Weighty Matters

Will a Little Kid Saying "Bye Bye" Brighten Your Day?

yonifreedhoff@gmail.com (Yoni Freedhoff) — Fri, 27 Jan 2012 10:30:00 +0000

Sure would mine.

Today's Funny Friday video involves the wide eyed, friendly innocence of youth.

Have a great weekend!

(email subscribers, you've got to visit the blog to watch).

Are Weight Ignorant Allied Health Professionals the Exception or the Norm?

yonifreedhoff@gmail.com (Yoni Freedhoff) — Thu, 26 Jan 2012 10:20:00 +0000

Probably the norm.

And frankly, I think it's unforgivable and that their ignorance belies the fact that weight bias is alive and well in allied health professions.

How is it possible that despite one third of the population having obesity that allied health professionals remain so clueless about how to even talk about weight, let alone how to manage weight related comorbidities, how to ensure they don't add to the problem with weight gaining medications, or how to assess whether that weight is truly problematic, or rather, a healthy variant of normal?

If 1 in 3 people had asthma, do you think allied health professionals would be beyond awesome at managing, counselling and dealing with it, along with recognizing when it's a big scary deal or rather a minor periodic inconvenience?

And it's only because we're talking about obesity that allied health professionals remain perfectly comfortable with their own ignorance. The fact that they can dismiss obesity as a moral failing of their patients - nothing to see here medically - helps to exonerate them mentally from having to actually help, counsel or treat the patient in front of them, or think about the problem's actual etiology. It also helps to exonerate them from actually taking it upon themselves to learn more - something they'd no doubt do were we talking about any other medical problem or condition that they might not know much about, but which affected over one third of their patient population.

Why the diatribe?

Today, my friend Travis Saunders, co-author of the blog Obesity Panacea, recounts his recent experience going to his doctor's. Brief background. Travis? He's stupid fit. He's the guy that makes you shake your head and wonder what kind of crazy crawled into him that makes him run, bike, and ski through sun, rain and snow, day in and day out. He's also an obesity researcher. A good one.

So what happened with Travis?

The nurse practitioner at his MD's office weighed him, saw that his BMI was nearing 25, and told him he should, "watch his weight" moving forward as he was nearing the "overweight" range.

You see Travis wasn't Travis to the nurse. He was BMI 24.5.

I suspect other folks visiting that nurse weren't Marge, or Bill or Peter, they were BMI 37, BMI 32, and BMI 29.

The fact that there was no thought on the part of the nurse? No consideration of Travis' lifestyle or actual health status? That's because I'd bet to her, weight's a very simple thing to deal with. It's not the complicated amalgam of hundreds of genetic, environmental, medical and behavioural contributors. It's not something that needs to be evaluated within the context of the whole. No. She's learned that when BMI is greater than 25, that's overweight, and when BMI's greater than 30, that's obesity. Easy peasy. No need for any further evaluation. Oh, and treatment? Easy, peasy too! Just, "watch your weight".

We all know how well that advice would work.

So is she a bad nurse? An exception? She's probably not either. You see as far as teaching goes, professional schools pretty much ignore obesity. That goes for medical schools, dietetic schools, nursing schools - etc. Instead they teach body mass indices, waist circumferences and waist to hip ratios. They teach numbers. But unlike virtually everything else that's taught, when it comes to obesity, those numbers stay in vacuums, where individuals and thorough and thoughtful exploration of the issue isn't taught or recommended, because sadly, even in medicine, obesity is still considered to be just a reflection of your patients' deadly sins, which is probably why Travis' nurse never even thought to consider him as a person rather than a number.

To read Travis' thoughts and experiences, head over to his blog and have a peek.

To my readers out there who are professors in various allied health training programs - what are your schools teaching about obesity? Is there a new tide turning?

I sure hope so.

Is Suffering Ever a Useful Strategy?

yonifreedhoff@gmail.com (Yoni Freedhoff) — Wed, 25 Jan 2012 10:30:00 +0000

Probably, but first some brief back story to serve as an illustration.

I turned 40 in August. And like many with big birthdays I decided to make some resolutions and included among them was weight lifting. I'd been fair to middling at aerobic activities all my life, but had never really focused much on resistance training. The thing is, as far as health and aging goes, resistance training's probably king, and so....

Anyhow, since August, aside from a brief back injury, I've been working out nearly daily. I've been alternating weights with something aerobic and Monday, Monday was weights day.

I truly didn't want to go. Now there have been days here and there where I haven't fully felt like exercising, but Monday was by far the worst. I was dreading exercising. I was tired, and the last thing I wanted to do was my weights.

I procrastinated for near 10 minutes in my office and finally, grudgingly, headed back to my gym.

My routine our fitness director Kelly has me on right now is a pyramid. I've got 2 groupings of 5 exercises and I'm supposed to run through each of the exercises 3 times in succession.

By the end of the first set of the first two exercises in the first grouping I was already trying to rationalize either stopping altogether, or dropping it down to just 2 sets of each rather than 3.

Instead?

I sucked it up and did it all.

And I'm not going to blow smoke and tell you I was so glad when I was done, that I felt great and alive. I actually felt pretty miserable.

The reason I pushed through? Not because one day of exercise really matters in the grand scheme of things, but rather because I didn't have any good reason not to do it and I knew that if I gave myself permission for no particularly good reason to shirk my exercise, it'd be that much easier to give myself permission the next time.

Of course sometimes there are great reasons not to follow through with various best intentions, plans and resolutions, but when there's no good reason, and it's just you vs. you, I recommend not giving yourself that proverbial inch.

But wait, didn't I just post yesterday that suffering was a bad idea?

Yup, but there's a difference. If every single time I headed to the gym I loathed it, well that'd be a clear cut sign that I'd better find myself another way to exercise. That'd be excessive, non-sustainable suffering. On the other hand, if I generally enjoy it, and here and there I don't feel like it, well that's a clear cut sign I'd better stay on top of myself, as follow through and consistency are how habits are gained (or broken).

And it doesn't apply just to exercise, it's life in general. Our human nature can easily get the best of us, if we let it.

So whatever you're trying to accomplish, sometimes, for your greater good, it might be worth suffering through a rough day, as habits? Well they're the things that persist through thick and thin, but at their beginnings, sometimes you need to really muscle through the thins.

Canadian Politicians go on Public Diet and Misinform Nation

yonifreedhoff@gmail.com (Yoni Freedhoff) — Tue, 24 Jan 2012 10:30:00 +0000

Oy vey.

Toronto Mayor Rob Ford, and his City Councilman brother Doug, have gone on a very public diet. They've challenged other politicians and the general public to "Cut the Waist", and they've received a tremendous amount of media attention.

Yesterday was their first weigh-in.

The Mayor lost 10lbs in a week, and his brother Doug, 9.

What's their strategy?

Suffering.

More specifically according to this article,

"Running a lot, lifting weights and eating like a rabbit."

It's the classic diet plan. Under-eat and over-exercise and lose in a great big hurry.

Of course if that approach to weight management were useful, the world would be a much lighter place and I'd be doing something else for a living. I mean who hasn't tried that at least once? There'd also be a great many fewer gallbladders as weight loss that rapid markedly increases the risk of gallstone formation. We'd also be a heck of a lot weaker as rapid weight loss leads to disproportionate losses of muscle, which is why, when folks do go on extreme diets and lose rapidly, when they can no longer live a life of suffering and head back simply to their old lifestyles, they have a tendency to gain back more than they lost.

In this case the sadder story is the fact that their efforts are being broadcast to a nation, and rather than actually serve a valuable role models to a thoughtful and sustainable approach to healthy living, instead they're championing the same old stupidity that has plagued traumatic dieters for centuries.

Suffering. Willpower. Crazy amounts of sweat. And I'm guessing their fair share of salads and grilled boneless, skinless chicken breasts.

I don't wish ill on their efforts, but if someone's taking book odds on their weights two years from now, if this is how they're planning on losing it, I'd like to put my money on heavier than day one of their challenge.

Guest Post: Surgeon Chris Cobourn Defends Lap-Bands

yonifreedhoff@gmail.com (Yoni Freedhoff) — Mon, 23 Jan 2012 10:30:00 +0000

Readers of my blog might remember a post from just last week in which I detailed the results of a case-matched sample of folks who received gastric bypasses vs. those who received gastric banding where the results were exceedingly favorable to the bypass. One of my readers and colleagues, Dr. Chris Cobourn the medical director of Toronto's Surgical Weight Loss Centre (where both lap-bands and gastric balloons are inserted) read the post and responded with a thoughtful rebuttal.

As is my practice here, I asked if it'd be alright if I posted it on the blog, and I've done so without commentary:

Good Morning Yoni:

I read your blog this morning with a little more than the usual interest and would appreciate the opportunity to give you some feedback on the Gastric Band vs. Gastric Bypass article that you reference, and some of the more relevant literature on this subject. As a surgeon with extensive experience in Lap-Band surgery (LAGB), I think it is important to ensure your readers that Lap-Band surgery is nowhere near being “destroyed”.

The decision to have bariatric surgery is a serious one, and it is important that individuals be presented with a balanced approach and current information. The senior author is Dr. Michel Suter from Switzerland. Dr. Suter has published previous articles (1) in this field and has a reputation as being very critical of the Lap-Band. Due to his early experience with the gastric band, Dr. Suter is no longer performing the procedure, so the current study is another reiteration of his original and now outdated experience. I debated Dr. Suter on a panel at the IFSO meeting in Capri a few years ago, when he presented his series of 300 Lap-Bands performed over a 10 year period. It is unfortunate that the results of such a limited experience, a number of years ago are published as representative of today’s technique and experience in high volume centres.

My specific concerns about this paper are:

· This study is described as a Case-Matched study. Although better than a random comparison, it does not have the strength or validity of a prospective randomized trial. There have been very few randomized controlled trials comparing RYGB and LAGB. I have included two of them as attachments for you to review. Although these studies show better weight loss with RYGB compared to the Lap-Band, the authors raise important questions as to whether the difference in weight loss is clinically relevant. Both procedures induce weight loss substantial enough to resolve comorbidities and improve health which is the obvious goal.

· All of the patients in this report had Lap-Band prior to June 2005 and thus all had the procedure prior to the introduction of the latest model of Lap-Band. As well, an undisclosed number had their Lap-Band procedure with a technique that is no longer used. The peri-gastric technique that was used was shown to have a higher risk of complications and has not been used for at least 8 years.

· Recent research into the mechanism of action of the Lap-Band has changed the way we manage post operative counseling and band adjustments for our patients. Again this has been shown to have a significant effect on reducing post operative complications. The patients in this paper did not have the opportunity to benefit from this new knowledge and this has likely contributed to some of the problems that were discussed.

· The authors spend very little time discussing the short term complications of the either procedure. This is a significant omission when comparing LAGB and RYGB. The short term complications of RYGB have been consistently demonstrated to be more common, and more severe when compared to LAGB. As well, there is a definite mortality risk associated with RYGB that is not discussed or identified in the study. The failure to define and document “major morbidity” is a conspicuous deficiency in this study. The relevance of this study is diminished without this discussion.

In regards to the discussion of long term LAGB complications, I have a number of comments:

o The authors report a 10% incidence of esophageal dilatation. This is extremely high when compared to the current literature. It likely relates to the principles used in band adjustment and the type of older model of band that was used in this series.

o The authors report a 7.7% incidence of band erosion. This again is extremely high. At the Surgical Weight Loss Centre (SWLC), in our first 3500 bands our erosion rate is 7/3500 = 0.2%

o Port catheter leak rate of 6.8%. Once again this is very high. Our rate in 3500 bands is 1.5%

o The authors report a 6.8% incidence of band removal for various reasons. Band intolerance at SWLC leading to explantation is < 1%. The authors have a high rate of conversion from band to other procedures such as RYGB and BPD. In our practice, where quick and easy access to RYGB is not available, we continue to work with patients to resolve their problems rather than remove the band or convert. This is a major contributing factor as to why our band removal rate is so low.

o No comment is made about long term nutritional issues after RYGB, which are well described. Failure to acknowledge and discuss this potentially serious complication is a weakness of the study if their intent was to truly compare the procedures.

o The methodology used to compare long term complications is not well described. Some of the LAGB complications may be duplicated. As well, the severity of the complications is not accounted for. It is not appropriate to assume that all complications are “equal” when some can lead to major surgery and major morbidity and others require only minimal intervention.

One of the areas not discussed in the Suter paper is the well recognized rate of weight regain, starting at about 3 years after RYGB surgery. You get a hint of it by looking at Figure 1 in the paper but it was not discussed by the authors. This is an important issue for bypass patients that is unfortunately rarely mentioned. There is a good paper by O’Brien and colleagues comparing both band and bypass in the long term (2) that shows no statistical difference in excess weight loss after the first few years.

Despite the attention that this paper will attract, it is not a definitive statement on the subject. I am not sure that there will ever be such a paper. RYGB and Lap-Band are different procedure both designed to produce sustained and significant weight loss. Both have been shown to be effective at doing so in high volume centres of excellence that provide the operations using the latest techniques and that provide comprehensive follow up care.

We are in the process of publishing our results showing weight loss results comparable with other major centres, and with a very low rate of both long and short term complications. We have already published our low rate of short term complications with Lap Band surgery (3).

Lap-Band surgery is a reversible procedure which is a significant benefit, the benefit of which is underestimated. If research leads to an effective non-invasive or pharmaceutical treatment for obesity, patients could have their La-Bands removed with a simple procedure and then embrace the new treatment option. This option is not available to any other bariatric surgical procedures.

The risks of bypass and band are very different and well understood. Although the weight loss may be more rapid, and potentially a little better with bypass, I do not believe there is consensus that the difference is clinically relevant. Although band patients may have a higher chance of revision surgery, the revision procedures are rarely performed for serious or life threatening complications. Lap Band surgery is reversible which may be a benefit, but may also lead to a higher rate of conversion to other procedures if the results are less than anticipated. Realistic expectations should be established, and a full and frank discussion of the short and long term risks are critical and mandatory for both procedures.

I appreciate your time and would be happy to discuss this paper and all the issues around it at your convenience.

Best Wishes

Dr. Chris Cobourn | Medical Director and Surgeon

Surgical Weight Loss Centre

www.swlc.ca

References

1. A 10-year experience with laparoscopic gastric banding for morbid obesity: high long-term complication and failure rates Obes Surg. 2006 Jul;16(7):829-35.

2. Systematic review of medium-term weight loss after bariatric operations. O'Brien PE, McPhail T, Chaston TB, Dixon JB. Obes Surg. 2006 Aug;16(8):1032-40.

3. Laparoscopic gastric banding is safe in outpatient surgical centers. Cobourn C, Mumford D, Chapman MA, Wells L. Obes Surg. 2010 Apr;20(4):415-22.

Saturday Stories: Ivory towers, farmwashing and antibiotics

yonifreedhoff@gmail.com (Yoni Freedhoff) — Sat, 21 Jan 2012 10:30:00 +0000

The Atlantic and the broken economics of ivory tower research publications.

Andy Bellatti covers Kellogg's Farmwashing

Marion Nestle covers the topic of antibiotic overuse and the FDA's undersight.

Star Wars Doggy Nerdgasm

yonifreedhoff@gmail.com (Yoni Freedhoff) — Fri, 20 Jan 2012 10:30:00 +0000

I think I need to buy a VW.

Don't know if you remember last Superbowl's VW Star Wars themed ad....but today Funny Friday is apparently a teaser for this year's.

[BTW, true story - I marched down the aisle to the Star Wars theme. I had wanted to walk down to the Death March, but I made the newbie mistake of telling my now wonderful wife the name of the tune]

(Email subscribers, you have to head to the blog to watch)

Have a great weekend!

Paula Deen has Diabetes and takes Victoza. So What?

yonifreedhoff@gmail.com (Yoni Freedhoff) — Thu, 19 Jan 2012 10:30:00 +0000

I've been kicking this story around in my head since it came out.

Celebrity TV chef with obesity who makes repulsively, insanely, calorificly obscene foods (like the bacon, fried egg, doughnut burger of hers pictured up above) develops type II diabetes, doesn't tell anyone for 3 years, and then not only has a big reveal, but signs a deal to endorse an injectable hypoglycemic medication.

So what?

Certainly the blogosphere's abuzz with outrage over the irony, the hypocrisy and the message being sent, and while I agree it's ironic, nutritionally hypocritical and a rather sad message, try as I might, the furthest I get is plain disappointed - I just can't work up any consternation.

Sure, the food she promotes (and presumably eats) is ridiculously decadent calorically and not what any would describe as healthful. Sure eating that sort of food on a regular basis would likely lead you to weight gain which in turn will put you at a much higher risk of diabetes. Sure the message of, "don't worry about your diabetes, there's a drug for that, so keep eating whatever you want" isn't exactly a healthy one. But I'm still confused as to why people are so up in arms.

What I mean is, Paula's not an allied health professional, she's a TV chef with diabetes who cooks far from healthy fare, who apparently now takes Victoza, who frankly was never even remotely seen as a healthy living role model even before her diabetes diagnosis. Did people really look to her or her meals and think she or they were such a picture of health that on that basis they increased the frequency with which they actually prepared her recipes?

We all accept differing degrees of risk into our lives. Jaywalking, biking without a helmet, driving short distances without a seatbelt, smoking, drinking, drugs, processed meats, trans-fats, improper weight lifting techniques, avoiding the doctor, not taking our medications, etc. The fact that Paula wants to continue to risk her health by presumably continuing to eat her bacon fried mac and cheese? That's her business, and were she explicitly telling people her extravagances were healthy, it would certainly be horribly hypocritical, but that's not how she sold them or herself. Consequently I don't think she or her show are any more or less reprehensible now than before her diagnosis.

I guess really what I'm getting at is that I don't for one millisecond believe that the reason people so regularly eat terrible diets is because Paula Deen cooks appalling food on her show. That'd be giving Paula way too much credit.

So could good come from Paula's diagnosis and drug deal?

Maybe.

What if her diagnosis inspired people who were already eating horrible Paula Deen'esque diets to go to their doctors to get checked for diabetes, or if they already have diabetes, go and ask about whether or not Victoza would be suitable for them?

Great I say. If her being a spokesperson for Victoza leads to improved secondary prevention of type 2 diabetic complications then bully for her, and who knows, some people with newly Paula Deen inspired diagnoses may even elect, unlike apparently Paula, to make marked lifestyle changes.

Yes, it'd be lovely if we all ate exceedingly healthful diets, yes it'd be great if we all exercised regularly, and yes it'd be great if we rarely if ever cooked any of Paula Deen's ludicrous concoctions. But that's not everyone's world, and for those already living in Paula's, becoming more aware of type 2 diabetes and its treatments is probably a good thing.

Could Paula have taken this opportunity to become a healthy role model for America? Yes. Did she? Clearly not, and while I would have hoped that as a human being she would have seen value in that, her obvious refusal to step up to that plate leaves her playing the same role she always has - a B list celebrity chef whose claim to fame is cooking nutritionally repugnant food.

Too bad she didn't trade up and become someone laudable.

Gastric Bypasses Destroy Lap-bands in Head to Head Study!

yonifreedhoff@gmail.com (Yoni Freedhoff) — Wed, 18 Jan 2012 10:30:00 +0000

While this wasn't a randomized or blinded trial, the results were striking.

442 case-matched patients were followed for 6 post-operative years. Half received a gastric bypass, and half a gastric band.

While early minor complications were higher in the gastric bypass group (triple the rate seen in banding), major complications were similar. Aside from that, it's all bypass with the bypassed patients enjoying quicker losses, larger maximal losses and significantly better maintenance of losses.

How much better?

After 6 years, for every failed gastric bypass, there were 4 failed lap bands (with failure determined by BMI greater than 35 or reversal of the procedure). For every 1 long-term bypass complication there were 2 lap band complications, and for every 1 re-operation of a bypassed patient, there were 2 of lap banded ones.

Given how damning these results were, the journal invited noted band surgeon Jacques Himpens from Brussels to try to provide some balance in an after article commentary.

Dr. Himpens critiques?

The study could have used surgeons known to be leading experts in banding and bypass.
The mechanistic failing of banding to impact on weight related gut peptides might turn out to be an advantage in the very long term.
The band is more readily reversible.

Of course Dr. Himpens also clearly stated that he himself agrees gastric bypass is a "better" procedure than gastric banding.

Seems like the decision of which surgery to have just became a great deal clearer for those who are considering one.

Romy, S., Donadini, A., Giusti, V., & Suter, M. (2012). Roux-en-Y Gastric Bypass vs Gastric Banding for Morbid Obesity: A Case-Matched Study of 442 Patients Archives of Surgery DOI: 10.1001/archsurg.2011.1708

McDonald's Invited to Teach Nutrition to 5th Graders in Connecticut?!

yonifreedhoff@gmail.com (Yoni Freedhoff) — Tue, 17 Jan 2012 10:30:00 +0000

A ways back I blogged about how in Japan McDonald's was rolling out lesson plans for elementary students and in so doing, blatantly healthwashing their food.

In my head I somehow figured that this was a practice unique to Japan, and that a program like it could never exist in North America.

Boy was I wrong.

In what sounds like a carbon copy, the Connecticut Post reports on workshops conducted by McDonald's for Eli Whitney Elementary School's 5th and 6th graders.

What are the kids being taught?

Well according to 11 year old Shannon Mullings who's quoted in the piece,

"I learned that McDonald's can be very healthy for you if you make the right choices."

11 year old Jack Kyzer (that's him in the photo up above) was quoted as stating,

"It was the best thing that ever happened to me."

The mind boggles.

Not in so much as McDonald's is running this sort of a program, but rather that at least one school board and one set of school administrators think it's a good idea.

What do you think?

A Campaign Against Body Hatred Heads to the British Parliament

yonifreedhoff@gmail.com (Yoni Freedhoff) — Mon, 16 Jan 2012 10:30:00 +0000

Today in England two fascinating events are going on. Firstly, the British Parliament is holding an all party inquiry into the causes and consequences of body image anxiety in the United Kingdom. Secondly, a group of women who've been burned by the diet and beauty industry's predatory marketing and traumatic programs are staging a protest outside the inquiry's doors.

What are they protesting?

"The role of the diet industry in de-stabilising women and girls’ appetites and desires. We believe that eating disorders and the so-called ‘obesity epidemic’ are merely more visible extremes of a much bigger, everyday phenomena: that we are accepting fear and hatred of our own bodies like gravity, that we are accepting ‘I am not good enough’ as a fact."

I couldn't be more supportive of either endeavor.

On a daily basis in my office I see first hand the personal devastation caused by traumatic dieting and unrealistic societal body image ideals.

In my home I can't help but worry about my 3 wonderful, little, girls growing up in a world where weight is portrayed synonymously with laziness, gluttony, stupidity, and greed. I see it in kids' movies like Kung Fu Panda, in children's books like Harry Potter with his "piggy" cousin Dudley Dursley, and sadly I hear about it when I have bedtime chats with my 7 year old and ask her about who gets picked on in school.

That's not to say I'm not supportive of efforts geared to help folks lose weight, just that society's ideas of what those efforts involve, the insanely unrealistic goals, the incredibly non-sustainable diets, and the quest for artificial body image ideals - those need to go.

My office promotes no specific diets. There are no forbidden foods. There are no required products. The goals we encourage our patients to consider are non-weight based and non-numerical, and consequently we don't utilize so-called "ideal" body weights, body mass index tables or waist circumferences.

The only goal worth pursing? Living the healthiest life a person can enjoy. Period. People need to be able to be proud of themselves living those lives, regardless of their weights, and there's no doubt that the diet and beauty industries as a whole go out of their way to purposely make people feel like failures so as to create a revolving door of need.

Good luck to the protesters, and let's hope that the British Parliament actually takes them, and the inquiry, seriously.

[Hat tip to the Canadian Obesity Network's communication director, and my good friend, Brad Hussey]

Saturday Stories: Diaries, portions and the common cold

yonifreedhoff@gmail.com (Yoni Freedhoff) — Sat, 14 Jan 2012 10:30:00 +0000

BBC's Ouch blog asks if keeping a positivity diary help with your chronic illness?

Marion Nestle covers New York City's latest shocking ad campaign - portion size.

Scott Gavura from Science Based Pharmacy (and Science Based Medicine) drums down the evidence of every so called cold remedy or preventative in the book

Canada for President of the United States!

yonifreedhoff@gmail.com (Yoni Freedhoff) — Fri, 13 Jan 2012 10:30:00 +0000

What a crazy week....but perhaps not as crazy as America's GOP hopefuls.

Today's Funny Friday is Canada's pitch to become a candidate.

Warning - NSFW language and painful fun being made of both of our countries.

Have a great weekend!

(email subscribers, head to the blog to watch)

Why Soda Taxes Aren't Fat Taxes and a few Other Thoughts

yonifreedhoff@gmail.com (Yoni Freedhoff) — Thu, 12 Jan 2012 10:30:00 +0000

Soda taxes are regularly being promoted and described as "fat taxes", "sin taxes" or "obesity taxes".

They're none of those things.

Why?

Some reality:

It's not a sin to drink soda
Skinny folks drink it too
Yes, the calories in soda are a real and likely player in our growing rates of obesity....and so are the calories in a great many other foods.

Taxes on sodas are meant to discourage an unhealthy behaviour - drinking boatloads of sugar. That's a bad plan both for people with, and for those without obesity. The World Health Organization has recommended that no more than 10% of everyone's daily calories come from added sugars. In regard to added sugars, sugared soda's certainly the most clear and present target, and especially here in Canada where medicine is socialized, discouraging behaviours that contribute to the burden of disease (and hence healthcare expenditures) is certainly in the Government's purvey, and hence the consideration of a soda tax.

So I think a better definition would be an, "unhealthy indulgence tax", which is the same way I'd describe tobacco's taxation.

But will a soda tax actually help decrease the burden of chronic disease?

No one knows. Some mathematical modeling has suggested it will, but even the best models can't truly predict real world behaviours. For instance, in this model they predict that 40% of the calories no longer consumed consequent to the tax would end up being consumed in increased milk and juice calories. But what if Big Beverage jumped on the tax to more heavily market juice? Given their job is to make money and given that every soda company worth its salt also sells juice, I wouldn't bet against that marketing. If the calorie and free sugar reduction disappears in the consumption of non zero-calorie beverage alternatives to soda, then the benefits of less soda would also disappear.

And what of the dollars raised? Is there any assurance that those dollars would be spent on healthcare? I remember a similar promise here in Ontario where the Liberal Government implemented a Health Care Premium that was promised to help fund the health care system but ended up funding water infrastructure.

Oh, and one last thing. Sometimes folks argue that this tax would be punitive to the poor. It's true that the lower your income, the more impacted by a tax you would be, but some perspective might help. First, the cost of a soda with inflation adjusted dollars has dropped 33% since 1978 (see chart up above) and most folks are recommending a less than 33% tax on the stuff. Second, on average we're all consuming 3x as much soda as we did back in the early to mid 1960s. So whatever a person is currently spending on soda, if that person continued to spend the exact same amount, but soda prices rose by 33%, on average that person would still be consuming double the per capita soda consumption of the mid 1960s. Double the soda consumption of the mid 60s doesn't sound too cost prohibitive to me.

So am I pro soda tax?

Yes, but cautiously. I say cautiously because of all those questions up above, and because I wonder about these sorts of taxes actual implementation. Ideally soda taxes would be rolled out with public education campaigns that talk of liquid calories, and ideally too, it'd be a tax that would apply to all sugar sweetened beverages (including both milk and juice). I'm not too confident those criteria would be met. But I'm supportive because at the end of the day, whether you have weight to lose or not, drinking less sugar is likely in our health care systems' best interest, and sugar sweetened beverages are by far the biggest, sweetest target.

[UPDATE: Please see the very thoughtful comment from Jocelyne Koepke of the Canadian Council for Tobacco Control on why the comparison with tobacco, an addiction, might not be appropriate]

No Soda Tax for Canadians

yonifreedhoff@gmail.com (Yoni Freedhoff) — Wed, 11 Jan 2012 10:30:00 +0000

It's a pretty common refrain out there.

Obesity is because we're less active.

And while activity certainly burns calories, doubly labeled water data on energy expenditures suggest that North Americans burn as many calories as folks in the third world, and more importantly, as many calories as we did back in the 70s and 80s when there was a lot less obesity.

Oh, and since the 70s? We're consuming roughly a meal more worth of calories per person per day.

To me the math seems pretty clear, but it may not be happy math. It's way more fun to exercise than to cut back on calories. But weight being about inactivity? That's what people want to hear as intuitively that makes sense.

And hear it they will. From glossy magazines and newspapers, to loved ones, to god-awful reality television shows and even from ill informed but well intentioned health professionals.

Oh, and also from Canada's Department of Agriculture. We were peeking at a document on their website the other day on food trends for Canadians through 2020 and came across this line,

"Canadians are well aware that their low levels of exercise contribute more to obesity than poor diet"

Uh huh.

And while I realize the Department of Agriculture's job is to protect and promote Canadian agriculture, I would have hoped that intuitive but erroneous misinformation would be something they'd do a better job protecting themselves (and us) against than the average glossy magazine.

What's worrisome of course is the fact that while I'm sure many politicians are exceedingly bright folks, they've got no choice but to rely on these types of reports to help inform their policy decisions. They're experts in policy, not obesity or nutrition.

Wonder if that's why yesterday Leona Aglukkaq ruled out a sugared soda tax here in Canada. After all, according to Agriculture Canada it's our low levels of exercise that are causing obesity. Surely the trebling of sugared soda consumption since the early to mid 1960s has nothing to do with it.

Phooey!

Are you a Talk Walker, or a Walk Talker - My Challenge to Health Professionals

yonifreedhoff@gmail.com (Yoni Freedhoff) — Tue, 10 Jan 2012 10:30:00 +0000

In health care it definitely helps if you know what your patients are going through.

It's not essential of course, thankfully there are far more diseases that I can treat than I have personal experience with, but common grounds give understanding and empathy that books and lectures simply can't.

But I'm not talking about diabetics being better at treating diabetics. I'm not talking about drugs or rehabilitative exercises. Here I'm talking about the things we ask our patients to do in the hopes of improving the health of their lifestyles.

Because let's face it, when it comes to healthy living, health professionals sure are great at providing advice, but that's not to say the advice is always great. I wonder how much better a health professional's healthy living advice would be if they actually lived it themselves? At the very least, it would provide that health professional with a true understanding of what it takes to follow through, and at best, it would highlight recommendations that from a doability perspective, might stand a bit of work. Either way, it'll help to provide true, genuine, empathy.

So if you're a health professional, my question to you is this. Do you actually walk your talk, or do you just talk it?

Me?

While I discuss a great many things with my patients, boiling it down, the bare bones thrust of my lifestyle recommendations usually involve eating every 3 hours, always including protein, tracking calories, weighing and measuring food, cooking (actually transforming raw ingredients) and exercising as often as they can enjoy.

And I'm not posting that to have a debate about the recommendations themselves. Different approaches for different people, bodies and goals. Some will succeed with 3 meals a day, some with intermittent fasting, some with truly low carbs, some with meal replacements, etc. What I care most about is that a patient likes their approach enough to continue with it. And while we have those recommendations up above as our base, we're happy to work with our patients on any approach they feel they might be able to sustain because the suggestion that there's only one way to go flies in the face of the evidence base. Why I'm posting it here is so that you'll know what our base recommendations are so that you can judge whether or not I'm doing them myself.

Because I'm a bit of an open book. My food diary is publicly available on Tweet What you Eat. At the time of writing today, I haven't missed tracking a meal or a snack for 248 consecutive days. I'm not obsessing about it either - it doesn't consume my every waking moment of time or attention. In fact, at this point I doubt it takes me more than 5 minutes a day of effort, and it's certainly not about being perfect. Have a peek and you'll see what I mean. For instance you'll find that this past weekend I went out twice to eat, including one insanely calorific pilgrimage for ribs. Scroll around some more and you'll see I also sometimes miss snacks, really enjoy alcohol, and also am partial to potato chips and sour patch kids. Good, bad, and ugly, I track it all - because it's not for judgment, it's just to know what the heck is going on and where and when I might stand to tighten my reins.

Fitness diary wise, I use a new online service called Fitocracy. Picture Facebook/Twitter, meets an exercise diary, meets an online role playing game. No, you don't pretend to be a dwarf and roll 20 sided dies for your constitution, but the more you exercise, the more you level up, and you can also complete quests, log, save and receive scores for your usual workouts (or your functional activities, they don't need to be gym based), and reach a community of folks who think exercise is important enough to get excited about. I've been tracking on Fitocracy for a little over a month and find it's a great way to stay on top of my goals and it does help give me a bit of a boost in motivation. Want to see what I'm doing exercise wise? Click here and feel free.

Now maybe I'm a bit hard core about this tracking business but of course I'd argue that the evidence base is solidly with me on its incredible value in cultivating healthy behaviours.

My challenge to you?

If you're a health professional, and you're providing lifestyle advice to your patients, commit, for at least a one month period, to make your life an open book, and not only try to live the life you encourage your patients to live, encourage them to watch!

Provide them with links to your profiles and maybe they'll even cheer you on. Honestly, if you've never tried to walk your talk, how can you truly be sure you're putting people on a walk-able path?

Dick Talens, the formerly obese teen role playing gamer turned fitness machine and Founder of Fitocracy has kindly provided me with some invites (it's still in a semi-closed beta).

If you're an allied health professional (including all you healthy living researchers and journalists), click here and not only will you be signed up, but you'll automatically be joined to the group I started just 2 days ago (Update: Have been told that after clicking the link you need to sign up manually rather than a Facebook or Twitter connect). It's called The Talk Walkers. Also? Spread this post to all of your email, Twitter and Facebook colleagues and encourage them to do the same.

If you're not a health professional click here and you can still sign up and get immersed into one of the literally dozens of other groups, or simply decide to tool around with it on your own. (Update: Have been told that after clicking the link you need to sign up manually rather than a Facebook or Twitter connect).

If you're not doing so already, it's definitely time you walked your talk. You owe it not only to yourselves, but to your patients.

(Thanks Dick, for the links - to read more about Dick and Fitocracy, here's CNN's coverage)

Are You Doomed to Regain? Thoughts on Tara Parker Pope's Fat Trap.

yonifreedhoff@gmail.com (Yoni Freedhoff) — Mon, 09 Jan 2012 10:30:00 +0000

If you haven't read Tara Parker Pope's Fat Trap in the New York Times, her premise is pretty straightforward - permanent weight loss is virtually impossible, and for those who succeed it requires near superhuman willpower.

Why?

According to Tara, the body adapts to weight loss in multiple ways that make weight gain easier, and it's basically a full time job to keep it off from a vigilance perspective.

I think Tara's article's great and highlights two tremendously important points. Firstly, that there's way more to all of this than simply pushing away from the table, as the body keeps tucking people right back in. Secondly, that society's approach and attitude towards weight management is just plain broken - and I suppose it's here where Tara and I effectively diverge.

Tara talks of extremely restrictive diets as if they're what are required to lose. I couldn't disagree more (I'll come back to this). Then she discusses the ongoing and incredible vigilance of successful losers, quoting Yale's Kelly Brownell as stating,

"Years later they are paying attention to every calorie, spending an hour a day on exercise. They never don’t think about their weight."

That does indeed sound rather severe, and she definitely writes about it with the spin of negativity.

What do I think? I think negative depends on approach and attitude. For instance where Tara might use the word vigilance, I'd use the word thoughtfulness and that being aware of every calorie doesn't mean you're not eating indulgent ones.

Tara picture though is definitely the incredibly strict life that typifies society's eye view of "dieting". But even if severity's what's required, why can't people just stay hard core? Superficially you might think people would in fact be able to remain hard core, because people really, really, really want to keep the weight off and I imagine this confuses many folks, including Tara.

How badly do people want this? In a now classic study, Rand and MacGregor revealed that formerly obese, bariatric surgical patients would rather be of normal weight and deaf, dyslexic, diabetic, legally blind, have very bad acne, have heart disease or one leg amputated, than return to being severely obese. If you felt that way about something, for whatever the reason, don't you think you'd do whatever it took to keep that weight off, even if it were a hardship?

So why do people gain it back if it's so important to them? If they'd rather be blind or have a leg amputated, why can't they just keep up with their weight management efforts? Is it because as Tara describes their bodies work against them? Certainly in part, but I think the bigger reason is because they've likely chosen inane methods of loss and maintenance - like those described by Tara. To lose their weight they've gone on highly restrictive diets, they're denying themselves the ability to use food for comfort or celebration, they're regularly white-knuckling through hunger and cravings, they've set ridiculous Boston Marathon style goals for their losses, and they'll often possess highly traumatic all-or-nothing attitudes towards their efforts. In short? They've chosen suffering as their weight management modality.

Suffering as their plan? Go figure it ain't working. Incredible desire or not, people aren't built for long term, relentless, suffering.

I guess what I'm getting at is that there is zero debate about the fact that weight management, whether it's losing or just not gaining, does require effort. What I'm positing here is that if your effort is personally perceived as a misery, given human nature, eventually you'll fail, not because you're weak willed, but rather because you're human, coupled with the fact that the world we live in is now a Willy Wonkian treasure trove of calories and dietary pleasure. This calorically non-intuitive wonderland is also why without ongoing thoughtfulness in terms of choices, lost weight comes back even for those who do it smart.

My weight management philosophy has always been rather straightforward - whatever you choose to do to lose your weight, you need to keep doing to keep it off, and therefore choosing a weight loss modality you don't enjoy is just a recipe for regain.

So is there one right way to do this? I don't think so. As far as weight loss and maintenance go there are many different strokes for many different folks, but there is one essential commonality for those who succeed where others fail - if you're going to keep it off you've got to like how you've lost it enough to keep doing it.

Now back to Tara's premise that almost no one keeps it off.

That graph up above?

It's from a recently published study of something called the Look AHEAD trial where Tom Wadden and colleagues studied those factors associated with long term weight loss success. The factors? Paying attention to intake, exercising, and applying the education they received from their expert research team. And would you take a look at that graph! By year 4, of the folks who'd lost more than 10% of their weight in the first year, some did indeed gain it back, but 42.2% kept off nearly 18% of their presenting weight for the full 4 years! In fact they kept off virtually all of their year one losses. Moreover, looking at all comers of the trial and not just the folks who lost a pile in year one, nearly 25% of all participants maintained a 4 year loss greater than 10% of their initial weight.

That's sure a far cry from no one. In fact if those results came from a pill some pharma company would be making billions of dollars.

So it is indeed doable, but ultimately weight loss and maintenance require lifelong effort, therefore if you don't like the effort required, you're not going to keep it up and your weight's going to return.

Somehow I wouldn't have thought an article that reinforces the fact that if you don't like the life you're living, you're not going to keep living that way would grace the pages of the New York Times.

Saturday Stories: Science, Wifi and Big Food

yonifreedhoff@gmail.com (Yoni Freedhoff) — Sat, 07 Jan 2012 10:30:00 +0000

Wired magazine asks if science is failing us.

Scienceish's Julia Belluz asks does WiFi pose a health risk?

Serious Bollocks' Matt explains how the UK's Big Food driven Change4Life obesity program now blatantly selling food.

Female? Single? You might want to rethink that cat.

yonifreedhoff@gmail.com (Yoni Freedhoff) — Fri, 06 Jan 2012 10:30:00 +0000

So for those of you who are new to the blog, Fridays are my day off the serious.

Fridays here are "Funny Friday's" and usually involve a video that made me smile.

This week's Funny Friday's no exception...it's about cats.

Email subscribers, if you want to watch the video, you've got to head to the blog.

Have a great weekend!

[Hat tip to my cousin Robin for posting this in her Facebook feed]

The Real Problem with those Controversial Atlanta Childhood Obesity Ads

yonifreedhoff@gmail.com (Yoni Freedhoff) — Thu, 05 Jan 2012 10:30:00 +0000

The ads cut straight to the point - childhood obesity is real and we can't continue to turn a blind eye towards it.

The ads have also been rather soundly criticized by experts who worry about their impact on the already rampant biases that are endured by children with obesity.

But the ads may well be necessary. Georgia has the second highest obesity rate in the country, and there's no doubt finding a means to reduce those rates, especially the childhood ones, would be a worthwhile endeavor.

So will these ads help?

I sure don't think so.

Instead they steer parents and children to a website full of rather useless one line recommendations. If it were as easy as doing things like, "When you are watching TV as a family, get up and move during the commercials—try running in place, dancing or jumping jacks", do you really think we'd have a problem? The website also encourages parents to speak to their children's doctors about the problem. But given that the vast majority of medical schools and residency programs teach pretty much nothing about nutrition and obesity, I'm not particularly hopeful their doctors' advice will be any more sage than the website's.

Without a doubt, the question of whether these ads stigmatize obesity further is an important discussion to have (and for the record, I think these ads simply highlight the issue, not stigmatize it), but I guess what I'm trying to say is this: Lost in the discussion of stigma, the reporters and experts have seemingly forgotten one very important fact. That fact? We simply don't yet have a reproducible and reliable treatment program that results in significant and sustained weight loss in children.

So while I'm all for public health campaigns to address childhood obesity, it's not the individual victims that I think we should be focusing on, it's the world they're growing up in.

To help illustrate my point, try to imagine childhood obesity as a flooding river with no end in sight. While teaching children how to swim might help temporarily in keeping them afloat, given that the flood isn't abating, chances are, even with the best swimming instructions, the kids are going to get tired and sink. So while swimming lessons certainly can't hurt, what we really need to be shouting about doing is actually changing their environment and building them a levee.

The real problem with these ads is that they suggest that we're going to solve this problem on an individualized case by case basis.

Childhood obesity is the symptom. The environment is the cause.

If we want a cure, it's the cause we need rally against, and not the symptom.

Nature Medicine Reinforces the Obesity is Gluttony Narrative (@naturemedicine)

yonifreedhoff@gmail.com (Yoni Freedhoff) — Wed, 04 Jan 2012 10:30:00 +0000

Sigh.

While I'm sure the intent was innocent, I was sad to see the infographic up above which highlighted Nature Medicine's Metabolic Syndrome Supplement (for non scientist and MD readers, Nature Medicine is one of the world's most prominent, peer reviewed, medical journals).

Yes, excess dietary intake leads to obesity, which in turn fuels metabolic syndrome, but the use of multiple large pieces of chocolate cake to represent intake just stokes the fire of weight bias and the belief that excess intake is consequent to simple gluttony.

This year, when you write or chat or think about obesity, why not take a moment and think about how you're characterizing it, and whether or not you too, perhaps unconsciously and inadvertently, are cultivating classic weight bias and stereotyping?

The crucial difference between a goal and a resolution.

yonifreedhoff@gmail.com (Yoni Freedhoff) — Tue, 03 Jan 2012 10:30:00 +0000

One's a hope, and one's a plan.

A goal might be to lose weight, get in shape, eat healthier, love better, get a promotion, higher grades in school, etc. Those are things you truly hope you'll do in 2012.

A resolution?

That'd be the plan that'll actually get you there. So your resolution might be to pack your lunches every day to work, to go for a 20min walk on your treadmill every morning before you shower, to tell you wife or husband you love them on an at least weekly basis and create a standing date night, to ensure you never leave work without having cleared out your inbox, that every weekend you dedicate at least 4 hours to library based study.

If you actually want to reach a goal, well then you'd better also figure out exactly how you're going to get there. So for instance don't just renew your gym membership, schedule workout times into your real agenda and treat yourself like your most important client.

This year, resolve to actually have plans, and not simply hopes.

Happy New Year one and all!

Stephen Colbert Night in Canada!

yonifreedhoff@gmail.com (Yoni Freedhoff) — Fri, 30 Dec 2011 10:30:00 +0000

Hope you're enjoying this holiday season! This week is traditionally my blog-cation and so instead of writing new posts, here is a favourite of mine from back in 2008.
I definitely have a man crush on Stephen Colbert.

There, I said it.

God love him, he's today's 2008 recycled Funny Friday.

Have a great weekend!

(email subscribers, head to the blog, this one's definitely worth it)

[Originally posted in May 2008]

My Loot Bag Manifesto

yonifreedhoff@gmail.com (Yoni Freedhoff) — Thu, 29 Dec 2011 10:30:00 +0000

Hope you're enjoying this holiday season! This week is traditionally my blog-cation and so instead of writing new posts, here is a favourite of mine from back in 2008.

My 4 year old came home from a birthday party the other day with a loot-bag that save for one small trinket, contained solely candy.

She's 4.

4 year olds are thrilled with anything. You could put coloured popsicle sticks and cotton balls in a loot bag and they'd be happy - why do you need to send home sugar?

For guests of our daughters we generally raid our local dollar store and buy things like little fairy skirts, wooden puzzles or cars that can be put together and painted with parents, felt doorknockers where we included lettering for kids' names, small dolls, stickers, beading kits for personalized bracelets, pirate hats, squishy balls and play-doh.

Thankfully, my loot bag manifesto is a short one:

I hereby proclaim that an enlightened loot bag contains no candy!

Pass it on!

[Originally published October 23rd, 2008]

Coca Cola Lies to Doctors?

yonifreedhoff@gmail.com (Yoni Freedhoff) — Wed, 28 Dec 2011 10:30:00 +0000

Hope you're enjoying this holiday season! This week is traditionally my blog-cation and so instead of writing new posts, here is a favourite of mine from back in 2008.

Sure looks that way to me.

The ad pictured above appeared on page 1632 of the June 17th edition of the Canadian Medical Association Journal.

The ad leads,

"Can't remember the last Coca-Cola ad targeted at children? There's a reason"

Reading the paragraph below,

"Parents tell us they prefer to be the ones teaching their children about beverage choices. That's why for over 50 years we've adhered to a company policy that prohibits advertising soft drinks to children."

Then they go on to brag about their voluntary efforts,

"And as a founding member of Canadian Children's Food and Beverage Advertising Initiative, we'vre recetnly extended this policy to include all forms of media, including broadcast, print, the web and beyond."

So what's my issue?

Well I can remember boatloads of Coca-Cola advertisements targeting children. From the famous Mean Joe Green football jersey commercial, to Santa Claus, little stuffed vending machine animals, animated polar bears, video games and recording and sports idols.

Thankfully, youtube remembers them as well and a smattering of them are posted down below (email subscribers, you'll have to actually visit the blog by clicking here as embedded videos don't make it into the email).

Visiting the Coca-Cola company's website you'll find that there's a lot of small print attached to their pledge but basically it comes down to this - it only applies to programming that is specifically geared towards children under the age of 12. I suppose that means targeting children during any family friendly shows (American/Canadian Idol, sports, some prime time stuff) is fair game and I suppose it also means Coca-Cola thinks your 12 year old is an adult.

What a beautiful example of how Big Food sponsored voluntary "regulation" through grandiose sounding endeavours such as the "Canadian Children's Food and Beverage Advertising Initiative" aren't worth the paper they're written on.

[Originally posted July 23rd, 2008]

MEAN JOE GREEN

SANTA CLAUS

CHRISTMAS (Entire commercial with 12 year olds)

STUFFED VENDING MACHINE ANIMALS

POLAR BEARS

NEW KIDS ON THE BLOCK

CHRISTINA AGUILERA

MICHAEL JORDAN

YAO MING & LeBRON JAMES

GRAND THEFT AUTO (Videogame)