Saturday Stories: Remembering, Revenge, And Not Debating

Anita Hill, February 2018

Jessica Shortall, in Medium, with a rage and sorrow inducing piece about everything she can remember.

Jennifer Weiner, in the New York Times, on wanting to burn the frat house of America to the ground.

Laurie Penny, in Longreads, on not debating.

And here's a recent live podcast I did with Darya Rose at this year's Fireside conference where we cover the basics of successful weight management and why I think chocolate's more important to success than hunger.

[Photo By Gage Skidmore, CC BY-SA 3.0, Link]

An Incredibly Innovative Solution For Parents And Politicians Concerned About The Potential End of School Organized Chocolate Milk Sales

Chocolate Milk And Health Canada's Inaction On Canada's Food Guide Just Cost The New Brunswick Liberals The Election

Yesterday there was an election in New Brunswick.

The Conservatives won by a single seat.

So what was the main issue New Brunswickers were voting for or against in this election?

Believe it or not, it was chocolate milk in schools, which was described by the Toronto Star as the issue at, "the centre of the New Brunswick election campaign".

Seriously.

The centre of the New Brunswick campaign was whether or not the sale of chocolate milk would be banned in New Brunswick schools, with Blaine Higg's Conservatives saying "No", and the Liberals Brian Gallant saying, "Yes".

PC Leader Blaine Higgs with Blair and Ashton having Chocolate milk on The Big Blue Bus. pic.twitter.com/MIuRn56AIy

— Paul D'Astous (@d_astous) August 31, 2018

But here's the thing.

If Canada's Food Guide stated that sugar-sweetened milks were not nutritionally equivalent to white milk, and that in fact sugar-sweetened milk consumption should be limited to half a cup daily in children, school chocolate milk sales wouldn't have been an election issue in the first place, as with that admonition, schools almost certainly would have put an end to the daily sale of an item Canada's Food Guide recommends kids explicitly limit.

And there's very little doubt that the next Food Guide, if it's ever released, won't be kind to chocolate milk. And that's not just me reading the tea leaves, it's also me remembering when Dr. Hasan Hutchinson, the Director General of the Health Canada unit responsible for the Food Guide stated, over 4 years ago (honestly, what could we possibly still be waiting for) during a public debate that we held,

"One thing we're doing right now (Note: Right now means February 2014) is doing a reassessment of all of those things and certainly me personally, I agree with Yoni that it (chocolate milk) should not be there either"

So the next time someone tells you that Canada's Food Guide doesn't matter you remind them that Health Canada's inexplicable foot dragging on its much needed revision just cost the New Brunswick Liberals the election.

(Stay tuned, because on Thursday, I'm going to post an incredibly innovative solution to the issue of chocolate milk in schools)

Saturday Stories: Obesity, Mortality, and Belief

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

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

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

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

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

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

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

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

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

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

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

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

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

Photo by David Whittaker from Pexels

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

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

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

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

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

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

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

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

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

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

By Gage Skidmore, CC BY-SA 2.0, Link

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Clinically useless truisms aside, obesity is complicated, and moreover we have yet to discover a non-surgical, reproducible, sustainable, and uniformly effective plan for the management of obesity. And while there's no argument about the fact that in a ideal world everyone would take it upon themselves to live the healthiest lives possible, there are two problems with that argument. Firstly, not everyone is interested or able to change their lifestyles, and secondly, statistically speaking, the majority of even those who are interested and successful with lifestyle change will ultimately regress.

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

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

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

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

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

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

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

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

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

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

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

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

If A Woman With Obesity Is Denied Fertility Treatment, Does She Have Grounds To Sue?

It is a fairly common practice for fertility clinics to deny treatments to women with obesity. The rationale presented usually references the increased risks posed to both mom and fetus consequent to mom's obesity.

And indeed, there are increased risks in pregnancy in women with obesity including of gestational diabetes, preeclampsia, prolonged first stage of labour, increased instrumental deliveries, shoulder dystocia, macrosomia (big babies), congenital anomalies, and C-Sections.

But here's the thing, there are plenty of pre-existing conditions that women seeking fertility treatments have that confer comparably increased risks, and yet those women are not denied access to treatment, instead they are counselled about those risks, informed consent is obtained, and treatment is provided.

Couple the above with the fact that there simply are no gold standard non-surgical means by which women with obesity can ensure they'll lose weight, and that denying fertility treatment to women has been shown to negatively affect self-esteem, social isolation, anxiety, and depression, and I can't help but wonder whether there are grounds for a lawsuit? Grounds that have been made that much stronger by the recent publication of the Canadian Fertility and Andrology Society's recommendations on obesity and reproduction which spell out all of the above (minus the legal question), and which are well worth a read by women with obesity seeking fertility treatments.

Two New Studies Pour Cold Water On Water's Role In Weight Management

Two new studies are bound to disappoint those who still want to believe water makes a difference in weight management.

The first of these studies, Increasing water intake influences hunger and food preference, but does not reliably suppress energy intake in adults, asked participants to drink 500, 1000, 1500, or 2000ml of water in the morning before an all you can eat lunch buffet to see if doing so reduced how much people ate. The researchers found that even drinking 2L of water before lunch didn't reduce how many calories were consumed at the buffet.

The second, Complementary and compensatory dietary changes associated with consumption or omission of plain water by US adults, compared the self-reported dietary intake patterns (which you should know aren't generally thought to be be reliable) of individuals who had days recorded with and without water intake to see if there were a difference in calories reportedly consumed. There wasn't.

As to how pervasive the belief that water is a key player in weight management, you might be surprised by how many people I meet in my office who believe water drinking makes or breaks an effort, though when you consider the fact that 63.4% of adults in a recent US survey of weight loss practices cited water drinking as one of theirs, maybe it shouldn't be all that shocking.

In my mind the only thing that's surprising is that I would have thought it to be fairly self-evident, that water drinking was an incredibly minor player at best, because if drinking 8 or more glasses of water a day contributed even moderately to successful weight management, we'd see a great many more success stories walking around.

[That said, if you replace all your regularly consumed caloric beverages with water, well that might lend a hand.]

Saturday Stories: Glyphosphate, Glyphosphate, And Katie Stubblefield

Robert O'Conner, in Medium, with his expert thoughts on glyphosphate (RoundUp) and cancer.

Andrew Kniss, in his blog, with his expert thoughts on glyphosphate and cancer.

Lynn Johnson, in National Geographic, with an incredible story about Katie Stubblefield's face and life.

Study Finds Giving Prebiotics To Kids Doesn't Change Their Energy Intake And Ups A Major Hunger Hormone Yet Still Concludes Prebiotics Have Potential To Help With Childhood Obesity?

Today will be discussing a study that had kids randomly assigned to taking either 8g oligofructose enriched inulin (prebiotic) per day or placebo (maltodextrin) for 16 weeks.

The study's pre-registered primary outcome measure, as recorded in ClinicalTrials.gov, was change in baseline fat mass at 16 weeks.

Secondary outcome measures (as recorded) were changes in baseline appetite at 16 weeks (assessed with visual analog scales and an eating behavior questionnaire), and objective appetite measures including a weighed breakfast buffet, weighted 3-day food records, and serum satiety hormone levels.

(Not preregistered as an outcome of interest? Body weight change or BMIz score.)

Outcome wise, here's a snapshot of the study's abstract:

Reading through the study, here's what I found as outcomes:

• According to their 3 day food diaries (but be aware, food diaries are notoriously inaccurate), there was no difference in 3 day energy intake between the prebiotic and placebo arms.
• When all ages were included in the analysis, there was no difference in all-you-can-eat breakfast buffet energy intake between the probiotic and placebo arms, BUT, by dividing the kids into those between the ages of 7-10 and 11-12, suddenly, but only in the older group, kids ate less breakfast in the prebiotic arm, while in the younger group, they ate more.
• The hunger hormone ghrelin was found to be significantly elevated in those taking the prebiotic (an increase of 28%) from baseline, whereas placebo was not demonstrably different from baseline (an increase of 8%).
• There was no difference reported in subjective post-breakfast buffet hunger in either group
• There was no difference reported in subjective eating behavior questionnaires between groups, but parents reported improvements in fullness, but equally in both prebiotic and placebo groups.
• The primary outcome of change in baseline fat mass was not mentioned anywhere in the study.

The authors' conclusions about a prebiotic supplement that was shown to markedly increase hunger hormone levels, that didn't decrease 3 day food diary energy intake, that didn't change all-you-can-eat breakfast buffet energy intake (unless you arbitrarily after the fact divided up the kids into those aged 7-10 and 11-12), and where the study's registered primary outcome wasn't mentioned in the study itself sure look differently than what you might expect, with their concluding sentence being,

"This simple dietary change has the potential to help with appetite regulation in children with obesity"

I also found it surprising that the study was free to read, and given the incredibly unexciting findings, it's more difficult to imagine the authors paying for its open access. Easier to imagine the company that makes the prebiotic that a randomized controlled trial published in an impactful journal explicitly concluded, "has the potential to help with appetite regulation in children with obesity" (even though it didn't), paying the extra fees as open access articles generally gather more citations.

As to what Beneo, the manufacturer of the prebiotic used in this study had to say, I found these quotes in an article published on the trade-zine Nutraingredients at the time of the study's publication,

"Beneo regards this research of highest importance",

and despite the study not even remotely coming to this conclusion also added,

"The intake of 8g of prebiotic inulin (Orafti Synergy 1) in a glass of water prior to dinner is a simple dietary intervention that supports children in their weight management efforts. The results show that they were naturally eating less (YF: no they didn't) than the control group having maltodextrin"

Beneo also put out an excited press release to publicize the study.

And you can bet your bottom dollar, it's studies and conclusions like this one that supplement companies use to suggest great benefits to their products, and it's also studies like this one where I wish the journal employed open peer review as I can't fathom how this one got through as is.

Lastly, while the authors didn't report any conflicts of interest with this particular study, the supplements and placebos were provided by Beneo, and it was noted that one of the authors had previously enjoyed funding from Beneo. Unfortunately there is no mention as to who paid for this study's open access.

Saturday Stories: Useless Multivitamins, Menopause, and Jordan Peterson

Timothy Caulfield, on NBC think, on the uselessness of multi-vitamins for all (happy to find this story for reader Pug Piper).

Jen Gunter, on her blog, with her combined personal and professional take on menopause.

Laurie Penny, in Longreads, covers Jordan Peterson, the intellectual this generation deserves.

[And if you don't follow me on Twitter or Facebook, here's a recent podcast I did where we chat about a whole slew of things including the app we're (slowly) developing, research on the DIET score, and why I think social media and physician champions are likely to extend the lifespans of today's fad diets]

Book Review: The Complete Guide to Weight Loss Surgery

Today's guest post comes from our office's newest RD Alex Friel who has reviewed a book for people considering or having bariatric surgery (full disclosure, was provided with a feee copy of the book by the authors)

Thinking about weight loss surgery? You’re not alone. Bariatric surgery has been shown to be one of the most effective treatments for obesity and the number of people who undergo the procedure is steadily rising every year. Here at BMI, I work with many different clients. Some are considering bariatric surgery, others are actively preparing for it, and still more have undergone the procedure and are adjusting to life with a new anatomy. At every stage of the weight loss journey, it helps to be well informed.

Last week I was introduced to a new book written by registered dietitians Lisa Kaouk and Monica Bashaw. It’s a worthwhile read so I thought I’d share it with you. ‘The Complete Guide to Bariatric Surgery’ draws from their experiences as Weight Loss Surgery (WLS) dietitians and the many patients they have counseled over the years. Here’s what I liked:

• It’s from a trusted source. The registered dietitian (RD) credential means that Lisa and Monica are trained in the science and physiology of human nutrition. Their training and practice is regulated in much same way as that of our doctors and nurses so you can rest assured that the recommendations they make are tried, true, and grounded in evidence.
• Written in a conversational style, the book is an easy and entertaining read (or at least as entertaining as a book about a surgical procedure can probably be). There’s no jargon and you won’t need a degree in medicine or nutrition to make sense of the topics covered.
• Because the topics are drawn from the real life concerns and questions of more than 5000 patients, the book provides an honest glimpse into the realities of life after WLS. It’s a useful reference, not only for those who are considering WLS and those who have had it, but also for the friends and family who are their cheerleaders and support system.
• If you’ve ever anxiously wondered if your experience is normal, this book can provide some fast reassurance. The table of contents allows you to quickly skim questions at a glance and is organized into topic sections that range from ‘Tolerance Issues’ to ‘Hair Loss’ to ‘Emotional Changes and Support.’
• Much like this post, it’s short, sweet, and to the point. You won’t need to set aside hours of time to get through it.

My only critique is that the authors don't provide much information on additional resources, support groups, or further reading. It’s good to be aware of what’s available. Obesity Canada, for example, functions as a resource hub for professionals and lay people alike. In addition to educational webinars and videos, they also link to tools you can use to access greater health benefits for obesity care. The Bariatric Cookery, run by food writer Carol Bowen Ball, hosts a wonderful collection recipes to try at every stage of the WLS journey. As a former WLS patient herself, Carol’s first-hand experience lends the site a level of authenticity that is hard to top. Finally, a quick search on Google or Facebook will undoubtedly reveal a whole host of virtual WLS forums and support groups. Find one that resonates with you.

The Complete Guide to Bariatric Surgery is available for purchase on Amazon. It’s also available as an e-book at www.baritricsurgerynutrition.com.

Alex Friel, MSc, RD is a nutrition science nerd and one of the newest dietitians to join the BMI team. She’s convinced that everyone has a passion for food (even if they don’t know it yet) and is always on the lookout for her next favorite recipe. Alex spent six years living in Atlanta, Georgia where she completed a BSc and MSc in Nutrition Science at Georgia State University. Much to the chagrin of her dinner guests, she also gained an appreciation for collard greens and okra that persists to this day.

Have You Been, Or Are You, On A Diet? Please Take 2 Minutes To Review This Brief Survey About How Easy Or Difficult It Is/Was.

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 the first work on using the DIET score has been conducted by Michelle Jospe at the University of Otago in New Zealand as part of the SWIFT trial, and her and Jill Haszard's early look at the data is promising.

Part of the process required to validate a questionnaire involves a qualitative review to see whether or not it's easy to use, comprehensive, and unbiased.

UPDATE: .....we did it! Thanks to everyone who already clicked! We've collected a sufficient number of responses. Do stay tuned though, because in the next rounds of data collection we'll be looking to explore DIET scores from those who are both doing wonderfully on specific diets, as well as collecting information about those diets people couldn't sustain and we'll need every response we can get!