Monday, July 15, 2019

From The Journal Of If Only It Were That Easy: Walking To School Was Not Associated With Lower Weights In 4-7 Year Olds

Walking school buses for kids are often promoted on the basis that if more kids were involved with them, their weights, fitness, and maybe even learning would improve.

Wouldn't that be great? After all, it's a relatively inexpensive intervention and one it seems everyone can at least theoretically get behind.

But does it work?

This is definitely not a good news story, nor frankly is it all that surprising, but here it is - recently the MOVI‐KIDS Study set out to explore whether or not there was an association between active transport in 4-7 year olds and their weights, fitness, and cognition.

The study involved 1,159 children in Spain and they were categorized on the basis of whether the active components of their school commutes totalled more or less than 15 minutes and then tested and measured to explore walking to school's possible impact. Heights and weight were measured, a validated cardiorespiratory fitness test was administered, as were multiple batteries of validated cognitive tests. Efforts were also made to control for familial socio-economic status, as well as of course the children's ages and sexes.

As you might have gathered, the walkers were found to be no better off on any studied variable with the authors very plainly concluding,
"Walking to school had no positive impact on adiposity, physical fitness, and cognition in 4‐ to 7‐year‐old children."
Too bad. Truly.

I have to say too, I did scratch my head reading the next bit of their conclusion though,
"it would be of interest for future studies to examine the intensity and duration of active commuting to school necessary to provide meaningful benefits for health and cognitive performance."
I can't say I agree with them here as I'm not sure lengthy, intense, daily school commutes for 4 year olds is something we need to explore regardless of their impact on anything. Moreover, I don't need to see "meaningful benefits" to want to continue promoting more movement and play in our children, and if we buy into the need for same, we'll risk the cessation of programs that don't prove themselves to provide perhaps broader reaching or more dramatic outcomes than could ever be fairly expected of them.

Tuesday, July 09, 2019

Only 41% Of People Who Were Given Free Preventive Medications Following Their Heart Attacks Were Still Taking Them 1.5 Years Later

You might think that having a heart attack would be motivating when it came to behaviour change, and that taking medications is a very straightforward behaviour.

And yet.

The Post-Myocardial Infarction Free Rx Event and Economic Evaluation (MI FREEE) trial set out to study whether or not cost had a role to play in why so many patients, even post heart attack, don't take the medications prescribed to them in the hopes of preventing another one by freely providing them with those medications.

Results wise, though the group receiving free preventive medications were taking more of them than the group that did not, at the end 1.5 years, only 41% of those receiving all their medications for free, medications prescribed to them after they had an actual heart attack, were taking them.

So file these results under human beings, even when faced with knowledge, and in this case knowledge coupled with a very real glimpse at mortality, struggle to maintain even the easiest of behaviour changes, and consider that in the context of the trope of education and personal responsibility as the sole means to target diet and weight related diseases. If we want to see population level changes, we're going to need to change the food environment.

Saturday, July 06, 2019

Tuesday, July 02, 2019

Cancer Research UK (@CR_UK) Launches Awful New Fat Shaming Advertising Campaign

According to Cancer Research UK's new public advertisements, obesity is apparently the new smoking.

What that means of course is that by formally adopting, amplifying, and promoting the message that obesity, like smoking, is a choice people make, Cancer Research UK fuels hateful weight based stigma.

More amazing perhaps is that the aim of the campaign is to apparently target the environment with their ads steering people, in the small print that people will likely miss and certainly can't click on in train stations, to their web page calling for an end to junk food advertising to kids.

Obesity is the normal consequence of normal people living in abnormal, obesigenic, environments. Obesity often has hugely negative impacts upon health and quality of life (especially at its extremes), fuelled in no small part by the never ending blame, shame, and scorn heaped upon those who have obesity by society, and yet here is Cancer Research UK's campaign to further justify that weight hate.

Shame on them. They absolutely should have known better.

Saturday, June 29, 2019

Monday, June 24, 2019

On Instagram, RD Working For Welch's Implies That Drinking Welch's Grape Juice Won't Raise Your Blood Sugar (By @DylanMacKayPhD)

Today's guest post comes from Dylan MacKay. Dylan is a nutritional biochemist who has type 1 diabetes and when I saw RD Marie Spano's Instagram post, I knew he would have both personal and professional thoughts to share and so I invited him to do so.
I don’t know what it is with grapes but they always seem to be raisin my ire…

I mean as a person with type 1 diabetes, a PhD in Human Nutritional Science, and who does diabetes research and occasionally clinical trials looking at glucose response, maybe I’m not the one to talk about this, but I just can’t not.

Recently a Welch’s (*cough* big grape juice) "nutrition advisor" posted the above nutrition translation travesty on Instagram.

This really surprised me because when I have low blood sugar I often drink grape juice, How am I still alive? I mean I can honestly say there are times grape juice may have saved my life (by raising my blood sugar). Yet you could potentially look at this Instagram post and fairly think
drinking 100% juice made from polyphenol-rich fruit juice does not raise your blood sugar
unlike apparently that bad candy or pop that raises your blood sugar.

That would be of course 100% wrong.

Polyphenols are not magic sugar blockers, otherwise we would be using them to treat diabetes and you would get serious gastrointestinal upset from eating berries and grapes. I feel like you don’t even really need to be an RD to see this messaging is bad (Seriously, Welch’s advisors, how much do you get paid for your credibility?). Especially on a social media platform, where someone might not scroll to the end of the associated comment and look at the “reference” provided.

Speaking of the reference used for this knowledge translation crime, it is for a review article called Impact of Dietary Polyphenols on Carbohydrate Metabolism and having reviewed it I can say it does not support the claim in that post. Most of the article talks about animal or cell culture results that show polyphenols may impact glucose digestion or absorption, but there's nothing in the article showing it stops it. It even concludes that
To confirm the implications of polyphenol consumption for prevention of insulin resistance, metabolic syndrome and eventually type 2 diabetes, human trials with well-defined diets, controlled study designs and clinically relevant endpoints… are needed.
The closest thing in the article supporting the Instagram post is
The shape of the plasma glucose curve with reduced concentrations in the early phase and a slightly elevated concentration in the later phase indicates delayed response due to berry consumption
about a study done with 12 healthy participants looking at berry puree (rich in polyphenols). The polyphenols (or something else in the berries) changed the timing of the blood sugar elevation.

I suppose the Welch’s RD nutrition advisor might say
well actually Dylan, changing the shape of the blood sugar elevation means it doesn’t actually raise blood sugar like candy
and we could get into a long argument of how you define “like”. When people are arguing over minutia or semantics big food companies have won.

This type of nutrition misinformation advertising works because ultimately it is designed to ruin peoples’ trust in nutritional science and nutrition experts (especially RDs). If consumers are confused and can’t trust anything in nutrition, they are ripe for the next trend or fad or advertising claim. That is a good thing for companies, but a bad thing for people.

If you like grape juice, drink it, I sometimes do when I have low blood sugar (I have chugged maple syrup for that too so…), but know that grape juice will raise your blood sugar, and liquid calories, like those found from the 9 teaspoons of sugar per glass of grape juice, are an easy way to go over on your energy intake. Most of us are trying to avoid excess energy intake, so for that, in my opinion, you can’t beat water.

Dylan MacKay PhD is a nutritional biochemist and an Assistant Professor at the University of Manitoba in Winnipeg. He is also a Clinical Trialist at the George and Fay Yee Center for Healthcare Innovation. Dylan has a special interest in human clinical trials related to lifestyle and diabetes. He is originally from St. John’s, Newfoundland where he started his graduate studies at Memorial University.

Saturday, June 22, 2019

Saturday Stories: Anti-Vax Conferences, Vulnerable Child Syndrome, and Taffy Brodesser-Akner

Anna Merlan, in Jezebel, in what she learned getting kicked out of America's biggest anti-vax conference.

Rachel Pearson, in The New Yorker, on vulnerable child syndrome

Jen Ortiz, in Cosmopolitan, with a fabulous profile of celebrity profiler and author of the book I ordered on my kindle yesterday Fleishman is in Trouble's Taffy Brodesser-Akner

[And if you don't follow me on Twitter or Facebook, here's my most recent piece for Medscape on what actually works for obesity at a population level (hint, it's not shame, blame, or fear)]

Wednesday, June 19, 2019

Scotland's "National Walking Strategy" Actually Increased Recreational Walking (A Tiny Bit) For The Whole Population!

Cynically, I've been known to ask for examples of population based initiatives that actually led to sustained increases in physical activity (with the expectation of there not being any).

Well, I can't do so anymore as Scotland's managed to increase recreational walking by 13% over a 6 year period for the whole of their population!

Their National Walking Strategy targeted Scotland's 5 million residents with messages about the health benefits of walking.

The strategy involved multiple sectors including:
  • Communication and public education.
  • Transport and the environment.
  • Urban design and infrastructure.
  • Health and social care.
  • Education.
  • Community-wide approaches.
  • Sport and recreation.
And together their aim was to create a culture of walking by way of developing better walking environments that supported ease and convenience.

How to counsel patients on physical activity became a topic in medical schools. The Daily Mile encouraged 1,000 schools to help every student walk, run, or jog a mile a day, increased funding for active transport programs was obtained including a doubling of infrastructure funding for same, #SoMe was leveraged to share encouragement and information to the public, and community walking programs were launched nationwide.

Now before you get too excited, the bar was low to begin with whereby the increase in walking represented the self-report of walking at least 30 minutes for recreation once over the past month, but at least it's a start.

Changing behaviour requires more than just education and a good reason to do so, it also requires a change to social norms and culture, as well as environmental engineering. Clearly there's more to do in Scotland and elsewhere, but nice to see that these needles might actually be movable.

Photo by Kim Traynor [CC BY-SA 3.0], via Wikimedia Commons


Saturday, June 15, 2019

Saturday Stories: Quantum Solutions, Stockpiled Insulin, and Multiple DNA Tests

Jana Asenbrennerova, in Quanta Magazine, on how a gifted grad student’s solution to a fundamental problem in quantum computing is an incredible breakthrough.

Maris Kreizman, in the New York Times, on why she's stockpiling insulin in her fridge.

Rafi Letzler, in Live Science, discusses the results of his 9 different commercial DNA tests.

Photo Richard Wheeler (Zephyris) at en.wikipedia - Originally from en.wikipedia; description page is/was here., GFDL, Link

Monday, June 10, 2019

Guess What? A Single In Office Visit Encouraging People To Weight Themselves More Often And Exercise Doesn't Prevent Weight Regain

From the Journal of Duh! (ok, actually it was PLOS Medicine) comes Behavioural intervention for weight loss maintenance versus standard weight advice in adults with obesity: A randomised controlled trial in the UK (NULevel Trial). The study involved 288 people who had lost ≥ 5% of their weight in the preceding 12 months who were randomized into two groups. One where they received periodic newsletters, and the other where they had a single face-to-face visit where they discussed goal setting and self-monitoring (including being told to weigh themselves daily) followed by every other day automated text messages. The hope was that the single visit and text messages would help prevent weight regain in the group that received them. So did that minimal intervention help?

No, both groups regained the same amount of weight over the study's duration.

What was most surprising about this study wasn't that minimal interventions don't help prevent weight regain, but rather that someone thought they might. Because if minimal interventions prevented weight regain, do you really think weight regain would be so commonplace?

So in case you were looking for proof that single office visits and text messages aren't in and of themselves sufficient to prevent weight regain, there you have it I suppose.

Saturday, June 08, 2019

Saturday Stories: Only One Read This Week

Every once and a while there's a story that has such an impact on me that I want to feature it by itself.

Today's Saturday Story, written by Dana Horn for the Atlantic, was searing. It detailed her recent visit to a "massive blockbuster exhibition (about the Holocaust) that opened in May at the Museum of Jewish Heritage in downtown Manhattan", by the same people who brought you Human Bodies, and how it left her feeling flat.

Her closing paragraph,
"The Auschwitz exhibition does everything right, and fixes nothing. I walked out of the museum, past the texting joggers by the cattle car, and I felt utterly broken. There is a swastika on a desk in my children’s public middle school, and it is no big deal. There is no one alive who can fix me."
shouldn't be the only one you read. Please click it for more.

Monday, June 03, 2019

Bullying Or Teasing Kids With Obesity Doesn't Lead Them To Lose Weight But It May Lead Them To Gain

The recently published Weight‐based teasing is associated with gain in BMI and fat mass among children and adolescents at‐risk for obesity: A longitudinal study is an important paper for many well-intentioned parents, educators, and physicians who think that weight based teasing might help motivate a child to make behaviour changes that will lead them to weight loss.

In it authors followed 110 children at risk or with overweight or obesity for 8.5 years and tracked their weight and its association with weight-based teasing. They found that after adjusting and controlling for baseline sex, race, age, socio-economic status, BMI and fatmass, kids who reported the most teasing gained the most weight (p≤.007). Quantified, the authors found that the most teased kids' fat masses increased by 91% more per year (1.4lbs/yr) than those not reporting weight based teasing.

While it's important to note that causality can't be proven here, certainly these results fit with the notion that if any amount of teasing led kids to lose weight, we'd be seeing dramatic reductions in childhood obesity rates because weight is far and away the number one target of school based bullies, and even at home, 60% of kids with excess weight report being teased about same.

If you have a child with obesity, sadly you can rest assured that they'll receive plenty of shame, blame, fear, and bullying from the world around them, and if you're worried about your child's weight, instead of burdening them with it, ask yourself what you as a parent can do to help, where if nothing else, one thing for certain you can do is to make your home a safe space where weight is not something anyone's welcome to joke about or comment on.

(and if you live in Ottawa, and you have a child between the ages of 5 and 12 whose weight is concerning, and you're interested in our office's parent-centric, Ministry of Health funded, inter-professional, Family Reset childhood obesity treatment program feel free to call us at 613-730-0264 and book an appointment to chat)

Saturday, June 01, 2019

Saturday, May 25, 2019

Wednesday, May 22, 2019

According To This Comparison Of Canadian Dietary Recall Data, Underestimations May Help To Explain Purported Decreasing Sugar Consumption

This recent report from Health Canada about sugar consumption was an interesting read.

Not so much in terms of sugar, and yes, the report says we eat too much of it (I'll come back to that) but rather in terms of dietary recall. It seems we're getting worse at it.

According to their determination, whereby they compared dietary recall data's caloric totals with those that would be predicted by a respondent's age, BMI (measured, not self-reported), sex and activity levels, if your self-reported intake was less than 70% of that predicted, you were classified as an under-reporter, and if it was more than 142% of predicted, you were classified as an over-reporter.

Overall, compared with 2004, people were significantly more likely to under-report and less likely to over-report. In adults, under-reporters increased by 22% (from 28.2% to 34.5%), in kids aged 9-18 by 59% (from 16.5% to 26.3%), and in younger children it more than doubled (from 6.7% to 14.1%). Simultaneously, over-reporting dropped by 45% in adults (from 13.6% to 7.4%), in kids aged 9-18 by 41% (from 22% to 12.8%), and in young children by 35% (from 27.6% to 18%).

So how does this affect sugar consumption data?

Well you may have read that dietary sugar consumption is decreasing. And maybe it is (dietary recall data is fraught with error). But this data suggests that while consumption is shifting, with more added sugars coming from food and less from beverages, totals, if looking at plausible reporters only, have stayed pretty much the same, and has increased slightly in children.

As to what's going on, could it be that with ongoing discussion of the dangers of unhealthy diets that people become less likely to want to disclose what they're eating? Either way, it's further evidence that we need a better way of tracking dietary intake and a possible confounder for those reporting that sugar consumption is decreasing.

Saturday, May 18, 2019

Tuesday, May 14, 2019

Calling People Successfully Maintaining Long Term Weight Loss "Unicorns" Is Dehumanizing, Unhelpful, And Misleading (And No, 95% Of Weight Loss Efforts Don't Fail)

A few weeks ago I tweeted about a patient of mine who is maintaining a 19% weight loss for 2 years, and who attributes her success to keeping a food diary and tracking calories, as well as to including protein with every meal and snack.

The point of my tweet was a simple pushback to those who want to claim that calories don't count or that counting can't help (like The Economist for instance whose recent article entitled Death of the calorie was the main reason I bothered to tweet), and those who claim that the only way to lose weight is their way (these days that's usually either #keto or #lchf).

A great many folks weighed in with their success stories, and some pointed to the National Weight Control Registry (where their over 10,000 registrants have kept off an average of 70lbs for 5.5 years). Others though weren't having it.

Instead they asserted that 95% of diets fail, that the weight loss industry was predatory (much of it is, no argument there), and called people who have succeeded "unicorns".

Unicorns. Not people. Mythical creatures.

And the implication of course is clear. Sustained weight loss is impossible. Those who succeed aren't human, or to succeed they employ superhuman efforts, sometimes even described as disordered eating and/or that those who succeed must be miserable. Consequently, trying is futile and those offering help (like me, as to be clear I am the medical director of a behavioural weight management centre) are unethical and are motivated by greed (despite the obvious irony that those championing explicitly non-weight loss programs are targeting the very same population of people and regularly charge a great deal of money for their services).

But boy, there sure are a heck of a lot of unicorns roaming around for something that supposedly fails 95% of the time. Putting aside the anecdotal facts that we all know people who have maintained weight losses, as well as my own office based experiences, this 2010 systematic review found that one year later 30% of participants had a weight loss ≥10%, 25% between 5% and 9.9%, and 40% ≤4.9%. In the LOOK AHEAD study, 8 years later, 50.3% of the intensive lifestyle intervention group and 35.7% of the usual care group were maintaining losses of ≥5%, while 26.9% of the intensive group and 17.2% of the usual care group were maintaining losses of ≥10%. Here's the DIRECT trial where mean weight loss at 2 years was 7.5% with 24% of participants maintaining losses greater than 22lbs. And in the recent year long DIETFITS study the average weight loss of all participants was 5%, with over 25% of participants losing more than 10% of their weights.

The Examine.com waterfall plots of the DIETFITS data

(And for an interesting thought experiment, have a peek at this thread from Kevin Bass that argues that even if the 95% failure number were true, those outcomes would be worlds better than the vast majority of medical treatments currently being offered for other chronic diseases)

So where does this 95% number come from? I could imagine it to be true if the goalpost for successful weight loss was total weight loss and reaching a so-called "healthy" or "normal" BMI. But that would be as useful a goalpost as qualifying for the Boston Marathon would be for running whereby the vast majority of marathoners won't ever run fast enough to qualify to run Boston. Does that mean non-qualifiers should be discouraged from running and told that running is impossible? It's also important to contextualize failures. If the methods being undertaken to lose weight are misery inducing overly restrictive diets, it's not people who are failing to sustain them, it's that their diets are failing to help them (which, with full disclosure, is the premise of my book The Diet Fix).

As far as what needs championing, it's certainly not failure. Given the medical benefits of weight loss, as well as the real impact weight often has on quality of life (especially at its extremes), what we need to collectively champion are the embrace of a plurality of treatments (including ethical behavioural and surgical weight management programs and greater access to them), along with more effective medications. What can simultaneously be championed is the removal of blame from the discussion of weight, fighting weight bias and stigma, recognizing that a person need not have a so-called "healthy" or "normal" BMI, that scales don't measure the presence or absence of health nor measure lifestyles, respecting people rights to have zero interest in losing weight or changing their lifestyles, that there is value to changing behaviours around food and fitness regardless of whether weight is lost as a consequence, and acknowledging that intentionally changing lifestyle in the name of health reflects a tremendous degree of privilege that many people simply don't possess.

Given the evidence maybe we can stop with the unhelpful, dehumanizing, and misleading unicorn talk, and while we're at it, stop telling everyone that failure is a foregone conclusion.

Saturday, May 11, 2019

Monday, May 06, 2019

What's The Point of Tracking Your Calories With a Food Logging App?

First up, the quantity and quality of calories matter both to health and to weight. You can't gain without a surplus. You can't lose without a deficit. And the quality of the calories you're consuming will affect health and satiety which in turn will affect the quantity of them that you consume. Moreover, the bioavailable calories you consume will differ by food, and also likely differs by individual (which is why some gain and lose with more ease than others).

Next up, we're crappy food historians. We may forget portions, choices, or both, not all the time, but certainly some of the time. We can't possibly know what's in meals we haven't cooked ourselves. And even if we are cooking ourselves, most aren't going to be weighing and measuring everything and eyes are terrible at both.

And a recent study confirms some of the above whereby researchers looking at users of myfitnesspal found the average user was missing nearly a meal's worth of calories a day (445). Yet studies on food diary use pretty much invariably report they markedly benefit weight loss efforts.

Personally, though I think having some rough inaccurate sense of caloric intake is valuable (if you were in a foreign country and didn't know the exchange rate, price tags would still be somewhat helpful), more valuable is the use of the food diary to remind yourself that you're trying to eat thoughtfully and likely differently.

Human nature being what it is, without a system designed to consciously remind you to change your usual default behaviours, you're likely to drift back to those behaviours, healthy or not, and a food diary, even if inaccurate, if kept in real-time, will remind you many times a day that you're trying to change.

So long as you're not using your food diary as a tool of judgment, as it's not meant to be there to make you feel badly about your choices, chances are it'll be of benefit, and likely it'll be of benefit regardless of what it is you're tracking (calories, macros, carbs, whatever) and even if inaccurate, because it's primary job is to serve you as your constant change reminder service, not as your judge and jury.

Saturday, May 04, 2019

Saturday Stories: Holocaust Memorial Day, Poway, And Synagogue Metal Detectors

Lori Gilbert-Kaye, may her memory be a blessing, murdered for being Jewish
A few days ago it was Holocaust Memorial Day, the day we commemorate the murder of 1 out of every 3 living Jews on earth prior to World War II. A week ago saw another murder for the crime of being Jewish, this time in California. Before that it was Pittsburgh. Though there's not much I can do about any of this, at least I can call your attention to these three pieces that try to weave it all together

Daniella Greenbaum Davis, in The Spectator, on antisemitism's new normal.

Rabbi Yisroel Goldstein, in The New York Times, on how being almost killed by a terrorist last week has affected his resolve.

Carly Pidlis, in Tablet Magazine, on how Jews can no longer simply consider themselves safe in America.

Monday, April 29, 2019

New Study Suggests ADHD Steers Children To An Unhealthy Diet, Not The Other Way Around

To be taken with a grain of dietary recall data, but a new study, Children's Attention-Deficit/Hyperactivity Disorder Symptoms Predict Lower Diet Quality but Not Vice Versa: Results from Bidirectional Analyses in a Population-Based Cohort, found that an ADHD diagnosis led children to a less healthy diet, whereas less healthy diets did not lead children to ADHD.

The study was conducted in the Netherlands and it followed 3,680 children starting at age 6 and then ending when they reached the age of 10.

Put plainly, though more ADHD symptoms at age 6 were associated with less healthy diets at age 8, diet quality at age 8 was not associated with ADHD symptoms at age 10.

There are a number of proposed pathways to help explain how ADHD might affect diet quality. ADHD and its impulsivity may increase the risk of binge eating or loss of control eating, and the impact of ADHD on neurotransmitters may affect hunger and fullness. It's also possible that some parents of children with ADHD may offer foods their children prefer in order to decrease risk of conflict and/or reward desired behaviour.

Clearly more research on this would be welcome.

Saturday, April 27, 2019

Saturday Stories: Freds, Sexism in Science, and Anti-Vaxx Marriage

Danielle Kosecki, in Medium, with her defense of Freds (less serious cyclists, and disclosure, I am one).

Mallory Picket, in The New York Times Magazine, on sexism in science's highest echelons.

Anonymous, in The Cut, on marriage with an anti-vaxxer.

Tuesday, April 23, 2019

Move More, Eat More? New Study Suggests People Do Eat More When They're More Active, But Not Much

One of the possible reasons that in freely living humans exercise doesn't seem to add up to weight loss as math might predict is that freely living humans might eat back their burned calories. Some may do so consequent to increased hunger. Others to a sense of virtue and the inclination to reward themselves for their hard work. Others still because marketing has convinced them that they must refuel, recover, replenish, etc..

A new study,Activity energy expenditure is an independent predictor of energy intake in humans, published this year in the International Journal of Obesity, set out to look at this phenomenon.

Now to be clear, the study certainly wasn't designed to explain exercise's impact on weight. It was just 7 days long and it involved the retrospective analysis of data from 5 prior studies and did not directly measure energy expenditure or energy intake. Instead researchers utilized estimated energy expenditure by way of heart rate and indirect calorimetry data, and energy intake by way of known to be problematic food diaries.

My stats skills are nowhere near good enough to comment on the various treatments of the data, but here's the scatter plot of the impact of energy expenditure on energy intake.

The increase in energy intake the authors attributed to energy expenditure wasn't high, roughly 3% of total daily calories (around 70 in this sample), an amount too small to explain away exercise's often uninspiring impact on weight loss.

Truth be told, I'd have predicted the difference to be larger as eating more consequent to exercise is something I know many people do for one or more of the various reasons mentioned above.

Of course none of this changes the fact that exercise has tremendous health benefits at any weight and that weight shouldn't be your driver for upping yours if you're able.

Saturday, April 20, 2019

Saturday Stories: IN MICE, Cancer, and Future Dementia

James Heathers, in Medium, explains why he started the Twitter account that only ever tweets "IN MICE"

Anne Boyer, in The New Yorker, on what cancer takes away.

Tia Powell, in Elemental (on Medium), on how she's preparing for her future dementia.

Wednesday, April 17, 2019

RDs! We're Hiring! Looking To Fill A Full-Time Permanent And Possibly Some Part-Time Positions

Will copy our job posting below, but the tl;dr version is we're both growing (our digital distance tool is deep into development and should be ready for beta-testing come late spring or early summer) and one of our wonderful RDs will be heading off on maternity leave. Consequently, we're looking for some great RDs!

Prior applicants are welcome by the way. In fact many of the RDs we've hired over the years had applied more than once.

Here's the posting. Please send resume and letter of interest to jobs@bmimedical.ca
The Bariatric Medical Institute (BMI) in Ottawa, an inter-professional weight management office that includes medical doctors, personal trainers, registered dietitians, a social worker, a clinical psychologist, and a therapy dog, is looking for a permanent full time dietitian to join our professional and unique team.

We are looking for an individual who loves working with people and technology, is great at multi-tasking, is a team players, thrives off of challenges and responsibility, and wants to utilize his or her skills in making a dramatic positive difference in people’s lives.

Responsibilities will include:
  • Collaboration with interprofessional team members.
  • One-on-one counselling sessions to motivate and help patients live the healthiest they can.
  • One-on-one counselling sessions with parents of children struggling with weight to help them navigate a healthy eating environment.
  • One-on-one counselling sessions to help prepare patients for bariatric surgery as well as post-surgery sessions to help patients ensure that they succeed.
  • Design individualized nutrition plans based on each individuals’ unique lifestyles, metabolic rates and dietary likes and dislikes.
  • Write for BMI’s different social media outlets: Website, blog, vlog, and monthly newsletter.
The skills you’ll need:
  • Exceptionally strong motivational counselling skills.
  • Must have excellent listening skills, empathetic and sensitive to patient’s needs. We do not ever utilize negative reinforcement in our counselling.
  • Able to adapt nutrition advice to recent scientific research with thoughtful critical appraisal.
  • Must be innovative and give patients realistic and helpful nutrition advice.
  • Positive and non-restrictive approach to weight management.
  • Comfortable giving presentations.
  • Possess sound professional judgment, initiative and enthusiasm.
  • Good time management skills and ability to organize.
  • Excellent computer skills, and comfort with social media
  • Strong cooking skills.
The requirements we’re looking for:
  • Minimum one year of clinical experience
  • Registered Dietitian
  • Member of the College of Dietitians of Ontario and in good standing (or willingness and ability to join).
  • Master level clinicians are preferred, although not required.
  • Previous experience working in weight management and childhood obesity is an asset.
  • Working with us you will have access to a full gym facility as well as shower and change rooms. Physical activity and healthy living are the primary focus of our work and therefore we view your active lifestyle as a great asset.
Because we are looking for the best candidate our wages are highly competitive with those in the community and after the 3 month probation period, medical and dental benefits are part of our package.

We look forward to hearing from and meeting with you.

Are You Successfully Maintaining A Weight Loss OR Have You Recently Quit A Diet? If Yes To Either Question, Please Spare 2 Minutes For Our Research (Shares Welcome!)

Back in 2012 I first posted my wish for there to be a questionnaire that would serve to help individuals and researchers determine how easy or difficult a particular diet would be to follow.

I called it the Diet Index Enjoyability Total or DIET score, and my hope was that by using a series of simple Likert scales (descriptive scales from 1-10), researchers could set out to evaluate a particular weight loss approach's DIET score where high scores would identify diets that could actually be enjoyed, and where low scores would identify under-eating, highly restrictive, quality of life degrading, dieting misery. This would be useful both to individuals who could use the DIET score to evaluate whatever approach they were considering, but might also serve as a surrogate for shorter term diet studies to give a sense as to whether or not there's a low or high likelihood of long term adherence to a particular study's strategy.

I'm happy to report that thanks to the hard work of Michelle Jospe and Jill Haszard of the University of Otago, along with your responses, we have completed the DIET score's qualitative review and this survey is meant as a simple pilot to test the hypothesis that higher scores associate with longer term success, and we hope, that once collected, these results will be compiled along with our qualitative review for the DIET Score's first published preliminary study!

So again, if you're currently following a diet, or if you've recently quit a diet, we would greatly appreciate it if you were able to take just a few minutes of your time to fill out our quick survey by clicking here.

Thank you in advance!

Yoni

[Today's survey is the final one (hopefully) before we submit our paper on the DIET SCORE. Consequent to our first two surveys we tweaked our questions to make them more relevant and representative by way our your comments and expert feedback. Even if you filled our survey out last time, if you've been successful on your diet (any dietary strategy or approach, we're not picky) OR if you've recently quit your diet, we'd dearly love to hear from you and we promise, it will barely take 2 minutes to complete]

Monday, April 15, 2019

Coca-Cola Claims It Doesn't Market Soft Drinks To Kids, Announces New Star Wars Themed Bottles For Disneyland And Disney World

Coca-Cola has gone on record to state,
"Parents tell us they prefer to be the ones teaching their children about beverage choices. That's why for over 50 years we've adhered to a company policy that prohibits advertising soft drinks to children"
So clearly their newly announced plans to sell Star Wars themed bottles at Disneyland and Disneyworld must be targeting adults.

Nothing wrong with a liquid candy company trying to sell liquid candy (that's their literal job after all), but don't lie and pretend you don't target children with your marketing or that you care about anything other than profit.

Monday, April 08, 2019

The Joe Rogan Experience Gary Taubes And Stephan Guyenet Debate And All That's Wrong With Modern Day Dieting Discourse

First some disclosures. As far as diets go, I'm egalitarian. I believe that the best diet for you may be the worst diet for someone else, and that all diets work by way of reducing caloric intake, but that calories from different foods will have differing impacts upon health and satiety. As far as Gary and Stephan go, I like both of them. I've had the opportunity to have a number of offline conversations with Gary over the years and though I'm guessing we generally spent the majority of our time in those chats disagreeing with one another (sometimes rudely), for reasons I find difficult to pin down, I've always enjoyed them. Stephan is someone whose work I've been reading for years and whose opinion I respect and value. And the 3 of us, in 2017, were involved with the Cato Institute for an online debate on sugar.

With those out of the way, onto the debate.

I certainly hadn't planned on writing about it. And I won't spend too much time nitpicking the discussion. Suffice to say, as many already have, it seemed that Gary the journalist relied on stories to make his points, while Stephan the scientist relied on studies. Gary constantly interrupted Stephan, and somehow also managed to recurrently mispronounce his name (despite corrections), and Stephan, perhaps as a consequence, at times treated Gary dismissively.

If you're looking for a more detailed play by play of the entire 2 hours and 37 minutes, by all means, here's Layne Norton's fairly exhaustive (and even time stamped) coverage, but what I want to cover today are a few thoughts inspired by the debate rather than the debate itself.

Much of the low-carb high-fat (LCHF) (now in many cases interchangeable with #Keto) world has raged on for years about mainstream medicine and science's disregard for their chosen diet and theories. An old photocopy of an American Heart Association pamphlet from 1991 that indeed promotes sugar consumption gets trotted out as some sort of gotcha for 2019. Young keto adherent physicians proudly tweet of the "torture" they experience reading opinions on diets other than their own (disclosure - including mine). Cardiologists with bestselling LCHF diet books write breathless articles in newspapers championing the idea that everything you've been taught about diet and heart disease is wrong and encourage the specific consumption of saturated fat. Self identified "science journalists" (note, this isn't actually a dig at Gary but rather others) who purport to care about evidence embrace and amplify the most idiotic of theories, stories, or comments so long as they suit their narratives. And if a study contradicts any of the aforementioned folks' belief systems, the fault is said to no doubt lie with the methodology, or the researcher being conflicted (as Gary repeatedly suggested in the debate when discussing the work of his former NuSi hire Kevin Hall, as well as Jim Hill and colleagues' metabolic ward study that utilized direct calorimetry to show that people gained equal amounts of weight when overfed fat or carbs), or both. And of course pretty much all of the most vocal gurus, even the ones from prestigious institutions like Harvard, appear more than happy to extend their credibilities to prop up whatever medical quack (Mercola, Oz, Hyman, etc.) is willing to promote them.

For various reasons, listening to this debate reminded me of all of that.

Despite Gary's very real comment in regard to diet related chronic disease and society that,
"Tragic shit is going on"
it would seem to me that the bulk of the energy spent by the loudest of the LCHF/#Keto crowd is mustered trying to prove everyone else is wrong or conflicted, and that there is only one, true, right, best, diet - a message that's especially off putting when it comes from MDs, given every single day physicians are reminded that different treatments work differently for different people - sometimes predictably, and sometimes not so much - which is why for instance for hypertension there are at least 10 different classes of medications, and multiple options within each.

The starkest difference between Gary and Stephan I think comes at the 2:24:08 mark where Stephan details how much he loved Gary's Good Calories, Bad Calories and how he found it so persuasive that he personally adopted a LCHF diet, but that then he turned from the historical narratives conveyed in Good Calories, Bad Calories, to the science, and he found that the science told a different story. Not a story that suggested LCHF was a bad diet, or the wrong diet, or an unhelpful diet, but just that the science underlying Gary's hypothesis doesn't hold water for Stephan. And then, over the course of the next few minutes, in what I can only assume is his rebuttal, Gary tries to narratively explain Stephan's personal, subjective, experiences on LCHF diets, and then discounts the various studies Stephan mentions as being poorly designed while trotting out one study he does like from the 60s that to his reading, supported his assertions.

And I know this wasn't the point of the debate - it was a debate after all - but wouldn't it be grand if instead of the constant need of so many (and yes, there are definitely exceptions - see note at end) to promote LCHF/#Keto as the one right, best, only, diet, LCHF/#Keto proponents, especially those who are themselves researchers and health professionals, took a deep breath and realized that if tragic shit is indeed going on, that perseverating on motives rather than data, and fanning the flames of online outrage mobs, and propping up quacks like Mercola and Hyman, and promoting the worst examples of science and opinion so long as it suits their narratives, and fear-mongering around statins, and spreading the bizarre notion that there's only one right diet and that anyone who suggests otherwise is wrong and likely conflicted, while I suppose providing fodder for online debates, is indefensible, unhelpful, and a very real reason why there's far less embrace and research of a strategy that absolutely has a place in the treatment and prevention of diet and weight related diseases.

(And for an example of a keto adherent physician who bucks the aforementioned trend, look no further than cardiologist Ethan Weiss who just the other day penned this great post about keto, LDL, and treatment, all the while embracing science and reason)

Saturday, April 06, 2019

Saturday Stories: Disney Money, Fertility Doctor's Secrets, And The Gefilte Manifesto

Sarah McVeigh, in The Cut, with an interview of Abigail Disney (yes, that Disney), on what it's like having more money than you could ever spend.

Sarah Zhang, in The Atlantic, on the fertility doctor's secret.

Daniel Summers, in Arc, with a lovely piece on how a Jewish Cookbook is helping him to reclaim his lost heritage.

Wednesday, April 03, 2019

Coca-Cola Funded ISCOLE Trial Continues To Conclude Lack Of Exercise Drives Childhood Obesity

When it comes to associations, causality matters - the importance of which is easily understood when considering childhood obesity and inactivity. Whether inactivity leads to kids to gain weight, or whether weight leads kids to become inactive have very different implications

My publicly expressed bias is that childhood obesity drives inactivity, and there's data to support that assertion including this study whereby when observed over time in 8-11 year olds, weight gain predicted inactivity, while inactivity did not predict weight gain, leading the authors of that study to conclude,
"adiposity is a better predictor of PA and sedentary behavior changes than the other way around."
As to what's going on, if I were to venture a guess, it'd be some combination of obesity related abject bullying (multiple studies demonstrate bullying is associated with decreased physical activity and obesity has been shown to be the number one target of schoolyard bullying, not to mention the fact that bullies may make fun of heavier kids when exercising explicitly), being one of the worst/slowest on a team, and increased effort involved, that lead heavier kids to decreased MVPA (moderate-to-vigorous physical activity).

Now I've blogged before about the Coca-Cola funded ISCOLE trial almost entirely ignoring the possibility that childhood obesity drives inactivity rather than the other way around, and recently, another study came out of the ISCOLE group that did the same.

(and if you're interested, here's a published discussion of the emails between ISCOLE investigators and Coca-Cola that not surprisingly suggests that these relationships have the very real potential to influence the framing of results even if funders not involved in study design)

The study, Joint associations between weekday and weekend physical activity or sedentary time and childhood obesity, published in the International Journal of Obesity, looked at weekday and weekend levels of MVPA and sedentary time in 9-11 year old children in 12 countries and their associations with obesity.

Yes, they were found to be associated.

Though they do have a single throwaway line speaking to causality,
"It is not known whether lower levels of physical activity are the cause or the consequence of obesity",
that did not stop them from writing this as their final line and conclusion,
"Since children have more discretionary time during weekend days than weekdays, children should be encouraged to increase physical activity during weekend days, especially a high level of MVPA"
which while true on the basis of health as a whole, when framed in the explicit context of childhood obesity as it is in this paper, seems to deny the much more likely case that weight simply slows kids down.

And honestly, that matters.

It matters because one of the most predominant stereotypical narratives of obesity is that it is a disease of laziness, and ISCOLE's recurrently utilized framing supports that stigmatizing message. It also matters because, if considered at least by the parents I regularly see in my office, inactive children with obesity are being regularly judged (and sometimes even shamed or bullied) by their well-intentioned parents for not being active enough to lead them to lighter weights and I can't help but wonder if this would still be the case if the meat of the discussions in these sorts of papers focused on the barriers to physical activity erected by childhood obesity itself?

I would love to see more research done on the various mechanisms by which childhood obesity might contributes to inactivity, and more longitudinal studies designed to test causality, rather than paper after paper with conclusions that to my confirmation bias at least, ignore the many reasons why kids with obesity are understandably less likely to be physically active, and in so doing, fail those poor kids.

Saturday, March 30, 2019

Saturday Stories: Vaping Risks, Doomsday Fungus, And A Friend With Cancer

Julia Belluz, in Vox, covers what we do and don't know about the risks of vaping.

Ed Yong, in The Atlantic, with the worst disease ever record.

Aaron E. Carroll, in The New York Times, on what his friend's cancer taught him about the healthcare system. 

(Photo by Lindsay Fox from Newport beach, United States - Vaping, CC BY 2.0, Link)

Wednesday, March 27, 2019

If You're Calling For A Ban On Bottled Water, But Not On Bottled Sugar Water (Soda, Juice, Sports Drinks, etc), You're Doing It Wrong

Apparently two former city Councillors, and some "water advocates" from a group named the Ottawa Water Study/Action Group, are lobbying the City of Ottawa to ban the sale of bottled water in all municipal buildings.

They rightly argue that Ottawa city tap water is terrific, and that the sale of bottled water is destructive to the environment.

But here's the thing.

All the other plastic bottles in the vending machine, you know, the ones that are just water with some sugar and flavour, they're in the very same bottles, and their consumption, unlike water's, isn't good for health.

So if you enact a ban on bottled water, but allow the sale of sugared waters, you're likely to shift sales to them, will do little to nothing towards for the environment, and you'll be promoting unhealthy beverages. Not something I can get behind.

I'm all for banning the sale of plastic bottles, but all plastic bottles, not just the ones containing the only actually healthy beverage being sold.

Monday, March 25, 2019

Shoppers At UK Supermarkets That Got Rid Of Checkout Aisle Junk Food Purchased 16% Less Small Pack Junk Food One Year Later

So it wasn't a randomized trial, but the results were interesting nonetheless.

In the UK, a number of supermarkets electively decided to stop the sale of impulse buy small pack checkout aisle junk food. Researchers curious about the impact had a peek at their sales data.

What they found was encouraging and they detailed their findings in their article Supermarket policies on less-healthy food at checkouts: Natural experimental evaluation using interrupted time series analyses of purchases. Plainly put, when compared with purchases from supermarkets still selling checkout aisle small pack junk, shoppers purchased 16% less small pack junk food from supermarkets that didn't offer checkout aisle junk food temptations.

Given the ubiquity of junk food in checkout aisles, and here I'm not just talking about the supermarket, but pretty much any and every checkout aisle, cleaning them up is a very real target in improving our food environment. And before you say it can't be done, it's been done with tobacco's "Power Walls" (but some irony here in that at least some of the new walls hiding cigarettes are being used to advertise junk food)



Saturday, March 23, 2019

Thursday, March 21, 2019

If You Tie Exercise To Weight Loss It Can Lead To Statements And Recommendations Like These

I've long called for a rebranding of exercise to promote it on the basis of all of its incredible benefits, and explicitly not in the name of weight loss.

While on paper there's no doubt that people can lose weight through exercise (and in research studies too), in practice they generally don't. And though there's also definitely the suggestion that exercise helps to keep weight off (or serves as a marker or inspiration for maintaining a whole slew of weight responsive behaviour changes), when it comes to public health, I believe focusing on weight loss as the outcome of choice in exercise interventions risks those interventions' dissolution when weight loss doesn't occur.

Helping to make my point is a recent study published in the American Journal of Preventative Medicine. The study, Implementing School-Based Policies to Prevent Obesity: Cluster Randomized Trial, looked at the impact school based nutrition and physical activity policies had on weight.

The study found that while school based nutrition policies seemed to have an impact on weight over time, school based physical activity policies didn't.

Not measured of course, or at least not mentioned, were the impacts those physical activity policies might have had on other health related parameters (blood pressure, blood sugar, non-alcoholic fatty liver disease, mood, sleep, attention, learning, physical literacy, and more) - things that I think the literature would support as being far more likely to see exercise-related improvements.

But it's the study's abstract's conclusion that got me, as I think it does a great job of highlighting the risk of clinging to exercise as an important driver of weight loss. Here it is in its entirety (highlighting mine),
"This cluster randomized trial demonstrated effectiveness of providing support for implementation of school-based nutrition policies, but not physical activity policies, to limit BMI increases among middle school students. Results can guide future school interventions."
Suffice to say I think it'd be an incredible shame if results like these guide any future school related physical activity interventions, as the benefits of exercise are myriad, something these results wholly ignore, and if these results guide anything, they'd guide the avoidance or elimination of school based physical activity policies which would let kids down on so many levels.

Tuesday, March 19, 2019

Why I Don't Celebrate Marketing Fruit To Children By Way Of Cartoon Characters

A few weeks ago I noticed the Center for Science in the Public Interest giving kudos to Disney and to The Lego Movie for their licensing of their cartoon characters to sell pineapples and bananas.

I don't share their enthusiasm.

In part that's because neither Disney nor the Lego Movie have any qualms licensing their characters to sell crap to kids. McDonald's recently announced that Disney's happily taking many millions of dollars from them (actual dollar cost not announced, last was $100 million) to once again include Disney toys in their Happy Meals, while the Lego Movie, well they're already in Happy Meals.



But my bigger objection is that we shouldn't be targeting children with advertising in the first place because why should anything be advertised to a population that has been shown to not be able to discern truth from advertising? And so even if the advertisements happen to fit with your definition of what's good for kids, it doesn't change the fact that it's plainly unethical to allow advertising to target children period.

Saturday, March 16, 2019

Saturday Stories: Feast Burden, Old Hate, And Wellness Cults

Bobbie Ann Mason, in The New Yorker, on the burden of the feast.

Isaac Chotiner, in The New Yorker, with a not at all gentle interview of Holocaust historian Deborah E. Lipstadt on the oldest hatred.

Margaret McCartney, in the Globe and Mail, on not falling prey to the cult of wellness.

Wednesday, March 13, 2019

Coca-Cola's New Simply Smoothie Strawberry Banana Contains 11.5 Teaspoons Of Sugar Per Cup

I should probably be putting "smoothie" in sneer quotes when discussing this new product.

The ingredients in this "smoothie" aren't simply water, strawberries, and bananas but rather they're strawberries, bananas, and apple, grape, and lemon juices.

Perhaps that's why in an 11.5oz serving of it, there's 44g of sugar (responsible for 85% of its 200 calories). For reference, drop for drop, actual Coca-Cola contains 15% less sugar and 33% fewer calories.

But of course no one confuses Coca-Cola for a healthy beverage.

But Coca-Cola (Simply's parent company) sure hopes you confuse this "smoothie" with one given they've festooned it with front of package shout outs that explicitly suggest it's good for you.

I'm also confused by its nutrition.

The ingredients report that 11.5oz of banana strawberry "smoothie" provides 1g of fibre - that's less than what would be found in just a 5th of a small banana, and yet to eat 44g of sugar from small bananas, you'd have to consume 18x that amount. And the 35% Vitamin C? You'd get that from just 2 strawberries.

Unless it's you doing your own blending (and even then, remember it's not likely to be as filling and you'll be able to consume a great deal more) eat your fruit, don't drink it.

Monday, March 11, 2019

Why Fund Or Publish Diet Studies That Have Little Relationship With Real Life?

I'm honestly not trying to be mean, but that was the thought that went through my mind when I read the recently published study, Log Often, Lose More: Electronic Dietary Self‐Monitoring for Weight Loss which purports to explore the relationship between food diary use and weight loss.

Don't get me wrong, I'm a huge proponent of using a food diary. Whether it's tracking calories, carbohydrates, macros, or whatever, there's ample evidence to suggest that tracking helps to maintain new behaviours, but is that what this study showed?

Well it did show that those keeping a food diary and using it more often had greater weight loss during a 24 week behavioural weight loss intervention.

So what's my problem?

I have two (well, two related to this study, clearly many overall).

The first is that the food tracker utilized was web based, and not a smartphone app. It's a minor quibble, but nonetheless, app based food diaries are the norm, why not use them? Given we have our phones wherever we go, but not our desktops and laptops, that might make a real difference to the percentage of people using them (and yes, I realize there are web browsers on phones, but that's just not the same).

I'm guessing the reason a smartphone app wasn't used is that using one would not have provided the researchers with the minutes users spent tracking, which brings me to my second, and more significant, concern.

Apparently, in the first month, successful users (those who ultimately lost more than 5% of their presenting weights) were shown to be using that web based food diary 23-24 minutes daily. And though some of that is likely consequent to learning curve, by month 6 it was still taking them 15-16 minutes of effort to record their daily meals and snacks.

Those are extremely high numbers. Having once done a stretch of 3 years of not missing a single day's use of, first a web based, and then an app based food diary, I can tell you that in short order, it really shouldn't take longer than 2-3 minutes daily to track. The learning curve is at most 2-3 weeks, and once beyond that, useful food diaries keep track of your entered meals and snacks such that re-entering them is a simple as a click.

Or at least that's how it should be.

Which means that the users in this study were either taught the world's least efficient means of keeping a food diary, or the web interface utilized was just awful (or both).

Either way, I'm not sure how the results of this study help much. Because while I'm definitely a believer when it comes to the benefits of food diary use, it would seem to me that what this study actually measured are the outcomes of people so incredibly dedicated to their behaviour change efforts, that they bothered putting up with an awful and time consuming food diary for 6 months.

[for some expanded thoughts from me on keeping a food diary, here's a piece I wrote for Greatist a number of years ago, and for full disclosure, I'm currently closing in on beta-testing our office's own food diary and behaviour change smartphone app]