Physicians Best To Have Practiced What They Preach Regarding Lifestyle

A few days ago I put out a tweet that stated that physicians (and with more characters here I'll say other allied health professionals as well) shouldn't give lifestyle advice unless they've followed it themselves. Given it led to a varied discussion, thought I'd expand more here.

First, I'm talking primarily about diet and fitness advice which pertain to any diet/fitness responsive condition or simply on healthy living as its own aim.

Second, while I think it'd be terrific if all physicians continually walked their talks, this isn't a reasonable expectation. What is however reasonable, at least in my opinion, is that a physician providing lifestyle advice has spent at least some time following their own advice (barring of course any physical or medical limitations that might preclude same).

Living the whys, wherefores, real-life challenges, and logistics, of their own lifestyle advice provides physicians with insights and empathy that in turn will help in their understandings of their patients' struggles and barriers. That understanding is likely to improve the counselling and support those physicians provide.

Whether it's keeping a food diary, following a particular diet, cooking the majority of meals from fresh whole ingredients, exercising a particular amount each week or day, mindfully meditating, etc - spending a real amount of time doing so (my non-evidence based suggestion would be for a month at least) will make you a better clinician.

[And to be clear, as there were those online who wanted to extrapolate my statement into one that suggested physicians must themselves all live incredibly healthful lives and maintain certain weights - that's definitely not what I'm saying, nor of course does weight provide real insight into the health of a person's lifestyle (as plenty of people with obesity live healthy lives, and plenty of people without don't).]

Early Childhood Physical Activity Does Not Vaccinate Against Obesity

By Pete (originally posted to Flickr as determination_0970) [CC BY-SA 2.0], via Wikimedia Commons

It's not uncommon when I meet parents of children with obesity for them to tell me either that it doesn't make sense because their child is extremely active, or that inactivity is to blame for their child's struggles.

And while my confirmation bias is that weight leads to inactivity in kids rather than inactivity to weight, data is somewhat mixed, with some studies finding total daily energy expenditure in very young children is associated with lesser weight gain, and others, not.

One of the shortcomings of prior studies were that they focused primarily on energy expenditure measured during a child's first year of life, and didn't cover the period known as adiposity rebound whereby BMI typically decreases until the age of 4-7 years before beginning to increase through late childhood.

A recent small study, High energy expenditure is not protective against increased adiposity in chldren, included that time period.

Briefly, 81 subjects who were classified as either at low risk of developing obesity (in that they had lean mothers with an average BMI of 19.5), or at high risk (mothers with an average BMI of 30.3), were recruited, and 53 remained through to the study's conclusion of 8 years. Three measures of adiposity at 8 years were collected - BMI percentile, BMI Z-score, and percent body fat. Total energy expenditure was measured using doubly labelled water at 4 months, 2, 4, 6, and 8 years of age (though only 58% of all total measurements were collected). Body composition was measured by way of bio-impedance analysis at ages 0.25 and 2 years, and by way of DEXA at ages 4 and 6.

What was found was that total daily energy expenditure increased with body size, but,

"there was no evidence supporting the hypothesis that a low habitual TEE for that body size leads to subsequent increase in BMI or % body fat"

Nor was there an association between measures of adiposity at age 8 and total energy expenditure between the ages of 0.25 and 6 years.

The authors overarching conclusion is that when it comes to the genesis of childhood obesity, it's energy in, not energy out.

I can't help but wonder, were that to be the prevailing belief, would parents with concerns about their children's weights be more conscious of their children's diets (especially liquid calories and purchased meals) as energy-in is something that many parents deemphasize during our initial discussions.

Saturday Stories: Trump's USDA, ORBITA, and 'Woman, Black',

Michael Lewis in Vanity Fair on Trump's USDA.

James Hamblin in The Atlantic covers the ORBITA trial and wonders how much of heart disease is a state of mind?

Future physician Chika Oriuwa with her spoken word poetry slam 'Woman, Black'

More Evidence That More Exercise Doesn't Up Total Daily Calorie Burn

Why is it that exercise doesn't seem to help appreciably with weight loss (and for those who enjoy building strawmen out there, note I'm talking about weight loss, not fat loss, nor fitness, nor health)?

One possible reason is that many people eat back their exercise in the form of a reward for doing it, or because they have been taught by savvy marketers that they need to refuel or recover something or other.

Another possible reason is that upping intentional exercise may lead bodies to decrease unintentional calorie burn (decreased fidgeting/NEAT, decreased autonomic tone, etc.) and also by way of improved exercise efficiency.

Overarchingly the latter theory is called constrained energy expenditure, and the evidence on all of this is early, and somewhat mixed.

Well a few months ago another block was added to the pile (at least for older women without obesity) suggesting constrained energy expenditure is a real phenomenon. It was a study published in Physiological Reports and it detailed the impact that a 4 month long moderate-intensity walking program had on the total daily energy expenditures of older women without obesity.

The study's 87 included participants reported being physically inactive, and weren't found to have any significant medical issues. The group was randomized into either receiving one of 2 doses of moderate intensity exercise for 4 months. Importantly, the exercise itself was supervised. Before and after measurements included resting energy expenditure (via indirect calorimeter), total daily energy expenditure (via doubly labeled water), body composition (via DEXA), graded exercise test (via treadmill VO2 max), physical energy expenditure (TDEE*0.9-RMR (to account for thermic effect of food reduced by 10%), and NEAT (by subtracting exercise energy expenditure - physical activity energy expenditure).

When it was all said and done, the lesser group added an average of 105 minutes of walking to their weeks, while the higher group added 160 minutes to their weeks.

There was a teeny tiny bit of weight lost in both groups (1.7lbs), and a tiny change to body fat percentage (-0.7%), but there were no between group differences. Expectedly, V02max improved more in the larger amount of exercise group.

What didn't change?

Everything else.

Despite marked increases in intentional exercise, and marked differences in adhered to doses of exercise, there were no differences found for participants' total daily energy expenditures, resting metabolic rates, NEAT, non-exercise physical activity or even total physical activity.

These results changed some when they further analyzed the data as they determined that those patients with higher baseline levels of physical activity showed lower levels of NEAT (important to note, difference did not reach statistical significance) post 4 months of exercise, whereas those with lower levels of baseline activity experienced decreases to resting metabolism with exercise (authors suggested latter might be due to weight loss, but given how small weight loss was, I find this confusing as the RMR drops were not small).

All this to say when it comes to exercise and its impact on calories burned, it's clearly far from a simple math formula. It's also incredibly unfair to weight. But as always, when it comes to improving health, nothing beats it.

[Thanks to Matt Woodward for sharing this study with me]

Guest Post: Special K Nourish Ad Perpetuates Supermom Nonsense

I've never been a fan of Kellogg's Special K's pretending to give a crap advertising, and so when I received an email from longtime reader Rosemary, who was unimpressed to say the least with one of their latest ads (embedded at the end of this post), I asked her if I could share her thoughts. She kindly agreed. Raw to say the least, and though I don't fully agree with every sentiment expressed herein, I'm betting they'll resonate with many.

I know soooo many women (and men!) that eat these products - thinking they are a whole / healthy choice.

This ad is so much ugh. Of course they had to throw in the shot of the well-endowed woman in the bra. "Casually getting dressed" ... while literally stuffing her face. Geneen Roth would not approve! Lol.

The whole "I am woman hear me roar - I can do anything - I am fierce - around food / being in charge of the food / feeding the kids - this media trope is so such nonsense. I dont know any women that work / live / eat the way this ad depicts.

Just perpetuating that myth -women- no, we don't deserve time carved aside to eat calmly - we are just too damn busy being everything to everyone. Just perpetuates this super mom woman role nonsense.

Most women I know / especially those with young school age children LOATHE grocery shopping / planning meals / making lunches / cleaning up (cuz let's face it, cooking proper whole foods is more work) / and just generally feeling the societal pressure to excel to be creative (and inspired! (Oh shut up Jamie Oliver))- about feeding their families. (And isn't this just code for "if you love your family you should be obsessing about this too like every other delusional Martha Stewart wannbe? Most of us are just so exhausted from overwork / we lose the motivation. In secret, we all admit how much we hate it and what drudgery it is.)

And there Kellogg's is trying dutifully to hit all their "diversity notes" - woman motorcycle mechanic / buzzcut lgbt-ish rainbow wristband girl - / It is all so contrived.

They are depicting the overworked woman - and they are the solution, when in fact, eating their crap that masquerades as "breakfast" and "food" probably actually contributes to feeling exhausted - re unstable blood sugar - carby weight gain - making one less energized to shop and prepare. It's a cycle.

I know when I eat next to no processed food - my energy levels are great. After about 4 days of not eating any crap.

The cereal is 10g's of sugar per 3/4 cup serving. That would maybe cover the bottom of the cereal bowl. No one eats only 3/4 cup of cereal when they pour a bowl.

And the granola bars are even worse - palm oil - and many different forms of sugar. Cane in the chocolate and corn syrup.

No reply necessary - yer bizzy - just wanted to pass it along.

Saturday Stories: Global Trolling, Pain Empires, and Fake News Towns

A non-bylined piece (at least not that I could see) in The Economist explaining how the world has been trolled and why social media is to blame.

Patrick Radden Keefe in The New Yorker on the Sackler family and their empire of pain.

Caitlin Dickerson in the New York Times on what fake news did to Twin Falls, Idaho

[If you find this blog entertaining, interesting, and/or valuable, know I'll never ask you for money to read it, nor will I subject you to ads, but I will, once a year, ask you for donations to support my #Movember efforts. Please to report I'm nearly halfway to my $3,500 fundraising goal! Click here to give. No amount is too small, you'll get a tax receipt, and if you don't want it known by me or anyone else that you hang out here from time to time, you can give wholly anonymously as well.]

And So It Begins (#Movember)

And so it begins (again).

This month I pledge to grow my something of a Pedro Pascal inspired lip-terpillar in the name of raising awareness (and $s) for men's health.

If you enjoy my blog, a blog fully free from advertising, I'd like to ask you to donate to my Movember fundraising efforts. I've kicked them off by donating $100 myself and I'm hoping to raise more than last year's $3,500.

Contrary to what some believe, Movember is not a prostate cancer charity per se, and though some of its funds do support prostate cancer research and treatment, Movemeber supports multiple men's health initiatives including those involving mental health, suicide, body image, eating disorders, testicular cancer, substance abuse, and more. Regarding prostate cancer, I was pleased to see that Movember encourages patients to speak with their physicians about the value (or lack thereof) of PSA screening, rather than suggesting it's a good idea for one and all.

Donating is easy. Just click here and give! And of course, Movember is a registered charity, so all donations are fully tax deductible.

In return I vow to continue to blog freely, to never allow advertisements, and to regularly post pictures of what might well have been an effective form of birth control in my home had I sported it year round back in the day.

For me the ask is also personal. My father was diagnosed with prostate cancer when I was in medical school, and soon I'll need to start wrestling with whether or not with that strong family history, I should walk the slippery slope of testing. My oldest cousin Marshall - we lost him to substance abuse.

Every dollar counts, no donation is too small.

(And if you want, you can make your donation anonymously so no one (me included) will know you hang out here from time to time.)

Food Industry Furious With Health Canada's Front-of-Package Plans

If Health Canada takes Chile's lead, we too might see Frosted Flakes boxes change from looking like those on the left to looking like those on the right.

When industry is furious with a government proposal it's a safe bet that proposal is likely to affect their sales, and so when I learned that the food industry was incensed by Health Canada's front-of-package plan proposals (Aric Sudicky, a final year medical resident who was rotating through our office at the time, watched the recent roundtable style consultation hosted to discuss the implementation of what will be a Canada wide front-of-package program, via teleconference and reported to me that industry was none too pleased), I wanted to learn more.

Now this post isn't going to delve into whether or not those are the best 3 targets for front-of-package symbols, instead I want to focus on the lobbying and machinations of industry.

First though, a tiny bit of background.

In creating a new front-of-package symbol for Canadian consumers, what Health Canada doesn't want is a program that emphasizes so-called positive nutrients as 50 percent of Canadian package fronts already have those (put there by the food industry directly to help sell food), or one that requires a second step of thinking to interpret (eg studying the nutrition facts table) as that has been shown to lead to misunderstanding, or a hodgepodge of programs (as more than 150 front-of-package labeling programs have already been documented in Canada) .

What Health Canada does want is a single, standardized system, that involves a prominent symbol, that's consistently located, that doesn't require nutritional knowledge to understand, to help consumers identify products with high levels of nutrients that Health Canada deems are concerning to public health, that by itself provides the required interpretation for its meaning. Such a system would be consistent with the core recommendations made by the U.S. Institute of Medicine.

Breaking it down further, what Health Canada wants is a system that conveys simple to understand information, rather than one that presents data requiring interpretation.

Further still?

Health Canada wants warnings.

In their recent meeting, Health Canada presented their wants to food industry stakeholders, as well as the evidence they feel supports them, and invited them to submit their thoughts and suggestions for a symbol to fit Health Canada's 4 design principles:

1. Follow the "high-in" approach
2. Focus only on the 3 nutrients of public health concern (sugar, sodium, and saturated fat)
3. Be 1 colour (red) or black and white; and
4. Provide Health Canada attribution

As to what this might look like, here are some mockups put together jointly by the Canadian Cancer Society, Canadian Medical Association, Canadian Public Health Association, Diabetes Canada, Dietitians of Canada, and the Heart and Stroke Foundation.

Given that warning symbols aren't likely to be good for business, I was curious as to industry's response to the ask.

Suffice to say, industry is indeed unhappy.

The Retail Council of Canada wants Health Canada to implement instead an instruction for consumers to turn products around and study their nutrition facts tables, and they don't want Health Canada's name mentioned on the symbol. They are apparently worried that including Health Canada's name on the symbol might be misinterpreted as a government endorsement which in turn would lead consumers to eat more of the products with the warning labels. They're also apparently simultaneously worried that if the symbol utilized is already recognized to be a danger symbol, it could lead consumers to believe there is a food safety risk, and that if used, children, accustomed to seeing these symbols on foods, might lead them to think that cleaning supplies with danger symbols are safe to consume.

The Food Processors of Canada used bold to point out that, "the meeting didn't agree to anything", and that, "Health Canada has lost its way on the obesity issue". They think that what's needed is more public education, not a front-of-package warning program.

The Canadian Beverage Association expressed their, "deep concerns", and that though they were happy to have been included in the meeting, their definition of "deep and meaningful dialogue" with industry should include a process whereby industry participants would all discuss and agree upon what the program would entail.

Food and Consumer Products of Canada also wanted to express their disappointment that they weren't provided the opportunity to be more directly involved in crafting the proposal's criteria and their concerns about "the integrity and transparency of the consultation process". They sent a second note expressing their hope that the criteria still have room to evolve and that their preference is for traffic lights as they believe, "information – good and bad – builds on consumer literacy".

Dairy Farmers of Canada expressed their concern that the proposed warning system lacks the nuance required "to distinguish between nutrient-dense and nutrient poor foods" (sweetened milk will likely be slapped with a high in sugar warning), and that they'd be happy to support, especially, "if coupled with exemptions for nutritious dairy products", those programs that would provide data for consumers to study and interpret (like for instance the Facts Up Front program illustrated below).

There was however, one response from industry that was heartening. It was from Nestlé, whose representative reported being, "a little embarrassed" by how industry presented their views during the roundtable, and, "that Nestlé is not fully aligned to some of the comments that were made by some of our trade associations, and a few of us are feeling very frustrated."

Whatever comes of all of this, one thing's for sure. The food industry's near uniform opposition to Health Canada's proposed front-of-package warning label criteria is strong indirect evidence in support of their utility, as for the food industry, salt, sugar, and fat are the drivers of profitability and palatability, and they'll oppose anything they worry might limit their use.

So kudos to Health Canada for sticking to their guns, and also for honouring their pledge to make this process transparent by sharing with me industry's responses.

(and if you clicked on any of the industry letters to read, this is the post roundtable letter from Health Canada to which they're all referring).

Saturday Stories: Motherisk, Blood Tests, and Kim Jong Nam

CC BY-SA 3.0, Link

Rachel Mendleson, in the Toronto Star, with Part I of her incredible reporting on the fallout from the Mortherisk scandal.

Christie Aschwanden, in Five Thirty Eight, details her experiences with direct to consumer blood tests in the name of athletics.

Doug Bock Clark, in GQ, with the strange but true story of Kim Jong Nam's assassination.

Hey American Youth Soccer Organization, Kids Don't Need Sugar To Play

It's difficult to overstate just how aggressively the American Youth Soccer Organization (AYSO) allows Nesquik to push chocolate milk on their young players.

The reason why is simple. In 2014, AYSO partnered with Nesquik and named it, "the official “Chocolate Milk” of AYSO."

Nesquik's AYSO enabled health washing centres around the supposedly "ideal ratio" in chocolate milk of carbohydrates to protein that "can help refuel and restore exhausted muscles".

"Exhausted muscles"?

I did a straw poll on Twitter of parents whose kids play soccer.

94% of the 269 respondents reports their kids as actually moving for less than 60 minutes per soccer outing, with vast majority of respondents reporting less then 30 minutes of movement.

Nonscientific #soccer #parent poll. When your kids play soccer, how many minutes of actually moving per outing do you think they get? RT pls

— Yoni Freedhoff, MD (@YoniFreedhoff) September 9, 2017

Those poll results correspond nicely with those found by objective measures and published in Pediatric Exercise Science whereby accelerometers revealed that kids only spend 17 minutes of a 50 minute soccer match engaging in moderate-to-vigorous activity.

Now putting aside the discussion of ratios and whether chocolate milk has a special role in "refueling", it's difficult for me to imagine that anyone would suggest that kids moving for less than 30 minutes at a stretch (or even an hour), have "exhausted muscles" that need any special attention.

But I'd be wrong, because Registered Dietitian Tara Collingwood is out there for Nesquik to tell parents that chocolate milk is a healthy, perhaps even necessary, choice.

I know this because a close friend of mine and father of recently AYSO soccer enrolled twin 8 year olds and a 5 year old, has been sending me the signed by Collingwood promotional materials that arrive courtesy of AYSO in his inbox.

Here are Collingwood's "Hydration Guidelines" that recommend not only post game chocolate milk, but also suggest kids quaff 4-8oz of a sports drink for every 15 minutes played.

Here's Collingwood's post game snacks handout which of course includes chocolate milk.

Here's Collingwood's grocery list that includes chocolate milk (with its nearly double the per drop calories of Coca-Cola along with 2.5 teaspoons of added sugar per cup) in her list of "best foods"

Here's Collingwood's game day recommendations, which if my calculations are remotely accurate, would provide my friend's barely moving 5 and 8 year olds with somewhere between 400-600 game based calories, and more than a day's worth of added sugar (especially if drinking sport drinks ever 15 minutes as she recommends) apiece.

And here's Collingwood touting chocolate milk as one of 5 "must-have" foods alongside spinach, salmon, bananas, and whole wheat wraps.

And please don't think that AYSO cares enough about your kids to not allow Nesquik to target them directly with marketing either.

Nesquik has also paid Latina Mommy Bloggers to spread the word about the miraculous marriage of soccer and sugar-sweetened milk.

Here's another

And another

And another

In fact there are many, many, more.

AYSO, if you honestly cared about kids' health and sports nutrition, you'd put an end to this partnership, as Collingwood's love of chocolate syrup notwithstanding, it's nutritionally indefensible.

Saturday Stories: 3 #MeToo Stories

Image Source: The Daily Beast

Scott Rosenberg, in Deadline Hollywood, says everybody knew.

Jim Beaver, on Facebook, and why he won't say #MeToo.

Kristen Patrick in the CMAJ on #MeToo in Medicine.

Good Lord! British NHS Just Banned Surgeries For Patients With Obesity (And Smokers)

In what is perhaps the world's most biased and blame based health policy, A British NHS just banned patients with obesity or who smoke from receiving elective surgeries in a bid presumably to inspire encourage help whip and prod people into losing weight (or quitting smoking - but I'm not going to touch on smoking in this piece, not because I agree with the policy, but rather because it's not my area of expertise).

The policy's two primary presumptions are ignorant and misguided.

The first has to do with the value of BMI as a clinical tool. While it's true that the risks of medical complications and morbidities rise with weight, BMI is a measure of bigness, not health. Half of the NFL have been reported to have BMIs greater than 30, as did my friend and colleague Dr. Spencer Nadolsky pictured below in his wrestling days when he sported a BMI of 32.

The second presumption is that obesity is a disease of personal responsibility and choice. While no doubt weight can be dumbed down to eat less, move more, I still find it shocking that public health professionals and policy makers exist who believe that somehow people with obesity simply haven't absorbed enough societal guilt, shame, and discrimination to finally lose weight.

Of course, even if you do want to embrace personal responsibility as the sole cause of obesity, medicine isn't about blame. We patch up drunk drivers and folks who don't wear seat belts. We treat people with asthma who don't bother keeping up with their puffers, pneumonias exacerbated by the early discontinuation of antibiotics, and the psychotic breaks of folks who stop their antipsychotics.

Oh, you want surgical examples?

How about liver transplants in patients who once suffered with alcoholism; or how about one that doesn't involve a so-called vice at all - heart bypasses on folks who simply didn't bother to take their blood pressure, cholesterol or diabetes medications?

We operate on them all in a timely manner, and so we should, but yet here the NHS feels comfortable discriminating against people with obesity, because they apparently still feel justified discussing obesity on the basis of blame based causation.

But putting those two erroneous presumptions aside, the notion that blame based medicine is something that the UK wants to adopt is plainly repugnant. Medicine's not about blaming and shaming. Life is complicated. And even if a person has the time and personal health to allow a run at intentional behavior change, how high on the list of priorities do you think healthy living lies for someone whose children struggle with substance abuse, or whose debts are staggering, or whose spouse is hobbled with post-traumatic stress disorder? Or someone with any of those same issues who is also unemployed?

Clinically useless truisms aside, obesity is complicated, and moreover we have yet to discover a non-surgical, reproducible, and uniformly effective plan for the management of obesity. And 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. Meanwhile the burden of suffering that the elective surgery those with obesity are being denied may add to absenteeism, presenteeism, pain, depression, and more.

If someone from the NHS' clinical commissioning groups (CCGs) in Hertfordshire (who thought up this loathsome, biased, and backwards policy) is reading this, I want to remind you of the NHS Constitution's first guiding principle:

"The NHS provides a comprehensive service, available to all

It is available to all irrespective of gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy and maternity or marital or civil partnership status."

Either you're going to have to reverse this idiotic policy, or amend that statement above to explicitly exclude those with obesity.

For shame.

(In rushing this post through, I utilized paragraphs from a number of previous stories I've written about obesity, blame, and bias)

PepsiCo Confirms They Care About Profit, Not Health

This post is not an indictment of PepsiCo.

In fact I've picked on PepsiCo far less than I have on Coca-Cola over the years because for the most part, PepsiCo hasn't cynically pretended that health mattered to them as vocally as has Coca-Cola.

For PepsiCo, health was always about sales. They simply wanted to make money selling less awful junk food.

Well, that hasn't worked out so well, and so PepsiCo, in a 3rd quarter investors meeting a few weeks ago, did as companies do when faced with disappointing sales figures - they pledged to increase their marketing of their flagship sugary beverages (Pepsi and Mountain Dew).

This shouldn't surprise anyone.

PepsiCo's job is to maximize their profits, and while there may be times when profits and public health collide, if they don't, PepsiCo will protect their interests, not yours and mine.

And this post comes with a serving of especially delicious irony in that just one day after PepsiCo's announcement that they were going to pump their sugary fare, PepsiCo's VP of marketing Gary So published this piece on Medium about how great PepsiCo's commitment is to reducing the consumption of calories and sugar from beverages.

As I've said before, the food industry is neither friend, nor foe, nor partner.

[Thanks to Consumerist Community Editor Laura Northrup for pointing me to the AP piece]

My Kids Go Trick or Treating. Yours Probably Should Too.

(A variation of this post was first published October 24th, 2013)

It's coming.

And I'm not really all that worried. At least not about Halloween night.

The fact is food's not simply fuel, and like it or not, Halloween and candy are part of the very fabric of North American culture, and so to suggest that kids shouldn't enjoy candy on Halloween isn't an approach I would support.

That said, Halloween sure isn't pretty. On average every Halloween sized candy contains in the order of 2 teaspoons of sugar and the calories of 2 Oreo cookies and I'd bet most Halloween eves there are more kids consuming 10 or more Halloween treats than less - 20 teaspoons of sugar and the calories of more than half an entire package of Oreos (there are 36 cookies in a package of Oreos).

So what's a health conscious parent to do?

Use Halloween as a teachable moment. After all, it's not Halloween day that's the real problem, the real problem are the other 364 days of Halloween where we as a society have very unwisely decided to reward, pacify and entertain kids with junk food or candy (see my piece on the 365 days of Halloween here). So what can be taught on Halloween?

Well firstly I think you can chat some about added sugar (and/or calories), and those rule of thumb figures up above provide easily visualized metrics for kids and parents alike.

Secondly it allows for a discussion around "thoughtful reduction". Ask them how many candies they think they'll need to enjoy Halloween? Remember, the goal is the healthiest life that can be enjoyed, and that goes for kids too, and consequently the smallest amount of candy that a kid is going to need to enjoy Halloween is likely a larger amount than a plain old boring Thursday. In my house our kids have determined 3 candies are required (and I'm guessing likely a few more on the road) - so our kids come home, they dump their sacks, and rather than just eat randomly from a massive pile they hunt out the 3 treats they think would be the most awesome and then silently learn a bit about mindful eating by taking their time to truly enjoy them.

The rest?

Well it goes into the cupboard and gets metered out at a rate of around a candy a day....but strangely....and I'm not entirely sure how this happens, maybe it's cupboard goblins, but after the kids go to sleep the piles seem to shrink more quickly than math would predict (though last year my oldest told me she believed it was her parents eating them and that she was going to count her candies each night). I've also heard of some families who grab glue guns and make a Halloween candy collage, and dentist offices who do Halloween candy buy-backs.

Lastly, a few years ago we discovered that the Switch Witch' territory had expanded to include Ottawa. Like her sister the Tooth Fairy, the Switch Witch, on Halloween, flies around looking for piles of candy to "switch" for toys in an attempt to keep kids' teeth free from cavities for her sister. The joy and excitement on my kids' faces when they came downstairs on November 1st that first Switch Witch year was something to behold, and is already a discussion between them this year.

And if you do happen upon our home, we haven't given out candy since 2006 and we haven't been egged either. You can buy Halloween coloured play-doh packs at Costco, Halloween glow sticks, stickers or temporary tattoos at the dollar store (glow sticks seem to be the biggest hit in our neighbourhood), or if your community is enlightened, you might even be able to pick up free swim or skate passes for your local arena (they run about 50 cents to a dollar per so if you're in a very busy neighbourhood this can get pricey).

[Here's me chatting about the subject with CBC Toronto's Matt Galloway]

Saturday Stories: Deaths, Blubber, and Running

Robert Fine and Jeffery Michel in Baylor University Medical Center Proceedings with their piece, Viaticum, on two different types of deaths.

Jonathan Reisman in Slate with a story of seal blubber and nutritionism run amuck.

Alex Hutchinson in Runners World with his final column there on what he calls the seven pillars of running wisdom (spoiler - it's not only applicable to running).

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.