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A conversation with Dennis M. Bier, MD
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In this issue, Endocrine Today talks with Editorial Board member Dennis M. Bier, MD, professor of pediatrics at Baylor College of Medicine in Houston. Since 1993, Bier has served as director of the U.S. Department of Agriculture/Agricultural Research Service (USDA/ARS) Children’s Nutrition Research Center at Baylor, which conducts investigations into the role of nutrition in maintaining maternal, infant and child health and informs national nutrition guidelines.
Bier is editor-in-chief of The American Journal of Clinical Nutrition and former editor-in-chief of Pediatric Research. He recently retired from his 25-year role as associate editor of the Annual Review of Nutrition. Throughout his career, he has held leadership positions with the Institute of Medicine, the American Society for Nutrition, the American Society for Nutritional Sciences, and the American Society for Clinical Nutrition, among others.
An avid fisherman, Bier welcomes invitations to speak at any event near a good fishing venue.
What was the defining moment that led you to your field?
Dr. Bier: The defining moment actually came after several years in medical school. It was the realization, first, that what we don’t know about disease is far more than what we think we know and, second, that one could actually make a career in medicine trying to answer questions about the physiologic basis of various diseases. Before medical school, I didn’t really realize that was a career option. I fully thought I was going to finish school and go out and practice medicine. When I left medical school, it was clear that I was more interested in pursuing an academic career where one could try to answer questions that were really important for patients.
What area of research in endocrinology most interests you right now and why?
Dr. Bier: In medical school and in house staff training, I became interested in the role of intermediary metabolism in mediating the causes, pathophysiology and recovery of various diseases. In other words, I was interested in metabolism. Endocrinologists as a rule are interested in hormones primarily and in their various metabolites or substrates secondarily, only insofar as these are regulated by the hormones. I was interested in the substrates and how they allowed people to move necessary metabolites between organs and interested in the hormones primarily because they were regulating how the substrates moved. When I started thinking of an academic career, the options for those interested in metabolism in children tended to be inborn errors of metabolism or pediatric endocrinology/diabetes because diabetes was one of the primary examples of metabolic fuel derangement present in pediatrics. Pediatric endocrinologists also took care of certain other kinds of metabolic problems that interested me, such as low blood sugar in newborns and toddlers. So my research interests in metabolism naturally directed me into the field of pediatric diabetes and endocrinology. My primary interests still lie in inter-organ fuel transport.
How has your research contributed to medical history?
Dr. Bier: When I started my career, it became apparent that one could not answer questions about the inter-organ transport rates of metabolic fuels only from static measurements of substrates in blood. For example, blood sugar can go up or down depending on various permutations of hepatic glucose production and peripheral glucose removal. The only way to understand the dynamics of inter-organ fuel transport is to measure them directly. At the time, the only available ways of tracing metabolic fuels was using radioactive tracers. These were just not generally acceptable to administer to infants and children. For that reason, we had very little dynamic information about fuel transport in children. Several other people in different universities and I spent great time and effort to develop the nonradioactive stabilized tracer field so that we could trace metabolic events in children. At the time, we weren’t trying to create a sea change in medical research because we were interested in the specific things that we wanted to measure in children; but today, stable isotrope tracer methods are the primary approach used in clinical medical research, and radioactive tracers have generally passed out of the picture for this purpose.
What do you think will have the greatest influence on your field in the next 10 years?
Dr. Bier: I think the principal influence on the field will be the transparency in research study design and reporting both in clinical research and in animal research. We need mandatory registration of all human and animal studies — in particular those human studies that today are often not registered, such as observational studies. We need a clear, explicit declaration of the primary endpoints and methods of analysis, and investigators must accept their responsibility for making primary data available for review and for alternative analysis when necessary. Right now, there is an immense black box around how people handle study data. There are widespread post hoc manipulations (so-called investigator degrees of freedom) that are directed toward ensuring that studies come out “positive.” That is, there is the tendency to publish results that support the authors’ allegiance biases rather than a comprehensive, balanced picture of the results that might not be as supportive of the authors’ interpretations. We need clear presentation of alternative interpretations, transparent discussion of the true limitations of a study rather than simply inserting the usual boiler plate text of limitations that appears in most journal articles. These problems are receiving attention in human research today, but they are only beginning to be addressed in the animal research community. The fundamental, entry-level requirements for publication of human studies, such as true randomization, allocation concealment and intention-to-treat analyses, are only occasionally applied in the animal research literature.
What advice would you offer a student in medical school today?
Dr. Bier: Medical students today have to make some early decisions about the direction of their careers. In part, this is because their education is so expensive. If they have a true interest in fundamental science and medicine, either at the bench level or at the clinical level, they have to consider very early whether they want to be a part of an MD/PhD program or some similar type of option that allows them to leave medical school with less debt. There is no more stimulating career than academic medicine. I have never regretted my decision to remain in the academic environment. However, there’s no gold standard of success hierarchy; that is, there’s no way of measuring the success of a practicing physician in a community vs. an academic position in a university because they’re both of great value. – by Jill Rollet