Tuesday, August 31, 2010

If Your Kids Hated Apples, Would you Feed Them Apple Pie?

What a great line! Credit goes to Ann Cooper of Chef Ann, and it was included in the New York Times' recent piece on the controversy surrounding schools and chocolate milk.

You know where I stand.

Chocolate milk's a liquid chocolate bar and should be consumed as a treat, not as a staple.

The "milk's got magical nutrients that make the calories and added sugars not scary" camp thinks that calcium and vitamin D are so important and kids are in such dire bone straits that they need to be coerced by sugar into drinking a beverage that we adults used to drink without a fight (probably because chocolate milk wasn't an option).

What boggles my mind is that despite the terrifying growth of childhood obesity and the absence of any robust, credible, tangible, evidence based long term negative consequence to kids not drinking huge amounts of milk (let alone chocolate milk), it seems that my camp's the minority.

I read an article last week about pushing milk hard in the Hamilton Spectator. It was written by registered dietitian Vicki Edwards who works for Hamilton's Public Health Services.

Here's Vicki's case for chocolate milk,
"Milk is a healthy beverage choice and is especially important for your calcium and vitamin D on a daily basis.

But surveys show that both teens and adults are not consuming the recommended number of Canada Food Guide servings of milk and alternatives for good health.

Adding chocolate or other flavourings to milk can enhance the taste and encourage more milk consumption.

Chocolate milk contains about the same amount of sugar as unsweetened juice.

And almost half of that is the naturally occurring sugar, lactose, which is also found in white milk.

And chocolate milk is a more nutritious replacement for other sweetened beverages such as pop, fruit beverages and sports drinks.
So Vicki, I'm assuming you know this, but in case not, the reason juice isn't sweetened with added sugar is because natural juice naturally contains a tremendous amount of sugar- 5 teaspoons a glass - which is one of the reasons why the American Academy of Pediatrics and the Canadian Pediatric Society recommend that kids 6 and under have a maximum 125mL of the stuff and that everyone else cap themselves at 250mL. Consequently, your statement comparing chocolate milk to juice does two public disservices. Firstly it encourages the consumption of more chocolate milk and secondly it suggests juice is a healthy beverage with no consumption limits.

In terms of the the nutrition of chocolate milk - you cannot look at foods and evaluate them on the basis of specific nutrients while ignoring others. Were Coca Cola to create a beverage with the same amount of protein, calcium and vitamin D as chocolate milk, I'm fairly certain you wouldn't be encouraging its consumption. Of course that'd be a shame because were there such a beverage it'd likely be a healthier choice than chocolate milk given that chocolate milk contains 80% more calories drop per drop than Coca Cola, and in case you hadn't heard, childhood obesity's a bit of a problem here in Canada.

So please Vicki, while I know I'm giving you a hard time here, the circulation of the Hamilton Spectator is 105,160, and I think you owe it to them to ensure that the recommendations you make are in fact nutritionally sound, and while we're certainly entitled to disagree, I'd love to see the evidence base that would support the ad libitum consumption by children of a beverage that has 80% more calories drop per drop than Coca Cola simply as a means to provide them calcium and vitamin D.

Monday, August 30, 2010

Nutrition policy in Britain hits bottom and digs.

Good lord.

First they abolished their national school lunch program.

Next they killed their front of package labeling plan.

Then they turned over control of their anti-obesity public health campaign to the food industry. Then they promised them they wouldn't regulate them.

After that they stripped their Food Standards Agency of their labeling oversight.

Then the British parliamentary under-secretary of state for health recommended that GPs start calling their obese patients, "fat".


Now they've recommended that basically anything that has a fruit or vegetable in it be counted towards the goal of their "5-A-Day" campaign for fruits and vegetables.

Stuff that'll be included now?

Godawful processed cereal bars, salty tomato sauces, sugar syrupy fruit salads and lots and lots of potatoes.

My prediction?

A decade or two from now Britain will overtake the United States for the title of the world's most obese nation, because while the States is far from perfect, public policy when it comes to nutrition and obesity, albeit slowly, is improving, while in Britain it seems it's free falling down the nutritional poop chute.

[Hat tip to Twitter's @evidencematters]

Saturday, August 28, 2010

Saturday Stories

An evidence based discussion on whether or not high fructose corn syrup is inherently evil.

How much do I love Skeptic North's new feature - Health Canada Approved? A lot!

My friend Arya on a new study that wonders whether or not diabetes and pre-diabetes in pregnancy has a role to play in a heightened susceptibility to obesity in children?

David Katz takes on that ridiculous editorial that called for the dispensation of cholesterol lowering medications with your fast food meals.

A nut allergy skeptic learns about nut allergies the very hard way.

Friday, August 27, 2010

Never argue with an ibex!

I think it's probably fair advice to never argue with anything or anyone that doesn't speak the language you're arguing in, but as is evidenced by this week's Funny Friday video, really, don't argue with an ibex.

(Not sure if you'll feel the same way but I spent much of the time I wasn't laughing watching the video wishing the ibex would gore the annoying human with his horns)

Thursday, August 26, 2010

Health Check's rotten tomato

Further to yesterday's post on the Heart and Stroke Foundation announcement that they finally figured out that chocolate milk and french fries aren't healthy choices comes an across the Health Check board reduction in their program's allowable levels of sodium.

Truly, the reductions are significant with some criteria and product categories now actually representing sodium levels that would in fact be considered low.

But not tomato juice.

According to these newer, more stringent criteria, tomato juice (and all vegetable juices and all soups), are still allowed to contain 480mg of sodium per serving.

480mg is in fact still quite a lot. One glass of Heart and Stroke Foundation endorsed tomato juice will now provide you with 32% of their own recommended daily maximum of 1,500mg and as any dietitian (and the Heart and Stroke Foundation themselves) will tell you, you should try to aim for foods that contain no more than 10% of your total daily recommended maximums.

Now one might argue that you can't expect people to tolerate a rapid reduction in sodium and so it's being reduced in a stepwise fashion with this reduction representing a 26% decrease in sodium from the prior Health Check allowance of 650mg. Only problem with that argument is that there are many categories in this most recent revision, where Health Check has reduced their sodium allowances by 50% and some where they've reduced it by 70%.

So what is so magical about tomato juice?

Looking at Medline records since 1950 there have been a grand total of 216 articles that included "tomato juice" as a keyword.

Looking at all of their abstracts, there were 3 that were worth noting:

The first, out of Finland, detailed a very small, very short study that looked at a 3 week low tomato product diet vs. a 3 week high tomato product diet on the LDL concentrations of 21 healthy individuals. The high tomato folks were given 400mL of tomato juice and 2 tablespoons of ketchup daily so results certainly can't be isolated to the juice. This short, small study found a decrease in LDL concentration in the high tomato diet of 12%.

The second, out of Connecticut, was a rat study whereby rats were force fed tomato juice for 3 weeks and then had their hearts extracted from their bodies and subjected to 30 minutes of no blood flow followed by 2 hours of restoration of blood flow. Those rats who had been force fed tomato juice's hearts had smaller areas of infarction than those who hadn't.

The third, out of Harvard, examined the intake of lycopenes and tomato based foods, including juice, and the risk of cardiovascular disease in 39,876 middle aged women over a 7.2 year period. Of all of the tomato based products examined, only tomato sauce and pizza were seen to have potential cardiovascular disease lowering effects.

Those sure don't sound like good reasons to continue to explicitly encourage Canadians to consume 32% of their total recommended daily sodium intake from one glass of the stuff.

Similarly there's soups where again, Health Check allows for 480mg per serving where a serving is in fact a single cup (despite the fact that in the real world people drink bowls (2 cups)).

So what's so special about soups and vegetable juices that they are allowed to contain 25% more sodium than each and every one of the 58 other single product categories in the Health Check universe?

The cynic in me says that what's so special about them is that among the denizens of the Health Check brand there is perhaps no company that has more products with Health Checks than the Campbell Soup Company who also happen to own V8. Therefore unlike some of Health Check's other corporate partners, a major change to soup and vegetable juice criteria would be decidedly bad for business and corporate relations for Health Check.

What do the folks from Health Check have to say about it?

Well once upon a time Terry Dean, the General Manager of Health Check was paraphrased by the Toronto Star as stating that,
"while some Health Check products may have a sugar or sodium content that is higher than optimal, the product must have redeeming nutritional value, such as calcium or fibre"
He himself stated further,
"In every case, there are two or three nutrients it has to have"
Ahhhhh, magic nutrients.

So Terry please tell me, what redeeming, magic, "two or three nutrients", does tomato juice and soup have that make them worthy of 32% of your total daily sodium allotment and a criteria limit 25% higher than virtually everything else you Check?

[Thanks to Twitter's @girldownthelane for the new and improved headline]

Wednesday, August 25, 2010

Health Check finally figures out chocolate milk and french fries aren't healthy!

What amused me the most about the Heart and Stroke Foundation's latest press release that announced that chocolate milk (and other sweetened milks) and french fries would no longer be awarded Health Checks was this line,
"Supporting the leadership role the Heart and Stroke Foundation is taking to combat obesity"
You mean by publishing reports about childhood obesity and not mentioning calories even once?

Or by having nutritional criteria for Health Check that don't include calorie limits?

Or maybe it's by giving out coupons for kids' meals at Boston Pizza where the meals can easily contain a full days worth of calories?

Or maybe it's by providing a Health Check to Slush Puppies?

Or maybe it's by giving out their seal of approval to foods based on serving sizes that are likely half of what people tend to eat?

Or maybe it's by giving that same seal to fruit-concentrate sweetened candy with more calories than actual candy and in so doing misinforming parents into thinking they're giving their kids fruit?


Leaders don't need to wait for the American Heart Association to come out and say added sugars are bad before they stop endorsing chocolate milk. Leaders don't need to pussy foot around issues of calories and children. Leaders don't need to hold hands with Canada's industry influenced Food Guide. Leaders don't maintain programs that are built on shaky foundations.

Leaders admit when they're wrong and don't try to sugar coat their mistakes. Leaders make tough calls, tough choices and do what's right regardless of what's come before. Leaders actually make substantive changes all on their own.

So while I'm thrilled that the Heart and Stroke Foundation, after over a decade of explicitly endorsing the consumption of chocolate milk and french fries as healthy choices, has finally (thank to the American Heart Association) figured out that they're not, I can only continue to hope that one day they'll actually demonstrate true leadership and make the sweeping changes that would be required to actually make the Health Check program nutritionally sound, relevant and helpful.

Tuesday, August 24, 2010

KFC, Pizza Hut, Taco Bell, and A&W treat you to free "exercise".

Aren't they sweet.

It's part of their, "Keep it Balanced" campaign which is meant to perpetuate the myth that exercise can out-train a bad diet.

Here's what Yum! brands wants you to know about how easy it is to maintain a healthy weight and still enjoy your KFC,
"Keep It Balanced means making informed choices and combining a sensible, balanced diet with appropriate exercise in order to maintain a healthy lifestyle. The food and beverages you consume put energy into your body and physical activity helps burn these calories. It's a simple formula: Energy In = Energy Out."
Yeah dummy, it's simple.

For instance, let's say you decide to have a 3 piece KFC dinner along with a medium fries and a Pepsi. That'd be 1,670 calories in.

Want 1,670 calories out?

Well perhaps that's unfair, you need some calories to live, let's say of that 1,670 calorie meal, 1,000 of 'em are more than you need and you'd like to simply burn through physical activity.

Here's a menu of options that'll do that for you:

- 1 hour of running at 6.7 miles and hour
- 2 hours of low impact aerobics
- 3.5 hours of weight lifting
- 7 hours of sex

And to help they're offering a free 1 month fitness membership. Not in an actual gym mind you, on an online fitness tracking website called eFitForMe.

Nothing screams fitness like a website membership.

Keep it balanced people!

Oh, and don't forget - also buy low and sell high in the stock market. That way not only are you going to be super skinny, you'll be super rich!

Easy, peasy.

Monday, August 23, 2010

Walking and cycling to work prevents obesity?


I'll admit up front that I can't access the full text of the article Walking and Cycling to Health: A Comparative Analysis of City, State, and International Data, so I can't comment on methodology.

The study was large in that it looked at 14 countries, all 50 US states and 50 of the largest US cities for a relationship between active transportation (walking and cycling to work) and obesity.

The abstract (and the media) strongly suggest that walking and cycling to work helps to prevent obesity.

Now there's no doubt that a daily human powered commute, unless you happen to live next door to work, would in fact burn a significant number of annual calories and consequently could easily play a role in weight.

There's also no doubt in my mind that at least here in North America, it's a rather unique person who walks or cycles to work.

Anectdotally I can think of 4 people off the top of my head who without fail cycle to work, rain, shine, sleet, snow or hail.

They're all health nuts.

Whether or not all daily human powered commuters are health nuts isn't something I can claim, but I'd be willing to wager that the lifestyle habits of human powered North American commuters are dramatically different than the folks who rely on internal combustion engines (Europeans may be different as their built environments may make walking or cycling a more commonplace choice).

At the very least, controlling for the dietary choices of the self-propelled would be extremely important in the correlation/causation discussion, and while I can't with any certainty claim that the authors didn't control for diet, if they did, it'd have been a herculean feat given how many different geographic locations they studied.

But let's say that's not the case.

Let's say that in fact diet's not a player in these findings.

Now let's look at Great Britain.

According to the Journal of Physical Activity and Health, nearly 40% of folks in Great Britain walk or cycle to work as you can see in that graph up above. According to that same graph, obesity rates in Great Britain are up at roughly the 22% mark.

Australia and Canada, both with rates of obesity nearly identical to Great Britain's, show active transport rates 1/4 and 1/2 of Great Britain's respectively. Shouldn't Canadians and Australians be markedly heavier (or Brits markedly lighter)?

Ok, so a couple of outliers don't disprove everything do they?

Fine. Well how about time?

Wouldn't rate of change over time matter more than absolute rates when it comes to a discussion of obesity rates and the impact of an intervention that presumably had been there as part of the culture, prior to the most recent sets of measurements? What I'm getting at is that if active transportation is indeed an effective vaccine against an increasingly obesogenic environment, then perhaps we might expect to see not only lower rates of obesity, but also slower rises in those rates in countries where there is more active transportation.

Looking at Great Britain again, according to the BBC, obesity rates have nearly quadrupled over the course of the past 25 years whereas in the US, according to the CDC, over the past 25 years obesity rates haven't quite doubled. How is it that despite all this active transportation Great Britain's obesity rates are rising nearly twice as fast?

Correlation doesn't prove causation which is precisely why I'm not getting excited about this study and also why I'm not trying to claim that active transportation actually raises the rate at which countries gain weight.

My take on all of this?

Comparing between countries isn't likely to be helpful as countries have widely divergent food and eating environments which if not controlled for, would make interpretation of results very challenging.

Comparing within countries (cities and states) isn't likely to be helpful as folks who cycle to work likely live far healthier lifestyles than those who don't and would consequently have a multitude of factors that would contribute to their being slimmer than their driving neighbours.

But maybe I'm making a fool of myself with this post in that the authors did explore all of these issues and really, walking and cycling to work are crucial. Don't think I'll lose sleep tonight worrying about that.

Bottom line for me. Walking or cycling to work is an exceedingly healthful thing to do, and would in fact likely help you to manage your weight, but increasing bike lanes and walking paths aren't likely interventions that're going to impact a whole population, they're ones that might impact a small, already health conscious subset.

Pucher, J., Buehler, R., Bassett, D., & Dannenberg, A. (2010). Walking and Cycling to Health: A Comparative Analysis of City, State, and International Data American Journal of Public Health DOI: 10.2105/AJPH.2009.189324

Friday, August 20, 2010

Ode to Joy - Muppet style

Today's Funny Friday video has one of my favourite muppets performing one of my favourite classical pieces.

Have a great weekend!

(email subscribers who want to watch, head over to the blog)

Thursday, August 19, 2010

Every nutrition professional must read this!

I've long argued that we live in the nutritional dark ages where belief seems to trump science and evidence in the creation of nutritional public health policy and recommendations.

Moreover even in cases where science is purported to be a cornerstone (for instance Canada's Food Guide), I believe the wrong science is given too much sway.

Putting aside my concerns regarding the hijacking of Canada's Food Guide by the food industry and political interests, the Guide was built explicitly to ensure Canadians met their recommended dietary allowances of various nutrients and micronutrients and as I've noted before, the bulk of the science on the interaction of diet on chronic disease prevention centres on the consumption of different patterns of foods, not nutrients.

In an editorial that clearly nails my confirmation biases square on their heads, Drs. Dariush Mozaffarian and David Ludwig take on this madness, and they do such an amazing job discussing the issue that I'm going to reprint a pile of it for those without institutional journal access to read,
"Nutritional science has advanced rapidly, and the evidence now demonstrates the major limitations of nutrient based metrics for prevention of chronic disease. The proportion of total energy from fat appears largely unrelated to risk of cardiovascular disease, cancer, diabetes, or obesity. Saturated fat—targeted by nearly all nutrition-related professional organizations and governmental agencies—has little relation to heart disease within most prevailing dietary patterns. Typical recommendations to consume at least half of total energy as carbohydrate, a nutrient for which humans have no absolute requirement, conflate foods with widely divergent physiologic effects (eg, brown rice, white bread, apples). Foods are grouped based on protein content (chicken, fish, beans, nuts) despite demonstrably different health effects. With few exceptions (eg, omega-3 fats, trans fat, salt), individual compounds in isolation have small effects on chronic diseases. Thus, little of the information found on food labels’ “nutrition facts” panels provides useful guidance for selecting healthier foods to prevent chronic disease.

In contrast with discrete nutrients, specific foods and dietary patterns substantially affect chronic disease risk, as shown by controlled trials of risk factors and prospective cohorts of disease end points. Fruits, vegetables, whole grains, and nuts are consistently associated with lower risk of disease. Fish consumption reduces risk of cardiac mortality, belying categorization with other protein sources. Conversely, processed meats, packaged and fast foods, and sugar sweetened beverages increase chronic disease risk. The effects of foods likely reflect complex, synergistic contributions from and interactions among food structure, preparation methods, fatty acid profile, carbohydrate quality (eg, glycemic index, fiber content), protein type, micronutrients, and phytochemicals. Healthy eating patterns share many characteristics, emphasizing whole or minimally processed foods and vegetable oils, with few highly processed foods or sugary beverages. Such diets are also naturally lower in salt, trans fat, saturated fat, refined carbohydrates, and added sugars; are higher in unsaturated fats, fiber, antioxidants, minerals, and phytochemicals; and are more satiating. Thus, a focus on foods increases the likelihood of consuming more healthy nutrients and fewer calories and decreasing chronic disease risk, whereas the opposite has arguably occurred through decades of nutrient-focused guidelines.

The nutrient-based approach may foster dietary practices that defy common sense. Countless highly processed products are now marketed in which refined carbohydrate replaces fat, providing an aura of healthiness but without actual health benefits. School nutrition guidelines specify a minimum number of total calories but a maximum proportion of fat calories, and foods like gelatin desserts and sugar-sweetened low-fat milk have been used to achieve these nutrient targets. Based primarily on consideration of a few nutrients, a national obesity prevention program categorizes whole-milk yogurt and cheese with donuts and french fries as foods to eat occasionally; sauteed vegetables and tuna canned in vegetable oil with processed cheese spread and pretzels as foods to eat sometimes; and fresh fruits and vegetables with trimmed beef and fat-free mayonnaise as foods to eat almost anytime. Taking the nutrient approach to self serving extremes, the food industry “fortifies” highly processed foods, like refined cereals and sugar-sweetened beverages, with selected micronutrients and recharacterizes them as nutritious. These marketing ploys provide little public health benefit and could potentially produce harm.

The prevailing nutrient-focused approach has broad consequences, influencing food-labeling priorities, school lunch and low-income food assistance policies, industry and restaurant product formulations, and public perceptions of healthier vs unhealthy foods. This focus contributes to confusion, distracts from more effective strategies, and promotes marketing and consumption of processed products that nominally meet selected nutrient cut points but undermine overall dietary quality. The relatively recent focus on nutrients parallels an increasing discrepancy between theory and practice: the greater the focus on nutrients, the less healthful foods have become. As national and international organizations update dietary guidelines, nutrient targets should largely be replaced by food-based targets. Such change would facilitate translation to the public, correspond with scientific advances in chronic disease prevention, mitigate industry manipulation, and remedy widespread misperceptions about what constitutes healthful diets.

Although this approach may seem radical, it actually represents a return to more traditional, time-tested ways of eating. Healthier food-based dietary patterns have existed for generations among some populations. Modern nutritional science now provides substantial evidence for how foods and food-based patterns affect health, guiding the design of more effective approaches for the prevention of chronic disease."

Wednesday, August 18, 2010

Alberta's Ministry of Health recommends post meal cheese to prevent cavities?!

Christine, a blog reader and bariatric nurse from Alberta, sent me an email last week tipping me off to Alberta's The Amazing Little Cookbook.

The book, published by the "Healthy U" arm of Alberta's Ministry of Health, is a cookbook meant for children that aims to teach them how to cook healthy meals.

So what's my proverbial beef?

Simple. The recipes represent lowest common denominator nutrition. Nary a whole grain to be found. White bread, white flour, added salt, processed cheese, instant oatmeal, processed meats, bouillon cubes, tortilla chips, white pastas, oodles of juices, oodles of store bought sauces, gobs of ice cream and squeezes of fudge sauce.

And it wasn't just the recipes that got to me.

Smattered throughout the book are tidbits of "helpful" information.

Here are a few that caught my eye,
"Try not to portray food as "good" or "bad." Encourage a healthy attitude towards food — all foods in moderation can be part of a healthy diet."

"Chocolate milk is just as nutritious as white. It has no more sugar than unsweetened orange juice - and kids think it’s a treat. Only you need to know its good for them too!"

"A cheesy smile is a good smile! Eating a piece of cheese after a meal or snack may actually prevent cavities because it helps protect against tooth decay."
Yes, Alberta's Ministry of Health in a cookbook specifically commissioned to help teach healthy eating to children teaches kids that there's no such thing as a bad food, that chocolate milk's a great choice and that eating cheese after a meal prevents cavities.

Hmm, those messages sure sound like Big Dairy messages.

And hey, when you look closer you find that of the 59 recipes, 49 include dairy products.

So colour me not surprised when I reached the end of the book to find the "Special Thanks" given to the Dairy Council of Alberta on the last page.

What an incredible waste of an opportunity to teach kids the joys of healthy cooking with whole fresh ingredients and provide some useful nutritional guidance. Instead Alberta's Ministry of Health has allowed their province's Dairy Council to put out a cookbook where the recipes basically scream out nutritional surrender; where they encourage child readers to grow themselves out of junk food; where they explicitly tell kids there's no such thing as junk food; where milk, even chocolate milk is magic; and where rather than make the crazy recommendation that kids brush their teeth after meals to prevent calories, advises them to eat cheese.

Brilliant work Alberta.

Tuesday, August 17, 2010

Dietitians - a question for you.

The question's simple and I don't think there's necessarily a "right" answer though I'm sure you'll be able to guess where I lean.

But before I get to my question, I need to give you some background.

This Sunday's local paper brought with it a magazine called, Ottawa Family Life. In the magazine was an article written by a local dietitian. The article was about calcium.

The author (and this time I'm going to leave the RD's name out as unlike other times this one isn't shilling for the food industry), who clearly subscribes to the there's a calcium emergency out there and milk's a magic, miracle food camps, gives a whole long list of things parents should do to ensure their kids get enough dairy.

Among the suggestions:

  • Make milk the main beverage at meals.

  • Make hot cocoa with milk instead of water.

  • Make cream soups with milk instead of water.

  • Have chocolate milk as a snack.

  • Choose milk or chocolate milk as the post-game sport drink of choice.

  • Drink milk yourself to show your child how important it is.

  • They also recommend that if your child is lactose intolerant that you look for vitamin D and calcium fortified juices to serve them.

    Now I'm not going to get into the fallacy of a societal calcium emergency or magic milk claims (though for readers who are curious where my thoughts lie - weight bearing exercise and adequate vitamin D intake are likely more important for bone health than calcium), I'm going to focus on calories. They're never mentioned.

    So here's a registered dietitian telling parents to serve their children chocolate milk as snacks, actually suggesting that kids need a post-game sports drink (they certainly don't) and that it ought to be chocolate milk, that kids who are lactose intolerant get calcium and vitamin D from fortified juices (despite calls to limit juice consumption in children to 1/2 - 1 cup daily) and that basically any dish that can be spiked with milk should be.

    Chocolate milk twice a day, even just a glass twice a day, would provide your child with the caloric equivalent of nearly a litre of Coca Cola a day along with 12 teaspoons of sugar.

    Making this all the more astounding to me is the fact that when I Googled this dietitian I found out that they work (or at least worked) at the Ottawa Civic's Weight Management Clinic and therefore is certainly no stranger to the risks of not paying attention to calories.

    So here's my question for all my dietitian readers (and anyone else who might want to weigh in).

    Given the problem of adult and childhood obesity, should that be an overarching consideration when writing articles or giving talks and interviews that provide dietary advice to society, especially those involving recommendations for children?

    (Another way to think about it? If 65-70% of the adult population routinely developed scurvy over the course of their lives, do you think there'd ever be an article written on dietary advice for children that didn't include a discussion on the importance of citrus fruit?)

    Monday, August 16, 2010

    Healthy Dads, Healthy Kids, and Unhealthy Peer Review.

    Last week Colby Vorland tweeted a link to a new study that looked at the impact of a lifestyle modification program geared at overweight fathers and their children.

    The study set out to randomly investigate something called the Healthy Dads, Healthy Kids Program - a 3 month program that delivers 10 hours of behavioural change counseling to overweight dads and their kids (where the kids showed up for 4 of those). The study looked at dads' and kids' weights at the end of the program and 3 months later, and for a control group they used dads and kids on the program's waiting list.

    The 6 month outcomes were quite predictable.

    Healthy dads lost significantly more weight (15lbs vs zip), and had statistically significant improvements in their waist circumferences, blood pressures and physical activity compared to controls. Importantly, they did not report any difference in their dietary intakes.

    Healthy kids showed an increase in physical activity and their mothers reported a dramatic decrease in the kids' caloric intake, reporting them eating on average 20 calories less per kilogram. Given the reported average weight of the children was 33kg, that'd be a decrease of 660 calories per kid per day - yet there was no change in weight in the children.

    So is this a slam dunk? Should we be rolling out this program across the globe?

    Not yet.

    You see there's an enormous flaw in the study, and it's a flaw that the folks who designed the study absolutely knew beforehand. Simply put, if you graph weight loss over time for virtually any weight management program, the losing phase lasts roughly 6 months which is then almost invariably followed by the regaining phase.

    Put another way, it's not particularly exciting to see a program effectively leading to weight loss at 6 months given that pretty much any intervention can do so. In fact I'd go so far as to say that publishing 6 month results of a weight loss program is a knowingly misleading thing to do and something that should be considered heavily by peer reviewers when evaluating such papers.

    Furthermore the study illustrates the difficulty of food frequency questionnaires in accurately tracking intake because here we've got a pile of kids who are apparently not governed by the laws of thermodynamics in that they're supposedly exercising significantly more and purportedly eating dramatically less and yet they aren't losing any weight.

    Dads wise - the study's fairly predictable too. Having treated over one thousand men in my program I can tell you, without frequent and explicit guidance to the contrary, men tend to hit the gym hard and fast and ignore food. While that may work in the short run, I've never seen it work in the long run in the absence of dietary change.

    So before you enroll in one of these programs I'd suggest you wait for the 18 month data.

    Of course the cynic in me says that data's never going to get published, not because of the International Journal of Obesity's negative publication bias, but rather because it's not data the researchers will likely want to brag about.

    Morgan, P., Lubans, D., Callister, R., Okely, A., Burrows, T., Fletcher, R., & Collins, C. (2010). The ‘Healthy Dads, Healthy Kids’ randomized controlled trial: efficacy of a healthy lifestyle program for overweight fathers and their children International Journal of Obesity DOI: 10.1038/ijo.2010.151

    Saturday, August 14, 2010

    Saturday Stories

    Ridiculously dedicated University professor allows himself to be sunk in a car in a lake dozens of time to determine the best way to escape a submerged car.

    Doctors in NYC are giving away coupons for fruits and vegetables to help fight childhood obesity.

    My friend and colleague Dr. David Haslam on who ought to be considered for bariatric surgery.

    The craziest hiking video I've ever seen (below)

    Friday, August 13, 2010

    Schadenfreude pranks

    Continuing on the theme of honesty (see yesterday's blog post), I've got to be honest with you, while I know what the folks in this clip do is awful, and while I'm sure were I a victim I'd be livid, I can't help but find this Funny Friday clip incredibly funny.

    Have a great weekend!

    [Hat tip to my friend and sensei Claudio who is getting ready to open a dojo in Ottawa - stay tuned for more details]

    Thursday, August 12, 2010

    On Confirmation Biases, Twitter and Blogs

    Confirmation bias is something I mention here from time to time.

    While simple in principle, in practice it's really quite important, especially for people who read blogs, or use Twitter or Facebook.

    Confirmation bias dictates that most people prefer information that supports their own beliefs. In turn this tends to lead people to accept things as true with lesser amounts of evidence if they agree with their preformed beliefs, and dismiss things, sometimes irrespective of the evidence, if those things don't agree with them. Like the cartoon above, it can also lead people to hear what they want to hear, rather than what's actually being said.

    My bet would be that as a consequence of confirmation bias we tend to only follow and read folks who more often than not espouse opinions with which we agree which in turn may serve only to further solidify our own confirmation biases.

    Of course there are a lot of folks who'll staunchly state that they don't have a confirmation bias, that they're evidence-based thinkers.

    I can't help but doubt them.

    Confirmation bias is something that's tough to shake, and while I like to think of myself as evidence-based, I'm sure that over the years confirmation bias has swayed me one way or the other on many occasions, both in my interpretation of research and my writings therein.

    To help readers of this blog navigate my postings, and while I believe the current state of the evidence supports the following statements, I'd like to lay bare my biases. So here are the most salient (and obvious) of the lot as they pertain to my regular postings:

    - Food, not fitness, is the primary societal driver of obesity.
    - The food industry only cares about your health when it affects their bottom lines.
    - Obesity's primary cause is environmental change, not individual lack of willpower.
    - Calories are the currency of weight, not fat, carbs or proteins.
    - Whole grains are healthier than refined.
    - The risks of red meat consumption greatly outweigh the benefits but ultimately are small when considered absolutely.
    - Dairy is not a magic food worthy of its own "group"
    - The Canadian Government panders more to industry concerns than public health concerns when it comes to nutrition

    There are probably more, but those are the ones that leap to mind.

    So happy reading and while I promise to try to not let my confirmation biases get the best of me (or you) and will do my best to accurately and fairly interpret studies and report, the likelihood is they'll probably still be there sometimes lurking in the shadows.

    Wednesday, August 11, 2010

    MS's controversial "liberation procedure" provides a lesson in obesity bias.

    I opened up the paper yesterday morning to see dueling columns discussing the controversial and currently highly experimental liberation procedure for multiple sclerosis.

    The columns came one day after a front page City section story detailing one individual's anecdotally positive experiences having paid for the procedure himself overseas.

    The first column, penned by Paula Simons, calls on provincial health plans to only fund proven therapies.

    The second, penned by a gentleman named Bart Bakker who himself suffers with MS, calls on the provinces to follow Saskatchewan's lead in that according to Premiere Brad Wall, they plan on funding trials of the procedure.

    The trials are likely to be exceedingly expensive and while as an evidence based clinician I welcome them, given the research that's already been published on the procedure, I wonder whether that'll be money well spent or whether Saskatchewan will be just funding hope. I also wonder whether there are proven treatments for other conditions that Saskatchewan's doing a poor job of funding where that money might be better spent.

    The reason Saskatchewan's premiere Brad Wall gave for the funding?
    "I think it's incumbent on us to explore what hope exists around this and to answer as many questions as we can"
    So what does this have to do with obesity?

    Well far from an experimental procedure, obesity has a proven surgical treatment. Studies have demonstrated that gastric bypass surgery increases longevity and decreases morbidity, curing many chronic conditions in the process, while markedly improving quality of life.

    Saskatchewan's gastric bypass surgery program?

    There's a single bariatric assessment centre in Saskatchewan and it's located in Regina. That's a single centre for a province that's 588,276 square kilometres (277,100 square miles), an area slightly larger than the great State of Texas. That's one single, solitary assessment centre for a population of just over a million people, roughly 30,000 of whom would meet the surgical criteria for bariatric surgery.

    Oh, and for icing on the proverbial cake, Saskatchewan boasts Canada's second highest provincial rate of obesity.

    I called Saskatchewan's lone bariatric surgical centre yesterday. I was told that if I sent in a referral that, "it would be at least 2 years" before my patient would get seen and then they'd need to complete a 6 month pre-surgical program which would involve a minimum of 6 visits. I was also told that the province won't pay for any travel expenses incurred for non Regina residents trying to get surgery and that once the pre-surgical program was completed there'd be an additional wait of many months before the surgery because currently they're only performing one a week.

    Putting that math to play, at one surgery a week, if even 10% of Saskatchewan's surgically eligible folks wanted to consider surgery it would take the province roughly 58 years to meet the demand. Good news though, the very kind person I spoke with on the phone mentioned they're hoping to soon be able to do 2 a week so that'll bring the wait down to 29 years.

    So to recap. On the one hand, a procedure that's experimental at best has the Premiere of Saskatchewan crowing about hope and wanting to spend money funding its research. On the other hand his province has a woefully underfunded bariatric surgery program for a proven procedure that not only increases both quality and quantity of life but also simultaneously decreases health care costs and in the long run would save the province money.

    So has Brad Wall ever said anything about bariatric surgery?

    If he has, I certainly couldn't any find mention of it.

    So why not?

    As far as the world goes, obesity is still a disease of willpower. Premieres and the public simply want to blame individuals for their weight, whereas MS is not something that a person is generally blamed for contracting.

    Though of course in our socialized medical system, even if it were a disease of willpower, given that bariatric surgery has been proven to save health care dollars, Premieres should be busting down doors trying to get the job done.

    So have people really changed over the course of this past 30 years? Is there really an epidemic lack of willpower?

    I guess that's what's causing early puberty in increasingly obese 7 year old girls. These 7 year olds nowadays. No willpower.

    Tuesday, August 10, 2010

    Another reason to avoid Wonder Bread.

    As if you needed another.

    Straightforward study that explored the impact of the great social experiment in which the past 40 years of low-fat recommendations have placed us.

    The study looks at the risk of having a heart attack as a function of macronutrients in 57,053 Danes over a 12 year period and then re-analyzes risk on the basis of the glycemic indices of their carbohydrate choices.

    The researchers used two models to investigate the risk of heart attack with a higher energy intake from carbohydrates and a concomitant lower energy intake from saturated fats (just like what we're still being told to do by national dietary guidelines, health organization and health related NGOs). The first model looked at macronutrients as a percentage of total energy intake. The second model further subdivided the carbohydrates into tertiles of dietary glycemic index. Both models controlled for alcohol intake, smoking status, physical activity and hypertension.

    The results probably won't surprise you.

    Folks who replaced saturated fats with high glycemic index carbohydrates (Wonder Bread for instance), had a statistically significant increase in their risk of heart attack, and while not statistically significant, replacing saturated fats with low glycemic index carbs appeared protective.

    What's surprising to me aren't these results but rather the fact that the blind low-fat message is still being put out there by governments and health organizations who if they don't know better, certainly should.

    What we should be telling folks to do is substitute healthy fats for unhealthy ones and perhaps more importantly, telling folks to substitute low glycemic index carbohydrates for high (or more simply put, whole for refined).

    Jakobsen, M., Dethlefsen, C., Joensen, A., Stegger, J., Tjonneland, A., Schmidt, E., & Overvad, K. (2010). Intake of carbohydrates compared with intake of saturated fatty acids and risk of myocardial infarction: importance of the glycemic index American Journal of Clinical Nutrition, 91 (6), 1764-1768 DOI: 10.3945/ajcn.2009.29099

    Monday, August 09, 2010

    Pregnant? Eating for 2? More like eating for 1.2.

    When I practiced more traditional family medicine and saw my pregnant patients many rationalized rapid and extreme weight gains as a rite of pregnancy and not a worry because after all, they were "eating for two".

    It's probably time to rethink those attitudes.

    Last week a paper was published in the Lancet which looked at a within family comparison of pregnancy weight gain and baby birth weight.

    The study was rather enormous in scope capturing 513,501 women and their 1,164,750 children. The findings were pretty straightforward too - babies of women who gained more than 50lbs during their pregnancies were roughly 1/3lb heavier at birth than those of women who gained between 17-22lbs.

    Moreover, compared to those gaining 17-22 pounds, the bigger gaining mothers were 1.7 times more likely to have a high-birth-weight baby, and those gaining more than 53 pounds were 2.3 times more likely to do so.

    Doesn't sound like much, but there are some other things to keep in mind when considering the results.

    Excessive pregnancy related weight gain is a very real driver of sustained maternal obesity, and bigger babies have been shown to be at greater risk of becoming obese adults.

    Why do bigger babies have a greater likelihood of turning out to be obese adults? The working theory in the paper is that the intra-uterine environments of babies born to women with greater pregnancy weight gains are different and that these differences in turn impact on dietary behaviours over the child's lifetime.

    Of course it's also possible that the dietary habits in homes of women who gain excessive weight during pregnancy differ from those who don't with these differences nurturing (rather than naturing) an impact on dietary behaviours over the child's lifetime.

    Either way one thing's for certain - pregnancy is a wonderful opportunity to explore your diet and remember that the "two" you're eating for, ain't exactly an equal in size.

    Eating for 1.2 sounds about right.

    David S. Ludwig, & Janet Currie (2010). The association between pregnancy weight gain and birthweight: a within-family comparison The Lancet : 10.1016/S0140- 6736(10)60751-9

    Saturday, August 07, 2010

    Saturday Stories

    Commercial Free Childhood's Josh Golin wonders why his 20 month old already knows who Elmo is.

    Before you sneer at the lady pushing the stroller riding a segway you ought to read the whole story.

    It's tough to find an MD who supports home births. Harriet Hall of Science Based Medicine explains why.

    Michele Simon on how Pepsi's buying up health experts to help bolster their image.

    Lastly, here's a video parody of Journey's Don't Stop Believin' by Ottawa Skeptics. It's called Don't Start Believin'.

    Friday, August 06, 2010

    Cross species bullying (size does matter)

    Poor dog.

    Have a great weekend!

    (email subscribers have to head to the blog to watch the video)

    Thursday, August 05, 2010

    Canada's trans-fat failure.

    The release of Canada's National Sodium Working Group's recommendations led me and many reporters to lament the lack of regulatory teeth.

    Of course if we look at what's happened with the recommendations of Health Canada's Trans-Fat Task Force, the one that did have regulatory teeth, it begs the question of whether or not these task forces and working groups are only being put together to make Canadians feel as if someone cares about their health, rather than to actually effect change.

    To recap, the Trans-Fat Task Force was industry inclusive, which meant that industry had veto power. Still, in June 2006 when the food industry inclusive task force released their recommendations, formal regulations were their immediate call to action,
    "Foods purchased by retailers or food service establishments from a manufacturer for direct sale to consumers be regulated on a finished product or output basis, and foods prepared on-site by retailers or food service establishments be regulated on an ingredient or input basis."
    Yup, the group that included Big Food actually called for regulations. They even included a timeline,
    •Draft regulations be published in the Canada Gazette, Part I, by June 2007;

    •Regulations be finalized and published in the Canada Gazette, Part II, by June 2008;

    •A basic phase-in period be set at one year from the date of entry into force of the final regulations
    So what did our feckless government do with these recommendations that had the explicit approval of the food industry? After a year of doing nothing, in June 2007 then Health Minister Tony Clement gave the food industry a two-year free pass, calling for them to voluntarily reduce trans-fats in the food supply,

    Said Clement at the time,
    "Today industry is being given notice they have two years to reduce the levels of trans fats or Health Canada will regulate their use."
    Well it's 411 days after that deadline, and over four years since the task force's final report, and yet we have still not heard a peep from Health Minister Leona Aglukkaq as to when we'll see regulations. This despite the fact that on April 22nd, 2010 she readily admitted voluntary efforts had failed.

    So why the wait?

    According to Sally Brown, the chairperson of the Trans-Fat Task Force,
    "The regulations are written, they're sitting there waiting to be promulgated",
    She went on to state,
    "It's alarming that something so clear, so well-researched, consultations that were a year-and-a-half long involving national and international experts from the health side and the food industry, came up with a clear consensus that this stuff has to be out, and it's still in. It's time."
    So while we may lament the lack of regulatory teeth in the Sodium Working Group's recommendations, perhaps our concern is misplaced. Because even with regulatory recommendations, the likelihood is our government won't do anything anyhow.

    As an aside, I do wonder whether or not there are grounds here for a class action lawsuit. A government task force recommends formal regulations. The government ignores those recommendations opting instead for a voluntary approach and promises a regulatory approach should the food industry's voluntary efforts fail. The government then admits that the voluntary approach has failed yet still does nothing despite the fact that the regulations have already been written and both the public and private sectors are clamouring for their adoption. Meanwhile, the Centre for Science in the Public Health estimates that since the release of the Trans Fat Task Force recommendations and their subsequent dismissal by the government, 12,000 Canadians have died due to the continued inclusion of trans-fat in our food supply.

    Wednesday, August 04, 2010

    Why the food industry's thrilled with Canada's Sodium Working Group

    With the release of Canada's Sodium Working Group's recommendations last week I imagine champagne corks were flying in Canada's food industry's boardrooms.


    1. There's no call for regulation. There's no call even for the most conservative recommendations like for instance limiting the amount of sodium per serving in toddler foods. With no call for regulation, there's no cause for urgency. With no cause for urgency, there's no cause for change. With no cause for change, there's no cause for spending any money reformulating and repackaging products.

    2. The call to post nutritional information on menu boards includes both calories and sodium. You might think industry would be upset by this. I'd guess you'd be wrong. I'd guess you'd be wrong because by coupling the call to action with a call to post both calories and sodium, the call is far less likely to be heeded. It simply adds a degree of difficulty to any push for menuboard reform and that of course in turn makes it far easier to fight.

    3. With the call to adopt the recommendations of the US' Institute of Medicine report on front-of-pack food labeling the food industry is likely hopeful that their recommendations will be more lenient than ours - a likely case scenario given that front-of-package health claims are far easier to make in the States than in Canada and so even with reform, they're still likely to allow the Canadian food industry to enjoy a robust expansion in their front-of-package labeling allowances.

    All said and done, the Sodium Working Group's recommendations, while broad reaching in theory, aren't particularly likely to be broad reaching in practice and demonstrate quite clearly why the inclusion of the food industry at the decision making table is a completely irresponsible practice.

    While the food industry is certainly a "stakeholder" in federal dietary recommendations and reforms, their role should be relegated to that of a consultancy whereby they're asked and encouraged to provide as much input as they'd like to a committee free of industry influence. That committee would in turn take the food industry's concerns into account when creating a series of recommendations whose primary goal is to improve the health of Canadians, not protect the wealth of Big Food.

    [Tellingly, when I was asked by Health Canada a few weeks ago to participate in a post-hoc survey on the implementation and design of Canada's 2007 Food Guide there was a question as to whether or not there were "stakeholders" who should have been consulted or whose concerns may have fallen by the wayside. I of course suggested that the question should also have asked whether or not there were stakeholders who should not have been consulted or whose concerns were overly represented in our awful Food Guide.]

    Tuesday, August 03, 2010

    The good, the bad and the ugly of Canada's recent sodium working group.

    Last week saw the release of the recommendations of Health Canada's Sodium Working Group (SWG) - a "multi-stakeholder" group with representation from public health folks, health related NGOs, the government and the food industry.

    The group was established in October 2007 and it's taken them nearly 3 years to come up with a series of recommendations meant to tackle the problem of sodium intake in Canada.

    Overall, I was pleasantly surprised by the recommendations themselves, though not by their lack of regulatory backing, and in fact I think some are more important than the media's given them credit.

    So first the good.

    Shockingly good in fact.

    The SWG's recommendations that Canada's Food Guide be revised to provide guidance on calories (and sodium) and updated far more frequently are exceedingly important. They're important because they're the first official admission that the 2007 Canada's Food Guide leaves much to be desired. So much so apparently, that a "multi-stakeholder" working group on sodium decided to make it a point to point it out.

    I was also pleased to see a call to action for nutritional fact panel reform so that there would no longer be such things as serving sizes that suggest they're a third of a cookie and that the percent daily value of sodium be calculated using the goal of 1,500mg rather than 2,300mg.

    Next, the bad.

    Unsurprisingly bad.

    The working group's recommendations are completely toothless. They couldn't even get the food industry to agree to a regulatory approach to the reduction of sodium in toddler foods. Of course that's not particularly surprising given the food industry was effectively given veto power at the table which is I suspect also why it's taken nearly 3 years for the SWG to come up with their recommendations.

    Finally, the ugly.

    Hideously, hideously ugly.

    By creating a, "multi-stakeholder" working group, Health Canada has continued its maddening and reckless practice of including the food industry at tables whose discussions and recommendations are meant to serve public health.

    As one SWG member said to me on Friday afternoon,
    "Effectively Health Canada has asked the food industry to help guide public health policy"
    because as this person described it to me, industry made the process exceedingly challenging whereby even the smallest victories necessitated industry catering compromises.

    Anyone else out there think it's horrifying that Health Canada most assuredly believes the food industry's interests are as important a consideration in the creation of public policy as is our health?

    Stay tuned tomorrow for a, "what's in it for the food industry post" regarding the SWG.

    Monday, August 02, 2010

    Consumers ignore the fine print when considering the health risks of fortified foods.

    While this was far from an easy paper to read, its results are important nonetheless.

    Researchers in France set out to determine the impact on purchasing behaviour that health claims, health risks and scientific uncertainty had when posted on yogurts.

    The study used Danacol, a Danone yogurt that's enriched with plant sterols and marketed as a means to help lower cholesterol.

    The subjects included folks with and without cholesterol problems and they were asked to compare taste and what they were willing to pay for 6 cups of the sterol enriched yogurt knowing the retail price for a comparable plain yogurt.

    The taste testing was blind whereby the yogurts' containers were covered with aluminum foil. Once taste testing was completed subjects were provided with information regarding phytosterols in general and then asked what they were willing to pay for the enriched yogurt as compared with plain yogurt. They were then provided information about health risks and scientific uncertainty associated with phytosterols and then asked again what they'd be willing to pay.

    The results I'm sure made every food marketer's day. While messaging of health benefits positively skewed purchase price, even among folks without cholesterol problems, health risk and scientific uncertainty messaging only had an impact on those without cholesterol issues, but rather than bring the price a person'd be willing to pay down to zero (which you might expect given there's risk reported and they don't have a cholesterol problem) they reported they'd still buy it, just not at an inflated price with a bizarre 38% of them reporting that they would in fact, eat Danacol in the future, despite not having cholesterol problems and despite being aware of the health risks and scientific uncertainties associated with phytosterols.

    Ultimately this article served to prove, at least in the case of yogurt, that health claims sell and more importantly, that the little bits of fine print that describe how there's scientific uncertainty and even risks associated with the products, don't discourage their consumption.

    A shame that the article is so painful to read as I do think the results, though not surprising, are important and something that governments should bear in mind when considering the regulation of fortified foods and their consequent health claims.

    Marette, S., Roosen, J., Blanchemanche, S., & Feinblatt-Mélèze, E. (2010). Functional food, uncertainty and consumers’ choices: A lab experiment with enriched yoghurts for lowering cholesterol Food Policy DOI: 10.1016/j.foodpol.2010.04.009