Tuesday, November 12, 2019

New Systematic Review Concludes No One Will Ever Successfully Maintain Their Lost Weight. Or Does It?

From the Journal I Can't Believe This Ever Got Published (ok, in this case from Obesity Reviews) comes The challenge of keeping it off, a descriptive systematic review of high-quality, follow-up studies of obesity treatments.

The paper apparently is meant to be a counterpoint to other systematic reviews of long term weight loss where,
"conclusions are generally positive and give the impression that weight loss interventions work and that weight loss can be maintained"
Well we can't have that now can we?

It appears these authors sure couldn't because here are the criteria they used in selecting papers for their systematic review that concluded long term weight loss is impossible:
  1. Studies must have follow up periods of at least 3 years
  2. Patients must not have had any continued interventions during the follow up period
  3. Medications approved for weight management aren't allowed
So what they ended up with were 8 studies of varied protocols being administered temporarily for a chronic medical condition where half provided what by definition were only temporary interventions (3 with very low energy diets, and one with hospital provided food). But guess what, chronic medical conditions require ongoing treatment, and what happens when you actually provide it? Well you get studies that would spoil the impossible narrative as noted by the authors of this paper,
"several of the non-included studies report a majority of participants achieving satisfactory weight loss and little regain, especially among studies with continued interventions during the follow-up period."
Imagine that! Appropriately treating a chronic medical condition with continued interventions works!

And this notwithstanding the fact that many (most? all?) of those studies that provided ongoing interventions likely did not include the appropriate prescription of medications to either help with losses or to prevent regain (just as we would with any other chronic condition) because weight loss medications are almost always excluded from use in weight loss diet studies. Which is odd by the way. Consider hypertension for instance. Sure some people might be able to resolve theirs by way of such things as lower sodium diets, increased exercise, and weight loss, but there's zero doubt that patients with hypertension will receive regular ongoing follow up visits with their physicians, and where appropriate, will be prescribed medications to help. Why? Because that's how chronic condition are managed! Which is why we'll never see a systematic review of hypertension treatments demonstrating that brief lifestyle counselling and the explicit exclusion of medications didn't lead to lower blood pressure 3 years later.

Leaving me to wonder, why publish a paper with the literal conclusion,
"that the majority of high-quality follow-up treatment studies of individuals with obesity are not successful in maintaining weight loss over time"
when really all your systematic review (of just 8 papers all with different dietary/lifestyle interventions) has proven is that delimited, lifestyle counselling doesn't miraculously cure a chronic medical problem, and where you admit in your paper that the appropriate provision of ongoing care might well in fact lead to sustained treatment benefits?

But I don't really need to wonder. Because the only reason that this paper was conceived and published is because of weight bias, whereby obesity has different rules applied to it, in this case, the notion that unlike so many other chronic medical conditions that are impacted strongly by lifestyle changes (eg. hypertension, type 2 diabetes, GERD, heart disease, COPD, gout, osteoarthritis, osteoporosis, kidney stones, and many more) people believe that for obesity some brief counselling should be enough to do the job, because that in turn plays into the trope of obesity being a disease of willpower and a deficiency of personal responsibility.

(Thanks to Dr. Andrew Dickson for sending my way)

Thanks to your generosity I'm over 2/3s of the way to my $3,000 Movember fundraising goal. While I'll never monetize this blog, this is my annual fundraiser and if you find value here, consider a donation! Remember, every dollar counts, it's tax deductible, and you can give anonymously! To donate, simply click here

Saturday, November 09, 2019

Saturday Stories: Mary Cain, Fatal Powerpoint, And Echo Chambers

Mary Cain, in the New York Times, tells her story of the intersection of abuse and elite sport.

Jamie, in McDreeamie Musings, on the Powerpoint slide that killed 7 people.

C Thi Nguyen, in Aeon, on the dangers of echo chambers

And if you haven't had a chance to donate yet to my lipterpillar, and you find some value or enjoyment from this blog, please consider and remember, every dollar counts. So far this year the generosity of friends and family have helped to raise $1,640. Movember is a tax deductible charity and you can give anonymously if you'd prefer. And of course, as I've mentioned, Movember funds multiple men's health initiatives including mental health, suicide, body image, eating disorders, substance use disorders, & testicular cancer. To donate, simply click here

Wednesday, November 06, 2019

"Severe" Energy Restriction Better For Weight Loss Than "Moderate" Energy Restriction?

Well according to this new RCT it is - in it they found that patients randomly assigned to 4 months of severe energy restriction (65-75% restriction of energy by way of total meal replacement/all liquid diet) followed by 8 months of moderate energy restriction (25-35%), at 12 months, lost significantly more weight than those assigned from the get go to the same degree of moderate energy restriction.

Hurrah?

So first off it's not remotely surprising that putting two groups on the exact same diet (25-35% energy restriction) but starting one group off with 4 months of extreme energy restriction sees those who had the extreme jump start lose more in total.

Secondly, it would appear that the extreme folks have a weight gain trajectory that may well erase the differences over time.

And thirdly, this got me thinking. Behavioural weight loss programs, because they don't involve products (unless medications are being tested, and here they were not), have outcomes that are likely significantly dependent on both material, and perhaps more importantly, on the service providers. Consequently I do wonder about the ability of any of these sorts of studies to be applicable to other offices or programs. Meaning here at least, it would appear the extreme folks did better, and the moderate folks dropped out more often (perhaps consequent to slower than desired initial losses), but would the same necessarily be true at a different site, with the same restrictions but with different service providers, collateral materials, attention and support?

I'd venture those things matter a great deal more than is generally ever mentioned in the medical literature.

And a Movember update! If you enjoy these posts (or even if you don't but you hate read them for something to rage about thereby adding some extra meaning or identity to your life) would love your tax deductible donation to my lipterpillar's growth (and remember, you can give anonymously too). And though I have a family history of prostate cancer (hi Dad!) I think it's important to note that beyond prostate cancer Movember funds multiple men's health initiatives including mental health, suicide, body image, eating disorders, substance use disorders, and testicular cancer. And while I will never charge a penny or host an advertisement on this site, I will, on an annual basis, ask for your donation to this cause. To donate, simply click here

Tuesday, November 05, 2019

Just Because Your Cafeteria Has A Salad Bar Does Not Make It Healthy

A few months ago I visited the Ottawa Hospital's Civic campus and decided to have a peek over at the cafeteria.

It won an award you see, an "Award of Recognition" to be exact, which according to the plaque was for,
"significant achievement in creating a supportive, healthy, nutrition environment across hospital retail food settings"
A supportive and health nutrition environment you say?

Um, about that:


Sigh

Saturday, November 02, 2019

Saturday Stories: Bad Nutrition Advice, Nell Scovell, And The Memo Method Of Fitness

Shauna Harrison, herself both a fitness instruction and a Ph.D. in public health, in Self, is begging you to stop taking nutrition advice from your fitness instructors.

Nell Scovell, in Vanity Fair, with an amazing piece of writing about her pre-#MeToo era interactions with David Letterman, and what it was like to sit down with him a decade later to discuss it.

Lindsay Crouse, Nayeema Raza, Taige Jensen and Max Cantor, in the New York Times, with just a lovely video on Guillermo PiƱeda Morales, a.k.a. Memo, and his fitness methodology.

Lastly, I've had many people write to me over the years about their enjoyment of Saturday Stories in particular. If that's you, and if it moves you, today is #Movember 2nd! and your donations  are my ෴'s fertilizer! You give, I grow. And beyond prostate cancer Movember funds multiple men's health initiatives including mental health, suicide, body image, eating disorders, substance use disorders, & testicular cancer. To donate, simply click here

Photo by Pete Souza - Cropped from https://www.flickr.com/photos/whitehouse/3994558942, Public Domain, Link

Thursday, October 31, 2019

Ideally Only Donut Conferences Should Be Handing Out Free Donuts #FNCE #RDChat #IfYouServeItWeWillEatIt

Lots of hoopla on nutrition Twitter this week because RD Tracey Fox questioned the wisdom of serving donuts at the Academy of Nutrition and Dietetics (AND) annual Food and Nutrition Conference and Expo (FNCE).

Hyperbole and fallacious arguments from both sides ensued.

The people hating on the donuts predictably likened sugar to *checks tweets, sighs* heroin and cigarettes, while the people defending them, their arguments are probably fairly summed up in this tweet:

It's these arguments that I want to very briefly address.
  1. Dietitians, and everyone else, are allowed to eat donut holes whenever they want, and criticizing the provision of donut holes at a dietetic conference does not suggest otherwise.
  2. No, the *giant eye-roll* consumption of one donut hole doesn't cause chronic disease, nor does criticizing the provision of donut holes at a dietetic conference suggest otherwise.
  3. No, donuts were not the only food served at FNCE, nor does criticizing the provision of donut holes at a dietetic conference suggest otherwise.
  4. Criticizing the provision of donut holes at a dietetic conference isn't shaming colleagues (but that tweet up above using sneering straw men to call out the RD who doesn't think donuts should be served at a dietetic conference sure is)
As I've written before in reference to a physician conference I attended where they were serving soda, Clif bars, and potato chips as a snack, human beings, including MDs and RDs, when faced with freely provided indulgent choices, tend to choose them, and I can't help but wonder had they not been offered how many RDs would have gone for a donut or cookie run?

And of course it's not "just one". We are all constantly faced with indulgent choices being offered to us freely to christen every event no matter how small, and we've created a food environment whereby we have to go out of our way to make healthy choices and to actively, regularly, say no to indulgent ones. Now I think indulgent choices are part of life, an enjoyable part at that, and ones that I even actively encourage my patients to make, but I also think it would be in everyone's best interest were that food environment reversed, where the healthy choices are the defaults and indulgent choices are readily available for anyone who wants to go out of their way to get them.

And by the way, at FNCE this year they were certainly readily available. The decadent Beiler's Bakery was 92ft away from the Pennsylvania Convention Centre, while more pedestrian Dunkin' was 135ft away.

Yes, the constant provision of junk food is a societal norm, but it certainly need not be.

And honestly, if even the Academy of Nutrition and Dietetics enables and encourages poor dietary choices at RD events, why would anyone expect better from others?

Until we stop leaning on the theoretical ability of people "just saying no", or that the provision of healthy choices somehow erases the provision of junk, as the primary means to address a food environment that incessantly offers and pushes nutritional chaff at every turn, we're not likely to ever see change, and frankly this is a charge that AND should be leading.

Monday, October 28, 2019

Yes, My Kids Eat Candy On Halloween And So Should Yours

(A variation of this post was first published October 24th, 2013)

It's coming.

And I'm not really all that worried. At least not about Halloween night.

The fact is food's not simply fuel, and like it or not, Halloween and candy are part of the very fabric of North American culture, and so to suggest that kids shouldn't enjoy candy on Halloween isn't an approach I support.

That said, Halloween sure isn't pretty. On average every Halloween sized candy contains in the order of 2 teaspoons of sugar and the calories of 2 Oreo cookies and I'd bet most Halloween eves there are more kids consuming 10 or more Halloween treats than less - 20 teaspoons of sugar and the calories of more than half an entire package of Oreos (there are 36 cookies in a package of Oreos).

So what's a health conscious parent to do?

Use Halloween as a teachable moment. After all, it's not Halloween day that's the real problem, the real problem are the other 364 days of Halloween where we as a society have very unwisely decided to reward, pacify and entertain kids with junk food or candy (see my piece on the 365 days of Halloween here). So what can be taught on Halloween?

Well firstly I think that if you'd like, you can chat some about added sugar and those rule of thumb figures up above provide easily visualized metrics for kids and parents alike.

Secondly it allows for a discussion around "thoughtful reduction". Ask your kids how many candies they think they'll need to enjoy Halloween? Remember, the goal is the healthiest life that can be enjoyed, and that goes for kids too, and consequently the smallest amount of candy that a kid is going to need to enjoy Halloween is likely a larger amount than a plain old boring Thursday. In my house our kids have determined 3 treats are required (and I'm absolutely guessing likely a few more on the road) - so our kids come home, they dump their sacks, and rather than just eat randomly from a massive pile they hunt out the 3 treats they think would be the most awesome and then silently learn a bit about mindful eating by taking their time to truly enjoy them.

The rest?

Well it goes into the cupboard and gets metered out at a rate of around a candy a day....but strangely....and I'm not entirely sure how this happens, maybe it's cupboard goblins, but after the kids go to sleep the piles seem to shrink more quickly than math would predict (though a few years ago my oldest told me she believed it was her parents eating them and that she was going to count her candies each night). I've also heard of some families who grab glue guns and make a Halloween candy collage, and dentist offices who host charitable Halloween candy buy-backs.

Lastly, a few years ago we discovered that the Switch Witch' territory had expanded to include Ottawa. Like her sister the Tooth Fairy, the Switch Witch likes to collect things and on Halloween, she flies around looking for piles of candy to "switch" for toys in an attempt to keep kids' teeth free from cavities for her sister. The joy and excitement on my kids' faces when they came downstairs on November 1st that first Switch Witch year was something to behold, and is already a discussion between them this year.

And if you do happen upon our home, we haven't given out candy since 2006 and we haven't been egged either. You can buy Halloween coloured play-doh packs at Costco, Halloween glow sticks, stickers or temporary tattoos at the dollar store (glow sticks seem to be the biggest hit in our neighbourhood), or if your community is enlightened, you might even be able to pick up free swim or skate passes for your local arena or YMCA.

[Here's me chatting about the subject with CBC Toronto's Matt Galloway]

Saturday, October 26, 2019

Saturday Stories: Meat, Diets, and German Antisemitism

James Hamblin, in The Atlantic, with his typically insightful thoughts, this time about whether meat is good or bad for you.

Kim Tingley, in the New York Times Magazine, asks why isn't there one best diet for everyone?

Andrew Mark Bennett, in Tablet, on modern day German antisemitism and what German Jews are doing about it..

[And if you don't follow me on Twitter or Facebook, had a chat with the ladies from The Social yesterday about vaccinations]

Thursday, October 24, 2019

Elementary Teachers Union (@ETFOeducators) Misleads Its 83,000 Members When Explaining Cutting Benefits' Actual Dietitian Coverage In Place Of Dial-A-Dietitian

Thanks to a person who wishes to remain nameless, I was recently alerted to the fact that the Elementary Teachers Federation of Ontario, a union representing 83,000 elementary teachers and education workers, have removed coverage for Registered Dietitians (RDs) from their benefits plan.

By way of background, here in Ontario, RDs are one of a limited number of regulated health professionals, and of course are the only profession dedicated exclusively to nutrition. Also here in Ontario (and pretty much everywhere), diet and weight related diseases have long since reached epidemic proportions.

As to why ETFO has delisted RDs, the province's only regulated nutrition professionals, according to a document distributed to their members it's because,
"these free services are now available through Ontario Telehealth"
But are they?

Telehealth RDs answer one-off nutrition questions by way of phone calls. They are most assuredly not there to provide individual counselling or comprehensive ongoing care.

Plainly, cutting RDs from ETFO benefits is shortsighted, and suggesting that actual RD services are the equivalent of a Dial-A-Dietitian service designed to answer simple questions is an outright lie.

If you're an ETFO member I'd encourage you to share this post, and to contact the ETFO ELHT Board of Trustees to ask that RD coverage be reinstated.

Monday, October 21, 2019

The Journal of Nutrition Describes Gut Bacteria Prevotella Abundance As "The Key To Successful Weight Loss" Following Short Study Where Subjects With No Prevotella Lost Comparable Amount Of Weight

Hype around preliminary findings, animal studies, cell culture studies, underwhelming studies, and more is the clickbait that sells papers and likes. Some of the time hype comes from journalists, sometimes from press-releases, and sometimes from the authors themselves. Today's blog post sees the hype coming from an invited oped published by the American Society of Nutrition's flagship The Journal of Nutrition.

The oped, entitled, The Key to Successful Weight Loss on a High-Fiber Diet May Be in Gut Microbiome Prevotella Abundance, was written in reference to the results of the study entitled, Prevotella Abundance Predicts Weight Loss Success in Healthy, Overweight Adults Consuming a Whole-Grain Diet Ad Libitum: A Post Hoc Analysis of a 6-Wk Randomized Controlled Trial.

The op-ed described the "key" to successful weight loss on a high-fiber diet as gut microbiomes containing an abundance of the bacterium Prevotella, and was written to amplify the - hold onto your hats now - findings from a very small, very short study that was not originally designed to test the relationship between Prevotella abundance and weight, that found a whole 3.5lb greater weight loss among the 15 study subjects with the highest Prevotella abundance vs. the lowest (but still present amount) when consuming a whole grain (WG) diet.

But wait, there's more!

Though it's confusing because of the way they reported weight loss, the same study found that particpants with microbiomes containing no Prevotella also lost weight on a WG diet. In fact, looking at the study's diagram detailing the losses between groups it sure appears as if subjects whose microbiomes contained no Prevotella (0-P) lost statistically comparable amounts of weight as those whose microbiomes contained the most Prevotella (High-P).


So to summarize, people with microbiomes containing what The Journal of Nutrition called, "the key to weight loss on a high-fibre diet" lost pretty much the same amount of weight as people with none of it on a high-fibre diet. Oh, and that key that worked as well as not having a key at all? If we make the enormous leap that it was causal, it led to a 3.48lb weight loss. Whoop whoop?

Bottom line I guess is that if you're going to describe something at the "key" to successful weight loss on a whole grain diet in the title of an op-ed in a prominent journal, and where we're talking about a 4lb weight loss, but having none of that key leads you to lose pretty much the same amount of weight, not only is that not much of a key, but it's incredibly irresponsible as it blatantly contributes to the ongoing erosion of societal scientific literacy and promotes the harmful and erroneous belief that magic exists when it comes to weight loss.

[Also, unless I'm misreading the very small amount of actual data provided, it would seem that the authors of the study also reported the difference between high Prevotella and low Prevotella groups wrong whereby the high group was found to have lost 4lbs (-1.8kg), and the low 0.5lbs (-0.22kg), but rather than report a -1.58kg (3.48lb) difference between the two, they added their losses and reported a -2.02kg (4.45lb) difference.]