Monday, February 25, 2019

More On Set Points And Why I'm Not Fond Of Them

Seems my last post struck many different chords depending on the lens with which it was read.

Some people read it as stating that they're not trying hard enough.

Others read it as there's no point in trying.

Others agreed with me.

So for clarity, here's a bit more.

Me stating that lifestyles matter, that sociology matters, that our lives' patterns matter, and that they in turn help to explain why people often regain all of their lost weight when what's usually an overly restrictive weight loss effort is abandoned isn't me stating that people ought to be able to just tough out overly restrictive weight loss efforts. It's me pointing out that if your weight is currently stable, you're in equilibrium. You have, like we all do, an average daily caloric intake and output which of course includes things beyond your control (including genetics, medical co-morbidities and medications, job requirements and responsibilities, caregiver responsibilities, and more), out of the realm of your conscious ability to control (food marketing, societal and social norms, the constant, usually well-intentioned thrust of food at every turn, and more), and things that are unfair to expect you to control (largely the normal use of food to socialize with your friends and families). These are the sorts of the things that make up something some refer to as your "expososome", and I think the impact emigration tends to have on weight, which depending on your starting and finishing countries may well increase or decrease yours, is a clear example of how it influences your equilibrium. But regardless of your expososome, yes, there are things within your control to change that can affect your weight (though definitely not free from being influenced from many of those out of control factors) like how many meals you cook and your cooking skills, your liquid calorie consumption, your frequency of meals and snacks, the macronutrient composition of your diets, exercise, and more. And it's also true that for some, their lives' realities preclude intentional behaviour change.

What I was talking about yesterday, are the people who regain all of the weight they've lost with any given effort. These tend to be people who ultimately, for various reasons, are unable to continue with their change efforts. Instead, likely, not all at once, their efforts wane, then end, and those people find their way back to all of the original behaviours, factors, and choices that they were living with prior to their changes, which in turn brings back all of their old calories, eventually bringing their weights back to that same place where they were before (or perhaps even slightly higher consequent to metabolic adaptation leading them to burn fewer calories at a comparable weight than prior to their weight loss effort).

Why does this happen?

I think for a significant percentage of people it happens because the changes they employed were too severe. Maybe they were perpetually hungry, or denying themselves foods they loved and enjoyed, or they cut out entire food groups, or they found themselves unable to enjoy a meal out with friends, or regularly having to cook multiple meals (one for them, and one for their family). In short, the efforts many people undertake aren't by definition sustainable. They're for-now efforts, not for-good efforts. And I think the reason so many choose those types of approaches is that society (including the public health and research communities) generally describe total weight loss as the goalpost, and so people take on extreme efforts, because that's pretty much the only way to get there.

On the other hand, those individuals who lose weight and keep it off? While they nearly never are people who lose every last ounce that some stupid table says they should, there are huge numbers of them who've managed to lose a subtotal amount of weight and keep it off. Knowing these people, reading about these people, their most common denominator is that they enjoy the new lifestyles they've crafted sufficiently so as not to perceive them as suffering.

So if you want to lose weight, you're going to have to change some of those things that are within your control to change, but you're also going to have to pick changes that you can honestly enjoy if you want to keep the weight you lose, off. And different people, for a whole host of reasons, will have fewer things they're able to change, not to mention the fact that life and circumstances will also have a say as time goes by. But for everyone, change generally means embracing imperfection, still eating food for comfort and celebration, still socializing with friends and family, and more. And the degree of changes you'll be able to sustain will undoubtedly be impacted by many things beyond your control, and your physiology will undeniably limit your losses and the amount you're able to change without suffering. But that doesn't mean that physiology will prevent you from ever making any changes.

Maybe, if we all aimed for smaller, more realistic, less extreme, but all the while plainly sustainable changes, and as a society we stopped with Biggest Loser style efforts, and we redefined success, we'd see a great deal more of it.

Why I Still Have Issues With Set Point Theory And Weight Regain

Last week I watched a few people who I both follow and respect chat about set point theory - you know, the one that posits your body defends a particular weight such that after you lose, your body will in a sense strive to get back to where it started. And I tried to do so with an open mind, I really did, but I guess my own confirmation biases got the best of me because the conversation left me sighing.

That's not to say metabolic adaptation doesn't exist. It most certainly does. Metabolic adaptation is the catch-all term that refers to the very real fact that weight loss leads to a decrease in resting metabolism, a decrease in the thermic effect of meals (the cost of metabolizing what you eat), decreased energy cost of physical activity, and to changes to hunger hormones which in turn might well lead you to eat more. In general this also leads to the very real fact that weight loss is far from linear and that it usually stops sooner than expected or desired.

But it's the set point blamed regain back to starting weights that I struggle with conceptually.


Because generally speaking, it's presented as physiologically driven. My belief is that while metabolic adaptation definitely and somewhat depressingly affects how much weight might be lost with any given effort, it's really sociology that drive the bulk of most people's regains.

What I'm getting at is that people don't regain most or all of their lost weight because their bodies effectively tell them to, they regain most or all of their lost weights because when they quit whatever diets they were on, they revert back to the diets they were consuming beforehand, and by diets, I also mean lifestyles.

For instance, they might stop packing their lunches and head back to their cafeterias, food courts, or drive thrus. They might resume their regular nights out with friends and go back to drinking more alcohol and/or sugar-sweetened beverages. They might bring back some (or more likely all) of the snack foods and indulgences that they'd cut out while "being good". They might return to their older pre-established automated portion sizes and of course their older pre-established dietary staples.

In short, people regain their lost weights when they regain their lost lifestyles, as doing so brings them directly back up to their pre-weight loss average daily caloric intakes which in turn supported their pre-weight loss weights.

Which brings me back to another seminal confirmation bias of mine. The more weight you'd like to permanently lose, the more of your life you'll need to permanently change, which is why the world's best diet for you, is the one you actually enjoy enough to sustain. No, it might not lead you to lose as much as a magic wand would allow because metabolic adaptation does occur, but if you actually enjoy your new diet, and you don't head back to your old lifestyle when you quit the overly strict diet that's leaving you miserable, you need not worry that somehow, magically, due to a "set point", you're going to end up right back where you started.

Saturday, February 23, 2019

Saturday Stories: Weight Hate, Sucky Recess, And The Fall Of UK Labour

Ted Kyle, Caroline Apovian, and Amanda Velazquez, in Medscape, respond to Medscape's recently posted fat shaming, hate-speech, garbage fire, of an editorial.

Naomi Buck, in The Globe and Mail, on why recess sucks now.

Stephen Daisley, in The Spectator, on the beginning of the end of the UK's Labour party.

Tuesday, February 19, 2019

Guest Post: The Problems With Balancing Accuracy And Reach In Science Communication: What To Do When Even Journals Want To Contribute To Media Hype (HIIT Edition)

Last week saw the publication of a new study in the BJSM entitled (highlighting mine), "Is interval training the magic bullet for fat loss? A systematic review and meta-analysis comparing moderate-intensity continuous training with high-intensity interval training (HIIT)". Understandably intrigued given a prominent medical journal was suggesting there was a magic bullet for fat loss, I clicked through, and then reading the piece I learned that the amount of fat lost that the BJSM was calling a "magic bullet" was a 1 pound difference, one which the study's abstract's conclusion described as, "a 28.5% greater reductions in total absolute fat mass (kg)". Duly surprised, I then took to Twitter to poke around and found that one of the study's authors, James Steele, was tweeting out a corrective thread to his own study's hype - hype which understandably and predictably led to an onslaught of media overreach. Intrigued, I approached him directly to ask about the discordance in tone between his tweets and his study's title and conclusion, and he sent me such a thorough and thoughtful response (explaining how it was the BJSM's editor who'd changed both), that I asked him if he'd mind my sharing his thoughts here as a guest post. Suffice to say, in my opinion, medical journals and their editors shouldn't be in the business of clickbait hype, as it diminishes themselves, research, and furthers societal scientific illiteracy by suggesting that such things as "magic bullets" for weight or fat loss can conceivably exist.
I was first slightly concerned that the findings would be overhyped and potentially misrepresented when I saw the press release that was sent to the media. I was forwarded various requests by our institutions news team and saw the wording of the first line of which was
Short bursts of high intensity exercise are better for weight loss than longer sessions in the gym, research suggests.
My colleague James Fisher noted to me that he also thought the press release didn’t reflect the findings accurately and wondered whether the title change resulted in the perception of a different finding.

The original title in our submission to the journal was
"Comparing the effects of interval training versus moderate-intensity continuous training on body adiposity: is it possible to find a signal in the noise? A systematic review and meta-analysis"
which was chosen as an homage to Nate Silvers' book and the use of meta-analysis to find the ‘signal’ from among the ‘noise’ of conflicting findings in smaller studies The paper underwent peer review as normal and we made changes suggested by the reviewers to improve the manuscript; but, none of the reviewers commented on the title if I recall. After the reviewers were happy with the paper and had no further changes they wanted we received a recommendation that it be published, but with minor revisions which were suggested by the editor. Most of the revisions suggested where helpful as they seemed to be aimed at improving readability of the manuscript. However, it was also suggested that the title was changed, as well as the addition of the percentage difference to the conclusion of the abstract. This was suggested to be intended to attract more attention to the article, make it seem more compelling, and ensure recognition was received for the work. I didn’t particularly like the newly suggested title, nor did some of my co-authors, but it was not strictly saying that anything ‘was’ a ‘magic bullet’ and so I did not push the issue. I must confess I did not at the time notice the seemingly minor change to the abstract conclusion though. I personally dislike the presentation of % values in this manner as to me they are often misleading and detract from whether the absolute values are really meaningful or not (a big problem in sport and exercise IMO wherein a lot of studies make interventions seem better than they are by reporting % values). The value is not inaccurate, but it does lead the less wary reader to potentially draw the wrong conclusions.

I did suspect that the changes were suggested because the paper would likely be selected for a press release which turned out to be correct. I’m glad the paper got some wide coverage, but wanted to make sure it was covered in a nuanced manner. So I tweeted a little thread to try and provide some balance and when I was interviewed about it on BBC World Service I also made sure to provide as balanced a commentary as I could in the time permitted.

It doesn’t surprise me that the media initially interpreted things to be saying that ‘HIIT’ (high-intensity interval training) was better than ‘MOD’ (moderate-intensity continuous training) for fat loss without considering all the nuance… that’s just how it goes sadly. I also can empathize with the journal and publisher in wanting to try and increase the reach of the work that they publish. To my mind if we can widen the reach of good science, and raise appreciation of its importance, then that’s a good thing. This is something I’d like to be able to do more of. But, though this is good in principle, in execution it proves to be difficult. It’s tough to get the nuance across because science is hard and most people aren’t really able to understand it. I guess it’s part of the media cycle though. The wider media wants ‘stories’ and just regular boring old science doesn’t make for a good story. So to get the wider media’s attention journals and academic publishers need to try and make things seem more exciting. In that process though nuance gets lost. However, I can’t think of any other way to communicate science more widely at the moment. I guess what we need to ensure is that, once the media get hold of a story and want to run it, the actual scientists themselves are the ones they speak to and interview so they end up with a platform and captive audience to explain the nuance and implications in an understandable manner. At least, that’s what I’ve tried to do and hope I achieved.

I think if I was able to ‘do over’ this example specifically then I would have likely pushed back more on the issues. I would like to have kept the original title and would have argued for this position as I suspect my co-authors likely would have too. I definitely would have pushed back on the change to the abstract conclusion and will be more vigilant to these issues in future. In likelihood this might have meant the paper would have been less ‘impactful’ as a story for the media. But it would have meant that the paper itself didn’t contribute to any potentially misleading publicity. The publisher could have still put out the press release as they desired… Can’t stop them from doing that. But at least the paper would have better reflected what we found in full. I think I would advise authors who face similar situations to make sure they think and have a conversation about this. We all want our work to reach the widest audience to hopefully have the biggest impact possible. But we don’t in the process want it to distort in terms of its message. Make sure to discuss it with your co-authors and the journal/publisher and find the right balance so that scientific integrity is retained, whilst reach is maximized. It’s tough to do, but worth striving for IMO.

Dr James Steele is the Principal Investigator at the ukactive Research Institute, and Associate Professor of Sport and Exercise Science at Solent University. James completed his BSc (Hons) in Applied Sport Science in 2010, and hid PhD examining the role of lumbar extensor resistance training in chronic low back pain in 2014. He has extensive experience of research and applied consultancy in the area of physical activity, exercise, and sport from over the past decade, working with a wide range of populations ranging from elite athletes across a range of sports, to the general population across the lifespan, and both those who are healthy and diseased. James has published numerous peer-reviewed articles and delivered several invited talks at international conferences on a variety of areas relating to sport, strength and conditioning, physical activity and exercise, health and fitness. He was appointed to the Expert Working Group revising the Chief Medical Officers Physical Activity Guidelines for the UK and is a Founding Member of the Strength and Conditioning Society, as well as the Society for Transparency, Openness, and Replication in Kinesiology, and member of both the British Association of Sport and Exercise Sciences and the American College of Sports Medicine.

Saturday, February 16, 2019

Saturday Stories: Animal Feelings, Essential Oils, and Sports Drinks

Ross Andersen, in The Atlantic, on the feelings of animals.

Ranjana Srivastava, in The Guardian, on her patient who chose essential oils over chemoterapy.

Christie Aschwanden, in Five Thirty Eight, on how and why you don't need sports drink to stay hydrated.

Friday, February 15, 2019

President Trump May Be A Racist, Antisemitic, Xenophobic, Man-Child, But Despite What You May Have Heard Yesterday, He's Not Obese

Yes, I know the medical report released on him yesterday stated that Trump's weight gives him a BMI of 30.4 and that 30 (for better or for worse - that's a whole other post) is where medicine defines the threshold of obesity. And yes, I know that the media consequently published piles of stories about him being obese, not to mention the many comments on social media.

But here's the thing. You can't "be" your chronic disease.

Chronic diseases are things people have, not who they are.

If you find this confusing, consider this - people have cancer, they aren't cancerous.

People first language puts people first, it doesn't define them by their medical conditions.

So yes, President Trump can be a racist, antisemitic, xenophobic, man-child with obesity, but not a racist, antisemitic, xenophobic, man-child who is obese.

For more on people first language and why it certainly matters with obesity, click here.

Tuesday, February 12, 2019

Groundbreaking New Study On Ultra-Processed Foods Provides Possible Causal Smoking Gun For Our Global Obesity Struggles

[Disclosure, the lead author, Kevin Hall, is a friend of mine and we co-authored a paper together in the past]
A huge deal pre-print paper was published yesterday, "Ultra-processed diets cause excess calorie intake and weight gain: A one-month inpatient randomized controlled trial of ad libitum food intake" that, if its results are replicable and shown to persist over longer time frames, might well explain the rapidly rising weights of the world.

While it has been shown that as food supplies become more industrialized (also referred to as Westernized), weights rise, the reasons why remained unclear. Many have tried to explain away the gains as shifts in the macronutrient composition of a society's diet and depending on the era (or the guru), have pointedly vilified dietary fat, dietary carbohydrates, animal protein, lectins, grains, sugar, and more. Some have done so in part on the basis that when their dietary demon of choice is removed from their adherents' diets, they are seen to lose weight, often even in the absence of tracking calories or anything else for that matter. But common to most of those diets and anecdotes, is their necessitation of forgoing our ultra-processed world and in its place bringing in a great deal more cooking and meal preparation.

Before we get to Kevin's study, here's a basic definition of ultra-processed foods
formulations mostly of cheap industrial sources of dietary energy and nutrients plus additives, using a series of processes
If you're interested, you can read more about them here. But for the sake of this study, think of them as the boxes and jars of ready-to-eat and ready-to-heat foods.

So what did Kevin and his colleagues do?

They admitted 10 male and 10 female weight stable adults as inpatients to the Metabolic Clinical Research Unit at the NIH where they lived for 28 days. They were randomly assigned to either the ultra-processed or unprocessed diet for 2 weeks at which point they crossed over to the other diet for two weeks.

During each diet arm, participants were offered 3 daily meals and they were instructed to eat as much or as little of them as they wanted. Menus were designed to be matched for total calories, energy density, macronutrients, fibre, sugar, and sodium, but differed in the percentage of calories coming from ultra-processed sources.

And the results?


When consuming ultra-processed food diets people ate on average 508 more calories per day. That's roughly a meal worth. That's huge!

And not surprisingly given this finding, people gained weight on the ultra-processed diet (1.7lbs in just 2 weeks) and lost weight on the flip side (2.4lbs in just 2 weeks).

And there was another surprise. Participants didn't rate the ultra-processed foods as being more pleasant or familiar - meaning the results don't appear to have been a reflection of the ultra-processed menu simply being more delicious.

As to what's going on?

People ate ultra-processed foods faster, and the energy densities of these foods are higher and both of these factors likely explain part of the increased caloric consumption, but the other possibility according to the authors might be protein. The ultra-processed diets contained slightly less protein, something that Kevin believes might help to explain up to 50% of the increased caloric intake by way of something called the protein leverage hypothesis which suggests our bodies attempt to maintain a constant protein intake, and so people consuming less protein from ultra-processed foods may be eating more of them to try to maintain some predetermined physiologically-desired/governed protein intake.

Now this is just a very brief overview, and there will undoubtedly be deeper dives into this including in regard to the various metabolic parameters measured (including hunger hormones and peptides), but given how significant the findings appear to be, I thought I ought to whip something up quickly and the calorie piece is by far the most striking and most important in the context of it being a unifying smoking gun for global weight gain.

It's also worth noting, and Kevin did so on Twitter and in the paper itself, while the results of this study definitely suggest that markedly reducing or eliminating ultra-processed foods in our diets may well help with our weights, doing so requires a great deal of privilege, time, skill, and expense. The good news though is that there are ample levers in our food environment that would help to do so and are ripe for reform that have nothing to do with the usual lenses of individualized blaming and shaming including:
  • Improved school foods and school food policies that reduce ultra-processed offerings
  • Bolstering the case for bringing back home economics
  • Furthering the calls to ban junk food marketing to children (and adults)
  • Changing food culture such that ultra-processed foods aren't the cornerstone of every event no matter how small
  • Pushing ultra-processed junk food out of sport and sport sponsorship
  • Putting an end to ultra-processed junk food fund raising
  • Institutional and corporate cafeterias' offerings' reforms
  • Strengthening front of package labeling reforms by perhaps not permitting front of package claims on ultra-processed foods (or adding warnings)
and no doubt there are many more.

Even more good news is that a focus on ultra-processed food as a whole, especially one coming from a place of causality, is a focus that pretty much every diet cult can get firmly behind.

Monday, February 11, 2019

Guest Post: The Truth about Detox Diets (and “Nutritionists”)

Todays guest post comes from Colleen O'Connor and Justine Horne, two registered dietitians who recently set out to investigate whether there's a difference between the information provided online by regulated health professionals (registered dietitians), and unregulated sources of dietary information (nutritionists), when it comes to "detox" diets. Guess what? There was. Here's their study published in the Canadian Journal of Dietetic Practice and Research and below are their thoughts on same
With January being prime time for New Year’s resolutions, you’ve probably recently seen a plethora of social media ads preaching the life-changing benefits of every diet under the sun, including detox diets.

So do we really need to detox? Is drinking lemon water for a week going to cleanse our bodies from all of those supposedly evil toxins that surround us day to day? Is a detox diet the solution to your life-long struggle with weight management? Is “cleansing” your body with things like activated charcoal beverages even safe?

You may have guessed that the answer to all of these questions is no. So why are we so intrigued by detox diets?

Part of the reason may lie in the information we read online. Our group from Brescia University College at Western University in London, Ontario reviewed information posted on nutrition blogs about detox diets and this research was published today in the Canadian Journal of Dietetic Practice and Research. The study aimed to determine if nutritionists and dietitians in Ontario are providing safe, science-based information and advice about detox diets online.

But there a difference between a dietitian and nutritionist?

In Ontario, yes there is - anyone can call themselves a nutritionist. That’s right, you can open up your own business as a self-proclaimed “nutritionist,” sell your nutrition services to friends, family, and whoever else you wish and hey, some insurance companies will even cover the cost of your services! You may have never read a single word about nutrition, yet you can call yourself a “nutritionist.” Do you see anything wrong with this situation?

We certainly do.

Alberta, Nova Scotia, and Quebec do too. That’s why their provincial legislation protects the title “nutritionist” for use exclusively by those with extensive scientific education and nutrition training - registered dietitians (also referred to as ‘dietitians’). Registered dietitians complete an accredited 4-year bachelor of science program to learn about the science behind food and nutrition, complete a competitive internship consisting of at least 1250 hours of supervised practical training, and pass a national 6 hr exam. They must continually keep up with the latest and greatest scientific evidence in nutrition, and are registered members of a regulatory college which is responsible for ensuring dietitians are promoting science-based, safe nutrition advice through a quality assurance program.

So our group from Brescia University College at Western University looked at the information posted online about detoxes from Ontario-based dietitians’ as well as “nutritionists’” websites. We compared this information to the latest peer-reviewed scientific review article on detox diets and overall, found the following:
  • Unregulated “nutritionists” are providing unproven, misleading, and potentially harmful information about detox diets on their blogs.
  • Registered dietitians, on the other hand, are providing safe, science-based information about detox diets on their blogs.
If you consider that anyone can call themselves a “nutritionist” in Ontario, these findings really aren’t surprising. But they are concerning.

Our study highlights that the current situation in Ontario has the potential to do harm to the general public. Ontario legislation around the open use of the term “nutritionist” needs to change. If you agree, feel free to show your support through e-signing this petition.

The fact that somebody can easily get roped into spending their precious time, energy and money on nutrition services that have no scientific merit and the potential to do harm is really upsetting. If you’re seeking out nutrition information, make sure it’s coming from someone credible, like a dietitian.  In Canada, you can search for a dietitian near you by clicking here, or by clicking here. Many health insurance companies cover the cost of dietitian services. Dietitians are also available through family health teams, hospitals, community health centres, and other public healthcare organizations. If you just have some quick questions about nutrition, dietitians are now part of TeleHealth Ontario. Give them a call at 1-866-797-0000 to chat for free or visit

So rather than detox dieting, devote your efforts to making sustainable, life-long, science-backed lifestyle changes. Start small, with 1 or 2 specific changes and keep these up until they become habits. Then add something new. Small, sustainable lifestyle changes can add up to a major lifestyle overhaul and set you on your road to health and well-being.

Colleen O’Connor is a registered dietitian and an associate professor in the School of Food and Nutritional Sciences at Brescia University. She worked as a clinical dietitian in various settings before returning to school and completing her Ph.D. at the University of Guelph. She teaches undergraduate and graduate courses in clinical nutrition. Recent research has included interests in the effects of fermented foods on human health, effects of smart phone apps on influencing healthy behaviours in youth, and nutrient intake of residents in long-term care. She is registered with the College of Dietitians of Ontario and is also a member of Dietitians of Canada and the Canadian Nutrition Society. You can find her on Twitter here.

Justine Horne is a registered dietitian and PhD candidate in Health and Aging at the University of Western Ontario. She received a CIHR Frederick Banting and Charles Best Doctoral Award for her PhD work, which aims to assess the utility of innovative personalized nutrition strategies to help patients improve health behaviours and achieve a healthy body weight. Justine currently works as a dietitian at the East Elgin Family Health Team. She is registered with the College of Dietitians of Ontario and is also a member of Dietitians of Canada and the Canadian Nutrition Society. You can find her on Twitter here.

Saturday, February 09, 2019

Saturday Stories: Banal Antisemitism, Quitting Surgery, And Brain Quackery

Stephen Daisley, in The Spectator, on the UK's Labour party and the banality of antisemitism.

Miko, in Mind Body Miko, on the ugly side of becoming a surgeon.

Joanna Hellmuth, Gil Rabinovici, and Bruce Miller, in JAMA, on the rise of quackery for dementia and brain health (read it before it disappears behind the paywall).

Thursday, February 07, 2019

Guest Post: If You Serve It, We Will Drink It (Medical Resident Edition)

12oz can of Coca-Cola = 39g of free sugar (9.75tsp) offered to residents at recent CaRMS event
Today's guest post comes from first year medical resident Jen Crichton (who you can follow on Twitter). After she came back from a recent CaRMS event and told me what was being served (she's spending a month with us at our office), it reminded me that people consume what they're given, and that of all people, physicians ought to be considering that in their offerings.
Canada’s 2019 Food Guide was released in January. One of many welcome changes is the recommendation for water as the beverage of choice. The new Guide also recommends that sugary drinks (100% fruit juice, milk or milk substitutes with added sugars, soda pop, sports and energy drinks, etc.) not be consumed regularly. Section 2 of the Guide states that:
"Foods and beverages offered in publicly funded institutions should align with Canada's Dietary Guidelines.”
Many universities have previously banned the sale of bottled water on campus (to name just a few: McGill, Ottawa, Queen’s, York). These initiatives are motivated by obvious and warranted sustainability concerns about plastics. However, by continuing the sale of other sugary drinks in plastic bottles we are ignoring the elephant in the room. Why do we vilify bottled water but not bottled water with added sugar? A 2016 guest post by Sean Bawden explored this idea:
“Bottled water is seen as wasteful and unnecessary (See this video as an example); a stigma that did not seem to attach to a similar disposable bottle if filled with something other than water […] A plastic bottle is a plastic bottle; any environmental concerns and any objections to the use of such containers should apply equally, regardless of the container’s contents.”
Sustainable water drinking containers are great but let’s not throw the baby out with the bathwater.
It’s no secret that food environments shape our choices. Anecdotally, I was a part of one undergraduate medical event where organizers made the effort to purchase still and sparkling water off campus and bring it back on-site themselves. Many students had a relieved and refreshed reaction at the less common option of sparkling water.

Conversely, having just completed the CaRMS tour a year ago, I remember the challenges of making healthy choices amid the constant travel, social events, and interview day breakfasts and lunches. This year I empathized with the candidates who were on just one of many stops on a cross-country journey. Each interview day is high stakes; all are hoping to match to a residency program in order to complete their medical training. Do they really need the added decision of choosing water over freely available orange juice or soda pop? Or perhaps it’s not even a conscious decision because of the social stigma associated with bottled water compared to other beverages? Or the stress and vulnerability of the day leads them to choose a sugary option that they would not otherwise consider? Similar to at other medical events:
“All of the [people] here are human, when faced with indulgent dietary choices, they choose them.”
As residents, we are the next generation of physicians in training. Across many different medical specialties, we counsel patients to avoid sugar-sweetened beverages for their own health. We lament with our patients that the food environment around us can be challenging to always make healthier choices. And then on a personal level, residency can be a time of sleep deprivation and limited self-care activities such as cooking and exercise. In medicine, and really in any field where one has public influence, we need to stop shying away from opportunities to be leaders in the promotion of water as the beverage of choice for health.

Sure, it can be hard to please everyone at events. However, in an area where there’s really no longer any debate in terms of health impacts and recommendations, let’s choose to be better role models with respect to excessive sugar consumption and its role in obesity and other chronic diseases. I’m not suggesting that we embrace the disposable plastic water bottle wholeheartedly but rather that we should re-think our indifference (or even preference) towards other sugary drinks delivered in plastic bottles or otherwise.

The challenge is ours in how to create supportive environments that remind us to bring a reusable bottle or cup, that make access to safe drinking water readily available, and that do not punish our health by offering sugary drink choices.

It does not need to be complicated. It just needs to be the default.

Proposed simple guidelines for colleges, universities, hospitals, and other publicly funded institutions to follow:
  1. Water’s number one: Always offer water as the beverage of choice.
  2. Sustainability whenever possible: Water delivered in an environmentally-friendly cup or bottle is optimal.
  3. Avoid sugary drinks: Do not forego bottled water in favour of 100% fruit juices, sodas, sports or energy drinks, or other sugar-sweetened beverages.
Jen Crichton is a Family Medicine resident doctor in training at the University of Ottawa with interests in nutrition and exercise as they intersect with all aspects of primary care. She loves all things active: CrossFit, running, and puppies.

Monday, February 04, 2019

Guest Post: What I Learned When I Actually Read That New BMJ Breakfast Study

Last week saw the BMJ's publication of a new meta-analysis on whether breakfast is useful to weight management. And, entirely predictably, it was clickbait for journalists as well as for those who believe breakfast's benefits are a myth. The question that leaped to my mind when reading the coverage was whether or not anyone actually read the study. Because to describe it as weak, at least in my opinion, would be unbearably generous. But at least one person read it. Finnish registered dietitian Reijo Laatikainen, as he published his own thoughts on his blog, and so rather than write up mine, I invited him to write an English language version here as a guest post.
Challenging deep-rooted health beliefs is always welcome and refreshing, and not something to be feared, but can the BMJ's new breakfast meta-analysis really conclude whether breakfast benefits weight management?

The meta-analysis of randomized controlled studies on breakfast skipping published last Tuesday along with a related op-ed by Tim Spector.

Both the meta-analysis and the opinion piece criticize the nutritional recommendations of many countries and organizations which promote the role of a balanced breakfast as an important part of a healthy dietary pattern. Interestingly, the role of breakfast in both of the BMJ papers is reduced to a weight management issue. Neither paper discusses other potential effects of breakfast consumption such as blood glucose control, energy expenditure, or lipid metabolism, and instead, without data, both papers seem to indirectly imply that breakfast has no health benefits whatsoever.

But back to weight management which was the scope of the study. The first sentence of the conclusions of the meta-analysis reads:
This study suggests that eating breakfast is not a good weight management strategy.
Does it though? My faith is tested.

In order to understand the effect of any strategy, dietary or otherwise, on weight management, first and foremost, the study must be long enough, ideally years, and in fact this is regularly seen with studies of different diets. For example, there are several meta-analyses of low-carbohydrate diet (LCD) RCTs with minimum durations of 6 months, and there are even studies with multi-year durations. This is appropriate of course given the question being asked is whether a particular diet has an impact on something that by definition is of long-term duration as temporarily lost weight may not stay lost forever.

This breakfast meta-analysis is not like those compiled for LCDs. Here, a total of 13 studies were included of which 4 did not last longer than a single day. In fact none of studies lasted even 6 months with the longest being 16 weeks, and the shortest just 8 hours.  Most studies lasted 1-4 weeks. When all these short, heterogenous studies were merged together, a 260 kcal increase in energy intake and 0.4 kg (0.88lb) weight gain was observed among breakfast eaters as compared with breakfast skippers.

And whether you're on team breakfast or not, I think all would agree that the studies included were of such short duration that even compiled together, they simply cannot reliably conclude anything about breakfast's utility to long-term weight management.

So what about the actual content of breakfast studied, what did the subjects eat? This is (inadequately) explained in Table 2. Commonly mentioned breakfast was juice with cereal and/or white bread. In one study, breakfast is described as follows:
"Bran cereal between 7 and 8 am, and a chocolate covered cookie between 10 30 and 11 am."
Does anyone really assume that such a breakfast would benefit weight management? In which country or organization's nutrition recommendation is such a breakfast recommended?

A few more things are worth noting. Studies on children and adolescents were excluded from the analysis. Similarly, studies of people with type 2 diabetes, where protein-rich breakfasts were shown to improve blood glucose control and reduce weight [ref, ref, and ref] were excluded from this analysis.

As a result of these shortcomings, this study clearly can't conclude anything about the impact of consuming a balanced and protein-rich breakfast on any aspect of long term health or weight management. Its conclusions are also contradicted by cohort studies which provide some information on long-term breakfast skipping which in turn suggest that skippers tend to be heavier.

Putting aside the problem with drawing long term conclusions on short term studies, at best, the most generous conclusion that can be drawn from this BMJ meta-analysis is that a low-quality breakfast does not help in weight management, and may even make it more difficult.

In order to truly decipher the role of breakfast to weight management and to health as whole, randomized trials of at least 6 months duration, with a balanced, protein-rich breakfast, are needed, and attention should be paid to its impacts on both healthy subjects as well as those with type 2 diabetes. Furthermore, changes in glucose metabolism and blood cholesterol, should be monitored as breakfast skipping might potentially worsen glucose tolerance even among healthy people and/or elevate their cholesterol.

One thing though is certain. This paper definitely does not provide even a remotely definitive answer to the breakfast question. At best, it reveals how weak the current quality of randomized breakfast studies.

PS. Just so that there's no confusion I'd like to explicitly state that breakfast is by no means a miraculous maneuver which is a categorial prerequisite for successful weight management. If you're a breakfast skipper, and your weight is managed to your satisfaction, you don't struggle with dietary restraint in the evenings, and your lipid and glucose values are within normal range, you are encouraged to continue to skipping breakfast.

Reijo Laatikainen, PhD, MBA, is registered dietitian working at Aava medical centre and Docrates cancer centre in Helsinki, Finland. You'll find him at Twitter @pronutritionist