Docs! Please Stop Telling Patients How Many Pounds They Need to Lose!

I don't think a week goes by without a patient in my office recounting how at their last physical their doctor told them how many pounds they ought to try to lose. Sometimes those MDs will be going by BMI tables and aiming patients at a BMI less than 27. Othertimes those MDs will be pulling those numbers right out of their proverbial butts with random guesses of how much would be "good" or "healthy".

No doubt too, in the majority of cases, the recommendation to lose a particular amount of weight didn't come with any useful advice on how exactly those pounds were supposed to get lost.

So fellow MDs, if you're reading this, if you think weight is having a negative impact on one of your patient's health or quality of life I do think a respectful discussion of the issue is warranted. But before you go down that road you need to know a few things. Firstly you need to know that despite what society teaches, we don't have direct control over our weights. Sure, indirectly behavioural choices can influence weight, and yes, we can likely suffer ourselves down to whatever weight we choose, but suffering doesn't last, and consequently the direct control of losing "x" pounds - that's nonsense - if desire, guilt or shame were sufficient to lead to specific amounts of loss the world would be quite slim. Secondly you need to understand that if you have no useful weight management advice to offer beyond the less than useful, "try to eat less and move more", all you're really doing is undermining your doctor-patient relationship as the likelihood of your patients not wanting to lose if their weights are truly affecting their health or quality of life, is likely close to zero, and yet here you are, their doctor, telling them something they already know, inferring quite clearly that you think that if they just put their minds to it they could make it happen, while simultaneously offering them no actionable help or support whatsoever.

Docs, if you're concerned about one of your patients' weights, make sure you have a realistically actionable plan to help them with. If you yourselves are providing lifestyle advice, please make sure you have personally lived by that advice for at least a two month stretch to ensure it's remotely realistic and to help you to understand what your patients might face as challenges with it. If you don't plan on providing any advice yourself, please explore your community's options and find an organization or an individual that you personally research in regard to their program's safety, efficacy and ethics. And lastly, don't ever target numbers on scales as there's simply no way to ensure your patients will get there, nor is there necessarily any need that they do given that markedly subtotal losses, when combined with lifestyle changes (or even lifestyle changes alone without weight loss), are likely more powerful medically than any drug you have ever prescribed.

Putting this another way, as my friend Dr. Jamie Beckerman is liable to say, the goal must be the journey itself, not the destination.

Just Because You Can Pronounce It Doesn't Mean It's Good For You

It's sad to see the cooptation of Michael Pollan's message of not eating anything with ingredients you can't pronounce.

True, that message is exceedingly oversimplified and does lend itself to chemophobia, but ultimately I believe Pollan meant it as a means to steer people away from relying on products in place of produce, or at the very least steer them to products that were closer to produce.

And here's Kellogg's capitalizing on Pollan's very popular and well known message with their ad up above whose copy reads in part,

"Made with simple ingredients you recognize, Rice Krispies cereal makes a great bedtime snack for little ones"

So what simple ingredients are we talking about?

Rice, sugar, salt, malt (corn flour, malted barley), bht.

Putting aside the fact that I'd imagine most parents wouldn't recognize "bht", those ingredients certainly aren't what I'd be rushing to feed my kids as a bedtime snack.

Moreover, why do kids need a bedtime snack? Is that a great habit to build in yours?

I'd encourage you to champion produce to your little ones, not products, and never let a shmaltzy ad dupe you into believing that health comes in boxes, or that pronunciation is in and of itself actually a virtue.

The 11th Myth of Modern Day Dieting: There Are Bottles Full of Weight Loss

There are no shortage of products promising remarkable weight loss benefits. You can buy them from actual pharmacies and sometimes they're even promoted on television by actual doctors (or at least by one actual doctor). Yet the only thing remarkable about those bottles is that they're legally allowed to be sold.

If there were such a thing as bottles full of weight loss, the world would be very slim indeed.

Saturday Stories: Cancer, Phineas, Confusion and Camels.

Oncologist Dr. Peter Back in the New Yorker and his heartbreaking story of losing his wife to cancer.

Sam Kean in Slate with the actually true story of Phineas Gage.

Alan Henry in Lifehacker explains where the world's confusion in nutrition and health comes from.

Helen Branswell in Slate discusses why we should fear the camel.

[And if you don't follow me on Twitter or Facebook, here's my review of the must-see movie Fed Up, and here's my call to arms from the Globe and Mail on what you can do to fight the food industry]

I Have Something Nice to Say About Pom Wonderful!

At least one person who works there has a great sense of humour.

Here's Pom Wonderful's response to Last Week Tonight's John Oliver following his recommendation that people print up stickers and affix them to bottles in the supermarket (seen up above).

Have a great weekend!

Ontario's Former Minister of Health Promotion Now Flipping Burgers at McDonald's?

Former Minister of Health Promotion Jim Watson at a 2012 "McHappy Day"

Here's the copy a local talk radio station sent out to promote the Mayor's yesterday appearance at McDonald's,

"Mayor Jim Watson will be lending a hand flipping burgers at a McDonald's in Orleans this morning. Craving a Big Mac well what a better day to cave in then McHappy day. One dollar from every big mac, happy meal, and McCafe hot beverage will go to Ronald McDonald House and the CHEO foundation."

Mayor Jim Watson, in case you haven't figured it out yet, is also Ontario's former Minister of Health Promotion Jim Watson, and so difficult to make the case that he's unaware of the health consequences of society's normalization of junk food and the charitable health washing of unhealthy brands.

That said, maybe he thinks he's really lending a hand. Maybe he's unaware of just how truly detached McDonald's the corporation is from Ronald McDonald House the charity. This past fall Eat Drink Politics' Michele Simon put out a report entitled Clowning Around With Charity: How McDonald's Exploits Philanthropy and Targets Children where among many other revelations she revealed that the money McDonald's the corporation spent on just a two month television advertising campaign for Ronald McDonald House was in fact three times as much money as they actually gave to Ronald McDonald House that year. If this was about charity and not sales and charitable brand-washing you'd expect those numbers to be reversed, wouldn't you?

I wrote about Simon's report for US News and World Report and while you can click here to get to that full piece, I wanted to leave you with my last paragraph therein:

There's no questioning the value of Ronald McDonald House Charities to those who need their services, just as there's no questioning the value they provide McDonald's in polishing their brand, creating good will and promoting sales and profit. There was a time when the tobacco industry gave generously in a similar bid to benefit from co-branded good will, yet now it would be unthinkable to donate or support a tobacco-branded charity. Perhaps the time is now to rethink co-branded food industry charities and charitable donations, and as Simon suggests, in the case of McDonald's, rename and rebrand Ronald McDonald House Charities and recognize that food industry money with strings that tie directly to illness may not be in society's best interests to continue to take – however worthy the cause.

So here we have a Mayor and former Minister of Health Promotion and the CHEO Foundation further normalizing our toxic culture of convenience. Frankly I'd have expected more leadership from both.

Coca-Cola, If You Don't Market To Kids How Do You Explain Your Dr. Seuss Soda Fountains?

"Parents tell us they prefer to be the ones teaching their children about beverage choices. That's why for over 50 years we've adhered to a company policy that prohibits advertising soft drinks to children."

- Coca-Cola advertisement in the Canadian Medical Association Journal

So from that I'd have to gather that Universal Studio's Seuss Landing in Orlando isn't geared to small children as I snapped these photos there two months ago.

Pretty sure they speak for themselves.

The food industry is not a partner in health.

Words Cannot Describe This Idiocy From The BC Children's Hospital Foundation

In a world awash with nearly never ending opportunities for society (and especially kids) to eat candy and junk food, wouldn't you think that children's hospitals would be among those working diligently to provide us with fewer, not more, opportunities to consume it?

And the icing on the BC Children's Hospital Foundation's incredibly shortsighted and painfully stupid chocolate bar fundraising campaign pictured up above?

Each bar not only contains 520 calories (more than 2 Twix bars) packed with 13 teaspoons of sugar (nearly 16 Oreo's worth) but the damn things also contain 0.4g of artery-clogging trans-fat.

The mind boggles.

Thanks to Jean Burrows for sharing.

The 10th Myth of Modern Day Dieting: You Should Save Your Calories For Dinner

If you know you've got a big dinner planned, while it might intuitively make sense to try to skimp on your daytime eating, if you show up to your indulgent meal hungry, you're likely to eat back your savings and then some.

Given the average restaurant appetizer packs between 400-600 calories, and that bread baskets beckon before appetizers even arrive, and that decadent mains and desserts festoon all menus, if you show up to a restaurant hungry because you skimped all day long and between the bread, an appetizer, a more indulgent hunger-influenced main that you're more likely to finish,  and whatever daytime calorie savings you racked up will likely begone even before your main course arrives. On the other hand, show up not particularly hungry and suddenly the bread's less tempting, there'll be no need for an appetizer, your main is likely to be less indulgent (and perhaps not finished), and dessert'll be easier to share.

Bottom line for most meals out - if you save your calories for dinner, your overall daily total may well wind up higher than if you don't.

Saturday Stories: Restriction, Lux, Cochrane, Confessions & A Must Read

Restricting your kids' food is going to backfire explains New York Times' Tara Parker Pope.

A thoughtful New York Times Mark Bittman piece on comfort food, bagels and lux, and worries for comfort food's future.

Science Based Medicine's Marc Crislip has some crisp words about the value of Cochrane Reviews including, "There was a time when I was under the impression that the conclusions of a Cochrane review were of value. No more. Now I see one and a roll my eyes. What kind of Food Babian nonsense is this one going to have?".

My friend, colleague, and perhaps the most pumped physician in history Spenser Nadolsky on Precision Nutrition details his experiences as a low-carber undertaking an n=1 personal high carb experiment.

And with the must-read piece of the week it's Brooke: Not on a Diet, and her refusal to put on a shirt for Shape magazine.

That Poor Dog

A rare Funny Friday double shot!

Poor Cooper.

Have a great weekend!

The 9th Myth of Modern Day Dieting: Muscle Gains Outweigh Fat Losses

Have you ever told yourself that the reason you're not losing weight is because you're gaining muscle?

Oh how I wish muscle were that easy to gain!

Bizarre Fail from Multiple Canadian Public Health Agencies

Thanks to a fellow Canadian MD for sharing this staggeringly horrible piece of public health advice that she found on a cafeteria table Toronto's St. Michael's hospital.

According to the directive,

"Choose 100% fruit juice. Otherwise you may be drinking mostly sugar and water!"

Perhaps someone from the Ontario Public Health Association, The Canadian Cancer Society, The Heart and Stroke Foundation, or Toronto Public Health would like to weigh in and explain what exactly people who drink 100% fruit juice will be consuming beyond mostly sugar and water? Honestly, I'd really love to know as I would have thought that contributing to the health halo of juice would not be in public health's best interest.

(Updates: An earlier version of this post had wrongly identified Eat Smart! as a Dietitians of Canada initiative rather than an OPHA initiative.

The Canadian Cancer Society has reached out to let me know that this is an old card that's somehow still floating around and that they no longer participate in the program and encourage reduced juice consumption)

Guest Post: Are Public Funds Being Used to Undermine Canadian Health?

Today's guest post comes from my friend and colleague Dr. Norm Campbell. He's borrowing my soapbox to tell you a bit about a conference on dietary salt that's slated for next week and his concern that it's designed to undermine the health of Canadians.

A prestigious national health and scientific organization uses public funds to undermine the health of Canadians?

The Canadian Academy of Health Sciences (CAHS) - a little known but prestigious organization of top Canadian scientists has decided to weigh on the recommendations for reducing dietary sodium. CAHS indicates it wants assess whether current dietary recommendations are supported by evidence, highlight new evidence and also to provide the spectrum of opinions on dietary salt. However, the meeting seems based on a very few highly vocal scientists who have publically opposed dietary salt reduction, including those that have had long standing relationships with the food and salt industries to address the issue. The only new evidence indicated to be presented is a study based on a very weak assessment of salt intake, questionable assessment of blood pressure and not surprisingly showed a weak association between the two. In fact, many of those opposed to sodium reduction have conducted research that has been highly critiqued as using weak methods that could explain their research findings. Much newly published literature associating high dietary salt to adverse health outcomes is overlooked by the organizers.

The opinions of those opposed to salt reduction and the deliberations of the scientific and health care organizations and experts that support dietary salt reduction has been highly published in scientific journals as well as in lay press. Although highly regarded national and international scientists who support reduction in dietary sodium have been invited, after learning the format of the meeting many have withdrawn or refused to participate.

Very recent research from the American Heart Association has delineated the impact of weak research methods on outcomes of sodium studies. The Cochrane Collaboration and many others have voiced concerns on the impact of conflicts of interest in general on research findings and new merging research indicates very substantive associations of author conflicts of interest on outcomes of diet related research. Cook and Gould commented that systematically appraising the evidence and providing transparent recommendations for practice, guidelines have the potential to improve both bedside decision making and health policy however they also indicated that, to be of optimal quality, such must not be tainted by conflicts of interest, and their authors must employ rigorous methodologies to evaluate the evidence before them. The CAHS symposium however has declined to have a session to address the impact of (weak) research methods on research findings and also declined to have a session on the impact of commercial conflicts of interest. Rather, based on a symposium lasting a few hours and with a foundation of a few dissenting scientists and people with close industry ties, the CAHS proposes to issue public reports clarifying the role of evidence on dietary sodium reductions.

The clinical and public health science of dietary sodium has been repeatedly reviewed by many major national and international scientific and health care professional organizations and over the last 10 years based on best available evidence has had uniform recommendations supporting reducing dietary sodium. The Global Burden of Disease (GBD) study conducted by over 450 of the top public health experts and epidemiologists in the world estimated dietary salt resulted in over 3 million deaths (61 million years of disability) in 2010. The estimate was for over 13,000 deaths and 200,000 years of disability in Canada in 2010. Based on the impact of dietary sodium on health, the World Health Organization and United Nations have made one of 9 global targets to prevent non communicable disease reducing dietary sodium. The World Health Organization calls sodium reduction one of very few ‘best buys’ to improve population health.

In stark contrast to the CAHS approach, careful and thorough reviews of the evidence on dietary salt and health by national and international scientific organizations take 1-2 years of research and deliberation and select a diversity of experts that represent public interest and exclude experts perceived to represent the financial interests of industry. Notably, organized opposition to salt reduction by the food and salt industries to reducing dietary sodium resulted in the formation of a global advocacy group, World Action on Salt and Health with over concerned 500 scientists and health care professional members.

While the CAHS symposium format might be expected to have been created with support from the food or salt industry, it is most startling that the CAHS is supported by a grant of $35 million federal tax dollars to the Council of Canadian Academies. Perhaps even more startling is that the CAHS has indicated it is specifically targeting a multimillion dollar public education program of Health Canada to reduce dietary sodium.

The rational for the CAHS meeting is unclear but one of the organizers Dr S. Yusuf is publicly on record to oppose dietary salt reductions. One of the sponsoring organizations with CAHS has not been able to be identified (World Federation of Cardiology). The other organization (World Heart Federation) that is indicated to be a sponsor is on public record supporting dietary salt reduction.

The bottom line is weak and conflicted research and highly select presentation of a single divergent research study will lead specifically to controversy. The CAHS meeting format seems designed to provide credence to both weak research methods and commercial interests and has an unclear rationale. Further, the CAHS needs to be accountable for spending public funds on this meeting that seems diametrically opposed to the public’s interest. With the United Nations and the World Economic Forum (representing the global corporate sector) declaring chronic non communicable diseases a major threat to global development and indicating reduction in dietary salt one of the primary causes, surely the CAHS, an organization representing Canadians top researchers can make a positive contribution to health of Canadians and the global population.

Norm Campbell MD FRCPC
Professor of Medicine, Physiology and Pharmacology and Community Health Sciences.
HSFC CIHR Chair in Hypertension Prevention and Control
Chair of the Canadian Hypertension Advisory Committee (of national health and scientific organizations to lead the nongovernmental effort to prevent and control hypertension).
President of the World Hypertension League
Co-Chair of the PAHO/WHO Technical Advisory Group on Cardiovascular
Disease Prevention through Dietary Salt Reduction
Co-chair of the Vascular Risk Reduction program of the Alberta Health Services Cardiovascular Health and Stroke Strategic Clinical Network.
Member of the World Health Organization Nutrition Advisory Group, Non Communicable Disease, (NutNCD group 2012-2016).
Member, World Action on Salt and Health

Canada's Right Wing Fraser Institute Pours Their Special Stupid on Obesity

It's so biased, massaged, and cherry picked that it's almost not worth commenting on, but given it may well be all over the Canadian news today here's my brief comment on the Fraser Institute's Obesity In Canada polemic.

Cherry picked data can support anyone's position. Here the Fraser Institute presents many cherries in an aim to prove that obesity rates haven't been rising, that obesity is not a medical concern worthy of alarm, and that government interventions that target obesity are folly and have already proven themselves to be ineffective.

To make their case they start out by publishing a great many graphs of various age groups vs. their self-reported body mass indices that are meant to impress readers that obesity rates aren't rising in Canada. While you're welcome to go take a peek at all of them, here's a graph of Canadian obesity rates that isn't part of the Fraser Institute's report:

As you can see, it demonstrates a near tripling in self-reported obesity rates since the mid 70s and it also reveals a not-so-surprising fact. When you call people up on the telephone and ask them to self-report how tall they are and how much they weigh, they magically wind up taller and lighter than their realities. To be more precise according to a 2014 Statistics Canada report, men's self-reported BMI's are 9% lower than in actuality, while women's are 6% lower. So when considering the Fraser Institute's graphs, none of which include any data prior to 2003 and most only from 2005 (clearly they went to the Fox school of how best to use an axis to make a point), you have to keep in mind that along with purposely and disingenuously ignoring the very dramatic rise in Canadian weights since the 1970s, all of their graphs present self-reported data and hence also knowingly and markedly under-report the actual weights of Canadians.

Regarding obesity not being a medical concern the report rightly begins by castigating BMI as a measure of health. BMI truly is a crappy measure which is why we who actually work with patients prefer the use of the Edmonton Obesity Staging System which in turn considers weight's impact on health. The fact that BMI is a sub-par measure of health isn't disputed by anyone, though you wouldn't know that from the Fraser report. Next the report cherry picks from the research to pull those papers that demonstrate less awful morbidity and mortality with obesity but yet do so with that same crappy BMI value that the report so rightly said was a poor measure as it falsely includes people with great health but higher weights. Chutzpah aside, this is a common attack on initiatives aimed at helping to either treat or prevent overweight and obesity and it's an odd one. Even the most conservative of data would suggest thousands of weight relatable deaths per year in North America. How many deaths would the Fraser Institute consider to be an alarming number? And of course it's not just about mortality there's morbidity to consider and when considered in the context of weight, morbidity markedly affects mortality as seen by Dr. Sharma's work below where mortality as a function of weight is plotted on the basis of EOSS score (higher scores represent individuals who have accumulated multiple weight responsive and relatable conditions)

And the chutzpah doesn't end there. Despite the Fraser Institute's report asserting that obesity doesn't dramatically increase mortality, later in this same report they go on to explain why obesity won't in fact be a burden on the healthcare system because those with obesity will die so much younger that their earlier than expected deaths will offset any potential increase in healthcare costs (and irony aside, following this logic I'm looking forward to the Fraser Institute's next likely report, The 3 Most Expensive S's in Canada: Seat-belts, Street-signs and Speed-limits)

The stupid culminates with the report's discussion of the failure and folly of government intervention. Like Margaret Wente before them, the Fraser Institute refuses to appreciate that there will never be a singular solution or intervention that will have an impact on obesity. Society's increasing weights are consequent to the perfect storm style convergence of dozens and dozens of changes to our environment. Getting worked up about singular interventions not working is akin to getting mad at a single sandbag for not stopping a flood.

Overall it's an idiotic read but not a surprising one given the source, after all, this is the same organization that as recently as 1999 put out, Passive Smoke: The EPA's Betrayal of Science and Policy which,

"highlighted the absence of any scientific evidence for linking cancer with second-hand smoke"

The first line of the Fraser Institute's mission statement is

"Our vision is a free and prosperous world where individuals benefit from greater choice, competitive markets, and personal responsibility."

which was translated brilliantly by Steven Lewis as stating,

"Public health care sucks because it must suck, because it’s public. Therefore, let’s gather skewed estimates on a hot-button issue, retail them as hard data, and lure Canadians toward the promised land of private medicine."

A perfect description of their most recently spun drivel.

Saturday Stories: No Sugar, Pay-to-Play Journals, Chemophobia, and Heart Healthy Foods

Source

Slate's L.V. Anderson eviscerates the new book Year of No Sugar calling it "a How-To Manual for an Eating Disorder".

McGill's Joe Schwartz eats the Food Babe for breakfast in The Gazette and calls out her non-evidenced based chemophobic fear mongering.

Tom Spears in the Ottawa Citizen exposes the dark underbelly of "evidence-based" studies and the pay-to-play scientific journal industry.

And Summer Tomato's Darya Pino explains why she'll never tell you to eat heart healthy foods.

[And if you don't follow me on Twitter or Facebook, here's my piece from US News and World Report explaining how Oregon's ban on chocolate milk was anything but a backfire, here's a Random House giveaway for 5 signed copies of my book The Diet Fix, and here's Runner's World's Alex Hutchinson's Three Good Books on Nutrition column (spoiler, mine's one of them)]

Can I Buy Thai Life Insurance in Canada

Today's not a Funny Friday, but rather an uplifting one with a spectacular commercial for Thai Life Insurance.

Not entirely sure what the commercial has to do with life insurance, but I'm definitely buying what it's selling.

Have a great weekend!

The 8th Myth of Modern Day Dieting: There's One Best Diet

A few weeks ago I shot some short videos in my office covering the 13 myths of modern day dieting that I wrote about in The Diet Fix. Believing in these myths can break anyone's weight management efforts. Over the coming days I'll be publishing them online.

Different strokes for different folks is definitely true diet wise, and it's dead simple to know if you're on the best diet for you. Just ask yourself the question, "Could I happily live like this forever?", and if the answer's "no", you're on the wrong diet. The corollary's true too - if the answer's "yes", and if you're happy with your health, don't let any diet guru or zealot try to tell you different.

The 7th Myth of Modern Day Dieting: Some Foods Must Be Forbidden

Source

A few weeks ago I shot some short videos in my office covering the 13 myths of modern day dieting that I wrote about in The Diet Fix. Believing in these myths can break anyone's weight management efforts. Over the coming days I'll be publishing them online.

I'd bet I've written more actual prescriptions for chocolate than any other physician in North America. While of course there's no all-you-can eat chocolate weight loss program, there's also little doubt that if chocolate is one of the loves of your life, the likelihood of you living forever-more without it is slim to none. It's about the smallest amount of chocolate you need to like your life, and for most chocolate lovers, zero isn't a sustainable amount.

The 6th Myth of Modern Day Dieting: Cheat Days Are Wise

A few weeks ago I shot some short videos in my office covering the 13 myths of modern day dieting that I wrote about in The Diet Fix. Believing in these myths can break anyone's weight management efforts. Over the coming days I'll be publishing them online.

That up above?

That's a photo of The Keg's carrot cake à la mode. I once referred to it at the world's most dangerous piece of cake because who in their right mind would ever guess it contained more than a day's worth of calories?

While I'm all for thoughtful indulgences (and even that piece of carrot cake if you've thoughtfully decided it's worth it), in our current non-intuitive, hyper-calorific food environment, cheat days, even cheat meals, can easily sink your weight management efforts. The answer to the question, "is it worth it?", is a personal one, but if you don't even ask the question because the day or the meal's a "cheat", you're liable to bite off far more than you'd have thoughtfully decided was actually worth chewing.

The 5th Myth of Modern Day Dieting: You Can Outrun Your Fork

A few weeks ago I shot some short videos in my office covering the 13 myths of modern day dieting that I wrote about in The Diet Fix. Believing in these myths can break anyone's weight management efforts. Over the coming days I'll be publishing them online.

80% of your modifiable weight is likely determined by your dietary choices leaving only 20% for your fitness choices. While exercise has truly fantastic health benefits and markedly mitigates the risks of weight, you're far more likely to lose weight in your kitchen than you are in your gym, and if you're exercising solely for the purpose of weight management, you run the risk of quitting perhaps the single healthiest behaviour you could adopt if and when the scales don't fly down. Unless you plan on spending a heroic part of each and every day running, you're not going to outrun your fork.

Saturday Stories: Hustles, HIV, and Watching

James Robinson in Pando Daily covers what he calls the Healbe Hustle, and why perhaps you should never trust or use Indiegogo.

Dr. Max Pemberton in The Spectator presents a compelling case for why he'd rather be diagnosed with HIV than diabetes.

And a heart breaking post by medical student Shara Yurkiewicz in her Scientific American column and an experience that in one way or another all of us MDs have sadly shared more than once.

[And if you don't follow me on Twitter or Facebook embedded below is a chat I had with Erica Ehm on why parental nos simply aren't sufficient to defend our children against the onslaught of junk food.]

A Great Use for Condoms, Nutella, Mentos, and Coca-Cola

Now I don't speak one word of Italian, but that didn't stop me from enjoying the heck out of today's Funny Friday science video involving condoms, nutella, mentos, Coca-Cola, and a very lovable Italian.

Have a great weekend!

The 4th Myth of Modern Day Dieting: You Shouldn't Eat Unless You're Hungry

A few weeks ago I shot some short videos in my office covering the 13 myths of modern day dieting that I wrote about in The Diet Fix. Believing in these myths can break anyone's weight management efforts. Over the coming days I'll be publishing them online.

For those who struggle with dietary control I can't imagine a more dangerous piece of advice than, "you should wait until you're hungry to eat". Hunger influences choice. Shop at the supermarket hungry and you'll see that influence in action. Sit down to a meal hungry and while you're not shopping from an aisle, instead you'll be shopping from your fridge, cupboard, plate or a menu and no doubt, your choices will be different. On the other hand, organize your eating so that you're not hungry, and then you've got a shot, as "willpower", when it comes to dietary choice, is often simply the absence of hunger.

The 3rd Myth of Modern Day Dieting: Dieting Must Be Difficult

A few weeks ago I shot some short videos in my office covering the 13 myths of modern day dieting that I wrote about in The Diet Fix. Believing in these myths can break anyone's weight management efforts. Over the coming days I'll be publishing them online.

Simply put, weight lost through suffering comes back. While there's no doubt that weight management and healthful living require effort, if the efforts required include regularly facing off with hunger, blindly denying yourself foods you enjoy, or following a dietary regime that doesn't fit your tastes, they're not going to last.

Whatever program or diet you undertake, the most important predictor of your likelihood of long-term success is being able to answer, "yes" to the question, "could you happily live this way for the rest of your life", with the key word there being, "happily".

The 2nd Myth of Modern Day Dieting: Scales Measure Health

A few weeks ago I shot some short videos in my office covering the 13 myths of modern day dieting that I wrote about in The Diet Fix. Believing in these myths can break anyone's weight management efforts. Over the coming days I'll be publishing them online.

Scales don't measure the presence or absence of health. Nor do they measure happiness, self-worth, or success. Scales measure one thing, and one thing only. Scales measure weight.

The 1st Myth of Modern Day Dieting: It's About Willpower

A few weeks ago I shot some short videos in my office covering the 13 myths of modern day dieting that I wrote about in The Diet Fix. Believing in these myths can break anyone's weight management efforts. Over the coming days I'll be publishing them online.

The first myth of modern day dieting is that willpower is required. Yet people often spend more willpower on weight management than any other area of their lives. Has there really been an epidemic global loss of willpower over the course of the past 60 years? I don't think so. We as a society haven't changed, the world around us has. In this day and age, and in this toxic food environment, weight struggles aren't a willpower issue, they're as Yale's Dr. David Katz would put it, a skillpower issue.

Saturday Stories: Malaria, Secret Surveillance, and Tamiflu Stockpiling

A fabulous long read from Ed Yong on why malaria keeps beating our best drugs.

A gripping piece from the BBC on the bad old days in Romania and the transcript of one woman's childhood.

Julia Belluz in Macleans covers the disappointing data on Tamiflu, and wonders why Canada's still stockpiling it (and why PHAC seems muzzled to talk about it).

[And if you don't follow me on Twitter or Facebook, on US News and World Report this week I ask whether or not milk and juice may be contributing to some children's struggles with weight, and here's a review of The Diet Fix and James Fell and Margaret Yufera-Leitch's Lose it Right written by the National Post's RD columnist Jennifer Sygo.]

If I Move to Japan, I think I'll Join this Gym

Thanks to trainer to the stars and friend Chad Landers for steering me to this unbelievably inspirational Funny Friday Japanese exercise video.

It's one of those that you have to see to believe.

Have a great weekend!

Guest Post: On the CBC, Homeopaths are Now Medical Experts?

Received an email yesterday morning from my friend, lawyer, author, Canada Research Chair in Health Law and Policy, and evidence-based science champion Professor Timothy Caulfield who was quite upset about the inclusion of a homeopathic doctor on an expert health panel convened by the CBC for their flagship news program The National. While Tim (side note - his mother greatly preferred Timothy so if you don't know him and already always call him Tim (like me and virtually everyone else), and you happen to meet him, stick with Timothy) isn't anti-complementary medicine, he is very pro-evidence, and when it comes to homeopathy the evidence is in and it's not complementary. As I often do with my blog when a friend has something to say, I invited Tim to write a guest post explaining his concerns, and he kindly obliged:

An Open Letter to CBC's Peter Mansbridge from Prof. Timothy Caulfield

Dear Peter Mansbridge:

I couldn’t sleep last night. And it is your fault.

The last thing I watched before I went to bed was The National’s new health panel. And it left me we a deep feeling of despair. I couldn’t shake the sensation that we are slipping into some kind of bizarre all-knowledge-is-relative Dark Age.

The panel has three “experts”, including the terrific and science-based Danielle Martin and Ali Zentner. The third is Bryce Wylde, a self-described homeopathic doctor (he has a diploma from the Ontario College of Homeopathic Medicine) and advocate for, among a host of other scientifically unproven therapies, “natural health” and supplementation.

Now, I don’t know Wylde. He seems like a nice, engaging individual – particularly when he is on Dr. Oz talking about how he “travels the globe in search of Mother Nature’s fountain of youth”. He does this with a mixture of scientific-sounding babble (“vasodilate blood to the brain”?) and everything-natural-is-good boyish enthusiasm. He is, no doubt about it, entertaining.

But including an advocate of homeopathic medicine – one of the most derided and scientifically preposterous of alternative therapies – on a national and highly respected TV news program as a “medical expert” and legitimate source of evidence-based health information is simply wrong. He wasn’t presented as an outsider. His views were not cast as extreme and scientifically questionable. And this was not Dr. Oz, Oprah or an infomercial.

The inclusion of Wylde on this panel is a wonderful (and depressing) example of the phenomenon of false balance. Naturally, it is always good to keep an open mind and to get different perspectives on important issues. I suspect that was the goal the CBC had in mind when they decided to include Wylde. But using a homeopath to comment on biomedical issues is like using an astrologer to balance the views of Stephen Hawking.

I won’t dissect the scientifically questionable comments he made on The National – such as his advocacy of supplements (which he markets on his website – a practice that creates an obvious conflict of interest) and his statements about the health value of organic food. I am more concerned about the impact of putting this perspective on a respected show like The National. It legitimizes pseudoscientific ideas – which may have serious adverse health consequences – and makes it more difficult for the public to differentiate between real and junk science.

The CBC decision is particularly frustrating given that there are so many wonderful, science-based health scholars in Canada, including many who explore the issues associated with and evidence surrounding alternative therapies (such as Drs. Heather Boon at the University of Toronto and Sunita Vohra at the University of Alberta).

So, Mr. Mansbridge, I sincerely hope you look for a different, science-based, commentator for your health panel. I need the sleep.

Timothy Caulfield
Canada Research Chair in Health Law and Policy
Trudeau Fellow
Author of The Cure for Everything: Untangling the Twisted Messages about Health, Fitness and Happiness
@CaulfieldTim

Timothy Caulfield is a Canada Research Chair in Health Law and Policy and a Professor in the Faculty of Law and the School of Public Health at the University of Alberta. He has been the Research Director of the Health Law Institute at the University of Alberta since 1993. Over the past several years he has been involved in a variety of interdisciplinary research endeavours that have allowed him to publish over 250 articles and book chapters. He is a Fellow of the Trudeau Foundation, a Health Senior Scholar with the Alberta Heritage Foundation for Medical Research and the Principal Investigator for a number of large interdisciplinary projects that explore the ethical, legal and health policy issues associated with a range of topics, including stem cell research, genetics, patient safety, the prevention of chronic disease, obesity policy, the commercialization of research, complementary and alternative medicine and access to health care. Professor Caulfield is and has been involved with a number of national and international policy and research ethics committees, including: Canadian Biotechnology Advisory Committee; Genome Canada’s Science Advisory Committee; the Ethics and Public Policy Committee for International Society for Stem Cell Research; and the Federal Panel on Research Ethics. He has won numerous academic awards and is a Fellow of the Royal Society of Canada and the Canadian Academy of Health Sciences. He writes frequently for the popular press on a range of health and science policy issues and is the author of The Cure for Everything: Untangling the Twisted Messages about Health, Fitness and Happiness (Penguin 2012).

Jenny Craig Thinks Calling People "Circus Fat" is Good for Business?

Caricature by Don

Now I'm no marketing guru, I'm just a doctor with a blog, and so maybe I'm missing something, but somehow my head says that using the term, "Circus Fat", to describe people who struggle with weight shouldn't be good for business for a company whose business it is to help people lose weight.

I hope I'm right as weight bias shouldn't be rewarded or encouraged, and no doubt Jenny Craig ought to know better.

Watch for yourself, maybe you have a different sense of humour than me.



[h/t to Twitter's Sue J.]

Have You Ever Encountered the "What's Your Better Idea?" Fallacy

Last week I did the math on Girl Scout cookies only to discover that their sale annually contributes over three quarters of a million pounds of trans fat and thirty million pounds of sugar to the American diet. I then suggested that the charitable sale of trans-fat laden, sugary cookies is a practice that in this day and age can no longer be considered charitable and instead is part of our growing dietary woes.

This upset people, and it also brought up the, "what's your better idea" fallacy. It's a fallacy of distraction in that a practice or a program can most assuredly be fairly described as awful regardless of whether or not a solution for said practice or program is proposed.

Logical fallacies are a frustrating bunch and familiarizing yourself with their various incarnations is well worth your time. Here's a handy dandy poster highlighting some of the most common ones.

Have you ever been faced with frustrating logical fallacies?

Badvertising: Dr. Joey's Skinny Chews

Do you think chewing on a tiny fibre filled candy would leave you feeling full?

Given there are no clinical trials out there, your guess is as good as mine, and mine sure isn't confident.

And yet here are Dr. Joey's Skinny Chews advertised to be

"the perfect long- lasting “on the go” treat to keep you on track to make healthier choices"

Dr. Joey instructs consumers,

"Next time you have a sweet tooth or a hunger pang that just won't quit – enjoy a couple Dr. Joey's Skinny Chews"

So what's in them?

Here's their nutrition facts panel:

How long do you think a couple of those will last you?

For comparison, wanna know the calories and sugar in an equivalently weighted 12grams of Tootsie Rolls? 7 more calories, and 0.7g more sugar. Doesn't seem so exciting to me, but if the fact that Dr. Joey's Skinny Chews truly are an ever so slightly better choice than Tootsie Rolls is exciting to you, please keep in mind that you're not likely to confuse Tootsie Rolls with a healthy between meal snack. And with nearly 60% of Skinny Chews' calories coming from sugar which in turn is responsible for over 40% of each Chew's actual physical weight, "healthy" seems quite a stretch.

But I'd bet people are confusing Skinny Chews with healthy because as as Dr. Joey mentioned to the dragons on Canada's venture capitalism reality show Dragons Den,

"People aren't buying a bag Dragons, they're buying 6 bags"

No real surprise there because who wouldn't be seduced by "Skinny" candy and no doubt, "Chocolate....with benefits" is a way better slogan than, "slightly less sugary candy with inulin".

Guess it's a good thing for sales that I wasn't hired as Dr. Joey's marketer.

[UPDATE: And then there's cost with Facebook commenter Cecilia noting 30 Skinny Chews are being sold for $16.97 at Canadian Walmarts, whereas you can buy 400 Tootsie Roll Midgees (at an American Walmart so they're likely a touch more expensive here) for $4.98.]

Saturday Stories: ADHD, Tuberculosis, and False Balance

Ryan D'Agostino in Esquire on how an astonishing 1 in 7 boys are diagnosed with ADHD.

A terrifying Storify from Maryn McKenna highlighting the rise and risk of drug resistant tuberculosis.

David Kroll in Forbes covers Dr. Paul Offit's call to jail (figuratively) journalists for false balance stories.

And last but not least, a fabulous New York Times short film about a physician who left it all to become Slomo.

Dogs and Disappearing Treats Make For a Great Two Minute Smile

It's all over the net so you may well have seen it, but if you haven't seen today's Funny Friday video, it's definitely worth a watch.

Have a great weekend!

You Won't Believe How Much Sugar and Trans-Fat the Girl Scouts SellEach Year

A few weeks ago, Dr. John Mandrola, my collegue in both blogging and medicine, published a piece critical of the Girl Scouts for continuing to sell their sugar and trans-fat laden cookies. Yesterday I was asked to chat with AirTalk's Larry Mantle about it.

In preparing for the piece I decided to do a little math homework (which unfortunately I got backwards on AirTalk yesterday where I under-reported trans-fat and over-reported sugar).

Using Wikipedia's sales data on Girl Scout Cookies, along with Xfinity's trans fat and sugar charts I crunched numbers on just how much trans-fat and sugar the sale of Girl Scout cookies injects into America.

The numbers shocked even me.

Assuming a likely low-ball 0.25g of trans-fat per trans-fat containing Girl Scout cookie serving (they're allowed to claim 0g trans fat if less than 0.5g per serving), and excluding the sales of those cookies known to be truly 100% trans-fat free, Girl Scout cookies saddle America with over three quarters of a million pounds of trans-fat annually (and in case you need a reminder, non-naturally occurring trans-fat is a toxin unsafe in any amount).

And sugar?

Wow. The average amount of sugar per two cookies sold is in the neighbourhood of 7g and the average package contains 20 cookies. Doing the math tells me that each year the Girl Scouts are selling over thirty million pounds of sugar. That's 3.5 billion teaspoons of sugar the Girl Guides are adding to the American food supply in the name of charitable fundraising.

Just as John notes on his blog, today isn't 50 years ago. What might have been a semi-innocuous practice when it began is now part of the problem, and given our current burden of diet and weight related illness, no matter how worthy the cause it can no longer be considered charitable to sell sugar and trans-fat.

[Math: 0.25g trans fat/serving x 8 servings avg/box x 200,000,000 boxes/year x 0.88 (% of cookie sales where partially hydrogenated an ingredient) / 1,000g/kg x 2.2lb/kg = 774,400lbs trans fat/year

7g sugar/2 cookies x 20 cookies avg/box x 200,000,000 boxes/year / 1,000g/kg x 2.2lb/kg = 30,800,000lbs of sugar/year]

Oh How I Wish These Awful New Kids' Toys Were an April Fools Joke

Hurray. I can buy my kids their very own branded play OPI nail salon, Dairy Queen store, Sprinkles cupcake bakery and Claire's jewellery retailer.

[h/t to my wonderful wife who saw these for sale in our local Walmart]

Should We be Treating Type 2 Diabetes With Bariatric Surgery?

I'm resurrecting this piece consequent to yesterday's online first publication in the New England Journal of Medicine of the 3 year data that continues to support the use of bariatric surgery to treat type 2 diabetes.

In case you missed the news, two recent studies (here and here) 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 studies here and dissect them for you, but I think that they were well done studies, and while admittedly we still don't know what their long, long, term benefit will be, at 2 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 5 or 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 5 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 type 2 diabetics with overweight or 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]

Juice is NOT a F@*#ing Fruit Part II

Juice is an incredibly frustrating beverage. Despite packing the same caloric and sugary punch of Coca-Cola, unlike sugared soda, juice's undeserved health halo regularly leads to its provision, consumption (and often over consumption) in the name of nutrition - especially to and by our children.

And kids really shouldn't be drinking the stuff, or at the very least, not in the name of health.

The Canadian Pediatric Society and the American Academy of Pediatrics both recommend that juice be capped for kids at half a cup daily. And make no mistake, the capping isn't because juice is so damn good for the kids that we don't want them to drink too much of it, but rather because every glass contains 5 teaspoons of sugar (or more) and calories which won't be compensated for with decreased portions at their next meals.

The World Health Organization also considers juice to be nothing more than a sugar delivery vehicle and in their recent draft guidelines on sugar consumption specifically call out juice as a source of undesirable free sugars.

Yet there's this piece that came across my Newswire just last week. It was a press release put out by Coca-Cola (makers of Minute Maid) and Breakfast Club of Canada and it featured Teresa Piruzza, MPP for Windsor West and Minister of Children and Youth Services launching the newest Ontario Breakfast Club, which judging from the press photo up above involves the indoctrination of children into believing that fruit juice is a healthy part of their breakfast and the provision of juice boxes (containing more juice than our experts' daily recommended maximum), festooned with cartoon characters that in turn might further increase a child's consumption and desire for same.

Can you imagine a similar scene with the Minister of Children and Youth Services grinning and handing out Vitamin C fortified soda, in cartoon covered cans, to children in the name of breakfast?

According to the press release,

"Breakfast Club of Canada supports healthy breakfast programs at 1,266 schools, supporting nearly 130,000 children and serves close to 21 million breakfasts every year and that Minute Maid® has partnered with Breakfast Club of Canada since 2003, donating Minute Maid® juices to support programs across Canada."

Breakfast I'm all for, but marketing sugar to children and washing it in BS "corporate social responsibility", food insecurity, and health is both incredibly misguided, and incredibly sad.

(And if you're looking for Juice is NOT a F@*#ing Fruit Part I click here)

Saturday Stories: Best Diet, Failing Kids, and Parasites

James Hamblin in the Atlantic covers the world's healthiest diet.

Hanna Rosin, also in the Atlantic, wonders whether we should be letting our kids fail more?

And lastly, here's a fabulous TED talk from Ed Yong about how parasites may be controlling our actions.

Did You Know that Oreos Are Responsible for the World's Cocaine Supply?

Today's Funny Friday video is truly shocking.

Gunpowder, cocaine, and more coming from Oreo's secret "unmaking" plants (some swearing).

Have a great weekend!

Health Canada Allows Cupcakes to Claim They're a Source of Calcium and Iron

Just in case you need more convincing that Canada's front-of-package labelling law's laxity leads to nonsensical front-of-package health claims look no further than Duncan Hines' new Strawberry Flavoured Cupcakes whose package reports they're a source of calcium and a source of iron.

And honestly, even if there were calcium and iron emergencies in the population (there aren't), and even if these cupcakes provided a significant amount of either (they don't - 6% of both per cupcake), nothing will change the fact that they're cupcakes and that cupcakes, while delicious, will never be healthful.

So what's in these calcium and iron containing cupcakes? Here's the ingredient list:

Sugar, Enriched Bleached Wheat Flour, Vegetable Oil Shortening [Palm Oil], Strawberry-Flavoured Bits [Sugar, Corn Syrup, Corn Cereal, Partially-Hydrogenated Vegetable Oil (Cottonseed And/Or Soybean), Modified Cornstarch, Citric Acid, Natural And Artificial Flavours, Colour], Sodium Bicarbonate, Sodium Aluminum Phosphate, Dicalcium Phosphate, Monocalcium Phosphate, Wheat Starch, Propylene Esters, Mono And Diglycerides, Sodium Stearoyl-Lactylate, Salt, Dextrose, Cellulose Gum, Xanthan Gum, Citric Acid, Natural And Artificial Flavour, Artificial Flavour, Colour. Frosting Mix: Powdered Sugar [Sugar, Cornstarch], Cream Cheese Powder [Cream Cheese (Cream, Milk, Skim Milk, Whey, Bacterial Culture, Salt, Microbial Enzyme), Whey, Natural Flavour, Tocopherol, Ascorbyl Palmitate], Natural And Artificial Flavour).

The onus shouldn't be on Canadians to have to study the backs of packages' nutrition facts panels to determine if the claims made on the fronts of those same packages hold true, and while you might think to yourself that no-one's going to get duped by a cupcake box, not only would I bet that you're wrong and that those claims may well influence some to consider them to be less unhealthy than they are, I would remind you that there are many other products that are equally but far less obviously awful whose packages dupe the best of us on a daily basis.

[h/t to Random House's Cassandra Sadek]

Canadian Breast Cancer Foundation Fundraising with Healthwashed Junk Food

Sigh.

Junk food fundraising is so common place nowadays that virtually no one blinks an eye when they see it. Worse still, in many cases the dollars received in lieu of healthwashing are minimal.

Take for instance the new partnership between the Canadian Breast Cancer Foundation (CBCF) and the so-called Canadian Healthy Vending company. In return for the use of the CBCF logo on their Max! Healthy Vending Machines the CBCF will receive $48,000.

In discussing the partnership Holly Henderson, the Canadian Breast Cancer Foundation’s Senior Director of Corporate Programs, explains why she feels the fit is good,

"The Foundation is particularly excited about this program as it allows us to extend our message about the importance of healthy lifestyles and reducing breast cancer risk. It’s never too early or too late to take steps to help reduce risk by making healthy choices and learning more about breast health."

So what healthy choices are sold in the pink and healthwashed Max! Healthy Vending Machines? Pretty much the same crap that's in any vending machine only this machine calls its contents healthy. There's sugared soda like Natural Brew Cream Soda (9.5 teaspoons of sugar) and Blue Sky Organic Soda New Century Cola (sweetened with 10 teaspoons organic cane sugar). There are cookies like Enjoy Life's Chocolate Chip and Snickerdoodles (each with the same calories and sugar of Oreos) and chocolate bars like Green & Black's Milk Chocolate (nutritionally nearly identical to the iconic Hershey's Milk Chocolate bar). And of course there are potato chips like Old Dutch Baked Ketchup Chips (which according to the nutritional information on the Old Dutch website chip per chip actually contain more calories and more sodium than their non-baked Old Dutch Ketchup Chip brothers).

These are not what I would describe as healthy snacks. In fact I've argued before that these sorts of snacks are worse than their non-healthwashed counterparts given the likelihood of their overconsumption or more frequent purchase consequent to their healthwashing. No doubt too, regularly consuming these sorts of products might in fact lead a person to gain weight. As far as weight and breast cancer goes, the links, though correlative, still give cause for concern. According to the National Cancer Institute, obesity increases the relative risk of developing post menopausal breast cancer by 50%. They also report that maintaining a body mass index of 25 could prevent 11,000 to 18,000 deaths per year from breast cancer in U.S. women over age 50, that breast cancer is more likely to be detected at a later stage in women with obesity, and that weight gain during adulthood has been found to be the most consistent and strongest predictor of breast cancer risk in studies in which it has been examined.

Shameful.

UPDATE: Crazy that it ever happened in the first place, but the good news is that the CBCF's contract with Canadian Healthy Vending has recently expired and they've no plans to renew!