Saturday, November 18, 2017

Saturday Stories: Gene Drives x 2, and The Uncounted

By Mariuswalter (Own work) [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)], via Wikimedia Commons
Ed Yong, in The Atlantic, on how New Zealand's war on rats might change the world (and not necessarily for the best).

Carl Zimmer, in The New York Times, on why scientists believe gene drives (like the one discussed in Ed Yong's article) are too risky to employ.

Azmat Khan and Anand Gopal, also in The New York Times, with an incredible piece of journalism on the accuracy, or lack thereof, of America's bombing of ISIS.

And lastly, if you enjoy my blog, please consider a donation to my Movember fundraising for men's health initiatives. Thanks to the generosity of friends, family and readers, I'm 91% of the way to my $3,500 goal. You can give anonymously and it's fully tax deductible. Just click here! No donation is too small.



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Thursday, November 16, 2017

Physicians Best To Have Practiced What They Preach Regarding Lifestyle

A few days ago I put out a tweet that stated that physicians (and with more characters here I'll say other allied health professionals as well) shouldn't give lifestyle advice unless they've followed it themselves. Given it led to a varied discussion, thought I'd expand more here.

First, I'm talking primarily about diet and fitness advice which pertain to any diet/fitness responsive condition or simply on healthy living as its own aim.

Second, while I think it'd be terrific if all physicians continually walked their talks, this isn't a reasonable expectation. What is however reasonable, at least in my opinion, is that a physician providing lifestyle advice has spent at least some time following their own advice (barring of course any physical or medical limitations that might preclude same).

Living the whys, wherefores, real-life challenges, and logistics, of their own lifestyle advice provides physicians with insights and empathy that in turn will help in their understandings of their patients' struggles and barriers. That understanding is likely to improve the counselling and support those physicians provide.

Whether it's keeping a food diary, following a particular diet, cooking the majority of meals from fresh whole ingredients, exercising a particular amount each week or day, mindfully meditating, etc - spending a real amount of time doing so (my non-evidence based suggestion would be for a month at least) will make you a better clinician.

[And to be clear, as there were those online who wanted to extrapolate my statement into one that suggested physicians must themselves all live incredibly healthful lives and maintain certain weights - that's definitely not what I'm saying, nor of course does weight provide real insight into the health of a person's lifestyle (as plenty of people with obesity live healthy lives, and plenty of people without don't).]

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Tuesday, November 14, 2017

Early Childhood Physical Activity Does Not Vaccinate Against Obesity

By Pete (originally posted to Flickr as determination_0970) [CC BY-SA 2.0], via Wikimedia Commons
It's not uncommon when I meet parents of children with obesity for them to tell me either that it doesn't make sense because their child is extremely active, or that inactivity is to blame for their child's struggles.

And while my confirmation bias is that weight leads to inactivity in kids rather than inactivity to weight, data is somewhat mixed, with some studies finding total daily energy expenditure in very young children is associated with lesser weight gain, and others, not.

One of the shortcomings of prior studies were that they focused primarily on energy expenditure measured during a child's first year of life, and didn't cover the period known as adiposity rebound whereby BMI typically decreases until the age of 4-7 years before beginning to increase through late childhood.

A recent small study, High energy expenditure is not protective against increased adiposity in chldren, included that time period.

Briefly, 81 subjects who were classified as either at low risk of developing obesity (in that they had lean mothers with an average BMI of 19.5), or at high risk (mothers with an average BMI of 30.3), were recruited, and 53 remained through to the study's conclusion of 8 years. Three measures of adiposity at 8 years were collected - BMI percentile, BMI Z-score, and percent body fat. Total energy expenditure was measured using doubly labelled water at 4 months, 2, 4, 6, and 8 years of age (though only 58% of all total measurements were collected). Body composition was measured by way of bio-impedance analysis at ages 0.25 and 2 years, and by way of DEXA at ages 4 and 6.

What was found was that total daily energy expenditure increased with body size, but,
"there was no evidence supporting the hypothesis that a low habitual TEE for that body size leads to subsequent increase in BMI or % body fat"
Nor was there an association between measures of adiposity at age 8 and total energy expenditure between the ages of 0.25 and 6 years.

The authors overarching conclusion is that when it comes to the genesis of childhood obesity, it's energy in, not energy out.

I can't help but wonder, were that to be the prevailing belief, would parents with concerns about their children's weights be more conscious of their children's diets (especially liquid calories and purchased meals) as energy-in is something that many parents deemphasize during our initial discussions.

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Saturday, November 11, 2017

Saturday Stories: Trump's USDA, ORBITA, and 'Woman, Black',

Michael Lewis in Vanity Fair on Trump's USDA.

James Hamblin in The Atlantic covers the ORBITA trial and wonders how much of heart disease is a state of mind?

Future physician Chika Oriuwa with her spoken word poetry slam 'Woman, Black'



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Thursday, November 09, 2017

More Evidence That More Exercise Doesn't Up Total Daily Calorie Burn

Why is it that exercise doesn't seem to help appreciably with weight loss (and for those who enjoy building strawmen out there, note I'm talking about weight loss, not fat loss, nor fitness, nor health)?

One possible reason is that many people eat back their exercise in the form of a reward for doing it, or because they have been taught by savvy marketers that they need to refuel or recover something or other.

Another possible reason is that upping intentional exercise may lead bodies to decrease unintentional calorie burn (decreased fidgeting/NEAT, decreased autonomic tone, etc.) and also by way of improved exercise efficiency.

Overarchingly the latter theory is called constrained energy expenditure, and the evidence on all of this is early, and somewhat mixed.

Well a few months ago another block was added to the pile (at least for older women without obesity) suggesting constrained energy expenditure is a real phenomenon. It was a study published in Physiological Reports and it detailed the impact that a 4 month long moderate-intensity walking program had on the total daily energy expenditures of older women without obesity.

The study's 87 included participants reported being physically inactive, and weren't found to have any significant medical issues. The group was randomized into either receiving one of 2 doses of moderate intensity exercise for 4 months. Importantly, the exercise itself was supervised. Before and after measurements included resting energy expenditure (via indirect calorimeter), total daily energy expenditure (via doubly labeled water), body composition (via DEXA), graded exercise test (via treadmill VO2 max), physical energy expenditure (TDEE*0.9-RMR (to account for thermic effect of food reduced by 10%), and NEAT (by subtracting exercise energy expenditure - physical activity energy expenditure).

When it was all said and done, the lesser group added an average of 105 minutes of walking to their weeks, while the higher group added 160 minutes to their weeks.

There was a teeny tiny bit of weight lost in both groups (1.7lbs), and a tiny change to body fat percentage (-0.7%), but there were no between group differences. Expectedly, V02max improved more in the larger amount of exercise group.

What didn't change?

Everything else.

Despite marked increases in intentional exercise, and marked differences in adhered to doses of exercise, there were no differences found for participants' total daily energy expenditures, resting metabolic rates, NEAT, non-exercise physical activity or even total physical activity.

These results changed some when they further analyzed the data as they determined that those patients with higher baseline levels of physical activity showed lower levels of NEAT (important to note, difference did not reach statistical significance) post 4 months of exercise, whereas those with lower levels of baseline activity experienced decreases to resting metabolism with exercise (authors suggested latter might be due to weight loss, but given how small weight loss was, I find this confusing as the RMR drops were not small).

All this to say when it comes to exercise and its impact on calories burned, it's clearly far from a simple math formula. It's also incredibly unfair to weight. But as always, when it comes to improving health, nothing beats it.

[Thanks to Matt Woodward for sharing this study with me]

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Monday, November 06, 2017

Guest Post: Special K Nourish Ad Perpetuates Supermom Nonsense

I've never been a fan of Kellogg's Special K's pretending to give a crap advertising, and so when I received an email from longtime reader Rosemary, who was unimpressed to say the least with one of their latest ads (embedded at the end of this post), I asked her if I could share her thoughts. She kindly agreed. Raw to say the least, and though I don't fully agree with every sentiment expressed herein, I'm betting they'll resonate with many.
I know soooo many women (and men!) that eat these products - thinking they are a whole / healthy choice.

This ad is so much ugh. Of course they had to throw in the shot of the well-endowed woman in the bra. "Casually getting dressed" ... while literally stuffing her face. Geneen Roth would not approve! Lol.

The whole "I am woman hear me roar - I can do anything - I am fierce - around food / being in charge of the food / feeding the kids - this media trope is so such nonsense. I dont know any women that work / live / eat the way this ad depicts.

Just perpetuating that myth -women- no, we don't deserve time carved aside to eat calmly - we are just too damn busy being everything to everyone. Just perpetuates this super mom woman role nonsense.

Most women I know / especially those with young school age children LOATHE grocery shopping / planning meals / making lunches / cleaning up (cuz let's face it, cooking proper whole foods is more work) / and just generally feeling the societal pressure to excel to be creative (and inspired! (Oh shut up Jamie Oliver))- about feeding their families. (And isn't this just code for "if you love your family you should be obsessing about this too like every other delusional Martha Stewart wannbe? Most of us are just so exhausted from overwork / we lose the motivation. In secret, we all admit how much we hate it and what drudgery it is.)

And there Kellogg's is trying dutifully to hit all their "diversity notes" - woman motorcycle mechanic / buzzcut lgbt-ish rainbow wristband girl - / It is all so contrived.

They are depicting the overworked woman - and they are the solution, when in fact, eating their crap that masquerades as "breakfast" and "food" probably actually contributes to feeling exhausted - re unstable blood sugar - carby weight gain - making one less energized to shop and prepare. It's a cycle.

I know when I eat next to no processed food - my energy levels are great. After about 4 days of not eating any crap.

The cereal is 10g's of sugar per 3/4 cup serving. That would maybe cover the bottom of the cereal bowl. No one eats only 3/4 cup of cereal when they pour a bowl.

And the granola bars are even worse - palm oil - and many different forms of sugar. Cane in the chocolate and corn syrup.

No reply necessary - yer bizzy - just wanted to pass it along.



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Saturday, November 04, 2017

Saturday Stories: Global Trolling, Pain Empires, and Fake News Towns

A non-bylined piece (at least not that I could see) in The Economist explaining how the world has been trolled and why social media is to blame.

Patrick Radden Keefe in The New Yorker on the Sackler family and their empire of pain.

Caitlin Dickerson in the New York Times on what fake news did to Twin Falls, Idaho

[If you find this blog entertaining, interesting, and/or valuable, know I'll never ask you for money to read it, nor will I subject you to ads, but I will, once a year, ask you for donations to support my #Movember efforts. Please to report I'm nearly halfway to my $3,500 fundraising goal! Click here to give. No amount is too small, you'll get a tax receipt, and if you don't want it known by me or anyone else that you hang out here from time to time, you can give wholly anonymously as well.]


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Wednesday, November 01, 2017

And So It Begins (#Movember)

And so it begins (again).

This month I pledge to grow my something of a Pedro Pascal inspired lip-terpillar in the name of raising awareness (and $s) for men's health.

If you enjoy my blog, a blog fully free from advertising, I'd like to ask you to donate to my Movember fundraising efforts. I've kicked them off by donating $100 myself and I'm hoping to raise more than last year's $3,500.

Contrary to what some believe, Movember is not a prostate cancer charity per se, and though some of its funds do support prostate cancer research and treatment, Movemeber supports multiple men's health initiatives including those involving mental health, suicide, body image, eating disorders, testicular cancer, substance abuse, and more. Regarding prostate cancer, I was pleased to see that Movember encourages patients to speak with their physicians about the value (or lack thereof) of PSA screening, rather than suggesting it's a good idea for one and all.

Donating is easy. Just click here and give! And of course, Movember is a registered charity, so all donations are fully tax deductible.

In return I vow to continue to blog freely, to never allow advertisements, and to regularly post pictures of what might well have been an effective form of birth control in my home had I sported it year round back in the day.

For me the ask is also personal. My father was diagnosed with prostate cancer when I was in medical school, and soon I'll need to start wrestling with whether or not with that strong family history, I should walk the slippery slope of testing. My oldest cousin Marshall - we lost him to substance abuse.

Every dollar counts, no donation is too small.

(And if you want, you can make your donation anonymously so no one (me included) will know you hang out here from time to time.)

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Monday, October 30, 2017

Food Industry Furious With Health Canada's Front-of-Package Plans

If Health Canada takes Chile's lead, we too might see Frosted Flakes boxes change from looking like those on the left to looking like those on the right.
When industry is furious with a government proposal it's a safe bet that proposal is likely to affect their sales, and so when I learned that the food industry was incensed by Health Canada's front-of-package plan proposals (Aric Sudicky, a final year medical resident who was rotating through our office at the time, watched the recent roundtable style consultation hosted to discuss the implementation of what will be a Canada wide front-of-package program, via teleconference and reported to me that industry was none too pleased), I wanted to learn more.

Now this post isn't going to delve into whether or not those are the best 3 targets for front-of-package symbols, instead I want to focus on the lobbying and machinations of industry.

First though, a tiny bit of background.

In creating a new front-of-package symbol for Canadian consumers, what Health Canada doesn't want is a program that emphasizes so-called positive nutrients as 50 percent of Canadian package fronts already have those (put there by the food industry directly to help sell food), or one that requires a second step of thinking to interpret (eg studying the nutrition facts table) as that has been shown to lead to misunderstanding, or a hodgepodge of programs (as more than 150 front-of-package labeling programs have already been documented in Canada) .

What Health Canada does want is a single, standardized system, that involves a prominent symbol, that's consistently located, that doesn't require nutritional knowledge to understand, to help consumers identify products with high levels of nutrients that Health Canada deems are concerning to public health, that by itself provides the required interpretation for its meaning. Such a system would be consistent with the core recommendations made by the U.S. Institute of Medicine.

Breaking it down further, what Health Canada wants is a system that conveys simple to understand information, rather than one that presents data requiring interpretation.

Further still?

Health Canada wants warnings.

In their recent meeting, Health Canada presented their wants to food industry stakeholders, as well as the evidence they feel supports them, and invited them to submit their thoughts and suggestions for a symbol to fit Health Canada's 4 design principles:
  1. Follow the "high-in" approach
  2. Focus only on the 3 nutrients of public health concern (sugar, sodium, and saturated fat)
  3. Be 1 colour (red) or black and white; and
  4. Provide Health Canada attribution
As to what this might look like, here are some mockups put together jointly by the Canadian Cancer Society, Canadian Medical Association, Canadian Public Health Association, Diabetes Canada, Dietitians of Canada, and the Heart and Stroke Foundation.

Given that warning symbols aren't likely to be good for business, I was curious as to industry's response to the ask.

Suffice to say, industry is indeed unhappy.

The Retail Council of Canada wants Health Canada to implement instead an instruction for consumers to turn products around and study their nutrition facts tables, and they don't want Health Canada's name mentioned on the symbol. They are apparently worried that including Health Canada's name on the symbol might be misinterpreted as a government endorsement which in turn would lead consumers to eat more of the products with the warning labels. They're also apparently simultaneously worried that if the symbol utilized is already recognized to be a danger symbol, it could lead consumers to believe there is a food safety risk, and that if used, children, accustomed to seeing these symbols on foods, might lead them to think that cleaning supplies with danger symbols are safe to consume.

The Food Processors of Canada used bold to point out that, "the meeting didn't agree to anything", and that, "Health Canada has lost its way on the obesity issue". They think that what's needed is more public education, not a front-of-package warning program.

The Canadian Beverage Association expressed their, "deep concerns", and that though they were happy to have been included in the meeting, their definition of "deep and meaningful dialogue" with industry should include a process whereby industry participants would all discuss and agree upon what the program would entail.

Food and Consumer Products of Canada also wanted to express their disappointment that they weren't provided the opportunity to be more directly involved in crafting the proposal's criteria and their concerns about "the integrity and transparency of the consultation process". They sent a second note expressing their hope that the criteria still have room to evolve and that their preference is for traffic lights as they believe, "information – good and bad – builds on consumer literacy".

Dairy Farmers of Canada expressed their concern that the proposed warning system lacks the nuance required "to distinguish between nutrient-dense and nutrient poor foods" (sweetened milk will likely be slapped with a high in sugar warning), and that they'd be happy to support, especially, "if coupled with exemptions for nutritious dairy products", those programs that would provide data for consumers to study and interpret (like for instance the Facts Up Front program illustrated below).

There was however, one response from industry that was heartening. It was from Nestlé, whose representative reported being, "a little embarrassed" by how industry presented their views during the roundtable, and, "that Nestlé is not fully aligned to some of the comments that were made by some of our trade associations, and a few of us are feeling very frustrated."

Whatever comes of all of this, one thing's for sure. The food industry's near uniform opposition to Health Canada's proposed front-of-package warning label criteria is strong indirect evidence in support of their utility, as for the food industry, salt, sugar, and fat are the drivers of profitability and palatability, and they'll oppose anything they worry might limit their use.

So kudos to Health Canada for sticking to their guns, and also for honouring their pledge to make this process transparent by sharing with me industry's responses.

(and if you clicked on any of the industry letters to read, this is the post roundtable letter from Health Canada to which they're all referring).

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Saturday, October 28, 2017

Saturday Stories: Motherisk, Blood Tests, and Kim Jong Nam

CC BY-SA 3.0, Link
Rachel Mendleson, in the Toronto Star, with Part I of her incredible reporting on the fallout from the Mortherisk scandal.

Christie Aschwanden, in Five Thirty Eight, details her experiences with direct to consumer blood tests in the name of athletics.

Doug Bock Clark, in GQ, with the strange but true story of Kim Jong Nam's assassination.

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