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 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.

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.

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?

Wow.

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.

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 wait...is 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 change.org 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 UnlockFood.ca.

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 Stories: Banal Antisemitism, Quitting Surgery, And Brain Quackery

QUACK QUACK

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).

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.

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

Saturday Stories: Rutabagas, Farming, And P.E.

Helen Rosner, in the New Yorker, with the story you didn't know you needed to read about rutabagas.

AC Shilton, in Outside, on how her transition from competitive endurance athlete to farmer saved her body image.

Alia Wong, in the Atlantic, on the terribleness that is often modern day P.E.

First Mood, Then Weight (#BellLetsTalk)

(First posted in 2017)

People often come to me wanting to lose weight or improve their lifestyle, but their moods are anything but well.

Sometimes, when I ask them about it, they'll say that their weight is why they think they're struggling with depression or anxiety.

I always tell them the same thing.

Mood comes first.

Intentional weight loss requires the very things that mood disturbances often preclude - the ability to consistently, plan, organize, and motivate. Setting yourself up to struggle with weight loss by attempting to affect intentional changes when your mood is squarely in the way is not only unfair, it might make matters worse by giving you something to feel guilty about when you're understandably and realistically challenged. And it's also important to note that your mental health is far more important than your weight.

So regardless of your weight, whether its working with your family physician, your employee assistance program, reading books, talking to friends, or looking into community based counselling resources (many of which offer sliding scales for payment), mental health should be your first priority.

Sometimes I use a running analogy.

You can't start work on learning to run if your ankle's currently sprained.

First you work on your ankle. Then you learn to run.

Same here.

First mood. Then weight.

(And remember, for every #BellLetsTalk tweet, RT, and Facebook share today, Bell will donate a nickel towards mental health. And yes, it's marketing for them, but unlike hospitals raising money with cookies, telecommunication does not contribute to the burden of societal illness or promote an unhealthy lifestyle - so tweet and share away!)

Canada's New Food Guide's Biggest Missed Opportunity (And How To Fix It)

As I mentioned last week, Canada's new Food Guide is a giant step forward.

But having read through all the published materials to date, and putting aside things that are beyond the ability of a food guide to address (like food insecurity for instance), I do believe there's one very large missed guidance opportunity - nutrition, kids and sports.

As it stands, I couldn't find anything.

And that's a shame because there's a huge amount of misinformation out there about kids  "refuelling", "recovering", or "rehydrating". There's also a massive industry built to prey on kids and their parents telling them that they need electrolyte enhanced sugar water, or chocolate milk every time they move for a few minutes. There are community races that teach kids running a 5km fun run that they need a banana, bagel, juice, and a protein bar for their 40 minute trot. There are league run programs like Tim Hortons' "I just played I'm thirsty" to bring kids and their parents in and cultivate brand loyalty. There are partnerships between dairy producers and the NFL designed to promote chocoloate milk, and I guess determined not to be left out, Nesquik partnered with the American Youth Soccer Organization to sell chocolate syrup.

And as any parent today knows, snack time for pretty much any organized sport is a sport-washed junk parade.

Consequently, I would have loved to see a section of Canada's Food Guide's guidance devoted to kids and sports. A section that explained that if it's less than an hour, probably the only thing the kids need is water - and even then, only if they're thirsty. And that there are no sugary beverages that kids can quaff that will appreciably improve their performance, or help them to recover, and that when it comes to organized sport, leagues and coaches should be encouraged to affect changes to see sidelines and post game snacking relegated to the water and fruit slices of yesteryear. Though that guidance alone would not lead to immediate change, having it be part of Canada's Food Guide would support public health advocates and parental champions in their efforts to affect change, and over time, slowly seep into the public consciousness.

As to how to fix it?

Well here's the thing. In 2019 the new Food Guide need not be a static set of documents. Living online the guide can expand, contract, and change on an evidence-based and as needed basis. Which means there's nothing stopping Health Canada from spending the tiny bit of time required to suss out this topic and publish it alongside already available guidance.

Here's hoping we see it soon.

Saturday Stories: Gym Safe Spaces, Doctor Rapp, and Time Flying

Fancy Feast, in Buzzfeed, on her surprise as a fat woman that the gym has become her sanctuary.

Jeff Maysh, in The Atlantic, with the incredible story of Doctor Rapp

Ephrat Livni, in Quartz, on the physics of why time passes faster the older you are

Now That Canada's Food Guide Has Markedly Improved, What's Left For Canadian Nutrition And Public Health Advocates To Champion?

Ok. So we have an exciting new food guide here in Canada, but please don't think that means there's nothing left to push for in Canadian nutrition policy.

Back in 2009, I published a piece about the top 10 nutritional hills worth fighting on.

Included on that list were:

• An evidence based food guide
• A national trans fat ban
• Mandatory menu-board calories

So it's nice that at least some progress has been made.

Though far from exhaustive, and in no particular order, here are 6 hills still worth fighting on (adapted from that same original post):

1. We need to get fast food out of our schools. Though pizza days, sub days, shawarma days, and more may well raise a bit of money for our school system, and may give parents a day where they need not pack their kids a lunch (assuming they haven't taught their children to do so - and here I'll say that yes, kids can do so, even kids as young as 8 or 9), I don't think those ends justify the means. And here I don't care if the fast food pizza (or whatever) is formulated in a way to satisfy a nutrition policy document, because it doesn't change the fact that school provided branded fast food weekly just because it's Thursday teaches children, even those who don't order it, that fast food is a normal and healthy part of weekly life. Given that some schools have a different fast food offering every day of the week, consider the message that's teaching our children.
2. We need a national school food program. Canada is one of very few Western nations that does not support a publicly funded national meal program for its students. It has been shown that school food programs markedly improve the mental and physical well being of students who utilize them with some reporting increases in standardized test scores, less illness, better discipline and improved alertness. According to Dr. David Butler-Jones, Canada's former Chief Medical Officer of Health,

   "When children go to school hungry or poorly nourished, their energy levels, memory, problem-solving skills, creativity, concentration and behaviour are all negatively impacted. Studies have shown that 31% of elementary students and 62% of secondary school students do not eat a nutritious breakfast before school. Almost one quarter of Canadian children in Grade 4 do not eat breakfast daily and, by Grade 8, that number jumps to almost half of all girls. The reasons for this vary – from a lack of available food or nutritious options in low-income homes, to poor eating choices made by children and/or their caregivers. As a result of being hungry at school, these children may not reach their full developmental potential – an outcome that can have a health impact throughout their entire lives"

   If interested, sign this formal House of Commons e-petition to the government requesting one.
   
3. We need to ban advertising to children. Plain and simple, young children are not able to discern the difference between truth and advertising and consequently I believe it's entirely unethical to allow marketers to target them. Furthermore food, and specifically unhealthy food, is the number one source of television commercials seen by children. Frankly to me whether or not they impact childhood obesity rates (they do) is beside the point as I think targeting children period is unethical.The somewhat heartening news is that unlike in 2009, there's action now, with Bill S-228 having passed its third reading in Canada's House of Commons, but given it has yet to receive royal assent, it still needs support.
4. We need a soda tax. Nanny state alarmists tend to try to paint soda taxes as a draconian cash grab and an infringement of civil liberties, but really what's generally called for is a nominal tax on beverage manufacturers for each ounce of sugar-sweetened beverages produced which would raise the cost of a can of soda by roughly 12 cents. Hardly a huge amount of money for each individual but likely to generate well over $1 billion annually in Canada which if utilized to fund such things as a National School Food Program, would be an unbelievably beneficial tax (and according to studies would also result in a 10% decrease in national soda consumption). And as far as the tax being regressive, as my friend RD Andy Bellatti has been heard to say, try diabetes, and also have a peek at this piece which expands on this thought in The Lancet.
5. We need to put an end to front-of-package health claims, or at the very least, dramatically rein them in. Sure, the new food guide states, "be aware of food marketing", but why should the onus be on the consumer to turn packages over to ensure that the claims on the front aren't deceitful, or that the product in the package isn't nutritional chaff? There's a great deal of room to improve our reality where Kellogg's can brag about Froot Loops' Vitamin D content and whole grains on the front of its boxes. Personally, I'd prefer a marketplace with no health claims, and though I don't think we're going to necessarily get there, boy does there look nice.
6. We need to treat the supplement industry (and their purveyors) the same way we do pharmaceuticals. Plainly, if a product is being sold to treat a medical condition, the same burden of proof we require of pharmaceuticals (actual evidence of safety and efficacy) should be applied to so-called nutraceuticals. That would mean a huge hit to supplement sales given Canada's Natural Health Product Directorate is comfortable accepting stuff like traditional use claims as a means to receive approval. Doing so costs Canadians in more ways than one in that not only do these products often cost a significant amount of money, but some will certainly forgo actual medical care and evaluation in place of shameless hucksters who prey upon fear, goodwill, and personal misfortune by selling hope in bottles.

Here's hoping that I can cross a few more of these off my list over the coming decade.

Why Canada's Food Guide Matters Even If No One Ever Looks At It

Milk marketing materials distributed to Ontario kindergarten students in their classroom

Though it's terrific to finally have a national food guide which if followed would lead individuals to far healthier diets and eating patterns than current Canadians' likely average diets, it's the guide's impact on the food environment and food culture that I think matters most.

Even if no one ever downloads a copy it, the new food guide will likely have profound effects on Canadian eating patterns and food culture, and it will do so in a manner that doesn't necessitate personal responsibility or privilege.

In brief:

• It will change Canadian school food policies as the guide serves Canada's schools as the scaffolding upon which those policies are built. This iteration, with its removal of juice and sugar-sweetened (chocolate) milk from the basket of healthy choices, will inevitably lead to the slow removal of both from the school system. Of course that won't mean parents who want their children to drink either will be banned from sending them in, it just means that schools will stop selling both and providing them in industry sponsored initiatives like breakfast and snack programs. It also likely means the end of "dairy educators" being invited to promote milk to elementary students, and certainly the end of kindergartner chocolate milk is good for you colouring books. But don't expect this to be an overnight change, but give it half a decade or so and I think both will be pretty much gone.
• It will similarly change what's being served in hospitals and nursing homes to patients, and will lend strength to public health advocates' calls for reforms to the foods being sold in arenas, government offices, and more.
• It will hamstring the food industry's marketing abilities as no longer does the guide suggest a minimum number of servings are required daily, a change that the dairy industry especially, who also no longer enjoy the unwarranted categorization of dairy as a food grouping of its own, will resent as they used the prior guide's minimum serving recommendations relentlessly in their advertising. It will also hamper the juice industry's efforts in that regard.
• It will bolster ongoing and future efforts related to nutritional reforms in Canada including banning food advertising to kids, front-of-package claims, and nutrition fact panel changes.
• It will, as past guides have done, slowly seep into our country's nutritional consciousness whereby media stories on various nutrition related issues will mention the guide's recommendation. For instance a story on juice or chocolate milk is likely now to include the message that neither are considered healthy choices by Canada's Food Guide. Over time, these sorts of mentions, lead to food culture shifts.
• It will, as past guides, also be taught to children in schools, and provided in RD's and MD's offices, and in prenatal classes, and more - and in so doing, again, will slowly influence the country's thinking around food and nutrition.

Now none of this will happen overnight, but check back with this post 5-10 years from now and see whether these predictions held up.

I'll tell you something else, given so many years of being incredibly critical of Canada's Food Guide, it's bizarre, and a real pleasure, for me to be praising it.

Tomorrow, what I'd still love to see change in Canada's nutrition landscape.

BREAKING: Canada's New Food Guide Is Out - And It's A Giant Step Forward #CanadasFoodGuide

Though it would have been wonderful to not have had to wait 12 years for 2007's awful Food Guide's replacement, beyond how long it took, there's not much to complain about the 2019 edition and there's much to praise.

Whether it was consequent to past criticisms, or the insulation of the revision process from the food industry, or a change in leadership, or some combination of those and more factors, the 2019 Food Guide is incredibly different from all of its predecessors. Gone is dairy as its own food group (that doesn't mean the guide is recommending against dairy consumption), gone is wishy-washy language that excused refined grains, gone are explicit recommendations to consume 2 glasses of milk and 2-3 tablespoons of vegetable oils daily, gone is overarching fat-phobia, gone is juice being a fruit and vegetable equivalent, gone is the notion that sugar-sweetened milk is a health food, and gone is an antiquated nutrient-focused approach.

What do we have instead?

The new guide's primary recommendations are easy to summarize:

• Regularly consume vegetables, fruit, whole grains, and "protein foods", where protein foods include everything from legumes, to nuts, to dairy, to meat, and where the guide suggests you consume plant-based proteins more often.
• When you can, consume unsaturated fats instead of saturated fats (with the guide explicitly noting that there's no need to get caught up in the total fat content of your diet)
• Make water your beverage of choice (with the guide explicitly mentioning that 100% fruit juice and sugar-sweetened milk are beverages that should be minimized)
• Limit your consumption of processed foods and beverages that contribute excess sodium, free sugars, and/or saturated fat (the new guide recommends less than 2300mg/day of sodium and less than 10% of total daily energy intake from free sugars and saturated fats respectively)
• Limit your consumption of alcohol
• Plan your meals, cook more often, enjoy your food (here guide is speaking to consideration of culture and food traditions), and eat with others
• Use food labels
• Be aware that food marketing can influence your choices (and here I'd have preferred if they used the word "beware" which is clearly what they're getting at)

Now you may read those recommendations and wonder where the granularity is? How many servings should I have? Which foods precisely should I eat?

The thing is, we don't really have granular evidence of eat this food, not that food beyond the broad recommendations noted above. And servings wise, first off, everyone is different in terms of their needs, but more importantly, prior guides' emphases on servings were a known point of confusion - one that both the public, and health care professionals agreed should go. People don't weigh and measure their foods, and consequently, people tended to underestimate how many servings they were consuming, all the while being spurred on by the food industry to eat at least a certain number. Though it's possible that in some of the ancillary collateral published in the future (there will be a steady trickle of food guide related materials being published over the coming months), there'll be a more specific calculator, not having prescribed numbers of servings in the guide, and instead steering to a more healthful pattern of eating seems both wise and appropriate. It also allows for a much wider variety of diets with differing percentages and types of proteins, carbs, and fats (something those geared up to be furious because it doesn't espouse their particular diet over all others might want to reread).

And of course there's more than just a short document that outlines and supports those aforementioned recommendations, as also released today was the 55 page long Canada's Dietary Guidelines For Health Professionals and Policy Makers and it serves to flesh out the above and provide their rationale and evidence.

No doubt there will be complaints. Dairy champions will clearly be quite unhappy, as will those who are pushing meat and saturated fat as health foods, and my guess is, given there's strength in numbers, people upset about those two issues will likely support one another.

Here I'll simply remind you of the consensus piece on dietary fat published recently in the BMJ that concluded, with prominent low-carb researchers Drs. Ludwig and Volek's approval, that just as the new food guide recommends, "Replacement of saturated fat with naturally occurring unsaturated fats provides health benefits for the general population."

And remember too, science isn't a static set of facts, it's our best interpretation of data, and it can and does change over time. Will we see future research into the impact of saturated fat on health in individuals following low-carb-high-fat diets lead to a specific mention that on those diets it's less of a concern (or not at all)? Maybe. Maybe not. We're just not there yet.

Bottom line?

Our new food guide is a giant step forward and those responsible should be justifiably proud of themselves. Stay tuned the next few days for posts on why the food guide matters even if the majority of Canadians literally never look at it, its policy implications, and where there's room for further reform.

[Oh, and reporters who want to cover the sugar-sweetened milk angle, a reminder that Dominic Cardy, New Brunswick's Minister of Education, is your go to guy to be upset about it as just last month he asserted school based chocolate milk sales provided important calories to children, while helping to combat food insecurity and poverty, which presumably is why his government, the New Brunswick Conservatives, reversed the prior Liberal government's decision to stop its sale and provision in schools - something that clearly this food guide strongly supports]

Saturday Stories: 'Oumuamua, A Probable Serial Rapist, and Running

Isaac Chotiner, in The New Yorker, interviewing Harvard's chair of astronomy, Avi Loeb, on why he believes 'Oumuamua may have been an alien spacecraft.

Matt Mencarini, in Lansing State Journal, with an infuriating story on probable serial rapist Calvin Kelly

Bella Mackie, in The Guardian, on the anti-anxiety medication she started when her life came crumbling down - running.

Because Finding Them Now Is Too Difficult? PepsiCo Launches Mobile, Self-Driving, Health-Washing, Vending Machines

Caught this the other day.

PepsiCo has partnered with the University of the Pacific campus in Stockton, California to launch mobile vending machines that, at least according to PepsiCo, deliver "healthier" snacks to college students by way of a smartphone app.

Peeking at the launch video one can see that the "healthier" snacks include Pure Leaf Lemon Flavor tea (with its > 10 teaspoons (41g) of added sugar), and an assortment of baked chips (which generally have marginally fewer calories but are otherwise comparable to their fully fried brethren).



Because no doubt it's tough these days for college students in in California to find junk food. I mean before Snackbots, they actually had to walk to buy some.

I wonder how much money the University of the Pacific is reaping from PepsiCo in return for feeding up their students and in so doing, helping to market sugar water and baked chips as "healthier"?

Saturday Stories: Life While Fat, Millennial Burnout, and Corporate Nannies

Tommy Tomlinson, in The Atlantic, with a sad and haunting essay on what life is like for him carrying 460lbs.

Anne Helen Petersen, in Buzzfeed, on the genesis of millennial burnout.

Martin McKee and David Butler, in the BMJ, on how corporations, not our government, became our proverbial nannies.

The Only Thing Public Health And The Food Industry Fully And Firmly Agree Upon About Canada's Next Food Guide Is That It Definitely Matters

Generally speaking, there probably isn't much that public health professionals and the food industry agree upon when it comes to Canada's imminent new Food Guide.

Briefly, public health would like to see the Guide discouraging the consumption of sugar sweetened beverages, ultra-processed foods, processed meats, trans-fats, and see a swap recommended so that people are encouraged to replace their saturated fats with unsaturated fats. Public health would also like to see the Guide discourage frequent use of restaurants, encourage cooking, and promote the free-from-distractions consumption of those cooked meals, ideally with loved ones, on a regular basis. There's more, but that's the basic gist.

The food industry would like to see the Guide avoid the discouragement of any particular food, would like to see dairy maintaining its undeserved separate food category while simultaneously not admonishing against chocolate milk, saturated fat swaps, and would like soft, ambiguous language around processed foods and more.

But there is one area where public health and the food industry wholeheartedly agree - they both agree that the Guide matters a great deal and it wields real influence on the eating patterns of Canadians.

No, Canadians don't shop with the Guide in hand, but industry relies on the Guide's messages in their marketing and sales. For instance, if the Guide, as drafts suggest, has indeed eliminated the dairy category and rightly lumped dairy in with other sources of protein, the dairy industry may no longer be able to suggest to kids (even kindergartners), parents, educators and more that we need a particular number of servings of dairy per day. This in turn, along with the removal of chocolate milk as a dairy equivalent, will likely, over time, affect school milk programs, and will certainly impact the "dairy educators" that schools bring in to chat with students. It will also preclude the dairy industry's ability to buy skewed surveys designed to provide a veneer of health to their products, to launch apps to ensure you're having enough, and when articles are written about dairy in the media, no longer will there be a throw away line included about how many servings the Guide recommends daily.

And all of that will undoubtedly affect dairy sales.

Which of course is why the dairy industry has mounted a years long campaign to try to prevent changes to the Guide's dairy recommendations. They've sent in letters to Health Canada and ministers, they've seeded the media with interviews and concerns, and they've even created an astroturf front group called "Keep Canadians Healthy" that pushed Facebook ads to the public encouraging them to be concern and upset about the plans to downgrade dairy, and provided the public with a call to action and a fill in the blank form to mail their MPs (scroll down through the link to see).

So the next time you hear someone cluelessly (or insidiously) suggesting that the Guide doesn't matter (like the feckless Canadian Taxpayers Federation did on CBC's The National two days ago for instance), remember that pretty much the only area where public health and the food industry fully agree in regards to the Guide is the fact that it matters a great deal to what Canadians buy, and consequently, to what Canadians eat.

Caring About The Quality of Your Food Is Not A Disorder (Orthorexia's Many False Media Positives)

That's not to say people can't see their concerns about diet quality not deteriorate into a disorder - where their concerns have sometimes even dramatically negative effects upon their qualities of life and/or mental health.

But that's not what I'm talking about here.

Here I'm talking about the knee jerk comfort people have in ascribing a disorder to someone else's dietary concerns or choices, especially in the both traditional and social media.

Just because you might personally find someone else's attention to their diet excessive, that doesn't mean it is to them. Their caring about the choice and types of their foods, so long as it isn't negatively affecting their physical health, mental health, or their quality of life, isn't an eating disorder!

Saturday Stories: Lesbian Cable Guy's America, The Fat Shaming Spider-Verse, And Alice Walker's Personal Racism

Lauren Hough, in Huff Post, on the reflections of America as seen through the her lens as a lesbian cable guy.

Jack Black reviews Spider-Man: Into the Spider-Verse, through the lens of fat shaming.

Nylah Burton, in New York Magazine, explains the possible personal roots of Alice Walker's racist anti-semitism.

Dominic Cardy, New Brunswick's Minister of Education, Champions School Chocolate Milk Sales In Name of Hunger, Poverty, Food Insecurity, And Fundraising

Before the break, New Brunswick's new Conservative government proudly honoured their promise to restore the elementary school sanctioned sale of chocolate milk.

Never mind that the World Health Organization and Canada's Heart and Stroke Foundation have explicitly called for the marked limitation of the free sugars provided to children.

Never mind that the Director General of Health Canada's Office of Nutrition Policy and Promotion (the folks in charge of the Food Guide), Dr. Hasan Hutchinson, has been on record since February 2014 that chocolate milk's inclusion in the 2007 (and sadly still current) Food Guide was a mistake - a mistake which almost certainly will be remedied when (if) the Food Guide's revisions are ever published.

Never mind that research on what happens when chocolate milk sales are stopped in schools found that stopping the sale of chocolate milk in schools did not affect the students' total daily milk or dairy consumption, that on average all students were meeting their daily recommended amounts of dairy, that kids who swapped from chocolate milk to white milk drank pretty much the same amount of white as they did chocolate (unless you think 4/5ths of a tablespoon of milk is a lot), and that by removing the sale of chocolate milk from the school, in the first month alone nearly half of the initial chocolate milk drinkers switched to white and in so doing, saved themselves piles of calories and the nearly 2 full cups of monthly added sugar.

No, the New Brunswick Conservatives clearly know better, and in late December, Dominic Cardy, their Minister of Education and Early Childhood Development, explained what it was about chocolate milk that made its sale in schools so important - calories. In an interview with the CBC, Cardy explained that selling chocolate milk in schools was important because, "Would you rather have kids have some calories in their stomach or none? You need the calories to start with"

So the sale of chocolate milk in schools is to ensure New Brunswick children consume enough calories? Given New Brunswick's own health council reports the province's rates of childhood obesity are among the highest in the country, I wouldn't have thought that was a problem, and that's putting aside the fact that white milk provides calories too.

And honestly, I wondered if perhaps he was misquoted, or his words were used out of context.

Apparently not. Oh, and also, there's more.

On Twitter, Cardy doubled down on his kids need calories therefore elementary schools need to sell them chocolate milk stance, and then added in that my concerns were due to my privilege and that the sale of chocolate milk was also there to address hunger,

And when RD Karine Comeau quickly pointed out that if food insecure New Brunswick children were the concern, enabling and promoting the excess consumption of sugar in that vulnerable population, a population already at increased risk of chronic disease, probably isn't in their best interest, and instead perhaps an emphasis should be placed on increasing their access to fresh fruits and vegetables, Cardy agreed but stated that the problem with the prior policy was, "yanking milk and juice with no replacement plan"

Yet milk and juice had not been "yanked". You might have noticed that I've bolded the word "sale" throughout this piece - the reasoning is simple - the policy that Cardy and the New Brunswick Conservatives have reversed was the end of school chocolate milk sales. Meaning there was never a ban on chocolate milk (or juice) - they weren't "yanked", they simply weren't sold. Nor were (or are) schools distributing chocolate milk freely to hungry, impoverished children. And when schools weren't selling it, there was nothing stopping a parent from sending their kids with a thermos of chocolate milk (or a juice box) to school, or signing their kids up for the white stuff's sale.

And finally, Cardy calls the concerns of various public health professionals, "self-righteous indignation", and shifts the goalposts a fifth time (from hunger, to poverty, to food insecurity, to yanking) to fundraising. As if there are no other ways to raise funds for schools than by selling sugar.

And perhaps here it's worth repeating, Cardy is New Brunswick's Minister of Education and Early Childhood Development. Drink that in for a moment.

(And reporters who will inevitably be covering the new Food Guide's eventual release, if the Guide, as expected, calls for a limitation on sugar-sweetened milk, I'd suggest an interview with Mr. Cardy with a focus on his chocolate milk beliefs and New Brunswick's school food policy might make for a delicious side story)