Should Statistically Significant But Clinically Meaningless Outcomes Still Be Reported As Significant?

Rather than call out the specific paper that led to this blog post (I also don’t want to add to its Altmetrics), just a question.

If your systematic review findings demonstrate that a particular supplement/food/diet led to an average total weight loss of 0.7lbs is it appropriate to describe that effect as significant even if statistically you believe you’re able to make that claim?

Personally, I don’t think so.

Especially not when we’re discussing food, because as Kevin Klatt recently pointed out on his blog, there are no food placebos. and as John Ionnidis pointed out, we eat thousands of chemicals in millions of different daily combinations which markedly challenges our ability to conclusively opine about the impact of any one food.

Worse though, is the fact that the media (both traditional and social), won’t bother to qualify their enthusiasm when describing these findings and instead will report them as beneficial, significant, and important, as of course will PubMed warriors.

So how to fix this? Perhaps including a qualifying, “but not likely to have any clinical relevance” statement in the abstract might lead to more balanced media coverage (or less media coverage ) which in turn would be less likely to report significant but clinically meaningless outcomes as important, which ultimately would be good for science and scientific literacy.

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EOSS Assesses More Than Just Cardiometablic Risk

Readers of these pages will be quite familiar with the Edmonton Obesity Staging System (EOSS) that is increasingly used in clinical practice to stratify patients presenting with overweight or obesity in terms of actual health status (rather than just BMI). Previous studies have shown that EOSS is a far better predictor of cardiovascular and overall mortality than BMI or waist circumference. However, its performance compared to other measures of cardiometabolic risk is not known. Now, a study by Keisuke Ejima and colleagues, published in Obesity, compares the predictive value for mortality and years of life lost between EOSS and Cardiometabolic Disease Staging (CMDS) in NHANES. Whereas CMDS is scored based on the the presence of cardiometabolic risk factors, EOSS is scored on a much broader range of parameters including mental, medical, and functional health. In their analyses, both CMDS and EOSS consistently identified individuals at higher mortality risk. Thus, the median years of life lost for EOSS scores 2 and 3 (low to high risk) for a reference person were 1.19 and 6.76 years. Those for CMDS scores 1, 2, 3, and 4 (low to high risk) were 1.53, 2.90, 3.91, and 8.51 years.  In their interpretation of these findings, the authors discuss that CMDS may have greater clinical utility not only because it appears to have better discriminatory power but also uses fewer items to risk stratify. To me the findings are not surprising and if all you are interested in is mortality, then clearly all you need to calculate is CMDS – which was specifically designed and validated to assess cardiometbolic risk. However, in clinical practice, mortality is only one of the parameters of interest. Many may argue that other parameters including mental health, chronic pain, or even just quality of life may be as, if not more important to patients, than whether or not they live a couple of years longer or not. Thus, clinical decisions around treatments need to take more into account than just cardiometabolic risk. It is for this very reason that EOSS was conceptualised as a much broader assessment of health than just cardiometabolic risk. Thus, it may well be that both staging systems may find their place in clinical practice – CMDS for clinicians and patients who prefer a narrower focus on mortality risk and life expectancy, EOSS for clinicians and patients who prefer to consider a broader definition of health that… Read More »

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Saturday Stories: Black Medical Academics, Brittany Ran A Marathon, And Body Positivity

Uché Blackstock, in STAT, on why black academic physicians like her are leaving their positions.

Sam Brennan, in Fit Is a Feminist Issue, on how she watched Brittany Runs a Marathon so you don’t have to.

Virginia Sole-Smith, in Elemental, asks whether the fitness industry and body positivity can co-exist?

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Product Reformulation Means Sugar Taxes Work Even If People Don’t Buy Less As A Consequence

Taxes work to decrease purchasing, and the higher the tax, the greater their impact. Period.

Which is why it’s always struck me as odd when people question whether or not sugar-sweetened beverage (SSB) taxes would affect SSB purchases (and consequently consumption).

But let’s leave that odd debate aside for a moment. If the goal of SSB taxes is to decrease added sugar consumption (which it explicitly is, while it is explicitly not about weight loss as societal obesity is not singularly caused by SSB consumption, and decreasing SSB consumption is healthy at every weight), it would appear that SSB taxes will decrease sugar consumption even if they don’t decrease purchasing.

How?

Because when SSB taxes are enacted, the beverage industry reformulates its products.

And at least according to this bulletin from the World Health Organization, they do so not insignificantly!

Of the 83 products they surveyed in both 2014 (before the UK’s SSB tax) and in 2018 (after the UK’s SSB tax), the mean sugar content decreased by 42% (from 9.1 g/100mL to 5.3 g/100mL) while the mean energy content decreased by 40% (from 38 kcal/100mL to 23 kcal/100mL). Putting this into the context of a standard 355ml can – that would represent 2.45 fewer teaspoons of sugar and 53 fewer calories per can.

And this was in response to a fairly nominal tax. Presumably larger taxes would drive larger (or more expansive) reformulations which of course would also be coupled with decreased purchasing as has been shown to not at all surprisingly occur where enacted.

All this to say, this is yet another reason why if you’re living somewhere without an SSB tax, my bet is that it’s a matter of when, not if, you will be.

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Saturday Stories: Larry David, Elizabeth Wurtzel, And The Ebola Vaccine

Brett Martin, in GQ, profiles the inimitable Larry David

Elizabeth Wurtzel, in Medium, discussing her life’s final year

Helen Branswell, in STAT, with the story of how scientists on 3 continents together produced an Ebola vaccine

Photo of Elizabeth Wurtzel by Blonde1967; this photo was taken with an iPhone SE by my mother, Lynne Winters – Own work, CC BY-SA 4.0, Link

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Canadian Donut Chain Launches Donut Flavoured Cereal And People Are Angry. Why I Think There Are Better Things (And Worse Cereals) To Be Angry About.

So last week saw the Canadian launch of timbits cereal and as evidenced by the number of people have sent press releases about it to me, not everyone is pleased.

Timbits, for readers who don’t know, are donut holes from Canadian donut chain giant Tim Hortons.

People are upset because apparently this sugary cereal is over the top and somehow extra wrong or extra awful.

But why?

Tim Horton’s certainly isn’t in the business of protecting or promoting public health. Nor is Post Foods. Nor should anyone expect either to be.

Presumably the sugar is a concern for people, and at 17g per cup (4.25 teaspoons), it’s definitely not an insignificant amount, but it’s not more than many other sugary cereals, and is in fact less than Post Raisin Bran which packs 24% more sugar at 21g (5.25 teaspoons) per cup.

All this to say, it’s difficult to get angry with Tim Horton’s or Post Foods for trying to sell food as selling food is literally their only job, and frankly this food isn’t any worse than comparable foods they’re already selling.

So what should the cereal aisle make people angry about?

How about laxity in advertising laws that allows for cartoon characters to be festooned on boxes of sugary cereals and prey on children? Or laxity in front-of-packaging laws that allow Froot Loops boxes to brag about their whole grain or vitamin D content? Or the failure of our government to create a front-of-package warning system like the one that was enacted in Chile.

What would life in Canadian cereal aisles look like if we followed Chile’s lead?

Here’s Frosted Flakes before and after Chile’s laws came into effect

Sure looks great to me.

(And for the grammar police, ‘donut’ is how Tim Hortons spells doughnut)

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How Much Do You Like Your Diet? Given Adherence Likely Dependent On Enjoyment, Our Recent Paper Set Out To Quantify That

Back in 2012, I wondered aloud about creating a scoring system for dietary enjoyment. I blogged about it a few times here and there, and happily, a wonderful team of researchers in New Zealand took notice. Now, thanks to the hard work of Michelle Jospe, along with Jillian Haszsard, and Rachel Taylor, the first step towards its formal use has been taken.

Our paper, A tool for assessing the satisfaction of a diet: Development and preliminary validation of the Diet Satisfaction Score, was published late last year and it details our Diet Satisfaction Score’s preliminary reliability and validity.

With the help of the 1,604 people (spanning 24 different countries!) who answered our survey questions, as well as 6 diverse experts (thanks to Melanie Dubyk, Kevin Hall, Scott Kahan, Silke Morrison, Marion Nestle, Sherry Pagoto, Arya Sharma and Ethan Weiss), we arrived on the following questions geared to address various aspects of dietary adherence and satisfaction

The simplest way to think of the Diet Satisfaction Score’s use is the higher the overall score (each question is answered on a 5 point Likert scale and the final DSS score is calculated by way of taking the mean of all available items yielding a total score between 1 and 5), the greater an individual’s satisfaction/enjoyment of that diet is. The hypothesis then would be higher scores correlating with better adherence and consequently better/sustained weight loss.

And that’s what our preliminary findings suggest whereby each 1-point higher Diet Satisfaction Score correlated with a 1.7 week longer diet duration. It was also found that compared with those who had abandoned their diets, those maintaining them reported larger losses.

The value of a simple and quick score like this to individuals would be as a means to assess how much (or how little) they were enjoying their diets taking into account more than just whether they like the foods they’re eating, but also the impact their chosen diet might be having on related aspects of life (socializing, time, cost, etc.). Those evaluating their new diets and finding their scores low, might explore means to tweak their diets, or to try new ones.

The DSS score’s value to clinicians would be as a quick means to screen their patients’ efforts and perhaps to use the tool to help trouble shoot, or to triage referrals to professional resources such as registered dietitians.

The value of the DSS score to researchers would be using this tool with shorter term studies as a means to predict whether or not their studied diets are likely to be sustainable (as who really cares how much weight a person might lose on a particular short term diet if few people would actually sustain it).

Of course now what’s required is the repeated use of the Diet Satisfaction score in a long-term prospective trial. The good news is that because the tool, like me, is diet agnostic, it can be administered with any and all dietary strategies. Should you be interested in using the Diet Satisfaction Score in your trial Dr. Jospe is the person to contact and her contact information is just this one click away.

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Saturday Stories: Suleimani, Left And Right Antisemitism, And Home Cooking Challenges

Dexter Filkins, in The New Yorker, with the definitive piece on who was Qassem Suleimani

Isaac Chotiner, also in The New Yorker, on the rise in antisemitism from both the left and the right.

Amanda Mull, in The Atlantic, on how modern life gets in the way of our home cooked best intentions

[And if you don’t follow me on Twitter or Facebook, My first byline for the New York Times is a balm for aggressive New Year’s resolutions, nutrivangelistic diet gurus, magic food stories, and all other forms of healthy living hyperbole]

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Teachers, Stop Teaching Kids To Reward Anything and Everything With Junk Food And Candy!

As has been my tradition, in December I repost old favourites from years gone by. This year am looking back to 2016.

The past 50 years of so have seen scads of unhealthy societal changes to how we use food, and near the top of that heap lies our now normalized use of junk food to reward, pacify, and entertain our children at every turn.

Take the jelly bean prayer up above. That was sent home with RD Nadine Devine‘s Junior Kindergartener in honour of Easter.

WWJD? Not that.

Or this needs-to-be-seen-to-be-believed note that was sent home with another friend’s 5 year old.

I imagine that the teachers responsible for those two examples don’t see either as unwise as why question normal behaviours? If everyone does them, they must be ok.

Yet I’d wager that if those same two Kindergarten teachers reflected on the lesson their use of classroom junk food is teaching their incredibly impressionable, young, students, they would recognize that teaching incredibly young children that it is normal to reward even the smallest of victories or celebrations with junk food is not in their students’ best interests.

Teachers, if you’re reading this, so far as rewarding kids go, it’s not difficult to do so without candy. Extra-recess, dressing your teacher up in funny clothing, being in charge of school announcements, a classroom dance party, have a class outside, hand out “no-homework” passes, stickers, bookmarks, etc…

I know that teachers care deeply about their students, which is why I genuinely believe that putting an end to junk-food classroom rewards is something that society, and teachers, can fix.

[And for some suggestions as to how you might begin to approach this with one your children’s teachers, coaches, whatever, here’s something I wrote a few years ago about shutting down your children’s sugar pushers]

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It’s More Important To Teach Your Kids to Cook Than to Play Soccer


Photo courtesy of yoshiyasu nishikawa 

As has been my tradition, in December I repost old favourites from years gone by. This year am looking back to 2016.

Yes, I know there will be people whose challenges and circumstances are real and severe enough that they genuinely can’t ensure their kids learn how to cook before leaving home. This post isn’t for them. This post is for everyone else.

For the first time in history the average American family is spending more money in restaurants than they are in grocery stores.

Kids are leaving home now knowing more about how to play soccer or hockey than they do about how to cook meals from fresh whole ingredients.

That’s so incredibly unfortunate, not only for those kids, but for their future families.

Cooking is a life skill and it’s a parents job to teach those before they leave home. If you aren’t comfortable with cooking yourself, take the opportunity to learn with your kids. Your kids learning how to cook will serve not only to help them in providing themselves and their futures with healthful meals, but will also save them money during their lean years and will likely reduce their risk of developing a myriad of diet-related, chronic, non-communicable diseases.

Whether by way of the ridiculous amount of online recipes and resources, or enrolling in a cooking course or supper club, cooking, like any skill, is obtained by way of practice. It doesn’t matter if you’re not good at cooking now. Take the time, and there’s no doubt you’ll get there.

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