Wednesday, February 28, 2018

Maybe Stop With The Hot-Take Childhood Obesity Rate Trend Stories And Reports?

Or at the very least stop until we're actually as a society trying to do something about it? Because why would we expect it to change if we're not doing anything about it?

As to why stop? Well because despite not doing anything as a society, it seems to be changing....but not really the way you might expect.

Here's what coverage has looked like for the past 8 years

FALL IN 2013
All this to say, these annual takes? They don't make sense both in terms of the outcomes (up, down, sideways, gone, up, down, etc.), but also not in the context of change. Changes tend to occur consequent to changes, and given there really aren't any initiatives going on in the US or Canada that one might expect to impact on childhood obesity rates, perhaps the coverage instead could be about our inaction as a society on this sad file, rather than whether there's been a tiny blip up, down, or sideways in some survey's reported incidence.

Monday, February 26, 2018

Yes, Calories Counted (Literally) In The Recent #DIETFITS, Low-Carb, Low-Fat, Shootout Study

(Credit goes to RD Daniel Schultz for finding this reference in his read of the DIETFITS study and for sharing it via his excellent Twitter thread of thoughts on same)
In case you somehow missed it (though that seems hard to imagine), last week saw the publication of the excellent DIETFITS study - a year long, randomized, controlled trial, that compared the effects of low-carb and low-fat diets, on weight loss and other metabolic outcomes.

Briefly (and if you want to read a detailed synthesis you can read this one over at, DIETFITS found that over the course of a year, both low-fat and low-carb diets produced similar weight losses and had similar effects on various metabolic outcomes.

The coverage of the study was widespread, and integral to it was this notion that counting calories isn't necessary for weight-loss, or that it's less important than the foods consumed, in that this successful study's approach involved counselling participants to eat whole foods, be they low-carb or low-fat, while eschewing the rest. Put another way, according to the coverage, people were taught to monitor and care about the quality of their calories, not their quantity, and that this was sufficient to drive significant weight change regardless of whether the foods they consumed were low-carb, or low-fat.

That conclusion is problematic for two reasons.

First, there was no study arm that explicitly taught participants to carefully track their quantity of consumed calories with no emphasis on their quality. Such an arm would be important to conclude that quality of calories trumps quantity of calories for dieters.

But more importantly, and again, thanks to Daniel Schultz, it would seem that the bulk of participants were in fact counting calories as reported by the previously published DIETFITS study design and methods wherein it was reported,
"The most common dietary monitoring method used was the on-line MyFitnessPal tool"
And as anyone who has ever used MyFitnessPal (or any of the other app based trackers - some of which were also utilized by DIETFITS participants) knows, while yes they'll track what you're eating, their primary end-user feedback is calories. And so even if somehow participants did not know in advance that calories were a consideration in weight loss, MyFitnessPal use would have seen to it that they learned that fact very quickly.

You see, setting up a MyFitnessPal account requires the input of a number of different variables: Weight, height, goal weight, age, sex, and some demographics.

And once input, MyFitnessPal then lets you know how many calories you should be aiming at daily to hit your stated weight loss goal.

Finally, when you start entering foods, though macronutrients are also tracked, calories are MyFitnessPal's most prominent field whereby there's a running calorie tally at the top of your diary, along with their meal by meal breakdown.

So while participants may not have been provided with specific calorie goals by the researchers, they were recruited on the basis of being involved in a weight loss study, and without a doubt, they all knew, that when it comes to weight loss, calories do count, and the majority of them used an app that tracked their calories, provided them with a personalized daily calorie goal based on their desired losses, and reported those calories to them prominently every time the app was utilized. And it's difficult for me to imagine that information didn't affect participants' choices, and certainly is enough of a confounder so as to render the conclusion that counselling solely on dietary quality is sufficient to drive significant weight loss.

This doesn't diminish the study's actual findings, but when it comes to calories' quantity and quality, it would seem that there are those who want to promote the existence of a false dichotomy stating that only one or the other of those two variables count. Honestly, I come across it all the time. Angry folks who claim that when it comes to weight and/or health, calories don't matter at all and that what really matters is the quality or types of foods, or the folks who claim that the quality or types of foods don't matter at all, it just comes down to calories.

It's both of course.

The currency of weight is certainly calories, and while we all have our own unique internal fuel efficiencies when it comes to using or extracting energy from food or from our fat stores, at the end of the day, we still need a surplus of calories to gain, and a deficit of calories to lose.

But don't kid yourself - foods matter too. Choice of food matters in terms of health, but also in terms of how many calories our body expends in digestion, and more importantly, upon satiety, which in turn has a marked impact upon how many calories, and which foods, we choose to eat (and of course to health, but that's a whole different matter).

All this to say, the DIETFITS study is terrific, and speaks directly to my published confirmation bias that adherence to one's dietary strategies matter far more than the macronutrient breakdown of said strategy. It also speaks to my bias that when armed with information about both the quality and quantity of the calories we're consuming, and provided with ongoing attention and support, weight loss and improvements to various metabolic parameters are far from an impossibility.

Saturday, February 24, 2018

Saturday Stories: World's Worst Roommate, Sobriety, and Sexual Harassment

William Brennan, in The New Yorker, with a surprising story about the world's worst roommate.

Edith Zimmerman, in Spiral Bound, detailing her first year sober.

Kayla Webley Adle, in Marie Claire, on sexual harassment in science.

Tuesday, February 20, 2018

McDonald's, But Not Your Child's Elementary School, Removes Chocolate Milk From Their Menu

Not sure if you caught this news release last week. It detailed McDonald's announcement that they'll be overhauling their standard Happy Meal offering in a bid to, "support families".

Part of that "support" (I'll come back to the word, I promise), is ensuring,
"at least 50 percent or more of the Happy Meals listed on menus (restaurant menu boards, primary ordering screen of kiosks and owned mobile ordering applications) in each market will meet McDonald's new Global Happy Meal Nutrition Criteria of less than or equal to 600 calories; 10 percent of calories from saturated fat; 650mg sodium; and 10 percent of calories from added sugar"
And to meet those goals cheeseburgers will only be available by special request, a kids; fry size (smaller than current small) will be developed, bottled water will be a featured beverage option, and chocolate milk will only be available by special request.

Though I'm certainly happy that McDonald's Happy Meals will generally be lower in calories and sugar, here's the rub. While the rollout of this initiative speaks to health, corporations never make changes that they think will hurt their bottom lines. This is not an indictment - corporations aren't social service organizations - their goals are profit driven, and McDonald's are no exception as evidenced by their press release's first line,
"Today, McDonald's (NYSE:MCD) announced an expanded commitment to families, supporting the company's long-term global growth plan by leveraging its reach to impact children's meals"
They hope that these changes will bring in more families more often for more meals at McDonald's, which is good for their investors, but probably not so much so for public health, even without chocolate milk.

But you know which organization's goals aren't profit driven? Your children's elementary schools', yet their chocolate milk programs continue with no end in sight, and not just for a sometimes treat, but daily. If you wouldn't serve kids who didn't eat fruit, daily pie, you might want to rethink their daily chocolate milk.

Motivation aside, it's odd to see McDonald's being more proactive than our kids' schools on this file.

Saturday, February 17, 2018

Wednesday, February 14, 2018

PSA: Please Don't Joke About Sometimes Wishing You Had Anorexia

Given what I do for a living, it happens not infrequently that someone will joke with me about sometimes wishing they had anorexia or bulimia in the context of their struggles with weight management.

And while I can see where their unfortunate attempt at humour is coming from, it always leads me to have a gentle chat with them that contains these truths.

Lives are ripped apart by eating disorders. Families are devastated. People die.

Eating disorders aren't punchlines.

Monday, February 12, 2018

Some Evidence Canada's New Food Guide Will Care About Evidence

Though there's no white smoke signifying the publication of a new Food Guide billowing out of Health Canada's food directorate's chimney, there are some signs that when it's finally published, it may be evidence based.

Take for example this story.

It details the concerns of Conservative agriculture critic John Barlow and it contained some heartening quotes.

Here's my favourite,
"It is very clear…that Health Canada is going in a direction that is detrimental to our agriculture sector, detrimental to our food processors as well as our producers on the ground."
Now while I feel for any sector impacted by the future Guide's recommendations, that Health Canada is not actively capitulating to agricultural interests suggests that perhaps instead, it's sticking with science as its underpinning.

According to Barlow, his office has been flooded with concern from a broad range of agriculture groups who are nervous about Health Canada's new policy of not kowtowing to industry,
"I want to really stress this point. These letters are not only from the livestock industry or the dairy industry, there’s letters in here from grain growers, the horticulture associations — none of them want us as a government, in this food guide document, to be picking winners and losers. They all want to be successful."
While there may well be some disagreement among health professionals as to what truly constitutes a healthy diet, where there likely is no disagreement is the notion that the desires of various agricultural sectors to be "successful" doesn't factor in to dietary health at all.

And just as an odd aside, in the same article is a quote from Agriculture Minister Lawrence MacAulay who was asked to comment about agricultural concerns. His response?
"Without a question, what I want to see is Canadians make sure that they express their view on what’s presented and that’s why things are gazetted. My opinion — really, it’s Canadians opinion that really reflects what takes place on this and anything else that’s gazetted to make sure that is what they do want to have happen."
Here's hoping that's not how policy works in Canada, as while not bashing the public, I'm pretty sure Food Guides shouldn't be built on what Canadians' personal opinions about food happen to be.

So bring on the evidence, and for the matter, bring on the new Food Guide. Remind me again, why are we still waiting?

Saturday, February 10, 2018

Saturday Stories: Gender Balance, One In 259, And Terminal Wisdom

Am somewhat pleased to report that after being inspired by this piece by Ed Yong in The Atlantic, on how he spent two years correcting the gender imbalance of his quoted sources, I went back over my last year of Saturday Story pieces to discover that 46% of the 292 stories I've shared were written by women.

Chika Stacy Oriuwa, the only black student in her medical school class of 259 at U of T, in Flare, on how in her white coat she is more black than ever.

Alastair McAlpine, in The Guardian, expounds on his viral tweets about the lessons he's learned from terminally ill children.

Wednesday, February 07, 2018

Have Diabetes And Motivated To Change Your Lifestyle? Virta (And Maybe #Keto) Could Be Right For You

A quick post regarding an exciting study that dropped today in the release of Virta Health's one year data on the impact their intensive lifestyle counselling, coupled with their ketotic diet, had on patients with type 2 diabetes.

The results were impressive.

Of the 262 patients who started the year long study, 83% finished, and of those their metabolic biomarkers and weight improved dramatically. On average their hemoglobin A1C (a long term measure of blood sugar) dropped from 7.6 to 6.3, type 2 diabetes medications other than metfromin dropped from 56.9% to 29.7%, and insulin was reduced or eliminated in 94% of subjects who started out on insulin, while sulfonylureas were eliminated entirely. Weight dropped an average of 30lbs. Insulin resistance as measured by HOMA-IR dropped by 55%, hs-CRP by 39%, and triglycerides by 24%. Though LDL did rise by 10%, HDL rose by 18% and apolipoprotein B was unchanged.

All this to say that if you have type 2 diabetes, and you're motivated to make lifestyle changes, Virta health's program definitely appears to be worth considering.

But there are some caveats.

Firstly the study looked at individuals who self-identified as wanting to affect lifestyle change, and so their comparison with "usual care", which consisted of individuals identified by their MDs as having diabetes and then being relegated to their local diabetes education program, may not be a fair one.

Secondly, the intervention was incredibly robust and intensive. That's not a knock. I think it's terrific. It included,
"continuous care through intensive, digitally-enabled support including telemedicine access to a medical provider (physician or nurse practitioner), health coaching, nutrition and behavior change education and individualized care plans, biometric feedback, and peer support via an online community"
And where behaviour change techniques taught included,
"education of natural consequences, shaping knowledge, goal setting, self-monitoring, feedback, monitoring and reinforcement from health coach and medical provider, self-belief, social support, relapse prevention, associations, and repetition"
Patients were provided a cellular connected body weight scale, a glucometer and ketometer, and a bp cuff. Patients were then given access to a web-based application to input data and where they received monitoring, education, and communication with their team.

Food wise participants reported daily hunger, cravings, energy, and mood by way of a Likert scale and health coaches worked with patients individually to adjust intake.

It is notable that daily protein intake was targeted to 1.5g/kg, and also that their weight losses had pretty much leveled off by year's end.

I bring up the robust intervention only in that I'm not aware of any prior interventions with other dietary strategies that would compare and therefore at this point it's difficult to divvy up what percentage of outcomes relate to the intensity and frequency of the intervention, and what percentage to their high protein, low-carb, ketotic diet.

The cost of Virta Health (if not covered by your insurer), is reported by them to be (I have no affiliation BTW) $400/month, but given the cost of diabetes medications and the outcomes reported herein, those costs may well be offset by your results.

Monday, February 05, 2018

Canada, Where Dr. Feelgood Beer Sales Are Banned, But Vitamin Water's Are Allowed

What's wrong with this picture?

Last month the Liquor Control Board of Ontario banned the sale of Dr. Feelgood IPA on the basis that the snake encircling the hops paddle, coupled with the prescriptive looking ℞ in the D℞., would implicitly lead consumers to believe that the beer was a health food.

Yet Vitamin Water's liquid candy sales are just dandy (including of course in stores frequented by children). And so too are the hundreds, if not thousands, of packaged foods that explicitly purport to confer health benefits, not to mention an entire industry of supplements that promise health miracles.

It is so disappointing that Canada continues to allow the food industry to dupe consumers with impunity.

(And for the record, and not just because I enjoy IPAs, I think the LCBO is overreaching here, while Health Canada and the CFIA don't bother lifting any fingers at all)

Saturday, February 03, 2018