Guest Post: Lifetime Peak Weight and the Risks of Obesity

Today's guest post comes from Dr. Andrew Stokes. Stokes' research interests centre around the question of whether or not the data around obesity is in fact all wrong - could excess weight in fact be healthful and protective? Certainly there are those who think so and while I readily agree that when it comes to individuals scales can't measure the presence or absence of health and that healthful lifestyles markedly mitigate the risks associated with weight, Stokes thinks he may understand why it is that there's debate when it comes to populations and the data sometimes referred to as the "obesity paradox". I reached out to Andrew last week and asked if he might be interested in sharing some thoughts here.

The effects of obesity on mortality—what can we learn from weight histories?

The New Year in 2013 began with release of a major study on the health risks of obesity. For a nation grappling with rising levels of obesity, the news was comforting. The data suggested that people with overweight could expect to live longer. The results also indicated that having slight obesity conferred no excess risk of death. The results were picked up by many major news outlets, was discussed in op-eds, and on social media and sparked livid reactions from critics. The influence of the study was tremendous, which was not surprising. It was the largest study ever carried out on the subject—summarizing data on close to 3 million individuals from 97 studies. Unfortunately, the debate quickly grew acrimonious. In a rare step, Nature issued a reprimand and urged the scientific community to accept the fact that obesity’s relationship with health might be less clear cut than imagined.

But is it? This is the question I set out to answer. It seemed a futile pursuit in the face of such a large and impressive study. But a part of me wondered whether the meta-analysis just reflected systematic bias in the underlying studies.

The very first step I took was to try to replicate an earlier study by Katherine Flegal and colleagues that came to much the same conclusions as the meta-analysis. The earlier paper was based on data from the National Health and Nutrition Examination Survey (NHANES), considered the gold standard survey for monitoring the health of the American population.

The most common critique of that study, which emerged again after the 2013 meta-analysis, was that the results—a protective effect of overweight, no increased risk of mild obesity—reflected confounding by illness or reverse causality. The idea is that being slim may appear risky if some people in the sample are slim because of an illness that caused them to lose weight.

A lot of studies have tried to address this bias, but none of the approaches used have proven satisfactory. One common strategy has been to try to isolate a healthy subset of the sample by excluding people with known or suspected illnesses, people who lost weight or people in poor self-rated health. However, this approach can introduce its own biases and has been criticized for excluding large fractions of people in the sample, calling into question the generalizability of the results.

It was clear to me that to improve upon the work by Flegal and colleagues I would need to get to the heart of the reverse causality matter and find a way to address it. So what could I do differently?

The solution turned out to be really simple. Studies of obesity and mortality were almost all based on weight at a single point in time. But many people gain or lose weight during their lifetimes, especially in times of illness. I needed to find a way to incorporate weight histories.

Incorporating histories is common practice in studies on smoking. In that literature, the non-smoking population is almost always separated into never-smokers and those who smoked in the past and quit. If you didn’t separate out these two groups, you’d likely reach the conclusion that smoking is not all that harmful—it might even appear protective. But that’s only because the low risks of the never-smokers are being masked by the much higher risk of the former smokers, many of whom smoked throughout their lives.

Surprisingly, this distinction, which is clearly essential for obtaining accurate estimates of the effects of smoking on mortality, is rarely made in the obesity literature. Studies almost always lump together individuals who have never had obesity, with individuals who no longer had obesity (but once did), despite the fact that these two groups may have very different mortality risks. If it were only possible to disentangle these two groups, we might be able to obtain better estimates of the effects of obesity on mortality that are not affected by reverse causality.

So after replicating the basic approach used by Flegal and colleagues, I took the next step of incorporating weight histories to determine what people weighed over the course of their lifetime. This was enabled by a question in the survey asking subjects to recall their lifetime maximum weight.

I used this information to separate the normal weight category into two groups: those who always maintained normal weight versus those who formerly had overweight or obesity and then lost weight. I found that mortality risks in the latter group were much higher than the risks in the former group. I demonstrated that combining these two groups raises the mortality rate in the normal weight category and obscures the low risks of those who maintained normal weight throughout life. Finally, I showed that when the normal weight category is redefined to only include the always normal weight individuals, the association between excess weight and mortality strengthens dramatically. These results were published last year in Population Health Metrics.

My findings thus suggest that weight histories are an essential piece of the puzzle for understanding obesity’s effects, just as former smoking status is important in the study of the effects of smoking on mortality. Failure to take weight histories into account has likely caused widespread bias in the literature, with the effect of obscuring obesity’s true toll.

Andrew Stokes is an Assistant Professor in the Department of Global Health at Boston University. His research is focused on the causes and consequences of the global obesity epidemic and developing novel approaches to combating obesity at the population level through interventions that target aspects of the social and physical environment. You can also follow him on Twitter.

Saturday Stories: Not Broken Science, First Nations, and Bingo

Christie Aschwanden in Five Thirty Eight Science with a phenomenal piece on how science isn't broken.

Gloria Galloway in The Globe and Mail with a heartbreaking piece on Canada's First Nations' health care failings.

Daniel Goldberg in the British Medical Journal presents his fabulous game of conflict of interest bingo.

American Kids Try Global School Lunches

Today's Funny Friday involves a bunch of kids trying a bunch of different typical school meals from around the globe. Worth watching even if just to see what's being served.

Have a great weekend!

Jersey Colour May Trump Need for Food Industry Sport Sponsorship

Never forget that the food industry's purchase of youth sport is about marketing and branding opportunities.

By way of example today I'll be discussing Mac's Convenience Stores' "Froster Active Kids" program.

First, for those who aren't aware, Frosters are Mac's Convenience Stores' answer to Slurpees.

Mac's conveniently spell out the requirements of teams who seek their sponsorship - among them:

• The sports team must agree to send pictures of jerseys, events, etc that can be used to post on our social media pages. Please note that a Photo Release form must be signed by each parent and returned to FrosterActiveKids@macs.ca before funds can be released.
• Where applicable: Sports team must disclose the expected number of audience for the events/tournaments. Froster Active Kids Program branding must be present at the event through team jerseys and potentially a banner.
• Mac’s and Froster Active Kids Program branding must be presented on the team or the association’s social media, web pages and other branding opportunities.
• Sampling opportunities for Mac’s will also be reviewed where applicable.

And then they get a great deal more specific in the application. What struck me from the application, is while there are plenty of questions about the sponsorship opportunities that would be afforded to Mac's, and of the aesthetic fit with Mac's logo, there were no questions, none, to help flesh out the deservedness or financial needs of the team.

Froster Active Kids Logo Exposure:

• When does the season start and end? Click here to enter text.
• How many jerseys will the logo appear on?: Click here to enter text.
• Will the logo appear in colour or black and white? (colour preferred): Click here to enter text.
• Will the logo appear on the home and away jersey, please clarify if only one: Click here to enter text.
• What is the colour(s) of the jersey?: Click here to enter text.
• Where will placement of the logo appear?: Click here to enter text.
• What other logos will appear on the Jersey (including other corporate sponsor logos): Click here to enter text.
• Can you send a team jersey to Mac’s with the number “15”? Click here to enter text.
• Is there a team banner that Froster Active Kids will receive logo exposure on? Click here to enter text.
• Additional opportunities for logo exposure i.e. hats, jackets, bags: Click here to enter text.
• Will the Froster Active Kids logo appear on the webpage and the social media page? If so, please provide the link to both: Click here to enter text.
• Will you be sending a team picture of the members wearing the jersey? Click here to enter text.
• Is there an opportunity for Mac’s to provide coupons (i.e. BOGO Froster, Free Froster)?: Click here to enter text.
• Is there an opportunity for Mac’s to come out to a tournament with a banner and sampling/coupons? If so, please describe: Click here to enter text.
• Additional marketing opportunities: Click here to enter text.

While other programs may provide lip service to altruism, it's refreshing to see Mac's Convenience Stores boldly tell us that it's not about us, it's about them.

And how much are these sponsorships worth? A few hundred dollars? A few thousand? Would it really be impossible to raise these funds in other ways - ways that might also teach the kids important lessons? My three girls went door to door selling flower bulbs for their school this year. They raised nearly $250 in an afternoon. I also recently came across a group of kids sitting outside the local liquor store collecting empties from returning customers so as to collect the bottle deposits for charity. In the few minutes I purposefully spent watching, I didn't see a single person enter the store without donating their bottles to the kids. Back of the envelope calculation has them raising at least $100/hr/store of sitting there.

Given most teams are between 10 and 20 kids strong, and weekends are two days long and multiple times a month, I struggle with the notion that funds can't be raised without turning kids into walking billboards and providing fast food marketers access to children along with a priceless emotional branding opportunity.

Pepsi Targeting Kids And Promoting Their Own "Energy Balance" Nonsense

And to help hammer their point home, PepsiCo has recruited the NFL's Manning brothers.

It's Gatorade's new "Sweat It To Get It" campaign, and their commercial spot has the football legends literally telling young teenage boys that 2 minutes of sweat buys them a Gatorade.



Regular Gatorade's first ingredient is water. Its second and third ingredients are sugar. 100% of its calories come from sugar. It also contains a tiny bit of sodium, and a tiny bit of potassium.

Most vending machine Gatorade is sold in 20oz bottles.

20oz of Gatorade contains 133 non-sating calories and just shy of 9 teaspoons of sugar.

2 minutes of moderate to high intensity exercise will burn at most 20 calories.

And just in case you're tempted to tell me that the Sweat It to Get It campaign targets university students (because despite the kids in the commercial looking way too young to be in University, the vending machines are to be set up there), you should know that Gatorade also has a comic book series entitled, "The League of Champions" pumping the beverage.

And for more on just how intensely Gatorade markets sugar water to children, have a read of Bettina Siegel's piece on Gatorade's G-Force and their high school infiltration.

Guest Post: Food Policy is not About Sexy Results (by Dan Taber)

Today's guest post if by Dr. Dan Taber. I've been following Dan on Twitter for some time and have always enjoyed what he's had to say. When he recently published a study on school food, I reached out and invited him to write a guest post. He kindly obliged.

Food Policy Is Not About Sexy Results

“Well … there’s good news and bad news.”

It’s not the sexiest opening line when I’m discussing my research. Nobody who wants a simple solution to childhood obesity likes those words. I don’t like them, either, and yet I use them all the time. Food policy is a sexy topic, but food policy research tends to give complicated, unsexy answers.

Food policies are more like young professional athletes – they come with a lot of hype, and thus everyone is eager to label them a “success” or “failure,” but the truth is usually in the middle. My latest study on school nutrition standards provided a perfect example. Furthermore, the study illustrates how any food policy can have the maximum benefit – by knowing what the policy is good at, acknowledging what the policy is not good at, and realizing where complementary policies/sandbags are needed.

In this recent study, I collaborated with researchers from Bridging the Gap, the National Cancer Institute, and the University of North Carolina-Chapel Hill, to dig into the details of how schools adhered to nutrition standards for foods and beverages sold in schools outside of federal school meal programs (a.k.a. ‘competitive foods’). We also dug into whether adherence differed by local area income. Encouragingly, we found that middle schools tended to sell fewer unhealthy items if states had healthier competitive food standards, particularly among schools in low-income areas.

Good news, right?

Sort of. The encouraging results came with a catch, as there was no evidence that schools were offering more healthy foods and beverages instead. Sugar-sweetened beverages were sold less, but they were not necessarily being swapped for clean water.

Why not? Because that is not what competitive food laws do. Competitive food laws are commonly designed to limit sugar, fat, or calorie content of school foods and beverages, but they do not require healthy alternatives.

That’s not a criticism of competitive food laws; it’s simply a limitation. That said, it’s a limitation that can ultimately affect disadvantaged populations. Our study found that low-income schools were substantially less likely to sell healthy alternatives.

If unhealthy items are banned, but healthy alternatives are not provided, there’s a tsunami of unhealthy options waiting for populations that are already at a higher risk for obesity. Low-income areas tend to have more unhealthy options in the community, and as recently reported by the Rudd Center, food/beverage marketing actively targets racial and ethnic minority children.

When disadvantaged communities face the tsunami of unhealthy options outside of school, they are less likely to benefit from any positive changes within school. Last May, a team of researchers in the Bay Area reported that California’s competitive food laws were associated with a decline in obesity, but predominantly in high-income areas. Obesity trends in low-income areas didn’t budge an inch.

As I wrote for Beyond Chron at the time, these results are inevitable if you expect a magical cure to obesity. Any single policy or program can only do what it is designed to do.

Competitive food laws are good at what they do by limiting unhealthy options at school. This may improve weight status in the general population, as I also found in a longitudinal study in 2012. We need to acknowledge, however, that competitive food laws may be less effective in low-income areas.

That is when other policies and programs become more important. The National School Lunch Program in the U.S., for example, is designed to do the exact opposite of competitive food laws – i.e., require healthy items for school meals, particularly to benefit students from low-income households. As a complementary pair, competitive food standards and school meal standards can benefit all children.

Food systems, like any kind of system, work best when different parts enhance each other in this way. Systems do not change when we think that any single part is going to drive change on its own.

My latest study adds to the mountain of evidence that competitive food policies are good at what they do. But, like any policy or program, they can achieve more if we understand their limitations.

Understanding a policy’s strengths and limitations isn’t about declaring the policy to be a “success” or “failure,” the sexy answers we all want. It’s about giving us a roadmap to understand where further action is needed.

Dr. Taber is an Assistant Professor at the University of Texas School of Public Health, where he specializes in childhood obesity policy research and systems science. For years, he has evalauated the impact of policies that are designed to improve diet and physical activity behaviors in children. Multiple studies led by Dr. Taber were cited in the United States Department of Agriculture’s landmark “Smart Snacks” rule for competitive foods. His research has been featured in the New York Times, NPR, CNN, Wall Street Journal, and several other media outlets, and he writes about obesity policy news on his personal blog. You can also find him on Twitter or his website. He also teaches “Systems Thinking in Public Health” at UTSPH. This article represents his personal views; any views or opinions expressed do not represent the University of Texas.

Book Review: Eat Like a Champion (A How To Feed Manual For Active Kids)

Today's guest post is by our office's own Rob Lazzinnaro who will be reviewing Jill Castle's Eat Like a Champion (which she sent me for review).

I work with families on a daily basis who are troubleshooting around how to provide proper sport nutrition for their kids - kids who are often also faced with weight issues. So when I was given the opportunity to review Eat Like a Champion by Registered Dietitian Jill Castle, I jumped on the chance as I'm also a big fan of Jill Castle's previous co-authored book Fearless Feeding: How to Raise Healthy Eaters from High Chair to High School, and currently enjoy following her blog Just The Right Byte.

Jill’s new book, Eat like a Champion, focuses on recommended dietary approaches for young athletes. From high level athletes to gym class, the book is meant to be resource for any child that engages in regular physical activity. The question of what to feed their active kids is one I hear often in my office from parents regarding nutrition around sports, but parents soon learn that it is more complex than just the “what.” In her new book Jill Castle does dedicate a well deserved portion of the book to the “what” but also tackles the difficult food environment for athletes and how paying attention to a multitude of factors around eating can ingrain healthy habits in your young athlete for a life time.

The book is divided into ten chapters:

1. The Growing Athlete Body and Brain
2. The Starting Lineup: Major Nutrients
3. The Second String: Vitamins and Minerals
4. The Relief Pitcher: Fluids and Hydration
5. Game Plan - One, Two, Three Meals
6. Take a Time Out - Top Off with Snacks
7. Foul Play - Supplements and Performance Aids
8. Getting Off the Bench - Healing the Body with Food
9. The Special Diet Dilemma
10. Changing the Youth Sports Nutrition Landscape

And of those, five really stood out for me.

Matching Calories for Growth and Sport

Every person who picks up this book will have a child with different needs and energy requirements - there is no one size fits all when it comes to eating. The key is not to become overly obsessed with these numbers but hopefully use them as rough guidelines to help assess whether you're offering your child too little or too much - peace of mind really. Of course, the parent would have to loosely track the child's intake for 4-5 consecutive days (hopefully w/o the child knowing) to see where they are landing. The author also includes a useful table for changes in calorie requirements depending on the sport played.

Busting the Myth about Carbohydrates

Apologies Paleo adherents and wheat haters but this chapter focuses on evidence, which points to carbs not being inherently evil and how they can be a joyful part of our dietary lives. An excellent overview of choose most often carbs compared to choose less often is detailed here as well; aka, not all carbs are created equal. Finally, in children with high activity levels, carbohydrates can become vital for peak performance, as children are limited in their ability to store carbohydrates.

Foul Play - Supplements and performance aids

This section is a vital resource for parents wondering about the safety and efficacy of performance supplements. Hint: most supplements are not worth anyones time or money; and many are detrimental not beneficial to health. Good reference charts on supplements provided here.

Diets, Dieting and the Young athlete

The most important chapter in this book. Young athletes can set themselves up for a lifetime of dieting, body image issues, and eating disorders with the wrong information and ideas about ideal weight for sport and how weight is managed. In this chapter the author helps bust myths about the efficacy of popular diets and presents, more importantly, the dangers that come with a dieting mentality

Changing the Youth Sports Nutrition Landscape

I was absolutely thrilled this chapter was in the book because the field has become the tipping point around the normalization of junk food. We have all had the after game Slurpee, ice cream, or other frozen treat, and it was great when those items were indeed treats that we had less often. Nowadays when kids are playing sports 2-5 days a week and being offered treats after every game (these on top of the treats likely offered for every other event however small in their daily lives) they have become excessive. Point is, the exercise = food reward is not a positive behaviour we should be teaching our kids.

And there are also a few themes in the book that I struggled with:

1. Chocolate Milk

Throughout the book chocolate milk is recommended as a high protein healthful snack. Regardless of whether or not your children are elite athletes or just regular organized sport lovers, chocolate milk is a treat, and I fear that providing it to a child under the guise of it being a good fuel for sport may provide the wrong message. p.s An 8 oz glass of chocolate milk has 12 g or 3 tsp of added sugar - a 500ml carton - 25g or ~6 tsp added sugar.

2. The Focus on Micronutrients

I feel the chapters around the vitamins and minerals might be useful for an RD, but I wonder whether or not they'll provide much utility to the average family or child athlete.

3. Protein Supplements

There is some vilification of protein supplementation. Truth be told, I am not a strong advocate of protein supplementation, but there is no evidence that I'm aware of that would suggest unadulterated protein powders are unsafe for children to use, e.g. to balance a fruit smoothie with. If said protein powder is adulterated and has a sketchy wt.loss or endurance supplement added to it, then yes, please steer clear.

In summary, Jill Castle has once again provided a valuable resource on child nutrition, whether you are reading it as a health professional or as a curious parent. The book lays down a solid resource on what to eat and how to fuel yourself within varying degrees of activity. However where I found the most value was in the closer look at how we eat, supplementing safely, the dangers of dieting, and the treacherous food environment that all child athletes must face these days. Just in time for the school year, go Dillon Panthers! ;)

If you're interested in your own copy, here is an Amazon Associates link for Eat Like a Champion.

Saturday Stories: Palestinian Genocide, Iranian Anti-Semitism, and the Sabbath

Palestinian journalist Khaled Abu Toameh via The Gatestone Institute on the ongoing ethnic cleansing of Palestinians

Jeffrey Goldberg in The Atlantic on why Iran's raging antisemitism matters.

Oliver Sacks, again in the New York Times, with an incredible read on the Sabbath and more.

Country Hip Hop the New Dance Craze

Today's Funny Friday video is a dance crazy that I'm hoping sweeps the nation.

Have a great weekend!

Guest Post: Dr. Kevin Hall Asks Is The Carbohydrate-Insulin Theory Dead?

For those who don't know Kevin, he's a researcher with the NIH and is undeniably one of the world's foremost experts in the area of metabolism. Last week he published a study that I tweeted out, "would be sure to rock the dogmatic", and it certainly did. There's been lots of angry comments and criticisms, and I thought it'd be great to hear from Kevin himself and I invited him to weigh in. And just as a reminder to readers, I have no horse in this race. As far as success with weight management goes, adherence is king and consequently I'm for any diet that a person enjoys enough to sustain. I also don't think low-carb diets are risky, I have patients in my office on low-carb diets, and I have been highly critical of studies that purported low-carb diets were dangerous when in fact it was more that those studies methodologies were poor. I put this proviso out there because when it comes to discussions about the tenets of low-carb dieting, the volume, and the nonsense, tends to rise rapidly.

Is the carbohydrate-insulin theory dead? Maybe not, but it’s at least wounded.

Thanks to Yoni for the invitation to describe our recent study in Cell Metabolism entitled Calorie for calorie, dietary fat restriction results in more body fat loss than carbohydrate restriction in people with obesity. But first, a bit of recent history:

In a 2010 blog post, journalist Gary Taubes berated nutrition scientists for not understanding the seemingly simple concept of controlling diet variables. He chastised the field for altering multiple diet components at once and said that controlling variables is something that even

“school children are supposed to understand”

The failure of nutrition scientists to understand this basic concept

“has led to what may be another of the great misconceptions in modern nutrition research”

Mr. Taubes then exposes the horrendous misconception:

“carbohydrate-restricted diets are ‘valuable tools’ in the arsenal against overweight and obesity, but they’re just one of the dietary tools.”

Why was such a seemingly reasonable statement proclaimed to be a “great misconception”? Because, in Mr. Taubes’ view, the carbohydrate-insulin theory implies

“that the only meaningful way to lose fat … is by reducing the amount of carbohydrates consumed.” [bold mine KH.]

Doubling down on this claim in his most recent book Why We Get Fat, Mr. Taubes states that

“any diet that succeeds does so because the dieter restricts fattening carbohydrates…Those who lose fat on a diet do so because of what they are not eating – the fattening carbohydrates.”

At the time, I read these proclamations with great interest. I had just begun collecting data from a carefully controlled metabolic ward study which is the first to avoid the confounding nature of changing multiple macronutrients at once. Thankful to have an understanding of clinical trial design equal to an average school child, I also realized that our study would directly test Mr. Taubes’ version of the carbohydrate-insulin theory which has become greatly influential.

We confined 19 consenting adults with obesity to a metabolic ward at the NIH Clinical Center for a pair of 2 week visits where all food intake and physical activities were monitored and controlled. For the first 5 days we fed people a standard baseline diet whose calories matched their energy expenditure and was composed of 35% fat, 15% protein and 50% carbohydrate with about 20% of total calories coming from sugar which is believed to represent a typical habitual diet. We then the cut diet calories by 30% for the next 6 days, either entirely through restricting carbohydrates (RC), keeping protein and fat at baseline, or selectively restricting fat (RF) keeping protein, carbs and sugar at baseline. On their first visit, the participants were randomly assigned the RC or RF diet. After a 2-4 week washout period, they returned for a second 2 week visit when the alternate diet was delivered. Therefore, both diets were studied in the same people.

The diet changes resulted in an average ~800 Calorie reduction from baseline and the composition of the RC diet was 21% protein, 50% fat, and 29% carbohydrate with ~8% sugar. The RF diet had the same calories and was 21% protein, 8% fat, and 71% carbohydrate with ~35% sugar. According to the carbohydrate-insulin theory, the RF diet should not lead to body fat loss because insulin secretion won’t decrease since total carbohydrates, sugar, and protein were unchanged from baseline. According to Mr. Taubes, if insulin doesn’t decrease, then fat is effectively trapped in fat cells. In contrast, because the RC diet decreased total carbohydrates and sugars, insulin secretion should decrease thereby mobilizing fat from fat tissue and increasing net fat oxidation resulting in body fat loss.

All but one of these predictions of Mr. Taubes’ version of the carbohydrate-insulin theory held true in our study. Unfortunately, a theory is disproven when any of its major predictions fail, and in this case the failure was a doozy!

Despite no significant change in insulin secretion, the RF diet resulted in body fat loss by all measures. This finding alone was enough to disprove the claim that body fat loss requires decreased carbohydrates and insulin secretion. Furthermore, the RF diet led to a significantly greater rate of fat loss than the RC diet using the most sensitive method for measuring body fat loss: metabolic balance. The other measurement of fat mass change (DXA) showed no statistically significant difference between the RF and RC diets, but this method is known to lack the precision required to detect such a small difference in body fat.

As you may have guessed, low-carb advocates have complained vehemently about many aspects of the study. One criticism is that the diets don’t emulate “real” low-carb or low-fat diets. However, we wanted to isolate the metabolic effects of restricting dietary carbohydrates versus fat. This made it arithmetically impossible to investigate a very low carbohydrate diet since dietary fat would have to be added to control for calories. This would commit the sin of not controlling as many diet variables as possible, and might lead to wearing the dunce cap in Mr. Taubes’ classroom. Nevertheless, the metabolic response to very low carbohydrate diets is an interesting question and one that we have invested some effort in studying, so stay tuned! [Whoa! Yoni here - you should click that link - describes the details concerning the now completed (but not yet published or discussed) 8 week! metabolic ward study done by Kevin.]

Another complaint is that the study only lasted for 6 days and therefore was not long enough for subjects to become “fat adapted”. However, it actually takes less than a week to reach a plateau in mobilizing fat from adipose tissue to provide the fuel required to support the increased fat oxidation which also reaches a plateau within 1 week. Many previous studies have observed this rapid transition to increase fat metabolism and it was also observed in our study with the RC diet. There is no evidence that fat oxidation increases after the first several days of cutting carbohydrates. However, this does not negate the fact that longer time periods, perhaps weeks, may be required to optimize exercise performance or improve general feelings of well-being on low carbohydrate diets. This is what most people mean when they say “fat adapted”, but exercise performance and cognitive function were not important for our study results.

Many of my critics in the low-carb camp have ignored the caveats that this basic human physiology study does not imply that low-carb diets don’t work. They may even be preferable for many people. I have repeatedly acknowledged that prescribing low-carb diets appears to be more effective in outpatient randomized controlled trials, at least for several months when diet adherence is likely to be highest. The question is why? Our small contribution is that Mr. Taubes’ version of the carbohydrate-insulin theory likely isn’t the explanation.

As a parting thought, imagine that the study results had been different. What if instead we found no changes in body fat with the RF diet? Would there still have been passionate objections from the low-carb community, or would this study have been touted as a major victory for the carbohydrate insulin theory?

Dr. Kevin Hall is a tenured Senior Investigator at the National Institute of Diabetes & Digestive & Kidney Diseases, one of the National Institutes of Health in Bethesda MD, where his main research interests are the regulation of food intake, macronutrient metabolism, energy balance, and body weight. Dr. Hall’s laboratory performs experiments in humans and rodents and develops mathematical models and computer simulations to help design, predict, and interpret the experimental data. Dr. Hall is the recipient of the NIH Director’s Award, the NIDDK Director’s Award, the Lilly Scientific Achievement Award from The Obesity Society, the Guyton Award for Excellence in Integrative Physiology from the American Society of Physiology, and his award-winning Body Weight Planner (Yoni note: Indirect blog post on this forthcoming) has been used by more than a million people to help predict how diet and physical activity dynamically interact to affect human body weight.

This is How Coca-Cola Teaches "Energy Balance" to Kids

By way of example, two of their initiatives.

The first is called, "Get the Ball Rolling" and according to Caren Pasquale Seckler, VP of Social Commitment at The Coca-Cola Company, it was launched because,

"At that time, we made an important decision to take a public stand against obesity. And the reason is simple: Coca-Cola cares about the health and happiness of everyone who drinks our beverages.built on our Company’s global commitments to help fight obesity"

Read about the program on Coca-Cola's website and you'll learn that apparently fighting obesity for Coca-Cola means handing out Coca-Cola branded soccer balls, driving traffic to "MyCokeRewards" loyalty program (which no doubt collects personal information, allows for permission marketing, and of course markets their beverages directly), asking people to vote for their favourite national park, and bringing their "Happiness Trucks" to events where kids are apparently placed in giant cans of Coca-Cola to race around in (photo up above). Oh, and of course, Coca-Cola beverages are distributed as noted in this Coca-Cola piece on a Get the Ball Rolling event with the Texas Rangers and the Boys and Girls Clubs of America,

"All Boys & Girls Clubs participants and coaches received a José Guzmán autographed baseball, Powerade t-shirt and goodie bag and Coca-Cola “Open Happiness” soccer ball, along with plenty of Powerade and Powerade Zero."

Next up is Mixify. Mixify is a joint project between Coca-Cola, Dr. Pepper, PepsiCo, and the American Beverage Association.

The intervention seems geared to directly target teens and teaches them that following sweaty workouts you should eat "whatever you're craving",

And at their travelling road show of events, Mixify literally has children "balancing" what they drink with exercise as illustrated by their real life Jenga game.

So what do you think? Helpful altruism, or slick marketing?

Ask a Coca-Cola Funded GEBN Scientist an Easy Question, Get a 560 Word Answer

A great many stories have been written following the New York Times' Anahad O'Connor's piece, Coca-Cola Funds Scientists Who Shift Blame for Obesity Away From Bad Diets, including one published yesterday in Alternet
by journalist Ari LeVaux who asked Global Energy Balance Network Executive Committee member Dr. Marianella Herrera, a question which sure sounded straightforward to me,

"Do you think sugary beverages have a place in a healthy diet?"

Her answer, which I'll post in its entirety down below, when I cut and pasted it into Word, turned out to be 560 words long.

Honestly, if your answer to a straightforward question is 560 words long, you probably didn't want to answer it.

For what it's worth, I took a stab at answering it. My answer was 30 words long,

"Sugary beverages are a treat, but not a healthful one, and consequently the right amount to include in your diet is the smallest amount you need to enjoy your life."

And given that the question didn't ask me about them, I didn't offer up my thoughts on fear of being assaulted or robbed, gut flora, or sleep quality.

But then again, unlike Dr. Herrera, I don't receive grant support from Coca-Cola, nor am I am a member of the currently embattled, Coca-Cola funded, Global Energy Balance Network, and I genuinely can't guarantee that if I were, my fire-exit answer to a question that might lead me to be critical of my funders' (and potentially friends') products, wouldn't have resembled hers.

Motivated bias isn't something any of us are able to avoid, and with their funding of scientists and non-profits and more, that's definitely part what Coca-Cola is counting on.

Here is LeVaux and Herrera's full exchange:

Ari LeVaux:

Do you think sugary beverages have a place in a healthy diet?

Dr. Herrera:

More than say that sugary beverages can or cannot be a part of a healthy diet, let’s see facts: American Diabetes Association has a recommendation that people should limit the intake of sugary beverages because too much sugar is linked to developing type 2 diabetes, but also make the statement that if you want to consume sweets you should also take into consideration how you substitute the consumption of other carbs in your diet. In other words watch what you are eating and drinking. Is it bad to have a coke? No. Is it bad to drink 6 cans of coke a day? Yes, that might get you into trouble, as could get you into trouble eating a whole cake on a regular basis or a tin of ice cream every other day! What we want to tell people is go for fruits and veggies, have your protein portions consumed, go for the right fats and if you have your birthday you can have a piece of cake and relax, but go in moderation. What is also happening is there is an emphasis of dieting because it has proved to be a successful way to lose weight, which is a big issue today, but in this battle against obesity we might have forgotten other factors. For example: how about start thinking about stopping the weight gain? For that, lifestyle changes are key: exercising which has to be thought in terms of personal security in the developing world, have we thought really how many people are not exercising because they fear they will be assaulted, robbed, etc at nights which is the time many people have for exercising outdoors? How about improving the sleep quality, are we making enough education strategies for population understanding that hormone cycles released during sleep time are crucial for weight maintenance, for children’s growth, for the appetite regulation? Do we have access to good water in the developing world? How this affects the gut flora and in consequence increases the risk for being obese? As you see obesity is a complex multifactorial disease (it is a chronic disease according to WHO) so limiting the cause to just one factor would not be responsible in my perspective. So if you have a healthy lifestyle, eat in moderation, exercise, sleep well drink safe water, you might choose the foods you like if you know how to eat them. Getting people to like foods such as fruits and veggies is our major challenge and should start in early childhood. The American Diabetes Association has excellent resources that helps with some myths about sugar and points out how difficult is this approach.

And we have not addressed the issue that energy imbalance implies undernourishment for many people and that is also important to be highlighted here. There are many people particularly in the global south that suffer from hunger and while the causes of obesity might have different factors including a monotonous diet, don’t forget that now people might have some income that allows them to buy the cheapest foods (sugary beverages are not always the cheapest in the developing world) leading to the so called hidden hunger as a consequence of the social inequities in the access to healthy foods. As you see the topic is immense and please let me know if I’ve covered this enough for you!

At this point I'll remind you again of the New York Times' headline, Coca-Cola Funds Scientists Who Shift Blame for Obesity Away From Bad Diets.

Is The Obesity Society's Silence on Coca-Cola Due to Motivated Bias?

That was the question I asked on Twitter last Thursday.

Is motivated bias the reason that @ObesitySociety hasn't shared a single tweet about massive Coca-Cola & GEBN story? http://t.co/dDvFtD2lbK

— Yoni Freedhoff, MD (@YoniFreedhoff) August 13, 2015

Pro or con, I think @ObesitySociety ought to have a position given their billing as North America's premiere sci. org. dedicated to obesity.

— Yoni Freedhoff, MD (@YoniFreedhoff) August 13, 2015

My tweets went unanswered, and in case you're not sure what they were all about, last week saw Anahad O'Connor's front page story on Coca-Cola's funding of the "Global Energy Balance Network" (GEBN) make some massive waves and generate huge public interest.

There were stories in (and this is just a small smattering - truly, this was an international blockbuster of a story):

The Washington Post
TIME
The Boston Globe
The Guardian
The Independent
The Takeaway
CBC The National
MSNBC
FOX News
The Atlanta Journal Constitution
Forbes
CBS News
Mother Jones
USA Today
Slate

And it wasn't just about covering the news.

Letter writers to the NYTs seemed furious.

So did The New York Times' and USA Today's editorial boards.

Regardless of where you fall in the debate on the messages being put forward by the Coca-Cola funded non-profit, I think it's safe to say that this story is the most publicized story ever written on partnerships between the food industry, scientists, and non-profit, obesity focused, NGOs.

You might think, given the story's topic, size, and importance, that The Obesity Society (TOS), an organization that bills itself as,

"The leading professional society dedicated to better understanding, preventing and treating obesity"

whose strategic plans' mission specifies their desire to,

"lead the cause in advancing the science-based understanding of the causes, consequences, prevention and treatment of obesity"

would feel it important to add its own voice to the discussion - pro or con.

Which brings me to "motivated bias".

Motivated bias refers to the phenomenon whereby,

"When people have a stake in an issue, they tend to process information in a selective fashion that supports their personal interests, a phenomenon known as “motivated reasoning.”

If dollars, partnerships and friendships make up personal interests, The Obesity Society may well have a motivated bias to ignore this story rather than risk criticizing the Coca-Cola/GEBN partnership or its messages. In fact TOS' interest in food industry collaboration is the reason I resigned my membership as I just couldn't be a part of an organization whose, "Guidelines for Accepting Funds from External Sources" position paper refuses to allow even the consideration of funding as a source of bias and,

"expressly eliminates all forms of evaluation or judgment of the funding source"

And then to prove they were serious about it struck a "Food Industry Outreach Task Force", which later morphed into their "Food Industry Engagement Council", the 2014 meeting of which included representatives from Kellogg's, PepsiCo, Nestlé, Dr. Pepper and Ocean Spray.

Friendships may also have a role to play in the silence here - friendships between TOS' leadership and the scientists headlining GEBN (one of who is a TOS past president), as well as friendships between TOS' leadership and Coca-Cola's, whereby judging from their tweets to one another, Coca-Cola's Chief Scientific Officer and one of TOS' current council members are genuine friends. Lastly, given there's no available list of GEBN members other than its executive, it's also possible there are many other TOS members involved.

It's important to note, motivated bias isn't nefarious, it's human nature, and given TOS' silence in the face of this story, along with their stated interest in food industry partnerships, I can't help but wonder if motivated bias is what's keeping them from weighing in.

Motivated biases and motivated silences, whether they're present in this case or not, are undeniably among the primary benefits the food industry enjoys when partnering with public health organizations whose causes may be negatively impacted by the partnering industry's products.

[For an example of what can happen when a public health NGO unshackles itself from the food industry, look no further than Canada's Heart and Stroke Foundation, and if you're interested, here's an opinion piece I wrote for Obesity Reviews on why the food industry is neither friend, nor foe, nor partner.]

Saturday Stories: Running Shoes, Russian Maps, and "Lifestyle"

Gretchen Reynolds in the New York Times does some myth busting around choosing the right running shoes (tl;dr - buy whichever ones feel the most comfortable, motion control doesn't matter).

Greg Miller in Wired with the amazing but true story of the secret world of cold war Russian maps.

Paul Lincoln in the UK Public Health Network's blog, calls for an end to the use of the word "lifestyle" in public health.

[And if you don't follow me on Facebook or Twitter, here's a very kind and generous profile of me from The Chronicle of Higher Education highlighting what I've been up to (in a sense), this past week.]

Artisanal Water - the Next Big Thing

Today's Funny Friday video explores The Timmy Brothers' new line of waters,

"Corporate water is soulless. Our water is about freedom."

Have a great weekend!

How About a Feel Good Food Partnership for a Change?

Thanks to Lindsay Zalot for sending this my way.

It's a partnership between the Greenbelt Farmers' Market Network and the TD Bank whereby the TD Bank provided their customers with "Market Bucks" that could be spent at a whole host of fresh farmers markets.

Kudos to the TD Bank and to Greenbelt Farmers' Market Network for a healthful partnership.

The DAISY Foundation Partners with Cinnabon, Not For Dollars But For Actual Cinnabons

I really thought I'd seen it all when it came to private-public partnerships between health promoting organizations and the food industry, but then I hadn't yet seen the DAISY Foundation/Cinnabon partnership.

The DAISY Foundation, established in 1999, is geared to give nurses thanks for the hard work that they do.

Apparently they thank them in Cinnabons. Literally.

"Cinnabon® has been with us from the beginning, contributing untold thousands of their very delicious cinnamon rolls that are a big part of every DAISY Award presentation. Thanks to the leadership of Cinnabon executives and the generosity of the company's franchise partners, Cinnabon has been DAISY’s Premier Sponsor for over a decade. Participating Cinnabon franchise bakeries and the company donate the Cinnabon cinnamon rolls for hospitals in their area, and during Nurses Week, all nurses are invited to enjoy a free Cinnabon cinnamon roll at participating bakeries. We are very proud to have Cinnabon’s involvement and deep support."

Each Cinnabon classic roll contains 880 calories and 14.5 teaspoons of sugar.

While the story of how and why The DAISY Foundation and Cinnabon partnership came to be is genuinely heart warming, I'm not sure the Foundation is doing nurses a kindness by providing Cinnabon with access to them, and in so doing providing Cinnabon with permission to market and an opportunity to generate tremendous brand loyalty and goodwill, in return for, well, Cinnabons.

Nurses are awesome. They're also under-appreciated. And so recognizing them with awards is a great idea, and given that The DAISY Foundation appears to have plenty of corporate partners who contribute something other than sugar-spiked calorie bombs, I wonder whether or not that appreciation could be delivered in a form that wasn't a giant sticky pastry? Something they might want to consider given nurses themselves have identified unhealthy hospital food environments and pressure from colleagues to eat junk as two of the main barriers that challenge their abilities to cultivate healthful lifestyles.

Why Does Ronald McDonald Keep Touring This Quebec Children's Hospital?

The hospital is Centre hospitalier de l'Université Laval (CHUL) which in turn houses Quebec City's paediatric teaching hospital. Somehow I would have thought that a teaching hospital might not need someone to point out that enabling McDonald's to build deep brand loyalty among vulnerable children and their parents probably isn't in those same kids' and parents' healths' best interests.

Below are a series of photos from their Facebook page from at least two separate visits.

[Thanks to "Le Nutritionniste Urbain" Bernard Lavallée for sending my way]

Canada's MS Society Sells A&W Burgers & Hosts Root Beer Chugging Contests

First there was poutine for the cure.

Next, maple syrup for the cure.

Now, A&W burgers for the cure, and according to a past press release about the annual "Cruisin' to end MS" partnership between Canada's MS Society and the A&W burger chain, there'll even be root beer chugging contests for the cure.

"More than 800 A&W restaurants across the country will host Cruisin’ to End MS events, which may include Cruisin’ the Dub® classic car and hot rod gatherings, retro music, car hop service, A&W Root Beer® chugging contests and visits from the Great A&W Root Bear®. In addition to buying a Teen Burger®, supporters can also purchase $1, $2 or $5 paper cutouts, give through in-store donation mugs or make online donations at cruisintoendms.ca; all of which goes towards supporting activities that help people touched by MS. A&W will also donate $1 to the MS Society of Canada for every RSVP to the A&W Cruisin’ to End MS event on Facebook and every tweet or retweet with the hashtag #CruisinToEndMS."

What might have made sense in the context of a world where fast and junk food was a rare treat, doesn't make sense in the reality of the world we actually live in. In this world, health organizations shouldn't be selling illness in the name of health and instead should be should be actively working to denormalize junk food's regular consumption, not encouraging its purchase and "chugging".

[Thanks to Steve Cooper for sending my way]

Saturday Stories: Deadly Sunscreen, Precision Medicine, And Onion Milk

Fabulous piece by dermatologist Jackie Dosal on whether or not you should be worrying about the safety of your sunscreens.

Ronald Bayer and Sandro Galea in the New England Journal of Medicine on the risks of the premature hope being foisted on precision medicine.

RD and friend Andy Bellatti with another great Civil Eats post - this one on the strange but true partnership between the dairy industry and The Onion!

"Technically it's Food". Arby's Has a Great Sense of Humour

Over the years, Jon Stewart has poked some fun at Arby's.

Today's Funny Friday is the video Arby's put out saying goodbye to Jon Stewart.

Have a great weekend!

MS Society of Canada also Encourages Drinking Maple Syrup to End MS

So yesterday I posted about the MS Society of Canada encouraging the consumption of XXL poutines to end MS.

Over on Facebook, I noticed this comment:

And suddenly I felt compelled to point out that the MS Society of Canada also included a "maple syrup with every meal" pledge in case you didn't want to eat XXL poutines,  stating on their blog,

"Incorporate maple syrup into as many of your dishes as possible. It could mean that your Canada Day party plays a part in finding an end to MS that really sticks. Wouldn’t that be sweet?"

They even featured a photo of someone doing a shot of it.

As far as whether or not that led genuinely kind and well intentioned people to chug the stuff (where just a single tablespoon contains more than half the Heart and Stroke Foundation's daily recommended limit on added sugar), here's a smattering from social media:

Just say no to junk food fundraising.

Multiple Sclerosis Society of Canada Says Eat Poutine to End MS

From the annals of junk food fundraising comes the Multiple Sclerosis Society of Canada and their call for you to eat an XXL sized poutine in the name of MS fundraising.

"It's true. By pledging to eat poutine, you can help end multiple sclerosis."

Poutine, for my non-Canadian friends, is French fries smothered in gravy and cheese curds (picture below).

Here in Canada, most poutine is served by chip wagons (think a French fry food truck). Figure that an XXL poutine packs between 2,000-3,000 calories, and given Health Canada doesn't care about trans-fats, an XXL poutine probably also packs 15-25g of trans-fats with each serving (more on this figure in an upcoming post).

Why health charities are comfortable fundraising by way of promoting unhealthy dietary choices and patterns is something I'll never understand.

We need to put an end to junk food fundraising.

[Thanks to Moniera for sending this my way]

More Questionably Legal Claims Made By The Dairy Farmers of Canada

You might remember a few weeks ago when I questioned the legality of the claims being made by the Dairy Farmers of Canada at a recent Canadian Obesity Network conference.

The issues at hand were two-fold.

Firstly claims were being made about milk products' abilities to prevent colon cancer and type 2 diabetes, improve bone health, and confer healthy blood pressure. Secondly, those claims were being made about milk products as a whole, and not about the nutrients found in milk.

Both of those are a no-no, as according to the Canadian Food Inspection Agency,

"Nutrient function claims may not refer to the treatment, prevention or cure of a Schedule A disease; or claim to treat, mitigate, or prevent a disease, disorder or physical state; or claim to correct, restore or modify an organic function [3(1) and 3(2), FDA]. Such claims are considered to be drug claims (see Drugs vs. Foods)."

And,

"Nutrient function claims are not made for a food per se; they may only be made respecting the energy value or nutrients in a food. For example, the nutrient function claim "Milk helps build strong bones and teeth" is unacceptable, because a nutrient function claim refers to the nutritional function of energy or a nutrient (e.g., calcium) in a food, not a particular food (e.g., milk). An acceptable claim is "Milk is an excellent source of calcium which helps build strong bones and teeth"."

The Dairy Farmers' Executive Director, Caroline Emond, reached out to me to explain that because the conference wasn't targeting the general public, Dairy Farmers of Canada were free to make whatever claims they wanted, and to support her case, she cited a 1987 decision of an Alberta Court of Appeals judge who stated,

"By including the word "general" as a modifier in s. 3(2) the broad term "public" is narrowed. The section totally prohibits advertisement to the general public. It is designed not to interfere with advertisements to the "specialized" professional medical community in specialized trade and professional publications, such as medical journals, pharmaceutical journals and so on."

And yet here, the Dairy Farmers of Canada are claiming, on their "Get Enough" website (and the same information and graphics are available in its accompanying app) - a venue that's definitely targeting the general public - that milk products reduce the risk of hypertension, keep your bones healthy, lower your risk of colon cancer, help you to manage your weight, and decrease your risk of developing type 2 diabetes.

My take on dairy literature is that milk products have not been proven to be magical or particularly dangerous. They're simply a protein source that includes calcium, and definitely aren't deserving of their own dietary category, or of their blind restriction. Seems to me though that the Dairy Farmers' inflated claims here might not meet the letter of the law - though perhaps there's another loophole that I'm unaware of that makes these kosher too.

If you'd like to read a different viewpoint on dairy, here's an interesting Q&A with Alissa Hamilton, the author of Got Milked, whose tough talk on dairy is certainly more extreme than mine, but if you're looking for something to balance the Dairy Farmer's magical claims, definitely have a peek.

[Thanks to the public health RD who'd prefer to remain anonymous who sent this my way]