Monday, April 24, 2017

Will Candy With 30% Less Sugar Just Make Matters Worse?

Once reformulated this candy will "only" be 36.5% free sugar by weight 
A few weeks ago I blogged about the new lower in sugar Kit Kat bar that contains 4 fewer calories than the old bar (with 0.7g less sugar). The front of its package doesn't shout out about lower sugars though, instead it hypes "extra milk and cocoa".

It was the first example I'd seen of the inevitable future of ultra-processed treats that are being designed and launched under the banner of sugar as our global, singular, dietary boogeyman.

While there's little doubt we over consume sugar, and that sugar is one of the primary drivers of hyper-palatability and obesity, if the marketplace sees an influx of "now with 30% less sugar" ultra-processed foods, I'm not sure they won't make matters worse.

And that's precisely the sort of thing we're going to see as evidenced by this new line of Nestlé candy which according to this news story, will be sold alongside the original candy "with a 30% less sugar banner on the packaging"

Sounds an awful lot like the early 1990s when we saw the launch of "Fat-Free" Snackwell cookies (and more of course).

Will the "Now With 30% Less Sugar" banner lead people to buy candy more often? To eat candy more frequently? To eat more candy at each sitting? To grudgingly give in to their naggy kids and pack it in their lunches because it's less bad? Or will it lead to an overall reduction in free sugars and calories consumed?

For the majority of folks, my money's on all of the former, and none of the latter.

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Saturday, April 22, 2017

Saturday Stories: Car Currency, SuperBabies, and a Supplement Scheme

Debbie Weingarten in Longreads explains the relationship between the currency of cars and how to leave a husband.

Heather Kirk Lanier in Vela on how superbabies don't cry.

Charles Rusnell and Jennie Russell in CBC News highlight a government funded Vitamin D supplement scheme.

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Friday, April 21, 2017

Buddy Mercury Sings His Ode To Post November 8th, 2016 America

And I have to say, I'm right there with today's Funny Friday's Buddy.

Have a great weekend

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Thursday, April 20, 2017

For Beginners, Maybe Cooking Shouldn't Be "Healthy"

Serious Eats' 3 Ingredient Stovetop Mac & Cheese
Having worked with literally thousands of patients on improving the quality of their diets I can tell you that the most common barrier I hear to their adoption of more regular home cooked meals is a real or perceived lack of skill or talent at it.

Sometimes their beliefs stem from personal experiences and experiments. Other times they come from one or more family members who have complained about a particular dish (rather than be thankful that someone took the time to cook for them).

I can also tell you that many of the folks who don't cook regularly believe that if they were to start doing so, they'd need to be cooking "healthy" foods.

Why sure, cooking especially healthy meals is a nice aspiration, but if you're a beginner in the kitchen, why not instead focus on cooking meals that while perhaps not incredibly healthy, are meals that you're confident that you or your family will enjoy?

The goal really is to gain comfort in the kitchen and/or to gain the trust of your family members that you can cook yummy things.

So if you're a beginner in the kitchen, maybe cutting your cooking teeth on less healthy meals will encourage you to gain the skills and comfort you'll need to slowly improve your repertoire, and in so doing make the kitchen a room in which you actually enjoy spending time.

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Monday, April 17, 2017

Hey MDs, Scales Measure Gravity, Not Health, And Not Lifestyle

Today's guest post comes from long-time reader Sarah Trend who shared with me the handout she received on leaving her most recent endocrinology appointment. She also provided me with her thoughts and kindly agreed to let me share them with you. All this to say, if you're an MD the only thing your patient's weight tells you is the gravitational pull of the earth on them at a given moment in time. It tells you nothing about the presence or absence of health, nor does it tell you anything about their lifestyles. And if you're planning on providing lifestyle related advice, best you explore your patients' actual lifestyles first - regardless of their weights. Plenty of people with higher weights have incredibly healthful lifestyles, and many people with lower weights live awfully unhealthy lives.
I went to the endocrinologist this morning. The PA had me step on the scale and she recorded my weight. There was no discussion whatsoever with her or with the doctor about my weight. Imagine my surprise when I reviewed the "follow up" instructions - photo attached.

For the record, I weigh about 5 lb more than their "long term goal weight". I am 5'8". Had there been any discussion whatsoever, the doctor would have learned that the "weight loss tips" are not of much value to me: I only drink water. I do not eat fast food. I eat breakfast (hard-boiled egg and some fruit) every morning. I watch, at most, one 30-minute TV show a day. My husband does all grocery shopping. We cook >95% of our meals at home (from scratch, not boxes) and I take leftovers for lunch every day. Many of these meals are vegetarian. I get 4-5 hours of vigorous exercise every week - in fact, before my appointment I ran 3.25 miles at a pace of 9:22/mile. I only take the stairs at work. I get >10K steps each day.

Also, my blood pressure, as taken by his PA in the appointment, is 91/56.

So yes, I would really like to lose 10-15 vanity pounds, but that is all they are - vanity pounds. And yes, my weight is a few pounds above a BMI of 25. Had he had a conversation with me, he would have learned that I worked 61 straight 12-16 hour days at the start of this year. Some days, yeah, I grabbed a bag of peanut M&Ms or skittles from the snack cupboard in the office. Because I'm a human. And also - my period is due, so I'm up about 3 pounds of water weight from that.

I am so angry. Is this what passes for medical advice now? Meaningless random comments about weight loss with no conversation about health? I am appalled that an endocrinologist (who presumably sees patients with a variety of weight issues) thinks this is appropriate. Thought you might like to see it.

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Saturday, April 15, 2017

Saturday Stories: Horseshoe Crabs, Math Proofs, and Fentanyl Addiction

By Asturnut (talk) - I (Asturnut (talk)) created this work entirely by myself., CC BY-SA 3.0, Link
Caren Chesler in Popular Mechanics on the irreplacable medical marvel that is horseshoe crab blood.

Natalie Wolchover in Wired on the retired German statistician who solved one of mathematics most elusive proofs.

Darryl Green (as told to Katherine Laidlaw) in Toronto Life details his journey from successful ER physician to a fentanyl addiction.

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Friday, April 14, 2017

Life Is A Real-Life Episode of Veep

I can't imagine you didn't catch Sean Spicer's recent press conference. If it weren't so horrifying, it'd fit perfectly in HBO's apparently prescient presidential comedy Veep as is evidenced by today's Funny Friday.

Have a great weekend!

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Wednesday, April 12, 2017

No, Grade 1 Teachers Shouldn't Use Fun Dip To Teach Adjectives

And here I thought I could no longer be shocked by the gratuitous use of junk food to reward, entertain, or pacify kids.

Silly me.

Thanks to a friend who'd rather remain anonymous, I learned that her son's Grade 1 class was given Fun Dip to eat and write about in an exercise on adjectives.

Little did they realize they were also being taught about marketing, and about how giving kids junk food has become so normalized, that their teacher didn't see anything wrong with this lesson.

That the use of candy as a teaching tool didn't give this particular Grade 1 teacher enough pause to not follow through speaks not to her skills as a teacher, but rather to just how pervasive this sort of practice has become. People don't question normal behaviour, but just because something's been normalized, does not make it wise.

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Monday, April 10, 2017

No, Juice Is Not, "Really Close To Fruit"

If I had to rank juice companies by how blatantly their packaging tried to convince consumers that vitamin-fortified sugar water was healthful, Oasis would come out on top by a mile. So I'm not at all surprised to learn that it's Oasis' packaging that now includes the statement,
"Really Close To Fruit"
Nor was I surprised by this new product that I spotted at my local convenience store.

It's candy gussied up by Welch's to infer that it's fruit.

With pictures of grapes across the front, it reports it's "Family Farmer Owned", that it's "Grape", that it's "bursting with fruit flavour", and "made with real fruit juice".

They're 50% sugar by weight.

While I doubt there'll be parents out there who confuse these with actual grapes, I bet the majority will think they're a "better for you" product than Twizzler's Nibs. Yet if you compared the two you'd discover they're pretty much the same, with the Welch's candy actually containing 2.5% more sugar gram for gram than the Nibs.

But at least they're calling them licorice and not "fruit chews" or something of that sort.

Until juice is explicitly removed from national dietary guidelines as being a fruit equivalent we'll continue to see this sort of health-washing.

Oh, and coming down the pipes perhaps to a McDonald's near you?

Minute Maid Slushies - which apparently were debuted at a McDonald's funded children's festival.

No word yet on how much sugar these new faux-healthy Slushies are packing.

[h/t to Christine T. for sharing the "Really Close To Fruit" photo with me on Twitter]

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Saturday, April 08, 2017

Saturday Stories: Concussions, Conservatism, and a Crusade

Reid Forgrave with his debut article in GQ, and it's a doozy - the concussion diaries.

Matthew Sitman in Dissent on leaving conservatism behind.

Maureen Dowd in Vanity Fair on Elon Musk's billion-dollar crusade to pre-empt the AI apocalypse.

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Friday, April 07, 2017

Pushy, Pushy, Cats

Ah to be one of these Funny Friday cats. Looks like they've got a pretty decent setup.

Have a great weekend!

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Wednesday, April 05, 2017

New Reduced Sugar Kit Kat Bars And The Risks of Overly Simplistic Dietary Demons

One of the things that proponents of low-carb high-fat diets rage against, and probably rightly so, is how the overly simplistic demonization of dietary fats led to the rise of an ultra-processed market place of low-fat (but often high sugar) packaged foods.

And yet many of those same folks spend much of their time beating another overly simplistic drum these days - sugar.

While there's no argument from me that society's excessive consumption of sugar is a large raindrop in our flood of calories and chronic non-communicable diseases, if it becomes a singular focus, we may wind up with products like this new Kit Kat bar.

Nestlé is promoting their new bar on the basis of its reduced sugar content, and its packaging also infers it's "healthier" than before with it's large shout out to having "extra milk and cocoa".

As to the bar itself?

It contains 4 fewer calories than the Kit Kat bar it's replacing along with 0.7g less sugar.

At the end of the day there's a world of difference between "inconsequentially less awful" and "healthier", but that's a distinction that will likely be lost as new lines of ultra-processed foods are launched under the banner of lower sugars.

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Monday, April 03, 2017

Clean Your Plate Club - The Board Game?!

Yep, eat everything your parents put on it and you get to the final, covered, space - dessert.

The plate has won a 2016 National Parenting Product Award, a 2016 Family Choice Award, and was featured by the National Parenting Product Awards.

Yet according to research on feeding kids, pressuring kids to eat "healthy foods" along with using food as a reward are linked with dis-inhibited children's eating patterns.

Having 3 kids, all of who went through their picky eater stages, I know what it feels like when they don't eat. But rather than pressure them, trick them, coerce them (with the promise of dessert if they eat their dinners), or encourage them to ignore whether or not they're full by having required portion sizing, we kept offering them healthy choices, encouraged just "one bite to be polite", allowed fruits and vegetables to their hearts' contents after any meal, involved them in both menu planning and cooking, and didn't ever link dessert with how much or what they ate for dinner (and yes, we have dessert at least once weekly and usually more).

And while your mileage may vary with the strategies we employed, if your kids are turning their noses up at what you're serving them, the gamification of the clean your plate club strikes me as something that could generate some unhealthy, unintended, consequences.

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Saturday, April 01, 2017

Saturday Stories: Scott Adams, Heady Topper, and Definition of Obesity

Caroline Winter in Bloomberg with an engaging longread about how Scott Adams (Dilbert) became captivated by Donald Trump.

Sam Riches in Longreads tells the story of Heady Topper - the best beer I've ever had.

My friend and colleague Arya Sharma, writing with Denise L. Campbell-Scherer, with an editorial in Obesity on why we need to stop using BMI as the means to define obesity.

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Friday, March 31, 2017

Meanwhile in Canadian Politics....

To be fair, today's Funny Friday video is from November 2016, but in light of the terrifying daily news cycle emanating from the States these days, I thought it would be illuminating to share a scandal from here in Canada.

Have a great weekend!

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Thursday, March 30, 2017

Guest Post: Introducing Froogie, the Fruit and Veggie Eating App for Kids

While many people spend their time bashing "screens" as our children's undoing, others, like my friend Dr. Sara Kirk and colleagues, spend their time trying to figure out ways to leverage reality to help with furthering public health goals. Recently she helped to design and launch a new smartphone app aimed at getting kids to eat more fruit and vegetables and I asked her if she'd like to share more about it here.
Helping Families Live Life on the Veg: A new, free, research-informed smartphone app designed to encourage families to eat more fruits and veggies!

We all want our children to have a healthy start and a healthy future. Healthy eating and active living are two of the most important things we can do to improve our general health and boost our overall feeling of well-being. As part of a healthy, balanced diet, a high intake of fruits and veggies (at least five servings every day) can reduce our risk for developing some types of chronic diseases. These include heart disease, diabetes and certain types of cancer. Although there are other things that we can do to be healthy, like cutting down on processed foods and sugary drinks and snacks, eating more fruits and veggies is an easy, positive change that we can all make for a big impact.

Unfortunately, only 1 in 10 Canadian children and youth are achieving the recommended intake of fruits and veggies. And our earlier research found that parents and youth reported that they were overscheduled in ways that limit options for healthy meal preparation. In other words, healthy eating was often being sacrificed due to scheduling of leisure-time physical activities, which took priority among busy families.

So we wanted to find ways to support healthy eating among busy, time-crunched families, using smartphone technology. Through support provided by the Canadian Institutes of Health Research (CIHR) and Heart and Stroke to the Healthy Populations Institute (HPI) at Dalhousie University, and informed by our earlier research, we worked with a local developer to craft the Froogie app for families to track their intake of fruits and veggies in an engaging way.

The Froogie app is designed to provide a fun and interactive experience for children and families to eat healthily together. A combination of the words “fruits” and “veggies”, Froogie offers tips and reminders to promote daily fruit and veggie intake and help meet age-appropriate goals. With each animated Froogie character having a special twist for families to discover, regular use can encourage families to eat more fruit and veggies, so they can live life on the veg!

You can learn more about Froogie by visiting The app is free to download on the App Store or Google Play and was featured as a “New and Notable” app on the App Store shortly after launch.

Dr. Sara Kirk is a Professor of Health Promotion and the Scientific Director of the Healthy Populations Institute at Dalhousie University in Halifax, Canada. She also holds cross-appointments with the IWK Health Centre and Mount Saint Vincent University, Halifax. Originally from the UK, Kirk worked as a registered dietitian for several years before entering academia. Having moved to Canada in 2007 she now runs a multi-million dollar research program to understand how we can create supportive environments for chronic disease prevention.

Kirks has led several nationally funded projects that focus on the environment within schools and has over 100 peer-reviewed publications in her academic career. Through her vibrant and highly policy relevant program of research, Dr. Kirk has mentored a new generation of applied health researchers, and was recently the inaugural recipient of the 2015 Dalhousie University Award for Excellence in Graduate Supervision.

You can also follow Sara on Twitter!

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Monday, March 27, 2017

The Nannies In Philadelphia Will No Longer Sell You 2L Bottles of Soda

Yup, you read that right - if you live in Philadelphia and you want to buy a 2L bottle of soda, soon you'll be forced to buy two 1L bottles.

And yet there's no outcry from the beverage industry.

You'd think there would be. After all, back when nanny Bloomberg tried to pass his cup size ban - the one that would have forced you to buy two 500ml cups if you wanted to drink the volume of a human stomach (1L) worth of soda at once, the beverage industry bought a full page advertisement in the New York Times to complain about it (that's it up above).

But what about Philadelphians' rights to buy as many giant bottles of Pepsi as they want? Why no screaming about Philadelphia's fun and freedom stealing nanny?

Because Philadelphia's nanny is the beverage industry. You see the beverage industry, consequent to Philadelphia's new soda tax, wants to ensure people keep buying plenty of product, and to help ease the tax' sting, they're going to stop selling 2L bottles (which incur more tax) altogether.

So the next time you're tempted to shout about the nanny state when someone like Bloomberg proposes a new policy designed to encourage decreased consumption of junk food, remember, you already live in a nanny state, and the food industry is your nanny.

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Friday, March 24, 2017

Rare Footage of the GOP's AHCA Planning and Prep

And yes, today is Funny Friday.

Have a great weekend!

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Wednesday, March 22, 2017

Junior Kindergarteners and The Unnecessary Crutch of Junk Food

Sent to me by a reader and I wanted to share.

It's part of a school newsletter for her kid's Junior Kindergarten class. Here's what caught her (and my) eye. On Wednesday's the school has a "WOW" day - where the students are encouraged to walk to school.

Those who did most recently received a free hot chocolate.

Also, kids who rode the bus to school received a free hot chocolate, because though not walkers, their use of public transport reduced greenhouse gas emissions.

Oh, and to raise money for the Canadian Wildlife Federation, the children were able to purchase hot chocolate. In all they raised $166.

In looking for a photo for this post, I came across another school's page discussing how, "Math plus Zippers equals Hot Chocolate Party!" whereby the kids in the class ate cookies and then learned how to graph by plotting how delicious they were, and then completed a second graph of whether or not they enjoyed marshmallows in their hot chocolate. Later that same week, to celebrate the fact that every kid learned how to do up their own jacket's zipper they were rewarded with a "Zipper Party" to celebrate the achievement with cookies and hot chocolate.

To be very clear, these schools aren't examples of schools that don't care about their kids, they're just examples of how normalized the use of junk food has become in rewarding and entertaining our children. Bet all of these kids would have had just as much, or more enjoyment, with an extra gym class, extended recess, a dress up day, a dance party, helping with the school's morning announcements, etc.

Just because junk food works, doesn't mean we need to use it.

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Monday, March 20, 2017

California Public Libraries Giving In-N-Out Burgers to 4 Year Olds

I've written about child literacy and junk food before with the young reader marketing partnerships and cause-washing of McDonald's, Pizza Hut, Burger King, and Arby's. Today's example comes from California Public Libraries and their promotion of In-N-Out's "Cover to Cover Club"

Here are the program's details as described by the Saratoga Springs Public Library

For every 5 library books your kid reads, they'll receive a coupon good for an "achievement award".

The award?

An In-N-Out hamburger or cheeseburger (limit 3 per child apparently)

Kids today have no shortage of opportunities to eat fast food. Should public libraries be encouraging, enabling, and permitting more? I'd also love to know if this initiative actually increases library foot traffic and books read or just rewards kids who were already reading for the love of reading with fast food?

And if city run public institutions wanted to provide some incentive for young kids to read and use libraries, how difficult would it be for them to partner with city run community centres to hand out coupons for free admissions to local public pools or with the Parks Service to hand out free day use fee coupons for a nearby State park?

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Friday, March 17, 2017

Just a Spectacular Supermarket Commercial Championing Produce Over Products

Thanks to one of my Facebook readers for sharing this incredible supermarket video that's serving as today's Funny Friday.

Have a great weekend!

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Thursday, March 16, 2017

A New Heart and Stroke Funded Report Calls For a "Sugary Drink" Tax

Not a soda tax. And not a sugar-sweetened beverage tax. Instead Canada's Heart and Stroke Foundation's (HSF) latest funded report makes the case for a "sugary drink" tax which would include of course sodas, sugar-sweetened beverages (chocolate milks and drinkable yogurts for instance), but also naturally sugary drinks like 100% juice.

According to the report, Canadians purchased an average of 444ml of sugary drinks per day. And that's a per capita average which includes people like the 5 members of my family who purchase an average of none a day - so clearly those who are drinking sugary drinks, are actually averaging more than that. Dishearteningly, things are even worse for youth with the report finding them buying 578ml per day for Canadians between 9-18 years old.

That's a huge amount, and while some might be confused given the regular coverage of decreasing soda and juice consumption, the report explains,
"Over the past 12 years (2004 to 2015), the per capita sales volume has decreased for regular soft drinks (-27%), fruit drinks (-22%), and 100% juice (-10%). In contrast, per capita sales volume increased for energy drinks (+638%), sweetened coffee (+579%), flavoured water (+527%), drinkable yogurt (+283%), sweetened tea (+36%), flavoured milk (+21%), and sports drinks (+4%). In 2004, sales of flavoured water, flavoured milk, drinkable yogurt, and energy drinks were negligible. However, by 2015, these categories accounted for approximately 18% of all sugary drink sales, and compensated for the 7% proportional reduction in sales of regular soft drinks since 2004."

Breaking it down into dollars and cents, the report estimates that sugary drink consumption will lead to over $50 billion in direct health care costs over the next 25 years coming from the costs associated with their projections of 25 years of unchecked sugary drink consumption contributing to
"900,000 new cases of type 2 diabetes, 300,000 new cases of ischemic heart disease, 100,000 new cases of cancer, and 40,000 strokes. Canadians’ sugary drink consumption is estimated to account for 63,000 deaths and almost 2.2 million disability adjusted life years (DALYs), which represent premature death or poor health."
In turn, according to their modelling, a 20% sugary drink tax would generate $43.6 billion in tax revenue as well as $11.5 billion in direct health care savings from averting many of the cases, conditions and DALYs noted above.

In my opinion it's a matter of when, not if, we'll have some form of sugary, or sugar-sweetened beverage tax in Canada, and the sooner, the better.

[If you're curious about the report's methodologies and assumptions, please head over to the HSF's media centre where they're hosting the full report.]

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Monday, March 13, 2017

New Research: Unless You Have Celiac Disease, It's Probably Not the Gluten

No one's saying that people's symptoms aren't real, but there's little doubt that more folks believe they have gluten sensitivities than actually have gluten sensitivities.

A recent study sought to explore that a bit further. The paper, Suspected Non-celiac Gluten Sensitivity Confirmed in few Patients After Gluten Challenge in Double-blind, Placebo-controlled Trials, examined all of the double blind placebo controlled trials that in turn showcased a gluten and a placebo challenge in people with self-identified non-celiac gluten sensitivity (NCGS). All told, when combined, there were 1,312 such study participants involved in 10 studies (most with differing methodologies).

Without getting stuck too deep in the weeds, the authors assert that someone who truly suffered with NCGS should both develop symptoms while being presented with their gluten inclusive challenge, as well as lack those same symptoms when presented with their placebo challenge. While many did in fact show sensitivity to the gluten challenge, they also demonstrated sensitivity to the placebo challenge (meaning they reported side effects on placebo too).

This finding led to the authors' conclusion
"The present review shows that over 80% of non-celiac patients, labelled as suffering from NCGS upon a favorable response to a gluten-free diet, cannot reach a formal diagnosis of NCGS after a double-blind, placebo-controlled gluten challenge."
Of course there are weaknesses to their analysis (as the authors point out) including the fact that there is no consistent, evidence based, methodology for these sorts of studies and that many of the studies used smaller gluten doses than the average daily amount currently being consumed in Western countries.

As to what's going on, the authors wonder too whether or not some studies are confounded by a failure to truly exclude those with celiac disease and/or whether some simply developed symptoms consequent to being sensitive to high FODMAPs. The authors also point out that it would be important to explore the many non-gluten proteins also found in wheat, and they included a diagram to explain the many possible symptomatic overlaps.

But at the end of the day, does it matter for those who report suffering?

Certainly if you suffer with a food sensitivity, and avoiding that food makes you feel better, no one, not me, nor the authors of this paper, would ever tell you to stop avoiding it.

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Saturday, March 11, 2017

Saturday Stories: Woolly Mammoths, Amish Forgiveness, Fetishised Virtue

By Flying Puffin - CC BY-SA 2.0
Ross Andersen in The Atlantic on how the resurrection of woolly mammoths might help in the fight against global warming.

Jake Edmiston in the National Post with a story of an Amish family's remarkable forgiveness.

Maajid Nawaz in The Times of Israel what what he sees as the fetishised "mother of all virtues".

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Friday, March 10, 2017

Real Italian Grandmothers Try The Olive Garden For The First Time

Today's Funny Friday is a treat. The Olive Garden? Not so much.

Have a great weekend!

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Wednesday, March 08, 2017

London Health Science Centre Says Eat Chicken Wings For Cancer

Today's installment of what seems like a never ending parade of questionable partnerships between hospitals and junk food is the eat chicken wings for cancer campaign being promoted by London Health Science Centre.

This particular campaign comes hot off the heels of the recent report in the British Medical Journal highlighting the strong evidence of obesity being a contributor to at least 11 different types of cancer.

Once again, I have to ask, are the dollars raised in these sorts of campaigns worth the promotion of lifestyles that themselves contribute to the burden of illness being seen by the very programs and providers the fundraising is meant to support?

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Monday, March 06, 2017

My Oldest Daughter Fixes Fronts of Packages - A Pictorial

For her science fair project, my oldest daughter looked at the impact of front of packages on consumer perceptions of health. As part of her study, she fixed up some package fronts with more realistic statements.

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Friday, March 03, 2017

Who Knew Guinea Pigs Loved Pumpkin Spice?

I sure didn't, but today's Funny Friday convinced me they do.

Have a great weekend!

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Wednesday, March 01, 2017

Should We Be Treating Type 2 Diabetes with Surgery?

Photo By Mr Hyde 
I'm resurrecting this piece, for the second time now, consequent to last week's online first publication in the New England Journal of Medicine of the 5 year data that continues to strongly support the use of bariatric surgery to treat type 2 diabetes.
In case you missed the news, a recent study published in the New England Journal of Medicine demonstrated dramatic superiority of surgery over intensive medical management in the treatment of type 2 diabetes.

Now I'm not going to get into the study here in great detail, but it's a continuation of a trial that's been running for 5 years now that is regarded as being well designed. And while admittedly we still don't know what their long, long, term benefit will be, at 5 years out, they look damn good with surgery coming out worlds better than "intensive medical therapy" for the treatment (and remission in many cases) of type 2 diabetes.

Of course time's definitely a fair concern. Meaning what if 10 years down the road the folks who had the surgery are no better off than those on medical therapy? Thing is, based on what we know already about the surgeries involved, all have well known 10 year data, and the bypasses and diversions much longer than that, and those studies, while they weren't specifically designed to look at diabetes alone, did look at weight and medical comorbidity regains, and I certainly don't recall anything that suggested diabetes returned with a vengeance.

So basically here we have a surgical intervention that is dramatically better than a medical one, for a condition that causes cumulative damage and can wreak havoc on a person's quality and quantity of life.

Yet many MDs, allied health professionals and health reporters, including some who I know, respect, and admire, are taking this opportunity to discuss how we shouldn't be looking to surgical solutions for diabetes because patients could instead use their forks and feet. While there's no argument about the fact that in a ideal world everyone would take it upon themselves to live the healthiest lives possible, there's two problems with that argument. Firstly, not everyone is interested in changing their lifestyle, and secondly, statistically speaking, the majority of even those who are interested and successful with lifestyle change will ultimately regress - the simple fact remains that we don't yet have a proven, reproducible and sustainable approach to lifestyle change.

And what of those folks not wanting to change?  I say, "so what?".   Since when did MDs, allied health professionals or health columnists earn the right to judge others on their abilities or desires to change? Our job is to provide patients with information - all information - including information on lifestyle change, medical management and surgery. We can even provide patients with our opinions as to which road we think may be best for them, and why, but honestly, given the results from these studies, I'm not sure how anyone could make an evidence based case that surgery isn't a very real and powerful option that ought to be discussed with all of their patients with type 2 diabetes and obesity.

Unless of course that someone has some form of weight (or simply anti-surgery) bias.

Let me give you another example. Let's say there was a surgical procedure that folks with breast cancer could undergo that would reduce their risk of breast cancer recurrence by roughly 30%.  Do you think anyone would question a woman's desire to have it? I can't imagine. And yet lifestyle - weight loss and exercise has indeed been shown to reduce risk of breast cancer recurrence by 30%. Think people would dare suggest the women choosing surgery were, "taking the easy way out", that they should just use their forks and feet?

We've got to get over ourselves.

Until we have a proven, remotely comparable, reproducible, sustainable, non-surgical option, if you bash the surgical option on its surface for being "easy", or "wrong", you might want to do a bit of soul searching as to whether or not you're practicing good medical caution, or if instead you're practicing plain, old, irrational bias.

[and for new readers to ensure there's no confusion - I'm not a surgeon]

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Monday, February 27, 2017

The Coca-Cola Company Supports Stricter Sugar Guidelines Than Health Canada

By Romain Behar
Last week Coca-Cola announced that they supported the World Health Organization's recommendation to limit added sugars to 10% of total daily calories.

Putting aside that it's difficult to limit that which you can't see or count, Health Canada recently announced that rather than recommend limits and listings to added sugars on food labels, they are going to do so only for total sugars.

Their rationale has been explained to me and others as being in part reflective of the fact that as a percentage of Canadians' total sugar consumption (the other was a regulatory concern that they couldn't identify added vs. intrinsic sugar by way of testing), added sugars make up roughly half of those, and therefore with Health Canada's proposed 100g limit to total sugars, and using simulated diets, they expect 50g of those to be free or added. Working off a 2,000 calorie diet (which itself may not be all that wise, but is the convention everywhere), that reflects the WHO's 10% recommended daily added sugar limit. Of course that's only if you follow Canada's Food Guide. And given that soda, candy, and what were once known as "other" foods, aren't part of the Guide, suggesting a total sugar value will serve as a useful surrogate will fail the vast majority of the population given studies have suggested  that 25% of the average Canadian's calories come from "other" foods.

Even if you put dietary reality aside for a moment, there's a big problem with the plan as more recent research calls Canadians' presumptive added sugar consumption into question. The research, spearheaded by PhD candidate Jodi Bernstein and working out of Dr. Mary L'Abbé's lab notes that prior guesstimates were based off data generated in part from the limited Canadian Nutrient File (CNF) - a database that according to Bernstein et al. lacks, "scheduled, systematic and comprehensive updating", and does not contain any brand specific data.

In the CNF's stead, Bernstein et al created their own database, the Food Label Information Program (FLIP) database, which they update every 3 years. The data was collected by way of boots on the ground in Toronto, Ottawa, and Calgary grocery stores representing 75% of the market share. There, researchers used a smartphone to scan and categorize every single item with a Nutrition Facts table (NFt). Next, an algorithm was utilized to calculate the products' free and added sugars.

Among their FLIP derived conclusions is that rather than the 50% derived from the CNF, 62% of consumed sugar in Canada is from free and added sources.

In turn that means that Health Canada's arguments in support of their much criticized plan to list simply total sugar on future NFts, are weak, and may underestimate added sugar consumption, and that if you consume 100g of total sugar, you'll be exceeding the WHO's recommended daily added sugar maximum by 24%.

It also means that The Coca-Cola Company may now be supporting stricter added sugar limits than Health Canada.

[I should note though, both the 50% and the 62% are best guess estimates. In turn I'd say that speaks to why we'd be far better off with an added rather than total sugar listing on our NFts.]

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Saturday, February 25, 2017

Saturday Stories: Facts, Evidence, and Drugs

Elizabeth Kolbert in The New Yorker on why facts don't change our minds.

David Epstein and Propublica in The Atlantic on when evidence says no, but the doctor say yes.

John LaMattina in Science on drug approval in the era of Trump.

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Friday, February 24, 2017

This Hour Has 22 Minutes Meets Governor Mike Huckabee

National Canadian treasure Rick Mercer interviews Governor Mike Huckabee who congratulates Canada on what-now for today's Funny Friday?

Have a great weekend!

[h/t to friend and colleague Dr. Mario Elia]

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Thursday, February 23, 2017

Industry Self-Regulation of Marketing to Kids is Worthless - McDonald's Edition

So maybe you've heard of The Canadian Children’s Food and Beverage Advertising Initiative Commitment (CAI) - it's the voluntary program that the food industry has adopted as their defense against a legislated ad ban for marketing their products to children. The thinking goes that legislated regulation (which undoubtedly will be stricter than the CAI) isn't necessary if the industry is able to police itself.

Just a few weeks ago I wrote about the Heart and Stroke Foundation's newest report card on health, The Kids Are Not Alright, which highlighted the fact that companies signed onto the CAI were serving up millions of online annual junk food advertisements to kids.

Well here's yet another example of the failure of industry self-regulation.

It was sent to me by a mom whose 2 year old came home from daycare on Valentine's day with a McDonald's coupon book.

Here are some of the coupons:

Now McDonald's is pretty clear on their CAI commitment. They committed to ensuring that 100% of their advertising to kids was for "healthy dietary choices" and/or promoting "healthy lifestyle messages" ,

Clearly these coupons don't meet either of those criteria.

And just in case you're tempted to suggest that these coupon books weren't meant for kids, you should know that the coupons are (their caplocks and bold, not mine),
If we as a society want to rein in the predatory marketing practices of the food industry that target our children, we're going to need to do that ourselves as industry self-regulation continually proves itself to be worthless.

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Tuesday, February 21, 2017

Running More Doesn't Burn Any Extra Overall Calories (In Mice)

In terms of the constrained energy expenditure model of physical activity (whereby beyond a certain increase in activity, total daily calorie expenditure stays the same), this small mouse study is pretty cool.

15 mice were housed in indirect calorimetry chambers that contained running wheels. The experiment included a habituation phase, then a locked wheel phase, and finally a run as much as they wanted phase.

All told, despite a doubling of wheel use, the mice' total daily energy expenditures stayed roughly the same - elevated somewhat from their wheel locked baseline, but stuck at an elevation seen with slight use.

The researchers observed a pattern they'd previously hypothesized - mice who ran more on the wheel, were less active when off the wheel. And though not measured, researchers also wondered whether increased muscle efficiencies with time might also be playing a role in the lack of increased energy expenditures.

The researchers' not-meant-for-mice conclusion echoes my confirmation bias,
"physical activity should be encouraged for its overall health benefits, while expectations concerning its role in weight loss should be kept realistic."
Exercise is primarily for health, not weight loss.

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