Groundbreaking New Study On Ultra-Processed Foods Provides Possible Causal Smoking Gun For Our Global Obesity Struggles

[Disclosure, the lead author, Kevin Hall, is a friend of mine and we co-authored a paper together in the past]

A huge deal pre-print paper was published yesterday, "Ultra-processed diets cause excess calorie intake and weight gain: A one-month inpatient randomized controlled trial of ad libitum food intake" that, if its results are replicable and shown to persist over longer time frames, might well explain the rapidly rising weights of the world.

While it has been shown that as food supplies become more industrialized (also referred to as Westernized), weights rise, the reasons why remained unclear. Many have tried to explain away the gains as shifts in the macronutrient composition of a society's diet and depending on the era (or the guru), have pointedly vilified dietary fat, dietary carbohydrates, animal protein, lectins, grains, sugar, and more. Some have done so in part on the basis that when their dietary demon of choice is removed from their adherents' diets, they are seen to lose weight, often even in the absence of tracking calories or anything else for that matter. But common to most of those diets and anecdotes, is their necessitation of forgoing our ultra-processed world and in its place bringing in a great deal more cooking and meal preparation.

Before we get to Kevin's study, here's a basic definition of ultra-processed foods

“formulations mostly of cheap industrial sources of dietary energy and nutrients plus additives, using a series of processes”

If you're interested, you can read more about them here. But for the sake of this study, think of them as the boxes and jars of ready-to-eat and ready-to-heat foods.

So what did Kevin and his colleagues do?

They admitted 10 male and 10 female weight stable adults as inpatients to the Metabolic Clinical Research Unit at the NIH where they lived for 28 days. They were randomly assigned to either the ultra-processed or unprocessed diet for 2 weeks at which point they crossed over to the other diet for two weeks.

During each diet arm, participants were offered 3 daily meals and they were instructed to eat as much or as little of them as they wanted. Menus were designed to be matched for total calories, energy density, macronutrients, fibre, sugar, and sodium, but differed in the percentage of calories coming from ultra-processed sources.

And the results?

Wow.

When consuming ultra-processed food diets people ate on average 508 more calories per day. That's roughly a meal worth. That's huge!

And not surprisingly given this finding, people gained weight on the ultra-processed diet (1.7lbs in just 2 weeks) and lost weight on the flip side (2.4lbs in just 2 weeks).

And there was another surprise. Participants didn't rate the ultra-processed foods as being more pleasant or familiar - meaning the results don't appear to have been a reflection of the ultra-processed menu simply being more delicious.

As to what's going on?

People ate ultra-processed foods faster, and the energy densities of these foods are higher and both of these factors likely explain part of the increased caloric consumption, but the other possibility according to the authors might be protein. The ultra-processed diets contained slightly less protein, something that Kevin believes might help to explain up to 50% of the increased caloric intake by way of something called the protein leverage hypothesis which suggests our bodies attempt to maintain a constant protein intake, and so people consuming less protein from ultra-processed foods may be eating more of them to try to maintain some predetermined physiologically-desired/governed protein intake.

Now this is just a very brief overview, and there will undoubtedly be deeper dives into this including in regard to the various metabolic parameters measured (including hunger hormones and peptides), but given how significant the findings appear to be, I thought I ought to whip something up quickly and the calorie piece is by far the most striking and most important in the context of it being a unifying smoking gun for global weight gain.

It's also worth noting, and Kevin did so on Twitter and in the paper itself, while the results of this study definitely suggest that markedly reducing or eliminating ultra-processed foods in our diets may well help with our weights, doing so requires a great deal of privilege, time, skill, and expense. The good news though is that there are ample levers in our food environment that would help to do so and are ripe for reform that have nothing to do with the usual lenses of individualized blaming and shaming including:

• Improved school foods and school food policies that reduce ultra-processed offerings
• Bolstering the case for bringing back home economics
• Furthering the calls to ban junk food marketing to children (and adults)
• Changing food culture such that ultra-processed foods aren't the cornerstone of every event no matter how small
• Pushing ultra-processed junk food out of sport and sport sponsorship
• Putting an end to ultra-processed junk food fund raising
• Institutional and corporate cafeterias' offerings' reforms
• Strengthening front of package labeling reforms by perhaps not permitting front of package claims on ultra-processed foods (or adding warnings)

and no doubt there are many more.

Even more good news is that a focus on ultra-processed food as a whole, especially one coming from a place of causality, is a focus that pretty much every diet cult can get firmly behind.

Yes, Calories Counted (Literally) In The Recent #DIETFITS, Low-Carb, Low-Fat, Shootout Study

(Credit goes to RD Daniel Schultz for finding this reference in his read of the DIETFITS study and for sharing it via his excellent Twitter thread of thoughts on same)

In case you somehow missed it (though that seems hard to imagine), last week saw the publication of the excellent DIETFITS study - a year long, randomized, controlled trial, that compared the effects of low-carb and low-fat diets, on weight loss and other metabolic outcomes.

Briefly (and if you want to read a detailed synthesis you can read this one over at Examine.com), DIETFITS found that over the course of a year, both low-fat and low-carb diets produced similar weight losses and had similar effects on various metabolic outcomes.

The coverage of the study was widespread, and integral to it was this notion that counting calories isn't necessary for weight-loss, or that it's less important than the foods consumed, in that this successful study's approach involved counselling participants to eat whole foods, be they low-carb or low-fat, while eschewing the rest. Put another way, according to the coverage, people were taught to monitor and care about the quality of their calories, not their quantity, and that this was sufficient to drive significant weight change regardless of whether the foods they consumed were low-carb, or low-fat.

That conclusion is problematic for two reasons.

First, there was no study arm that explicitly taught participants to carefully track their quantity of consumed calories with no emphasis on their quality. Such an arm would be important to conclude that quality of calories trumps quantity of calories for dieters.

But more importantly, and again, thanks to Daniel Schultz, it would seem that the bulk of participants were in fact counting calories as reported by the previously published DIETFITS study design and methods wherein it was reported,

"The most common dietary monitoring method used was the on-line MyFitnessPal tool"

And as anyone who has ever used MyFitnessPal (or any of the other app based trackers - some of which were also utilized by DIETFITS participants) knows, while yes they'll track what you're eating, their primary end-user feedback is calories. And so even if somehow participants did not know in advance that calories were a consideration in weight loss, MyFitnessPal use would have seen to it that they learned that fact very quickly.

You see, setting up a MyFitnessPal account requires the input of a number of different variables: Weight, height, goal weight, age, sex, and some demographics.

And once input, MyFitnessPal then lets you know how many calories you should be aiming at daily to hit your stated weight loss goal.

Finally, when you start entering foods, though macronutrients are also tracked, calories are MyFitnessPal's most prominent field whereby there's a running calorie tally at the top of your diary, along with their meal by meal breakdown.

So while participants may not have been provided with specific calorie goals by the researchers, they were recruited on the basis of being involved in a weight loss study, and without a doubt, they all knew, that when it comes to weight loss, calories do count, and the majority of them used an app that tracked their calories, provided them with a personalized daily calorie goal based on their desired losses, and reported those calories to them prominently every time the app was utilized. And it's difficult for me to imagine that information didn't affect participants' choices, and certainly is enough of a confounder so as to render the conclusion that counselling solely on dietary quality is sufficient to drive significant weight loss.

This doesn't diminish the study's actual findings, but when it comes to calories' quantity and quality, it would seem that there are those who want to promote the existence of a false dichotomy stating that only one or the other of those two variables count. Honestly, I come across it all the time. Angry folks who claim that when it comes to weight and/or health, calories don't matter at all and that what really matters is the quality or types of foods, or the folks who claim that the quality or types of foods don't matter at all, it just comes down to calories.

It's both of course.

The currency of weight is certainly calories, and while we all have our own unique internal fuel efficiencies when it comes to using or extracting energy from food or from our fat stores, at the end of the day, we still need a surplus of calories to gain, and a deficit of calories to lose.

But don't kid yourself - foods matter too. Choice of food matters in terms of health, but also in terms of how many calories our body expends in digestion, and more importantly, upon satiety, which in turn has a marked impact upon how many calories, and which foods, we choose to eat (and of course to health, but that's a whole different matter).

All this to say, the DIETFITS study is terrific, and speaks directly to my published confirmation bias that adherence to one's dietary strategies matter far more than the macronutrient breakdown of said strategy. It also speaks to my bias that when armed with information about both the quality and quantity of the calories we're consuming, and provided with ongoing attention and support, weight loss and improvements to various metabolic parameters are far from an impossibility.

Guest Post: Public Health RD Questions Ontario's Calorie Labelling Rollout

Last week an RD who'd prefer to remain anonymous asked me if they could share their thoughts on Ontario's new calorie labelling initiative with my readers. I readily agreed, and I agree with much of this post. I'm strongly supportive of calorie labelling, but the rollout certainly could have been more thoughtful. And while I agree with all of this RD's closing points, I don't see calorie labelling vs. other changes as being either or - I'd like to see them all.

On January 1st of this year it became mandatory for restaurants with at least 20 locations in Ontario to post the calories on their menus. Many dietitians and other healthcare professionals rejoiced as this information would help people to make better, or at least more informed choices when eating out. Personally, I was a little more skeptical. From what I had seen from other places implementing similar legislation resulted in little if any change in eating habits. We are always talking about evidence-informed decision making in healthcare, yet this legislation from the Ministry of Health and Long-term Care seemed to be based more on appearances than on evidence.

There were problems from the start. Training for public health inspectors (who are responsible for enforcing the legislation) didn’t take place until just over a month before the legislation took effect. It was made very clear to the PHIs that they were to only ensure that eating establishments adhere to the legislation; i.e. that calories were posted in the appropriate places in large enough font and that the contextual statement was posted. They were not to question the calorie counts posted. Some of you might remember the time everyone got upset about Chipotles posting the calories for just the chorizo in a wrap, rather than for the entire wrap. Well, if something like this were to happen in Ontario, unless a complaint came from the public, the PHIs have no recourse. They might see calories posted that seem blatantly incorrect but they have been instructed not to question them. Restaurant owners and operators need only use means that they “reasonably believe” to determine the calorie counts. That means that calorie counts could be determined by a bomb calorimeter (accurate) or by myfitnesspal (questionable) as long as the owner believes it to be accurate. The Ministry declined to provide PHIs with any guidance as to what methods and tools would be appropriate so they are left to take restaurant owners at their word.

Framing this as an initiative to decrease childhood obesity was a huge mistake in my mind. Teaching children to calorie count is not healthy or helpful. Nor is simply providing calorie amounts to parents when caloric needs vary so much among children. Sometimes providing just a little information can be dangerous. I’m sure that the government meant well and they thought this would be a great visible way to show that they’re tackling childhood obesity while downloading the cost onto restaurant owners, win-win. However, this legislation should have been targeted toward adults only. Children should never be counting calories.

The point of this legislation is ostensibly to help the public make informed choices. To that end, you would think that there would have been a public education campaign launched well in advance of the implementation of the legislation. You would be wrong. Despite numerous requests from public health dietitians, and assurances that public education was coming, it wasn’t until over a month after the legislation came into effect that any “education” was undertaken. As a dietitian, I was expecting information on how to use the newly available calorie postings to make better choices. Boy was I wrong. Instead, the Ministry released a series of ads that read more like fast food advertisements and essentially just say “calories are now on menus”.

Let’s fill our kids with ideas about eating right.

A post shared by Ontario Government (@ongov) on Mar 8, 2017 at 11:36am PST

The calories in your food are being revealed. Look for them on menus today. Depending on age and activity, an average of 2000 calories a day is recommended for teens.

A post shared by Ontario Government (@ongov) on Mar 28, 2017 at 1:44pm PDT

I see these and I think, “wow! Poutine and hash browns are so low in calories. They’re not as bad a choice as I thought.” Not at all the message that I think should be coming through this campaign. It’s embarrassing that the government used our tax dollars to pay people to come up with these terrible ads. Apparently they focus group tested them and the teens thought they were hilarious. Perhaps they can’t tell the difference between laughing with you and laughing at you? Regardless, there should have been someone working on this campaign who saw that it wasn’t sending the intended message (check out the comments). They should also realize that simply telling people that calories are posted on menus isn’t sufficient to aid them in appropriately using this information. As it stands, it only serves to help those who are already health conscious and who know roughly how many calories per day they should be consuming. They should have been giving people the information and tools to better understand and use the calorie counts.

Does putting calories on menus even work? There was a recent webinar by Health Evidence on this and they said that on average, it led to reductions of about 70 calories per day. Which sounds great except that the average caloric intake of people in the studies was about 3000 calories a day, about 1000 calories more than the recommended daily calories for an average adult. So, yes, putting calories on menus may lead some people to choose items with fewer calories but if they’re still consuming about 900 more calories than they need I’m not sure that’s anything to write home about.

Calories are only one piece of information and I worry about putting too much emphasis on it. Restaurant meals tend to be obscenely high in sodium but the calories won’t tell us anything about this. Calories also don’t tell us if a menu item is nutrient dense or nutrient void. It can make it appear that deep-fried foods are equal to salads.

Something else to consider, beyond the concerns I mentioned above about the accuracy of the methods used to determine the calorie counts, is the human factor. Even if the calories are accurately measured, that’s based on the sample as provided by the restaurant which you can bet is going to put that food in the best light possible. Do you really think that line cooks in a restaurant, or teenagers at Five Guys are concerned about portioning things so that meals contain the same number of calories as is posted on the menus? I doubt it. they’re probably using more oil on that stir-fry or scooping extra fries onto that plate. It’s pretty safe to assume that the actual number of calories in any given menu item is going to be higher than the number posted on the menu so take the number on the menu with a grain of salt.

I’m sure that there are people reading this thinking “but at least they’re doing something. What would you do?” I would bring back mandatory home ec in schools. I would help to ensure better access to and affordability of nutritious foods across the province. I would provide more support and funding for healthy eating and food literacy initiatives for all ages. Instead of accepting that people are going to eat out regularly, and assuming that providing calories on menus is going to make people healthier, we should be encouraging people to get in the kitchen.

The False Dichotomy Between Food Calories and Food Quality

I come across it all the time. Angry folks who claim that when it comes to weight and/or health, calories don't matter at all and that what really matters is the quality or types of foods, or the folks who claim that the quality or types of foods don't matter at all, it just comes down to calories.

It's both of course.

The currency of weight is certainly calories, and while we all have our own unique internal fuel efficiencies when it comes to using or extracting energy from food or from our fat stores, we still need a surplus of calories to gain and a deficit to lose.

But foods matter too. Choice of food matters in terms of health, but also in terms of how many calories our body expends in digesting, and more importantly, upon satiety, which in turn has a marked impact upon how many calories, and which foods, we choose to eat.

So if you do come across a zealot from either camp that claims one or the other doesn't matter, feel free to ignore them.

"Snack" Size Cadbury Creme Egg McFlurry Has More Calories than a Big Mac

Well maybe there are some folks out there who "snack" on Big Macs.

And it's also great at treating sugar deficiencies as the "snack" (I can't not use quotes for that word) size McFlurry packs 18 teaspoons of sugar.

Go for the "Regular" size and now we're talking the calories of a Big Mac plus a small fries with those calories coming in large part from its more than half a cup of sugar.

Why Semantics Matter To Food Diaries

Just a quickie on calories and diaries.

As I've mentioned before,

• People are not walking math formulas whereby if they have 3,500 more or less calories than they burn they'll gain or lose a pound.
• 3,500 calories of one food or type of food will likely have a different impact on health, hunger, thermic effect, and weight than 3,500 calories of another food or type of food.
• Different people have different caloric efficiencies whereby they are seemingly able to extract more calories from food or reserves than others and lose weight with more difficulty (and gain with greater ease).

And yet here's the only truth that matters.

From a weight management perspective, the currency of weight is calories. While exchange rates undoubtedly do vary between foods and between individuals, you'll always need your own personal deficit to lose, and surplus to gain.

But "counting" suggests upper limits or ceilings you can't crash. So too do the words, "accountability", and, "honesty" - and yet those words underscore most people's approaches with food diaries.

Food diaries aren't there to tell you whether or not you've been good or bad, how much you're allowed, or how much room is left for dinner. That said, a food diary is for information and while calories certainly aren't the only nutritional determinant of health the fact that they're imperfect doesn't divorce them from having some importance if weight's a concern. The more information you have before you make a decision, the better that decision's likely to be, and in our Willy Wonkian wonderland of food, having more information is a good thing so long you use it as only one piece of a non-judgemental decision.

I guess what I'm trying to say is that the smallest number of calories you'll need to enjoy Christmas is likely to be higher than the smallest number you'll need to enjoy today and that if your general food diary practice is to allow non-contextualized calories make you feel badly about yourself when you "go over", there's a good chance that eventually the guilt you'll feel when real life leads you to higher numbers will see you stop considering the numbers altogether.

No, Low-Fat Doughnuts Aren't Going to Cure Obesity

Sigh.

I had many people send me a piece from the Ottawa Citizen entitled, "People line up for Almonte inventor's lower-fat doughnuts" that included their inventor Ed Atwell's unopposed comment,

"I believe this is a technology that is going to curb if not eliminate the obesity epidemic"

I guess he's never read any of Brian Wansink's work that suggests the doughnuts' "low-fat" label will likely contribute to obesity's rise, rather than help it's fall. Why? Because the label and the story provide a health-halo that the evidence would suggest will lead people to consume more calories from these purportedly "healthy" or at the very least, "healthier" doughnuts than if they just hit the full strength versions (something to which the store's out the door lineup to buy speaks directly).

My favourite part of the story though has to be the nutritional information disclosure.

Apparently Ed's average obesity-fighting miracle doughnut contains 190 calories.

Want to know how many calories are in Tim Horton's classic chocolate dip?

190.

Blargh!

The Average Full Service Restaurant Meal Contains a Full Day's Worth of Calories!

Very straight forward study out of Drexel University.

Nutrient profiles for 21 chain full-service sit-down restaurants' 2,615 items were compiled and then some basic math to calculate caloric averages.

A standard adult meal consisting of a shared appetizer and an entree with a side dish averaged 1,495 calories and rose to 2,020 calories after including a beverage and a shared dessert.

And apparently we're going to restaurants twice as often as we did back in the late 1970s.

Eating out is a truly wonderful indulgence, but please, try to do so for occasions only, and Fridays (or any other day of the week) aren't in and of themselves occasions.

More Evidence It's Not Just Restaurants Where Portions Have Grown

Reminiscent of the work of Brian Wansink and Collin Payne who showed that those few recipes that found in every edition of the Joy of Cooking from 1936 through 2006 grew with time, here's a group from Denmark who've gone and done the same with seminal Danish cookbook "Food" with editions from 1909 through 2009.

What'd they find?

"The mean portion size in calories from a composed homemade meal increased by 77%. The mean portion size in calories from meat increased by 27%, starchy products increased by 148%, vegetables increased by 37% and sauce increased by 47% throughout the years."

Well at least they're eating more vegetables....

Is Coca-Cola's Latest Calorie Dictionary Ad Purposely Deceptive?

You be the judge.

Below is the embedded copy of Coca-Cola's most recent anti-obesity advertisement. It's called, "Calorie Dictionary".

Watching Calorie Dictionary the inference is that it's incredibly easy to burn off the calories of a Coke.

They show various activities and then their apparent calorie counts. They also, at the beginning, note that the calorie values are for 5 minutes of the activity shown. Clearly though Coca-Cola expects the brief mention of 5 minutes to be forgotten as the bulk of their portrayed activities in real life are only momentary, like hugging a friend, falling, jumping out of a tree, or zipping up a dress which according to Coca-Cola respectively burn 7, 18, 11 and 12 calories. Seems to me that the message Coca-Cola is trying to hammer home is that calories are way easier to burn than you thought and that if you just move a teeny little bit, you can easily burn off their sugar water. Too bad it's not a truthful one.

According to the commercial if you spend 50 minutes (divided into 5 minute blocks) hugging people, swinging a sledgehammer, climbing fences, falling off mechanical bulls, jumping out of trees, running, shouting, lifting young children onto your back, diving to the ground, and zipping up a dress then you too will burn the number of calories you'd find in a 13.5 oz bottle of Coca-Cola.

Such nonsense, and more to the point, want to know what's way easier? Not drinking them.

(And if you wanted to burn off the much more ubiquitous 20oz bottle you'll need to combine 75 minutes worth of 7.5 minute blocks of those same ridiculous examples.)



So what say you? Purposely deceptive or a helpful part of the "solution"?

Food Frequency Questionnaires Suck Say Who's Who of Obesity Researchers

Hot off the heels of my blog post about giant pears, last week a letter to the editor of the American Journal of Clinical Nutrition was published. It was signed by some very familiar names in obesity research and its title is also its summary, "Self-report-based estimates of energy intake offer an inadequate basis for scientific conclusions".

The letter was triggered by a recently reported and heavily publicized study that suggested energy intake has decreased significantly since 2003-2004 - with an average reported decrease of 98 cals/day. The letter's authors note that the data used to come up with the exciting decrease has been shown to be flawed before, and moreover, that it would appear as if bias in reporting of energy intake may be increasing (perhaps due to increased attention and bias versus those with obesity). They also note that were it in fact true the population ought to have lost an average of nearly 8lbs since 2003.

Their final conclusion is firm and one I agree with in regard to studies designed to look at ways to prevent or treat obesity,

"Going forward we should accept that self reported energy intake is fatally flawed and we should stop publishing inaccurate and misleading energy intake data."

Signed,

Dale Schoeller
Steven Blair
Steven Heymsfield
David Allison
James Hill
Richard Atkinson
Barbara Corkey
Nikhil Dhurandhar
Eric Ravussin
Kevin Hall
John Kral
John Foreyt
Diana Thomas
Edward Archer
Michael Goran
Berit Heitmann
Barbara Hansen

[And for good measure, up above is another of my collection of photos of gigantic fruit - this time a 10oz plum bigger than an apple.]

Did You Hear the One About the McDonald's CEO Losing Weight Eating McDonald's Everyday?

Yeah, I did too and that's him up above.

His 20lbs McDonald's fueled weight loss has been all over the news.

But here's the thing. At the end of the day if the bioavailable calories you consume are less than those that you burn you lose.

The fact weight can be lost eating at McDonald’s everyday is not news, but the fact that the news is covering it is. What the coverage suggests is that the world still doesn’t understand weight management because if it did there wouldn’t be news stories on the guy who ate fewer calories than he burned and lost weight.

1.5 Trillion Calories!

According to press releases and nonsensically breathless articles like this one out of Forbes, last week's announcement from the food industry that they'd removed 1.5 trillion calories from the food supply was huge.

But is it?

When broken down by person it amounts to 14 fewer calories purchased per person per day last year from vending machines, convenience stores, drug stores, grocery stores, supermarkets and mass merchants.

And that's not a bad thing and were it truly consequent to the food industry shaving calories off their products it'd certainly be worth our giving them a gentle pat on the back, but I guess I'm stuck trying to understand both the market forces that may have led to the reduction, as well as whether or not the reduction occurred despite the food industry's best efforts, not because of them.

Could the reduction not simply reflect shifting societal attitudes and norms and in fact have occurred despite the food industry's persistent, tenacious, merciless and at times deceitful and ethically questionable marketing of salt, sugar and fat?

I'm curious too to see the independent non-industry analysis of these results which is currently being undertaken by Dr. Barry Popkin and his colleagues.

All that said, 14 fewer calories per day aren't likely to take us too far given that estimates suggest we're eating 500 more calories per person per day since the early 1970s. Still plenty of work to do on the remaining 486.

Should We Be Banning the Marketing of Insane Meals?

Thanks to blog reader Chris for sending along a photo and the nutritional breakdown for what Wendy's is calling the "Ultimate Canadian Combo".

To save you the trouble of clicking or magnifying the photo this "Ultimate Canadian" combo of a Baconator, poutine and a medium Coke weighs more than a kilogram and contains a cool 1,860 calories, 3,380mg of sodium and thanks primarily to the "medium" Coca-Cola, 17 teaspoons of sugar.

Wow.

Makes me wonder whether or not a day will come when politicians will try to ban the advertisement (not the sale) or the discounted bundling of combos containing more than a predetermined amount of calories or other nutrients?

City of Ottawa Encourages Exercise As An Excuse to Eat Junk Food?

Sure, I get it. I'm sure I've even done it. I've eaten indulgently, "because I exercised", but when I was driving behind the bus that told me, "Less Sit, More Whip", with a photo of what looks like a mocha frappuccino, I did a double take.

Honestly, it said, "Less sit, more whip".

Yes, if you actually bother finding the www.ibikeihike.ca URL and heading to it you'll learn it comes from a City run campaign encouraging active commuting and indeed, if your commute to work includes a brisk walk of 1hr and 20mins each way you'd burn off the Quarter Pounder worth of calories in a Grande Mocha Frappuccino with Whip. Cycling's a bit better - there it'd just take you a fair paced 30 minutes each way.

Unfortunately this campaign does two things wrong. It implies exercise burns far more calories than it actually does, and it basically serves as free advertising for junk food.

Off the top of my head couldn't the campaign have focused on things like coming off medications, playing with grandchildren, going on dream active vacations?

Yes junk food's part of our modern day world. And yes, even I sometimes indulge in it, but my double take had to do with the fact that there's no question in my mind cities (and my tax dollars) shouldn't be encouraging the consumption of junk food or suggesting that exercise buys people a free pass to the candy store.

[Also of note - Ottawa's Public Health (OPH) department had privately criticized this message before it was unleashed on the public. In speaking with them yesterday they noted, "it's counter-productive to everything we're trying to do", and that they are, "very disappointed that they (the folks who commissioned the ad) didn't feel strongly enough to change their visuals". Makes me wonder why the OPH isn't given more clout in City sponsored public health messaging?]

The Most Painfully Stupid Thing I've Read in a While

It was written by the American Beverage Association in response to the barrage of articles condemning sugar-sweetened beverages (SSBs) the New England Journal of Medicine published this past Friday. The articles beat the dead horse that sugar-sweetened beverages contribute to rising weights.

It's a dead horse because as the American Beverage Association themselves report,

"Sugar-sweetened beverages contribute about 7 percent of the calories in the average American’s diet."

And guess what? 7% is a lot!  If you lose 7% of your total daily calories you're probably going to either lose weight or gain more slowly.

Of course even that's disingenuous as what the ABA doesn't report is that the percentage of sugar-sweetened calories is dramatically higher in teens (as much as 25% of calories coming from sugar sweetened beverages), and moreover, looking at all comers, ignores the fact that there are many folks who don't drink any sugar-sweetened beverages at all meaning that for the actual drinkers, the percentage and/or number of SSB calories they're consuming are likely much, much, higher.

What other arguments are trotted out by the ABA to defend the regular consumption of sugar water?

1. All calories count
2. You can balance calories in with calories out
3. Consumption of soda is going down, yet obesity rates are going up
4. There are people who struggle with weight who don't drink SSBs
5. SSB manufacturers also make non-SSBs
6. We don't advertise SSBs to kids
7. We're part of the solution because we've worked with Bill Clinton and Michele Obama

My responses?

1. And?
2. Sure, just balance those calories you consumed in all of 3 minutes each day by adding 3.5-7 HOURS of exercise a week.  Easy peasy.
3. And?
4. So?
5. And?
6. LOL!
7. Sigh.

Really?  These are the best arguments the beverage industry's got?  If that's the case, I'd say we're getting somewhere!

Here's hoping that America's current Surgeon General Regina Benjamin takes this opportunity to grab a page out of C. Everett Koop's shoes and actually take a useful stand on a product that's undermining global health.

If for some mind bogglingly bizarre reason you're still on the fence on SSBs and their contribution to weight, why not have a read of the editorial published in NEJM and perhaps the articles themselves (they're free).

Study Reveals Overweight Teens Have Fewer Arms Than Healthy-Weight Ones

A truly shocking study published today ahead of print in the journal Pediatrics revealed that overweight teens reported having one fewer arm than their healthy weight counterparts.

Sigh.

(I'm sighing a lot these days).

No, overweight teens don't have fewer arms than their healthy weight counterparts, and I'm equally doubtful that overweight teens eat fewer calories than so-called healthy weight teens either, yet that's what's been trumpeted all over the media and blogosphere for the past few days.

The reporting stems from a paper entitled, "Self-Reported Energy Intake by Age in Overweight and Healthy Weight Children in NHANES, 2001-2008". In it researchers detailed the "surprising" finding that overweight and obese girls over age 7, and overweight and obese boys over age 10 reported consuming fewer calories than their healthy weight peers.

What I find rather amazing though is that the researchers, rather than focus on the story being overweight girls as young as 7 and boys as young as 10 may have already suffered sufficient societal stigma to under report their dietary intake when asked how much they're eating, instead decided to conclude that contrary to what the laws of thermodynamics require, overweight kids and teens either have created for themselves a, "self-perpetuating" state of obesity, or that they're significantly less active.

Now to be fair they also mention a third possibility, that perhaps overweight kids under report their dietary intakes, but then they explain why they think that isn't the case.

So is there evidence out there suggesting that overweight teens are in fact the world's worst dietary historians?

Why yes there is.

In February of last year there was a review paper published in the International Journal of Pediatric Obesity titled, Assessing dietary intake in children and adolescents: Considerations and recommendations for obesity research. Regarding under-estimation, here's what the review paper's authors had to say,

"One of the most robust findings in dietary studies of children and adolescents is the positive association between under reporting and increased body fatness, particularly in adolescents (4,14,15). This is consistent with studies in overweight and obese adults (16). The extent of mis-reporting irrespective of weight status increases with age and has been reported as 14% of energy intake in 6-year-olds (17), 25% in 10-year-olds (18) and 40% (4,19) to 50% (14) in obese adolescents.."

The authors further report that the type of study most likely to suffer from under-reporting is the very type performed here,

"Studies characterising under-reporting have focused on total diet assessment methods and in particular, energy intake"

So let me ask you a question.

If we knew that when polled obese teens under-reported their number of limbs by 50% do you think it'd be wise to take their reporting at face value and come up with theories as to why one of their arms fell off, or would it be more useful and important to try to understand the drivers that led those teens to misrepresent their limb status'?

Sir William Osler one of the founders of modern medicine once said,

"When you hear hoof-beats think horses, not zebras"

The horse is under-reported calories. Moreover it's a horse that's been spotted many times. To ignore that horse and instead focus on one-armed teen zebras? The only explanations for that behaviour I can come up with are ignorance, or willful misrepresentation in the name of publication or publicity - and neither are pretty.

Gary Taubes Launches Non-Profit to Prove His Low-Carb Hypothesis

Today marks the formal launch of Gary Taubes' new non-profit organization NuSI whose stated mission is to, "improve the quality of science in nutrition and obesity research", and whose implied mission is to prove Gary Taubes' carbohydrate hypothesis of obesity is as correct as he clearly believes it to be.

So let's for a moment presume that Gary Taubes is one hundred percent right. That what his NuSI backgrounder calls a "controversial" hypothesis,

"that the fundamental cause of overweight and obesity is the overconsumption of food in relationship to physical activity",

is truly dead wrong and that instead it's,

"the quantity and quality of the carbohydrates – plays the more critical role in both the accumulation of excess body fat and the chronic diseases that are associated with obesity"

So that means for the moment just ignore data like those from the Ewe tribe who were recorded as having an obesity rate of 0.8% despite diets that were 84% carb. Ignore the various studies that held calories constant while varying macronutrients that demonstrated weight stability. Ignore the results from Cuba's "natural experiment" in the 1990s.  Ignore the folks from the National Weight Control Registry who've lost and sustained their losses with widely divergent dietary strategies.  Ignore the fact that even the most low-carb positive studies demonstrate only minor differences in weight loss as compared with higher or middle of the road carb diets. Instead I want to ask you whether or not, assuming Mr. Taubes' shiny new researcher's bench is entirely, incontrovertibly, 100% right in placing blame squarely on carbohydrate consumption, would that bench-side proof actually have broadly applicable clinical utility for folks who struggle with their weight?

My bed-side says no.

That's certainly not to say that low-carb dieting doesn't help some manage their weights and health, it just means that no amount of bench-made "proof" will change the fact that low-carb dieting, for many, is far more of a restrictive diet than it is a livable, long-term lifestyle. Meaning that even if low-carb were the holy grail of diets on paper, that fact would be worthless in practice unless you happened to enjoy low-carb enough to stick with it, and judging from the folks I see regularly in my office, that's far from a given. In fact it's a very rare person that I meet who hasn't tried a low-carb diet at least once.  And all of those folks? No doubt when they undertook their low-carb diets they were true believers. As far as they were concerned low-carb was to be their salvation, and many report to me having had real success losing but that they just as rapidly regained everything when they couldn't stomach living low-carb anymore. It's that last bit that makes me think that regardless of the outcomes of Mr. Taubes' new non-profit's future studies, low-carb diets aren't going to be a panacea, just as they weren't in Banting's 1860s or Atkins' 1990s.

Mr. Taubes thinks that study design is the broken paradigm that's crippling weight management. He thinks that nutritional research hasn't asked the right questions or used the right methodologies and so that's why we're mired in this mess. And while it's easy to agree with him that there have been libraries filled with poorly designed studies, as far as clinical weight management utility goes, more effectively asking or studying whether low-carb diets have better outcomes than low-fat or other diets isn't likely to help much.

I think the paradigm that's crippling weight management are "diets" themselves.

Whether it's low-carb diets, low-fat diets, GI diets, middle-ground diets, vegan diets, and even bat-shit crazy diets, there are long term success stories and recurrent failures with each and every one, where the common ground to success is a person actually liking their life enough to sustain their new patterns of reduced dietary intake, and where the common ground to failure is suffering or restriction beyond an individual's capacity to enjoy their life.

And so while I don't share Mr. Taubes' view that there is one simple or predominant cause and treatment for obesity, and would in fact argue that anyone who thinks there's a singular cause for the society's weight struggles almost certainly doesn't work with actual living, breathing, human beings on their weights, I do agree that the research on what works and what doesn't work is inherently flawed. But it's a flaw that Mr. Taubes' is likely setting out to sustain and fund in that the flaw I see from my bedside is the arrogant belief that there's one right way to go and only one path to weight gain (or loss).

There's also the issue of spin.  Now I appreciate you've got to tell a good story when you're trying to raise money, but given Mr. Taubes has built his empire on the notion that science has misrepresented data on obesity for decades, you'd sure hope that he wouldn't simply do the same.

Without getting into it too deeply I want to present one graph that he includes in his non-profit's backgrounder that he uses to prove his point that it's the carbs, stupid.

The graphs are meant to be very clear. Carbohydrate intake has gone up since 1971 while fat and protein have gone down, and hey look, weight's gone up too. Must be the carbohydrates, right?

But yet a deconstruction of the first graph by Evelyn over at her Carb-Sane Asylum really gets right to the meat of things with this statement when considering the graph on the left,

"looking at this data, we have the men reducing fat % from 37 to 33% while carbs rose from 42 to 49% of intake. And the women? Fat went from 38% to 33% while carbs rose from 45% to 52%. Given all the studies done where the low carb diets were "hardly low carb" according to the militant keto wing of the movement, can we at least have a wee bit of intellectual honesty here and admit that the differences in macro proportions is largely insignificant?"

What she's saying is that from a macronutrient percentage perspective, the difference between the 1970s consumption of a diet containing 45% carbs (for women) and the 2000s diet of 52% (and for men the difference between 42% and 49%) is pretty insignificant and that 1970 diets were anything but low-carb and yet our weights were so much better.

But more disingenuous is the fact that Mr. Taubes left out his arch nemesis from the graph. Calories.

Here's a graph from Stephan Guyenet that superimposes increased American calorie consumption over that graph on the right hand side of Mr. Taubes' slide.

And would you look at that. As weight rose, so too did caloric intake.  Pretty much perfectly.

Sigh.

Why we're eating more is the question that needs to be answered, and while the increased consumption of highly refined carbohydrates may indeed be a player, there's zero doubt in this bed-side's mind, the game that's being played isn't one-on-one. There's no doubt it's not as simple as, "eat less, move more", and there's equally no doubt it's not as simple as just cut carbs.  If either were true, everyone who wanted to be would already be skinny.

So huge props to Mr. Taubes for being such a passionate man and for truly wanting to see his theories proven - honestly, his bordering on pathological tenacity is genuinely laudable, though I wish he would hold his own spin and writing up to the same degree of scrutiny to which he holds others'. But ultimately, whereas Mr. Taubes now wants to trade in his pen for a bench and conduct research that presumably he himself won't instantaneously and churlishly deride as being useless, when it comes to clinical utility and weight management, the last thing the world needs is to believe that there's only one right way to go.

The Ewe Super High Carb Diet - 99.2% Effective!

This one was yanked from the vaults by Whole Health Source's Stephan Guyenet.

It details a 1987 study in the Lancet that involved exploring the diets, diabetes prevalence, and weights of 1,381 rural West Africans of the Ewe tribe who subsided primarily on carbohydrates which in their case primarily took the form of cassava roots (basically an African potato - that's it up above).

The researchers estimated the Ewe's average calorie consumption by actually measuring their common food portions and reported that the average young male was consuming just under 2,000 calories daily with a macro-nutrient breakdown of 84% carbohydrates, 8% fat and 8% protein.

The results were pretty straightforward. There was no detectable cases of diabetes as measured by blood glucose levels. Weight wise, mean BMI was just over 20. There were only 11 total individuals with BMIs exceeding 27 (0.8%).

Weight wise the results aren't particularly surprising either as less than 2,000 calories a day for men will sustain a very lean weight. But what of the folks who believe calories don't count and it's all and only about the carbs?

More on that tomorrow.

Does It Matter if Almonds Now Contain Fewer Calories?

Image from Fooducate - one of my most favorite blogs!

Not sure if you caught the buzz on this, but according to a new study we've been measuring almond calories wrong for years.

So does it matter?

Depends. If you're aiming to ensure you hit at least a minimum number of calories per meal or snack - absolutely as if correct, you may be getting less than your aim (where hitting minimums may be part of a strategy to reduce hunger or to gain weight).

On the other hand, if your hunger is well managed and you're eating almonds as snacks - I certainly wouldn't take it upon yourself to up the number as despite the fact that each almond may have fewer calories than you thought, eating more of them will of course increase total calories.

And what if we're calculating the calories wrong in everything (which may in fact be what we're doing)? Well it'll certainly impact upon formal recommendations (including my own), but unless eating too few calories is your primary problem, it's nothing I'd lose sleep over.

My advice? Aim for the smallest number of calories that leaves you happily satisfied, and if suddenly that number is in fact smaller than it was before, that won't change the fact that you were already happily satisfied.