Friday, December 31, 2010

"All vegetable crisco" - your tub of health!

Today's recycled Funny Friday? A classic Steve Carell skit from the Daily Show exploring the virtues of Crisco. Unfortunately, the lead-in to this skit was pulled from Youtube but thankfully this survived.

Mmmm, all Vegetable.

Have a great weekend!

Thursday, December 30, 2010

Weight loss is personal

[Originally posted October 2007]

Even if you're blogging about it.

So currently I'm working with one of the local newspapers as one of their panel of experts for a lengthy series on nutrition.

The launch was last weekend and included in the launch was an article written by a very young man who's just barely overweight. The article was about his month long experiment of following Canada's Food Guide and he's also keeping a blog about his experiences aiming at reaching a numerical goal weight (the weight needed to give him a body mass index of 25).

Now readers of my blog will certainly know that I'm not a fan of using BMI or "pound" goals because frankly they overlook the bigger picture - reality. Fact is, the best goal is whatever weight you reach when you're living the healthiest life you can enjoy. But put that aside for now. The important question to ask regardless is, "So is he enjoying his life?"

Not according to his newspaper articles and blog entries he isn't.

According to them he's been saving up his calories for supper and in so doing often finding himself starving and battling hunger demons (like the ones that live in Pizza shops). He reports being "desperate" for steak because his Food Guide approach doesn't allow him to eat large ones. He reports being tired and finding it difficult to find 60 minutes a day of exercise. He reports that he fell off his new wagon within one month of embarking on it. He notes that on at least one occasion when he ate more than he planned in the daytime he compensated and went to bed following a dinner consisting solely of a plate of green beans with two slices of toast. He reports that the "red numbers" on the scale motivate him and help him with what he feels his efforts require - "focus, attention and willpower".

In short, he's on a diet.

Given my chosen career and my experience with quite literally thousands of folks trying to lose weight, reading his article and his blog, I decided that there's no way that he's adopted a long term approach here. He's dieting and both anectdotally and in the medical literature, diets fail in the long term over 95% of the time.

So what type of diet behaviours does he admit to? By using the scale as a source of support, he's chosen the proverbial dark side of weight loss, letting the seduction of the numbers inspire him to greater acts of willpower - a problem when the scale stops whispering sweet nothings into his ear. By saving calories until the end of the day and cultivating blindly restrictive food limits, he's cultivating hunger which will lead him to battle hunger - a battle that if fought frequently, eventually just gets too irritating and bitter to fight. By trying to cram 60 minutes of exercise a day into likely a very busy and youthfully all over the place lifestyle, he's liable to get frustrated with the exercise and simply let the whole thing go. He appears to be trying to live the healthiest life he can tolerate - and for me, that's the definition of a diet.

So here's where it gets interesting.

I decided to write to him and in the email I told him that it seemed painfully obvious that he didn't particularly relish his new healthiest-he-could-tolerate lifestyle and that in the long run, if he didn't enjoy his life, he wouldn't continue living that way.

I also offered him our help with no strings attached. I recommended that he see our dietitian and told him that should he come and see her, he need not feel that he would have to mention the visit or our help in his blog or in his articles.

I logged onto his blog the other day and read what sounded to me like a fairly irritated entry from him stating that I had written to him, told him that he was going to fail and that I tried to convince him to join my office's weight loss program.

Now the later part's simply not true, I had offered him a free visit with out dietitian with no strings attached, but I'll chalk that one up to misinterpreted email, but the former part I suppose is true, and frankly, I'm sorry that I emailed him and more sorry that I clearly have upset him.

You'd think of all people, I'd know that weight loss is personal. It's my exclusive area of practice and thinking about weight and weight management probably takes up at least 2/3rd of my total waking hours.

I should have known better than to offer my opinions or even offer to help because the mistake that I made, was assuming he wanted my opinions or my help.

Weight loss is a personal journey. No one should feel comfortable muscling in on someone else's weight loss effort.

My mistake was an honest one. For heaven's sake, having a blog and writing articles about weight management pretty much opens the door to having folks comment on your efforts, but frankly I still should have known better.

Best of luck to him, and should he decide that in fact my opinion and help would be useful to him, he's still welcome to give me a call.

For all of the friends and spouses of folks trying to lose weight out there, here's the only question you should ever ask your weight-conscious friends, "Is there any way that you feel I can help you". If the answer's "No", then just leave it at that, if they want your opinion or help, they'll ask.

Wednesday, December 29, 2010

Set point theory is stupid!

[Originally posted June 2007]

Yesterday someone in the comments asked me what I thought about "Set Point Theory".

What set point theory suggests is that a person's body, metabolism and caloric drive strive to maintain a specific preset weight and therefore if your "preset" weight is high and you lose weight, your body will just try its darndest to gain it back.

I think it's an asinine theory.

Some obvious problems (one pointed out quite rightly by the comment yesterday):
  1. Why have the world's setpoints gone up dramatically over the course of the past 50-100 years?
  2. Why is the world getting bigger so much faster (are all of our setpoints 1,000lbs?)
  3. Why do the setpoints of many non-American folks seem to change the moment they step into North America?
Set point theory is something that allows folks and governments to take even less responsibility in treatment design and implementation.

Now it is indeed true that as the body loses weight it does compensate in multiple ways to try to preserve the weight it's losing. The body of course perceives weight loss as an environmental threat - an ice age or a flood or something, and so it jumps into action and changes the way the body handles certain processes, decreases something called the thermic effect of food and basically tries to hold on but it doesn't throw any magical switches to get folks to open their freezers and cupboard doors.

I don't completely discount the whole theory however. I do believe that there is a range of weight within which a person can comfortably live, but I also believe that range is very wide and it depends not only on the genetic makeup of the individual, but also his or her learned and fixed environment.

You might even stretch and say that I do believe in set point theory, but in my own version of it - I'll call it Life-Set Theory with weight being primarily lifestyle related.

People regain their weight as they regain their old lifestyles.

I say this to new patients daily,
"The more weight you'd like to permanently lose, the more of your lifestyle you'll need to permanently change"
The problem is, most weight loss efforts don't really do much to address lifestyle. Weight loss usually involves a food regime - either overt overall restriction and hunger or the magic food approach of this food's good and that food's bad. Those approaches are of course non-sustainable becase they invoke the suffering of hunger or of blind, thoughtless restriction. Any weight lost through suffering will be gained back when the suffering stops and the person reverts back to their prior life that might have led them to have weight to lose, but was easy to live.

The environment also of course matters. Look at the Pima Indians - heaviest people in the World in Arizona and while still heavy, much lighter weights back home in Mexico. I'd imagine this would work in reverse too. For example, take someone who's lost weight with a restrictive approach while working a sedentary job in an urban environment and plop him or her down on a farm where they've got to work all day long and there's no access to food other than what they cook and grow themselves. Do you think their "set point" will have them magically gain? Of course not, because their environment no longer allows for their prior calorie rich lifestyle.

So to sum up this rant. For me lifestyle dictates set point. Change your lifestyle and eating patterns (combining hunger prevention strategies like frequent eating and increased protein with calorie awareness and an explicit lack of forbidden foods) and you've definitely got a shot, but do remember with lifestyle change it's not necessarily the changes that are difficult, it's change itself.

Tuesday, December 28, 2010

Big Milk's dietitians recommend French fries, hot dogs and milk shakes!

[Originally posted March 2007]

My wife and I were cleaning the house this past weekend in preparation of showing our house. She came across this handy fridge magnet that was given to her at the hospital following the birth of our now 2 month old daughter. It's entitled, "How to Build a Better Baby".

It was developed by the registered dietitians of the Dairy Farmers of Canada as evidenced by the seal at the bottom and by this seal on the back:

It is meant to guide pregnant and breast feeding women to healthier choices in order to "build better babies".

According to the back of the magnet,
"Your diet is essential to you and your baby. Until birth and during breast feeding your baby depends on you to supply everything needed for growth and development. What you eat during pregnancy and during breast feeding will help you be healthy and give your baby a healthy start in life"
Want to know what the registered dietitians of the Dairy Farmers of Canada feel women should eat in order to make "better" babies and help mom "be healthy" and give baby, "a healthy start in life"?

Apparently whole milk, chocolate milk, ice cream, milk desserts, milkshakes, hot dogs and french fries.

I kid you not.

Take a look at these enlargements. They're from the bottom of the chart and they summarize the registered dietitians of the Dairy Farmers of Canada's guidance and examples as to what constitute "healthy" milk, meat and vegetable choices and servings.

When I showed this to our dietitian at BMI, she sighed sadly.

I can't imagine how the dietitians from the Dairy Farmers of Canada responsible for this handout go to bed at night.

Monday, December 27, 2010

Calorie burning soda - $14,600/lb of weight loss.

[Originally posted February 2007]

Celsius Cola - Raises your metabolism by 12% for 3 hours!

Sounds great right?

Umm, not so much to me.

Forget about whether or not the data supports the conclusion, let's work with it just like we did with the other so-called energy burning drink, "Enviga".

So a 12% increase in metabolism for 3 hours.

I burn 2,250 Calories per day or 93.75 Calories per hour.

12% more than 93.75 is an additional 11.75 Calories per hour.

11.75 Calories per hour x 3 hours = 33.75 additionally burned Calories.

But wait, the drink has 10 calories therefore it's only an additional 22.75 Calories.

But wait again, if I drank 355ml of ice water instead of ice cold Celsius I would burn 12 more Calories bringing the temperature of the ice water up from 0 degrees Celsius to 37 degrees Celsius, therefore now we're down to an additional 10.75 Calories drinking Celsius over ice water.

If I drink one a day for a year I'll therefore burn an additional 3,923 Calories representing 1.1lbs, at a cost of $2 per bottle = $730.

That's $664/lb!

And I'm a fairly fit, somewhat young, 5'8" man who burns a fair number of Calories.

What if you burn less Calories than me?

Let's say instead you burn 1,500 Calories daily. Then your cost per lb of weight loss after all the calculations ends up being $14,600/lb and if you simply had a glass of ice water daily, you'd get virtually the same benefit as one Celsius drink daily.

How do I figure?

1,500 Calories / 24 hrs = 62.5 Calories per hour.

62.5 Calories/hr * 0.12 (12 % increase) * 3 hours = 22.5 Calories extra.

22.5 Calories extra - 10 Calories for the drink = 12.5 Calories extra.

12.5 Calories extra - 12 Calories raising the temperature of 355ml of ice water = 0.5 Calories extra.

0.5 additional Calories per day * 365 days per year = 182.5 Calories per year

182.5 Calories / 3,500 Calories per pound = 0.05lbs.

$730/0.05lbs = $14,600/lb

Makes me almost rather give my money to Aquamantra!

Saturday, December 25, 2010

The "cornification" of our diets.

[Originally posted August 2007]

The media is awash about different causes of obesity. Just last week we were bombarded with reports on how diet foods cause childhood obesity. While I was planning to talk about how ridiculously the media handled that particular story, instead I've found something else that I thought was more worth posting. It's Peter Jennings' fantastic 2004 report "How to get fat without even trying", on the role North American governments and the food industry play in the explosive growth of obesity.

Thanks to Dr. Marion Nestle who is the Paulette Goddard Professor of Nutrition, Food Studies, and Public Health at New York University whose fantastic book Food Politics apparently inspired Peter Jennings to do the piece and thanks to Dr. Nestle as well for posting a link to the piece on her fabulous blog two days ago.

It's a long video (10 mins).

It's not funny.

It's a great watch.

Friday, December 24, 2010

"I said Poo!" (Don't give your kid books for Christmas)

So that's it for me for 2010! Thanks for reading!

Blog-cation next week but I plan on reposting some of my favourite posts from 2007 as I've got a great deal more readers now than then.

Today's final Funny Friday is apropos for the season and involves a kid who certainly is comfortable telling his parents how he feels about his Christmas presents.

Hope those who are celebrating have a wonderful Christmas and wishing everybody a Happy New Year.

Thursday, December 23, 2010

Exercise 6hrs/wk for 20 years. Still gain weight. :(

I guess the good news is that you gained less weight. The bad news is if your motivation for exercising was weight loss, your 20 years of exercise not only didn't help you lose weight but your weight gain was only marginally less than your couch potato friends.

What am I talking about?

A study published last week in the Journal of the American Medical Association which using data from the CARDIA trial, sought to examine the relationship between exercise and weight gain over a 20 year period.

3,554 young adult participants were followed through to middle age. At baseline and years 2, 5, 7, 10, 15 and 20, their physical activity was measured by means of the CARDIA Physical Activity History questionnaire which scored, you guessed it, physical activity. Subjects were also weighed and had their heights and waist circumferences measured at all visits. Dietary intake was examined at baseline and years 7 and 20 by means of a food frequency questionnaire.

The results?

After controlling for age, race, baseline BMI, education, smoking status and alcohol use, habitual high activity was associated with smaller increases in weight and waist circumferences. Men who exercised a minimum of 5 hours a week gained 5.7 fewer pounds, and had 1.22 inches smaller waists than men exercising less than 90 minutes a week. Women who exercised a minimum of 5 hours a week gained 13.42 fewer pounds (though women as a percentile gained more weight than men in total) and had 1.54 inches smaller waists than women exercising less than 90 minutes a week.

Put another way, exercise 1hr/day, 6 days a week and if you're a man you'll gain 4.5 fewer ounces a year than if you exercised less than 15mins/day. If you're a woman you'll gain 11 fewer ounces.

But you'll still gain.

Put another way - it ain't about exercise.

If you want to manage your weight, you've got to manage your intake.

Of course if you want to stay healthy, you've got to exercise. No one said life was fair, so exercise to improve your cardiovascular health, reduce your risk of diabetes, improve glycemic control, increase your mobility, increase your endurance, extend your life and provide you with functional independence.

But please, please don't make the mistake of honouring your New Year's weight loss resolution by exercising like stink and not changing your diet because in a best case scenario it would seem that all you'll end up doing is gaining less in 2011 and likely quitting an incredibly beneficial and healthful behaviour because it didn't lead you to dramatic weight loss results.

Hankinson, A., Daviglus, M., Bouchard, C., Carnethon, M., Lewis, C., Schreiner, P., Liu, K., & Sidney, S. (2010). Maintaining a High Physical Activity Level Over 20 Years and Weight Gain JAMA: The Journal of the American Medical Association, 304 (23), 2603-2610 DOI: 10.1001/jama.2010.1843

Wednesday, December 22, 2010

Coca Cola's latest deceit revisited.

I last blogged about this ad in April. I called it, a case study on deceitful marketing that I cut out of my local newspaper.

The ad screams,
"Up-front calorie labeling. Easy any way you look at it"
and goes on to explain,
"the easier it is to find the calories, the easier it is to make the choices that help you and your family achieve a sensible, balanced diet"
Now putting aside the fact that Coca Cola has no place in a sensible balanced diet let's go back to how easy it is to find the calories.

Looking at this helpful new label it would appear that the bottle of Coca Cola has 110 calories. No need to read between the lines.

What it doesn't mention is that while there might not be a need to read between the lines, there's a need to read below the lines and then follow that up with some long division and multiplication.

If you look just below the large fonted 110 you might notice the small fonted calories/250ml qualifier.

The bottle is 591mL.

591mL/250mL * 110 calories = 260 calories.

Coca Cola folks, when you read this - 260 calories in big type on your 591mL bottle would be up-front labeling. especially given that's how you label it in stores. 110 calories in big type on a 591mL bottle with small print below stating /250mL? That's still just slimy marketing.

Of course with this latest reiteration of the campaign, (which from what I can gather, is a huge one) Coca-Cola's coupled deceit with misdirection in that the original ad now has a friend - a co-branded Coca-Cola/ParticipACTION ad that talk about how Coca-Cola cares about health and their desire to make "Playtime our National Pastime",

And while that sounds lovely I can't help but imagine that Coca-Cola's true goal is that by making us feel like Coca-Cola is part of the solution that somehow we minimize the fact that drinking sugar water contributes to weight gain, and that inactivity, not the consumption of their empty calories, is what's responsible for childhood obesity.

After all, it's all about "balanced, active lifestyles", isn't it?

Tuesday, December 21, 2010

More health claim woes for yogurt

I've blogged about Danone (Dannon in the States) and their yogurt claims before.

To recap briefly:

  • In 2008 Dannon USA settled a class action lawsuit regarding purportedly misleading yogurt health claims to the tune of $35 million.

  • In 2009 Danone withdrew Activia and DanActive yogurts' health claims from consideration in the EU.

  • 10 months later they resubmitted Activia and DanActive's health claims dossiers to the EU, only to re-withdraw them a short while later.

    So what's the latest?

    Last week the EU rejected Danone's Actimel diarrhea relieving health claim. Nutraingredients then reported Danone's reaction that the rejection was, "incomprehensible".

    Then two days ago the Federal Trade Commission in the States and Dannon reached a $21 million settlement to drop Dannon's yogurts' exaggerated health claims with the terms of the settlement requiring,
    "Dannon is prohibited from claiming that any yogurt, dairy drink, or probiotic food or drink reduces the likelihood of getting a cold or the flu, unless the claim is approved by the Food and Drug Administration.

    Dannon may not claim that Activia yogurt will relieve temporary irregularity or help with slow intestinal transit time, unless the claim is not misleading and the ad conveys that three servings of Activia yogurt must be eaten each day to obtain these benefits.

    Dannon may not claim that any other yogurt, dairy drink, or probiotic food or drink will relieve temporary irregularity or help with slow intestinal transit time unless the claim is not misleading and the company has two well-designed human clinical studies that substantiate the claim.

    Dannon may not make any other claims about the health benefits, performance, or efficacy of any yogurt, dairy drink, or probiotic food or drink, unless the claims are true and backed by competent and reliable scientific evidence. Dannon also is prohibited from misrepresenting the results of any tests or studies
  • Interesting thing too, according to Nutraingredients Dannon USA has no intention of ceasing and desisting with the intestinal and immunity claims.

    I find that amazing in that in the US Dannon's now settled to the tune of $56,000,000 and lord knows how much in their own legal fees.

    I would think, and I'm no business maven, that corporations don't spend $56,000,000 because they don't feel like fighting injustices. I would think that corporations only spend $56,000,000 in settlements when they can't prove they're right.

    Oh, and when you can't prove you're right, that certainly often means you're not.

    Or maybe it's just the cost of doing business. After all, according to Danone, they sell 6 million cups of yogurt a day.

    Monday, December 20, 2010

    Fortified junk food to displace healthier fare?

    There's no disputing the fact that Health Canada wants to allow food and product manufacturers to fortify foods with vitamins and minerals at their discretion.

    It would have already done so except for the fact that Health Minister Leona Aglukkak balked at the last minute as she didn't want to be known as, "the junk food queen".

    The worry among folks who care more about the health of Canadians than about food and product manufacturers' desire to sell junk food is that the fortification of junk food will make junk food all the more appealing and in turn provide a false sense of dietary security to the folks who are already eating it (potentially leading them to eat more) and may shift folks currently consuming healthier diets to choose less healthy fare.

    The thing is, without this policy moving forward, it's difficult to say whether or not those worries are valid, but to lend a bit of weight to the argument that yes indeed they are comes a new paper from Sacco and Tarasuk of the University of Toronto.

    What they set out to determine was what exactly the consumption patterns were for the folks consuming those foods set to be fortified by Health Canada's proposed policy.

    Ultimately what they found was that 95% of the 34,383 folks they studied consumed at least one fortifiable food daily. More importantly, they found that for many teens between 14-18 years of age, fortifiable foods contributed nearly 50% of usual energy intake for many and averaged 35% for all.

    They also found an inverse relationship between the consumption of fortifiable foods and actual healthy foods (whole ingredients).

    What does this mean?

    It means that were Health Canada to enact such a policy we'd all be a party to an experiment that has no particularly meritorious benefits (there's no indication fortification of foods will improve our health) and certainly has the potential to harm - especially given the huge amounts our growing teens will be consuming.

    The potential to harm comes from the fact that we'll be exposing our population to nutrient levels which may well exceed recommended upper limits and moreover may shift consumption away from the very foods evidence-based nutrition has in fact proven to be beneficial to health.

    Ultimately all it will do is pander to lowest common denominator nutrition by allowing food manufacturers to smear lipstick all over their dietary pigs, dressing them up for dates with trusting, nutritionally naive Canadians.

    Sacco JE, & Tarasuk V (2010). Discretionary addition of vitamins and minerals to foods: implications for healthy eating. European journal of clinical nutrition PMID: 21119698

    Saturday, December 18, 2010

    Saturday Stories

    Meet the woman without fear!

    Dr. Sharma details a study that reveals (shocker) that people don't have a clue when it comes to calories.

    Melanie Warner succinctly covers the McDonald's Happy Meal lawsuit.

    Slate's Timothy Noah also covers the need for regulation of such things as Happy Meals.

    Friday, December 17, 2010

    So you want to be a journalist?

    Today's Funny Friday is a fabulous Xtranormal discussion involving a nice young man who wants to be a journalist.

    Have a great weekend!

    Thursday, December 16, 2010

    Holiday Strategy: Top 10 travel tips to reduce the gain.

    Are you one of the lucky ones that's going on vacation?

    Though I haven't seen the studies to prove it, I've heard that the average weight gain during a week of cruising nears 7lbs and certainly I've seen plenty of folks gain 4-5lbs at a weekly all-inclusive.

    Those are some hefty numbers as to gain 1lb a week you need to eat at least 3,500 more calories than you burn and most folks, especially folks who may have weight to lose, are likely burning between 1,800 and 2,800 calories daily meaning to gain those kinds of numbers you'd need to be consuming in the neighbourhood of 6,000 calories a day.

    That's the caloric equivalent of eating a McDonald's Quarter Pounder each and every waking hour from 8am to 11pm.

    Of course once you factor in alcohol, buffets, and disorganized eating that's all too easy.

    So how to get by?

    Here's my top ten list of travel strategies:

    1. Eat every 2-3 hours and make sure to get breakfast within 30-60 mins of waking up. Not eating frequently and leaving too long between meals and snacks leads to evening hunger. Hunger plus alcohol plus vacationing plus a buffet leads to boat loads of calories.

    2. Control breakfast. Poached eggs don't have added calories from oils or butter. Those with 2 slices of toast with a light smear of butter along with a large plate of fresh fruit is still an indulgent tropical breakfast, but not calorically.

    3. Eat your fruit, don't drink it. Or at least don't drink it regularly. Yes, fresh squeezed juices are a wonderful indulgence but figure that the tall glass of orange juice you just downed had the caloric equivalent of more than 3 oranges and drop per drop the same number of calories and sugar as Coca Cola. That giant pina colada? If it's one of the giant ones I've had each one's packing a Big Mac of calories.

    4. Include protein with every meal and snack.

    5. Try the a la carte restaurants rather than the buffets.

    6. Booze after the meal. Alcohol is an appetite stimulant. If you can hold off on the drinking until after you've eaten you're less likely to over do it.

    7. Consider packing your own snacks or buying them from the hotel gift shop. Prepackaged nuts are readily available and don't melt by the pool.

    8. Use your minibar to store fruits, cheeses and yogurts pilfered from the buffet.

    9. Grilled seafood is your friend.

    10. As per yesterday's post - it's better to indulge thoughtfully and gain a pound or two than to be excessively strict and have you one step closer to abandoning your weight management effort altogether.

    Have a great trip!

    Wednesday, December 15, 2010

    Holiday Strategy: Indulge!

    But do it thoughtfully.

    I've blogged before about the two questions to ask before you indulge and they're just as pertinent this time of year.

    1. Is it worth the calories?
    2. How much of it do I need to be happy?

    Frankly during Christmas time, there may well be foods that despite most of the year not being worth their calories, suddenly are, and folks who are so extreme as to deny themselves indulgences over holidays, birthdays and other special occasions are denying themselves a real and valuable part of the human condition - celebrating with food. Denying that will almost certainly lead a person to abandon whatever eating strategy they've adopted that's led them to be overly strict.

    Remember though if you ask those two questions and you're hungry when you ask them, the calories you'll consume will be far greater than if you ask them having had well organized meals and snacks all day long.

    I figure everyone's got a food that fits into the line,
    "A Christmas without ______ for dinner/dessert just wouldn't be Christmas"
    Make sure you fill in your blank, just do it thoughtfully.

    Tuesday, December 14, 2010

    Holiday Strategy: Silencing the Food Pusher!

    Food pushers.

    They're everywhere during the holiday season.

    You know them, they're the folks who insist you take far more than you want. Who ladle gigantic portions of everything on your plate and bully and pressure you into taking more and more and more.

    They're also easier than you might think to deal with.

    Step 1: Make up a reason why you have to serve yourself. Easiest made up reasons? Either you've recently developed some new weird food intolerance or your doctor's recently reviewed your blood work with you and they're pissed and have very specific instructions for what you're allowed and not allowed.

    Step 2: Purposely take significantly less food than you actually want, especially the stuff you think you'll enjoy and want the most, and yes, I realize this is going to upset your hosts.

    Step 3: When you've finished your purposely small portions make a minor production with your host of how much you liked such and such and would it be alright if you went back for seconds?

    At the end of the meal? You're happy because you've controlled your portions. Host's happy 'cause you loved their food enough to have seconds and has long since forgotten you didn't take all that much to begin with.

    Done. Food pusher defused.

    [And no, that's not an illustration of my mother-in-law. Mine's lovely (though she is most certainly a food pusher).]

    Monday, December 13, 2010

    Holiday Strategy: Don't save your calories for dinner!

    One of the most common holiday strategies is to save up calories for dinner. It's also one of the least wise.

    So first the thinking behind the budgeting. People believe that by saving their daytime calories by skipping meals or eating light then they'll have more caloric room for their indulgent dinners.

    Of course as a consequence they'll also show up at their dinners hungry.

    That's a problem.

    You see hunger affects choice. Think about the last time you hit the supermarket hungry. You almost certainly bought different foods.

    Sit down to a meal hungry and now you're shopping from your plate, and in the case of a festive meal, from an table full of dietary extravagances.

    Chance are your portions will be larger, you might well have seconds and you won't skimp on dessert.

    But what if you weren't particularly hungry when you sat down?

    Well then you'd be able to thoughtfully navigate the table. You likely wouldn't need or want seconds and you'd have much greater control over how much dessert you ultimately had.

    I'd bet not showing up hungry would likely save you a minimum of 1,500 calories and in order to not show up hungry chances are that would only cost you on the order of 400-800 calories of ensuring you snack between meals and don't skimp on your breakfast and lunch portions.

    Seems to me spending 800 calories to save 1,500 calories seems like a much wiser plan.

    Saturday, December 11, 2010

    Saturday Stories

    Carly Weeks covers one of the saddest and creepiest prescription drugs the world has ever seen.

    Dave Munger from Seed Magazine pours arsenic over arsenic based life forms.

    Gizmodo details how to fly around the world, through 4 continents, 9 countries and 15 cities, for $418 taxes in.

    Peter and Travis from Obesity Panacea tackle the couch in a 5 part series on the science of being sedentary.

    Friday, December 10, 2010

    "You got a dog? You got a gym!"

    Today's Funny Friday explains how there's no excuses for you not to be exercising (if you've got a dog).

    Have a great weekend!

    Dog Gym - watch more funny videos

    Thursday, December 09, 2010

    Nonshocker! Preschool kids think thinner is better.

    I'm not surprised, are you?

    A study out of the journal Sex Roles took a look at preschoolers' attitudes towards obesity by means of Candy Land and Chutes and Ladders. They took 55 girls aged 3-5 and had them choose which character they wanted to be. 69% chose the thinnest, 20% the average and 11% the largest. Moreover when asked to swap thinnest for largest, 63% refused.

    One of the study's authors apparently was surprised by the findings and she was quoted in the Montreal Gazette stating,
    "I was surprised that kids as young as 3 were so emotionally invested in their game piece that they would say to a complete stranger, 'No, I don't want to switch with you. No, I hate that one'. It was completely shocking to me"

    You were surprised that 3-5 year olds didn't want to switch from the character they initially chose by themselves? I'm guessing you don't have kids or you've forgotten what 3-5 year olds are like.

    I'm also not shocked by the bias.


    Because kids' movies quite regularly point out that fat is either bad, clumsy, funny or stupid, and unlike thin villains and foils, obese characters' weights are almost always central to the jokes and situations they find themselves in so even when not an outright villain like Ursula, they are shown to succeed despite their weights (Kung Fu Panda and Shrek leap to mind).

    Oh, and lots of parents say awful things about weight. Whether it's comments like, "Do these jeans make me look fat" or disparaging remarks about others, it's not as if weight isn't the last socially acceptable form of stereotype and it's not as if kids don't pick up on the things their parents say.

    So colour me unsurprisingly sad by this study. It's too bad that the authors didn't take their sound bite opportunities to drive home how sadly unshocking these results were.

    Harriger, J., Calogero, R., Witherington, D., & Smith, J. (2010). Body Size Stereotyping and Internalization of the Thin Ideal in Preschool Girls Sex Roles, 63 (9-10), 609-620 DOI: 10.1007/s11199-010-9868-1

    Wednesday, December 08, 2010

    Do nutrition facts panels make weight management more difficult?

    Honestly, how does anyone stand a chance?

    So our dietitian Joanne Kurtz decided to buy some whole grain mini pitas.

    Looking at the back of the bag she clearly saw that 1 serving was listed as 2 pitas which weighed 14grams and contained 40 calories.

    Being a dietitian, and moreover a dietitian whose work involves helping folks with weight management (and hence someone who talks and looks at lots of labels), she knew something was fishy so she cracked out her trusty scale.

    What'd she find?

    She found that each pita weighed 20grams, that's 185% more than the 7grams it was supposed to weigh.

    Of course that also means the nutrition facts panel underestimates calories by 185%.

    So even if you're watching your calories, even if you're diarizing what you're eating, even if you're doing everything right, if you trust your nutrition facts panels and you don't actually crack out your digital scale to double check your labels, you might be eating more than twice as many calories as you had thought.

    Nearly three times as many calories does not help with weight management.

    Tuesday, December 07, 2010

    Ridiculous serving sizes at Costco

    And unlike what you might expect, I mean small.

    Thanks to our wonderful dietitian Joanne Kurtz I now know how many pieces to cut a Costco mille-feuille (Napoleon) pastry if I wanted to adhere to their nutrition facts panel's serving information.

    Apparently the answer's 34.

    Now I realize that the math involved in calculating calories in more realistic servings isn't all the difficult, but that's certainly not something the average consumer's ever going to spend time doing even if they do bother to read the label.

    A wonderful example of why Canada's practice of allowing corporations to publish completely arbitrary serving sizes is an unfortunate one.

    Monday, December 06, 2010

    Badvertising: Get Real, Get Jelly Belly

    After reading this ad which brags,
    "Jelly Belly Jelly Beans look and taste so authentic because we insist on using real ingredients whenever possible, like real blueberries, real pomegranate and real cherry juices (to name just a few)"
    I couldn't resist heading over to Jelly Belly corporate headquarters to have a gander at their awesome "real" ingredients (as opposed to fake ones I suppose).

    So what other real ingredients do you get besides a few fruit juices? Here's just a smattering.

    Acidity Regulator: E330
    Glazing Agents: E901, E903, E904
    Colours: E102 [Tartrazine], E110, E132, E133, E150d, E171
    Emulsifier: E332

    Delicious! They might as well just be little fruits.

    I really have to remember to plant a Glazing Agent E901 tree this year.

    Saturday, December 04, 2010

    Saturday Stories

    The New York Times says Wii Fit is useless for fitness - unless you're old.

    Sarah Palin continues to prove how ignorant she is about obesity.

    Rosie Schwartz takes Health Canada to task for their record of nutritional inaction.

    Alex Hutchinson of Sweat Science tells you to rethink your drink for exercise.

    Friday, December 03, 2010

    Advice for young girls from Snow White

    My poor babies.

    Today's Funny Friday is the next installment in Second City's Advice from Disney Princesses.

    Have a great weekend!

    Thursday, December 02, 2010

    Are Ontario's bariatric surgical wait times legal?

    Did you know that if you apply for out-of-country bariatric surgery and you're rejected (as is automatic nowadays with a form letter directing you to apply through the bariatric registry) that you have the right to an appeal under section 20(1) of the Health Insurance Act, Revised Statutes of Ontario, 1990, Chapter H.6?

    Many people don't.

    Many people also don't know that from the date that you receive your rejection, your window to launch an appeal is only a scant 15 days.

    So how does this process work?

    Thankfully, I was recently given a tour by a gentleman whose wife launched a successful appeal of her rejection of her pre-approved gastric bypass, and given the system itself fails to inform patients of their right to an appeal with their rejections, I feel it's my duty to do so and to steer you a bit as to how to organize it.

    Bottom line, the process is likely to take up to a year, but given the waits for bariatric surgery in Ontario are likely to soon be as long as 3-4 years, it may still be a worthwhile process. I'll get into the nitty gritty of it all below but first, are there grounds for an appeal?

    I think so.

    Let's look at wait times. The province of Ontario has published guidelines on wait times and they've ranked those wait times in terms of priority levels.

    For general surgery, a priority level 2 procedure involves a condition with:

    • Constant, frequent or severe pain/symptoms (biological, psychological)

    • Significantly impacts ability to perform usual activities

    • High probability of disease progression with morbidity that might affect function or life expectancy

    • Recurring unscheduled visits i.e. ED/primary care physician/surgeon.

    Sure sounds like morbid obesity to me. The access target (recommended maximal wait time) for a priority 2 general surgery procedure? 4 weeks. But to be fair, bariatric surgery is a procedure that does in fact require a great deal of pre-operative patient screening, education and preparation and consequently will certainly require more time than a month.

    So how long should a maximal wait for bariatric surgery be? I posed that question to Dr. Nicolas Christou, Director of Bariatric Surgery, McGill University Health Center. His answer?
    "I have asked this question from many colleagues and the answer varied from 30 days to maximum 6 months based on the increased mortality risk. In our negotiations with the Ministry of Health we settled on a MAXIMUM wait of 1 year from the time a patients contacts a Bariatric Surgical Center of Excellence."
    And when I asked Dr. Arya Sharma, Scientific Director of the Canadian Obesity Network he suggested triage would matter in that,
    "I would say this depends on age, comorbidity, employment, etc."
    Though of course in Ontario, the maximal recommended limits even on a priority 4 general surgery case, the lowest level of priority with "minimal risk of morbidity incurred by waiting" is 6 months, and it's difficult to imagine why the wait for bariatric surgery, a priority 2 case, should exceed that.

    Furthermore, prior to the establishment of Ontario's bariatric registry system, patients were regularly granted access to out-of-country services based on the facts that wait times here in Ontario were 1-2 years in length, and that obesity and its comorbidities most certainly increase mortality and lead to cumulative, irreversible tissue damage. Given that obesity hasn't suddenly become benign and with wait times now reflecting 900 new monthly referrals for a procedure that Ontario's hoping to perform 2,200 of, I'd argue that those shut doors have been shut prematurely.


    Because according to Section 28.4 of Regulation 552 of the Health Insurance Act, R.S.O. 1990, c. H.6access to out-of-country services must be provided by OHIP so long if:
    a. The treatment is generally accepted in Ontario as appropriate for a person in the same medical circumstances as the insured person;


    b. Either,

    i. That kind of treatment is not performed in Ontario by an identical or equivalent procedure,


    ii. That kind of treatment is performed, but it is necessary that the insured person travel outside of Canada to avoid a delay that would result in death or medically significant irreversible tissue damage.
    And indeed, bariatric surgery is indisputably a generally accepted and appropriate procedure for the treatment of morbid of obesity in Ontario, and delays certainly may result in death or medically significant irreversible tissue damage - either directly as a consequence of the physical effects of the weight itself, or indirectly due to a weight-related comorbidity that in turn leads to cumulative, irreversible damage (diabetes, hypertension, hyperlipidemia, etc.).

    As well, it's also potentially worth noting in any appeal of an out-of-country rejection, that the current system has physicians who due to their belief that their patient is at a significant increase in risk of death or irreversible tissue damage with the current wait times, apply for their patient to have out-of-country surgery, receive a form letter back instructing them to apply to have the patient seen at a bariatric assessement centre. What that means is that effectively Ontario's new policy forces patients to experience a significant delay in treatment that may in fact lead to significant irreversible tissue damage or death, simply in order to be evaluated for surgical suitability this despite their licensed Ontario physician's own assessment of urgency, an assessment which just 12 months ago, was accepted regularly at face value (and well it should - physicians don't sign off on forms like that lightly).

    At the end of the day one of two things is true. Either the system is literally broke and that's why things have been put together they way that they have, or else fatism and weight bias exists among the folks who put this new system together as how else can you explain the fact that it is acceptable to OHIP that bariatric surgeries have access times more than quadruple the Province's aim for the very lowest of priority procedures?

    So how do you appeal? Well I'll post a step by step guide below but first some random thoughts that might help should you choose to appeal:

    - Once rejected for out-of-country, immediately request a referral to a Bariatric Assessment Center in Ontario. Your own wait time is evidence, so a long appeal process isn't a bad thing.

    - I've been told that OHIP in the past has tried to suggest that the time spent waiting after you've had the information session but before you've finished meeting with the team at the bariatric assessment centres for some reason I cannot fathom doesn't count as wait time. Make sure you keep careful records of all of your various dates.

    - I've been told that OHIP cooks the books with wait times in that folks who are shuffled to a centre different from the one they were originally waiting for leads OHIP to reset the clock to suggest their wait time was virtually nil.

    - It may be helpful, were there an organized group of presurgical patients out there, if they were to keep a public registry of their own of referral dates and wait times which in turn could be used to support the assertion that waits are exceedingly lengthy - an assertion it would seem OHIP tries its best to obscure.

    - OHIP will likely point to the fact that their advisory board has recommended that all patients be screened in Ontario to determine surgical suitability. You should know too that their advisory board members are the very same folks who run the screening centres. The fact though remains that the Health Insurance Act spells out the requirement for out-of-country funding, "Is it the right procedure in Ontario? Is done in Ontario? Is the wait too long here?". The Health Insurance Act should trump the recommendations of an advisory board staffed by people with conflicted interests.

    - I've been told that you should choose to appeal in writing, as while it may sound enticing to be able to meet your foe in court, writing will allow you to formulate your thoughts and arguments more cogently than you might in the heat of the moment.

    - It is illegal for OHIP to present false or misleading evidence under HSARB rule 19.04(1).

    - Don't spend a fortune on lawyers or U.S. specialists. Costs are almost never recovered, even if you win.

    Ok, so now you're ready to go. Here's a basic step by step guide:

    1. You have your physician apply for out-of-country consideration for a gastric bypass (here's the form) whereby your physician believes that delay might lead to either death or irreversible tissue damage.

    2. You're rejected by means of form letter that directs your physician to refer you to a bariatric assessment centre.

    3. Within 15 days of receipt of your rejection submit a Notice of Appeal - a letter identifying the OHIP decision and saying you intend to appeal because you meet the criteria set out in Section 28.4 of Regulation 552 of the Health Insurance Act, R.S.O. 1990, c. H.6. There's a FAQ and the forms to fill out are available on this page. And don't worry that you'll never be able to get everything together in 15 days, all you need to do in the initial letter is to identify the decision and your intent to appeal. You'll have time to make your arguments later.

    4. You will receive a letter from the Health Services Appeal and Review Board stating that they've received your request for an appeal and they'll provide you with a deadline of 2.5 months to submit the details of your case. You will be given the option of a written, teleconference or in-person hearing. You may designate someone else to represent you. You will also be assigned a case officer (who in the case of the gentleman writing to me was noted to be very helpful).

    5. Be sure to address all parts of Section 28.4. You need evidence that the specific procedure is appropriate for someone in your circumstances, evidence that a delay will cause irreversible tissue damage or death and evidence there IS a delay. Possible evidence includes the form sent to OHIP, and supporting letters and records from your physician, quoted wait times from your closest surgical centre, etc. Ontario medical opinions are preferred.

    6. Once you submit your case, OHIP will be given 2.5 months to file their Grounds of Response.

    7. You will receive a copy of their response and you will be given 10 days to respond to it and the gentleman who went through it believes that this will continue until you no longer have a response to their ongoing responses.

    8. HSARB will schedule a pre-hearing conference which OHIP may or may not decide to attend.

    9. A few months later you'll get a formal hearing date.

    You should know too, historically OHIP doesn't lose many appeal, though with thousands of bariatric patients stacking up on waiting lists, I think their record is about to change.

    [Sincere thanks to the family that went through all this who has guided me through the ins and outs of HSARB appeals. Here's hoping her surgery is uneventful and her recovery quick!]

    Wednesday, December 01, 2010

    Ontario's bariatric surgical wait times set to skyrocket.

    One of the things that is quite true about Ontario's efforts in increasing in-province access to bariatric surgery is that Ontario is light years ahead of virtually all of Canada's other provinces.

    That said, the likelihood Ontario will ever be able to meet bariatric surgical demand is virtually nil.

    Why do I say that?

    Well in his lecture this past Saturday, Dr. Mehran Anvari, project lead of Ontario's bariatric registry, talked about numbers. And the numbers just don't add up.

    Currently he reports that this year Ontario will perform 1,700 surgeries. Next year 2,200, and the year after that 2,800. He also reports,
    "Our goal is eventually to reach close to three and a half thousand to four thousand which we believe is what is necessary in Ontario"
    In terms of demand, we know that between 2006 and 2009 demand for out-of-country bariatric surgery for Ontarians tripled to near 1,600.

    That sure sounds like a rapid rise in demand, and perhaps if demand were to triple again by 2012 and if somehow Ontario was on track to do even 5,000 bariatric surgeries a year that'd be enough to keep up. Assuming of course demand didn't continue to rise.

    But here's the rub.

    Dr. Anvari reports that Ontario's current monthly average of referrals through the bariatric registry is 800-900/month. That means that even without an increase in demand (a strange assumption given the apparently exponential rise in same), 2011 alone will see roughly 10,000 referrals. And yet Dr. Anvari is talking about a 2011 goal of performing 2,200 surgeries, a 2012 goal of 2800 surgeries and an "eventual" goal of 4,000 surgeries. That means that by the end of 2011, even if only 70% of those referred were appropriate and actually went on to seek surgery, there'll be a 3.1 year wait list for surgery (not even counting those already waiting). By the end of 2012, it'll be 4.2 years. And even if we even somehow manage to reach what Dr. Anvari called an "eventual" goal of 4,000 surgeries a year, and still assuming no increase in demand and only 70% of folks referred going on to have surgery, we'd see the wait list grow by another 8 months each and every year.

    Now while I'm scared to tempt Dan Gardner's scorn, I'd guess that given the meteoric rise Ontario has experienced in bariatric surgical demand, combined with the ongoing rise in obesity rates, increasing public and physician understanding of bariatric surgery, and more and more success stories to spread the word themselves, demand will continue to rise and there's a great deal of room for movement. Remember, in terms of eligibility, there are likely on the order of 360,000 Ontarians that would meet bariatric surgical criteria and that's a number that to some extent is self-replenishing. That means the 10,000 projected referrals for this year represents less than 3% of eligible patients.

    Remember too, these aren't benign waitlists. Unlike wait times for things like joint replacements, suffering will increase and some people will likely die as a consequence of not having access to this procedure sooner.

    Ultimately our system is broken. The sooner the public and politicians understand that, the sooner we're likely to see innovation.