Small Study Suggests Body Contouring Surgery Augments Bariatric Surgery

Source: Kayla Butcher's GoFundMe page for skin removal surgery

One of the nearly inevitable adverse effects of bariatric surgery is loose, excess, skin, and generally speaking, the only recourse for dealing with it is more surgery.

Here in Canada, whereas bariatric surgery is covered by our healthcare system, with the exception of medically necessary panniculectomies, post bariatric surgery body contouring surgery is not.

Putting aside both quality of life and aesthetics as rationale for skin removal surgery (and there are very reasonable arguments supporting both), here's a new one (at least for me). If the outcomes of this small study hold true, body contouring surgery may dramatically enhance long term weight loss outcomes.

The study was retrospective and it sought simply to compare the long term weights of those who had both body contouring surgery and bariatric surgery with those who only had bariatric surgery.

Interestingly, the study found that while weight loss was comparable between subjects 2 years post bariatric surgery at 35.6% in the bypass/contouring group and 30.0% in just bypass group (with the 5% additional difference perhaps explicable simply on the basis of the weight of removed skin), with time, the just bypass group regained significantly more weight. By 5 years (the duration of the study), the bypass/contouring group were maintaining a 30.8% loss, while the just bypass group had regained such that they were only maintaining a 22.7% loss.

Now this was a small study, and retrospective rather than randomized - in turn this might mean that the association is related to other factors (for instance socio-economics as body contouring is expensive and clearly those that can afford it, may well have other privileges and circumstances that might be beneficial to post-surgical weight management). Also worth noting that the 5 year losses of the just bypass group aren't as high as seen in other bariatric surgery studies.

Am looking forward to more research on this (ideally randomized), as for many post bariatric surgery patients, excess skin has a dramatically negative effect on their quality of life, and perhaps, if it was shown that body contouring surgery helped patients maintain their losses, insurers and governments might cover the procedure.

Should We Be Treating Type 2 Diabetes With Bariatric Surgery?

Photo By Mr Hyde 

I'm resurrecting and tweaking this piece, for the third time now, consequent to the publication in the New England Journal of Medicine of the 12 year data that continues to strongly support the use of bariatric surgery to treat type 2 diabetes.

In case you missed the news, a recent study published in the New England Journal of Medicine demonstrated dramatic benefits of bariatric surgery in the treatment of type 2 diabetes.

Now I'm not going to get into the study here in great detail, but it followed 1,156 patients from for 12 years and divided them into 3 groups. Those who sought and chose not to have bariatric surgery. Those who sought and had bariatric surgery. And those who did not seek nor have bariatric surgery. Researchers examined all of them at baseline, 2 years, 6 years, and 12 years in terms of whether they had type 2 diabetes, hypertension, or hyperlipidemia.

The results were striking.

With a follow up rate of 90% at 10 years researchers demonstrated that not only were patients 12 years post bariatric surgery maintaining an average loss of 77lbs/26.9% (the non-surgical groups at 12 years lost an average of nothing), but that amoung those patients who had diabetes pre-surgically, 12 years later, 51% were in remission. And for those who are curious about such things as odds ratios, the odds ratio for the incidence of type 2 diabetes at 12 years was 0.08 (95% CI, 0.03 to 0.24) for the surgery group versus the non-surgery group.

(and though they weren't quite as striking, the surgery group at 12 years also had markedly higher remission rates and lower incidences of both hypertension and hyperlpidemia)

So basically here we have a surgical intervention that is dramatically better medical management for type 2 diabetes - 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, regularly 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 of any sort.

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

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

Let me give you another example. Let's say there was a surgical procedure that women 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]

Saturday Stories: Hazing, Intellectual Freedom, and "Madness"

Caitlin Flanagan, in The Atlantic, deep dives into the story of an infuriating fraternity hazing death.

Alice Dreger, in The Chronicle of Higher Education, with a masterpiece on Universities, freedom of speech, and where we've gone wrong.

David Dobbs, in Pacific Standard, on how society and culture shapes mental illness.

Kindergartners Don't Need "Fun Snack" Days

Received this from a long time reader.

It was the note sent home with her first Kindergartner from his school. Apparently mini-donuts are this month's "Fun Snack".

Next month's Fun Snacks, my reader was told, will be from A&W.

The question that leaps to my mind is, "Why?"

Why do 5 year olds need "Fun Snack" days at school?

I mean if schools wanted to provide 5 year olds with a special snack day, why not something like, "Funky Snacks", where once a month kids try foods and flavours specific to different ethnic backgrounds (ideally foods reflecting their class' different cultural backgrounds)? Given it doesn't take much to get a 5 year old excited, this might be a great way to expand their horizons and taste buds.

But why a food based day at all?

Why not a monthly "Fun Reading Day", "Fun Dress Up Day", or "Fun Singing Day"? Or how about "Fun Extra Recess Day", or "Fun Fitness Day"?

Why don't more people question the wisdom of teaching 5 year olds that fun is found in a mini-donut, or A&W fries?

Why are so many schools and teachers seemingly incapable of (or unwilling to) finding creative ways to entertain and reward their students?

The answer?

No one's paying attention.

Fun Snack Days for Kindergartners are our new normal.

We're all frogs in a steaming pot of junk food that has taken roughly the past 60 years to reach a rolling boil.

Maybe Physicians Should Stop Wondering Why Patients Visit Quacks

Last week I received an email from a long time reader who recounted her experiences seeking help following her heart attack (at age 43!). I want to share her story as it speaks to just how poor a job our medical education system is doing in providing physicians with training in lifestyle modification (including diet, fitness, sleep, stress, etc.). The tl;dr version is that despite her incredible willingness and interest in affecting change, none of the physicians she saw were able to provide her with any specific and actionable advice. Clearly if this is the norm, we need not wonder why our patients are turning to quacks for help at times. For my take on the physician's role in lifestyle, here's a brief op-ed I wrote for the CMAJ, and as far as this reader goes, I steered her to these 8 big ticket items as her first line priorities. While she wanted to remain anonymous, she did agree to allow me to share her letter

On March 12, 2015, I had a heart attack. I had a heart attack. I had a heart attack. Sometimes I feel like I have to say it again and again because it doesn’t seem real to me. I was 43 years old and what I thought was relatively healthy.

The events of how my day started were mundane. I woke, made coffee, had a shower, poured coffee and sat on my bed to drink my coffee and decide what to wear that day. What began as an uncomfortable feeling in my chest, that I thought would pass, increased in discomfort to a point where I began to feel like I was suffocating. My mind was racing, I wondered if I had any aspirin, I wondered if I should go to the hospital, I wondered if I should call the ambulance. I decided to wake my son and have him drive me to the hospital.

When I arrived at the hospital, my son dropped me off. He had to go home to drive my other kids to school. I walked into the hospital. I believe that arriving at the hospital myself and walking in myself led the people working in triage to believe that whatever was going on with me was not serious. She asked me to have a seat, she asked me to move to a different seat, she called other people in ahead of me. I waited about 20 minutes before being called in to see a doctor. I get it, I probably didn’t fit the ‘profile’.

When I was finally hooked up with an EKG, I believe that they could see the irregularities in my heart rhythm, I was offered two aspirin to chew and they took blood. The blood work confirmed that I was having a heart attack and I was given the antithrombotic injection. By 11:00 I was heading to St. John, NB to have a dye test.

In St. John, I saw plenty of doctors. They set me up with a cardiac catheter that day. During the procedure, the doctor stopped and asked if I was experiencing any stress in my life, that there were no blockages and he didn’t have to complete the procedure because he could see there were no blockages. He asked about stress, because usually there is residue after a blockage is broken down by the antithrombotic and I had no residue.

I left St. John the next day. As I was leaving, I asked if there was anything I needed to know. I was on a battery of medication, but no one talked to me about lifestyle. Whether I should take it easy, whether I should avoid activities, how I should get back into my daily life. I asked and I was told to just do what I could.

I went home without seeing a dietitian. No one spoke to me at all about nutrition, activity, or managing stress. I do have family history, and it seemed that that family history completely defined my experience. No one was curious about why I had a heart attack, because I have family history. Family history was as deep as they looked.

That was 2.5 years ago

I continue to ask….and no one refers me to anyone who can help me with my diet, managing stress, or incorporating activity into my life. I search out this information myself. Always looking for what I should be doing. I see a nutritionist weekly, one that I sought out and pay for out of pocket. I see a trainer at the gym. I google search reputable sites on lowering LDL and improving heart health.

Most recently, I saw my heart doctor. My LDL was higher than it should be. I am not taking medication. I asked if there’s anything he can tell me about my diet or activity…anything at all. I practically begged for a referral, an insight, an idea…..what I got were to handouts. One distributed by Becel and one from the egg Farmers of Canada. I left mad and frustrated.

The next day my family doctor’s nurse called to see if my heart doctor had gone over the results of my blood work. I said that I had seen him and that he “sort of” went over the blood work. I was leaving an opening for her to suggest an appointment to go over my blood work. Her reply was “OK, I was just wondering if you knew”.

The health system has continually left me feeling unimportant and let down through this experience. I am so willing to make the changes I need to but there is no one in the health care system making suggestions.

So I am writing to you, partly to assuage my frustration in being offered healthy diet handouts from Becel and egg farmers by my heart doctor, partly to feel some support, and partly for advise or information or insights.

Saturday Stories: Special Yom Kippur Edition

For those who aren't Jewish, today is Yom Kippur, the holiest day of the Jewish year. Consequently, here's an all Jewish Saturday Stories lineup.

Yair Rosenberg in Tablet unpacks the BBC interview with Ken Loach that perfectly illustrates Britain's left-wing problem with anti-Semitism.

Jonathan Freedland in The Guardian, with his take on British Labour's denial of anti-Semitism.

Brett Stephens in The New York Times on the many beliefs that are required if you want to deny the existence of the global scourge of anti-Semitism.

Here's Maajid Nawaz discussing the institutionalized anti-Semitism of the British Labour party and Britain as a whole.



And lastly a video from an LBC British radio host who reports he now "gets it" regarding we Jews.

The Number Of School Pizza Days, Not The Number Of Slices, Are The Problem

Image source

This struck me as an odd story.

Apparently an elementary school in Ottawa (where I live) has decided to limit the number of slices of pizza that kids can have on pizza days to one. Their rationale is that two slices would exceed the limit on saturated fats as set by the Ministry of Health.

Not surprisingly the story has made some waves, with the bulk of the outrage being about liberty and fun and the overstepping of the school on the rights of children and their parents.

My take?

It's not the number of slices that should be limited, it's the number of pizza days.

The message taught to kids (and parents) by school pizza days, regardless of the number of slices involved, or whether the slices' ingredients comply with Ministry guidelines, is that fast food pizza weekly, for no better reason than the fact that it's Thursday (or whatever day), is an acceptably normal part of life.

Don't get me wrong, I'm not suggesting that fast food pizza is something that shouldn't ever be consumed, in fact my family often orders it on our kids' birthdays or when my father comes to town to visit, but given it is the second largest food source of calories in North American kids' lives, as well as the rise of chronic, non-communicable, diet-related diseases in kids, along with the ubiquity of junk food invading every single facet of modern day life, maybe schools should be doing more to teach kids that fast food is a rare treat, rather than endorsing it as a weekly norm.

Edmundston Burger King Offers High School Students Free Daily Lunch Bus

This one left me nearly speechless.

A local Burger King/St. Hubert franchise in Edmundston, New Brunswick, has started sending high school seniors from Cité des Jeunes A.M. Sormany (CDJ) a free lunchtime school bus to bring them to their restaurants.

The restaurants, located roughly 1km away and across a highway, clearly expect sufficient high-schooler traffic so as to make their bus and driver outlay worthwhile.

Though I regularly write about different food industry sponsored predatory advertising, this feels different. This isn't a large, nameless, multi-national corporation with a deceptive advertisement. This is a local franchisee who who has chosen to explicitly exploit their own local community's children to make a buck.

While it may be unrealistic to expect more from multi-nationals, here's hoping that this local franchisee reflects on the ethics of what strikes me to be an especially predatory practice.

[Thanks to the frustrated parent who sent this my way]

UPDATE: One week after this blog's posting (and subsequently a great deal of local media attention) the Burger King bus was cancelled.

Saturday Stories: One Solitary Must-Read Piece

An absolutely must long-read by Andrew Jacobs and Matt Richtel in the New York Times on how the food industry is targeting the poor in Brazil.

Consider the incredible and deeply disturbing reporting in this story the next time you want to try to kid yourself that something other than profits matters to the food industry.

Why Does The Boys and Girls Club Want You And Your Kids To Eat Poorly?

The short answer of course is money.

The slightly longer answer is society's normalized use of junk food to fund raise.

In the Boys and Girls Club's case, they're apparently quite comfortable taking money from fast food restaurants who, in a brilliant bit of marketing, sell packs of free kids meals in return for a donation (which presumably gets shared with The Boys and Girls Club).

Give $3 to Montana's (a fast casual BBQ restaurant chain in Canada), and you'll get 3 free kids meals.

Give $5 to Swiss Chalet (a fast casual rotisserie chicken restaurant chain in Canada) and you'll get 5 free kids meals.

As far as kids meals go, the Center for Science in the Public Interest once ran a comprehensive study of various kids meals. They determined that of the over 3,500 they analyzed, 97% were either too high in calories, sodium, or sugar (or all of the above).

Of course, the adult meals aren't any better and also provide wallops of calories, sodium, and/or sugar, and no doubt, the business model for the restaurants is that they can give away the kids meals because of course, their parents will be eating too.

Also notable is the irony found in The Boys and Girls Club's Twitter banner where they include "Healthy Snacks and Meals" in their listing of what they do.

While fundraising without junk food may be more difficult, it's certainly doable.

Yesterday morning I tweeted about a friend of mine's kid who's fundraising for her hockey team by way of selling pumpkins (and if you click through to the tweet's replies, you'll see many more examples).

There are ways to fundraise that don't involve selling junk food. Friend's kid's hockey team is fundraising by selling pumpkins!

— Yoni Freedhoff, MD (@YoniFreedhoff) September 19, 2017

Rather than enabling, permitting, and encouraging a fast food lifestyle, what organizations like The Boys and Girls Club should be doing is demonstrating leadership by ending - purposefully and vocally - the practice of junk food fundraising, and championing and promoting healthier fund raising options in its stead.

Saturday Stories: Watson, Goop, and Nutrients

(Yes)

Casey Ross and Ike Swetlitz in STAT on the disappointment that is IBM's Watson and cancer.

Olga Khazan in The Atlantic ponders why it is that Goop is so popular.

Helena Bottemiller Evich in Politico discusses the fall of our foods' nutrients.

Canadians, Please Step Away From The Chip Wagons

My office's local chip wagon (for Americans, think of a food truck, but where fries are their dedicated specialty) is a case study as to why trans-fats need to be regulated out of the food supply.

Walking by the truck with Dr. Aric Sudicky we noticed outside of it, were empty fryer oil buckets. The buckets were a perfect size to brine a turkey and so I asked if I could have one. Kindly, the chip wagon folks said, "sure".

When we saw its trans-fat content our jaws dropped.

It contained 1.9g of trans-fat in every 9.2g of deep fryer shortening.

A quick spin online found us an article that reported that 17.1% of the weight of a french fry came from its absorbed frying oil.

A purchase of a large fries, a kitchen scale, and a smidgen of math later and it turns out that there are a staggering 20.5g of trans-fat in a large serving of our chip wagon's fries.

Here's the video we shot to help put all of this in perspective.



Non-naturally occurring trans-fats, according to the head of Health Canada's trans-fat task force (and everyone really), are a toxin unsafe in any amount, and 20.5g? Well that's the equivalent amount found in 11.4 teaspoons of the most trans-fat laden stick margarine we could find in the supermarket, the No Frills No Name All Vegetable Shortening which according to its package packed 3.5g of trans fat into every 2 teaspoons.

Now Health Canada had promised back in 2007 to regulate trans-fat out of the food supply if voluntary measures failed, and despite those measures' epic failure, for inexplicable reasons, regulation never happened.

The good news though is that I have it on good authority that Health Canada will be moving imminently on the trans-fat file. Given people have literally died waiting for them, their announcement can't come too soon.

[Interesting short side note: When looking up the margarine's trans-fat content online (I was looking for better photos than the one that had been shared with me), I found that No Frills' No Name All Vegetable Shortening was reported to only contain 0.1g of trans-fat per 2 teaspoons (as opposed to the actual label's reported 3.5).

Seemed really odd until I also noticed, in a very faint and difficult to read font (that's it in the hard to read light grey at the bottom) the line,

"The values stated are approximate and may not be fully representational of this products (sic) vitamins, minerals, and ingredients"

. Um...WTF?]

[And lastly, huge thanks to Dr. Aric Sudicky who shot and edited the video. Aric is a resident finishing up his last year of training and is spending the month with me. You can follow Aric on Twitter, and he's much more active on Instagram than me (I'm old).]

Unbelievable Grade One Snack List Highlights Unhealthy Social Norms

Thanks to nutritional biochemist Dr. Dylan MacKay (following him on Twitter is well worth it) for sharing the handout his 6 year old daughter's school sent home to parents to provide them with examples of peanut free snacks that their kids could bring.

The list is unbelievable. In part it's difficult to believe that a school would suggest these options, but more, it's difficult to believe that whoever put this together didn't take a minute to pause and consider what they were writing.

That they didn't doesn't speak to their lack of intellect, competence, or caring, but rather speaks to just how normal it has become to rely on ultra-processed junk to feed our children. Plainly put, people tend not to question or scrutinize social norms.

Here's the list transcribed

Cookies and Crackers

Dare: Wagon wheels, Bear paws, Vinta crackers, Grissol breads
Christie: If no peanut/nut warning on pkg then safe. Chips Ahoy, Oreos, Animal Crackers, Ritz, Stoned Wheat Thins, Triscuit, Premium Plus
Peek Freans: Shortbread, Creme-Filled, Digestive Cookies
Kellogg's: Rice Krispie squares (except for peanut type), Nutri-grain bars, Pop Tarts, Special K bars
President's Choice: Various cookies and crackers, Granola bars, Rice Crispie squares, animal crackers, fruit snacks
Pepperidge Farms: Goldfish crackers (various flavors)
Betty Crocker/General Mills: Fruit snacks, fruit roll-up, Dunkaroos

Chips

Old Dutch: All flavors, popcorn twists, pretzels, taco chips
Frito/Lays: All flavors, tortilla, taco chips, cheezies
Pringles: All flavors
Hawkins: Cheezies

Yogurt: Most yogurts are safe except those that contain Muesli

Puddings: Jello, Magic moments, Superstore brands are all safe, Fruit cups and applesauces

Candy/Chocolates

Dare Candy: all Dare candy made in a peanut/nut free facility
Wonka Candy: Sweet tarts, Nerds, Gobstoppers
Hershey's: *some products have peanut free symbol, Twizzlers, Nibs, Tootsie rolls, Kisses (read label for safe flavors), treat size bars
Nestle: Aero, Kit Kat, Coffee Crisp, Mirage, Mint Aero, Smarties, also treat size bars (seasonal or special shaped (heart, or ball) treats may not be safe)
Effem: *Mars bars with peanut free symbol, Skittles
Trebor-Allan: Various candy, Laces, Big foot, Hot lips, Lollipops
Vadeboncoeur: #peanut free symbol. Variety of chocolates

And then, as an afterthought, outside the main list iat the very bottom of the page, is this non-highlighted single line,

"Fruits and Vegetables are healthy choices and are also peanut free"

Hopefully, moving forward, the school will utilize the revised version that Dylan mocked up for them, and if your kid's school sends you a similar list, free free to share it with them as well.

Saturday Stories: Flinging Feces, Undermining Health, And Science Sense

From the BBC comes a byline free story about feces flinging that though not even remotely deep, scientific, important, or fascinating, is just too golden not to share.

Rob Moodie, in The Conversation, covers what he refers to as the seven tactics unhealthy industries use to undermine public health policies.

Cornelia Dean, in Undark, with a terrific excerpt from her book, Making Sense of Science

Ask The Wrong Question, Get The Wrong Answer, Risk Public Health

An example of a Kompan 'Supernova'

Saw a recent study in the International Journal of Obesity. The study, The effect of increasing risk and challenge in the school playground on physical activity and weight in children: a cluster randomised controlled trial (PLAY), set to measure the impact of school playground redesigns aimed at encouraging "imaginative and independent free play" on Grade 1-8 students' weight, waist circumferences, BMI z-scores, and their accelerometer measured activity intensity and duration.

All the schools involved in the intervention arm made substantial changes to their playgrounds which sound so fantastic that here's the paper's description,

"All eight intervention schools made substantial changes to their school play spaces, which promoted greater risk and challenge through building new areas (hills and tunnels), adding more dynamic equipment (for example, a Kompan ‘Supernova’ that requires co-ordination and teamwork to use), or via relaxing the rules (letting children ride their bicycles or scooters on school grounds, allowing children to climb trees or play outside in the rain). Children were able to engage more with natural elements, create imaginative play opportunities with loose parts (carrying tree stumps around to form a spaceship or a jumping game where the ground cannot be touched) or long grass (places to hide, roll around in, throw mown grass at each other). Some schools also ensured greater equity in access for all ages, or made different aspects of the playground more attractive"

The results weren't shocking.

The installation of awesome sounding playgrounds and relaxing playground rules wasn't shown to have any effect on kids' weights, waists, or BMI z-scores.

I say the results aren't surprising because why would anyone expect, even with a best case scenario, that an increase in schoolyard imaginative or challenging play could change kids' weights or waists? How many minutes messing around on a Koman Supernova would it take a young child to burn 100 calories more than they would lazily moving and resting in a plain lot? If I were a betting man, my vote would be in the neighbourhood 2-3 hours, or more than a week's worth of recess. But that's not a fair way to consider those calories given that those 100 calories aren't likely to be above and beyond the calories those same kids would have burned if they were engaged in less imaginative or challenging play.

As to activity, at least according to the kids' accelerometers, there wasn't an increase, though I'm fairly sure that they're unable to measure imagination.

What didn't the study measure? Physical literacy, fun, or happiness.

Honestly I can't understand why this study was conducted, at least in the context of the kids' weights and such. There's no mechanism by which anyone could reasonably expect fancier playground equipment to lead to significant weight change, but now that the study's out there, I wonder if it'll serve to discourage schools from undertaking awesome playground remodels of their own? I sure hope not. They sound great.

UK Gov's ParkLives Kids' Exercise Partnership Markets Coca-Cola

ParkLives is a joint project between Coca-Cola and the British government that aims to promote free physical fitness activities at local UK parks.

At least that's what's in it for the British government.

What's in it for Coca-Cola?

Well of course they can spin it as strong corporate social responsibility which helps their claim that they're on team health and in so doing provide themselves with ammunition to possibly forestall or block industry unfriendly legislation.

But there's more.

There's marketing.

A recent study set out to look at the ParkLives project through the lens of advertising.

The study analyzed two weeks worth of #ParkLives tweets during two separate weeks. The first week was during a week of school vacation (where the marketing might be expected to be thicker and the events more frequent), while the second was during the school year, but spanning National Fitness Day.

Every identified tweet was then coded for category of content (marketing or otherwise)

Over the two weeks of collection, 318 tweets containing 216 images were identified, and of those, 57% included a Coca-Cola logo (usually on banners or staff shirts).

The authors note that the exposure to Coca-Cola branding is perhaps more powerful here in that with ParkLives, Coca-Cola is associated with fun, healthy, family activities.

The authors' take on all of this?

"ParkLives is indicative of a CSR project that aims to create a health halo around a brand and influence wider socio-ecological factors by guiding public discourse and directing opinion on the determinants of public health issues away from corporate influence and toward individual responsibility"

Partnerships, by definition, benefit both involved parties. Perhaps governments shouldn't be helping out in the business of marketing the world's largest liquid candy brand.

Saturday Stories: Dr. Con Man, Dr. Bad News, and Possibly Cancer Causing Vitamins

John Rasko and Carl Power in The Guardian with the story of Dr. Con Man, Surgeon Paolo Macchiarini

Ranjana Srivastava, also in The Guardian, with her first person discussion of what it's like to be an oncologist and be the bearer of bad news.

James Hamblin in The Atlantic on a newly found association between B vitamins and cancer in men that the natural experiment of selling mega-dose supplements has uncovered.

Could Health Canada's Future Front-of-Package Stoplights Reform Deceptive Claims?

So on Monday I blogged about how there are plenty of foods of dubious nutritional quality with fronts-of-package claims that while legal, are deceptive.

Looking ahead, there is the chance that Health Canada will be implementing a national front-of-package food labeling program which in turn would highlight products' higher than desired nutrient contents (perhaps by way of stoplights for instance).

So here's my straightforward suggestion.

Regardless of the system implemented, if a product's ingredients score it a front-of-package warning from Health Canada, that product's packaging should be legally prohibited from including any front-of-package health claims or inferences (where inferences for example would be a package of Froot Loops shouting out to its inclusion of whole grains or Vitamin D, but without an actual functional health claim).

Though imperfect, this simple step might help tilt the playing field ever so slightly away from the food industry's current unfair advantage.

The Canadian Food Inspection Agency Asks For Examples of Deceptive Food Labels

Saw this tweet from the CFIA and so I decided to take a supermarket field trip and found plenty of what I would describe as deceptive food labels.

5 teaspoons of sugar per bar along with 210 calories 

31% more sugar cup per cup than Froot Loops

By weight, this product is 48% sugar

Cookie for cookie more than double the sugar of an Oreo

Drop for drop more sugar and calories than Coca-Cola

With 2.75tsp of sugar per "Twist", contains the sugar of 2.3 actual Twizzlers

Each popsicle contains the sodium found in 93/100ths of one single grain of table salt (along with 2 teaspoons of sugar)

But here's the problem, none of the products' labels above break any Canadian packaging laws, and if the labelling laws themselves explicitly permit deceptive labels, consumers don't stand a chance.

Why have a system where the onus is on the consumer to study the products' nutrition fact panels to determine if their healthy front of package claims are supported?

Saturday Stories: Anne Frank Center, Post-Truth America, and Front Lawn Farming

Before you share that next clever Anne Frank Center for Mutual Respect zinger, please read Albert Eisenberg in National Review on how the center is a disgrace to Anne Frank's name and memory, and Emma Green in The Atlantic, with her detailed history of the center.

Kurt Anderson in the Atlantic with a great but depressing longread on how America has lost its collective mind.

Arielle Dollinger, in the New York Times, on the rise of front lawn farmers.

[And for those who don't follow me on Twitter or Facebook, I've decided to try to resurrect my Weighty Mutters podcast. You can find it on Anchor, iTunes, and Google Play]

PSA: Scales Measure Gravity, Not Health, Happiness, Success, or Effort

Just a periodic reminder that scales measure the gravitational pull of the earth at a given moment in time - nothing else.

Scales don't measure the presence or absence of health.

Scales don't measure happiness.

Scales don't measure success.

And scales don't measure effort.

Too many people believe scales measure things other than gravity, and for some, those beliefs lead them to abandon their best efforts.

If you're ever curious about how you're doing, consider the fact that the answer to that question has to do with the doing.

Are you cooking more frequently? Minimizing your liquid calories? Decreasing your restaurant reliance? Not drinking to excess? Cultivating sleep? Exercising as much and as often as you can reasonably enjoy? Keeping a food diary of some sort?

The answer to those questions (and of course that list isn't exhaustive, nor will all questions apply to all people) are how you're doing.

Please don't confuse what you weigh with how you're doing. Though there's often overlap, they're definitely not one in the same.

UC Davis Now Marketing HealBe Calorie Counting Indiegogo Scam

Do you remember HealBe?

They're the Russian company that raised over $1 million on Indiegogo in 2014 for a wearable that was supposed to track, just by your wearing it, how many calories you consumed.

They've been rightly pilloried for years by Pando Daily including a delicious quote from ZDogg on their technology who described it as

"some straight Ghostbusters, Peter Venkman bullshit"

Plainly put, the device hasn't delivered on its promises to magically measure the calories you consume, though it does deliver something - money into the pockets of its owners who don't seem to have any scruples about selling to a desperate population a device that hasn't been proven to work (review from Engadget here).

And if you don't believe me about the proof, the quote that HealBe's co-founder Stanislav Povolotsky gave Pando Daily's James Robinson succinctly sums it up,

"Proof, yeah… that is a tough piece for us."

And proof shouldn't be hard to come by. Controlled feeding for even just a few days while wearing the GoBe wearable and poof, if validated, a goldmine, not only for the investors, but for obesity researchers and the public the world over.

That 3 years after launch they're still nowhere, without a single peer reviewed publication, speaks volumes.

And with that all said, I just can't wrap my head around the fact that just a few months ago, researchers at the University of California Davis, entered into a 5 year agreement with HealBe to study their device.

Now I know what's in it for HealBe. Marketing.

As to what's in it for UC Davis?

There I'm at a loss.

Saturday Stories: Charlottesville, Charlottesville, and Charlottesville

United States of America, 2017

Emma Green in The Atlantic, on why Charlottesville marchers were obsessed with Jews.

Alan Zimmerman, president of Congregation Beth Israel in Charlottesville, VA, in Reform Judaism, recounts his experiences during the march.

And if you haven't yet spent the time to watch VICE's short Charlottesville documentary, please do.

Who Will Be The First To Sue A Fertility Treatment Centre For Weight Discrimination?

Did you know that women are regularly denied service from fertility clinics simply because of their weights?

I've met dozens of women struggling to conceive, who though healthy, exceeded a BMI threshold (usually in the neighbourhood of 35), and consequently were denied the opportunity to undergo fertility treatments and start a family.

I remember one who recounted how the fertility doctor who saw her suggested that perhaps God didn't want her to have a child (because she was unable to lose weight), but generally the reasons they're provided tend to focus on safety to them or to their future baby.

It's always struck me as arbitrary and biased as there are other conditions that confer risk that aren't exclusionary, and so I was thrilled to read a recent paper taking on the arguments in Human Reproduction Open. The paper, It is not justified to reject fertility treatment based on obesity, in my mind lays a basic groundwork for a future lawsuit.

It explains how though the risks of hypertensive disorders, gestational diabetes and caesarean sections are indeed higher in pregnancies of women with obesity, suggesting that this is a justification for withholding fertility treatment is dramatically weakened when considering that fertility treatments are not withheld from women with diabetes who in turn are at higher risks of developing hypertensive disorders, stillbirths and premature labour.

Similarly, when addressing the risks to the child - congenital malformations, premature birth with related morbidity, macrosomia and shoulder dystocia, future obesity, and a higher risk of metabolic syndrome - the authors note that children of women with diabetes also have increased risks of congenital anomalies, macrosomia and shoulder dystocia, and premature birth with related morbidity.

In speaking with an obstetrician friend, they pointed out that what's genuinely required (and unfortunately often absent or weak) is a frank discussion with the patient with obesity about the risks of the pregnancy - which indeed are real - but that denial of treatment simply on the basis of weight, is not justifiable. At worst it's conscious weight bias, at best, unconscious. Either way, it's ugly.

Dear Reporters, The Cure For Obesity Is Unlikely To Be For Sale On Indiegogo

Last week a reporter contacted me looking for a quote.

She was doing a story on a $449 weight-loss product that is being sold on Indiegogo.

Briefly, the device reportedly works by stimulating the vestibular nerve, which, according to the people selling it, triggers the body to reduce fat storage, and all with just one hour of wear per day!

Of course there's this proviso (emphasis mine),

"Used in conjunction with a healthy diet and regular exercise the average user should notice a significant difference in body fat percentage."

Does the product have peer reviewed studies proving it works?

Of course not.

But it does have an unpublished preprint hosted freely online featuring a 6 person treatment group, only half of who completed the treatments.

The preprint also features a 3 person control group who somehow managed to post an 8.6% increase in truncal fat and a 6% increase in total body fat during the study's short 4 month period.

And it includes the authors' assertion that neither group changed their diet and exercise habits - this despite the fact that the authors didn't track their subjects' diet and exercise habits, and also despite the fact that the control group gained a significant amount of fat in a very short period of time.

After looking at all of this, I politely declined the reporter's request for an interview, as a story at this point on this product, even with a dissenting voice in it, is not simply premature, it's unethical. It's unethical not simply because it further perpetuates the narrative that magic, quick, and easy exists in regard to weight management, but because as is evidenced by the product's Indiegogo page, a story, any story, on this already for sale evidence-free product will be used by its manufacturers to market it to a desperate, constantly preyed upon population (who at the time of this post's writing, have already given this product's promoters $728,463 USD)

Now I realize that reporters are busy, and many don't have the background to pick apart studies, but I'd like to propose that the simple rule of,

"Don't cover medical devices being sold on Indiegogo or Kickstarter as a means to magically treat anything"

is probably a safe one, and one that I wish went without saying.

Saturday Stories: The Magnitsky Act, The Hateful Left, And Not So Safe Spaces

By VOA - Прокуратура призывает снять обвинения с подсудимого в деле Магнитского, Public Domain, Link

Julia Ioffe in The Atlantic explains why Russia hates the Magnitsky Act (and of course explains what it is)

Bari Weiss in the New York Times wonders whether the left will have more spine than the right in policing the hate in their ranks

Mark Joseph Stern in Slate on the one group not allowed in safe spaces.

The Strange New Reason Why You Shouldn't Drink Sugar With Your Meals

Granted, it's a small study, but its results were interesting.

The study, Postprandial energy metabolism and substrate oxidation in response to the inclusion of a sugar- or non-nutritive sweetened beverage with meals differing in protein content, looked at the impact sugar sweetened beverages had on the appetite suppression benefits of higher protein meals.

The authors note that,

"increasing dietary protein while maintaining energy intake produces a greater and more prolonged thermic effect and greater total energy expenditure",

that protein,

"potentially increases fat oxidation by up to 50%,"

that

"decreasing protein consumption may stimulate an increase in energy intake in an attempt to maintain a constant absolute intake of dietary protein",

and that,

"a 1.5%E decrease in dietary protein intake increases energy intake from carbohydrates and fats by 14%, perhaps in an attempt to increase protein intake from less protein-rich food sources (and point out that) in a 4-day in-patient ad libitum crossover feeding trial, a 5%E decrease in dietary protein intake produced a 12% increase in total energy intake"

So the authors were curious whether or not the inclusion of a sugary beverage would change the impact that a high protein meal had on consumption, appetite, and fat oxidation, and to explore, they studied those variables in 27 adults (without obesity) on two separate occasions in a direct (room) calorimeter after the consumption of a sugar-sweetened beverage or a non-nutritive sweetened beverage along with meals that varied in protein composition (15% vs. 30%).

The authors found, as expected (and certainly in line with the experiences I've seen among thousands of patients), that meals with higher protein content decreased hunger, increased fullness, and decreased the desire for fatty/salty/savory foods (sweet desires weren't affected).

The authors also found that when consumed along with a higher protein meal, sugar sweetened beverages increased the desire for fatty/salty/savory foods, and simultaneously decreased diet induced thermogenesis (the energy spent on processing/storing food), and fat oxidation (which the authors postulate may lead to a greater tendency of the body to store fat).

All this to say, treating sugar sweetened beverages (including juice) like the liquid candy that they are, and consuming them as treats, in the smallest quantities you need to be happily satisfied, rather than drinking them along with your meals, is probably a good plan.

The Canadian Cancer Society Wants You To Drink Sugar And Eat At Chipotle

A few years ago I pointed out the hypocrisy of the Canadian Cancer Society encouraging people to eat Domino's pizza in the name of fundraising.

I noted that sure, fast food pizza here and there isn't going to kill you or give you cancer, but that there's little doubt that one of the major drivers of our society's struggles with diet and weight related illnesses is the normalization of fast and junky foods as regular, everyday parts of our lives.

My belief is that this normalized culture of convenience is in part encouraged by the cause-washed use of candy and junk food for fundraising - a practice which may have been inconsequential (and rare) 60 years ago, but superimposed on our health issues today, is just plain wrong (and constant). And it's especially wrong when adopted by health organizations whose cause, like that of the the Canadian Cancer Society, is itself impacted by low quality diets.

So this year's Canadian Cancer Society junk food partners are Chipotle, PepsiCo, and the Dole Food Company.

The Canadian Cancer Society's partnership with Chipotle sees them encouraging a trip to the giant fast food burrito maker in the name of 50% of a single day's sales, while their partnership with PepsiCo and Dole come from one of their flagship events - the Run For The Cure - where PepsiCo and Dole serve as the Run's, "National Official Suppliers". As such, at the finish line of the short 5km fundraising run (which of course isn't of a distance long enough to worry about any fuel or hydration needs), PepsiCo and Dole will be there to market hand out the beverages that the Run For The Cure website notes provide participants, year after year, with "delicious refreshment".

Of course they'll also provide participants with piles of sugar given that Dole Sparklers, a "real fruit beverage", pack 4 teaspoons of free sugar per can, while Real Tea's offerings can pack up to a whopping 12 per bottle depending on flavour.

It's a good thing then I guess that the Run For The Cure is on October 1st rather than September 30th given that in September the Canadian Cancer Society's fundraising effort is a much more appropriate Sugar Free September initiative

And as the Canadian Cancer Society is explicitly aware, fruit drinks and sweetened tea, are common sources of free and added sugars in our diets.

One of the other reasons why these partnerships are so unwise is the way they're utilized by the junk food partner. For instance Dole's gone ahead and leveraged their partnership for in store sales of their sugar water by using it to cause-wash their products directly.

Given that the last time around the Canadian Cancer Society reported they were incredibly proud of their partnership with Dominos, I imagine this time will be no different.

Not sure pride is the emotion I'd recommend when reflecting on their comfort with junk food fundraising.

Saturday Stories: Vaginal Debunking, p-Values, and Dying

Meghana Keshavan in STAT profiles the great vaginal debunker Dr. Jennifer Gunter

Brian Resnick in Vox with a terrific explainer on p-values and scientific significance.

Cory Taylor in The New Yorker with her first person account of actively dying.