Saturday Stories: Dietary Guidelines, “Vaccine Injury”, and “Chronic Lyme”

Kevin Bass, in his blog Nutritional Revolution, with the data driven case on how you can’t blame people following dietary guidelines for a country’s obesity rates.

James Hamblin, in The Atlantic, on the truth behind vaccine injury compensation.

Abby Hartman, in It’s Training Cats and Dogs, with her first person account on walking to, and then away from, treatment for “chronic lyme disease”.

Pic By Alan R WalkerOwn work, CC BY-SA 3.0, Link

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2018 European Obesity Day – Tackling Obesity Together

This week I am in Dublin for the 7th Conference of the Association for the Study of Obesity on the Island of Ireland (asoi), which co-incides with the 2018 European Obesity Day (Saturday, May 18). As any “day”, the aim of the Obesity Day is to draw attention to and foster discussions about obesity, its causes, and possible solutions. The accompanying website provides links to a number of interesting and helpful resources, including Obesity Facts, messages to Policy Makers, Patient Perspectives, Addressing Obesity Stigma, and Patient and Expert videos. How much these activities change the narrative and actions on obesity remain to be seen, but no doubt, any initiative that promotes greater awareness and discussion of the science of obesity is much appreciated. @DrSharmaDublin, Ireland

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Rural Areas Drive Global Obesity

To anyone working in obesity, it is no secret that obesity is now far more common in rural (and suburban) areas (at least in industrialised countries) than in big cities. This may appear counterintuitive, as access to food services is much greater and easier in cities than in rural areas. In contrast, there is a wide-spread assumption that people living in rural areas mainly consume produce from their own farms and gardens, and have less access to ultra-processed and packaged food. Now, a paper by the international NCD Risk Factor Collaboration, published in Nature, shows that rural obesity, even in many low- and middle-income countries (LMICs), is rising much faster than in urban populations. The study collates 2,009 population-based studies, with measurements of height and weight in more than 112 million adults, to report national, regional and global trends in mean BMI segregated by place of residence (a rural or urban area) from 1985 to 2017.  The data shows that, with the exception of women in sub-Saharan Africa, more than 55% of the global rise in mean BMI from 1985 to 2017—and more than 80% in some low- and middle-income regions—was due to increases in BMI in rural areas. Thus, “these trends have in turn resulted in a closing—and in some countries reversal—of the gap in BMI between urban and rural areas in low- and middle-income countries, especially for women. In high-income and industrialized countries, we noted a persistently higher rural BMI, especially for women.”  The authors attribute this trend to the urbanisation of rural life, which includes not only the decreased need for physical labour thanks to agricultural mechanisation, dependence on cars, rising income, and the increased availability and consumption of highly processed calorie-dense foods. In contrast, “The lower urban BMI in high-income and industrialized countries reflects a growing rural economic and social disadvantage, including lower education and income, lower availability and higher price of healthy and fresh foods, less access to, and use of, public transport and walking than in cities, and limited availability of facilities for sports and recreational activity, which account for a significant share of overall physical activity in high-income and industrialized countries.“ Clearly, this alarming trend poses new challenges for public health initiatives to curb the obesity epidemic, which have thus far largely (albeit with little effect), focussed on urban populations. Although not discussed in the paper, this trend also poses new challenges for the health care system, which… Read More »

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Obesity And Perinatal Care

Last week, I had the pleasure of sitting on the thesis defence committees of two extraordinarily dedicated young trainees, currently completing their medical residencies in obstetrics and gynaecology. Both theses focussed on issues related to obesity within the obstetric community as well as the implications of obesity for the care of women during the gestational period and during delivery (more on these theses in coming posts). For those interested in this topic, I would like to draw your attention to a short review paper by Cecilia Jevitt, Chair of the Midwifery Program at the University of British Columbia, published in the Journal of Perinatal and Neonatal Nursing. Although the paper focusses on the social determinants of health that underly a substantial proportion of the risk for developing obesity (these include socio-economic disparities in employment, education, healthcare access, food quality, and availability), the paper also looks at many of the environment and biological factors that may promote obesity including environmental toxins, epigentics, and the microbiota. As for the impacts of excess body fat on pregnancy, Levitt lists over 30 conditions that can affect the pregnancy, delivery, and the post-partum period, threathening the health of mother and child, which are far more common in women with obesity. This is not to say that many of these problems can not also be encountered in the care of women without obesity, however, excess body weight makes these conditions far more likely and often much more difficult to manage. As Levitt points out, reducing the risk for obesity in the first place would need comprehensive changes at the policy level that not only address issues related to food and activity but also the socio-economic and other social determinants of health that disproportionately affect women of lower socio-economic status. As currently, no such policies are in sight, those charged with the care of women of childbearing age will continue having to watch for and deal with the increased risk for adverse outcomes in women with excess weight – a challenge that is only slowly (as evidenced by the theses mentioned above) coming to the centre of attention of obstetric health professionals. On the positive side, Levitt reminds us that, “Although obesity places women at risk for numerous morbidities, most women with obese BMIs [sic] complete pregnancy and birth without complications.” Improved training of health professionals in the care of women with obesity can no doubt further… Read More »

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Ethical Dilemmas in Obesity Prevention and Management

Later this week, I have been invited to present the opening address at the 7th Annual Meeting of the Association for the Study of Obesity on the Island of Ireland in Dublin. The topic I was asked to speak about, concerns some of the ethical dilemmas we face in trying to address the prevention and management of obesity. The following is the abstract of my presentation, which will hopefully stimulate some interesting discussion on this important issue: Obesity is highly stigmatised and people living with obesity face bias and discrimination in virtually all societal settings including education, professional life, and even health care. Although obesity is now increasingly recognised as a complex chronic disease (not unlike hypertension or type 2 diabetes), both the public health and clinical approaches to obesity prevention and management embrace a rather simplistic narrative of “eat-less-move-more”, which fails to fully acknowledge that complex interaction between environmental and neurobiological mechanisms play a large role in determining body shape and size, much of which is beyond the control of the individual. Thus, there is currently no proven public health approach to reducing obesity in a population, nor does diet and exercise help sustain long-term weight loss in the vast majority of people living with obesity. Despite an abundance of weight loss attempts and a diversity of diets and weight-loss programs, sustained weight loss over years remains the exception – for most people, weight regain (relapse) is just a matter or time.  This is in contrast to medical or surgical treatments of obesity, which have proven to be far superior to behavioural interventions alone in sustaining long-term weight loss. Given that obesity now affects almost one in four adults in most Western countries, health administrators face important dilemmas regarding how to best provide access to effective treatments to the millions of people living with this chronic disease. In this regard, learning from other chronic diseases like type 2 diabetes can be helpful and will be discussed. @DrSharmaBerlin, Germany

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Calling People Successfully Maintaining Long Term Weight Loss “Unicorns” Is Dehumanizing, Unhelpful, And Misleading (And No, 95% Of Weight Loss Efforts Don’t Fail)

A few weeks ago I tweeted about a patient of mine who is maintaining a 19% weight loss for 2 years, and who attributes her success to keeping a food diary and tracking calories, as well as to including protein with every meal and snack.

The point of my tweet was a simple pushback to those who want to claim that calories don’t count or that counting can’t help (like The Economist for instance whose recent article entitled Death of the calorie was the main reason I bothered to tweet), and those who claim that the only way to lose weight is their way (these days that’s usually either #keto or #lchf).

A great many folks weighed in with their success stories, and some pointed to the National Weight Control Registry (where their over 10,000 registrants have kept off an average of 70lbs for 5.5 years). Others though weren’t having it.

Instead they asserted that 95% of diets fail, that the weight loss industry was predatory (much of it is, no argument there), and called people who have succeeded “unicorns“.

Unicorns. Not people. Mythical creatures.

And the implication of course is clear. Sustained weight loss is impossible. Those who succeed aren’t human, or to succeed they employ superhuman efforts, sometimes even described as disordered eating and/or that those who succeed must be miserable. Consequently, trying is futile and those offering help (like me, as to be clear I am the medical director of a behavioural weight management centre) are unethical and are motivated by greed (despite the obvious irony that those championing explicitly non-weight loss programs are targeting the very same population of people and regularly charge a great deal of money for their services).

But boy, there sure are a heck of a lot of unicorns roaming around for something that supposedly fails 95% of the time. Putting aside the anecdotal facts that we all know people who have maintained weight losses, as well as my own office based experiences, this 2010 systematic review found that one year later 30% of participants had a weight loss ≥10%, 25% between 5% and 9.9%, and 40% ≤4.9%. In the LOOK AHEAD study, 8 years later, 50.3% of the intensive lifestyle intervention group and 35.7% of the usual care group were maintaining losses of ≥5%, while 26.9% of the intensive group and 17.2% of the usual care group were maintaining losses of ≥10%. Here’s the DIRECT trial where mean weight loss at 2 years was 7.5% with 24% of participants maintaining losses greater than 22lbs. And in the recent year long DIETFITS study the average weight loss of all participants was 5%, with over 25% of participants losing more than 10% of their weights.

The waterfall plots of the DIETFITS data

(And for an interesting thought experiment, have a peek at this thread from Kevin Bass that argues that even if the 95% failure number were true, those outcomes would be worlds better than the vast majority of medical treatments currently being offered for other chronic diseases)

So where does this 95% number come from? Certainly I could imagine it to be true if the goalpost for successful weight loss was total weight loss and reaching a so-called “healthy” or “normal” BMI. But that would be as useful a goalpost as qualifying for the Boston Marathon would be for running whereby the vast majority of marathoners won’t ever run fast enough to qualify to run Boston. Does that mean non-qualifiers should be discouraged from running and told that running is impossible? It’s also important to contextualize failures. If the methods being undertaken to lose weight are misery inducing overly restrictive diets, it’s not people who are failing to sustain them, it’s that their diets are failing to help them (which, with full disclosure, is the premise of my book The Diet Fix).

As far as what needs championing, it’s certainly not failure. Given the medical benefits of weight loss, as well as the real impact weight often has on quality of life (especially at its extremes), what we need to collectively champion are the embrace of a plurality of treatments (including ethical behavioural and surgical weight management programs and greater access to them), along with more effective medications. What can simultaneously be championed is the removal of blame from the discussion of weight, fighting weight bias and stigma, recognizing that a person need not have a so-called “healthy” or “normal” BMI, that scales don’t measure the presence or absence of health nor measure lifestyles, respecting people rights to have zero interest in losing weight or changing their lifestyles, that there is value to changing behaviours around food and fitness regardless of whether weight is lost as a consequence, and acknowledging that intentionally changing lifestyle in the name of health reflects a tremendous degree of privilege that many people simply don’t possess.

Given the evidence maybe we can stop with the unhelpful, dehumanizing, and misleading unicorn talk, and while we’re at it, stop telling everyone that failure is a foregone conclusion.

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Does A New Canadian Study on Cancer Inadvertently Make a Strong Case For Treating Obesity?

Last week, a series of papers by a pan-Canadian team of cancer researchers, published in Preventive Medicine, looks at the current and future burden of more than 30 different cancer types due to more than 20 different modifiable cancer risk factors. Not surprisingly, the ComPARe study shows that currently the top five leading preventable causes of cancer in Canada are smoking tobacco, followed by physical inactivity, excess weight, low fruit, and sun – factors that have long been implicated in the development of a wide range of cancers. According to the researchers, overweight and obesity now rank just behind smoking as a key driver of cancer risk. Obviously, this makes a strong case for increasing efforts at obesity prevention – the caveat being that thus far, no society has yet figured out exactly how this can be effectively achieved at a population level. While, for obvious reasons, the papers focus on preventative approaches to reduce the burden of cancer, there is little mention of the potential benefits in terms of cancer prevention that could come from offering more effective obesity management to the 8,000,000 Canadians are already living with this chronic disease, who are unlikely to substantially benefit from population strategies to prevent obesity. Fortunately, there is now a growing body of evidence showing that effective obesity treatment, including bariatric surgery, can substantially reduce cancer risk in people living with obesity. Thus, if anything, these data provide even more reason to get serious about treating obesity (not just hoping that it will somehow disappear if we just keep talking about prevention). Obviously, even without effective obesity treatments, Canadians living with obesity (like everyone else) will likely benefit from smoking cessation, reducing sedentariness, and increasing their fruit and vegetable consumption (most of them already stay out of the sun). However, effective obesity management aimed at both preventing further weight gain as well as reducing excess body weight (in a sustainable manner) will potentially have even greater benefits in this population. Unfortunately, as evidenced in the recent 2019 Obesity Canada Report Card on Access to Obesity Treatments, the vast majority of Canadians have little, if any access to obesity treatments within their health care systems – this needs to change if we are to not only reduce the burden of cancers but also of obesity related cardiometabolic disease, arthritis, sleep apnea, and a host of other medical complications. While we wait for… Read More »

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Saturday Stories: Assisted Death, Insulin Pumps, And Supplements

Kathleen Venema, in The Globe and Mail, on her mother and why we need to change the rules surrounding assisted death for those with dementia.

Sarah Zhang, in The Atlantic, on why there’s an underground market for old insulin pumps.

Markham Heid, in Medium, on how the evidence against the regular use of supplements is stronger than ever (happy to find this story for reader Pug Piper).

[And if you don’t follow me on Twitter or Facebook, here’s my first column for Medscape on what scales do and don’t measure and why that matters]

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What’s The Point of Tracking Your Calories With a Food Logging App?

First up, the quantity and quality of calories matter both to health and to weight. You can’t gain without a surplus. You can’t lose without a deficit. And the quality of the calories you’re consuming will affect health and satiety which in turn will affect the quantity of them that you consume. Moreover, the bioavailable calories you consume will differ by food, and also likely differs by individual (which is why some gain and lose with more ease than others).

Next up, we’re crappy food historians. We may forget portions, choices, or both, not all the time, but certainly some of the time. We can’t possibly know what’s in meals we haven’t cooked ourselves. And even if we are cooking ourselves, most aren’t going to be weighing and measuring everything and eyes are terrible at both.

And a recent study confirms some of the above whereby researchers looking at users of myfitnesspal found the average user was missing nearly a meal’s worth of calories a day (445). Yet studies on food diary use pretty much invariably report they markedly benefit weight loss efforts.

Personally, though I think having some rough inaccurate sense of caloric intake is valuable (if you were in a foreign country and didn’t know the exchange rate, price tags would still be somewhat helpful), more valuable is the use of the food diary to remind yourself that you’re trying to eat thoughtfully and likely differently.

Human nature being what it is, without a system designed to consciously remind you to change your usual default behaviours, you’re likely to drift back to those behaviours, healthy or not, and a food diary, even if inaccurate, if kept in real-time, will remind you many times a day that you’re trying to change.

So long as you’re not using your food diary as a tool of judgment, as it’s not meant to be there to make you feel badly about your choices, chances are it’ll be of benefit, and likely it’ll be of benefit regardless of what it is you’re tracking (calories, macros, carbs, whatever) and even if inaccurate, because it’s primary job is to serve you as your constant change reminder service, not as your judge and jury.

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Saturday Stories: Holocaust Memorial Day, Ponway, And Synagogue Metal Detectors

Lori Gilbert-Kaye, may her memory be a blessing, murdered for being Jewish

A few days ago it was Holocaust Memorial Day, the day we commemorate the murder of 1 out of every 3 living Jews on earth prior to World War II. A week ago saw another murder for the crime of being Jewish, this time in California. Before that it was Pittsburgh. Though there’s not much I can do about any of this, at least I can call your attention to these three pieces that try to weave it all together

Daniella Greenbaum Davis, in The Spectator, on antisemitism’s new normal.

Rabbi Yisroel Goldstein, in The New York Times, on how being almost killed by a terrorist last week has affected his resolve.

Carly Pidlis, in Tablet Magazine, on how Jews can no longer simply consider themselves safe in America.

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