The Dark side of Sci-Hub

Circa 2011, a graduate student from Kazakhstan was tired of the profiteering by the large publishing houses and decided enough is enough. Alexandra Elbakyan created an online repository of scholarly articles, which would change the way we access science once and for all. In essence, she is the digital Robin Hood of our times. After all, when the law of the land oppresses the people, the outlaw takes his (or her) place in history.

Alexandra Elbakyan – the founder of Sci-Hub

I still remember my MD days, when the access to even the big 5 (NEJM,Lancet, BMJ,JAMA and Annals) were limited and we had to ask our friends in foreign countries to mail us the articles. The process was time consuming and naturally didn’t allow for quick tangential segue from the reference section of the article we were reading. Today those troubles of access seem like a distant memory. Scihub has become such a central part of our work that most academics wouldn’t know what to do if the site went kaput. Western Europe is the only part of the world with more scihub activity than south India – and they are mostly a mix of contributors and users. 

Map of SciHub users -source

Scihub’s story is eerily similar to many superhero stories. A disgruntled superhero, pure at heart, armed with nothing but goodwill and courage, takes on the global elites to deliver the masses from darkness. It’s a tad cliched -but still academics all over the world believe this fairytale. Perhaps we need to believe in heroes. We don’t often stop to think whether there could be a dark side.

In order to proceed further, we need to see how Scihub works

How does Scihub work?

The graphic below shows how Scihub works.

The crucial element is how the repository is built. Scihub claims that the main access comes from donated usernames and passwords by academics. Unfortunately there have been attempts (possibly successful) at phishing campaigns directed at individual academics. Worse, Oxford university reported a successful 48 hour brute force dictionary attack that led to retrieval of six passwords. ( while you might scoff at those 6 poor souls who had just a dictionary word as a password, you would be surprised to find out that a lot of people have insecure passwords).

Through a compromised university account, automated attacks are possible – for instance, one single attack at 350+ portals and 45000+ incursions has been documents with the stolen access. 

How much of the scholarly literature is accessible through Scihub?

A lot , actually. This interactive web app, shows that >90% of CrossRef articles can be accessed through Scihub, but the mileage varies depending on  the journal and publisher.

The login credentials aren’t exactly kosher: so what?

One might wonder, I don’t care how they get the articles, as long as they serve me one, when I input a doi (digital object identifier). The problem is that , as cyber security experts say, they have never met a cyber criminal who gets into a database, takes only what is necessary and gets out. Chances are he looks around. Pilfers something else that might be of value. Or worse still leaves behind something nasty.( as of this writing, there is no evidence that Scihub or its partners have actually compromised the security of the universities with any malware).

Moreover when a password is hacked, the hacker has access to the bare minimum information in the database – for example a library database. The details such as username, age, gender, timing of visiting the library, date of joining, last visit taken, last book etc can be easily gotten. From then it is only a matter of social engineering to gain access to other portals – email, social media etc. It is also a matter of concern that some people have the same password for all their sites ! 

Are the pdfs safe?

So far, there has been no incident of malware hidden in the pdf. 

Will the publishers react?

Elsevier actually filed a case against Elbakyan and won 15 million dollars in compensation. The western establishment and the publishers hate her so much that  a species of parasitoid wasp was named after her – Idiogramma elbakyanae. However, she has refused to acknowledge the legitimacy of the ruling by the American court and resides in a jurisdiction out of reach of any western court.

This however doesn’t mean the publishers won’t tighten access – perhaps a DRM (digital rights management) or two factor authentication might be introduced – so even if the passwords are stolen by phishing attacks/attacks on university, it will become harder to access the articles.

Can there be more to this story than meets the eye?

Frankly no one can answer this question. However those who play by probabilities and professional realists have questioned the ability of a single researcher to handle a project as large as this. To make things worse, nothing in Russia can be done without the tacit approval of the government. It is  a well known fact that , as a price for such approval, the government/non governmental actors might want to be a ‘part’ of the project, presumably not to download science articles. She being a marked woman, with no other refuge, would have to yield to their pressure or face the music. People have disappeared for daring to disobey the non-governmental actors in Russia.

This is where the possibility of compromised passwords providing access to the university systems causes worry. However all of this remains conjecture – or the feverish imagination of jobless bloggers at the moment. (But who doesn’t love the bragging rights to ‘I told you so’ when a disaster strikes in the future).

There is also evidence that China has been downloading a lot more than the usual academic download – although for what purpose isn’t known. Also Iran is the third largest access site – that too, a small city in Iran, raising eyebrows about what is going on.

I am an Indian researcher , with no money, no login credentials, no institutional access, nothing of “value” to be stolen. Should I worry?

Probably not. However, it is prudent to know the basics of cybersecurity and keep yourself protected.

I am a western researcher who thinks “Viva la revolución” the moment I hear about Scihub. What’s the big deal?

Great for the researchers in poor countries who benefit out of your generosity*. However, you should understand the inherent risks of any revolution. In this case, the revolution is fought in the cyberspace, with probably more actors involved than you might realize. 

To wrap up, perhaps life is simple after all. Perhaps the Robin Hood fairy tale is true. God, I dearly wish it to be true. But, no one knows for sure and it doesn’t hurt to be safe. 

Further Reading


Taxonomy to tackle authorship issues in research

I had recently attended a program called Evening with Endocrinology – an exclusive meeting for endocrinologists, conducted under the aegis of ESTN. One of the topics I spoke about was Creation of Registries. Of course, we weren’t the first ones to come up with this idea.

Registries – multicentric ones, have been tried before in India. One of the prime issues is that arise in such situations is the problem of authorship order- the wretched problem even plagues simple publications in some centers. The root of the problem is our tendency for first order approximation – when we see a list of names, we want to assign importance to them based on some parameter- in this case, the position /distance from the first element. This also has a practical significance – for promotions and tenure, organizations require first authored publications or require you to be a corresponding author.

Thus if your contribution was manuscript writing or securing funding or data analysis or data collection – it doesn’t matter. What matters is the order in which your name appears in the paper. This ordering of authors can sometimes be arbitrary. In other cases, it may be impossible to ascertain a natural order – due to perception differences in the importance of a particular research task. Who should get more value? The one who writes the manuscript or the one who secures funding?

The author ordering creates a zero sum situation – the importance you gain, is often at the expense of someone else.

Even if we fail to acknowledge it, authorship issues have often prevented people from attempting multicentric investigator initiated research, leading to the formation of silos of information. This information could often be combined to produce better value, but such an effort is rarely taken due to ‘human’ reasons.

One way to deal with this is to do away with authors’ order and adapt a authorship taxonomy . Such a taxonomy was pioneered by Wellcome Trust, MIT, Digital Science, and others in 2014. The taxonomy recognizes roles like data curation, development of design methodology, programming and software development, application of statistical or mathematical techniques to analyze data, data visualization, verification or results, and so on.

You can read about the authorship taxonomy at the CASRAI -CRediT website CRediT

1ConceptualizationIdeas; formulation or evolution of overarching research goals and aims.\
2Data curationManagement activities to annotate (produce metadata), scrub data and maintain research data (including software code, where it is necessary for interpreting the data itself) for initial use and later re-use.
3Formal analysisApplication of statistical, mathematical, computational, or other formal techniques to analyse or synthesize study data.
4Funding acquisitionAcquisition of the financial support for the project leading to this publication.
5InvestigationConducting a research and investigation process, specifically performing the experiments, or data/evidence collection.
6MethodologyDevelopment or design of methodology; creation of models.
7Project administrationManagement and coordination responsibility for the research activity planning and execution.
8ResourcesProvision of study materials, reagents, materials, patients, laboratory samples, animals, instrumentation, computing resources, or other analysis tools.
9SoftwareProgramming, software development; designing computer programs; implementation of the computer code and supporting algorithms; testing of existing code components.
10SupervisionOversight and leadership responsibility for the research activity planning and execution, including mentorship external to the core team.
11ValidationVerification, whether as a part of the activity or separate, of the overall replication/reproducibility of results/experiments and other research outputs.
12VisualizationPreparation, creation and/or presentation of the published work, specifically visualization/data presentation.
13Writing — original draftPreparation, creation and/or presentation of the published work, specifically writing the initial draft (including substantive translation).
14Writing — review & editingPreparation, creation and/or presentation of the published work by those from the original research group, specifically critical review, commentary or revision — including pre- or post-publication stages.

Several advantages for this system exist – including the potential to solve authorship disputes. Moreover the CRediT tagged contributions can be coded in a machine readable format (JAT xml v 1.2) making it potentially possible to query a database for those authors whose primary contribution is – say- data visualization or programming. Then it is a matter of communicating with the particular author.

Of course, this alone will not make collaboration between institutions happen. However, I believe , when authors and publishers adopt the CRediT taxonomy – it might take scholarly publication beyond the authorship squabbles. This may well be one of the small pieces of the big puzzle – of how to make large multicentric investigator initiated studies/ registries happen in a diverse country like India.

Do we need an admission holiday?

There are times when you start a blog post and it seems like you might say something heretic that might additionally  come off as snobbish or selfish. Nevertheless you have to trust your instincts and write what you feel – even if it means wandering off from the clearly marked zones of acceptability.  

Tamilnadu government enforces a 45 to 60 day fishing ban every year – to prevent depletion of the seas. I am no ecologist , but this seems to make sense. The population is increasing every year and with more fish being consumed, it is important for us to preserve the oceans , and one of the ways is to just cool off for a couple of months. Is it inconvenient to the consumer? Probably. Is it troublesome for the fishermen? perhaps. Is is necessary to preserve the balance in the long run – yes.

Let’s focus on medical education in India.

Medical education and care in India , like in other countries, has its own problems. One of the commonly cited problems is the dismal doctor to patient ratio. Like any ratio, it can be low if either the numerator (no. of doctors) is low or the denominator (no. of patients) is high. However, the reality is that we actually have a surplus of doctors – provided you restrict the denominator to the ‘well off patients who can pay’. The problem is not that there are no doctors – they aren’t working  in areas which are poor/rural/underserved. 

The money, prestige, academic satisfaction , life style for self and family are all generally poor  in the rural areas. India spends a dismal < 2% of its GDP on healthcare and a small percentage on infra – making the possibility of these rural areas improving in the short to medium term very unlikely.  A doctor, especially a specialist, spends at the minimum 8. 5 years of his prime to become a specialist ( 11.5 years for a super specialist/subspecialist). Because of the high voltage competition to get into these courses, only the most driven and brightest get into these courses in the first short – for the vast majority it takes a couple of years more. So it is safe to say that the average time to produce a specialist is a decade for MD/MS courses and 14-15 years for DM/MCh courses. The only silver lining is that – if they are lucky enough to study in government institutes – they don’t end up having a huge debt.

Medicine as a profession is basically a life long training in delayed gratification – for many the gratification doesn’t even come. Against this backdrop, it is easy to understand why any system based on the good will of the already delayed to the market ‘workforce’ to endure the same penury for longer , by slogging in rural areas is foolish. I have seen countless people asking,” why don’t doctors leave if it’s so bad?”. The answer – the same reason why so many bad marriages persist – social issues and the reality of sunk costs.

Even after taking all this into account, a doctor in the late 80s or 90s could hope to succeed financially in a reasonable time frame – because the competition was a little less. Today that is no longer the case. 

Take a top speciality like cardiology for example – the field is so saturated that you can’t walk through a small locality without seeing a couple of cardio boards. The upfront costs of setting up a cardiac center are pretty high – so much so that only the wealthiest can do it. That is only the beginning of the problems – the patient flow ( the ones who are willing to pay) will be likely low because of heavy competition. It is literally a blood bath. It is the classic red ocean scenario – too many doctors vying for the fairly stagnant pool of paying patients. There is no better recipe of incentives /disincentives to produce a ripe scenario for dodgy practice.

PM Modi has announced that the government spending on healthcare will increase to 2.5% of GDP . However it is like a drop in the ocean. The number of paying patients aren’t likely to increase a lot. The  government insurance schemes will probably drive down the profits of hospitals even further. The peanuts that the doctors receive will probably become even more shrivelled. The disappearing individual practices and the insurance advantage of big hospitals means that there will be a steady erosion of doctor’s autonomy, like in the US. 

Is there something we can do to improve the situation without increasing the spending on GDP? 

We currently  have a top heavy medical establishment – with too many specialists and too little patient load for any of them.Since our spending on research is so low, hardly any doctor goes into research either and the ones that do want to, find that the culture of obsequiousness that pervades Indian universities and the lack of originality means they have to fly abroad. 

The politicians continue to churn out doctors, through the colleges they own directly or indirectly, with absolutely no regard for what the community needs or willing to absorb.

This is where the fishing freeze idea comes in.

We can stop freeze superspecialty / PG admissions – for example, only admit students in alternate years. This can even be dictated by the community needs – for example, cardiology and Neurology are far more saturated compared to endocrinology or immunology. Protectionism isn’t necessarily bad, if it is time bound – allowing for the fields to recover. This should also extend to private bodies, offering meaningless certificate courses and muddying the waters further. These pseudo specialists make things worse – and  professional bodies  should act decisively against individuals and organisations indulging in such acts.

In the off years, the  freshly minted PG students can be engaged in 

– government service

– rotations in specialties in which they had no exposure

– practice for those who aren’t interested in pursuing further education anyway

The government service will help them build up some cash reserves, while rotations will give them a much needed perspective.

The experience by Siddharamiah government and others shows that just throwing money at docs won’t bring them to rural areas magically. With the NMC replacing MCI, the number of pg seats are probably going to increase – with more doctors coming out and finding out that the supply/demand ratio is no where close to what they have imagined. At this rate, we will only have to export them to foreign countries!

If we can’t have a hold on the pg factories, we are probably doomed. We  lineed an admission holiday, just like the oceans need a fishing holiday.

The Accidental Vegan

Every once in a while you meet a patient who fundamentally changes the way you view the world. They show you the infinite shades of grey if we care to look through the prism of their eyes.The trials and tribulations of poverty make these shades much darker. I recently saw a patient with androgen insensitivity. She ran a trust to help the needy and worked as a teacher in a local school. She seemed a little distraught. I switched off my mobile and decided to listen to her.
Her androgen receptors were only mildly sensitive to testosterone. She had been brought up as a girl and had all the feminine sensitivity of a typical Indian woman. The androgen insensitivity had not been complete – this made here develop some pubic hair and not ‘enough’ breast. Thus flat chest became her main complaint and her perennial obsession. In a cruel irony, all she ever wanted was for her disorder to be complete – that the receptors to not respond to androgen at all. When even that didn’t happen, she felt like the nature had betrayed her.

Years of social conditioning had made her bury her self worth in her chest – literally. In a country where endocrinologists are scarce, she had been running from pillar to post to explain her rather delicate situation to any doctor who would lend an ear. Some doctors empathised with her. Others didn’t understand her condition and gave her platitudes that she was a late bloomer. How late is too late, she wondered. She dreamt of normalcy, the way normal people would dream of more. Her parents celebrated her non existent puberty in an elaborate ritual- to show the world that all was fine.

She did all she could to hide her breast development – or the lack of it thereof. It turned out that it is harder to hide something you don’t have much of. She wore a traditional South Indian sari to college. The sari is a longish silken cloth that one drapes around oneself. It can be as sensual as you want it to be and as demure as you want it to be – just like the typical Indian girl it sought to cover.
She told me that she would always either face the board or the students – and never assume a midway posture, for she was conscious of her flat chest. Soon she noticed that it was affecting her confidence. Her solution to the vexing problem was push-up bra – a local variant at least. Each one cost her Rs 300 ($4.5). She lamented their poor quality. The bra was made up of a sponge like material and it lost its texture once she washed it. This meant that she had to save money just to buy more brassiere s that she hoped would prop up her dignity.

I asked her ‘ Have you ever consulted an endocrinologist?’

To my surprise, she gave me a look that was the best real life rendition of the ‘meh’ emoji I have seen. She said ‘yes, but they didn’t help much’. She had been prescribed oestrogen, even in reasonable doses. She swore that she took those pills, but they, like the doctor’s words when she was younger, never made her bloom. I quickly went through her records and the pathologist’s notes of her previous gonadal biopsy was clear: it was a testis. There was no diagnostic dilemma.

With her meagre salary, it was becoming increasingly harder to afford this. She told me she had gone online and searched about plastic surgery. She was reluctant to go under the surgeon’s knife and instead decided to invest in more such bra. Since there was no way for her to augment her income, she decided to cut down on expenses instead. She confided in me ‘ I sometimes feel like a burden to my parents. To save them some money, I have become a vegan’. This was – in many ways – one of the weirdest reasons I have heard for becoming a vegan. She had imposed upon herself a form of culinary exile, partly to assuage her perceived guilt.

Vegetarianism, is commonly associated with purity in Indian society. So much so that it is common to hear the phrase ‘pure vegetarian’ in colloquial language. I wondered if she thought that ritual purity (or some equivalent) would make her hormones work. A word cloud was beginning to form in my head – of poverty, societal expectations, hope, fears, biases, dreams and everything that connected this. I couldn’t let the word cloud, cloud my thinking and I snapped back to reality.

I explained to her, the pathophysiology of her disease, as best as I could. It seemed so hollow. I knew that she had crossed a cultural chasm as wide as anyone can imagine, to let me know her innermost thoughts. I told her I would do everything in our power to restore a semblance of normalcy to her. She said that she felt better talking to me. I was acutely aware that I hadn’t provided any solution to her problems. It didn’t matter though. I asked her if I could share her story to the world. She nodded.

My undergraduate professor always used to tell us “It is not the stethoscope in your ears that matter, but what lies between those ears”. It seemed to convey that being brainy is the most important qualification for a doctor. We had assumed that the listening ear is just an insignificant milestone on the information highway to the brain. This accidental vegan taught me otherwise – a listening ear is as important as a discerning brain.

Endocrine Checklists

Yesterday I attended the Evening with Endocrinology program organised by Endocrine Society of Tamilnadu and Pondicherry. This is a novel program – by endocrinologists , of endocrinologists and for endocrinologists. Consequently the depth of discussion was much better than the usual conferences we attend. The talks were focused, small and peppered with a lot of discussion.

One of the talks was on precautions to be taken while sending samples for workup of adrenal incidentaloma. As we wall know , some hormones are flimsy – they are the inanimate versions of the fastidious bacteria we read about in microbiology. Make a tiny mistake and the accuracy goes for a toss.

It becomes quite difficult to ensure the accuracy in smaller clinics ( and sometimes even in larger hospitals). So this is a problem – and like every other problem, it is also an opportunity.

Problem at hand: Reducing pre-analytical error in hormone assays

For such an important issue, many methods have been tried with variable success. I felt that one of the solutions could be a dead simple , non technical piece of paper : A checklist.

As Atul Gawande speaks about in his wonderful book , A Checklist Manifesto, this simple tool has been used in areas as diverse as the Formula 1 racing to the sober operating room. The idea is to conquer complexity with simplicity.

Since the people who draw blood and send the samples are often nurses or interns, who aren’t likely to know the details of hormonal assays, it is probably worthwhile to make a checklist of things to be done before sending uncommon hormone samples. The lab can be instructed to receive the sample only if it is accompanied by a signed checklist.

This will help in a few things
1. The intern learns about the nuances of hormone measurement in a painless manner, with the learning baked into the workflow
2. It can potentially reduce pre analytical errors
3. The data collected for analysis – from many centers – for example , plasma renin activity, can be standardized to some extent with a checklist.

To the best of my knowledge , a simple checklist for reduction of pre-analytical errors in hormone assays isn’t being followed by most centers in India.

The idea of this blog post is to get an idea from fellow endocrinologists/ other doctors about what they feel about this . Kindly take the following survey.

If your answer to the previous question is yes, please let me know if you might be interested in working together. (or WhatsApp me)

Out of sight, out of mind

I just got back from ESICON 2018, our flagship annual endocrine conference. It was in many ways one of the best conferences I had attended – the most memorable thing being the warm hospitality of Team Odisha and their precision in time management rivalling the best Swiss watchmakers.

Just when I was returning, I got message of a personal emergency and had to travel to my native place, giving me quite a bit of time of kill and blog :-). I opened the conference app and went through the talks.

Recently I had attended a Twitter discussion on Endocrine curriculum. The endocrine folks from the US thought that only 2 % of their curriculum is dedicated to learning about the management of LGBTQ community. No one was ever asked a long question on the management of transpeople. Nor had they gotten a long case in the practical exams.

This is fairly consistent with our experience in India too. We rarely see transgender patients in teaching hospitals. Most Endocrine programs don’t have transgender clinics. In some hospitals, the transgenders are perhaps actively discouraged – by the other patients themselves. It would be naive to think that this social exclusion is something to unique to hospitals. Wherever we go – it’s hard to find transgenders in respectable places : temples (or other places of worship), offices, supermarkets, malls or parks. The only places I have seen the trans people in the wild are in signals or trains – usually begging. The other time , I saw some of them soliciting customers for sex work. This unfortunately reinforces a negative stereotype and no one wants to have anything to do with them in India. It is almost like they are out of our sight in respectable places, and thus out of our mind. There are perhaps economic reasons as well – since if you own a private clinic and transgenders frequent that clinic, it might make the ‘’normal’’ clients uncomfortable. (There is however no data to suggest that this actually happens)

Against this backdrop, certain governments like the government of Kerala has taken welcome steps – like providing them jobs in Railways and government assistance for treatment(upto Rs 2 lacs). Yet the endocrine community in India still doesn’t have national guidelines for management of transgender and capacity building has been slow, even in the best of centers. We don’t have a national transgender registry either and any guideline will be full of only level C evidence – expert opinion. Most conferences don’t have any talks on transgender management either.

It’s high time we addressed the unmet needs of this left out community. We could start by actually listening to the patients themselves – the transgenders. This will help us in chalking out a plan to create locally relevant, culturally appropriate guidelines on management of these people. It is good to be data centric, but it is even better to be patient centric.

Next year’s ESICON is planned in the state of Maharashtra. By popular accounts, Maharashtra(especially Mumbai) has some of the strongest support systems for transgender people. Like the ISPAD guys, perhaps we endocrinologists could think of inviting a successful transgender person – for an invited lecture in ESICON 2019. After all, they have lived through the transition to tell the tale – both social and medical. This will also set up a stage for patient participation in medical conferences – starting with the most marginalised group of them all.

LCHF diet – A boon in obesity management?

I recently debated on whether LCHF (low carb high fat diet) is a boon in the management of obesity. I had spoken against the LCHF diet. The process of preparing for this talk sent me through the bowels of the internet and made me wonder about the role of debate ( not for the first time ) in questions of medical importance.
Why not a debate?
In the last half century alone more than 250000 papers have been published. Regardless of which side you argue about, you are certain to find some papers supporting your argument. It then becomes a matter of easy cherry picking.

In a conference, you get limited time to talk about stuff. Consequently a speaker has to choose his points carefully. The very nature of the debate and the urge to win a debate might paradoxically force the debater to avoid the nuances. One of the easier ways to win a debate is to go for the limbic cortex of the audience and not their frontal cortex. This nefarious technique only rekindles the lurking confirmation bias in the audience – making them move to more extreme positions in the direction that they re already inclined.

On the other hand, being too equivocal, causes the debate to be extremely prosaic and is a sure way to get the audience to sleep. For a good debate, on intellectual terms, with as minimum ’masala’ as possible, your performance isn’t enough. You need an opponent who shares the same values and respect for science and guarantees civility.
I thank Dr Premkumar for being exactly that kind of opponent in this debate.

Why a debate?
In spite of its short comings, the debate is one of the most interesting ways to learn things. Despite logical sleights of mind, a mature audience can discriminate a strong argument from a weak one. If a rhetoric filter is in place, they can distinguish the diamonds from dross.
The role of the organisers is to make this process easier. Here are some things that can be done

  1. The presenters can be given more time – this will eliminate the urge to highlight the most exciting, but least applicable points.
  2. The judges need to be almost as prepared as the authors – to spot the errors and give a neutral perspective.
  3. The presenters can be given a predetermined set of references – this has the advantage that it will limit and set the scope of arguments and preselect studies with reasonable quality. This is not too different from a meta analysis. A common argument against such an approach is – will this cause bias and cherry picking? The answer is – yes. But there are solid reasons for this. Imagine you go to a cherry orchard. You pick a bunch of cherries – and find that half of them are rotten. Would you eat all the cherries just because you are afraid someone will accuse you of cherry picking? Obviously not. In the same way, there are some studies which reek of poor methodology, industry bias and occasionally plain nonsense. One cannot just include them and give them equal value as all other studies.
  4. The presenters can be encouraged to publish a Point – Counter Point article. The advantage of this approach – people are far more critical while reading static text in a paper than the moving text in a presentation. They would form a deeper understanding of the subject.
  5. The presentations can be made freely available. I am not sure if it will help, but I do it for all my presentations anyway.

Where is the LCHF presentation?
Due to lack of time, I had to shorten the presentation. Since there is no such time limit in a blog, I am posting the full version of the presentation, along with the sources for further reading.
You can download the presentation by clicking this link.
LCHF Diet: A boon in Obesity Management?
It is my fervent hope that people saw LCHF in the most balanced way possible – the pros, the cons and everything in between.