat, poultry, fish, eggs, milk, cheese, and soy. Sources not in the “good” category include cereals, grains, nuts, and vegetables. In meal planning, protein intake should be greater than 0.8 g · kg−1 · day−1 to account for mixed protein quality in foods.

      The dietary intake of protein for individuals with diabetes is similar to that of the general public and usually does not exceed 20% of energy intake. A number of studies in healthy individuals and in individuals with type 2 diabetes have demonstrated that glucose produced from ingested protein does not increase plasma glucose concentration but does produce increases in serum insulin responses ( 1 , 66 ). Abnormalities in protein metabolism may be caused by insulin deficiency and insulin resistance; however, these are usually corrected with good blood glucose control ( 67 ).

      Small, short-term studies in diabetes suggest that diets with protein content >20% of total energy reduce glucose and insulin concentrations, reduce appetite, and increase satiety ( 68 , 69 ). However, the effects of high-protein diets on long-term regulation of energy intake, satiety, weight, and the ability of individuals to follow such diets long term have not been adequately studied.

      Dietary protein and its relationships to hypoglycemia and nephropathy are addressed in later sections.

      Optimal mix of macronutrients

      Although numerous studies have attempted to identify the optimal mix of macronutrients for the diabetic diet, it is unlikely that one such combination of macronutrients exists. The best mix of carbohydrate, protein, and fat appears to vary depending on individual circumstances. For those individuals seeking guidance as to macronutrient distribution in healthy adults, the Dietary Reference Intakes (DRIs) may be helpful ( 22 ). The DRI report recommends that, to meet the body’s daily nutritional needs while minimizing risk for chronic diseases, healthy adults should consume 45–65% of total energy from carbohydrate, 20–35% from fat, and 10–35% from protein. It must be clearly recognized that regardless of the macronutrient mix, total caloric intake must be appropriate to weight management goals. Additionally, the above ranges should be modified, as needed, based on the considerations noted above for each macronutrient group.

      Alcohol in diabetes management

      Recommendations

      • If adults with diabetes choose to use alcohol, daily intake should be limited to a moderate amount (one drink per day or less for women and two drinks per day or less for men). (E)

      • To reduce risk of nocturnal hypoglycemia in individuals using insulin or insulin secretagogues, alcohol should be consumed with food. (E)

      • In individuals with diabetes, moderate alcohol consumption (when ingested alone) has no acute effect on glucose and insulin concentrations but carbohydrate coingested with alcohol (as in a mixed drink) may raise blood glucose. (B)

      Abstention from alcohol should be advised for people with a history of alcohol abuse or dependence, women during pregnancy, and people with medical problems such as liver disease, pancreatitis, advanced neuropathy, or severe hypertriglyceridemia. If individuals choose to use alcohol, intake should be limited to a moderate amount (less than one drink per day for adult women and less than two drinks per day for adult men). One alcohol containing beverage is defined as 12 oz beer, 5 oz wine, or 1.5 oz distilled spirits. Each contains ∼15 g alcohol.

      Moderate amounts of alcohol, when ingested with food, have minimal acute effects on plasma glucose and serum insulin concentrations ( 42 ). However, carbohydrate coingested with alcohol may raise blood glucose. For individuals using insulin or insulin secretagogues, alcohol should be consumed with food to avoid hypoglycemia. Evening consumption of alcohol may increase the risk of nocturnal and fasting hypoglycemia, particularly in individuals with type 1 diabetes ( 70 ). Occasional use of alcoholic beverages should be considered an addition to the regular meal plan, and no food should be omitted. Excessive amounts of alcohol (three or more drinks per day), on a consistent basis, contributes to hyperglycemia ( 42 ).

      In individuals with diabetes, light to moderate alcohol intake (one to two drinks per day; 15–30 g alcohol) is associated with a decreased risk of CVD ( 42 ). The reduction in CVD does not appear to be due to an increase in plasma HDL cholesterol. The type of alcohol-containing beverage consumed does not appear to make a difference.

      Micronutrients in diabetes management

      Recommendations

      • There is no clear evidence of benefit from vitamin or mineral supplementation in people with diabetes (compared with the general population) who do not have underlying deficiencies. (A)

      • Routine supplementation with antioxidants, such as vitamins E and C and carotene, is not advised because of lack of evidence of efficacy and concern related to long-term safety. (A)

      • Benefit from chromium supplementation in individuals with diabetes or obesity has not been clearly demonstrated and therefore can not be recommended. (E)

      Uncontrolled diabetes is often associated with micronutrient deficiencies ( 71 ). Individuals with diabetes should be aware of the importance of acquiring daily vitamin and mineral requirements from natural food sources and a balanced diet. Health care providers should focus on nutrition counseling rather than micronutrient supplementation in order to reach metabolic control of their patients. Research including long-term trials is needed to assess the safety and potentially beneficial role of chromium, magnesium, and antioxidant supplements and other complementary therapies in the management of type 2 diabetes ( 71a , 71b ). In select groups such as the elderly, pregnant or lactating women, strict vegetarians, or those on calorie-restricted diets, a multivitamin supplement may be needed ( 1 ).

      Antioxidants in diabetes management.

      Since diabetes may be a state of increased oxidative stress, there has been interest in antioxidant therapy. Unfortunately, there are no studies examining the effects of dietary intervention on circulating levels of antioxidants and inflammatory biomarkers in diabetic volunteers. The few small clinical studies involving diabetes and functional foods thought to have high antioxidant potential (e.g., tea, cocoa, coffee) are inconclusive. Clinical trial data not only indicate the lack of benefit with respect to glycemic control and progression of complications but also provide evidence of the potential harm of vitamin E, carotene, and other antioxidant supplements ( 1 , 72 , 73 ). In addition, available data do not support the use of antioxidant supplements for CVD risk reduction ( 74 ).

      Chromium, other minerals, and herbs in diabetes management.

      Chromium, potassium, magnesium, and possibly zinc deficiency may aggravate carbohydrate intolerance. Serum levels can readily detect the need for potassium or magnesium replacement, but detecting deficiency of zinc or chromium is more difficult ( 75 ). In the late 1990s, two randomized placebo-controlled studies in China found that chromium supplementation had beneficial effects on glycemia ( 76 – 78 ), but the chromium status of the study populations was not evaluated either at baseline or following supplementation. Data from recent small studies indicate that chromium supplementation may have a role in the management of glucose intolerance, gestational diabetes mellitus (GDM), and corticosteroid-induced diabetes ( 76 – 78 ). However, other well-designed studies have failed to demonstrate any significant benefit of chromium supplementation in individuals with impaired glucose intolerance or type 2 diabetes ( 79 , 80 ). Similarly, a meta-analysis of randomized controlled trials failed to demonstrate any benefit of chromium picolinate supplementation in reducing body weight ( 81 ). The FDA concluded that although a small study suggested that chromium picolinate may reduce insulin resistance, the existence of such a relationship between chromium picolinate and either insulin resistance or type 2 diabetes was uncertain ( http:/www.cfsan.fda.gov/∼dms/qhccr.html ).

      There is insufficient evidence to demonstrate efficacy of individual herbs and supplements in diabetes management ( 82 ). In addition, commercially available products are not standardized and vary in the content of active ingredients. Herbal preparations also have the potential to interact with other medications ( 83 ). Therefore, it is important that health care providers be aware when patients with diabetes are using these products and look for unusual side effects and herb-drug or herb-herb interactions

      NUTRITION INTERVENTIONS FOR SPECIFIC POPULATIONS

      Nutrition interventions for type 1 diabetes

      Recommendations

      • For individuals with type 1 diabetes, insulin therapy should be integrated into an individual’s dietary and physical activity pattern. (E)

      • Individuals using rapid-acting insulin by injection or an insulin pump should adjust the meal and snack insulin doses based on the carbohydrate content of the meals and snacks. (A)

      • For individuals using fixed daily insulin doses, carbohydrate intake on a day-to-day basis should be kept consistent with respect to time and amount. (C)

      • For planned exercise, insulin doses can be adjusted. For unplanned exercise, extra carbohydrate may be needed. (E)

      The first nutrition priority for individuals requiring insulin therapy is to integrate an insulin regimen into their lifestyle. With the many insulin options now available, an appropriate insulin regimen can usually be developed to conform to an individual’s preferred meal routine, food choices, and physical activity pattern. For individuals receiving basal-bolus insulin therapy, the total carbohydrate content of meals and snacks is the major determinant of bolus insulin doses ( 84 ). Insulin-to-carbohydrate ratios can be used to adjust mealtime insulin doses. Several methods can be used to estimate the nutrient content of meals, including carbohydrate counting, the exchange system, and experience-based estimation. The DAFNE (Dose Adjustment for Normal Eating) study ( 85 ) demonstrated that patients can learn how to use glucose testing to better match insulin to carbohydrate intake. Improvement in A1C without a significant increase in severe hypoglycemia was demonstrated, as were positive effects on quality of life, satisfaction with treatment, and psychological well-being, even though increases in the number of insulin injections and blood glucose tests were necessary.

      For planned exercise, reduction in insulin dosage is the preferred method to prevent hypoglycemia ( 86 ). For unplanned exercise, intake of additional carbohydrate is usually needed. Moderate-intensity exercise increases glucose utilization by 2–3 mg · kg−1 · min−1 above usual requirements ( 87 ). Thus, a 70-kg person would need ∼10–15 g additional carbohydrate per hour of moderate intensity physical activity. More carbohydrate is needed for intense activity.

      A 2005 American Diabetes Association statement addresses diabetes MNT for children and adolescents with type 1 diabetes ( 88 ).

      Nutrition interventions for type 2 diabetes

      Recommendations

      • Individuals with type 2 diabetes are encouraged to implement lifestyle modifications that reduce intakes of energy, saturated and trans fatty acids, cholesterol, and sodium and to increase physical activity in an effort to improve glycemia, dyslipidemia, and blood pressure. (E)

      • Plasma glucose monitoring can be used to determine whether adjustments in foods and meals will be sufficient to achieve blood glucose goals or if medication(s) needs to be combined with MNT. (E)

      Healthy lifestyle nutrition recommendations for the general public are also appropriate for individuals with type 2 diabetes. Because many individuals with type 2 diabetes are overweight and insulin resistant, MNT should emphasize lifestyle changes that result in reduced energy intake and increased energy expenditure through physical activity. Because many individuals also have dyslipidemia and hypertension, reducing saturated and trans fatty acids, cholesterol, and sodium is often desirable. Therefore, the first nutrition priority is to encourage individuals with type 2 diabetes to implement lifestyle strategies that will improve glycemia, dyslipidemia, and blood pressure.

      Although there are similarities to those above for type 1 diabetes, MNT recommendations for established type 2 diabetes differ in several aspects from both recommendations for type 1 diabetes and the prevention of diabetes. MNT progresses from prevention of overweight and obesity, to improving insulin resistance and preventing or delaying the onset of diabetes, and to contributing to improved metabolic control in those with diabetes. With established type 2 diabetes treated with fixed doses of insulin or insulin secretagogues, consistency in timing and carbohydrate content of meals is important. However, rapid-acting insulins and rapid-acting insulin secretagogues allow for more flexible food intake and lifestyle as in individuals with type 1 diabetes.

      Increased physical activity by individuals with type 2 diabetes can lead to improved glycemia, decreased insulin resistance, and a reduction in cardiovascular risk factors, independent of change in body weight. At least 150 min/week of moderate-intensity aerobic physical activity, distributed over at least 3 days and with no more than 2 consecutive days without physical activity is recommended ( 89 ). Resistance training is also effective in improving glycemia and, in the absence of proliferative retinopathy, people with type 2 diabetes can be encouraged to perform resistance exercise three times a week ( 89 ).

      Nutrition interventions for pregnancy and lactation with diabetes

      Recommendations

      • Adequate energy intake that provides appropriate weight gain is recommended during pregnancy. Weight loss is not recommended; however, for overweight and obese women with GDM, modest energy and carbohydrate restriction may be appropriate. (E)

      • Ketonemia from ketoacidosis or starvation ketosis should be avoided. (C)

      • MNT for GDM focuses on food choices for appropriate weight gain, normoglycemia, and absence of ketones. (E)

      • Because GDM is a risk factor for subsequent type 2 diabetes, after delivery, lifestyle modifications aimed at reducing weight and increasing physical activity are recommended. (A)

      Prepregnancy MNT includes an individualized prenatal meal plan to optimize blood glucose control. During pregnancy, the distribution of energy and carbohydrate intake should be based on the woman’s food and eating habits and plasma glucose responses. Due to the continuous fetal draw of glucose from the mother, maintaining consistency of times and amounts of food eaten are important to avoidance of hypoglycemia. Plasma glucose monitoring and daily food records provide valuable information for insulin and meal plan adjustments.

      MNT for GDM primarily involves a carbohydrate-controlled meal plan that promotes optimal nutrition for maternal and fetal health with adequate energy for appropriate gestational weight gain, achievement and maintenance of normoglycemia, and absence of ketosis. Specific nutrition and food recommendations are determined and subsequently modified based on individual assessment and self-monitoring of blood glucose. All women with GDM should receive MNT at the time of diagnosis. A recent large clinical trial reported that treatment of GDM with nutrition therapy, blood glucose monitoring, and insulin therapy as required for glycemic control reduced serious perinatal complications without increasing the rate of cesarean delivery as compared with routine care ( 90 ). Maternal health–related quality of life was also improved.

      Hypocaloric diets in obese women with GDM can result in ketonemia and ketonuria. However, moderate caloric restriction (reduction by 30% of estimated energy needs) in obese women with GDM may improve glycemic control without ketonemia and reduce maternal weight gain. Insufficient data are available to determine how such diets affect perinatal outcomes. Daily food records, weekly weight checks, and ketone testing can be used to determine individual energy requirements and whether a woman is undereating to avoid insulin therapy.

      The amount and distribution of carbohydrate should be based on clinical outcome measures (hunger, plasma glucose levels, weight gain, ketone levels), but a minimum of 175 g carbohydrate/day should be provided ( 22 ). Carbohydrate should be distributed throughout the day in three small- to moderate-sized meals and two to four snacks. An evening snack may be needed to prevent accelerated ketosis overnight. Carbohydrate is generally less well tolerated at breakfast than at other meals.

      Regular physical activity can help lower fasting and postprandial plasma glucose concentrations and may be used as an adjunct to improve maternal glycemia. If insulin therapy is added to MNT, maintaining carbohydrate consistency at meals and snacks becomes a primary goal.

      Although most women with GDM revert to normal glucose tolerance postpartum, they are at increased risk of GDM in subsequent pregnancies and type 2 diabetes later in life. Lifestyle modifications after pregnancy aimed at reducing weight and increasing physical activity are recommended, as they reduce the risk of subsequent diabetes ( 26 , 91 ). Breast-feeding is recommended for infants of women with preexisting diabetes or GDM; however, successful lactation requires planning and coordination of care ( 92 ). In most situations, breast-feeding mothers require less insulin because of the calories expended with nursing. Lactating women have reported fluctuations in blood glucose related to nursing sessions, often requiring a snack containing carbohydrate before or during breast-feeding ( 92 ).

      Nutrition interventions for older adults with diabetes

      Recommendations

      • Obese older adults with diabetes may benefit from modest energy restriction and an increase in physical activity; energy requirement may be less than for a younger individual of a similar weight. (E)

      • A daily multivitamin supplement may be appropriate, especially for those older adults with reduced energy intake. (C)

      The American Geriatrics Society emphasizes the importance of MNT for older adults with diabetes. For obese individuals, a modest weight loss of 5–10% of body weight may be indicated ( 93 , 94 ). However, an involuntary gain or loss of >10 lb or 10% of body weight in <6 months should be addressed in the MNT evaluation ( 1 , 95 , 96 ). Physical activity is needed to attenuate loss of lean body mass that can occur with energy restriction. Exercise training can significantly reduce the decline in maximal aerobic capacity that occurs with age, improve risk factors for atherosclerosis, slow the age-related decline in lean body mass, decrease central adiposity, and improve insulin sensitivity—all potentially beneficial for the older adult with diabetes ( 89 , 97 ). However, exercise can also pose potential risks such as cardiac ischemia, musculoskeletal injuries, and hypoglycemia in patients treated with insulin or insulin secretagogues.

      NUTRITION RECOMMENDATIONS FOR CONTROLLING DIABETES COMPLICATIONS (TERTIARY PREVENTION)

      Microvascular complications

      Recommendations

      • Reduction of protein intake to 0.8–1.0 g · kg body wt−1 · day−1 in individuals with diabetes and the earlier stages of chronic kidney disease (CKD) and to 0.8 g · kg body wt−1 · day−1 in the later stages of CKD may improve measures of renal function (urine albumin excretion rate, glomerular filtration rate) and is recommended. (B)

      • MNT that favorably affects cardiovascular risk factors may also have a favorable effect on microvascular complications such as retinopathy and nephropathy. (C)

      Progression of diabetes complications may be modified by improving glycemic control, lowering blood pressure, and, potentially, reducing protein intake. Normal protein intake (15–20% of energy) does not appear to be associated with risk of developing diabetic nephropathy ( 1 ), but the long-term effect on development of nephropathy of dietary protein intake >20% of energy has not been determined. In several studies of subjects with diabetes and microalbuminuria, urinary albumin excretion rate and decline in glomerular filtration were favorably influenced by reduction of protein intake to 0.8–1.0 g · kg body wt−1 · day−1 (see protein in diabetes management section) ( 98 – 101 ). Although reduction of protein intake to 0.8 g · kg body wt−1 · day−1 was prescribed, subjects who were not able to achieve this level of reduction also showed improvements in renal function ( 99 , 100 ).

      In individuals with diabetes and macroalbuminuria, reducing protein from all sources to 0.8 g · kg body wt−1 · day−1 has been associated with slowing the decline in renal function ( 1 , 102 ); however, such reductions in protein need to maintain good nutritional status in patients with chronic renal failure ( 103 ). Although several studies have explored the potential benefit of plant proteins in place of animal proteins and specific animal proteins in diabetic individuals with microalbuninuria, the data are inconclusive ( 1 , 104 ).

      Observational data suggest that dyslipidemia may increase albumin excretion and the rate of progression of diabetic nephropathy ( 105 ). Elevation of plasma cholesterol in both type 1 and 2 diabetic subjects and plasma triglycerides in type 2 diabetic subjects were predictors of the need for renal replacement therapy ( 106 ). Whereas these observations do not confirm that MNT will affect diabetic nephropathy, MNT designed to reduce the risk for CVD may have favorable effects on microvascular complications of diabetes.

      Treatment and management of CVD risk

      Recommendations

      • Target A1C is as close to normal as possible without significant hypoglycemia. (B)

      • For patients with diabetes at risk for CVD, diets high in fruits, vegetables, whole grains, and nuts may reduce the risk. (C)

      • For patients with diabetes and symptomatic heart failure, dietary sodium intake of <2,000 mg/day may reduce symptoms. (C)

      • In normotensive and hypertensive individuals, a reduced sodium intake (e.g., 2,300 mg/day) with a diet high in fruits, vegetables, and low-fat dairy products lowers blood pressure. (A)

      • In most individuals, a modest amount of weight loss beneficially affects blood pressure. (C)

      In the EDIC (Epidemiology of Diabetes Interventions and Complications) study, the follow-up of the DCCT (Diabetes Control and Complications Trial), intensive treatment of type 1 diabetic subjects during the DCCT study period improved glycemic control and significantly reduced the risk of the combined end point of cardiovascular death, myocardial infarction, and stroke ( 107 ). Adjustment for A1C explained most of the treatment effect. The risk reductions obtained with improved glycemia exceeded those that have been demonstrated for other interventions such as cholesterol and blood pressure reductions. Observational data from the UKPDS suggest that CVD risk in type 2 diabetes is also proportionate to the level of A1C elevation ( 107a ).

      There are no large-scale randomized trials to guide MNT recommendations for CVD risk reduction in individuals with type 2 diabetes. However, because CVD risk factors are similar in individuals with and without diabetes, benefits observed in nutrition studies in the general population are probably applicable to individuals with diabetes. The previous section on dietary fat addresses the need to reduce intake of saturated and trans fatty acids and cholesterol.

      Hypertension, which is predictive of progression of micro- as well as macrovascular complications of diabetes, can be prevented and managed with interventions including weight loss, physical activity, moderation of alcohol intake, and diets such as DASH (Dietary Approaches to Stop Hypertension). The DASH diet emphasized fruits, vegetables, and low-fat dairy products; included whole grains, poultry, fish, and nuts; and was reduced in fats, red meat, sweets, and sugar-containing beverages ( 7 , 108 , 109 ). The effects of lifestyle interventions on hypertension appear to be additive.

      Reduction in blood pressure in people with diabetes can occur with a modest amount of weight loss, although there is great variability in response ( 1 , 7 ). Regular aerobic physical activity, such as brisk walking, has an antihypertensive effect ( 7 ). Although chronic excessive alcohol intake is associated with an increased risk of hypertension, light to moderate alcohol consumption is associated with reductions in blood pressure ( 7 ).

      Heart failure and peripheral vascular disease are common in individuals with diabetes, but little is known about the role of MNT in treating these complications. Nutrition recommendations from the American College of Physicians/American Heart Association suggest moderate sodium restriction (<2,000 mg/day) for patients with structural heart disease or symptomatic heart failure ( 110 ). Alcohol intake is discouraged in patients at high risk for heart failure.

      NUTRITION INTERVENTIONS FOR ACUTE COMPLICATIONS AND SPECIAL CONSIDERATIONS FOR PATIENTS WITH COMORBIDITIES IN ACUTE AND CHONIC CARE FACILITIES

      Hypoglycemia

      Recommendations

      • Ingestion of 15–20 g glucose is the preferred treatment for hypoglycemia, although any form of carbohydrate that contains glucose may be used. (A)

      • The response to treatment of hypoglycemia should be apparent in 10–20 min; however, plasma glucose should be tested again in ∼60 min, as additional treatment may be necessary. (B)

      In individuals taking insulin or insulin secretagogues, changes in food intake, physical activity, and medication can contribute to the development of hypoglycemia. Treatment of hypoglycemia (plasma glucose <70 mg/dl) requires ingestion of glucose or glucose-containing foods. The acute glycemic response correlates better with the glucose content than with the carbohydrate content of the food ( 1 ). With insulin-induced hypoglycemia, 10 g oral glucose raises plasma glucose levels by ∼40 mg/dl over 30 min, while 20 g oral glucose raises plasma glucose levels by ∼60 mg/dl over 45 min. In each case, glucose levels often begin to fall ∼60 min after glucose ingestion ( 111 ).

      Although pure glucose may be the preferred treatment, any form of carbohydrate that contains glucose will raise blood glucose ( 111 ). Adding protein to carbohydrate does not affect the glycemic response and does not prevent subsequent hypoglycemia. Adding fat, however, may retard and then prolong the acute glycemic response. During hypoglycemia, gastric-emptying rates are twice as fast as during euglycemia and are similar for liquid and solid foods.

      Acute illness

      Recommendations

      • During acute illnesses, insulin and oral glucose-lowering medications should be continued. (A)

      • During acute illnesses, testing of plasma glucose and ketones, drinking adequate amounts of fluids, and ingesting carbohydrate are all important. (B)

      Acute illnesses can lead to the development of hyperglycemia and, in individuals with type 1 diabetes, ketoacidosis. During acute illnesses, with the usual accompanying increases in counterregulatory hormones, the need for insulin and oral glucose-lowering medications continues and often is increased. Testing plasma glucose and ketones, drinking adequate amounts of fluid, and ingesting carbohydrate, especially if plasma glucose is <100 mg/dl, are all important during acute illness. In adults, ingestion of 150–200 g carbohydrate daily (45–50 g every 3–4 h) should be sufficient to prevent starvation ketosis ( 1 ).

      Patients with diabetes in acute health care facilities

      Recommendations

      • Establishing an interdisciplinary team, implementation of MNT, and timely diabetes-specific discharge planning improves the care of patients with diabetes during and after hospitalizations. (E)

      • Hospitals should consider implementing a diabetes meal-planning system that provides consistency in the carbohydrate content of specific meals. (E)

      Hyperglycemia in hospitalized patients is common and represents an important marker of poor clinical outcome and mortality in both patients with and without diabetes ( 112 ). Optimizing glucose control in these patients is associated with better outcomes ( 113 ). An interdisciplinary team is needed to integrate MNT into the overall management plan ( 114 , 115 ). Diabetes nutrition self-management education, although potentially initiated in the hospital, is usually best provided in an outpatient or home setting where the individual with diabetes is better able to focus on learning needs ( 114 , 115 ).

      There is no single meal planning system that is ideal for hospitalized patients. However, it is suggested that hospitals consider implementing a consistent-carbohydrate diabetes meal-planning system ( 114 , 115 ). This systems uses meal plans without a specific calorie level but consistency in the carbohydrate content of meals. The carbohydrate contents of breakfast, lunch, dinner, and snacks may vary, but the day-to-day carbohydrate content of specific meals and snacks is kept constant ( 114 , 115 ). It is recommended that the term “ADA diet” no longer be used, since the ADA no longer endorses a single nutrition prescription or percentages of macronutrients.

      Special nutrition issues include liquid diets, surgical diets, catabolic illnesses, and enteral or parenteral nutrition ( 114 , 115 ). Patients requiring clear or full liquid diets should receive ∼200 g carbohydrate/day in equally divided amounts at meal and snack times. Liquids should not be sugar free. Patients require carbohydrate and calories, and sugar-free liquids do not meet these nutritional needs. For tube feedings, either a standard enteral formula (50% carbohydrate) or a lower–carbohydrate content formula (33–40% carbohydrate) may be used. Calorie needs for most patients are in the range of 25–35 kcal/kg every 24 h. Care must be taken not to overfeed patients because this can exacerbate hyperglycemia. After surgery, food intake should be initiated as quickly as possible. Progression from clear liquids to full liquids to solid foods should be completed as rapidly as tolerated.

      Patients with diabetes in long-term care facilities

      Recommendations

      • The imposition of dietary restrictions on elderly patients with diabetes in long-term care facilities is not warranted. Residents with diabetes should be served a regular menu, with consistency in the amount and timing of carbohydrate. (C)

      • An interdisciplinary team approach is necessary to integrate MNT for patients with diabetes into overall management. (E)

      • There is no evidence to support prescribing diets such as “no concentrated sweets” or “no sugar added.” (E)

      • In the institutionalized elderly, undernutrition is likely and caution should be exercised when prescribing weight loss diets. (B)

      Although the prevalence of undiagnosed diabetes in elderly nursing home residents is high, not all of such individuals require pharmacologic therapy ( 115 , 116 ). Older residents with diabetes in nursing homes tend to be underweight rather than overweight ( 114 ). Low body weight has been associated with greater morbidity and mortality in this population ( 114 , 115 ). Experience has shown that residents eat better when they are given less restrictive diets ( 115 , 116 ). Specialized diabetic diets do not appear to be superior to standard diets in such settings ( 117 , 118 ). Meal plans such as no concentrated sweets, no sugar added, low sugar, and liberal diabetic diet also are no longer appropriate. These diets do not reflect current diabetes nutrition recommendations and unnecessarily restrict sucrose. (These types of diets are more likely in long-term care facilities than acute care.) Making medication changes to control glucose, lipids, and blood pressure rather than implementing food restrictions can reduce the risk of iatrogenic malnutrition. The specific nutrition interventions recommended will depend on a variety of factors, including age, life expectancy, comorbidities, and patient preferences ( 119 ).

      SUMMARY: NUTRITION RECOMMENDATIONS AND INTERVENTIONS FOR DIABETES—

      Major nutrition recommendations and interventions for diabetes are listed in Table 3 . Monitoring of metabolic parameters, including glucose, A1C, lipids, blood pressure, body weight, and renal function is essential to assess the need for changes in therapy and to ensure successful outcomes. Many aspects of MNT require additional research.

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      Table 1—

      Nutrition and MNT

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      Table 2—

      Classification of overweight and obesity by BMI, waist circumference, and associated disease risk

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      Table 3—

      Major nutrition recommendations and interventions

      Footnotes

      • Originally approved 2006.

        Writing panel: John P. Bantle (Co-Chair), Judith Wylie-Rosett (Co-Chair), Ann L. Albright, Caroline M. Apovian, Nathaniel G. Clark, Marion J. Franz, Byron J. Hoogwerf, Alice H. Lichtenstein, Elizabeth Mayer-Davis, Arshag D. Mooradian, and Madelyn L. Wheeler.

      • DIABETES CARE

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      January 2007, 30(suppl 1)

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      Nutrition Recommendations and Interventions for Diabetes
      American Diabetes Association
      Diabetes Care Jan 2007, 30 (suppl 1) S48-S65; DOI: 10.2337/dc07-S048









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      • Article
        • GOALS OF MNT FOR PREVENTION AND TREATMENT OF DIABETES
        • EFFECTIVENESS OF MNT
        • ENERGY BALANCE, OVERWEIGHT, AND OBESITY
        • NUTRITION RECOMMENDATIONS AND INTERVENTIONS FOR THE PREVENTION OF DIABETES (PRIMARY PREVENTION)
        • NUTRITION RECOMMENDATIONS FOR THE MANAGEMENT OF DIABETES (SECONDARY PREVENTION)
        • NUTRITION INTERVENTIONS FOR SPECIFIC POPULATIONS
        • NUTRITION RECOMMENDATIONS FOR CONTROLLING DIABETES COMPLICATIONS (TERTIARY PREVENTION)
        • NUTRITION INTERVENTIONS FOR ACUTE COMPLICATIONS AND SPECIAL CONSIDERATIONS FOR PATIENTS WITH COMORBIDITIES IN ACUTE AND CHONIC CARE FACILITIES
        • SUMMARY: NUTRITION RECOMMENDATIONS AND INTERVENTIONS FOR DIABETES—
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