Saturday Stories: Obesity, Mortality, and Belief

Michael Hobbes, in Huffington Post's Highline, explains why everything you know about obesity may be wrong.

Bari Weiss, in The New York Times, on the occasion of Yom Kippur, with her thoughts on facing our own mortality.

Caitlin Flanagan, in The Atlantic, with a powerful piece on why she believes Dr. Christine Blasey Ford.

There's No Realistically Prescribable Amount Of Exercise That Will By Itself Lead To Useful Weight Loss, But That Doesn't Mean You Shouldn't Exercise!

This isn't the first time I've noted that there is no realistically prescribable amount of exercise that by itself will lead to clinically meaningful weight loss, and it probably won't be the last. And that said, it doesn't mean it's impossible, but reality really is a useful place to live, and is probably a worthwhile frame of reference.

Today's reiteration stems from a recent-ish study that looked at "energy compensation in response to aerobic exercise training in overweight adults" which when translated refers to whether or not people eat back the calories they burn exercising and if that's why the results of exercise for weight loss studies so often disappoint.

The authors followed 36 men and women with varying degrees of excess weight (BMIs ranged from 25-35) and randomly assigned them to exercise either 30 minutes daily or 60 minutes daily, 5 days a week, for 12 weeks.

3 months on analyzed data later and the authors summarized conclusions include this statement,

"Results of the current study suggest the recommendation should be closer to 300 minutes per week to achieve appreciable fat loss"

because in their study it was only the participants who averaged 335 minutes of weekly exercise who were seen to lose a statistically significant amount of weight (and though significant statistically, it was only an average of 5.7lbs).

Though it's not noted in the study, it should go without saying that whatever intervention you employ to lose weight, if you stop that intervention, the weight you lost by way of its impact will likely return. And so while perhaps 335 minutes of weekly exercise for another bunch of months would lead to further loss, if you stop or decrease exercising that much, the weight you lost with it is likely to return.

Back to the headline of this blog post. If you think the average person, living a real life, replete with its many stressors, challenges, and responsibilities, can sustainably and consistently find upwards of 300 minutes of weekly exercise, I'd invite you first to get that much yourself even for just 3 weeks, as for the majority of people out there, it's not even a remotely realistically prescribable amount.

Instead of continuing to tie exercise to weight, and in so doing motivate people to start exercising in the name of weight loss, which in turn risks disappointment and the cessation of exercise if while successfully increasing exercise to a more realistically obtainable amount no weight is lost, the focus needs to shift to the fact that exercise is arguably the single healthiest modifiable behaviour anyone can undertake, that any amount is terrific, and that it's incredibly beneficial regardless of whether or not weight is lost in the process.

Photo by David Whittaker from Pexels

Saturday Stories: Museum Fires, Non-Sexual Harassment, and Lucy Wills

Ed Yong, in the Atlantic, with his coverage of the devastating Brazilian museum fire.

Linda Bloodworth Thomason, in The Hollywood Reporter, on Les Moonves and how not all harassment is sexual 

Hilda Bastian, in The James Lind Library, with the life and times of the remarkable Lucy Wills

Every Physician Ought To Know Which Common Medications Cause The Most Weight Gain

While it would be wonderful if all primary care physicians were interested enough in understanding how to treat their practices' most prevalent chronic condition to actually go out of their way and take the time to learn how to do so, there's a bare minimum that I think they do need to know, and that's which medications contribute to weight gain and their weight friendly alternatives.

Last week, my friend and colleague Sean Wharton, along with his collaborators, published an open access article summarizing drugs and weight gain, and I think it's a must read for all prescribers.

And for those who struggle with clicking, here's a summary of their summary by way of the article's various tables, because while it may be too much to ask for all MDs to truly take the time to learn about obesity, understanding which drugs are more likely than others to cause weight gain is something there's no excuse for them not to know.

[Cautionary note: If you're currently on one or more of the medications that are shown below to lead to greater weight gain, please don't stop it without first consulting with your prescriber, but do feel free to bring these lists along with you to discuss whether or not there are possible alternatives]

Saturday Stories: Tucker Carlson, Medical Error, and Physicans' Moral Injuries

By Gage Skidmore, CC BY-SA 2.0, Link

Lyz Lenz in Columbia Journalism Review, with a masterful profile of Tucker Carlson.

Deborah Cohen in BBC news details the heart breaking case of the medical error of Dr. Bawa-Garba.

Simon G. Talbot and Wendy Dean in STAT, on physicians' moral injuries.

Small, Short, Crossover Breakfast Study Says Maybe You Shouldn't Skip It

This was a very small study, but unlike many other "breakfast" studies, it prescribed specific breakfasts, and more to the point, they're not bowls of ultra-processed carbs, but rather high protein options with a breakdown of 340 calories made up of 30g of protein, 36g of carbohydrates, and 9g fat.

What the authors were interested in were the differences, in the same individuals, of having a high protein breakfast vs. skipping breakfast (first meal at noon), on hunger, fullness, desire to eat, prospective food consumption (PFC) and related hormones, food cue–stimulated functional magnetic resonance imaging (fMRI) brain scans, ad libitum evening food intake, sleep quantity and sleep quality.

The participants were healthy young men and women without obesity and each arm of the experiment lasted for 7 days with a 3 day washout period in between.

The results saw breakfast eaters see their hunger, desire to eat, PFC, and ghrelin levels decrease on breakfast days versus skipping days, while their fullness and related hormones increased.

What didn't differ however was total energy consumed, this despite the fact that when they ate breakfast, participants on average consumed 30% fewer carb based evening snacks. There was also no real impact on sleep or sleep markers.

What was great about this study was that it didn't just look at next meal consumption, but rather the impact of breakfast on whole days, something my clinical experience has been screaming for years was necessary. That said, at least in this short study, it didn't seem to matter, at least not to total daily energy intake.

So does this mean you shouldn't skip breakfast? Not exactly, but it does suggest that eating a high protein breakfast, though it won't make you eat fewer calories, it may leave you feeling fuller and decrease evening processed food snacking.

And so once again, the answer is personal and not particularly complicated. If breakfast helps you to eat less, eat better, or feel better, then yes, you should eat it, and if it doesn't, don't.

Saturday Stories: Rape Culture, Alcohol, And Food Need Hierarchies

Molly Galbraith, on her Facebook page, in light of recent events, discusses rape culture in the fitness industry.

Julia Belluz, in Vox, takes on nutritional epidemiology and what amount of alcohol is safe to drink.

Jason Lusk, on his blog, with his take on how the hierarchies of food needs fuel dietary fads and nutritionism.

Taking Medication For Obesity (Or Anything Else For That Matter) Is Not A Failure

The other day a GP tweeted at me that there was "no role for pharmacology" in the treatment of obesity along with an #LCHF hashtag. I can only presume she believes low-carb high-fat diets are the global panacea that everyone needs, and that those not adopting and succeeding with them are personal failures.

And hers isn't an isolated viewpoint, nor is it one that's relegated only to the #LCHF crowd as I've heard from other non-LCHF hashtagged physicians that forks and feet are what's required, not medications or surgery.

But those viewpoints tend only to be extended to obesity, not to any of the literally dozens of other chronic, non-communicable diseases, that lifestyle may prevent or treat, and so yes, while useless truisms like eating less and exercising more would help people to lose weight, and while #LCHF would help some too, it's bias that has obesity as the sole medical condition that people feel comfortable proclaiming that medication (or surgery) has no role in treatment.

Clinically useless truisms aside, obesity is complicated, and moreover we have yet to discover a non-surgical, reproducible, sustainable, 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 are two problems with that argument. Firstly, not everyone is interested or able to change their lifestyles, and secondly, statistically speaking, the majority of even those who are interested and successful with lifestyle change will ultimately regress.

Is it lazy to want to improve your quality and/or quantity of life? Because for many that's what the treatment of obesity would do, and that's true for pharmacologically assisted weight loss and surgical weight loss too. And yes, sure, it'd be lovely if everyone had the very real luxuries of possessing the health, time, money, and inclination to regularly and genuinely exercise, cook, and life broadly healthful lives everyday, forevermore, but except in the minds of those filled with dripping I can do it and so should you lifestyle sanctimony, that's simply not the case for a large percentage of our real life population.

So yes, medications for those who want and need them. Same with surgery. And also varied dietary approaches and behavioural strategies. Because my job as a physician is to provide people with enough information about their options for them to make their own informed decisions, it's not to be a myopic, biased, patient-blaming, blowhard, dietligious, zealot

Please Stop Judging Other People's Shopping Carts And Fast Food Orders

Ever wonder if you're biased against people with obesity?

Have you ever stood in line behind someone with obesity at the supermarket and judged them on the basis of the items they were pulling out of their cart? Or behind someone with obesity at a fast food place and judged them on the basis of their order?

Now ask yourself if you have, or would have, similarly judged a thin person pulling out those same items or making that same order.

And it's worth noting, there's no good answer here.

If you answered, no, you wouldn't have judged a thin person similarly, well that reflects weight bias.

And if you answered, yes, you'd be judging them the same way, well that reflects you judging people on the basis of things that are none of your business.

Everyone's life is complicated, and moreover, food plays roles far beyond fuel and serves as comfort, as celebration, is one of life's most seminal pleasures, and it's not for anyone to judge anyone else on the basis of their choices therein.

Saturday Stories: A Single Read Week (It's A Really Worthy Read)

John Ioannidis, in JAMA, on the incredibly flawed foundations of nutritional research and dietary recommendations. Given subscribers here are likely interested in nutrition, I believe this to be an important enough read that I don't want to recommend you read anything else.