A Magic Label Reading Hack For Choosing Higher Quality Carbohydrates

Ok, so it's not magic - it's better - it's evidence based!

With a team of some of the who's who in nutritional epidemiology Dr. Rebecca Mozaffarian and colleagues explored the various whole grain identifiers currently festooned on fronts-of-packages. They looked at that food industry sponsored Whole Grain stamp (up above), whole grain as the first ingredient, whole grains first without added sugars, the word "whole" before any grain in the ingredients as well as the ratio of total carbohydrate to fibre. With each they further investigated their relationship with other health-related criteria including fibre, sugar, sodium, calories, trans-fat and price.

The results?

545 products later and guess what? Products proudly displaying that food industry sponsored whole grain stamp were found to be significantly higher in both sugar and calories. So too were products identified on the basis of a simple hunt for "whole grain" as a first ingredient and the word "whole" before each grain.

The best measure?

The ratio of total carbohydrates to fibre where a ratio of 10:1 or lower was the best measure and identified products that broadly contained more fibre, less sugars, less sodium and less trans-fat, along with fewer calories.

So if you're trying to figure out which bread, cracker or cereal to buy, to help with your decision, simply divide any product's total carbohydrates by its fibre and look for a number less than 10.

Now this isn't a perfect formula as many products nowadays are now being spiked with ingredients such as oat hulls to artificially increase fibre content, but in a pinch, it's certainly an easy rule to remember.

Of course the real lesson to be learned here is one that is not particularly surprising - it's that the food industry sponsored whole grain stamp seen up above should be ignored, as should pretty much all industry sponsored front-of-package claims and programs.

Why "Just Shop the Periphery" Isn't Necessarily Great Advice - A Photo Essay

Why I Don't Buy the "I Don't" Approach to Dietary Discretion

Not sure if you caught the LA Times last week and their piece on the utility of using the words, "I Don't", in place of, "I Can't", when considering a dietary indulgence. The crux of the piece is that when you want a cookie let's say, rather than tell yourself that you can't have one, tell yourself that you don't eat them.

The recommendations didn't come out of nowhere either, they came from a paper published in August's Journal of Consumer Research where researchers found that when it came to resisting cravings self talk saying, "I don't", was 3 times as effective as saying, "no", and 8 times as effective as saying, "I can't".

My issue isn't with whether or not the words, "I don't", are good ones (clearly they're better than "no" and "I can't"), my issue is whether or not blind restriction is a sustainable long term strategy.  My experience says that it isn't, and that blind restriction, the belief that if you're trying to manage weight or live healthfully you simply can't (or don't) eat nutritionally bereft but hedonically wonderful foods, is one of the reasons so many dieters ultimately fail.

Thinking you're going to live a life where you're not allowed to take pleasure from food? I don't think that's realistic and I don't think it's a good plan as I agree with the article, we're hardwired to enjoy the bad stuff.

As always I'm a broken record. It's about the healthiest life that you can enjoy, not the healthiest life that you can tolerate, and that means the smallest amount of bad-for-you indulgence that you need to enjoy your life, and that amount should definitely not be none.  Saying "I don't" every time you face the desire to take pleasure from food just means that you're on a diet - something that history has likely already taught you is a temporary state of being.  If you really want to say I don't, how about saying, "I don't diet", the next time you think that blind restriction is the way to go.

How Many Meals a Day Should You Eat?

"Should" is such a strong word.

Looking to the evidence base isn't much help either as there's plenty of evidence to support pretty much each and every eating style, modality, and diet.  Moreover, I'd argue that even if the evidence did firmly fall into the camp of one style or diet being "the best", that wouldn't change the fact that following it may prove non-enjoyable (and hence non-sustainable) to many.

"Should" presumes that everyone is the same. Same genetics, same co-morbidities, same lifestyles, same likes, same dislikes, same, same, same.

The thing is we're not all the same.

In my practice we tend to start people on 3 meals and 2-3 snacks a day, all inclusive of protein and at least 300 calories a meal and 100 a snack. We do that because experientially with us, for a great many folks, that spread has proven helpful in reducing cravings, hunger and struggle, and for busy people with jobs and young families, it's often more practical than larger, less frequent meals.

But it's not useful for everyone!

We have other folks on 3 square meal a day regimes.

I've even suggested an intermittent fasting (IF) style 2 meals a day to folks whose lifestyles and struggles suggested they may be well suited to it.

And as far as dietary style goes we've had Paleo folks, classic low-carb'ers, vegetarians, vegans, low-fat fanatics and certainly everything in between.

In my clinical practice, I'm not married to anything other than a person living the healthiest life they can honestly enjoy.

Those folks who firmly believe everyone "should" be doing things a certain way? That there's one "right" way to diet; one "right" way to eat; one "right" form of exercise; one "right" road to health?

I think they're wrong.

It Doesn't Need To Be So Complicated

I received an email on Friday from a reader who had read some of the writings of a nutrition guru and wanted my take on them. I get emails like that a lot.

Regardless of the guru, my answer's always the same, "It doesn't need to be so complicated" I'll tell them.

Even if the nutritional gurus and zealots were absolutely, 100%, scientifically bang-on with their edicts and commandments, I'd still stick with that message.

Not because I necessarily know better about nutrition, but rather because I work with actual people, real life folks who go to work, who worry about their finances, who shuttle their kids back and forth to hockey, who are trying to do their best. And while there's no doubt that it's possible one of these nutrition gurus will actually, indisputably, get it right, it won't change the fact that real people need to like the lives they're living, even if they're not nutritionally perfect.

Real life folks? Here are my recommendations:

• Cook more.
• Use whole ingredients.
• Eat out less frequently.
• Cook together as a family.
• Eat together around a table.
• Exercise regularly and with joy.

And while those instructions may not satisfy the gurus and zealots who demand perfection, I'm guessing they'll take you a very long way health wise.

It doesn't need to be so complicated.

What Reading that White Rice and Diabetes Study Actually Told Me

The short version of what it told me was that the BMJ is actively and willfully abusing the public's trust, and it also told me that many low-carb and paleo diet guru bloggers and tweeps don't care about bad nutritional epidemiology so long as it vilifies carbs.

Here's the longer version starting with the BMJ.

Last week the BMJ published another observational dietary study out of Harvard. This time the study's focus was on white rice and it involved a meta-analysis of the medical literature on white rice consumption and its impact upon the risk of developing type 2 diabetes.

According to the study's authors, prior studies on white rice and type 2 diabetes had mixed results, and so in order to try to illuminate them, they undertook a literature review. In the end the authors' exclusion criteria left them with only 4 studies detailing 7 separate cohort analyses. Follow ups in these cohorts ranged from 4 to 22 years, and of them, 2 had exceedingly low incidences of type 2 diabetes development and so the authors had to perform some statistical sleight of hand to include them.

Of the 7 cohort analyses, 2 did not control for differences in dietary consumption patterns (probably important if you're looking at the impact of dietary factors on diabetes development), 1 did not control for family history of diabetes, 6 did not control for income/socioeconomic status, and none controlled for consumption of other refined grains or sugars. Let me go over that last one again not one of their 7 cohort analyses controlled for consumption patterns of refined grains or added sugars (though 2 controlled for consumption of "bread" and "noodles" but these weren't broken down any further).

Pooling the data together led researchers to a relative risk of type 2 diabetes development of 1.27 for the highest white rice consumption with a 95% confidence interval possessing significant heterogeneity and starting at 1.04, which for the non-statisticians reading this means the finding is just barely interesting.

When the researchers then stratified the data by ethnicity they found that for Asian populations the pooled relative risk was 1.55 with a confidence interval starting at 1.2, and for Western populations a pooled relative risk of 1.12 with confidence intervals ranging from 0.94-1.33, meaning that according to their findings, the impact of white rice on diabetes risk only seems to exist in Asians.

Translation?

The most generous way I can spin it would be that this study, using pooled cohorts that left out tremendously important controls and considerations, when analyzed, suggested that white rice consumption increases the risk of diabetes development in Asian, but not Western, populations.

The worst way to spin it? The fact the cohorts used to determine this study's conclusions failed to consider incredibly relevant diabetes confounders like family history of diabetes, socioeconomic status, and dietary consumption patterns, including the dietary consumption of other categories of refined grains, makes quantifying the effect on diabetes development due to white rice consumption from this data set impossible.

And yet it was published in the BMJ?

But that's not the truly shocking part. This is. The BMJ published an accompanying editorial that rightly called the paper out on its methodological and statistical inadequacies and in conclusion stated,

"Although the findings of the current study are interesting they have few immediate implications for doctors, patients, or public health services and cannot support large scale action. Further research is needed to develop and substantiate the research hypothesis"

Yet what's the title and first line of the very same BMJ's press release regarding this statistically and methodologically weak paper,

"White Rice Increases Risk of Type 2 Diabetes

The risk of type 2 diabetes is significantly increased if white rice is eaten regularly, claims a study published today on bmj.com."

Where the next 6 paragraphs of the press release continue in that same conclusive and important sounding vein only to end with this last line,

"In an accompanying editorial, Dr Bruce Neal from the University of Sydney suggests that more, bigger studies are needed to substantiate the research hypothesis that white rice increases the chances of getting type 2 diabetes."

Guess which 7 of 8 press release paragraphs the media paid attention to?

Here are a sampling of actual media headlines as a consequence of the BMJ's misleading press release,

"Eating White Rice Daily Up Diabetes Risk" - CBS News

"White Rice 'Could Cause Diabetes'" - The Independent

"Think Twice About Rice? New Study's Advice" - ABC News

"White Rice Raises T2 Diabetes Risk, Claim Academics" - The Daily Telegraph

"White Rice Linked to Diabetes Risk" - WebMD

"White Rice May Increase Your Risk of Diabetes" - MSNBC

And of course the Twitterverse went crazy too and rice bashing tweets abounded, and from some rather influential tweeps including Dr. Sanjiv Chopra, Dean of Continuing Education at Harvard Medical School, the Harvard School of Public Health itself, journalist Greta Van Susteren, the American Society of Nephrology, the Drudge Report, and many, many, many, many more.

Now I'm not suggesting white rice is a wise food to consume. On the contrary, I generally recommend people try to minimize its consumption, but to be very clear, this study does not in any formative way, shape or form have the strength to draw any conclusions whatsoever on the specific impact white rice has on the risk of developing type 2 diabetes.

And what the hell is up with the BMJ? Publish a paper so weak that you feel the need to co-publish an editorial questioning the paper's design and conclusions and then simultaneously put out a press release that in turn purposely glosses over and misinforms the media about the paper's weak conclusions?

And lastly, where is the low-carb and paleo bloggers' and tweeps' outrage? We saw it surge like never before when a far more rigorously controlled and designed observational study on red meat came out just a week before, and yet here there's pretty much critical silence (Zoe Harcombe being a notable exception).  There were even examples where prominent low-carb and paleo folks retweeted the press releases to their followers as if they were facts, when just days before those very same tweeps were tweeting their outrage at what they saw as the meat study's undeserved promotion.

The real lessons here?  Confirmation biases and impact factors sure do cloud our judgements and analyses.

What Reading that Red Meat and Die Study Actually Told Me

According to the authors, their study was undertaken because prior studies demonstrating risk to red meat consumption were flawed. Some had utilized populations that weren't representative of the average, while others didn't differentiate between unprocessed and processed meats, and where others still had covariates assessed at baseline only.

Here the authors analyzed 28 and 22 years of data respectively (2.96 million person years) from the Nurses Health Study and the Healthy Professionals Follow Up Study involving 37,698 men and 83,644 women who were free of cardiovascular disease and cancer at baseline, and whose diets were assessed by 7 sequential (every 2-4 years) validated food frequency questionnaires. Given dietary recall difficulties, undoubtedly the questionnaires are from from perfect, however unlike the vast majority of other food/risk studies that utilize them (there's not a huge amount of choice but to do so), the data from the questionnaires here were adjusted using the correlation coefficients that separate and published validity analyses (here and here) of their own specific study population's food frequency questionnaires determined were required to at least try to account for their subjects' dietary recall inaccuracies.

The authors also controlled for the following potentially confounding variables:

• Age
• Body mass index
• Ethnicity (though this was weak, white or non white were the only two choices)
• Smoking status (never, past, current with current being subdivided into 3 quantities)
• Alcohol intake (4 gradations)
• Physical activity level (5 gradations)
• Multivitamin use
• Aspirin use
• Family history of diabetes
• Family history of myocardial infarction
• Family history of cancer
• Baseline history of diabetes
• Baseline history of hypertension
• Baseline history of hypercholesterolemia
• Menopausal status
• Menopausal hormone use
• Total caloric intake
• Quintiles of fish consumption
• Quintiles of poultry consumption
• Quintiles of nut consumption
• Quintiles of legume consumption
• Quintiles of dairy consumption
• Quintiles of dietary glycemic load
• Quintiles of dietary cereal fiber consumption
• Quintiles of dietary magnesium consumption
• Quintiles of dietary polyunsatured fat consumption
• Quintiles of dietary trans-fat consumption

Further, they performed a whole bunch of beyond my pay scale statistics when exploring red meat specifically (eg "restricted cubic spline regressions with 4 knots").

When analyzing the data they discovered that men and women with higher intakes of red meat were less likely to be physically active and were more likely to be current smokers, to drink alcohol, to have a higher body mass index, to consume greater total amounts of calories and to have lower intakes of whole grains, fruits and vegetables, but even after controlling for all of those confounders, unprocessed and processed red meat consumption were found to be associated with an increased risk of total mortality, cardiovascular mortality and cancer mortality.

So are you going to die if you eat red meat?

Well you're going to die regardless of what you eat, but this study would suggest that you'll die ever so slightly younger if you eat red meat each and every day of the week, and even younger still if you eat processed red meat each and every day of the week. Did you catch the caveat of each and every day of the week? It certainly wasn't hidden in the study.

So how much younger will you die? According to the study, eat unprocessed red meat daily and your risk of death will be 13% higher than if you don't. Eat processed meat daily and it'll be 20% higher. Those of course are relative risks. In absolute terms your risk of dying younger due to red or processed meat consumption doesn't amount to a huge number, nor do the study authors sensationalize their paper to suggest that it does. The media (and perhaps the study's press release - haven't seen it) did that. But that doesn't change the finding that this study did indeed determine there to be more risk associated to red meat consumption than other protein sources.

As to what it is about red meat that's seems to confer risk? We don't know.

All in all this is a strong study in that there's an incredible wealth of data along with tremendous confounder controls and considerations. We'll never have perfect studies regarding foods and risks because we'll never randomize folks to long term diets differing in single variables and so studies like this one - long term, huge numbers, confounder controlled, thoughtfully considered - are the best we're going to get, and while I'm sure there are variables some axe grinders will wish were included, or analyses they'd love to have seen, to me at least it seems they included all the big ticket issues, and some smaller ticket ones for good measure.

If there's criticism to be had it's in the study's reporting, where the distinction of eating red or processed meat daily is lost in the hype, and where the reporting leaves readers thinking they can never safely enjoy a burger, a steak or a hot dog.

That's certainly not what the study or its authors said. In fact one of the authors, Harvard's Frank Hu stated,

"A moderate consumption, for example one serving every other day, I think is fine."

While the study's lead author An Pan told the LA Times whose headline ran, "All Red Meat is Bad For You" that he eats two servings of red meat a week.

And this isn't really news. Basically the study's take home message is that proteins come in both healthy and unhealthy packaging.

And that's where my Internet confusion comes in. Just as ridiculous as the all encompassing, "All Meat is Bad" chant that came from the mass media was the, "this study is terrible" chant of the Internet, a chant generally coming from those same people who will readily agree that there are less and more healthful carbohydrates (and fats). Seems to me a careful read of the paper would have perhaps toned down both the media's reporting and the Internet's rhetoric, whereas relying on press releases and newspaper reports, well that fuels misinformation, and apparently in this case, what comes off like frank anger.

I adore red meat. I also adore processed red meat. But ultimately this study just adds more weight to what the bulk of the literature has already concluded - processed and unprocessed red meats aren't my best protein choices and if consumed daily, carry risks, albeit absolutely small ones, that other protein sources seemingly don't.

Now maybe my read of the paper is off, and admittedly my stats days are long behind me so please feel free after actually reading the paper to weigh in if you think I've missed something, but for me, for now, yes, burgers are still on my menu this weekend (Mmmmmm, burgers), they're just not on it every day this week.

Pan, A., Sun, Q., Bernstein, A., Schulze, M., Manson, J., Stampfer, M., Willett, W., & Hu, F. (2012). Red Meat Consumption and Mortality: Results From 2 Prospective Cohort Studies Archives of Internal Medicine DOI: 10.1001/archinternmed.2011.2287

You Must be This Tall to Order This Meal

There's no doubt that one of the most significant drivers of societal weight gain over the decades has been our increasing reliance on eating foods prepared outside of our homes. Couple more frequent meals out with larger portions and certainly that's a recipe for gain for anyone, but an even more dangerous recipe for anyone with an impaired calorie burning ability.

What I mean is that if two folks sit down at a restaurant to eat together, regardless of the differences between those two folks, if they order the same meal, they'll get the same meal.  Sedentary 5ft tall middle aged mom with fibromyalgia sitting down to eat with her 6ft 2in College football linebacker son - same order, same meal.

But what if one of those folks burns fewer calories?

There are a great many reasons for someone to burn smaller numbers of calories. Among the most common of those would be advanced age, medications that impair metabolisms, and of course, vertical challenge.

It's a phenomenon that also plays out in households sometimes. I remember somewhere near to when my wife and I were married and she gained a small amount of weight. I wasn't involved in nutrition or weight management at the time, and I only had the most rudimentary understanding of things, but I figured that the crux of the matter was my wife was matching my portions. She told me that she felt she deserved to eat as much as I did, and while I certainly didn't disagree (I've always known better than to ever do that), the simplest way to put it was that yes, she could eat as much as me, but given that the amount of food I was eating supported my weight, my guess was that if she ate the same amount as me, eventually she'd weigh the same too....and I've got quite a few inches of height on her.

At the end of the day, folks with reasons to burn fewer calories, if they're concerned about their weights, understanding and calorie awareness becomes that much more important, as does minimizing meals out because after all, there are no signs on the menu reading,

"You must be this tall to order this meal."

(photo by Flickr's Futurowoman)

Have you Engaged an Indulgence Autopilot?

It's something I hear about frequently when I meet new patients,

"....and Friday is Pizza Night",

"Every Thursday the gang at work goes out for Dim Sum at lunch",

"After the kids' hockey on Saturday mornings we do drive thru Tim Horton's and share 20 Timbits"

Now I'm not knocking any of those choices directly. While certainly they're not healthy choices, and where I might even label them as nutritionally "bad" foods, the fact is they might be great indulgent choices.

What I mean is that we don't just eat food for sustenance.

Whether it's pizza, Chinese food or doughnuts, if those are part of your life's seminal guilty dietary indulgences, well then I think you probably owe it to yourself to continue to have them, because blindly cutting them out? I'm not sure taking away your favourite foods in honour of your health is a great plan because doing so will likely, over time, lead you to fully abandon whatever overly strict healthy living strategy you've adopted.

That said, you might want to take a moment to ask yourself a question like,

"Is the fact that it's Friday a good enough reason to order in pizza"

Ultimately, when it comes to dietary indulgences and hedonistic pleasure, the question isn't, "Are you allowed", but rather, "Is it worth it" and if so, "how much do I need to be satisfied?", where sometimes the answer may be, "No and none", and other times significantly more than that.  To illustrate what I mean - I'm thinking you'll be eating far more indulgent foods on your birthday than you'll be eating on my birthday.

But just because it's Friday? I'm guessing you can do better.

Disengage your indulgence autopilot and thoughtfully navigate your nutritional skies!

Mixing, Pouring, Adding, and Stirring Ain't Cooking!

As far as health goes, it may be Big Food's most destructive legacy - this notion that "home cooking" can consist of mixing packets, jars, and boxes together.

It's incredibly pervasive too.

Some examples:

Take box of dehydrated frozen refined flour noodles. Boil water. Add box. "Cook". Open jar of sauce. Add sauce.

Brown meat of choice. Add packet of "flavouring". Stir. Add to store bought buns, wraps or rehydrated "noodles".

Take frozen box of "food" of choice. Microwave or heat in oven. Optional - serve alongside baked bagged French fries.

Take ready made pizza. Heat in oven.

Mix package of brown powder with eggs and water. Put in cake pan. "Bake".

I could go on.

When I meet new patients, I'll always go through their eating out history, but rarely their eating-out-eating-in history, but I probably should.

Those examples up above? They'll get me as close to actual cooking as watching movies will get me to winning an Oscar.

Cooking, actual cooking, is the transformation of raw ingredients. And there's definitely something special about actual cooking. A sense of accomplishment, of healthfulness, of basic goodness - even when cooking less than stellar meals nutritionally.

Sadly, over the years, the food industry has aimed to co-opt that something special, literally designing foods that require the most basic of input and effort so as to perpetuate the gigantic white lie that we're "home cooking".

Is there a meal in your home you've unfairly labeled "home cooked"? If there is, how about trying to actually home cook it this week? It may well be easier than you think, and guaranteed, it'll be far more rewarding.

Does Dietary Elitism Scare People off "Healthy" Eating?

What is "healthy" eating?

I suppose everyone has their own definitions of what's involved, and certainly there are some dietary adherents where food becomes nearly a religion, but forget about them. I'm talking about the masses, the folks who don't spend their every waking moment living and breathing a particular dietary regime. What do your average Joes and Janes who aren't inherently keyed into nutrition picture when they hear the word, "healthy" regarding food?

My guess?

Sprouts - both brussel and otherwise.

And certainly salads. And maybe weird looking (to them) plates full of grains with currants or raisins. Maybe cottage cheese.  Definitely lots of water.

Probably also they think "vegetarian" or "fancy", or "complicated".

And while "healthy" need not be any of those things, sometimes I do have to wonder whether or not part of the problem in inspiring the world to choose healthier food is that the notion that healthy's fancy is one that does in fact get regularly perpetuated by folks preaching eating healthfully.

Take for example last week's New York Times. In it readers are presented with Martha Rose Shulman's ideas for, "a week’s worth of light and simple ideas for dishes that travel well.....lunches they can take to work and eat at a desk". Her ideas? I'll present them in picture form down below, but among them they include the ingredients: Beet greens, Swiss chard, chickpeas, Lundberg Black Japonica Rice, edamame, soaked red lentils, dark sesame oil, walnut oil, pinenuts, lightly toasted cumin seeds, Aleppo pepper, fennel, nigella seeds, and peeled kohlrabi.

Really? Those are "simple"? If that's "simple" for healthy eating, I'd hate to see fancy. And I bet I'm not alone.

Could articles suggesting dishes like these are "simple" actually hinder progress towards nudging people back into their kitchens?  Do we over complicate "healthy"?

Me? I'm pretty damn happy with my oven roasted chicken sandwich on whole grain bread with an apple, but I guess the problem with that "recipe" is that it wouldn't sell newspapers, books or glossy magazines.

So if the media is our primary influence on what is and isn't healthy, and if actually simple recipes don't grab readers, who's going to help get our nation re-learning how to cook actually simple, healthy meals?

I've got nothing.  Do you have any ideas?

(all food photos taken by Andrew Scrivani)

Dr. Sharma and I Have Single Bypasses!

Hope you're enjoying this holiday season! This week is traditionally my blog-cation and so instead of writing new posts, here is a favourite of mine from back in 2008.

What you see above is a picture of me and my friend and colleague Dr. Arya Sharma (The guy on the left. The guy with the stethoscope? That’s the Grill’s owner “Dr.” Jon) at the Heart Attack Grill (blogged about previously here), but really what you're seeing is a picture of Arya and me practicing what we preach.

You might think that my statement above doesn't make sense, after all, the Canadian Medical Association Journal labeled me a "nutritional watchdog" and I run a behavioural weight management program and Arya, well Arya's the head of Capital Health's Weight Wise - the country's largest tertiary care bariatric centre and the scientific director of the Canadian Obesity Network, how could us eating - "flatliner" fries and "single bypass" burgers reflect our practices?

Simple - we preach that food and calories, while worth monitoring for nutrition and weight, are also used in life for comfort and celebration, and if you can't use food for comfort and celebration from time to time, you're probably on a diet and long-term, it's probably going to fail.

In terms of my lifestyle, excluding vacations and conferences I probably eat out a maximum of twice a month and just like most folks, I enjoy the taste of some foods that are let's say less than optimally nutritious, and sometimes I'll indulge. However what I don't do is give myself a carte blanche during those meals out - instead I choose the healthiest option that I think I'll enjoy so for instance at the Heart Attack Grill I had the single bypass (rather than the double, triple or quadruple), shared a fries with Arya and had water to drink.

As I regularly say weight management and healthy eating - they're about living the healthiest lives you can enjoy, not the healthiest lives you can tolerate. The former's a liveable lifestyle, the latter's just another short-term diet.

So if you're in Phoenix and you're so inclined, the Heart Attack Grill might well be worth a visit, but as the posting on their door states in big, bold, red writing,

"Caution! This Establishment is BAD for your Health!"

[Originally posted October 9th, 2008]

Has Your Doctor Ever Taken a Lifestyle History?

Whether you're worried about your weight or not, how you live your life - how you eat and how you play - will markedly impact on your health and well being. In fact it'll impact on your health far more than any drug your physician could ever prescribe.

So why is it that most people have never had their physicians discuss healthy living with them?

Sure, a doc may ask you whether or not you exercise, and might even inquire into your sleep, but do they delve further?

My belief, though unproven, isn't that doctors aren't interested, and it's not that they're unaware of the benefits of healthy living, but rather that they're simply not taught to consider lifestyle in their clinical history taking, nor how to champion healthy living effectively.

So what are the top 10 things I would want physicians to explore with you at a bare minimum?

In no particular order:

1. How many meals do you eat out (including cafeterias), order in or take out (including prepared supermarket counter foods) per week?
2. Do you feel comfortable cooking?
3. How many meals a week do you cook yourself by means of the actual transformation of raw ingredients?
4. How many glasses of milk, juice, sugared soda and/or alcohol do you drink a day?
5. What do you put in your coffee or tea, and how many do you drink a day?
6. What's your typical pattern of daily eating (ie do you miss meals or snacks and what do you typically have for breakfast/snacks/etc.?)?
7. (If married and/or with children) How many meals a week do you eat together as a family?
8. What was your favourite sport or activity as a kid and why aren't you doing it today?
9. How many minutes of simple walking might you be able to add to your day without it being a hardship, and when would it be (ensuring goal here is Specific, Measurable, Attainable, Realistic and Timely)?
10. (If a parent of still at home children) Are you living the life, food, fitness and health wise, that you want your child to be living, and if not, what do you think you might improve?

While I realize this list is by no means exhaustive (for instance it doesn't touch on other hugely important issues like relationships, friendships, sleep, job satisfaction, parental struggles, sandwich generation issues, socio-economic stressors, etc.) and may only scratch the surface of healthy living, it would certainly help a physician to get a sense of how their patients are managing their two most important determinants of health, and provide a myriad of opportunities to try to help collaboratively trouble shoot common barriers to healthy lifestyles.

Unfortunately, while we physicians are all taught to examine the micro level minutia of each and every physical system in our annual review of systems, I strongly and firmly believe that as far as health benefits go, it'd be far more valuable to our patients to review the macro level of how they're are actually living their lives.

Of course asking those questions up above will also necessitate having answers...and sadly, therein lies the problem.

Medical schools and residency programs may do wonderful jobs at preparing us on how to treat illness with pharmacotherapy, but sadly the vast majority do a respectively terrible job at preparing us how to help patients manage, as Yale's David Katz puts it, "medical destiny's master levers" - forks and feet.

Here's hoping that one day, the day will come where forks and feet get the medical respect they so clearly and desperately deserve.

Is "Fourth Meal" contributing to rising obesity rates?

Never heard of "Fourth Meal"?

According to Taco Bell it's, "the meal between dinner and breakfast", and kidding aside, it makes me think.

Certainly for College students out partying, Fourth Meal's pretty normal. I certainly had my share of Fourth Meals back in the day.

But what about the rest of us?

I'm betting that Fourth Meal is far more common than most might think. Now it may not be a formalized meal, but I know that night eating is certainly a prevalent affair. And it may actually only be "Second Meal" as that person may well have skipped breakfast and lunch.

I'm guessing there are a great many packs of cookies and whole bags of chips that make up home based Fourth Meals.

My take on night eating is that more often than not it's a response to poorly organized daytime eating and that once a person's eating every 2-3 hours, with sufficient calories and protein, nighttime struggles (and Fourth Meals) tend to disappear.

Don't believe me? It certainly can't hurt to try.

Here's what I'd recommend:

Breakfast within 60 minutes of waking up.

Eating every 2-3 hours.

Meals with a minimum of 300 calories for women and 400 calories for men.

Snacks with a minimum of 100 calories for women and 150 calories for men.

8 or more grams of protein with every meal and snack.

A rose may be a rose but perhaps a calorie's not a calorie

File this one under cool data!

Simple study published in Food and Nutrition Research to look at the differences between whole foods and processed foods and the calories the body utilizes to metabolize them (something called diet induced thermogenesis and also known as the thermic effect of food).

18 subjects were enrolled in a cross-over study (meaning they each ate both test meals) whereby the thermic effect of food was measured following the ingestion of two different cheese sandwiches.

One cheese sandwich was made with cheddar cheese and a multi-grain bread containing whole sunflower seeds and whole-grain kernels, while the other cheese sandwich was made with white bread and processed cheese.

Both sandwiches contained the same number of calories.

The results?

While subjects reported that the whole food sandwich was tastier, both sandwiches conferred equal levels of satiety, and in a not completely surprising, but ultimately fascinating result, eating the whole food sandwich led to roughly double the thermic effect of food than the processed sandwich and that effect lasted nearly an hour longer than the processed meals.

Why wasn't this surprising?

Whole grains take longer to digest due to the protective fibrous sheath that processing removes. We also would expect the whole grain sandwich to have more protein and fat (which it did) which in turn delays the speed with which the body is able to break down its accompanying carbohydrates.

Calorically what does this mean?

It takes more energy to release the nutrients of the whole food sandwich with the differences between meals resulting in a 9.7% increase in the net energy gain of the processed food meal.

Translation?

Eat processed crap and you're effectively consuming 10% more calories than you would be were you eating healthier whole food alternatives.

Now this is a small study and certainly it's too soon to extrapolate this across the board, but were it to be true for all processed foods, given their viral spread across the developed world these past 30 years, and given that a 10% net energy gain is huge, this might be another great reason to ditch the Wonder bread and Velveeta.

Barr, S., & Wright, J. (2010). Postprandial energy expenditure in whole-food and processed-food meals: implications for daily energy expenditure Food & Nutrition Research, 53 DOI: 10.3402/fnr.v54i0.5144

I call "Bullshit" on Penn and Teller

Thanks to Ottawa Skeptics founder and Reality Check podcast host Jonathan Abrams for passing on a link to Penn and Teller's recent Bullshit! episode on fast food.

Up front I'll tell you I've been a big Bullshit! fan and for those who aren't familiar basically it's a show where mouthy magicians Penn and Teller question the facts behind commonly held beliefs, institutions and ideals.

For the vast majority of the topics they cover, I really don't have an expert opinion and generally I've tended to agreed with Penn and Teller's take on just how backwards some people think about a certain subject matter.

They're also magicians and when I've seen them perform their tricks, I've been wowed.

That said, I wonder if I'd have been just as wowed were I a magician and was able to see through their misdirection and sleight of hand.

With regards to their Bullshit! episode on fast food, given that I do know a fair bit about fast food, obesity and nutritional advocacy, I can tell you it sure wasn't tough to see through their misdirection and sleight of tongue.

The episode (and you can watch it below and draw your own opinions) hinges on some simple premises:

1. Opponents of fast food want it regulated out of existence.
2. Opponents of fast food believe that eating it makes you fat.
3. Opponents of fast food think those who eat it are inherently lazy or otherwise flawed.
4. Opponents of fast food think there's a conspiracy among fast food purveyors to create addictive foodstuff.
5. Opponents of fast food want the government to control everything we eat.
6. Proponents of fast food are hard working mothers and fathers who rely on it to serve healthy meals on the quick to their families.

I'll get to those points in a moment but first let me talk about who they decided to interview to champion the anti fast food cause. Her name is MeMe Roth and she's certainly the lunatic fringe of anti-obesity activism. I've blogged about her loathsomeness in the past and not surprisingly she's got some pretty loony things to say (go figure - when you interview someone from the lunatic fringe you'll get some pretty wild statements). Choosing MeMe to represent the anti-fast food argument would be like choosing Pat Robertson to represent modern Christianity or Osama Bin Laden to represents the tenets of 21st century Islam.

With regards to the show's main arguments, plainly put they're asinine.

Healthy eating advocates don't believe that eating fast food magically causes weight gain - they know that caloric imbalance does, and that restaurants fast and slow alike, are a huge contributor to that imbalance. They know that over the course of the past 30 years people have stopped cooking, and more and more dollars are being spent on food purchased outside of the home, foods with boatloads of calories, cups of salt and buckets of sugar - things that aren't good for our health.

Healthy eating advocates don't believe in banning fast or slow food, they believe in empowering people with enough information to make healthier and more educated choices in all restaurants and about protecting our most vulnerable and most precious resource - our kids from predatory marketing practices.

Being a healthy eating advocate myself I can tell you what I want to see change:

- I want a level playing field where people are provided with calorie counts at point of purchase in clearly visible locations so as to help those people make informed caloric decisions.

- I want to end the predatory practice of targeting children too young to discern truth from advertising with spots that extol the virtues of nutritional garbage or cartoon characters that beckon from the grocery aisle.

- I want taxes in place that discourage the consumption of products that are exceedingly unhealthy (and here I can't fault Penn and Teller, but since their show aired there's proof out of Harvard that sugar-sweetened taxes do indeed work to reduce soda consumption) which in turn impacts on the bottom line of Canada's health care expenditures, GDP and my taxes. And it's not as if there isn't precedent here. Regulating unnecessary risk is certainly part of the purvey of government, especially a government in a country with socialized medicine. From tobacco taxes, to seat-belt and helmet laws, to licensing requirements etc., governments do it all the time.

- I want changes in fast food zoning around schools as studies have shown disproportionate placement of fast food locations within walking distance of them.

The one argument I agreed with in this episode was the fact that governments are considering creating soda taxes while simultaneously subsidizing the production of corn. That is a ridiculous dichotomy as the artificially low prices of corn (and consequently high fructose corn syrup) are one of the primary drivers of cheap calories.

The biggest bullshit in this episode? For me it had to be the skinny active family who were talking about how much time they save with fast food. How long does it take to make oatmeal or some eggs for breakfast? How long would it take to do a quick stirfry or make some sandwiches for supper? And $20 to feed a family of 4 for a single meal? I can feed my family of 5 healthily on less than half of that.

Penn and Teller sum up this episode by letting the skinny mom who feeds her kids a diet heavy in fast food state,

"It's up to everyone to choose what they want to eat"

And she's absolutely right and only truly loony folks like MeMe would argue otherwise. What I want, and what most healthy eating advocates want, is an environment that doesn't stack the deck in favour of selling fast food but rather stacks it in favour of informed, healthier choices.

Watching this episode and knowing a great deal about the subject matter certainly has me questioning Bullshit! as a whole. If this is how they report on fast food, who's to say that they don't grossly mischaracterize other arguments in other episodes?

If Penn and Teller really want to do a good Bullshit! episode let's see them take on the notion that it's faster or cheaper or just as healthy to buy fast food for your family than actually taking the time to cook. To that, and to pretty much this whole episode, I call bullshit.

Want to judge for yourself, here's the episode as posted on YouTube (until it gets yanked by Bravo):

food with a lower-case "f"!

Though most of us call it, "processed food" in this case Mrs. Q.'s going to show us it's, "school food".

Who's Mrs. Q.?

She's an anonymous teacher, at an anonymous school, in an anonymous State, who's taken it upon herself to eat school lunch, "just like the kids", every day in 2010.

She's also blogging about her experience.

Her blog, Fed Up: School Lunch Project describes what we're feeding our children and while her school's in the States, there's no reason to believe things are any better here in Canada.

What really blows me away - and I'm not talking about the obvious how can we serve kids the stuff we teach them is bad for us? What really blows me away is the fact that people make arguments about why it is we can't possibly change what the kids are eating because it'd be too difficult and/or too expensive.

Really? You want to save money on the backs of our children's health? We shouldn't try because it'd be challenging?

Great lessons for our kids there.

Oh, and for the Canadian readers, too expensive? Can't just look at school bottom lines as we live in a country with socialized medicine where the effects of poor diets indeed hit the country's bottom lines (and bottoms).

Too expensive to reform school food in Canada? I'd argue we can't afford not to.

In case you're wondering what good school food looks like, Mrs. Q. provided a link to Madison Wisconsin's REAP Program. Have a peek and see what can be done.

Just because something's tough to do, doesn't mean we shouldn't figure out a way to do it.

Food with a capital "F"!

I'm sure you've heard of Jamie Oliver. He's a 34 year old chef from England who has launched one of the world's more effective campaigns for healthy eating.

The crux of his message? Cook. Don't pick up takeout. Don't reheat boxes. Cook. Take actual whole foods, spend a few moments in your kitchen, and cook.

If you were only allowed to choose one intervention to make to improve your health there's no doubt it should be to cook.

Great chance too that it'd have a positive impact on your weight.

Are cooking classes mandatory in Canadian schools? Nope.

Are there free government sponsored cooking workshops? Nope.

Is the government considering a means to subsidize whole foods, the building blocks of cooking? Nope.

Would any of those measures be difficult to implement? Nope.

Should we hold our breath until they happen? Nope.

Sadly I don't think things have got bad enough to warrant our government actually taking food seriously. Yet Jamie's right to label this a catastrophe.

You know there is this bad habit of folks stepping back and saying that all of this is too complicated. That healthy eating is too complicated, that obesity is too complicated. That everything is too complicated to turn around. Consequently it seems public health efforts are paralyzed.

You know what, yup this stuff is complicated. How we got to this point is complicated. Food labeling is complicated. Nutrients are complicated.

Cooking on the other hand isn't all that complicated and its impact would be immense.

Combine Jamie Oliver's perfectly aimed recommendation to ensure every graduating high school student knows how to cook at least 10 healthy, affordable meals, with Michael Pollan's 7 word manifesto,

"Eat food. Not too much. Mostly plants."

and we'd be saving innumerable lives.

Jamie's wish?

"My wish is for you to help a strong, sustainable movement, to educate every child about food. To inspire families to cook again and empower people everywhere to fight obesity."

Watch Jamie's speech from TED 2010. Set aside the 20 mins and if you don't have time today, bookmark this post and come back when you've got a moment.

Stay tuned tomorrow when I show you what we're up against in the schools.

A personal trainer for eating your vegetables?

I've got one.

It's my subscription to a local farm's community shared agriculture (CSA) opportunity.

Why? Because really I'm like everyone else. Sometimes it's difficult to motivate myself to exercise and sometimes it's difficult to motivate myself to eat healthier.

To that end this year my family subscribed to Bryson Farms' CSA program. It's fantastic. Yes, it's more expensive than buying vegetables in the supermarket, but when left to our own devices my wife and I certainly weren't the most adventurous vegetable consumers. Now, each week, we receive a large bag of vegetables. Some are familiar to us while some are not. Bottom line for us it's analagous to folks using personal trainers to insprie themselves to exercise except here instead of paying for it and exercising we're paying for it and eating it.

In so doing we're also supporting local agriculture, eating pesticide free produce and just in general eating a heck of a lot more vegetables than we used to.

[If you're in Ottawa and you're interested in Bryson Farms' CSA just head over to their website to learn about their various options.]

The World's Best Holiday Weight Advice

3 words.

Don't. Get. Hungry.

Christmas (or Hanukkah or Kwanzaa or Muharram or any religious holiday) isn't preventable.

Hunger is.

Life includes Christmas.

Worst thing you could do to help control portions/foods/calories on Christmas? Save them up for the day because you know you have a big night. If you do that you'll hit your festive meal hungry and way over do it.

Best thing you could do? The day of - eat every 2-3 hours, include protein with every meal and snack, have at least 350 calories per meal and 150 calories per snack and then indulge because it's Christmas and not because you're hungry on Christmas.

Merry everything and Happy New Year!
Yoni

(On Blog-cation until January 5th!)