Ontario's bariatric surgery strategy reflects monetary realities.

This will be the first of a few posts this week on bariatric surgery including a post detailing one patient's experience in successfully overturning Ontario's Ministry of Health's cancellation of her pre-approved out-of-country gastric bypass.

Today's post though will cover a topic that I've blogged about before - why the changes?

The Ministry of Health, through their press releases and official spokespeople, has stated that the point of shutting the doors to out-of-country surgical access and spending $75 million on increasing access to in-province surgical care was to improve timely access to surgery and to improve the quality of patient care.

Unfortunately to date all they've succeeded in doing is markedly increase wait times and put people at increased risk of surgical mortality. What do I mean? Well prior to shutting the doors to patients accessing the 18 American bariatric surgical centres of excellence (a moniker they earned rather than one they simply awarded themselves) the MOH covered , patients could go from referral to surgery within 4 months of application and surgical mortality was in the order of 1 in 1,000 or better. Since the American corridor has been shut wait times have easily reached 1-2 years with Ontario striving towards the procedure's reported all comers "average" death rate of 1/200, a rate that still isn't the one I'd be striving to hit for as noted, the American centres of excellence, where their high volume gives them a tremendous amount of experience, have death rates markedly better than the 1/200 average and tend to range between 0.5 and 1 in a thousand.

Sure doesn't sound like improved access to better care to me.

So why have they made these changes?

My belief has always been that the primary driver for changes was, is, and always will be, money. And frankly that's a very fair consideration in our single-payer health care system. Problem is, without identifying that as the driver for change, we're obscuring the real problem - the system's failing, and pretending that this is all about delivery of care means that we'll be far less likely to try to fix it.

Well, my belief was confirmed on Saturday when I was sharing a podium with Dr. Mehran Anvari, one of the principle investigators of the new bariatric registry program in Ontario. Between his talk and the answers he was able to provide to my questions, he clarified a few things.

Firstly he commented on how one of the main problems with the out-of-country surgeries wasn't the surgery itself, but rather after-care. A very valid point and one that makes me wish at least some of the $75 million dollars Ontario recently allocated to bariatric surgery was spent on the creation and propagation of educational tools and resources for family physicians and general surgeons that would help instruct them on the needs and common complications of the post-operative patient.

He also said this,

"We simply as a province, we cannot afford to send every patient who requires bariatric surgery to the US"

I believe it. At the end of the day despite having patients "requiring" surgery, the monetary truth is we simply can't offer to pay for everyone, and as I'll be discussing later this week, I don't think we have or will have the funding to do them in Ontario either.

Once again I must point out that money is a fair consideration here in Canada, and perhaps if more people were as up front about it as Dr. Anvari we'd be busier trying to find innovative and creative solutions rather than trying to protect an already broken system from valid criticism.

Of course fair or not I imagine the Ministry of Health will soon find itself in quite a pickle because as far as I'm aware, money may enter the equation of whether or not a procedure should be funded, but I'm not aware of it being a defensible rationale for an approved procedure having an inordinately long wait list. But more on that over the course of the next few days.

Hypnotize your stomach into believing you've had bariatric surgery?

Sadly the commercial weight loss industry in Canada is a wholly unregulated one and consequently anyone can put up a weight loss shingle.

Anyone including a Halifax based hypnotherapy office that's promoting what they're calling a, "virtual gastric band".

Apparently,

"This treatment uses hypnosis, NLP and powerful imagery, along with behavioral modifications, to convince your unconscious mind that you’ve had gastric band surgery."

According to the site, the "virtual" gastric band treatment was pioneered by a UK Clinical Hypnotherapist who claims on her website that 99% of patients in her two "trials" were successful in losing weight.

Quite the surprise that those trials weren't published. It would certainly be a boon to medicine to have a 99% effective weight loss treatment. That's better than actual bariatric surgery. I guess they're too busy curing people to be publishing.

So how awesomely successful is the procedure?

Well according to the BBC news report posted on the founder of this procedure's cite, one of her 99% successful trials had 25 people losing "14 stone between them".

Sounds impressive, no?

No.

In pounds 14 stone over 25 people translates into 8lbs a piece.

Also in the generally positive news report? A spokesperson from the UK's Hypnotherapy Association explains that the only evidence to suggest hypnotherapy is effective for weight loss is subjective in nature.

The worst part of this story?

The fact that the BBC decided to run a lengthy and generally positive story on a treatment backed up only by subjective evidence where even the subjective outcomes are awful.



[Hat tip to Dr. Michael Vallis, a Haligonian that I imagine is not referring his patients for this "virtual" procedure]

Saturday Stories

Science Based Medicine tackles Bill Clinton's diet.

Time with one of the best headlines I've seen in a while, Afterbirth - it's what's for Dinner.

My friends Peter and Travis launched a new blog this week geared for scientists on the "Science of Blogging"

So ya wanna be a rock star?

Apparently all you need to do is learn four chords!

Very cool video for today's Funny Friday.

Have a great weekend!

"Making a difference one pizza at a time"

That's the title of Heart and Stroke Foundation Dietitian Samara Foisy's blog post on why she's thrilled to have had the opportunity to work with Pizzaville in bringing them Health Check'ed menu items (something I blogged about yesterday).

Well, a friend of mine (who'd prefer to remain anonymous) had a gander at her blog post and sent me his creative edit of it.

Words in parentheses are hers, while the bold words are his modifications.

I think it rather brilliantly illuminates the problem with Samara's and the Heart and Stroke Foundation's logic.

Making a difference one (pizza) needle at a time

As a (dietitian) police officer I sometimes get asked why I have decided to work with (restaurants) drug dealers to help them offer (healthier) safer items (on their menus) to their customers. Especially (pizza restaurants) heroin addicts. Shouldn’t I just be telling people not to (eat pizza) use heroin? And shouldn’t I just be telling people to (cook) go to their doctors (from scratch) for their drugs and (eat) use all of their (meals) drugs at home?

In fact I do this. I encourage people to plan and shop for (meals) drugs, and (prepare them) take them as directed at home. This is something almost all of us could, and should, do more of. But the reality is Canadians (eat out) use drugs. A lot. (About one of every ten meals we eat comes from a restaurant. According to Stats Can one in four Canadians consume an item from a fast food restaurant daily.) And what are we choosing? About (40%) 80% of the time (either a sandwich, hamburger, hot dog or pizza) alcohol, but 25% of the time it’s prescription drugs and 15% of the time it’s marijuana; in 5% to 14% of cases it’s heroin. (Pizza) Heroin is not a surprising choice. It is (delicious) cheap and readily available. There are (7500 pizza restaurant operators) thousands of drug dealers in Canada and thousands of (restaurants) them include (pizza) heroin on their menus. In 2002 alone there were (more than 351 million pizza transactions in Canadian restaurants) nearly 100,000 arrests in Canada for drug-related offenses. Thatsa lotta (pizza) drugs.

So along with encouraging Canadians to (cook) get drugs primarily from their doctors as often as they can, and trying to make a difference this way, I also want to be practical. A big part of working in health promotion is meeting people where they are. If I can help people make (healthy eating) better drug choices when they are (eating out) abusing drugs, then I have definitely made a difference. By working with (restaurants) drug dealers to get some healthier items on their menus and identifying these healthier items for customers I have the opportunity to help a lot of people. And as a (dietitian) police officer, this is an opportunity I don’t want to miss.

"Health Check makes it easier for Ontarians to make healthy choices at Pizzaville"

That was the wording of the Heart and Stroke Foundation's Health Check program's proud press release headline on Monday.

Hurray?!

I suppose now eating out at Pizzaville is a healthy, good for you, endorsed by the Heart and Stroke Foundation's own dietitians thing to do.

Never you mind that Health Checks on menus might in fact encourage people to eat out at restaurants more frequently. Never you mind that even health conscious, spurred by Health Check's involvement folks, once in Pizzaville may decide to order something else off the menu. Never you mind that there are no Health Check appetizers, desserts, or kids' meals at Pizzaville. Never you mind that research has shown that simply having healthier options on a menu inspires less healthy choices. Never you mind that most people don't hit restaurants alone and their not as health conscious friends, spouses or children will likely order some other nutritionally god-awful fare. It's all good, right?

So what could Health Check's dietitians possibly be thinking?

Basically their argument is that people are eating out anyhow so why not help them make healthier choices?

In fact in her blog post titled (I kid you not), "Making a difference one Pizza at a time", Health Check dietitian Samara Foisy spells this out quite explicitly. She points out that,

"Canadians eat out. A lot. About one of every ten meals we eat comes from a restaurant. According to Stats Can one in four Canadians consume an item from a fast food restaurant daily. And what are we choosing? About 40% of the time either a sandwich, hamburger, hot dog or pizza."

So rather than have the Heart and Stroke Foundation actually try to discourage such frequent meals out Samara wants, "to be practical",

"If I can help people make healthy eating choices when they are eating out, then I have definitely made a difference. By working with restaurants to get some healthier items on their menus and identifying these healthier items for customers I have the opportunity to help a lot of people. And as a dietitian, this is an opportunity I don’t want to miss."

By this logic I'd expect that knowing that lots of folks still drink and drive should have MADD celebrating the creation of a MADD sponsored 2% alcohol brew, or find the Canadian Lung Association knowing that there are still a great many teen smokers proudly stamping their seal of approval on a package of half length cigarettes.

Ultimately while I think it's great that Pizzaville is trying to offer less bad for you fare, I find it horrifying that going to Pizzaville for dinner is effectively being encouraged by the Heart and Stroke Foundation.

Ok, so you folks certainly know where I stand on this, but I'm curious what the dietitians and non-health professionals reading my blog think.

Is the Heart and Stroke Foundation an enormous, hypocritical, nutritional sellout by enabling Canadians to justify eating out at restaurants and in so doing further normalize regular meals out (one of the major contributors to growing rates of obesity and chronic disease in Canada) , or are they in fact rising to an opportunistic challenge?

Ottawa Post : So you want to be on TV?

Consider this post a casting call.

I'm working with CBC's the National on a segment that will explore what Canadian families are eating.

It's not going to be a finger pointing, make you feel horrible about your choices show, but rather an educational one.

It'll be shooting around the first week of December and air sometime early in the New Year and it'll take a week of your time and your reward will include some free groceries and a free digital food scale.

We need 3 families of 4 (though we've already cast one - Andrea Tomkins' from a peek inside the fishbowl) with nearish to tween age kids.

We're still looking for a) a family who due to their lifestyles or preferences tend to value convenience in their meals and b) a family who is trying to retain their own ethnic cuisine despite living in Canada.

If you're interested and think you fit the bill, please email me at yonifreedhoff courtesy of gmail and I'll be able to put you in touch with the segment's producer.

Back to this blog's regular programming tomorrow.

Frankenfood: Tillman's Toasty Pork Pop-Tarts!

Because who wouldn't want pork Pop-Tarts?

They also make poultry Pop-Tarts, bacon and egg Pop-Tarts and, "garden vegetable" Pop-Tarts.

And while Michael Pollan's great-grandmother likely wouldn't have recognized them as "food", I'm sure she'd have loved them just the same.

To brighten your morning, here's a creepy German Tillman's Toasty television commercial.

Interesting that the commercial explicitly asks you not to call "it" schnitzel, yet that's what's written on our North American box.

But really, don't call them schnitzel.

No, I mean it, don't.



[Hat tip to my wonderful coupon cutting wife]

Saturday Stories

The National Post's Jonathan Kay takes on the Star's Andrea Gordon for promoting debunked anti-vaccine looniness.

Ever wonder what would happen if you were a Polish neo-Nazi skinhead and you found out that you were in fact Jewish? Well wonder no more and click here to watch an amazing video.

Spain is full of crazy people

No, this isn't a running of the bulls video, or a massive tomato fight video. This week's Funny Friday is a video of the tallest human tower competition in Spain, and while it's not classically funny, I still thought it was worth sharing.

Now maybe I'm just an overprotective parent, but what parent lets their kid be the tower peak?

Have a great weekend!

Casteller from Mike Randolph on Vimeo.

Prison powered electricity?

Here's a Fermi question for you.

How much energy could be generated if every inmate in the USA rode an electricity generating stationary bike for 2.5 hours a day?

Well the folks over at Treehugger, inspired by a sheriff in Arizona who installed just such a bike to power the inmates' television, did the math.

Their results?

363,641 kWh of electricity which at $0.12/kWh amounts to $109,092/day or nearly $40,000,0000 per year.

Beats making license plates.

Sarah Palin brings on the nutritional stupid.

Remember a few days ago when I commented on San Francisco Mayor Newsom's adoption of Big Food's demonizing position - that government shouldn't tell people what to eat? That legislation like banning the sale of toys with nutritionally bereft food or posting of calories somehow tramples on your civil liberties?

Well good ole Sarah Palin, she's done gone one better.

Not only did she parrot the whole, government shouldn't tell people what to eat bit (this in reference to the government simply providing nutritional guidance),

"Who should be deciding what I eat? Should it be government, or should it be parents?"

That wasn't enough.

Nope.

Instead she also brought cookies to give to the students and explained in her Twitter feed,

"2 PA school speech; I’ll intro kids 2 beauty of laissez-faire via serving them cookies amidst school cookie ban debate;Nanny state run amok"

Because what could be more laissez-faire than pushing cookies on school children as a prop to promote your own political aspirations?

Who should decide what American kids eat? Their parents or Sarah Palin?

She's a gem alright. A regular American Andrew Lansley.

[Hat tip to Martin Collis via MEDIAite and great photo illustration by Mario Piperni]

Tim Horton's new death by chocolate

Not sure if they're South of the border but here in Canada, Tim Horton's has taken to the airwaves to sell their new, "Hot Chocolate Supreme", and, "Triple Chocolate Donuts".

The hot chocolate is advertised as hot chocolate with chocolate syrup, while the triple chocolate donuts are stuffed with some fudgy like substance.

I couldn't resist peeking at their nutritional information.

Grab a medium hot chocolate supreme along with a triple chocolate donut and you'll be consuming 640 calories, 0.4g of trans fat, 590mg of sodium and 18.25 teaspoons of sugar!

That's more than 2 Snickers bars worth of calories, more sodium than 2 gas station sized bags of Ruffles and just a hair less sugar than you'd find in 3 cans of Coca Cola.

San Francisco's Mayor Newsom - devious or just plain dumb?

What am I talking about?

Well a couple of weeks ago San Francisco's Board of Supervisors voted 8-3 to restrict the sale of toys along with fast food to those meals that met certain nutritional criteria.

What didn't the Board do?

The Board did not vote to ban the sale of Happy Meals or any other food. Regardless of the Board's decision, McDonald's can continue to sell Happy Meals and parents can sadly continue to buy them, only now if parents also want to buy their children toys, they'll likely have to buy them in a toy store rather than in a fast food restaurant.

Yet on Saturday San Francisco's Mayor Gavin Newsom, during the press conference he called to announce his veto of the Board's vote, supported his decision by stating,

"Parents, not politicians, should decide what their children eat, especially when it comes to spending their own money".

But as I mentioned, the Board's proposed ban has nothing to do with what a parent decides to feed their child, it has to do with McDonald's predatory practice of enticing children with the glitter of toys to nag their parents to take them there.

So is Mayor Newsom cognitively challenged or is he purposely trying to mislead the public and knowingly helping perpetuate one of the most common Big Food demonizing positions - that somehow politicians who care about nutrition are trying to usurp your personal liberties rather than simply trying to protect children and empower parents?

Either way, shame on you Mayor Newsom.

OMG, OMG, OMG!

An exceedingly rare Sunday post.

A quickie.

I've blogged before about England being the dumbest place on earth when it came to health policy.

Well here's another statement. Andrew Lansley is the stupidest Health secretary or minister that the world has ever seen. Or the most corrupt.

Because only intense stupidity or deep corruption can explain his plan to allow folks like PepsiCo, McDonald's and KFC to write actual governmental obesity prevention policy in England.

I had already predicted that due to the decisions of Andrew Lansley in 20 years or so Britain will be crowned the fattest nation on earth. Perhaps he's trying to hit that goal in 10?

From this day forward on my blog (and other bloggers, feel free to come onboard), anytime an elected Health official makes a wantonly stupid decision, I'll be reporting it as a Lansley!

Saturday Stories

Who cut the cheese? Fantastic New York Times piece on how the US government is simultaneously talking weight loss while actively pushing high calorie cheese.

James Fell has a great piece on the blather in the grocery store checkout aisle. My favourite line had to be his query regarding the juice that apparently leads to a 9lb weekly weight loss, "Lose nine pounds in one week? Is the juice made out of tapeworms?"

A pilot tells Salon.com that the terrorists have won. Sadly I don't disagree.

Arya Sharma wonders whether or not the FDA is stifling obesity drug research.

The honest Four Loko commercial

Have you heard of Four Loko?

It's the energy drink with booze that was banned this week in four different States.

Today's Funny Friday is College Humour's take on an "honest" Four Loko commercial.

Have a great weekend!

Apparently nobody's good at keeping food records.

[My heartfelt thanks to all those brave men and women who gave their lives for our freedom]

Food diaries are the mainstay of any behavioural weight management program worth its salt, but are people actually good at keeping them?

We use food diaries at my offices and there's no doubt some folks are better than others, but given the incredible access we have to food, the lack of caloric information in most restaurants, the reluctance of most folks to weigh and measure what they're eating, and the nibbles and bites we may randomly have, accurate record keeping's tough.

A study done nearly a decade ago helps to illustrate how tough.

Simply designed, the study compared the calories recorded in 7 day food diaries with the calories inferred by doubly labeled water testing. The extra wrinkle with this study? Half of the subjects were registered dietitians while half were plain old folk, with the assumption being that the dietitians would be record keeping ringers, especially given the fact that the study was presented to them as a challenge to record their dietary intake with enough accuracy so as not to deviate from the estimate obtained via doubly labeled water.

The results?

First the non-dietitians. Despite actually keeping food records they missed 18% of the calories they consumed. Over 40lbs a year worth.

Now for the dietitians who were trying their best to be perfectly accurate. They missed 10.5% of the calories they consumed. Due to a small sample size, this wasn't deemed statistically significant, but over a year were that discrepancy maintained, they'd have missed 22lbs worth of 'em.

At my office we sometimes ask patients to do what we call, "science experiments" where for a one or two week period they become as anal about record keeping as they possibly can. Weighing and measuring everything. Recording food within minutes of eating it and ideally, not eating out even once. Almost invariably patients who felt they were fairly accurate with their records before the experiment find anywhere from 200-500 calories they didn't even realize were there.

Of course just because something's challenging to do, doesn't mean a person shouldn't do it and if you're trying to lose weight, there's no doubt keeping a food diary has been proven to help.

Remember, food diarizing isn't for judgment. It isn't there to tell you if you've been good or bad, or how much you're allowed, or how much room is left for dinner. What a food diary's for is information, because the more information you have before you make any decision in life, the better that decision's going to be, and knowing how many calories you're having will certainly help you in deciding which ones are worth it and which ones aren't.

Champagne CM, Bray GA, Kurtz AA, Monteiro JB, Tucker E, Volaufova J, & Delany JP (2002). Energy intake and energy expenditure: a controlled study comparing dietitians and non-dietitians. Journal of the American Dietetic Association, 102 (10), 1428-32 PMID: 12396160

Amazing new diet! Man eats fewer calories than he burns and loses weight!

It's been all over the news.

Dr. Mark Haub, a professor of nutrition at Kansas State University spent the last two months eating pretty much nothing but junk food and lost 27lbs and improved his cholesterol profile.

How did he do it?

He ate fewer calories than he burned.

Is it important?

Yes, but not perhaps in the way you might think.

It's not important as a pure news story. There's simply no surprise that a nutrition professor eating a calorie reduced diet lost weight. If that were news we'd also regularly be seeing stories about the amazing business professor who saved more money than he spent and saw his bank account climb. There's also not too much surprise that his cholesterol improved in that the benefits of losing 13.5% of your body weight likely outweigh any risks inherent to the diet that led to that loss.

No, what's truly important here is the fact that this story made headlines the world over. That's important because it hammers home one incredibly unfortunate fact - the world doesn't understand calories.

Calories are the currency of weight and we need to empower people to use and understand them. From posted calories on menu boards and school cafeterias, to incorporating them into elementary school curricula, to including them on medical licensing examinations, to ensuring that even physical activity guidelines clearly spell them out. Calories, and more importantly a thorough understanding of how many each of us needs and how many we're having, must become part of our nutritional consciousness if we ever hope to put a dent in obesity.

So thanks to Dr. Haub for proving what shouldn't have needed proving, because truly, the fact that the world was wowed by a guy losing weight eating fewer calories than he burns highlights just how far we've got left to go in educating the public.

A shame that doesn't appear to be the message that he's chosen to promote.

The future babble of obesity prognostication

Lies, damn lies and statistics.

Now to be fair I've been primed to disbelieve most future predictions by being mid-way through Dan Gardner's excellent Future Babble, but really, obesity rates to hit 42% is headline news?

The headlines referred to a study published last week in PLoS Computational Biology that had some truly fancy Harvard folks hammer out a formula to predict what obesity's going to do down the road. Those fancy folks are building on a prior study of theirs that proved that obesity is socially contagious and this one takes that one to it's apparently logical mathematical landing point of 42% of everyone you know's going to be obese one day.

Of course obesity is a highly complicated condition. Yes, it's simple to describe, more energy goes in than out, but ultimately there are a great many variables at play which impact on intake and output.

This most recent study doesn't appear to me to address any of those. For instance off the top of my head I would have thought it important in a study of prognostication to provide fancy statistical ways to explain why it wouldn't matter to outcomes if portions sizes continued to grow in restaurants, advertisers continue to ramp up their targeting of children, food delivery becomes even more ubiquitous, incentive or disincentive taxation schemes were enacted, or if suddenly our governments stopped subsidizing the base ingredients that allow food manufacturers to make calories insanely cheap, but hey, I admit quite readily, I'm no mathematician.

More importantly I've got to ask, "So what?". Arguing about how high obesity rates are going to climb is about as useful to helping the problem as folks on the Titanic arguing about exactly how big that iceberg is that's looming on the horizon.

I realize that basic research is important and I admit that I've been set off more by the news coverage than by the study, but at the end of the day what I'm trying to say is that while I'm sure the intellectual exercise of guesstimating how high obesity rates can climb was personally rewarding for those researchers, I can't help but wish that instead they'd have used their massive collective brainpower to work on something that actually has even the remotest bit of clinical relevance.

Quid tum!

Hill, A., Rand, D., Nowak, M., & Christakis, N. (2010). Infectious Disease Modeling of Social Contagion in Networks PLoS Computational Biology, 6 (11) DOI: 10.1371/journal.pcbi.1000968

[thanks to Idea Sandbox for the graphic up above]